J Shoulder Elbow Surg (2014) 23, 1473-1480
www.elsevier.com/locate/ymse
2014 Neer Award Paper: Neuromonitoring the
Latarjet procedure
Ruth A. Delaney, MB BCh, BAO, MRCSa, Michael T. Freehill, MDa, David R. Janfaza, MDb,
Kamen V. Vlassakov, MDb, Laurence D. Higgins, MDc, Jon J.P. Warner, MDa,*
a
Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA
Department of Anesthesiology, Brigham & Women’s Hospital, Boston, MA, USA
c
Boston Shoulder Institute, Brigham & Women’s Hospital, Boston, MA, USA
b
Background: We used intraoperative neuromonitoring to define the stages of the Latarjet procedure during
which the nerves are at greatest risk.
Methods: Thirty-four patients with a mean age of 28.4 years were included. The Latarjet procedure was
divided into 9 defined stages. Bilateral median and ulnar somatosensory evoked responses and transcranial
motor evoked potentials from all arm myotomes were continuously monitored. A ‘‘nerve alert’’ was
defined as averaged 50% amplitude attenuation or 10% latency prolongation of ipsilateral somatosensory
evoked responses and transcranial motor evoked potentials. For each nerve alert, the surgeon altered
retractor placement, and if there was no response to this, the position of the operative extremity was
then changed.
Results: Of 34 patients, 26 (76.5%) had 45 separate nerve alert episodes. The most common stages of the
procedure for a nerve alert to occur were glenoid exposure and graft insertion. The axillary nerve was
involved in 35 alerts; the musculocutaneous nerve, in 22. Of the 34 patients, 7 (20.6%) had a clinically
detectable nerve deficit postoperatively, all correlated with an intraoperative nerve alert. All cases involved
the axillary nerve, and all resolved completely from 28 to 165 days postoperatively. Prior surgery and body
mass index were not predictive of a neurologic deficit postoperatively. However, total operative time
(P ¼ .042) and duration of the stage of the procedure in which the concordant nerve alert occurred
(P ¼ .010) were statistically significant predictors of a postoperative nerve deficit.
Conclusions: The nerves, in particular the axillary and musculocutaneous nerves, are at risk during the
Latarjet procedure, especially during glenoid exposure and graft insertion.
Level of evidence: Level IV, Case Series, Treatment Study.
Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Instability; Latarjet procedure; neurologic complications; axillary nerve; musculocutaneous
nerve
Partners Healthcare Institutional Review Board approval: Protocol #
2011P000188.
*Reprint requests: Jon J.P. Warner, MD, The Harvard Shoulder Service,
55 Fruit St, Yawkey Center for Outpatient Care, Suite 3200, 3G, Room 3046, Boston, MA 02114, USA.
E-mail address: jwarner@partners.org (J.J.P. Warner).
The Latarjet procedure is a proven, established method
of treating glenohumeral instability, particularly when there
is bone loss of the glenoid or after a failed soft tissue
instability repair. One large series reported a 5% redislocation rate and 96% patient satisfaction.5 Other large
series have reported more than 1000 procedures with an
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2014.04.003
1474
R.A. Delaney et al.
Figure 1 Typical surgical positioning and neuromonitoring lead placement before (A) and after (B) placement of iodophor surgical drape.
(Note that the leads distal to the elbow were placed and protected before the arm was placed in the holder.)
instability recurrence of 1%.14,15 There is concern that the
nonanatomic transfer of the coracoid alters anatomy of the
surrounding nerves. It has been shown in a cadaveric study
that the Latarjet procedure resulted in significant alterations
in the anatomic relationships of the axillary and musculocutaneous nerves.2 In addition, the challenges of performing a Latarjet procedure have been highlighted in the
literature by reports of its complications.17 A recent systematic review concluded that this procedure has a 30%
overall complication rate and a 1.8% rate of neurovascular
complication.3 Furthermore, short-term complications of
the Latarjet procedure were reported to have an overall rate
of 25%, with a 10.4% rate of neurologic injury. In that
series, there was a 4% rate of neurologic injury that did not
improve with conservative measures.12
Neuromonitoring has been used in such varied disciplines
as intracranial surgery, vascular surgery, and thyroid surgery
and extensively in spine surgery. More recently, neuromonitoring has been used in shoulder surgery, including
arthroplasty and proximal humerus fracture fixation.11,16
Given the reported rate of neurologic injury, we undertook to study in more depth the neurologic complications of
the Latarjet procedure by using intraoperative neuromonitoring to define the stages of the procedure during
which the nerves are at greatest risk for iatrogenic injury.
