Orthopedics

Feature Article 

An Anatomic Intraoperatively Prepared Antibiotic Spacer in Two-Stage Shoulder Reimplantation for Deep Infection: The Potential for Early Rehabilitation

William R. Aibinder, MD; Julia Lee, MD; Dave R. Shukla, MD; Robert H. Cofield, MD; Joaquin Sanchez-Sotelo, MD; John W. Sperling, MD

Abstract

Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211–218.]

Abstract

Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211–218.]

Periprosthetic joint infection (PJI) following shoulder arthroplasty represents a challenging problem in many orthopedic surgery practices and is a relatively common mode of failure requiring additional surgery.1–3 Treatment options include component retention with irrigation and debridement,4,5 resection arthroplasty,6,7 one-stage component exchange,8–10 and two-stage reimplantation.11–14 On the basis of better outcomes with two-stage revision in the hip and knee arthroplasty literature, the current authors' preference is to perform a two-stage reimplantation for most shoulder PJIs.15 Several studies evaluating two-stage reimplantation in the shoulder have reported eradication rates between 60% and 100% for PJI.3,4,11,14,16–18 An antibiotic-impregnated cement spacer of some sort is commonly implanted in the first stage, including a hand-molded spherical spacer with no stem,19 a hand-molded spacer with no metal component,20 a hand-molded spacer fashioned around a metal plate or flexible rod,11,12,14 a thin stem metal hemiarthroplasty coated with antibiotic-impregnated cement,21,22 or a prefabricated cement spacer with premixed antibiotic powder.13,23

So-called dynamic or articulating spacers have become popular for the management of knee PJI.24 The potential benefits of an articulating cement spacer in the shoulder are four-fold: (1) A spacer shaped like a humeral head in several available sizes provides the ideal geometry to reestablish soft tissue tension. (2) With a preserved capsule and rotator cuff, motion may be allowed in between the first and second stage procedures, which may decrease joint contracture and facilitate exposure at the time of reimplantation. (3) The spacer provides continued elution of antibiotics into the area of infection. (4) In patients with substantial comorbidities, an articulating spacer may serve as a definitive prosthesis, provided it is well tolerated.25,26 Hand-molded spacers, however, are not perfectly concentric when allowing range of motion. Use of a functional spacer with a thin stem hemiarthroplasty resolves this issue specifically with the goal of avoiding a second stage reimplantation; however, this results in retention of a metallic component and may necessitate chronic antibiotic suppression.21,22 Prefabricated molded antibiotic spacers are available but have limited size options and do not allow customization of antibiotic regimens.23 In recent years, in the authors' practice, an anatomic antibiotic cement spacer that can be custom shaped and sized intraoperatively to a hemiarthroplasty (StageOne; Zimmer-Biomet, Warsaw, Indiana) has been increasingly used. This device provides several benefits, including the possibility of customizing antibiotics incorporated in the spacer, multiple size options, and the ability to achieve a secure fit of the spacer in the canal with the use of standard reamers and broaches. Additionally, when the capsule and rotator cuff are largely preserved, range of motion exercises may be instituted in between stages. The benefit of mobile spacers in the shoulder for facilitating exposure at the time of the second stage and their impact on the final range of motion remain undetermined. The purpose of this study was to evaluate the efficacy and safety of using this molded spacer and the potential for early rehabilitation in the treatment of shoulder infections during two-stage reimplantation.

