Arthroscopic instability repair has overtaken open
instability repair for most patients with shoulder instability in the last
decade. Technological advances as well as improved understanding of the anatomy
and pathology have led to this change in approach. However, increasing
awareness of bone loss of the glenoid and humeral head have led to a better
understanding of when advanced arthroscopic techniques or bone augmentation
procedures are necessary to avoid surgical failure.
We have assembled some of the world’s foremost
thought leaders and surgeons in this Orthopedics Today Round
Table discussion to share their experiences and insights into bone loss and
its role in the unstable shoulder. Our hope is that this will assist our
readers in the management and care of patients with shoulder instability and
William N. Levine, MD
|Round Table Participants
William N. Levine, MD
University Medical Center New York, N.Y.
Christopher S. Ahmad, MD
University Medical Center New York, N.Y.
Augustus D. Mazzocca, MS, MD
England Musculoskeletal Institute University of Connecticut Health Center
R. Cadet, MD
Columbia University College of Physicians and Surgeons New
York-Presbyterian/Columbia University Medical Center New York, N.Y.
Matthew T. Provencher, MD,
CDR, MC, USN
Naval Medical Center San Diego San Diego, Calif.
T. Bradley Edwards, MD
Orthopedic Group Houston, Texas
William N. Levine, MD: How do you evaluate the
patient with recurrent anterior instability following prior arthroscopic labral
Christopher S. Ahmad, MD: In general, failed
surgery is challenging, and it is helpful as a clinician to develop an
organized evaluation approach. I prefer to organize the causes of failure as
problems that occur prior to, during or after surgery. Prior to surgery, we are
concerned with problems related to misdiagnosis, such as a patient with
multidirectional instability (MDI) or posterior instability
that undergoes an isolated anterior stabilization procedure, voluntary
instability, collagen disorders and osseous deficiencies — with osseous
deficiency being on the top of list. Also important prior to surgery is
appreciating the patient’s expectations and risk factors such as
participation in collision sports.
Problems that occur during surgery focus on technical
issues and include failure to address all aspects of capsular and labral
injury, poor anchor placement (such as being too medial on glenoid) and use of
too few anchors. Problems after surgery are related to non-compliance with
rehabilitation and repeat trauma.
History taking, therefore, attempts to determine the
patient’s age, activity level, number of dislocations prior to surgery and
ability to self-reduce, and number of dislocations after surgery and ability to
self reduce. Lack of an interval of symptomatic improvement following surgery
suggests the possibility of an incorrect diagnosis or missed pathology.
Operative reports often indicate the observed pathology at the time of surgery,
the technique of capsulolabral repair, the number of anchors used and if
thermal capsular shrinkage was used.
Physical exam should attempt to elicit generalized
laxity, translation testing and apprehension. Apprehension at minimal degrees
of abduction and external rotation suggests bony deficiency. It is important to
obtain plain X-rays with an axillary view and note if anchors are placed
inferior (close to 6 o’clock) and lateral on the glenoid.
For failed instability, we routinely obtain an MRI scan
with intra-articular gadolinium for soft tissue evaluation. Because of the high
incidence of bone loss associated with failed surgery, we always obtain a CT
scan with 3-D reconstructions that isolate the humeral head and the glenoid.
Edwin R. Cadet, MD: My approach first begins with
a thorough history. I try to exclude preceding trauma as one possible cause for
recurrent instability following shoulder stabilization surgery. It is also
important to discern whether symptoms of instability are that of frank
dislocation or subluxation. Is the patient able to voluntarily dislocate the
shoulder, and if not, what activities and what arm positions does that shoulder
dislocate or feel unstable? At times you can elicit the direction of
instability based on the patient’s subjective description, but often with
the patient’s recollection of specific arm positions and activities that
induce subjective or objective signs of instability. The previous operative
report is critical to determine what was done initially. Was the initial
surgery performed arthroscopically or open? That is an important concept as
with open approaches as subscapularis deficiency may come into play.
Physical examination must always be conducted with the
upper torso disrobed. For me, anterior/posterior load and shift in the supine
position is extremely helpful. Downward traction of the arm (sulcus) sign in
neutral and external rotation in the upright position will help determine if
multidirectional instability exists and test the competency of the rotator
interval. The Gagey hyperabduction test has also been a useful tool for me.
