European Surgical Orthopaedics and Traumatology

George Bentley
Editor
European Surgical
Orthopaedics and
Traumatology
The EFORT Textbook
1 3Reference
European Surgical Orthopaedics
and Traumatology
European Federation of National Associations
of Orthopaedics and Traumatology
Committees and Task Forces
EFORT Executive Committee Ethics Committee

Mr. Michael Benson
Executive Board
Dr. Manuel Cassiano Neves President EA & L Committee
Ass. Prof. Dr. Per Kjaersgaard-Andersen, Prof. Dr. Wolfhart Puhl
Secretary General Finance Committee
Prof. Dr. Pierre Hoffmeyer, Immediate Past Prof. Dr. Maurilio Marcacci
President
Mr. Stephen R. Cannon, 1st Vice President Health Service Research
Committee
Prof. Dr. Enric Caceres Palou, 2nd Vice President Prof. Dr. Karsten Dreinhofer
Prof. Dr. Maurilio Marcacci, Treasurer Portal Steering Committee
Prof. Dr. Klaus-Peter Gunther, Member at Large Prof. Elke Viehweger
Dr. George Macheras, Member at Large
Prof. Dr. Philippe Neyret, Member at Large Publications Committee
Prof. Dr. George Bentley
Co-Opted Members
Mr. John Albert Scientific Congress Committee
Mr. Michael Benson Prof. Dr. Enric Caceres Palou
Prof. Dr. Thierry Begue Speciality Society Standing
Committee
Prof. Dr. George Bentley, Past President Dr. Matteo Denti
Prof. Dr. Nikolaus Bohler, Past President
Dr. Matteo Denti
Prof. Dr. Karsten Dreinhofer
Task Forces and Ad Hoc
Committees
Prof. Dr. Pavel Dungl Awards & Prizes Committee
Prof. Dr. Norbert Haas Prof. Dr. George Bentley
Prof. Dr. Karl Knahr
Fora
Prof. Dr. Wolfhart Puhl, Past President
Prof. Dr. Thierry Begue
Prof. Dr. Nejat Hakki Sur
Prof. Dr. Karl-Goran Thorngren, Past President Travelling & Visiting
Fellowships
Prof. Dr. Philippe Neyret
Scientific Coordination 15th EFORT Musculoskeletal Trauma Task
Force
Congress, London 2014 Prof. Dr. Norbert Haas
Chairman EFORT Foundation Committee
Mr. Stephen Cannon Prof. Dr. Karl-Goran
Thorngren
Standing Committees
EAR Committee
Prof. Dr. Nikolaus Bohler
Education Committee
Prof. Dr. Klaus-Peter Gunther
George Bentley
Editor
European Surgical
Orthopaedics and
Traumatology
The EFORT Textbook
With 3294 Figures and 278 Tables

Editor
George Bentley
University College London
London, UK
Royal National Orthopaedic Hospital
Stanmore, Middlesex, UK
ISBN 978-3-642-34745-0 ISBN 978-3-642-34746-7 (eBook)

ISBN 978-3-642-34747-4 (print and electronic bundle)
DOI 10.1007/978-3-642-34746-7
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014932431
# EFORT 2014
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Foreword
In recent years, we have seen Europe going through major changes in

different fields, and education is no exception. The search for the best practice
in order to meet the increasing expectations of the patients becomes obliga-
tory in our daily activities, and education plays a major role in achieving
this goal.
EFORT is also conscious that even in well-developed orthopaedic resident
programmes in Europe, there can be considerable inconsistencies in the level
of knowledge that is required to proceed to consultant practice, and we are
also aware that in terms of assessment at the end of training there is also
a wide variation.
A decade ago, Jacques Duparc took the first initiative of providing
a European view in the orthopaedic speciality by publishing Surgical
Techniques in Orthopaedics and Traumatology. Presently, we are witnessing
constant changes in many aspects of our lives in Europe and especially in
orthopaedics and traumatology. During the last years, we have seen major
improvements in our field; so we thought it was the time to provide an updated
comprehensive textbook covering the major fields of current importance.
This book will provide a major source for all trainees in the preparation for
their end-of-training examinations and assessments but also to all others
involved in the practice of our speciality. The launch of the textbook
European Surgical Orthopaedics and Traumatology offers a new perspective
in terms of Orthopaedic education and will contribute to the minimizing of the
variations still seen throughout Europe.
The European flavour provided by the most prominent orthopaedic and
traumatology surgeons from different countries will allow for the develop-
ment of the best current practice across Europe and enhance the process of
harmonization of orthopaedic education. The standardization of the minimal
requirements for the training in orthopaedics and traumatology has been one
of the major goals of EFORT, and this textbook will provide important
guidance in this sense.
It would have been impossible to launch this textbook/encyclopaedia
without the participation of a multitude of anonymous people that have
contributed to it in a disinterested way, but I have to thank especially the
Editor, George Bentley, for his tremendous work. Without his tenacity,
commitment, vision and most of all his expertise and hard work, it would
have been impossible to arrive at the stage of publication. Also a special
thanks to our publisher Springer and their team for their professionalism.
v
vi
Foreword
As President of EFORT, I am very proud of this major achievement and

I trust that this book will be useful for both trainees and specialists in their
current practice as well as in expanding their knowledge and surgical
horizons.
Manuel Cassiano Neves/Lisbon, 2014

EFORT President 20132014
Preface
This EFORT textbook was developed by the Executive Committee following

the excellent Surgical Techniques in Orthopaedics and Traumatology edited
by Prof. Jacques Duparc a decade ago.
Following discussions with two major publishers, we were assured that
a hard copy textbook/encyclopedia would fill an important niche in the
surgical literature.
Our aim was to produce a text which would act as a surgical techniques
guide, but also embrace the total management of the patients which, it is now
realised, is vital to best surgical practice and maximal patient outcomes.
I was very enthusiastic because, as an Englishman with some exposure to
European literature and practice, I realised this book would present an
exciting opportunity to bring together and publicise the rich variety and
quality of clinical practice, research, and literature available in Europe,
which was not fully appreciated by much of the English-speaking world.
The layout of the book is traditional in some ways, but I was anxious
that all the authors should present their views in their own personal style.
Therefore the book is arranged in 10 sections and the chapters have a common
overall format. Each chapter has a contents section for easy checking and
keywords, but the flavour of the authors professional approach to the topic
is apparent from reading each individual chapter.
Hence, this book is a unique collection of chapters on all the major
conditions we deal with in orthopaedics and traumatology, presented in
a lively way and embracing many well-tested techniques and management
protocols.
The overall aim was to produce a source (major reference work) which will
be equally valuable to trainees, all those involved in education and training,
and those whose profession is in a general rather than super-specialised
practice. Hence each chapter has sub-sections on, literature, relevant basic
sciences, clinical assessment, indications for surgery, pre-operative planning,
surgical techniques, post-operative management, rehabilitation, complica-
tions and outcomes.
I must pay tribute to the Section Editors who have been excellent and
without whom the book would not have been started, let alone written. Here
I must mention particularly Franz Langlais, who was tragically taken from us
early on. Their expertise and enthusiasm have been invaluable. Nevertheless,
because of the requirement to have a common approach and theme, and
vii
viii
Preface
conscious that many authors are not primary English speakers, I thought it
essential to edit and review the whole text personally. Therefore, any defects
are mine.
Throughout I have had unqualified support from all my colleagues on the
Executive Committee, in particular the supervising Presidents, Karl-Goran
Thorngren, Miklos Szendroi, Pierre Hoffmeyer and Manuel Cassiano Neves,
together with an abundance of useful advice. Per Kjaersgaard-Anderson has
been a tower of strength as my adviser especially in our final preparation and
negotiations.
The actual process of producing such a book is sometimes challenging.
It would not have been possible without my secretary/PA, Rosemary
Radband. Her rapid and expert way of handling data, and some authors,
made it possible. The Springer team Gabriele Schroeder, Sylvia Blago
and particularly Simone Giesler has been excellent, expert, completely
professional, and a pleasure to work with. Latterly Susan Davenport of
EFORT has given unstinting support.
This task has been a great privilege and pleasure for me. I have come to
appreciate and sometimes wonder at the works of my author colleagues.
My thanks are not sufficient to express my gratitude to you all.
This book may never be published again in hard copy but the E-copy will
be easy to update in future. We now have an authoritative and unique
European base for our future educational programmes which will, I hope,
enrich all our surgical lives.
George Bentley London, 2014

About the Editor
Professor George Bentley D.Sc., MB, ChB, E.C.F.M.G. (USA), ChM,

FRCS (Eng.), FRCS (Ed.), F.Med.Sci.
Professor Bentley is Emeritus Professor of Orthopaedics at University

College London and Honorary Consultant Orthopaedic Surgeon at the
Royal National Orthopaedic Hospital NHS Trust, London.
From 1991 he was Director and Professor of Orthopaedics, in the Institute
of Orthopaedics and Musculo-Skeletal Science, University College London
(UCL), and Director of Clinical Studies at the Royal National Orthopaedic
Hospital, Stanmore.
His training in Orthopaedics and Traumatology was in the University
Hospitals of Sheffield, Birmingham, Manchester, Pittsburgh (USA) and
Oxford, where he was University Reader in Orthopaedics, before spending
6 years as Professor of Orthopaedic and Accident Surgery in the University of
Liverpool and the Royal Liverpool and Childrens Hospitals.
From 1982 he took up the only Chair of Orthopaedics in the University of
London, based at the Royal National Orthopaedic and Middlesex Hospitals.
His pioneering research in cell-engineering, on successful transplantation
of articular and growth-plate chondrocytes in both normal and arthritic knee
joints, published in Nature in 1971, laid the foundation of present-day human
cell-engineering, now a worldwide clinical field.
Clinically, he established major units for hip and knee joint replacement
and the first cartilage cell transplantation unit in the UK. He has completed
10 randomised controlled clinical trials in scoliosis, hip and knee joint
replacement and cartilage cell transplantation.
He is a renowned surgical educator, having won the Golden Stethoscope
awarded to the best clinical teacher, in the University of Oxford. In London, at
ix
x
About the Editor
RNOH, he established the largest postgraduate training programme in the

UK, which trains 25 % of orthopaedic and trauma surgeons in Britain. During
his time as elected Fellow and Vice-President on the Council of the Royal
College of Surgeons of England, he chaired the Training Board, responsible
for supervision of all surgical training in the England and Wales. Simulta-
neously he was Chairman of the Intercollegiate Examinations Board for the
UK qualifying diploma of F.R.C.S. (Tr. and Orth.), from 1996 to1999.
He founded an orthopaedic educational programme at RNOH and associ-
ated hospitals which, over 3 years, covers all aspects of Orthopaedics and
Traumatology, and an M.Sc. degree course of London University.
Undergraduate teaching and examination has been a continuing lifelong
commitment in Sheffield, Birmingham, Manchester, Oxford, Liverpool and
UCL Medical Schools.
The Institute of Orthopaedics and Musculo-Skeletal Science employs
100+ scientific and clinical staff and is funded by the research councils and
charitable institutions. Professor Bentley and his colleagues have published
over 500 peer-reviewed scientific papers and he has presented over 500
lectures at universities and specialist centres worldwide.
He has written three major textbooks and contributed chapters to many
other orthopaedic and trauma texts.
In 1985 he was elected President of the British Orthopaedic Research
Society, and in 1990 Vice-President and President of the British Orthopaedic
Association. In 1995 he was elected Chairman of the Scientific Committee of
EFORT and was responsible for developing the scientific programmes of the
Barcelona Congress and subsequent congresses and instructional courses
across Europe.
Through 2002 to 2005 he served as Vice-President and President of
EFORT.
Currently, as Chairman of the Scientific Publications Committee of
EFORT, he has developed educational programmes and a curriculum for
trainees, especially those who wish to sit the European Board of Orthopaedics
and Traumatology (EBOT) examination. Additionally, he has edited the
EFORT Instructional Course Lecture Books for the last 5 years.
As well as being a member and reviewer for many scientific
journals JBJS, BJJ, BJr, Journal of Orthopaedic Research, British Medical
Journal, Lancet, Journal of Rheumatology, Biomaterials, The Knee etc. he
has been European Editor-in-Chief of the Journal of Arthroplasty since 2001.
In 1999 he was elected Honorary Fellow Membre dHonneur of the
Societe Francaise de Chirurgie Orthopedique et Traumatologique (S.O.F.C.O.T.)
and of the Royal College of Surgeons of Edinburgh. He was the first
orthopaedic surgeon to be elected to the prestigious Fellowship of the
Medical Academy of Science, London, and, in 2009, to the Honorary fellowship
of the Royal Society of Medicine.
He is married to Ann and they have one daughter, Sarah, and two sons,
Paul and Stephen.
Section Editors
General Orthopaedics and Traumatology

George Bentley University College London, London, UK
Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
Karl-Goran Thorngren Department of Orthopaedics, Lund University
Hospital, Lund, Sweden
Spine
Bjorn Stromqvist Department of Orthopedics, Skane University Hospital,
Malmo, Sweden
Shoulder
Pierre Hoffmeyer University Hospitals of Geneva, Geneva, Switzerland
Arm, Elbow and Forearm

Konrad Mader Section Trauma Surgery, Hand and Upper Extremity
Reconstructive Surgery, Department of Orthopaedic Surgery, Frde
Sentralsjukehus, Frde, Norway
Hand and Wrist

Frank Burke The Pulvertaft Hand Centre, Derbyshire Royal Hospital,
Derby, UK
xi
xii Section
Editors

Pelvis and Hip

Klaus-Peter G unther Department of Orthopaedic Surgery, University
Hospital Carl Gustav Carus Dresden, Medical Faculty of the Technical
University Dresden, Dresden, Germany
Thigh, Knee and Shin

Nikolaus Bohler Orthopadische Abteilung, Allgemeines Krankhaus Linz,
Linz, Austria
Ankle and Foot

Dishan Singh Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
Musculo-Skeletal Tumours
Stephen Cannon Clementine Churchill Hospital, Harrow, Middlesex, UK
Sarcoma Unit, Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
George Bentley Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
Paediatric Orthopaedics and Traumatology

Aresh Hashemi-Nejad Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
Manuel Cassiano Neves Orthopaedic Department, Hospital Cuf
Descobertas, Parque das Nacoes, Lisboa, Portugal
Contents
Volume 1
Part I General Orthopaedics and Traumatology . . . . . . . . . .

1
Musculo-Skeletal
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Philippa Tyler and Asif Saifuddin
Operating Theatres and Avoidance of Surgical Sepsis . . . . . . .
63
Paolo Gallinaro, Elena Maria Brach del Prever, Alessandro Bistolfi,
Antonio Odasso, Matteo Bo, and Carlo Marco Masoero
Bone Autografting, Allografting and Banking . . . . . . . . . . . . . .
77
Tom Van Isacker, Olivier Cornu, Olivier Barbier,
Denis Dufrane, Antoine de Gheldere, and Christian Delloye
Bone Substitutes in Clinical Practice . . . . . . . . . . . . . . . . . . . . . .
91
Jari Salo
Organisational Aspects of Trauma Care . . . . . . . . . . . . . . . . . . .
97
Imran Anwar, Dan Butler, and Keith Willett
Classification of Long Bone Fractures . . . . . . . . . . . . . . . . . . . . .
115
Thierry Rod Fleury and Richard Stern
Non-Operative Treatment of Long Bone Fractures
in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 139
J. Fabry and Pierre-Paul Casteleyn
External Fixation in Fracture Management . . . . . . . . . . . . . . . .
159
Peter Calder
Fractures with Arterial
Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Panayotis N. Soucacos and Zinon T. Kokkalis
Biologics in Open Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 211
Christian Kleber and Norbert P. Haas
Compartment Syndromes in the Lower Limb . . . . . . . . . . . . . .
221
Peter V. Giannoudis, Rozalia Dimitriou, and George Kontakis
Management of Delayed Union, Non-Union and
Mal-Union of Long Bone Fractures . . . . . . . . . . . . . . . . . . . . . . .
241
Gershon Volpin and Haim Shtarker
xiii
xiv
Contents
Necrotising Fasciitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 267
Nikolaos K. Kanakaris and Peter V. Giannoudis
Osteoporosis, Fragility, Falls and Fractures . . . . . . . . . . . . . . . .
281
Karl-Goran Thorngren
Management of Synovial Disorders . . . . . . . . . . . . . . . . . . . . . . .
301
Zois P. Stavrou and Petros Z. Stavrou
Orthopaedic Management of the Haemophilias . . . . . . . . . . . . .
319
Richard Wallensten
Infections in Orthopaedics and Fractures . . . . . . . . . . . . . . . . . .
331
Eivind Witso
Thromboprophylaxis ..................................
365
David Warwick
Surgical
Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
375
John C. Angel
Volume 2
Part II Spine .......................................

405
Applications of Prostheses and Fusion in the
Cervical
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 407
Robert W. Marshall and Neta Raz
Surgical Treatment of the Cervical Spine in
Rheumatoid
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
425
Zdenek Klezl and Jan Stulik
Thoracic Outlet
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
449
Henk Giele
Conservative Management of Spinal Deformity
in
Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 463
Federico Canavese, Dimitri Ceroni, and Andre Kaelin
New Surgical Techniques in Scoliosis .....................
483
Acke Ohlin
Surgical Management of Neuromuscular
Scoliosis .......... 499
J. Brad Williamson
Surgical Management of Adult Scoliosis . . . . . . . . . . . . . . . . . . .
521
Norbert Passuti, G. A. Odri, and P. M. Longis
Spondylolysis With or Without
Spondylolisthesis ........... 533
Philippe Gillet
Microdiscectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 557
Trichy S. Rajagopal and Robert W. Marshall
Contents
xv
Applications of Lumbar Spinal Fusion and Disc
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 581
Spinal Osteotomy Indications and Techniques

............ 609
Enric Ca`ceres Palou
Posterior Decompression for Lumbar Spinal Stenosis . . . . . . . .

625
Franco Postacchini and Roberto Postacchini
Minimally-Invasive Anterior Lumbar Spinal Fusion . . . . . . . . .

643
H. Michael Mayer
Sub-Total and Total Vertebrectomy for Tumours . . . . . . . . . . .

661
Stefano Boriani, Joseph Schwab, Stefano Bandiera,
Simone Colangeli, Riccardo Ghermandi, and
Alessandro Gasbarrini
Computer-Aided Spine Surgery . . . . . . . . . . . . . . . . . . . . . .

. . . . 677
sterman, Timo Yrjonen, and
Teija Lund, Timo Laine, Heikki O
Dietrich Schlenzka
General Management of Spinal

Injuries . . . . . . . . . . . . . . . . . . . 697
Cesar Vincent and Charles Court
Injuries of the Cervical Spine . . . . . . . . . . . . . . . . . . . . .

. . . . . . . 717
Spiros G. Pneumaticos, Georgios K. Triantafyllopoulos, and
Peter V. Giannoudis
Treatment of Thoraco-Lumbar Spinal Injuries . . . . . . . . . . . . .

743
Antonio A. Faundez
Kyphoplasty - the Current Treatment for Osteoporotic

Vertebral
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
761
Guillem Salo
Strategies for Low Back Pain . . . . . . . . . . . . . . . . . . . . . .

. . . . . . 777
Richard Eyb and G. Grabmeier
Treatment of the Aging

Spine ........................... 785
Max Aebi
Infections of the
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801
Jose Guimaraes Consciencia, Rui Pinto, and Tiago Saldanha
Surgical Management of
Spondylodiscitis . . . . . . . . . . . . . . . . . . 813
Maite Ubierna and Enric Caceres Palou
Surgical Management of Tuberculosis of the Spine . . . . . . . . . .

829
Ahmet Alanay and Deniz Olgun
xvi
Contents
Part III Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 845
Biomechanics of the Shoulder ...........................
847
David Limb
Principles of Shoulder Imaging . . . . . . . . . . . . . . . . . . . . . . . . . .
865
S. Shetty and Paul ODonnell
Outcome Scores for Shoulder Dysfunction . . . . . . . . . . . . . . . . .
881
Simon M. Lambert
Traumatic Lesions of the Brachial Plexus . . . . . . . . . . . . . . . . . .
891
Rolfe Birch
Scapular
Dysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
925
Tim Bunker
Snapping
Scapula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
935
Roger J. H. Emery and Thomas M. Gregory
Fractures of the
Scapula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
943
Norbert Suedkamp and Kaywan Izadpanah
Scapulothoracic Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . .
969
Deborah Higgs and Simon M. Lambert
Sternoclavicular Joint and Medial Clavicle Injuries . . . . . . . . .
977
Alistair M. Pace and Lars Neumann
Fractures of the Shaft of the Clavicle . . . . . . . . . . . . . . . . . . . . .
993
Iain R. Murray, L. A. Kashif Khan, and C. Michael Robinson
Acromioclavicular
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1019
Jonas Franke and Lars Neumann
The Fibrous Lock (Skeleton) of the Rotator Cuff . . . . . . . . . . . .
1039
Olivier Gagey
Rotator Cuff Tears-Open Repair . . . . . . . . . . . . . . . . . . . . . . . . .
1043
Tim Bunker
Partial Rotator Cuff Ruptures . . . . . . . . . . . . . . . . . . . . . . . . . . .
1063
Antonio Cartucho
Arthroscopic Management of Full-Thickness Rotator
Cuff
Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1083
Jean-Francois Kempf, Aristote Hans-Moevi, and Philippe Clavert
Inverse/Reverse Polarity Arthroplasty for Cuff Tears with
Arthritis (Including Cuff Tear Arthropathy) . . . . . . . . . . . . . . .
1105
Alexander Van Tongel and Lieven De Wilde
Glenohumeral Instability an Overview ..................
1123
Pierre Hoffmeyer
Contents
xvii
Recurrent Glenohumeral Instability . . . . . . . . . . . . . . . . . . .

. . . 1137
Mark Tauber and Peter Habermeyer
Open Capsuloplasty for Antero-Inferior and
Multi-Directional Instability of the
Shoulder . . . . . . . . . . . . . . . 1153
Pierre Hoffmeyer
Shoulder Instability in Children and Adolescents
........... 1163
Jorn Kircher and Rudiger Krauspe
Frozen
Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1185
Tim Bunker and Chris Smith
Shoulder Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1201
Jean-Luc Jouve, Gerard Bollini, R. Legre, C. Guardia,
E. Choufani, J. Demakakos, and B. Blondel
Resurfacing Arthroplasty of the
Shoulder ................. 1217
Stephen A. Copeland and Jai G. Relwani
Treatment of Proximal Humerus Fractures by Plate
Osteosynthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 1229
David Limb
Intramedullary Nail Fixation of the Proximal Humerus . . . . . .
1247
Carlos Torrens
Fractures of the Proximal Humerus Treated by
Plate Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 1259
Pierre Hoffmeyer
Hemi-Arthroplasty for Fractures of the Proximal
Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1277
Tony Corner and Panagiotis D. Gikas
Humeral Shaft Fractures - Principles of Management
....... 1293
Deborah Higgs
Volume 3
Part IV Arm, Elbow and Forearm . . . . . . . . . . . . . . . . . .

. . . . 1303
Biomechanics of the
Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1305
David Limb
Surgical Anatomy, Approaches and Biomechanics of

the
Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1317
Raul Barco, Jose Ballesteros, Manuel Llusa, and
Samuel A. Antuna
Arthroscopic Techniques in the Elbow . . . . . . . . . . . . . . . . . .

. . 1339
Izaak F. Kodde, Frank T. G. Rahusen, and Denise Eygendaal
xviii
Contents
Distal Biceps and Triceps Avulsions . . . . . . . . . . . . . . . . . . . . . .

1355
R. Amirfeyz and David Stanley
Epicondylitis, Lateral and Medial; Biceps and Triceps
Tendonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1365
Taco Gosens
Acute and Chronic Ligamentous Injury of the Elbow . . . . . . . .
1381
David Cloke and David Stanley
Distal Humerus Fractures 90# Plating . . . . . . . . . . . . . . . . . . .
1395
Klaus Burkhart, Jens Dargel, and Lars P. Muller
Fractures of the Distal Humerus Total Elbow
Arthroplasty (Hemi-Arthroplasty) . . . . . . . . . . . . . . . . . . . . . . .
1407
Lars Adolfsson
Fracture Dislocations of the Elbow - the Elbow Fixator
Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1423
Konrad Mader, Jens Dargel, and Thomas Gausepohl
Fractures of the Olecranon, Radial Head/Neck, and
Coronoid
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1451
Peter Kloen, Thomas Christian Koslowsky, and Konrad Mader
Post-Traumatic Elbow Stiffness - Arthrolysis and
Mechanical
Distraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1479
Konrad Mader and Dietmar Pennig
The Forearm Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1509
Christian Dumontier and Marc Soubeyrand
Surgical Anatomy and Approaches for Fracture Treatment
in the
Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1525
Marc Soubeyrand, Vincent Wasserman, Gregoire Ciais,
Marina Clement-Rigolet, Christian Dumontier, and Olivier Gagey
Monteggia, Galeazzi and Essex-Lopresti Injuries
of the
Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1539
Doug Campbell and David Limb
Peripheral Nerve Injuries and Repair . . . . . . . . . . . . . . . . . . . . .
1555
Tim Hems
Tendon Transfers for Median, Radial and Ulnar
Nerve Palsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1579
Panayotis N. Soucacos, Alexandros Touliatos, and
Elizabeth O. Johnson
Part V Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1595
Surgical Anatomy and Approaches to the Hand and Wrist
... 1597
Panayotis N. Soucacos and Elizabeth O. Johnson
Contents
xix
Arthroscopy of the Wrist . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . 1621
Tommy Lindau and Ash Moaveni
Congenital Hand
Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1653
R. Jose, Mary OBrien, and Frank Burke
Treatment of Distal Radial Fractures . . . . . . . . . . . . . . . . . .
. . . 1675
Philippe Kopylov, Antonio Abramo, Ante Mrkonjic, and
Magnus Tagil
Scaphoid and Carpal Bone Fractures . . . . . . . . . . . . . . . . . . .
. . 1699
Joseph J. Dias and Harvinder Singh
Kienbocks
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1727
Ian A. Trail
Ligamentous Injuries of the
Wrist . . . . . . . . . . . . . . . . . . . . . . . . 1739
Carlos Heras-Palou
The Ulnar Corner (Distal Radio-Ulnar
Joint) .............. 1755
David Warwick and Eleni Balabanidou
Ligamentous Injuries and Instability of the Fingers
and
Thumb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1781
Frank Burke and Mark G. Swindells
Basal Thumb Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1797
Frank Burke and Dan Armstrong
Osteoarthritis of the
Fingers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1811
Tim A. Coughlin and Timothy Cresswell
Swellings of the Hand and
Wrist . . . . . . . . . . . . . . . . . . . . . . . . . 1825
Tim Hems
Hand Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 1847
Tracy Horton
Nerve Compression in the Upper
Limb . . . . . . . . . . . . . . . . . . . . 1885
Frank Burke and A. Barnard
The Management of Painful
Nerves ...................... 1909
David Elliot and H. van Dam
Flexor and Extensor Injuries in the Hand . . . . . . . . . . . . . . . .
. . 1955
Mary OBrien and Frank Burke
Coverage of Traumatic Injuries of the Hand and Wrist . . . . . .
1977
Mikko Larsen, Caroline Bijnen-Girardot, and
Marco J. P. F. Ritt
High Pressure Injection Injuries of the Hand . . . . . . . . . . . . . .
. 2001
Frank Burke
Infections of the Hand . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 2009
Zoe H. Dailiana and Nikolaos Rigopoulos
xx
Contents
Management of Cerebral Palsy in the Upper Limb . . . . . . . . . .

2033
Michael Alan Tonkin
Surgical Management of the Rheumatoid

Hand ............ 2051
Alberto Lluch
Re-Implantation and Amputation of the Digits

and Thumb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 2087
Panayotis N. Soucacos
Volume 4
Part VI Pelvis and Hip ...............................

2105
Total Hip Arthroplasty - Current Approaches . . . . . . . . . . . . . .
2107
Martin Krismer and Michael Nogler
Osteonecrosis of the Femoral Head . . . . . . . . . . . . . . . . . . . . . . .

2133
Paolo Gallinaro, Alessandro Masse`, Angiola Valente, and
C. Cuocolo
Hip Arthroscopy and Treatment of Acetabular Retroversion

and Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 2147
Chris Paliobeis and Richard Villar
Hip Dislocation and Femoral Head Fractures . . . . . . . . . . . . . .

2179
Paul Gillespie, Alessandro Aprato, and Martin Bircher
Fractures of the Femoral Neck and Proximal

Femur ........ 2203
Acetabular
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2269
Gianfranco Zinghi and Lorenzo Ponziani
Fractures and Dislocations of the Pelvic Ring . . . . . . . . . . . . . .

2319
Joerg H. Holstein, D. Koehler, U. Culemann, and Tim Pohlemann
Chiari Osteotomy of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2335
Peter Zenz and Wolfgang Schwagerl
Bernese Peri-Acetabular Osteotomy . . . . . . . . . . . . . . . . . . . . . .

2343
Rafael J. Sierra, Michael Leunig, and Reinhold Ganz
Tribology of Hip Joint Replacement . . . . . . . . . . . . . . . . . . . . . .
2365
Zhongmin Jin and John Fisher
Cementless Total Hip Joint Replacement . . . . . . . . . . . . . . . . . .

2379
Klaus-Peter G
unther, Firas Al-Dabouby, and Peter Bernstein
Cemented Total Hip Replacement . . . . . . . . . . . . . . . . . . . . . . . .

2397
J. R. Morley, R. Barker, and Jonathan R. Howell
Contents
xxi
Exposure of the Hip - Trochanteric Osteotomy,

Re-Attachment and
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2423
B. M. Wroblewski, P. D. Siney, and P. A. Fleming
Hip Replacement for Old Developmental Dysplasia

of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 2441
Xavier Flecher, J. M. Aubaniac, S. Parratte, and
Jean-Noel Argenson
Total Hip Replacement for Ankylosed Hips . . . . . . . . . . . . . . . .
2453
Marcel Kerboull, George Bentley, Luc Kerboull, and
Moussah Hamadouche
Ceramic-on-Ceramic Total Hip Replacement
.............. 2461
Laurent Sedel
Pain Management After Total Hip Replacement . . . . . . . . . . . .

2473
Per Kjrsgaard-Andersen and Kirsten Specht
The Role of Navigation in Hip Arthroplasty . . . . . . . . . . . . . . .

. 2483
Thomas Mattes and Ralf Decking
Complications of Total Hip Replacement Including
Dislocation of Total Hip Replacement . . . . . . . . . . . . . . . . . .
. . . 2495
Klaus-Peter Gunther, Stephan Kirschner, Maik Stiehler, and
Albrecht Hartmann
Periprosthetic Infection . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 2511
Carsten Perka and Michael Muller
Periprosthetic Femoral Fractures in Total
Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 2527
Luigi Zagra and Roberto Giacometti Ceroni
Aseptic Loosening of Total Hip Replacements - Acetabulum . . . .
2553
Hans Gollwitzer, Rudiger von Eisenhart-Rothe, and
Reiner Gradinger
Acetabular Revision in Total Hip Arthroplasty Using
Bone Impaction Grafting and Cement . . . . . . . . . . . . . . . . . . .
. 2573
W. H. C. Rijnen, J. W. M. Gardeniers, P. Buma, and
B. W. Schreurs
Femoral Impaction Grafting . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 2583
Samantha Hook and Jonathan R. Howell
Revision Total Hip Replacement with Transfemoral
Extended Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 2609
Roberto Binazzi and Per Kjrsgaard-Andersen
Resurfacing Arthroplasty of the
Hip . . . . . . . . . . . . . . . . . . . . . . 2621
Maik Stiehler, Stephan Kirschner, and Klaus-Peter Gunther
xxii
Contents
Dual Mobility Concept - Bipolar Hip Replacement . . . . . . . . . .

2635
Michel-Henri Fessy
Resection Arthroplasty of the Hip . . . . . . . . . . . . . . . . . . . . . . . .

2649
Michael Muller and Carsten Perka
Volume 5
Part VII Thigh, Knee and

Shin . . . . . . . . . . . . . . . . . . . . . . . . . 2661
Surgical Approaches to the Femur . . . . . . . . . . . . . . . . . . . . . . .
2663
Jean-Marc Feron, Bertrand Cherrier, and Francois Signoret
Nailing of Femoral Shaft Fractures . . . . . . . . . . . . . . . . . . . . . . .
2677
Peter V. Giannoudis, Petros Z. Stavrou, and Costas Papakostidis
Fractures of the Distal Femur . . . . . . . . . . . . . . . . . . . . . . . . . . .
2699
Cameron Downs, Arne Berner, and Michael Schutz
Knee Arthroscopy - Principles and Technique . . . . . . . . . . . . . .
2717
Philippe Beaufils and N. Pujol-Cervini
Complications of Knee Arthroscopy . . . . . . . . . . . . . . . . . . . . . .
2729
Robin Allum
Surgical Approaches to the Knee . . . . . . . . . . . . . . . . . . . . . . . . .
2745
Michael T. Hirschmann, Faik K. Afifi, and Niklaus F. Friederich
Quadriceps Tendon Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2755
Robert A. Magnussen, Guillaume Demey, Pooler Archbold, and
Philippe Neyret
Fractures of the
Patella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2765
Florent Weppe, Guillaume Demey, Camdon Fary, and
Philippe Neyret
Patellar
Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 2789
Simon Donell
Patellar Instability in Children and Adolescents . . . . . . . . . . . .
2803
Jorn Kircher and Rudiger Krauspe
Management of Proximal Tibial Fractures . . . . . . . . . . . . . . . . .
2825
Christos Garnavos
Tibial Shaft
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2853
Rozalia Dimitriou and Peter V. Giannoudis
Meniscal Lesions Today - Evidence for Treatment . . . . . . . . . .
2879
Nicolas Pujol, Philippe Beaufils, and Philippe Boisrenoult
Meniscal Allografts of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . .
2897
Rene Verdonk, Peter Verdonk, Marie Van Laer, and
Karl Fredrik Almqvist
Contents
xxiii
Repair of Osteochondral Defects Employing Chondrocyte
Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 2905
George Bentley and Panagiotis D. Gikas
Mosaicplasty for Articular Cartilage Defects . . . . . . . . . . . . . .
. 2913
gnes Berta
Laszlo Hangody and A
Structural Allografts for Bone Loss in the
Knee - Arthroplasty
Options . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2925
Raul A. Kuchinad, Shawn Garbedian, Benedict A. Rogers,
David Backstein, Oleg Safir, and Allan E. Gross
Unicondylar Osteo-Articular Allografts in Knee
Reconstructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 2937
Giuseppe Bianchi, Eric L. Staals, Davide Donati, and
Mario Mercuri
Acute Knee Ligament Injuries and Knee Dislocation
........ 2949
John F. Keating
Anterior Cruciate Ligament (ACL) Reconstruction Using
Hamstring Tendon Graft . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 2973
Andy M. Williams, Danyal H. Nawabi, and Claus Locherbach
Anterior Cruciate Ligament Reconstruction with
Bone Patellar Tendon Bone
Autograft . . . . . . . . . . . . . . . . . 2991
Elcil Kaya Bicer, Elvire Servien, Sebastien Lustig, and
Philippe Neyret
Patellar Tendon
Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3019
Robert A. Magnussen, Guillaume Demey, Pooler Archbold, and
Philippe Neyret
Posterior Cruciate Ligament and Posterolateral
Corner
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 3031
George Dowd and Fares Sami Haddad
Postero-Lateral Knee Ligament Repair . . . . . . . . . . . . . . . . . .
. 3071
Pablo E. Gelber, Joan C. Monllau, and Joao Espregueira-Mendes
MCL (Medial Collateral Ligament) and PMC
(Postero-Medial Corner) Injuries of the Knee . . . . . . . . . . . . . .
3093
Sujith Konan and Fares Sami Haddad
Failed Anterior Cruciate Ligament Repair . . . . . . . . . . . . . . . .
. 3113
Helder Pereira, Nuno Sevivas, Pedro Varanda, Alberto Monteiro,
Joan C. Monllau, and Joao Espregueira-Mendes
Supracondylar Femoral Osteotomy for Osteoarthritis
of the
Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 3129
Matthias Jacobi and Roland P. Jakob
Upper Tibial Osteotomy for Osteoarthritis of the Knee
...... 3143
Daniel Fritschy
xxiv
Contents
Unicompartmental Knee Replacement (UKR) . . . . . . . . . . . . . .

3155
Nikolaus Bohler
Patello-Femoral Arthroplasty (PFR) . . . . . . . . . . . . . . . . . . . . . .
3163
John Newman
Posterior Cruciate Ligament-Retaining Total Knee
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 3179
Danyal H. Nawabi, Ali Abbasian, and Timothy W. R. Briggs
Posterior Cruciate Ligament (PCL)-Sacrificing Total Knee
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 3201
Matthew T. Brown, Jagmeet S. Bhamra, J. Palmer, A. Olivier,
Panagiotis D. Gikas, and Timothy W. R. Briggs
Mobile-Bearing Knee Prostheses . . . . . . . . . . . . . . . . . . . . . . . . .
3211
Urs K. Munzinger and Jens G. Boldt
Computer-Assisted and Minimally-Invasive Total Knee
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 3227
Peter Ritschl
Periprosthetic Fractures of the Knee Above Total Knee Joint
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 3245
Gershon Volpin, Chanan Tauber, Roger Sevi, and
Haim Shtarker
Revision Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . .
3261
Karl Knahr and Delio Pramhas
One-Stage Management of the Infected Total Knee
Prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 3279
Thorsten Gehrke
The Stiff Knee in
Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3295
Tomas K. Drobny
Knee
Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 3319
Bernd Preininger, Georg Matziolis, and Carsten Perka
Gait Analysis and the Assessment of Total Knee
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 3333
Fabio Catani, M. G. Benedetti, and Sandro Giannini
Management of the Athletes Knee . . . . . . . . . . . . . . . . . . . . . . .
3349
Maurilio Marcacci, S. Zaffagnini, G. M. Marcheggiani Muccioli,
T. Bonanzinga, Giuseppe Filardo, D. Bruni, A. Benzi, and A. Grassi
Knee Scoring
Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3371
Elizaveta Kon, Giulio Altadonna, Giuseppe Filardo,
Berardo Di Matteo, and Maurilio Marcacci
The Knee in Cerebral
Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3389
Walter Michael Strobl and Franz Grill
Contents
xxv
Volume 6
Part VIII Ankle and

Foot ............................. 3407
Hallux Interphalangeus . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 3409
Timothy Huw David Williams and Dishan Singh
Hallux Valgus - Distal Osteotomies . . . . . . . . . . . . . . . . . . .
. . . . 3417
Reinhard Schuh and Hans-Jorg Trnka
The Short Scarf 1st Metatarsal Osteotomy . . . . . . . . . . . . . . . .
. 3433
Pierre Barouk, Mihai Vioreanu, and Louis Samuel Barouk
Arthrodesis of the First Metatarsocuneiform Joint . . . . . . . . . .
3451
Thanos Badekas and Panagiotis Symeonidis
Osteoarthritis of the Great Toe Metatarsophalangeal
Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 3457
David Gordon and Dishan Singh
Lesser Toe Deformities . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 3469
Jan W. Louwerens and J. C. M. Schrier
Bunionette Deformities . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 3503
Andy J. Goldberg
Metatarsalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 3511
James C. Stanley and Michael M. Stephens
Mortons Neuroma . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 3537
Sandro Giannini, M. Cadossi, D. Luciani, and F. Vannini
Midfoot
Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3547
Monika Horisberger and Victor Valderrabano
Sub-Talar
Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3567
David Loveday, Mark Farndon, and Nicholas Geary
Flat Foot Deformity Correction by Tendon Transfer
........ 3583
Simon A. Henderson and K. Deogaonkar
Surgical Treatment of Cavus Foot Deformity . . . . . . . . . . . . . . .
3595
Thomas Dreher and Wolfram Wenz
Tibialis Posterior Tendon
Rupture . . . . . . . . . . . . . . . . . . . . . . . 3621
Steve Parsons
Peroneal Tendon
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3637
Paul Hamilton and Andrew H. N. Robinson
Ankle
Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3659
Johannes I. Wiegerinck and C. N. van Dijk
Ankle Instability (Ankle Sprain) . . . . . . . . . . . . . . . . . . . .
. . . . . 3679
Derek H. Park and Dishan Singh
xxvi
Contents
Ankle Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 3691
gren
Per-Henrik A
Total Ankle Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 3705
Paul H. Cooke and Andy J. Goldberg
Osteochondral Lesions of the Talus (O.L.T.) . . . . . . . . . . . . . . .

