Orthopaedic Insights - Cleveland Clinic · gressive spine deformity seen largely in teenage girls. Bracing a growing child has been shown to delay or prevent curve progression in

Orthopaedic Insights

Fall 2011

A Physician’s Newsletter from the Department of Orthopaedic Surgery

In This Issue:

3 MIS Technique

Promising for AIS

4 Anatomy of the MUCL

6 Early Referral for

Metastatic Bone Disease

10 Improving OR Efficiency

12 Proximal Femoral

and Acetabular Alignment

15 Image of the Issue

16 Preventing Wound

Complications after

Calcaneus Fracture Surgery

18 Musculoskeletal Ultrasound

22 Cleveland Clinic’s MyConsult

23 Orthopaedic Residency

Update 2011

ORThOPAEDIC INSIghTS2 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096

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

is ranked No. 4 in the nation by U.S.News

& World Report – the top ranking

in the state of Ohio.

Dear Colleague, Welcome to the Fall 2011 issue of Orthopaedic Insights, which provides

an overview of our clinical care, research and academics here in Cleveland

Clinic’s Department of Orthopaedic Surgery.

In this issue, we feature research by Dr. Mark Schickendantz to better un-

derstand why long-term outcomes following medial ulnar collateral ligament

reconstruction are so widely varied (p. 4). Drs. Nathan Mesko, David Joyce,

Steven Lietman and Michael Joyce discuss why early referral is so critical to

improved outcomes in patients with metastatic bone disease (p. 6), and Dr.

Ryan goodwin shares a minimally invasive technique that is promising for

adolescent idiopathic scoliosis (p. 3). On p. 16, Dr. Mark Berkowitz discusses

using a negative pressure dressing to prevent wound complications after sur-

gical treatment of calcaneus fractures. We also take a look at how a dedicat-

ed orthopaedic operating room unit improves operating room efficiency, with

Drs. Wael K. Barsoum and Bishoy V. gad, and Alison K. Klika, Jim Leonard

and Loran Monir-Soliman (p. 10).

These articles and the others in this issue demonstrate the way our ortho-

paedic surgeons continually strive to improve care for our patients. They also

highlight the strengths of Cleveland Clinic’s institute model. Our Orthopaedic

& Rheumatologic Institute (ORI), of which our department is a part, success-

fully combines the strengths of our Orthopaedic and Rheumatologic pro-

grams, both ranked among the top 5 nationally by U.S.News & World Report.

In our institute, orthopaedic specialists, musculoskeletal radiologists, biomedi-

cal engineers, rheumatologists, immunologists and physiatrists collaborate to

most effectively assess and manage patients with musculoskeletal diseases.

I hope that you enjoy this issue of Orthopaedic Insights and find the informa-

tion useful in your practice. Please feel free to contact us anytime with ques-

tions or for more information on how we can help you care for your patients.

Richard D. Parker, MD Chairman, Department of Orthopaedic Surgery

Professor, Cleveland Clinic Lerner College of Medicine

216.444.2992

[email protected]

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

Joseph P. Iannotti, MD, PhD Chair, Orthopaedic & Rheumatologic Institute

Richard D. Parker, MD, Chair, Orthopaedic Surgery Ryan C. Goodwin, MD, Medical Editor Ann Milanowski, Editor Irwin Krieger, Art Director

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

The Orthopaedic & Rheumatologic Institute, one of 26 institutes at

Cleveland Clinic, is staffed by physicians, scientists and engineers

who pursue excellence and innovation in the care of patients with joint,

bone, muscle, connective tissue and immune disorders. Cleveland

Clinic is a nonprofit, multispecialty academic medical center. Founded

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

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

beds, an education institute and a research institute.

Orthopaedic Insights is written for physicians and should be relied

upon for medical education purposes only. It does not provide a

complete overview of the topics covered, and should not replace a

physician’s independent judgment about the appropriateness or risks

of a procedure for a given patient.

© 2011 The Cleveland Clinic Foundation 11-ORT-016

ORThOPAEDIC INSIghTS 2011 3Visit clevelandclinic.org/ortho

Minimally Invasive Technique Promising for Adolescent Ideopathic Scoliosis By Ryan Goodwin, MD

The etiology of adolescent idiopathic scoliosis (AIS) remains

elusive. The condition presents as a typically painless pro-

gressive spine deformity seen largely in teenage girls. Bracing

a growing child has been shown to delay or prevent curve

progression in some patients. Progressive curves, however,

are best treated operatively.

The gold-standard surgical treatment for AIS is spinal fusion.

Most are performed via a posterior approach with segmental

instrumentation and bone graft. Goals of surgery are to halt

progression of the curve and obtain a safe correction of the

deformity. While the morbidity of spine fusion surgery is typ-

ically well-tolerated by teenagers, newer minimally invasive

techniques have been developed to reduce patient morbidity

while achieving the same outcomes.

The MIS approach to spine fusion deformity allows safe

instrumentation of the spine as well as preparation of the

fusion and bone graft via a muscle-sparing approach. The

procedure begins with the patient under general anesthesia

and prone on the operating table. Spinal cord monitoring

is used and baselines are checked prior to proceeding.

The skin is incised longitudinally the length of the proposed

fusion. While the incision is comparable to an open fusion,

the muscle dissection is quite different. The pedicle screw

insertion point is exposed by splitting the semispinalis and

multifidus muscles at each instrumented level. There is

minimal blood loss with this approach as compared to with

a complete subperiosteal exposure of the posterior elements

of the spine.

Once the pedicle screw insertion point is identified, the ped-

icle is entered and confirmed with a probe and radiographi-

cally. A guidewire is inserted to mark the pedicle. Prior to

screw insertion, the facet is obliterated, the surrounding

bone is decorticated to prepare the fusion, and the bone graft

is applied. Fusion preparation at this stage is critical to the

success of this technique, as a robust fusion is the ultimate

goal of the procedure.

The pedicle screw is then placed over the wire and checked

with image intensification. When all the bone anchors

are placed, a rod is contoured and placed across the screw

construct on each side of the spine. Corrective forces are

applied, with close attention paid to neurologic monitoring.

Once the correction is completed, the rods are tightened to

the screws. The wound is closed with absorbable sutures.

Postoperative recovery includes pain control and early pa-

tient mobilization. Bracing is typically not required. Muscle

relaxants and narcotics are a critical part of the analgesic

regimen. Hospital discharge is often one to two days sooner

than with traditional open exposure. Intraoperative blood

loss is significantly less with the muscle-splitting technique.

Currently, there is little long-term data on fusion rates com-

pared to traditional open procedures; however, short-term

results seem comparable.

Overall, this new minimally invasive technique appears to

be a promising advance in the surgical treatment of AIS.

Reduced intraoperatve blood loss, a shorter hospital stay and

decreased postoperative pain make this an attractive option

for patients with progressive idiopathic scoliosis. Long-term

data is necessary to validate these early findings before its

widespread use.

About the AuthoR

Dr. goodwin specializes in pediatric orthopaedics, including scoliosis surgery, hip disorders, hip arthroscopy and orthopaedic trauma. he can be contacted at 216.444.4024 or [email protected].

Preoperative AP radiograph of a 13-year-old female with progressive idiopathic scoliosis.

PA scoliosis radiograph 6 months after MIS spine fusion. the correction has been maintained and the spine remains balanced.