Abnormal glenohumeral abduction against resisted scapular
motion is defined as greater than 105°. This signifies inferior capsular
In addition to a full series of radiographs including
anteroposterior (AP) views in neutral, external and internal rotation and an
axillary view (West Point or “standard” axillary is adequate), I
order MRI with intra-articular contrast, particularly in the postoperative
setting. Three-dimensional CT is an important adjunct as it provides excellent
detail regarding the osseous anatomy to identify regions of critical bone loss.
CT scans often show the location and number of anchor tracks form prior surgery
better than plain radiographs.
T. Bradley Edwards, MD: I first take a thorough
history starting with the patient’s chief complaint – instability,
pain or both. If instability is a complaint, I ask about frank dislocation
requiring a reduction maneuver or subluxation. Just because a patient has had a
prior labral repair does not mean recurrent instability is why the prior
surgery failed. Patients who complain primarily of pain make me consider other
etiologies of failure, not just recurrent instability. The number and type of
prior surgeries are reviewed along with operative reports and intraoperative
photographs if available. Additionally, other factors such as co-morbidities
(Ehlers-Danlos syndrome) or confounding factors (workman’s compensation)
are elucidated from the history.
For patients with prior instability surgery, the
examination specifically focuses on presence of prior incisions, shoulder
mobility, rotator cuff testing, instability testing and neurovascular status.
Prior skin incisions are noted and checked for any signs of infection. Both
active and passive shoulder mobility are evaluated checking mainly for any
signs of capsular stiffness, which can indicate an over-tightened shoulder and
the presence of
glenohumeral crepitus, which can indicate the presence of
instability arthropathy. The rotator cuff is then systematically examined for
presence of disease, which is more likely to be present in older patients.
My rotator cuff exam consists of Jobe’s test for
the supraspinatus, the external rotation lag sign, external rotation strength
for the infraspinatus, the horn blower’s sign for the teres minor, and the
lift-off and belly-press tests for the subscapularis. Instability examination
begins with looking for signs of hyperlaxity using the sulcus sign and the
presence of greater than 90° of passive external rotation with the arm at
the side. Standard anterior apprehension and relocation tests are used along
with their posterior corollaries. I also use O’Brien’s
active-compression test for superior labral pathology, although I find this
test rather non-specific. Lastly, I perform a thorough neurovascular
My standard instability radiographic series includes an
AP view of the glenohumeral joint with the arm internally rotated to look for a
humeral head impaction fracture (Hill-Sachs lesion), and a Bernageau glenoid
profile view with a comparative Bernageau view of the unaffected shoulder
(Figure 1). If the patient is older and I am suspicious of rotator cuff
pathology or arthropathy, I obtain an AP view of the glenohumeral joint with
the arm in neutral rotation, an axillary lateral view and a scapular outlet
view. These radiographs are performed using fluoroscopy and controlled for
magnification. If these radiographs clearly define the problem, for example the
presence of anterior glenoid bone loss and a Hill-Sachs lesion, no further
imaging is performed unless suspicion exists for additional pathology such as a
rotator cuff tear. If radiographs are normal, my secondary imaging modality of
choice is magnetic resonance arthrography (MRA).
| Figure 1. Bernageau glenoid profile
radiograph shows anterior bone loss (arrows) with normal contralateral
Images: Edwards B
Augustus D. Mazzocca, MS, MD: I look to the
initial history of instability that brought the patient to have the surgery in
the first place. I consider the type of trauma that originally caused the event
and how many times it has happened, including the position of the arm, activity
the patient was doing and the amount of force applied to the shoulder. Also, I
think that it is important to determine the decisions made by the previous
surgeon, i.e., how the original surgery was performed (arthroscopically or
open), how many anchors were placed, where the anchors were placed and the
overall condition of the intra-articular glenohumeral joint at the time of the
initial surgical procedure (cartilage defects, articular-sided rotator
We then delve into a detailed history of how the patient
did postoperatively — the rehabilitation program, how long the patient
wore a sling, the type of exercises the patient did in therapy and how long
physical therapy was. This information is important for me to know if I think
perhaps the rehab was too fast or aggressive, if the exercises done in the
beginning stretched out or pulled the capsule or, on the contrary, maybe the
anterior labrum was fixed and the inferior labrum was left a little looser and
the patient now has a hourglass type of problem.
Once I have this information, I ask the patient
questions about mid-range instability. We know that the inferior glenohumeral
capsule (both the anterior and posterior bands), as well as the superior and
middle glenohumeral ligament, are in effect only at the end ranges of motion.