3725
Lee Parker, Andy J. Goldberg, and Dishan Singh
Ankle Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 3735
Nikolaos Gougoulias and Anthony Sakellariou
Fractures of the Distal Tibia ............................

3767
Mathieu Assal
Fractures of the
Talus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3787
Stefan Rammelt and Hans Zwipp
Fractures of the
Calcaneus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3813
Hans Zwipp and Stefan Rammelt
Chopart and Lisfranc Fracture-Dislocations . . . . . . . . . . . . . . .

3835
Stefan Rammelt
Acute Achilles Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . .

3859
Bernhard Devos Bevernage, Pierre Maldague,
Vincent Gombault, Paul-Andre Deleu, and Thibaut Leemrijse
Achilles Tendon Disorders - Chronic Rupture

and
Tendinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 3875
Jean-Luc Besse
Heel Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 3901
Nicholas Cullen and A. Ghassemi
The Diabetic Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . 3915
Patrick Laing
Rheumatoid Forefoot Reconstruction . . . . . . . . . . . . . . . . . . . . .

3963
Amit Amin and Dishan Singh
Volume 7
Part IX Musculo-Skeletal Tumours . . . . . . . . . . . . . . . . . . . . .

3975
Imaging Algorithm in the Diagnosis, Therapy Control
and Follow-up of Musculo-Skeletal Tumours and
Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 3977
Iris M. Noebauer-Huhmann, Joannis Panotopoulos, and
Rainer I. Kotz
Biopsy of Bone and Soft Tissue Sarcomas . . . . . . . . . . . . . . . . . .

3995
Asif Saifuddin and Andrew W. Clarke
Contents
xxvii
Tumour-Like Lesions of
Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . 4017
Miklos Szendroi and George Szoke
Giant-Cell Tumour of Bone

(GCT) . . . . . . . . . . . . . . . . . . . . . . . 4037
Miklos Szendroi
Surgery for Soft Tissue Sarcomas . . . . . . . . . . . . . . . . . . . .

. . . . 4055
Rodolfo Capanna and F. Frenos
Cartilage Tumours of
Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4079
Antonie H. M. Taminiau, Judith V. M. G. Bovee, Carla S. P. van
Rijswijk, Hans A. J. Gelderblom, and Michiel A. J. van de Sande
Comprehensive Management of Bone Tumours . . . . . . . . . . . . .

4105
Stephen Cannon
Fixation of Endoprostheses in Tumour Replacement

........ 4119
Gordon Blunn and Melanie Coathup
Van Nes-Borggreve Rotationplasty of the Knee . . . . . . . . . . . . .

4135
Michiel A. J. van de Sande, A. J. H. Vochteloo,
P. D. S. Dijkstra, and Antonie H. M. Taminiau
Excision and Reconstruction in the Upper Limb . . . . . . . . . . . .

4149
Tymoteusz Budny, J. Hardes, and Georg Gosheger
Excision and Reconstruction Around the Pelvis and Hip

Rotationplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 4171
W. Winkelmann
Disarticulation of the Hip and Hemipelvectomy . . . . . . . . . . . . .

4197
Johnny Keller
Excision and Reconstruction of Upper Femur and Hip . . . . . . .

4211
Timothy W. R. Briggs and Jonathan Miles
Excision and Reconstruction Around the Knee . . . . . . . . . . . . .

4223
Robert J. Grimer
Diaphyseal Reconstruction for Bone Tumours . . . . . . . . . . . . . .

4241
Stephen Cannon
Limb Salvage in Children . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 4251
Mikel San-Julian, B. L. Vazquez-Garca, and L. Sierrasesumaga
Bone Metastases of Long Bones and Pelvis . . . . . . . . . . . . . . . .

. 4281
Johnny Keller
Management of Bone
Metastases . . . . . . . . . . . . . . . . . . . . . . . . . 4295
Roger M. Tillman and Czar Louie Gaston
Management of Spinal
Metastases . . . . . . . . . . . . . . . . . . . . . . . . 4309
Enric Caceres Palou
xxviii
Contents
Part X Paediatric Orthopaedics and Traumatology . . . . . . .

4325
Congenital Pseudarthrosis of the Tibia . . . . . . . . . . . . . . . . . . . .
4327
Christopher Bradish
Leg-Length Discrepancy in Children .....................
4345
Christopher Bradish
Tibial Varus Deformity and Blounts Disease . . . . . . . . . . . . . . .
4371
Peter Calder
Hip Dysplasia-Management in the First Year . . . . . . . . . . . . . .
4385
Nicola Portinaro, Artemisia Panou, and Sara Camurri
Hip Dysplasia-Management to Adolescence . . . . . . . . . . . . . . . .
4405
Aresh Hashemi-Nejad and Francois Tudor
Developmental Coxa Vara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4419
Andreas Roposch
Slipped Capital Femoral Epiphysis (SCFE) . . . . . . . . . . . . . . . .
4425
Christoph Zilkens, B. Bittersohl, Young-Jo Kim,
Michael B. Millis, and Rudiger Krauspe
Legg-Calve-Perthes Disease ............................
4443
Colin Bruce and Daniel Perry
Septic Arthritis in Infancy and Childhood . . . . . . . . . . . . . . . . .
4469
Manuel Cassiano Neves, J. L. Campagnolo, M. J. Brito, and
C. F. Gouveia
Management of
Clubfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4483
Ernesto Ippolito, Pasquale Farsetti, and Matteo Benedetti
Valentini
Disorders of the Foot in Children . . . . . . . . . . . . . . . . . . . . . . . .
4511
Philippe Wicart and Raphael Seringe
The Foot in Children and Adolescents ....................
4553
Sally Tennant
Orthopaedic Management of Cerebral Palsy and
Myelomeningocoele - Lower Limb . . . . . . . . . . . . . . . . . . . . . . .
4575
Martin Gough
Orthopaedic Management of CP/Myelomeningocele -
Upper
Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 4609
Eva Ponten
Orthopaedic Management of Arthrogryposis
Multiplex Congenita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 4627
Andrew J. Graydon and Deborah M. Eastwood
Brachial Plexus Injuries in Children . . . . . . . . . . . . . . . . . . . . . .
4645
Marco Sinisi
Contents
xxix
Epiphyseal Growth-Plate Injuries . . . . . . . . . . . . . . . . . . . .

. . . . 4653
Surjit Lidder and Manoj Ramachandran
Flexible Intramedullary Nailing (FIN) in Diaphyseal
Fractures in
Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4669
Pierre Lascombes
Shoulder Injuries in
Children . . . . . . . . . . . . . . . . . . . . . . . . . . .
4691
Adam Pandit and Deborah Higgs
Elbow Injuries in Children . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 4703
Prakash Jayakumar and Manoj Ramachandran
Fractures of the Forearm in Children . . . . . . . . . . . . . . . . . .
. . . 4749
Matthew Barry
Paediatric Hand Trauma . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 4767
Grainne Bourke
Paediatric Hip and Pelvic Trauma . . . . . . . . . . . . . . . . . . . .
. . . 4789
Russell Hawkins, Hesham Al-Khateeb, and Aresh Hashemi-Nejad
Paediatric Fractures of the Femur, Knee, Tibia
and Fibula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 4807
Nick Nicolaou
Fractures of the Foot and Ankle in
Children . . . . . . . . . . . . . . . 4831
Sally Tennant
Paediatric Sports Injuries - Principles of Management . . . . . . .
4853
Panteleimon Chan and Manoj Ramachandran
Knee Stiffness in Children . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 4871
John A. Fixsen
Tendon Transfers for Paralysis Affecting the Knee
in
Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 4879
John A. Fixsen
Management of
Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . .
4885
Sammy A. Hanna and Jonathan Miles
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 4897
Contributors
Ali Abbasian Guys and St Thomas Hospital, London, UK

Antonio Abramo Hand and Upper Extremity Unit, Department of
Orthopedics, Lund University Hospital, Lund, Sweden
Lars Adolfsson Department of Orthopaedics, Linkoping University Hospital,
Linkoping, Sweden
Max Aebi MEM Research Center, University of Bern and Orthopaedic
Department, Hirslanden-Salem Hospital, Bern, Switzerland
Faik K. Afifi Department of Orthopaedic Surgery and Traumatology,
Kantonsspital Baselland, Bruderholz, Switzerland
gren Stockholms Fotkirurgklinik, Sophiahemmet, Stockholm,
Per-Henrik A
Sweden
Ahmet Alanay Department of Orthopaedics and Traumatology, Compre-
hensive Spine Center, Acibadem Maslak Hospital, Istanbul, Turkey
Firas Al-Dabouby Orthopedic Division, Hashemite University, Prince
Hamza Teaching Hospital, Amman, Jordan
Hesham Al-Khateeb Royal National Orthopaedic Hospital, NHS, Stanmore,
Middlesex, UK
Robin Allum Heatherwood and Wexham Park Hospitals NHS Trust,
Berkshire, UK
Karl Fredrik Almqvist Department of Orthopaedic Surgery and
Traumatology, Ghent State University, Ghent, Belgium
Giulio Altadonna Clinic of Orthopaedic and Sports Traumatology, Biome-
chanics Laboratory, Rizzoli Orthopaedic Institute, Bologna University,
Bologna, Italy
Amit Amin St Georges Hospital, Tooting, London, UK
R. Amirfeyz Bristol Royal Infirmary, Bristol, UK
John C. Angel Royal National Orthopaedic Hospital, London, UK
Samuel A. Antuna Shoulder and Elbow Unit, La Paz University Hospital,
Universidad Autonoma de Madrid, Madrid, Spain
xxxi
xxxii
Contributors
Imran Anwar Kadoorie Centre for Critical Care Research and Education,
Trauma Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK
Alessandro Aprato Orthopaedic Department, University of Turin, Turin,
Italy
Pooler Archbold Royal Victoria Hospital, Belfast, Northern Ireland, UK
Jean-Noel Argenson Institute for Motion and Locomotion, Center for
Osteoarthritis Surgery, Universite de la Mediterranee, Assistance Publique
des Hopitaux de Marseille, CHU Sainte Marguerite, Marseille, France
Dan Armstrong Pulvertaft Hand Centre, Derby, UK
Mathieu Assal Clinique La Colline, Geneva, Switzerland
J. M. Aubaniac Institute for Motion and Locomotion, Center for Osteoar-
thritis Surgery, Universite de la Mediterranee, Assistance Publique des
Hopitaux de Marseille, CHU Sainte Marguerite, Marseille, France
David Backstein Mount Sinai Hospital, University of Toronto, Toronto,
ON, Canada
Thanos Badekas Foot and Ankle Clinic Metropolitan Hospital, Athens,
Greece
Eleni Balabanidou University Hospital Southampton, Southampton, UK
Jose Ballesteros Orthopedic Department, Hospital Clnico Barcelona,
Barcelona, Spain
Stefano Bandiera Department of Oncologic and Degenerative Spine
Surgery, Istituto Rizzoli, Bologna, Italy
Olivier Barbier Service dOrthopedie et de Traumatologie, Cliniques
Universitaires St-Luc, Universite Catholique de Louvain, Bruxelles, Belgium
Raul Barco Shoulder and Elbow Unit, La Paz University Hospital,
R. Barker Princess Elizabeth Orthopaedic Unit, Royal Devon and Exeter
Hospital, Devon, UK
A. Barnard Pulvertaft Hand Centre, Derby, UK
Louis Samuel Barouk Yvrac, France
Pierre Barouk Clinique du Sport, Merginac, France
Matthew Barry The Royal London Hospital, Whitechapel, London, UK
Philippe Beaufils Orthopaedic Department, Centre Hospitalier de
Versailles, Le Chesnay, France
M. G. Benedetti Movement Analysis Laboratory, Istituto Ortopedico
Rizzoli, University of Bologna, Bologna, Italy
Contributors
xxxiii

A. Benzi Sports Traumatolgy Department, Rizzoli Othopaedic
Institute,
University of Bologna, Bologna, Italy
Arne Berner Queensland University of Technology, Brisbane, Australia
Peter Bernstein Department of Orthopaedic Surgery, University
Hospital
Carl Gustav Carus Dresden, Dresden, Germany
gnes Berta Department of Orthopaedics, Uzsoki Hospital, Budapest,
A
Hungary
Jean-Luc Besse Universite Lyon 1, IFSTTAR, LBMC UMRT 9406
Laboratoire de Biomecanique et Mecanique des Chocs, Bron, France
Hospices Civils de Lyon, Centre Hospitalier LyonSud, Service de
Chirurgie
Orthopedique et Traumatologique, PierreBenite, France
Jagmeet S. Bhamra The London Sarcoma Service, Royal National
Orthopaedic Hospital, Stanmore, Middlesex, UK
Giuseppe Bianchi Istituti Ortopedici Rizzoli, 5th Division, Bologna,
Italy
Elcil Kaya Bicer Centre Albert Trillat, Groupe Hospitalier Nord,
Hospices
Civils de Lyon, Lyon-Caluire, France
Caroline Bijnen-Girardot Hong Kong, Hong Kong SAR
Roberto Binazzi Department of Orthopedic Surgery, Villa Erbosa
Hospital,
Rolfe Birch War Nerve Injury Clinic at Defence Medical
Rehabilitation
Centre, Epsom, Surrey, UK
Martin Bircher Department of Trauma and Orthopaedics, St. Georges
Hospital, London, UK
Alessandro Bistolfi Department of Orthopaedics, Traumatology and
Reha-
bilitation, CTO/M Adelaide Hospital, Turin, Italy
B. Bittersohl Department of Orthopedic Surgery, University Hospital
of
Dusseldorf, Dusseldorf, Germany
B. Blondel Orthopedic Pediatric Department, Timone Children
Hospital,
Marseille, France
Hospital for Joint Diseases, New York University, New York, NY, USA
Gordon Blunn John Scales Centre for Biomedical Engineering,
Institute of
Orthopaedics and Musculo-Skeletal Science, University College
London,
Matteo Bo Expert Consultant in Industrial Installations, Prodim srl,
Turin,
Italy
xxxiv
Contributors
Nikolaus Bohler Orthopadische Abteilung, Allgemeines Krankhaus Linz,

Linz, Austria
Philippe Boisrenoult Orthopaedic Department, Versailles Hospital,
Le Chesnay, France
Jens G. Boldt Siloah Hospital Guemligen, Orthopaedic Centre, Muri/Bern,
Switzerland
Gerard Bollini Orthopedic Pediatric Department, Timone Children
Hospital, Marseille, France
T. Bonanzinga Sports Traumatolgy Department, Rizzoli Othopaedic Insti-
tute, University of Bologna, Bologna, Italy
Stefano Boriani Department of Oncologic and Degenerative Spine Surgery,
Istituto Rizzoli, Bologna, Italy
Grainne Bourke Leeds Teaching Hospitals Trust, Leeds, UK
Judith V. M. G. Bovee Leiden University Medical Centre, Leiden,
The Netherlands
Elena Maria Brach del Prever Department of Orthopaedics, Traumatology
and Rehabilitation, University of the Studies of Turin, Turin, Italy
Christopher Bradish Great Ormond Street Hospital, London, UK
Timothy W. R. Briggs The London Sarcoma Service, Royal National
M. J. Brito Infectious Disease Department, Hospital Dona Estefania,
Lisbon, Portugal
Matthew T. Brown The London Sarcoma Service, Royal National
Colin Bruce Department Childrens Orthopaedic Surgery, Alder Hey
Childrens Hospital, Liverpool, UK
D. Bruni Sports Traumatolgy Department, Rizzoli Orthopaedic Institute,
Tymoteusz Budny Zentrum fur Orthopadie, Klinik fur Allgemeine
Orthopadie, M
unster, Germany
P. Buma Department of Orthopedics, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands
Tim Bunker Princess Elizabeth Orthopaedic Centre, Exeter, UK
Frank Burke The Pulvertaft Hand Centre, Derbyshire Royal Hospital,
Derby, UK
Klaus Burkhart Department of Orthopaedic and Trauma Surgery, Univer-
sity of Cologne, Cologne, Germany
Contributors
xxxv
Dan Butler Kadoorie Centre for Critical Care Research and Education,
Trauma Unit, John Radcliffe Hospital, University of Oxford, Oxford,
UK
Enric Caceres Palou Department Hospital Vall dHebron, Autonomous

University of Barcelona, Barcelona, Spain
M. Cadossi Department of Orthopaedic and Trauma Surgery, Istituto

Ortopedico Rizzoli, Bologna, Italy
Peter Calder The Royal National Orthopaedic Hospital, Stanmore,

Middlesex, UK
J. L. Campagnolo Orthopaedic Department, Hospital Dona Estefania,

Lisbon, Portugal
Doug Campbell Leeds General Infirmary, Leeds, UK
Sara Camurri Orthopaedic and Trauma Department, Orthopaedic

Pediatrics and Neuro-Orthopedic Unit, Humanitas Research Hospital,
Rozzano Milano, Italy
Federico Canavese Department of Pediatric Surgery, University

Hospital
Estaing, Clermont Ferrand, France
Stephen Cannon Clementine Churchill Hospital, Harrow, Middlesex, UK

Sarcoma Unit, Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
Rodolfo Capanna Centro Traumatologico Ortopedico (CTO), Policlinico

di
Careggi, Firenze, Italy
Antonio Cartucho Orthopaedic Department, Hospital Cuf Descobertas,

Lisbon, Portugal
Manuel Cassiano Neves Orthopaedic Department, Hospital

Cuf
Descobertas, Parque das Nacoes, Lisboa, Portugal
Pierre-Paul Casteleyn Department of Orthopaedics and Traumatology,

University Hospital, Brussels, Belgium
Fabio Catani Movement Analysis Laboratory, Istituto Ortopedico

Rizzoli,
Dimitri Ceroni Department of Paediatric Orthopaedics, Childrens

Hospital
and University Hospital Geneva, Geneva, Switzerland
Panteleimon Chan Barts and The London NHS Trust and The London
Childrens Hospital, Whitechapel, London, UK
Bertrand Cherrier Saint Antoine Hospital, Pierre et Marie Curie
Univer-
sity, Paris, France
E. Choufani Orthopedic Pediatric Department, Timone Children

Hospital,
Marseille, France
xxxvi
Contributors
Gregoire Ciais Service de Chirurgie Orthopedique, Hopital Universitaire de

Bicetre, Le Kremlin-Bicetre, France
Andrew W. Clarke Royal National Orthopaedic Hospital NHS Trust,
Philippe Clavert Centre de Chirurgie Orthopedique et de la Main, Illkirch-
Graffenstaden, France
Marina Clement-Rigolet Service de Chirurgie Orthopedique, Hopital
Universitaire de Bicetre, Le Kremlin-Bicetre, France
David Cloke Department of Orthopaedics, Freeman Hospital, High Heaton,
Newcastle-upon-Tyne, UK
Melanie Coathup John Scales Centre for Biomedical Engineering, Institute
of Orthopaedics and Musculo-Skeletal Science, University College London,
Simone Colangeli Department of Oncologic and Degenerative Spine
Paul H. Cooke Nuffield Orthopaedic Centre, Headington, Oxford, UK
Stephen A. Copeland The Reading Shoulder Surgery Unit, Capio Reading
Hospital, Reading, UK
Tony Corner West Hertfordshire Hospitals NHS Trust, Watford and
St. Albans Hospitals, Watford, UK
Olivier Cornu Service dOrthopedie et de Traumatologie, Cliniques
Universitaires St-Luc, Universite Catholique de Louvain, Bruxelles, Belgium
Tim A. Coughlin Pulvertaft Hand Centre, Royal Derby Hospital,
Derby, UK
Charles Court Spine Unit, Orthopaedic Department, Bicetre University
Hospital, AP-HP Paris, Universite Paris-Sud ORSAY, Le Kremlin Bicetre,
France
Timothy Cresswell Pulvertaft Hand Centre, Royal Derby Hospital,
Derby, UK
U. Culemann Celle General Hospital, Celle, Germany
Nicholas Cullen The Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
C. Cuocolo Department of Orthopaedics, Traumatology and Occupational
Medicine, University of Turin, Turin, Italy
Zoe H. Dailiana Department of Orthopaedic Surgery, Faculty of Medicine,
School of Health Sciences, University of Thessalia, Biopolis, Larissa, Greece
Jens Dargel Department of Orthopaedic and Trauma Surgery, University of
Cologne, Cologne, Germany
Contributors
xxxvii
Lieven De Wilde Department of Orthopaedic Surgery and Traumatology,

Ghent University Hospital, Ghent, Belgium
Ralf Decking Department of Orthopaedics, St. Remigius Krankenhaus
Opladen, Germany
Paul-Andre Deleu Foot and Ankle Institute, Parc Leopold Clinic,
Brussels,
Belgium
Christian Delloye Service dOrthopedie et de Traumatologie,
Cliniques
Universitaires St-Luc, Universite Catholique de Louvain, Bruxelles,
Belgium
J. Demakakos Hospital for Joint Diseases, New York University,
New York, NY, USA
Guillaume Demey Centre Albert Trillat Hopital de le Croix-Rousse,
Lyon,
France
Lyon Ortho Clinic Clinique de la Sauvegarde, Lyon, France
K. Deogaonkar Northern Ireland Higher Surgical Training Programme
for
Trauma and Orthopaedics, Musgrave Park Hospital, Belfast, UK
Bernhard Devos Bevernage Foot and Ankle Institute, Parc Leopold
Clinic,
Brussels, Belgium
Berardo Di Matteo Clinic of Orthopaedic and Sports Traumatology,
Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Bologna
Univer-
sity, Bologna, Italy
Joseph J. Dias University Hospitals of Leicester NHS Trust,
Leicester
General Hospital, Leicester, UK
P. D. S. Dijkstra Leiden University Medical Centre,
Leiden,
The Netherlands
Rozalia Dimitriou Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
Davide Donati Istituti Ortopedici Rizzoli, 5th Division, Bologna,
Italy
Simon Donell Norfolk and Norwich University Hospital, Norfolk, UK
George Dowd Royal Free Hospital/Wellington Hospital, London, UK
Cameron Downs Princess Alexandra Hospital, Queensland University of
Technology, Brisbane, Australia
Thomas Dreher Paediatric Orthopaedics and Foot Surgery, Department
for
Orthopaedic and Trauma Surgery, Heidelberg University Clinics,
Heidel-
berg, Germany
Tomas K. Drobny Reconstructive Knee Surgery, Schulthess Klinik,
Zurich,
Switzerland
Denis Dufrane Banque de tissus de lAppareil locomoteur, Cliniques
Belgium
xxxviii
Contributors
Christian Dumontier Hopital Saint Antoine, Paris, France
Deborah M. Eastwood Royal National Orthopaedic Hospital, Stanmore,

Middlesex, UK
David Elliot Hand Surgery Department, St Andrews Centre for Plastic

Surgery, Broomfield Hospital, Chelmsford, Essex, UK
Roger J. H. Emery St. Marys Hospital, Imperial College NHS Trust,

London, UK
Department of Mechanical Engineering, Imperial College, London, UK
European Hospital Georges Pompidou, APHP, University Paris Descartes,
Paris, France
Joao Espregueira-Mendes Clnica Saude Atlantica Porto, Minho University,

Braga, Portugal
Richard Eyb Orthopadische Abteilung, Sozialmedizinisches Zentrum Ost

Donauspital, Wien, Austria
Denise Eygendaal Department of Orthopaedics, Upper Limb Unit, Amphia

Hospital, Breda, The Netherlands
J. Fabry Department of Orthopaedics and Traumatology, University

Hospital, Brussels, Belgium
Mark Farndon Harrogate District Hospital, Harrogate, North Yorkshire,

UK
Pasquale Farsetti Department of Orthopaedic Surgery, University of Rome

Tor Vergata, Rome, Italy
Camdon Fary Western Health, Footscray, VIC, Australia
Antonio A. Faundez Department of Surgery, Service de Chirurgie

Orthopedique et Traumatologie de lAppareil Moteur, University of Geneva
Hospitals and Faculty of Medicine, Geneva, Switzerland
Jean-Marc Feron Orthopaedic and Trauma Surgery Department, Saint

Antoine Hospital, Pierre et Marie Curie University, Paris, France
Michel-Henri Fessy Centre Hospitalier Lyon Sud, Chirurgie Orthopedique

et Traumatologique, Pierre Benite, France
Giuseppe Filardo Clinic of Orthopaedic and Sports Traumatology, Biome-

Bologna, Italy
John Fisher Institute of Medical and Biological Engineering, School of

Mechanical Engineering, University of Leeds, Leeds, UK
John A. Fixsen Hospital for Sick Children, London, UK

Contributors
xxxix
Xavier Flecher Institute for Motion and Locomotion, Center for

Osteoar-
thritis Surgery, Universite de la Mediterranee, Assistance
Publique des
Hopitaux de Marseille, CHU Sainte Marguerite, Marseille, France
P. A. Fleming The John Charnley Research Institute, Wrightington

Hospital,
Wigan, Lancashire, UK
Jonas Franke Nottingham Shoulder and Elbow Unit, Nottingham Univer-

sity Hospitals, Nottingham, UK
F. Frenos Centro Traumatologico Ortopedico (CTO), Policlinico di

Careggi, Firenze, Italy
Niklaus F. Friederich Department of Orthopaedic Surgery

and
Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
Daniel Fritschy Hopital de La Tour, Meyrin, Switzerland
Olivier Gagey Orthopaedic Department, Paris-South University, Paris,

France
Paolo Gallinaro Department of Orthopaedics, Traumatology and

Rehabil-
itation, University of the Studies of Turin, Turin, Italy
Reinhold Ganz Faculty of Medicine, University of Bern, Bern,

Switzerland
Shawn Garbedian Mount Sinai Hospital, University of Toronto,

Toronto,
ON, Canada
J. W. M. Gardeniers Department of Orthopedics, Radboud University

Nijmegen Medical Centre, Nijmegen, The Netherlands
Christos Garnavos Glyfada, Athens, Greece
Alessandro Gasbarrini Department of Oncologic and Degenerative Spine

Czar Louie Gaston Oncology Unit, Royal Orthopaedic Hospital NHS

Foundation Trust, Birmingham, UK
Thomas Gausepohl Klinik fur Unfallchirurgie, Hand- und

Wiederherstel-
lungschirurgie, Klinikum Vest GmbH, Marl, Germany
Nicholas Geary Wirral University NHS Trust, Upton, Wirral, UK
Thorsten Gehrke Orthopaedic Surgery, ENDO-Klinik Hamburg, Hamburg,

Germany
Pablo E. Gelber Hospital de la Santa Creu i Sant Pau, Universitat
Auto`noma
de Barcelona (UAB), Barcelona, Spain
Hans A. J. Gelderblom Leiden University Medical Centre, Leiden, The

Netherlands
A. Ghassemi University College Hospital, London, UK

xl
Contributors
Antoine de Gheldere The Newcastle upon Tyne Hospitals - NHS Founda-

tion Trust, Newcastle upon Tyne, UK
Riccardo Ghermandi Department of Oncologic and Degenerative Spine
Roberto Giacometti Ceroni Hip Department, IRCCS Istituto Ortopedico
Galeazzi, Milan, Italy
Sandro Giannini Movement Analysis Laboratory, Istituto Ortopedico
Rizzoli, University of Bologna, Bologna, Italy
Department of Orthopaedic and Trauma Surgery, Istituto Ortopedico Rizzoli,
Bologna, Italy
Peter V. Giannoudis Academic Department of Trauma and Orthopae-
dics, School of Medicine, University of Leeds, Leeds, UK
Henk Giele Oxford Radcliffe Hospitals, Oxford, UK
Panagiotis D. Gikas The London Sarcoma Service, Royal National Ortho-
paedic Hospital, Stanmore, Middlesex, UK
West Hertfordshire Hospitals NHS Trust, Watford and St. Albans Hospitals,
Watford, UK
Paul Gillespie Department of Trauma and Orthopaedics, St. Georges
Hospital, London, UK
Philippe Gillet Centre Hospitalier Universitaire, Lie`ge, Belgium
Andy J. Goldberg UCL Institute of Orthopaedics & Musculoskeletal
Science, Royal National Orthopaedic Hospital NHS Trust, Stanmore,
Middlesex, UK
Hans Gollwitzer ATOS Klinik Munchen, and Klinik fur Orthopadie und
Sportorthopadie am Klinikum rechts der Isar, Technische Universitat
Munchen, M unchen, Germany
Vincent Gombault Foot and Ankle Institute, Parc Leopold Clinic, Brussels,
Belgium
David Gordon Luton and Dunstable University Hospital, Luton, UK
Taco Gosens St. Elisabeth Hospital Tilburg, Tilburg, The Netherlands
Georg Gosheger Zentrum fur Orthopadie, Klinik fur Allgemeine
Orthopadie, M
unster, Germany
Martin Gough Evelina Childrens Hospital/One Small Step Gait Labora-
tory, Guys and St Thomas NHS Foundation Trust, London, UK
Nikolaos Gougoulias Frimley Park Hospital, Frimley, Frimley, UK
C. F. Gouveia Infectious Disease Department, Hospital Dona Estefania,
Lisbon, Portugal
Contributors
xli
G. Grabmeier Orthopadische Abteilung, Sozialmedizinisches Zentrum

Ost
Donauspital, Wien, Austria
Reiner Gradinger Klinik fur Orthopadie und Sportorthopadie am
Klinikum
rechts der Isar, Technische Universitat Munchen, Munchen, Germany
A. Grassi Sports Traumatolgy Department, Rizzoli Othopaedic
Institute,
Andrew J. Graydon Starship Hospital, Auckland, New Zealand
Thomas M. Gregory St. Marys Hospital, Imperial College NHS Trust,
London, UK
Department of Mechanical Engineering, Imperial College, London, UK
European Hospital Georges Pompidou, APHP, University Paris
Descartes,
Paris, France
Franz Grill Pediatric Orthopaedic Department, Orthopaedic Hospital,
Speising, Vienna, Austria
Robert J. Grimer Royal Orthopaedic Hospital, Birmingham, UK
Allan E. Gross Mount Sinai Hospital, Toronto, ON, Canada
C. Guardia Orthopedic Pediatric Department, Timone Children
Hospital,
Marseille, France
Jose Guimaraes Consciencia Orthopaedic Department, FCM-Lisbon New
University, Lisbon, Portugal
Klaus-Peter G unther Department of Orthopaedic Surgery, University
Norbert P. Haas Center for Musculoskeletal Surgery, Charite
Universitatsmedizin Berlin, Berlin, Germany
Peter Habermeyer Section for Shoulder and Elbow Surgery, ATOS
Clinic,
Munich, Germany
Fares Sami Haddad University College London Hospitals, NHS Trust,
London, UK
Moussah Hamadouche Department of Orthopaedic and Reconstructive
Surgery, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris,
France
Paul Hamilton Cambridge University Hospitals, NHS Foundation Trust,
Cambridge, UK
Laszlo Hangody Department of Orthopaedics, Uzsoki Hospital,
Budapest,
Hungary
Sammy A. Hanna Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
xlii
Contributors
Aristote Hans-Moevi Centre de Chirurgie Orthopedique et de la Main,

Illkirch-Graffenstaden, France
J. Hardes Zentrum fur Orthopadie, Klinik fur Allgemeine Orthopadie,
Munster, Germany
Albrecht Hartmann Department of Orthopaedic Surgery, University
Aresh Hashemi-Nejad Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
Russell Hawkins Royal National Orthopaedic Hospital, NHS, Stanmore,
Middlesex, UK
Tim Hems The Hand Clinic, Department of Orthopaedic Surgery, The
Victoria Infirmary, Glasgow, UK
Simon A. Henderson Musgrave Park Hospital, Belfast, UK
Carlos Heras-Palou Pulvertaft Hand Centre, Derby, UK
Deborah Higgs Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
Michael T. Hirschmann Department of Orthopaedic Surgery and
Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
Pierre Hoffmeyer University Hospitals of Geneva, Geneva, Switzerland
Joerg H. Holstein Department of Trauma, Hand and Reconstructive
Surgery, University of Saarland, Homburg/Saar, Germany
Samantha Hook Princess Elizabeth Orthopaedic Centre, Exeter, Devon,
UK
Monika Horisberger Orthopaedic Department, University Hospital Basel,
Basel, Switzerland
Tracy Horton Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
Jonathan R. Howell Princess Elizabeth Orthopaedic Unit, Royal Devon and
Exeter Hospital, Devon, UK
Ernesto Ippolito Department of Orthopaedic Surgery, University of Rome
Tor Vergata, Rome, Italy
Kaywan Izadpanah Department for Orthopedic Surgery and
Traumatology, Freiburg University Hospital, Freiburg, Germany
Matthias Jacobi Orthopaedic Department, Hopital Cantonal Fribourg,
Fribourg, Switzerland
Roland P. Jakob Orthopaedic Department, Hopital Cantonal Fribourg,
Fribourg, Switzerland
Contributors
xliii
Prakash Jayakumar Barts Health NHS Trust, Whitechapel, London, UK

Zhongmin Jin State Key Laboratory for Manufacturing System
Engineering,
Xian Jiaotong University, Xian, China
Institute of Medical and Biological Engineering, School of
Mechanical
Engineering, University of Leeds, Leeds, UK
Elizabeth O. Johnson School of Medicine, University of Athens,
Athens,
Greece
R. Jose University Hospitals Birmingham, Birmingham, UK
Jean-Luc Jouve Orthopedic Pediatric Department, Timone Children
Andre Kaelin Clinique des Grangettes, Chene-Bougeries, Switzerland
Nikolaos K. Kanakaris Academic Department of Trauma and Orthopae-
dics, School of Medicine, Leeds General Infirmary, Leeds, West
Yorkshire,
UK
John F. Keating Department of Orthopaedic Trauma, Royal Infirmary,
Little France, Edinburgh, Scotland, UK
Johnny Keller Department of Orthopaedic Surgery, University Hospital
of
Aarhus, Aarhus, Denmark
Jean-Francois Kempf Centre de Chirurgie Orthopedique et de la Main,
Illkirch-Graffenstaden, France
Luc Kerboull Marcel Kerboull Institute, Paris, France
Marcel Kerboull Marcel Kerboull Institute, Paris, France
L. A. Kashif Khan The Edinburgh Shoulder Clinic, Royal Infirmary of
Edinburgh, Edinburgh, UK
Young-Jo Kim Harvard Medical School, Adolescent and Young Adult Hip
Unit, Childrens Hospital Boston, Boston, MA, USA
Jorn Kircher Shoulder and Elbow Surgery, Klinik Fleetinsel Hamburg,
Hamburg, Germany
Department of Orthopaedics, Medical Faculty, HeinrichHeine
University,
Dusseldorf, Germany
Stephan Kirschner Department of Orthopaedic Surgery, University
Hospi-
tal Carl Gustav Carus Dresden, Medical Faculty of the Technical
University
Dresden, Dresden, Germany
Per Kjrsgaard-Andersen Section for Hip and Knee Replacement,
Department of Orthopaedics, Vejle Hospital, University of South
Denmark,
Vejle, Denmark
Christian Kleber Center for Musculoskeletal Surgery, Charite
Universitatsmedizin Berlin, Berlin, Germany
xliv
Contributors
Zdenek Klezl Department of Trauma and Orthopaedics, Spinal Unit, Royal

Derby Hospital, Derby, UK
Peter Kloen Department of Orthopaedic Surgery, Academic Medical
Center, Amsterdam, The Netherlands
Karl Knahr Surgical Orthopaedics and Traumatology, Vienna, Austria
Izaak F. Kodde Department of Orthopaedics, Upper Limb Unit, Amphia
D. Koehler University of Saarland, Homburg/Saar, Germany
Zinon T. Kokkalis School of Medicine, University of Athens, Haidari,
Athens, Greece
Elizaveta Kon Clinic of Orthopaedic and Sports Traumatology, Biome-
Bologna, Italy
Sujith Konan Orthopaedic Trainee NE(UCH) Thames Rotation, London,
UK
George Kontakis Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Crete, Crete, Greece
Philippe Kopylov Hand and Upper Extremity Unit, Department of Ortho-
pedics, Lund University Hospital, Lund, Sweden
Thomas Christian Koslowsky Department of Surgery, St. Elisabeth
Hospital, Cologne, Germany
Rainer I. Kotz Department of Orthopaedics, Medical University Vienna,
Vienna, Austria
Rudiger Krauspe Department of Orthopedic Surgery, University Hospital
of D
usseldorf, D
usseldorf, Germany
Martin Krismer Department of Orthopaedics, Innsbruck Medical Univer-
sity, Innsbruck, Austria
Raul A. Kuchinad Health Sciences Centre, University of Calgary, Calgary,
AB, Canada
Timo Laine ORTON Orthopaedic Hospital, Helsinki, Finland
Patrick Laing Department of Orthopaedics, Wrexham Maelor Hospital,
Wrexham, North Wales, UK
Simon M. Lambert The Shoulder and Elbow Service, Royal National
Mikko Larsen Department of Plastic, Reconstructive and Hand Surgery,
Launceston General Hospital, Launceston, TAS, Australia
Pierre Lascombes Pediatric Orthopedics, University of Geneva HUG,
Geneva, Switzerland
Contributors
xlv
Thibaut Leemrijse Foot and Ankle Institute, Parc Leopold Clinic,