Each year, hundreds of athletes undergo reconstructive sur-

gery of the medial ulnar collateral ligament (MUCL) to treat

functional valgus instability of the elbow. The vast majority

of these patients are involved in overhead throwing sports,

particularly baseball pitching. Since 1975, when Frank Jobe,

MD, performed the first such operation on Los Angeles

Dodgers left-handed pitcher Tommy John, the surgical

technique has evolved in an attempt to improve clinical

outcomes. Despite these refinements, clinical success, as

measured by return to play at the same or higher level for

at minimum of one full season, remains highly variable.

While some authors report success rates as high as 92 per-

cent, others have published results demonstrating that only

79 percent successfully return to high-level throwing.

In an effort to help better understand why the long-term

outcomes following MUCL reconstruction are so widely

varied, we undertook a study to look critically at the MUCL’s

anatomy. In particular, we were interested in the relation-

ship between the MUCL footprint and the ulnar sublime

tubercle. The sublime tubercle is a well-known small

prominence of bone just distal to the articular surface of

the semilunar notch. Current descriptions of the ulnar

attachment of the MUCL state that the ligament attaches

to the proximal ulna at the level of the sublime tubercle.

As such, contemporary surgical techniques use this

prominence as a landmark for reconstructive surgery. We

postulated that the MUCL has a broader attachment along

the proximal ulna.

Led by principal investigator Lutul Farrow, MD, we utilized

the Hamann-Todd Osteological Collection at the Cleveland

Museum of Natural History, selecting 100 skeletally mature

ulnae. There were 50 male and 50 female specimens, aged 20

to 30 years. Critical visual inspection of each specimen was

carried out. The sublime tubercle was identified in all speci-

mens. In addition, we consistently noted the presence of a pre-

viously undescribed ridge of bone extending from the tubercle

distally along the proximal medial ulna, which we have called

the medial ulnar collateral ridge. The length of this ridge

was measured from the most prominent point of the sublime

tubercle to its termination distally, utilizing digital calipers.

To further define the anatomy of the medial ulnar collateral

ridge, 10 additional nonpaired ulnae underwent computed

tomography (CT) with 3-D reconstructions. Using digital

measuring tools, the ridge was again measured. Finally, 10

cadaveric specimens were dissected to critically identify the

relationship of the MUCL to the medial ulnar collateral ridge.

The anterior band of the ligament was carefully identified and

measured along its entire length, extending from its proximal

attachment at the medial epicondyle to its attachment along

the ridge. After in-situ measurements were taken with digital

calipers, the ligament was completely dissected free from all

its bony attachments and measured again.

Anatomy of the MuCL as previously described.

The Anatomy of the Medial Ulnar Collateral Ligament of the Elbow By Mark Schickendantz, MD


Our results were fully supportive of our hypothesis. Rather

than having a proximal attachment limited to the sublime

tubercle, we found that the ligament indeed has a very broad

attachment along the ridge of bone that extends distally from

the tubercle, the ridge we have called the medial ulnar collat-

eral ligament ridge. In fact, the average length of the ulnar at-

tachment of the MUCL was found to be 29.2 mm. The average

overall length of the MUCL was found to be 53.9 mm. Based

upon these findings, it is apparent that currently employed

reconstruction techniques fail to accurately reproduce the

distal attachment of the MUCL onto the proximal ulna. Thus,

we are likely not restoring the normal biomechanics of the

medial side of the elbow.

Certainly, further work needs to be done in order to translate

these in vitro results into improved clinical outcomes. We are

presently studying reconstruction techniques that more ac-

curately reproduce the native anatomy of the MUCL. We hope

that our better understanding of the anatomy, combined with

the application of more anatomic surgical techniques, will

result in improved outcomes for athletes undergoing recon-

structive surgery of the medial ulnar collateral ligament.

About the AuthoR:

Dr. Schickendantz is the Director of Cleveland Clinic Sports health. he serves as head Team Physician for the Cleveland Indians professional baseball team and Cleveland Browns pro-fessional football team. he can be reached at [email protected].

SuGGeSteD ReADInG

Farrow LD, Mahoney AJ, Stefancin JJ, Taljanovic MS, Sheppard JE, Schickendantz MS. Quantitative Analysis of the Medial Ulnar Collateral Ligament Ulnar Footprint and Its Relationship to the Ulnar Sublime Tubercle. Am J Sports Med. 2011; Sep;39(9):1936-1941. Epub 2011 May 9.

“new” anatomy, based on our study’s data.


Metastatic Bone Disease: Early Referral Can Be Key to Improved Outcomes

By Nathan W. Mesko, MD, David Joyce, MD, Steven Lietman, MD, and Michael Joyce, MD

A SobeRInG ReALIty

The recognition and treatment of destructive bone lesions

in adults over 40 are becoming an increasingly important

part of the orthopaedic surgeon’s clinical practice. Of the

1.52 million new cancer diagnoses in 2010, up to 70 percent

will have metastatic bony involvement during their lifetime.

Metastatic bone disease is the most common cause of the

isolated destructive bony lesions, with less common causes

in the adult including multiple

myeloma, lymphoma, osteomyelitis

and, rarely, primary bone sarcoma.

With novel advances in chemother-

apy and targeted radiation therapy

leading to improved survivorship in

patients with metastatic carcinoma,

methods for repairing the bony le-

sions must provide a stable enough

construct to endure the demand

of patient activity for a timeline

scaled to years rather than months.

This rationale, balanced with a

greater availability of reconstructive

options in orthopaedic oncology,

should draw consideration for early

referral to a musculoskeletal oncol-

ogy center in an attempt to improve

both short- and long-term function-

ality and survivorship outcomes.

IMPoRtAnCe oF the CLInICAL

exAM AnD FIRSt PReSentAtIon

The initial office visit or inpatient

consultation with the orthopaedic

surgeon should find its foundation

in a detailed history and physical

exam. Historical items, such as progressive/persistent pain,

onset of pain (nocturnal/ambulatory/rest), neurologic com-

promise, personal history of malignancy, and environmental

exposures can provide significant clues toward uncovering

the etiology of the complaint or primary cancer. A heavy

smoking history combined with a productive cough should

elevate suspicion for primary lung malignancy.

Swelling, point tenderness, limited joint range of motion

and neurologic deficits should be central foci to the skeletal

exam. With any concern of spinal cord involvement, reflexes

and a rectal exam should be routinely performed. A careful

multi-organ system examination

eliciting findings such as thyroid

nodules, flank pain (renal cell car-

cinoma), breast lumps or prostate

asymmetry also can elevate suspi-

cion for metastatic disease.

Laboratory studies are the next

step in narrowing the differential,

providing insight as to the nature

of the bony metabolism or location

of primary malignancy. A routine

complete metabolic panel (CMP),

complete blood count (CBC),

phosphorus or serum/urine protein

electrophoresis (SPEP/UPEP) can

help identify the primary malig-

nancy for a metastatic bone lesion.

A urinary analysis with hematuria

may elevate concerns for renal

cell carcinoma, while an elevated

prostate-specific antigen (PSA) levels

in males should heighten suspicion

for prostate malignancy. Mark-

edly elevated alkaline phosphatase

(2-10x normal limits) may help

differentiate Paget’s disease from

blastic metastatic prostate disease.

Any suspicion about the presence

of infection should be verified using the CRP and ESR tests,

as osteomyelitis can mimic malignancy in both clinical and

radiographic appearance.

Figure 1: 61-year-old female with metastatic breast cancer to the femur previously treated with radiation

The following images show the progression of metastatic melanoma to the bone that was prophylactically fixed with an intramedullary device. the patient passed prior to hardware failure. the x-rays and evident progression illustrate the dilemma of having the instrumentation outlast the patient’s survival. In a period of less than three years, the patient went from having intact femoral cortices to missing the majority of the cortex in the femur in the area of the lesion.