Materials and Methods

Following institutional review board approval, a retrospective review was performed between January 2014 and December 2015. During this period, the authors identified 29 shoulders treated for a shoulder infection with a two-stage procedure using an intraoperatively molded antibiotic cement spacer in the shape of a hemiarthroplasty (StageOne; Zimmer-Biomet) during the first stage. Two patients were lost to follow-up prior to 2 years; the remaining 27 shoulders were followed for a minimum of 2 years. Demographic and medical comorbidities for these 27 shoulders are summarized in Table 1. The indication for two-stage reimplantation was a PJI in 18 shoulders, a native shoulder infection in 8, and osteomyelitis following open reduction and internal fixation of a proximal humerus fracture in 1. Among the cases of PJI, 6 were infected reverse total shoulder arthroplasties, 9 were infected anatomic total shoulder arthroplasties, and 3 were infected hemiarthroplasties. Of the native shoulder infections, 7 had at least one prior procedure, which included rotator cuff repairs in 5, a Latarjet in 1, and an arthroscopic debridement for a presumed shoulder infection in 1. The diagnosis of infection was based on positive culture results and other well-accepted criteria for infection. This cohort included 3 shoulders deemed to have a persistent culture-negative infection.27 These 3 shoulders were referred to the authors' institution after management at an outside institution of culture-positive infections with persistent pain and concern for infection. One had undergone an arthroscopic debridement, one had 2 irrigation and debridement procedures with retention of components, and one had undergone a failed two-stage revision. All 3 of these patients were taking antibiotics at presentation. Microbiology records from the outside institution were not available at the time of this retrospective review.

Demographic Data

Table 1:

Demographic Data

Mean age at the time of the first stage was 59 years (range, 37 to 76 years). Mean time between spacer implantation and the second stage was 71.7 days (range, 42 to 240 days). Mean follow-up was 29.6 months (range, 24 to 45 months). At the time of the first stage surgery, patients had already undergone an average of 2.2 (range, 1 to 5) prior procedures. The causative organism was identified in 24 of 27 (89%) shoulders (Table 2). Patients were allowed to perform motion exercises with passive external rotation to neutral and passive elevation to 90° (group I, n=16) or were instructed to avoid motion (group II, n=11) after spacer implantation, depending on the condition of the rotator cuff. In the current cohort, no patients were left with the antibiotic spacer as their definitive prosthesis.

Causative Organism and Frequency, as Determined by Intraoperative Cultures

Table 2:

Causative Organism and Frequency, as Determined by Intraoperative Cultures

Pain, range of motion, reinfection, and reoperation rates were analyzed. Pain was assessed using a visual analog scale and graded based on a 5-point scale.28 Additionally, operative factors such as anesthesia time and operative time during the first and second stage procedures were recorded. Preoperative radiographs, interval radiographs with the spacer in place, immediate post-reimplantation radiographs, and final radiographs were reviewed. Computed tomography scans were also reviewed whenever available.

All procedures were performed by 2 of the senior authors (J.S.S., J.W.S.). The deltopectoral approach was used. A subscapularis tenotomy was performed if the subscapularis was present. In cases of native glenohumeral septic arthritis, a humeral head osteotomy was performed with the aid of a cutting guide. In cases of PJI with well-fixed components, a pencil-tip bur and a square-tip impactor were used to aid in implant removal. An attempt was made to remove all retained cement in shoulders with previously cemented components. If present, the glenoid component was removed as well. The humeral head osteotomy was performed using a guide as previously discussed. Five tissue samples were obtained and sent for culture. Current practice is to obtain each culture specimen with a sterile hemostat and a fresh knife blade from the glenoid and humeral interfaces. Sequential reamers and broaches from a compatible system (Comprehensive Total Shoulder System; Zimmer-Biomet) were then used to prepare the humeral canal. There are 5 spacer mold sizes based on stem size: 6 mm, 8 mm, 10 mm, 12 mm, and 14 mm. If the canal is wider than 14 mm, additional antibiotic cement is placed around the stem to allow a better fit.