Brussels,
Belgium
R. Legre Plastic and Reconstructive Surgery Department, Conception
Michael Leunig Department of Orthopedics, Schulthess Clinic,
Zurich,
Switzerland
Surjit Lidder Barts and The London NHS Trust and The London
Childrens
Hospital, Whitechapel, London, UK
David Limb Chapel Allerton Hospital, Leeds, UK
Tommy Lindau Pulvertaft Hand Centre, Derby, UK
University of Derby, Derby, UK
University of Bergen, Bergen, Norway
European Wrist Arthroscopy Society (EWAS)
Alberto Lluch Institut Kaplan, Barcelona, Spain
Manuel Llusa Orthopedic Department, Valle Hebron Hospital,
University
of Barcelona, Barcelona, Spain
Claus Locherbach University of Lausanne, Lausanne, Switzerland
P. M. Longis Faculte de Medecine, Nantes, France
Jan W. Louwerens Sint Maartenskliniek, Nijmegen, The Netherlands
David Loveday Norfolk and Norwich University Hospital, Norwich, UK
D. Luciani Department of Orthopaedic and Trauma Surgery, Istituto
Teija Lund ORTON Orthopaedic Hospital, Helsinki, Finland
Sebastien Lustig Centre Albert Trillat, Groupe Hospitalier Nord,
Hospices
Konrad Mader Section Trauma Surgery, Hand and Upper Extremity
Reconstructive Surgery, Department of Orthopaedic Surgery, Frde
Sentralsjukehus, Frde, Norway
Robert A. Magnussen Department of Orthopaedics, Sports Health and
Performance Institute, The Ohio State University, Columbus, OH, USA
Pierre Maldague Foot and Ankle Institute, Parc Leopold Clinic,
Brussels,
Belgium
Maurilio Marcacci Clinic of Orthopaedic and Sports Traumatology,
Bio-
mechanics Laboratory, Rizzoli Orthopaedic Institute, Bologna
University,
Bologna, Italy
G. M. Marcheggiani Muccioli Sports Traumatolgy Department, Rizzoli
Othopaedic Institute, University of Bologna, Bologna, Italy
xlvi
Contributors
Robert W. Marshall Department of Orthopaedic Surgery, Royal Berkshire

Carlo Marco Masoero Department of Energetics, Polytechnic School of
Engineering of Turin, Turin, Italy
Alessandro Masse` Department of Orthopaedics, Traumatology and
Occupational Medicine, University of Turin, Turin, Italy
Thomas Mattes Department of Orthopaedics and Traumatology, Klinik am
Eichert, Goppingen, Germany
Georg Matziolis Department of Orthopaedics, Center for Musculoskeletal
Surgery, Charite-Universitatsmedizin Berlin, Berlin, Germany
H. Michael Mayer Spine Centre Munich, Schon Klinik Munchen
Harlaching, M
unchen, Germany
Mario Mercuri Istituti Ortopedici Rizzoli, 5th Division, Bologna, Italy
Jonathan Miles Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
Michael B. Millis Harvard Medical School, Adolescent and Young Adult
Hip Unit, Childrens Hospital Boston, Boston, MA, USA
Ash Moaveni Pulvertaft Hand Centre, Derby, UK
Joan C. Monllau Hospital de la Santa Creu i Sant Pau, Universitat
Autonoma de Barcelona (UAB), Barcelona, Spain
Alberto Monteiro Clnica Espregueira-Mendes F.C. Porto Stadium FIFA
Medical Centre of Excellence, Porto, Portugal
J. R. Morley Princess Elizabeth Orthopaedic Unit, Royal Devon and Exeter
Hospital, Devon, UK
Ante Mrkonjic Hand and Upper Extremity Unit, Department of Orthope-
dics, Lund University Hospital, Lund, Sweden
uller Department of Orthopaedic and Trauma Surgery, University
Lars P. M
of Cologne, Cologne, Germany
Michael M uller Department of Orthopaedics and Department of Accident
and Reconstructive Surgery, Centre for Musculoskeletal Surgery, Charite
University Medicine, Berlin, Germany
Urs K. Munzinger Orthopadie am Zurichberg, Zurich, Switzerland
Iain R. Murray Department of Trauma and Orthopaedics, The University of
Danyal H. Nawabi Chelsea and Westminster Hospital, London, UK
Hospital for Special Surgery, New York, NY, USA
Contributors
xlvii
Lars Neumann Nottingham Shoulder and Elbow Unit, Nottingham Univer-

sity Hospitals, Nottingham, UK
John Newman Litfield House Medical Centre, Bristol, UK
Philippe Neyret Centre Albert Trillat, Groupe Hospitalier Nord,
Hospices
Nick Nicolaou Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK
Iris M. Noebauer-Huhmann Department of Biomedical Imaging and
Image-guided Therapy, Medical University Vienna, Vienna, Austria
Michael Nogler Department of Orthopaedics, Innsbruck Medical
University,
Innsbruck, Austria
Mary OBrien Pulvertaft Hand Centre, Derby, UK
Antonio Odasso Health Medicine, Turin, Italy
Paul ODonnell Department of Radiology, Royal National Orthopaedic
Hospital, Middlesex, Stanmore, UK
G. A. Odri Faculte de Medecine, Nantes, France
Acke Ohlin Lund University, Sweden, Malmo, Sweden
Deniz Olgun Department of Orthopaedics and Traumatology, Hacettepe
University, Ankara, Turkey
A. Olivier The London Sarcoma Service, Royal National Orthopaedic
Hospital, Middlesex, Stanmore, UK
sterman ORTON Orthopaedic Hospital, Helsinki, Finland
Heikki O
Alistair M. Pace York Teaching Hospital NHS Foundation Trust, York,
UK
Chris Paliobeis The Wellington Hospital, London, UK
J. Palmer The London Sarcoma Service, Royal National Orthopaedic
Hospital, Stanmore, Middlesex, UK
Adam Pandit The Shoulder and Elbow Service, Royal National Orthopae-
dic, Stanmore, Middlesex, UK
Joannis Panotopoulos Department of Orthopaedics, Medical University
Vienna, Vienna, Austria
Artemisia Panou Orthopaedic and Trauma Department, Orthopaedic Pedi-
atrics and Neuro-Orthopedic Unit, Humanitas Research Hospital,
Rozzano
Milano, Italy
Costas Papakostidis Department of Trauma and Orthopaedic Surgery,
Hatzikosta General Hospital, Ioannina, Greece
Derek H. Park Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
xlviii
Contributors
Lee Parker Royal National Orthopaedic Hospital, Stanmore, Middlesex,

UK
S. Parratte Institute for Motion and Locomotion, Center for Osteoarthritis

Surgery, Universite de la Mediterranee, Assistance Publique des Hopitaux de
Marseille, CHU Sainte Marguerite, Marseille, France
Steve Parsons Royal Cornwall Hospitals, Cornwall, UK
Norbert Passuti Faculte de Medecine, Nantes, France
Dietmar Pennig Klinik fur Unfallchirurgie/Orthopadie, Hand- und

Wiederherstellungschirurgie, St. Vinzenz- Hospital Koln, Koln, Germany
Helder Pereira Centro Hospitalar Po`voa de Varzim-Vila do Conde, Clnica

Espregueira-Mendes F.C. Porto Stadium FIFA Medical Centre of Excel-
lence, Porto, Portugal
Carsten Perka Department of Orthopaedics and Department of Accident

and Reconstructive Surgery, Centre for Musculoskeletal Surgery, Charite
University Medicine, Berlin, Germany
Daniel Perry School of Population, Community and Behavioural Sciences,

University of Liverpool, Liverpool, UK
Department Childrens Orthopaedic Surgery, Alder Hey Childrens Hospital,
Liverpool, UK
o Hospital, Porto, Portugal
Rui Pinto Orthopaedic Department, S. JoA
Spiros G. Pneumaticos 3rd Department of Orthopaedic Surgery, School of

Medicine, University of Athens, Athens, Greece
Tim Pohlemann University of Saarland, Homburg/Saar, Germany
Eva Ponten Department of Pediatric Orthopaedic Surgery, Astrid Lindgren

Childrens Hospital, Karolinska University Hospital, Stockholm, Sweden
Lorenzo Ponziani Orthopedic Unit at the Ceccarini Hospital, Riccione,

Italy
Nicola Portinaro Orthopaedic and Trauma Department, Orthopaedic Pedi-

atrics and Neuro-Orthopedic Unit, Humanitas Research Hospital, Rozzano
Milano, Italy
Franco Postacchini Department of Orthopaedic Surgery, University

Sapienza, Rome, Italy
Roberto Postacchini Department Orthopaedic Surgery Israelitic Hospital,

IUSM, Rome, Italy
Delio Pramhas Surgical Orthopaedics and Traumatology, Vienna, Austria
Bernd Preininger Department of Orthopaedics, Center for Musculoskeletal

Surgery, Charite-Universitatsmedizin Berlin, Berlin, Germany
Contributors
xlix
Nicolas Pujol Orthopaedic Department, Versailles Hospital, Le

Chesnay,
France
N. Pujol-Cervini Orthopaedic Department, Centre Hospitalier de Ver-
sailles, Le Chesnay, France
Frank T. G. Rahusen Department of Orthopaedics, St. Jans Gasthuis,
Weert, The Netherlands
Trichy S. Rajagopal Department of Orthopaedic Surgery, Royal
Berkshire
Manoj Ramachandran Barts and The London NHS Trust and The London
Childrens Hospital, Whitechapel, London, UK
Stefan Rammelt Clinic for Trauma and Reconstructive Surgery,
University
Hospital Carl-Gustav Carus, Dresden, Germany
Neta Raz Department of Orthopaedic Surgery, Royal Berkshire
Hospital,
Reading, UK
Bnai Zion Medical Center, Haifa, Israel
Jai G. Relwani East Kent University Hospital, Ashford, Kent, UK
Nikolaos Rigopoulos Department of Orthopaedic Surgery, Faculty of
Med-
icine, School of Health Sciences, University of Thessalia, Biopolis,
Larissa,
Greece
W. H. C. Rijnen Department of Orthopedics, Radboud University
Nijmegen Medical Centre, Nijmegen, The Netherlands
Carla S. P. van Rijswijk Leiden University Medical Centre, Leiden,
The
Netherlands
Peter Ritschl Orthopaedic Clinic Gersthof, Vienna, Austria
Marco J. P. F. Ritt Department of Plastic, Reconstructive and Hand
Surgery, VU Medical Centre, Amsterdam, The Netherlands
Andrew H. N. Robinson Cambridge University Hospitals, NHS Foundation
Trust, Cambridge, UK
C. Michael Robinson The Edinburgh Shoulder Clinic, Royal Infirmary
of
Thierry Rod Fleury Division of Orthopaedics and Trauma Surgery,
University Hospitals of Geneva, Geneva, Switzerland
Benedict A. Rogers Mount Sinai Hospital, University of Toronto,
Toronto,
ON, Canada
Andreas Roposch Great Ormond Street Hospital for Children, Institute
of
Child Health, University College London, London, UK
Oleg Safir Mount Sinai Hospital, University of Toronto, Toronto, ON,
Canada
l
Contributors
Asif Saifuddin Royal National Orthopaedic Hospital NHS Trust, Stanmore,

Middlesex, UK
Anthony Sakellariou Frimley Park Hospital, Frimley, Frimley, UK
Tiago Saldanha Giology Department, EGAS Moniz Hospital - CHLO,
Lisboa, Portugal
Guillem Salo Orthopaedic Department, Spine Unit, Universitat Auto`noma
de Barcelona, Barcelona, Spain
Jari Salo Helsinki University Hospital, Toolo Hospital, HUS, Helsinki,
Finland
Mikel San-Julian Department of Orthopaedic Surgery, University of
Navarra, Pamplona, Spain
Dietrich Schlenzka ORTON Orthopaedic Hospital, Helsinki, Finland
B. W. Schreurs Department of Orthopedics, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands
J. C. M. Schrier Orthopedics and Traumatology, Isala Clinics, Zwolle,
The Netherlands
Reinhard Schuh Foot and Ankle Center Vienna, Vienna, Austria
Department of Orthopaedics, Medical University of Vienna, Vienna, Austria
Michael Schutz Princess Alexandra Hospital, Queensland University of
Technology, Brisbane, Australia
Joseph Schwab Department of Orthopedic Surgery, Massachusetts General
Hospital, Boston, MA, USA
Wolfgang Schw
agerl Wien, Austria
Laurent Sedel Orthopaedic Department, University of Paris Denis Diderot,
Hopital Lariboisie`re (APHP), Paris, France
Raphael Seringe Hopital Cochin APHP, Universite Paris-Descartes, Paris,
France
Elvire Servien Centre Albert Trillat, Groupe Hospitalier Nord, Hospices
Roger Sevi Hille Yafe Hospital, Hadera, Israel
Nuno Sevivas Hospital de Braga, Clnica Espregueira-Mendes F.C. Porto
Stadium FIFA Medical Centre of Excellence, Porto, Portugal
S. Shetty Department of Radiology, Royal National Orthopaedic Hospital,
Haim Shtarker Department of Orthopaedic Surgery and Traumatology,
Western Galilee Hospital, Nahariya, Israel
Contributors
li
Rafael J. Sierra Mayo Clinic, Rochester, MN, USA

L. Sierrasesumaga University of Navarra, Pamplona, Spain
Francois Signoret Saint Antoine Hospital, Pierre et Marie Curie
University,
Paris, France
P. D. Siney The John Charnley Research Institute, Wrightington
Hospital,
Wigan, Lancashire, UK
Dishan Singh Royal National Orthopaedic Hospital,
Stanmore,
Middlesex, UK
Harvinder Singh University Hospitals of Leicester NHS Trust,
Leicester
General Hospital, Leicester, UK
Marco Sinisi Peripheral Nerve Injury Unit, Royal National
Orthopaedic
Chris Smith Princess Elizabeth Orthopaedic Centre, Exeter, UK
Marc Soubeyrand Service de Chirurgie Orthopedique, Hopital du
Kremlin-
Bicetre, Le Kremlin-Bicetre, France
Panayotis N. Soucacos School of Medicine, University of Athens,
Athens,
Greece
Kirsten Specht Section for Hip and Knee Replacement, Department of
Orthopaedics, Vejle Hospital, University of South Denmark, Vejle,
Denmark
Eric L. Staals Istituti Ortopedici Rizzoli, 5th Division, Bologna,
Italy
David Stanley Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
James C. Stanley York Teaching Hospital, NHS Foundation Trust, York,
UK
Petros Z. Stavrou Academic Department of Trauma and Orthopaedics,
School of Medicine, Leeds General Infirmary, Clarendon Wing, Leeds,
UK
Evangelismos Hospital, Athens, Greece
Zois P. Stavrou Henry Dunant Hospital, Athens, Greece
Michael M. Stephens Mater Private Hospital, Dublin, Ireland
Richard Stern Division of Orthopaedics and Trauma Surgery,
University
Hospitals of Geneva, Geneva, Switzerland
Maik Stiehler University Centre for Orthopaedics and Traumatology,
University Hospital Carl Gustav Carus, Dresden, Germany
Walter Michael Strobl Clinic for Pediatric Orthopaedic and
Neuroorthopaedic Surgery, Orthopaedic Hospital Rummelsberg,
Schwarzenbruck, Nuremberg, Germany
lii
Contributors
Jan Stulik Spine Surgery Department, University Hospital Motol, Praha,

Czech Republic
Norbert Suedkamp Department for Orthopedic Surgery and Traumatology,

Freiburg University Hospital, Freiburg, Germany
Mark G. Swindells Pulvertaft Hand Centre, Derby, UK
Panagiotis Symeonidis 2nd Orthopedic Clinic University of Thessaloniki,

Thessaloniki, Greece
Miklos Szendroi Department of Orthopaedics, Semmelweis University,

Budapest, Hungary
George Szoke Department of Orthopaedics, Semmelweis University, Buda-

pest, Hungary
Magnus Tagil Hand and Upper Extremity Unit, Department of Orthopedics,

Lund University Hospital, Lund, Sweden
Antonie H. M. Taminiau Department of Orthopaedics, Leiden University

Medical Centre, Leiden, The Netherlands
Chanan Tauber Kaplan Hospital Rehovot, Rehovot, Israel
Mark Tauber Section for Shoulder and Elbow Surgery, ATOS Clinic,
Munich, Germany
Sally Tennant Royal National Orthopaedic Hospital, Stanmore, Middlesex,

UK
Karl-Goran Thorngren Department of Orthopaedics, Lund University

Hospital, Lund, Sweden
Roger M. Tillman Oncology Unit, Royal Orthopaedic Hospital NHS Foun-

dation Trust, Birmingham, UK
Michael Alan Tonkin Royal North Shore Hospital, University of Sydney,

Sydney, Australia
Carlos Torrens Orthopedic Department, Hospital Universitario del Mar de

Barcelona, Barcelona, Spain
Alexandros Touliatos Department of the First Orthopaedic Department,

General Hospital of Athens, Athens, Greece
Ian A. Trail Hand and Upper Limb Surgery, Wrightington Hospital, Wigan,
Lancashire, UK
Georgios K. Triantafyllopoulos 3rd Department of Orthopaedic Surgery,

School of Medicine, University of Athens, Athens, Greece
Hans-Jorg Trnka Foot and Ankle Center Vienna, Vienna, Austria

Contributors
liii
Francois Tudor British Orthopaedic Trainees Association, Stanmore,

Middlesex, UK
Philippa Tyler The Royal National Orthopaedic Hospital, Stanmore,
Middlesex, London, UK
Maite Ubierna Spine Unit, Hospital Germas Trias i Pujol Badalona,
Barce-
lona, Spain
Victor Valderrabano Orthopaedic Department, University Hospital
Basel,
Basel, Switzerland
Angiola Valente Department of Orthopaedic and Traumatology, San
Luigi
Gonzaga Hospital, University of Turin, Turin, Italy
Matteo Benedetti Valentini Department of Orthopaedic Surgery,
University
of Rome Tor Vergata, Rome, Italy
H. van Dam Hand Surgery Department, St Andrews Centre for Plastic
Surgery, Broomfield Hospital, Chelmsford, Essex, UK
Michiel A. J. van de Sande Leiden University Medical Centre, Leiden,
The Netherlands
C. N. van Dijk Department of Orthopaedic Surgery, Academic Medical
Center, University of Amsterdam, Amsterdam, The Netherlands
Tom Van Isacker Service dOrthopedie et de Traumatologie, Cliniques
Belgium
Marie Van Laer Department of Orthopaedic Surgery and Traumatology,
Alexander Van Tongel Department of Orthopaedic Surgery and
Traumatology, Ghent University Hospital, Ghent, Belgium
F. Vannini Department of Orthopaedic and Trauma Surgery, Istituto
Pedro Varanda Hospital de Braga, Clnica Espregueira-Mendes F.C.
Porto
Stadium FIFA Medical Centre of Excellence, Porto, Portugal
B. L. Vazquez-Garca University of Navarra, Pamplona, Spain
Peter Verdonk Department of Orthopaedic Surgery and Traumatology,
Monica Ziekenhuizen, Antwerpen, Belgium
Rene Verdonk Department of Orthopaedic Surgery and Traumatology,
Richard Villar The Wellington Hospital, London, UK
Cesar Vincent Spine Unit, Orthopaedic Department, Bicetre
University
Hospital, AP-HP Paris, Universite Paris-Sud ORSAY, Le Kremlin
Bicetre,
France
liv
Contributors
Mihai Vioreanu Royal College of Surgeons Ireland, Ballinteer, Ireland

A. J. H. Vochteloo Leiden University Medical Centre, Leiden, The
Netherlands
Gershon Volpin Departments of Orthopaedic Surgery and Traumatology,
udiger von Eisenhart-Rothe Klinik fur Orthopadie und Sportorthopadie
R
am Klinikum rechts der Isar, Technische Universitat Munchen, Munchen,
Germany
Richard Wallensten Department of Orthopaedics, Karolinska University
Hospital, Stockholm, Sweden
David Warwick Hand Surgery, University Hospital Southampton,
Southampton, UK
Vincent Wasserman Service de Chirurgie Orthopedique, Hopital
Universitaire de Bicetre, Le Kremlin-Bicetre, France
Wolfram Wenz Paediatric Orthopaedics and Foot Surgery, Department
for Orthopaedic and Trauma Surgery, Heidelberg University Clinics,
Heidelberg, Germany
Florent Weppe Centre Albert Trillat Hopital de le Croix-Rousse, Lyon,
France
Philippe Wicart Hopital Necker Enfants malades AP-HP, Universite
Paris-Descartes, Paris, France
Johannes I. Wiegerinck Department of Orthopaedic Surgery, Academic
Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Keith Willett Kadoorie Centre for Critical Care Research and Education,
Trauma Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK
Andy M. Williams Chelsea and Westminster Hospital, London, UK
Timothy Huw David Williams Royal National Orthopaedic Hospital,
J. Brad Williamson Division of Neurosciences, Salford Royal Hospital,
Salford, UK
W. Winkelmann Department of Orthopedics, University Hospital and
Medical School, Munster, Germany
Eivind Witso St. Olavs University Hospital, Norwegian University of
Science Trondheim, Trondheim, Norway
B. M. Wroblewski The John Charnley Research Institute, Wrightington
Hospital, Wigan, Lancashire, UK
Timo Yrjonen ORTON Orthopaedic Hospital, Helsinki, Finland
Contributors
lv
S. Zaffagnini Sports Traumatolgy Department, Rizzoli Othopaedic

Institute, University of Bologna, Bologna, Italy
Luigi Zagra Hip Department, IRCCS Istituto Ortopedico Galeazzi,
Milan,
Italy
Peter Zenz Orthopadisches Zentrum Otto Wagner Spital, Wien, Austria
Christoph Zilkens Department of Orthopedic Surgery, University
Hospital
of Dusseldorf, Dusseldorf, Germany
Gianfranco Zinghi Rizzoli Orthopedic Institute, University of
Bologna,
Bologna, Italy
Hans Zwipp Clinic for Trauma and Reconstructive Surgery, University
Hospital Carl-Gustav Carus, Dresden, Germany
Part I
General Orthopaedics and Traumatology
Musculo-Skeletal Imaging
Philippa Tyler and Asif

Saifuddin
Contents
Bone Marrow Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
PET (Positron Emission Tomography) . . . . . . . . . . . . . . . 30

Musculo-Skeletal Radiography . . . . . . . . . . . . . . . . . . . . .
4 White Cell
Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
Basic Radiographic Physics . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Conventional Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Musculo-Skeletal Ultrasound . . . . . . . . . . . . . . . . . . . . . . .
33
Computed Radiography (CR) . . . . . . . . . . . . . . . . . . . . . . . .
5 Pitfalls and Limitations of Ultrasound . . . . . . . . . . . . . . .
33
Digital Radiography (DR or DX) . . . . . . . . . . . . . . . . . . . .
5 Indications for Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 34
Indications for Plain Radiographs . . . . . . . . . . . . . . . . . . . .
5 Ultrasound of Musculo-Skeletal Structures . . . . . . . . . .
35
Clinical Applications of Ultrasound . . . . . . . . . . . . . . . . . .

38
Musculo-Skeletal Computed Tomography . . . . . . . .
14 Interventional
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
Basic CT
Physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
CT Contrast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 14 Musculo-Skeletal MRI . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 42
Indications for
CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17 Basic MR Physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 42
TR and TE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 42
Radionuclide Imaging (Scintigraphy)
MR Image Contrast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 43
of the Musculo-Skeletal System . . . . . . . . . . . . . . . .
20 Image
Sequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 43
Basic Physics of Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . .
21 Contrast-Enhanced
MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
Radiopharmaceuticals: Bone Scan . . . . . . . . . . . . . . . . . . .
22 MRI Appearances of Musculoskeletal Tissues . . . . . .
49
Imaging
Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 22 Specific Clinical Applications of MRI . . . . . . . . . . . .
. . . 54
The Normal Bone Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23 Pitfalls of MR Imaging of the MSK System . . . . . . . . .
60
The Abnormal Bone Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23 Interventional MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 60
Primary Bone Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24 High Field MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 60
Metastatic
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24 Upright
MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 60
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 25 MRI Safety . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 60
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 26
AVN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 27 References . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 62
Joint
Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 27
Inflammatory Arthropathies . . . . . . . . . . . . . . . . . . . . . . . . . .
27
Metabolic Bone Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
SPECT (Single Photon Emission Computed
Tomography) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 29
P. Tyler (*)
The Royal National Orthopaedic Hospital, Stanmore,
Middlesex, London, UK
e-mail: philippa.tyler@rnoh.nhs.uk
A. Saifuddin
Royal National Orthopaedic Hospital NHS Trust,
e-mail: asif.saifuddin@rnoh.nhs.uk
G. Bentley (ed.), European Surgical Orthopaedics and Traumatology,

3
DOI 10.1007/978-3-642-34746-7_12, # EFORT 2014
4
P. Tyler and A. Saifuddin
Abstract
The Orthopaedic surgeon must learn to appro-
priately request and interpret a variety of diag-
nostic imaging studies, which requires a basic
understanding of the principles involved in
obtaining images in each technique, plus the
advantages, disadvantages and risks associ-
ated with each procedure.
Fig. 1 Orthopantomogram of
the mandible
Keywords
Xray # Ionizing radiation # Fluoroscopy # An accelerating voltage of
30150 kV between
Computed tomography (CT) # Ionic contrast the anode and cathode
drives the electron current
medium # Interventional radiology # Nuclear towards the target. The
tube current (mA) ranges
medicine (Scintigraphy) # Radio-isotope # Bone between 0.5 and 1,000 mA
and is controlled by
scan # White cell scan # Bone marrow scan # varying the filament
temperature. The kV and
SPECT # PET # Ultrasound # Transducer # mA can be varied
independently.
Artefact # MRI # Magnetic moment # X-rays interact with
matter in a variety of ways:
Radiofrequency pulse # Receiver coil # TR Transmitted (unaffected
by passing through
(repetition time), TE (echo time) # MR matter)
sequence # MR arthrography # MR safety Absorbed (complete or
partial transfer of their
energy to matter)
Scattered (diverted in a
new direction on inter-
Musculo-Skeletal Radiography action with matter,
with or without loss of
energy) [1].
Radiographs have been used for imaging since The x-ray beam is
attenuated by its interaction
their discovery by Roentgen in 1895, and are with body tissues, the
degree of absorption or
usually the initial method performed for scatter being determined by
the type and thick-
investigating musculo-skeletal pathology. The ness of tissue.
most-frequently requested diagnostic studies, Filtration is used to
remove low energy pho-
they are obtained relatively quickly and cheaply. tons before they reach the
patient, as they
Radiography continues to be a vital imaging tech- increase the radiation dose
to the patient without
nique in all spheres of Orthopaedic practice. contributing to the image.
Aluminium, copper
and molybdenum are the
filters most frequently
used in radiography, with
the latter used specifi-
Basic Radiographic Physics cally in mammography. Image
quality and radia-
tion dose are further
optimised by manipulation
Radiographs are generated when electrons are of the kV, mA, focus-film
distance and the use of
accelerated through a potential difference and grids to reduce scatter.
impact on a metal target. The kinetic energy of Tomography is achieved
by simultaneous
the electrons is converted into x-rays (1 %) and movement of the x-ray tube
and the film in oppo-
heat (99 %) [1]. The basic x-ray unit consists of site directions.
a glass tube containing a vacuum, within which Tomography is still
used in IVU investigations
are a negative electrode (cathode) incorporating and to produce the
Orthopantomogram (OPG) for
a tungsten coil, and a positive electrode (anode) imaging the mandible (Fig.
1). Only structures
containing a target, which is also usually made of in a slice at a particular
depth in the patient are
tungsten. When the element is heated to 2,200 # C, imaged clearly, with
blurring of the layers above
electrons are emitted by thermionic emission. and below this plane.
5
Fluoroscopy produces a real-time visible x-ray images, the main

difference being that in
image on a phosphor screen by converting the computed radiography, the
conventional film is
pattern of x-rays leaving the patient into replaced with an imaging
plate made of a photo-
a corresponding pattern of light. This is processed stimulable phosphor, housed
in a cassette placed
into an image visible on the viewing screen. under the body part. The
imaging plate is then
Ionising radiation interacts with tissue and can processed in order to obtain
a visible image.
cause tissue damage either directly to the individ- After the x-ray exposure
has been performed,
ual exposed (somatic effect), or to the descendents the photo-stimulable
phosphors store the exposure
due to damage to germinal tissues (genetic information as specific
electron energies, which
effects). The effective dose of radiation to differ- emit light when passed
through a CR laser reader.
ent body tissues is calculated by multiplying the The light is detected by a
photo-multiplier tube
radiation dose to a particular organ by the relevant which converts the
information into a digital form,
organ weighting factor. The gonads are the most producing the image. This
dispenses with the need
radio-sensitive and have the highest tissue for the darkroom processing
of traditional films,
weighting factor in the body. This fact should be and allows the image to be
viewed within
taken into account when requesting radiographs. seconds of processing. The
image is deleted from
Conventional radiography is now rarely avail- the imaging plate after
processing, and the plate
able, with most Imaging Departments now can be re-used thousands of
times.
utilising either Computed Radiography (CR) or
Digital Radiography (DR or DX) systems with
storage to PACS (Picture Archiving and Commu- Digital Radiography (DR or
DX)
nications Systems).
Digital Radiography is a
film-less system of x-ray
image capture. Digital x-ray
sensors are used
Conventional Radiography instead of photographic
film, and the images are
immediately available,
avoiding the processing,
Conventional radiography uses x-ray cassettes, management and storage
involved with conven-
which consist of an x-ray film located between tional films. The main
advantages of digital
a pair of phosphor crystal intensifying screens. imaging include a wide
dynamic range, post-
X-rays pass through the patient and fall on the processing capabilities,
multiple viewing
cassette. The screens transform x-rays into light options, electronic transfer
and easily accessible
photons, with the intensity of the emitted light archiving. A more consistent
image quality is
being proportional to the intensity of the x-rays. achieved, with a reduced
frequency of under- or
Radiographic films typically consist of a polyester over-exposure. Two types of
digital image cap-
base coated with silver iodo-bromide crystals. ture devices are currently
available: flat panel
These crystals are sensitive to visible light, detectors (FPDs) which
utilise amorphous silicon
ultraviolet light and x-rays, and when each crystal or selenium detectors, and
High Density Line
has absorbed approximately 100 light photons, Scan Solid State devices.
a tiny speck of silver is formed on the film, pro-
ducing a latent image. The film is then developed
and fixed in order to obtain a visible image [1]. Indications for Plain
Radiographs
The plain radiograph is the

most commonly-
Computed Radiography (CR) requested radiological
investigation and is used
to diagnose:
Conventional radiography has largely been super- Fractures
seded by computed radiography (CR). Both Primary and metastatic
bone tumours
systems use similar equipment to produce the Developmental
abnormalities
6
Inflammatory, infective and degenerative

conditions
Metabolic bone diseases; hand radiographs
alone may be the only investigations required,
for example in hyperparathyroidism
Before and after arthroplasty for operative
planning, confirmation of correct placement
and detection of post-operative complications
Fig. 2 Horizontal beam
lateral radiograph of the knee
Fluoroscopic therapeutic joint injections and demonstrating a
lipohaemarthrosis (arrow) in a patient
diagnostic arthrography use x-ray guidance with a complex, intra-
articular proximal tibial fracture
for needle placement and confirmation of (black arrowhead)
intra-articular location by the injection of
radio-opaque iodinated contrast medium.
The following examinations are generally not Bones: Deformity, loss of
alignment,
indicated unless requested by a specialist, focal defects, cortical
destruction or disconti-
according to RCR Guidelines 2007 [2]: nuity, areas of increased
or decreased
Skull series (except for suspected non- bone density, periosteal
reaction, callus
accidental injury in children, as part of the formation.
skeletal survey, myeloma screen or in the case Joints: Articular surfaces
for flattening, erosion,
of suspected intra-cranial metallic fragments sclerosis, cyst and
osteophyte formation. Joint
prior to MRI): Plain radiography of the skull space narrowing indicates
loss of articular
may have a role in situations where CT is not cartilage. Look for lesions
indicative of
available. CT is indicated for suspected basal osteo-chondral defects.
Joint effusion and lipo-
skull fracture, depressed skull fracture, in the haemarthrosis are easily
identified, although
unconscious patient, reduced Glasgow Coma ahorizontal beam lateral
may be required
Scale (GCS), retrograde amnesia, focal neurol- (Fig. 2).
ogy or suspected intra-cranial haemorrhage.
Sinus series Fractures
Nasal bone Virtually all fractures may
be visualised on one or
Rib series: However, a chest x-ray may be more views. The application
of certain
indicated to exclude a pneumothorax or rules regarding alignment
and angulation of
haemothorax in a patient with post-traumatic axes of bones and articular
surfaces allows a
rib pain. confident diagnosis of a
number of traumatic,
Coccyx developmental and congenital
abnormalities to be
Metastatic bone survey (radionuclide bone made. This is particularly
true in the cervical
scan is the investigation of choice): However, spine, shoulder, elbow (Fig.
3), wrist, hip and
multiple myeloma is investigated with a plain calcaneum.
film series as these lesions typically show no
or reduced uptake on a bone scan. Bone Tumours
A fundamental principle of musculo-skeletal The initial investigation of
a bone tumour is usu-
radiography is the need for 2 views of every joint ally a radiograph. Primary
tumours may be benign
or bone imaged, typically anteroposterior (AP) or malignant, and a
differential diagnosis is made
and lateral. One view may fail to adequately demon consideration of the
appearance and site of the
onstrate a fracture or dislocation. Radiographs lesion, and the age of the
patient. Of particular
should be interpreted in a methodical way: importance are the pattern of
bone destruction
Identify the age and gender of the patient. (geographic, moth-eaten,
permeative), the pres-
Soft tissues: Swelling, wasting, areas of calci- ence and type of matrix
mineralisation, the cortical
fication, fat or gas. and periosteal response and
the presence of a soft
7
range of radiographic
abnormalities, the majority
of which are most
easily examined and
categorised by
looking at their effect on the
hands. However, it
should be appreciated that by
the time radiographs
are abnormal, the disease
process is well
established.
Simple rules allow
the formulation of
a sensible
differential diagnosis:
Arthropathy
Distribution in the Hands
Proximal:
Rheumatoid
arthritis (RA)
Calcium
pyrophosphate dehydrate deposition
disease (CPPD)
Distal:
Psoriasis
Reiters
Osteoarthritis (OA)
Symmetrical
Arthropathy
Rheumatoid
arthritis
Primary OA
Fig. 3 Lateral view of the elbow showing a supracondylar
fracture of the distal humerus with the capitellum lying
completely posterior to the anterior humeral line. Note the
Sacro-Iliac Joint
Involvement
abnormally elevated posterior fat pad (arrow) Ankylosing
spondylitis (AS)
Inflammatory bowel
disease
Psoriasis
tissue mass, which allow an assessment of the rate Reiters syndrome
of growth and the likely tissue of origin. Based on Infection
(including TB)
these features, a correct radiographic diagnosis can Hyperparathyroidism
be suggested in 8090 % of cases (Fig. 4). Osteoarthritis
Radiographs also allow surveillance of lesions Normal bone
mineralisation is seen in the follow-
following treatment. ing: OA, CPPD, gout,
pigmented villonodular
synovitis (PVNS),
synovial osteochondromatosis
Developmental/Congenital (SOC).
Abnormalities Hallmarks of OA:
Joint space narrowing,
Diagnosis of a range of congenital abnormalities is osteophyte formation,
sub-chondral sclerosis
made on radiographic findings (Fig. 5). Screening and cysts (Fig. 6a).
programmmes for neonatal diagnosis of DDH Hallmarks of RA:
Bilaterally symmetrical
involve the use of ultrasound. However, diagnosis proximal
abnormalities within the hands,
and surveillance in older age groups relies on plain soft tissue swelling,
peri-articular osteoporosis,
radiographs. joint space
narrowing, marginal erosions
(Fig. 6b).
Inflammatory/Degenerative Conditions Hallmarks of AS:
Squaring of the vertebral
Sero-positive and sero-negative arthropathies, bodies, osteopenia,
ligament and disc ossifica-
collagen vascular disorders, osteoarthritis and tion, facet ankylosis
(Fig. 6c) and sacro-iliac
crystal-induced arthropathies produce a wide joint fusion (Fig.
6d).
8
a b c
d e
Fig. 4 (a) AP radiograph of the humerus showing a well- aneurismal bone cyst
(ABC). (c) AP radiograph of the
defined expansile lesion, with a narrow zone of transition lower limb showing
permeative bone destruction of the
and ground glass appearance, typical of fibrous dyspla- proximal fibular
metaphysis and an associated soft tissue
sia. (b) AP radiograph of the ankle showing a well-defined mass (arrow) in a case
of Ewing sarcoma. (d) AP radio-
expansile lesion of the distal fibula typical of an graph of the distal
femur showing aggressive bone
9
a c
Fig. 5 (a) AP radiograph of the pelvis demonstrating left cuneiforms (arrow).