If the patient has a dislocation or subluxation or feels apprehension in
mid-range, that would lead me to believe there is more bone abnormality. Does
the patient dislocate or have subluxation events while sleeping? Does it take
decreasing force to reduce after dislocation or subluxation?
The exam always begins with inspection to observe
atrophy or any asymmetry between the deltoid. We then perform a cervical spine
exam to ensure that there are no conflicting cervical spine issues. After range
of motion, we perform a supine exam – abduction to 90°, external
rotation to determine where the apprehension lies, internal rotation with the
scapula fixed and a load-shift maneuver.
With the patient in the supine position, I get a better
feel and can relax the patient as I sit on a small stool next to him or her.
The shoulder hangs over the edge of the table with the scapula stabilized on
the edge. This positioning allows for a load to be applied to center the
humeral head on the glenoid and then an anteroinferior force is applied and
graded 1+ (to the edge), 2+ (over the edge and back) and 3+ (locked). We also
do this posteriorly. We will also do a posterior jerk test making sure that the
forward elevation is past 140° and the Kim test in a seated position,
paying special attention to the posterior aspect to make sure there is no
missed posterior inferior problem. As Cadet suggested, we also do a sulcus sign
supine and in external rotation to determine competency of the rotator
interval. Finally, we look at the strength of the anterior/middle and posterior
deltoid, supraspinatus and subscapularis.
We do a series of X-rays including a standard AP, a West
Point view, an axillary view, a striker notch view, and I usually add a Zanca
view. Following radiographs, we will get a CT scan with 3-D, reconstruction,
subtracting the humerus and glenoid to see those bones by themselves and to
assess the amount of bone loss. Finally, we get a MRA to assess that there is
no humeral avulsion of the glenohumeral ligaments or other missed problem.
Matthew T. Provencher, MD, CDR, MC, USN: The
patient with a potentially failed instability repair presents a diagnostic
challenge. I try to keep in mind that the index instability procedure may have
failed for many different and potentially overlapping reasons (not just
recurrent instability or redislocation event), including recurrent instability,
persistent pain, weakness or stiffness. Thus, it is important to ascertain what
is the main issue for the potential failure after instability repair with a
comprehensive history and physical examination.
When taking the patient history, it is important to
document the level of energy to cause the recurrence as well as the arm
position of the instability event. This provides information regarding the
integrity of the repair and position of instability. Patients with a history of
hyperlaxity may be at increased risk for recurrence after arthroscopic
instability repair secondary to an inability to optimally re-tension the
One should also investigate the frequency of instability
events, determine if there is a progressive ease of instability and what arm
positions the patient avoids. In addition, does the patient have a history of
bilateral shoulder instability (glenoid hypoplasia), relatively low-energy
mechanism (glenoid or humeral bone injury) and superior labrum anterior
posterior (SLAP) signs? This will provide information on the level of energy
required for an instability event, and to ascertain if glenoid and/or humeral
head bone loss may be a contributing factor.
On examination, one should pay attention to hyperlaxity
signs, the sulcus test (indicating inferior capsule and/or rotator interval
incompetence and the predominant position and direction of instability. As
glenoid bone loss is one of the leading causes of arthroscopic instability
repair failure, one of the most important examination findings is to determine
if the patient has instability in mid-ranges of motion (arm abducted 45°
with external rotation), rather than the full apprehension position. In
addition, if a patient has limited and asymmetrical external rotation at the
side (a seemingly tight shoulder), but recurrent anterior instability findings,
one should be suspicious that the anteroinferior structures were either
reinjured or inadequately addressed in the primary repair construct.
A comprehensive radiographic evaluation should be
performed in the setting of a failed instability repair – including plain
radiographs (AP, True AP, supraspinatus outlet and West Point axillary view), a
MRI or MRA, and I almost always obtain a 3-D CT scan in order to ascertain for
glenoid and humeral head bone loss, version issues, or other bony erosion that
may be leading to the recurrence.
Levine: Anything different for the patient who
has recurrent anterior instability following prior open Bankart/capsular shift?
Ahmad: A patient who has undergone an open
stabilization procedure from the anterior side has unique features that should
be evaluated including the integrity of the subscapularis which could be
assessed with a lift-off test, belly press, internal rotation strength and
increased passive external rotation at the side. In addition, technical aspects
of open capsular shift may neglect inferior capsular tensioning. Inferior
translation should be assessed with a sulcus sign as well as posterior
translation and degree of external rotation. Imaging studies should also look
for the possibility of asymmetric tightening, which is evident with posterior
translation of the humeral head and the integrity of the subscapularis
(axillary view will show anterior subluxation with a deficient subscapularis).