Methods
We prospectively performed intraoperative neuromonitoring of 40
patients undergoing the Latarjet procedure for shoulder instability
between April 1, 2011, and December 31, 2012, by the two senior
surgeons. We excluded 2 patients from the study because of
limitation of neuromonitoring to somatosensory evoked potentials
(SSEPs) due to a history of brain trauma and the presence of
aneurysm clips. Three more patients were excluded because of
technical difficulties with the neuromonitoring equipment intraoperatively. One patient required inhalational anesthesia, which
degraded the quality of the neuromonitoring, and this patient was
excluded from the study. Therefore, 34 patients (28 male patients,
6 female patients) met the inclusion criteria. Mean age at surgery
Figure 2 Motor (TcMEP and EMG) baseline tracings at the
beginning of a case.
was 28.4 years (range, 15-66 years). Eighteen patients (52.9%)
had surgery on the dominant extremity.
All Latarjet procedures were performed open, in the beach
chair position, through a deltopectoral approach. Propofol was
used for induction of anesthesia, and a short-acting neuromuscular
blocking agent (succinylcholine) was used to facilitate intubation.
The standardized anesthesia was total intravenous anesthesia with
continuous depth of anesthesia monitoring and without muscle
relaxation or peripheral nerve block.
The neuromonitoring protocol was based on published literature11,16 and on the advice of two board-certified attending neurophysiologists. After patient positioning, stimulating and
recording leads were placed in the scalp and the upper extremities,
respectively (Fig. 1). The parameters measured were median
Neuromonitoring the Latarjet procedure
1475
Figure 3 Key stages of the Latarjet procedure. (A) Coracoid exposure. (B) Coracoid harvest. (C) Subscapularis split. (D) Glenoid
exposure. (E). Graft placement.
SSEPs, myogenic motor evoked responses evoked by transcranial
electrical stimulation (TcMEPs), and free electromyogram
(EMG). TcMEPs and free EMG were recorded from deltoid, triceps, biceps, extensor carpi radialis longus, abductor pollicis
brevis, and abductor digiti minimi muscles. Myotomes were
selected on the basis of major innervation patterns of the brachial
plexus and peripheral nerves considered to be at risk during this
procedure. Contralateral median nerve SSEPs as well as contralateral arm TcMEPs and free EMG were recorded for reference.
Before incision, adequate reversal of the neuromuscular
blocking agent was confirmed by obtaining 4 muscle twitches
from the abductor digiti minimi muscle of the nonoperative extremity in response to train-of-4 electrical stimulation of the ulnar
nerve, stimulating at 2 Hz at a supramaximal stimulus plus 10%.
Baseline TcMEPs were measured 20 minutes after induction,
before incision (Fig. 2). These were recorded with the operative
arm in neutral position, in external and internal rotation with the
arm at the side, and in neutral abduction and abducted external
and internal rotation.
Depth of anesthesia was monitored throughout the procedure,
and if there was any change greater than 15%, new TcMEP
baselines were measured. Otherwise, there was no change in
stimulation strength for SSEPs to MEPs after baseline responses
were collected.
A significant nerve alert event, implying impending excessive
traction on a neural element, was defined as 50% attenuation and
10% prolongation of latency in SSEPs; 50% attenuation, 10%
latency prolongation in TcMEPs (highest peak to lowest trough),
1476
or significant change (80% decrease) in waveform amplitude; or
sustained neurotonic discharge on EMG. An early warning alert
was called if a polyphasic TcMEP response became biphasic.
The Latarjet procedure was divided into 9 stages: (1) incision,
(2) coracoid exposure, (3) coracoid harvest, (4) subscapularis split,
(5) glenoid exposure, (6) glenoid preparation, (7) graft insertion,
(8) subscapularis closure, and (9) skin closure (Fig. 3). The
duration of each stage was recorded intraoperatively, as was the
total operative time. When a nerve alert was signaled by the
neurophysiologist, retractors were removed in a step-wise fashion,
beginning with the retractor believed by the surgeon to be most
likely causing the stretch or insult of the nerve involved in the
alert. If this did not result in improvement of the neuromonitoring
parameters, the operative arm was returned to a more neutral
position. For each nerve alert, the nerves involved, the stage of the
procedure, the number and position of retractors, the position of
the operative arm, and the time elapsed until return to above nerve
alert threshold were recorded by a separate member of the
research team not directly involved in the surgery. After a nerve
alert, the procedure continued with an attempt to limit or, where
possible, completely avoid the provocative position.
