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. 2018 Apr 26;476(7):1468–1476. doi: 10.1097/01.blo.0000533627.07650.bb

Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

Paul M Lichstein 1,2,✉, John P Kleimeyer 1,2, Michael Githens 1,2, John S Vorhies 1,2, Michael J Gardner 1,2, Michael Bellino 1,2, Julius Bishop 1,2
PMCID: PMC6437565  PMID: 29698292

Abstract

Background

A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated.

Questions/purposes

(1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?

Methods

Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm2) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation.

Results

After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm2 (95% confidence interval [CI], 0.45-4.28 cm2; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm2 (95% CI, 1.42-5.24 cm2; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470).

Conclusions

In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach.

Clinical Relevance

Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

Introduction

Displaced femoral neck fractures are an important source of morbidity and mortality in orthopaedic trauma patients. In young patients, anatomic reduction and stable internal fixation are the surgical goal; quality of reduction is a crucial predictor of outcome [13, 16, 34, 42, 46]. When closed manipulation is inadequate for anatomic reduction, an open surgical approach is frequently advocated to further facilitate fracture reduction. The modified Smith-Petersen approach (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approach to the femoral neck are commonly used for fracture reduction and fixation [47]. Each approach has distinct advantages and disadvantages. The Watson-Jones approach allows fracture reduction and implant placement through a single incision and may be preferred to address basicervical fracture patterns; however, some surgeons believe direct visualization of the anterior femoral neck and placement of reduction aids can be difficult. In addition, although the plane of dissection is intermuscular between the gluteus medius and tensor fasica lata, there is no internervous plane and abductor weakening may occur. In contrast, the modified Smith-Petersen approach utilizes a true intermuscular and internervous plane, allows more direct access to the femoral neck for visualization and manipulative reduction, and may be utilized to address additional pathology such as femoral head fractures [38]. However, an additional lateral approach is needed for the placement of laterally based implants and there is risk of iatrogenic injury to the lateral femoral cutaneous nerve (LFCN).

A surgical exposure that facilitates visualization, reduction, and stable fixation is critical to successful surgical treatment. Although previous research has demonstrated that the modified Smith-Petersen approach provides excellent exposure to the femoral neck [7], we are not aware of any previous investigation that has compared the visualized and indirect exposure of the femoral neck and other anatomic landmarks offered by these commonly used approaches.

We therefore asked: (1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?

Materials and Methods

We conducted an experimental anatomic study using cadaveric femoral neck exposures using 10 fresh-frozen human cadaver pelvis specimens sectioned from L1 through the bilateral femoral isthmus (Table 1). We excluded specimens that had undergone previous hip or pelvis surgery, evidence of pelvic/acetabular trauma, pelvic/acetabular neoplasm, or hip trauma. Each specimen was accompanied by donor demographics including medical history, cause of death, gender, height, weight, and body mass index.

Table 1.

Specimen demographic data

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All specimens underwent both approaches; 10 modified Smith-Petersen and 10 Watson-Jones approaches were performed in total. The laterality assigned to each modified Smith-Petersen approach was randomized with a digital randomization application and the Watson-Jones was then performed on the contralateral hip. A team of fellowship-trained orthopaedic traumatologists (MG, MB, JB) performed the surgical exposures using standard surgical instruments and retractors. The surgical technique for each approach was reviewed before the dissections and a standardized approach and retractor placement were agreed on to ensure steps were consistent between surgeons. Each surgeon performed both dissections on a single specimen independently. Two surgeons performed exposures for three specimens each, and one surgeon performed the exposures for four. All three surgeons (MG, MB, JB) each perform approximately 10 open reductions with internal fixation of femoral neck fractures annually using the modified Smith-Petersen or Watson-Jones approach. In addition, one surgeon (MB) performs approximately 150 direct anterior THAs with the modified Smith-Petersen approach annually.