(c) AP radiograph of the lumbar spine
DDH, with a small proximal femoral ossification centre showing a congenital
scoliosis due to a right L2/L3
and shallow acetabulum. (b) Oblique radiograph of the hemivertebra (arrow)
foot showing coalition between the talus, navicular and
Metabolic Disorders Arthroplasty

Primary and secondary disorders of calcium Pre-operative
pathology and post-operative
metabolism produce characteristic x-ray findings. complications are
identified on plain radiography.
Metabolic disorders commonly encountered Peri-prosthetic
lucency can be seen in loosening,
include osteoporosis, osteomalacia, renal infection and
granulomatous reaction and
osteodystrophy, hyperparathyroidism (Fig. 7a, b) may initially be very
subtle, requiring clinical
and Pagets disease (Fig. 7c). Radiographs may correlation and
careful comparison with previous
also be used to assess response to treatment and radiographs. In
general, lucency more than
to identify complications (e.g., fractures in osteo- 2 mm in width at the
bone-prosthesis interface,
porosis and osteomalacia or secondary tumours in cement-bone interface
or prosthesis-cement
Pagets disease). interface is a
significant finding (Fig. 8).
Fig. 4 (continued) destruction, medullary sclerosis and a chondral-type matrix

mineralisation and bone expansion
mineralised soft tissue mass in a case of osteosarcoma. (e) without associated
cortical destruction in the ulna, consis-
AP radiograph of the distal forearm showing an area of tent with a low-grade
chondral tumour
10
a b c
Fig. 6 (a) Radiograph of the distal inter-phalangeal joint, appearances of

ankylosing spondylitis, with squaring
showing typical changes of osteoarthritis with loss of joint of the vertebral
bodies (arrow), osteopenia and
space, sub-chondral sclerosis and osteophyte formation. facet joint
ankylosis. (d) AP radiograph of the
(b) Rheumatoid arthritis, with erosions at the proximal sacroiliac joints in
ankylosing spondylitis, showing verte-
inter-phalangeal joint of the little toe. (c) Lateral radio- bral syndesmophyte
formation (arrows) and fusion of
graph of the thoracic spine showing the typical the SIJs
11
a b
Fig. 7 (a) AP radiograph of the hand showing radial sub- lobular lytic lesion
in the patella (arrows) due to a brown
periosteal bone resorption (horizontal arrow) and terminal tumour of
hyperparathyroidism. (c) AP radiograph of the
phalyngeal tuft erosions (oblique arrow) in a case of hyper- left hemipelvis
showing cortical thickening and a coarse
parathyroidism. (b) AP radiograph of the knee showing a trabecular pattern
involving the left ilium in Pagets disease
12
Fig. 8 AP radiograph showing lucency at the cement-

bone interface of the femoral component of a right THR
(arrows) in a patient with septic loosening of the femoral
prosthesis
Fractures through bone or cement may occur, with

the latter frequently clinically silent. Radiographs
also allow accurate evaluation of prosthesis
alignment. Fig. 9 (a) Lateral
radiograph of the elbow, showing a
relatively radiolucent
lipoma (arrow) projected over the
Soft-Tissue Abnormalities anterior elbow joint.
(b) Lateral radiograph of the ankle
The size and site of soft tissue masses, effusions, demonstrating lobular
soft tissue calcification posterior to
the tibiotalar
artticulation
collections or wasting can be seen on radiographs,
as can fat (Fig. 9a), although MRI, CT and ultra-
sound are more sensitive. Bone involvement and (Fig. 10b) and
myelography (Fig. 10c), which are
presence of soft tissue calcification (Fig. 9b) will frequently
supplemented by additional cross-
also be evident [3]. sectional imaging.
Xray-Guided Intervention Bone Density

Measurement
Fluoroscopy allows dynamic intervention, and is Dual x-ray
absorptiometry (DEXA) bone densi-
commonly used for diagnostic and therapeutic tometry assesses bone
mineral density and is
intra-articular injections (Fig. 10a), discography used to assess the
risk of osteoporotic fractures.
13
a c
Fig. 10 (a) Wrist arthrogram showing a subtle tear of the deep to the PLL
(arrowhead). (c) cervical myelogram
TFCC (arrow) with contrast entering the distal radioulnar showing
pseudomeningocele formation (arrows) follow-
joint (arrowhead). (b) lumbar discogram showing a pos- ing adult brachial
plexus trauma
terior annular tear (arrow) and leak of contrast medium
Two x-ray beams, each with a differing energy a comparison of the

patients bone density to a
level are used, and bone density is calculated fol- young adult of the same
gender with peak bone
lowing subtraction of soft tissue x-ray absorption. mass. A T-score above
#1 is normal, #1 to #2.5
A T-score and Z-score are obtained. The T-score is signifies osteopaenia,
and osteoporosis is defined
14
as a T-score below #2.5. The Z-score compares and width may also be
adjusted manually.
the patients bone density score with an age and Windowing allows pixels of a
specific range
gender-matched standard. of HU to be displayed as
shades of grey
Radiographic examinations are the most within the range of black to
white, with pixels
commonly performed imaging studies, are rela- containing CT numbers outside
the selected
tively cheap and quick to perform. Minimising range displayed as
undifferentiated areas of
patient radiation dose, while obtaining an optimal black or white.
image is of primary concern. Unnecessary exam- CT provides exquisite
detail of osseous struc-
inations result in a significant radiation dose to tures in multiple planes, can
demonstrate fat and
the patient with no benefit, and are a waste of can distinguish between fluid
and solid soft tissues
resources. (Fig. 11a). There are many
clinical settings in
which CT is considered
superior to MRI. The
advent of multi-detector
(MDCT)/multi-slice CT
Musculo-Skeletal Computed scanners has enabled rapid
acquisition of high
Tomography quality images in thin slices
which can be
reconstructed into multi-
planar re-formats and 3D
Basic CT Physics images (Fig. 11). Unlike MRI,
interventional pro-
cedures are easily performed
under CT-guidance
Computed tomography (CT), invented by Sir and there are no absolute
contra-indications to CT.
Godfrey Hounsfield and first used in 1971, Flat-panel volume CT (fpVCT)
is a recent
employs the method of tomography by using development in imaging and
has the advantages
mutliple x-ray generators and detectors rotating of producing images of high
spatial resolution,
around the body as the patient is moved through with volumetric coverage and
allows dynamic
the CT scanner. Digital geometry computer scanning and combined
fluoroscopy and tomogra-
processing is used to generate a three-dimensional phy (omni-scanning). However,
contrast resolu-
image of the internal structure of the body part tion is slightly inferior to
MDCT [4].
from a series of two-dimensional x-ray images
taken around the axis of rotation. The varying
levels of brightness on the CT image represent CT Contrast
the relative densities of the structures within
each CT slice, and the brightness levels are quan- CT scans can be enhanced by
the use of iodinated
tified as Hounsfield Units (HU). The appearance contrast, which may be
administered via an
of body tissues on CT is similar to plain radiogra- intravenous, intra-thecal (CT
myelography),
phy, with bone appearing white or hyperdense intra-discal (CT discography)
or intra-articular
(HU 1000), water as light grey (HU 0), fat as (CT arthrography) route.
dark grey (HU #30 to #190) and air as black Intravenous contrast is
used to identify
(HU #1000). Acute haemorrhage is hyperdense; vessels and determine the
pattern and rate of
blood has a HU ranging from 50 to 80, depending contrast uptake by lesions,
thus increasing
on the age of the haemorrhage. diagnostic confidence. Cystic
lesions may show
Although historically the images generated peripheral enhancement, while
solid masses
were in the axial plane, modern scanners allow typically show a more
homogeneous pattern of
this volume of data to be re-formatted in various enhancement. Necrotic areas
do not show sig-
planes or even as volumetric (3D) representations nificant contrast
enhancement.
of structures. Windowing is used to optimise Bolus tracking technology
allows accurate
the image depending on the tissue type of interest. triggering of a CT scan to
image a body part
Pre-set window levels such as bone, lung, when contrast passes a
specific point within
mediastinum, brain and liver are available on a vessel. Examples include CT
pulmonary angi-
most CT viewing systems, but the window level ography (CTPA) to identify
pulmonary embolus,
15
a b
Fig. 11 (a) Coronal CT MPR viewed on soft tissue appears much darker
than the adjacent muscle. (b) CT 3D
windows showing urine in the bladder (arrow) which reconstruction of the
rib cage showing multiple rib fractures
appears slightly darker (hypodense) than the adjacent mus- (arrows). (c) Coronal
CT MPR of the right femur showing an
culature, and a lipoma (arrowhead) in the left thigh, which intra-cortical
sequestrum in a case of osteomyelitis (arrow)
or CT angiography to identify an arterial stenosis, the patient undergoes

a CT scan. CT arthrography
aneurysm or rupture (Fig. 12a). is a sensitive
technique for identification of
CT arthrograms are used in situations where ligamentous
disruption and articular cartilage
patients are unable to have an MRI arthrogram, defects (Fig. 12b).
when a detailed visualisation of articular bone is CT myelography is
an invasive diagnostic pro-
required, or where double contrast arthrography cedure in which non-
ionic contrast is administered
is helpful. The contrast (and air if a double intra-thecally, used
when a plain CT is inconclusive
contrast study is to be performed) is injected and MRI is not
available or is contra-indicated.
into the joint under fluoroscopic guidance, before Indications are now
limited but include location of
16
a b
Fig. 12 (a) 3D reconstruction of a normal CT angiogram of the iliac and femoral

vessels. (b) Coronal MPR of
single contrast right hip CT arthrogram showing a chondral fissure (arrow) in the
femoral head articular cartilage
the site of a CSF leak or dural tear, diagnosis responsible for

approximately 40 % of the total
of traumatic nerve root avulsion and for the radiation dose produced
by diagnostic imaging.
assessment of spinal stenosis. The following effective
radiation doses should be
Non-ionic contrast approved for intra-thecal considered when
requesting a CT study [5]:
use is administered fluoroscopically via lumbar
puncture typically at the L2-3 or L3-4 levels. Cer-
vical myelography may be performed by a lateral Effective
No. of chest x-rays
puncture at C1-C2, or a lumbar puncture can be dose of CT
required for equivalent
Body part (mSv)
radiation dose
performed followed by tilting the table, using
Cervical 4.36
55
gravity to run the contrast into the neck. The spine
patient will then undergo a CT study (Fig. 13), Thoracic 17.99
225
with reconstructions in three planes. spine
CT is one of the most accessible and rapid Lumbar 19.15
240
cross sectional imaging modalities available, spine
and currently accounts for about 5 % of all radio- Shoulder 2.06
26
Hip 3.09
39
graphic examinations performed. However, CT is
17
Fig. 14 3D CT
reconstruction of the pelvis showing
undisplaced fractures of
the pubic rami and right sacral
ala (arrows)
of MDCT allowing rapid

high quality imaging of
acutely unwell patients
in non-anatomic positions
Fig. 13 Axial cervical CT myelogram showing a post-
has led to an increase
in the use of CT in the initial
traumatic meningocoele (arrowhead) extending into the
right C5-C6 intervertebral foramen and complete avulsion imaging of the poly-
trauma patient. These patients
of the ventral and dorsal C6 nerve roots (arrow) are frequently imaged
with CT for potential pathol-
ogy in the head, chest,
abdomen or pelvis and
adding an extra scan to
evaluate musculoskeletal
Indications for CT
pathology does not
greatly increase the total scan
time. The spine is
frequently inadequately imaged
Trauma of the axial and appendicular
on plain radiographs in
the trauma setting. MDCT
skeleton, particularly when plain radiographs
detects 97100 % of
cervical spine fractures com-
alone do not fully demonstrate the full extent
pared to 6070 % on
plain radiograph lateral views
of the bony injury (e.g., tibial plateau, spinal
alone [6]. CT can also
demonstrate soft tissue inju-
and pelvic fractures)
ries. However,
ligamentous structures, particularly
Pre-operative planning (e.g., for CAD-CAM
those in the spine are
better visualised on MRI.
joint prostheses)
Complex fractures of
the pelvis, acetabulum,
CT-guided intervention (biopsy, injection,
ankle and tibial plateau
are usually imaged
vertebroplasty)
with CT. Multi-planar
re-formats and 3D recon-
Tumour and infection (bone and soft-tissue)
structions (Fig. 14) are
particularly helpful in pre-
Assessment of congenital abnormalities,
operative planning.
Facial trauma can be difficult
femoro-acetabular impingement, patello-
to assess on plain
radiographs and CT should be
femoral mal-alignment and mal-tracking
considered in all
instances where facial fractures
Post-operative assessment (e.g., joint prosthe-
are suspected,
particularly orbital blow-out frac-
ses and spinal fusion)
tures and Le Fort
fractures [7]. Stress fractures in
Imaging in patients for whom MRI is contra-
the pars inter-
articularis and appendicular skeleton
indicated.
are well-visualised on
CT, and have a variable
Trauma appearance depending on
the age of the lesion,
The initial imaging of major trauma involves including endosteal
sclerosis, cortical thickening
a series of radiographs. However, the advantages and a lucent fracture
line (Fig. 15).
18
With the
availability of digital radiology sys-
tems such as PACS,
femoral ante-version or ret-
roversion are easily
evaluated. Kinematic CT
allows evaluation of
patellar mal-tracking and
mal-alignment [8].
Post-Operative
Assessment
CT is valuable for the
assessment of the painful
hip prosthesis when
radiography is normal,
showing subtle
osteolysis (Fig. 18a) or mini-
mally-displaced peri-
prosthetic fractures. The
assessment of bony
fusion, either following
trauma or surgery is
also optimally demonstrated
Fig. 15 Axial CT image of the L5 vertebra showing by CT (Fig. 18b).
bilateral healing pars inter-articularis stress fractures
(arrows) Imaging When MRI is
Contra-Indicated
CT may be used as an
alternative imaging modal-
ity in situations where
MRI is contra-indicated or
Tumours and Infections impractical. CT may be
requested if excessive
MRI is generally considered superior to CT in artefact from metallic
devices is likely to reduce
evaluating bone and soft tissue tumours. However, the diagnostic quality
on MRI. Alternatively, the
there are circumstances when CT is of value in patient may be
medically unstable, claustrophobic
tumour imaging, for example the identification of or have a pacemaker in
situ. Useful information
the nidus of an osteoid osteoma (Fig. 16a), dem- can still be acquired,
even in situations where MRI
onstration of occult matrix mineralisation, or the is the imaging modality
of choice. For example, in
soft tissue calcification in myositis ossificans the lumbar spine, CT
may demonstrate a prolapsed
(Fig. 16b, c). Trabecular abnormalities in mye- or sequestered disc,
stenosis of the spinal canal,
loma are demonstrated on CT before plain film neural foramen or
lateral recess, spondylolisthesis,
evidence of the disease is apparent. Sometimes an spondylolysis,
degenerative changes of the facet
osteoid osteoma may be impossible to differenti- joints, and end-plate
changes. Further information
ate from a small focus of osteomyelitis on CT, regarding the spinal
canal and nerve roots can be
MRI and plain radiographs, and in this situation, acquired following a CT
myelogram.
a biopsy may be required for definitive diagnosis.
In osteomyelitis, CT demonstrates the elevated Reduction of Metallic
Artefacts
periosteum, sequestrum (Fig. 11c) or cloaca, Streak artefacts from
metallic devices are com-
and will identify associated soft tissue oedema monly encountered and
can cause difficulties in
and fluid collections. the interpretation of
images (Fig. 19). Several fac-
tors affect the amount
of CT artefact from prosthe-
Assessment of Congenital Abnormalities ses: type of metal,
shape and thickness of the
Tarsal coalition is a common congenital abnor- prosthesis, body site
involved, method of image
mality routinely imaged with CT, which allows reconstruction and kVp
and mAs used. Titanium
surgical planning, or to decide whether generates fewer
artefacts than other metals [9].
arthrodesis is necessary. Talo-calcaneal coalitions
are best visualised on coronal imaging, while Interventional CT
calcaneo-navicular coalition is best imaged in the CT Arthrography (CTA)
axial plane (Fig. 17). Joint narrowing, secondary Most diagnostic
arthrograms of the shoulder and
degenerative changes and fibrous or osseous hip are performed using
MRI. However, CTA is
coalition can also be identified. quick, has a higher
spatial resolution and may
19
a b
Fig. 16 (a) Axial CT image through the thigh showing an swelling and oedema of
the vastus medialis muscle
osteoid osteoma nidus (arrow) in the thickened posterior (arrow). Corresponding
axial CT image (c) through the
femoral cortex. Axial T2W FSE MR image (b) showing thigh showing maturing
myositis ossificans (arrow)
suffer less from metallic artefact than MRI. accuracy in the

evaluation of cartilage thickness
CTA has a sensitivity of 93 % and a specificity in the ankle and elbow.
of 89 % for the diagnosis of recurrent meniscal
tears following partial meniscectomy [10]. Wrist CT-guided Injection and
Biopsy
ligament tears are well-demonstrated with CT-guidance allows
accurate needle placement
CTA, which has been shown to be more for performing bone and
soft tissue biopsies
accurate than MR arthrography or plain MRI, (Fig. 20a), nerve root
(Fig. 20b), facet joint
particularly in the evaluation of partial tears of (Fig. 20c) and a variety
of intra-articular injec-
the scapho-lunate and lunato-triquetral ligations. In difficult
cases, the needle may be placed
ments [11]. CTA and MRA have a similar under fluoroscopic CT-
guidance.
20
Fig. 17 Coronal CT image through the ankle, demon-

strating talo-calcaneal osseous coalition (arrow)
Radiofrequency Ablation (RFA)

RFA is a procedure using radio waves or electric
current to generate sufficient heat to destroy
a lesion or interrupt nerve conduction. CT guid-
ance is used to accurately place the RFA needle Fig. 18 (a) Axial CT of the
hips showing osteolysis
into an osteoid osteoma, and the lesion ablated (arrow) at the acetabular
prosthesis-bone interface.
(b) Coronal CT MPR following
2-level circumferential
leading to destruction of the nidus (Fig. 21). RFA instrumented lumbar spinal
fusion showing solid anterior
is also used for the treatment of facet joint pain, interbody bone graft at
L4/L5 (arrow)
with ablation interrupting the facet joint innerva-
tion on a semi-permanent basis.
Radionuclide Imaging (Scintigraphy)

of the Musculo-Skeletal System
Scintigraphy is a sensitive, but often non-specific

tool for the investigation of musculoskeletal
disorders. Conventional skeletal scintigraphy pri-
marily investigates the bone or bone marrow and
to a lesser extent, the soft tissues.
Bone scans are used to investigate a wide range
of diseases, including metabolic disorders, infec-
tion, infarction and malignancy. Scintigraphy
works by demonstrating changes in blood flow Fig. 19 Axial CT image
through the pelvis, demonstrat-
and osteoblastic activity within a bone. Correlation ing streak artefact from the
bilateral total hip
with other imaging modalities allows greater replacements
21
a b
Fig. 20 (a) Axial CT image showing biopsy of a lytic lesion has been injected to
confirm correct needle position, and is
in the tibia. (b) Axial image through the lumbar spine show- seen outlining the
nerve root (arrow). (c) Axial CT image
ing needle placement during a nerve root injection. Contrast showing the needle
position in an L5/S1 facet joint injection
diagnostic accuracy. Scintigraphy involves a signif- from a stable

nucleus. Isotopes of an element are
icant radiation dose to the patient a typical Tc99m nuclides which have
the same number of protons,
methylene diphosphonate (MDP) bone scan atomic number and
chemical properties, but
involves the same radiation dose as a year of back- a different number
of neutrons, mass number
ground radiation. and density.
Radionuclides may be produced in
a nuclear reactor or
cyclotron and undergo radio-
active decay to a
more stable form by emitting
Basic Physics of Scintigraphy alpha, beta or gamma
radiation.
Diagnostic
nuclear medicine involves the
Scintigraphy involves the use of radio-isotopes administration of a
substance labelled with a
(tracers), which are unstable nuclides produced radionuclide, which
is then taken up by specific
by the addition or subtraction of a neutron to or tissues. As the
radio-nuclide decays, the emitted
22
a b
Fig. 21 (a) Axial CT image through the tibia showing the nidus of an osteoid
osteoma within the lateral tibial cortex.
(b) Axial CT image showing electrode position during treatment with CT guided
radiofrequency ablation
gamma rays leave the body and are detected by a An interrupted

sympathetic nerve supply will also
gamma camera. They react with a crystal result in an
increased uptake of Tc99m -MDP in the
photomultiplier to produce light energy, which is affected extremity
[12]. The radionuclide is initially
recorded and transformed into a final image [12]. adsorbed onto the
bone surface, before binding to
the bone matrix.
Approximately 5060 % of the
radionuclide fixes to
bone and the rest is excreted
Radiopharmaceuticals: Bone Scan by the kidneys [13].
Due to the rapid renal excre-
tion, a high bone-to-
soft tissue ratio is achieved
The radionuclides used for bone scanning are phos- 23 h after
injection.
phate analogues labelled with Tc99m, which is
a pure gamma-emitter, has good localisation to
bone and fairly rapid excretion from the body. Imaging Protocol
The half life of Tc99m is 6 h: long enough to perform
a radionuclide clinical study but short enough to Conventional (static)
images are usually acquired
avoid an excessive radiation dose to the patient. The 34 h after the
injection of the isotope. When
chelator-nuclide complex most commonly used in a bone or joint
infection is suspected, or when
bone scanning is Tc99m -MDP (methylene- assessment of blood
flow to a primary bone
diphosphonate). After intravenous administration, tumour is required, a
triple phase bone scan is
the Tc99m -MDP localises to the bone, with the rate performed.
and degree of tracer uptake depending on the bone This technique
incorporates a vascular phase
metabolism and blood supply. The quantity of (with images acquired
up to 1 min after injec-
mineralised bone, and patient hormone and vitamin tion), followed by
scans at 35 min post-injection
levels determine the amount of uptake to a lesser (blood-pool phase),
in which the radiopharma-
extent. Areas with an increased metabolism, blood ceutical is
predominantly in the extra-cellular
flow and osteoblastic activity, as occur in infection, compartment, although
some will have already
trauma, inflammation and the majority of tumours, been taken into bone.
This phase demonstrates
will have a high tracer uptake on a bone scan. any hyperaemic areas
in bones, joints or
23
a b
L R
L
e i
e
f g
f
t h
t
t
Fig. 22 (a) A normal paediatric whole body Tc99m -MDP bone scan. Note the linear
increased isotope uptake at the
open physes. (b) A normal adult whole body Tc99m -MDP bone scan
soft tissues. Delayed or static images are obtained The Abnormal Bone Scan
at 24 h, after the patient has emptied their blad-
der. A shorter delay between the injection and the Abnormalities usually
manifest themselves as
acquisition of static images may be used in chil- areas of increased uptake
of radionuclide tracer,
dren. The entire skeleton is imaged either as although some lesions have
a photopoenic
anterior and posterior whole body images or as appearance on
scintigraphy.
numerous localised views, the latter allowing the
acquisition of oblique views, and images of Causes of localised
increased uptake on a bone
greater spatial resolution. scan:
Primary and metastatic
bone tumours
Osteomyelitis
The Normal Bone Scan Fracture (including
stress fractures)
Loose prostheses
Most bones can be recognised individually. Open Arthritis
growth-plates show a high uptake of radionuclide Localised asymmetric
increased blood flow
(Fig. 22a): this appearance will reduce and even- (e.g., reflex
sympathetic dystrophy)
tually disappear with fusion of the growth-plate Non-skeletal tissues
(areas of soft tissue calci-
and uptake will eventually be similar to that of the fication, infarction,
haematoma, thrombophle-
remainder of the skeleton (Fig. 22b). bitis, some liver and
lung metastases)
24
Fig. 23 Blood pool (top BLOOD POOL

KNEE
left image) and static phase
image from a Tc99m -MDP
bone scan in a patient with
left distal femoral osteoid
osteoma, showing increase
isotope uptake on both
phases (arrows) indicating
a vascular, osteoblastic
nidus
RT ANTERIOR LT RT
ANTERIOR LT
KNEE
KNEE
Causes of generalised increased uptake on a bone tumours can show increased

activity within the
scan: matrix, even if they appear
radiographically
Primary hyperparathyroidism lucent. Scintigraphy can be
useful in the assess-
Renal osteodystrophy ment of osteoid osteoma
(OO), which classically
Multiple metastases (superscan) shows a double-density
sign related to the
Haematological diseases, e.g., thalassaemia increased activity of the
central osteoblastic
nidus and the slightly less
intense increased activ-
Causes of localised decreased uptake on a bone ity of the surrounding
osteoblastic response
scan: (Fig. 23). A normal bone
scan essentially excludes
Lytic metastases (e.g., renal cell carcinoma), the possibility of an OO.
However, the diagnosis
myeloma, Langerhans cell histiocytosis of OO is now usually made
by a combination of
Early AVN or infarction radiography, MRI and CT,
with scintigraphy gen-
Attenuation artefacts from overlying pace- erally adding no further
diagnostic information.
makers, breast implants, metallic objects and
prostheses.
Prior radiotherapy Metastatic Disease
Causes of generalised decreased skeletal uptake Bone scans are frequently

requested for the detec-
on a bone scan: tion of metastatic disease
as an aid to staging and to
Cardiac failure (poor tracer uptake) assess response to
treatment. Virtually all malignant
Vitamin D treatment tumours may metastasise to
bone, with the most
common primaries including
breast, lung, bowel
and prostate. Bone
metastases usually produce an
Primary Bone Tumours osteoblastic response (Fig.
24), but lytic lesions
such as myeloma and renal
cell metastases may
Bone scans show increased focal activity in the produce photopenic areas
(Fig. 25). A superscan
majority of primary benign and malignant bone occurs when there is
coalescence of multiple focal
tumours due primarily to the reactive osteoblastic lesions leading to a
diffusely high uptake of tracer
response of the host bone adjacent to the lesion, throughout the skeleton,
with an accompanying
but this is of little diagnostic value. Bone-forming reduction in the normal
renal uptake.
25
Fig. 24 Whole body Tc99m -MDP bone scan showing

multifocal areas of increased activity involving the Fig. 25 Whole body
Tc99m -MDP bone in a patient with
spine, ribs, pelvis and femora due to widespread skeletal metastatic renal cell
carcinoma, showing localised
metastases reduced isotope uptake
in a lytic metastasis of the proxi-
mal tibia (single
arrow). Note the absence of renal uptake
following nephrectomy
(double arrows)
The pattern of uptake and location of Infection

lesions may help to differentiate between
benign and malignant lesions: for example, Increased radionuclide
uptake is seen on all phases
metastases are frequently multiple and when of the bone scan in
osteomyelitis (Fig. 26). This
occurring in the spine, often result in allows differentiation
from cellulitis, which only
increased uptake in the pedicle or diffusely demonstrates increased
soft tissue uptake in the
throughout the vertebral body. They infre- first two phases, with
no increased uptake in the
quently occur as focal deposits in the vertebral delayed phase,
indicating no abnormality within
bodies or as lesions in the facet joints [14]. the bone. A fourth
phase at 24 h may be useful to
Similarly, multi-focal areas of increased activity demonstrate
osteomyelitis in an extremity which
related to the joints, especially the AC joints, was poorly visualised
in the 3 h delayed phase.
knees and feet are typical of OA rather than Gallium studies,
labelled white cell scans with or
metastatic disease (Fig. 22b). without bone marrow
scintigraphy, and positron
26
RMLL PERF
RT ANT
PERF LT
3HRS RMLL
Fig. 26 Tc99m -MDP bone scan of the lower legs of a

patient with tibial osteomyelitis, demonstrating increased
isotope uptake (arrows) in the distal right tibia on the RT ANT
3HRS LT
perfusion scan (upper image), and the 3 hour delayed
scan (lower image) Fig. 27 Tc99m -MDP
bone scan showing increased radio-
nuclide uptake on both
the perfusion scan (upper image)
and on delayed 3 hour
scan (lower image), consistent with
emission tomography (PET) are also of use, par- periprosthetic
infection of a distal femoral replacement.
ticularly in the case of the infected prosthesis. On this study,
increased uptake is shown as a black area
around the radiopoenic
prosthesis
While MRI is now the modality of choice for the
diagnosis of osteomyelitis, scintigraphy has
a definite advantage over MRI and CT in imaging
of the infected prosthesis as the images are not
degraded by metallic artefact (Fig. 27). on plain radiography,
but can be identified on
bone scans. Bone scans
are usually abnormal
within 24 h following
a fracture, and will remain
Fractures positive for up to 2
years, depending on the frac-
ture site, type and
age of the patient. Fractures
Most fractures will be detected radiographically. treated with internal
fixation may remain positive
However, some fractures may initially be occult for up to 3 years.
Radionuclide imaging was
27
a b
c
Fig. 28 (a) Tc99m -MDP bone scan showing decreased image of the left humerus
in the same patient, showing a
activity (arrow) within the superior suarticular left serpiginous linear hypo-
intensity in the oedematous
humeral head in a case of AVN. (b) Plain radiograph humeral head (black
arrow). There is also diffuse marrow
demonstrating sclerosis and early collapse of the left oedema involving the
humeral shaft, resulting from co-
humeral head secondary to AVN. (c) Coronal STIR existing osteomyelitis
(white arrow)
commonly used for the detection of occult frac- Joint Prostheses

tures of the scaphoid bone and femoral neck, and
for detecting stress and insufficiency fractures of Loosening or infection
around joint prostheses
the lumbar spine and sacrum. MRI is now more causes increased peri-
prosthetic uptake of radio-
frequently used for the early detection of nuclide. The initial post-
surgical increased
suspected fractures not visualised on plain radio- uptake usually decreases
rapidly, returning to
graphs. SPECT CT (see later) has an important normal within 12 months
around the femoral
role in the detection of spondylolysis and peri- component, 2 years around
the acetabular com-
prosthetic fractures. ponent, and 18 months
around the knee [15].
Persistent non-dynamic
activity around the pros-
thesis tip or lesser
trochanter is suggestive of
AVN aseptic loosening (Fig.
29), while more general-
ised activity evident on
all three phases indicates
Bone infarction is a recognised complication of infection (Fig. 27).
Suspected peri-prosthetic
fractures, and may also be caused by a number of infection may be further
investigated by the use
factors including sickle cell disease, alcoholism, of SPECT CT, PET, gallium
and labelled white
pancreatitis and the use of steroids. Initially the cell/bone marrow scans and
aspiration of articu-
affected bone appears photopenic (Fig. 28), but lar/peri-prosthetic fluid
collections [16].
uptake will increase in the reparative phase, mak-
ing diagnosis more difficult. Pattern recognition,
correlation with other imaging modalities and Inflammatory Arthropathies
patient clinical history all allow greater diagnos-
tic confidence in difficult cases. SPECT scans of Bone scans show increased
uptake in active inflam-
femoral head AVN typically demonstrate matory arthropathies and
osteoarthritis, with pattern
a photopenic centre surrounded by an area of recognition of disease
distribution assisting in the
increased activity [15]. differentiation between
types of arthropathy.
28
b
Fig. 29 Tc99m -MDP bone scan showing aseptic loosen-
ing of bilateral THRs with focal increased activity at the
right greater trochanter and the tip of the left femoral stem
(arrows)
Scintigraphy in active rheumatoid arthritis

(RA) demonstrates increased activity on both
the dynamic and static phases, with uptake
paralleling other markers of disease activity [17].
99mTc-labelled human immunoglobin has been
found to be sensitive and specific in the evalua-
tion of disease extent and activity in RA [18, 19].
Bone scan activity precedes radiographic change
in osteoarthritis, but is rarely performed for
primary diagnosis.
Increased sacro-iliac joint uptake precedes
radiographic changes in ankylosing spondylitis
and can be utilised as a diagnostic tool, although
POST 5HRS
MRI is now the investigation of choice (Fig. 30).
Fig. 30 (a) AP
radiograph of the SI joints showing bilat-
eral SI joint
erosion and sclerosis in ankylosing spondyli-
tis. (b) Tc99m-MDP
bone scan image taken 5hrs post
Metabolic Bone Disease injection,
demonstrating symmetrical increased radionu-
clide up at both
sacroiliac joints
Osteoporosis
Bone scans are useful in the detection and ageing
of vertebral fractures, with uptake returning to
normal limits 618 months after the fracture.
As a result, the likelihood of the fracture being Transient
osteoporosis and regional migratory
the cause for back pain can be assessed and other osteoporosis are
seen as areas of increased uptake
causes of back pain such as facet joint syndrome, within the femoral
head and greater trochanter on
metastases or infection can be identified. all three phases of
a triple phase study.
29
multi-planar images of
the distribution of
Tc99mMDP. The gamma
camera stops every 6#
to detect the
emissions, allowing the reconstruction
of slices of tissue in
a manner similar to a CT scan.
However, the images
suffer from poor resolution
and greater noise than
occurs with conventional CT.
SPECT may be
combined with high-
resolution computed
tomography (CT) equip-
ment in a
single/hybrid system. The isotope
tomography/SPECT and
anatomic CT images
can then be displayed
separately or co-registered
as fused images.
SPECT/CT is particularly use-
ful in imaging small
abnormalities, for example
pars defects (Fig. 32)
and facet joint pathology
in the lumbar spine
and AVN in the femoral
heads. SPECT white
cell scans are used to accu-
rately locate foci of
infection, and are of partic-
ular use in cases of
periprosthetic infection
(Fig. 33).
Bone Marrow
Scintigraphy
Bone marrow consists

of a haemopoetic compo-
nent and a
reticuloendothelial component,
which is imaged using
a technetium-labelled
nano-colloid. Tc-99 m
nano-colloid is taken up
by the
reticuloendothelial cells present in bone
Fig. 31 Whole body Tc99m -MDP bone scan showing marrow and is the
basis for this imaging proce-
diffuse increase activity in the expanded right hemipelvis dure. Particles are
delivered via the blood supply;
due to Pagets disease therefore images also
reflect regional blood flow.
Pagets Disease Indications:

Pagets disease involves an initial phase of bone Haematological
disease to identify marrow
resorption, followed by an intense osteoblastic distribution,
replacement or activity
response, producing a characteristic scintigraphic Investigation of
metastases
appearance. Markedly increased activity is seen Osteomyelitis (in
conjunction with a labelled
in the involved bone or bones, together with bone white cell scan)
expansion and deformity in the chronic stage Sarcoma
(Fig. 31). Bone uptake may resolve partially or Differentiation of
infarct from osteomyelitis
completely on bisphosphonate therapy. in sickle cell
disease (in conjunction with
a bone scan)
SPECT (Single Photon Emission Normal Bone Marrow

Scan
Computed Tomography) Tc-99 m nano-colloids
are used as a tracer, and
imaging takes place 30
min after injection, with
SPECT utilises a double headed gamma camera 75 % of the nano-
colloid distributed to the liver
which rotates around the patient to create and spleen, and the
remainder to the skeleton.
30
Fig. 32 SPECT scan showing bilateral L4 spondylolysis on SPECT (a), CT scan (b) and
fused SPECT/CT scan (c),
with increased isotope uptake indicating osteoblastic activity seen as orange areas
Abnormal Bone Marrow Scan PET (Positron Emission

Tomography)
Pathological extension of bone marrow into the
appendicular skeleton as occurs in haematological 18F fluorodeoxyglucose-
positron emission tomog-
conditions such as thalassaemia is seen as raphy (FDG-PET) is an
imaging modality increas-
increased tracer uptake extending further than 1/3 ingly utilised as a
diagnostic tool in the detection of
of the way down the humerus or femur and within malignancy and infection.
FGD is a glucose ana-
the skull. Marrow insufficiency results in globally- logue labelled with F-18,
which is taken up by
reduced tracer uptake, while metastases result in metabolically active cells
and decays with the
focal areas of photopenia. Conversely, osteosarco- production of a positron.
Each positron is annihi-
mata generally display focal increased uptake of lated by interaction with an
electron within the
tracer. patient, resulting in the
emission of two photons
Osteomyelitis results in a focal decrease in of 511 keV of gamma
radiation in opposite direc-
reticulo-endothelial function and decreased tions. The gamma radiation
is detected by cam-
tracer uptake on bone marrow scans. Acute eras and transformed into an
image. Like SPECT,
infarction causes focal decreased tracer uptake PET can be combined with CT.
PET studies are
on bone marrow scans (Fig. 34), but without associated with a
significant radiation dose to
the pattern of tracer uptake typical of osteomye- the patient.
litis on a bone scan, a factor helpful in FDG-PET measures glucose
uptake by tissues
differentiating infarction from infection in sickle and is used primarily in
oncological imaging.
cell disease. Osseous metastases are
typically represented as
31
Fig. 34 Bone marrow scan of

the abdomen and pelvis
showing reduced uptake in
the L5 vertebral body (arrow)
secondary to an acute
infarct in a patient with sickle cell
disease. A Tc99m -MDP bone
scan performed during the
same episode showed no
evidence of osteomyelitis
discrete foci of FDG uptake

(Fig. 35). Fractures
may present in a similar
fashion, although the
uptake is greater in
malignant than benign frac-
tures [20]. PET has a
particular use in the inves-
tigation of chronic
infection as FDG is avidly
taken up by the macrophages
which predominate
in the chronic phases of
infection, and has a better
sensitivity and specificity
in this clinical situation
than labelled white cell
scans [21]. Images are
obtained 45 min after the
tracer is injected, and
areas of increased activity
are seen as bright foci
on the scan. FDG-PET may be
used in the diag-
nosis of infected
prostheses, although images
must be interpreted with
caution as prosthetic
joint loosening can also
lead to a positive scan.
Potential pitfalls in
oncological FDG-PET
Fig. 33 SPECT Indium 111 white cell scan showing imaging include mis-
interpretation of increased
a soft tissue abscess in the right thigh (arrows) on uptake occurring in
osteomyelitis, inflammatory
axial CT (upper image), white cell scan (middle
image) and fused white cell scan and axial CT scan arthropathies, fractures,
osteoarthritis and
(lower image) osteophytes.
32
Fig. 35 Sagittal CT (image on left), PET (central image) and fused CT + PET(image
on right) demonstrating increased
uptake in the T10 vertebra secondary to a metastasis
White Cell Scan
The patients own white blood cells are removed

111In-WBCs
by means of venesection and are labelled with
Indium or Tc99m. The labelled leucocytes are then
injected back into the patient and accumulate in
the reticuloendothelial system (physiological
uptake) i.e., marrow, liver and spleen, but are
also attracted to sites of active infection (as
opposed to the diphosphonates used in bone
scans, which accumulate in bone). Therefore,
there will be increased tracer uptake in areas of
infection rather than areas of increased bone turn-
over (Fig. 36). White cell scans are of particular
value in assessing suspected infection around
a prosthesis, and have the additional benefit 24 HR
ANT PELVIS
of not suffering from the metallic artefact typi-
Fig. 36 White cell scan
in a patient with an infected
cally seen on CT or MRI. They are also useful femoral component of a
right THR, with mild increased
in evaluating multi-focal infection, as, the uptake in the soft
tissues of the lateral right thigh, second-
entire body can be imaged in a single study. ary to abscess formation
(arrow)
33
Increased specificity (but a slightly lower sensi- to as anechoic. Structures of

equal echogenicity
tivity) is achieved by combining white cell scans are termed iso-echoic.
with bone or bone marrow scans [16]. The skin surface is
conventionally at the top of
the US image. The depth, focus
level and gain
(brightness) can all be
adjusted to optimise the
Musculo-Skeletal Ultrasound image.
Power Doppler or colour
Doppler functions
Ultrasound (US) obtains images by the use of utilise the Doppler Effect to
detect velocity and
sound waves rather than ionising radiation or direction of blood flow. It is
also possible to deter-
magnetic resonance, and has the advantage of mine flow patterns and degrees
of vascular steno-
being dynamic, with real-time image acquisition sis. Doppler imaging is of
value in determining the
particularly well-suited to image-guided inter- vascularity of a structure,
its proximity to vessels
ventional procedures. and the presence of any
thrombus within a vessel.
The US transducer transforms electrical The compressibility of
structures or masses can
energy into sound waves, with coupling gel also be assessed during an
ultrasound examina-
allowing transmission of sound waves into the tion. Elastography is a new
technique but its appli-
soft tissues. These sound waves are reflected cation to the musculo-skeletal
system is as yet
back to the transducer from tissue interfaces. unclear. Similarly, the use of
US contrast media
The transducer transforms the echo back into is not routine in musculo-
skeletal US.
electrical energy, producing the US image.
The soft tissues within the body have different
levels of impedance and absorption. Reflection is Pitfalls and Limitations of
Ultrasound
increased if the tissue interface is perpendicular
to the US beam. Sound wave absorption increases Anisotropy occurs when the
US beam is not
with increasing transducer frequency and perpendicular to the target
structure, resulting
increasing tissue viscosity [22]. Each transducer in normal tissues appearing
abnormally hypo-
produces sound waves of a specific frequency echoic. This is a particular
problem in the
range, and most US machines contain a variety imaging of tendons and
ligaments (Fig. 37).
of probes, each of a different frequency. Probe Reverberation artefact
occurs when the US
frequency is directly proportional to image reso- beam repeatedly reverberates
between
lution and inversely proportional to depth of a highly reflective surface
such as bone or
penetration of the US beam. As a result, the a needle, and the ultrasound
probe (Fig. 38).
higher frequency probes used in musculo-skeletal Acoustic shadowing occurs
when reflective
imaging produce high resolution images of rela- structures such as bone,
calcium or air prevent
tively superficial structures, such as tendons and the transmission of the US
beam beyond that
ligaments. structure, resulting in an
anechoic region deep
Transducers may be linear or curvilinear. to that structure (Fig. 39).
Linear high frequency probes are generally used Acoustic enhancement:
structures allowing
for musculo-skeletal imaging, as they achieve high transmission of the US
beam result in
maximal resolution with minimal artefact. a hyperechoic area beyond
that structure.
Tissue interfaces that are strongly reflective Examples include cystic
lesions (Fig. 40),
produce a very bright echo (for example at some homogeneous mass
lesions and the
a bone-soft tissue interface) with shadowing bladder.
deep to the interface, due to lack of penetration Operator dependency results
in variability in
of the US beam. Bright areas are termed hyper- interpretation of imaging
findings, and
echoic, darker areas are termed hypo-echoic, and can make it difficult to
review US images
tissues completely devoid of echoes are referred produced by a different
operator.
34
Fig. 39 US image of
the chest wall showing normal
subcutaneous fat (F),
muscle (M) and ribs (R). Note the
acoustic shadowing
obscuring visualisation of structures
deep to the ribs
Fig. 37 Transverse US scan of the shoulder at the level of

the bicipital groove. The normal hyperechoic long head
biceps tendon (a) can appear hypoechoic (b) if the US
probe is angled during scanning, thus mimicking
pathology
Fig. 40 US image of an
anechoic cyst (white arrow),
demonstrating
posterior acoustic enhancement (black
arrows)
Indications for
Ultrasound
Soft-tissue injury
Dynamic study
required
Fig. 38 Reverberation artefact: resulting in
Soft-tissue or
joint infection or inflammation
multiple reflective lines parallel to the biopsy needle Soft-tissue mass
(differentiation of solid vs.
(arrows) cystic)
35
Vascular study, e.g., Doppler US to exclude

DVT
US-guided intervention
Patient/lesion not suitable for other imaging
modality, e.g., MRI
Ultrasound of Musculo-Skeletal
Structures
Muscle
Normal muscle is of intermediate/low
echogenicity, with clear demonstration of muscle Fig. 41 Transverse image
through the proximal anterior
fibre architecture, particularly on images parallel thigh showing the sartorius
and rectus femoris muscles,
to the long axis of the muscle. with a small herniation of
rectus femoris through a fascial
Muscle injury may result from direct impact, defect (arrow)
laceration or distraction.
Compressive (direct impact) muscle injuries which appears or increases
in size on muscle
tend occur in the muscle belly and are fre- contraction (Fig. 41).
Sonography is best
quently seen in contact sports. Following the performed as a dynamic
examination, with
initial hyperechoic haemorhhage, they appear scanning of the hernia
during active muscle
as hypo-echoic areas with ill-defined borders. contraction and
relaxation. Large hernias
Muscle distraction injuries or tears typically become obvious as the
muscle bulges through
occur at the musculo-tendinous junction the fascial defect on
contraction. Subtle eleva-
and follow sudden forceful muscle contraction or thinning of the
fascia on muscle con-
tion. They are classified as Grade 1 traction is seen in less
obvious hernias that can
(elongation injury with no fibre disruption easily be overlooked. Care
must be taken to
identified on US), Grade 2 (partial avoid excessive transducer
pressure, which
muscle tear) or Grade 3 (complete tear of can efface the hernia.
muscle fibres), with a haematoma being pre-
sent in grade 2 and 3 tears. The prognosis Muscle trauma is best
assessed at about 48 h
depends on the grade of injury. Muscle after the injury, when the
haematoma has become
retraction occurs with full thickness tears hypoechoic or anechoic and
best outlines
and can be demonstrated by active muscle a potential tear [23]. MRI
tends to over-estimate
contraction or passive movement at the joint. the size of an acute muscle
tear, with US provid-
Acute haemorrhage appears hyperechoic, ing a more accurate tool for
evaluating the extent
and reduces in size and echogenicity of injury.
over time.
Muscle laceration can also result in partial or Tendons
full thickness tears. US can be used to identify
tendon rupture,
Muscle hernias-most frequently occur in the tendinopathy and
tenosynovitis. Normal tendons
lower limb, commonly involving tibialis ante- are hyper-echoic on US with a
fine fibrillar inter-
rior. They are often encountered in sporting nal structure that cannot be
appreciated with MRI
adolescents or young adults, with causes (Fig. 42).
including sports-related injuries, chronic com- Tendinopathy is seen as a
thickened,
partment syndrome and defects in overlying hypoechoic tendon, which
has lost its normal
fascia at sites of perforation by vessels. The fibrillar pattern (Fig.
42). Increased blood flow
hernia typically presents as a painless mass, may be seen on colour
Doppler imaging.
36
Fig. 42 Longitudinal (a) and transverse (b) images and a thickened, hypoechoic
and heterogeneous right
through the middle 1/3 of the bilateral Achilles Achilles tendon, typical of
tendinopathy
tendons, demonstrating a normal left Achilles tendon
Tendon rupture may be partial or complete.

