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J Bone Joint Surg Am. 2019 Oct 16; 101(20): 1852–1859.
Published online 2019 Oct 16. doi:10.2106/JBJS.18.01256
PMCID: PMC7406148
PMID: 31626010
Effect of Posterior Tilt on Rates of Subsequent Arthroplasty
Kanu Okike, MD, MPH,
1 Ugochukwu N. Udogwu, BA,2 Marckenley Isaac, BA,3 Sheila Sprague, PhD,4,5 Marc F. Swiontkowski, MD,6 Mohit Bhandari, MD, PhD, FRCSC,4,5 and Gerard P. Slobogean, MD, MPH7, on behalf of the FAITH Investigators*
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Associated Data
- Data Availability Statement
Background:
Internal fixation is currently the standard of care for Garden-I and II femoral neck fractures in elderly patients. However, there may be a degree of posterior tilt (measured on preoperative lateral radiograph) above which failure is likely, and primary arthroplasty would be preferred. The purpose of this analysis was to determine the association between posterior tilt and the risk of subsequent arthroplasty following internal fixation of Garden-I and II femoral neck fractures in elderly patients.
Methods:
This study is a preplanned secondary analysis of data collected in the FAITH (Fixation using Alternative Implants for the Treatment of Hip fractures) trial, an international, multicenter, randomized controlled trial comparing the sliding hip screw with cannulated screws in the treatment of femoral neck fractures in patients ≥50 years old. For each patient who sustained a Garden-I or II femoral neck fracture and had an adequate preoperative lateral radiograph, the amount of posterior tilt was categorized as <20° or ≥20°. Multivariable Cox proportional hazards analysis was used to assess the association between posterior tilt and subsequent arthroplasty during the 2-year follow-up period, controlling for potential confounders.
Results:
Of the 555 patients in the study sample, 67 (12.1%) had posterior tilt ≥20° and 488 (87.9%) had posterior tilt <20°. Overall, 73 (13.2%) of 555 patients underwent subsequent arthroplasty in the 24-month follow-up period. In the multivariable analysis, patients with posterior tilt ≥20° had a significantly higher risk of subsequent arthroplasty compared with those with posterior tilt <20° (22.4% [15 of 67] compared with 11.9% [58 of 488]; hazard ratio, 2.22; 95% confidence interval, 1.24 to 4.00; p = 0.008). The other factor associated with subsequent arthroplasty was age ≥80 years (p = 0.03).
Conclusions:
In this analysis of patients with Garden-I and II femoral neck fractures, posterior tilt ≥20° was associated with a significantly increased risk of subsequent arthroplasty. Primary arthroplasty may be considered for Garden-I and II femoral neck fractures with posterior tilt ≥20°, especially among older patients.
Level of Evidence:
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Internal fixation is currently considered the standard of care for Garden-I and II femoral neck fractures in elderly patients1. However, outcomes following this procedure are not uniformly positive, as prior studies have documented rates of reoperation ranging from 8% to 23%2-12. Given that the subsequent procedure is often arthroplasty, some have questioned whether there is a subset of Garden-I and II femoral neck fractures that would be better treated with arthroplasty at the outset4.
One factor commonly considered as a potential predictor of failure following internal fixation of Garden-I and II femoral neck fractures is the degree of posterior tilt on the preoperative lateral radiograph. Prior research on this topic has been contradictory, however, as some studies have suggested that posterior tilt may predispose to failure2,3,6,13,14 whereas 1 report did not detect such an association5. In addition, these prior studies have primarily considered cannulated screw fixation of nondisplaced femoral neck fractures and not fixation with a sliding hip screw. As a result, there is currently no consensus as to whether there is a certain degree of posterior tilt on the preoperative lateral radiograph above which failure is likely and primary arthroplasty would be preferred.
The purpose of the present study was to determine whether the degree of posterior tilt on the preoperative lateral radiograph predisposes to failure (in the form of subsequent arthroplasty) following internal fixation of Garden-I and II femoral neck fractures in the elderly.
Materials and Methods
This study is a preplanned secondary analysis of the data collected in the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial (ClinicalTrials.gov NCT00761813), which compared the use of a sliding hip screw with the use of cannulated screws in the treatment of low-energy femoral neck fractures in patients ≥50 years old15. The study included 1,079 patients, and the surgical procedures were performed at 81 clinical sites in the United States, Canada, Australia, the Netherlands, Norway, Germany, the United Kingdom, and India. Fracture reduction, when required, was left to the discretion of the surgeon and was not specified by the study protocol. Fracture reduction was assessed postoperatively by a central adjudication committee and was found to be acceptable in 97.8% of cases (543 of 555). Patients were assessed clinically at 1 week, 10 weeks, and 6, 9, 12, 18, and 24 months postoperatively. All revision procedures were also reviewed by the central adjudication committee. The FAITH trial was approved by the Hamilton Integrated Research Ethics Board (#06-402) and by the research ethics boards/institutional review boards of all participating clinical sites. The trial protocol and results have been published previously15,16.
