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Figure 3 MRI of common occult bone bruises associated with ACL injuries in the sulcus terminalis of the lateral femoral condyle (A) and the posterolateral tibial plateau (B).
Alternatives to surgery are also being promoted in substrate for the biosynthesis of chondroitin sulfate, hy-
the treatment of arthritis. Viscosupplementation, or aluronic acid, and other macromolecules located in the
intra-articular injections of hyaluronic acid, has been cartilage matrix. Chondroitin sulfate, which is covalently
used to treat osteoarthritis. The proposed mechanisms bound to the proteins as proteoglycans, is secreted into
of action result from the physical properties of the hy- the ECM. The load-bearing properties of the cartilage
aluronic acid, as well as the anti-inflammatory, anabolic, are attributable to the compressive resilience and affin-
local analgesic, and chondroprotective effects. Hyalu- ity for water that the proteoglycans possess. Studies
ronic acid has both viscous and elastic properties. At have supported the effectiveness of glucosamine and
high shear forces, the molecules exhibit increased elastic chondroitin sulfate for the relief of symptoms of os-
properties and reduced viscosity. At low shear forces, teoarthritis based on clinical trials and short-term
the opposite effects are seen. The anti-inflammatory ef- follow-up. These studies have shown a progressive and
fects of hyaluronic acid include inhibition of phagocyto- gradual decline of joint pain and tenderness and im-
sis, adherence, and mitogen-induced stimulation. The an- proved motion; few side effects have been reported.
abolic effects have been demonstrated in vivo with However, many questions surround the long-term ef-
studies showing that intra-articular injections of hyalu- fects, the most effective dosage and delivery route, and
ronic acid may stimulate fibroblasts. The anti- the purity of glucosamine and chondroitin sulfate prod-
inflammatory effects may explain the analgesic effect. ucts. Prospective studies that use validated outcome
Although hyaluronic acid has been shown to stimulate measures for pretreatment and posttreatment and that
cartilage matrix production, the chondroprotective ef- stratify major confounding variables are needed.
fects have not been confirmed. Several studies have
failed to show a statistically significant benefit for hyalu-
ronic acid injections when compared with a placebo. Meniscus
Furthermore, viscosupplementation is relatively expen- Structure and Function
sive, with the cost of a series of injections at more than The meniscus is a specialized viscoelastic fibrocartilagi-
$500 per knee. nous structure capable of load transmission, shock ab-
Numerous studies have investigated other potential sorption, stability, articular cartilage lubrication, and
chondroprotective agents (substances that are capable proprioception. The meniscus is more elastic and less
of increasing the anabolic activity of chondrocytes while permeable than articular cartilage and is composed of a
suppressing the degradative effects of cytokine media- complex three-dimensional interlacing network of col-
tors) on cartilage. These agents include chondroitin sul- lagen fibers, proteoglycan, glycoproteins, and fibrochon-
fate, glucosamine sulfate, piroxicam, tetracylines, corti- drocytes that are responsible for the synthesis and main-
costeroids, and heparinoids. Glucosamine serves as a tenance of the ECM. The meniscus is composed of 75%
mining the end point of fusion and incorporating the effect of Green SA: Ilizarov method. Clin Orthop 1992;280:2-6.
patient parameters.
Muschler GF, Boehm C, Easley K: Aspiration to obtain
osteoblast progenitor cells from human bone marrow:
Rubin C, Bolander M, Ryaby JP, Hadjiargyrou M: The
use of low-intensity ultrasound to accelerate the healing The influence of aspiration volume. J Bone Joint Surg
of fractures. J Bone Joint Surg Am 2001;83-A:259-270. Am 1997;79:1699-1709.
A review of the efficacy of low-intensity ultrasound in
Rhinelander FW: Tibial blood supply in relation to frac-
fracture management is presented.
ture healing. Clin Orthop 1974;105:34-81.
Musculoskeletal Biomechanics
Vijay K. Goel, PhD
Ashutosh Khandha, MS
Sasidhar Vadapalli, MS
Introduction gram. The resultant force (or the force that can replace
Biomechanics involves the use of the tools of mechanics the two vectors and still have the same effect on the
(the branch of physics that analyzes the actions of forces) body as the two original vectors) is the diagonal of the
in the study of anatomic and functional aspects of living parallelogram (R).
organisms. The musculoskeletal interactions are a good An example of vector resolution to predict contact
example of a mechanical system. The primary functions force at the knee joint is shown in Figure 1. If the direc-
of the musculoskeletal system are to transmit forces from tion and magnitude of the muscle and tendon forces are
one part of the body to another and to protect certain or- as shown in the figure, the resultant joint contact force
gans (such as the brain) from mechanical forces that could can be found by using the parallelogram law. The result-
result in damage. Therefore, the principal biologic role of ant joint contact force is at a 45 angle to the line of ac-
skeletal tissues is to bear loads with limited deformation. tion of the tendon force and its magnitude is given by
To appreciate the mechanical functions that these tissues the vector addition (the square root of the squares of
must perform, it is necessary to understand the forces that the two forces), which is 71 lb.
whole bones normally carry. In most cases, these forces re- Tensors, defined mathematically, are simply arrays of
sult from loads being passed from the part of the body in numbers, or functions, which transform according to cer-
contact with a more or less rigid environmental surface tain rules, under a change of coordinates. In physics, ten-
(such as the heel and the ground surface during walking) sors characterize the properties of a physical system. A
through one or more bones to the applied or supported tensor consisting of a single number is referred to as a
load (such as the torso). In addition to the forces trans- tensor of order zero, or simply, a scalar. A tensor of or-
mitted through bone-to-bone contact, large and important der one, known as a vector, is a single row or a single
forces exerted by the muscles and ligaments act on the column of numbers. Tensors can be defined to all orders.
bones. Most muscle, ligament, and bone-to-bone contact The next order above a vector are tensors of order two,
forces act in or near the bodys major diarthrodial joints. which are often referred to as matrices. Second order
Basic engineering concepts used in the conventional anal- components are not only associated with magnitude and
ysis of mechanical systems and their principles can be ap- direction, but they are also dependent on the plane over
plied to the musculoskeletal system. which they are determined. The components of a second
order tensor can be written as a two-dimensional array
consisting of rows and columns as shown below:
Concepts and Terminology of Mechanics
Scalars, Vectors, and Tensors
xx xy xz
In mechanics, two basic quantities are defined. Scalar
quantities (such as mass, temperature, work, and energy) yx yy yz
have magnitude. A vector quantity (such as force, veloc-
ity, and acceleration) has both magnitude and direction. zx zy zz
Unlike scalars, vector quantities add in a tip to tail fash-
ion. Just as vectors represent physical properties more com-
Consider two force vectors, A and B. The length of plex than scalars, matrices represent physical properties
the vectors represents the magnitude and arrows point more complex than can be described by vectors.
in the direction of the forces. To replace these two vec-
tors with a single vector that has the same effect on the Force, Mass, and Weight
body, the two vectors are drawn tail to tail. Next, lines Force may be defined as mechanical disturbance or load
are drawn parallel to each vector to create a parallelo- and is associated with the result of muscle activity.
Mo = 0 :
FB a WF b WO c = 0
1
FB = (bW + cW )
a F O
Fy = 0 :
RF - F B + WF + WO = 0
RF = F B WF WO
A = bh
3
bh
I = 12
A = r o2
4
I = 4 r0
J = 2 r04
A = (ro2 ri2)
4 4
I = 4 (r0 ri )
J = 2 (r04 ri4)
Figure 8 Area moment of inertia and polar moment for three geometries: rectangle
(a), solid cylinder (b), and hollow cylinder (c). a = Area ; i = area moment of inertia; j =
polar moment of inertia; NA = neutral axis. (Reproduced with permission from Ozkaya
N, Nordin M: Fundamentals of Biomechanics, ed 2. New York, NY, Springer-Verlag,
1998.)
Figure 7 Area and polar moment of inertia defined for a cross section of bone.
Strain
Strain, which is also known as unit deformation, is a
measurement of the degree or intensity of deformation.
Consider a rod with initial length L which is stretched
to a length L' (Figure 10). The strain measure , a di-
mensionless ratio, is defined as the ratio of elongation
with respect to the original length.
Equation 9:
L' L
= L
Figure 11 Stress-strain diagram. (Adapted from Examining the effects of space flight
on the skeletal system, Houston, Texas, National Space Biomedical Research Institute.)
Torsion
Torsion occurs when a structure is caused to twist about
its longitudinal axis, typically when one end of the struc-
Figure 14 Shear force (F) deforms a cube into a parallelepiped. ture is fixed. Torsional fractures of the tibia are common
in football and skiing injuries in which the foot is held in
a fixed position while the rest of the body undergoes a
twisting motion. The magnitude of the shear stress () is
Youngs Modulus, Shear Modulus, and Poissons Ratio related to the magnitude M of the applied torque, the
The modulus of elasticity in tension, also known as cross-sectional area of the shaft, and the radial distance
Youngs modulus (E), is the ratio of stress to strain on (r) between the center line and the point at which shear
the loading plane along the loading direction when stress is to be determined.
the material is in the elastic limit. Equation 13:
Equation 10:
xx = (M) (r)
E=
xx (J)
Common sense (and the second law of thermodynamics) Mechanical Properties of Tissues
indicates that a material under uniaxial tension must Biomechanical principles guide the manner in which
elongate in length. Therefore, the Youngs modulus (E) is components of the musculoskeletal system respond to
trauma, stresses, and loads and therefore determine the
required to be nonnegative for all materials (E > 0).
success of this system to withstand external forces that
A similar property known as shear modulus is used to
may threaten the more vulnerable organs. These princi-
define material stiffness. Shear modulus is the ratio of
ples also apply to body motions such as bending, lifting,
shear stress to shear strain of a material. Shear modulus
and fine manipulation. It also is important to realize
(G) is measured in Pa or newton per square meter (N/m2).
that the behavior of the muscles and tissues depends on
In the cube shown in Figure 14, application of a shear
intrinsic material properties. In general, materials re-
force (F) deforms the cube into a parallelepiped (a solid
spond differently to different loading configurations. For
with parallel sides that are not perpendicular to each
a given material, there may be different mechanical
other).This results in shear stress, (F/A) and shear strain,
properties that must be considered in analyzing its re-
(D/L).
sponse to, for example, tensile loading as compared with
Equation 11:
loading that may cause bending or torsion. To apply bio-
(F / A) mechanical principles to the musculoskeletal system, it
Shear modulus, (G) = (D / L) = / is essential to understand the mechanical properties of
tissues.
Also, a rod-like specimen subjected to uniaxial tension
will exhibit some shrinkage in the lateral direction for
most materials. The opposite is true for the compression Extensibility and Elasticity
force. The ratio of lateral strain and axial strain is de- The properties of extensibility and elasticity are com-
fined as Poissons ratio (). mon to many biologic tissues. Extensibility is the ability
Equation 12: to be stretched and elasticity is the ability to return to
normal length after extension or contraction.
yy The elastic behavior of muscle consists of two major
v=
xx conceptual components. As shown in Figure 15, the
muscle membranes represent the parallel elastic compo-
The Poissons ratio for most materials will fall in the nent, which provides resistive tension when a muscle is
range, passively stretched. The tendons represent the series
elastic component, which acts as a spring to store elastic
1
0v2 energy when an active muscle is stretched. These com-
Figure 16 Lines of fracture vary depending on whether the load is a combination of (Reproduced with permission from An Kn: In vivo force and strain of tendon, ligament, and
compressive and bending forces (a), bending force (b), torsional force (c), compressive capsule, in Guilak F, Butler DL, Goldstein SA, Mooney D (eds): Functional Tissue Engineer-
force (d), and tensile force (e). ing. New York, NY, Springer, 2003.)
monly encountered in the vertebrae of elderly patients, Compared with tendons, ligaments often contain a
whose bones are weakened as a result of aging. Clini- greater proportion of elastic fibers that account for their
cally, most bone fractures occur as a result of complex high extensibility but lower strength and stiffness. Like
combined loading situations rather than simple loading tendons, they are viscoelastic and exhibit hysteresis, but
mechanisms. Figure 16 shows the differing lines along deform elastically up to strains of about 0.25 (yield
which fractures in bone occur depending on the type of strain), which is about five times as much as the yield
load encountered. strain of tendons.
Weeping Lubrication
Weeping lubrication is a mechanism by which the joint
load is borne by the hydrostatic pressure created by the
water phase of the synovial fluid escaping from the car-
tilage. Because cartilage is permeable, the water phase
of the synovial fluid can move in and out of it. Under
the application of load, the water phase of the synovial
fluid is released from cartilage. As the fluid is pushed
into the joint cavity, it separates the two cartilage sur-
faces because of its hydrostatic pressure and, thus, de-
creases the friction. The reverse happens when the joint
is unloaded and the water phase of the synovial fluid is
sucked into the cartilage, thus completing the cycle. This
squeeze-out/suck-in occurrence provides a self pressur-
izing and load-bearing mechanism that is not dependent
on the speed of sliding. This theory is based on some ex-
perimental studies of animal joint lubrication.
Figure 17 Hydrodynamic lubrication. (Reproduced with permission from Panjabi MM,
White AA III: Joint friction, wear, and lubrication, in Biomechanics of the Musculoskele-
tal System. New York, NY, Churchill Livingstone, 2001.) Squeeze Film Lubrication
Squeeze film lubrication is a mechanism by which the
joint load is carried by the fluid pressure developed be-
ternal load, the lubricant is squeezed out and there is di- tween the two surfaces as a result of the relative move-
rect contact between the shaft and its bearing. However, ment of the approaching surfaces. As the two surfaces
when the shaft starts rotating, the fluid is brought in be- approach each other, the fluid trapped between the cav-
tween the shaft and the bearing, creating a fluid wedge ities of the cartilage is squeezed out, thus creating a
(Figure 17, B). This action has the effect of lifting the cushion and providing a load-bearing capacity for the
shaft above the bearing and thus decreasing friction and joint. When the surfaces touch, there is no longer a
wear. Although this lubrication mechanism explains the squeeze film. Thus, this mechanism cannot explain the
low friction found in high speed and highly loaded ma- joint lubrication under normal physiologic conditions.
chinery (for example, the bearings of the automotive However, in situations where a joint is suddenly loaded,
crankshaft), it does not explain the lubrication of a body such as landing on the ground after a jump, the squeeze
joint, which has a sliding velocity that is too slow to gen- film mechanism may be responsible for reducing shock
erate any significant wedge of fluid film. and injury to the cartilage.
An KN: In vivo force and strain of tendon, ligament and Panjabi MM, White AA III: Biomechanics of the Muscu-
capsule, in Guilak F, Butler DL, Goldstein SA, Mooney loskeletal System. New York, NY, Churchill Livingstone,
DJ (eds): Functional Tissue Engineering. New York, NY, 2001.
Springer, 2003, pp 96-105. This book describes the principles of biomechanics in a
In vivo force and strain measurements in soft tissue were simple manner and is suitable for orthopaedic residents and
presented in six groups: tendon tension, ligament deformation, fellows.
capsular pressure, tendon surface friction, soft-tissue stress,
and soft-tissue strain.
Puska MA, Kokkari AK, Nrhi TO, Vallittu PK: Me-
chanical properties of oligomer-modified acrylic bone
Ateshian GA, Hung CT: Functional properties of native cement. Biomaterials 2003;24:417-425.
articular cartilage, in Guilak F, Butler DL, Goldstein Mechanical properties of oligomer-modified acrylic bone
SA, Mooney DJ (eds): Functional Tissue Engineering. cement with glass fibers were studied. The three-point bending
New York, NY, Springer, 2003, pp 46-68. test was used to measure the flexural strength and modulus of
Important mechanical properties of the cartilage including the acrylic bone cement composites using analysis of variance
viscoelasticity, anisotropy, tension-compression nonlinearity, between groups. A scanning electron microscope was used to
and inhomogeneity were assessed. Valuable measures of the examine the surface structure of the acrylic bone cement com-
functionality of the tissue-engineered constructs were in- posites.
cluded.
(Adapted from McKellop HA: Bearing surfaces in total hip replacements: State of the art and future developments. Instr Course Lect 2001;50:174.)
try and the Food and Drug Administration (FDA) to ide, which serves as a protective passive layer between
bring improved technologies to the marketplace safely the corrosive body environment and the bulk steel.
and expeditiously. Current evaluation of the perfor- Cobalt alloys are composed primarily of cobalt,
mance of new bearing materials must be centered on chromium, and molybdenum. Chromium is added for in-
their intended benefits and disadvantages (Table 1) and creased hardness and corrosion resistance. As is the case
the results of laboratory and short-term clinical tests. with stainless steel, the chromium forms a strongly ad-
herent passive oxide film. Molybdenum is added to pro-
Metallic Materials vide high strength. Standard cobalt alloy contains signif-
Stainless steels, cobalt alloys, and titanium alloys have icant amounts of carbon that allows for the formation of
been used in orthopaedic devices for decades. They are hard carbides, which strengthen the alloy and improve
generally corrosion resistant and biocompatible and its wear resistance. The addition of nickel forms an alloy
possess mechanical properties sufficient for use as struc- suitable for forging, which further enhances the materi-
tural load-bearing implants. These materials are fabri- als strength.
cated using a wide variety of techniques (including cast- The most commonly used titanium alloy for ortho-
ing, forging, extrusion, and hot isostatic pressing) which paedic applications is titanium-aluminum-vanadium al-
lend flexibility in terms of both mechanical properties loy, often referred to as Ti-6Al-4V because the primary
and shape. alloying elements, aluminum and vanadium, comprise
Stainless steels are predominantly iron-carbon al- about 6% and 4%, respectively, of the alloy. Titanium
loys. Carbon is added to allow the formation of metallic has the ability to self passivate, forming its own oxide
carbides within the microstructure. Carbides are much that imparts a high degree of corrosion resistance. Oxy-
harder than the surrounding material, and a uniform gen concentration is kept very low to maximize strength
distribution of carbides provides strength. Additions of and ductility. Despite long-term clinical evidence of ex-
other alloying elements, such as molybdenum, stabilize cellent biocompatibility, concern that the release of va-
the carbides. Chromium provides the stainless quality to nadium (a cytotoxic element) could cause local and sys-
stainless steel. It forms a strongly adherent surface ox- temic complications has led to the introduction of other
Figure 2 Wear tracks from a conventional polyethylene (1050 resin irradiated at 25 kGy) (A) and an elevated cross-linked polyethylene (1050 resin irradiated at 65 kGy) (B),
which were tested on a knee-like wear apparatus for 2 million cycles under identical conditions show more severe damage in the conventional material. The elastic moduli were
1.0 GPa for the conventional and 800 MPa for the elevated cross-linked material. (Reproduced with permission from Furman BD, Maher SA, Morgan T, Wright TM: Elevated
crosslinking alone does not explain polyethylene wear resistance, in Kurtz SM, Gsell R, Martell J (eds): Crosslinked and Thermally Treated Ultra-High Molecular Weight Polyethyl-
ene for Joint Arthroplasties ASTM STP 1445. West Conshohocken, PA, ASTM International, pp 248-261.)
Hopper RH Jr, Young AM, Orishimo KF, Engh CA Jr: Urban JA, Garvin KL, Boese CK, et al: Ceramic-on-
Effect of terminal sterilization with gas plasma or polyethylene bearing surfaces in total hip arthroplasty:
gamma radiation on wear of polyethylene liners. J Bone Seventeen to twenty-one-year results. J Bone Joint Surg
Joint Surg Am 2003;85:464-468. Am 2001;83:1688-1694.
Patients who received hip replacements with polyethylene Findings showed that long-term use of ceramic-on-
acetabular liners sterilized with gamma radiation (61 hips at polyethylene bearings implanted with cement by one surgeon
mean follow-up of 5.2 years) experienced an average of 50% resulted in outstanding long-term clinical and radiographic re-
less wear than patients with noncross-linked liners sterilized sults and wear rates lower than those previously reported for
with gas plasma (63 hips at mean follow-up of 3.9 years). metal-on-polyethylene bearings. These findings support the
use of such bearings in total hip arthroplasty.
Muratoglu OK, Bragdon CR, OConnor DO, Perinchief
RS, Jasty M, Harris WH: Aggressive wear testing of a Cements
cross-linked polyethylene in total knee arthroplasty. Cassidy C, Jupiter JB, Cohen M, et al: Norian SRS ce-
Clin Orthop 2002;404:89-95. ment compared with conventional fixation in distal ra-
A knee simulator study comparing elevated cross-linked dial fractures: A randomized study. J Bone Joint Surg
and conventional tibial inserts showed extensive delamination Am 2003;85:2127-2137.
and cracking as early as 50,000 cycles for conventional poly- A prospective, randomized multicenter study of closed re-
ethylene inserts, whereas the cross-linked polyethylene inserts duction and immobilization with and without the use of cal-
did not show any subsurface cracking or delamination at cium phosphate bone cement for the treatment of distal radial
0.5 million cycles. fractures, found significant clinical improvement during the
first 3 months of treatment with cement augmentation.
Ceramics
Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Mi- Garfin SR, Reilley MA: Minimally invasive treatment of
gaud H, Goutallier D: Revision total hip arthroplasty osteoporotic vertebral body compression fractures.
performed after fracture of a ceramic femoral head: A Spine J 2002;2:76-80.
multicenter survivorship study. J Bone Joint Surg Am A literature review with presentation of early results of a
2003;85:825-830. national, clinical study showed 95% of patients treated for
One hundred five surgical revisions to treat a fracture of a painful osteoporotic compression fractures had significant im-
ceramic femoral head, performed at 35 institutions, were stud- provement in symptoms and function after kyphoplasty or ver-
ied. Although the fractures were potentially serious events, tebroplasty. Only kyphoplasty improved vertebral height and
treatment with total synovectomy, cup exchange, and insertion kyphosis.
of a cobalt-chromium or new ceramic femoral ball minimized
the risk of early loosening and the need for one or more re- Lewis G: Fatigue testing and performance of acrylic
peat revisions. bone-cement materials: State-of-the-art review.
J Biomed Mater Res 2003;66B:457-486.
Hamadouche M, Boutin P, Daussange J, Bolander ME, A literature review of the fatigue behavior of acrylic bone-
Sedel L: Alumina-on-alumina total hip arthroplasty: A cement formulations showed that an increase in molecular
minimum 18.5-year follow-up study. J Bone Joint Surg weight leads to an increase in fatigue life; the effect of vacuum
Am 2002;84:69-77. mixing on fatigue life remains controversial.
A retrospective long-term study showed a 20-year survival
rate of 85% for alumina-on-alumina hip replacements with Biodegradable Polymers
minimal wear rates and limited osteolysis, provided that the Grande DA, Mason J, Light E, Dines D: Stem cells as
acetabular component remained well-fixed. No alumina head platforms for delivery of genes to enhance cartilage re-
or socket fractures occurred and osteolysis was moderate in pair. J Bone Joint Surg Am 2003;85(suppl 2):111-116.
about 10% of the patients. Stem cells transduced with either bone morphogenetic
protein-7 or sonic hedgehog gene were delivered to osteo-
Hernigou P, Bahrami T: Zirconia and alumina ceramics chondral defects in rabbits using bioresorbable scaffolds. The
in comparison with stainless-steel heads: Polyethylene addition of either factor enhanced the quality of the repaired
tissue, showing the utility of tissue-engineering gene therapy
wear after a minimum ten-year follow-up. J Bone Joint
strategies.
Surg Br 2003;85:504-509.
Comparison of ceramic and metal bearing surfaces showed
increased polyethylene wear at 5- to 12-year follow-up for zir- Hovis WD, Kaiser BW, Watson JT, Bucholz RW: Treat-
conia and metal heads. The group with the zirconia heads had ment of syndesmotic disruptions of the ankle with bio-
Wigfield C, Robertson J, Gill S, Nelson R: Clinical expe- Jacobs JJ, Skipor AK, Patterson LM, et al: Metal release
rience with porous tantalum cervical interbody implants in patients who have had a primary total hip arthroplas-
in a prospective randomized controlled trial. Br J ty: A prospective, controlled, longitudinal study. J Bone
Neurosurg 2003;17:418-425. Joint Surg Am 1998;80:1447-1458.
A prospective randomized study of the ability of porous
McKellop H, Shen FW, Lu B, Campbell P, Salovey R:
tantalum implants to achieve cervical interbody fusion showed
Development of an extremely wear-resistant ultra high
inferior end-plate lucency in four patients raising concerns
molecular weight polyethylene for total hip replace-
about delayed or nonfusion. Fusion subsequently occurred in
ments. J Orthop Res 1999;17:157-167.
all patients at 12 months after surgery.
Oonishi H, Kadoya Y: Wear of high-dose gamma-
Classic Bibliography irradiated polyethylene in total hip replacements.
J Orthop Sci 2000;5:223-228.
Bartel DL, Rawlinson JJ, Burstein AH, Ranawat CS,
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canine model. J Arthroplasty 1999;14:347-354. ogy. Biomaterials 2000;21:2607-2613.
Physiology of Aging
Susan V. Bukata, MD
Mathias Bostrom, MD
Joseph A. Buckwalter, MD
Joseph M. Lane, MD
Age-Related Changes in Articular Cartilage Age-Related Changes in Tendon, Ligament, and Joint
Degroot J, Verzijl N, Wenting-van Wijk MJ, et al: Accu-
Capsule
mulation of advanced glycation end products as a mo-
lecular mechanism for aging as a risk factor in osteoar- Sargon MF, Doral MN, Atay OA: Age-related changes
thritis. Arthritis Rheum 2004;50:1207-1215. in human PCLs: A light and electron microscopic study.
This study examined the role of AGEs in the development Knee Surg Sports Traumatol Arthrosc 2004;12:280-284.
This study of 36 specimens from patients of various ages
of osteoarthritis. Using a canine ACL transection model, the
used light and transmission electron microscopy to analyze ul-
affected joints were injected with ribose to mimic the presence
trastructural differences. Collagen fibers were most variable in
of AGE found in older dogs. The development of osteoarthri-
diameter in patients age 10 to 19 years. Aging was associated
tis and the degree of collagen damage and proteoglycan re-
with a decrease in collagen fiber diameter and an increase in
lease was then analyzed. AGEs were associated with more se-
collagen fibril concentration with a maximum fibril concentra-
vere osteoarthritis.
tion occurring in patients age 60 to 69 years.
Exercise and Fall Prevention Galea V: Changes in motor unit estimates with aging.
DeRedeneire N, Visser M, Peila R, et al: Is a fall just a J Clin Neurophysiol 1996;13:253-260.
fall? Correlates of falling in healthy older persons: The
Health, Aging, and Body Composition Study. J Am Galloway MT, Jokl P: Aging successfully: The impor-
Geriatr Soc 2003;51:841-846. tance of physical activity in maintaining health and
This study evaluated 3,075 high-functioning adults (70 to
function. J Am Acad Orthop Surg 2000;8:37-44.
79 years of age) who were living independently in the commu-
nity. Frequency of falls over a 1-year period were studied. Re-
sults indicated that 24% of women and 18% of men in this Hannan MT, Tucker KL, Sawson-Hughes B, Cupples
study fell at least once during that 1-year period. Factors asso- LA, Felson DT, Kiel DP: Effect of dietary protein on
Melton LJ: Epidemiology of hip fractures: Implications Sherman S: Human aging at the millennium, in Rosen
of the exponential increase with age. Bone 1996;18:121S- CJ, Glowacki J, Bilizikian JP (eds): The Aging Skeleton.
125S. New York, NY, Academic Press, 1999, pp 11-18.
Nishida S, Endo N, Yamagiwa H, et al: Number of os- Taafe DR, Marcus R: Musculoskeletal health and the
teoprogenitor cells in human bone marrow markedly older adult. J Rehabil Res Dev 2000;37:245-254.
decreases after skeletal maturation. J Bone Miner Metab
1999;17:171-177. Woo SL-Y, Hollis JM, Adams DJ, et al: Tensile proper-
ties of the human femur-anterior cruciate ligament-tibia
Noyes FR, Grood ES: The strength of the anterior cruci- complex: The effects of specimen age and orientation.
ate ligament in humans and rhesus monkeys: Age- Am J Sports Med 1991;19:217-225.
Table 2 | What Privacy Rule Says About Disclosure of Pro- Enforcement of Compliance/Penalties for
tected Health Information Noncompliance
Uses and Disclo- Compliance with the Privacy Rule standards is volun-
sures of Patient tary. The OCR of the Department of Health and Hu-
Health Information Situations man Services will perform the enforcement of compli-
ance. The OCR will investigate reports of violation and
Required disclo- To the individual (or individuals representative)
sures who is the subject of information covered entities will be subjected to progressive disci-
To Department of Health and Human Services plinary actions to demonstrate compliance. The OCR
during a compliance review, investigation or en- may impose civil penalties of $100 for each act of non-
forcement action compliance of the standards and up to $25,000 per year
Permitted uses and To the individual who is the subject of information for multiple identical violations. However, for criminal
disclosures (with- For treatment, payment, and health care operations penalties, the Department of Justice will perform the in-
out an individuals By simply asking for permission from the individual vestigation, and may impose a fine depending on the se-
authorization) which then give the individual the opportunity to verity of violation from $50,000 to $250,000 and impris-
agree or object
Use or disclosure of information incident to an onment of 1 to 5 years (OCR Privacy Brief, 2003, pp 17-
already permitted use or disclosure of information 18).
as long as the covered entity has adopted reason-
able safeguards and the release of information is Patient Safety Issues
limited to the minimum amount of protected The Joint Commission on Accreditation of Healthcare
health information needed to accomplish the
Organizations (JCAHO) is the major accrediting agency
pur pose as required by the Privacy Rule
Public interest and benefit activities (eg, court for hospitals. In 1996, JCAHO developed a sentinel-
order, serious threat to health or safety, essential event reporting policy that encouraged an accredited
government functions) health care organization to voluntarily report sentinel
Limited dataset for the purposes of research, pub- events within 5 days and to submit a root cause analysis
lic health or health care operation within 45 days following discovery. JCAHO expects
No restriction De-Identified Health Information (removal of indi- health care organizations to perform root cause analyses
vidually identifiable health information) of systems and processes of the organization rather than
Not covered under Employment records held or maintained by a cov- the performance of individuals. JCAHO defines a senti-
privacy rule ered entity as an employer nel event as an unexpected occurrence involving death
Education and other records defined in the Family
or serious physical or psychological injury or the risk for
Educational Rights and Privacy Act
which a recurrence would carry a significant chance of a
serious adverse outcome.
ered entities (such as health plans, health care clearing- Based on the root cause analyses of sentinel events
houses, and health care providers) and its business asso- reported by accredited organizations, JCAHO has iden-
ciates to implement the national standards to protect tified the need to establish national patient safety goals
the security and privacy of all individually identifiable (Table 3). JCAHO intends to reevaluate the national
health information. The Privacy Rule also requires cov- patient safety goals every year. The goals are to be an-
ered entities to provide individuals an adequate notice nounced in July of each year and to become effective in
of its privacy practices and a description of their individ- January of the following year. In July 2002, JCAHO an-
ual rights. Furthermore, covered entities are to make a nounced the first National Patient Safety Goals, and in
good faith effort to obtain a written acknowledgment of January 1, 2003, all accredited health care organizations
notice of receipt from the individual (Federal Register, were required to comply with the established patient
2002, p. 53182.). safety goals and its corresponding recommendations.
Protected health information includes demographic JCAHO will allow accredited organizations to imple-
information such as name, address, birth date, Social Se- ment alternatives to specific recommendations as long
curity number, medical record number, and account as the alternative is as effective as the original recom-
numbers that relate to: (1) the individuals past, present, mendation in achieving a specific patient safety goal.
or future physical or mental health, or (2) the provisions Accredited organizations may submit alternative ap-
of health care to the individual, or (3) the past, present, proaches by completing a Request for Review of an
or future payment for the provision of health care to the Alternative Approach to a National Patient Safety Goal
individual. (Office of Civil Rights [OCR] Privacy Brief, Requirement form available on the JCAHO Website:
2003, p. 4). Table 2 presents information about uses and http://www.jcaho.org/accredited+organizations/
disclosures of Protected health information. patient+safety/04+npsg/04_npsg_altform.htm.
Information disclosure Consumers have the right to receive accurate and easily understood information about health plan, health care
professionals, and health care facilities.
Suggestions for health care organizations to ensure this right:
Provide reasonable accommodation to meet the needs of patients with language barrier, physical or mental
disability.
Health care providers educational preparation (eg, education, board certification, recertification) and
appropriate experience in performing procedures and services.
Performance measures such as consumer satisfaction.
Provide complaints and appeals processes.
Choice of providers and plans Consumers have the right to a choice of health care providers that is sufficient to ensure access to appropriate
high-quality health care.
Suggestion for health plans to ensure this right:
Provide sufficient numbers and types of providers to encompass all covered services.
Access to emergency services Consumers have the right to access emergency health care services when and where the need arises. Health
plans should provide payment when a consumer presents to an emergency department with acute symptoms
of sufficient severity including severe pain such than a prudent layperson could reasonably expect the
absence of medical attention to result in placing that consumers health in serious jeopardy, serious
impairment to bodily functions, or serious dysfunction of any bodily organ or part.
Suggestions to ensure this right:
Health plans to educate their members about availability, location, and appropriate use of emergency and
other medical services.
Emergency department personnel to contact the patients primary care provider or health plan as quickly as
possible to discuss continuity of care.
Participation in treatment decisions Consumers have the right and responsibility to fully participate in all decisions related to their health care.
Consumers who are unable to fully participate in treatment decisions have the right to be represented by
parents, guardians, family members, or other conservators.
Suggestions for health care organizations/health care providers to ensure this right:
Provide patients with easily understood information and opportunity to decide among treatment options
consistent with informed consent.
Provide effective communication with health care providers for patients with disabilities.
Respect the decisions made by patients and/or representatives consistent with the informed consent process.
Respect and nondiscrimination Consumers have the right to considerate, respectful care from all members of the health care system at all
times and under all circumstances. An environment of mutual respect is essential to maintain a quality health
care system.
Suggestion for health care organizations to ensure this right:
Provide health care services to patients consistent with the benefits covered in their policy or as required by
law based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation,
genetic information, or source of payment.
Confidentiality of health information Consumers have the right to communicate with health care providers in confidence and to have the
confidentiality of their individually identifiable health care information protected. Consumers also have the
right to review and copy their own medical records and request amendments to their records.
Suggestion to ensure this right:
Compliance with the Privacy Rule standards.
Complaints and appeals Consumers have the right to a fair and efficient process for resolving differences with their health plans, health
care providers, and the institutions that serve them, including a rigorous system of internal review and an
independent system of external review.
Suggestion to ensure this right:
Internal and external appeals systems and procedures should be made available to patients and resolution
should be performed in a timely manner and/or consistent as required by Medicare (eg, 72 hours).
Patient Rights and Safety premise that a physicians bedside manner and interpersonal
skills can help influence patient satisfaction is discussed.
The Advisory Commission on Consumer Protection and
Quality in Health Care Industry, appointed by President
Clinton in 1997, drafted a consumer bill of rights. Joint Commission on Accreditation of Health Care Or-
Health care organizations, both public and private, have ganizations web site: 2004 National Patient Safety
adopted the general principles as cited in the consumer Goals. Available at: http://www.jcaho.org/. Accessed De-
bill of rights (Table 4). cember 18, 2003.
The JCAHOs National Patient Safety Goals are listed,
which were developed as a result of lessons learned from sen-
Annotated Bibliography tinel events reported by health care organizations.
Danner C: Working with angry patients. Behavioral Sage WM: Putting the patient in safety: Linking patient
Medicine Brief, Department of Family Practice and complaints and malpractice risk. JAMA 2002;287:3003-
Community Health. Minneapolis, MN, Family Medicine 3005.
and Community Health, University of Minnesota, Issue Customer satisfaction is connected to clinical safety.
19, 2001. Health care organizations should document information from
This article discusses how anger can influence the patients relevant to patient safety and provide that informa-
physician-patient relationship. A three-step model for physi- tion to health care professionals who manage and provide
cians for effective physical and mental management of critical health care.
and angry patients is outlined. The need for the physician to
successfully manage anger in order to avoid a malpractice suit
US Department of Health and Human Services web
and compromised patient care are also discussed.
site: Office for Civil Rights. OCR Privacy Brief: Sum-
mary of the HIPAA Privacy Rule. Washington, DC,
Hickson GB, Federspiel CF, Pichert JW, Miller CS, GPO, May 2003. Available at: http://www.hhs.gov/ocr/
Gauld-Jaeger J, Bost P: Patient complaints and malprac- privacysummary.pdf. Accessed August 8, 2003.
tice risk. JAMA 2002;287:2951-2957. A summary of the HIPAA Privacy Rule such as statutory
The topic of this article is physicians who receive a large and regulatory background, who is covered by the Privacy
number of malpractice claims, resulting in high costs. The Rule, what information is protected, general principles for us-
age and disclosures, and enforcement and penalties for non- Wang EC: Dealing with the angry patient. Permanante J
compliance is presented. 2003;7:77-78.
Communication skills for physicians faced with an angry
US Department of Health and Human Services web patient are discussed, along with insight on what steps might
site: Office of the Secretary. 45 CFR Parts 160 and 164 be taken for management of this situation.
Standards for Privacy of Individually Identifiable
Health Information; Final Rule. Federal Register. Wash- Classic Bibliography
ington, DC, GPO, August 14, 2002. Available at: http://
www.hhs.gov/ocr/hipaa/privrulepd.pdf. Accessed August Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel
8, 2003. RM: Physician-patient communication: The relationship
The entire document of the rules and regulations for the with malpractice claims among primary care physicians
Privacy Rule released by the Department of Health and Hu- and surgeons. JAMA 1997;277:553-559.
man Services is presented.
Rogers C: Communicate, in The American Academy of
Orthopaedic Surgeons, Bulletin. Rosemont, IL, 2003, vol
Presidents Advisory Commission on Consumer Protec-
48, No 6.
tion and Quality in the Health Care Industry web site:
Consumer Bill of Rights and Responsibilities. Executive
Summary. Washington, DC, GPO, November 1997.
Available at: http://www.hcqualitycommission.gov/cborr/
exsumm.html. Accessed August 3, 2003.
A summary of the Consumer Bill of Rights and Responsi-
bilities is presented.
Surgical Ethics in the 21st Century come increasingly complex and consent forms get
Ethical values that guide surgeons toward concrete ac- longer, truly informed consent may seem a distant goal.
tions in the care of patients are provided by ethicists Perceptions of what constitutes physical harm have
and by the professional surgical societies. The ethical also changed, albeit in many separate and perhaps less
principles of beneficence, nonmalfeasance, respect for obvious ways. Therapies that were once state-of-the-art
autonomy, and justice were first presented in 1979 as may now be considered obsolete and perhaps even
part of the framework known as principlism. Attention harmful. As new evidence about outcomes became
is given in the literature to virtue as an additional moral available, procedures have been reshaped or aban-
doned. Evidence-based surgery continues to expand. It
value to be considered. This renewed interest in virtue
is no longer sufficient to offer a procedure to a patient
as an ethical requirement is one that is in concert with
merely based on good intentions without some evidence
surgeons perceptions of what it means to be a moral
of benefit. Although modern surgery demands scientific
physician. Professional societies such as the American
evidence, this requirement is not always so easy to com-
College of Surgeons (ACS) and the American Academy
ply with. Although drugs can be tested in a randomized
of Orthopaedic Surgeons (AAOS) have adopted state-
controlled trial using a placebo for the control, surgeons
ments referring to an honorable surgeons character.
must invent more intricate and sometimes more inva-
The AAOS adopted ten Principles of Medical Ethics sive placebos. Although challenging this goal is not im-
and Professionalism in Orthopaedic Surgery, first in possible, the use of sham surgery is not without contro-
1991 and most recently revised in 2002. The principles versy. Despite strong criticism of such research designs,
are considered standards of conduct, not laws, defining it must be conceded that surgical controls are a difficult
the essentials of appropriate behavior. issue and surgery itself can possibly have quite a strong
Perceptions of a moral physicians conduct have placebo effect.
shifted somewhat during the past century. For example, Some predicted developments in the future of sur-
paternalism was perfectly acceptable in medical and sur- gery are dazzling and will pose new moral challenges.
gical practice for many years, but since the mid 1960s One example is the use of computers and robotics to
has been considered a breach of patient autonomy. Ma- enhance surgical precision and safety. These technolo-
jor improvements in respecting a patients autonomy gies raise ethical questions about training (Who is quali-
were also made in the area of human subject research. fied to operate such devices, and how much expertise is
Currently, it would be unthinkable to enroll a patient or required?), responsibility (Who is responsible for oper-
a healthy volunteer into a clinical trial without their in- ating the device, who is legally responsible for break-
formed consent, a requirement that was not obvious to downs?), and perhaps even fears of too much depen-
early investigators. As will be discussed later, informed dence on machinery (What if it breaks down? Should
consent for some types of surgical research is still not the surgeon be skilled to perform the procedure without
uniform and is an issue for orthopaedic surgeons to con- it? Or will the procedure be abandoned?).
sider carefully. Other advances will challenge conventional thinking.
In some areas of medicine the patient is the sole As discussed in a recent article, some of these develop-
medical decision maker, with the physician as mere ments include human cloning, genetic engineering, tis-
counselor, offering a virtual and perhaps overwhelming sue engineering, limb morphogenesis, intelligent robot-
assortment of available therapies. In surgical situations, ics, nanotechnology, suspended animation, regeneration,
this approach is not always feasible, because some of the and species prolongation. The potential of these new
decision making occurs while the patient is unconscious technologies to disrupt conventional surgical thinking is
and incapable of making decisions. As procedures be- huge. Of direct impact on orthopaedics in the 21st cen-
tury are the ethical issues concerning tissue engineering, The patient is extubated 2 days after the index pro-
regeneration, and intelligent prostheses. Bioartificial cedures. Severe tissue necrosis becomes apparent at the
skin and blood vessel segments already can be found in open wounds on both legs. He is unable to tolerate ele-
laboratories. The anticipated long-term goal is the re- vation of the head of the bed more than 30 because of
generation of body parts, such as parts of limbs and hip pain. Although he recognized his daughter, the pa-
eventually, complete prostheses. Will the orthopaedic tient remains poorly oriented to place and time and co-
surgeons of the future simply replace a diseased hip herent conversations with the patient remain very diffi-
joint, intervertebral disk, or leg with a new one? To ap- cult. The Mini-Mental Status Examination is consistent
proach these new technologies, an ethical framework with early dementia.
will be required. Controversy about the management of this case
causes moral distress among staff and leads to heated
Ethical Approaches to a Patient Dilemma discussions. Therefore, a meeting with the ethics com-
Every day, physicians are faced with different dilemmas mittee is requested. Two designees of the committee, a
in patient care. These vary from simple issues such as or- lawyer from the Department of Risk Management and
dering diagnostic tests or surgical scheduling to more a psychiatrist not involved in the case, are present. Dur-
complex issues involving decisions about terminal ill- ing this meeting, the daughter continues to strongly
nesses and withdrawal of treatment. Deciding on the refuse consent for further treatment, stating that those
morally best course can be challenging. Although it is were his wishes. Although sympathetic to the surgeons
impossible to provide formulaic answers to every ethical plight, the attorney states that it would be legally inad-
dilemma encountered in clinical practice, ethical theo- visable to continue with the surgical intervention as the
ries can guide the orthopaedic surgeon in moral deci- patients earlier wishes were conveyed by the power of
sion making. An actual case is presented to illustrate the attorney, and it is impossible to clearly establish whether
prominent ethical theories and to serve as an example he had any decisional capacity to counter this. A sur-
of how to work through the nuances of ethical thinking. geon on the committee thought the attorneys advice to
be outrageous, stating that not treating this patient
The Case amounted to torturing the patient to death.
Mr. B is an 87-year-old man who has severe injuries, but
no head, severe chest, or abdominal injuries, after a Discussion
head-on motor vehicle collision. He is transferred to a The approaches that dominate the ethical literature are
Level 1 trauma center. However, he has several severe deontology and utilitarianism. In addition to these two
orthopaedic injuries, including bilateral grade IIIB open major moral philosophies, clinical ethics cannot be un-
pilon and segmental tibial shaft fractures, a right closed derstood without taking into account the principles of
tibial plateau fracture, a displaced femoral neck frac- biomedical ethics: self-determination, beneficence, non-
ture, and a left closed supracondylar femur fracture. He maleficence, and justice. Important ethical principles are
also has bilateral comminuted foot fractures and domi- listed and defined in Table 1.
nant right arm fractures. Prior to the accident he had The deontologic approach is also called duty-based
lived independently, close to his only daughter. ethics, considering the duties that people have toward
Mr. B undergoes emergent irrigation and dbride- one another. In this case, it is reminiscent of the familiar
ment and A-frame external fixator placement of both notion that the surgeon has certain special duties to-
legs. He is then transferred, while intubated and in sta- ward the care of the patient with whom a therapeutic
ble condition, to the surgical intensive care unit for fur- relationship has been established. From a strictly deon-
ther management. A durable power of attorney had tologic point of view, the right approach would be for
been granted to his daughter. She is contacted to obtain the orthopaedists to perform the surgeries they believe
consent for urgent right below-knee amputation, repeat are indicated, as it is their duty as Mr. Bs treating physi-
irrigation and dbridement of the left ankle with possi- cians to give him the necessary treatments. This is what
ble amputation, and hemiarthroplasty replacement of the orthopaedic surgeons in this case suggested be done
the right hip. Despite repeated requests, she strongly re- and requested consent for, to no avail, leading to the
fuses to give approval for any further interventions that ethical controversy in the first place.
could prolong her fathers life, despite the understand- The utilitarianism approach is the view that actions
ing of the severity of the open fractures and the risk for are to be morally evaluated according to the amount of
sepsis or pulmonary complications. She states that she well being they promote. This approach is consistent
and her father had discussed his wishes many years be- with preoccupation with the outcomes or consequences
fore, and he had expressed his desire to die at home of an intervention, and is why one treatment is recom-
without any nursing home care or dependency on a ven- mended over another if it is more likely to provide a de-
tilator for a prolonged period of time. sired result. Although this approach has been criticized
Assessing if a proposed study met all the criteria proving the system of oversight and enforcing the de-
above was initially left to the discretion of the partments regulations.
physician-investigator, but the dual roles of research sci- Regardless of the criticism they endure, IRBs are
entist and clinical practitioner pull in different direc- currently the only formal and federal mechanism to
tions and present conflicting obligations and interest, safeguard the interests of human research subjects. As
endangering the objectivity of the assessment. There- such, they are an important line of protection to safe-
fore, the responsibility to assess the morality of clinical guard human participants of clinical research. Most
research was given to outside reviewers. In its 1989 revi- IRBs have a home page on their institutions Website,
sion of the Declaration of Helsinki, the World Medical on which they provide information and submission
Association sets as the international standard for bio- forms to download and complete.
medical research involving human subjects this require- Although the regulations for submitting research
ment: Each experimental procedure involving human proposals to an IRB are fairly straightforward, uncer-
subjects should be clearly formulated in an experimen- tainties remain as to what protocols should and should
tal protocol which should be transmitted for consider- not be reviewed. This is especially the case among clini-
ation, comment and guidance to a specially appointed cians who do not regularly perform research with hu-
committee independent of the investigator and spon- man participants. One common false assumption is that
sor. retrospective studies do not require IRB review. Retro-
The purpose of the Institutional Review Board spective studies whose results are to be published or
(IRB) is to ensure that research with human volunteers otherwise professionally shared do need to be reviewed
is designed to conform to the relevant ethical standards. by an IRB. Another common misperception is that a
These standards concern protecting the rights and wel- study that is likely to be exempt does not have to be re-
fare of individual research subjects, ensuring voluntary viewed. Officially, only an IRB can make the determina-
informed consent is obtained before participation in a tion that a study is exempt from full review, although
study, and an evaluation of risks and benefits. Since many IRBs will have an expedited review process for
1978, an additional moral standard has been added by studies that are exempt. The important principle to re-
the National Commission for the Protection of Human member is that all human research should be submitted
Subjects of Biomedical and Behavioral Research (The
for IRB review, whether it entails a simple chart review
National Commission). The Commissions Belmont
or an extensive intervention.
Report required IRBs to guarantee equity in the selec-
Another area of debate is the use of innovative or
tion and recruitment of human subjects.
experimental surgery. The introduction of surgical inno-
Across the United States, IRBs may have local
vations frequently occurs under the header of therapeu-
names, such as Human Investigations Committee or
tic intervention, without protocols or consents. This sce-
Committee for Research Subject Protection, and have
nario has the potential to produce an informal study
a decidedly local character, although they are required
without specific study consent, which is currently being
to comply with federal regulations when reviewing ac-
examined by the surgical and ethical communities alike.
tivities involving Food and Drug Administration-
In the future, federal regulations or at least professional
regulated investigational drugs or devices, and when
reviewing research supported by federal funds. Further- standards will likely be developed to address this area
more, all institutions that receive federal research grants of surgery to ensure that new innovations are conducted
and contracts are required to file a statement of assur- with appropriate protection of human subjects while
ance of compliance with federal regulations. In these promoting research and technical advances within the
assurances virtually all institutions voluntarily promise field. Presently, the issue of what constitutes a signifi-
to apply the principles of federal regulations to all re- cant enough innovation as to require an ethical review
search they conduct, regardless of the source of funding. or specific consent is left to the discretion of the sur-
The IRB system has long been subject to criticism, geon.
accused of stifling creativity and impeding progress. In
many institutions, there is a paucity of surgeons that sit New Technology in Orthopaedic Surgery
on IRBs, thus risking that decisions about surgical stud- Developing new technologies has been the driving force
ies will be made with insufficient surgical knowledge. for improvement in surgery. Innovation is necessary if
IRBs have also been accused by bioethicists and patient future gains in patient care are desired. Orthopaedists
advocates of providing inadequate protection to pro- are among the most innovative surgeons in the United
spective research subjects. Even the US federal govern- States; therefore, attention needs to be paid to the ethics
ment criticized the work of several IRBs through its Of- of innovation in orthopaedic surgery. This seems espe-
fice of Human Research Protections (OHRP). The cially important given the promise of emerging new
OHRP was reconstituted by the Department of Health technologies such as cell therapy or the use of growth
and Human Services in 2002 and is responsible for im- factors, for which there currently are no clear federal
regulations, nor are there any clear guidelines pertaining to patients is greatest during certain definable
to innovative surgical procedures. exposure-prone procedures. Exposure-prone proce-
On a professional level, some attempts have been dures include insertion of a needle tip into a body cav-
made to address the issue. The ACS has adopted self- ity, or the simultaneous presence of a health care work-
imposed guidelines for emerging surgical technologies ers fingers and a needle or other sharp object in a
and their application to the care of patients, as formu- highly confined anatomic site. Health care workers who
lated by the Committee on Emerging Surgical Technolo- are positive for HIV or HBV should not perform
gies and Education. The introduction of new technology exposure-prone procedures unless they have obtained
to surgeons and the public must be done ethically in ac- expert counsel regarding the circumstances under which
cordance with the ACS Statement on Principles. These they may perform such procedures. Furthermore, health
Principles require prior and continued IRB (or equiva- care workers should inform patients of their infection
lent) review of the protocol, full description of the pro- status before conducting exposure-prone procedures.
cedure, and informed consent of the patient. Arguably, there are some limitations to the CDC recom-
As major innovators, orthopaedic surgeons should mendations. First, they do not specify exposure-prone
assume an active role in thinking through the issue of procedures, leaving such determinations to the expert
new surgical technologies. By doing so, orthopaedists counsel, allowing for a diversity of opinions and deci-
can provide practical guidance for their colleagues as sions impacting individual infected surgeons or health
well as take on a leadership role within the entire surgi- care workers. In addition, there are no recommenda-
cal community. Differing views often exist on how to tions that restrict professional activities of health care
best introduce surgical innovations in an ethically re- workers infected with HCV, although five cases of viral
sponsible way. Although there is no uniform policy to transmission from health care workers to patient have
date, some truths appear valid and of practical use to been documented to date. Of these cases of viral trans-
the innovative orthopaedic surgeon. First, the innovator mission, three involved surgeons; one gynecologist and
should be familiar with existing rules and regulations two cardiac surgeons. Perhaps the most important short-
that govern human subject research, and know if and coming is that serostatus disclosure as proposed by the
when an innovation is in fact a research activity. This de- CDC does not improve patient safety, while it violates
termination includes the question of whether IRB sub- physician privacy.
mission and the patients informed consent is necessary. In addition to the CDC recommendations, other
When a proposed surgical procedure falls short of being professional societies such as the American Cancer So-
definite research but yet is experimental in a narrower ciety, American Medical Association (AMA), and
sense, or when expected risks are deemed significant or AAOS have issued guidelines. Unfortunately, most
risks and benefits are largely unknown because of the guidelines offer no, minimal, or fairly nonspecific guid-
very novelty of the procedure, additional precautions ance as to what constitutes exposure-prone procedures.
appear prudent and moral. Reasonable precautions are Also, the issue of disclosure to patients remains contro-
prior consultation (for example, with peers, surgeon-in- versial. Most organizations do not recognize a need for
chief, and department chair or division head) and full disclosure; some guidelines still favor either postexpo-
disclosure of the experimental nature of the procedure sure or preprocedure disclosure and/or identification of
to the patient with perhaps a separate consent form. It the source of infection. It has been argued that the law
would also be necessary to carefully monitor the out- should not require health care workers to disclose their
come of the new technology, if only to assess if further HIV status (or HBV or HCV status) because this is
formal evaluation in a trial would be warranted. seen as an invasion of privacy.
Regardless of the ongoing controversy, some rele-
Other Selected Ethical Issues vant experiential information is available to the HIV- or
HCV-infected orthopaedic surgeon. The AAOS pro-
in Orthopaedics vides practical guidance for HIV-, HBV-, and HCV-
The HIV-Positive or Hepatitis B- or C-Positive Health infected orthopaedic surgeons to ensure the maximum
Care Worker safety of the patient. Orthopaedic surgeons infected
There still is considerable debate concerning the man- with HCV should always follow strict aseptic technique
agement of health care workers infected with hepatitis and vigorously adhere to universal precautions. In addi-
B virus (HBV), hepatitis C virus (HCV), or human im- tion, they should seek medical evaluation and treatment
munodeficiency virus (HIV). In 1991, the Centers for to prevent chronic liver disease. Specific recommenda-
Disease Control and Prevention (CDC) issued guide- tions for the prevention of HCV transmission from in-
lines for health care workers infected with HBV or HIV. fected health care workers may be developed as more is
These guidelines set restrictions that still apply today. learned about the virus and its associated risks. HIV car-
The CDCs guidelines were established with the ries a lower risk of transmission than either HBV or
premise that the risk for transmission of HBV and HIV HCV. There are only two known cases of HIV transmis-
sion occurring from an infected health care worker to a cess to medical care. The obligations of society and the
patient, and one instance where transmission is sus- medical profession to treat the medically underserved
pected. In 1990, a cluster of six patients was infected by are also discussed. These recommendations are based on
a dentist in Florida. In 1997, an orthopaedic surgeon in the 1993 AMA Council on Ethical and Judicial Affairs
France transmitted HIV to one of his patients during a guideline.
total hip joint arthroplasty. A third case where transmis- Also noted in the document, it is stated that physi-
sion is suspected concerns an instance of HIV transmis- cians should be encouraged to devote some time to the
sion from an infected nurse to a surgical patient in provision of care for individuals who have no means of
France. paying.
Although current data indicate that the risk of trans- Caring for the uninsured, however, can have a con-
mitting a blood-borne pathogen in a health care setting siderable impact on the orthopaedic surgeons practice.
is exceedingly low, some risk is still present. The ortho- One challenge surgeons encounter when attending to
paedic surgeon should therefore be familiar with the es- the uninsured or underinsured is how to discuss treat-
tablished guidelines of the CDC and the AAOS. It is im- ment plans. According to the literature, the economic
portant that all recommendations to prevent the constraints on the available care are beyond the physi-
transmission of blood-borne pathogens are consistently cians control, yet they raise specific ethical issues for
followed. In general, the guidelines for preventing trans- the physician. The question is whether the physician is
mission from patients to health care workers also apply obligated to disclose all potentially beneficial medical
to preventing transmission from health care workers to treatment, even the ones that exceed ordinary standards
patients. Additionally, health care workers are encour- of care, and which probably will be unaffordable or un-
aged to know their own HBV, HCV, and HIV infection available.
statuses. Voluntary and confidential testing of health Another more pressing problem is the question of
care workers for blood-borne pathogens is recom- how much care an orthopaedic surgeon is required to
mended. Preventing injuries to health care workers and offer the uninsured. This has become more of an issue
subsequent blood exposure to patients offers the great- since the implementation of the 1986 Emergency Medi-
est level of protection. Health care workers who have cal Treatment and Active Labor Act (EMTALA). This
act mandates that emergency departments provide med-
preexisting conditions, such as exudative lesions or
ical screening examinations to every person seeking
weeping dermatitis, should refrain from direct patient
treatment regardless of their ability to pay or whether it
care until the condition is resolved. The affected health
is the appropriate point of service. As a result of this
care worker should also refrain from handling patient-
law, many patients have also been seeking and receiving
care equipment and devices used to perform invasive
specialty care for nonemergent problems, although this
procedures. If a member of a surgical team is injured
was arguably not the original intent of this law. This
during a procedure, the instrument responsible should
consequence of EMTALA has left hospitals and physi-
be removed from the surgical field without being reused
cians facing a crisis of overcrowded emergency depart-
on the patient until appropriately resterilized. Addition-
ments and uncompensated care, which in turn threatens
ally, any disposable items that come into contact with a
patient access to quality care.
health care workers blood should be removed from the Other current economic and political changes also
surgical field and discarded into an appropriate biohaz- have major impact on hospitals and health care provid-
ard bag or container. ers, such as declines in Medicare payments for graduate
Finally, it is advisable for any orthopaedic surgeon medical education, lower disproportionate share pay-
infected with HIV or HCV to seek expert legal counsel ments, growth of Medicaid managed care, increased
in addition to medical treatment. An infected surgeon costs resulting from new government regulations such as
may encounter problems with malpractice insurability, the Healthcare Insurance Portability and Accountability
even while in remission and expected to practice. Also, Act (HIPAA) and Center for Medicare and Medicaid
legal charges have been leveled against seropositive sur- Services rules, increased costs of malpractice insurance,
geons by former patients, even in the absence of infec- increased costs resulting from limited house staff duty
tion, claiming psychological stress. hours and decreased payments for services provided
from Medicare and other third party payers. These fac-
Care of the Uninsured Patient tors combined place a strain on orthopaedic surgeons,
The AAOS Opinion on Ethics and Professionalism: especially those in public and teaching hospitals that
Care and Treatment of the Medically Underserved, orig- shoulder a disproportionate share of the care for the un-
inally formulated in 1998 and recently revised, discusses insured.
the dismal health care insurance situation in the United It appears appropriate to adopt a prudent stance to-
States, noting that increasing percentages of Americans ward providing services at no cost. Caring for the unin-
are uninsured, underinsured, and have inadequate ac- sured is an intrinsic part of orthopaedic surgery in a na-
Table 2 | Why Physicians May Conceal a Medical Error Table 3 | How To Approach Patients After a Medical Error
The medical profession values perfection Notify professional insurer and seek assistance from those who might
Feelings of shame or guilt help with disclosure (for example, attending physician or risk manager)
The admission may damage the physicians professional reputation Disclose promptly what is known about the event; concentrate on what
Possible drop in referrals or an impact on income happened and the possible consequences
Desire to maintain the trust of the patients family Take the lead in disclosure; do not wait for the patient to ask
Pressure felt from various sources: Outline a plan of care to rectify the harm and prevent recurrence
Managed care organizations Offer to get prompt second opinions where appropriate
Hospital administration Offer the option of a family meeting and the option of having other
Malpractice insurers representatives (for example, lawyers) present
Fear of punishment or, in the case of trainees, dismissal Document important discussions
Fear of a malpractice lawsuit Offer the option of follow-up meetings and keep appointments
Be prepared for strong emotions
(Adapted with permission from Selbst SM: The difficult duty of disclosing medical errors. Accept responsibility for outcomes, but avoid attributions of blame
Contemp Pediatr 2003;20:51-53.)
Apologies and expressions of sorrow are appropriate
(Adapted with permission from Selbst SM: The difficult duty of disclosing medical errors.
tion where a great number of people cannot afford even Contemp Pediatr 2003;20:51-53.)
basic health care.
Disclosure in Medical Mistakes In another study, three case scenarios were pre-
Each year thousands of injuries and deaths in US hospi- sented that varied in the degree of outcome severity to
tals result from medical errors. Errors involving medica- 400 patients. The respondents generally indicated that
tions have been reported in 4% to 17% of all hospital they would be more likely to file a lawsuit if the doctor
admissions. Although most of the information available withheld information about a mistake that subsequently
about medical errors pertains to hospitalized patients, surfaced. About 40% said they would stay with the phy-
errors can occur anywhere in the health care system sician after open disclosure of a mistake was made; how-
(operating room, office, clinic, emergency department, ever, only 8% said they would continue to see a doctor
or elsewhere). who did not disclose a mistake. Only 12% said they
The AMA Code of Ethics provides important guide- would sue if the physician informed them of a mistake
lines for professional practice including medical mis- that did not result in permanent aftereffects. However,
takes. The Joint Commission on the Accreditation of 20% said they would sue if they found out about a mis-
Healthcare Organizations requires health care workers take that the physician tried to cover up.
to inform patients when they have been harmed by These results underscore the fact that patients gener-
medical mistakes. However, this may not always occur ally appreciate an open, honest relationship with their
as illustrated by one survey of house officers where they physicians. In fact, a good doctor-patient relationship is
reported that they told an attending physician about se- one of the greatest factors that reduces the risk of a law-
rious mistakes only about half the time; errors were suit if a poor outcome occurs. Prompt disclosure follow-
conveyed to patient or family in only 24% of the cases. ing a medical error will make the physician appear hon-
In one study, simulated case scenarios involving est in the event of litigation and trial (Table 3). In
wrong medications were presented to 150 medical stu- contrast, nondisclosure can have significant negative le-
dents, house officers, and attending physicians. The re- gal implications as the legal statute of limitations may
searchers found that as severity of injury increased, will- be extended if a physician is found to have knowingly
ingness to admit an error declined. About 95% of the and intentionally concealed information from a patient.
students and physicians said they would admit an error
to a patient when the outcome was minimal. However, Evaluation of the Risk/Benefits Ratio in Patients With
only 79% said they would admit an error that resulted Difficult-to-Treat Problems
in the death of a patient. Another 17% said they would Acute, high-risk surgery involves operations on patients
admit the error if they were asked directly about the who often face a significant risk of morbidity and mor-
event. tality without surgery, but for whom surgery itself in-
Although concealing a medical error violates ethical volves a significant risk of morbidity and mortality as
codes, fear of professional censure or medical malpractice well. If nonsurgical management indeed involves a
lawsuits can pressure health care workers to be less than higher risk than surgery (for example, acute compart-
forthcoming when a mistake has occurred (Table 2). ment syndrome, unstable open book pelvis injury), the
choice seems simple. However, most situations are not searcher. Orthopaedic surgeons sometimes serve as con-
as straightforward. Informing the patient about surgical sultants to companies whose products they are studying
and nonsurgical statistics becomes important so that the or join a companys advisory board and speakers bu-
pros and cons of surgery can be carefully weighed. In reau, as well as enter into patent and royalty agree-
general, the reasonable person standard requires phy- ments, which may further complicate financial relation-
sicians to tell patients about a therapys likely complica- ships. Arguably, such complex and considerable financial
tions, especially if surgery is more likely to result in in- relationships may create some (perceived) dependency
jury, disease, or a patients death than an alternative and/or loss of impartiality for the orthopaedic surgeon.
treatment. The best interest for patients is then calcu- The appropriate ethical approach to take when
lated by weighing the benefits against the burdens of faced with financial conflict of interest has been in-
treatment. If the treatment burdens outweigh the bene- tensely debated, with editorialized pronouncements ap-
fit, then the treatment is considered not to be in the pa- pearing in the nations leading medical journals; societ-
tients best interests. Benefits of treatment might include ies and professional associations have addressed the
saving or prolonging life, alleviation of pain or restora- issue of financial conflicts of interest in research.
tion of function to an acceptable level or quality of life. For the moral orthopaedic surgeon, it is appropriate
to be familiar with such professional statements, and to
Relationships With Industry apply them to everyday practice and research as much
Most orthopaedic surgeons foster active relationships as possible. Although financial conflicts of interest can
with industry partners. Representatives of companies probably never be fully eradicated, they can be dimin-
that produce prostheses, instrumentation, and other de- ished and brought to a morally more desirable level.
vices are frequent visitors to orthopaedic departments. One way this can be achieved is by meticulously disclos-
Their companies regularly serve as sponsors of depart- ing all financial interests to patients and research sub-
mental functions and books for residents, and often jects. Although disclosure is not a curative measure as
fund clinical research when done to study their prod- advertising financial ties will not break them, it will
ucts. These types of financial relationships occur in ev- lessen the potential for harm. In addition, orthopaedic
ery branch of medicine and are no less common in or- surgeons should remain vigilant and cognizant of their
thopaedic surgery. For orthopaedic surgeons, it is ongoing relationships with industry, and regularly criti-
therefore important to be aware of the potential ethical cally evaluate the extent of and the impact such ties
problems these relationships can bring about, as such have upon their practice and research.
relationships may cause conflicting interests. These con-
flicts of interest may seriously compromise the integrity Annotated Bibliography
of clinical medicine, and may hamper the protection and General Reference
safety of human research participants. The troublesome American Academy of Orthopaedic Surgeons (ed):
effects of conflicts of interest emerging from the re- Guide to the Ethical Practice of Orthopaedic Surgery, ed
search setting can be far-reaching, as published results 4. Rosemont, IL, American Academy of Orthopaedic
often establish a standard that is followed by physicians Surgeons, 2003.
treating patients worldwide. The first edition of this booklet was published in 1991. The
A conflict of interest is defined here as any financial Guide provides standards of conduct and the essentials of eth-
arrangement that compromises, has the capacity to com- ical behavior for orthopaedic surgeons. This book can be con-
promise, or has the appearance of compromising trust in sidered required reading for the morally conscious ortho-
clinical care and/or clinical research. There are many paedic surgeon and resident.
different types of financial relationships that may sur-
face between industry and orthopaedic surgeons and American Medical Association Council on Ethical and
their institutions. For example, academic orthopaedic Judicial Affairs (ed): Code of Medical Ethics: Current
surgeons may be provided grants to study a sponsors Opinions With Annotations. Chicago, IL, American
drug or product. Such grants may be a major source of Medical Association, 2000-2001.
salary support for investigators and their personnel. It is This text is presently the most comprehensive and current
also often the case that device manufacturers offer in- guide available to physicians in the United States. It is regu-
vestigators financial incentives for entering patients into larly revised and updated, and includes the seven basic princi-
a study. Although these enrollment fees are intended ples of medical ethics and more than 180 opinions of the
to cover the cost of the subjects participation, they typi- AMAs EJA-Council on a wide spectrum of topics.
cally exceed these costs. Academic orthopaedic surgeons
may use the excess funds to support personnel, travel to Beauchamp TL, Childress JF: Principles of Biomedical
meetings, or laboratory supplies and equipment, while in Ethics, ed 5. New York, NY, Oxford University Press,
private practice these bonuses often remain with the re- 2001, pp 319-320.
This book is one of the most influential and important ba- www.facs.org/fellows_info/statements/stonprin.html#top.
sic texts on bioethics, offering the theory of the four guiding Accessed August 25, 2004.
principles: respect for autonomy, beneficence, nonmaleficence, This website discusses codes of professional conduct and
and justice. relationships between patients and surgeons.
Surgical Ethics in the 21st Century Cronin DC II, Millis JM, Siegler M: Transplantation of
American Academy of Orthopaedic Surgeons Principles liver grafts from living donors into adults: Too much, too
of Medical Ethics and Professionalism in Orthopaedic soon. N Engl J Med 2001;344:1633-1637.
Surgery, 2002. Available at: http//www.aaos.org/ In this article, the rapid implementation of an experimen-
wordhtml/papers/ethics/prin.htm. Accessed August 25, tal procedure into transplantation surgery is criticized.
2004.
These ten principles are standards of conduct that define
Margo C: When is surgery research? Towards an opera-
the essential aspects of honorable behavior.
tional definition of human research. J Med Ethics 2001;
27:40-43.
Moseley JB, OMalley K, Petersen NJ, et al: A con- This article analyzes the vague definition of clinical re-
trolled trial of arthroscopic surgery for osteoarthritis of search in surgery and criticizes the wide implementation of so-
the knee. N Engl J Med 2002;347:81-88. called informal research.
In this groundbreaking article the authors use sham sur-
gery as a placebo in the randomized trial, concluding that ar-
throscopic knee surgery for this particular indication is no bet-
Reitsma AM, Moreno JD: Ethical regulations for inno-
ter than a placebo. vative surgery: The last frontier? J Am Coll Surg 2002;
194:792-801.
This article discusses the regulatory gap between the pro-
Satava RM: Disruptive visions. Surg Endosc 2003;17: tection of human subjects involved in research and those un-
104-107. dergoing experimental surgery. Results of a survey among sur-
This visionary article paints a picture of the future of sur- geons are presented.
gery, with technologies that seem like science fiction now but
may very well be available within decades.
Other Selected Ethical Issues in Orthopaedics
ABIM Foundation: American Board of Internal Medi-
The Role of the Institutional Review Board in Modern cine, ACP-ASIM Foundation, American College of Phy-
Orthopaedics sicians, American Society of Internal Medicine, Euro-
United States Department of Health and Human Ser- pean Federation of Internal Medicine: Medical
vices Website. Protecting Personal Health Information professionalism in the new millennium: A physician
in Research: Understanding the HIPAA Privacy Rule. charter. Ann Intern Med 2002;136:243-246.
Available at: http://privacyruleandresearch.nih.gov/ This article presents a discussion on professionalism, prin-
pr_02.asp. Accessed February 2004. ciples, and responsibilities for physicians.
The Department of Health and Human Services issued the
Standards for Privacy of Individually Identifiable Health In-
formation (the Privacy Rule) under the HIPAA of 1996 to American Academy of Orthopaedic Surgeons Website.
provide the first comprehensive federal protection for the pri- American Academy of Orthopaedic Surgeons Advisory
vacy of personal health information. Many of those who must Statement: Preventing the Transmission of Bloodborne
comply with the Privacy Rule complied by April 14, 2003. Pathogens. Available at: http://www.aaos.org/wordhtml/
papers/advistmt/1018.htm. Accessed February, 2001.
Practical guidance for all clinically active orthopaedic sur-
Department of Health and Human Services National geons infected with HIV, HBV, or HCV.
Institutes of Health Office for Protection from Research
Risks Website. Available at: http://ohrp.osophs.dhhs.gov/
humansubjects/guidance/45cfr46.htm. Accessed Febru- American Academy of Orthopaedic Surgeons Opinions
ary, 2004. on Ethics and Professionalism: Care and Treatment of
The Office of Human Research Protections (formerly the the Medically Underserved. May 1998, revised May
Office for Protection from Research Risks, OPRR), provides 2002. Available at: http://www.aaos.org/wordhtml/papers/
online decision charts, assisting prospective investigators in de- ethics/1210eth.htm. Accessed August 25, 2004.
termining the need for IRB review and/or the subjects in- The AAOS applies its principles of medical ethics and pro-
formed consent for research. fessionalism in orthopaedic surgery to this pressing issue.
Selbst SM: The difficult duty of disclosing medical er- Statements on emerging surgical technologies and the
rors. Contemp Pediatr 2003;20:51-53. evaluation of credentials: American College of Sur-
This article discusses how to manage medical mistakes and geons. Bull Am Coll Surg 1994;79:40-41.
examines the reasons why disclosure is so difficult.
Statement on Issues to be Considered Before New Sur-
Tereskerz PM: Research accountability and financial gical Technology is Applied to the Care of Patients:
conflicts of interest in industry sponsored clinical re- Committee on Emerging Surgical Technology and Edu-
search: A review. Account Res 2003;10:137-158. cation, American College of Surgeons. Bull Am Coll
A discussion of financial conflicts of interest, research ac- Surg 1995;80:46-47.
countability, and other aspects of industry relationships are
discussed. Sweet MP, Bernat JL: A study of the ethical duty of phy-
sicians to disclose errors. J Clin Ethics 1997;8:341-348.
United Kingdom Department of Health Website. HIV US National Commission for the Protection of Human
infected health care workers: A consultation paper on Subjects of Biomedical and Behavioral Research: The
management and patient notification. Available at:
Belmont Report: Ethical Principles and Guidelines for
www.doh.gov.uk/aids.htm. A list of exposure-prone pro-
the Protection of Human Subjects of Research. Septem-
cedures available at: www.doh.gov.uk/pub/docs/aids.pdf.
ber 30, 1978. Superintendent of Documents, US Govern-
Accessed February, 2004.
Although UK policy obviously does not apply to US sur- ment Printing Office. Washington, DC, DHEW Publica-
geons, it is worthwhile to review the detailed list of exposure- tion No. 78-0013.
prone procedures as a reference.
World Medical Association Recommendations Guiding
Physicians in Biomedical Research Involving Human
Wears RL, Wu AW: Dealing with failure: The aftermath Subjects (document 17.1). Helsinki, Finland, June 1964.
of errors and adverse events. Ann Emerg Med 2002;39:
344-346. Wu AW, Folkman S, McPhee SJ, Lo B: Do house officers
This article discusses what happens after a medical mis-
learn from their mistakes? JAMA 1991;265:2089-2094.
take has occurred and how patients and health care workers
can be guided through this situation.
Outcomes Instruments in Orthopaedic measures of care, which are not always under the pa-
tients or the doctors control.
Surgery An outcomes instrument is the survey tool or instru-
Traditional approaches to clinical research and reports
ment used to measure these variables (Table 1). These
of surgical interventions are commonly associated with
measures are not designed or intended to substitute or
the measurement of variables that are either easily
replace the traditional measures or clinical end points,
available retrospectively from the medical record, or
but are to be used in parallel with clinical measures.
variables of primary interest to the researcher. These bi- An outcomes instrument, in order to be useful,
ologic, physiologic, and anatomic measures include mor- should have clinical sensibility, meaning that the ques-
tality, strength measurement, range of motion, and ra- tionnaire includes relevant content and is appropriate
diographic findings. These examples of hard outcome for both the patient population and the setting in which
measures or surrogate outcomes have a very weak asso- it is to be used. The feasibility of the questionnaire is de-
ciation with the symptoms and functionality of the end termined in part by its length, degree of respondent bur-
result of therapeutic interventions and are only of den, ease of scoring and analyzing the results, and the
modest relevance to patients and society. The perceived costs of its use. In constructing a questionnaire, it must
attractiveness of hard measures is that they are believed be reliable; the results must be reproducible from one
to be objective (unbiased judgment), have preservability time to another or between interviewers. The question-
(radiographs) and have dimension (measurement of ra- naire must also have internal consistency. The instru-
diographic findings). However, if the goal of treatment ment must be validated, meaning that there are correla-
is to reduce pain and improve function, these constructs tions in the expected direction and magnitude with a
should be measured directly rather than assuming that variety of external measures that are somewhat differ-
surrogate hard measures will suffice. ent but are expected to have predictable associations. In
More recently, the goals of clinical research have addition, the instrument must be responsive, or have the
transitioned to the measurement of variables primarily ability to measure and detect small but clinically impor-
critical to the patient, or soft outcome measures. tant differences between groups, or over time.
These patient-reported outcomes of symptoms, physical Outcomes instruments may be used for multiple pur-
function, and health may take several forms and include poses as outlined in Table 2. The increasing interest in
the assessment by disease-specific measures, general the use of outcomes measures is relatively new and is a
health measures, and satisfaction measures. These so- rapidly evolving methodology. Many issues remain con-
called soft outcomes measures are more reliable and troversial, raising several questions, such as: Which mea-
more consistent than the traditional, hard measures. surements are important? When and specifically how
Outcomes research often refers to the study of a group should they be measured? Are the outcomes instru-
or cohort of patients often with the same diagnosis, and ments valid? Are there controls? What other factors (bi-
relates their clinical and health outcomes to the care ologic, physiologic, environmental) may influence the
they received. measurement results? Are generic measures sufficient
Outcomes research also includes methods of analysis or are disease-specific measures also important? Over
for small (single site) and/or large (often multiple site) half a century ago, Lembcke noted that the best mea-
databases, small-area analysis, structured literature re- sures of quality is not how well or how frequently a
views (meta-analysis), prospective clinical trials, decision medical service is given, but how closely the result ap-
analysis, and guideline development. The focus of out- proaches the fundamental objectives of prolonging life,
comes research is often on patient-centered outcomes of relieving stress, restoring function and preventing dis-
care (patient self-report) rather than on the process ability. The goal of outcomes research and the use of
Table 1 | Common Outcomes Survey Instruments Table 3 | Key Factors in the Construct, Design, and Use of
Outcomes Instruments
General health outcomes instruments
Short Form-36 or Short Form-12 general health survey Content, Population, Setting, and Purpose
Health Related Quality of Life (HRQOL) Which outcomes are to be measured (biologic, physiologic, function,
Sickness impact Profile (SIP Nottingham Health Profile (NHP) general health, quality of life, satisfaction)?
Million Visual Analog Scale (VAS) Which population will be studied and in what setting (age, gender)?
Duke Health Profile What is the purpose of the study (to describe, predict, measure change,
Patient satisfaction measures measure one point in time or change over time, or impact of an inter-
Patient Satisfaction Questionnaire (PSQ) vention)?
Client Satisfaction Questionnaire (CSQ) Content Validity
Patient Satisfaction Survey (PSS)
What domains (health concepts) and items are included?
Disease or condition specific instruments include
Spine Are there important omissions or inappropriate inclusions?
Oswestry Disability Index (ODI) for low back pain Face Validity
Roland-Morris Disability Questionnaire (RMDQ) Do these measures make good clinical sense?
Waddell Disability Index Is each question phrased in a suitable way?
Low Back Pain Outcome Score (LBOS) Are the response categories appropriate?
Clinical Back Pain Questionnaire (CBPQ) Is there an overall score summarizing across questions, and how is
Quebec Back Pain Disability Scale (QBPDS) this score calculated?
Low Back Pain Rating Scale (LBPRS)
Is there correlation with other outcomes measures?
North American Spine Society Lumbar Spine Questionnaire (NASS
LSQ) Are these measures predictive of future events?
Resumption of Activities of Daily Living Scale (RADL) Feasibility
Upper extremity Is the instrument easy to use and understand?
Constant Shoulder Function Scoring System Is the instrument acceptable to the population and the clinician/
Carpal Tunnel Syndrome Evaluation investigator?
Upper Extremity Disabilities of the Arm, Shoulder, and Head (DASH) What is its format (self-administered, telephone, personal interview,
Shoulder Pain Score computer, paper/pen)?
Elbow questionnaire How long does it take to administer and report the results?
Lower extremity
Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) Responsiveness
Harris Hip Score Is the instrument able to detect subtle but clinically relevant change
Trauma over time or with intervention?
Short Musculoskeletal Function Assessment Questionnaire (SMAF)
determined before the initiation of the study to avoid power is equal to 1-beta error. Therefore, in calculating
chance, given the smallest clinically relevant differences a sample size, if the investigators accept a 20% possibil-
in outcome and the variability in measures. It is neces- ity of missing a true finding (beta error = 0.2), then the
sary to have sufficient statistical power (the ability to study should have a statistical power of 0.8 or 80%. That
detect a difference of the magnitude required if one means that the investigators are 80% confident that
truly exists) to determine whether the efficacy of one they will be able to detect a true difference of the size
treatment is superior to another. that they specify with the sample size that they deter-
mine. By design, the investigator accepts a 20% chance
Sample Size Calculations of false-negative results. The best way to incorporate
One of the more difficult issues determining the success beta error into the study is to include it beforehand in
of a study is sample size calculation, which must be the determination of sample size, which is simple to do,
done prior to the initiation of the clinical study. Sample but it increases the sample size considerably. A large
size calculations are always an approximation, yet they sample size can be viewed as a means of decreasing the
are important in providing information about two study false-negative results rate when a real treatment effect
design questions. The first is how many subjects should exists.
participate in the intended study and second, is this For the comparison of groups in which the data set
study worth doing if only N number of subjects partici- variance is high, when the investigators want the answer
pate? In some cases the study may not be worth doing if to be close to the true value, and when the smallest
the likelihood of demonstrating a significant clinical ef- clinically significant difference detected is to be ex-
fect or difference between two treatments is very small tremely small, a large sample size will be required. In
or if the population needed to answer the question is calculating the sample size, investigators must first de-
extremely large. Variables critical to determining sample termine the appropriate formula to be used, based on
size include data type (paired data [observations before the type of study and the type of error to be considered.
and after treatment in the same study group] and un- Four common formulas for the determination of sample
paired data [observations in an observation and control size are listed in Table 4. As the complexity of the
group], consideration of error type (beta errors [type II groups and error types increase, the N correspondingly
or false-negative errors] and alpha errors [type I or increases.
false-positive errors]), variance in data set (large and The adverse affects of bias, confounding, and chance
small), alpha level (usually set at P = 0.05 in the two- can be minimized by proper study design and statistical
tailed test and confidence interval of 95%), beta level analysis. The purpose of prospective studies is to mini-
(usually set at 0.2), and determining the size of the de- mize bias from selection, information, recall, and nonre-
tectable difference between groups. sponder factors. Randomization minimizes selection
bias and equally distributes the confounders. Random
Beta Error Importance assignment implies that each individual has the same
Statistical power refers to the sensitivity for detecting a chance of receiving each of the possible treatments and
mean difference in a clinical study, whereas sensitivity that the probability that a given subject will receive a
refers to the same difference in a clinical test (statistical particular allocation is independent of the probability
power + beta error = 1.0). This means that the statistical that any other subject will receive the same treatment
assignment. The decision regarding study design and Table 5 | Barriers to Overcome Before Proceeding With
data collection may be the most critical part of planning Prospective Randomized Clinical Trials Involving a
a clinical trial. The study design is the map from which Surgical Procedure
data collection follows, and which enables the physician
History
to accurately produce data forms and collect data. The
prospective randomized clinical trial with concurrent Competition
controls is the gold standard in clinical research. Tradi- Equipoise/uncertainty
tional randomized trials tell about the efficacy (whether Infrastructure
the treatment can work under ideal circumstances), Study design and statistics
whereas outcomes research more typically studies the Surgical trials
effectiveness (how well a treatment works when applied Events
in routine care). Effectiveness is a function of efficacy, Risk assessment
but also of diagnostic accuracy, physician skill in apply- Commitment
ing treatment, and patient compliance with prescribed
regimens. Any of these factors may create a gap be-
tween efficacy and effectiveness. The prospective ran- clinical epidemiology can affect study design and statis-
domized clinical trial provides not only qualitative con- tics. The study design and implementation depends
clusions about whether a treatment is better, but also heavily on and will be most successful when a core mul-
quantitative estimates of the extent to which it is better. tidisciplinary group of researchers (including clinicians,
epidemiologists, and statisticians) all contribute their ex-
Barriers to a Randomized Clinical Trial pertise to the project.
There are many barriers that must be overcome to The inherent variability of surgery requires precise
proceed with a prospective randomized clinical trial in- definitions of the diagnosis, interventions, and close
volving a surgical procedure (Table 5). History has not monitoring of its quality. Surgical learning curves might
favored the validation of surgical procedures by ran- cause difficulty in timing and performing randomized
domized trials. Many commonly performed surgical pro- clinical trials. Blinding is often difficult in surgical trials,
cedures were introduced well before randomized trials and it is not always possible or necessary. Events are
became established in medicine. Once a procedure be- conditions that may be emergent or life-threatening that
comes accepted, it is difficult to test it against a control. may cause difficulties with recruitment, consent, and
For many common procedures performed, orthopaedic randomization of clinical trials. Multicenter studies are
surgeons cannot fall back on history to explain the lack often required under these conditions. In addition, com-
of rigor in surgical research. parison of surgical and nonsurgical treatments with
Surgeons can be tempted to ignore evidence that greatly different risks causes difficulties with patient
threatens their personal interests because of competi- equipoise, and thus recruitment. Finally, all involved
tion and prestige. Objectivity about procedures central must be absolutely committed to all aspects of the trial
to a surgeons reputation is difficult and randomized if it is to succeed.
clinical trials may seem threatening. The literature must These barriers to randomized clinical trials have
support and the investigators must feel comfortable stimulated some to question the need for randomized
with a state of equipoise, which is a point of maximum clinical trials in surgery, and the debate is substantial.
uncertainty, a state of balance or equilibrium between For many medical questions, a large amount of evidence
two alternative therapies such that there is no prefer- has been accumulated through nonrandomized studies.
ence between treatments. Some also refer to this as the The risk of nonrandomized studies is that the studies
uncertainty principle in which clinicians, researchers, may spuriously overestimate treatment benefits as they
and patients acknowledge having hunches about a treat- are more susceptible to unaccounted confounding, yield-
ments effectiveness, but that the boundaries (or confi- ing misleading conclusions. Observational studies may
dence intervals) around their hunches may run from provide sufficient evidence of a procedures effective-
one extreme (extremely effective) to the other (harm- ness, but the treatment effect of the procedure must be
ful). If the answer to the clinical research question is quite large, and the study well designed to be convinc-
clear, the randomized clinical trial cannot ethically pro- ing. However, it is very difficult to use historical con-
ceed with the comparison of a known successful treat- trols, obtained under less rigorous scientific standards of
ment with a known ineffective treatment. data collection, against which to test a new procedure.
The infrastructure within which to perform the study Many previously well established surgical procedures,
must be well planned and developed to function effi- once thought to provide significant clinical benefits in
ciently. This includes knowledge to obtain funding and the hands of proponents, have been subsequently
to perform statistical analysis. A lack of education in proven ineffective when tested rigorously in well-
protected. Computerized data must be backed up regu- enough to determine whether or not the treatment has
larly. Specific identifying data for each patient is critical been successful, and then to inquire if not, why not?
for providing and maintaining confidentiality and con- Evidence-based medicine is not restricted to ran-
sistency. Dedicated personnel whose responsibilities are domized clinical trials and meta-analyses. It involves
specific to data management infrastructure are critical tracking down the best external evidence with which to
to this process. answer the clinical questions. Best available external ev-
The role of maintaining the safety of the participants idence includes clinically relevant research from both
in the clinical trial is performed by the Data and Safety the basic sciences and patient-centered clinical research.
Monitoring Board (DSMB). This group is commonly It is when questions are asked about therapy that the
composed of five non participating individuals who are nonexperimental approaches should be avoided, as
knowledgeable about the disease process and statistical these often lead to falsely positive conclusions about ef-
and study design. This committee reviews the summaries ficacy. The randomized clinical trial is the gold standard
of safety, accrual and progress of the trial, the quality of for judging whether a treatment does more harm than
the data, and blinded interim efficacy and effectiveness good. A systematic review of several randomized trials
analyses and reports its findings to the principal investi- provides even greater degree of confidence in the level
gator and executive working group. It is also responsible of evidence.
for interpreting data on adverse side effects. The DSMB Without current best evidence, a clinical practice
meets every 6 months and makes recommendations to risks the possibility of rapidly becoming out of date, to
the principal investigator and executive working group the detriment of the patient. Three evidence-based med-
regarding actions to ensure patient safety and that par- icine strategies have been developed to help the clini-
ticipants are not exposed to undue risks. The mandate of cian maintain and expand clinically important knowl-
the DSMB should comply with the July 1, 1999 release edge: learning evidence-based medicine, seeking and
of the National Institutes of Health policy for Data and applying evidence-based medicine summaries generated
Safety Monitoring, with the primary function being to by others, and accepting evidence-based protocols and
ensure the safety of participants and validity and integ- practice guidelines developed by others.
rity of the data. The DSMB has direct communications
with the funding agency and can stop a clinical trial Classification of Study Strength
when public health or safety is at risk, or when study Evidence is a critical component in the decision-making
goals are not met. process for delivering care to patients. For many ques-
tions, however, the amount of information is over-
whelming and the conclusions often contradictory. Most
Evidence-Based Medicine surgeons would agree that to make the best decisions,
Physicians seek to base their decisions on the best avail-
evidence must be easily available in a comprehensive
able evidence. Often this represents experience, teach-
and timely fashion.
ing, and extrapolations of pathophysiologic principles
Levels of evidence, based on the rigor of the study
and logic rather than established facts based on data de-
design, are a way to sort through and evaluate the liter-
rived from patients. The advent of randomized con-
ature. Levels of evidence may also be used in the devel-
trolled clinical trials has led to an increase in the quality
opment of practice guidelines to weigh the strength of
of evidence concerning clinical treatment interventions, the recommendations, and should be used by practicing
making clinical reasoning more comprehensible. The surgeons to wade through the multiple types of evi-
ability to track down and critically appraise and incor- dence to help determine which information is useful to
porate evidence into clinical practice has been termed them and their patients.
evidence-based medicine. It is the conscientious, ex- Levels of evidence provide only a rough guide to the
plicit, and judicious use of current best evidence in mak- study quality. Level I evidence may not be available for
ing decisions about the care of individual patients using all clinical questions, and level II and III evidence can
patient-centered clinical and basic science research data still have great value to the practicing surgeon. No sin-
along with the patients values and expectations. gle study will provide all the definitive answers.
Evidence-based medicine is not cookbook medicine. The classification of levels of evidence was devel-
It is the integration of the best external evidence with oped to minimize therapeutic harm to patients by using
individual clinical expertise and patients choice; neither evidence that is least likely to be wrong. The Center
alone is enough. for Evidence-Based Medicine (http://cebm.net/
Many of these concepts were proposed by Codman in levels_of_evidence.asp) has created the categories for
the early 1900s, who implemented the end result idea. defining study strength (level of evidence) (Table 7) and
Codman attempted to put into practice the notion that grades (Table 8) for recommendations in common use
each hospital should follow every patient it treats, long today. Similar levels and grades have also been devel-
Table 7 | Oxford Centre for Evidence-Based Medicine Levels of Evidence and Journal of Bone and Joint Surgery: Instructions to
Authors
Therapeutic Studies: Prognostic Studies: Economic and Decision
Investigating the Results of Investigating the Outcome of Diagnostic Studies: Analysis: Developing an
Treatment Disease Investigating a Diagnostic Test Economic or Decision Model
Level I Randomized controlled trial Prospective study Testing of previously developed Clinically sensible costs and
Significant difference Systematic review of Level I diagnostic criteria in series of alternatives; values obtained
No significant difference but studies consecutive patients (with from many studies; multiway
narrow CIs* universally applied reference sensitivity analyses
Systematic review of Level I gold standard) System review of Level I studies
randomized controlled trials Systematic review of Level I
(studies were homogeneous) studies
Level II Prospective cohort study Retrospective study Development of diagnostic Clinically sensible costs and
Poor-quality randomized Study of untreated controls from a criteria based on basis of alternatives; values obtained
controlled trial (eg, < 80% previous randomized controlled consecutive patients (with from many studies; multiway
follow-up trial universally applied reference sensitivity analyses
Systematic review Systematic review of Level II gold standard) System review of Level II studies
Level II studies studies Systematic review of Level II
Nonhomogeneous Level I studies studies
Level III Case-control study Study of nonconsecutive patients Limited alternatives and costs;
Retrospective study (no consistently applied poor estimates
Systematic review of Level III reference gold standard) Systematic review of Level III
studies Systematic review of Level III studies
studies
Level IV Case series (no, or historical, Case series Case-control study No sensitivity analyses
control group) Poor reference standard
Level V Expert opinion Expert opinion Expert opinion Expert opinion
Ioannidis JP, Haidich A, Papa M, et al: Comparison of Daum WJ, Brinker MR, Nash DB: Quality and outcome
evidence of treatment effects in randomized and non- determination in health care and orthopaedics: evolu-
randomized studies. JAMA 2001;286:821-830. tion and current structure. J Am Acad Orthop Surg
In this review of 45 topics in selected medical topics, anal- 2000;8:133-139.
ysis of the results demonstrates larger treatment effects and
discrepancy beyond chance nonrandomized studies compared Deyo RA, Weinstein JN: Outcomes research for spinal
with randomized trials. disorders, in Herkowitz H, Garfin S, Balderston R, Eis-
mont F, Bell G, Wiesel S (eds): Rothman-Simeone: The
Spine, ed 4. Philadelphia, PA, WB Saunders, 1999.
Kocher MS, Zurakowski D: Clinical epidemiology and
biostatistics: An orthopaedic primer. J Bone Joint Surg Gartland JJ: Orthopaedic clinical research: Deficiencies
Am 2001; Orthopaedic Journal Club: 1-12. in experimental design and determinations of outcome.
This is a primer of clinical epidemiology and biostatistics J Bone Joint Surg Am 1988;70:1357-1364.
for the orthopaedic surgeon.
Hennekens C: Buring J: Interventional studies, in May-
rent S (ed): Epidemiology in Medicine. Boston, MA, Lit-
McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D:
tle, Brown and Company, 1987, pp178-212.
Randomised trials in surgery: Problems and possible so-
lutions. BMJ 2002;324:1448-1451. Jekel JJ, Elmore JG, Katz DL (eds): Epidemiology, Bio-
The quality and quantity of randomized trials in surgery is statistics and Preventive Medicine. Philadelphia, PA, WB
acknowledged to be limited. Some aspects of surgical trials Saunders, 1996, pp 160-171.
present special difficulties for randomized trials and these dif-
ficulties and proposed solutions for improving the standards of Kaska SC, Weinstein JN: Historical perspective: Ernest
clinical trials in surgery are discussed. Amory Codman, 1869-1940: A pioneer of evidence-
based medicine. The end result of an idea. Spine 1998;
Sackett DL: Why randomized controlled trials fail but 23:629-633.
neednt: 2. Failure to employ physiological statistics, or
Keller RB: Outcomes research in orthopaedics. J Am
the only formula a clinician-trialist is ever likely to need
Acad Orthop Surg 1993;1:122-129.
(or understand!). CMAJ 2001;165:1226-1237.
Causes of failure in randomized controlled trials is neither Kopec JA: Measuring functional outcomes in persons
with the teacher nor the trialist, but lies in the mismatch be- with back pain: A review of back-specific question-
tween what is judged necessary to be learned about biostatis- naires. Spine 2000;25:3110-3114.
tics and who learns it. Pitfalls in conducting clinical trials are
discussed, along with appropriate sample size and eligibility Matthews DE, Farewell VT: Using and Understanding
and erosion of study participants. Medical Statistics. Basel, Germany, Karger, 1985, pp 184-
195.
Watters WC III: Evidence-based practice and the use of Rosenberg WM, Sackett DL: On the need for evidence-
practice guidelines. AAOS Bulletin, August 2003, pp 15- based medicine. Therapie 1996;51:212-217.
16.
Scientific journals, textbooks, and presentations provide Sackett DL: Evidence-based medicine. Spine 1998;23:
the cornerstone of good clinical decision making and patient 1085-1086.
care. The benefits and use of evidence-based medicine to pro-
duce and practice guidelines in the context of clinical quality Sackett DL: Why randomized controlled trials fail but
improvement cycle is demonstrated. neednt: 1. Failure to gain coal-face commitment and
to use the uncertainty principle. CMAJ 2000;162:1311-
1314.
Wright J: Summarizing the evidence. AAOSBulletin,
June 2003, pp 51-52. Sackett DL, Rosenberg WM, Muir Gray JA, Hayes RB,
Evidence-based medicine, levels of evidence, and strate- Richardson WS: Evidence based medicine: What it is
gies for summarizing evidence are reviewed for the practicing and what it isnt. BMJ 1996;312:71-72.
orthopaedic surgeon faced with determining treatment recom-
mendations. Ware JE, Snow KK, Kosinski M, Gandek B: SF-36
Health Survey: Manual and Interpretation Guide. Bos-
Classic Bibliography ton, MA, The Health Institute, New England Medical
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Introduction improve the course of the patient with this illness and
The concept of evidence-based medicine implies that manifestations?
the medical care of individual patients should be based The first question asks for the most probable diag-
on results obtained from patient-oriented quantitative nosis or illness given the clinical (such as symptoms,
research, rather than on qualitative research or clinical signs, test results) and nonclinical (such as age, sex, and
experience. Patient-oriented quantitative research is socioeconomic status) profile of the patient. The answer
also referred to as clinical epidemiologic research. to the second question, which asks for the cause of the
Traditionally, epidemiologic research focused on the illness, is often impossible to give. Often, adequate care
occurrence of infectious diseases and tried to unravel can be provided without knowing the cause of an illness.
determinants of infectious disease epidemics across pop- For example, a torn meniscus can effectively be treated
ulations. Over time, however, it has been shown that by the orthopaedic surgeon without knowing how the
methods used for this type of epidemiologic research injury occurred. The most challenging question concerns
a prediction of the clinical course of the patient given
(population epidemiology) can be applied in a similar
the clinical and nonclinical profile, the underlying ill-
manner to investigate clinical questions. Clinical epide-
ness, and the possible etiology of that illness (question
miology is a term commonly used for epidemiology
3). This prediction of the patients clinical course may be
dealing with questions relevant to medical practice. Ac-
made without considering treatment (baseline progno-
cordingly, evidence-based medicine is particularly
sis) as well as with the consideration of the effects of
served by results from clinical epidemiologic research.
possible treatments. Differences in the estimated course
The distinction between clinical epidemiology and pop-
with and without treatment may guide the physicians
ulation epidemiology may be somewhat artificial be-
decision on whether to initiate treatment and in the
cause both types of studies use largely the same meth-
choice between various treatment options. For example,
ods for design and analysis. To properly serve clinical
if in a patient with a torn meniscus the probability of an
practice and provide for evidence-based medicine, clini- unfavorable outcome (such as pain with activity) is
cal epidemiologic studies should address relevant clini- much higher without surgery (baseline prognosis) than
cal questions, be validly executed, and should yield re- with surgery, it is likely that surgery would be chosen as
sults with sufficient precision. the proper course of action (question 4).
For a physician to meet the challenges of clinical de-
cision making, quantitative or probabilistic knowledge is
Clinical Epidemiologic Research Questions required. Diagnostic research yields quantitative knowl-
Understanding the challenges related to clinical practice edge about the probability of disease presence or ab-
is essential for understanding the objectives of clinical sence given the patients clinical and nonclinical profile
epidemiologic research. Beginning with the patient- (addressing question 1). Results from etiologic research
physician encounter, four principal challenges or ques- help the physician to answer questions about the proba-
tions in clinical practice can be defined. These questions bility that a particular disease will occur when a particu-
relate back to Hippocrates and form the basis of the lar risk factor is present (question 2). Prognostic re-
evidenced-based medicine movement. In hierarchical search provides quantitative knowledge about the
order these questions are: (1) What is the illness of the probability that a particular outcome (death, complica-
patient given the clinical and nonclinical profile? tion, recurrence, or improved quality of life) may occur
(2) Why did this illness occur in this patient at this time? over a particular period of time in relation to the pa-
(3) What will be the course of the patient with this ill- tients profile, illness, and etiology (question 3). Treat-
ness and manifestations? (4) How can I, as a physician, ment decisions require knowledge about the probability
Table 1 | Main Design Characteristics of Diagnostic, Etiologic, Prognostic, and Therapeutic Studies
Determinant(s) Outcome Occurrence Relation Domain
General Factor(s) under study that are Health parameter (eg disease, Association between the Larger, theoretical population
definition related to the outcome survival, complication, quality outcome occurrence and the to whom the study results
occurrence of life) under study determinant(s) can be applied (generalized)
Type of research
Diagnostic Test results under study Presence/absence of target Presence (prevalence) of Patients with particular
research disease disease in relation to symptom/sign suspected of
combination of test results particular disease
Etiologic Causal factor under study Incidence of disease under Incidence of the outcome in Those potentially at risk to
research study relation to the causal factor, develop the outcome at
accounted for all possible interest
confounders
Prognostic Prognostic predictors under Incidence of disease (eg, Incidence of the outcome in Patients potentially at risk to
research study disease, survival, relation to combination of develop the outcome at
complication, quality of life) prognostic predictors interest
under study
Therapeutic Treatment (relative to a control Incidence of disease (eg, Incidence of the outcome in Patients with a particular
research group) under study disease, survival, relation to the treatment, disease for whom the
complication, quality of life) accounted for all possible treatment under study is
under study confounders indicated
or extent to which a treatment improves the prognosis needs to be documented. From these empirical data, the
(intended effect) and at what cost (such as treatment true nature and strength of the association between de-
risks [unintended effects] and monetary costs). terminant and outcome is quantified.
In medical practice, few outcomes are certain or To apply the findings with confidence in patient care,
pathognomonic. Hence, the objective of clinical epide- the study results or estimated association need to be
miologic research is to provide probabilistic knowledge generalized to a larger population (domain) from which
on diagnosis, etiology, prognosis, and treatment of ill- the patients of the study population were selected. The
nesses as a means to enhance patient care. The design, extent to which the results found in a particular study
conduction, and data analysis of clinical studies on diag- population can be applied to a larger (theoretical) pa-
nosis, etiology, prognosis, or treatment each have their tient population is called the generalizability of the
own characteristics. study results.
Therefore, regardless of the question studied, each
Basic Principles of Clinical Epidemiologic type of clinical epidemiologic study (diagnostic, etio-
Studies logic, prognostic, or therapeutic) has certain basic ele-
Research Question, Study Population, ments: the occurrence relation, outcome, determi-
and Generalization nant(s), study population, and domain. These elements
are described later in this chapter according to each
Any research question related to patient care is either
type of study and also are outlined in Table 1.
diagnostic, etiologic, prognostic, or therapeutic in na-
ture. Although each type of study has its own character-
istics, every research question and thus each type of Causal Versus Descriptive Research
study addresses an association between the occurrence A major distinction first should be made between causal
or probability of an outcome on one side and factors and descriptive epidemiologic research, because of the
that are related to this outcome occurrence on the other major consequences for study design, conduction, and
side. These factors are commonly called determinants. data analysis. The difference is directed by the determi-
Accordingly, central to clinical epidemiologic research is nant(s) under study. Although determinant is a term
the occurrence relation or the association between the that seems to refer to factors that cause the occurrence
outcome occurrence and its determinant(s). of an outcome, it should be stressed that a determinant,
To quantify this relation requires empirical data, and therefore clinical epidemiologic research, may be
which in turn requires a study population. For each causal or noncausal (descriptive).
member or patient of the study population, both the Causal studies quantify whether a specific determi-
presence of the determinant(s) and of the outcome nant is causally related to an outcome; for example,
trauma as a causal factor for vertebral fractures or im- from patient history (each question, including simple
mobility as a causal factor for pulmonary embolism. The questions on age and sex, is a different diagnostic test),
goal of causal studies is to explain the occurrence of an physical examination, and additional tests such as imag-
outcome in relation to a causal determinant. Treatment ing, electrophysiology, and laboratory tests. Currently,
studies are also causal studies. A treatment cannot be many diagnostic tests are used, sometimes with consid-
effective if it does not interfere in some way in the erable burden to patients and health care budgets.
causal pathway of the outcome, such as progress of the Therefore, it is important for physicians, patients, and
disease or complications. A treatment is also a causal health care providers to know which additional tests
determinant, although it does not induce outcome (such truly contribute to the distinction between disease pres-
as trauma and immobility) but rather reduces the likeli- ence and absence beyond the information obtained
hood or prevents the occurrence of outcomes. The fact from patient history and physical examination. Quanti-
that therapeutic studies are causal studies is very impor- tative diagnostic research is needed to acquire this
tant, as the design and data analysis of causal studies are knowledge. For example, a patient with low back pain
quite different from the design and analysis of descrip- who is suspected of having a herniated disk (target dis-
tive studies. ease) is referred to an orthopaedic surgeon. A possible
In descriptive studies, the occurrence of the outcome diagnostic question could concern which results from
is only described by the determinant(s) at interest. The the patients history (age, trauma, pain when seated)
motive of descriptive studies is to quantify whether a and from the physical examination (notably the Lasgue
determinant predicts rather than explains the occur- test) are relevant to predict or estimate the probability
rence of the outcome. Causality is not investigated. Con- of the presence of a herniated disk. Also, does the con-
sider, for example, a study to quantify whether the skin ventional radiograph of the lower back provide added
color of a neonate (one of the items of the Apgar score) predictive value?
is predictive for its survival (a prognostic study ques-
tion). Skin color obviously is not causally related to Occurrence Relation, Study Population,
mortality. Accordingly, prognostic research that does not and Determinants
involve questions about the effects of treatment is de- The occurrence relation of a diagnostic study to answer
scriptive research. Diagnostic studies are descriptive as the above question would concern the frequency (or
well. For example, in a patient who reports symptoms of probability) of a herniated disk in relation to patient
a knee disorder, abnormalities on the MRI scan of the history, physical examination, and radiographic results.
knee may predict the presence of knee arthrosis. Results To study this relation, the study population should in-
of the MRI scan obviously are not the cause of the knee clude a sufficient number of patients with low back pain
arthrosis, but may predict the likelihood of the presence who have suspected disk herniation. Each patient
or absence of the condition. should undergo all diagnostic tests under study (all rele-
Therefore, etiologic and therapeutic research ques- vant tests indicated from patient history, physical exami-
tions address causality between a determinant and out- nation, and lower back radiography). These tests are
come. To answer these questions requires a causal study called the diagnostic determinants under study.
design and causal data analysis. Diagnostic and prognos-
tic research questions address the predictive value be- Outcome and Data Analysis
tween determinants and outcome. Causality is not inves- Subsequently, each study patient should undergo the
tigated. To answer diagnostic and prognostic research reference or gold standard test to assess the patients di-
questions requires a descriptive study design and corre-
agnostic outcome or diagnostic truth. The procedure
sponding data analysis. The distinction between causal
that is used in practice (at the time of study initiation)
and descriptive research is further explained using clini-
to ultimately determine the presence or absence of the
cal examples in the next section.
target disease, should be used as a reference standard in
a scientific diagnostic study. In the example of the herni-
Characteristics of Diagnostic, Etiologic, ated disk, MRI of the low back could be the reference
Prognostic, and Therapeutic Studies standard. The results of the reference standard should
Diagnostic Research always be interpreted without knowledge of the diag-
Diagnosis in practice starts with a patient presenting nostic tests or determinants under study, to prevent in-
with a particular set of symptoms or signs that lead the formation bias. Some diseases may lack a single refer-
physician to suspect a particular disease, the so-called ence standard and sometimes it may be unethical or too
target disease. The goal of the physician is to estimate costly to perform the reference standard in each patient.
the probability of the presence of the underlying dis- In such situations, a combination of tests or the so-
ease. This probability is (often implicitly) estimated us- called consensus diagnosis is commonly used to deter-
ing diagnostic test results. These test results are obtained mine the diagnostic truth in each study patient.
Documented patient data from the study in the ex- Occurrence Relation, Study Population,
ample can then be used to quantify the probability of a and Determinants
herniated disk in patients with particular symptoms and The occurrence relation of this study would be the oc-
signs, and to quantify whether radiographs increase or currence (probability) of hip fractures in relation to the
decrease this probability, and to what extent. The latter frequency of falling. To study this relation, for example,
reflect the added value of the radiographs beyond the a group (cohort) of study subjects (men and women
information obtained from the history and physical find- older than 70 years who have not had a hip fracture)
ings. Causality between the determinants (test results) can be recruited and followed for a 5-year period. Each
and outcome (final diagnosis) is not an issue. The only year, for example, the study subjects visit the research
matter of importance is whether they predict the out- center so that the number of falls in the previous year
come presence. Diagnostic research is therefore descrip- can be assessed. In contrast to diagnostic and prognostic
tive or predictive research. To properly serve clinical studies, etiologic studies focus on the quantification of
practice, diagnostic studies should address multiple de- the causal relation of a single determinant (falling) to
terminants or tests rather than one single test. In prac- the outcome (hip fractures).
tice, any diagnosis is rarely set by a single test. Results
from patient history and physical examination will al- Outcome and Data Analysis
ways be considered before additional tests are applied. During the study period, whether and when a hip frac-
ture has occurred is documented for each subject. After
Domain and Generalization the study period, the number of falls and whether a hip
The domain or theoretical target population should be a fracture has occurred is known for each subject. In the
defined group (such as all patients presenting in second- analysis, two determinant groups can be formed. One
ary care with symptoms or signs indicative of herniated group includes subjects with a high frequency of falling
disk) to which the results of the diagnostic study can be (on average three or more times per year) and the other
generalized. In general, the domain of a diagnostic study with a low frequency (less than three times per year).
is first of all determined by the symptoms and signs ex- Accordingly, whether the occurrence of hip fractures is
hibited by the study patients. The domain definition of- significantly higher in those with high versus low num-
ten includes the setting (primary, secondary, or tertiary ber of falls can be quantified. In addition, the data can
care) as well. be analyzed using a cutoff value other than three, or us-
The selection or recruitment of any study population ing more than two determinant groups (nonfallers, those
is often restricted by logistic circumstances, such as ne- with less than three falls, and those with more than
cessity of patients to live nearby the research center or three falls per year).
the availability of time to participate in the study. These
characteristics, however, are unlikely to influence the Domain
applicability and generalization of clinical study results. The domain to which the study result can be generalized
It is important and challenging for the physician to ap- will include all patients older than 70 years with no his-
preciate which characteristics truly affect the generaliz- tory of a hip fracture. In general, the domain of an etio-
ability of results obtained from a particular study popu- logic study includes all persons who are potentially at
lation. This appreciation usually requires external risk to develop the outcome at interest. As stated ear-
knowledge of characteristics of the study population lier, other characteristics of the study population that
and of the research setting that may change the nature may affect the generalizability of the estimated associa-
and strength of the estimated associations between de- tion also need to be considered in the domain defini-
terminant(s) and outcome. Therefore, generalizability or tion. Such generalization remains a matter of subjective
definition of the domain of a clinical study is not an ob- reasoning requiring external knowledge of the studied
jective process that can be framed in statistical terms. determinant-outcome or occurrence relation.
Generalizability is a matter of reasoning.
Confounders
In contrast to diagnostic and prognostic research, in eti-
Etiologic Research ologic research the role of confounders is an additional
Clinicians and epidemiologists seem to be most familiar issue that must be considered. Suppose the example
with etiologic research despite its limited direct rele- study would yield an incidence of hip fractures (within 5
vance to patient care and its methodologic complexities. years) of 6% among the frequent fallers and 3% among
The goal of etiologic studies is to quantify whether a the nonfrequent fallers. The initial conclusion would be
single, specific determinant is indeed causally related to that frequent falling causes a twofold increased risk of
the outcome under study. Consider, for example, a study hip fractures in subjects older than 70 years. This obser-
to quantify whether frequent falling may cause hip frac- vation, however, might not be true. The observed differ-
tures in the elderly. ence in frequency of hip fractures could be caused by
the determinant and outcome, depending on the distri- Occurrence Relation, Study Population,
bution of the confounders across the determinant cate- and Determinants
gories and whether the confounder is a risk factor or The occurrence relation of a prognostic study to answer
preventive factor of the outcome. In the example study, this example question would be the frequency (or prob-
adjustment for age and BMI would dilute the crude as- ability) of postoperative nausea and vomiting within
sociation of 3% difference in hip fractures because in- 24 hours in relation to multiple preoperative patient
creased age and low BMI both increase the occurrence characteristics, such as planned duration of surgery, age,
of hip fractures, and the frequent fallers were on aver- sex, history of postoperative nausea and vomiting, and
age older and leaner than the nonfrequent fallers. Stud- smoking status. The study population could include pa-
ies whose purpose is to quantify whether an unintended tients at a particular hospital undergoing any ortho-
effect of a treatment is truly caused by that treatment paedic surgery who are at risk of developing postopera-
tive nausea and vomiting. All prognostic predictors of
are etiologic studies as well and should follow the above
the outcome should be documented from each study pa-
principles.
tient. Similarly, as in diagnostic research, prognostic re-
search should address multiple predictors rather than a
Prognostic Research single prognostic predictor because in practice, no prog-
Prognostic research has received limited attention in ap- nosis is set by a single predictor.
plied medical research. In practice, to set a prognosis is
to estimate the probability that a patient with a particu- Outcome and Data Analysis
lar illness and clinical and nonclinical profile will de- Each patient should be followed up to measure whether
velop a particular outcome (death, a complication, re- the outcome has occurred. In the example, this measure-
currence of disease, or a good quality of life) within a ment is done at 24 hours after surgery, using a simple
certain period of time. The prognostic probability could questionnaire. As with diagnostic research, the person
also be estimated given that the patient has undergone a measuring the outcome must be blinded to the patients
particular treatment. Here, treatment is considered as predictor values to prevent information bias. Particu-
one of the prognostic factors. Prognosis in practice does larly in prognostic (and therapeutic) research, outcomes
not simply imply the typical course of an illness or diag- that are important to patients (such as degree of pain
nosis; it refers to the course of a patient with particular and quality of life issues) should be investigated. Re-
clinical and nonclinical characteristics. Just as with diag- searchers too often rely on so-called proxy outcomes
nostic questions, it is relevant for physicians to know such as duration of intensive care stay or intraopera-
which information is truly needed to estimate a patients tively measured physiologic parameters such as body
prognosis. As with diagnosis, the probability should pref- temperature or blood pressure rather than on patient
erably be estimated with information or determinants outcomes.
that are easily obtainable from the patient using nonin- The preoperative predictors that truly have predic-
vasive, low-cost methods. The principles of design and tive value (that is, may predict the occurrence of postop-
analysis of prognostic research are similar to those of di- erative nausea and vomiting within 24 hours) and which
agnostic research, because both can be grouped under information actually is redundant to determine the pa-
tients prognosis can be easily quantified from the data.
the heading of descriptive or prediction research. Their
study goal is to quantify the predictive association be-
Domain
tween the determinant(s) and the outcome; causal ex-
In general, the domain of a prognostic study is deter-
planation of the outcome is not necessary.
mined by the diagnosis or illness that places the patient
An example of a prognostic question is whether pre-
at risk of developing the outcome at interest. As with di-
operative patient characteristics are predictive for the agnostic research, the setting (for example, primary or
occurrence of postoperative nausea and vomiting within secondary) is often included if it is not inherent to the
24 hours in patients undergoing orthopaedic surgery. If study population. Similarly, other characteristics of the
this occurrence can be estimated preoperatively, prefer- study population that may affect the generalizability of
ably using easily obtainable patient variables, the anes- the estimated association also need to be included. The
thesiologist or orthopaedic surgeon could perform a domain of the example study would include all patients
timely intervention in high-risk patients to reduce the scheduled for orthopaedic surgery. However, there may
risk of postoperative nausea and vomiting. For example, be no reason to assume that the predictors estimated
instead of using isoflurane, desflurane, or sevoflurane from the orthopaedic study population would not also
for general anesthesia, intravenous propofol, which has apply to other surgical patients. Therefore, the results of
been proven to cause less postoperative nausea and the example study could perhaps be generalized to all
vomiting could be used, or preemptive administration of types of surgery. However, as discussed previously, this
antiemetics could be done. generalization requires external knowledge and subjec-
tive judgment. The question to be asked is whether in served outcome could be caused by other factors such
these other types of surgery that were not included in as natural course or, because the patient is aware of the
the study population the same predictors would be treatment, change in patient perception and lifestyle
found with the same predictive values. changes that might influence the outcome occurrence.
The example study shows that as with diagnostic re- The latter is particularly the case when the study out-
search, prognostic studies (apart from studies on treat- come is a subjective outcome requiring patient report-
ment effects) aim to describe or predict the occurrence ing, such as pain and quality of life. If the outcome, for
of a future outcome and possible given combinations of example, is death, factors such as patient perception and
prognostic determinants. Causality between the deter- lifestyle changes have much less influence on the out-
minants and outcome is not at issue. A similar approach come. In situations in which an extreme change in out-
as that described above has been applied to predict the come is observed that is unlikely to be related to other
need for intraoperative blood transfusion in orthopaedic factors, a controlled study may not be necessary. This sit-
and other types of surgery. uation, however, is rare in medicine. However, it may,
for example, apply to the benefits of total hip replace-
Therapeutic Research ment, which leads to such a dramatic change in mobility
Studies to quantify the intended effect of a treatment, of a patient that the result can validly be assumed to be
including surgical treatment (further referred to as ther- the consequence of the intervention. Generally, how-
ever, the determinant in a therapeutic study includes a
apeutic or intervention studies) are the most popular
group that receives the treatment (index group) and a
form of clinical epidemiologic research. The methods for
control group that does not.
design and analysis of intervention studies, including the
The control group may receive either placebo treat-
well-known Consolidate Standards of Reporting Trials
ment or an existing treatment. A placebo treatment is
(CONSORT), has been extensively documented in the
exactly the same as the index treatment except that it
literature. The principles of therapeutic research can be
does not include the effective part or substance of the
described by considering the following example of a
treatment. Placebo treatment for a control group is
study question: does arthroscopic dbridement in pa-
common for drug therapies, but is also possible for non-
tients with osteoarthritis of the knee reduce the occur-
pharmacologic or surgical interventions. The placebo
rence of pain?
drug has the same color, size, taste, or mode of use as
The question of how the clinical course of a patient the index drug, except that it does not include the phar-
with a particular illness and manifestations can be modi- macologic substance. Administering one half of the
fied indicates that therapeutic research is a form of study population the index and the other half the pla-
prognostic research. As stated earlier, the goal of a ther- cebo treatment, and blinding the patient to the received
apeutic study is to quantify whether an observed in- treatment, excludes the influence of many factors that
tended effect is truly caused by the treatment under could influence the difference in outcome between the
study, excluding any other causes. Therapeutic studies two groups. These factors include patient perception and
are also a form of causal research and the characteristics lifestyle changes but also treatment-related factors such
described for etiologic research similarly apply to inter- as taste, size, or mode of use of a drug. As both patient
vention research. groups are unaware of the received treatment, the ex-
tent to which these factors operate will be the same
Occurrence Relation and Study Population across both groups and cannot cause any differences in
The occurrence relation of the example study question outcome occurrence.
(regarding patients with osteoarthritis of the knee) However, the use of a placebo treatment is not al-
would be the average level of pain at 24 months postop- ways feasible or ethical, especially for surgical therapies.
eratively in relation to arthroscopic dbridement. Study For example, when quantifying the effect of coronary ar-
subjects could include men and women of all ages, with tery bypass grafting (CABG) it would be unethical to
osteoarthritis of the knee who have an indication for ar- perform a placebo-CABG. Placebo-CABG would in-
throscopy. The study subjects could be selected from volve the same procedure as the index-CABG, including
four different hospitals, for example. undergoing general anesthesia plus sternotomy, but
without the bypassing which is in fact the effective
Determinant (pharmacologic) substance of the CABG treatment.
Proper definition of the determinant in therapeutic Treatments or diseases that do not allow for a placebo
studies requires some explanation. To quantify the effect comparison require comparison with an existing treat-
of a treatment always requires a control group. A single ment. Existing treatment also could be no treatment
group of patients that has been treated with the inter- (wait and see).
vention under study, a so-called case series, is insuffi- Besides ethical constraints, using an existing treat-
cient to properly quantify the treatment effect. Any ob- ment as a control might also be favored to better reflect
Characteristics of Therapeutic Studies Guyatt GH, Sackett DL, Cook DJ: Users guides to the
Altman DG, Schulz KF, Moher D, et al: The revised medical literature: II. How to use an article about ther-
CONSORT statement for reporting randomized trials: apy or prevention: B. What were the results and will
Explanation and elaboration. Ann Intern Med 2001;134: they help me in caring for my patients?: Evidence-
663-694. Based Medicine Working Group. JAMA 1994;271:59-63.
This article addresses a list of criteria that will enhance the
Hennekens CE, Buring JE: Epidemiology in Medicine.
reporting and conduction of randomized therapeutic studies. Boston, Massachusetts, Little, Brown & Co, 1987.
Helms PJ: Real world pragmatic clinical trials: What are Jaeschke R, Guyatt GH, Sackett DL: Users guides to
they and what do they tell us? Pediatr Allergy Immunol the medical literature: III. How to use an article about a
2002;13:4-9. diagnostic test: A. Are the results of the study valid?:
This article presents a clear explanation of the differences Evidence-Based MedicineWorking Group. JAMA 1994;
between explanatory (such as placebo-controlled) randomized
271:389-391.
therapeutic studies and pragmatic randomized therapeutic Laupacis A, Sekar N, Stiell IG: Clinical prediction rules:
studies. A review and suggested modifications of methodologi-
cal standards. JAMA 1997;277:488-494.
Moher D, Schulz KF, Altman D: The CONSORT state-
ment: Revised recommendations for improving the Laupacis A, Wells G, Richardson WS, Tugwell P: Users
guides to the medical literature: V. How to use an article
quality of reports of parallel-group randomized trials.
about prognosis: Evidence-Based Medicine Working
JAMA 2001;285:1987-1991.
Group. JAMA 1994;272:234-237.
This article addresses a list of criteria to enhance the re-
porting and conduction of randomized therapeutic studies. Levine M, Walter S, Lee H, Haines T, Holbrook A,
Moyer V: Users guides to the medical literature: IV.
Moseley JB, OMalley K, Petersen NJ, et al: A con- How to use an article about harm: Evidence-Based
trolled trial of arthroscopic surgery for osteoarthritis of Medicine Working Group. JAMA 1994;271:1615-1619.
the knee. N Engl J Med 2002;347:81-88.
McAlister FA, Graham I, Karr GW, Laupacis A:
A good example of an explanatory (such as placebo-
Evidence-based medicine and the practicing clinician.
controlled) therapeutic study of a surgical intervention is pre-
J Gen Intern Med 1999;14:236-242.
sented.
Moons KG, van Es GA, Michel BC, Buller HR,
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Available Imaging Modalities try rotation intervals combined with multiple detectors
All medical imaging modalities that are available clini- providing increased coverage along the z-axis. Currently
cally have musculoskeletal applications. There have there are configurations with up to 64 channel detectors
been significant technologic advancements in the areas available. The data from a multislice CT scanner can be
of radiography, CT, ultrasound, nuclear medicine, and used to generate images of different thickness from the
MRI. same acquisition. The minimum section thickness is re-
duced to approximately 0.5 mm and images can be re-
constructed at this 0.5-mm interval. Isotropic (equal di-
Radiography
mension) voxels measuring 0.5 mm in x, y, and z
Digital radiography exists in the form of computed radi-
directions greatly improve the spatial resolution and the
ography or direct radiography. Image processing and dis-
quality of reconstructing algorithms, allowing generation
tribution is achieved through a picture archiving and com-
of exquisite multiplanar reformats (Figure 1) and three-
munication system. The images can be placed on a
dimensional images. These three-dimensional image
compact disk with an imbedded viewer. The widespread
processing and display techniques are particularly useful
availability of computers with compact disk readers allows for regions of complex anatomy such as the pelvis, or
this method of image processing to be a more portable for bones for which it is difficult to obtain isolated pro-
mechanism of transporting and managing images. View- jections without overlap, such as the scapula or the cer-
ing the images in the soft copy environment allows for vical spine (Figure 2). Multiplanar reformats can be cre-
panning, zooming, windowing, and leveling so that the ated in any plane or using a curved surface to reduce
viewing experience and diagnostic yield are optimal. distortion. Other advantages include increased speed
There are certain tradeoffs; the spatial resolution of dig- and increased total volume coverage. Therefore, a single
ital radiography systems is not as great as that with film pass whole body protocol may be feasible, particularly
screen radiography. However, as additional experience with 16-detector scanners that can image from the head
and data are accumulated, it has been found that the im- vertex to below the hips in less than 1 minute. The abil-
proved contrast resolution is more important than spatial ity to acquire high-quality images in the presence of
resolution for diagnostic efficacy, making less defined spa- hardware/joint implants has improved using multislice
tial resolution a reasonable trade-off (Figure 1). CT. Metal artifacts are caused by photopenic defects in
the back projection and are displayed on CT images as
Computed Tomography streak artifact. With multislice CT, the holes in the fil-
The latest generation of CT scanners uses multiple de- tered back projection are not as pronounced, resulting
tector row arrays. Multislice CT represents a major im- in a less severe streak artifact. This improvement is at
provement in helical CT technology, wherein simulta- the expense of excess tissue radiation along the penum-
neous activation of multiple detector rows positioned bra of the beam, which is then picked up by adjacent
along the longitudinal or z-axis (direction of table or detector channels filling in these photopenic defects in
gantry) allows acquisition of interweaving helical sec- the projection. This technology has forced radiologists
tions. The principal difference between multislice CT into redefining the image viewing process to a volumet-
and predecessor generations of CT is the improved res- ric paradigm rather than a simple tile mode or section-
olution in the z-axis. More of the photons generated by by-section viewing. In addition, CT protocols have to be
the x-ray tube are ultimately used to produce imaging reformulated. There is also an expanded range of CT
data. With this design, section thickness is determined applications and indications. The challenges associated
by detector size and not by the collimator itself. Rapid with multislice CT include selection of optimal imaging
data acquisition times are possible because of short gan- sequences, controlling radiation exposure to the patient,
and efficiently managing the large amount of data gen- tons per voxels; because smaller voxels tend to have
erated. Some disadvantages of multislice CT are high fewer photons, increased image noise is the result. To
radiation dose to the tissue and potentially noisy im- keep the noise level reasonable, the exposure (and thus
ages. Noise is inversely related to the number of pho- radiation dose) must be increased.
fer occurs inherently with fast spin-echo or turbo spin- seen in MRI. T2 is fairly constant at different field
echo techniques. The driven equilibrium Fourier trans- strengths, but T1 increases with increasing field strength.
form contrast method is another promising approach for Fat suppression is improved at 3T because the peaks be-
imaging of cartilage disorders. This method produces tween water and fat are further separated (greater
image contrast that is a function of proton density, chemical shift effect; the nature of the chemical shift
T1/T2 and echo time/repetition time (TE/TR). Many tis- phenomenon is that protons associated with long chain
sues have competing T1 and T2 contrast, so the T1 to T2 aliphatic fat molecules have precessional frequencies
ratio for driven equilibrium Fourier transform contrast slightly lower than protons associated with mobile water
tends to be synergistic. Driven equilibrium Fourier molecules, which is field strength-dependent), providing
transform contrast is well suited to imaging articular more robust spectral fat suppression. The US Food and
cartilage because synovial fluid is high and articular car- Drug Administration and manufacturers have mandated
tilage is intermediate in signal intensity; the osseous the use of power monitoring systems for 3T because of
structures are dark and lipids can be suppressed using increased danger of RF burns. The more problematic se-
spectral fat saturation techniques. This creates an image quences are fast spin-echo/turbo spin-echo (unless the
in which cartilage is easily distinguishable from all adja- refocusing pulse is reduced to less than 180) and short
cent tissues based on signal intensity alone, aiding seg- TR spin-echo sequences (T1-weighted). Motion artifacts
mentation and volume calculation. appear worse at 3T and may be because of the overall
Magnetic resonance arthrography has also been ap- higher signal to noise ratio. Susceptibility artifacts will
plied to the evaluation of cartilage and may be per- be increased, and postoperative imaging may be more
formed directly (a dilute gadolinium-containing solution problematic at higher field strengths. Increasing the re-
is percutaneously placed into the joint via a needle) or
ceiver bandwidth may also help alleviate these artifacts.
indirectly (intravenous gadolinium is administered and
There are improvements in speed because the signal to
allowed to diffuse into the joint). Gadolinium-enhanced
noise ratio is proportional to the square of the imaging
imaging has the potential to monitor glycosaminoglycan
time, and therefore it is possible to go up to four times
(GAG) content within the cartilage. GAGs are funda-
faster at 3T than 1.5T while maintaining an equal signal
mentally important for several reasons: they play a ma-
to noise ratio.
jor mechanical support role, they are lost early in the
Another trend is the use of dedicated extremity
course of cartilage degeneration, and may need to be re-
scanners that typically operate at low field to midfield
plenished during the course of any effective cartilage
ranges. Low field open scanners or extremity scanners
treatment regimen. GAGs contribute strong negative
have been available for several years. However, recently
charge to the cartilage matrix and mobile ions will dis-
tribute to reflect local GAG concentration. When a higher field extremity scanner at 1.0 T has become
GAGs are lost as part of the degenerative process, the available (Orthone, ONI, Inc, Wilmington, MA). This
negative charge conferred to the cartilage also is lost. unit can image the elbow, hand, wrist, knee, foot, and an-
Consequently, when a negatively charged contrast agent kle but cannot acquire images of the shoulder, hip, or
is administered (either intravenously or intra- spine. Therefore, it is not considered a stand-alone unit
articularly) it preferentially distributes into the de- but may be useful for a high volume site with a backlog
graded cartilage and the T1 effect of this contrast mate- of musculoskeletal patients to supplement a whole body
rial can be qualitatively visualized and quantitatively unit. The site requirements are less than those for a con-
measured. With direct magnetic resonance arthrography, ventional high field strength system, making it a more
it takes 3 hours for the contrast to sufficiently diffuse economical option. The image quality is much improved
into the cartilage, whereas with indirect magnetic reso- over the typical low field open MRI or very low field
nance arthrography it only takes approximately 1.5 extremity scanners, and this type of device will likely
hours. have a niche role providing high-quality clinical images
Clinical higher field MRI systems, typically 3.0 Tesla for the amenable body parts (Figure 4). It is also a use-
(or 3T) are becoming widely available. The higher in- ful option for claustrophobic patients. There are Larger
trinsic signal-to-noise ratio of high-field strength MRI and smaller diameter RF coils available. Both coils are
can be used to improve imaging speed or resolution but quadrature types of volume transmit-receive coils, which
changes in relaxation time at 3T as well as increased ar- contribute to the improved image quality. There are cer-
tifacts must be considered. Nevertheless, 3T MRI offers tain advantages when this method is compared with tra-
the opportunity to explore physiologic imaging of joints ditional high field closed MRI systems. The images are
as well as morphologic features. Tissues in a magnetic of high quality despite the fact that the field strength is
field are categorized by two types of relaxation: T1 lower. Loss of signal to noise ratio and artifacts from off
(spin-lattice relaxation time) and T2 (spin-spin relax- isocenter imaging are minimized. The majority of pulse
ation time). Manipulation of imaging parameters of the sequences are available, including spectral fat suppres-
TE and the TR produce the various types of contrast sion.
Figure 4 High-field open dedicated extremity MRI system. Elbow common extensor tendinopathy and partial tear: axial T1-weighted image (A) shows intermediate signal at the
common extensor tendon ulnar attachment (arrowhead), coronal oblique T2-weighted image (B) with spectral fat suppression shows a small fluid gap (arrow) but not complete
discontinuity of the common extensor tendon ulnar attachment reflecting a partial tear. Achilles tendinopathy (insertional tendinitis): axial T1-weighted image (C) through distal
Achilles tendon (subjacent to marker) shows tendinosis manifested by enlargement (loss of the normal comma shape) and intermediate signal, sagittal T2-weighted image with
spectral fat suppression. (Images courtesy of Barbara N. Weissman, MD and Rosemary J. Klecker, MD, Harvard Medical School, Brigham and Womens Hospital.)
Parallel imaging is a relatively new class of tech- In terms of improving communications between pro-
niques capable of significantly increasing the speed of viders there is a multispecialty, multisociety-endorsed no-
MRI acquisitions. Although a variety of different tech- menclature for the lumbar spine disk disease (some ad-
niques have emerged, the common principle is to use vocate that this system may be used for cervical and
the spatial information inherent in the elements of an thoracic spine descriptors also). It is important to recog-
RF coil array to allow a reduction in the number of nize that the definitions of diagnoses should not define or
time-consuming phase-encode steps required during the imply external etiologic events such as trauma, should not
scan. Recent technical advances and increased availabil- imply relationship to symptoms and do imply need for
ity to imaging centers place parallel imaging on the specific treatment. Hence, the following are pathoana-
verge of widespread clinical use. tomic descriptors that do not imply a specific pathoetiol-
ogy or syndrome. Osteoarthritis or osteoarthrosis is a pro-
Imaging of Specific Orthopaedic Conditions cess of synovial joints. Therefore, in the spine it is
Spine appropriately applied to the zygoapophyseal (Z-joint,
Disk Disease Nomenclature facet), atlantoaxial, costovertebral, and sacroiliac joints.
Spine imaging can exquisitely provide information re- Degenerative disk disease is a term applied specifically to
garding pathoanatomy of degenerative disk disease but intervertebral disk degeneration. The term spondylosis is
does not define a specific painful clinical syndrome be- often used in general as synonymous with degeneration,
cause of the nonspecific appearance of painful versus which would include both nucleus pulposus and anulus fi-
painless degenerative conditions. However, abnormal brosus processes, but such usage is confusing, so it is best
imaging findings of the lumbar disks may be degenera- that degeneration be the general term and spondylosis
tive, adaptive, genetic, or a combination of environmen- deformans a specifically defined subclassification of de-
tal and determined factors. Many findings may simply generation characterized by marginal osteophytosis with-
represent senescent changes that are the natural conse- out substantial disk height loss (reflecting predominantly
quences of stress applied during the course of a lifetime. anulus fibrosis disease). Intervertebral osteochondrosis is
The imaging appearance of lumbar spine degenerative the term applied to the condition of mainly nucleus pul-
disk disease has a similar incidence in symptomatic and posus and the vertebral body end-plates disease including
asymptomatic patients. Therefore, the appropriate use of annular fissuring (tearing).
imaging modalities within a defined clinical context is Normally, the posterior disk margin tends to be con-
paramount. For some patients with complicated or re- cave in the upper lumbosacral spine (Figure 5, A), and is
calcitrant symptoms, the most useful aspect for ad- straight or slightly convex at L4-5 and L5-S1. The poste-
vanced imaging techniques may be in the exclusion of rior margin typically projects no more than 1 mm be-
more serious causes of axial low back pain such as infec- yond the end plate. An annular bulge is described as a
tion, neoplasm, or fracture rather than the inclusion of generalized displacement (greater than 180) of disk
any specific degenerative findings. margin beyond the normal margin of the intervertebral
Figure 5 Lumbar disk contour abnormalities; all are axial T2-weighted images at the level of the intervertebral
disk. A, Normal: the posterior disk margin (arrowhead) should have a slight concavity, with the exception of the
lumbosacral junction, which may have a slight convexity. B, Annular bulge: There is generalized displacement
(arrowheads) of greater than 180 of the disk margin beyond the normal margin of the intervertebral disk space
and is the result of disk degeneration with an intact anulus fibrosus. C, Disk protrusion: The base against the
parent disk margin is broader than any other diameter of the herniation. Extension of nucleus pulposus through a
partial defect in the anulus fibrosus is identified (arrow) but the herniated disk is contained by some intact
annular fibers. D, Disk extrusion: The base against the parent disk margin is narrower than any other diameter of
the herniation (arrowhead). There may be extension of the nucleus pulposus through a complete focal defect in
the anulus fibrosus. Substantial mass effect is present, causing moderate central canal and severe left lateral
recess stenosis.
disk (Figure 5, B). The normal margin is defined by the than 90 circumference). Extrusion refers to a herniated
vertebral body ring apophysis exclusive of osteophytes. disk in which, in at least one plane, any one distance be-
The annular bulge can be the result of disk degenera- tween the edges of the disk material beyond the disk
tion with a grossly intact anulus. Disk margins tend to space is greater than the distance between the edges of
be smooth, symmetric, or eccentric and nonfocal, and the base in the same plane (Figure 5, D), or when no
may have a level-specific appearance in the lumbar continuity exists between the disk material beyond the
spine. Disk herniation is a localized displacement (less disk space and that within the disk space. An extrusion
than 180 of the circumference) of disk material beyond is characterized by the following: the base against the
the normal margin of the intervertebral disk space (Fig- parent disk margin tends to be narrower than any other
ure 5, C). This material may consist of nucleus pulposus, diameter of the herniation; extension of the nucleus pul-
cartilage, fragmented apophyseal bone, or fragmented posus through a complete focal defect in the anulus fi-
annular tissue. It is often the result of disk degeneration brosus. Extruded disks in which all continuity with the
with some degree of focal annular disruption. The types disk of origin is lost may be further characterized as se-
of disk herniation are designated as protrusion, extru- questrated. Disk material displaced away from the site
sion, and free fragment (sequestration). Protrusion re- of extrusion may be characterized as migrated; it may
fers to a herniated disk in which the greatest distance in stay subligamentous, contained by the posterior longitu-
any plane between the edges of the disk material be- dinal ligament or may migrate widely. Schmorls nodes
yond the disk space is less than the distance between are intervertebral disk herniations (transosseous disk
the edges of the base in the same plane. It is character- extrusion). Herniation of the nucleus pulposus occurs
ized by the following: the base against the parent disk through the cartilaginous end plate into the vertebral
margin is broader than any other diameter of the herni- body. These herniations often have a characteristic
ation; extension of nucleus pulposus may occur through round or lobulated appearance. They may enhance after
a partial defect in the anulus fibrosus but is contained contrast administration with ring-like enhancement be-
by some intact outer annular fibers and the posterior ing most common. They are often incidental and likely
longitudinal ligament. The types of protrusions may be to be developmental or posttraumatic rather than
broad based (90 to 180 circumference) or focal (less purely degenerative or adaptive. There is now imaging
evidence of a significant genetic association between the weight-bearing paradigm becomes validated, then the
COL9A3 tryptophan allele (Trp3 allele), Scheuermanns currently installed base of magnets can be used without
disease, and intervertebral disk degeneration among having to deploy new, costly space-occupying devices.
symptomatic patients. Further studies comparing simulated weight-bearing
There are no formal staging systems for lumbar degen- versus upright imaging will be needed to show whether
erative disk disease and most physicians will commonly new magnets are required for this purpose.
report findings using the designations of mild, moderate,
and severe disease. However, these designations will hold Sports Medicine: Magnetic Resonance Arthrography
different meaning among physicians, especially with re-
For any joint the placement of intra-articular contrast
spect to degree of disk degeneration. The following
whether by direct or indirect means can be used to as-
scheme is used to define the degree of canal compromise
sist the evaluation of ligaments, cartilage, synovial pro-
produced by disk displacement based on the goals of be-
liferation, or intra-articular loose bodies. MRI provides
ing practical, objective, reasonably precise, and clinically
relevant. Measurements are typically taken from an axial cross-sectional and multiplanar imaging for precise spa-
section at the site of the most severe compromise. Canal tial delineation and an additional capability to supply
compromise of less than one third of the canal at that sec- soft-tissue contrast outside of the joint cavity (tendons,
tion is mild, between one and two thirds is moderate, and muscles, and bone marrow) unavailable by any other
over two thirds represents severe disease. This scheme modalities. Pertinent issues for optimizing diagnostic
may also be applied to foraminal (neural canal) narrow- yield include technical considerations in performing
ing with the sagittal images also playing a useful role for magnetic resonance examinations, properly identifying
defining the degree of narrowing. Observer interpreta- structures of interest, and the clinical significance of the
tions are also made with various degrees of confidence. incidental findings. Magnetic resonance arthrography
Statement of the degree of confidence is an important has been most extensively studied in the shoulder and
component of communication. The interpretation should to a lesser degree in the hip and the postoperative knee.
be characterized as definite if there is no doubt, prob- Other joints in which it has been applied include the el-
able if there is some doubt but the likelihood is greater bow and wrist and to a lesser degree the ankle.
than 50%, and possible if there is reason to consider but Direct magnetic resonance arthrography, most often
the likelihood is less than 50%. done with injection of diluted gadolinium or less often
with saline solution, can be useful for evaluating certain
Positional, Load-Bearing, and Dynamic pathologic conditions in the joints. Gadolinium-based
(Functional) Imaging contrast agents have not been approved by the US Food
Because imaging in the supine position may not fully re- and Drug Administration for intra-articular injection
veal the anatomic lesions, there has been an interest in but may be used clinically under the doctrine of the
performing functioning, positional, or load-bearing im- practice of medicine. These agents are most helpful for
aging of the spine. Spine imaging position options avail- outlining labral-ligamentous abnormalities in the shoul-
able are supine, supine with axial loading (simulated der (Figure 6) and distinguishing partial-thickness from
weight bearing), seated, or standing upright position. full-thickness tears in the rotator cuff, demonstrating la-
Noncompressive lesions on conventional MRI may
bral tears in the hip, showing partial- and full-thickness
show encroachment and neural element impingement
tears of the collateral ligament of the elbow and delin-
on dynamic load-bearing (seated) scans. Fluctuating po-
eating bands in the elbow, identifying residual or recur-
sitional foraminal and central spinal canal stenosis has
rent tears in the knee after meniscectomy (Figure 7), in-
also been shown in the cervical spine between recum-
creasing the certainty of perforations of the ligaments
bent and upright neutral position. This situation has led
to a concept of fluctuating kinetic central spinal canal and triangular fibrocartilage in the wrist, correctly iden-
stenosis (fluctuating fluid disk herniation) that can only tifying ligament tears in the ankle and increasing the
be shown with these different positions. Cervical spine sensitivity for ankle impingement syndromes, assessing
imaging in the recumbent position showing posterior os- the stability of osteochondral lesions in the articular sur-
teophytes may only reveal cord compression with face of joints, and delineating loose bodies in joints. Di-
upright-extension positioning. Because of the preva- rect magnetic resonance arthrography has become a
lence of back pain that occurs in a nonsupine position well-established method of delineating various joint
and the inability of routine supine MRI to satisfactorily structures that otherwise show poor contrast on conven-
reveal clinical syndromes, it is likely that positional im- tional MRI. However, direct magnetic resonance ar-
aging will have a role in the future but how it exactly thrography is minimally invasive and usually necessi-
will be implemented is as yet undetermined; the role of tates fluoroscopic guidance for joint injection (some
imaging the hip, knee, and ankle under axial load also authors have described doing blind injections or using
warrants further investigation. If the supine simulated other modalities such as ultrasound or MRI).
Figure 6 Direct magnetic resonance arthrography of the shoulder. T1-weighted fat-suppressed images obtained after the intra-articular injection of a dilute gadolinium solution.
A, Buford complex: axial image at the level of the coracoid process shows a deficient anterosuperior labrum (white arrow) with a thick cord-like middle glenohumeral ligament
(black arrowhead) reflecting a normal developmental variant. B, Bankart lesion: axial image caudal to the level of the coracoid process shows contrast intravasation into an
irregular deformed anteroinferior glenoid labrum (arrow) distinct from the middle glenohumeral ligament (arrowhead). C, Superior labral anterior and posterior lesion: coronal
oblique image posterior to the biceps attachment to the glenoid shows an irregular collection of contrast material (arrow) extending into the superior labrum with partial
detachment.
nology allows the use of a microscopy coil, which pro- the signal intensity is directly proportional to the
vides high-resolution MRI of the hand and wrist. High- amount of extracellular water. Contrast enhancement
resolution MRI with a microscopy coil is a promising occurs in areas of BME irrespective of etiology (benign
method to diagnose triangular fibrocartilage complex or malignant, infectious or noninflammatory). The po-
and other ligament lesions. The limitation of microscopy tential etiologies of BME include diseases in the cate-
coils is that the depiction of deep structures is inade- gory of trauma, biomechanical, developmental, vascular,
quate. However, this may be resolved by combined posi- neoplastic, inflammatory, neuropathic, metabolic, degen-
tioning with a larger surface coil or a flexible coil. In ad- erative, iatrogenic, and potentially idiopathic conditions
dition, the limited sensitivity of microscopy coils may (transient BME syndromes).
sometimes make accurate coil setting difficult over tar- Occult injuries result from an acute overt episode of
geted structure or suspected lesions. The availability of trauma. The physician should suspect a fracture in these
superconducting coils has also been applied to small patients. The traditional modality applied to fracture de-
joint imaging. Overall, it is likely that advanced coil de- tection has been radiography, which may be negative or
velopment will lead to improved diagnostic perfor- indeterminate for nondisplaced fractures or a fracture
mance of MRI because high spatial resolution imaging plane that is not tangential to the x-ray beam. In this
is paramount to detect infrastructural features of the context MRI serves as a more sensitive technique for
wrist and elbow when evaluating for internal arrange- fracture detection and characterization. Contusions, also
ments. known as bone bruises, are considered microtrabecular
fractures. On MRI there is no fracture line and the pat-
Foot and Ankle: Bone Marrow Edema-Like Lesions tern may be a clue or secondary sign of ligament or ten-
don injury. These fractures often occur in a subarticular
Bone marrow edema (BME)-like lesions are often ob-
location from osteochondral impaction injuries.
served on MRI. Although BME-like signal is not spe-
In terms of developmental conditions the normal
cific on MRI, additional morphologic findings are often
conversion of red marrow to yellow marrow sometimes
useful to reveal the etiology of many BME patterns.
has areas of slight T2 or STIR hyperintensity but these
Normal marrow constituents have three components:
usually are not as bright as pathologic lesions. Areas of
osseous, myeloid elements, and adipose cells. Hemato-
a developmental synchondrosis with failure of segmen-
poietic (red) marrow has approximately 40% fat con-
tation of the primitive mesenchyme may cause symp-
tent and fatty (yellow) marrow has 80% fat content. The toms via abnormal biomechanics. Symptomatic fibrous
appendicular skeleton tends to have more fatty marrow or cartilaginous tarsal coalitions often show reciprocal
than hematopoietic marrow and this serves as a natural areas of BME. Anatomic variants that can present as
contrast agent, showing bright T1 signal and suppression painful lesions may be considered a separate but related
on fat saturation images. MRI to detect BME relies on category. Those of chronic chondro-osseous disruption
fluid-sensitive sequences (short-tau inversion recovery include bipartite patella, dorsal defect of the patella, and
[STIR] and fat suppressed T2-weighted images). T1- os subfibulare of the ankle. Those in the congenital syn-
weighted images can supplement T2-weighted images chondrosis category include accessory navicular bone
and are very specific for the infiltrative process, but are and os trigonum. There are lesions that may predispose
not as sensitive if there is nonfat marrow or no substan- to premature degenerative joint disease; one example is
tial degree of edema. Gradient echo images are poor for the os intermetatarsarum, which can contribute to hal-
assessing marrow because of increased susceptibility re- lux valgus by causing excessive metatarsus varus. When
lated to the interfaces between the trabecula and he- these variants are symptomatic they often demonstrate
matopoietic marrow. Gradient echo images can be use- BME-like signal about the abnormality, reflecting al-
ful to reveal other diagnoses such as lesions that contain tered biomechanics, chronic stress, or sometimes areas
iron, calcium, or hemosiderin (pigmented villonodular of osteonecrosis. It is thought that MRI can form an ob-
synovitis). Other novel MRI techniques that have been jective basis for management of the lesions, particularly
variably applied include chemical shift imaging, diffu- when surgery is considered.
sion weighted imaging, and magnetic resonance spec- The well-established vascular causes of BME-like
troscopy. signal may be related to either hyperemic or ischemic
BME lesions can reflect nonspecific response to in- conditions. Of the hyperemic etiologies, inflammatory
jury or excess stress. The pathophysiology is related to disorders that increase vascularity or disuse may cause
the extracellular fluid, which can be affected by hyper- subarticular BME patterns. The disuse pattern is also
vascularity and hyperperfusion (hyperemia), an inflam- partly related to increased blood flow, can be character-
matory infiltrate causing resorption, granulation (fi- istic and parallels the radiographic appearance of ag-
brovascular) tissue or an adaptive/reactive phenomena gressive osteoporosis with diffuse or multiple rounded
related to biomechanical alterations (MRI manifesta- areas of fluid-like hyperintensity in a subarticular and
tion of Wolffs Law). The pathoetiologies are legion and metaphyseal distribution predominantly in the hindfoot
Figure 9 Osteomyelitis superimposed on neuropathic arthropathy. A, Axial T1-weighted spin-echo image of the midfoot reveals disorganization and dislocation of the Chopart
joint, showing replacement of the normal marrow with diffuse infiltration of hypointense signal (arrowheads) in the tarsal bones. B, Sagittal T2-weighted fast spin-echo image
reveals marrow edema in the midfoot and hindfoot bones, tarsus effusions, a rocker bottom deformity and fluid-like signal in the overlying subcutaneous tissues (arrow). C,
Sagittal T1-weighted spin-echo contrast-enhanced image shows rim enhancement around plantar sinus tracts (small arrows) from the ulcer base and extending into midfoot
reflecting a plantar space abscess (large arrow). The marrow edema is enhancing, which is nonspecific, but there is cortical irregularity of the anterior aspect of the cuboid
adjacent to the soft-issue enhancement (arrowhead). The secondary signs of cutaneous ulcer, sinus tract, and cortical interruption have the highest positive predictive value for
osteomyelitis.
and midfoot. In terms of ischemic lesions, the broad cat- One notable exception is an ulceration that develops
egory of osteonecrosis (infarct, osteonecrosis) can have because of poorly fitting footwear, or foot deformity
BME early in the course of the disorder associated with and altered weight bearing that can cause atypical loca-
acute, painful symptomatology. Pain improvement usu- tion of osteomyelitis. However, there should be a soft-
ally parallels the resolution of the BME-like signal. The tissue defect identified over these areas to diagnose os-
MRI pattern shows early BME with loss of subchondral teomyelitis. The epicenters of signal abnormalities can
fat signal intensity. The double line sign is specific and be useful. Neuropathic disease has an articular epicenter
most often identified as a ring of T1 hypointensity and and usually multiple joints are involved with a regional
T2 hyperintensity. This likely reflects a reactive interface instability pattern. Osteomyelitis has a marrow epicen-
rather than chemical shift artifact. MRI signal of the ne- ter with focal centripetal spread throughout the bone. It
crotic segment may be reconstituted and appear fatty is important to emphasize that transcutaneous spread is
because of the lipid content (the signal is not signifi- the route of inoculation in more than 90% of cases of
cantly altered because of the reduced metabolic state). osteomyelitis of the foot in patients with diabetes.
MRI findings may be seen as early as 10 to 15 days and Therefore, secondary soft-tissue signs are paramount; a
for most patients within 30 days after the vascular in- subcutaneous ulcer with interruption of cutaneous sig-
sult. Transient osteoporosis or the MRI correlate, tran- nal, cellulitis, soft-tissue mass effect from a phlegmon,
sient bone marrow edema syndrome, may occur in nu- soft-tissue abscess (well-defined rim enhancing fluid col-
merous other low extremity locations including the hip, lection) and particularly a sinus tract strongly support
knee, talus, cuboid, navicular, and metatarsals. In addi- infection (Figure 9).
tion, it may be migratory and occur in a ray pattern. It has been recently recognized that degenerative
Some believe that these lesions may reflect salvaged os- conditions are associated with areas of BME. These de-
teonecrosis but it is likely that many of these lesions generative conditions may occur with either primary or
may simply be biomechanical in nature. secondary osteoarthritis. Geodes (subchondral cysts)
In the inflammatory category it is well established are one of the imaging hallmarks of osteoarthritis and
that infectious etiologies cause BME. One difficult dif- can be identified on MRI. Early during the course of
ferential diagnosis in the setting of diabetic neuropathy disease, ill-defined areas of BME appear and later form
is distinguishing osteomyelitis from a Charcot joint. discrete cystic structures. Some of these areas with hy-
There are several MRI findings that may help in the dif- perintensity have been shown by pathologic studies not
ferentiation. Osteomyelitis is more common in the pha- to reflect the fluid. It has been hypothesized that some
langes, distal metatarsals, and calcaneus (secondary to of these findings are likely mechanical or adaptive re-
overlying ulceration) whereas neuropathic disease is sponses related to the altered mechanics from the joint
more common in the Lisfranc, Chopart, and ankle joints. failure and may be considered the MRI manifestation
of Wolffs Law. In the knee (and possibly in the ankle neus (along the peroneal tubercle). Noninfectious in-
and foot) bone marrow findings are strongly associated flammatory enthesopathies such as psoriatic or reactive
with the presence of pain, and moderate or larger fu- arthritis cause prominent flame-shaped BME patterns
sions in synovial thickening are more frequent among at the tendon-bone junction (enthesis) often with an as-
those with pain than those without pain adjusted for de- sociated erosion that may be better appreciated with ra-
gree of radiographic osteoarthritis. In addition, focal diography.
subchondral BME may be a clue to focal cartilage de- There are several miscellaneous but important causes
fects (potential treatable cartilage defects), which pre- of lower extremity BME patterns. Hematopoietic (red)
sumably are posttraumatic events. The cartilage abnor- marrow can sometimes be confused for an abnormal
mality itself may be relatively inconspicuous on MRI BME pattern. Hematopoietic marrow is most prominent
pulse sequence selection or spatial resolution and there- in the pediatric population and there is a conversion pat-
fore an area of subarticular flame-shaped BME in a tern progression from distal to proximal. One important
nonarthritic joint can be a helpful secondary sign. An- realization is that once an epiphysis is ossified, it should
other recently described pattern of BME is a subtendi- contain fatty signal with a couple of important exceptions
nous location. This has been identified as a response to (reconversion not infrequently occurs in proximal femo-
tendon abnormality and hypothesized to be from me- ral epiphysis). In general, reconversion related to anemia
chanical friction, hyperemia, or because of biomechani- or other conditions is in the opposite direction. In terms
cal reasons. A subtendinous location is most common in of marrow replacement disorders (leukemia and lym-
the lower extremity, particularly in the foot and ankle, phoma) the pattern may be a diffuse or focal area of mar-
and is most often seen with posterior tibialis tendon row signal abnormality.With infiltrative diseases, the mar-
(PTT) dysfunction (Figure 10, A). The areas of edema row pattern tends to have some asymmetry and
related to PTT dysfunction are the medial tibia (malleo- pathologic processes tend to have more T2 prolongation
lus), navicular tubercle, calcaneous, and talus. This find- and higher signal intensity (brighter BME). Neoplasms of-
ing is not seen in most people with PTT dysfunction but ten show lesional or perilesional BME. The signal inten-
may be a sign for a more advanced stage and poorer sities are unreliable for histology and there is substantial
tendon quality. Less frequently, BME may also be re- overlap between benign and malignant conditions. Met-
lated to peroneal tendinopathy (Figure 10, B): typically astatic deposits are hematogenous in origin and are pre-
in the lateral fibula (lateral malleolus) or lateral calca- dominantly located in red marrow areas (axial skeleton)
but can also be present in the appendicular skeleton, es- formed. Early MRI evaluation in children with lower
pecially for deposits from bronchogenic or breast carci- extremity fractures can be prognostic. Physeal narrow-
noma. For primary neoplasms, the degree of BME does ing or tethering in the absence of growth arrest lines
not correspond to malignancy potential.There are several was found in those patients who subsequently required
well-known benign lesions that are characterized by very late surgical intervention. The MRI in acute phase pro-
prominent BME: chondroblastoma, osteoid osteoma, and vided accurate evaluation of physeal fracture anatomy
Langerhans cell histiocytosis. Patients who have under- and could often augment the staging of the Salter-Harris
gone radiotherapy or chemotherapy, those who are tak- classification. The course and level of injury within the
ing bone marrow recovery agents, and patients who have cartilage physeal fracture-separation can be defined
recently undergone dbridement may show BME de- with MRI. Extension into the juxtaepiphyseal region is
pending on the time course of the treatment. another potential risk factor for growth arrest and is de-
tectable by MRI. Early MRI can demonstrate transphy-
Pediatrics: Physeal Lesions and Growth Arrest seal bridging or altered arrest lines in physeal fracture
The growing skeleton is susceptible to injury. Advances before they become manifest on radiographs. Physeal
in pediatric musculoskeletal radiology have been made enhancement decreases with physeal closure as ex-
in imaging the cartilage, epiphysis, and physis. Closure pected. In the marrow and the extremities, contrast en-
disturbance of the long bones in children is frequently hancement is greater in the metaphyseal metathesis por-
posttraumatic but also occurs because of physeal, epi- tion than the fatty epiphyseal portion. In both areas
physeal, or metaphyseal ischemia. The growth mecha- enhancement decreases as the marrow becomes more
nism represented by the cartilage structures at the ends fatty. Local physeal widening in a growing bone may
of growing bones is not directly visible on radiography represent the imprint of the previous or ongoing inter-
but is well visualized by MRI. Improved definition of ference with endochondral ossification. Widening can be
cartilaginous abnormality by MRI may permit earlier seen on a fluid-sensitive pulse sequences in physeal dys-
detection and treatment of disorders and thus prevent function without bridge formation. Physeal widening
bone deformity. The formation of physeal bars (bony with focal palisading morphology, central distribution in
bridges across the growth plate) is one active area of pe- the metaphysis and concomitant epiphyseal signal ab-
diatric musculoskeletal radiology research. Premature normalities are significant predictors of subsequent
bony fusion in children is most often posttraumatic and growth disturbance. Therefore, MRI should be consid-
disproportionately involves the tibia and femur with ered as part of the evaluation for patients at high risk
bridges tending to develop as the site of earliest physio- for growth disturbance, especially young children with
logic closures (anteromedially and centrally). The distal extensive residual growth potential and those that in-
tibia, proximal femur, and proximal tibia physes are dis- volve particularly vulnerable growth plates (such as
proportionally at risk because of the complex geometry. about the knee) and pediatric patients with severe com-
The central undulations in the distal femur and Kumps plex fractures. MRI is now a standard of care and helps
bump in the distal tibia are sites of initial physiologic surgical management for these patient populations with
closure and the most frequently involved in the prema- cartilage-sensitive sequences, exquisitely showing the
ture fusions. Animal studies with physeal and metaphy- disturbance and associated abnormality that may follow
seal injuries have shown MRI can identify persistence of physeal injuries.
abnormality in the growth cartilage after physeal inju-
ries and evolution of abnormalities after metaphyseal Orthopaedic Oncology: Metabolic Imaging
injury best seen on T2-weighted images. It has been Distinguishing benign from malignant soft-tissue lesions
shown on MRI in animal models that abnormalities in in the extremities is a difficult if not impossible task by
the physeal cartilage result in development of a trans- imaging using either signal, morphologic, or enhance-
physeal vascularity that precedes the formation of bony ment criteria. Follow-up imaging for sarcoma patients is
bridge after trauma. MRI can detect this transphyseal also complicated by complex prostheses, which can pro-
vascular lesion within the first 2 weeks of injury. In vivo duce artifacts and limit visualization at the surgical site.
studies in humans confirm that MRI defect abnormali- PET scanning, discussed earlier in the chapter, holds
ties in the cartilage are associated with subsequent promise in showing metabolically active areas and may
growth disturbances and provide accurate mapping of be particularly suitable for monitoring patients after
physeal bridging and associated growth abnormality in therapy (resection, chemotherapy, or radiotherapy).
the posttraumatic population (Salter-Harris injuries).
Contrast enhancement can be useful in showing recon- Orthopaedic Traumatology: Multislice
stitution of metaphyseal vascularity after injury but does Computed Tomography
not reliably enable the detection of transphyseal vascu- One of the most recently evident benefits of multislice CT
larity after physeal injury until a distinct bony bridge is is in the setting of appendicular and axial trauma. CT
greatly improves the anatomic depiction of spinal injury use of spinal injections should be considered a team ef-
when compared with projectional radiography. Compared fort in conjunction with an experienced clinical diagnos-
with single detector helical CT scanners, multislice CT tician who can accurately diagnose the patients prob-
scanners have increased tube heating capacity and run at lem and recommend the appropriate procedure.
a higher table speed, allowing an increased volume of cov- Performance of these procedures requires an intimate
erage with the same amount of scanning time. This makes knowledge of relevant anatomy, appropriate equipment
screening examination of part of the spine or the entire and facilities, and apprenticeship with an experienced
spine feasible, which may eliminate screening radiographs practitioner. Selective epidural injections can offer sig-
in certain settings. Examinations of the thorax and the nificant diagnostic and therapeutic benefit for patients
lumbar spine can be extracted from a CT examination of with radicular pain. Attention to proper technique will
the chest abdomen and pelvis. minimize risk of complications from these procedures
There are several pitfalls to be aware of but the most while maximizing their benefit.
important image artifacts are not unique to multislice CT. Controversy and differences in opinion related to
These pitfalls include metal-induced streak artifact and epidural steroid injections often revolve around choice
patient motion. Because of the higher spatial resolution, of trajectory (transforaminal versus transflaval [trans-
vascular channels of the vertebral bodies are better appre- laminar, interlaminar]) and whether to use image guid-
ciated and may be mistaken for normal structures. Mul- ance. Transflaval injections may be done with or without
tislice CT has some risk predominantly related to the ra- image guidance (using loss of resistance techniques),
diation dose to the individual patient and to the whereas transforaminal injections are done with image
population. The radiation dose of the patient increases as guidance. Studies reviewing the efficacy of epidural ste-
the volume of coverage increases. Multislice CT allows roid injections favor it as a useful treatment overall.
imaging of very thin sections quickly, much faster than However, controlled clinical trials performed without
previously possible, allowing for effective screening of spi- fluoroscopic guidance are not unanimous in demonstrat-
nal injuries and evaluating extremity injuries. Screening ing the benefits of lumbar epidural steroid injections
CT of the entire cervical spine is cost effective if high-risk with a broad range of successful results, ranging from
criteria, such as focal neurologic deficit referable to the 18% to 90%. This broad range may be related to the ac-
cervical spine, head injury (skull fracture, intracranial tual location of medication deposition. The incidence of
hemorrhage) or loss of conscious at the time of examina- failure to reach the epidural space using a nonimage-
tion, and high-energy mechanism (motor vehicle accident guided transflaval approach ranges from 13% to 30%
at a speed of greater than 35 mm, pedestrian struck by a and may target the wrong interlaminar space by one or
car, or a fall greater than 10 feet). more levels. The transforaminal approach demonstrates
superior ventral opacification, whereas the transflaval
method shows predominantly dorsal opacification (us-
Diagnostic and Therapeutic Procedures ing CT as the reference standard to confirm contrast lo-
Spinal Injections cation after fluoroscopically-guided epidurography).
Epidural steroid injections, sacroiliac joint injections, Dorsal deposition may be less effective because the ste-
zygapophyseal (facet) joint injections, diskography, and roid is remote from the source of irritation (for exa-
vertebral augmentation are image-guided procedures mple, disk herniation). There is an increased risk of a
that are important components of a comprehensive dural puncture (intrathecal administration), spinal head-
management approach to spine pain syndromes for es- ache (may require blood patch treatment), intrathecal
tablishing a diagnosis, directing or administering ther- administration of steroid or residual preservatives of lo-
apy, and facilitating rehabilitation and functional resto- cal anesthesia leading to nerve root injury, hypotension,
ration. or dyspnea. For several reasons image-guided epidural
Demand for epidural injections is rapidly expanding. steroid injection is favored; it adds only minimal risk
Patient satisfaction elicited from these procedures is of- (radiation) and may not add to the overall costs of spine
ten a direct result of imaging guidance, which can injections but may even reduce costs by eliminating re-
shorten and simplify procedures, minimize potential for peat injections (a nonimage-guided paradigm is to per-
complications, and verify accurate localization of the form two to three successive transflaval epidural steroid
needle to selectively provide the lowest necessary dose injections because the miss rate of the epidural space is
of analgesic to the optimal area. These procedures can about 33%).
greatly contribute to patient management and surgical Intra-articular injections have an established role for
planning by determining sources of pain and treating identifying zygapophyseal (facet) and sacroiliac joint ar-
pain generators. Participation of an experienced radiolo- ticulations as nociceptors. However, intra-articular injec-
gist in performing these procedures optimizes patient tions with anesthetic or corticosteroid are often not suf-
care, because radiologists are trained in anatomy and ficient for a long lasting therapeutic effect. Once a
image-guided needle localization procedures. However, zygapophyseal joint has been implicated as a substantial
Figure 11 CT characterization after intradiskal contrast injection. Postdiskography transaxial CT images. A, Normal nucleogram characterized by central globule of contrast
material that remains within the expected confines of the nucleus pulposus. B, Annular fissure. Contrast material is noted within the nucleus pulposus, but also extends in a radial
fashion posterolaterally beyond the expected confines of the nucleus pulposus into the region of the anulus fibrosus (arrow). There is also a circumferential component noted in
the anulus fibrosus (arrowhead).
or significant nociceptor then targeted therapy options indications include patients with persistent pain in
exist that may include a neuroablative procedure (me- whom noninvasive imaging and other tests have not
dial branch neurotomy) in conjunction with functional provided sufficient diagnostic information. In patients
restoration via physical therapy. Sacroiliac joint treat- who are to undergo fusion, diskography can be used to
ment can be more problematic given the diffuse inner- determine if disks within the proposed fusion segment
vation of the articulation; however, sacroiliac joint fu- are symptomatic and if the adjacent disks are normal.
sion is a technique practiced by some orthopaedic Surgeons concerned with limiting the extent of fusion
surgeons. For true inflammatory sacroiliitis related to a are interested in obtaining more evidence beyond MRI
spondyloarthropathy, there is good evidence from sev- abnormalities to document what intervertebral disk lev-
eral clinical trials that intra-articular corticosteroid is els are contributing to the painful syndrome. In postop-
proven to be an effective component of treatment. erative patients who continue to experience significant
However, the data on the efficacy of steroid intra- pain, diskography can be used to assist in differentiating
articular injections for mechanical somatic dysfunction between postoperative scar and recurrent disk hernia-
are conflicting. For an intracanalicular synovial cyst em- tion (when MRI or CT is equivocal); or to evaluate seg-
anating from an adjacent zygapophyseal joint that is ments adjacent to the arthrodesis. Postdiskography CT
causing lateral recess stenosis with radicular symptoms, can also be used to confirm a contained disk herniation
intra-articular injection with corticosteroid assists in de- as a prelude to minimally invasive intradiskal therapy
creasing the perineural inflammation, reducing the size (Figure 11). Diskography is also being used as part of
of the cyst, and alleviating the radicular symptoms. the selection criteria for many clinical trials assessing
lumbar interbody fusion devices or percutaneous in-
Diskography tradiskal treatments.
The primary purpose for diskography is for documenta-
tion of the disk as a significant nociceptor. For patients
who have chronic pain that is predominantly axial, non- Annotated Bibliography
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juries and painful conditions of the athlete. With portable ultra- clature that is workable for all forms of observation, that ad-
sound units, examinations can be performed on the playing field, dresses contour, content, integrity, organization, and spatial re-
immediately at the time of the acute injury, for rapid diagnosis. lationships of the lumbar disk; and that serves as a system of
Ultrasound can be used to guide therapeutic procedures. classification and reporting built upon that nomenclature.
Yoshioka H, Stevens K, Hargreaves BA, et al: Magnetic Karppinen J, Paakko E, Paassilta P, et al: Radiologic
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three-dimensional DEFT imaging, and correlation with The results of this study indicate that the presence of Trp3
arthroscopy. J Magn Reson Imaging 2004;20:857-864. allele is associated with Scheuermanns disease and interverte-
In this study, signal to noise ratios and contrast to noise ra- bral disk degeneration. No associations were found for other
tios were compared in various magnetic resonance sequences, radiologic phenotypes.
including fat-suppressed three-dimensional spoiled gradient
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fast spin echo imaging showed high sensitivity and high negative large patient group with advanced pedal infection and to com-
predictive values, but relatively low specificity. pare ulcer location with the distribution of osteomyelitis and
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Table 1 |Basic Workers Compensation Terms Table 2 | Waddells Nonorganic Physical Signs in Low
Back Pain
Impairment Deviation from normal function, which may be
either permanent or temporary. 1. Tenderness Tenderness related to physical disease should
Disability A nonmedical term pertaining to the loss or be specific and localized to specific anatomic
diminution of the ability to perform a function structures.
or functions. It is possible to be impaired Superficial: tenderness to pinch or light touch
without necessarily being disabled. A tran- over a wide area of lumbar skin.
scriptionist with a below-knee amputation has Nonanatomic: deep tenderness over a wide
an impairment but is still able to perform all area, not localized to a specific structure.
of his or her job functions. The terms are often 2. Simulation Tests These tests should not be uncomfortable.
incorrectly used interchangeably. Disability Axial loading reproduction of low back pain
may be partial or total as well as temporary with vertical pressure on the skull.
or permanent. Disability determinations help Rotation reproduction of back pain when
establish the amount of ongoing financial shoulders and pelvis are passively rotated in
compensation received during periods of the same plane.
disability. The amount is usually a percentage 3. Distraction Tests Findings that are present during physical exam-
of the regular salary. ination and disappear at other times, particu-
Apportionment A term referring to the relative contribution of larly while the patient is distracted.
different factors to overall disability. This ap- 4. Regional Findings inconsistent with neuroanatomy.
plies in cases of either underlying illnesses or Disturbances Motor nonanatomic voluntary release or
prior injuries that make the current disability unexplained giving way of muscle groups.
materially and substantially greater than it Sensory nondermatomal sensory abnormali-
would otherwise be. Both treating and inde- ties.
pendent medical physicians are often asked 5. Overreaction Disproportionate verbal or physical reactions.
to assign fixed percentages to the relative
contributing factors.
Loss of use Usually refers to a permanent relatively static
loss of function, usually of an extremity. This is The occupational descriptions should include a list of
a distinct category from disability. In certain the specific activities performed for each job, as well as
states, loss of use determinations are used to their frequency and duration. It is also important to
help determine the appropriate lump sum note any recreational activity involving significant phys-
settlement necessary to settle a case. ical exertion. Obviously, any history of other claims as
Maximal medical The point at which no further recovery from an well as nonwork-related injuries or illnesses should be
improvement injury or illness is expected. documented.
the employers insurance carrier employs the casework- Does This Exist and Is It an Epidemic?
ers, it also is possible that bias can be introduced into There is little doubt that CTDs exist, but that does not
the system. mean that they are easy to describe or quantify. If a
body is exposed to repetitive force over time, given
enough repetitions the body will show signs of wear.
Many CTDs have multifactorial causes and represent
Cumulative Trauma Disorders and Ergonomics changes that may have occurred over a significant time
What is the Concept? period. Controversy exists because an immediate cause
Cumulative trauma disorders (CTDs) is a term applying and ultimate responsibility for CTDs can therefore be
to health disorders arising from repetitive biomechani- hard to determine.
cal stress. A discussion of ergonomics is central to this With carpal tunnel syndrome, for example, there is
topic. Ergonomics is a relatively recent word, dating to support in the literature for the role of extreme wrist
approximately 1945, defined as a branch of ecology per- position and vibration exposure in the development of
taining to human factors in machine design and opera- the condition, both of which are potential occupational
tion as well as the physical environment. The Occupa- causes. Many nonoccupational causes exist, including
tional Safety and Health Administrations (OSHA) gender, obesity, tobacco use, and diabetes. Therefore, it
current definitions of ergonomics listed on their website is difficult to ascribe causation to one particular factor.
include both the science of fitting the job to the worker The situation is similar with other CTDs. This issue is
and the practice of designing equipment and tasks con- paramount in workers compensation because causation
forming to workers capabilities. plays a key role in who ultimately pays for care.
The Occupational Safety and Health Act of 1970 Further epidemiologic study is necessary to estimate
states that it is the employers responsibility to provide relative causation in diseases with more than one risk
a workplace free from serious hazards. This includes the factor and ergonomic intervention needs to be preferen-
tially directed toward high-risk groups. High-risk groups
prevention of ergonomic hazards. To meet these goals,
include patients with multiple claims, multiple medical
OSHA has developed a series of manuals and programs
problems, and prolonged absence from work.
to help employers meet workers ergonomic needs that
include a generalized framework of health and safety
programs as well as guidelines for specific industries. Legal Issues in Occupational Medicine
These guidelines have been developed with the assis- Workers compensation is generally set up as a no-fault
system. As such, employers are legally shielded from be-
tance of the National Institute for Occupational Safety
ing sued for negligence. Many of the legal issues focus
and Health, current scientific information, the medical
therefore on causal relationship, degree of ongoing dis-
literature, and OSHAs own enforcement experience.
ability, and ultimate disability settlement.
Specifically, the guidelines include a process for pro-
Causal relationship is the key factor that determines
tecting workers as well as a means of identifying specific who pays for care. The clinician must be careful to docu-
problems and implementing solutions. There are also ment any evidence of a presumed causally-related ill-
sections on task-specific training. Appropriately, most of ness or injury. It is also important to document any his-
the focus is on prevention. tory of prior illnesses and injuries, especially any that
CTDs refer to disorders from trauma occurring over resulted in missed work. Patients recreational and other
time, rather than from one specific incident. In the early nonoccupational activities need to be carefully noted.
1990s there was a significant increase in the reporting of The duration and relative number of repetitions of both
CTDs. According to the Bureau of Labor, statistics from work and nonwork activities should be dutifully re-
that time show that CTDs represented half of the occu- corded. If there is any possible evidence that an injury is
pational illnesses reported in their annual survey. The not causally related, an insurance carrier is likely to at-
very term cumulative trauma disorder is fraught with tempt to avoid payment for the condition. Direct com-
controversy because it implies a level of a presumed munication with the insurance adjuster can sometimes
knowledge regarding the etiology of certain conditions, help expedite care decisions.
which does not necessarily exist. OSHA literature now
uses the less specific and therefore more benign term Assignment of Disability
musculoskeletal disorders. OSHA manuals mention low Disability Rating
back pain, sciatica, rotator cuff injuries, epicondylitis, Because disability is not a medical term, disability rating
and carpal tunnel syndrome as common musculoskeletal is not based solely on medical factors. Disability can be
disorders, conceding that more needs to be learned partial or total as well as temporary or permanent. Cer-
about the connection between the workplace and these tain states publish guidelines giving criteria for types of
disorders. partial disability. Ultimately, the physician makes a
somewhat arbitrary determination of whether or not the One area of recent controversy has been docu-
patient is capable of performing his or her job and to mented reports of insurance companies altering reports
what degree. Administrative panels or workers com- as well as requesting specific opinions and wording from
pensation judges often settle disputes and make final the examining physician. Presumably because of this, the
determinations. state of New York recently changed regulations regard-
Disputes can arise between worker and employer ing reports, specifying that they can only be issued after
over the issue of partial disability. Insurance carriers of- being read and signed by the examining physician.
ten urge physicians to state that patients are available The certification process for qualified medical exam-
for light duty and thus not totally disabled. Unfortu- iners is an evolving process and varies considerably
nately, they often make these urgings in the absence of from state to state. In the state of New York, laws have
firsthand knowledge regarding the workplace and the recently changed requiring that examining physicians be
availability of specific types of light duty. Another prob- board certified. Ironically, there is no such requirement
lem with so-called light duty designations is that they of treating physicians, allowing the possibility that a sur-
are often not job-specific and only provide simple lifting geon may legally operate on compensation patients, but
and time restrictions. Caseworker jobsite visits and com- not be able to render independent opinions.
munication with the physician, patient, and employer In addition to orthopaedic board certification, there
can help resolve some of these issues. are other types of certification such as those by the
board of disability examiners, which enable physician
Role and Certification of the Qualified credentialing, and courses on occupational orthopaedics
Medical Examiner and workers compensation.
The theoretical role of the qualified medical examiner is
to provide an independent opinion regarding the pa- Return to Work Strategies
tients illness or injury as well as the care they have re- The Maximal Medical Improvement Concept
ceived. These are most commonly requested and paid As stated earlier, maximal medical improvement is the
for by the employers insurance carrier. The typical as-
point at which no further improvement is generally ex-
sessment usually includes a history of present illness,
pected. When this occurs, the patient is evaluated to de-
past medical and surgical history, occupational and so-
termine if there is any permanent impairment. In cases
cial history, record review, physical examination, and the
of permanent impairment, a final settlement is made.
formulation of an opinion. Examiners are usually asked
Different criteria exist for establishing these settle-
to comment on specific issues requested by the carrier
ments, which can be grouped into three main categories:
and not to offer unsolicited opinions. Commonly, opin-
functional, anatomic, and diagnostic.
ions are requested regarding diagnosis, causal relation-
The functional impairment system is based on what
ship, treatment to date, further treatment recommenda-
tions, and degree of disability. In certain instances where effect the impairment has had on the ability to work.
there have been prior injuries or underlying illnesses, The anatomic system is based on the loss of a body part.
examiners may comment on apportionment. An amputation is a 100% loss; lesser injuries are quanti-
The IME is often a rate-limiting step of workers fied via mobility, sensibility, and strength measurements
compensation care. Insurance adjusters commonly as compared with normal findings. The diagnostic sys-
refuse to authorize diagnostic testing as well as both sur- tem is based on the diagnosis code. All of these tech-
gical and nonsurgical care without a concurring inde- niques are incorporated into the Fifth Edition of the
pendent opinion. If the treating and independent opin- American Medical Association Guides to the Evaluation
ions differ, a compensation judge or administrative of Permanent Impairment.
panel often has to settle the dispute. These steps can de- Generally, most states rely on some form of the ana-
lay care for many months. tomic system to determine final settlement sums. The
There continues to be a lack of consensus regarding state of New York divides final determinations into loss
how to manage workers compensation claims. Typically of use and disability. In static cases of extremity injuries
and predictably, the more say patients have in their care in which patients are not completely disabled and fur-
the more satisfied they are with the outcome. However, ther dramatic deterioration in function is not expected,
this does not consistently result in measurable outcome a percentage loss of use is determined based on the in-
differences. The prevailing fear against allowing more volved body part. The award is then based on that per-
patient and physician autonomy is that costs will rise. centage as well as the occupation and income level of
However, experience has thus far not borne out this the injured worker.
fear. In fact, there has been evidence that increased us- Patients with neck and back problems as well as ex-
age of musculoskeletal specialists tends to decrease tremity injuries involving ongoing significant disability,
overall costs. Additional prospective study is necessary. particularly where further deterioration is expected,
may be classified as permanently disabled on either a This article studies the effect of using visiting musculoskel-
partial or total basis. etal specialists to assist primary care physicians. Claim costs
Wisconsin uses a modification of the no-fault system. were significantly lower in this system than in a typical work-
Awards can be increased or decreased in cases of unsafe ers compensation managed care model.
work places and unsafe work practices, respectively.
Minnesota is one of the only states to rely on diag- Bernacki EJ, Tsai SP: Ten years experience using an in-
nosis codes to determine impairment, whereas Califor- tegrated workers compensation management system to
nia is one of the only states to rely on functional deter- control workers compensation costs. J Occup Environ
mination. Regardless of the system, one must remain Med 2003;45:508-516.
This article examines the positive effect of an integrative
cognizant of the distinction between disability and im-
approach to managing workers compensation claims. It pre-
pairment and make a determination based on the guide-
sents 10 years of experience using a small group of health care
lines of the particular system.
providers who address both physical and psychological needs.
It also illustrates the importance of maintaining open lines of
Work Hardening: How Does This Work? communication between all involved parties.
Work hardening is an intermediate step between ther-
apy and return to work. It has evolved over the past two
Durand MJ, Loisel P, Hong QN, Charpentier N: Helping
decades as an outgrowth of traditional rehabilitation. A
clinicians in work disability prevention: The work dis-
work-like environment is created for the recovering ability diagnosis interview. J Occup Rehabil 2002;12:191-
worker, who is then able to build both physical stamina 204.
and psychological confidence by replicating work activi- This article illuminates the multifactorial nature of muscu-
ties in a controlled environment. loskeletal disorders. It describes the development of a work
In this unique setting, the therapist provides disability diagnosis interview as a means of helping detect
occupation-specific ergonomic instruction, hopefully prognostic factors in musculoskeletal pain patients.
minimizing risk factors for re-injury upon return to
work. Although additional prospective controlled effi- Gross DP, Battie MC: Reliability of safe maximum lift-
cacy studies of work hardening would be helpful, there ing determinations of a functional capacity evaluation.
already exists significant documented evidence of its Phys Ther 2002;82:264-271.
benefits. Functional capacity evaluations are evaluated for both in-
terrater and test-retest reliability. Overall, functional capacity
evaluations demonstrated excellent interrater and good test-
Summary
retest reproducibility. The greatest source of variability was in-
The intent of the workers compensation system is ad-
consistent patient performance.
mirable, namely treating and compensating workers for
work-related injuries. Ultimately that intent is usually
realized. Most of the patient and physician dissatisfac- Harper JD: Determining foot and ankle impairments by
tion with the system stems from the mode and timing of the AMA Fifth Edition guides. Foot Ankle Clin 2002;7:
291-303.
rendered care. Unfortunately, most state systems are
This article describes how to determine impairments based
cumbersome with multiple layers of administration, on the American Medical Association Fifth Edition guide. It
leading simultaneously to delayed care delivery and in- offers a good discussion of the different techniques of deter-
creased overall costs. mining impairment and the difficulty of accounting for pain as
Several states have experimented with different part of this determination.
models of administered care. Successful strategies in-
clude more integrated care, increased physician auton- Lincoln AE, Feuerstein M, Shaw WS: MillerVI: Impact
omy, increased specialist involvement, and use of well- of case manager training on worksite accommodations
trained case managers. Additional study is necessary. in workers compensation claimants with upper extrem-
Hopefully, in the coming years, some of these strategies ity disorders. J Occup Environ Med 2002;44:237-245.
can be implemented on a larger scale. This is a case control study that illustrates the effect of a
two-day training course on the ability of nurse case managers
Annotated Bibliography to design and implement workplace changes. The trained
nurses offered more specific accommodations and modifica-
tions whereas the untrained nurses more often recommended
Atcheson SG, Brunner RL, Greenwald EJ, Rivera VG,
light duty and lifting restrictions.
Cox JC, Bigos SJ: Paying doctors more: Use of muscu-
loskeletal specialists and increased physicians pay to de-
crease workers compensation cost. J Occup Environ Schonstein E, Kenny DT, Keating J, Koes BW: Work
Med 2001;43:672-679. conditioning, work hardening and functional restoration
for workers with back and neck pain, Cochrane Data- Classic Bibliography
base System Review (on CD-ROM). 2003;(1)
CD001822. Cocchiarella L, Anderson GBJ (eds): Guides to the
This article compares the effectiveness of management Evaluation of Permanent Impairment, ed 5. Chicago, IL,
strategies for return to work in patients with back and neck American Medical Association, 2000.
pain. Patients with chronic back pain benefited from physical
conditioning, even when non-job specific, having a reduced Creighton J: Workers compensation and job disability,
number of sick days compared with patients who did not un- in Peimer CA (ed): Surgery of the Hand and Upper Ex-
dergo physical conditioning. tremity. McGraw Hill, 1996, pp 2345-2351.
Figure 1 Sample preparticipation examination health questionnaire. (Reproduced with permission from Fields KB: Preparticipation evaluation of the school athlete, in Rich-
mond JC, Shahaday EJ, Fields KB (eds): Sports Medicine for Primary Care. Ann Arbor, MI, Blackwell Science, 1996, p 68.)
Table 1 | Classification of Sports by Contact Table 2 | Medical Conditions Affecting Sports Participation
Contact Noncontact Conditions Requiring Clearance Before Sports Participation
Collision/Contact Limited Contact Strenuous Nonstrenuous
Atlantoaxial instability
Basketball Baseball Dancing Archery Hypertension
Field hockey Cycling Discus Bowling Dysrhythmia
Football Diving Javelin Golf Heart murmur/valvular heart disease
Ice hockey Fencing Shot put Rifle
Diabetes mellitus
Lacrosse Field Rowing
Martial arts High jump Running/Cross Heat illness history
Soccer Pole vault country Hepatomegaly, splenomegaly
Water polo Gymnastics Strength training History of repeated concussion
Wrestling Raquetball Swimming Asthma
Skating Tennis Absent/undescended testicle
Skiing Track One-eyed athletes or athletes with vision < 20/40 in one eye
Softball
Volleyball Bleeding diathesis
Congenital heart disease
Seizure disorder
Febrile illness
general health problems such as obesity and hyperten-
Eating disorders
sion should quickly be identified. Multiple studies have
One-kidney athletes
directly linked increased body mass indices with in-
creased morbidity and mortality rates. Recent, stricter Malignancy
blood pressure screening guidelines established for the Organ transplant recipient
general public will no doubt affect preparticipation ex- Obesity
aminations as well. Dermatologic disorder
The role of screening tests in the routine medical
evaluation of athletes remains unproven. Many studies,
looking at long-term benefits of screening modalities
such as electrocardiograms, echocardiograms, or even ment of a conditioning program. Whether it be sport-
urinalysis and chemistry screening profiles, have repeat- specific or for general overall fitness, concepts such as
edly failed to show any clear benefit. Thus, at this time specificity, prioritization, periodization, and work over-
these screening tests cannot be universally recom- load need to be addressed. Also, it needs to be under-
mended unless specifically indicated by the history or stood that conditioning and readiness is a combined
physical examination. product of overall general fitness, sport-specific fitness,
Clearance for participation and fitness assessment is and skills specific to the individual sport. Becoming fa-
dependent on the preparticipation physical examina- miliar with calculation of workloads for the purpose of
tion. The results of the examination then must be evalu- outlining a conditioning and fitness program using heart
ated in conjunction with the specific demands of the rates and metabolic measurements such as maximum
sport before a final determination on clearance for par- oxygen consumption (MVO2) can be useful as well.
ticipation can be made. Sport-specific requirements such Conditioning specificity refers to the unique condi-
as degree of exertion, degree of contact, agility, and en- tioning demands of an individual sport and the neces-
vironmental influences play a role in determining eligi- sary adjustments an athlete has to make to accommo-
bility (Tables 1 and 2). date those demands. Each sport has differences in
The team physician must be skilled and knowledge- muscle groups needed, aerobic capacity, flexibility, envi-
able about acting on any clearance recommendations. A ronmental and even psychological factors. Thus, the spe-
willingness to clearly communicate and document the cifics of a conditioning program are adjusted to meet
results of the preparticipation evaluation with the ath- these particular demands.
lete must be established. It is preferable that the exam- Prioritization refers to different levels of emphasis
ining physician coordinate any follow-up required to placed on certain components of a conditioning pro-
complete or change the clearance determination. gram based on the athletes preference with varying lev-
els of input from coaches, trainers, and ultimately, physi-
Conditioning and Preparation cians. Basketball players looking to improve their
Several basic principles of conditioning must be under- jumping ability may prioritize lower extremity strength-
stood to provide medical consultation in the develop- ening and agility training much in the same way a base-
ball pitcher may emphasize upper extremity and arm bility is the ability of joints and particular muscle groups
flexibility workouts. to maximize their natural range of motion without com-
Periodization refers to a planned variation in inten- promising strength and endurance. Certainly flexibility
sity and duration of a specific workout over a pre- can vary from athlete to athlete. Thus, no set standard
defined duration of time. A distance runner training for can be developed for outlining a flexibility program. A
an upcoming marathon uses periodization as a condi- large body of evidence suggests that improved flexibility
tioning method by changing the length in miles and in- decreases risk for injury although few data exist to im-
tensity measured in speed at each training session be- ply improved performance.
fore competition. The ultimate goal of periodization is In contrast to flexibility, specific standards and
obtaining maximal performance based on the concept of guidelines can be developed for both aerobic capacity
progressive overload, one at which conditioning is and strength training. For aerobic training, three meth-
started at moderate tolerable levels of exertion and pro- ods are preferred to establish training guidelines. The
gressively pushed to maximum exertion. Multiple stud- first, which is relatively easy to calculate, uses the maxi-
ies have demonstrated this method of conditioning is su- mum heart rate as a predictor of intensity. The sug-
perior to training techniques in which intensity and gested intensity level is expressed as a percentage of the
duration of training are kept constant over a given pe- maximal predicted HR. The target HR for conditioning
riod of time. Periodization cycles are defined by length should be 60% to 90% of the maximum HR. A more
of time and are referred to as macrocycles, mesocycles, highly competitive athlete would aim for a larger per-
or microcycles. Macrocycles generally refer to an entire centage of the maximum rate, whereas the daily jogger
training year (season to season), mesocycles 3 to trying to stay in shape may use a lower percentage. For
6 months, and microcycles 3 to 6 weeks. Multiple vari- example, a 40-year-old recreational jogger may use 75%
ables can be adjusted during a periodization cycle in ad- of his maximum HR to calculate his target HR. Calcula-
dition to intensity and duration of a conditioning work- tion of the maximum predicted HR is done by subtract-
out. They can include variations in types of exercises, ing his age from 220. In this instance it would be 180
number of repetitions of individual exercises, or length beats per minute (bpm); 180 is then multiplied by 0.75
of rest periods between exercises. for a product of 135, which now becomes a projected
Conditioning can be further defined as a product of target HR of 135 bpm. The second method requires a
aerobic capacity, strength, and flexibility. Aerobic capac- few simple calculations. First, the maximal predicted HR
ity cannot only be subjectively measured by perfor- is established (example: age 40; 220 40 = 180 bpm HR
mance, but also objectively by measurement of the maximum). Next, the HR reserve is calculated by sub-
MVO2 or VO2max, referred to as maximum oxygen up- tracting the resting HR from the maximal predicted
take. MVO2 represents the maximum oxygen-carrying HR. The HR reserve is then multiplied by an intensity
capacity of the oxygen transport system, which drives factor based on an individual athletes goals and level of
adenosine triphosphate (ATP) synthesis during aerobic conditioning. A beginner should use an intensity factor
metabolism. The oxygen transport system allows tissue in the range of 50% to 65% of HR reserve. A moderate
to extract oxygen from oxygenated blood and synthesize conditioned or recreational athlete should use 65% to
ATP for energy for muscle activity. A very efficient sys- 75% of HR reserve. Finally, a highly conditioned athlete
tem allows for maximum performance. The MVO2 is de- trying to maximize aerobic capacity for competition
fined as the product of heart rate (HR), stroke volume uses 75% to 85% of HR reserve. The product of the HR
(SV), and the difference between arterial and mixed reserve and intensity factor (example: HR reserve 140
venous oxygen concentrations (a VO2), or: MVO2 = 0.70 for a recreational athlete) is then added to the rest-
HR SV a VO2. ing HR to calculate the target exercise HR.
HR times SV is referred to as the cardiac output, A third method, which requires direct measurement
whereas SV is the difference in left ventricular volume of MVO2 via calorimetry during maximal exercise stress
between end diastole and end systole. Routine measure- testing, is less practical but ultimately more accurate
ment of MVO2 is not practical because it requires the than the second method. Similar to the HR method, the
use of a calorimeter, which may not be readily available. oximetry method establishes the target as a percentage
Strength is an integral component to overall condi- of the MVO2 obtained during maximum exercise testing.
tioning and fitness and is defined as the ability of a par- Similar intensity factors are used as guidelines for these
ticular muscle or muscle group to perform work. Al- percentages. For example, an elite athlete should target
though specific strength training programs are beyond 75% to 85% of the MVO2 as his conditioning intensity
the scope of this chapter, the concepts mentioned earlier whereas an intermediate or novice athlete would target
of specificity, periodization, and progressive work over- ranges from 65% to 75% and 55% to 65%, respectively.
load all apply here as well. A relationship can then be established between heart
Flexibility training and development represents the rate and VO2 during exercise testing to determine a tar-
final component of a total conditioning program. Flexi- get HR for training.
Much in the way HR or MVO2 are central to devel- competition, and involves review of the athletes pro-
oping guidelines for aerobic training, the repetition posed competition schedule.
maximum (RM) can be used for developing strength- Medical care of the athlete involves coordination of
training guidelines. The repetition maximum, or 1-RM, administrative duties such as establishment and docu-
is defined as the maximum amount of weight or resis- mentation of an emergency response plan for the seri-
tance that can be lifted for one repetition. An RM also ously ill or injured competitor. Additionally, a policy to
refers to a specific number of repetitions limited by a assess playing condition and environmental factors at
particular weight or resistance. For example, a weight the time of competition must be established, and a pro-
that can be lifted 10 times until fatigue would be 10- tocol involving administrators, competition officials,
RM. A preferable utilization of the RM allows the pre- coaches, and staff to make an educated decision regard-
scriber to establish an RM training zone based on the ing safe competition conditions should be clearly delin-
target goal of strength training. A training zone is usu- eated. Finally, medical record keeping is essential in the
ally a range of three RMs (eg, 8 to 10 RM), which re- care of athletes and preseason planning should ensure
duces the need to exercise to fatigue with each set. that this takes place.
The concept of specificity mentioned earlier can be Game-day preparations and operations involve the
applied to strength training based on the goals and de- assessment and management of game-day injuries and
mands of an individual athletes sport. Four common illnesses and final determinations on clearance for par-
variables may be adjusted within the training program ticipation. A review of game-time playing conditions is
to achieve target goals. The RM, number of repetitions, conducted according to the established preseason policy
number of sets, and rest period between sets can all be and any concerns should be promptly brought to the at-
adjusted to optimize power, strength, and endurance. tention of coaches, officials, and relevant staff. A well-
Exercises focusing on improvements in power use lower prepared medical staff also needs to be familiar with
RMs (ie, higher weights or resistance), fewer numbers medical equipment and examination and treatment fa-
of repetitions, higher numbers of sets, and longer recov- cilities available. When traveling, game-time review of
ery times between sets. In contrast, training focusing on locations of examination areas, x-ray equipment, ambu-
lances, and local hospitals with the hometown medical
muscular endurance uses higher RMs (ie, lower weights
staff is essential to ensure a quick and efficient response
or resistance), much higher number of repetitions, fewer
to any athletic injuries. The team physician also needs to
number of sets and less recovery time in between sets.
have a clear vantage point of the competition and easy
Strength training uses lower RMs than does power and
access to the athletes competing. Return to competition
endurance training with repetition numbers, set num-
decisions are a part of the game-day responsibilities.
bers, and recovery times being similar to that of power
Evaluation of concussions, soft-tissue injuries, and eye
training.
trauma are a few examples where return to play deci-
sions are made by the team physician during competi-
Sideline Medicine tion. Game-day assessment also requires a postcompeti-
Sideline medicine is a phrase used to refer to the team tion review of all injuries and illnesses that have
physicians approach to handling game-time injuries and developed and an action plan to ensure necessary
illnesses and developing a well-documented and orga- follow-up. The postcompetition assessment should in-
nized plan for implementation at the site of competition volve the team physician, trainers, coaches, and relevant
and practices. From a consensus statement released in administrators.