Figure 2A-D: X-rays show the progression of bone destruction due to metastatic melanoma, emphasizing the need for prophylactic fixation to be strong enough to survive as long as the patient.


IMAGInG: ChARACteRIzInG the LeSIon

Plain film imaging should provide the foundation for imag-

ing analysis, with orthogonal view imaging of the entire bone

being available for study. Plain films should be scrutinized

for such lesional characteristics as blastic vs. lytic processes,

location within the bone, matrix formation, cortical involve-

ment and the presence of fracture. The most common areas

of bony metastases are the spine, ribs, pelvis and proximal

long bones.

CT scans of the lung, abdomen and pelvis aid with the iden-

tification of the primary malignancy in 85 percent of cases,

with site-specific CT scans useful for assessing the structural

integrity of involved bone. Further primary characteriza-

tion or metastatic involvement can be ascertained with bone

scans, PET scans and magnetic resonance imaging (MRI)

modalities. MRI further aids in diagnosis by revealing the

extent of bony marrow and soft tissue involvement or distin-

guishing metastatic lesions from those of infectious etiology.

Angiography plays a role in identifying hypervascular lesions,

such as kidney, thyroid or melanoma metastases. Preopera-

tive embolization can dramatically improve hemostasis dur-

ing definitive operative reconstruction.


bIoPSy IS InDICAteD In SPeCIAL SCenARIoS

Biopsy of a bone lesion can provide confirmation of a meta-

static lesion or diagnosis of an unknown primary malig-

nancy, as well as aid in the staging and treatment planning

of malignancies. Specimen interpretation by an experienced

pathologist is a vital part of the process for diagnosising the

isolated bony destructive lesion in the adult. In the hands of

an experienced pathologist, core needle biopsies can accu-

rately identify metastatic bony lesions 98 percent of the time.

In the setting of known primary disease and multiple bone

lesions, biopsy may not be necessary, but consultation with

an experienced orthopaedic oncologist still can prevent cata-

strophic complications related to treatment of primary bone

sarcoma under the false assumption of “metastatic bone

disease.” All biopsy principles should be followed, regardless

of how “sure” one is of metastatic etiology for a bony lesion.

If there is any concern about the role of biopsy or for ensuing

definitive management, a low threshold for referral to a fel-

lowship-trained orthopaedic oncologist should be exercised.

Common fixation techniques, such as intramedullary fixa-

tion, are not without risk. A surgeon should be prepared to

swiftly handle rare, yet life-threatening, complications such

as of intraoperative bleeding, canal pressurization sequalae

or tumor embolism phenomena.

tReAtMent oPtIonS DePenD on LoCAtIon

The typical principles of treatment for metastatic bony le-

sions advocate for closed reduction and intramedullary fixa-

tion in diaphyseal lesions, while a paradigm shift to cement-

ed prosthetic replacement has helped negate nonunion rates

in metaphyseal/epiphyseal lesions. Less commonly, open re-

duction techniques can be used to directly expose the lesion.

One exception to the above rule is with proximal humerus

metaphyseal lesions, where a history of poor prosthetic

replacement performance, combined with promising results

using proximal humeral locking fixation technology, renders

bony fixation a viable option. Heavily irradiated bone, though

less of a problem in metastatic lesions due to limited- dose ra-

Figure 4: Renal cell carcinoma metastasis treated with distal humeral resection and hinge elbow arthroplasty.

Figure 3: Renal cell carcinoma metastasis of the proximal humerus treated with an allograft prosthetic composite; the greater trochanter is allograft.

Metastatic Bone Disease: Continued


diation therapy (as compared to primary bone sarcoma), can

predispose one to a high nonunion rate and warrants careful

preoperative planning as to management options.

Impending fractures through metastatic bony lesions have

been categorized through multiple scoring systems in order

to predict the likelihood of pathologic fracture at various

locations. Some classification systems (e.g., Mirels) rely on

location, pain, blastic vs. lytic characteristics, and size to

predict fracture likelihood. More recently, van der Linden et.

al. described measurements concerning length of axial corti-

cal involvement and circumferential cortical involvement to

predict femoral fracture risk, with 23 percent of patients with

femoral cortical involvement > 30 mm in length going on to

eventual fracture.

Regardless of the classification predictor model used, preven-

tion of fracture and prophylactic fixation in patients with

destructive bony metastatic lesions helps to improve patient

comfort and functionality, decrease patient morbidity and

minimize risks specific to pathologic fractures, such as

urgency in stabilization timing, elevated technique difficulty

and nonunion. Prophylactic internal fixation versus pros-

thetic replacement is a decision that is not to be taken lightly,

and can be best determined in the hands of an experienced

musculoskeletal orthopaedic oncologist.

eARLy ReFeRRAL to A MuSCuLoSKeLetAL

onCoLoGy CenteR IS Key

With the advent of increasing reconstructive options and eas-

ier access to a multidisciplinary team approach, referral to an

orthopaedic musculoskeletal oncology center should occur

with the vast majority of all bony lesions, including those for

which there is a high suspicion of metastatic etiology. These

centers provide additional access to a musculoskeletal team

consisting of fellowship-trained pathologists, radiologists,

hematologists/oncologists, radiation oncologists, interven-

tional radiologists, spine surgeons and various surgical sub-

specialty practices. Together these experts can provide swift

diagnosis, accurate interpretation and effective stabilization,

leading to improved outcomes.

About the AuthoRS:

Nathan W. Mesko is a PgY-4 orthopaedic resident at Cleveland Clinic, and Dr. David Joyce is a PgY-5 orthopaedic resident at Cleveland Clinic.

Dr. Lietman, Director of the Musculoskeletal Tumor Center, specializes in orthopaedic oncology and adult reconstruction. he can be reached at 216.445.2742 or [email protected].

Dr. Michael Joyce specializes in trauma, oncology, total joint replacement and musculoskeletal tissue banking. he may be reached at 216.444.4282 or [email protected].

SuGGeSteD ReADInG

Mirels h. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. December 1989;(249):256-264.

van der Linden YM, Kroon hM, Dijkstra SP, Lok JJ, Noordijk EM, Leer JW, Marijnen CA; Dutch Bone Metastasis Study group. Simple radiographic parameter predicts fracturing in metastatic femoral bone lesions: results from a randomised trial. Radiother Oncol. October

2003; 69(1):21-31.


Dedicated Orthopaedic Operating Room Unit (Closed Unit) Improves Operating Room EfficiencyBy Wael K. Barsoum, MD, Bishoy V. Gad, MD, Alison K. Klika, Jim Leonard and Loran Monir-Soliman

A Continuous Improvement initiative was undertaken by Sur-

gical Operations and Orthopaedic Surgery in 2009, with the

ultimate goal of increasing operating room (OR) efficiency

and throughput without increasing total OR time by utilizing

a closed-unit approach. A closed unit offers several theoreti-

cal advantages, including improved consistency in the level

of care offered to patients, a specialized surgical staff with

an orthopaedic focus, and greater employee satisfaction and

retention.

Six ORs with nurses, anesthesiologists and staff devoted spe-

cifically to those ORs were identified as the closed orthopae-

dic unit. Beginning on April 1, 2009, the group of total joints

orthopaedic ORs at Cleveland Clinic began to function as

an isolated unit from other services. Data were collected for

control (i.e., open-unit) from cases performed between Nov. 1,

2008 and Feb. 28, 2009 (control n = 343), and from closed-unit

cases from surgeries performed between Nov. 1, 2009 and

Feb. 28, 2010 (closed unit n = 393).