Common sites include the Achilles tendon
(mid-tendon or at musculotendinous junc-
tion), patellar tendon (common in track and
field athletes), quadriceps tendon (usually
incomplete tears at the musculo-tendinous
junction of the rectus femoris tendon), biceps
tendon and rotator cuff injuries, with the
supraspinatus tendon most commonly injured
(Fig. 43).
Ligaments
Ligaments have a similar appearance to tendons, Fig. 43 Longitudinal
shoulder US showing a complete
but are slightly more hyper-echoic, with a more tear of the supraspinatus
tendon with proximal retraction
compact fibrillar pattern (Fig. 44). (dotted line)
37
Fig. 44 Transverse-oblique image of the antero-lateral

ankle showing the talus (T), distal fibula (F) and anterior
talofibular ligament (arrow)
US may be used to evaluate the ligaments of

many joints, including the digits, elbow, ankle
and knee.
Grade 1 injuries are characterised by adjacent
hypoechoic/anechoic fluid but an intact Fig. 45 Longitudinal
US of the knee showing synovial
ligament. thickening (arrow) in
suprapatellar bursal synovitis
Grade 2 injuries are partial thickness tears.
Grade 3 injuries are full-thickness tears, with
complete disruption of the ligament, a
haemorrhage and surrounding fluid.
Dynamic imaging with differing stresses dem-
onstrates varying degrees of joint widening,
depending on the grade of ligamentous injury.
In the knee, medial collateral injury is suggested
when the femoral attachment is more than 6 mm
thick and the tibial attachment is more than
3.6 mm thick [24]. b
Synovium
Normal synovium is thin and of medium
echogenicity and should not show blood flow on
colour Doppler imaging.
Fig. 46 (a) Normal
knee. Longitudinal (coronal) image
In inflammatory synovitis, the synovium of the medial joint
line showing the medial collateral
becomes thickened, hypo-echoic and vascular ligament (arrow),
medial meniscus (M) and the
(Fig. 45). Synovial proliferation is also seen in hyperechoic tibial
and femoral cortices. (b) Panoramic
view of the knee
demonstrating the quadriceps tendon
pigmented villonodular synovitis (PVNS), lipoma
(QT), patella (P) and
patellar tendon (PT)
arborescens and synovial osteochondromatosis.
Cartilage (Fig. 46) and

peripheral meniscal tears, cysts and
Hyaline cartilage is anechoic, while fibrocartilage extrusions can all be
identified. However, MRI
is hyperechoic on US. The peripheral portions of remains the gold
standard for imaging assessment
the menisci are easily assessed on ultrasound of the menisci.
38
a c
Fig. 47 Soft tissue masses on US. Well-defined lipoma posterior acoustic

enhancement (b). Heterogeneous sar-
(arrows) of similar echogenicity to surrounding subcuta- coma containing central
necrosis and haemorrhage
neous fat (a). Well-defined hypointense fibroma with (arrow) (c)
Clinical Applications of Ultrasound Cellulitis may be seen

as hyper-echoic thick-
ening of the
subcutaneous tissues acutely, but
Soft Tissue Masses later develops a hypo-
echoic reticular pattern
Ultrasound is able to differentiate between solid of oedema tracking
between fat lobules.
and cystic masses, and evaluate the degree of Hyperaemia evident on
colour Doppler
vascularity of a mass. imaging helps to
differentiate subcutaneous
Lipomata are common soft tissue masses, oedema of venous
insufficiency or cardiac
which are oval, homogeneously hypo/isoechoic failure from infective
cellulitis.
and contain no blood flow on Doppler imaging. Abscesses are usually
round or oval in shape,
A rapidly enlarging, painful or vascular mass is but can be elongated
or irregular (Fig. 48).
suspicious of malignancy, and further imaging They vary in
echogenicity from anechoic to
and biopsy is required. hyper-echoic, although
are typically anechoic/
Soft tissue sarcomas tend to be predominantly hypoechoic with
posterior acoustic enhance-
hypo-echoic, hypervascular and often contain ment. Doppler imaging
typically demonstrates
areas of necrosis (Fig. 47). increased vascularity
of the abscess wall and
surrounding tissues.
Abscesses may occur in
Infection muscle, bursae and in
tissues adjacent to
US can localise the extent and site of an infective infected metalwork or
an infected bone (oste-
focus, determine whether a fluid collection is omyelitis). In the
latter case, cortical irregu-
present and guide subsequent drainage, biopsy larity and periosteal
elevation may be
or aspiration. identified (Fig. 49).
US cannot reliably
39
a b
Fig. 48 Abscess in the subcutaneous tissues of the lateral antecubital fossa,

demonstrated on US (a) and T2 fat-
suppressed MRI (b)
differentiate between infective and non- and tendon sheath, with

increased vascularity
infective bursitis, and an aspiration of fluid is of the tendon sheath
and sometimes the
required for diagnosis [23]. peripheral aspects of
the tendon. Hypo-
Septic arthritis requires early diagnosis and echoic fluid within the
tendon sheath may
treatment to minimise the risks of long-term be identified. Rice
bodies may be seen
complications. US is helpful to differentiate in the tendon sheath
fluid in TB
between septic arthritis and septic bursitis and tenosynovitis [26].
guides needle aspiration. Hip joint effusions
are particularly common in children, and Vascular Malformations
US is frequently used to identify and guide Arterio-venous
Malformations (AVM) are seen
aspiration of increased joint fluid (Fig. 50). as heterogeneous variably
echogenic masses
A hip joint effusion is identified if the containing disorganised
channels of vascular
distance between the cortex of the femoral flow on Doppler imaging.
AVMs and
neck and outer margin of the hip capsule is haemangiomata frequently
contain foci of calci-
greater than 5 mm (9 mm in adults) or if this fication and fat. An AVM
must be differentiated
distance is 2 mm greater than on the contralat- from a malignant neoplasm.
Complete compress-
eral side [25]. Absence of a visible joint ibility of the lesion
favours a diagnosis of vascu-
effusion in joints with a non-distensible cap- lar malformation (Fig.
51).
sule such as the SIJ does not exclude septic
arthritis, and diagnosis should be made by Miscellaneous
MRI [23]. Foreign bodies are seen as
hyperechoic struc-
Infective tenosynovitis most frequently tures, often linear in
shape. A hypo-echoic area
involves the flexor tendons of the hands and surrounding a foreign body
may represent
wrists, and leads to thickening of the tendon haemorrhage, an abscess or
granulation tissue.
40
Fig. 50 US of septic
arthritis in the paediatric hip, show-
ing intra-articular fluid
(double arrow) and a thickened
joint capsule (arrow)
associated haematoma.
Plain radiographs and/or
MRI are required for
accurate diagnosis.
Nerve entrapment or
neuroma is seen as
hypoechoic thickening of
a nerve. US is the
modality of choice for
diagnosis of a Mortons
neuroma, which is seen as
a focal hypoechoic
thickening of a plantar
nerve in the forefoot.
A plantar fibroma
manifests as a hypoechoic
area of thickening on the
plantar fascia (Fig. 52).
Plantar fasciitis is
seen as a hypo-echoic
thickening (>4 mm) of the
plantar fascia
(Fig. 53).
Bakers cyst
formation is due to distension of
the semimembranosus-
gastrocnemius bursa. Com-
munication between the
bursa and knee joint occurs
in at least half of
patients over the age of 50. The
cyst may be simple or
complex, occasionally with
hyper-echoic contents
secondary to haemorrhage,
synovitis or PVNS.
Rupture of a Bakers cyst
causes pain and oedema in
the subcutaneous tissues
Fig. 49 Distal tibial subperiosteal collection located of the calf, mimicking a
DVT.
between the periosteum and cortex (double arrow) Bursitis the normal
bursa may contain
seen on longitudinal US scan (a). Corresponding T2 Fat- a trace of fluid.
Bursitis manifests as
saturated MR images of the leg in a patient with
Staphylococcal osteomyelitis (b) a generalised or focal
thickening of the bursal
walls, with increased
vascularity in cases of true
synovitis. Bursal fluid
distension may be seen,
and can vary in
appearance from anechoic to
Fractures may be identified on US as cortical hyperechoic, depending on
the underlying
disruption, often with an associated haematoma. cause. Causes of sub-
acromial bursitis include
It is important not to mistake osteomyelitis with impingement, infection,
rotator cuff tear and
cloaca and abscess formation as a fracture and an haemorrhage (Fig. 54).
41
a b
Fig. 51 Ultrasound image of a vascular malformation (a), which shows complete

compressibility with pressure applied
to the ultrasound probe (b)
Fig. 52 Longitudinal US image of the mid-foot, with a

hypoechoic plantar fibroma (white arrows) on the superfi-
cial surface of the distal plantar fascia. Note the acoustic
Fig. 54 Thickening
of the subacronial-subdeltoid bursa
enhancement deep to the fibroma (black arrow)
(arrows) overlying
the surpasinatus tendon
Developmental
dysplasia of the hip (DDH) is
usually diagnosed on
US scanning of neonates
(Fig. 55), and a
national screening programme
is in place in order
to initiate early diagnosis
and treatment and
minimise long-term
complications.
Interventional
Ultrasound
The dynamic, real-

time nature of US ensures that it
is well-suited to
image-guided intervention. It also
Fig. 53 Longitudinal US image of thickened and
has the advantage of
demonstrating vessels and
hypoechoic plantar fascia (dotted line) at its calcaneal vascular areas of
tissue, which ensure increased
origin (arrow), typical of plantar fasciitis safety and accuracy
during injections and biopsies.
42
principle that MR active

nuclei (nuclei with an
odd number of protons
such as Hydrogen 1,
Carbon 13, Oxygen 17)
combine a net charge
with net spin, and in
doing so induce magnetic
moments about
themselves. The hydrogen
nucleus contains a
single proton and is the MR
active nucleus used in
routine clinical MRI as it
has a large magnetic
moment and is abundant in
the fat and water of the
body.
The application of
an external magnetic field
causes the magnetic
moments to align with
the magnetic field
direction and spin at a certain
frequency determined by
the external magnetic
field strength. The
magnetic moments are said to
be in-phase when they
are all at the same orien-
Fig. 55 Ultrasound image of the infant hip, showing the tation in their
precessional path at a single point
femoral head (dotted line) lying in a shallow acetabulum
in a patient with developmental dysplasia of the hip in time.
The application of a
radiofrequency (RF) pulse
at the same frequency as
the precessing hydrogen
nuclei, and at 90# to
the direction of the external
US may be used to guide intra-articular, magnetic field induces
resonance, leading to the
intra-bursal and tendon sheath injections of steroid hydrogen nuclei
absorbing energy from the RF
and/or local anaesthetic for diagnostic and thera- pulse. The magnetic
moments move in phase
peutic purposes, and also for the biopsy of super- with each other and the
net magnetic vector
ficial soft tissue tumours and the extra-osseous (NMV) comes to lie in
the transverse plane, 90#
components of appendicular bone sarcomas. to the direction of the
magnetic field.
The receiver coil
also lies in the transverse
plane. A voltage (the MR
signal) is induced in
Musculo-Skeletal MRI the receiver coil as a
result of the NMV rotating
around the transverse
plane at resonance.
Magnetic Resonance Imaging (MRI) is now the The RF pulse is then
removed and the MR signal
technique of choice for an increasing number of starts to decrease,
until the next RF pulse is applied.
musculo-skeletal pathologies in both the acute and
non-acute setting. Continuous advances are
being made in the field of musculo-skeletal MRI TR and TE
in terms of increasing field strength, new
sequences and interventional techniques. While The TR is the repetition
time between the
a comprehensive understanding of complex MR consecutive RF pulses
and controls the degree
physics is not necessary in order to interpret of T1 weighting of an
image. A short TR maxi-
the majority of MRI studies encountered in general mises T1 differences,
while a long TR minimises
Orthopaedics, a basic knowledge of the normal and T1 differences between
tissues.
abnormal appearances of musculo-skeletal struc- The TE (echo time)
represents the time
tures in different MRI sequences is essential. between the RF pulse and
collection of the
subsequently produced
signal. The TE used
Basic MR Physics determines the degree of
T2-weighting, with
a short TE minimising
and a long TE maximising
All protons and neutrons spin about their own T2 differences between
tissues.
axes within the nucleus. MRI is based on the TR and TE are
measured in milli-seconds (ms).
43
MR Image Contrast Hyperintense

Intermediate Hypointense
on T1 on
T1 on T1
Water consists of small molecules with Fat
Skeletal Fluid
little inertia, which are not able to absorb
muscle
Subacute
Spinal cord Fibrous tissue
energy efficiently, while fat consists of large
haemorrhage
(incl.
molecules which have slower motion, greater (methaemaglobin)
fibrocartilage)
inertia and are able to absorb energy more Proteinaceous
Hyaline Chronic
efficiently. It is these differences that cause fluid
cartilage haemorrhage/
the magnetisation in different tissues to relax
haemosiderin
at different rates when the RF pulseis removed, Gadolinium
Intervertebral Cortical bone
disc
and calcification
and is the basis for the contrast between
Tendons
tissuesthat contain varying amounts of fat or
Air
water.
Contrast refers to the presence of areas of Typical parameters for T1W
sequences:
high signal (white) and low signal (dark) and TR < 800 ms (short), TE < 30 ms
(short)
intermediate signal (grey) within an image. (Fig. 56a).
Image contrast relates to the size of the trans-
verse component of magnetisation of a specific
tissue at resonance and depends on the T2 Weighting
make-up of the tissue, in terms of water content, T2W sequences require a long TE
and TR, and
fat content, proton density and the presence are used to detect fluid and
general pathology.
of any CSF or blood flow. Image contrast Fat is slightly less hyper-
intense than on the
can also be controlled by the operator by T1W sequences, and will appear
hypo-intense if
means of manipulating other factors, including fat-saturation techniques have
been applied (see
the TE and TR [27, 28]. later). Normal muscle is of
intermediate-low sig-
nal intensity, while fluid is
very bright.
Conventional spin echo (CSE)
T2W
Image Sequences sequences have the drawback of
long acquisition
times. To overcome this, fast
spin echo (FSE)
A typical musculo-skeletal MRI examination sequences are now routinely
used (see later).
will involve between two and six
Intermediate Hypointense
sequences, obtained in at least 2 anatomical Hyperintense on T2
on T2 on T2
planes. CSF, joint fluid, urine,
Skeletal Fibrous tissue
Spin echo (SE) pulse sequences include T1 fluid collections
muscle
weighted (T1W), T2 weighted (T2W) and proton Oedema associated
Spinal cord Cortical bone
density weighted (PDW). with infection,
and
inflammation, acute
calcification
trauma
T1 Weighting
Hyaline Chronic
T1 weighted (T1W) sequences best demonstrate
cartilage haemorrhage/
anatomy and bone marrow architecture, and are
haemosiderin
also useful for demonstrating fat content Fat (unless T2
Tendons,
within masses, sub-acute haemorrhage and Fat-saturated)
ligaments
abnormal tissue enhancement following IV Subacute
Air
haemorrhage
Gadolinium. They are less sensitive than
Intervertebral disc
T2W fat-saturated or STIR (Short Tau Inversion nucleus
Recovery) sequences for the detection
of soft tissue oedema and bone marrow Typical parameters for CSE
T2W sequences:
pathology. TR > 2,000 ms, TE > 60 ms (Fig.
56b)
44
a b
Fig. 56 T1-weighted (a) and T2-weighted (b) sagittal nuclear SI in the L4/L5
and L5/S1 discs consistent with
images of the lumbar spine. Fat is hyperintense on both disc degeneration. An
annular tear is seen as a focal high
sequences, but CSF is hypointense on T1- and intensity zone in the
posterior aspect of the L5/S1
hyperintense on T2-weighted sequences. Note reduced intervertebral disc
(arrow)
Proton Density (PD) Fast Spin Echo (FSE)

In PD-weighted images, contrast is mainly FSE or turbo spin echo
sequences can be used
due to differences in the relative density of to produce T1W, T2W and
PDW images. They
protons in different tissues. The T1 and T2 are used to image the
brain, pelvis, spine, bones
effects are diminished by using an intermedi- and joints, but are not
well-suited for MRI of the
ate/long TR and a short TE. Anatomical chest and abdomen.
detail is optimally demonstrated on PDW Advantages of FSE
imaging include
sequences (Fig. 57). However, they are rela- shorter scan times,
increased matrix size
tively insensitive to marrow pathology and allowing greater spatial
resolution, reduced
the presence of fluid unless fat-saturation is metallic artefact and
reduced patient movement
used. artefact.
Typical parameters for PD sequences: TR > Disadvantages of FSE
sequences include
1,000 ms, TE < 30 ms increased fat signal on
T2W sequence, requiring
45
In the musculo-
skeletal system, the short tau
inversion recovery
(STIR) sequence is com-
monly used to acquire
images with enhanced
sensitivity for the
detection of fluid, combined
with suppression of
the signal from fat, and
works by exploiting
the difference in T1 between
water and adipose
tissue.
STIR sequences
achieve a more homogeneous
fat suppression than
standard T2W fat-saturated
sequences, but cannot
be used with gadolinium
contrast. Fluid
attenuated inversion recovery
(FLAIR) sequences are
used as a sensitive
sequence for the
detection of pathology in the
CNS, as the signal
from CSF is suppressed, mak-
ing hyper-intense
peri-ventricular and spinal cord
lesions more obvious.
Typical parameters:
STIR: TR > 2,000 ms,
TE > 30 ms (for T2W
imaging), Time to
Inversion (TI): 120150 ms
FLAIR: TR > 2,000, TE
> 30 ms (for T2W
Fig. 57 Sagittal PDW image of the normal knee, demon- imaging), TI: 1,500
ms (Fig. 58).
strating the hypointense meniscus, quadriceps and patellar
tendons, intermediate SI hyaline cartilage and muscle and
hyperintense bone marrow and fat
Frequency-Selective
Fat Saturation
Frequency-selective
fat saturation exploits the
fat-suppression, flow artefacts, blurring at difference in the
resonant frequency of protons
tissue margins and reduced conspicuity of in fat compared to
that of protons in water.
haemorrhage [27]. At 1.5 T, fat protons
precess at a frequency
225 Hz slower than
water protons. An RF
Fat Suppression spoiler pulse is
applied at the resonant
It is frequently advantageous to reduce or sup- frequency of fat, thus
removing its signal.
press the bright signal of fat on T1 and T2- Frequency-selective
fat suppression has the
weighted images. Indications for fat-suppressed advantage that it can
be used with any
sequences include increasing the conspicuity of MR sequence, and may
be used with gadolinium
fluid, oedema or haemorrhage, confirmation of contrast agents.
However, it is prone to inhomo-
the presence of fat within a lesion or to identify geneous fat
suppression and can only be used
areas of tissue enhancement following the admin- with field strengths
of 1 T or above.
istration of intravenous contrast.
There are several techniques available for Opposed Phase Imaging
achieving fat suppression, with the sequence of This technique relies
on the fact that the protons
choice dependent upon the tissue of interest and in fat and water will
not be at exactly the
clinical situation. same position or phase
during precession, due
to the slight
difference in their resonant
Inversion Recovery frequencies. Opposed
phase imaging is best
Inversion recovery (IR) sequences are used as suited to the
detection of lesions containing
a means of homogeneously suppressing signal small amounts of fluid
or fat, such as in imaging
from specific tissue types. of adrenal adenomata.
46
Fig. 59 Coronal T2*W GE

image of the knee showing an
osteochondral defect of
the medial femoral condyle
(arrow)
glenoid and acetabular

labrum and ligaments,
the ability to obtain 3-
dimensional (volume)
acquisitions and the
increased conspicuity of
haemorrhage, loose bodies
or gas (Fig. 59).
Disadvantages of GE
sequences include
increased metallic
artefact, poor demonstration
of marrow pathology in
the absence of trabecular
destruction, and over-
estimation of the size of
Fig. 58 Coronal STIR image of the knee showing the osteophytes in the spine.
expected low signal intensity of the bone marrow and GE sequences can be
used to acquire T1 and
sub-cutaneous fat, and high signal within the lobulated T2 images.
ganglion cyst (arrow) adjacent to the medial femoral
condyle
T1W: short TR (<50 ms),
short TE (510 ms),
flip angle usually
#90#
T2*W: long TR (<500 ms),
fairly long TE
Gradient Echo (1520 ms), small flip
angle (<30# )
Gradient echo (GE) sequences use a magnetic PDW: long TR (200600
ms), short TE
gradient to reduce magnetic field inhomogeneities, (515 ms), small flip
angle (520# )
as opposed to an additional 180# RF pulse which
is used for this purpose in SE sequences. Diffusion-Weighted
Sequences
Fluid appears bright on gradient echo T2W In diffusion-weighted MRI
(DWI-MRI), the
sequences (termed T2*), but other tissues and signal intensity of a
tissue is determined by the
structures have slightly different signal charac- degree of Brownian motion
of water molecules
teristics on T2* GE as compared to the T2W SE when a magnetic field
gradient is applied. DWI
sequence. may help to distinguish
between malignant
Advantages of GE sequences include and non-malignant
lesions. Within the field
better imaging of articular cartilage, menisci, of musculoskeletal MRI,
it is used most
47
a b c
Fig. 60 Sagittal T1W (a) and T2 fat-suppressed (b) benign or malignant

aetiology. On the b800 DWI image
images of the thoracolumbar spine in a patient with dis- (c), the increased
signal intensity (restricted diffusion) in
seminated breast metastases and previous radiotherapy the T11, L1 and L2
vertebral bodies is consistent with
from L3-L5. On the T1W and T2 fat-suppressed metastatic lesions,
but the absence of high signal intensity
sequences, the signal change at T11 indicates a vertebral in the collapsed L4
vertebral body indicates a benign
body metastasis (arrowhead), but it is difficult to deter- aetiology to the
vertebral body collapse. (images courtesy
mine whether the collapsed L4 vertebral body has a of Khoo et al,
Skeletal Radiology (2011) 40:665-681)
frequently to distinguish benign osteoporotic Gadolinium is a

paramagnetic T1-shortening
collapse from malignant vertebral compression agent that causes
increased signal intensity on
fractures. Malignant tissues show restricted T1W images. When given
intravenously it causes
diffusion due to the high cellularity of tumour a degree of
enhancement proportional to the
tissue (Fig. 60). vascularity of the
tissue. To ensure accuracy of
interpretation of
contrast-enhanced images, it is
necessary to obtain
T1W preferably fat-saturated
Contrast-Enhanced MRI sequences both pre-
and post-IV contrast.
Indications for
intravenous gadolinium
Gadolinium is a metal that binds to include:
differentiating between diffusely enhanc-
membranes and which in its unchelated form ing solid (Fig. 61)
Vs. peripherally-enhancing cys-
cannot be excreted. To allow its excretion tic masses; non-
enhancing necrotic vs enhancing
from the body, gadolinium must be chelated viable tissue; oedema
vs abscesses with a thick
with other compounds, most commonly as the enhancing wall and
non-enhancing contents; and
ligand diethylene triaminepentaacetic acid to enhancing scar tissue
versus variably-enhancing
form Gd-DTPA. disc material in the
post-operative spine [29].
48
a b
Fig. 61 Axial T1W SE (a) and sagittal T2W FSE (b) image (c) shows diffuse
heterogeneous enhancement
images through the thigh showing a subcutaneous mass of confirming that the mass
is solid
uncertain nature (arrow). Post-contrast coronal T1W SE
Indirect MR arthrography is the imaging of Recognised side

effects of IV Gd-DTPA include
joints after administration of intravenous nausea and vomiting,
hypotension, headache, rash
Gadolinium followed by joint exercise (to and a transient rise in
bilirubin and serum ferritin.
produce a small effusion). However, this has the A serious and long-
lasting potential side-effect of
major disadvantage compared to direct MR IV gadolinium is
nephrogenic systemic fibrosis
arthrography of lacking capsular distension, and (NSF), a rare but serious
complication following
therefore poor demonstration of intra-articular the administration of
intravenous gadolinium to
soft tissue structures. patients in renal
failure.
49
Fig. 63 Post-contrast
venous phase MR angiogram, dem-
onstrating abnormally
large and tortuous vessels in a slow
flow venous
malformation in the lateral aspect of the foot
MR Angiography
Selective MR imaging of
vessels can be
Fig. 62 (a) Axial T1W SE fat-suppressed direct gadolin- achieved using
intravenous gadolinium, com-
ium shoulder MR arthrogram showing an abnormal bined with T1-weighted
sequences. However,
blunted anterior labrum (arrow) following anterior dislo-
cation. (b) Coronal T2W FSE fat-suppressed direct saline
time of flight (TOF)
and phase contrast tech-
shoulder MR arthrogram showing a small loose body niques allow sensitive
and reliable vascular imag-
within the axillary recess (arrow) ing, without the need
for administration of IV
contrast. 2D and 3D
images may be acquired
Direct MR Arthrography (Fig. 63).
A dilute solution of gadolinium may also be
injected into joints to delineate fibrocartilage, lig-
amentous and articular cartilage tears, for example MRI Appearances of
Musculoskeletal
in the shoulder, hip and wrist joints. The gadolin- Tissues
ium solution appears as intra-articular high signal
on T1W fat-saturated images (Fig. 62a). Bone:
An intra-articular injection of saline imaged Cortical bone is
black on all MR
on T2W fat-saturated sequences produces similar pulse sequences, due
to its lack of mobile
results (Fig. 62b). protons
50
Fig. 65 Axial fat

suppressed post-contrast T1W
SE image of the knee
showing diffuse thickening
and enhancement of the
suprapatellar synovium (arrows)
Fig. 64 Sagittal T1W SE image of the knee, showing

a linear hypointense tibial stress fracture (arrow) and
surrounding bone marrow oedema (arrowhead), the latter hypo-intense on all
sequences. The menisci
seen as mildly reduced signal intensity of children and young
adults may contain
areas of
intermediate-high signal,
particularly
peripherally in the posterior
Marrow: Normal fatty marrow is hyper-intense horns, as a result of
normal vascularity.
on T1W, and haematopoetic marrow slightly Meniscal tears manifest
as linear areas of
hypo-intense to fat on T1W, and slightly hyper- high signal extending
to an articular
intense to muscle on all sequences. surface, and may have
oblique, radial, hori-
STIR, T2W and PDW-fat-saturated sequences zontal, vertical or
bucket handle morphol-
are good for identifying pathology ogy (Fig. 66a, b).
Increased signal
which appears hyper-intense on these sequences intensity within a
meniscus that does not
due to the associated oedema. Hypo-intense extend to an articular
surface is termed
areas within fatty marrow on T1W sequences intra-substance/myxoid
degeneration.
also suggest pathology such as trauma, infection A discoid meniscus
occurs in 3 % of the
or malignancy (Fig. 64). population, and
most commonly
involves the lateral
meniscus. Discoid
Synovium: menisci are prone to
cystic degeneration
Normal synovium is poorly visualised on MRI and subsequent tears,
and are seen as
Abnormal synovium appears thickened and a thickened bow tie
on more than three
enhances on post-gadolinium T1W fat satu- successive 4 mm
sagittal slices.
rated images (Fig. 65). Articular cartilage
appears dark grey on STIR
and T2W fat-saturated
images, with good dif-
Cartilage: ferentiation from
adjacent joint fluid. PDW
Fibrocartilage: Meniscal pathology is best sequences are
particularly helpful for evaluating
evaluated on fast spin echo PDW sequences articular cartilage
(Fig. 66c), which should
(Fig. 57). The normal adult meniscus is be mildly hyper-intense
on this sequence.
51
a b
Fig. 66 (a) Sagittal PDW FSE image of the knee showing showing good
differentiation between the hypointense
a peripheral vertical tear (arrow) of the medial meniscus marrow, mildly
hyperintense signal intensity articular
posterior horn. (b) Sagittal PDW FSE image of the knee cartilage and
hyperintense joint fluid. (d) Sagittal proton
showing the double PCL sign (arrow) resulting from a density weighted
image demonstrating a large femoral
bucket-handle meniscal tear. (c) Axial Proton density fat osteochondral defect
(arrow)
suppressed image through the patellofemoral joint,
Global thinning or focal defects within the artic- following intra-

articular injection of dilute
ular cartilage are easily identified (Fig. 67d). gadolinium or T2W
fat-saturated images if
Labral pathology is best demonstrated on an saline has been
injected) (Fig. 62). Good
MR arthrogram (T1W with fat-saturation visualisation
without administration of
52 P.
Tyler and A. Saifuddin
a b
Fig. 67 (a) Sagittal PDW FSE image of the ankle showing the normal hypointense
Achilles tendon (arrows).
(b) Sagittal PDW FSE image of the ankle showing a normal hypointense ATFL (arrow)
intra-articular contrast may be achieved in Partial tears are seen

as thickened, hyper-
the presence of a joint effusion. intense areas within the
tendon or ligament.
Acute tears are associated
with abnormal fluid
Ligaments and tendons: around the site of injury.
Normal ligaments and tendons are generally
hypo-intense on all MR sequences (Fig. 67), Muscle:
although some structures such as the normal Normal muscle is of
intermediate signal inten-
ACL and quadriceps tendon may have sity on T1W, STIR and PDW
images and is
a striated appearance. T1W, T2W, PDW FSE relatively hypo-intense on
T2W FSE
and gradient echo T2* are useful sequences to sequences. Muscle tears are
associated with
assess these structures. intramuscular haematomata,
seen as areas of
Sprains are seen as fluid around an variable intensity on MR
sequences, depending
otherwise normal tendon or ligament on age of the injury. Sub-
acute blood is rela-
(Fig. 68a). Complete tendon and ligaments tively hyper-intense on T1W
images. The use
tears are seen as discontinuity of the normal of fat-saturated images will
avoid misinterpre-
low signal intensity of the structure, with tation of fat as an area of
haemorrhage. Muscle
or without retraction of the torn ends tears most frequently occur
at the musculo-
(Fig. 68b, c). tendinous junction.
53
a b
Fig. 68 (a) Coronal PDW FSE FS image of the foot associated joint effusion
(arrowhead). (c) Sagittal
showing fluid around the peroneus longus tendon oblique T2W FSE image of the
shoulder showing a
(arrow). (b) Sagittal PDW FSE image showing an full-thickness rotator cuff tear
(arrow)
acute complete ACL (arrow) rupture with a large
54
a b
Fig. 69 Sagittal T2W FSE (a) and axial T1W SE (b) images of the lumbar spine
showing a degenerate L5/S1 disc with a
central/right paracentral disc protrusion (arrow) displacing and compressing the
right S1 nerve root
Intervertebral discs (Fig. 56b). Disc

bulges, protrusions, extrusions
Normal inter-vertebral discs are of and sequestrations
may occur (Fig. 69).
intermediate signal on T1W sequences, being
hypo-intense to marrow and of a similar inten-
sity to muscle. On T1W images, the nucleus Specific Clinical
Applications of MRI
and annulus are not reliably distinguished
(Fig. 56a). Avascular Necrosis (AVN)
On T2W sequences, the disc nucleus is uni- MRI is the most
sensitive imaging technique for
formly hyper-intense with a horizontal band of early detection of AVN,
but also has a role in the
low SI, while the peripheral annulus is hypo- imaging of established
AVN, where it can be
intense due to its fibrocartilaginous nature used to assess disease
progression or to map
(Fig. 56b). a known focus of AVN
prior to a rotational
Abnormal discs may contain an annular tear, osteotomy designed to
reposition necrotic bone
seen as a focus of T2-hyperintensity, or may be away from a weight-
bearing area. The MRI
dehydrated and of low signal intensity on T2W appearance of AVN varies
according to the
55
a Sclerosis and collapse

of infarcted bone occurs
late in the disease
process (Fig. 70b), appearing
hypo-intense on all
sequences.
Neoplasm
Bone Tumours
Plain radiography has
an important role in the
imaging diagnosis of
bone tumours as MRI
appearances are
frequently non-specific, with an
overlap of findings in
benign and malignant
lesions. As a result,
most diagnoses are made
following evaluation
of multi-modality imaging,
combined with bone
biopsy.
b MRI is the standard
technique for tumour
staging, accurately
delineating the intra-osseous
and extra-osseous
tumour extent, skip lesions and
neurovascular,
articular and nodal involvement.
The multi-planar
capabilities of MRI are of par-
ticular use in the
planning of tumour resection.
Follow-up scans are
used for post-operative sur-
veillance, although
caution is required in
interpreting these
studies, as post-surgical and
post-radiotherapy
changes may be mistaken for
tumour recurrence.
Benign and
malignant bone lesions are fre-
quently of
intermediate signal on T1W images
(Fig. 71a) and hyper-
intense on fat suppressed
T2W FSE or STIR images
(Fig. 71b). However,
exceptions frequently
occur.
Hyper-intense on T1W:
Intra-osseous lipoma
Fig. 70 (a) Coronal T1W SE image of the hips showing Haemangioma
serpiginous linear hypointensity in the subarticular femo- Bone infarct
(healed)
ral heads in a patient with bilateral AVN. (b) Coronal Pagets disease
(end-stage)
T1W SE image of the wrist, demonstrating uniform low
SI in the lunate following avascular necrosis with second-
ary collapse (arrow) Hypo-intense on T2W:
Fibrosis/Sclerosis
Calcification
stage of the lesion. Marrow oedema is seen as Chronic haemorrhage
(e.g., GCT)
high signal on T2W and intermediate to Primary bone
lymphoma
low signal on T1W images early in the disease, Malignant lesions
are more likely to invade
with a serpiginous geographical appearance neurovascular
structures and are associated with
developing later (Fig. 70a). Joint effusions necrosis and
haemorrhage, resulting in hetero-
are usually present in cases of acute AVN. In geneous signal
intensity. Haemorrhage may also
80 % of cases of AVN, a high signal intensity line produce the appearance
of fluid-fluid levels,
develops on T2W images, adjacent to a low signal which are optimally
appreciated on sagittal or
serpiginous line, producing a double line sign. axial T2W (Fig. 72) or
STIR sequences.
56
a b
Fig. 71 Coronal T1W SE (a) and fat suppressed T2W FSE (b) of the tibia showing
marrow infiltration due to
osteosarcoma
Soft Tissue Tumours between the mass and the

fascia. Rapid
The majority of soft tissue masses are enhancement post IV
gadolinium, indicating
benign, with soft tissue sarcomas representing neovascularity is also more
suggestive of
less than 1 % of all soft tissue tumours. a malignant lesion.
Features suggestive of malignancy include There is considerable
overlap between appear-
a history of pain, rapid growth, increasing ances of benign and malignant
soft tissue neo-
patient age, lesions deep to the fascia and plasms, which like bone
tumours, are frequently
>5 cm in size. Lesions less than 3 cm in size hyperintense on fat-suppressed
T2W sequences,
have a positive predictive value for benignity and of intermediate signal
intensity on T1W
of 88 %. (Figs. 73a, b).
Malignancy can be predicted with a sensitivity Lesions which may be hyper-
intense on T1W
and specificity of 81 % in the presence of the sequences include:
following signs: Lipoma
Absence of T2W hypointensity Hibernoma (a benign tumour
of brown fat)
Inhomogeneous signal intensity on T1W Well-differentiated
liposarcoma (Fig. 73c)
Mean lesion diameter >3.3 cm [30]. Sub-acute haematoma
Other factors suggestive of malignancy Melanoma
include: the presence of necrosis, bone or Lesions which may contain
low signal on
neurovascular involvement, the lesion crossing T2W include:
the fascia and the formation of an obtuse angle PVNS/Giant cell tumour of
tendon sheath
57
developing between the