Postoperatively, the patient received a complete neurologic
examination of the operative extremity at the earliest possible
opportunity in the recovery room. Any clinically detectable deficits and their correlation with intraoperative nerve alerts were
recorded.
The occurrence of a nerve alert and the occurrence of a clinically detectable postoperative neurologic deficit were each
analyzed as separate outcomes. Statistical analysis of potential
risk factors for each outcome was performed with the Fisher exact
test, the Student t-test, and logistic regression. The following
factors were analyzed: prior surgery on the operative shoulder,
body mass index, total operative duration, and duration of stage of
the procedure.
Of the 34 patients, 19 had prior surgery on the shoulder undergoing the Latarjet procedure, including 5 patients who had 2
previous failed procedures. The prior procedures included
arthroscopic Bankart repair (n ¼ 17 in 14 shoulders), arthroscopic
bony Bankart repair (n ¼ 1), open labral repair/capsular shift
(n ¼ 4 in 3 shoulders), and arthroscopic repair of humeral avulsion
of the glenohumeral ligaments (n ¼ 2 in 1 shoulder).
There were no complications related to the neuromonitoring.
Two patients, both young men with questionable postoperative
compliance and no other overt cause of failure, displaced their
coracoid graft within 6 weeks and were revised to an EdenHybinette procedure, both of which were also neuromonitored,
with no nerve alerts occurring during either the primary Latarjet
procedure or the revision Eden-Hybinette procedure. There were
no other recurrences of instability.
The patients were seen at regular intervals postoperatively, as
is standard for the Latarjet procedure, with the first visit at 10 to
14 days postoperatively and subsequent visits at approximately
6 weeks and 3 months. At each visit, a detailed neurologic examination of the operative extremity was documented.
Results
Of the 34 patients, 26 (76.5%) had at least 1 nerve alert
during their surgery. Of these, 12 patients had 1 nerve alert,
11 patients had 2 nerve alerts, 1 patient had 3 nerve alerts,
R.A. Delaney et al.
Figure 4 An axillary nerve alert during glenoid exposure.
Attenuation of the axillary nerve TcMEP is shown in the top left
of the screen (white tracing), in contrast to the normal TcMEP
tracing in the right panel for the nonoperative arm.
Table I Intraoperative nerve alerts and nerves affected
during each stage of the procedure
Stage
1.
2.
3.
4.
5.
6.
7.
8.
No. of Nerves involved
nerve
alerts
Incision
0
Coracoid exposure
3
Coracoid harvest
4
Subscapularis split
2
Glenoid exposure
12
Glenoid preparation 4
Graft placement
17
0
Subscapularis
closure
9. Skin closure
3
d
MC, ulnar, Ax þ MC
Ax, MC, ulnar, Ax þ MC
Ax, Ax þ radial
Ax (2), MC (3), Ax þ MC (7)
MC (2), Ax þ MC (2)
Ax (13), MC (1), Ax þ MC (2)
d
Ax (3)
Ax, axillary nerve; MC, musculocutaneous nerve.
Total 45 alerts.
and 2 patients each had 4 nerve alert events. Eight patients
had no nerve alerts and no clinically detectable deficit
postoperatively. The most common nerve to be involved in
a nerve alert was the axillary nerve (involved in 35 alerts of
45 total alerts [78%]). Most of the alerts (41 of 45 alerts
[91%]) were based on attenuation of TcMEPs to less than
50% of baseline (Fig. 4). Two alerts were based on SSEPs,
1 was based on EMG, and 1 was based on both EMG and
TcMEPs. Of the total 45 nerve alerts, 15 alerts involved 2
Neuromonitoring the Latarjet procedure
1477
Figure 5 Number of nerve alerts in relation to whether retractors were in place at the time (yes/no) and arm position at the time of alert
(yes/no for each given position). ER, external rotation; ABD, abduction; FLEX, flexion.
nerves simultaneously (most commonly axillary and musculocutaneous). No alert involved more than 2 peripheral
nerves (Table I). In 20 of the 26 nerve alerts (77%), baseline neuromonitoring parameters were recovered at a mean
of 10 minutes (range, 0.5-34 minutes).