2001 regarding sideline preparedness for the team phy- The postseason evaluation involves a comprehensive
sician, the definition of sideline medicine is the identifi- summary of all athletic injuries and illnesses acquired
cation of and planning for medical services to promote during competition. It provides a good opportunity to
the safety of the athlete. Goals are to limit injury and collect data and identify trends during recent competi-
provide medical care at the site of competition. In addi- tion. It also is the time for the team physician to coordi-
tion, sideline medicine deals with three integrated as- nate appropriate follow-up during the off-season.
pects of athletic competition: preseason planning, game-
day operations, and postseason evaluation. Dehydration and Heat Syndromes
Preseason planning involves the use of the prepartic- Dehydration is a loss of all body water caused by de-
ipation evaluation to identify potential problems during creased intake or increased losses by evaporation and
the season. The team physician must have access to any excretion. Prolonged dehydration can lead to tissue dys-
prior relevant health information before determining el- function and eventual hemodynamic collapse as the cir-
igibility for participation. Timely completion of the culating intravascular volume drops to a critical level
preparticipation evaluation is advantageous because it sufficient to lower cardiac output. As cardiac output de-
allows treatment or follow-up to be initiated before creases, so does blood supply to the skin, resulting in de-
Table 3 | Participants at Risk for Dehydration/Heatstroke Table 4 | Total Body Water/Na+ Deficit Calculations
General Calculation of Total Body Water
Poorly acclimated or inexperienced competitors Deficit Calculation of Na+ Deficit
TBW = 0.6 (wt in kg) x ( 140 1)
[Na+]
Obese or poorly conditioned Meq Na+ deficit = 0.6 (wt in kg)
Elderly (140 [Na+]) + (140) x (vol def in
Prior history of dehydration/heatstroke L)
Medication Usage
Antihistamines TBW = total body water; [Na+] = measured serum sodium concentration (mEq/L)
Anticholinergics
Diuretics
Neuroleptics
Illness Table 5 | Clinical Estimates of Degree of Dehydration
Acute febrile illness
Recent vomiting or diarrhea % Dehydration (% wt) Clinical Signs/Symptoms
Uncontrolled systemic condition (for example, diabetes mellitus or
hypertension) 3% to 5% (Mild to Moderate) Orthostasis
Thirst
Decreased voiding
Dry mucous membranes
creased heat dissipation and a subsequent rise in core Reduced skin turgor
body temperature. At extremes of dehydration, sweating Dry axillary folds
mechanisms cease in an attempt to preserve intravascu- 8% to 10% (Moderate to Severe) All of the above plus:
lar volume. This in turn can lead to further increases in Supine hypotension
core body temperature, which left unchecked can be fa- Lethargy
tal. As little as a 1% drop in total body water has been Tachycardia
shown to affect performance. Tachypnea
Athletes are particularly at risk for dehydration and 12% to 15% (Severe) Hemodynamic collapse
heat illnesses based on the increased demands of com-
petition. It is not unusual for competitive athletes to
lose as much as 1 to 2 L of sweat per hour with vigor- creases in serum sodium levels can produce fatigue, leth-
ous, intense exercise. Athletic participants at risk for de- argy, weakness, confusion, and even hemodynamic col-
hydration and heatstroke are outlined in Table 3. lapse and death. Salt loading is not recommended
Aggressive volume replacement is essential during because of the plasma hypertonicity it may produce. Ta-
exercise. Rehydration also requires electrolyte replace- bles 4 through 7 serve as a brief guide for fluid and elec-
ment in addition to volume. Although electrolyte con- trolyte replacement.
centrations are highly variable, sodium is the cation ex- Thirst is a poor indicator of hydration status in hu-
creted in the highest concentration, with lower mans and should not be used alone as a guide for vol-
concentrations of potassium usually found. Both elec- ume replacement. Measurement of the weight of the
trolytes should be replaced, although the necessity is athlete while unclothed, both before and after competi-
lessened in low-intensity or short-duration exercise and tion, is an excellent way to monitor fluid losses. Hydra-
in those who consume a normal diet. At least 16 oz of tion before, during, and after exercise should be empha-
fluid supplemented with sodium and potassium should sized.
be ingested for every pound of weight lost with exercise.
Hypotonic salt, or isotonic, carbohydrate supplemented
beverages referred to as sports drinks are effective re-
Overuse Injuries
Overuse injuries refer to musculoskeletal maladies that
hydration solutions for palatability and rapid effective
develop as a result of environmental, biomechanical,
absorption. The presence of increased ingested sodium
and equipment factors. They involve one of the follow-
and glucose in the intestinal lumen promotes their
cotransport for absorption in the small intestine. This ac- ing anatomic structures: bursae, tendons, bones, joints,
tive transport creates an osmotic gradient that enhances and ligaments. Overuse injuries are often classified into
net water absorption by passive mechanisms. Plain wa- four stages based on degree of pain. Stage 1 is mild pain
ter ingestion can be effective for maintaining hydration, that develops only after activity. Stage 2 is moderate
but rehydration after exercise can be slowed by the pain that occurs during activity but does not restrict or
drop in serum osmolality it may create. If allowed to interfere with performance. Stage 3 is moderate to se-
progress, replacement of sweat losses with hypotonic vere pain that interferes with performance. Stage 4 is
fluid (water) leads to hyponatremia. Significant de- the most severe form of an overuse injury with signifi-
NSAIDs = nonsteroidal anti-inflammatory drugs; PT = physical therapy; ECSWT = extracorporeal shock wave therapy
of intermediate intensity most days of the week com- history is often central to the development of menstrual
bined with strength and flexibility exercises is essential to irregularities. Menstrual dysfunction is believed to be
the health of the postmenopausal athlete. Improvements caused by a lack of a pulsatile release of gonadotropin-
in bone density measurements, lipid profiles, body mass releasing hormone from the hypothalamus, which in
indices, and sleep quality, all problematic in postmeno- turn leads to diminished release of luteinizing and
pausal females, are well established with regular condi- follicle-stimulating hormone from the anterior pituitary
tioning. gland. The exact cause of diminished gonadotropin-
The female athlete triad consists of abnormal bone releasing hormone release is unclear but the role of cir-
metabolism, disordered eating, and abnormal menstrual culating -endorphins, cortisol, catecholamines, melato-
function. The exact incidence of the disorder is unknown nin, and androgens are all currently under investigation.
but several recent studies suggest that it may be as high Treatment options include optimizing diet and nutri-
as 12% of all competitive female athletes. Prevalence tional status, exercise intensity modification, and hor-
rates differ among individual components of the triad ex- mone therapy.
isting independently and also differ among individual Eating disorders encompass everything from restric-
sports. A prevalence rate of nearly 50% for menstrual tion before competition to frank starvation or binging
dysfunction has been reported in some distance runners and purging, referred to as anorexia nervosa and bu-
compared with a general prevalence rate of 2% to 5%. limia nervosa, respectively. Signs and symptoms include
Menstrual dysfunction comprises an entire spectrum a characteristically thin body habitus, thin hair and hir-
of irregularity of menstruation. From delayed onset of sute features, parotid gland hypertrophy, dental caries,
menarche, defined as onset of menses after age 16 years, subconjunctival hemorrhages, scarring on the dorsum of
to complete amenorrhea, defined as the absence of 3 to the hands, and rectal tears. Treatment depends on the
12 consecutive menstrual periods in the absence of severity of the condition and often involves a multispe-
pregnancy, to oligomenorrhea (irregular, infrequent cialty approach including physicians, mental health spe-
menses), menstrual dysfunction is common in the fe- cialists, and nutritionists. The exact prevalence of eating
male athlete. Females at risk tend to be younger, nullip- disorders among female athletes is unknown.
arous, have lower body weights, and are involved with Regular exercise in females leads to increased bone
more strenuous, high-intensity sports. A poor dietary density by increasing mechanical stress on bone. A low
estrogen state seen with delayed or infrequent me- contribute to abnormal patellar tracking. A wider pelvis
narche, as is the case with the female triad, leads to poor and increased Q angles have also been proposed as pos-
primary bone mass accumulation and the early develop- sible etiologic factors. A propensity for plantar flexion
ment of osteoporosis. If allowed to continue, the hy- leading to internal torsion of the tibia and femur accen-
poestrogenic state promotes premature bone resorption, tuates lateral patellar tracking and is also believed to be
further compounding the problem. Combined with poor a contributing factor. Treatment consists of biomechani-
nutrition status, in particular a deficiency in calcium and cal modification and physical therapy modalities.
vitamin D, the rate of bone loss can be startling. Several
studies have recorded bone densities of female athletes
in their 20s that were comparable to those of females in
Annotated Bibliography
their 60s and 70s. Preparticipation Examination
Although not exclusive to female athletes, several Chobanian AV, Bakris GL, Black HR, et al: The Seventh
common musculoskeletal athletic injuries are often seen Report of the Joint National Committee on Prevention,
in females. Two ligamentous injuries more commonly Detection, Evaluation, and Treatment of High Blood
seen in females include ankle sprains (particularly ante- Pressure: The JNC 7 report. JAMA 2003;289:2560-2572.
rior talofibular) and anterior cruciate sprains and com- This article presents new guidelines for hypertension man-
plete tears. Women are particularly vulnerable to ante- agement and prevention.
rior cruciate injuries but the exact cause is believed to
be multifactorial. Hormonally-mediated ligamentous hy- Carek PJ, Hunter L: The preparticipation physical exam-
perlaxity, decreased ligament size, and a narrowed inter- ination for athletics: A critical review of current recom-
condylar notch have all been proposed as possible etio- mendations. J Med Liban 2001;49:292-297.
logic factors. Ankle sprains seem to be more easily A critical review of current recommendations for the
explained because of the relatively reduced stability of preparticipation examination is presented.
the talus from an inflexible heel cord and the propensity
of the female foot to favor a plantar-flexed position.
Seto CK: Preparticipation cardiovascular screening. Clin
Lateral epicondylitis and rotator cuff tendinitis tend
Sports Med 2003;22:23-35.
to be more prevalent in females, who are believed to be
This review article advocates the standardization of the
more susceptible to these injuries because of postural
preparticipation examination.
differences produced by strength deficiencies and soft-
tissue laxity.
Overuse injuries of bone, particularly stress frac- Conditioning and Preparation
tures, are more commonly encountered in females who American Academy of Family Physicians, American
comprise the classic triad. Healthy female athletes also Academy of Orthopaedic Surgeons, American College
are at increased risk because of hormonal factors and of Sports Medicine, American Orthopaedic Society for
lower muscle to body mass ratios. Spondylolysis, a stress Sports Medicine, American Osteopathic Academy for
fracture to the pars interarticularis of the lumbar spine, Sports Medicine, American Medical Society for Sports
is also seen more frequently in female athletes. Medicine: The team physician and conditioning of ath-
Mechanical low back pain is ubiquitous among fe- letes for sports: A consensus statement. Med Sci Sports
males; the etiology is usually multifactorial. Two unique Exerc 2001;33:1789-1793.
sources of back pain among women are the aforemen- This article presents a governing body consensus state-
tioned spondylolysis and pelvic instability produced by ment on conditioning principles for athletes.
sacroiliac joint dysfunction. Hormonal and mechanical
(particularly the effects of childbirth) factors lead to in- Ebben WP, Blackard DO: Strength and conditioning
creased laxity among the ligamentous, muscular, and practices of National Football League strength and con-
joint structures that comprise the pelvic ring. This in- ditioning coaches. J Strength Cond Res 2001;15:48-58.
creased laxity leads to a propensity for subluxation, par- A review of conditioning practices in the National Foot-
ticularly anteriorly, that leads to pelvic ring asymmetry ball League reveals 69% of conditioning coaches follow a pe-
and subsequent back pain. riodization model.
Patellofemoral syndrome is another athletic injury
common in females. The athlete has anterior deep knee Kraemer WJ, Knuttgen HG: Strength training basics:
pain with varying degrees of swelling and pain that of- Designing workouts to meet patients goals. Phys Sports
ten is noted to be worsened by walking down steps. The Med 2003;31:39-45.
increased propensity in females is believed to be the re- Human power production capabilities and differences of
sult of increased ligamentous laxity leading to abnormal physiologic response to varying intensities of exercise are out-
lateral patellar tracking. A lack of flexibility and weak- lined.
ness of the hamstrings and vastus medialis obliquus also
Spine
Injuries to the spinal column should always be sought in
polytrauma patients. Occult spinal injuries may be over-
looked in patients with an altered level of conscious-
ness. Inadequate immobilization and excessive manipu-
lation may cause additional damage in a patient with
spinal injury and may worsen the outcome. In hemody-
namically unstable patients or patients with respiratory
difficulty, exclusion of spine injury may be deferred as
long as the patients spine is safely immobilized and
protected during the primary survey and initial care.
Moreover, maintaining tissue perfusion and oxygenation
will help stop progression of any existing cord injury.
The secondary spinal assessment should be performed
once life-threatening issues have been dealt with.The goal
of the secondary assessment is to identify and initially
manage neurologically and mechanically unstable spinal
injuries.
Log rolling the patient is essential for an adequate
spinal examination. The soft tissues should be assessed
for swelling, ecchymosis, wounds, deformity, or boggi-
ness. Spinous processes should be palpated individually
with particular emphasis placed on areas of tenderness.
A complete motor, sensory, and reflex examination
should be performed, including tests for perianal sensa-
tion, rectal sphincter tone, and bulbocavernosus reflex.
Serial examinations should be performed to document Figure 1 Radiograph of a patient who sustained multiple injuries during a head-on
motor vehicle accident. Cognitively impaired because of head injury and intoxication,
any progression of neurologic deficits. A neurologic def- the patient was combative, denied neck or extremity pain, and demanded release from
icit may be classified as complete, in which there is total the cervical collar. Cervical precautions were maintained through resuscitation, emer-
absence of motor or sensory function below the level of gent laparotomy, and multiple emergent studies. Definitive cervical radiographs dem-
onstrated grossly unstable three-column cervical dissociation. The patient was treated
injury, or incomplete. Identifying any distal motor or definitively during the secondary stabilization period, with no neurologic injury or im-
sensory sparing (incomplete injury) is essential, as these pairment.
patients warrant treatment on a more urgent basis.
Spinal shock refers to the flaccidity and loss of re-
A full radiographic spinal survey, including cervical,
flexes, specifically sacral reflexes, after spinal cord injury.
thoracic, and lumbosacral radiographs, is necessary in all
The return of these reflexes marks the end of spinal shock.
The diagnosis of a complete neurologic injury cannot be patients with a suspected spinal cord injury. Patients
made during spinal shock. with spinal cord injury at one level may have another
Neurogenic shock manifests itself through hypoten- injury at a noncontiguous level 5% to 20% of the time.
sion and bradycardia, and must be distinguished from car- Lateral cervical radiographs must show the cervicotho-
diogenic shock, which is characterized by hypotension and racic junction, or a lateral swimmers view or CT should
tachycardia. Neurogenic shock should be treated with ju- be obtained through this area. An AP odontoid view
dicious use of fluid resuscitation and vasopressors. Atro- should also be obtained. Although patients with persis-
pine may be useful to treat the bradycardia. tent pain despite normal radiographs may eventually
It is unlikely that an awake, alert, neurologically nor- benefit from flexion/extension views to identify liga-
mal patient without pain or tenderness along the spine mentous injury, there is rarely a role for flexion/
has any spinal injury. However, patients with an altered extension radiographs in the initial evaluation of the
level of consciousness (head injury, intoxication, hy- trauma patient.
poxia) need to have their normal radiographs corrobo- CT is useful in delineating the extent of bony inju-
rated via an adequate physical examination before neck ries detected on plain radiographs. MRI is useful in pa-
injury can be formally ruled out (Figure 1). tients with abnormal neurologic findings. In patients
with specific lesions such as facet dislocations and who Particular attention should be paid to open pelvic in-
are undergoing closed reduction, MRI should be done juries because they are associated with exceptional mor-
to rule out extruded disks that may cause neurologic bidity and mortality and will require emergent dbride-
damage during closed reduction. MRI is indicated in ment. Rectal and vaginal examinations must be
any patient with a progressive neurologic deficit, or a performed to rule out lacerations. Associated urologic
deficit that does not match the level of the recognized injuries should be sought. Clinical findings that may in-
spinal injury (C7 cord deficit in the face of a T10 burst dicate injury include blood at the urethral meatus, high-
fracture). riding prostate, or inability to pass a Foley catheter.
These patients will require retrograde urethrogram or
Pelvis cystogram, depending on the particular injury.
The primary survey of the pelvis involves mechanical The AP radiograph of the pelvis is used in correla-
assessment of stability and continuity: the physician tion with the physical examination to determine the sta-
quickly checks for fractures or disruption by medially bility of the pelvis. In a recent study, it was determined
compressing the iliac wings, applying an anterior- that physical examination was accurate in identifying in-
posterior stress through the ASIS, and by checking sta- juries of the posterior pelvic ring. Signs of instability in-
bility during hip range of motion. The secondary survey cluded more than 5 mm of displacement of the posterior
involves a more thorough history, physical examination, sacroiliac joint, the presence of a posterior fracture gap,
and analysis of an AP radiograph of the pelvis. and the presence of an avulsion fracture of the trans-
The history should determine the mechanism of in- verse process of the fifth lumbar vertebrae. Pelvic ring
jury. Higher energy injuries are more likely to be associ- injuries can be classified based on anatomic location,
mechanism, or stability. The mechanistic classification
ated with an increased severity of fracture. Pelvic frac-
can help predict blood loss and guide management. This
tures occur more frequently with lateral impact than
classification as defined by Young and Burgess divides
frontal impact. Patients on the side of impact are more
pelvic injuries into four mechanisms of injury: lateral
likely to have a severe injury.
compression, anteroposterior compression, vertical
Physical findings of pelvic injury may include scrotal/
shear, and combined mechanism. Inlet and outlet radio-
labial swelling, open lacerations in the perineum and va-
graphs as well as CT scan can help further clarify the
gina or rectum, associated urologic or neurologic inju-
degree of pelvic instability.
ries, or excessive internal/external rotation of the lower
Classification of these injuries can help guide defini-
extremity. Provocative maneuvers test the stability of
tive management. (1) The estimated blood loss for a se-
the pelvis to internal and external rotation of the hip.
vere lateral compression injury is approximately 3.6
The pelvis should move as a single unit. If a hemipelvis units whereas blood loss from an AP compression injury
moves separately, the ring is disrupted and the pelvis is is 14.8 units. (2) AP compression injuries have a higher
mechanically unstable. Once a pelvic injury is deter- mortality and a higher incidence of shock and ARDS
mined to be unstable, further manipulation that might than lateral compression fractures. (3) Moderate lateral
dislodge clots that have formed within the fracture compression injuries have a higher incidence of brain
should be avoided. injury, and vertical shear injuries also have a high inci-
Pelvic injuries can result in massive hemorrhage. In dence of associated injuries as well as mortality.
polytrauma patients, intrathoracic and intra-abdominal
injuries are common, causing or contributing to hemor- Lower Extremity Injuries
rhage and hypotension. Open wounds and long bone Femoral shaft fractures are high-energy injuries, usually
fractures such as femur fractures also contribute to occurring in the young patient population. Patients with
blood loss. Hypotension caused specifically by a pelvic bilateral fractures typically have a high ISS, higher mor-
injury is invariably associated with a mechanically un- tality, and higher risk of ARDS. Early treatment of
stable pelvis, and may prove difficult to control until the these injuries is important to survival and morbidity. An
pelvis is stabilized. unsplinted closed femur fracture can lose up to four
Early control of hemorrhage is crucial, in addition to units of blood into the thigh. Tibial fractures are associ-
staying ahead of volume requirements. Resuscitation of ated with severe soft-tissue and neurovascular trauma
a hypotensive patient may result in hypothermia and ac- that can render the extremity dysfunctional or even
idosis. These factors may contribute to coagulopathy, nonviable.
complicating the existing problem and leading to further Initial evaluation includes palpation of the entire ex-
bleeding. Persistent hypotension can aggravate pulmo- tremity to the foot and a thorough neurovascular exam-
nary and neurologic injury, and compromise renal, cere- ination. Assessment of soft-tissue injury should be done
bral, and cardiac function. In addition, the risk of sepsis, to rule out an open fracture. AP and lateral radiographs
adult respiratory distress syndrome (ARDS), and multi- should include the joints above and below the fracture.
ple organ failure is increased in these patients. Special attention should be paid to the ipsilateral hip to
trauma patients is far from proven. Several studies are Table 3 | Criteria for Adequate Resuscitation
available that suggest that other factors may be to
blame for the increase in complications seen among Hemodynamically stablewarm and well perfused
these more seriously injured patients. Although many Stable oxygen saturation
authors suggest that reamed intramedullary nailing is Lactate level < 2 mmol/L
the culprit, particularly in the face of pulmonary trauma No coagulopathy, INR < 1.25
and contusion, comparative studies have shown no dif- Normal body temperature
ference in the incidence of ARDS or mortality relative Urine output > 1 mL/kg/h
to that treatment. Similarly, the adequacy of early fluid Not requiring inotropic support
resuscitation has long been believed to influence the re-
covery of these severely injured patients. Finally, studies INR= International Normalized Ratio
of intramedullary fixation among severely injured pa-
tients have shown not only that the patients undergoing
nailing had no increased risk compared with patients
treated otherwise, but that, within these groups, the pa- ally straightforward and carries a low risk of infection
tients treated with immediate rodding had less pulmo- within the first week of treatment. These methods of de-
nary compromise and a lower incidence of ARDS than finitive fixation may be performed after the patient has
patients treated with intramedullary rodding on a de- achieved optimal medical status.
layed basis.
However, it may be inappropriate to attempt defini- Prioritizing Orthopaedic Care
tive procedures in some patients with severe chest Early and stable fracture fixation is of utmost impor-
trauma or hemodynamic instability. Damage control tance in the orthopaedic management of most poly-
principles are well applied in these circumstances. trauma patients. If initial long bone stabilization is de-
The first stage care of orthopaedic injuries consists layed the patient could be at risk for greater morbidity
of fracture and joint reduction, rapid skeletal stabiliza- and mortality. It is useful to prioritize the orthopaedic
tion, and control of hemorrhage. Wounds can generally problems of polytrauma patients with respect to four
be washed and superficially dbrided as the patient is relative periods for intervention, as described by
being resuscitated and ventilated, but procedures that Tscherne: (1) acute care (first 3 hours after injury);
generate more blood loss or tissue damage are avoided. (2) primary stabilization period (1 to 72 hours); (3) sec-
The second stage of damage control care focuses on ondary stabilization period (3 to 8 days after injury);
resuscitation and optimization of the patients medical and (4) tertiary stabilization or rehabilitation period (af-
status. This may require several days in an intensive care ter 6 to 8 days).
setting, but may also be accomplished over the course of
a few hours without the patient ever leaving the resusci- Acute Care
tation area or operating theater. The patients condition In the acute period, the primary survey and secondary
may be considered stable for definitive care whenever assessment and hemodynamic resuscitation are accom-
specific parameters are met (Table 3). The trauma team plished. Head, chest, abdomen, and pelvic injury are all
may find circumstances under which it is believed recognized and life-saving/limb-saving interventions are
worthwhile to push harder for stabilization of specific initiated. Significant epidural and subdural bleeding re-
injuries to mobilize the patient and obtain a vertical quires immediate evacuation. Once a hemothorax is di-
chest for improved ventilation and pulmonary toilet. agnosed, a chest tube drainage should be placed. If
Spinal and pelvic stabilization are sometimes afforded more than 1,500 mL of blood is obtained through the
priority to allow the patient to be safely moved and po- chest tube or if drainage of more than 200 mL/h for 2 to
sitioned. Similarly, rapid revascularization of a compro- 4 hours occurs, surgery should be considered. Continued
mised extremity warrants additional consideration, and hemorrhage into the peritoneal cavity of a hemodynam-
can be accomplished with a temporary shunt and exter- ically unstable patient requires emergent laparotomy.
nal fixation. Bleeding from the pelvic region must be ruled out be-
It is in the third and final stage that delayed defini- fore laparotomy is done.
tive care of individual fractures is performed. Two meth- External immobilization must be performed if the
ods by which rapid, temporary fracture stabilization can pelvic ring is determined to be unstable. Initial external
be performed on the pelvis or long bones are external immobilization consists of sandbags and straps, bean-
fixation and unreamed intramedullary fixation. External bags, or military antishock trousers. The use of military
fixation can be accomplished rapidly, with minimal antishock trousers, however, has been associated with
blood loss, and can be used to span simple, complex, and compartment syndrome and decreased respiratory abil-
segmental fractures as well as traumatized joints. Con- ity. In the emergency department, external immobiliza-
version to an intramedullary nail or fixation plate is usu- tion has been shown to decrease blood loss and to lower
ISS dependent mortality. Moreover, transfusion require- probably benefit from early intervention to relieve per-
ments are decreased in patients treated with external sistent neurologic compression.
immobilization. External fixation can be applied in the On the other hand, urgent surgical treatment (< 24
emergency department or operating room in concert hours after injury) does not increase the risk to the spi-
with other trauma surgery procedures. nal cord injured patient, compared with early care (1 to
Open fractures and joint injuries will require emer- 3 days after injury), and can improve the overall out-
gent dbridement and stabilization. These wounds come of the polytrauma patient. Urgent stabilization of
should not be closed primarily, and may require deep the fractured spine allows immediate mobilization of
dbridement and repeated irrigation when the patient is the patient, reducing risks of prolonged recumbency
more stable. Open pelvic injuries require emergent (thrombophlebitis, pulmonary embolism, pneumonia,
dbridement, and perineal wounds that communicate urosepsis, and ARDS). This appears to hold true for
with the rectum or colon require diverting colostomy. even the most severely injured patients. Urgent surgical
Vaginal injuries associated with pelvic ring disruptions stabilization among patients with a mean ISS of 40 or
should be repaired to stop hemorrhage and to prevent greater reduced overall mortality from expected, and re-
the development of abscesses. Degloving injuries of the duced or eliminated pulmonary complications such as
skin should be dbrided. pneumonia, pulmonary embolus, and ARDS. Although
Established or incipient compartment syndromes this does not suggest that all spine fracture patients
should be treated with adequate fasciotomy at the first should be rushed to the operating room for urgent sur-
opportunity. Although fully developed compartment gery, it does suggest that it is safe to proceed on an ur-
gent basis when compelled to do so.
syndrome is rarely seen at initial presentation, patients
The benefits of early long bone stabilization have
with severe crushing injuries or prolonged ischemia of
been well established. It has been shown that patients
the limb should undergo prophylactic fasciotomy under
with femoral shaft fractures with an ISS greater than 18
their first anesthetic, if at all possible.
who had early stabilization experienced a decrease in
the incidence of ARDS, pulmonary complications, and
Primary Stabilization Period
length of intensive care unit stay.
Maintaining adequate perfusion of the spinal cord helps
Controversy exists regarding reaming during in-
to minimize secondary injury to the neural elements. Ur-
tramedullary nailing in patients with severe pulmonary
gent care then focuses on methods of preventing further
injury. Marrow contents and bone fragments may embo-
damage and rapid realignment of the spine to decom-
lize during reaming, and it has been proposed that em-
press neurologic structures. High-dose methylpredniso-
bolization of such contents may lead to an inflammatory
lone is commonly used to treat patients presenting with response as well as mechanical blockage, exacerbating
a spinal cord injury with no contraindications to use. the existing pulmonary injury. However, several recent
Despite widespread use and a perception that steroid studies have suggested that the extent of the primary
therapy represents the standard of care for spinal cord pulmonary injury is the major determinant of pulmo-
injured patients, in reality steroid therapy simply repre- nary morbidity. As noted earlier, a study examining in-
sents a treatment option, and a controversial one at tramedullary fixation versus plating of femur fractures
that. There is scant evidence that this intervention pro- demonstrated no difference in pulmonary complica-
vides consistent or functionally significant improvement tions.
in neurologic outcomes. H2 blockers or proton pump in- Vascular injury must be recognized immediately in
hibitors should be considered to prevent formation of injured extremities. Timely diagnosis and treatment can
gastric stress ulcers. minimize ischemic injury. Although arterial reconstruc-
Compression of the neural elements from spinal tion has high priority, bony stability may need to be
malalignment such as a cervical spine facet dislocation achieved before vascular repair. If immediate repair is
should be addressed as soon as hemodynamic and respi- not possible, a temporary shunt may be placed. Com-
ratory stability has been achieved. Although a contro- partment syndrome should be anticipated and treated
versial issue, the use of MRI before reduction of dislo- immediately with fasciotomy. In obtunded polytrauma
cations to rule out disk extrusion that could compress patients clinical examination may not prove to be reli-
the cord after reduction has been advocated. MRI also able. Compartment pressures within 30 mm Hg of dias-
provides details of bone or disk fragments causing spi- tolic pressure are consistent with compartment syn-
nal cord compression or the presence of hematoma. drome and thus a fasciotomy should be performed.
The issue of when to surgically stabilize patients Treatment of open fractures involves administration
with spinal injury and neurologic deficit remains contro- of antibiotics and extensive surgical dbridement. Stable
versial. Emergency surgery for spinal cord injury has not fixation of the fracture is advocated. Currently, exten-
been clinically proven to be beneficial. However, some sive soft-tissue injuries and associated tibia and femur
studies indicate that patients with incomplete lesions fractures (grade III) are safely treated with intramedul-
lary nailing whereas in the past these injuries were among patients with multiple extremity fractures have
treated with external fixation. demonstrated that functional disabilities are greatest for
Soft-tissue injuries may require extensive dbride- injuries below the knee. Intra-articular injuries to the
ment and reconstruction to ensure adequate coverage of foot and ankle, in particular, tend to impair patients who
bone, tendons, vessels, nerves, and implants. If a large have had an otherwise satisfactory recovery from
soft-tissue defect is present, the decision on the type of trauma. Additionally, recent evidence indicates that
reconstruction should be made at the second dbride- polytrauma patients sustaining cord or cauda equina in-
ment or second look, which is usually performed at jury at the time of spinal fracture have poorer func-
48 hours. Coverage with either a local or free vascular- tional outcomes and poorer return to work, even among
ized flap should be performed within 72 hours of injury. those with good neurologic recovery.
In the setting of multiple closed fractures, long bone
fractures of the lower extremity should be stabilized
first. Because of the extensive soft-tissue damage and
Annotated Bibliography
blood loss associated with uncontrolled spasm and insta- Bhandari M, Guyatt GH, Khera V, Kulkarni AV, Spra-
bility, femur and tibia fractures should be reduced and gue S, Schemitsch EH: Operative management of lower
stabilized first, whereas fractures of the upper extremity extremity fractures in patients with head injuries. Clin
can be splinted initially, with good results. Pelvic and Orthop 2003;407:187-198.
spinal fractures may be definitively treated after treat- The authors compared femoral plating versus intramedul-
ing the lower extremity fractures, in most cases, but un- lary nailing and tibial plating versus intramedullary nailing in
stable cervical injuries may warrant earlier treatment, head-injured patients. The study group included 119 patients
maintaining the long bone fractures in traction until the with severe head injuries and lower extremity fractures. There
spinal segment is adequately fixed. Upper extremity was no significant difference in mortality rates between pa-
fractures may be definitively managed after addressing tients treated with intramedullary nailing or plating. The stron-
the above injuries. gest predictor of mortality was the severity of the initial head
injury.
Secondary Stabilization Period
During the secondary stabilization period, the patient is
Cook RE, Keating JF, Gillespie I: The role of angiogra-
hemodynamically stable and surgical intervention is per-
phy in the management of hemorrhage from major frac-
formed on a semielective basis. It is at this time that
tures of the pelvis. J Bone Joint Surg Br 2002;84:178-182.
dbridement of any areas of soft-tissue necrosis is per- This study examined 150 patients with unstable pelvic frac-
formed. Secondary wound closure and some soft-tissue tures and uncontrollable hypotension. In those patients under-
reconstructions may be achieved. Intra-articular recon- going angiography prior to external fixation or laparotomy,
struction, hand, foot, and upper extremity fracture fixa- more than half of them died. The authors recommended that
tion, and complex spinal and pelvic and acetabular re- angiography be used in refractory cases after skeletal stabiliza-
construction may be performed at this time. tion has been attempted in those patients with unstable pelvic
injuries.
Tertiary Stabilization Period
Late reconstructive procedures may be performed in
Giannoudis PV: Surgical priorities in damage control in
the tertiary stabilization period, including definitive clo-
polytrauma. J Bone Joint Surg Br 2003;85:478-483.
sure of amputation sites or any procedure that may
The author provides a review of the current trends and
have been postponed during the secondary stabilization
principles in orthopaedic management of polytrauma, includ-
period. The prognosis of the patient is usually known. ing principles of damage control surgery.
If the patient is stable and is extubated, rehabilita-
tion may begin. This process should be started on an in-
patient basis and should be taken through the outpa- Inaba K, Kirkpatrick AW, Finkelstein J, et al: Blunt ab-
tient phase if necessary. dominal aortic trauma in association with thoracolum-
bar spine fractures. Injury 2001;32:201-207.
The authors report their experience with blunt abdominal
Long-Term Outcome aortic disruption at regional trauma centers. Eight cases were
Advanced age and increased severity of injury is associ-
identified, six of which were associated with thoracolumbar
ated with increased mortality in the short term. Long-
fractures, with a mean ISS of 42. All spinal fractures were as-
term outcomes of polytrauma patients vary with the se-
sociated with a distractive force pattern. The authors con-
verity of injury initially sustained. Severity of injury is
cluded that with all distractive thoracolumbar injuries, aortic
associated with greater disability, higher rate of unem-
disruption must be considered as this injury may occur as a re-
ployment after injury, and lower quality of life. Studies
sult of similar distractive forces.
examining both subjective and objective outcomes data
McCormick JP, Morgan SJ, Smith WR: Clinical effective- Boulanger BR, Stephen D, Brennemann FD: Thoracic
ness of the physical examination in diagnosis of poste- trauma and early intramedullary nailing of femur frac-
rior pelvic injuries. J Orthop Trauma 2003;17:257-261. tures: Are we doing harm? J Trauma 1997;43:24-28.
This article presents a prospective study evaluating the
correlation of physical examination to radiographic studies in Chapman MW: The role of intramedullary fixation in
the diagnosis of posterior pelvic ring disruptions. Of those pa- open fractures. Clin Orthop 1986;212:26-34.
tients found to have posterior pelvic ring disruptions as shown
on CT scan, 98% had posterior pelvic pain on examination. Civil ID, Schwab CW: The Abbreviated Injury Scale,
The authors concluded that physical examination was accurate 1985 revision: A condensed chart for clinical use.
in detecting injuries of the posterior pelvic ring. J Trauma 1988;28:87-90.
Zalavras CG, Patzakis MJ: Open fractures: Evaluation Schwab CW, Shayne JP, Turner J: Immediate trauma re-
and management. J Am Acad Orthop Surg 2003;11:212- suscitation with type O uncrossmatched blood: A two-
219. year prospective experience. J Trauma 1986;26:897-902.
This article is a review of the literature regarding manage-
ment of open fractures. The authors discuss the controversies Shackford SR, Hollingsworth-Fridlund P, Cooper GF,
regarding wound closure. Soft-tissue coverage of large and Eastman AB: The effect of regionalization on the qual-
contaminated wounds is also discussed. ity of trauma care as assessed by concurrent audit be-
fore and after institution of a trauma system: A prelimi-
Classic Bibliography nary report. J Trauma 1986;26:812-820.
Bohlman HH: Acute fractures and dislocations of the Tscherne H, Regel G, Pape HC, Pohlemann T, Kretteck
cervical spine: An analysis of three hundred hospitalized C: Internal fixation of multiple fractures in patients with
patients and review of the literature. J Bone Joint Surg polytrauma. Clin Orthop 1998;347:62-78.
Am 1979;61:1119-1142.
Winquist RA, Hansen ST Jr, Clawson DK: Closed in-
Bone L, Bucholz R: The management of fractures in the tramedullary nailing of femoral fractures: A report of
patient with multiple trauma. J Bone Joint Surg Am five hundred and twenty cases. J Bone Joint Surg Am
1986;68:945-949. 1984;66:529-539.
Bone LB, Johnson KD, Weigelt J, Scheinbeng R: Early
versus delayed stabilization of fractures: A prospective,
randomized study. J Bone Joint Surg Am 1989;71:336-
340.
Figure 1 The coagulation pathways. PT measures the function of the extrinsic and common pathways, whereas the PTT measures the function of the intrinsic and common
pathways. FPA = fibrinopeptide A; FPB = fibrinopeptide B. (Reproduced with permission from Stead RB: Regulation of hemostasis, in Goldhaber SZ (ed): Pulmonary Embolism and
Deep Venous Thromboembolism. Philadelphia, PA, WB Saunders, 1985, p 32.)
replacement. In patients with spontaneous bleeds, the risk of human immunodeficiency virus transmission. Al-
goal is to achieve circulating levels that are approxi- though uncommon, hemophilia patients with factor in-
mately 40% to 50% of normal. If surgical intervention is hibitors, antibodies that neutralize the coagulation fac-
planned, the deficient factor should be replaced to lev- tor, should be identified.
els near 100%. Continuous or intermittent boluses of Various congenital bleeding disorders exist that may
high-purity plasma derivatives or recombinant factor affect proper coagulation, the most common being von
concentrates can be given and have greatly reduced the Willebrands disease, an autosomal dominant disorder.
Table 1 | List of Common Antithrombotic Medications With Mechanism of Action and Laboratory Monitoring Method
Medication Mechanism of Action Laboratory Monitoring Method
Warfarin (Coumadin) Prevents the vitamin K dependent -carboxylation of Prothrombin time - International Normalized Ratio
factors II, VII, IX, and X, proteins C and S, slowing thrombin
production
Low molecular weight heparin Upregulates the inhibitory effect of antithrombin on serine None necessary in uncomplicated cases; Chromogenic
(enoxaparin) proteases thrombin, IXa, Xa, XIa, and XIIa with greatest anti-Xa assay available in complicated cases
effect upon Xa
Salicylates (aspirin) Irreversibly inhibits cyclo-oxgenase activity in platelets and None necessary, although bleeding times may be
vascular endothelium prolonged
Traditional nonsteroidal Inhibition of COX-1 and 2, and leukotriene synthesis None necessary, although bleeding times may be
anti-inflammatory drugs prolonged
(ibuprofen)
Selective COX-2 inhibitors Selective inhibition of COX-2 None necessary, although bleeding times may be
Celecoxib (Celebrex) prolonged
Thienopyridines Binds to the GPIIb/IIIa receptor to irreversible blocking None necessary, although bleeding times may be
Ticlopidine (Ticlid) Adenosine diphosphate-induced platelet aggregation prolonged
Clopidogrel (Plavix)
It occurs secondary to a deficiency of von Willebrands suggest that in patients undergoing primary total knee
factor, which is important for promoting normal platelet arthroplasty, fibrin sealant may safely reduce postopera-
function and stabilizing factor VIII. Although most pa- tive wound drain output while maintaining higher post-
tients will respond to desmopressin, a few may require operative hemoglobin levels.
the use of clotting factor concentrates.
Treatment of the acquired coagulopathies centers on Thromboembolic Disease
identifying the cause. Prior to surgery, medications that Thromboembolic disease refers to a group of disorders
inhibit platelet function and the coagulation pathway that includes thrombosis and embolic disorders, which
should be stopped if possible and blood work rechecked can occur in either the arterial or venous system. In the
if necessary (Table 1). Nutrition should be optimized, es- orthopaedic patient, venous thromboembolic disease is
pecially in older patients. If necessary, platelets and more common, and includes deep venous thrombosis
fresh frozen plasma (FFP) should be available for infu- (DVT) and pulmonary embolism (PE).
sion perioperatively. Because FFP contains only the nor-
mal amount of clotting factor per milliliter of plasma,
achieving sufficient factor levels can require greater
Pathophysiology
volumes. In the 19th century, Virchow described the three major
Recombinant factor VII has been used in patients pathophysiologic factors (stasis, endothelial injury, and
with a high titer inhibitor directed against factor V, VIII, hypercoagulable states) contributing to thromboembolic
or IX. More recent studies focus on the role of various disease. Thrombosis secondary to stasis occurs more
recombinant factor concentrates to achieve hemostasis commonly in the low-velocity, high capacitance venous
in patients demonstrating massive bleeding refractory to system (venostasis) and is the result of a disruption of
FFP and platelets. This may be the case in patients who the normal laminar blood flow. These venous thrombi
develop consumptive coagulopathies secondary to mas- are typically composed of fibrin and trapped red cells
sive bleeding from multitrauma or massive blood vol- and contain few platelets. Endothelial injury leads to
ume replacement postoperatively, and in patients who thrombus formation secondary to traumatic exposure of
develop dilutional coagulopathies during prolonged sur- extracellular matrix components (collagen) within the
geries. The lower volumes required with the use of these vessel walls to circulating platelets. Although this can
recombinant factors may result in less fluid overload, occur in the venous system, it more typically is present
decreased fluid shifts, and anasarca in critically ill pa- in the high-velocity arterial system and is usually com-
tients; however, additional studies are required to more posed of platelets with little fibrin. The third cause, hy-
clearly define the optimal dosing, safety, and efficacy percoagulability, remains the least understood, and oc-
of these recombinant factors before routine use curs in conditions such as malignancy, pregnancy,
is recommended. hormone replacement, in smokers, and during the post-
Other areas of investigation include the local use of operative state. Hereditary causes, such as resistance or
fibrin sealant and topical thrombin. Preliminary data deficiencies in antithrombin III, factor C, factor S, factor
V Leiden mutations, and antiphospholipid syndrome, cant relationship was the increased use of postoperative
have also been identified. Clinically, these patients are cast immobilization and no weight bearing, which in-
at increased risk for stroke and vascular and cardiac dis- creased the relative risk by 0.04%.
ease, and may have an increased risk of osteonecrosis,
Legg-Calv-Perthes disease, and other thrombotic disor-
ders. Treatment Strategies
Treatment consists of either thromboembolic disease
Epidemiology prevention (thromboprophylaxis) or management of es-
tablished thromboembolic disease. Because of high rates
Venous thromboembolic disease occurs for the first
time in approximately 100 per 100,000 persons each of venous thromboembolic disease in the orthopaedic
year and increases exponentially with age from a negli- patient, initial management should center on thrombo-
gible rate for those younger than 15 years up to 500 per prophylaxis. Treatment strategies include either mechan-
100,000 in individuals older than 80 years. Two thirds of ical or pharmacologic methods or a combination of
symptomatic venous thromboembolic diseases present both. Management techniques for the treatment of es-
as a DVT, whereas one third present with PE. In large tablished thromboembolic disease is beyond the scope
epidemiologic studies, the incidence is statistically of this chapter.
higher among Caucasians and African Americans than
in Hispanics and Asian-Pacific Islanders. Recurrence Mechanical Approaches
rates, even after successful anticoagulant therapy, are Current mechanical options include pneumatic com-
approximately 7% at 6 months after the initial event. pression boots, plantar foot compression devices, and
The risk of venous thromboembolic disease also var- elastic compression stockings. Pneumatic compression
ies depending on the procedure being performed. The
boots reduce stasis by directly increasing the velocity of
reported rate of DVT in the total hip arthroplasty pa-
venous blood flow. Because these boots also increase
tient ranges from 15% to 25% and can be as high as
the systemic release of endogenous fibrinolytic activity,
50% in the patient undergoing a total knee arthroplasty,
their benefit can be realized even when used on a single
whereas the risk of fatal PE without thromboprophy-
limb or placed on the upper extremity. Plantar foot
laxis is between 0.1% to 0.5%. The use of either chemi-
compression devices mimic the hemodynamic effects of
cal or mechanical prophylaxis has decreased these rates
ambulation, thus increasing venous return and decreas-
by half.
ing venostasis. Although elastic compression stockings
In patients with pelvic, acetabular, periacetabular,
decrease lower extremity venous pooling and stasis,
and hip fractures, reported DVT rates vary from 20% to
their use alone as an effective thromboprophylaxis is
60% and increase when surgery is delayed by 2 days or
unclear. In patients undergoing combined anterior and
longer. Although symptomatic PE rates range from 2%
to 10%, fatal PE occurs in approximately 0.5% to 2%. posterior spinal procedures and in those who have had
In these patients, the occurrence of more proximal joint arthroplasty, if possible, elastic compressive stock-
thrombi, particularly those in the pelvis, may result in a ings should be used in conjunction with other prophy-
higher risk of embolization (up to 50%). lactic agents.
Identifying rates of thromboembolic disorders in the The greatest advantages of these mechanical meth-
patient undergoing spinal surgery has been more diffi- ods are that there is almost no risk of bleeding, minimal
cult. Studies are limited, but reported rates of DVT to no side effects, and they do not require laboratory
range from 0.3% to 26%. In patients undergoing poste- monitoring. A less common, more invasive mechanical
rior spinal procedures alone there does not appear to be device is the inferior vena cava filter. This device can be
a difference in DVT rates when compared by sex, length associated with substantial morbidity; therefore, its rou-
of procedure, number of levels performed, and/or the tine use as a thromboprophylactic agent is not encour-
addition of one- or two-level fusions. However, al- aged. However, it may have a role in management of
though still not clear, DVT rates may be higher in pa- patients with known DVT and recurrent PE despite ad-
tients undergoing combined anterior and posterior spi- equate anticoagulant therapy, patients in whom antico-
nal surgery than in those undergoing posterior-alone agulant therapy is contraindicated, and potentially in
procedures. patients noncompliant with anticoagulant therapy. The
In a prospective multicenter study of 2,733 patients use of temporary inferior vena cava filters (which are
who underwent foot and ankle surgery, the reported removed typically within 10 days from the time of inser-
DVT rate was 0.22% with a 0.15% rate of nonfatal PE tion) is currently being investigated in various clinical
without occurrence of fatal PE. The authors did not find scenarios, such as in the critically ill, multitrauma patient
a statistical relationship with tourniquet use or history requiring multiple surgical interventions over a short
of thromboembolic disease. The only statistically signifi- time period.
tor VII for coagulopathy in fulminant hepatic failure prospective and randomized clinical study. J Bone Joint
compared with conventional therapy. Liver Transpl Surg Br 2003;85:661-665.
2003;9:138-143. The authors prospectively followed 200 patients who un-
The authors found a statistically significant difference in derwent primary total hip arthroplasties (THAs). DVT rates
correction of coagulopathy and decreased anasarca in patients were 26% for bilateral THA and 20% for unilateral THA, but
with severe coagulopathy from fulminant hepatic failure after in the 72 patients with venogram confirmed thrombi, all
a single dose of recombinant activated factor VII compared thrombi had spontaneously and completely resolved at 6
with those receiving fresh frozen plasma alone. months regardless of site and size.
Wang GJ, Hungerford DS, Savory CG, et al: Use of fi- Offner PJ, Hawkes A, Madayag R, Seale F, Maines C:
brin sealant to reduce bloody drainage and hemoglobin The role of temporary inferior vena cava filters in criti-
loss after total knee arthroplasty: A brief note on a ran- cally ill surgical patients. Arch Surg 2003;138:591-595.
domized prospective trial. J Bone Joint Surg Am 2001; The authors concluded from a prospective cohort study of
83:1503-1505. 44 patients at a level I trauma center that temporary inferior
Preliminary data from a phase III trial of 53 patients under- vena cava filters are a safe and effective approach to prevent-
going unilateral primary total knee arthroplasty demonstrated a ing venous thromboembolic disease in the multitrauma, criti-
reduction in bloody drainage and higher postoperative hemo- cally ill surgical patient.
globin in the fibrin sealant group than in the control group.
Samama CM: Venous thromboembolism deserves your
Thromboembolic Disease attention. Critical Care 2001;5:277-279.
Edelsberg J, Ollendorf D, Oster G: Venous thromboem- The author surveyed intensive care unit directors in Can-
bolism following major orthopedic surgery: Review of ada and reviewed the use of traditional and advanced com-
epidemiology and economics. Am J Health Syst Pharm pression techniques, as well as unfractionated versus low mo-
2001;58(suppl 2):S4-S13. lecular weight heparin for the prevention and treatment of
A review of epidemiology of venous thromboembolic dis- DVT and venous thromboembolic disease. The recommenda-
ease in joint replacement and hip fracture surgery is pre- tions were that mechanical prophylaxis should be used alone
sented. Costs associated with the diagnosis, treatment, and re- or in combination with chemoprophylaxis in patients in the in-
covery from venous thromboembolic disease is substantial, tensive care unit and that pharmacologic prophylaxis should
with the initial therapy consuming 90% of the total cost. always be combined with mechanical prophylaxis; however,
large randomized controlled trials are needed.
Hyers TM: Management of venous thromboembolism: White RH: The epidemiology of venous thromboembo-
Past, present, and future. Arch Intern Med 2003;163:759- lism. Circulation 2003;107(suppl 23):I4-I8.
First-time venous thromboembolic disease occurs in ap-
768.
A review of the state of current chemoprophylatic meth- proximately 100 per 100,000 persons each year and a recur-
ods, including unfractionated heparin and low molecular rence rate of 7% has been reported. Risk factors identified
weight heparin and their potential adverse effects and theoret- from large epidemiologic studies include ethnicity, and ad-
vanced age. Gender does not appear to be a factor.
ical basis for failure is presented. Newer agents recently ap-
proved for venous thromboembolic disease, such as hep-
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Assessment of the Patient During and After million using newer screening techniques such as nucleic
acid testing.
the Administration of a Blood Product Blood components containing white blood cells are
The transfusion of a specific blood product is indicated
unpredictably prone to contain cytomegalovirus, with up
only when that blood product is deficient and the risk of
to 70% of donors positive for the disease. Transmission
transfusion is outweighed by the potential benefit.
of cytomegalovirus is a concern primarily for immuno-
RBCs, fresh frozen plasma, cryoprecipitated antihemo-
compromised patients. Some infectious agents, such as
philic factor, or platelets should never be used for vol-
Babesia sp., Bartonella sp., Borrelia sp., Brucella sp., Col-
ume expansion alone. Although a specific laboratory
orado tick fever, Leishmania sp., Parvovirus sp., plasmo-
value as the sole basis for a transfusion decision is not
dia, rickettsia, Toxoplasma sp., malaria, and some trypa-
appropriate, some general principles should be fol-
nosomes, are not screened for because pertinent tests
lowed.
are not available. Theoretically, Creutzfeldt-Jakob dis-
The patients vital signs should be monitored closely
ease may also be transmitted through blood products.
during transfusion of a blood product, with close atten-
Although rare, bacterial contamination may occur
tion paid to temperature elevation, tachycardia, respira-
and may cause severe effects, including death. In the
tory rate, blood pressure, and mental status. A signifi-
United States, septic reactions from bacterial contami-
cant temperature elevation of more than 2C may
nation of blood components resulted in 77 of 694
indicate bacterial infection or an acute hemolytic reac-
transfusion-related deaths reported to the Food and
tion. Dyspnea, chest pain, or tachypnea may reflect fluid
Drug Administration (FDA) from 1985 to 1999. Plate-
overload with subsequent pulmonary edema, which may
lets are the most likely among blood components to be
occur especially in at-risk patients or patients given
contaminated. Skin flora are the most common patho-
large transfusions over a short period of time. Pulmo-
gens. Endotoxemia may occur as a result of Yersinia en-
nary edema may not manifest clinically for up to 24
terocolitica contamination of RBC products.
hours after transfusion. Hypothermia after rapid infu-
sion of large blood volumes may result if the blood is
chilled and an approved blood warmer is not used. Fi- Immunologic Complications
nally, metabolic complications may occur when the vol- Immunologic complications can be acute or delayed and
ume of transfused blood exceeds the patients normal may vary significantly in clinical presentation. Although
blood volume. These metabolic complications include current cross-matching techniques minimize risk for im-
hypokalemia or hyperkalemia, citrate toxicity, and am- mune reactions, the incidence has not been completely
monia toxicity with possible acidosis or alkalosis. In ad- eliminated.
dition to measurement of circulating electrolytes and Hemolytic transfusion reactions usually occur as a
renal function, ionized calcium testing and electro- result of antigen or ABO incompatibility of transfused
cardiogram monitoring may be indicated. RBCs, although nonimmunologic reactions may occur.
Patient symptoms include elevated temperature and
pulse, chest or back pain, and dyspnea. In unresponsive
Safety in Banking of Blood and patients or patients under general anesthesia, dissemi-
Blood Products nated intravascular coagulopathy may be the initial clin-
The risks associated with blood transfusions include ical presentation. Laboratory studies helpful to confirm
transmission of viral disease, hemolysis caused by ABO the diagnosis include hemoglobin, serum bilirubin, and
incompatibility, acute lung injury, transmission of bacte- direct antiglobulin test. Delayed hemolytic reactions are
ria or endotoxins, transmission of parasites, graft versus possible in patients who are alloimmunized, with pre-
host disease, alloimmunization, allergic reaction, and im- sentation of symptoms as late as 14 days after transfu-
munosuppression. sion. In contrast to the potentially fatal course of acute
hemolytic reactions, delayed hemolytic reactions do not
Infectious Disease require treatment and are usually benign.
Transmission of infectious disease via transfusion of hu- Febrile nonhemolytic reactions and allergic reactions
man blood may be caused by known or unknown organ- may also occur and are common. Febrile reactions occur
isms. Current screening criteria exclude donors with hu- in 1% of transfusions and require only antipyretics for
man immunodeficiency virus (HIV), human T cell palliative treatment. Most allergic reactions are minor
leukemia virus (HTLV), hepatitis, and other known with the primary report of urticaria and are adequately
agents. Blood is also screened for hepatitis B and C, treated with antihistamines. Anaphylactic reactions, al-
HIV-1 and -2 including HIV antigen, and HTLV-I and though rare, may also occur and require aggressive im-
HTLV-II. Although the risk of viral transmission has not mediate treatment.
been totally eliminated, the risk of transmission of hepa- A potentially fatal immunologic complication is
titis C and HIV has been decreased to less than 1:2 to 4 transfusion-related acute lung injury, which occurs
through an unknown mechanism. This condition mani- proved planning and minimizing the use of allogeneic
fests within 6 hours (most often occurring within blood. Effective perioperative blood management strat-
2 hours) of transfusion and requires aggressive pulmo- egy may include use of agents that increase the preoper-
nary treatment and maintenance of the hemodynamic ative hemoglobin level, agents or techniques that mini-
status of the patient. Clinical manifestation of mize intraoperative and postoperative blood loss, or
transfusion-related acute lung injury is the sudden onset protocols that allow for reinfusion of salvaged blood.
of pulmonary edema, shortness of breath, hypotension Recombinant human erythropoietin (EPO), a glyco-
unresponsive to intravenous fluids, and hypovolemia protein hormone secreted by the kidneys with a minor
with or without fever. Rapid progression of severe hy- hepatic contribution in conditions of extreme stress, is
poxia follows. Results from radiographic evaluation of responsible for regulation of erythropoiesis. Data sug-
the chest mimic adult respiratory distress syndrome. Al- gest that there is a dose-related relationship between al-
though adult respiratory distress syndrome and logeneic transfusion and preoperative administration of
transfusion-related acute lung injury are clinically iden- EPO such that patients given higher doses of EPO are
tical, other causes of pulmonary edema should be ex- at lower risk of transfusion when undergoing major or-
cluded to confirm the diagnosis of transfusion-related thopaedic operations. Use of EPO is indicated for pa-
acute lung injury. Risk factors for this condition are un- tients with a preoperative hemoglobin level between
known and most patients have not been reported to 10.0 g/dL and 13.0 g/dL and an expected blood loss of
have a previous history of transfusion reaction. two units of blood. No significant adverse reactions
Other delayed immunologic complications are al- have been associated with preoperative use of EPO in
loimmunization and graft versus host disease. Alloim- appropriate patients.
munization, which may occur after transfusion of any Reported use of EPO in athletes as a form of blood
blood component and is asymptomatic, may result in doping is of concern. The term blood doping refers to
shortened survival of subsequent blood products trans- the use of blood transfusion as an ergogenic aid but has
fused, as in immune-mediated platelet destruction. Graft also been applied to use of EPO. Although banned by
versus host disease may occur when T lymphocytes in the International Olympic Committee, illicit use of EPO
the transfused component react to recipient tissue anti- is difficult to detect. Urine tests that can differentiate
recombinant human EPO and endogenous EPO have
gens.
been described but have not yet been determined to be
Immunosuppression is associated with transfusion of
a reliable screening tool.
allogeneic blood and is considered to be one of the
Perioperative use of pharmacologic therapies to re-
greatest risks to the recipient. Although the mechanism
duce blood loss is an effective strategy to reduce risk of
is not well defined in humans, several studies have dem-
blood transfusion. Topical use of fibrin tissue sealants
onstrated transfusion of allogeneic blood to be an inde-
has been studied extensively. Fibrin tissue adhesive is
pendent risk factor for development of postoperative
composed of variable amounts of thrombin and fibrino-
infection in patients undergoing uncontaminated ortho-
gen. According to a 1999 study, use of fibrin tissue adhe-
paedic surgery. In a multicenter study of patients under-
sive in total knee arthroplasty reduces postoperative
going total joint arthroplasty, the infection rate in pa-
blood loss and requirement for blood transfusions from
tients who had allogeneic blood transfusions was more 28% to 17%. Antifibrinolytic agents such as aprotinin,
than twice that of patients who did not undergo transfu- tranexamic acid, and aminocaproic acid have been
sion. Other studies suggest a range of risk of infection to shown to reduce surgical blood loss. Aprotinin is a natu-
be zero to 10 times greater in patients receiving alloge- rally occurring broad-spectrum protease peptide that in-
neic blood. hibits trypsin, plasmin, tissue kallikreins, and plasmin
kallikreins. Although the exact mechanism of action is
Trends in Transfusion Medicine not known, aprotinin is thought to regulate fibrinolysis,
Preoperative assessment of the patient is important in stabilize platelet function, and modulate the intrinsic co-
determining the risk for postoperative transfusion. The agulation pathway. Aprotinin, used commonly in cardio-
most significant factor associated with risk of postopera- thoracic surgery and liver transplantation, has been
tive transfusion is preoperative hemoglobin. Most re- shown to have slightly better efficacy than the other an-
cent data indicate that a preoperative hemoglobin level tifibrinolytic agents. Aprotinin is also effective in ortho-
of less than 13.0 g/dL carries a substantial increased risk paedic surgery and has been determined to be a safe
of transfusion. Conversely, a preoperative hemoglobin agent for maintaining hemostasis in total hip arthro-
level of more than 15.0 g/dL has a significantly dimin- plasty. There is a theoretical increased risk of deep
ished risk. Duration of surgery, smaller patient size, and venous thrombosis with this agent, however. Desmo-
female gender have also been associated with increased pressin is a valuable agent to minimize blood loss in pa-
risk of transfusion in several studies. Preoperative pa- tients with hemophilia A and von Willebrands disease,
tient assessment for transfusion risk is essential for im- but has not been shown beneficial in patients without
coagulopathy undergoing elective surgery. Recombinant human hemoglobin from Escherichia coli, salvaged from
factor VIIa (eptacog alfa) is currently under investiga- expired human blood, or purified from bovine blood.
tion but preliminary data suggest that it may be effec- The success of first-generation, cell-free preparations
tive in reduction of blood loss in surgical patients with- was marred by nephrotoxicity and excessive oxygen
out coagulopathy. binding affinity. Some preparations have been discontin-
Acute normovolemic hemodilution is a technique ued after clinical trials demonstrated increased mortal-
during which whole blood is drawn from the patient be- ity in trauma patients with hemoglobin substitutes com-
fore or early in the surgical procedure, usually after ini- pared with placebo. The second-generation, liposome-
tiation of anesthesia, while intravascular volume is based hemoglobin carriers currently demonstrate some
maintained with a crystalloid and solutions. Thus, the promise in preclinical animal studies and phase 2 and 3
blood loss during the procedure is diluted and the whole clinical trials.
blood removed at the beginning of the procedure is re- Perfluorocarbon emulsions are another alternative
infused. Acute normovolemic hemodilution has been to hemoglobin-based blood products and substitutes.
shown to be as effective as preoperative autologous These agents are hydrocarbon analogs substituting fluo-
blood donation in patients undergoing total hip arthro- rine for hydrogen. Perfluorocarbons have 20 to 30 times
plasty in the reduction of risk of allogeneic blood trans- the oxygen solubility of plasma. Fluosol-DA-20 is cur-
fusion. Hypervolemic hemodilution has been found to rently the only FDA-approved blood substitute. Its use,
be as beneficial as normovolemic hemodilution in one however, has been associated with hepatosplenomegaly,
study and has the advantage of being simpler to per- complement-induced hypertension, and anaphylactoid
form without the need for blood withdrawal. Patients reaction.
with cardiac disease may not be candidates for either
technique. Religious Practices and Transfusion
Intraoperative salvage of shed blood that is spun and Alternatives
washed of contaminants and debris is well established as The Jehovahs Witnesses is a growing religious group
a means of avoiding blood transfusion. Comparison of that originated during the Adventist movement of the
different techniques of intraoperative cell salvage such 19th century. The Watchtower Bible and Tract Society is
as centrifuge, direct transfusion, and ultrafiltration has the controlling theological organization and has out-
shown no difference in transfusion risk in each of these lined rigid religious doctrine with specific relevance to
modalities. Cell salvage is generally considered in pa- medical care. Jehovahs Witnesses freely accept medical
tients in whom intraoperative blood loss is expected to and surgical care, but most refuse the acceptance of
exceed 1,000 mL. Postoperative blood salvage requires blood and blood products based on their interpretation
transfusion of unwashed blood from a blood collection of the Old Testament. Deviation from this doctrine not
device. Several studies have indicated that postoperative only is believed to be a direct spiritual betrayal, but also
blood salvage significantly reduces the risk for postoper- carries profound social implications with shunning
ative blood transfusion. The safety of this technique is and excommunication from church and family.
somewhat controversial because there are increased Judicial precedent protects the sacrosanct position of
risks of infection by contaminated blood, as well as re- Jehovahs Witnesses to refuse blood willingly against
ports of hyperthermia and hypotension. medical advice. Under the protection of informed con-
sent, the Supreme Court and state courts have ruled re-
Blood Substitutes peatedly that the integrity of the medical profession
The ideal blood substitute would be readily available cannot supersede the wishes or religious beliefs of the
and without the associated risks of transfusion and patient. The American Medical Association has likewise
transfusion-related infections. Blood alternatives are ei- supported physicians and hospitals that provide care of
ther plasma expanders or oxygen-based carrier substi- Jehovahs Witnesses who provide informed consent.
tutes. Blood volume expanders include crystalloid and Most Jehovahs Witnesses will not accept blood or
colloid replacement. Crystalloid replacement with com- most blood products, including whole blood, red blood
binations of saline, lactated Ringers solution, and glu- cells, autologous blood donation, platelets, and plasma.
cose solutions are the first line of volume supplementa- Under specific circumstances outlined by the Watch-
tion. Patients who are at risk of excessive intravascular tower Society, however, Jehovahs Witnesses may accept
volume overload may tolerate colloid replacement with clotting factors, stem cells, bone marrow transplants, and
albumin, dextran, or gelatins. separated plasma proteins of albumin, fibrin, and globu-
Oxygen-based carrier substitutes encompass a novel lin. Jehovahs Witnesses may also accept dialysis, plas-
class of therapeutic agents. Hemoglobin-based prepara- mapheresis, and intraoperative blood salvage where the
tions are either cell free or liposome enclosed as a sub- extracorporeal circulation is uninterrupted. The medical
strate carrier. The molecules are genetically engineered team needs to consult with each patient to determine
acceptable alternatives. The Watchtower Society readily ease and immune-mediated transfusion reactions. The
provides patient resources through its Hospital Informa- potential risk of transfusion error caused by clerical is-
tion Society and its regional Hospital Liaison Commit- sues still exists with the use of preoperative autologous
tees. blood donation, but the major disadvantage is the cost
The surgical care of Jehovahs Witnesses can be suc- related to this method. The high cost of preoperative au-
cessfully managed using anesthetic and pharmacologic tologous blood donation is magnified by the significant
alternatives. Many Jehovahs Witnesses will accept pre- wastage of blood that occurs with preoperative autolo-
operatively the red cell production stimulating factor gous blood donation. Rates of discarded blood have
EPO and white cell stimulators granulocyte-colony been reported to be as high as 83% of units, with most
stimulating factor and granulocyte-macrophage colony studies demonstrating wastage in the 50% range. Better
stimulating factor. Jehovahs Witnesses accept the use of identification of patients likely to require transfusion
fibrin glue as a hemostatic agent intraoperatively and before embarking on preoperative autologous blood do-
the pharmacologic antifibrinolytics such as aprotinin nation is required to reduce the waste associated with
and tranexamic acid. Proven anesthetic techniques in this technique.
these patients involve hypotension, hypothermia, and Most studies indicate that preoperative autologous
acute normovolemic hemodilution. Intravascular vol- blood donation is an effective way to minimize risk of
ume can be acceptably maintained with colloid and allogeneic transfusion and lend support for its continued
crystalloid replacement. use. One concern related to preoperative autologous
With such protocols, major surgery on Jehovahs blood donation is donation-induced preoperative ane-
Witnesses has been successfully performed. The com- mia. Blood donations within 2 weeks of surgery are
bined literature from cardiac, urologic, and obstetric sur- more likely to result in preoperative anemia because of
gery has demonstrated successful outcomes after major an insufficient erythropoietic response. A recent study
surgery without blood transfusion. Safe outcomes have of total joint arthroplasty patients presented convincing
also been reported after total joint surgery and major data that the use of EPO preoperatively in patients also
spine surgery. A study of 100 Jehovahs Witnesses under- undergoing preoperative autologous blood donation sig-
going total hip replacement reported no deaths, and nificantly decreased the allogeneic transfusion rate in
smaller studies of spinal fusion for scoliosis have also re- patients either receiving EPO or using preoperative au-
ported success without mortality. tologous blood donation alone. Patients with a hemoglo-
Controversy remains regarding the emergent care of bin level less than 10.0 g/dL are not considered candi-
the exsanguinating and obtunded patient and in the care dates for preoperative autologous blood donation.
of minors. A 1998 report determined that during a life- Transfusion of autologous blood continues to be the
threatening emergency when the patient cannot provide most commonly used alternative to allogeneic transfu-
informed consent and where there is no valid advance sion.
directive, emergency blood transfusions may be given
until the patients condition stabilizes. Interestingly, pa- Annotated Bibliography
tients who are unconsciously transfused are not subject
to religious sanction or the threat of excommunication. Allain JP: Transfusion risks of yesterday and of today.
Regarding children, the American Academy of Pediat- Transfus Clin Biol 2003;10:1-5.
rics in 1997 stated that the constitutional guarantees of Improved screening techniques decrease risk of disease
freedom of religion do not permit children to be transmission with transfusion but may not be cost effective.
harmed through religious practice. Furthermore, an
anonymous group of Jehovahs Witnesses called the As-
Bezwada HP, Nazarian DG, Henry DH, Booth RE: Pre-
sociated Jehovahs Witnesses for Reform on Blood Pol-
operative use of recombinant human erythropoietin be-
icy have voiced dissent over the religions official blood fore total joint arthroplasty. J Bone Joint Surg Am 2003;
policy. Consultation with the hospital ombudsman or 85:1795-1800.
ethics committee may be necessary to obtain consent in In this prospective randomized study, the efficacy of eryth-
cases where life-saving transfusion is essential in a juve- ropoietin and autologous blood in combination was demon-
nile or incompetent patient whose guardian is a Jeho- strated to have the lowest risk of allogeneic blood transfusion.
vahs Witness.
Cable R, Carlson B, Chambers L, et al (eds): Practice
Autologous Blood Donation: Current Trends Guidelines for Blood Transfusion: A Compilation From
The impetus for the use of preoperative autologous Recent Peer-Reviewed Literature. Washington, DC,
blood donation in perioperative blood management in American National Red Cross, 2002, pp 1-48.
orthopaedic surgery is to avoid the major risks of allo- A thorough review of blood products, indications, and
geneic transfusions, especially the transmission of dis- risks associated with transfusion is presented.
Dodd RY: Bacterial contamination and transfusion safe- patients with and without deposited autologous units.
ty: Experience in the United States. Transfus Clin Biol J Bone Joint Surg Am 2000;82:951-954.
2003;10:6-9.
Septic transfusion reactions from 1985-1999 are reviewed. Hatzidakis AM, Mendlick R, McKillip T, Reddy RL,
Garvin KL: Preoperative autologous donation for total
Salido JA, Marin LA, Gomez LA, Zorrilla P, Martinez joint arthroplasty: An analysis of risk factors for alloge-
C: Preoperative hemoglobin levels and the need for neic transfusion. J Bone Joint Surg Am 2000;82:89-100.
transfusion after prosthetic hip and knee surgery: Analy-
Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski
sis of predictive factors. J Bone Joint Surg Am 2002;84:
H: The use of fibrin tissue adhesive to reduce blood loss
216-220.
The most important predictive factor related to risk of
and the need for blood transfusion after total knee ar-
postoperative transfusion is preoperative hemoglobin. Dura- throplasty. J Bone Joint Surg Am 1999;81:1580-1588.
tion of surgery, gender, and patient size were also predictive
Lundberg GD: Practice parameter for the use of fresh-
factors.
frozen plasma, cryoprecipitate, and platelets. JAMA
1994;271:777-781.
Sullivan MT, McCullough J, Schreiber GB, Wallace EL:
Blood collection and transfusion in the United States in Migden DR. Braen GR: The Jehovahs Witness blood
1997. Transfusion 2002;42:1253-1260. refusal card: Ethical and medicolegal considerations for
A review of supply and demand of blood products in 1994 emergency physicians. Acad Emerg Med 1998;5:815-824.
and 1997 for comparison.
Murkin JM, Haig GM, Beer KJ, et al: Aprotinin de-
Classic Bibliography creases exposure to allogeneic blood during primary
unilateral total hip arthroplasty. J Bone Joint Surg Am
Anders MJ, Lifeso RM, Landis M, Mikulsky J, Meinking 2000;82:675-684.
C, McCracken KS: Effect of preoperative donation of
autologous blood on deep-vein thrombosis following to- NIH Consensus Statement available on perioperative
tal joint arthroplasty of the hip or knee. J Bone Joint red cell transfusion. Am J Public Health 1988;78:1588.
Surg Am 1996;78:574-580.
Practice guidelines for blood component therapy: A re-
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, port by the American Society of Anesthesiologists Task
Tooms RE, Welch RB: An analysis of blood manage-
Force on Blood Component Therary. Anesthesiology
ment in patients having a total hip or knee arthroplasty.
1996;84:732-747.
J Bone Joint Surg Am 1999;81:2-10.
Faris PM, Ritter MA, Abels RI: The effects of recombi- Religious objections to medical care: American Acad-
nant human erythropoietin on perioperative transfusion emy of Pediatrics Committee on Bioethics. Pediatrics
requirements in patients having a major orthopaedic op- 1997;99:279-281.
eration: The American Erythropoietin Study Group.
Simon TL, Alverson DC: AuBuchon J, et al: Practice pa-
J Bone Joint Surg Am 1996;78:62-72.
rameter for the use of red blood cell transfusions: De-
Feagin BG, Wong CJ, Kirkley A, et al: Erythropoietin veloped by the Red Blood Cell Administration Practice
with iron supplementation to prevent allogeneic blood Guideline Development Task Force of the College of
transfusion in total hip joint arthroplasty: A random- American Pathologists. Arch Pathol Lab Med 1998;122:
ized, controlled trial. Ann Intern Med 2000;133:845-854. 130-138.
Goodnough LT, Despotis GJ, Merkel K, Monk TG: A Sparling EA, Nelson CL, Lavender R, Smith J: The use
randomized trial comparing acute normovolemic he- of erythropoietin in the management of Jehovahs Wit-
modilution and preoperative autologous blood donation nesses who have revision total hip arthroplasty. J Bone
in total hip arthroplasty. Transfusion 2000;40:1054-1057. Joint Surg Am 1996;78:1548-1552.
Grosvenor D, Goyal V, Goodman S: Efficacy of postop- Spence RK: Surgical red blood cell transfusion practice
erative blood salvage following total hip arthroplasty in policies. Am J Surg 1995;170(suppl 6A):3S-15S.
Phosphate absorption is decreased in the vitamin D- tion of bone and the release of calcium, phosphate, and
deficient individual. Phosphorus resorption takes place matrix proteins into the circulation. PTH stimulates ex-
primarily in the proximal tubule (85%) against an elec- pression of RANKL on the cell surfaces of osteoblasts,
trochemical gradient. Three sodium gradient-dependent and stimulates synthesis of macrophage colony-
phosphate transporters have been described (Npt1, stimulating factor, which act together to stimulate matu-
Npt2, and Npt3). Npt2 is highly regulated and responsi- ration of osteoclasts. PTH also inhibits the expression of
ble for most phosphorus transport. FGF-23 has been osteoprotegerin, a decoy protein that blocks the effect
identified as a regulator of Npt2. The PHEX gene prod- of RANKL; this action further increases osteoclastogen-
uct metabolizes FGF-23 and mutations in the PHEX esis and the activity of mature osteoclasts. Intermittent
gene can cause hypophosphatemia because of the in- PTH exposure, however, appears to result in increased
ability to metabolize FGF-23 (X-linked hypophos- bone remodeling and a net increase in trabecular bone.
phatemic rickets). The mechanisms by which PTH increases bone forma-
tion are not fully understood. PTH increases the num-
Hormonal Regulation of Calcium and Phosphorus ber of osteoblasts and may act by increasing local con-
Metabolism centrations of growth factors, such as insulin-like growth
Parathyroid Hormone factor-I (IGF-I) and FGFs, which then exert paracrine
The principal regulators of calcium metabolism are actions on the bone to stimulate growth and new bone
PTH and vitamin D. PTH acts in the bone to stimulate formation. This observation of the anabolic actions of
the release of calcium and phosphorus into the circula- PTH may lead to new therapies for the treatment of os-
tion and in the renal tubules to increase the resorption teoporosis.
of calcium and the excretion of phosphorus. It also in-
creases the 1- hydroxylase activity, thereby raising the Vitamin D
concentration of 1,25(OH)2D, which acts to enhance the Vitamin D is a classic steroid hormone that is derived
intestinal absorption of calcium and phosphorus. from cholesterol and undergoes hydroxylation in the
The major physiologic regulator of PTH secretion is liver and kidney to its biologically active form,
the extracellular calcium concentration. Low calcium 1,25(OH)2D. The primary role of vitamin D is to main-
concentrations increase, and high calcium concentra- tain calcium levels within the normal range by increas-
tions decrease the PTH secretory rate, PTH gene ex- ing intestinal absorption of calcium and by increasing
pression, and parathyroid cell proliferation. The CaSR maturation of osteoclasts to mobilize calcium from the
appears to be the principal mediator of calcium concen- bone when needed. In addition, vitamin D has effects on
tration and PTH response. The CaSR is a G-protein cell differentiation and proliferation and on the immune
coupled receptor; binding activates several intracellular system. It enhances insulin secretion and downregulates
signaling pathways including protein kinase C and inosi- the renin-angiotensin system. Vitamin D is produced in
tol triphosphate, which increase cytosolic calcium con- the skin during exposure to sunlight (ultraviolet B, 290
centrations and several mitogen-activated protein ki- to 315 nm) and absorbed from dietary intake. The pro-
nases. These changes modulate the expression of genes
duction of vitamin D by sunlight exposure is severely
controlling cell proliferation, differentiation, and apop-
impaired by the use of sunscreens. Natural dietary
tosis. CaSR also stimulates the influx of extracellular
sources of vitamin D are limited to oily fish such as
calcium ions through a mechanism that is not yet fully
mackerel and salmon. Dietary vitamin D is also avail-
understood. In the parathyroid gland, CaSR has three
able from fortified foods such as milk and orange juice,
key regulatory actions: PTH secretion, PTH gene ex-
and from multivitamins. A recent increase in the inci-
pression, and cell proliferation. Mouse gene knockout
dence of rickets in children has led the American Acad-
studies and human gene mutations both have shown the
key role of CaSR in the regulation of PTH. A drop in emy of Pediatrics to release new recommendations for
serum calcium concentration, perceived by the CaSR, is the intake of vitamin D in infants.
translated into a rapid release (in seconds) of PTH, a
decreased intracellular PTH degradation rate that in- Sex Steroids/Estrogen
creases the amount of bioavailable PTH for release (in Adolescence is a time of rapid increase in skeletal mass
minutes), increased transcription of the PTH gene (in resulting from the concurrent release of sex steroids and
hours to days) and eventually increased proliferation of an increase in the growth hormone secretory rate. Up to
parathyroid cells (in days to weeks). 25% of peak bone mass is accumulated during the peak
PTH has complex actions in bone with a net result of pubertal growth. At peak height velocity, adolescents
that may be either anabolic or catabolic. Chronic PTH have reached 90% of adult height but only 57% of peak
exposure leads to a catabolic state; increased numbers bone mass. Over the next several years, the bone density
of osteoclasts and osteoclast activity increase degrada- increases.
Adult women, at the end of the reproductive life cy- teopenia can be defined for both the lumbar spine and
cle, experience rapid loss of bone mass associated with for the femoral neck. There are inherent limitations in
menopause and declining estrogen production. Bone BMD measurements that limit their applicability in de-
loss also occurs in men, although at a slower rate, as tes- fining standards of osteopenia and osteoporosis in
tosterone production declines. Evidence suggests that it adults, and even more so in pediatric patients. Dual-
is the circulating estradiol concentration in men that is energy x-ray absorptiometry (DEXA) scans interpret
most correlated with bone loss. Both osteoblasts and os- the bone density unicompartmentally with no ability to
teoclasts possess estrogen receptors. Estrogen promotes evaluate the cortical density separately from the trabec-
the differentiation of osteoblasts and suppresses osteo- ular density, although each may respond differently to
clast activity in part by increasing osteoclast apoptosis. disease state or therapy. Response of one compartment
Estrogen may also act through the stromal cells in the rather than another could potentially alter outcomes. A
bone marrow to decrease cytokine production, which DEXA scan provides limited information on bone in-
decreases osteoclast recruitment. tegrity and is unlikely to impart the complete status of
In the elderly population, growth hormone secretion bone health.
also declines and may contribute to decreased bone In postmenopausal women, the mainstay of treat-
mineralization. In response to decreased growth hor- ment of osteoporosis has been hormone replacement
mone levels, IGF-I concentration is reduced. The magni- therapy (HRT) using an estrogen preparation. Because
tude of the decrease of human growth hormone and bone loss resumes when estrogen therapy is stopped, it
IGF-I on bone loss is unclear. Glucocorticoids inhibit was believed by some physicians that therapy should be
bone formation by shortening osteoblast lifespan via a lifelong. Recently that recommendation has been ques-
combination of decreased replication and increased ap- tioned by the results of the Womens Health Initiative.
optosis and decreased transcription of type I collagen, This long-term study was designed to compare treat-
osteocalcin, and other matrix proteins. Glucocorticoids ment of postmenopausal women with an estrogen and
suppress IGF-I and insulin-like growth factor binding progestin combination arm, an unopposed estrogen arm,
protein expression in osteoblasts. IGF-I and insulin-like and a placebo arm; outcome measures were incidence of
growth factor binding protein act in a paracrine manner colorectal cancer, breast cancer, heart disease, and frac-
to increase bone formation. Glucocorticoids increase tures. After 5 years, the study arm using the estrogen
bone resorption, decrease sex steroid concentrations, and progestin combination was terminated early when
and inhibit calcium absorption in the intestine. All of an interim analysis indicated evidence of an increased
these factors result in increased bone resorption and risk for breast cancer. This finding, along with evidence
subsequent osteoporosis. of some increased risk for cardiovascular disease, stroke,
and pulmonary embolism, outweighed the benefits of a
Metabolic Bone Disease reduced risk for fractures and the possible benefits in
Bone formation and bone resorption pathways are preventing colorectal cancer. The study arm using estro-
tightly coupled. When there is a disruption in either gen alone is continuing. The study has significant limita-
component of bone formation or bone resorption, the tions, but it is likely to discourage some women from us-
result is metabolic bone disease. Depending on the na- ing postmenopausal HRT.
ture of the disturbance, either bone formation or bone Authors of a recent meta-analysis of pooled results
resorption will predominate, resulting in increased or from randomized studies concluded that multiple thera-
decreased bone formation. pies, including vitamin D, calcitonin, raloxifene, and alen-
dronate decrease the incidence of vertebral fractures.
Osteoporosis Based on the quality of the available studies, the magni-
Osteoporosis is a global problem that is becoming more tude of the treatment effects, the narrow confidence in-
prevalent with the increasing age of the population. The tervals, and the consistent positive results throughout
major clinical outcome of osteoporosis is fracture, but each study, the authors of this meta-analysis concluded
multiple factors contribute to fracture risk. The most that the evidence most strongly supports the effect of al-
readily available and best standarized clinical measure endronate and risedronate for reducing vertebral frac-
of osteoporosis is the BMD measurement; BMD is tures; the effects of other agents remain unclear. The
strongly correlated with bone strength and is a predictor data on HRT indicate a confidence interval that in-
of fracture risk. The World Health Organization has de- cludes a possible increase in risk for vertebral fractures.
fined osteopenia and osteoporosis based on BMD val- It has been shown that HRT increases BMD; studies of
ues, which are defined in adult women by a T score. A longer duration may ultimately prove that it also de-
T score of 0 is equal to the mean for age. A T score of creases the incidence of vertebral fractures. Large ran-
1.0 to 2.5 defines osteopenia, and a T score of less domized controlled studies, such as the Womens Health
than 2.5 defines osteoporosis. Osteoporosis and os- Initiative, are needed to definitively determine the ben-
efit and risk/benefit ratio. Most studies that have shown data to interpret pediatric scans will result in an under-
an impact for HRT have been case controlled or cohort estimate of BMD, leading to misdiagnosis of osteoporo-
studies. sis and osteopenia. Incorrect diagnoses of these condi-
tions in children and teens may lead to excessive
Pediatric Bone Health parental concern, increased health care expenditures,
Osteoporosis has been considered to be a disease of and unnecessary therapy. Unnecessary restrictions on
adulthood; however, there is increasing evidence that patient activity could prove detrimental rather than
the roots of osteoporosis begin much earlier in life. Os- helpful.
teoporosis is often assumed to be the result of bone loss The lack of diagnostic criteria for osteoporosis is a
in the older patient, however, a patient who does not at- major limitation to the usefulness of DEXA data in the
tain optimal bone mass is at increased risk for acceler- pediatric population. Currently, BMD data will allow
ated bone loss and premature osteoporosis. Peak bone comparison of a pediatric patient with an age-matched,
mass is attained as a result of bone mass acquisition dur- gender-matched, and possibly a pubertal stage-matched
ing childhood and adolescence. Therefore, any factors average; however, this comparison does not allow for
that inhibit the maximal acquisition of bone mass can the prediction of fracture risk. Studies that correlate
contribute to lower peak bone mass and the subsequent BMD with fracture incidence in the pediatric popula-
development of osteoporosis and its inherent health tion are ongoing, but data are not yet available.
consequences. Attainment of peak bone mass is a func- Serum and urine markers of bone formation and re-
tion of intrinsic, unalterable factors such race, gender, sorption have been used in adult patients to determine
and genetics, and extrinsic or alterable factors such as the etiology of bone loss and to follow up on treatment
diet, participation in weight-bearing exercise, the effects effectiveness (Table 2); however, the data are of limited
of illness, and the use of certain medications. use in the pediatric and adolescent populations. Refer-
It is more difficult to assess bone health in children ence ranges must be determined for age and pubertal
than in adults because there is limited information status and any values must be interpreted with knowl-
about normal or average bone mass acquisition and vir- edge of the patients pubertal status. The fact that peak
tually no data correlating fracture incidence with BMD. growth and bone mineral acquisition correlates with in-
Fracture incidence during childhood may not be the cor- creased bone turnover and net bone formation, should
rect end point to assess bone health. The DEXA scan is be reflected in the markers of bone metabolism and will
more difficult to interpret in children and adolescents alter the reference range for a child of any age. As bet-
because diagnostic standards developed by the World ter standards are developed, bone markers in conjunc-
Health Organization are based on adult bone mass and tion with an imaging modality may help to identify chil-
are not applicable to pediatric and adolescent patients, dren with bone mass acquisition deficiencies and assist
who are still acquiring bone. For the pediatric and ado- in determining therapeutic plans.
lescent patient, it is crucial to have the DEXA scan
done on a machine that has a pediatric software data- Rickets
base and to have the scan interpreted by a health pro- Rickets is a disease of growing bone resulting in de-
fessional experienced with pediatric scans. Pediatric creased mineralization of new bone, which can ulti-
BMD measurements are subject to many variables not mately limit peak bone mass if not recognized and
encountered in the adult population. During puberty, treated. The deficiencies that cause rickets are present
there is a substantial increase in skeletal mass and min- long before physical signs are evident. Rickets easily can
eralization exerted by the growth stimulating effects of be diagnosed with a radiograph of the wrist or knee and
the sex steroids (estrogen and testosterone) and by laboratory evaluation, which is essential to determine
growth hormone. The timing of peak growth velocity the etiology of the disease (Tables 3 and 4).
and peak bone mass is different in males and females In the past several years, a resurgence of nutritional
with peak growth of the skeleton preceding the attain- rickets has become evident. In response to this resur-
ment of peak bone mass. Pubertal status has a major ef- gence, the American Academy of Pediatrics published
fect on bone mineralization; it may be more appropriate new guidelines in 2003 for the intake of vitamin D in in-
to compare patients by pubertal stage (Tanner stage) fants and children (Table 5). The increase in the inci-
rather than by chronologic age. Some centers with large dence of rickets is probably a consequence of several
databases can provide that information. factors. (1) There has been an increased emphasis on
All pediatric DEXA scans must be interpreted with breastfeeding infants. Human breast milk typically has a
a Z score rather than a T score. The T score relates the low concentration of vitamin D (< 136 IU/L), which is
patients BMD measurement with an adult reference limited even with maternal supplementation. Also, many
standard. The Z score relates the patients BMD to age- women do not maintain an adequate intake of calcium
and gender-matched controls. The use of adult reference and vitamin D during lactation. (2) Over the years, it
was assumed that normal casual sunlight exposure in 7-dehydrocholesterol to previtamin D in the skin. Even
older children and adolescents ensured adequate vita- in regions with high amounts of sunlight, it is likely that
min D production (especially in areas of the country the proper use of sunscreens will markedly reduce the
that enjoy many days of bright sunlight throughout the endogenous production of vitamin D in children. (3) Di-
year). However, it is difficult to quantify the amount of etary calcium deficiency may contribute to the increase
sunlight exposure of any individual and to determine in the number of observed cases of rickets. Many chil-
the amount of sunlight necessary to ensure adequate vi- dren who are breast fed for most of the first year of life
tamin D production. This situation is further compli- are being weaned from breast milk to nondairy drinks;
cated by the American Academy of Pediatrics recom- many children drink little or no milk and some consume
mendation for sunscreen use on children and for the virtually no dairy products. Older toddlers are at risk for
limitation of sunlight exposure in very young children to developing rickets because of inadequate calcium intake
decrease the risk of skin cancer. The use of sunscreens compounded by marginal vitamin D status. Surveys of
markedly decreases skin production of vitamin D; appli- children and teens have repeatedly documented calcium
cation of a 5% p-aminobenzoic acid solution (sun pro- intake of less than 50% of the American Dietetic Asso-
tection factor 8) blocks over 95% of the conversion of ciation guidelines (Table 6).
Table 4 | Laboratory Tests to Evaluate Suspected Rickets Table 5 | The 2003 American Academy of Pediatrics Guide-
lines for Vitamin D Intake for Infants and Children
Assay/Test Purpose
The ingestion of 200 IU of vitamin D per day is recommended for healthy
Calcium, phosphorus Assess for deficiency infants and children
Alkaline phosphatase High level indicates increased bone A supplement of 200 IU of vitamin D per day is recommended for:
turnover All breastfed infants unless they are weaned to at least 500 mL per
Blood urea nitrogen, creatinine, Evaluate renal function day of vitamin-D fortified formula or milk
bicarbonate All nonbreastfed infants who are ingesting less than 500 mL per day of
25(OH)D, 1,25(OH)2D Assess for deficiency and vitamin D vitamin-D fortified formula or milk
metabolism Children and adolescents who do not get regular exposure to sunlight
PTH Evaluate PTH response and who do not ingest at least 500 mL per day of vitaminD- fortified
Urine calcium: creatinine ratio Rule out hypercalciuria; young child milk
has higher levels than does older
child or adult (normal values
< 0.25 in older child or adult)
Tubular resorption of phosphorus Assess for renal phosphorus Table 6 | Recommendations for Daily Calcium Intake
wasting Adequate Age Range Recommended
Age Range (years) Intake* (mg/d) (years) Intake (mg/d)
0.0 to 0.5 210 0.0 to 0.5 400
The American Academy of Pediatrics guidelines on
vitamin D intake in infants and children (Table 5) are 0.5 to 1.0 270 0.5 to 1.0 600
designed for these patients to achieve a serum concen- 1.0 to 3.0 500 1.0 to 5.0 800
tration of vitamin D greater than 11 ng/mL. This is a 4.0 to 8.0 800 6.0 to 10.0 800 to 1,200
conservative target and was determined from studies 9.0 to 13.0 1,300 11.0 to 18.0 1,200 to 1,500
that evaluated the dosage required to prevent rickets. 14.0 to 18.0 1,300
Traditionally, serum levels or 10 to 12 ng/mL have been
considered adequate for sufficient vitamin D stores; *Institute of Medicine
however, most endocrinologists now recommend serum National Institutes of Health Guidelines
levels of at least 15 to 20 ng/mL. Based on serum vita-
min D levels and studies on the use of supplemental vi-
tamin D, an intake of 300 to 400 IU/day is probably nec- roidism is a result of several factors including hypocal-
essary to maximize bone health in the absence of cemia and hyperphosphatemia, decreased 1,25(OH)2D
sunlight. In the presence of sunlight, the requirement for production by the kidney, skeletal resistance to PTH ac-
dietary vitamin D may be lower. Nutritional rickets is a tion, altered PTH gene transcription, and reduced ex-
preventable disease. The cost of prevention is low and pression of CaSR and vitamin D receptors on the par-
the safety profile of vitamin D is good. athyroid cells. With sustained elevation of serum PTH
levels, osteoblastic and osteoclastic activity in bone in-
Renal Osteodystrophy creases and results in increased bone turnover.
Impaired renal function results in disordered mineral Low turnover bone disease occurs when the PTH
metabolism that is manifested in multiple tissues. Renal level is normal or minimally elevated. This disease had
osteodystrophy includes multiple disorders of bone me- previously been associated with aluminum toxicity. Cur-
tabolism associated with chronic renal disease. Chronic rently, low turnover bone disease is more likely to be as-
renal disease leads to altered PTH synthesis and secre- sociated with diabetes, corticosteroid use, or advanced
tion, parathyroid gland hyperplasia, abnormal calcium age. The recent use of large doses of oral calcium and
and vitamin D metabolism, chronic acidosis, and inhibi- active vitamin D analogs can lead to lowered PTH lev-
tion of growth hormone action. All of these effects alter els and decreased stimulus for bone turnover; this situa-
bone metabolism and manifest in renal bone diseases. tion probably accounts for the increase in adynamic dis-
The spectrum of renal bone disease includes both in- ease, which is histologically evidenced by increased
creased and decreased turnover states. In general, high osteoid and undermineralized bone collagen. The long-
turnover states are associated with increased PTH levels term consequences of low turnover renal osteodystro-
and low turnover states with normal or low PTH levels. phy are unknown.
The definitive method for determining the type of renal
disease is bone histology. Hyperparathyroidism
High turnover renal bone disease is a consequence Hyperparathyroidism is characterized by hypercalcemia
of sustained high PTH levels. Secondary hyperparathy- resulting from excessive PTH secretion. The normal
feedback control of PTH secretion is disrupted, leading data are available from randomized clinical trials for the
to increased secretion that is not normally responsive to use of bisphosphonate treatment in children and teenag-
an increased calcium concentration. Most patients ers. Although bisphosphonates may prove beneficial,
(80%) with primary hyperparathyroidism have solitary they should be used with extreme caution. Growing
adenoma in one parathyroid gland. In about 15% of pa- bone requires coordination of bone resorption and bone
tients, hyperparathyroidism is a consequence of four- formation. Bone formation predominates in children
gland hyperplasia, which can occur in conjunction with and teens, and thus the pharmacologic suppression of
multiple endocrine neoplasia type 1 or type 2. Very resorption may have different consequences than seen
rarely (in < 1% of patients), it is a result of parathyroid in adult patients. Also, the half-life of the bisphospho-
carcinoma. The exact molecular basis for primary hyper- nates is nearly a decade. Treating a young woman before
parathyroidism is unknown. Familial causes of hyperpar- or during childbearing years may have unforeseen con-
athyroidism include multiple endocrine neoplasias sequences for the fetus and mother. It is important to
(1 and 2A). Germline mutations in a nuclear protein tu- select patients for treatment in whom the risk to benefit
mor suppressor gene encoded on chromosome 11 have ratio is apparent; this information should be clearly
been described in patients with both familial and spo- communicated with the parents and the child or teen.
radic multiple endocrine neoplasm 1. Multiple endo-
crine neoplasm 2 is caused by mutations in the RET Pagets Disease
proto-oncogene. Pagets disease is a localized disorder of bone remodel-
Primary hyperparathyroidism is treated by removal ing; it has a familial pattern of aggregation, but no single
of the abnormal parathyroid tissue. Medical manage- gene abnormality has been implicated in the etiology.
ment is more difficult but bisphosphonates can be used Infectious agents have also been implicated as a possi-
to acutely lower serum calcium levels. Over the long ble cause. The initial defect in Pagets disease is in-
course, bisphosphonates may help protect bone density creased bone resorption associated with abnormalities
in patients with hyperparathyroidism who cannot have of osteoclasts found in the lesion. Osteoclasts in a Pag-
or choose not to have surgery. ets lesion are more numerous and contain more nuclei
than normal. Early lesions usually contain abundant os-
Osteopetrosis teoblasts and increased new bone formation. The in-
Osteopetrosis (marble bone disease) is a disorder char- creased bone turnover is manifested by increased uri-
acterized by increased bone mass. It can result from a nary excretion of biomarkers indicative of increased
defect in a variety of genes or gene products, but the fi- bone resorption. Pagets disease is slightly more pre-
nal common pathway is a failure of osteoclast mediated dominant in men than in women and occurs most often
bone resorption. in patients older than 40 years of age. The most common
Infantile osteopetrosis is evident in infancy and is presenting symptom is bone pain. The diagnosis is usu-
rapidly fatal. Cranial nerve deficits, delayed dental erup- ally evident from the radiographic appearance of a lo-
tion, hypersplenism, and hemolysis may occur. Treat- calized lesion consisting of cortical thickening, cortical
ment may include bone marrow transplant, high-dose expansion, mixed areas of lucency and sclerosis, and lab-
glucocorticoids, limitation of dietary calcium, and high- oratory evaluation showing increased markers of bone
dose calcitriol. resorption in the urine and increased alkaline phos-
Intermediate osteopetrosis causes short stature, re- phatase in the serum.
current fractures, and possible cranial nerve deficits. The treatment of Pagets disease is directed at de-
One variant of intermediate osteopetrosis is caused by creasing the activity of the pagetic osteoclasts. Ap-
carbonic anhydrase II deficiency; it is characterized by proved pharmacologic therapies include the bisphos-
osteopetrosis, renal tubular acidosis, and cerebral calcifi- phonates and calcitonin. Medical treatment is indicated
cations and is inherited in an autosomal recessive pat- for patients with painful lesions in the long bones, skull,
tern. and vertebrae, which may cause neurologic damage or
Some individuals with adult osteopetrosis are asymp- secondary arthritis. Although intended to alleviate pain
tomatic, whereas others have facial cranial nerve in- and to prevent complications, few data exist to show
volvement, carpal tunnel syndrome, slipped capital fem- that pharmacologic intervention actually prevents com-
oral epiphysis, and osteoarthritis. plications from this metabolic bone disease.
Iatrogenic suppression of osteoclast activity is an-
other potential etiology of osteopetrosis. Because of Future Directions
promising results seen with the use of bisphosphonates Bone Mineral Density
in the treatment of children with osteogenesis imper- BMD has been a useful tool in the understanding of
fecta, the use of bisphosphonates in treating children bone health and in identifying patients with osteoporo-
with a variety of conditions has increased. However, few sis. It is also increasingly clear that there are limitations
Bone-Forming Tumors of the flat bones or the proximal femur can be very
Osteoid Osteoma large and take on a cauliflower appearance. Secondary
Osteoid osteoma most commonly occurs during the first chondrosarcomatous degeneration occurs in less than
two decades of life and appears as a small lytic nidus, of- 1% of patients and should be suspected in any osteo-
ten with a target appearance surrounded by significant chondroma that grows after puberty or has a cartilage
sclerosis (Figure 1). The nidus may be very tiny and dif- cap of greater than 3 cm during adulthood.
ficult to find on a radiograph. MRI scans will show ex-
tensive edema, which may be mistaken for a marrow re- Osteosarcoma
placing neoplasm. A CT scan with fine cuts (for Osteosarcoma usually occurs during the first through
example, 1 mm) is the study of choice for locating the third decades of life with a second peak in occurrence
lesion. Bone scintigraphy shows focal intense uptake. after the sixth decade. These tumors present as perme-
Osteoid osteomas are associated with a classic pattern ative metaphyseal lesions with soft-tissue extension and
of constant pain secondary to prostaglandin secretion. new bone formation (Figure 4). Periosteal reaction is
For this reason, pain resulting from these lesions is re- common and frequently takes on a sunburst or hair on
lieved significantly for short periods by drugs such as as- end appearance. Osteosarcoma needs to be considered
pirin or ibuprofen that inhibit prostaglandin synthesis. in the differential diagnosis of every aggressive lesion
seen in bone in patients of all ages. It may appear as a
Osteoblastoma purely lytic lesion with no radiographically apparent
Osteoblastoma is a rare neoplasm most often occurring bone formation.
in the posterior elements of the spine or in the metadia-
physeal region of long bones. This tumor has a variable Blastic Metastasis and Pagets Disease
appearance, may be blastic or lytic, and is rarely diag- Blastic metastasis is most frequently seen with prostate
nosed correctly before histologic material is reviewed. and breast carcinoma and typically presents as a perme-
The classic appearance is that of a calcified lesion in the ative lesion with infrequent soft-tissue extension. Pag-
posterior elements of the spine (Figure 2). ets disease may mimic other conditions and can exhibit
a variety of radiographic appearances. Early stage Pag-
Osteochondroma ets disease is characterized by lytic bone, whereas in
Osteochondromas are formed by radial growth of bone late stage Pagets disease, bone is blastic with coarse tra-
during childhood and are characterized by a lesion that beculae and thickened cortices (Figure 5).
grows away from the bone at an angle from the adjacent
growth plate. The hallmark of an osteochondroma is Cartilage-Forming Tumors
that, because it grows away from the underlying bone, Chondroblastoma
the cortex of the lesion is confluent with the cortex of Chondroblastoma usually appears as a painful lytic le-
the bone of origin and it pulls medullary bone up into sion in the epiphysis of a child; significant edema is seen
itself (Figure 3). A tumor that is located on an intact on an MRI scan. In older adolescents, it can occasionally
cortex is never an osteochondroma. Osteochondromas grow across an old epiphyseal line to involve the adja-
can be sessile or pedunculated and many that grow out cent metaphysis. This classic picture of a painful epiphy-
Figure 2 CT scan of the spine showing osteoblastoma Figure 3 Radiograph showing a typical osteo- Figure 4 Radiograph showing a typical osteoblastic
(arrow) in the posterior elements. chondroma. osteosarcoma.
seal lytic lesion with abundant edema may cause this le- slight scalloping; however, the scallops seen on radio-
sion to be confused with infection or osteochondritis graphs are usually short and less than 1 cm each. When
dissecans. enchondromas occur in thin or small bones such as the
fibular head or scapula, some expansion may be seen in
Chondromyxoid Fibroma the radiographic appearance. Because enchondromas
Chondromyxoid fibroma is a rare tumor usually pre- do not know what bone they are in, some cortical ex-
senting as a lytic metaphyseal lesion with cortical thin- pansion in small or thin bones may be present when the
ning but no periosteal reaction (Figure 6). This tumor lesion grows to a typical size.
usually occurs during the first through third decades of
life and is most often located in the proximal tibia. It Chondrosarcoma
frequently has the appearance of a very large nonossify- Unlike enchondromas, chondrosarcomas are active le-
ing fibroma. sions that grow and alter the host bone over time (Fig-
ure 7). Working from the inside of the bone to the out-
Enchondroma side, the changes associated with chondrosarcomas
An enchondroma is a nest of cartilage tissue typically include intralesional lysis, endosteal scalloping, cortical
found in a metaphyseal region and is usually discovered thinning, and expansion. Most chondrosarcomas show
as an incidental finding in adult patients. These lesions chondroid calcification but some may appear purely lyt-
are commonly found when a radiograph of the adjacent ic; they also cause pain.
joint is obtained for reasons unrelated to the enchon-
droma itself. Enchondromas tend to be noncalcified or
minimally calcified in young adults and usually show an Other Tumors
increase in calcification but not an increase in size with Lesions Caused by Infection
long-term follow-up. The calcification has a typical stip- Infection can also mimic the appearance and symptoms
pled or popcorn pattern. These lesions usually do not of other lesions and can exhibit a variety of radio-
cause pain but typically appear hot on a technetium graphic appearances from geographic to permeative and
bone scan. Unlike chondrosarcomas, enchondromas do from lytic to blastic. Periosteal reaction is commonly
not damage the host bone because they do not cause seen on radiographs; localized heat and erythema are
cortical thinning or expansion. They may cause some often found on physical examination.
Figure 5 Radiograph showing typical findings of late Figure 6 Radiograph showing chondromyxoid fibroma Figure 7 Radiograph of chondrosarcoma of the proxi-
Pagets disease including cortical thickening and of the proximal tibia. mal femur.
coarse trabeculae.
Metastatic Lesions itary bone lesion. If no other bone lesions are found and
Metastatic lesions are the most common, aggressive, de- a random bone marrow aspirate from another bone
structive lesions in adults and can exhibit a variety of ra- shows fewer than 5% plasma cells, then a solitary plas-
diographic appearances from lytic to blastic. Metastasis macytoma exists and the prognosis is much better than
frequently results in multiple lesions and may be the for a patient with multiple myeloma. Only 25% of pa-
first presentation of the underlying neoplasm. Although tients with solitary plasmacytoma will have a positive
some metastatic bone lesions, especially those from kid- serum or urine myeloma protein (m-protein) whereas
ney and lung tumors, may grow beyond the confines of most patients with multiple myeloma will have measur-
the bone involved, the presence of an associated soft- able m-proteins detected by serum and urine protein
tissue mass should increase the suspicion of a sarcoma. electrophoresis. The levels of these m-proteins are use-
ful for tumor staging and also for assessing response to
Round Cell Tumors treatment. MRI scans, especially of the spine, are useful
Pediatric round cell tumors include Ewings sarcoma screening studies; technetium bone scans are usually
and metastatic neuroblastoma. Ewings sarcoma classi- normal in patients with multiple myeloma. Lymphoma
cally presents as a diaphyseal permeative lesion with is typically a very permeative but minimally destructive
onion skin periosteal reaction and a large associated lesion, which usually progresses by filling the medullary
soft-tissue mass. Alternatively, Ewings sarcoma may be canal and then growing into the surrounding soft tissues
more metaphyseal and destructive, and it should be con- while causing little destruction of the bone itself (Figure
sidered in the differential diagnosis of such a lesion 11). Radiographs may be remarkably normal, whereas
(Figure 8). Twenty percent of patients with Ewings sar- MRI scans show marrow replacement and often an as-
coma will have associated systemic symptoms such as sociated soft-tissue mass.
fever, chills, and a high white blood cell count, which
may cause the lesion to mimic osteomyelitis. Neuroblas-
toma (Figure 9) appears as a permeative lesion with Unicameral (Simple) Bone Cyst
medullary bone replacement and varying degrees of os- Unicameral bone cysts are usually found in the proxi-
teolysis. Adult round cell lesions include myeloma and mal humerus; are always central, full width lesions; may
lymphoma. Myeloma occurs as solitary or multiple med- cause cortical thinning and minimal expansion; and usu-
ullary lytic lesions with sharp margins but little reaction ally have no associated periosteal reaction. The widest
(Figure 10). Whereas most myeloma patients present portion of these lesions is usually no wider than the wid-
with multiple lesions, a small percentage will have a sol- est portion of the adjacent metaphysis (Figure 12).
Figure 8 Radiograph of Ewings sarcoma of the proxi- Figure 9 Radiograph of metastatic neuroblastoma in Figure 10 Radiograph of myeloma of the proximal
mal fibula. the proximal humerus of a child. humerus.
Radiographic Findings
Certain radiographic findings are important to consider
when making a specific differential diagnosis. By using
the information described in Table 2, a very complete
differential diagnosis of most lesions should be possible.
For example, the radiograph in Figure 17 shows a juxta-
articular lytic lesion in the proximal tibia with a moth-
eaten margin, cortical thinning, and no periosteal reac-
tion in a 19-year-old man with a 6-week history of
progressive knee pain that is worse at night and with
weight bearing. A reasonable differential diagnosis us-
ing the lists in Table 1, and taking into consideration the
patients age, includes osteosarcoma, infection, Ewings
sarcoma, giant cell tumor, and ABC. Biopsy proved the
lesion to be a giant cell tumor. If the same radiograph
had been taken of a 50-year-old man, the differential di-
agnosis would include osteosarcoma, chondrosarcoma,
metastasis, myeloma, lymphoma, and giant cell tumor. In
either case, having a list of lesions to mentally review
greatly increases the completeness of a radiographic dif-
ferential diagnosis and is helpful in ensuring that rele-
vant lesions are considered in the diagnosis.
Imaging Studies
Computed Tomography
Figure 12 Radiograph of a unicameral bone cyst of the proxi- The major role of a CT scan is to show bony detail in-
mal humerus.
cluding bone formation as well as bone destruction. CT
scans are the best study for determining the amount of
Obvious blunt, acute trauma does not usually mimic bone destruction and the presence of soft-tissue calcifi-
tumors, whereas patients with chronic stress factures cation. The ability of CT scans to detect the extent of a
may present with bony reaction that can mimic and be permeative lesion in bone, soft-tissue extension from a
confused with lesions such as lymphoma, osteoid os- bone lesion, or the extent of a lesion in soft tissue is less
teoma, metastasis, or infection. than optimal.
Figure 13 A and B, Radiographs of an aneurysmal bone cyst of the proximal ulna. Figure 14 Radiograph of a nonossifying fibroma of the
distal tibia that is spontaneously resolving.
Magnetic Resonance Imaging are normal on bone scan, are usually old and inactive.
MRI scans are excellent for showing the extent (starting Most metastatic carcinomas and sarcomas in bone are
and stopping points) of a lesion in bone. They are also hot on bone scans, although this finding is not a con-
excellent for showing the presence and extent of edema stant.
within bone and the presence or absence of an associ-
ated soft-tissue extension. MRI is the study of choice for Biopsy
any soft-tissue lesion. The addition of contrast to an If after careful clinical evaluation and imaging studies a
MRI scan can help distinguish areas of cyst formation diagnosis has not been confirmed, a biopsy is the next step.
(which do not enhance with contrast but may show rim The ideal biopsy provides all of the tissue needed to es-
enhancement) from areas of solid tumor (which do en- tablish a histologic diagnosis without affecting subsequent
hance). One exception to this generalization are chon- treatment options. Biopsy has caused much concern
droid lesions, such as low grade chondrosarcomas, which among clinicians and several studies have reported the
may also show rim enhancement with little internal en- problems caused by poorly planned and executed biop-
hancement and, in this regard, may mimic a cyst. Care sies. There is disagreement on whether a community or-
must be taken to differentiate edema in bone and tumor thopaedic surgeon or a specialized orthopaedic oncologist
in bone. Lymphoma frequently presents as high signal in should perform a biopsy. If the diagnosing physician
marrow and must be included in the differential diagno- deems that referral to a tumor specialist for treatment
sis of traumatic marrow lesions such as stress fractures would be appropriate, the physician should defer perform-
or bone bruises. ing the biopsy. The physician who will ultimately treat the
lesion should determine if and how a biopsy is performed.
Technetium Bone Scan For example, in a 17-year old boy with a large painful mass
Technetium bone scans are most useful as a skeletal sur- about the distal femur and radiographic findings indica-
vey tool to determine the total number of lesions tive of osteosarcoma, most orthopaedic surgeons would
present or to locate a single lesion that is suspected but not perform the resection and reconstruction of such a le-
not seen on the initial radiograph. All active bone- sion. Therefore, the patient should be referred to a sub-
forming lesions appear hot, whereas some lytic lesions, specialist who will perform the biopsy in a manner that
which engender no bone reaction, may be normal or will not compromise the definitive treatment. It is under-
cold (for example, myeloma). Sclerotic lesions, which stood that the treating surgeon should be familiar with the
Figure 15 Radiograph of fibrous dysplasia of the dis- Figure 16 Radiograph of a giant cell tumor of the Figure 17 Radiograph of a giant cell tumor of the
tal humerus showing the ground glass appearance. distal femur. proximal tibia.
guidelines concerning the type of biopsy to be performed histologic lesions and as the relationship of histologic
and the appropriate biopsy techniques. findings to a differential diagnosis based on available
Current biopsy options include both open and nee- imaging studies, the whole spectrum of histologic diag-
dle techniques. The advantage of percutaneous needle noses, at least at an elementary level, is more under-
biopsies is that they cause little soft-tissue contamina- standable.
tion and require little or no anesthesia. They are fre-
quently performed under CT scan or ultrasound guid- Bone-Forming Tumors
ance, which can direct a biopsy needle into an Bone forming tumors, including fracture callus, myositis
underlying lesion. The disadvantage of percutaneous ossificans, osteoid osteoma, osteoblastoma, fibrous dys-
needle biopsy is that only a small amount of tissue is ob- plasia, parosteal osteosarcoma, and osteosarcoma, typi-
tained for the pathologist to review. Such biopsies can cally contain woven bone and a spindle cell stroma,
frequently be nondiagnostic. More importantly, primary each of which needs to be scrutinized to understand the
bone tumors are notoriously heterogeneous, thereby nature of the lesion. Histologic evaluation of bone-
creating a great potential for sampling error with closed forming lesions requires an understanding that the bone
techniques. Needle biopsies are optimal for initial sam- differentiates reactive from neoplastic lesions and the
pling of lesions in anatomically inaccessible areas such stromal cells differentiate benign from malignant neo-
as the spine or pelvis. In most locations, however, the plasms. First, the bone produced by a specific lesion
carefully performed open biopsy is still the gold stan- should be examined. Figure 18, A shows lamellar bone
dard. Important rules that should be considered when with a surrounding round cell infiltrate (Ewings sar-
performing an open biopsy are outlined in Table 3. coma) in which the lines of individual bone lamellae can
be seen. Lamellar bone is rarely produced by tumors
and is usually just native host bone entrapped in a le-
Histologic Evaluation sion or part of a mature bone reaction. However, woven
The histologic diagnosis of musculoskeletal tumors is bone can be either neoplastic or reactive, which is deter-
difficult and complicated; one of the difficulties encoun- mined by the presence or absence of osteoblastic rim-
tered in musculoskeletal pathology is the large number ming. Typically, woven bone with significant osteoblastic
of potential diagnoses. If all lesions are considered sepa- rimming is reactive and indicative of fracture callus, pe-
rately, it may be very difficult for the orthopaedist to riosteal reaction, or myositis ossificans (Figure 18, B). In
place a specific lesion into a reasonable differential di- such lesions, spindled stromal cells also may be present
agnosis. By considering trends and patterns of groups of and have some mild atypia (especially in early myositis
or early fracture callus). In contrast, woven bone that Table 2 | Important Radiographic Findings for Making a
shows no osteoblastic rimming is usually neoplastic in Specific Differential Diagnosis
origin and is seen with both benign and malignant bone-
forming neoplasms (Figure 19, A). Neoplastic woven Finding Differential Diagnosis
bone (bone with no osteoblastic rimming) found in as- Sclerotic soap bubble lesion in the Adamantinoma
sociation with a benign spindle cell stroma is indicative anterior cortex of the tibial shaft Cortical fibrous dysplasia
of a benign bone-forming neoplasm. Such lesions in- Small sclerotic lesion with a Osteoid Osteoma
clude osteoid osteoma, osteoblastoma, and fibrous dys- central lytic nidus Stress fracture
plasia. Also included in this histologic differential diag- Infection
nosis is parosteal osteosarcoma, a grade 1 malignant Changes that indicate edema in Intramedullary changes caused by
tumor, which presents with a stroma with little overt bone* lymphoma
atypia. The final pattern seen in bone-forming lesions is Intramedullary edema caused by a
the presence of neoplastic woven bone in association bone bruise or stress reaction
with a malignant spindle cell stroma that constitutes os- Cauliflower exophytic lesion Cauliflower osteochondroma
teosarcoma (Figure 19, B). The findings that make a Secondary chondrosarcoma arising
spindle cell stroma appear malignant include increased in an osteochondroma
cellularity, spontaneous necrosis, the presence of signifi- Multiple bone lesions Metastases
cant atypia or pleomorphism, and a high mitotic rate Myeloma
Enchondromas
with many abnormal mitoses.
Histiocytosis
These bone-forming lesions tend to look very differ- Fibrous dysplasia
ent radiographically; therefore, a radiographic differen- Nonossifying fibromas
tial diagnosis integrated into the histologic differential Lytic lesion in the humeral shaft of Simple bone cyst
diagnosis helps to determine the final diagnosis. a child with no periosteal
reaction
Cartilage-Forming Tumors Lytic lesion in the sacrum Chordoma
There are three histologic patterns of cartilage tumors: Chondrosarcoma
(1) benign cartilage (enchondroma) merging into low- Giant cell tumor
grade cartilage which merges into intermediate and high Metastasis
grade chondrosarcoma; (2) chondroblastoma that is Myeloma
characterized by cobblestone chondroblasts and inter- Calcified lesion on the bone Osteochondroma
surface Periosteal osteosarcoma
vening chicken-wire calcification with immature carti-
Parosteal osteosarcoma
lage; (3) chondromyxoid fibroma that is a benign spin- Myositis ossificans
dle cell lesion with some areas of immature cartilage. Periosteal chondroma
In the first histologic pattern, it is essential to under- Periosteal chondrosarcoma
stand the spectrum of cartilage appearances that match Aggressive metaepiphyseal lesion in Osteosarcoma
the spectrum of histologic grading. Normal cartilage has patients younger than age 30 Ewings sarcoma
two components: cells and matrix. Both are important years Infection
when evaluating cartilage histologically. Normal carti- Aneurysmal bone cyst
lage is sparsely cellular (Figure 20, A). The cells have Giant cell tumor
small oval (pyknotic) nuclei and only one nucleus per Aggressive metaepiphyseal lesion in Osteosarcoma
cell. There is only one cell per lacuna and there are patients 30 years of age or older Chondrosarcoma
rarely cells outside of the lacunae. The matrix is well- Metastasis
Adult round cell tumor
formed and regular with no areas that are loose or fall-
Giant cell tumor
ing apart (myxoid change).
Lytic lesion in the epiphysis of a Chondroblastoma
As cartilage changes from benign to low grade the
child with edema seen on MRI Infection
following changes occurincreased cellularity, the pres-
ence of plump nuclei, occasional binucleate cells, more *Sequential MRI scans of lymphomas show stable or progressive marrow replacement,
whereas sequential MRI scans of stress reaction or a bone bruise show a decrease in
than one cell in some lacunae, some cells outside the la- bone edema over time
cunae, and myxoid change in the matrix.
It is important to measure the thickness of the cartilage cap
The finding of low-grade cartilage includes the spec-
trum of lesions ranging from cellular or active enchon-
dromas to what are sometimes called grade one-half
chondrosarcoma, to grade 1 chondrosarcoma. It is criti- continued growth. Throughout this range of histologic
cal to appreciate that tumors in this range have a vari- appearance, pathologists have no effective means of
able biologic potential in terms of their propensity for predicting growth; therefore, an attempt to artificially
determine where cellular enchondroma ends and low- example, a painful lytic lesion in the epiphysis of a
grade chondrosarcoma begins would be arbitrary. The child). Histologically, a pattern of cobblestone chondro-
term low-grade cartilage tumor has become popular, de- blasts (polygonal cells with well-defined cell borders)
noting the fact that the pathologist is acknowledging the are seen (Figure 20, B). In association with these cells, a
position of the tumor somewhere within this spectrum branching pattern of calcification referred to as chicken
of behavior. The key for the treating physician is to wire is also common, as is the presence of immature
evaluate the clinical history and imaging studies and to chondroid matrix. These histologic findings in associa-
determine a reasonable course of treatment. Options tion with an epiphyseal lytic lesion in a child yield a
may range from careful observation, to curettage, to re- fairly straightforward diagnosis of chondroblastoma.
section depending on a host of factors including the The third histologic pattern seen in cartilage tumors
presence or absence of pain, the age of the patient, the is found in chondromyxoid fibroma. This is a rare lesion
bone involved, and the presence or absence of radio- that is composed of benign spindle cells in a collagenous
graphic changes typical of chondrosarcomas. matrix with varying amounts of immature chondroid
Chondrocytes look less normal and behave in a less (Figure 20, C). This histologic pattern in association with
normal fashion with increasing grades of malignancy; the typical radiographic findings helps in determining
the chondrocytes develop dark, plump nuclei, cellularity the diagnosis.
increases appreciably, and mitoses become more com- Many bone- and cartilage-forming lesions can be ac-
mon. The cells make less or no matrix, or may produce curately diagnosed by first assembling a radiographic
an abnormal matrix, which may look nothing like recog- differential diagnosis via the radiology lists and then as-
nizable chondroid. Associated with this histologic pro- sessing the histologic spectrum of bone and cartilage
gression is a progressive increase in biologic potential in forming lesions using a knowledge of simple trends and
terms of local aggressiveness and metastatic behavior. pattern recognition. For example, in a 40-year-old
The second histologic pattern in chondroid lesions is woman with a recent history of knee pain who has oth-
seen in chondroblastoma. This lesion is often suspected erwise been in good health, radiographs show an aggres-
even before histologic material is examined because of sive lytic lesion in the distal femur with cortical bone
its characteristic radiographic and clinical features (for destruction and soft-tissue extension. The radiographic
Figure 18 A, Lamellar bone with a surrounding round cell tumor. B, Reactive woven bone showing abundant osteoblastic rimming (arrow) of trabecular surfaces.
Figure 19 A, Neoplastic woven bone showing the absence of osteoblastic rimming and the presence of an associated benign spindle cell stroma typical of a benign bone
forming neoplasm. B, Osteosarcoma showing neoplastic woven bone in association with a malignant spindle cell stroma.
differential of this lesion includes osteosarcoma, chond- disorders should be considered: infection (ie, osteomy-
rosarcoma, metastasis, myeloma, lymphoma, and giant elitis), Langerhans cell histiocytosis, primary round cell
cell tumor. The histology shows woven bone with no os- tumors, and small round cell metastatic carcinomas.
teoblastic rimming compatible with neoplastic woven The histology of bone infection includes the pres-
bone (Figure 19, B). A malignant spindle cell stroma is ence of acute and chronic inflammatory cells. Whereas
also seen histologically. The final diagnosis, osteosar- lymphocytes, which tend to be associated with chronic
coma, is compatible with the radiograph. Although this inflammatory conditions, may resemble lymphoid cells
system cannot encompass and diagnose every muscu- seen in lymphoma, polymorphonuclear leukocytes are
loskeletal lesion, it can provide a framework for devel- usually easy to see and, when present in large numbers,
oping an approach to these diagnoses. indicate a diagnosis of infection. When a round cell infil-
trate is seen and most of the cells can be shown to be
Other Tumors polymorphonuclear leukocytes, then infection is the
Round Cell Tumors likely diagnosis. Confirmation requires culture of an ap-
Round cell tumors are another group of bone lesions propriate pathogenic microorganism.
and include Ewings sarcoma and neuroblastoma in chil- Langerhans cell histiocytosis is also a type of inflam-
dren and myeloma, lymphoma, and small round cell matory condition in bone and can present as a round
metastatic carcinomas in adults. Also included in the dif- cell infiltrate. As the name implies it is composed of foci
ferential diagnosis of this group of tumors are nonmalig- of proliferating histiocytes; varying numbers of small
nant lesions such as Langerhans cell histiocytosis and in- round cells including lymphocytes, neutrophils and, most
fection. The common thread between all of these lesions notably, eosinophils are also present. Histiocytes are
is that they are composed in part or in whole of small large cells with ill-defined cytoplasmic borders and an
round cells. When round cell infiltrate is present in a his- oval or indented nucleus and are often difficult for a
tologic slide from a bone lesion, the following classes of nonpathologist to recognize. Eosinophils are distinctive
Radiographic Evaluation
Most soft-tissue masses are seen poorly or not at all on
plain radiographs; however, those with calcification will
be more apparent. Although myositis ossificans is the
most common lesion characterized by soft-tissue calcifi-
Figure 21 Radiograph of a densely calcified synovial sarcoma mimicking myositis cation, synovial sarcoma may present in this manner
ossificans.
also. The calcification seen in synovial sarcomas can
vary considerably from minute, almost imperceptible
present in soft tissue and include rhabdomyomas, rhab- calcifications to very dense calcification, which may
domyosarcomas, leiomyomas, and leiomyosarcomas. mimic a benign lesion (Figure 21).
Desmin is also occasionally present in desmoid tumors
and in primitive neuroectodermal tumors. Like desmin, MRI Findings
actin is indicative of myogenous differentiation and its MRI is the gold standard for the evaluation of lesions in
tissue-specificity parallels that of desmin. soft tissue. MRI is quite useful in locating a lesion but
less useful in delineating the nature of the lesion. There
S-100 are, however, some notable exceptions to this generali-
S-100 is a protein that derives its name from the fact zation. The classic MRI finding in most soft-tissue tu-
that it is soluble in 100% solution of ammonium sulfate. mors is that of a lesion that is well circumscribed and
It has a wide distribution in human tissues and the showing dark signal on T1, and high signal on T2, fat-
stains indicating the presence of this protein are most suppressed T2, or short-tau inversion recovery (STIR)
commonly associated with neural, chondroid, or mel- views (Figure 22). The possible etiology of such a lesion
anocytic differentiation. includes benign tumor, malignant tumor, abscess, cyst,
and hematoma. It is often incorrectly believed that soft-
Factor VIII Related Antigen tissue sarcomas are grossly invasive whereas benign le-
Factor VIII related antigens (also called von Wille- sions are radiographically distinct and encapsulated.
brands factor) are found in lesions with vascular differ- Most soft-tissue sarcomas are very distinct and often
entiation. These antigens are typically seen in benign show some edema in the compartment in which they oc-
and low-grade vascular lesions such as hemangiomas cur, whereas many benign lesions including desmoid tu-
and hemangioendotheliomas; they usually are not mors, hemangiomas, inflammation, injury, and infection
present in high-grade angiosarcomas. are poorly marginated on MRI scans. Lesions with a
characteristic MRI appearance include lipomas, atypical
Soft-Tissue Tumors lipomas, myositis ossificans, and hemangiomas.
Soft-tissue tumors, like bone lesions, require a system-
atic approach for diagnosis. These lesions have a limited Lipoma
number of clinical presentations. Histologically, how- Lipoma is one of the few histologic diagnoses that can
ever, they form a large and diverse group with fewer be made confidently on the basis of MRI and clinical
trends in their histologic appearance than those found findings alone. Benign lipomas appear as masses of uni-
in bone tumors. form fat density and parallel the appearance of normal
subcutaneous fat on all sequences. They are bright on T1
Clinical Presentation and T2 views (Figure 23) but suppress, as does normal
Most soft-tissue tumors present with pain and/or a mass. fat, on fat-suppressed T2 and STIR views. A mass seen
As noted previously, there is often a history of trauma on MRI as a uniform fat density with no interstitial
as patients tend to relate the emergence of a mass lesion markings is diagnostic of benign lipoma.
Myositis Ossificans
Late inactive myositis ossificans lesions present radio- There are many specific tumors to consider and the
graphically as uniform, well marginated, and benign ap- range of lesions goes beyond the scope of this chapter.
pearing calcification in soft tissue. The calcification often
is more prominent peripherally and is termed eggshell cal-
cification (Figure 25). Early lesions show little or no cal-
Treatment of Musculoskeletal Tumors
Several treatment options are available for musculoskel-
cification but do show tremendous inflammation and
etal tumors. Lesions in bone may be treated with op-
edema in the adjacent soft tissues. In such cases, the area
tions ranging from simple curettage, to aggressive in-
of edema is much larger in volume than the area of the
tralesional excision, to wide and radical resection.
lesion itself.
Simple curettage is sufficient for lesions that tend to be
self-limited such as nonossifying fibroma and eosino-
Hemangioma
philic granuloma. Aggressive benign lesions such as gi-
Hemangiomas are typically diffuse heterogeneous le- ant cell tumor, aneurysmal bone cyst, chondromyxoid fi-
sions with serpiginous borders (Figure 26). The classic broma, and osteoblastoma require a more aggressive
findings of a hemangioma include the presence of a surgical technique entailing several steps, which to-
painful lesion in soft tissue which presents with a soft- gether allow the surgeon to control the tumor bed and
tissue mass seen on MRI scan but with no mass effect. result in a high likelihood of local control. These steps
Atrophy, underlying pain, and smooth soft-tissue calcifi- for aggressive intralesional excision are shown in Table
cations (phleboliths) are common. 4. It is only through the meticulous and methodic appli-
cation of these steps that eradication of the underlying
Histology of Soft-Tissue Tumors lesion can be reliably achieved.
The histology of soft-tissue tumors has fewer common Soft-tissue tumors may be treated with a full range of
trends compared with the histology of bone lesions. surgical options including debulking, marginal excision,
Figure 23 A benign lipoma (arrow) of the thigh show- Figure 24 An atypical lipoma (well-differentiated li- Figure 25 Myositis ossificans of the elbow with typi-
ing a uniform fat density with no interstitial markings. posarcoma) showing lobules of fat with surrounding fi- cal eggshell calcification.
brous strands.
wide resection, and radical resection. Most benign soft- lesions in soft tissue. Like hemangiomas, these lesions
tissue masses such as lipomas, schwannomas, and myxo- have a very high rate of recurrence following even ag-
mas can be easily excised. Soft-tissue tumors with a gressive attempts at local resection and are often large
greater tendency for local invasion and infiltration can and may involve significant portions of major functional
be very challenging to treat and may require a variety of structures. The idea of a major and morbid resection for
treatment modalities beyond simple surgical techniques. a benign lesion is often unacceptable. Nonsurgical op-
Benign vascular lesions, for example, have a high rate of tions exist and have replaced surgery in many centers.
recurrence following surgical excision and often involve Treatment using low-dose chemotherapy with methotr-
such large areas of tissue that excision is not reason- exate, vinblastine, or vinorelbine has been reported by
able. These lesions may be treated with a variety of non- several authors and achieves a high rate of local control
surgical techniques such as embolization or direct alco- with minimal morbidity. Radiation is also a reasonable
hol injection. Many patients with benign vascular lesions option but is a cause for concern for subsequent malig-
such as hemangiomas and arteriovenous malformations nant transformation because of the young age of most
are difficult to cure; many will have prolonged symptoms patients with desmoid tumors.
and disability despite therapeutic intervention. Desmoid The treatment options for sarcomas of bone and soft
tumors are another example of benign yet problematic tissue are summarized in Table 5. The therapeutic strat-
egy is to apply treatments to specific lesions that re- Table 5 | Sarcoma Treatment Modalities
spond to that type of treatment and to avoid options
that are not effective. The differentiation of local versus Radioresistant Tumors Radiosensitive Tumors
systemic treatments is also important. Local treatment
options include surgery and radiation. In the context of Low Grade Surgery Surgery + Radiation
Chondrosarcoma Low-grade soft-tissue
sarcoma treatment, surgery usually refers to procedures
Chordoma sarcomas
that achieve wide margins around the tumor. Current Adamantinoma
musculoskeletal oncology surgery infrequently requires High Grade Surgery + Chemotherapy Surgery + Radiation +
amputation or radical margin surgery for extremity sar- Chemotherapy
comas. The primary indication for such procedures Osteosarcoma High-grade soft-tissue
would involve long-neglected lesions or lesions with the Ewings sarcoma sarcomas
direct involvement of neurovascular structures, whose Other high grade bone
resection would preclude the maintenance of a func- sarcomas
tional limb. Adjuvant treatments such as chemotherapy
and radiation have permitted wide margins to become
increasingly thin, especially along neurovascular struc-
tures. These surgical procedures allow functional preser-
plan should be individualized for each patient with con-
vation and still achieve good rates of local control that
sideration for the potential benefits of each treatment
are not statistically different from those obtained with
option.
amputation. Both surgery and radiation are aimed at lo-
cal control and do not affect the systemic tumor burden. Low-grade soft-tissue sarcomas respond well to a
Chemotherapy is a systemic treatment that has the po- combination of wide resection surgery and local radia-
tential to act effectively against tumor cells throughout tion. The radiation can be given either preoperatively or
the body even if they cannot be detected by current im- postoperatively because there is no difference in local
aging techniques. Chemotherapy may affect the local tu- control if the treatments are well planned. The major
mor as well as any distant disease. Low-grade malignant advantage to preoperative radiation is that the presence
tumors tend to metastasize at a lower rate than do high- of the lesion in situ allows the radiation oncologist to
grade lesions; therefore, it is reasonable to approach the concentrate the field of radiation on the lesion, which
former with local treatments only. High-grade lesions, usually allows treatment of a smaller field size than in
which carry a high likelihood of metastasis, are best patients where the lesion has been removed. Radiation
treated with a systemic treatment designed to cure sys- also has beneficial effects on the local tumor, which usu-
temic spread and increase the resectability of the pri- ally will decrease in size and vascularity and increase in
mary lesion, followed by local treatment designed to re- firmness, thereby greatly facilitating resection. The dis-
move the primary tumor. advantage of preoperative radiation treatment is that it
Low-grade bone sarcomas such as chondrosarcoma, necessitates working with tissues that have been dam-
chordoma, and adamantinoma respond poorly to radia- aged by radiation (usually 50 cGy [5,000 rads] of radia-
tion and chemotherapy, making surgery the best treat- tion); this carries a 20% risk of major wound complica-
ment option. High-grade bone sarcomas such as os- tions in most series.
teosarcoma and Ewings sarcoma respond well to High-grade soft-tissue sarcomas still present a major
chemotherapy and it is therefore a consistent part of challenge to the oncology team. Local control can be
treatment protocols. Other high-grade bone sarcomas
achieved with radiation and wide resection as with the
such as malignant fibrous histiocytoma in bone, high-
low-grade malignant lesions. Ideally, the high-grade le-
grade chondrosarcoma, and dedifferentiated chondrosar-
sions should also receive systemic treatment in the form
coma present a challenge because of their predilection
of chemotherapy because of the higher rate of metasta-
to metastasize. Although less data are available than for
osteosarcoma, chemotherapy is often used in an attempt sis associated with high-grade histology. Although these
to both increase resectability and decrease the appear- patients are usually treated with protocols that include
ance or progression of systemic spread. Radiation is still multidrug chemotherapy, the results of this treatment in
a possible local treatment choice for Ewings sarcoma, terms of improved survival are not as dramatic as would
but usually has been replaced by surgery because of the be hoped. Chemotherapy for high-grade soft-tissue sar-
potential for postradiation morbidity and malignant comas continues to be a controversial topic and the sub-
transformation. Despite these concerns, radiation is still ject of much research. It is hoped that new findings re-
used and reasonable in patients where resection carries garding the molecular and genetic bases of these
the risk for unacceptable morbidity or when surgical diseases will spawn new drug treatments for all types of
margins are closer than desired. These principles also sarcomas and further improve the survival of these pa-
apply to other high-grade bone sarcomas; a treatment tients.
Turcotte RE, Wunder JS, Isler MH, et al: Giant cell tu- Enneking WF, Spanier SS, Goodman MA: A system for
mor of long bone: A Canadian Sarcoma Group study. the surgical staging of musculoskeletal sarcoma. Clin
Clin Orthop 2002;397:248-258. Orthop 1980;153:106-120.
A multicenter study of 186 patients with giant cell tumor
of long bone showed a local recurrence rate of 18% after Glasser DB, Lane JM: Stage IIB osteogenic sarcoma.
curettage and 16% after resection. The nature of the filling Clin Orthop 1991;270:29-39.
material or adjuvant uses did not alter recurrence risk.
Mankin HJ, Gebhardt MC, Tomford WW: The use of
Zeegen EN, Aponte-Tinao LA, Hornicek FJ, Gebhardt frozen cadaveric allografts in the management of pa-
MC, Mankin HJ: Survivorship analysis of 141 modular tients with bone tumors of the extremities. Orthop Clin
metallic endoprostheses at early followup. Clin Orthop North Am 1987;18:275-289.
2004;420:239-250.
A review done at one center of endoprostheses about the Mankin HJ, Lange TA, Spanier SS: The hazards of bi-
hip, knee, and shoulder, which included a short mean opsy in patients with malignant primary bone and soft-
follow-up of less than 2 years, is presented. Statistical data and tissue tumors. J Bone Joint Surg Am 1982;64:1121-1127.
Kaplan-Meier analyses are presented and provide a good indi-
cation of short-term complications and short-term prosthetic Mankin HJ, Mankin CJ, Simon MA: The hazards of the
survival. biopsy, revisited: Members of the Musculoskeletal Tu-
mor Society. J Bone Joint Surg Am 1996;78:656-663.
Emerging Concepts and Future Directions
Bacci G, Ferrarri S, Bertoni F, et al: Histologic response Nelson TE, Enneking WF: Staging of bone and soft-
of high-grade nonmetastatic osteosarcoma of the ex- tissue sarcomas revisited, in Stauffer RN (ed): Advances
tremity to chemotherapy. Clin Orthop 2001;386:186-196. in Operative Orthopedics. St. Louis, MO, Mosby Year-
In 510 consecutive patients with high-grade osteosarcoma Book, 1994, vol 2, pp 379-391.
of the extremity, the histologic response to chemotherapy de-
pended on the number of drugs given and the histologic sub-
Pisters PW, Leung DHY, Woodruff J, Shi W, Brennan
type of the tumor. Four drug regimens and telangiectatic tu-
MF: Analysis of prognostic factors in 1041 patients with
mors each correlated with an improved prognosis. localized soft tissue sarcomas of the extremities. J Clin
Oncol 1996;14:1679-1689.
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Table 2 | Most Common Pathogens and Suggested Empiric Antibiotic Therapy in Musculoskeletal Infections
Infection and Clinical Setting Most Common Pathogens Empiric Antibiotic Therapy
Osteomyelitis and septic arthritis
Infant S aureus Penicillinase-resistant penicillin and aminoglycoside or
S pyogenes ceftriaxone
S pneumoniae
Gram-negative organisms
Child younger than age 3 years S aureus Ceftriaxone
S pneumoniae
H influenzae (if nonimmunized)
Older child S aureus Cefazolin or Penicillinase-resistant penicillin
Child with sickle cell disease Salmonella species Ceftriaxone
S aureus
Adult S aureus Penicillinase-resistant penicillin
Suspected MRSA Vancomycin or clindamycin
Immunocompromised adult or child Gram-positive cocci Penicillinase-resistant penicillin and aminoglycoside
Gram-negative organisms
Septic arthritis in sexually active patients S aureus Ceftriaxone
N gonorrhoeae
Diskitis S aureus Penicillinase-resistant penicillin
Lyme disease B burgdorferi Amoxicillin-doxycycline
Clenched-fist bite wounds E corrodens Ampicillin-sulbactam or piperacillin-tazobactam
P multocida
Anaerobes
Nail puncture wounds S aureus Penicillinase-resistant penicillin and aminoglycoside or
P aeruginosa piperacillin-tazobactam
Necrotizing fasciitis Streptococcus group A Penicillin and Clindamycin Aminoglycoside
beta-hemolytic
Gram-positive cocci, anaerobes
Gram-negative organisms
very early stage and is a highly sensitive modality for 19% sensitivity and a 98% specificity; frozen section his-
detecting osteomyelitis with a sensitivity approaching tologic examination for the presence of more than five
100%. The increased water content secondary to edema polymorphonuclear cells per high-power field has an
and hyperemia results in a decreased marrow signal in 80% sensitivity and a 94% specificity.
T1-weighted images, and an increased signal in T2- Cultures remain the gold standard for establishing
weighted images, respectively. In the diagnosis of septic the diagnosis of infection. However, the prior adminis-
arthritis, studies have shown that MRI has 97% sensitiv- tration of antibiotics, inadequate specimen sampling, or
ity and 92% specificity. It allows for the detection of in- improper handling of specimens may preclude the
creased intra-articular fluid, and for the evaluation of growth of pathogens.
potential spread of infection into adjacent bone or soft Molecular diagnostic techniques are available and
tissue. may improve diagnostic efficacy in the future. A recent
Identification of organisms following Gram stain of study indicates that polymerase chain reaction (PCR)
specimens from the involved area occurs in approxi- can amplify and detect bacterial DNA, potentially lead-
mately one third of cases. Despite its low yield, the ing to an earlier diagnosis compared with cultures. An-
Gram stain examination can be useful because it is other advantage of this technique is that the results are
highly specific and may help the physician to determine not affected by the concurrent use of antibiotics because
the most appropriate antibiotic for initial therapy. For PCR does not depend on in vitro growth of the organ-
infections occurring after hip arthroplasty, evaluation of ism. However, concerns about false-positive results sec-
inflamed tissue specimens with Gram staining has a ondary to contamination still exist.
Osteomyelitis in Adults rulent fluid, soft tissue, and bone from the affected area
Osteomyelitis (bone inflammation secondary to the require aerobic, anaerobic, mycobacterial, and fungal
presence of microbial pathogens) can be classified based cultures. The latter two cultures are especially important
on the pathogenesis (hematogenous, traumatic, contigu- in immunocompromised patients or those with chronic
ous spread), the duration of the process (acute, sub- osteomyelitis. The wound is copiously irrigated with sa-
acute, chronic), and the age of the patient (adult versus line; antibiotics may be added to the irrigation fluid.
pediatric). The dead space that results from dbridement is
Osteomyelitis in adults usually results from trauma filled with physician-made polymethylmethacrylate
(open fractures), surgical procedures (postoperative in- beads impregnated with antibiotics such as tobramycin,
fections after open reduction and internal fixation of vancomycin, cefepime, or other microbial-specific anti-
fractures), or contiguous spread from adjacent infec- biotics available in powder form. Elution of antibiotics
depends on the surface area and characteristics of the
tions. The tibia is the most common site of adult osteo-
antibiotic delivery vehicle, the type and concentration of
myelitis. Hematogenous osteomyelitis is uncommon in
the antibiotic(s) used, the presence of fluid, and the rate
adults but may occur in intravenous drug users. The
of fluid turnover. Local antibiotic delivery is a useful op-
most common pathogen is S aureus; however, a variety
tion resulting in high local concentration and low sys-
of organisms may be involved depending on the clinical
temic side effects and can supplement systemic therapy,
setting. Pseudomonas aeruginosa or other gram-
provided the pathogen is susceptible to the eluted anti-
negative organisms may be responsible for the infection
biotic. Nonabsorbable antibiotic delivery vehicles may
in intravenous drug users, and less virulent microbes or
require revision for removal. Intravenous administration
fungi in immunocompromised patients. Adult osteomy-
of antibiotics for 4 to 6 weeks is the recommended ther-
elitis can be staged with the Cierny-Mader classification
apy and can be accomplished on an outpatient basis.
system, which evaluates the anatomic type of bone in- Oral administration of linezolid or quinolones can
volvement (medullary, superficial, localized, diffuse) and achieve adequate blood and tissue concentration levels
the physiologic class of the host (A: normal; B: systemic, and may be a useful alternative to intravenous therapy.
local, or combined compromise of the host; C: morbidity Antibiotic administration is a key part of the treatment
of treatment worse than that of disease). but will not be effective without adequate dbridement.
A diagnosis is based on clinical findings (pain, Development of resistant organisms may occur.
erythema, draining sinuses, systemic symptoms), labora- Skeletal stabilization in the presence of fractures
tory tests (elevated CRP, ESR), imaging modalities (ra- that have not yet united is necessary for infection con-
diographs, MRI, scintigraphy), Gram stain, and cultures. trol. The optimal method of stabilization depends on the
It should be noted that osteomyelitis may be clinically involved bone and the condition of its soft-tissue enve-
silent, so a high index of suspicion is warranted in situa- lope. The need for careful consideration of the soft tis-
tions such as atrophic nonunions after an open fracture sue when planning fixation constructs cannot be over-
or internal fixation of a closed fracture. Chronic drain- emphasized.
ing sinuses may be complicated by malignant transfor- The second stage of the protocol consists of wound
mation and development of squamous cell carcinoma management. If the soft-tissue envelope is adequate, de-
(Marjolins ulcer) in approximately 1% of patients. layed closure can be performed. In the presence of com-
Osteomyelitis can be a limb-threatening condition. promised soft tissues, coverage should be achieved by
Treatment may be prolonged and financially and so- local or free muscle flaps, depending on the location and
cially demanding for the patient; therefore, amputation extent of the soft-tissue defect. Muscle flaps eliminate
may be a reasonable option in some complex cases. dead space, provide soft-tissue coverage, prevent con-
Treatment of osteomyelitis with a limb-salvage protocol tamination with new pathogens, improve the local vas-
consists of dbridement, systemic and local antibiotic cularity and biologic environment, assist the host de-
treatment, skeletal stabilization, soft-tissue coverage, fense mechanisms, enhance antibiotic delivery, and
and treatment of bone defects and nonunited fractures. promote the healing process. Flap coverage is usually
These principles can be incorporated in a staged proto- done 3 to 7 days after the initial dbridement. Local
col. muscle flaps used for coverage of the tibia include the
The first stage of a limb salvage protocol includes gastrocnemius for proximal third defects and the soleus
radical dbridement of all nonviable tissues and skeletal for middle third defects. It is important to consider the
stabilization. Dbridement should proceed until bleed- biologic status of the local muscle to be transferred to
ing, definitively viable tissue is present at the resection avoid using muscle that has itself been compromised by
margins. Inadequate dbridement leads to recurrence of the injury or by ischemic changes. In patients with distal
infection despite antibiotic therapy, because pathogens third tibial defects, a free muscle flap is necessary.
form biofilms on nonviable tissue and escape antibiotic The third stage of the treatment regimen consists of
therapy and host defense mechanisms. Specimens of pu- management of existing bone defects, usually by autoge-
nous bone grafting, which is performed when the soft- detecting a joint effusion. MRI, in addition to detecting
tissue envelope has healed (usually 6 to 8 weeks after a joint effusion, delineates any bone and soft-tissue in-
the muscle transfer). At this stage, viability of the flap volvement.
and control of infection have been determined. For an- Aspiration of the involved joint always should be
terior defects and most nonunions of the tibia, the mus- done to establish the diagnosis and to identify the
cle flap is elevated and the graft is placed at the site of pathogen. The joint aspirate should be sent for Gram
the nonunion or defect. Posterolateral tibia bone graft- stain, cultures, sensitivity testing, WBC count with differ-
ing is an alternative if there is no anterior sequestrum or ential, and crystal analysis. A WBC count greater than
need for a soft-tissue procedure anteriorly. The useful- 50,000 cells/mm3 and a differential with polymorphonu-
ness of bone graft substitutes as void fillers in a defect clear leukocytes exceeding 75% indicate septic arthritis;
of infectious etiology is still being evaluated. Bone de- however, lower values do not preclude the diagnosis.
fects greater than 6 cm require specialized reconstruc- Synovial fluid cultures are positive in approximately
tive procedures such as vascularized bone grafts or dis- 90% of patients with nongonococcal arthritis, compared
traction osteogenesis. Limb salvage can result in a with 25% of those with gonococcal arthritis. Blood cul-
satisfactory functional outcome. An outcomes study of tures are positive in approximately 50% of patients with
patients with chronic osteomyelitis of the tibia done in nongonococcal arthritis, whereas the yield is only 10%
2000 showed that at a mean follow-up of 5 years, 39 of in those with gonococcal arthritis.
46 patients (85%) were able to ambulate independently Surgical decompression by arthrotomy of a septic
without pain. Patient age (advanced age) and a history joint relieves pressure and evacuates enzymes, inflam-
of smoking adversely affected the outcome. matory mediators, and bacteria from the joint to mini-
mize cartilage damage. Arthroscopic irrigation may be
an alternative. Repeated joint aspirations may be satis-
Septic Arthritis in Adults factory in some knee infections but should not be used
The portals of pathogen entry in patients with septic ar- for infections of the hip or small joints. Synovial biopsy
thritis include hematogenous inoculation, spread from for culture and histology is recommended for joints un-
an adjacent area of infection, or inoculation by a pene- dergoing arthrotomy. In chronic or recurrent infections,
trating or surgical wound. Susceptibility to septic arthri- a complete synovectomy is warranted. Septic arthritis
tis is increased in immunocompromised hosts, patients after anterior cruciate ligament reconstruction occurs in
with preexisting joint pathology, and patients with fre- approximately 0.2% to 0.5% of patients. According to
quent bacteremic episodes. Microorganisms trigger an one recent study, the rate of infection after anterior cru-
inflammatory response that recruits polymorphonuclear ciate ligament reconstruction was 0.14% in 3,500 con-
cells. Enzymes released by bacteria and polymorphonu- secutive procedures. In early (occurring from up to 4 to
clear and synovial cells promote the degradation of gly- 6 weeks) postoperative infections, graft retention may
cosaminoglycans and the subsequent loss of collagen, be possible with prompt irrigation, dbridement, and an-
which results in gross damage to the articular cartilage. tibiotic therapy.
Neisseria gonorrhoeae is the most common pathogen Empiric systemic antibiotic therapy should be
causing septic arthritis in otherwise healthy adults; started immediately after cultures have been collected
women are more frequently affected than men. Clinical and should cover the most likely pathogens based on
symptoms of disseminated disease include migratory the clinical setting. In otherwise healthy adults, both
polyarthritis, rash, and tenosynovitis of the dorsal aspect N gonorrhoeae and S aureus should be covered, usually
of the wrist and hand. Septic involvement of a single with a third generation cephalosporin. Immunocompro-
joint also may occur with the knee joint most commonly mised hosts and intravenous drug users should receive
affected. S aureus is the second most common pathogen coverage for both S aureus and P aeruginosa. The dura-
causing adult septic arthritis. Immunocompromised tion of antibiotic therapy is usually 4 weeks for non-
hosts may have infections with gram-negative organ- gonococcal arthritis and 1 week in gonococcal arthritis
isms, or unusual pathogens, such as mycobacteria or that responds well to therapy.
fungi. Intravenous drug users, in addition to being sus- Lyme disease is a multisystem spirochetal disorder
ceptible to S aureus, are prone to infections with caused by Borrelia burgdorferi, which is transmitted by
Pseudomonas aeruginosa or Serratia marcescens. the bite of an infected tick. It usually occurs in the
Septic arthritis is more common in joints of the Northeast, Midwest, and Northwest regions of the
lower extremity, with the knee most frequently in- United States. The disease occurs in three clinical stages.
volved. The affected joint is painful, swollen, has limited In the first stage (early localized disease) a pathogno-
range of motion, and is often erythematous. The CRP monic skin lesion (erythema migrans) emerges and pro-
and ESR are generally elevated, and the WBC count is gressively increases in size. The second stage (early dis-
elevated in approximately 50% of patients. Radiographs seminated disease) is characterized by neurologic and
help assess bone involvement and ultrasound is useful in cardiac manifestations. In the third stage (late disease)
musculoskeletal symptoms develop in 80% of untreated pneumoniae, and Streptococcus pyogenes. Children with
patients and include arthralgia, intermittent episodes of sickle cell disease are more prone to infections from the
arthritis, and subsequently chronic monoarthritis, usually Salmonella species compared with the normal pediatric
of the knee. Acute monoarthritis may clinically resem- population. Similarly, immunocompromised children are
ble septic arthritis. The synovial fluid in acute noninfec- more susceptible to osteomyelitis from less virulent mi-
tious monoarthritis usually has a WBC count of 10,000 crobes or fungi than patients with uncompromised im-
to 25,000 cells/mm3 with an increased number of poly- mune systems.
morphonuclear cells; a higher count may be present, cre- Pediatric acute hematogenous osteomyelitis has a
ating a resemblance to a more typical bacterial infec- predilection for the metaphysis of long bones. The meta-
tion. Chronic Lyme arthritis is rarely destructive and has physis is perfused by end-arteries that enter large
been associated with HLA-DRB1*040, thereby suggest- venous sinusoids. The sluggish circulation and defective
ing an autoimmune mechanism. Enzyme-linked immun- phagocytosis in the capillary loops allow bacteria to in-
osorbent assay establishes the diagnosis. Oral antibiotic oculate in the metaphyseal area by the physeal plate.
therapy with amoxicillin or doxycycline for approxi- The infection subsequently may spread through Volk-
mately 4 weeks is recommended. Intravenous therapy manns canals of the metaphyseal bone to the subperi-
with ceftriaxone may be used for patients with recurrent osteal region where a resultant abscess may elevate the
episodes of arthritis and for those with neurologic in- periosteum and devitalize cortical bone. Osteomyelitis
volvement. A single 200-mg dose of doxycycline given may spread to the epiphysis, especially in infants be-
within 72 hours after a tick bite that occurs in an en- cause of their distinct vascular pattern with metaphyseal
demic area can prevent the development of Lyme dis- vessels traversing into the epiphyseal area. Septic in-
ease. volvement of the adjacent joint occurs in 33% of pa-
Tuberculosis should be considered in the differential tients with metaphyseal osteomyelitis. The most com-
diagnosis of arthritis and chronic osteomyelitis, espe- monly affected joint is the knee. Joint involvement is
cially in immunocompromised patients and in patients facilitated if the metaphysis is intra-articular (proximal
from areas endemic for tuberculosis outside of the femur, proximal humerus, proximal radius, distal lateral
United States. Tubercular arthritis usually affects the hip tibia). Therefore, careful evaluation of the adjacent joint
and the knee, and is characterized by an insidious onset, should be an important part of the evaluation for any
subtle inflammatory signs, and disproportionately exten- child with osteomyelitis. The infectious process may also
sive bone involvement relative to the symptoms present. spread to the surrounding soft tissues and to the medul-
Radiographic changes include subchondral bone ero- lary canal. Acute hematogenous osteomyelitis in older
sions and joint space narrowing. Synovial biopsy, acid- children usually involves a single site. However, in neo-
fast stains, and cultures help to establish the diagnosis. nates, polyostotic involvement occurs in 30% of pa-
Growth of the organism in solid medium culture re- tients, and may be identified with a bone scan.
quires up to 8 weeks and sensitivity testing should al- Clinical findings of acute hematogenous pediatric os-
teomyelitis include pain, refusal to bear weight, inability
ways be performed. Therapy for tuberculosis should in-
to use the affected extremity, and fever. Previous trauma
clude a multidrug regimen with isoniazid, rifampin,
to the affected site is present in 30% to 50% of patients.
pyrazinamide, and ethambutol. When sensitivity results
The patient history should include the presence of med-
are available, ethambutol can be discontinued if the or-
ical conditions (useful for assessing the likely pathogen)
ganism is fully susceptible. The duration of therapy
and any recent antibiotic administration (likely to alter
ranges from 6 to 9 months.
the clinical presentation). Diagnosis can be challenging
in neonates because the clinical picture is often subtle.
Pediatric Musculoskeletal Infections The proximal femur and hip joint are most commonly
Osteomyelitis in Children involved and a high index of suspicion is needed for
Osteomyelitis in children is usually hematogenous in or- early diagnosis; pseudoparalysis in a neonate should be
igin. Osteomyelitis is more common in males, the lower carefully evaluated.
extremity, and increases in incidence during the warmer Laboratory tests include a WBC count and differen-
months. The most common organism causing pediatric tial, ESR, and CRP. Bone aspiration and blood cultures
osteomyelitis is S aureus. Neonates may also have infec- are essential. Bone aspiration or intraoperative cultures
tions with group B Streptococci or gram-negative patho- identify the pathogen in 48% to 85% of patients,
gens. Haemophilus influenzae type B was previously a whereas blood cultures are positive in 30% to 60%. The
common musculoskeletal pathogen in children between combination of data from bone aspiration and blood
1 and 4 years of age, but vaccination against this organ- cultures is important to achieve accurate diagnosis. Ra-
ism has almost eliminated its role in pediatric osteomy- diographs show soft-tissue swelling but are of limited
elitis. In children younger than 3 years of age, the most value in identifying osseous changes, which typically do
common pathogens include S aureus, Streptococcus not occur until 7 to 14 days later. Bone scanning is use-
ful when the location of the pathology is uncertain or knee and hip joints. Septic arthritis may originate from
multiple locations are suspected, such as in the neonate. contiguous spread of adjacent infection or osteomyelitis.
In children with sickle cell anemia, osteomyelitis can be In neonates, osteomyelitis in the metaphysis can spread
differentiated from bone infarction with acute bone to the epiphysis via blood vessels traversing the physis,
pain by a combination of sequential bone marrow and and then to the joint space via the thin bone cortex.
bone scintigraphy. Pathogens also may be directly inoculated into the joint
Treatment of pediatric acute hematogenous osteo- by a penetrating injury.
myelitis consists of prompt systemic antibiotic adminis- Clinical symptoms include fever, pain, inability to
tration and close monitoring of the patient. Surgical use the upper extremity (pseudoparalysis), or refusal to
treatment is based on the presence of an abscess. In ap- walk when the lower extremity is affected. The range of
proximately 50% of patients, surgery is not necessary motion of the involved joint is markedly decreased and
because early antibiotic therapy contains the infectious painful. In septic arthritis of the hip, the joint is posi-
process before an abscess can form. Surgical interven- tioned in external rotation, abduction, and mild flexion
tion is warranted if an abscess is present (diagnosed by to increase joint volume and release tension on the cap-
aspiration, or MRI), if the adjacent joint is septically in- sule.
volved, or if changes are present on plain radiographs, An elevated CRP and ESR are present in at least
indicating late presentation. 90% of patients with septic arthritis, whereas the WBC
Antibiotics should be given immediately after bone count is elevated in approximately 50%. MRI shows
aspiration and blood cultures have been obtained. Em- fluid collection in the joint and also is useful in elevating
pirical antibiotic administration while the culture results any adjacent bone or soft-tissue involvement. Ultra-
are pending should target the most likely pathogens sonography can detect a joint effusion. Scintigraphy is
based on the age of the child and should always cover useful for the evaluation of multiple joints when the
S aureus, which is the most frequent pathogen in all age pathologic process cannot be localized to a single joint,
groups. Systemic antibiotics can be substituted with oral or when the joint involved is not clinically apparent.
therapy provided the patient is afebrile, shows consider- Joint aspiration should always be performed. Fluoro-
able clinical improvement, and in whom CRP levels scopic or ultrasonographic guidance is useful for hip as-
piration. The joint aspirate should be sent for a Gram
have normalized or considerably decreased. Antibiotics
stain, cultures, sensitivity testing, and WBC count and
are usually given for 4 to 6 weeks.
differential. A WBC count greater than 50,000/mm3 is
In some patients subacute osteomyelitis may insidi-
found in approximately 50% of patients.
ously develop over a period of months until the patient
Transient synovitis of the hip in a young child (age
develops symptoms, such a pain and limp. The radio-
3 to 8 years) may present as an acutely irritable hip with
graphic appearance of subacute osteomyelitis may re-
an effusion; the clinical presentation may be indistin-
semble a tumor, and biopsy is frequently necessary to
guishable from septic arthritis. The presence of a fever,
establish the diagnosis.
the inability to bear weight, an ESR greater than
40 mm/h, and a peripheral WBC count greater than
Chronic Recurrent Multifocal Osteomyelitis 12,000 cells/mm3 are independent variables that can
Chronic recurrent multifocal osteomyelitis is character- help distinguish the two conditions. According to a 1999
ized by bilateral, usually symmetric bone involvement. study, the probability of a correct diagnosis of septic ar-
The onset is insidious and inflammatory symptoms may thritis was found to be 99.6% for children with all four
wax and wane over time. The clavicle and the metaphy- factors, 93.1% for those with three factors, 40% for
ses of long bones usually are affected; lytic and sclerotic those with two factors, and 3% for those with only one
changes are seen on radiographs. A pustular rash on the factor.
palms and soles may be present. Cultures are negative Inflammatory arthritides, such as juvenile rheuma-
and the diagnosis is one of exclusion after microbial os- toid arthritis, poststreptococcal arthritis, and rheumatic
teomyelitis or bone tumors are ruled out. No effective fever should be included in the differential diagnosis of
treatment exists; however, anti-inflammatory medication pediatric arthritis with joint effusion. Juvenile rheuma-
may relieve symptoms. Antibiotics are not needed if cul- toid arthritis may present as a single acutely swollen and
tures are negative. Although symptoms tend to recur painful joint. However, in juvenile rheumatoid arthritis
over a 2-year period, the long-term prognosis appears to the onset is usually gradual, the patient may be able to
be good. walk, systemic symptoms are milder, the joint fluid
WBC count is usually less than 50,000 cells/mm3, and
Septic Arthritis the Gram stain and cultures are negative.
Septic arthritis is usually hematogenous in origin, is Surgical decompression of a septic joint may be ac-
caused by pathogens similar to those involved in he- complished by open arthrotomy or arthroscopy. Re-
matogenous osteomyelitis, and commonly occurs in the peated joint aspiration may be an alternative in some
patients in whom the affected joints are easily accessi- Surgical dbridement is seldom necessary, except in the
ble; however, failure to respond to nonsurgical treat- presence of an abscess.
ment within 24 to 48 hours warrants surgical interven-
tion. In patients with a septic hip, prompt surgical Wound Infections
arthrotomy, irrigation, and dbridement are mandatory Wound infections involve a wide spectrum of anatomic
because delayed or incomplete decompression impairs locations and etiologic mechanisms. An awareness of
perfusion of the femoral head and may cause further the potential for infection in particular wounds, such as
morbidity, such as osteonecrosis, hip dislocation, and os- clenched-fist injuries and nail puncture wounds, is
teomyelitis. The anterior approach is preferred to avoid needed for proper treatment. Identification and prompt
any damage to the vascularity of the femoral head. treatment of severe life-threatening infections, such as
Antibiotic therapy should be started immediately af- necrotizing fasciitis, are essential to reduce mortality
ter cultures have been collected and should target the and morbidity.
most probable pathogens based on the childs age and
Clenched-fist injuries represent human bite wounds
the clinical setting. In sexually active adolescents N gon-
with a high potential for damage of underlying tissues
orrhoeae is a potential pathogen. Systemic antibiotics
and infection. Violation of the joint capsule of the
can be converted to oral therapy as the patient clinically
metacarpophalangeal joints occurs in 68% of patients.
improves. The total duration of therapy is usually 3
Eikenella corrodens and Pasteurella multocida are gram-
weeks. Contiguous osteomyelitis should be suspected if
negative, facultative anaerobes, often found in human
the clinical course is not dramatically improved after
mouth flora. All patients with clenched-fist lacerations
drainage of the septic joint and the CRP remains ele-
or puncture wounds over joints should be treated with
vated.
surgical dbridement and exploration of the deep struc-
tures, including the joint and the extensor tendon, at the
Diskitis
time of initial medical care. The wound should not be
Diskitis is a hematogenous infection involving the disk
closed primarily. Antibiotic therapy consisting of wide-
and vertebral body. S aureus is the most common patho-
spectrum antibiotics active against anaerobes should be
gen. Clinical symptoms may be insidious and may in-
administered.
clude back pain, abdominal pain, or inability to walk.
Nail puncture wounds to the foot may lead to bone
Tenderness is present over the involved vertebrae. Sys-
or joint penetration and predispose the patient to osteo-
temic symptoms and signs of infection may be absent;
myelitis and/or septic arthritis. The area overlying the
ESR and CRP are usually elevated but the WBC count
metatarsal neck region and extending distally to the
may be normal. Radiographs are initially noncontribu-
tory but subsequently show disk space narrowing. MRI toes carries the highest risk for infection, because the
reveals early changes in the disk and the adjacent verte- metatarsal heads are a major weight-bearing area with a
bral bodies. Bone scintigraphy may be helpful when the limited amount of overlying tissue. Approximately 97%
location of the pathologic process is uncertain. Blood of patients requiring hospitalization for septic complica-
cultures should be obtained. Needle or open biopsy and tions had sustained a puncture wound through this re-
cultures may be helpful if the diagnosis is uncertain; gion. P aeruginosa is the most common pathogen in-
however, the yield (as low as 27%), the potential com- volved, especially if the nail enters through an athletic
plications of biopsy, and the preponderance of S aureus shoe; the exact reason for this is unknown. If increasing
infections do not justify routine biopsy. Although the in- tenderness is present over a puncture wound area, ad-
fectious nature of diskitis has been questioned based on mission to the hospital is needed for antibiotic therapy
the low yield of biopsy cultures and the resolution of and surgical dbridement.
symptoms with rest alone, treatment should include rest Necrotizing fasciitis involves the fascia and overlying
and antibiotic therapy with an antistaphylococcal agent. tissues but spares the muscles. Although group A strep-
tococcus is often involved, the disease may be polymi-
Sacroiliac Joint Infection crobial. Immunocompromised hosts and children with
Sacroiliac joint infection may present with a variety of varicella infections are at increased risk for developing
symptoms including back pain, abdominal pain, pain in the disease. Necrotizing fasciitis initially may resemble
the gluteal area, limp, fever, malaise, and tenderness cellulitis, but the edema and induration extend beyond
over the involved area. The FABER test (flexion, abduc- the area of erythema. The infection rapidly spreads
tion, external rotation) and compression of the pelvis along fascial planes, results in septic shock, and does not
elicit pain. MRI is useful in determining the location of respond to antibiotic therapy alone. Emergent surgical
the infectious process and the extent of bone and soft- dbridement is warranted. The disease carries a high
tissue involvement. S aureus is the most common patho- mortality rate ranging from 6% to 76%, especially if
gen and should be covered by initial antibiotic therapy. surgical treatment is delayed.
Infection in the Setting of Internal Fixation be considered in selected patients. Treatment choice de-
In the presence of internal fixation, microorganisms pends on duration of infection, virulence of the organ-
grow in a biofilm that adheres to the implant surface ism, implant stability, the patients immune and medical
and protects them from host defense mechanisms and status, and the condition of the local soft-tissue enve-
antibiotics. The choice of retaining or removing infected lope. Staging systems may be useful to evaluate these
implants depends on several factors including time since factors, compare results among treatment centers, and to
fracture fixation, stability provided by the hardware, and establish guidelines for care.
bone healing status. In the early postoperative period, Irrigation, dbridement, exchange of the polyethy-
before the fracture is united, internal fixation is neces- lene liner, and retention of the components are options
sary to maintain reduction of the fracture. Treatment for patients who develop infections in the early postop-
should include irrigation, dbridement, intraoperative erative period (less than 1 month), and in patients with
cultures, brushing of exposed implants, and antibiotic acute hematogenous infections (symptoms of duration
therapy for 6 weeks. If the fracture is healed, internal less than 2 to 4 weeks in a previously well-functioning
fixation is removed. Loose hardware that does not pro- patient) with well-fixed components. Component reten-
tion is associated with lower rates of infection control
vide stability should be removed regardless of the time
(50% to 71%), possibly because of concurrent hematog-
frame. If the fracture is not healed, it should be stabi-
enous seeding and osteomyelitis of adjacent bone, bio-
lized with another device, preferably an external fixator
film formation, and limited dbridement.
for the tibia and an intramedullary rod for the femur. In
Exchange arthroplasty is the preferred option for
intra-articular united fractures, internal fixation should
patients with chronic late-developing infections (devel-
not be removed or replaced unless it is loose and not
oping more than 1 month after the procedure with indo-
providing stability.
lent course and duration greater than 2 to 4 weeks), and
for those with acute hematogenous infections with im-
Infection in the Setting of Arthroplasty plant loosening (provided that the patient is in good
Infection occurs in approximately 1% of patients who condition and the bone stock is adequate or reconstruct-
have undergone total joint arthroplasty, with S epidermi- ible). Flap coverage may be warranted for treatment of
dis and S aureus the most common infecting organisms. an infected arthroplasty with a poor soft-tissue enve-
The pathogenesis of infection involves either direct in- lope. Following irrigation and dbridement, the ex-
oculation of the organisms (during the procedure and in change arthroplasty can be performed at the same time
the early postoperative period) or hematogenous spread (one stage), or preferably as a subsequent procedure
(at any point during the life of the implant). with an interval of 6 weeks or longer (two stage). Local
The clinical indicators of periprosthetic infection antibiotic delivery during the reimplantation interval
may be straightforward and consist of pain, decreased can be accomplished by using antibiotic-impregnated
range of motion, drainage, and systemic symptoms. spacers. Two-stage exchange arthroplasty has a higher
However, the clinical picture is often subtle with pain as rate of eradication of infection (88% to 95%) compared
the only symptom. Laboratory tests (ESR and CRP), with the one-stage technique (70% to 85%).
bone scintigraphy, and joint aspiration are useful. The Reimplantation of a prosthesis may not be possible
combination of normal ESR and CRP levels reliably because of a severely compromised host, deficient bone
predicts the absence of infection. Aspiration has 86% stock, poor condition of the soft tissues, the presence of
sensitivity and 94% specificity in the absence of existing infection with resistant organisms, or repeated failed ex-
antibiotic therapy and should be used when the ESR or changed arthroplasties. In this situation, resection ar-
the CRP level is elevated or when a clinical suspicion of throplasty is an option. Arthrodesis may be a preferable
infection remains. In addition, intraoperative tests, such choice for use in the lower extremity of active patients,
as cultures (94% sensitivity and 97% specificity), and because it offers improved function compared with re-
frozen sections evaluating the number of polymorpho- section arthroplasty. Chronic antibiotic suppression is an
nuclear leukocytes per high-power field (80% sensitivity option for severely compromised patients, or for pa-
and 94% specificity) can be helpful in equivocal cases. tients with limited life expectancy, provided the infect-
The Gram stain is unreliable (19% sensitivity and 98% ing organism is sensitive to oral antibiotics. Amputation
specificity) for determining the presence of peripros- of the extremity may be needed for persistent uncon-
thetic infection. trolled infection in a severely compromised patient.
Treatment options, in addition to administration of Episodes of bacteremia may cause hematogenous
systemic antibiotics for 4 to 6 weeks, include irrigation seeding of implants; therefore, patients should be in
and dbridement with retention of components, or ex- good dental health before a total joint arthroplasty is
change arthroplasty (one-stage versus two-stage). Sal- done and should maintain good oral hygiene after the
vage procedures include permanent resection or arthro- procedure. Single-dose antibiotic prophylaxis with ceph-
desis. Chronic antibiotic suppression or amputation may alosporin or amoxicillin (clindamycin in patients allergic
in 48% of hips and 18% of knees infected with methicillin- Perlman MH, Patzakis MJ, Kumar PJ, Holtom P: The in-
resistant S aureus or S epidermidis, compared with 81% of cidence of joint involvement with adjacent osteomyelitis
hips and 89% of knees infected with antibiotic-sensitive or- in pediatric patients. J Pediatr Orthop 2000;20:40-43.
ganisms.
Scott RJ, Christofersen MR, Robertson WW Jr, David-
Lehman CR, Ries MD, Paiement GD, Davidson AB: In- son RS, Rankin L, Drummond DS: Acute osteomyelitis
fection after total joint arthroplasty in patients with hu- in children: A review of 116 cases. J Pediatr Orthop
man immunodeficiency virus or intravenous drug use. 1990;10:649-652.
J Arthroplasty 2001;16:330-335.
Patients infected with the human immunodeficiency virus Siegel HJ, Patzakis MJ, Holtom PD, Sherman R, Shep-
and/or intravenous drug users are susceptible to deep herd L: Limb salvage for chronic tibial osteomyelitis: An
periprosthetic infection. The infection rate was 14% (4 of 28) outcomes study. J Trauma 2000;48:484-489.
in human immunodeficiency virus-positive patients undergo-
Spangehl MJ, Masri BA, OConnell JX, Duncan CP:
ing total joint arthroplasty and 25% (2 of 8) in intravenous
drug users.
Prospective analysis of preoperative and intraoperative
investigations for the diagnosis of infection at the sites
of two hundred and two revision total hip arthroplasties.
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Introduction
Arthritis encompasses a heterogeneous group of more
than 100 diseases that involve the synovial joints and
the periarticular structures. The exact pathoetiologic
mechanisms underlying most of these disorders are un-
certain; however, pathology of the synovium, articular
cartilage, and their subcomponents are believed to be
the primary cause of the most common types of arthri-
tis. Correct diagnosis relies primarily on clinical features
that may be both musculoskeletal and nonmusculoskel-
etal in nature. Patients with arthritic involvement of
their joints have significant pain, loss of motion, defor-
mity, and instability. The mainstay of contemporary
treatment is nonsurgical and includes patient education,
lifestyle and activity modifications, and pharmacologic
agents. Surgical intervention, particularly in the hip and
knee, may be necessary for the treatment of severe Figure 1 High power photomicrograph of normal cartilage from a rat knee. (Courtesy
of Dr. Michael Nimmo.)
symptoms, and occasionally may be indicated as a pre-
ventive measure. Pain relief remains the most predict-
able result of reconstructive surgery and represents the
primary indication for most surgical interventions. Res-
stand the high shear forces created by the muscles that
toration of motion and function is less predictable;
typically insert near the joint with short lever arms.
therefore, preoperative assessments need to be individu-
alized and patients should be counseled concerning
functional expectations. The development of novel phar-
Chondrocytes
macologic strategies is underway to treat and possibly Chondrocytes are isolated cells within cartilage that
alter the natural history of these disorders. Innovations function to produce, maintain, and remodel the extracel-
in prosthetic design and surgical technique are improv- lular matrix constituents. Chondrocyte activity is regu-
ing the outcomes for patients requiring surgical inter- lated by mechanical factors, cytokines, and growth fac-
vention. tors. For example, interleukin (IL)-1 can stimulate
chondrocytes to produce proinflammatory mediators
Cartilage Structure and Physiology such as matrix metalloproteinases (MMPs), while trans-
The two major types of articular cartilage are fibrocarti- forming growth factor beta stimulates chondrocytes to
lage and hyaline cartilage. Menisci are typical examples differentiate and produce type II collagen and pro-
of fibrocartilage. Hyaline cartilage, which is the predom- teoglycans. IL-4 is a chondroprotective cytokine that is
inant form of articular cartilage, covers the cortical bone activated with mechanical loading of the chondrocyte.
ends and protects them by absorbing force, providing an Mechanical forces across the cartilage stimulate chon-
extremely low coefficient of friction, and improving drocyte synthesis of proteoglycan and collagen; con-
joint stability (Figure 1). Articular hyaline cartilage is versely, prolonged inactivity contributes to degenerative
securely fastened to cortical bone by a layer of calcified changes in the cartilage through reduction in extracellu-
cartilage. The low friction joint surface helps to with- lar matrix synthesis by chondrocytes.
Synovial Fluid
Synovial fluid is an acellular plasma ultrafiltrate that
protects the subchondral structures and lubricates the
joint. Its high viscosity gives it important mechanical
properties and is related to large amounts of polymer-
ized hyaluronic acid.
Cartilage Homeostasis
Figure 2 Diagram of aggrecan, collagen. (Courtesy of Dr. Andrew Thompson.) In the normal joint, there is a homeostasis between the
breakdown of cartilage matrix and the formation of
newly synthesized matrix. Growth factors stimulate
Collagen
chondrocytes to produce matrix constituents whereas
Collagen provides tensile strength to the cartilage and
cytokines such as IL-1 and tumor necrosis factor alpha
provides the extracellular matrix architecture for the (TNF-) stimulate matrix degradation. When this bal-
proteoglycans and chondrocytes to fill (Figure 2). Type ance is disturbed, there is a shift toward excessive deg-
II collagen comprises 90% of the articular cartilage with radation, which causes disruption of the structural and
additional small amounts of collagen type IX and XI. functional integrity of the cartilage.
Type II collagen is oriented tangentially to the articular Collagenase, stromelysin, and gelatinase are MMPs
surface in the superficial zone of the articular cartilage. that act as degradative enzymes. They contain zinc at
This orientation allows the cartilage to withstand the the active site and are produced by the chondrocyte as
high-intensity shearing forces in this area. Collagen fi- part of the cartilage development process. The cytokine
bers curve downward to form vertical sheets through IL-1 stimulates production of MMPs by infiltrating leu-
the middle and deep zones of articular cartilage to pro- kocytes and connective tissue cells. MMP activity is in-
vide further vertical tensile strength. Type IX collagen hibited by tissue inhibitor of metalloproteinase located
helps to maintain the orientation of the ubiquitous type in the cartilage. The complex interplay between MMPs,
II collagen network. tissue inhibitor of metalloproteinase, and the various cy-
tokines that mediate chondrocyte activity will influence
Proteoglycans the overall structural integrity of the articular cartilage.
Aggrecan, biglycan, and decorin are the three main pro-
teoglycans in the extracellular matrix. Aggrecan, the Osteoarthritis
predominant proteoglycan and thereby the best studied, Epidemiology
is a large aggregation of long-chain, negatively charged Osteoarthritis (OA) is the most common form of arthri-
glycosaminoglycan molecules attached covalently to a tis and a leading cause of disability in the developed
protein core that itself attaches via a link protein to hy- world. Hip and knee OA rarely occur before the age of
aluronic acid (Figure 2). The glycosaminoglycan mole- 50 years. The prevalence of clinically apparent knee OA
cules are composed of chondroitin sulfate and keratan is 30% in the population older than 75 years; OA of at
sulfate. A single hyaluronic acid chain will have many least one joint occurs in 80% of this population. Au-
aggrecan molecules linked to it. Biglycan and decorin topsy and radiographic studies show a much higher rate
are nonaggregating proteoglycans that have roles in the of OA than do epidemiologic studies. The fact that the
cartilage matrix structure. incidence of OA increases significantly with age has led
Aggrecan provides elastic strength to articular carti- to the erroneous conclusion that OA is simply an age-
lage, and as a polyanionic molecule attracts water, which related degenerative condition. The prevalence of OA
allows the cartilage to swell. The swelling, however, is increases with age because of ligamentous laxity, a fail-
ure of the periarticular structures such as muscles and TABLE 1 | Classification of Osteoarthritis
proprioceptors to function appropriately, a reduction in
matrix production by chondrocytes, or decreased re- Primary (idiopathic)
sponsiveness of chondrocytes to growth factors. Other Peripheral joints
risk factors for OA include gender, genetic predisposi- Nodal (at PIP and DIP joints)
tion, obesity, higher than normal bone mineral density, First CMC and first MTP
and joint trauma. The incidence of OA is higher in Large joints (hip and knee)
women than in men, especially after the age of 50 years. Spine
Variant OA
Inflammatory OA
Etiology Generalized OA
OA is likely a genetically heterogeneous disease where Diffuse idiopathic skeletal hyperostosis
local factors (such as excessive load) act within the con- Secondary
text of a systemic susceptibility (such as a genetic predis- Traumatic (occupational, sports)
position). OA can be classified as primary (idiopathic) or Local joint disorders
secondary (Table 1). Secondary causes of OA can result Osteonecrosis
from highly intense or abnormal chronic forces across Postinfectious
the joint (for example, from trauma or occupational Diffuse joint disorders
Rheumatoid arthritis
overuse) or from a disorder in a joint constituent (for ex-
Hypermobility syndrome
ample, hemochromatosis, chronic inflammatory arthritis, Endocrine disorders
chronic crystal joint disease, septic arthritis). The inci- Diabetes
dence of OA is increased with certain occupations. Farm- Acromegaly
ers and miners have an increased incidence of hip OA. Systemic metabolic diseases
Occupations that require regular kneeling and squatting Hemochromatosis
are correlated with an increased incidence of knee OA. Ochronosis
Elite athletes, but not recreational athletes, have an in- Wilsons disease
creased incidence of knee OA. Crystal joint disease
Gout
Calcium crystal diseases
Pathogenesis Calcium pyrophosphate dihydrate
In the common forms of OA such as polyarticular small Calcium apatite
joint nodal arthritis in women, there is a familial compo- Neuropathic diseases (Charcot joint)
nent. However, in rare subtypes of OA (such as osteo- Tabes dorsalis
chondrodysplastic syndromes), genetic susceptibility Diabetes mellitus
may follow mendelian inheritance modes, and often in-
volve the genes that code type II collagen. Mutations in PIP = proximal interphalangeal; DIP = distal interphalangeal; CMC = carpometacarpal;
MTP = metatarsophalangeal
the COL2A1 gene (type II procollagen) were found in
rare types of OA in certain families. Mutations in this
same gene have been found to cause skeletal dysplasias
that clinically resemble OA. However, in families with
bone density with OA of weight-bearing joints may be the
common forms of OA there were no mutations in the
result of the presence of stronger, stiffer subchondral
COL2A1 gene.
bone, which deforms less under loading, therefore increas-
Obesity is an important, modifiable risk factor for
ing stress to the cartilage.
bilateral knee OA in both the patellofemoral joint and
tibiofemoral joint. Fortunately, weight loss reduces the Several local factors may play a role in the incidence
risk of knee OA. The association of obesity and knee or progression of OA including knee injury, which has
OA is stronger in women than in men. Obesity may in- been associated with a subsequent increase in the inci-
crease the incidence of knee OA by increasing force dence of both hip and knee OA. Abnormal knee align-
across the knee, by increasing bone density (which may ment also increases the incidence of OA. A varus or val-
be independently associated with OA), or by the adi- gus deformity of 4 to 5 results in a fourfold increase in
pose tissue increasing production of OA-causing growth the risk of medial and lateral knee OA. Weakness of the
factors or hormones. Obesity is also associated with OA quadriceps plays a small role in OA in women, but not
in the hand, which suggests that weight is not the sole in men. Conversely, increased hand muscle strength is
explanation linking obesity and knee OA. Obesity has associated with hand OA in men. Development abnor-
not been consistently associated with hip OA. malities, such as acetabular dysplasia and slipped capital
Higher bone density has been linked to OA of the hip femoral epiphysis, frequently lead to premature OA of
and knee, but not the hand. The relationship of higher the hip.
TABLE 2 | Relative Risk of Traditional NSAID-Induced GI TABLE 3 | Recommended Dosage for Coxibs Available in
Complications the United States
Risk Factor Relative Risk 95% CI Coxib OA dose RA dose
Age (> 60 years) 5.5 4.6 to 6.6 Celecoxib 100 to 200 mg/day 200 mg/bid
Prior GI event 4.8 4.1 to 5.6 Valdecoxib 10 mg/day 20 mg/day
Severe RA 2.3 1.1 to 4.7
Concurrent corticosteroids 4.4 2.0 to 9.7
Concurrent anticoagulants 12.7 6.3 to 25.7
CI = confidence interval
*Requirements: A patient shall be said to have RA if he/she has satisfied at least four of the seven criteria. Criteria 1 through 4 must have been present for at least 6 weeks. Patients with two
clinical diagnoses are not excluded. Designation as classic, definite, or probable RA is not to be made.
PIP = proximal interphalangeal; MCP = metacarpophalangeal; MTP = metatarsophalangeal
(Reproduced with permission from Arnett FG, Edworthy SM, Bloch DA, McShane OJ, et al: The American Rhematism Association 1987 Revised Criteria for the Classification of Rheumatoid
Arthritis. Arthritis Rheum 1988;31:315-324.)
Short- or long-acting codeine, oxycodone, or pro- osteotomy. Arthrodesis may be most appropriate for
poxyphene can be used, preferably on a fixed interval ba- joints that are severely compromised or in patients too
sis for less than 2 weeks at a time. Patients with severe OA young for successful prosthetic arthroplasty. Prosthetic
who are not surgical candidates and have severe pain that joint arthroplasty is often recommended for patients
is unresponsive to other agents should be treated with ap- with advanced OA and/or advanced symptoms of OA
propriate long-term opioid analgesics.Although there are that are no longer responding to maximal nonsurgical
limited data to suggest that combination medications con- modalities. Although complication rates are low in pros-
taining caffeine may have additional analgesic properties, thetic hip and knee joints, prosthetic elbow and ankle
caffeine has significant side effects including sleep distur- joints have higher complication rates.
bances and withdrawal headache. The ability of the prosthetic arthroplasty intervention
to alleviate pain and improve function has been described
Surgical Management as one of the great advances in 20th century health care.
The goals of surgical intervention in OA are to decrease Whereas traditional indications for prosthetic arthro-
or eliminate pain and to improve function. The success plasty included incapacitating symptoms, old age, and sed-
of joint arthroplasty in achieving these goals has re- entary lifestyle, contemporary advances in arthroplasty
sulted in substantial investment in and development of technique and prosthetic design have expanded the indi-
prosthetic joints and techniques for their implantation. cations to younger patients with intractable symptoms.
However, it is important to consider that other proce-
dures that decrease pain and improve function by re-
storing, resecting, or replacing the joint also have a role
Rheumatoid Arthritis
and are attractive alternatives for young patients who Epidemiology
do not desire a prosthetic joint or for patients with less Rheumatoid arthritis (RA) is an autoimmune disease
advanced joint degeneration who want to maintain a that affects 1% of the white population. All racial
high level of activity. groups are affected but aboriginal North Americans
Procedures to treat OA by preserving or restoring have a higher prevalence. RA is a chronic, fluctuating
articular cartilage surfaces include osteotomies and polyarthritis that is symmetric, erosive, and eventually
muscle releases, joint dbridement, partial resection or deforming (Table 4).
perforation of subchondral bone to stimulate fibrocarti-
lage healing, resection arthroplasty, and the use of vari- Clinical Features
ous autografts and allografts. Joints compromised by ad- In most patients, RA manifests over weeks to months
jacent bony deformity may be appropriate for with an insidious onset of fatigue and joint pain, which
Figure 5 Photograph showing early RA of the hand. Figure 6 Rheumatoid nodules are shown.
Rheumatoid Factor
may be transient early in the course of the disease.
Rheumatoid factors are immunoglobulin M antibodies
However, 10% of patients will experience an acute on-
directed against the constant fragment region of the im-
set of symptoms that occurs within days. Eventually,
munoglobulin G molecule. Rheumatoid factor is present
joint inflammation becomes more persistent with
in as few as half the patients with early RA, is found in
warmth, effusion, tenderness, and loss of function. Early
5% of healthy individuals, and is found in a host of
morning joint stiffness occurs in most patients and im-
chronic inflammatory and infectious conditions. There-
proves with physical activity. Morning stiffness usually
fore, as a diagnostic test, rheumatoid factor has been
exceeds 60 minutes and its duration correlates with the
overvalued; however, its presence has some prognostic
extent of synovial inflammation. Classic areas of sym-
value because a positive test portends a more aggressive
metric polyarthritis are the wrists, metacarpophalangeal
course of RA with a higher morbidity and mortality.
(MCP), metatarsophalangeal (MTP), and proximal in-
terphalangeal (PIP) joints of the hands and feet (Fig-
ures 5 through 7). Structural damage to the joints, once Etiology
believed to occur only after 1 or more years, has been Although the exact etiology of RA is unknown, genetic
shown by MRI to occur within months of RA onset. susceptibility and environmental factors have some de-
monstrable importance. Compared with a prevalence of
Figure 7 Medium power photomicrograph of rheumatoid nodule depicting palisading Figure 8 High power photomicrograph of normal synovium showing a thin layer of
histiocytes and central fibrinoid necrosis. (Courtesy of Dr. Michael Nimmo.) cells. (Courtesy of Dr. Michael Nimmo.)
Pathogenesis
RA probably begins with an antigen-mediated activa-
tion of T cells in an immunogenetically susceptible host,
which then initiates a cascade of events including endo-
Figure 9 Medium power photomicrograph of pannus. Thick villi of synovium with
neovascularization and lymphoid aggregates are seen. (Courtesy of Dr. Michael thelial cell activation, proliferation of type A and B syn-
Nimmo.) oviocytes, and recruitment of additional inflammatory
cells from the bone marrow. TNF- and IL-1 are the
apex of a cytokine cascade leading to the production of
1% in the general population, the concordance rate in
proteases and autoantibodies. When the immune re-
monozygotic twins is 12% to 15%, and is 2% to 5% for
sponse is triggered by the antigen, additional antigens
dizygotic twins and siblings. About half of the genetic
may be created and recognized by the T cell to create
susceptibility resides within the major histocompatibility
an ongoing immune response. The synovium is trans-
complex class II loci, in which the DR4 chains with the
formed from a thin layer only several cells deep (Figure
greatest association with RA are DRB*0401 and 8), to a proliferative and invasive synovium (pannus)
DRB*0404. The remaining genetic predisposition is be- composed of synoviocytes, T cells, and macrophages
lieved to lie within other loci that are currently being in- (Figure 9). The synovitis and vascular proliferation in-
vestigated. Such loci include the major histocompatibil- vade adjacent cartilage and bone. TNF- and IL-1 stim-
ity complex class III genes for TNF-, heat shock ulate chondrocytes to degrade cartilage and osteoclasts
protein 70 (HSP70), and complement C4, as well as to promote periarticular bony erosion and osteopenia.
genes not included in the major histocompatibility com- A significant humoral component may be involved
plex such as T cell and immunoglobulin genes. in the pathogenesis of RA. Whereas T cells outnumber
B cells in the synovium, there are active plasma cells in
the synovium and the expanded B lymphocyte pool, Compared with traditional DMARDs, these agents have
which exhibits an origin from a limited number of B cell remarkable efficacy with minimal adverse events in the
clones. It is intriguing that the B cell-depleting therapy, treatment of RA. Immunosuppression and the risk of
rituximab, has shown remarkable preliminary benefits in infection (including reactivation of mycobacterium tu-
the treatment of RA and has provided further evidence berculosis) are potential complications with all anti-
that B cells are important in the pathogenesis of RA. TNF- drugs. There have been rare reports of demyeli-
The improved understanding of RA pathogenesis has nating diseases with the use of etanercept. Infliximab
resulted in important therapeutic breakthroughs. must be given concomitantly with methotrexate or aza-
thioprine (in the methotrexate intolerant patient),
Pharmacologic Therapy whereas etanercept and adalimumab can be given as
The traditional approach to the treatment of early RA monotherapy or in combination with methotrexate. In-
has been the use of analgesics and NSAIDs to reduce fliximab has been shown to exacerbate congestive heart
symptoms. Such pharmacotherapies, however, do not failure.
prevent joint erosion and articular damage. MRI has Anakinra is the only IL-1 inhibitor currently avail-
shown that joint erosions can occur within months of able. There is less reduction of inflammation with anak-
symptom onset, and the rate of progression of erosions inra than with the anti-TNF- agents; however, anakinra
is highest in the first 3 years after RA onset. The recog- has a good safety profile. Injection site reactions with
anakinra are frequent, but are generally mild and self-
nition of these early changes has resulted in a dramatic
limiting. Anakinra use is also associated with a small in-
shift in treatment philosophy for patients with RA. RA
crease in the incidence of pneumonia and urinary tract
must be treated early and aggressively. The evidence is
infections.
overwhelming that a delay in instituting disease-
There is no perioperative standard of practice to
modifying antirheumatic drug (DMARD) therapy or a
guide the use of anticytokine DMARDs. It is recom-
failure to maintain disease suppression with DMARDs
mended that surgery be performed when presumed lev-
can result in irreversible joint destruction and disability.
els of the therapies are at their lowest2 weeks prior to
DMARDs, previously considered second-line drugs,
the infliximab infusion; 3 days after the etanercept injec-
are currently the mainstay of the pharmacologic treat-
tion; 10 days after the adalimumab injection. Some phy-
ment of RA.This heterogeneous group of medications re-
sicians will postpone resumption of the medications for
duces inflamed joint counts, acute phase reactants, and 1 to 2 weeks postoperatively, in the hope that the re-
erosion scores and stabilizes or even improves functional duced immunosuppression therapy will reduce the risk
status and reduces long-term disability (Table 7). Metho- of subsequent postoperative infection. However, this ap-
trexate is the most commonly used DMARD in North proach may necessitate the use of perioperative corti-
America. It is relatively potent compared with the other costeroids or cause a flare of synovitis, which could con-
DMARDs and more patients will continue to use meth- tribute to a poor postoperative recovery and an
otrexate over the long term than other traditional increased risk of infection. The other approach is to con-
DMARDs. About 50% of patients who begin treatment tinue the use of DMARDs unless there are contraindi-
with methotrexate will remain on the medication after cations (such as an active infection). There is no consen-
5 years compared with 20% of patients who are initially sus on which of these two methods is safer; few data are
treated with intramuscular gold or sulfasalazine. Newer currently available.
DMARDs include leflunomide and anticytokine agents.
In addition to beginning early treatment with Glucocorticoids
DMARDs, a new but well-established development is The DMARDs generally have a slow onset of action,
the early use of combination drug therapy. Established and although they are effective in reducing pain and in-
examples of drugs used in combination with methotrex- flammation, patients usually require ongoing analgesic
ate are hydroxychloroquine, sulfasalazine, gold, cy- and anti-inflammatory medication. While waiting for
closporine, and anti-TNF- agents. DMARDs to take effect, some rheumatologists pre-
Understanding the cytokine cascade in RA has scribe a course of bridging glucocorticoid (GC) medi-
helped in the development of novel new therapies that cation such as prednisone (10 mg daily) on a tapering
target these factors. TNF- and IL-1 are key proinflam- dose over several weeks to months. GCs are powerful
matory cytokines in RA. In clinical studies, inhibition of suppressors of inflammation, but long-term side effects
TNF- has resulted in a dramatic reduction in the and an absence of disease modifying benefits preclude
symptoms of RA, an improvement in function, and a re- their long-term use. GCs can be given orally, parenter-
tardation of radiographic progression. Etanercept, inflix- ally, and intra-articularly. High-dose parenteral GC can
imab, and adalimumab are the available anti-TNF- be used to treat severe extra-articular manifestations
agents. The mode of action and route of administration such as interstitial lung disease, ocular inflammation, or
of these anticytokine DMARDs are shown in Table 8. vasculitis. Intra-articular therapy causes few systemic
side effects and can be particularly useful for patients not be the only therapeutic agent used.
with a few resistant, inflamed joints.
Surgical Management of Rheumatoid Arthritis
Nonsteroidal Anti-Inflammatory Drugs Because patients with RA often have special needs be-
NSAIDs are useful for reduction of pain and inflamma- cause of multiple joint involvement, it is important that
tion in RA; however, their use in RA as in OA is com- a multidisciplinary team (surgeon, rheumatologist,
plicated by GI and other toxicities. Patients with RA are nurse, physiotherapist, occupational therapist, and social
more prone to developing symptomatic GI ulcers than worker) be consulted before surgical intervention. The
patients with OA. GCs also increase the incidence of GI team should ensure that planning, staging, and rehabili-
ulcers independently. Therefore, if anti-inflammatory tation after surgery is appropriate and that the patient is
medications are indicated in a patient with RA, a coxib provided with optimal information on goals, expecta-
is the preferential therapy. Although anti-inflammatory tions, and opportunities to improve outcome and mini-
medications reduce the symptoms of RA, they do not mize complications.
prevent the progression of damage and therefore should
Seronegative Spondyloarthropathies
Figure 10 Photograph of nail pits in a
Clinical Features patient with psoriatic arthritis.