The modified Smith-Petersen approach was performed without a rectus femoris tenotomy for initial assessment of the exposed area followed by release of the rectus femoris reflected head to facilitate further exposure. Similar to the approach and measurement techniques used by Blair et al. [7], the cadaver was placed supine and the skin incision initiated at a point 2 cm distal and 2 cm lateral to the anterosuperior iliac spine (ASIS) (Fig. 1). The incision was then extended 12 cm in a lateral trajectory in line with the lateral edge of the patella and centered over the tensor fascia lata muscle belly. Dissection was then carried down to the tensor fascia lata. The fascia was then incised inline and the tensor fascia lata muscle mobilized laterally with a subfascial plane to expose the interval between the rectus femoris and gluteus medius. By utilizing a more lateral incision and a subfascial plane, the nerve bundles of the LFCN were avoided. The ascending branches of the lateral femoral circumflex artery were preserved. The exposure was completed with medial elevation of the iliocapsularis followed by a T-shaped capsulotomy, which spared the labrum. As per our routine practice, we did not place retractors on the posterior aspect of the femoral neck because this may endanger the femoral head blood supply. Femoral neck exposure was recorded with a photograph taken from the surgeon’s viewpoint (Fig. 2). The surgeons characterized seven anatomic landmarks—the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater and lesser trochanters, and medial neck—as visible, readily palpable with a tonsil clamp, or both. After thorough assessment, the surgeon then performed a tenotomy of the rectus femoris reflected head, took another photograph, and repeated the same assessment of exposure (Fig. 3).

Fig. 1.

Fig. 1

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This image displays a cadaveric study specimen with planned superficial incisions for the modified Smith-Petersen and Watson-Jones approaches.

Fig. 2.

Fig. 2

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This image displays a cadaveric study specimen with exposure of the femoral neck utilizing a modified Smith-Petersen approach without rectus femoris tenotomy.

Fig. 3.

Fig. 3

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This image displays a cadaveric study specimen with exposure of the femoral neck utilizing a modified Smith-Petersen approach with rectus femoris tenotomy.

The Watson-Jones exposure was conducted on the contralateral hip according to the originally described surgical technique [12, 53]. With the cadaver supine, the surgeon began the incision 2.5 cm posterior and distal to the ASIS and carried it distally over the posterior third of the greater trochanter and down the femur for a total of 12 cm (Fig. 1). Deep dissection used the plane between the tensor fascia lata and the gluteus medius. The hip capsule was then exposed, and a distally based T-shaped capsulotomy was performed. The same principles of retractor placement were followed. Femoral neck exposure was again recorded with a photograph taken from the surgeon’s viewpoint (Fig. 4), and the seven anatomic landmarks were characterized as visible, palpable, or both.

Fig. 4.

Fig. 4

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This image displays the exposure of the femoral neck with the Watson-Jones approach with the shaded area and ruler scale utilized to calculate exposure. The black line traces the articular margin to calculate articular area.

We used the digital photographs taken from the surgeon’s perspective to measure the surgical exposure of each approach as described by Blair et al. (Fig. 4) [7]. Images were analyzed independently by the second author (JPK) with the ImageJ software program (National Institutes of Health, Bethesda, MD, USA), which allows for quantification of the area of a two-dimensional space using a calibrated digital image. Proximal, femoral, and articular areas were measured separately to evaluate the exposure of the femoral neck and head. Kappa values were not performed; however, this methodology and software program have been reliably used to quantify exposure in previously published surgical exposure studies [5, 7, 8, 25, 26, 30, 43, 44]. Seven anatomic landmarks—the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater and lesser trochanters, and medial neck—were characterized as visible, readily palpable with a tonsil clamp, or both. Each surgeon evaluated the ability to visualize or palpate the structures of only the cadavers where they had performed the dissection.

Statistical Analysis

We compared the area (cm2) of the proximal femur exposed by the modified Smith-Petersen approach (with and without rectus femoris tenotomy) to the area (cm2) of the proximal femur exposed by the Watson-Jones approach to quantify the area exposed for assessment of a femoral neck fracture, reduction quality, and possible placement of accessory fixation. We compared the area (cm2) of the articular surface exposed by each approach to quantify the area exposed for assessment of femoral head fractures. We then compared the ability of each approach to provide visualization or palpation of surrounding soft tissue and bone structures that may prove useful for intraoperative orientation, facilitating fixation, and assessment of osseous and soft tissue integrity.