elevated periosteum
and underlying cortex.
Eventually cortical disrup-
tion occurs, and a
T2W/STIR hyper-intense
cloaca, abscess cavity
or sinus tract may
develop. Intravenous
contrast-enhancement
assists with the
differentiation between oedema
and an abscess, the
latter demonstrating peripheral
capsular enhancement,
with a non-enhancing
centre.
Brodies abscess
also has characteristic MRI
features, appearing as
an irregular cavity with
a thin, mildly hyper-
intense, enhancing wall
(the penumbra sign)
and associated marrow/
soft tissue oedema
oedema, commonly with
active periostitis
(Fig. 74b, c).
Septic Arthritis
Infection should
always be considered in
the presence of a
mono-arthritis. MRI findings of
septic arthritis are
non-specific, and include joint
effusion and enhancing
thickened synovium.
T2/STIR hyper-
intensity in the adjacent bone and
soft tissues is
particularly suggestive of a septic
Fig. 72 Sagittal T2W FSE image through the proximal arthritis (Fig. 74d).
tibia showing multiple fluid-fluid levels in an aneurysmal
bone cyst Soft Tissue Infection
MRI is highly
sensitive for the detection of soft
tissue infection.
Cellulitis
represents inflammation of the skin
Fibromatosis (Fig. 73d) and sub-cutaneous
fat. Skin thickening and
Chronic haematoma (within the wall) a reticular
pattern of T1W hypo-intensity/T2W
Amyloid hyper-intensity in
the sub-cutaneous fat is
Soft tissue and bone tumours frequently can- typical, with
affected areas demonstrating
not be diagnosed by MRI alone. Patient age, post-contrast
enhancement.
location of the lesion and appearance on other Pyomyositis is
usually due to Staphylococcus
imaging techniques all assist in forming aureus infection
and initially manifests as
a differential diagnosis. Frequently, a biopsy is focal muscle
oedema and swelling, followed
required for a definitive diagnosis. by abscess
formation, seen as focal T2W/
STIR hyper-intense
lesions, with rim-
Infection enhancement.
Osteomyelitis Necrotising
fasciitis is a rare and frequently
MRI is a sensitive tool for the detection of fatal infection of
subcutaneous tissues,
early osteomyelitis (Fig. 74a). Initial signs include with MRI findings
of T2 hyper-intensity
oedematous bone marrow, seen as hyper-intensity in the
subcutaneous tissues and fascial
on STIR/T2W fat-saturated images and low or planes. Abnormal
areas show post-contrast
intermediate signal on T1W. Elevation of the enhancement,
although necrotic tissue will not
hypo-intense periosteum occurs with disease enhance. Gas
within the soft tissues is seen as
progression, with T2W/STIR hyper-intensity foci of low signal
on all sequences.
58
a b
Fig. 73 Coronal T1W SE (a) and axial fat suppressed well-differentiated

liposarcoma (arrows) in the anterior
T2W FSE (b) images through the left thigh showing a high compartment. (d)
Sagittal T2W FSE images of the knee
grade soft tissue sarcoma (arrows). (c) Axial T1W showing an irregular
hypointense mass (arrows) in the
SE image through the thigh showing a hyperintense popliteal fossa in a
case of fibromatosis
59
a b
c d
Fig. 74 (a) Coronal STIR image of the left femur in a with surrounding
marrow oedema. (d) Coronal fat
young boy showing diffuse marrow oedema (arrow) in the suppressed T2W FSE
image of the shoulder in a case of
proximal metaphysis consistent with acute osteomyelitis. septic arthritis of
the glenohumeral joint, resulting in
Axial T1W SE (b) and sagittal STIR (c) images of the articular cartilage
destruction, bone marrow oedema and
ankle showing a Brodies abscess (arrows) in the calcaneus a joint effusion
60
ablation are currently

used in specialised centres
for the treatment of a
variety of bone and soft
tissue tumours.
High Field MRI
MRI scanners for routine

use in hospitals are now
using higher magnetic
fields, with 3-T scanners
becoming increasingly
common. They frequently
produce images with
excellent resolution and
minimal noise, but can
lead to interpretational
difficulties for the
unwary, as protocols and rela-
tive tissue intensities
may vary from those dem-
onstrated on conventional
1.5T scanners, and
artefacts are more
pronounced.
Fig. 75 Coronal oblique PDW FSE image of the shoulder

showing apparent increased SI within the distal rotator Upright MRI
cuff tendon (arrow) due to magic angle effect
MRI scanning of patients

in the upright or
sitting positions can
demonstrate alteration in
vertebral alignment with
posture. The degree of
Pitfalls of MR Imaging of the MSK spondylolisthesis or disc
protrusion may vary
System significantly between
upright, sitting and supine
positions. This technique
is of particular value in
Interpretational errors by evaluating structures patients with posture-
dependent symptoms, and
on inappropriate sequences a supine MRI examination
that shows no root
Magic angle artefact causing erroneous compression (Fig. 76).
interpretation of pathology, e.g., apparent Claustrophobic
patients are frequently better
hyper-intense pathology in ligaments, tendons able to tolerate the open
upright MRI scanner
or menisci when they lie at 55# to the main than standard MRI
scanners.
magnetic field on T1W, PDW, and most GE Disadvantages of the
upright MRI scanners
sequences (Fig. 75). Magic angle phenomenon include a lower magnetic
field strength and
is confirmed when normal appearances are limited availability.
seen on T2W sequences.
MRI Safety
Interventional MRI
Patient safety is of
paramount importance in the
MRI is less suited to intervention than other MRI Department.
Ferromagnetic objects must not
modalities, due to the high magnetic field, lack be taken into the
scanner. MRI is contra-indicated
of real-time imaging capabilities and problems if the patient has any of
the following:
associated with metallic artefact. However, MR- Pacemakers are contra-
indicated. Pace-
guided biopsy is a well-established procedure. makers may even be
affected by the magnetic
MR-guided focussed ultrasound and laser field outside the
scanning room. A new
61
a b
Fig. 76 Positional MRI of the lumbar spine. Sagittal T2 FSE images of the lumbar
spine, demonstrating the change in
the degree of lumbar lordosis and spinal canal dimensions in the sitting (a) and
standing (b) positions
generation of pacemakers with some MR-safe MRI is usually

avoided in pregnancy, particu-
features are being developed, but as a rule, larly in the 1st
trimester, except when the benefit
patients with pacemakers should never have outweighs the potential
risk, for instance in
an MRI scan. potential malignancy.
Spinal cord stimulators Orthopaedic implants
are usually MR-safe,
Cochlear implants but not necessarily MR-
compatible (i.e., they
Infusion catheters cause artifact that
distorts the image). The nature
Metallic fragments in the eyes of a metallic implant
should be known before
Shrapnel in the body, depending on the site, scanning. If in doubt,
do not proceed with an
nature and field strength involved MRI scan. Induced
currents can flow around the
Aneurysm clips, depending on MR metallic rings of halos
and Ilizarov frames, with
compatibility of the clips and institutional the risk of heating;
patients with these devices
protocols. should not undergo an
MRI scan.
62
Acknowledgments The authors wish to thank Dr. A. thoracic and

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Operating Theatres and
Avoidance
of Surgical Sepsis
Paolo Gallinaro, Elena Maria

Brach del Prever,
Alessandro Bistolfi, Antonio
Odasso, Matteo Bo,
and Carlo Marco Masoero
Contents
System Construction and Management . . . . . . . . . . . . . .
70
Design Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 70
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 64 VCCAC System
Characteristics . . . . . . . . . . . . . . . . . . . . . .
71
Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 65 General System Specifications . . . . . . . . . . . . . .
. . . . . . . . . 72
Hand Washing and Scrubbing . . . . . . . . . . . . . . . . . . . . . . . .
65 Energy Saving Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 74
Dress in Theatre: Surgical Gowns, Mask, Gloves,
Sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 74
Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 66
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 75
Surgical Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 68
Organisation and Responsibility of the Operating
Appendix 1 National and International
Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 68
Standards/Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Design and
Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 75
General Design
Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Ventilation and Controlled-Contamination
Air-Conditioning Systems . . . . . . . . . . . . . . . . . . . . . . . . 69
P. Gallinaro (*) # E.M. Brach del Prever

Department of Orthopaedics, Traumatology and
Rehabilitation, University of the Studies of Turin, Turin,
Italy
e-mail: paolo.gallinaro@unito.it
A. Bistolfi
Department of Orthopaedics, Traumatology and
Rehabilitation, CTO/M Adelaide Hospital, Turin, Italy
A. Odasso
Health Medicine, Turin, Italy
M. Bo
Expert Consultant in Industrial Installations, Prodim srl,
Turin, Italy
C.M. Masoero
Department of Energetics, Polytechnic School of
Engineering of Turin, Turin, Italy

63
DOI 10.1007/978-3-642-34746-7_220, # EFORT 2014
64
P. Gallinaro et al.
classification of the
level of air cleanliness,
Abstract
the risk of
contamination due to chemical
The Operating Room (OR) is the heart of any
agents, the air
changes, the thermal comfort
surgical hospital and it is the place where the
conditions and
technical aspects such as the
most dangerous accidents can rarely occur
pressure, noise and the
recovery time.
either to the patients or to the operating team.
The main difference
from the past is that
Post-surgical infection is one of the most
now a complete
programme of risk manage-
important complications, in particular in Ortho-
ment, checklists,
protocols, group management
paedic surgery. A new aspect of the life in
and European directives
have a role rather than
the OR is the personal protection of the staff:
the old good sense
surgical practices.
the OR is now under the severe regulation of the
legislation regarding the safety in workplace.
Keywords
The rule of the 5 Ds according to Joubert,
5 Ds-disciplne, design
# Construction
the historical key-stone in the strategy of the
and management #
Defence mechanisms
fight against infection, can be still adopted in
(patient) # Devices #
Drugs # Energy-saving #
the more complex fight against OR errors
Gloving # Operating
theatres # Sterilisation #
for a good quality of life for patient
Surgical teams #
Theatre dress # Ventilation
and personnel: 1. Discipline, 2. Design,
systems
3. Devices, 4. Defence mechanism of the
patient, 5. Drugs. The first three of these are
the subject of this article. Introduction
Discipline is a critical issue, as it has the
capacity of decreasing the efficacy of other The Operating Room (OR) is
the heart of any
factors. It concerns the personnel and the Orthopaedic hospital and
the theatre of the major-
patients, independently from the hierarchy, ity of the Orthopaedic
treatments, where the
sex and job. Discipline must be considered health of the patient is
decided and the life of
a fundamental instrument for reducing the surgeons and personnel is
spent for many hours
risk of infections related to surgery and for every week. In the OR the
highest professional-
increasing the personal safety of each member ism meets the highest
risks: the most modern and
of the operating team. Many points are sophisticated instruments
are employed and
discussed and the European directives men- occasionally the most
serious accident can occur
tion: protocols and checklists, surgical team either to the patients or
to the operators. It is well
and risk management and the preparation of known that surgery-related
infections are
the personnel from the surgical hand washing the worst of the
complication in Orthopaedic
to the clothing, gowns and masks. surgery, but also other
risks must be considered
Secondly, the building regulations for the both for the patient and
the operating team.
ideal operating block and OR must be The correct evaluation
and control of the risks
followed according to the actual regulations; related to all the
different aspects of the surgical
the need to renovate old operating blocks and activity (clinical,
organisational, human, eco-
to adopt strategies, also in organisation, are nomical and monitoring),
i.e. a complete
discussed. The development of surgery, programme of risk
management, is a useful
including Day and Week-End Surgeries, and instrument for all
Orthopaedic surgeons. Written
of many new devices, and consequently of the procedures, guidelines and
check lists should be
need for more space, more instruments and used to assure a good
quality of work and to
more expert staff, are presented. increase the safety of the
patients and personnel.
Thirdly, the ventilation and controlled- In 2008 the World Health
Organization published
contamination air-conditioning systems safety-oriented guidelines
to ensure the safety of
(VCCAC) are presented, considering the surgical patients [1]; the
importance of guidelines
Operating Theatres and Avoidance of Surgical Sepsis
65
is strongly underlined [2] also by EFORT, who independently from the

hospital hierarchy,
encourage check lists in the OR in order to reduce gender and job.
Discipline must be considered
the complications and the incidents during a fundamental instrument
for reducing the risk
surgery, for example avoiding the wrong side of infections related to
surgery and for increasing
surgery and similar problems. the personal safety of
each member of the
Other factors have changed the life in OR: in operating team [5].
recent years, the evolution of the technology There are many
sources of bacteria and
made possible such as computerized control of methods of diffusion
which have a strong depen-
the OR; now it is possible to record data of the dence on human behaviour.
The human skin bac-
patient, description of surgery, equipment, drugs, teria are both residents
(deep in the skin), and
devices, anaesthesia, sterilisation processes, transients due to
temporary contamination (in
etc. In addition, the systems of environment mon- the superficial skin
layers). They can contaminate
itoring make possible the surveillance of the the environment either by
direct contamination or
quality of the air and of any airborne bacterial by airborne
contamination.
contamination. Many human activities
and instruments can be
A new aspect of the life in OR is the personal adopted in the strategy
to reduce infections, first
protection of the operating and support staff: the of all the surveillance.
For its application are
OR is under the strict regulation of the legislation required standardized
definitions of infection,
regarding the safety in workplace. It is not the and also methods of
evaluation, data collection
purpose of this paper to analyse the intricate and and feedback of
information to surgeons and
numerous directives (e.g., the DPP Directive other relevant staff [6].
In addition, through
89/686/EEC); however it is important to under- a surveillance programme,
the results can be
line that safety in OR, as work place, is the used for the development
and improvement of
responsibility of the surgeon, who is the chief in protocols for the
prevention of the infections [7].
the OR; also the Chief of the Department and the The concepts of
antisepsis and dedicated pro-
General Director are responsible, even if they are tocols have been
developed during the last
not present in the theatre. decades. Nevertheless,
even if the incidence of
This paper, while representing an update of wound infection following
total joint arthroplasty
previous texts [3], also discusses some new con- has fallen, it still may
occur with dramatic con-
cepts and controversial problems concerning sequences. The respect of
the principles and
where to place and to build the OR and also of the protocols is still
the key-point in infection
who is responsible and what is the role of each prevention now more than
years ago [8, 9]. In fact
member of staff. it has been suggested
that an excess of faith in the
The rule of the 5 Ds [4], the historical improved technology in
the operating room
key-stone in the strategy of the fight against (clean air suites, ultra-
clean air theatres) may
infection, can be still adopted in the more lead to a less strict
respect for the theatre
complex fight against errors in achieving a good protocols [10].
quality of life for patient and personnel: Last but not least,
it is important to remember
1. Discipline, 2. Design, 3. Devices, 4. Defence that studies have
indicated a less strict respect of
mechanism of the patient, 5. Drugs. The first the protocols amongst the
unscrubbed people com-
three of these are the subject of this article. pared with surgeons and
scrubbed nurses [11].
Discipline Hand Washing and

Scrubbing
Discipline is a critical factor, as it has the capacity All personnel entering

the operating block must
of decreasing the efficacy of other factors. It wash their hands to
eliminate the dirt and remove
concerns the personnel and the patients, mechanically the
transient superficial bacteria;
66
P. Gallinaro et al.
they must perform the social hand washing Dress in Theatre: Surgical
Gowns,
based on the rubbing of the hands, with a liquid Mask, Gloves, Hood
soap, for at least 20 s. The soap, or detergent,
must be non-irritating. Surgeons and surgical The European regulation
concerning the
nurses, before surgery, must perform the Personal Protective Equipment
Directive
surgical hand washing (or scrubbing) with an (89/686/EEC) identifies the
principal use
antiseptic solution, with the aim of reducing to intended for the product: the
protection for the
the minimum (elimination) of the resident deep patient and the protection
for the operators.
bacteria. The European Standard EN
13795 regulates
The antiseptic solution must be non-irritat- to the surgical gowns, drapes
and clean-air suits
ing, fast-acting, persistent and effective in used as medical device for
patients, clinical staff
reducing the bacteria on intact skin and must and equipment. It consists of
three separate parts
have a large spectrum. There is not general and focusses on relevant
Essential Requirements
agreement about the ideal solution, the optimal arising from the Medical
Device Directive
time and the correct manoeuvres; legendary 93/42/EEC. The first part, EN
13795-1 of 2002,
ritual sequential manoeuvres were developed gives general indications on
the characteristics
in an effort to fill in the time. The efficacy of for each kind of product for
single-use or
the surgical hand scrubbing is based on the re-usable use. It gives the
details of the quality
chemical reaction time-depending of the anti- system relating to
manufacturing and
septic solution-with skin and bacteria. It has processing, including
traceability processes and
been demonstrated that only a continued contact validation of all steps. The
second part, EN
of the skin with the antiseptic for a minimum 13795-2 of 2004, according to
the characteristics
time of 2 min without any interruption (e.g., to described in EN 13795-1,
regulates the test
rinse) provides an acceptable reduction of the methods to evaluate the
products, which must
number of bacteria. Five minutes scrubbing is be all tested before
commercialization. The third
generally acknowledged as the correct time, but part, EN 13795-3 of 2006,
defines the minimum
also 2 min can be enough if performed correctly standards for a product to
meet the requirement
and with the proper solution. Ten minutes of Directive 93/42/EEC and EN
13795.
scrubbing and vigorous brushing can damage Two classifications are
made according to the
the skin and therefore must be avoided; hypothesized conditions of
surgery. The first
brushing must be limited to nails in order to distinction is made between
products with stan-
distribute the antiseptic liquid in narrow site dard level performance and
those with high level
around nails. performance, which is
established depending on
In general, the most active agents in reducing the duration, mechanical
stress, biological or
the skin bacterial count are formulations other liquids employed
throughout the surgical
containing chlorhexidine gluconate (generally in procedure. Among the
characteristics to be eval-
concentration of 2 % or 4 %), iodophors uated, there are: resistance
to liquid and to
and triclosan, listed in order of decreasing activ- microbial penetration dry and
wet, cleanliness,
ity and persistency of the antimicrobial activity. bursting strength and tensile
strength dry and
Sixty to ninety five percent alcohol-based wet. The second distinction
identifies the critical
solutions in adequate quantity, sufficient to and less critical areas of a
product. The critical
wet completely the hands, have efficacy after areas are defined as product
areas with the
evaporation, but they do not provide a persistent highest probability to be
involved in the transfer
antimicrobial activity. Solutions containing of infective agents to the
wound or the invasive
6095 % alcohol and 0,51 % chlorhexidine glu- area, or from the wound,
such as sleeves, front
conate might combine the benefits in term of and the areas closest to the
operative site of
immediate and persistent efficacy of both the surgical gowns. In addition,
for re-usable
preparations [12]. devices, information on
cleaning, disinfection,
67
packing, methods of sterilization, number of Recently, it has been

demonstrated that a high
reuses and any restriction are given. number of splashes are
generated during a total
Surgical gowns are used to prevent direct joint replacement and that
the correlation between
contact transfer of infective agents from the sur- duration of surgery and the
amount of pulsed
gical team to the operating wound and vice-versa; irrigation used with a splash
is respectively
they have efficacy only if made of a suitable significant and highly
significant [13]. These
material and used in combination with clean-air findings would suggest the
use of Type II-R
systems. Comfort and minimisation of bacteria- masks during total joint
replacements (knee in
carrying particle dispersion from the contaminat- particular), even if no
definitive directions exist.
ing skin zones should be combined: shirt closed Since hair and scalp are
an important source
at the neck, elasticised tissues closing the arms, of contamination, they must
be fully covered.
and trousers closed at the ankle. No specific Therefore, the hood should be
used rather
directions regulate the clothes to be worn in the than the surgical cap. In
particular, the use of
operating room. Traditional cotton garments collared head-gear covering
the neck is
allow both wet-strike-through contamination recommended for personnel
working around the
and free egress of bacteria, as the weft enlarges surgical table.
after multiple washings. Non-woven imperme- The presence of
pathogenic bacteria on theatre
able tissues are effective in the protection of shoes, coagulase-negative
staphylococci in par-
both the personnel and patient; new technology ticular, has been
demonstrated. These bacteria
has decreased the risk of stressful humidity con- are potential source for
post-operative infection
centration and heat to personnel [3]. either by their contribution
to a proportion of
The European Standard EN 14683:2005 airborne CFUs within theatre
and by the
specifies the production and performance contamination of the hands
while donning the
requirements and the test methods for the surgi- shoes at the beginning of the
duty. Therefore
cal masks. A difference is made between the a combination of dedicated
theatre shoes use
main use to protect the patient from contamina- and a good floor washing
protocol to control the
tion and the additional use to protect the wearer level of shoe contamination
are mandatory [14].
against splashes. The European Standard defines Even if their efficacy in
controlling bacterial floor
two categories of surgical mask according to the contamination is
controversial [3], it is likely
bacterial filtration efficacy and differential that, with these easy
procedures a heavy
pressure and, in addition, each category is divided proportion of contamination
should be avoided.
again according to the splash resistance In addition, the use of
completely machine-
(R splash resistance pressure >120 mmHg). washable plastic boots and
clogs is advisable
The bacterial filtration efficiency is >95 % for and waterproof shoes have the
potential to
Type I and Type I-R and >98 % for Type II and decrease personnel
contamination and are
Type II-R, respectively. The differential a discipline factor,
modifying behaviour [3].
pressure is <29.4 Pa for Type I and Type I-R Requirements for surgical
gloves are given in
and <49.0 Pa for Type II and Type II-R, respec- the EN 455 series of European
Standards.
tively. According to the norm, surgical masks Surgical glove usage must
follow the
must not disintegrate, split or tear during use implications of the Medical
Device Directives
and must ensure adequate coverage of nose, (93/42/EEC) in relation to
medical devices
mouth and chin. The supplier must provide containing natural rubber
latex. Nevertheless,
documentation stating the fulfilment of the per- concerns have been expressed
regarding the use
formances requested, made by a qualified third of powdered gloves in
surgical operations and
party and not self-certificated. On the contrary, therefore they should be
abandoned. Two pairs
the purchaser must control the conformity to the of gloves is a good rule to
prevent surgeon
norm. The issue of the contamination contamination and decreased
infection risk for
during prosthetic surgery is of actual interest. patient [15]. Outer latex
gloves are perforated
68
P. Gallinaro et al.
more than inner gloves and the number of

punctures increases when operation lasts longer Design and Devices
than 3 h; it is a good rule to change periodically
the outer glove. Designing operating
theatres is commonly seen
as the job of specialised
architects and engineers.
Surgeons and nurses and, in
general, people who
Surgical Team will eventually work there,
are seldom involved
in the projects, while
their contribution as
The operating room is an ambient space where experts might be useful.
The concept of the
several different professional individuals work operating block has
developed through the years
with the health of the patient as the final shared and has become more and
more complex. In
goal, The need of a proper teamwork it has been parallel, the costs have
risen, both for realization
compared to that in aviation [16]. One of the and maintaining of its
efficiency.
major problems is that often each member of the
operating team knows his/her role, but does
not know the role and the needs of the other General Design Rules
people [17]. A shared mental model, identifica-
tion and respect of all the professional roles and When building a new
hospital, it must be consid-
effective communication have been indicated as ered where best to locate
the operating block:
the fundamental factors for the proper function of a less crowded area is
preferable and thus an
teamwork [18]. The lack of teamwork in the area with free space for
further enlargements.
operating room creates a potential situation for Building the operating
block underground is
error [19]. Four categories of error have been technically feasible but
not advisable. Working
identified in a work by teams: procedural errors, underground without an
outlook to the sky, sun,
communication errors, decision errors and inten- rain or snow is not so
comfortable. Double win-
tional non-compliance errors [20]. dows, well-sealed and
blinded from outside are
a good and comfortable
solution.
The model of operating
block, which has
Organisation and Responsibility been adopted for a few
decades ago, is based
of the Operating Block on the concept of
separation of the clean and
dirty areas. This was
realised by the typical
All the aforementioned rules, culminating with peripheric corridor used
for the elimination of
the surgical team formation, need a centralised the dirt. This model is
no longer considered
organisation and responsibility, a co-ordination the ideal solution to
reduce infections, because
of hospital politics and economical choices, and it has been shown that
operating blocks without
cannot be limited to the operating block work the double corridor have
the same infections
alone. The operating team must be selected rate compared with blocks
with the clean-dirt
according to specific training programmes and corridor. Indeed, the so
called clean corridor
the maintenance of discipline protocols. Selection is more polluted than the
dirty one: this because
of theatre personnel based on other criteria must of the continuous flow
outwards of materials,
be excluded. Therefore, it follows that the liability patients, instruments and
air. In addition,
of the surgeons, when the unfortunate outcome is according to the currently
used protocols of
an infection, is not precisely clear. When the the OR, the used and
contaminated materials
surgeon is a simple manual operator, working in are immediately stored in
closed packages
a badly-organised block, where maintenance, ser- which are quickly removed
from the theatre.
vicing and ventilation controls are not routinely Last but not least, the
corridor is an unjustified
scheduled and performed, the responsibility waste of space. It is true
that still there are
should be borne by the hospital management. many operating blocks based
on the old concept
69
of the corridor with the external polluted room, which is still located
in the operating
corridor considered as an orientation area. block in order to provide a
better surveillance of
The operating block can be built either with the patients in the first
post-operative period.
bricks and walls or with pre-fabricated panels In the block, wide spaces
for storage are
linked to a metal skeleton. The first is cheaper, mandatory. Toilets and
showers are forbidden in
while the second can be modified if necessary. the clean area.
The second is a cleaner technique of construction. In modern general
hospitals, for economic and
The OR must have a large surface, related to organizing reasons, it is
possible that the ORs. are
the increasing demand for surgery. At least not specifically dedicated
to Orthopaedics.
200 m2 are recommended for each single room. In such a scenario, it is
preferable to dedicate
A wide space is mandatory for the movement of specific rooms for
Orthopaedic surgery only.
the surgeons and for the increasing number of These rooms must be chosen
amongst those far
devices and instrumentats, such as X-ray, from corridors, flows and
dirty areas. A separate
computer-guided surgery and filmless imaging, block should be dedicated
for surgeries of ISO
tractions, blood-saving instruments and instru- Class 5 (see section Design
Conditions). If this
ments to keep the patient warm. It must be solution is not applicable,
at least it is mandatory
noted that, all around the world, even the best to schedule only clean
surgeries in the same
new operating blocks, according to the OR theatres as Orthopaedic
surgeries and to schedule
personnel, lack space enough to store instruments different surgeries on
different days. All these
and devices. problems do not exist in a
specialized hospital
Many different and expensive materials have dedicated to Orthopaedics
surgery. In such
been used in the past as surfaces for walls and a hospital, a separate block
can be dedicated for
roofs (varnished stainless steel, vitreous enamel traumatology and for
emergencies. Also, septic
steel, Corian ). In truth, the more important char- surgery should be performed
in dedicated rooms
acteristic is the homogeneity of the surface and or, at least, scheduled on
specific days.
the resistance to the procedures of cleaning and Recent years have seen
the growth of the day
disinfection. surgery and week-end
hospital; actually, they
The roof must ensure a sufficient height for the now amount to at least 30 %
of the surgical activity
air distribution system. All devices must be in Orthopaedics, but this 30
% will probably
anchored to the roof instead of on the floor: this increase up to 50 % in the
future. The OR dedicated
includes lights, saws, monitors and anaesthetic to the day and week-end
surgeries must have the
equipment, medical gases, sockets. This will same facilities as the OR
dedicated to traditional
provide more space into the operating room and surgery. Modern designs must
provide surgical and
will facilitate cleaning. recovery spaces dedicated to
specific surgeries for
The use of Maquet or similar surgical tables is correct organisation of the
hospital and facilities of
useful in saving time and in avoiding many patient transfer to and from
the OR.
manoeuvres which could be cause of
contamination.
The washing (Scrub-up) room is the only room Ventilation and Controlled-
directly connected to the OR. It can serve one or Contamination Air-
Conditioning
two ORs (in this case it will be placed between Systems
the two ORs). Surgeons can dress in the washing
room or into the operating room, according to the Although opinioms among the
European scientific
space and their habits. The room for the prepara- communities about the
existence of a strict corre-
tion of the patient and the dedicated recovery lation between airborne
microbiological pollution
room must be placed close to but outside the and risk of post-
intervention infections are not
OR. From the dedicated recovery room the completely homogeneous, it
is universally
patients are taken to the common recovery accepted that the OR should
be equipped with
70
P. Gallinaro et al.
a dedicated Ventilation and Controlled- (a) system construction

and performance
Contamination Air Conditioning (VCCAC) requirements; (b)
criteria and procedures
system. The specifications about design, construc- for system qualification
and acceptance;
tion, operation of VCCAC systems described in (c) system operation and
maintenance criteria.
this chapter are largely based on the technical 2. Development of the
system design.
literature produced by the leading international 3. Design qualification
(completeness and
professional associations [21, 22] and on national congruence of the design
documents,
and international standards (Appendix 1). compliance of the design
with the PDD and
Operating rooms used for long-duration with the applicable
codes and standards).
(>60 min) Orthopaedic surgery, in particular 4. Installation and
commissioning of the system.
when biomaterials are implanted such as total 5. Qualification and
acceptance tests of the
joint replacements, should be classified among OR (both at rest and
operational); such tests
those requiring the highest level of asepsis and should include
measurements of air flow
the maximum protection of the risk area rate, differential
pressures, particulate con-
(operating table, surgical instrument table, and tamination classes,
microbial charge (both in
surgery operating space), and consequently the the air supply and in
the ambient air), room
lowest contamination levels. temperature and air
velocity fields, and room
The VCCAC systems of an operating block recovery time.
must be able to maintain: 6. Periodical tests and
checks.
Total (biological and inert) airborne particu-
late concentration below specified limits;
Thermo-hygrometric conditions suitable for Design Conditions
a regular performance of the surgical
procedure; Air Cleanliness Level
Classification
Chemical pollutants concentration below The air cleanliness level
with respect to airborne
specified limits; suspended particles must be
established
Stable and measurable positive-pressure gra- and declared acceptable in
the PDD for all the
dients between spaces with higher versus spaces and for all the areas
which are considered
lower contamination protection requirements; critical, depending on the
risk level implied by
Temporally-constant values of the specified the surgical procedure.
Normally, high-asepsis
environmental parameters. operating rooms for
Orthopaedic surgery
Since the surgical activities may be classified should have a minimum
contamination class
as a pharmacopoedic processes, with a relevant ISO 5, according to standard
EN ISO 14644-1.
impact on human health, the satisfaction of Such contamination class is
identified in terms
process requirements has a higher priority, and of maximum number of 0.5 mm
size particles
should therefore be considered as prevailing, in per unit volume (3,250
particles/m3), measured
comparison with human comfort requirements, as at rest.
specified by applicable technical standards.
Contamination Due to Chemical
Agents
Recommended limit values for
the concentration
System Construction and Management of common volatile
anaesthetics and for
the exposure to anaesthetic
gases and vapours
The correct construction and management of the are:
VCCAC system for an operating block should Atmospheric Nitrous Oxide
(N2O): <25 ppm
include the following phases: (TLV-TWA)
1. Preliminary Design Document (PDD), Atmospheric alogenates: <2
ppm (TLV-
specifying: ceiling)
71
Air Changes Noise Levels

The number of external air changes in OR should For process requirements,
allowable Sound Pres-
be enough to limit the chemical air contamination sure Levels (SPL) in
operating rooms are usually
through a continuous process of dilution of the higher then specified for
human comfort. Since
pollutants that are produced within the space by noise levels have a
significant impact on comfort,
different sources. For this purpose, values in the and therefore on the
productivity of the surgical
1015 ACH (Air Changes per Hour) range are team, it is however
recommended to keep the
generally considered adequate by codes and SPL to the lowest value
compatible with the
standards. building and equipment
context, and in any case
not to exceed 45 dB(A).
Thermal Comfort Conditions
The temperature, relative humidity and terminal Recovery Time
velocity of air in the occupied zone should The recovery time represents
the time necessary
possibly be compatible with comfort conditions to re-establish the
environmental design condi-
for the surgical team, allowing exceptions for tions following a complete
shutdown or partial
specific surgical procedures requiring hypother- setback of the VCCAC system.
The recovery
mia, and taking into account the requirements performance may be evaluated
by means of the
imposed by the generation of as stable as possible 100:1 recovery time, which is
defined as the time
unidirectional airflow conditions in the operating required to reduce the
initial contaminant
field. When defining the comfort conditions, due concentration by a factor of
100. The evaluation
consideration to the clothing type of the staff procedure for recovery time
is described in
should be given; this may imply air temperature the EN ISO 14644-3 (2006)
standard. For OR
and humidity values that significantly differ from the recovery time should not
exceed 15 min,
usual air conditioning standards. Air relative starting from a partial
system operation regime.
humidity has a relevant impact on sweating and
therefore on the generation of biologically active
particles. Recommended values of air tempera- VCCAC System Characteristics
ture, humidity, and velocity in the occupied zone
are the following: The VCCAC systems for a high
aseptic OR,
Temperature: adjustable values in the with contamination class at
rest ISO 5, are of
1924 # C range for each room independently the all-air type (partly
external and partly
Relative humidity: in the 40 % (winter) 60 % recirculated air). The air
distribution device is
(summer) range a mono-directional diffuser
equipped with
Air velocity: <0.25 m/s HEPA H14 terminal filters,
installed to protect
Compatibly with the fulfilment of process the risk area, which consists
of the operating
requirements, the environmental parameters table, surgical instrument
table, and surgery oper-
should guarantee a Predicted Percentage of Dis- ating space.
satisfied (PPD) below 10 % (PMV in the #0.5 to The diffuser size should
cover the entire risk
+0.5 range), according to standard EN ISO 7730. area, which is normally
identified as a square of
approximately 3 m # 3 m. The
DIN 1946-4
Pressure Gradients (2005) standard prescribes a
minimum size for
A pressure gradient of at least 5 Pa should be the air diffuser equal to 3.2
m # 3.2 m. In order to
maintained between spaces having different optimize its function
eliminating airborne con-
cleanliness classes, according to standard EN taminants from the surgical
area, the unidirec-
ISO 14644. The positive pressure of operating tional diffuser should:
rooms with respect to the external environment Guarantee a low-turbulence
flow over the
should be at least 1520 Pa. entire protected area;
72
P. Gallinaro et al.
Assure a minimum airstream velocity, and an efficiency filters (F6), in

order to block textile
air temperature always slightly below fibres, which may easily be
removed and cleaned.
ambient;
Take into account the potential disturbance
effect created by the presence of people and General System
Specifications
of the operating cialitic lamp, and by the buoy-
ant airflow induced by such elements. All components of the VCCAC
system should
For these purposes, it is advisable to select not contribute to the
production and dispersal of
diffusers that have undergone accurate experi- contaminants and should be
easily accessible.
mental qualification tests according to procedures The architecture of the
equipment and system
specified by DIN 1946-4. and their insertion in the
building should be
In order to reduce the air treatment energy defined and designed in
order to facilitate opera-
demand, VCCAC systems may foresee, in tion, checking and
maintenance, as well as the
addition to the specified external air changes replacement of worn or
obsolete parts. Specifi-
(e.g., 15 ACH), also a given amount of re- cally, all VCCAC system
components should be
circulated air. The total (external + re-circulated) installed in dedicated
closed spaces, easily
air changes depend on the diffuser size and on the accessible for inspection
and maintenance.
air velocity recommended by the manufacturer in It should be possible to
isolate each operating
order to guarantee a stable airflow pattern. room, with respect both to
the VCCAC system and
Resulting values are typically on the order of to adjoining spaces, to
permit cleaning and disin-
5070 ACH. Air recirculation is allowed, pro- fection while the other
parts of the block are in use.
vided that: Outside air intakes and
re-circulation grilles
re-circulated air is taken from the same should be placed to minimise
the influence of
operating room; external contamination
(gases, particles, dust,
re-circulated air is subjected to the same filtra- bacteria, etc.) on the
controlled environment.
tion level as external air. Outdoor intakes should be
installed far and
As far as possible, plant solutions foreseeing upwind from potential
pollutant sources, such as
one AHU (Air Handling Unit) for each operating road traffic, parking lots,
exhaust air openings,
room (and possibly for its ancillary spaces), plus sewage vents, stacks, hood
vents, cooling towers
extra AHUs for the remaining areas of the oper- and evaporation condensers.
The intake should
ating block, should be adopted. be at least 34 m above
ground or, if installed on
The cooling and dehumidifying decks should a roof, be at least 0.81 m
above the roof surface.
preferably be placed upstream of the mixing ple- AHUs. should be built in
such a way to avoid
num between external and re-circulated air. contamination due to
stagnation and wet resid-
No return of re-circulated air across the uals, corrosion, or
deposition, and be easily
extraction grilles should take place, even in case accessible for cleaning and
disinfection of all
of failure of the re-circulation fan or of wind parts. Therefore, AHU
materials and compo-
backpressure on the exhaust outlets. nents, including seals and
gaskets, should be
Extraction grilles must be placed in such a way resistant to corrosion, fire
and humidity, and
that an effective washing of the space is should not generate
pollution or become pabulum
achieved, in order to avoid areas in which air for bacteria, fungi or
spores. It is advisable that
pollutants or particulates may accumulate. internal surfaces are smooth
and free of asperi-
Grilles should therefore be placed at the four ties, easy to clean and made
of materials resistant
corners of the room, by subdividing the extrac- to detergents and
disinfectants. Internal AHU
tion flow rate between top (1/3) and bottom (2/3), components should preferably
be accessible
and checking that the airflow pattern in the criti- from both sides for cleaning
and sterilization, or
cal area (operating field) is not disturbed; extrac- should be removable from the
AHU in an easy
tion grilles should be equipped with medium and safe way.
73
With reference to standard EN 1886, the Whenever outdoor

temperatures below #5 # C
structure of an AHU for controlled contamination are expected, it is
mandatory to install a finless
spaces should be rated at least in air tightness pre-heating deck, capable
of raising the air
class B, in both positive and negative pressure temperature by about 5 #
C, in order to prevent
sections, and at least in class T1 for thermal filter freezing.
conductance of the envelope. Second bed, consisting of a
filter having effi-
Air humidification must be achieved with ciency F9 according to EN
779 standard
steam systems only, using chemical contami- placed at the AHU outlet
i.e. at the supply
nant-free saturated or superheated steam (sterile air duct inlet in order
to keep the duct tract
steam). The steam distribution system must be between AHU and operating
room clean.
installed between the first and second filter Filters must be installed
using an airtight
beds and be easily accessible. Steam supply gasket system capable of
preventing any air
should be interlocked with the correct operation leakage between filter
segments and between
of the ventilation system (e.g., steam supply is the filter bed and its
supporting frame; the
interrupted in the absence of air flow, or when the pressure drop across any of
the filtering beds
maximum supply humidity set-point is reached, should be detected by a
suitable measurement
or if steam pressure is too low, etc.) control system, in order to
provide an indication
The fan section must be installed between the of the filter clogging level.
first and second filter beds and should preferably The constant cleaning of
the air ducts
consist of two fans, one acting as back-up unit. connecting the AHU and the
air diffusion
Such fans which should preferably be of terminals installed inside
the controlled contam-
the plug fan type to make blade cleaning easier, ination spaces is one of the
more complex tasks in
must definitely be equipped with an inverter- the operation and maintenance
of a VCCAC
based rotation speed control, in order to system. It is therefore
convenient that the layout
guarantee a constant air flow as the filters get of the ducts is as compact as
possible;
progressively clogged. this result may be achieved
by installing the
All air treatment decks must be installed AHUs in a dedicated technical
area adjacent
between the first and second filter beds and (and preferably directly
above or under) the
should be removed and cleaned easily. operating block.
All condensate collecting pans should be The air ducts must be
built with non-
made of stainless steel, be easy to clean and degradable and non-flammable
materials, hav-
disinfect, and above all present such constructive ing a mechanical resistance
suitable for the
characteristics and slope that even a minimal application, and with a
specified air leakage
water stagnation is avoided. They should be rate. Internal duct surfaces
must be resistant to
equipped with a water drainage port of adequate abrasion and corrosion, have
longitudinal or
size to permit evacuation in presence of negative transverse connections of
certified air tightness,
pressure and protected by a correctly sized be free of sharp and
protruding internal ele-
siphon with retaining system. This is essential to ments (screws, flanges,
stiffeners, etc.), be
guarantee that, in case of system shut-off or smooth and inspectable to
facilitate manual or
malfunctioning, no solid, liquid or gaseous mechanized cleaning. Flexible
ducts, provided
impurities may re-enter the AHU through the their length does not exceed
1 m, may only be
drainage port. employed for connecting the
ductwork to the
In order to avoid fouling of the AHU and of the air diffusers.
air ducts, two filter beds are indispensable: Internal inspection of the
ductwork must
First bed (Pre-filter), consisting of a filter be made possible by
installing airtight access
with minimum efficiency G4 + F6 (according panels, which should be
positioned according to
to EN 779 standard), placed at the AHU EN 12097 standard, or at
least in correspondence
inlet, in order to keep the AHU clean. of non-removable devices such
as balancing
74
P. Gallinaro et al.
dampers, valves, fire dampers, air treatment Reduced (Standby) working

regime during the
decks, and silencers, where present. Such inspec- periods in which the
operating room is not in
tion apertures should always be easily accessible, use. In standby operation,
the air flow rate
free of obstructions or obstacles due to other (particularly the external
fraction) is reduced;
components or systems, and be sufficiently large this may imply a variation
of the indoor
to allow for a visual inspection. Whenever it is thermo-hygrometric
parameters with respect
unfeasible to install access panels, the duct tract to the design conditions
specified by the
should be removable. PDD. The reduced flow rate
should however
No insulating materials must be placed in be able to guarantee the
specified air cleanli-
direct contact with treated air; therefore, if the ness level and the
differential pressure
air duct needs thermal insulation, this should be between adjoining spaces,
as well as to main-
achieved by placing the material on the outer side tain to an acceptable level
the concentration of
of the duct. chemical pollutants that
may be present in the
Acoustic silencers must not release fibres room. All doors and
potential outdoor contacts
when crossed by the air flux. Therefore the should be airtight and kept
closed. In such
silencers should be built with surface linings conditions, access to the
rooms should be
that limit dirt accumulation and prevent fibre impaired not to alter the
cleanliness and
dispersal. Whenever possible it is preferable to aseptic levels. Use of the
operating block
install the silencer directly inside the AHU, should be allowed only when
the standard
upstream the F9 outlet filter. working regime is restored.
In-situ signalling
Particular attention must be placed to mechan- of the VCCAC system
operating status should
ical shafts and service volumes that have a direct be present.
impact on the operating block, such as the space Provision of heat
recuperators, capable of
between false ceiling and slab and the air return recovering the main part of
the heat contained
sections, in order to avoid that contaminant in the exhaust air.
Recuperators should be
agents thereby generated or transported may selected in order to avoid
cross-contamination
enter the controlled area. This may be achieved between exhaust and supply
air. The best
both with constructive solutions that guarantee energy recovery performance
is achieved
a good air tightness, and by keeping the negative with active recuperators,
based on heat pump
pressure of such spaces at 5 Pa with respect to the technology, in which
exhaust air acts as the
controlled area. low-temperature heat source
of the heat pump
thermodynamic cycle.
Energy Saving Measures