Cadet: The subscapularis comes into play when
discussing recurrent anterior instability following an open procedure.
Subscapularis deficiency can be a source of anterior instability. How was the
subscapularis managed at the initial surgery? This is important information
that needs to be elucidated from the operative report. In addition, the type of
shift (medial or laterally based), if any, is also important to know as this
will affect preoperative planning regarding managing the capsule at the time of
Edwards: I do nothing different for the patient
with a failed open repair.
Mazzocca: There would be nothing different. We
would spend the same time performing the same exam, history taking, and imaging
studies for someone who has had an open or arthroscopic procedure. We would pay
close attention to any change in strength between uninvolved and involved
Provencher: The open
Bankart repair remains the gold standard for instability
repair and has proven effective even in the setting of mild to moderate glenoid
bone loss. Thus, if a patient has recurrent anterior instability after an open
Bankart repair, one should carefully evaluate for more extensive bone loss with
a 3-D CT scan with the humeral head digitally subtracted to optimally visualize
the glenoid face. In addition, the subscapularis should be carefully evaluated,
both clinically and with MRI, to assess muscle volume, as recurrent instability
may be secondary to poor dynamic stabilization of the shoulder joint secondary
to subscapularis dysfunction.
If a shoulder is stiff in external rotation at the side
and still has instability, particular attention should be paid to the inferior
and anteroinferior capsule as these structures may not have been adequately
tensioned or reinjured in the recurrent instability event.
Levine: How do you determine how much bone
loss has occurred on the glenoid side? How much glenoid bone loss is “too
much” and should preclude a soft tissue reconstruction?
Ahmad: Bone loss on the glenoid side is best
detected with a CT scan with 3-D reconstructions that allows the percent of
glenoid deficiency to be determined. One method is to create a best-fit circle
on the inferior two-thirds of the glenoid, and then from the center of that
best-fit circle, estimate the amount of anterior bone loss. The average
diameter of inferior glenoid approximates 24 mm. Basic science and clinical
reports suggest that less than 15% of bone loss, which equates to 3 mm to 4 mm
of bone loss, can be managed with a standard soft tissue instability repair.
However, greater magnitudes from 15% to 30%, which equates to 4 mm to 9 mm of
bone loss, can be significant for some high risk patients and greater than 30%
of bone loss, which equates to 8 mm to 9 mm, will be significant in most
patients. Diagnostic arthroscopy can confirm the magnitude of bone loss using
the bare spot as described by Burkhart et al. In the setting of significant
bone loss, especially in failed previous surgery, consideration should be given
for bone augmentation procedures such as the coracoid transfer.
Cadet: The amount of bone loss can be determined
preoperatively and postoperatively. The pattern of glenoid bone loss also has
to be determined. Burkhart’s “inverted pear” description is a
nice way to define glenoid bone loss qualitatively. Basically, the shape of a
pear is largest at its base, just as with the glenoid. If this relationship is
distorted, specifically, if the base of the glenoid has similar or less bone
than the superior glenoid, then you are dealing with significant bone loss.
Quantitatively, on the sagittal view on CT or MRI scans, one can identify the
center of the glenoid, which usually corresponds to the “bare spot”
intraoperatively. The shape of the inferior glenoid is considered circular, and
one can draw a best-fit circle. The radius (B) is measured from the center to
the posterior edge of the glenoid (assuming no posterior glenoid bone loss). 2B
represents the diameter of the glenoid undisturbed. Distance A is the distance
from the center to the most anterior edge of the glenoid (excluding the Bankart
fragment). Thus, I calculate the percentage bone loss based on the formula
described by Sugaya et al.
Percent bone loss = [(B-A)/2B] X 100
Intraoperatively, I use the “bare spot” as my
reference point for the center of my measurement. The greatest diameter of the
glenoid at this point should be approximately 24 mm (radius is 12 mm from the
point of the “bare spot” to the anterior or posterior edge). The
diameter of the probe is generally 3 mm. Thus, greater than 6 mm of bone loss
from the bare spot would be 25%. Greater than 25% is what I consider to be
“too much” and would preclude an isolated “soft tissue
Edwards: I compare the Bernageau glenoid profile
views and make measurements of the anteroposterior glenoid diameter using a
digital caliper. We do not know how much bone loss is “too much,” but
we are currently researching use of a ratio created from these measurements to
help guide our decision-making.