The seronegative spondyloarthropathies are a group of
four conditions: ankylosing spondylitis (AS), psoriatic ar-
thritis (PsA), reactive arthritis (ReA), and arthritis asso- ripheral joint inflammation often can flare with bowel
ciated with inflammatory bowel disease. AS is a chronic disease activity, whereas the axial inflammation does not
inflammatory disease of the axial skeleton. The major flare in conjunction with the inflammatory bowel dis-
symptoms of AS are back pain with prolonged (longer ease.
than 1 hour) morning stiffness and progressive loss of mo- These four spondyloarthropathies often have over-
tion of the axial spine. Other clinical features that help to lapping symptoms of axial inflammation including sac-
distinguish AS from the much more common mechanical roiliitis and enthesitis. The enthesis is the structure that
back pain are back pain that awakens the patient at night includes the ligament and tendon attachment to the
and pain that is relieved by light exercise. The hallmark bone as well as the extension into the bone cortex. En-
radiologic findings are sacroiliitis and progressive fusion thesitis is a characteristic finding.
of the spine (called a bamboo spine), which occurs in a
later stage of the disease.AS typically affects young adults Human Leukocyte Antigen-B27
between 15 and 35 years of age. The onset of axial symp- The major factor in the pathogenesis of the spondyloar-
toms is insidious. Other symptoms include frequent pe- thropathies is the class I major histocompatibility anti-
ripheral joint inflammation (usually oligoarticular and gen, HLA-B27. HLA-B27 is present in 5% to 8% of the
asymmetric), acute, unilateral anterior uveitis, and rarely, general population, but is present in 95% of white pa-
cardiac and pulmonary disease. tients and 50% of black patients with AS. This antigen
There are five types of PsA. The most common is an also is found in 50% to 80% of patients with other se-
oligoarticular, asymmetric pattern. Other types include a ronegative spondyloarthropathies. The presence of
polyarticular symmetric arthritis similar to RA, a pat- HLA-B27 is not needed to confirm a diagnosis of AS;
tern of axial involvement similar to AS, a distal inter- however, it can be used as a diagnostic test in children
phalangeal joint involvement pattern, and arthritis muti- and young women who may have normal radiographs
lans with telescoping digits. PsA usually is preceded by and in patients who have an atypical presentation.
cutaneous psoriasis, but in about 20% of patients, the ar-
thritis precedes the psoriasis. PsA usually is associated Treatment
with nail pitting (Figure 10) and patients may have dac- Treatment protocols of the spondyloarthropathies in-
tylitis (sausage digit) with a fusiform swelling of the en- clude maintenance of posture, back range-of-motion ex-
tire digit. ercises, and the use of NSAIDs. If there is chronic pe-
ReA was previously called Reiters syndrome and is ripheral joint involvement, methotrexate and
triggered by a sexually transmitted disease (infecting sulfasalazine are frequently used to reduce joint ero-
bacteriaChlamydia) or a bowel infection (infecting sions and damage, similar to the therapy used for RA
bacteriaYersinia, Salmonella, Campylobacter, Shi- (Table 7). Local GC injections may be useful for large
gella). Typical features of ReA include asymmetric joint involvement, but systemic steroids are not often
lower limb oligoarthritis, conjunctivitis, and dysuria. The used. For patients with ReA, the triggering infection
dysuria can be either caused by a Chlamydia pyuria or should be treated. If the joint inflammation persists af-
by a sterile pyuria that can be triggered by a bowel in- ter the infection has been eradicated, long-term antibi-
fection. otic use has not been shown to be effective. Studies of
Approximately 20% of patients with inflammatory the use of anti-TNF- therapies for patients with PsA
bowel disease will develop an inflammatory arthritis have found remarkable improvement in joint pain, dam-
with axial and/or peripheral joint involvement. The pe- age control, and function, as well as in the psoriasis le-
sions. In resistant patients with AS, anti-TNF- can ment of RA that is currently under investigation. Al-
cause dramatic clinical improvement. No treatment has though the treatment of RA has advanced greatly in
been shown to prevent the ankylosis of the axial spine; recent years, the possible causes of RA are still un-
however, current studies show that the anti-TNF- known. Understanding the causes of RA offers the best
agents used in the treatment of AS are promising. chance for finding a cure or a preventive therapy.
Treatment of the spondyloarthropathies also will
Surgical Management benefit from the anti-TNF- research in RA. These
The protocols for the perioperative use of DMARDs agents may be the first to actually reduce long-term pro-
and NSAIDs in RA also apply to their use in treatment gression of axial disease. Investigating the trigger for the
of the spondyloarthropathies. Additional surgical issues spondyloarthropathies may lead to the identification of
need to be considered for AS patients. These patients other infectious organisms, similar to those found in
have diminished chest excursion, which creates a greater ReA.
risk for postoperative pulmonary complications. Intuba- Stem cell transplant has been tested in patients with
tion also may be extremely difficult because of cervical RA, JIA, and other autoimmune diseases with the goal
spine rigidity; fiberoptic intubation may be necessary. of replacing most of the activated cells with uncommit-
Ossification of the anulus fibrosus and spinal ligaments ted stem cells (based on the assumption that the original
may make administration of spinal anesthetic difficult. triggers for the disease are no longer present). A recent
When such patients are positioned on the operating ta- study noted that positive responses were found with
ble, great care must be exercised to ensure that the 59% remission for up to 4 years in patients with JIA.
spine is adequately padded and supported, particularly Transplant mortality was 1.4% for RA patients and
if a significant kyphotic deformity exists. Patients with 12.5% for those with JIA. Most RA patients who did
AS often fail to fully regain the same range of motion not experience remission regained sensitivity to anti-
after joint reconstruction in comparison with other rheumatic medications, allowing for better disease con-
groups of patients. Although postoperative range of mo- trol. There is one report of the development of RA after
tion may be less, it is still often adequate to significantly autologous peripheral blood stem cell transplantation.
improve the patients ability to perform activities of
daily living. Patients with AS may have an increased risk Annotated Bibliography
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Osteoarthritis
tive radiation may be used to decrease this risk.
Brown KN, Saunders MM, Kirsch T, Donahue HJ, Reid
Patients with PsA may have skin involvement in the
JS: Effect of COX-2-specific inhibition on fracture-
area of the proposed surgical incision. Because local healing in the rat femur. J Bone Joint Surg Am 2004;86:
bacterial contamination may increase the risk of infec- 116-123.
tion, it is recommended that the skin be treated aggres- The results of this study on rats with nondisplaced frac-
sively with topical agents or ultraviolet light before any tures of the femur showed that a traditional NSAID (in-
surgical procedure. In addition, patients should use anti- domethacin) delayed fracture healing more than a coxib (cele-
microbial soaps before surgery. coxib) or placebo.
Emerging Concepts and Future Directions DeGroot J, Bank RA, Tchetverikov I, Verzijl N, TeKop-
There is increasing knowledge about the systemic risk fac- pele JM: Molecular markers for osteoarthritis: The road
tors of OA and the modification of these risk factors to ahead. Curr Opin Rheumatol 2002;14:585-589.
prevent OA. The search for the first disease-modifying This is an excellent recent summary of the developments
OA drug (similar to a DMARD in RA) continues; this made in the study of molecular markers for osteoarthritis.
process will be facilitated by the increased understanding
of the molecular basis of articular cartilage degradation. DeMaria AN, Weir MR: Coxibs: Beyond the GI tract:
Possible candidates for such a disease-modifying agent in- Renal and cardiovascular issues. J Pain Symptom
clude the combination cyclooxygenase/lipoxygenase in- Manage 2003;25(suppl 2):S41-S49.
hibitors, MMP inhibitors, IL-1, and nitric oxide blockade. This article presents an important review of the clinical
Although the anti-TNF- therapies have dramati- implications of the use of coxibs on the renal and cardiovascu-
cally improved function and quality of life for patients lar systems. The article also reviews the lack of platelet effect
with RA, the use of these agents has not led to a perma- of the coxibs and the role of supplemental acetylsalicylic acid
nent remission of inflammation in RA patients. There in those patients who require an antiplatelet agent for cardio-
are probably other factors contributing to the persistent vascular prophylaxis.
systemic inflammation in RA. Other cytokine inhibitors
are currently in clinical trials and are showing good pre- Fries JF, Lorig K, Holman HR: Patient self-management
liminary results. B cell inhibition is a promising treat- in arthritis: Yes! J Rheumatol 2003;30:1130-1132.
This article reviews the importance of patient self- Ravelli A: Toward an understanding of the long-term
management in arthritis. Patients who learn about their arthri- outcome of juvenile idiopathic arthritis. Clin Exp
tis and who take an active role in the management of this Rheumatol 2004;22:271-275.
chronic condition have better long-term outcomes. This article presents an analysis of the outcome of JIA in
terms of clinical remission, physical disability, and radiographic
damage. The extensive prognostic indicators and the subtypes
Jordan JM, Kraus VB, Hochberg MC: Genetics of os-
that persist into adulthood are reviewed.
teoarthritis. Curr Rheumatol Rep 2004;6:7-13.
This article provides a perspective on the various genetic
studies of OA and the limitations of these studies given the Seronegative Spondyloarthropathies
variation in study populations and diagnostic criteria. Davis JC Jr, Van Der Heijde D, Braun J, et al: Recombi-
nant human tumor necrosis factor receptor (etanercept)
for treating ankylosing spondylitis: A randomized, con-
Rheumatoid Arthritis trolled trial. Arthritis Rheum 2003;48:3230-3231.
Alderman AK, Ubel PA, Kim HM, Fox DA, Chung KC: This study of patients with moderate to severe ankylosing
Surgical management of the rheumatoid hand: Consen- spondylitis showed that etanercept was highly effective and
sus and controversy among rheumatologists and hand well tolerated. Patients showed a dramatic improvement in
surgeons. J Rheumatol 2003;30:1464-1472. symptoms and measures of spinal mobility. It also had a good
This article describes the large discrepancy in communica- safety profile.
tion between rheumatologists and hand surgeons and knowl-
edge of timing and options in hand surgery. Emerging Concepts and Future Directions
Edwards JC, Leandro MJ, Cambridge G: B lymphocyte
Cannella AC, ODell JR: Is there still a role for traditional depletion therapy with rituximab in rheumatoid arthri-
disease-modifying antirheumatic drugs (DMARDs) in tis. Rheum Dis Clin North Am 2004;30:393-403.
rheumatoid arthritis? Curr Opin Rheumatol 2003;15:185- Most of the current DMARD therapy for RA focuses on
192. T cell inhibition. This article discusses the concept of B-cell in-
This article reviews recent and relevant trials in the treat- hibition with rituximab as a promising new therapy for RA.
ment of RA, suggests a treatment algorithm, and argues that tra-
ditional disease-modifying antirheumatic drugs continue to play Furst DE: The status of stem cell transplantation for
a pivotal role in treatment. A more aggressive approach using rheumatoid arthritis: A rheumatologists view.
combination DMARDs and biologics in the treatment of early J Rheumatol Suppl 2001;64:60-61.
RA is discussed. Stem cell transplantation may become an important ther-
apy for the treatment of certain subtypes of RA. This review
discusses specific selection criteria and outcome measure-
Laine L, Bombardier C, Hawkey CJ, et al: Stratifying ments.
the risk of NSAID-related upper gastrointestinal clinical
events: Results of a double-blind outcomes study in pa-
tients with rheumatoid arthritis. Gastroenterology 2002; Wulffraat NM, Brinkman D, Ferster A, et al: Long-term
123:1006-1012. follow-up of autologous stem cell transplantation for re-
The risks of traditional NSAIDs in the treatment of RA is
fractory juvenile idiopathic arthritis. Bone Marrow
Transplant 2003;32(suppl 1):S61-S64.
investigated with a review of the recent literature.
This review discusses the outcome of autologous stem cell
transplantation in 31 children with JIA from eight pediatric
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teoarthritis of the hip and knee: 2000 update: American
Introduction Hypermobility
Connective tissue disorders such as Ehlers-Danlos syn- The hypermobility subtype (formerly type III) is the most
drome (EDS), osteogenesis imperfecta (OI), and orthopaedically debilitating of all forms of EDS, and the
Marfan syndrome are phenotypic expressions of inher- most likely to require orthopaedic surgical intervention.
ited collagen and/or fibrillin anomalies. The errors of the It is an autosomal dominant variant of unknown molec-
extracellular matrix of the involved tissues in these dis- ular basis; therefore, no diagnostic test presently exists.
eases lead to pathology within the bone, vascular sys- Clinically, these patients present with soft skin and both
tem, and viscera. Although the genetics and pathophysi- small and large joint hypermobility; recurrent and/or
ology are different, the underlying similarity of chronic dislocations may also be present. Up to 20% of
abnormal genetic expression leading to systemic disease patients may have aortic root anomalies. Multidirectional
is unmistakable. instability of the shoulder, patella subluxation, and chronic
ankle instability are common. A snapping of the iliotibial
band is often misinterpreted as a dislocated hip, although
Ehlers-Danlos Syndrome true dislocations can occur (albeit rarely) even in the pres-
EDS includes a group of the most common heritable ence of radiographically normal bony architecture (Fig-
disorders of the connective tissue. Although all have ure 2). Surgical interventions such as capsular shift or pli-
features of skin and joint hypermobility, they are a het- cation should be undertaken only if physical therapy is
erogenous group presently classified based on genetic ineffective. Excellent results are elusive. Bracing is fre-
transmission, biochemical anomaly, and major and mi- quently used, especially of the hands because of finger in-
nor clinical findings. The previous classification system stability. Nearly 90% of patients have debilitating pain, of-
of 11 different types has been reduced to 6 in the ten with abnormal gait or the need for assistive devices.
present Villefranche classification system (Table 1).
Vascular
Classic The vascular subtype (formerly type IV) is most often au-
Classic EDS includes the former type I (gravis) and tosomal dominant and occasionally autosomal recessive.
type II (mitis) subsets. The classic type combined with Biochemically, a defect in the COL3A1 gene for type III
hypermobility and vascular types are by far the most collagen is present in more than 90% of the patients.As in
common, comprising more than 90% of all types of the other EDS subtypes, hypermobility of the small joints
EDS. The classic form is an autosomal dominant condi- and clubfoot may be present. However, the hallmark of
tion with 40% to 50% of patients manifesting a the vascular subtype is malignant involvement of the vis-
COL5A1 or COL5A2 gene mutation of type V col- cera and arteries. These patients have thin, translucent
lagen. The major clinical diagnostic criteria include skin skin, and may experience spontaneous rupture of the
hypermobility, widened atrophic scars, and joint hyper- bowel, uterus, or large arteries. Aortic root dilatation is
mobility. Up to 33% of patients will have aortic root di- present in more than 75% of patients.Twenty-five percent
latations and therefore, echocardiography is suggested. of women die during pregnancy because of complications,
Other minor criteria include velvety skin, spheroids, hy- most often uterine rupture. Life expectancy is 45 to
potonia, and tissue fragility. Nearly 30% of patients will 50 years.
have scoliosis, with most having the thoracic or thora-
columbar type. Tower vertebra may be seen (Figure 1). Kyphoscoliosis
More than 50% of these patients may have chronic This rare subtype (previously type VI) is an autosomal
musculoskeletal pain. recessive disorder with a biochemical deficiency in lysyl
Figure 3 A and B, Radiographs of a 3-year-old girl with bilateral developmental dysplasia of the hip, a family history of EDS, and arthrochalasis. After bilateral reduction of the
hip through an anterior approach and capsulorrhaphy, the left hip has resubluxated.
drome as patients have scoliotic, cardiac, and ocular in- Osteogenesis Imperfecta
volvement and often a tall, thin body habitus. OI is a hereditary condition resulting from an abnor-
mality in type I collagen that is manifested by an in-
Arthrochalasis creased fragility of bones and low bone mass (osteope-
This extremely rare form of EDS was previously classi- nia). It is estimated that in the United States alone,
fied as types VIIA and VIIB. This autosomal dominant 20,000 to 50,000 people are affected with OI.
form is characterized by a deficiency in the pro- I or Eighty percent to 90% of patients with OI can be
pro- 2 collagen type I chains at their N-terminal end. grouped into the Sillence type I to IV categories and
Children with arthrochalasis type EDS are born with bi- have mutations of one of the two type I collagen genes.
lateral developmental dysplasia of the hip that is often (Recently, types V, VI, and VII have also been added).
recalcitrant to surgical intervention (Figure 3). They The COL1A gene encodes the pro-1(I) protein chain
may also, as minor criteria, display skin hyperextensibil- and the COL2A gene encodes pro-2(I) protein chain
ity, muscle hypotonia, osteopenia, and kyphoscoliosis. of type I procollagen. The etiologies of the remaining
Easy bruising and tissue fragility also exist. 10% to 20% remain unclear.
Iliac crest biopsies of patients with OI show a de-
crease in cortical widths and cancellous bone volume,
Dermatosparaxis
with increased bone remodeling. There is a direct rela-
Dermatosparaxis is a rare, autosomal recessive form of
tionship between the increase in bone turnover and the
EDS (formally known as type VIIC) notable for a defi-
severity of the disease.
ciency of procollagen I N-terminal peptidase. Patients
The clinical features of OI are osteopenia, bone fra-
have redundant, severely fragile, and often sagging skin.
gility, and fractures and may include some or all of the
Premature rupture of fetal membranes, large hernias,
following: joint laxity, gray-blue sclerae, dentogenesis
and easy bruising also may be seen.
imperfecta, premature deafness, kyphoscoliosis, and
basilar invagination (prolapse of the upper cervical
Other Forms spine into the base of the skull). In OI, the bones can be
In addition to the six major forms of the Villefranche biologically soft, producing deformities such as pro-
classification, other forms of EDS exist encompassing trusio acetabuli in the pelvis and basilar invagination at
previous types V, VIII, and X and include those with pe- the craniovertebral junction. It is believed that repeated
riodontal friability (VIII), and the poor clotting/ microfractures in OI bone combined with healing and
fibronectin deficient type (X). In addition, a form of remodeling is responsible for the soft bones.
EDS with symptoms similar to the classic form exists, Symptoms of basilar invagination in OI typically oc-
but with an X-linked inheritance pattern. This was for- cur in the third and fourth decades but may be present
merly type V EDS and has been described in only a sin- during the teenage years. These symptoms include brain-
gle family. stem dysfunction such as apnea, altered consciousness,
lower cranial nerve deficits, myelopathy, and ataxia. Neu- has been used in the past because of its anabolic effects
rologic abnormalities are consequences of direct neural on bone; however, clinical studies showed no increase in
compression, altered cerebrospinal fluid flow, or vascular bone mass or change in natural history. For the past
compromise. The recommended treatment of basilar in- 10 years, bisphosphonates have been used to treat pa-
vagination in OI consists of extensive removal of bony tients with types III and IV OI. Bisphosphonates de-
compression by a transoral approach followed by a pos- crease the resorption of bone by suppressing the activity
terior fusion and posterior rigid fixation that transfers the of osteoclasts. Pamidronate, an injectable bisphospho-
weight of the head to the thoracic spine. nate, increases cortical bone thickness and, in severe
Although it may be difficult, determining the clinical forms of OI, improves overall bone mass. Pamidronate
distinction between children with OI and those with therapy decreases the incidence of fractures, relieves
nonaccidental trauma has obviously important implica- chronic bone pain, increases activity levels, decreases
tions. Skin biopsies and fibroblast cultures may be help- the reliance on mobility aids, and increases the height of
ful, but are only positive in 80% of patients with the collapsed vertebral bodies. Unfortunately, there has
type IV OI (the most commonly confused with nonacci- been no decrease in the incidence of scoliosis. Radio-
dental trauma) (Table 2). graphically, pamidronate therapy creates growth lines in
the bone (Figure 4). These radiodense areas of bone
Nonsurgical Treatment probably represent the inhibition of osteoclastic resorp-
The medical treatment of OI involves strategies to im- tion, whereas the clear areas between the lines repre-
prove bone mass. Recombinant human growth hormone sent the interval growth between treatment cycles.
sion may be considered in the very young patient to mity (pectus excavatum > pectus carinatum), general-
prevent crankshafting of the spine. Surgery for basilar ized ligamentous laxity, severe planovalgus, and/or long
invagination is indicated for patients with radiographic thin feet with a disproportionately long great toe. Scoli-
progression or with neurologic deficits resulting from osis is seen in 60% to 70% of patients (right thoracic
brainstem and high cervical cord compression. lordotic curves are the most common); males and fe-
males are equally affected. The head and neck reveal a
Marfan Syndrome high arched palate, myopia, corneal flatness, dislocation
Marfan syndrome is an inherited connective tissue dis- of lenses (ectopia lentis) and iridodonesis (tremor of the
order that is usually transmitted as an autosomal domi- iris secondary to lens dislocation). Cardiac manifesta-
nant trait. Approximately 25% of cases arise from new tions include mitral valve prolapse, mitral regurgitation,
mutations. The incidence is roughly 1:10,000 with ap- dilatation of aortic root, aortic regurgitation, aortic dis-
proximately 200,000 people in the United States having section, and aortic aneurysm. Marfan syndrome may
Marfan syndrome. There is no ethnic or gender predilec- lead to spontaneous pneumothorax secondary to lung
tion. bullae and striae distensae.
The genetic mutation of Marfan syndrome is on the A severe neonatal form of Marfan syndrome exists.
fibrillin-1 (FBN1) gene located on chromosome 15q21. These children are identified within the first few months
More than 135 mutations in the FBN1 gene have been of life by serious cardiac abnormalities and congenital
identified. The genetic heterogenicity explains the pleio- contractures. This form of the syndrome is believed to
tropic manifestations of Marfan syndrome with variable result from a spontaneous mutation in the FBN1 gene.
phenotypic expression. FBN1 is the main component of The diagnosis of Marfan syndrome is based on fam-
the 10 to 20 nm extracellular microfibrils that are impor- ily history, evaluation of six organ systems, and molecu-
tant for elastogenesis, elasticity, and homeostasis of elas- lar data. The Ghent system outlines diagnostic criteria
tic fibers. for both the index patient (the first case in a family) and
The clinical features include increased height, dispro- for subsequent relatives (Table 3). To establish the diag-
portionately long, gracile limbs (dolichostenomelia), nosis of Marfan syndrome in the index case, the patient
arachnodactyly with a positive wrist (Walker) and must fulfill one major criteria in at least two different
thumb (Steinberg) sign, an arm span greater than height organ systems and have involvement of a third system.
(span to height ratio > 1.05), anterior chest wall defor- To establish the diagnosis in a relative of an index case,
*Two or more major or one major plus two minor criteria required for involvement
At least two minor criteria required for involvement
One major or minor criterion required for involvement
One major criterion required for involvement
||One minor criterion required for involvement
(Adapted from Miller NH: Connective tissue disorders, in Koval KJ (ed): Orthopaedic Knowledge Update: 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 201-207.)
a major criterion in the family history needs to be There are no specific laboratory investigations for
present, the individual must have one major criterion in Marfan syndrome, although genetic testing is now avail-
any organ system and involvement of a second organ able in some centers. Prenatal molecular diagnosis is
system. possible only if the familys mutation is known or sev-
Marfan syndrome must be differentiated from the eral affected family members are available for genetic
MASS phenotype, an acronym assigned to the following linkage analysis.
clinical features: mitral valve prolapse, aortic root diam- Radiographic analysis of Marfan syndrome may re-
eter at the upper limits of normal, stretch marks, and veal the presence of scoliosis, protrusio acetabuli, chon-
skeletal features of Marfan syndrome (including scolio- drolysis, and high-grade spondylolisthesis (Figure 7).
MRI reveals dural ectasia in more than 60% of patients.
sis, pectus excavatum or carinatum, and joint hypermo-
Other important investigations include transesophageal
bility). The aortic root diameter may be at the upper
echocardiogram, electrocardiogram, slit lamp examina-
limits of normal for body size, but there is no progres-
tion, and keratometry.
sion to aneurysm or predisposition to dissection. Ecto-
The medical treatment of Marfan syndrome includes
pia lentis does not occur. MASS patients therefore have the use of -blockers to slow the progression of aortic
a better prognosis than those with classic Marfan syn- dissection. Aortic replacement is indicated if aortic di-
drome. This condition can be inherited within families ameter is greater than 5 cm. Pregnant women with aor-
and has been shown to result from mutations in the tic dilatation should have a cesarean section at 38
FBN1 gene. weeks. The success rate for bracing of spinal deformities
In addition to the MASS phenotype, the differential is much lower than in adolescent idiopathic scoliosis.
diagnosis of Marfan syndrome includes congenital con- Curves greater than 25 in children with Risser grade II
tractural arachnodactyly (Beals syndrome), Sticklers skeletal maturity will likely require surgery despite
syndrome, arthrochalasis type EDS, hypermobility syn- bracing. Preoperative imaging of the spine with MRI to
drome, and homocystinuria. identify dural ectasia and CT to assess fixation points
Annotated Bibliography
Ehlers-Danlos Syndrome
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Figure 7 Radiograph of the hip of a 13-year-old girl with Marfan syndrome showing Twenty-eight percent of all EDS patients have aortic root
classic protrusio acetabuli.
dilatation (25% in classic form, 17% in the hypermobile
form). Patients without the vascular form of EDS also should
be carefully monitored for this complication.
are essential. Preoperative cardiopulmonary evaluation
is mandatory. There is an increased incidence of pseu- Osteogenesis Imperfecta
darthrosis in posterior spinal fusion. Closure of the tri- Cole WG: Advances in osteogenesis imperfecta. Clin
radiate cartilage to treat protrusio acetabuli also has Orthop 2002;401:6-16.
been proposed. This article presents a review of the current state of
If untreated, the life expectancy of a patient with knowledge regarding collagen mutations in OI.
Marfan syndrome is 30 to 40 years, with death resulting
from aortic dissection, aortic rupture, or valvular in- Glorieux FH: The use of bisphosphonates in children
duced cardiac failure. With modern cardiovascular treat- with osteogenesis imperfecta. J Pediatr Endocrinol
ment regimens, the average lifespan is now 70 years. It is Metab 2001;14(suppl 6):1491-1495.
important to remember that the tall, agile, athletic pa- One of the more recent reviews on the use of bisphospho-
tient with Marfan syndrome is at risk for aortic dissec- nates for patients with OI is presented by the group who first
tion and sudden death. It is imperative to educate pa- studied the use of bisphosphonates for this condition.
tients about the signs and symptoms of aortic and
cardiac disease, and to counsel them on activity restric- Osteogenesis imperfecta. NIH Medline Plus Website.
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osteogenesisimperfecta.html. Accessed June, 2004.
Future Directions A complete, up-to-date review of all aspects of OI is pre-
As recent studies indicate, an advanced understanding sented, with numerous links to related websites.
of the genetic basis behind inherited connective tissue
disorders will potentially allow for intervention at a mo- Osteogenesis Imperfecta Foundation Website. Available
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with EDS, osteoblasts for those with OI, or fibrillin for mation for health professionals and families dealing with all
those with Marfan syndrome is presently elusive, it aspects of OI.
should become a reality. Several new strains of Marfan
mice have recently been developed with mutant
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the treatment of their symptoms has become more com-
cludes excellent photographs.
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macologic treatment has and will continue to lead to de-
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throwing, whereas athletes with posterior laxity will re- tive, the joint subluxates in the internally rotated, cross-
port shoulder discomfort and instability symptoms on body position, and reduction occurs with further rota-
the follow-through phase of throwing. The dead arm tion. The posterior apprehension test is performed by
syndrome may occur after anterior joint instability. An applying a posterior force to the shoulder with the arm
overhead throwing athlete with transient anterior insta- in a forward flexed and internally rotated position. In
bility may experience sudden, sharp pain associated the Jahnke test, a posterior directed force is applied to
with loss of control of the extremity, numbness, and an the forward flexed shoulder. The shoulder is then
inability to throw the ball. These symptoms are tran- moved into the coronal plane as an anterior-directed
sient, and usually resolve within a few seconds to min- force is applied to the humeral head. A clunk occurs as
utes. the humural head reduces from the subluxated position.
The apprehension test is useful in assessing for ante- The sulcus sign is used to evaluate inferior laxity and
rior instability. The examiner applies an anteriorly di- associated inferior instability. The test is performed with
rected force to the humeral head with the shoulder in the athlete in a sitting position with the arm at the side.
abduction and external rotation. A positive test results A distraction force is applied longitudinally along the
with the patient having apprehension that the joint will humerus. The magnitude of displacement and the pres-
dislocate. This maneuver mimics the position of instabil- ence of discomfort or apprehension is compared with
ity and causes reflex guarding. The relocation test is pos- that of the contralateral limb.
itive if relief occurs when a posteriorly directed force is Initial treatment should be nonsurgical, consisting of
applied to the humeral head. rehabilitation of the glenohumeral and scapular mus-
Treatment, especially in patients who have symptom- cles, and surgical treatment should be considered if non-
atic laxity as the result of repetitive microtrauma, surgical treatment fails. Posterior stabilization may be
should focus on a rehabilitation program that avoids the performed with arthroscopic or open techniques, and in-
provocative position during the first 6 to 8 weeks and cludes repair of the posterior labral avulsion and plica-
incorporates a strengthening program to enhance the tion of the stretched posterior capsuloligamentous struc-
function of the dynamic stabilizers. Following a period tures. Special attention should be sought for associated
of tissue healing, proprioception training followed by a inferior instability and rotator internal lesions should be
slow return to sport-specific activities should occur. repaired if present. Patient selection is important, be-
Surgical intervention should be reserved for patients cause those with a traumatic etiology and no evidence
in whom conservative treatment is unsuccessful, or who of generalized ligamentous laxity have the best progno-
represent a population with a high risk of failure, such sis.
as young patients with a history of a traumatic anterior
dislocation. Identification of the pathoanatomy is essen-
tial for relieving the athletes instability; a patient-
Superior Labral Anterior and Posterior
specific selective capsular repair can be done, along with Lesions
refraining from addressing all instability problems with The SLAP lesion was first described in 1985. A more ex-
a single type of surgical procedure. Arthroscopically, pa- tensive injury pattern was subsequently identified that
tients with a history of a traumatic anterior event can involved the superior labrum; four basic types were de-
have their Bankart lesion repaired anatomically with su- scribed (Figure 1). Type II lesions were further subdi-
ture anchors. Treatment of specific capsuloligamentous vided into a type II lesion with an anterior component
structures for predetermined directional instabilities can (A), a posterior component (B), or a combined antero-
be accomplished with arthroscopic techniques of suture posterior lesion (C). A peel-back phenomenon was de-
plication, thermal capsulorrhaphy, and, when necessary, scribed that is part of the pathoanatomy associated with
closure of the rotator interval. type II SLAP lesions that have a posterior component
(B or C), which is observed arthroscopically in the ab-
Posterior Glenohumeral Joint Instability ducted and externally rotated position and may contrib-
Posterior instability results either from avulsion of the ute to posterosuperior glenohumeral instability. Ana-
posterior glenoid labrum from the posterior glenoid, or tomic repair of the SLAP lesion has been shown to
stretching of the posterior capsuloligamentous struc- eliminate the dynamic peel-back of the posterior supe-
tures. Posterior instability is often difficult to diagnose. rior labrum.
No single test has high sensitivity and specificity. During The diagnosis of a SLAP lesion is difficult because
the circumduction test, the patient actively rotates the the injury may be caused by either the repetitive nature
shoulder from the side to an internally rotated and of overhead throwing, or as the result of a traumatic
cross-body position, to a fully elevated position, to an event. SLAP lesions are commonly associated with
abducted and externally rotated position, and then re- other injuries and usually have overlapping, nonspecific
turns the arm to the side. The examiner stands behind symptoms. The patient may have difficulty describing
the patient and palpates the posterior shoulder. If posi- their pain. The discomfort is typically associated with
Figure 1 SLAP classification. A, Type I: fraying and degeneration of the superior labrum with a normal biceps tendon anchor. B, Type II: pathologic detachment of the labrum and
biceps anchor from the superior glenoid. C, Type III: vertical tear of the superior labrum analogous to a bucket-handle tear. D, Type IV: tear extending into biceps tendon.
(Reproduced with permission from Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder. Arthroscopy 1990;6:274.)
the late cocking phase of throwing as the arm begins to repair to the bony glenoid rim. Lesions producing signif-
accelerate forward. The patient may feel a sudden, sharp icant defects extending into the biceps tendon may re-
pain in the extreme abducted and externally rotated po- quire biceps tenotomy, with or without tenodesis.
sition followed by a dead arm sensation. These symp- Rehabilitation following a SLAP repair allows for a
toms usually result in an inability to throw with prein- 6-week interval for tissue healing. During this time, pa-
jury velocity. tients are in a gentle range-of-motion program with set
No finding on physical examination has been found limitations, followed by a progressive strengthening pro-
to be specific for identifying patients with a SLAP le- gram. Sport-specific activities are begun at about 3 to 4
sion. Provocative tests that have been suggestive of the months with a return to sports activity at approximately
existence of superior labral pathology include Speeds 6 months. Success following this procedure has been re-
test, the OBrien test, and the Jobe relocation test. The ported to be as high as an 87% return to preinjury level
OBrien test (active compression test) may be the most of competition.
useful. The internally rotated shoulder is forward flexed
to 90 and brought across the body in horizontal abduc- Rotator Cuff Tears
tion about 10. The test is positive if the patient has pain Rotator cuff pathology in the overhead throwing athlete
with resisted forward flexion that is relieved by external is seen primarily as a partial-thickness articular-sided
rotation of the shoulder. It should be noted that a posi- tear of the supraspinatus and, to a lesser extent, the in-
tive relocation test for patients with superior labral pa- fraspinatus tendons. Factors that predispose the rotator
thology is highlighted by posterosuperior glenohumeral cuff to this injury include not only the abnormal contact
joint pain with the arm in the abducted and externally between the greater tuberosity and posterosuperior gle-
rotated position that is relieved by the relocation ma- noid rim, but also a less vascular articular cuff surface, a
neuver. Imaging studies including plain radiographs and higher modulus of elasticity, higher eccentric forces, and
MRI evaluation should be done to rule out coexisting a less favorable stress-strain curve than on the bursal
pathologies. A magnetic resonance arthrogram may help side. Full-thickness tears are less common in the over-
in the diagnosis of a SLAP lesion. Diagnostic arthros- head throwing athlete and can be the result of a partial-
copy remains the best means to definitively diagnose thickness tear progressing to a full-thickness tear or the
SLAP lesions. result of a traumatic event.
Because patient complaints can be nonspecific with
no preceding traumatic event, treatment generally be- Acromioclavicular Joint
gins with a physical therapy program focusing on Repetitive overhead throwing can result in microtrau-
strengthening of the dynamic stabilizers with the goal of matic wear and tear of the AC joint resulting in osteoly-
improving joint stability during overhead throwing. Sur- sis of the distal end of the clavicle. Patients report pain
gical intervention is usually reserved for patients in localized to the AC joint that becomes worse with both
whom conservative management has failed and is ac- overhead motion and cross-body adduction. Physical ex-
complished through an arthroscopic approach. Meaning- amination reveals tenderness at the AC joint, and pain
ful detachment of the capsulolabral structures requires with a cross-body adduction compression test. Radio-
graphic evaluation of the AC joint with a Zanca view sion at the suprascapular notch, possibly from a hypertro-
may show osteolysis or arthritic changes. Diagnosis and phied transverse scapular ligament, decompression is
treatment can be accomplished by performing a local in- best with an open technique.
jection into the AC joint with a combination of a local
anesthetic and a corticosteroid. Vascular Injuries
Patients who fail to improve with conservative treat- Vascular injuries in the overhead throwing athlete are
ment will benefit from a distal clavicle resection, which rare, and include digital vessel thrombosis, proximal
can be done either through an open or arthroscopic ap- thrombosis with distal embolization, aneurysms, and
proach. If there is concern about additional shoulder pa- vessel compression such as thoracic outlet syndrome
thology, arthroscopic evaluation of the glenohumeral and quadrilateral space syndrome.
joint and the subacromial space is recommended before Aneurysms in overhead throwing athletes have been
the distal clavicle is resected. Although the best amount reported in the subclavian artery, axillary artery, and the
of resection is unknown, between 5 and 10 mm is ac- posterior humeral circumflex artery. It is believed that
ceptable. Postoperatively, patients are placed in a physi- these injuries occur as a result of repetitive trauma or
cal therapy program with the goal of regaining motion impingement during the throwing motion. The pectora-
and strength; cross-body adduction should be avoided lis muscle and humeral head have both been implicated
for 6 weeks. A slow progression to sport specific acti- as a source of the traumatic impingement when the arm
vities is followed by a return to sports activity in about 2 is in the abducted and externally rotated position.
to 3 months. Quadrilateral space syndrome is another neurovas-
cular compression syndrome that appears to be unique
Suprascapular Neuropathy to overhead throwing athletes. The quadilateral space is
Suprascapular neuropathy is a rare condition in over- the area bordered by the teres minor superiorly, the hu-
head throwing athletes. In elite volleyball players, it may meral shaft laterally, the teres major inferiorly, and the
result from a stretch injury or direct compression of the long head of the triceps medially. Arteriograms have
nerve. A paralabral ganglion cyst compression at the documented compression of the posterior humeral cir-
transverse scapular ligament or the spinoglenoid notch cumflex artery with abduction and external rotation, but
is possible. Proximal compression at the suprascapular it is believed that the symptoms are caused by compres-
notch will result in denervation of the supraspinatus and sion of the axillary nerve, which runs with the artery.
infraspinatus muscles. Distal compression at the spino- Conservative management is the standard of care fo-
glenoid notch results in denervation of the infraspinatus cusing on stretching of both the posterior capsule and
only. In the late cocking phase of throwing, the medial the teres minor. Patients in whom conservative manage-
tendinous margin between the supraspinatus and in- ment has failed can undergo open decompression of the
fraspinatus may compress the infraspinatus branch of quadrilateral space, which has proved to be a successful
the suprascapular nerve against the scapular spine. procedure for resistant cases.
Patients with suprascapular neuropathy present with
a history of weakness and dull shoulder pain. On physi- Elbow
cal examination, weakness of the supraspinatus and in- In the overhead throwing athlete, most injuries seen in
fraspinatus muscles correlates with the location of nerve the elbow are related to the repetitive nature of throw-
compression. Chronic injuries are associated with mus- ing, and are best characterized as medial tension and
cular atrophy. MRI will help to identify a ganglion cyst, lateral compression injuries. During the late cocking and
which will appear as high signal intensity on a T2 image, early acceleration phases of throwing, the medial elbow
and aids in ruling out a rotator cuff tear as the etiology is subject to significant tensile forces, whereas the lateral
of weakness. Electrodiagnostic studies confirm the diag- elbow experiences considerable compressive forces. Un-
nosis. Increased latency on the affected side is consistent like the shoulder, the elbow derives most of its stability
with nerve impairment and can be used to localize the from its bony configuration. The ligaments surrounding
suprascapular nerve compression. the elbow help to further stabilize the joint. It is the ul-
When an anatomic reason cannot be identified, con- nar or medial collateral ligament (MCL) on the medial
servative treatment with a well-organized physical thera- side that functions as the primary stabilizer to valgus
py program is helpful for most patients. When compres- stress, whereas the lateral collateral ligament resists
sion is localized to an anatomic reason, surgical both varus and external rotation stresses. Dynamic mus-
decompression is recommended. Ganglion cysts in the cle contraction also contributes to elbow stability by in-
spinoglenoid notch can be treated with an arthroscopic creasing the joint compression forces during muscle
technique. Because the cyst usually originates from the contraction. Repetitive trauma to the MCL allows for
glenohumeral joint, a repair of the labrum may be re- increased secondary compression at the radiocapitellar
quired to prevent recurrence. For patients with compres- joint on the lateral side, which can ultimately lead to
chondromalacia about the elbow and possibly loose Radiographs may be normal. In patients with
body formation. chronic MCL injuries, radiographs may show calcifica-
tion of the MCL, medial spurs on the humerus and ulna,
Medial Elbow Pain posterior spurs on the olecranon tip, and loose bodies
The MCL is divided into three segments: the anterior within the joint. AP stress radiographs of the elbow are
bundle, the posterior bundle, and the transverse seg- useful when a wider medial opening in the unstable el-
ment. It is the primary stabilizing structure to valgus bow is found compared with the contralateral normal
stresses about the elbow and is most often injured dur- side. When the history and physical examination support
ing the late cocking and acceleration phases of throw- the diagnosis of an MCL injury, a magnetic resonance
ing. About one third of patients will not report a preced- arthrogram is especially useful if a T sign of ulnar avul-
ing acute event, and in those who do, a subset of them sion or if humeral avulsion or a midsubstance tear is
will describe a period of nondescript elbow discomfort found.
before the traumatic event. Pain is usually localized to MCL injuries initially can be treated with a conser-
the medial side of the elbow. Athletes with chronic vative approach focusing on a rehabilitation program
MCL incompetence may develop concomitant ulnar that incorporates modality treatments such as phono-
nerve neuritis, and this neuritis may be accompanied by phoresis, electrical stimulation, and iontophoresis, a
posterior elbow pain caused by posteromedial olecra- stretching program, and a strengthening protocol focus-
non impingement. ing on the medial side flexor-pronator muscle mass.
On physical examination, patients with an acute in- Sport-specific throwing, beginning with soft tossing of
jury may develop medial-sided ecchymosis. Tenderness the ball, usually starts 3 months after initiation of treat-
to palpation on the medial side will lend support to the ment. Adjustments in the athletes mechanics during
diagnosis, but positive results on provocative testing are throwing may further support a return to previous levels
also required. The valgus stress test is positive if the ap- of competition.
plied valgus stress reproduces the symptoms of medial Overhead throwing athletes with MCL injuries who
elbow pain, and the valgus laxity is greater on the af- continue to throw run the risk of developing posterome-
fected side than the uninjured side. This test must be dial olecranon impingement and subsequent ulno-
done with the elbow flexed 20 to unlock the olecranon humeral arthritis. Surgical treatment is recommended
from within the olecranon fossa. A gravity stress test is for athletes who wish to continue sports participation
performed with the athlete supine, the shoulder exter- and in whom conservative management has failed, and
nally rotated to 90, and the elbow flexed 20 so that for elite athletes who are unable to throw at their nor-
gravity is used to elicit the valgus stress. If the ulnar col- mal level. Surgical treatment consists of reconstruction
lateral ligament (UCL) has been injured but remains in- of the MCL with a tendon graft. Direct repair should be
tact, stress testing may elicit pain but no instability. The considered only in those patients who sustain an acute
milking maneuver will also elicit pain along the medial traumatic avulsion injury. Graft options include the ipsi-
side of the elbow (Figure 2). An additional test recently lateral or contralateral palmaris longus tendon, the
described, called the moving valgus stress test, repro- fourth toe extensor tendon, the plantaris tendon, and
duces the patients medial elbow pain and symptoms by the gracilis tendon.
rapidly extending the elbow from a starting position of Approximately 40% of athletes requiring an MCL
full flexion while maintaining a constant valgus torque. reconstruction reportedly have ulnar nerve symptoms,
yet surgical treatment is rarely needed. Only patients closure is usually completed within 1 year. Avulsion of
who demonstrate muscle involvement on physical exam- the medial epicondyle is confirmed on radiographic ex-
ination or electrodiagnostic testing, or experience pain amination. Patients are usually treated with surgery if
from ulnar nerve subluxation require treatment. More the epicondyle is displaced greater than 1 cm, ulnar neu-
than 70% of throwers who have undergone an MCL re- ropathy exists, valgus instability is documented, or the
construction are able to return to their previous level of medial epicondyle displaces into the elbow joint. The
competition. surgical technique is open reduction with internal fixa-
tion with Kirschner wires or a single screw.
Posterior Elbow Impingement
Impingement may result from mechanical abutment of Osteochondritis Dissecans
bone and soft tissues in the posterior elbow. This condi- On the lateral side, the repetitive compression loads ex-
tion may or may not be associated with injury of the perienced during throwing result in microtrauma of the
MCL. Pure hyperextension injuries associated with an articular cartilage that may lead to focal osteonecrosis
intact MCL occur in gymnasts, football linemen, and of the capitellum or the radial head. Osteochondritis
weightlifters. The lesion is usually located in the center dissecans of the capitellum is seen in throwing athletes
of the posterior elbow and is reproduced by forcible ex- 13 to 15 years of age. The exact cause is still unknown,
tension of the elbow. In athletes with MCL insufficiency, but the pathology is attributed to trauma, vascular insult
as often occurs with overhead throwing athletes, the resulting from the trauma, and family predisposition.
posterior elbow impingement occurs posteromedially. Osteochondritis dissecans may be associated with the
Then, the impingement is located between the medial development of loose bodies, which can cause mechani-
aspect of the olecranon and the lateral side of the me- cal symptoms. Patients usually present with activity-
dial wall of the olecranon fossa. Pain may be repro- related pain that resolves with rest. If loose bodies are
duced with the valgus stress test as previously described present, patients may report clicking, catching, or lock-
for valgus instability, but the pain is posteromedial as ing. Radiographs will show irregularities of the capitel-
well as medial. Clinically, a flexion contracture is com- lum, typically with a defect seen on the AP view, and
monly present. Radiographs, including AP, lateral, and possibly loose body formation. The initial treatment of
oblique views, may show osteophytes of the olecranon osteochondritis dissecans is rest until symptoms resolve.
fossa. Surgical treatment is reserved for those patients with
loose bodies, which can be successfully removed using
Elbow Injuries in the Skeletally Immature Throwing an arthroscopic technique. Microfracture of the defect
Athlete to obtain a fibrocartilage scar may also be helpful. Fixa-
Little Leaguers Elbow tion of osteochondral fragments can be attempted if
Overhead throwing exposes the elbow of skeletally im- they are large enough.
mature athletes to specific pathology. As in the mature
thrower, the elbow is exposed to tension injuries on the Annotated Bibliography
medial side and compression injuries on the lateral side. Shoulder
On the medial side, the medial epicondyle growth plate Altchek DW, Hatch JD: Rotator cuff injuries in over-
(apophysis) is weaker and therefore more susceptible to head athletes. Oper Tech Orthop 2001;11:2-16.
trauma than the MCL. Patients may experience medial- A review of the diagnosis and treatment of rotator cuff in-
sided elbow pain from apophysitis, or little leaguers el- juries in the overhead throwing athlete, with a focus on the
bow that occurs during the cocking and acceleration surgical technique for treating partial-thickness and full-
phases of throwing, partly from tension in the MCL, and thickness rotator cuff tears.
partly from the pronator flexor muscle pull that occurs
during throwing. The medial epicondyle growth plate is Andrews JR, Cain EL: Open treatment of anterior
vulnerable to injury in athletes between the ages of 11 shoulder instability in the overhead athlete. Oper Tech
and 13 years when the growth plate is beginning to Orthop 2001;11:9-16.
close. Avulsion of the medial epicondyle may also be the This article presents a review of the diagnosis and treat-
result of a sudden muscle contraction or a traumatic ment of anterior shoulder instability in the overhead throwing
event. Physical examination reveals point tenderness at athlete, focusing on the technique of open surgical stabiliza-
the medial epicondyle, which is often associated with a tion procedures.
10 to 15 flexion contracture of the elbow. Radio-
graphic evaluation may show widening of the medial ep- Cohen B, Cole BJ, Romeo AA: Thermal capsulorrhaphy
icondyle apophysis compared with the contralateral of the shoulder. Oper Tech Orthop 2001;11:38-45.
side. Patients are treated with a period of rest. Throwing The diagnosis of shoulder instability, including anterior,
is avoided for 2 to 3 months and normal growth plate posterior, and multidirectional instability, and the treatement
of these different instabilities with thermal capsulorrhaphy, is The anatomy of the ulnar nerve and the diagnosis and
discussed. treatment of ulnar neuropathy in the throwing athlete are re-
viewed.
Parten PM, Burkhart SS: The relationship of superior la- Williams RJ III, Urquhart ER, Altchek DW: Medial col-
bral anteroposterior (SLAP) lesions and pseudolaxity to lateral ligament tears in the throwing athlete. Instr
shoulder injuries in the overhead athlete. Oper Tech Course Lect 2004;53:579-585.
Sports Med 2002;10:10-17. Surgical treatment of MCL injuries, specifically using re-
This article reviews the three subtypes of a type II SLAP construction of the MCL using a single ulnar tunnel and single
lesion and how this condition contributes to the pathome- humeral tunnel performed through a muscle-splitting ap-
chanic changes experienced by patients with internal impinge- proach, is discussed.
ment. Diagnosis and surgical treatment of patients with type II
SLAP lesions are also reviewed. Yadao MA, Field LD, Savoie FH III: Osteochondritis
dissecans of the elbow. Instr Course Lect 2004;53:599-
Pinto MC, Snyder SJ: SLAP lesions: Current operative 606.
techniques and management. Oper Tech Orthop 2001;11: A discussion of the natural history, clinical presentation,
30-37. classification, and treatment of osteochondritis dissecans of
A review of SLAP lesions with a focus on diagnosis and the elbow is presented.
treatment of the four types of SLAP lesions, and a technique
review of the surgical repair of type II and IV lesions is pre- Classic Bibliography
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Figure 1 Radiograph (A) and intraoperative photograph (B) of a symptomatic clavicular malunion. C and D, Biplanar osteotomy with correction of deformity. Fixation was
achieved with a 3.5 mm dynamic compression locking plate. No intercalary graft was required.
midshaft clavicular nonunions with a 3.5-mm pelvic re- A recent patient-based outcome study of 15 patients
construction plate, lag screw, and bone graft has been with clavicular midshaft malunion revealed a mean 2.9
described and resulted in a 100% union rate in 12 pa- cm of clavicular shortening. All patients had major func-
tients. The advantages of this technique include a longer tional deficits including chronic pain, shoulder weak-
bicortical screw purchase because the anteroposterior ness, and thoracic outlet symptoms for 1 year after in-
diameter of the clavicle is much greater than its supero- jury. After corrective osteotomy, it was possible to
inferior dimension. The plate in this position acts as a appose two fresh osseous surfaces in all patients without
buttress with theoretically less risk of screw pullout the need for intercalary bone graft. The distal fragment
from the lateral fragment and less chance of neurovas- was typically rotated such that the flat superior surface
cular injury during screw placement. Alternatively, a su- faced anteriorly, and this malrotation was corrected be-
periorly placed dynamic compression plate in compres- fore fixation with a 3.5-mm limited contact dynamic
sion mode can be used for more transverse fracture compression plate, using a minimum of six holes. This
patterns. The newer AO locking plates may be particu- plate was believed to be stronger than the reconstruc-
larly advantageous for this indication. Care must be tion plate and easier to contour than the standard com-
taken to restore clavicular length and alignment during pression plate. Postoperatively the mean degree of
nonunion correction. Prior reports have described the shortening was 0.4 cm and most patients were satisfied
use of a locked intramedullary device; however, the res- with the result (Figure 1).
toration of length with this device is more difficult. Fi-
nally, the use of a vascularized fibula graft to salvage a Distal Third Fractures
recalcitrant clavicular nonunion with segmental bone Neer classified distal third clavicle fractures into three
loss was described in three patients. Both pain and types. Type I fractures are the most common and remain
shoulder function were improved and all patients stable as the conoid and trapezoid ligaments remain in-
achieved union. tact. Type II fractures occur medial to the coracoclavicu-
Figure 2 A through C, fixation methods for type II distal clavicle fractures include coracoclavicular stabilization, using screws or tapes, with or without tension band fixation of
the distal clavicular segment. (Reproduced with permission from Lazarus MD: Fractures of the clavicle, in Bucholz RW, Heckman JD (eds): Rockwood and Greens Fractures in
Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001.)
lar ligaments, thus the lateral fragment is usually unsta- fractures and these may delay the diagnosis. The associ-
ble and displaced inferiorly with a high incidence of ated mortality rate is 10% to 15% and this outcome
nonunion. Type III fractures extend into the acromio- usually is secondary to pulmonary sepsis or head injury.
clavicular joint and usually do not involve ligamentous Half of all patients with scapula fractures have other in-
injury. sults to the ipsilateral extremity, including vascular and
Distal third fractures account for 15% of clavicular brachial plexus injuries in 13%. Other associated inju-
fractures, and type II distal third fractures have a rate of ries include hemopneumothorax, pulmonary contusion
delayed union and nonunion between 30% and 45%. with rib fractures, and spinal cord injury. Ninety percent
Fixation techniques described in the literature include of scapula fractures are minimally displaced or nondis-
transacromial Kirschner wires, coracoclavicular screws, placed, and thus can be treated nonsurgically.
plates, Dacron tapes, and tension wires (Figure 2). Fixa-
tion between the clavicle and coracoid or clavicle and Classification
acromion will often fail because it interferes with the The classification of glenoid fossa fractures was recently
normal rotation of the clavicle that occurs with arm ele- modified to better estimate scapular body involvement
vation. Thus, a second operation is required to remove and provide more consistent guidance for choosing a
the fixation before full mobilization is commenced. A surgical approach. Type I injuries represent isolated in-
modification of Neviasers technique has been de- volvement of the anteroinferior articular surface and
scribed, in which two No. 1 polydioxanone sutures are may be associated with a glenohumeral dislocation.
used as a superior figure-of-8 tension band between the Treatment is based on instability criteria with fracture
fracture fragments. If the distal fragment is too small, fixation, either arthroscopically or through a deltopec-
the lateral drill hole can be passed through the acro- toral approach, indicated for fractures that involve more
mion because the fixation is absorbable and the acromi- than 25% of the articular surface. Type II fractures in-
oclavicular joint is not violated. All fractures healed at 6 volve the superior one third to one half of the articular
weeks with no complication. surface in continuity with the coracoid. Types I and II
A retrospective comparison of type II distal clavicle can be treated surgically via a standard deltopectoral
fractures treated nonsurgically versus those that under- approach. A Schanz screw used as a joystick or a dental
went open reduction and coracoclavicular stabilization pic may aid reduction before fixation with 2.7-mm or
was reported. Nonsurgical treatment resulted in a 43% 3.5-mm cortical screws.
nonunion rate; however, the nonunion had no signifi- Types III, IV, and V fracture patterns involve a vari-
cant effect on functional outcome or strength. This study able portion of the lateral border of the scapula and
suggests that most type II distal clavicle fractures can be usually require the posterior approach described by Ju-
treated nonsurgically. det. Type V patterns, which involve a large separate
coracoid or superior articular surface fragment, may re-
Scapula Fractures quire a combined Judet and deltopectoral approach.
Epidemiology Surgical indications for glenoid fractures have been de-
Scapula fractures account for 3% to 5% of all fractures scribed as displacement greater than 5 mm or any dis-
involving the shoulder girdle. Injury to the scapula is placement associated with subluxation of the humeral
rare because it is enveloped by a well-developed muscu- head. For scapula neck fractures, surgery has been rec-
lar layer and lies flush with the thorax. However, other ommended if the glenoid is medially displaced greater
injuries occur concomitantly in patients with scapula than 2 cm or if there is more than 40 of angular dis-
placement. Surgical indications for type V fractures in- tion, a significant number of patients may still require
clude articular step-off of 5 mm or greater, severe dia- surgical intervention for postoperative stiffness. Unfor-
stasis of the articular surfaces, inferior displacement of tunately, associated injuries, especially those to the pe-
the glenoid fragment with inferior subluxation of the ripheral or central nervous system, will negatively affect
humeral head, or severe disruption of the superior rehabilitation.
shoulder suspensory complex.
Superior Shoulder Suspensory Complex Injuries
Glenoid Fractures The superior shoulder suspensory complex is a bony
Glenoid fractures are rare injuries that account for only soft-tissue ring made up of the glenoid, coracoid, acro-
9% to 20% of all scapula fractures, and only 10% of gle- mion process, distal clavicle, acromioclavicular joint, and
noid fractures are substantially displaced. Common sur- coracoclavicular ligaments. The superior strut is the mid-
gical indications for extra-articular glenoid fractures in- dle clavicle and the inferior strut is the lateral scapula.
clude angulation greater than 40, displacement of the Injury to any two of these elements is believed to result
glenoid segment greater than 1 cm, or a fracture associ- in the potential for a large amount of scapula fracture
ated with ipsilateral clavicle fracture (such as floating displacement with resultant disability to the patient. It is
shoulder). Surgical indications for intra-articular glenoid generally believed that displacement of the scapular
rim fractures include displacement greater than 10 mm, neck will alter the relationship of the glenohumeral
recurrent glenohumeral instability, or for fractures in- joint with the acromion and create a functional imbal-
volving more than 25% of the anterior rim or 33% of ance. However, the exact amount of displacement or an-
the posterior rim. Complex intra-articular fractures are gulation required to create this functional imbalance has
treated with surgery when there is greater than 5 mm not been quantified. Abduction weakness, decreased
displacement or persistent glenohumeral subluxation. range of motion, and nonunion are the frequently impli-
Nonsurgical treatment of minimally displaced fractures cated complications of nonsurgical treatment.
has been successful. Thus, the decision for surgery must
be based not only on fracture character but also on pa- Floating Shoulder Injuries
tient age, hand dominance, and activity level. The floating shoulder constitutes a double disruption of
Arthroscopic fixation of a displaced posterior gle- the superior shoulder suspensory complex and occurs in
noid rim fracture involving more that one third of the only 0.1% of all fractures. In the past, this injury has
glenoid cavity has been described. Ligamentotaxis on been considered unstable and thought to require surgi-
the surgical extremity held in lateral decubitus traction cal stabilization of one or both elements. Most glenoid
was believed to have assisted reduction. neck fractures exit the superior scapular border medial
Glenoid neck fractures are best visualized through a to the base of the coracoid process, near the suprascapu-
posterior approach, which includes the more limited lar notch. This results in a distal fragment consisting of
muscle-sparing, or the extensile Judet approaches. A the glenoid and coracoid process, and a proximal frag-
muscle-sparing approach can be used for isolated poste- ment consisting of the acromion, scapular spine, and
rior glenoid rim or isolated glenoid neck fractures. scapular body. The distal fragment is still attached to the
The incision for the Judet approach begins at the proximal fragment by the coracoacromial ligament, and
posterolateral corner of the acromion, extends along the through the coracoclavicular ligament and distal clavicu-
scapular spine, and then curves inferiorly along the me- lar fragment by the acromioclavicular capsular liga-
dial scapular border. The deltoid is detached from the ments.
scapular spine and reflected laterally. The infraspinatus In one study, 20 patients with a floating shoulder
is then elevated from the scapular body on its neurovas- were treated nonsurgically and functional scores were
cular pedicle and reflected laterally, giving wide expo- equivalent to those from studies involving surgery. Al-
sure to the posterior scapula. The fracture is identified though most of the scapula fractures in this study were
and directly reduced. Provisional fixation can be ob- minimally displaced, the five patients who did have se-
tained with Kirschner wires by passing them through vere displacement of both scapula and clavicle fractures
the acromion into the glenoid fragment from a superior had outcomes comparable to those with minimal dis-
direction. A 3.5-mm reconstruction plate is contoured placement. Nonsurgical treatment of floating shoulder
and applied to the lateral scapular body and posterior injuries, especially those with less than 5 mm displace-
glenoid. Intraoperative radiographs or fluoroscopy is ment, is recommended. The criteria for surgical inter-
used to confirm anatomic reduction and prevent intra- vention needs better delineation.
articular screw penetration. A recent study was the first to directly compare the
Postoperative stiffness is a concern. Prophylaxis functional and clinical outcomes of surgical versus non-
against heterotopic ossification should be considered in surgical treatment of displaced ipsilateral fractures of
all patients with closed head injury. Despite early mo- the clavicle and glenoid neck. The surgically treated pa-
greater tuberosity fractures can be associated with rota- blood flow to the humeral head when the anterior hu-
tor cuff tears, but in many surgical cases, the cuff re- meral circumflex artery has been interrupted. Plates
mains intact and only a capsular rent is observed. If ra- were applied lateral to the bicipital groove to avoid in-
diographs do not adequately show the fracture jury to the anterior humeral circumflex artery. No signif-
displacement, a CT scan may be necessary. In addition, icant relationship was found between the method of fix-
ultrasound can detect occult nondisplaced greater tuber- ation (cerclage wire versus plate) and the development
osity fractures. of osteonecrosis. Although most patients in this study
Most authors advocate conservative treatment of frac- who had four-part fractures developed osteonecrosis,
tures with less than 5 mm displacement and surgery for the results were generally good.
displacement greater than 5 mm. Given the literature to Newer fixation devices have led to improved tech-
date, any greater tuberosity fracture displaced 5 mm or niques for ORIF of two-, three-, and four-part fractures
more should be treated with reduction and fixation. of the proximal humerus. The use of a blade plate and
Isolated screw fixation of greater tuberosity frac- interfragmentary sutures has been shown to provide
tures should be used only in younger patients because, firm fixation and a good functional result in the treat-
with aging, the bone of the tuberosity becomes fragile ment of 34 three-part and 8 four-part fractures of the
and prone to comminution. The fracture can be fixed proximal humerus in elderly patients. The blade plate
percutaneously with arthroscopic assistance. The supe- has primarily been used for two-part surgical neck frac-
rior approach typically permits easier fragment reduc- tures. The use of a blade plate and autogenous cancel-
tion, whereas the deltopectoral approach allows easier lous bone graft resulted in good or excellent results in
suture placement. The edge of the fragment can be 80% of patients with two-part nonunions (and in 90%
aligned with the edge of the fracture bed of the proxi- of low two-part nonunions). Low two-part nonunions
mal humerus. The sutures are passed around the greater were easier to treat because the proximal fragment is
tuberosity and through the attachment of the rotator larger and thus easier to secure.
cuff tendons and then cross in a figure-of-8 fashion The advent of the locking compression plate, with a
across the fracture site to avoid overreduction of the plate specifically designed for the proximal humerus, is
fragment. Because no hardware is used, there is no con- an excellent new option for ORIF of proximal humeral
cern about hardware failure. Subacromial scarring, even fractures. With this technique, it is crucial that the surgi-
without displacement and capsular contracture, may cal approach preserve soft-tissue attachments as much
limit motion postoperatively. This complication is best as possible. It is mandatory to use the drill guide that
avoided by initiating passive range-of-motion exercises threads directly into the screw hole in the plate because
early in the postoperative period. this ensures that the screw threads will engage precisely
with the plate threads. Locking screws will not bring the
Three- and Four-Part Fractures plate to the bone, which is not a critical feature of the
In three-part fractures, one tuberosity is displaced and technique (as opposed to the standard dynamic com-
there is a displaced unimpacted surgical neck fracture that pression plate) and may actually increase the blood sup-
allows the head to be rotated by the attached tuberosity. ply to the bone and enhance the biology of healing.
Four-part fractures involve displacement of all four seg- Some plate-bone contact may be required to im-
ments (the greater and lesser tuberosities, the articular prove fracture alignment and diminish the prominence
segment, and the shaft), and the articular fragment is usu- of the implant. This goal can be accomplished by using a
ally devoid of soft-tissue attachments. Three- and four- few standard (nonlocking) screws. A mechanical study
part fractures represent 13% to 16% of proximal humeral in cadavers showed that the locking compression plate
fractures. Surgical modalities have included plates, pins, for the proximal humerus was a more elastic implant
screws, staples, intramedullary nails, wires, sutures, or any than the spiral blade, T-plate, and humeral nail, a prop-
combination of these, and arthroplasty. Neer preferred erty making this plate less likely to fail in osteoporotic
ORIF for two- and three-part fractures and arthroplasty bone, compared with the other implants.
for four-part fractures. Others have approached all three-
and four-part fractures that are amenable to stable inter- Valgus-Impacted Three- and Four-Part Fractures
nal fixation with minimal osteosynthesis. The valgus-impacted pattern of a proximal humeral
Osteonecrosis of the humeral head after four-part fracture is characterized by preservation of the postero-
fracture of the proximal humerus has an incidence of medial capsular attachments to the humeral articular
21% to 75%, which is believed to be the result of the in- surface. Radiographically, this pattern is defined by the
jury pattern itself. It is important to preserve the as- alignment between the medial shaft and head segments.
cending branch of the anterior humeral circumflex ar- The results of treatment of the three-part valgus-
tery, which is the primary vessel supplying the humeral impacted fracture variant are better than for the stan-
head. The posteromedial vessels may preserve some dard Neer three-part fracture. The intact posteromedial
soft tissue supplying residual perfusion to the humeral to allow for stable fixation, tuberosity fragments that in-
head is presumably responsible for a better prognosis clude a substantial portion of the articular surface, and
with the valgus-impacted fracture. In a recent study, inability to obtain an acceptable reduction. These pa-
80% of patients had a good or excellent result by Neers tients are best treated with hemiarthroplasty or total
outcome criteria with nonsurgical care. Patients will re- shoulder arthroplasty depending on the condition of the
gain only 80% of abduction and flexion strength but do glenoid surface and rotator cuff.
not require full motion or strength to return to daily ac- Hemiarthroplasty is primarily indicated for displaced
tivities. four-part fractures. Tuberosity osteolysis, malunion, and
A new technique of minimal fixation for valgus- nonunion are implicated as the main causes of failure.
impacted fractures of the humeral head has been intro- Late arthroplasty after failed primary treatment of
duced. An open technique without any sharp deep soft- proximal humeral fractures improves pain, range of mo-
tissue dissection was used, and the split between the tion, and function, but most authors have found that the
tuberosities was opened to allow elevation of the im- results of late arthroplasty are inferior compared with
pacted humeral head fragment. The tuberosities were proximal humerus fractures treated acutely with hu-
reduced to hold the humeral head fragment in place and meral head replacement.
repaired with heavy absorbable suture (No. 2 Vicryl) be- Prognostic factors in prosthetic replacement for
tween the rotator cuff insertions. No bone grafting, Kir- acute proximal humeral fractures were studied in 32 pa-
schner wire, or additional fixation was used. No attempt tients retrospectively. Fracture type, gender, and type of
was made to secure the head to the shaft because the prosthesis were found to be irrelevant with respect to
fracture configuration was considered stable. For 11 pa- outcome. Increased age and an increased preoperative
tients with an average age of 55 years, the mean delay correlated with a poorer clinical outcome. Patients
follow-up was 69 months. The mean Constant-Morley who had surgery within 14 days had a better general
score as a percentage compared with the opposite side outcome. This study showed a strong correlation be-
was 86%. One patient (9%) developed osteonecrosis. tween the radiologic position of the tuberosities and the
This rate of osteonecrosis was similar to other reported quantitative as well as qualitative clinical outcome. Tu-
rates using closed techniques. Most of the soft-tissue dis- berosity complications were the most common compli-
cation and were seen in 50% of patients. Humeral offset
section occurred at the time of fracture, so if the princi-
is defined as the distance between the geometric center
ple of minimal further disruption of the soft tissues is
of the humeral head and the lateral edge of the greater
adhered to, an open technique such as this should not
tuberosity. The average humeral offset of patients with a
increase the rate of osteonecrosis.
good or excellent outcome (25.39 mm) was significantly
higher than the average offset in patients with unsatis-
Role of Arthroscopy factory outcomes (20.20 mm). Patients with a humeral
Arthroscopy was used to preoperatively assess 80 shoul- offset of 23 mm or more had a significantly better out-
der fractures, including 52 proximal humerus fractures, come. Also, patients with a head height of 14 mm or less
20 fracture-dislocations, and 8 glenoid and/or scapula had a better outcome. Lateralizing the tuberosities re-
fractures. Overall, 20% of fractures were found to have sults in a better outcome and their distal transfer causes
a full-thickness supraspinatus and/or infraspinatus cuff a poorer outcome. Stable fixation and anatomic reposi-
tear and 30% had partial tears. Eighteen percent had tioning of the tuberosities must be achieved during sur-
subscapularis tendon tears. Two-part fractures had a gery.
31% incidence of complete labral tear, whereas only In a similar study reviewing outcome of hemiarthro-
10% of three- and four-part fractures had a complete la- plasty for fractures of the proximal humerus, it was de-
bral tear, presumably because more energy is dissipated termined that early surgical intervention within 2 weeks
at the fracture site in the more complex patterns. Proxi- of injury and accurate tuberosity reconstruction were
mal humeral fracture-dislocations showed a 56% inci- two factors that were found to have the greatest impact
dence of complete labral tear. on functional outcome. The height of the superior hu-
meral articular surface with respect to the greater tuber-
Role of Arthroplasty osity is termed the head-to-tuberosity distance (HTD)
Incongruity of the humeral head or complete detach- and is 8 3 mm as measured in cadaver specimens. The
ment of the articular blood supply are the main indica- tuberosity was considered malreduced if the fragment
tions for humeral arthroplasty, which typically includes was superior to the humeral head or if the HTD was
some three-part fractures, most four-part fractures, hu- greater than 20 mm.
meral head-splitting injuries, and humeral head impres- Proper height was established by placing the articu-
sion defects involving greater than 40% of the articular lar surface of the prosthetic head at the midpoint of the
surface. Other factors that may favor arthroplasty in- glenoid, and with gentle traction, the prosthetic head re-
clude excessive comminution, inadequate bone quality mained within the glenoid fossa. The humeral compo-
nent was cemented in all patients and the tuberosities transepicondylar axis had posterior migration of the
were then reconstructed so that the greater tuberosity greater tuberosity and a poor functional result.
was overlying the lateral fin or was repaired to the ante- In a related study, shoulder arthroplasty for the
rior fin in a three-fin design. Other studies indicate that treatment of sequelae of fractures of the proximal hu-
when a prosthesis is inserted for fracture, the lateral fin merus was evaluated. The most significant factor affect-
should be a mean distance of 5.2 2.6 mm from the ing functional outcome was greater tuberosity osteot-
posterior edge of the bicipital groove. In a recent bio- omy. All patients who underwent greater tuberosity
mechanical study, it was shown that a horizontal circum- osteotomy had either fair or poor results and did not re-
ferential cerclage suture passed through the medial hole gain active elevation above 90. Whenever possible, os-
of the prosthesis and around the tuberosity fragments teotomy of the greater tuberosity should not be done,
substantially improves fracture stability, and, in theory, and the prosthesis should be implanted by attempting to
minimizes the potential for nonunion of the tuberosities. adapt the implant to the modified anatomy. This goal is
Another study considered an HTD of 3 to 20 mm as accomplished by changing the inclination or offset of a
an anatomic reconstruction. Acceptable alignment and modular prosthesis. All complications concerning the
position of the tuberosities was achieved in 79% of pa- greater tuberosity (nonunion, bone resorption, and tu-
tients. The most common complication was malreduc- berosity migration) occurred after osteotomy. Another
tion of the greater tuberosity in the vertical plane. In pa- study showed that 10 of 24 patients who underwent os-
tients with a nearly anatomic reduction of the greater teotomy had a complication related to tuberosity non-
tuberosity, American Shoulder and Elbow Surgeons and union, malunion, or resorption.
the Simple Shoulder Test scores, patient satisfaction, and A promising surgical option for severe tuberosity
motion were all significantly better than in those pa- nonunions or long-standing surgical neck nonunions
tients in whom an anatomic reduction was not achieved. may be a reverse prosthesis. In theory, by placing a gle-
Superior migration was associated with pain, impinge- nosphere, the proximal humerus can gain a motion ful-
ment, and motion loss. These patients either had a crum without the necessity of a rotator cuff centering
malunion or nonunion of the tuberosities. It is now rec- force. There are long-term risks associated with this im-
ommended that the greater tuberosity be placed 10 mm plant, including glenoid notching and fracture and loos-
below the superior articular surface of the humeral ening of the glenoid component. Also, implantation is
head, but not overreduced, as this places the supraspina- technically demanding. Long-term efficacy studies are
tus under increased tension and jeopardizes tuberosity needed to determine if a reverse prosthesis is the an-
fixation. Technical errors that can result in an increased swer for these difficult reconstructive cases.
HTD include humeral lengthening by cementing the
prosthesis proud, using a head segment that is too thick, Nerve Injury
and overreduction of the greater tuberosity distal to its A prospective study of 143 consecutive proximal hu-
normal anatomic location. merus fractures found evidence of nerve injury by elec-
Reasons for poor outcomes after hemiarthroplasty tromyography in 67% of patients. The axillary nerve was
for displaced fractures of the proximal humerus have involved in 58% and the suprascapular nerve in 48%. A
been analyzed. Initial tuberosity malposition was found combination of nerve lesions was frequently seen. As
to be present postoperatively in 27% of patients and tu- might be expected, nerve lesions were more common in
berosity detachment and migration were noted in 23%. displaced fractures. Although the nerve lesions recov-
Final tuberosity malposition was present in 50% and ered in all patients, restoration of shoulder function was
correlated with an unsatisfactory result, superior migra- less favorable. This finding has implications for patients
tion of the prosthesis, stiffness, weakness, and pain. The treated both surgically and nonsurgically.
worst association was a prosthesis that was too high and
too retroverted with a low greater tuberosity. This un- Humeral Shaft Fractures
happy triad was associated with migration of the Acute Fractures
greater tuberosity and proximal migration of the pros- Since Sarmientos original description in 1977, func-
thesis under the acromion in all cases. The functional re- tional bracing has been considered the gold standard
sults after hemiarthroplasty for three- and four-part treatment for acute humeral shaft fractures. One recent
proximal humerus fractures are directly associated with study revealed a 95% union rate in patients. The rate of
tuberosity osteosynthesis. Lengthening of the prosthesis nonunion has been reported as low as 1.5% for closed
greater than 10 mm because of a proud prosthesis sig- fractures and 5.8% for open fractures with the brace re-
nificantly correlated with tuberosity detachment and moved between 10 and 13 weeks. Varus angulation after
proximal migration of the prosthesis. The most common treatment with functional bracing is common. However,
mistake was excessive retroversion of the prosthesis. All the angulation in most patients is usually functionally
patients with retroversion exceeding 40 relative to the and cosmetically acceptable. The high rate of union and
no chance of postsurgical infection imply an earlier re- teopenic bone, and in patients with overlying burns and
turn to daily function and a lower cost of care. in those with multiple traumas. The advantages of in-
Transverse fracture patterns are the most likely to tramedullary nailing over plate fixation include preser-
develop angular deformity. Axial distraction between vation of fracture hematoma and local blood supply,
the fragments implies a high level of soft-tissue injury, smaller surgical incision, a load-sharing as opposed to a
and these fractures are more likely to develop delayed stress-shielding device, and the theoretical advantage of
union or nonunion. In general, fractures at various lev- earlier weight bearing. However, immediate weight
els heal at the same speed and with similar degrees of bearing in acutely plated fractures has also been shown
angulation. It is not necessary for the brace to fully to have no detrimental effect.
cover every proximal or distal fragment. The brace Recent biomechanical studies show increased initial
should begin approximately 1 inch (2.5 cm) distal to the fracture stability when nails are inserted antegrade for
axilla and should terminate 1 inch proximal to the hu- proximal humeral shaft fractures and retrograde for dis-
meral condyles. Supra-acromial and supracondylar ex- tal humeral shaft fractures. Intramedullary nails can be
tensions are unnecessary. Active exercises may begin as inserted for shaft fractures in the region 2 cm distal to
soon as symptoms allow. However, active abduction and the surgical neck and 3 cm proximal to the olecranon
elevation of the shoulder must be avoided until after the fossa. The nonunion rate for intramedullary nailing was
fracture is clinically stable because these movements shown to be 5.6%, a rate comparable to that for plating.
may produce angular deformities. However, a complication rate of 19% for humeral
Indications for surgical intervention include open locked nailing indicates that the procedure is not simply
fractures, segmental and pathologic fractures, bilateral benign and noninvasive. Antegrade nailing carries the
humeral fractures, fractures associated with vascular in- risk of shoulder pain and disability in 16% to 37% of
juries, fractures where radial nerve palsy develops after patients. Retrograde nailing has a significantly higher
reduction, multiple trauma with substantial chest/head risk of surgical comminution, and this comminution sig-
injuries, floating elbow injuries (ipsilateral fractures of nificantly increases the risk of nonunion. Great care
both forearm and arm), obesity that prevents adequate must be taken to avoid anterior cortical notching during
reduction, severe neurologic disorder, and inability to retrograde reaming. In addition, radial nerve explora-
maintain satisfactory alignment. For a patient in the re- tion has been recommended before intramedullary rod-
cumbent position for an extended period, it is difficult ding of distal third spiral fractures regardless of the
to control the fracture with closed treatment. Also, pa- presence or absence of nerve palsy because the radial
tients with concomitant chest injury are poor candidates nerve is in imminent danger when intramedullary rod-
for sling and swathe treatment. Alignment is considered ding is attempted with this fracture pattern.
acceptable with up to 20 anterior angulation, 30 of Several studies in recent years have compared plate
varus angulation, and 3 cm of shortening. fixation of humeral shaft fractures with intramedullary
A radial nerve palsy sustained during humeral frac- devices and have reached different conclusions. In re-
ture is not an indication for exploration of the nerve or ports in which plate and intramedullary rod fixation are
for internal fracture fixation. However, whenever the directly compared, the rate of complications associated
nerve is explored and the fracture is not healed, internal with intramedullary rodding appears higher than that
fixation is recommended. Patients with associated bra- associated with plate fixation. The complications associ-
chial plexus injury should undergo internal fixation be- ated with intramedullary rodding are related to rates of
cause stabilization of the humeral fracture allows earlier union (which appear to be somewhat lower than after
rehabilitation of the injured extremity. Fractures that oc- plate fixation) and increased functional symptoms such
cur in the proximal and distal quarters of the humerus as shoulder pain and weakness. Complications such as
without an intervening diaphyseal fracture component infection, radial nerve palsy, delayed union, and failure
should be treated separately. These fractures are ex- of fixation seem to occur at an equivalent rate with both
posed through separate incisions and fixed with sepa- types of intervention.
rate plates. A prospective multicenter study reported the first
Plate osteosynthesis has been the most accepted clinical results of the Locking Compression Plate (Syn-
method for surgical treatment of both acute humeral thes, Paoli, PA) in 169 fractures in 144 patients, includ-
shaft fractures and nonunions. The rate of union after ing 45 humeral fractures. In 86% of all fractures treated,
compression plate fixation has been reported to be healing occurred within the expected time period and
greater than 95%. The disadvantages include consider- without complication. The 1.5% infection rate was low
able soft-tissue stripping, poor screw purchase in os- considering the heterogenous sample with numerous
teoporotic bone, difficulties in complex fractures, and open fractures and many revision surgeries. This report
the risks associated with hardware removal. provided several guidelines regarding when to use com-
Closed intramedullary nailing is considered for pression technique or a bridging technique with the
pathologic fractures, segmental fractures, fractures of os- locking compression plate. Compression technique can
be used for joint fractures and simple metadiaphyseal fractures, which is in contrast to the good results
fracture patterns. The bridging technique is recom- achieved for exchange nailing of femoral and tibial non-
mended for multifragmentary metadiaphyseal and dia- unions.
physeal fractures. A combined approach is warranted in Humeral nonunion defects of 6 cm or greater
only two situations: (1) in joint fractures with multifrag- present a reconstructive challenge. A vascularized bone
mentary metadiaphyseal components, the compression graft remains alive, does not resorb, maintains its struc-
technique should be used for the joint and bridging tural characteristics, and can hypertrophy, thus increas-
technique used for the metadiaphyseal segment; (2) in ing its structural integrity. The healing of a vascularized
two-level fractures with different fracture patterns, the bone graft is a process similar to acute fracture healing,
compression technique is used for the simple fracture in contrast to the long-standing process of creeping sub-
part and the bridging technique for the multifragmen- stitution, which must be endured with a nonvascularized
tary segment. allograft. The technique involves the creation of an in-
tramedullary dowel of the vascularized fibula graft that
is placed in the medullary canal of the humerus. The
Nonunion graft is impacted 1 to 2 cm at each end and the con-
Nonunion is defined as lack of union after 24 weeks. struct is stabilized with a 4.5-mm dynamic compression
Nonunion of the humeral shaft occurs in 2% to 10% of plate (Synthes, Paoli, PA). The fibula is applied as an on-
nonsurgically treated fractures and up to 15% of frac- lay graft if the construct is already stable, as with a re-
tures treated by primary ORIF. An increased incidence tained intramedullary rod. The peroneal artery is usually
of nonunion can be seen with open fractures, high- anastomosed end-to-side with the brachial artery. The
energy injuries, bone loss, soft-tissue interposition, un- peroneal vein is anastomosed end-to-side with either
stable or segmental fracture patterns, impaired blood the venae comitantes of the brachial artery, or the ba-
supply, infection, and initial treatment with a hanging silic or cephalic vein. According to one recent study, 11
arm cast. Preexisting elbow or shoulder stiffness can of 15 humeral nonunions united with this technique.
cause increased motion at the fracture site and predis- Three of these 11, however, sustained a fracture of the
pose to nonunion. Obesity, osteoporosis, alcoholism, fibula transplant at a mean of 8 months postoperatively
and required additional bone grafting and plating but
malnutrition, smoking, and noncompliance are all pa-
progressed to healing. Three other patients with early
tient factors that may increase the risk of nonunion.
fixation failure underwent plating and bone grafting and
A 98% consolidation rate was reported after ORIF
eventually healed. One patient developed an infection
of humeral nonunion using an anterolateral approach
and required a second vascularized fibula graft. Three
and autogenous bone grafting. A wave plate was applied
patients had early revision of the venous anastomosis
in two instances when an intramedullary nail was in
because laser Doppler readings were below 40% of the
place and its removal was believed to be too hazardous.
initial reading for 30 minutes and clinical observation of
Only 2 of 51 patients had a transient sensory radial neu- the skin island showed questionable perfusion. Only 5
ropathy. An anterolateral approach with routine identi- of 15 patients regained nearly normal function, illustrat-
fication and ample release of the radial nerve well be- ing the complexity of the humeral reconstruction.
yond the nonunion ensures a very low rate of radial
nerve injury. This broad exposure allows a plate of suffi-
cient length to be applied, which increases the probabil-
Annotated Bibliography
ity of union. Clavicle Fractures
A recent study reported on results of the use of Edelson JG: The bony anatomy of clavicular malunions.
wave-plate fixation and autologous bone grafting in the J Shoulder Elbow Surg 2003;12:173-180.
Seventy-three fractures and 54 malunions were found in a
management of humeral nonunion with a retained in-
study of 1,430 clavicles from adult skeletons. A consistent pat-
tramedullary nail. None of the patients had a prominent
tern of clavicular shortening involving anterior-posterior angu-
nail, which might represent a source of shoulder pain. lation is described.
Healing occurred in all six patients at a mean of 16
weeks postoperatively. The 4.5-mm wave plates were
Grassi FA, Tajana MS, DAngelo F: Management of
bent at two different locations so that the middle por-
midclavicular fractures: Comparison between nonopera-
tion of the plate was standing 5 to 10 mm off the bone
tive an open intramedullary fixation in 80 patients.
at the level of the nonunion. At least three bicortical J Trauma 2001;50:1096-1100.
screws were applied proximally and distally. Autologous This study compared figure-of-8 bandaging to intramedul-
cancellous graft was packed under the elevated portion lary fixation for midclavicular fractures and found that nonsur-
of the plate at the site of nonunion. A high rate of non- gical treatment appeared more advantageous for most patients
union has been shown after exchange nailing of humeral with midclavicular fractures.
Levy O: Simple minimally invasive surgical technique Schandelmaier P, Blauth M, Schneider C, Krettek C:
for treatment of type 2 fractures of the distal clavicle. Fractures of the glenoid treated by operation: A 5 to 23
J Shoulder Elbow Surg 2003;12:24-28. year follow-up of 22 cases. J Bone Joint Surg Br 2002;84:
A minimally invasive technique is described in 12 patients, 173-177.
which uses absorbable suture fixation to treat Neer type II dis- The results after ORIF of 22 displaced glenoid fractures
tal clavicle fractures. Union was achieved in all fractures with with a mean follow-up of 10 years is described. At follow-up,
no complications. the median Constant score was 94%. The score was less than
50% in four patients, including two patients who developed an
McKee MD, Wild LM, Schemitsch EH: Midshaft infection.
malunions of the clavicle. J Bone Joint Surg Am 2003;85-
A:790-797. Williams GR Jr, Naranja J, Klimkiewicz J, Karduna A,
Fifteen patients who had a malunion following nonsurgical Iannotti JP, Ramsey M: The floating shoulder: A biome-
treatment of a clavicle fracture underwent corrective osteot- chanical basis for classification and management. J Bone
omy through the original fracture line and internal fixation Joint Surg Am 2001;83-A:1182-1187.
without bone graft. The mean amount of clavicular shortening After a standardized neck fracture was made in 12 cadaver
was 2.9 cm preoperatively and 0.4 cm after surgery. shoulders, the resistance to medial displacement was deter-
mined following sequential creation of an ipsilateral clavicle
Postacchini F, Gumina S, DeSantis P, Albo F: Epidemiol- fracture, coracoacromial ligament disruption, and acromioclav-
ogy of clavicle fractures. J Shoulder Elbow Surg 2002;11: icular capsular disruption. In another group, resistance to me-
452-456. dial displacement was determined following sequential release
An epidemiologic study of 535 isolated clavicle fractures of the coracoacromial and coracoclavicular ligaments. Ipsilat-
during an 11-year period was performed. Most patients (68%) eral scapular neck and clavicle fractures do not produce a
were men. The left side was involved in 61% and fractures of floating shoulder until the coracoacromial and acromioclavicu-
the middle third were the most common (81%). lar capsular ligaments are disrupted.
Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Proximal Humeral Fractures
Cuomo F, Gallagher MA: A comparison of nonopera- Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS,
tive and operative treatment of type II distal clavicle Mole D: Tuberosity malposition and migration: Reasons
fractures. Bull Hosp Joint Dis 2002;61:32-39. for poor outcomes after hemiarthroplasty for displaced
This retrospective study compared nonsurgical and surgi- fractures of the proximal humerus. J Shoulder Elbow
cal treatment of type II distal clavicular fractures. At an aver- Surg 2002;11:401-412.
age follow-up of 53.5 months, 7 of 16 patients that were The results of hemiarthroplasty for displaced proximal hu-
treated nonsurgically had a nonunion. However, nonunion had meral fractures is evaluated. Final tuberosity malposition oc-
no significant impact on functional outcome or strength. curred in 33 patients (50%) and correlated with superior mi-
gration of the prosthesis, stiffness, weakness, and persistent
Scapula Fractures pain.
Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse
MJ, Kellam JF: The floating shoulder: Clinical and func- Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A,
tional results. J Bone Joint Surg Am 2001;83-A:1188- Sinnerton R: Shoulder arthroplasty for the treatment of
1194. sequelae of fractures of the proximal humerus. J Shoul-
Nineteen patients with a floating shoulder injury were der Elbow Surg 2001;10:299-308.
compared with respect to fracture healing, functional outcome, Seventy-one sequelae of proximal humeral fractures were
patient satisfaction, and muscular strength. Treatment was treated with shoulder arthroplasty with the same modular
nonsurgical in 12 patients and surgical in 7 patients. There was prosthesis (Aequalis) in this multicenter study. The most sig-
no significant difference between groups with regard to the nificant factor affecting functional outcome was greater tuber-
three functional outcome measures. osity osteotomy. Surgeons should accept the distorted anat-
omy of the proximal humerus and adapt the prosthesis to the
McAdams TR, Blevins FT, Martin P, DeCoster TA: The modified anatomy if possible, to avoid tuberosity osteotomy.
role of plain films and computed tomography in the
evaluation of scapular neck fractures. J Orthop Trauma Brorson S, Bagger J, Sylvest A, Hobjartsson A: Im-
2002;16:7-10. proved interobserver variation after training of doctors
Scapular neck fracture displacement, angulation, and ana- in the Neer system: A randomized trial. J Bone Joint
tomic classification showed moderate interobserver reliability Surg Br 2002;84:950-954.
by plain films and was not enhanced when supplemented with Fourteen doctors were randomly assigned to two training
CT. CT may be useful to assess associated injuries to the supe- sessions or to no training and asked to categorize 42 pairs of
rior shoulder suspensory complex, which could be missed plain radiographs of proximal humerus fractures according to
when using plain films alone. the Neer system. The kappa value for interobserver variation
improved (especially for specialists) from 0.30 to 0.79 with for- Mighell MA, Kolm GP, Collinge CA, Frankle MA: Out-
mal training in the Neer system. comes of hemiarthroplasty for fractures of the proximal
humerus. J Shoulder Elbow Surg 2003;12:569-577.
Court-Brown CM, Cattermole H, McQueen MM: Im- Eighty shoulders that had been treated with hemiarthro-
pacted valgus fractures of the proximal humerus. The re- plasty for proximal humeral fractures were reviewed. Tuberos-
sults of non-operative treatment. J Bone Joint Surg Br ity complications occurred in 16 shoulders. Healing of the
2002;84:504-508. greater tuberosity more than 2 cm below the humeral head
In this retrospective study of 125 patients with valgus- correlated with a worse functional result.
impacted fractures of the proximal humeral, all were treated
nonsurgically. At 1-year follow-up, 80.6% of patients had a Ogawa K, Yoshida A, Ikegami H: Isolated fractures of
good or excellent result. the greater tuberosity of the humerus: Solutions in rec-
ognizing a frequently overlooked fracture. J Trauma
Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y: 2003;54:713-717.
Prognostic factors in prosthetic replacement for acute Isolated greater tuberosity fractures were overlooked in 58
proximal humerus fractures. J Orthop Trauma 2003;17: of 99 shoulders (59%) that had been initially examined at
181-189. other clinics. A smaller fragment correlated with a higher rate
This retrospective study investigated the effect of radio- of missed diagnosis. The presence of tenderness on the lateral
logic and other factors on the outcome of prosthetic replace- wall of the greater tuberosity is a clinically effective method to
ment in 32 patients with acute proximal humeral fractures. The avoid a missed diagnosis.
humeral offset was directly correlated to the amount of for-
ward elevation and Constant score. The head height was in- Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN,
versely correlated to the same parameters. Bigliani LU: Two-part and three-part fractures of the
proximal humerus treated with suture fixation. J Orthop
Frankle MA, Ondrovic LE, Markee BA, Harris ML, Lee Trauma 2003;17:319-325.
WE III: Stability of tuberosity reattachment in proximal The radiographic and clinical outcomes of patients with
humeral hemiarthroplasty. J Shoulder Elbow Surg 2002; displaced two- and three-part proximal humeral fractures that
11:413-420. were treated with nonabsorbable cuff-incorporating sutures
This biomechanical study compared the stability of differ- were reviewed. Both groups had similar outcomes; some resid-
ent reconstructive techniques of tuberosity reattachment for ual deformity did not preclude an excellent outcome.
proximal humeral head replacement in four-part fractures us-
ing eight fresh-frozen cadaver shoulders. Mercury strain Ring D, McKee MD, Perey BH, Jupiter JB: The use of a
gauges were used to measure bony fragment displacement blade plate and autogenous cancellous bone graft in the
during cyclic loading. Repairs that used a medial circumferen- treatment of ununited fractures of the proximal hu-
tial cerclage had significantly lower displacements and strains. merus. J Shoulder Elbow Surg 2001;10:501-507.
A blade-plate with autogenous cancellous graft was used
to treat proximal humeral nonunions in 25 patients with a
Hockings M, Haines JF: Least possible fixation of frac-
mean age of 61 years. Union was achieved in 23 of 25 patients
tures of the proximal humerus. Injury 2003;34:443-447.
An open technique with no deep dissection is described (92%). The results were classified as good or excellent in 20 of
25 patients.
for the fixation of valgus-impacted proximal humeral frac-
tures. No bone grafting, Kirschner wires, or other fixation was
used. The mean Constant-Murley score as compared with the Robinson CM, Page RS: Severely impacted valgus prox-
opposite side was 86%. imal humerus fractures. J Bone Joint Surg Am 2003;85-
A:1047-1055.
Twenty-five patients with severely impacted valgus proxi-
Lee SH, Dargent-Molina P, Breart G: Risk factors for
mal humeral fractures were treated with open reduction, fixa-
fractures of the proximal humerus: Results for the
tion with screws or a buttress plate, and the fracture defect
EPIDOS prospective study. J Bone Miner Res 2002;17:
was filled with Norian Skeletal Repair system bone substitute.
817-825.
All fractures united within the first year and no patient had
The EPIDOS study evaluated 6,901 white women age 75
signs of osteonecrosis at latest follow-up. The functional result
years and older. The examination included measurements of
continued to be satisfactory for the 12 patients who were fol-
femoral neck bone mineral density, calcaneal ultrasound pa-
lowed for 2 years.
rameters, a functional clinical examination, and lifestyle ques-
tionnaire. The incidence of proximal humerus fractures was
greatly increased in women who had osteoporosis and a high Rowles DJ, McGrory JE: Percutaneous pinning of the
risk score for falling. proximal part of the humerus: An anatomic study.
J Bone Joint Surg Am 2001;83-A:1695-1699.
In 10 fresh-frozen cadaver shoulders the intact proximal Fifteen patients with an average 9.3-cm segmental humeral
humerus was pinned using fluoroscopic guidance and a stan- defect were treated with osteoseptocutaneous fibular trans-
dard published technique. The specimens were dissected to de- plant. This treatment can be successful but has a high rate of
termine the distance of each pin from vital neurovascular complications.
structures. Some modifications of technique and a knowledge
of local anatomy are needed to avoid injury to the axillary
Koch PP, Gross DF, Gerber C: The results of functional
nerve, musculocutaneous nerve, and biceps tendon.
(Sarmiento) bracing of humeral shaft fractures. J Shoul-
der Elbow Surg 2002;11:143-150.
Stoffel K, Dieter U, Stachowiak G, Gachter A, Kuster Sixty-seven humeral shaft fractures were treated by
MS: Biomechanical testing of the LCP: How can stabil- Sarmiento bracing over a 15-year period. At a mean of 10
ity in locked internal fixators be controlled? Injury weeks, 87% had healed clinically. Among nine cases of delayed
2003;34(suppl 2):B11-B19. or nonunion leading to surgery, there were six cases with
A biomechanical analysis including axial stiffness and tor- transverse fractures. Reasons for failed nonsurgical treatment
sional rigidity, fatigue testing, and finite element analysis were included incorrect indication, significant axial deformity, and a
undertaken to evaluate the locking compression plate. Opti- hyperextended position of the fracture fragments.
mal use of the locking compression plate as it relates to bio-
mechanical principles is discussed. For comminuted fractures
Lin J, Shen PW, Hou SM: Complications of locked nail-
of the humerus, it is recommended that innermost screws be
ing in humeral shaft fractures. J Trauma 2003;54:943-
placed as close to the fracture as practicable. The distance be-
949.
tween the plate and the bone should be kept small. Long
Delayed unions, nonunions, and acute humeral shaft frac-
plates should be used to provide sufficient axial stiffness.
tures in 159 patients were treated with humeral locked nails
and followed for an average 25.4 months. Surgical comminu-
Visser CP, Coene LN, Brand R, Tavy DL: Nerve lesions tion was significantly higher in retrograde nailing and surgical
in proximal humeral fractures. J Shoulder Elbow Surg comminution and significantly increased the risk of nonunion.
2001;10:421-427. Other complications included functional shoulder impairment,
Fourteen consecutive proximal humeral fractures were angular malunion, and postnailing radial nerve palsy.
evaluated with electromyograms in this prospective study. The
electromyogram showed denervation in 96 patients (67%),
with the axillary (58%) and the suprascapular nerves (48%) Marti RK, Verheyen CC, Besselaar PP: Humeral shaft
most frequently involved. nonunion: Evaluation of uniform surgical repair in fifty-
one patients. J Orthop Trauma 2002;16:108-115.
This article presents a review of the standard treatment of
Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, aseptic humeral shaft nonunions involving an anterolateral ap-
Marti RK: Open reduction and internal fixation of three proach, radial nerve identification, compression plating, and
and four-part fractures of the proximal part of the hu- autogenous bone grafting. This approach is reliable and
merus. J Bone Joint Surg Am 2002;84-A:1919-1925. achieves union without a significant risk of complications.
The long-term results were assessed for 60 patients with a
three- or four-part fracture of the proximal humerus who had
undergone ORIF with cerclage or a T-plate. Thirty-seven per- Ring D, Jupiter JB: Internal Fixation of the humerus
cent of patients had development of osteonecrosis and 77% of with locking compression plates. Tech Shoulder Elbow
these had a good or excellent Constant score. Surg 2003;4:169-174.
The drawbacks of previous methods of internal fixation
for humeral fractures and nonunions is discussed. The advan-
Humeral Shaft Fractures tages of and technique for the application of Locking Com-
Gerber A, Marti R, Jupiter J: Surgical management of pression Plates to humeral fractures and nonunions is pre-
diaphyseal humeral nonunion after intramedullary nail- sented. Preliminary results are also discussed.
ing: Wave-plate fixation and autologous bone grafting
without nail removal. J Shoulder Elbow Surg 2003;12: Sommer C, Gautier E, Muller M, Helfet DL, Wagner M:
309-313. First clinical results of the Locking Compression Plate
Sic patients with a nonunion of the humeral diaphysis af- (LCP). Injury 2003;34(suppl 2):B43-B54.
ter intramedullary nailing were treated with a wave-plate and A prospective multicenter study of the combined Euro-
autologous bone grafting. Union can be achieved without re- pean and American experience with the new locking compres-
moval of the intramedullary device. sion plate system used to treat various fractures in 144 pa-
tients is presented. In this study, tibial fractures (n = 46) and
Heitmann C, Erdmann D, Levin LS: Treatments of seg- humeral fractures (n = 45) predominated. General principles
mental defects of the humerus with an osteoseptocuta- for the application of the locking compression plate to dif-
neous fibular transplant. J Bone Joint Surg Am 2002;84- ferent fracture configurations as well as to humeral fractures,
A:2216-2223. are discussed. The low infection rate (1.5%) in this heteroge-
nous sample with numerous open fractures and revision pro- Hintermann B, Trouillier HH, Schafer D: Rigid internal
cedures attests to the good biology of the implant. fixation of fractures of the proximal humerus in older
patients. J Bone Joint Surg Br 2000;82:1107-1112.
Stannard JP, Harris HW, McGwin G Jr, Volgas DA,
Alonso JE: Intramedullary nailing of humeral shaft frac- Mayo KA, Benirschke SK, Mast JW: Displaced fractures
tures with a locking flexible nail. J Bone Joint Surg Am of the glenoid fossa: Results of open reduction and in-
2003;85-A:2103-2110. ternal fixation. Clin Orthop 1998;347:122-130.
A flexible humeral nail is described that allows both ante-
grade and retrograde insertion and static locking without vio-
McCormack RG, Brien D, Buckley RE, McKee MD,
lating the rotator cuff or humeral articular surface. Although Powell J, Schemitsch EH: Fixation of fractures of the
the nail functioned well in most patients, the use of the smaller shaft of the humerus by dynamic compression plate or
(7.5 mm) nail was associated with a higher complication rate. intramedullary nail: A prospective, randomized trial.
This implant should be used with caution in any patient with a J Bone Joint Surg Br 2000;82:336-339.
medullary canal diameter of 8 mm or less.
Momberger NG, Smith J, Coleman DA: Vascularized
fibular grafts for salvage reconstruction of clavicle non-
Classic Bibliography union. J Shoulder Elbow Surg 2000;9:389-394.
Chapman JR, Henley MB, Agel J, Benca PJ: Random-
ized prospective study of humeral shaft fracture fixa- Schai PA, Hintermann B, Koris MJ: Preoperative arthro-
tion: Iintramedullary nails versus plates. J Orthop scopic assessment of fractures about the shoulder. Ar-
Trauma 2000;14:162-166. throscopy 1999;15:827-835.
Edwards SG, Whittle AP, Wood GW II: Nonoperative Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD: Effect
treatment of ipsilateral fractures of the scapula and of immediate weightbearing on plated fractures of the
clavicle. J Bone Joint Surg Am 2000;82:774-780. humeral shaft. J Trauma 2000;49:278-280.
Galatz LM, Iannotti JP: Management of surgical neck Webber MC, Haines JF: The treatment of lateral clavicle
nonunions. Orthop Clin North Am 2000;31:51-61. fractures. Injury 2000;31:175-179.
Natural History the rotator cuff muscles, biceps, and periscapular mus-
The glenohumeral joint is the most mobile articulation cles. In general, the capsular ligaments provide stability
in the body and the most commonly dislocated diarth- at end range of motion; however, during midrange of
roidal joint, with peaks in the incidence of dislocation motion, the capsuloligamentous structures are lax and
occurring during the second and sixth decades of life. In- the joint is stabilized by dynamic joint compression.
stability of the glenohumeral joint ranges from subtle Glenohumeral instability occurs when there is a defi-
increased laxity to recurrent frank dislocation. No single ciency in the bony, soft-tissue, or dynamic muscular re-
disease or lesion is responsible for all types of shoulder straints to translation of the humeral head on the gle-
instability, and treatment has evolved to anatomically noid. Rehabilitation following instability episodes is
address specific lesions. directed toward optimizing the dynamic stabilizers,
Traumatic injury is the major cause of shoulder in- whereas surgical intervention restores the static stabiliz-
stability, accounting for approximately 95% of shoulder ers.
The oval glenoid is longest in its inferior-superior di-
dislocations. The sequela of traumatic anterior disloca-
ameter and has a nearly flat articular surface. Although
tion is associated with the age of the patient at the time
the osseous shape of the glenoid does not contribute
of initial dislocation and the degree of injury. Age at the
greatly to stability, the peripheral chondral surface of
time of the initial dislocation is inversely related to the
the glenoid is thickened, creating a concave articular
recurrence rate. In patients younger than 20 years of
surface that augments glenohumeral stability. The la-
age, recurrent dislocation rates may be as high as 90%
brum is a fibrous structure firmly bound to the glenoid
in the athletic population. The rate of recurrences drops
at its inferior margin and bound more loosely superi-
to 50% to 75% in patients 20 to 25 years of age. In pa-
orly, where it is confluent with the origin of the tendon
tients older than 40 years, anterior dislocation is associ-
of the long head of the biceps. The labral tissue contrib-
ated with lower rates of redislocation, but high rates of
utes to glenohumeral stability by deepening the glenoid
rotator cuff tears. Although the incidence of rotator cuff by approximately 50%. The labrum is thought to act as
tears in patients older than 40 years at the time of initial a chock block and has been shown to decrease resis-
dislocation is 15%, this incidence reaches 40% in pa- tance to humeral translation by 10% to 20%. In addi-
tients older than 60 years. The degree of injury (pres- tion, the labrum serves as an attachment site connecting
ence and size of Bankart tear, presence and size of os- the glenoid to the capsule, ligaments, and biceps tendon.
seous lesions including Hill-Sachs defects and osseous The capsule of the glenohumeral joint is lax under
Bankart lesions, capsular tears such as a humeral avul- normal circumstances, which allows for great range of
sion of the glenohumeral ligament, and the presence of motion of the joint. The capsule attaches medially to the
associated rotator cuff pathology) is directly related to glenoid and labrum and extends lateral to the surgical
the recurrence rate. neck of the humerus. In addition to providing structural
stability, the capsule maintains the negative joint pres-
Pathophysiology sure, which creates a negative vacuum that augments
The normal humeral head translates only 1 mm from joint stability.
the center of the glenoid during active motion. The gle- The ligaments of the glenohumeral joint are discrete
nohumeral joint is stabilized by both static and dynamic bands that insert onto the glenoid labrum. The most im-
stabilizers. The static restraints consist of the glenoid la- portant ligaments in the glenohumeral joint are the
brum, the articular anatomy, negative intra-articular superior glenohumeral ligament (SGHL), the middle
pressure, joint fluid adhesion, and the capsuloligamen- glenohumeral ligament (MGHL), and the inferior gle-
tous structures. Dynamic stabilizers of the joint include nohumeral ligament complex (IGHLC) (Figure 1).
Figure 2 The glenohumeral ligaments provide static restraint in different functional positions. A, With the shoulder in adduction and external rotation, the ligament SGHL and
MGHL are taut while the anterior band (AB) and posterior band (PB) of the IGHLC are lax. B, With the shoulder in abduction and external rotation, the AB of the IGHLC tightens
and the SGHL and MGHL become lax. (Reproduced with permission from Warner JP, Boardman ND III: Anatomy, biomechanics, and pathophysiology of glenohumeral instability, in
Warren RF, Craig EV, Altcheck DW (eds): The Unstable Shoulder. Philadelphia, PA, Lippincott-Raven, 1999, pp 51-76.)
Patient Evaluation
Multiple static and dynamic structures contribute to
shoulder stability; therefore, proper classification of
shoulder instability is essential to identify injured struc-
tures and plan treatment. Shoulder instability is classi-
fied by the degree, frequency, etiology, and direction of
instability (Table 1). Patient history and physical exami-
nation should focus on accurately classifying the insta-
bility pattern.
History
A careful history is essential to begin to classify the pa-
tients instability. The etiology of the instability may be
readily apparent as the patient may describe a frank trau-
matic dislocation event, history of repetitive microtrauma
with overhead activity, or generalized laxity that is famil-
ial. Patients are usually able to clearly describe the fre-
quency and chronicity of instability episodes. Pain or in-
stability with particular movements or positions may
Figure 3 Schematic drawing of the anatomy of the Bankart lesion demonstrating
reveal the direction of instability. Patients with anterior in- avulsion of the capsulolabral structures off the inferior rim of the glenoid. A = anterior;
stability report symptoms with the arm in an abducted and P = posterior l(Reproduced with permission from Warner JP, Caborn DNM: Overview of
externally rotated position. Posterior instability often oc- shoulder instability. Crit Rev Phys Rehabil Med 1992;4:145-198.)
curs with the arm flexed, internally rotated, and adducted.
Patients may experience symptoms while pushing open a
door or heavy object. Patients with inferior instability of- Physical Examination
ten have pain while carrying heavy objects; they may also Examination of shoulder instability begins with a thor-
experience traction paresthesias. ough evaluation of the cervical spine. Careful inspection
Traumatic glenohumeral defects have been associ- ture anchor fixation. At a mean follow-up of 39 months,
ated with failed Bankart repairs, particularly when per- 96% of these patients had a stable shoulder and were
formed arthroscopically. Two bony lesions in particular, able to return to their prior sports activity with few or
the engaging Hill-Sachs lesion and the inverted-pear no limitations.
glenoid, have been associated with high rates of recur-
rent instability after arthroscopic repair, particularly in Multidirectional Instability
athletes who participate in contact sports. In the engag- There is a common misconception that multidirectional
ing Hill-Sachs lesion, the orientation of the Hill-Sachs instability is limited to young sedentary patients with
lesion is such that it engages the anterior glenoid in ab- generalized ligamentous laxity, an atraumatic history,
duction and external rotation. In the inverted-pear gle- and bilateral symptoms. Although a subgroup of such
noid, the normal pear-shaped configuration of the gle- patients exists, shoulders with multidirectional instabil-
noid is altered because of significant anteroinferior ity are often seen in athletic patients, many of whom
bone loss, which creates an inverted pear appearance. have had an injury. Activities such as gymnastics or but-
With these osseous findings, open procedures with re- terfly swimming may have resulted in repetitive mi-
construction of the osseous defects may be warranted. crotrauma that selectively stretched out the shoulders,
and other joints may not be lax on examination. Addi-
Posterior Instability tionally, Bankart lesions and humeral head impression
Posterior instability occurs in 2% to 4% of patients with defects may be present in patients with multidirectional
shoulder instability. Causative factors for posterior in- instability, although less commonly than in patients with
stability include major trauma, repetitive microtrauma unidirectional traumatic instability.
as in overhead athletes, and generalized ligamentous Symptoms typically include episodes of pain and in-
laxity. Acute posterior dislocations occur with load to a stability that are positional or occur after minimal force.
flexed, adducted, and internally rotated upper arm and The lesion in multidirectional instability was classically
are commonly missed at initial presentation. Patients thought to be a loose redundant inferior pouch with a
present with an adducted, internally rotated arm and large rotator interval. However, the etiology of multidi-
are unable to externally rotate the shoulder. The classic rectional instability appears to be multifactorial and
radiographic findings on the AP view include a loss of may include aberrant muscle firing patterns and abnor-
the humeral neck profile, a vacant glenoid sign, and an mal connective tissue. In a recent MRI study, isometric
anterior humeral head compression fracture (reverse muscle activity leads to an off-centered humeral head
Hill-Sachs lesion). After recognition, gentle reduction position in patients with multidirectional instability
should be performed with lateral traction, external rota- compared with a recentered humeral head position dur-
tion, and abduction. Initial treatment after radiographic ing muscle firing in patients with traumatic instability.
confirmation of reduction is immobilization in slight ex- Initial treatment focuses on rehabilitation, which has
tension and external rotation followed by physical ther- a greater than 80% success rate if sustained for 6 to
apy. 12 months.
Most authors recommend a prolonged period of re- The goal of arthroscopic and open procedures is to
habilitation for symptoms of posterior instability. In pa- reduce the capsular volume of the joint while maintain-
tients who do not respond to nonsurgical treatment, a ing motion. Capsular shift, performed anteriorly or pos-
variety of surgical and arthroscopic interventions have teriorly, has an 85% to 90% success rate. Humeral-
been described. Open procedures include posterior cap- based as well as glenoid-based shift procedures have
sulorrhaphy, bone block procedures, and glenoid or hu- been described and have yielded similar success rates.
meral osteotomy. One study reported results of open Arthroscopic techniques include capsular plication,
posterior capsulorrhaphy for traumatic recurrent poste- rotator interval closure, and thermal capsular shrinkage.
rior subluxations in athletic patients; good or excellent Various arthroscopic devices have been developed to
results were achieved in 13 of 14 patients. Arthroscopic deliver heat to capsular tissue. Investigators have noted
procedures include posterior capsular plication, thermal a 15% to 40% reduction in the length of collagenous tis-
shrinkage, and capsulolabral repair. In a recent retro- sue when it is heated to 65 to 72C. This reduction in
spective review of 27 shoulders treated with arthro- length has been shown to be caused by thermal denatur-
scopic repair using bioabsorbable tack fixation for a ation of the collagen triple helix structure with subse-
posterior capsulolabral detachment (posterior Bankart quent reorganization into a random coil formation at a
lesion), symptoms of pain and posterior instability were shorter length. A recent retrospective review of the re-
eliminated in 92% of patients at a mean follow-up of 5.1 sults of arthroscopic laser-assisted capsular shrinkage in
years. In another review of patients with traumatic uni- 27 shoulders with multidirectional instability has shown
lateral posterior instability, 27 patients with posterior an overall success rate of 81.5% (with recurrent instabil-
Bankart lesions underwent arthroscopic repair using su- ity as a measure of failure) at an average follow-up of
28 months. In another study using arthroscopic thermal Irreparable capsular deficiency after failed stabiliza-
capsulorrhaphy to treat multidirectional instability in 30 tion procedures presents a particularly challenging situ-
shoulders, 76% of patients had a good or excellent re- ation. Capsular deficiency has been described after open
sult at an average follow-up of 3 years. The long-term procedures because of subscapsularis tendon incompe-
sequela of thermal shrinkage techniques is not known. tence and after arthroscopic thermal capsulorrhaphy
Recent studies of the behavior of lax ligaments treated caused by excessive thermal injury and tissue necrosis.
with electrothermal shrinkage in animal models have Deficiencies of the subscapularis tendon can be recon-
found that although thermal shrinkage reduced laxity, structed using a transfer of the sternal head of the pec-
there was increased potential for creep and failure at toralis major tendon. Capsular deficiencies can be re-
low physiologic stresses. A recent histologic analysis of constructed with a portion of the subscapularis tendon,
the capsule from seven patients after failed thermal cap- autograft tissue, or allograft tendon. A recent report in
sulorrhaphy showed denudation of the synovial layer which the iliotibial band was used to reconstruct the de-
and morphologic changes in the collagen layer that ficient capsular tissues in seven patients showed the
included, in some cases, a hyalinization appearance. elimination of instability and the maintenance of a phys-
Although no pathognomonic histologic changes were iologic range of motion.
identified, the study demonstrated that histologic abnor- Osseous deficiency of the humerus or of the glenoid
malities may be present for years after failed thermal is a rare etiology of recurrent instability after failed sta-
capsulorrhaphy.
bilization. Bone procedures to reconstruct osseous defi-
ciencies include the Latarjet and the Bristow procedures
Failed Instability Surgery in which a portion of the coracoid is used to reconstruct
Recurrent instability after surgical treatment of instabil- an inferior glenoid deficiency. Hill-Sachs lesions, an im-
ity may occur because of new trauma, incomplete treat- paction fracture of the posterolateral margin of the hu-
ment of pathologic lesions, poor rehabilitation, abnor- meral head, are found in more than 80% of patients
mal host healing response, or diagnostic error. with traumatic anterior instability. These lesions are
Treatment of recurrent stability after surgical stabiliza- thought to play a significant role in recurrent instability
tion is difficult. Prior to surgical intervention, careful if they comprise more than 30% of the proximal hu-
evaluation by history, physical examination, and diag- merus articular surface or if they engage the glenoid.
nostic imaging should be performed to identify the
Large Hill-Sachs lesions that engage the glenoid and
cause of the recurrence. Recurrent instability after
contribute to recurrent instability may be treated with
failed stabilization should be classified according to di-
osteochondral allografts.
rection, degree, and frequency of instability.
In patients with multiple failed stabilization proce-
Initial treatment almost always consists of extensive
dures and recurrent, debilitating instability, arthrodesis
rehabilitation. New traumatic lesions may heal, and
may be considered as a salvage procedure. A recent
strengthening and improved control of the dynamic
study evaluated the efficacy of shoulder arthrodesis per-
muscular stabilizers may make the instability more tol-
erable. formed after an average of seven failed stabilization at-
Surgical intervention should be directed by the etiol- tempts. The results of eight patients were reviewed at a
ogy of the recurrent instability. Common findings at re- mean follow-up of 35 months. All patients had achieved
vision surgery include excessive capsular redundancy, bony union and all patients reported that they would re-
uncorrected Bankart lesions, and bone loss from the gle- peat the surgery.
noid or from the humeral head. Incomplete correction
of pathologic lesions, particularly Bankart lesions, Chronic Dislocations
should be repaired anatomically. An inferior capsular The diagnosis of chronic locked anterior or posterior
shift should be performed in patients with capsular lax- shoulder dislocations may be made after physical exam-
ity, particularly in those with a patulous axillary pouch. ination and proper radiographic analysis. Nonsurgical
One retrospective review investigated the outcome treatment may be considered in elderly patients with
of 50 patients who underwent revision anterior stabiliza- poor general mental status, especially when the condi-
tion. Forty-nine of the procedures involved an open cap- tion is associated with limited pain. Surgical treatment is
sular shift, and 23 shoulders underwent concomitant re- necessary for reduction of the joint. Humeral head im-
pair of a Bankart lesion. At an average 4.7-year follow- paction fracture (Hill-Sachs lesions with chronic ante-
up, good or excellent results were obtained in 78% of rior dislocations and reverse Hill-Sachs lesions with
patients. The authors identified factors associated with chronic posterior dislocations) may preclude stable re-
poor results of the revision procedure that included duction.
atraumatic causes of failure, voluntary dislocations, and
multiple prior stabilization attempts.
Figure 5 The Rockwood classification of ligamentous injuries to the acromioclavicular joint. Type I, no disruption of the acromioclavicular or coracoclavicular ligaments. Type II,
disruption of the acromioclavicular ligament (coracoclavicular ligaments remain intact.) Type III, disruption of the acromioclavicular and coracoclavicular ligaments. Type IV,
disruption of the acromioclavicular and coracoclavicular ligaments, and the distal end of the clavicle is displaced posteriorly into or through the trapezius muscle. Type V,
disruption of the acromioclavicular and coracoclavicular ligaments, along with disruption of the muscle attachments and creation of a major separation between the clavicle and
the acromion. Type VI, disruption of the acromioclavicular and coracoclavicular ligaments. Inferior dislocation of the distal clavicle in which the clavicle is inferior to the coracoid
process and posterior to the biceps and coracobrachialis tendons. (Reproduced with permission from Rockwood CA, Williams GR, Young DC: Shoulder instability, in Rockwood CA,
Green DP, Bucholz RN, Heckman JD (eds): Rockwood and Greens Fractures in Adults. Philadelphia, PA, Lippincott-Raven, 1996, p 1354.)
Acromioclavicular Separations past to help distinguish between type II and type III AC
The acromioclavicular (AC) joint is a sturdy structure joint separation; however, this technique is no longer fa-
that affixes the clavicle to the scapula. Injury to the AC vored because it usually does not influence the choice of
joint is common (comprising approximately 9% of treatment.
shoulder girdle injuries) and occurs most often in males Type I and II AC separations are considered incom-
in their 20s. The AC joint is surrounded by and stabi- plete lesions and may be treated conservatively with ice,
lized by a capsule and AC ligaments (superior, inferior, rest, and a brief period of immobilization followed by
anterior, and posterior). Additional joint stability is pro- therapy. Types IV, V, and VI are complete injuries that
vided by the coracoclavicular ligaments (trapezoid and usually require surgical reconstruction. Treatment of
conoid) as well as the coracoacromial ligament. type III injuries remains controversial.
Injury to the AC joint is understood as a sequential
loss of AC stabilizers. The classification of AC joint in- Sternoclavicular Dislocations
stability reflects this anatomic progression of injury The sternoclavicular joint is the only true articulation
(Figure 5) and is useful in directing treatment. between the clavicle and the axial skeleton. Sternoclav-
Radiographic evaluation of the AC joint may be per- icular dislocations are usually the result of high-energy
formed with standard AP and lateral views of the shoul- force sustained during a motor vehicle accident or dur-
der. However, improved visualization of the AC joint is ing contact sports activity.
achieved with a Zanca view, performed by tilting the Classification of sternoclavicular dislocations is
beam 10 to 15 cephalad. Additionally, only one third based on anatomic findings. Anterior dislocations are
to one half of the penetration strength for a standard most common and are present when the medial end of
AP of the glenohumeral joint is used to more precisely the clavicle is displaced anterior or anterosuperior to
visualize the AC joint; standard shoulder radiographic the sternum. Patients with anterior dislocations have a
penetration will overpenetrate the less dense AC joint. palpable medial clavicular head mass that may be more
Stress views, using 5-lb weights placed on the wrist and pronounced with abduction and elevation. Posterior dis-
comparing both AC joints, have been advocated in the locations are uncommon but more concerning. The me-
dial end of the clavicle is displaced posteriorly or postero- Twenty-one active duty military personnel between the
superiorly and may impinge on vital structures. The ages of 18 and 26 years with primary, traumatic shoulder dislo-
patient presents with a hollow region just lateral to the cation were randomized to nonsurgical treatment or arthro-
sternum, and may also present with dyspnea or dysph- scopic Bankart repair using a bioabsorbable tack. At an aver-
agia. age of 3 years follow-up, 75% of patients treated nonsurgically
Radiographic evaluation involves standard chest ra- versus 11% of the patients treated with arthroscopic repair de-
diographs as well as the serendipity view obtained by di- veloped recurrent instability. Six of nine patients treated non-
surgically who developed recurrent instability required subse-
recting the x-ray beam 40 cephalad to visualize both
quent open Bankart repair.
sternoclavicular joints. CT scan and/or MRI are cur-
rently the best techniques to evaluate the sternoclavicu-
lar joint and clearly distinguish the direction of the dis- Buss DD, Lynch GP, Meyer CP, Huber SM, Freehill MQ:
location as well as any associated fractures. In patients Nonoperative management for in-season athletes with
with posterior dislocation, CT and/or MRI allow for the anterior shoulder instability. Am J Sports Med 2004;32:
evaluation of mediastinal structures and visualization of 1430-1433.
Thirty in-season athletes with either acute or recurrent an-
the medial clavicular head in relationship to these struc-
terior instability were treated with physical therapy and, if ap-
tures.
propriate, bracing. Eighty-seven percent of athletes were able
Acute reduction of anterior sternoclavicular disloca-
to return to their sport in season and an average of 1.4 recur-
tions may be attempted with traction of the extended rent instability episodes per season per athlete occurred. No
arm. Residual anterior instability is well tolerated but further injuries were attributable to the shoulder instability.
may result in persistent deformity. Posterior dislocations Fifty-three percent of patients had subsequent surgical stabili-
should be reduced in the operating room with care zation in the off-season.
taken to avoid damage to the mediastinal structures.
DeBerardino TM, Arciero RA, Taylor DC, et al: Pro-
Annotated Bibliography spective evaluation of arthroscopic stabilization of
Pathophysiology acute, initial anterior shoulder dislocations in young ath-
Urayama M, Itoi E, Hatakeyama Y, Pradhan RL, Sato letes: Two- to five-year follow-up. Am J Sports Med
K: Function of the 3 portions of the inferior gleno- 2001;29:586-592.
humeral ligament: A cadaveric study. J Shoulder Elbow Forty-eight cadets at the US Military Academy with 49 an-
Surg 2001;10:589-594. terior dislocations were treated with primary arthroscopic re-
The strain of the three portions or sections of the inferior pair using bioabsorbable tacks. At an average follow-up of 37
glenohumeral ligament in 17 fresh-frozen cadaveric shoulders months, the average Rowe score was 92%, and 88% of shoul-
was studied during elevation and rotational maneuvers. The ders remained stable. Factors associated with failure included
anterior band and axillary pouch showed the greatest strain in a history of bilateral shoulder instability, a 2+ sulcus sign, and
abduction and external rotation, confirming their role as ante- poor capsulolabral tissue at the time of repair. All patients
rior stabilizers. The posterior band showed the greatest strain with stable shoulders returned to their preinjury levels of ath-
with flexion and internal rotation, suggesting a key role as a letic activity. These results are favorable compared with non-
posterior stabilizer. surgical treatment in young, active adults at the US Military
Academy.
Urayama M, Itoi E, Sashi R, Minagawa H, Sato K: Cap-
sular elongation in shoulders with recurrent anterior Itoi E, Hatakeyama Y, Kido T, et al: A new method of
dislocation: Quantitative assessment with magnetic reso- immobilization after traumatic anterior dislocation of
nance arthrography. Am J Sports Med 2003;31:64-67. the shoulder: A preliminary study. J Shoulder Elbow
Magnetic resonance arthrography was used to evaluate the Surg 2003;12:413-415.
length of the anteroinferior, inferior, and posteroinferior cap- Forty patients were randomly assigned to immobilization
sule in 12 patients with unilateral recurrent anterior instability. in external rotation versus immobilization in internal rotation
Unaffected shoulders were used as controls. The anteroinfe- for 3 weeks after initial anterior dislocation. The average ages
rior and inferior portions of the shoulder capsule were elon- in the internal and external groups were 38 years and 40 years,
gated an average of 19% in shoulders with recurrent anterior respectively, with similar numbers of patients under the age of
dislocation compared with the unaffected shoulders. 29 years. At approximately 1-year follow-up, the recurrence
rate was 30% in the internal rotation group and 0% in the ex-
Treatment of Acute Dislocation ternal rotation group. Anterior apprehension was positive in
Bottoni CR, Wilckens JH, DeBerardino TM, et al: A 14% of the internal rotation group without recurrence and 5%
prospective, randomized evaluation of arthroscopic sta- of the external rotation group.
bilization versus nonoperative treatment in patients
with acute, traumatic, first-time shoulder dislocations. Miller SL, Cleeman E, Auerbach J, Flatow EL: Compar-
Am J Sports Med 2002;30:576-580. ison of intra-articular lidocaine and intravenous seda-
tion for reduction of shoulder dislocations: A random- (23%) at a mean of 13 months (range, 5 to 21 months) after
ized, prospective study. J Bone Joint Surg Am 2002;84: surgery. In the open group, there were recurrences in 3 of 26
2135-2139. patients (12%) at a mean of 10 months (range, 2 to 23
In a prospective study, 30 patients with anterior gleno- months) after surgery (P = not significant). A tendency toward
humeral dislocation were randomized to receive either intra- more redislocations in the arthroscopic group was noted.
articular lidocaine or intravenous sedation before relocation
using the Stimson method. There was no significant difference Posterior Instability
between the two groups with regard to pain, success of the Kim SH, Ha KI, Park JH, et al: Arthroscopic posterior
Stimson technique, or time required for reduction of the labral and capsular shift for traumatic unidirectional re-
shoulder. The lidocaine group spent significantly less time in
current posterior subluxation of the shoulder. J Bone
the emergency department and required less nursing re-
Joint Surg Am 2003;85:1479-1487.
sources. Twenty-seven patients with unidirectional posterior insta-
bility were treated with arthroscopic labral repair and poste-
Treatment of Recurrent Traumatic Instability rior capsular shift using suture anchors. At a mean postopera-
Karlsson J, Magnusson L, Ejerhed L, Huttenheim I, tive follow-up of 39 months, all patients had a stable shoulder
Lundin O, Kartus J: Comparison of open and arthro- by subjective and objective measurements except for one pa-
scopic stabilization for recurrent shoulder dislocation in tient who had recurrent subluxation. Twenty-six patients re-
patients with a Bankart lesion. Am J Sports Med 2001; turned to prior sports activity with few or no limitations. The
29:538-542. authors also describe arthroscopic findings in traumatic unidi-
One hundred eight shoulders with symptomatic, recurrent rectional recurrent posterior instability.
anterior instability and a Bankart lesion underwent either
open stabilization or arthroscopic stabilization with bioabsorb-
able tack fixation. At a mean follow-up of 28 months, the re-
Williams RJ III, Strickland S, Cohen M, Altchek DW,
currence rate, including both dislocations and subluxations, Warren RF: Arthroscopic repair for traumatic posterior
was 9 of 60 (15%) in the arthroscopic group, compared with shoulder instability. Am J Sports Med 2003;31:203-209.
Twenty-seven shoulders in 26 patients with traumatic pos-
5 of 48 (10%) in the open group. No significant differences
terior shoulder instability were treated with arthroscopic re-
were found between the study groups for the Rowe or Con-
stant scores at follow up. The only significant difference in pair using bioabsorbable tack fixation. At a mean follow-up of
range of motion assessment was in external rotation in abduc- 5.1 years, no patients showed a range-of-motion deficit. There
tion, which was 90 (range, 50 to 135) in the arthroscopic was no instability greater than 1+ in the anterior, posterior, or
group and 80 (range, 25 to 115) in the open group. The inferior directions. Symptoms of pain and instability were
treatment groups in this study were not randomized. eliminated in 24 patients (92%). Two patients (8%) required
additional surgery after arthroscopic repair of the posterior
Bankart lesion.
Kim SH, Ha KI, Cho YB, Ryu BD, Oh I: Arthroscopic
anterior stabilization of the shoulder: Two to six-year
follow up. J Bone Joint Surg Am 2003;85:1511-1517. Multidirectional Instability
One hundred sixty-seven patients with traumatic recurrent Favorito PJ, Langenderfer MA, Colosimo AJ, Heidt RS
anterior instability were treated with arthroscopic Bankart re- Jr, Carolonas RL: Arthroscopic laser-assisted capsular
pair using suture anchors. At a mean follow-up of 44 months, shift in the treatment of patients with multidirectional
the rate of postoperative recurrence of instability was 4% with shoulder instability. Am J Sports Med 2002;30:322-328.
a mean loss of external rotation of 2. Postoperative recur- Twenty-seven shoulders in 25 patients with multidirec-
rence was related to an osseous defect of more than 30% of tional shoulder instability were treated with an arthroscopic
the glenoid circumference. These results compare favorably laser-assisted capsular shift procedure. At an average
with historical results of open stabilization. follow-up of 28 months, 22 shoulders had no recurrent symp-
toms and required no further surgical intervention. In five
shoulders, treatment was considered a failure because of re-
Sperber A, Hamberg P, Karlsson J, Sward L, Wredmark
current pain or instability and the need for an open capsular
T: Comparison of an arthroscopic and an open proce-
shift procedure. With recurrent instability as a measure of fail-
dure for posttraumatic instability of the shoulder: A
ure, the overall success rate was 81.5%.
prospective, randomized multicenter study. J Shoulder
Elbow Surg 2001;10:105-108.
Fifty-six patients with anterior instability and a Bankart le- Fitzgerald BT, Watson BT, Lapoint JM: The use of ther-
sion were randomized to either open stabilization or arthro- mal capsulorrhaphy in the treatment of multidirectional
scopic stabilization with the use of bioabsorbable tacks. Pa- instability. J Shoulder Elbow Surg 2002;11:108-113.
tients were evaluated at 2, 12, and 24 months postoperatively. Thirty shoulders with multidirectional instability were
Thirty patients were surgically treated with the arthroscopic treated with arthroscopic thermal capsulorrhaphy. At a mean
technique and 26 patients with the open technique. In the ar- follow-up of 36 months (range, 24 to 40 months), 3 excellent,
throscopic group, there were recurrences in 7 of 30 patients 20 good, and 7 poor results were reported using the University
of California, Los Angeles score. Twenty-three patients (76%) Eight patients with recurrent shoulder instability with an
returned to full activity. average of seven prior stabilization attempts were treated with
glenohumeral arthrodesis. The average time to bony union af-
McFarland EG, Kim TK, Banchasuek P, McCarthy EF: ter arthrodesis was 3.5 months (range, 2.5 to 5 months). At
Histologic evaluation of the shoulder capsule in normal mean follow-up of 35 months, the patients reported significant
shoulders, unstable shoulders, and after failed thermal overall subjective improvement as a group after fusion. None
capsulorrhaphy. Am J Sports Med 2002;30:636-642. of the patients reported instability postoperatively. All eight
Shoulder capsules were evaluated histologically in 12 pa- patients stated that they would repeat the surgery again under
tients with traumatic anterior instability and in 7 patients who similar preoperative circumstances.
experienced recurrent instability after a thermal capsulorrha-
phy. The capsules of six fresh-frozen cadavers with no shoulder Iannotti JP, Antoniou J, William GR, Ramsey ML: Ili-
lesions were used as controls. In patients who had a history of
otibial band reconstruction for treatment of gleno-
traumatic instability, a denuded synovial layer was present in
humeral instability associated with irreparable capsular
58%, subsynovial edema in 58%, increased cellularity in 25%,
deficiency. J Shoulder Elbow Surg 2002;11:618-623.
and increased vascularity in 83%. At the time of surgery, five
Seven patients with recurrent anterior instability after
of seven shoulders in the failed thermal capsulorrhaphy group
failed surgery complicated by the loss of capsular tissue under-
(71%) were subjectively felt to be thin and attenuated. De-
went reconstruction of the capsular ligaments using the iliotib-
nuded synovium was found in 100% of these patients, subsyn-
ial band. After iliotibial band reconstruction, the patients
ovial edema in 43%, and changes in the collagen layer in
showed significant improvement in their American Shoulder
100%. Changes in the collagen layer in these patients included
the appearance of hyalinization in five patients (71%), in- and Elbow Surgeons score (P =0.0004), and no patient had
creased collagen fibrosis in two patients (29%), and increased any persistent symptoms of instability. Physiologic range of
cellularity in two patients (29%). motion and function were maintained. The authors describe
their surgical technique for iliotibial band reconstruction for
capsular deficiency.
von Eisenhart-Rothe RM, Jager A, Englmeier KH, Vogl
TJ, Graichen H: Relevance of arm position and muscle
activity on three-dimensional glenohumeral translation Acromioclavicular Separations
in patients with traumatic and atraumatic shoulder in- Schlegel TF, Burks RT, Marcus RL, Dunn HK: A pro-
stability. Am J Sports Med 2002;30:514-522. spective evaluation of untreated acute grade III acromi-
Open MRI and three-dimensional post processing tech- oclavicular separations. Am J Sports Med 2001;29:699-
nique was used to evaluate glenohumeral translation with dif- 703.
ferent arm positions with and without muscle activation in 12 Twenty patients with acute grade III AC separations were
patients with traumatic and 10 patients with atraumatic insta- treated nonsurgically with a sling for comfort through progres-
bility. In patients with traumatic instability, increased transla- sive early range of motion as tolerated and completed a 1-year
tion was observed only in functionally important arm posi- evaluation and strength-testing protocol. Subjectively, 4 of the
tions, whereas intact active stabilizers showede sufficient 20 patients (20%) thought that their long-term outcome was
recentering. In patients with atraumatic instability, a decentral- suboptimal, although 3 of them did not believe that the out-
ized head position was recorded also during muscle activity, come should warrant surgery. Objective examination and
suggesting alterations of the active stabilizers. strength testing of the 20 patients revealed no limitation of
shoulder motion in the injured extremity and no difference
Wallace AL, Hollinshead RM: FrankCB: Electrothermal between sides in rotational shoulder muscle strength. The
shrinkage reduces laxity but alters creep behavior in a lap- bench press was the only strength test that showed a signifi-
ine ligament model. J Shoulder Elbow Surg 2001;10:1-6. cant short-term difference, with the injured extremity being an
Using a lapine medial collateral ligament laxity model, the average of 17% weaker.
acute effects of radiofrequency shrinkage were assessed. Ther-
mal treatment resulted in restoration of laxity but a significant
increase in the cyclic and static creep strains compared with con-
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Burkhart SS, DeBeer JF: Traumatic glenohumeral bone
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Diaz JA, Cohen SB, Warren RF, Craig EV, Allen AA: Bankart repairs: Significance of the inverted-pear
Arthrodesis as a salvage procedure for recurrent insta- glenoid and humeral engaging Hill-Sachs lesion.
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Curl LA, Warren RF: Glenohumeral joint stability: Se- Thomas SC, Matsen FA III: An approach to the repair
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Clin Orthop 1996;330:54-65. agement of traumatic anterior glenohumeral instability.
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Rotator Cuff Tear tears. Histologic changes in chronic rotator cuff tissue
Pathophysiology tears have shown degenerative changes, but there is lit-
The etiology of rotator cuff tears has not been clearly tle evidence of acute inflammation. This finding rein-
forces the notion that changes in proteoglycan and
elucidated. Focus has centered primarily on intrinsic and
other extracellular matrix protein content in the aging
extrinsic mechanisms of generating rotator cuff tears,
tendon may have a role in attritional changes leading to
with reports in the early literature primarily focused on
tears. More research is necessary to make definitive
an extrinsic mechanism. Three types of acromial mor-
conclusions regarding the true etiology, and it is likely
phology were defined (types I, II, and III), with increas-
that both intrinsic and extrinsic mechanisms as well as
ing curvature of each type. Type III acromions, with
patient-related factors contribute to the development of
maximal curvature or hooking of the undersurface, were
rotator cuff disease.
associated with an increased incidence of rotator cuff
After a rotator cuff is torn, several changes can
tears resulting from increased mechanical contact of the
occur in the shoulder joint. Clinically these changes
cuff with the bone. Recent studies have provided data
manifest as pain and decreased strength and range of
that do not substantiate this early information and sug- motion. Radiographic changes can include proximal mi-
gest a much more complex etiology for rotator cuff gration of the humeral head, narrowing of the acromial-
tears. humeral interval, sclerosis of the undersurface of the ac-
Attention has focused on the role and contribution romion and superior humeral head, acetabularization or
of plain radiographic imaging for the diagnosis and de- rounding of the undersurface of the acromion such that
tection of full-thickness rotator cuff tears. Acromial os- it is congruent with the humeral head, and degenerative
teophytes or spurring, acromioclavicular degeneration, changes of the glenohumeral joint. Most of these
and lateral clavicular and acromial sclerosis seen on changes occur only with massive, long-standing rotator
plain radiographs have been correlated with age rather cuff tears. These structural changes to the joint with ro-
than rotator cuff disease. Rotator cuff disease, especially tator cuff tears result from kinematic changes secondary
involving full-thickness tears, has also been correlated to loss of the normal muscle forces about the shoulder.
with age, complicating the issue. Although some cadav- The purposes of the rotator cuff are to keep the hu-
eric studies have demonstrated an association between meral head centered on the glenoid (termed concavity
spurring of the anterior acromion and the acromioclav- compression) by counteracting the superior vector of
icular joint and rotator cuff tears, a direct causal rela- the deltoid, and to add strength and dynamic stability to
tionship between degenerative radiographic changes glenohumeral motion.
and full-thickness tears has not been definitively Several recent basic science studies have been per-
proven. One recent study of radiographic changes in 40 formed to investigate the changes in forces and motion
patients with full-thickness cuff tears and a large group patterns associated with rotator cuff tears. One cadav-
of age-matched controls found no association between eric study examined the effect of rotator cuff tears on
acromial morphology and rotator cuff tears. Findings joint reaction forces at the glenohumeral joint. There
that were indicative of cuff tears included sclerosis, os- were no significant differences in joint reaction force
teophytes, subchondral cysts, and osteolysis of the magnitude or direction with abduction motion between
greater tuberosity. There was no relationship between the intact state, partial supraspinatus tear, or complete
any of these findings in the greater tuberosity and tear supraspinatus tear. Extension of tears beyond the su-
size. praspinatus tendon resulted in a significant decrease in
Intrinsic mechanisms of rotator cuff degeneration the magnitude of the joint reaction force. Additionally,
have been implicated in the etiology of rotator cuff the vector of the force changed direction toward the de-
ficient area. Clinically, this finding may explain why Examination should begin with an inspection of both
some patients with fairly large tears may still maintain shoulders to detect asymmetry or muscle atrophy. The
function. The critical tear size at which the force couple examiner should stand behind the patient and observe
of the remaining musculature is overcome and pseu- the scapulae during overhead elevation for winging and
doparalysis of the shoulder results is yet to be deter- motion pattern. Range of motion should be recorded
mined, and clinically seems to differ between individu- for elevation in the scapular plane, external rotation at
als. the side, and external rotation in abduction to fully ex-
Another cadaveric study was performed to compare amine the anterior capsule. Internal rotation can be
the effects of supraspinatus detachments, tendon de- tested by internal rotation of the shoulder with the arm
fects, and muscle retraction. Simply detaching a portion in 90 of abduction and by asking the patient to reach
of the supraspinatus tendon had no effect on the force behind the back. Side-to-side comparison is critical to
transmitted by the rotator cuff. Detaching or creating a determine normal motion, as range of motion differs be-
defect of the entire supraspinatus tendon led to a mod- tween individuals.
erate decrease in force transmission (11% and 17%, re- Supraspinatus strength is tested by external rotation
spectively). However, when the investigators simulated with the arm at the side with the shoulder in neutral or
muscle retraction of the tendon by incising medially to slight internal rotation. Testing external rotation with
detach the tendon from adjacent tendon tissue, there the shoulder in external rotation allows substitution by
were substantial reductions in force transmission (58% the posterior deltoid. Placing the arm in 90 of abduc-
with involvement of the entire supraspinatus). Side-to- tion in the scapular plane with the thumbs down and
side repair of smaller defects restored force capability, asking the patient to resist downward pressure is an-
but a deficit remained even after side-to-side repair of other way to isolate the supraspinatus. This test (Jobes)
the entire supraspinatus tendon retraction simulation. is useful for both strength and pain. A lag sign (for test-
This study supports the cable concept of force transmis- ing the posterosuperior rotator cuff) is performed by
sion of the rotator cuff, and suggests that the amount of placing the arm in maximal external rotation. A patient
retraction and not just transverse diameter may be an with a large or massive tear will not be able to maintain
important factor in functional deficit after a rotator cuff the arm in this position and the hand will swing toward
tear. neutral rotation. In a patient with a massive tear, includ-
ing the teres minor, the hornblowers sign will be posi-
Natural History tive (the patient is unable to externally rotate the arm
The severity of rotator cuff disease ranges from painful to 90 with the arm in abduction). Positive results from
cuffs without tears to partial-thickness tears to full- these two tests are usually associated with massive tears
thickness tear. It is not known whether this is a continu- and there is correlation with fatty degeneration of the
ous spectrum in which a patient will go from one stage cuff musculature.
to the next as part of the natural history of their condi- Subscapularis integrity is tested using the lift-off test
tion or whether some patients present at one stage, and the abdominal compression test. The lift-off test in-
never progressing to another. One longitudinal ultra- volves placing the arm behind the back, at the midline,
sonographic study showed that over a time period of at waist level. The patient is asked to raise the hand off
5 years, approximately 28% of patients had an increase the back, a motion requiring an intact subscapularis. An
in size of known full-thickness rotator cuff tears. Addi- abdominal compression test is performed by placing the
tionally, more recent data show a high prevalence of hand flat on the abdomen with a straight line between
full-thickness tears in the opposite shoulders of patients the hand, wrist, and elbow. A patient with a torn sub-
with full-thickness tears, and this was also seen more of- scapularis will either bend the wrist to keep the hand on
ten as patients get older. Research on the natural his- the abdomen or lose contact. Internal strength can be
tory of tears is ongoing and more information will likely tested in this position as well.
be available in the near future. The Neer and Hawkins impingement signs are used
to detect pain related to rotator cuff disease by provok-
Evaluation ing impingement in the subacromial space by internally
History and Examination rotating the shoulder, bringing the greater tuberosity
Patients with rotator cuff tears report a history of shoul- underneath the acromion, and minimizing space avail-
der pain and/or weakness. Pain associated with rotator able for the cuff. A thorough examination should also
cuff tears is usually located on the anterolateral aspect include evaluation of the acromioclavicular joint for
of the shoulder and often radiates distally toward the pain on direct palpation and pain with cross-body ad-
deltoid insertion. Pain that radiates below the elbow to duction. Biceps tendon pathology is often associated
the hand should raise suspicion of cervical radiculopa- with rotator cuff tears. The Speed and Yergason tests are
thy or peripheral nerve compression. sensitive for biceps tendon pain.
Diagnostic Studies clude the following: (1) tears are easier to repair when
Plain radiographs should be the initial radiographic they are smaller, and there is documented evidence that
study of choice. A standard series should include an AP tear size can increase with time; (2) there is a higher re-
radiograph of the shoulder with the arm in internal ro- currence rate after repair of large and massive tears;
tation, an AP radiograph of the scapula with the arm in (3) long-standing chronic tears are associated with muscle
neutral or slight external rotation, an outlet view, and an atrophy and fatty degeneration, which are irreversible
axillary view. The acromioclavicular joint is best visual- changes that can compromise functional outcome after re-
ized on the AP view of the shoulder. The glenohumeral pair; and (4) there may be attritional changes in the ten-
joint space is assessed on the scapular AP and the axil- don edge of chronic tears that may compromise healing
lary views, in which degenerative changes are best de- potential.
tected. The outlet view enables evaluation of acromial
morphology. MRI is valuable for evaluating the soft tis- Surgical Approaches
sues about the shoulder and is a sensitive and specific An open surgical approach involves an incision and re-
test for rotator cuff pathology. The role of ultrasonogra- moval of the anterior deltoid origin from the acromion
phy in the evaluation of the rotator cuff has gained pop- to maximize exposure. The major advantage of an open
ularity in recent years because it is highly accurate in repair is the extensive exposure and ability to mobilize
making the diagnosis of full-thickness and partial- the cuff under direct observation. It also requires no ar-
thickness tears. Because the reliability of ultrasonogra- throscopic skills. A mini-open repair is alternatively per-
phy is operator-dependent, significant experience should formed through a deltoid split rather than removing the
be gained before this study is used independently. MRI deltoid origin. To achieve a repair using a mini-open ap-
has largely replaced arthrography, which is rarely used; proach, arthroscopic assistance is used. Because expo-
however, arthrography remains a good alternative if an sure is more limited, inspection, cuff mobilization, and
MRI evaluation cannot be obtained and an ultrasound the acromioplasty are performed with the use of the ar-
is not available. throscope, obviating the need for a more extensile ap-
proach. The major advantage of a mini-open repair is
that the deltoid is not removed from the acromion. Re-
Treatment of Partial-Thickness Rotator Cuff Tears moval of the deltoid is one of the more painful aspects
Partial-thickness tears are often managed successfully
of the open procedure, and failure of the deltoid repair
with nonsurgical treatment. An exercise program fo- is a serious and painful complication for which there is
cuses on range of motion, stretching, and strengthening no reliable option for correction.
of the rotator cuff, deltoid, and scapular stabilizers. Arthroscopic repair of full-thickness tears has gained
Partial-thickness tears that do not become asymptom- recent popularity. As equipment and techniques con-
atic with nonsurgical treatment can be effectively tinue to advance, this approach will likely continue to
treated surgically. Arthroscopic treatment entails dbri- become easier and more achievable with advanced ar-
dement of the tear after careful inspection of both the throscopic skills. Potential advantages of an arthroscopic
articular and bursal sides. In general, if the tear involves approach include decreased scarring, easier rehabilita-
less than 50% of the thickness of the cuff, dbridement tion, decreased pain, and improved cosmesis. Damage to
should be adequate. If the tear involves more than 50% the deltoid is minimized with an arthroscopic approach.
of the thickness of the cuff or the remaining tissue is de- One disadvantage to an arthroscopic repair may be a
generative and easily dbrided, then the tear is ex- higher recurrence rate after repair of large and massive
panded to a full-thickness tear and healthy tissue is re- tears. The procedure requires advanced arthroscopic
paired primarily. Recently, several arthroscopic methods skills, which may be considered by some to be a disad-
of imbricating partial-thickness tears and repairing lami- vantage of using the procedure; however, the use of
nated flaps have been described, and offer promising minimally invasive approaches is becoming mainstream.
options in the management of partial-thickness tears.
Role of Acromioplasty
Treatment of Full-Thickness Rotator Cuff Tears An acromioplasty has historically been a standard as-
Nonsurgical treatment for full-thickness tears is the same pect of a rotator cuff repair based on Neers classic de-
as for partial-thickness tears in terms of exercise and pain scription of impingement syndrome and the theory that
control measures. Surgical treatment of symptomatic full- contact with the rigid coracoacromial arch is the me-
thickness rotator cuff tears is indicated in patients in chanical impetus for rotator cuff tears. An acromio-
whom nonsurgical treatment has failed and who are can- plasty entails takedown of the coracoacromial ligament
didates for surgery, those with acute tears, and patients from the anterior acromion and removal of bone from
with tears associated with a sudden loss of strength and the undersurface of the acromion to increase the space
function. Relative indications include younger people of available for the rotator cuff. Historically, removal of
working age with a painful tear. Factors to consider in- large amounts of bone, including full-thickness removal
Figure 1 A, Radiograph of a shoulder after failed rotator cuff repair and distal clavicle resection. The anchors have failed, the humeral head has migrated anteriorly and
superiorly, and degenerative changes have begun to involve the glenohumeral joint. B, MRI of the shoulder demonstrates the massive rotator cuff tear and proximal migration.
C, A sagittal oblique cut of the MRI demonstrates the cuff insufficiency as well as the deltoid attenuation.
of bone from the anterior acromion in some instances, series of tears involving the subscapularis, a lower Con-
was recommended. The more recent trend for acromio- stant score correlated with duration of symptoms longer
plasty is to remove enough bone to make the undersur- than 6 months and the appearance of fatty degeneration
face of the acromion flat to protect the origin of the del- and atrophy of the subscapularis muscle as detected by
toid. One anatomic study found that the average MRI. The authors recommended repair of the subscapu-
thickness of the acromion was 7 mm. Therefore, removal laris before 6 months of symptoms to maximize func-
of large amounts of bone, as had been previously rec- tional outcome.
ommended, could potentially compromise the acromion
and deltoid origin. Complications
The rate of complications after rotator cuff repair is low
Results of Treatment in most series. Potential complications include stiffness,
Rotator cuff repair has historically been a reliable op- infection, deltoid dehiscence after open repair, failure of
tion for pain relief over time. This finding has been sub- repair, and less commonly, neurovascular injury. Al-
stantiated by two long-term follow-up studies. In a re- though the incidence of infection is low after rotator
cent study, results of a large number of patients treated cuff repair, recently one organism, Propionibacterium
with open cuff repair, V-Y plasty, tendon transposition, acnes, has gained attention as a frequent cause of infec-
and reinforcement with fascia lata were reported. Tear tion in the shoulder. This is a low virulence organism
size was the most important determinant of outcome that was found in the few infections in a large series of
with regard to active motion, strength, rating of the re- mini-open rotator cuff repairs.
sult, patient satisfaction, and need for another opera- Another complication that has become increasingly
tion. Another recent study reported over 90% good to recognized is anterior-superior instability in the shoul-
excellent results in a prospective series of patients after der associated with massive, irreparable cuff tears. This
open cuff repair on the shoulder. These patients were complication results from a combination of rotator cuff
studied longitudinally over a 10-year period. Outcome insufficiency, disruption of the coracoacromial arch, and
at 10 years had not deteriorated from the 2-year results, anterior deltoid dehiscence. Anterior-superior instability
demonstrating the longevity of results after rotator cuff usually is an iatrogenic complication after open cuff re-
repair. pair and subacromial decompression where the deltoid
One recent study showed 46 of 48 good to excellent and rotator cuff repair have failed (Figure 1). Clinically,
results after arthroscopic repair of medium to large full- it is recognized by proximal and anterior migration of
thickness rotator cuff repairs. Forty-four of 45 patients the humeral head to the subcutaneous position and obli-
were satisfied with the results. Another study reported gates extension of the shoulder with attempted over-
on the results of arthroscopic rotator cuff repair of large head elevation. This condition occurs because the intact
and massive chronic tears. Despite a high rate of satis- posterior and lateral deltoid exert a superior vector on
faction and significantly improved functional outcome, the humerus, with no rotator cuff or coracoacromial
ultrasonographic analysis revealed 17 of 18 patients had arch to keep the head contained. Surgical attempts at
recurrent tears. These results suggest that success in coracoacromial arch reconstruction and muscle transfers
terms of functional outcome and pain relief may not for treatment of this problem have met with unpredict-
correlate with anatomic healing of the rotator cuff. In a able results and limited success.
patient and an intact subscapularis. Inferior results are Glenohumeral Joint Arthritis
reported for patients with concurrent subscapularis Etiology
tears. The deltoid must also be intact and functioning Glenohumeral joint arthritis results from multiple dif-
well. A muscle transfer is a major reconstructive proce- ferent etiologies, including primary osteoarthritis, the
dure with a long period of rehabilitation, and should synovial-based arthroses such as rheumatoid arthritis,
only be considered as a salvage operation for patients osteonecrosis, posttraumatic arthritis, malunion or non-
willing and able to undergo the operation and comply union of the proximal humerus, rotator cuff arthropathy,
with the rehabilitative program. and arthritis associated with instability or surgery for in-
stability. The etiology of shoulder arthritis is important
Role of the Biceps Tendon because each of these entities is associated with certain
The role of the long head of the biceps tendon contin- characteristics that impact the technique and/or out-
ues to generate interest and controversy. Its exact func- come of the surgery.
tion, if any, in the shoulder is a subject of debate with Primary osteoarthritis is associated with osteophyte
both cadaveric and clinical studies that support several formation and posterior glenoid wear. Posterior wear
differing viewpoints. Nevertheless, the long head of the can make glenoid implantation very challenging and at
biceps tendon is an increasingly recognized source of times can even preclude glenoid insertion. One solution
pain in the shoulder in conjunction with rotator cuff pa- to this problem is bone grafting the glenoid with inter-
thology. The synovial lining of the glenohumeral joint is nally fixed corticocancellous bone. A recent report on
continuous with the tenosynovium of the proximal bi- this procedure in 21 shoulders with an average correc-
ceps so any inflammatory process involving the joint can tion of 33 demonstrated that this is a technically de-
affect the biceps tendon as well. manding procedure with failure in eight patients. Rheu-
The biceps tendon should be carefully inspected dur- matoid arthritis, on the other hand, can be associated
ing any rotator cuff repair to rule out any concurrent pa- with osteophyte formation but more typically presents
thology. This evaluation is generally performed as part of with central wear of the glenoid, osteopenia, bone ero-
the arthroscopic assessment.The portion of the biceps ten- sions, and subchondral cyst formation.
don from the intertubercular groove should be pulled into Arthritis secondary to previous instability surgery is
the joint for inspection as well. Lesions of the tendon can thought to arise because of an imbalance in the soft tis-
include inflammation of the tendon, tearing, or instability sues surrounding the shoulder. This condition most often
relative to the intertubercular groove. Instability is always occurs after older instability procedures that involved
associated with subscapularis tears or tears of the rotator transfer or imbrication of the subscapularis have been
interval. In some circumstances, the tendon may have al- done, leaving the shoulder extremely deficient in exter-
ready ruptured. This condition is more common in con- nal rotation. These shoulders also have large osteophyte
junction with larger tears. formation and preferential posterior glenoid wear. The
Minor fraying involving only a minimal amount of soft-tissue contractures and scarring about the shoulder
the tendon proper can be dbrided; however, a tear in- make the approach and exposure for shoulder arthro-
volving 50% or more of the tendon should be treated plasty extremely difficult. Static posterior subluxation of
with tenotomy or tenodesis. Any instability of the ten- the humeral head has recently been recognized as a pos-
don should also be treated in this fashion. The issue of sible etiology of early glenohumeral arthritis in young
whether to use tenotomy or tenodesis of the long head adults. One recent article discussing a small group of
of the biceps tendon is also a subject of debate. In gen- men (average age, 40 years) with early arthritis found an
eral, tenodesis is indicated in younger patients (younger increase in mean glenoid retroversion and marked static
than 55 years) because of concerns about muscle cramp- posterior subluxation. The condition was unresponsive to
ing and cosmesis. Potential disadvantages are increased surgical treatment, and could indicate a risk for the de-
length of the procedure, possible pain at the tenodesis velopment of glenohumeral arthritis in some patients.
site, and the possibility of an additional incision. Older Arthroplasty after nonunion or malunion of the
patients have done well with simple tenotomy, with little proximal humerus is another very difficult problem to
to no noticeable deformity, but it is important to discuss manage. The outcome is better if the reconstruction
the possibility of either procedure with patients preop- does not involve osteotomy of the tuberosities. There-
eratively. fore, every effort should be made to accommodate the
Recently, biceps tenotomy has been performed as abnormal bony anatomy with a modular prosthesis (Fig-
part of the surgical procedure for massive rotator cuff ure 3). Osteonecrosis is characterized by sclerosis early,
tears. In one series containing the largest number of pa- bone collapse at the later stages, and degenerative
tients treated with tenotomy for rotator cuff tears, teno- changes on both the glenoid and humeral sides at the
tomy was found to be particularly effective for massive last stage. Stiffness is often a prominent characteristic of
tears. arthritis associated with osteonecrosis.
Figure 3 A, A healed proximal humerus fracture has left the surgical neck with a varus malunion. The glenohumeral joint shows evidence of posttraumatic arthritis.
B, A prosthesis has been placed without osteotomy of the surgical neck or greater tuberosity. Modularity of the prosthesis facilitates an attempt to recreate normal anatomy.
Figure 4 A, A hemiarthroplasty was placed for osteoarthritis in this patient, without relief of pain. The head is slightly proud and asymmetric glenoid wear has occurred such that
the center of the glenoid is worn to the base of the coracoid. B, The hemiarthroplasty was converted to a total shoulder arthroplasty. A pegged glenoid component was inserted to
restore joint space and help lateralize the joint line to a more anatomic location.
migration of the humeral component by more than tator cuff arthropathy has historically been discouraged
5 mm in 28% and medial migration by more than 2 mm because of concerns over early loosening. Earlier rec-
in 16%. This migration did adversely affect the outcome ommendations were to oversize the humeral head in
in these patients. Overall, the 8-year survival rate was these shoulders. The technique of humeral head replac-
92% in this population. The issue of bone wear in rheu- ment has evolved, however, and anatomic head sizing is
matoid arthritis remains a critical complication in terms now advised. Overstuffing the joint has been associated
of potential reconstruction. Rheumatoid shoulders tend with painful arthroplasty because of soft-tissue stretch.
to have central wear of the glenoid, which can eventu- This overstuffing also lateralizes the deltoid insertion,
ally preclude implantation of a prosthetic component. compromising its function. Preservation of the coracoac-
Therefore, at this point, the standard of care is to per- romial arch is critical during humeral head replacement
form a total shoulder arthroplasty in a rheumatoid for rotator cuff arthropathy to prevent anterior-superior
shoulder unless severe bone wear already makes this instability. Bipolar components have not demonstrated
impossible. improved results in these cases and are rarely used. Re-
When osteonecrosis is diagnosed at an early stage verse ball and socket prostheses are still under investi-
before the development of degenerative changes on the gation and may hold promise for future use in treating
glenoid, the results of hemiarthroplasty have been con- rotator cuff arthropathy.
sistently favorable. In patients with long-standing dis-
ease with radiographic involvement of the glenoid or in Total Shoulder Arthroplasty
patients in whom cartilage wear is discovered at the Total shoulder arthroplasty is a reliable operation for
time of surgery, total shoulder arthroplasty is recom- pain relief and good function can be anticipated. Re-
mended. cently, a large study reported the results of arthroplasty
Glenoid implantation is generally not recommended for osteoarthritis using a third generation, anatomically
in patients with rotator cuff arthropathy. These shoul- designed shoulder prosthesis. Patients were evaluated
ders are characterized by severe degenerative changes using the age-adjusted Constant score an average of
to the glenohumeral joint, with complete loss of the 30 months postoperatively. The score improved from an
joint space in combination with a massive rotator cuff average of 37 to 97 postoperatively. Good or excellent
tear with subsequent loss of rotator cuff function, result- results were obtained in 77% of patients, and 94% were
ing in proximal migration of the humeral head such that satisfied or very satisfied. Forward elevation was 145.
it articulates with the undersurface of the acromion. Another recent study investigated the effect of rota-
There also is often a slight anterior superior sublux- tor cuff disease on the outcome of total shoulder arthro-
ation. Glenoid implantation during arthroplasty for ro- plasty. Rotator cuff tears are uncommon in patients with
osteoarthritis, occurring in less than 5%. In this series of bone grafting of the defects; these patients may be can-
514 patients, 41 had a partial-thickness tear and 42 had a didates for glenoid component placement after graft
full-thickness tear. Supraspinatus tears did not adversely consolidation.
affect outcome, satisfaction, or mobility. Treatment of
the tears did not change outcome parameters. However, Nonprosthetic Treatment Options for Glenohumeral
shoulders with moderate or severe fatty degeneration of Arthritis The role of arthroscopy in the treatment of
the infraspinatus were associated with poorer results. glenohumeral joint arthritis remains unknown and re-
This study suggests that small tears limited to the su- cent studies of results in the knee joint have made this a
praspinatus do not negatively affect the outcome; how- controversial topic. Nevertheless, there are several re-
ever, more global degenerative changes in the rotator cent reports of small studies of arthroscopic treatment
cuff musculature will. of arthritis in the shoulder suggesting favorable short-
Another prospective study further substantiates the term results. Indications for arthroscopic surgery for ar-
fact that small tears of the supraspinatus do not ad- thritis are ill defined, but generally include younger pa-
versely affect the outcome after total shoulder arthro- tients in whom it is desirable to prolong the need for
plasty. This study was performed to determine the effect prosthetic arthroplasty, and those with concentric wear
of tears, preoperative glenoid bone erosion, and radio- of the glenoid, absence of severe joint contracture, loose
graphic evidence of subluxation of the humeral head on bodies, and minimal if any bone loss. Arthroscopic treat-
the outcome of shoulder arthroplasty. Tears of the su- ment is most useful in alleviating mechanical symptoms
praspinatus tendon did not adversely affect the out- from loose cartilage fragments or interposed soft tissue.
come. Radiographic posterior subluxation of the hu- Contraindications to arthroscopy for the treatment of
meral head was associated with a lower outcome score, arthritis include older patients with global arthritis who
and patients with moderate to severe glenoid erosion are candidates for shoulder arthroplasty, marked poste-
did much better after total shoulder arthroplasty than rior or otherwise nonconcentric wear of the glenoid, se-
humeral head replacement. Based on these data, the use vere joint contracture, and bone loss on the humeral
of a glenoid component is recommended in shoulders side. Other arthroscopic procedures such as microfrac-
with preoperative glenoid erosion. ture arthroplasty and glenoidplasty (burring nonconcen-
Glenohumeral arthritis can occur after surgery for tric wear) have been suggested, but their usefulness has
shoulder instability, and in general occurs more often af- not yet been substantiated in the peer-reviewed litera-
ter nonanatomic repairs where there is excessive short- ture.
ening of the anterior capsule and subscapularis resulting
in severe limitation of external rotation. The reported Soft-Tissue Resurfacing With or Without Hemi-
results for arthroplasty for arthritis of this etiology are arthroplasty Soft-tissue interposition arthroplasty has
not as good as those for primary arthritis. One reason received significant attention in recent years, given the
may be that the patients are in general younger, and complications associated with early glenoid wear and
have higher physical demands and expectations. Two re- the frequency of radiolucencies associated with glenoid
cent studies showed definite improvements in range of implantation. The two most common materials used are
motion and pain relief. However, both studies had rela- fascia lata, both allograft and autograft, and allograft
tively high revision rates and some unsatisfactory re- knee meniscus. One early report of fascia lata interposi-
sults. The survivorship of the components at 10 years tion is promising, with failure in only one patient in
was 61% and is significant because the average age of whom the graft was found to have lost fixation at the
patients undergoing arthroplasty was 46 to 47 years in time of revision surgery. However, the numbers are
both studies. small and follow-up has been short term.
Glenoid component loosening has been recognized More recently, several centers have successfully used
as one of the most common reasons for revision shoul- the lateral knee meniscus as an interposition tissue. The
der arthroplasty surgery. Although radiolucency around rationale for the use of the lateral meniscus is that it is
the glenoid component occurs in a much higher number tissue designed to withstand significant load with weight
of patients than the number that ultimately require revi- bearing under normal physiologic conditions. The lateral
sion for glenoid loosening, the glenoid component re- meniscus is used because it is more discoid in shape and
mains the most likely to fail of the shoulder arthroplasty gives better glenoid coverage. It is secured to the gle-
components. It has been shown in a series of 48 shoul- noid surface in place of a prosthetic component using
ders undergoing glenoid component revision surgery bone anchors in the glenoid in a circumferential fashion.
that satisfactory pain relief was achieved in a much Early results show maintenance of the joint space radio-
higher percentage of patients that had a new glenoid graphically and excellent functional results. Long-term
component inserted than in those who had glenoid com- survival analysis of this construct is still not available.
ponent removal without reimplantation. Patients who The effect of severe posterior glenoid wear is also not
did not have reinsertion of a component underwent clearly delineated at this point, but it may be a relative
contraindication to the use of soft-tissue interposition disturbing the ligaments and deltoid. Care must still be
because of the risk of continued bone loss that may taken not to violate the ligaments with the arthroscopic
make future reconstructive options difficult or impossi- instruments. The surgeon must adequately assess for
ble. complete bone removal. The most commonly missed
The primary indication for soft-tissue interposition bone is located superiorly and posteriorly, and symp-
arthroplasty is young patients with severe arthritis who toms may continue if resection is not thorough.
are candidates for arthroplasty, but have a high likeli-
hood of needing revision surgery in the future because
of their young age. In general, this includes patients in Annotated Bibliography
their 40s and active, higher-demand patients in their
early 50s. There is always a small risk of disease trans- Rotator Cuff Tear
mission with use of allograft material, and recipients Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup
should be made aware of this risk. Although the long- DM, Rowland CM: Surgical repair of chronic rotator
term results of this procedure are still not available and cuff tears. J Bone Joint Surg Am 2001;83:71-77.
the indications are still developing, soft-tissue interposi- This is a prospective long-term study examining the results
tion in the shoulder holds significant promise for the of open surgical repair and acromioplasty of chronic rotator
treatment of arthritis in the young patient. cuff tears. Satisfactory pain relief was obtained in 96 of 105
shoulders. Tear size was the most important determinant of
outcome with regard to active motion, strength, rating of re-
Acromioclavicular Joint Arthritis
sults, patient satisfaction, and need for revision.
Symptomatic acromioclavicular joint arthritis is a clini-
cal rather than a radiographic diagnosis. Examination
findings include tenderness with palpation at the acro- Fenlin JM Jr, Chase JM, Rushton SA, Frieman BG: Tu-
mioclavicular joint and pain with cross-body adduction. beroplasty, creation of an acromiohumeral articulation:
Radiographic changes are extremely common and do A treatment option for massive, irreparable rotator cuff
not correlate with symptomatic pathology that requires repairs. J Shoulder Elbow Surg 2002;11:136-142.
treatment. Nonsurgical treatment of isolated acro- The authors discuss results of tuberoplasty in 20 patients.
mioclavicular joint pain includes nonsteroidal anti- Overall results (improved pain relief and return to daily activ-
inflammatory drugs, rest from inciting activity, and corti- ities) were good.
costeroid injections. If the condition is associated with
rotator cuff pathology, physical therapy may be of bene-
Galatz LM, Griggs S, Cameron BD, Iannotti JP: Pro-
fit. Nonsurgical treatment of at least 3 to 6 months is spective longitudinal analysis of postoperative shoulder
generally recommended before surgical treatment function: A ten-year follow-up study of full-thickness ro-
should be considered. tator cuff tears. J Bone Joint Surg Am 2001;83:1052-
A persistently painful acromioclavicular joint that is 1056.
not responsive to nonsurgical treatment is surgically The authors reported that early results of rotator cuff re-
treated with a distal clavicle resection that can be per- pairs do not deteriorate with time in this prospective longitu-
formed through an open or an arthroscopic approach. If dinal study.
the procedure is performed through an open incision,
care should be taken to repair the acromioclavicular lig-
aments. The superior and posterior acromioclavicular Halder AM, ODriscoll SW, Heers G, et al: Biomechani-
ligaments are the most important for maintaining stabil- cal comparison of effects of supraspinatus tendon de-
ity. Disadvantages of the open approach are that the lig- tachments, tendon defects, and muscle retractions.
aments must be violated and subperiosteally removed J Bone Joint Surg Am 2002;84:780-785.
from the distal clavicle. A portion of the deltoid is also The effects of supraspinatus tendon detachments, tendon
defects, and muscle retraction on in vitro force transmission by
removed from the anterior acromion and clavicle. This
the rotator cuff to the humerus were compared.
removal is of little consequence if appropriately re-
paired, but failure to do so results in significantly com-
promised outcome. Murray TF, Lajtai G, Mileski RM, Snyder SJ: Arthro-
An arthroscopic distal clavicle resection is per- scopic repair of medium to large full-thickness rotator
formed with the arthroscope in the posterior or postero- cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder
lateral portal into the subacromial space. The working Elbow Surg 2002;11:19-24.
instruments are inserted through the rotator interval Forty-eight arthroscopic repairs of medium to large rota-
portal redirected into the subacromial space or through tor cuff tears were evaluated 2 to 6 years after surgery. There
a separate portal to access the acromioclavicular joint. were 35 excellent, 11 good, 2 fair, and no poor results. Only
This approach allows excision of the clavicle without one patient had clinical evidence of failed repair.
Parsons IM, Apreleva M, Fu FH, Woo SL: The effect of Edwards TB, Boulahia A, Kempf J-F, Boileau P, Nemoz
rotator cuff tears on reaction forces at the glenohumeral C, Walch G: The influence of rotator cuff disease on the
joint. J Orthop Res 2002;20:439-446. results of shoulder arthroplasty for primary osteoarthri-
Results from this study of nine cadaveric upper extremi- tis: Results of a multicenter study. J Bone Joint Surg Am
ties indicate that the integrity of the rotator cuff has a signifi- 2002;84:2240-2248.
cant effect on joint reaction forces. Rotator cuff tears are uncommon in primary gleno-
humeral arthritis. This study examined the effect of full-
Pearsall AW IV, Bonsell S, Heitman RJ, Helms CA, Os- thickness tears, partial-thickness tears, and fatty degeneration
bahr D, Speer K: Radiographic findings associated with of the rotator cuff on the outcome. Supraspinatus tears were
symptomatic rotator cuff tears. J Shoulder Elbow Surg not found to influence the postoperative outcome. Addition-
2003;12:122-127. ally, treatment of these tears did not influence outcome pa-
Radiographs of 40 patients with a documented rotator cuff rameters. However, shoulders with severe and moderate fatty
tear were compared with those of asymptomatic age-matched degeneration of the infraspinatus had poorer results.
control patients. Results indicate that radiographs of patients
with rotator cuff tear have greater tuberosity radiographic ab- Godeneche A, Boileau P, Favard L, et al: Prosthetic re-
normalities that are not seen in the asymptomatic patients. placement in the treatment of osteoarthritis of the
shoulder: Early results of 268 cases. J Shoulder Elbow
Postacchini F, Gumina S: Results of surgery after failed Surg 2002;11:11-18.
attempt at repair of irreparable rotator cuff tear. Clin This is a study reporting the results of 268 shoulder arthro-
Orthop 2002;397:332-341. plasties for primary osteoarthritis. Good to excellent results
This is a study of a small number of patients who had an were observed in 77% of patients and there was a 94% satis-
open attempt at rotator cuff repair including deltoid detach- faction rate. Mean active forward elevation was 145 postoper-
ment and acromioplasty. At the time of surgery, the tears were atively. In this study, glenoid radiolucent lines were present in
found to be irreparable. Shoulder function deteriorated in 11 58% of cases and were associated with a less satisfactory re-
patients. The authors recommended against attempted open sult. Patients who underwent biceps tenodesis had better pain
repair of irreparable cuff tears because the functional results relief. Complications occurred in 8.6% of cases.
are generally poor.
Hill JM, Norris TR: Long-term results of total shoulder
Warner JJ, Higgins L, Parsons IM IV, Dowdy P: Diagno- arthroplasty following bone grafting of the glenoid.
sis and treatment of anterosuperior rotator cuff tears. J Bone Joint Surg Am 2001;83:877-883.
J Shoulder Elbow Surg 2001;10:37-46. Bone grafting of the glenoid can restore bone stock in pa-
According to results of this study, repair within 6 months tients with structural defects.
of subscapularis tear may produce a better functional out-
come. Iannotti JP, Norris TR: Influence of preoperative factors
on outcome of shoulder arthroplasty for glenohumeral
Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.
SA, Middleton WD: Natural history of asymptomatic ro- The purpose of this study was to evaluate the influence of
tator cuff tears: A longitudinal analysis of asymptomatic full-thickness rotator cuff tears, preoperative erosion of gle-
tears detected sonographically. J Shoulder Elbow Surg noid bone, radiographic evidence of subluxation of the hu-
2001;10:199-203. meral head, and preoperative range of motion on the outcome
The natural history of asymptomatic rotator cuff tears was shoulder arthroplasty. Repairable full-thickness tears of the
studied over a 5-year period to determine risk of tear progres- supraspinatus tendon did not affect outcome. Shoulders with
sion and development of symptoms. severe or moderate glenoid erosion had better results with to-
tal shoulder arthroplasty than hemiarthroplasty. Based on
Glenohumeral Joint Arthritis these results, it is recommended that a glenoid component be
Antuna SA, Sperling JW, Cofield RH, Rowland CM: inserted in shoulders with glenoid erosion. A repairable tear
Glenoid revision surgery after total shoulder arthro- of the supraspinatus tendon is not a contraindication to the
plasty. J Shoulder Elbow Surg 2001;10:217-224. use of a glenoid component.
Glenoid component revision surgery was performed on
48 shoulders. The indications for surgery were glenoid compo- Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck C,
nent loosening in 29 shoulders, implant failure in 14, and com- Cofield RH: Shoulder arthroplasty for arthritis after in-
ponent malposition or wear leading to instability in 5 shoul- stability surgery. J Bone Joint Surg Am 2002;84:1775-
ders. Satisfactory pain relief was acute in 86% of patients who 1781.
had another glenoid component inserted and in 66% of pa- Arthroplasty was associated with significant pain relief.
tients who underwent glenoid component removal. Patients There was not a significant difference between the hemiar-
who have bone grafting may be candidates for glenoid compo- throplasty and total shoulder arthroplasty groups with regard
nent placement after graft consolidation. to external rotation, abduction, or pain. The survival of the
components at 10 years was 61%. The data from these studies Gerber C, Fuchs B, Hodler J: The results of repair of
suggest that arthroplasty in this particular group of patients is massive tears of the rotator cuff. J Bone Joint Surg Am
associated with good pain relief; however, there were high 2000;82:505-515.
rates of revision surgery and unsatisfactory results because of
component failure instability and glenoid arthritis in the hemi- Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin
arthroplasty group. MC: Fatty muscle degeneration in cuff ruptures: Pre-
and postoperative evaluation by CT scan. Clin Orthop
Trail IA, Nuttall D: The results of shoulder arthroplasty 1994;304:78-83.
in patients with rheumatoid arthritis. J Bone Joint Surg
Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis:
Br 2002;84:1121-1125.
A clinical and radiologic analysis of 105 shoulder arthro- A late complication of the Putti-Platt repair. J Bone
plasties in patients with rheumatoid arthritis was performed. Joint Surg Am 1990;72:1193-1197.
Constant scores and American Shoulder and Elbow Surgeons
Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Will-
scores were improved, and both scores were statistically signif-
icant.
iams GR: Postoperative assessment of shoulder func-
tion: A prospective study of full-thickness rotator cuff
tears. J Shoulder Elbow Surg 1996;5:449-457.
Classic Bibliography
Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES: Op- Neer CS II: Replacement arthroplasty for glenohumeral
erative repair of massive rotator cuff tears: Long term osteoarthritis. J Bone Joint Surg Am 1974;56:1-13.
results. J Shoulder Elbow Surg 1992;1:120-130.
Neer CS II, Watson KC, Stanton FJ: Recent experience
Brenner BC, Ferlic DC, Clayton ML, Dennis DA: Survi- in total shoulder replacement. J Bone Joint Surg Am
vorship of unconstrained total shoulder arthroplasty. 1982;64:319-337.
J Bone Joint Surg Am 1989;71:1289-1296.
Rodosky M, Bigliani L: Indications for glenoid resurfac-
Burkhead WZ Jr, Hutton KS: Biologic resurfacing of ing in shoulder arthroplasty. J Shoulder Elbow Surg
the glenoid with hemiarthroplasty of the shoulder. 1996;5:231-248.
J Shoulder Elbow Surg 1995;4:263-270.
Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD:
Gartsman G, Khan M, Hammerman S: Arthroscopic re- Long-term functional outcome of repair of large and
pair of full-thickness tears of the rotator cuff. J Bone massive chronic tears of the rotator cuff. J Bone Joint
Joint Surg Am 1998;80:832-840. Surg Am 1991;81:991-997.
Gartsman GM, Roddey TS, Hammerman SM: Shoulder Walch G, Boileau P: Prosthetic adaptability: A new con-
arthroplasty with or without resurfacing of the glenoid cept for shoulder arthroplasty. J Shoulder Elbow Surg
in patients who have osteoarthritis. J Bone Joint Surg 1999;8:443-451.
2000;82:26-34.
Distal Humeral Fractures osteotomy provides the best exposure of the distal hu-
Fractures Involving the Metaphyseal Columns of the merus. The authors of this study also report that with at-
tention to detail in the creation and repair of the olecra-
Distal Humerus
non osteotomy the rate of complications and revisions
Fractures of the distal humerus are usually bicolumnar,
specifically to address prominent wires is acceptable.
and most will involve the articular surface. Although of-
The use of two plates in orthogonal planes has be-
ten depicted as Y- or T-shaped fractures with a simple
come well established in the treatment of fractures of
articular split, it is becoming evident that these rela-
the distal humerus. However, there is biomechanical
tively simple fracture patterns are not as common as the
support for the use of parallel plates placed on the di-
more complex metaphyseal and articular fractures. Most
rect medial and lateral aspects of the columns, and this
fractures involve one of the following factors that in-
configuration is often better suited to the treatment of
crease the challenge of surgical treatment: (1) low (dis-
complex fracture patterns. Newer plate designs include
tal) fracture of one or both columns (at the level of the
precontoured shapes and smaller 2.7-mm screws placed
base of the olecranon fossa); (2) metaphyseal fragmen-
distally to facilitate internal fixation.
tation of one or both columns; (3) complex fragmenta-
Total elbow arthroplasty is now an accepted treat-
tion of the articular surface, including entirely or nearly
ment option for older, less active patients with fractures
entirely articular fragments (especially those with a
of the distal humerus. Several studies, including a recent
coronal plane fracture line).
The surgical treatment of fractures of the distal hu- comparative study of arthroplasty and plate and screw
merus remains unsatisfactory in approximately 25% of fixation, document very good early results; however,
patients in most reported series. Some series have re- long-term follow-up is needed because elbow arthro-
ported a greater complication rate in older patients, plasties have a limited life span and eventually wear
probably because of poor bone quality, but perhaps also out. In addition, patients who undergo total elbow ar-
resulting from more difficult injury patterns. On the throplasty require a 5-kg lifting restriction, and patients
other hand, two recent series evaluated the results of who undergo this procedure are more prone to infection
treatment using the Disabilities of the Arm, Shoulder, and other complications than those who undergo total
and Hand outcomes instrument and found reasonably hip or knee arthroplasty. The best candidate for total el-
good restoration of function from the patients perspec- bow arthroplasty is an older, infirm, and inactive patient
tive. with a fracture of the distal humerus, or a patient with a
Olecranon osteotomy for exposure of fractures of fracture of the distal humerus with an elbow joint that is
the distal humerus has waned in popularity primarily already compromised by rheumatoid arthritis.
because of problems related to the wires or screws used
to repair the osteotomy. Alternative exposures com- Fractures Involving Primarily the Articular Surface
monly in use include the recently introduced triceps- The discussion of fractures involving primarily the artic-
reflecting anconeus pedicle modification of the triceps ular surface of the distal humerus is often limited to
elevating exposure of Bryan and Morrey; the traditional fractures of the capitellum. It is now known that iso-
Campbell exposure (midline triceps split), with addi- lated fractures of the capitellum are uncommon. An ap-
tional elevation of the triceps off of the proximal ulna; parent fracture of the capitellum nearly always extends
and the reintroduced Allonso-Llamas exposure (in into the lateral trochlear lip (the so-called coronal shear
which the triceps is elevated off of the back of the hu- fracture) and may also involve a fracture of the lateral
merus, but its insertion onto the olecranon is preserved). epicondyle, impaction of the posterior aspect of the lat-
However, a recent cadaver study showed that olecranon eral column, fracture of the posterior aspect of the tro-
Figure 1 Illustration of the lateral lip of the trochlea (1), lateral epicondyle (2), poste-
rior aspect of the lateral column (3), posterior trochlea (4), and medial epicondyle (5).
Apparent fractures of the capitellum usually involve region 1, and injuries with greater
complexity can involve fractures in regions 2 through 5. ( Copyright D. Ring, MD &
J.B. Jupiter, MD.)
align the anterior fracture fragments. The articular frag- fractures (type 2), and complete head fractures (type 3).
ments are secured with countersunk screws (screws with There are few data in the literature to support any sub-
threads on the head, such as Herbert screws, can be classification based on the size or displacement of par-
used), small threaded Kirschner wires, or screws enter- tial head fractures. Several important factors are not ac-
ing from the nonarticular parts of the distal humerus, counted for in this classification system, and they are
such as the posterior aspect of the lateral column. The only partially accounted for in the more recent compre-
lateral epicondyle is secured with a tension band wire to hensive classification of fractures, including: (1) the
incorporate the common extensor fascia; a screw or a number of fracture fragments; (2) lost or unrecoverable
plate is also used if the fragment is large enough. articular fragments; (3) central impaction and deforma-
Ideally, active-assisted exercises and use of the arm tion of the radial head; (4) the quality of the fracture
for light daily activities are started the day after surgical fragments (amount of subchondral bone, osteoporosis);
fixation of a fracture of the distal humerus. However, if and (5) metaphyseal comminution. These factors all will
the fracture is complex or the bone quality is poor and have a substantial impact on attempts at surgical repair
the fixation is therefore not optimal, it may be prefera- of a radial head fracture. In particular, a recent study
ble to immobilize the elbow for 4 weeks before initiat- suggested that patients with fractures of the entire ra-
ing exercises. A healed stiff elbow will be easier to sal- dial head that create more than three articular frag-
vage than a nonhealed elbow, particularly in patients ments have high rates of early failure, nonunion, and
with complex fractures. poor forearm rotation after surgical fixation.
Excision of a complex fracture of the radial head
without prosthetic replacement is still a viable treatment
Radial Head Fractures option. To do this safely, surgeons must make sure that
Isolated radial head fractures usually involve part of the
there is no forearm ligament injury by using the recently
radial head and heal well with nonsurgical treatment.
described radius pull test and ensure that there is no
Sometimes they are displaced enough to block forearm fracture of the coronoid (terrible triad). Although it is
rotation and benefit from surgical treatment. The most usually preferable to treat an elbow fracture-dislocation
important complication of isolated partial radial head with either repair or replacement of the radial head,
fractures is elbow stiffness, and the most important as- reasonable results have been reported after radial head
pect of treatment is mobilization of the elbow. resection as long as the coronoid is not also fractured.
As documented in two recent case series, nonsurgi- Excision of the radial head without prosthetic replace-
cally treated minimally displaced fractures of the radial ment is considered primarily in older patients with lim-
neck will occasionally fail to heal. The prevalence of ited demands and simple injury patterns.
nonunion is obscured for several reasons: (1) nonunion Partial excision of the radial head has traditionally
of the radial head is usually asymptomatic; (2) radio- been associated with less optimal results. Even a small
graphs are rarely obtained until union in the treatment portion of the radial head can be important to stability
of patients with this type of fracture; and (3) a fracture of the forearm or elbow. In the setting of an unstable
of the radial head that is unhealed 1 year after the in- fracture-dislocation of the forearm or elbow, if a partial
jury may still eventually heal 2 years or longer after the radial head fracture has inadequate fragments for re-
injury. pair, it may be preferable to proceed with prosthetic re-
Fractures of the radial headparticularly complex placement.
fractures involving the entire head and neckare often Surgical repair should be used only for patients with
associated with one of the following five injury types: simple fractures with three or fewer fragments with
(1) an Essex-Lopresti fracture-dislocation of the fore- good quality bone and little or no impaction. The im-
arm or a variant thereof; (2) rupture of the medial col- plants must be placed directly laterally, with the arm in
lateral ligament complex; (3) dislocation of the elbow; neutral rotation to avoid impingement on the ulna with
(4) dislocation of the elbow with fractures of the radial forearm rotation. Another rough guide for placement is
head and coronoid processthe so-called terrible triad provided by the arc defined by the radial styloid and
of the elbow; and (5) an olecranon fracture-disloca- Listers tubercle. Implants placed on the articular sur-
tionusually with an apex posterior fracture of the face of the radial head must be countersunk beneath the
proximal ulna or olecranon (the so-called posterior articular surface.
Monteggia lesion). In each type, the associated fractures Several metal radial head prostheses are in common
and ligament injuries may compromise forearm or el- use. Two studies support the use of a loose-stemmed
bow instability, thereby increasing the importance of the metal prosthesis that acts as a stiff spacer, and another
radial head. study supports the use of a bipolar prosthesis that is ce-
Although the classification system of Mason is still mented into the neck of the radius. Surgeons should be
used, it is often modified. The Mason classification dis- careful not to place a prosthesis that is too long or wide
tinguished nondisplaced fractures (type 1), partial head and always err toward using a slightly smaller prosthesis
bilization, are prone to dislocation after surgical treat- simple olecranon fractures, and good results have been
ment (particularly if radiocapitellar contact is not re- reported; however, 20% of patients had a second sur-
stored), and can have a high prevalence of unsatisfactory gery for plate removal. Furthermore, it may not be wise
treatment results. Because of the poor results associated to rely on screws to secure a small osteopenic proximal
with the treatment of this type of fracture, many surgeons fragment. The long-term results of successful surgical re-
are routinely repairing the coronoid fracture, usually pair of olecranon fractures are good.
with suture placed through drill holes in the ulna.
Fractures of the anteromedial facet of the coronoid Diaphyseal Forearm Fractures
process are usually associated with injury to the lateral Mechanics
collateral ligament complex and can be difficult to man- Several recent studies have examined the impact of rota-
age. These have been labeled posteromedial varus rota- tional malalignment of the radius and ulna on forearm ro-
tional instability pattern injuries. This type of fracture is tation. These studies consistently show that rotational
repaired with a plate and screws through a medial expo- malalignment of the ulna has less impact on forearm ro-
sure between the two heads of the flexor carpi ulnaris tation than radius malrotation. In both the radius and the
(where the ulnar nerve usually sits), more anteriorly ulna, forearm motion was not impacted unless there was
through a split in the flexor pronator mass, or both. substantial malalignment (at least 30 malrotation)an
Large coronoid fractures are nearly always associ- amount of malalignment that is unlikely to occur in the
ated with an olecranon fracture-dislocation. These frac- management of patients. Prior studies have shown a more
tures typically involve multiple fragments, particularly substantial impact with even minor angular malalign-
when part of a posterior olecranon fracture-dislocation. ments of the radius and ulna, particularly loss of the nor-
They can be accessed and manipulated through the ole- mal radial bow.
cranon fracture itself and fixed with a dorsal plate and A biomechanical study of dynamic compression plates
screws with or without an additional medial plate. The applied to transverse diaphyseal osteotomies of the radius
results of treatment of anterior transolecranon fracture- showed that even relatively small plates could achieve a
dislocations have been quite good, whereas the treat- bending stiffness comparable to that of the intact bone
ment of posterior olecranon fracture-dislocations has and that longer plates with bicortical screws at the ends of
been associated with a greater number of complications the plates had better torsional stiffness. This is consistent
and revisions and diminished results. Patients with large with the findings of previous studies and emphasizes the
fractures with complex comminution or poor bone advantages of longer plates and bicortical screws in a set-
quality may occasionally benefit from protection with ting with substantial torsional stresses such as the forearm.
hinged external fixation. These advantages may be even more pronounced in pa-
tients with comminuted fractures.
Olecranon Fractures
The Mayo classification of olecranon fractures charac- Ulnar Fractures
terizes fractures based on the three most important fac- Two recently published meta-analyses of the treatment
tors in treatment considerations: comminution, displace- of isolated fractures of the ulnar diaphysis (the so-called
ment, and fracture-dislocation. nightstick fracture) identified only retrospective case se-
There is wide variation regarding the treatment of ries and therefore could not make definitive recommen-
olecranon fractures. A biomechanical study found that a dations regarding treatment. Fractures with greater than
large screw was best for internal fixation of olecranon 50% of displacement or 10 of angulation can impact
fractures, but reported that the stability was insufficient forearm rotation. Because surgical treatment of these
to allow active elbow exercises. Conversely, internal fix- fractures is straightforward, it is recommended that sur-
ation of olecranon osteotomies and fractures with small geons have a low threshold for surgical treatment for
caliber wires with immediate active mobilization has displaced fractures. For less displaced fractures, nonsur-
been shown to be very successful in practice, at least gical treatmenteven simple symptomatic treatment
when specific techniques are used. will usually result in union with good function, but the
The major disadvantage of tension band wiring con- time to complete healing can be quite prolonged. There-
tinues to be a high rate of subsequent surgical proce- fore, surgical treatment is also a reasonable option for
dures for removal of symptomatic prominent hardware, motivated patients with less displaced fractures.
which has been reported in one long-term study as rang- Diaphyseal ulnar fractures with anterior or lateral
ing between 43% and 81% (depending on technique); dislocation of the proximal radioulnar joint (anterior or
however, in another study, it was reported to be only lateral Monteggia lesions) are uncommon in adults.
13% when specific techniques intended to limit the Plate and screw fixation of the ulna in anatomic align-
prominence of the wires were used. Plates are becoming ment usually restores good function. Open reduction of
a more popular treatment option for fixation of even the proximal radioulnar and radiocapitellar joints is
Radial Fractures
Although textbooks describe isolated fractures of the
ulnar diaphysis without proximal or distal radioulnar Figure 6 Preoperative radiograph of a patient with a radial diaphysis fracture. Many
joint injury (nightstick fractures), isolated radial frac- such fractures do not have associated injury to the distal radioulnar joint and can be
tures are often omitted, with classification systems skip- managed with early mobilization after plate fixation. Preoperative radiographic align-
ment and location of the radius fracture can be helpful, but surgeons should always
ping directly to Galeazzi fractures (fracture of radial di- base treatment decisions on a careful evaluation of the distal radioulnar joint after
aphysis and dislocation of the distal radioulnar joint). A plate fixation. ( Copyright D. Ring, MD & J.B. Jupiter, MD.)
recent article suggests that isolated fractures of the dia-
physeal radius are unlikely to be associated with major
injury to the distal radioulnar joint (triangular fibrocar- Annotated Bibliography
tilage complex) when the ulnar fracture is greater than Distal Humeral Fractures
7.5 cm from the radiocarpal joint. It may be unwise to Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey
be complacent about the distal radioulnar joint based MB, Sanders RW: A comparison of open reduction and
on the location of the fracture, but what this study sup- internal fixation and primary total elbow arthroplasty in
ports is the idea that many isolated fractures of the ra- the treatment of intraarticular distal humerus fractures
dius occur without major radioulnar ligament injury in women older than age 65. J Orthop Trauma 2003;17:
(Figure 6). After stable anatomic fixation of the radius, 473-480.
the distal radioulnar joint should be evaluated and com- The authors of this study retrospectively reviewed 24 pa-
pared with a preoperative examination of the opposite, tients older than 65 years with bicondylar (C2 or C3) fractures
uninjured side. In the absence of substantial instability, of the distal humerus that were treated with either total elbow
immediate active mobilization may be safe and worth- arthroplasty (12 patients) or plate and screw fixation (12 pa-
while. If the distal radioulnar joint is unstable there are tients). At a short-term follow-up of between 2 and 6 years
several treatment options: (1) repair of a large ulnar sty- (average just under 4 years), the functional results were some-
loid fracture if present; (2) repair of the triangular fibro- what better in the total elbow arthroplasty than the internal
cartilage complex; (3) immobilization of the forearm in fixation group, with an average arc of flexion of 113 versus
midsupination; and (4) cross-pinning of the radius and 100 and an average Mayo Elbow Performance Index of 95
the ulna in midsupination. versus 88 points, respectively.
Pajarinen J, Bjorkenheim JM: Operative treatment of tures is desirable: A prospective randomised study of
type C intercondylar fractures of the distal humerus: two protocols. Injury 2002;33:801-806.
Results after a mean follow-up of 2 years in a series of In this study, 60 patients with minimally displaced frac-
18 patients. J Shoulder Elbow Surg 2002;11:48-52. tures of the radial head were prospectively randomized to un-
In this study, 8 of 18 patients (all of whom were older than dergo either immediate active mobilization or 5 days of splint
50 years) had an unsatisfactory result after plate and screw fix- immobilization. All patients achieved excellent results. Pa-
ation of a bicolumnar fracture of the distal humerus. Poor tients treated with immediate mobilization had less pain and
bone quality and open fracture were also associated with infe- better elbow function at 1 week. There were no adverse conse-
rior results. quences of immediate mobilization.
Ring D, Jupiter JB, Gulotta L: Articular fractures of the Moro JK, Werier J, MacDermid JC, Patterson SD, King
distal part of the humerus. J Bone Joint Surg Am 2003; GJ: Arthroplasty with a metal radial head for unrecon-
85:232-238. structible fractures of the radial head. J Bone Joint Surg
In this study, 21 patients with apparent fractures of the Am 2001;83:1201-1211.
capitellum had more complex fractures of the articular surface In this study, 25 patients with metal radial head prostheses
of the distal humerus. The authors report that fixation with were evaluated an average of 39 months after injury. The aver-
buried screws and wires achieved healing with slight settling of age flexion arc was 132, the average forearm arc was 146, the
the fracture fragments in two patients and no major osteone- average disabilities of the arm, shoulder, and hand score was
crosis. Ten patients required a second surgical procedure, and 17, and the average Mayo Elbow Performance Index score
five patients had an unsatisfactory functional result related to was 80. There were eight unsatisfactory results related to asso-
persistent elbow stiffness. ciated injuries, psychiatric problems, and secondary gain.
Asymptomatic lucencies around the stem were the rule be-
Ring D, Gulotta L, Chin K, Jupiter JB: Olecranon os- cause the implant functions as a spacer and is not intended to
teotomy for exposure of fractures and nonunions of the have a tight fit in the radial neck.
distal humerus. J Orthop Trauma 2004;18:446-449.
In this study, 45 patients had an apex distal chevron- Pomianowski S, Morrey BF, Neale PG, Park MJ,
shaped olecranon osteotomy repaired with Kirschner wires di- ODriscoll SW, An KN: Contribution of monoblock and
rected out the anterior ulnar cortex distal to the coronoid pro- bipolar radial head prostheses to valgus stability of the
cess, and bent 180 and impacted into the olecranon elbow. J Bone Joint Surg Am 2001;83-A:1829-1834.
proximally with two 22-gauge figure-of-8 stainless steel ten- In this study, three metal radial head prostheses were
sion wires. The only failure occurred in a patient who returned shown to restore valgus stability in the medial collateral liga-
to athletic activities too soon. Only six patients (13%) had a ment deficient elbow close to the status with an intact radial
subsequent surgical procedure performed specifically to re- head.
move the wires.
Ring D, Psychoyios VN, Chin KR, Jupiter JB: Nonunion
Schildhauer TA, Nork SE, Mills WJ, Henley MB: Exten- of nonoperatively treated fractures of the radial head.
sor mechanism-sparing paratricipital posterior approach Clin Orthop 2002;398:235-238.
to the distal humerus. J Orthop Trauma 2003;17:374-378. The authors of this study describe five patients with a ra-
Extra-articular fractures (Opthopaedic Trauma Associa- dial neck nonunion after a minimally displaced radial head
tion [OTA] type A) and simple articular distal humeral frac- fracture. These fractures are usually asymptomatic.
tures with simple or multifragmentary metaphyseal involve-
ment (OTA type C1 and C2) were treated by elevating the
triceps off of the back of the humerus and working through
Ring D, Quintero J, Jupiter JB: Open reduction and in-
the medial and lateral paratricipital windows (an exposure de-
ternal fixation of fractures of the radial head. J Bone
scribed previously by Allonso-Llamas).
Joint Surg Am 2002;84:1811-1815.
In this study, 56 patients in whom an intra-articular frac-
ture of the radial head had been treated with open reduction
Wilkinson JM, Stanley D: Posterior surgical approaches and internal fixation were evaluated at an average of 48
to the elbow: A comparative anatomic study. J Shoulder months after injury. The authors report that good results were
Elbow Surg 2001;10:380-382. obtained in all of the patients with isolated partial radial head
In this study, the median-exposed articular surface for tri- fractures, in 4 of 15 of those with partial radial head fractures
ceps splitting, triceps reflecting, and olecranon osteotomy ap- that were part of a complex injury to the elbow or forearm,
proaches was 35%, 46%, and 57%, respectively. and in 11 of 12 of those with fracture of the entire head into
two or three large fragments. Among patients with fracture of
Radial Head Fractures the entire head into greater than three fragments, 13 of 14 had
Liow RY, Cregan A, Nanda R, Montgomery RJ: Early an unsatisfactory result, with three early failures and six non-
mobilisation for minimally displaced radial head frac- unions.
Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch the arm (a mainstay of effective treatment and not associated
DS: Radius pull test: Predictor of longitudinal forearm with major problems in prior clinical series).
instability. J Bone Joint Surg Am 2002;84:1970-1976.
In this sequential cutting study in cadavers, the authors Karlsson MK, Hasserius R, Besjakov J, Karlsson C, Jo-
showed that after radial head resection 3 mm of proximal ra- sefsson PO: Comparison of tension-band and figure-of-
dial migration with longitudinal traction indicated disruption eight wiring techniques for treatment of olecranon frac-
of the interosseous membrane and migration of 6 mm or tures. J Shoulder Elbow Surg 2002;11:377-382.
greater indicated gross longitudinal instability with disruption In a long-term study of olecranon fractures, one subset of
of all ligamentous structures of the forearm. patients was treated with tension band wiring and the other
was treated with a simple figure-of-8 wire. The authors report
Elbow Dislocations that the results were comparable for both groups, with a high
McKee MD, Schemitsch EH, Sala MJ, ODriscoll SW: rate of hardware removal occurring in both groups after ten-
The pathoanatomy of lateral ligamentous disruption in sion band wiring (81% of patients) and after figure-of-8 wiring
complex elbow instability. J Shoulder Elbow Surg 2003; (43%).
12:391-396.