Metrics used to compare the two groups included anesthesia

controlled time (ACT), operative time and turnover time, as

defined in Figure 1. A retrospective review was conducted

to test whether a closed orthopaedic unit could improve ef-

ficiency by decreasing these metrics for total knee and total

hip arthroplasties. Entry to the OR (i.e., wheels in), time of

incision, exit from OR (i.e., wheels out) were extracted from

the Navicare® database (Hill-Rom, Batesville, Ind.) for each

case in each OR. Group comparisons using the student’s t-

test evaluated performance over time.

Average time between OR entry to incision time (49.0 min

control vs. 43.3 min closed; p < 0.001), total average operative

time (154.2 min control vs. 139.8 min closed; p < 0.0001) and

specific operative time for total knee (159.4 min control vs.

149.4 min closed; p < 0.02) and total hip (146.1 min control vs.

123.1 min closed; p < 0.00001) showed significant improve-

ment in the closed-unit cases. Turnover time was an average

3.3 minutes longer for control cases, although this was not

statistically significant (p = 0.27).

This study demonstrated that a dedicated OR team can in-

crease OR efficiency by significantly improving operative and

nonoperative times, which resulted in an average savings of

24 minutes per case. The enhanced familiarity and expertise

with orthopaedic procedures gained by anesthesiologists,

nurses and support staff may account for the improved

operative times observed in our study. These time savings

allow for cases to be added without additional fixed cost by

not extending the end of the OR day. Extrapolations from

these data may show higher revenue figures are achievable

by increasing throughput and efficiency while maintaining

semi-fixed OR costs.

About the AuthoRS

Dr. Barsoum is Chairman of Surgical Operations and Vice Chairman in the Orthopaedic Surgery Department. he can be reached at 216.445.8326 or [email protected]. Dr. gad is an orthopaedic surgery resident in the department. Ms. Klika is a research coordinator for the department. Mr. Leonard is the former administrator for Surgical Operations, and Mr. Monir-Soliman is a staff anesthesiologist.

Healthcare expenditures exceeded $2.8 trillion nationally in 2008, 30 percent of which are estimated to be due to healthcare system inefficiencies. The success of healthcare relies on our ability to meet increases in volume resulting from expanded coverage while providing the highest quality care to our patients.


SuGGeSteD ReADInG

1. www.kaiseredu.org/Issue-Modules/US-health-Care-Costs/Back-ground-Brief.aspx; 2011.

2. Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker gR, Doran D, grober E, Orser B, Bohnen J, Reznick R. getting teams to talk: development and pilot implementation of a checklist to promote in-terprofessional communication in the OR. Qual Saf Health Care October 2005;14(5):340-346.

3. Krupka DC, Sandberg WS. Operating room design and its impact on operating room economics. Current Opinion in Anaesthesiology 2006;19:85-191.

4. Stepaniak PS, heij C, Mannaerts gh, de Quelerij M, de Vries g. Modeling procedure and surgical times for current procedural terminol-ogy-anesthesia-surgeon combinations and evaluation in terms of case-duration prediction and operating room efficiency: A multicenter study. Anesth Analg 2009;109:1232-1245.

5. harders M, Malangoni MA, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery 2006;140:509-516.

6. Smith M, Sandbert WS, Foss J, Massoli K, Kanda M, Barsoum W, Schubert A. high-throughput operating room system for joint arthro-plasties durably outperforms routine processes. Anesthesiology, July 2008;109(1):25-35.

Figure 1. Timeline definition of key metrics used.

AnesthesiA

ContRolleD tiMe

(ACt)

oPeRAtive tiMe tuRnoveR tiMe

PAtient 1 in

RooM

(wheels in)

PRoCeDuRe

stARt tiMe

PAtient out

of RooM

(wheels out)

PAtient 2

in RooM

(wheels in)


The bony architecture of the hip depends upon functional

adaptation to mechanical usage via dynamic interactions

between the acetabulum and femoral head. Variation in the

orientation of the acetabulum,1 proximal femur2 or a com-

bination of both3 are believed to directly damage the hip.

Acetabular retroversion is thought to contribute to pincer-

type femoroacetabular impingement (FAI).4 Acetabular

retroversion occurs when the acetabular opening is situated

in a more posterolateral direction in the sagittal plane when

compared with the normal anatomic anterolateral opening.

Despite evidence demonstrating a lack of reliability,5 the

diagnosis of pincer-type FAI is currently based upon plain

film or computer tomography (CT) radiographic evidence of

acetabular retroversion. For some orthopaedic surgeons, evi-

dence of acetabular retroversion (i.e., crossover sign, ischial

spine sign, posterior wall sign) on plain film radiographs

warrants prophylactic debridement or reorientation of the ac-

etabulum by periacetabular osteotomy. The rationale behind

this treatment is the belief that it will prevent progression to

osteoarthritis. No prospective data exist to suggest pincer-

type FAI is a cause of osteoarthritis, and studies in pathologic

hip joints suggest proximal femoral anatomy compensates

for acetabular retroversion.

To address this issue, members of the Cleveland Clinic Or-

thopaedic Surgery and Biomedical Engineering departments

utilized a three-dimensional CT-based simulator developed

in-house, which allows a patient’s unique osseous anatomy to

be rotated and viewed from any angle and analyzed as a free

body, independent of patient orientation within the gantry.

The purpose of this study was to determine if a predictable

relationship exists between proximal femoral and acetabular

angles, age and gender in normal hip joints. We hypothesized

that, through functional adaptation to mechanical loading,

a complementary developmental relationship exists between

the acetabulum and proximal femur.

Computed tomography scans fully depicting the pelvis and

lower extremities of 143 de-identified subjects were ob-

tained from a previously established database of vascular

CT angiography scans investigating either peripheral artery

disease or lower extremity aneurysm between November

2007 and March 2010. Twenty-eight scans were excluded due

to radiographic evidence of osteoarthritis, defined as nar-

rowing of the joint space, subchondral sclerosis, bony cysts,

marginal osteophytes, bony erosions or loose bodies. A chart

review was performed to ensure the remaining 115 subjects

did not have hip symptoms (i.e., difficulty walking, joint pain,

joint redness, joint stiffness, joint swelling) during any prior

orthopaedic or rheumatologic visits, or during a primary

care visit in which a musculoskeletal review of systems and a

physical examination were performed. Images were recon-

structed at 1 mm increments and loaded into our proprietary

Relationship Between Proximal Femoral and Acetabular Alignment in Normal Hips: A Three-Dimensional Analysis

By Leonard T. Buller, BA, James Rosneck, MD, and Wael K. Barsoum, MD

Figure 1: Best-fit sphere around the femoral head shown as (A) coronal plane, (B) sagittal plane, (C) transverse plane, (D) 3-D sphere. Center of femoral head (black marker), center of femoral neck (white marker), femoral neck axis (white line).


Figure 2: Femoral version. (A) Level of distal femur: medial and lateral epicondyles (white) define the posterior condylar axis in the transverse/axial plane, (B) Level of femoral neck: version defined by angle (Ɵ) between posterior condylar axis and femoral neck axis in transverse/axial plane.

Figure 3: 3-D reconstruction showing location of proximal and distal shaft markers (black markers) and neck shaft angle (Ɵ).

Table 1. Reduced model correlations between angle measurements. Coefficient, standard error and p-value reported for statistically significant independent variables (p < 0.05). Nonstatistically significant independent variables (p > 0.05) reported as NS for angle measurements and not included if gender or age.