Statistical analysis was performed with Stata 14 (StataCorp LLC, College Station, TX, USA). We used a multilevel mixed-effects regression to compare the difference in area exposed with the modified Smith-Petersen approach (with and without rectus femoris tenotomy) and with the Watson-Jones approach. The paired nature of this analysis allowed us to take into account nesting of variance within each cadaver based on anatomic differences from specimen to specimen. Fisher’s exact test was used to compare proportions of cadavers with visible or palpable landmarks after each approach. A threshold for statistical significance was established at p ≤ 0.05. The small number of cadaveric specimens in this study did not provide a large enough sample size to generate reliable estimates of odds ratios and confidence intervals to describe the odds of visualizing or palpating a given structure based on approach. This was beyond the scope of the current study. Therefore, descriptive statistics and comparisons of the frequencies and proportions were presented with simple Fisher’s exact tests.

Results

We found that the modified Smith-Petersen approach with and without rectus femoris tenotomy exposed more proximal femoral neck and articular area than the Watson-Jones approach (Table 2). The modified Smith-Petersen approach without rectus femoris tenotomy exposed 2.4 cm2 more neck area (p = 0.015) and 1.6 cm2 more articular surface area (p = 0.001) than the Watson-Jones approach. The modified Smith-Petersen approach with rectus femoris tenotomy exposed 3.3 cm2 more neck area (p = 0.001) than the Watson-Jones approach (Table 3) and 1.6 cm2 more articular area (p = 0.001) than the Watson-Jones approach (Table 4).

Table 2.

Mean visible area and summary statistics stratified by the three approaches (cm2)

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Table 3.

Differences in visible femoral neck area between approaches

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Table 4.

Difference in visible articular area between approaches

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All 10 modified Smith-Petersen and Watson-Jones approaches allowed visualization and palpation of the labrum, femoral head, subcapital neck, and basicervical neck (Table 5). The greater trochanter was palpated in all 10 modified Smith-Petersen and Watson-Jones approaches. Although the greater trochanter was visible in all 10 Watson-Jones approaches, it was not visible in one of 10 modified Smith-Petersen approaches (p = 1.0). Although the lesser trochanter was palpable in all 10 modified Smith-Petersen approaches, it was not palpable in any (zero of 10) Watson-Jones approaches (p < 0.001). Visualization of the lesser trochanter was possible in two of 10 modified Smith-Petersen approaches and zero of 10 Watson-Jones approaches (p = 0.47). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 (p = 0.47).

Table 5.

Anatomic structures visualized and palpated by approach

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Discussion

Patients with femoral neck fractures who are physiologically young and active are commonly treated with open reduction and internal fixation. An international survey of trauma surgeons found that the majority perform an open reduction in < 25% of their cases; however, approximately 25% performed an open reduction in > 50% of their cases [47]. Reduction quality has been shown to be the most critical variable in successful healing of femoral neck fractures [13, 42, 46]. An open approach that facilitates exposure may make a more accurate reduction possible, thereby decreasing the likelihood of malunion, nonunion, femoral head osteonecrosis, and arthritis [15, 31]. The modified Smith-Petersen and Watson-Jones approaches are frequently utilized to treat femoral neck fractures when closed manipulation does not achieve anatomic reduction and have also been suggested for additional intraarticular pathology such as femoral head fractures and irreducible femoral head fracture-dislocations [22, 31, 36–38, 49, 51]. In the survey conducted by Slobogean et al. [47], the respondents reported utilizing a Watson-Jones approach (19.9%) more frequently than the modified Smith-Petersen approach (13.8%). To our knowledge, our study is the first to compare the two most commonly used open approaches and to identify the modified Smith-Petersen approach with or without rectus femoris tenotomy as superior to the Watson-Jones approach for visualization and palpation of the femoral neck and surrounding structures.