Generally, two batches (40 g each) of prewarmed Simplex P bone cement (Stryker, Mahwah, New Jersey) are used. The cement is mixed in a mixing canister. Typically, two vials (1 g each) of vancomycin antibiotic powder and two vials (1.4 g each) of gentamicin antibiotic powder are mixed with the cement. If there is concern for a fungal species infection, then one vial of amphotericin B powder is added. Two milliliters of methylene blue 1% dye is added. The mixing rod is then removed and the canister is attached to a delivery gun. The mold is then threaded onto the canister delivery system and filled with the prepared cement. The cement is allowed to cure. Next, the silicone mold is cut using a scalpel to retrieve the spacer. Often, small areas of cement need to be trimmed near vent holes to allow for a smooth articulating surface. The spacer can then be implanted into the humeral canal with reasonable axial stability. A repair of the subscapularis tenotomy was performed in a standard fashion whenever tendon quality and excursion allowed. The surgical wound was then closed in a layered fashion. Shoulders were placed in an immobilizer. Based on the quality of the subscapularis and remaining rotator cuff, a decision was made whether passive range of motion should be initiated. Intravenous antibiotic therapy was used according to the recommendations of infectious disease specialists.

Patients typically return to the clinic 8 weeks postoperatively and are evaluated for signs of persistent infection. Nineteen of 27 (70%) shoulders also underwent a computed tomography scan in between stages with the spacer in place for preoperative planning of the reimplantation. When there was concern, an infection work-up with inflammatory markers and an aspiration was performed. When there were positive results, the authors consulted with their infectious disease colleagues to determine if a repeat debridement, prolonged antibiotic therapy, or both was required. When the infection was considered to have been eradicated, reimplantation was performed shortly thereafter. The second stage reimplantation was performed using a hemiarthroplasty in 5 shoulders and a reverse shoulder arthroplasty in 22 shoulders.

Statistical Methods

Continuous data were reported as means and ranges. Means were compared using t tests. Group comparisons for pain, range of motion, and radiographic outcomes were performed using a Wilcoxon rank-sum test for non-parametric data. Pre- and postoperative means were compared using t tests. Statistical significance was set at P<.05.

Results

Clinical Outcomes

Overall, pain scores decreased significantly from a mean of 3.6 to 1.7 (P<.0001). Patients in group I had significantly less pain at final follow-up, with a mean pain score of 1.3, compared with 2.4 in group II (P=.03).

Significant improvements were noted regarding active elevation and external rotation (P=.0002 and .009, respectively). Active elevation improved from a mean of 48° to 105°, while external rotation improved from a mean 20° to 36°. Internal rotation improved from an ability of the thumb to reach the sacrum to L5 (P=.12). Patients in group I showed a trend toward better active elevation with a mean of 115° (range, 42° to 160°), compared with 93° (range, 30° to 165°) in group II (P=.3). The mean external rotation in group I was 37°, compared with 38° in group II (P=.9). The mean internal rotation was the ability to reach L5 in both groups (P=.7) (Table 3).

Range of Motion

Table 3:

Range of Motion

Operative Times

There was no statistically significant difference regarding anesthesia or operative time between the two groups based on whether patients were allowed to perform passive range of motion exercises. There was, however, a trend toward a shorter operative time in group I, which was, on average, 10 minutes faster (Table 4).

Anesthesia and Operative Times

Table 4:

Anesthesia and Operative Times

Reinfections and Reoperations

Staged reimplantation eradicated infection in all but 4 shoulders, with a resultant persistent infection rate of 15%. Three patients with a persistent infection were active smokers. The indication for treatment in these 4 patients was an infected open reduction and internal fixation in 1, a native shoulder infection in 1, and PJI in 2. The causative organism was methicillin-resistant Staphylococcus aureus in 3 (the fourth was considered a culture-negative infection). Data related to these 4 shoulders are summarized in Table 5. One of these patients previously underwent 5 procedures, including a hemiarthroplasty for avascular necrosis followed by conversion to an anatomic total shoulder arthroplasty that was complicated by glenoid loosening requiring component removal. Ultimately, this was complicated by infection that failed 2 prior irrigation and debridements. Another patient had failed two-stage exchange after an infected reverse total shoulder arthroplasty performed elsewhere.