The present analysis was conducted among patients enrolled in the FAITH trial whose femoral neck fracture was classified as Garden I or II. Classifications were assigned on the basis of anteroposterior radiographs, with Garden I representing a valgus-impacted incomplete fracture; Garden II, a complete but nondisplaced fracture; Garden III, a complete fracture with partial displacement; and Garden IV, a complete fracture with complete displacement as indicated by parallel orientation of the trabeculae17,18. Patients without an adequate preoperative lateral radiograph were excluded from the present analysis. For each patient, the preoperative lateral radiograph was reviewed to categorize the amount of posterior tilt as <20° or ≥20° with use of the technique described by Palm et al.6. Review of the radiographs was done in duplicate with discrepancies resolved by a third reviewer, and all reviewers were blinded to clinical outcomes. The primary outcome measure was subsequent arthroplasty during the 24-month follow-up period. As noted above, all revision procedures were reviewed by a central adjudication committee.
To assess for an association between posterior tilt and subsequent arthroplasty, multivariable Cox proportional hazards regression was performed, controlling for potential confounders. Confounders were selected a priori on the basis of prior studies13,19, ensuring that there were ≥10 events for each variable to avoid having an overfitted or unstable model20. In this manner, potential confounders were selected a priori as age13, sex19, preoperative functional status13, and quality of implant placement19. With regard to preoperative functional status, each patient included in the present analysis was classified as either an “independent ambulator” or “not an independent ambulator” (e.g., if the patient used an ambulatory aid prior to femoral neck fracture). Quality of implant placement was classified as acceptable or unacceptable and was adjudicated by the central adjudication committee. As defined in the FAITH trial, implant placement was deemed unacceptable if, on the immediate postoperative radiographs, the lag screw was too high, there was screw penetration, or there was evidence of prominent screws at the lateral femoral cortex. Results are reported as hazard ratios (HRs), 95% confidence intervals (CIs), and p values. Tests were 2-tailed and significance was set at 0.05.
Results
Seven hundred and thirty-four of the 1,079 patients enrolled in the FAITH trial had a Garden-I or II femoral neck fracture. Patients without an adequate preoperative lateral radiograph were excluded (n = 179), leaving 555 patients for analysis. The included patients had an average age of 74.8 years, and 380 (68.5%) were female. Sixty-seven patients (12.1%) had fractures with posterior tilt ≥20° on the lateral radiograph, and 488 (87.9%) had fractures with posterior tilt <20° (Table I). Reviewer agreement in the assessment of posterior tilt was substantial (89.7% agreement; kappa = 0.61).
TABLE I
Patient Characteristics*
| Patient Demographics | No. of Patients (%) |
| Age in yr | |
| 50-59 | 70 (12.6%) |
| 60-79 | 256 (46.1%) |
| ≥80 | 229 (41.3%) |
| Sex | |
| Male | 175 (31.5%) |
| Female | 380 (68.5%) |
| Ethnicity | |
| Nonwhite | 42 (7.6%) |
| White | 512 (92.3%) |
| BMI (kg/m2) | |
| Underweight (<18.5) | 46 (8.3%) |
| Normal (18.5-24.9) | 300 (54.1%) |
| Overweight (25-29.9) | 154 (27.7%) |
| Obese (≥30) | 48 (8.6%) |
| ASA classification | |
| 1 | 70 (12.6%) |
| 2 | 238 (42.9%) |
| 3 | 224 (40.4%) |
| 4 | 23 (4.1%) |
| Diabetes | |
| No | 464 (83.6%) |
| Yes | 87 (15.7%) |
| Smoking | |
| Never | 273 (49.2%) |
| Former | 186 (33.5%) |
| Current | 93 (16.8%) |
| Pre-fracture living setting | |
| Not institutionalized | 530 (95.5%) |
| Institutionalized | 25 (4.5%) |
| Pre-fracture functional status | |
| Independent ambulator | 414 (74.6%) |
| Using ambulatory aid | 141 (25.4%) |
| Fracture characteristics | |
| Garden classification | |
| I | 374 (67.4%) |
| II | 181 (32.6%) |
| Pauwels classification | |
| I | 128 (23.1%) |
| II | 377 (67.9%) |
| III | 50 (9.0%) |
| Fracture level | |
| Subcapital | 394 (71.0%) |
| Midcapital | 146 (26.3%) |
| Basicervical | 15 (2.7%) |
| Posterior tilt | |
| <20° | 488 (87.9%) |
| ≥20° | 67 (12.1%) |
| Surgical factors | |
| Surgical delay | |
| <24 hr | 157 (28.3%) |
| 24-48 hr | 208 (37.5%) |
| >48 hr | 182 (32.8%) |
| Type of reduction | |
| None | 282 (50.8%) |
| Closed | 248 (44.7%) |
| Open | 24 (4.3%) |
| Implant type | |
| Sliding hip screw | 278 (50.1%) |
| Cannulated screws | 277 (49.9%) |
| Quality of implant placement | |
| Acceptable | 521 (93.9%) |
| Unacceptable | 19 (3.4%) |
| Unable to assess | 15 (2.7%) |
| Total | 555 (100.0%) |
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*Data were missing for the following variables: ethnicity (n = 1), BMI (n = 7), diabetes (n = 4), smoking status (n = 3), type of reduction (n = 1), and surgical delay (n = 8). BMI = body mass index, and ASA = American Society of Anesthesiologists.