There are some limitations to our study. The low number of specimens was a limitation. The use of fresh-frozen cadavers without fractures and within a bloodless field may have facilitated better exposure than can be attained in clinical practice. However, this should have affected both exposures equally, and the difference between the two remains pertinent. Additionally, the software we used only performs two-dimensional calculations of area and does not calculate volume. It is unknown if either exposure offers any important improvements in overall volume of exposure, especially in patients with differing body habitus. Although use of the surgeon’s perspective may be somewhat variable and alter the perceived exposed area, we endeavored to generate images that offered the maximal en face view of the exposed field. This technique has been used in a previous investigation into exposure of the proximal femur by other authors and we feel this method best replicates the actual vantage point during surgical procedures [7]. Additional studies have compared surgical exposures with digital imaging in other anatomic locations, often with the goal of improving access for fracture care [5, 7, 25, 26, 43, 44]. These studies have used similar methodology, the same software package (ImageJ), and have yielded clinically useful insights. Cross-comparisons between surgeon-rated palpability and visibility of the anatomic landmarks were not conducted for individual specimens. Instead, each surgeon only conducted assessments on specimens where they performed the approach. Although this may hinder the validity of measurements, each surgeon is proficient in the anatomy and surgical approach and this method reflects the intraoperative experience and has been performed in a similar investigation [7]. Another limitation is the use of a static image for calculation of exposure, which may in fact underestimate the actual ability to facilitate visualization intraoperatively because retractors may be manipulated to maximize field of view for a particular zone of interest during various stages of the procedure. Fixation was not completed laterally or at the medial neck in the Watson-Jones approach or through a separate incision after completing the modified Smith-Petersen approach because evaluation of fixation strategies was not a goal of this study. Future cadaveric studies could compare the femoral neck fracture quality of reduction and fixation placement obtained by closed reduction with internal fixation (CRIF) versus open reduction internal fixation (ORIF). Similarly, evaluation of injury to the surrounding neurovascular structures including the lateral femoral circumflex artery, the LFCN, the lateral epiphyseal vessels, and retinacular branches was not completed.

Despite a great deal of debate regarding strategy, preservation of femoral head perfusion is requisite to prevent osteonecrosis and nonunion. Rates of the incidence of osteonecrosis in young adults with femoral neck fractures is widely variable, ranging from 16% to 86% [11, 24, 45, 52]. Femoral neck fractures tend to result in local hemarthrosis and resultant intracapsular tamponade. Aside from direct traumatic disruption of blood supply to the femoral head, the increased pressure may have a compressive effect on retinacular vessels and contribute to the development of osteonecrosis [2, 14]. The preferred method for addressing this potentially deleterious cascade is unclear with some surgeons advocating for an open approach and capsulotomy to release the intracapsular pressure, whereas others argue this may cause further vascular insult [17, 18, 20, 27, 50]. Future investigations comparing approach, method of capsulotomy, and retractor placement could elucidate the potential vascular compromise associated with differing treatment strategies.

Iatrogenic injury of the LFCN has been well documented in arthroplasty studies with rates of paresthesia ranging from < 1% to 67% [6, 23]. However, persistent meralgia paresthetica is rare, occurring in < 1% of patients undergoing direct anterior THA [35]. These rates have been documented in a setting where traction, repeated dislocation, and extensive manipulation are used and may not be reflective of fracture surgery. Our modified Smith-Petersen approach with a skin incision centered laterally over the tensor fascia lata muscle belly and carried medially in a subfascial manner may reduce the incidence of LFCN injury versus an approach centered directly on the intermuscular plan. Although the incidence of LFCN injury associated with the open treatment of femoral neck fractures remains unknown, it is likely higher with the utilization of a modified Smith-Petersen approach than a Watson-Jones approach and cautious dissection is recommended. Future cadaveric studies could compare the risk of iatrogenic damage to such structures.

Another important limitation of this cadaveric study is the inability to directly translate improved exposure and fixation to improved clinical outcomes. A systematic review and meta-analysis conducted by Ghayoumi et al. [21] compared rates of nonunion, osteonecrosis, and deep infection after CRIF with ORIF of displaced femoral neck fractures in young adults (average age < 50 years old). This investigation reviewed 21 studies and found insufficient evidence to determine a difference between ORIF and CRIF with regard to nonunion (14.9% versus 11.6%, respectively) and osteonecrosis (17.7% versus 17.2%, respectively), but did find an increase in the rate of deep infection with ORIF versus CRIF (0.49% versus 3.9%, respectively). The study reported a lower overall complication rate for CRIF (29.2%) compared with an incidence of 36.5% with ORIF. The authors were unable to elucidate definitive evidence to make recommendations given the overall paucity of high-quality comparative studies and outcomes. Future randomized controlled trials could compare the outcomes of CRIF with ORIF with standardized techniques to determine the utility of each treatment.