Mazzocca: We use CT scan with 3-D reconstruction
as our primary imaging to determine bone loss. This method of imaging provides
an idea of the area and significance of the bone loss.
Yamamoto et al and Detterline et al have described the
clinically significant combined lesions called the glenoid track. In general,
the width of the glenoid track is 85% of the glenoid with no defect. The
take-home point is if the medial margin of the humeral head defect is greater
than the glenoid tract, the humeral head is likely to engage. We really believe
in this, so we will measure the distance of the Hill-Sachs lesion and the
glenoid and take 85% of that and look to see. We also will assess with
Gerber’s method and Sugaya’s method to get a sense of bone loss. We
spend a lot of time speaking with the patient regarding the risks and benefits
of bone augmentation with hardware vs. arthroscopic soft tissue repair.
Provencher: The gold standard to determine
glenoid bone loss is with a 3-D CT scan with the humeral head digitally
subtracted so you can view the glenoid directly en face (Figure 2). As
discussed by the other faculty, the inferior two-thirds of the glenoid is a
well-conserved circle, so with simple measurement by placing a circle in the
bottom of the glenoid (either electronically or with pencil), you can determine
the amount of glenoid bone loss across the diameter of the circle. When
measuring in the lab, or for clinical studies, we have measured the surface
area of bone loss and expressed in mm2, although this is likely too
cumbersome for routine clinical use. If there is concern about the radiation
associated with a CT scan, a MRA, especially with a reasonable magnet strength
(>1.5 Tesla) can also measure the amount of bone in a similar fashion. I
think that plain radiographs are inadequate to determine the amount of glenoid
bone loss for treatment decisions.
2. Sagittal 3-D CT reconstruction with humerus removed in a 25-year-old male
after arthroscopic instability repair with recurrent anteroinferior
instability. Note the glenoid bone deficiency and the “inverted pear”
Image: Columbia University Center
for Shoulder, Elbow and Sports Medicine
An additional and simple way to measure bone loss is
arthroscopically with the glenoid bare spot technique. With the arthroscope in
the anterosuperior portal, a graduated probe is brought in from the back, and
the relative amount of bone loss anterior to the bare spot is measured vs. the
amount of bone that is present from the bare spot posteriorly and expressed as
a percentage of loss.
Clinical evidence would suggest that there is no
“hard” number of the amount of glenoid bone loss that would preclude
a soft tissue repair. The main reason for this is that there are many
complexities involved in recurrent shoulder instability associated with glenoid
bone loss. For example, a patient who skydives for a living cannot dislocate
when jumping out of an airplane. The amount of glenoid bone loss that a
skydiver or wrestler may tolerate may be less than say someone who participates
in recreational sports, is an older instability patient or one who has lesser
demands. That being said, in general, patients with 15% of less of glenoid bone
loss, a soft tissue repair is a reasonable approach, especially if there is a
bone fragment that can be incorporated into the repair construct. For this type
of patient, an open repair may also add additional stability over an
arthroscopic repair. For patients with 15% to 25% bone loss, this represents a
level in which an arthroscopic repair should be approached with caution.
Patients with a bony fragment that can be incorporated into the repair may have
better outcomes in terms of stability as the glenoid can effectively be
anatomically restored. For patients with more than 25% loss, a bone
augmentation procedure is generally recommended.
Levine: How do you determine how much bone
loss has occurred on the humeral side? How much humeral bone loss is “too
much” and would lead you to consider addressing it?
Cadet: I consider a Hill-Sachs lesion greater
than 40% with less than 20% glenoid bone loss to be too much. However, an
engaging Hill-Sachs lesion that is less than 40% but is deep may also be too
much. Quantifying the Hill-Sachs preoperatively can sometimes be difficult. I
will quantify it based on a percentage of the diameter of the humeral head on
axial and coronal sections at the Hill-Sachs largest diameter and width.
Edwards: In the absence of a fixed glenohumeral
dislocation, humeral bone loss that significantly affects stability is very
rare in my practice. To this point, I have only used radiographs to evaluate
humeral bone loss, specifically the AP internal rotation view and the axillary
lateral view. I have addressed the vast majority of large Hill-Sachs lesions in
my practice via the glenoidplasty effect provided by the Latarjet. The Latarjet
increases the AP diameter of the glenoid prohibiting sufficient anterior
translation to allow engagement of the humeral head lesion.