Overall, 73 (13.2%) of 555 patients underwent subsequent arthroplasty in the 24-month follow-up period. A representative case is presented in Figures Figures11 through through4.4. In the multivariable analysis, patients with posterior tilt ≥20° had a significantly increased risk of subsequent arthroplasty compared with those with posterior tilt <20° (22.4% [15 of 67] compared with 11.9% [58 of 488], respectively; HR, 2.22; 95% CI, 1.24 to 4.00; p = 0.008). The other factor found to be associated with arthroplasty was older age, as patients ≥80 years old were more likely to undergo arthroplasty in the 24-month follow-up period compared with patients 50 to 59 years old (15.3% [35 of 229] compared with 4.3% [3 of 70], respectively; HR, 3.88; 95% CI, 1.16 to 12.90; p = 0.03). There was also a trend toward an increased risk of arthroplasty for female patients, although it did not reach significance (HR, 1.72; 95% CI, 0.97 to 3.05; p = 0.06) (Table II). Among patients with all 3 of these risk factors (i.e., posterior tilt ≥20°, age ≥80 years, and female sex), the failure rate was 42.9% (6 of 14). Among patients without any of these 3 risk factors, the failure rate was 5.8% (5 of 86).
Figs. 1-A and 1-B Preoperative radiographs of a 79-year-old woman showing valgus impaction on the anteroposterior view (Fig. 1-A) and posterior tilt of 32°, as measured via the technique described by Palm et al.6, on the shoot-through lateral view (Fig. 1-B).
Fig. 1-A
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Fig. 1-B
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Fig. 4
Anteroposterior radiograph of the same patient as in Figures Figures11-A and 11-B, made following revision for hardware removal and conversion to total hip arthroplasty.
Figs. 2-A and 2-B Anteroposterior (Fig. 2-A) and shoot-through lateral (Fig. 2-B) radiographs of the same patient as in Figures Figures1-A1-A and and1-B,1-B, made immediately postoperatively, showing appropriate fracture reduction and implant placement.
Fig. 2-A
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Fig. 2-B
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Figs. 3-A and 3-B Radiographs of the same patient as in Figures Figures11-A and 11-B, made 11 months postoperatively, showing osteonecrosis on the anteroposterior view (Fig. 3-A) and intra-articular penetration of the sliding hip screw on the shoot-through lateral view (Fig. 3-B).
Fig. 3-A
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Fig. 3-B
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TABLE II
Factors Associated with Subsequent Arthroplasty
| Variable | Crude Rate of Subsequent Arthroplasty* | Multivariable Hazard Ratio† (95% CI) | P Value |
| Age in yr | |||
| 50-59‡ | 4.3% (3/70) | 1.00 | — |
| 60-79 | 13.7% (35/256) | 3.06 (0.94, 10.01) | 0.06 |
| ≥80 | 15.3% (35/229) | 3.88 (1.16, 12.90) | 0.03 |
| Sex | |||
| Male‡ | 9.1% (16/175) | 1.00 | — |
| Female | 15.0% (57/380) | 1.72 (0.97, 3.05) | 0.06 |
| Pre-fracture functional status | |||
| Independent ambulator‡ | 12.8% (53/414) | 1.00 | — |
| Using ambulatory aid | 14.2% (20/141) | 1.09 (0.63, 1.89) | 0.76 |
| Quality of implant placement | |||
| Acceptable‡ | 12.7% (66/521) | 1.00 | — |
| Unacceptable | 26.3% (5/19) | 1.95 (0.77, 4.93) | 0.16 |
| Unable to assess | 13.3% (2/15) | 1.39 (0.34, 5.69) | 0.65 |
| Posterior tilt | |||
| <20°‡ | 11.9% (58/488) | 1.00 | — |
| ≥20° | 22.4% (15/67) | 2.22 (1.24, 4.00) | 0.008 |
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*Values are given as the percentage of patients who underwent subsequent arthroplasty, with the count in parentheses. N = 555; 73 events.