Dependent Variable Independent Variable Coefficient Standard error p-value

Femoral version Acetabular version 0.38 0.1161 0.0014 Femoral version Acetabular inclination -0.49 0.16 0.0026 Femoral version Acetabular center edge angle nS Femoral neck shaft angle Acetabular version 0.21 0.085 0.0134 Age -0.17 0.0469 0.0005 Femoral neck shaft angle Acetabular center edge angle nS Age -0.176 0.047 0.0003 Femoral neck shaft angle Acetabular inclination nS Age -0.176 0.047 0.0003 Femoral neck shaft angle Femoral version nS Age -0.176 0.047 0.0003 Acetabular version Acetabular center edge angle 0.229 0.08 0.0047 Acetabular version Acetabular inclination -0.32 0.123 0.012 Female 2.6 1.09 0.018 Acetabular center edge angle Acetabular inclination -0.64 0.132 <0.0001 Female 2.79 1.16 0.018

OrthOpaedic insights14 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096

Figure 4: 3-D pelvis reconstruction demonstrating acetabular rim planes used to calculate acetabular

version and inclination.

software package. Three-dimensional volumetric images

were generated, and the femoral neck version (Figures 1,2);

femoral neck shaft angle (Figure 3); acetabular version, ac-

etabular inclination and acetabular center edge angle (Figure

4) were measured in 230 normal hip joints from 115 adults.

Correlations between the angles, age and gender were exam-

ined using stepwise regression with backward elimination.

Positive correlations were found between femoral version and

acetabular version (p = 0.0014), femoral neck shaft angle and

acetabular version (p = 0.0134), acetabular version and gender

(p=0.018), and center edge angle and gender (p = 0.018) (Table

1). Negative correlations were observed between femoral

neck shaft angle and age (p = 0.0003), and femoral version

and acetabular inclination (p = 0.0026), although this latter

relationship was observed only unilaterally (i.e., left hip)

(Table 1).

The correlation between multiple proximal femoral and

acetabular angles demonstrated in this study supports the

hypothesis that a complementary developmental relation-

ship occurs between the femoral head and acetabulum. The

results of this study suggest that, in some patients, what is

thought to result in pincer-type FAI acetabular retroversion

may actually be normal anatomy with compensated femoral

version. Future investigation into the relationship between

these angles in patients with the signs and symptoms of

pincer-type FAI may alter a surgeon’s approach to treating

this patient population.

About the AuthoRS:

Dr. Barsoum, Chair of the Cleveland Clinic Department of Surgi-cal Operations and Vice Chair of the Department of Orthopaedic Surgery, specializes in reconstructive surgery of the hip and knee joints, including arthroscopy, minimally invasive surgery of the hip and knee, and primary and revision joint replacements. Physicians may reach him at 216.444.7515 or [email protected].

Dr. Rosneck is associate staff in the Department of Orthopaedic Surgery, specializing in sports medicine conditions, including acute sports injuries and hip and knee arthroscopy. Physicians may reach him at 216.518.3444 or [email protected].

Mr. Buller is a medical student at the Cleveland Clinic Lerner College of Medicine.

SuGGeSteD ReADInG

1. Reynolds D, Lucas J, Klaue K. 1999. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br 1999;81:281-288.

2. Eijer h, Myers SR, ganz R. Anterior femoroacetabular impingement after femoral neck fractures. J Orthop Trauma 2001;15:475-481.

3. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018.

4. Kim WY, hutchinson CE, Andrew Jg, Allen PD. The relationship between acetabular retroversion and osteoarthritis of the hip. J Bone Joint Surg 2006;88:727-729.

5. Palmer WE. Femoroacetabular impingement: caution is warranted in making imaging-based assumptions and diagnoses. Radiology

2010;257:4-7.

OrthOpaedic insights 2011 15Visit clevelandclinic.org/ortho

A 16-year-old male patient presented with anterior left knee

pain of approximately one-year duration. The pain was not

related to activities and appeared to be worse at night.

Initial radiographs were negative. After persistent pain, an

MRI of the knee was obtained for further evaluation. A small

lesion was seen in the proximal tibia with marked surround-

ing bone marrow edema, suggestive of an osteoid osteoma.

A CT examination showed a calcified nidus (Figure 1). A

CT-guided biopsy was followed by radiofrequency ablation

(Figure 2) for six minutes at 95 degrees Celsius under general

anesthesia. The patient experienced complete pain relief

after the procedure with no further problems.

Osteoid osteoma is a benign tumor usually seen in children

and young adults. Patients with osteoid osteoma typically

present with pain that is worse at night and relieved by non-

steroidal anti-inflammatory drugs such as aspirin. Diagnosis

is usually established with a combination of clinical evalua-

tion and radiological findings.

Complete surgical resection has historically been the treat-

ment of choice for osteoid osteoma. Since its introduction in

1989, radiofrequency ablation has been the standard treat-

ment for osteoid osteoma, with success rates of 89 to 95 per-

cent. The procedure is performed under general anesthesia

for pain control, and patients are usually discharged home

on the same day.

About the AuthoR

Dr. Ilaslan is a staff radiologist in the Musculoskeletal Radiology Section at Cleveland Clinic. his specialty interests include bone tumors, MRI and radiofrequency ablation of osteoid osteomas.

Image of the Issue:Radiofrequency Ablation for Treatment of Osteoid Osteomas

By Hakan Ilaslan, MD

Figure 1: Coronal t2-weighted image of the left knee showing a small nidus with surrounding bone marrow edema.

Figure 2: Axial Ct image of proximal tibia showing radiofrequency ablation probe in the nidus.

OrthOpaedic insights16 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096

Wound breakdown after surgical treatment of calcaneus

fractures remains an extremely common problem. Wound

complication rates range from 13 to 33 percent, with dehis-

cence in up to 30 percent and serious infection in up to 20

percent of cases.1 At Cleveland Clinic, we have adopted the

use of incisional negative pressure wound therapy (NPWT) in

an attempt to decrease wound complications after calcaneus

fracture surgery.

Several factors contribute to the high rate of wound break-

down after calcaneus fracture. Foremost among these is the

fact that calcaneus fractures are invariably accompanied

by severe soft-tissue injury. Swelling is often dramatic, and

fracture blisters are common. Additionally, the surgical treat-

ment usually involves an extended L-shaped flap over the

lateral part of the heel. The apex of this flap is susceptible to

skin-edge necrosis and is often where wound complications

begin. Smoking can further compromise the viability of the

flap, and in most large series of calcaneus fractures, a third

of the patients were smokers.

Several strategies exist for decreasing wound complications

after surgical treatment of calcaneal fractures. Patients with

uncontrolled diabetes, peripheral vascular disease, cardio-

pulmonary disease or immunosuppression are at high risk

for wound complications and are likely best treated non-sur-

gically. But nonsurgical treatment creates as many problems

as it prevents because the patient is left with a misshapen,

malaligned heel and a malreduced subtalar joint. In fact, a

Canadian study comparing nonsurgical to surgical treatment

found a similar rate of major complications in each group.2

The key, then, is preventing wound complications in those

patients who do undergo surgery. Meticulous surgical tech-

nique is the foundation of this preventative strategy. The inci-

sion is placed to respect the angiosomes of the lateral heel.3 A

“no-touch” technique is employed to eliminate retraction on

the skin edges. Closure is achieved using the least strangulat-

ing suture pattern as described by Allgower-Donati.4

Preventing Wound Complications After Surgical Treatment of Calcaneus Fractures Using a Negative Pressure DressingBy Mark Berkowitz, MD

OrthOpaedic insights 2011 17Visit clevelandclinic.org/ortho

Negative pressure wound therapy applied to a closed inci-

sion is a relatively new technique. It was first described by

Stannard et al.,5 who observed a significant decrease in

drainage in a large series of severe lower extremity fractures.