Six patterns of injury to the lateral collateral ligament in-
Karlsson MK, Hasserius R, Karlsson C, Besjakov J, Jo-
jury were observed in 62 patients with a surgically treated dis-
sefsson PO: Fractures of the olecranon: A 15- to 25-year
location or fracture-dislocation of the elbow (proximal avul-
followup of 73 patients. Clin Orthop 2002;403:205-212.
sions in 32, bony avulsions of the lateral epicondyle in 5,
In a long-term follow-up of 70 patients who were treated
midsubstance ruptures in 18, ulnar detachments of the lateral
for olecranon fractures, the authors report excellent or good
collateral ligament in 3, ulnar bony avulsions in 1, and com-
results in 96%, slight loss of elbow flexion and extension and
bined patterns in 3). The common extensor origin was also
mild or moderate degenerative changes in over 50%. The au-
ruptured in 41 patients (66%).
thors conclude that adequately treated fractures of the olecra-
non have a favorable long-term outcome.
Coronoid Fractures
Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of
Diaphyseal Forearm Fractures
the elbow with fractures of the radial head and coro-
Dumont CE, Thalmann R, Macy JC: The effect of rota-
noid. J Bone Joint Surg Am 2002;84-A:547-551.
The authors of this article describe 7 of 11 terrible triad el-
tional malunion of the radius and the ulna on supination
bows that redislocated in a splint after manipulative reduction. and pronation. J Bone Joint Surg Br 2002;84:1070-1074.
In this cadaver study, the authors report that substantial
Five patients, including four who were treated with resection
rotational malalignment of the radius and/or ulna was neces-
of the radial head, experienced redislocation after surgical
sary before forearm rotation was affected.
treatment. Only four patients reported satisfactory results, all
of whom had retained the radial head and two of whom had
lateral collateral ligament repair. The subsequent letters to the Handoll HH, Pearce PK: Interventions for isolated
editor adds additional perspective to the current concepts re- diaphyseal fractures of the ulna in adults. Cochrane
garding the treatment of these injuries. Database Syst Rev 2004;2:CD000523.
A review of trials was performed to determine the effects
Olecranon Fractures of different treatment methods (in adults) for isolated frac-
tures of the ulnar shaft. The authors concluded that there was
Bailey CS, MacDermid J, Patterson SD, King GJ: Out-
insufficient evidence from randomized trials to determine the
come of plate fixation of olecranon fractures. J Orthop
most appropriate treatment method.
Trauma 2001;15:542-548.
Near normal motion, strength, and disabilities of the arm,
shoulder, and hand scores were observed after plate fixation Hertel R, Eijer H, Meisser A, Hauke C, Perren SM: Bio-
of 25 displaced olecranon fractures. The authors report that mechanical and biological considerations relating to the
20% of patients requested plate removal. clinical use of the Point Contact-Fixator: Evaluation of
the device handling test in the treatment of diaphyseal
Hutchinson DT, Horwitz DS, Ha G, Thomas CW, Ba- fractures of the radius and/or ulna. Injury 2001;32(suppl
chus KN: Cyclic loading of olecranon fracture fixation 2):B10-B14.
In this study of 83 diaphyseal forearm fractures in 52 pa-
constructs. J Bone Joint Surg Am 2003;85:831-837.
As might be expected based on the size of the implants tients that were repaired using a Point Contact-Fixator (Syn-
alone, a large screw limits displacement of an olecranon os- thes, Paoli, PA), 76 bones healed with callus without further
teotomy better than Kirschner wires with a tension band wire intervention. Stripping of the hexagonal slot was reported to
in biomechanical tests in cadavers. Unfortunately, the authors be a problem at removal of the implant.
of this study interpreted their data as disproving the tension
band concept (a basic engineering principle that cannot be dis- Kasten P, Krefft M, Hesselbach J, Weinberg AM: How
proved) and as discouraging immediate active mobilization of does torsional deformity of the radial shaft influence the
rotation of the forearm? A biomechanical study. J Or- Chapman MW, Gordon JE, Zissimos AG: Compression
thop Trauma 2003;17:57-60. plate fixation of acute fractures of the diaphysis of the
The authors of this study report that significant loss of radius and ulna. J Bone Joint Surg Am 1989;71:159-169.
forearm rotation was not observed until a minimum of 30 of
rotational malunion. Josefsson PO, Gentz CF, Johnell O, Wendeberg: Disloca-
tions of the elbow and intraarticular fractures. Clin Or-
Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A thop 1989;246:126-130.
new treatment-oriented classification. J Hand Surg Am
Mason ML: Some observations on fractures of the head
2001;26:228-235.
In this review of 40 patients with Galeazzi fracture- of the radius with a review of one hundred cases. Br J
dislocations, the authors suggest that more proximal fractures Surg 1959;42:123-132.
are less likely to have distal radioulnar joint instability. Among
McKee MD, Wilson TL, Winston L, Schemitsch EH, Ri-
22 fractures in the distal third of the radius (within 7.5 cm of
chards RR: Functional outcome following surgical treat-
the radiocarpal joint), 12 had intraoperative distal radioulnar
joint instability. Among 18 more proximal fractures, only one
ment of intra-articular distal humeral fractures through
had intraoperative distal radioulnar joint instability after plat- a posterior approach. J Bone Joint Surg Am 2000;82:
ing of the radius. 1701-1707.
Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss Ring D, Jupiter JB, Simpson NS: Monteggia fractures in
RN: Prosthetic radial head components and proximal adults. J Bone Joint Surg Am 1998;80:1733-1744.
radial morphology: A mismatch. J Shoulder Elbow Surg
Schemitsch EH, Richards RR: The effect of malunion
1999;8:471-475.
on functional outcome after plate fixation of fractures
Broberg MA, Morrey BF: Results of treatment of of both bones of the forearm in adults. J Bone Joint Surg
fracture-dislocations of the elbow. Clin Orthop 1987;216: Am 1992;74:1068-1078.
109-119.
Elbow arthroscopy can be performed in either the su- cisely. Distending the elbow with saline before making
pine, prone, or lateral decubitus position. the initial starting portal and inflating the tourniquet is
The lateral decubitus position is fairly easy to main- extremely helpful. With the elbow joint distended, the
tain and is probably the most popularly used position. major neurovascular structures are positioned further
At the time of surgery, the ulnar nerve is palpated to be from the starting portal and entry into the joint is also
sure of its location and to check that it does not sublux- easier.
ate from the cubital fossa. It is best to mark all portal Once the arthroscope has been successfully placed
sites before surgery when the elbow is not distended into the joint, visualization can be maintained by either
and palpation of bony landmarks can be done more pre- pressure distention of the capsule or by retraction. Pres-
Figure 3 Portals marked with a surgical pen prior to beginning arthroscopy. A long Figure 4 Arthroscopic view of coronoid as viewed from the anterolateral portal.
dotted line represents the area of the ulnar nerve. The retractor is placed between
anteromedial portals.
sure distention works quite well but will eventually lead An anteromedial portal may be placed before the
to significant fluid extravasation during a long arthro- anterolateral portal based on the surgeons preference.
scopic procedure.The use of retractors is an alternative to The anteromedial portal is placed 2 cm distal and 2 cm
pressure distention. Retractors for elbow arthroscopy are anterior to the medial epicondyle. This will penetrate
simple lever-type retractors such as a Howarth or a large the common flexor origin and the brachialis. The medial
blunt Steinmann pin. Retractors are placed into the elbow antebrachiocutaneous nerve is at risk with its portal, of-
joint via accessory portals, which are typically 2 to 3 cm ten only several millimeters from the starting position.
proximal to the standard arthroscopic viewing portals. The posterolateral portal is an excellent initial view-
By holding the capsule away from the joint, retractors al- ing portal for the posterior aspect of the elbow. Unlike
low adequate visualization with a low-pressure inflow sys- the anterior portals, where palpation of the median or
tem. radial nerve is not possible, establishment of posterior
portals should be a safe undertaking once the ulnar
nerve is palpated and identified. The posterolateral por-
Portal Placement
tal is made lateral and level with the tip of the olecra-
Safe initial portal entry can be made either from the me-
non with the elbow flexed 90. The trocar should be
dial or lateral side of the elbow depending on the prefer-
aimed at the center of the olecranon fossa. Viewing is
ence of the surgeon (Figure 3). The anterolateral portal is
often difficult initially posteriorly, because the fat pad
often the initial portal placed and is usually placed just an-
normally occupies a large portion of the potential joint
terior to the sulcus between the capitellum and radial
space. The direct posterior portal is a good initial work-
head. This is an easily located anatomic area to find in
ing portal. Through this portal loose bodies and osteo-
most patients.The radial nerve is in close proximity to this phytes in the entire olecranon fossa can be removed
portal. Once the arthroscope has been placed into the while viewing from a posterolateral portal. This portal is
joint from the anterolateral portal, the surgeon should be established 2 cm proximal to the tip of the olecranon at
able to visualize the trochlea, coronoid process, coronoid the proximal margin of the olecranon fossa. After creat-
fossa, and the medial aspect of the radial head (Figure 4). ing this portal, a shaver can be placed into the joint and
After it has been confirmed that the arthroscope is in the dbridement performed. The arthroscope and shaver
elbow joint, then an anteromedial working portal can be can be switched back and forth between the direct and
established. This maneuver is easiest to perform from an the posterolateral portal to enable efficient completion
inside-out approach.The arthroscope is removed from the of posterior dbridement.
sheath and a blunt trocar placed back in and then gently
pushed straight across the joint. With gentle pushing and Arthroscopic Treatment of Degenerative Arthritis
rotation, the tip of the trocar will begin tenting the skin on Degenerative arthritis is accompanied by osteophyte for-
the medial side of the elbow. The skin is then incised over mation and capsular contraction. In addition to removal
the tip of the trocar and the sheath pushed out of the skin. of loose bodies, the surgeon should be prepared to remove
A working cannula can then be placed over the tip of the all impinging osteophytes and to release a potentially
sheath and pushed back into the joint. tight, thickened capsule. It is the rare patient who has an
isolated loose body, perhaps after an osteochondral injury. Knowledge of the static and dynamic constraints of
After initial joint inspection and removal of all obvious the elbow is helpful in understanding the progression of
loose bodies, bony work should commence. A shaver or acute elbow instability. The three primary static con-
burr can be used to remove osteophytes from the radial straints are the ulnohumeral articulation, anterior band
and coronoid fossae of the humerus and the tip of the of the medial collateral ligament (MCL), and the lateral
coronoid can be excised. The medial coronoid should also ulnocollateral ligament (LUCL). The secondary con-
be examined for osteophytes, which may be missed if not straints include the radiocapitellar articulation, common
positively identified. It is helpful to perform most of the flexor and extensor origins, and the capsule. The flexor
bony work using a burr before completion of the capsulec- and extensor muscle groups across the elbow play a ma-
tomy because neurovascular structures are better pro- jor role in creating dynamic instability and in producing
tected and visualization is improved before muscle or soft compressive forces at the elbow joint. Particularly, the
tissue impedes the arthroscopic view. Once the osteo- anconeus, because of its origin in the lateral epicondyle
phytes have been excised, the anterior capsule can be re- and broad insertion on the ulna, is designed to function
moved. It is often helpful to take the capsule off the hu- as a dynamic stabilizer against posterolateral rotatory
merus as a first step. Care should be taken when excising instability. An elbow will remain stable if the three pri-
capsule just anterior to the radial head. The radial nerve mary constraints are intact. If the MCL is disrupted, the
is at great risk of injury at this location. Often a small fat radial head and coronoid become more critical for sta-
pad can be visualized in this area, the radial nerve being bility. If the coronoid is fractured, the radial head be-
just anterior. comes the prime stabilizer and must be reconstructed or
replaced. Likewise, if the radial head is fractured, stabil-
Complications ity will be difficult to achieve if the coronoid fracture re-
Complications that can arise from elbow arthroscopy in- mains unrepaired.
clude compartment syndrome, septic arthritis, and nerve
injury. In a report of 473 elbow arthroscopies, there Posterolateral Rotatory Dislocation
were four types of minor complications in 50 proce- A simple elbow dislocation is usually the result of poste-
dures, including infection, nerve injury, prolonged drain- rolateral rotatory instability. This injury pattern occurs
age, and contracture. The most common complication during a valgus moment to the elbow with simultaneous
was persistent portal drainage. Neurologic complications forearm supination. Progressively the radial head and
were limited to transient nerve palsy. The rate of perma- coronoid rotate under the capitellum and dislocation oc-
nent neurologic injury appears to be higher in the elbow curs. The disruption of the soft tissues begins laterally
than in the knee or shoulder. The risk of nerve injury is and progresses to the medial side of the elbow (Figure
higher in patients with rheumatoid arthritis or in those 5). This progressive disruption occurs in a circle pattern
undergoing a capsular release. Significant nerve injury simultaneously anteriorly and posteriorly and has been
during elbow arthroscopy has been reported involving referred to as the Horii circle and is analogous to the
the radial, median, and ulnar nerves. The use of retrac- Mayfield circle of progressive carpal instability.
tors is probably the most important factor in preventing
nerve injury. In some instances, arthroscopic identifica- Varus Posteromedial Rotatory Dislocation
tion of nerves will allow for safer capsulectomy. Similar to posterolateral rotatory instability, varus pos-
teromedial rotary dislocation also occurs during axial
Instability loading of the elbow during flexion. A varus moment
Pathophysiology occurs with internal rotation of the forearm resulting in
Interest in elbow instability has increased over the past a fracture of the anteromedial coronoid with disruption
several years as more has been learned about the patho- of the LUCL. Unlike posterolateral rotatory instability,
anatomy of elbow dislocation. There are essentially where dislocation can occur without a fracture, the key
three patterns of acute elbow instability: (1) posterolat- to varus posteromedial rotatory dislocation is an antero-
eral rotatory, (2) valgus, and (3) varus posteromedial ro- medial coronoid fracture (Figure 6).
tatory instability. Posterolateral rotatory instability is the
most common mechanism of acute instability and can Recurrent Valgus Instability
progress from a simple dislocation to a complex Valgus instability can occur as an acute event or after
fracture-dislocation (terrible triad). Valgus instability oc- chronic valgus overload. This condition involves a dis-
curs most commonly as a chronic overload problem, tinctly different pattern of instability as compared with
particularly in throwers. Varus posteromedial rotatory posterolateral rotatory instability. As an acute event it
instability has recently been recognized as a significant results in rupture of the MCL from a pure valgus load
pattern of instability, usually associated with a medial to the elbow. As the injury occurs, the force is transmit-
coronoid fracture. ted from medial to lateral, potentially resulting in radial
Figure 6 A, CT scan showing varus posteromedial rotatory instability. The comminuted fracture of the coronoid and collapse pattern is best seen on the three-dimensional
reconstruction (B).
head fracture. If in this situation the radial head is ex- Posterolateral Rotatory Instability
cised, the elbow is at significant risk of remaining per- Recurrent instability following simple dislocation of the
manently unstable in valgus. This injury pattern does not elbow involves posterolateral rotatory instability in al-
typically result in an acute dislocation. Acute rupture of most every case. The essential lesion is detachment or
the MCL may occur as a catastrophic terminal event in attenuation of the LUCL. Although both the MCL and
high-demand overhead throwing athletes but is usually LUCL are usually disrupted, the LUCL is at risk of not
the result of a chronic valgus overload. healing because of repetitive varus stresses applied to
Figure 8 Comminuted radial head fracture. Pieces of the radial head have been removed (A). The shaft of the radius is then reamed and the end of the fracture is planed to a
level position. The radial head implant is then ready for placement (B).
the elbow, caused by the force of gravity when the tionally been performed. This viewpoint has begun to
shoulder is abducted. The typical patient has a history of change as newer prostheses have been developed and as
recurrent painful snapping or locking of the elbow. A greater awareness occurs of the accelerated degenera-
careful history would demonstrate that symptoms occur tive process that can occur at the ulnohumeral joint af-
during extension arc of motion with the forearm in supi- ter radial head excision even with an initially stable
nation. Examination for posterolateral rotatory instabil- MCL. In long-term studies in which patients were exam-
ity is best performed with the patient supine and the af- ined after radial head excision, a high percentage of pa-
fected extremity overhead (Figure 7). tients developed significant radiographic ulnohumeral
arthrosis. Additionally, radial head excision may cause
Radial Head Replacement decreased grip strength, wrist pain, and progressive val-
Radial head replacement is indicated for comminuted gus instability.
fractures of the radial head associated with elbow insta-
bility (Figure 8). Routine replacement of comminuted Elbow Contractures
radial head fractures without associated MCL disrup- Most elbow contractures are mild and usually well toler-
tion or interosseous membrane disruption has not tradi- ated. The functional range of motion has been defined
as between 30 full extension to 130 flexion. Mild loss The medial over-the-top release allows decompres-
of terminal extension is usually well tolerated, but there sion to the ulnar nerve in patients with preoperative ul-
are certain exceptions. Basketball players with loss of nar nerve symptoms. The lateral approach has been
extension typically report that the contracture affects popularized in several studies; this type of release is par-
their jump shot; loss of extension affects gymnasts as ticularly advantageous in the treatment of patients with-
well. Primary loss of flexion is usually not well tolerated out preoperative ulnar nerve symptoms. In this ap-
because it often affects the ability to perform common proach, the origin of the extensor digitorum communis
activities of daily life. and extensor carpi radialis brevis is elevated to expose
The pathogenesis of elbow contractures is poorly un- the joint capsule. The joint capsule is then excised. The
derstood. Patients with an injured elbow typically will posterior compartment is slightly more difficult to ap-
hold the extremity in a flexed position, which minimizes proach from the lateral side. It is important to approach
the intra-articular pressure from a joint effusion. A fi- the posterior compartment by subperiosteally elevating
brous tissue response occurs as a result of periarticular the triceps and working proximal to distal. The key is to
muscular and capsular tearing. The capsule hypertro- approach the olecranon fossa proximally and avoid dis-
phies to a thick contracted structure (normal capsules section and involvement of the lateral ulnohumeral
are transparent and thin). There are severe intrinsic and complex. The olecranon fossa is dbrided, and the tip is
extrinsic factors involved in an elbow contracture. In- excised.
trinsic factors include joint incongruity, loose bodies, The risk of recurrent heterotopic ossification is low,
synovitis, articular surface ankylosis, and capsular con- but some patients may be candidates for postoperative
tracture, all of which may be amenable to treatment radiation. Although there is significant evidence in the
with arthroscopic elbow contracture release. Extrinsic literature to support the use of postoperative radiation
factors include heterotopic bone formation, myositis os- in patients with acetabular fractures who have under-
sification, collateral ligament contracture, and muscle gone hip replacement, its use in patients with hetero-
contractures, all of which are more amenable to treat- topic ossification of the elbow remains undefined.
ment with open elbow contracture release. In many pa- One study recently reported the results of 20 pa-
tients, intrinsic and extrinsic factors coexist. tients with complete ankylosis of the elbow caused by
Heterotopic ossification has been shown to occur in heterotopic bone formation who underwent surgical re-
3% of patients with elbow dislocations. It has been doc- lease without severe injury to the central nervous sys-
umented that the incidence of heterotopic ossification tem. In this series, the average arc of ulnar humeral mo-
increases to 20% in patients with an elbow dislocation tion was 81 in patients with burns and 94 in patients
associated with a fracture. Heterotopic ossification oc- with ankylosis secondary to trauma. Six of 11 limbs in
curs in 5% of patients with isolated neuraxis trauma and the burn group and 5 of 9 patients in the trauma group
increases dramatically to 75% to 86% when brain injury had good results. The authors concluded that surgeons
is associated with elbow trauma. An increased incidence should be aware of the small risk of recurrent hetero-
of heterotopic ossification has also been shown to occur topic ossification, mild pain, and recurrent contracture
in patients with thermal injuries. after surgical release. However, they believed the proce-
Patients with less than 40 of extension or 105 of dure was effective and safe.
flexion are candidates for elbow contracture release.
The ulnar nerve is particularly vulnerable to injury and Techniques of Elbow Reconstruction
scarring. In patients with preoperative ulnar nerve Rheumatoid arthritis, posttraumatic arthritis, and os-
symptoms and loss of marked flexion of the elbow, neu- teoarthritis are the three major types of arthritis that af-
rolysis and transposition of the ulnar nerve should be fect the elbow. Pain is the primary complaint of patients
considered. with these disorders, although some may also experi-
The traditional timing of release was to wait at least ence stiffness, weakness, and potentially instability. Sev-
1 year after the initial injury. Other previous recommen- eral treatment options are available, depending on the
dations included waiting until bone scans became cold type and stage of arthritic changes.
and nonreactive and to follow serial alkaline phos-
phatase levels until a normal range was reached. How- Synovectomy
ever, in reality, patients rarely gain motion after Rheumatoid arthritis is the most frequent type of arthri-
6 months, with the exception of pediatric patients. Dur- tis that affects the elbow joint. Four stages of rheumatic
ing this time, the soft-tissue contractures continue to disease of the elbow have been described based on ra-
mature. New recommendations have been made that diographic and pathologic criteria. In stage I rheumatic
suggest elbow contracture release be considered after disease, synovitis is present, but a normal joint surface
6 months when patients have no significant improve- has been maintained. In stage II, mild to moderate syno-
ment from physical therapy. vitis is present and evidence of joint space narrowing is
seen on radiographs, but the joint contour is still main- decreased pain. One patient developed a synovial fis-
tained. In stage III, mild to moderate synovitis and mild sula, two patients required repeat synovectomy, and one
to moderate alteration of the joint surface are typically patient required a total elbow arthroplasty.
present, and there is loss of joint space. In stage IV, me-
chanical instability with bone on bone articulation and Outerbridge-Kashiwagi (Ulnohumeral) Arthroplasty
complete joint space destruction is evident on radio- In patients with primary degenerative arthritis or post-
graphs. traumatic degenerative arthritis who have pain on ter-
When conservative measures fail to relieve symp- minal flexion and extension, the traditional procedure
toms, arthroscopic or open synovectomy is frequently has been the Outerbridge-Kashiwagi (ulnohumeral) ar-
recommended. The role of radial head excision with throplasty. This procedure may be performed open or
synovectomy, however, remains controversial. Good arthroscopically. In the open procedure, an incision is
pain relief and preservation of motion have been re- made 3 cm proximal to the tip of the olecranon with
ported with arthroscopic and open synovectomy. splitting of the triceps. The tip of the olecranon is ex-
The commonly described approaches for open syn- cised, and a foramenectomy in the distal humerus can
ovectomy include extended lateral approach, mediolat- then be made using a 4.5-mm drill bit and then enlarged
eral approach, and transolecranon approach. A total with a burr. Care must be taken not to involve the me-
synovectomy may be performed using the extended lat- dial and lateral columns of the elbow.
eral approach with radial head excision. The proximal This procedure is done arthroscopically through a tro-
ulna is displaced medially for adequate medial compart- car, and a 4.5-mm drill bit is used to create a foramina in
ment synovectomy when this approach is selected. the center of the olecranon fossa. Once the initial foram-
Arthroscopy allows a complete synovectomy to be ina has been made with the drill, it is then enlarged by an
done without the need for large capsular incisions, arthroscopic burr inserted in the posterior central portal.
which are required for any open approach. The arthro- In one report of 12 patients, all had relief of pain and lock-
scope with a blunt trocar is introduced into the anterior ing at follow-up of 3 to 30 months. A similar experience
compartment after it is inflated with approximately
was reported in 21 patients who underwent dbridement
20 mL of sterile lactated Ringers solution. A proximal
and removal of loose bodies in both anterior and poste-
anterolateral portal is made using either the inside-out
rior compartments. In this group, the average follow-up
or outside-in technique. The view offered by the more
was 3 years, and 84% noted satisfactory outcomes.
proximal portals allows excellent visualization of both
the medial and lateral anterior compartments of the el-
bow. The goal is to excise the excessive synovitis, taking
Interposition Arthroplasty
care not to aggressively cut through the anterior cap- Patients with posttraumatic arthritis may present with
sule. The arthroscope and shaver will need to be stiffness, pain, or a combination of both. Traditionally,
switched between the portals to gain good access for the total joint arthroplasty has not provided favorable expe-
synovectomy. Once the synovium has been resected, the rience in the management of patients with posttrau-
radiocapitellar articulation is evaluated. If there is sig- matic arthritis. In younger patients with posttraumatic
nificant involvement of the radial head, then radial head arthritis, an interposition arthroplasty is the treatment
excision may be required. A synovectomy of the poste- of choice. If this procedure is performed, the elbow is
rior compartment is then performed. often protected with an external fixator, which decom-
Open synovectomy of the elbow is an accepted pro- presses the joint to decentralize motion while the tissues
cedure with good results. The published results on this are healing.
remain consistent. Pain relief is regularly seen in 80% to
90% of patients at 3- to 5-year follow-up. Although re- Arthrodesis
currence of synovitis is common at 10- to 20-year The functional use of the hand depends on the elbow. It
follow-up, approximately two thirds of patients were has been show that approximately 50% loss of elbow
satisfied with the results of the procedure. Range of mo- motion results in an 80% loss of function to the upper
tion will improve in approximately 40% of patients, de- extremity. Additionally, elbow flexion is usually not well
crease somewhat in approximately 15%, and the re- tolerated. Arthrodesis of the elbow is not compatible
mainder will be unchanged. Arthroscopic synovectomy with satisfactory function because range of motion of
is a highly demanding procedure. One study of 14 ar- the elbow is essential for use of the hand. There is no
throscopic synovectomies revealed an early success rate single ideal position for arthrodesis. Indications for ar-
of 95%. However, at 3-year follow-up, approximately throdesis include the presence of intractable sepsis and
60% of patients reported satisfaction with the results. in patients for whom there is no possibility of total el-
One study reported on 46 elbows that underwent ar- bow reconstruction. Because arthrodesis is primarily a
throscopic synovectomy for the treatment of inflamma- salvage procedure, its use in young men who perform
tory arthritis. All 46 elbows had improved motion and heavy labor is controversial.
Figure 10 AP (A) and lateral (B) radiographs of a 68-year-old woman with rheumatoid arthritis and elbow trauma with bone deformity and ligament instability. C, AP radiograph
after a linked total elbow implant was inserted. The decision to link the elbow was made because of the bone deformity and ligament instability.
identification and protection of the nerve without for- Warsaw, IN), with 91% excellent or good results re-
mal transposition. ported at 4-year follow-up.
A Bryan-Morrey approach is typically used for a In another study, 26 patients underwent either a
linked arthroplasty. The triceps is elevated from medial linked or unlinked total elbow arthroplasty; all proce-
to lateral off the olecranon in continuity with the anco- dures were performed by a single surgeon. The authors
neus muscle. Before this approach is attempted, the ul- reported that no significant differences were found in
nar nerve should be well identified and protected. A functional performance or progressive radiolucent loos-
long periosteal strip of the triceps off of the olecranon ening and concluded that, when properly performed, to-
and proximal ulna is made, creating a continuous exten- tal elbow arthroplasty with either type of prosthesis
sor mechanism sling. The triceps tendon with the long yielded satisfactory results.
periosteal sleeve is then reattached with sutures through Recently, linked elbow arthroplasty has been recom-
mended for the treatment of elderly patients with se-
multiple drill holes in the olecranon.
verely comminuted intra-articular fractures of the distal
There are numerous published reports of unlinked
humerus. Additionally, elbow arthroplasty has been rec-
elbow arthroplasties. Pain relief and restoration by func-
ommended for distal humeral nonunions (Figure 11).
tional arc of motion have been reported in more than
Under certain conditions, it is standard practice to ex-
90% of patients. The designers of this implant report ex- cise humeral condyles during insertion of the linked to-
cellent results in patients with rheumatoid arthritis, with tal elbow prosthesis. One study recently reviewed the
only a 1.5% incidence of postoperative dislocation and results of condylar resection on forearm, wrist, and hand
a low incidence of aseptic loosening. strength in 32 patients who underwent total elbow ar-
The success of linked total elbow arthroplasty has throplasty. The normal contralateral limb served as the
also been well documented. A series of 58 modified control, and strength values were given as a percentage
Coonrad semiconstrained total elbow arthroplasties fol- of the normal side. The humeral condyles were intact in
lowed for 3.8 years postoperatively yielded a 91% excel- 16 patients and had been resected in the other 16 pa-
lent or good result, with 84% of patients having no pain. tients. The authors found no significant difference be-
Similar results were reported with the use of a semicon- tween the two groups with regard to strength of prona-
strained prosthesis (GSB III Elbow System, Zimmer, tion and supination, wrist extension, or grip strength.
Techniques of Elbow Reconstruction Jones GS, Savoie FH: Arthroscopic capsular release of
King GJ: New frontiers in elbow reconstruction: Total flexion contractures (arthrofibrosis) of the elbow.
elbow arthroplasty. Instr Course Lect 2002;51:43-51. Arthroscopy 1993;9:277-283.
This article reviews the literature comparing linked and
unlinked total elbow arthroplasty and the relative indications King GJ, Morrey BF, An K-N: Stabilizers of the elbow.
for each type of prosthesis. J Shoulder Elbow Surg 1993;2:165-174.
Ring D, Jupiter JB: Fracture-dislocation of the elbow. Thal R: Arthritis, in Savoie FH, Field LD (eds): Arthros-
J Bone Joint Surg Am 1998;80:566-580. copy of the Elbow. New York, NY, Churchill Livingstone
1996, pp 103-116.
Ross G, McDevitt ER, Chronister R, Ove PN: Treat-
ment of simple elbow dislocation using an immediate Tulp NJ, Winia WP: Synovectomy of the elbow in rheu-
motion protocol. Am J Sports Med 1999;27:308-311. matoid arthritis: Long term results. J Bone Joint Surg Br
1989;71:664-666.
Rymaszewski L, Glass K, Parikh R: Post-traumatic el-
bow contracture treated by arthrolysis and continued Vasen AP, Lacey SH, Keith MW, et al: Functional range
passive motion under brachial plexus anesthesia. J Bone of motion of the elbow. J Hand Surg Am 1995;20:288-
Joint Surg Br 1996;76:S30. 291.
Rymaszewski LA, Mackay I, Amis AA, Miller JH: Wright TW, Wong AM, Jaffe R: Functional outcome
Long-term effects of excision of the radial head in rheu- comparison of semiconstrained and unconstrained total
matoid arthritis. J Bone Joint Surg Br 1984;66:109-113.
elbow arthroplasties. J Shoulder Elbow Surg
Savoie FH III, Nunley PD, Field LD: Arthroscopic man- 2000;9:524-531.
agement of the arthritic elbow: Indications, technique,
and results. J Shoulder Elbow Surg 1999;8:214-219.
Distal Radius Fractures the risk of injury to the sensory branch of the radial
Distal radius fractures are the most common ortho- nerve and the radial artery with percutaneous pinning
paedic fractures. These fractures are associated with os- through the snuffbox. Limited incisions or protective
teoporosis in the elderly and high-energy trauma in devices such as angiocatheters can be used to protect
younger patients. Successful treatment outcomes are the distal radial sensory nerve branches from injury. Ex-
correlated with accuracy of articular reduction, restora- ternal fixation should be used in unstable fractures to
tion of normal anatomic relationships, and early efforts provide distraction at the fracture site and prevent col-
at regaining motion in the fingers and wrist. lapse and loss of reduction over time. External fixation
The mechanism of injury is most commonly an axial relies on ligamentotaxis to maintain a reduction, but ex-
load through the hand and wrist. Useful imaging studies cessive traction across the wrist ligaments leads to stiff-
include AP, lateral, and oblique radiographs, arthro- ness and can precipitate complex regional pain syn-
gram, CT, and MRI. Reconstructed CT studies are help- drome. Clinical range of motion of the fingers
ful in planning for articular reduction of die-punch le- intraoperatively along with radiographic evaluation of
sions, and MRI studies identify associated soft-tissue joint distraction can help avoid overdistraction. The ad-
injuries in complex fractures such as to the triangular fi- dition of two Kirschner wires to facilitate external fixa-
brocartilage complex (TFCC) and scapholunate, and the tion has been shown to increase stability of the fracture
lunotriquetral ligaments. with digital and forearm motion, in some patterns ap-
Several classification systems describe fracture pat- proaching a 3.5-mm AO plating technique. Bicolumnar
terns. Restoration of radial height (average, 13 mm), plating uses orthogonal plates, which provide greater
volar tilt (average, 11), radial inclination (average, 23), stability with smaller lower profile plates. This paper-
and articular surface are associated with good outcomes clip system of plating uses several small incisions to ap-
(Figure 1). In extra-articular fractures, radial shortening proach the radial, dorsal, and ulnar columns of the distal
is associated with the greatest loss of wrist function and radius and place plates at 90 to each other. Multiple in-
incidence of wrist degenerative changes, including cisions and increased technical difficulty are disadvan-
changes to the TFCC. Intra-articular fractures with tages to this system. Dorsal plating has historically been
greater than 1 mm of articular incongruity are also asso- associated with extensor tendon irritation, plate promi-
ciated with early radiocarpal degenerative changes. nence, and tendon rupture. Newer systems have been
developed using lower profile plates with recessed screw
Extra-articular Distal Radius Fractures heads but there is still a low incidence of tendon irrita-
Extra-articular fractures with minimal displacement can tion and synovitis. Recently, volar plates that are similar
be treated nonsurgically with closed reduction and in concept to a blade plate have been introduced. These
splinting or casting with the wrist in a neutral position. more rigid plates with locking screw or peg constructs
Studies have shown increased carpal tunnel pressures have been designed to support the subchondral bone at
associated with increasing wrist flexion and extension the articular surface, and even the dorsal articular sur-
positions, and extreme flexion or extension should be face if necessary.
avoided when immobilizing wrist fractures. Closed re-
duction and percutaneous pinning relies on either in- Intra-articular Distal Radius Fractures
trafocal manipulation and pinning or manual traction, Indications for surgical treatment of intra-articular frac-
reduction, and pinning to hold the fracture in appropri- tures are based on patient age and activity level and in-
ate anatomic alignment. A percutaneous or limited inci- clude articular step-off and gap greater than 2 mm, ob-
sion technique is involved. Anatomic studies confirm lique volar fractures, die-punch fractures, significant
Figure 1 A, Normal anatomy of the distal radius on lateral radiograph. Volar or palmar tilt is 11 to 12. B, Normal anatomy of the distal radius on AP radiograph. Radial
inclination is 22 to 23 and radial height between the tip of the radial styloid and the ulnar border of the radius is 11 to 13. (Reproduced with permission from Jafarnia K,
Jupiter J. Distal radius fracture: Anatomy, biomechanics and classification, in Trumble T (ed): Hand Surgery Update 3. Rosemont, IL, American Society for Surgery of the Hand,
2003, p 84.)
dorsal comminution involving more than one third the Distal Ulna Injuries
anteroposterior diameter of the radius, and fractures When distal radius fractures are displaced more than 1
that lose reduction in the first weeks after injury. Treat- cm, ulnar-sided injuries such as TFCC tears or ulnar sty-
ment options are similar to those for extra-articular loid fractures are the rule. Concomitant assessment of
fractures. Closed reduction and percutaneous fixation, the stability of the DRUJ is key to deciding when to re-
external fixation, plating using orthogonal plating, and pair distal ulna fractures or ligamentous injuries. The ul-
dorsal or volar plating have been described to restore nar styloid is devoid of ligamentous attachments, but the
articular and cortical alignment and relationships. Ar- fovea at the base of the styloid is where the ulnar-sided
throscopy has been used to assess and improve these ligaments of the TFCC attach. Nondisplaced fractures
described treatment options. A study of 34 intra- proximal to the ulnar styloid can be treated with cast
articular fractures revealed improved clinical outcomes immobilization. Displaced fractures or bony avulsions of
with arthroscopically-assisted reduction compared with the ligamentous structures in the face of a grossly unsta-
classic open reduction and internal fixation of these ble DRUJ should be repaired. An unstable DRUJ can
fractures. Complex fractures may benefit from bone be defined as an ulnar head that subluxates its full width
grafting at the time of surgery. Autograft, allograft, and out of the sigmoid notch with the forearm in a neutral
synthetic grafts all are available, as well as bone cement, position.
which can provide temporary structural support before In patients with complex elbow injuries, wrist radio-
being absorbed. graphs should be obtained and a careful clinical exami-
At the time of definitive treatment, assessment of nation of the wrist should be performed. In an Essex-
distal radioulnar joint (DRUJ) function is critical to as- Lopresti injury pattern, radial head pathology is coupled
certain adequate pronation and supination without un- with an interosseous membrane injury extending to the
due instability. Complications associated with distal ra- DRUJ, creating an unstable relationship between the ra-
dius fractures include malunion, nonunion, extensor dius and ulna. Proximal migration of the radius results
pollicis longus rupture, and early degenerative changes. in secondary DRUJ pathology and ulnocarpal abut-
Reconstructive options will be discussed in detail in ment. Following appropriate treatment of the bony pa-
chapter 30. thology (radial head, shaft fracture), pinning the DRUJ
Carpal Fractures
The scaphoid is the most commonly fractured carpal
bone. More than half of the bone is covered by articular
cartilage. The dorsal surface of the scaphoid has a non-
articular ridge where the dorsal carpal branch of the ra- Figure 3 Methods of fixation for unstable distal ulna fractures. (Courtesy of Thomas
dial artery enters and provides blood supply to the Trumble, MD.)
proximal pole and 80% of the scaphoid. The superficial
volar branch of the radial artery supplies the remainder
of the blood supply to the scaphoid. The usual mecha- lique 45 view with the hand in pronation. Even with
nism of injury is an axial load across a hyperextended, normal radiographs, a high level of clinical suspicion
ulnarly deviated wrist. Pain with resisted pronation, should lead to immobilization in a thumb spica splint or
snuffbox tenderness, and scaphoid tuberosity tenderness cast and reevaluation in 14 to 21 days. Repeat films af-
should raise the suspicion of a scaphoid fracture. Radio- ter 14 to 21 days can reveal an occult scaphoid fracture.
graphs should include an AP, lateral, and PA view of the Bone scans have an 85% to 93% positive predictive
scaphoid with the hand in ulnar deviation, and an ob- value at 72 hours after injury and have been used when
Figure 5 Palmar classification of TFCC injuries. Class 1A injuries involve the horizontal or central portion of the TFCC disk and are treated nonsurgically or with dbridement.
Class 1B tears represent an avulsion of the peripheral portion of the TFCC from the insertion on the distal ulna. Class 1C tears involve disruption of the ulnocarpal ligaments
creating an avulsion of the TFCC from its carpal attachment. Class 1D tears are an avulsion of the TFCC from its radial attachment. (Courtesy of Thomas Trumble, MD.)
Figure 6 A and B, Transscaphoid perilunate carpal dislocation. Note the widened scapholunate interval suggesting a scapholunate ligament tear. (Courtesy of the University of
California, San Francisco, CA.)
carpal instability with a dorsiflexed lunate and a volar- Tenderness directly over the scapholunate ligament can
flexed scaphoid, frequently caused by a disruption of be expected and a positive scaphoid shift test (Watson
the scapholunate ligament (Figure 8). Volar intercalated test) is helpful but must be compared with the contralat-
segment instability (VISI) describes the opposite defor- eral side to confirm true ligamentous laxity (Figure 9).
mity with a volar-flexed lunate, frequently caused by Radiographic diastasis of the scapholunate joint
disruption of the lunotriquetral ligament. The abnormal greater than 2 mm is associated with a complete tear, al-
distribution of forces across the midcarpal and radiocar- though the reliability of this measurement on plain ra-
pal joints leads to pain, weakness, and early degenera- diographs has been questioned and contralateral com-
tive changes. SLAC describes a scenario in which the parison views are essential. Neutral PA, clenched fist
chronic dissociation between the scaphoid and lunate AP, true lateral, ulnar deviation PA, and fully flexed lat-
results in wear, sclerosis, and a degenerative arthritis ini- eral radiographs provide helpful information. Important
tially involving the radioscaphoid and capitolunate radiographic findings include a scapholunate angle
joints (Table 1). greater than 70, dorsal flexion of the lunate greater
Careful clinical and radiographic examination is im- than 15 on a neutral lateral radiograph, and the
portant. Common symptoms include difficulty bearing scaphoid ring sign in which the flexed distal pole of the
loads across the wrist, symptomatic dysfunction, and ab- scaphoid projects a ring pattern at the distal scaphoid
normal kinematics through the full range of motion. on the AP projection. MRI studies show poor sensitivity
DISI, dorsal intercalated segment instability; SLAC, scapholunate advanced collapse; SL, scapholunate; RL, radiolunate; SLIL, scapholunate interosseous ligament; DJD, degenerative joint disease;
CL, capitolunate; RS, radioscaphoid; ST, scaphotrapezium
Phalangeal Fractures
Phalangeal fractures may have significant angulation re-
sulting from the opposing pull of intrinsic and extrinsic
tendons across fracture sites. Intrinsic structures insert
relatively proximally and function as flexors. Extrinsic
structures insert relatively distally and function as ex-
tensors. Phalangeal fractures consequently tend toward Figure 9 Watsons scaphoid shift test. The thumb is placed on the volar scaphoid
tuberosity and pressure applied while moving the hand from ulnar to radial deviation.
apex-volar angulation. Closed reduction is best accom- The scaphoid will move from extension in ulnar deviation to flexion in radial deviation.
plished by flexion of the distal fragment to match the Palmar pressure on the scaphoid tubercle prevents scaphoid flexion and will produce
volar angulation of the proximal fragment. Stable closed dorsal subluxation of the scaphoid in a patient with a torn or lax scapholunate liga-
ment producing a painful snap. (Reproduced with permission from Watson HK, Weinz-
reduction may be limited by these forces, and internal weig J: Intercarpal arthrodesis, in Green DP, Hotchkiss RN, Pederson WC (eds):
fixation with Kirschner wires or plating may be more re- Greens Operative Hand Surgery. Philadelphia, PA, Churchill Livingstone, 1993, p 115.)
liable in ensuring acceptable bony alignment. Distal
phalanx tuft fractures frequently involve the nail bed,
and suture repair of the nail bed may be sufficient to re- usually results in a stable, pain-free digit over time.
duce the bony fragments and allow a bony or fibrous Flexor digitorum profundus-avulsion fractures can be
union. Alternatively, longitudinal pin fixation may be treated with open reduction and repaired over a button
used. Fibrous union of comminuted distal tuft fractures or with suture anchors. Volar fractures of the base of the
Figure 10 A, Intra-articular condylar fracture of the middle phalanx with 2 mm of displacement. B, Limited open reduction and screw fixation of intra-articular condyle fracture.
Intra-articular Fractures
Proximal interphalangeal (PIP) joint fracture-
dislocations result from axial loading of the PIP joint in
hyperextension and are difficult to treat. Volar lip frac-
tures involving less than 30% of the articular surface are
treated in extension blocking splints to maintain a con-
gruent joint reduction while gradually increasing mo-
tion. The articular contour is less important than pre-
Figure 11 Scissoring of the fingers after index and middle metacarpal fractures pre- served range of motion in these fractures. Fractures
vents the patient from making a composite fist.
involving more than 30% of the joint surface frequently
are unstable and difficult to control. Fixation options in-
distal phalanx should be pinned or they will displace clude volar plate arthroplasty, open reduction, external
with the pull of the flexor on the fragment. fixation, or dynamic traction (Figure 13). Use of osteo-
chondral grafts from sources such as the distal dorsal
Thumb Fractures hamate bone has been described.
Fractures of the base of the thumb metacarpal require
anatomic reduction and fixation as needed to maintain Ligament Injuries of the Hand
the reduction. Nondisplaced intra-articular fractures can PIP joint injuries represent the most common ligamen-
be treated in a thumb spica cast for 4 weeks. Bennetts tous injuries in the hand. These range from jamming
fracture-dislocations of the metacarpal from a bony the finger to irreducible dislocations and fracture-
fragment attached to the volar beak ligament are usu- dislocations. Dorsal dislocations are most common and
ally unstable from the pull of the abductor pollicis lon- varying degrees of volar plate, collateral, and accessory
gus on the metacarpal base (Figure 12). The reduction collateral ligaments are torn with the injury. The volar
maneuver is traction, pronation, and ulnar pressure over plate, soft tissues, and fracture fragments can be inter-
the base of the metacarpal. Kirschner wires can be posed between joint surfaces, preventing a concentric
placed across the fracture, into the adjacent index reduction. Stable motion is the goal; dynamic traction,
metacarpal, or from the thumb metacarpal into the tra- extension blocking splints or pins, open reduction, and
Gamekeepers Thumb
Ulnar collateral ligament (UCL) injury in the thumb
MCP joint is known as gamekeepers thumb or skiers
thumb. The mechanism of acute injury is a radially di-
rected force to the flexed MCP joint of the thumb. Test-
ing the thumb in 30 of flexion isolates the proper col-
lateral ligament, whereas positioning the thumb in Figure 13 Diagram of Eatons method of volar plate arthroplasty using suture or wire
extension tests the volar plate and accessory collateral through the volar plate and a trough in the distal insertion site tied over a button. VP =
volar plate. (Reproduced with permission from Glickel SZ, Barron OA, Eaton RG: Dislo-
ligament. The lack of a defined end point or 30 of laxity cations and ligament injuries in the digits, in Green DP, Hotchkiss RN, Pederson WC
greater than the contralateral thumb in both extension (eds): Greens Operative Hand Surgery. Philadelphia, PA, Churchill Livingstone, 1993, p
778.)
and flexion suggests a complete tear of the ligament.
Anatomy
In the forearm, the flexor digitorum profundus muscle
Figure 14 Radiographic views of a physeal gamekeepers avulsion fracture. Failure of and musculotendinous structures are dorsal to the flexor
the physis occurs before failure of the collateral ligament.
digitorum superficialis. This relationship persists in the
hand where the flexor digitorum superficialis tendon
crosses the palm volar to the flexor digitorum profun-
UCL avulsions can be associated with a small bony frag- dus. At the level of the A1 pulley, flexor digitorum su-
ment, which usually involves minimal articular surface. perficialis divides and moves dorsal to the flexor digi-
Distal tears are five times more common than proximal torum profundus and inserts on the proximal end of the
tears. Skeletally immature patients present with bony middle phalanx. The flexor digitorum profundus tendon
avulsions more commonly than ligamentous avulsions then continues to insert on the proximal end of the dis-
(Figure 14). The Stener lesion involves complete rupture tal phalanx.
of the UCL distally with interposition of the adductor The course of the flexor tendon system in the hand
aponeurosis. The aponeurosis prevents reapposition of has been divided into zones used to describe the level of
the UCL to the proximal phalanx. Thus, complete rup- injury and prognosis for repair (Figure 15). Zone I is
tures should be surgically repaired primarily, with pull- distal to the insertion of the flexor digitorum superficia-
out sutures or with suture anchors. Partial ruptures, lis. In the thumb, zone TI is overlying and distal to the
however, can be treated with 4 weeks of immobilization interphalangeal joint. Zone II (no-mans land) starts at
followed by 2 weeks of gradual motion and a total of 3 the distal palmar crease and ends at the flexor digi-
months of protected activity. Differentiating between torum superficialis insertion. Zone TII in the thumb is
partial and complete tears is important in choosing a between the MCP joint and the interphalangeal joint.
treatment plan. Ultrasound has been used with moder- Zone III is the zone of lumbrical origin and extends
ate reliability, whereas MRI provides the most accurate from the distal palmar crease to the distal edge of the
diagnosis with up to 94% specificity for Stener lesions. transverse carpal ligament. Zone TIII refers to the
Thumb carpometacarpal dislocations involve rupture flexor tendons to the thumb as they pass through the
of the volar beak ligament and radial collateral liga- thenar region of the hand. Zone IV is the carpal tunnel,
ment. A PA stress radiograph of both thumbs pressed and zone V is the distal forearm. The pulley system in
together along their radial borders moves the proximal the fingers and hand provides a biomechanical advan-
metacarpal laterally and will show a shift of the meta- tage for maximal tendon excursion and range of motion.
carpal on the trapezium. The reduction must maintain The vascular supply to the flexor tendons dorsally is via
the metacarpal-trapezial relationship and casting or pin- the vincula, which contain vessels coursing from in-
ning can be used to hold the reduction. If the metacar- traosseous vessels. The volar flexor tendon receives its
pal is unstable, reconstruction of the ligament with blood supply from small vessels in the peritenon.
flexor carpi radialis or abductor pollicis brevis should be
considered. Flexor Tendon Repair
Increasing the caliber of the suture and increasing the
Flexor Tendon Injuries number of strands in the core suture improves overall
Rapid and reliable restoration of function is the goal of tendon repair performance in terms of load to failure,
flexor tendon surgery. Healing of injured or lacerated gap formation, and cyclic loading strength. At the same
tendons has been demonstrated on a biologic basis with- time, increasing the number of strands of core suture
out significant input from the circulating blood and ele- may increase the work of flexion. This suture method
vents flexor bowstringing and maximizes end range of mallet finger deformity. This condition presents clini-
motion. cally as lack of active extension at the DIP joint. Closed
An antiadhesion barrier gel has been used for pre- mallet fingers are best treated by continuous splinting in
vention of adhesion in Europe for flexor tendon inju- extension for 8 weeks. This treatment is effective in pa-
ries. In one clinical study of zone II flexor tendon re- tients with acute injury, and in patients in whom diagno-
pairs, the active PIP joint motion was improved (89.5 sis and treatment are delayed for weeks or even months.
compared with 65 in controls). Polyvinyl alcohol shields Active PIP joint motion is important and should be
have been used to decrease tendon adhesions but have maintained during the splinting period. Weaning from
also shown an increase in repair site rupture. the splint begins after 8 weeks, and night splints are rec-
5-fluorouracil is also being investigated to reduce peri- ommended for an additional 4 to 8 weeks. The skin
tendinous adhesions; adverse tendon healing effects should be monitored for maceration and necrosis; splint-
have not been shown. ing changes may be necessary. Splints should hold the
DIP joint in slight hyperextension. A slight residual ex-
Rehabilitation of Flexor Tendon Injuries tensor lag (< 10) may result from closed treatment. Sig-
Many different protocols have been followed to protect nificant persistent extensor lags, open mallet injuries,
flexor tendon repair but prevent adhesions that ulti- and large bony avulsions should be treated with open
mately affect motion. Immobilization is recommended repair; however, complications from surgical treatment
for children and patients with cognitive deficits. Passive of mallet injuries approach 50%.
mobilization, a variant of early passive mobilization, and
an active place and hold model of mobilization have Boutonniere Deformity
been described. The goal, regardless of the protocol cho- Disruption of the central slip results in loss of extension
sen, is early motion while protecting the repair suffi- at the PIP joint and hyperextension of the DIP joint or
ciently to allow healing. Current studies are aimed at a boutonniere deformity. The primary injury is to the
providing repairs that led to earlier active motion. A re- central slip, the jammed finger. The clinical picture is a
cent study used flexor tendon force transducers to show result of subluxation of the lateral bands from an exten-
that tenodesis motion requires less force than place and sor position to a flexor position at the PIP joint. Treat-
hold motion. A tendon healing study found that break- ment with splinting in extension at the PIP joint allows
ing strength and cellular activity increased with both for DIP joint motion and allows maintenance of normal
early motion and tension. Therefore, current recommen- lateral band length and position.
dations of four- to eight-strand repairs with a deep epi- Surgical indications for an acute boutonniere defor-
tendinous running suture are directed at earlier active mity include a displaced avulsion fracture at the base of
motion. the middle phalanx, axial and lateral instability of the
PIP joint associated with loss of active or passive exten-
Extensor Tendon Injuries sion of the finger, or failed nonsurgical treatment. Pass-
The extensor mechanism of the hand is a complex struc- ing a suture through the central tendon and securing it
ture that when damaged requires recognition of injury, to the middle phalanx (with or without the bony frag-
appropriate repair, and early motion to preserve maxi- ment) accomplishes primary repair of an avulsion frac-
mum function. More than 60% of injuries to the exten- ture. Dorsal fixation of the lateral bands addresses the
sor mechanism are also associated with bony, joint, or soft-tissue boutonniere deformity, and transarticular pin
ligamentous injuries. Suture repair of extensor tendon fixation of the PIP joint is often used to secure full ex-
laceration should be with a modified Kessler or modi- tension. If primary repair is not possible, portions of the
fied Bunnell repair using 4-0 synthetic nonabsorbable lateral bands can be sutured together in the dorsal mid-
suture. The extensor tendon excursion is less than the line to reconstruct the central slip.
flexor tendon excursion; therefore, preservation of
length and prevention of gapping is important to pre- Zone V Injuries
vent loss of motion. The extensor mechanism, like the The most common injury to the extensor mechanism in
flexor system, is divided into zones for discussion of in- zone V is from a fight bite sustained through a lacera-
jury and treatment (Figure 15). The even zones are over- tion from a human tooth when striking a blow to the
lying the bones (phalanges, metacarpals, and forearm face. This injury occurs with the MCP joint in flexion.
bones) and the odd zones are overlying the joints (distal Deeper injury to the extensor tendon will be proximal
interphalangeal [DIP], PIP, and MCP joints, and wrist). to the skin wound when the fingers are extended. These
partial tendon injuries can be treated conservatively.
Mallet Finger The skin wound, however, should be treated aggres-
Disruption of the extensor tendon at the level of the sively with thorough wound assessment, cultures, surgi-
DIP joint as a tendinous or bony avulsion results in a cal dbridement, broad-spectrum intravenous antibiot-
ics, and initial splinting with gradual transition to Nerve Injury and Repair
range-of-motion exercises. Devastating complications Injury
including articular damage, septic arthritis, and osteomy- Peripheral nerve injuries can be classified by injury se-
elitis can arise from a human bite. verity. Neurapraxia describes temporary failure of con-
Rupture of a sagittal band can result from a blunt in- duction in a nerve usually caused by contusion or
jury to the MCP joint. Most commonly, the radial sagit- stretch in injury. Neurapraxic injuries heal without sig-
tal band is damaged and the extensor tendon subluxates nificant delay or sequelae. Axonotmesis describes a dis-
into the ulnar gutter. This injury presents as lack of full ruption of the nerve fibrils but an intact endoneurium
extension at the MCP joint. The tendon can be seen on and epineurium. The intact neural tube functions as a
the ulnar aspect of the MCP joint and passively reduced conduit to allow nerve healing and regeneration. Nerve
into a central position. Active flexion produces a painful regeneration can be followed by an advancing Tinels
snap as the tendon dislodges into the ulnar gutter. Non- sign. A fibroblastic reaction within the nerve sheath can
surgical treatment of an acute injury can be attempted impede nerve growth leading to a neuroma in continu-
with the finger splinted in extension for 6 weeks. If this ity. These injuries can result from crush or severe stretch
treatment fails or if the diagnosis is delayed, surgical re- mechanisms. A completely lacerated nerve is an exam-
pair is indicated. Primary repair reinforced with an ple of neurotmesis in which the axons and endoneurial
ulnar-based flap of extensor tendon is strong enough to tubes are disrupted. The proximal nerve ending under-
allow early active motion. goes retrograde degeneration to the next node of Ran-
Closed rupture of the extensor pollicis longus follow- vier where a disorganized tangle of regenerating axons
ing a distal radius fracture has become a well-recognized forms a neuroma. The distal nerve ending undergoes
entity. Attritional rupture secondary to irritation from wallerian degeneration, resulting in an end bulb glioma.
fracture fragments, ischemia, or hemorrhage within the These injuries are best treated with surgical repair.
tendon sheath are commonly proposed theories of injury.
The patient will present several weeks after fracture with Repair
loss of interphalangeal joint extension and weak adduc- Nerve regeneration following repair is dependent on the
tion of the thumb. Nonsurgical treatment is not appropri- type of injury, location, degree of contamination, resid-
ate and direct surgical repair is often not possible. Free ual gap, tension, and many other factors currently being
tendon grafting with an intercalated graft or extensor in- investigated. Studies in animals have identified growth
dicis proprius-to-extensor pollicis longus transfer are two factors such as fibroblast growth factor-1 and insulin-
common techniques for reconstruction and both are as- like growth factor that promote nerve regeneration and
sociated with good results. improve outcomes. Different constructs such as reversed
vein entubulation, synthetic tubes, and fibrin glue are
Rehabilitation of Extensor Tendon Injuries being studied to replace nerve grafts. One animal study
in rat sciatic nerve found that muscle-enriched vein
Static splinting has been the standard with good long-
graft potentiates Schwann cell proliferation and is a
term results following extensor tendon repairs. Recently,
promising alternative conduit for nerve grafting. Studies
early active motion using dynamic splinting has shown
using synthetic conduits have shown favorable func-
better functional results. Immobilization of tendons is
tional outcomes for digital nerve repair with a gap of 4
associated with adherence of the tendon to surrounding
mm or less.
soft tissues, producing loss of both extension and flex- Nerve repair techniques include epineurial suturing,
ion. The immobilized tendon loses strength over time, group fascicular repair, and individual fascicular repair.
and aggressive rehabilitation following prolonged im- Epineural repair and group fascicular repair are most
mobilization can further attenuate the repair. Con- commonly used and the decision of which method to
trolled motion has been shown to increase tensile use is dependent on the level of nerve injury, and the
strength of tendons, improve gliding properties, increase appearance of and the ability to line up the fascicles. No
repair-site DNA, and accelerate changes in the sur- study has shown better results with one repair method
rounding vascularity. over the other, which may result from the difficulty in
Dynamic extension splinting allows several millime- appropriately matching the fascicles. Sensorimotor map-
ters of extensor gliding without placing stress across the ping can be used intraoperatively to maximize pairing of
repair site. A splint holding the wrist in extension and motor and sensory fascicles. This method requires signif-
the MCP joints in 10 to 15 of flexion allows limited icant patient cooperation and meticulous repair by the
motion at the interphalangeal joints both in active flex- surgeon.
ion and passive extension. Improved outcomes have The external epineurium is a layer of connective tis-
been shown using dynamic extension splinting for proxi- sue that can hold a suture better than internal epineu-
mal injuries. rium and perineurium. Tension in the repair, however,
must be avoided and nerve grafting should be consid- part in a child. Other factors impacting the decision to
ered if there is too much stretch to allow approximation replant a part are ischemic time, patient age, crush ver-
of the nerve endings. Early nerve repair of transected sus sharp injury, and segmental injuries. Warm ischemia
nerves should be done within 10 to 14 days. Crushed time should be less than 6 hours; in digits where there is
and contused nerves can be followed over time, and no muscle, warm ischemia time can be up to 12 hours.
early electromyograms (obtained 2 to 3 weeks after in- The amputated part should either be immersed in saline
jury) can be compared with later studies (obtained after in a bag or sterile container, or wrapped in saline-
6 weeks to 3 months) to identify areas of healing. If soaked gauze and then placed on ice. Replantation with
there are no changes at 3 months, nerve exploration is bony stabilization should proceed first, followed by ten-
indicated. Waiting longer than approximately 18 months don repair, arterial anastomosis, venous anastomosis,
leads to intraneural fibrosis and muscle fibrosis that nerve repair, and finally careful skin approximation or
may not be reversible. closure, avoiding tension across neurovascular struc-
tures.
Rehabilitation and Results Soft-tissue coverage of defects associated with am-
Postoperative care involves splinting to protect the re- putations depends on the size of the defect, the required
pair from stress for 2 to 3 weeks followed by gradual sensibility of that area, and other functional needs. Cuta-
range of motion across the repair site. Regeneration oc- neous flaps such as a groin flap are useful for covering
curs at a rate of approximately 1 mm per day. Results of moderate soft-tissue defects of the hand. The radial
nerve repair are better in the younger patient popula- forearm flap is a fasciocutaneous flap that can be used
tion, possibly because of more effective cortical reedu- either as a pedicled flap or a free flap. Myocutaneous
cation. In patients younger than age 20 years, 75% flaps using the rectus abdominis, latissimus dorsi, and
achieved two-point discrimination of less than 6 mm af- gracilis muscles can be taken to provide larger soft-
ter digital nerve repair. In adults, only 25% to 50% tissue coverage options. In these flaps, the associated
achieve that level of recovery. Median and ulnar nerve nerve can be taken and the flap used for reinnervation
recovery can improve for up to 5 years after repair. The and replacement of lost motor function in the extremity.
results of median and ulnar nerve repair are better for
lesions below the elbow than above. Studies have shown Infections
that 29% to 37% of patients regain two-point discrimi- Infections in the hand are challenging to treat because
nation less than 12 mm, and 14% to 27% regain func- of the anatomic spaces in the hand, which can allow or-
tional motor activity. Sensory reeducation is now recog- ganisms to spread quickly from distal points of injury to
nized as an important component in nerve recovery and proximal locations. The areas of the hand that facilitate
involves desensitization, motion, and tactile discrimina- the spread of infection are the dorsal cutaneous space,
tion training. Sensory reeducation has been shown to be thenar and midpalmar spaces, Paronas space, the inter-
more difficult when both the flexor tendon and nerve digital web spaces, the tendon sheaths, and articular
are repaired. This situation suggests that fine motor con- spaces.
trol assists sensory interpretation in the fingers.
Bacterial Infections
Fingertip Injuries The most common bacterial pathogen in hand infections
These common injuries require careful assessment and is Staphylococcus aureus. Vancomycin-resistant S aureus
treatment to maintain proper coverage and functionality is increasingly prevalent in community-acquired infec-
of the finger following injury. Appropriate padding and tions. Many infections begin as cellulitis, which, if recog-
sensibility must be preserved in the fingertip. Nail bed nized early, can be treated with antibiotics, elevation,
injuries also need careful treatment to avoid painful and and immobilization. The fundamental principles of
cosmetically unappealing results. treatment are appropriate antibiotic therapy, adequate
dbridement and drainage, a period of immobilization
Replantation and Local Flaps and elevation, and early remobilization. Tetanus immu-
The viability of replanted digits and hands has been nization needs to be up to date. Untreated cellulitis may
shown over many microsurgical centers to be approxi- develop into an abscess, which must be drained before
mately 80%. Revascularized parts have higher success antibiotics will be effective.
rates because some venous outflow is usually preserved. A paronychia is an infection involving the nail bed
Replantation should be considered when the amputated that evolves into an abscess that is easily drained by lift-
part is a thumb, multiple digits, partial hand (through ing the paronychial skin off the nail plate. Collar button
the palm), wrist, forearm, elbow, sharp amputation abscesses are located in the webspace and palmar ab-
above the elbow, and individual digits distal to the scesses usually involve the thenar or hypothenar bursas.
flexor digitorum superficialis insertion, and almost any Infected wounds overlying the dorsal MCP joint are of-
ten a result of contact with teeth or an open mouth. phytes such as Trichophyton rubrum. Superficial skin in-
These wounds may involve the extensor mechanism fections are caused by dermatophytes and Candida.
proximal to the wound. Evaluation of the extensor with These relatively superficial nail and skin infections are
the hand in a fully flexed fist position may reveal partial treated with topical antifungal agents, with conversion
tendon laceration and allows appropriate dbridement to oral agents when treatment appears ineffective. Gran-
of the involved extensor mechanism. A felon is a finger- ulomatous or mycobacterial infections show a predilec-
tip pulp infection that requires surgical drainage to pre- tion for synovium. They may present in a manner
vent a compartment syndrome and potential necrosis of similar to rheumatoid arthritis and frequently involve
the entire pulp of the finger. the wrist. Cultures must be directed toward detecting
Purulent flexor tenosynovitis warrants early atten- these slow-growing pathogens. Mycobacterium tubercu-
tion because it is a potentially devastating infection with losis, M avium-intracellulare, and M marinum have been
significant long-term morbidity. This infection involves a described in the hand and may be resistant to multiple
penetrating injury or hematogenous seeding inside the chemotherapeutic agents. Herpetic whitlow presents as
flexor sheath. Because the sheath extends across the a clear vesicular lesion on the tip of the finger caused by
palm, the infection can easily track into the forearm. Pa- herpes simplex virus type 1 or type 2. Treatment is non-
tients with this type of infection will present with Kana- surgical and the infection is self-limiting and resolved
vels signs of a digit resting in flexion, pain with passive over 3 to 4 weeks.
extension, pain along the flexor sheath, and fusiform
swelling in the digit. The most sensitive sign is pain with Burns
passive extension. Flexor tenosynovitis can be treated Burns over a large surface area are devastating injuries,
with irrigation of the flexor sheath once it has been resulting in months of hospitalization, multiple proce-
opened. A preferred method of irrigation is to place a dures, and prolonged wound care. Over 2 million burn in-
16-gauge catheter in the proximal sheath and a penrose juries are reported to require medical care each year, and
drain in the distal sheath in the finger. Every 2 hours, 50 approximately 6% result in death, usually from smoke in-
mL of sterile saline is irrigated through the sheath for halation. Most burn injuries are relatively minor and pa-
48 hours. Motion should begin within the week to pre- tients are discharged following outpatient treatment. Of
vent excessive stiffness. those patients who require hospitalization, approximately
Antibiotic coverage of hand infections should be tai- 20,000 are admitted directly or by referral to hospitals
lored to the cultured organism. As mentioned, the most with special capabilities in the treatment of burn injuries.
common pathogen is Staphylococcus but human bite The average hospital stay is 2 months. Criteria for referral
wound infections often contain Eikenella corrodens and to a burn unit are shown in Table 2.
virulent cat bite infections are caused by Pasteurella Burns are classified according to the depth of ther-
multocida. Penicillin is the drug of choice for these bite mal injury, which in turn guides prognosis and treatment
infections. plans. The trend is toward classifying burns as partial
Necrotizing fasciitis is a severe, rapidly spreading in- thickness, which heal on their own, and full thickness,
fection that carries mortality rates of 8% to 73%. There which require skin grafting.
are two groups of organisms responsible for this infec- Partial-thickness burns include first- and second-
tion. Group one includes anaerobic bacteria such as En- degree burns. First-degree burns only involve the epi-
terobacter and non-group A streptococci. Group two dermis and require removal of the source of injury and
includes group A streptococci with S aureus or Staphy- analgesic care. The skin heals within 1 week and there is
lococcus epidermidis. Patients may present with wounds no permanent damage.
from minor trauma that progress rapidly from cellulitis Second-degree burns destroy the epidermis and in-
and low-grade fever to multisystem organ failure, coma, volve varying amounts of the dermis. The more superfi-
and hemodynamic compromise. Patients in the intensive cial second-degree burns heal within 2 weeks and leave
care unit are at increased risk of infection by more un- little permanent scarring. This injury is usually accompa-
usual pathogens such as Pseudomonas and Acineto- nied by blisters that progress over time. Deep second-
bacter. These patients require multiple antimicrobial degree burns produce more scarring, which increases
agent therapy because of multiagent resistant organ- the time to healing. Healing depends on residual epithe-
isms. lial cells in deep dermal sweat glands and hair follicles.
Hypertrophic scarring can lead to prolonged healing
Fungal, Mycobacterial, and Viral Infections and infections so that excision and skin grafting may be
Fungal infections in the hand occur in the paronychium, considered.
nail, and skin. Chronic paronychial infections are usually Third-degree or full-thickness burns involve all of
caused by Candida albicans. Onychomycosis, or fungal the dermis and varying amounts of underlying fat, mus-
nail bed infection, is commonly caused by dermato- cle, and bone. The skin may appear white and waxy and
New concepts in surgical treatment. Instr Course Lect central placement of the screw demonstrated 43% greater
2003;52:591-605. stiffness, 113% greater load at 2 mm of displacement, and 39%
New techniques of internal fixation, postoperative rehabil- greater load at failure. Central placement of the screw in the
itation, and emphasis on functional as well as radiographic proximal fragment of the scaphoid offers a biomechanical ad-
outcome have refined the surgical treatment of complex frac- vantage in the internal fixation of an osteotomy of the
tures of the glenoid, humeral head, supracondylar and intra- scaphoid waist. Clinical efforts and techniques that facilitate
condylar humerus, olecranon, radial head, distal radius, and central placement of the screw in the fixation of fractures of
distal radioulnar joint over the past decade. Early stabilization the scaphoid waist should be encouraged.
and rehabilitation of these injuries leads to soft-tissue stabili-
zation and facilitates the patients ability to place the hand in
Polsky MB, Kozin SH, Porter ST, Thoder JJ: Scaphoid
three-dimensional space.
fractures: Dorsal versus volar approach. Orthopedics
2002;25:817-819.
Hanel DP, Jones MD, Trumble TE: Wrist fractures. Twenty-six patients with scaphoid fractures were treated
Orthop Clin North Am 2002;33:35-57. with internal fixation using a cannulated differential pitch
The benefits of a well-reduced and well-healed wrist frac- compression screw. Sixteen patients underwent a dorsal ap-
ture are predictable. After either closed or open reduction, the proach (group 1) and 10 patients a volar approach (group 2).
integrity of the volar ulnar corner of the radius, articular step- Average time from injury to surgery was 6.6 months (range,
off, metaphyseal comminution, and DRUJ stability should be 0.3 to 19 months) for group 1 and 8.3 months (range, 0.3 to 24
assessed. Reconstruction of the subluxated or dislocated months) for group 2. The rate of union, determined by radio-
DRUJ starts with the reduction of the radius, frequently obvi- graphs and clinical examination, was 81% in group 1 and 80%
ating the need to address fractures involving the ulnar head in group 2. No significant differences were noted between the
and styloid. Most importantly, the results of treatment reflect groups for dorsiflexion/palmar flexion, radial deviation, grip
surgical decision over the fixation method. strength, and pain level.
Herzberg G, Forissier D: Acute dorsal trans-scaphoid Skoff HD: Postfracture extensor pollicis longus tenosyn-
perilunate fracture-dislocations: Medium-term results. ovitis and tendon rupture: a scientific study and per-
J Hand Surg Br 2002;27:498-502. sonal series. Am J Orthop 2003;32:245-247.
The purpose of this study was to investigate the medium- A review of treatment of 200 consecutive patients with
term results (mean follow-up, 8 years) of a series of 14 trans- distal radius fractures found that the incidence of rupture of
scaphoid dorsal perilunate fracture-dislocations treated surgi- the extensor pollicis longus tendon is 3%. Diagnosis is based
cally at an average of 6 days following injury. Eleven patients
on persistent dorsal wrist pain and a positive retroflexion sign.
underwent open reduction and internal fixation through a dor-
In the prerupture setting, recommended treatments include a
sal approach. Combined palmar and dorsal approaches were
third dorsal compartment release with or without an extensor
used in three fractures, open reduction and internal fixation in
retinacular patch graft. If after an acute rupture primary repair
two, and proximal row carpectomy in one. The Mayo Wrist
is not possible, a palmaris longus graft or a transfer from the
Score revealed five excellent, three good, five fair, and one
extensor indicis proprius to the extensor pollicis longus tendon
poor result. The average score was 79% (range, 55% to 95%).
can be used in the subacute or chronic setting. Results of all
All internally fixed scaphoids healed and no lunate or
treatments seem to be clinically satisfactory.
scaphoid fragment osteonecrosis with collapse was observed.
Carpal alignment was satisfactory in most patients. Posttrau-
matic radiologic midcarpal and/or radiocarpal arthritis were Slade JF III, Gutow AP, Geissler WB: Percutaneous in-
almost always observed at follow-up, but this did not correlate ternal fixation of scaphoid fractures via an arthroscopi-
with the Mayo Wrist Score. cally assisted dorsal approach. J Bone Joint Surg Am
2002;84(suppl 2):21-36.
In a consecutive series of 27 fractures (17 waist fractures
McCallister WV, Knight J, Kaliappan R, Trumble TE:
and 10 proximal pole fractures) treated with arthroscopically
Central placement of the screw in simulated fractures of
assisted dorsal percutaneous fixation, CT confirmed 100%
the scaphoid waist: A biomechanical study. J Bone Joint
union at an average of 12 weeks. Eighteen fractures were
Surg Am 2003;85:72-77.
treated within 1 month after the injury, and nine were treated
Recent reports on internal fixation of acute fractures of
more than 1 month after the injury. In this series, the fractures
the scaphoid waist have demonstrated higher rates of central
that were treated early (less than 1 month after the injury)
placement of the screw when cannulated screws were used
healed more quickly than those treated later.
than when noncannulated screws were used. This cadaveric
study was designed to determine whether central placement in
the proximal fragment of the scaphoid offers a biomechanical Wigderowitz CA, Cunningham T, Rowley DI, Mole PA,
advantage. Central placement of the screw in the proximal Paterson CR: Peripheral bone mineral density in pa-
fragment of the scaphoid had superior results compared with tients with distal radial fractures. J Bone Joint Surg Br
those using eccentric positioning of the screw. Fixation with 2003;85:423-425.
Fractures of the distal forearm are widely regarded as the digitorum superficialis after repair of both flexor ten-
result of fragility. This study examines the extent to which dons in zone II: A biomechanical study. J Bone Joint
patients with Colles fractures have osteopenia. Bone mineral Surg Am 2002;84:2039-2045.
density was measured in the contralateral radius of 235 The effects of two strategies to improve postoperative
women presenting with Colles fractures over a period of 2 gliding in a human cadaveric hand were studied. Complete lac-
years. Although women of all ages had low values for ultradis- erations and repairs were made to the profundus and superfi-
tal bone mineral density, the age-matched values were particu- cialis tendons at a location where both repair sites would pass
larly low among premenopausal women age 45 years or beneath the A2 pulley with the proximal interphalangeal joint
younger. This finding did not occur because of the presence of in 45 of flexion. Pulley plasty and resection of one slip of the
women with early menopause. This large survey confirms and flexor digitorum superficialis tendon both significantly de-
extends the findings from earlier small studies. The authors creased gliding resistance compared with repair of both slips
conclude that it is particularly important to investigate young (P < 0.001). There was no difference in the mean gliding resis-
patients with fractures of the distal forearm to identify those tance between the pulley plasty and one-slip resection groups.
with osteoporosis, to seek an underlying cause, and to consider The flexor digitorum superficialis slip was stronger after repair
treatment. with a Becker suture than after repair with a modified Kessler
or a zigzag suture. Both pulley plasty and resection of one slip
Flexor Tendon Injuries of the flexor digitorum superficialis reduce gliding resistance
Angeles JG, Heminger H, Mass DP: Comparative bio- after tendon repair in zone II of the hand.
mechanical performances of 4-strand core suture repairs
for zone II flexor tendon lacerations. J Hand Surg [Am] Zhao C, Amadio PC, Zobitz ME, Momose T, Couvreur
2002;27:508-517. P, An KN: Effect of synergistic motion on flexor digi-
This study compared four-strand core suture repairs, the torum profundus tendon excursion. Clin Orthop 2002;
modified Becker, modified double Tsuge, Lee, locked cruciate, 396:223-230.
Robertson, and Strickland suture repairs. Work of flexion and The dog model was used to evaluate synergistic motion on
ultimate tensile strength were compared, as well as cyclic load- the flexor digitorum profundus. Eighty percent of lacerations
ing. The greatest interference for gliding was in the modified were created and repaired using 4-0 Ticron modified Kessler
Becker repair, and the least in the modified double Tsuge re- core suture with circumferential epitenon running 6-0 nylon
pair. None of these repairs had mean gaps after 1,000 cycles to suture repairs. Metal markers were placed and then divided
a 3.9 N pulp pinch load approach the clinically important limit into two experimental groups. One group had passive flexion
of 3 mm of gap. Ultimate tensile strength was highest in the and extension of the digits with the wrist fixed in 45 of flex-
modified Becker (69.4 8.2N) compared to the modified dou- ion; in the second group, dogs received synergistic wrist mo-
ble Tsuge (60.3 15.3N) and locked cruciate (64.1 16.2N), tion with passive digit flexion combined with wrist extension,
but this was not statistically significant. These authors stated and passive digit extension with wrist flexion. Time points
that ease of performance for the surgeon and less interference were 1, 3, and 6 weeks. At 1, 3, and 6 weeks after surgery, the
with tendon gliding favored the locked cruciate and modified synergistic motion group was superior in total excursion, ex-
double Tsuge repairs compared with the modified Becker re- tension excursion, flexion excursio, and overall percentage of
pair. motion compared with unoperated controls.
Boyer MI, Strickland JW, Engles D, Sachar K, Le- Extensor Tendon Injuries
versedge FJ: Flexor tendon repair and rehabilitation: Chester DL, Beale S, Beveridge L, Nancarrow JD, Titley
State of the art in 2002. Instr Course Lect 2003;52:137- OG: A prospective, controlled, randomized trial compar-
161. ing early active extension with passive extension using a
The application of modern multistrand suture repair tech- dynamic splint in the rehabilitation of repaired extensor
niques as well as postoperative rehabilitation protocols em- tendons. J Hand Surg Br 2002;27:283-288.
phasizing the application of intrasynovial repair site excursion Two methods of rehabilitation were compared after exten-
has led to a protocol for treatment of intrasynovial flexor ten- sor tendon repairs in zones IV through VIII. Nineteen patients
don lacerations emphasizing a strong initial repair followed by followed an early active mobilization program and 17 patients
the application of postoperative passive motion rehabilitation. followed a dynamic splinting regimen. Data were collected at
Protocols for the reconstruction of failed initial treatment 4 weeks and at final follow up (median = 3 months). Extension
have likewise undergone modification given new findings on lag, flexion deficit, and total active motion were measured. At
the biologic and clinical behavior of flexor tendon grafts. Cur- 4 weeks, the patients on a dynamic splinting program had bet-
rently accepted treatment protocols following flexor tendon ter total active motion; however, there were no significant dif-
repair and reconstruction are based on current clinical and sci- ferences in the two groups at final follow-up.
entific data.
Nerve Injury and Repair
Paillard PJ, Amadio PC, Zhao C, Zobitz ME, An KN: Bell Krotoski JA: Flexor tendon and peripheral nerve
Pulley plasty versus resection of one slip of the flexor repair. Hand Surg 2002;7:83-109.
When peripheral nerve injury is combined with flexor ten- Garberman SF, Diao E, Peimer CA: Mallet finger: Re-
don injury, sensibility is directly impaired. There is a loss in the sults of early versus delayed closed treatment. J Hand
sense of finger or thumb position, pain, temperature, and Surg Am 1994;19:850-852.
touch/pressure recognition, in addition to the tendon injury.
Geissler WB, Freeland AE, et al: Intracarpal soft-tissue
lesions associated with an intra-articular fracture of the
Day CS, Buranapanitkit B, Riano FA, et al: Insulin distal end of the radius. J Bone Joint Surg Am 1996;78:
growth factor-1 decreases muscle atrophy following den- 357-365.
ervation. Microsurgery 2002;22:144-151.
The purpose of this study was to evaluate the histologic, Gelberman RH, Boyer MI, Brodt MD, Winters SC, Silva
immunohistochemical, and electrophysiologic differences be- MJ: The effect of gap formation at the repair site on the
tween normal, denervated, and insulin-like growth factor-1 strength and excursion of intrasynovial flexor tendons:
denervated muscle over an 8-week period. Denervated mice An experimental study on the early stages of tendon-
gastrocnemius muscles demonstrated a decrease in muscle healing in dogs. J Bone Joint Surg Am 1999;81:975-982.
weight, a decrease in myofiber diameter, an absence of muscle
Lotz JC, Hariharan JS, Diao E: Analytic model to pre-
regeneration, an early increase in the number of neuromuscu-
dict the strength of tendon repairs. J Orthop Res 1998;
lar junctions, and a decrease in fast-twitch and maximum teta-
16:399-405.
nic strength compared with normal muscle up to 8 weeks fol-
lowing denervation. Insulin-like growth factor-1 denervated Okafor B, Mbubaegbu C: Mallet deformity of the finger:
muscle, on the other hand, sustained muscle diameter and Five-year follow-up of conservative treatment. J Bone
muscle weight, maintained a smaller number of neuromuscu- Joint Surg Br 1997;79:544-547.
lar junctions, and relatively sustained fast-twitch and maxi-
mum tetanic strength compared with normal muscle over 8 Rockwell WB, Butler PN, et al: Extensor tendon: Anat-
weeks. These data suggest that insulin-like growth factor-1 omy, injury, and reconstruction. Plast Reconstr Surg
may help prevent muscle atrophy and secondary functional 2000;106:1592-1603.
compromise after denervation.
Soejima O, Diao E, Lotz JC, Hariharan JS: Comparative
mechanical analysis of dorsal versus palmar placement
Classic Bibliography of core suture for flexor tendon repairs. J Hand Surg
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Allen CH: Functional results of primary nerve repair.
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ripheral suture depth on strength of tendon repairs.
J Hand Surg Am 1996;21:234-239. Toby EB, Butler TE, et al: A comparison of fixation
screws for the scaphoid during application of cyclical
Dunning CE, Lindsay CS, Bicknell RT, Patterson SD, bending loads. J Bone Joint Surg Am 1997;79:1190-1197.
Johnson JA, King GJ: Supplemental pinning improves
the stability of external fixation in distal radius fractures Wolfe SW, Austin G, et al: A biomechanical comparison
during simulated finger and forearm motion. J Hand of different wrist external fixators with and without
Surg Am 1999;24:992-1000. K-wire augmentation. J Hand Surg Am 1999;24:516-524.
Figure 1 Corrective osteotomy with tricortical bone graft for a distal radius malunion. The osteotomy and graft shape should be designed to correct the radial height (A), radial
inclination (B), and palmar tilt (C). (Reproduced with permission from Trumble TE: Fractures and malunions of the distal radius, in Trumble TE (ed): Principles of Hand Surgery and
Therapy. Philadelphia, PA, 2000, p 172.)
Scaphoid Nonunion Advanced Collapse of the scaphoid is usually successful in halting progres-
Untreated scaphoid nonunions also lead to a predict- sion of the arthrosis. If there is evidence of more ad-
able progressive pattern of wrist arthrosis, termed vanced carpal arthrosis (stage II or greater SNAC),
scaphoid nonunion advanced collapse (SNAC) (Figure bone grafting will not reliably relieve the patients
3). Similar to a wrist with SLAC, degenerative changes symptoms and a salvage procedure is more appropriate
first develop in the radial styloid (stage I). In stage II (proximal row carpectomy or four-corner fusion).
SNAC, there is joint space narrowing of the entire ra- An option for patients without capitolunate arthrosis
dioscaphoid articulation. In stage III SNAC, the capitate is excision of the distal pole of the scaphoid. A recent
migrates proximally, resulting in a loss of carpal height. study suggests that this procedure improves range of
As the disease progresses to its final stage (IV), the motion and increases grip strength in patients with stage
midcarpal and radiocarpal articulations develop degen- II SNAC. Patients who do not have radiocarpal disease
erative changes. The radiolunate joint and the articular may also benefit from either a four-corner fusion and
surface under the proximal fragment of the scaphoid are scaphoidectomy (Figure 4) or a proximal row carpec-
usually preserved. tomy.
As with the treatment of SLAC, various techniques A proximal row carpectomy is a good procedure to
have been described for the treatment of SNAC. The eliminate pain and preserve wrist motion. However,
appropriate procedure depends on multiple factors, in- once the progression of arthrosis involves the capitolu-
cluding the stage of the progression and individual pa- nate articulation, a proximal row carpectomy is no
tient factors. In patients with a scaphoid nonunion who longer indicated. Therefore, stage III SNAC is most ap-
have developed degenerative changes of the radial sty- propriately treated with a four-corner fusion and
loid (stage I SNAC), radial styloidectomy in addition to scaphoidectomy, and stage IV SNAC is best treated with
open reduction and internal fixation with bone grafting a total wrist arthrodesis.
Figure 2 The stages of SLAC. In stage I, there is beaking of the radial styloid. In stage Figure 3 The stages of SNAC. Similar to SLAC, stage I is hallmarked with radial styloid
II, there is narrowing and arthrosis of the radioscaphoid joint. In stage III, there is arthritis. In stage II, there is progression of the arthritis to the scaphoid fossa. In stage
arthrosis between the capitate and the scaphoid and/or lunate as the capitate dis- III, capitolunate arthritis is observed. In stage IV, there is diffuse carpal arthritis with
places between the scaphoid and lunate with the carpal collapse. In stage IV, all of sparing of the lunate fossa. (Reproduced with permission from Knoll VD, Trumble TE:
the above changes occur along with degeneration of the radiolunate joint. (Repro- Scaphoid fractures and nonunions, in Trumble TE (ed): Principles of Hand Surgery and
duced with permission from Trumble TE, Gardner, GC: Arthritis, in Trumble TE (ed): Therapy. Philadelphia, PA, 2000, p 167.)
Principles of Hand Surgery and Therapy. Philadelphia, PA, 2000, p 406.)
Figure 7 Fine-cut coronal (A) and sagittal (B) CT images provide excellent detail of fracture fragments (arrowheads) of the scaphoid nonunion. (Reproduced with permission
from Trumble TE, Fractures and dislocations of the carpus, in Trumble TE (ed): Principles of Hand Surgery and Therapy. Philadelphia, PA, 2000, p 102.)
The TFCC arises from the articular cartilage at the in supination. In pronation, the radius also moves vol-
corner of the sigmoid notch of the radius and inserts onto arly relative to the ulna, tightening the dorsal ligament
the base of the ulnar styloid and volarly into the ulnocar- fibers of the TFCC. In supination, the radius moves dor-
pal ligament complex formed by the ulnar triquetral lig- sally such that the volar ligament fibers of the TFCC
ament and the ulnar lunate ligament. The ligaments and tighten. As these respective ligaments tighten, they help
the TFCC, which support the DRUJ and ulnar portion of to support the carpus on the distal forearm.
the carpus, form a three-walled pyramidal structure. The
triangular fibrocartilage is the floor of this pyramid. The Triangular Fibrocartilage Complex Injuries
ligaments forming the walls of this pyramid stabilize the TFCC injuries can be classified into two basic catego-
carpus to the triangular fibrocartilage and the ulnar sty- ries: type I, traumatic injuries, and type II, degenerative
loid so that they maintain their relationship to the TFCC lesions. Traumatic lesions are classified according to the
while rotating around the ulna. The ulnar triquetral liga- location of the tear within the TFCC; degenerative le-
ment and the ulnar lunate ligament form the volar wall of sions are associated with positive ulnar variance and of-
this box. The undersurface of the extensor carpi ulnaris ten have associated pathology (for example, lunotrique-
tendon forms the ulnar wall of the box, and the dorsal ra- tral ligament attenuation or carpal arthrosis) (Table 3).
dial triquetral ligament forms the dorsal wall of this com- Type IA lesions are usually treated with arthroscopic
partment. These structures maintain the relationship be- dbridement of the unstable portion of the tear that has
tween the carpus and the ulna. occurred in the avascular zone. If more than two thirds
In addition to the DRUJ and ulnocarpal ligaments, of the central disk is dbrided, the DRUJ becomes un-
the TFCC is a key stabilizer of the DRUJ and a stabi- stable. The peripheral 2 mm of the triangular fibrocarti-
lizer of the ulnar carpus. The amount of load transferred lage must be maintained to avoid DRUJ instability.
to the distal ulna from the carpus is directly propor- Chronic type IB lesions can be difficult to diagnose.
tional to the ulnar variance. In neutral ulnar variance, Examination shows ulnar-sided wrist pain and mild
approximately 20% of the load is transmitted via the DRUJ instability. Radiographs may demonstrate an
TFCC. With positive ulnar variance, the load across the ulna styloid fracture or may be normal. Diagnostic ar-
TFCC is increased, with a resultant thinning of its cen- throscopy reveals that the TFCC has lost its normal ten-
tral disk. In pronation, the radius moves proximally rela- sion. Isolated peripheral tears are repaired arthroscopi-
tive to the ulna, while in supination the radius moves cally. If the tear is associated with an ulna styloid
distally. This movement results in a relative positive fracture and instability, an open reduction with internal
variance in pronation and a relative negative variance in fixation of the ulnar styloid fragment or styloidectomy is
supination. Thus, a greater load is transferred to the dis- performed before reattaching the TFCC to the remain-
tal ulna from the carpus via the TFCC in pronation than ing distal ulna. Treatment of this injury consists of ar-
Figure 8 MRI of scaphoid nonunion showing proximal pole avascularity. Each image shows hypoechoic signal in the proximal pole suggestive of avascularity.
Patients with instability associated with arthritis are of the distal ulna, or combined radial head excision and
at increased risk for persistent instability and are best distal ulna excision were treated with arthrodesis of the
treated with a procedure designed to stabilize the ulna radius and ulna (creation of a one-bone forearm) per-
and buffer the distal radioulnar articulation, such as an formed as a salvage procedure. A total DRUJ prosthesis
ulnar hemiresection with tendon interposition. In is now available and has many advantages over the one-
younger patients, with posttraumatic DRUJ arthritis and bone forearm. Currently, there are several designs avail-
an intact TFCC, a Sauv-Kapandji procedure is an alter- able for ulnar head implants and total DRUJ prosthe-
native approach described to maintain grip strength. In ses. However, although these devices show promise,
the Sauv-Kapandji procedure, the DRUJ is fused and a there are no long-term clinical studies that clearly delin-
pseudarthrosis is created proximal to the DRUJ to al- eate the indications for their use.
low for rotation of the radius around the ulna. The
Sauv-Kapandji procedure is often subject to complica- Degenerative Arthrosis of the Thumb and
tions related to an unstable proximal stump.
Distal ulna implant arthroplasty is an attractive al- Fingers
ternative for the treatment of DRUJ arthritis and insta- Thumb Carpometacarpal Joint
bility (Figure 15). Normal mechanical function and sta- The CMC joint of the thumb has a biconcave saddle
bility of the DRUJ requires an intact ulnar head. A shape, which imparts little intrinsic bony stability. In a
functional ulnar head implant would alleviate impinge- recent study, 16 ligaments surrounding the trapezio-
ment and restore near-normal load transmission. Thus, metacarpal joint were identified. The deep volar (ante-
ulnar head replacement may be an alternative to the rior oblique) ligament, which passes from the trapezium
modified Darrach procedure. In the past, patients with to the volar beak of the thumb metacarpal, and the dor-
recurrent instability of the ulna caused by excessive soradial ligament play the most significant role in main-
proximal excision of the radial head, excessive resection taining CMC stability. The deep volar ligament resists
Figure 11 Arthroscopically assisted TFCC repair using the outside-in technique. A, Shows the 3-4 and 6R portals used to access the TFCC. A needle is used to pierce the TFCC.
(B) A suture is threaded through the needle and grasped. The suture is tied to the capsule. (Reproduced with permission from Trumble TE: Distal radioulnar joint triangular
fibrocartilage complex, in Trumble TE (ed): Principles of Hand Surgery and Therapy. Philadelphia, PA, 2000, pp 136-137.)
Figure 21 Submuscular transposition of the ulnar nerve. FCU = flexor carpi ulnaris.
(Reproduced with permission from Trumble TE: Compressive neuropathies, in Trumble
TE (ed): Principles of Hand Surgery and Therapy. Philadelphia, PA, 2000, p 328.)
Figure 23 A, The anterior approach (Henrys approach) for decompression of the distal portion of the radial nerve and the posterior interosseous nerve. B, The posterior
approach (Thompsons approach) for radial nerve decompression. ECRL = extensor carpi radialis longus, ECRB = extensor carpi radialis brevis, EDC = extensor digiti communis,
APL = abductor pollicis longus. (Reproduced with permission from Trumble TE: Compressive neuropathies, in Trumble TE (ed): Principles of Hand Surgery and Therapy. Philadel-
phia, PA, 2000, p 328.)
before there is notable atrophy. Patients with milder with resection or grafting, depending on the competency
compression are best treated with night splints. of the palmar arch.
Annotated Bibliography
Wrist Imaging
Steinborn M, Schurmann M, Staebler A, et al: MR imag-
ing of ulnocarpal impaction after fracture of the distal
radius. AJR Am J Roentgenol 2003;181:195-198.
Ulnocarpal impaction is a common finding after distal ra-
dius fracture. MRI can detect characteristic bone marrow
changes of the lunate early after the trauma. A significant cor-
Figure 24 Cable grafts are used to bypass the large zone of scar tissue in the region relation exists between MRI findings and the extent of post-
of the scalene muscle just distal to the brachial plexus roots. Cable grafts are in place traumatic ulnar variance and pain levels.
in the brachial plexus (A). Close-up view of the cable nerve graft (B). (Reproduced with
permission from Trumble TE: Brachial plexus injuries, in Trumble TE (ed): Principles of
Hand Surgery and Therapy. Philadelphia, PA, 2000, p 305.) Wrist Arthroscopy
Shih JT, Lee HM, Hou YT, Tan CM: Arthroscopically-
graft, nerve transfers, tendon transfers, free muscle assisted reduction of intra-articular fractures and soft
transfers, and arthrodesis and/or tenodesis to stabilize tissue management of distal radius. Hand Surg 2001;6:
joints. Depending on the injury and the patient, one or 127-135.
Arthroscopy was used to help reduce intra-articular frac-
more of the techniques may be used in an attempt to
ture of the distal radius and treat soft-tissue injuries in 33
improve function. The first priority of reconstruction is
acute patients. The fractures were treated by reduction under
to reestablish elbow flexion. Without the ability to posi-
arthroscopic control and percutaneous fixation with or with-
tion the hand in space, hand function is severely com-
out external fixation. The TFCC was torn in 18 of 33 patients
promised. The second goal is to stabilize the shoulder.
(54%). All tears were peripheral and were repaired with ar-
Because it is difficult to position the extremity in a pa- throscopic procedures. Scapholunate ligament injuries with in-
tient with a fused shoulder, if a shoulder arthrodesis is stability of the scapholunate joint were noted in 6 patients
indicated, this procedure should be the last step in the (18%). This injury was treated with scapholunate dbridement
series of reconstructive procedures. The next set of ob- and stabilization of the joint with Kirschner wires. Four pa-
jectives includes obtaining and maintaining wrist and tients (12%) had lunotriquetral ligament injuries; three of
digit motion. these patients were treated with Kirschner wire transfixion.
The most proximal muscles are more successfully Six patients (18%) had chondral fractures. All 33 patients
reinnervated after nerve reconstruction, because they healed without measurable incongruity of the joint surface
require less axonal input and are a shorter distance and excellent or good results according to the modified Mayo
from the site of injury. After 12 to 18 months without wrist score.
neurologic input, the motor end plates in the muscle
completely degenerate and the muscle loses its ability to Wrist Arthritis Secondary to Trauma
be successfully reinnervated. The success rate for rein- Cohen MS, Kozin SH: Degenerative arthritis of the
nervation of the muscles innervated by the axillary, su- wrist: Proximal row carpectomy versus scaphoid exci-
prascapular, and musculocutaneous nerves approaches sion and four-corner arthrodesis. J Hand Surg [Am]
70% to 80%. Unfortunately, more distal muscles in the 2001;26:94-104.
forearm and hand have a much poorer prognosis for Two cohort populations of 19 patients from separate insti-
reinnervation. Younger patients and patients who re- tutions who underwent either a scaphoid excision and four-
ceive nerve grafts within the first 3 months after injury corner arthrodesis or proximal row carpectomy for scapholu-
have the best prognosis. nate advanced collapse were compared. The results of the
A recent study demonstrated reliable deltoid recon- study suggest that both proximal row carpectomy and
struction for upper arm brachial plexus injury by nerve scaphoid excision and the four-corner arthrodesis are motion-
transfer to the deltoid using the nerve to the long head preserving options for the treatment of scapholunate ad-
of the triceps in conjunction with spinal accessory nerve vanced collapse. There were minimal subjective or objective
transfer to the suprascapular nerve. The ipsilateral C7 differences in short-term follow-up evaluations.
nerve root also may be transferred with or without si-
multaneous transfer of the spinal accessory nerve to the Soejima O, Iida H, Hanamura T, Naito M: Resection of
suprascapular nerve to treat C5 and C6 root avulsions the distal pole of the scaphoid for scaphoid nonunion
Introduction curs when the foot is in the air for limb advancement.
Gait analysis is a useful clinical tool and a recognized The stance phase can be subdivided into five subphases:
medical procedure for evaluating and treating patients initial contact, loading response, midstance, terminal
with ambulatory impairments. It is challenging for many stance, and preswing. The swing phase can be divided
physicians to achieve a clear understanding of gait anal- into three functional subphases: initial swing, midswing,
ysis data and to meaningfully interpret the clinical appli- and terminal swing (Figure 1) (Table 1).
cability of the data to a patients impairment, disability, The stance phase can alternately be subdivided into
or handicap. Familiarity with the complex physiologic three periods according to floor contact patterns. Both
interactions of normal gait and movement biomechan- the beginning and the end of the stance phase are the
ics, functional anatomy, normal and abnormal patterns double support period during which both feet are in
of motor control, and with the technology used for its contact with the floor. Single limb support begins when
assessment will contribute to better care for patients the opposite foot is lifted for the swing phase. The broad
with ambulatory difficulties. normal distribution of the periods of floor contact dur-
Gait can be described as an interplay between the ing the gait cycle are 40% for the swing phase and 60%
two lower limbs, one in touch with the ground, produc- for the stance phase (each double support time period
ing sequential restraint and propulsion, while the other accounts for approximately 10% of the stance phase).
swings freely and carries with it the forward momentum These ratios apply to individuals with normal gait pat-
of the body. By the age of 4 to 8 years, most healthy in- terns who are walking at a self-selected, comfortable
dividuals have established a similar manner of walking speed. These proportions will vary greatly with changes
because of a common, basic anatomic and physiologic in walking velocity. For example, walking more slowly
makeup. However, because of inherent differences in will reduce single limb support time and will increase
body proportions, level of coordination, motivation, and double limb support time. With increasing cadence
other factors, each persons gait pattern is unique. De- (steps per minute), the double limb support period
spite these complexities, gait patterns are highly repeat- steadily decreases, and disappears during running.
able both within a subject and between subjects; how- The step period is the time measured from initial
ever, each person has a unique walking style. contact in one foot to the subsequent occurrence of the
The modern quantitative study of human locomo- same event in the other foot. There are two steps in
tion dates back to the early part of the 19th century each stride or gait cycle. The stride period can be de-
with Muybridges sequential photographs. Inman and fined as the time from initial ground contact of one foot
associates, from the University of California, refined the until the next ground contact for the same foot; the
simultaneous recording of multiple muscle group activ- stride period is normally equal for left and right strides.
ity during normal ambulation and published their find- Stride length is the distance covered during one stride.
ings in a textbook, which has become a classic reference The stride period is often normalized to the full gait cy-
for the field. cle for the purpose of averaging gait parameters over
several strides both within and between subjects. The
Normal Locomotion step period is useful for identifying and measuring
Based on the timing of reciprocal floor contacts, the gait asymmetry between the two sides of the body, especially
cycle can be defined as a single sequence of functions by in pathologic conditions. Step length is the distance cov-
one limb. Each gait cycle has two basic components ered during one step. Side-to-side symmetry of step
the stance phase, which designates the duration of foot length and step time is characteristic in individuals with
contact with the ground; and the swing phase, which oc- normal gait.
the stance limb permits ankle dorsiflexion to control be processed and displayed as a function of time or as a
forward progression of the tibia, while knee and hip ex- percent of the stride period. Derived data include joint
tension and pelvic tilt and internal rotation take place. angles, angular velocities, acceleration, and limb seg-
ment rotation.
Quantitative Gait Analysis
Visual analysis of gait is routinely done as part of the Kinetics
clinical assessment of patients. This type of analysis does Kinetic analysis involves study of the forces that de-
not provide quantitative information and has many limi- velop during walking. Ground reaction forces are gener-
tations because of the complexity and speed of the ally measured using a triaxial force platform. It is pre-
events that occur during walking, coupled with devia- ferred that two platforms, placed adjacent to each other,
tions and possible compensations that occur in patho- be used so that the forces transmitted through the con-
logic gait. Three primary components of quantitative tact surface for each foot can be recorded simulta-
gait analysis that can be recorded are kinetics (the anal- neously and independently. The reaction forces are di-
ysis of forces that produce motion), polyelectromyogra- vided into their orthogonal components, and plotted as
phy (poly-EMG) or dynamic EMG (the analysis of mus- a function of time or as a function of the stride time per-
cle activity), and kinematics (the analysis of motion and centage. For comparison to standards, the measured
the resulting temporal and stride measurements). Gait ground reaction forces are often normalized and re-
analysis that is useful in the clinical evaluation of pa- ported as a percentage of body mass.
tients and in choosing treatment options must provide Two orthogonal components of force define a time-
measured parameters that correlate with the functional varying force vector. In some laboratories the vertical/
capacity of the patient, supply additional and more rele- sagittal vector is displayed using laser optics or com-
vant information than clinical examination, be accurate puter technology in real time and superimposed on the
and repeatable, and must result from a test that does image of the walking subject (Figure 4).
not alter the natural performance of the patient. The magnitude of the ground reaction forces and
their relationship to anatomic joint centers are the fac-
Kinematics tors that determine moments or torque about a joint,
Temporal and Spatial Descriptive Measures which indicate the direction and magnitude of joint ro-
tation. Internal forces generated by muscles, tendons,
To characterize gait, basic variables concerning the
and ligaments act to control these external forces.
temporal-spatial sequencing of stance and swing phases
can be measured (Figure 2). These data can be obtained
by measuring the distances and timing involved in the Electromyographic Activation Patterns in
foot-floor contacts. Temporal-spatial footfall patterns Human Gait
are the end product of the total integrated locomotor Because of the redundant relationship between muscles
movement. Techniques to obtain these data include the about a joint, there is no unique association between a
use of simple ink and paper to foot switches and other particular joint movement and the pattern of muscle
more sophisticated measuring systems. By comparing in- forces giving rise to that movement. In normal locomo-
formation from the two legs, measures of symmetry can tion, the gravitational forces are carefully controlled by
be obtained to determine the extent of unilateral im- opposing muscle forces to yield a smooth and energy-
pairment. efficient movement pattern. The EMG signal can be
used as an indication of neurologic control over muscle
Motion Analysis activation. Superficial muscles can be studied using
Kinematic data provide a description of movement bipolar surface electrodes. For deep muscles or to differ-
without regard to the force generating it (Figure 3). Ear- entiate between adjacent muscles, indwelling Teflon-
lier techniques included photographic and cinemato- coated wire electrodes are inserted through a hypoder-
graphic analysis. Other techniques include the use of ac- mic needle.
celerometers and electrogoniometry. Modern systems EMG timing patterns from a patient can be com-
involve the use of high-speed video recording or special- pared to normative data (including both a mean and
ized optoelectronic apparatus in which passive (such as standard deviation) (Figure 5) to identify deviations
retroreflective markers) or active optical sources (such from normal EMG patterns. Because EMG patterns are
as light emitting infrared diodes) are attached to the very sensitive to walking velocity, data from a patient
subject and serve as markers. walking at a slow speed should not be compared with
In optoelectronic systems, the spatial coordinates of data from an able-bodied control patient who walks at a
the markers are generated directly by the computer af- higher velocity and with a natural cadence.
ter the system has been calibrated. Kinematic informa- A particular muscle may be overactive or underac-
tion can be used to provide coordinate data, which can tive during a given segment of the gait cycle. When such
Figure 2 An example of gait temporal-spatial data that depicts measurement of symmetry and timing.
Figure 3 Normal three-dimensional sagittal kinematic gait data obtained with CODA mpx30 motion tracking system (Charnwood Dynamics, Leicestershire, England). Normalized
gait cycle; 0 = initial contact, vertical line swing phase, 100 = next initial contact.
Figure 5 Representative raw EMG data for gastrocnemius during walking. Normalized
gait cycle; 0 = initial contact, vertical line swing phase; 100 = next initial contact.
Solid horizontal bar represents normative data.
Figure 6 A, Patient with swing phase equinovarus ankle foot posture second to upper motor neuron syndrome. B, Dynamic EMG confirms overactive tibialis posterior and
gastrocnemius-soleus complex during the swing phase of gait. Normalized gait cycle; 0 = initial contact, vertical line indicates swing phase; 100 = ipsilateral initial contact.
lect patients who would benefit from joint arthroplasty tension can all interfere with normal gait. An inade-
and to assess the impact of such surgery on gait biome- quate base of support can result in instability of the
chanics. In patients with chronic neurologic impairment, entire body; therefore, the correction of the abnormal
gait analysis together with selective nerve and motor ankle/foot posture by conservative, interventional, or
point blocks can be used to differentiate fixed contrac- surgical methods is essential.
tures (static deformity) from spasticity and muscle over- Equinovarus deformity is one of the most common ab-
activity (dynamic deformity), allowing more appropriate normal lower limb postures seen in patients with neuro-
treatment selection. logic disorders. Contact with the ground occurs with the
forefoot first (with decreased or absent heel contact), re-
Pathologic Gait sulting in the weight being borne primarily on the lateral
Functional gait deviations may be applicable to many border of the foot, which can produce an unstable base of
conditions rather than just to a specific disease. From a support. Limited ankle dorsiflexion will prevent forward
functional perspective, gait deficiencies can be catego- progression of the tibia over the stationary foot, resulting
rized based on their timing with respect to the gait cy- in knee hyperextension and interference with terminal
cle. During the stance phase, an abnormal base of sup- stance and preswing and loss of the propulsive phase of
port and limb instability may make walking unsteady gait. During the swing phase, there is a sustained plantar-
and energy inefficient, and possibly painful. Inadequate flexed and inverted posture of the foot resulting in diffi-
limb clearance and advancement during the swing phase culty with limb clearance. Results of dynamic poly-EMG
will interfere with balance and energy efficiency. show that prolonged activation of the gastrocnemius-
soleus complex is the most common cause of sustained
Abnormal Base of Support plantar flexion. Inversion is the result of the abnormal ac-
The ankle/foot posture is critical in the interface with tivities of the tibialis posterior and/or tibialis anterior in
the walking surface during the stance phase. Ankle plan- combination with long toe flexors and the gastrocnemius-
tar flexion, inversion or eversion, and toe flexion or ex- soleus complex group (Figure 6).
Figure 7 Polio survivor with weak left knee extensors that require a knee ankle-foot Figure 8 Patient with insufficient hip abductor musculature that produces a compen-
orthosis to stabilize the knee joint. Note line of force through the knee joint of the sated gluteus medius gait. Note lateral trunk lean toward the stance limb.
orthotic device.
An abnormal base of support also occurs in foot ment that occurs during the early stance phase. This ab-
drop. The use of a mechanical device (such as an ankle- normality may be evident in a transfemoral amputee
foot orthosis) during the stance and swing phases may and can interfere with the ability to ambulate or may re-
help to control the abnormal ankle posture. sult in hyperextension of the knee joint as a compensa-
Studies have shown that botulinum toxin injected tory mechanism. The dynamic poly-EMG shows short-
into the hyperactive musculature can provide selective ened or uncoordinated activities of the quadriceps
time-limited relief of spasticity. Surgical interventions musculature. Occasionally, increased activities of the
such as gastrocnemius-soleus complexsoleus lengthen- knee flexors also are found. A shoe with a soft heel, a
ing, split tibialis anterior, tendon transfer, and lengthen- molded ankle-foot orthosis (set in a few degrees of
ing of the tibialis posterior and of the toe flexors to at- plantar flexion), or a knee-ankle-foot orthosis with pos-
tain a balanced foot posture may be necessary. terior offset knee joints or stance phase stabilization
joints all can provide improved knee stability by posi-
tioning the ground reaction force anterior to the knee
Abnormal Limb Stability joint center. For the above-the-knee amputee, changes
Knee flexion or hyperextension during the early stance in alignment to improve knee stability, the use of an ar-
phase caused by ligamentous instability, degenerative ticulated prosthetic foot, or the use of a mechanical
joint disease, muscle weakness, or flaccidity can make knee lock is required (Figure 7).
walking unsteady and increase the risk for falling. The Knee hyperextension during the stance phase may
patient is unable to control the normal knee flexor mo- occur as the result of spasticity of the ankle plantar flex-
Figure 9 Stiff-knee gait EMG and three-dimensional data. Overactive rectus femoris
is the cause of reduced knee flexion in swing phase when compared with normal data.
Normalized gait cycle; 0 = initial contact, vertical line indicates swing phase;
100 = ipsilateral initial contact.
ors or knee extensors, a plantar flexion contracture, or perextension control is indicated to compensate for
as a compensatory mechanism for quadriceps weakness. knee extensor weakness when present.
This abnormal posture of the knee prevents normal for-
ward advancement of the tibia during the stance phase Trendelenburg Gait
and restricts contralateral limb advancement. Correc- Insufficient hip abductor musculature or mechanical de-
tion of the knee deformity can be achieved by decreas- ficiency of the hip joint caused by pain, degenerative
ing the ankle plantar flexor or knee extensor spasticity, changes, malalignment, or a nerve injury can result in a
if present, by the use of selected botulinum toxin injec- gluteus medius gait pattern (Figure 8). During the
tion into the gastrocnemius-soleus complex or by appro- stance phase, the patient will have an exaggerated ipsi-
priate surgical intervention through gastrocnemius- lateral trunk lean (compensated gluteus medius gait) in
soleus complex lengthening. Compensation for the an attempt to stabilize the pelvis. Some patients will be
ankle deformity can be achieved with the use of a heel unable to compensate and have a pelvic drop of the
lift to accommodate the ankle equinus. The use of a swinging limb resulting in a noncompensated gluteus
knee-ankle-foot orthosis with offset knee joints and hy- medius gait. The use of a cane held by the contralateral
hand should result in a marked improvement in this deviation. This condition interferes with ipsilateral limb
pathologic gait pattern. advancement as the knee will be flexed and the limb is
not able to easily reach the ground. Contralateral limb
Limb Clearance and Advancement clearance also will be affected as a decrease in total
Limb clearance and advancement occurs during the functional height will occur, requiring increased hip and
swing phase of gait. When limb clearance is inadequate, knee flexion to avoid foot drag. Total knee joint replace-
limb advancement is compromised. The most common ment or hamstring release may be useful as a treatment
causes of limb clearance difficulties are lack of adequate option.
hip flexion, and inadequate knee flexion and/or ankle Hip retraction or lack of pelvic rotation affecting the
dorsiflexion. It is important to recognize that synchro- involved limb during the gait cycle may interfere with
nized lower limb motion during the swing phase is es- limb advancement, resulting in a shortened step length
sential to produce adequate limb clearance. because of limited hip motion. Total hip arthroplasty or
Stiff-knee gait pattern can result from orthopaedic iliopsoas lengthening may address this gait deviation.
intervention intended to provide joint stability or re-
lieve pain (knee fusion) or may be found in patients Annotated Bibliography
with spasticity. The patient is unable to flex the knee ad-
equately, creating a large moment of inertia, which in- Al-Zahrani KS, Bakheit AM: A study of the gait charac-
creases the energy required to initiate the swing phase teristics of patients with chronic osteoarthritis of the
of the involved limb. This condition requires the patient knee. Disabil Rehabil 2002;24:275-280.
to use ipsilateral hip, trunk, and contralateral limb com- The kinematic and kinetic parameters of gait and the pat-
pensatory motions. Even if the ankle-foot system has an tern of activation of four lower limb muscles were examined
appropriate position, early swing toe drag can occur and during walking at a self-selected pace on level ground in this
can be corrected only by increasing hip flexion, increas- study. The spatiotemporal parameters of gait were also com-
ing the contralateral limb length, or generating knee puted in 58 patients with severe osteoarthritis of the knee and
flexion. a control group of 25 age-matched healthy people. The pa-
In patients with a spastic stiff knee, a dynamic poly- tients with osteoarthritis had a significantly reduced walking
speed; shorter stride length; a more prolonged stance phase of
EMG will show increased activity in the quadriceps
the gait cycle; less range of motion at the hip, knee and ankle
muscles as a group. In patients who have had a stroke,
joints; and generated less moments and powers at the ankle
preferential activation of the rectus femoris and vastus
and more moments at the knee than the control group. It was
intermedius with or without hamstrings co-contraction
concluded that the observed gait abnormalities were caused
is found (Figure 9). Lack of momentum caused by de- by instability of the knee joint in the stance phase. This finding
creased walking speed can be another possible cause for may have important clinical implications for the rehabilitation
stiff-knee gait. Quadriceps chemodenervation, selective of patients with severe osteoarthritis of the knee.
surgical releases, or tendon transfer may be useful treat-
ments.
Esquenazi A, Mayer NH, Keenan MA: Dynamic poly-
In some patients, inadequate hip flexion is also a
electromyography, neurolysis, and chemodenervation
cause of abnormal limb clearance. This condition effec-
with botulinum toxin A for assessment and treatment of
tively prevents physiologic shortening of the limb, pro-
gait dysfunction. Adv Neurol 2001;87:321-331.
ducing a swing phase toe drag. Decreased muscle This review article describes evaluation techniques using
strength or delayed activation of the iliopsoas (as shown gait analysis and possible treatment options for patients with
with EMG) is a primary cause of this gait deviation. gait dysfunction resulting from upper motor neuron syndrome.
Strengthening of the iliopsoas, if possible, or a contralat- Treatment interventions ranging from focal injections of botu-
eral shoe lift to facilitate limb clearance can be used to linum toxin to surgery are described.
treat this gait deviation.
Increased hip adduction can interfere with ipsilateral
Fantozzi S, Benedetti MG, Leardini A, et al: Fluoro-
and contralateral limb advancement. Increased activity scopic and gait analysis of the functional performance in
of the hip adductor musculature or imbalance in stair ascent of two total knee replacement designs. Gait
strength between the hip abductor and adductor muscle Posture 2003;17:225-234.
groups is the main cause of this type of abnormal gait. This article reviews stair ascent kinematics and kinetics of
Percutaneous phenolization of the obturator nerve or two types of knee joints (mobile bearing or posterior stabi-
obturator neurectomy (with or without adductor tenot- lized) using three-dimensional fluoroscopy and gait analysis
omy) is the most common treatment. techniques. Statistical significant correlation was found be-
Incomplete knee extension during the late swing and tween knee flexion at foot strike and the position of the mid-
early stance phases, which result from joint derange- condylar contact points and between maximum knee adduc-
ment or hamstrings spasticity, is another important gait tion moment and corresponding trunk tilt. Results of this
study suggested that a combined evaluation technique is more Schmalz T, Blumentritt S, Jarasch R: Energy expenditure
useful than fluoroscopic assessment of the knee alone. and biomechanical characteristics of lower limb ampu-
tee gait: The influence of prosthetic alignment and dif-
Fuchs S, Tibesku CO, Frisse D, Laass H, Rosenbaum D: ferent prosthetic components. Gait Posture 2002;16:255-
Quality of life and gait after unicondylar knee prosthe- 263.
sis are inferior to age-matched control subjects. Am J The influence of different prosthetic alignments and com-
Phys Med Rehabil 2003;82:441-446. ponents on oxygen consumption and the important biome-
A total of 17 patients were examined at an average chanical characteristics of the normal gait pattern of 15 trans-
follow-up of 21.5 months after implantation of unicondylar tibial and 12 transfemoral amputees was studied. Oxygen
sledge knee prostheses. Patients had clinical evaluation, three- consumption while walking on a treadmill was analyzed and
dimensional gait analysis, surface EMG investigation of the biomechanical parameters during walking on even ground at a
lower limb, and quality-of-life assessment using the Short self-selected speed were defined. It was found that variations
Form-36 health questionnaire. Results were compared with a of the prosthetic alignment affect the energy consumption of
control group of 11 healthy individuals. Significantly poorer transfemoral amputees more significantly than transtibial am-
results were found for the patient group in the Hospital for putees. All investigated variations could be clearly character-
Special Surgery score, the Knee Society score, the patella ized by the sagittal moments acting on the joints of the pros-
score, and the Visual Analog Scale for pain. Significant differ- thetic limb during gait.
ences also were found in the level of physical functioning, role
limitation because of physical complications, and the presence
of pain. EMG activities during gait were significantly lower in Stevens PM, MacWilliams B, Mohr RA: Gait analysis of
the patient group, except for the rectus femoris and the tibialis stapling for genu valgum. J Pediatr Orthop 2004;24:70-
anterior. Gait analysis showed a significant difference between 74.
the two groups for ground reactive forces and stride length; This article evaluates the effects of stapling or epiphysiod-
maximum knee extension and flexion did not vary signifi- esis of the distal medial femur as a treatment for correcting
cantly. genu valgum. Clinical improvement (in appearance, pain, and
function) and objective evidence of kinetic and kinematic im-
Fuller DA, Keenan MA, Esquenazi A, Whyte J, Mayer provement was shown. Preoperative and postoperative mea-
N, Fidler-Sheppard R: The impact of instrumented gait surements in a series of patients treated for genu valgum were
analysis on surgical planning: Treatment of spastic compared to document the benefits of normalizing the me-
equinovarus deformity of the foot and ankle. Foot Ankle chanical axis. Results indicated that knee and hip angles and
Int 2002;23:738-743. knee moments were returned to the normal range (compared
This article reports the results of a prospective investiga- with an age-matched control group) for patients treated with
tion of the impact of instrumented gait analysis on surgical surgery.
planning for the treatment of equinovarus foot deformity in
patients with spasticity. The patients in the study had instru- Classic Bibliography
mented gait analysis and poly-EMG data collection using a
standard protocol. The agreement between the surgical plans Esquenazi A, Talaty M: Physical medicine and rehabili-
of two surgeons were compared before and after the gait tation: The complete approach, in Grabois M, Garrison
study. Results showed that instrumented gait analysis can pro- SJ, Hart KA, Lehmkuhl LD (eds): Normal and Patho-
duce higher agreement between surgeons in surgical planning logical Gait Analysis. New York, NY, Blackwell Science,
for patients with spastic equinovarus deformity of the foot and 2000, pp 242-262.
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Perry J: Gait Analysis: Normal and Pathological Func-
13 elderly patients with unilateral knee osteoarthritis and a
tion. Thorofare, NJ, Slack Inc, 1992.
control group of 10 age-matched healthy people studied dur-
ing preferred and paced speed gait. Patients with knee os-
Perry J, Waters RL, Perrin T: Electromyographic analy-
teoarthritis had a lower (but not significantly different) walk-
sis of equinovarus following stroke. Clin Orthop
ing speed and step length compared to the control group, and
had significantly different joint kinetic profiles.
1978;131:47-53.
Figure 1 Young-Burgess classification of mechanism of injury. A, Lateral compression, grade I. B, Lateral compression, grade II. C, Lateral compression, grade III. D, Anterior-
posterior compression, grade I. E, Anterior-posterior compression, grade II. F, Anterior-posterior compression, grade III. G, Vertical shear. (Reproduced from Tornetta P III: Pelvis
and acetabulum: Trauma, in Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 427-439.)
patients treated with angiography followed by laparotomy complicated by neurologic or vascular injury, infection,
compared with a group first treated with laparotomy. wound complications, and nonunion or malunion of the
Stable fracture patterns also may be complicated by pelvic ring, and loss of reduction.
arterial bleeding and may be appropriate for treatment
by selective embolization. Arterial bleeding can occur in Anterior Pelvic Ring Injuries
up to 18% of patients with mechanically stable pelvic Injuries to the anterior pelvic ring include symphysis
fractures. In one study however, an intra-abdominal dislocations, pubic body fractures, and pubic rami frac-
source of bleeding was found in 85% of patients who tures. These injuries may occur alone, in combination, or
were hemodynamically unstable but had mechanically in association with a posterior pelvic ring injury. All
stable pelvic fractures. complete dislocations of the symphysis pubis should be
stabilized. Displacements of less than 2.5 cm in conjunc-
Definitive Treatment tion with an intact posterior pelvic ring are incomplete
Most pelvic fractures are mechanically stable injuries injuries and can be considered for nonsurgical treat-
and are often caused by a lateral compression mecha- ment. Because radiographs of the injury may not reflect
nism resulting in an anterior impaction fracture of the the magnitude of the initial displacement, close
sacrum and pubic rami fractures. If there is less than follow-up is warranted if nonsurgical treatment is se-
1 cm of posterior pelvic ring displacement and no neu- lected. The symphysis dislocation is most effectively and
rologic deficit, these injuries are appropriate for nonsur- efficiently treated with a single plate applied superiorly
gical treatment with progressive mobilization. Repeat through a rectus-splitting Pfannenstiel approach. This
radiographs should be obtained after mobilization to procedure may be done in conjunction with an emer-
ensure that there has been no further displacement. gent laparotomy or urologic surgery and adds the least
Fractures of the processes of the pelvis, such as anterior amount of additional soft-tissue disruption.
superior iliac spine avulsion fractures, do not disrupt the Fractures of the superior pubic ramus rarely require
stability of the pelvic ring and are usually treated non- stabilization; even those that occur in association with
surgically unless significant displacement is present. symphyseal dislocations are usually treated nonsurgi-
cally. Pouparts, Coopers, and the inguinal ligaments
External Fixation combine with the periosteum of the ramus to provide
External fixation as definitive treatment is generally only stability for these injuries. It is believed that more than
appropriate for rotationally unstable injuries. The most 2 cm of residual distraction or fracture gap of the ramus
common scenario involves an AP compression injury, after treatment of the posterior pelvic injury implies dis-
which results in an external rotation of one or both hemi- ruption of these soft tissues and fixation may be needed.
pelves. The anterior ring usually fails as a symphysis dis- Fixation may be achieved with open reduction and plate
location or less commonly as fractures of the pubic rami. osteosynthesis; intramedullary screw fixation or external
The posterior ring injury is incomplete. In this situation, fixation also has been used. If the fracture involves the
the external fixator may provide enough anterior stability body of the pubis (medial to the pubic tubercle), the
to allow the anterior injury to heal. In a lateral compres- supporting tissues mentioned above are all lateral to the
sion injury, distraction external fixation with external ro- site of injury and cannot contribute to stability. Pubic
tation of the injured hemipelvis has been used with suc- body fractures are generally treated as symphysis dislo-
cess; this treatment is only required if there is neurologic cations and require reduction and plate fixation.
compression or unacceptable deformity. Although it may
be used in association with internal fixation for some in- Posterior Pelvic Ring Injuries
juries, external fixation alone is not appropriate for the The posterior pelvic ring is the most important compo-
treatment of unstable posterior pelvic ring injuries. The nent in overall stability and function of the pelvis. The
posterior pelvic ring injury may ultimately heal; however, anatomic site of injury will determine the surgical ap-
it will heal in a displaced position and may lead to pelvic proach and the type of fixation used. Unstable posterior
obliquity, pain, and long-term disability. pelvic ring injuries are ilium fractures, sacroiliac (SI)
joint dislocations, sacral fractures, or SI joint fracture-
Internal Fixation dislocations. It is usually best to reduce the posterior
Internal fixation is the most biomechanically stable fixa- pelvic ring injury first, building to the intact portion of
tion for the pelvic ring. The implants are situated closer the pelvis. This is particularly crucial if there are many
to the site of injury than in external fixation and may be sites of pelvic displacement. If there are only two sites
optimally located to resist the forces applied to the pel- of injury within the pelvic ring, reduction of the anterior
vic ring. Achieving an accurate reduction of the pelvic ring may facilitate reduction of the posterior pelvis in
ring may be a prerequisite to achieving stable fixation. some circumstances; however, beginning treatment with
Placement of internal fixation for the pelvis may be the posterior injury is still recommended.
Figure 2 A, Radiograph showing dislocation of the symphysis pubis and incomplete injuries to both SI joints. B, Radiograph at 2 years shows maintenance of the reduction of
the pelvic ring without evidence of SI joint arthrosis.
Ilium Fractures visualization of the cranial aspect of the joint to the pel-
Ilium fractures typically propagate from the iliac crest vic brim, and the ilium can be manipulated through the
to the greater sciatic notch and are unstable injuries. Al- placement of clamps on the crest or through the inter-
though nondisplaced fractures may be treated nonsurgi- spinous notch. Excessive retraction or retractors placed
cally, displaced fractures require reduction and fixation. too medially on the sacrum may cause injury to the L5
A posterior pelvic approach is useful, although some nerve root. Fixation is achieved through the use of
fracture patterns may be treated through the lateral plates applied with a single screw in the sacrum and
window of the ilioinguinal approach. Fractures that in- with one or two screws placed into the ilium. The use of
volve only the iliac wing are stable injuries, are often two plates, oriented at 90 to each other, is recom-
minimally displaced, and can be treated nonsurgically. If mended. In the obese patient, reduction and fixation
significant displacement is present, open reduction and through the anterior approach can be very difficult be-
internal fixation may be indicated. These fractures are cause of the inability to retract the abdominal contents.
generally reduced and fixed through the lateral window Fixation also may be compromised if there is a marginal
of the ilioinguinal approach. Iliac wing fractures have a fracture of the sacral lip of the SI joint. This fracture can
high incidence of local arterial injuries, bowel injury, and be identified on the CT scan preoperatively and may
soft-tissue degloving. Plate or screw fixation between preclude stable plate fixation from the anterior ap-
the tables of the ilium can be useful. proach. Fixation also can be achieved through iliosacral
screws placed percutaneously while the patient is supine
Sacroiliac Joint Dislocations and while the reduction is assessed and held from the
A complete radiographic evaluation including CT scan anterior approach.
is often required to differentiate between incomplete SI Reduction and fixation is facilitated by the use of an
joint injuries and complete SI dislocations. The anterior open reduction done through the posterior pelvic ap-
pelvic ring and anterior SI ligaments may be signifi- proach with the patient prone. The posterior-inferior SI
cantly disrupted, whereas the posterior SI ligaments re- joint is visualized while the anterior joint is palpated
main intact. These injuries are only rotationally unstable through the greater sciatic notch. Reduction is per-
and usually require treatment of only the anterior ring formed with a combination of clamps placed between
injury (Figure 2). The posterior ring injury will reduce the ilium and sacrum. Fixation is achieved with the fluo-
indirectly and be stabilized by the anterior ring fixation. roscopically guided placement of iliosacral lag screws.
Complete dislocations of the SI joint are vertically un- The iliosacral screws are inserted through a separate in-
stable injuries and require posterior pelvic ring fixation cision with a percutaneous technique; it is rarely possi-
in addition to anterior ring fixation (Figure 3). ble to insert the screws through the posterior approach
Reduction and fixation of the SI joint may be done incision. If the reduction of the SI joint can be achieved
either open (through an anterior or posterior approach) with closed manipulation and traction, the joint may be
or through closed manipulation with percutaneous fixa- similarly stabilized with iliosacral lag screws placed with
tion. The anterior approach to the SI joint allows direct the patient either prone or supine.
Figure 3 A, Patient with dislocation of the symphysis pubis, incomplete injury to the right SI joint, and complete dislocation of the left SI joint. Note the cranial displacement of
the left hemipelvis. B, Open reduction of the SI joint was performed through a posterior pelvic approach and the joint stabilized with iliosacral screw fixation. Open reduction and
internal fixation of the symphysis pubis followed.
complications associated with the acetabular fracture, and and may be later recognized by the presence of a fluctu-
other skeletal injuries requiring treatment.Approximately ant circumscribed area of cutaneous anesthesia and ec-
one half of patients with an acetabular fracture will have chymosis. These injuries should be treated with dbride-
an injury to another organ system. ment and delayed acetabular fixation because of the
Although hemodynamic instability occurs infre- significant incidence of positive bacterial culture from
quently with isolated fractures of the acetabulum, per- these lesions.
sistent unexplained blood loss despite resuscitation may
be caused by vascular injury. Fractures involving the Diagnosis and Classification
greater sciatic notch may injure the superior gluteal ar- The diagnosis of acetabular fractures begins with appro-
tery, requiring angiography and selective embolization. priately positioned, well-penetrated, plain radiographs.
Neurologic injury is frequently associated with fractures The AP pelvis radiograph and the Judet views (45 ob-
of the acetabulum and may be present in up to 20% of turator and iliac oblique) are needed for accurate inter-
patients. The peroneal division of the sciatic nerve is the pretation and fracture classification. A CT scan can bet-
most frequently injured. Closed reduction of associated ter define rotational displacements, intra-articular
hip dislocations should be performed as quickly as pos- fragments, marginal articular impactions, and associated
sible to reduce the risk of osteonecrosis of the femoral femoral head injuries. A three-dimensional CT recon-
head. Persistent subluxation of the hip may be caused struction may be helpful in understanding the relation-
by either the fracture displacement or from intra- ships between multiple sites of injury, but is not a re-
articular fracture fragments and should be treated with placement for plain radiographs. The classification
urgent skeletal traction to prevent the head from wear- system of Letournel and Judet, which groups acetabular
ing against the fracture edge or incarcerated fragment. fractures into five elementary and five associated frac-
Soft-tissue degloving injuries (Morel-Lavall lesions) ture patterns, is used to classify the fractures (Figure 4).
may be initially recognized by a fluid wave on palpation The interobserver and intraobserver reliability of the
Figure 6 A, Associated transtectal transverse plus posterior wall acetabular fracture in an 18-year-old woman. B, AP and Judet radiographs at 3 years after injury. The patients
hip is rated 6,6,6 on the modified DAubigne and Postel scale.
in patients treated with indomethacin for concurrent ac- the AP pelvic radiograph at identifying pelvic fracture in the
etabular or pelvic fractures. awake, alert trauma patient.
Deep venous thrombosis and pulmonary embolism
are common complications after pelvic or acetabular Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock
fractures treated without prophylaxis. Chemoprophy- S: Vertically unstable pelvic fractures fixed with percuta-
laxis with low molecular weight heparin or warfarin so- neous iliosacral screws: Does posterior injury pattern
dium may reduce the incidence of thromboembolic dis- predict fixation failure? J Orthop Trauma 2003;17:399-
ease, particularly in association with mechanical 405.
prophylaxis. Duplex ultrasound is typically used preop- Sixty-two patients were treated with closed reduction and
eratively to identify patients with venous thrombosis, percutaneous iliosacral screw fixation for posterior pelvic ring
however, it is limited in its ability to detect proximal injuries. Results show that sacral fractures were significantly
thrombi. Despite earlier studies that suggested that more likely to displace than other posterior lesions. Twenty
magnetic resonance venography was more sensitive percent (6 of 30) of sacral fractures displaced and 67% of
than ultrasound at detecting proximal thrombi, an eval- those required revision fixation surgery.
uation of contrast CT and magnetic resonance venogra-
phy showed a significant false positive rate in both stud-
Kabak S, Halicik M: Tuncel M Avsarogullari L, Baktir
ies. This finding was confirmed by invasive contrast
A, Bastruk M: Functional outcome of open reduction
venography. If thrombi are present, the placement of an
and internal fixation for completely unstable pelvic ring
inferior vena caval filter is recommended before frac-
fractures (type C): A report of 40 cases. J Orthop
ture surgery.
Trauma 2003;17:555-562.
Iatrogenic neurologic injury has been reported in
This study involved 40 patients with type C pelvic frac-
2% to 15% of patients who were surgically treated for
tures. At 1-year follow-up, sexual dysfunction was found in
acetabular fractures. Intraoperative neurologic monitor-
44% of patients and correlated with anxiety disorder and ma-
ing has been recommended but there is no evidence jor or moderate depression. Seventy-two percent of patients
that the routine use of monitoring lowers the incidence had returned to work at their original jobs, and of those who
of iatrogenic injury. A direct comparison of monitored did not, an increased incidence of depression was found. Per-
and nonmonitored acetabular fracture surgeries used sistent pelvic pain was reported by 25% of patients.
both sensory and motor pathway monitoring but failed
to show a difference in the incidence of iatrogenic nerve
injury. Most orthopaedic trauma surgeons use prophy- Mayher BE, Guyton JL, Gingrich JR: Impact of urethral
laxis to help prevent heterotopic ossification and deep injury management on the treatment and outcome of
venous thrombosis; however, nerve monitoring is not concurrent pelvic fractures. Urology 2001;57:439-442.
In 61 patients with combined pelvic and lower urinary
routinely used.
tract injuries, urologic treatment affected the orthopaedic
treatment choices in 35% of patients. Long-term suprapubic
Annotated Bibliography catheterization precluded surgical treatment in four patients;
Pelvic Fractures three had poor results. The authors recommend early endo-
Eastridge BJ, Starr A, Minei JP, OKeefe GE, Scalea scopic realignment for urethral injuries and improved commu-
TM: The importance of fracture pattern in giving thera- nication and cooperation between subspecialty groups.
peutic decision-making in patients with hemorrhagic
shock and pelvic ring disruptions. J Trauma 2002;53:446-
Miller MT, Pasquale MD, Bromberg WJ, Wasser TE,
451.
Cox J: Not so FAST. J Trauma 2003;54:52-59.
In 86 patients with pelvic fracture with persistent hemody-
In this study, 359 patients with blunt abdominal injury
namic instability, abdominal hemorrhage was responsible for
were evaluated with focused assessment with sonography for
hypotension in 85% of stable pelvic fractures. Hemorrhage
trauma (FAST) and contrast CT of the abdomen and pelvis.
was from pelvic sources in 59% of patients with unstable frac-
ture patterns. Patients with unstable fracture patterns had a FAST resulted in an underdiagnosis of intra-abdominal injury
higher mortality (60%) when celiotomy was performed before with a false negative rate of 6% (27% of the false negatives
angiography when compared with patients in which angiogra- required laparotomy). The authors recommended that CT
phy was performed first (25% mortality). with contrast remain the gold standard for the evaluation of
patients with suspected blunt abdominal injury.
In this study, 29 men with urethral injuries had primary en- and intraobserver reliability. J Bone Joint Surg Am 2003;
doscopic urethral realignment. At an average follow-up of 5.6 85-A:1704-1709.
years, improved rates of continence, potency, and stricture for- The intraobserver and interobserver reliability of the
mation were found when compared with rates for patients Letournel-Judet classification system for acetabular fractures
who had delayed open urethroplasty. The authors recom- was assessed by surgeons who studied with Letournel, sur-
mended early realignment as an effective and safe technique. geons who specialize in acetabular fracture surgery, and gen-
eral orthopaedic trauma surgeons. The reliability of the classi-
fication was excellent in the first two groups. Use of the CT
Pehle B, Nast-Kolb D, Oberbeck R, Waydhas C, Ruch-
scan in addition to the plain radiographs did not increase the
holtz S: Significance of physical examination and radiog-
reliability of the classification system.
raphy of the pelvis during treatment in the shock emer-
gency room. Unfallchirurg 2003;106:642-648.
In this study, 979 blunt trauma patients were evaluated for Burd TA, Hughes MS, Anglen JO: Heterotopic ossifica-
pelvic instability. Physical examination alone had a sensitivity tion prophylaxis with indomethacin increase the risk of
of 44% and a specificity of 99% for detecting pelvic fracture. long-bone nonunion. J Bone Joint Surg Br 2003;85:700-
Surgically significant pelvic injury could not be reliably ruled 705.
out by examination alone. Patients receiving indomethacin for heterotopic ossifica-
tion prophylaxis were compared with those receiving external
radiation therapy. The 38 patients receiving indomethacin had
Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens a statistically significant increase in the incidence of long bone
FF: The effect of sacral fracture malreduction on the fracture nonunion compared with the 38 patients receiving ex-
safe placement of iliosacral screws. J Orthop Trauma ternal radiation therapy (26% versus 7%). No difference in
2003;17:88-94. the efficacy of both methods of prophylaxis was found in the
In a cadaveric model of a zone 2 sacral fracture, increasing authors previous study.
cranial displacement of the hemipelvis was found to correlate
with a decrease in the space available for the safe placement
of iliosacral screws. Space available for safe screw placement Burd TA, Lowry KJ, Anglen JO: Indomethacin com-
was insufficient at displacements greater than 1 cm. pared with localized irradiation for the prevention of
heterotopic ossification following surgical treatment of
acetabular fractures. J Bone Joint Surg Am 2001;83:
Rommens PM, Hessmann MH: Staged reconstruction of 1783-1788.
pelvic ring disruption: Differences in morbidity, mortal- In this study, 166 patients were treated surgically for a
ity, radiologic results, and functional outcome between fracture of the acetabulum. Seventy-eight patients received ex-
B1, B2/B3, and C-type lesions. J Orthop Trauma 2002;16: ternal beam radiotherapy, 72 received 6 weeks of indometha-
92-98. cin, and 16 patients received no prophylaxis. Grade 3 or 4 het-
A review of functional outcome of 122 patients with surgi- erotopic ossification developed in 7% of the treated groups
cally treated pelvic ring injuries was done. Mortality was higher and 38% of the untreated group. No difference between the
in patients with type C injuries than in those with type B two treated groups was identified.
(15% versus 5%). Higher rates of anatomic reductions were
found in B1 (open-book) injuries than in lateral compression
injuries (B2, B3) or C-type injuries. Good or excellent out-
Haidukewych GJ, Scaduto J, Herscovici D Jr, Sanders
RW, DiPasquale T: Iatrogenic nerve injury in acetabular
comes were obtained in 74% of patients with B1 injuries, 92%
fracture surgery: a comparison of monitored and un-
with B2/B3 injuries, and 71% of those with C injuries.
monitored procedures. J Orthop Trauma 2002;16:297-
301.
Starr AJ, Griffin DR, Reinert CM, et al: Pelvic ring dis- This article is a retrospective review of acetabular fracture
ruptions: Prediction of associated injuries, transfusion surgery performed with and without somatosensory evoked
requirement, pelvic arteriography, complications, and potential or electromyography nerve monitoring. The use of
mortality. J Orthop Trauma 2002;16:553-561. intraoperative nerve monitoring did not decrease the rate of
In a review of 325 trauma patients with pelvic ring injury, iatrogenic nerve palsy. Seven of 10 iatrogenic nerve injuries in
the presence of shock on arrival in the emergency department the monitored group had previously had normal intraopera-
was associated with increased mortality, transfusion require- tive monitoring.
ments, and injury severity score. Mortality of patients present-
ing in shock was 57%. The authors were unable to identify an Moed BR, Carr SE, Gruson KI, Watson JT, Craig JG:
association between fracture classification and outcome or Computed tomographic assessment of fractures of the
fracture presence and/or type of associated injuries. posterior wall of the acetabulum after operative treat-
ment. J Bone Joint Surg Am 2003;85-A:512-522.
Acetabular Fractures In this study, 67 patients with surgically treated posterior
Beaule PE, Dorey FJ, Matta JM: Letournel classification wall acetabular fractures were evaluated for radiographic and
for acetabular fractures: assessment of interobserver functional outcome at a mean of 4 years after injury. Use of
postoperative CT scanning to document reduction revealed a ual, and reproductive function. J Orthop Trauma 1997;
strong correlation between quality of reduction and functional 11:73-81.
outcome. Residual displacement after reduction of posterior
wall fractures was more accurately determined on the CT scan Dalal SA, Burgess AR, Siegal JH, et al: Pelvic fracture
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Moed BR: WillsonCarr SE, Watson JT: Results of opera-
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In the largest published study to date, the authors present
Am 1987;18:25-41.
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A prospective comparison of magnetic resonance venogra-
phy and CT venography as screening examinations for pelvic Matta JM, Siebenrock KA: Does indomethacin reduces
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venography was used as the confirmatory study. The false pos- ular fractures?: A prospective randomized study. J Bone
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for CT venography was 50%. The authors question the use of
either test as the sole means of screening for pelvic deep Routt ML Jr, Simonian PT, Mills WJ: Iliosacral screw
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Bucholz RW: The pathological anatomy of Malgaigne pelvis: A report on 163 patients. Acta Chir Scand 1972;
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Copeland CE, Bosse MJ, McCarthy ML, et al: Effect of treated unstable posterior pelvic ring disruptions. Clin
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also been reported to occur after traumatic hip sublux- Hip Fractures
ations. Early reduction of simple dislocations and General Considerations and Risk Factors
fracture-dislocations has been suggested to lower the Although hip fractures typically occur in elderly, os-
rate of osteonecrosis. Sciatic nerve injuries, most com- teopenic patients, often after a low-energy fall, these in-
monly associated with posterior dislocations, have been juries also occur in younger active patients, usually as a
documented in as many as 8% to 19% of patients. result of high-energy trauma. The number of hip frac-
tures that occur annually continues to rise in proportion
Femoral Head Fractures to the increasing elderly population. Decision making
Femoral head fractures have been categorized by Pipkin regarding treatment is based on fracture pattern, patient
into four types based on location of the fracture frag- age, associated injuries, and medical comorbidities.
ment in relation to the fovea centralis and presence of
associated fractures. Type 1 fractures are inferior to the Clinical and Radiographic Evaluation
fovea, type 2 fractures are superior to the fovea, type 3 In the frail, elderly population with multiple medical co-
also involve a femoral neck fracture, and type 4 also in- morbidities, preoperative medical evaluation and opti-
volve a fracture of the acetabulum. Patients with type 1, mization is important, along with attention to associated
type 2, and type 4 femoral head fractures should un- injuries that often involve the ipsilateral upper extrem-
dergo emergent closed reduction of the hip dislocation ity. Elderly patients with hip fractures should be brought
with postreduction CT scanning to evaluate fracture dis- to surgery as soon as medically optimal; the benefits of
placement. In general, femoral head fractures are early mobilization cannot be overemphasized. In the
treated based on fragment location, size, displacement, younger patient population, life-threatening injuries, if
and hip stability. A nondisplaced or minimally displaced present, should be managed first, and then the hip frac-
Pipkin type 1 fracture can be managed nonsurgically. ture should be treated in an urgent fashion.
Simple excision of a small or comminuted displaced Pip- Most hip fractures will be evident on AP and lateral
kin type 1 fracture can usually be done because this radiographs. However, occult or stress fractures of the
femoral neck may require additional imaging studies for
type of fracture is located below the weight-bearing
diagnosis. MRI can be helpful in not only quickly deter-
dome of the femoral head; larger fragments may require
mining whether a fracture is present but also ruling out
surgical fixation. Pipkin type 2 fractures require accu-
other potential causes of hip pain, such as pubic ramus
rate anatomic reduction and stable internal fixation. Ti-
fractures or osteonecrosis. MRI can also provide infor-
tanium countersunk screw fixation is preferred to allow
mation about fracture location (femoral neck or inter-
subsequent MRI if needed. The anterior Smith-Peterson trochanteric) and fracture verticality. Radionuclide bone
approach is generally preferred because it provides im- scanning can also be useful in this setting, especially if
proved visualization for reduction and internal fixation symptoms have been present for several days; however,
and a lower complication rate as compared with a pos- it cannot provide as much information as MRI.
terior approach. A trochanteric flip approach may be
added. Pipkin type 3 fractures are extremely rare and
usually occur in younger patients. These fractures should
Femoral Neck Fractures
be treated with internal fixation of the femoral neck and
Classification
Multiple classification schemes for femoral neck frac-
femoral head fracture. In older patients with poor bone
tures exist; the Garden classification is the most com-
quality and low functional demands, prosthetic replace-
mon. Although the Garden classification comprises four
ment is probably more predictable and is generally pre-
types, most surgeons group these fractures into those
ferred. Pipkin type 4 fractures are treated based on the
that are displaced (stage III and IV) or nondisplaced
location of the femoral head fracture and the type of as- (stage I and II) because treatment decisions and prog-
sociated acetabular fracture. The most common clinical nosis are also grouped in this manner. The Orthopaedic
scenario is a posterior wall acetabular fracture associ- Trauma Association classification has also been used.
ated with a small, displaced, inferior (infrafoveal) femo- Although more cumbersome, it distinguishes subcapital,
ral head fracture. This combination of injuries may be transcervical, and basicervical fractures and also takes
treated through a Kocher-Langenbeck approach with into account other potentially important variables such
excision of the inferior femoral head fragment and si- as fracture verticality. The Pauwels classification has di-
multaneous internal fixation of the posterior acetabular vided femoral neck fractures based on increasing
wall fracture. A larger (suprafoveal) femoral head frac- amounts of fracture verticality measured from the hori-
ture in this situation may require an anterior exposure, zontal as type 1, less than 30; type 2, 30 to 50; and
for femoral head fracture fixation, and a posterior expo- type 3, more than 50. These fractures are believed to
sure for posterior acetabular wall fixation or the use of behave in biomechanically distinct ways based on the
an extensile approach. increase in shear forces imparted at the fracture site by
Figure 1 AP view (A), and lateral view (B) of a valgus impacted femoral neck fracture treated with three cannulated cancellous screws.
increasing degrees of fracture verticality. Some authors placement can kink any vessels that have not been dis-
have recommended the use of a fixed angle internal fix- rupted by the injury. Additionally, intracapsular tampon-
ation device for higher shear angle (more vertical) tran- ade can occur because of fracture hematoma that may
scervical and basicervical fractures, and cancellous impede blood flow to the femoral head. Clinical data
screws alone for fractures with lower shear angle (more have documented lower rates of osteonecrosis with
horizontal) transcervical fractures based on this theoret- early treatment. A gentle closed reduction attempt is
ical concern. reasonable; however, multiple aggressive attempts at
closed reduction are not indicated because of potential
Nondisplaced Femoral Neck Fractures damage to the remaining femoral head vascularity or
Treatment of nondisplaced fractures is the same regard- potential fracture comminution. If closed reduction is
less of patient age, with internal fixation typically in- excellent, internal fixation should be performed as frac-
volving multiple parallel cannulated cancellous screws. ture pattern (verticality) dictates. If closed reduction
Nonsurgical treatment is reserved for only the most cannot be achieved, then open reduction is indicated.
frail, essentially nonambulatory patients with prohibi- No generally accepted guidelines exist on what consti-
tive medical comorbidity and minimal discomfort from tutes an acceptable femoral neck fracture reduction. In
the injury. Subsequent displacement of nondisplaced or general, anatomic reduction is recommended. A slight
valgus impacted fractures treated nonsurgically has valgus reduction is acceptable; however, any varus
been demonstrated in nearly 40% of patients in a recent should be avoided. Review of a radiograph of the con-
series, accompanied by increased rates of osteonecrosis tralateral hip can assist the surgeon in determining the
and nonunion. Recent cadaveric data demonstrated su- neck-shaft angle that is anatomic for the patient. Typi-
periority of three screws over two screws when used to cally the Watson-Jones or Hardinge approaches allow
stabilize subcapital fractures in an inverted triangular direct visualization of the fracture fragments, anatomic
configuration. It is important to place the screws near reduction, and internal fixation, usually with multiple
the cortex of the femoral neck to allow host bone to parallel cannulated cancellous screws. If the fracture ex-
support the shafts of the screws and avoid varus, short- hibits high verticality and a tendency to shear intraoper-
ening, and external rotation displacement (Figure 1). atively, screws alone are not recommended and a fixed
Rates of nonunion of less than 5% and osteonecrosis of angle device should be used. In one series, transcervical
less than 10% have been reported with this technique. shear fractures exhibited a high failure rate when
Early postoperative mobilization is encouraged. treated with screws alone. More data are needed to de-
termine the ideal fixation device for the vertical femoral
Displaced Femoral Neck Fractures: Young Patients neck fracture.
A displaced femoral neck fracture in the young patient The role of capsulotomy in the treatment of femoral
should be treated expeditiously. In theory, fracture dis- neck fractures remains controversial. Original fracture
Figure 4 Failed fixation and cut-out of a reverse obliquity fracture treated with a
sliding hip screw.
Figure 3 A well-placed sliding hip screw with deep and central position of the lag Intertrochanteric Hip Fractures
screw into the femoral head. Classification
Various classifications for intertrochanteric fractures
have been proposed, but none has been widely ac-
larger diameter femoral heads, and should be consid- cepted. Commonly, fractures are described by the num-
ered when performing total hip arthroplasty in this set- ber of parts and the presence of certain fracture char-
ting. acteristics that indicate greater instability. For example,
a large posteromedial fragment, a reverse obliquity con-
figuration, or subtrochanteric extension are commonly
Complications
considered fracture features that result in more unsta-
Nonunion is rare in the younger patient, with most se-
ble fractures. Intertrochanteric fractures are treated
ries reporting nonunion rates of less than 10%. Second-
similarly regardless of patient age. Choice of internal
ary surgeries such as valgus-producing osteotomies are fixation device should be based on fracture pattern.
successful in ultimately achieving union, probably be-
cause of the excellent bone stock and healing potential
Sliding Hip Screw
in the young patient. Valgus intertrochanteric osteoto-
The most important variables under a surgeons control
mies convert the shear forces of a vertical fracture line when treating an intertrochanteric hip fracture include
to compressive forces by increasing fracture horizontal- correct device selection based on fracture pattern, accu-
ity. Nonunion is more common in the older patient, with rate reduction, and placement of the lag screw into the
rates averaging less than 5% for nondisplaced fractures center of the femoral head. Most intertrochanteric frac-
and to over 30% for displaced fractures. Nonunion in tures can be treated successfully with a sliding hip screw.
the older patient is typically treated with hip arthro- This device offers the advantages of a simple, predict-
plasty. able surgical technique, and a long clinical history of
Rates of posttraumatic osteonecrosis have averaged successful results. An increasing rate of failure and hard-
10% for nondisplaced fractures and 25% for displaced ware cutout with poor implant placement or poor re-
fractures. Not all patients with osteonecrosis will be duction has been documented. The tip to apex distance
symptomatic and require further treatment. The treat- has been described as a guide to accurate screw place-
ment of symptomatic posttraumatic osteonecrosis varies ment, and should be less than 25 mm. Ideally, a center-
with patient age and osteonecrosis grade. center position with the lag screw within 1 cm of the
Figure 5 A, Four-part comminuted intertrochanteric fracture with reverse obliquity. B, Postoperative view after treatment with an intramedullary hip screw.
the most benefit from intramedullary fixation and (low) subtrochanteric fractures. In general, if the pirifor-
whether further design refinements will decrease the mis fossa is intact, a nailing technique is preferred. If the
number of complications noted in earlier series, thereby lesser trochanter is intact and the proximal fragment is
making intramedullary fixation more widely applicable. of sufficient length, then fixation into the femoral head
is usually not necessary and a standard antegrade nail
Primary Prosthetic Replacement with locking into the lesser trochanter is adequate. With
The role of primary prosthetic replacement for intertro- shorter proximal fragments without piriformis fossa in-
chanteric fractures remains controversial. The potential volvement, cephalomedullary reconstruction nailing
advantages of primary prosthetic replacement in the with interlocking screw fixation into the femoral head
face of an unstable intertrochanteric fracture in a pa- and neck is preferred. A preoperative CT scan may be
tient with severely osteopenic bone include relatively helpful to evaluate the integrity of the proximal frag-
predictable pain relief, early mobilization, and the fact ment when plain radiographs are difficult to interpret
that revision rates may be lower. The disadvantages in- because of factors such as patient size or proximal frag-
clude the more extensive nature of the surgical proce- ment rotation. If plating techniques are chosen for com-
dure, the frequent necessity to use calcar replacing, long- minuted fractures, the vascularity of the medial bony
stem cemented implants in medically frail patients, and fragments should be carefully preserved by avoiding dis-
the fact that often comminuted, osteopenic trochanteric section and periosteal stripping in this region. Areas of
fragments need to be stabilized with some form of inter- comminution should be bridged and stable proximal
nal fixation. It should be noted from the literature that and distal fixation should be obtained while maintaining
the overwhelming majority of well-reduced intertro- correct limb alignment, length, and rotation. Such indi-
chanteric hip fractures treated with properly selected rect reduction techniques have demonstrated high union
and accurately implanted internal fixation devices will rates but are technically demanding. Although plating
heal predictably without complication. Additionally, techniques are associated with potentially lower rates of
should failure occur, prosthetic replacement for salvage malalignment, dissection and blood loss can be substan-
of failed internal fixation has demonstrated excellent tial. Biomechanically, intramedullary fixation of subtro-
durability and predictable pain relief. Prosthetic replace- chanteric fractures is generally preferred. Nails provide
ment as the acute treatment of intertrochanteric frac- load-sharing stability that allows early postoperative
tures should be reserved for patients with pathologic weight bearing that plated fractures typically cannot tol-
fractures as a result of neoplasm, neglected fractures erate. This condition may be advantageous in multiple
with deformity and poor bone stock precluding internal trauma patients with other extremity injuries. Nailing
fixation, or for patients in whom internal fixation at- short subtrochanteric fractures can be challenging be-
tempts have failed. Additionally, prosthetic replacement cause of the flexed, abducted, and externally rotated po-
may be a reasonable therapeutic option for patients sition of the proximal fragment. Great care should be
with severe ipsilateral symptomatic degenerative joint taken to avoid varus proximal fragment malalignment,
disease, or certain unfavorable fracture patterns associ- which can occur with conventional antegrade nails
ated with poor bone quality. placed through a starting point that is too lateral. The
use of newer nails designed for entry through the tip of
Subtrochanteric Fractures the greater trochanter may facilitate access to the in-
The subtrochanteric area of the femur experiences some tramedullary canal and result in less potential malalign-
of the highest biomechanical stresses in the human ment for these challenging fractures; however, there are
body. In general, the subtrochanteric region is consid- few data to substantiate this speculation.
ered the anatomic region immediately below the lesser
trochanter to the proximal aspect of the femoral isth- Pathologic Fractures of the Proximal Femur
mus. Various classification systems, including the Metastatic disease commonly involves the proximal fe-
Russell-Taylor classification, have been proposed based mur, affecting the femoral neck in 50%, subtrochanteric
on the location of the fracture relative to the lesser tro- region in 30%, and intertrochanteric region in 20%. De-
chanter and the presence of the fracture line extension cision making regarding whether some form of prophy-
into the piriformis fossa. More proximal subtrochanteric lactic internal fixation or hip arthroplasty is appropriate
fractures often involve extension of the fracture line is based on the anatomic location of the lesion, size of
into the piriformis fossa, which influences internal fixa- the lesion, the extent of bony destruction, and antici-
tion device selection. Multiple fixation methods have pated life expectancy of the patient. In general, lesions
been described, including the use of the sliding hip that cause more than 50% destruction of a cortex or
screw, dynamic condylar screw, or angled blade plate for those that present with functional pain should be stabi-
more proximal (high) subtrochanteric fractures, and in- lized. Complete fractures should be treated surgically in
terlocking cephalomedullary nailing for more distal all but the most infirm patients. High-quality preopera-
tive radiographs of the acetabulum and entire length of ers with traumatic hip subluxation. Two of eight patients de-
the femur are mandatory to evaluate for ipsilateral le- veloped osteonecrosis and required total hip arthroplasty.
sions. Other sites of bony pain should also be evaluated
by plain films and bone scintigraphy. Appropriate pre- Sahin V, Karakas ES, Aksu S, Atlihan D, Turk CY, Halici
operative workup in consultation with an oncologist is M: Traumatic dislocation and fracture-dislocation of the
recommended. A fracture resulting from a solitary hip: A long term follow-up study. J Trauma 2003;54:520-
pathologic lesion of the proximal femur requires a 529.
pathologic tissue diagnosis before internal fixation or Forty-seven patients with hip dislocation and fracture-
prosthetic replacement, even in a patient with a history dislocation were followed for a mean of 9.6 years. Seventy-one
of cancer. These preoperative studies will help avoid the percent had medium to very good results. Sixteen percent de-
rare, but potentially disastrous complication of internal veloped posttraumatic degenerative joint disease, and 9.6%
fixation of a primary malignancy. If necessary, a CT scan developed osteonecrosis. Early reduction improved outcomes.
of the proximal femur and the acetabulum can be ob-
tained to further evaluate for proximal lesions. The en- Femoral Neck Fractures
tire femur should be protected by the internal fixation Bartonicek J: Pauwels classification of femoral neck
device, typically a third-generation cephalomedullary fractures: Correct interpretation of the original.
nail. Lesion debulking and methacrylate augmentation J Orthop Trauma 2001; 15:358-360.
of the fixation construct may be necessary for larger le- This article discusses Pauwels classification and gives the
correct interpretation of the values.
sions. If extensive involvement of the proximal femur
precludes predictable and durable internal fixation, then
prosthetic replacement can provide functional improve- Bhandari M, Devereaux PJ, Swiontkowski MF, et al: In-
ment and pain relief in this cohort. Modular, so-called ternal fixation compared with arthroplasty for displaced
tumor prostheses are available to manage bony defi- fractures of the femoral neck: A meta-analysis. J Bone
ciency and restore leg length and hip stability. Patho- Joint Surg Am 2003;85:1673-1681.
The authors evaluated published trials between 1969 and
logic fractures of the femoral neck, head, and intertro-
2002 on the treatment of displaced femoral neck fractures in
chanteric region often require treatment with prosthetic
patients age 65 years or older. Arthroplasty provided a signifi-
replacement. Medical comorbidities are quite common
cantly lower rate of revision surgery (P = 0.0003) but was as-
and multidisciplinary management with a medical on- sociated with greater blood loss, longer surgical time, and a
cologist, radiation oncologist, or nutritionist is recom- trend toward higher mortality in the first 4 months after sur-
mended. Postoperative radiation to the entire construct gery (not significant).
and surgical bed, after the surgical wound has healed, is
recommended to minimize the chance of tumor progres-
Haidukewych GJ, Israel TA, Berry DJ: Long-term survi-
sion and implant failure. Should fixation failure occur,
vorship of cemented bipolar hemiarthroplasty for frac-
conversion to hip arthroplasty has been shown to pre-
ture of the femoral neck. Clin Orthop 2002;403:118-126.
dictably improve function and relieve pain; however, The results of 212 patients older than age 60 years treated
these reconstructions are plagued by a high rate of post- with cemented bipolar hemiarthroplasty are reported. Overall
operative infection. 10-year survivorship free of reoperation for any reason was
94%. Only one patient was revised for acetabular cartilage
Annotated Bibliography wear. More than 90% of patients had no or minimal pain at
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Hip Dislocations and Femoral Head Fractures
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tramedullary nail versus dynamic screw and plate for in-
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mens with subcapital osteotomies. thors concluded that the routine use of an intramedullary de-
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No difference in functional outcome at midterm follow-up sliding hip screw was used for a reverse obliquity fracture. The
was noted between unipolar and bipolar cemented hemiar- 95 blade plate had the lowest failure rate. Few patients were
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Figure 1 A, AP radiograph of a patient with dysplasia of the right hip. Note the superior inclination of the weight-bearing region (high Tonnis angle), lateralized hip center of
rotation, anterolateral deficiency of the femoral head coverage, and coxa valga. B, A schematic presentation of the same hip demonstrating the various radiographic measure-
ments that can be used to evaluate dysplasia.
Figure 3 The magnetic resonance arthrogram shows the labral destruction and a
secondary ossicle on the femoral neck that resulted from linear contact between the
Figure 2 AP radiograph of a patient with bilateral acetabular retroversion is evident femoral neck and the acetabular rim during flexion (femoroacetabular impingement).
by the crossover (Reynolds) sign of the anterior and posterior walls on the left side. The
patient has undergone reverse periacetabular osteotomy to correct the retroversion.
Note that the anterior and posterior wall marking meet at the point of sourcil and do
not cross. symptoms. The abnormal contact between the femoral
neck and acetabular rim leads to labral injury, particu-
larly in the anterosuperior zone of the acetabulum (Fig-
tory explanation for development of arthritis in young ure 4). The labral tear as seen on arthroscopy or mag-
patients with apparently normal skeletal structures and netic resonance arthrogram is frequently accompanied
intra-articular pressures. Femoroacetabular impinge- by chondral damage. The typical patient with femoroac-
ment has been proposed as a possible etiologic mecha- etabular impingement is young and has groin pain that is
nism for the development of OA in this patient group. exacerbated by activity or long periods of sitting (such as
The condition occurs either as a result of morphologic while driving). Examination of the hip often reveals lim-
abnormality involving the femur (cam) (Figure 4), the itation of motion, particularly internal rotation and ab-
acetabulum (pincer) (Figure 5), or both. Excessive and duction in flexion. The impingement test, which is almost
supraphysiologic demand on the hip may precipitate always positive, is performed with the patient supine. The
Figure 4 A, Schematic presentation shows the mechanism for cam impingement when nonspherical portion of the femoral head abuts against the acetabular rim during hip
flexion. B, The AP radiograph appears normal. C, The nonspherical femoral head leading to reduced offset at the neck and predisposition to cam-type impingement is visible on
the lateral radiograph. D, The magnetic resonance arthrogram confirms labral tear and chondral injury resulting from impingement. (Reproduced with permission from Ganz R,
Parvizi J, Beck M, Leunig M, Ntzli H, Siebenrock KA: Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop 2003;417:112-120.)
hip is internally rotated as it is passively flexed to about ative anterior overcoverage, coxa profunda, protrusio
90 and adducted. Flexion and adduction lead to the ap- acetabuli, coxa vara, or extreme coxa valga may only be-
proximation of the femoral neck and the acetabular rim. come apparent upon systematic examination of the
Forceful additional internal rotation creates a sharp pain plain radiographs. Magnetic resonance arthrogram using
when there is a chondral and/or labral lesion. radial sequences is very useful for diagnosis. If conserva-
The radiographs often appear normal at first glance. tive treatment is unsuccessful, femoroacetabular im-
However, upon detailed review some abnormalities may pingement can be treated by surgical dislocation of the
become apparent. This includes the presence of a bony hip and improvement of femoral head-neck contour.
prominence usually in the anterolateral head and neck The acetabular rim can also be trimmed. A reverse peri-
junction that is best seen on lateral radiographs (Figure acetabular osteotomy may be performed in patients
4, C), reduced anterior offset of the femoral neck and with excessive retroversion and inadequate posterior
head junction, and changes on the acetabular rim such coverage (posterior rim lies medial to a vertical line
as os acetabuli or double line that are seen with rim os- drawn through the center of the head).
sification. Close scrutiny of the femoral neck may reveal
the presence of a herniation pit that is indicative of im- Hip Arthroscopy
pingement. Morphologic changes affecting the acetabu- Hip arthroscopy is being used more often for diagnostic
lum and/or the proximal femur such as retroversion, rel- as well as therapeutic treatment of intra-articular pa-
ever, satisfactory results in terms of hip pain relief and require THA. The results of most pelvic osteotomies
functional improvement may be expected. Compared have been encouraging. The Bernese osteotomy is pre-
with individuals who have not undergone surgery, pa- ferred by most reconstructive surgeons for treatment of
tients who have undergone arthrodesis of the hip have dysplasia in adults because it allows a large degree of
an approximate increase in energy expenditure during correction, permits joint medialization (reducing the
ambulation of 30%. joint forces), does not breach the weight-bearing poste-
Abnormal gait resulting from hip fusion causes in- rior column (allowing early ambulation), does not vio-
creased stress on the lumbar spine, and other joints of late the abductors, and is associated with a relatively
the lower extremities. Low back pain, ipsilateral knee low incidence of complications and morbidities.
pain and instability, and contralateral hip arthritis de-
velop in as many as 60% of patients after hip arthrode- Femoral Osteotomy
sis. Pain in the low back or knee typically develops Femoral osteotomy, a once popular option for treatment
within 25 years of hip fusion and may become disabling of dysplasia, has been mostly abandoned in favor of pel-
over the long term. vic osteotomy. The current indications for femoral os-
Patients with associated contralateral hip, low back, teotomy include severe deformity of the proximal fe-
or knee problems may require conversion of the hip fu- mur, treatment of femoral neck nonunions in young
sion to total hip arthroplasty. Patients undergoing ipsi- patients, and patients with osteonecrosis. Varus-
lateral knee replacement may gain better knee function producing osteotomy (rotation of the proximal femur
if the hip arthrodesis is converted to total hip arthro- into varus) is a valuable option used in isolation or in
plasty (THA) before knee replacement. Low back pain combination with pelvic osteotomy for treatment of
may improve after conversion to THA. Because many symptomatic coxa valga.
patients with arthrodesis will eventually require conver-
sion to THA, this eventual possibility should be taken Osteonecrosis of the Femoral Head
into account during surgery. Suggested surgical tech- The incidence of osteonecrosis is not known with cer-
niques include preservation of the abductor muscula- tainty. Osteonecrosis is more common in males and typ-
ture, placing the hip in 20 to 25 of flexion, and plate ically affects patients in their late 30s or early 40s. Os-
fixation. Because ipsilateral knee and back pain are teonecrosis of the femoral head is bilateral in
more common in patients whose hips are fused in ab- approximately 50% of cases.
duction, neutral abduction is suggested. Symptoms include pain in the groin region that is ex-
acerbated with ambulation and activity. Some patients
Osteotomy with early disease may be asymptomatic; therefore, a di-
Osteotomies around the hip are important biologic agnosis may require a high index of suspicion. MRI or
treatment modalities for patients younger than age 40 to bone scan may show changes in the femoral head before
50 years because they may preserve the host hip joint. plain radiographs.
For symptomatic patients with structural hip abnormali- Osteonecrosis of the femoral head occurs as a result
ties and mild or no arthritis, osteotomy may provide of altered blood supply to the femoral head, which can
long-term pain relief and improve function. result in bone necrosis, subcortical fracture, collapse,
and eventual destruction of the hip joint. In some situa-
Pelvic Osteotomy tions, the etiology of vascular compromise is clear (such
Pelvic osteotomy is indicated for treatment of symptom- as hip dislocation or femoral neck fracture with trau-
atic dysplasia in young, active patients. Pelvic osteotomy matic disruption of the blood vessels). In addition to di-
has traditionally been classified into reconstructive and rect blood flow disruption, other associated causes of
salvage osteotomy. The latter (shelf and Chiari) does not osteonecrosis include corticosteroid use, ethanol abuse,
provide articular cartilage coverage for the femoral and hypercoagulable states. Osteonecrosis is associated
head. Salvage osteotomies have been abandoned in fa- with hip trauma in 10% of patients. More than one third
vor of THA, except in rare circumstances. Reconstruc- of patients have idiopathic osteonecrosis. Patients re-
tive osteotomies rely on redirection of the acetabulum ceiving medical treatment for the virus that causes ac-
to provide better coverage for the femoral head. It is quired immunodeficiency syndrome apparently are at
believed that improvement in femoral head coverage risk for osteonecrosis of the hip and other joints.
halts or retards the progression of the degenerative pro- The widely used classification system for osteonecro-
cess in most of these patients. In a recent review of sis of the femoral head is a modified version of one pro-
more than 800 patients receiving Ganz or Bernese os- posed by Ficat. In stage zero, osteonecrosis changes of
teotomy, the procedure failed in 42 patients and THA the hip are noted only on MRI in an asymptomatic pa-
was required at a mean of 6.8 years after the osteotomy. tient. Stage one osteonecrosis is seen in a symptomatic
Function was not affected in the patients who did not patient with positive MRI findings but no evidence of
abnormalities on plain radiographs. In stage two, radio- provide stability without possibility of subsidence (cal-
graphs reveal sclerotic bone of the femoral head with- car resting stems), whereas others allow controlled sub-
out subchondral bone collapse. In stage three, subchon- sidence of the stem within the cement mantle over time.
dral bone collapse (crescent sign) is seen on plain Surface finish of the component also contributes to the
radiographs. In stage four, there is collapse of the femo- stability of the stem. The roughened surfaces allow bet-
ral head with secondary degenerative changes of the hip ter cement interdigitation and minimize subsidence. The
joint. Poor prognostic factors for osteonecrosis of the smooth stems, on the other hand, permit taper-slip sub-
femoral head include high degree of femoral head in- sidence. There is conflicting evidence in the literature
volvement (greater than 30%) and continued cortico- regarding which type of surface finish will provide bet-
steroid use. ter long-term results. One of the primary mechanisms
Surgical treatment of osteonecrosis of the femoral for failure of cemented stems is initiation and propaga-
head depends on the stage at the time of diagnosis. tion of cracks in the cement mantle through preexisting
Stage four is best managed with hip replacement pores. Modern generation cementing techniques with
whereas precollapse stages (zero, one, and two) may be emphasis on porosity reduction, good pressurization of
initially treated with joint-preserving measures (core de- the cement to obtain a uniform cement mantle, and op-
compression or vascularized fibular graft). The treat- timal interdigitation into cancellous bone is believed to
ment of stage three disease in middle-aged and older be a critical determinant of success of cemented femoral
patients usually is THA; in younger patients, joint- components. The long-term performance of cemented
sparing procedures of hemiresurfacing arthroplasty may femoral stems is likely to be influenced by a combina-
be considered. In recent years bone grafting of the fem- tion of these factors.
oral head by elevating the articular cartilage flap (trap-
door approach) has been attempted for patients with
Cementless Femoral Component
stage two and three disease.
The premise that cement was responsible for the failure
Core decompression involves drilling multiple holes
of hip arthroplasties led to the development of cement-
through the avascular portion of the femoral head un-
less hip components to decrease the incidence of aseptic
der fluoroscopic guidance. Vascularized bone grafting,
on the other hand, involves the use of a vascularized fib- loosening following THA. In recent years, there has
ular graft with microsurgical anastomosis to local blood been a shift toward the use of cementless femoral com-
vessels. The vascularized graft is harvested from the cen- ponents in North America, particularly in young pa-
tral portion of the fibula. It is then inserted through a tients. Various factors are known to influence the per-
drill hole into the avascular zone of the femoral head. formance of cementless femoral components, such as
One recent study noted a survival rate of 67% for post- geometry, surface finish, and the extent of coating. Early
collapse osteonecrosis of the femoral head treated using clinical studies have shown mixed results for cementless
this technique. hip femoral components. Some femoral stem designs
had high failure rates, whereas others have enjoyed
Total Hip Arthroplasty higher rates of success. Durable fixation and a low rate
of thigh pain have been reported for different stem de-
Cemented Femoral Component
signs, including proximally- and extensively-coated
The best choice for fixation of femoral components con-
stems with different geometries. The value of coating
tinues to be a subject of debate. Several studies have re-
the femoral stem with hydroxyapatite is debatable; it
ported excellent mid-term and long-term survivorship
enhanced fixation in one design but has had no influ-
with cemented femoral components, particularly with
ence on the performance of other femoral components.
the use of modern cementation techniques. There are a
number of important factors that affect the outcome of
arthroplasty using a cemented femoral stem. Some of Cementless Cups
these factors are patient selection, geometry and surface Durable results for porous-coated cups have been re-
finish of the implant, femoral neck design of the im- ported by various centers. A recent study reported the
plant, material used for the implant, and surgical tech- 15-year outcome of 120 primary THAs performed with
nique. Overall, younger patients, who are more active, a cementless cup in a relatively young patient popula-
have an increased risk of cemented femoral component tion. More than half of the patients were still alive after
failure than older patients. Men have an approximate 15 years. No cup was revised for loosening. The linear
twofold higher risk of failure than women. Torsional and polyethylene wear was 0.15 mm/yr. Pelvic osteolysis was
axial stability in the cement mantle is an important de- observed in 6.9% of the surviving patients. The durabil-
terminant of the success of cemented femoral compo- ity of fixation was excellent and was superior to that as-
nents. Numerous designs of femoral stems have been sociated with cups that had been inserted with cement
successful in providing stability. Some designs aim to by the same surgeon.
(Reproduced from McKellop HA: Bear surfaces in total hip replacements: State of the art and future developments. Instr Course Lect 2001;50:165-179.)
thought to be related to the presence of smaller car- prophylaxis is preferred in North America. Coumadin
bides, has also been observed with some first- and has been shown to be effective in preventing fatal pul-
second-generation metal-on-metal prostheses. Although monary embolism. Low molecular weight heparin is also
micropitting was not associated with high wear rates, an effective method of prophylaxis but carries a higher
this complication represents an area for potential im- rate of bleeding complications according to most stud-
provement. Hard-on-hard surfaces (metal-on-metal and ies. Mechanical methods such as pneumatic compression
ceramic-on-ceramic) probably have better wear charac- devices have been shown to be effective for reducing
teristics with large femoral heads and these large diame- the prevalence of thrombosis after THA. These devices
ter bearings may also reduce the risk of intra-articular are believed to achieve their efficacy by increasing
impingement and dislocation. However, any intra- blood flow and localized fibrinolysis (systemic fibrinoly-
articular impingement with hard-on-hard surfaces can sis, once believed to be important, could not be demon-
create greater potential problems than with metal-on- strated by a recent study). Oral anticoagulation agents
polyethylene bearings. that do not require serologic monitoring have recently
been tested in clinical trails for prevention of deep
Osteolysis venous thrombosis following total knee arthroplasty,
Improving bearing surfaces and reducing wear particles with promising results.
hopefully will reduce particle-induced periprosthetic os-
teolysis in the future; currently, osteolysis continues to Periprosthetic Fractures After Total Hip
be a major long-term complication of hip arthroplasty. Arthroplasty
Osteolysis generally develops and progresses in the ab- Periprosthetic fractures following THA occur in a vari-
sence of clinical symptoms. Hence, close monitoring of ety of different clinical situations. They may occur intra-
hip arthroplasties to detect and treat osteolysis is impor- operatively, during the postoperative period, or many
tant. Radiographs underestimate the extent of osteoly- years after hip replacement. Periprosthetic fractures
sis, particularly in the periacetabular region. CT with may occur as a result of trauma or secondary to late del-
special software has been used for quantification of pel- eterious effects of hip replacement components on the
vis osteolysis. Osteolysis related to particulate debris oc- surrounding bone (such as osteolysis or stress shield-
curs as a result of phagocytosis of wear debris, which in ing).
turn leads to activation of inflammatory cells (macro- The incidence of intraoperative periprosthetic frac-
phages) and ultimately recruitment of osteoclasts. The tures after THA is higher using cementless rather than
cytokine OPG/RANKL/RANK is believed to be an im- cemented hip replacement components. The location of
portant mediator of differentiation of osteoclasts and intraoperative fractures related to cementless compo-
their interaction with osteoblasts. Osteoprotegrin nents depends on the type of prosthesis used. Wedge-fit,
(OPG) decreases osteoclast differentiation by working tapered stems tend to cause proximal femur fractures
through a receptor-ligand interaction (RANKL). Tumor and cylindrical fully porous-coated stems tend to cause
necrosis factor-, a cytokine released in response to a distal split in the femoral shaft.
phagocytosis of wear particles, is found to have a role in Several classification systems for periprosthetic fe-
stimulating osteoclast formation. mur fractures exist. The Vancouver classification of
periprosthetic fractures takes into consideration the sta-
Dislocation bility of the prosthesis as well as the location of the frac-
In one study, the cumulative risk of any dislocations was ture and the quality of the surrounding bone. Type A
2.2% at 1 year, 3.8% at 10 years, and 6% at 20 years. fractures occur in the trochanteric region. Type B frac-
The 10-year risk was 3.2% for anterolateral approach tures occur around the stem or just below it. Patients in
and 6.8% for posterolateral approach. One third to two subgroup B1 have a well-fixed stem, in B2 the stem is
thirds of dislocations can be treated by closed reduction loose, and in B3 the stem is loose and the proximal bone
without further complications. Dislocation is more com- is of poor quality or severely comminuted. Type C frac-
mon in association with the following factors: postero- tures occur well below the prosthesis.
lateral approach, smaller femoral head size, trochanteric Management of periprosthetic fractures depends on
nonunion, obesity, alcoholism, neuromuscular condi- the location of the fracture as well as the quality of
tions, and revision surgery. bone stock and stability or fixation of the hip arthro-
plasty components. Type A periprosthetic femur frac-
Thromboembolic Disease tures commonly are associated with osteolysis, which
The ultimate goal of prophylaxis is to prevent fatal pul- may require treatment of the process causing osteolysis.
monary embolism. Deep venous thrombosis may also Type B1 periprosthetic fractures almost always are
lead to postthrombotic limb syndrome with swelling, ul- treated surgically, usually with open reduction and inter-
ceration, and extremity pain. The chemical method of nal fixation. Cortical strut allografts, cerclage cables, and
locking plates with unicortical screws may be necessary Ganz R, Gill TJ, Gautier E, et al: Surgical dislocation of
to achieve adequate fixation. Type B2 periprosthetic fe- the adult hip: A technique with full access to femoral
mur fracture (femoral component is loose) usually are head and acetabulum without the risk of avascular ne-
treated with revision of the femoral component and fix- crosis. J Bone Joint Surg Br 2001;83:1119-1124.
ation of the fracture fragment. Type B3 periprosthetic The authors describe a novel technique for surgical dislo-
fractures require femoral component revision. Usually, cation of the hip, based on detailed anatomic studies of the
either proximal femoral allograft or proximal femoral blood supply. The approach involves anterior dislocation
replacement is necessary. Type C periprosthetic femur through a posterior approach with a trochanteric flip osteot-
omy. The external rotator muscles are not divided and the me-
fractures usually are treated with open reduction and in-
dial femoral circumflex artery is protected by the intact obtu-
ternal fixation. The hip replacement components can
rator externus.
usually be left alone.
Periprosthetic acetabular fractures are less common
than femoral fractures. With cementless acetabular com- Ganz R, Parvizi J, Beck M, Leunig M, Ntzli H, Sieben-
ponents, a tight interference fit is achieved by under- rock KA: Femoroacetabular impingement: A cause for
reaming the acetabulum. Underreaming by more than osteoarthritis of the hip. Clin Orthop 2003;417:112-120.
The authors, based on clinical experience with more than
2 mm may create excess stress in acetabular bone, re-
600 surgical dislocations of the hip, allowing in situ inspection
sulting in intraoperative fracture. If acetabular fracture
of the damage pattern and the dynamic proof of its origin, pro-
is noted, additional cup fixation with screws may be
pose femoroacetabular impingement as a mechanism for the
needed. Osteolysis may result in significant weakening
development of early OA for most nondysplastic hips.
of the retroacetabular bone. Fracture through this weak-
ened bone can cause acute failure of the acetabular
component.
Hip Arthroscopy
Clarke MT, Arora A, Villar RN: Hip arthroscopy: com-
Prevention of periprosthetic fractures requires rec-
plications in 1054 cases. Clin Orthop 2003;406:84-88.
ognition of risk factors. Adequate surgical exposure dur- Complications in a large series of hip arthroscopies are re-
ing primary and revision procedures is necessary. Con- viewed.
trolled osteotomy is preferable to damaging weak
proximal femoral bone during retraction or implant re-
moval. Special care must be taken when using cement- McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J:
The role of labral lesion to development of early degen-
less implants in patients with poor bone stock, such as
erative hip disease. Clin Orthop 2001;393:25-37.
those with rheumatoid arthritis or severe osteoporosis.
Arthroscopic findings in a large series of hip arthroscopies
Cortical perforations must be bypassed with the im-
are correlated with cadaveric specimens to support the idea
plant, structural bone graft, or fracture plate to a suffi- that acetabular labral tears and degenerative arthritis are part
cient degree to avoid a stress riser. Careful, regular of a continuum of disease.
follow-up of arthroplasty patients is necessary to evalu-
ate for failure of implants. Elective revision of failed im-
Osteonecrosis of the Femoral Head
plants with osteolysis and mechanical failure of compo-
Berend KR, Gunneson EE, Urbaniak JR: Free vascular-
nents may prevent some periprosthetic fractures.
ized fibular grafting for the treatment of postcollapse
osteonecrosis of the femoral head. J Bone Joint Surg
Annotated Bibliography Am 2003;85:987-993.
Femoroacetabular Impingement A survival rate of 67% is noted for postcollapse osteone-
Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz crosis of the femoral head treated with free vascularized fibula
R: Anterior femoroacetabular impingement: Part II. grafting.
Midterm results of surgical treatment. Clin Orthop 2004;
418:67-73. Total Hip Arthroplasty
The outcome of surgical dislocation and osteoplasty of the Boucher HR, Lynch C, Young AM, Engh CA Jr, Engh C
femur and the acetabulum in 19 patients with a mean age of Sr: Dislocation after polyethylene liner exchange in to-
36 years (range, 21 to 52 years) was reported. The follow-up tal hip arthoplasty. J Arthroplasty 2003;18:654-657.
averaged 4.7 years (range, 4 to 5.2 years). Using the Merle Twenty-four patients undergoing an isolated polyethylene
dAubigne hip score, 13 hips were rated excellent to good. In liner exchange for wear or osteolysis with retention of the ace-
the hips without subluxation of the head into the acetabular tabular shell and femoral stem were assessed. At a mean 56-
cartilage defect, no additional joint space narrowing occurred. month follow-up, six hips (25%) had dislocated. Of these, two
According to this study, surgical dislocation with correction of underwent repeat surgery for recurrent dislocation; one had
femoroacetabular impingement yields good results in patients three dislocations, one had two dislocations, and two had sin-
with early degenerative changes not exceeding grade 1 os- gle dislocations. It was concluded that polyethylene liner ex-
teoarthrosis. changes, with or without femoral head exchange for wear or
osteolysis, are associated with a high risk of dislocation and precoating is not detrimental to successful fixation of primary
possible decrease in function. hybrid THA.
Davis CM III, Berry DJ, Harmsen WS: Cemented revi- Laupacis A, Bourne R, Rorabeck C, Feeny D, Tugwell P,
sion of failed uncemented femoral components of total Wong C: Comparison of total hip arthroplasty per-
hip arthroplasty. J Bone Joint Surg Am 2003;85:1264- formed with and without cement: a randomized trial.
1269. J Bone Joint Surg Am 2002;84:1823-1828.
Forty-eight consecutive hips in which a failed primary ce- The study reported the intermediate-term outcome of a
mentless femoral component was revised with use of cement prospective, randomized clinical trial in which 250 patients
at the Mayo Clinic. Rate of loosening at the time of were randomly assigned to receive a hip prosthesis with ce-
intermediate-term follow-up was higher than that commonly ment or the same prosthesis designed for insertion without ce-
reported after revision of failed cemented implants with use of ment. At 6.3-year follow-up, the number of stem revisions in
cement and also was higher than that commonly reported af- the group that had fixation with cement was significantly
ter revision with use of cementless extensively porous-coated higher than that in the group that had fixation without cement
implants. (P < 0.002).
Gaffey JL, Callaghan JJ, Pedersen DR, Goetz DD, Sulli- Parvizi J, Sharkey PF, Hozack WJ, Orzoco F, Bissett GA,
van PM, Johnston RC: Cementless acetabular fixation at Rothman RH: Prospective matched-pair analysis of
fifteen years: A comparison with the same surgeons re- hydroxyapatite-coated and uncoated femoral stems in
sults following acetabular fixation with cement. J Bone total hip arthroplasty: A concise follow-up of a previous
Joint Surg Am 2004;86:257-261. report. J Bone Joint Surg Am 2004;86:783-786.
The outcome of THA using Harris-Galante I cementless This prospective study reporting the results of THA using
acetabular component and cemented femoral stem in 120 pa- tapered cementless femoral component with and without hy-
tients at 13 to 15 years was evaluated. No acetabular compo- droxyapatite coating in a matched-pair group of 52 patients
nent had been revised because of aseptic loosening, and no ac- noted no difference in osseointegration, revision rate, or radi-
etabular component had migrated. Among the 70 hips with at
olucency between the femoral components in each group at
least 13 years of radiographic follow-up, 5 had pelvic osteolysis
9.8-year follow-up.
and 3 had revision of a well-fixed acetabular component be-
cause of pelvic osteolysis secondary to polyethylene wear. The
mean linear wear rate was 0.15 mm/yr. Patel JV, Masonis JL, Bourne RB, Rorabeck CH: The
fate of cementless jumbo cups in revision hip arthro-
plasty. J Arthroplasty 2003;18:129-133.
Klapach AS, Callaghan JJ, Goetz DD, Olejniczak JP, This study reported 5-year minimum results of cementless
Johnston RC: Charnley total hip arthroplasty with use
oversized cups used in revision hip arthroplasty, with signifi-
of improved cementing techniques: A minimum twenty-
cant associated bone defects. Forty-three porous-coated jumbo
year follow-up study. J Bone Joint Surg Am 2001;83:
cups were used to treat acetabular defects in revision hip ar-
1840-1848.
throplasty in 42 patients with a mean age of 63 years (range,
Of the 91 hips in the 82 patients who were alive at a mini-
25 to 86 years). Morcellized allograft only was used in 27 hips,
mum of 20 years, authors reported five (5%) revisions for
and bulk allograft was used in 8. At a mean follow-up of 10
aseptic loosening of the femoral component. The rate of fail-
years, two acetabular components were revised for aseptic
ure when radiographic signs of loosening were included was
loosening and graft resorption. Dislocation occurred in two
4.8%. Adequate filling of the femoral canal with cement was
found to be associated with improved survival of the femoral hips. A satisfactory 92% Kaplan-Meier shell survival rate was
component. seen at 14 years.
Lachiewicz PF, Messick P: Precoated femoral compo- Teloken MA, Bissett G, Hozack WJ, Sharkey PF, Roth-
nent in primary hybrid total hip arthroplasty: Results at man RH: Ten to fifteen-year follow-up after total hip ar-
a mean of 10-year follow-up. J Arthroplasty 2003;18:1-5. throplasty with a tapered cobalt-chromium femoral
This study reports the midterm results of a precoated fem- component (tri-lock) inserted without cement. J Bone
oral component used in primary hybrid THA. Of an original Joint Surg Am 2002;84:2140-2144.
cohort of 98 hips undergoing THA performed by one surgeon, Excellent 15-year results were reported in a study of 49
75 hips in 65 patients were prospectively followed up for 7 to patients receieving tapered cobalt-chromium, collarless,
12 years. All hips had the same porous-coated acetabular com- proximally-coated tapered stems. No stems were revised for
ponent and a precoated femoral component (with an oval loosening, while two were judged to be loose radiographically.
cross-section) implanted using bone cement. There was no Most importantly, no stem that was judged to be bone-
femoral component loosening or revision. The authors con- ingrown at 2 years afer surgery progressed to loosening.
cluded that if used in this manner in this patient population,
inhibits wear debris-induced osteolysis. J Bone Joint McDonald DJ, Fitzgerald RH Jr, Ilstrup DM: Two-stage
Surg Am 2002;84:1405-1412. reconstruction of a total hip arthroplasty because of in-
The role of gene therapy using a recombinant adeno- fection. J Bone Joint Surg Am 1989;71:828-834.
associated viral vector expressing OPG, a natural decoy pro-
tein that inhibits osteoclast activation and bone resorption, to
Mont MA, Carbone JJ, Fairbank AC: Core decompres-
inhibit wear debris-induced osteolysis in a mouse calvarial
sion versus nonoperative management for osteonecrosis
model was investigated. A single intramuscular injection of the
vector efficiently tranduced myocytes to produce high levels
of the hip. Clin Orthop 1996;324:169-178.
of OPG. The OPG effectively inhibited wear debris-induced
osteoclastogenesis and osteolysis. Reynolds D, Lucas J, Klaue K: Retroversion of the ace-
tabulum: A cause of hip pain. J Bone Joint Surg Br 1999;
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Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA:
Charnley J, Eftekhar N: Postoperative infection in total Treatment of osteonecrosis of the femoral head with
prosthetic replacement arthroplasty of the hip joint with free vascularized fibular grafting: A long-term follow-up
special reference to the bacterial content of the air in study of one hundred and three hips. J Bone Joint Surg
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Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timper- Younger TI, Bradford MS, Magnus RE, Paprosky W: Ex-
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William M. Ricci, MD
Femoral Shaft Fractures juries. The mechanism of injury should heighten the sus-
Classification picion for other particular injuries. Motor vehicle crashes,
The Winquist and Hansen classification system for fem- especially those with dashboard impact, have a high inci-
oral shaft fractures is based on the diameter of bone that dence of associated knee pathology (up to 60%), includ-
is comminuted (Figure 1). Type I fractures have a small ing ligamentous injuries, meniscal injuries, and bone con-
area of comminution, with greater than 75% of the diam- tusions. Knee stability should be evaluated with the
eter of the bone remaining in continuity. Type II fractures patient under anesthesia and immediately after bony sta-
have increased comminution, but with at least 50% of the bilization. Patients with persistent knee pain should be
diameter intact.Type III fractures have less than 50% cor- evaluated for occult internal derangement and bone con-
tical contact. Type IV fractures are defined as having no tusion. Falls from a height can be associated with other in-
abutment of the cortices at the level of the fracture to pre- juries that are common after axial loading such as calca-
vent shortening. Type I and II fractures are axially stable, neal fractures and spinal compression fractures. Visceral,
whereas type III and IV fractures are both axially and ro- chest, and head trauma should always be a consideration
tationally unstable. Rotational stability for less commi- in patients with high-energy femoral shaft fractures.
nuted fractures is determined by the amount of commi- Bleeding at the site of the fracture is usually self-limited,
nution and obliquity of the fracture, with more transverse but several hundred milliliters of blood can be lost. In pa-
fracture patterns being less rotationally stable.Axially sta- tients with bilateral femoral shaft fractures or those with
ble fractures are more amenable to earlier weight bear- other long bone fractures, the cumulative bleeding asso-
ing, especially after intramedullary (IM) nailing. ciated with these fractures can become clinically signifi-
The AO/Orthopaedic Trauma Association (OTA) clas- cant. These patients should be monitored closely for ane-
sification system is also commonly used, especially for mia and hemodynamic changes.Associated neurovascular
comparative investigations (Figure 2). Fractures of the injury is uncommon, but patients with diminished or
femoral shaft are designated as 32. Type 32A fractures asymmetric pulses should be carefully evaluated for this
are simple (without comminution), type 32B are commi- type of injury. Neurologic deficit associated with penetrat-
nuted but maintain some degree of cortical continuity be- ing trauma may require acute surgical exploration. Al-
tween the proximal and distal shaft fragments, and type though found in only 2.5% to 6% of patients with femoral
32C fractures have complete loss of continuity between shaft fractures, associated femoral neck fractures have a
the proximal and distal fragments. Further subtypes rep- high incidence (> 30%) of misdiagnosis. All patients with
resent increasing fracture complexity. femoral shaft fractures should have AP and lateral radio-
The location of the fracture along the length of the graphic views of the entire femur and a separate evalua-
shaft is usually described as being of the proximal, mid- tion of the femoral neck with at least AP and lateral ra-
dle, or distal one third. There is some overlap between diographic views. CT scans, which are often performed to
subtrochanteric fractures and proximal one third shaft evaluate the abdomen and pelvis, can be useful to diag-
fractures. Fractures located within 5 cm of the lesser tro- nose nondisplaced associated femoral neck fractures and
chanter are considered to be in the subtrochanteric re- have been advocated as routine screening in patients at
gion. high risk.
Evaluation Treatment
Fractures of the femur are usually associated with rela- Nonsurgical Treatment
tively high-energy trauma.Accordingly, patients should be Nonsurgical treatment has a very limited role for adult
carefully and systematically evaluated for associated in- patients with femoral shaft fractures. Severely debili-
Intramedullary Nailing
Reamed locked antegrade IM nailing through the piri-
formis fossa remains the gold standard for treatment of
femoral shaft fractures. Healing rates as high as 99%
with low complication rates have been achieved with
this treatment. Patients with multiple injuries who are
treated with early fracture stabilization (within 24
hours) have an improved prognosis, decreased mortality,
and fewer pulmonary complications (adult respiratory
distress syndrome, fat embolism syndrome, pneumonia,
and pulmonary failure). The advantage of early stabili-
zation is therefore magnified in patients with chest
trauma. Prospective randomized trials have shown that
reamed nail insertion provides better healing rates than
nonreamed insertion. Increased IM pressures and fat
embolization during the reaming process has made
reaming controversial in patients with chest and lung in-
jury. Evidence indicates that the clinical relevance of
marrow content embolization during the reaming pro-
cess is negligible and is outweighed by the benefits of
Figure 2 The AO classification of femur fractures. Simple (A), Wedge (B), Complex (C).
reaming on the healing process. Nonetheless, sharp (Reproduced with permission from Mller ME, Nazarian S, Koch P, Schatzker J (eds):
reamers, proper reamer design, and slow passage of the The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany,
reamer can decrease IM pressures and fat embolization Springer-Verlag, 1990.)
Obese Patients
Complications
It is estimated that approximately 30% to 40% of adults Malalignment
in the United States are obese. Difficulty in obtaining a Fractures of the middle third of the shaft have a low in-
proper starting point for antegrade nailing in obese pa- cidence of angular malalignment (2%), whereas frac-
tients has been recognized, and is responsible for the in- tures of the proximal and distal thirds of the shaft are at
creased number of complications when nailing with an highest risk of malalignment (30% and 10%, respec-
entry site through the piriformis fossa is performed. Bet- tively). Antegrade nailing can facilitate improved reduc-
ter results have been obtained with nailing through the tion for proximal fractures, and retrograde nailing can
tip of the greater trochanter, especially with newer im- be used for distal fractures. All patients should be evalu-
plants that have a proximal lateral bend designed for ated for rotational symmetry compared with the unin-
this insertion site. Patient obesity is a relative indication jured limb before leaving the operating room. When ro-
for retrograde nailing. tational malalignment is identified, immediate
correction should be performed.
Floating Knee (Ipsilateral Associated Tibial Fracture)
Femoral shaft fractures associated with tibial fractures Delayed Unions and Nonunions
(the floating knee) are usually caused by high-energy in- Dynamization for nonunited femoral shaft fractures has
jury mechanisms. Good results, similar to those found been less successful than for tibial fractures and should
after high-energy isolated injury, have been obtained be reserved for axially stable fracture patterns to avoid
with retrograde nailing of the femur followed by ante- limb shortening. Reamed nailing (exchange nailing with
grade nailing of the tibia through a single anterior knee the presence of a prior nail) is the treatment of choice
approach. for femoral shaft nonunions, particularly in the absence
of angular deformity. Nonunion repair with compression
Ipsilateral Proximal Femur and Shaft Fractures plate osteosynthesis with judicious use of autologous
Femoral shaft fractures associated with femoral neck or bone graft is an effective alternative, especially when ex-
intertrochanteric fractures are challenging injuries to change nailing has failed or when deformity correction
treat. The femoral neck component of such injuries is is necessary.
Other Complications
Use of the hemilithotomy position for antegrade femo-
ral nailing increases compartment pressures in the non-
operated leg. Prolonged use of this position should be
avoided to prevent contralateral leg compartment syn-
drome, especially in patients with injury to the con-
tralateral limb. Excessive and prolonged traction against
a perineal post should be avoided to minimize the risk
of pudendal and sciatic nerve injury from compression
and stretch, respectively.
Figure 3 The Mller classification system of supracondylar/intracondylar femur frac-
Supracondylar/Intracondylar Femur Fractures tures. (Reproduced with permission from Mller ME, Nazarian S, Koch P, Schatzker J
(eds): The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany,
Classification Springer-Verlag, 1990.)