Reinfections

Table 5:

Reinfections

There were 4 additional reoperations. Two patients underwent revision of their antibiotic spacer. The first returned to the clinic with drainage and elevated inflammatory markers 3 weeks following the initial spacer placement. The second patient had significant bone loss with a spacer that showed loss of axial stability associated with increasing inflammatory markers at 4 months. This patient had a prolonged course of intravenous antibiotics due to a Candida parapsilosis infection. The spacer contained amphotericin B in addition to gentamicin and vancomycin. A third patient who underwent reimplantation of a hemiarthroplasty developed symptomatic glenoid erosion and underwent conversion to a reverse total shoulder arthroplasty with a satisfactory result. The fourth patient had a periprosthetic fracture with substantial proximal humeral bone loss and was revised to an allograft prosthetic composite reconstruction.

Radiographic Outcomes

Radiographs with the spacer in place were available for all shoulders. The spacer was found to be grossly unstable with loss of axial stability in 3 (4%) shoulders. In each instance, there was significant proximal humeral bone loss, which ultimately required an allograft prosthetic composite in 1 and metal augmentation in 1. On the anteroposterior radiographs, 17 (63%) spacers were noted to have moderate or severe superior subluxation, 13 of which were in group I. On the axillary lateral radiographs, 16 (59%) spacers were perfectly centered on the glenoid, 4 (15%) had slight anterior subluxation, and 7 (26%) had severe anterior subluxation or dislocation (Figure 1). Five of the severe subluxations occurred in group II. The other 2 cases of severe anterior subluxation, which were noted in group I, occurred in shoulders with massive proximal humeral bone loss. Regarding implant fixation after the second stage reimplantation, none of the humeral or glenoid components were considered radiographically loose, with no lucent lines and no change in component position.

Anteroposterior (A) and lateral (B) radiographs of a well-centered and balanced molded antibiotic spacer used to treat a patient with an infected reverse total shoulder arthroplasty as part of a two-stage treatment.

Figure 1:

Anteroposterior (A) and lateral (B) radiographs of a well-centered and balanced molded antibiotic spacer used to treat a patient with an infected reverse total shoulder arthroplasty as part of a two-stage treatment.

Discussion

Deep glenohumeral joint infections may require different treatment strategies depending on the condition of the shoulder, the nature of the infection, comorbidities, and other factors. Although irrigation and debridement with component retention and one-stage reimplantation are accepted alternatives for selected patients, two-stage reimplantation is particularly common in North America, especially for PJIs.4,5,9,29,30 Potential benefits of two-stage reimplantation include the ability to perform a repeat thorough debridement if necessary, more reproducible results, and theoretically a decreased need for chronic suppression by performing complete surgical eradication of the infectious organism.3,16

The use of a molded antibiotic spacer serves several functions. Most importantly, like all antibiotic spacers, it allows for local elution of antibiotics to help eradicate an infection.31 Additionally, by maintaining adequate soft tissue tension of the rotator cuff and glenohumeral capsular tissue, it provides an opportunity for these structures to heal with the correct length. Furthermore, when motion can be instituted in between stages, less stiffness and more anatomic tissue planes may facilitate exposure and implantation of a definitive prosthesis during the second stage. The results of the current study seem to indicate that two-stage reimplantation with the use of a temporary molded antibiotic spacer may lead to eradication of infection in 85% of the shoulders. Furthermore, the findings of this study support spacer stability and the implementation of early formal physical therapy when there is sufficient proximal humeral bone support and adequate capsule and rotator cuff tissues. Early rehabilitation may result in an easier reimplantation, shorter operative times, better pain scores at most recent follow-up, and a trend toward better motion.