The technique is extremely well-suited to calcaneus fracture

wounds. The incisional negative pressure dressing increases

blood flow and oxygenation of the flap edges, decreases local

edema, removes local inflammatory mediators, and tampon-

ades the flap to eliminate dead space and prevent hematoma.

The technique is simple: The skin is prepared with adhesive.

Plastic strips are applied along the periphery of the incision

to protect the skin from maceration (Figure 1). The sponge is

cut to cover the incision and placed over a layer of petroleum

gauze (Figures 3,4). The sponge is then covered with adhe-

sive plastic to create a seal and the machine set at 75 mm Hg

(Figure 4). The dressing is left in place for 72 hours, at which

point the incision is usually dry and completely sealed (Fig-

ure 5). A standard dressing is then applied, and early range-of

-motion exercises can be instituted.

Wound breakdown will never be completely eliminated from

the surgical treatment of calcaneus fractures, but incisional

negative pressure wound therapy holds promise to signifi-

cantly reduce this troublesome complication.

About the AuthoR

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

SuGGeSteD ReADInG

Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18(1):1-6.

Borrelli J Jr., Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma 1999;13(2):73-77.

Sagi hC, Papp S, DiPasquale T. The effect of suture patten and tension on cutaneous blood flow as assessed by laser flowmetry in a pig model. J Orthop Trauma 2008;22(3):171-175.

Stannard JP, Robinson JT, Ratliffe ER, Mcgwin g, Volgas DA, Alonso JE. Negative-pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. Injury 2006;60(6):1301-1306.

howard JL, Buckey R, McCormac R, Pate g, Leighton R, Petrie D, gal-pin R. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop

Trauma 2003;17(4):241-249.


IntRoDuCtIon

Cleveland Clinic now offers ultrasound guidance for condi-

tions involving the musculoskeletal system. Ultrasound is

used at the patient’s bedside to accurately and quickly identify

pathology and to precisely guide needles directly to the de-

sired target.

Ultrasound imaging is a rapidly growing field with applica-

tions in many specialties. Advantages of ultrasound include

immediate accessibility at the patient’s bedside, identification

of soft-tissue pathology, dynamic joint assessment, avoidance

of radiation exposure, low cost, improved accuracy of injec-

tion, improved patient comfort during procedures, and better

outcomes after injection.

CASe exAMPLe

A 46-year-old personal fitness trainer with a remote history

of rotator cuff repair was seen for chronic shoulder pain. He

complained of new severe anterior shoulder pain that had

been present for about two years. He had physical therapy

and an injection of the subacromial space by a different physi-

cian 18 months prior, with temporary relief. A subsequent

injection into the shoulder glenohumeral joint provided no re-

lief, so he sought another opinion. He had tenderness on the

anterior aspect of the shoulder, pain with forward flexion, and

mild impingement. In Cleveland Clinic’s Arthritis Center,

a biceps tendon sheath injection was performed with ultra-

sound guidance. However, as part of the routine pre-injection

sonographic assessment, it was noted that the patient had a

longitudinal split tear of the long head of the biceps tendon

(Figures 1, 2), and the possibility of a small tear in the supra-

spinatus tendon was also noted. Within four days the patient

was seen by an orthopedic surgeon, and the findings were

confirmed by MRI scan. Arthroscopic surgery was scheduled

eight days later. The patient underwent a biceps tenodesis

and a rotator cuff repair with excellent relief. After eight

weeks he had no pain in the shoulder and started physical

therapy. By 16 weeks, he had returned to weight lifting, still

without shoulder pain.

In this case, the application of ultrasound imaging (at the

patient’s first visit to the Arthritis Center) resulted in an

expedited diagnosis and probably spared the patient another

prolonged course of therapy.

Figure 1: Ultrasound image showing transverse (axial) view of biceps tendon (long head) with longitudinal tear.

Musculoskeletal UltrasoundBy Michael P. Schaefer, MD


uLtRASounD SCAnnInG AnD InJeCtIon teChnIQue

During a typical musculoskeletal ultrasound session, images

are obtained with a laptop sized unit directly at the patient’s

bedside. A small transducer is passed over the affected areas

in multiple positions and angles, and the patient’s body part

is placed in standardized positions to obtain optimal images.

Assessment is made for joint effusion, synovitis, or connec-

tive tissue disruption. For dynamic imaging, the patient is

asked to reproduce his or her symptoms during real-time

image collection. In cases with mechanical symptoms, the

physician is able to see specifically which structure may be

catching or subluxing within the joint. Bony surfaces are

often visible with ultrasound, but sound waves are unable to

penetrate through bone. Therefore X-ray or CT scan is often

used to complement the ultrasound images.

Figure 2: transducer placement for visualization and injection of biceps tendon.

During the injection technique, the procedure site is prepped

and draped, and a sterile barrier is placed over the ultra-

sound transducer. During an injection an optimal image

is obtained, including a sonographic ”window” that allows

visualization of the needle as it is advanced toward the target

tissue. In cases where aspiration is necessary, the amount

and location of abnormal fluid is identified.

Subsequently, the “color Doppler” mode of the device is

activated, showing vascular structures (Figure 3A). If needed,

the injection approach can be changed to avoid accidental

damage of vessels and nerves. Finally, under real-time guid-

ance, the tip of the needle is inserted and is seen advancing

through the overlying tissues (Figure 3B). When the target

is reached, aspiration of fluid and injection of medication

is visualized, again under real-time conditions. Thus, the

physician is able to determine if the medication has been ac-

curately delivered.

When images are obtained at the patient’s bedside, they are

stored electronically in Cleveland Clinic’s electronic medical

record and are accessible by any provider within Cleveland

Clinic’s network, even outside of Greater Cleveland.

IMPRoVeD outCoMeS

Multiple research studies have shown improved accuracy

with the addition of ultrasound guidance. [Cunnington 2010,

Peck 2010, Raza 2003, Rutten 2009, Sabeti-Aschraf 2011, Sib-

bit 2009] In two recent research articles, patient’s reported

less pain during shoulder injection procedures compared

to the same procedures done without guidance. [Rutten

2009, Sibbit 2009] When compared to fluoroscopy, one study

reported significantly less procedural time required for injec-

tion of the glenohumeral joint. [Rutten 2009]. Most im-

portant, there is evidence of improved pain relief following

accurately placed injections. [Chen 2006, Cunnington 2010,

Eustace JA 1997, Sibbit 2009, Ucuncu 2009]


CuRRent CLInICAL APPLICAtIonS

Ultrasound guidance is most commonly used during deeper

joint injections such as those for shoulder or hip joints, but

it is also very effective for injections into smaller joints such

as the acromio-clavicular [Peck 2010], carpal-metacarpal

joints [Raza 2003] and tendon sheaths in the hand [Lee 2011].

Superficial injections may be attempted without ultrasound

guidance, but in our current practice, patients are often

directed to follow up for ultrasound-guided procedures if

the initial attempt was not successful. Patients with abnor-

mal anatomy or severe obesity are often sent directly for

ultrasound guidance. For cases with chronic tendinopathy,

ultrasound is used for accurate placement of platelet-rich

plasma injections, autologous blood injections, or needle

tenotomies that are guided to the areas showing the most

tendon degeneration.