According to the AO/OTA classification, supracondylar/
intracondylar femur fractures are designated as type
33 (Figure 3). Type 33A fractures are extra-articular, tients who are nonambulatory, or for those who are not
type 33B are partially articular (with a portion of the ar- candidates for surgery. Long leg casts or cast-braces can
ticular surface remaining in continuity with the shaft), be used in such circumstances, but they are associated
and type 33C fractures are completely articular (no part with poor results when treating displaced fractures in
of the articular surface remains in continuity with the ambulatory patients.
shaft). Subtypes of 33A fractures, 33A1 to 33A3 repre-
sent increasing comminution of the metaphyseal frac- Surgical
ture. Subtypes of 33B fractures represent unicondylar Most supracondylar and intracondylar distal femur frac-
sagittal splits of the lateral femoral condyle (33B1), me- tures are amenable to surgical fixation with either plate
dial femoral condyle (33B2), or fracture in the frontal osteosynthesis or IM nailing. Surgical goals include ana-
plane, the so-called Hoffa fracture (33B3). Subtypes of tomic reconstruction of the articular surface with resto-
33C fractures represent simple articular with simple ration of limb length, alignment, and rotation with sta-
metaphyseal fractures (33C1), simple articular with ble fixation to allow early mobilization and knee range
comminuted metaphyseal fractures (33C2), and frac- of motion. The more distal the fracture and the more
tures with articular comminution (33C3). intra-articular involvement, the more amenable such
fractures are to plate and screw osteosynthesis. As is
Treatment true of most articular fractures, the articular reduction
Nonsurgical and fixation is of paramount importance. After this ob-
Nonsurgical treatment may be indicated for nondis- jective is accomplished, the articular segment is attached
placed extra-articular supracondylar fractures, for pa- to the shaft with attention to proper length, alignment,
Table 1 | Schatzker Classification of Tibial Plateau are completely displaced. A fourth type, the commi-
Fractures nuted tibial eminence fracture, has been described.
Arthroscopically-Assisted Reduction
Several authors have advocated arthroscopy as an ad-
junctive technique in the treatment of tibial plateau
fractures. Stated advantages include assessment and
treatment of associated intra-articular ligamentous and
meniscal injuries. A direct assessment of the articular re-
duction can be obtained with arthroscopy. A potential
complication associated with arthroscopically-assisted
reduction and fixation of tibial plateau fractures in-
volves the extravasation of arthroscopy fluid through
the fracture planes and into the lower extremity com-
partments. Compartment syndrome has been reported
after using this technique. Arthroscopic fluid pumps
should not be used or should be kept at low pressure in
these circumstances. No studies have shown superior
outcomes for tibial plateau fractures treated with ad-
junctive arthroscopy.
Annotated Bibliography
Patellar Fractures
Stein DA, Hunt SA, Rosen JE, Sherman OH: The inci-
dence and outcome of patella fractures after anterior
cruciate ligament reconstruction. Arthroscopy 2002;18:
578-583.
In eight patients, the diagnosis of patellar fractures was
made after 618 ACL bone-patellar-bone autograft reconstruc-
tions. Five of the injuries were the result of indirect trauma
and three were the result of direct injury. All patients regained
a full flexion arc. These outcomes were consistent with the re-
maining population of patients with ACL reconstructions. The
authors determined that there were minimal residual sequelae
after postoperative patellar fracture following ACL recon-
struction.
tibial plateau fractures: Arthroscopic versus fluoroscopic In this study of 105 patients with 110 open tibial fractures
control of reduction. J Orthop Trauma 1999;13:426-431. treated with external fixation or IM nailing, smoking was
Thirty-three patients with unicondylar tibial plateau inju- noted to have a deleterious effect on healing. A union rate of
ries were reviewed; 10 had arthroscopically assessed reduction. 84% occurred in patients who smoked compared with 94% of
The remaining 23 patients had the reduction judged fluoro- those who did not smoke. A higher incidence of delayed
scopically. The authors concluded that there was no difference unions and nonunions occurred in the smoking group com-
in arthroscopic compared with fluoroscopic assessment of re- pared with the nonsmoking group.
duction in terms of outcome after limited internal fixation of
unicondylar tibial plateau fractures.
Ricci WM, OBoyle M, Borrelli J, Bellabarba C, Sanders
R: Fractures of the proximal third of the tibial shaft
Shepherd L, Abdollahi K, Lee J, Vangsness T Jr: The treated with intramedullary nails and blocking screws.
prevalence of soft-tissue injuries in nonoperative tibial J Orthop Trauma 2001;15:264-270.
plateau fractures as determined by magnetic residence In 12 patients with proximal third tibial shaft fractures
imaging. J Orthop Trauma 2002;16:628-631. treated with IM nailing and blocking screws, the authors con-
Twenty nonsurgically treated tibial plateau fractures were
cluded that posterior and lateral blocking screws in the proxi-
evaluated with MRI; 80% had meniscal tears and 40% had
mal fracture reduced procurvatum and valgus malalignment,
complete ligamentous disruptions. Meniscal injuries were asso-
respectively. These complications are associated with the nail-
ciated with lateral condylar fractures or bicondylar fractures
ing of proximal third tibial shaft fractures. The authors con-
and less with medial condylar fractures. The authors concluded
that the use of MRI for tibial plateau fractures can result in cluded that blocking screws for proximal third tibial fractures
the diagnosis of many soft-tissue injuries. are a useful adjunctive technique to control reduction during
IM nailing.
Tibial Shaft Fractures
Bhandari M, Tornetta P III, Sprague S, et al: Predictors Schmitz MA, Finnegan M, Natarajan R, Champine J: Ef-
of reoperation following operative management of frac- fect of smoking on tibial shaft fracture healing. Clin
tures of the tibial shaft. J Orthop Trauma 2003;17:353- Orthop 1999;365:184-200.
361. In a study of 146 tibial fractures treated either surgically
Two hundred patients with tibial shaft fractures were eval- or nonsurgically, absolute union rate was not significantly dif-
uated for predictors of reoperation within 1 year of the index ferent between smokers and nonsmokers. However, time to
procedure. Variables that were prognostic for reoperation in- union was significantly delayed in patients who smoked with
cluded an open fracture wound, lack of cortical continuity be- average time to healing at 136 days for nonsmokers and 269
tween the fracture ends after fixation, and a transverse frac- days for smokers. In patients treated nonsurgically, these dif-
ture pattern. ferences were not significant.
Bosse MJ, MacKenzie EJ, Kellam JF, et al: A prospec- Toivanen JA, Vaisto O, Kannus P, Latvala K, Honkonen
tive evaluation of the clinical utility of the lower ex- SE, Jarvinen J: Anterior knee pain after intramedullary
tremity injury severity scores. J Bone Joint Surg 2001;83: nailing of fractures of the tibial shaft: A prospective,
3-14. randomized study comparing two different nail-
The Lower Extremity Assessment Project (LEAP Study) insertion techniques. J Bone Joint Surg Am 2002;84-A:
was a National Institutes of Health investigation to evaluate
580-585.
limb salvage versus amputation in severe lower extremity inju-
In this randomized study of 50 patients undergoing either
ries. An open fracture classification system was clearly defined
transtendinous or paratendinous tibial nailing, 21 patients in
by the LEAP authors, so that final grading was determined at
both groups had an average 3-year follow-up. No difference
the time of definitive closure or amputation. Analysis of pro-
was noted in anterior knee pain with either approach. Knee
spective data for 556 high-energy, lower extremity injuries re-
scoring systems, muscle strength measurements, and functional
vealed that none of the tested limb salvage indices demon-
tests showed no significant difference between the techniques.
strated any validated clinical utility. Additionally, a high
specificity confirmed that limb salvage with low index scores The authors concluded that there were no significant differ-
could be predicted, but a low sensitivity failed to support any ences in outcomes for patients treated with the transpatellar
index as a valid predictor of amputation. Currently, no limb versus peritendinous approach for tibial nail insertion.
salvage index has been statistically confirmed to be reliable in
the evaluation and treatment of patients with severely man- Classic Bibliography
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MB: Deleterious effect of smoking on healing of open analysis. J Orthop Trauma 2000;14:2-9.
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Bosse MJ, MacKenzie EJ, Kellam JF, et al: A prospec- fragments after insertion of small-diameter intramedul-
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Collateral Ligament Injury ruption of the LCL with associated posterolateral cor-
Injuries to the medial collateral ligament (MCL) occur ner tears with involvement of a cruciate ligament is
much more frequently than to the lateral collateral liga- likely. Primary surgical repair is indicated, usually with
ment (LCL). The mechanism of MCL injury is a valgus cruciate reconstruction. In combined injuries to the
force caused by lateral contact to the knee or lower leg, LCL and posterolateral corner, MRI can help localize
which either injures the distal femoral physis (in the the site of injury (femur versus midsubstance versus fib-
skeletally immature patient), MCL (in the young to ular head) and identify associated injuries.
middle-aged adult), or the lateral tibial plateau (in the Figure 1 outlines the evaluation and treatment ap-
middle-aged to older adult or senior citizen). Careful proach. Evaluation for growth plate injuries in adoles-
physical examination of the knee can confirm the pres- cents, for instability in extension (indicating a postero-
ence of a Salter-Harris injury to the distal physis in the lateral or medial capsular tear), and for complete
adolescent athlete; pain proximal to the normal inser- cruciate ligament injuries is essential. Isolated injuries
tion of the MCL and, more importantly, pain extending documented on physical examination are usually treated
across the femur to the lateral side is common. Radio- nonsurgically with protection from valgus (MCL) and
graphs or MRI also can confirm diagnosis. Physical ex- varus (LCL) forces in the healing phase.
amination determines whether treatment of MCL or
LCL sprains is nonsurgical (majority of tears) or surgi-
cal (associated with cruciate and/or posteromedial cor- Anterior Cruciate Ligament Injury
ner tears). Isolated injuries to the MCL are most com- The physical examination, imaging, timing of surgical re-
mon, with knee laxity at 20 to 30 of flexion; however, construction, and rehabilitation of the ACL have been
these injuries are stable with the knee in full extension well defined in the literature. However, there has been
(indicating intact posteromedial capsule). Isolated MCL intense scientific activity on the choice of autograft, with
injuries associated with anterior cruciate ligament several randomized clinical trials comparing patellar
(ACL) tears are usually treated nonsurgically at the tendon with hamstrings. New techniques for hamstring
time of ACL reconstruction. In the relatively rare case fixation have improved stability of the construct and al-
of MCL injuries with laxity in full extension, the poster- lowed more aggressive rehabilitation.
omedial corner is torn and usually one or both cruciates The most common mechanisms of injury for ACL
have been torn. In this circumstance, MRI to localize tears are noncontact (approximately 70%), sports-
the site of the tear and fully define the associated inju- related (approximately 80%), and recollection of a
ries (especially of the cruciates) is helpful in surgical re- pop (approximately 70%). The overwhelming major-
construction of one or both cruciates and repair of the ity of patients do not return to play in most sports after
MCL and posteromedial capsule tears. the injury without surgery. Contact injuries are more
Isolated injuries to the LCL are relatively rare but likely to involve MCL injuries. Patients injured while
can occur with a contact mechanism that causes a com- jumping have a significant increase in intra-articular in-
plete ACL rupture. juries. Female athletes have a twofold to fourfold in-
If laxity is present only in 20 to 30 of flexion, a pal- creased risk of ACL tears when participating in the
pable LCL in the figure-of-4 position is found, and no same sports and at the same levels as male athletes.
laxity is present in full extension, then a complete dis- Physical examination remains the mainstay in diag-
ruption of LCL is not present and the knee can be pro- nosis of ACL (Lachman test) and PCL (posterior
tected from varus stress with a brace. When significant drawer test) tears. A positive Lachman test is the ab-
laxity is present in full extension, then a complete dis- sence of a firm end point with or without a perceived in-
crease in excursion. A complete ACL tear is confirmed common during motor vehicle crashes (higher-velocity
by a positive pivot shift test. Radiographs are normal in mechanism of injury) and are discussed in the section
more than 95% of young, active athletes. The rare pres- on multiple ligament injuries.
ence of a tiny fleck of bone on the lateral side at the lat-
eral tibial plateau is indicative of a Segond fracture, Anterior Cruciate Ligament Reconstruction
which is pathognomonic for an ACL tear. In the middle- Patients with partial tears of the ACL or PCL who meet
aged athlete, radiographs obtained while the patient is the criteria outlined in Figure 2 can achieve a high level
standing should be reviewed for evidence of arthritis of function and return to sports after rehabilitation. The
(narrowing of joint or cartilage space) or evidence of a variables that need to be considered in the decision of
chronic ACL tear (notch stenosis and tibial spine spurs). whether to reconstruct the ACL-deficient knee without
MRI is particularly helpful when the diagnosis is in a complete tear of the collateral ligaments or PCL are
doubt or for identifying clinically relevant pathology, in- diagrammed in Figure 3. Key factors to consider include
cluding collateral tears or bucket handle meniscus tears. the presence of a repairable meniscus lesion, desired re-
Figure 2 outlines recommended treatment approaches turn to competitive sports activity, and involvement in
for a patient whose cruciate ligament is injured during sports activity involving cutting and pivoting. Prerequi-
sports activity. Complete posterior cruciate ligament sites to ACL reconstruction are nearly full range of mo-
(PCL) tears are extremely uncommon during sports ac- tion, good quadriceps tone, normal gait, and limited ef-
tivity (relatively low-velocity mechanism of injury), with fusion; all are signs that the knee has recovered from
the exception of occasional knee dislocations. However, acute inflammatory trauma of hemarthrosis and that ar-
PCL tears involving one or both collateral ligaments are throfibrosis is less likely to develop postoperatively. Al-
though the exact type and frequency of supervised reha- (HTO) is indicated if a varus thrust is seen with or with-
bilitation for patients undergoing ACL reconstruction out medial arthritis because without correction of me-
has not been determined, monitored rehabilitation by a chanical axis, the ACL graft will eventually fail because
qualified therapy team immediately after surgery is varus thrusting overstresses the graft. The decision to
helpful. Successful home rehabilitation protocols all in- perform an HTO should be based on the patients
clude preoperative instruction, written materials for pa- symptoms and the shift of the weight-bearing axis or
tients, regular supervised intervals, and the option for away from a degenerative medial compartment. If ar-
patients to call for advice. Principles of rehabilitation in- thritic symptoms are believed to be the predominant
clude immediate range-of-motion exercises, early weight complaint, then HTO should be considered before ACL
bearing, closed chain exercises, safe restoration of quad- reconstruction. Unless an experienced surgeon is confi-
riceps strength, and an emphasis on proprioceptive dent that stable fixation of HTO and ACL graft can be
training to guide the safe return to sports activity. achieved so that early motion can begin, staging of these
There has been debate on the definition of acute procedures may be more advantageous.
versus delayed or chronic ACL reconstruction. As men- An evidence-based review of ACL ligament surgery
tioned previously, a prerequisite consideration for ACL shows that the results of randomized clinical trials sup-
reconstruction is restoration of the normal activities of port the failure of primary repair, and an improved sta-
daily living, which indicates that acute inflammatory bility and decreased rate of meniscus reinjury after ACL
trauma has subsided and is important in the prevention reconstruction. Randomized trials have not shown dif-
of postoperative arthrofibrosis. Reinjury to an ACL- ferences in outcomes using autograft patellar tendon
deficient knee has been shown to increase the frequency versus hamstring approaches, or arthroscopic surgical
of meniscal tears and articular cartilage injuries, includ- techniques (two-incision [rear entry] versus single-
ing arthritis. Thus, acute reconstruction can be indicated incision [endoscopic]). Thus, ACL reconstructions are
for patients who have not been reinjured, and delayed performed to resume short-term function (2 years), es-
or chronic rehabilitation can be indicated for patients pecially for participation in sports activities requiring
experiencing additional episodes of giving way. No exact cutting and pivoting. Whether ACL reconstruction pre-
time frame is recommended. In contrast, some authors vents or delays knee osteoarthritis is unknown. Accu-
believe acute reconstruction should take place within 6 rate tunnel placement, strong graft choices, solid initial
weeks of injury. fixation of grafts within the tunnel, and a rational reha-
A patient with chronic ACL deficiency may have de- bilitation program are factors that have been shown to
veloped medial compartment arthritis, especially if par- bring about good to excellent short-term results. Place-
tial medial meniscectomy has been performed. Stiffness ment of the femoral tunnel within 1 to 3 mm over the
and pain are usually the result of arthritis and not insta- top position and tibial tunnel placement behind the in-
bility. Instability from ACL deficiency is associated with tercondylar roof in full extension also are important.
giving way or patients describing a shifting of the Coupling a proven fixation technique with the use of a
knee. Radiographs should be obtained with the patient specific graft and with aggressive rehabilitation seems
standing, and careful evaluation of the patient while appropriate. For example, patellar tendon graft with in-
walking should be performed. A high tibial osteotomy terference screws in young patients allows aggressive re-
habilitation. Newer hamstring fixation methods allow Results/Outcomes of Anterior Cruciate Ligament
similar rehabilitation. Recently, the use of improved ap- Reconstruction
erture fixation at the femoral tunnel with a cross-pin Overall, the intermediate (5 years) or long-term (10
and metallic washer at the tibial tunnel have provided years or longer) results for ACL reconstruction are not
improved biomechanical fixation, resulting in adoption known. Traditional instruments used to judge clinical
of similar rehabilitation protocols as patellar tendon outcomes following ACL surgery have been anteropos-
grafts. terior stability, nonvalidated activity level scales, and
Typically, autogenous grafts are harvested from the nonvalidated scales combining objective with subjective
ipsilateral knee; however, the use of the contralateral results into a combined score (International Knee Doc-
patellar tendon for ACL reconstruction has been shown umenting Committee [IKDC]). Evidence-based medi-
to have good results. Advantages cited are decreased cine has focused on development of validated,
morbidity on the reconstructed knee and faster patient questionnaire-based assessment tools, first in knee os-
recovery. teoarthritis with the Western Ontario and McMaster
Graft sources other than autogenous grafts are often Universities Arthritis Index and with the Medical Out-
used. Attempts at reproducing the ACL with synthetic comes Short Form-36. Sport-specific validated measures
grafts was popular in the mid 1980s. Fueled by the de- of surgical outcome on activity level developed between
sire to decrease donor morbidity and potentially speed 1998 and 2001 include the Knee Injury and Osteoarthri-
rehabilitation, alternative graft sources included three tis Score and the IKDC questionnaire. The first vali-
broad categories of synthetic ligament replacements: (1) dated measure of sports activity was developed in 2001.
permanent replacement of the ACL with a prosthesis These validated outcome instruments are currently in
(for example, the Gore-Tex graft; Gore-Tex, Flagstaff, use by multicenter prospective cohort studies to address
AZ); (2) use of a stent to augment a biologic graft and clinically relevant questions on putative risk factor as-
protect it during the early postoperative period (for ex- sessment for pain, physical function, return to activity
level, and global score. The use of these instruments will
ample, the Kennedy ligament augmentation device; 3M,
supplement and provide information not available from
St. Paul, MN); and (3) use of a scaffold for appropriate
smaller stability outcome measures.
support for collagen ingrowth to recreate the ligament
Table 1 is a systematic review of nine randomized
(for example, the Leeds-Keio polyester device; Yufo
controlled trials in the literature. All had equal preoper-
Seiki, Tokyo, Japan). These methods were largely aban-
ative groups, the same type of rehabilitation, no continu-
doned by the mid 1990s because of high rates of compli- ous passive motion, return to sports at approximately 6
cations and failures. Complications included an inflam- months, and follow-up at 2 to 3 years. Several conclu-
matory response to the graft and graft wear. Despite sions are evident from these trials. First, 44% (four of
these failures, the search for a synthetic graft continues. nine randomized controlled trials) showed from 0.5 to
Two future options are a biologic scaffold and/or a 3.4 loss of range of motion with patellar tendon recon-
bioengineered prosthesis. struction. Second, 43% (three of seven randomized con-
Allograft use for knee ligamentous reconstruction trolled trials) showed hamstring weakness with ham-
has increased significantly in the past decade. Some of string reconstruction. Third, 43% (three of seven
the main reasons cited for the use of allografts include randomized controlled trials) of reconstructions using
decreased surgical morbidity associated with the graft patellar tendons were more stable by KT-1000 [Med-
harvest, a quicker recovery time, smaller incisions, and metric, San Diego, CA] arthrometer testing in the 1.0 to
decreased surgical time. Inherent disadvantages to using 3.4 mm range. Fourth, 89% (eight of nine randomized
allograft tissue include the potential risk of disease controlled trials) showed no difference in anterior or
transmission, cost, a possibly slower biologic remodeling patellofemoral pain, but 100% (four of four randomized
process, and a theoretic slow chronic immunologic re- controlled trials) of the patellar tendon group had more
sponse to the tissue. The allograft tissue provides the kneeling pain. Fifth, there was no difference in nonvali-
collagen scaffold for a process of incorporation of host dated measures of return to preinjury function, Tegner
tissue. The stages of allograft incorporation are similar activity level of outcomes by Lysholm, Cincinnati, or
to those of autograft; however, the remodeling phase of original IKDC 1991. Finally, no validated outcome tools
the allograft can be one and a half times as long. The previously mentioned were used in the best studies to
use of allograft tissue for reconstruction of all knee liga- date on ACL surgery.
ments is becoming more popular. It is appealing for
multiligament injuries in which autograft choices may Posterior Cruciate Ligament Injury
be limited. Some studies have shown good results using PCL injuries with or without associated MCL/
allograft tissue for ACL reconstruction, although long- posteromedial capsular or LCL/posterolateral capsular
term results are lacking. injuries have been investigated using in vitro biome-
Table 1 | Randomized Controlled Trials Outcomes for ACL Reconstruction: Hamstring Versus Patellar Tendon
Ant Knee Kneeling Return Tegner
ROM ISO KT(n) Pain Pain XR Preinjury Activity Lysholm Cinn IKDC
ONeill Ns Ns Ns Ns Ns Ns
( 1996) (maximum
manual)
Anderson Ns Ns PT 1.0 mm Ns Ns PT best
et al better
(2001)
Aune et al Ns Ham Ns Ns PT pain Ns
(2001)
Eriksson PT3 Ns PT pain Ns Ns
et al
(2001)
Shaieb PT3.4 PT > Ham Ns Ns
et al 6 + 24
(2002) months
Beynnon Ns Ham PT 3.4 mm Ns Ns
et al better
(2002)
Feller and PT1.5 Ham 7% PT 1.1 mm Ns PT pain Ns Ns Ns Ns
Webster better
(2003)
Jansson PT0.5 Ns Ns Ns Ns Ns Ns Ns
et al Ext
(2003)
Ejerhed Ns Ns Ns Ns PT pain Ns Ns Ns
et al
(2003)
ROM = range of motion; ISO = isokinetic strength hamstring versus patellar tendon; KT(n) = KT 1000 stability anterior to posterior (n) = Newtons; Ant knee pain = anterior or patellofemoral knee
pain; XR = x-rays or radiographs; Cinn = Cincinnati University Knee Rating; IKDC = original subjective and objective scale; PT = patellar tendon; Ham = hamstring; Ns = not significant (P >0.05).
chanical studies. Key decision-making criteria in the partial PCL injuries have shown healing over time on
clinical management include magnitude of trauma follow-up MRI. It has been shown that 1+ or 2+ (5 to 10
(sports activity versus motor vehicle crashes), the de- mm) posterior laxity is well tolerated even in the highly
gree of posterior laxity in reference to the anterior fe- competitive athlete. Complete PCL tears are more com-
mur, and associated collateral or ACL tears. The poste- mon from high-velocity injuries resulting from motor
rior drawer test is performed with the knee flexed and vehicle crashes and are often associated with collateral
both hands placed around the knee. The joint line is pal- injuries and possible knee dislocation. Figure 2 summa-
pated with the thumbs. The degree of laxity is then rizes treatment approaches to sports-related injuries to
judged by comparing the posterior tibial translation to the PCL.
the contralateral normal knee with the tibia anterior to When PCL reconstructions are considered, the
the femur. Partial tears to the PCL have an end point choice of surgical approach and grafts should be
and laxity with posterior force with the tibia even or matched. Traditionally a single femoral tunnel approach
slightly posterior to the femur. Complete tears have no was used, but several authors have recently proposed
end point to posterior force, even with internal rotation the use of two tunnels. A subject of current debate is
and significant displacement posterior to the femur. whether a tibial tunnel with the so-called killer curve
Plain radiographs are indicated to rule out bony avul- versus tibial onlay should be used. Tibial onlay requires
sions, which can be repaired. MRI can be helpful in de- a bone block and either a patellar tendon or Achilles
termining partial versus complete injuries; some fibers tendon allograft. If tibial onlay is preferred and au-
have continuity with partial tears. Partial tears are more tograft tissue is used, then a single femoral tunnel with
common in low-velocity injuries (especially from sports interference screws is used. An Achilles tendon allograft
activities) and are treated nonsurgically. Patients with can be fixed as tibial only and either single or dual tun-
nels can be used. Reproducible in vitro biomechanical asymptomatic individuals. The external rotation recurva-
studies have not identified the best approach or graft tum test is performed in a supine patient by grasping
choice to date; however, research is ongoing. No com- the great toes of both feet and lifting both lower limbs
parative in vivo animal models or clinical studies have off the examining table. Posterolateral corner injury is
provided a preferred technique. The surgeon should indicated by recurvatum or varus deformity of the knee
choose the safest, most reproducible approach and tech- and external rotation of the tibia. Other tests for injury
nique to improve posterior stability. to the posterolateral corner include the posterolateral
drawer test, adduction stress test, and dynamic posterior
Posterolateral Complex Injury shift test.
The posterolateral complex includes the biceps tendon, Plain film radiography may reveal an avulsion frac-
iliotibial band, popliteus tendon, popliteofibular liga- ture of the fibular head from pull of the biceps femoris
ment, arcuate ligament, and LCL. The functional and or LCL. MRI has also proved to be useful for evalua-
clinical significance of these closely interrelated struc- tion of these multiligamentous injuries and should in-
tures is not yet completely understood. The posterolat- clude imaging of the entire fibular head.
eral structures act synergistically with the PCL to resist For partial injuries to the posterolateral corner, in-
posterior translation and external and varus rotation of cluding grade I and II instability with a good end point,
the knee. The biceps femoris, a dynamic lateral stabilizer nonsurgical treatment is recommended. This entails a
of the knee, inserts on the fibular head. The iliotibial 3-week period of immobilization with the knee in full
band is an anterolateral stabilizer. The primary function extension followed by progressive range-of-motion and
of the popliteus tendon is to externally rotate the femur, strengthening exercises. For acute injuries, primary re-
unlocking the knee to allow flexion when the knee is pair of the posterolateral structures offers the best
loaded. The popliteofibular ligament attaches the popli- chance for a successful clinical outcome. Avulsion frac-
teus tendon to the posterior fibular head and the ante- tures of the fibular head can be repaired directly. Repair
rior lateral femoral condyle, providing resistance to pos- can be augmented with allograft or autogenous tissue.
terior translation and external rotation of the tibia. The For chronic injuries, various techniques for reconstruc-
arcuate ligament courses from the fibula styloid process tion have been recommended with varied clinical re-
to the lateral femoral condyle, with limbs to the popli- sults. Graft reconstructions recreating the popliteus ten-
teus tendon and fascia overlying the popliteus muscle. don and LCL seem to fare the best. Postoperative
The LCL is the primary static restraint to varus stress rehabilitation after surgical treatment of injuries to the
on the knee, and secondary restraint to external rotation posterolateral corner involves protection from external
of the tibia. rotation and varus stress with a hinged knee brace for a
The most common mechanisms of injury to the pos- minimum of 2 months, followed by gradual range-of-
terolateral structures are a direct blow to the anterome- motion and strengthening exercises.
dial tibia and hyperextension with a varus twisting force.
Physical examination for evaluation of the postero- Knee Dislocation
lateral corner include the tibia external rotation test, in Knee dislocation is a devastating injury that usually re-
which the degree of external rotation of the tibia in re- sults from high-energy trauma. Any three-ligament in-
lation to the femur of each lower extremity is tested at jury should be considered and treated as a knee disloca-
both 30 and 90 of knee flexion. An increase in exter- tion. With improvements in surgical technique and
nal rotation (of at least 10), found only at 30 of knee instrumentation, the results of surgical treatment have
flexion, is indicative of an isolated injury to the postero- surpassed those of conservative methods and are now
lateral corner. Associated injury to the PCL yields in- the primary form of treatment of the dislocated knee.
creased external rotation at 90 of flexion. The postero- Knee dislocation is classified primarily by the direc-
lateral external rotation test is similar to the tibia tion of the dislocated tibia in relation to the femur (an-
external rotation test, except a coupled force of poste- terior, posterior, medial, lateral, and rotatory). Deter-
rior translation and external rotation is applied to the mining the direction of the dislocation provides
knee. The test is positive if posterolateral subluxation of information about the likelihood of associated neu-
the proximal tibia is noted at 30 of flexion. The reverse rovascular injury. Injury to the popliteal artery is more
pivot-shift test, which is not specific for injury to the likely with posterior dislocation, whereas injury to the
posterolateral corner, is performed by applying a valgus common peroneal nerve is more likely with posterolat-
stress to the knee while externally rotating the foot and eral dislocation.
extending the knee from 90 of flexion. A positive test is Associated injuries with knee dislocation are com-
elicited when a palpable jerk is noted during reduction mon. The incidence of vascular injury with all disloca-
of the posteriorly subluxated lateral tibia plateau. This tions has been estimated at 32%. The popliteal artery is
test has been reported to be positive in up to 35% of injured either by a stretching mechanism secondary to
tethering of the vessel at the adductor hiatus or by di- but it is a contraindication to closed reduction because
rect contusion by the posterior tibia plateau. Thrombus of the risk of skin necrosis.
formation secondary to intimal damage can occur sev- Indications for acute surgery after knee dislocation
eral days after injury. Decreased pulses or vascular com- include vascular injury, open fracture, open dislocation,
promise should never be attributed to arterial spasm, irreducible dislocation, and compartment syndrome.
and additional investigation is warranted. Injury to the Restoration of vascular integrity takes precedence over
popliteal vein is rare. Injury to the peroneal nerve, or other injuries. Open injuries require immediate surgical
less commonly the tibial nerve, has been estimated to irrigation and dbridement.
occur in 20% to 30% of knee dislocations. The incidence Improved surgical techniques and postoperative re-
of associated fractures, usually of the tibia plateau or habilitation protocols, and the use of allografts have im-
the distal femur, has been estimated at 60%. proved the clinical results for surgical treatment of knee
The diagnosis of a dislocated knee is usually obvi- dislocation. Factors to consider in the timing of surgical
ous; however, it is crucial to remember that a dislocated treatment of knee dislocations include the vascular sta-
knee can reduce spontaneously. A spontaneously re- tus of the patient, the presence of open wounds, the suc-
duced knee is characterized by gross instability and ex- cess of closed reduction, the stability of the joint after
tensive soft-tissue swelling. With a suspected knee dislo- reduction, and the presence of associated injuries.
cation, immediate evaluation of the vascular status of There has been debate over the timing of surgical pro-
the involved limb is important because limb ischemia of cedures after knee dislocation. Two reasons cited for de-
more than 8 hours duration is likely to result in amputa- laying surgery include allowing a period of vascular mon-
tion. Vascular injury has been reported in the presence itoring and reducing the risk of arthrofibrosis. Multiple
of normal pulses, Doppler studies, and capillary refill. ligament injuries may require staged procedures. Postero-
Repeat neurovascular examination should be performed lateral structures, capsular structures, and avulsion frac-
after any reduction maneuver. tures can be repaired acutely. Combined ACL and PCL
Plain film radiographs should be obtained in two reconstruction can be performed in delayed fashion with
planes to determine the direction and severity of the acceptable results. Graft options for ligament reconstruc-
dislocation, as well as for evaluation for any associated tion in the multiligament-injured knee include patellar
fractures. Slight joint space widening may be indicative tendon, hamstring, and quadriceps tendon autografts,
of a spontaneously reduced knee dislocation. Plain film and/or allografts. The literature does not support the use
radiographs should also be evaluated for avulsion frac- of one graft type over another or the use of a particular
tures, which may alter the surgical plan. Repeat plain ra- technique for reconstruction. After combined reconstruc-
diographs should be obtained after any reduction ma-
tion of the cruciate ligaments, the knee has traditionally
neuver to ensure satisfactory alignment of the joint.
been kept in extension with no weight bearing for 6 weeks.
With a suspected arterial injury, immediate arterio-
Postoperative rehabilitation programs after a knee dislo-
graphy and vascular consultation are warranted. Al-
cation should allow range-of-motion exercises as soon as
though arteriograms have been used historically as a
the integrity of soft-tissue repair, vascular repair, and lig-
screening tool for arterial injury, it is a low yield study in
ament reconstruction permit.
the presence of a normal vascular examination. With no
evidence of vascular compromise on physical examina-
tion, foregoing an arteriogram and performing regular, Meniscal Injury
detailed neurovascular examinations in an inpatient set- The primary function of the meniscus is to evenly dis-
ting is accepted treatment. If vascular compromise is tribute the weight-bearing load across the knee joint.
noted, immediate surgical intervention is indicated. For- The menisci transmit approximately 50% of the load
mal angiography is bypassed to lessen ischemic time. with the knee in extension, and close to 90% of the load
After the initial survey and acute treatment, MRI is at 90 of knee flexion. With flexion past 90, most of the
useful for evaluation of ligament and meniscus status, force is transmitted through the posterior horns. The lat-
occult fracture, and capsular disruption. MRI gives es- eral meniscus has been shown to transmit a greater per-
sential information for preoperative planning for liga- centage of the load compared with the medial meniscus.
ment reconstruction, such as the number of allografts When meniscal integrity is lost, abnormal articular
that will be needed. contact stresses result, leading to potential increased
Timely closed reduction is indicated for any dislo- wear of the articular cartilage and early degenerative
cated knee. Physical and radiographic examination changes. The more meniscal tissue that is lost, the
should be performed immediately after reduction to greater the loss of contact surface area and the greater
confirm proper reduction and evaluate postreduction the increase in peak local contact stresses. Thus, the pri-
neurovascular status. The presence of the dimple sign mary goal of treatment of a meniscal tear is to maintain
is indicative of an irreducible posterolateral dislocation, as much healthy meniscus tissue as possible.
joint have been well documented in the literature. The ologic issues of healing and techniques to stimulate or
excision of a tear or degenerative tissue will retain func- augment that healing. In the past, techniques such as
tional meniscus. Long-term results after partial menis- trephination of meniscal tissue, rasping, and fibrin clot
cectomy seem to indicate satisfactory results, but deteri- have been used to augment the repair of the meniscus.
oration of articular cartilage may still occur. More recently, investigations have targeted growth fac-
Degenerative changes on radiographs and a decrease in tors and gene therapy to enhance the healing of the me-
function have been shown to occur earlier in patients niscus.
undergoing partial lateral meniscectomy than in those If a total meniscectomy or subtotal meniscectomy
undergoing partial medical meniscectomy. Additionally, previously has been performed, a meniscal substitute is
the results of partial meniscectomies are better in pa- reasonable. Because genetically engineered or other
tients with acute traumatic tears than in those who have similar biologic replacements are still experimental, a vi-
degenerative tears. able option for the meniscectomized knee is a meniscal
If a repair is performed, it is important to consider allograft. Meniscal allografts have been used for over a
the numerous factors involved in healing, such as loca- decade with reasonable results. With proper technique,
tion and vascularity of the tear, the type of the tear, and the grafts have been shown to heal in the peripheral re-
quality of the meniscal tissue. The stability of the knee is pair site and at its bony insertion. Grafts placed without
important because repairs are more successful in a sta- a bony base, either a plug or block, have been found to
ble knee. Also, those repairs concurrently performed have a higher failure rate. A symptomatic patient with
with an ACL reconstruction have a higher rate of heal- lack of a functional meniscus is a candidate for a menis-
ing, probably because of the various growth factors in cal allograft. Factors that contribute to the failure of a
the associated hemarthrosis. Chronicity is also a factor. meniscal allograft and thus are considered contraindica-
In general, results of meniscal repair are better acutely tions include patients with grade IV chondral changes,
after tear (< 8 weeks after injury) than a chronic tear ligamentous instability, and knee malalignment.
secondary to the potential deterioration of the meniscal
tissue with time. Patient age is also a factor. Younger pa-
tients have higher healing rates and axial alignment. Patellofemoral Disorders
Those patients with a varus alignment have a lower Patellofemoral pain continues to be an enigma. Condi-
healing rate for medial repairs. tions causing patellofemoral symptoms include patello-
Meniscal repair can be done by either an open or an femoral pain syndrome, tracking disorders, instability/
arthroscopic technique. Although the open technique dislocation, and chondromalacia.
has good results, most surgeons now prefer arthroscopic The initial patient history should determine if the
techniques. The traditional gold standard for meniscal chief symptom is pain or instability. The patient should
repair is the inside-out repair, which is performed with be questioned about a history of trauma, instability, and
either absorbable or nonabsorbable sutures placed ar- activities that initiate or increase symptoms (often as-
throscopically with long needles and retrieved through a cending or descending stairs). The typical patient with
small incision on the outside of the capsule. The patellofemoral symptoms is a female adolescent or
outside-in technique involves placing a monofilament young adult. The onset of anterior knee pain is usually
suture through a spinal needle percutaneously into the insidious but can be acute. The symptoms of pain are
knee joint and retrieving it through one of the arthro- usually worse with activity.
scopic portals. The all-inside technique is performed Physical examination must include assessment of
through the anterior knee portals and uses numerous lower extremity alignment, quadriceps angle, patellar
devices and variations of techniques to stabilize the me- tracking and mobility, crepitus, patellar apprehension,
niscus. Most of the devices are absorbable stents, and and specific areas of tenderness.
some are a combination of suture attached to the stent. Standard radiographic evaluation of the knee should
A cited theoretical advantage to the all-inside technique include AP, lateral, axial, and long-standing (for align-
is a decreased risk of a neurovascular injury that may ment) views. The lateral view, which should be obtained
occur with the use of the needles in the other tech- with the knee in at least 30 of flexion, is used to assess
niques. All of the meniscal repair techniques have the position of the patella in relation to the patellar ten-
shown reasonable rates of clinical success (73% to 98%) don (the Insall-Salvati ratio). The average ratio is 1.02,
as determined by the absence of symptoms and the pa- with a value over 1.2 indicative of patella alta and a
tients return to activities. In studies of second-look ar- value less than 0.8 indicative of patella baja.
throscopy, healing rates have ranged from 45% to 91%. Various techniques for axial views of the patellofem-
Most of the studies on meniscal repair have been retro- oral joint are used to evaluate trochlear morphology
spective. and patellar tilt. The Merchant/sunrise view is obtained
Devices and techniques continue to be developed with the knee flexed 45 and the x-ray tube angled 30
for meniscal repair. Research is focusing more on the bi- from horizontal. The sulcus and congruence angles are
both measured on the Merchant view. Patellar tilt and ing for associated injuries, such as osteochondral injuries
congruence angles can also be measured using CT mid- to the medial facet of the patella or the lateral femoral
patellar transverse images with the knee flexed 15, 30, condyle.
and 45. MRI is useful for the evaluation of articular As studies of nonsurgical treatment have reported
cartilage status. redislocation rates ranging from 15% to 44%, there has
Nonsurgical treatment continues to be the primary been renewed interest in surgical treatment of patellar
treatment for patients with a new onset of anterior knee dislocation. Surgery is also considered for treatment of
pain. A well-supervised rehabilitation program is aug- associated injuries with an acute patellar dislocation,
mented by anti-inflammatory medication and local mo- such as removal, fixation, or dbridement of osteochon-
dalities. The goal of the rehabilitation program is to dral injuries. In the young athletic patient, direct repair
reduce symptoms by emphasizing quadriceps and ham- of the medial patellofemoral ligament to its attachments
string stretching, strengthening, and endurance. to the adductor tubercle and vastus medialis obliquus
As biomechanical studies have shown that patello- has been advocated. A lateral release can be performed
femoral contact pressures are lowest between 0 and 30 if concomitant patellar tilt is appreciated. For the skele-
of knee flexion, closed-chain, short-arc knee extensions tally mature patient experiencing recurrent episodes of
performed within a pain-free arc of motion are the patellar subluxation or recurrent dislocation despite
mainstay exercises for quadriceps strengthening. Patel- nonsurgical treatment, a distal patellar realignment pro-
lar bracing and the McConnell taping technique have cedure, such as a Fulkerson or Elmslie-Trillat procedure,
been used as an adjunct to a rehabilitation program. should be considered. The Fulkerson procedure is an
Lateral patellar compression syndrome is character- oblique osteotomy of the tibial tuberosity posterolater-
ally to anteromedially resulting in an anteromedial
ized by anterior knee pain that increases with patellar
transfer of the tuberosity, decreased patellofemoral con-
loading activities and a patella centered without radio-
tact forces, and realignment of the extensor mechanism
graphic tilt. The syndrome has been associated with an
medially. The Elmslie-Trillat procedure is done by per-
increased Q angle (the angle formed by a line drawn
forming the osteotomy laterally to medially, preserving
from the middle of the tibial tuberosity to the middle of
a distal pedicle of the tuberosity and resulting in a me-
the patella to the anterior-superior iliac spine) and a
dial transfer of the tuberosity.
tight lateral retinaculum. Patients sometimes experience
Patellofemoral chondromalacia continues to be an
subjective episodes of instability, which are likely caused
enigma because studies have shown 9% to 69% of pa-
by quadriceps inhibition. Routine radiographic studies
tients with patellofemoral pain have normal cartilage in
yield little useful information. If nonsurgical treatment
the patellofemoral joint at the time of arthroscopy. Non-
fails and the patient has a tight lateral retinaculum, ar- surgical treatment of patellofemoral chondromalacia
throscopic lateral release has yielded successful results consists of activity modification and anti-inflammatory
in 60% to 91% of patients. medication to reduce inflammation followed by exten-
Patellar tilt is similar clinically to lateral patellar sor mechanism strengthening, particularly of the vastus
compression syndrome with the exception that axial im- medialis obliquus. Surgical treatment of patellofemoral
aging reveals patellar tilt within the trochlear groove. chondromalacia falls into two categories: (1) treatment
Initial treatment is nonsurgical, followed by arthro- aimed at relieving symptoms by decompressing the pa-
scopic lateral release if no improvement is noted. Poten- tellofemoral joint or correcting malalignment, and (2)
tial complications following arthroscopic lateral release surgery aimed at directly addressing the chondromala-
include hemarthrosis and prolonged quadriceps weak- cia. Surgical treatment of patellofemoral chondromala-
ness. cia secondary to increased compression caused by mala-
Patellar instability can be classified as subluxation or lignment or a tight lateral retinaculum includes lateral
dislocation. Acute dislocation often occurs with a twist- release and anteromedialization of the tibial tubercle.
ing movement of the knee. Predisposing factors for pa- One study has suggested that release of adhesions in the
tellar dislocation include patella alta, generalized liga- interval of soft tissue between the anterior proximal
mentous laxity, lateral femoral condyle hypoplasia, tibia and the patellar tendon can decompress the patel-
lateral insertion of the patellar tendon, and an increased lofemoral joint. Patellar chondroplasty is used to de-
Q angle. Dislocation results from injury to the medial crease the mechanical symptoms by using a motorized
patellofemoral ligament. The patient may note that the shaver to smooth or remove regions of cartilage fibrilla-
patella initially lies on the lateral aspect of the knee, tion or loose flaps. Uniformly successful results with pa-
then relocates with knee extension. There is often an as- tellar chondroplasty have not been reported. For re-
sociated hemarthrosis. Physical examination frequently gions of grade IV chondromalacia, marrow stimulation
reveals tenderness over the medial retinaculum and the techniques, such as microfracture or subchondral drill-
medial femoral epicondyle. MRI is useful for evaluating ing, have been advocated. Results with marrow stimula-
injury to the medial patellofemoral ligament and assess- tion techniques have been unpredictable.
tendon grafts) were assessed after 24 months. Anterior knee Peterson RK, Shelton WR, Bomboy AL: Allograft ver-
pain was not significantly different between the two groups, sus autograft patellar tendon anterior cruciate ligament
but pain with kneeling was present in the group with patellar reconstruction: A 5-year follow-up. Arthroscopy 2001;17:
tendon reconstructions. 9-13.
A prospective nonrandomized study to compare the long-
term results of allograft versus autograft central one third
Beynnon BD, Johnson RJ, Fleming BC, et al: Anterior
bone-patellar tendon-bone reconstruction of the ACL showed
cruciate ligament replacement: Comparison of bone-
no statistically significant differences in the presence of pain,
patellar tendon-bone grafts with two-strand hamstring
giving way, effusion, Lachman and pivot shift results, or ar-
grafts. A prospective, randomized study. J Bone Joint
thrometer measurements.
Surg Am 2002;84:1503-1513.
Results from this study indicated that, after 3-year follow-
up, ACL replacement with a bone-patellar tendon-bone au- Shaieb MD, Chang SK, Marumoto JM, Richardson AB:
tograft was superior to replacement with a two-strand A prospective randomized comparison of patellar ten-
semitendinosus-gracilis graft; knee laxity, pivot-shift grade and don versus semitendinosus and gracilis tendon au-
strength of the knee flexor muscles were improved. tografts for anterior cruciate ligament reconstruction.
Am J Sports Med 2002;30:214-220.
In this randomized study, 70 patients with patellar tendon
Ejerhed L, Kartus J, Sernert N, et al: Patellar tendon or
or hamstring tendon autografts for single-incision ACL recon-
simitendinosus tendon autografts for anterior cruciate struction were evaluated at 2-year follow-up. Hamstring ten-
ligament reconstruction: A prospective randomized don autografts performed similarly to patellar tendon grafts;
study with a two-year follow-up. Am J Sports Med 2003; however, more patients who received patellar tendon grafts
31:19-25. had patellofemoral pain and loss of motion.
According to this study, the semitendinosus tendon graft
can be considered an equivalent option to the bone-patellar
tendon-bone graft for ACL reconstruction. Shelbourne KD: Contralateral patellar tendon autograft
for anterior cruciate ligament reconstruction. Instr
Course Lect 2002;51:325-328.
Eriksson K, Anderberg P, Hamberg, et al: A comparison This article reviews the use and benefits of using the con-
of quadruple semitendinosus and patellar tendon grafts tralateral patellar tendon for ACL reconstruction.
in reconstruction of the anterior cruciate ligament.
J Bone Joint Surg Br 2001;83:348-354.
Siebold R, Buelow JU, Bos L, Ellermann A: Primary
In this randomized study of 164 patients with unilateral in-
ACL reconstruction with fresh-frozen patellar versus
stability of the ACL, arthroscopic reconstruction with a patel-
Achilles tendon allografts. Arch Orthop Trauma Surg
lar tendon graft using interference screw fixation or a quadru-
2003;123:180-185.
ple semitendinosus graft using endobutton fixation was done.
The authors retrospectively evaluated the clinical outcome
The authors concluded that medium-term outcomes between
of 251 fresh-frozen patellar versus Achilles tendon allografts
the two methods were similar. for primary ACL reconstruction with a mean follow-up of 3
years. The authors concluded that satisfactory clinical results
Feller JA, Webster KE: A randomized comparison of can be achieved with the use of allografts for primary ACL re-
patellar tendon and hamstring tendon anterior cruciate construction. They indicated that the Achilles tendon-bone al-
ligament reconstruction. Am J Sports Med 2003;31:564- lograft seemed to be advantageous over the bone-tendon-
573. bone allograft for ACL reconstruction because the failure rate
In this randomized study of 65 patients, patellar tendon was significantly lower.
and hamstring tendon autografts both resulted in satisfactory
functional outcomes; morbidity was increased in the patients Posterior Cruciate Ligament Injury
who received patellar tendon grafts, and knee laxity and radio- Oakes D, Markolf K, McWilliams J, Young C, McAllister
graphic femoral tunnel widening was increased in the patients D: A biomechanical comparison of tibial inlay and tibial
who received hamstring tendon. tunnel posterior cruciate ligament reconstruction tech-
niques: Analysis of graft forces. J Bone Joint Surg Am
Jansson KA, Linko E, Sandelin J, et al: A prospective 2002;84:938-944.
randomized study of patellar versus hamstring tendon This study examines the biomechanics of the tibial tunnel
technique compared with the use of a tibial inlay in recon-
autografts for anterior cruciate ligament reconstruction.
struction of the PCL.
Am J Sports Med 2003;31:12-18.
In this randomized study of 99 patients (89 of whom were
available for 2-year follow-up), results were similar for patel- Posterolateral Complex Injury
lar and hamstring tendon autografts for ACL reconstruction. Kanamori A, Lee JM, Haemmerle MJ, Vogrin TM,
Harner SD: A biomechanical analysis of two reconstruc-
tive approaches to the posterolateral corner of the knee. and Fairbank changes in 92.9% of the radiographs. The au-
Knee Surg Sports Traumatol Arthrosc 2003;11:312-317. thors noted that the extent of the resection is a significant fac-
This article reviews a biomechanical study comparing the tor.
effects of biceps tenodesis with those of popliteofibular liga-
ment reconstruction. Ten human cadavers were tested intact McCarty EC, Marx RG, DeHaven KE: Meniscus repair:
and in the posterolateral corner-condition, deficient, with each Considerations in treatment and update of clinical re-
type of reconstruction.The authors concluded that the popliteo- sults. Clin Orthop 2002;402:122-143.
fibular ligament reconstruction more closely reproduces the An updated review of meniscus repair techniques and
primary function of the posterolateral corner compared with published results is presented.
the biceps tenodesis.
Rankin CC, Lintner DM, Noble PC, Paravic V, Greer E:
McGuire DA, Wolchok JC: Posterolateral corner recon- A biomechanical analysis of meniscal repair techniques.
struction. Arthroscopy 2003;19:790-793. Am J Sports Med 2002;30:492-497.
This article describes a posterolateral corner reconstruc- Various methods that are used in the repair of meniscal
tion procedure that uses allograft and interference screw fixa- tears were evaluated in bovine meniscus, including a bio-
tion. The authors recommend the use of this procedure in con- degradable meniscal implant without sutures, a suture anchor
junction with PCL reconstruction to restore rotatory and device, and horizontal and vertical mattress sutures. Suture
posterior knee instability in the multiligament-injured knee. techniques were stronger at all levels of testing. The ultimate
strength of repair was strongest for the vertical sutures (202
Knee Dislocation 7 N) and lowest for the arrow and suture anchor device (95.9
Liow RY, McNicholas MJ, Keating JF, Nutton RW: Liga- 8 N and 99.4 8 N, respectively).
ment repair and reconstruction in traumatic dislocation
of the knee. J Bone Joint Surg Br 2003;85:845-851. Shelbourne KD, Carr DR: Meniscal repair compared
This study compared 8 knee dislocations that were treated with meniscectomy for bucket-handle medial meniscal
acutely (<2 weeks after injury) and 14 dislocations that were tears in anterior cruciate ligament-reconstructed knees.
treated at least 6 months after injury. Both groups of knees Am J Sports Med 2003;31:718-723.
were treated with a combination of repair or reconstruction of This article presents a retrospective review of 155 patients
all injured ligaments. Although differences were small, the out- with isolated bucket handle medial meniscal tears and ACL
come in terms of overall knee function, activity levels, and an- tears. Outcomes from meniscal repair were not superior to
terior tibial translation were better for the patients whose those from partial removal. Patients with repaired degenera-
knees were reconstructed within 2 weeks of injury. tive tears had significantly lower subjective scores than those
with nondegenerative tears.
Shelbourne KD, Carr DR: Combined anterior and pos-
terior cruciate and medial collateral ligament injury: Venkatachalam S, Godsiff SP, Harding ML: Review of
Nonsurgical and delayed surgical treatment. Instr the clinical results of arthroscopic meniscal repair. Knee
Course Lect 2003;52:413-418. 2001;8:129-133.
This article reviews management principles of the multiple A retrospective review of 62 arthroscopic meniscal repairs
ligament-injured knee. Four treatment principles are stressed: is presented. Early repair within 3 months of the tear gave bet-
(1) medial-side injuries can heal with proper nonsurgical treat- ter results (91%) than if performed later (58%). Suture repair
ment; (2) PCL tears with grade II laxity or less can heal with alone yielded better results (78%) than meniscal arrows or a
similar long-term results as grade I injuries; therefore, surgery suture anchor device (56%). Healing rates of atraumatic me-
may not be indicated; (3) PCL laxity greater than grade II and niscal tears were much lower than for traumatic tears (42%
a soft end point should be considered for semiacute recon- versus 73%). The isolated atraumatic medial meniscal tear ap-
struction; and (4) ACL injuries in combination with medial or peared to heal poorly (33% healing) and was believed to be
PCL injuries can initially be treated nonsurgically and recon- better treated by meniscectomy.
structed at a later date as symptoms dictate.
Patellofemoral Disorders
Meniscal Injury Aderinto J, Cobb AG: Lateral release for patellofemoral
Bonneux I, Vandekerckhove B: Arthroscopic partial lat- arthritis. Arthroscopy 2002;18:399-403.
eral meniscectomy long-term results in athletes. Acta A retrospective study of 53 patients who underwent lateral
Orthop Belg 2002;68:356-361. retinacular release for symptomatic patellofemoral arthritis is
A retrospective case-control study of arthroscopic partial presented. Four patients underwent total knee replacement
meniscectomy for isolated lesions of the lateral meniscus is within 18 months after the lateral release. Of the remaining
presented. An 8-year follow-up on 31 knees found deteriora- patients, 80% had a reduction in their preoperative pain, 16%
tion of results with decreased Tegner scores (7.2 down to 5.7) were unchanged, and 4% were worse.
Bizzini M, Childs JD, Piva SR, Delitto A: Systematic re- study with a long-term followup period. Clin Orthop
view of the quality of randomized controlled trials for 1991;264:255-263.
patellofemoral pain syndrome. J Orthop Sports Phys
Ther 2003;33:4-20. Arnoczky SP, Warren RF: Microvasculature of the hu-
Based on the results of trials exhibiting a sufficient level of man meniscus. Am J Sports Med 1982;10:90-95.
quality, treatments that were effective in reducing pain and
Burks RT, Metcalf MH, Metcalf RW: Fifteen year
improving function in patients with patellofemoral pain syn-
follow-up of arthroscopic partial meniscectomy. Arthros-
drome included acupuncture, quadriceps strengthening, resis-
copy 1997;13:673-679.
tive bracing, and a combination of exercises with patellar tap-
ing and biofeedback. Burks RT, Schaffer JJ: A simplified approach to the tib-
ial attachment of the posterior cruciate ligament. Clin
Schneider F, Labs K, Wagner S: Chronic patellofemoral Orthop 1990;254:216-219.
pain syndrome: Alternatives for cases of therapy resis-
tance. Knee Surg Sports Traumatol Arthrosc 2001;9:290- Daniel DM, Stone ML, Dobson BE, Fithian DC, Ross-
295. man DJ, Kaufman KR: Fate of the ACL-injured patient:
The results of a prospective randomized study comparing A prospective outcome study. Am J Sports Med 1994;22:
20 patients treated with proprioceptive neuromuscular facilita- 632-644.
tion and 20 patients treated with a special training program
Fairbank TJ: Knee joint changes after meniscectomy.
using a resistance-controlled knee splint are presented. The J Bone Joint Surg Br 1948;30:664-670.
knee splint proved more effective than proprioceptive neuro-
muscular facilitation for treating patellofemoral pain syn- Fulkerson JP: Anteromedialization of the tibial tuberos-
drome resistant to conservative therapy. ity for patellofemoral malalignment. Clin Orthop 1983;
177:176-181.
Knee Plica
Irha E, Vrdoljak J: Medial synovial plica syndrome of Fulkerson JP: Patellofemoral pain disorders: Evaluation
and management. J Am Acad Orthop Surg 1994;2:124-
the knee: A diagnostic pitfall in adolescent athletes.
132.
J Pediatr Orthop B 2003;12:44-48.
A prospective study of clinical criteria for the diagnosis of Indelicato PA: Non-operative treatment of complete
medial plica syndrome is presented. Two physical examination tears of the medial collateral ligament of the knee.
tests that improve the accuracy of the clinical examination for J Bone Joint Surg Am 1983;65:323-329.
diagnosis of medial plica syndrome are described.
Maenpaa H, Lehto MU: Patellar dislocation: The long-
Extensor Mechanism Disruption term results of nonoperative management in 100 pa-
Richards DP, Barber FA: Repair of quadriceps tendon tients. Am J Sports Med 1997;25:213-217.
ruptures using suture anchors. Arthroscopy 2002;18:556-
ONeill DB: Arthroscopically assisted reconstruction of
559.
The authors state that this is the first report in the English
the anterior cruciate ligament: A prospective random-
ized analysis of three techniques. J Bone Joint Surg Am
language literature of a technique using suture anchors to at-
1996;78:803-813.
tach the quadriceps tendon to bone.
Seebacher J, Inglis A, Marshall J, Warren R: The struc-
Classic Bibliography ture of the posterolateral aspect of the knee. J Bone
Joint Surg Am 1982;64:536-541.
Ahmad CS, Kwak D, Ateshian GA, Warden WH, Stead-
man JR, Mow VC: Effects of patellar tendon adhesion Shelbourne KD, Davis TJ, Patel DV: The natural history
to the anterior tibia on knee mechanics. Am J Sports of acute, isolated, nonoperatively treated posterior cru-
Med 1998;26:715-724. ciate ligament injuries: A prospective study. Am J Sports
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Ahmed AM, Burke DL: In-vitro measurement of static
pressure distribution in synovial joints: Part I. Tibial sur- Tenuta JJ, Arciero RA: Arthroscopic evaluation of me-
face of the knee. J Biomech Eng 1983;105:216-225. niscal repairs: Factors that effect healing. Am J Sports
Med 1994;22:797-802.
Andersson C, Odensten M, Gillquist J: Knee function
after surgical or nonsurgical treatment of the acute rup- Veltri DM, Warren RF: Posterolateral instability of the
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Osteotomy
Malalignment resulting in focal overload of either the
medial or lateral compartment of the knee can be suc-
cessfully managed with osteotomy to restore the me-
chanical axis of the knee. This strategy has the distinct
advantage of joint preservation that is particularly at-
tractive for younger, more active patients. Osteotomy is
most likely to succeed when the disease affects predom-
inantly one compartment, and there is therefore healthy
tissue onto which to redirect the load. Despite this ob-
servation, no advantage has been demonstrated with ar-
throscopic evaluation of the knee done at the same set-
ting as osteotomy, except to treat mechanically
significant lesions. To maintain a joint line perpendicular
to the weight-bearing axis, and to avoid joint line obliq-
uity, varus malalignment is most commonly corrected
through proximal tibial osteotomy, whereas valgus mal-
alignment is most commonly corrected through supra-
condylar femoral osteotomy. When the degree of valgus
deformity is not severe, and has resulted from proximal
tibial deformity such as may occur following tibial pla-
teau fracture, opening wedge varus-producing tibial os-
teotomy has yielded acceptable results.
Figure 1 Opening wedge valgus osteotomy of the tibia with plate fixation.
Valgus-Producing Tibial Osteotomy
performed procedures for the diseased knee because of High tibial osteotomy requires careful patient selection
its ease of application and proven efficacy. Its success in and exacting surgical technique. The ideal patient is
the treatment of the arthritic knee is directly propor- younger than age 50 years and active, with high func-
tional to the degree of mechanical symptoms present tional demands likely to place undesirable stress on an
preoperatively and inversely proportional to the sever- arthroplasty. The procedure works best when performed
ity of the underlying arthritis. Although the underlying early enough that symptoms and cartilage loss predomi-
disease process of cartilage degradation has not been nate on the medial side and there is no suggestion of in-
shown to be favorably impacted by arthroscopic inter- volvement of either of the other two compartments, ei-
vention, the symptoms associated with the secondary, ther clinically or radiographically. Contraindications
mechanically significant lesions such as loose bodies, generally include inflammatory arthritis, poor flexion
meniscal tears, and unstable cartilaginous flaps can be (< 90), flexion contracture, ligament instability, and tri-
successfully addressed. Arthroscopic treatment of the compartmental arthritis. The procedure is less successful
arthritic knee is less likely to be effective in the pres- in smokers and in patients age 60 years or older, when
ence of malalignment that causes overloading of the the degree of deformity increases beyond 10 and when
most diseased portion of the knee. the involvement of the remaining compartments in-
A recent and widely discussed randomized compari- creases.
son of knee arthroscopy with lavage and sham surgery Valgus correction can be achieved by medial length-
failed to demonstrate superiority of arthroscopy over ening rather than lateral shortening, using either an
sham surgery in a population of men with advanced ar- opening wedge osteotomy and interposition plating or a
thritis. A separate review of arthroscopic dbridement medial external fixator with gradual distraction. The ad-
performed in a large group of patients older than age 50 vantages of correction on the medial side include more
years with a variety of diagnoses found that within 3 years, anatomic restoration with resultant improvement in lig-
18% of patients needed total knee arthroplasty (TKA), ament stability, and the ability to more finely tune the
suggesting overutilization of the index procedure. The ef- correction. The main disadvantage of this technique is
fect of previous arthroscopic knee surgery on the results the risk of nonunion and loss of correction (Figure 1).
Figure 2 Distal femoral varus osteotomy (A), with medial closing wedge and plate fixation (B).
Figure 5 A, Preoperative AP radiograph demonstrating medial compartment arthritis. B, Postoperative AP radiograph at 3-year follow-up. C, Postoperative lateral radiograph at
3-year follow-up.
such as patella fracture or component loosening, are Advantages of unicompartmental arthroplasty may
more common following patella resurfacing and are dif- include quicker recovery, fewer short-term complica-
ficult to treat, often resulting in inferior outcomes. Thus, tions, and better functional outcome. There is a high rate
the consensus has emerged that knees without patellar of short- to mid-term satisfaction, but long-term survi-
resurfacing are at a somewhat increased risk for ante- vorship has not been comparable to TKA when mea-
rior knee pain, but are at a decreased risk for serious sured by revision rates.
patellar complications. Failure of a unicompartmental arthroplasty may oc-
cur as a result of implant wear, loosening or subsidence,
Unicompartmental Arthroplasty or progression of symptomatic arthritis in the lateral or
Unicompartmental arthroplasty is an alternative to patellar compartments. Different failure mechanisms
TKA or osteotomy when the arthritis predominantly af- may predominate depending on design, with fixed bear-
fects one compartment of the knee (Figure 5). In such ing designs exhibiting more component failure and mo-
instances, it is possible to resurface the diseased com- bile bearing designs failing because of disease progres-
partment and restore knee alignment that allows for sion. Overcorrection may lead to deterioration of the
load to be shared between the replaced and unreplaced compartment to which load is redirected, whereas un-
compartments. Although this procedure lost favor after dercorrection risks overloading the implant. Patellar im-
evidence of inferior survivorship data of several early pingement against the femoral implant can be symptom-
series, newer techniques and patient demand has driven atic and lead to revision. Patellar arthritis generally is
a resurgence of interest, and survivorship of greater well tolerated in unicompartmental arthroplasty. Revi-
than 90% at 10 years has been documented. sion of a unicompartmental arthroplasty has been
Patient selection and surgical technique are essential shown to be less complex than revision TKA. Neverthe-
elements of a successful outcome. Pain that is well local- less, defects in the replaced compartment may necessi-
ized to the compartment exhibiting disease responds tate the use of augments, bone grafting, and/or stems.
better to treatment than diffuse or global pain, and al- Newer instrumentation has increased the appeal of
though the status of the patellofemoral joint has not the unicompartmental arthroplasty by allowing for small
been consistently correlated with success, the presence incisions with attendant lower patient morbidity, includ-
of pain in the lateral or patellofemoral joint preopera- ing less pain and shorter hospital stays. Care must be
tively is a predictor of persistent pain after surgery. Con- taken when using a minimally invasive approach to be
traindications include inflammatory arthritis, severe certain that final implant fixation and alignment, keys to
fixed deformity, previous opposite compartment menis- longevity of the construct, are not compromised. The
cectomy, and tricompartmental arthritis. Correction of long-term results of these techniques are not yet avail-
deformity must allow appropriate load transfer to pre- able, and common sense suggests that the incision size
vent premature failure, but overcorrection adversely im- should not be the dominant outcome measure of this
pacts the retained compartment, and also can lead to technique. Similarly, as this procedure gains popular ap-
early failure. Recommended correction of the varus peal, its application to younger patients awaits long-
knee has ranged from 1 to 5 of postoperative valgus. term follow-up of success in this population.
polyethylene component was used. Two revisions demon- Extra-articular deformity can be corrected using intra-
strated tibial post impingement and backside wear of the poly- articular bone resection and ligament balancing when coronal
ethylene. plane deformity is less than 20 in the femur and less than 30
in the tibia.
Parvizi J, Lajam CM, Trousdale RT, Shaughnessy WJ,
Cabanela ME: Total knee arthroplasty in young patients Complications
with juvenile rheumatoid arthritis. J Bone Joint Surg Am Crossett LS, Sinha RK, Sechriest VF, Rubash HE: Re-
2003;85:1090-1094. construction of a ruptured patellar tendon with Achilles
TKA in patients with juvenile rheumatoid arthritis can be tendon allograft following total knee arthroplasty.
successful, but poor preoperative function, involvement of J Bone Joint Surg Am 2002;84-A:1354-1361.
multiple joints, and compromised immune system lead to in- Rupture of the patellar tendon can be successfully man-
creased rates of postoperative stiffness and infection. aged by reconstruction using an Achilles tendon allograft.
Technical details are critical with proper bone attachment to
the tibia and broad soft-tissue repair to the quadriceps. Recur-
Puloski SKT, McCalden RW, MacDonald SJ, Rorabeck rent failure is minimized with this approach.
CH, Bourne RB: Tibial post wear in posterior stabilized
total knee arthroplasty: An unrecognized source of
Dennis DA: Periprosthetic fractures following total
polyethylene debris. J Bone Joint Surg Am 2001;83-A:
knee arthroplasty. Instr Course Lect 2001;50:379-389.
390-397.
The management of periprosthetic fractures around knee
Retrieval analysis of posterior stabilized knee replacement
arthroplasty is reviewed. Key determinants of treatment in-
identified that the tibial post can exhibit significant wear and
clude fracture displacement, bone quality, and status of im-
damage as a result of impingement. This phenomenon was de-
plant fixation. Closed treatment, open reduction and fixation,
scribed for several implants and may be related to flexion of
and component revision are the primary options.
the femoral component, or hyperextension of the knee.
to accepted techniques of gap balancing. All patients in this se- Blount WP: Dont throw away the cane. J Bone Joint
ries had improved motion and satisfactory pain relief and Surg Am 2003;85-A:380.
function.
Callaghan JJ, Squire MW, Goetz DD, Sullivan PM,
Johnston RC: Cemented rotating-platform total knee
Clatworthy MG, Balance J, Brick GW, Chandler HP,
replacement: A nine to twelve-year follow-up study.
Gross AE: The use of structural allograft for uncon-
J Bone Joint Surg Am 2000;82:705-711.
tained defects in revision total knee arthroplasty: A
minimum five-year review. J Bone Joint Surg Am 2001; Cartier P, Sanouiller JL, Grelsamer RP: Unicompart-
83-A:404-411. mental knee surgery: 10-year minimum follow-up pe-
Structural allograft used for the treatment of uncontained riod. J Arthroplasty 1996;11:782-788.
bone loss around the knee demonstrated a 72% survivorship
at 10-year follow-up. Failure occurred as a result of infection Chandler HP, Tigges RG: The role of allografts in the
or nonunion. treatment of periprosthetic femoral fractures. Instr
Course Lect 1998;47:257-264.
Hansen AD: Bone grafting for severe patellar bone loss
during revision knee arthroplasty. J Bone Joint Surg Am Colizza WA, Insall JN, Scuderi GR: The posterior stabi-
2001;83:171-176. lized total knee prosthesis: Assessment of polyethylene
Severe patellar deficiency encountered during revision damage and osteolysis after a 10-year minimum follow-
TKA that precludes reinsertion of a prosthetic component was up. J Bone Joint Surg Am 1995;77:1713-1720.
treated with bone grafting inside a soft-tissue envelope, with
Coventry MB, Ilstrup DM, Wallrichs SL: Proximal tibial
improved tracking and restoration of patellar thickness.
osteotomy: A critical long-term study of eighty-seven
cases. J Bone Joint Surg Am 1993;75:196-201.
Mason JB, Fehring TK, Odum SM, Griffin WL, Nuss-
man DS: The value of white blood cell counts before re- Coyte PC, Hawker G, Croxford R, Wright JG: Rates of
vision total knee arthroplasty. J Arthroplasty 2003;18: revision knee replacement in Ontario, Canada. J Bone
1038-1043. Joint Surg Am 1999;81:773-782.
Analysis of synovial fluid prior to revision TKA is useful
in differentiating septic from nonseptic knees. White blood cell Dennis DA, Konistek RD, Stiehl JB, Walker SA, Dennis
counts over 2,500/mm3 with over 60% polymorphonucleocytes KN: Range of motion after total knee arthroplasty: The
is highly suggestive of infection. effect of implant design and weight-bearing conditions.
J Arthroplasty 1998;13:748-752.
Saleh KJ, Dykes DC, Tweedie RL, Heck DA: Functional Duff GP, Lachiewicz PF, Kelley SS: Aspiration of the
outcome after total knee arthroplasty revision: A meta- knee joint before revision arthroplasty. Clin Orthop
analysis. J Arthroplasty 2002;17:967-977. 1996;331:132-139.
In this review of 42 studies on revision arthroplasty, the
procedure was shown to be effective in improving knee symp- Healy WL, Wasilewski SA, Takei R, Oberlander M: Pa-
toms and function. Complications occur in 26% of cases and tellofemoral complications following total knee arthro-
rerevision is necessary in 13% of cases for a variety of reasons plasty: Correlation with implant design and patient risk
including infection, extensor mechanism failure, and loosening. factors. J Arthroplasty 1995;10:197-201.
arthroplasty: A 15-year survivorship study. Clin Orthop Squire MW, Callaghan JJ, Goetz DD, Sullivan PM,
1993;286:94-102. Johnston RC: Unicompartmental knee replacement: A
minimum 15-year follow-up study. Clin Orthop 1999;
Ritter MA, Herbst SA, Keating EM, Faris PM, Meding 367:61-72.
JB: Long-term survival analysis of a posterior cruciate-
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Orthop 1994;309:136-145. sults after follow-up of nine to twelve years. J Bone Joint
Surg Am 1992;74:980-986.
Figure 1 A, Schematic diagram and case examples of Lauge-Hansen supination-external rotation and supination-adduction ankle fractures. A supinated foot sustains either an
external rotation or adduction force and creates the successive stages of injury shown in the diagram. The supination-external rotation mechanism has four stages of injury, and
the supination-adduction mechanism has two stages. tib-fib = tibiofibular (Reproduced with permission from Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD
(eds): Rockwood and Greens Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2001-2090.)
Figure 1 B, Schematic diagram and case examples of Lauge-Hansen pronation-external rotation and pronation-abduction ankle fractures. A pronated foot sustains either an
external rotation or abduction force and creates the successive stages of injury shown in the diagram. The pronation-external rotation mechanism has four stages of injury, and
the pronation-abduction mechanism has three stages. tib-fib = tibiofibular (Reproduced with permission from Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman
JD (eds): Rockwood and Greens Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2001-2090.)
Trimalleolar Fractures
Fractures involving the posterior malleolus are a result
of posteroinferior tibiofibular ligament avulsion, or im-
paction from the talus. Frequently, anatomic reduction
Figure 2 Weber/AO fractures. The staging is completely determined by the level of of the lateral malleolus and medial malleolus combined
fibular fracture. Type A occurs below the plafond, whereas type C starts above the with dorsiflexion of the ankle reduces the posterior mal-
plafond. (Reproduced from Michelson JD: Ankle fractures resulting from rotational in-
juries. J Am Acad Orthop Surg 2003;11:403-412.) leolar fragment. Fragments with less than 25% involve-
ment of the articular surface or those with less than 2
mm of displacement do not require internal fixation.
ment and medial displacement. Medial shift of greater Anterior to posterior percutaneous fixation may be pos-
than 2 mm requires surgical intervention, typically with sible, although at times a formal posterolateral or pos-
two parallel 4.0-mm lag screws or a lag screw with dero- teromedial approach is necessary to free up interposed
tation Kirschner wire. Poor bone quality or significant soft tissues.
comminution may necessitate the use of tension band
wiring. If a vertical shear pattern is noted, the screws Syndesmotic Complex Injury
should be placed perpendicular to the shaft, at times in
Disruption of the inferior syndesmosis ranges from sub-
conjunction with a medial buttress plate to avoid the
tle sprain to gross instability seen with pronation-
risk of proximal migration of the medial malleolar frag-
external rotation and Weber C injuries. Patients with
ment. Stress fracture of the medial malleolus has also tenderness over the medial malleolus, proximal fibula,
been described, particularly in patients with a varus heel or interosseous membrane should be evaluated for syn-
and repeated adduction moments. desmotic injury. With subtle injury, MRI or bone scan
may help in the diagnosis. Weight-bearing ankle views
Bimalleolar Fractures can sufficiently stress the interosseous membrane and
Bimalleolar fractures with displacement or rotational anterior talofibular ligament to allow for evaluation of
deformity at the time of injury frequently require open the syndesmosis and should be obtained as pain allows.
reduction and internal fixation. If the medial malleolar As previously discussed, medial clear space widening
fracture occurs below the level of the plafond, closed with loss of tibiofibular overlap indicates deltoid and
treatment may be possible; however, the risk of dis- syndesmotic disruption. In patients with isolated syndes-
placement and the need for frequent reevaluation typi- motic disruption, reduction with percutaneous internal
cally results in surgical intervention, if the patients fixation is possible if the medial clear space adequately
medical condition permits. The timing of surgical inter- reduces. If not, a medial arthrotomy is necessary to re-
vention is dependent on ankle edema and the quality of move the interposed deltoid ligament. A fully threaded
the soft tissues. Restoration of lateral malleolar length 3.5- or 4.5-mm screw is placed across three or four corti-
and rotation is key to reduction, and any significant lat- ces, without compressive lagging. The screw should be
eral shift or shortening of the lateral malleolus can re- placed 1.5 to 3.0 mm above the joint and directed 30
sult in alterations of contact characteristics of the ankle anteriorly. Both three- and four-cortex fixation has been
joint. A recent study indicated that both lateral and pos- advocated, with four-cortex fixation offering greater sta-
terior antiglide plating of the lateral malleolus have bility, but no study has shown superior results with ei-
equivalent clinical and radiographic results, with slightly ther method of fixation. Although traditionally the syn-
more peroneal tendon irritation with the antiglide tech- desmotic screw is placed with the ankle in a neutral
nique. The use of lag screws without plate application position, the position of the ankle at the time of screw
has been successfully reported for management of ob- placement does not affect postoperative range of mo-
tion. Patients do not bear weight for 8 weeks to allow sive surgical dissection and soft-tissue stripping. Newer
for sufficient syndesmotic healing, and screws are re- surgical techniques include percutaneous internal fixa-
moved at 3 months to allow for restoration of normal tion, limited open reduction, and subcutaneous plating,
distal fibular motion. Bioabsorbable screws have been thus avoiding soft-tissue healing complications. Care is
shown to have equivalent clinical outcomes compared taken to perform a wound closure free of tension. If a
with metallic screws and avoid the need for screw re- solid construct can be obtained, the external fixator can
moval. For Weber B and C injuries, the fibular fracture be removed at the time of definitive treatment; how-
is rigidly fixed, then the syndesmosis is stressed with ex- ever, this is generally only possible for type I fractures,
ternal rotation of the talus within the mortise with the whereas the higher energy level injuries require a pro-
ankle in a neutral position. Additionally, the fibula can longed course of fixator usage, frequently 2 to 3 months,
be grasped with a towel clip, and distal syndesmotic sta- to provide additional stability. If extensive bone loss is
bility evaluated. Typically, fractures less than 4.5 mm encountered, bone grafting at 6 to 8 weeks after injury
above the joint do not require a syndesmotic screw, but is performed, with consideration given for the applica-
this parameter is variable, and intraoperative stressing is tion of a bone stimulator.
advised for all fibular fractures above the level of the
joint. Hindfoot Fractures
Talus Fractures
Pilon Fractures The talus acts as a link between the ankle, subtalar, and
Classification transverse tarsal joints. It is devoid of muscle or tendon
Tibial pilon fractures occur as a result of either a low- attachments, and 70% of its surface is covered by articu-
energy rotational mechanism with less comminution and lar cartilage for its five weight-bearing surfaces. Its
soft-tissue damage or a high-energy injury secondary to blood supply is limited to the nonarticular surfaces;
vertical compression that can result in significant com- therefore, vascular compromise may be associated with
minution, chondral damage, and soft-tissue involvement. fractures, particularly those involving the talar neck.
Foot position at the time of impact can also result in ad- Fractures are classified according to anatomic location:
ditional injury to the malleoli, talus, and calcaneus. The body, neck, or head.
Ruedi and Allgower classification remains the most
commonly used for pilon fractures. Type I fractures are Talar Body
intra-articular with minimal displacement. Type II frac- Talar body fractures involve the superior articular carti-
tures have significant articular displacement with little lage and may be classified as coronal, sagittal, or hori-
comminution, whereas type III fractures have greater zontal fractures. These fractures are commonly associ-
comminution and metaphyseal involvement. CT is use- ated with high-energy ankle fractures. Osteochondral
ful in determining the full extent of the injury and helps fractures are also associated with ankle fractures, partic-
with definitive surgical planning. ularly supination-external rotation fracture patterns.
Other anatomic locations include fracture of the lateral
Treatment and posterior processes. Lateral process fractures, also
Nonsurgical treatment is possible if articular incongruity described as snowboarder fractures, are created by
is less than 2 mm and is generally reserved for low- forced dorsiflexion and external rotation of the foot.
energy injuries. Many pilon fractures require surgical in- This fracture is commonly missed on initial presenta-
tervention, which is performed in stages. The application tion, but is usually present on plain radiographs of the
of an external fixator at the time of injury allows for ankle. CT is helpful to ascertain the extent of the frac-
restoration of length and partial reduction via ligamen- ture, which may encompass a significant portion of the
totaxis, while minimizing further soft-tissue damage. The lateral aspect of the posterior facet. If the fragment size
fixator may be uniplanar or multiplanar, may cross the is large and displacement is greater than 2 mm, open re-
ankle and subtalar joints, or be limited to the tibia. Plat- duction and internal fixation is performed. Comminuted
ing of the fibula helps restore length, but is not neces- fractures may be initially treated with casting or imme-
sary at the time of initial fixator stabilization. CT is per- diate excision with early range of motion. No prospec-
formed after fixator application to better ascertain tive study has evaluated the superiority of either treat-
fracture configuration and can help determine the ment method. The posterior process consists of
proper surgical approach to limit soft-tissue stripping. posteromedial and posterolateral tubercles. Fractures
Definitive treatment cannot be undertaken until the soft occur as a result of avulsion of the posterior talotibial
tissues have healed and swelling has resolved, usually 10 and posterior talofibular ligaments, respectively. The
to 21 days after injury. Treatment goals include restora- posterolateral tubercle is more frequently involved, and
tion of articular congruity and reestablishing proper because of the close proximity of the flexor hallucis lon-
length, rotation, and angulation, while avoiding exces- gus tendon in its posterior groove, flexion and extension
Calcaneal Fractures
The calcaneus is the most frequently fractured tarsal
bone, with most fractures occurring as a result of axial
loading, such as a fall from a height or during a motor
vehicle crash. Given the mechanism of injury, patients
should be evaluated for associated injury of the lumbar
spine, which occurs in approximately 10% of patients
with calcaneal fractures. Axial loading creates an ob-
lique shear fracture caused by impaction of the lateral
process of the talus that results in a superomedial frag-
ment that consists of the sustentaculum (constant
fragment) and a superolateral fragment that has an
intra-articular component. In addition to this primary
fracture line, a secondary fracture component may be
created, based on additional energy imparted and the
position of the foot at the time of injury.
Radiographic evaluation should include standard
foot views, as well as a Harris axial view, which can pro-
vide information concerning shortening and varus angu- Figure 4 Schematic diagram of Sanders classification. (Reproduced with permission
lation of the heel. An AP ankle radiograph may also al- from Sanders R, Fortin P, Pasquale T, et al: Operative treatment in 120 displaced
low for evaluation of lateral wall extrusion and intra-articular calcaneal fractures: Results using a prognostic computed tomography
scan classification. Clin Orthop 1993;290:87-95.)
impingement. Although specialized projections of the
subtalar joint have been described (Broden and Isher-
wood projections), CT imaging provides the most com- into account. Treatment options include no surgery,
plete, reliable assessment of these fractures. closed reduction with manipulation with or without lim-
Fractures may be classified as either extra-articular ited internal fixation, open reduction with internal fixa-
or intra-articular. Avulsion injuries account for most tion, and primary arthrodesis. Nonsurgical treatment is
extra-articular fractures and result in fracture of the an- limited to patients with a type I fracture pattern or
terior process, sustentaculum, or calcaneal tuberosity, those with factors or comorbidities that preclude good
which is secondary to avulsion of the Achilles tendon in- surgical outcome. The fracture is immobilized until the
sertion. Occasionally, oblique fractures that do not in- soft-tissue swelling and fracture blisters resolve, then
volve the subtalar joint are seen as well. Surgical indica- range-of-motion exercises are instituted. The patient is
tions are detachment of the Achilles tendon insertion, to refrain from bearing weight for 10 to 12 weeks.
or displacement of greater than 2 mm of the sustentacu- Closed reduction and manipulation with or without lim-
lum or anterior process. ited internal fixation can be used for those fractures
Intra-articular fractures occur in 75% of patients with mild shortening or lateral impingement, as well as
with calcaneal fractures, and characterization of the de- tongue-type fractures that are amenable to this form of
gree of displacement and number of posterior facet ar- treatment. As a result, the late complication of subfibu-
ticular fragments is helpful for treatment recommenda- lar impingement with peroneal involvement can be
tions and predictive of treatment outcomes. The Sanders avoided and more normal hindfoot anatomy can be re-
CT classification system is based on the number and lo- stored, while avoiding potential complications associ-
cation of articular fragments seen on coronal projec- ated with open techniques.
tions (Figure 4). There are four types, based on the Open reduction and internal fixation is indicated for
number of fragments of the posterior facet, with dis- type II and III fractures. Surgery is delayed until swell-
placement of greater than 2 mm considered significant. ing subsides, and a wrinkle sign is present on the lat-
Type I fractures are nondisplaced, regardless of the eral aspect of the heel, usually 10 to 14 days after injury.
number of fragments. Types II, III, and IV have corre- If a fracture blister is present in the area of the pro-
sponding numbers of displaced articular fragments. In posed incision, it must resorb and begin to reepithelial-
addition to displacement of the posterior facet, the sur- ize before surgery. The lateral extensile right-angle inci-
geon must take into account factors such as shortening sion is most commonly used, and although the medial
and widening of the heel, lateral wall impingement, and approach has been used successfully, it is typically re-
peroneal subluxation/dislocation when making surgical served for fractures with an irreducible medial frag-
decisions. Patient factors, such as overall medical condi- ment. A full-thickness flap is created to maintain soft-
tion, peripheral vascular disease, compromised soft tis- tissue integrity, and the posterior facet is elevated and
sues, and a history of smoking also need to be taken reduced. Manipulation of the tuberosity with a Schanz
or Steinmann pin can correct shortening and varus an- relative to the hindfoot. Given the extensive articular
gulation and help with reduction of the posterior facet. surfaces of the navicular, vessels enter from the navicu-
Following provisional reduction maintained by Kir- lar tuberosity and dorsal and plantar surfaces, with a rel-
schner wires, a low profile lateral plate and screws are atively avascular central portion, which has implications
applied, first stabilizing the posterior facet. Meticulous for fracture healing and the development of osteonecro-
closure is performed, and the patient is immobilized in a sis.
bulky posterior and U splint. Sutures are removed 10 to Fractures can be described as avulsion (chip), tuber-
14 days after surgery, and if the soft tissues allow, early osity, or body fractures. Avulsion fractures of the dorsal
range of motion is instituted. Patients do not bear lip are the most common and occur secondary to a plan-
weight for 10 weeks, at which time progressive weight tar flexion force with varying degrees of inversion or
bearing is begun. eversion. The patient should be evaluated for associated
Primary subtalar arthrodesis combined with open re- midfoot or ankle injury. Immobilization is used until
duction and internal fixation to restore anatomic height, symptoms resolve, and for more severe fractures with a
width, and calcaneal pitch is used for type IV fractures. larger avulsion fragment and soft-tissue swelling, a non
This approach appears to be superior to initial neglect weight-bearing cast should be used. Delayed excision of
of the fracture followed by delayed subtalar fusion or fragments is undertaken if they remain symptomatic. If
primary open reduction and internal fixation. a fragment includes more than 25% of the articular sur-
The surgical outcomes of calcaneal fractures corre- face, open reduction and internal fixation is indicated to
late with the quality of reduction and number of intra- avoid midtarsal subluxation and posttraumatic arthrosis.
articular fragments. Two-part fractures are associated Navicular tuberosity fractures result from an eversion
with a better outcome than three-part fractures, and force applied to the foot, with resultant contraction of
four-part fractures have uniformly poor outcomes. The the posterior tibial tendon and tension on the superficial
extent of initial injury, initial nonsurgical treatment, and deltoid attachment to the navicular. This may also rep-
workers compensation cases are predictors for eventual resent a diastasis of the synchondrosis of an accessory
subtalar fusion. More than half of patients will require a navicular. Oblique foot radiographs obtained with the
supportive device. Bilateral fractures treated surgically foot in 45 of internal rotation may help identify the
have a worse outcome than unilateral fractures treated fracture, which is differentiated from an accessory bone
surgically, but have a better outcome than those man- by the presence of sharp, irregular cleavage lines. Treat-
aged nonsurgically. A recent Canadian study has shown ment is based on the severity of symptoms; however,
comparable results in patients treated surgically and given the possible late sequelae of posttraumatic flat-
nonsurgically; however, when workers compensation foot deformity, cautious treatment of these injuries is
patients were excluded, those managed surgically had warranted. Injuries with minimal symptoms may be
significantly higher satisfaction scores. Complications treated with immobilization and weight bearing as toler-
occur in 18% to 40% of surgical cases. Falls from a ated. In more symptomatic injuries with diastasis less
than 3 mm, a nonweight-bearing cast is applied for 4 to
height, surgical treatment earlier than 7 days after in-
6 weeks, followed by gradual mobilization of the foot.
jury, longer surgical time, and a history of smoking were
Diastasis greater than 3 mm usually requires open re-
factors associated with complications.
duction and internal fixation, with care taken to repair
Neglected displaced fractures often result in a wide,
the posterior tibial tendon and deltoid ligament attach-
shortened heel, problems with shoe wear, subfibular
ments.
peroneal impingement, and posttraumatic arthrosis. This
Body fractures of the navicular are the result of di-
may necessitate decompression of the lateral wall of the
rect axial loading, as occurs with a fall from a height.
calcaneus, peroneal relocation, and subtalar distraction
Given the strong ligamentous attachments, this probably
arthrodesis to restore proper calcaneal pitch and height.
requires a plantar flexion/dorsiflexion and rotational
moment in addition to axial loading. Three fracture
Midfoot Trauma types have been described. Type I is a transverse frac-
Navicular Fractures ture in the coronal plane, with the dorsal fragment less
The midfoot consists of the navicular, cuboid, the me- than 50% of the body, and no angular deformity of the
dial, middle, and lateral cuneiforms, as well as the foot. Type II, the most common, is an oblique fracture,
metatarsal-cuneiform articulations. The midfoot has from a dorsomedial to plantar lateral direction. The lat-
constrained motion because of multiple recessed articu- eral fragment is smaller and often comminuted. There
lations as well as strong ligamentous and capsular at- may be an adduction deformity of the foot. Type III
tachments. The navicular articulates with the cunei- fractures occur as a result of axial loading with lateral
forms, cuboid, calcaneus, and talus. Coupled motion compression that results in central or lateral comminu-
between these structures (transverse tarsal joint) pro- tion and midfoot abduction deformity. The cuboid and
vides inversion and eversion of the midfoot and forefoot anterior calcaneus may also be injured.
Figure 6 Bony avulsion at the base of the second metatarsal. This fleck sign (arrow)
indicates a Lisfranc injury.
total incongruity, partial incongruity, or divergent, but ated with a Lisfranc ligamentous injury at the tar-
because of tremendous variation in mechanism of in- sometatarsal junction, surgical stabilization is necessary
jury, there is great variation in radiographic presenta- because of inherent instability. Surgical stabilization
tion. may be achieved with Kirschner wires, compression
Nonsurgical treatment is used for nondisplaced frac- screws, or minifragment plating, as the fracture pattern
tures and consists of a nonweight-bearing cast for 8 dictates.
weeks, followed by gradual weight bearing in a remov- Treatment of fifth metatarsal base fractures is de-
able boot brace. Surgery is performed for injuries with pendent on fracture location. It is helpful to separate
any displacement seen on radiographs. If anatomic re- fractures of the base of the fifth metatarsal into three
duction can be obtained by closed means, percutaneous types, based on location of the fracture. Type I fractures
internal fixation is possible, but interposed Lisfranc liga- are true avulsion injuries of the tuberosity, or styloid
ment remnant can frequently block reduction and result process, which occur secondary to contraction of the
in the joint springing open once internal fixation is re- long plantar ligament and peroneus brevis insertion;
moved. Therefore, open reduction is frequently neces- many are extra-articular. These fractures can typically
sary through a single or dual longitudinal incision as dic- be treated with a stiff-soled shoe and weight bearing as
tated by the injury pattern. Fixation is achieved with tolerated once symptoms diminish, with many patients
either 3.5- or 4.0-mm screws for the medial (first tar- sufficiently asymptomatic after 3 weeks of treatment. If
sometatarsal joint) and middle (second, third tarsometa- there is a large intra-articular fragment with displace-
tarsal joints) columns and Kirschner wires for the lateral ment or if the base fragment has retracted proximally,
(fourth, fifth tarsometatarsal joints) column. A severe indicative of peroneus brevis retraction, acute surgical
abduction mechanism may result in compression of the intervention is occasionally necessary. Continued symp-
cuboid, termed a nutcracker injury. This injury may re- toms after nonsurgical treatment are rare and may ne-
quire lateral plating and bone grafting to avoid residual cessitate removal of the nonunion fragment, with evalu-
abduction. Patients should not bear weight for 8 weeks, ation of the peroneus brevis for possible reattachment
followed by gradual weight bearing in a removable boot directly to bone, or with the use of a suture anchor.
brace. Screws are removed 3 to 4 months after surgery Type II fractures occur at the metaphyseal-
diaphyseal junction, approximately 2.5 cm distal to the
to avoid screw breakage and to allow restoration of sag-
base. This is a circulatory watershed region that is sub-
ittal motion at the tarsometatarsal junction. Alterna-
ject to nonunion secondary to poor blood supply. The
tively, bioabsorbable screws may also be used, obviating
acute Jones fracture should be treated with either a
the need for additional surgery for screw removal. Im-
nonweight-bearing cast for 6 to 8 weeks, or in a high-
mediate complete arthrodesis of the midfoot has poor
performance athlete, with placement of an intramedul-
results, although partial arthrodesis tends to have better
lary screw, which allows for earlier mobilization. The op-
results. Late arthrosis is common, even with anatomic
timal screw size is largely dependent on the size of the
reduction. Poor results are associated with nonanatomic
intramedullary canal. One study has shown comparable
reduction, open injury, and extensive comminution.
initial and ultimate failure loads for 4.5- and 5.5-mm
partially threaded cannulated screws, whereas another
Metatarsal Fractures study compared 5.0- and 6.5-mm partially threaded
Acute metatarsal fractures may occur as a result of a di- screws and found no difference in bending stiffness, but
rect blow, which usually results in a transverse fracture, greater pull-out strength with the 6.5-mm screws. Clini-
or as a result of an indirect twisting, or avulsion mecha- cally, failure of fixation has been noted in athletes who
nism. Metatarsal base fractures are associated with mid- returned to full activities before radiographic evidence
foot injury, and these fractures carry a high index of sus- of complete radiographic union.
picion for additional injury. Compartment syndrome can Type III fractures occur in the diaphysis and are typ-
be seen in patients with more severe fractures, particu- ically stress fractures. Possible etiologic factors include
larly those resulting from a direct blow. Nonsurgical low arches and associated first metatarsal hypermobility,
treatment is indicated if displacement is less than 3 mm as well as cavovarus deformities, both of which can re-
or angulation is less than 10. Treatment can vary from sult in abnormally high stresses placed on the lateral
the use of a postoperative shoe with weight bearing as foot. Altered lateral stresses may also be seen in pa-
tolerated for a stable fracture to casting with no weight tients with hereditary sensorimotor neuropathy and dia-
bearing for an unstable fracture pattern prone to dis- betic neuropathy. Poor blood supply in this region may
placement. Surgery is indicated for displacement of also predispose an individual to injury and impair injury
greater than 3 to 4 mm or sagittal displacement of healing, resulting in nonunion. Strict adherence to no
greater than 10 because this can lead to either direct weight bearing is necessary after a proximal diaphyseal
overload of a displaced plantar fragment, or transfer fracture is diagnosed and should be continued until ra-
metatarsalgia if dorsal displacement is noted. If associ- diographic evidence of fracture healing. Pulsed electro-
In this study, 52% of patients with surgically treated bimal- postoperative wound healing complications was significantly
leolar fractures had good or excellent results; 24% of patients higher with brace treatment.
had a poor outcome.
Loren GJ, Ferkel RD: Arthroscopic assessment of occult
Dickson KF, Montgomery S, Field J: High energy intra-articular injury in acute ankle fractures. Arthros-
plafond fractures treated by a spanning external fixator copy 2002;18:412-421.
initially and followed by a second stage open reduction Sixty-three percent of fractures showed chondral injury,
internal fixation of the articular surface: Preliminary re- more frequently on the medial aspect of the talus. Pronation-
port. Injury 2001;32(suppl 4):SD92-SD98. external rotation fractures had a higher incidence of injury
This protocol, used to treat patients with highly commi- (70%) than supination-external rotation fractures (46%).
nuted fractures, resulted in 81% good or excellent results, a Seventy-five percent of fractures with syndesmotic disruption
35% complication rate, and 28% radiographic arthrosis. had chondral damage.
Dietrich A, Lill H, Engel T, Schonfelder M, Josten C: Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino
Conservative functional treatment of ankle fractures. SG: The effects of rotation on radiographic evaluation
Arch Orthop Trauma Surg 2002;122:165-168. of the tibiofibular syndesmosis. Foot Ankle Int 2002;23:
Ninety percent of patients with an isolated Weber B frac- 107-111.
ture with less than 1 mm of displacement were treated suc- Comparisons were made between the tibiofibular clear
cessfully with a functional brace. space, tibiofibular overlap, width of the tibia and fibula, and
medial clear space. The width of the tibiofibular clear space
Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti did not change with rotation, whereas the other parameters
SF: Foot and ankle fractures in elderly white women: In- did.
cidence and risk factors. J Bone Joint Surg Am 2003;
85:820-824. Sinisaari IP, Luthje PM, Mikkonen RH: Ruptured tibio-
Fibular fractures were the most common ankle fracture fibular syndesmosis: Comparison study of metallic to
(prevalence 57.6%) and occur in younger women with a high bioabsorbable fixation. Foot Ankle Int 2002;23:744-748.
body mass index. Fractures of the fifth metatarsal are the most Poly-L-lactide bioabsorbable screws showed equivalent re-
common foot fractures in women with low bone mineral den- sults with radiographic measurements, range of motion, and
sity. subjective outcome compared with metallic fixation.
Hovis WD, Kaiser BW, Watson JT, Bucholz RW: Treat- Tornetta P III, Creevy W: Lag screw only fixation of the
ment of syndesmotic disruptions of the ankle with bio- lateral malleolus. J Orthop Trauma 2001;15:119-121.
absorbable screw fixation. J Bone Joint Surg Am 2002; Lag screw only fixation of simple oblique fractures, when
84:26-31. compared with plate fixation, resulted in less lateral pain, no
Polyevolactic acid screws were used to stabilize syndes- palpable hardware (56% plate), fewer shoe wear restrictions,
motic disruptions in 33 patients. Twenty-four patients were fol- no hardware removal requirements (31% plate), and no loss
lowed for 34 months after surgery. All patients healed un- of fracture reduction.
eventfully, with or without fixation; no patient had osteolysis
or inflammation. Tornetta P III, Spoo JE, Reynolds FA, Lee C: Overtight-
ening of the ankle syndesmosis: Is it really possible?
Lamontagne J, Blachut PA, Broekhuyse HM; OBrien J Bone Joint Surg Am 2001;83-A:489-492.
PJ, Meek RN: Surgical treatment of a displaced lateral There was no difference between the values for maximal
malleolus fracture: The antiglide technique versus lat- dorsiflexion before and after syndesmotic compression in ca-
eral plate fixation. J Orthop Trauma 2002;16:498-502. daveric specimens fixed with a syndesmotic screw while held
In this study, surgical outcome, complication rate, and re- in plantar flexion.
quirement for hardware removal was equivalent in the two
groups. Hindfoot Fractures
Bibbo C, Anderson RB, Davis WH: Injury characteris-
Lehtonen H, Jarvinen TL, Honkonen S, Nyman M, Vih- tics and the clinical outcome of subtalar dislocations: A
tonen K, Jarvinen M: Use of a cast compared with a clinical and radiographic analysis of 25 cases. Foot Ankle
functional ankle brace after operative treatment of an Int 2003;24:158-163.
ankle fracture: A prospective, randomized study. J Bone High-energy mechanisms accounted for 68% of subtalar
Joint Surg Am 2003;85-A:205-211. dislocations; 75% of dislocations were closed, 65% were me-
The long-term functional outcome was equivalent between dial dislocations, and 32% of dislocations were irreducible. Ra-
the two groups, with similar fracture healing. The incidence of diographic evidence of arthrosis was noted in 89% of ankle
and subtalar joints; the subtalar joint was more frequently A 90% satisfaction rate was noted with surgical treatment.
symptomatic. Bilateral injuries resulted in poorer outcome. Delay in opera-
tion was associated in a higher infection rate, whereas smoking
Bibbo C, Lin SS, Abidi N, et al: Missed and associated did not.
injuries after subtalar dislocation: The role of CT. Foot
Ankle Int 2001;22:324-328. Midfoot Trauma
In all patients, CT scans identified additional injuries Fulkerson E, Razi A, Tejwani N: Review: Acute com-
missed on plain radiographs, which altered treatment plans in partment syndrome of the foot. Foot Ankle Int 2003;24:
44% of patients. 180-187.
An excellent review of acute foot compartment syndrome
is presented.
Buckley R, Tough S, McCormack R, et al: Operative
compared with nonoperative treatment of displaced
intra-articular calcaneal fractures: A prospective, ran- Glasoe WM, Allen MK, Kepros T, Stonewall L, Ludewig
domized, controlled multicenter trial. J Bone Joint Surg PM: Dorsal first ray mobility in women athletes with a
Am 2002;84-A:1733-1744. history of stress fracture of the second or third metatar-
Equivalent outcomes were noted between the two groups; sal. J Orthop Sports Phys Ther 2002;32:560-565.
however, when patients receiving workers compensation were First ray hypermobility is not associated with stress frac-
removed from the comparison, significantly better results were ture of the second or third metatarsal.
noted with surgical treatment.
Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA: In-
Csizy M, Buckley R, Tough S, et al: Displaced intra- tramedullary screw fixation of Jones fractures. Foot An-
articular calcaneal fractures: Variables predicting late kle Int 2001;22:585-589.
subtalar fusion. J Orthop Trauma 2003;17:106-112. No significant difference was reported between failure
Initial injury severity, Bohler angle less than 0, workers loads of 5.0- and 6.5-mm. screws. Pull-out strength was signifi-
compensation patients, heavy laborers, and those fractures ini- cantly higher for the 6.5-mm screws.
tially treated nonsurgically were factors that were more likely
to lead to fusion. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A:
Risk factors for recurrent stress fractures in athletes.
Huefner T, Thermann H, Geerling J, Pape HC, Pohle- Am J Sports Med 2001;29:304-310.
Biomechanical factors associated with multiple stress frac-
mann T: Primary subtalar arthrodesis of calcaneal frac-
tures include a high longitudinal arch, forefoot varus, and leg-
tures. Foot Ankle Int 2001;22:9-14.
Primary fusion for extremely comminuted calcaneal frac- length inequality. Nearly half of female runners reported men-
tures led to good functional outcome. strual irregularity.
Ricci WM, Bellabarba C, Sanders R: Transcalcaneal tal- Mollica MB, Duyshart SC: Analysis of pre- and postex-
onavicular dislocation. J Bone Joint Surg Am 2002;84-A: ercise compartment pressures in the medial compart-
ment of the foot. Am J Sports Med 2002;30:268-271.
557-561.
Normative pressures of the medial foot compartment are
Dorsal dislocation of the navicular with an associated cal-
comparable to those in the leg. Previous criteria for diagnosis
caneal fracture is a severe injury, resulting in severe functional
of chronic exertional compartment syndrome of the leg may
limitations, osteomyelitis, and amputation.
be used for diagnosis of chronic exertional compartment syn-
drome of the foot.
Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G:
Surgical treatment of talus fractures: A retrospective
Mulier T, Reynders P, Dereymaeker G, Broos P: Severe
study of 80 cases followed for 1-15 years. Acta Orthop
Lisfrancs injuries: Primary arthrodesis or ORIF? Foot
Scand 2002;73:344-351.
Ankle Int 2002;23:902-905.
Ankle or subtalar arthrosis was noted in two thirds of frac-
Primary complete arthrodesis resulted in inferior pain
tures. Talar necrosis was noted in 11%; 44% had good or ex-
scores, more stiffness, a loss of longitudinal arch, and higher
cellent function.
rate of sympathetic dystrophy.
Tennent TD, Calder PR, Salisbury RD, Allen PW, East- Nunley JA, Vertullo CJ: Classification, investigation and
wood DM: The operative management of displaced management of midfoot sprains: Lisfranc injuries in the
intra-articular fractures of the calcaneum: A two-centre athlete. Am J Sports Med 2002;30:871-878.
study using a defined protocol. Injury 2001;32:491-496. Primary fusion for extremely comminuted calcaneal frac-
tures led to good functional outcome.
Peicha G, Labovitz J, Seibert FJ, et al: The anatomy of Benirschke SK, Sangeorzan BJ: Extensive intraarticular
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case control study. J Bone Joint Surg Br 2002;84:981-985.
A decreased medial depth of the mortise between the me- Blotter RH, Connolly E, Wasan A, Chapman MW:
dial and middle cuneiforms increases the risk of Lisfranc in- Acute complications in the operative treatment of iso-
jury. Lateral depth and second metatarsal length are not risk lated ankle fractures in patients with diabetes mellitus.
factors. Foot Ankle Int 1999;20:687-694.
Al-Mudhaffar M, Prasad CV, Mofidi A: Wound compli- Myerson M, Manoli A: Compartment syndromes of the
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Myerson MS: Experimental decompression of the fas- reduction and internal fixation of talar neck fractures.
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314. Wyrsch B, McFerran MA, McAndrew M, et al: Opera-
tive treatment of fractures of the tibial plafond: A ran-
Quill GE Jr: Fractures of the proximal fifth metatarsal. domized, prospective study. J Bone Joint Surg Am 1996;
Orthop Clin North Am 1995;26:353-361. 78:1646-1657.
Sasse M, Nigg BM, Stefanyshyn DJ: Tibiotalar motion: Yablon IG, Heller FG, Shouse L: The key role of the lat-
Effect of fibular displacement and deltoid ligament eral malleolus in displaced fractures of the ankle. J Bone
transaction: In vitro study. Foot Ankle Int 1999;20:733- Joint Surg Am 1977;59:169-173.
737.
Yamaguchi K, Martin CH, Boden SD, Labropoulos PA:
Sanders R, Fortin P, DiPasquale T, Walling A: Operative Operative treatment of syndesmotic disruptions without
treatment in 120 displaced intraarticular calcaneal frac-
use of a syndesmotic screw: A prospective clinical study.
tures: Results using a prognostic computed tomography
Foot Ankle Int 1994;5:407-414.
scan classification. Clin Orthop 1993;290:87-95.
Zufferey P, Boubaker A, Bischof Delaloye A, So AK,
Thordarson DB, Motamed S, Hedman T, Ebramzadeh
E, Bakshian S: The effect of fibular malreduction on Duvoisin B: Prognostic aspects of scintigraphy and MRI
contact pressures in an ankle fracture malunion model. during the first 6 months of reflex sympathetic dystro-
J Bone Joint Surg Am 1997;79:1809-1815. phy of the distal lower limb: A preliminary prospective
study of 4 cases. J Radiol 1999;80:373-377.
Thordarson DB, Triffon MJ, Terk MR: Magnetic reso-
nance imaging to detect avascular necrosis after open
Forefoot
Hallux Valgus
Hallux valgus deformity results from progressive devia-
tion and pronation of the great toe and medial deviation
of the first metatarsal (metatarsus primus varus). Hallux
valgus deformity is most common in females and shoe-
wearing societies; there is a high prevalence of bunion
deformity in American women in the fourth to sixth de-
cades of life.
The patient with hallux valgus deformity experiences
difficulty with shoe wear, particularly at the prominent
medial eminence. The patient should be evaluated while
standing to determine the presence of pes planus and
the severity of the deformity. With the patient seated, as-
sessment of medial eminence tenderness, first metatar-
sophalangeal (MTP) joint range of motion, and hyper-
mobility of the first tarsometatarsal (TMT) joint are
performed. First ray hypermobility remains a diagnostic
challenge because physiologically normal values of first
MTP joint mobility have not been defined. Weight-
bearing radiographs are required to determine the se-
verity of the bone and joint malalignment, presence of
arthrosis, and other factors that influence surgical treat- Figure 1 Schematic showing intermetatarsal, hallux valgus, and hallux valgus inter-
ment. Radiographic assessment of the distal metatarsal phalangeus angles. The angles in parentheses are angles considered physiologic in
articular angle (DMAA) continues to present diagnostic patients without hallux valgus. (Reproduced with permission from Coughlin MJ: Hallux
valgus in men: Effect of the distal metatarsal articular angle in the hallux valgus
challenges, and interobserver reliability for DMAA as- correction. Foot Ankle Int 1997;18:463-470.)
sessment remains poor (Figures 1 and 2).
Nonsurgical treatment involves shoe stretching at
the medial eminence or shoes with a wider toe box. Sur- described. Although the crescentic, (proximal) chevron,
gical correction is indicated when shoe modifications and proximal oblique osteotomies are most popular, the
prove ineffective; surgery should not be performed for Scarf osteotomy has gained wider acceptance. A symp-
cosmetic reasons alone. More than 100 procedures have tomatic hallux valgus associated with hypermobility
been described for correction of hallux valgus; the or- and/or first TMT joint degeneration warrants correction
thopaedic surgeon treating hallux valgus need not be fa- via a combination first TMT joint arthrodesis and distal
miliar with all of them but needs an adequate knowl- soft-tissue procedure (Lapidus procedure). A medial
edge base to address all aspects of hallux valgus closing wedge osteotomy of the proximal phalanx (Akin
deformity (Figure 3). The distal chevron osteotomy is procedure) is performed to correct hallux valgus inter-
reserved for mild deformity. A combination of a proxi- phalangeus, but may also serve as an adjunctive proce-
mal metatarsal osteotomy and distal soft-tissue proce- dure for severe hallux valgus addressed with proximal
dure is indicated for moderate to severe deformity. correction and distal soft-tissue procedure. The Keller
Many proximal first metatarsal osteotomies have been resection arthroplasty (base of proximal phalanx resec-
Figure 4 Schematic lateral view of a Weil lesser metatarsal shortening osteotomy stabilized with screw fixation. (Reproduced from Deland JT: Angular deformities of the second
toe, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp
77-84.)
moiditis is usually receptive to nonsurgical manage- Nonsurgical treatment of flexible deformities in-
ment; successful conservative management of fractures cludes pads, inserts, and extra depth to the toe box.
and osteonecrosis is less predictable. Repair with bone Hammer toe slings (Budin slings) extend the flexible
grafting may be possible, but generally excision of the hammer or claw toes while orthotic device or metatarsal
diseased sesamoid is necessary. The entire sesamoid pad can provide support to compensate for the distally
need not be routinely excised; instead, depending on migrated fat pad. Intra-articular steroid injections can
specific pathology, excision of only the proximal pole or be useful to decrease symptoms related to synovitis, but
plantar shaving suffices. must be used judiciously as excessive exposure to ste-
roid may further weaken the attenuated capsular struc-
Lesser Toes tures and worsen deformity. A flexible hammer or claw
Lesser toe deformities include hammer toes (extended toe can be corrected with a flexor-to-extensor tendon
transfer, whereas a fixed toe deformity requires a proxi-
MTP joint, flexed proximal interphalangeal joint, ex-
mal interphalangeal joint resection arthroplasty or ar-
tended distal interphalangeal joint), mallet toes (flexed
throdesis. Long-standing fixed hammer or claw toe de-
distal interphalangeal joints), and claw toes (extended
formity may also require extensor tendon lengthening,
MTP joint, flexed proximal interphalangeal and distal
dorsal MTP joint capsulotomy, and collateral ligament
interphalangeal joints). Hammer toes often arise sec-
release. If associated with a relatively long second meta-
ondary to tight shoe wear and are sometimes associated tarsal, a metatarsal shortening osteotomy can be per-
with long second and/or third rays. Mallet toes may re- formed with preservation of the collateral ligaments be-
sult from tighter shoe wear but are associated with de- cause the osteotomized metatarsal head relies solely on
generative distal interphalangeal joint arthritis. Claw its extracapsular blood supply through the collateral lig-
toes occur with intrinsic muscle weakness, creating an aments. Although multiple bony procedures for metatar-
imbalance of the extrinsic and intrinsic foot muscula- sal shortening have been described, the Weil osteotomy
ture, and may be linked to neuromuscular disease, cavus is currently favored (Figure 4). A transverse metatarsal
foot deformity, neuropathy, and sequelae of compart- cut is made in line with the plantar foot through the
ment syndrome. Chronic MTP joint synovitis and/or in- dorsal 5% to 10% of the articular cartilage. The meta-
flammatory arthritis may lead to attenuation of the tarsal head is translated proximally several millimeters,
plantar plate and capsule, resulting in MTP joint exten- but not beyond the adjacent lesser metatarsal head un-
sion and eventual clawing. If simultaneous collateral lig- less it is to be shortened as well. Fixation is typically
ament attenuation should occur, medial or lateral devia- performed with a low-profile screw. The overlapping
tion ensues, ultimately leading to a crossover toe bone on the proximal fragment is resected to create the
deformity. Frequently, a crossover second toe deformity new contour of the shortened metatarsal.
is observed with hallux valgus. With hammer and claw
toe deformities, the plantar fat pad may be displaced Bunionette Deformity
distally, subjecting the metatarsal head to overload, cal- Bunionette deformities, to an extent, mirror hallux val-
lus formation, and potential intractable plantar kerato- gus deformities. Bunionette deformities can be grouped
sis. Radiographs demonstrate toe deformity and may re- into three types: type I, enlarged/prominent fifth meta-
veal a relatively long metatarsal that contributes to the tarsal head; type II, congenital lateral fifth metatarsal
deformity. bow; and type III, increased 4-5 intermetatarsal angle.
Patients present with pain over the lateral fifth metatar- iform and/or first through third TMT joints because
sal head and difficulty with shoe wear because of fifth these are considered nonessential joints and physiologi-
metatarsal head pressure. Occasionally, a bunionette will cally the foot should be relatively rigid in this location.
be associated with plantar fifth metatarsal head pain In contrast, it is essential to maintain motion of the 4-5
and remain symptomatic even when shoes are removed. metatarsal-cuboid articulations to preserve the foots ac-
Physical examination reveals lateral and/or plantar fifth commodative function during the stance phase of gait.
metatarsal head tenderness, a wide forefoot (in types II Infrequently, advanced degeneration involves the 4-5
and III) and medial deviation of the fifth toe. AP radio- metatarsal-cuboid articulations, and use of interposi-
graphs define the deformity. Shoe stretching over the tional tendon arthroplasties have proven effective in se-
lateral fifth metatarsal and shoes with a wider toe box lect patients. In rare instances, such as Charcot midfoot
are usually sufficient to relieve symptoms. Surgical neuroarthropathy with midfoot collapse, the lateral col-
treatment is indicated for bunionettes not responding to umn of the midfoot may also be fused to ensure ade-
shoe modifications. All three types generally require a quate stability.
lateral capsulotomy, lateral eminence excision, and lat-
eral capsular plication. Type II can be corrected with a
distal metatarsal osteotomy that displaces the metatar- Hindfoot and Ankle
sal head medially. More severe type II and type III de-
formities are managed with a midshaft long oblique os-
Ankle/Subtalar Instability
Although ankle sprains are the most common sports in-
teotomy analogous to the proximal oblique osteotomy
of the first metatarsal head. In the fifth metatarsal, the jury, only 20% of patients develop residual symptoms.
osteotomy is not performed proximally, given the water- Many of these symptoms represent associated injuries
shed area complicating healing of Jones fractures. such as peroneal tendon tears, peroneal tendon
subluxation/dislocation, fractures of the lateral process
of the calcaneus, and osteochondral lesions. These diag-
noses, among others, should be considered in patients
Midfoot Arthritis with chronic symptoms following ankle sprain. Ankle in-
Midfoot arthritis may be primary, inflammatory, or post-
stability that is not related to any associated pathology
traumatic, with primary arthritis as the most common
is categorized into functional instability (pain that
cause. The midfoot articulations comprise the naviculo-
causes the ankle to give way) and mechanical instability
cuneiform and metatarsocuneiform/cuboid joints. Pa-
(weakened static ankle restraints that are responsible
tients have pain with weight bearing in the dorsal mid-
for excessive lateral ankle subluxation and resultant
foot and arch, particularly during push-off. Examination
pain). Furthermore, ankle (tibiotalar) instability is fre-
reveals tenderness at the midfoot joints, especially with
stress at the TMT joints (dorsiflexion/plantar flexion, quently associated with subtalar (talocalcaneal) instabil-
twisting of midfoot, and forced forefoot abduction). Be- ity. CT analysis suggests that hindfoot varus and an al-
cause the TMT joints may be difficult to differentiate, a tered mortise position (with a more posterior fibular
piano key test has been proposed in which the hind- position) is more prevalent in patients with chronic lat-
foot is stabilized while a plantar force is applied to the eral ankle instability. Patients with mechanical instabil-
associated metatarsal head (like striking an individual ity report a history of chronic ankle sprains but are rela-
piano key). With the patient bearing weight, loss of the tively pain free if the ankle is not injured. Examination
longitudinal arch is appreciated and is often associated may reveal tenderness over the anterior talofibular liga-
with forefoot abduction. Radiographs confirm these ment and/or the calcaneofibular ligament, and the diag-
findings with forefoot abduction (AP radiographs) and nosis is confirmed with anterior drawer and inversion
a break in the physiologic talar declination angle (lat- testing. Although a clinical grading scheme (grades I
eral radiographs). Subtle joint space narrowing in the through III) and mechanical devices to test anterior
TMT and naviculocuneiform joints may be detected drawer/talar tilt exist, stress radiographs probably offer
with standard weight-bearing foot radiographs. Nonsur- the best objective demonstration of tibiotalar instability.
gical treatment includes longitudinal arch support, Abnormal tibiotalar tilt has been defined anywhere
stiffer soled shoes or orthotic devices, and/or rocker bot- from 3 to 15 relative to the contralateral side and for-
tom shoes. Steroid injections may be both diagnostic ward talar translation on the tibia greater than 3 mm
and temporarily therapeutic. Because these are small than on the contralateral side. Subtalar instability re-
joints, fluoroscopic guidance is helpful to deliver the ste- mains a diagnostic challenge. Clinical examination typi-
roid directly to the involved articulation(s). Surgical cally fails to distinguish tibiotalar from subtalar instabil-
management is indicated when conservative measures ity. Brodens views have limited value. A recently
fail. The recommended surgical treatment of midfoot developed ultrasound method may be useful, but re-
degenerative arthritis is arthrodesis of the naviculocune- mains operator dependent.
Ankle and hindfoot sprains are initially treated with teonecrosis of the talus, and inflammatory arthritides,
the familiar regimen of rest, ice, application, compres- but may also develop as primary ankle degeneration.
sion, and elevation, early weight bearing, and functional The incidence of primary and inflammatory ankle ar-
rehabilitation. Generally, 15% to 30% of residual symp- thritis is uncommon relative to the incidence of hip and
toms after routine initial management can be attributed knee arthritis. Comparative studies of ankle versus hip
to peroneal weakness caused by inadequate rehabilita- and knee cartilage suggest that cartilage in the ankle
tion. Treatment with more directed and supervised phys- possesses factors that protect it from primary degenera-
ical therapy is usually successful in these situations. tion; by far the most common etiology of ankle arthritis
Surgical intervention is considered when propriocep- is trauma. With isolated ankle arthritis, the patient re-
tive and peroneal rehabilitation for chronic mechanical ports pain in the anterior aspect of the ankle with
instability is unsuccessful. Currently, anatomic recon- weight bearing and particularly with push-off. Whereas
struction is favored. When the condition of residual lat- diffuse ankle arthritis may also produce medial and lat-
eral ligamentous tissues is adequate for anatomic repair, eral pain, early degenerative disease creates symptoms
a modified Brostrm procedure is recommended, with confined to the anterior ankle. Physical examination
imbrication of the anterior talofibular ligament and/or demonstrates tenderness about the ankle, pain with
the calcaneofibular ligament and augmentation with the range of motion, and restricted range of motion (partic-
inferior extensor retinaculum (Gould modification). ularly ankle dorsiflexion). Evaluation while the patient
This anatomic reconstruction has been shown to have is bearing weight may reveal malalignment, which is of-
superior outcome when compared with a functional re- ten most evident during ambulation. Weight-bearing ra-
habilitation program and to a nonanatomic reconstruc- diographs of the ankle confirm the diagnosis, and
tion using the peroneus brevis tendon (Evans proce- weight-bearing radiographs of the foot are important
dure). Recently, advanced methods of lateral ankle to identify any associated hindfoot malalignment/
stabilization have been introduced; suture anchors (bio- degeneration that may have a bearing on surgical man-
absorbable and metallic) to reattach/advance the ante- agement.
rior talofibular ligament and calcaneofibular ligament to Nonsurgical treatment includes anti-inflammatory
the distal fibula have gained popularity. Traditionally, agents, activity modification, bracing, rocker bottom
shoe modification, and corticosteroid injection. Failure
with insufficient residual lateral ankle ligamentous tis-
of conservative management is an indication for surgical
sue, reconstruction involved harvest of part or all of a
management. Mild degenerative disease with impinge-
peroneal tendon. However, concerns over loss of the dy-
ment during dorsiflexion can be effectively managed
namic stabilizers have prompted greater interest in au-
with anterior ankle cheilectomy (exostectomy of ante-
tologous tendon transfers. Hamstring autografts, includ-
rior ankle osteophytes). Ankle arthrodesis remains the
ing the semitendinosus or gracilis, have been used with
gold standard for surgical treatment of diffuse ankle ar-
greater frequency to reestablish the deficient anterior
thritis. With minimal malalignment, arthroscopic or
talofibular ligament and calcaneofibular ligament with-
mini-arthrotomy techniques offer the advantage of a
out compromising the dynamic stabilizing effect of the
minimally invasive approach and generally shorter time
intact peroneal tendons. If hindfoot varus coexists with
to fusion when compared with traditional arthrotomy
mechanical lateral ankle instability, then a valgus- techniques. The transfibular approach is recommended
producing calcaneal osteotomy is typically recom- with increased malalignment. Because long-term
mended. Furthermore, hindfoot varus may be driven by follow-up of ankle arthrodesis demonstrates that many
a plantar flexed first metatarsal, which can be diagnosed patients develop adjacent hindfoot arthritis, some sur-
via the Coleman block test. In this situation, surgical geons advocate that ankle arthrodesis be performed
correction should include a dorsiflexion first metatarsal through an anterior approach to facilitate potential fu-
osteotomy performed judiciously to avoid overload of ture conversion of the fusion to an ankle replacement.
the lesser metatarsal heads. Improved union rates have been reported in complex
Although isolated subtalar instability may exist, re- hindfoot arthrodeses with increased risk for nonunion
constructive procedures restricted to the subtalar joint using implantable bone stimulation. Smokers are at 2.7
have not been clearly defined. Reconstructive proce- times greater risk for nonunion than nonsmokers. In pa-
dures that cross both the ankle and subtalar joints (cal- tients with concomitant ankle and hindfoot arthritis, ti-
caneofibular ligament repair/reconstruction and aug- biotalocalcaneal or pantalar arthrodesis may be consid-
mentation with the inferior extensor retinaculum) ered. Reported techniques of retrograde intramedullary
remain the mainstay of treatment. nailing and blade plate fixation (inserted via lateral or
posterior approaches) have favorable union rates and
Ankle Arthritis provide acceptable pain relief.
Ankle arthritis may develop secondary to trauma To limit development of hindfoot arthritis following
(ankle/pilon fractures), chronic ankle instability, os- ankle fusion or to manage patients with concomitant an-
kle and hindfoot arthritis, several attractive surgical al- reveals a high incidence of osteochondral injuries. No
ternatives to ankle arthrodesis that maintain ankle mo- clear association between focal osteochondral lesions of
tion continue to show promise. Joint distraction the talus and development of diffuse ankle osteoarthri-
arthroplasty with or without joint dbridement involves tis has been identified. Although radiographs often sug-
maintaining 5 mm of ankle joint distraction with thin gest an osteochondral lesion of the talus, findings may
wire ring fixation. Patients are allowed to bear weight be subtle. Occasionally, a loose body (detached frag-
during the 3 months of joint distraction. Early to inter- ment) is evident. MRI is the favored screening tool to
mediate results suggest that 75% of patients experi- identify osteochondral lesions of the talus, and both
enced improvement of symptoms and did not require MRI and CT provide useful information in defining spe-
further surgical management. Fresh tibiotalar shell al- cific characteristics. Although classification schemes for
lografts have been used in carefully selected patients. osteochondral lesions of the talus have been developed
An osteochondral allograft comprising both aspects of using both MRI and CT, arthroscopic evaluation is
the tibiotalar joint replaces the patients corresponding probably most accurate.
resected articular surfaces. To optimize the fit of the al- Nonsurgical management of symptomatic osteo-
lograft, total ankle replacement cutting guides are used. chondral lesions of the talus consists of immobilization
Early results are encouraging, but the technique remains and protective weight bearing to promote stabilization
experimental. Improved component design and surgical of the osteochondral fragment and nonsteroidal anti-
technique for modern-generation total ankle arthro- inflammatory drugs and/or steroid injection for pain
plasty have improved results over those for first- relief/controlling inflammation. Adult patients rarely ex-
generation implants. Although several different prosthe- perience spontaneous healing of osteochondral lesions
ses, each with unique design features, have been of the talus, but some authors have recently reported
introduced worldwide, only the semi-constrained, fixed- good to excellent results at intermediate-term follow-up
bearing Agility ankle (DePuy, Warsaw, IN) has been ap- with nonsurgical treatment of osteochondral lesions of
proved by the US Food and Drug Administration the talus thought only to respond to surgical interven-
(FDA) (Figure 5). The Agility ankle technique warrants tion. Although arthroscopic dbridement and drilling/
a syndesmotic arthrodesis to increase the surface area microfracture remains the standard of surgical care for
and support for the tibial component. The mobile bear- symptomatic osteochondral lesions of the talus (good to
ing Scandinavian Total Ankle Replacement (Waldemar- excellent results of 70% to 90% at intermediate follow-
Link, Hamburg, Germany) prosthesis affords the advan- up), the concern remains that replacing larger defects
tage of limited bone resection, a resurfacing talar with fibrocartilage and not hyaline cartilage may not be
component, and the mobile bearing that reduces con- a sensible solution. Although cartilage resurfacing pro-
straint and provides modularity to improve soft-tissue cedures, including osteochondral autograft/allograft
balance. As of this writing, the Scandinavian Total Ankle transfer (mosaicplasty) and autologous chondrocyte
Replacement implant was in clinical trial, awaiting FDA transplantation (Carticel procedure), continue to be
approval. Although techniques for total ankle arthro- viewed as salvage procedures, some consideration is be-
plasty have been refined, the procedure remains techni- ing given to applying these techniques as primary surgi-
cally demanding. A steep learning curve has been dem- cal treatment of larger osteochondral lesions of the ta-
onstrated for total ankle arthroplasty. As with total hip lus, particularly those associated with subchondral cysts
and total knee arthroplasty, proper alignment and soft- (Figure 6). Outcome of osteochondral transfer from the
tissue balance are crucial for successful outcome. Cur- knee to the ankle (osteochondral autograft/allograft
rent recommendations are for total ankle arthroplasty transfer and mosaicplasty) have been promising at
to be performed by surgeons who have completed spe- short- to intermediate-term follow-up, with 88% to 94%
cial training for this technique, either through fellowship good to excellent results for primary and revision sur-
or learning center experience. geries. Autologous chondrocyte transplantation has also
proven effective at early follow-up. Cartilage resurfacing
Osteochondral Lesions of the Talus in the ankle often warrants medial or lateral malleolar
Osteochondral lesions of the ankle are commonly ob- osteotomies to provide adequate access to the osteo-
served anterolaterally and posteromedially on the talar chondral lesions of the talus. Currently, malleolar os-
dome. Not all of these lesions are symptomatic and may teotomy techniques are being refined and potential lo-
represent incidental findings. Most osteochondral le- cal cartilage harvest sites are being identified to
sions of the talus are a result of ankle trauma (sprain/ decrease the morbidity to the ankle and ipsilateral knee.
fracture), but patients do not always recall a specific Lateral defects, particularly those associated with lateral
traumatic event. Ankle arthroscopy performed simulta- ligamentous instability, may be treated with release and
neously with open reduction and internal fixation of an- subsequent tightening of the anterior talofibular liga-
kle fractures or in patients with chronic ankle sprains ment and calcaneofibular ligament.
Figure 5 Several currently available total ankle prosthesis are shown. A, Agility Total Ankle System. (Courtesy of DePuy, Warsaw, IN.) B, STAR system. (Courtesy of Waldemar-Link,
Hamburg, Germany.) C, Buechel-Pappas ankle system. (Courtesy of Endotec, South Orange, NJ.) D, Hintegra ankle system. (Courtesy of New Deal, Vienne, France.)
Insertional Achilles Tendinopathy the Achilles tendon on the calcaneus with direct pres-
Insertional Achilles tendinopathy is an enthesopathy of sure and during push-off; swelling at the insertion limits
the Achilles tendon insertion that most likely is a result shoe wear with a hard heel counter. Symptoms are exac-
of cumulative trauma/repetitive stress. Although inflam- erbated by walking an incline or during activities that
mation accompanies this disease process, the primary cause dorsiflexion of the ankle. Physical examination
pathology is tendon degeneration at the Achilles tendon will demonstrate an intact Achilles tendon, but often
insertion. Patients report pain directly at the junction of with hyperdorsiflexion of the ankle (secondary to Achil-
in contrast, lateral column lengthening (either through standing. The point of maximal tenderness is usually at
the anterior calcaneus or calcaneocuboid joint) is associ- the plantar fascia origin on the plantar medial heel; ten-
ated with a higher complication rate, particularly with derness slightly more proximal and medial is suggestive
regard to nonunion. With proper technique, use of struc- of compressive neuropathy.
tural autograft and allograft yields equal and favorable Treatment of plantar fasciitis is rarely surgical; tradi-
results. Associated spring ligament attenuation can usu- tional treatment with Achilles tendon stretching, night
ally be corrected with soft-tissue plication; however, splinting, heel cushion, and nonsteroidal anti-
larger spring ligament defects represent a greater chal- inflammatory drugs continues to be recommended. A
lenge. The optimal spring ligament reconstruction has prospective, randomized trial suggests that a stretching
yet to be defined. Currently, arthrodesis is usually re- protocol specific to the plantar fascia may provide ad-
quired to manage large spring ligament tears. Subtalar vantages over Achilles tendon stretching. Low- and
arthroereisis, a technique traditionally reserved for pedi- high-energy extracorporeal shock wave therapy are
atric patients, has been introduced as an adjunctive pro- available to treat plantar fasciitis. Prospective random-
cedure in the management of the flexible adult acquired ized studies and meta-analyses demonstrate that both
flatfoot deformity; preliminary results and anecdotal ex- the low- and high-energy devices are safe; however,
perience with this sinus tarsi implant that distracts the whether extracorporeal shock wave therapy is effective
subtalar joint show promise. In some patients, a double for recalcitrant plantar fasciitis remains a controversial
calcaneal osteotomy (medial displacement calcaneal os- issue. Surgical treatment is reserved for patients in
teotomy and lateral column lengthening) has proved ef- whom 6 months to 1 year of nonsurgical treatment is
fective in correcting hindfoot valgus and forefoot abduc- unsuccessful. Only the medial third of the plantar fascia
tion when combined with tendon reconstruction. Fixed should be released; complete release may result in per-
stage III flatfoot deformity cannot be corrected with sistent lateral foot pain. Plantar fascia release may be
joint-sparing procedures and requires realignment performed with open or endoscopic techniques. Given
through arthrodesis, typically triple arthrodesis. Because the overlap of plantar fasciitis and compression neurop-
posterior tibial tendon dysfunction often is associated athy, open plantar fascia release can be combined with
with an equinus contracture, correction of deformity re- distal tarsal tunnel decompression; good to excellent re-
quires Achilles tendon lengthening. Traditionally, the sults can be expected in more than 85% of patients with
Hoke triple cut percutaneous lengthening technique has recalcitrant symptoms who undergo the combined pro-
been used, but anatomic studies demonstrate that the cedure.
triple cut technique generally fails to follow the orienta-
tion of the Achilles tendon fibers. Recently, gastroc- Diabetic Foot/Ankle and Charcot Neuroarthropathy
nemius-soleus recession has gained popularity as an ef- More than 16 million people in the United States have
fective method for Achilles tendon lengthening; diabetes, and foot problems related to diabetes repre-
although the traditional open technique is most com- sent 20% of hospital admissions for diabetics. The life-
monly used, interest has been generated for a less inva- time incidence for foot ulceration in diabetic patients is
sive endoscopic technique. Stage IV flatfoot deformity 15%, and 3% to 5% of diabetic patients are amputees.
remains difficult to treat because an ideal deltoid liga- More than 50% of all amputations performed in the
ment reconstruction has not been developed. When as- United States are for diabetics. Within 3 years of lower
sociated with ankle arthritis, pantalar arthrodesis may extremity amputation, 30% of diabetic patients lose
be required for severe stage IV disease. their contralateral leg, and 50% die. Up to half of these
amputations are considered preventable. Diabetic risk
Plantar Fasciitis factors for foot ulceration include neuropathy (sensory,
The etiology of plantar fasciitis is not fully understood, motor, and autonomic), vascular insufficiency, poor gly-
but the condition is believed to result from cumulative cemic control, malnutrition, and impaired wound heal-
trauma or repetitive stress. Symptoms usually are con- ing. Sensory neuropathy (Semmes-Weinstein monofila-
centrated at the plantar fascia origin on the plantar me- ment < 5.07) leaves patients without protective
dial heel and typically have an insidious onset. Occa- sensation. Motor neuropathy may lead to joint
sionally, plantar heel pain may be associated with a deformities/contractures that create areas of pressure
compressive neuropathy of the first branch of the lateral concentration and difficulties with shoe wear. Auto-
plantar nerve (Baxters nerve). A heel pain triad has nomic neuropathy results in dry skin with fissures (risk
been described with the coexistence of posterior tibial bacterial penetration) and peripheral edema (reduces
tendon dysfunction, plantar fasciitis, and tarsal tunnel collateral blood flow/healing potential). Vascular insuffi-
syndrome. Patients typically report start-up pain (heel ciency (ankle brachial index < 0.45, absolute toe pres-
pain experienced with initial weight bearing after a pe- sures < 50 to 60 mm Hg, transcutaneous oxygen mea-
riod of rest) and increasing heel pain after prolonged sures < 30 mm Hg) diminishes the patients ability to
algorithms. Although complex, such classification 9. Complications included three nonunions, all in patients
schemes demonstrate good interobserver and intraob- who smoked.
server reliability. It is predicted that such schemes may
facilitate treatment strategies. Surgical salvage proce- Coughlin MJ, Freund E: The reliability of angular mea-
dures for ankle, hindfoot, and midfoot Charcot defor- surements in hallux valgus deformities. Foot Ankle Int
mity typically require multiplanar realignment osteoto- 2001;22:369-379.
mies with arthrodesis and tend to ignore traditional Interobserver and intraobserver reliability within 5 is high
anatomic landmarks. Techniques for internal fixation for the intermetatarsal angle (97%), good for the hallux valgus
have been described, but recently developed methods of angle (86%), and poor for the distal metatarsal articular angle
external fixation for Charcot neuroarthropathy for the (59%).
diabetic foot and ankle have shown promise. Whereas
resolution of ulceration and infection is typically neces- Faber FW, Kleinrensink GJ, Mulder PG, Verhaar JA:
sary before internal fixation of Charcot deformity, exter- Mobility of the first tarsometatarsal joint in hallux val-
nal fixation affords the potential advantage of single- gus patients: A radiographic analysis. Foot Ankle Int
stage resection of the osteomyelitic prominence, ulcer 2001;22:965-969.
excision, multiplanar realignment osteotomy, and arth- Ninety-four feet with symptomatic hallux valgus deformity
rodesis stabilized without implanted hardware. prompting surgical correction were evaluated clinically and ra-
Salvage procedures may be successful in limb preser- diographically using the modified Coleman block test. The
vation for diabetic patients with ulceration, infection, mean first ray motion was 13 and proved to be significantly
and/or Charcot neuroarthropathy; however, amputation greater in the group that demonstrated clinical hypermobility.
may remain the only recourse in some situations. If fea-
sible, partial foot amputations provide the advantage of Glasoe WM, Allen MK, Saltzman CL: First ray dorsal
limb support without a prosthesis. However, the patient mobility in relation to hallux valgus deformity and first
still may be predisposed to ulceration, and transtibial intermetatarsal angle. Foot Ankle Int 2001;22:98-101.
amputation may be the safest solution. A comparison of 14 hallux valgus patients and asymptom-
atic controls demonstrated increased mobility in the hallux
Annotated Bibliography valgus group. A load-cell device was used to determine the de-
gree of hypermobility.
Forefoot: Hallux Valgus
Chi TD, Davitt J, Younger A, Holt S: Intra-and inter-
observer reliability of the distal metatarsal articular an- Kristen KH, Berger C, Stelzig E, Thalhammer E: The
gle in adult hallux valgus. Foot Ankle Int 2002;23:722- SCARF osteotomy for the correction of hallux valgus
726. deformities. Foot Ankle Int 2002;23:221-229.
Preoperative and postoperative radiographs of 32 patients A retrospective analysis of 111 Scarf osteotomies in 89
undergoing hallux valgus correction using a proximal bony consecutive patients with moderate to severe hallux valgus re-
procedure demonstrated a reduction in the DMAA by an av- vealed an average hallux valgus angle improvement of 19 and
erage of 3.9, noted by all observers. However, interobserver intermetatarsal angle improvement of 7. The average Ameri-
reliability of preoperative and postoperative DMAA was can Orthopaedic Foot and Ankle Society forefoot score im-
poor. proved from 50 to 91 points. Seven patients (6%) experienced
a recurrence of deformity and 5% suffered either superficial
wound infection, displacement of the distal fragment, or hallux
Coetzee JC: Scarf osteotomy for hallux valgus repair:
MTP joint stiffness.
The dark side. Foot Ankle Int 2003;24:29-33.
The Scarf osteotomy was performed in 20 consecutive pa-
tients, resulting in a high complication rate, limited improve- Nery C, Barroco R, Ressio C: Biplanar chevron osteot-
ment in the American Orthopaedic Foot and Ankle Society omy. Foot Ankle Int 2002;23:792-798.
forefoot score, and only a 55% patient satisfaction rate. Fifty-four biplanar distal chevron osteotomies were per-
formed in 32 patients to correct moderate hallux valgus defor-
mity associated with an increased distal metatarsal articular
Coetzee JC, Resig SG, Kuskowski M, Saleh KJ: The lapi-
angle. With follow-up of 2 years or longer, the average Ameri-
dus procedure as salvage after failed surgical treatment
can Orthopaedic Foot and Ankle Society forefoot score im-
of hallux valgus. J Bone Joint Surg Am 2003;85-A:60-65.
Twenty-four patients with 26 symptomatic hallux valgus proved from 50 to 90 points, the average hallux valgus angle
recurrences were selected to undergo the Lapidus procedure. improved 9, the intermetatarsal angle improved 4, and the
At an average follow-up of 24 months, the average American distal metatarsal articular angle improved from 15 to 5.
Orthopaedic Foot and Ankle Society score improved from 47
to 88 points, with average improvements in the hallux valgus Nyska M, Trnka HJ, Parks BG, Myerson MS: The Lud-
angles from 37 to 17 and intermetatarsal angles from 18 to loff metatarsal osteotomy: Guidelines for optimal cor-
rection on a geometric analysis conducted on a sawbone bility: Long-term results of treatment. Foot Ankle Int
model. Foot Ankle Int 2003;24:34-39. 2002;23:1018-1025.
Using a saw bone model, the authors describe technical as- Twenty percent (24 of 121 consecutive patients (131 feet
pects to achieving desired correction for the modified Ludloff and 136 neuromas) were treated for concomitant excision of a
proximal oblique first metatarsal osteotomy for hallux valgus second web space neuroma and stabilization of a second MTP
correction. joint capsular instability. At an average follow-up of 80
months, 21 feet were available for evaluation. In 15 feet, the
Forefoot: Hallux Rigidus procedures were performed simultaneously; in 6 feet, the pro-
Coughlin MJ, Shurnas PS: Hallux rigidus: Demograph- cedures were staged. Subjective patient satisfaction was high;
ics, etiology, and radiographic assessment. Foot Ankle Int subjective and objective results were lower in patients with
2003;24:731-743. persistent MTP joint instability.
This retrospective review of 114 patients treated surgically
for hallux rigidus demonstrated that hallux rigidus was associ- Koti M, Maffulli N: Bunionette. J Bone Joint Surg Am
ated with hallux valgus interphalangeus, female gender, unilat- 2001;83-A:1076-1082.
eral disease (history of trauma), and bilateral disease (family This article presents an excellent current review of evalua-
history). The condition was not associated with metatarsus pri- tion and management of bunionette deformity.
mus elevatus, a long first metatarsal, or first ray hypermobility.
Petersen WJ, Lankes JM, Paulsen F, Hassenpflug J: The
Coughlin MJ, Shurnas PS: Hallux rigidus: Grading and arterial supply of the lesser metatarsal heads: A vascular
long-term results of operative treatment. J Bone Joint injection study in human cadavers. Foot Ankle Int 2002;
Surg Am 2003;85-A:2072-2088. 23:491-495.
A retrospective review of 114 patients treated surgically Epoxy resin injections performed in cadaveric foot speci-
for hallux rigidus is presented. Eighty patients (93 feet) had mens demonstrated an anastomosis of arteries about the lesser
undergone cheilectomy; 30 patients (34 feet) were treated with metatarsal heads arising from both the dorsalis pedis and pos-
first MTP joint arthrodesis. Based on 96% of patients avail- terior tibial arteries. This vascular network is closely associated
able at an average follow-up of 8.9 years, 97% of patients had with the joint capsule. The authors caution that extensive cap-
good or excellent results (American Orthopaedic Foot and sular stripping during metatarsal osteotomies may damage this
Ankle Society forefoot scoring system). Cheilectomy was pre- vascular network.
dictable in lesser grades or first MTP arthritis; arthrodesis was
favored for greater degrees of arthritis. Trnka HJ, Gebhard C, Muhlbauer M, et al: The Weil os-
teotomy for treatment of dislocated lesser metatar-
DeFrino PF, Brodsky JW, Pollo FE, et al: First metatar- sophalangeal joints: Good outcome in 21 patients with
sophalangeal arthrodesis: A clinical, pedobarographic 42 osteotomies. Acta Orthop Scand 2002;73:190-194.
and gait analysis study. Foot Ankle Int 2002;23:496-502. A retrospective review of 60 Weil metatarsal osteotomies
Clinical outcome, dynamic pedobarography (EMED) anal- performed in 31 patients for dislocated lesser MTP joints at an
ysis, and kinematic and kinetic gait analysis were studied in average follow-up of 30 months showed 42 excellent results
9 patients (10 feet) who underwent first MTP joint arthrodesis (21 patients). A major complication was penetrating hardware
for severe hallux rigidus. The mean American Orthopaedic in 10 patients.
Foot and Ankle Society score improved from 38 to 90 points,
and the EMED analysis demonstrated restoration of the Trnka HJ, Nyska M, Parks BG, Myerson MS: Dorsiflex-
weight-bearing function of the first ray. Kinematic data indi- ion contracture after the Weil osteotomy: Results of ca-
cated a shorter step length/loss of ankle plantar flexion and daver study and three-dimensional analysis. Foot Ankle
the kinetic data indicated a reduction in ankle power push-off. Int 2001;22:47-50.
Using both cadaver and saw bone models, the authors
Forefoot: Sesamoid Disorders demonstrated that the Weil metatarsal osteotomy always cre-
Allen MA, Casillas MM: The Passive Axial Compres- ates plantar fragment depression that changes the center of
sion (PAC) test: A new adjunctive provocative maneu- rotation of the MTP joint, causing the interosseous muscles to
ver for the clinical diagnosis of hallucal sesamoiditis. act more as dorsiflexors than plantar flexors. These findings
Foot Ankle 2001;22:345-346. are believed to be responsible for the high rate of dorsiflexion
The authors describe a new provocative test that clinically contractures following Weil metatarsal osteotomies.
reproduces the symptoms of sesamoid disorders. The maneu-
ver may be useful in initial diagnosis and monitoring response Midfoot Arthritis
to treatment of sesamoid problems. Berlet GC, Anderson RB: Tendon arthroplasty for basal
fourth and fifth metatarsal arthritis. Foot Ankle Int 2002;
Forefoot: Lesser Toes and Bunionette Deformity 23:440-446.
Coughlin MJ, Schenck RC, Shurnas PJ, Bloome DM: At an average follow-up of 25 months, 12 patients under-
Concurrent interdigital neuroma and MTP joint insta- going tendon interpositional arthroplasty for fourth and fifth
TMT joint arthritis recalcitrant to nonsurgical treatment were Sabonghy EP, Wood RM, Ambrorse CG, McGarvey
evaluated. In eight patients, the diagnosis was confirmed with WC, Clanton TO: Tendon transfer fixation: Comparing a
preoperative differential injections; six of the eight patients tendon to tendon technique versus bioabsorbable inter-
would undergo the procedure again. Outcome, based on the ference. Fit screw fixation. Foot Ankle Int 2003;24:260-
American Orthopaedic Foot and Ankle Society midfoot scale, 262.
was most favorable in patients who had a positive response to In 10 paired fresh cadaver specimens, load to failure was
a preoperative differential injection. greater using bioabsorbable tendon fixation when compared
with traditional fixation techniques. However, the authors sup-
ported the use of bioabsorbable screw as the mean fixation
Keiserman LS, Cassandra J, Amis JA: The Piano Key strength provides physiologic strength at the tendon-bone in-
Test: A clinical sign for the identification of subtle tar- terface.
sometatarsal pathology. Foot Ankle Int 2003;24:437-438.
The authors describe a simple test to identify and isolate
TMT synovitis and/or arthritis. Van Bergeyk AB, Younger A, Carson B: CT Analysis of
hindfoot alignment in chronic lateral ankle instability.
Foot Ankle Int 2002;23:37-42.
Hindfoot and Ankle: Ankle/Subtalar Instability The authors compared simulated weight-bearing hindfoot
Jeys LM, Harris NJ: Ankle stabilization with hamstring CT scans of 14 ankles with chronic ankle instability to 12 con-
autograft: A new technique using interference screws. trols in a prospective case control format. Patients with ankle
Foot Ankle Int 2003;24:677-679. instability had statistically significantly greater hindfoot varus
An anatomic reconstruction of the lateral ankle ligaments based on the radiographic parameters evaluated. The authors
is described using bioabsorbable interference screw fixation of suggested that although a valgus-producing calcaneal osteot-
a hamstring autograft. omy is not routinely indicated, it may have a role in selected
patients who fail to respond to isolated lateral ankle ligament
Keefe DT, Haddad SL: Subtalar instability: Etiology, di- reconstruction.
agnosis, and treatment. Foot Ankle Clin 2002;7:577-609.
The authors present a comprehensive review of the cur- Hindfoot and Ankle: Ankle Arthritis
rent state of the art for the evaluation and treatment of subta- Anderson T, Montgomery F, Carlsson A: Uncemented
lar joint instability. STAR total ankle prostheses: Three- to eight-year
follow-up of fifty-one consecutive ankles. J Bone Joint
Krips R, Brandsson S, Swensson C, et al: Anatomical re- Surg Am 2003;85-A:1321-1329.
Fifty-one consecutive cementless mobile-bearing Scandi-
construction and Evans tenodesis of the lateral liga-
navian Total Ankle Replacement ankle procedures were eval-
ments of the ankle: Clinical and radiological findings af-
uated at intermediate follow-up. The median Kofoed score im-
ter followup for 15-30 years. J Bone Joint Surg Br 2002; proved from 39 to 70 points at the time of follow-up. Twelve
84:232-236. ankles had to be revised (seven loosening, two bearing frac-
This retrospective review compares 54 patients undergoing
ture, three other complications) and eight other ankles had ra-
an anatomic reconstruction of the lateral ankle ligaments and diographic signs of loosening. Median range of motion was the
45 patients treated with an Evans tenodesis for lateral ankle same preoperatively and postoperatively. With revision as the
instability. The study demonstrated that the functional out- end point, the estimated 5-year survival was 70%.
come of the Evans tenodesis deteriorated more rapidly than
the anatomic reconstruction. Good to excellent results were
Buechel FF, Buechel FF Jr, Pappas MJ: Ten-year evalua-
noted in 43 patients in the anatomic reconstruction group and
tion of cementless Buechel-Pappas meniscal bearing to-
15 in the Evans tenodesis group.
tal ankle replacement. Foot Ankle Int 2003;24:462-472.
Fifty cementless Buechel-Pappas mobile-bearing total an-
Pijnenburg AC, Bogaard K, Krips R, et al: Operative kle replacements in 49 patients were evaluated. Good to excel-
and functional treatment of rupture of the lateral liga- lent results were observed in 88% of patients. Postoperative
ment of the ankle: A randomized, prospective trial. range of motion was similar to preoperative motion. Revision
J Bone Joint Surg Br 2003;85:525-530. was required in 4% of patients. Cumulative survivorship (us-
The authors prospectively randomized 370 patients with a ing revision as an end point) was 94% at 10 years.
rupture of at least one lateral ankle ligament to undergo ei-
ther functional or surgical treatment. At a median follow-up of Coester LM, Saltzman CL, Leupold J, Pontarelli W:
8 years, 86% of patients were available for evaluation with the Long-term results following ankle arthrodesis for post-
Povacz score and anterior drawer testing. Surgical treatment traumatic arthritis. J Bone Joint Surg Am 2001;83-A:219-
gave better long-term outcome with regard to residual pain, 236.
recurrent sprains (22% versus 34%), and stability (anterior At a mean follow-up of 22 years, 23 patients who had a
drawer positive, 30% versus 54%). successful isolated ankle arthrodesis for posttraumatic tibiota-
lar arthritis were evaluated. Most patients had substantial, ac-
celerated arthritic changes in the ipsilateral foot that often 46 to 53 (mental). Four of seven patients reported good to ex-
limited function when compared with the contralateral foot. cellent results; follow-up radiographs revealed joint space nar-
Osteoarthritis did not develop more frequently in the ipsilat- rowing, osteophytes, and sclerosis even in patients with excel-
eral knee or contralateral foot. lent clinical status. There was a 42% failure rate.
Improvements in technique may lead to a more favorable out-
Coull R, Raffiq T, James LE, Stephens MM: Open treat- come.
ment of anterior impingement of the ankle. J Bone Joint
Surg Br 2003;85:550-553. Marijnissen AC, Van Roermund PM, Van Melkebeek J,
The outcome for the open treatment of anterior ankle im- Lafeber FP: Clinical benefit of joint distraction in the
pingement was evaluated at a mean follow-up of 7.3 years in treatment of ankle osteoarthritis. Foot Ankle Clin 2003;
23 patients. The Ogilvie-Harris score improved in all patients. 8:335-346.
Ankle dorsiflexion did not return to normal, but symptomatic The authors describe their technique and results with dis-
relief allowed 79% of patients to return to athletic activity at traction arthroplasty for ankle osteoarthritis.
the same level. Two patients with preoperative joint space nar-
rowing had a poor result. Myerson MS, Mroczek K: Perioperative complications
of total ankle arthroplasty. Foot Ankle Int 2003;24:17-21.
Donley BG, Ward DM: Implantable electrical stimula- This retrospective review of a single surgeons experience
tion in high-risk hindfoot fusions. Foot Ankle Int 2002; with 50 consecutive total ankle replacements compares the
23:13-18. first 25 with the second 25 procedures. The distinct improve-
The authors report a single surgeons experience with 13 ment in component position and fewer complications in the
implantable bone stimulators used as an adjunct for ankle/ second group suggest that a learning curve exists in perfor-
hindfoot arthrodeses performed in patients with increased risk mance of total ankle arthroplasty.
for nonunion. At an average follow-up of 25 months, 92% of
patients achieved successful fusion. The subcutaneous device Saltzman CL, Amendola A, Anderson R, et al: Surgeon
was bothersome to eight patients. training and complications in total ankle arthroplasty.
Foot Ankle Int 2003;24:514-518.
Fuchs S, Sandmann C, Skwara A, et al: Quality of life 20 The first 10 total ankle replacements of nine orthopaedic
years after arthrodesis of the ankle: A study of adjacent foot and ankle surgeons were reviewed. No method of training
joints. J Bone Joint Surg Br 2003;85:994-998. (observing inventor, hands-on surgical training course, foot
Retrospective, long-term follow-up of 18 successful ankle and ankle fellowship) had a statistically demonstrable positive
arthrodeses (17 patients) demonstrated significant deficits of impact on preparing surgeons for total ankle replacement.
functional outcome, limitations of activities of daily living, and
radiographic changes in adjacent foot articulations, based on Thomas RH, Daniels TR: Current concepts review: An-
the Olerud Molander Ankle score, radiographic evaluation, kle arthritis. J Bone Joint Surg Am 2003;85-A:923-936.
and the Medical Outcomes Study Short Form-36 outcomes in- The authors present a review of the current standards for
strument. evaluation and treatment of ankle arthritis.
Ishikawa SN, Murphy GA, Richardson EG: The effect Wood PL, Deakin S: Total ankle replacement: The re-
of cigarette smoking on hindfoot fusions. Foot Ankle Int sults in 200 ankles. J Bone Joint Surg Br 2003;85:334-
2002;23:996-998. 341.
In a group of 160 patients who had hindfoot fusions, smok- At a mean follow-up of 46 months, the authors reviewed
ers had a significantly higher nonunion rate than nonsmokers the results in 200 mobile-bearing cementless Scandinavian To-
(19% versus 7%). The relative risk of nonunion was 2.7 times tal Ankle Replacements. The cumulative survival rate at 5
higher for smokers than nonsmokers. No statistically signifi- years was 93%, with decision for revision used as an end
cant difference was noted in the rate of infection or delayed point. Most frequent complications were delayed wound heal-
wound healing between the groups. ing and malleolar fracture. A complication requiring further
surgery developed in 8 ankles, and 14 ankles were either re-
Kim CW, Jamali A, Tontz W Jr, et al: Treatment of post- vised or converted to arthrodesis.
traumatic ankle arthrosis with bipolar tibiotalar osteo-
chondral shell allografts. Foot Ankle Int 2002;23:1091- Hindfoot and Ankle: Osteochondral Lesions of the
1102. Talus
Seven patients undergoing fresh tibiotalar osteochondral Al Shaikh RA, Chou LB, Mann JA, et al: Autologous
shell allografts for posttraumatic ankle arthrosis were evalu- osteochondral grafting for talar cartilage defects. Foot
ated at an average follow-up of 12 years. The ankle scores in- Ankle Int 2002;23:381-389.
creased from 25 to 43 points; the Medical Outcomes Study 12- At an average follow-up of 16 months, 19 osteochondral
Item Short Form scores increased from 30 to 38 (physical) and lesions of the talus treated with osteochondral autograft trans-
fer system from the ipsilateral knee trochlear border were findings have implications should cartilage repair procedures
evaluated. All patients had failed to respond to nonsurgical be planned based on arthroscopic sizing of osteochondral de-
measures and 68% had failed to respond to dbridement/ fects of the talar dome.
excision. The average size of the lesions before the autologous
osteochondral grafting procedure was 10 mm 12 mm. Four- Shearer C, Loomer R, Clement D: Nonoperataively
teen patients required malleolar osteotomy (13 medial, 1 lat- managed stage V osteochondral talar lesions. Foot Ankle
eral). The average postoperative American Orthopaedic Foot Int 2002;23:651-654.
and Ankle Society score at follow-up was 91; the average Ly- Based on nonsurgical treatment of 25 osteochondral le-
sholm knee score was 97. sions of the talus associated with subchondral cysts, the au-
thors suggested that (1) most lesions remain radiographically
Hangody L, Kish G, Modis L, et al: Mosaicplasty for the stable, (2) nonsurgical management is a viable option for stage
treatment of osteochondritis dissecans of the talus: Two V osteochondral lesions with little risk of developing signifi-
to seven year results in 36 patients. Foot Ankle Int 2001; cant osteoarthritis, (3) the general course of stage V lesions is
22:552-558. benign in most patients, and (4) the development of mild ra-
Intermediate follow-up of a single surgeons experience diographic changes of osteoarthritis does not correlate with
with 36 osteochondral lesions of the talus treated using the outcome. However, the authors acknowledged that lesions that
mosaicplasty technique he invented demonstrated 94% good increase significantly in size correlate with poor outcome.
to excellent results (Hannover scoring system for ankle func-
tion). Osteochondral plugs were transferred from the ipsilat- Schimmer RC, Dick W, Hintermann B: The role of ankle
eral knee; no long-term donor site morbidity was observed. arthroscopy in the treatment strategies of osteochondri-
tis dissecans lesions of the talus. Foot Ankle Int 2001;22:
Hintermann B, Boss A, Schafer D: Arthroscopic findings 895-900.
in patients with chronic ankle instability. Am J Sports The authors report that arthroscopy represents a helpful
Med 2002;30:402-409. diagnostic tool in assessing extent and, in particular, stability
Based on a cohort of 148 patients with symptomatic and integrity of the osteochondral talar defect. They recom-
chronic ankle instability undergoing ankle arthroscopy, 66% of mend that arthroscopy be performed in all patients with os-
ankles with lateral ligament instability and 98% with deltoid teochondral lesions of the talus to define the treatment strat-
ligament injuries were noted to have associated cartilage dam- egy.
age, respectively.
Schuman L, Struijs PA, Van Dijk CN: Arthroscopic
Peterson L, Brittberg M, Lindahl A: Autologous chon- treatment for osteochondral defects of the talus: Results
drocyte transplantation of the ankle. Foot Ankle Clin at followup at 2 to 11 years. J Bone Joint Surg Br 2002;
2003;8:291-303. 84:364-368.
The inventors of autologous chondrocyte transplantation Thirty-eight patients who had been treated with arthro-
(Carticel procedure) present their experience with this tech- scopic dbridement and drilling for osteochondral lesions of
nique in the management of osteochondral lesions of the talus. the talus were evaluated at a mean follow-up of 4.8 years.
Twenty-two patients underwent a primary procedure, and 16
had failed previous surgery. Good to excellent results were
Sammarco GJ, Makwana MK: Treatment of talar osteo-
found in 86% of the primary procedures and 75% of revision
chondral lesions using local osteochondral graft. Foot
cases.
Ankle Int 2002;23:693-698.
The authors describe a technique for local osteochondral
transfer in the management of osteochondral talar dome le- Scranton PE Jr, McDermott JE: Treatment of Type V
sions; the graft was harvested from the medial or lateral talar osteochondral lesions of the talus with ipsilateral knee
articular facet. Exposure to the defect was facilitated through osteochondral autografts. Foot Ankle Int 2001;22:380-
a replaceable bone block removed from the anterior tibial 384.
plafond. In 12 patients with an average follow-up of 25 Ten consecutive patients who had osteochondral lesions of
months, the average American Orthopaedic Foot and Ankle the talus were treated with osteochondral autograft transplan-
Society score improved from 64 to 91 points. No complications tation and were evaluated at short-term follow-up. All lesions
were reported. were associated with subchondral cysts. These preliminary re-
sults suggest significant improvement in all 10 patients, with an
average increase in the American Orthopaedic Foot and An-
Schafer D, Boss A, Hintermann B: Accuracy of arthro-
kle Society ankle/hindfoot score of 27 points.
scopic assessment of anterior ankle cartilage lesions.
Foot Ankle Int 2003;24:317-320.
The authors demonstrated that iatrogenically created talar Thordarson DB, Bains R, Shepherd LE: The role of an-
dome defects were overestimated and underestimated when kle arthroscopy on the surgical management of ankle
evaluated arthroscopically in 10 cadaver specimens. These fractures. Foot Ankle Int 2001;22:123-125.
Nineteen patients with surgical treatment of their unstable Hindfoot and Ankle: Acquired Flatfoot Defromity
ankle fractures were prospectively randomized to include or Choi K, Lee S, Otis JC, Deland JT: Anatomical recon-
not include ankle arthroscopy. Eight of nine patients random- struction of the spring ligament using peroneus longus
ized to the arthroscopy group had articular damage that tendon graft. Foot Ankle Int 2003;24:430-436.
prompted arthroscopic treatment. At an average follow-up of Using a cadaver foot-ankle flatfoot model comparing
21 months, no difference was noted in the Medical Outcomes three methods of spring ligament reconstruction using the per-
Study Short Form-36 Health Survey or lower extremity scores oneus longus tendon, it was shown that a superomedial/
between the two groups. plantar passage of tendon through the calcaneus and navicular
was most effective.
Hindfoot and Ankle: Insertional Achilles Tendinopathy
Calder JD, Saxby TS: Surgical treatment of insertional Coetzee JC, Hansen ST: Surgical management of severe
Achilles tendinosis. Foot Ankle Int 2003;24:119-121. deformity resulting from posterior tibial tendon dys-
A chart review of 49 open dbridements of insertional
function. Foot Ankle Int 2001;22:944-949.
Achilles tendinosis in which less than 50% of the tendon was A retrospective review of 12 feet in 11 patients undergoing
excised suggested that early mobilization does not predispose major hindfoot corrective surgery with an extended triple ar-
to postsurgical rupture. At a minimum follow-up of 6 months, throdesis for severe acquired pes planovalgus deformity dem-
only two failures were noted: one patient with psoriatic arthri- onstrated a statistically significant improvement in the average
tis and another who had bilateral simultaneous procedures.
American Orthopaedic Foot and Ankle Society hindfoot score
(30 to 74) and radiographic parameters. Despite multiple com-
Den Hartog BD: Flexor hallucis longus transfer for plications (wound problems, delayed unions) requiring revi-
chronic Achilles tendinosis. Foot Ankle Int 2003;24:233- sion surgery, the extensive procedure provided a justifiable im-
237. provement in patients quality of life.
Twenty-nine tendons (26 patients) undergoing reconstruc-
tion for chronic Achilles tendinosis using a flexor hallucis lon-
Guyton GP, Jeng C, Krieger LE, Mann RA: Flexor digi-
gus augmentation were evaluated at an average follow-up of 3
torum longus transfer and medial displacement calca-
years. Time to maximum improvement was 8.2 months. The av-
neal osteotomy for posterior tibial tendon dysfunction:
erage American Orthopaedic Foot and Ankle Society ankle-
A middle-term clinical follow-up. Foot Ankle Int 2001;
hindfoot score improved from 42 to 90 points. No patient had
22:627-632.
a clinically significant functional deficit of the hallux.
At an average follow-up of 32 months, 26 patients under-
going flexor digitorum longus tendon transfer with medial dis-
McGarvey WC, Palumbo RC, Baxter DE, Leibman BD: placement calcaneal osteotomy for stage II posterior tibial
Insertional Achilles tendinosis: Surgical treatment tendon dysfunction were evaluated. Only 16 patients were
through a central tendon splitting approach. Foot Ankle evaluated by physical examination for the follow-up evalua-
Int 2002;23:19-25. tion. The average American Orthopaedic Foot and Ankle So-
Twenty-two patients with insertional Achilles tendinosis ciety hindfoot pain subscale score was 35 of 40 and the Ameri-
were treated through a central tendon splitting approach with can Orthopaedic Foot and Ankle Society functional score was
tendon dbridement, retrocalcaneal bursectomy, and partial 27 of 28. Three failures included two early failures of fixation
calcanectomy. This approach revealed that the disease process of the flexor digitorum longus tendon and one failure at ap-
was isolated to the central tendon insertion in 21 of the pa- proximately 6 years during pregnancy.
tients. At an average follow-up of 33 months, 82% of patients
were satisfied with the surgery, 77% would have the surgery
Louden KW, Ambrose CG, Beaty SG, et al: Tendon
again, but only 59% were completely pain free and could re-
transfer fixation in the foot and ankle: Biomechanical
turn to unlimited activities.
study evaluating two sizes of pilot holes for bioabsorb-
able screws. Foot Ankle Int 2003;24:67-72.
Tashjian RZ, Hur J, Sullivan RJ, et al: Flexor hallucis Bioabsorbable screw fixation for tendon transfer proce-
longus transfer for repair of chronic achilles tendinopa- dures, including flexor digitorum longus or flexor hallucis lon-
thy. Foot Ankle Int 2003;24:673-676. gus transfer to the navicular for correction of posterior tibial
Using 14 fresh-frozen cadaver lower limbs, a short flexor tendon insufficiency, is being used with greater frequency in
hallucis longus tendon harvest (posteromedial ankle incision) foot and ankle surgery. This biomechanical study performed in
was compared with a long (traditional) flexor hallucis longus cadaver specimens demonstrates that initial pull-out strength
tendon harvest (second medial midfoot incision). The short for 5- or 7-mm screws exceeds the requisite strength for ten-
flexor hallucis longus tendon harvest yielded an average ten- don transfer to the navicular. The 7-mm screw diameter with
don length of 5.2 cm; the long flexor hallucis longus harvest pilot holes of 5.5 mm or 6.5 mm may be preferable given the
yielded and average tendon length of 8.1 cm. average flexor digitorum longus or flexor hallucis longus ten-
don diameter approaching 5 mm.
Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen ST transfer for posterior tibial tendon dysfunction. American Or-
Jr, Sangeorzan BJ: Talocalcaneal and subfibular im- thopaedic Foot and Ankle Society hindfoot scores and radio-
pingement in symptomatic flatfoot in adults. J Bone graphic parameters were significantly improved for both
Joint Surg Am 2002;84-A:2005-2009. groups. The complication rate (reported for 34 feet) was high
Nineteen patients with symptomatic acquired flatfoot de- for both groups; the rate of nonunion (12%) and delayed
formity were evaluated with simulated weight-bearing CT union (18%) was considerable for the calcaneocuboid distrac-
analysis of the hindfoot and compared with a control group. In tion arthrodesis group.
the study group, sinus tarsi impingement was noted in 92%
and subfibular impingement was observed in 66% versus 0
and 5% in the control group, respectively.
Viladot R, Pons M, Alvarez F, Omana J: Subtalar arthro-
ereisis for posterior tibial tendon dysfunction: A prelim-
inary report. Foot Ankle Int 2003;24:600-606.
Moseir-LaClair S, Pomeroy G, Manoli A: Intermediate Twenty-one patients with stage II flexible posterior tibial
follow-up of the double osteotomy and tendon transfer tendon dysfunction were treated with flexor digitorum longus
procedure for stage II posterior tibial tendon insuffi- augmentation or flexor hallucis longus tendon transfer and
ciency. Foot Ankle Int 2001;22:283-291. subtalar arthroereisis (sinus tarsi implant). Nineteen patients
Twenty-six patients with 28 acquired pes planovalgus feet
reviewed at an average 27-month follow-up had an average
(Johnson stage II) were managed with flexor digitorum longus
improvement in the American Orthopaedic Foot and Ankle
transfer, Achilles tendon lengthening, and a double calcaneal
Society score from 47 to 82 points. Two patients required re-
osteotomy (medial displacement and lateral column lengthen-
moval of the implant secondary to pain.
ing). At a mean follow-up of 5 years, the mean American Or-
thopaedic Foot and Ankle Society ankle-hindfoot score was
90. All osteotomies united and average radiographic parame- Wacker JT, Hennessy MS, Saxby TS: Calcaneal osteot-
ters remained improved at follow-up. Fourteen percent of pa- omy and transfer of the tendon of flexor digitorum lon-
tients demonstrated radiographic signs of calcaneocuboid ar- gus for stage-II dysfunction of tibialis posterior:
thritis. Three-to five-year results. J Bone Joint Surg Br 2002;84:
54-58.
Sammarco GJ, Hockenbury RT: Treatment of stage II At mean follow-up of 51 months, 44 patients treated with
posterior tibial tendon dysfunction with flexor hallucis flexor digitorum longus transfer and medial displacement cal-
longus transfer and medial displacement calcaneal os- caneal osteotomy had an average improvement in the Ameri-
teotomy. Foot Ankle Int 2001;22: 305-312. can Orthopaedic Foot and Ankle Society hindfoot score from
At an average follow-up of 18 months, 17 patients who 49 to 88 points. The outcome was good to excellent in 43 pa-
had undergone medial displacement calcaneal osteotomy and tients for pain and function, and good to excellent in 36 pa-
flexor hallucis longus tendon reconstruction for stage II poste- tients for alignment. No poor results were observed.
rior tibial tendon reconstruction were evaluated. The average
American Orthopaedic Foot and Ankle Society hindfoot score Hindfoot and Ankle: Plantar Fasciitis
improved from 62 to 84 points. Despite radiographic assess-
DiGiovanni BF, Nawoczenski DA, Lintal ME, et al: Tis-
ment demonstrating that there was no statistically significant
sue specific plantar fascia-stretching exercise enhances
improvement in the medial longitudinal arch in the study
outcomes in patients with chronic heel pain. J Bone
group, good to excellent results were reported in most pa-
Joint Surg Am 2003;85-A:1270-1277.
tients.
One hundred one patients with chronic plantar fasciitis
were randomized to undergo either plantar fascia tissue or
Tashjian RZ, Appel AJ, Banerjee R, DiGiovanni CW: traditional Achilles tendonstretching regimen. Greater im-
Endoscopic gastocnemius recession: evaluation in a ca- provement was observed in the plantar fasciastretching pro-
daver model. Foot Ankle Int 2003;24: 607-613. gram with regard to pain, activity limitation, and patient satis-
Endoscopic gastrocnemius recession was evaluated in 15
faction.
cadaver specimens. The sural nerve was definitively visualized
in 33% of the procedures and an average of 83% of the gas-
trocnemius aponeurosis was transected. Improvement in mean Haake M, Buch M, Schoellner C, Goebel F: Extracorpo-
ankle dorsiflexion with the knee flexed was 20. real shock wave therapy for plantar fasciitis: Random-
ized controlled multicentre trial. BMJ 2003;327:75.
This multicenter study of 272 patients with chronic plantar
Thomas RL, Wells BC, Garrison RL, Prada SA: Prelimi-
fasciitis compared extracorporeal shock wave therapy with a
nary results comparing two methods of lateral column
lengthening. Foot Ankle Int 2001;22:107-119. placebo group. The success rate at 12 weeks was 34% in the
At a minimum follow-up of at least 1 year, 10 Evans open- shock wave therapy group and 30% in the placebo group. The
ing wedge osteotomies were compared with 17 calcaneocuboid authors concluded that extracorporeal shock wave therapy is
distraction arthrodeses, both of which were performed with ineffective in treating chronic plantar fasciitis.
structural iliac crest autograft and flexor digitorum longus
Labib SA, Gould JS, Rodriguez-del-Rio FA, Lyman S: At an average follow-up of 27 months, 22 patients with
Heel Pain Triad (HPT): The combination of plantar fas- nonhealing heel wounds were treated with partial calcanec-
ciitis, posterior tibial tendon dysfunction and tarsal tun- tomy. Wounds healed in all patients; none required subsequent
nel syndrome. Foot Ankle Int 2002;23:212-220. transtibial amputation. Twelve patients had delayed wound
Fourteen patients were surgically treated for a combina- healing, and 11 additional procedures were performed on the
tion of plantar fasciitis, posterior tibial tendon dysfunction, heels of 9 patients.
and tarsal tunnel syndrome. At a mean follow-up of 17
months, a marked improvement was noted in 88% of patients
Cooper PS: Application of external fixators for manage-
for pain, activity level, walking distance, walking surface, and
limp.
ment of Charcot deformities of the foot and ankle. Foot
Ankle Clin 2002;7:207-254.
A single surgeons experience with external fixation for
Rompe JD, Schoellner C, Nafe B: Evaluation of low- the management of infected and noninfected Charcot neuro-
energy extracorporeal shock-wave application for treat- pathic deformities of the foot and ankle is presented.
ment of chronic plantar fasciitis. J Bone Joint Surg Am
2002;84-A:335-341.
This prospective, randomized, controlled trial of 112 pa- Guyton GP, Saltzman CL: The diabetic foot: Basic
tients with chronic plantar fasciitis compared three applica- mechanism of disease. Instr Course Lect 2002;51:169-
tions of 1,000 low-energy shock wave impulses (group I) to 181.
three applications of 10 low-energy shock wave impulses The authors present a review of the pertinent basic sci-
(group II). At 6 months, the rate of good to excellent results ence, evaluation, and current state of the art in the manage-
was significantly better (47%) in group I than in group II. By ment of diabetic foot problems.
5 years, 13% of patients in group I and 58% in group II had
undergone surgical plantar fascia release. The authors con- Mueller MJ, Sinacore DR, Hastings MK, et al: Effect of
cluded that treatment with 1,000 impulses of low-energy shock
Achilles tendon lengthening on neuropathic plantar ul-
waves may be an effective therapy for plantar fasciitis and
cers. J Bone Joint Surg Am 2003;85-A:1436-1445.
may help patients avoid surgery.
Sixty-four patients with neuropathic ulcers were random-
ized to receive total contact casting alone or combined with
Speed CA, Nichols D, Wies J, et al: Extracorporeal percutaneous Achilles tendon lengthening. Eighty-eight per-
shock wave therapy for plantar fasciitis: A double blind cent of the ulcers in the total contact cast group and 100% in
randomized controlled trial. J Orthop Res 2003;21:937- the Achilles tendon lengthening group healed after a mean
940. duration of 41 days and 58 days, respectively. The risk for ulcer
This double-blind randomized controlled trial compared
recurrence was 75% less at 7 months and 52% less at 2 years
active therapy (moderate-dose shock wave therapy) to sham
in the Achilles tendon lengthening group than in the isolated
therapy for 88 patients with plantar fasciitis of at least 3
total contact cast group.
months duration. Over a 6-month period, both groups showed
significant improvement, but no statistically significant differ-
ences were observed in any outcome measures. Classic Bibliography
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2002;23:530-537. Brostrom L: Sprained ankles: V. Treatment and progno-
Seventy-five patients (80 heels) with an average of 20 sis in recent ligament ruptures. Acta Chir Scand 1966;
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rigidus following treatment with cheilectomy. Clin agement of midfoot diabetic neuroarthropathy. Foot
Orthop 1988;226:182-191. Ankle Int 1994;15:233-241.
Hepple S, Winson IG, Glew D: Osteochondral lesions of Papa J, Myerson M, Girard P: Salvage, with arthrodesis,
the talus: A revised classification. Foot Ankle Int 1999; in intractable diabetic neuropathic arthropathy of the
20:789-793. foot and ankle. J Bone Joint Surg Am 1993;75:1056-1066.
Johnson KA, Strom DA: Tibialis posterior tendon dys- Pell RF, Myerson MS, Schon LC: Clinical outcome after
function. Clin Orthop 1989;239:196-206. primary triple arthrodesis. J Bone Joint Surg Am 2000;
Kumai T, Takakura Y, Higashiyama I, Tamai S: Arthro- 82:47-57.
scopic drilling for the treatment of osteochondral le- Sangeorzan BJ, Hansen ST Jr: Modified Lapidus proce-
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Mann RA, Clanton TO: Hallux rigidus: Treatment by
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cheilectomy. J Bone Joint Surg Am 1988;70:400-406.
luxation of the foot: Early results after distraction arthro-
Mann RA, Rudicel S, Graves SC: Repair of hallux val- desis of the calcaneocuboid joint in conjunction with
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metatarsal osteotomy. A long-term follow-up. J Bone gus tendon to, the midfoot to treat acquired pes planov-
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Cervical Spine Trauma ary survey. Absence of a neurologic deficit is not suffi-
Clinical Evaluation cient to exclude such an injury, and a hard cervical col-
The initial evaluation and management of patients with lar should be applied until the cervical spine has been
formally cleared and patients are considered with rea-
spinal injuries is usually initiated in the field by para-
sonable certainty to be stable and free of significant in-
medical personnel. These injuries are frequently the re-
jury. Motorcyclists in particular have a higher incidence
sult of high-energy trauma, and patients may require
of thoracic spinal injuries, and evidence of blunt chest
rapid evaluation and resuscitation according to the
trauma should lead to further evaluation of the thoracic
guidelines established by the American College of Sur-
spine. Abdominal ecchymoses or abrasions from lap belt
geons. Treatment of potential spinal injury begins at the
injury are associated with flexion-distraction injury of
accident scene with proper immobilization using a rigid
the thoracolumbar spine. Extremity fractures may dis-
cervical collar, tape, or straps to secure the patients
tract the emergency personnel from identification of a
neck, and transport on a firm spine board with lateral
spinal injury requiring treatment. Every multiple trauma
support devices. In the setting of sports-related injuries,
patient should undergo visual inspection of the back. A
helmet and shoulder pads should be left on until arrival thorough neurologic examination including sensorimo-
at the hospital where experienced personnel can per- tor function and level of consciousness is the final com-
form simultaneous removal of both in controlled fash- ponent of the secondary survey. Any neurologic deficit
ion. suggests the possibility of an injury to the spinal axis.
During the primary survey, protection of the spine Patients with ankylosing spondylitis or diffuse idio-
and spinal cord is the important management principle. pathic skeletal hyperostosis represent a special subpop-
It should be assumed that all trauma patients have a ulation for which extra vigilance is required. Spinal in-
cervical spine injury until proven otherwise, especially volvement with these conditions, particularly ankylosing
those with altered mental status or following blunt head spondylitis, appears to increase the risk of fracture, and
or neck trauma. Inadequate initial stabilization can con- patients reporting neck or back pain after even rela-
tribute to further neurologic deterioration in a patient tively minor trauma should be considered for supple-
with an acute spinal cord injury and significantly worsen mental evaluation with CT. Nondisplaced fractures com-
eventual outcome. It has been estimated that 3% to monly occur in this setting, most frequently through an
25% of spinal cord injuries may occur after the initial ankylosed disk space, and carry a high rate of delayed
traumatic episode during early management or trans- or missed diagnosis. These fractures are typically unsta-
port. While securing an airway, excessive head and neck ble and can lead to spinal cord injury if not stabilized
movement should be avoided and manual in-line immo- appropriately.
bilization of the head and neck should be maintained A variety of clinical grading systems have been de-
whenever immobilization devices are removed. Over veloped for assessing and reporting neurologic status in
the past 30 years, significant improvements in the sur- spinal cord injury patients. The Frankel scale has been
vival and outcome of patients with spinal cord injuries supplanted in clinical use by the American Spinal Injury
have been observed, primarily because of improved ini- Association (ASIA) scale (Figure 1). This scale was first
tial management and rapid delivery by emergency ser- introduced in 1984 and has undergone revisions in 1989,
vices. 1992, and most recently in 1996. The most recent version
Although the initial neurologic evaluation only as- includes separate motor and sensory scores as well as a
sesses the patients level of alertness and consciousness, general impairment scale and incorporates the func-
a more thorough assessment of neurologic status and tional independence measure, a tool that assesses the
potential spinal injury is performed during the second- functional effect of spinal cord injury. The motor score
Figure 1 ASIA form for standard neurologic classification of spinal cord injury. (Reproduced from the American Spinal Injury Association.)
radiographic evaluation of the cervical spine in symptom- morphology and biomechanical characteristics. The third
atic trauma patients. Specifically, a cervical spine series through sixth vertebrae (C3-C6) are considered typical
consisting of AP and lateral views in addition to open- cervical vertebrae with small cylindrical bodies and
mouth odontoid views is recommended. Supplemental CT short bifid spinous processes. The seventh cervical verte-
examination is recommended to provide more detail of in- bra (C7) is a transitional vertebra between the cervical
adequately visualized levels.The most common reason for and thoracic spinal regions and has a large nonbifid
missing a significant injury appears to be inadequate vi- spinous process known as the vertebra prominens.
sualization of the injured level, most frequently the occip- The atlas is a ring containing two articular lateral
itoatlantoaxial region or cervicothoracic junction. How- masses with neither a body nor spinous process (Figure
ever, even with adequate plain radiographic visualization, 3). Incomplete formation of the posterior ring is rela-
it has been estimated that this three-view series will miss tively common as a developmental variation and does
15% to 17% of injuries. not represent a traumatic injury. The axis contains the
Following initial plain radiographs and possibly a CT odontoid process or dens, which articulates with the an-
scan, multiple options for determining safe collar re- terior arch of the axis against which it is stabilized by
moval in symptomatic patients have been proposed. The the transverse ligament (Figure 4).
negative predictive value of a three-view series and CT Morphology of the subaxial cervical spine from C3
is greater than 99%, and in certain instances supplemen- to C6 is relatively consistent. The articular processes are
tal CT evaluation may be sufficient. However, despite located at the junction of the laminae and pedicles and
the absence of apparent osseous injury, instability can form pillars referred to as the lateral masses (Figure 5).
exist from spinal soft-tissue disruption of ligaments, The vertebral bodies are predominantly cancellous bone
facet capsules, and disk tissue. MRI is exquisitely sensi- surrounded by thin cortical bone. Superior end plates
tive for acute soft-tissue injury and may be an option, are concave in the coronal plane and convex in the sag-
but the incidence of MRI abnormalities has been shown ittal plane, whereas the matching inferior end plates are
to be between 25% to 40%, suggesting that MRI may convex in the coronal plane and concave in the sagittal
be oversensitive. Moreover, MRI is only reliable for plane. The uncinate processes are osseous projections
identifying soft-tissue injury within 48 hours of the trau- off the posterolateral surfaces of the superior end
plates. Their articulation with the convex inferolateral
matic event.
surface of the more rostral vertebra comprises the joints
Flexion-extension radiographs are frequently ob-
of Luschka.
tained to rule out significant instability. In awake and alert
The posterior facet joints caudal to C2 are encapsu-
patients, active flexion-extension radiographs are safe, and
lated synovial joints with overlying hyaline cartilage and
no significant complications have been reported.The neg-
containing small menisci. The facet joint angle approxi-
ative predictive value of plain films in conjunction with
mates 45 in the sagittal plane. The transverse processes
flexion-extension views is in excess of 99%.
of each cervical vertebra contain a vascular foramen. The
The most controversy surrounds cervical spine clear-
vertebral artery typically passes anterior to the transverse
ance in the obtunded patient. Again, MRI has been sug-
processes of C7 before entering the spine at the C6 vas-
gested as an adjunctive test but may be of limited use-
cular foramen. An accessory vertebral vein typically oc-
fulness because of the lack of correlation between MRI cupies the C7 foramen. At C1, the vertebral arteries pass
findings and clinically significant injury. Passive flexion- through a foramen, and then turn posteromedially around
extension manipulation of the cervical spine under fluo- the superior articular process before entering the foramen
roscopy has been advocated by several investigators. magnum and joining to form the basilar artery. An anom-
However, there is a theoretic risk of causing iatrogenic alous course for the vertebral artery is present 3% of the
spinal cord injury to these patients because of unrecog- time and most commonly involves medial deviation to-
nized disk herniation. It has been suggested that many ward the vertebral body at its midpoint. The incidence of
obtunded patients are at low risk for any significant in- unilateral absence or hypoplasia of the vertebral artery is
jury and can be cleared on the basis of plain radio- 5% to 10%. Arterial supply of the anterior two thirds of
graphs and CT. Proposed high-risk criteria indicating the cervical spinal cord derives from a single anterior spi-
the need for further evaluation include high-velocity nal artery, which is fed by segmental arteries derived from
motor vehicle accidents (> 35 mph), any fall from a the vertebral arteries. Paired posterior spinal arteries de-
height of more than 10 feet, closed-head injuries, neuro- rived from either the vertebral arteries or the posterior in-
logic deficits referable to the cervical spine, and pelvis ferior cerebellar artery supply the posterior one third of
or extremity fractures. the cord. Branches of the vertebral arteries provide a ro-
bust blood supply for individual vertebra. Odontoid non-
Anatomy of the Cervical Spine unions were previously attributed to inadequate arterial
The cervical spine includes seven vertebrae. The rostral perfusion; however, recent anatomic studies have revealed
two vertebrae, the atlas (C1) and axis (C2), have distinct an extensive arterial arcade surrounding the odontoid
Figure 3 Illustrations of the osseous anatomy of the first cervical vertebra (C1; atlas). A, Cranial view of the atlas. B, Caudal view of the atlas. (Reproduced with permission from
Heller JG, Pedlow FX Jr: Anatomy of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 3-36.)
Figure 5 Cranial (A) and lateral (B) illustrations of the osseous anatomy of the subaxial cervical spine. (Reproduced with permission from Heller JG, Pedlow FX Jr: Anatomy of
the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 3-36.)
Figure 7 Illustrations of the cross-sectional anatomy of the cervical spinal cord. A, S = sacral; L = lumbar; T = thoracic; C = cervical. B, 1 = fasciculus gracilis; 2 = fasciculus
cuneatus; 3 = dorsal spinocerebellar tract; 4 = ventral spinocerebellar tract; 5 = lateral spinothalamic tract; 6 = spinoolivary tract; 7 = ventral corticospinal tract; 8 = tectospinal
tract; 9 = vestibulospinal tract; 10 = olivospinal tract; 11 = propriospinal tract; 12 = lateral corticospinal tract. (Reproduced with permission from Heller JG, Pedlow FX Jr:
Anatomy of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 3-36.)
Table 1 | Criteria for Identifying Instability at the Occipito- Table 2 | Checklist for the Diagnosis of Clinical Instability
cervical Junction in the Middle and Lower Cervical Spine
fractures requires ruling out occipitocervical dissocia- ing of the transverse ligament. Because data from ca-
tion, particularly in patients with type III fractures, fol- daveric studies indicate that a combined lateral mass
lowed by external immobilization in a cervical orthosis. displacement in excess of 7 mm strongly suggests liga-
ment disruption, an 18% radiographic magnification
Occipitocervical Dissociation factor has been incorporated, resulting in an increase in
Most instances of traumatic occipitocervical dissociation the measurement to 8.1 mm. However, with improve-
are lethal, with approximately 100 cases having been re- ments in MRI technology, it has become a more sensi-
ported in the literature. Survivors may demonstrate a tive means of detecting a ligamentous injury than plain
wide range of neurologic injuries ranging from complete radiographs. Two types of transverse ligament injury
spinal cord lesions to isolated cranial nerve palsies have been described. Midsubstance ruptures (type I in-
(most commonly affecting cranial nerves VI, X, and juries) are least likely to heal, and early surgical treat-
XII). Occipitocervical dissociation injuries have been ment with C1-2 fusion may be necessary. Type II injuries
classified as anterior type I, longitudinal type II, or pos- involve an avulsion fracture of the ligamentous inser-
terior type III. tion. Because of higher rates of healing, an initial at-
Diagnosis of this condition can be challenging be- tempt at external immobilization using a halo vest is a
cause of the poorly visualized osseous detail on plain ra- reasonable treatment option in these patients.
diographs of this region. The most frequently described In general, most isolated anterior or posterior arch
measurement is the Powers ratio, which divides the ba- fractures and lateral mass and transverse process frac-
sion to posterior arch distance by the anterior arch to tures of the atlas can be treated conservatively with 6 to
opisthion distance. A ratio greater than 1 suggests possi- 12 weeks of external immobilization. Burst fractures in-
ble anterior dissociation. Other measurements consid- volving both anterior and posterior arches with an intact
ered suggestive of injury include a basion to odontoid transverse ligament are considered stable injuries that
distance greater than 10 mm, posterior mandible to an- should also be treated with external immobilization.
terior atlas distance greater than 13 mm, and posterior Disruption of the transverse ligament introduces the op-
mandible to odontoid distance greater than 20 mm. The tion of early surgical fusion, typically involving a poste-
Harris basion-axial intervalbasion-dental interval rior C1-2 fusion. Multiple procedures have been de-
method measures distance from the basion to a line scribed, including various wiring techniques and screw-
drawn tangentially to the posterior border of C2 (a dis- rod constructs. C1-2 transarticular screw placement is
tance greater than 12 mm or less than 4 mm is abnor- the most stable form of fixation currently in general use
mal) as well as the distance from the basion to the od- and obviates the need for postoperative halo immobili-
ontoid (greater than 12 mm is abnormal) and is zation required with C1-2 wiring techniques.
considered by some to be the most sensitive measure-
ment. Overall, the sensitivity of plain radiographs for Axis Fractures
occipitocervical dissociation is approximately 57%. The Odontoid fractures are the most common type of axis
sensitivity of CT and MRI has been estimated to be fracture and have been classified by Anderson and
84% and 86%, respectively, and one or both of these ad- DAlonzo as type I avulsion fractures of the tip, type II
junctive studies is recommended for patients with sus- fractures through the waist of the odontoid process, or
pected occipitocervical dissociation injuries. type III fractures extending into the C2 vertebral body.
Use of traction is associated with a 10% rate of neu- Nearly all odontoid fractures will require some form of
rologic deterioration and should be avoided in patients treatment.
with these injuries. In patients with survivable injuries, Type I fractures can be treated with an external
an instrumented occipitocervical fusion is recom- orthosis once the possibility of an associated occipito-
mended. Different techniques of fixation have been de- cervical dissociation has been excluded. Type III frac-
scribed, including occipital and cervical wiring, wire tures have been reported to have a sufficiently high
mesh and methylmethacrylate, and occipitocervical plat- healing rate with rigid external immobilization in a halo
ing. More recently, modular occipital plates have been vest. Treatment of type II fractures is controversial and
developed that can be rigidly locked to longitudinal depends largely on specific patient and fracture charac-
rods placed across the subaxial cervical spine (Figure 8). teristics. Elderly patients tolerate halo vest immobiliza-
tion poorly, demonstrate decreased healing rates, and
Atlas Fractures should be considered for early C1-2 surgical fusion. Eld-
Fractures of the atlas constitute approximately 7% of erly debilitated patients who are at increased risk of
cervical spine fractures. Jefferson fractures are bilateral medical complications from surgical treatment can be
fractures of the anterior and posterior arches resulting treated with an external orthosis for 6 to 12 weeks with
from an axial load (Figure 9). Long-term stability de- the understanding that successful fusion is unlikely to
pends on the mechanism of injury and subsequent heal- occur. In most patients, a fibrous nonunion develops
Figure 8 Lateral (A) and AP (B) radiographs of occipitocervical segmental fixation implants (DePuy AcroMed Summit system, Raynham, MA).
that provides sufficient stability for routine daily activi- complishing a posterior C1-2 fusion. Traditional sublam-
ties. Nevertheless, these patients should be informed inar wiring techniques (Gallie and Brooks fusions) are
that they remain at risk for spinal cord injury in the being supplemented or replaced by more rigid fixation
event of a fall or motor vehicle accident. methods such as C1-2 transarticular screws and C1 lat-
In younger, healthy patients with a type II fracture, eral mass and C2 pedicle screw-rod constructs (Figure
specific fracture characteristics assume increased signifi- 11). These more rigid fixation techniques provide the
cance. Nondisplaced fractures diagnosed early should be surgeon with the opportunity to avoid postoperative
treated with halo vest immobilization for 6 to 12 weeks. halo vest immobilization.
Risk factors for nonunion include fracture comminu-
tion, displacement of more than 6 mm, posterior dis- Traumatic Spondylolisthesis of the Axis
placement, delay in diagnosis, and patient age greater
This injury is characterized by bilateral fractures of the
than 50 years. Early surgical treatment is an option for
pars interarticularis and is also known as a hangmans
patients with any of these risk factors. Surgical treat-
ment should also be considered for fractures in which fracture, although recent efforts have been made to re-
reduction cannot be achieved or maintained. place this term with traumatic spondylolisthesis of the
Anterior odontoid screw osteosynthesis using a sin- axis. Most injuries of this type that occur in the United
gle screw placed with lag technique is an option for States are the result of motor vehicle accidents, and the
treating both type II and type III noncomminuted frac- forces involved are likely a combination of hyperexten-
tures. For the best results using this technique, the frac- sion, compression, and rebound flexion. The currently
ture should be diagnosed early, reduction must be possi- popular classification scheme is Levine and Edwards
ble, and patient body habitus must allow achievement of modification of previous systems described by Effendi
proper intraoperative screw trajectory (Figure 10). In and Francis and is based on mechanism of injury (Fig-
addition, odontoid fracture obliquity should run from ure 12). Type I fractures result from axial compression
anterosuperior to posteroinferior. Otherwise, surgical and hyperextension and demonstrate less than 3 mm
treatment may involve any of several methods for ac- displacement and no angulation. Type II fractures result
from hyperextension and axial load followed by re- up to 5 mm of displacement can occur without disruption
bound flexion and demonstrate translation of greater of posterior ligaments or the C2-3 disk. Suggested indica-
than 3 mm as well as angulation. Type IIA fractures are tions for surgical treatment include type II fractures with
characterized by angulation without significant transla- severe angulation, type III fractures with disruption of the
tion and result from a flexion-distraction injury. Identifi- C2-3 disk, or inability to achieve or maintain fracture re-
cation of this fracture type is important because applica- duction. All type III fractures associated with facet dislo-
tion of traction may cause further fracture displacement cation require open reduction and fusion. Surgical options
and should be avoided. Type III fractures are essentially include anterior C2-3 interbody fusion, posterior C1-3 fu-
type I pars fractures associated with injury to the C2-3 sion, or bilateral C2 pars screw osteosynthesis.
facet joints, most commonly bilateral facet dislocation.
These fractures are thought to result from flexion- Fractures and Dislocations of the Subaxial Spine
distraction followed by hyperextension. A type IA frac- The most commonly used classification system for sub-
ture pattern was recently added to this classification sys- axial spine injuries is the system developed by Allen and
tem to describe asymmetric fracture lines with minimal associates. Six distinct phylogenies were described based
translation and no angulation. This fracture is thought to on mechanism of injury, with each phylogeny being sub-
result from hyperextension with a component of lateral divided into stages of progressive severity. The three
bending forces. commonly observed categories are compressive flexion,
Most patients with traumatic spondylolisthesis of the distractive flexion, and compressive extension. Vertical
axis can be successfully treated with 6 to 12 weeks of ex- compression is observed less commonly, and the two
ternal immobilization in a cervical orthosis or halo vest. least common categories are distractive extension and
Data from a recent cadaveric study have suggested that lateral flexion.
Facet Dislocations
Patients with cervical facet dislocations should undergo
timely reduction of their injuries upon diagnosis. Classi-
cally, plain radiographic evidence of vertebral body sub-
luxation of 25% has been reported to suggest a uni-
lateral facet dislocation, whereas vertebral body
subluxation of 50% has been reported to suggest a bilat-
eral dislocation (Figure 13). Unilateral facet dislocations
are commonly associated with a monoradiculopathy
that improves following application of traction. Bilateral
facet dislocations are often associated with significant
spinal cord injuries. Awake and alert patients can safely
undergo closed reduction with progressive application
of axial traction forces. It is crucial that these patients
be closely monitored with serial neurologic examina-
tions and plain radiographic assessment following the
placement of each additional weight. Development of
new or worsening neurologic deficits is an indication to
cease attempts at closed reduction, and an MRI scan
should be obtained to rule out herniated disk material.
Overall, as many as 26% of patients with cervical facet
dislocations will fail attempted closed reduction, with
higher failure rates observed for patients with unilateral
facet dislocations. Although 50% of patients with facet
dislocations will demonstrate signs of disk disruption on
Figure 10 Odontoid radiograph of anterior odontoid screw fixation. (Reproduced with MRI, most of these signs are of uncertain clinical signif-
permission from Klein GR, Vaccaro AR: Cervical spine trauma: Upper and lower, in icance.
Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery.