Mazzocca: Once again, we use the glenoid track
but, in general, we use the 30% rule where we will measure that off of a CT
Provencher: Humeral bone loss determination
remains a challenge. This is due to the fact that the humeral head defect is
3-D and usually in the shape of an orange slice. The best way to identify and
measure a Hill-Sachs is with either ultrasound, MRI or CT scan. Plain
radiographs may also identify the presence of a Hill-Sachs lesion.
It is a rare case to have a large amount of humeral head
bone loss without a corresponding significant glenoid bone injury. However, the
relatively harder anterior glenoid bone may cause a significant impaction on
the humeral head without glenoid bone loss. The more usual case is that the
glenoid and humeral head have concomitant bone injuries, which are usually
addressed on the glenoid side with either a soft tissue repair or a bony
augmentation case. As Mazzocca mentioned above, we have learned that the
glenoid track is an important emerging concept to look at the size of the
Hill-Sachs lesion relative to the glenoid.
Unless the humeral head easily “engages” on
the glenoid, a soft tissue procedure is generally adequate. However, in larger
defects (Hill-Sachs lesions greater than 20% to 25% depth of the humeral head)
that easily engage, a combination of procedures may be performed –
including capsulolabral soft tissue repair and potential remplissage (tenodesis
of the infraspinatus into the humeral head defect) vs. a glenoid bone
augmentation procedure that effectively prevents the humeral head engagement.
In general, I prefer a bone augmentation procedure if there is humeral head
bony engagement, which usually suggests a combined humeral head and glenoid
A note from the editors:
Look for Part 2 of this Round Table discussion in
the June issue.
- Burkhart SS, de beer JF, Tehrany AM, Parten PM. Quantifying glenoid
bone loss arthroscopically in shoulder instability. Arthroscopy.
- Detterline AJ, Provencher MT, Ghodadra N, et al. A new arthroscopic
technique to determine anterior-inferior glenoid bone loss: validation of the
secant chord theory in a cadaveric model. Arthroscopy.
- Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an
indicator of significant glenoid bone loss. Arthroscopy.
- Pagnani MJ. Open capsular repair without bone block for recurrent
anterior shoulder instability in patients with and without bony defects of the
glenoid and/or humeral head. Am J Sports Med. 2008;36:1805-1812.
- Sugaya H, Kon Y, Tsuchiya A. Arthroscopic repair of glenoid
fractures using suture anchors. Arthroscopy. 2005;21:635.
- Yamamoto N, Itoi E, Abe H, et al. Contact between the glenoid and
the humeral head in abduction, external rotation, and horizontal extension: A
new concept of glenoid track. J Shoulder Elbow Surg.
- Christopher S. Ahmad, MD, can be reached at the Center for
Shoulder, Elbow and Sports Medicine, Columbia University, 622 W. 168th St., New
York, NY 10032; 212-305-5561; email: email@example.com.
- Edwin R. Cadet, MD, can be reached at Columbia University Medical
Center, 622 W. 168th St., PH-1117 Center, New York, NY 10032; 212-305-4626;
- T. Bradley Edwards, MD, can be reached at Fondren Orthopedic Group
LLP, 7401 South Main St., Houston, TX 77030; 713-799-2300; email:
- William N. Levine, MD, can be reached at Columbia University
Medical Center, 622 W. 168th St., PH-1117r, New York, NY 10032; 212-305-0762;
- Augustus D. Mazzocca, MS, MD, can be reached at New England
Musculoskeletal Institute, Medical Arts and Research Building, Room 4017,
University of Connecticut, 263 Farmington Ave., Farmington, CT 06034-4037;
860-679-6633; email: firstname.lastname@example.org.
- Matthew T. Provencher, MD, MC USN, can be reached at the U.S. Naval
Medical Center, San Diego, Department of Orthopaedic Surgery, 34800 Bob Wilson
Drive, San Diego, CA 92134; 619-532-8427; email:
- Disclosures: Ahmad is a paid consultant for Arthrex and
Acumed, and receives research support from Stryker, Zimmer and Arthrex. Cadet
previously received research support in the form of research materials from
Smith & Nephew. Edwards has no relevant financial disclosures. Levine and
Provencher have no relevant financial disclosures. Mazzocca is consultant for
and receives research funding from Arthrex Inc.