We found that the modified Smith-Petersen approach with or without rectus femoris tenotomy exposed more proximal femoral neck and articular area than the Watson-Jones approach (Table 2). This suggests that the modified Smith-Petersen approach may provide improved exposure in assessment of a femoral neck fracture, reduction quality, and placement of fixation. This may be of particular benefit in more proximal fractures or fractures involving the articular surface. To our knowledge, no study has previously been performed comparing femoral neck exposures. However, Blair et al. [7] quantified femoral neck exposure using a modified Smith-Petersen approach without a rectus femoris tenotomy and found an average exposure of 20.31 cm2. This was a relatively large exposure compared with our average area of 11.6 cm2 and may be related to our avoidance of circumferential and levering-type retractors and utilization of a T-shaped arthrotomy. Blair et al. utilized an H-shaped arthrotomy along the intertrochanteric line and placed retractors within the joint capsule around the neck and over the brim of the acetabulum near the ASIS. Although an H-shaped arthrotomy has been demonstrated to preserve femoral head blood supply [17, 19], it may lend to iatrogenic labral injury. In addition, placement of retractors directly against the neck and over the acetabulum is efficacious in terms of exposure, but may impose a biologic cost by injuring the blood supply of the femoral head and causing iatrogenic femoral nerve injury [32, 33].

Similar to Blair et al., we found the modified Smith-Petersen approach provided direct exposure of the femoral neck beyond the boundaries of any femoral neck fracture. The modified Smith-Petersen approach allowed improved palpation of the lesser trochanter and visualization of the medial femoral neck. The mechanism of displaced femoral neck fractures in young patients tends to be high energy in nature and creates unstable patterns involving the basicervical femoral neck, propagates in a vertical orientation, and may be associated with comminution [3, 4, 9, 10, 48]. The improved exposure of the medial femoral neck afforded by the modified Smith-Petersen approach may provide improved assessment of reduction and application of supplemental fixation such as a medial buttress plate, independent interfragmentary screws, or manipulative reduction screws in vertically oriented or fractures with comminution [40, 54, 55]. Although it has been suggested that open treatment of basicervical femoral neck fractures may be better facilitated with a Watson-Jones approach [39], both the modified Smith-Petersen and Watson-Jones approaches allowed visualization and palpation of the basicervical neck (Table 5).

The modified Smith-Petersen and Watson-Jones approaches have also been suggested for additional intraarticular pathology such as relevant femoral head fractures, including irreducible femoral head fracture-dislocations [22, 36–38, 49, 51]. Our results suggest improved exposure of the cortical and articular surfaces of the proximal femur with the modified Smith-Petersen approach to fully assess femoral neck fractures and associated femoral head or chondral injury. This may be explained by increased visualization of the medial neck with rectus femoris reflected head tenotomy without additional exposure of the reduced femoral head based on retractor replacement. This finding is similar to Molnar and Routt [40] who conducted exposure of the femoral neck utilizing a tenotomy and tagging of the entire common tendon followed by retraction of the muscle belly. However, other authors have advocated against tenotomy, most frequently in arthroplasty research [28, 29]. The clinical relevance and morbidity of rectus tenotomy for these indications are unknown.

In summary, the modified Smith-Petersen approach utilizes an intermuscular and internervous plane of dissection provides larger exposure of the proximal femur and allows improved visualization and palpation of relevant structures when compared with the Watson-Jones approach. This may facilitate improved assessment of femoral neck fractures and associated osseous and chondral injury, more accurate reductions, better fixation, and improved patient outcomes. Although not all surgeons will be familiar with this approach, it is being performed with increasing frequency given the increasing popularity of the direct anterior THA and the learning curve has been established in this context [1, 41]. Surgeons treating femoral neck fractures with ORIF should familiarize themselves with the modified Smith-Petersen approach. Future research is indicated to compare the clinical efficacy of these different approaches for treatment of femoral neck fractures in the young patient not only limited to the quality of reduction and fixation, but including patient functional outcomes and health-related quality of life.

Footnotes

One of the authors (PML) received funding from the Foundation for Orthopaedic Trauma.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at the Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, CA, USA.

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