Philadelphia, PA, Mosby, 2003, pp 441-462.) Following successful closed reduction, surgical stabi-
lization of these injuries is typically necessary. In the ab-
sence of a traumatic disk herniation, posterior instru-
Compression and Burst Fractures mented fusion is recommended. However, various
Compression fractures are defined by compressive fail- treatment options are available for associated disk her-
ure of the anterior half of the vertebral body (anterior niation. After successful closed reduction, an MRI scan
column) without disruption of the posterior body cortex of the cervical spine should be obtained to rule out the
and without retropulsion into the spinal canal. Patients presence of associated disk herniation. Anterior diskec-
are typically neurologically intact, and in the absence of tomy and fusion with anterior plating has been reported
significant deformity or instability, most fractures can be to be successful, although associated with kyphotic de-
treated with external immobilization for 6 to 12 weeks. formity in some instances. For this reason, patients with
Burst fractures are characterized by compressive persistent kyphosis following closed reduction who have
failure of the vertebral body with fracture extension anterior compression from disk material may require
through the posterior body cortex and some degree of anterior decompression and grafting with a concomitant
bone retropulsion into the spinal canal. Burst fractures posterior stabilization.
have a significantly higher rate of instability when com- Failure of closed reduction mandates open reduction
pared with compression fractures and are frequently as- and instrumented cervical fusion. A preoperative MRI
sociated with spinal cord injury. A burst fracture in the scan is required to rule out the presence of a herniated
presence of either complete or incomplete spinal cord disk, which, if present, indicates the need for anterior
injury will typically require surgical decompression and diskectomy and fusion. A unilateral facet dislocation
stabilization. In most patients with burst fractures, surgi- can often be reduced anteriorly using vertebral body
cal decompression can be best achieved through an an- Caspar pins. This technique involves maintaining dis-
terior approach with corpectomy of the involved lev- traction across these pins followed by rotation of the
el(s). Interbody fusion with anterior plate fixation may proximal pin toward the side of the dislocated facet
be insufficient to stabilize these fractures in the setting joint. Alternatively, for unilateral or bilateral disloca-
Figure 11 Lateral (A) and AP (B) radiographs showing C1-2 transarticular screw fixation.
Figure 12 Illustrations of types of traumatic spondylolisthesis of the axis using the Levine and Edwards modification of the Effendi classification system. A, Type I. B, Type II.
C, Type IIA. D, Type III. (Reproduced with permission from Klein GR, Vaccaro AR: Cervical spine trauma: Upper and lower, in Vaccaro AR, Betz RR, Zeidman SM (eds): Principles
and Practice of Spine Surgery. Philadelphia, PA, Mosby, 2003, pp 441-462.)
tions associated with a significant disk herniation, an cant kyphosis or subluxations can be considered for
anti-kickout plate can be used to avoid the need for a nonsurgical treatment with 6 to 12 weeks of external im-
second anterior stage of the surgery. Following anterior mobilization in a halo vest or cervical orthosis. Kyphotic
diskectomy and placement of an interbody graft, the deformity, significant subluxations, or radiculopathy
plate is fixed only to the superior body. Open reduction should be considered for open reduction and posterior
can then be performed posteriorly with the plate main- instrumented stabilization. Bilateral facet fractures and
taining position of the graft. lateral mass dissociations are typically unstable injuries
Unilateral facet fractures are the most frequently and may be treated with anterior or posterior instru-
missed significant cervical spine injuries on plain radio- mented fusion.
graphs. These injuries may reduce in the supine position
during initial trauma evaluation. Subtle subluxations or Thoracic Spine Trauma
rotational malalignment visualized on plain radiographs Thoracic spine fractures represent approximately 16%
should prompt further study with CT. The superior facet of fractures involving the thoracic and lumbar spine.
is more frequently fractured. Fractures without signifi- These injuries typically result from high-energy blunt
trauma, and patients must be evaluated thoroughly for vertebral bodies are typically 1 to 2 mm smaller in
other injuries. Although they represent only a small per- height anteriorly, resulting in the kyphosis seen in the
centage of thoracolumbar fractures, the narrow thoracic thoracic spine. The kyphotic alignment of the thoracic
spinal canal and the precarious blood supply to the tho- spine results in the concentration of axial load transmis-
racic spinal cord make these injuries potentially devas- sion in the anterior column. The apex of the kyphosis is
tating. normally over T6 through T8, where maximal anterior
Fractures of the thoracic spine from T2 through T10 column forces are generated and fractures within the rib
are relatively infrequent as a result of unique anatomic cage are most likely to occur.
features of the thoracic spine that provide enhanced sta-
bility. Fractures of the thoracolumbar spine from T11 Diagnostic Imaging
through L2 will be discussed separately because the
Plain films of the thoracic spine should provide an ini-
transition from the rigid thoracic spine to the more flex-
tial assessment of any fracture as well as its impact on
ible lumbar spine creates a transition zone that is sus-
overall sagittal alignment. It is of paramount importance
ceptible to injury.
to evaluate the entire spine once a fracture is identified
because concomitant spinal fractures can be present in
Biomechanics
up to 20% of patients. CT scans should be obtained in
The thoracic spine has several unique anatomic features
patients with fractures on plain films, in any multiple
that provide it with more stability than either the cervi-
trauma patient with lower extremity neurologic deficits,
cal or lumbar spine. Each thoracic vertebra has articula-
and for any patients with inadequate plain films. The ax-
tions with and ligamentous attachments to the adjacent
ribs at both the transverse process and the vertebral ial images will help evaluate the vertebral body fracture
body that increase rigidity. In addition, the ribs articu- anatomy, pedicle anatomy, and presence of bony retro-
late with the sternum, which provides another point of pulsion. Coronal and sagittal reconstructions may reveal
fixation and thereby limits thoracic motion. The facets fractures missed in the axial plane, and they provide a
of the thoracic spine are oriented in the coronal plane, better appreciation of the fracture anatomy. MRI can be
with the lamina and spinous processes arranged in a useful in evaluating the soft tissues of the spine. The an-
shingled fashion, which reduces the amount of extension terior and posterior ligamentous complexes can be eval-
of the thoracic spine. The intervertebral disks of the tho- uated for injury as well as spinal cord encroachment by
racic spine are very thin, which provides increased stiff- either disk or osseous material. In addition, the spinal
ness and more rotational stability. The vertebral bodies cord can be evaluated for the presence of edema or
are asymmetric in height from anterior to posterior. The hemorrhage.
Classification systems for spinal fractures have been decompression and stabilization of these injuries has yet
difficult to standardize because of the complex loads to be demonstrated in the scientific literature. Patients
that are applied to result in these injuries. A compre- who have a complete neurologic injury are typically sta-
hensive classification system has been proposed for tho- bilized posteriorly in a nonemergent fashion to facilitate
racic and lumbar fractures based on their radiographic earlier rehabilitation.
morphology. Three basic forcescompression, distrac-
tion, and rotationwere found to be responsible for the Flexion-Distraction Injuries
injuries and are labeled A, B, and C, respectively. In ad- Flexion-distraction injuries result from a flexion mo-
dition, each group is subdivided into three subgroups. ment that is combined with a fulcrum located at varying
The severity of the injury increases from group A to distances from the anterior portion of the vertebral col-
group C. Because describing every variant in this system umn. The resulting injury can involve bone, ligament, or
is beyond the scope of this text, only the classic exam- a combination of bone and ligament. When the fulcrum
ples from each group will be discussed. is located adjacent to the vertebral body, the anterior
column will fail in compression and the middle and pos-
Compression Fractures terior columns will fail in tension. As the fulcrum moves
In its purest form, a compression fracture results from more anterior, the deforming forces become purely dis-
an axial load applied to the spine. The anterior column tractive and all three columns will fail in tension. Pa-
of the spine (vertebral body and disk) is involved with- tients with pure ligamentous and combined bony and
out involvement of the middle column (posterior verte- ligamentous injuries should undergo a posterior stabili-
bral cortex and posterior longitudinal ligament). Radio- zation procedure because of involvement of all three
graphs will demonstrate a wedge-shaped defect in the columns and the poor healing properties of ligaments.
vertebral body that results in varying degrees of kypho- Typically, these injuries can be treated with short-
sis. Neurologically intact patients with less than 30 of segment posterior compression constructs. Patients with
kyphosis and less than 50% loss of vertebral body a purely bony injury can undergo reduction in extension
height can be treated with a hyperextension orthosis. and can be treated in a thoracolumbosacral orthosis be-
Patients with more than 30 of kyphosis or more than cause of the healing properties of bone. They should be
50% loss of vertebral body height can also be treated assessed for nonunion and deformity progression.
nonsurgically, but must be watched carefully for possible
failure of the posterior ligamentous structures. These pa- Fracture-Dislocations
tients are more likely to develop a kyphotic deformity, Fracture-dislocations are common injuries in the tho-
and close radiographic and clinical follow-up is war- racic spine because of the significant forces acting on a
ranted. In patients with fractures above T6, a cervical rigid portion of the spine. Up to 90% of these injuries
extension on the thoracolumbosacral orthosis should be are associated with a spinal cord injury, most commonly
used for better control. complete (ASIA impairment scale category A). Because
all three spinal columns are involved, these fractures are
Burst Fractures very unstable. In patients with complete neurologic in-
Burst fractures also result from an axial load and are in- jury, a posterior stabilization procedure can be per-
herently unstable because of the involvement of the an- formed once their clinical condition is optimized. This
terior and middle columns of the spine. Radiographs will allow for early mobilization and help minimize the
will typically demonstrate a widening of the pedicles at morbidity and mortality associated with these injuries.
the affected vertebral body and a varying degree of
bony retropulsion into the canal. Treatment of these in- Thoracic Pedicle Screws
juries must be based on consideration of neurologic sta- The use of thoracic pedicle screws has become more
tus, sagittal alignment, and the integrity of the posterior widespread based on numerous reports of safe place-
ligamentous structures. Patients who are neurologically ment techniques and success in clinical practice. Pedicle
intact with less than 30 of kyphosis and less than 50% screws offer several advantages over traditional hook
loss of vertebral body height can be managed in a thora- and rod constructs. The pedicle is the strongest bony at-
columbosacral orthosis. Patients with more than 30 of tachment to the vertebra and provides excellent pur-
kyphosis and more than 50% loss of vertebral body chase, even in osteoporotic bone. Pedicle screws provide
height with failure of the posterior column should be fixation of all three spinal columns, which provides for
considered for a posterior stabilization procedure. better sagittal and coronal stability. This increased sta-
Patients with incomplete neurologic deficits and ra- bility can decrease the number of levels included in a
diographic evidence of spinal cord compression may fusion construct.
benefit from an acute anterior decompression and stabi- The thoracic pedicles are the narrowest in the T4-6
lization. However, the benefit of early versus delayed region and become progressively larger toward the lum-
bar spine. Preoperative planning with CT is critical in nation of fracture stability. A two-column model of the
evaluating the diameter of the pedicles to ensure they spine was proposed in which it was hypothesized that
can accommodate instrumentation. Pedicle screws can injuries with involvement of the posterior column are
be placed with the assistance of fluoroscopy or by using associated with instability. Denis proposed a three-
anatomic landmarks. One method that has been de- column concept that stressed the importance of the
scribed for screw placement between T3 and T10 uses newly defined middle column, which comprises the pos-
the intersection of a vertical line through the middle of terior 50% of the vertebral body and disk along with
the cephalad articular surface and a horizontal line at the posterior longitudinal ligament (Figure 15). Based
the superior border of the transverse process (Figure 14, on biomechanical data, Denis proposed that an isolated
A). At the T11 and T12 levels, the horizontal line should posterior ligamentous complex injury was not sufficient
be made from the middle of the transverse process (Fig- to produce instability and that concomitant involvement
ure 14, B). of the middle column resulted in instability in flexion.
The complications of thoracic pedicle screw place- However, the integrity of the posterior ligamentous
ment can be devastating. Injuries to the spinal cord,
complex (supraspinous and interspinous ligaments) is a
nerve roots, esophagus, and major blood vessels have all
crucial factor in determining stability because posterior
been reported. Thorough preoperative planning with ax-
column disruption in conjunction with involvement of
ial CT that documents the diameter and length of the
the anterior and middle columns creates instability and
pedicle as well as the angle of insertion and intraopera-
increases the risk of posttraumatic kyphosis.
tive neurophysiologic monitoring are important for
avoiding complications.
Treatment
The treatment of most patients with thoracolumbar
Thoracolumbar Junction Trauma
fractures is nonsurgical. Patients who are neurologically
Biomechanics
intact with less than 25 kyphosis, less than 50% loss of
Injuries to the thoracolumbar junction (T11 through L2)
vertebral body height, and less than 50% of canal occlu-
are usually the result of significant blunt trauma. These
sion and an intact posterior longitudinal ligament are
injuries represent approximately 50% of all thoracic and
the best candidates for nonsurgical treatment. Depend-
lumbar fractures. This increased incidence of fractures
ing on the severity of the collapse, these patients may be
to the thoracolumbar junction is the result of its loca-
tion at the transition point between the rigid thoracic managed with hyperextension body casting and/or a
rib cage and the more mobile lumbar spine. In addition, thoracolumbosacral orthosis for 3 months. Regular clini-
the sagittal alignment of the spine changes from kypho- cal and radiographic follow-up of these patients is im-
sis to lordosis, which more evenly distributes stress on portant to rule out the development of progressive ky-
the anterior and middle columns. The facet alignment phosis or neurologic deficits.
changes from a coronal orientation in the thoracic spine Surgical treatment should be reserved for patients
to a sagittal alignment in the lumbar spine, allowing for with unstable fracture patterns and/or neurologic defi-
greater flexion and extension motion. Also, the interver- cits. For patients with incomplete neurologic injuries
tebral disks are taller than in the thoracic spine, decreas- and spinal cord compression, anterior decompression
ing anterior column stiffness. and stabilization is typically required. The anterior pro-
The indications for surgical management of thora- cedure may need to be performed in conjunction with a
columbar fractures remain controversial. Central to de- posterior stabilization procedure in patients with poste-
fining the need for surgical management is the determi- rior column involvement. Early stabilization of patients
with neurologic injuries will allow for early mobilization Lower Lumbar Spine Trauma
and rehabilitation placement. Biomechanics
Patients with unstable burst fractures that include Fractures of the lower lumbar spine (L3-L5) are less
failure of the posterior column should undergo an initial common than in the thoracolumbar region. The lower
posterior stabilization procedure. Posterior instrumenta- lumbar spine is the lordotic alignment in the sagittal
tion on a lordosing frame can help restore the normal plane, which results in a weight-bearing axis that falls
sagittal alignment of the thoracolumbar spine and will through the middle and posterior columns, making this
assist in the reduction via ligamentotaxis of the retro- anatomic region more intrinsically stable. Such fractures
pulsed fragment. However, patients with excessively are unlikely to progress into a kyphotic deformity. In
comminuted vertebral body fractures may be candidates addition, the facets of the lumbar spine are oriented in
for a staged anterior procedure. the sagittal plane, which can accommodate greater
Recently, prospective studies have compared pa- flexion-extension bending moments. Finally, the lum-
tients with stable burst fractures of the thoracolumbar bosacral junction can withstand large forces transmitted
junction treated surgically and nonsurgically with regard across it.
to pain, spinal canal compromise, and residual kyphosis. Because the load-bearing axis is more posterior,
In patients with mild to moderate initial kyphosis, much compression fractures are much less common than burst
of the sagittal correction gained surgically is lost over fractures in the lower lumbar spine. For the anterior col-
time, approaching the final segmental kyphosis seen for umn to fail, a significant flexion moment must be ap-
these fractures in the nonsurgical treatment group. In plied. However, these large flexion moments are typi-
addition, residual kyphosis has not been a reliable pre- cally neutralized by the increased ability of the lumbar
dictor of chronic pain. Similarly, the degree of spinal ca- spine to accommodate loads in the sagittal plane. If a
nal encroachment has also not been associated with in- compression fracture is detected, suspicion should be
high for a concomitant posterior ligamentous injury, es-
jury to neural structures over the long term. Canal
pecially in the setting of more than 50% loss of verte-
remodeling is to be expected, and up to 50% of the ca-
bral body height.
nal can be restored. The degree of remodeling has been
Burst fractures are the most common fracture pat-
reported to be similar in groups of patients treated sur-
tern seen in the lower lumbar spine. Most of these inju-
gically or nonsurgically. ries occur with the spine in a neutral position, resulting
in axial loading of both anterior and middle columns of
the spine. As with burst fractures in other parts of the
spine, a variable amount of bone may be retropulsed
Figure 16 A, An axial CT scan demonstrates the narrowest portion along the sacral pedicle. B, Sagittal view of the narrowest portion of the sacral ala with height and width
dimensions. C, Drawing demonstrating the adjacent bony structures and the L5 and S1 nerve roots. (Reproduced with permission from Noojin FK, Malkani AL, Haikal L, Lundquist
C: Cross-sectional geometry of the sacral ala for safe insertion of iliosacral lag screws: A computed tomography model. J Orthop Trauma 2000;14:31-35.)
into the spinal canal. However, the incidence of signifi- The length of the fusion in the lower lumbar spine
cant and/or permanent neurologic sequelae from these typically involves the fractured level and the cephalad
injuries is much lower than elsewhere in the spinal col- and caudad levels. If the fracture involves the L5 level,
umn; the spinal cord ends above this level, and the fusion to the sacrum will be necessary, and attention to
nerve roots of the cauda equina are more tolerant of the maintenance of the normal lordotic sagittal align-
compression than the spinal cord. ment is important. Isolated injuries of the posterior liga-
Flexion-distraction injuries account for less than mentous complex may be addressed with a single-level
10% of lumbar spine fractures. They are most com- compression construct using screws or hooks. Patients
monly seen at L2, L3, or L4 and are typically the result with these injuries may also require a course of postop-
of the increased stability imparted at the level of L5 to erative immobilization in a thoracolumbosacral orthosis,
the pelvis via the iliolumbar ligaments. The large flexion which possibly includes leg extension.
moments cause flexion of the upper lumbar segments,
whereas the lower segments are stabilized. As a result, Sacral Spine Trauma
the posterior elements fail in tension from the distrac- Biomechanics
tive forces. Sacral fractures are usually the result of high-energy
trauma and occur in isolation in fewer than 5% of pa-
Treatment tients. As a result, a thorough evaluation of the pelvis
Most patients with lower lumbar fractures can be and spine should be undertaken for associated fractures.
treated conservatively with external immobilization, a Sacral fractures are generally classified according to the
short course of bed rest, and a custom-molded thora- direction of the fracture line. Fractures may be vertical,
columbosacral orthosis. A single leg spica attachment transverse, or oblique, although vertical fractures are the
most common. Denis classification system divides the
may be necessary for fractures of L4 and L5 to allow for
sacrum into three zones. Zone 1 spans the sacral ala to
control of the pelvis and immobilization of the lum-
the lateral border of the neural foramen. Zone 2 repre-
bosacral junction. Patients should wear a brace for ap-
sents the neural foramen. Zone 3 involves the central
proximately 8 to 12 weeks and undergo regular clinical
sacrum and canal.
and radiographic follow-up.
Sacral injuries commonly are associated with sacral
Patients who have a cauda equina syndrome or sig- root deficits. Because of the relative kyphosis of the
nificant neurologic deficit with canal compromise sacrum, the sacral nerve roots are tethered and re-
should be considered for surgical treatment. Such pa- stricted within long bony tunnels and therefore not
tients will typically have near-complete canal occlusion much motion is allowed. These two anatomic factors
from bony fragments and should undergo decompres- predispose the neural structures to injury. In addition,
sion and a posterior stabilizing procedure using pedicle the direction of the fracture line and type of fracture de-
screws. The decompression can usually be performed termine the likelihood of a neurologic injury. Neurologic
posteriorly via a laminectomy. If a posterior decompres- injuries of the lower sacral roots (S2-S4) are often
sion is going to be performed in a patient with a neuro- missed because only L5 and S1 can be evaluated by
logic deficit, evaluation for the presence of a laminar manual muscle testing. Perianal sensory changes should
fracture should be sought. Case reports have described be sought in patients with this type of injury. In the
herniated nerve root entrapment within the laminar Denis classification system, zone 1 vertical injuries have
fracture site. a 5.9% incidence of neural injury. If there is a neural in-
jury, it is usually an injury to the L5 nerve root or the restoring and maintaining sagittal alignment and minimizing
sciatic nerve. Zone 2 fractures have an incidence of the rate of treatment failures.
28.4% of neural injury. The nerve injuries are commonly
unilateral in nature. This is important because patients Guidelines for management of acute cervical spinal in-
with unilateral sacral root injuries usually have normal juries. Neurosurgery 2002;50(suppl 3):S1-S179.
bowel and bladder function. Zone 3 injuries have a 50% Under the sponsorship of the American Association of
incidence of neurologic injuries, and most of these pa- Neurologic Surgeons and the Congress of Neurologic Sur-
tients will have bilateral sacral root involvement with geons, a computerized English-language literature search was
bowel, bladder, and sexual dysfunction. performed covering the preceding 25 years. Studies involving
cervical spinal trauma were reviewed and critically evaluated.
Treatment Results were organized and presented in several topical sec-
tions designed to provide reasonable standards, guidelines, and
Indications for surgical management of sacral fractures
options for care of patients with acute cervical spinal injuries.
include bowel and bladder dysfunction in the setting of
an unstable fracture with substantial coronal or sagittal
deformity. Vertical fractures can typically be treated Peris MD, Donaldson WF, Towers J, Blanc R, Muzzoni-
with posterior sacroiliac plating or percutaneously gro TS: Helmet and shoulder pad removal in suspected
placed sacroiliac screws. Placement of percutaneous sac- cervical spine injury. Spine 2002;27:995-999.
This fluoroscopic study supports the efficacy of the current
roiliac screws can be technically demanding, and the L5
protocol used by the National Athletic Trainers Association
and S1 nerve roots are at risk during the procedure
that uses four individuals for the safe removal of the helmet
(Figure 16). If this technique is used to treat a zone 2 in-
and shoulder pads from an injured football player with mini-
jury, the screw should not be loaded in compression to mal cervical motion.
avoid neural injury. Patients who have displaced trans-
verse or oblique fractures may undergo bilateral plating.
Neural decompression via laminectomy may be indi- Vaccaro AR, Madigan L, Bauerle WB, Blescia BS, Cot-
cated in patients with neurologic deficits and canal com- ler JM: Early halo immobilization of displaced trau-
matic spondylolisthesis of the axis. Spine 2002;27:2229-
promise, and recovery of bowel and bladder function
2233.
may be seen. In patients without neurologic injury who
This retrospective study of 31 patients with traumatic
have minimally displaced fractures, bracing is only nec- spondylolisthesis of the axis confirms that early halo immobili-
essary in the setting of fractures, which extend to or zation after traction reduction is a safe and effective form of
above the level of the sacroiliac joint. treatment in this patient population. Patients with type II frac-
tures angled greater than or equal to 12 may require more
Annotated Bibliography extended periods of traction.
Cervical Spine Trauma
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This study identifies a new patient recovery position, the This prospective study evaluated 17 patients with flexion-
modified HAINES position, in which the patient is in the lat- distraction injuries of the thoracic and lumbar spine. The pa-
eral position with the head lying on the fully abducted depen- tients had an average follow-up of 17.6 months and were
dent arm and both legs are drawn up, with hips and knees treated with single-level posterior fixation. The average preop-
flexed. This position results in a more neutral position of the erative kyphosis was 10.1, which was corrected to a postoper-
spine compared with the traditional lateral recovery position ative lordosis of 0.9. The mean Oswestry score was 11.5 and
and may be preferable to the lateral recovery position during 88% of the patients reported having only minimal disabilities.
resuscitation of trauma patients.
Wood K, Butterman G, Mehbod A, Garvey T, Jhanjee
Fisher CG, Dvorak MFS, Leith J, Wing PC: Comparison R, Sechriest V: Operative compared with nonoperative
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flexion teardrop fractures indicates that anterior cervical plat- tive patients with a thoracolumbar fracture without neurologic
ing is a safe and effective treatment of this patient population deficit for a minimum 2-year follow-up. The group of patients
and may be superior to halo vest immobilization in terms of that underwent surgical treatment had a mean preoperative
and postoperative kyphosis of 10.1 and 13, respectively. The patients and review of the literature. J Bone Joint Surg
group of patients that underwent nonsurgical treatment had a Am 1979;61:1119-1142.
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Yue J, Sossan A, Selgrath C, et al: The treatment of un-
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This study evaluated 32 patients in a 3-year consecutive
prospective experience of using pedicle screw fixation to treat Hoffman JR, Mower WR, Wolfson AB, Todd KH,
unstable thoracic spine injuries. Fracture healing was noted to Zucker MI: Validity of a set of clinical criteria to rule
take place at an average of 4.8 months. Two-hundred fifty-two out injury to the cervical spine in patients with blunt
pedicle screws were placed without any intraoperative compli- trauma: National Emergency X-Radiography Utilization
cations. The Gardner segmental kyphotic deformity angle pre- Study Group. N Engl J Med 2000;343:94-99.
operative mean was 15.9 and the mean postoperative angle
was 10.6 (which was significant). All neurologically intact pa- Levine AM, Edwards CC: The management of trau-
tients reported very good to good results with regard to pain, matic spondylolisthesis of the axis. J Bone Joint Surg
activity, function, employment, and satisfaction. Am 1985;67:217-226.
Figure 1 Upper extremity motor testing for the cervical spine. Note there is dual innervation of some of these muscles.
Imaging Studies
Plain radiographs are appropriate in the evaluation of
neck pain, cervical radiculopathy, and cervical myelogra-
phy. Such series include AP and lateral films to assess
overall spinal alignment and level of spondylosis, as well
as to rule out other structural lesions and deformity.
Flexion and extension radiographs can be used to as-
sess angular or translational instability and demonstrate
whether a patient can achieve normal lordosis. Oblique
radiographs better visualize the neural foramen and fac-
ets and can facilitate visualization of the cervicothoracic
junction. A swimmers view allows for visualization of
the cervicothoracic junction, if not otherwise possible,
by limiting the obstructions imposed by the shoulders.
Other views such as the open mouth odontoid radio-
graph are generally not needed for degenerative condi-
Figure 3 The C7 nerve root exits the thecal sac above the C7 pedicle and is most
tions. likely to be affected by pathology at the C6-7 interspace.
Plain radiographs are often all that is needed to ini-
tiate conservative treatment. However, if concerns are
raised, or if a patients symptoms persist beyond appro- though much of this information can be obtained with
priate conservative treatments, advanced imaging may noninvasive MRI, myelography is particularly useful for
be indicated. MRI is the axial imaging modality of patients who cannot have an MRI secondary to im-
choice for the cervical spine, allowing visualization of planted devices such as pacemakers. In other patients,
the soft tissues including disks, spinal cord, nerve roots, myelography can be useful if the results of MRI are in-
and ligaments. Sagittal imaging provides a good over- conclusive, such as with dynamic compression of the
view of the levels of cord compression and central disk neural elements that cannot be demonstrated with static
pathology. However, sagittal imaging can give the false imaging. Flexion-extension radiographs following my-
impression of cervical kyphosis if the head of the pa-
elography can reveal this dynamic compression.
tient if flexed during the imaging study. Parasagittal im-
Diskography has been used to evaluate cervical disk
aging can provide information about lateral disk hernia-
degeneration. The procedure is performed via an ante-
tions and foraminal narrowing. Axial imaging refines
rior approach in a trajectory similar to that used for the
information about cord or root compression and allows
standard anterior cervical approach. Once needles are
for visualization of other surrounding structures such as
in place in the intervertebral disks, fluid can be injected
the vertebral artery or muscles.
and the distribution and pain provocation can be stud-
CT can be used to define the bony anatomy of the
cervical spine. However, as the relationship to the neu- ied. However, the validity and usefulness of this proce-
ral elements must be inferred, the use of CT is best dure is controversial. The risks of this procedure include
combined with an intrathecal injection of a contrast me- esophageal puncture and potential mediastinal or disk
dium for imaging of degenerative conditions (myelogra- space infection.
phy). The contrast medium is injected into the thecal sac
via a C1-C2 puncture and allowed to diffuse caudally, or Electrodiagnostic Studies
via a lumbar puncture and allowed to diffuse proximally In most patients, the history and clinical examination
with the patient in the Trendelenburg position. This al- can reliably identify the presence and level of nerve
lows precise visualization of the neural elements, with root or spinal cord pathology. Combined with radiogra-
filling voids present at sites of neural compression. Al- phy and advanced imaging modalities, accuracy rates
Figure 4 Preoperative sagittal MRI (A) and postoperative lateral radiograph (B) of a patient with persistent C6 radicular symptoms who underwent anterior cervical diskectomy
and fusion with autograft and instrumentation.
are even higher. In some patients, however, the radia- experienced by the spine. Traction may be useful for
tion of arm pain or symptoms such as paresthesias can- radicular symptoms and should generally be done with
not be localized to a specific spinal level. In other pa- some degree of flexion to open the neural foramen. Al-
tients, clinical examination may not correlate with though modalities often are useful at the time of appli-
imaging studies or root symptoms may not be ade- cation, they are not believed to provide lasting relief.
quately differentiated from more distal nerve compres- These therapeutic interventions may break the cycle
sion. In these patients, electromyogram and/or nerve of irritation and splinting, allowing the reestablishment
conduction velocity studies may be useful to differenti- of painless range of motion. Therapy should then focus
ate acute or chronic radiculopathy from more distal on neuromuscular control and active range-of-motion
compressive neuropathies such as carpal tunnel syn- and stabilization exercises. Finally, general aerobic con-
drome or cubital tunnel compression, which may mimic ditioning should be added.
Medical management generally consists of nonste-
cervical root compression.
roidal anti-inflammatory drugs. These drugs can help
control the inflammatory factors that are often responsi-
Nonsurgical Care ble for acute symptoms. Oral steroids can be considered
Management of neck pain and cervical radiculopathy for significant exacerbations of symptoms, but potential
should start with conservative, nonsurgical measures, in- adverse effects must be considered. The role of narcotics
cluding physical therapy, traction, activity modification, in such degenerative processes is limited. Narcotics
and certain medications. should be reserved for acute injuries or exacerbations,
With physical therapy, extremes of motion are gener- and they should only be used for a limited period. Nar-
ally not an important objective. Rather, physical therapy cotics should clearly be avoided for chronic pain.
should emphasize isometric exercises to build tone and Selective nerve root blocks and epidural steroid in-
control for debilitated muscles and limit the shear forces jections can be beneficial both diagnostically and thera-
Surgical Indications
Axial neck pain from degenerative disk disease is rarely
an indication for surgical intervention. In patients who
have been resistant to conservative measures, success
rates of surgical fusion for axial neck pain have gener-
ally only been in the 60% to 70% range. This may be re-
lated to an incomplete understanding of the associated
pain generators and potential painful foci at other cervi-
cal levels, posterior facets, or nonspinal sources.
In recent years, clinical trials of cervical disk replace-
ments have begun in the United States. Goals of this Figure 5 When a patient has cord compression behind the vertebral bodies as well
technology are to allow decompression or removal of a as at the disk spaces, corpectomy should be considered as shown in this radiograph,
with a C4 and C5 corpectomy, allograft strut graft, and anterior instrumentation.
degenerative disk while preserving motion. However,
the role and long-term outcome of such implants have
not yet been defined. incisions may be necessary for longer exposures. The
In contrast to axial neck pain, radiculopathy re- level of incision can be guided by anatomic landmarks.
sponds well to a variety of surgical treatments. When an For example, the carotid tubercle, which can be palpated
appropriate course of nonsurgical management has percutaneously, is the lateral process of C6. The cricoid
failed, and radiculopathy persists, the surgeon can offer cartilage is approximately at the C6 level, and the thy-
greater than 90% success rates with surgical interven- roid cartilage at the C4-C5 level. The anterior approach
tion. Clinically significant myelopathy is generally be- is carried down medial to the sternocleidomastoid and
lieved to be an indication for surgical intervention. carotid sheath and lateral to the trachea and esophagus.
This provides exposure to the anterior aspect of the cer-
Surgical Treatment Options for Radiculopathy vical spine. The longus coli are then elevated to allow
and Myelopathy access to the entire disk space.
The type of surgical procedure advocated for cervical Once a diskectomy is carried back to the posterior
arthrosis is dictated by the location and extent of the disk space, the posterior osteophytes can be taken down
pathology. There are also situations in which similar pa- with or without the associated posterior longitudinal lig-
thology can be addressed in several ways, with roughly ament. This scenario may be associated with more im-
similar results. mediate and complete relief of symptoms, more com-
Anterior decompression can be performed, as ini- plete foraminal decompression, and better identification
tially described in the classic study by Smith and Robin- of extruded disk fragments. Some authors have found
son. When there is a central disk herniation, significant that taking down the posterior osteophytes and poste-
uncovertebral spurring, or central canal stenosis, ante- rior longitudinal ligament is not always necessary and
rior decompression is the most direct means of decom- that disk height restoration and fusion (with its associ-
pressing the neural elements. Transverse incisions are ated elimination of motion) may be adequate and asso-
made for one, two, or arguably three levels, and oblique ciated with lesser bleeding and surgical times.
Figure 6 Preoperative sagittal MRI (A) and postoperative lateral (B) and AP (C) radiographs of a patient with multilevel cervical stenosis and myelopathy who was treated with
posterior decompression and fusion.
Once the diskectomy and decompression have been the vertebral bodies can be addressed. It also offers
achieved, interbody fusion is performed by decorticating fewer surfaces to fuse compared with multiple interbody
the end plates and inserting a bone graft. This has tradi- grafts, potentially increasing fusion rates (Figure 5).
tionally been iliac crest autograft. However, according Bone graft can be autograft, structural allograft (poten-
to a recent study, allograft has been shown to afford al- tially filled with local corpectomy bone), or synthetic
most identical fusion rates for single-level procedures cages. As constructs grow in length to corpectomies of
without the donor site morbidity associated with au- two or more vertebral bodies, consideration should be
tograft. This phenomenon does not appear to be as true given to supplementation with posterior stabilization.
for multilevel procedures or in the presence of factors However, it is generally believed that lordosis can be re-
that inhibit fusion such as smoking. Diskectomy without stored and maintained better with multiple interbody
fusion has largely been abandoned because of its associ- grafts.
ation with kyphotic collapse, neck pain, and potential Alternatively, if there is purely foraminal stenosis
for recurrent foraminal narrowing. and radiculopathy from a soft disk or hypertrophied
Plate fixation can be added to potentially increase facet or uncovertebral joint, posterior laminoforaminot-
the rate of union, limit kyphotic collapse, and minimize omy may be considered. This procedure allows decom-
the need for external cervical orthoses (Figure 4). Many pression without fusion, and destabilization is avoided
types of plates exist. All current plate systems lock the as long as the surgeon avoids total facetectomy unilater-
screw to the plate to prevent screw backout. Some sys- ally or partial facetectomy bilaterally. Because the disk,
tems allow for variable angle screw insertions to facili- which is often thought to be the pain generator for axial
tate implantation. Others systems allow for settling of pain, is not directly addressed, posterior laminaforami-
the screws within the plate (dynamic plates) to allow the notomy is not a good treatment option if axial pain is a
graft to be better loaded. Although plates are now rou- large component of a patients symptoms. This approach
tinely used by many surgeons, the justification for this is avoids the dangers of anterior dissection, such as recur-
uncertain given the high fusion rate in single-level non- rent laryngeal nerve palsy, and preserves the motion
instrumented fusions. The potential benefits of plating segment. However, central pathology cannot be ad-
must be contrasted with the expense and the potential, dressed because the spinal cord cannot be retracted to
but limited, risks of implantation. allow access to the region. Furthermore, disadvantages
With larger procedures such as multilevel diskec- lie in the muscle dissection and facet capsule disruption
tomy, corpectomy, or partial corpectomy, recent studies inherent in the procedure.
have indicated that strut grafting is a good surgical alter- Myelopathy can be treated from posterior as well as
native. With this technique, central compression behind anterior approaches. The choice of approach depends on
factors including the site of compression (anterior spurs/ screws at C3-C6 and pedicle screws at C2, C7, and below.
ossification of the posterior longitudinal ligament versus The disadvantages of this technique include the morbid-
posterior ligamentum flavum hypertrophy/redundancy), ity of muscle dissection from a posterior cervical approach
overall spinal alignment, and number of levels involved. and the associated loss of motion.
The anterior approach allows removal of anterior cord As an alternative to fusion, laminaplasty was devel-
compression, but this must often involve removal of the oped in Japan for the treatment of cervical myelopathy as-
vertebral body if compression is in this region. sociated with ossification of the posterior longitudinal lig-
Posterior decompression in the form of laminectomy ament. Laminaplasty involves hinging open the lamina at
has previously been the standard procedure, but was as- multiple levels, affecting decompression. Such openings
sociated with postlaminectomy kyphosis in a large per- can be held with sutures, instrumentation, and/or struc-
centage of patients. Posterior cervical fusion is thus now tural bone grafts. The goal of the procedure is to decom-
generally performed with a laminectomy to restore and press without adding the complications inherent to fusion.
maintain cervical lordosis and allow the spinal cord to Outcome studies support these goals, but potential ad-
float away from any anterior compressive pathology (Fig- verse effects include increased axial neck pain and loss of
ure 6). Posterior fixation can be achieved with lateral mass motion (Figure 7).
Fusion procedures may be associated with acceler- disk spaces even if there is not compression behind the verte-
ated degenerative changes adjacent to the fused seg- bral body.
ments. This phenomenon may be alleviated with lamina-
plasty as opposed to decompression and fusion. In Malloy KM, Hilibrand AS: Autograft versus allograft in
addition, disk arthroplasty may help limit the incidence degenerative cervical disease. Clin Orthop 2002;394:27-
of adjacent level disease in the cervical spine, but this 38.
has not yet been conclusively demonstrated. Although allograft is the gold standard bone grafting ma-
terial, high fusion rates have been observed when allograft is
Annotated Bibliography used, especially for single-level cases in nonsmokers. This of-
fers the potential of eliminating the morbidity associated with
Bryan VE: Cervical motion segment replacement. Eur the harvest of autograft.
Spine J 2002;11:S92-S97.
Cervical disk arthroplasty is being developed as an alter-
Patel CK, Fischgrund J: Complications of anterior cervi-
native to fusion procedures. The possibility of limiting adjacent
cal spine surgery. Instr Course Lect 2003;52:465-469.
level degeneration is one of the potential benefits.
This article presents a review of the potential complica-
tions associated with anterior cervical spine surgery for which
Edwards CC, Heller JG, Murakami H: Corpectomy ver- the incidence is relatively low.
sus laminoplasty for multilevel cervical myelopathy: An
independent matched-cohort analysis. Spine 2002;27:
1168-1175. Sampath P, Bendebba M, Davis JD, Ducker TB: Out-
In this study, corpectomy and laminaplasty were found to come of patients treated for cervical myelopathy: A pro-
arrest myelopathic progression and offer the potential for neu- spective, multicenter study with independent clinical re-
rologic recovery. However, this study suggested that the lami- view. Spine 2000;25:670-676.
naplasty group had less pain at follow-up than the multilevel Authors of this multicenter study of patients with cervical
corpectomy group. myelopathy concluded that patients treated with surgery ap-
pear to do better than those treated nonsurgically.
Fouyas IP, Statham PFX, Sandercock PA: Cochrane re-
view of the role of surgery in cervical spondylotic radic- Classic Bibliography
ulomyelopathy. Spine 2002;27:736-747. Bohlman HH, Emery SE, Goodfellow DB, Jones PK:
In this critical review of the literature, it was difficult to
Robinson anterior cervical discectomy and arthrodesis
draw reliable conclusions about the risk/benefit balance for
for cervical radiculopathy. J Bone Joint Surg Am 1993;
cervical spine surgery for spondylotic radiculopathy or my-
75:1298-1307.
elopathy.
Herkowitz HN: A comparison of anterior cervical fu-
Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohl- sion, cervical laminectomy, and cervical laminoplasty for
man HH: Increased rate of arthrodesis with strut graft- the surgical management of multiple level spondylotic
ing after multilevel anterior cervical decompression. radiculoparhy. Spine 1988;13:774-780.
Spine 2002;27:146-151.
A higher rate of fusion was seen after corpectomy and Smith GW, Robinson RA: The treatment of certain
strut grafting than after multilevel diskectomy and interbody cervical-spine disorders by anterior removal of the inter-
grafting. This therefore suggests that strut grafting should be vertebral disc and interbody fusion. J Bone Joint Surg
considered in patients requiring surgical attention at multiple Am 1958;40:607-624.
Introduction
Symptomatic thoracic disk disease is relatively uncom-
mon compared with disk disease in the cervical and
lumbar regions, with an estimated incidence of between
1 in 10,000 and 1 in 1 million persons. The occurrence of
symptomatic thoracic disk herniation is greatest be-
tween the fourth and sixth decade of life, with a peak in-
cidence in the fifth decade. Diagnosis can be difficult
because of a variety of clinical presentations. Wide-
spread availability and use of MRI has aided in the di-
agnosis of symptomatic thoracic disk herniations (Fig-
ure 1). However, one MRI study documented thoracic
degenerative changes in 73% of asymptomatic individu-
als, with 37% showing a disk herniation.
racic back pain and myelopathy is extensive. The differ- and highly sensitive. However, as mentioned previously,
ential diagnosis includes thoracic herniated nucleus pul- the findings should be interpreted in the context of clin-
posus, thoracic degenerative disk disease, cervical and ical findings because of the high percentage of abnormal
lumbar herniated nucleus pulposus, intercostal neural- MRI findings in asymptomatic individuals. A CT myelo-
gia, multiple sclerosis, amyotrophic lateral sclerosis, gram is also highly sensitive, but this modality is inva-
ankylosing spondylitis, fractures, metabolic bone disor- sive and should be reserved for patients who cannot un-
ders, tumors, infection, herpes zoster, and diseases of the dergo MRI. Diskography is controversial but can be
thoracic and lumbar viscera including aneurysm. A thor- considered in patients with axial pain, multilevel dis-
ough history and physical examination are the best tools ease, and no neurologic findings. At this time, no out-
for the expeditious diagnosis and treatment of patients come studies exist that demonstrate a correlation be-
with thoracic disk disease. tween diskography results and surgical outcomes.
Symptoms of thoracic disk herniations occur in one
of three distinct patternsaxial, radicular, or myelo- Nonsurgical Treatment
pathic. Axial pain usually presents in the mid- to lower To decide on the best treatment course for thoracic disk
thoracic regions, worsens with activity, and improves disease, its natural history must first be understood.
with rest. Radicular symptoms typically arise from a lat- Asymptomatic patients with abnormal MRI findings
eral disk herniation impinging on a nerve root and pro- were noted to remain asymptomatic at a follow-up of
ducing symptoms that follow the course of that nerve more than 26 months. Children with painful calcified
root. Most commonly, pain and paresthesias are re- thoracic disks improve spontaneously with resorption of
ported starting in the back and radiating anteriorly in a calcification; however, these children should be closely
band-like pattern in the distribution of the more caudal followed because a few instances of neurologic deficit
nerve root. Thoracic dermatomes can be roughly identi- requiring surgical intervention have been reported in
fied by the following landmarks: T4 at the nipple line, this population. In adults, the natural history of acute
T7 at the xiphoid process, T10 at the umbilicus, and T12 thoracic disk herniations without neurologic deficit is
at the inguinal crease. If any skin lesions are noted in a benign. Most patients can be treated with activity modi-
dermatomal pattern, herpes zoster may be the underly- fication, anti-inflammatory medications, exercise, and
ing cause. Although motor testing is difficult in this re- with bracing in rare occasions. Most patients are ex-
gion, the patient can do a partial sit-up to help identify pected to return to their normal activities, including vig-
an asymmetric contraction of the segmentally inner- orous sports and work. In patients with radicular symp-
vated rectus abdominis. toms, corticosteroid injections of intercostal nerves
Myelopathy may also be the presentation of a tho- should be considered when other modalities do not pro-
racic disk herniation when there is significant spinal vide adequate pain relief.
cord compression. The presentation can vary from sub-
tle sensory changes to obvious paraparesis and bowel Surgical Treatment
and bladder dysfunction. In addition to the motor and Indications for surgery include progressive neurologic
sensory examination, attention should focus on upper deficit, myelopathy, and pain refractory to conservative
motor neuron signs such as lower extremity hyperre- treatment. The herniated thoracic disk can be accessed
flexia, clonus, Babinski sign, wide-based gait, and super- using the posterior, posterolateral, lateral, or anterior
ficial abdominal reflexes. The Romberg sign can help approach (Figure 2).
detect subtle changes in proprioception. The results of Laminectomy and the transpedicular approach are
an upper extremity neurologic examination should be posterior approaches. The surgical approach of choice
normal in addition to the patient exhibiting a negative was once straight posterior laminectomy and disk exci-
Hoffmann sign. sion. However, because this approach was associated
with significant risk of neurologic deterioration, it has
Diagnostic Imaging been largely abandoned. The transpedicular approach
Plain radiographs should be obtained first. In addition was developed to allow less retraction of the spinal cord
to being used to assess overall alignment, the plain ra- by removing the pedicle and facet joint. Although this
diographs should be scrutinized for degenerative approach is well suited for the treatment of a lateral
changes, calcification in the disk space or in the canal, disk herniation, a central or paramedial disk herniation
fractures, and tumors. Intradiskal calcification is noted is difficult to excise using this approach because of poor
in 45% to 71% of patients with symptomatic thoracic visualization. Removal of the pedicle and facet joint
herniated disks compared with 10% of asymptomatic in- complex may lead to instability and postoperative pain.
dividuals. The posterolateral approach is also known as a costo-
MRI is the diagnostic modality of choice in further transversectomy. In this approach, the posteromedial por-
evaluation of these patients because it is noninvasive tion of the ipsilateral rib along with the transverse process,
Figure 2 Illustration of four surgical approaches to the thoracic disk pathology: transpedicular (A), extracavitary (B), costotransversectomy (C), and transthoracic (D). (Repro-
duced from Wood KB, Mehbad A: Thoracic disk herniation, in Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, pp
621-625.)
a portion of the pedicle, and the posterosuperior vertebral with the available exposure. Many authors have re-
body are removed. This allows gentle removal of the disk ported good visualization and excellent results with this
fragment without manipulating the cord. This approach technique. The drawbacks of this technique include the
can be used for multiple levels and allows resection of possibility of pneumothorax, pulmonary contusion,
paramedian as well as lateral disks. Visualization of cen- atelectasis, pneumonia, and the need for a postoperative
tral disks is poor with this approach, and it does involve a chest tube.
generous amount of bone resection and significant disrup- VATS was first reported in 1993 as a minimally inva-
tion of the paraspinal musculature. sive procedure that can minimize the morbidity of an
The lateral extracavitary approach, another extra- open thoracotomy and allow excellent visualization of
pleural approach, is a modification of the lateral thora- the anterior approach. One of the main disadvantages
cotomy approach that involves resection of the postero- of this technique is the steep learning curve to attain the
medial rib in addition to the transverse process, pedicle, high level of technical skills required for the procedure.
facet, and posterosuperior portion of the vertebral bod- Calcified protrusions can be adherent to or penetrate
ies. Midline access is less than optimal, and a large through the dura and can be difficult to treat via VATS.
amount of bone resection and disruption of paraspinal Two-year follow-up data are now available and suggest
musculature can lead to postoperative pain. that VATS is effective in a select group of patients.
The anterior approaches include thoracotomy and The role of fusion in thoracic disk surgery is contro-
video-assisted thoracoscopic surgery (VATS). Anterior versial. Relative indications for fusion include multilevel
approach via a thoracotomy was first reported in 1969 diskectomy, Scheuermanns disease, and bony resection
and since then has gained wide popularity. This ap- that removes a large portion of the vertebral body or
proach allows excellent visualization of midline and lat- the pedicle facet complex. The resected rib often pro-
eral pathology from T5 through T12. Multilevel access is vides sufficient autologous bone graft material without
also readily available. The base of the rib articulating the need for added morbidity from harvesting a graft. A
with the body and a portion of the pedicle are removed, small fibular allograft augmented with local autograft
followed by a partial diskectomy. Using a burr, a trough can also be used. Instrumentation is generally not used
is created into which disk material can be pulled for- because the rib cage provides a protective splinting ef-
ward to decompress the canal and remove the herniated fect. If deformity correction is desired in multilevel
fragment. Fusion can easily be added to the diskectomy cases, instrumentation should be considered.
Most patients with thoracic disk herniation and axial Dickman CA, Rosenthal D, Regan JJ: Reoperation for
pain alone can be treated successfully with nonsurgical herniated thoracic discs. J Neurosurg 1999;91(suppl 2):
treatment. In patients who do not respond well to non- 157-162.
surgical treatment, thoracic diskectomy and fusion can
be considered; however, the role of surgical intervention Fessler RG, Sturgill M: Review: complications of surgery
is controversial. for thoracic disc disease. Surg Neurol 1998;49:609-618.
tion at the site of constriction, nerve root fibrosis, and Clinical Features
wallerian degeneration of the motor root and posterior
Classically, patients have back, buttock, or posterior leg
spinal tracts contribute to subsequent neurologic mani- pain that gets worse with standing and walking. Leg
festations. The same general rules appear to apply to the symptoms may also be described as cramps, burning
human lumbar canal, with significant symptoms appear- pain, or weakness. Flexion of the trunk alleviates symp-
ing when the stenosis is greater than 75%. Claudication toms, and extension aggravates the symptoms. Leaning
symptoms from lumbar spinal stenosis occur in 90% of on a cart helps, primarily because of the flexed posture
patients who have a cross-sectional spinal canal area of the trunk in this position. Sleeping is comfortable in
less than 100 mm2. the fetal position. The limitations in activity and stooped
In animal studies, the rate of onset of compression forward posture are commonly attributed to age, and
plays a role in the pathophysiology of stenosis. Rapid many patients learn to work within their limitations. Au-
onset (0.05 to 0.10 s) compression causes more damage tonomic sphincter dysfunction manifests as recurrent
than insidious onset (20 s) pressure. The compressive le- urinary tract infection associated with an atonic bladder,
sion results in greater mechanical deformation at the incontinence, or retention, and occurs in up to 10% of
edge of nerve root, a phenomenon referred to as the patients with advanced degrees of stenosis.
edge effect. Histologic examination of edge segments Claudication manifests as diffuse buttock and/or leg
has revealed significant microvascular and neural tissue pain, nonspecific paresthesias, or radicular symptoms
that commence with walking for varying distances. Un- tectomy can result in iatrogenic instability and may re-
like vascular disease, the claudication distance with quire fusion.
symptomatic spinal stenosis may vary considerably and There are no guidelines on whether adjacent levels
is relieved by sitting and not by standing. Activities per- with lesser degrees of stenosis should be included in the
formed with the trunk flexed, such as cycling or walking decompression. The benefits of a greater decompression
uphill, are performed more easily. The exertion-induced of the neural elements need to be weighed against the
symptoms of spinal stenosis can be accurately repro- potential morbidity of a longer operation. In general, a
duced using a treadmill, providing a method for preop- level with mild stenosis may be excluded if radicular
erative and postoperative quantification of symptoms. symptoms corresponding to that level are absent. De-
The manifestations of central and lateral canal compressing too few levels may be a source of persis-
stenosis are not easily distinguished. Unilateral radicular tent symptoms postoperatively. Somatosensory-evoked
pain from foraminal stenosis is worsened by extension potential techniques may serve as a guide to the extent
to the painful side (Kemp sign). Paresthetic and dyses- of decompression in the future.
thetic symptoms may be an indicator of dorsal root gan- The anulus fibrosus is left intact when possible, re-
glion entrapment in the foramen. Unlike disk hernia- secting only free fragments or extruded segments of the
tions, radicular pain from stenosis is typically not disk that result in neural impingement. Diffuse bulging
aggravated by Valsalva maneuvers or accompanied by a of the disk is unlikely to result in continued neural com-
positive straight leg raising sign. pression in patients who have undergone a wide lami-
nectomy with bilateral partial facetectomy.
Management Based on the existing literature, a fusion should be
Nonsurgical therapy with anti-inflammatory agents, an- considered following decompressive laminectomy in (1)
algesics, activity modification, exercises, and soft braces patients who have stenosis with degenerative spondy-
may help patients with exacerbations of pain but seldom lolisthesis; (2) when radiographic criteria for instability
achieve sustained improvement. Epidural steroid injec- exist preoperatively; (3) when more than a combined
tions or selective nerve root injections result in substan- 50% of the bilateral facet joints are resected as part of
tial relief of radicular pain and may obviate the need for the decompression; and (4) when decompression is per-
surgery over the short term in a subset of patients. Ide- formed in a patient with a flexible or progressive degen-
ally, the injections are performed at the level of the erative scoliosis.
symptomatic nerve root through a fluoroscopically di- The precise role of instrumentation in lumbar spinal
rected transforaminal technique. One to three injections stenosis is currently unclear. The aims of pedicle screw
are typically performed, with 1-to 2-week intervals be- instrumentation in spinal stenosis surgery include defor-
tween injections. mity correction, immediate stabilization of an unstable
Patients with persistent lower extremity symptoms spine, improvement in fusion rates, and faster mobiliza-
from lumbar spinal stenosis are generally offered surgi- tion of patients. The advantages of instrumentation need
cal decompression. The physician should make clear to be weighed against the potential morbidity of extend-
that the aim of surgery is to relieve current disability ing the surgical procedure. A randomized prospective
rather than prevent future complications. There is no study showed that the addition of instrumentation to
conclusive evidence that disability from spinal stenosis lumbar decompression and posterolateral arthrodesis
worsens over time. Less frequent indications for surgery for degenerative spondylolisthesis with stenosis resulted
include progressive neurologic deficit or cauda equina in improved fusion rates, but it did not improve the
syndrome. overall clinical outcome of patients.
The optimal surgical approach combines maximal
thecal sac and nerve root decompression and preserves Alternative Surgical Techniques
stability. The facet joints, capsule, intervertebral disk, Several limited approaches have been proposed as alter-
and interspinous ligaments are important lumbar spine natives to the traditional decompressive laminectomy
stabilizers. In typical degenerative lumbar spinal steno- and partial facetectomy. The rationale for these ap-
sis, maximal compression of the thecal sac occurs at the proaches involves decreased patient morbidity and
level of the disk. Decompression of a single level is faster rehabilitation with a more limited operation, lim-
achieved by resection of approximately 50% of the iting the surgery to the pathologic area (the bony and
cephalad and caudad laminae and the intervening liga- soft-tissue pathology in most patients with degenerative
mentum flavum. After creation of a central trough, the stenosis is at the level of the interlaminar window and
decompression is extended laterally to the medial wall can be adequately addressed through an interlaminar
of the pedicle bilaterally to ensure that the traversing fenestration or laminotomy), decreased postoperative
nerve root is free of pressure. Greater than 50% exci- radiographic listhesis, reduced scarring posterior to the
sion of the bilateral facets or unilateral complete face- thecal sac and root, awareness that paraspinal muscle
atrophy with wide exposure may be a source of postop- preoperatively may be a negative prognostic indicator.
erative back pain, and limited surgical destabilization, The results in general deteriorate over a 5- to 10-year
which potentially obviates the need for fusion. The ben- period, with increasing back pain, claudication, and rates
efits of these approaches need to be weighed against of revision surgery. Mortality in these elderly patients is
their limitations, which include a higher incidence of 0.6% to 1.0% following surgery.
nerve root injury and dural tears, bone regrowth poten- The rates of lumbar fusion vary considerably across
tially compromising the result, the need for technically geographic regions and specialties, suggesting uncer-
demanding procedures and longer surgical times, the tainty among surgeons on the indications for fusion fol-
fact that most of these procedures do not address cen- lowing decompressive laminectomy. In a multicenter
tral stenosis, and the lack of long-term clinical efficacy study of patient selection and outcomes following de-
studies. compressive laminectomy, instrumented and noninstru-
A unilateral hemilaminectomy or laminotomy may mented fusion in patients with degenerative spinal
be indicated in a patient with one-sided symptoms from stenosis, the major predictor of the decision to perform
lateral stenosis and no significant central stenosis. Simul- arthrodesis was found to be the individual surgeon.
taneous diskectomy should be performed if there is re- Other factors associated with this decision were the
sidual bulging of the disk, especially when the patient presence of more than 5 mm of spondylolisthesis,
has good disk height. Bilateral or multilevel laminotomy younger age, female patients, scoliosis greater than 15,
may be considered in patients with degenerative steno- patients with greater severity of back pain, and fewer
sis at multiple levels. Myelography in these patients usu- levels decompressed. The authors reported significantly
ally shows an hourglass compression of the thecal sac at greater relief of back pain after 6 and 24 months in the
several levels, with spacious intervening areas. The pro- noninstrumented arthrodesis group. The decreased satis-
cedure differs from the traditional multilevel laminec- faction in the instrumented arthrodesis group at these
tomy by leaving the spinous processes and interspinous earlier stages cannot be well explained, but it may be re-
ligaments intact. In unilateral laminotomy with bilateral lated to pain associated with the instrumentation itself.
decompression, an ipsilateral laminotomy and decom- The increased likelihood of a successful arthrodesis with
pression is followed by decompression of the contralat- instrumentation may result in improved results in this
eral side by angling the microscope or endoscope across group over a longer period. Hospital costs were highest
the top of the dural sac. Resection of the contralateral in patients who underwent instrumented arthrodesis.
ligamentum flavum allows good exposure of the con-
tralateral side. Lumbar Disk Herniation
Pathoanatomy
Prognosis and Outcomes A disk herniation is a localized displacement of disk
There is little published information regarding the true material beyond the limits of the intervertebral space.
natural history of lumbar spinal stenosis. Studies that in- The disk material can be nucleus pulposus, cartilage, an-
clude nonsurgical treatment show that about 15% to ulus fibrosus, fragments of apophyseal bone, or any
20% of patients improve, 15% to 20% get worse, and combination of these materials. A herniated disk should
60% to 70% remain unchanged. Surgery appears to im- be distinguished from a disk bulge, which is a diffuse
prove short-term outcomes in patients with severe symmetric outpouching of the anulus fibrosus associated
stenosis. In one study, 52% of nonsurgically treated pa- with varying degrees of disk degeneration. A true herni-
tients showed improvement at 4-year follow-up com- ation may either be a protrusion, extrusion, or seques-
pared with 70% of surgically treated patients. Patients tration (Figure 2). The base of a protrusion is wider than
undergoing surgical treatment generally had more se- any diameter of the displaced material. In an extrusion,
vere degrees of stenosis and were more symptomatic the diameter of the displaced material in at least one
than the nonsurgically managed group. plane is greater than the width at its base. If a displaced
Appropriate patient selection and thorough decom- fragment loses all continuity with the parent disk, it is
pression result in good long-term results following de- termed a sequestration, and is prone to migrate within
compressive lumbar laminectomy with or without fu- the spinal canal. The relationship of the herniated nu-
sion. A meta-analysis of the surgical treatment of spinal clear material to the surrounding anulus fibrosus and
stenosis found that the average proportion of good to the overlying posterior longitudinal ligament defines its
excellent results in 74 studies was 64%. There were no containment. A herniation completely enveloped by an-
consistent predictors of clinical outcome, but younger ulus fibrosus, posterior longitudinal ligament, or both is
age, greater severity and duration of symptoms, previous termed a contained herniation. Nuclear material that es-
back surgery, multilevel involvement, coexisting medical capes through the annular periphery and rests beneath
morbidity, and litigation issues were associated with the posterior longitudinal ligament has been referred to
poorer outcome. The presence of bladder symptoms as subligamentous.
Figure 3 Illustration of the motor, reflex, and sensory radicular findings in various types of lumbar disk herniation.
lower limb weakness, saddle anesthesia, and bowel/ headlight and a small posterior midline incision cen-
bladder changes. One percent to 10% of all patients un- tered on the disk space. Surgeons must be aware of the
dergoing surgery for lumbar disk herniation have symp- anatomic peculiarities of the upper lumbar canal when
toms of cauda equina syndrome. The incidence may be treating patients with high lumbar disk herniations. Ana-
higher when patients with subtle urinary symptoms are tomic peculiarities include smaller interlaminar spaces,
included. Pain varies substantially in patients, and it is greater coverage of the disk space by the lamina of the
modified and influenced by several factors including in- superior vertebra, proximity to the conus medullaris, a
dividual cultural and psychologic factors, sleep depriva- smaller spinal canal with a higher volume of nerve tis-
tion, and secondary gain. Evaluation of the patient sue, and a more horizontal orientation of the upper lum-
should include a skillful appraisal of these issues. bar nerve roots. An extraforaminal disk herniation is
ideally accessed through the Wiltse paraspinal approach,
Management which preserves motion segment stability by avoiding
Nonsurgical measures including activity modification, injury to the lamina and facet joints. Injury to the dorsal
anti-inflammatory agents, physical therapy modalities, root ganglion with postoperative dysesthesias is a poten-
exercises, spinal manipulation, corsets, epidural injec- tial complication when treating patients with this form
tions, and nerve root blocks result in good resolution of of disk herniation. Endoscopic and other percutaneous
symptoms in most patients. It is unclear whether any of techniques for disk decompression are discussed in
these treatment options actually alters the natural his- chapter 50.
tory of disease.
Foraminal epidural steroid injections accurately ad- Prognosis and Outcome Following Intervention
ministered under fluoroscopic control may help in com- Lumbar disk herniation is a self-limiting disease in most
bating the chemical mediators of pain and inflammation patients. Eighty percent to 90% of patients obtain satis-
associated with disk herniations. A positive response is factory resolution of symptoms with nonsurgical treat-
usually indicated by a reduction of leg pain by more ment. Imaging studies that monitor the changes in size
than 50%. The steroid load generally precludes more of nonsurgically treated disk herniations have shown a
than three to four injections over a 1-year period. The progressive decrease in the size of herniations over
most important application of these injections may be in time. Large extrusions have a greater likelihood of total
shortening the pain-control phase of treatment, which resorption; they are phagocytosed by cells attracted by
allows early reconditioning to begin. the disk-incited inflammatory response or from desicca-
Persistent intractable pain following nonsurgical tion and atrophy secondary to loss of nutrient supply.
treatment during a minimum 6-week period is the most Nonsurgical treatments will likely result in favorable
frequent indication for surgery. There is some evidence outcomes when the duration of sciatica is less than 6
that results of surgery deteriorate when nonsurgical care months, the patient is younger, and there is no litigation
exceeds 12 months. Imaging studies must correlate with involved. The results of surgical treatment are better in
the symptoms and neurologic findings. The presence of patients with large anterior-posterior herniated disk
a nerve tension sign improves the likelihood of a good length and in patients who have a greater compromise
postoperative result. of the canal area by the disk herniation. Patients who
Other factors that influence the decision to proceed have an extruded or sequestered fragment with a mini-
with surgery include disk herniation into a stenotic ca- mal fissure in the anulus fibrosus or those who have a
nal, which may lead to recurrent or persistent symp- detached fragment lying beneath an intact anulus fibro-
toms; inability of patients to comply with the dictates of sus are likely to do better following surgery than those
a conservative therapy regimen; and the number of sci- who have an extruded disk with a large or massive an-
atica episodes experienced by a patient. Among patients nular defect or those who have an intact anulus fibrosus
experiencing a second episode of sciatica, 90% will im- and no detached fragment beneath the anulus fibrosus.
prove but 50% will have a recurrence of symptoms. The The likelihood of recovery of neurologic deficit is in-
incidence of future episodes of sciatica rises to almost dependent of surgical intervention, and patients with
100% in patients who have experienced three prior epi- neurologic deficit but no pain do not require surgery.
sodes. Absolute indications for surgery in lumbar disk Surgery is considered in some patients with painless mo-
herniation are bladder and bowel involvement and pro- tor deficits when there is functional weakness in a major
gressive neurologic deficit. muscle group or in those with significant motor deficits
A laminotomy and diskectomy (microdiskectomy) is and no return of function after 6 weeks. Recovery of
the gold standard for surgical treatment of a posterolat- motor deficit is the general rule, although in some pa-
eral lumbar disk herniation. This treatment is frequently tients complete recovery may take a long time. Long-
performed as an outpatient or short-stay procedure us- term studies have shown that 30% of patients will con-
ing an operating microscope or surgical loupes with a tinue to have sensory deficits despite resolution of pain.
This finding is consistent with the fact that sensory fi- herniations in patients in this age group are more fre-
bers are the most vulnerable to compression (they are quent in the upper lumbar spine. Nerve root tension
affected first and recover last). signs such as the straight leg raising test are commonly
One prospective controlled study compared out- negative in elderly patients. This may be secondary to
comes of surgical and nonsurgical treatment in a group reduced resting tension in the nerve roots as a result of
of patients with lumbar radicular pain and concordant reduced disk height from the degenerative process or
myelograms. Surgery was superior to nonsurgical treat- reduced limb length from degenerative hip and knee
ment at 1-year follow-up and continued to be slightly changes. Chronic fibrosis of the roots from compro-
better at 4-year follow-up. Outcomes were similar in mised microcirculation may contribute to the severity of
both groups at 10-year follow-up. Approximately 60% the radicular pain. Histologically, the herniated disk
of both groups of patients were symptom free at 10-year fragment primarily contains sections of anulus fibrosus.
follow-up, although clinical recovery occurred earlier in Spontaneous resorption and improvement is less likely
the surgically treated group. In another 5-year follow-up to occur.
study, 56% of nonsurgically managed patients reported
symptomatic improvement compared with 70% of surgi- Disk Herniation in Young Patients
cally treated patients. Pediatric disk herniations constitute 1% to 3% of all in-
Long-term success rates following open diskectomy stances of lumbar disk herniation. Previous trauma and
are between 76% and 93%. In a study of 63 patients 10 vertebral column abnormalities such as congenital
years after interlaminar fenestration and diskectomy, stenosis or transitional vertebrae may increase the like-
75% of patients reported some back pain, but only 13% lihood of herniation. The clinical presentation is similar
reported severe back pain. Younger patients with preop- to that for adults, with back pain and nerve tension signs
erative degenerative changes at the disk had a higher in- being frequently reported; neurologic deficits in these
cidence of back pain. Sensory disturbances were present patients is typically uncommon. The herniation is fre-
in 81% of patients preoperatively, but in only 31% of quently an avulsed fragment of the ring apophysis of the
patients at final follow-up. Motor deficits were present vertebral body. In children and adolescents who have
in 76% of patients preoperatively, and in 14% of pa- persistent symptoms despite nonsurgical treatment, sur-
tients at 10-year follow-up. A complete foot drop was gery usually results in good relief of symptoms. A uni-
present in four patients preoperatively and this symp- lateral hemilaminectomy with partial diskectomy is
tom did not improve after surgery. The straight leg rais- sufficient treatment for most patients. A bilateral lami-
ing test was negative in 97% of patients at the 10-year nectomy is occasionally necessary when the avulsed
follow-up. Mild preoperative urinary disturbances in apophysis fragment is large.
four patients resolved completely.
Discogenic Low Back Pain
Special Situations Discogenic pain refers to pain originating from a degen-
Recurrent Herniation and Reoperation erative lumbar disk, which is characterized by axial low
Recurrent herniations at the same level occur in ap- back pain without associated radicular findings, spinal
proximately 5% of surgically treated patients at 5-year deformity, or instability. The controversy surrounding
follow-up and can be ipsilateral or, less frequently, con- discogenic low back pain primarily exists because de-
tralateral. Survival analysis or rates of revision are a generative changes at the disks are ubiquitous, yet
better measure of surgical success. A recent large symptoms arise in only a few patients; multiple addi-
population-based study from Finland analyzed the risk tional anatomic sources of low back pain exist (Table 2);
of reoperations after lumbar diskectomy. Fourteen per- the diagnosis of discogenic low back pain is made pri-
cent of a total of 35,309 patients in the study group un- marily with provocative diskography, which is controver-
derwent a second procedure during the 10-year period sial in itself; it is unclear whether the treatment options
of the study. The second procedure was diskectomy in for discogenic low back pain are superior to the natural
63% of patients, decompression in 23%, and fusion in history of the disorder over the long term. Notwith-
14%. Among the patients who underwent a second pro- standing these issues, the degenerative lumbar disk is
cedure, there was a 25% cumulative risk of needing a being increasingly recognized as a valid source of axial
third spinal surgical procedure within the next 10 years. low back pain.
A pain-free interval of more than 1 year was associated
with a lower risk of revision. Pathoanatomy and Pathophysiology
As the disk ages, several chemical and mechanical
Disk Herniation in the Elderly changes occur within it, which result in a continuum of
Disk herniation in elderly patients commonly occurs in changes that can be observed using radiographic imag-
the setting of spinal stenosis or spondylolisthesis. Disk ing. Type II collagen in the nucleus pulposus and anulus
Patients Without Loss of Disk Height other patients may be associated with approach-related
Plain radiographs in patients without evidence of loss of muscle denervation and necrosis or disruption of the ad-
disk height generally do not show any significant jacent facet joints. Posterior lumbar interbody fusion or
changes. Disk height is maintained, and there are no transforaminal interbody fusion can allow posterior de-
facet joint nor end plate changes. MRI typically shows compression and concurrent anterior column stabiliza-
mild changes such as desiccated disks with low signal on tion, while avoiding the morbidity of a separate anterior
T2-weighted imaging or annular tears. operation. The drawbacks include limitations on the size
of the anterior graft or implant, nerve root injury, epidu-
Prognosis ral fibrosis and chronic radiculitis, and potential instabil-
The natural history of acute low back pain is generally ity from resection of the facet joints needed for expo-
excellent. Ninety percent of patients will go on to com- sure.
plete pain relief within 2 to 6 weeks. In patients who Anterior lumbar interbody fusion (ALIF) has sev-
have chronic pain, one study found that 40% of patients eral theoretic benefits in the treatment of discogenic
could be diagnosed as having discogenic back pain with low back pain. It can remove pain fibers and receptors
positive diskograms at L4-L5 or L5-S1. There is limited from the anulus fibrosus and nucleus pulposus, elimi-
information on the natural history of confirmed disco- nate motion across disk, restore disk height and indi-
genic low back pain. One study found 68% of patients rectly decompress foramen, and enable surgeons to
improved, 24% worsened, and 8% remained unchanged avoid posterior muscle disruption during the approach.
over a 5-year period. Fusion rates are high, varying from 80% to 96% of pa-
tients. The disadvantages of the anterior approach are
Management the risks of major vessel injury and, in males, retrograde
Anti-inflammatory, analgesic, and antispasmolytic medi- ejaculation and impotence. Laparoscopic ALIF tech-
cations are effective in the management of acute back niques require a skilled general surgeon for the ap-
pain, although their usefulness in managing chronic proach and are more likely to be successful at the L5-S1
back pain is unclear. Gastrointestinal toxicity and renal interspace. The type of anterior structural support used
impairment are concerns with the use of these drugs, es- in ALIF surgery has received much attention. Autolo-
pecially in the elderly population. Flexible or rigid spi- gous cancellous bone shows high fusion rates, but migra-
nal supports may reduce lumbar mobility and decrease tion and collapse have been drawbacks. Threaded cages
intradiskal pressure in certain positions of lumbar flex- or machined allografts are being increasingly used with
ion. A program of physical therapy should be directed interbody fusion, with the aim of reducing the morbidity
at ergonomic instruction, stretching maneuvers, and iso- associated with bone graft harvest. Bone morphogenetic
metric stabilization exercises. Nonimpact type exercise protein used within threaded interbody cages in ALIF
such as swimming or cycling is recommended. Other shows high fusion rates and relief of back pain similar to
measures used with varying degrees of success include autograft over the short term.
acupuncture, hydrotherapy, ultrasound, biofeedback,
electrical stimulation, manipulation, massage, and psy- Annotated Bibliography
chotherapy. Intradiskal electrothermal therapy has been Lumbar Spinal Stenosis
proposed as an option in the management of discogenic Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE:
back pain (see chapter 50). Surgical and nonsurgical management of lumbar spinal
Lumbar fusion is the surgical procedure of choice stenosis: 4-year outcomes from the Maine Lumbar
for the treatment of discogenic low back pain in patients Spine Study. Spine 2000;25:556-562.
who have intractable pain after an aggressive nonsur- A cohort of 119 patients underwent either surgical or non-
gical management program, MRI findings of disk de- surgical treatment and were followed for 4 years. Seventy per-
generation, and concordant diskography at one or two cent of surgically treated patients and 52% of nonsurgically
levels. Disk excision or other disk decompression proce- treated patients reported improvement in symptoms. The au-
dures are not recommended for these patients. thors report that the relative benefits of surgery diminished
The fusion approach may be posterior, anterior, or over time but remained superior to those of nonsurgically
both. Instrumentation is generally used with posterior treated patients.
fusion, and implants or bone graft are used with inter-
body fusion. Successful fusion is obtained in 60% to Fischgrund JS, Mackay M, Herkowitz HN, Brower R,
90% of patients who undergo a posterior procedure, but Montgomery D, Kurz LT: Degenerative lumbar spondy-
clinical outcomes are satisfactory in only 40% to 70%. lolisthesis with spinal stenosis: A prospective, random-
Even with posterior instrumentation, there is some mo- ized study comparing decompressive laminectomy and
tion across the disk space that may account for persis- arthrodesis with and without spinal instrumentation.
tent symptoms in some patients. Residual symptoms in Spine 1997;22:2807-2812.
This randomized study showed that fusion rates were su- Osterman H, Sund R, Seitsalo S, Keskimaki I: Risk of
perior in instrumented patients undergoing single level sur- multiple reoperations after lumbar discectomy: A
gery, but overall clinical improvement was identical in instru- population-based study. Spine 2003;28:621-627.
mented and noninstrumented groups. This 11-year review of 35,309 patients who underwent dis-
kectomy showed that 14% had at least one more operation,
Iguchi T, Kurihara A, Nakayama J, Sato K, Kurosaka M, whereas 2.3% had two or more operations. Sixty-three percent
Yamasaki K: Minimum 10-year outcome of decompres- of the second operations were diskectomies, 14% were fusions,
sive laminectomy for degenerative lumbar spinal steno- and 23% were decompressions.
sis. Spine 2000;25:1754-1759.
In this study, decompressive laminectomies without fusion Yorimitsu E, Chiba K, Toyama Y, Hirabayashi K: Long-
in patients older than 60 years were shown to produce long- term outcomes of standard discectomy for lumbar disc
term satisfactory results in more than half of the patients. The herniation. Spine 2001;26:652-657.
authors concluded that the presence of sagittal rotation of In this study, 74% of patients who underwent lumbar dis-
more than 10 in patients needing multiple laminectomies may kectomy reported some back pain at 10 years, although dis-
be related to deterioration of outcome. abling pain was reported in only 12.7%. Decreased disk height
was associated with more disability, whereas recurrent hernia-
Katz JN, Lipson SJ, Lew RA, et al: Lumbar laminectomy tions were more common in those with preserved disk height.
alone or with instrumented or noninstrumented arthro-
desis in degenerative lumbar spinal stenosis: Patient se- Discogenic Low Back Pain
lection, costs, and surgical outcomes. Spine 1997;22:1123- Fritzell P, Hagg O, Wessberg P: Nordwall Anders, Swed-
1131. ish Lumbar Spine Study Group: Lumbar fusion versus
The authors of this study report that adding arthrodesis to nonsurgical treatment for chronic low back pain. Spine
decompression for spinal stenosis depends primarily on sur- 2001;26:2521-2534.
geon preference and that noninstrumented fusions produce This randomized controlled multicenter study showed that
superior relief of back pain, whereas instrumentation adds lumbar fusion in a carefully selected group of patients with se-
substantial costs to the treatment. vere chronic low back pain decreases pain and disability more
than nonsurgical treatment.
Rao RD, Wang M, Singhal P, McGrady LM, Rao S: In-
tradiscal pressure and kinematic behavior of lumbar Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lau-
spine after bilateral laminotomy and laminectomy. Spine ryssen CC, Goette K: The effect of nerve-root injections
J 2002;2:320-326. on the need for operative treatment of lumbar radicular
This article presents a biomechanical analysis of bilateral pain: A prospective, randomized, controlled, double-
laminotomy as an alternative to wide laminectomy in the de- blind study. J Bone Joint Surg Am 2000;82:1589-1593.
compression of patients with lumbar spinal stenosis. This prospective study demonstrated the efficacy of selec-
tive nerve root injections of corticosteroid in patients with
Lumbar Disk Herniation lumbar radiculopathy. Twenty of 28 patients who received in-
Atlas SJ, Keller RB, Chang Y, Deyo RA, Singer DE: jection of bupivacaine and betamethasone declined surgery
Surgical and nonsurgical management of sciatica sec- over a 13- to 28-month period after receiving one to four in-
ondary to a lumbar disc herniation: Five-year outcomes jections, whereas the remainder of the patients eventually un-
from the Maine Lumbar Spine Study. Spine 2001;26: derwent surgery.
1179-1187.
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Figure 1 Lateral radiograph showing a Meyerding grade 1 slip. slips, and therefore, they have less potential for slip pro-
gression.
Acquired spondylolisthesis occurs as a result of ac-
quired pathology, such as pars defects, trauma, degener-
ative facets, pathologic instability, and iatrogenic injury.
The main difference between the developmental and ac-
quired categories is that the basic spinal architecture is
developed normally in the acquired group and therefore
has more potential stability or less potential for progres-
sion of slippage.
Diagnostic Imaging
Plain Radiographs
Initial assessment should at least consist of standing AP
and lateral radiographs. The standing position may ac-
centuate existing translational deformity. Spondylolis-
thesis can be missed on supine lateral films up to 20%
of the time because of reduction of the deformity when
the patient is in the supine position. Standing films may
also accentuate angular deformities better than those
Figure 3 Lateral radiograph showing a Meyerding grade 4 slip. As in Figure 2, signifi- obtained with the patient supine. Pars interarticularis
cant dysplastic features are present. defects and other defects of the posterior arch such as
spina bifida occulta may be identified on AP views. In
patients with high-grade slips with significant angulation
etiology and prognostic factors. Slips are divided into of the cephalad vertebra, a Napoleons hat sign may be
two main categories: developmental and acquired. De- seen on AP views (Figure 4). A standard AP view may
velopmental spondylolisthesis is categorized as either not be helpful for visualization of the pedicles and other
high dysplastic or low dysplastic. Dysplastic features of surgical anatomy in patients with high-grade slips. In
the anterior and posterior elements, which lead to insta- these patients, a Ferguson view (AP radiograph angled
bility, characterize developmental slips. Posteriorly, the 30 cephalad) will yield a true AP view of the lumbosac-
pars interarticularis, laminae, or facets may be incompe- ral junction.
tent; anteriorly, the L5 body tends to be trapezoidal and Although pars interarticularis defects are usually
oriented toward the floor and the S1 superior end plate identifiable on lateral films, right and left oblique radio-
tends to be rounded. Low dysplastic slips tend to have graphs may help in the diagnosis of subtle pars defects
less profound dysplastic features than high dysplastic not readily seen on AP or lateral views.
Computed Tomography
CT scans are useful in the diagnosis of occult pars inter-
articularis defects. Thin section cuts (1 to 2 mm) should
be obtained because larger axial sections may miss the
defects. Sagittal reconstruction technology is also help-
ful because pars interarticularis defects may be difficult
to see on axial images. These defects often lie in a simi-
lar plane to the axial cuts. Pars interarticularis defects
tend to lie more dorsal and posterior to the facet joints
on the axial images and are often associated with signif-
icant bony and cartilaginous overgrowth. In the degen-
erative spine, axial CT images allow assessment of the
orientation of facet joints (coronal or sagittal) to help Figure 4 AP radiograph of a high-grade slip. The Napoleons hat sign is outlined.
determine the relative stability of a segment after de- Severe angulation of the L5 body allows an end-on axial projection on AP views.
compression. CT scans are also helpful in assessing sur-
gical bony anatomy, such as pedicle size and orientation.
end plate changes are also signs of disk degeneration.
Myelograms in conjunction with CT scans are help-
Often disks adjacent to slips may be radiographically
ful in assessment of the neuroanatomy. Although central
normal, but they elicit significant degenerative changes
and lateral recess stenosis is easily identified, foraminal
stenosis may be missed because the compression occurs on MRI, which must be considered during surgical plan-
lateral to the root sleeve beyond the extent of the my- ning. Although knowing the status of the adjacent disk
elogram dye. is important, there are no conclusive findings that war-
rant routinely incorporating the adjacent degenerative
Magnetic Resonance Imaging level in patients with spondylolisthesis.
MRI scans are not often helpful in identifying spondy-
litic defects. They are most helpful in the evaluation of Nuclear Medicine Studies
the neuroanatomy and disks. Central and lateral recess Technetium bone scans have been historically popular
stenosis caused by facet hypertrophy, overgrown pars in- in the diagnosis of spondylolysis. These scans are used to
terarticularis defects, and translational offset is easily determine the acuteness of a pars injury, with positive
seen. Also, sagittal images allow accurate assessment of scans suggesting a more acute injury and greater poten-
the nerve root in the foramina. tial for healing with bracing or conservative care. Nega-
MRI scans can evaluate the status of the interverte- tive scans indicate an old or chronic defect with little
bral disks at the affected and adjacent levels. Normal healing potential. Recently, single photon emission CT
disks appear bright on T2-weighted images because of has been shown to be more specific and sensitive in de-
good hydration, and they appear dark when degenera- tecting radiographically occult pars defects than techne-
tion (relative dehydration) is present. Reactive bony tium scans.
ure of 6 to 12 weeks of nonsurgical therapy to relieve has not been shown to consistently improve outcome
symptoms. Absolute indications for surgery include pro- over noninstrumented arthrodesis. No known random-
gressive and evolving motor deficits and cauda equina ized prospective data have been published to date re-
syndrome. Surgical intervention should address the two garding the role of interbody fusion in the treatment of
components of degenerative spondylolisthesisspinal degenerative spondylolisthesis.
stenosis and instability.
The management of spinal stenosis includes laminec- Acquired Isthmic Spondylolisthesis in Adults
tomy or laminotomy with partial or total facetectomy. Pathogenesis/Pathoanatomy
Depending on symptoms, decompression may be unilat-
The primary lesion responsible for isthmic or lytic
eral or bilateral. All regions of compression must be ad-
spondylolisthesis is a defect of the pars interarticularis.
dressed because incomplete decompression of the lat-
Several etiologies for this defect have been proposed,
eral recess and stenosis can lead to persistent symptoms
including acute or chronic traumatic injuries. Congenital
and poor outcome. Outcomes of decompression without
abnormalities can contribute to instability as well. There
fusion in the face of degenerative spondylolisthesis are
are several types of pars defects: chronic stress fractures,
mixed. Several studies show significant improvement in
elongated pars from healing of multiple stress fractures
leg symptoms initially; however, up to 33% of patients
over time, and acute pars fractures. These lesions are ac-
had severe worsening of back and leg symptoms by 5
quired, not congenital, and result from repeated mi-
years, with nearly 25% requiring reoperation for the
crotrauma of the pars as it is loaded in extension. Isth-
treatment of recurrence of stenosis and/or progression
mic spondylolisthesis occurs at L5-S1 in 82% of patients
of instability. In one study, more than half of the pa-
compared with 11% at L4-5 and 0.5% at L3-4 and L2-3.
tients with decompression alone were unable to walk
Forces in the lumbar spine are greatest at the lumbosac-
more than two blocks after 3 to 6 years, and 25% of pa-
ral junction and likely are the reason for the high preva-
tients were very dissatisfied with the treatment out-
lence of pars defects at L5-S1.
come.
Several studies have addressed the role of arthrode-
sis in addition to decompression for the treatment of de- Natural History
generative spondylolisthesis. In a prospective random- Relatively few patients with spondylolysis will acquire
ized study comparing decompression alone to spondylolisthesis. Those who do typically have some as-
decompression with posterolateral noninstrumented fu- sociated dysplastic features such that the true incidence
sion, at 3-year follow-up 96% of the patients who under- of acquired isthmic spondylolisthesis may be much less.
went decompression alone had radiographic slip pro- Many patients who eventually acquire spondylolisthesis
gression compared with 28% of those in the arthrodesis are asymptomatic. True acquired slips are almost always
group. Despite a pseudarthrosis rate of 36%, 96% of pa- grade I or II and rarely progress beyond grade I or II
tients in the arthrodesis group had good or excellent re- severity unless there is dysplasia present. Isthmic
sults compared with 44% of those who underwent de- spondylolisthesis that progresses beyond Meyerding
compression alone. grade II almost always is associated with dysplasia as
Numerous studies have also assessed the effects of well.
using instrumentation in conjunction with arthrodesis. A Progression of isthmic spondylolisthesis is most com-
randomized prospective study comparing single-level mon in the adolescent population. Significant increase
laminectomy and posterolateral fusion with and without in slippage in adulthood is uncommon. In contrast to
transpedicular fixation showed that the addition of in- the L5-S1 isthmic slip, lesions at L4-5 or other more cra-
strumentation significantly improves fusion rates. De- nial levels may remain unstable into the third and
spite the significant difference in fusion rates, in 83% of fourth decades of life, with progression of translation
patients in the instrumented group versus 45% of those and increase in back and leg symptoms. An isthmic le-
in the noninstrumented group, there was no significant sion at L4-5 is less stiff in sagittal rotation and shear
difference in clinical outcomes, with 78% to 85% of translation than a lesion at L5-S1. Overloading a lesion
those in both groups reporting good and excellent re- at L4-5 may lead to premature translational wear of the
sults. Several other authors have reported an improve- disk, contribute to the inherent instability of the seg-
ment in both fusion rates and clinical outcomes when ment, and may be the reason why previously asymptom-
comparing instrumented and noninstrumented fusions atic isthmic slips at L4-5 progress later in adulthood.
for the treatment of patients with degenerative spondy-
lolisthesis. Clinical Presentation
When surgical treatment is indicated, a thorough de- The most common presenting symptom is low back
compression is mandatory, and the addition of arthrode- pain. Patients often have a long history of periodic self-
sis improves intermediate- and long-term outcomes. The limited low back pain episodes that vary in intensity
addition of instrumentation increases fusion rates, but it and/or duration. Neurologic deficits are infrequent be-
cause slips rarely progress beyond grade II and the rela- been used. These approaches include anterior interbody
tive detachment of the posterior arch prevents signifi- fusion, posterolateral fusion with and without instru-
cant central canal stenosis. Patients may present with mentation, anterior-posterior procedures, and posterior
unilateral or bilateral radiculopathy. Radicular symp- interbody procedures.
toms may be caused by nerve root irritation from the Posterolateral fusion is commonly used to treat pa-
reactive tissue around the pars defect combined with tients with isthmic spondylolisthesis. Midline dissection
the micromotion of the unstable posterior arch. Addi- is performed laterally over the facet joints and trans-
tionally, significant foraminal stenosis may occur as a re- verse processes and sacral alae. Abundant lateral bone
sult of loss of sagittal foraminal height from the transla- graft leads to stabilization of the segment by intertrans-
tion and degeneration of the intervertebral disk. verse process fusion. A Gill laminectomy may be done
Typically, the exiting nerve root (L5) is most affected for in conjunction with the posterior fusion. Removal of the
an L5-S1 isthmic spondylolisthesis. loose lamina and inflammatory pars defect allows de-
compression of the nerve roots, direct visualization of
Nonsurgical Treatment the pedicles for hardware placement, and potentially re-
Most patients with acquired isthmic spondylolisthesis moves part of the inflammatory back pain generator. In
will respond to nonsurgical management. Medical treat- addition, the laminectomy bone may be processed for
ment should follow similar guidelines for nonspecific bone graft. Although the roles of instrumentation and
decompression with posterolateral fusion remain con-
low back pain. Oral anti-inflammatory drugs may re-
troversial, Gill decompression without fusion is not rec-
duce acute pain and improve function. Long-term use of
ommended. Potential complications of the posterior ap-
these drugs should be avoided if possible because of po-
proach include infection, dural tear, nerve root injury,
tential renal and gastrointestinal adverse effects. Nar-
hematoma, and pedicle fracture.
cotic pain medication, muscle relaxers, and other con-
Anterior lumbar interbody fusion (ALIF) can be
trolled substances should be used with extreme caution
successfully used to treat isthmic spondylolisthesis even
and definitely should be avoided in long-term treat-
when radicular symptoms are present. Although the di-
ment.
rect decompression of nerves is difficult, indirect de-
There are no known studies that address the role of
compression can be obtained by foraminal distraction.
injections in the facet joints or pars defects in patients
A transabdominal retroperitoneal approach is usually
with isthmic spondylolisthesis. Injection of local anes- used to minimize the risk to abdominal viscera. Caudal
thetic and corticosteroid into the facets or pars defects to the iliac vessels, cautery should be used sparingly to
may have therapeutic effects. However, diagnostic infor- decrease the risk of injuring the presacral nerves, which
mation from these injections is at best difficult to inter- may result in retrograde ejaculation and sexual dysfunc-
pret because the pars defects often communicate with tion. The anterior approach allows for an aggressive disk-
the facet joints, causing an uncontrolled extravasation of ectomy with good removal of cartilage from the verte-
steroid and local anesthetic. In patients with radicular bral end plates and increase of the fusion surface area.
symptoms, selective nerve blocks or epidural steroid in- Additionally, anterior grafts provide excellent anterior
jections may be used for diagnostic and therapeutic pur- column support and may aid in partial reduction of the
poses. No prospective studies have yet been conducted slip as well as restoration of disk space height. The
that address the effectiveness of these injections in isth- choice of graft material is generally based on surgeon
mic spondylolisthesis. preference and includes autologous iliac crest, structural
The use of external bracing in the treatment of pa- allograft, and various metallic cages packed with autog-
tients with acquired isthmic spondylolisthesis has been enous cancellous graft. This method of anterior diskec-
reported. In addition, patients may benefit from initial tomy and interbody fusion cannot be done in patients
rest in the acute phase followed by physical therapy that with high-grade spondylolisthesis because of the pres-
is focused on strengthening of the abdominal and lum- ence of significant translational and angular deformity.
bosacral muscles. Physical therapy has been shown to Risks of the anterior approach include wound infection,
decrease pain and functional disability. Once the acute vascular injury, deep venous thrombosis, pulmonary em-
pain is resolved, the focus of physical therapy is on ham- bolism, sympathetic chain injury, retrograde ejaculation,
string stretching, pelvic tilts, and abdominal and pelvic and ventral hernia.
stabilizer strengthening for approximately 6 months. Stand-alone ALIF reconstruction for patients with
isthmic spondylolisthesis works best for those with a
Surgical Treatment Meyerding grade 1 slip. Several clinical studies have
Failure of conservative management (persistence of shown adequate results with good and excellent results
pain, progression of neurologic symptoms, or progres- ranging from 87% to 94% at 2 years. One study re-
sion of slippage) is an indication for surgical treatment. ported that 75% of patients had excellent and 20% had
Numerous approaches to surgical reconstruction have satisfactory results at 10-year follow-up. The fusion rates
rates of pseudarthrosis, progression of slippage, and rior translation forces are used to gradually reduce the
hardware failure have also been reported after reduc- slip. In the past, repeated wake-up tests were used
tion and posterolateral instrumented fusion. One study during the reduction. Electrophysiologic monitoring
reported implant failure in five of six patients who had (somatosensory-evoked potentials, electromyograms,
an isolated posterolateral instrumented fusion following and motor-evoked potentials) should be used with this
reduction. The addition of anterior interbody fusion af- procedure.
ter reduction and posterolateral instrumented fusion has High rates of implant failure and loss of reduction
been shown to decrease these complications. have been reported when reduction is performed and
Recent improvements in spinal instrumentation have only posterior instrumented fusion is used for stabiliza-
increased the interest in the use of open reduction to tion. The reduction of the spondylolisthesis normalizes
treat patients with spondylolisthesis. Several techniques the shear forces at the lumbosacral junction; however,
have been described. One technique involves pedicle an anterior column defect is also created by the reduc-
screw instrumentation from L4 to S1 or S2. A wide de- tion. Posterior instrumentation may fatigue and fail, re-
compression is performed so that the nerve roots are di- sulting in loss of reduction. Posterior distraction forces
rectly visualized during reduction. Distraction and poste- do not adequately resist shear, and compression forces
applied through posterior instrumentation may result in bar interbody fusion improve outcome over posterolat-
foraminal stenosis. The best way to biomechanically re- eral fusion? J Neurosurg 2003;99(suppl 2):143-150.
sist these shear forces is by providing anterior column Addition of a PLIF procedure to posterolateral instru-
support in the form of interbody fusion to augment the mented fusion in patients with isthmic spondylolisthesis im-
posterior instrumentation. If reduction is near anatomic, proves slip correction and maintenance of reduction over pos-
traditional ALIF or PLIF procedures can be used for terolateral instrumented fusion alone. The authors report no
anterior column support, depending on surgeon prefer- difference in fusion rates or functional and neurologic out-
ence. Several studies have reported decreased nonunion come.
rates when either ALIF or PLIF procedures were com-
bined with posterior instrumented open reduction. In Natarajan RN, Garretson RB III, Biyani A, Lim TH,
the treatment of patients with high-grade spondylolis- Andersson GBJ, An HS: Effects of slip severity and
thesis the benefits of reduction must be weighed against loading directions on the stability of isthmic spondylolis-
the significant potential complications and these issues thesis: A finite element model study. Spine 2003;28:1103-
should be discussed with the patient and family in great 1112.
detail. This study shows that the stiffness of a spondylolisthetic
motion segment decreases with increasing slip progression.
Annotated Bibliography The authors also report that lateral bending and torsion cause
the most resultant motion.
Bartolozzi P, Sandri A, Cassini M, Ricci M: One-stage
posterior decompression-stabilization and transsacral in- Classic Bibliography
terbody fusion after partial reduction for severe L5-S1
spondylolisthesis. Spine 2003;28:1135-1141. Boos N, Marchesi D, Zuber K, Aebi M: Treatment of se-
This retrospective study suggests that posterior decom- vere spondylolisthesis by reduction and pedicular fixa-
pression with partial reduction and stabilization with pedicle tion: A 4-6 year follow up study. Spine 1993;18:1655-
screw fixation and titanium cage transsacral interbody fusion 1661.
is a safe and effective treatment for patients with high-grade
spondylolisthesis. Bradford DS, Boachie-Adjei O: Treatment of severe
spondylolisthesis by anterior and posterior reduction
and stabilization: A long-term follow-up study. J Bone
Beutler WJ, Frederickson MD, Murtland A, Sweeney
Joint Surg Am 1990;72:1060-1066.
MA, Grant WD, Baker D: The natural history of
spondylolysis and spondylolisthesis: 45-year follow-up Carragee EJ: Single-level posterolateral fusion, with or
evaluation. Spine 2003;28:1027-1035. without posterior decompression, for the treatment of
This is a prospective study of the natural history of
isthmic spondylolisthesis in adults. J Bone Joint Surg Am
spondylolysis and spondylolisthesis over 45 years. The authors
1997;79:1175-1180.
report that patients with pars defects follow a clinical course
similar to the general population and that slip progression Fischgrund JS, Mackay M, Herkowitz HN, Brower R,
markedly slows with each decade. Montgomery DM, Kurz LT: Degenerative lumbar
spondylolisthesis with spinal stenosis: A prospective,
Hanson DS, Bridwell KH, Rhee JM, Lenke LG: Corre- randomized study comparing decompressive laminec-
lation of pelvic incidence with low- and high-grade isth- tomy and arthrodesis with and without spinal instru-
mic spondylolisthesis. Spine 2002;27:2026-2029. mentation. Spine 1997;22:2807-2812.
This study shows that pelvic incidence is significantly
higher in low- and high-grade slips compared with control Herkowitz HN, Kurz LT: Degenerative spondylolisthesis
groups. Pelvic incidence also has a significant correlation with with spinal stenosis: A prospective study comparing de-
Meyerding-Newman scores. compression with decompression and intertransverse ar-
throdesis. J Bone Joint Surg Am 1991;73:802-808.
Hanson DS, Bridwell KH, Rhee JM, Lenke LG: Dowel
fibular strut grafts for high-grade dysplastic isthmic Katz JN, Lipson SJ, Chang LC, Levine SA, Fossel AH,
spondylolisthesis. Spine 2002;27:1982-1988. Liang MH: Seven- to 10-year outcome of decompressive
This study shows that fibular strut grafting is a safe and ef- surgery for degenerative lumbar spinal stenosis. Spine
fective method for treating patients with partially reduced 1996;21:92-98.
high-grade slips. The authors found no significant difference
between the use of allograft and autograft. Marchetti PG, Bartolozzi P: Classification of spondy-
lolisthesis as a guideline for treatment, in Bridwell KH,
DeWald RL (eds): Textbook of Spinal Surgery. Philadel-
La Rosa G, Conti A, Cacciola F, et al: Pedicle screw fixa-
phia, PA, Lippincott-Raven, 1997, pp 1211-1254.
tion for isthmic spondylolisthesis: Does posterior lum-
Smith MD, Bohlman HH: Spondylolisthesis treated by a fixation and posterolateral fusion after decompression
single-stage operation combining decompression with in in spondylolotic spondylolisthesis. Spine 1997;22:210-
situ posterolateral and anterior fusion: An analysis of 219.
eleven patients who had long-term follow-up. J Bone
Joint Surg Am 1990;72:415-421. Wiltse LL, Newman PH, Macnab I: Classification of
spondylolysis and spondylolisthesis. Clin Orthop
Suk S, Lee C, Kim WJ, Lee JH, Cho KJ, Kim HG: Add- 1976;117:23-29.
ing posterior lumbar interbody fusion to pedicle screw
Introduction curves (> 60) show the greatest risk for progression. In
The evaluation and management of adult patients with a large cohort of patients with adolescent idiopathic
spinal deformity has undergone a rapid evolution in the scoliosis that was followed for more than 40 years, 68%
past decade. Increasing knowledge about the natural of patients had progression of their curvature after skel-
history of adult spinal deformity and the biologic events etal maturity. Thoracic curves greater than 50 pro-
that mediate the processes of spinal fusion have pro- gressed an average of 1 per year. Thoracolumbar
vided the spinal surgeon with a greater ability to evalu- curves progressed about 0.5 per year and lumbar
ate and treat these complex disorders. Despite these ad- curves progressed 0.24 per year. Thoracic curves less
vances, evaluation and optimal treatment of adult spinal than 30 tended not to progress.
deformity remains a significant challenge. In addition, Patients with degenerative scoliosis exhibited a
the increasing number of technical options available to higher rate of curve progression, which on average was
the spinal surgeon as well as the many spinal instrumen- about 3.3 per year. The prevalence of lumbar scoliosis
in adult patients with low back pain was estimated to be
tation systems available today have not made manage-
about 7.5%. The prevalence increased with age and in-
ment of adult spinal deformity any less challenging.
cluded 15% of patients with low back pain who were
It is now well established that untreated scoliosis in
older than 60 years. Risk factors for curve progression
the adult is not a benign condition. Common associa-
include the presence of a curvature greater than 30,
tions include painful, degenerative, spinal osteoarthritis;
apical rotation greater than 33%, more than 6 mm of
progressive deformity; spinal stenosis with radiculopa-
lateral listhesis, and poor seating of L5 on S1.
thy; muscle fatigue from coronal and sagittal plane im-
In contrast to adolescent patients with scoliosis who
balance; and poor cosmesis. Accurate determination of
are usually asymptomatic, adult patients with scoliosis
pain, impairment in the quality of life, and cosmetic ef-
often report back pain. In a recent European study in-
fects of deformity are difficult to measure and compare
volving 16,394 adolescents and their parents, the lifetime
among groups of patients. These factors, when weighed prevalence of low back pain was 50.9% for boys and
against the increased complication rate of surgical treat- 69.3% for girls with scoliosis as an independent risk fac-
ment, makes the decision to operate as important or tor. Other smaller but better designed studies have dem-
more important than the technique and expertise with onstrated that patients with scoliosis have a higher inci-
which the procedure is performed. dence of back pain than age- and sex-matched controls.
In general, the overall incidence of pain ranges from
Prevalence and Natural History 40% to 90%, and the overall prevalence of painful de-
Adult spinal deformity can arise as a sequela of un- formity ranges from 60% to 80%. The etiology of the
treated adolescent idiopathic scoliosis, failed surgical or pain is multifactorial. It can arise from muscle fatigue
nonsurgical treatment, or de novo spinal deformity de- on the convexity of the curvature, trunk imbalance, facet
veloping in the adult. The latter can be caused by degen- arthropathy on the concavity of the curvature, and de-
erative changes of the spinal column leading to instabil- generative disk disease. Back pain is more common in
ity and deformity, by iatrogenic instability after patients with lumbar curves and in patients with thora-
decompressive procedures for spinal stenosis and radic- columbar and lumbar curves exceeding 45 with apical
ulopathy, and possibly by metabolic bone diseases such rotation and coronal imbalance. Although the incidence
as osteoporosis. The prevalence of scoliosis in adults has of back pain in patients with adult scoliosis is similar to
been reported to range from 1.4% to 20%. that in the general population, many studies suggest that
Clearly, scoliosis can continue to progress after skel- back pain in patients with scoliosis is greater and more
etal maturity and into late adulthood. Large thoracic persistent. In addition to back pain, adult patients are
more likely to experience symptoms of spinal stenosis sette 14- 36-inch weight-bearing scoliosis radiographs
and radiculopathy from osteoarthritis of the spine, rota- are necessary to fully assess the extent of the primary
tory subluxations, anterior listhesis, and lateral listhesis curvature as well as any compensatory curves that may
of the vertebral bodies that result in stretching and/or exist. The weight-bearing radiographs also allow physi-
impingement of nerve roots. Again, neurogenic symp- cians to evaluate both coronal and sagittal plane bal-
toms are more common in patients with lumbar curva- ance. If surgery is contemplated, lateral supine bending
tures. However, paresis or paraplegia from untreated films are obtained to assess the flexibility of secondary
scoliosis has not been reported. curvatures. Occasionally, flexion and extension views are
Decreased vital capacity and other parameters of pul- helpful to determine lumbar spine flexibility and the
monary function may occur in patients with severe tho- presence of sagittal plane instability. These views have
racic curves (> 60), especially in the presence of thoracic been sufficient in most patients for preoperative plan-
lordosis that effectively decreases the anterior-posterior ning. Traction views may be helpful for assessing severe
chest diameter. In one study, up to 35% of patients with deformities, but in deformities less than 60, bending
thoracic curves reported cardiopulmonary symptoms. films provide a better assessment of curve flexibility. A
However, significant alterations in vital capacity as a re- fulcrum bending view (in which the PA radiograph is
sult of restrictive lung disease have not been observed un- taken with the patient in the lateral decubitus position
til the curve magnitude exceeds 90 to 100. In addition, with the apex of the curvature over a large bolster) or a
there is no evidence to suggest that an adult patient with push-prone radiograph (in which the pelvis of the prone
previously normal pulmonary function after skeletal ma- patient is stabilized while the surgeon applies lateral
turity will experience deterioration in pulmonary function pressure to the major curve) can help access thoracic
with progression of the curvature without a preexisting curve flexibility.
history of smoking or some other pulmonary disease. In general, curve magnitude and patient age are the
Finally, the psychologic impact of chronic pain and main predictors of curve flexibility. Every 10 increase
deformity must be considered. In a world where appear- in curve magnitude over 40 results in a 10% decrease
ance and health become increasingly important for so- in curve flexibility. Every 10-year increase in age de-
cial acceptance and well-being, the inability of individu- creases the flexibility of the structural curve by 5% and
als to function at the level of their peers because of pain the lumbosacral fractional curve by 10%.
or deformity can create a huge psychologic burden. The MRI is reserved to evaluate rapidly progressive
influence of spinal deformity on psychologic well-being curves and to determine the cause of any neurologic ab-
has not been determined in the adult population. Small normalities on physical examination. Myelography is
series of patients with adult scoliosis have been reported helpful for evaluating the neural elements in patients
to show a significant negative impact of the spinal defor- with severe rotational deformity and in those with metal
mity on patients perception of health. implants that may obscure the clarity of MRI scans. Dis-
kography has been recommended by some authors as a
Patient Assessment means of evaluating discogenic pain. This is especially
History and Physical Examination relevant in the evaluation of patients with low back pain
A complete history followed by a careful physical exam- and lumbar scoliosis to help determine the distal extent
ination (including a complete neurologic examination) of fusion, especially in patients with disk degeneration
is essential in a patient with adult spinal deformity. The and axial low back pain. A positive diskogram in a pa-
importance of social and family history and occupa- tient with a degenerated disk below the anticipated fu-
tional history cannot be overstated. Depression, sub- sion levels would be a relative indication to extend the
stance abuse, and chronic smoking in patients with adult fusion to encompass the involved degenerated disk.
spinal deformity can result in a less than ideal outcome However, there are no prospective studies to confirm or
after major spinal reconstructive surgery. Overall, the refute the efficacy of this rationale because the results
evaluation of the adult with scoliosis is much more diffi- of provocative diskograms seem to depend to a great
cult than that of adolescents because the usual criteria extent on the interpretation and the technique of the
for surgical treatment are more difficult to interpret. In examiner.
addition, the surgical treatment of scoliosis in adults car- Preoperative pulmonary function testing is useful for
ries a higher rate of complications and involves a longer patients with thoracic curves exceeding 70, patients
recovery period than in adolescents. Proper patient se- with a history of pulmonary disease (chronic smokers),
lection is critical for achieving a successful result. and patients who will require thoracoplasty. Adults who
undergo thoracoplasty experience a 27% decline in pul-
Imaging Studies monary function by 3 months postoperatively, which, in
Standard PA and lateral full-length spine radiographs contrast to adolescents, does not improve appreciably
are an essential part of the evaluation process. Long cas- after 2-year follow-up. Thus, an adult patient with bor-
derline pulmonary function may not tolerate thoraco- which can result from malnutrition. Use of sequential
plasty or thoracotomy. compression devices or foot pumps to minimize the risk
of deep venous thrombosis, mobilization with the assis-
Treatment tance of physical therapy, and aggressive respiratory
Nonsurgical Treatment therapy should be routine. Other useful adjuncts to sur-
gery include an autologous blood exchange program,
The initial treatment of patients with back pain and
the use of the Cell Saver autologous blood recovery sys-
scoliosis should not differ from the treatment of patients
tem (Haemonetics, Braintree, MA) at the time of sur-
with mechanical back pain in the absence of deformity.
gery, carefully monitored intraoperative hypotension,
A relative indication for nonsurgical treatment includes
routine neurologic monitoring, and an experienced an-
patients who physically cannot tolerate the amount of
esthesia staff that can manage the blood loss and fluid
surgery necessary to properly address their pain, defor-
shifts that occur during complex spinal reconstruction.
mity, and neurologic dysfunction. A physical therapy
Finally, redosing of antibiotics every 4 hours or after
program should be instituted to improve aerobic capac-
1,500 mL of blood loss to maintain the antibiotic con-
ity, strengthen muscles, and improve flexibility and joint
centration above the minimum inhibitory concentration
motion. Although local heat application, analgesics, and
is recommended.
bracing all may aid in the amelioration of symptoms,
It is important to remember that the amount of cor-
they do not prevent curve progression. Corticosteroid
rection obtained in the adult patient is secondary to the
injections in the form of nerve root blocks, facet injec-
achievement of coronal and sagittal plane balance. Tho-
tions, and epidural steroid injections may be of consider-
racic rib prominence is best corrected with thoraco-
able value in the arsenal of conservative management of
plasty rather than with overcorrection of the thoracic
adult spinal deformity. In patients who are not surgical
curve. The choice of fixation used to achieve correction
candidates, spinal bracing during ambulation may pro-
and balance is extremely important because osteoporo-
vide some symptomatic relief to improve functionality.
sis is often present in the adult patient. Segmental fixa-
tion provides improved purchase in weakened bone and
Surgical Treatment creates a large area for force transmission in the correc-
The indications for surgery in the adult patient with tion of deformity.
scoliosis include thoracic curve greater than 50 to 60, The use of thoracic pedicle screws in the treatment
with chronic pain that is unrelieved by conservative of traumatic conditions of the spinal column has be-
management; significant loss of pulmonary function not come more popular as experience with the technique in-
attributable to underlying pulmonary disease; docu- creases. The primary benefit of pedicle screw fixation is
mented curve progression with coronal or sagittal plane the ability to shorten the length of fusion across the in-
imbalance; symptomatic deformity that is unacceptable jured level while still having significant three-
to the patient; and lumbar curvature with associated dimensional control over the spinal deformity to be able
back or radicular pain or symptoms of spinal stenosis. to reduce it. Pedicle screw fixation may also provide a
Adult patients have a greater risk of experiencing more secure anchor at the cephalad extent of the fusion
surgical complications than adolescents. Major compli- compared with that provided by hooks. The use of trans-
cations include pseudarthrosis in 5% to 27% of patients, pedicular fixation in the thoracic spine is still controver-
residual pain in 5% to 15%, neurologic injury in 1% to sial because the presence of deformity makes insertion
5%, infection in 0.5% to 5%, and thromboembolism in of screws more difficult and hazardous. In addition, in
1% to 20%. the presence of osteoporosis, the spinal lamina is often
To avoid the detrimental effects of prolonged immo- the most secure point of fixation. In such instances, ex-
bilization, surgical procedures should be designed to cellent correction of thoracic curves can be obtained
provide maximum stability and thus allow early mobili- with a combination of laminar hooks and sublaminar
zation with minimal external support. Combined proce- wires. In contrast to adolescent scoliosis, adult curva-
dures are preferable to staged procedures if this is tech- tures tend to be less flexible and adult patients tend to
nically and physiologically feasible. Combined anterior- have osteoporosis and less healing potential. Thus, pedi-
posterior spinal reconstructive surgery has a lower cle screw fixation alone does not substitute for appro-
infection rate than staged procedures as a result of pa- priate anterior column releases and fusion.
tient malnutrition at the time of the posterior proce- Intraoperative somatosensory-evoked potential and
dure. motor-evoked potential monitoring are especially help-
Normalization of nutritional status does not occur ful when there is a possibility of extensive blood loss,
until 6 to 12 weeks after the index procedure. If surgical hypotension, significant deformity correction, and stiff
procedures need to be staged, the use of hyperalimenta- curvatures. When this type of monitoring is not avail-
tion or enteral nutritional supplementation between able, a wake-up test should be performed after instru-
stages is recommended to help decrease complications, mentation and correction of the curvatures. Combined
somatosensory-evoked potential and motor-evoked po- formity to obtain a balanced correction of the curvature.
tential monitoring is superior to single modality tech- Curvatures that exceed 90 to 100 are often associated
niques in the assessment of real-time root and spinal with rigid ankylosis of the spine and severe coronal im-
cord function. With the development of intercostal mus- balance. In patients with this degree of deformity, a
cle and rectus abdominis intraoperative electromyo- three-stage posterior-anterior-posterior procedure or a
graphic monitoring, thoracic pedicle screws can be vertebral resection procedure is required to gain suffi-
tested to minimize the risk of perforation into the spinal cient spinal mobility and to gain sufficient curve correc-
canal or the neural foramen. tion to obtain spinal balance.
Before any surgical procedure, both surgeon and pa- Patients with spinal stenosis should have decompres-
tient must have realistic expectations for the outcome of sion of the stenotic levels before instrumentation and
the operation. Most studies report a 69% to 95% reduc- correction of the curvatures. Patients with severe lum-
tion in the severity of pain and a 30% to 40% correction bar spinal stenosis who also have decompensation in the
of deformity. sagittal plane can be treated with staged posterior and
In general, the approach to the surgical treatment of anterior surgery. In these patients, decompression of the
adult spinal deformity is based on accepted methods of stenotic levels should be performed before restoration
choosing fusion levels, placement of instrumentation, of sagittal balance. Restoration of lordosis in these pa-
and curve reduction techniques that were derived from tients before decompression of the stenotic levels may
experience in the treatment of adolescent spinal defor- result in a neurologic deficit.
mities. These techniques are then modified to take into Once the spinal deformity is corrected with the appro-
consideration the various challenges presented by adult priate release and instrumentation, a meticulous spinal fu-
patients. These surgical challenges include the presence sion with bone grafting should be performed.Autogenous
of spinal stenosis, stiffer deformities, sagittal plane im- graft from the local fusion bed and the iliac crest are
balance, less potential for healing, osteoporosis, the need placed over the decorticated posterior elements.
to extend the fusion to the sacrum because of stiff frac-
tional curvatures in the lower lumbar spine or the pres-
ence of spinal stenosis, and discogenic pain. In addition, Degenerative Lumbar Scoliosis
an anatomic correction of the spinal deformity is not of- Degenerative lumbar scoliosis can result from untreated
ten achieved or warranted in the adult patient. The goal idiopathic scoliosis, but it more frequently occurs inde-
of surgical correction is to obtain a balanced spine in pendently as a sequela of the aging process in combina-
the sagittal and coronal planes. tion with osteoporosis. Many patients with degenerative
Fusion levels are often determined from the weight- lumbar scoliosis have a combination of both mechanical
bearing PA radiographs, with modifications determined back pain and spinal stenosis. Patients may also present
by lateral bending and weight-bearing lateral radio- with radiculopathy because the neural foramen are nar-
graphs. Some general guidelines exist. All of the struc- rowed at the concavity of the spinal deformity. Fortu-
tural curves should be included in the fusion. The end nately, most of these patients are well balanced in the
vertebra of the fusion should be within the Harrington sagittal and coronal planes despite the magnitude of the
stable zone and should be neutrally rotated when the curvature, and their main symptoms are the result of
deformity corrects on lateral bending. The first unfused neural compression. Decompression of the stenotic spi-
disk space at the caudal end of the fusion should be nal canal and neural foramen often results in significant
flexible on lateral bending. The fusion should not be improvement in pain and function in these patients. Un-
stopped within the apex of the thoracic kyphosis or ad- less the decompressed segments are severely ankylosed,
jacent to a kyphotic motion segment. these levels should be fused to prevent progression of
Curves less than 60 to 70 on the Cobb measure- the scoliosis (Figure 1). The entire deformity does not
ment without significant coronal or sagittal plane dec- need to be included in the fusion as long as the patient
ompensation can be treated effectively using a single is balanced in the sagittal and coronal planes. However,
posterior approach. In patients with this type of spinal fusion levels should be chosen so as not to end the fu-
deformity, radical facetectomies and osteotomies of sion at a listhetic level, the apex of the curvature, or a
ankylosed segments will allow sufficient mobility to kyphotic segment. If instrumentation is used and the pa-
achieve curve correction and balance. Curvatures tient still has lumbar lordosis, mild distraction between
greater than 70 are often associated with coronal and the pedicle screws at the concavity of the curvature
sagittal plane decompensation. These deformities are helps to enlarge and stabilize the neuroforamen.
best treated with a combined anterior-posterior ap- Patients with long fusions to the sacrum should also
proach. Anterior releases and fusions of the most struc- have selective anterior fusion at the L4-5 and L5-S1 seg-
tural portions of the curvature followed by posterior re- ments, with structural grafting to maximize fusion rates
leases and osteotomies with or without rib resections and decrease the possibility of failure of the sacral
will, in most patients, allow sufficient mobility of the de- screws.
Figure 1 PA (A) and lateral (B) weight-bearing radiographs of the lumbar spine of a 50-year-old woman with degenerative scoliosis and spinal stenosis who was treated with
lumbar laminectomy radical facetectomies, instrumentation with correction of scoliosis, and spinal fusion. Postoperative PA (C) and lateral (D) weight-bearing radiographs of the
same patient after decompression and fusion.
In general, arthrodesis to the sacrum for idiopathic or in those in whom previously placed sacral screws
scoliosis should be avoided if possible. Long fusions to have failed, iliac fixation is usually necessary. In the
the sacrum are associated with a higher rate of pseudar- adult patient, Luque-Galveston fixation is associated
throsis, fixed sagittal deformity, instrumentation failure, with a high rate of pseudarthrosis (30% to 40%). Al-
and limited function. Indications to extend the fusion to though iliac fixation with iliac screws is biomechanically
the sacrum include lumbosacral pain secondary to de- strong, iliac screws can be prominent in very thin indi-
generative disk disease below a lumbar curvature when viduals (Figure 2).
a decision has been made to correct the lumbar curve,
an unbalanced lumbosacral curvature with lumbar scoli- Salvage Procedures in Adult Patients
osis for which balance in the lumbosacral curve is not The indications for revision scoliosis surgery in the adult
achieved (as assessed using appropriate side bending ra- include painful pseudarthrosis, progressive deformity
diographs), and the presence of substantial degenera- from pseudarthrosis or inadequate fusion levels, flat-
tion of the motion segments of L4-5 and L5-S1 anteri- back syndrome from distraction implants across the
orly and posteriorly. In selected patients with a fixed lumbar spine, symptomatic adjacent segment degenera-
lumbosacral fractional curve, fusion to the sacrum can tion or vertebral body fracture, and unacceptable resid-
be avoided by an end plate osteotomy at L4 or L5 (with ual deformity.
concave osteophyte excision) to make the end vertebra The goals of surgery are the same as in primary sur-
horizontal, reduce the fractional curve, and create a sta- geryto obtain a solid arthrodesis, achieve three-
ble end vertebra above the pelvis. dimensional spinal balance, and provide rigid internal
When performing long fusions to the sacrum in fixation. The management of pseudarthrosis in the adult
adults, a combined approach is recommended to maxi- patient with scoliosis depends on the level of the pseud-
mize the fusion rate, reestablish lumbar lordosis, and arthrosis, the presence or absence of deformity, the se-
prevent implant failure across the lumbosacral junction. curity of preexisting fixation, and especially the pres-
Two-stage surgery is preferable with the anterior diskec- ence or absence of pain. A painful pseudarthrosis
tomies and fusion, with structural grafts or cages per- associated with progressive deformity and loss of fixa-
formed first followed by posterior fusion and instrumen- tion is a clear indication for spinal revision surgery via a
tation. combined approach. However, thoracic pseudarthrosis
Many techniques are available to secure fixation that is not associated with deformity or loss of fixation
across the lumbosacral junction. These include sacral can be adequately managed by single-stage anterior and
screws placed in a bicortical fashion, sacral screws with posterior repair with copious autogenous bone grafting.
intrasacral rods, iliac wing screws, Galveston technique, Adult patients may present with curve progression
and convergent and divergent sacral screws. Bicortical above or below a previous fusion that was done in child-
sacral screw fixation with structural anterior fusion at hood or adolescence. This condition may be secondary
L5-S1 appears to be an adequate anchor for most long to crankshaft phenomena or the primary fusion being
fusions to the sacrum. In patients with poor bone stock too short. For minor degrees of deformity in young
Figure 2 Preoperative PA (A) and lateral (B) weight-bearing radiographs of an adult patient with scoliosis who was treated with staged anterior and posterior fusion with
posterior fixation to the pelvis using iliac screw fixation. Postoperative PA (C) and lateral (D) weight-bearing radiographs of the same patient.
adults with good bone stock, extension of the fusion to result is associated with increasing patient comorbidi-
include the involved segments and reinstrumentation ties, thoracic pseudarthrosis, and adjacent segment
are sufficient treatment. However, in patients with a breakdown caudad to the fusion. To restore lumbar lor-
fixed deformity with coronal or sagittal imbalance, espe- dosis in patients with multiple pseudarthrosis or fusions
cially in the presence of osteopenia, a combined ap- that are not intact to the sacrum, a combined approach
proach is preferable. is preferable. This may be performed as a first-stage pos-
Disk degeneration may develop below a fusion and terior procedure with osteotomies and instrumentation
require salvage reconstruction. If there is isolated spinal to the sacrum followed by anterior interbody fusion
stenosis, decompression alone is usually sufficient. If the with structural allograft or vice versa (Figure 4). For se-
patient has a vertebral insufficiency fracture below the vere, rigid, unbalanced deformity, a spinal shortening
fusion, extension of the fusion and instrumentation is procedure such as a vertebral body resection is neces-
necessary. sary.
Loss of lumbar lordosis occurs gradually with aging. Postoperatively, adult patients are mobilized within
Iatrogenic loss of lumbar lordosis is typically caused by 24 to 48 hours depending on pain tolerance and overall
the use of distraction implants across the lumbar spine. general condition. Then the patient is given intravenous
Some patients who undergo salvage procedures experi- narcotic medication via a patient-controlled pump until
ence loss of lumbar lordosis secondary to sagittal plane oral pain medication is tolerated. The use of postopera-
imbalance. In these patients, the primary goal of the in- tive anti-inflammatory agents such as ketorolac is con-
dex procedure was coronal plane correction. These pa- traindicated because the fusion rate is adversely af-
tients are best treated with a combined surgical proce- fected. Perioperative antibiotics can be continued for 36
dure. For patients with a solid arthrodesis, a pedicle to 48 hours. Antiembolic stockings and sequential com-
subtraction osteotomy with vertebral body decancella- pression devices are used to minimize the incidence of
tion using the posterior approach and rigid internal fixa- venous thrombosis until the patients are ambulatory.
tion can provide up to 30 to 40 of sagittal plane cor- Anticoagulation is not performed routinely, but it may
rection. This procedure is particularly useful in patients be considered in high-risk patients and in patients with
with combined anterior and posterior fusion who still a preexisting history of thromboembolic disease. In pa-
have flat-back deformity (Figure 3). A poorer clinical tients with a history of pulmonary embolism, a vena
Figure 3 PA (A) and lateral (B) full-length weight-bearing radiographs of a 56-year-old woman with lumbar flat-back syndrome following lumbar decompression and instru-
mented fusion. The patient had severe sagittal plane decompensation and recurrent spinal stenosis with back pain and bilateral buttock and leg radiculopathy. Note that the
lateral radiograph demonstrates evidence of severe sagittal plane decompensation. Postoperative PA (C) and lateral (D) full-length weight-bearing radiographs of the same
patient after revision laminectomy and transpedicular wedge resection at L3 with restoration of sagittal balance.
cava filter may be considered before surgical interven- source of bone graft. It is well known that pulmonary
tion. The patients are fitted with a lightweight plastic function can deteriorate after thoracotomy and thoraco-
orthosis within 5 to 7 days of surgery and are instructed plasty. These procedures should be used with extreme
to wear the brace full time, except when in bed and for caution in patients with severely compromised pulmo-
hygiene. nary function. Unlike adolescents, adult patients with
scoliosis do not recover lost pulmonary function, even at
Controversial Issues in Managing Adult 2-year follow-up.
Patients With Scoliosis
The absolute indications for combined surgery versus Results and Complications
posterior fusion and instrumentation alone are unclear. The results of surgical correction of spinal deformity in
Combined surgery allows for better correction and rees- adults have improved significantly over the past decade.
tablishment of physiologic lumbar lordosis through the The rate of complications ranges from 12% to 23% of
use of anterior structural grafting, and it increases the patients. Pseudarthrosis rates have varied between 5%
probability of successful fusion. In patients with com- to 27% of patients, with higher rates of pseudarthrosis
plex deformities involving the lumbar spine in which fu- occurring after revision surgery and after using nonseg-
sion across the lumbosacral junction is necessary to mental posterior implants in distraction mode. Pain in
achieve spinal balance, combined procedures are prefer- these patients is seldom totally alleviated by surgical
able because 15% to 20% of patients who undergo pos- correction. However, reports of residual pain after com-
terior instrumentation and fusion have pseudarthrosis, plex spinal reconstructive surgery vary between 5% and
even when the stiffer third-generation instrumentation 25% of patients. Approximately 61% of patients report
systems are used. improved sleep patterns after surgical treatment, and
Thoracoplasty is a useful adjunct in treating patients 57% are able to return to work. Mortality remains low
with spinal deformity. Thoracoplasty reduces rib promi- in patients who undergo complex spinal reconstructive
nence by 71% compared with only a 17% reduction in surgery, but it is not insignificant (< 1% to 5% of pa-
control subjects. Rib resection also provides a good tients). Overall, patient outcomes as assessed by the
Figure 4 Preoperative PA (A) and lateral (B) full-length weight-bearing radiographs of a 50-year-old woman with flat-back syndrome and pseudarthrosis after posterior lumbar
interbody fusion with threaded cages at L4-5 and instrumented posterolateral fusion at L5-S1. Note that the lateral radiograph shows evidence of significant sagittal plane
decompensation. Postoperative PA (C) and lateral (D) radiographs of the same patient after multiple level Smith-Peterson osteotomies and instrumented fusion and repair of
pseudarthrosis. Note that the postoperative lateral radiograph shows evidence of restoration of lumbar lordosis.
Medical Outcomes Study Short Form 36-Item Health of the curve, and preexisting atherosclerosis. Thus,
Survey (SF-36) and the American Academy of Ortho- proper postoperative volume support and vigilance are
paedic Surgeons Modems Instrument are significantly essential. Loss of vision as a complication of spinal re-
associated with radiographic correction of the lumbar constructive surgery is a rare but often permanent event
lordosis to greater than 25 and coronal plumb align- that can occur as the result of ischemic optic neuropa-
ment to within 2.5 cm. Patients with primary degenera- thy, retinal artery occlusion, or cerebral ischemia. The
tive lumbar scoliosis as well as those who have had long incidence of pulmonary embolism varies from 1% to
fusions to L4, L5, or the sacrum have improved gait pa- 20% of patients, depending on the series. Air embolism
rameters (both speed and endurance) after spinal de- can occur in patients with patent foramen ovale. How-
compression and fusion, with restoration of coronal and ever, only a few isolated instances of this complication
sagittal balance. Outcomes assessment in this challeng- have been reported. Flail chest can occur with overag-
ing group of patients is necessary to determine the im- gressive thoracoplasty, especially in revision situations.
pact of deformity correction on the patients quality of Infection is a relatively rare event in patients who
life and daily function. The Modified Scoliosis Research undergo surgery for spinal deformities; it occurs in be-
Society Outcomes Instrument for Adult Deformity, the tween 1% and 8% of patients. In addition, infection af-
Oswestry Disability Index, and the SF-36 are the most ter anterior surgery alone occurs in about 1% of pa-
commonly used validated outcomes questionnaires for tients. However, the sequelae of deep postoperative
adult patients undergoing spinal deformity surgery. infection are substantial, with up to 38% to 64% of pa-
Neurologic injury occurs in fewer than 1% to 5% of tients having pseudarthrosis at 37-month follow-up. De-
patients who undergo surgical treatment for spinal de- layed infections can occur more than 2 years postopera-
formities. Significant risk factors for major intraopera- tively, typically with low virulent organisms.
tive neurologic deficits include combined anterior and If coronal and sagittal balance is achieved and main-
posterior surgery and hyperkyphosis. Delayed postoper- tained with a solid fusion, the outcomes are generally
ative paraplegia is another devastating complication af- excellent. Pulmonary improvement after correction of
ter extensive spinal reconstructive surgery, and it can oc- spinal deformity is unlikely to occur in the adult and the
cur several hours after the completion of the procedure. use of thoracoplasty may actually reduce pulmonary
This phenomenon has been attributed to ischemia of function. The correction of curvature varies from 30%
the spinal cord from postoperative hypovolemia, me- to 60% and depends on the nature and flexibility of the
chanical tension of spinal blood vessels on the concavity patients preoperative curve and the technique used for
correction. Despite these relatively modest gains, satis- Suk S, Kim WJ, Lee SM, et al: Thoracic pedicle screw
faction with surgical correction is generally high and can fixation in spinal deformities: Are they really safe?
reach up to 90% of patients. Spine 2001;26:2049-2057.
In this study, 4,604 thoracic pedicle screws were placed in
the treatment of adult patients with spinal deformity; the au-
Annotated Bibliography thors report an overall rate of screw malposition of 1.5%.
Prevalence and Natural History Most thoracic pedicle screws were placed inferior or lateral to
Kovacs FM, Gestoso M, Gil del Real MT, Lopez J, Mu- the pedicle. Screw-related complications occurred in 0.8% of
fraggi N, Mendez JI: Risks factors for non-specific low patients. Deformity correction was 69.9% for patients with
back pain in school children and their parents: A popu- coronal plane deformities and 47 for those with kyphosis.
lation based study. Pain 2003;103:259-268.
In this European study involving 16,394 adolescents and Voos K, Boachie-Adeji O, Rawlins BA: Multiple verte-
their parents, the lifetime prevalence of low back pain was bral osteotomies in the treatment of rigid adult spinal
50.9% for males and 69.3% for females. Scoliosis was an inde- deformities. Spine 2001;26:526-533.
pendent risk factor. This retrospective chart and radiographic review of 27
consecutive adult patients with spinal deformity demonstrated
Schwab F, Dubey A, Pagala M, et al: Adult scoliosis: A the efficacy of multiple vertebral osteotomies in the manage-
health assessment analysis by SF-36. Spine 2003;28:602- ment of rigid adult spinal deformities. The authors reported
606. that the average scoliosis correction for these patients was
This prospective self-assessment of a consecutive series of 40% and the average correction in sagittal balance was 6.5 cm.
adult patients with scoliosis showed that scoliosis has a signifi-
cant impact on patients perception of health. Degenerative Lumbar Scoliosis
Berven S, Hu SS, Deverin V: Lumbar end plate osteot-
omy in adult patients with scoliosis. Clin Orthop 2003;
Weinstein SL, Dolan LA, Spratt KF, Peterson KK,
411:70-76.
Spoonamore MJ, Ponseti IV: Health and function of pa- The authors of this study discuss a technique of end plate
tients with untreated idiopathic scoliosis: A 50-year nat- osteotomy and concave osteophyte excision in adults with
ural history study. JAMA 2003;289:559-567. fixed lumbosacral fractional curves that avoids extension of
This prospective cohort analysis of 117 untreated patients fusion to the sacrum.
with idiopathic scoliosis followed over a 50-year span showed
a greater incidence for back pain and cosmetic deformity in
patients with scoliosis compared with 62 control patients. Pa- Bridwell KH, Edwards CC II, Lenke LG: The pros and
tients with thoracic curves greater than 80 were more likely cons to saving the L5-S1 motion segment in a long scoli-
to report shortness of breath, suggesting a deterioration of
osis fusion construct. Spine 2003;28:S234-S242.
This article presents a review of the literature and the au-
pulmonary function in this subgroup.
thors personal experiences concerning the advantages and
disadvantages of extending a long scoliosis fusion to the
Patient Assessment sacrum. The subject is controversial and no good studies exist
Davis BJ, Gadgil A, Trivedi J: Ahmed el NB: Traction ra- that definitively answer the question.
diography performed under general anesthetic: A new
technique for assessing idiopathic scoliosis curves. Spine Tribus CB: Degenerative lumbar scoliosis: Evaluation
2004;29:2466-2470. and management. J Am Acad Orthop Surg 2003;11:174-
Traction radiographs taken with the patient under general
183.
anesthesia allow a better assessment of curve flexibility than This article presents a review of evaluation and treatment
standard supine bending radiographs. This finding may obviate of degenerative scoliosis.
the need for anterior release and fusion in select patients.
Comparison to fulcrum bending radiographs was not per-
Salvage Procedures in Adult Patients
formed in this study.
Berven SH, Deviren V, Smith JA, Hu SH, Bradford DS:
Management of fixed sagittal plane deformity: Outcome
Treatment of combined anterior and posterior surgery. Spine 2003;
Ali R, Boachie-Adjei O, Rawlins BA: Functional and ra- 28:1710-1715.
diographic outcomes after surgery for adult scoliosis us- Twenty-five patients with fixed sagittal imbalances were
ing third-generation instrumentation techniques. Spine treated with combined anterior-posterior fusion. This study
2003;28:1163-1169. showed that combined surgery is an effective method to treat
This retrospective radiographic and chart review of 28 pa- fixed sagittal deformity. Patients with preoperative hypolordo-
tients with adult scoliosis treated with primary corrective sur- sis (relative flat-back syndrome) who had good restoration of
gery showed significant clinical and radiographic improve- lumbar lordosis and sagittal plane balance had the best out-
ments using third-generation spinal implants. comes.
Bridwell K, Lewis S, Lenke LG, et al: Pedicle subtrac- evaluated for severity of back pain and overall function. Func-
tion osteotomy for the treatment of fixed sagittal imbal- tional scores for patients with scoliosis were lower than those
ance. J Bone Joint Surg Am 2003;85-A:454-463. for the control group. Frequency and severity of back pain
In this study, 27 consecutive patients with fixed sagittal im- scores were lower in patients treated with fusion than in the
balance and treated with pedicle subtraction osteotomy were patients with untreated scoliosis.
evaluated using Oswestry and Modified Scoliosis Research So-
ciety Outcomes Instrument for Adult Deformity question-
naires. The authors report that pedicle subtraction osteotomy
Classic Bibliography
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cant improvements in overall Oswestry scores and decreased Health outcome assessment before and after adult de-
pain scores. A poorer clinical result was associated with in- formity surgery: A prospective study. Spine 1995;20:
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spine, and subsequent breakdown caudad to the fusion.
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history of untreated idiopathic scoliosis after skeletal
Results and Complications maturity. Spine 1986;11:784-789.
Eck KR, Bridwell KH, Ungacta FF, et al: Complications
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L5, and the sacrum. Spine 2001;26:E182-E192. tion and arthrodesis for complex spinal deformities.
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follow-up). They report that patients with fusions short of the the treatment of rigid coronal decompensation. Spine
sacrum who developed distal spinal degeneration had worse 1997;22:1590-1599.
outcomes that those patients with fusion to the sacrum.
Collis DK, Ponseti IV: Long-term follow-up of patients
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nal deformity. Spine 2002;27:776-786. Dickson JH, Mirkovic S, Noble PC, Nalty T, Erwin WD:
This is a retrospective study of 54 adult patients with spi- Results of operative treatment of idiopathic scoliosis in
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anterior and posterior reconstruction with a minimum 2-year Goldberg MS, Mayo NE, Poitras B, Scott S, Hanley J:
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complications in adult deformity patients having com- Hu SS, Fontaine F, Kelly B, Bradford DS: Nutritional
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This outcomes analysis compares the complication rates of 1405.
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results demonstrated similar rates of minor complications of age. J Spinal Disord 1996;9:460-469.
(22% to 23% of patients). The primary surgery group had a
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rate of pseudarthrosis compared with the revision surgery
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Table 1 | Risk Factors for Pyogenic Vertebral Osteomyelitis Table 2 | Risk Factors for Neurologic Deterioration With
Vertebral Osteomyelitis
Male sex
Intravenous drug abuse Diabetes mellitus
Diabetes mellitus Rheumatoid arthritis
Urinary tract infection Systemic corticosteroid use
Respiratory tract infection Advanced age
Recent genitourinary procedure Cephalad level of infection (high thoracic or cervical)
Previous spinal procedure Staphylococcal infection
Morbid obesity
Alcohol abuse
Human immunodeficiency virus/acquired immunodeficiency syndrome to paralysis include diabetes, rheumatoid arthritis, sys-
Malignancy temic steroid use, increasing age, Staphylococcus infec-
Corticosteroid use tion, and a more cephalad level of infection. The risk
Penetrating trauma factors for neurologic deterioration with vertebral os-
teomyelitis are summarized in Table 2.
sive techniques such as endoscopic or thoracoscopic ap- dality of choice for the diagnosis of spinal infections.
proaches may be considered when appropriate. Open MRI has a sensitivity of 96% and specificity of 93% for
biopsies yield positive results in more than 80% of pa- the diagnosis of vertebral osteomyelitis. On T1-weighted
tients. All biopsy specimens should be sent for Gram images, the affected vertebral body and disk both show
stain, acid-fast and potassium hydroxide staining, and low signal intensity with loss of distinction at their mar-
cultures (including aerobic, anaerobic, mycobacterium, gins, secondary to the marrow edema and decreased fat
fungi, and atypical mycobacterium). All cultures should content. In contrast, on T2-weighted images, the verte-
be retained to allow for the growth of mycobacterium bral body has increased signal intensity secondary to the
and low virulence organisms. Especially with low- increase in water content associated with the inflamma-
virulence and indolent bacteria, polymerase chain reac- tion and edema. On gadolinium-enhanced T1-weighted
tion has facilitated earlier identification of the infecting images, abscess collections show abnormal rim enhance-
organism. Caution is needed to avoid cross contamina- ment, whereas areas of active inflammation in the verte-
tion with the use of polymerase chain reaction. Speci- bral body and disk are enhanced.
mens also should routinely be sent for histologic analy-
sis to rule out malignancy. Treatment
Malnutrition is often coincident with spinal infec- The goals for treatment of spinal infections include es-
tion; therefore, an evaluation of the patients nutritional tablishing a diagnosis and identifying the organism,
status is crucial in determining appropriate nutritional eliminating the infection, preventing or improving neu-
therapy as a part of treatment. Laboratory measures rologic involvement, and maintaining spinal stability. As
such as serum albumin level less than 3 g/dL, a serum with other illnesses, nutritional repletion and optimiza-
transferrin level of less than 150 ug/dL, and an absolute tion of medical comorbidities are crucial to eradication
lymphocyte count less than 800/mL suggest severe mal- of the infection.
nutrition, which should be addressed as part of the Treatment of vertebral osteomyelitis usually entails a
treatment of the vertebral osteomyelitis. trial of nonsurgical treatment with spinal immobiliza-
tion, early ambulation, proper nutritional support, and
Radiographic Evaluation intravenous antibiotics followed by oral antibiotics (spe-
Imaging studies lag behind the clinical course of pyo- cific for the organism cultured). If the offending organ-
genic vertebral osteomyelitis but are vital in localizing ism cannot be identified even after biopsy, empiric
and determining the extent of involvement of the infec- parenteral antibiotics should be administered.
tion and for assessing the response to treatment. Plain Parenteral antibiotics are generally recommended for 4
radiographs can show subtle paravertebral soft-tissue to 6 weeks to prevent high failure rates of nonsurgical
swelling in the first few days of infection. After 7 to 10 treatment in patients with pyogenic infections. Patients
days, disk space narrowing can be observed. After sev- are converted to oral antibiotics after signs of clinical
eral weeks, radiographs show frank erosion and destruc- improvement, normalization of the ESR and CRP lev-
tion of the vertebral end plates and anterior vertebrae els, or resolution of the infection on imaging studies.
with extension into the central portion of the vertebral Immobilization of the affected area helps prevent
body. The disk space continues to collapse and vertebral deformity and aids in pain relief. The application of a
compression and paraspinal mass are noted. CT scans rigid contact brace is effective in the lumbar region. A
show paravertebral soft-tissue masses and, most impor- rigid cervicothoracic orthosis or halo is often required
tantly, define the extent of bony involvement of the in- for cervical osteomyelitis. Serial laboratory tests (CRP
fection. CT scans show the anatomy in detail and can be and ESR) should be followed to monitor response to
used to guide percutaneous drainage or biopsy and for treatment. Approximately 75% of patients respond to
preoperative planning. nonsurgical treatment with resolution of pain and often
Radionuclide studies also are useful in evaluating spontaneous fusion.
spinal infections and can be positive before the develop- Surgical intervention is warranted to obtain a tissue
ment of radiographic changes. Technetium Tc 99m bone diagnosis after failed percutaneous needle biopsies, to
scintigraphy is more than 90% sensitive, but it lacks address neurologic deficit secondary to compression, to
specificity for infection. Scans that combine technetium treat spinal instability or significant deformity, to drain
Tc 99m with gallium 67 increase both the sensitivity and infectious foci causing sepsis, or for failure of nonsurgi-
specificity for identifying infection. Indium 111-labeled cal medical treatment alone. Nonsurgical treatment is
leukocyte scans are not recommended for vertebral os- often unsuccessful in elderly and immunocompromised
teomyelitis because of poor sensitivity (17%). Gallium patients, who then require surgical management. The lo-
scans may be used to follow treatment response because cation of the infection and the goals of the surgery dic-
they begin to normalize during the recovery phase. MRI tate the intervention performed. If the surgery is in-
with gadolinium contrast has become the imaging mo- tended to obtain a specimen for diagnosis, then an
Figure 1 Imaging studies of an 80-year-old man with a 3-month history of increasing neck pain and recent onset of fever. A, A lateral radiograph shows collapse of the C5
vertebral body and end plate erosion of C4 and C6 with segmental kyphosis secondary to pyogenic vertebral osteomyelitis. The patient was treated with anterior dbridement and
corpectomy of C5, with partial corpectomy of C4 and C6, and with allograft fibula strut graft. This treatment was followed by posterior stabilization with C3-7 lateral mass fixation
and iliac crest bone graft. Postoperative lateral (B) and AP (C) radiographs.
Figure 2 Imaging studies of a 60-year-old man who had worsening back pain for 2 months. A, Lateral radiograph of the lumbar spine shows complete loss of disk space at L3-4
and end plate erosions of the L3 and L4 vertebrae. B, T2-fat suppressed MRI scan of the lumbar spine shows L3-4 diskitis and associated pyogenic vertebral osteomyelitis. C, The
patient was treated with anterior dbridement with interbody fusion using allograft strut followed by posterior fusion with instrumentation.
teriorly. The majority of spinal epidural abscesses are Patients with an acute epidural abscess usually have
found in the thoracic (51%) and lumbar (35%) spine. more systemic illness than those patients with vertebral
Most of these infections are posterior unless contiguous osteomyelitis. Laboratory evaluation shows leukocytosis
with vertebral osteomyelitis. Three to four spinal seg- (mean, 22,000 cells/mm3), elevated ESR (mean, 86.3 mm
ments are usually involved, but the entire spinal column in 1 hour), and an elevated CRP. Plain radiographs are
is at risk. usually normal unless contiguous vertebral osteomyelitis
Initially, there is an inflammatory reaction in the epi- or diskitis has been present long enough for the radio-
dural fat that progresses to suppuration, necrosis, and fi- graphic findings to be positive. CT scans have a poor
brosis in the epidural space. The pathogenesis of the sensitivity for epidural abscess. MRI with gadolinium
neurologic manifestations is related either to direct contrast is the imaging modality of choice for the diag-
compression of the neural elements or to compromise nosis and evaluation of spinal epidural abscess. The ex-
of the intrinsic circulation of the spinal cord. act location and extent of the abscess, the amount of
neurologic compression, and the presence and severity
of contiguous infection can all be evaluated with MRI.
Clinical Characteristics and Diagnosis Pus in the epidural space will enhance with gadolinium,
Intractable back or neck pain is the most common whereas the cerebrospinal fluid will show low signal in-
symptom in patients with a spinal epidural abscess. tensity on T1-weighted images. Biopsy of the adjacent
However, the clinical presentation of a patient with an disk, vertebral body, or surrounding tissue provides the
epidural abscess can be highly variable; this variability definitive diagnosis of spinal epidural abscess and iden-
leads to frequent misdiagnosis on initial presentation. tification of the offending organism.
Most patients with an acute spinal epidural abscess have
fever, back pain, and spinal tenderness; however, these Treatment and Prognosis
outward signs may be absent if the disease is chronic. If Historically, the presence of spinal epidural abscess has
treatment is not initiated early, the back pain is followed been regarded as a medical and surgical emergency. The
by radicular pain, weakness, paralysis, and even frank objectives of treatment of epidural abscesses are eradi-
sepsis. The immune status of the host and the virulence cation of infection, prevention or improvement of neu-
of the offending pathogen dictate the timing and sever- rologic sequelae, and preservation of spinal stability.
ity of the progression of the infection. If the abscess Nonsurgical treatment of a spinal epidural abscess is
penetrates the dura, a subdural abscess or meningitis only indicated in patients who are neurologically stable
may occur. or are unsuitable surgical candidates because of medical
comorbidities. A recent study showed that nonsurgical with spinal epidural abscess included younger age, less
treatment of spinal epidural abscess is possible if no than 50% thecal sac compression, lumbosacral location,
neurologic compromise has occurred. A new or progres- the presence of pustular abscesses as opposed to granu-
sive neurologic deterioration warrants immediate lation tissue, and shorter duration of symptoms.
change from nonsurgical to surgical treatment.
Surgical intervention is the current treatment for Nonpyogenic Vertebral Osteomyelitis
most patients with spinal epidural abscess. The surgical Nonpyogenic or granulomatous infections of the spine
approach and technique depend on the location and ex- may be caused by fungi, atypical bacteria, or spiro-
tent of the infection. Because the location is usually pos- chetes. These infections are grouped together because,
terior, a decompressive laminectomy over the involved although the lesions resulting from these causes are not
levels generally is the treatment of choice. Wide decom- common, when they occur they have a similar clinical
pression with facetectomy is not usually required for ad- and histologic presentation. Most spinal infections in pa-
equate dbridement and should be avoided because iat- tients in the United States are pyogenic; however, with
rogenic spinal instability may result. If anterior the increased number of immunocompromised hosts,
vertebral osteomyelitis or diskitis is present, combined more nonpyogenic infections have emerged in the past
anterior and posterior dbridement may be necessary decade. The pathophysiology of granulomatous spinal
(Figure 3). Reconstruction of the anterior column with infection differs from that of pyogenic infections. By far,
structural graft or instrumentation may be required if the most common granulomatous disease of the spine is
significant bony destruction has occurred. Posterior fu- caused by Mycobacterium tuberculosis. Tuberculous
sion with instrumentation often is preferred when acute spondylitis (Potts disease) is the most extensively re-
infection is present after anterior dbridement. searched disease in this group of infections.
Parenteral antibiotics are chosen based on the culture
and sensitivity results, and are continued for 2 to 4 Epidemiology and Pathogenesis
weeks after adequate surgical dbridement. If vertebral Although tuberculosis (TB) is endemic in many devel-
osteomyelitis is present, parenteral antibiotics should be oping countries, it was nearly eradicated in the United
administered for at least 6 weeks. States. Nevertheless, there has been a resurgence of TB
Spinal epidural abscesses continue to have signifi- infection in the past decade, with the disease often oc-
cant morbidity and mortality as a result of diagnostic curring in immunocompromised patients and with resis-
delay. Recent literature reports that early diagnosis re- tant strains of the organism. The human immunodefi-
mains the most essential factor in preventing devastat- ciency virus and acquired immunodeficiency syndrome
ing outcomes. A recent retrospective study found that epidemic is a major cause of the increase in TB infec-
factors associated with improved outcome of patients tion in the United States. Ten percent of patients in-
fected with TB will develop musculoskeletal infection, tional symptoms of chronic illness including intermittent
but 50% of these patients will have spinal involvement. fever, malaise, night sweats, and weight loss. Neurologic
Hematogenous seeding from the respiratory or geni- deficit is present in 10% to 47% of patients with Potts
tourinary tract is the usual mode of spread of infection disease. Deformity at the time of diagnosis is more com-
to the spine. Local spread by direct extension is also mon in TB infection than in pyogenic spinal infection.
possible. Most active cases of spinal TB in adults are ac- Laboratory studies are helpful but nonspecific. The
tually reactivations of quiescent lesions from previous white blood cell count often is not elevated. The ESR is
infection. usually elevated but may be normal in up to 25% of pa-
The three major types of spinal involvement of ver- tients. Purified protein derivative skin tests typically are
tebral TB describe the pattern of bony involvement. The positive, which suggests either active or previous dis-
most common form is the peridiskal type, which begins ease. False negative results are possible because of an-
with infection in the metaphyseal area that spreads un- ergy, which could result from any condition that com-
der the anterior longitudinal ligament and later involves promises host immunity. A chest radiograph should be
the adjacent vertebral bodies. In contrast to pyogenic in- obtained in all patients to rule out active lung involve-
fection, the disk is relatively resistant to infection and is ment.
often preserved until late in the infection process de- Plain radiographs are useful in diagnosis, but they
spite extensive bony destruction. With the anterior type, will vary in appearance depending on the pathologic
infection spreads beneath the anterior longitudinal liga- type and chronicity of the infection. After several weeks
ment and may involve several vertebral levels, causing of infection, radiographs show vertebral end plate lu-
anterior erosions on the involved vertebral bodies. Cen- cency and loss of cortical margins. Soft-tissue swelling
tral type infections often are mistaken for tumors be- and expansion across two to three spinal segments fol-
cause they remain isolated to one vertebra and often low. Eventually, the classic pattern of disk space destruc-
cause collapse and deformity. Isolated posterior element tion with lucency and compression of adjacent vertebral
involvement has been described but is exceedingly rare. bodies is seen, followed by further collapse into a ky-
The pathologic findings in tuberculous spondylitis photic deformity.
differ in several respects from pyogenic vertebral osteo- Nuclear medicine studies with a combination of
myelitis. The disk is relatively resistant to infection by technetium and gallium nuclear scans have been shown
TB. In addition, the development of the infection takes to have the highest sensitivity for detecting infection.
a longer period of time, and more deformity is typically CT scans are beneficial in evaluating the extent of bony
observed at the time of presentation. Large paraspinal destruction and in surgical planning. However, the pre-
abscesses are more common with tuberculous infections. ferred imaging study for the diagnosis of tuberculous
The thoracic spine is the most common location for spi- and fungal infections remains MRI with gadolinium
nal TB followed by lumbar involvement. The cervical contrast. MRI helps to differentiate metastatic disease
spine is rarely involved. from vertebral osteomyelitis; the lack of disk space in-
Other etiologies of granulomatous infection are also volvement is seen with MRI only with metastatic dis-
increasing in incidence with the increasing number of ease.
immunocompromised hosts. Atypical bacteria such as Definitive diagnosis requires a positive biopsy with
Actinomyces israelii, Nocardia asteroids, and Brucella culture of the organism. Studies have shown that CT-
species also cause chronic granulomatous infection. Tre- guided biopsy with cultures and staining allows identifi-
ponema pallidum, the organism responsible for syphilis, cation of the organism. Mycobacteria are acid-fast ba-
causes gummatous lesions in the spine, which are syphi- cilli and may take up to 10 weeks to grow in culture.
litic granulomas representing the local reaction of the Polymerase chain reaction has been used for fast identi-
tissues to the organism and its products. Fungal infec- fication of mycobacteria with a sensitivity of 95% and
tions of the spine are uncommon and often have a sig- accuracy of 93%.
nificant delay in diagnosis. Coccidioides immitis, Blasto-
myces dermatitidis, Cryptococcus neoformans, Candida Treatment
species, and Aspergillosis are all responsible for fungal Nonpyogenic vertebral osteomyelitis is usually treated
infections of the spine. In a recent study of patients with with chemotherapy directed at the offending pathogen.
fungal spinal infections, the Candida species were the Additionally, an external immobilization device may be
most common fungal pathogens. used for pain control and prevention of deformity. Tu-
berculous spondylitis is treated with isoniazid, rifampin,
Clinical Presentation and Evaluation and pyrazinamide for 9 to 18 months depending on re-
The onset of symptoms with tuberculous spondylitis is sponse to treatment. Ethambutol or streptomycin is usu-
typically more insidious than with a pyogenic infection. ally added to the regimen for at least part of the treat-
Patients usually report pain in the spine and constitu- ment. It is recommended that an infectious disease
Figure 4 Imaging studies of a 48-year-old woman who presented with a 6-month history of severe low back pain. A, Plain radiograph shows evidence of chronic pyogenic
vertebral osteomyelitis of L4-5 with sclerosis and apparent autofusion consistent with the duration of symptoms. B, Sagittal T2-weighted MRI shows continued enhancement of L4
and L5 vertebral bodies as well as diskitis at L5-S1. AP (C) and lateral (D) postoperative radiographs of the patient who was treated with anterior dbridement and interbody
fusion of L4-L5 and L5-S1, with femoral ring allografts followed by posterior fusion with instrumentation.
consultation be done in conjunction with the chemo- gest that anterior instrumentation reduces kyphotic de-
therapy regimen because of varying regional resistance formity without increasing the risk of disease recur-
patterns. Amphotericin B and ketoconazole provide the rence. In patients with neurologic deficit, earlier
mainstay for the treatment of most fungal infections. dbridement led to a faster and better neurologic recov-
Brucellosis is typically treated with tetracycline and ery. There is a direct correlation between duration of
streptomycin. Nocardia infections are treated with sul- preoperative symptoms and neurologic recovery.
fonamides, whereas actinomycosis is still treated with
penicillin. Postoperative Spinal Infections
The surgical indications for treatment of nonpyo- An increase in the incidence of postoperative infections
genic spinal infections are neurologic deficits, failure of has been documented in the past decade. Postoperative
response to nonsurgical treatment after 3 to 6 months, infections result from inoculation during the index pro-
the need for tissue for diagnosis, spinal instability, pro- cedure or by hematogenous seeding of the surgical site.
gressive kyphotic deformity, and/or recurrence of the Lumbar diskectomy performed with the use of prophy-
disease. Surgical options include anterior dbridement lactic antibiotics carries a 0.7% incidence of infection.
and strut graft alone or with posterior instrumentation The use of the operating microscope for diskectomy in-
and fusion (Figure 4), or posterior dbridement without creases that rate to 1.4%. Studies have shown that lum-
anterior surgery done only for isolated posterior dis- bar fusion with instrumentation has an estimated inci-
ease. If a laminectomy were performed for isolated pos- dence of postoperative infection of 6%. A recent
terior arch disease or posterior epidural abscess, then a retrospective review showed a wound infection rate of
supplemental fusion would be recommended. Anterior 10% in trauma patients who underwent fusion for tho-
dbridement and reconstruction at the site of pathology racolumbar fractures. The authors concluded that the
has shown the best long-term neurologic and structural overall risk of infection is higher in the trauma patient
results. Graft choice is dependent on surgeon prefer- than in the elective surgery population and that those
ence. Autogenous and allograft strut grafts are accept- patients with complete neurologic deficit are at a
able with good results. A recent study showed that ante- greater risk of infection. Another recent study showed
rior spinal instrumentation with structural allograft that late pain at the surgical site appearing 12 to
fibula could be used after proper anterior dbridement 20 months after scoliosis surgery with posterior instru-
of tuberculous spondylitis with a 96% fusion rate and mentation is most often attributable to a subacute low-
no recurrence of infection. Patients did not require ex- grade implant infection.
ternal support in the postoperative period. Another Prophylactic antibiotics have been shown in several
study, using fresh frozen femoral allografts and stabiliza- studies to significantly reduce the incidence of postoper-
tion with a single-rod construct after anterior dbride- ative infections. Prophylactic antibiotics should reach
ment, showed excellent results with incorporation of the peak concentrations quickly and cover S aureus and
allografts between 12 and 18 months. These studies sug- S epidermidis. Cefazolin, a first-generation cephalospo-
Table 3 | Risk Factors for Developing Postoperative tibiotics taken for 6 weeks are required for patients with
Infections deep infection, bony involvement, or retained hardware.
Advanced age
Annotated Bibliography
Obesity
Diabetes mellitus Pyogenic Vertebral Osteomyelitis
Hee HT, Majd ME, Holt RT, Pienkowski D: Better
Smoking
treatment of vertebral osteomyelitis using posterior sta-
Immunocompromised host
bilization and titanium mesh cages. J Spinal Disord Tech
Length of preoperative hospitalization 2002;15:149-156.
Myelodysplasia The authors evaluated the efficacy of using titanium mesh
Revision surgery cages anteriorly and posterior instrumentation after anterior
Increased surgical time dbridement in the surgical treatment of vertebral osteomyeli-
Spinal instrumentation tis. Patients treated with cages had better sagittal and coronal
Bone graft correction.
Methylmethacrylate
Arthrodesis Schimmer RC, Jeanneret C, Nunley PD, Jeanneret B:
Trauma Osteomyelitis of the cervical spine: A potentially dra-
matic disease. J Spinal Disord Tech 2002;15:110-117.
A retrospective review of 15 patients treated for osteomy-
elitis of the cervical spine is presented. Good results were
rin, has good Staphylococcus coverage and should be ad- achieved by early and aggressive surgical intervention.
ministered at least 20 minutes before surgery. To prevent
resistance, vancomycin should be used for prophylaxis
Spinal Epidural Abscess
only in patients at high risk for methicillin-resistant S au-
Tang HJ, Lin HJ, Liu YC, Li CM: Spinal epidural ab-
reus. Risk factors for postoperative spinal infections are scess: Experience with 46 patients and evaluation of
listed in Table 3. prognostic factors. J Infect 2002;45:76-81.
Clinical presentation of postoperative infections de- This article reviewed 46 patients treated for spinal epidu-
pends on timing and the depth of the infection. In the ral abscess with emphasis on defining clinical characteristics,
immediate postoperative period, patients with superfi- treatment options, and evaluation of prognostic factors.
cial wound infections may have pain, fever, tenderness,
erythema, and drainage from the incision site. Diagnosis Nonpyogenic Vertebral Osteomyelitis
of deep wound infections is more difficult because com- Frazier DD, Campbell DR, Garvey TA, Wiesel S, Bohl-
plete onset may be delayed, with only constitutional man HH, Eismont FJ: Fungal infections of the spine:
symptoms and a well healed surgical incision. Labora- Report of eleven patients with long-term follow-up.
tory values including leukocyte count, ESR, and CRP J Bone Joint Surg Am 2001;83:560-565.
are often elevated. The acute phase reactants are nor- This article presents a retrospective review of 11 patients
mally elevated in the immediate postoperative period. treated for spinal osteomyelitis caused by a fungus. The au-
The ESR remains elevated for up to 6 weeks, whereas thors describe delay in treatment and diagnosis as important
factors in poor outcomes. They recommend performing fungal
the CRP normalizes in approximately 2 weeks. S aureus
cultures whenever a spinal infection is suspected.
is cultured in about 60% of wound infections.
Aggressive surgical intervention is generally recom-
mended for postoperative infections. Administration of Govender S: The outcome of allografts and anterior in-
antibiotics should be delayed until intraoperative super- strumentation in spinal tuberculosis. Clin Orthop 2002;
398:50-59.
ficial and deep cultures are obtained. Aggressive d-
This article presents a review of 41 patients with neuro-
bridement followed by copious irrigation is recom- logic deficits caused by spinal TB who were treated with radi-
mended. Wound closure over closed suction drains is cal anterior decompression with reconstruction of the anterior
required unless the wound is packed open for repeat column with fresh-frozen femoral ring allograft and stabilized
dbridements. Recent studies advocate the use of antibi- with a single-rod screw instrumentation construct.
otic beads, especially in the presence of hardware. Un-
less the fusion is solid, most surgeons retain the instru- Ozdemir HM, Us AK, Ogun T: The role of anterior spi-
mentation and bone graft. If significant soft-tissue nal instrumentation and allograft fibula for the treat-
necrosis or dead space is present, plastic surgical tech- ment of pott disease. Spine 2003;28:474-479.
niques including musculocutaneous flaps may be neces- The authors retrospectively reviewed 28 patients with mul-
sary. For patients with soft-tissue and wound infections, tilevel spinal TB who had anterior dbridement, decompres-
10 to 14 days of antibiotics are sufficient. Parenteral an- sion, and fusion with anterior spinal instrumentation and fibu-
lar allograft. A 96% fusion rate with no graft complications tumors and infections with magnetic resonance imaging.
was recorded. Spine 1991;16(suppl 8):S334-S338.
Tay BK, Deckey J, Hu SS: Spinal Infections. J Am Acad Moon MS: Tuberculosis of the spine: Controversies and
Orthop Surg 2002;10:188-197. a new challenge. Spine 1997;22:1791-1797.
A thorough review of the literature and a concise descrip-
tion of current methods of diagnosis, laboratory assessment, Rezai AR, Woo HH, Errico TJ, Cooper PR: Contempo-
imaging, and treatment of spinal infections in both children rary management of spinal osteomyelitis. Neurosurgery
and adults are presented. 1999;44:1018-1026.
Introduction represent perhaps the most sensitive test for osteoid os-
Primary and metastatic tumors of the spine encompass a teoma, a CT scan is the most specific. Treatment of this
wide spectrum of disease processes requiring many dif- disorder includes both medical and surgical options.
ferent treatment algorithms. The treatment of spinal tu- Pain associated with osteoid osteoma, as a rule, re-
mors has evolved over the course of the past decade sponds to treatment with NSAIDs. Given the usually
with the advent of improved diagnosis, staging, and non- self-limited nature of osteoid osteoma, NSAIDs and ob-
surgical and surgical treatment. servation are the initial treatment. In patients in whom
NSAIDs are either not tolerated or are contraindicated
or in patients whose osteoid osteoma is associated with
Primary Tumors progressive scoliotic deformities, more aggressive thera-
Primary tumors of the spine account for 2% to 5% of pies can be considered. Excision of the lesions results in
all spinal neoplasms, with metastatic tumors accounting reliable pain relief, and most associated scoliotic defor-
for most spinal tumors. Within the group of primary tu- mities improve. Good short-term results with percutane-
mors, benign tumors are far more common than malig- ous radiofrequency ablation of osteoid osteoma have
nant tumors. been reported.
teoblastoma. Debate exists regarding the adequacy of ited number of patients with this disorder, it is difficult
curettage in the treatment of osteoblastoma, and it has yet to define a clear predilection for either the anterior or
to be determined whether marginal resection results in a posterior spinal elements; however, it has been reported
lower risk of recurrence. Surgical treatment (simple curet- that most spinal chondroblastomas occur in the poste-
tage or resection) should be planned based on the loca- rior elements. Chondroblastomas usually contain nu-
tion of the lesion, concomitant symptoms, and risk of mor- merous osteoclast-like giant cells; matrix calcification,
bidity. Malignant transformation of osteoblastomas has when present, often has a distinctive chicken-wire ap-
been documented. pearance, which is a histologic hallmark of this lesion.
Cellular atypia can vary from moderate to high, which is
Giant Cell Tumor believed to reflect the spectrum of behavior of chondro-
Giant cell tumors can range in behavior from slowly blastoma from slowly progressive local growth to ag-
growing, relatively innocuous tumors to locally aggres- gressive local growth and metastatic spread. Treatment
sive tumors that metastasize. The spine is a relatively of these lesions consists predominantly of curettage or
common site for giant cell tumors, comprising between excision; however, it is not clear whether this treatment
5% and 10% of all instances of giant cell tumor. Unlike is effective in the spine, given the limited number of pa-
their appendicular counterparts, however, there is often tients with spinal chondroblastomas. The recurrence rate
a significant delay between the onset of symptoms in for chondroblastomas of the spine is likewise unclear.
the spine and the diagnosis. Pain and radiculopathy are
the most common presenting symptoms, and they have Osteochondroma
often been present for several months before the pa- Spinal osteochondromas account for less than 10% of
tients initial contact with a physician. Spinal giant cell all osteochondromas. They usually arise from the poste-
tumors are most commonly diagnosed during the third rior elements. Typically, they are slow-growing masses
and fourth decades of life, and they occur at a slightly and rarely cause mechanical or compressive symptoms.
more frequent rate in women. Within the axial skeleton, They are therefore largely observed unless they begin to
the sacrum is the most common region affected, and le- cause problems such as persistent pain or radiculopathy.
sions are typically found in the vertebral body. Plain If this occurs, these tumors can be resected. The rate of
films generally demonstrate a well-demarcated, radiolu- recurrence after resection in adults is low, and in skele-
cent lesion with a variable amount of cortical expansion tally immature patients it is imperative to resect the car-
and local remodeling. Even in the most aggressive in- tilage cap to prevent recurrence. Malignant transforma-
stances of giant cell tumor, a thin shell of cortical bone tion to chondrosarcomas has been reported and occurs
will usually remain at the periphery of the lesion, which more commonly in patients with multiple hereditary ex-
helps distinguish it from a malignant bone tumor. Giant ostoses. These lesions tend to be low grade and respond
cell tumors involving the spine are typically treated by well to local wide resection.
curettage. En bloc surgical resection is considered to be
the optimal treatment of this disorder and appears to Langerhans Cell Histiocytosis
reduce the rate of local recurrence. In the spine, the This condition, more commonly known as eosinophilic
proximity of vital structures to the lesion, as well as the granuloma, represents a usually benign, self-limiting
considerable morbidity associated with this approach process that usually causes focal areas of well-
has limited the use of en bloc resections. Spinal giant demarcated bone resorption, which in the spine gives
cell tumors have a considerably poorer prognosis than rise to the classic vertebra plana sign. The underlying
those in the appendicular skeleton, with recurrence etiology of this disorder is unknown, and it usually af-
rates reaching almost 80% in grade III giant cell tumors. fects individuals during the first and second decades of
Furthermore, metastasis occurs in just under 10% of pa- life, with a 2:1 predilection for males. The spine is in-
tients. volved in 10% to 15% of patients, but the condition
more commonly affects the skull and flat bones of the
Chondroblastoma pelvis, rib cage, and shoulder. Although most instances
Chondroblastoma of the spine is extremely rare, and of this disorder are self-limiting and resolve on their
published articles regarding spinal chondroblastoma are own, surgical intervention may be indicated in patients
mostly limited to case reports. Nonetheless, most pa- with progressive kyphosis or neurologic symptoms. Low-
tients with this disorder have been diagnosed during the dose radiation therapy has also shown to be effective in
second or third decade of life. Radiographic evaluation patients who are not amenable to resection. It is impor-
of spinal chondroblastomas generally reveals a well- tant to be aware of two systemic disease processes asso-
demarcated radiolucent lesion. Evidence of internal ma- ciated with eosinophilic granuloma: Hand-Schller-
trix calcification may be apparent on plain radiographs Christian disease and Letterer-Siwe disease. Both of
or CT scans; however, this is not a universal finding in these disease processes involve multifocal lesions along
all patients with chondroblastoma. Because of the lim- with other systemic manifestations.
ments such as radiation therapy. The treatment of chon- in the spine. Originating from remnants of the noto-
drosarcoma is complicated by its lack of response to chord, chordomas typically involve either the sacrococ-
conventional chemotherapy and/or radiation therapy. cygeal or sphenooccipital regions of the axial skeleton.
No known clinical trials have demonstrated any survival The average age at diagnosis is 56 years; however, these
benefit among patients receiving chemotherapy, and the tumors can occur in almost any age group. Clinical pre-
use of radiation in this patient population is controver- sentation is often subtle, with a gradual onset of neuro-
sial. Surgical excision, therefore, is the mainstay of treat- logic symptoms including pain, numbness, motor weak-
ment of chondrosarcoma. As a result, the survival rate ness, incontinence, and constipation. Chordomas are
of patients with chondrosarcoma is closely associated slowly growing lesions and are often quite large when
with adequate lesion excision and clean margins. Me- initially discovered. When located in the sacrum, the
dian survival in patients with chondrosarcoma of the mass usually protrudes anteriorly, thereby preventing
spine is approximately 6 years. the lesion from causing a noticeable external mass. On
radiographic evaluation, the bone from which the tumor
Ewings Sarcoma arises may demonstrate noticeable changes, but the
Ewings sarcoma of the spine is a relatively rare entity, most impressive feature of chordomas is the large soft-
accounting for only 8% of a large reported series of pa- tissue mass. Unless a significant amount of internal cal-
tients with Ewings sarcoma. It is actually more common cification is present, the soft-tissue component can be
for this tumor to metastasize to the spine from other lo- missed or underestimated on the basis of plain radio-
cations than it is for it to originate in the spine as a pri- graphs; therefore, either CT or MRI is required for de-
mary tumor. Its clinical features are similar to those for finitive evaluation. On MRI chordomas are lobulated
all patients with Ewings sarcoma; it most commonly masses with a distinctly myxoid (mucoid) consistency.
arises during the second decade of life, and it affects Because they are generally slow-growing tumors, they
males more frequently than females. The most common are associated with a pseudocapsule. The histologic ap-
presenting symptom among patients with Ewings sar- pearance of chordomas can vary from relatively cellular
coma is pain, often in the sacrococcygeal area. Although masses to fluid-filled cysts. Classically, they are com-
instances of Ewings sarcoma involving the cervical posed of chords of physaliphorous cells that are orga-
spine have been reported, they are extremely rare. Os- nized into lobules. Similar to chondrosarcoma, chordo-
seous findings in patients with Ewings sarcoma can be mas demonstrate a poor response to both radiotherapy
extremely subtle. Plain radiographs can, therefore, ap- and chemotherapy. Surgical excision with wide margins,
pear normal, often belying a large soft-tissue mass. In therefore, offers the only significant possibility of cure
this respect, CT or MRI may be far more informative in in these patients. The average 10-year survival rate
defining tumor extent. In patients with Ewings sar- among patients with sacral chordomas is 20% to 40%,
coma, these imaging modalities can demonstrate evi- usually because of recurrence and direct spread of the
dence of a large mass originating in the vertebral body, tumor. The reported rate of metastasis varies widely in
with variable amounts of internal mineralization. different series, ranging from 10% to 27% for sacral le-
C-reactive protein levels and erythrocyte sedimentation sions; however, this rarely represents the cause of death
rates are often elevated, and can therefore be useful ad- in patients with chordomas.
juncts for the diagnosis of Ewings sarcoma. Histologi-
cally, Ewings sarcomas are composed of sheets of small Multiple Myeloma
blue cells, occasionally forming pseudorosettes around Multiple myeloma and its solitary counterpart, plasma-
areas of necrosis. Nearly all Ewings sarcomas possess a cytoma, are both B-cell lymphoproliferative diseases.
characteristic t11:22 chromosomal translocation. Al- Solitary plasmacytoma often progresses to multiple my-
though the treatment of patients with Ewings sarcoma eloma. Multiple myeloma is the most common primary
has varied considerably, the condition currently is malignancy of bone and the spine. Patients often
treated using a combination of chemotherapy, surgical present with pain from spontaneous vertebral compres-
resection, and radiation therapy, each of which is effec- sion fractures. Multiple punched-out lesions on a lateral
tive against this tumor individually. The use of adjuvant skull radiograph are a classic finding, and this warrants a
treatments is especially critical given the difficulty of skeletal survey which may reveal other lesions. Bone
performing wide resection in the spine. scans are classically negative because of the lack of local
bone reaction, and the diagnosis is confirmed with the
Chordoma presence of a monoclonal spike with serum electro-
Chordomas are the most common nonhematogenous phoresis. Chemotherapy and radiation therapy have
primary malignant tumors of the spine, and, unlike long been the mainstays of treatment of this condition.
other malignant tumors discussed, they do not normally With advances in chemotherapeutic treatments, pa-
occur outside of the spine. They account for 1% to 4% tients with multiple myeloma often live longer than pa-
of all primary bone tumors, with 20% of those occurring tients with bone metastases from other malignancies.
This has prompted a more aggressive approach in the sible, excision is indicated. Although epidural lipomas
treatment of myeloma affecting the spine to improve are uncommon, they are a well-documented entity and
quality of life. Radiation may be quite effective in treat- can cause cord compression. Lipomatosis, especially
ing spinal cord compression from epidural tumor. In pa- when steroid-induced, is another possible diagnosis in
tients with vertebral collapse with neurologic symptoms patients with extradural tumors. Extradural tumors can
or advanced kyphosis, surgery may be indicated. Even initially be observed using MRI, but excision is recom-
with more advanced disease, surgical decompression mended in patients with any progressive neurologic def-
and reconstruction may be warranted, and the outcomes icits. Epidural hemangioma and meningioma are both
from a recent study seem to favor this approach in care- rare.
fully selected patients. Similarly, in patients with my- Intradural-extramedullary tumors make up approxi-
eloma and pathologic vertebral compression fractures, mately 85% of intradural tumors and largely consist of
kyphoplasty has been shown to result in improved qual- neurofibromas, meningiomas, and ependymomas. The
ity of life as well as correction of vertebral deformity. two predominant intramedullary tumors are astrocy-
toma (high and low grade) and ependymomas, with he-
Metastatic Tumors mangiomas and lipomas being exceedingly rare. As with
Because the spine is the most common site of skeletal extradural neurofibromas, the intradural counterpart
involvement of metastatic disease, metastases account also arises from the nerve roots, usually the dorsal sen-
for most tumors surgically encountered in the spine. Ap- sory roots. The so-called dumbbell tumor is an intra-
proximately 50% of these tumors arise from carcinoma dural neurofibroma that is following the nerve root
(lung or breast), lymphoma, or myeloma. In regard to through the foramen. Again, complete excision is the
the solid tumor primaries, breast, lung, and prostate are treatment of choice. Meningiomas are usually found in
the most common, followed by renal, thyroid, gas- the anterolateral canal and should be excised when
trointestinal, and rarely primary soft-tissue sarcomas. identified. Ependymomas usually arise from within the
Breast, prostate, and renal metastases are more likely to cord and should be excised; however, extramedullary
be seen by the spine surgeon than either pulmonary or ependymomas can arise from the tip of the conus at its
gastrointestinal tumors because of longer patient sur- junction with the filum terminale. Astrocytomas are in-
vival rates. tramedullary and should be excised. High-grade astrocy-
The most common and usually the first symptom of tomas have no visible margin and are usually debulked
spinal metastases is that of localized pain, which may followed by neoadjuvant chemotherapy. Patients with
occur at night and awaken patients from sleep. Patients high-grade astrocytomas have a bleak prognosis.
may also present with radicular or myelopathic symp-
toms. If a suspected metastatic spinal lesion is found, a Diagnosis and Evaluation
search for the primary tumor as well as for other sites of The most common presenting symptom among patients
metastatic disease must be made. This workup may with tumors of the spine is pain, which is reported by
identify other lesions that are more accessible for biopsy more than 80% of patients at initial visit. Typically, tu-
than the spine. The type of tumor often dictates the mors with a more rapid onset of pain reflect more ag-
treatment; however, the goals of treatment include de- gressive tumors, whereas benign or more slowly growing
creasing the tumor burden, relief of pain, prevention tumors may be characterized by gradually increasing
and reversal of neurologic deficits, and preserving or re- pain spanning several months to years, with sudden in-
storing spinal stability. The modes of treatment will be creases in pain suggesting pathologic fracture. Neuro-
discussed later in the chapter. logic compromise can also be a presenting symptom be-
cause of compression of either nerve roots or the spinal
Spinal Cord Tumors cord. Depending on the precise location and size of the
Tumors of the spinal cord are divided into three catego- tumor, neurologic symptoms can range from subtle mo-
ries: extradural, intradural-extramedullary, and intra- tor or sensory deficits to paraplegia. Other presenting
medullary. symptoms such as spinal deformity are considerably less
Extradural tumors are very uncommon. The most common. A careful history should also include constitu-
common malignancy in the epidural space is lymphoma, tional symptoms such as weight loss, fevers and chills,
with most being spread from the vertebral body or and lethargy as well as a complete medical history, in-
paraspinous nodes; however, a small number do arise cluding any personal history or family history of malig-
primarily from the epidural space. Excision and poste- nancy.
rior neural decompression is usually the treatment of Radiographic evaluation generally begins with plain
choice for extradural tumors. Ten percent of neurofibro- films, with notation of the location of the lesion, any
mas are extradural. They usually arise from a spinal soft-tissue extension, the zone of transition, and internal
nerve root, and because malignant degeneration is pos- characteristics. For tumors involving the spine, certain
Figure 2 Ennekings oncologic stages (IA, IIA, IB, and IIB) of malignant tumors to the
spine. 1 = tumor capsule, 2 = pseudocapsule, 3 = tumor with pseudocapsule, 4 = skip
metastases. (Reproduced with permission from Boriani S, Biagini R, DeJure F: Bone
tumors of the spine and epidural cord compression: Treatment options. Semin Spine
Surg 1995;7:317-322.)
Nonsurgical Treatment
The management of patients with benign primary tu-
mors includes close clinical and radiographic observa-
tion. Bracing has a limited role in treatment, but it may
provide some symptomatic relief of pain. Specific strate- Figure 3 Proposed system of surgical staging of spine tumors, defining the extent of
gies for certain tumors have been discussed individually. the tumor. A = extraosseous soft tissues, B = intraosseous (superficial), C = in-
Surgical excision should be considered when the patient traosseous (deep), D = extraosseous (extradural), E = extraosseous (intradural), and
M = metastasis. Numbers 1 through 12 represent location of tumor. (Reproduced with
has evidence of neurologic deficit, tumor progression, permission from Boriani S, Weinstein JN, Biagini R: Primary bone tumors of the spine.
progressive deformity, or pain. Spine 1997;22:1036-1044.)
In patients with malignancies, chemotherapy plays
an important role in treating tumors such as osteosar-
and/or neurologic deterioration may be considered. Spe-
coma, Ewings sarcoma, and lymphoma for which che-
cific treatment considerations for the various types of
motherapeutic regimens have proved to be systemically
spinal tumors have been discussed. In patients with
effective. Chemotherapy can be used both preopera-
tively and postoperatively as an adjuvant agent, and in highly vascular tumors such as renal cell carcinoma, pre-
some patients, it can even be used as a primary treat- operative tumor embolization may help reduce intraop-
ment to reduce tumor burden. Stem cell and bone mar- erative bleeding. In general, the location and extent of
row salvage is allowing higher doses of chemotherapy to the tumor dictate the approach (anterior, posterior, or
be administered for longer periods, which in turn is combined), and the extent of destabilization caused by
more lethal to tumors. Radiation therapy, as with che- the decompression or removal of tumor then deter-
motherapy, can be used either as an adjuvant or primary mines the method of restabilization and reconstruction
treatment. Patients with radiosensitive tumors (lung, of the spine. The immediate proximity of vital structures
prostate, breast) who present early with metastatic dis- (particularly the neural elements) to the tumor often
ease without spinal instability or dense neurologic com- precludes wide surgical excision, and spinal tumors are
promise can be managed with radiation therapy. In pa- invariably treated with intralesional surgery. Such sur-
tients with higher tumor load requiring surgical geries are therefore palliative, and are performed in an
intervention, external beam irradiation can be used as attempt to improve the quality of the patients life.
an adjuvant therapy either preoperatively or postopera-
tively. Recent advances in radiosurgery allow the deliv- Spinal Stability
ery of a single, large dose of radiation (proton beam) to The definition of spinal instability in the setting of ver-
a localized tumor using a stereotactic approach, result- tebral destruction by tumor remains elusive. Unlike long
ing in precise delivery to the target. This may be useful bones, the spine may continue to exhibit a degree of
in the treatment of chordomas, recurrent tumors, or sar- load bearing without catastrophic failure after fracture,
comas without clear resection margins. so that the concept of patients being at risk for patho-
logic fracture is not as intuitive for those with tumor-
Surgical Treatment related spinal instability. Although various criteria for
The primary goals of surgery in patients with spinal tu- spinal stability in the face of spinal tumors have been
mors are to reduce pain, to preserve or restore neuro- reported, they have not been particularly useful in pre-
logic function, and to establish spinal column structural dicting which patients may benefit from spinal surgery
integrity. Less commonly, excision of the tumor in an at- before the development of profound instability or neu-
tempt at a cure is performed. In patients with tumors rologic deficit.
that do not respond to radiotherapy and chemotherapy, Varied grading systems and parameters have been
earlier surgery to prevent impending vertebral collapse devised to determine when surgical intervention is re-
quired to treat impending instability as a result of to unnecessary risks, morbidity, and a prolonged recov-
pathologic vertebral replacement. In the thoracic spine, ery. In patients for whom posterior stability is main-
50% to 60% of vertebral body involvement or 25% to tained, reconstructing the anterior spinal column with
30% of body involvement with costovertebral involve- anterior surgery only after tumor removal may be all
ment have been suggested as criteria for impending col- that is necessary. The corollary to this is that performing
lapse. In the lumbar spine the suggested criteria for im- too little surgery does the patient a similar disservice.
pending collapse are 35% to 40% of body involvement In patients with significant comorbidities and reduced
alone or 25% of body involvement with pedicle or pos- life expectancy, it is tempting to perform a lesser proce-
terior body involvement. Even when adhering to these dure. If however the patient does not leave the operat-
guidelines, each patient should be assessed individually, ing room with effective neural decompression and spi-
taking tumor load, type, location, and prognosis of the nal stability, the likelihood of early or late failure is
patient into account. More recently, finite element mod- great. Having to return a patient to surgery after a
els have shown that tumor size, magnitude of spinal failed initial surgical procedure is an extremely undesir-
loading, and bone density are predictive of the initiation able and potentially avoidable situation.
of burst fractures in metastatically affected vertebrae In general, the site of the lesion dictates the surgical
and that pedicle involvement and disk degeneration are approach. When the vertebral body is involved and neu-
less important. ral compression is anterior, an anterior approach will al-
low for tumor resection and direct decompression of the
Radiation Treatment neural elements. Anterior reconstruction, usually involv-
In patients with spinal tumors causing neural compres- ing a strut spanning the excised level or levels is re-
sion, treating physicians are required to weigh the rela- quired to restore spinal stability. The involved segments
tive advantages of initiating treatment with radiation are typically further stabilized with rigid anterior instru-
therapy against primary surgical decompression. If the mentation. If the morbidity of an anterior approach is
tumor is radiosensitive and neural progression is grad- prohibitive, vertebral body excision and anterior neural
ual, radiotherapy may be the initial treatment of choice. decompression may be accomplished through a postero-
Patients with limited ambulatory function as a result of lateral approach involving removal of the pedicles so
tumor causing neural compression have a 60% chance that the vertebral body can be accessed lateral to the
of improvement after undergoing radiation treatment. dura. A posterior approach is also preferred when the
Patients who have lost sphincter function have less than tumor involves the posterior elements (Figure 5). The
a 40% chance of regaining function after radiation posterior approach will also allow for multilevel poste-
treatment. When spinal radiation is ineffective in im- rior segmental fixation to stabilize the spine, whereas
proving neurologic deficits, subsequent surgical decom- anterior approaches tend to allow for stabilization of
pression is fraught with complications. Operating fewer segments. If both the vertebral body and posterior
through a radiated field will increase the risk of wound elements of the spine are involved, posterior instrumen-
nonhealing and surgical site infections. In some patients, tation in addition to anterior decompression-recon-
radiation injury to the skin in the surgical field may pre- struction will be necessary to stabilize the involved
vent or delay surgical intervention. In addition, the po- spine (Figure 6). Isolated laminectomy has a small role
tential advantages of initiating radiation treatments af- in the treatment of spinal tumors.
ter surgical resection (when the tumor volume has been Optimal timing of treatments such as chemotherapy
significantly reduced) must be considered. and radiation therapy after spinal surgery remains
poorly defined. These treatments will interfere with
Surgical Approach wound healing as well as with bone graft incorporation
Performing an anterior and posterior surgery when ei- and fusion. Animal research suggests that radiation ther-
ther approach alone would suffice exposes the patient apy should be delayed for 6 weeks after spinal recon-
struction involving arthrodesis to permit the critical This has been reported to provide palliation in many se-
early phases of bone graft revascularization. Obviously, ries; however, the recurrence rates have been quite high.
decisions regarding the timing of adjuvant treatments This has prompted interest in en bloc spondylectomy
need to be made by taking into account the likely for the treatment of patients with solitary metastases or
course of the patients underlying malignancy. intracompartmental primary malignant tumors. In case
reports, en bloc resection or total spondylectomy has
En Bloc Tumor Resection been suggested to decrease recurrence and improve sur-
Surgery for spinal tumors typically involves intralesional vival. En bloc spondylectomy usually involves removal
excision with debulking followed by adjuvant therapy. of the posterior elements and osteotomy of the pedicles,
followed by posterior stabilization with pedicle fixation
one to two levels above and below the resected level. vere pain and preventing neurologic impairment, includ-
This is followed by the en bloc removal of the vertebral ing retention of bowel and bladder control. Recent stud-
body and reconstruction of the anterior column, which ies have demonstrated that in appropriately selected
can be accomplished either through the same posterior patients, surgical management is able to positively affect
surgical approach or through a separate anterior ap- the overall quality of life in those with spinal me-
proach. tastases.
mor infiltration. The indications for these techniques in- Nonsurgical Treatment
clude refractory pain without neurologic compromise. Ryu S, Fang YF, Rock J, et al: Image-guided and
The posterior vertebral body wall must be intact to pre- intensity-modulated radiosurgery for patients with spi-
vent extravasation of cement into the spinal canal. nal metastasis. Cancer 2003;97:2013-2018.
Short-term results appear promising, with good and In this study, 10 patients with spinal metastasis were
rapid relief of pain, improved function, and even resto- treated with image-guided and intensity-modulated radiosur-
ration of vertebral body height with kyphoplasty in gery. The authors reported that the most patients had pain re-
some patients. Most reported complications in patients lief within 2 to 4 weeks of treatment.
who have undergone vertebroplasty have been the re-
sult of extravertebral cement extravasation. This risk is Surgical Treatment
higher when treating patients with metastatic as op- Dudeney S, Lieberman IH, Reinhardt MK, Hussein M:
posed to osteoporotic vertebral fractures. Kyphoplasty, Kyphoplasty in the treatment of osteolytic vertebral
which involves the creation of an intravertebral cavity compression fractures as a result of multiple myeloma.
with a balloon tamp, has a lower risk of extravertebral J Clin Oncol 2002;20:2382-2387.
Fifty-five consecutive kyphoplasties were prospectively
cement extravasation than vertebroplasty. Although
evaluated in 18 patients. Mean follow-up was 7.4 months, and
these minimally invasive treatments may not impact the
there was significant improvement in Short Form-36 scores for
prognosis or the disease process, they can provide sub-
bodily pain, physical function, vitality, and social function.
stantial and immediate pain relief with a reported low
risk of complications.
Fourney DR, Schomer DF, Nader R, et al: Percutaneous
vertebroplasty and kyphoplasty for painful vertebral
Annotated Bibliography body fractures in cancer patients. J Neurosurg 2003;98:
Primary Tumors 21-30.
Abe E, Koboyashi T, Murai H, et al: Total spondylec- In this study, 97 procedures (65 vertebroplasty and 32 ky-
tomy for primary malignant, aggressive benign and soli- phoplasty) were performed in 56 patients with myeloma and
tary metastatic bone tumors of the thoracolumbar spine. primary malignancies. The authors report that 84% of patients
J Spinal Disord 2001;14:237-246. experienced complete pain relief at a median follow-up of 4.5
Fourteen patients with malignant or aggressive benign ver- months.
tebral tumors of the thoracolumbar spine underwent total
spondylectomy. Pain relief was achieved in all 14 patients, and Krepler P, Windhager R, Bretschneider W, et al: Total
no serious complications occurred. Local recurrence was vertebrectomy for primary malignant tumors of the
found in three patients at a mean follow-up of 3.2 years. Total spine. J Bone Joint Surg Br 2002;84:712-715.
spondylectomy appears to be an effective method for control- Vertebrectomy was performed on seven patients, with a
ling local recurrence without major complications. mean follow-up of 52 months. In five patients, a wide resection
was achieved. The authors conclude that vertebrectomy seems
Durr HR, Wegener B, Krodel A, Muller PE, Jansson V, to be an appropriate procedure for the treatment of primary
Refior HJ: Multiple myeloma: Surgery of the spine. Ret- lesions of the spine.
rospective analysis of 27 patients. Spine 2002;27:320-324.
This is a report on the clinical course of 27 consecutive pa- Sundaresan N, Rothman A, Manhart K, Kelliher K: Sur-
tients who were surgically treated for solitary or multiple my- gery for solitary metastases of the spine, rationale and
eloma of the spine. Life quality, reported to be 48% before results of treatment. Spine 2002;27:1802-1806.
surgery, improved to 59% 1 month after surgery and to 73% This is a retrospective review of 80 consecutive patients
in 24 survivors after 1 year. The authors concluded that surgi- with solitary sites of spine involvement from solid tumors. The
cal treatment of myeloma of the spine seemed to be an effec- overall median length of survival after surgery was 30 months.
tive method of treatment with respect to neurologic function Complete surgical excision before irradiation was recom-
and life quality in selected patients. mended to increase the prospects of palliation and possible
cure.
Ghanem I, Collet LM, Kharrat K, et al: Percutaneous
radiofrequency coagulation of osteoid osteoma in chil- Wai EK, Finkelstein JA, Tangente RP, et al: Quality of
dren and adolescents. J Pediatr Orthop B 2003;12:244- life in surgical treatment of metastatic spine disease.
252. Spine 2003;28:508-512.
In this study, 23 patients who underwent percutaneous ra- In this study, 25 consecutive patients undergoing surgery
diofrequency coagulation for osteoid osteoma were retrospec- for spinal metastases were prospectively evaluated. After sur-
tively reviewed. Pain disappeared immediately after the proce- gery, the largest improvement was with pain, but there were
dure in 21 patients. At an average of 3.5-year follow-up, all also improvements with tiredness, nausea, anxiety, drowsiness,
patients were pain free. appetite, and well-being.
Whyne CM, Hu SS, Lotz JC: Burst fracture in the meta- cutaneous catheter embolisation. Neuroradiology 1972;
statically involved spine: Development, validation, and 3:160-164.
parametric analysis of a three-dimensional poroelastic
finite-element model. Spine 2003;28:652-660. Kostuik JP, Errico TJ, Gleason TF, Errico CC: Spinal sta-
A finite-element study and in vitro experimental valida- bilization of vertebral column tumors. Spine 1988;13:
tion was performed for an investigation of features that con- 250-256.
tribute to burst fracture risk. The authors report that the prin-
cipal factors affecting the initiation of fracture were tumor Marsh BW, Bonfiglio M, Brady LP, Enneking WF: Be-
size, magnitude of spinal loading, and bone density. nign osteoblastoma: Range of manifestations. J Bone
Joint Surg Am 1975;57:1-9.
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Imaging
Plain Radiographs
Plain radiographs remain the standard modality to diag-
nose, classify, and monitor spinal arthropathy. Plain im-
ages provide cost-effective screening for skeletal
changes. Early radiographic changes including the pres-
ence of osteophytes and disk space narrowing may not
be symptomatic. Flexion and extension lateral views are
used to define stability between the spinal segments and
are the primary method to assess the cervical spine for
the primary spinal deformities that occur in rheumatoid
arthritis. The use of select digital imaging and software
allows electronic measurements such as the atlanto-dens
interval.
transarticular screws because the path of the vertebral and spreads cephalad. Neck pain caused by spontaneous
artery is avoided. anterior atlantoaxial subluxation has been reported as
an initial symptom. One study showed that 49% of pa-
Surgical Outcomes tients (89 of 181) with ankylosing spondylitis had radio-
The benefits of surgical intervention have been well graphic changes, but atlantoaxial subluxation was
documented and recent outcomes studies have sup- present in 2% to 20% of patients with ankylosing
ported this treatment option. For irreducible atlantoax- spondylitis compared with 16% to 25% of adult patients
ial instability with myelopathy in patients with rheuma- with rheumatoid arthritis; superior migration of the od-
toid arthritis, C1 laminectomy and fusion with ontoid has not been reported with ankylosing spondyli-
rectangular rod fixation from the occiput to C2 (16 pa- tis alone.
tients) to C3 (2 patients) or to C4 (1 patient) led to 68%
improvement of at least one Ranawat class and 5- and Natural History
10-year survival rates of 84% and 37%, respectively. The natural history of ankylosing spondylitis is progres-
Without surgery, 21 matched patients were all bedridden sive loss of posture and mobility. The rate of progression
within 3 years and died within 8 years. Similar neuro- is variable. Mild spinal changes in ankylosing spondylitis
logic improvements were noted in 67% of patients (37 occur first, with squaring of the lumbar bodies and syn-
of 55) with occipital neuralgia, myelopathy, or both desmophytes. More severe involvement leads to changes
treated with various procedures. Mortality at 2 years characteristic of so-called bamboo spine. Spinal defor-
was 27% and resulted mainly from nonsurgery-related
mity in ankylosing spondylitis develops secondary to
causes.
limitation of motion at ankylosed areas or increased
Patients with inflammatory spondylitis often have
motion at nonankylosed areas. Pain can develop at re-
multiple comorbid medical conditions that contribute
maining motion segments but resolves once that seg-
significantly to management and potential complica-
ment is ankylosed. Ankylosis in a relatively kyphotic po-
tions. Involvement of the temporomandibular joint may
sition occurs at the cervical, thoracic, and lumbar spine,
interfere with intubation, and peripheral joint contrac-
but etiology for kyphosis has not been defined.
tures can make surgical positioning and rehabilitation
more challenging. Osteoporosis impairs fixation poten- With long rigid spinal segments and focused areas of
tial, and many authors recommend the use of orthotic osteoporosis, fractures are common even with minimal
devices after surgery if osteoporosis is present. Poor trauma and can cause significant morbidity and mortal-
skin quality, impaired healing, and dental problems in- ity. Mortality can occur from initial injury, fracture treat-
crease the risk of infection. Despite all the potential ment, or epidural hematomas that can develop up to
risks, careful patient preparation and planning com- weeks after injury. Recent articles on trauma have em-
bined with up-to-date skilled care can improve function phasized the importance of strict neck immobilization
and survival. for patients with ankylosing spondylitis, even in those
who have experienced mild low-energy injuries.
Ankylosing Spondylitis
Definition Imaging
Plain Radiographs
Ankylosing spondylitis is the prototype disease of se-
ronegative spondyloarthropathiesa family of arthritic Plain radiographs may provide clues for the initial diag-
conditions not associated with positive rheumatoid fac- nosis of ankylosing spondylitis. Classic changes at the
tor serology. Other related conditions are reactive ar- sacroiliac joints may not be identified initially, but initial
thritis (Reiters syndrome), spondylitic forms of psori- presentation with thoracic spine changes in a female pa-
atic arthritis and inflammatory bowel disease (Crohns tient has been reported. Spondylodiskitis (also known as
disease), juvenile spondyloarthropathy, and undifferenti- Andersson lesions) is a destructive diskovertebral lesion
ated spondyloarthropathy. Disease onset typically oc- occurring in ankylosing spondylitis that usually occurs at
curs between the ages of 20 and 30 years. Males are the thoracolumbar junction. Both inflammatory and
more commonly affected, and symptoms in females are noninflammatory types of destructive lesions occur. The
usually milder and harder to diagnose. Early symptoms inflammatory type is defined radiologically as a reduced
of ankylosing spondylitis are commonly overlooked in disk space with a defect of vertebral bodies and dense
young adults as simply back pain, but awareness of cancellous bone sclerosis. The noninflammatory type is
early findings such as lumbar stiffness and decreased associated with a fracture through an ankylosed disk or
lordosis may lead to a correct diagnosis. Positive HLA- a pseudarthrosis. Lateral flexion and extension views of
B27 assay is present in 80% to 98% of patients with the cervical, thoracic, and lumbar spine are essential to
ankylosing spondylitis versus 8% of the general popula- identifying instability and ankylosis in patients with
tion. Spinal involvement is primarily lumbar at onset ankylosing spondylitis.