Sterilisation
The following energy saving measures may be
adopted without influencing the performance It is now common that the
sterilisation of the
levels of the VCCAC system: surgical instruments and of
all the material is
Reduction to an indispensable minimum of performed in a sterilisation
area, which often
the external air and increase of re-circulated serves all the hospital.
Sometimes it is conducted
air. The abatement of particle contamination by outsourcing. The
centralisation of the
requires high flow rates of filtered air. If re- sterilisation procedures has
many reasons, first
circulated air is supplied in addition to of all economics but also,
not of minor impor-
the required external air, care should be tance, it provides more
safety. The single
taken to avoid cross-contamination, by func- sterilisation rooms placed
close to the OR are
tionally separating the re-circulation loops, now abandoned. However, for
urgent and
when a single AHU serves more then one unpredictable processes of
sterilisation a vapour
room. system should be provided in
the operating block.
75
All the procedures that lead to the production

of sterile medical devices must be performed in Appendix 1 National and
International
observance of the European Directive 93/42. In Standards/Guidelines
the sterilisation area can be placed the implant for
the cold sterilisation of the thermo-sensible EN-ISO 14644 Cleanrooms and
associated
materials. controlled environments.
Part 1: Classification of
air cleanliness.
Ed. 01/05/99
Conclusions Part 2: Specifications
for testing and monitor-
ing to prove
continued compliance with
The last decades have seen a rapid development ISO 14644-1.
of specialized surgery thanks to the improvement Part 3: Metrology and
test metods.
of technologies such as fibre-optics, imaging, Part 4: Desing,
constraction and start-up.
informatics, robotics, tissue banking and tissue Part 5: Operations
manipulation. The operating room is still the France: Norme NF
S 90-351:2003,
heart of modern surgical hospitals, where all Etablissements de sante
. Salles propres et
these technologies apply. It is therefore clear environnements matrise
s et apparentes.
that old operating rooms are anymore in line Exigences relatives pour
la matrise de la
with the needs of modern surgery: from the pro- contamination aeroporte
e.
ject to the storage and transportation of the Germany: DIN 1946-4, 2005:02
Ventilation and
devices. Also, old practices are insufficient. air conditioning - Part
4: Ventilation in
Many differences from years ago have been intro- hospitals
duced thanks to the European Union, which gave Switzerland: Swki 400/5/2003
R-99-3, Guidelines
regulations and directives regarding the products on Heating, Ventilating
and Air Conditioning
and the devices and the acquisition of instru- in Hospitals.
ments. All these new directives and indications Austria: O NORM
H 6021-1-2003
must be known and applied by the staff of the Luftungstechnische
Anlagen Reinhaltung
operating rooms. In addiction, many times the und Reinigung.
surgeon has a predominant position which United Kingdom: Health
Technical Memoran-
involves the role of control of instruments and dum HTM 2025: Ventilation
in Healthcare
other staff. The construction of a new operating Premises.
block is under strict regulation, many aspects are Italy: ISPESL Dipartimento
igiene del Lavoro
driven by European standards or directives but Linee guida per la
definizione degli standard
many experience-based suggestions are still very di sicurezza e di igiene
ambientale dei reparti
useful. operatori, 1999.
Therefore, in order to avoid future conflicts or
disagreements, a hospital consulting committee
should work together with the architects staff. References
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Bone Autografting,
Allografting
and Banking
Tom Van Isacker, Olivier

Cornu, Olivier Barbier, Denis Dufrane,
Antoine de Gheldere, and
Christian Delloye
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 77 Today, the risk of contamination for the recip-
ient of bone allograft remains very low and the

Properties of a Bone Grafting Material . . . . . . . . . . . 78
european demand of bone allograft is still

Preparation of the Host Bone Bed . . . . . . . . . . . . . . . . . 78
high. But nevertheless, the best performant
Bone Autografting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 78 bone graft continues to be the autograft
Handling Precautions for Autogenous Bone . . . . . . . . .
78 because of its osteogenicity.
Advantages and Complications of Autografting . . . . .
78
Types of Autografted Material . . . . . . . . . . . . . . . . . . . . . . .
79
Techniques of Procurement of a Free Cancellous
Keywords
Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 80 Allografts-source # Autografting-sources #
Technique of a Free Vacularised Fibula Transfer . . .
82 Bone graft harvesting-techniques # Bone
Bone Allografting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 82 grafting # Bone types-Cortico-cancellous #
An Increased Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82 Complications of bone grafting # Marrow
Risk of Transmitting Disease with Bone
bone (RIA) # Material # Osteo-conductive #
Allografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 83
Osteo-inductive # Processing and preservation

Source of
Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
83
Bone Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 83 # Structural # Transmitted disease #
Preservation of Bone and Influence
Vascularised
of the Sterilisation Technique . . . . . . . . . . . . . . . . . . . .
84
Types of Bone Allografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 87 Introduction
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 87
For many decades, bone has been considered by
surgeons as the reference material to fill any
bone defect. The iliac crest of the patient was

T. Van Isacker # O. Cornu # O. Barbier # C. Delloye (*)
Service dOrthopedie et de Traumatologie, Cliniques
the first source of bone. There was neither
Universitaires St-Luc, Universite Catholique de Louvain,
immune response nor transferred disease. How-
Bruxelles, Belgium
ever, pain at the iliac crest and the limited
e-mail: christiandelloye@gmail.com
amount of bone available has gradually pro-

D. Dufrane
moted the use of bone allograft. With the advent
Banque de tissus de lAppareil locomoteur, Cliniques
of bone allograft and tissue banks, it has become

Universitaires St-Luc, Universite Catholique de Louvain,
Bruxelles, Belgium
gradually apparent that a bone allograft itself
could transmit disease from a donor. This poten-

A. de Gheldere
The Newcastle upon Tyne Hospitals - NHS Foundation
tial risk of a recipient contamination by bone
Trust, Newcastle upon Tyne, UK
has led from 2004 to publication of stringent

77
DOI 10.1007/978-3-642-34746-7_21, # EFORT 2014
78
T. Van Isacker et al.
guidelines by European authorities. This threat

has also encouraged the use of non-osseous bone Bone Autografting
substitutes.
This chapter will cover bone autografting, The transfer of a living
piece of bone from the
allografting and banking. patient skeleton is a time-
honoured procedure.
The most often
preferred location for bone pro-
curement is the iliac crest
because this site can offer
Properties of a Bone Grafting Material cancellous or cortico-
cancellous bone [4].
Bone autograft remains
today unchallenged as
Any grafting material is considered as osteogenic it is the only native graft
that combines osteo-
if it contains living osteogenic cells. This require- genic, osteo-conductive and
osteo-inductive
ment is only met by autogenous bone that will be properties. Cancellous bone
is richer in osteo-
immediately implanted and by any enriched bone genic cells than cortical
bone because its surface
substitute supplemented with cultured osteogenic area is comparatively
larger. Iliac crest is consid-
cells from the host. ered to be the best
available osteogenic source as
A material can be considered as osteo- it still contains red
marrow with stromal cells.
conductive when its structure can support migrat- This osteogenic site has
been recently challenged
ing cells from the host. The support must promote by the endosteal lining
from a reamed long bone
migration and attachment whereas the local at the lower limb [57].
environment must favour differentiation into
osteogenic cells. New bone formation within the
scaffolding is the expected end-result. Osteo- Handling Precautions for
Autogenous
conduction can be assayed and measured exper- Bone
imentally [1]. This property is not bone specific
as other substitutes such as porous ceramics have Only part of the cellular
population lining the
the same capacity. trabeculae of cancellous
bone from the iliac crest
A bone graft is osteo-inductive when it is able will survive the surgical
trauma and will be able to
to elicit the differentiation of mesenchymal cells take part to the healing
process of the grafted bone.
into osteoblasts. This property can only be Cell survival is possible
because they are lying on
ascertained in vivo by heterotopic implantation the bone surface from which
the cells can derive
of the bone graft into a non-osteogenic site such their nutrients. A distance
of 300 m from the sur-
as a muscle [2]. Unless it contains a preserved face is considered the
critical distance beyond
osteo-inductive factor, no bone grafting material which cells will not resist
anoxia [8].
can be considered as osteo-inductive. The trauma of
procurement should be mini-
mized as it correlates with
the cell survival and
re-vascularization of the
tissue [9]. However,
Preparation of the Host Bone Bed elapsed time and conditions
of the graft mainte-
nance between harvest and
implantation are crit-
This step is very important as it will also ical. Direct exposure to
air is harmful whereas
influence the take of the graft. The host bone moist surrounding s will be
more appropriate for
bed must be cleaned of fibrous and necrotic preservation of the graft
vitality [1012].
tissues. Host bone must be bleeding to promote
vascular in-growth into the porous bone. The
grafting material must be rigidly fixed into the Advantages and
Complications
recipient bone, avoiding any micromotion of Autografting
that could interfere with the vascular in-growth.
The interface with the material must be tight There are many advantages
to using an auto-
and without interposing soft tissue [3]. graft: the biological
superiority of the graft
Bone Autografting, Allografting and Banking
79
a b c
d
Retractor Curette
Fig. 1 Procurement of bone from the iliac crest. (a) Pre- a curette. (d)
Closure of muscles and skin with allograft
operative profile of iliac crest. (b) iliac crest exposed from seen in blue
above. (c) Removal of cancellous bone from the crest with
with its osteogenic cells, the absence of disease Cancellous or

Cortico-Cancellous Bone
transmission risk and immune response. In most This is the most
used grafting material. Most of
patients, bone from the ilium is transferable and these grafts are
procured from the iliac crest
when considered, the patient must be pre- either anterior
or posterior.
operatively informed. Procurement of bone
from the iliac crest and in particular the anterior Anterior Iliac
Crest
one, carries the risks of major and minor com- This standard
site of bone harvest is associated
plications such as nerve and arterial injuries, with the most
complications, chronic pain being
fracture of the ilium, and visceral injuries. The the most frequent
one [15]. To minimize them, an
larger the graft procured, the higher the rate of incision at a
distance of 3 cm from the anterior
complications. Chronic pain remains the most superior iliac
spine, sub-periosteal dissection,
frequent one [1317]. uni-cortical
cancellous or pure cancellous grafts
Preserving the outer iliac cortex for a bone should be
considered.
harvest appears not to change the complication Full iliac
crest including the roof and both
rate [18]. A percutaneous technique of procure- inner and outer
wall can be procured when strong
ment decreases the local morbidity with less pain osteogenic
material is considered. The procure-
on walking and skin dysaesthesia [19]. ment of bone
should however be limited, when
possible, to its
cancellous content (Fig. 1) or to
cortico-
cancellous material including either the
Types of Autografted Material outer or the
inner cortical wall.
An
alternative method is to use an acetabular
There are two types of bone autograft: cancellous reamer against
the outer wall before reaching the
and cortical. inner cortex
[20].
Bone can be harvested free or with its vascular When bone
pegs are needed in limited quantity,
supply. the surgeon can
use a trephine either percutane-
The vast majority of bone autografts are non- ously or through
a minimal approach.
vascularised pieces of bone that will be trans- At our
institution, we use a bone allograft to
ferred to the site to be grafted during the main fill the gap in
order to decrease pain and bleed-
surgical procedure. ing. Percutaneous
procurement of bone can be
80
made using a trephine through a small incision Finally, a rongeur may

be used to finely cut the
centered over the iliac crest. The procedure cancellous bone into a
mouldable puttylike graft.
clearly reduces early and late morbidity, but An alternative method for
obtaining such mate-
procures less than 10 ml. of bone. rial is to use an ace
tabular reamer that is held
against the outer aspect
of the ilium. The partic-
Posterior Iliac Crest ulate bone graft material
is harvested intermit-
The posterosuperior iliac spine area is the best tently. The procedure is
stopped once the inner
source of cancellous bone and gives more bone table is reached [20].
When a concave-shaped
than the anterior part of the iliac bone (up to 30 ml). graft is required, the
inner aspect of the ilium is
A prone position is the best way to get bone more appropriate for
procurement.
at this site but lateral decubitus can also be When a tri-cortical
graft is considered (e.g.,
used. Colterjohn [21] suggested a modified for corrective
osteotomies), then a full thickness
incision more vertical which allows preservation of the crest should be
procured, after both outer
of clunial nerves. During spine surgery, the and inner aspects have
been exposed.
posterior crest can be approach by subcutaneous Depending on the
quantity of the procured
dissection avoiding a second skin incision [22]. bone, a cancellous bone
allograft can be
Fewer complications have been reported for implanted to reshape the
defect in case multiple
posterior iliac crest procurement comparatively grafting procedures are
anticipated, especially in
with an anterior approach [15]. the young (e.g., patient
with a tumour). The apo-
neurosis is sutured over
a wound drainage tube.
Techniques of Procurement of a Free Posterior Iliac Crest

Cancellous Bone The largest amount of
cortico-cancellous bone
can be procured from this
location.
Anterior Iliac Crest The patient is usually
prone but can also be
The patient is placed in a supine position. placed in a lateral
position with the side to be
The iliac tubercle is approached through a skin operated facing upwards.
The procurement can
incision parallel to but just inferior to the iliac be performed separately,
or as part of any poste-
crest. The tubercle, being the widest part of the rior spine surgery.
crest, contains the largest amount of cortico- The classical incision
begins at the posterior
cancellous boue. The incision starts 1 cm behind superior iliac spine,
following the iliac crest for
the anterior superior iliac spine, to avoid injury about 8 cm anteriorly.
Beyond that distance, the
to the lateral femoral cutaneous nerve. The apex clunial nerves cross the
iliac crest and their injury
of the crest is incised longitudinally, between can cause a loss of skin
innervation. As this
the abdominal and gluteus muscles, where the procedure crosses the
point of pressure over the
intermuscular plane is relatively avascular. In posterior aspect of the
pelvis, it may be compli-
children, the growing apophysis is split in two, cated by skin necrosis.
releasing the muscles on either side. The material Another access is
through a more vertical inci-
can either be taken from the inner or the outer sion, 2 cm lateral to the
posterior spine. This
aspect of the ilium (Fig. 1). The corresponding lateral approach has been
found to have a lesser
muscles are elevated by sub-periosteal dissection incidence of skin
complications.
over the considered site and retracted. Cortico- The subcutaneous fat
is incised on the line of
cancellous or cancellous bone is procured with incision, to expose the
gluteus maximums. The
straight and/or curved chisels, curettes and gouges. gluteal fascia is incised
along the crest. The mus-
When particulate cancellous graft is needed, cle is elevated by sub-
periosteal dissection. If
the inner or outer aspect of the cortex is elevated a large amount of bone is
needed, the outer iliac
with a chisel, while a gouge or curette procures fossa can be exposed as
far as the superior border
chips of cancellous bone. of the greater sciatic
notch. The thick portion of
81
bone that forms the notch must be left intact to Fig. 2 Procurement of
preserve the stability of the pelvis. The superior cancellous bone from
femoral marrow by intra-
gluteal neurovascular bundle should be identified medullary reaming
and protected.
Should a tri-cortical bone block be required,
the thoraco-lumbar fascia is dissected free from
the inner aspect of the crest. A full thickness
segment of the crest can be removed, taking
care to preserve the articular surface of the sacro-
iliac joint.
The iliac bone defect can be covered by
a haemostatic sheet or substituted by a bone
allograft in case recurrent bone graft procure-
ment is anticipated. The aponeurotic plane
is sutured over a wound drainage tube. During
spine surgery, the posterior iliac crest can be
approached by subcutaneous dissection
from the midline to the posterior crest. The
dissection can be sharper along the posterior
gluteal line, at the tendinous origin of the
muscle.
Other Sources of Cancellous Bone

If the bone defect is small, it is sometimes less
demanding to harvest cancellous graft from the
ipsilateral extremity undergoing operation (e.g.,
distal radius, proximal tibia or femoral condyle,
a rib during thoracotomy).
There is often a variance of the osteogenic
capacity of cancellous bone in an adult patient. the iliac crest. This
technique allows the procure-
Bone-forming capacity of the autogenous ment of large volume of bone
(as high as 75 ml)
bone is related to the number of osteogenic cells without major complications
[5, 24]. It consists of
present in the procured bone. When the bone endosteal bone particles
that have been proven to
marrow is haematopoietic such as at the iliac be highly osteogenic whereas
the aspirate fluid
crest, the osteogenic potential is optimal. displays also osteogenic
capacity [25]. Over-
In another area where bone marrow is fatty such reaming may alter the bone
resistance to torque
as the distal radius, proximal tibia or femoral and cause iatrogenic
fracture [5].
condyles, the osteogenic capacity is
questionable [23]. Bone Marrow and Stromal
Cells
Bone marrow is composed of
haematopoietic and
Endosteal Cellular Material stromal cells. The latter
provide a micro-
A new source of osteogenic material has been environment for
haematopoiesis and are the
recently identified: reaming products from the source for mesenchymal cells
among which are
medullary canal of a long bone (Fig. 2). The osteogenic cells. Aspiration
of bone marrow
reamer-irrigator-aspirator (RIA) technique that through a needle has also
become popular in
instruments the medullary canal femur or tibia order to supplement any
implant with bone mar-
has been developed to avoid the complication row cells or to directly
inject into delayed union
rate that is associated with the harvest of bone at [26, 27].
82
Cortical Bone interosseous membrane must

be left intact. Place
Compact bone is procured at the medial aspect of the patient supine on the
operative table with
the tibial diaphysis or at the fibula. tourniquet. Use the Henrys
approach, avoiding
Cortical bone is less cellular, hence less oste- injury to the fibular nerve.
The plane between
ogenic but is a strong and resistant material and is the soleus and fibular
muscles is developed. The
considered whenever a structural graft is consid- interosseous membrane is
incised close to
ered. Today, cortical bone allograft is preferred the fibula. The plane
between the fibular vessels
for that specific purpose instead of procurement and posterior tibial nerve
is dissected including
of a cortical bone from a patients tibia. a cuff of the tibialis
posterior muscle. Make
the transversal distal cut
first with a water-cooled
Tibial Graft saw while protecting
muscles. Dissect sub-
The anteromedial surface of the tibia periosteally from distal to
proximal up to the
provides a large and long (up to 30 cm) correct length. Cut in the
same way the proximal
corticocancellous graft with good mechanical part of the fibula. A
cutaneous flap can be trans-
properties. To avoid any stress fracture of ferred at the same time, if
necessary.
the donor site, the anterior and posteromedial
tibial crests should be excluded.
Bone Allografting
Fibular Graft
For fibular graft, the entire proximal three- An Increased Demand
quarters can be used, but is rarely needed.
Bone allografts have now a
long history as
Vascularised Bone Autograft a natural substitute for
repairing any size of
Posterior iliac crest harvest can be used with its large skeletal defects. They
are an attractive alter-
lumbar muscular attachment providing native to a bone autograft
because their supply is
a vascularised autograft for use in posterior lum- less limited, their surfaces
are a natural support
bar or sacro-iliac arthrodesis. for bone formation and they
allow any structural
A free vascular graft, with microsurgical restoration of the skeleton.
Bone allografts when
sutures, is used in case of a bone transfer far available tend to supersede
bone autografts
away from the host bone bed. Many techniques because of their ease of use
and the gain of
have been described: iliac bone, forearm bones, operative time [31].
ribs, but the most used is still a free vascularised The demand for bone
allograft has expanded
fibula [28]. Large segmental bone defect, non- rapidly, driven by the
expanding number of revi-
union, osteomyelitis or congenital anomaly are sion arthroplasties for
loosening in an ageing
the most frequent indications. population and by newer
trends of minimally-
The key advantage of using a vascularised invasive surgery
particularly in the spine area
bone is its preserved vitality with subsequent where the need of bone
grafts or substitutes is
osteogenic potential. growing fast. The number of
bone grafts avail-
able in Europe has increased
sharply over the past
years and mirrors the
situation previously
Technique of a Free Vacularised Fibula observed in USA [3234].
Transfer In 2013, bone allografts
remain the most used
bone substitutes in Europe.
The proximal two-thirds of the fibular diaphysis This sustained demand for
bone allografts
are approached laterally [29]. The distal 10 cm. is makes their supply difficult
when the femoral
preferably left intact to avoid any instability head from living donors is
the only source [35, 36].
problem with the ankle [30]. To avoid it, Nationwide operating
tissue banks recover
syndesmotic ligaments and the distal portion of allografts not only from
living donors but also
83
from organ donors in an operating theatre under kept in mind that tissue
banks screen a limited
aseptic conditions or from post-mortem donors number of known viruses and
that transmission of
[37, 38]. Procurement from an organ donor unknown pathogens still
remains possible.
remains the most secure way to obtain a long
bone [39, 40]. Large bone segments will be
mainly used in Orthopaedic oncology or can be Source of Tissue
processed in smaller units for further use in other
clinical indications. Tissue implantation is never Living Donors
an emergency surgical procedure and safety of The femoral head from a
patient undergoing a hip
any bone allograft remains a major concern. To arthroplasty is the usual
source. The patient is
minimize the risk of disease transmission, the reviewed for another
screening after 46 months
European community has issued from 2004 post surgery. During this
period, the bone is
a directive and related documents on the quality quarantined. It turns out
that in UK, an average
and security of human tissues [41]. Tissue bank- 48 % of potential live
donors of a femoral head
ing has become highly regulated. must be rejected after
medical guidelines selection
and from those accepted,
another 22 % will be
rejected after medical
screening [36]. Instead of
Risk of Transmitting Disease with Bone reviewing the patient for
further screening, the fem-
Allografts oral head can be processed
with chemical solutions
if the initial screening at
the time of surgery was
The ultimate goal in tissue banking is to provide negative. Another method
used to avoid additional
surgeons with safe and appropriate tissues. Safety late screening of a living
donor is to include, at the
of bone allografts remains a concern as an time of harvesting, virus
nucleic acid testing assays.
implanted bone allograft can transmit disease
[40, 42, 43]. Amongst the potential transmittable Multi-Organ Donors
diseases, virus and prions are the most difficult to Long bones are procured in
sterile conditions in the
track. Hepatitis C virus (HCV) and human immu- operating theatre after
organ explantation. In addi-
nodeficiency virus (HIV) transmission through tion, the mechanical
resistance of bones is optimal
bone grafting material has been well-documented originating from a rather
young population. The
[42, 43]. Dura mater implants but not bone and procurement team has been
always led by an Ortho-
related tissues have caused Creutzfeldt-Jakob paedic surgeon. The donor is
always screened with
disease. Donor selection is considered as an effi- a large panel of tests
including viral nucleic acid
cient measure to reduce the risk of this agent testing [37, 38]. To
maximize the safety of bone
transmission [44]. Although HIV virus remains allografts, we indirectly
screen back the donor by
the most present in the world of media, HCV is testing the organ recipients
at 3 months [39].
more prevalent and as such carries more risks for
transmission [4547]. Even bacterial contamina- Post-Mortem Tissue Donors
tion of the allograft can occur and be life- Testing cadaver tissue
donors raises two concerns:
threatening [48]. a false negative results
making transmission of an
Procedures have been designed to ensure the undetected viral disease
possible and a false posi-
supply of safe bone [39, 40]. tive result with subsequent
tissue discard due to
Tissue banking is now regulated at the European the degradation of non
circulating blood [49].
level. With a multi-step screening-policy, stringent
donor selection guidelines, the risk of viral trans-
mission through a tissue remains remote, being Bone Processing
much lower than most other risks associated with
surgical procedures and is become nearly virtual Processing means any
activity performed on
with tissue processing [40]. However, it should be recovered tissues from well-
selected donors.
84
One of the purposes of processing is to shape radicals are produced [59].

In freeze-dried mate-
and size the graft material for its intended use rial, most of the water
content has been removed
(bone morsels, dowels, threaded cages etc. . .). but ionisation has a direct
effect of breaking the
Processing also includes several steps to inac- collagen chains and hence the
mechanical resis-
tivate and remove harmful agents. Amongst the tance [60]. Freeze-dried and
sterilized bone can
most important steps are the bone marrow and provide some mechanical
support, mainly in com-
cellular debris elimination with fluid and pression but being less
resistant, must be used in an
detergents through validated different methods. area that will be
mechanically protected with or
Fluid pressurisation allows the full penetration without an osteosynthesis.
of the inactivating or eliminating agent in Frozen bone can be
handled and re-shaped like
large bone structure [50, 51]. Delipidation the native bone. Frozen bone
is fully workable. In
has been shown to promote better osteo- contrast, freeze-dried bone
unless rehydrated in
conduction [52]. The complete removal of saline, is brittle and as
such, not fully workable.
blood debris allows the un-matching of Rhesus As with a ceramic, the
surgeon must be acquainted
factor from the donor to any young female with the material properties
of a freeze-dried bone.
recipient [53, 54].
Ethanol, acetone and ether are often used as
they were shown to inactivate coated viruses such Types of Bone Allografts
as HIV and hepatitis viruses [55]. Hydrogen per-
oxide has been long used as a bleaching agent and Cortico-Cancellous Bone
Allografts
has been shown to be virucidal and bactericidal This grafting material is
made from cortico-
due to its capacity to form free radicals. cancellous bone. It has only
osteo-conductive
property and has no
osteogenic nor osteo-inductive
capacity.
Preservation of Bone and Influence Any bone allograft can be
enriched with
of the Sterilisation Technique growth factors or cultured
mesenchymal stem
cells in order to stimulate
vascular invasion of
Freezing either at #80 # C or in liquid nitrogen at the graft and new bone
formation [61, 62]. Sup-
#196 # C or freeze-drying with subsequent stor- plementation of these
expensive biological mate-
age at room temperature are the current methods rials appears to promote the
incorporation of the
of bone preservation [56]. Bone can be processed bone to the host at least in
experimental condi-
under strict aseptic conditions or be sterilised at tions but adverse unexpected
results might also
the final stage, usually with irradiation. At the be observed [63]. Such
additional procedure is
usual dose of 25 KGy, bacterial sterilization is not yet part of the routine
today.
achieved if the bone has been properly managed Bone allograft is readily
available in many
before the final sterilization. However, this dose tissue banks and is
subsequently the most used
is not virucidal for HIV [57] whose risk preven- bone substitute. A modern
bank will have various
tion should rely on tissue-bank screening proce- bone preparations available
for the surgeon.
dures and inactivating treatments. Sterile frozen femoral
heads: This is the main
A deep-frozen bone whether irradiated or not, source of bones for many
local and regional tissue
retains its original mechanical properties. Non- banks in Europe. They are
delivered unprocessed
irradiated freeze-dried bone retains also its or processed.
mechanical strength but irradiation of a dried Processed cortico-
cancellous bone: The bone
bone will substantially decrease its mechanical source can be either an
osteoarthritic femoral
capacity [58]. In the frozen state, damage to the head from a living donor or
an epiphysis from
bone collagen is reduced due to the lesser amounts an organ donor. Processing
will include de-
of free radicals generated by ionisation of frozen fatting and bone marrow
removal. Processed
water whereas at room temperature, more free bone can be stored frozen or
freeze-dried.
85
For convenience, we generally recommend healing in 11 out of the 13

patients with a long
freeze-dried bone for small, contained defects follow-up [27].
(<5 cm3) while for larger, non-contained cavi-
ties, we would prefer frozen material. Structural Bone Allografts
Cortico-cancellous bone morcels: They can be Bone allografts have been
used primarily for limb
used either as frozen or dried material. However, salvage procedures in
Orthopaedic oncology and
impaction at the femur is easier and faster still today remains an option
to consider to recon-
obtained with freeze-dried bone morcels than struct larger bony defects
created by limb-sparing
with frozen ones [64]. procedures where they can
provide an immediate
structural support that can
be associated if neces-
Osteo-Inductive Bone Allografts sary with a prothesis, an
osteosynthesis or
The demineralised bone matrix (DBM) is the a vascularised fibula [66
68]. Most of the time,
only bone allograft that expresses an osteo- they are sterilely-procured
from organ donors,
inductive capacity. The osteo-inductive capacity they are stored frozen at #80
# C. Among advan-
of demineralised cortical bone was discovered by tages, their use allows: an
anatomical reconstruc-
Urist in 1965 [2] and led after four decades to the tion of the skeletal defect,
a biological union to
isolation of the bone morphogenetic proteins host bone through callus
formation, the soft-
(BMP). Once demineralised, cortical bone still tissue adherence around the
grafted bone and
contains collagen, bone proteins, glycoprotein the possibility of a tendon
re-insertion on its
and proteoglycans. For osteo-induction to occur, counterpart left on the bone
graft.
three conditions must be met: the presence of
BMP, the carrier (most often collagen type I) Complications Observed with
Massive,
and the responding (inducible) cells. The major Structural Allografts
advantage of DBMs is that they already contain Among the disadvantages,
there are: a risk
two of the three conditions in a native condition albeit remote, of disease
transmission through
(human BMP and collagen type I). the implant, a high rate of
non-union and frac-
There are various ready-for-use bone prepara- ture with an approximate
prevalence of
tions available to surgeons but they all contain 1530 % in the case of large
structural bone
demineralised bone mixed with expanding sub- allografts [69].
stances such as calcium sulphate. The consis-
tency (morcels, paste, mould, putty) is variable Non-Union
but always easy and convenient for use by the Vander Griend et al. [70]
reported an 11 % of
surgeon [32, 33, 65]. non-union with large frozen
allografts. The mode
Most products have a set of experimental data of fixation had no influence
on the rate but plating
that allow delineating their main characteristics. was significantly associated
with fracture of an
However, it remains difficult for the surgeon to allograft. An initial gap of
three millimetres
select which product fits best his indication. appeared to be critical in
the non-union formation
Most often, there is no available comparison [70]. The diaphyseal junction
healed by 912
between substitutes nor between a substitute months whereas the
metaphyseal junction healed
with an autograft. Osteo-induction can be veri- more rapidly, usually by 6
months [70]. The
fied by the new bone formation after implanta- mode of osteosynthesis is
still a matter of debate.
tion of a DBM in the dermis or the muscle in rats We reported a 36 % rate in a
large series of 140
[2]. True indications for DBM will be non-union large bone allografts [69].
or delayed union. Relative indications are The aim of fixation
should be to obtain
trauma and any conditions requiring bone for- a uniform contact between
host and allograft
mation. Another interesting indication is its use bones with a stable interface
which is more easily
to halt the osteolytic phase of a primary aneu- achievable with plating than
nailing [70]. Making
rysmal bone cyst. We were able to achieve a step-cut to improve the
rotational stability when
86
intramedullary fixation is used, produces well Infection

size-matched bony ends [71]. Augmentation of Infection of an allograft
is a devastating compli-
the junction with bone autografting is not a pre- cation resulting in a bad
outcome as many
requisite for obtaining bone healing but the use of procedures or amputation
will be necessary.
an autograft bone will promote a callus by its The incidence is variable
between 5 % and
intrinsic osteogenetic capacity and will help to 13 % [69, 79]. The proximal
tibia has the highest
reduce junction voids. Another potential alterna- incidence. Many factors
such as blood transfu-
tive is the replacement of the autogenous bone by sion, location of the
tumour, re-operation,
an osteo-inductive substitute or growth factors. arthrodesis have been
advocated and the risk is
cumulative [79]. The
necessity to achieve
Fracture a viable cover of the graft
is imperative. One
Fracture is another major complication and way to better control the
infection rate has been
occurred with a prevalence of 1618 % at to promote the soaking of
the bone allograft in
2 years after implantation [72, 73] and even antibiotic solution.
higher at longer follow-up periods [69]. Struc- It has been shown that a
bone can be an
tural fracture through the shaft of the allograft is appropriate vehicle for the
local delivery of
usually irreversible due to the limited intrinsic antibiotics such as
vancomycin or rifampicin
healing potential of the allograft. Fracture may [80, 81]. Biopsy of
vancomycin-impregnated
jeopardize the outcome of a massive bone graft bone morcels used to revise
hip arthroplasty has
and its occurrence remains rather unpredictable. shown nrmal bone formation
around the graft,
Spontaneous healing may be observed usually at suggesting that vancomycin
did not influence
the tibia and in young adults. Bone autografting at the bone healing [82].
the fracture site has not been consistently suc-
cessful with about about 30 % of fracture healing Indications and Forms for
Structural
[68, 72, 73]. In our experience, replacement of Bone Allografts
a fractured allograft elsewhere than the tibia is the They are used for skeletal
reconstruction mostly
rule. Furthermore, attempts to heal these fractures after tumour resection and
arthroplasty revision
with BMP-2 or BMP-7 were failures [74]. It is and more rarely after
trauma. The indication, as
generally believed that most fractures of struc- well as fixation, will be
greatly influenced by the
tural allograft occurred through areas where surgeons experience. In
most cases, deep-frozen
revascularisation and host-tissue in-growth are bone will be preferred to
freeze-dried because of
absent [73]. As any inorganic material, a bone its better workability at
surgery.
allograft will fatigue with appearance of micro- There are various forms
of structural bone
cracks with an ensuing failure [75]. Wheeler and allografts.
Enneking, [76] investigated retrieved massive Osteochondral allograft:
This form of allograft
bone allografts for failure and observed that, will be considered for
a partial joint recon-
with time of implantation, a reduction in strength struction in children
at the knee or the ankle
of the bone and an increase in crack density and in adults at the
upper limb in adults. Total
occurred. These failures are related to the joint reconstruction
with a preserved joint
non-vitality of the bone graft. To manage such allograft is not so far
a good option for
potential complications, one should either a long-term result [83]
as they will develop
re-inforce mechanically the structure of allograft a Charcot joint with
rapid deterioration.
by cementing the medullary canal [68, 77] or by Intercalary allografts:
This reconstruction
improving the allograft revascularization through includes the use of a
similar bone segment as
cortical perforation [78]. Another approach is the the one removed.
use of growth factors but the good response Segmental allograft with
arthrodesis: This type
observed experimentally has not been so far of reconstruction is
usually performed at the
confirmed with human allograft [74]. knee or the ankle.
87
Table 1 Practical recommendations when using bone demanding and require

dedication to high stan-
allografts dards. The ultimate
goal is to provide a safe and
Confirm your order at the tissue bank, leaving appropriate grafting
material.
a precise address with the patient references.
Send back to the tissue bank the post-operative
traceability sheet with patient and graft references.
Frozen Material References
Prepare a thawing container and pour 37 # C heated
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new bone chamber used for measuring
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Wait for complete thawing before cutting, trimming
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Bone Substitutes in Clinical
Practice
Jari Salo
Contents
Abstract
Bone
Substitutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 92 Clinical use of bone substitutes is becoming
a routine procedure. The eve- increasing

Clinical Use of Bone Substitutes . . . . . . . . . . . . . . . . . . . . 93
variety of commercially- available materials

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 95 offers many new possibilities, but can be
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 96 embarrassing, too. Is this material resorbable,
does it have compression strength, how can it
be applied, is it of living origin etc.? are com-
mon questions in the Surgeons mind. Last,
but not least, what is the price of the selected
material. Should I still use the good old
method of autologous bone graft, and try to
save money?
In this paper will try to give an overview of
current materials based on the biology and
clinical use, not based on commercial or mar-
keting strategies.
Bone substitutes can all be classified as
osteoconductive, osteo-inductive or osteo-
genic material. Their clinical use differs in
many ways. Osteoconductive materials
form a bridge over the bone void area to
offer a possibility for bone formation in
bony environment without too much scar

formation. Osteo-induction is based on the
stimulation of mesenchymal stem cells to
differentiate and form bone tissue. Osteo-
genic material works both ways in some
extent, and it also has active cells. Tradi-
tional osteogenic material, autograft, is fac-
ing new challengers as material and tissue