In patients with multiple comorbidities and at high risk for perioperative medical complications, a molded antibiotic spacer that is radiographically stable can serve as the definitive prosthesis. In the current cohort, no patients met this criterion. However, several other studies have reported on the use of an antibiotic spacer as a definitive prosthesis.25,26,32–34 Mahure et al25 reported on 9 patients who underwent definitive insertion of a prefabricated antibiotic spacer shaped to a hemiarthroplasty. They reported reasonable functional outcomes with a mean American Shoulder and Elbow Surgeons score of 57, but with limited range of motion (mean forward flexion, 67°). Romanò et al33 reported on 15 patients who underwent treatment of chronic PJI with a permanent antibiotic spacer. Eighty percent of the patients treated with a definitive spacer had an excellent or satisfactory modified Neer rating, with a mean shoulder abduction of 51°. Thus, based on the available literature, although a definitive antibiotic spacer is a reasonable option for low-demand patients with multiple comorbidities, the functional outcomes are generally limited.32

These studies illustrate several challenges with other prefabricated molded antibiotic spacers, including inability to customize antibiotics and restricted size options.13,25,26 Although the current authors generally follow a standard antibiotic regimen as mentioned earlier, the antibiotics to be added to the spacer may be modified if needed. For instance, patients with a known fungal infection have amphotericin B antibiotic powder added to the spacer. Regarding sizing of an antibiotic spacer, the ability to employ varying stem sizes and head diameters allows the surgeon to control rotational stem stability and tensioning of the soft tissues for subsequent procedures and restore joint stability.

Another benefit to molded cement spacers is the overall ease of use and potential for decreased operative time. Several studies have shown effective results for eradicating infection with the use of hand-molded spacers. Padegimas et al19 demonstrated 100% eradication in 37 shoulders using stemless or stemmed hand-molded antibiotic spacers. The average operative times, however, were 127 and 130 minutes, respectively. This is compared with an overall mean of 65 minutes in the current cohort.

Magnan et al13 reported on 7 patients treated with a preformed antibiotic-loaded spacer for PJI in 2, osteomyelitis after open reduction and internal fixation in 2, and native septic arthritis in 3. The spacer contained only gentamicin, but Magnan et al13 added additional cement that had vancomycin added to it. Passive range of motion was permitted in all cases. Magnan et al13 reported overall good outcomes, with a mean elevation of 102.5°. The current data indicate that the introduction of range of motion exercises in between stages does make the reimplantation faster and seems to improve final range of active elevation without apparent detriment for infection eradication. Given the small sample, however, some of these trends did not reach statistical significance.

This study had several additional limitations. The indications for treatment were heterogeneous, with varied past histories based on the number of prior procedures and whether an attempt to treat an infection had been made previously. Additionally, during the study period, the authors did not verify the extent to which patients were performing range of motion exercises, nor did they confirm the compliance of patients who were instructed not to perform range of motion exercises in between stages.

Nonetheless, this study highlights several key factors of molded antibiotic cement spacers used to treat shoulder infections. First, the ability to customize antibiotics is a clear benefit, particularly for patients with infections caused by less commonly encountered bacteria as well as fungal infections. Second, the ability to have multiple size options aids with providing stability of the spacer and an appropriate length tension relationship of the shoulder girdle musculature. The ability to have multiple head options improves the centering of the humeral head on the glenoid and can perhaps minimize interval glenoid bone loss prior to the second stage. In the current cohort, several spacers were revised due to loss of axial stability, particularly in shoulders with substantial proximal humeral bone loss. In these circumstances, the authors now favor additional proximal cement to increase the stability of the cement spacer. Third, an appropriately shaped and fitting antibiotic spacer that permits range of motion, maintains neuromuscular activity of the shoulder girdle musculature, and allows a smooth surface to articulate with the glenoid may in fact allow for ease of reimplantation, greater patient satisfaction with a challenging condition, and ultimately better pain relief and better range of motion.

Conclusion

Implantation of an antibiotic-impregnated cement spacer molded intraoperatively to the shape of hemiarthroplasty safely allows range of motion exercises in between surgical stages, provided the capsule, rotator cuff, and bone quality are sufficient. Therapy in between stages seems to facilitate the second stage and trends toward improved pain and range of motion. Further improvements in the management of shoulder PJI are required to decrease the rate of persistent infection.