†Hazard ratios adjusted for age, sex, preoperative functional status, and quality of implant placement.
‡Reference category.
Discussion
Fracture fixation is currently considered the standard of care for Garden-I and II femoral neck fractures; however, outcomes following this procedure are not uniformly positive, as prior studies have documented rates of reoperation ranging from 8% to 23%2-12.
In the present analysis we found that posterior tilt ≥20° was associated with failure (in the form of subsequent arthroplasty) following internal fixation of Garden-I and II femoral neck fractures. The present findings are in agreement with some of the studies that have been performed previously2,3,6,13,14. In a retrospective analysis of 113 patients ≥60 years old with Garden-I or II fractures treated with 2 Olmed screws or Hansson pins in Denmark, Palm et al. described the most widely accepted method of measuring posterior tilt on the lateral radiograph and found that posterior tilt ≥20° was associated with an increased risk of reoperation compared with posterior tilt <20° (56.0% [14 of 25] compared with 13.6% [12 of 88]: p < 0.001)6. In a study analyzing 322 patients with an age range of 53 to 97 years and with Garden-I or II femoral neck fractures treated with 2 Olmed screws in Norway, Dolatowski et al. also found posterior tilt ≥20° to be predictive of failure compared with posterior tilt <20° (18.6% [8 of 43] compared with 8.2% [23 of 279]; HR, 2.4; 95% CI, 1.1 to 5.4; p = 0.03)3. In a study reviewing data for 162 patients ≥65 years old with Garden-I and II fractures treated with 3 AO cannulated screws in Scotland, Clement et al. found that posterior tilt ≥10° was associated with an increased risk of fixation failure compared with posterior tilt <10° (40.7% [11 of 27] compared with 12.6% [17 of 135]; p < 0.001)2. In contrast, Lapidus and colleagues analyzed 379 patients who underwent fixation of a Garden-I or II femoral neck fracture with 2 Olmed screws in Sweden, and did not find any association between posterior tilt and reoperation (posterior tilt 0° to 9°, 14.7% [25 of 170]; 10° to 19°, 9.4% [13 of 139]; and ≥20°, 9.6% [7 of 73]; p = 0.3)5. However, all of these prior studies primarily considered fractures stabilized with cannulated screws, and not a sliding hip screw.
The other factor that we found to be associated with subsequent arthroplasty was patient age ≥80 years. This finding is in agreement with prior research by Conn and Parker, who also found increased age to be predictive of fracture-healing complications13. However, other studies did not detect any association between age and reoperation following Garden-I and II femoral neck fractures2,3,5,6.
The present analysis benefits from the fact that we used prospectively collected data from a large number of patients managed at a wide variety of clinical sites in 8 different countries, which may enhance generalizability. In contrast to prior studies, which have primarily examined fractures treated with cannulated screws, the present study considered fractures treated with a sliding hip screw as well as cannulated screws. In addition, all reoperations were adjudicated by the central adjudication committee of the FAITH trial. However, the present analysis also has limitations. Given that the present analysis was not randomized, our findings should be taken to represent association and not necessarily causation. Additionally, we were unable to analyze the effect of potentially influential factors that were not recorded in the initial FAITH trial, such as osteoporosis. Finally, because of missing and poor-quality radiographs, not all FAITH-trial patients could be included in the present analysis.
In summary, approximately 1 out of every 8 elderly patients who underwent fixation of a Garden-I or II femoral neck fracture in the FAITH trial went on to require arthroplasty in the 24 months following the initial procedure. This risk was especially high for patients who demonstrated posterior tilt ≥20° on the preoperative lateral radiograph. These patients may be better managed with primary arthroplasty, especially if they are ≥80 years.
Acknowledgments
Note:
The FAITH Investigators
Steering Committee: Mohit Bhandari, McMaster University, Hamilton, Ontario, Canada; Marc Swiontkowski, University of Minnesota, Minneapolis, Minnesota; P.J. Devereaux, McMaster University; Gordon Guyatt, McMaster University; Martin J. Heetveld, Spaarne Gasthuis, Haarlem, the Netherlands; Kyle Jeray, Greenville Health System, Greeneville, South Carolina; Susan Liew, The Alfred, Melbourne, Victoria, Australia; Martin Richardson, University of Melbourne, Melbourne, Victoria, Australia; Emil H. Schemitsch, University of Western Ontario, London, Ontario, Canada; Lehana Thabane, McMaster University; Paul Tornetta III, Boston University Medical Center, Boston, Massachusetts; and Stephen D. Walter, McMaster University.