The number of nerve alerts for different arm positions
and presence of retractors is illustrated in Figure 5. In 4 of
the 45 alerts (9%), there were no retractors in place at the
time of the alert. During these 4 alerts, the arm was in
neutral position. One of these alerts involved the ulnar
nerve, and the stockinette and arm holder were adjusted,
with return to baseline of the ulnar nerve SSEP that had
defined the alert. The other 3 alerts occurred in neutral
position with no retractors in place during skin closure.
These all involved the axillary nerve, and 2 of the 3 patients
had previously had an axillary nerve alert during an earlier
stage of the procedure. These alerts may reflect failure to
fully recover from the previous alert or stretch on
the axillary nerve as it accommodates to the new, nonanatomic course imposed on it by the presence of the coracoid
graft.
Seven patients (20.6%) had a clinically detectable
neurologic deficit postoperatively, all involving the axillary
nerve and all correlating with an intraoperative axillary
nerve alert. These patients’ nerve alerts, intraoperative action taken, and details of the nerve palsies are summarized
in Table II. Two patients had previous arthroscopic Bankart
repairs; the other 5 had no prior surgery on that shoulder.
All seven patients’ nerve palsies had fully resolved by the
time of latest follow-up, with a mean time to resolution of
86.6 days (range, 28-165 days) (Table II).
In three patients who had a nerve deficit postoperatively,
additional steps were taken intraoperatively in an attempt to
relieve tension from the axillary and musculocutaneous
nerves: repositioning of the coracoid graft (2 patients) and
division of fascia over conjoined tendon with specific
axillary nerve release (1 patient). In the 2 patients whose
coracoid graft was repositioned, the graft was removed
because of failure to recover baseline signals in the axillary
and musculocutaneous nerves after a nerve alert during
graft insertion. In both cases, the graft was reinserted in a
more superior position, and in one case, a hand surgeon
with expertise in nerve microsurgery scrubbed in and
verified that the axillary nerve was grossly intact. Both of
these patients had a mild sensory axillary neurapraxia and
one had in addition mild deltoid weakness. These clinical
findings persisted at 12 days postoperatively in both patients and resolved by 28 and 37 days postoperatively,
respectively. In the one patient for whom division of the
fascia over the conjoined tendon and release of the axillary
nerve from all tension was performed, the axillary nerve did
not fully recover on neuromonitoring. Postoperatively, he
had a sensory neurapraxia and deltoid weakness. Plain film
radiographs demonstrated inferior humeral head subluxation. This had resolved at 120 days postoperatively, with
return of full deltoid strength.
Statistical analysis showed that prior surgery, body mass
index, total operative time, and duration of stage of the
procedure were not statistically significant predictors of the
occurrence of a nerve alert, although total operative time
and duration of stage of the procedure each showed a
relationship trending toward significance (P ¼ .063 and
P ¼ .061, respectively).
Prior surgery, body mass index, and number of nerve
alerts during surgery were not predictive of a clinically
detectable neurologic deficit postoperatively; however, total
operative time and duration of the stage of the procedure in
which the concordant nerve alert occurred were statistically
significant predictors of a postoperative nerve deficit
(Fig. 6).
The mean operative time in the group with no clinical
nerve deficit was 106 minutes, and the mean operative time
in patients with a clinically detectable neurologic deficit
was 139.6 minutes (P ¼ .042). The mean duration of a stage
1478
R.A. Delaney et al.
Table II
Summary of clinically detectable neurologic deficits
Study Nerve alerts
ID
101
110
115
119
Action taken
1. Axillary
Retractor removed
Arm repositioned from
abduction to adduction
1. Musculocutaneous Retractor removed
2. Axillary
Retractors removed
3. Axillary
Retractors removed
Graft removed and reinserted
more superiorly
4. Axillary
Retractors removed
Conjoined tendon taken down
completely and tenodesed,
coracoid placed as free graft
1. Axillary þ
Retractors removed
musculocutaneous
2. Axillary þ
Retractors removed
musculocutaneous
1. Musculocutaneous Retractors removed
2. Axillary þ
Retractors removed
musculocutaneous
122
3. Axillary þ
Retractor removed
musculocutaneous Graft removed and reinserted
more superiorly
1. Axillary
Retractors removed
124
1. Axillary
126
1. Axillary and
Retractors removed
musculocutaneous Fascia over the transferred
conjoined tendon divided
to take tension off axillary
nerve
Retractors removed
of the procedure during which a nerve alert occurred,
resulting in a clinical deficit, was 26.8 minutes compared
with a mean stage duration of 11.2 minutes when there was
a nerve alert but with no resulting clinical nerve deficit
from that stage (P ¼ .010) (Fig. 6).