Computed Tomography and Magnetic Resonance solves but can improve with surgery. In 11 patients with
Imaging ankylosing spondylitis and fractures, 6 had neurologic
Excellent evaluation of the sacroiliac joints is possible deficits; 3 of 6 patients had improved neurologic func-
with CT. Sacroiliac joint space narrowing, erosions, and tion with surgery. Most fractures are unstable because
sclerosis are all classically seen on the axial views with- the ankylosis forms a rigid column that does not follow
out reconstruction or contrast. Canal stenosis secondary the same three-column criteria of Denis for stability as
to the combined effects of kyphosis and ankylosis is well seen in normal spines. The rigid columns act as long
defined with MRI. Contrast gives better definition of level arms concentrating forces (such as motion) at the
which structures are involved and if spinal cord pathol- fracture site. Epidural hematomas commonly produce
ogy is present. neurologic impairment because of the confined rigid ca-
nal. Surgery for unstable fractures and epidural hemato-
Bone Scan mas is required and combined anterior and posterior
The presence of activity in the sacroiliac joints and in approaches and extended fixation must be considered.
the spinal column on bone scans may help with the di- Only minor nonstructural fractures should be consid-
agnosis of ankylosing spondylitis. Nuclear imaging is an ered stable fractures that can be treated nonsurgically in
effective screening tool to identify occult fractures in patients with ankylosing spondylitis.
ankylosing spondylitis and should be considered early in
the assessment of patients with this disease who sustain
even minor trauma. There have been reports of devas-
Surgical Treatment
tating complications from undiagnosed fractures.
Decompression
Emergency decompression is indicated for epidural he-
Bone Density Studies
matomas. Laminectomy is required for cauda equina
A decrease in bone density has been shown to be re-
lated to persistent systemic inflammation in patients syndrome in patients with ankylosing spondylitis. A
with ankylosing spondylitis. Spinal density measured by study found that 55 patients who had nonsurgical treat-
dual-energy x-ray absorptiometry (DEXA) increases as ment showed no improvement of sensory, bowel, or
ankylosis progresses; therefore, DEXA hip measure- bladder deficit; only 2 of these patients had motor im-
ments or quantitative CT should be used. provement.
Osteotomy
Surgical Indications Extension osteotomy to correct kyphosis at both the
Neurologic compromise may be less obvious in patients cervicothoracic junction and lumbar spine is well de-
with ankylosing spondylitis than in those with rheuma- scribed in patients with ankylosing spondylitis. Cervical
toid arthritis. A recent meta-analysis of 52 articles dis- deformity is best corrected with osteotomy between C7
cussing 86 patients with ankylosing spondylitis and and T1, which is the widest area of the cervical canal
cauda equina syndrome showed that nearly all patients and is caudal to the vertebral artery entry at C6. Cervi-
had sensory, motor, or reflex deficits on examination cal osteotomies above C7 are rarely required and have a
and 30% had previous prostate surgery without im- higher risk of complications.
provement for incontinence. Compensations in gait Thoracic kyphosis is best treated with extension os-
caused by spinal ankylosis may mask the true myelo- teotomy at or below L2. Thoracic osteotomies are rarely
pathic contribution to gait. As myelopathy is associated indicated. Patients who have osteotomy at L4 may have
with rheumatoid arthritis, any myelopathic findings difficulty sitting on the floor; however, the procedure
should be considered a surgical indication. may need to be considered if two osteotomies are being
There are no specific indications for correction of performed. Two levels of osteotomy are recommended
chin on chest deformity from cervical kyphosis; how- for deformity greater than 70 and should be separated
ever, commonly accepted indications for surgical inter- by one or two levels to distribute the amount of anterior
vention include the inability to perform the activities of angulation and distraction.
daily living (including those related to personal hy-
giene). Correction of thoracolumbar kyphosis was rec- Arthrodesis and Instrumentation
ommended if the global kyphosis was greater than 50, Arthrodesis is required for fractures and after kyphec-
or in patients with less severe kyphosis in whom nonsur- tomy. Fusion rates are similar to those seen in the nor-
gical management of symptomatic spondylodiskitis was mal spine. Modifications to the standard techniques of
unsuccessful. instrumentation may be necessary because of the oblit-
Fractures associated with ankylosing spondylitis of- eration of bony landmarks that ordinarily serve as refer-
ten are associated with neurologic deficit that rarely re- ence points.
Table 1 | Fractures Less Likely to Improve With Standard for 17 minutes. Possible goals include collagen fibril
Medical Management shrinkage to stabilize the motion segment or destruction
of nociceptive fibers.
Fractures of thoracolumbar junction (T11-L2) The published indications for IDET include more
Bursting fracture patterns than 6 months of discogenic pain, more than 3 months
Wedge compression fractures with > 30 of sagittal angulation of failed medical treatment and physical therapy, con-
Vacuum shadow in fractured body (ischemic necrosis of bone) cordant diskography, maintenance of at least 50% resid-
Progressive collapse seen in office follow-up ual disk height, and the absence of neurocompressive
pathology.
Initial outcomes reports have been highly varied. A
extruded or sequestered fragments. Although good re- designer series of 25 consecutive patients reported a
sults continue to be published in the world literature, 2-point difference in pain scores at an average follow-up
chymopapain injection has fallen out of favor in North of 7 months. Improvements in the Medical Outcomes
America because of complications, including anaphy- Study Short Form 36-Item (SF-36) scores for physical
laxis and transverse myelitis. function and body pain subscales were noted in 72% of
Several percutaneous techniques of microdiskec- patients. No complications were reported. A recent up-
tomy have been developed as well. In the 1970s, instru- date, also by the products designers, found that im-
mentation was developed to access the disk space per- provements increased from 1- to 2-year follow-up. These
cutaneously from a posterolateral approach. These and other IDET articles have been criticized for the rel-
procedures were believed to debulk the central disk, atively low hurdle (for example, 2 points on the visual
thereby indirectly reducing nerve root irritation and no- analog scale) that was used to determine significance.
ciceptor stimulation of the anulus fibrosus. Modifica- Others argue that in the absence of significant complica-
tions of the procedure allowed direct visualization tions, IDET remains a viable modality in a small num-
through an arthroscope. Like chymopapain injections, ber of patients. Yet, complications have been reported,
these techniques, which continue to be performed at including diskitis and cauda equina syndrome.
some institutions, are reserved for patients with con- Recent basic studies questioned the ability of the
tained herniations and bulges. Studies comparing auto- IDET probe to affect collagen denaturation or nocicep-
mated percutaneous diskectomy with open microdiskec- tive fibers. One biomechanical study showed an increase
tomy usually demonstrate better results with open in motion at the treated segment, raising the possibility
microdiskectomy. of long-term destabilization. A recent MRI study found
Endoscopic diskectomy is performed in a manner no change in the appearance of the high-intensity zone
nearly identical to open diskectomy, with the exception in degenerated disks after IDET.
that the surgical instruments are passed through a tubu-
lar retractor. With these systems, a transmuscular rather Vertebral Body Augmentation (Vertebroplasty and
than subperiosteal approach is undertaken because it is Kyphoplasty)
theorized that the smaller incisions will result in re- In the United States, approximately 700,000 os-
duced postoperative pain and improved mobilization. teoporotic vertebral compression fractures occur each
Potential disadvantages with these techniques in- year. Traditionally, these fractures were thought to heal
clude limited visualization, a long learning curve during uneventfully with few, if any, sequelae. However, com-
which complications are more frequent, the risk of inad- pression fractures represent a serious and growing
equate exposure or incomplete decompression, the risk health care problem worldwide. Long-term sequelae of
of vessel or nerve root damage, limits in the ability to vertebral compression fractures are common and in-
treat lateral recess and foraminal stenosis, and difficulty clude pain, deformity, pulmonary decline, gastrointesti-
accessing the L5-S1 disk space from a far lateral ap- nal disturbance, gait and functional decline, and in-
proach in some patients (especially male patients with a creased mortality. Population studies report that
narrow pelvis). significant functional impairment can occur among peo-
ple with vertebral compression fractures who do not
Intradiskal Electrothermal Therapy seek medical attention.
Given the mixed outcomes of fusion surgery when treat- The pain associated with a given vertebral compres-
ing patients with discogenic back pain, newer modalities sion fracture is highly variable. Of those patients pre-
such as thermal energy have been applied to the disk. senting to physicians with pain after a vertebral com-
IDET is conceptually based on the conversion of radio- pression fracture, many respond to treatment with
frequency energy into thermal energy. With fluoroscopic narcotic pain medications and bracing. In some patients,
guidance, a catheter probe is steered along the posterior bracing is not well tolerated or it does not immobilize
annular wall. Once in place, the tissues are heated to 65 the fracture adequately (Table 1). It has been estimated
that each year approximately 150,000 patients with com- ture and possible instrument trajectories. In patients
pression fractures require hospitalization with pro- who are unable to undergo MRI, a bone scan may esti-
tracted periods of bed rest and administration of intra- mate fracture acuity. A CT scan will provide similar
venous narcotics. In elderly patients, osteoporosis with morphologic information, particularly when sagittal re-
bed rest is associated with an additional 4% loss of bone constructions are ordered.
mineral density. Vertebroplasty involves a unilateral or bilateral per-
On plain radiographs, vertebral compression frac- cutaneous approach to the vertebral body. Various nee-
tures have different configurations. In the thoracic dle and applicator systems are available through which
spine, fractures often have a wedge appearance caused liquid polymethylmethacrylate bone cement is intro-
by kyphotic loading. In the lumbar spine, central end duced into the vertebral body. The early clinical results
plate cupping of lordotic lumbar bodies is seen. These of vertebroplasty suggest that it is effective in decreas-
levels are also more likely to demonstrate a bursting ing pain in most patients. However, the mechanism of
pattern. It may be difficult to distinguish fracture age pain relief is controversial. Patient groups responding
using plain radiographs alone. A sclerotic band below well to these techniques typically have mechanical in-
the end plate may represent healing or merely com- competence of their vertebral body. Polymethyl-
pressed trabeculae. Comparison with older films (even a methacrylate bone cement restores the load-bearing ca-
recent chest radiograph) may help. MRI has a high sen- pacity of the vertebral body. This restoration of stiffness
sitivity for fracture acuity, which is reflected by peri is thought to provide pain relief. A degree of postural
end-plate edema and is typically seen as an increased reduction is also possible in some fractures treated with
signal on T2-weighted or short T1 inversion recovery vertebroplasty.
images (Figure 1). T1-weighted signal intensity is usually Kyphoplasty extends the vertebroplasty concept.
diminished. MRI is also used to assess fracture architec- During this procedure, a bilateral approach to the verte-
Table 2 | Precautions and Contraindications to Kyphoplasty Table 3 | Applications for Video-Assisted Thoracic Spinal
and Vertebroplasty Surgery
Neurologic symptoms Infection
Young patients* Biopsy
Pregnancy Dbridement
High-velocity fractures Drainage of abscess
Fractures pedicles or facets Tumor
Burst fracture with retropulsed bone Biopsy
Medical issues Tumor excision
Allergy to devices Corpectomy and grafting
Allergy to contrast medium Degenerative disease
Bleeding disorders Excision of herniated thoracic disk
Severe cardiopulmonary difficulties Trauma
Technically not feasible Corpectomy
Vertebra plana Cancellous bone grafting
Multiple painful vertebral bodies Deformity
Level above T5 Anterior releases for scoliosis or kyphosis
Neoplasm Anterior fusion and instrumentation
Osteoblastic metastasis Hemivertebra excision
Patients with significant long-term survivability Internal thoracoplasty
Primary spinal neoplasm
Severe cortical destruction
Local spinal infection Table 4 | Contraindications to Thoracoscopic Spine Surgery
*Age range varies; caution in patients younger than 65 years Inability to tolerate one-lung ventilation
Severe pulmonary problems precluding prone positioning because of vertebral size or Severe or acute respiratory insufficiency
imaging problems High airway pressures with positive pressure ventilation
Pleural symphysis
Bullous lung pathology
bral body is made through 1-cm incisions. Cannulas al- Empyema (relative)
low introduction of balloon tamponades. Sequential in- Previous thoracotomy (relative)
flation of these tamponades creates a void in the Previous tube thoracostomy (relative)
cancellous bone of the vertebral body and attempts to Narrow anterior posterior chest diameter (relative)
reduce the deformity. The balloon tamponades are then
removed. Another theoretic advantage is that viscous
polymethylmethacrylate bone cement can be introduced possible with kyphoplasty, but it may be variable as a
into the void for a more controlled fill. function of fracture age.
Vertebral body augmentation should be considered
in patients who are bedridden because of pain or in
Endoscopic and Mini-Open Procedures
those whose pain does not begin to decline after several
Thoracic Spine
weeks of nonsurgical care. Results are best for patients
Most endoscopic spine surgery is directed anteriorly
with focal, intense, deep pain in the midline. Usually,
where larger incisions and postthoracotomy pain may
pain worsens with activity and is relieved when recum-
be avoided. Video-assisted thoracic spinal surgery has
bent. The contraindications of vertebral body augmenta- the same indications and goals as open thoracotomy
tion are listed in Table 2. (Tables 3 and 4).
Vertebral body augmentation procedures are usually Many of these techniques are technically demanding
well tolerated. Good to excellent short-term pain relief and are only performed in select centers worldwide. Be-
has been reported in more than 80% of patients. Com- fore attempting thoracoscopic approaches to the spine,
plications typically occur in association with polymethyl- the surgeon must be thoroughly familiar with open an-
methacrylate bone cement extravasation and can lead to terior spinal anatomy and have considerable animal lab-
canal compromise or pulmonary embolism. These com- oratory and proctored surgical experience. The largest
plications appear to be more common among patients early experience with video-assisted thoracic surgery
who undergo vertebroplasty. Additional reduction is has been in patients undergoing treatment for spinal de-
formities. A thoracoscope can be used to assist anterior Table 5 | Advantages and Disadvantages of Endoscopy
release surgery in patients with large kyphotic or scoli-
otic deformities. The advantages and disadvantages of Advantages
thoracoscopic surgery are listed in Table 5. Less postoperative pain
Thoracoscopic spinal surgery requires a fluoroscopic Alleviates the physiologic concerns of healing associated with large
table and selective double lumen endotracheal intuba- incisions into the thoracic, peritoneal, or retroperitoneal cavities
tion. Surgery proceeds in stages, beginning with the se- Improved visualization of the target tissues
lection of access sites. The sixth intercostal space at the Improved cosmetic result with smaller incisions
midaxillary line gives an unobstructed view of the entire Reduced recovery time and hospital stay
hemithorax. The rib cage and chest wall form a rigid Disadvantages
open space in which to work. Unlike laparoscopy, car- Steep learning curve
bon dioxide insufflation is not required during thoraco- Cost
scopic spinal surgery.
Limitations in tactile feedback
Instruments are centered at the level of the pathol-
Increased working distance from 4 to 30 cm
ogy. The lung may require retraction with an endoscopic
Two-dimensional video visualization
fan retractor or strategically placed sponges. Once the
level of the pathology has been identified, the parietal Triangulation
pleura is incised. The parietal pleura is bluntly dissected Limited depth perception
proximally, distally, and anteriorly to expose as much of Necessity for specialized instruments
the vertebral margins as necessary. Adverse effect on ability to deal with certain complications (such as
After the anulus fibrosus is incised with cautery, the brisk arterial bleeding)
disk and cartilage end plates are removed to bleeding As experience is gained, disadvantages much less limiting
bone with long pituitaries, Cobb elevators, and curets.
For patients undergoing kyphosis correction, the ante-
rior longitudinal ligament and opposite side of the anu- be completed by negotiating allograft struts or mesh
lus fibrosus is incised. In patients undergoing releases cages into the defect after inserting them into the chest
for the treatment of scoliosis, it is mandatory to incise through an enlarged portal.
the posterolateral corner of the disk spaces in the con- Techniques for endoscopic transthoracic spinal in-
cavity of the curve. Morcellized rib or iliac crest graft strumentation continue to evolve with the development
can be delivered by a funnel or a structural graft (femo- of new implants capable of stabilization and correction.
ral ring allograft or cage) delivered through an enlarged Threaded cylindrical interbody fusion cages, in wide-
portal. spread use in the treatment of deformities of the lumbar
In certain patients, a thoracoscopic release, with the spine, are now being used to treat deformities of the
patient in the prone position, may be done concurrently
thoracic spine in the coronal or oblique plane. Such tho-
with open posterior stabilization. Similarly, internal tho-
racic cage application may be technically less demand-
racoplasty may also be performed concurrently or as an
ing, but the consequences of malpositioning are signifi-
independent procedure. Rib resections are planned as
cant. The fusion rates for patients with single thoracic
an ellipse to ensure smooth chest contours. The perios-
cages have yet to be evaluated. Existing posterior or an-
teum of the rib portion to be resected is stripped, and a
high-speed burr creates the osteotomy. terior rod and screw implant systems have been modi-
Patients with symptomatic thoracic disk herniations fied for application in an endoscopic fashion.
may be amenable to treatment with endoscopic trans- Increasingly, open and endoscopic approaches are
thoracic decompressions. Patient selection is a critical is- being combined for instrumentation. In such proce-
sue because patients rarely have true radicular or my- dures, one of the portals is enlarged to a 5-cm incision,
elopathic symptoms. Patients with diffuse midthoracic which allows the use of more standard surgical instru-
back pain and diagnostic imaging showing evidence of ments and significantly simplifies implant introduction.
multiple degenerative segments with or without hernia- In the postoperative period, most patients are extu-
tions are not good candidates for either open or endo- bated immediately. A chest tube is maintained at water
scopic diskectomy. seal and removed 1 to 2 days postoperatively. An inten-
Comparable endoscopic techniques have been de- sive care unit stay is not usually needed. Aggressive res-
scribed for vertebral corpectomies or osteotomies. The piratory care is required to prevent down lung
spine is exposed by bluntly dissecting the pleura and li- atelectasis and pneumonia.
gating only those segmental vessels in the surgical field. Complications of thoracoscopic surgery are essen-
A combination of pituitary rongeurs, curets, Cobb eleva- tially the same as with an open approach. As in any spi-
tors, and high-speed burrs are used as they would be nal cord level procedure, spinal cord injury or ischemia
with the chest open. The corpectomy reconstruction can is possible. Dural laceration may be noted. Intercostal
neuralgia is common (21% of patients), but it is usually interbody fusion techniques, have been described and
transient. Endoscopic releases may be less complete are marketed with specialized instruments by the vari-
than open releases. Also, trocar or instrument injury to ous implant manufacturers. Long-term results of fusions
the lung, diaphragm, heart, great vessels, thoracic duct, with these implants are not yet available.
azygos vein, esophagus, segmental arteries, sympathetic Interestingly, much of the current interest in percuta-
chain, and splanchnic nerves is possible. neous pedicle screw technology comes from the in-
One series compared video-assisted thoracoscopic creased use of anterior lumbar interbody cages, them-
surgery to open thoracotomy in a sheep model. In this selves part of the vanguard of minimally invasive spine
series, histologic, biomechanical, and radiographic out- surgery. Increasingly, the late instability of fusion con-
comes were comparable to those of open surgery. How- structs resulting from the use of these threaded fusion
ever, endoscopic procedures were associated with pro- cages in motion segments with preserved disk height has
tracted learning periods, long surgical times, increased been described. Additionally, posterior stabilization has
blood loss, and increased animal morbidity. Others re- been recommended. Translaminar facet screws repre-
port that, with increased surgeon experience with these sent another method of achieving posterior fixation
procedures, tissue damage, blood loss, postoperative through small incisions with minimal tissue stripping.
pain, intensive care unit and hospital stays are reduced Most truly endoscopic lumbar spine procedures are
and that respiratory and shoulder function are less af- anterior. Unlike the posterior approach, there are sev-
fected. eral critical anatomic structures that must be avoided
when approaching the spine anteriorly, including the in-
Lumbar Spine ferior epigastric artery and vein, which lie deep to the
surface of the rectus muscle. Placement of endoscopic
Several methods have been described to reduce the ex-
ports through these structures is associated with postop-
posure needed for posterior decompression surgery. The
erative hematoma formation. The ureters run obliquely
most common is use of a surgical microscope. Microdis-
from the retroperitoneal space into the abdomen. The
kectomy is the most commonly performed minimally in-
left ureter runs obliquely in the mesentery deep to the
vasive approach to partial disk removal (see chapter
sigmoid and is not usually seen. The right ureter runs
44).
obliquely over the right iliac into the pelvis and may oc-
A newer endoscopic diskectomy technique uses a tu-
casionally be injured. The ureter will sometimes course
bular working cannula. The fiberoptic image bundle is in midline directly over the L5-S1 disk space and may
housed in a sidewall of the cannula. Standard instru- be directly damaged by surgical exposures. Overretrac-
ments, such as pituitary or Kerrison rongeurs, are in- tion of the psoas muscle may injure the lumbar plexus.
serted under direct vision. This technique has also been Injury to the lumbar sympathetic chain, just anterior to
used to treat cervical disk herniations (via lamino- the L5-S1 disk, may result in retrograde ejaculation.
foraminotomy) and for microdecompression of lateral Contraindications to anterior spinal endoscopic sur-
recess lumbar spinal stenosis. The benefits of this tech- gery include peritoneal or pelvic infections, prior open
nique over the more traditional microdiskectomy have anterior spine surgery, or prior lower abdominal surgery
not yet been established. For most spine surgeons, mi- (such as colon resection or hysterectomy). Endometrio-
crodiskectomy remains the safer technique. sis also causes adhesions that can limit anterior spinal
The role of posterior endoscopic and minimally in- endoscopy.
vasive techniques in the treatment of metastatic disease, Anterior spinal endoscopy can be performed with or
fractures, and infections is evolving. Although the ante- without insufflation. Insufflation involves the use of car-
rior approach to metastatic disease is favored overall, bon dioxide to inflate the abdominal cavity to more
the use of an endoscope to assist posterolateral decom- completely visualize surrounding anatomic structures.
pression may obviate the need for a second anterior sur- Insufflated surgery is a direct extension of conventional
gery in patients undergoing posterior stabilization. laparoscopic surgery. It gives direct access to L5-S1,
The medial branch of the dorsal primary ramus can L4-5, and occasionally to L3-4. The advantages of insuf-
be injured when a midline approach is carried beyond flation include organ retraction, more rapid exposure,
the facets and over the transverse processes. To mini- increased working space, and decreased bleeding. How-
mize this type of injury, several newer techniques have ever, special instruments are required, including expen-
been developed that use a muscle-splitting approach in sive trocars with diaphragms. Additionally, air may leak
the interval between the multifidus medially and the during the procedure. Moreover, carbon dioxide insuf-
longissimus laterally. This approach is similar to that de- flation of the peritoneal cavity increases mean arterial
scribed by Wiltse for far lateral diskectomy. Exploiting pressure and decreases venous return. Carbon dioxide
this plane, endoscopic, fluoroscopic, or navigation sys- absorption may lead to hypercapnia and decreased dia-
tem assistance allows for transpedicular instrumentation phragmatic excursion. Carbon dioxide embolism from
through smaller incisions. Several variations, including open veins has also been reported.
Figure 2 A, Photograph of the introduction of a working portal during thoracoscopy. B, Photograph of the initial thoracoscopic approach to the disk space.
With a gasless approach, the anatomic approach re- firmed on fluoroscopy (Figure 2).
mains the same, but the working space is created by lift- The retroperitoneal approach uses a potential space
ing the anterior abdominal wall with a fan retractor and behind the peritoneal sac. Advantages of this approach
hydraulic arm (Laparolift, Origin Medsystems, Menlo include improved spinal access from T12 to S1. In that
Park, CA). This technique decreases costs because con- the peritoneum contains the bowel loops, retraction is
ventional instruments are used. However, gasless sur- facilitated. Additionally, conventional instruments may
gery takes longer and is technically more difficult to be used and conversion from a pure percutaneous endo-
perform. Moreover, lateral vision is limited with the use scopic to an endoscopically assisted anterior approach
of this technique. A combined approach using insuffla- may be performed if increased difficulty is encountered.
tion for the initial spine exposure to place retractors and In retroperitoneal approaches, a left lateral decubi-
Steinmann pins and the subsequent conversion to a tus positioning of the patient allows abdominal contents
gasless/Laparolift procedure falls in the midrange in to fall freely forward. A skin incision is made, the inter-
terms of cost and ease of use. nal and external obliques are identified, and fibers are
Operating room positioning of the patient is critical spread bluntly. This exposes the transversalis fascia,
for these procedures. Drains including a Foley catheter which is also incised. A finger may be used to bluntly
and nasogastric tube are placed. The patient is supine dissect in the retroperitoneal space along the twelfth rib
with one or both arms tucked at the side or overhead to the transverse process of T12 or L1. The potential
(for fluoroscopic control). Steep Trendelenburg posi- space may be increased by inserting an insufflating bal-
tioning is often required; therefore, a special shoulder loon or a gasless technique with a Laparolift or insuf-
harness or foot stirrups may also be needed. Fluoros- flated technique may be used. The blunt dissection is
copy and endoscopy monitors must be in the direct line carried posteriorly to the psoas fibers until the disk
of sight of spine and endoscopic surgeons. The prepara- space is identified.
tion materials and drape must allow for bone graft har- Titanium cage or bone dowel implantation, which is
vest and conversion to an open procedure, if necessary. among the most commonly performed lumbar endo-
The actual approach to the spine may be transperi- scopic techniques, is typically used for anterior column
toneal or retroperitoneal. In transperitoneal endoscopy, fusion in patients with disk-related pain (Figure 3). Ad-
the procedure begins with placement of the first (umbil- vantages include avoidance of extensor muscle strip-
ical) portal. Once in place, the peritoneum is insufflated ping, more rigid anterior fusion, and lower pseudarthro-
to 15 mm with carbon dioxide. Secondary ports are then sis rates from grafting under compression. Reports of
placed under visual guidance, including a 17-mm supra- failure of these implants as stand-alone devices have
pubic working portal. A superficial incision in the mid- dimmed the initial enthusiasm.
line peritoneum from the sacral promontory to vascular The implementation of endoscopic approaches to
bifurcation is made, exposing the spine. Blunt dissection the anterior spine has fostered a renewed interest in de-
in the retroperitoneal space is used to identify the mid- creasing the morbidity of traditional open anterior pro-
dle sacral artery and the several medial branches of the cedures. Various mini-open anterior paramedian muscle-
iliac veins, which are clipped. More blunt dissection will sparing approaches to the lumbar spine have been
expose the disk spaces, the levels of which are con- recently described. Proponents argue that this cosmeti-
20% of patients reported worsening of baseline symptoms at gery: An intraoperative EMG study. Eur Spine J 2002;
final follow-up. They concluded that IDET should not be used 11:20-26.
as a substitute for spinal fusion in the treatment of chronic dis- This electromyographic study demonstrated that less me-
cogenic low back pain in active-duty soldiers. chanical irritation of the nerve root occurred with endoscopic
approaches than with traditional open surgery.
Lieberman IH, Dudeney S, Reinhardt MK, Bell G: Ini-
tial outcome and efficacy of kyphoplasty in the treat- Spruit M, Jacobs WC: Pain and function after intradiscal
ment of painful osteoporotic vertebral compression electrothermal treatment (IDET) for symptomatic lum-
fractures. Spine 2001;26:1631-1638. bar disc degeneration. Eur Spine J 2002;11:589-593.
This is a prospective study of kyphoplasty procedures that This small series of prospectively evaluated patients failed
were performed in 30 patients. The results demonstrate excel- to show significant improvement of patient symptoms after
lent outcomes and low complications. undergoing IDET.
Lindsay R, Silverman SL, Cooper C, et al: Risk of new Yeung AT, Tsou PM: Posterolateral endoscopic excision
vertebral fracture in the year following a fracture. for lumbar disc herniation: Surgical technique, outcome,
JAMA 2001;285:320-323. and complications in 307 consecutive cases. Spine 2002;
This article reviews the clinical consequences of vertebral 27:722-731.
compression fractures and largely dispels the notion that these In this retrospective review of 1-year outcomes in 307 con-
injuries follow a benign, self-limited course. secutive patients with lumbar disk herniation who underwent
posterolateral endoscopic diskectomy, the response rate to the
Muramatsu K, Hachiya Y, Morita C: Postoperative mag- questionnaire was 91%, and 90.7% of those patients reported
netic resonance imaging of lumbar disc herniation: being satisfied with their surgical outcomes. The combined ma-
Comparison of microendoscopic discectomy and Loves jor and minor complication rate was 3.5%.
method. Spine 2001;26:1599-1605.
The authors of this study compared postoperative MRI Endoscopic and Mini-Open Procedures
studies and found that the effect of microendoscopic diskec- Anand N, Regan JJ: Video-assisted thoracoscopic sur-
tomy on the cauda equina was comparable to that of open disk- gery for thoracic disc disease: Classification and out-
ectomy. Furthermore, the postoperative images of the route of come study of 100 consecutive cases with a 2-year mini-
entry failed to show that microendoscopic diskectomy is ap- mum follow-up period. Spine 2002;27:871-879.
preciably less invasive with respect to the paravertebral mus- In this retrospective review of prospectively collected
cles. 4-year follow-up data in 100 consecutive patients who under-
went video-assisted thoracoscopic surgery, no permanent com-
Phillips FM, Ho E, Campbell-Hupp M, McNally T, Todd plications or spinal cord injuries were reported. The average
Wetzel F, Gupta P: Early radiographic and clinical re- percentage of improvement in Oswestry scores was most sig-
sults of balloon kyphoplasty for the treatment of os- nificant in grade 4 patients (myelopathy, 60%), followed by
teoporotic vertebral compression fractures. Spine 2003; grade 3A patients (axial and thoracic radicular pain, 37%),
28:2260-2265. grade 3B patients (axial with leg pain, 28%), and grade 1 pa-
This is an outcomes report of 29 patients who underwent tients (pure axial, 24%). The authors concluded that the proce-
kyphoplasty in 37 separate sessions; a total of 61 vertebral dure was associated with significant clinical improvement in
compression fractures were treated. In 30 of the 52 fractures most treated patients.
that were considered reducible, a mean 14.2 of correction was
noted. Significant pain relief was noted with minimal compli-
Escobar E, Transfeldt E, Garvey T, Ogilvie J, Graber J,
cations.
Schultz L: Video-assisted versus open anterior lumbar
spine fusion surgery: A comparison of four techniques
Saal JA, Saal JS: Intradiscal electrothermal treatment and complications in 135 patients. Spine 2003;28:729-
for chronic discogenic low back pain: Prospective out- 732.
come study with a minimum 2-year follow-up. Spine This is a retrospective report comparing the outcomes of
2002;27:966-973. anterior lumbar interbody fusion in 135 patients using one of
This 2-year follow-up study of the original designer series the following four approaches: transperitoneal endoscopy with
demonstrated that the statistically significant improvement in insufflation, retroperitoneal endoscopic surgery, mini-open
pain scores and SF-36 quality of life scores that was previously surgery, or traditional open approaches. The incidence of com-
reported increased between the 1- and 2-year observation plications for video-assisted techniques was found to be con-
points. sistent with that reported in the medical literature, but it was
higher than that for open techniques. The authors note that
Schick U, Dhnert J, Richter A, Knig A, Vitzthum HE: they no longer use video-assisted techniques as a result of
Microendoscopic lumbar discectomy versus open sur- these findings.
Khoo LT, Beisse R, Potulski M: Thoracoscopic-assisted CT scan fusion rate at 2-year follow-up was 16.6% and was
treatment of thoracic and lumbar fractures: A series of deemed unacceptably low.
371 consecutive cases. Neurosurgery 2002;51(5 suppl):
104-117. Classic Bibliography
In this report of 371 patients with thoracic and thora-
columbar spine fractures who were treated with thoracoscopic Do HM: Magnetic resonance imaging in the evaluation
assistance, the severe complication rate was low (1.3%), with of patients for percutaneous vertebroplasty. Topics in
only one instance of each of the following reported: aortic in- MRI 2000;14:235-244.
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fluid leak, and severe wound infection. Grados F, Depriester C, Cayrolle G, et al: Long-term ob-
servations of vertebral osteoporotic fractures treated by
Pellis F, Puig O, Rivas A, Bag J, Villanueva C: Low fu- percutaneous vertebroplasty. Rheumatology (Oxford)
sion rate after L5-S1 laparoscopic anterior lumbar inter- 2000;39:1410-1414.
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metastatic thoracic neoplasms. Spine 1998;23:1130-1135.
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Silverman SL: The clinical consequences of vertebral
nificant improvements in visual analog scores, Prolo scores,
compression fractures. Bone 1993;13:S27-S31.
and Waddell Disability Index scores were noted, the overall
Figure 2 Etiology of SCI since 1990. Figure 3 Current percentage of injuries by ASIA classification (since 1991).
for evaluation over the first hours to days after injury; on the face. The sensory level is the most caudal der-
however, neurologic status can change over the first few matome to have intact (2/2) sensation for both pinprick
days and is influenced by resuscitative procedures. The and light touch on both sides of the body.
period from 72 hours to 1 week after injury is the earli- The ASIA motor examination consists of testing 10
est time period after injury when detailed neurologic key muscles (5 in the upper limb and 5 in the lower
evaluations can reliably be performed to predict neuro- limb) on each side of the body (Table 1). The patient is
logic recovery. supine during testing and strength is graded on a six-
The ASIA sensory examination consists of 28 key point scale from 0 to 5. The motor level is defined as the
dermatomes, each separately tested for pinprick/dull lowest key muscle that has a grade of at least 3, pro-
(with a safety pin) and light touch (with cotton) sensa- vided that the segments above that level are graded as
tion on both sides of the body. A three-point scale from 5. Grade 4 is not considered normal, as it previously
0 to 2 is used, with the face serving as the normal refer- was, unless the examiner judges that certain factors in-
ence point. A score of 0 represents absent sensation, in- hibited full effort, including pain, positioning, disuse, or
cluding inability to distinguish the sharp and dull edge hypertonicity. In patients in whom there is no key mus-
of the pin; a score of 1 represents impaired sensation, in- cle for a segment that has intact sensory dermatomes
cluding hyperesthesia; and a score of 2 is given when the (C2-C4, T2-L1, and S2-S5), the sensory level defines the
pin or cotton is felt in the same manner as when tested motor level.
Table 1 | Key Muscle Groups Involved in ASIA Motor Table 2 | ASIA Impairment Scale
Examination
A = Complete. No motor or sensory function is preserved in the sacral
Root Level Muscle Group Root Level Muscle Group segments S4-S5.
B = Incomplete. Sensory but no motor function preserved below the
C5 Elbow flexors L2 Hip flexors
neurologic level and includes the sacral segments S4-S5.
C6 Wrist extensors L3 Knee extensors
C = Incomplete. Motor function is preserved below the neurologic level,
C7 Elbow extensors L4 Ankle dorsiflexors and more than half of the key muscles below the neurologic level have a
C8 Long finger flexors L5 Long toe extensor muscle grade less than 3.
T1 Small finger abduc- S1 Ankle plantar flexors D = Incomplete. Motor function is preserved below the neurologic level,
tors and at least half of the key muscles below the neurologic level have a
muscle grade greater than or equal to 3.
E = Normal. Sensory and motor functions are normal.
The skeletal level of injury is defined as the spinal
level where, by radiographic examination, the greatest A is a complete injury, while B through E represent incomplete injuries. For an individual to
receive a grade of C or D, the injury must be incomplete and have either voluntary anal
vertebral damage is found. The neurologic level of in- contraction or sparing of motor function more than three levels below the motor level
jury is the most caudal level at which both motor and
sensory modalities are intact on both sides of the body.
Because of a poor correlation between vertebral injury
and function, the neurologic level of injury is preferred.
Spinal Cord Injury Syndromes
Because these levels can be different from side to side,
Central Cord Syndrome
The most common of the incomplete syndromes is cen-
up to four levels (right C6 sensory, left C8 sensory, right
tral cord syndrome, which is characterized by motor
C5 motor, left C8 motor) may be needed to present a
weakness of the upper extremities greater than the
clearer picture of the patients status.
lower extremities, in association with sacral sparing.
Tetraplegia, previously called quadriplegia, is defined
Central cord syndrome most frequently occurs in older
as impairment or loss of motor or sensory function in
patients with cervical spondylosis and a hyperextension
the cervical segments of the spinal cord caused by dam-
injury, but can occur in any age group or with any mech-
age of the neural elements within the spinal cord. Tetra-
anism. The mechanism of injury involves compression of
plegia results in impairment of function of the arms as
the cord during hyperextension, caused by an inward
well as the trunk and legs. Paraplegia refers to impair-
bulging of the ligamentum flavum on an already nar-
ment of motor or sensory function in the thoracic, lum-
rowed canal.
bar, or sacral segments of the spinal cord secondary to Central cord syndrome has a typical pattern of re-
damage of the neural elements within the spinal cord. covery that begins with the lower extremities, followed
Paraplegia results in impairment of the trunk and legs, by bowel and bladder function, proximal upper extremi-
depending on the level of injury, but the arms are ties, and hand function. The prognosis is dependent on
spared. Plexus injury or injury to the peripheral nerves the patients age, with those younger than age 50 years
outside the neural canal are not included. The terms having a much better prognosis for independence than
quadriparesis and paraparesis are discouraged because older patients. However, for patients with ASIA D tet-
they imprecisely describe incomplete lesions. raplegia, the prognosis for recovery of independent am-
Complete injury is defined as the absence of sensory bulation is excellent, even for those older than age 50
or motor function in the lowest sacral segments, and in- years.
complete injury is defined as preservation of motor or
sensory sensation below the neurologic level of injury Brown-Squard Syndrome
that includes the lowest sacral segments, also known as Brown-Squard syndrome involves hemisection of the
sacral sparing. Sacral sparing is tested by light touch and spinal cord and accounts for 2% to 4% of all traumatic
pinprick at the anal mucocutaneous junction (S4-5 der- SCIs. Neurologically, there is an ipsilateral loss of posi-
matome) on both sides, as well as by testing for volun- tion, light touch, vibration, and motor loss, and a con-
tary anal contraction and deep anal sensation. If any of tralateral loss of pain and temperature below the level
these sensations is present, even if impaired, the patient of the lesion. Neuroanatomically, this is explained by the
has an incomplete injury. The zone of partial preserva- crossing of the spinothalamic tracts at the spinal cord
tion refers to those dermatomes and myotomes caudal level and the crossing of the corticospinal and dorsal
to the neurologic level that remain partially innervated columns at the medulla.
and is used only in complete injuries. The ASIA Impair- Overall, patients with Brown-Squard syndrome
ment Scale describes five levels of SCI severity have the best prognosis for functional outcome and po-
(Table 2). tential for ambulation. Approximately 75% to 90% of
patients ambulate independently upon discharge from When the trauma patient is initially assessed at the
rehabilitation; patients are more likely to ambulate scene of injury, if there is any suspicion of SCI, addi-
when the upper limb is weaker than the lower limb on tional attention is given to maintaining maximal oxygen-
the affected side. ation and normalization of blood pressure. These crucial
early interventions help to protect the fragile spinal
Anterior Cord Syndrome cord blood perfusion. Generally these interventions in-
Anterior cord syndrome is associated with lesions that clude nasal cannula administration of oxygen and vaso-
affect the anterior two thirds of the spinal cord but pre- pressors to maintain an optimal blood pressure. Crystal-
serve the dorsal columns. Although anterior cord syn- loids are initially administered; however, if adequate
pressures cannot be maintained in the SCI patient, pres-
drome can be associated with direct injury to the ante-
sors (dopamine) should be quickly added to resuscita-
rior cord, it is most commonly caused by lesions of the
tion efforts. Blood pressure should be maintained at a
anterior spinal artery, which supplies the anterior two
systolic pressure between 80 and 100 mm Hg to mini-
thirds of the spinal cord and can be injured through
mize the proliferation of secondary insults to the spinal
thrombosis or embolism. There is inconsistent and vari-
cord from hypoxemia.
able loss of motor strength and pinprick sensation with The importance of maintaining adequate spinal cord
preservation of light touch, deep pressure, and proprio- perfusion following injury is widely accepted though
ception. Prognosis is poor with less than a 20% chance largely unproven. There exists a hypothetical watershed
of motor recovery. region of partial injury within the cord tissue that has
the potential for functional recovery if perfusion is
Conus Medullaris and Cauda Equina Syndromes maintained and further trauma avoided. Healthy cord
The conus medullaris is the terminal segment of the spi- tissue demonstrates autoregulation of blood flow capa-
nal cord. The segment above it is termed the epiconus ble of maintaining perfusion through a wide range of
and it consists of spinal cord segments L4 to S1. Lesions systemic blood pressure. This autoregulatory function
of the epiconus cause upper motor neuron dysfunction can be lost following injury, leaving the watershed re-
of the lower lumbar and sacral segments. Recovery is gion vulnerable to fluctuations in systemic blood pres-
similar to that of other upper motor neuron SCIs. Le- sure. Maintenance of mean arterial pressure above
sions of the conus medullaris affect the S2-S5 segments 85 mm Hg has been recommended for at least 7 days
and there is a combination of upper and lower motor following injury. Initial efforts at volume expansion us-
neuron deficits because the cauda equina is often in- ing crystalloid or colloid may be insufficient, and re-
jured simultaneously. Frequently the lower motor neu- quire subsequent administration of dopamine or neo-
ron deficits predominate. With conus medullaris injuries, synephrine.
recovery is limited. Mortality in the acute phase of SCI is frequently sec-
Lesions below the L1 vertebral level injure the ondary to pulmonary failure and shock. Shock is ini-
cauda equina, producing motor weakness and atrophy tially managed by the Advanced Trauma Life Support
of the lower extremities with bowel and bladder in- protocol of crystalloid resuscitation, until it is clear that
volvement and areflexia. Cauda equina injuries have a supplementary pressors are required to maintain ade-
better prognosis for recovery than other SCIs, because quate blood pressure. Early and aggressive pulmonary
the roots are histologically peripheral nerves and regen- support is essential in the acute stages after injury. Pneu-
eration can occur. Often, traumatic SCI will cause a monia and atelectasis are difficult to avoid and repre-
sent the most common early complications. The fre-
combination of conus and cauda equina injuries.
quency and severity of these occurrences is related to
the level of the SCI, as it relates to the remaining inner-
Acute Management of Spinal Cord Injury vation of the respiratory muscles. In the patient with
Acute intervention after SCI may be surgical or nonsur- acute SCI, respiratory support is often required.
gical. Nonsurgical intervention consists of pharmaco- The loss of sympathetic tone, found with lesions
logic and realignment techniques. The role of surgical above the T6 level, leads to unopposed vagal input. This
intervention for acute SCIs is still widely debated; how- imbalanced neural activity can cause increased bron-
ever, there exists a significant body of information iden- chial secretions and ultimately lead to mucus plug for-
tifying the benefit of urgent surgical intervention in ani- mation. Mucus plugs, an impaired cough reflex, and
mal SCI models. Human clinical trials and retrospective compromised respiratory muscles all can cause early
analysis have been unable to show a statistical improve- respiratory arrest in the patient with acute SCI.
ment in neurologic outcome related to surgical interven- High-dose steroids are administered in the patient
tion. According to one recent study, subacute and late with acute SCI. Intravenous administration of the gluco-
decompressive procedures have a major role in the corticoid methylprednisolone in high doses (loading
treatment of incomplete SCI. dose 30 mg/kg bolus over 15 minutes followed by
5.4 mg/kg hr) is recommended, with the length of time ting. These injuries pose the risk of significant neuro-
of administration dependent on the time of presenta- logic deterioration if undiagnosed or untreated.
tion. If administration of the steroid is initiated within 3 Indirect reduction is infrequently performed in the
hours of the SCI, administration for 23 hours is recom- acute setting for the treatment of a thoracolumbar or
mended, whereas if steroid administration is initiated lumbar injury in the presence of a spinal cord, conus, or
between 3 to 8 hours after SCI, the steroid should be cauda equina injury. Some physicians advocate early
continued for 48 hours. The original clinical trials did open reduction and stabilization of thoracolumbar
not recommend the use of methylprednisolone if the pa- fracture-dislocations with accompanying neural deficits.
tient presents after 12 hours from the time of injury. Ad- Keeping in mind that most SCI models show irrevers-
ditionally, the study cohort did not include cord injuries ible cord pathophysiology within 6 to 8 hours, advocates
caused by ballistic/penetrating trauma or those with of early decompression, realignment, and stabilization
nerve root injury. The studies supporting this protocol stress the importance of acute intervention. Such inter-
have come under increasing scrutiny over the past few vention, however, often is not possible because of
years. ground transportation of patients and hospital referral
Shortcomings of the Second National Acute Spinal networks.
Cord Injury Study (NASCIS II) include lack of data re-
garding the functional significance of apparently incre- Medical Complications of Spinal Cord Injury
mental improvements in neurologic scores, failure to
Cardiac
present raw study data, and absence of a clearly defined
The most important postinjury treatment issue is cardio-
initial study hypothesis. Follow-up post hoc subgroup
vascular sequelae. These are often subdivided into direct
analysis suggests that placebo administration greater
complications resulting from the injury itself (for exam-
than 8 hours following injury achieved an equivalent im-
ple, hypotension, bradycardia, and autonomic dysre-
provement in motor score in patients who had methyl-
flexia) after spinal shock has resolved and indirect com-
prednisolone administered within 8 hours of injury.
NASCIS II has also been criticized for lacking func- plications resulting from sequelae of immobilization and
tional outcome measures. Currently the use of high-dose the relatively sedentary lifestyle postinjury (for exam-
steroids in the treatment of SCI is an off-label use of ple, deep venous thrombosis [DVT], pulmonary embo-
this drug and has not been approved for this indication lism, and coronary artery disease).
by the Food and Drug Administration. High-dose ste- Autonomic dysreflexia is characterized by a sudden
roid treatment also has been associated with an in- sympathetic discharge causing an exaggerated increase
creased incidence of gastrointestinal bleeding as well as in blood pressure, often with bradycardia, in response to
an increased rate of infection. a noxious stimulus originating below the injury. This
The glucocorticoids are stabilizing agents that have syndrome usually occurs in 48% to 85% of patients with
been shown to affect the neural membranes, preventing SCI above the T6 level. Associated symptoms include
uncontrolled intracellular calcium influx. Additional headache, mydriasis, piloerection, nasal congestion,
stated positive effects include decreasing the lysosomal flushing, and sweating. The patient can also experience
enzyme effects and reducing secondary swelling and in- no symptoms at all, with silent blood pressure elevation.
flammation. The most common cause of autonomic dysreflexia is
A second nonsurgical intervention is early indirect bladder distention, followed by fecal impaction, pressure
reduction of the spinal canal via cranial tong traction. ulcers, ingrown toenails, fractures, and abdominal emer-
The increasing availability of MRI has dampened some gencies. Treatment includes putting the patient in a sit-
of the enthusiasm for rapid closed reduction techniques, ting position, removal of precipitating stimuli, and if the
as MRI has identified the presence of associated herni- cause cannot be found, use of antihypertensive agents
ated intervertebral disks. Closed reduction of the trau- (such as nifedipine, nitrates, and angiotensin-converting
matic deformity is directed toward restoration of the enzyme inhibitors).
spinal column to its premorbid alignment and re-
establishment of the diameter of the bony spinal canal. Deep Venous Thrombosis
This reduction maneuver is applicable to cervical spine DVT has been reported in 15% to 80% of SCI patients
injuries only. Additionally, before any significant amount and usually develops during the first 2 weeks after in-
of traction (> 10 lb) can be applied through the tongs, jury. Residual motor function in the lower extremities
special effort must be made to rule out the possibility of and the level of SCI contribute to the overall incidence.
an associated occult craniocervical injury. For patients The estimated incidence of pulmonary embolism is 2%
with distractive injuries of the cervical spine, craniocer- to 16%. All patients should receive prophylaxis for
vical dissociations, or fracture-dislocations associated DVT unless otherwise contraindicated. If prophylaxis is
with ankylosing spondylitis, application of a holding de- delayed more than 72 hours, tests to exclude the pres-
vice such as a halo is recommended in the urgent set- ence of clots should be done. Anticoagulant prophylaxis
with either low-molecular-weight heparin or adjusted Individuals with SCI are at a high risk for urinary
dose unfractionated heparin should be initiated, unless tract infection; complications caused by such infections
contraindicated, within 72 hours of injury. Vena cava fil- are the most common cause of SCI morbidity. Other
ter placement is recommended in SCI patients for complications include bladder and renal calculi, renal
whom anticoagulant prophylaxis has failed or who have failure, and bladder carcinoma. Individuals with SCI
anticoagulation contraindications. Filters should also be should have annual urologic evaluations including func-
considered for SCI patients with high-level tetraplegia, tional studies.
or for those with thrombosis of the inferior vena cava
despite the use of anticoagulants. Anticoagulant prophy- Bowel
laxis should continue for patients who are categorized Similar to the neurogenic bladder, the neurogenic bowel
as motor incomplete on the ASIA impairment scale may be either spastic or flaccid. Patients are placed on a
while they are hospitalized and for 8 to 12 weeks in mo- bowel program with predictable, regular, timely, and
tor complete patients, depending on risk factors. Pa- thorough evacuation of the bowels without the occur-
tients with chronic SCI remain at increased risk for rence of incontinence or complications. Pharmacologic
DVT, and reinstitution of prophylactic measures should agents are not always needed for long-term use but can
be considered for patients with chronic SCI who are im- be an effective adjunctive tool to facilitate the bowel
mobilized and on bed rest for a prolonged period, or for program. A common starting routine for patients with a
those who are to undergo surgical procedures. neurogenic bowel includes a stool softener three times
daily, a laxative at bedtime, and a suppository in the
Pulmonary morning after breakfast. A bowel routine after eating
Pulmonary complications after SCI remain the leading makes use of the gastrocolic reflex. If a patient usually
cause of death in patients with tetraplegia and paraple- has a bowel movement in the evening, then the laxative
gia. Pneumonia accounts for 18.9% of deaths in the first can be given at noon and an enema or suppository in
year after injury. The problems of pulmonary manage- the evening after dinner. It is difficult for patients with a
ment can be classified into three main categories: secre- true lower motor neuron bowel to achieve continence
tion management, atelectasis (and its sequelae), and hy- and a bulk laxative may be needed to limit loose stool
poventilation. At least two of the following treatments formation with diarrhea.
should be available to patients: deep pulmonary suction-
ing, chest physiotherapy, assisted cough methods (for Skin
example, quad cough), mechanical insufflation- Pressure ulcers are a daily concern for patients with
exsufflation, abdominal binders, frequent position SCI. It is estimated that up to 80% of individuals with
changes, incentive spirometry or resistive devices, and SCI will have a pressure sore during their lifetime, and
positive pressure ventilation. 30% will have more than one pressure sore. Education
in pressure ulcer etiology (including pressure and
Bladder shear), use of appropriate equipment to help decrease
The bladder is usually affected in one of two ways after ulcers, and weight shifts, while seated and in bed is nec-
injury. A spastic bladder, or upper motor neuron blad- essary. The treatment of pressure sores may include
der, fills with urine and a reflex automatically triggers dressings, bed rest, and surgery. All factors that contrib-
the bladder to empty. A flaccid bladder, or lower motor uted to pressure ulcer development must be eliminated
neuron bladder, results when the reflexes of the bladder or minimized. Treatment can be very costly in terms of
muscles are slowed or absent. A flaccid bladder can be- lost wages and additional medical expenses.
come overdistended or stretched. Although the upper
tracts are at risk in both conditions, they are at greater Neuromusculoskeletal
risk in a spastic bladder. Bladder sphincter dyssynergia After SCI, many changes occur in bone metabolism. An
occurs when the sphincter muscles do not relax when imbalance between bone formation and bone resorption
the bladder contracts, which may also place the upper rapidly develops, resulting in bone loss and osteoporosis.
tracts at risk for injury. This may occur with upper mo- Within the first 4 to 6 months, 25% or more of bone
tor neuron dysfunction. To treat the neurogenic bladder, mass is lost. By 16 months, bone mass homeostasis is
SCI patients are placed on a bladder management pro- reached with bone mass at 50% to 70% of normal and
gram, which will allow acceptable bladder emptying near the fracture threshold. Fractures are very common
with convenience and help to avoid bladder accidents in patients with SCI. Data from the Model SCI Systems
and infection, and long-term upper tract damage sec- show that 14% of patients with SCI will have had a frac-
ondary to reflux. Common treatment options include ture within 5 years after injury. This percentage in-
clean intermittent catheterization, an indwelling cathe- creases to 28% after 10 years, and 39% after 15 years.
ter, and for men, an external condom catheter. The frequency of fractures increases with age and com-
pleteness of injury, and is higher in women than men. there is an improved prognosis of recovering antigravity
Most fractures are in the lower extremities and result strength the faster the recovery begins. According to the
from falls; fractures can also occur with routine activi- literature, muscles with grade 1 and 2 strength at
ties of daily living and range-of-motion exercises. Treat- 30 days have a 97% chance of recovery to 3/5 strength
ment of fractures in nonambulatory patients with SCI is at 1 year. In comparison, in the first muscle below the
somewhat controversial. Circumferential plaster casts or neurologic level of injury with 0/5 strength at 1 month,
traction can cause skin breakdown, and surgical inter- only 57% recover to at least 1/5 strength, and only 27%
vention for femoral shaft and distal femur fractures is recover to 3/5 or more strength at 1 year. Most upper
associated with a high complication rate because of extremity recovery occurs during the first 6 months,
bone quality, risk of osteomyelitis, and recurrent bacter- with the greatest rate of change during the first 3
emia. Surgical intervention may be indicated when non- months.
surgical management fails to control rotational defor- Upper extremity recovery in patients with incom-
mity, if vascular supply is jeopardized, or in proximal plete tetraplegia is approximately twice as great as for
femur fractures with severe spasticity. Often fractures those with complete tetraplegia. For patients who are
are treated with soft splints without bed rest, and a initially sensory incomplete, the prognosis for motor re-
wheelchair is used to provide functional positioning for covery is much more favorable in those with pinprick
healing. sparing than in those in whom light touch sensation
Heterotopic ossification is the formation of true alone is spared.
bone at ectopic sites and occurs in up to 50% of adults For patients with complete paraplegia, 76% do not
with SCI. Ankylosis occurs in approximately 5% of pa- show a change in neurologic level of injury from 1
tients. Most commonly, heterotopic ossification develops month to 1 year after injury. Even without a change in
between 1 to 4 months after injury and 90% develops neurologic level, patients with incomplete paraplegia
around the hip, followed by the knee and elbow. De- have the best prognosis for lower extremity and func-
scription of the diagnosis and treatment of this condi- tional recovery. Overall, 80% of patients with incom-
tion can be found in chapter 53. plete paraplegia regain strength to grade 3 or more in
Spasticity is a common sequelae of upper motor hip flexors and knee extensors at 1 year. The absence of
neuron SCI. It may enhance function and maintain mus- any motor function at 1 month after injury is not an ab-
cle bulk, but when poorly controlled, spasticity may lead solute indicator of poor motor recovery.
to impaired function, pain, and decreased quality of life. Most of the recovery after SCI is spontaneous, but it
A full discussion of spasticity is found in chapter 52. may be enhanced by several factors. Active exercise can
promote motor recovery whereas immobilization may
Prognosis After Spinal Cord Injury impede motor recovery. Using body weight-supported
Recovery of motor function has been documented for at and interactive locomotor training, ambulation recovery
least 2 years after injury and changes in neurologic sta- may be enhanced in patients with incomplete SCI. Sero-
tus may continue after 2 years. Recovery from SCI de- tonergic and neuroadrenergic drugs may enhance loco-
pends on the initial strength of the muscles, and most motor recovery, whereas drugs with gamma-
importantly, on whether the injury is complete or in- aminobutyric acid may impede ambulation.
complete. Vertebral displacement less than 30% and age
younger than 30 years at the time of injury are factors Functional Outcomes
associated with improved recovery. No correlation has C1 through C4 Tetraplegia
been found between degree of vertebral wedging, type Patients with C1 and C2 lesions may have functional
of fracture, or etiology of injuries. In evaluating changes phrenic nerves. In these patients, implanted phrenic
after SCI, MRI is the best modality to show intramedul- nerve pacemakers can be used, and pacing of the dia-
lary detail such as hematoma and edema. A hemorrhage phragms may be simultaneous or alternating. If secre-
found with acute MRI correlates with the poorest prog- tions are not a problem, tracheostomies may be plugged
nosis, followed by contusion and edema. A normal MRI or discontinued.
scan correlates with the best prognosis. Although MRI Patients with C3 lesions have impaired breathing
may augment the physical examination, it alone is not as and are often ventilator-dependent. They can shrug their
accurate a predictor of SCI recovery as the physical ex- shoulders and have neck motion, which may permit the
amination. operation of specially adapted power wheelchairs and
Ninety percent of patients with complete tetraplegia equipment (such as tape recorders, computers, tele-
will recover one root level of function. The initial phones, page turners, automatic door openers, and other
strength of the muscle is a significant predictor of environmental control units). Adaptive devices include
achieving antigravity strength and the rate of strength mouth (sip and puff) and voice activation controls, or
recovery. In patients with no initial motor strength, chin, head, eyebrow, or eye blink controls. Patients with
of Alabama at Birmingham, Birmingham, AL. Available Barbeau H, Ladouceur M, Norman K, Pepin A, Leroux
at: www.spinalcord.uab.edu. Accessed May 2001. A: Walking after spinal cord injury: Evaluation, treat-
The National Spinal Cord Injury Database has been in ex- ment, and functional recovery. Arch Phys Med Rehabil
istence since 1973 and includes data from an estimated 13% of 1999;80:225-235.
new SCI patients in the United States. Since its inception, 25
federally funded Model SCI Care Systems have contributed Bracken MB, Shepard MJ, Collins WF, et al: A random-
data to the National SCI Database. As of July 2004, the data- ized, controlled trial of methylprednisolone or naloxone
base contained information on 22,992 patients who sustained in the treatment of acute spinal cord injury: Results of
traumatic SCI. the Second National Acute Spinal Cord Injury Study.
N Engl J Med 1990;322:1405-1411.
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sion for cervical spinal cord injury: Feasibility and out- cord injury: One-year follow-up data: Results of the
come. J Trauma 2002;52:323-332. second National Acute Spinal Cord Injury Study.
Ninety-one consecutive patients with acute, traumatic cer- J Neurosurg 1992;76:23-31.
vical SCI (1990-1997) were prospectively studied to determine
the effect of immediate surgical spinal cord decompression on Bracken MB, Shepard MJ, Holford TR, et al: Adminis-
neurologic outcome. The authors concluded that immediate tration of methylprednisolone for 24 or 48 hours or tir-
spinal column stabilization and spinal cord decompression, ilazad mesylate for 48 hours in the treatment of acute
based on MRI, may significantly improve neurologic out- spinal cord injury: Results of the Third National Acute
comes. Spinal Cord Injury Randomized Controlled Trial. Na-
tional Acute Spinal Cord Injury Study. JAMA 1997;277:
Sekhon LH, Fehlings MG: Epidemiology, demographics, 1597-1604.
and pathophysiology of acute spinal cord injury. Spine
Brunette DD, Rackswold GL: Neurologic recovery fol-
2001;26(suppl 24):S2-S12.
lowing rapid spinal realignment for complete cervical
This review examines the epidemiology, demographics, and
spinal cord injury. J Trauma 1987;27:445-447.
pathophysiology of acute SCI. The authors also discuss future
goals of increasing understanding of both primary and second- Cotler HB, Miller LS, DeLucia FA, Cotler JM, Dayne
ary mechanisms of injury, the roles of calcium, free radicals, so- SH: Closed reduction of cervical spine dislocations. Clin
dium, excitatory amino acids, vascular mediators, and apop- Orthop 1987;214:185-199.
tosis.
Delamarter RB, Sherman JE, Carr JB: Cauda equina
Winslow C, Bode RK, Felton D, Chen D, Meyer PR Jr: syndrome: Neurologic recovery following immediate,
Impact of respiratory complications on length of stay early, or late decompression. Spine 1991;16:1022-1029.
and hospital costs in acute cervical spine injury. Chest
Dolan EJ, Tator CH, Endrenyi L: The value of decom-
2002;121:1548-1554.
pression for acute experimental spinal cord compression
This article attempts to determine if respiratory complica-
injury. J Neurosurg 1980;53:749-755.
tions experienced during the initial acute-care hospitalization
in patients with acute traumatic cervical spinal injury are more Frisbie JH: Fractures after myelopathy. J Spinal Cord
important determinants of the length of stay and total hospital Med 1997;20:66-69.
costs than level of injury. A retrospective analysis of an incep-
tion cohort (413 patients) for the 5-year period from 1993 to Galandiuk S, Raque G, Appel S, Polk HC Jr: The two-
1997 was performed. The results showed that both mean edged sword of large-dose steroids for spinal cord
length of stay and hospital costs increased monotonically with trauma. Ann Surg 1993;218:419-425.
the number of respiratory complications experienced. The au-
thors concluded that the number of respiratory complications George ER, Scholten DJ, Buechler CM, Jordan-Tibbs J,
experienced during the initial acute-care hospitalization for Mattice C, Albrecht RM: Failure of methylprednisolone
cervical spine injury is a more important determinant of to improve the outcome of spinal cord injuries. Am Surg
length of stay and hospital costs than level of injury. 1995;61:659-663.
American Spinal Injury Association: International Stan- Guha A, Tator CH, Endrenyi L, Piper I: Decompression
dards for Neurological Classification of Spinal Cord In- of the spinal cord improves recovery after acute experi-
jury, revised 2002. Chicago, IL, American Spinal Injury mental spinal cord compression injury. Paraplegia 1987;
Association, 2002. 25:324-339.
Merli GJ, Crabbe S, Doyle L: Mechanical plus pharma- Stover SL, Fine PR: The epidemiology and economics of
cological prophylaxis and deep vein thrombosis in acute spinal cord injury. Paraplegia 1987;25:225-228.
spinal cord injury. Paraplegia 1992;30:558-562.
Tarlov IM, Klinger H: Spinal cord compression studies:
Moberg EA: The present state of surgical rehabilitation II. Time limits for recovery after acute compression in
for the upper limb in tetraplegia. Paraplegia 1987;25: dogs. AMA Arch Neurol Psychiatry 1954;71:271-290.
351-356.
Tator CH, Duncan EG, Edmond VE, Lapczak LI, An-
Nesathurai S: Steroids and spinal cord injury: Revisiting drews DE: Complications and costs of management of
the NASCIS II and NASCIS III Trials. J Trauma 1998; acute spinal cord injury. Paraplegia 1993;31:700-714.
45:1088-1093.
Vaccaro AR, An HS, Betz RR: The management of
Parsons KC, Lammerts DP: Rehabilitation in spinal acute spinal trauma: Prehospital and in-hospital emer-
cord disorders: 1. Epidemiology, prevention, and system gency care. Instr Course Lect 1997;46:113-125.
care of spinal cord disorders. Arch Phys Med Rehabil
1991;72(suppl):S293-S294. Vaccaro AR, Daugherty RJ, Sheehan TP, et al: Neuro-
logic outcome of early versus late surgery for cervical
Staas WE, Formal CS, Freedman MK, et al: Spinal cord spinal cord injury. Spine 1997;22:2609-2613.
injury and spinal cord injury medicine, in DeLisa JA
(ed): Rehabilitation Medicine Principles and Practice, ed Waters RL, Adkins RH, Yakura JS: Motor and sensory
3. Philadelphia, PA, Lippincott Raven, 1998, pp 1259- recovery following complete tetraplegia. Arch Phys Med
1292. Rehabil 1993;74:242-247.
blood-brain barrier. It has been noted that a low protein with dysesthesias. The peripheral neuropathy can be re-
diet allows for more consistent results with levodopa. versible if vitamin B12 is given early in the disease pro-
Levodopa has also been noted to improve the hypoki- cess.
netic dysarthria, allowing for faster and more natural lip Paraproteinemias including multiple myeloma, amy-
movement and thereby improving speech intelligibility. loidosis, lymphoma, Waldenstrms macroglobulinemia,
chronic lymphocytic leukemia, and nonmalignant gam-
Peripheral Polyneuropathy mopathy may also lead to a neuropathy. Frequently this
Peripheral polyneuropathy is a common condition in or- is a diffuse distal symmetrical problem. Multiple my-
thopaedic patients. The lower motor neurons of the pe- eloma most commonly occurs in patients between 40
ripheral nervous system may be damaged in a variety of and 70 years of age. A distal sensorimotor involvement
diseases. Patients often will have abnormal sensation will present in about 5% of the patients with multiple
that may be described as dull, prickling, numbing, or the myeloma. Radicular pain may occur with or without
vertebral fractures. Many demyelinating neuropathies
feeling of pins and needles. In addition, autonomic ner-
with a diffuse symmetric pattern are inherited; for ex-
vous system involvement may produce gastroparesis,
ample, Charcot-Marie-Tooth disease that presents with
postural hypotension, and problems with regulation of
a progressive symmetric distal muscular atrophy.
heart rate. It is important to start with a detailed history
HIV is commonly associated with peripheral poly-
and physical examination evaluating weakness, atrophy,
neuropathy. Fifty percent of patients with acquired im-
areflexia, and sensory loss. Physical assessment deter-
munodeficiency syndrome show symptoms of a periph-
mines whether involvement is in a focal region of the
eral polyneuropathy. The HIV infection may produce a
body associated with an entrapment site such as carpal
neuropathy, which is clinically indistinguishable from
tunnel syndrome or whether it is a diffuse peripheral
Guillain-Barr syndrome. The presentation of the demy-
condition. Electrodiagnostics can provide an added ben-
elinative neuropathy occurs early in the HIV infection
efit in helping to clarify the nerve disease process. Nee- and may in fact be the presenting symptom. Guillain-
dle electromyography and nerve conduction velocity Barr syndrome is the most common disease producing
studies can help determine whether the neuropathic an acute generalized paralysis from an inflammatory de-
process is predominantly axonal, demyelinating, or a myelinating polyneuropathy. Patients present with distal
combination of both. These studies can also determine paresthesias and then a generalized weakness that
whether the findings involve primarily motor or sensory progresses. Cranial nerve involvement is not uncom-
nerves, and whether they are symmetric versus multifo- mon, with the facial nerve being affected in up to one
cal. A careful family history of primary family members half of the patients. Early mortality in Guillain-Barr
can evaluate for inherited neuropathies, which can ap- syndrome is related to respiratory failure, and up to
pear without a readily apparent clinical etiology. 30% of patients may require mechanical ventilation. Au-
Diabetes is the most common cause of peripheral tonomic nervous system involvement will result in diffi-
neuropathy. It affects multiple organ systems, including culties regulating blood pressure, heart rate, and body
the peripheral nervous system. The incidence of periph- temperature as well as bowel and bladder function.
eral neuropathy in diabetic patients depends largely on Overall, about 16% of patients with Guillain-Barr syn-
how it is defined. If it is defined by patient symptoms, drome will be left with a degree of permanent disability.
about half of the individuals are affected. If electrodiag- Electromyogram studies of the amplitude of the com-
nostic characteristics are considered, the incidence in- pound of motor action potential have a strong predic-
creases to 90%. Peripheral neuropathy is also associated tive value for ambulation. Children have a much greater
with end stage renal disease. Studies indicate that at the potential for recovery.
time dialysis is initiated, as many as 65% of the patients With all the neuropathies a thorough patient history
have a peripheral neuropathy; axonal damage is more and physical examination followed by a search for revers-
common than demyelination. The specific etiology is un- ible causes are critical. Musculoskeletal treatment empha-
clear but it appears to be related to toxin buildup be- sizes maintaining basic health status by monitoring auto-
cause hemodialysis, peritoneal dialysis, and renal trans- nomic functions including blood pressure, temperature,
plantation have led to an improvement in symptoms and breathing. Musculoskeletal supports include a condi-
and electrodiagnostic study results. Chronic alcohol in- tioning endurance program. Musculoskeletal weakness
gestion leads to a similar type of peripheral neuropathy can be addressed through range-of-motion activities and
affecting the axons and leading to significant demyelina- orthotic devices such as a lightweight plastic AFO to
tion. Abstinence from alcohol may improve symptoms. maintain function. Surgical treatment consisting of Achil-
Pernicious anemia is frequently caused by a deficiency les tendon lengthening, split anterior tibial tendon trans-
of gastric intrinsic factor leading to a malabsorption of fer, and plantar fascial release may prevent later problems.
vitamin B12 from the ileum. In patients with pernicious Before performing surgical procedures, it should be deter-
anemia, an axonal peripheral neuropathy is common mined whether the underlying process is progressive, such
as Charcot-Marie-Tooth disease, whether there are re- Joy JE, Johnston RB (eds): Multiple Sclerosis: Current
versible factors as in vitamin B12 deficiency, or ominous Status and Strategies for the Future. Washington, DC, Na-
factors such as HIV infection. tional Academy Press, 2001, pp 29-69.
This review article is an excellent overview that highlights
the pathophysiology, diagnosis, prognosis, and treatment of
Postpolio Syndrome multiple sclerosis.
Postpolio syndrome occurs in patients with a history of
acute polio. It has been estimated that 25% to 60% of
the patients who had acute polio may experience latent Keenan MA, Esquenazi A, Mayer NH: The use of labo-
ratory gait analysis for surgical decision making in per-
effects of the disease. The characteristics of postpolio
sons with upper motor neuron syndromes. Phys Med
syndrome include musculoskeletal pain, fatigue, new
Rehabil State Art Rev 2002;16:249-261.
muscle weakness or atrophy, respiratory impairment, A description of laboratory gait analysis and its use in
cold intolerance, and a decline in the ability to perform identifying muscle groups causing spasticity is presented. The
activities of daily living. The specific cause of postpolio use of this information for presurgical planning is discussed.
syndrome is unknown; the etiology has been attributed
to pathophysiologic and functional causes. Pathophysio-
Rammohan KW: Axonal injury in multiple sclerosis.
logic causes include chronic poliovirus infection, death
Curr Neurol Neurosci Rep 2003;3:231-237.
of the remaining motor neurons with aging, premature The pathophysiology and pathogenesis of MS are dis-
aging, damage to the remaining motor neurons caused cussed. Axonal injury is recognized as an early occurrence in
by increased demands or secondary insults, and an the inflammatory lesions of MS. Neurologic functional impair-
immune-mediated syndrome. Functional etiologies for ment correlates best with axonal damage.
postpolio syndrome include greater energy expenditure
as a result of weight gain and muscle weakness caused Shapiro RT: Pharmacologic options for the management
by disuse or overuse. of multiple sclerosis symptoms. Neurorehabil Neural
A mild conditioning program for patients with post- Repair 2002;16:223-231.
polio syndrome may be beneficial while avoiding any This article reviews pharmacologic management of MS.
overuse or excessive fatigue that can be detrimental. Immunomodulatory drugs that control the underlying disease
Most orthopaedic needs are based on joint, muscle, or process but do not cure MS are reviewed. The article empha-
back pain. Many patients require revision of orthotic sizes that optimal disease treatment requires a multidisci-
devices such as braces, canes, and crutches or new plinary approach combining medication, rehabilitation, and
orthotic devices to treat new symptoms. Common issues patient education.
include genu recurvatum, knee pain, back pain, degener-
ative arthritis, or arthralgia. Surgery for scoliosis or frac- Yablon SA: Botulinum neurotoxin intramuscular
tures may also be necessary to treat new conditions. chemodenervation: Role in the management of spastic
hypertonia and related motor disorders. Phys Med
Annotated Bibliography Rehabil Clin N Am 2001;12:833-874.
Botulinum neurotoxin intramuscular chemodenervation
Multiple Sclerosis use is an important therapeutic tool in focal spasticity manage-
Frohman EM: Multiple sclerosis. Med Clin North Am ment. Botulinum toxin injections have been shown to be effec-
2003;87:867-897. tive and safe. Techniques, dosage, targeted muscles, and func-
MS is the most common disabling neurologic disease of tional goals are discussed in this review article.
young people. It affects up to 450,000 people in the United
States. Substantial advances have been made in diagnosis and Parkinsons Disease
treatment over the past decade. This excellent review article Samii A, Nutt JG, Ransom BR: Parkinsons disease.
helps in the formation of initial diagnostic and treatment Lancet 2004;363:1783-1793.
plans. Parkinsons disease is the most common serious move-
ment disorder in the world, affecting about 1% of adults older
Jin YP, de Pedro-Cuesta J, Huang YH, Soderstrom M: than 60 years. This review article covers diagnosis, treatment,
Predicting multiple sclerosis at optic neuritis onset. Mult and pathogenesis.
Scler 2003;9:135-141.
This prospective study examines patients who develop def- Peripheral Polyneuropathy
inite MS at the onset of optic neuritis. Correlations made with Cannon A, Fernandez Castaner M, Conget I, Carreras
MRI and oligoclonal bands in cerebrospinal fluid aid in the di- G, Castell C, Tresserras R: Type 1 diabetes mellitus in
agnosis. The study indicated a strong correlation between optic Catalonia: Chronic complications and metabolic control
neuritis leading to definite MS in patients with brain and spi- ten years after onset. Med Sci Monit 2004;10:CR185-
nal cord lesions. CR190.
This review article confirms that diabetic microvascular LaBan MM, Martin T, Pechur J, Sarnacki S: Physical and
complications including polyneuropathy and retinopathy were occupational therapy in the in the treatment of patient
already present 10 years after the onset of diabetes. with multiple sclerosis. Phys Med Rehabil Clin N Am
1998;9:603-614.
Postpolio Syndrome
Jubelt B: Post-polio syndrome. Curr Treat Options McDeavitt JT, Graziani V, Kowalske KJ, Hays RM: Neu-
Neurol 2004;6:87-93. romuscular disease: Rehabilitation and electrodiagnosis:
Postpolio syndrome describes the late manifestations that 2. Nerve disease. Arch Phys Med Rehabil 1995;76:S10-
occur in patients 30 to 40 years after acute poliomyelitis, such S20.
as new weakness, muscle pain, joint pain, peripheral nerve
compression, fatigue, and cold intolerance. This review article Meythaler JM, DeVivo MJ, Braswell WC: Rehabilitation
discusses the diagnosis and treatment plan. outcomes of patients who have developed Guillain-
Barr syndrome. Am J Phys Med Rehabil 1997;76:411-
419.
Classic Bibliography
Cheng Q, Jiang GX, Press R, et al: Clinical epidemiol- Miller RG, Peterson GW, Daube JR, Albers JW: Prog-
ogy of Guillain-Barre syndrome in adults in Sweden in nostic value of electrodiagnosis in Guillain-Barr syn-
1996-97: A prospective study. Eur J Neurol 2000;7:685- drome. Muscle Nerve 1988;11:769-774.
692.
Epidemiology tween the severity of the skull fracture and the severity
Traumatic brain injury is defined as any insult to the brain of the neurologic injuries. A cranial vault fracture may
caused by an external force, causing temporary or perma- be linear or stellate, and depressed or nondepressed. A
nent impairments in physical function, cognitive ability, depressed skull fracture initially may be missed second-
and/or disturbance of behavioral and emotional function. ary to few or no neurologic symptoms. The mortality
These impairments may cause total or partial functional rate in individuals with a depressed skull fracture is
disability and psychosocial maladjustment. Two million 11%. Approximately 11% of patients with a depressed
brain injuries occur in the United States each year. Ap- skull fracture will be left with permanent neurologic
proximately 50,000 patients die from acute brain injury. deficits. Depressed skull fractures can be further subdi-
Leading causes of traumatic brain injury include mo- vided into simple or closed (15%) and compound or
tor vehicle crashes (50%), falls (21%), gunshot wounds open (85%). A simple fracture is not associated with a
(12%), and recreational injuries (10%). Alcohol is a fac- laceration. There is no evidence to suggest that surgical
tor in approximately 60% of injuries across all age elevation of a simple, depressed skull fracture reduces
groups. the incidence of seizures or improves neurologic deficits
Approximately 750,000 Americans suffer strokes unless there is a skull fragment compressing the cere-
each year; nearly one third of these patients die. Those bral hemisphere. A compound, depressed skull fracture
who survive experience significant levels of disability, is associated with a scalp laceration. These types of skull
with hemiparesis as the most common impairment. Only fractures should be explored and surgically elevated to
10% of stroke survivors experience a full recovery. An- reduce the risk of central nervous system infection. A
other 10% fail to improve. The remaining 80% have basilar skull fracture increases the risk of meningitis
varying degrees of neurologic impairment that will im- with a dural tear, pneumocephalus, cerebrospinal fluid
prove with rehabilitative intervention. fistula, and cranial nerve injury.
Secondary injuries include the effects of intracranial
Mechanism of Injury pressure, cerebral edema, and hydrocephalus, which may
There are primary and secondary mechanisms of injury cause cerebral ischemia and hypoxia of brain tissue.
in traumatic brain injury. Primary injury occurs immedi- They may also include brain herniation syndromes,
ately at the time of impact and is associated with which can cause significant damage to the brainstem.
acceleration-deceleration and rotational forces. Second- The two major mechanisms causing stroke are is-
ary injury is the neurochemical and physiologic sequelae chemia (80%) and hemorrhage (20%). These two groups
of the primary brain insult, which occurs over hours to can be further subdivided by location and cause. Ischemic
days after the initial injury. stroke has three main mechanisms: thrombosis, embolism,
Primary injury includes skull fracture, intracranial and systemic hypoperfusion. Each of these mechanisms
hemorrhage, cortical contusion, diffuse axonal injury (a can result from various underlying pathologic conditions.
significant injury to the white matter of the brain), and Hemorrhages are most commonly associated with uncon-
penetrating injury. The two basic types of skull fractures trolled hypertension, aneurysms, and arteriovenous mal-
are those of the cranial vault and the basilar skull. Frac- formations.
tures of the occipital condyles also may occur. Intracranial
hemorrhages include epidural and subdural hematomas
and intracerebral and subarachnoid hemorrhages. Types of Deficits
Although skull fractures increase the risk of seizure Stroke and brain injury can cause mobility and self-care
and intracranial hematoma, there is no correlation be- deficits and behavioral, emotional, and cognitive dys-
(Reproduced with permission from Blount PJ, Bockenek WL: Heterotopic ossification, in
Frontera W, Silver J (eds): Essentials of Physical Medicine. Philadelphia, PA, Hanley and Heterotopic Ossification
Belfus, 2002, pp 569-574.) HO is a musculoskeletal complication that may occur
following traumatic brain injury and less frequently af-
ter stroke. HO is described as new bone formation in
Atelectasis, pneumonia, deep venous thrombosis nonskeletal tissue, located periarticularly. HO is not spe-
(DVT), pulmonary embolism, and pneumothorax are cific to traumatic brain injury and stroke; it also can de-
possible complications after stroke and traumatic brain velop following a spinal cord injury, burn, fracture, total
injury. The more severely affected patients will require joint arthroplasty, or trauma to muscle or joints. HO is
ventilator support and many will require a tracheo- defined as neurogenic when it occurs secondary to trau-
stomy. Cardiovascular complications include hyperten- matic brain, stroke, or spinal cord injury. The reported
sion, arrhythmias, cardiomyopathy, myocardial infarc- incidence of HO after traumatic brain injury varies de-
tion, and endocarditis. pending on the study and ranges from 11% to 75%.
DVT has been reported in up to 70% of unprotected There is an increased incidence to 76% in patients with
stroke patients and in approximately 20% of patients af- severe traumatic brain injury. Approximately 20% to
ter traumatic brain injury. Risk factors include bed rest, 30% of patients have clinically significant loss of ROM
hemiplegia, flaccidity, older age, obesity, history of ma- from HO and 10% to 15% have complete ankylosis. The
lignancy, and previous thrombosis. An additional risk Brooker classification system has been used to describe
factor in the posttraumatic brain-injured population is HO of the hip (Table 1).
lower extremity fracture. The risk of DVT appears low- Risk factors for developing HO subsequent to trau-
est in patients capable of ambulating a distance of more matic brain injury include the presence of fractures, es-
than 100 feet. Differential diagnosis includes cellulites, pecially those of the long bones; prolonged coma (more
fracture, tumor, CRPS, and HO. A full discussion of than 2 weeks); spasticity; and decreased ROM. HO usu-
treatment of DVT is found in chapter 51, Spinal Cord ally develops within 1 to 6 months of injury but it may
Injury. develop as early as 2 weeks or as late as 12 months after
injury. The clinical presentation of HO is variable. Most
Seizure Disorder commonly it presents initially as decreased joint ROM
A seizure occurs in 5% to 25% of stroke survivors. The or increased spasticity. A patient may also present with
highest rates follow hemorrhagic, cortical, and embolic a low-grade fever, erythema, pain, swelling, or tender-
strokes. Seizure disorder following traumatic brain in- ness. Less frequently HO may present with a nerve
jury occurs in 1.5% of patients with mild injuries, 2.9% compression, vascular compression, or lymphedema. It
with moderate injuries, and 17% of those with severe in- is most frequently found at the hips, then the shoulders
juries. These posttraumatic seizures can be classified as and elbows, then the knees. In the hip, HO can form in-
immediate (occurring within hours of the injury), early feromedially, anterolaterally, or posteriorly. In the knee
(first detected within the first week of injury), and late it is usually found anteromedially, in the shoulder it usu-
(occurring more than 1 week after injury). It is esti- ally forms inferomedially, and in the elbow it forms
mated that 12% to 15% of new onset seizures following along the medial collateral ligament. Alternative diag-
a traumatic brain injury occur 10 to 30 years after the noses include DVT, cellulitis, CRPS, septic joint, he-
acute injury. Risk factors for posttraumatic seizures in- matoma, or tumor. The gold standard for diagnosing
clude depressed skull fractures, prolonged posttraumatic HO is the three-phase radionuclide bone scan. Phase I
amnesia, missile injuries with penetration and retained and II of the bone scan can detect the condition as early
metal fragments, loss of consciousness for more than 24 as 2 to 3 weeks after the onset and phase III may be
hours, focal neurologic signs on initial examination, in- positive in 4 to 8 weeks. The bone scan usually normal-
tracerebral hemorrhage, diffuse brain contusion, cortical izes 7 to 12 months from the time of initial diagnosis. Al-
injury with subcortical extension, advanced age, and rec- though its sensitivity is high, the disadvantage of using
the bone scan for diagnosing HO is its lack of specific- quate hemostasis, neurovascular bundle isolation, and
ity. Serum alkaline phosphatase is another test used in adequate bone mass exposure are other measures to re-
the diagnosis of HO, with elevated levels associated with duce morbidity. Postoperative complications include
clinically significant HO. Normal levels range from 38 to hemorrhage, sepsis, and recurrence of HO. Postopera-
126 IU. Serum alkaline phosphatase levels begin rising tive prophylaxis to prevent recurrence includes medica-
to the upper limits of normal within the first 2 weeks tions such as etidronate disodium or NSAIDs. Also, low
and may begin to exceed normal values within the first dose radiation of 600 to 750 rads may be an option.
3 weeks from the initial onset of HO; peak levels are There have been some studies exploring the use of a
reached at approximately 10 weeks and elevation may postoperative continuous passive ROM machine. Ther-
persist for up to 6 months. Serum alkaline phosphatase apy for ROM begins when pain and swelling have sub-
levels parallel the clinical course of HO. Elevated serum sided, usually 10 to 14 days postoperatively.
alkaline phosphatase levels also are not specific. Levels
may be elevated in clinical findings such as hepatic dys- Fractures
function or fractures. If there is a suspicion of HO based There are certain complications such as fractures and
on elevated serum alkaline phosphatase levels, a three- nerve injuries that occur specifically after traumatic
phase bone scan should be performed for confirmation. brain injury. Fractures occur in approximately 34% of
Treatment of HO includes physical therapy, medica- patients; 11% are estimated to be occult fractures. Com-
tion, and surgical intervention. Physical therapy includes mon types include those of the pelvis, hip, knee, shoul-
early aggressive ROM exercises, stretching, and joint der, and cervical spine fractures and dislocations.
mobilization. There is no evidence to suggest that this Screening diagnostic studies including radiographs of
intervention increases the formation of HO because of the cervical and thoracic spine, pelvis, hips, and long
an inflammatory response. At times, manipulation under bones should be obtained in comatose patients, espe-
anesthesia is necessary for active ROM of a joint that cially those with high velocity injuries. Bone scan should
has not responded to conservative physical therapy. also be considered as a screening study. Treatment of
Medication options for treatment of HO include eti- these fractures should include early fixation because of
dronate disodium and nonsteroidal anti-inflammatory the strong possibility that these patients may eventually
drugs (NSAIDs). Etidronate disodium is a biphospho- become agitated and confused. Delayed treatment of
nate that limits ossification by blocking the formation of these fractures may become more difficult because of
hydroxyapatite crystals. The prophylactic oral dose is 20 the increased risk for the development of hypertonicity
mg/kg/day for 2 weeks, then 10 mg/kg/day for 10 weeks. and spasticity. Early stabilization is associated with
The treatment oral dose is 20 mg/kg/day for 6 months or fewer pulmonary complications, decreased use of pain
20 mg/kg/day for 3 months, then 10 mg/kg/day for 3 medications, fewer joint contractures, decreased mortal-
months. Adverse effects of etidronate disodium include
ity, and shortened hospital stays. It also allows for ear-
nausea, vomiting, diarrhea, and abdominal discomfort; it
lier mobilization and thus facilitates earlier rehabilita-
can also contribute to osteoporosis and impaired frac-
tion.
ture healing. NSAIDs reduce bone formation by inhibit-
ing prostaglandin synthetase. They have been shown to
be effective in preventing HO following total hip ar-
Nerve Injury
throplasty and HO resection. Indomethacin is the Peripheral nerve injuries occur in approximately 34% of
NSAID most often used for treatment. NSAIDs have patients with severe traumatic brain injuries; 11% are
not been proven specifically to decrease the incidence occult injuries. Causes include direct trauma, improper
of neurogenic HO. positioning, postoperative complications, and HO. Cra-
Indications for surgical intervention for HO include nial nerve injuries may also occur and are associated
impaired positioning, which causes difficulty with sitting, with the direct trauma.
lying, hygiene, ambulation, and activities of daily living;
and ankylosed joints, which cause skin breakdown, pro- Assessment
found pain, and progressive nerve compression. Some There are multiple assessment tools used to measure
studies have indicated that patients with good neuro- both severity of brain injury and function after injury.
muscular control in general have the best postoperative The Glasgow Coma Scale is the gold standard for mea-
functional outcome. Those with a poor neurologic recov- suring severity of injury in the acute stage. One score to-
ery and persistent spasticity have a higher incidence of taling from 3 to 15 is obtained based upon eye opening,
recurrence and less functional improvement in the limb. verbal response, and best motor response (Table 2). In-
The surgery may be a wedge or complete resection. It is jury is classified as severe if the score is 3 to 8, moderate
essential to defer the surgery until the bone formation is from 9 to 12, and mild from 13 to 15. Loss of conscious-
mature, at least 18 to 24 months from the initial diagno- ness for more than 6 hours is indicative of a severe in-
sis, to limit excessive bleeding. Cautious dissection, ade- jury. Posttraumatic amnesia is memory loss following in-
Rehabilitative Intervention Gardner MJ, Ong BC, Liporace F, Koval KJ: Orthopedic
Effective rehabilitation of the multiple impairments issues after cerebrovascular accident. Am J Orthop
arising from stroke and brain injury requires a team ap- 2002;31:559-568.
proach. Traditional team members include a physician, A review of the most common orthopaedic problems and
nurse, psychologist, and physical, occupational, speech, deformities experienced after stroke is presented. Muscle
and recreational therapists. Experienced case manage- spasticity, contractures, and HO are discussed along with
ment is crucial for overall coordination, communication, methods of prevention and surgical intervention.
and successful discharge. Any restrictions such as weight
bearing or ROM must be identified before beginning Melamed E, Robinson D, Halperin N, Wallach N, Keren
rehabilitation. Conventional approaches include ROM O, Groswasser Z: Brain injury-related heterotopic bone
exercises, mobilization activities, and teaching compen- formation: Treatment strategy and results. Am J Phys
satory skills. Newer promising treatments of stroke and Med Rehabil 2002;81:670-674.
brain injury are focused on central nervous system re- In this study, the results of 12 excisions of HO in 9 patients
covery using periods of intensive active motor training. were assessed. Functional improvement was noted in all pa-
Theoretical explanations for success of these newer tients 1 year after intervention. There was no evidence of re-
currence. Recommendations were made regarding indications recovery in both acute and chronic hemiparesis using more in-
for excision of HO. tense periods of active use of paretic limbs is explored. Poten-
tial efficacy with other impairments such as dystonia, aphasia,
Assessment and phantom pain are addressed.
Burke DT: Traumatic brain injury, in Frontera W, Silver
J (eds): Essentials of Physical Medicine, Philadelphia, Yu D, Chae J: Neuromuscular stimulation for treating
PA, Hanley and Belfus, 2002, pp 806-812. shoulder dysfunction in hemiplegia. Crit Rev Phys Med
This chapter presents an overview of a number of func- Rehabil 2002;14:1-23.
tional assessment tools used for patients with posttraumatic A review of several randomized controlled trials of neuro-
brain injury. muscular stimulation to treat shoulder subluxation and pain in
hemiplegic patients is presented. Potential causes of shoulder
Rehabilitative Intervention pain are reviewed.
Chae J: Neuromuscular electrical stimulation for motor
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Incidence and Etiology tients who underwent reconstruction were not signifi-
The most recent (1993) National Health and Human cantly different from those who underwent amputation.
Services data show that there are about 1.5 million am- However, reconstruction was associated with a higher
putees in the United States, with 50,000 new amputa- risk of complications, additional surgeries, and rehospi-
tions occurring each year. About 5% of amputations are talization.
tumor related, 15% result from trauma, and the remain-
ing approximately 80% are vascular in etiology, with Surgical Technique and Functional Outcomes
diabetes-related ischemic vascular disease as the major Bone
cause. In the United States there was a 27% increase in In general, ambulation and prosthetic control are opti-
the overall rate of dysvascular amputations from 1988 to mized with the preservation of the knee joint and main-
1996, with a large part of the increase occurring in geri- tenance of a longer residual bone length, which provides
atric and minority populations. Traumatic and cancer- better pressure distribution that minimizes skin break-
related amputations decreased by one half within the down with prosthetic wear. A longer residual bone
same period. The average age for patients with amputa- length also provides a longer torque arm, improving
tion resulting from vascular etiologies is between age 51 control and decreasing the metabolic demands of pros-
to 69 years, whereas the average patient age for trauma- thetic ambulation. In geriatric dysvascular amputees,
related amputations is 21 to 30 years. The overall male 90% of transtibial amputees will successfully use a pros-
to female ratio is approximately 2:1. thesis compared with 25% or fewer of transfemoral am-
Most adult limb amputations occur in the lower ex- putees. Postoperative surgical wound healing is rela-
tremity (80%); partial foot amputations comprise 50% tively higher at the transfemoral level (70% to 98%)
and transtibial and transfemoral amputations about compared with the transtibial level (30% to 90%) in
25% each. Upper extremity amputations account for dysvascular patients. This finding suggests that the trans-
the remaining 20% of all amputations, with most result- femoral level may be more suitable for geriatric patients
ing from work-related injuries involving the dominant with fewer activity demands. Younger patients can have
arm in healthy younger patients. The most common up- excellent outcomes at the transfemoral level with appro-
per limb amputations are at the transradial level (57%), priate prosthetic prescriptions and training.
followed by transhumeral amputations (23%). At the transtibial level, the ideal surgical margin is at
Congenital abnormalities are the most common the musculocutaneous junction of the gastrocnemius
cause of limb deficiencies for patients younger than age muscle. Longer bone lengths provide less soft-tissue
10 years. Causes of congenital amputation include intra- padding and poorer blood supply for the myocutaneous
partum exposure to drugs and radiation (10%) and ge- flap. Furthermore, because of the height requirements
netic deficits (20%); the etiology of the remaining 70% of the foot and ankle assembly, longer bone lengths may
is unknown. Congenital upper limb absence is usually preclude the addition of important components such as
seen at the level of the transverse upper third of the left a vertical shock pylon and rotator unit. The recom-
radius. mended transtibial residual limb length is 12.5 cm to
Limb salvage or reconstruction has recently become 17.5 cm or approximately 2.5 cm of bone length per 30
an increasingly viable alternative to amputation for pa- cm of body height. A residual limb length that measures
tients with a traumatic or oncologic etiology. A recent 33% to 50% of the intact tibial length from the medial
multicenter study comparing surgical reconstruction tibial plateau to the medial malleolus is also recom-
with limb amputation after major trauma (type IIIB, mended. In transfemoral amputations, a 5-cm stump
IIIC tibial fractures) reported that the outcomes for pa- length measured from the greater trochanter is fitted as
a hip disarticulation. A transfemoral residual bone ever, soft-tissue coverage is less than attained in poste-
length between 50% to 75% of the intact femur mea- rior flap closures.
sured from the greater trochanter to the lateral femoral
condyle is considered optimal. Nerve
Beveling the cut cortical bone at the site of amputa- Careful attention should be given to the treatment of
tion is recommended regardless of surgical level. Ideally, the transected nerves in an attempt to prevent symp-
a 45 angle may prevent pressure on the anterior skin tomatic neuroma formation to minimize future pain.
flap. In transtibial amputations, sectioning the fibula 1.2 Careful traction followed by transection allows the
cm shorter than the tibia is also recommended. Com- nerve to recoil within the soft tissues of the residual
plete removal of the fibula and adjacent muscle bulk limb. Silicone capping, grafting with an epidural nerve
was previously performed for short residual limbs; how- sheath, or a venous graft may prevent disorganized
ever, this practice is not currently recommended be- nerve regeneration and sprouting. However, most tech-
cause retention of the fibular head is important for an- niques currently in use do not eliminate neuroma for-
choring the total contact socket within the residual limb. mation and more studies are required to determine the
best long-term outcomes.
Soft Tissue
Adequate padding and coverage to the distal bone is Preoperative Consultation
achieved by muscle stabilization techniques and skin Optimal care begins before surgery. When amputation is
flaps with the goal of attaining a muscular, cylindrical, considered, patient consultation with a physiatrist, phys-
residual limb to provide ideal prosthetic fitting. Muscle ical therapist, prosthetist, and a functioning amputee is
stabilization through myoplasty and tension myodesis necessary to facilitate a smoother transition into pros-
not only provides more soft-tissue coverage but also thetic training. The physiatrist coordinates all the efforts
acts as a replacement insertion that facilitates muscle of the rehabilitative team, provides input on the recom-
contraction and movement. In tension myodesis, mended surgical level of amputation and limb length, in-
transected muscle groups are sutured to bone under forms the patient about the anticipated postoperative
physiologic tension. In myoplasty, the muscle is sutured rehabilitation protocol and outcomes, and explains po-
into soft-tissue fascia or opposing muscle groups. In tential problems. The physical therapist can initiate pre-
younger more active patients who need firmer stabiliza- prosthetic training before surgery by educating the pa-
tion, a myodesis is preferred. In transfemoral amputa- tient on conditioning and range-of-motion exercises for
tions, it has been reported that the absence of adductor the affected extremity. The prosthetist can provide valu-
magnus myodesis results in a loss of 70% of hip adduc- able input on the latest advances in rehabilitation tech-
tion power. Furthermore, myodesis prevents the antero- nology, concentrating on limitations so as not to create
lateral drift of the distal femur caused by muscular im- false expectations. A functioning amputee provides the
balance from the hip abductors that are unaffected by patient with psychological reassurance that a health pro-
the transfemoral amputation. Both procedures are rela- fessional may not be able to convey.
tively contraindicated in ischemic limbs because they
may further compromise the already marginal blood Immediate Postoperative Treatment
supply. Wound Protection and Coverage
The type of skin and soft-tissue flaps are determined Wound protection and edema control can be achieved
by the vascular supply of the distal limb. In transtibial simultaneously with a postoperative compressive dress-
amputations, blood supply in the posterior and medial ing such as an elastic stockinette (stump shrinkers) or
aspects of the leg is more abundant than in the antero- elastic bandages. Elastic bandages require proper appli-
lateral region. In ischemic limbs, a long posterior myo- cation to avoid proximal constriction from a tourniquet
cutaneous flap and a short or even absent anterior flap effect. An elastic stockinette tends to be easier to apply
is recommended. A posterior flap that measures 1 cm and provides reasonable control of edema. Some pa-
more than the diameter of the leg at the level of the tients may experience pain as the stockinette is pulled
bone division is recommended. To preserve all intact across the incision line and function better with elastic
vascular connections between muscle and skin, dissec- bandages. A nonremovable plaster cast can be placed
tion along tissue planes is avoided and myocutaneous immediately after the amputation for protection; how-
flaps are used. Occasionally, to provide more coverage, a ever, this technique prevents wound inspection and can
vascular graft can be taken from the other leg. result in pistoning and skin breakdown when residual
The fish mouth or guillotine transtibial amputation limb edema subsides. A removable rigid dressing made
is indicated for patients with ischemic limbs or those of thermoplastic provides wound coverage and edema
who require delayed primary wound closure. The proce- control and allows wound inspection and dressing
dure uses equal length anterior and posterior flaps; how- changes. It can be fabricated to resemble a socket to im-
prove residual limb shape or it can be formed into a bi- include -2 agonists (clonidine), N-methyl D-aspartate
valve or clamshell design. This approach can be used for receptor antagonists (amantidine, dextromethorphan),
patients who need protection from falling and acciden- anti-inflammatory agents, magnesium sulfate, or cannab-
tal contact while waiting for the residual limb to mature. inoids.
Preoperative analgesia with intrathecal anesthetics
Range of Motion or opioids has been beneficial in patients with long-
A range-of-motion and contracture prevention protocol standing preamputation pain. This regimen is initiated
is integral in the early postoperative course. Lying preoperatively and continued for up to 3 days after am-
prone, bedside range-of-motion exercises, and early mo- putation before converting to an oral regimen. Neuroma
bilization can prevent knee flexion and hip abduction/ excision with the combination of funiculectomy, epineu-
external rotation contractures that are seen in lower ex- ral sleeve suture ligation, or silicone capping is being
tremity amputees. It has been shown that early performed but long-term outcome studies are not yet
contracture was independently associated with the in- available. Local neurolysis with phenol/glycerin has pro-
ability to complete an inpatient prosthetic rehabilitation vided relief in patients for whom neuroma excision has
program soon after amputation surgery. been unsuccessful. Ultrasound for identification and
guidance during neurolysis also has been used with
Postamputation Pain moderate success. Cortical, thalamic, and dorsal column
The treatment of pain has important functional and stimulators implanted to stimulate neuroinhibitory path-
prognostic implications. Pain is present in up to 70% of ways can provide neuromodulation of neuropathic pain
amputees immediately after surgery and in 50% after 5 but not nociceptive pain. Intrathecal pumps that infuse
years. Along with ambulation distance, pain is the most clonidine, anesthetics, or opioids have been implanted in
important amputation-specific determinant of health- patients with intractable pain.
related quality of life. Pain is experienced as hyperalge- Mechanical stimulation by gentle residual limb tap-
sia (a stronger or earlier withdrawal response to noxious ping and the application of transcutaneous electrical or
stimuli) or allodynia (the sensation of pain from non- vibratory stimulation have been the usual physical mo-
noxious stimuli). Phantom limb pain is defined as the dalities for treating postamputation pain. The use of
nociceptive sensation of the amputated limb. transcutaneous nerve stimulation has had moderate suc-
Generally, postamputation pain can be attributed to cess and can be applied directly to the site of pain, on
local and biomechanical factors affecting the residual the contralateral limb, or even auricularly. Prosthetic
limb or to the changes to the peripheral and central ner- wear and early mobilization promotes afferent signals
vous systems caused by the amputation. Local factors that increase cortical reorganization and may relieve
include ischemia, infection, wound dehiscence, and skel- neuropathic pain in many patients.
etal abnormalities (such as ectopic bone formation, ex-
cess fibular length, and inadequate tibial beveling). Neu- Prosthetic Training
ropathic pain is often manifested as residual limb pain Prior research has supported both immediate prosthetic
secondary to a neuroma, pain in the missing limb (phan- training and delayed prosthetic fitting. Vascular transtib-
tom limb pain), or sympathetically driven pain. ial amputees treated with a rigid intrasurgical plaster
The treatment of neuropathic pain after amputation cast followed by early postoperative prosthetic limb fit-
does not produce perfect results and often requires a ting have been compared with those referred to an am-
multidisciplinary approach. Pain management protocols putee clinic for fitting several weeks after hospital dis-
include pharmacologic agents, mechanical, surgical, and charge. A significant decrease in the number of total
physical modalities (exercise), psychological counseling, hospitalization days was noted in the group who had
and behavioral approaches including imagery tech- early prosthetic limb fitting, implying increased cost ef-
niques. fectiveness with this approach. In another study, out-
The antiepileptics, tricyclic antidepressants, and opio- comes for patients with immediate prosthetic transtibial
ids are the most commonly used oral medications for fitting were examined and no significant variation was
postamputation neuropathic pain. Gabapentin, an antie- found in terms of local necrosis or infection. In a more
pileptic agent with both gamma-aminobutyric acid and recent study, a 68% success rate in early prosthetic fit-
glutamate antagonist properties, is shown to decrease ting was reported despite strict inclusion criteria that
neuropathic pain and is relatively well tolerated. De- only admitted patients who it was believed would bene-
sipramine, a tricyclic antidepressant, could also be con- fit from this approach. Based on this data, a postopera-
sidered a first-line drug. The role of opioids in the treat- tive delay of about 3 weeks before beginning prosthetic
ment of neuropathic pain is controversial but remains rehabilitation was recommended, although some pa-
clearly indicated in acute postamputation pain. Other tients will require a preprosthetic rehabilitation pro-
medications that are used in neuropathic pain disorders gram.
Early functional training includes donning and main- are done to prevent the equinus deformity. For this level
tenance of the prosthetic device, residual limb desensiti- of amputation, a special shoe or a slipper-like prosthesis
zation, strengthening, gradual and monitored increased or a combination of both is provided. A ground-reacting
prosthetic wear, and gait retraining. Strengthening of ankle-foot orthosis with anterior and posterior shells is
the quadriceps, glutei, and hamstring muscles must be prescribed in a muscularly imbalanced and pressure-
done as these muscle groups compensate for the loss of sensitive foot to provide maximal control.
the ankle and/or knee. The duration of prosthetic wear The Boyd amputation excises all the tarsal bones ex-
should be gradual, beginning with 30-minute intervals cept the calcaneus. Because of resultant residual limb
two times a day and increasing to several hours at a problems, it is not a popular procedure and is used pri-
time with frequent skin checks. Gait training is started marily for the pediatric congenital amputee. The Symes
with parallel bars to facilitate weight acceptance on the
amputation is an ankle disarticulation with a heel flap
residual limb. Weight bearing is gradually increased on
attached securely to the distal tibia to provide weight
the prosthetic limb. Gait retraining is initiated using a
bearing on the residual limb. Cosmetic concerns may
step to gait pattern leading to a step through gait pat-
limit acceptance of this procedure because the distal re-
tern. It is important to achieve a smooth gait pattern
with equal step-lengths to avoid gait deviations that in- sidual limb has a bulbous shape. The Symes prosthesis
crease metabolic energy expenditure. The early estab- extends to the proximal tibia but has a removable me-
lishment of an energy-efficient walking pattern has con- dial wall to allow the bulbous distal limb to enter the
siderable long-term implications that affect function and socket. The foot component is similar to that used in a
independence. transtibial amputation but with a lower profile to ac-
commodate the residual limb.
dolite (Endolite North America, Centerville, OH) de- don, the pretibial muscles, the gastrocnemius/
signs are common examples of multiaxis foot assem- gastrocnemius-soleus complex muscles, the popliteal
blies. fossa, the lateral flat aspect of the fibula, and the medial
Heel height adjustability is a feature developed to tibial flare. The pressure-sensitive areas include the tib-
address cosmetic issues in patients who use footwear of ial crest, tubercles, condyles, the fibular head, the distal
varying heel heights. This option is often incorporated tibia and fibula, and the hamstring tendons.
into the foot assembly. The Century 22 (Otto Bock The patellar tendon-bearing socket is the most fre-
North America) foot offers manual adjustment of vary- quently used. Although it is designed to put substantial
ing heel heights from 35 to 50 mm. weight on the patellar tendon, its intimate contact with
Occasionally, a torque absorber is placed between the entire residual limb provides even distribution of
the shank and the foot assembly to absorb torsional pressure with minimal distal end bearing. The trim line
forces as the prosthesis twists around the residual limb extends anteriorly to the lower patella level, mediolater-
during ambulation. This modification is recommended ally to the femoral condyles, and posteriorly below the
for patients with skin conditions or for those who partic- level of the hamstring tendon insertions.
ipate in sport activities or vocations that require signifi- For shorter residual limbs and those with mediolat-
cant foot rotation. eral instability, a patellar tendon supracondylar socket is
more appropriately prescribed. A supracondylar socket
Pylon extends above the medial and lateral femoral condyles
The pylon is the interphase between the foot assembly using the bony ridges to suspend the prosthesis. It pro-
and the socket and is classified as having an endoskele- vides better mediolateral knee support and is appro-
tal or exoskeletal design. Endoskeletal pylons consist of priate for shorter residual limbs. A supracondylar/
a rigid and unyielding central support surrounded by a suprapatellar suspension uses the same design but
polyurethane, soft cosmetic cover to allow for a more extends the anterior trim line to envelop the patella for
natural appearance. Substitution of isolated components added support. This particular feature also helps coun-
(socket, shank, and foot) is also possible without dis- teract genu recurvatum forces.
carding the entire prosthesis. This situation is ideal in
early prosthetic rehabilitation when a temporary or in- Suspension Systems
termediate prosthesis is provided or in the pediatric Mechanical suspension devices are external devices that
population to allow for limb growth. Recent improve- are attached to anchor on bony prominences to provide
ments in material construction using titanium and car- stabilization. They are indicated early after amputation
bon fiber have significantly increased the weight limit when there is significant volume fluctuation along the
for these pylons to as much as 350 lb. residual limb secondary to edema. They also are useful
Exoskeletal or crustacean shanks are solid blocks of in older amputees with poor hand dexterity and poor
hard plastic or wood molded to resemble the intact limb residual limb bulk and tone. Examples include: (1) A su-
and hollowed in the middle to reduce weight. The exte- prapatellar suspension strap that is fastened to the me-
rior surfaces are laminated to provide waterproofing. dial and lateral socket walls passing over the superior
Although more rigid and stronger than the endoskeletal border of the patella. This device offers some resistance
pylon designs, they are heavier and revisions often en- to knee hyperextension forces and is relatively easy to
tail discarding the entire prosthesis. Their use is limited put on and take off; however, it is prone to mild piston-
to relatively obese patients or people such as farmers or ing and is not indicated for short, painful residual limbs
outdoorsmen who are constantly exposed to environ- with mediolateral instability. (2) A thigh corset secured
ments that could corrode the more intricate components to the socket by sidebars and a knee joint assembly is
of the endoskeletal pylon. useful to take weight off of the residual limb and to pro-
Recent designs have also incorporated the pylon vide better rotational stability. (3) Anteriorly, a fork
with the foot assembly. The Re-Flex Vertical Shock py- strap can be attached to a waist or pelvic belt to add sta-
lon (Ossur North America) integrates a foot with a ver- bility in the anteroposterior plane and to help suspend
tical shock-absorbing pylon that returns energy both in the prosthesis, especially in knee flexion. It is indicated
the vertical and sagittal planes. for shorter residual limbs and for obese patients who
cannot use a suprapatellar strap. (4) Over-the-knee
Socket sleeves are fabricated from a flexible material such as
The socket acts as an interphase between the residual neoprene, which extends from the proximal end of the
limb and the prosthesis and applies weight-supporting prosthesis to the distal thigh.
forces to the residual limb. In socket fabrication, Atmospheric or suction types of suspension are gen-
pressure-tolerant areas are built up for more contact erally preferred over mechanical types to minimize pis-
and pressure-sensitive areas are relieved to minimize toning and shearing forces. However, they require ade-
contact. Pressure-tolerant areas include the patellar ten- quate hand and visual function to apply. Furthermore,
suction suspensions may provide undue stress to a heal- ity, or lack of rotational control. Less restrictive suspen-
ing surgical wound, thus promoting delayed wound sion would include a Silesian belt or total elastic suspen-
healing or wound dehiscence; they are typically with- sion belt, which is composed of neoprene with
held early in the postoperative period until volume fluc- reinforced elastic bands running at oblique angles poste-
tuations have stabilized. One example is a prefabricated, riorly and anteriorly around the waist. A silicone liner
closed-end silicone elastomer liner that is flexible with a distal pin and shuttle lock similar to that found in
enough to adapt to the irregular surfaces in the residual transtibial devices can be used. This component adds
limb and to promote an airtight environment to achieve length and in combination with the knee unit may cause
suspension. This device is rolled proximally up and over an uneven knee axis (prosthetic thigh longer than intact
the knee and is secured to the socket by means of a thigh), leading to cosmetic and biomechanical deficits. A
shuttle lock mechanism, which consists of a pin at the suction suspension is ideal for patients with mature re-
distal end of the liner and a locking mechanism located sidual limbs. Surface tension, negative pressure, and
at the bottom of the socket. Early in the postamputation muscle contractions suspend the prosthesis from the
period when the residual limb volume fluctuates signifi- limb without the need for a waist belt. Suction is gener-
cantly, the pin and shuttle lock mechanism can be de- ated by placing the residual limb into the socket with a
ferred in lieu of a supracondylar strap. The Iceross (Os- nylon pull sock or using a lubricating lotion, then expel-
sur North America) and Alpha (Ohio Willow Wood) ling air with a one-way valve.
liners are examples of silicone liners. Another example
is the Vacuum Assisted Socket System (Otto Bock Knee Assembly
North America), which consists of a silicone liner, a sus- Knee assemblies consist of a joint or bolt that allows
pension sleeve, and an air evacuation pump that creates flexion and extension, an extension stop that limits hy-
an elevated vacuum of 15 mm Hg between the liner and perextension, and a friction device that provides
the socket wall. This design controls volume fluctuation smoother motion along the assembly. General classifica-
and promotes a more secure and intimate fit between tions are based on axis and control, either on swing or
the residual limb and socket. stance phase.
A single axis knee assembly acts as a hinged joint
Transfemoral Components and is preferred for its simplicity, reliability, minimal
Socket Design maintenance, and cost. It is also ideal for children be-
The two main transfemoral socket designs are termed cause growth entails frequent changes in prosthetic
quadrilateral and ischial containment. The quadrilateral components. A polycentric or multiaxis knee is more
socket has its posterior border under the ischial tuberos- physiologic and uses multiple bar linkages along the
ity and buttocks for weight bearing, with the anterior bolt to allow a shifting mechanical axis during flexion
border providing a posteriorly directed force to control and extension. This feature provides more stability while
the femur. Therefore, it is narrow anteroposteriorly and allowing for improved performance at higher walking
wide mediolaterally. An ischial containment socket speeds.
should contain the ischial tuberosity and apply counter Control is provided either at the stance or swing
pressure from the lateral wall of the socket. It is narrow phase. Stance phase control is provided for patients with
mediolaterally and wider anteroposteriorly. Quadrilat- knee instability who cannot control knee flexion. A
eral socket designs are useful for obese patients, manual locking knee is used to maximize stability; how-
whereas more active patients may benefit from the is- ever, this eliminates knee motion throughout the gait
chial containment design that maintains the femur in cycle and is recommended for limited household ambu-
adduction, allowing the gluteal musculature to generate lators. Stance phase weight-activated control is used for
maximal tension at an ideal resting length. Material con- those with slightly better overall knee stability who
struction can be either rigid (wood, plastic laminates), need support during upright activities.
flexible, or a combination of both (Scandinavian or The presence and type of swing phase control is de-
Icelandic-Swedish-New York sockets). The outer hard termined by the patients ability to vary cadence. A con-
socket can be windowed posteriorly and anteriorly to al- stant friction device is used for elderly patients who
low improved comfort with sitting. In this situation, a walk at a constant speed. This unit has a split bushing
flexible inner liner is used in contact with the skin. and clamp around the knee bolt, which provides con-
stant friction throughout the swing phase. The amount
Suspension Device of friction is controlled by a friction adjusting screw that
The transfemoral suspension devices can either be me- tightens or loosens the bushing. For active patients who
chanical or atmospheric. A pelvic belt and hip joint of- want to vary walking speeds and run, hydraulic or pneu-
fers maximal stabilization and is best suited to those matic swing phase control devices are used. Hydraulic
with short residual limbs, significant mediolateral stabil- and pneumatic mechanisms adjust resistance to changes
(Data from Czerniecki JM: Rehabilitation in limb deficiency: Gait and motion analysis. Arch
Upper Limb Amputation and Prosthetic
Phys Med Rehabil 1996;77:S3-S8.) Components
Levels of Amputation
The transradial amputation is the most common and
Vaulting is described as excessive plantar flexion of preferred upper extremity amputation. The residual
the intact foot during the prosthetic swing phase and oc- limb length can be classified as either long (55% to
curs because of a functionally longer prosthetic limb 90%), medium (35% to 54%), or short (0 to 34%)
length for reasons similar to those that create a circum- based on the length of the intact forearm measured
duction moment. from the medial epicondyle to the distal ulna or radius.
Medial or lateral heel whip is often caused by rota- Because of component weight and length consider-
tional malalignment of the knee apparatus in compari- ations, the long transradial residual limb provides the
son to the tibial components. A knee unit placed in ex- longest lever arm most suitable for a body-powered
cessive external rotation leads to a medial whip; a knee prosthesis. A medium length transradial residual length
unit placed in excessive internal rotation results in a lat-
provides enough clearance for externally powered pros-
eral whip.
thetic components. The short transradial limb is difficult
to suspend and may promote deficits in elbow strength
Long-Term Prosthetic Rehabilitation Issues and range of motion. Elbow disarticulations may pose
Metabolic Requirements cosmetic concerns because of limited options in exter-
The metabolic requirements of ambulation increase nally-powered elbow units available for this amputation
proportionally with decreased length of the amputated level.
limb, the number of amputated joints, and the number Transhumeral amputations are also classified by re-
of amputated limbs. Furthermore, vascular amputees sidual limb length (short, medium, and long), but the
have higher metabolic requirements than their trau- prosthetic options and rehabilitative interventions are
matic counterparts. Amputees, however, offset the in- similar at each level. Shoulder disarticulations and fore-
creased metabolic demands by choosing a slower self- quarter amputations are reserved for tumor excision
selected walking pace. Patients should not be denied
surgeries because of the difficulty in providing a pros-
prosthetic fitting and training on the basis of cardiopul-
thesis with adequate suspension.
monary limitations unless these limitations are pro-
found. The metabolic cost of ambulation based on the
level and nature of amputation is shown in Table 2. Prosthetic Control
Upper extremity prosthetic control is usually either
Functional Outcomes and Work Reintegration body powered, externally powered, or a combination of
The long-term survival rate for patients after dysvascu- both. Body-powered control is provided by the intact
lar lower extremity amputation is 50% to 70% at 2 movements of the residual limb that connects to cables
years, and 30% to 40% at 5 years with a postoperative to flex and extend the elbow or open and close the ter-
mortality rate of 10% to 30%. Heart disease is the most minal device. The movements include scapular abduc-
common cause of death (51%), followed by carcinoma- tion; chest expansion; shoulder depression, flexion and
tosis (14%) and cerebrovascular accidents (6%). The abduction; and elbow flexion. Myoelectric controls use
risk of contralateral limb amputation reaches 15% to the electrical activity generated by muscle contractions
20% in 2 years after the initial amputation and the to control the flow of energy from a battery to a motor
reamputation rate of the ipsilateral limb in a transtibial controlling the terminal device or elbow unit. Compara-
dysvascular patient ranges from 4% to 30%. tive studies between myoelectric and body-powered
Traumatic amputees show more favorable outcomes. hands showed no significant difference in terms of per-
In a 2001 study, a 9% acute admission mortality rate with formance that could limit application of this technology
only a 3.5% 10-year mortality rate was found. Further- to specialized situations.
Prosthetic Components Dillingham TR, Pezzin LE, MacKenzie EJ: Limb ampu-
The terminal device attempts to approximate the complex tation and limb deficiency: Epidemiology and recent
functions of the hand and is available in different designs trends in the United States. South Med J 2002;95:
based on the users preference. The devices can either be 875-883.
This study provides a comprehensive perspective on the
hooks that provide lateral pinch or hands that provide a
epidemiology of limb amputations in the United States using
three-jaw chuck pinch. They can be passive or purely cos- linear regression techniques on data from 1988 to 1996. Dys-
metic, body powered, or externally powered. Body- vascular amputations have increased to 27%, accounting for
powered designs are either voluntary opening or volun- 82% of all limb loss. Rates of trauma and cancer-related am-
tary closing; the selection depends on the patients putations have declined by one half and the incidence of con-
anticipated use (for example, an amputee who plans to genital deficiencies has remained stable.
work in a factory would benefit from a voluntary closing
terminal device, which would not get caught in the assem- Immediate Postoperative Treatment
bly line). Terminal devices cannot provide the sensory Bone M, Critchley P, Buggy DJ: Gabapentin in postam-
feedback and dexterity of an intact hand. Myoelectric- putation phantom limb pain: A randomized, double-
powered hands allow for a proportional grasp. Slip con- blind, placebo-controlled, cross-over study. Reg Anesth
trol systems have microprocessors that maintain constant Pain Med 2002;27:481-486.
pressure on the object to prevent slippage. This study used a randomized, double blind, placebo-
Wrist designs can be manually or externally con- controlled crossover methodology. Subjects with severe phan-
trolled, and most provide passive supination and prona- tom limb pain were enrolled in a 6-week course of gabapentin
therapy titrated by increments of 300 mg to a maximum of
tion with a friction lock to control rotation when lifting
2,400 mg per day versus the control group. Significant im-
heavier objects. Quick disconnect wrists allow for easy
provement in terms of pain intensity was found in patients
interchange of terminal devices. Elbow mechanisms are
treated with gabapentin as compared with those given the pla-
either internal or external and can also be passive, body cebo. However, no differences were noticed in terms of rescue
powered, or externally powered. Body-powered designs medication (codeine/paracetamol) required, sleep disturbance,
are controlled with mechanical cables through move- or function as measured by the Barthel index.
ments of the residual limb or can be manually locked by
the contralateral hand, chin, or the ipsilateral shoulder.
Ernberg LA, Adler RS, Lane J: Ultrasound in detection
Electrical elbows are operated by electrical switches or and treatment of painful stump neuroma. Skeletal
myoelectric impulses. Radiol 2003;32:306-309.
Prosthetic socket design also has progressed with the The use of ultrasound has shown considerable success in
development of lightweight and durable materials. Flex- the assessment of amputation stump neuromas. This study in-
ible thermoplastics provide better fit and comfort and vestigates the usefulness of ultrasound guided localization for
are used in the internal layer, which comes in close con- steroid injection of amputation stump neuromas.
tact with the residual limb. Carbon fiber has replaced
wood or laminated plastics in the external layer. Me- Munin MC, Espejo-De Guzman MC, Boninger ML,
chanical suspension devices usually consist of harness Fitzgerald SG, Penrod LE, Singh J: Predictive factors for
systems that anchor across the shoulders. Fabric liners as successful early prosthetic ambulation among lower-
well as silicone suction suspension systems are also limb amputees. J Rehabil Res Dev 2001;38:379-384.
available for the upper extremity prostheses. In an effort to predict successful outcomes with early pros-
thetic rehabilitation, demographic and medical factors were
analyzed in a group of lower extremity amputees admitted to
Annotated Bibliography an inpatient rehabilitation facility. Sixty-eight percent of the
Incidence and Etiology patients met criteria for successful ambulation at time of dis-
Bosse M, MacKenzie EJ, Kellam JF, et al: An analysis of charge. The absence of lower extremity contractures and
outcomes of reconstruction or amputation after leg longer length of inpatient rehabilitation stay were significantly
threatening injuries. N Engl J Med 2002;347:1924-1931. related to successful prosthetic ambulation.
Limb salvage has replaced amputation as the primary sur-
gical treatment in severe limb trauma. This prospective cohort van der Schans CP, Geertzen JH, Schoppen T, Dijkstra
study examines the long-term outcomes of significant lower PU: Phantom pain and health-related quality of life in
extremity injury (grade III tibial or ankle fractures, severe dys- lower limb amputees. J Pain Symptom Manage 2002;24:
vascular and soft-tissue injury) treated either with amputation 429-436.
or limb salvage. The functional outcomes are similar between This study analyzed the determinants of health-related
the two treatment options; however, longer hospital stays, in- quality of life in a population of 437 lower extremity amputees
creased number of complications, and more surgeries were using the RAND-36 Item Health Survey (Dutch Language
found in the limb-salvage group. Version) questionnaire. In general, the most important
amputation-specific determinants of health-related quality of Czerniecki JM: Rehabilitation in limb deficiency: 1. Gait
life were walking distance and stump pain. Amputees with and motion analysis. Arch Phys Med Rehabil 1996;
phantom limb pain had poorer quality of life than those with 77(suppl 3):S3-S8.
only phantom limb sensation.
Edelstein JE, Berger N: Performance comparison
Prosthetic Components and Prescription among children fitted with myoelectric and body-
Carnesale PG: Amputation of the lower extremity, in powered hands. Arch Phys Med Rehabil 1993;74:376-
Canale ST (ed): Campbells Operative Orthopedics. Phil- 380.
adelphia, PA, Mosby, 2003, pp 575-595.
This chapter examines the different levels of lower ex- Esquenazi A: Upper limb amputee rehabilitation and
tremity amputations including their indications, techniques, prosthetic restoration, in Braddom RL (ed): Physical
and postoperative treatment. Noticeable differences occur in Medicine and Rehabilitation. Philadelphia, PA, WB
approaches taken in the nonischemic and ischemic lower ex- Saunders, 2000, pp 263-278.
tremity.
Gottschalk F: Transfemoral amputation: Biomechanics
and surgery. Clin Orthop 1999;361:15-22.
Schmaltz T, Blumentritt S, Tsukishiro K, Kocher L, Dietl
H: Energy efficiency of trans-femoral amputees walking Kane TJ III, Pollak EW: The rigid versus soft postopera-
on computer-controlled prosthetic knee joint: C-LEG. tive dressing controversy: A controlled study in vascular
Otto Bock Website. Available at: http:// below-knee amputees. Am Surg 1980;46:244-247.
www.ottobockus.com/products/lower_limb_prosthetics/
c-leg_energy.pdf. Accessed June, 2004. Leonard EI, McAnelly RD, Lomba M, Faulkner VW:
This online article reviews a study of the energy expendi-
Lower limb prosthesis, in Braddom RL (ed): Physical
ture needed for walking by six transfemoral amputees using
Medicine and Rehabilitation. Philadelphia, PA, WB
several prosthetic devices including the C-Leg with electronic
Saunders, 2000, pp 279-311.
controls.
Leonard JA, Meier RH: Upper and lower extremity
Long-Term Prosthetic Rehabilitation Issues prosthesis, in DeLisa JA, Gans BM (eds): Rehabilitation
Schoppen T, Boonstra A, Groothoff JW, deVries J, Medicine: Principles and Practice. Philadelphia, PA,
Goeken LN, Eisma WH: Employment status, job charac- Lippincott-Raven, 1998, pp 669-697.
teristics and work-related health experience of people
with a lower limb amputation in the Netherlands. Arch Pezzin LE, Dillingham TR, MacKenzie EJ: Rehabilita-
Phys Med Rehabil 2001;82:239-245. tion and the long-term outcomes of persons with
This study examined the occupational status of lower limb
trauma-related amputations. Arch Phys Med Rehabil
amputees in the Netherlands and compared the health experi-
2000;81:292-300.
ence of working and nonworking amputees. Patients who
stopped working because of the amputation had a worse Pinzur MS, Littooy F, Osterman H, Wafer D: Early post-
health experience compared with those who continued to surgical prosthetic limb fitting in dysvascular below-
work. Patients who later returned to work, reported problems
knee amputees with a pre-fabricated temporary limb.
(such as finding a suitable job or obtaining workplace modifi-
Orthopedics 1988;11:1051-1053.
cations) stemming from the long delay between the amputa-
tion and the return to work. Yuksel F, Kislaoglu E, Durak N, Ucar C, Karacaoglu E:
Prevention of painful neuromas by epineural ligatures,
Classic Bibliography flaps and grafts. Br J Plast Surg 1997;50:282-185.
Carabelli RA, Kellerman WC: Phantom limb pain: Re-
lief by application of TENS to contralateral extremity.
Arch Phys Med Rehabil 1985;66:466-467.
tion with substantial alcohol intake. Comparisons of ef- outcomes. It is essential to understand indications and
fectiveness with nonsteroidal anti-inflammatory drugs contraindications of specific modalities when prescrib-
(NSAIDs) are inconsistent. NSAIDs, all of which are ing these agents. In general, short-term use (1 to
analgesic, antipyretic, and anti-inflammatory, show no 3 weeks) of physical modalities may be appropriate for
significant differences among the various available com- an acute musculoskeletal problem or a flare-up of a
pounds. Some patients reported a marked preference chronic condition. No single modality has been shown
and variation in efficacy of different NSAIDs, thus war- to be superior to others for relief of musculoskeletal
ranting a trial of a second or third class of medication if pain. Prolonged use of these passive modalities should
one class provides no pain relief. An adequate trial of be discouraged. Newer treatments such as vertebral ax-
NSAIDs may be 2 to 3 weeks. Several rare, serious ad- ial decompression and continuous passive motion have
verse effects including clinical hepatitis, aplastic anemia, been purported to alleviate acute and chronic pain. Un-
and agranulocytosis can occur. Gastrointestinal adverse til clinical studies confirm these findings, use of these
effects are the most common and occur in approxi- treatments should be viewed as another physical modal-
mately 25% of patients taking NSAIDs, whereas silent ity and treated accordingly.
endoscopically demonstrated lesions occur in as many Injections of a variety of medications in various ana-
as 60% of patients. The overall risk for serious gas- tomic locations can be an adjunct to treating acute pain-
trointestinal bleeding in patients treated with NSAIDs ful musculoskeletal conditions. Epidural injections have
is 1 per 1,000 patients, with the risk significantly greater been shown to be effective in reducing radicular pain;
in patients older than 65 years. however, the results in some controlled, prospective
Other medications used for acute pain symptoms studies are variable. The benefit of facet joint and sacro-
with muscle spasms are muscle relaxants. These medica- iliac injections is controversial. They may provide some
tions are centrally acting drugs, which produce nonspe- short-term pain relief that serves as an adjunct to other
cific sedation that accounts for their muscle relaxation treatments (for example, manipulation, mobilization,
effect. Although peripherally acting muscle relaxants ex- and exercise) by facilitating joint movement in other-
ist (such as dantrolene sodium), these medications are wise hypomobile joints or segments. Trigger point injec-
not used for musculoskeletal disorders because of po- tions may provide some temporary relief for tight, pain-
tential severe adverse effects. Muscle relaxants have
ful muscle spasms to allow earlier activation of the
been found to be more effective than a placebo in the
musculoskeletal system. Multiple, repeat injections with-
relief of symptoms of acute musculoskeletal disorders.
out concomitant activation of the patient is probably of
Oral corticosteroids also may be useful as a strong anti-
little benefit.
inflammatory agent for patients with radicular symp-
toms in the cervical and/or lumbar region. Short-term
use (7 to 10 days) or corticosteroids taken at a high dos- Secondary Rehabilitation
age (30 to 40 mg prednisone or equivalent) have not Secondary rehabilitation focuses on restoring function
been associated with major adverse effects. Opioid anal- to the musculoskeletal system once initial pain symp-
gesics, on occasion, can be used for acute pain symp- toms have subsided and tissue healing has been initi-
toms. Opioid analgesics act primarily by binding opiate ated. No single component of musculoskeletal rehabili-
receptors in the central nervous system and can be asso- tation is effective for every disorder; most disorders
ciated with tolerance, toxicity, addiction, and illicit use require multiple components to provide a comprehen-
with long-term administration. Even short-term use of sive program. Understanding the roles and skills of chi-
these medications should be undertaken with caution ropractors, physical therapists, and other health care
because of an association of adverse effects including providers is critical to avoid overuse and abuse of any
demotivation, early reactive hyperalgesia, and early de- one treatment. Cornerstones of restoring function are
pendency problems in a select group of patients. Al- activation of the patient to prevent the sequelae of im-
though more potent than NSAIDs and acetaminophen, mobility and exercise to restore muscle flexibility, mus-
in two of three clinical trials, narcotic analgesics were cle balance, and coordination. Initially, exercises are em-
found to be no more effective than these medications in phasized in nonpainful ranges and planes of motion.
relieving pain. The dosage schedule should be defined Manual treatments and mobilization of restricted joints
and use limited to patients whose pain is unresponsive and soft tissues, either by chiropractors, osteopaths, ther-
to alternative medications. apists, or physicians, are often initiated before beginning
Physical agents including ultrasound, electrical stim- focused strengthening programs. Injections for pain con-
ulation, and heat and cold have been used to promote trol (for example, local corticosteroids and epidural in-
tissue healing, increase circulation, decrease inflamma- jections) may play some role in this phase of rehabilita-
tion, and reduce pain. Although physical agents are fre- tion if the injections are used as an adjunct to increasing
quently used for symptomatic relief, these passive mo- the patients active participation in therapy or exercise.
dalities do not appear to have any effect on clinical Exercise programs for musculoskeletal rehabilitation
should focus not only on mobility and absolute muscle should take place. This assessment should include all ap-
strength but also on muscle balance (agonist and antag- propriate imaging tests, supportive electrodiagnostic
onist strength ratios), kinetic chain issues (proximal and tests, and diagnostic injection procedures as needed.
distal segment interplay with an injured segment), and Electromyography, nerve conduction velocity tests,
muscle endurance or ability to function without fatigu- MRI, CT, myelography, diskography, selective nerve
ing. Exercise programs should focus on strengthening root block, peripheral nerve block, and sympathetic
weaker structures, with minimal aggravation of pain block tests may be included. Careful surgical decision-
symptoms. Nonspecific exercise programs for nonspe- making and discussions with the patient and family
cific diagnoses yield nonspecific and often unsuccessful about surgical options should then take place. If the pa-
results. tient agrees to surgery, it should proceed with appropri-
Repetitive flexion-biased exercises for a patient with ate postoperative secondary care. Tertiary rehabilitation
a typical posterolateral disk herniation may increase is the last resort when all reasonable surgical interven-
symptoms. Exercises that emphasize centralization of tions have been exhausted or the patient is unwilling to
pain symptoms to the lumbar spine in patients with low elect additional surgery.
back and leg symptoms may prove useful. The benefit of As a prelude to the tertiary rehabilitation process,
determining the directional preference and proper plane special assessment of physical and functional capacity
for flexion for each patient with back pain before initi- and psychosocial status is needed. From a physical per-
ating exercise treatment has been well documented. A spective, patients have usually already undergone many
recent study of patients with acute low back pain has weeks or months of physical therapy guided by a variety
shown that a classification-based exercise program im- of health professionals and limited by resistance, fear,
proved disability and returns to work status in the exer- and inhibition of function (often termed fear-
cise group compared with a control group followed for 1 avoidance). During tertiary rehabilitation, the quantifi-
year. Aerobic conditioning has been shown to be benefi- cation of physical function by objective measures may
cial in terms of improving aerobic capacity, muscle help to guide the treatment approach by setting param-
strength, and flexibility in patients with nonactive to eters for exercise, by providing feedback on progress to
moderately active rheumatoid arthritis and osteoarthri- the patient, and by leading to better assessment of per-
tis of the hip and/or knee. Short periods of immobiliza- manent impairment. Measurements of the mobility and
tion immediately after surgery may be required for ade- strength around the injured joint(s) or spinal region(s),
quate tissue healing. However, during the postoperative aerobic capacity, and the functional capacity of perform-
period, and especially following anterior cruciate liga- ing various activities of daily living (such as lifting, grip-
ment reconstruction, early rehabilitation to prevent loss ping, climbing) are important. Such tests are often
of range of motion and muscle strength has been shown termed physical or functional capacity evaluations and
to improve functional outcome. may involve goniometers, inclinometers, or three-
Physical conditioning programs, called work condi- dimensional digitizers to measure mobility; isometric,
isoinertial, or isokinetic strength testing devices; bicycle
tioning or work hardening programs, attempt to im-
or treadmill ergometers; and a variety of lifting proto-
prove work status and function; however, there is no ev-
cols and devices. In unmotivated patients or those with
idence of their efficacy for acute back pain. Emphasis
chronic pain, measurements of functional capacities may
should be placed on use of programs that focus on re-
not reflect their true physiologic functional abilities.
turn to work. Patients should participate in restoration
Psychosocial assessment is also an essential prereq-
programs that simulate the activities of daily living that
uisite for planning tertiary rehabilitation. Traditionally,
they need to perform, and emphasize improvement in
clinicians have searched for causes of pain, seeking a
function. Programs that emphasize pain relief alone and
physical basis for pain complaints that, once identified,
that use short-term passive modalities are not effective.
could be eliminated or blocked. When no organic basis
If no improvement is seen in a 4- to 6-week period with
was identified, a psychological cause was assumed,
physical conditioning or work hardening programs,
hence the term psychogenic pain. However, the concept
other options such as tertiary rehabilitation should be
of a simple dichotomy, that pain is physical or psycho-
considered.
logical, is inadequate. It is more accurate and clinically
effective to identify a variety of psychosocioeconomic
Tertiary Rehabilitation barriers to recovery or risk factors creating entitlement,
Multidisciplinary Assessment resistance, or fear-avoidance. A variety of simple vali-
Because the diagnosis in patients with chronic pain or dated questionnaires have been developed that can be
disability may be multifactorial, the involvement of used to assess pain, disability, health status, and depres-
many health professionals is often required. Before in- sion (Table 1). A psychiatric diagnosis can be made us-
stituting a tertiary rehabilitation program, a multidisci- ing the Structured Clinical Interview for the Diagnostic
plinary assessment of the patients treatment options and Statistical Manual of Mental Health Disorders,
the patients medical care. Although psychotropic drugs classification-based approach resulted in improvement in dis-
and NSAIDs may also be used, the type of narcotic and ability and return-to-work status after 4 weeks as compared
dosage tends to determine much about the patients ul- with therapy based on clinical guidelines.
timate physical and psychological well-being. The regu-
lar use of continuous release narcotics (for example, Secondary Rehabilitation
methadone, meperidine hydrochloride, hydromorphone Mayer T, Polatin P, Smith B, et al: Spine rehabilitation:
hydrochloride), or narcotic pumps is a rapidly growing Secondary and tertiary nonoperative care. Spine J 2003;
trend. Psychologic therapies focus on stress manage- 3(suppl 3):28S-36S.
ment and learning techniques to cope with inactivity This Contemporary Concepts Review presents a position
and lack of societal productivity, even in younger indi- statement of the North American Spine Society Board and
viduals. Federal disability benefits (Supplemental Secu- summarizes aspects of secondary and tertiary rehabilitation
rity or Social Security Disability benefits) provide a specific to spinal disorders in greater detail.
safety value for those with preretirement disabilities,
with the number of patients receiving such payments in- van Tulder MW, Malmivaara A, Esmail R, Koes BW: Ex-
creasing from four million to nine million in the United ercise therapy for low back pain, in The Cochrane Li-
States over the past 20 years. These benefits have in- brary (Update Software on CD-ROM), Issue 3, 2003.
creased from $40 billion to $100 billion over the same Thirty-nine randomized controlled trials were identified.
time period, now accounting for 5% of the US federal Exercise therapy was shown to be more effective than the
budget. Outcome measurement may be problematic, be- usual care given by general practitioners and equally effective
cause the patients self-assessment of pain and health as conventional physiotherapy for chronic low back pain. Ex-
status may be markedly influenced by the treatment ercises may be helpful for patients with chronic low back pain
team and requirements for continued narcotic use. to facilitate earlier return to normal daily activities and work.
habilitation of chronic musculoskeletal disorders. J Bone Mayer T, Gatchel R, Polatin P: Occupational Musculosk-
Joint Surg Am 2004;86:62-69. eletal Disorders: Function, Outcomes and Evidence. Lip-
Comparison of patients who persistently seek health care pincott Williams & Wilkins, Philadelphia, PA, 1999.
after tertiary rehabilitation with those who do not reveals that
persistent healthcare seekers demonstrate poor outcomes in
Mayer T, Gatchel R, Polatin P, Evans T: Outcomes com-
work-related injuries that lead to higher societal costs and de-
parison of treatment for chronic disabling work-related
creased worker productivity.
upper extremity disorders and spinal disorders. J Occup
Environ Med 1999;41:761-770.
Schonstein E, Kenny D, Keating J, Koes B, Herbert RD:
Physical conditioning programs for workers with back
and neck pain: A Cochrane systematic review. Spine Mayer T, McMahon MJ, Gatchel RJ, Sparks B, Wright
2003;28:E391-E395. A, Pegues P: Socioeconomic outcomes of combined
A meta-analysis by the Cochrane collaboration of ran- spine surgery and functional restoration in workers
domized trials of chronic back pain in work-related injuries compensation spinal disorders with matched controls.
demonstrates that physical conditioning programs that incor- Spine 1998;23:598-606.
porate a cognitive behavioral approach reduce work loss.
Mayer TG, Gatchel RJ, Mayer H, Kishino N, Keeley J,
Classic Bibliography Mooney V: A prospective two-year study of functional
restoration in industrial low back injury: An objective
Bendix AE, Bendix T, Haestrup C, Busch E: A prospec- assessment procedure. JAMA 1987; 258:1763-1767.
tive, randomized 5-year follow-up study of functional
restoration in chronic low back pain patients. Eur Spine Mazanec D: Medication use in sports rehabilitation, in
J 1998;7:111-119.
Kibler WB, Herring SA, Press JM (eds): Functional Re-
habilitation of Sports and Musculoskeletal Injuries.
Hazard RG, Fenwick JW, Kalisch SM, et al: Functional Gaithersburg, MD, Aspen, 1998, pp 71-79.
restoration with behavioral support: A one-year pro-
spective study of patients with chronic low-back pain.
Spine 1989;14:157-161. OSullivan PB, Phyty GD, Twomey LT, Allison GT: Eval-
uation of specific stabilizing exercise in the treatment of
chronic low back pain with radiologic diagnosis of
Jordan KD, Mayer TG, Gatchel RJ: Should extended spondylolysis or spondylolisthesis. Spine 1997;22:
disability be an exclusion criterion for tertiary rehabili-
2959-2967.
tation? Socioeconomic outcomes of early versus late
functional restoration in compensation spinal disorders.
Spine 1998;23:2110-2117.
Figure 2 Radiograph showing anterolateral bowing in a child with neurofibromatosis, which progressed to congenital pseudarthrosis of the tibia.
Skeletal Dysplasias
Achondroplasia and Related Disorders
Several chondrodysplasia phenotypes result from muta- Figure 3 Typical radiographic appearance of multiple osteochondromas around the
knees in a patient with hereditary multiple exostosis.
tions in the fibroblast growth factor receptor 3 gene, in-
Figure 4 Typical clinical (A) and radiographic (B) findings in a child with achondroplasia.
cluding achondroplasia, hypochondroplasia, thanato- achondroplasia involves the proximal limb bones, in-
phoric dysplasia, and severe achondroplasia with cluding the humerus and femur, whereas children with
developmental delay and acanthosis nigricans dysplasia. other disorders have mesomelia (shortening of the fore-
These disorders are closely related and represent a con- arm and leg) and acromelia (shortening of the hands
tinuum of severity. and feet). The diagnosis is often made prenatally by ul-
trasound; if not identified prenatally, this disorder is
Achondroplasia identified at birth by the presence of rhizomelic short-
Achondroplasia, the most common form of dwarfism, is ening, a trunk of normal length, macrocephaly, frontal
an autosomal dominant disorder that is caused by a sin- bossing, a depressed nasal bridge, and trident hands
gle nucleotide substitution. More than 90% of instances (Figure 4). Elbow flexion contractures are the result of
of achondroplasia result from a sporadic mutation. The bowing of the distal humerus and posterior radial head
specific mutation in achondroplasia converts either gua- subluxation/dislocation. Classic radiographic findings in-
nine to arginine or guanine to cysteine at position 380 in clude shortening of the long bones, progressive narrow-
the transmembrane domain of the protein, resulting in a ing of the interpedicular distance through the lumbar
glycine to arginine substitution. This single amino acid spine, squared iliac wings, horizontal acetabula, and nar-
substitution not only causes stabilization of the fibro- row sacrosciatic notches.
blast growth factor receptor protein and its accumula- Foramen magnum and upper cervical stenosis is a
tion on the cell surface, but also results in uncontrolled, life-threatening disorder that affects these children at
prolonged ligand-dependent activation of the receptor. birth and in early life. Cervicomedullary cord compres-
The result of this sustained fibroblast growth factor re- sion can result in hypotonia, delayed development,
ceptor activity is growth retardation in the proliferative weakness, and apnea. The central apnea can be compli-
zone of the growth plate, leading to decreased bone cated by obstructive components, including abnormal
length. The most profound effect on the skeleton is in nasopharyngeal development and enlarged tonsils and
the areas of greatest endochondral growth (humerus adenoids. Routine perinatal screening with MRI is con-
and femur), resulting in the characteristic rhizomelia. troversial. Symptomatic children are typically assessed
The rhizomelic pattern of shortening in children with with MRI and a sleep study. Surgical management in-
cludes decompression and occasionally shunting for hy- with thoracolumbar kyphosis and those with significant
drocephalus. Unlike other forms of skeletal dysplasias, degenerative changes. Scoliosis is unusual in this patient
cervical instability is rare. population.
Thoracolumbar kyphosis occurs commonly in in- Genu varum is typical in over 90% of patients with
fants. It is thought to be secondary to truncal hypotonia achondroplasia. The deformity may occur at multiple
and weakness and an enlarged head. Avoidance of levels, including the distal femur, the proximal and distal
propped sitting is advocated. The kyphosis typically re- tibia, and through the lateral ligaments of the knee. Re-
solves as children achieve independent ambulation alignment osteotomies are recommended for patients
(later than in children of average stature with achondro- with progressive, symptomatic genu varum. Correction
plasia who typically have a mean walking age range of of the associated internal tibial torsion is done concur-
18 to 24 months) (Figure 5). rently.
Bracing is reserved for those children with severe Short stature in achondroplasia is moderately severe
progressive kyphosis and wedging of the apical verte- and can result in functional limitations. Teenagers with
bra. Anterior and posterior spinal fusion is indicated in achondroplasia have concerns about their body image.
older children with persistent severe kyphosis, but it is Adult studies indicate that function and self-image in
rarely required. Lumbar spinal stenosis is common patients with achondroplasia are similar to those of
(30% of children are symptomatic in the second de- average-statured adults. Growth hormone has been ad-
cade), and it is caused by interpedicular narrowing, vocated in growing children, but its use is controversial
short pedicles, disk bulging, and hyperlordosis. In older because the improvement in final height is variable. Ex-
patients, the stenosis is aggravated by degenerative tended limb lengthening to increase stature has been
changes. Lumbosacral decompression is recommended used commonly in Europe, but is more controversial in
for patients with symptomatic spinal stenosis. Spinal fu- North America. Long-term effects on the adjacent artic-
sion is required in addition to decompression in patients ular surfaces have not been well studied.
Spondyloepiphyseal Dysplasia
Spondyloepiphyseal dysplasias are characterized by
short stature secondary to a short trunk and short limbs.
Many different types of this disorder exist, with the
most common type being the congenita form. This is
caused by mutations in COL2A1 (collagen type II 1
chain). This gene encodes type II collagen, which is
found primarily in cartilage and in the vitreous humor,
locations consistent with the phenotype of spondyloepi-
physeal dysplasia congenita and other disorders such as
Kniest dysplasia and type I Sticklers syndrome. Radio-
graphic changes include abnormal spinal development
with odontoid hypoplasia and platyspondyly, abnormal
formation of the long bone epiphyses with variable
metaphyseal involvement, and generalized delay in epi-
physeal ossification. The diagnosis is made at birth. Pa-
tients have marked short stature with a very short trunk
and often a barrel-shaped chest (Figure 6). Lumbar lor-
Figure 6 Photograph showing typical clinical appearance of a child with spondyloepi- dosis is typical, and progressive kyphoscoliosis occurs.
physeal dysplasia congenita. Retinal detachment, severe myopia, and sensorineural
hearing loss are common in childhood and adult life.
Atlantoaxial instability resulting from odontoid hypo-
Hypochondroplasia
plasia and ligamentous laxity must be evaluated early in
Hypochondroplasia is an autosomal dominant disorder life and monitored on a regular basis with flexion-
with clinical features and radiographic findings similar extension lateral C-spine radiographs and/or MRI. Surgi-
to those associated with achondroplasia, but to a milder cal management is indicated in patients with significant
degree. The diagnosis is rarely apparent before age instability or cervical myelopathy. Progressive kypho-
2 years and typically results from investigation of short scoliosis in the growing child can be managed with a brace;
stature. Musculoskeletal problems that present for man- however, with progression, surgical management is usually
agement in hypochondroplasia include lumbar spinal required. Lower extremity malalignment is common in
stenosis, genu varum, and short stature. Management of these children. Coxa vara, genu valgum, valgus alignment
hypochondroplasia is the same as for the disorders asso- of the distal tibia, and planovalgus foot deformities are
ciated with achondroplasia. typical. These deformities can result in significant gait ab-
normalities consisting of increased lumbar lordosis, a wad-
Thanatophoric Dysplasia dling gait, and a crouch gait with the knees knocking to-
Thanatophoric dysplasia is a severe, usually lethal disor- gether. The coxa vara is often progressive and is difficult
der resulting from mutations in the fibroblast growth to assess radiographically because of the delayed capital
factor receptor 3. Clinical features of this dysplasia in- femoral ossification (Figure 7).
Kniest Dysplasia
Kniest dysplasia is an autosomal dominant disorder
caused by mutations in COL2A1. The trunk is dispro-
portionately shorter than the limbs in patients with Kni-
est dysplasia, and the face is flattened with midface hy-
poplasia. Myopia, retinal detachment, deafness, joint
contractures, limb malalignment, and kyphoscoliosis can
occur throughout life in this patient population. The ra-
diographic features include dumbbell-shaped long bones
with broad metaphyses and irregular dysplastic epiphy-
ses. Joint stiffness and pain typically result from deterio-
ration of the articular cartilage.
Metaphyseal Chondrodysplasia
Although many forms of metaphyseal dysplasia have
been described, metaphyseal involvement with short
stature and bowing of the legs is a common feature to
all. The most common Schmid type is autosomal domi- Figure 7 Radiograph showing coxa vara in a child with spondyloepiphyseal dysplasia
congenita.
nant and is caused by a type X collagen mutation
(COL110A1). This type is the mildest in this group, with
patients typically exhibiting moderate short stature, a mutation of RMRP, a nuclear gene (RNA component of
waddling gait, and genu varum. The diagnosis is usually mitochondrial RNA processing endoribonuclease). Pa-
made in early childhood. The radiographic features re- tients with this disorder have fine, sparse body hair and
semble those seen in patients with rickets and include significant complications, including impaired cellular im-
metaphyseal irregularity and flaring with widening of munity, anemia, Hirschsprungs disease, and malignancy.
the physes. Patients with metaphyseal chondrodysplasia may need
The Jansen type is a rare autosomal dominant disor- surgical management of short stature and limb malalign-
der caused by a mutation in the parathyroid hormone ment (Figure 8).
receptor gene that regulates the differentiation of
growth plate chondrocytes. Severe short stature with de- Pseudoachondroplasia
formity is typical, and some affected children have hy- Pseudoachondroplasia is an autosomal dominant disor-
percalcemia, hypercalciuria, and hyperphosphaturia. der caused by a mutation in the gene encoding for carti-
The McKusick type is an autosomal recessive disor- lage oligomeric matrix protein (COMP). COMP is an
der (also called cartilage-hair hypoplasia) caused by a extracellular calcium-binding glycoprotein belonging to
Gomez P, Garcia O, Ginebreda M, Gairi T, Vilarrubius The authors of this article report that scoliosis is common
G: Lumbar canal stenosis in achondroplasia: Prevention among patients with diastrophic dysplasia; types include early
and correction of lumbosacral lordosis. An Esp Pediatr progressive in 10% of patients, idiopathic-like in 50%, and
2001;54:126-131. mild nonprogressive in 40%.
The authors of this article report that femoral lengthening
improves lumbar hyperlordosis and reduces the symptoms of Stanley G, McLoughlin S, Beals RK: Observations on
lumbar spinal stenosis. the cause of bowlegs in achondroplasia. J Pediatr
Orthop 2002;22:112-116.
Helenius I, Remes V, Tallroth K, Peltonen J, Possa M, The authors of this study report that tibia vara increased
Paavilainen T: Total hip arthroplasty in diastrophic dys- during growth in patients with achondroplasia and that
plasia. J Bone Joint Surg Am 2003;85-A:441-447. younger children with this disorder tended to have proximal
The authors of this article report that the rate of implant tibial varus and older children tended to have distal tibial
survival is good and that Harris hip scores increased signifi- varus. Increased fibular length was thought to play a role.
cantly in patients with diastrophic dysplasia who underwent
total hip arthroplasty. Classic Bibliography
Bailey JA II: Orthopaedic aspects of achondroplasia.
Kitoh H, Kitakoji T, Kurita K, Katoh M, Takamine Y: J Bone Joint Surg Am 1970;52:1285-1301.
Deformities of the elbow in achondroplasia. J Bone
Joint Surg Br 2002;84:680-683. Bethem D, Winter RB, Lutter I, et al: Spinal disorders of
The authors of this article report that posterior bowing of dwarfism: Review of the literature and report of eighty
the distal humerus (primarily) and posterior dislocation of the cases. J Bone Joint Surg Am 1981;63:1412-1425.
radial head result in loss of elbow extension.
Fairbank T: Dysplasia epiphysealis multiplex. Br J Surg
Morgan K, Rehman M, Schwartz R: Morquios syn- 1947;34:325.
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Hastbacka J, Superti-furga A, Wilcox WR, Rimoin DL,
Anaesth 2002;12:641-644.
Cohn DH, Lander ES: Sulfate transport in chondrodys-
The authors of this article provide a review of anesthetic
plasia. Ann N Y Acad Sci 1996;785:131-136.
care for children with Morquio syndrome.
Kopits SE: Orthopaedic complications of dwarfism. Clin
Munns C, Glass I, LaBrom R, et al: Histopathological Orthop 1976;114:153-179.
analysis of Leri-Weill dyschondrosteosis: Disordered
growth plate. Hand Surg 2001;6:13-23. Mackenzie WG, Bassett GS, Mandell GA, Scott CI Jr:
The authors of this article report that the zone of dyschon- Avascular necrosis of the hip in multiple epiphyseal dys-
drosteosis is characterized by marked disruption of the normal plasia. J Pediatr Orthop 1989;9:666-671.
physeal arrangement.
Peltonen JL, Hoikka V, Poussa M, Paavilainen T, Kaitila
I: Cementless hip arthroplasty in diastrophic dysplasia.
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J: Cervical spine in patients with diastrophic dysplasia:
Radiographic findings in 122 patients. Pediatr Radiol Poussa M, Merikano J, Ryoppy S, Marttinen E, Kaitila I:
2002;32:621-628. The spine in diastrophic dysplasia. Spine 1991;16:881-
The authors of this article report that the most common 887.
alignment of the cervical spine in adulthood is cervical lordo-
sis and that degenerative changes are common. As the preva- Remes V, Marttinen E, Poussa M, et al: Cervical kypho-
lence of spina bifida occulta is high, the authors recommend sis in diastrophic dysplasia. Spine 1999;24:1990-1995.
that care be taken during the surgical approach for patients
with diastrophic dysplasia.
Ribbing S: Studien uber Hereditaire multiple Epiphy-
senstorungen. Acta Radiol 1937;1(suppl):34.
Remes V, Poussa M, Peltonen J: Scoliosis in patients Ryoeppy S, Poussa M, Merikanto J, Marttinen E, Kaitila
with diastrophic dysplasia: A new classification. Spine I: Foot deformities in diastrophic dysplasia: An analysis
2001;26:1689-1697. of 102 patients. J Bone Joint Surg Br 1992;74:441-444.
Myelomeningocele often correlates with the last intact laminar arch (Table
Myelomeningocele (spina bifida, myelodysplasia) is the 1). Ambulation is generally predicted by age 2 years. A
most common major birth defect, with an incidence in child with myelomeningocele who is not a community
the United States ranging from 0.6 per 1,000 to 0.9 per ambulator by the age of 6 years is not likely to reach
1,000 births. This neural tube defect results from embry- this goal.
ologic failure of closure of neural crests during the neu- Serial, well-documented orthopaedic and neurologic
rulation phase of the spine in the third to fourth week examinations are key components in detecting and
after fertilization. The failure results in a cerebrospinal avoiding progressive deterioration caused by neurologic
fluid-filled swelling of dura and arachnoid with spinal loss. Major areas of concern include loss of motor func-
nerve roots contained in the sac. In 85% to 95% of pa- tion and rapid progression of scoliosis. Common causes
tients, the disorder is caused by dietary deficiency of of increasing spasticity and loss of function include hy-
folate. Daily supplementation of 0.4 mg (400 g) of folic drocephalus, shunt malfunction, tethered cord, syringo-
acid before conception and during the pregnancy re- myelia, and posterior fossa compression from Arnold-
duces the risk of neural tube defects significantly. Chiari malformation.
Prenatal diagnosis via enzyme elevation of maternal
serum -fetal protein has an accuracy rate of 60% to Hip Deformities
95% for screening neural tube defects. An improved ul- Hip flexion contracture in children with myelomeningo-
trasonographic technique for prenatal diagnosis also has cele is caused by muscle imbalance (weak extensors/
allowed informed prenatal assessment for possible elec- strong flexors), spasticity as seen in tethered cord pa-
tive termination. Cesarean section is the preferred tients, or habitual sitting posture. During the first
method of delivery when the diagnosis is known be- 2 years of life, hip flexion contracture decreases except
cause it avoids trauma to the large myelomeningocele in high thoracic-level patients. Surgery is usually not in-
and its neural elements. Fetal sac closure surgery has dicated in patients younger than 2 years of age. In pa-
been postulated to improve neurologic outcome. In one tients with high thoracic lesions, flexion contracture of
study of 59 patients, intrauterine myelomeningocele re- 30 to 40 may be tolerated. Greater than 30 to 40 of
pair reduced the incidence of hindbrain herniation (4% contracture will result in impairment of standing ability,
versus 50%) and the incidence of shunt-dependent hy- short stride length, and increased lumbar lordosis. In pa-
drocephalus (58% versus 92%). Functional level was tients with low lumbar motor deficit, hip flexion con-
unchanged. Currently, multicenter prospective studies to tracture of more than 20 causes decreased walking abil-
assess risk and benefits of intrauterine myelomeningo- ity as a result of anterior pelvic tilt, decreased velocity,
cele repair continue. and increased demand of the upper extremities.
Latex allergy, sensitivity, or anaphylaxis affects 20% Treatment of hip subluxation in patients with my-
to 70% of patients with myelomeningocele. The etiology elomeningocele depends on their functional level and
is proposed as a result of multiple exposures to latex. the physical demand on the hip. Gait symmetry often
Therefore, routine precautions, including latex-free envi- corresponds more to the absence of hip contractures
ronments, should be taken to limit latex exposure. and less to the presence of hip dislocation. Therefore,
hip reduction is unnecessary in the low-demand hip.
Orthopaedic Considerations Management of most hips focuses on contracture re-
The goal of orthopaedic treatment is to maximize func- lease and/or realignment osteotomies to prevent bracing
tion; ambulation is one main goal. Ambulation ability is difficulties and spinal deformities except where signifi-
related to the level of the last intact motor root, which cant asymmetry is present. In children with community
RGO = reciprocating gait orthosis; UCBL = University of California/Berkley Lab (orthosis); KAFO = knee-ankle-foot orthosis; AFO = ankle-foot orthosis; HKAFO = hip-knee-ankle-foot orthosis
ambulation skills, the instability is addressed aggres- present at birth and may lead to a significant in-toeing
sively with a goal of achieving concentric reduction and gait. In patients age 5 years or younger, treatment is ob-
acetabular coverage for the high functioning child. servation; orthotic devices may be used. If the condition
persists in a child older than 5 years of age, an external
Knee Contractures and Torsional Deformities supramalleolar tibial/fibular derotation osteotomy is indi-
Knee flexion contractures and extension contractures cated.
are the most common knee deformity in children. Stud-
ies have shown that increased knee flexion during gait Foot Deformities
has a high energy cost. Correction of knee flexion con- The goal of treatment is to achieve a supple, braceable,
tracture of 20 or more is indicated. In some patients, and plantigrade foot. Approximately 30% of children
hamstring lengthening is insufficient and a posterior with myelomeningocele have a rigid clubfoot at birth.
capsulotomy of the knee may be required. Supracondy- Initial treatment includes serial casting, but correction is
lar extension osteotomy of the distal femur is recom- rarely achieved by nonsurgical treatment. Comprehen-
mended in older ambulatory children with fixed flexion sive posteromedial lateral release is indicated at or be-
deformity of 20 or more after failed radical knee flexor fore walking age.
release. Acquired equinus deformity occurs more frequently
Knee extension contractures are much less common in children with high lumbar and thoracic-level lesions.
than flexion contractures. Treatment with serial casting Prevention is attempted by bracing and physical ther-
to achieve 90 of flexion is successful in most patients. If apy. Heel cord resection is indicated to achieve a planti-
nonsurgical treatment fails, V-Y lengthening of the grade and braceable foot. In patients with mild deformi-
quadriceps is favored. ties who are high functioning, Achilles tendon resection
Moderate and severe torsional deformities impede can be performed. With severe deformity, a radical pos-
walking and place abnormal stress on the knee. A study terior release including capsulotomy is required.
of 25 patients with lumbosacral myelomeningocele Coronal plane malalignments include valgus defor-
showed that increased external tibial torsion increased mity of the ankle or the hindfoot and are commonly
clinical valgus knee stress. A thigh-foot angle greater seen in patients with L4-5 level deformity; this condition
than 20 significantly increased this stress and supramal- can lead to difficulty with brace fitting and pressure
leolar tibial/fibular osteotomy is indicated. sores over the medial malleolus. Radiographs help de-
Internal tibial torsion is not an acquired deformity in termine the location of the deformity. Ankles in mild
a child younger than 5 years of age with spina bifida. It is valgus are treated with percutaneous screw hemi-
epiphysiodesis. In severe deformities and in older chil- rate of pseudarthrosis. Surgical complications include
dren, supramalleolar closing wedge osteotomy is indi- wound infection (6% to 15%), fixation failure (15%),
cated. For hindfoot valgus, a medial sliding osteotomy of and pseudarthrosis (7% to 28%). Patients have an im-
the calcaneus with displacement of 50% of the width of proved sitting balance after surgery, but ambulation may
the fragment is recommended. be more difficult.
Typical findings include acetabular dysplasia (usually su- formed more commonly. Nonselective Achilles tendon
perior or posterosuperior), increased femoral antever- lengthening is reserved for more severe myostatic defor-
sion, and increased femoral neck-shaft angle. Soft-tissue mities. There is greater risk of overlengthening with
release of the adductors shows a failure rate of 40%. Achilles tendon lengthening, which can result in disrup-
Osteotomies of the proximal femur (varus-producing) in tion of the ankle plantar flexion-knee extension couple,
addition to acetabular osteotomies improve the cover- leading to a crouch gait pattern.
age and stability of the developing hip and are typically
done after age 4 years. Combined procedures may carry Foot
an increased risk of proximal femoral osteonecrosis. Planovalgus and hallux valgus deformities are common
Untreated hip dislocation in the older child or young in patients with CP. In nonambulatory patients, a shoe-
adult remains a difficult diagnostic and therapeutic chal- able plantigrade foot is the goal of treatment. In ambu-
lenge. Recent studies show that not all dislocated hips latory patients, treatment is directed toward correction
are painful and not all painful hips are dislocated. De- of skeletal lever arm deficiency to maximize ankle plan-
termining the degree of pain from a dislocated hip re- tar flexion function and to facilitate bracing. Surgical
mains difficult. Long-term benefits of salvage operations treatment involves posterior calf muscle lengthening
such as proximal femoral resection or hemiarthroplasty and skeletal realignment by calcaneal lengthening
are yet to be determined. For patients with unilateral and/or subtalar arthrodesis. Hallux valgus deformities
hip dislocation and the absence of spinal deformity, hip often require metatarsophalangeal fusion in patients
fusion may be an alternative procedure, with a recent with CP to prevent recurrence.
review showing diminished pain and postural improve-
Equinovarus foot deformity is seen in the setting of
ment following hip fusion in a series of older patients
a spastic posterior tibialis tendon. For flexible deformi-
with CP.
ties, surgical considerations include posterior calf
lengthening, intramuscular or Z-lengthening of the pos-
Knee
terior tibial tendon, or split posterior or anterior tibial
Spastic hamstring muscles increase knee flexion during
tendon transfers. A recent long-term follow-up survey
the stance phase of gait. Untreated knee flexion con-
showed a failure rate in 75% of patients with low-level
tractures and worsening crouch gait can lead to in-
ambulatory diplegia and quadriplegia undergoing these
creased loads across the patellofemoral joint, resulting
procedures before age 8 years.
in pain and late arthritis. Decreased dynamic range and
poor transition from stance to swing secondary to rectus
Transverse Plane
femoris spasticity are commonly seen. Treatment con-
sists of medial hamstring lengthening with concomitant In some ambulatory patients with CP, increased femoral
posterior transfer of the rectus tendon. Knee flexion anteversion fails to resolve with growth, resulting in le-
contractures following hamstring lengthening can be ad- ver deficiency at the level of the hip. Assessing the de-
dressed using serial stretch casting during the postoper- gree of pathologic femoral anteversion requires some
ative period. Lateral hamstring release is reserved for combination of clinical examination, two-dimensional
the older patient with resistant knee flexion contrac- CT, and gait analysis. Compensatory actions during the
tures or for patients with previous medial hamstring re- gait cycle include internal rotation of the hip and exter-
lease. Risks of lateral hamstring lengthening include ex- nal rotation of the pelvis to restore the lever arm. Cor-
cessive weakness leading to knee hyperextension during rection of these deviations can be achieved following
the stance phase. Extension osteotomy can be per- correction of the increased anteversion by derotational
formed at the level of the distal femur for resistant con- osteotomy of the femur. This procedure can be per-
tractures. formed proximally by an intertrochanteric or subtro-
chanteric osteotomy, or distally above the metaphyseal
Ankle flare. A prospective study comparing both methods
Equinus is the most common deformity in CP and showed excellent clinical results with either technique. If
causes adverse effects during standing and gait. For chil- this condition is not corrected by the teenage years, pa-
dren younger than 3 years of age, developmental ther- tients may develop compensatory increased external tib-
apy and orthotic devices are used. From ages 3 to 6 ial torsion. In such cases, the transverse plane malalign-
years, a combination treatment with serial casting, botu- ment may need to be corrected at both the femoral and
linum toxin, and orthotic devices is recommended. De- tibial levels. Tibial rotation osteotomy is best performed
finitive muscle-tendon surgery is preferably delayed un- at the supramalleolar level to minimize the risk of com-
til at least age 6 years for persistent equinus deformity partment syndrome and neurologic injury. Simultaneous
to minimize risk of recurrence. Surgical options vary de- procedures will necessitate an aggressive postoperative
pending on the degree of deformity and contracture. Se- physical therapy regimen to enable the patient to return
lective gastrocnemius-soleus complex recession is per- to their preoperative functional level.
tients 6 months of age or younger. The babies exhibit lit- 1,500 abnormal guanine-adenosine-adenosine repeats.
tle or no movement of their extremities, with character- The number of added repeats may correlate with the se-
istic tongue fasciculations and absent deep tendon verity of disease or age of onset. Frataxin is a mitochon-
reflexes. Most die of respiratory infections before the drial protein, involved in iron metabolism and oxidative
age of 2 years. Longer survival is possible with trache- stress. Knowledge of the role of frataxin has led to the
ostomy or noninvasive ventilation. Orthopaedic treat- initiation of treatment with antioxidants such as Coen-
ment is limited to splinting of fractures that may occur zyme Q, which has been shown in preliminary studies to
at birth. decrease the rate of cardiac deterioration but not the
Patients with type II or chronic infantile spinal mus- ataxia.
cular atrophy, present between 6 and 12 months of age.
These babies have muscle weakness that is more ad- Orthopaedic Manifestations
vanced in the legs than in the arms. They achieve head Patients with Friedreichs ataxia often present for the
control, and most can sit, but they cannot walk. Survival evaluation of frequently falling and have cavus or
into adulthood is common. cavovarus feet. Surgery to prolong ambulation is per-
Type III spinal muscular atrophy is known as formed in selected patients when the position of the
Kugelberg-Welander syndrome and has an age of onset foot exacerbates the instability during gait. Scoliosis oc-
between 2 and 15 years, when proximal muscle weak- curs in more than 80% of patients. Curve types vary be-
ness becomes noticeable. Patients ambulate as children, tween idiopathic-looking curves to long, sweeping tho-
but become wheelchair users in adulthood. racolumbar curves. Increased thoracic kyphosis is
common. Progression is linked to early age at diagnosis
Orthopaedic Manifestations and to curve magnitude. Bracing is ineffective at pre-
Currently there is no effective medical treatment for venting progression, and may interfere with mobility.
spinal muscular atrophy. Orthopaedic treatment is Curves that stabilize at less than 40 at skeletal maturity
needed for scoliosis, which is widespread in patients rarely progress. Surgery is indicated for curves of 60 or
with type II and III. Soft orthotic devices can delay but greater. Posterior spinal fusion from the upper thoracic
not prevent surgery in children younger than 10 years of to the lower lumbar spine is effective.
age. Posterior spinal fusion is recommended for most
progressive curves, with fusion to the pelvis in nonam- Charcot-Marie-Tooth Disease
bulatory patients. Charcot-Marie-Tooth disease is a clinically and geneti-
Hip dislocation and subluxation occur in 62% of cally heterogeneous group of hereditary motor senso-
hips in patients with type II spinal muscular atrophy, rineuropathies. Traditionally, Charcot-Marie-Tooth dis-
and less frequently in type III patients. Although open ease has been divided into demyelinating forms that
reduction of the hip can be performed, even with con- slow nerve conduction velocity (Charcot-Marie-Tooth
comitant pelvic osteotomy, redislocation frequently oc- types 1, 3, and 4), and axonal forms that decrease the
curs because of the inherent muscle weakness. Long- compound muscle action potential (Charcot-Marie-
term studies show that nearly all hip dislocations in Tooth type 2). Overlap between these two forms exists.
patients with spinal muscular atrophy remain painless; To date, 10 genes causing various forms of Charcot-
surgery should be avoided in nonambulatory patients. Marie-Tooth disease have been identified. These genes
are expressed either by Schwann cells and/or accompa-
Friedreichs Ataxia nying neurons. The most common mutation involves
Friedreichs ataxia is characterized by involvement of overexpression of the peripheral myelin protein 22 gene
the cerebellum and the spinal cord pathways. Clinically, on chromosome 17, producing autosomal dominant
patients present with the classic triad of ataxia, loss of Charcot-Marie-Tooth disease type 1A. Other genes
deep tendon reflexes, and an extensor Babinski re- commonly disturbed include the myelin protein zero
sponse. Associated medical conditions include hyper- gene, and connexin 32, which is present in the x-linked
trophic cardiomyopathy, and in some patients, diabetes Charcot-Marie-Tooth disease.
mellitus. The average age of onset is 12 years, and death In most patients the disease manifests during the
occurs on average 25 years after diagnosis because of second decade of life. Cavovarus foot deformity is fre-
cardiac deterioration. quently the presenting symptom. Physical examination
Friedreichs ataxia is inherited in an autosomal re- is notable for lower limb areflexia, calf atrophy, an in-
cessive fashion. The disease is caused by the presence of creased longitudinal arch, and clawing of the toes.
an expanded guanine-adenosine-adenosine trinucleotide
repeat in both copies of the frataxin gene on chromo- Orthopaedic Manifestations
some 9. The normal number of repeats is less than 33, The first line of treatment of mild cavus and cavovarus
whereas patients with Friedreichs ataxia have 66 to is the use of orthotic devices. AFOs can improve gait in
patients with flexible deformities. Patients with Charcot- repair of 13 patients showed one third were spared the need
Marie-Tooth disease frequently have significant foot for a shunt at 1 year of age, but improvement in neurologic
drop during swing phase, and this is improved by use of function was unclear.
AFOs.
Surgical treatment of the cavovarus foot deformity is Nolden MT, Sarwark JF, Vora A, Grayhack JJ: A
based on the flexibility of the deformity. In patients with kyphectomy technique with reduced perioperative mor-
mild flexible hindfoot varus, plantar fascia release and bidity for myelomeningocele kyphosis. Spine 2002;27:
first metatarsal dorsal closing wedge osteotomy, with or 1807-1813.
without transfer of the peroneus longus to peroneus Evaluation of 11 patients with myelomeningocele and
brevis, can improve the deformity. The posterior tibialis lumbar kyphosis showed subtraction vertebrectomy with pos-
tendon can be transferred to the dorsum of the midfoot terior instrumentation to be a safe and efficacious technique
to improve swing phase foot drop. When the hindfoot is for correction and stabilization of myelomeningocele kyphosis
rigid, calcaneal osteotomy is necessary. After correction in young patients.
of the hindfoot deformity is achieved, metatarsal osteot-
omies to align the forefoot may be performed. Alterna- Scoliosis
tively, midfoot dorsal closing wedge osteotomy improves Berven S, Bradford DS: Neuromuscular scoliosis:
cavovarus by correcting midfoot and forefoot equinus. Causes of deformity and principles for evaluation and
In severe cases, triple arthrodesis is necessary to obtain management. Semin Neurol 2002;22:167-178.
and maintain correction. Clawing of the toes may be im- In a review of the literature, outcomes in patients with
neuromuscular deformity who were treated with a combined
proved with transfer of the toe extensors to the metatar-
anterior and posterior fusion showed improvement of the ma-
sal necks. Although initial results following cavovarus
jor curve of up to 60%, more effective correction of pelvic
surgery are usually satisfactory, progression of the neu-
obliquity, and a decreased pseudarthrosis rate.
rologic disease often leads to recurrence of deformity.
Hip dysplasia is also associated with Charcot-Marie-
Tooth disease. Ambulatory patients may report symp- Trivedi J, Thomson JD, Slakey JB, Banta JV, Jones PW:
toms during adolescence. Symptomatic acetabular dys- Clinical and radiographic predictors of scoliosis in my-
plasia can be treated by pelvic osteotomies. Patients elomeningocele. J Bone Joint Surg Am 2002;84-A:1389-
with hereditary motor sensorineuropathies are more 1394.
In a retrospective review of patients with myelomeningo-
prone to sciatic nerve palsy after pelvic surgery.
cele over a 5-year period with an average follow-up of 9.4
Scoliosis occurs more frequently in patients with
years, curves of less than 20 often resolved. Clinical motor
Charcot-Marie-Tooth disease. Left thoracic and ky- level, ambulatory status, and last intact laminar arch were pre-
photic curves distinguish the radiographic appearance of dictive factors for development of scoliosis.
many of these curves from idiopathic scoliosis. Although
bracing rarely is effective, surgical correction can be per-
Cerebral Palsy
formed without an increase in complications.
Anderson C, Mattsson E: Adults with cerebral palsy: A
survey describing problems, needs, and resources, with
Annotated Bibliography special emphasis on locomotion. Dev Med Child Neurol
Myelomeningocele 2001;43:76-82.
Gabrieli AP, Vankoski S, Dias L, et al: Gait analysis in This article presents a report of a survey of adult CP pa-
low lumbar myelomeningocele patients with unilateral tients discussing natural history and progression. Of those
hip dislocation or subluxation. J Pediatr Orthop 2003;23: polled, 77% had difficulty with spasticity, 18% had full disabil-
330-334. ity pension, 35% reported decreased walking ability, and 18%
Gait symmetry using motion analysis of 20 patients with had pain every day.
low lumbar myelomeningocele with unilateral hip dislocation
or subluxation and no scoliosis corresponded to the absence of Bell KJ, Ounpuu S, DeLuca PA, Romness MJ: Natural
hip contractures and had no relation to the presence of hip progression of gait in children with cerebral palsy.
dislocation. The authors concluded that reduction of the hip is J Pediatr Orthop 2002;22:677-682.
unnecessary. Using clinical measures and gait analysis, gait function in
patients with CP decreased longitudinally compared with the
Farmer DL, von Koch CS, Peacock WJ, et al: In utero re- group who had orthopaedic intervention.
pair of myelomeningocele: Experimental pathophysiol-
ogy, initial clinical experience, and outcomes. Arch Surg Bower E, Michell D, Burnett M, Campbell M, McLellan
2003;138:872-878. D: Randomized control trial of physiotherapy in 56 chil-
Fetoscopic repair of neural tube defects before 22 weeks dren with cerebral palsy followed for 18 months. Dev
gestation is physiologically and technically feasible. Surgical Med Child Neurol 2001;43:4-15.
Patients in aim and goal directed therapy showed no ad- No relationship between strength and spasticity in patients
vantage in acquisition of gross motor function or performance with CP was identified.
compared with patients undergoing more traditional forms of
therapy.
Saraph V, Zwick EB, Zwick G, Steinwender C, Stein-
wender G, Linhart W: Multilevel surgery in spastic di-
Flynn JM, Miller F: Management of hip disorders in pa- plegia: Evaluation by physical examination and gait
tients with cerebral palsy. J Am Acad Orthop Surg 2002; analysis in 25 children. J Pediatr Orthop 2002;22:150-
10:198-209. 157.
This review article discusses surgical options for hip disor- Clinical, kinematic, and kinetic improvements are shown
ders in CP. Childhood and adult hip pathology with treatment following multilevel bony and soft-tissue procedures in ambu-
options are discussed. latory CP patients.
Graham K, Selber P: Musculoskeletal aspects of cere- Smucker JD, Miller F: Crankshaft effect after posterior
bral palsy. J Bone Joint Surg Br 2003;85:157-166. spinal fusion and unit rod instrumentation in children
A comprehensive review of the role of the orthopaedic with cerebral palsy. J Pediatr Orthop 2001;21:108-112.
surgeon in the management of CP is detailed. The etiology, In skeletally immature children with cerebral palsy, poste-
natural history, pathophysiology, and surgical strategies are rior spinal fusion alone with unit rod instrumentation was suc-
discussed.
cessful in maintaining correction of neuromuscular scoliosis.
Crankshaft deformity was not identified in this series of 50 pa-
Henderson RC, Lark RK, Kecskemethy HH, Miller F, tients treated with isolated posterior procedures.
Harcke HT, Bachrach SJ: Bisphosphonates to treat os-
teopenia in children with quadriplegic cerebral palsy: A
Sterba J, Rogers B, France A, Vokes D: Horseback
randomized, placebo-controlled clinical trial. J Pediatr
riding in children with cerebral palsy: Effect on gross
2002;141:644-651.
This small clinical trial demonstrated increased bone min- motor function. Dev Med Child Neurol 2002;44:301-308.
A small clinical trial evaluated the effect of recreational
eral density following administration of bisphosphonates in
nonambulatory children with CP. horseback riding therapy on Gross Motor Function Measure
scores. An increase of 7.6% in these scores was seen after
18 weeks of horseback riding therapy and returned to control
McLaughlin J, Bjornson K, Temkin N, et al: Selective levels 6 weeks following therapy. A minimal increase in walk-
dorsal rhizotomy: Meta-analysis of three randomized ing, running, and jumping ability was seen after horseback
controlled trials. Dev Med Child Neurol 2002;44:17-25. riding therapy.
A consistent reduction in spasticity in seen following selec-
tive dorsal rhizotomy (SDR). With respect to functional out-
come, the difference between SDR alone and SDR with phys- Vitale MG, Levy DE, Moskowitz AJ, et al: Capturing
ical therapy was minimal. quality of life in pediatric orthopaedics: Two recent
measures compared. J Pediatr Orthop 2001;21:629-635.
Cross-sectional application of Child Health Questionnaire
Pirpiris M, Trivett A, Baker J, Rodda G, Nattrass R, Gra-
ham H: Femoral derotation osteotomy in spastic diple- and Pediatric Outcomes Data Collection Instrument among
gia. J Bone Joint Surg Br 2003;85:265-272. varying diagnoses. The instruments were able to distinguish
Proximal and distal femoral derotation osteotomy was physical from psychosocial health problems.
found to be equally effective for correction of increased femo-
ral anteversion and intoeing gait. Distal osteotomy may pro- Muscular Dystrophy
vide faster rehabilitation and a decrease in surgical complica- Bentley G, Haddad F, Bull TM, et al: Treatment of scoli-
tions. osis in muscular dystrophy using modified Luque and
Harrington-Luque instrumentation. J Bone Joint Surg
Rosenbaum PL, Walter SD, Hanna SE, et al: Prognosis Br 2001;83:22-28.
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Figure 2 A, Arthroscopic view of the anterior compartment in the elbow of an 8-year-old boy with hemophilic (hemosiderotic) synovitis. Note the vascular villi produced by this
proliferative synovitis. B, Arthroscopic view of the same region of the anterior elbow compartment seen near the completion of an arthroscopic synovectomy. Note that most of
the villi have been removed, but the capsule remains intact. (Reproduced with permission from Dunn AL, Busch MT, Wyly JB, Sullivan KM, Abshire TC: Arthroscopic synovectomy
for hemophilic joint disease in a pediatric population. J Pediatr Orthop 2004;24:414-426.)
effective, especially in more severely affected joints. Ar- Heterozygous individuals have a normal gene for he-
throscopic synovectomy also avoids the long-term risks moglobin A and a gene for hemoglobin S. Carriers are
of radiation exposure. Regardless of the type of syn- typically asymptomatic because hemoglobin A still ac-
ovectomy, the key to success is early intervention. Most counts for about 55% to 60% of an individuals total he-
patients with severe hemophilia who are managed with moglobin. Only rarely do individuals with sickle cell
on-demand therapy protocols will develop a target trait display symptoms. Homozygous individuals with
joint by adolescence, and an early synovectomy res- two genes for hemoglobin S, however, have no hemoglo-
cue is essential to minimize the risk of premature ar- bin A, and every organ and tissue in the body can be ad-
thritis. versely affected.
As oxygen tension decreases, the hemoglobin S mol-
ecules polymerize within the red cells and lead to alter-
Sickle Cell Disease ation in red cell shape, membrane changes, cellular de-
Normal hemoglobin is composed of and chains. The hydration, decreased deformability, and shorter life span
gene for globulin is located on chromosome 11, and a of the red cells. Tissues with low oxygen tension and end
single substitution of valine for glutamic acid at the vessel flow are particularly vulnerable. Musculoskeletal
symptoms account for 80% of all hospital admissions.
sixth amino acid position causes an abnormally func-
In infancy, individuals with sickle cell disease are
tioning hemoglobin (the gene for hemoglobin S) to be
protected by fetal hemoglobin (hemoglobin F). In in-
produced. Heterogeneous individuals have sickle cell
fants age 4 to 6 months with sickle cell disease, the
trait, and homozygous individuals have sickle cell dis-
amount of hemoglobin F begins to decrease and symp-
ease. Other abnormalities can occur in the and glob- toms can occur. Dactylitis (hand-foot syndrome) typi-
ulin chains and cause sickle cell disorders, including cally presents between the ages of 6 months and 4 years.
sickle cell thalassemia, sickle cell hemoglobin D, and This condition is characterized by swelling and tender-
sickle cell hemoglobin E. ness in the hands or feet, and occurs in about 70% of all
Sickle cell trait is common in western Africa, where individuals with sickle cell disease. Dactylitis is thought
it provides some protection against malaria. In the to represent a vaso-occlusive episode. Treatment con-
United States, about 10% of the African-American pop- sists of analgesia, oxygen, and hydration, with symptoms
ulation carries the hemoglobin S gene, and 1 in 600 has typically lasting 3 to 7 days. Osteomyelitis must remain
sickle cell disease. Sickle cell disease primarily affects in the differential diagnosis, and aspiration can be used
blacks, but it can occur in other ethnic groups. to aid in determining the proper treatment. Dactylitis is
rare after age 6 years, when hematopoietic marrow dis- duction, which results in a severe hemolytic, microcytic,
appears in the digits. Forty percent of individuals can hypochromic anemia. Bone marrow hyperplasia ensues,
have recurrent dactylitis. causing bone fragility, growth retardation, and an in-
The incidence of sickle cell crises in patients with creased rate of fractures. Slipped capital femoral epi-
sickle cell disease is around 0.8 episodes per year. Hy- physis and early osteoarthritis occur at increased rates.
droxyurea has been shown to decrease the number of Radiographic findings include widened marrow spaces,
painful episodes in adults, and a multicenter trial of hy- thinned cortices, severe osteopenia, and hair-on-end
droxyurea in children is currently underway. appearance of the skull. Extramedullary hematopoiesis
Although individuals with sickle cell disease are in the vertebrae can cause paraparesis by compression
more prone to infection, the incidence of osteomyelitis of the spinal cord. Increased body iron loads can cause
remains quite low (< 1% per year), and bone infarcts tissue fibrosis, resulting in cardiomyopathy, diabetes
are 50 times more common. Nonetheless, differentiating mellitus, and adrenal, parathyroid, and thyroid hypo-
between osteomyelitis and bone infarcts can be difficult function. Splenectomy in childhood lessens the transfu-
because their signs and symptoms are quite similar. sion requirements, but it increases the already higher
Pain, swelling, redness, warmth, stiffness, and elevated than normal rate of infections. Treatments of individuals
laboratory parameters are common. Erythrocyte sedi- with thalassemia include early transfusion therapy
mentation rates are unreliable in patients with sickle (maintaining hemoglobin > 9 g/dL), iron chelation, bone
cell disease because of the altered red cells. Blood cul- marrow transplantation, splenectomy, and supportive
tures should be included in routine work-up, and bone medical management.
aspiration should be done in patients with suspected
sickle cell disease. Several imaging modalities have been Leukemia
studied to help differentiate between infection and in- Acute leukemia is the most common malignancy in
farct, including bone scans and MRI. Ultrasonography childhood, accounting for nearly one third of instances
may be less expensive and equally effective. A recent re- of cancer in children. Acute lymphocytic leukemia ac-
port has identified serum procalcitonin concentration as counts for approximately 80% of these instances. With
a negative predictor of serious musculoskeletal infec- current therapies, approximately 80% of children with
tion. Common pathogens include Staphylococcus au- acute lymphocytic leukemia now survive.
reus, Salmonella, and Streptococcus pneumoniae. Treat- Although leukemia is primarily a disease of the bone
ment consists of antibiotics, hydration, oxygenation, and marrow, any organ can be infiltrated by the malignant
surgical drainage of abscesses. Reactive arthritis and cell, and this accounts for the highly variable clinical
septic arthritis can also occur. presentation. The musculoskeletal system is often in-
Bone marrow hyperplasia can cause bony changes in volved, including pain in the extremities, back pain, os-
patients with sickle cell disease. Osteopenia in the verte- teomyelitis, septic arthritis, or fracture. Twenty percent
bral bodies can lead to bulging of the intervertebral of patients present with a primary report of limp or ex-
disks, compression fractures, and progressive kyphosis. tremity pain, and up to 50% of patients have these
Long bone growth can be affected, and pathologic frac- symptoms as secondary complaints at the time of initial
tures can occur. Growth retardation is common in pa- diagnosis. Although long bone pain is the most common
tients with sickle cell disease, with height and weight sig- symptom, the spine may be involved. This becomes an
nificantly lower than average at 2 years of age. Skeletal important consideration in the differential diagnosis of
maturity can also be delayed. Osteonecrosis of the fem- the child presenting with back pain. At the onset of the
oral and humeral heads commonly occurs, with preva- disease, 10% of children have normal peripheral blood
lences of 30% and 6%, respectively. Treatment options counts, making the diagnosis even more challenging.
include restricted weightbearing, core decompression, MRI may be helpful because it is very sensitive to mar-
polymethylmethacrylate injection, vascularized fibular row changes caused by infiltration and secondary inf-
grafts, hemiresurfacing, and total joint arthroplasty. Joint arct.
arthroplasty is complicated by higher rates of infection Painful joint swelling and fever are common present-
and loosening. ing symptoms of the musculoskeletal manifestations of
leukemia. These symptoms may mimic sepsis or acute
Thalassemia onset of a juvenile idiopathic arthritis (formerly called
The thalassemia syndromes comprise a heterogeneous juvenile rheumatoid arthritis). Typically, patients with
group of hemolytic anemias that result from mutations juvenile idiopathic arthritis present with morning stiff-
that affect globulin synthesis. Normal hemoglobin is ness and pain localized to the joints, whereas patients
composed of and chains; therefore, and thalas- with leukemia more often present with night pain and
semias can occur. Individuals with thalassemia major are nonarticular bone pain. The radiographs of patients with
homozygous. There is very low to no hemoglobin A pro- juvenile idiopathic arthritis may show joint effusions
and mild osteopenia surrounding joints, whereas the ra- Lower extremity anomalies occur in up to 80% of
diographic changes suggestive of acute leukemia include patients, and they include severe genu varum, instability,
diffuse osteopenia, metaphyseal bands, periosteal new and patellar abnormalities, which has prompted some to
bone formation, geographic lytic lesions, sclerosis, mixed rename this syndrome TARK, with the letter K signify-
sclerosis/lysis, and permeative destruction. ing involvement of the knee. Other associated deformi-
Once considered rare, acute megakaryoblastic leuke- ties include hip dysplasia, pes valgus, talipes equino-
mia now accounts for about 12% of all instances of varus, synostosis in the metatarsals, and syndactyly
acute myeloid leukemia in children. Most instances of involving the toes.
acute megakaryoblastic leukemia are difficult to diag- Management of patients with TAR syndrome in-
nose because of their complex clinical presentation and cludes hematologic support, including platelet transfu-
unusual bone marrow morphologic features. In children, sions until the patients condition stabilizes, usually
acute megakaryoblastic leukemia is often confused with around 2 years of age. Musculoskeletal management in-
metastatic solid tumors or myelodysplastic syndrome. cludes radiographs for patients with occult hip dyspla-
These abnormalities (bilaterally symmetric periostitis sia. Varus angulation and internal tibial rotation usually
and osteolytic lesions) differ markedly from those com- recur after corrective osteotomy, which has prompted
monly reported in association with pediatric acute leu- some to advocate a more conservative management ap-
kemias. proach using simple adaptive devices and powered mo-
Treatment protocols for leukemia often include sig- bility aids. Foot and ankle reconstruction including pos-
nificant doses of steroids because of their antilympho- teromedial release and/or heel cord lengthening have
cytic effects. MRI shows changes consistent with areas been recommended. The goals of surgical treatment of
of osteonecrosis in approximately 25% of children re- the upper extremity deformities are to obtain and main-
ceiving high-dose steroid regimens. Children younger tain correction of the radial deviation. The primary indi-
than 10 years are generally not affected. One third or cation for upper extremity surgery correction is persis-
more of those affected develop symptomatic complica- tent wrist contracture and reconstruction of function-
tions of weight-bearing joints. When these complications limiting thumb deficiency.
do occur, treatment options are limited, and end stage
joint disease can develop. Annotated Bibliography
Hemophilia
Thrombocytopenia With Absent Radii Butler RB, McClure W, Wulff K: Practice patterns in
Thrombocytopenia with absent radii (TAR) syndrome is haemophilia A therapy: A survey of treatment centres
an autosomal recessive, rare disorder characterized by in the United States. Haemophilia 2003;9:549-554.
congenital hypomegakaryocytic thrombocytopenia and This study surveyed 52 hemophilia centers with a total of
bilateral absence of the radius, with shortening of the 4,129 patients receiving treatment. Among patients with se-
ulna and a normal thumb. This syndrome develops be- vere hemophilia, 49% were receiving on-demand treatment,
tween the fourth and eighth weeks of gestation when whereas 44% were receiving some form of prophylaxis (13%
the radii develop and platelet production begins. Signifi- primary, 20% secondary, and 11% tertiary). Primary prophy-
cant complications that can occur in infancy secondary laxis was the most common type in children younger than
to thrombocytopenia include intracranial hemorrhage, 5 years, who comprised 25% of this age group. In children age
anemia, and frequent occurrences of epistaxis. Charac- 6 to 18 years, 58% were receiving some type of prophylactic
teristic hematologic findings include hypomegakaryo- regimen, whereas on-demand treatment was most frequent
cytic thrombocytopenia, periodic leukemoid reactions, among adult patients.
and eosinophilia. Mortality in early infancy approaches
40% of patients; however, if the child is able to survive Dunn AL, Busch MT, Wyly JB, Abshire TC: Radionu-
the first 1 to 2 years of life, the thrombocytopenia usu- clide synovectomy for hemophilic arthropathy: A com-
ally resolves and the musculoskeletal problems become prehensive review of safety and efficacy and recommen-
the chief manifestation of TAR. dation for a standardized treatment protocol. Thromb
The upper extremity anomalies include bilateral ab- Haemost 2002;87:383-393.
sence of the radii with radial deviation at the wrist, a This review article compiles the published experience to
shortened and bowed ulna, and normal thumbs. Re- date using radionuclide synovectomy for hemophilic joint dis-
cently, an anomalous muscle spanning the elbow with its ease. A suggested treatment protocol is presented.
origin on the humeral shaft at the deltoid tubercle and
insertion into the hand and carpal bones (termed the Dunn AL, Busch MT, Wyly JB, Sullivan KM, Abshire
brachiocarpalis) has been described and its excision has TC: Arthroscopic synovectomy for hemophilic joint dis-
been recommended to negate the strong radial devia- ease in a pediatric population. J Pediatr Orthop 2004;24:
tion to the hand. 414-426.
This study provides data on 47 pediatric patients who un- absent radius (TAR) syndrome and discussion of its
derwent arthroscopic synovectomy (40 ankles, 22 elbows, 9 clinical significance, in American Society for Surgery of
knees, and 2 shoulders) for hemophilic joint disease. The me- the Hand Meeting Abstracts, Phoenix, AZ, 2002, p 13.
dian patient age at time of surgery was 10.3 years, and median Available at: http://www.assh.org. Accessed October 6,
follow-up was 79 months. The authors report that joints with 2004.
sufficient follow-up data showed a median bleeding frequency The authors of this retrospective review of 16 patients with
decline of 84% (P < 0.001). thrombocytopenia absent radius syndrome show the presence
of an anomalous muscle spanning the elbow (termed the bra-
Journeycake JM, Miller KL, Anderson AM, Buchanan chiocarpalis) and emphasize its contribution to the radial de-
GR, Finnegan M: Arthroscopic synovectomy in children formity. They recommend excision in patients with progressive
and adolescents with hemophilia. J Pediatr Hematol radial deviation.
Oncol 2003;25:726-731.
In this study, 28 arthroscopic synovectomies (11 knees, 12
ankles, and 5 elbows) were done on 26 joints in 20 patients
Classic Bibliography
with hemophilia. The authors report that the frequency of he- Arnold WD, Hilgartner MW: Hemophilic arthropathy:
marthrosis diminished significantly in the first year and was Current concepts of pathogenesis and management.
maintained for up to 5 years in all but three joints. J Bone Joint Surg Am 1977;59:287-305.
Sickle Cell Disease Chambers JB, Forsythe DA, Bertrand SL, Iwinski HJ,
Scott LK, Grier LR, Arnold TC, Conrad SA: Serum pro- Steflik DE: Retrospective review of osteoarticular infec-
calcitonin concentration as a negative predictor of seri- tions in a pediatric sickle cell age group. J Pediatr
ous bacterial infection in acute sickle cell pain crisis. Orthop 2000;20:682-685.
Med Sci Monit 2003;9:CR426-CR431.
In this preliminary study of 24 patients with sickle cell dis- Christensen CP, Ferguson RL: Lower extremity defor-
ease, pain crisis, and acute inflammation, procalcitonin levels mities associated with thrombocytopenia in absent ra-
were measured and levels less than 2 ng/mL were reported to dius syndrome. Clin Orthop 2000;375:202-206.
have a good negative predictive value of serious infection.
Hedberg VA, Lipton JM: Thrombocytopenia with absent
radii: A review of 100 cases. Am J Pediatr Hematol
Skaggs DL, Kim SK, Greene NW, Harris D, Miller JH: Oncol 1988;10:51-64.
Differentiation between bone infarction and acute os-
teomyelitis in children with sickle-cell disease with use Heinrich SD, Gallagher D, Warrior R, Phelan K, George
of sequential radionuclide bone-marrow and bone scans. VT, MacEwen GD: The prognostic significance of the
J Bone Joint Surg Am 2001;83:1810-1813. skeletal manifestations of acute lymphoblastic leukemia
This is a study of 70 patients with sickle cell disease and of childhood. J Pediatr Orthop 1994;14:105-111.
acute bone pain. The findings suggest that serial radionuclide
bone marrow and bone scan scintigraphy can provide some Mattano LA Jr, Sather HN, Trigg ME, Nachman JB: Os-
differentiation between osteomyelitis and bone infarction. teonecrosis as a complication of treating acute lympho-
blastic leukemia in children: A report from the Chil-
Leukemia drens Cancer Group. J Clin Oncol 2000;18:3262-3272.
States LJ: Imaging of metabolic bone disease and mar-
row disorders in children. Radiol Clin North Am 2001; McLaurin TM, Bukrey CD, Lovett RJ, Mochel DM:
39:749-772. Management of thrombocytopenia-absent radius (TAR)
In this study, the author reports that MRI provides de- syndrome. J Pediatr Orthop 1999;19:289-296.
tailed information about bone marrow and is gaining an in-
creasingly important role in the management of disorders of Schoenecker PL, Cohn AK, Sedgwick WG, Manske PR,
bone marrow infiltration. Salafsky I, Millar EA: Dysplasia of the knee associated
with the syndrome of thrombocytopenia and absent ra-
Thrombocytopenia With Absent Radii dius. J Bone Joint Surg Am 1984;66:421-427.
Carter PR, Mills J, Ezaki M: (Abstract) Anatomical de-
scription of an anomalous muscle in thrombocytopenia
Figure 1 Early radiographic changes associated with glenohumeral dysplasia in a child with upper trunk birth brachial plexus injury are shown. These changes include immature
ossification of the epiphysis compared with the contralateral side with scapular winging. Secondary skeletal changes include retroversion of the glenoid, posterior subluxation,
medial flattening of the humeral head, and elongation with prominence of the acromion.