Global Methods Center: Mohit Bhandari (Principal Investigator), Sheila Sprague (Research Methodologist), Paula McKay (Manager), Taryn Scott, Alisha Garibaldi, Helena Viveiros, Marilyn Swinton (Research Coordination), Mark Gichuru, Sofia Bzovsky (Adjudication Coordination), Diane Heels-Ansdell, Qi Zhou (Statistical Analysis), Lisa Buckingham, Aravin Duraikannan (Data Management), Deborah Maddock, and Nicole Simunovic (Grants Management) (McMaster University).
United States Methods Center: Marc Swiontkowski (Principal Investigator) and Julie Agel (Research Coordination) (University of Minnesota).
Netherlands Method Center: Martin J. Heetveld (Principal Investigator), Esther M.M. Van Lieshout (Research Coordination), and Stephanie M. Zielinski (Trial Coordination) (Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands).
United Kingdom Method Center: Amar Rangan (Principal Investigator), Birgit C. Hanusch, Lucksy Kottam, and Rachel Clarkson (Research Coordination) (The James Cook University Hospital, Middlesbrough, United Kingsom).
Adjudication Committee: Gregory J. Della Rocca (Chair) (Duke University, Durham, North Carolina), Robert Haverlag (Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands), Susan Liew (The Alfred), Gerard P. Slobogean (University of Maryland), and Kyle Jeray (Greenville Health System).
Members of Participating Clinical Sites
Canada: Robert McCormack, Kelly Apostle, Dory Boyer, Farhad Moola, Bertrand Perey, Trevor Stone, Darius Viskontas, H. Michael Lemke, Mauri Zomar, Karyn Moon, Raely Moon, Amber Oatt (Royal Columbian Hospital, Fraser Health Authority, University of British Columbia, Vancouver, British Columbia); Richard E. Buckley, Paul Duffy, Robert Korley, Shannon Puloski, James Powell, Kelly Johnston, Kimberly Carcary, Melissa Lorenzo, Ross McKercher (Foothills Medical Centre, Calgary, Alberta); David Sanders, Mark MacLeod, Abdel-Rahman Lawendy, Christina Tieszer (London Health Sciences Centre, London, Ontario); David Stephen, Hans Kreder, Richard Jenkinson, Markku Nousiainen, Terry Axelrod, John Murnaghan, Diane Nam, Veronica Wadey, Albert Yee, Katrine Milner, Monica Kunz, Wesley Ghent (Sunnybrook Health Sciences Centre, Toronto, Ontario); Emil H. Schemitsch, Michael D. McKee, Jeremy A. Hall, Aaron Nauth, Henry Ahn, Daniel B. Whelan, Milena R. Vicente, Lisa M. Wild, Ryan M. Khan, Jennifer T. Hidy (St. Michael’s Hospital, Toronto); Chad Coles, Ross Leighton, Michael Biddulph, David Johnston, Mark Glazebrook, David Alexander, Catherine Coady, Michael Dunbar, J. David Amirault, Michael Gross, William Oxner, Gerald Reardon, C. Glen Richardson, J. Andrew Trenholm, Ivan Wong, Kelly Trask, Shelley MacDonald, Gwendolyn Dobbin (Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia); Ryan Bicknell, Jeff Yach, Davide Bardana, Gavin Wood, Mark Harrison, David Yen, Sue Lambert, Fiona Howells, Angela Ward (Human Mobility Research Centre, Queen’s University and Kingston General Hospital, Kingston, Ontario); Paul Zalzal, Heather Brien, V. Naumetz, Brad Weening, Nicole Simunovic (Oakville Trafalgar Memorial Hospital, Oakville, Ontario); Eugene K. Wai, Steve Papp, Wade T. Gofton, Allen Liew, Stephen P. Kingwell, Garth Johnson, Joseph O’Neil, Darren M. Roffey, Vivian Borsella (The Ottawa Hospital, Ottawa, Ontario); and Victoria Avram (Juravinski Hospital and Cancer Centre, Hamilton, Ontario).