Discussion
The Latarjet procedure, first described in 1954,8 has
regained popularity in North America as a surgical option
for the treatment of both primary and recurrent shoulder
instability. Latarjet first described a series of 4 patients with
recurrent anterior instability of the shoulder in whom he
transferred the coracoid process with the conjoined tendon
to the anterior scapular neck, securing it with a bone screw.
Neuromonitoring
return to above
alert threshold
Clinical deficit
Timing of resolution
No
Yes
Mild axillary sensory
neurapraxia
Yes
Yes
No
Yes
Mild axillary sensory
and motor
neurapraxia
Deficit present at 40
days, resolved by
89 days
Deficit present at
12 days, resolved
by 37 days
No
No
Yes
Mild axillary sensory
neurapraxia
Deficit present at
12 days, resolved
by 40 days
No
Mild axillary sensory
Axillary returned;
neurapraxia
musculocutaneous
incomplete
No
Incomplete recovery
of both nerves
Yes
Mild axillary sensory
neurapraxia and
deltoid weakness
Deficit present at
12 days, resolved
by 28 days
Yes
Yes
No
No
Both deficits present
at 12 days; motor
resolved by 47 days,
sensory resolved
by 127 days
Deltoid weakness
Deficit present at
35 days, resolved
by 165 days
Deltoid weakness and Both deficits present
in recovery room;
mild sensory
sensory resolved
neurapraxia
by 12 days, motor
resolved by 120 days
The original technique of coracoid transfer as described by
Latarjet involved cutting the subscapularis tendon; this has
subsequently been modified to a subscapularis split in some
technique descriptions, preserving the tendon attachment.
Helfet described the Bristow procedure in 1958, named for
his former chief, W. Rowley Bristow.4 In this procedure, the
osteotomized coracoid (although a shorter graft length than
the traditional Latarjet) and conjoined tendon were sutured
only to the capsuloperiosteal elements of the anterior glenoid. Later, May described a modification to the Bristow
procedure that again fixed the transferred coracoid fragment and conjoined tendon with a bone screw in a manner
similar to the original Latarjet procedure.10
In Europe, some surgeons use the Latarjet procedure as
the primary procedure of choice for anterior instability of
the shoulder, with the Eden-Hybinette procedure as the
Neuromonitoring the Latarjet procedure
Figure 6 Mean duration of the stage of the procedure during
which a nerve alert occurred, resulting in a clinical deficit,
compared with mean stage duration when no clinical nerve deficit
resulted from that stage.
procedure of choice for any recurrence of instability after
Latarjet.9 High reported failure rates of arthroscopic soft
tissue stabilization in cases of glenoid deficiency may
explain the resurgence of the Latarjet procedure.1
The incidence of neurologic injury after the Latarjet
procedure has been reported to vary from 1.8% to
10.4%.4,12,17 There have also been isolated reports of injury
to the musculocutaneous nerve and the suprascapular
nerve.7,13 Freehill et al described the alteration in the
anatomy of the musculocutaneous and axillary nerves after
the Latarjet procedure.2 Their cadaveric study found that
the musculocutaneous nerve moved inferior to the anterior
glenoid rim after the Latarjet procedure. The axillary and
musculocutaneous nerves also became more medial to their
original position, which may make them vulnerable to
injury if a subsequent procedure is performed. They also
showed that the musculocutaneous and axillary nerves
consistently overlap each other after a Latarjet procedure,
obscuring the future identification of either nerve. However,
in that study, the graft was placed after taking the upper
subscapularis down vs a split in the muscle, and therefore
tensions and positions of nerves may have slight differences
on the basis of the technique used.