Clavicle Fractures Figure 2 A CT scan more effectively evaluates glenohumeral dysplasia. Radiographic
A recent study that prospectively screened newborn in- measurements should include glenoid version and the percent of humeral head cover-
fants for clavicle fractures reported the incidence of 5 frac- age.
Figure 3 Severe fixed glenohumeral dysplasia in the skeletally mature adolescent occurs with untreated residual upper trunk dysfunction. Because of the severity of the
dysplasia and loss of passive joint motion, a humeral rotation osteotomy was necessary for treatment. A and B, Preoperative radiographs. C, CT scan. D, Postoperative radiograph.
tures per 1,000 live births. The fractures occurred equally During the first decade of life, 88% of clavicle frac-
on the right and left side and occurred equally in males tures are midshaft and 55% are nondisplaced. A recent
and females. All fractures occurred during vaginal deliv- report of surgical treatment of clavicle fractures indi-
eries. No clavicle fractures occurred with breech presen- cated that over a 21-year period, only 15 patients with
tation. Risk factors for fracture included large birth clavicle fractures required surgical stabilization. Surgical
weight, shoulder dystocia, mechanically assisted delivery, treatment was indicated primarily in the older child with
and prolonged gestational age. One in 11 newborns with a displaced, unstable fracture pattern. Intramedullary
a clavicle fracture had an associated brachial plexus palsy. elastic nails or plates and screws are options for internal
fixation. However, surgery is very rarely needed for pe- mentation rate (that may rise above 100 mm/hr) and in-
diatric clavicle fractures. creased white blood cell count also may be seen.
After an isolated nondisplaced midshaft clavicle The initial radiographs are frequently normal; ultra-
fracture, the risks of nonunion, malunion, or neurovas- sonography supports the diagnosis in some patients by
cular complications are exceptionally rare; therefore, showing an accumulation of fluid inside the joint space.
follow-up beyond the initial diagnostic visit is rarely Aspiration of synovial fluid from the affected gleno-
necessary. humeral joint is necessary to evaluate the offending
pathogen. In a recent review, false-negative Gram stains
Proximal Humerus and Shaft Fractures occurred in approximately 90% of patients, whereas
Fractures of the proximal humerus are relatively rare synovial fluid cultures showed the pathogen in 88% of
(0.5% of all childhood fractures), compared with the patients. Blood cultures were positive in 90% of pediat-
more common distal radius, supracondylar elbow, and ric patients. The most common isolated pathogen was
forearm shaft fractures. Salter-Harris type I injuries are Staphylococcus aureus, which accounted for 41% of in-
most common in neonates and children younger than fections. Gram-negative bacilli, which accounted for
age 5 years; metaphyseal fractures are most common in about 20% of infections, are more prevalent in the pedi-
children 5 to 11 years old; and Salter-Harris type II frac- atric population, especially in neonates.
tures are most common in those older than 11 years. Pyogenic shoulder arthritis should be treated with
Diagnosis of proximal humeral fractures in the new- intravenous antibiotics after synovial fluid aspiration
born may be difficult because these fractures must be and joint irrigation. Irrigation (using a wrist arthro-
distinguished from septic arthritis, brachial plexus inju- scope) or arthrotomy may be chosen.
ries, and clavicle fractures in the infant with pseudopa- The close proximity of the proximal humeral meta-
ralysis of the arm. Plain films may not be helpful in the physis to the shoulder joint capsule, as well as the perfo-
diagnosis because the proximal humerus epiphysis does rating vessels from the physis to the metaphysis of the
not ossifiy until after 6 months of age. MRI, ultrasound, proximal humerus, necessitate investigation to deter-
or aspiration/arthrogram may be necessary. As the child mine if septic arthritis of the shoulder joint coexists with
approaches skeletal maturity, pain with arm dysfunction, osteomyelitis of the proximal humerus. About half of af-
a history of a fall on an outstretched hand, or a direct fected children have both conditions. Treatment of sep-
blow to the shoulder region along with positive radio- tic arthritis in these children should include intravenous
graphs confirm the diagnosis. antibiotics and drilling of the metaphyseal bone of the
Fractures of the proximal humerus are usually
proximal humerus at the time of joint washout. The
treated using closed techniques. The need for a closed
presence of persistent pain, swelling, and fever in chil-
reduction is determined by the extent of displacement
dren who have had an arthrotomy or arthroscopy for
and the remodeling remaining, based on the childs age.
septic arthritis of the shoulder may indicate concurrent
General guidelines include up to 70 of angulation in
osteomyelitis.
the child younger than 5 years old; 40 to 70 of angula-
Certain systemic diseases such as sickle cell disease
tion in the child 5 to 12 years old; and up to 40 of angu-
tend to be more closely associated with the develop-
lation in the child older than 12 years.
When reduction cannot be achieved, or when reduc- ment of osteomyelitis. Tuberculous osteomyelitis of the
tion is lost as the arm is moved down to the side, percu- proximal humerus has been described, with the diagno-
taneous pinning is usually recommended. Open reduc- sis confirmed by tissue biopsy and culture. The presence
tions are reserved for special circumstances such as in of Mycobacterium tuberculosis is confirmed by its
patients with associated injuries, open injuries, concomi- growth at body temperature on the agar in the
tant glenohumeral dislocation, or significant muscle in- Lwenstein-Jensen culture medium, or can be seen his-
terposition. In patients with open injuries, the use of ex- tologically with caseating granulomas. The importance
ternal fixation has been used with good results. of tissue diagnosis cannot be overemphasized. A high
degree of suspicion in patients from immigrant popula-
tions is appropriate, as osteomyelitis is more common in
Septic Arthritis and Osteomyelitis this patient group.
Septic arthritis of the shoulder joint remains an uncom-
mon and difficult diagnosis that requires a high index of
suspicion. The disease usually involves very young in- Annotated Bibliography
fants and has a high prevalence of associated infections. Sprengels Deformity
In a recent review of the literature, elevated body tem- Chinn DH: Prenatal ultrasonographic diagnosis of
perature was present in 90% of pediatric patients with Sprengels deformity. J Ultrasound Med 2001;20:693-697.
septic arthritis and was the most constant finding of the This article describes the use of ultrasound for prenatal di-
physical examination. An increased erythrocyte sedi- agnosis of Sprengels deformity.
Lossos IS, Yossepowitch O, Kandel L, Yardeni D, Arber Webb LX, Mooney JF: Fractures and dislocations about
N: Septic arthritis of the glenohumeral joint: A report of the shoulder, in Green NE, Swiontkowski MF (eds):
11 cases and review of the literature. Medicine (Balti- Skeletal Trauma in Children, ed 2. Philadelphia, PA, WB
more) 1998;77:177-187. Saunders, 1998, pp 319-341.
McBride MT, Hennrikus WL, Mologne TS: Newborn Waters PM, Smith GR, Jaramillo D: Glenohumeral de-
clavicle fractures. Orthopedics 1998;21:317-320. formity secondary to brachial plexus birth palsy. J Bone
Joint Surg Am 1998;80:668-677.
Schnall SB, King JD, Marrero G: Congenital pseudart-
hrosis of the clavicle: A review of the literature and sur- Woodward JW: Congenital elevation of the scapula:
gical results of six cases. J Pediatr Orthop 1988;8:316- Correction by release and transplantation of muscle ori-
321. gins. J Bone Joint Surg Am 1961;43:219-228.
Pediatric Elbow Fractures Type I fractures are minimally displaced, type II are dis-
Pediatric elbow fractures are common; however, they placed with an intact posterior cortex, and type III frac-
are challenging to evaluate and treat even for the expe- tures have a completely displaced distal fragment. In
rienced orthopaedist. The elbow of a young child is posteromedial fractures (occurring in approximately
composed predominantly of unossified cartilage. In 75% of patients), the radial nerve is at risk, whereas in
older children, multiple centers of ossification make posterolateral fractures, the brachial artery and median
evaluation difficult. Associated neurovascular injuries nerve are at risk. About 2% of supracondylar fractures
frequently occur and may significantly impact the ur- are flexion injuries with disruption of the posterior peri-
gency and method of treatment. In general, the pediatric osteum. The flexion pattern is considered much more
elbow has a relatively limited remodeling capacity. The difficult to treat with standard closed pinning tech-
elbow physes grow more slowly than those in the proxi- niques. A recent study of 29 flexion-type supracondylar
mal humerus and distal radius. As a hinge joint, the el- humerus fractures reported 86% good or excellent re-
bow has a poor tolerance for coronal plane deformities sults with casting for minimally displaced fractures, and
and has a particular propensity for loss of motion. These with closed reduction and percutaneous pinning for all
factors help to explain the disproportionate number of type II and III flexion injuries.
medical liability claims and the anxiety related to pedi-
atric elbow fracture treatment. Treatment
Initial evaluation of a child with an injured elbow The goal of treatment of a pediatric supracondylar hu-
should begin with a general examination and a search merus fracture is to restore alignment to a position
for other sites of injury. Next, the involved upper ex- where there is no varus malalignment and the anterior
tremity should be examined carefully for the point of humeral line intersects the capitellar ossification center.
maximal tenderness in the area with maximum swelling. Reduction and stabilization should be done without
Any upper extremity deformity or a break in the skin causing iatrogenic nerve injury or using elbow hyper-
integrity should be noted. Because of the high preva- flexion to a degree that will compromise distal perfu-
lence of neurovascular injuries, a careful neurovascular sion. The use of a long arm cast for 3 weeks is satisfac-
examination, including a check of the anterior in- tory treatment for type I fractures, and for type II
terosseous nerve, is essential. The carrying angle of the fractures in which the anterior humeral line intersects
uninjured side should be noted, especially in a child the capitellar ossification center and Baumanns angle is
with a supracondylar humerus fracture. acceptable. Closed reduction and percutaneous pinning
Radiographic evaluation should include the bones is indicated for any fracture that does not meet these
and joints above and below the site of injury. The pres- conditions. The trend toward pinning most type II and
ence of a posterior fat pad is an important sign of a pos- III supracondylar humerus fractures has dramatically
sible occult elbow fracture. Radiographs should be stud- reduced the incidence of clinically important malunions.
ied closely for signs of a secondary injury. Because the technique of reduction and hyperflexion of
the elbow is now avoided, Volkmanns ischemic contrac-
Supracondylar Fractures ture is rare.
Supracondylar fractures, which represent 60% of elbow Initial evaluation includes a careful neurologic and
fractures in children, are classified based on the extent vascular examination and AP and lateral radiographs of
and direction of the displacement of the distal fragment; the distal humerus, with separate views of the entire
98% are extension injuries. The modified Gartland clas- forearm to check for associated injuries. The urgency of
sification system is used to describe the extent of injury. surgery was analyzed in a recent study of 158 well-
lateral rotatory instability with this condition. Most os- schner wires are placed to stabilize the fracture. The
teotomy techniques and fixation strategies have been pins are removed at 4 weeks, followed by 2 additional
described in small studies. A recent report describes the weeks of casting. Pins left in for longer than 4 weeks are
use of an external fixator to stabilize the fragment after increasingly likely to lead to irritation or infection. A re-
an oblique, incomplete medial opening wedge osteot- cent study evaluated the rate of healing in 55 patients
omy. The complication rate for all techniques tends to with lateral condyle fractures. The authors found that
be quite high. Currently, there is no clear standard tech- radiographic evidence of complete bony healing was not
nique for the treatment of cubitus varus after a pediatric present until 6 weeks after injury, even in children be-
supracondylar humerus fracture. tween 1 and 5 years of age.
Lateral condyle fractures are one of the few types of
Lateral Condyle Fractures fractures in children in which delayed union or non-
Because lateral humeral condyle fractures in children union is not unusual. If open reduction to an anatomic
involve both the joint and growth cartilage, they are as- realignment is done more than 3 weeks after injury, os-
sociated with a host of complications including non- teonecrosis may result if extensive soft-tissue stripping
union, malunion, loss of motion, osteonecrosis, and cubi- is performed to achieve the reduction. In a recent re-
tus valgus. The most clinically valuable classification view of 11 children who had open reduction and inter-
system involves stages of displacement (Figure 2). The nal fixation without soft-tissue stripping, none of the
oblique radiograph is most helpful in assessing the ex- children had osteonecrosis. The authors recommended
tent of displacement. A recently published study of the that nonunions with greater than 1 cm of displacement
MRI evaluation of lateral condyle fractures with 0 to be fixed without soft-tissue stripping and without resto-
3 mm of displacement confirmed previous arthrogram ration to the anatomic position. It was found that de-
studies and concluded that the stability of the fracture is spite fixation in a nonanatomic position, overall elbow
related to the integrity of the cartilage hinge. Lateral alignment and range of motion were good. Late lateral
condyle fractures with up to 2 mm of displacement can condyle nonunion is asymptomatic in some patients,
be treated with casting and close observation. An AP, whereas others develop cubitus valgus and a delayed ul-
lateral, and oblique radiograph of the distal humerus nar nerve palsy. Some authors have recommended a su-
with the cast removed should be obtained after about pracondylar medial closing wedge osteotomy and trans-
5 days and again at about 2 weeks to ensure that there position of the ulnar nerve for symptomatic patients.
is no progressive displacement. If displacement is seen,
reduction and pinning is the recommended treatment. Medial Epicondyle Fractures
Closed reduction and percutaneous pinning is the Fractures of the medial epicondyle account for 7% to
preferred treatment for fresh fractures that are only dis- 11% of all pediatric elbow fractures. These fractures re-
placed from 2 to 5 mm, are relatively stable, and can be sult from avulsion of the epicondyle by the flexor-
reduced to the anatomic position. Open reduction and pronator muscles and medial collateral ligament during
internal fixation is usually required in the treatment of valgus stress or elbow dislocation. In patients with el-
lateral condyle fractures. The technique involves a stan- bow dislocation where spontaneous or manipulative re-
dard lateral approach to the distal humerus with no pos- duction entraps the medial epicondyle in the joint, the
terior dissection (the blood supply to the lateral condyle medial epicondyle ossification center may be obscured
is posterior). An anatomic reduction is ensured both vi- by the distal humerus or mistaken as the trochlear ossi-
sually and radiographically and two percutaneous Kir- fication center. Careful evaluation of radiographs is im-
portant whenever a medial elbow injury is suspected nique was biomechanically equivalent to tension band
in a child. wiring without requiring exposure of the fracture site. A
Treatment recomendations for medial epicondyle recent review of 39 patients with pediatric olecranon
fractures are somewhat controversial. Reduction and fractures with a mean follow-up of 32 years found en-
pin or screw fixation of fractures displaced more than 2 couraging results. Poor results were seen in only three
to 5 mm is recommended in three circumstances: if a patients, two of whom had associated radial head frac-
medial epicondyle is entrapped in the joint; in a fracture tures. The presence of associated injury may be more
with associated ulnar nerve dysfunction; or for displaced important than the degree of displacement of the ole-
fractures in children who place high physical demands cranon fracture in determining outcome.
on their elbow. The latter group is difficult to define;
however, gymnasts and throwing athletes are included. Proximal Radius Fractures
A recent study retrospectively reviewed the results (at Although not a common injury, fractures of the proxi-
more than 30-year follow-up) of 42 patients with medial mal radius in children result in many complications. In
epicondyle fractures displaced more than 5 mm. Pa- contrast to similar fractures in adults, however, fractures
tients treated with cast immobilization had similar func- through the neck of the radius are more common than
tional results to those treated surgically, although radio- radial head fractures. A variety of treatment algorithms
graphic union was much more common in the group exist for radial neck fractures based on the degree of
treated surgically. Those treated with excision did displacement. Radial neck fractures with less than 3 mm
poorly. Based on these findings, the authors questioned of translation and less than 30 of angulation can be
surgical treatment of fractures displaced as much as 15 treated with a brief period of immobilization for com-
mm, and did not recommend primary surgical excision. fort, followed by early motion. More displaced or angu-
lated fractures should be reduced. Closed reduction is
Medial Condyle Fractures often successful; if it fails, reduction with the use of a
True medial condyle fractures are rare, accounting for percutaneous Kirschner wire manipulation can be done.
only 1% to 2% of pediatric elbow fractures. Diagnosis If these methods of reduction fail, and angulation is
may be difficult in the young child, especially before the greater than 60, open reduction should be performed.
appearance of the trochlear ossification center. How- Fixation is usually achieved with the use of Kirschner
ever, the fracture typically involves a metaphyseal bony wires across the fracture but not the joint. A similar al-
fragment, clearly differentiating it from a medial epi- gorithm was used to treat 24 patients in a recent study.
condyle fracture. Treatment principles for medial All of the fractures were reduced to less than 15 of an-
condyle fractures are similar to those for lateral condyle gulation, and all patients had excellent functional and
fractures. Nondisplaced fractures may be treated with radiographic results at 14- to 25-year follow-up.
cast immobilization, whereas displaced fractures should Radial head fractures, unlike radial neck fractures,
undergo closed or open reduction with internal fixation. are intra-articular and deserve anatomic alignment.
Arthrography or MRI may be helpful in determining ar- Open reduction is often required to achieve this goal.
ticular displacement and guiding the choice of treat-
ment. A recent study of 21 patients with medial condyle Monteggia Fractures
fractures showed that such fractures are associated with Monteggia lesions include a fracture of the proximal
a high rate of complications, including delayed or ulna with a radial head dislocation. The ulnar fracture
missed diagnosis, osteonecrosis of the trochlea, non- also may be a plastic deformation. A Monteggia fracture
union, fixation failure, and significant elbow stiffness. should be suspected whenever an isolated ulna frac-
ture or radial head dislocation is seen. In a child, closed
Olecranon Fractures reduction of the ulna usually reduces the radial head,
Olecranon fractures account for approximately 4% to and the fracture often can be treated with a long arm
6% of pediatric elbow fractures and are associated with cast. However, open reduction and internal fixation of
other elbow fractures in up to 41% of patients. Olecra- the ulna is required when an anatomic reduction of the
non fractures in children are similar to those in adults, ulna, radiocapitellar joint, and proximal radioulnar joint
in that they are usually intra-articular and metaphyseal. cannot be obtained or maintained by closed methods.
However, unlike in adults, many olecranon fractures in Previous reports have discouraged attempted open
children are minimally displaced and suitable for closed reduction of a chronic radial head dislocation with or
immobilization. Fractures with more than 2 mm of artic- without annular ligament reconstruction because of the
ular displacement should be reduced and stabilized with high rate of redislocation and other complications. A re-
internal fixation. A recent report described a new fixa- cent study reviewed 22 patients treated for chronic post-
tion technique using a pin with a threaded tip and an traumatic radial head dislocation. The authors con-
adjustable locking device at the opposite end. This tech- cluded that ulnar osteotomy to correct the malunion
Figure 3 A schematic drawing of the distal humeral proximal radius and ulnar relationship in various pediatric elbow injuries. A, Normal elbow. B, Elbow dislocation. C, Lateral
condyle fracture. D, Supracondylar fracture. E, Distal humeral epiphyseal separation. (Adapted with permission from Delee JC, Wilkins KE, Rogers LF, Rockwood CA: Fracture-
separation of the distal humeral epiphysis. J Bone Joint Surg Am 1980;62:46-51.)
was essential in treating missed Monteggia fractures, if a injuries. Noninvasive measures such as splinting and
normal radial head contour remained. A similar report physical therapy are successful in many patients. The
of 15 patients who underwent open reduction of chronic technique of open capsular release has been used exten-
radial head dislocations and ulnar osteotomies found sively in adults; some authors have reported its use in
good to excellent functional results in 12 patients, al- children. A report on elbow release in 13 adolescent pa-
though most lost some degree of pronation postopera- tients with posttraumatic stiffness showed than an aver-
tively. age increase of 54 was produced in the flexion exten-
sion arc. Only one patient lost motion. Nine patients
Transphyseal Distal Humerus Fractures (69%) achieved at least a 25 to 120 arc of motion. A
Displaced fractures through the distal humeral physis recent review of 37 patients receiving similar treatment
can be difficult to diagnose. In the infant, the only sign showed only a 25 to 30 improvement in arc of motion;
may be malalignment of the radial and ulnar shafts rela- a useful (30 to 130) arc was achieved only in 46% of
tive to the distal humerus. This injury is often associated patients. After an extended period of observation, surgi-
with battered child syndrome (Figure 3). Ultrasound, cal release can be a valuable tool in the treatment of
MRI, arthrography, and stress radiographs can help clar- stiffness after complex pediatric elbow injuries. The pa-
ify the diagnosis of a transphyseal fracture. Treatment is tient and family should be counseled regarding expected
similar to that for supracondylar fractures. improvements in arc of motion.
They concluded that to avoid unnecessary elevation of pres- The authors report on 25 instances of cubitus varus defor-
sures, elbows should not be immobilized in greater than 90 of mity (average 15) subsequent to a pediatric distal humeral
flexion. fracture or congenital anomaly in 24 patients who developed
posterolateral rotatory instability of the elbow two to three
De Boeck H: Flexion-type supracondylar elbow frac- decades afterward. Surgery was performed on 22 limbs, and
only 3 limbs had persistent instability at 3-year follow-up. The
tures in children. J Pediatr Orthop 2001;21:460-463.
Twenty-nine children with a flexion-type supracondylar authors propose that the repetitive external rotation torque on
humerus fracture were reevaluated with an average follow-up the ulna, resulting from the medial displacment of the me-
of 6.3 years. Seven children with a flexion-type supracondylar chanical axis, the olecranon, and the triceps line of pull, can
humerus fracture were treated in a cast and 22 children with a stretch the lateral collateral ligament complex and lead to pos-
displaced flexion-type fracture were treated with closed reduc- terolateral rotatory instability in patients with cubitus varus
tion and percutaneous pinning. Good or excellent results were deformity. Surgical correction can relieve symptoms of insta-
noted in 86.2% of the patients. All patients were satisfied with bility.
the end result and had normal use of the elbow. This article re-
ports on a large number of relatively rare flexion-type supra- Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM:
condylar fractures and highlights the good results that can be Lateral-entry pin fixation in the management of supra-
obtained without an open reduction, even in patients with dis- condylar fractures in children. J Bone Joint Surg Am
placed and unstable fractures. 2004;86:702-707.
The authors reported on 124 consecutive Gartland types II
and III supracondylar humerus fractures treated with two or
Koch PP, Exner GU: Supracondylar medial open wedge
three lateral entry pins. The only complication reported was a
osteotomy with external fixation for cubitus varus defor-
pin tract infection. There was no loss of reduction, cubitus
mity. J Pediatr Orthop B 2003;12:116-122.
varus, hyperextension, loss of motion, or iatrogenic nerve pal-
The authors describe a technique in which an anterome-
sies, and no additional surgeries. The authors concluded that
dial approach and a medial opening wedge osteotomy with ex-
the most important technical points for assuring fixation with
ternal fixation are used to treat cubitus varus in children after
lateral-entry pins were: separating the pins at the fracture site;
a malunion and following a supracondylar humerus fracture.
engaging the medial and lateral columns proximal to the frac-
The mean valgus correction was 21.75. At 2-year follow-up,
ture and sufficient bone in both the proximal segment and the
three of the four children had symmetric elbow alignment and
distal fragment; and using three pins to provide additional sta-
one had slight residual varus deformity. The authors concluded
bility when necessary.
that this is a good technique for treating cubitus varus defor-
mity allowing correction of both valgus and flexion.
Lateral Condyle Fractures
Cardona JI, Riddle E, Kumar SJ: Displaced fractures of
Lee ST, Mahar AT, Meisen D, Newton PO: Displaced the lateral humeral condyle: Criteria for implant re-
pediatric supracondylar humerus fractures: Biomechani- moval. J Pediatr Orthop 2002;22:194-197.
cal analysis of percutaneous pinning techniques. The authors reviewed 55 lateral condylar fractures treated
J Pediatr Orthop 2002;22:440-443. at their institution over a 10-year period, with special attention
This biomechanical study of different supracondylar pin- to the rate of healing of the fracture. They concluded that in
ning techniques used a pediatric synthetic bone model. The 50 patients, the fracture was clinically and radiographically
authors concluded that divergent lateral pins had similar sta- healed at 6 weeks. Four patients showed radiographic healing
bility compared with cross pins in extension, varus, and valgus at 5 weeks and one patient at 4 weeks.
testing. In axial testing, cross pins were more stable. Divergent
lateral pins also had statistically greater stability than parallel
lateral pins under varus and valgus loading.
Horn DH, Herman MJ, Crisci K, Pizzutillo PD,
MacEwan GD: Fracture of the lateral humeral fracture
condyle: Role of the cartilage hinge in fracture stability.
Leet AI, Frisancho J, Ebramzadeh, E: Delayed treat- J Pediatr Orthop 2002;22:8-11.
ment of type 3 supracondylar humerus fractures in chil- The authors studied 16 patients with a lateral condyle frac-
dren. J Pediatr Orthop 2002;22:203-207. ture who had both radiographs and MRI. All unstable frac-
A retrospective review of 158 patients with well-profused tures had complete fractures on MRI scans. Ten of the 12 pa-
type III supracondylar humerus fractures showed no correla- tients with radiographically stable injuries had incomplete
tion between an increase in time to surgical intervention and fractures on MRI scans. The authors concluded that the stabil-
the complication rate. The average time from injury to surgical ity of the lateral humeral condyle fractures is related to the in-
treatment was 21.3 hours. tegrity of the cartilage hinge.
ODriscoll SW, Spinner RJ, McKee MD, et al: Tardy pos- Wattenbarger JM, Gerardi J, Johnston CE: Late open
terolateral rotatory instability of the elbow due to cubi- reduction internal fixation of lateral condyle fractures.
tus varus. J Bone Joint Surg Am 2001;83:1358-1369. J Pediatr Orthop 2002;22:394-398.
The authors reviewed the records of 11 children who had a The authors describe a novel fixation technique for olecra-
malunion or nonunion of a lateral condyle fracture treated non fractures in children. A pin with a threaded tip is inserted
more than 3 weeks after injury and found no patients with os- antegrade across the fracture site, without opening the frac-
teonecrosis. In fractures with greater than 1 cm of displace- ture. A locking device is placed proximally on the pin to pro-
ment, the fragment position was minimally improved by surgi- vide compression. A biomechanical analysis found this tech-
cal treatment, but final alignment and range of motion were nique as strong as tension band wiring. The authors
good. The authors concluded that the risk of osteonecrosis recommended this new technique over tension band wiring
with open reduction of lateral condyle fractures at greater because it obviates the need to expose the fracture site.
than 3 weeks is reduced if no tissue is stripped off the fracture
fragment posteriorly. Even children without an anatomic re- Proximal Radius Fractures
duction had functional arms and little or no pain. Malmvik J, Herbertsson P, Josefsson PO, Hasserius R,
Besjakov J, Karlsson MK: Fracture of the radial head
Medial Epicondyle Fractures and neck of Mason types II and III during growth: A
Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term 14-25 year follow-up. J Pediatr Orthop B 2003;12:63-83.
Twenty-four patients with angulated radial head and neck
results of treatment of fractures of the medial humeral
fractures during childhood were evaluated at a mean
epicondyle in children. J Bone Joint Surg Am 2001;83-A:
follow-up of 19 years. Two patients ultimately required radial
1299-1305.
The authors retrospectively reviewed 42 patients with me- head excision. Of the remainder, all but three patients had re-
ceived closed treatment. All patients had less than 15 of an-
dial epicondyle fractures that were displaced more than 5 mm.
gulation after primary treatment. Nineteen patients had no
Nineteen patients were treated with cast immobilization with-
pain at follow-up, although elbow flexion was typically limited
out reduction, 17 underwent open reduction and internal fixa-
compared with the uninjured side.
tion, and 6 patients had fragment excision. The functional re-
sults at 30-year follow-up were identical for the first two
groups, but worse for the excision group. The authors argue Waters PM, Stewart SL: Radial neck fracture nonunion
that nonsurgical treatment is as effective as open reduction in children. J Pediatr Orthop 2001;21:570-576.
and internal fixation for fractures with displacement of more The authors describe nine children with radial neck non-
than 5 mm. unions; eight had associated elbow injuries. Eight children un-
derwent open reduction and fixation, and one had repeated
closed reduction attempts with percutaneous fixation. In each
Medial Condyle Fractures
case, fixation failed and led to loss of reduction. Four patients
Leet AI, Young C, Hoffer MM: Medial condyle fractures
were pain free, but all had restriction of motion. Secondary
of the humerus in children. J Pediatr Orthop 2002;22:2-7.
open repair of the nonunion did not guarantee good func-
The authors reviewed a series of 21 children with medial
tional outcome.
condyle fractures. MRI was used to make the diagnosis or as-
sess displacement in four children. Of the nine patients with
displaced fractures that were treated surgically, four had com- Monteggia Fractures
plications, including two patients who lost reduction and re- Horii E, Nakamura R, Koh S, Inagaki H, Yajima H, Na-
quired revision with open reduction and internal fixation. Of kao E: Surgical treatment for chronic radial head dislo-
the 12 patients who were treated in a cast, 2 developed non- cation. J Bone Joint Surg Am 2002;84-A:1183-1188.
The authors reviewed 22 patients treated for chronic post-
unions and 1 developed osteonecrosis of the trochlea. Almost
traumatic radial head dislocation. Thirteen patients underwent
half of the children had some impairment in range of motion.
open reduction without ulnar osteotomy, and seven had redis-
location of the radial head. In a subsequent group of nine pa-
Olecranon Fractures tients who had an ulnar osteotomy, the radial heads of two pa-
Caterini R, Farsetti P, DArrigo C, Ippolito E: Fractures tients were subluxated at follow-up. Both patients had radial
of the olecranon in children: Long-term follow-up of 39 head abnormalities preoperatively. The authors concluded that
cases. J Pediatr Orthop B 2002;11:320-328. ulnar osteotomy to correct malunion is essential in treating
Thirty-nine patients with olecranon fractures in childhood missed Monteggia fractures if a normal radial head contour
were followed at a mean of 32 years. Thirty-four patients had remains.
good results and three had poor results. All had minimally dis-
placed olecranon fractures and other associated fractures. Ar-
Kim HT, Park BG, Suh JT, Yoo CI: Chronic radial head
thritis was rare. The authors concluded that associated injuries
dislocation in children: Part 2. Results of open treatment
may be a stronger predictor of outcome than the degree of
and factors affecting final outcome. J Pediatr Orthop
displacement in patients with olecranon fractures.
2002;22:591-597.
The authors describe 15 cases (14 patients) of open reduc-
Gicquel P, Maximin MC, Boutemy P, et al: Biomechani- tion and reconstruction of chronic radial head dislocations, 12
cal analysis of olecranon fracture fixation in children. of which were posttraumatic. Results were classified as excel-
J Pediatr Orthop 2002;22:17-21. lent in 10 elbows, good in 2, fair in 2, and poor in 1. One pa-
tient developed a radioulnar synostosis, and 10 lost some de- Bernstein SM, McKeever P, Bernstein L: Percutaneous
gree of pronation postoperatively. All radial heads in the reduction of displaced radial neck fractures in children.
posttraumatic patients remained reduced at follow-up. The au- J Pediatr Orthop 1993;13:85-88.
thors argue that the results of their series should encourage at-
tempts at reducing chronically dislocated radial heads, espe- Cramer KE, Green NE, Devito DP: Incidence of ante-
cially in posttraumatic patients. rior interosseous nerve palsy in supracondylar humerus
fractures in children. J Pediatr Orthop 1993;13:502-505.
Floating Elbow Culp RW, Ostermann AL, Davidson RS, Skirven T, Bora
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The authors reviewed a series of 16 patients with pediatric
Am 1990;72:1211-1215.
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distal forearm fractures were treated with closed reduction of the lateral humeral condyle in children: An update.
and cast immobilization. Of these 10 patients, 2 developed J Pediatr Orthop 1989;9:691-696.
compartment syndrome with 1 patient having a subsequent
Volkmann ischemic contracture. An additional 4 of these 10 Foster DE, Sullivan JA, Gross RH: Lateral humeral
patients required cast removal because of excessive swelling condylar fractures in children. J Pediatr Orthop 1985;5:
and impending compartment syndrome. The remaining six pa- 16-22.
tients were treated with pin fixation of their distal forearm
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developed compartment syndrome. The authors recommended with avulsion of the medial humeral epicondyle. J Bone
surgical treatment of all fractures in this injury pattern to Joint Surg Br 1990;72:102-104.
avoid the high rate of potentially devastating complications as-
sociated with cast immobilization.
France J, Strong M: Deformity and function in supra-
condylar fractures of the humerus in children variously
treated by closed reduction and splinting, traction, and
Elbow Contractures percutaneous pinning. J Pediatr Orthop 1992;12:494-498.
Bae DS, Waters PM: Surgical treatment of posttraumatic
elbow contracture in adolescents. J Pediatr Orthop 2001; Gaddy BC, Strecker WB, Schoenecker PL: Surgical
21:580-584. treatment of displaced olecranon fractures in children.
The authors describe 13 adolescents who had elbow capsu- J Pediatr Orthop 1997;17:321-324.
lar release for posttraumatic stiffness. An average increase of
54 was achieved in the flexion-extension arc. Nine patients Garbuz DS, Leitch K, Wright JG: The treatment of su-
(69%) achieved at least a 25 to 120 arc of motion; one pa- pracondylar fractures in children with an absent radial
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cal release of elbow contractures in adolescents.
Keenan WN, Clegg J: Variation of Baumanns angle with
age, sex and side: Implications for its use in radiological
Stans AA, Maritz NG, ODriscoll SW, Morrey BF: Oper-
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The authors describe surgical elbow releases in 37 patients
Evaluation of the role of comparison radiographs in the
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Archibeck MJ, Scott SM, Peters CL: Brachialis muscle
entrapment in displaced supracondylar humerus frac- Roye DP Jr, Bini SA, Infosino A: Late surgical treat-
tures: A technique of closed reduction and report of ini- ment of lateral condylar fractures in children. J Pediatr
tial results. J Pediatr Orthop 1997;17:298-302. Orthop 1991;11:195-199.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Man- angle: An aid in assessment of supracondylar fractures.
agement of pulseless pink hand in pediatric supracondy- J Pediatr Orthop 1992;12:636-639.
lar fractures of the humerus. J Pediatr Orthop 1997;17:
303-310. Zionts LE, McKellop HA, Hathaway R: Torsional
strength of pin configuration used to fix supracondylar
Williamson DM, Coates CJ, Miller RK, Cole WG: Nor- fractures of the humerus in children. J Bone Joint Surg
mal characteristics of the Baumann (humerocapitellar) Am 1994;76:253-256.
Treatment
perficialis to profundus flexor tendon transfers, and Initial treatment involves passive range-of-motion ther-
bony procedures are reserved for patients with severe apy and nighttime splinting to improve joint motion and
contractures and limited function (usually found in the digital strength. The condition of many children im-
patient with quadriparesis). proves with growth and therapy over the first several
Thumb-in-palm deformity limits dynamic pinch and years of life. At the elbow, triceps V-Y lengthening and
grasp and makes hygiene difficult because of severe posterior capsulectomy are performed at 18 months to 3
contractures. Static contractures are corrected with web years of age if passive elbow flexion of approximately
space Z-plasty and adductor releases. At times, the static 90 does not occur. The wrist palmar flexion contracture
contractures include the flexor pollicis longus and is treated with both soft-tissue and bony procedures. A
brevis; these muscles will need to be appropriately flexor carpi ulnaris release with lengthening or transfer
lengthened or released. Dynamic rebalancing is per- to the wrist extensors is performed in conjunction with a
formed with tendon transfers to weak abductors and ex- dorsal carpal closing wedge osteotomy.
tensors of the thumb. There are many possible donor The thumb-in-palm contracture is treated with a
muscles including the palmaris longus, flexor carpi radi- Z-plasty syndactyly release. Care must be taken not to
alis, and brachioradialis. The recipient tendons include overrelease the adductor. Transfers for thumb abduction
the extensor pollicis brevis and longus and the abductor and extension are predominantly tenodesis procedures
pollicis longus. The metacarpophalangeal joint needs to because of the limited strength of the donor muscles.
be stable postoperatively. In most patients, stability is Children with arthrogryposis will have permanent
achieved by muscle rebalancing. On occasion, a capsul- limited motion and strength in their arms and hands.
odesis or arthrodesis procedure will be needed. Because of their high level of intelligence, these children
Some patients with cerebral palsy have disabling often are quite functionally adaptive.
swan neck deformities. If the fingers at the proximal in-
terphalangeal joint lock and hyperextend more than 40 Forearm and Wrist Trauma
and lock, limited grasp and pain may result. Multiple Epidemiology and Prevention Updates
surgical procedures have been advised, including flexor In a longitudinal study from New Zealand, it was deter-
digitorum superficialis tenodesis, intrinsic muscle slide, mined that 51% of boys and 40% of girls will experi-
lateral band rerouting, spiral oblique ligament recon- ence a single fracture by 18 years of age. The most com-
Distal Radius Physeal Fractures patients with distal radius fractures and 50% of patients
Most distal radius physeal fractures are Salter-Harris with distal ulna fractures had a symptomatic growth dis-
type II injuries that occur in adolescents. Displacement crepancy greater than 1 cm. In addition, 38 asymptomatic
is typically dorsal with apex volar angulation. An atrau- patients had growth discrepancies between 2 to 9 mm. Pa-
matic closed reduction and long arm cast immobiliza- tients with redisplacement or late presentation should not
tion is indicated for fractures with greater than 10 of undergo a repeat reduction after 7 days to avoid iatro-
malangulation. The most significant complications are genic physeal arrest. Late open reduction should be
associated with future growth arrest and acute neu- avoided for the same reason. Because these fractures dis-
rovascular compromise. The incidence of associated
place in the plane of motion of the wrist joint and are jux-
nerve injuries is approximately 8%. Studies indicate that
taphyseal, there is tremendous potential for remodeling
patients with signs or symptoms of median nerve injury
of a malunion in the younger adolescent patient. If the
at the time of presentation would be best treated by
percutaneous pin fixation rather than cast immobiliza- malunion does not remodel with growth, a dorsal opening
tion to lessen the risk of forearm compartment syn- wedge osteotomy with bone graft and internal fixation
drome, acute carpal tunnel syndrome, or median neu- may be needed for the skeletally mature patient with
ropathy. There is limited evidence of a significant risk of greater than 10 apex dorsal malangulation. Patients with
growth arrest with the use of smooth, small diameter displaced physeal fractures should be examined for 1 to 2
pins. The pins should be removed at 3 to 4 weeks post- years after the fracture occurrence to rule out a growth
operatively to lessen the risk of growth arrest. disturbance. If a radial growth arrest occurs, the contin-
Long-term follow-up (average, 25.5 years) of 157 pa- ued ulnar growth can lead to distal radioulnar joint incon-
tients with distal radius and ulna physeal fractures who gruity, ulnocarpal impaction, and a triangular fibrocarti-
were treated with closed reduction showed that 4.4% of lage tear (Figure 3).
Figure 3 A, Radiograph shows distal radial physeal arrest after repetitive closed reductions of a Salter-Harris type II fracture. Note the ulnar overgrowth with open physis and the
radial growth arrest. B, Clinical photograph of the patient showing the deformity resulting in ulnar-carpal impaction.
appropriate for fractures that are not suitable for closed excursion with wrist tenodesis serve as the basis for di-
reduction, and can be performed with a volar, midaxial, agnosis of a flexor tendon laceration. If doubt exits, the
or dorsal approach. Restoration of an anatomic joint wound should be explored with the patient under anes-
lessens the risk of long-term arthritis, malalignment, and thesia. Repair of the tendon lacerations in zones I and
loss of motion. II requires meticulous technique with fine sutures. Post-
The major complication of diaphyseal-level pha- operative cast immobilization for 4 weeks is effective.
langeal fractures is malrotation. Frequently, children will No differences have been found in total active mo-
refuse to actively move the affected finger in the acute set- tion (TAM) between patients treated with early mobili-
ting, thus preventing accurate assessment of digital align- zation protocols and those treated with cast immobiliza-
ment. However, possible tenodesis of the wrist enables the tion for 4 weeks. If cast immobilization continues
physician to assess malrotation and should be performed beyond 4 weeks, TAM may decrease by up to 40% by 6
on all phalangeal and metacarpal fractures regardless of weeks. There was no difference in the results in groups
radiographic appearance. If closed treatment is chosen, a from 0 to 15 years of age.
solitary finger should never be immobilized; it should be Two-stage reconstruction of unrecognized zone II
secured to the adjacent digits to prevent subsequent loss lacerations in children has poorer results than in adults,
of reduction. If the fracture is malrotated and unstable, a with a higher rate of complications and a mean TAM of
reduction pin or screw is necessary for stabilization. Al- only 140. Better results are achieved with supervised
though malrotation is uncommon, it can result in a major rehabilitation. In a study on uncomplicated flexor polli-
complication if it is not discovered until after union takes cis longus tendon laceration repairs, long-term limited
place. The malrotated digit impairs the function of the ad- motion (> 30) of the interphalangeal joint occurred in
jacent digits secondary to overlap, and can only be cor- one third of the patients. Short splint immobilization
rected with osteotomy. had a negative effect on outcome; however, zone of in-
jury, an early mobilization program, or concurrent digi-
Scaphoid Fractures tal nerve injury had no significant effect on long-term
Distal pole scaphoid fractures in the skeletally imma- outcome.
ture patient heal readily with cast immobilization with-
out risk of nonunion or osteonecrosis. Scaphoid waist Amputations
fractures are common in the adolescent age group. Re- The treatment of proximal, complete digital amputa-
cent studies have indicated that both adults and children tions with replantation in children as young as 1 year of
with clinical pain in the region of the scaphoid and nor- age is now standard. In children, the indication for re-
mal radiographs may benefit from MRI, the results of plantation is more liberal than in adult patients and in-
which will alter treatment choices in a high percentage cludes cases of multiple digit, thumb, midpalm, hand,
of patients. Waist fractures carry the same risks of non- and distal forearm amputations, as well as single digit
union and osteonecrosis in the child as they do in an amputations in zones I and II. Crush amputations
adult. Open reduction, bone grafting, and internal fixa- caused by compression from doors, heavy objects, or bi-
tion should be used to treat an established nonunion in cycle chains have a peak incidence in children 5 years of
a child. The epidemiology of scaphoid fractures contin- age, whereas amputations caused by sharp objects occur
ues to change; proximal pole fractures, nonunions, and more commonly in adolescents. Digital survival rates
osteonecrosis now have been described in adolescents. from replantation range from 69% to 89% in pediatric
Treatment with distal radial vascularized bone graft has studies. Indications that favor digital survival are ampu-
been recommended for these unique complications. The tations resulting from sharp objects, patient body weight
treatment of acute scaphoid fractures, even nondis- greater than 11 kg, more than one vein repaired, bone
placed fractures, with percutaneous screw fixation is shortening, interosseous wire fixation, and vein grafting
controversial. The complication rates in patients with of arteries and veins. Vessel size generally exceeds 0.8
acute scaphoid fractures who were treated with casting mm in digital replants in children and is not a technical
compared with those treated with screw fixation have problem for the skilled microvascular surgeon. Index
been statistically equivalent. and long finger replants have been more successful than
small finger replants in children. A digital survival rate
Flexor Tendon Injuries of 95% occurred in children if prompt reperfusion was
Tendon Lacerations seen after arterial repair with at least one successful
The diagnosis, surgical care, and postoperative rehabili- venous anastomosis. Neural recovery rates far exceed
tation of a flexor tendon injury may be more difficult in those found in adult patients; return of two-point dis-
a child than in an adult. Treatment is especially difficult crimination of less than 5 mm often occurs. Tenolysis
in a toddler or preschool-age child who offers limited may be necessary after tendon repair. Growth arrest or
cooperation. The presenting digital cascade and digital deformity is more common if there is a crush compo-
Table 2 | Classification of Congenital Upper Limb eries of more than 12,000 children have not found this
Malformations condition to be present at birth, supporting the belief
that it is not a true congenital condition. The child will
I Failure of formation have a flexion deformity of the interphalangeal joint
A Transverse arrest that may not be passively correctable. A compensatory
B Longitudinal arrest
hyperextension deformity at the metacarpophalangeal
II Failure of differentiation (separation) joint may also develop. A palpable nodule at the level of
III Congenital tumorous conditions the A1 pulley of the thumb, which appears to be caused
IV Duplication by edema within the tendon, will also be present.
V Overgrowth Spontaneous resolution occurs in a small number of
VI Undergrowth patients. Nonsurgical treatment has been most popular
VII Congenital constriction ring syndrome in Asia where a combination of splinting and passive
VIII Generalized skeletal abnormalities motion has been shown to allow for correction in up to
two thirds of affected patients. When the thumb does
not show any sign of spontaneous correction, A1 pulley
nent to the amputation. Microvascular toe to thumb release is indicated. This procedure may be performed
transfer is a successful alternative to pollicization as by either transverse incision or a chevron type incision
treatment for a failed replant in a young child. centered over the metacarpophalangeal joint. Longitudi-
nal incisions over this site have been shown to adversely
Congenital Upper Extremity Malformations affect range of motion and appearance. Long-term stud-
The prevalence of congenital upper limb anomalies is 2 ies of trigger thumb release have found that although
per 1,000 live births. Forty-six percent of these infants also recurrence of triggering is extremely rare, approxi-
have another nonhand anomaly; bilateral hand anomalies mately 25% of the patients show some limitation in in-
are found in more than 50% of these patients. Overall, terphalangeal joint motion compared with the unaf-
boys are affected more than girls by a ratio of 3:2. Ad- fected thumb. No long-term functional deficits have
vanced maternal age significantly increases the prevalence been noted with trigger thumb release.
of congenital upper extremity malformations.
Recent advances in embryology have greatly im- Trigger Finger
proved the understanding of human limb development. Based on large population studies, trigger finger, like
Growth factors influence the apical ectodermal ridge trigger thumb, has not been found at birth. Patients with
and numerous genes influence the zone of polarizing ac- trigger fingers have a higher rate of spontaneous resolu-
tivity and polarity. Genes responsible for specific defor- tion and an earlier age of onset than patients with trig-
mities such as triphalangeal thumb have been identified ger thumbs. For those digits not showing spontaneous
on specific chromosomes. Modern ultrasound tech- correction, abnormalities are found well beyond the A1
niques also have increased the rate of prenatal diagnosis pulley and may include abnormalities of the flexor digi-
of these disorders and may lead to parental consultation torum sublimis tendon insertion and the A3 pulley. Sur-
before birth. gical treatment of a trigger finger requires exploration
During embryologic growth, the limb bud appears 26 of the digit well beyond the A1 pulley because almost
days after fertilization. The final stage of upper extrem- 50% of patients undergoing simple A1 pulley release
ity development, separation of the ring and small digits, will have residual triggering.
is completed by day 56. Events occurring at various
stages of embryologic growth may have profound ef- Polydactyly
fects on the ultimate appearance of the limb. Polydactyly occurs as an isolated disorder, in association
with other malformations of the extremities, or as part
Classification of a syndrome. It usually occurs sporadically but may be
The most commonly used classification system is that inherited with a mainly autosomal dominant inherit-
proposed by the American Society for Surgery of the ance. Polydactyly is categorized as radial, central, or ul-
Hand and the International Federation of Societies for nar with the small finger the most commonly duplicated
Surgery of the Hand. This system includes eight catego- digit.
ries that are based on the proposed etiologic pathways Small finger duplication may occur as either a skin
and are found in Table 2. tag or a fully developed digit including a fully formed
metacarpal bone (Figure 4). The incidence of this disor-
Trigger Thumb der has been reported as high as 1 in 300 births in the
Trigger thumb is one of the most common malforma- African American population and 1 in 3,000 in the
tions in children. Two large studies of consecutive deliv- white population. In the African American population,
Figure 7 Ring finger delta phalanx. Figure 8 Constriction ring syndrome with web base separation.
the level of the web space (Figure 8). The underlying nism. Camptodactyly has a bimodal type of distribution,
structures are usually normal to the level of the digital with type I presenting in infancy and type II presenting
absence; separation of digits may be easily performed as in adolescence. In type III, the condition is found as part
the proper level of the web is already established. Cir- of a syndrome.
cumferential rings may best be released by performing Most type I patients improve with stretching and
surgery on one half of the circumference at a time. On splinting. Patients with type II camptodactyly may im-
rare occasion, this disorder may occur with significant prove with splinting and may have significant residual
compromise to the digit distal to the site of the constric- flexion deformity, as do type III patients. Surgery for
tion ring and will require release of the ring during the this disorder must be undertaken with caution because
first few days of life. In most patients with ring release, a significant residual flexion deformity is usually noted.
deep fibrous layer must be excised in addition to Most authors recommend reserving surgical release for
Z-plasty, which is usually performed at the skin level. contractures greater than 60.
Camptodactyly Syndactyly
Camptodactyly is an isolated congenital flexion defor- Syndactyly is the most common congenital hand defor-
mity of the proximal interphalangeal joint. The patients mity occurring in approximately 1 in 2,200 births. It may
may present with a broad spectrum of deformity and in- be inherited with an autosomal dominant pattern in up
volvement. The digits have abnormalities of numerous to 40% of patients. Although numerous syndromes in-
structures including skin, fascia, tendon sheaths, flexor clude syndactyly, the most common are Aperts syn-
digitorum sublimis tendons, lumbrical and interosseous drome and Polands syndrome. Syndactyly may be com-
muscles, bony surfaces, and the central extensor mecha- plete or incomplete based on the distal extent of the
Annotated Bibliography pared with only 10% requiring hospitalization when fractures
occurred during the winter.
Forearm and Wrist Trauma
Boyd KT, Brownson P, Hunter JB: Distal radial frac-
tures in young goalkeepers: A case for an appropriately Waters PM, Bae D, Montgomery K: The surgical man-
sized soccer ball. Br J Sports Med 2001;35:409-411. agement of post-traumatic distal radial physeal growth
In a prospective, clinic-based study of young goalkeepers, arrest in adolescents. J Pediatr Orthop 2002;22:717-724.
it was shown that the size of the ball had a direct effect on the The authors present a case study of patients with distal ra-
risk of a distal radius fracture. dial physeal arrests with consequential ulnar overgrowth re-
sulting in complications with ulnar-carpal impaction, distal
radial-ulnar joint incongruity, and triangular fibrocartilage
Cannata G, DeMaio F, Mancini F, Ippolito E: Physeal tears. Surgical planning and treatment options are outlined for
fractures of the distal radius and ulna: Long-term prog- corrective osteotomies and soft-tissue repairs.
nosis. J Orthop Trauma 2003;17:172-179.
One hundred sixty-three fractures of the distal radius and
ulna physes in 157 patients were reviewed at an average
Hand Trauma
follow-up of 25.5 years (14 to 46 years). Seventy-seven were Mahabir RC, Kazemi AR, Cannon WG, et al: Pediatric
isolated fractures of the distal radius, 54 were associated with hand fractures: A review. Pediatr Emerg Care 2001;17:
ulnar styloid fractures, and 26 were associated with ulnar 153-156.
The incidence and epidemiology of hand fractures in chil-
metaphyseal fractures. Eighteen were Salter-Harris type I frac-
dren are discussed.
tures and 139 were type II fractures. Symptomatic growth dis-
crepancy of greater than 1 cm at skeletal maturity occurred in
4.4% of the distal radius physeal fractures and 50% of distal Rajesh A, Basu AK, Vaidhyanath R, Finlay D: Hand
ulnar physeal fractures. fractures: A study of their site and type in childhood.
Clin Radiol 2001;56:667-669.
Radiographs of 280 children with hand fractures were re-
Jones IE, Williams SM, Dow N, Goulding A: How many
viewed and categorized by site of the injury and age of the pa-
children remain fracture-free during growth?: A longitu-
tient. Distal tuft fractures were the most common in the 0- to
dinal study of children and adolescents participating in
4-year age group; distal phalanx fractures occurred most fre-
the Dunedin Multidisciplinary Health and Development
quently in the 5- to 8-year age group; fractures of the proximal
Study. Osteoporos Int 2002;13:990-995.
Results of a longitudinal study of 601 people from New phalanx of the small finger were most common in the 9- to 12-
Zealand showed that approximately half (60% girls, 50% year age group; and fractures of the small finger metacarpal
boys) of the children in the study did not have a fracture occurred most frequently in the 13- to 16-year old age group.
throughout their growth period. More than one fracture oc-
curred in 119 children (16% girls, 23% boys). The forearm was Congenital Upper Extremity Malformations
the most common site of fracture (24%). Giele H, Giele C, Bover C, et al: The incidence and epi-
demiology of congenital upper limb anomalies: A total
Ronning R, Ronning I, Gerner T, Engebretsen L: The population study. J Hand Surg [Am] 2001;26:628-634.
A homogeneous population study found congenital upper
efficacy of wrist protectors in preventing snowboarding
extremity anomalies in approximately 2 per 1,000 live births
injuries. Am J Sports Med 2001;29:581-585.
Results of a randomized, prospective study of 5,029 snow- with nearly 50% of those affected having some other anomaly.
boarders in Norway is presented. A significant decrease in in- Failure of separation and duplications were the most common
jury rate was found with the use of wrist protectors. Beginners malformations and increased in number with advanced mater-
and those using rental equipment were at highest risk for wrist nal age.
injury.
Goldfarb CA, Klepps SJ, Dailey LA, et al: Functional
Wareham K, Johansen A, Stone MD, Saunders J, Jones outcome after centralization for radius dysplasia.
S, Lyons RA: Seasonal variation in the incidence of J Hand Surg [Am] 2002;27:118-124.
This long-term review of patients undergoing centraliza-
wrist and forearm fractures and its consequences. Injury
tion found residual radial angulation of 36, wrist arc of mo-
2003;34:219-222.
A longitudinal study from Wales showed a seasonal varia- tion of 31, and an average ulnar length that was 54% of that
tion in the incidence of wrist and forearm fractures in children found in the uninvolved contralateral ulna. Surgery resulted in
younger than 15 years of age. The incidence in the three win- improvement in wrist alignment but with less benefit to func-
ter months (5.7/1,000 per year) was half the incidence for frac- tional improvement than previously believed.
tures the rest of the year (10.7/1,000 per year). The fractures
that occurred during the nonwinter months were more severe Greuse M, Coessens BC: Congenital syndactyly: Defat-
with 23% of patients with forearm and wrist fractures requir- ting facilitates closure without skin graft. J Hand Surg
ing hospitalization during the spring, summer, and fall com- [Am] 2001;26:589-594.
The authors performed syndactyly separation with the use This long-term retrospective review found that most pa-
of graft by performing extensive defatting. Skin graft was re- tients with Madelungs deformity are female (77%), with a
quired for complex cases and reoperation was performed in 2 positive family history in 13% of those affected. Despite sur-
of 16 patients. gery, almost all patients had limited range of motion.
Schmidt-Rohlfing B, Schwobel B, Pauschert R, et al: Manske PR, Rotman MB, Dailey LA: Long-term func-
Madelung deformity: Clinical features, therapy and re- tional results after pollicization for the congenitally defi-
sults. J Pediatr Orthop B 2001;10:344-348. cient thumb. J Hand Surg [Am] 1992;17:1064-1072.
McCarroll HR: Congenital anomalies: A 25 year over- Proctor MT, Moore DJ, Paterson JM: Redisplacement
view. J Hand Surg [Am] 2000;25:1007-1037. after manipulation of distal radial fractures in children.
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OConnell SJ, Moore MM, Strickland JW, et al: Results ullary pinning technique in the treatment of pediatric
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Developmental Dysplasia of the Hip decreased or abnormal fetal movement is a feature, such
Incidence as arthrogryposis and spina bifida. Treatment of these
Most newborn screening studies, usually based on physi- hips depends as much on the nature of the overall disor-
cal examination techniques, suggest that some degree of der as on the dislocated hip itself. Although ligamentous
hip instability can be detected in 1 in 100 to 1 in 250 ba- laxity has been suggested as a risk factor, DDH is not
bies. Actual dislocated or dislocatable hips are much less especially associated with genetic conditions such as the
frequent, being found in 1 to 1.5 of 1,000 live births. Marfan, Ehlers-Danlos, or Down syndromes, in which
Late presentation of developmental dysplasia of the hip generalized joint laxity is a prominent feature.
(DDH) is found in approximately 4 per 10,000 children. In infants who are otherwise normal, the most im-
portant risk factors for DDH are female gender, family
Etiology history, and breech positioning. In addition to routine
screening, some types of imaging studies are often rec-
There is no single cause of DDH. The basic structures of
ommended for these infants.
the human hip joint are well formed by the 11th fetal
week. Subsequent development of the hip requires a
continuous synergistic molding and growth of the imma- Diagnosis
ture femoral head and the acetabulum. Any process or Physical Examination
event that interrupts this interaction can result in struc- For newborns and neonates, the mainstay of physical di-
tural abnormality and instability. Those hips that dislo- agnosis has been the palpable sensation of the hip slid-
cate early during the course of fetal development will ing out of or into the acetabulum. Barlows test is a pro-
have extreme anatomic abnormalities, and are called vocative maneuver in which the examiner attempts to
teratologic dislocations. subluxate or dislocate the hip by pressing gently down-
The risk of DDH has been found to be 34% in iden- ward on the flexed, adducted thigh. Ortolanis test is a
tical twins, but only 3% in fraternal twins. The frequency reduction maneuver performed by abducting the flexed
in siblings is approximately 6% to 7%. If one parent hip while lifting gently forward under the greater tro-
and one sibling have DDH, the risk to subsequent in- chanter. Palpable luxation or reduction of the joint con-
fants rises to 36%. The genetic influence may also be stitutes a positive test. Most high-pitched clicks are
seen in comparisons of different ethnic groups, with transmitted from the greater trochanteric or knee areas,
high rates among Lappish and very low rates among and are inconsequential.
Bantus. Between 3 and 6 months of age, the soft tissues
Infants who have been in the breech position during tighten sufficiently that a reduced hip does not dislocate
the third trimester and/or perinatally have a higher risk with Barlows test and a dislocated hip cannot be re-
of DDH, as high as 20% for those in the frank breech duced with Ortolanis test. Hip abduction in flexion will
position. An increased incidence is also found with con- be limited on the affected side, and the thigh will be
ditions typically associated with intrauterine crowding, foreshortened. In unilateral cases, the shortening is con-
such as oligohydramnios, congenital recurvatum or dis- veniently demonstrated by the Galeazzi (or Allis) test,
location of the knee, and congenital muscular torticollis. in which the infant is positioned supine with the hips
Postnatally, a high incidence of DDH is found in those and knees flexed so that the relative height of the knees
societies where infants are customarily strapped or can be assessed.
swaddled with the thighs adducted. After these children begin to stand, a flexion con-
DDH is associated with certain neuromuscular con- tracture usually develops at the affected hip. Increased
ditions and genetic syndromes, especially those in which lumbar lordosis and pelvic obliquity are seen. The pa-
Anteromedial and medial approaches have most of- Capsulorrhaphy and pelvic osteotomy can be performed
ten been recommended for younger children (2 years through this approach. Postoperative immobilization is
old or younger). All approaches include division of the in the functional position, with approximately 15 of
origin of the adductor longus. One anteromedial varia- flexion, 15 of abduction, and neutral rotation.
tion then proceeds between the pectineus medially and Femoral shortening at the time of open reduction
the femoral neurovascular bundle laterally. Division of has taken the place of preoperative traction for reduc-
the psoas tendon allows direct access to the anterome- ing soft-tissue tension around the hip. This procedure is
dial hip capsule. With exception of an inverted labrum, virtually always necessary for children older than age 2
obstacles to reduction can be easily visualized and re- years, but should be considered in each patient. A sepa-
moved. However, there is no opportunity to perform rate lateral approach is necessary. The hip is reduced, a
capsulorrhaphy or osteotomy through this exposure. A subtrochanteric osteotomy of the femur is performed,
potential disadvantage is that the medial femoral cir- and the soft tissues are allowed to retract. The resulting
cumflex artery is in the field of deep dissection, which overlapped segment of proximal femur is resected, and
some believe increases the risk of ischemic necrosis. the femur is internally fixed with a plate and screws.
Alternatively, after division of the origin of the ad- Varus and rotation can be adjusted through this osteot-
ductor brevis, the pectineus may be retracted laterally omy as needed for hip stability. It is important to avoid
and the deep dissection can then proceed either anterior excessive retroversion of the femur, especially if con-
or posterior to the adductor brevis. These two variations comitant pelvic osteotomy is done, as this increases the
are conceptually less direct than the anteromedial ap- risk of posterior redislocation of the hip.
proach, and are not well suited for high dislocations. In older children, the acetabulum will be more se-
Other indications and limitations are similar. verely dysplastic. Anterolateral coverage will be insuffi-
The most commonly used anterior approach for open cient. It is frequently necessary to consider concomitant
hip reduction is that of Smith-Peterson, generally modi- pelvic osteotomy at the time of open reduction to en-
fied by using a bikini incision parallel to the groin flexion sure stability of the hip. The Salter innominate osteot-
crease. Dissection is deepened between the tensor fascia omy will redirect the acetabulum to restore approxi-
femoris and the sartorius, mobilizing the origins of the ten-
mately 25 of lateral coverage and 10 of anterior
sor fascia femoris from the iliac wing. Division of the or-
coverage (Figure 2). As indicated previously, combined
igins of the rectus femoris then gives access to the ante-
pelvic and femoral osteotomy must be done carefully to
rior, superior, and lateral hip capsule. A separate
avoid posterior instability of the joint.
tenotomy, either percutaneous or open, of the adductor
longus is recommended. All of the impediments to reduc-
tion can be addressed via this approach. If an inverted la- Upper Age Limits
brum is identified, it can be released by making several Beyond a certain age, surgical treatment is unlikely to
radial cuts in the tight area. The labrum should not be ex- produce a stable, mobile, pain-free joint for the long
cised. term. Despite obvious gait abnormalities, bilateral pain-
This approach is suitable for all age groups. The dis- free dislocations probably should not be reduced after
section preserves the medial femoral circumflex vessels. age 6 or 7 years. Unilateral dislocations are generally
Complications
Redislocation
Redislocation after closed reduction can usually be
treated by repeat closed reduction or open reduction with
no deleterious effect on long-term outcome. Redislocation
following open reduction is usually attributable to some
flaw in the initial procedure. Inadequate inferior capsular
release, inadequate capsulorrhaphy, and posterior instabil-
ity from combined pelvic and femoral osteotomies are
common errors. Repeat surgery is almost always neces- Figure 3 Reshaping osteotomy of Dega, which preserves the sciatic notch and a
sary to correct the problem, and results are generally variable portion of the inner table of the ileum. (Reproduced with permission from
worse than with primary open reduction. Vitale MG, Skaggs DL: Developmental dysplasia of the hip from six months to four
years of age. J Am Acad Orthop Surg 2001;9:401-411.)
Ischemic Necrosis
Ischemic necrosis of the femoral head is seen with all osteotomies that reorient the acetabulum without chang-
forms of treatment. Causes include extrinsic compres- ing its shape have been described, and the choice, in
sion of the vasculature supplying the capital femoral ep- large measure, depends on patient age (Figure 2). The
iphysis, and excessive direct pressure on the cartilagi- single innominate osteotomy (Salter) depends on flexi-
nous head. Excessive or forceful abduction, previous bility of the symphysis pubis to allow sufficient rotation
failed closed treatment, and repeat surgery are associ- of the acetabular segment. In older children this flexibil-
ated with increased rates of ischemic necrosis. The ques- ity is lost, and triple osteotomy (Steel or Tonnis) is pre-
tion of whether ossification of the femoral head before ferred so that the acetabular segment of the pelvis can
treatment might affect ischemic necrosis rates is not be rotated without violating the triradiate growth poten-
fully resolved. tial. After closure of the triradiate cartilage, the periace-
The diagnosis of ischemic necrosis is based on radio- tabular osteotomy (Bernese) is appropriate.
graphic findings that include failure of appearance or If the intrinsic shape of the acetabulum must be al-
growth of the ossific nucleus 1 year after reduction, tered to improve congruence, reshaping osteotomies
broadening of the femoral neck 1 year after reduction, such as the Pemberton or the Dega should be consid-
increased density and then fragmentation of the ossified ered. These osteotomies require an open triradiate carti-
femoral head, or residual deformity of the femoral head lage to allow hinging through the acetabulum itself. The
and neck after ossification. Classifications of ischemic inner and outer tables of the ileum are divided in the
necrosis separate partial involvement from complete ne- Pemberton, whereas only the outer table is cut in the
crosis, which causes progressive femoral head and neck Dega (Figure 3). Both proceed into the posterior limb
deformity. Treatment depends on degree of severity. of the triradiate, and preserve the posterior wall of the
ischium at the sciatic notch.
Late Dysplasia Salvage osteotomies increase the surface area avail-
In a growing child, the mechanically stable hip that is able for weight bearing, and depend on fibrocartilagi-
reduced but dysplastic may be monitored with serial ra- nous metaplasia of the interposed hip capsule to form
diographs. Failure of improvement with growth is an in- an articulating surface. The Chiari innominate osteot-
dication for intervention, as is symptomatic dysplasia in omy and various shelf acetabular augmentations are
the adolescent. Analysis of the late dysplastic hip is fa- available (Figure 4).
cilitated by CT or MRI studies with three-dimensional
reconstruction. Femoral, pelvic, or concomitant osteot- Developmental Coxa Vara
omy may be required, according to the location of the Developmental coxa vara has an estimated incidence of
major deformity. Pelvic osteotomies are grouped into 1 in 25,000 live births. Males and females are affected
reconstructive and salvage types. with equal frequency, there is no predilection for the
If it is possible to concentrically and congruently re- right or left side, and the condition is bilateral in ap-
duce a dysplastic hip, a reconstructive osteotomy may be proximately 50% of patients.
indicated to improve coverage of the femoral head with The underlying defect of this condition is unknown.
the native articular cartilage of the acetabulum. Several The most widely accepted theory regarding the progres-
Figure 5 Hilgenreiners physeal angle is created by a line through the triradiate carti-
lage and its intersection with a line through the physis. The normal angle is about 25.
(Reproduced with permission from Beals RK: Coxa vara in childhood: Evaluation and
management. J Am Acad Orthop Surg 1998;6:93-99.)
knee pain instead of hip pain, and those patients with ical limp. When the patient bears weight on the painful
hip pain are often initially believed to have a pulled lower extremity, they will lean over that extremity dur-
groin muscle. Historically, the condition and its treat- ing the stance phase of gait. This unusual limp pattern
ment have been fraught with frequent complications helps localize the cause of pain to the hip. Conversely,
such as chondrolysis, osteonecrosis, slip progression, patients tend to lean away from the involved side if the
intra-articular pin penetration, hip stiffness, and degen- pain emanates from below the hip. Patients with SCFE
erative arthritis. Currently, with early diagnosis and sin- tend to externally rotate their lower extremity while
gle cannulated screw fixation, the outcome is usually ex- walking.
cellent in stable SCFE with minimal or moderate The hallmark of the clinical examination is that as
displacement. Osteonecrosis, which is usually seen only the examiner flexes the hip of a patient with SCFE, the
in unstable SCFE, and severe slip displacement can lead patients leg will externally rotate obligatorily. There is
to early hip degeneration. usually complete loss of internal rotation, and any at-
tempt at testing hip internal rotation causes pain. The
Etiology diagnosis of SCFE is confirmed with AP and frog-lateral
The etiology of SCFE is unknown, but it is probably a hip radiographs. The earliest radiographic sign of SCFE
mechanical problem of increased sheer stress across a can be growth plate widening or lucency (termed epi-
capital femoral growth plate weakened either by rapid physiolysis) and patients with chronic slips may develop
growth, or by a condition such as pelvic radiation, hy- a radiodense blush sign on the metaphyseal side of the
pothyroidism, renal failure, or growth hormone treat- capital femoral growth plate. On the AP radiograph of a
ment. Most children with SCFE are above the 95th per- normal hip, a line drawn up along the superior border of
centile for weight and are obese; these factors place the femoral neck (Kleins line) should project over the
increased stress across the growth plate. Growth plates lateral edge of the femoral head. In a child with SCFE
show physiologic weakness during periods of rapid the femoral head may not project over this line (Figure
growth such as the pubertal growth spurt. Endocrine 6). Patients who have the earliest stage of SCFE may
consultation or endocrine screening laboratories are not have normal radiographs (preslip). MRI can help diag-
indicated unless the patient has atypical endocrine find- nose a preslip condition by showing metaphyseal high
ings. Children with SCFE who are younger than 10 signal next to the growth plate and growth plate
years of age or 16 years and older, or whose weight is widening.
below the 50th percentile have a high incidence of atyp-
ical SCFE and may require further workup. No specific Classification
genetic component has been identified with SCFE. In the most useful classification for SCFE, the condition
is either stable or unstable. Stable slips are defined by
Epidemiology the mode of clinical presentation. If a patient can walk
The prevalence of SCFE in the United States ranges be- into the examiners office, with or without crutches, they
tween 2 to 10 cases per 100,000 children. Male children have a stable slip. With an unstable slip, the patient has
outnumber females with the disease by a 3:2 ratio, and difficulty with ambulation and usually presents on a gur-
the mean age for diagnosis is about 13.5 years for boys ney or in a wheelchair. This classification helps with
and 12 years for girls, which corresponds with the age at prognosis in that the most feared complication of SCFE,
which the adolescent growth spurt occurs. Fifty percent osteonecrosis of the femoral head, is usually only seen
of children with SCFE are above the 95th percentile for with unstable slips. Increased SCFE displacement and
weight according to age. There is an increased incidence increased angle of the slip relative to normal anatomy
of SCFE during the summer and fall months and it re- correlate with less favorable outcomes than mild slips.
portedly is bilateral in 17% to 50% of patients. Approx-
imately half the children who have bilateral hip involve- Treatment
ment are identified at the time of initial presentation. The most popular treatment of SCFE is single screw fix-
Therefore, both hips should be examined and bilateral ation across the capital femoral growth plate performed
radiographs obtained for every patient with a unilateral in situ (without reduction) in stable slips. Although sin-
presentation of SCFE. gle screw fixation seems to be the gold standard for
most slips, recent articles have shown slip progression
Diagnosis after single screw fixation. Single screw fixation using
Studies show that approximately 85% of children have a modern fluoroscopic techniques that avoid persistent
history of hip or proximal thigh pain and 15% have only joint penetration have virtually eliminated the risk of
knee pain. Therefore, in any adolescent with knee pain, chondrolysis (cartilage deterioration and hip stiffness)
range of motion should be assessed on the ipsilateral that was previously a common complication of SCFE
hip. The patient with SCFE will usually have a paradox- pinning. The success and simplicity of single cannulated
children age 2 years to teens. It is distinguished from chanter. This four-stage process typically evolves over
adult osteonecrosis of the hip primarily because of its 3 to 5 years and tends to proceed more quickly in
much better healing and revascularization potential. The younger children than in older children.
male to female ratio of occurrence is 5:1. The condition
tends to be bilateral in about 10% of children; however, Clinical Presentation
it usually does not present at the same time in both hips. The typical child with Legg-Calv-Perthes disease has a
The differential diagnosis for simultaneous bilateral hip painless limp. The patient may report intermittent hip,
osteonecrosis includes Meyers dysplasia, spondyloepi- thigh, or even knee pain that is typically not severe and
physeal dysplasia, multiple epiphyseal dysplasia, sickle does not necessitate use of a crutch. The patient may
cell disease, Gauchers disease, and hypothyroidism. have a Trendelenburg gait in which body weight is
shifted over the affected hip during the stance phase of
Etiology gait. This gait pattern (shifting weight away from the af-
The etiology of Legg-Calv-Perthes disease is unknown. fected side during the stance phase of gait) helps to
Thrombosis caused by abnormalities in the clotting cas- identify the hip as the source of the patients pain. On
cade have been recently investigated as the primary eti- clinical examination, the patient usually exhibits joint
ology with an initial study showing that approximately stiffness that is most apparent with loss of hip internal
75% of children with this disease have abnormal clot- rotation and hip abduction. Limb-length discrepancy
ting factors. Although the rate of clotting factor abnor- and leg muscle atrophy are late findings that can occur
malities is small, more recent studies have not validated in patients with more severe hip involvement. On clini-
the high rate of inherited thrombosis and thrombophilia cal presentation, the differential diagnosis will include
in patients or animals with Legg-Calv-Perthes disease. septic arthritis, transient synovitis, proximal femoral os-
Animal models have shown that multiple episodes of in- teomyelitis, SCFE, and hip dysplasia. Infectious etiolo-
farction are necessary to create changes that simulate gies can usually be ruled out through the clinical history
the human Legg-Calv-Perthes disease. As a group, chil- and laboratory studies including erythrocyte sedimenta-
dren with this disease tend to be of shorter stature, have tion rate and C-reactive protein levels. DDH and SCFE
a delay in bone maturation of approximately 2 years, are usually identified on the radiographs. Transient syn-
have a high rate of attention deficit disorder, and have ovitis of the hip usually improves with anti-
high rates of exposure to secondhand smoke. However, inflammatory medications within 1 week and is typically
no systemic causes have been identified in children with completely resolved within 4 weeks of presentation, ver-
Legg-Calv-Perthes disease. Approximately 2% of chil- sus the longer time course of Legg-Calv-Perthes dis-
dren with transient synovitis of the hip will develop ease.
Legg-Calv-Perthes disease; however this scenario prob-
ably results from an initial misdiagnosis and is not a Radiographic Findings
cause of the disease. The earliest radiographic finding in Legg-Calv-Perthes
disease is an apparent joint space widening caused by
Stages/Pathogenesis failure of the involved femoral ossific nucleus to grow
The stages of Legg-Calv-Perthes disease are based on after the ischemic event.
radiographs. During the initial stage the infarction oc- Irregularity and increased density of the femoral head
curs, and radiographs may remain occult for the first 3 to ossification center are also early findings. A subchondral
6 months after this initial ischemic event. Most patients lucent line (crescent sign) can appear in the femoral head,
present to a physician after radiographic alterations in and forms the basis for the Salter-Thompson classification
the femoral head have been noted. In the fragmentation system. A crescent sign involving less than half the fem-
stage, the femoral head appears to fragment or dissolve, oral head is class A, and if it involves more than half the
either partially or totally. This indicator typically occurs femoral head it is class B. The extent of fragmentation of
during revascularization as the infarcted bone is re- the ossific nucleus forms the basis of the Catterall and
sorbed, leaving behind a lucent zone in the femoral head. Herring lateral pillar classifications. In the Catterall clas-
The third phase, termed reossification, occurs when new sification stages 1 and 2, fragmentation involves less than
bone appears. In the healing stage the femoral head half the femoral head, and in stages 3 and 4 it involves
reossifies back to normal bone density; however, residual more than half the femoral head. The Herring lateral pil-
femoral head and neck deformity including shortening lar classification is based on an AP hip radiograph ob-
(coxa breva), widening (coxa magna), and flattening may tained approximately at the start of the fragmentation
exist. phase (Figure 7). Only the lateral third of the ossific nu-
If the capital femoral growth plate is involved in the cleus is evaluated on this view. A lateral pillar that main-
process, there can be tilting of the femoral neck (coxa tains its full height is classified as group A. A lateral pillar
valga) and relative overgrowth of the greater tro- that partially collapses but maintains greater than 50% of
Prognosis
The long-term prognosis of Legg-Calv-Perthes disease
is improved with younger age of onset, especially with
an onset in patients younger than 6 years, and also with
less residual hip joint deformity at skeletal maturity. A
recent study suggests that the percentage of physeal in-
volvement on MRI scan may correlate better with long-
term prognosis than the percentage of femoral head in-
volvement. The Stulberg classification is the gold stan-
dard for rating the residual femoral head deformity and
joint congruence at skeletal maturity; however, a recent
study has questioned the interobserver and intraob-
server reliability of this five-tier grading scale. Lateral
epiphyseal calcification and hip subluxation over 4 mm
have been recognized as risk factors for poor prognosis.
Although most patients with Legg-Calv-Perthes dis-
ease do well during adolescence and early adult life, by
age 50 or 60 years 50% of patients develop disabling de-
generative arthritis. A recent study indicates that con-
trary to the popular belief that girls with Legg-Calv-
Perthes disease have a poorer prognosis, the outcomes
for boys and girls with the disease are essentially equal.
Figure 7 Lateral pillar classification. A, Herring group A, right hip with no loss of
Treatment
height in the lateral third of the epiphysis compared with the normal left hip. B, Less Initial treatment of Legg-Calv-Perthes disease is typi-
than 50% collapse of the lateral pillar is shown in the right hip, rendering it a Herring cally rest, activity restrictions, the use of nonsteroidal
group B hip. C, A Herring group C hip with greater than 50% collapse of the lateral anti-inflammatory drugs, and physical therapy to regain
pillar.
hip motion. Bracing is no longer preferred because two
studies showed no significant effect using this treatment.
its height is group B, and a lateral pillar that maintains less The goal of all treatments is to maintain motion of the
than 50% of its height is group C. The increasing grade hip and to keep the femoral head contained within the
within each classification system tends to correlate with a acetabulum. Patients who lose substantial motion, who
poorer prognosis. develop hinge abduction, or who start to subluxate or
Hinge abduction, in which a bump deformity of the dislocate the hip joint may require more aggressive
lateral femoral head prevents it from rotating under the treatment. Surgical treatment remains highly controver-
acetabulum, is considered a poor prognostic sign. Hinge sial, but appears to be best suited for children older
abduction can be seen on arthrogram taken with the pa- than 8 years with moderate femoral head involvement.
tient under anesthesia, or can be inferred by comparing Preliminary results from a large multicenter trial show
an AP hip radiograph obtained in neutral abduction that surgical treatment is associated with better out-
come in lateral pillar B and B/C border hips in patients This article explains and removes the confusion surround-
who are age 8 years and older at onset. Surgical treat- ing this osteotomy. Results for 22 patients are presented.
ment was not beneficial to lateral pillar A and C hips.
Lateral pillar classification alone does not seem to be Guille J, Pizzutillo P, MacEwen G: Developmental dys-
prognostic; however, taking into account other factors plasia of the hip from birth to six months. J Am Acad
such as age of the patient and head at risk signs (such Orthop Surg 2000;8:232-242.
as calcification lateral to the epiphysis, metaphyseal le- This article reviews diagnosis and management of DDH in
sions, lateral subluxation of the femoral head, and a hor- children from birth to age 6 months.
izontal growth plate) improves the prognostic value. Pa-
tients who develop severe stiffness or whose femoral Holen KJ, Tegnander A, Bredland T, et al: Universal or
heads do not remain contained within the acetabulum selective screening of the neonatal hip using ultra-
may benefit from Petrie casting with or without a soft- sound?: A prospective, randomized trial of 15,529 new-
tissue release. born infants. J Bone Joint Surg Br 2002;84:886-890.
Femoral varus osteotomy and acetabular rotational The effect of screening was measured by the rate of late
osteotomy can also enhance containment but should detection of dysplasia in children from age 6 to 11 years. Uni-
only be performed after hip stiffness is resolved preop- versal ultrasound screening was not statistically better than
eratively. Salvage procedures such as a shelf arthro- universal screening by physical examination, with ultrasound
plasty or Chiari osteotomy or valgus femoral neck os- reserved for questionable cases.
teotomy can be considered for severe disease.
Some patients who have had Legg-Calv-Perthes Konigsberg DE, Karol LA, Colby S, OBrien S: Results
disease will develop recurrence of pain and locking or of medial open reduction of the hip in infants with de-
catching of the hip during their teenage years. Osteo- velopmental dislocation of the hip. J Pediatr Orthop
chondritis dissecans or loose fragments of cartilage can 2003;23:1-9.
develop and are best investigated with MRI or CT scan. Forty hips in 32 patients were reviewed at an average of
The presence of an osteochondritis dissecans lesion in a 10.3 years after medial open reduction. Satisfactory results
patient who has had Legg-Calv-Perthes disease is not were obtained in 75% of patients. The authors endorse the
an indication for open or arthroscopic removal. Nonsur- procedure as an option for patients younger than 1 year of
gical treatment seems to work well; the osteochondritis age.
dissecans lesion can end up in the cotyloid fossa where
it will cause minimal complications. Older children with Lerman JA, Emans JB, Millis MB, Share J, Zurakowski
Legg-Calv-Perthes disease can also develop labral D, Kasser JR: Early failure of Pavlik harness treatment
tears that can be treated with open or arthroscopic pro- for developmental hip dysplasia: Clinical and ultrasound
cedures. predictors. J Pediatr Orthop 2001;21:348-353.
In 26 of 137 hips, Pavlik harness treatment failed to
achieve or maintain hip reduction. Univariate risk factors for
Annotated Bibliography failure were bilaterality, initial clinical examination, and initial
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In this study, osteonecrosis was found only with unstable
view of coxa vara in children.
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stable SCFE was associated with a higher rate of osteonecro-
Burns KA, Stevens PM: Coxa vara: Another option for sis.
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Anterior Cruciate Ligament Injuries at Tanner stage 4 to 5 can probably be considered skele-
Anterior cruciate ligament (ACL) tears in patients with tally mature and therefore receive adult treatments. If a
an open physis are on the rise, and optimum treatment child has more than 2 cm of growth remaining, ham-
still remains controversial. Most of these injuries occur string reconstruction should be considered to lessen the
during participation in sports activities. The mechanism likelihood of injury to the physes. More importantly,
is a noncontact, deceleration injury with a valgus stress careful attention should be paid to fixation to prevent
component or a hyperextension injury. Patients almost damage to the physis.
always report immediate pain and early onset of knee Primary repair of the ACL has never been shown to
effusion. Accurate history and physical examination in be successful. Extra-articular reconstruction has a high
the child younger than 12 years is often difficult because rate of failure (greater than 50%) over time and may
children are not able to provide a good history. The ex- need to be revised with an intra-articular method when
amination may not confirm the diagnosis with only 50% the child is skeletally mature. Intra-articular reconstruc-
correlation of physical examination findings with find- tion in the skeletally immature patient carries the risk of
ings on MRI or at time of arthroscopy. Most patients growth disturbance. This possibility needs to be weighed
will have a positive Lachman test, but a pivot shift is of- against the inevitable risk of further and potentially ir-
ten difficult to elicit. Effusion and loss of motion will be reversible risk of meniscal damage. Transepiphyseal
present. techniques that avoid the physis potentially offer the so-
Imaging should consist of plain radiographs of the lution but are technically demanding and not well stud-
knee, including AP, lateral, tunnel, and Merchant views. ied to date. The literature has reported instances of in-
MRI is the imaging study of choice for evaluation of an jury to the physis in younger children after intra-
ACL tear. Studies have shown that MRI can be just as articular ACL reconstruction but most of these injuries
accurate in adolescents with ACL injuries as in adults. are related to technical error in graft placement or fixa-
Specificity and sensitivity of clinical examination (done tion.
by experienced surgeons) and MRI were shown to cor- Partial tears of the ACL are unusual but do occur in
relate well with findings at arthroscopy. However, in children younger than skeletal age 14 years with a nor-
children younger than 12 years, MRI findings were sig- mal Lachman test; tears involving less than 50% of the
nificantly lower in both sensitivity and specificity. fibers have been shown to respond well to nonsurgical
In children with open physis at the knee, treatment reconstruction. Many MRI studies have shown partial
is still controversial. Modifying sports activity or not tears of the ACL, however, no good data exist on which
participating in pivoting sports until near skeletal matu- tears to treat surgically and which to treat nonsurgically
rity are options, but often are not acceptable to the fam- with rehabilitation.
ily and patient. Bracing and physical therapy may help
but will not eliminate the possibility of recurrent epi- Meniscal Tears
sodes of instability that expose the menisci to injury. Meniscal tears in children are still difficult to diagnose,
Complete tears of the ACL are associated with a higher with many children not reporting a significant injury
rate of meniscal injury than partial tears, and patients and physical examination being less reproducible, espe-
with recurrent episodes of subluxation are at greater cially in children 12 years of age or younger. MRI can
risk to eventually injure the meniscus. A teenager with have a higher false-positive rate for diagnosing meniscal
nearly closed physes, with skeletal age 14 years or older tears because of increased vascularity of the meniscus in
(boys tend to be 2 years behind in skeletal maturity children; diagnosis is improved with review by a good
compared with girls of the same chronologic age), and pediatric skeletal radiologist. Tears of the medial menis-
cus are more common than lateral meniscal tears if dis- tures, respectively. Treatment of type I injuries is usually
coid menisci are excluded. ACL tears have a 50% rate long leg casting with the knee in extension or 10 to 15
of associated meniscal tear. flexion for 4 to 6 weeks. Type II lesions can undergo
Meniscal repair should be attempted in children and closed reduction with hyperextension of the knee, then
adolescents to preserve meniscal tissue if possible. Su- long leg casting with close follow-up to check for dis-
ture repair is still the gold standard, with the vertical placement. If the fragment does not reduce to less than
mattress inside-out technique shown to be the strongest. 2 mm of displacement, then the same treatment as for
Not only will peripheral tears or red-on-white tears type III lesions should be done. Type III fractures are
heal, but new evidence suggests that tears that extend typically treated with open or arthroscopic reduction of
into the white zone greater than 4 mm from the periph- the fragment and fixation to secure the fragment while
ery had a 75% healing rate with stable inside-out repair. it heals.
The anterior horn of the medial meniscus or the trans-
Discoid Meniscus verse meniscal ligament may be trapped beneath the frag-
Discoid menisci occur in 3% to 5% of the population. ment in many patients and must be mobilized while the
They are more often lateral, with 25% occurring bilater- fragment is reduced and then secured. Meniscal entrap-
ally. Discoid menisci are often asymptomatic but can be- ment is reported in 26% of type II injuries and more than
come symptomatic at any age. Symptoms often include 90% of type III injuries. Several different methods of fix-
pain and popping in the lateral joint line and mechani- ation have been reported, including use of Steinmann
cal symptoms of catching and locking. The discoid me- pins, cannulated screws into the fragment stopping short
niscus does not have the same strength characteristics as of the physis, or suture technique through fibers of the
a normal meniscus and can be more prone to tear with- ACL at its base and then down through the crater, exiting
out significant trauma. Classification by Watanabe con- out the anterior tibial epiphysis.
sists of three types. In type I, the meniscus covers the Controversy exists as to whether long-term instabil-
entire lateral plateau and is stable. In type II, the menis- ity continues, either objectively or subjectively, no mat-
cus only covers part of the plateau and is stable. Type III ter how well the fragment is reduced. The thought is
discoid menisci (Wrisberg variant) are unstable because that some ligaments undergo appreciable interstitial
of absent meniscotibial attachment posteriorly. failure before the fracture and that even if the fracture
Treatment in asymptomatic patients with no tear is is reduced, the ligament may have residual laxity. Most
observation. For symptomatic patients, treatment con- reports show that even if there is some objective laxity
sists of repair or dbridement if a tear is present and on clinical examination, most patients (84%) return to
saucerization of the meniscus. For type III unstable me- their previous level of activity. A recent report on a
nisci, suture stabilization to the capsule is necessary small number of patients demonstrates that residual lax-
along with saucerization. Complete meniscectomy ity may not be inevitable because good results with min-
should be avoided because the meniscus will not regen- imal objective or subjective laxity were obtained.
erate.
Juvenile Osteochondritis Dissecans
Tibial Eminence Fracture Juvenile osteochondritis dissecans refers to an osteo-
Avulsion of the tibial eminence occurs with a mecha- chondritis dissecans lesion that occurs before physeal
nism similar to an ACL tear. Usually occurring between closure. An avascular portion of the subchondral bone
8 to 14 years of age, the attachment of the ACL on the in severe cases can undergo separation from the under-
tibial eminence is avulsed off, bringing a varying amount lying epiphyseal cancellous bone. The cartilage sepa-
of bony fragment with it. Historically, these injuries oc- rates with the subchondral bone, although sometimes
curred after a fall from a bicycle, but recently more are there is very little bone remaining on the back side of
reported from mishaps during skiing or while playing the cartilage. The severity ranges from minimal involve-
football. The mechanism of injury is usually forceful hy- ment that results in a soft cartilage bed to complete sep-
perextension or a direct blow to the distal end of the fe- aration with production of a loose body. The etiology of
mur with a flexed knee. A high incidence of associated this disease is unknown but is highly associated with re-
injuries (up to 40%) such as medial collateral ligament petitive microtrauma and/or vascular disruption. Boys
(MCL) injuries or meniscal tears has been reported. are affected twice as often as girls, and most patients are
Meyers and McKeever classify injuries into three very active in sports, giving credence to the theory of
types. Type I is nondisplaced, type II is elevation of the trauma as an etiology. The lateral aspect of the medial
anterior fragment up to 3 mm with the posterior hinge femoral condyle is most often involved (75%). The lat-
intact, and type III is complete displacement of the eral condyle, patella, trochlea, and tibial plateau can also
avulsed fragment; they occur in approximately 15%, develop lesions but are affected much less often. The
39%, and 45% of patients with tibial eminence frac- posterior aspect of the lateral femoral condyle can have
normal variations in ossification that can mimic an os- trochlea, tibia, and patella do not have as good a re-
teochondritis dissecans lesion on plain radiographs. sponse to the same treatment.
Approximately 50% of patients describe a history of With larger lesions, newer techniques of cartilage res-
trauma to the knee with reports of ongoing, vague knee toration can be considered. At a mean 5-year follow-up
pain during athletic activities. The pain often improves (range, 1 to 10 years) of autologous chondrocyte trans-
with rest. Mechanical symptoms of locking, catching, or plantation, 90% of patients had good results. However,
popping can occur when the condition is more advanced only seven patients in this study were younger than 18
and loose fragments are present. Patients may have pain years. Mosaicplasty gave the same results at the same
with palpation over the condyle that is involved. Effu- length of follow-up; again, most patients who were treated
sion may or not be present. had adult-onset lesions. The outcome of these procedures
A tunnel view is important, along with an AP and in the younger population is still unknown because results
lateral view of the knee, as many lesions are best seen are not separated from those found with adult-onset le-
on the tunnel view. MRI can be helpful in making treat- sions.
ment decisions. MRI stage I lesions have articular carti-
lage thickening but no break in the cartilage. Stage II le- Tibial Tubercle Fractures
sions have a break in the cartilage but no increased These fractures are rare and account for approximately
signal intensity on T2-weighted images between the 2% of all epiphyseal fractures. The mechanism of injury
bone fragment and the intact subchondral bone. Stage is usually jumping or landing during some type of sports
III lesions have the increased signal intensity at this in- activity, often basketball or track. The force of the mas-
terface, an indication that fluid is present between the sive quadriceps contraction on takeoff or landing
fragment and the host bone. This finding is a sign of in- against the acutely flexing knee pulls off the tubercle.
stability of the fragment. Stage IV lesions are loose bod- The Watson-Jones classification of these fractures in-
ies. MRI with gadolinium enhancement helps to distin- cludes type I (the fracture line is between the ossifica-
guish between type II and type III lesions tion centers of the tibial tubercle and the epiphysis be-
Treatment in skeletally immature patients with a sta- fore closure), type II (the fracture pattern courses
ble lesion depends on the symptoms. Patients with open between the tibial tubercle and the plateau), and type
physes have a better prognosis for healing of the lesions. III (the fracture extends vertically behind the tibial tu-
If the patient is relatively asymptomatic, then activity bercle and through the tibial plateau). A few instances
restriction alone may be enough. However, if symptoms have been reported in which a tubercle avulsion frac-
of pain and joint effusion are present, restricted weight ture with an accompanying epiphyseal fracture, either
bearing and possibly immobilization may be warranted Salter-Harris II, III, or IV occurs (making a case for a
for 6 weeks. Range-of-motion exercises should be per- type IV tibial tubercle fracture pattern). These types of
formed out of the brace. This treatment plan can result fractures are extremely rare but can have higher poten-
in healing in up to 90% of patients at 3 to 6 months. If tial for compartment syndrome.
symptoms persist or the MRI signal does not change, Treatment of nondisplaced type I injuries is cast im-
then drilling of the lesion may be indicated. This proce- mobilization for 6 weeks with the leg in extension. Dis-
dure helps induce vascular supply into the lesion and fa- placed type II and III lesions require open reduction and
cilitates healing. The lesions may be drilled retrograde screw fixation for stability. Meniscal injury can also occur
through a portal while visualizing through the scope or in type III fractures. Most injuries occur in older children
antegrade with fluoroscopic guidance to avoid penetrat- just before physeal closure and heal well; however, if this
ing intact cartilage. injury occurs in younger children, smooth pin fixation
If the lesion is unstable (type III or IV), surgical in- should be considered to avoid further damage to the prox-
tervention is indicated. If subchondral bone is present, imal tibial physis. Children may have resultant recurvatum
the bed can be dbrided and drilled and the fragment deformity if younger than 11 years at the time of injury.
fixed with pins or screws. Results are variable with fixa-
tion. If there is no subchondral bone on the fragment, Distal Femoral Physeal Fractures
the piece should be removed and the bed dbrided and These fractures comprise less than 1% of all pediatric
drilled. Other options include autologous chondrocyte fractures and about 5% to 6% of physeal fractures. The
transplantation and osteochondral grafts. If the lesion is undulation of the physis contributes to its stability. The
smaller than 2.5 cm, dbridement of the frayed cartilage, mechanism of injury is usually a football injury or being
drilling, or microfracture may allow the lesion to heal hit by a motor vehicle. Concomitant ligament injury
with fibrocartilage. In larger lesions, fixation of the frag- may occur in up to 50% of patients but often is unrec-
ment should be attempted only if there is subchondral ognized initially. Most injuries are closed, and patients
bone attached to the cartilage. Lesions on the medial have pain, deformity, inability to bear weight, and knee
femoral condyle tend to respond the best; lesions of the effusion (if the fracture is intra-articular).
Salter-Harris type II fractures are the most common V account for 3% of these injuries. Type V patterns are
pattern and are seen in adolescents. The risk of growth not usually not noticed until deformity occurs after the in-
arrest is significant (between 19% to 25%) even in this jury.
pattern. Salter-Harris type III fractures usually result Treatment of Salter-Harris type I and II patterns is
from a valgus stress and involve the medial condyle. casting for 6 to 8 weeks if nondisplaced and gentle
These fractures may be minimally displaced. Salter- closed reduction, often under general anesthetic, if dis-
Harris type IV is uncommon and Salter-Harris type V is placed. Crossed pins should be considered for stability
extremely rare, with the diagnosis often made later after or cannulated screws should be used if the metaphyseal
deformity occurs from growth disturbance. Infants re- fragment if large enough. Salter-Harris type III and IV
spond to remodeling and require minimal reduction patterns require open reduction and internal fixation if
even with significant displacement. In adolescents, mini- any displacement is present. They can be fixed with can-
mal remodeling of varus/valgus can be expected; there- nulated screws across the epiphysis for type III and
fore, reduction needs to be near anatomic. across both metaphysis and epiphysis for type IV. These
Treatment of nondisplaced Salter-Harris type I and injuries can cause unrecognized arterial damage and
II fractures consists of cast immobilization with close lead to compartment syndrome.
follow-up. If reduction is required, these injuries are un-
stable and fixation should be considered. Smooth Stein-
mann pins crossed in the metaphysis are effective for Congenital Dislocation of the Knee
Salter-Harris type I and II fractures with a small meta- Congenital knee dislocation is a spectrum of deformity
physeal fragment. If the metaphyseal fragment is large from simple positional contractures that correct sponta-
enough, cannulated screws can be used transversely neously to rigid dislocation of the knee joint requiring
through the metaphyseal fragment into the remaining surgical intervention. The condition often occurs in chil-
metaphysis, thereby avoiding the physis. Salter-Harris dren with myelomeningocele, arthrogryposis, or other
type III and IV fracture patterns require anatomic re- syndromes such as Larsens. This deformity is often as-
duction. If no displacement is present, simple immobili- sociated with developmental dysplasia of the hip, club-
zation is adequate; however, most Salter-Harris type III foot, and metatarsus adductus. It is extremely important
and IV fractures will require open anatomic reduction to look for associated hip dysplasia when a knee
and fixation. Cannulated screws placed parallel to the dislocation is present. The deformity is recognized at
physis, which travel transversely across the epiphysis birth with a knee that is hyperextended and a foot that
and the metaphysis, are excellent constructs. is extended toward the patients head because of a
flexed hip. The pathology consists of one or all of the
following conditions: contractures of the quadriceps ten-
Proximal Tibial Physeal Fractures don, an absent suprapatellar pouch, tight collateral liga-
Proximal tibial physeal fractures are rare injuries occur- ments, and anterior subluxation of the hamstring ten-
ring in patients age 8 to 15 years. Half of these fractures dons.
result from motor vehicle crashes and half from injury If the condition results from positioning in utero, of-
during sports participation. They can also be found in ten the deformity is mild and the knee is still fairly flex-
the newborn and in patients with arthrogryposis who ible. The knee will correct spontaneously within a few
have undergone aggressive stretching in an attempt to weeks or can be assisted by gentle range-of-motion ther-
improve range of motion. The mechanism of injury can apy to accelerate correction. Serial casting also may be
be a direct force, flexion injury, or abduction with or helpful if hip dysplasia is present. A Pavlik harness is
without hyperextension of the lower leg. An associated applied once knee range of motion increases enough to
MCL injury may be present, especially in Salter-Harris allow proper fit.
type III fractures. A more severe contracture or true dislocation shows
Salter-Harris type fractures account for 15% of the in- minimal response to stretching and casting. This condi-
juries and about half are nondisplaced. For those that are tion usually is evident within the first 3 months of treat-
displaced, the metaphyseal portion typically is displaced ment. Failure to gain 30 of knee flexion by 3 months is
medially or posteriorly. Salter-Harris type II fracture pat- an indication for surgery. Surgical treatment is with V-Y
terns (43%) are nondisplaced in up to two thirds of pa- quadricepsplasty or Z-lengthening of the tendon, re-
tients. When displacement does occur, the metaphyseal lease of the anterior joint capsule, transposition posteri-
fragment is usually displaced medially. Salter-Harris type orly of the hamstring tendons, and mobilization of the
III fractures (22%) usually involve the lateral epiphysis, collateral ligaments. Ninety degrees of knee flexion
and the MCL is often torn in this pattern. Salter-Harris should be achieved and then the knee should be placed
type IV fractures account for 27% and Salter-Harris type in a cast in 45 to 60 flexion for 3 to 4 weeks.
Congenital Dislocation of the Patella Treatment options vary but generally follow the
A true congenital dislocation of the patella is rare. This same guidelines as for adult fractures. Nondisplaced
entity must be distinguished from a recurrent disloca- fractures can be treated in a cast. For displacement
tion that occurs later in life. In congenital dislocation of greater than 3 mm, open reduction and fixation is rec-
the patella, the patella is hypoplastic or absent, and the ommended. Small fracture pieces may be excised and
femoral trochlea is often flattened. The lateral retinacu- screw fixation of a larger fragment should be consid-
lum is tight, and the patella is completely dislocated lat- ered.
erally. The patella is often adherent to the iliotibial band
and often irreducible over the condyle. Genu valgus is Evaluation of Genu Varum in Infants and
often present, as is a flexion contracture of the knee. Children
Surgical intervention is required and involves extensive Bowing of the lower extremities in infants and children
lateral retinacular release, often to the greater tro- is a common reason for referral to an orthopaedic sur-
chanter, medial plication, and either hamstring tenodesis geon. Infantile genu varum is physiologic in most in-
or transfer of one half of the patellar tendon. stances. Pathologic causes include infantile Blounts dis-
ease, skeletal dysplasias, rachitic syndromes (nutritional
Nail-Patella Syndrome or metabolic), posttraumatic or postinfectious deformi-
Nail-patella syndrome is rare, involving a tetrad of or- ties, and rarely, focal fibrocartilagenous dysplasia.
thopaedic manifestations: (1) nail dysplasia; (2) hypo- Historical features that elevate the index of suspi-
plastic (or absent) and often dislocated patellae; (3) iliac cion for infantile Blounts disease include obesity, early
horns; and (4) elbow dysplasia, mostly consisting of ra- ambulation, race (African American), and rarely, a posi-
dial head dislocation. The syndrome is of autosomal tive family history. The deformity is localized to the
dominant inheritance with great variability in the phe- proximal tibia, in contrast to physiologic bowing, where
notype. Foot abnormalities may also accompany the di- the deformity is usually more evenly distributed
agnosis, as well as upper and lower extremity tendon throughout the diaphyseal region. A varus thrust also
contractures. The foot deformities include metatarsus should raise the index of suspicion.
adductus, pes planus, equinus, clubfoot, vertical talus, A host of radiographic parameters have been inves-
and calcaneovalgus. Many patients have nephropathy tigated to screen for the development of infantile
and glaucoma. Blounts disease (Figure 1). The tibial metaphyseal-
The orthopaedic implications primarily involve the diaphyseal angle (TMDA) is most frequently used for
patellar dislocations. Most patients will require early this purpose. The TMDA has been shown in several
surgical intervention to stabilize the extensor mecha- studies to be effective (< 5% error) for angles less than
nism and prevent long-term complications. Surgical 9 (physiologic) or greater than 16 (Blounts); however,
treatment is with lateral release (extensive), medial pli- a significant percentage of cases may be indeterminate
cation, and hemipatellar tendon transfer or hamstring (9 to 16).
tenodesis. The nail problems are usually well tolerated. In an attempt to improve the accuracy of radio-
Surgery for radial head dislocation is usually not needed graphic screening, several other measurements have
because patients usually will not have significant com- been evaluated for their sensitivity, specificity, and pre-
plications. The iliac horns are asymptomatic. dictive value. Both the percentage of tibial deformity
(tibial varus/total limb varus) and the ratio of the femo-
ral metaphyseal-diaphyseal angle to the TMDA may be
Patellar Fracture more sensitive and more specific than the TMDA alone.
Fractures of the patella are uncommon in children The epiphyseal-metaphyseal angle (EMA) may also be
younger than 16 years. Diagnosis in the younger patient helpful because patients 1 to 3 years of age with a
is difficult and often delayed. The mechanism of injury TMDA of 10 or greater and an EMA of greater than
is by direct impact or contraction of the quadriceps 20 are at increased risk for Blounts disease. Serial ra-
muscle. Osteochondral fractures are more likely in the diographs are often required to establish the diagnosis,
younger age group, especially after a dislocation event. and a comprehensive approach to screening should in-
Avulsion fractures are classified by location. Superior clude both standardized measurements and knowledge
pole avulsion is least common; medial avulsion is often of the sequential radiographic changes described by
caused by dislocation of the patella and is the most Langenskild.
common, followed by inferior pole avulsion. Lateral
avulsion must be distinguished from the congenital vari- Blounts Disease
ant bipartite patella. Often a larger fragment is frac- Infantile Blounts disease is a progressive varus defor-
tured off than appears on radiographs because of the mity of the proximal tibia. The etiology is most likely
large cartilaginous portion. multifactorial, and the pathophysiology involves a dis-
Figure 1 Radiographic indices used in the evaluation of lower extremity bowing in infants and children. A, Tibiofemoral angle (mechanical). This is the angle in between a line
drawn from the center of the hip to the center of the knee and a line from the center of the knee to the center of the ankle. B, TMDA. The TMDA has been used most commonly
and is measured as the angle between a line drawn though the most distal aspect of the medial and lateral beaks of the proximal tibia and a line perpendicular to the anatomic
axis (most reproducible if drawn along the lateral tibial cortex). C, Femoral metaphyseal-diaphyseal angle. This angle is measured in between the anatomic axis of the femur and
a line drawn perpendicular to a line parallel to the distal femoral physis. D, Epiphyseal-metaphyseal angle. This represents the angle between a line drawn through the proximal
tibial physis (parallel to the base of the epiphyseal ossification center) and a line connecting the midpoint of the base of the epiphyseal ossification center with the most distal
point on he medial beak of the tibia. E, Percent deformity of the tibia ([%DT] = tibial varus [TV]/total limb varus). The %DT is calculated as the degree of tibial varus (angle
between the mechanical axis of the tibia and a line parallel to the distal femoral condyles) divided by the total limb varus (tibial varus + femoral varus [FV]). Femoral varus
represents the angle between the mechanical axis of the femur and the line parallel to the distal condyles of the femur.
turbance of growth in the posterior and medial regions distal fragment should be translated laterally. An intra-
of the proximal tibia, most likely caused by mechanical operative arthrogram facilitates visualization of the tib-
overload in a genetically susceptible individual. The se- ial joint surface. The lowest risk of recurrence is seen in
quence of radiographic changes that evolves over the those with Langenskild III disease who are younger
first decade of life has been described by Langenskild. than 4 years. Unfortunately, recurrence remains com-
Plain radiographs may suggest a depression in the me- mon even after a well-executed osteotomy.
dial tibial plateau in later stages of the disease; however, Although MRI is not routinely indicated, it may be
arthrography (or MRI) often reveals that this region is helpful in documenting the presence, size, and location
occupied by unossified cartilage. of a physeal bar in later stages of the disease. Treatment
The best outcomes are associated with early diagno- of a physeal bar must be individualized. In addition to
sis and unloading of the medial joint by either bracing angular correction, either a resection of the bar or a lat-
or osteotomy. Although somewhat controversial, a knee- eral hemiepiphysiodesis may be required. Limb lengths
ankle-foot orthosis may be indicated for patients with should be followed closely, and either lengthening or
stage I and II disease who are younger than 3 years. The contralateral epiphysiodesis may be indicated.
device should be worn at least during weight-bearing Adolescent or late-onset Blounts disease also in-
hours, and desirable features include a drop lock and a volves a progressive varus deformity of the proximal
valgus producing strap. tibia and is diagnosed in children older than 8 years.
Valgus osteotomy is indicated for patients with pro- Most patients are obese, and mechanical overload has
gressive deformity. Overcorrection is essential, and the been implicated. A common radiographic feature is wid-
Figure 3 The Kalamchi and Dawe classification for longitudinal deficiency of the tibia. A, Type I represents complete absence of the tibia. B, Type II deficiencies are associated
with absence of the distal tibia. C, Type III deficiencies have a distal tibial deficiency (hypoplasia) with a diastasis of the distal tibiofibular articulation.
projected discrepancy may be treated by foot recon- Longitudinal Deficiency of the Tibia
struction and an epiphysiodesis, a single lengthening A spectrum of limb abnormalities is seen in patients
procedure, or both. A foot with three or more rays can with partial or complete absence of the tibia. Clinical
potentially be treated by reconstruction rather than am- concerns include instability at the knee and the ankle,
putation. Those extremities with a nonfunctional foot an equinovarus foot deformity with or without the loss
and/or a large projected limb-length discrepancy (up to of medial rays, and limb-length discrepancy. The classifi-
25 cm) are most commonly treated by amputation cation scheme presented by Kalamchi and Dawe is per-
(Syme or Boyd). In general, most patients with com- haps most practical (Figure 3). The condition occurs
plete absence of the fibula require amputation. The indi- sporadically; however, both autosomal dominant and
cations for amputation versus limb salvage remain neb- autosomal recessive forms of transmission have been
ulous for the subset of patients with a functional (or documented. In contrast to fibular deficiencies, associ-
reconstructable) foot and a large projected discrepancy. ated congenital anomalies in the musculoskeletal system
Although a staged reconstruction including two or three (most often in the hand) and the viscera (congenital
lengthening procedures is technically feasible, it remains heart disease, testicular anomalies) have been reported
to be determined whether limb function and patient sat- in patients with tibial deficiencies.
isfaction will be enhanced compared with early amputa- Complete absence of the tibia is usually treated by
tion. The psychosocial impact of multiple reconstructive through knee amputation. A small subset of patients
procedures during childhood and adolescence must also with a strong quadriceps muscle and no knee flexion
be considered. contracture may be candidates for fibular centralization
Coexisting deformities must also be addressed to (Brown procedure). Because a significant subset of
maximize outcome. The severity of ankle valgus corre- these patients may subsequently require an amputation
lates with the degree of fibular deficiency. There is typi- for progressive flexion contracture, most physicians
cally a wedge-shaped distal tibial epiphysis and a tarsal have abandoned this procedure. When the proximal
coalition. Milder degrees of ankle valgus may be treated tibia has ossified, stability is achieved by proximal ti-
by hemiepiphysiodesis, whereas techniques to restore biofibular synostosis, and either amputation (Syme or
the lateral buttress in patients with greater deformity in- Boyd) or foot salvage is also performed depending on
clude fibular lengthening or distal tibial osteotomy. Val- the local anatomy. Two or more limb lengthenings may
gus deformity at the knee results from hypoplasia of the be required if the foot is retained, and the patients fam-
lateral femoral condyle, and treatment options include a ily must be prepared for the effects on the patient of
distal femoral osteotomy or distal femoral hemiepiphys- multiple procedures throughout childhood and adoles-
iodesis (open versus physeal stapling). Anteromedial cence.
bowing of the tibia is common but typically only re- The third major type of deformity involves hypopla-
quires an osteotomy in patients with complete absence sia of the distal tibia associated with a diastasis between
of the fibula. the distal tibia and fibula, for which the most common
treatment has been early Syme or Boyd amputation. tibial fragments. A coexisting pseudarthrosis of the fib-
Limbs with lesser degrees of anticipated discrepancy ula worsens the prognosis and should be treated by re-
and a functional (or reconstructable) foot may be con- section and grafting as well. Intramedullary fixation of
sidered for salvage, and the choice of procedure is based the fibula should be considered. Ankle valgus may be
on the local anatomy. Options for ankle stabilization in- treated by medial distal tibial hemiepiphysiodesis or dis-
clude arthrodesis of either the distal tibia or fibula to ei- tal tibiofibular synostosis because a distal tibial osteot-
ther the talus or the calcaneus. Talectomy may be re- omy may fail to unite.
quired to facilitate closure of the diastasis, and There has been considerable interest in the use of
synostosis of the distal tibia to the fibula may be re- external fixation and distraction osteogenesis. Following
quired to maintain stability. An osteotomy of the distal resection of the pathologic tissue, acute shortening and
tibia and fibula also may be required to correct angular compression at the pseudarthrosis site may be combined
deformity, and limb-length discrepancy will need to be with bone transport via a proximal tibial corticotomy.
treated by one or more lengthenings and/or epiphysiod- Excellent rates of union have been reported; however,
esis. refracture remains a concern. The technique is most ap-
propriate for children older than 5 years. Intramedullary
Congenital Pseudarthrosis of the Tibia fixation may help to protect against refracture once
and/or Fibula union has been achieved.
The etiology of congenital pseudarthrosis of the tibia re- Free vascularized fibular grafting results in union
mains unknown, and the pathophysiology appears to in- rates of 92% to 95%; however, additional procedures
volve a localized deregulation of bone modeling and are commonly required for delayed union at the distal
growth. The condition is associated with neurofibroma- transfer site, for refracture or stress fractures, for ankle
tosis in approximately 50% of patients; however, only valgus, and for limb-length discrepancy. Pseudarthrosis
10% of patients with neurofibromatosis will develop may recur above or below the site of transfer. Donor
pseudarthrosis of the tibia. In contrast to anterolateral site morbidity (weakness, ankle valgus) remains a con-
bowing of the tibia, which is associated with a prepseud- cern, and restoring fibular continuity by grafting of the
arthrosis or frank pseudarthrosis of the tibia, postero- periosteal envelope, or by distal tibiofibular fusion,
medial bowing is generally benign and improves with should be considered. Ipsilateral fibular transfer may be
time. However, patients with posteromedial bowing will considered in those with no evidence of fibular involve-
require either an epiphysiodesis or a limb lengthening ment.
to treat limb-length discrepancy. Amputation is most commonly performed for resis-
The goal of treatment is not only to obtain union,
tant pseudarthroses following multiple attempts to
but also to prevent progressive deformity/refracture, to
achieve union or when union has been achieved but
treat coexisting limb-length discrepancy and ankle val-
function is impaired by chronic pain or stiffness. The
gus, and to maximize function of the foot and ankle.
Syme or Boyd techniques are preferred in children,
Follow-up beyond skeletal maturity is required to deter-
whereas below-knee amputation may be considered in
mine the outcome of a given treatment method. There is
skeletally mature patients.
evidence to suggest that delaying surgery may increase
Isolated congenital pseudarthrosis of the fibula is ex-
the chances of achieving union and that results of treat-
ment may be better in patients presenting for surgery at tremely rare. The lesion is typically in the distal third,
a later age (older than 5 years). and the goals of treatment are to restore fibular conti-
For patients with anterolateral bowing and a pre- nuity and to prevent or treat ankle valgus. Although ob-
pseudarthrosis, the goal is to prevent or delay fracture servation or splinting may be an option in the absence
by full-time immobilization in a clamshell ankle-foot of a progressive ankle valgus, an attempt to restore fibu-
orthosis or similar device. Prophylactic bypass grafting lar continuity by resection, bone grafting, and intramed-
has not been widely accepted. The primary goal for an ullary fixation is generally recommended. In younger
established pseudarthrosis is to achieve union. Princi- children, valgus may improve with growth if union is
ples of surgery include resecting all abnormal tissue, achieved. Arthrodesis of the distal fibula to the distal
providing a stable mechanical environment, and grafting tibia may be performed as an alternative to resection
with autogenous bone. The role of electrical stimulation and grafting or following failed attempts to achieve
as an adjunct has yet to be determined. union at the pseudarthrosis. The procedure will prevent
Resection and grafting with intramedullary fixation the progression of ankle valgus in older children and ad-
has been associated with variable rates of union (28% olescents but will not result in correction of valgus. The
to 80%); concomitant fibular surgery may improve the most common treatment of an established valgus defor-
outcome. In the absence of fibular involvement, osteot- mity is either distal tibial hemiepiphysiodesis or osteot-
omy is usually required to facilitate apposition of the omy.
Tibial Eminence Fracture Davids JR, Blackhurst DW, Allen BL Jr: Radiographic
Owens BD, Crane GK, Plante T, Busconi BD: Treatment evaluation of bowed legs in children. J Pediatr Orthop
of type III tibial intercondylar eminence fractures in 2001;21:257-263.
skeletally immature athletes. Am J Orthop 2003;32:103- The sensitivity, specificity, and positive predictive value of
105. the mechanical axis, the TMDA, and the EMA were evaluated
In this study, 12 patients with type III tibial eminence frac- in children 1 to 3 years of age. Those with a TMDA of 10 or
tures had good results with absorbable suture repair. These greater and an EMA of greater than 20 are at increased risk
patients had 1 mm or less residual laxity at an average for Blounts disease.
follow-up of 36 months. Five of the 12 patients had associated
injuries, including two MCL injuries, two lateral meniscal
McCarthy JJ, Betz RR, Kim A, et al: Early radiographic
tears, one medial meniscal tear, and one patellar tendon avul-
differentiation of infantile tibia vara from physiologic
sion.
bowing using the femoral-tibial ratio. J Pediatr Orthop
2001;21:545-548.
Shepley RW: Arthroscopic treatment of type III tibial A femoral-tibial ratio (FTR = femoral metaphyseal-
spine fractures using absorbable fixation. Orthopedics diaphyseal angle/tibial metaphyseal-diaphyseal angle) of 0.7 or
2004;27:767-769. less or 1.4 or greater was associated with a less than 5% error
Five patients (average age, 15 years) were treated with ab- risk. The FTR had a greater sensitivity and specificity versus
sorbable polydioxanone pins for type III tibial spine fractures. the TMDA alone, with less rotational effect.
Longitudinal Deficiency of the Tibia Anderson DJ, Schoeneker PL, Sheridan JJ, et al: Use of
Alekberov C, Shevtsov VI, Karatosun V, et al: Treatment an intramedullary rod for the treatment of congenital
of tibia vara by the Ilizarov method. Clin Orthop 2003; pseudarthrosis of the tibia. J Bone Joint Surg Am 1992;
409:199-208. 74:161-168.
Feldman DS, Madan SS, Koval KJ, et al: Correction of
Boyd HB: Pathology and natural history of congenital
tibia vara with six-axis deformity analysis and the Taylor
pseudarthrosis of the tibia. Clin Orthop 1982;166:5-13.
spatial frame. J Pediatr Orthop 2003;23:387-391.
In these two studies the advantages of external fixation for
Feldman MD, Schoenecker PL: Use of the metaphyseal-
the treatment of infantile and adolescent Blounts disease are
diaphyseal angle in the evaluation of bowed legs. J Bone
shown in 91 patients. Multiplanar correction can be achieved
Joint Surg Am 1993;75:1602-1609.
gradually, and alignment can be adjusted based on standing ra-
diographs. Limb-length discrepancy can be addressed simulta- Greene WB: Infantile Tibia Vara. J Bone Joint Surg Am
neously. 1993;75:130-143.
Tokmakova K, Riddle EC, Kumar SJ: Type IV congeni- Johnston CE II: Infantile Tibia Vara. Clin Orthop 1990;
tal deficiency of the tibia. J Pediatr Orthop 2003;23:649- 255:13-23.
653.
Both reconstruction and amputation are considered for
Jones D, Barnes J, Lloyd-Roberts GC: Congenital apla-
this rare deformity, and patients with a functional (or recon- sia and dysplasia of the tibia with intact fibula: Classifi-
structable) foot and a lesser degree of projected limb-length cation and management. J Bone Joint Surg Br 1978;60:
discrepancy may benefit from reconstruction of the ankle mor- 31-39.
tise and subsequent limb lengthening.
Kalamchi A, Dawe RV: Congenital deficiency of the
tibia. J Bone Joint Surg Br 1985;67:581-584.
Congenital Pseudarthrosis of the Tibia and/or Fibula
Johnston CE II: Congenital pseudarthrosis of the tibia: Schoeneker PL, Capelli AM, Millar EA, et al: Congeni-
Results of technical variations in the Charnley-Williams tal longitudinal deficiency of the tibia. J Bone Joint Surg
procedure. J Bone Joint Surg Am 2002;84-A:1799-1810. Am 1989;71:278-287.
Clubfoot (Talipes Equinovarus) stress dorsiflexion AP and lateral views. There is no in-
Idiopathic clubfoot occurs in approximately 1 of every dication for routine radiographs or ultrasound imaging
1,000 live births, affects males twice as often as females, of the childs hips.
and is bilateral in approximately 50% of cases. Recent The goal of treatment is a plantigrade foot with good
genetic research supports the hypothesis of a multifacto- joint mobility that is functional, painless, stable over
rial pattern of inheritance in which genetics plays a cen- time, and free of calluses. Initial treatment is nonsurgi-
tral role. Environmental factors, such as maternal smok- cal. More than 50 years ago, Kite and Ponseti indepen-
ing and amniocentesis in the first trimester, may dently proposed significantly different manipulation and
casting techniques for clubfoot deformity correction
modulate the genetic expression of the disorder. Club-
with each reporting extremely high success rates. For
foot can be identified on fetal ultrasound as early as the
unknown reasons, neither technique came into wide-
12th week of gestation. The sensitivity and specificity
spread use and the past five decades have been marked
are high, making prenatal counseling about treatment
by a proliferation of extensive and radical clubfoot sur-
and prognosis an appropriate and beneficial activity.
geries. Short- and intermediate-term follow-up studies
The clubfoot is characterized by four basic deformi-
on these radical surgical procedures revealed a high per-
ties: (1) cavus (plantar flexion of the forefoot on the
centage of painful, stiff, and deformed feet with the
hindfoot, also described as pronation of the forefoot on need for additional surgery in 5% to 50% of cases.
the hindfoot); (2) adductus of the forefoot on the mid- The Ponseti method has recently been reintroduced,
foot/hindfoot; (3) varus (or inversion) of the subtalar based on scientific support of the efficacy of this
joint complex; and (4) equinus of the foot at the ankle. method that was documented in a long-term follow-up
These deformities are not passively correctable. There is study that was published in 1995. That study showed lit-
a single (occasionally double) posterior ankle skin tle difference in appearance, comfort, and function in
crease and a deep transverse skin crease across the mid- 25- to 45-year-old patients with clubfoot who were
foot. In a clubfoot, the talus is smaller than normal, and treated as infants, compared with age-matched controls.
the talar neck is deviated in a plantar medial direction. With the Ponseti method, the clubfoot is manipu-
The axes of the anterior and middle facets of the calca- lated for 1 to 2 minutes before application of an above-
neus create a more acute angle than in the normal foot, knee cast. Cavus is corrected first, by dorsiflexing the
with the anterior facet oriented inward. This creates a first metatarsal against a fulcrum that is the dorsolateral
corresponding varus deformity of the distal end of the aspect of the head of the talus. In subsequent weekly
calcaneus, resulting in a medial orientation of the calca- manipulations and above-knee cast applications, the ad-
neocuboid joint. There also may be varying degrees of ductus and varus are corrected by abducting the fore-
medial subluxation at that joint. foot against the same fulcrum. Cavus, adductus, and
A complete physical examination of the child is indi- varus are slightly overcorrected and the foot is exter-
cated to rule out a neurogenic or syndromic cause for nally rotated 60 to 70 in relation to the thigh after four
the deformity. There is no reported increased risk for to seven casts have been worn. Percutaneous tenotomy
developmental dysplasia of the hip in children with of the Achilles tendon is performed in approximately
clubfoot; however, examination of the hips in a newborn 90% of feet. The final above-knee cast is worn for 3
is always an important part of the musculoskeletal weeks. The Achilles tendon reforms in a lengthened
screening examination. The diagnosis of clubfoot in a state during that time. Straight-last shoes externally ro-
newborn can and should be based solely on clinical find- tated on an abduction bar are then worn full-time for 3
ings. If radiographs are obtained, either before, during, months and at night for up to 3 years. At least 95% of
or after initiation of treatment, they should be taken as clubfoot deformities can be corrected without the need
for extensive surgery if the treatment is begun soon af- the site of the deformity and is associated with few risks
ter birth. To be successful, this method must be studied or complications. It may be necessary to perform a con-
in detail, mastered, and should not be modified. current closing wedge osteotomy of the cuboid or os-
Up to 40% of clubfeet will require lateral transfer of teotomies at the base of the lesser metatarsals.
the tibialis anterior to the lateral cuneiform between the
ages of 2 and 5 years to correct a dynamic muscle imbal-
ance (supination deformity) that is inherent in the club- Congenital Vertical Talus
foot and not related to the initial method of deformity Congential vertical talus is a dorsolateral dislocation of
correction. the talonavicular joint associated with extreme plantar
flexion of the talus. The foot has a rocker-bottom ap-
pearance, and the head of the talus is prominent and
Metatarsus Adductus palpable on the plantar-medial aspect of the midfoot.
Metatarsus adductus is characterized by medial devia- The hindfoot is plantar flexed. There is a dorsiflexion
tion of the forefoot on the midfoot with neutral or slight contracture of the forefoot on the hindfoot that pre-
valgus alignment of the hindfoot. An important patho- vents the creation of a longitudinal arch by passive ma-
genic factor may be a developmental abnormality that nipulation. It is reported that the deformity occurs in as-
results in a trapezoid shape of the medial cuneiform sociation with syndromes such as arthrogryposis,
with medial orientation of the first metatarsal-medial myelomeningocele, and sacral agenesis in more than
cuneiform joint. Metatarsus varus refers to a similar de- 50% of patients. Congential vertical talus is bilateral in
formity in which the metatarsals are adducted as well as 50% of affected children. The primary differential diag-
supinated. A skewfoot combines adduction and plantar nosis is positional calcaneovalgus deformity, a condition
flexion of the forefoot, with moderate to severe valgus that resolves completely in most patients. It is differenti-
deformity of the hindfoot. The literature is inconsistent ated clinically by flexibility of the midfoot but a dorsi-
with these definitions. flexion contracture of the ankle joint. A lateral radio-
Metatarsus adductus can be classified according to graph of a congenital vertical talus in maximum
the degree of deformity as mild, moderate, or severe us-
dorsiflexion shows fixed plantar flexion of the talus. A
ing the heel bisector line. A second classification system,
lateral radiograph in maximum plantar flexion shows an
based on flexibility, is prognostic. Flexible metatarsus
irreducible dislocation of the talonavicular joint and
adductus deformities can be easily abducted beyond
confirms the diagnosis.
straight alignment. Partly flexible metatarsus adductus
Surgery is required for deformity correction in
deformities correct to a straight foot alignment with
nearly all feet with congenital vertical talus. Preliminary
passive abduction, and rigid feet do not straighten man-
serial plantar flexion casting is used to stretch the dorsal
ually. Flexible metatarsus adductus, which accounts for
tendons, skin, and neurovascular structures of the foot.
90% to 95% of all deformities, corrects spontaneously
Reduction of the talonavicular joint dislocation is de-
in the first 3 to 5 years of life. Partly flexible and rigid
sired, but rarely achieved with casting.
feet benefit from serial manipulation and casting in in-
In the past, treatment has been surgical reconstruc-
fants younger than 1 year of age. The lateral pressure
point is at the calcaneocuboid joint, not the head of the tion between ages 6 and 18 months using a single stage
talus as in clubfoot casting. The subtalar joint is held in circumferential release. Surgical reconstruction through
slight inversion and the ankle in slight plantar flexion to a dorsal approach to the talonavicular joint, with con-
prevent inadvertent eversion of the subtalar joint. Three current Achilles tendon lengthening, has more recently
to four weekly manipulations and long leg cast applica- been shown to result in excellent and lasting deformity
tions are needed to slightly overcorrect the deformity. A correction, with less scar formation and shorter surgical
holding device, such as a reverse or straight-last shoe, time. Naviculectomy, by shortening the elongated me-
should be used for several months thereafter to prevent dial column of the foot, is an effective surgery for cor-
recurrence of deformity. Good results can be expected recting recurrent or untreated congenital vertical talus
at long-term follow-up without a need for surgery, even deformity in the older child. This procedure preserves
when there is mild to moderate residual deformity. Se- some motion in the resultant pseudo-subtalar joint com-
vere, rigid deformity in the older child may cause pain, plex. Subtalar and triple arthrodeses have also been rec-
callus formation, and shoe-fitting problems for which ommended in the older age group, but it is technically
surgery would be indicated. challenging to correct severe valgus deformity of the
Tarsometatarsal capsulotomies and osteotomies at hindfoot with either procedure, and these surgeries lead
the base of the metatarsals are associated with signifi- to stress transfer to adjacent joints. Subtalar arthrodesis
cant complications. An opening wedge osteotomy of the has also been associated with progressive overcorrection
trapezoid-shaped medial cuneiform offers treatment at of the deformity in some feet.
Tarsal Coalition coalitions have been good, but the results deteriorate
Tarsal coalition is a fibrous, cartilaginous, or bony con- rapidly with time and long-term studies are not avail-
nection between two or more tarsal bones that results able. Unsatisfactory results with resection have been re-
from a congenital failure of differentiation and segmen- ported in feet in which the ratio of the surface area of
tation of primitive mesenchyme. It affects at least 1% to the coalition to the surface area of the posterior facet
2% of the general population and is most commonly was greater than 50% (as determined by CT scan) and
seen as an autosomal dominant condition with nearly in which there was significant valgus deformity of the
full penetrance. Talocalcaneal and calcaneonavicular co- hindfoot and narrowing of the posterior facet. The inde-
alitions occur with about equal frequency, are usually bi- pendent influence of the size of the coalition was not
lateral, and together account for nearly all coalitions. determined in that or any other study. Some authors
There may be more than one tarsal coalition in the recommend resection of a symptomatic talocalcaneal
same foot. coalition regardless of its size if the foot is not fixed in
Maturation of the coalition coincides with the devel- severe valgus alignment. The presence of a talar beak
opment of progressive valgus deformity of the hindfoot does not necessarily indicate the presence of degenera-
and restriction of subtalar motion, all of which are more tive arthrosis and is not, by itself, a contraindication for
severe in a foot with a talocalcaneal coalition. For an in- resection. Documented degenerative arthrosis and per-
dividual with a tarsal coalition who develops pain, the sistence or recurrence of pain following coalition resec-
onset of symptoms may coincide with bony transforma- tion are considered by some to be indications for triple
tion of a previously cartilaginous coalition. This gener- arthrodesis, though supportive data are lacking. Severe
ally occurs between 8 and 12 years of age for those chil- symptomatic valgus deformity of the hindfoot associ-
dren with calcaneonavicular coalitions, and between 12 ated with a talocalcaneal coalition can be corrected and
and 16 years of age for those with talocalcaneal coali- pain relieved with a calcaneal osteotomy with or with-
tions. The onset of vague, aching, activity-related pain in out concurrent resection of the coalition.
the sinus tarsi area or along the medial aspect of the
hindfoot is often insidious. The peroneal tendons appear Fractures
to be in spasm and can develop a late contracture. The Intra-articular ankle fractures are uncommon but prob-
exact etiology and the anatomic location of the pain and lematic in children. Four general fracture types are me-
spasm are debated. Examination of the foot reveals dial malleolar fractures, Tillaux fractures, triplane frac-
stiffness or rigidity of an everted subtalar joint. The tures, and pilon fractures. Controversial aspects in the
hindfoot remains in valgus alignment even with toe treatment of these injuries include the indications for a
standing. CT scan and how much displacement indicates reduc-
Calcaneonavicular coalitions are best seen on an ob- tion and fixation. Complications stemming from these
lique radiograph of the foot. Talocalcaneal coalitions are injuries center on growth arrest and articular incongru-
best seen on coronal plane images of a CT scan. A CT ity.
scan should be obtained for feet with calcaneonavicular Medial malleolar fractures occur in young children
coalitions because a talocalcaneal coalition may coexist. with an average age of injury of 8 years. The mechanism
MRI is helpful in identifying coalitions that are still in of injury is supination and inversion of the foot resulting
the fibrous stage and not visualized on radiographs or in a Salter-Harris type III or IV injury. Three radio-
CT scans, but this should not be a first-line study. A graphic views of the ankle are recommended: AP (Fig-
bone scan can be helpful in identifying other possible ure 1), lateral, and oblique. CT is not needed in most in-
etiologies for a rigid flatfoot with an atypical presenta- stances. Any displacement of a physeal fracture of the
tion of pain (osteoid osteoma, infection, fracture). medial malleolus requires reduction and possible fixa-
Treatment is indicated for symptomatic tarsal coali- tion. These injuries occur in younger children with many
tions. Nonsurgical treatment such as cast immobiliza- years of growth remaining; therefore, anatomic reduc-
tion, soft orthotic devices, and anti-inflammatory medi- tion is needed to minimize angular deformity and short-
cations should be used initially. Surgical treatment is ening. Treatment strategies involve closed reduction and
indicated if pain recurs after initially successful nonsur- pinning or cannulated screw fixation. If open reduction
gical treatment. Good long-term pain relief can be ex- and internal fixation is needed, minimal stripping of the
pected in most patients after resection of calcaneonavic- periosteum is recommended to prevent iatrogenic
ular coalitions with interposition of the extensor growth arrest (Figure 2). When treating a Salter-Harris
digitorum brevis. An osteologic study has shown at least type IV injury, the Thurston-Holland fragment can be
three anatomic variations for calcaneonavicular coali- safely removed to visualize the physis. Visualization of
tions. Poor results may correlate with the exact patho- the joint can be accomplished by a small anterior ar-
logic anatomy of the coalition. The short-term results of throtomy. Fixation should be performed parallel to
resection and soft-tissue interposition for talocalcaneal rather than across the physis. Screws provide compres-
Figure 1 AP radiograph of the ankle showing a displaced medial malleolar physeal Figure 2 AP radiograph following closed reduction of the fibular fracture and open
fracture and a displaced distal fibular physeal fracture. reduction and internal fixation of the medial malleolar fracture.
sion and may therefore be superior to Kirschner wires. (Figure 3). Treatment strategies include attempted
Osteotomy and physeal bar resection may be needed if closed reduction by internal rotation, supination, and di-
growth arrest occurs. Long-term follow-up shows that rect pressure; percutaneous manipulation with a Stein-
osteoarthritis results in about 10% of these injuries. mann pin; and open reduction and internal fixation us-
Tillaux fractures occur in older children (average ing a small anterior arthrotomy. Compression screw
age, 13 years). The mechanism of injury is supination fixation can cross the physis because the remaining
and external rotation resulting in the avulsion of the growth potential is minimal. Long-term follow-up stud-
anterior-lateral distal tibial physis by the pull of the ies are needed.
anterior-inferior tibia-fibula ligament. The maturing dis- Triplane fractures occur in children nearing skeletal
tal tibial physis closes centrally, then medially, then lat- maturity (average age, 14 years). The mechanism of in-
erally. The open lateral physis is vulnerable to injury in jury is supination and external rotation. The number of
this age group. Three radiographic views are needed. In fracture fragments depends on which part of the physis
one third of patients, the Tillaux fracture is only seen on is closed at the time of injury. The fracture occurs in
the oblique view. The articular surface displacement three planes: the coronal planethe lateral radiograph
needs to be reduced to less than 2 mm to minimize the shows a Salter-Harris type II fracture; transverse
development of osteoarthritis. Articular congruity is the planeepiphysiolysis through the anterior and lateral
major concern; physeal arrest is not a concern because physis; or sagittal planethe AP radiograph typically
the patient is close to skeletal maturity. CT is commonly shows a Salter-Harris type III fracture. The extent of the
used and appears to be better than radiographs in deter- injury is often underappreciated on plain films; there-
mining if the fracture is displaced greater than 2 mm fore, CT is recommended in most cases. CT defines the
pain is common, and patient education about the natu- osteotomy or shortening osteotomy. Metatarsal head re-
ral history of Severs disease is key. The problem abates section is not recommended because this procedure may
at skeletal maturity when the apophysis closes. No long- transfer pressure and pain to an adjacent metatarsal
term complications have been reported. head.
cades ago and recently, and revealed superiority over the tra- tational weeks/day). The authors hypothesize that decreased
ditional method. amniotic fluid in the early group, during the time of maximum
foot growth velocity, leads to decreased fetal movement result-
ing in joint and limb deformities.
Ippolito E, Farsetti P, Caterini R, Tudisco C: Long-term
comparative results in patients with congenital clubfoot
treated with two different protocols. J Bone Joint Surg Congenital Vertical Talus
Am 2003;85-A:1286-1294. Mazzocca AD, Thomson JD, Deluca PA, Romness MJ:
Forty-seven clubfeet treated with extensive posteromedial Comparison of the posterior approach versus the dorsal
release (after an average of 16 abduction/pronation casts) approach in the treatment on congenital vertical talus.
were compared with 49 clubfeet treated with an open Achilles J Pediatr Orthop 2001;21:212-217.
Z-lengthening and posterior ankle capsulotomy (after an aver- Twenty-five consecutive congenital vertical tali that were
age of six Ponseti-type supination/abduction casts). Follow-up treated with a traditional posterior release operation (average
at 25 years for group one and 19 years for group two showed age, 18 months; range, 6 to 67 months) were compared with
significantly better results in the second group, although not as eight consecutive feet treated with deformity correction via
good as the results reported by Cooper and Dietz using the the dorsal approach (average age, 26.5 months; range, 6 to 65
traditional Ponseti technique with percutaneous Achilles tenot- months). The dorsal approach group required 30% less surgi-
omy. The authors recommend treating clubfeet according to cal time, had better clinical scores, and fewer complications in-
the method of Ponseti. cluding no recurrences (versus 32%) and no cases of osteone-
crosis of the talus (versus 48%).
Leets M, Davidson D, McCaffrey M: The adolescent pi- Clark M, DAmbrosia R, Ferguson A: Congenital verti-
lon fracture: management and outcome. J Pediatr cal talus: Treatment by open reduction and navicular ex-
Orthop 2001;21:20-26. cision. J Bone Joint Surg Am 1977;59:816-824.
Pilon fractures in adolescents result from high-energy
trauma and are associated with a high complication rate. Re- Cooper D, Dietz F: Treatment of idiopathic clubfoot: A
sults were good to excellent in only 63% of cases. The authors thirty-year follow-up note. J Bone Joint Surg Am 1995;
suggest a new classification system for adolescent pilon frac- 77:1477-1489.
tures.
Coughlin MJ, Bordelon RL, Johnson KA, et al: Evalua-
tion and treatment of juvenile hallux valgus. Contemp
Marsh JL, Buckwalter J, Gelberman R, et al: Articular
Orthop 1990;21:169-203.
fractures: does anatomic reduction really change the re-
sult? J Bone Joint Surg Am 2002;84-A:1259-1271. Duncan RD, Fixsen JA: Congenital convex pes valgus.
The authors suggest that there is no convincing evidence
J Bone Joint Surg Br 1999;81:250-254.
that improved articular reduction leads to a better outcome or
a lower risk of osteoarthritis. Rather, the authors suggest that Ezra E, Hayek S, Gilai AN, Khermosh O, Wientroub S:
damage to the articular cartilage at the time of injury is the Tibialis anterior tendon transfer for residual dynamic
most important factor in outcome. supination deformity in treated clubfeet. J Pediatr Or-
thop B 2000;9:207-211.
Seifert J, Matthes G, Hinz P, et al: Role of MRI in the di-
agnosis of distal tibia fractures in adolescents. J Pediatr Farsetti P, Weinstein SL, Ponseti IV: The long-term func-
Orthop 2003;23:727-732. tional and radiographic outcomes of untreated and non-
The authors report that MRI provided anatomic detail and operatively treated metatarsus adductus. J Bone Joint
information about the joint surfaces superior to plain film ra- Surg Am 1994;76:257-265.
diographs.
Freiberg AH: The so-called infarction of the second
Apophysitis/Osteochondrosis metatarsal bone. J Bone Joint Surg 1926;8:257.
Tang SF, Chen CP, Pan JL, et al: The effects of a new Grosoia JA: Juvenile hallux valgus: A conservative ap-
foot-toe orthosis in treating painful hallux valgus. Arch proach to treatment. J Bone Joint Surg Am 1992;74:
Phys Med Rehabil 2002;83:1792-1795. 1367-1374.
The authors report that using a total contact insole with a
fixed toe separator reduced pain and improved the hallux val- Honein MA, Paulozzi LJ, Moore CA: Family history,
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Bilateral Kohlers disease in identical twins suggests that a Huurman WW, Bhuller GS: Nonoperative treatment of
genetic predisposition to the disorder may exist. retained radio lucent foreign bodies in lower limbs.
J Pediatr Orthop 1982;2:506-508.
Volpon JB, de Carvalo Filho G: Calcaneal apophysitis: A
Ippolitoo E, Ricciardi Pollini PT, Falez F: Kohlers dis-
quantitative radiographic evaluation of the secondary
ease of the tarsal navicular: Long-term follow up of 12
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A radiographic study of patients with Severs disease com- Katcherian DA: Treatment of Freibergs disease. Orthop
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aspect of the calcaneus apophysis is a normal finding and
should not be used to establish the diagnosis of Severs dis- Kling TF, Bright RW, Hensinger RN: Distal tibial phy-
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tion. J Bone Joint Surg Am 1984;66:647-657.
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Kumar S, Guille J, Lee M, Couto J: Osseous and non-
Bleck E: Metatarsus adductus: Classification and rela- osseous coalition of the middle facet of the talocalca-
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McHale KA, Lenhart MK: Treatment of residual club- Schwab RA, Powers RD: Conservative therapy for plan-
foot deformity, the bean-shaped foot, by open wedge tar puncture wounds. J Emerg Med 1995;13:291-295.
medial cuneiform osteotomy and closing wedge cuboid
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J Pediatr Orthop 1991;11:374-381. lus under the age of 2 years. J Pediatr Orthop 1987;7:
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Figure 1 A, Ossification centers of the atlas. B, Ossification centers for the axis.
(Reproduced from Copley LA, Dormans JP: Cervical spine disorders in infants and
children. J Am Acad Orthop Surg 1998;6:205.)
Figure 4 Spine boards used for transportation of young children should be modified
to include either an occipital recess (top figure) or a mattress pad (bottom figure) to
accommodate the relatively large head. (Reproduced from Dormans JP: Evaluation of
children with suspected cervical spine injury. Instr Course Lect 2002;51:403.)
Figure 3 The spinolaminar (Swischuks) line is used to differentiate pseudosublux-
ation from true injury. (Reproduced from Copley LA, Dormans JP: Cervical spine disor-
ders in infants and children. J Am Acad Orthop Surg 1998;6:205.)
Figure 7 Fielding and Hawkins classification of atlantoaxial rotatory displacement showing four types of rotatory fixation. A, Type I, no anterior displacement and odontoid acting
as the pivot. B, Type II, anterior displacement of 3 to 5 mm and one lateral articular process acting as the pivot. C, Type III, anterior displacement of more than 5 mm.
D, Type IV, posterior displacement. (Reproduced with permission from Dormans JP: Evaluation of children with suspected cervical spine injury. Instr Course Lect 2002;51:403.)
of C2 on C3. This injury must be differentiated from a inch-lb is generally successful. In younger children, more
persistent synchondrosis of the axis. Treatment is symp- pins (up to 12) placed with lower insertional torques (2-
tomatic, with immobilization in a Minerva cast, halo, or to 4-inch-lb) have been advocated (Figure 8). Standard
cervical orthosis for 8 to 12 weeks. If union does not oc- pediatric halo rings fit most children, but infants and
cur, posterior or anterior arthrodesis can be done to sta- toddlers usually require custom sizing. Although stan-
bilize the fracture. dard pediatric halo vests are available, custom vests or
body casts generally provide superior fit and immobili-
Subaxial Injuries zation.
Fractures and dislocations involving C3 through C7 are
rare in children and infants. Because these injuries occur Spinal Cord Injury Without Radiographic
most frequently in older children and adolescents and Abnormality
have fracture patterns similar to those in adults, they The possibility of spinal cord injury without radio-
generally can be treated as in adults. Atlantoaxial screws graphic abnormality (SCIWORA) should be considered
and lateral mass plates have been used successfully for in children, particularly in patients younger than 8 years.
fixation of unstable fractures of the cervical spine in SCIWORA is defined as spinal cord injury in a patient
children. Image-guided techniques make accurate place- in whom there is no visible fracture on plain radio-
ment of these implants easier in a childs small verte- graphs or CT scan. MRI may be diagnostic in showing
brae. spinal cord edema or hemorrhage, soft-tissue or liga-
mentous injury, or apophyseal end plate or disk disrup-
Pediatric Halo Use tion, but is completely normal in approximately 25% of
patients. SCIWORA is the cause of paralysis in approxi-
Halo vest immobilization is being used with increasing
mately 20% to 30% of children with injuries of the spi-
frequency in children with cervical spine injuries. It af-
nal cord. Involvement of the cervical spine has been
fords superior immobilization to a rigid cervical collar
found to be slightly more common than other levels in
and is easier to apply and more versatile than a Minerva
most studies.
cast. It permits access for skin and wound care while
Potential mechanisms of SCIWORA include hyper-
avoiding the skin problems (maceration, ulceration) typ- extension of the cervical spine, which can cause com-
ically associated with both hard collars and casts. How- pression of the spinal cord by the ligamentum flavum
ever, complication rates as high as 68% have been re- followed by flexion, which can cause longitudinal trac-
ported with pediatric halo use. The most common tion; transient subluxation without gross failure; or un-
problems are pin site infections; however, pin perfora- recognized cartilaginous end plate failure (Salter-Harris
tion and brain abscesses have also been reported. The type I fracture). Ligamentous laxity, hypermobility of
thickness of the skull in children is decreased and, in the spine, and immature spinal vasculature are thought
children younger than age 6 years, it has been suggested to be contributing factors. Regardless of the specific
that CT of the skull to measure calvarial thickness can mechanism, injury to the spinal cord in this syndrome
be helpful in determining optimal sites for pin place- occurs because of the variable elasticity of the elements
ment. of the immature spinal column. Experimentally, it has
In children older than 6 years, the standard adult been shown that the bone, cartilage, and soft tissue in
halo construct using four pins (two anterolaterally, two the spinal column can stretch about 2 inches without
posterolaterally) inserted at standard torques of 6- to 8- disruption but that the spinal cord ruptures after a 0.25-
D is a posterior ligamentous disruption with laminar frac- clude two levels above and below the fracture. In chil-
ture and disruption of the vertebral apophysis. Because of dren with complete neurologic deficits, longer constructs
the transverse plane of orientation of this group of inju- provide better stability and may prevent subsequent
ries, abnormalities may be missed by thick-section CT and paralytic spinal deformity from occurring.
may not be detected even with complementary thin sec-
tions, unless sagittal reconstructions are included. A lat- Annotated Bibliography
eral radiograph showing widening of the interspinous
space is the most helpful study in diagnosing this fracture,
Specific Cervical Spine Injuries
although increased distance between the spinous pro- Flynn JM, Closkey RF, Mahboubi S, Dormans JP: Role
of magnetic resonance imaging in the assessment of pe-
cesses may occasionally be seen on the AP radiograph.
diatric cervical spine injuries. J Pediatr Orthop 2002;22:
MRI may be the single best imaging modality because it
573-577.
can accurately identify soft-tissue and disk injury as well In this study of 74 children, MRI confirmed the plain radi-
as having predictive value in determining spinal cord and ography diagnosis in 66% and altered the diagnosis in 34%.
neural injury. MRI is valuable in the evaluation of potential cervical spine
Approximately two thirds of patients have intra- injury, especially in obtunded children or those with equivocal
abdominal injuries including ruptures of internal organs plain radiographs.
and mesenteric tears, which may be life-threatening if
not diagnosed and treated appropriately. Neurologic in-
Kenter K: Worley G, Griffin T, Fitch RD: Pediatric trau-
jury is unusual. Lap belt injuries with mostly bony in-
matic atlanto-occipital dislocation: Five cases and a re-
volvement and kyphosis less than 20 can be treated
view. J Pediatr Orthop 2001;21:585-589.
with hyperextension casting. Those with posterior liga- Of five children with traumatic atlanto-occipital disloca-
mentous disruption and soft-tissue injury require surgi- tion, the three survivors had posterior occipitovertebral fu-
cal stabilization with compression instrumentation and sions. The diagnosis was missed initially in three children. The
posterior arthrodesis. authors recommend detailed measurements of the initial cer-
Fracture of the vertebral end plate (slipped vertebral vical spine radiographs in pediatric patients at risk for trau-
apophysis) usually occurs in teenagers and is character- matic atlanto-occipital dislocation.
ized by traumatic disruption of the vertebral ring apo-
physis and disk into the spinal canal. The clinical symp-
Lustrin ES, Karakas SP, Ortiz AO, et al: Pediatric cervi-
toms are essentially the same as a herniated disk.
cal spine: Normal anatomy, variants, and trauma.
Patients may have muscle weakness, sensory changes,
Radiographics 2003;23:539-560.
absent reflexes, and root tension signs. This injury most Knowledge of the normal embryologic development and
commonly involves the caudal end plate of L4, but may anatomy of the cervical spine is important to avoid mistaking
occur at any level in the lumbar spine. The injuries may synchondroses for fractures and to correctly interpret imaging
be purely cartilaginous with herniation of the apophysis studies. Familiarity with mechanisms of injury and appropriate
and disk or osseous with fractures of the cortical and imaging modalities also aids in the correct interpretation of ra-
cancellous rim of the vertebral body. This injury usually diographs of the pediatric cervical spine.
cannot be identified on plain radiographs. CT or MRI is
needed to make the diagnosis. Treatment is removal of Thoracic and Lumbar Fractures
the bony and cartilaginous fragments and usually re- Clark P, Letts M: Trauma to the thoracic and lumbar
quires more extensive exposure (bilateral laminotomies) spine in the adolescent. Can J Surg 2001;44:337-345.
than simple diskectomy. This article describes thoracolumbar fractures in adoles-
Fracture-dislocations of the spine are unstable inju- cents. The treatment of these injuries follows many of the
ries that usually occur at the thoracolumbar junction same principles as spinal fractures in adults. Nonsurgical treat-
and often are associated with neurologic deficits. They ment is used more frequently because there is less spinal insta-
are rare injuries in children that require surgical stabili- bility and better tolerance of bed rest and spinal immobiliza-
zation and fusion. Burst fractures are also rare injuries tion in this population.
in children that result from axial compression and typi-
cally occur at the thoracolumbar junction or in the lum- Lalonde F, Letts M, Yang JP, Thomas K: An analysis of
bar spine. The need for surgical treatment is determined burst fractures of the spine in adolescents. Am J Orthop
by the stability of the fracture and the presence of neu- 2001;30:115-120.
rologic deficits. Nonsurgical treatment is a viable option This article describes the results of treatment in 11 chil-
in neurologically intact children, although most will de- dren (average age 14.4 years) with burst fractures of the spine;
velop a progressive angular deformity during the first 6 children were treated with posterior spinal fusion and instru-
year after the fracture. It has been shown that surgical mentation. Results showed that (1) mild progressive angular
stabilization prevents kyphotic deformity and decreases deformity developed at the site of the fracture; (2) spinal in-
the length of hospitalization. Instrumentation should in- strumentation and fusion prevented kyphotic deformity and
decreased the length of hospitalization without contributing to tal dislocation: Underdiagnosis, recognition, treatment,
further spinal cord injury; and (3) nonsurgical treatment was a and review of the literature. Pediatr Neurosurg 1994;21:
viable option in neurologically intact children, but progressive 105-111.
angular deformity occurred during the first year after the frac-
ture. Dormans JP, Criscitiello AA, Drummond DS, Davidson
RS: Complications in children managed with immobili-
Reddy SP, Junewick JJ, Backstrom JW: Distribution of zation in a halo vest. J Bone Joint Surg Am 1995;77:
spinal fractures in children: does age, mechanism of in- 1370-1373.
jury, or gender play a significant role? Pediatr Radiol
Finch GD, Barnes MJ: Major cervical spine injuries in
2003;33:776-781.
Of the 2,614 pediatric patients referred to a trauma center children and adolescents. J Pediatr Orthop 1998;18:811-
over a 5-year period, 84 sustained vertebral fracture and 50 814.
had neurologic injury without radiographic abnormality. A to-
Glass RB, Sivit CJ, Sturm PF, Bulas DI, Eichelberger
tal of 164 fractures were identified. The thoracic region (T2-
T10) was most commonly injured, accounting for 47 fractures
MR: Lumbar spine injury in a pediatric population: Dif-
(28.7%), followed by the lumbar region (L2-L5) with 38 frac- ficulties with computed tomographic diagnosis.
tures (23.2%), the midcervical region with 31 fractures J Trauma 1994;37:815-819.
(18.9%), the thoracolumbar junction with 24 fractures
Harris JH, Carson GC, Wagner LK: Radiologic diagno-
(14.6%), the cervicothoracic junction with 13 fractures (7.9%),
sis of traumatic occipitovertebral dissociation: 1. Normal
and the cervicocranium with 11 fractures (6.7%). There was no
relationship to gender or mechanism of injury.
occipitovertebral relationships on lateral radiographs of
supine subjects. AJR Am J Roentgenol 1994;162:881-886.
Sledge JB, Allred D, Hyman J: Use of magnetic reso- Herzenberg JE, Hensinger RN, Dedrick DK, Phillips
nance imaging in evaluating injuries to the pediatric WA: Emergency transport and positioning of young
thoracolumbar spine. J Pediatr Orthop 2001;21:288-293. children who have an injury of the cervical spine. J Bone
This study is a retrospective review of 19 children with
Joint Surg Am 1989;71:15-22.
thoracolumbar fractures associated with neurologic deficits
from three level 1 trauma centers. The authors conclude that Judd DB, Liem LK, Petermann G: Pediatric atlas frac-
MRI is the imaging modality of choice for these fractures be-
ture: a case of fracture through a synchondrosis and re-
cause it can accurately classify injury to bones and ligaments
view of the literature. Neurosurgery 2000;46:991-994.
and because the cord patterns as determined by MRI have
predictive value of neurologic status. Mubarak SJ, Camp JF, Vueltich W, et al: Halo applica-
tion in the infant. J Pediatr Orthop 1989;9:612-614.
Banerian KG, Wang AM, Samberg LC, Kerr HH, Weso- Pouliquen JC, Kassis B, Glorion C, Langlais J: Vertebral
lowski DP: Association of vertebral end plate fracture growth after thoracic or lumbar fracture of the spine in
with pediatric lumbar intervertebral disk herniation: children. J Pediatr Orthop 1997;17:115-120.
Value of CT and MR imaging. Radiology 1990;177:763-
Subach BR, McLaughlin MR, Albright AL, Pollack IF:
765.
Current management of pediatric atlantoaxial rotatory
Donahue DJ, Muhlbauer MS, Kaufman RA, Warner subluxation. Spine 1998;23:2174-2179.
WC, Sandford RA: Childhood survival of atlantooccipi-
tients with idiopathic scoliosis have juvenile idiopathic present. The rate of progression in these curves is ap-
scoliosis. Females are more commonly affected than proximately 1 per year.
males, and this disparity increases with age. As with ado- Patients with adolescent idiopathic scoliosis should
lescent idiopathic scoliosis, right thoracic curves are have a complete and organized clinical evaluation to
more common. confirm the diagnosis, rule out neural axis abnormalities,
The natural history of juvenile idiopathic scoliosis is and assist in determining treatment. A careful inspec-
one of steady progression until age 10 years, when tion of the skin is necessary to rule out lesions such as
curves generally progress fairly rapidly. Unlike infantile caf-au-lait spots (neurofibromatosis) and cutaneous
idiopathic scoliosis, 95% of all patients with juvenile id- manifestations of dysraphism. The extremities, especially
iopathic scoliosis have progressive curves, whereas only the feet, should be inspected to ensure that no deformi-
5% resolve. The thoracic curves tend to progress more ties (cavovarus feet indicating neural axis abnormalities)
commonly and require fusion more often. Curve pat- are present. Observation of gait (including heel and toe
terns may change with extension of the primary curve walking) will allow the surgeon to obtain a general
or a development of secondary structural curves. sense of the patients strength and coordination. The
As with those with infantile idiopathic scoliosis, pa- neurologic examination should include an assessment of
tients with juvenile idiopathic scoliosis should have MRI motor function in all muscle groups, a sensory examina-
studies to evaluate the neural axis because of a 20% to tion, and deep tendon reflexes. Abdominal reflexes that
25% incidence of abnormalities. These abnormalities of- are symmetric confirm a normal neural axis; when ab-
ten require surgical treatment; therefore, it has been dominal reflexes are asymmetric, the surgeon should ob-
recommended that MRI be done at the time of the ini- tain an MRI scan. Examination of the patients back in-
tial evaluation. cludes an assessment of balance, trunk imbalance, waist
The nonsurgical treatment of juvenile idiopathic asymmetry, pelvic tilt, and limb-length discrepancy.
scoliosis is similar to that for adolescent idiopathic scoli- Shoulder height differences are important, especially
osis. Bracing is used to treat patients with curves that when deciding whether an upper thoracic curve requires
have progressed to 30 or for those with curves exceed- fusion. The Adams forward bend test is performed to
ing 20 that have demonstrated 5 of progression. Surgi- analyze axial plane deformity, which is an indication
that the curve is structural. Asymmetric forward bend-
cal management is also similar to that for patients with
ing of the patient or tenderness of the spine to palpation
adolescent idiopathic scoliosis, although the crankshaft
may indicate a neural axis abnormality.
phenomenon assumes greater importance in the skele-
Initial radiographic examination should include PA
tally immature patient.
and lateral radiographs of the entire spine (lower cervi-
cal spine down to the hips). The PA radiograph should
Adolescent Idiopathic Scoliosis be used to evaluate the spine and determine the Cobb
Adolescent idiopathic scoliosis is relatively common, angle for all curves. Skeletal maturity should be assessed
with a reported incidence of 2% to 3% for curves be- using the Risser sign and the maturity of the triradiate
tween 10 and 20, and an incidence of 0.3% for curves cartilage (open or closed). The PA radiograph should al-
greater than 30. There is an equal incidence of smaller ways be assessed to ensure that two pedicles are present
curves among males and females, whereas the female to for each vertebra, no signs of congenital vertebra exist,
male ratio of curves greater than 30 is 10:1. and that there is no evidence for other abnormalities
The natural history of adolescent idiopathic scoliosis such as neurofibromatosis (penciling of the ribs, en-
has been well studied, and it is generally accepted that dosteal scalloping, or significantly wedged vertebra). An
curves progress in two scenarios: (1) continued spine assessment of spinal balance can be made by dropping a
growth and (2) large curve magnitude despite the com- C7 plumb line and comparing it with the center sacral
pletion of spine growth. Continued spine growth is as- vertical line. Structural characteristics of the proximal
sessed using an array of both clinical and radiographic thoracic curve include T1 tilt, Cobb angle of greater
parameters. Clinical parameters include female menar- than 30, Nash-Moe apical rotation of II or greater, and
cheal status and height measurements performed at a transitional vertebra between the upper and middle
each clinic visit to determine growth velocity. Peak thoracic curves of T6 or lower. Recently, the clavicle an-
growth velocity is approximately 10 cm per year and oc- gle (the angle subtended by the intersection of a hori-
curs just before the onset of menses in females. Radio- zontal line and the line that is tangential to the highest
graphic parameters that indicate skeletal immaturity in- points of each clavicle) has been shown to be the best
clude an open triradiate cartilage, and a Risser grade 0 predictor of postoperative shoulder balance. The lateral
to 1. Following the completion of growth, curve progres- radiograph can be used to assess sagittal balance, which
sion is more likely for patients with thoracic curves ex- is variable, and to ensure that thoracic hypokyphosis is
ceeding 45 to 50 and thoracolumbar/lumbar curves ex- present. The rib heads of the thoracic curve should dem-
ceeding 40, especially when coronal imbalance is onstrate apical lordosis in patients with adolescent idio-
pathic scoliosis, and its absence should warrant investi- fective in treating thoracolumbar/lumbar curves that
gation of the neural axis with MRI. A recent study measure between 25 and 35.
demonstrated that 97% of patients with adolescent idio-
pathic scoliosis and a normal MRI study had apical lor- Surgical Treatment
dosis, whereas this sign was absent in 75% of patients Generally, the indications for surgical treatment of pa-
with scoliosis and a syringomyelia. The presence of a tients with adolescent idiopathic scoliosis are thoracic
spondylolysis and/or spondylolisthesis should always be curves greater than 45 in the skeletally immature pa-
evaluated at the lumbosacral junction and is present in tient or greater than 50 in the skeletally mature pa-
1% to 2% of patients with adolescent idiopathic scolio- tient. Because thoracolumbar/lumbar curves are more
sis. Preoperative radiographic assessment should include likely to progress despite a smaller curve magnitude,
supine best-effort bend films to the right and left. surgical intervention is indicated for patients with
MRI should not be used as a screening tool and is curves greater than 40 to 45, especially when there is
indicated when there is an atypical curve pattern, ab- significant rotation and/or translation. The first goal of
sence of thoracic lordosis, atypical pain, neurologic ab- surgery is to prevent curve progression with spinal ar-
normalities or foot deformities, or extremely rapid curve throdesis. The second goal of surgery is to safely im-
progression. prove the three-dimensional deformity. Surgical plan-
The King-Moe classification has been traditionally ning depends on the radiographic and clinical deformity
used for determining curve types in patients with ado- present and the skeletal maturity of the patient. Fusion
lescent idiopathic scoliosis. This is a five-part classifica- levels depend on the surgical approach used and a care-
tion that was developed to describe thoracic curve pat- ful assessment of the radiographs and clinical deformity.
terns to help guide the surgeon when implanting The standard, more traditional posterior approach can
Harrington instrumentation. As with many orthopaedic be used for all curve patterns, and it is best for double
classifications, it has fair interobserver and intraobserver or triple curves. The anterior approach is more com-
reliability. The newer classification system described by monly used for thoracolumbar/lumbar curve patterns
Lenke and associates provides a more comprehensive because removal of the disk assists in achieving im-
evaluation of both the PA and lateral radiographs and provement in coronal plane deformity, and lumbar lor-
also uses best-effort supine bend films. The following dosis can be restored. The anterior approach can also be
three components are defined in this classification sys- used for thoracic curve patterns, especially when hy-
tem: curve types (1 through 6), lumbar modifiers (A, B, pokyphosis is present. In this instance, correction is
or C), and thoracic kyphosis (negative, N = normal, or achieved with convex compression, which produces ky-
positive). Although more comprehensive, this classifica- phosis. Use of anterior instrumentation requires close
tion system has 42 possible combinations and therefore attention to screw length and direction (in the vertebral
introduces more complexity into the curve evaluations. body) because of the proximity of the aorta to the left
When each of the three components were evaluated in- side of the spine in patients with right thoracic scoliosis.
dividually, the reliability was similar to that of the King- For those undergoing posterior instrumentation and
Moe classification. As with any classification system for fusion, an anterior diskectomy and fusion should also be
adolescent idiopathic scoliosis, it should always be used performed in those who are skeletally immature (Risser
in conjunction with a careful clinical evaluation of the grade 0 with open triradiate cartilage) and in those pa-
patient. tients who have very large (> 80) and stiff (< 50% flex-
Nonsurgical treatment includes observation and ibility index) curves.
management with an orthotic device. Observation is in- Advances in spinal instrumentation have improved
dicated for any curve less than 45 in a skeletally mature the correction of scoliotic deformities. Studies have
patient without significant clinical deformity. In the skel- demonstrated improvement and maintenance of defor-
etally immature patient, observation of curves less than mity when pedicle screws are used in the thora-
25 is warranted. Bracing is used for the skeletally im- columbar/lumbar spine (Figure 1). The use of pedicle
mature patient (Risser grades 0, 1, or 2) with a curve be- screws in the thoracic spine also improves curve correc-
tween 30 and 45 or an initial curve between 20 and tion when compared with hooks, and initial reports
25 that has demonstrated 5 of progression. Although demonstrate safe placement (Figure 2). However, ana-
numerous braces are available today, the Boston and tomic studies demonstrate that it may be challenging to
Charleston braces are most commonly used. The Boston place thoracic pedicle screws, especially on the concav-
brace can be used to treat all curve patterns. Successful ity of the curve, because of the narrow width of the
treatment depends on the amount of time the brace is pedicle and the proximity of the aorta laterally and spi-
worn, as was reported in a recent study in which a com- nal cord medially. Improvement in lateral and posterior
pliance monitor was incorporated into the brace. The translation of the thoracic spine may not be significantly
Charleston (nighttime) brace has been shown to be ef- improved when compared with segmental hook and
Figure 1 Preoperative AP (A) and lateral (B) and 3-year postoperative AP (C) and lateral (D) radiographs of a 14-year-old girl who underwent posterior spinal fusion and
instrumentation with a combination of hooks, sublaminar wires, and pedicle screw fixation. Restoration of coronal and sagittal balance is seen in the postoperative radiographs,
with excellent correction of the lumbar curve.
Figure 2 Preoperative (A and B) and 2-year postoperative (C and D) radiographs of a 14-year-old boy after posterior spinal fusion and instrumentation using pedicle screw
fixation alone.
wire fixation; however, the improvement in the ability to rior thoracoscopic release/fusion performed with the pa-
correct axial rotation may prove to be its greatest ad- tient in the prone position is very effective and better
vantage. Confirmation of screw placement is more diffi- tolerated when compared with a thoracoscopic release
cult in the thoracic spine because radiographic visualiza- with the patient in the lateral position. Thoracoscopic
tion is obscured by the ribs and soft tissues. The results instrumentation for single thoracic curves achieves cor-
of using electromyographic stimulation of screws to con- rection comparable to open anterior or posterior instru-
firm intrapedicle placement is not as reliable as lumbar mentation (Figure 3). Although less scarring provides
screw stimulation. excellent cosmetic improvement, the duration of thora-
The thoracoscopic approach to perform an anterior coscopic surgery continues to be significantly longer
release appears as effective as open thoracotomy and when compared with more conventional approaches.
has minimized the incisions required for anterior access Despite recent advancements in spinal instrumenta-
to the spine. A recent study demonstrated that an ante- tion and techniques, the ultimate goal of surgical treat-
Figure 3 Preoperative (A and B) and 3-year postoperative (C and D) radiographs of a 14-year-old girl after a thoracoscopic anterior spinal fusion and instrumentation.
ment is to achieve solid fusion while minimizing compli- consistent, and comparable in reliability and validity to
cations. Autogenous iliac crest bone continues to be the the Medical Outcomes Study Short Form-36 Health Sur-
gold standard to promote fusion in adolescent idiopathic vey Questionnaire (SF-36). The Scoliosis Research
scoliosis. Neurologic monitoring using somatosensory- Society-22 Patient Outcome Instrument (SRS-22) is
evoked potentials and/or motor-evoked potentials is now shorter and more focused on health issues related to
the standard of care. A 50% decrease in amplitude and/ scoliosis than is the SF-36. Following surgical treatment
or an increase in latency of 10% are generally considered for adolescent idiopathic scoliosis, outcomes using the
thresholds for concern for neurologic injury when assess- SRS-22 have shown significant improvement from the
ing patients using somatosensory-evoked potentials. Crit- preoperative status in the domains of pain, general self-
ical threshold values for motor-evoked potentials are not image, function from back condition, and level of activ-
as clear and are dependent on the mode of stimulation. ity. Improvement in coronal Cobb angle correction does
The Stagnara wake-up test, which is used when neurolog- not correlate with improved SRS-22 scores.
ic injury is suspected, is the gold standard for neurologic One study reported that minimum 20-year follow-up
assessment. Acute complications from the surgical treat- for patients who had posterior surgery with Harrington
ment of adolescent idiopathic scoliosis are relatively rare. instrumentation for idiopathic scoliosis demonstrated
However, the need for revision following a posterior spi- similar back function when these patients were com-
nal fusion can be as high as 19%, with revision for late- pared with an age-matched control group from the gen-
onset surgical pain from prominent hardware occurring eral population. Those who underwent surgery had a
in 8% of patients. Delayed infections can occur up to 3 to greater likelihood of having back pain (78% versus
4 years postoperatively and can present as a small drain- 58%) and lumbar pain (65% versus 47%). In a 50-year
ing wound or fluctuance, accompanied by low-grade fe- follow-up study of untreated patients compared with a
vers and a mildly elevated erythrocyte sedimentation matched control group, the authors reported a greater
rate. Treatment consists of removal of the instrumenta- incidence of shortness of breath (22% versus 15%),
tion and primary closure, followed by oral administration which was associated with a Cobb angle of greater than
of antibiotics. Intraoperative cultures usually grow Sta- 80. Despite a greater likelihood of chronic back pain
phylococcus epidermidis or Propionibacterium acnes, an (61% versus 35%), patients with scoliosis were produc-
organism that requires culture incubation up to 2 weeks. tive and functioning at a high level.
dentified in patients with congenital vertebral abnor- company unilateral segmentation defects on the concav-
malities. Recently, congenital scoliosis has been docu- ity of the curve may adversely affect thoracic growth, re-
mented in two monozygotic twins, a finding that sulting in severe limitations in pulmonary function and
contradicts most of the findings in the congenital defor- growth. This rare condition is known as thoracic insuffi-
mity literature. A potential increase in exposure to ciency syndrome, which is defined as the inability of the
chemical fumes and carbon monoxide in mothers of thorax to support normal respiration or lung growth.
children with congenital spine deformities has also been Left untreated, progressive deterioration occurs and can
reported. result in death at an early age. Methods to expand the
Spinal dysraphism, which includes numerous abnor- thoracic cage are being investigated, with the goals be-
malities such as diastematomyelia, syringomyelia, diplo- ing to provide an acute increase in the thoracic volume
myelia, Arnold-Chiari malformations, intraspinal tumors, with stabilization of any flail chest wall defects and to
and tethering of the spinal cord, is consistently found in maintain these improvements as the patient grows.
30% to 40% of patients with congenital spinal deformi- In patients with severe congenital scoliosis, plain ra-
ties. MRI, which best identifies these dysraphic abnor- diographs may not provide sufficient information re-
malities, has been recently recommended for all patients garding vertebral abnormalities. Should surgical inter-
with congenital spinal deformity as part of the initial vention be necessary, a CT scan with reformatted three-
evaluation, even in the absence of clinical findings. The dimensional reconstruction provides excellent detail for
mere presence of a potentially tethering intraspinal le- the understanding of the deformity. These reconstruc-
sion may be sufficient reason for prophylactic surgical tions are extremely valuable in the preoperative plan-
treatment to address the lesion before the development ning for severe deformities. MRI of the spine also must
of any neural dysfunction. This approach, in the absence be done for all patients with congenital scoliosis who
of neurologic findings, remains controversial. are undergoing surgical intervention to assess intracanal
abnormalities (30% to 40% prevalence). Currently, re-
formatted images from MRI can provide a clear picture
Congenital Scoliosis
of the canal contents despite the severe three-
The variety of vertebral anomalies found in congenital
dimensional deformity associated with some congenital
scoliosis makes its natural history uncertain. The two ba-
scoliosis patients.
sic types, defects of vertebral formation and defects of
Although bracing has no beneficial effect on congen-
vertebral segmentation, may occur separately or in com- ital curves, it may help to control long flexible compen-
bination. In 80% of patients with congenital scoliosis, satory curves below the congenital component. The pri-
the anomalies can be classified into one of the two mary goal of surgical intervention is to stop further
types. progression. Partial correction that can be obtained
Defects of vertebral formation may be partial or safely is an added benefit. Even if the curves are rela-
complete. True hemivertebrae result from the complete tively small (< 40), once curve progression has been
failure of formation on one side and cause the forma- confirmed, surgical intervention should be undertaken.
tion of laterally based wedges consisting of half the ver- Surgery should be performed prior to the development
tebral body, a single pedicle, and hemilamina. When of notable deformity, a concept different from that in id-
present in the thoracic spine, hemivertebrae are usually iopathic scoliosis. Various surgical approaches are used
accompanied by extra ribs. When located at the lum- depending on patient maturity, deformity location, and
bosacral junction, a significant obliquity between the type of deformity. These approaches include anterior
spine and pelvis can result and is usually accompanied and posterior convex hemiepiphysiodesis, anterior and
above by a long compensatory scoliosis. This lumbosac- posterior spinal fusion, posterior fusion with or without
ral deformity is best treated surgically (usually with instrumentation, hemivertebra excision, and spine os-
hemivertebrectomy) at an early age before the compen- teotomies. Expansion thoracoplasty, a new approach to
satory curve becomes fixed. surgery for congenital scoliosis, is indicated for very
Defects of segmentation result in an osseous bridge young patients who either have or will potentially have
between two or more vertebrae, either unilaterally or thoracic insufficiency syndrome. It consists of lengthen-
involving the entire segment. The combination of unilat- ing the concave hemithorax with rib distraction by
eral failure of segmentation and contralateral hemiver- means of a prosthetic rib distractor (Figure 4). This re-
tebra carries the worst prognosis in congenital scoliosis sults in increased growth of both the concave and con-
because it produces the most severe and rapidly pro- vex sides of the curve, thus allowing additional volume
gressive deformity. Curves of this kind located in the for growth of the underlying lungs. This technique, cur-
thoracolumbar spine can be expected to exceed 50 by rently undergoing clinical trials, appears very promising.
the age of 2 years. Without treatment, patients with tho- In patients with severe congenital spinal deformities,
racolumbar, midthoracic, or lumbar curves experience slow gradual correction has recently been reported to
severe deformity at an early age. Rib fusions that ac- be successful in some individuals using preoperative
Figure 4 A, Radiograph of a 4-month-old girl with congenital scoliosis, fused ribs, and a unilateral unsegmented bar. B, Radiograph of the same patient at age 11 years. After
several expansion thoracoplasty procedures, the patients hemithorax is increased in size beyond that expected with no intervention.
halo traction for 6 to 12 weeks. If this method is used, the two. In contrast to congenital scoliosis, failure of seg-
very close monitoring for any neurologic change (numb- mentation in congenital kyphosis is less common and
ness, tingling, and weakness) is essential. When partial produces much less deformity than failure of formation.
correction is obtained or a plateau has been reached, In type 1 kyphosis, there is a partial (or complete) defi-
the spine is stabilized by instrumentation and fusion. ciency of the vertebral body, but the posterior elements
Few patients with congenital scoliosis secondary to a remain present. With growth, a relentless progression in
hemivertebra need to have the hemivertebra excised. the kyphosis occurs, leading to anterior impingement on
The main indication for hemivertebra excision is a fixed the spinal cord. When this type of deformity is diag-
decompensation in a patient in whom adequate align- nosed, plans for surgical intervention should begin im-
ment cannot be achieved through other procedures mediately because of the risk of neurologic deficits.
(usually involving a hemivertebra of the fourth or fifth In type 2 kyphosis, the anterior portion of two or
lumbar level). Although a combined anterior and poste- more adjacent vertebral bodies are fused, which leads to
rior resection has been the standard procedure for a deformity that is less progressive, produces less defor-
hemivertebra excision, several recent studies report suc- mity, and has a much lower risk of paraplegia than that
cess with excision through a posterior approach only, seen in patients with type 1 kyphosis.
with correction maintained using transpedicular instru- When imaging congenital kyphosis, MRI will pro-
mentation. vide the clearest picture of the spinal cord and, in very
young patients, the clearest picture of the vertebral bod-
Congenital Kyphosis ies. Cord compression may be evident on MRI before
Congenital kyphosis represents an abrupt posterior an- any clinical neurologic deficits. Three-dimensional imag-
gulation of the spine resulting from a localized congeni- ing of the spine using CT scan reconstructions is useful
tal malformation of one or more vertebrae. This defor- for the evaluation of the vertebral anomalies, especially
mity is caused either by defects of formation (type 1), in the older child. Both tests should be obtained before
defects of segmentation (type 2), or a combination of any surgical intervention.
Because nonsurgical treatment has no beneficial ef- Patients usually present with pain localized to the
fect on congenital kyphosis, the use of an orthotic de- low back that is usually aggravated by extension activi-
vice is inappropriate. In patients with type 1 kyphosis, ties and relieved by rest. Radiation of the pain into the
surgical intervention should be considered, even in the buttocks or posterior thighs is uncommon and a neuro-
infant, with the primary goal being prevention of future logic deficit is rare. Unless the slippage is high grade, the
paraplegia. If the deformity is recognized in patients back alignment appears normal and no localized tender-
younger than age 3 to 5 years and before the kyphosis ness is present. Hamstring tightness may be present and
exceeds 50, simple posterior fusion without instrumen- can lead to a shortened stride length. In patients with a
tation may be considered. A hyperextension cast is used high-grade slip, the buttocks may appear flattened, a
postoperatively for 4 to 6 months followed by a thora- step-off may be palpable between the area of the unaf-
columbosacral orthosis for another 6 months. This ap- fected lumbar spine and loose posterior elements, the
proach may allow for some growth anteriorly in the ab- torso may appear short, and an olisthetic scoliosis may
normal region of the spine, which, over time, may result be present. L5 or S1 nerve root compression symptoms
are rare.
in progressive improvement in the localized kyphosis.
Spondylolisthesis is always evident on an upright lat-
Alternatively, in patients with kyphosis that exceeds 50,
eral radiograph of the lumbosacral junction, but spondy-
an anterior release with strut graft must accompany the
lolysis may be difficult to visualize. If suspicion of
posterior fusion. In the older child or the adult, com-
spondylolysis is high, oblique lumbar radiographs
bined anterior and posterior arthrodesis is mandatory.
should demonstrate sclerosis, elongation, or a distinct
defect in the pars interarticularis. If these radiographs
Rotatory Dislocation are not conclusive, single photon emission CT may dem-
Segmental spinal dysgenesis, congenital dislocation of onstrate increased uptake in patients with recent
the spine, and congenital vertebral displacement of the spondylolysis or prefractured stressed regions, but may
spine are conditions that create the most severe local- be normal in patients with established spondylolysis. CT
ized kyphosis of the spine and lead to a neurologic defi- will definitively demonstrate the occult fracture that
cit in 50% to 60% of patients. These conditions can be may not be evident on oblique radiographs. MRI is not
difficult to differentiate from one another. The deformi- needed for diagnosis.
ties include severe kyphosis; anterior, posterior, or lat- The two most common types of spondylolysis seen
eral subluxation of the spine; and scoliosis in association in children are isthmic and dysplastic spondylolysis. Isth-
with a severely stenotic spinal canal. The treatment re- mic spondylolysis is more common and represents a fa-
quires combined anterior and posterior spinal fusion be- tigue fracture of the pars interarticularis. The dysplastic
cause posterior fusion alone is insufficient to achieve type occurs only at L5-S1 and results from congenital
solid arthrodesis in patients with these types of congeni- dysplasia of the L5-S1 facet joints. Patients with this
tal instabilities. Exploration and augmentation of the type of spondylolysis have an elongated pars interarticu-
posterior fusion mass should be considered because of a laris and are more prone to developing neurologic
high occurrence of pseudarthrosis. No sudden correction symptoms and deformity during growth.
should be attempted in older patients with severe angu- Traditionally, radiographic sagittal descriptions of
lar kyphosis and progressive neurologic deficit. Function spondylolisthesis have involved the Meyerding classifi-
must be favored over cosmetic appearance. Neurosurgi- cation (grades I through IV) and the slip angle. The
cal decompression should be used only for patients with Meyerding classification measures the forward transla-
tion of L5 on the sacrum. The slip angle measures the
a proven recent and progressive neurologic deficit.
sagittal rotation of L5 on the sacrum and reflects the lo-
calized kyphosis at this junction, increasing in higher-
Spondylolysis and Spondylolisthesis grade deformities (Meyerding grade IV or spondy-
Spondylolysis is a defect of one or both of the pars in- loptosis). Pelvic incidence, a newer radiographic
terarticularis in the posterior element of a lower lumbar measurement that assesses the sacral anatomy and its
vertebra. Although it generally results from repetitive relationship to the pelvis and spine balance, appears to
stress to the pars interarticularis, it can occur abruptly. be more predictive of spondylolisthesis progression. It
Seen in 4% to 6% of the general population, spondylo- describes the obliquity of the sacrum to the pelvis and is
lysis has a predilection in those whose activities involve measured on the lateral radiograph by the angle be-
increased hyperextension of the lumbar spine. The con- tween the line perpendicular to the middle of the sacral
dition primarily affects L5 (in 87% to 95% of patients) plate and the line joining the middle of the sacral plate
and less frequently L4 (in up to 10%) and L3 (in up to to the center of the acetabular axis (femoral heads)
3%). Spondylolisthesis represents a forward slippage of (Figure 5). This fixed angle is significantly larger in
all or part of one vertebra on another and in children is those patients with higher-grade deformities (when
nearly always located between L5 and the sacrum. compared with those with low-grade slips and control
lolysis. Mild scoliosis is present in 15% of patients, but Danielsson A: Back pain and function 23 years after fu-
the neurologic examination is almost always normal. sion for adolescent idiopathic scoliosis: A case control
Radiographic features of Scheuermanns disease in- study. Part II. Spine 2003;28:E373-E383.
clude kyphosis exceeding 45, with the apex usually in This is a study of 142 patients who had posterior spinal fu-
the middle to lower thoracic spine. If the exaggerated sion and instrumentation using Harrington rods at a minimum
20-year follow-up; these patients were compared with 100 age-
kyphosis is mild, then other accompanying features
and sex-matched control subjects. Patients with scoliosis had
must be recognized to differentiate Scheuermanns dis-
significantly more degenerative disk changes and lumbar pain
ease from postural kyphosis. These include anterior
than control subjects (65% versus 47%, respectively). How-
wedging of three or more adjacent vertebrae in the api- ever, only 25% of patients who underwent fusion had daily
cal region, end plate irregularities, and narrowing of disk pain, and there were no differences in back function or gen-
spaces. Schmorls nodes (herniation of the disk into the eral health-related quality of life. Patients who underwent fu-
vertebral end plate) are occasionally present. Hyperex- sion also reported pain over their iliac crest incisions when it
tension lateral radiographs are also helpful in differenti- was made separately.
ating Scheuermanns disease from postural kyphosis be-
cause the apical region in patients with Scheuermanns Dobbs M, Lenke LG, Szymanski DA, et al: Prevalence
disease will remain relatively inflexible. Preoperative of neural axis abnormalities in patients with infantile id-
MRI can be used to rule out disk herniation if neces- iopathic scoliosis. J Bone Joint Surg Am 2002;84:2230-
sary. 2234.
Nonsurgical treatment consists of exercises and brac- This multicenter study analyzed 46 consecutive patients
ing. Although exercises can help alleviate thoracic and between 1992 and 2000 with infantile idiopathic scoliosis and a
lumbar discomfort, they will not result in improvement curve magnitude greater than or equal to 20. Ten of the 46
of the kyphosis. Bracing has been reported to be effec- patients (21%) had evidence of neural axis abnormalities on
tive in improving moderate deformity, but lack of pa- MRI. Eight of these 10 patients had neurosurgical treatment
of these abnormalities.
tient compliance is a primary limitation.
Surgical indications include large deformities
(> 70), curve progression, persistent pain despite non- Kuklo TR, Lenke LG, Graham EJ, et al: Correlation of
surgical treatment, and, most importantly, genuine cos- radiographic, clinical, and patient assessment of shoul-
metic concerns of the patient. Over the past 15 years, der balance following fusion versus nonfusion of the
anterior release followed by posterior instrumentation proximal thoracic curve in adolescent idiopathic scolio-
sis. Spine 2002;27:2013-2020.
and fusion has been most commonly used. However, re-
In this retrospective review of 112 patients who underwent
cent reports documenting the success of posterior fusion surgical treatment for a double thoracic curve pattern, the au-
alone, particularly with the use of threaded 4.8-mm thors evaluated T1 tilt, clavicle angle, coracoid height differ-
compression rods, may obviate the need for additional ence, trapezius length, first rib-clavicle height difference, shoul-
anterior surgery. Progressive localized kyphosis above der asymmetry as measured by soft-tissue shadows on
or below the fusion can be avoided if the implant ex- radiographs, and the translation of the structural curves. They
tends from the second thoracic vertebra proximally to reported that the clavicle angle was the best preoperative pre-
one level beyond the first lordotic lumbar disk space in- dictor of postoperative shoulder balance.
feriorly and if the correction is not excessive (> 50%).
Lenke LG, Betz RR, Harms J, et al: Adolescent idio-
Annotated Bibliography pathic scoliosis: A new classification to determine extent
of spinal arthrodesis. J Bone Joint Surg Am 2001;83:
Idiopathic Scoliosis 1169-1181.
Asher M, Min Lai S, Burton D, Manna B: The reliability This study introduced the new scoliosis classification,
and concurrent validity of the Scoliosis Research which includes the following three components: curve type,
Society-22 patient questionnaire for idiopathic scoliosis. lumbar spine modifier, and a sagittal thoracic modifier. The
Spine 2003;28:63-69. authors who developed the new system and seven randomly
selected surgeons from the Scoliosis Research Society then
Asher M, Min Lai S, Burton D, Manna B: Scoliosis Re- tested its reliability. The interobserver and intraobserver cap
search Society-22 patient questionnaire: Responsiveness of values for the components of the classification were ana-
to change associated with surgical treatment. Spine lyzed and demonstrated good interobserver and intraobserver
2003;28:70-73. reliability.
These two studies confirm the reliability and validity of
the SRS-22 questionnaire when compared with the SF-36. The Liljenqvist UR, Allkemper T, Hackenberg L, Link TM,
authors conclude that the SRS-22 is responsive to changes in Steinbeck J, Halm HF: Analysis of vertebral morphol-
the postoperative period. ogy in idiopathic scoliosis with use of magnetic reso-
nance imaging and multiplanar reconstruction. J Bone or juvenile idiopathic scoliosis. The authors concluded that
Joint Surg Am 2002;84:359-368. convex epiphysiodesis together with Luque trolley instrumen-
The authors analyzed the morphology of the thoracic pedi- tation may slow down or improve progressive infantile or ju-
cles in 307 vertebrae using MRI in multiplanar reconstruction. venile idiopathic curves.
Maximum intravertebral deformity at the apex of the curve
was noted, with transverse endosteal width of the apical pedi- Richards BS: Delayed infections following posterior spi-
cles between 2.3 to 3.2 mm on the concavity and 3.9 to 4.4 mm nal instrumentation for the treatment of idiopathic
on the convexity. scoliosis. J Bone Joint Surg Am 1995;77:524-529.
Ten patients (average age, 25 months) with delayed treat-
Merola AA, Haher TR, Brkaric M, et al: A multi-center ment of deep wound infections were observed after undergo-
study of the outcomes of the surgical treatment of ado- ing posterior instrumentation for adolescent idiopathic scolio-
lescent idiopathic scoliosis using the Scoliosis Research sis. The authors reported that the patients usually had
Society (SRS) Outcome Instrument. Spine 2002;27:2046- drainage from the wound, fluctuance, and mildly elevated
2051. erythrocyte sedimentation rates and were treated using instru-
This multicenter study measured outcomes following sur- mentation removal, primary wound closure, and short-term
gical treatment of adolescent idiopathic scoliosis in 242 pa- administration of antibiotics. The authors also discuss the im-
tients. Outcome categories included improvement from preop- portance of longer culture incubation to identify the infectious
erative pain, general self-image, function from back condition, organisms.
and level of activity. Overall, the patients were satisfied with
the results of surgery. The authors concluded that preoperative Richards BS, Sucato DJ, Konigsberg DE, Ouellet JA:
pain is typically present in patients with adolescent idiopathic Comparison of reliability between the Lenke and King
scoliosis, and it improves significantly following surgical treat- classification systems for adolescent idiopathic scoliosis
ment. using radiographs that were not premeasured. Spine
2003;28:1148-1157.
Newton PO, Betz R, Clements DH, et al: Anterior tho- Four surgeons analyzed 50 radiographs that had not been
racoscopic instrumentation: A matched comparison to premeasured and assigned a classification using both the King
anterior open instrumentation and posterior open in- and the Lenke classification. The intraobserver and interob-
strumentation. 70th Annual Meeting Proceedings. Rose- server reliability of the King classification were 83.5% and
mont, IL, American Academy of Orthopaedic Surgeons, 68.0%, respectively. These values were similar when only the
2003. Lenke curve types were analyzed; however, when the com-
This multicenter study compared three treatment ap- plete classifications were assigned (curve type, lumbar modi-
proaches (thoracoscopic, open anterior, and posterior) for pa- fier, and thoracic sagittal modifier), there was fair intraob-
tients with right thoracic curves. The radiographic and func- server and interobserver reliability (65.0% and 55.5%,
tional outcomes were similar for the three approaches; respectively).
however, the patients who had thoracoscopic anterior instru-
mentation and fusion had longer surgical times. Sucato DJ, Duchene C: The position of the aorta rela-
tive to the spine: A comparison of patients with and
Ouellet JA, LaPlaza J, Erickson M, Birch JG, Burke S, without idiopathic scoliosis. J Bone Joint Surg Am 2003;
Browne R: Sagittal plane deformity in the thoracic 85:1461-1469.
spine: A clue to the presence of syringomyelia as a Axial T1-weighted MRI scans of the thoracic and lumbar
cause of scoliosis. Spine 2003;28:2147-2151. spine were compared for normal control subjects and patients
Thirty patients with scoliosis and documented evidence of with right idiopathic scoliosis. The aorta was positioned more
syringomyelia were compared with 54 patients with adolescent laterally and posteriorly to the vertebral bodies in patients
idiopathic scoliosis and a normal MRI. The authors analyzed with idiopathic scoliosis, which was in line with a well-placed
the lateral radiographs for the presence or absence of Dickson vertebral body screw and would be in jeopardy of a laterally
apical lordosis. Apical lordosis was seen in 97% of patients misplaced left pedicle screw.
with adolescent idiopathic scoliosis and normal MRI scan,
whereas only 25% of patients with syringomyelia-associated Sucato DJ, Elerson E: A comparison between the prone
scoliosis had apical lordosis. and lateral position for performing a thoracoscopic an-
terior release and fusion for pediatric spinal deformity.
Pratt R, Webb JK, Burwell RG, Cummings SL: Luque Spine 2003;28:2176-2180.
trolley and convex epiphysiodesis in the management of The technique of an anterior thoracoscopic release using a
infantile and juvenile idiopathic scoliosis. Spine 1999;24: regular endotracheal tube is described, with ventilation of
1538-1547. both lungs with lower tidal volumes. The patient is positioned
The authors reported 5-year follow-up of patients in whom prone. When compared with patients who underwent this pro-
either a Luque trolley alone or a Luque trolley together with a cedure in the lateral position (double lumen endotracheal
convex epiphysiodesis was used to treat progressive infantile tube for single-lung ventilation), the anesthesia preparation
time and the delay between the anterior and posterior proce- normal respiration or lung growth, which is caused by a rare
dure were both shorter and there were fewer respiratory com- condition of multiple fused ribs and congenital scoliosis.
plications (in 0 versus 14.8% of patients).
Kim YJ, Otsuka NY, Flynn JM, et al: Surgical treatment
Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER: Thoracic of congenital kyphosis. Spine 2001;26:2251-2257.
pedicle screw fixation in spinal deformities: Are they re- In this study, 26 patients were retrospectively reviewed.
ally safe? Spine 2001;26:2049-2057. The authors found a low rate of pseudarthrosis even without
This study analyzed 462 patients who had 4,604 thoracic routine augmentation of the fusion mass if instrumentation
screws placed to treat spinal deformity. Neurologic complica- was used. They report that although gradual correction of ky-
tions directly related to the screws occurred in four patients phosis occurs with growth in patients younger than 3 years of
(0.8%), one of whom had transient paraparesis and three had age with type II and type III deformities after posterior fusion,
dural tears. The authors concluded that thoracic pedicle screw it appears to be unpredictable.
fixation is safe when treating spinal deformity.
Klemme WR, Polly DW, Orchowske JR: Hemivertebral
Weinstein SL, Dolan LA, Spratt KF, Peterson KK, excision for congenital scoliosis in very young children.
Spoonamore MJ, Ponseti IV: Health and function of pa- J Pediatr Orthop 2001;21:761-764.
Six children (average age, 19 months) underwent anterior-
tients with untreated idiopathic scoliosis. JAMA 2003;
posterior hemivertebra excision. Correction was maintained
289:559-567.
with plaster immobilization for 3 months. The authors reported
In this prospective natural history study, 117 patients with
that excellent improvements in the curves were obtained and
untreated scoliosis were compared with 62 age- and sex-
maintained at a minimum 2-year follow-up.
matched control subjects. The minimum follow-up was 50
years, and multiple parameters were evaluated. The probabil-
ity of survival was similar between the two groups, however, McMaster MJ, Singh H: The surgical management of
the incidence of shortness of breath and chronic back pain congenital kyphosis and kyphoscoliosis. Spine 2001;26:
were greater in patients with scoliosis. 2146-2154.
In this study, 65 patients with congenital kyphosis or ky-
phoscoliosis were treated with spine arthrodesis. The authors
concluded that all patients with type I or type III congenital
Congenital Spinal Deformities kyphosis or kyphoscoliosis should be treated using posterior
Basu PS, Elsebaie H, Noordeen MH: Congenital spinal arthrodesis before age 5 years and before the kyphosis ex-
deformity: A comprehensive assessment at presentation. ceeds 50. If the kyphosis does not reduce to less than 50, an
Spine 2002;27:2255-2259. anterior release and arthrodesis using strut grafting is needed
A series of 126 consecutive patients with congenital spinal before posterior arthrodesis can be done.
deformity were assessed for incidence of intraspinal anomaly.
This incidence was found in 37% of patients (26% of patients
had cardiac defects and 21% had urogenital anomalies). The
Ruf M, Harms J: Hemivertebra resection by a posterior
approach: Innovative operative technique and first re-
authors concluded that MRI and echocardiography should be
sults. Spine 2002;27:1116-1123.
an essential part of the evaluation of patients with congenital
In this retrospective study, 21 consecutive patients with
spinal deformity.
congenital scoliosis were treated with hemivertebra resection
using a posterior approach only with transpedicular instru-
Campbell RM, Hell-Vocke AK: Growth of the thoracic mentation. Early surgery is recommended to avert severe local
spine in congenital scoliosis after expansion thoraco- deformities, to prevent secondary structural changes, and to
plasty. J Bone Joint Surg Am 2003;85:409-420. avert extensive fusions.
Expansion thoracoplasty consists of osteotomizing fused
ribs on the concavity of the spine followed by expansion of the Sink EL, Karol LA, Sanders J, et al: Efficacy of periop-
chest cage using a vertical, expandable prosthetic titanium rib erative halo-gravity traction in the treatment of severe
implant. The authors reported that longitudinal growth of the scoliosis in children. J Pediatr Orthop 2001;21:519-524.
spine was achieved using this technique, likely providing addi- Perioperative halo traction was used in 19 patients, includ-
tional volume for growth of the underlying lungs. ing those with congenital scoliosis. The technique improved bal-
ance and frontal and sagittal alignment. No neurologic compli-
Campbell RM, Smith MD, Mayes TC, et al: The charac- cations occurred.
teristics of thoracic insufficiency syndrome associated
with fused ribs and congenital scoliosis. J Bone Joint Sturm PF, Chung R, Bormze SR: Hemivertebra in
Surg Am 2003;85-A:399-408. monozygotic twins. Spine 2001;26:1389-1391.
This landmark article introduces and defines thoracic in- This is a report on two monozygotic female twins with tho-
sufficiency syndrome, the inability of the thorax to support racic hemivertebrae that led to scoliosis.
Suh SW, Sarwark JF, Vora A, et al: Evaluating congeni- Papagelopoulos PJ, Klassen RA, Peterson HA, et al:
tal spine deformities for intraspinal anomalies with mag- Surgical treatment of Scheuermanns disease with seg-
netic resonance imaging. J Pediatr Orthop 2001;21:525- mental compression instrumentation. Clin Orthop 2001;
531. 386:139-149.
In this study, 41 children with congenital spinal deformities Twenty-one patients with kyphotic deformities of 50 or
underwent MRI. Evidence of intraspinal anomalies were visi- greater underwent posterior compression instrumentation.
ble for 31% of the patients, including tethered cord, syringo- Seven patients also had anterior release. The authors con-
myelia, and diastematomyelia. The authors recommend MRI cluded that the use of the posterior procedure by itself pro-
as part of the initial evaluation, even in the absence of clinical vided significant correction, thereby avoiding the development
findings. of any secondary deformity in most patients.