FutuRe oF MuSCuLoSKeLetAL uLtRASounD

Musculoskeletal ultrasound is expected to become even more

popular, both in frequency of use and scope of practice. Cur-

rently, the greatest limitation is provider skill level, particu-

larly in diagnostic assessments. There is a lack of structured

training programs and an absence of official certification

criteria. Also, ultrasound can be time consuming for the

provider, and documentation of multiple images requires

investment in personnel and electronic equipment.

Further research is needed to determine appropriate use of

ultrasound both in bedside diagnosis and in treatment algo-

rithms. Quality standards for technicians and practitioners

are currently in development.

In the future, ultrasound may be used intraoperatively to

guide minimally invasive surgical techniques, or preopera-

tively to place surgical markers to guide surgical techniques.

As advanced biological therapies are further developed for

musculoskeletal conditions, ultrasound will probably play a

role in ensuring their accurate delivery to target locations.

About the AuthoR:

Dr. Schaefer is the Director of Musculoskeletal Rehabilitation in the Orthopedic & Rheumatologic Institute, and also has an ap-pointment in the Department of Physical Medicine and Rehabili-tation (PM&R). He is board-certified in PM&R, sports medicine and pain medicine. he has specialty interests in sports, muscu-loskeletal medicine, and osteoarthritis. he performs injections with both ultrasound and fluoroscopic guidance.

Figure 3b: baker’s cyst aspiration showing needle tip inside cyst and needle shaft passing above the location of the vascular structures. note the marked reduction in the size of the cyst.

Figure 3A: ultrasound image of a baker’s cyst before aspiration, showing vascular structures using color Doppler imaging (red areas).


SuGGeSteD ReADInG

Balint PV, Kane D, hunter J, McInnes IB, Field M, Sturrock RD. Ultra-sound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. J Rheumatol 2002; 29:2209-2213.

Chen MJL, Lew hL, hsu TC, Tsai WC, Lin WC, Tang SFT, Lee YC, hsu, RCh, Chen CPC. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehab 2006;85(1):31-35.

Cunnington J et al. A randomized, double-blind, controlled study of ultrasound guided corticosteroid injections into the joint of patients with inflammatory arthritis. Arthritis and Rheum 2010;62(7):1862-1869.

Eustace JA, Brophy D, gibney RP, Bresnihan B, Fitzgerald O. Com-parison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997;56:59-63.

Lee Dh et al. Sonographically guided tendon sheath injections are more accurate than blind injections. J Ultrasound Med 2011;30(2):197-203.

Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31(2):308-314.

Peck E, Lai JK, Pawlina W, Smith J. Accuracy of ultrasound-guided versus palpation-guided acromioclavicular joint injections: a cadaveric study. PM&R 2010;2(9):817-821.

Raza K, Lee CY, Pilling D, et al. Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology 2003;42(8):976-979.

Rutten MJ, Collins JM, Maresch BJ et al. glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol 2009;19:722-730.

Rutten MJ, Maresh BJ, Jager JG, Malefijt MC Injections of the Sub-acromial Bursa: Blind or Ultrasound guided? Acta Orthopaedica 2007; 78(2) 254-57.

Sabeti-Aschraf M, Lemmerhofer B, Lang S, et al. Ultrasound guid-ance imporves the accuracy of the acromioclavicular joint Infiltration: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 2011;19(2):292-295.

Sibbit WL, Peisajovich A, Michael AA, Park KS, Sibbitt RR. Does so-nographic needle guidance affect the clinical outcome of intra-articular injections? J Rheumatology 2009;36:1892-1902.

Ucnucu F, Capkin E, Kancucak M, Ozden g, Cakirbay h, Tosun M, guler M. A comparison of the effectiveness of landmark-guided injec-tions and ultrasonography guided Injections for shoulder pain. Clin J Pain 2009;25(9):786-789.

Learn from Cleveland Clinic Top Executives

The competencies needed to lead and manage differ from

those needed to be an effective administrator, clinician or

scientist. Take advantage of this opportunity to acquire skills

and insights into the business of healthcare excellence from

top executives at Cleveland Clinic.

Two-day and two-week programs are open to healthcare

executives including physicians, nurses and administrators.

Visit www.clevelandclinic.org/ExecutiveEducation for details,

including the opportunity to earn 72.5 CME credits.

Orthopaedic Outcomes Data Available

The latest data from our Department of Orthopaedics are

now available in the Cleveland Clinic Orthopaedic & Rheu-

matologic Institute’s 2010 Outcomes book. This book also

offers summary reviews of medical trends and approaches.

Charts, graphs and data illustrate the scope and volume of

treatments provided for patients in our department each

year, and information is offered about our many research

projects. To view this and other Cleveland Clinic Outcomes

books, please visit clevelandclinic.org/quality.

22 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096ORThOPAEDIC INSIghTS

According to the old real estate ad-

age, a property’s value is determined

by three things: location, location,

location. But for the individuals who

make up the estimated 1 percent of

our nation’s population who face

a life-threatening or life-altering

medical diagnosis each year, physi-

cal location should not be a barrier

to obtaining what could be truly a

life-changing second opinion.

Since 2001, Cleveland Clinic’s MyConsult® online medical

second opinion program has been fundamentally changing

the healthcare landscape for patients the world over by pro-

viding access to the expertise of Cleveland Clinic specialists

through a secure, web-based environment.

From the very beginning, our mission has been to offer

patients, regardless of their physical location, a Web-based

medical second opinion service that is both secure and

simple to use. While our online approach may be high-tech,

the heart of the service is high-touch, with our nurses and

technology specialists available to answer questions on the

phone or via email.

There are more than 1,200 diagnoses for which patients may

request an online medical second opinion via MyConsult.

The site includes an online tutorial and frequently asked

questions specific to the MyConsult process. It also offers

a view of a sample consultation and provides firsthand ac-

counts from patients who have used the service.

Requesting a MyConsult online medical second opinion is

easy: First, a patient creates a unique user name and pass-

word. Then, the patient selects his or her current diagnosis

and fills out the online medical questionnaire that was cre-

ated by Cleveland Clinic physicians who specialize in that

particular condition. After the patient sends in the required

supporting documentation, such as clinical notes from physi-

cians, imaging studies such as X-ray films and laboratory

test results received from the physician providing the first

opinion, everything is organized, assembled and delivered to

the appropriate Cleveland Clinic specialist for review.

The patient views the completed second opinion in his or her

secure account on the MyConsult website, and a day or two

later receives a follow-up email from a Cleveland Clinic nurse

clinician, confirming receipt of the report and inquiring if

the patient has any questions about the MyConsult report.

From there, the patient can discuss the results of his online

consultation with his hometown physician and confidently

proceed with the original course of treatment, modify the

therapy by including an alternative treatment suggested in

the MyConsult online second opinion, or even arrange to visit

Cleveland Clinic for on-site care.

To date, Cleveland Clinic’s MyConsult online medical second

opinion program has connected patients from virtually

every state in the nation and over 80 countries to the medical

expertise of Cleveland Clinic’s internationally recognized

physician specialists.

Cleveland Clinic is truly a global healthcare resource. MyCon-

sult represents yet another trusted Cleveland Clinic innova-

tion that is improving the lives of people everywhere.

For more information about MyConsult secure online ser-

vices, please visit clevelandclinic.org/myconsult.

About the AuthoR

Jonathan Schaffer, MD, MBA, is Managing Director of eCleve-land Clinic in the Information Technology Division of Cleveland Clinic and is a joint and reconstructive orthopaedic surgeon in the Department of Orthopaedic Surgery.