United States: Todd M. Oliver, Vicki Jones, Michelle Vogt (Boone Hospital Center – Columbia Orthopaedic Group, Columbia, Missouri); Clifford B. Jones, James R. Ringler, Terrence J. Endres, Debra L. Sietsema, Jane E. Walker (Orthopaedic Associates of Michigan, Grand Rapids, Michigan); Kyle J. Jeray, J. Scott Broderick, David R. Goetz, Thomas B. Pace, Thomas M. Schaller, Scott E. Porter, Michael L. Beckish, John D. Adams, Benjamin B. Barden, Aaron T. Creek, Stephen H. Finley, Jonathan L. Foret, Garland K. Gudger Jr., Richard W. Gurich Jr., Austin D. Hill, Steven M. Hollenbeck, Lyle T. Jackson, Kevin K. Kruse III, Wesley G. Lackey, Justin W. Langan, Julia Lee, Lauren C. Leffler, Timothy J. Miller, R. Lee Murphy Jr., Lawrence K. O’Malley II, Melissa E. Peters, Dustin M. Price, John A. Tanksley Jr., Erick T. Torres, Dylan J. Watson, Scott T. Watson, Stephanie L. Tanner, Rebecca G. Snider, Lauren A. Nastoff, Shea A. Bielby, Robert J. Teasdall (Greenville Health System, Greenville, South Carolina); Julie A. Switzer, Peter A. Cole, Sarah A. Anderson, Paul M. Lafferty, Mengnai Li, Thuan V. Ly, Scott B. Marston, Amy L. Foley, Sandy Vang, David M. Wright (Regions Hospital-University of Minnesota, Minneapolis, Minnesota); Andrew J. Marcantonio, Michael S.H. Kain, Richard Iorio, Lawrence M. Specht, John F. Tilzey, Margaret J. Lobo, John S. Garfi (Lahey Hospital & Medical Center, Burlington, Massachusetts); Heather A. Vallier, Andrea Dolenc, Mary Breslin (MetroHealth Medical Center, Cleveland, Ohio); Michael J. Prayson, Richard Laughlin, L. Joseph Rubino, Jedediah May, Geoffrey Ryan Rieser, Liz Dulaney-Cripe, Chris Gayton (Miami Valley Hospital, Dayton, Ohio); James Shaer, Tyson Schrickel, Barbara Hileman (St. Elizabeth Youngstown Hospital, Youngstown, Ohio); John T. Gorczyca, Jonathan M. Gross, Catherine A. Humphrey, Stephen Kates, John P. Ketz, Krista Noble, Allison W. McIntyre, Kaili Pecorella (University of Rochester Medical Center, Rochester, New York); Craig A. Davis, Stuart Weinerman, Peter Weingarten, Philip Stull, Stephen Lindenbaum, Michael Hewitt, John Schwappach, Janell K. Baker, Tori Rutherford, Heike Newman, Shane Lieberman, Erin Finn, Kristin Robbins, Meghan Hurley, Lindsey Lyle, Khalis Mitchell, Kieran Browner, Erica Whatley, Krystal Payton, Christina Reeves (Colorado Orthopedic Consultants, Aurora, Colorado); Lisa K. Cannada, David E. Karges, Sarah A. Dawson (St. Louis University Hospital, St. Louis, Missouri); Samir Mehta, John Esterhai, Jaimo Ahn, Derek Donegan, Annamarie D. Horan, Patrick J. Hesketh, Evan R. Bannister (University of Pennsylvania, Philadelphia, Pennsylvania); Jonathan P. Keeve, Christopher G. Anderson, Michael D. McDonald, Jodi M. Hoffman (Northwest Orthopaedic Specialists, Spokane, Washington); Ivan Tarkin, Peter Siska, Gary Gruen, Andrew Evans, Dana J. Farrell, James Irrgang, Arlene Luther (University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania); William W. Cross III, Joseph R. Cass, Stephen A. Sems, Michael E. Torchia, Tyson Scrabeck (Mayo Clinic, Rochester, Minnesota); Mark Jenkins, Jules Dumais, Amanda W. Romero (Texas Tech University Health Sciences Center – Lubbock, Lubbock, Texas); Carlos A. Sagebien, Mark S. Butler, James T. Monica, Patricia Seuffert (University Orthopaedic Associates, LLC, Somerset, New Jersey); Joseph R. Hsu, Daniel Stinner, James Ficke, Michael Charlton, Matthew Napierala, Mary Fan (US Army Institute of Surgical Research, San Antonio, Texas); Paul Tornetta III, Chadi Tannoury, Hope Carlisle, Heather Silva (Boston University Medical Center, Boston, Massachusetts); Michael Archdeacon, Ryan Finnan, Toan Le, John Wyrick, Shelley Hess (UC Health and University of Cincinnati Medical Center, Cincinnati, Ohio); Michael L. Brennan, Robert Probe, Evelyn Kile, Kelli Mills, Lydia Clipper, Michelle Yu, Katie Erwin (Scott and White Memorial Hospital, Temple, Texas); Daniel Horwitz, Kent Strohecker, Teresa K. Swenson (Geisinger Medical Center, Danville, Pennsylvania); Andrew H. Schmidt, Jerald R. Westberg (Hennepin County Medical Center, Minneapolis, Minnesota); Kamran Aurang, Gary Zohman, Brett Peterson, Roger B. Huff (Kaiser Permanente, Oakland, California); Joseph Baele, Timothy