References

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Demographic Data

CharacteristicGroup I ROM (16 Shoulders)Group II No ROM (11 Shoulders)Overall (27 Shoulders)Group I vs Group II P
Sex.382
  Male62%45%56%
  Female38%55%44%
Age at shoulder surgery, mean, y62.454.859.3.041a
Dominant extremity56%73%63%.387
Body mass index, mean, kg/m233.427.531.0.002a
Prevalence of diabetes13%27%19%.344
Tobacco use.094
  Never56%27%44%
  Current25%27%26%
  Past19%46%30%
Steroid use6%0%4%.303
ASA score, mean (range)2.0 (2 to 2)2.5 (2 to 3)2.2 (1 to 3).002a
Follow-up, mean (range), mo31.0 (24.0 to 45.2)27.8 (24.0 to 37.6)29.6 (24.0 to 45.2).154

Causative Organism and Frequency, as Determined by Intraoperative Cultures

Causative OrganismNo.
Propionibacterium acnes10
Methicillin-resistant Staphylococcus aureus3
Methicillin-sensitive Staphylococcus aureus2
Staphylococcus lugdunensis2
Candida parapsilosis2
Staphylococcus epidermidis1
Streptococcus viridans1
Peptostreptococcus species1
Polymicrobial
   Serratia marcescens, Pseudomonas aeruginosa1
No growth3

Range of Motion

ROMGroup I ROM (16 Shoulders)Group II No ROM (11 Shoulders)P
Elevation, mean (range)115° (42° to 160°)93° (30° to 165°).3
External rotation, mean (range)37° (10° to 80°)38° (10° to 70°).9
Internal rotationL5L5.7

Anesthesia and Operative Times

Procedure Time per StageGroup I ROM (16 Shoulders)Group II No ROM (11 Shoulders)P
Stage 1
  Anesthesia time, mean (range), min142.1 (97 to 182)153.6 (102 to 228).43
  Operative time, mean (range), min59.1 (35 to 96)73.5 (25 to 153).25
Stage 2
  Anesthesia time, mean (range), min155.6 (133 to 180)165.6 (122 to 249).37
  Operative time, mean (range), min82.9 (53 to 104)92.7 (53 to 104).26

Reinfections

Patient Age, y/SexGroupTobacco UseNo. of Prior ProceduresBMI, kg/m2Causative OrganismIndicationReimplanted ProsthesisTime to Reinfection, moOther ComplicationsManagement
45/MIIYes125.8MRSAInfected ORIFRTSA7Multiple prosthetic dislocations requiring 2 open reductions eventually leading to reinfectionConverted to resection arthroplasty
63/FIIYes124.6MRSANative shoulder infection after rotator cuff repairRTSA24Repeat two-stage exchange with conversion to hemiarthroplasty due to significant glenoid bone loss
56/MIIYes530.5MRSAPJI—failed I&DRTSA1Repeat two-stage exchange with conversion to hemiarthroplasty due to significant glenoid bone loss
69/FINo331.7No growthPJI—failed two stageRTSA3Repeat two-stage exchange with only 3-mo follow-up
Authors

The authors are from the Mayo Clinic, Rochester, Minnesota.

Drs Aibinder and Shukla have no relevant financial relationships to disclose. Dr Lee has received grants from Wright-Tornier and Arthrex and is a paid speaker for Arthrex. Dr Cofield receives royalties from DJO. Dr Sanchez-Sotelo is a paid consultant for Stryker. Dr Sperling receives royalties from Zimmer-Biomet.

Correspondence should be addressed to: John W. Sperling, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ( Sperling.john@mayo.edu).

Received: February 27, 2019
Accepted: June 03, 2019

10.3928/01477447-20190701-01

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