Cleveland Clinic’s MyConsult Online Medical Second Opinion Program: Eliminating the Geographic Barriers to Quality Care

By Jonathan Schaffer, MD, MBA


Orthopaedic Residency Update 2011By Thomas E. Kuivila, MD

Last year, I opened my Orthopaedic Resi-dency Update article by loosely paraphras-ing the 19th-century English novelist Jane Austen. Surprisingly, I was taken to task on this by more than one of my orthopaedic brethren, most notably Paul Jacobson, MD (CCF ORS class of I-can’t-quite-remember- when) who sent an email that said simply,

“Jane Austen? – Seriously?” I suppose that I really should have written back explaining my aim in merely trying to elevate the sta-tus of the orthopaedic surgeon in the eyes of the reader. But then again, most of the readers of this publication are themselves orthopaedic surgeons, and we already have a fairly high opinion of ourselves…

In any event, to draw once again on the more literate for words to help describe our emotions on the parting residents, I can only say “parting is [indeed] such sweet sorrow” – but not so sorrowful that we would want them to continue living in the basement playing video games until they’re 40, but I digress. With that said, we will indeed miss our graduating chief residents, who have left the nest and set off to make a mark on the orthopaedic world.

thIS yeAR’S GRouP oF

GenuIneLy outStAnDInG

GRADuAtInG ChIeFS:

Damien billow, MD, who will commence fellowship training in orthopaedic trauma-tology at Vanderbilt University in Nashville, Tenn. It is unclear whether a connection exists between multi-trauma and country music.

John bottros, MD, begins an adult reconstructive surgery fellowship at Rush Presbyterian Medical Center in Chicago, fol-lowing in the steps of several recent gradu-ates who have pursued similar training there, including new-on-staff Trevor Murray, MD, and local orthopaedic surgeon Jessie Templeton, MD.

Wes Cheng, MD, is at the University of Wisconsin, Madison, where he is a fellow in orthopaedic sports medicine. We await a photo of Dr. Cheng with his block-of-cheese-hat on.

Carlos higuera, MD, is a fellow in adult reconstructive surgery at the Rothman In-stitute in Philadelphia. Dr. higuera is slated to return to Cleveland Clinic’s orthopaedic staff in August 2012.

John Ryan, MD, is at the Ohio State University School of Medicine in Columbus as a sports medicine fellow. We are not yet quite certain whether the plaque he re-ceived for finishing his orthopaedic surgery residency and the meal we purchased for him at the graduation dinner will be inter-preted as breaking any NCAA rules.

Finally, Jamie Walsh, Do, has traded his Cleveland Clinic civilian attire for Air Force blue. Dr. Walsh is serving in the United States Air Force as an orthopaedic surgeon at Langley AFB, Va. he apparently now has a bumper sticker on his minivan that reads

“my other car is an F-15.” Right.

As always, we wish our graduates im-measurable success and happiness in their future life endeavors.

I am happy to report that 2010 was yet an-other highly successful orthopaedic surgery resident recruitment year. As in years past, we received more than 600 applications for the six physician openings in the residency program. Of these fairly solid citizens, we interviewed 48 outstanding candidates and subsequently matched six future orthopae-dic all-stars into our program.

thIS yeAR’S enteRInG

CLASS oF InteRnS:

Joseph Styron, MD, PhD, obtained his un-dergraduate, graduate and medical school education (as well as degrees) from Case Western Reserve University.

timothy Joyce, MD, is a graduate of John Carroll University and University of Louisville School of Medicine. he joins his brother, David, in the residency stable.

Robert Cagle, MD, received his undergrad-uate education at Purdue University and his medical degree from Indiana University School of Medicine.

Salvatore Frangiamore, MD, also was edu-cated in the undergraduate realm at John Carroll University and is a graduate of the University of Toledo College of Medicine.

Seth Richmond, MD, received his under-graduate credentials at Cornell University and his medical degree from the State University of New York at Syracuse.

bishoy Gad, MD, MbA, is also a Case Western Reserve University “triple threat,” having matriculated as an undergraduate, graduate and medical student at our neigh-boring institution of higher learning.

Despite the challenges of work-hour restric-tions, ACgME, JCAhO, government and third-party payor mandates, the resident educational process remains solid and robust as a result of young, inquiring minds and a cadre of orthopaedic surgeons dedi-cated to quality care and education.

A good teacher always wishes that his pupils will succeed and surpass the teacher himself. Thus far, our graduates continue to excel, set the bar ever higher and make us all proud.

About the AuthoR

Dr. Kuivila is Residency Program Director for the Department of Orthopaedic Surgery and Vice-Chairman for Education in the Orthopaedic & Rheumatologic Institute. he can be reached at 216.444.2741 or at [email protected].

Resources for PhysiciansPhySICIAn DIReCtoRy

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

ReFeRRInG PhySICIAn CenteR

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

specialists and services, details about CME opportunities, and

more, contact the Referring Physician Center at [email protected],

or 216.448.0900 or 888.637.0568.

tRACK youR PAtIent’S CARe onLIne

DrConnect is a secure online service providing our physician

colleagues with real-time information about the treatment their

patients receive at Cleveland Clinic. To receive your next patient

report electronically, establish a DrConnect account at

clevelandclinic.org/drconnect.

ReQueSt MeDICAL ReCoRDS

216.445.2547 or 800.223.2273, ext. 52547

CRItICAL CARe tRAnSPoRt WoRLDWIDe

Cleveland Clinic’s critical care transport teams and fleet of mobile

ICU vehicles, helicopters and fixed-wing aircraft serve critically

ill and highly complex patients across the globe. Transport is

available for children and adults. To arrange a transfer for STEMI

(ST elevated myocardial infarction), acute stroke, ICh (intracerebral

hemorrhage), SAh (subarachnoid hemorrhage) or aortic syndromes,

call 877.379.CODE (2633). For all other critical care transfers,

call 216.448.7000 or 866.547.1467 or visit clevelandclinic.org/

criticalcaretransport.

outCoMeS DAtA

View clinical Outcomes books from Orthopaedic and

Rheumatologic Institute and other Cleveland Clinic institutes

at clevelandclinic.org/quality/outcomes.

StAy ConneCteD to CLeVeLAnD CLInIC

Resources for PatientsMeDICAL ConCIeRGe

For complimentary assistance for out-of-state patients

and families, call 800.223.2273, ext. 55580, or email

[email protected].

GLobAL PAtIent SeRVICeS

For complimentary assistance for national and international

patients and families, call 001.216.444.8184 or visit

clevelandclinic.org/gps.

MyChARt®

Cleveland Clinic MyChart® is a secure, online personal

healthcare management tool that connects patients to

portions of their medical record at any time of day or night.

Patients may view test results, renew prescriptions, review

past appointments and request new ones. A new feature,

Schedule My Appointment, allows patients to view their

primary physician’s open schedule and make appoint-

ments online in real time. Patients may register for MyChart

through their physician’s office or by going online to

clevelandclinic.org/mychart.

Orthopaedic Insights Fall 2011

A Physician’s Newsletter from the Department of Orthopaedic Surgery

CMe oPPoRtunItIeS: LIVe AnD onLIne

Cleveland Clinic’s Center for Continuing Education’s website

offers convenient, complimentary learning opportunities, from

patient simulations, webcasts and podcasts to a host of medical

publications and a schedule of live CME courses. Physicians

can manage CME credits using the myCME.com Web portal

available 24/7. Visit ccfcme.org.

11-ORT-016

Orthopaedic Insights - Cleveland Clinic · gressive spine deformity seen largely in teenage girls. Bracing a growing child has been shown to delay or prevent curve progression in

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