Weber, Matt Edison (OrthoIndy Trauma, St. Vincent Trauma Center, Indianapolis, Indiana); Jessica Cooper McBeth (Santa Clara Valley Medical Center, Fruitdale, California); Karl Shively, Janos P. Ertl, Brian Mullis, J. Andrew Parr, Ripley Worman, Valda Frizzell, Molly M. Moore (Indiana University – Eskenazi Health Services, Indianapolis, Indiana); Charles J. DePaolo, Rachel Alosky, Leslie E. Shell, Lynne Hampton, Stephanie Shepard, Tracy Nanney, Claudine Cuento (Mission Hospital Research Institute, Asheville, North Carolina); Robert V. Cantu, Eric R. Henderson, Linda S. Eickhoff (Dartmouth-Hitchco*ck Medical Center, Lebanon, New Hampshire); E. Mark Hammerberg, Philip Stahel, David Hak, Cyril Mauffrey, Corey Henderson, Hannah Gissel, Douglas Gibula (Denver Health and Hospital Authority, Denver, Colorado); David P. Zamorano, Martin C. Tynan, Deeba Pourmand, Deanna Lawson (University of California Irvine Medical Center, Orange, California); Gregory J. Della Rocca, Brett D. Crist, Yvonne M. Murtha, Linda K. Anderson (University of Missouri Health Care, Columbia, Missouri); Colleen Linehan, Lindsey Pilling (Covenant Healthcare of Saginaw, Saginaw, Michigan); Courtland G. Lewis, Stephanie Caminiti, Raymond J. Sullivan, Elizabeth Roper (Hartford Hospital, Hartford, Connecticut); William Obremskey, Philip Kregor, Justin E. Richards, Kenya Stringfellow (Vanderbilt University Medical Center, Nashville, Tennessee); Michael P. Dohm, and Abby Zellar (Western Slope Study Group, Grand Junction, Colorado).
The Netherlands: Michiel J.M. Segers, Jacco A.C. Zijl, Bart Verhoeven, Anke B. Smits, Jean Paul P.M. de Vries, Bram Fioole, Henk van der Hoeven, Evert B.M. Theunissen, Tammo S. de Vries Reilingh, Lonneke Govaert, Philippe Wittich, Maurits de Brauw, Jan Wille, Peter M.N.Y.M. Go, Ewan D. Ritchie, Ronald N. Wessel, Eric R. Hammacher (St. Antonius Ziekenhuis, Nieuwegein); Martin J. Heetveld, Gijs A. Visser, Heyn Stockmann, Rob Silvis, Jaap P. Snellen, Bram Rijbroek, Joris J.G. Scheepers, Erik G.J. Vermeulen, Michiel P.C. Siroen, Ronald Vuylsteke, Hans L.F. Brom, Herman Rijna (Kennemer Gasthuis, Haarlem); Piet A.R. de Rijcke, Cees L. Koppert, Steven E. Buijk, Richard P.R. Groenendijk, Imro Dawson, Geert W.M. Tetteroo, Milko M.M. Bruijninckx, Pascal G. Doornebosch, Eelco J.R. de Graaf (IJsselland Ziekenhuis, Capelle aan den IJssel); Maarten van der Elst, Carmen C. van der Pol, Martijne van ’t Riet, Tom M. Karsten, Mark R. de Vries, Laurents P.S. Stassen, Niels W.L. Schep, G. Ben Schmidt, W.H. Hoffman (Reinier de Graaf Gasthuis, Delft); Rudolf W. Poolman, Maarten P. Simons, Frank H.W.M. van der Heijden, W. Jaap Willems, Frank R.A.J. de Meulemeester, Cor P. van der Hart, Kahn Turckan, Sebastiaan Festen, Frank de Nies, Robert Haverlag, Nico J.M. Out, Jan Bosma (Onze Lieve Vrouwe Gasthuis, Amsterdam); Albert van Kampen, Jan Biert, Arie B. van Vugt, Michael J.R. Edwards, Taco J. Blokhuis, Jan Paul M. Frölke, Leo M.G. Geeraedts, Jean W.M. Gardeniers, Edward C.T.H. Tan, Lodewijk M.S.J. Poelhekke, Maarten C. de Waal Malefijt, Bart Schreurs (University Medical Center St. Radboud, Nijmegen); Gert R. Roukema, Hong A. Josaputra, Paul Keller, Peter D. de Rooij, Hans Kuiken, Han Boxma, Berry I. Cleffken, Ronald Liem (Maasstad Ziekenhuis, Rotterdam); Steven J. Rhemrev, co*ks H.R. Bosman, Alexander de Mol van Otterloo, Jochem Hoogendoorn, Alexander C. de Vries, Sven A.G. Meylaerts (Medisch Centrum Haaglanden, Den Haag); Michiel H.J. Verhofstad, Joost Meijer, Teun van Egmond, Frank H.W.M. van der Heijden, Igor van der Brand (St. Elisabeth Ziekenhuis, Tilburg); Peter Patka, Martin G. Eversdijk, Rolf Peters, Dennis Den Hartog, Oscar J.F. Van Waes, Pim Oprel (Erasmus MC, University Medical Center Rotterdam, Rotterdam); Harm M. van der Vis, Martin Campo, Ronald Verhagen, G.H. Robert Albers, Arthur W. Zurcher (Tergooi Ziekenhuizen, Hilversum); Rogier K.J. Simmermacher, Jeroen van Mulken, Karlijn van Wessem, Taco J. Blokhuis, Steven M. van Gaalen, Luke P.H. Leenen (University Medical Center Utrecht, Utrecht); Maarten W.G.A. Bronkhorst, Onno R. Guicherit (Bronovo Ziekenhuis, Den Haag); J. Carel Goslings, Robert Haverlag, and Kees Jan Ponsen (Academic Medical Center, Amsterdam).