We acknowledge limitations of our study. First, the
small sample size was underpowered to demonstrate a
difference in incidence of neurologic complication due to
neuromonitoring. Second, there was susceptibility to
observer bias as the clinicians examining the patients
postoperatively looking for a neurologic deficit were aware
of the study and the need for a thorough neurologic examination, which may not have been consistently performed in other Latarjet patients outside of this study. Prior
studies on the incidence of neurologic injury after the
Latarjet procedure have diagnosed injury primarily through
the postoperative examination.12 This may cause the reported incidence to be lower, as complete neurologic examination of the postoperative shoulder is often difficult
1479
and limited by pain. Furthermore, given that most nerve
injuries are thought to be transient, it is possible that some
of the intraoperative nerve injuries resolve before they are
recognized clinically. Third, it is challenging to reconcile
the high sensitivity of the intraoperative neuromonitoring
with clinical significance postoperatively. Some intraoperative nerve alerts, although physiologically valid,
had no postoperative clinical relevance as evidenced by the
19 patients in our series who had intraoperative nerve
alerts but no clinically detectable neurologic deficit
postoperatively.
In our series of 34 patients, 26 (76.5%) had intraoperative nerve alerts, necessitating a surgical pause,
removal of retractors, and in some cases repositioning of
the operative arm to a more neutral position. It is likely that
a nerve injury was prevented in at least some of these patients. In 27 of the 45 alerts (79.4%), the operative arm was
positioned in external rotation at the time of the nerve alert.
External rotation and abduction have been shown biomechanically by Kwaan and Rappaport to produce traction on
the brachial plexus,6 supporting the theory that these nerve
alerts were most likely caused by stretch of the nerves
involved. This finding can be used by surgeons in performing the procedure to periodically relax the arm when it
is noted that the axillary nerve is on high stretch.
In 5 patients, additional steps were taken in an attempt to
reduce the risk of nerve injury. In 2 patients, the graft was
removed and repositioned more superiorly when other
measures (retractor removal, arm repositioning) did not
resolve a nerve alert that had occurred during graft insertion.
The altered course of the axillary nerve around the transplanted coracoid appears to risk stretching of the nerve, and a
slightly more superior graft position may therefore be protective. However, the coracoid graft must still remain subequatorial if stability is to be reliably achieved. We typically
aim for a graft position at 4 to 5 o’clock on the glenoid of a
right shoulder.
Of the 45 nerve alerts, 29 (64.4%) occurred during either
glenoid exposure or graft insertion, highlighting that these
stages of the procedure carry the highest risk of neurologic
injury.
Operative time and duration of high-risk stages of the
procedure were shown to be risk factors for a clinically
detectable neurologic injury. These data provide a rationale
for moving expeditiously through these stages of the procedure and, if there is an intraoperative delay for any reason,
removing retractors and repositioning the arm to neutral.
Conclusion
The nerves of the brachial plexus, in particular the
axillary nerve and the musculocutaneous nerve, are
at risk during the Latarjet procedure. During neuromonitoring, nerve alerts happen frequently, and it can be
1480
possible for the surgeon to reduce them with some
technical measures. Transient neurologic deficits are
noted after this surgery that may be missed if careful
neurologic examination is not performed. Neuromonitoring may especially have a role in situations in
which one might anticipate risk to nerves, such as
longer, revision surgery with severe scarring and
distortion of anatomy. The most common stages of the
Latarjet procedure during which the nerves are under
excessive tension are glenoid exposure and graft insertion. During these stages, the arm is often externally
rotated, and the surgeon should be especially meticulous
and consider duration of retraction during these stages,
with potential periods of retractor and arm relaxation.
The significant predictors of a clinical neurologic deficit
postoperatively were the total operative duration and the
duration of these high-risk stages of the procedure,
suggesting that the surgery, in particular those high-risk
stages, should be completed as expeditiously as possible.
R.A. Delaney et al.
2.
3.
4.
5.
6.
7.
8.
9.
Disclaimer
Michael T. Freehill is a consultant for Smith & Nephew.
Laurence D. Higgins receives fellowship support
from Arthrocare; DJ Orthopaedics; Arthrex, Inc; Mitek;
Breg; and Smith & Nephew.
Jon J.P. Warner receives fellowship support from
Arthrocare; DJ Orthopaedics; Arthrex, Inc; Mitek; Breg;
and Smith & Nephew. He receives royalties from Tornier, Inc, and has equity in Orthospace and Vumedi.
The other authors, their immediate families, and any
research foundation with which they are affiliated did not
receive any financial payments or other benefits from any
commercial entity related to the subject of this article.
10.
11.
12.
13.
14.
15.
16.
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