International: Mahesh Bhatia, Vinod Arora, Vivek Tyagi (RLB Hospital and Research Centre, India); Susan Liew, Harvinder Bedi, Ashley Carr, Hamish Curry, Andrew Chia, Steve Csongvay, Craig Donohue, Stephen Doig, Elton Edwards, Greg Etherington, Max Esser, Andrew Gong, Arvind Jain, Doug Li, Russell Miller, Ash Moaveni, Matthias Russ, Lu Ton, Otis Wang, Adam Dowrick, Zoe Murdoch, Claire Sage (The Alfred); Frede Frihagen, John Clarke-Jenssen, Geir Hjorthaug, Torben Ianssen, Asgeir Amundsen, Jan Egil Brattgjerd, Tor Borch, Berthe Bøe, Bernhard Flatøy, Sondre Hasselund, Knut Jørgen Haug, Kim Hemlock, Tor Magne Hoseth, Geir Jomaas, Thomas Kibsgård, Tarjei Lona, Gilbert Moatshe, Oliver Müller, Marius Molund, Tor Nicolaisen, Fredrik Nilsen, Jonas Rydinge, Morten Smedsrud, Are Stødle, Axel Trommer, Stein Ugland, Anders Karlsten, Guri Ekås, Elise Berg Vesterhus, Anne Christine Brekke (Oslo University Hospital, Norway); Ajay Gupta, Neeraj Jain, Farah Khan (Nirmal Hospital, India); Ateet Sharma, Amir Sanghavi, Mittal Trivedi (Satellite Orthopaedic Hospital and Research Centre, India); Anil Rai, Subash, Kamal Rai (Highway Hospital, India); Vineet Yadav, Sanjay Singh, Kamal Rai (Popular Hospital, India); Kevin Tetsworth, Geoff Donald, Patrick Weinrauch, Paul Pincus, Steven Yang, Brett Halliday, Trevor Gervais, Michael Holt, Annette Flynn (Royal Brisbane and Women’s Hospital, Australia); Amal Shankar Prasad, Vimlesh Mishra (Madhuraj Nursing Home, India); D.C. Sundaresh, Angshuman Khanna (M.S. Rammaiah Medical College & Hospital, India); Joe Joseph Cherian, Davy J. Olakkengil, Gaurav Sharma (St. John’s Medical College Hospital, India); Marinis Pirpiris, David Love, Andrew Bucknill, Richard J. Farrugia (Royal Melbourne Hospital); Hans-Christoph Pape, Matthias Knobe, Roman Pfeifer (University of Aachen Medical Center, Germany); Peter Hull, Sophie Lewis, Simone Evans (Cambridge University Hospitals, England); Rajesh Nanda, Rajanikanth Logishetty, Sanjeev Anand, Carol Bowler (University Hospital of North Tees, England); Akhil Dadi, Naveen Palla, Utsav Ganguly (Sunshine Hospital, India); B. Sachidananda Rai, Janakiraman Rajakumar (Unity Health Complex, India); Andrew Jennings, Graham Chuter, Glynis Rose, Gillian Horner (University Hospital of North Durham and Darlington Memorial Hospital, England); Callum Clark, Kate Eke (Wexham Park Hospital, England); Mike Reed, Dominic Inman, Chris Herriott, and Christine Dobb (Northumbria Healthcare NHS Foundation Trust, England).
Footnotes
*A list of the FAITH Investigators is included as a note at the end of the article.
Disclosure: The authors indicated that funding was received from the National Institutes of Health (NIH) grant 1R01AR055267-01A1 during the conduct of the study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F480).
Data Sharing
A data-sharing statement is provided with the online version of the article (http://links.lww.com/JBJS/F487).
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