J. Salo
technology proceed.
Helsinki University Hospital, Toolo Hospital, HUS,
Helsinki, Finland
e-mail: jari.salo@hus.fi

91
DOI 10.1007/978-3-642-34746-7_11, # EFORT 2014
92
J. Salo
Keywords vessels inside large filling

spaces. There also are
Bone grafts # Bone healing # Bone substitutes extremely hard solutions,
like old bone cement or
# Clinical applications # Growth factors # a newer castor bean-based
compound, for sites
Organic bone fillers # Osteoconduction # with a need for high
compression strength.
Recombinant technology # Synthetic fillers Other non-injectable
materials include e.g.,
inorganic small porous
particles, wedges or
blocks. Materials vary from
CaP/HA to bioactive
glass, having differences in
composition, micro-
Bone Substitutes structure or manufacturing
methods. Depending
on the product type they can
have a limited to
The problem of bone void has been known for moderate compression
strength. These materials
a long time. Historical documents include e.g., are osteoconductive.
Especially in this group it is
the use of stone, wood, animal bones, corals and important to estimate the
surface area/volume
auto-, allo- and xenografts. Autografts or allo- ratio of the bone
substitute. The ratio can have
grafts still are regarded as the gold standard in a remarkable effect on the
remodelling speed and
the treatment of bone voids either in primary on tissue reaction at the
filled site.
trauma, delayed bone grafting, non-unions, Organic bone substitutes
are mostly based on
arthro-/spondylodesis or endoprosthesis surgery. demineralised bone. They are
commercially
Tumour surgery can have special indications available as strips, putty,
paste etc. They are of
where non-living material is preferred. Different living origin and have a
theoretical risk of trans-
indications also have different demands on fillers. mitting diseases. After
donor screening and
One can create different kinds of classifications heavy processing during
demineralisation it can
depending on each clinical situation, surgical be assumed that this risk is
far lower than in
hardware and the bone substitute used. normal allografts. De-
mineralised matrix-based
The clinical goals for each procedure should be: products are
osteoconductive, and some of them
1. The final outcome is formation of good quality also have a limited osteo-
inductive capacity. My
bone in desired extent personal opinion is that
their most important fea-
2. The surgical procedure can most likely be ture is the wide [1],
although mild, spectrum of
done all at one operation natural growth factors
(VEGF, IGF, BMPs etc.)
3. The costs and morbidity of the procedure is promoting healing of
mesenchymal tissues.
tolerable. Recombinant technology
has opened a new era
The structure, and handling, of bone substi- in osteo-induction. Although
still very expensive,
tutes varies largely. Some of the first generation BMP-2 and BMP-7 are
commercially available
tricalcium phosphate or hydroxyapatite-based and can be used to kick-off
bone formation in
materials are injectable, harden within the first severe cases. There are
several estimates and stud-
day(s), and can be used in weight-bearing areas. ies on the economical impact
of these products if
Limited cohesion force can cause spreading of fracture healing can be
achieved faster and more
the material around the actual treatment site. Sec- reliably. The risk is that
molecules originally in
ond generation materials are more easy to handle high concentration are
rinsed away from the bone
even in wet surroundings, but the principle in void area. The volume filled
with the scaffold is
healing is the same. Limited sized voids are limited, and the use of
BMPs. has moved towards
resorbed and remodelled in months or years combination of recombinant
BMPs. and allo- or
whilst larger fillings risk being encapsulated and autografts to fill larger
defects.
in that way become a dead tissue inside the bone. PMMA is still used in
tumour surgery, and
The newest materials still have the advantage of also as a spacer when a two-
phase reconstruction
injectability, in addition they should become is used. Then the initial,
often critical size, bone
porous after injection. This is a property which defect is filled with PMMA
and in the second
is thought to support cell migration and growth of operation at 45 weeks the
biological membrane
Bone Substitutes in Clinical Practice
93
Structure of void fillers
Surface area / volume

Mechanical strenght
Fig. 1 The structure of bone void filler has a remarkable effect on mechanical
strength and remodelling of the filled site
around the spacer is opened, re-filled with auto- bone, can provide
custom-made instrumentations
graft (+/# bone substitutes) and preserved as [3] and scaffolds
pre-loaded with cultured cells.
a closed space for bone graft. These techniques are
already available but the
The material itself (Fig. 1) has a remarkable final clinical
breakthrough is still to come.
effect on remodelling of the filled site. Bone sub-
stitute faces a healthy bone in which it should
temporarily integrate closely enough to prevent Clinical Use of Bone
Substitutes
fibroblast invasion. In optimal conditions material
is then gradually resorbed and replaced by new The conventional test
setting often includes head-
osteoid and finally by mineralised bone (Fig. 2). to-head comparison of
a potential bone void filler
If the surface area/volume ratio is high, cells have against autograft. It
has to be pointed out, how-
a good possibility to rapidly remodel the bone ever, that we then
miss the other side of the coin.
substitute material. This can in some cases, and It cannot be assumed
that one single graft would
with some materials, be even undesirable if the work in the same way
in different patients, or
resorption happens too fast or causes inflammatory even in different
bones in the same patient. It is
reactions or local changes in pH. This kinds of known from modern
imaging techniques that
ultra-porous materials are also limited in their com- some bones live with
just a sufficient circulation
pression strength. Totally solid material is the other and perfusion to keep
the bone alive, even in
end of the line, then a moderate to high compres- young healthy
patients. Combining smoking or
sion strength is achieved, but the risk is that the other risk factors
for circulation can turn this
final result is a dead piece inside living bone. balance remarkably
and lead to disturbance in
Whether it is a risk or not can be discussed. bone regeneration.
Seen from this aspect, we
The near future clearly offers some new should remember that
the normal reaction to
combinations of familiar and novel materials and bone fracture or void
is proper healing. If this
cell technology [2]. Rapid prototyping and does not happen, we
have some biological or
manufacturing in large scale tissue defects, also in mechanical problem.
More attention should be
94
J. Salo
Osteoconduction
Void filler ensures bony bridge formation in bony environment
r
fille
Void
60 = 7.5 m
40
20 id
teo
d bo
ne
Os
ralise
Mine
0
0, 2, 4, 6 wks 12 wks
6 mths
Fig. 2 The role of osteoconductive bone void filler can be mineralised to

normal bone. This typically takes
seen as a temporary scaffold preventing the invasion of 200220 days as a
minimum, depending on the size and
fibroblasts to the bone defect area. Remodelling of the the properties of
the filling material and on the function of
scaffold or autograft proceeds gradually, the degraded the patients
tissues
material being first replaced by osteoid which then is
paid to the environment in which the modern One special,

and often very complicated,
materials are inserted. An other interesting question is
filling of a bone void after deep infec-
question is whether an autograft in patients over tion. In these
cases laboratory tests can be clean,
75-years is sufficient. If we compare it to the bone even cultures
from biopsies can be negative, but
graft in 30-year old healthy patient it certainly is still there is a
risk of having a new infection if
not of good enough quality, but is it worse than a large amount of
foreign material is inserted in
bone in the area where it should be grafted in such the bone to fill
the cavity. The immune system
an elderly patient? can react very
aggressively even without any
Bone healing requires many other things than living bacteria
at the site. Toll-like receptors can
just proper scaffold or administration of local recognise even
some constructional components
growth factors. Formation of bone and articular of bacteria, like
lipopolysaccarides, and this can
cartilage in adult skeleton share several features clinically mimic
infection. The only bone substi-
[4]. The relative amounts and time of appearance tute material at
the moment showing antibacterial
of different stimulants or inhibitors vary, but basi- effects itself is
bioactive glass. It has earlier been
cally it can be generalised that the origin of cells used in chronic
sinusitis, but has now also
and their biological surroundings is roughly the successful
according to preliminary data on
same. What does then cause formation of either post-infective
bone defects [5].
bone or cartilage? Differentiation of these tissues Many patient-
related factors have a known
is highly dependent on the pO2, perfusion and pH, effect on
fracture healing, e.g. smoking and
along with the type of mechanical loading on the some medications
can disturb normal bone
regeneration area. Continuous cyclical loading, low healing. Non-
unions still are some of the most
pH and low pO2 can turn bone formation towards difficult bone
voids to treat. It is not uncommon
non-union or cartilage formation (Table 1). for one single
fracture site which has been
Bone Substitutes in Clinical Practice
95
Table 1 Bone grafts or substitutes are used in complex surroundings having partly
known effects on regeneration.
Much in this field is still to be discovered
Stable fixation
Contact area
Implants Direct healing No
compression Grafts
Mobilisation No inflammation Comminution
Scaffols
Weight bearing Less scar Gap
Active implants
Bone Healing
Nutrition
O2, pH, etc
Circulation Patient rel probl Scar
ExCorp stimulation
Soft tissues Medicines Cartilage
Vascular grafts
Periosteum Nerves Bone
Bacterial infection
Cells
Local factors
Bone cells Grafts VEGF
BMP2, BMP7
Pericytes MSCs FGF
Coupling
Blood cells Inflammatory cells IGF
COX2
Table 2 Some basic principles in selecting an appropriate bone void filler

Clinical question Mechanical properties
Biology Price Product?
Tibial plateau fractures +++
+/# ++
Atrophic non-union # +
++ ?/#
Spondylodesis # +
+ ++
Revision arthroplasties +++ +
+ ++
Intra-articular fractures +++ +
++ ?/#
Benighn cyst # +
++ ++
Old patient ? ?
?
Infection related defect +/? +
++ ?/#
initially fixed in a reasonable position with sta- and

environment. Some clinical problems are
ble fixation to need re-operation due to non- mentioned in
Table 2, which is are presented to
union. In these cases it is good first to think stimulate
thinking on how to select between
what are the possible patient-related limitations different
bone substitutes. There is not a single
or factors leading to impaired bone formation. method to
employ in all cases.
We cannot overcome these limitations just by
adding osteoconductive or osteo-inductive
materials, both of which already were there Conclusions
prior to non-union in the form of osteogenic,
host bone. It is also crucial that these additional 1. A fracture
is there to heal, but it can enlarge
materials or growth factors have cells to fill the into a
bone void especially after repeated
scaffold or to be stimulated by the BMPs and operations
other factors. 2. Autograft
works well, it can be successfully
As mentioned earlier, every patient with replaced
with current bone void fillers but only
a problem in bone formation has to be taken as if living
cells are present.
a new clinical challenge, and every bone in that 3. Make
exposures deep enough to get contact to
single patient should be thought of as an individ- healthy
bone applying dead material on dead
ual organ with its own circulation, function bone will
not work.
96
J. Salo
prototyping -
VR@P 2009, Leiria, Portugal, 610 Oct
References 2009.
Balkema/Jarj: Polytechnic Institute of
Leiria/Taylor &
Francis Group / CRC Press. p. 199204.
1. Bormann N, Pruss A, Schmidmaier G, Wildemann B. 4. Caplan AI.
Mesenchymal stem cells. J Orthopaedic
In vitro testing of the osteoinductive potential of differ- Res.
1991;9:64150.
ent bony allograft preparations. Arch Orthop Trauma 5. Lindfors NC,
Hyvonen P, Nyyssonen M, Kirjavainen
Surg. 2009;130(1):1439. M, Kankare J,
Gullichsen E, Salo J. Bioactive glass
2. Muschler GF, Nakamoto C, Griffith LG. Engineering S53P4 as bone
graft substitute in the treatment of
principles of clinical cell-based tissue engineering. osteomyelitis.
Bone. 2010;47(2):2128.
J Bone Joint Surg Am. 2004;86:154158. 6. Takagi M,
Tamaki Y, Hasegawa H, Takakubo Y,
3. Bjorkstrand R, Tuomi J, Paloheimo M, Salo J, Lindahl J. Konttinen L,
Tiainen VM, Lappalainen R,
3D-Digitalization of ankle movement and 3D-CAD Konttinen YT,
Salo J. Toll-like receptors in the inter-
method for patient specific external ankle support face membrane
around loosening total hip replacement
development and rapid manufacturing. 4th international implants. J
Biomed Mater Res A. 2007;81(4):101726.
conference on advanced research in virtual and rapid
Organisational Aspects of Trauma
Care
Imran Anwar, Dan Butler, and

Keith Willett
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 97 Traumatic injury is one of the leading causes of
mortality, accounting for 1 in every 10 deaths

Trauma Patient Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98
worldwide. In developed countries the last few

Scoring Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 99 decades have seen many improvements in the
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 101 care provided to trauma patients. A major
Pre-Hospital Care and Transport Systems . . . . . . 102
development in many regions has been the
Trauma
Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
105 reconfiguration of various components of
Optimal Elements of a Trauma System . . . . . . . . . . . . .
107 trauma services into nationally or regionally
Inclusive/Exclusive Systems . . . . . . . . . . . . . . . . . . . . . . . .
107 co-ordinated systems. Such trauma systems
Patient
Volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
integrate all aspects of patient care, from emer-

Provision of Specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
Integration of all Aspects of Trauma Care . . . . . . . . . .
109 gency care at the scene, through triage and
transport to an appropriately equipped facility,

Trauma Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 109
in-hospital care, post-discharge rehabilitation,

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 111 prevention and research. In considering the
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 112 ideal trauma service the components of each
stage of the patients journey, from the moment
of injury to rehabilitation back into the commu-
nity and employment, must be optimized to
ensure the best outcomes are achieved. In this

chapter we examine developments in each of
these organisational aspects of trauma care.
Keywords
Pre-hospital care and transport # Scoring sys-
tems # Summary # Trauma patient triage #
Trauma registries # Trauma systems
I. Anwar (*) # D. Butler # K. Willett

Introduction
Kadoorie Centre for Critical Care Research and
Education, Trauma Unit, John Radcliffe Hospital,
Traumatic injury is one of the leading causes of

University of Oxford, Oxford, UK
e-mail: i.anwar@doctors.org.uk; dan.butler@doctors.org.uk;
mortality, accounting for 1 in every 10 deaths
keith.willett@dh.gsi.gov.uk; keith.willett@ndorms.ox.ac.uk
worldwide. The number of deaths attributable to

97
DOI 10.1007/978-3-642-34746-7_4, # EFORT 2014
98
I. Anwar et al.
injury is projected to increase by 28 % between be operated upon by

the surgeon-general. Those
2004 and 2030 [1]. Most of this is expected in who are dangerously
wounded should receive the
first attention,
without regard to rank or distinc-
developing countries where the number of motor tion. They who are
injured in a less degree
vehicles on the road is expected to increase. In may wait until their
brethren-in-arms, who are
developed countries the last few decades have badly mutilated,
have been operated and dressed,
seen many improvements in prevention otherwise the latter
would not survive many hours;
rarely until the
succeeding day. Besides
programmes, road safety initiatives and in the with a slight wound,
it is easy to repair to the
care provided to trauma patients. Trauma regis- hospital of the
first or second line, especially for
tries have been set up in many countries, improv- the officers who
generally have means of transpor-
ing the collection of data on patient outcomes tation. Finally,
life is not endangered by such
wounds.
following injury. A major development in many
regions has been the reconfiguration of various From this military
experience casualty triage
components of trauma services into Nationally or evolved. However to
deal with mass-casualty
Regionally co-ordinated systems. events, when medical
resources would become
Such trauma systems integrate all aspects of over-whelmed, quite
contrasting triage protocols
patient care, from emergency care at the scene, evolved. For the
latter, the priority was to provide
through triage and transport to an appropriately the greatest good for
the greatest number of injured.
equipped facility, in-hospital care, post-discharge Resources were
therefore focussed on treating
rehabilitation, prevention and research. Monitoring those with life-
threatening but survivable injuries
of outcomes and frequent evaluation of standards rather than those with
a strong likelihood of death.
of care is an essential component of such systems. Mass-casualty
events are, however, rare
In considering the ideal trauma service the within the civilian
population and as a result,
components of each stage of the patients journey, pre-hospital triage
protocols for transport and
from the moment of injury to re-ablement back into treatment can assume
facilities readily available.
the community and employment, must be opti- Prior to the evidence
supporting role of multi-
mized to ensure the best outcomes are achieved. specialty regional
centres for the severely injured
In this chapter we examine developments in each of [2], major trauma
patients were transported to the
these organisational aspects of trauma care. nearest hospital for
treatment. Often little consid-
eration was given to
the immediate interventions
the patient was likely
to require upon arrival and
whether that facility
had the capacity or expertise
Trauma Patient Triage
to perform these
procedures. The result was sig-
nificant delays to
definitive treatment and conse-
Appropriate trauma patient triage is crucial to an
quent avoidable
morbidity and mortality. Triage
effective trauma system. Patients should receive
protocols have
subsequently been developed to
care at a facility able to definitively manage their
ensure that injured
patients are transported from
injuries ideally avoiding both over- and under-
the scene of injury
rapidly and safely to
triage.
a specialist facility
(major trauma centre). This
The concept of patient triage in the modern
may be either direct or
via a local hospital for
world is first attributed to the field surgeon-in-
stabilisation and
transfer. Those algorithms have
chief, Dominique Jean Larrey in the Napoleonic
been designed and
evolved predominantly in
era:
those developed
countries with challenging travel
The best plan that can be adopted in such emer- times to their major
trauma centres. They need to
gencies, to prevent the evil consequences of leaving be appropriate for all
levels of pre-hospital health
soldiers who are severely wounded without assis- care providers and
scenarios.
tance, is to place the ambulances as near as possi-
Early attempts to
score patients on their injury
ble to the line of the battle, and to establish
headquarters, to which all the wounded, who severity began in 1976
[3], but the first formal
require delicate operations, shall be collected to protocol guiding pre-
hospital health care
Organisational Aspects of Trauma Care
99
providers on the most appropriate centre for an have been developed with
varying success. Trau-
individual patients treatment was not created matic injury presents a
complex spectrum of
until 1987 [4]. This considered physiological pathologies with
patients frequently presenting
parameters, mechanism and anatomical location with multiple injuries
of varying severity. Further-
of injury and patient co-morbidities. These more, patient specific
factors, such as age and co-
American College of Surgeons (ACS) protocols morbidities, heavily
influence outcome. It is for
have been modified over time, but the concept these reasons that
current trauma scoring systems
remains the same. The current version of the ACS remain imperfect in
survival prediction but they do
triage protocol [5] assumes the presence of a fully facilitate comparisons
in audit and research that
integrated trauma system within which all neces- can assist in service
design. In this regard, trauma
sary facilities are available and inter-facility scoring has proven to be
a useful tool.
transfer can be rapidly arranged if a patient is Firstly, scoring
injuries and physiological
initially under-triaged in the field. There have impact can help pre-
hospital health care providers
been many additional triage systems developed make decisions on
appropriate triage, on the best
beyond those by the ACS. A popular score was treatment facility for
the patient and therefore the
CRAMS, (circulation, respiration, abdomen, most suitable method of
transport. It has
motor and speech), although this took no account a particular role in
situations where there are
of injury mechanism or co-morbidities [6]. large numbers of
casualties and finite resources
There are logistical difficulties in performing or where there may be
several destination options.
an accurate evaluation at the scene of injury. Within the hospital
setting, trauma scores can
Patients demonstrate considerable individual var- focus trauma teams in
determining treatment pri-
iability both in their tolerance of severe injury orities. Secondly,
trauma scores can offer a method
and in their capacity for maintaining homeosta- to predict patient
outcome. This may assist clini-
sis. Expedited transfer to a major trauma centre cians during the
clinical decision process and in
should remain the guiding principle even in the resource allocation and
offer a common language
presence of uncertainty. Experience varies with of severity to improve
communication between
the application of triage protocols in different teams regarding the
condition of the patient. Pre-
countries and trauma systems. The relatively dictive tools may also
help in the discussion about
high sensitivity and low specificity for identify- the patient prognosis
but on an individual basis are
ing the most severely injured patients is an issue of limited value as
discussed previously.
with logistic and economic implications of over- With the advent of
trauma systems and the
triage. As a result, it is unlikely that a single set of requirement for rigorous
auditing of trauma
field triage criteria will be uniformly suitable and care, scoring systems
provide a method to com-
local adaptation is appropriate. Different trauma pare outcomes within and
between trauma cen-
systems will need to model the serious injury tres, hospitals and
networks. This feeds the
incident frequency, locations and travel times clinical governance
process to identify unex-
and modify their triage protocols accordingly to pected deaths and
generate inquiry as to whether
fit their regional arrangement of services. observed differences are
the result of a different
patient populations or
persistent variation in the
level of care provided.
Scoring Systems Finally, trauma
scoring systems have been
widely adopted for
research purposes. Trauma
The need to quantify injury severity and predict research is often
dependent upon an ability to
patient outcome is of upmost importance in trauma categorise patients on
their injury severity. This
system performance and research. Attempts to allows for direct
comparison of separate patient
stratify patients depending on the severity of their groups exposed to
different interventions by either
injuries began in 1976 [3]. Since then, multiple stratifying patients in
subgroups dependent upon
modifications and alternative scoring systems their injury severity,
or taking measures to control
100
I. Anwar et al.
Table 1 The revised trauma score Table 2 The emergency trauma

score (EMTRAS)
Coded
Base Prothrombin
value GCS SBP (mm Hg) RR (breaths/min)
excess time (% of
0 3 0 0 Value Age GCS
(mmol/L) reference)
1 45 <50 <5 0 <40 1315
>#1 >80
2 68 5075 59 1 4060 1012
#1 to #5 5080
3 912 7690 >30 2 6175 69
#5.1 to 2049
4 1315 >90 1030
#10
3 >75 35
<#10 <20
for patient injuries or physiological metrics using determinant of outcome.

Finally, the respiratory
multivariate logistic regression analysis. rate and GCS may be
impossible to quantify in
Trauma scoring systems can be categorised the setting of early
intubation and the use of
into those that score physiological parameters muscle-relaxants. Trauma
registries report that
and those that assess the anatomical site and consistent recording of the
respiratory rate has
severity of a patients injuries. Some scores com- proven very difficult to
obtain.
bine both variables. The APACHE and SOFA
scoring systems were
Commonly utilised physiological scores designed for use in patients
being managed in
include the Glasgow Coma Scale (GCS), Revised an intensive-care setting and
are not trauma
Trauma Score (RTS), Acute Physiology and specific. The APACHE system
was first conceived
Chronic Health Evaluation (APACHE), Sequen- in 1981 [9] and there have
been two subsequent
tial Organ Failure and Assessment (SOFA) score modifications, the most
popular of which is the
and the EMergency TRAuma Score (EMTRAS). APACHE II scoring system [10,
11]. The APACHE
The RTS was an adaptation of the initial scoring systems consider both
the patients pre-
Trauma Score [7] and has been widely used in morbid state along with their
current acute physio-
both pre-hospital care and for research purposes. logical parameters. The
APACHE I and II scores
It measures 3 physiological parameters: GCS, contain no anatomical
component and tend to under-
respiratory rate and systolic blood pressure [8] estimate the mortality risk
and, as such, are felt to be
(Table 1). Each variable is scored from 0 to 4 of limited use in trauma
[12]. They are now predom-
giving a total range of 012. A lower score inantly used to predict a
patients clinical course in
represents increasing severity and a score of hospital, rather than their
prognosis early after injury.
fewer than 11 has been used to define the need The EMTRAS score (Table
2) has been shown
for transfer to a trauma centre. There is an adap- to be a good predictor of
trauma mortality even
tation of the RTS system, which is coded in such though there is no anatomical
component to the
a way as to account for the increased importance score [13]. It is, however,
dependent upon blood
of head injuries in trauma outcome. This has test results and is therefore
confined to the hospi-
been adopted for research purposes, but its tal setting with little
application to pre-hospital
increased complexity has prevented it from triage. The score was
designed as an early prog-
widespread use in the pre-hospital setting. nosis predictior and uses
only blood tests that
There are multiple limitations to the RTS. report within 30 min of
hospital admission (pro-
Firstly, there is no reference to a patients co- thrombin time and base
excess).
morbidities and, therefore, a single time-point Many anatomical scoring
systems have been
observation of an individuals physiological developed. The first was the
Abbreviated Injury
parameters may be misleading. Secondly, the Scale (AIS) [14]. In this
scoring system, each
standard version of the RTS gives no weighting injury to the body was given
a score of 16,
to the GCS and, therefore, no weighting to with a score of 1 for minor
injuries and a score
traumatic brain injury, often the primary of 6 for non-survivable
injuries. Each injury was
101
given an AIS grade by a panel of experts and, for each ICD-9 discharge
diagnosis. The scores
following six revisions to the system, it now given for each injury are
then added together to
describes over 1,300 injuries. give the final ICISS. This
score has an advantage
Perhaps a more important outcome from the over the ISS as it accounts
for all of the patients
AIS was the development of the Injury Severity injuries and the ICD-9 SRRs
are readily available.
Score (ISS) [15]. The ISS attempted to offer Furthermore, unlike the ISS,
the ICISS does factor
a compounding scoring system for patients with in patient co-morbidities by
including the SRR for
multiple injuries based on the AIS numeric allo- these. The ICISS has also
shown to better predict
cation. The ISS splits the body into six regions trauma patient mortality,
hospital charges and hos-
(head, face, thorax, abdomen, extremities includ- pital length of stay than the
ISS [20] but has failed
ing pelvis, and external structures) and takes the to supersede other scoring
systems in either the
highest scored injury from the three most clinical or research
environment.
severely injured regions; these are then used to Scoring systems have been
also been developed
calculate the score. Those three AIS scores are that combine anatomical and
physiological vari-
squared and the sum of these forms the final ISS. ables. The Trauma and Injury
Severity Score
The maximum ISS is 75; any single AIS of 6 (TRISS) has been widely used
for research pur-
gives the patient an automatic ISS of 75. It is poses since its inception in
1987 [21]. TRISS com-
generally accepted that a patient with a score of bines anatomical (ISS),
physiological (RTS) and
>15 has major trauma, has a significant risk of age (cut-off is over 55) into
a logistic regression
death and should benefit from care in a trauma model with dependent variable
mortality. The b-
centre [16]. As with the AIS, the ISS does not coefficients were calculated
from the Major
take into account any physiological variables that Trauma Outcome Study. TRISS
then gives
are likely to serve as predictors of patient out- a probability of survival.
TRISS is, however,
come. It also underestimates the severity of injury dependent on the reliability
of the ISS and RTS
in patients with multiple severe injuries to only and, therefore, has the same
limitations of its two
one area of the body, only one severe injury to contributors. There are also
a high number of cases
only one area of the body and severe injuries to with unrecorded data, thus
making it impossible to
more than three areas of the body. The first two calculate a patients RTS
and, therefore, their
cause particular problems in the setting of pene- TRISS. An alternative
combined trauma score is
trating trauma and multiple severe limb fractures. the A Severity
Characterisation of Trauma
The system also fails to weight the scores (ASCOT) score [22]. The
widespread use of
depending on the importance of region of the ASCOT has been limited due to
its complexity.
body affected. The New Injury Severity Score The British Trauma Audit
and Research Net-
(NISS) has attempted to address these problems work (TARN) registry have
generated
by choosing the three most severe injuries to the a prognostic scoring system
called the Ps09
body, regardless of which region they are in [17]. [23]. This system considers a
patients ISS,
Both the ISS and NISS are, however, retrospec- GCS, age, gender and whether
intubation was
tive scoring systems, which are calculated at undertaken at the scene. This
score attempts to
patient discharge. As such, the final score can be address a number of the
limitations involved with
directly influenced by the level of investigation the TRISS score, such as the
need for a RTS and
provided [18]. This decreases the reliability of the exclusion of patients
intubated at the scene. It
these scores for comparing performance and has yet to be validated
outside of TARN.
diminishes any predictive role.
An alternative anatomical scoring system is the
International Classification of Diseases-based Summary
Injury Severity Score (ICISS) [19]. Each of the
patients injuries is given a value, which is the There have been attempts to
identify scoring sys-
survival risk ratio (SRR) that has been calculated tems that accurately predict
trauma patient
102
I. Anwar et al.
Fig. 1 The components Clinical approach

involved in designing a pre- (BLS vs ALS)
Staffing
hospital trauma service
Design of regional trauma Pre-hospital

trauma service Geography
system
Transport
Medical team
Patient
outcome (mortality) for nearly 40 years. Cur- bystander first-aid

and life support should not be
rently, no scoring system has demonstrated that underestimated in the
time prior to arrival of
it can perform this task to a high degree of accu- ambulance personnel
[25]. The historic concept
racy, reliability or with suitable specificity. An of the golden hour
was useful but limited and
ideal scoring system needs to take into account a more appropriate
pre-hospital planning concept
the degree and duration of physiological abnor- is to consider how to
address two aims:
mality, the patients own physiological reserve (1) accessing life-
saving time-critical interven-
and the anatomical location of the injuries. It tions, and (2) safe
and rapid transfer to an insti-
must also account for blunt and penetrating tution capable of the
definitive care of the
trauma and be applicable to different countries injuries. Because of
the unpredictability of
and healthcare systems, where the demographics trauma incidents in
time and geography detailed
of trauma patients and care vary. Most trauma modelling is most
beneficial for planning
scoring systems currently focus on predicting resources and their
location. Moderate to
patient mortality without consideration to mor- severely-injured
trauma patients are best man-
bidity and disability, which are of equal social aged at specialist
major trauma centres.
and economic importance. A network is
essential to support the rapid iden-
Current trauma scoring systems do offer tification and
transfer of such patients from dis-
a useful guide to doctors for clinical governance trict hospitals or
directly from the scene [2].
and assist researchers in analysing trauma care but Pre-hospital
care:
must be used with caution given their limitations. A number of
variables need to be considered
Further study is required in the area of prediction when planning pre-
hospital services for a given
of complications such as secondary multiple organ region (Fig. 1):
failure to assist in decision-making on the appro- 1. The level of
training and skills retention of
priate level of interventions in this era of damage ambulance
technicians and paramedics.
control surgery in major trauma. 2. The incidence of
casualty events where there
is a transfer
delay from the scene.
3. The individuals
and skills contributing to an
Pre-Hospital Care and Transport enhanced
emergency medical service (EMS)
Systems team to attend
such events.
4. The mode of
transport for:
Organised pre-hospital care is vital for delivery of a. The EMS team
to scene (if appropriate)
an effective trauma service. During the golden b. The patient
from scene to hospital
hour [24] following injury, the patient is fre- 5. The clinical
approach on-scene (scoop and
quently outside of hospital care. The value of run vs stay and
play).
103
6. The geography of the region in which the There was a significantly

higher mean ISS and
trauma service operates. on-scene time in the
physician group; in patients
7. The trauma network within the region. with severe, but survivable
injuries (ISS 2549),
Many factors impact upon each of these vari- there was still an
association with a significantly
ables and therefore the ideal design for pre- higher mortality rate in the
physician-treated
hospital care will vary considerably from region group.
to region and country to country. This Canadian study
highlights the current
The personnel that arrive at the scene of injury debate of using basic life
support interventions
can consist of nurses, emergency medical techni- (BLS) (scoop and run)
versus advanced life
cians, paramedics and/or physicians. There is support (ALS) (stay and
play) in the pre-
debate as to the most appropriate configuration hospital setting. BLS in
trauma consists of
of the pre-hospital trauma teams and whether basic airway and breathing
and circulation
there is benefit from advanced interventions. An manoeuvres, spinal
immobilisation, fracture
experienced trauma physician may bring a high splinting, wound
dressing/compression and
level of clinical skills and judgement both for the non-invasive cardiopulmonary
resuscitation.
initial management and also in deciding the most ALS includes these
interventions, plus endotra-
appropriate facility for the patients treatment. cheal intubation and
intravenous access, chest
There are, however, concerns that the addition decompression and
thoracotomy. The rationale
of physicians to the pre-hospital trauma team behind such additional
intervention is to bring
results in an increase in the on-scene time [26] the time-critical
interventions to the scene.
and over-triage, although others have not found Dispatching an enhanced
intervention team and
such an association [27, 28]. The cost- undertaking these procedures,
however results
effectiveness remains unproven. in a prolonged pre-hospital
time and delay to
There is limited literature analysing team definitive management.
Current evidence sug-
configuration within the helicopter emergency gests there is no clear
advantage of ALS over
medical service (HEMS). An early randomised BLS at the scene in urban
situations [3235] and
controlled trial comparing a physician/nurse there may be a mortality
benefit from adopting
crew with a paramedic/nurse crew found the scoop and run approach,
particularly in the
a significant improvement in patient mortality setting of penetrating
trauma. Entrapment or
when a physician was present [29]. Similar multiple casualties at the
scene may be indica-
results were found in a retrospective cohort tions for deploying an EMS
team where there is
study performed in Australia [30]. An no detrimental delay effect
from deployment.
American study, however, found no significant However most of the studies
addressing this
difference in trauma patient mortality following issue are limited by poor
study design and
a retrospective analysis of mortality before and a lack of control for the
numerous variables
after removal of physicians from the HEMS between the two treatment
groups that are likely
team [31]. to confound the results.
Results also suggesting physician presence In the rural setting with
helicopters used as the
was not of benefit in the pre-hospital setting transport platform to deliver
the EMS team there
were shown in studies performed with ground is some evidence that
aggressive early interven-
medical transport (GMT) of trauma patients. tion does improve trauma
patient mortality, as
A Canadian study [32] compared three groups demonstrated by a study
comparing a German
of trauma patients injured in an urban setting HEMS (physician-staffed) to
an American
and transported by GMT to a level 1 trauma HEMS (nurse/paramedic-
staffed), both of which
centre. They reported that those receiving physi- were ALS-trained [36].
Helicopter deployment is
cian-provided ALS had a higher mortality rate more likely when the patient
is a long distance
than those receiving paramedic-provided ALS from an appropriate facility,
or a prolonged extri-
or emergency medical technician-provided BLS. cation is expected, both of
which will prolong
104
I. Anwar et al.
pre-hospital time. A registry-based analysis of The time and cost of

attempting to train multiple
12,417 trauma deaths found that patients ground crews to that level of
expertise would be
transported by GMT from a rural setting had great; the use of HEMS to
deliver the specialist
a significantly lower mortality if the paramedic EMS team to the scene [44] is
a logical option.
team was ALS trained [37]. This suggests that in The use of helicopters does,
however, also bring
circumstances where prolonged pre-hospital significant cost implications
[45]. Since 1995 the
times are expected, regardless of clinician inter- Netherlands have separated
the transport of the
vention attempts should be made to begin defin- EMS team from the transport
of the patient. Four
itive treatment. helicopter-transported
medical teams (HMTs),
There is also conflicting evidence for the ben- consisting of a specially
trained trauma physi-
efit of individual advanced interventions on cians and paramedics,
currently cover 75 % of
patient outcome. Even the rationale for the Dutch population [46].
This service can either
performing on-scene intravenous cannulation to be deployed in response to
the emergency call, or
increase the patients circulating volume and to support a GMT team at the
scene. Only rarely
improve tissue perfusion is questioned. A recent is the patient transported by
helicopter from the
study showed that intravenous cannulation at the scene recognising that
helicopter transport suf-
scene takes, on average, 4.4 min [38]. A meta- fers the disadvantages of
noise, disorientation
analysis of 14 studies demonstrated that less than and limited space.
1 l of fluid was infused during the pre-hospital The debate surrounding
the most appropriate
phase [39]. Furthermore, there are also concerns form of trauma patient
transport from the scene of
regarding the dilutional effects on clotting of injury has spanned 25 years
and remains
hypertonic saline and colloids given at the scene unresolved. The first major
use of helicopter
in actively bleeding patients [40]. transfer for trauma patients
was in the Korean
Severe traumatic brain injury is the most War and developed further
during the Vietnam
important predictor of mortality in trauma cases War. The first permanent
helicopter air
[41]. Endotracheal intubation (ETI) is known to ambulance service was set-up
in 1970 in Munich,
be of benefit in the definitive management of Germany. The use of
helicopters in the transport
these patients. Pre-hospital ETI as opposed to of trauma patients may confer
a benefit through
emergency department intubation in HEMS four different means:
transported patients with severe head injuries To retrieve patients from
remote locations.
has been reported to improve outcome [42]. But Rapid transportation of a
specialist EMS team
of greater importance seems to be the post- to the scene of injury.
intubation ventilation management. Although Gives the option to
transfer the patient directly
the introduction of paramedics trained in rapid to a specialist centre
with appropriate facilities
sequence intubation increased the success rate of to deal with the
patients injuries.
intubation, the actual mortality rate of head- Expedite transfer of
patients between facilities
injured patients was shown to have increased where that is a long
distance.
compared to historical, non-intubated, matched There is some Level 2 and
3 research evidence
controls [43]. This was attributed to sub-optimal in support of the use of
helicopter transport of
performance of rapid sequence induction of trauma patients from the
scene of injury conferring
anaesthesia and poor subsequent ventilation man- a mortality benefit compared
to ground medical
agement due to inexperience. transport (GMT) [42, 4657].
Other European
It is evident that advanced procedural skills studies have, however, found
no significant differ-
should only be performed by individuals with the ence [26, 58, 59]. This
conflict within the evi-
experience and expertise to do so. This lends dence-base is likely to be
the result of a number
support for the formation of specialist EMS of factors. Much of the early
work [48, 49, 55, 56]
teams delivering care at the scene of injury in supporting a helicopter
emergency medical ser-
certain circumstances, such as entrapment. vice (HEMS) in the transport
of trauma patients
105
was undertaken in the 1980s and it is likely that Table 3 The advantages and
disadvantages of the heli-
current pre-hospital services and trauma networks copter emergency services
perform very differently. Also the data come from Advantages
Disadvantages
multiple countries with different helicopter EMS Increased speed of
High cost
transport
services (staffing, airway skills, transfer/attend
Potential to cover great
Requires take-off and
patient), different geography and different trauma distances
landing site
systems available to receive the patient. There is Can deliver a skilled
Needs a skilled flight crew
great variety in the study inclusion criteria, control trauma team over
patients and follow-up period between the avail- a wide geographical
able studies. There is also variation in the level of area
adjustment performed to account for any Can access remote
Cramped working
locations
environment
confounding variables. These factors create diffi-
Expedite inter-facility
Noisy
culties in comparing studies or reaching transfer
a consensus opinion.
Most only operate during the
Helicopters do have the ability to cover greater
day and in good weather
distances than GMT. This means that patients
Safety issues
transported by HEMS are more likely than those
transported by GMT to be able to be taken
directly to the most appropriate trauma facility
in larger countries. This was demonstrated in care specific to each
network based on 24-h crit-
a Germany in 2004 [26]. Trauma patients with ical incident frequency
and travel times. The
an ISS > 15 were treated in four different ways: requirement for emergency
medical team skills
(1) HEMS transport to a university hospital on scene should be
considered separately from
(HEMS-UNI); (2) GMT to a university those of the transport
platform (airframes or land
hospital (GMT-UNI); (3) GMT to a regional vehicles); helicopters may
be one of the solutions
hospital (GMT-REG), and (4) GMT to a for moving the emergency
medical team, or
regional hospital with subsequent transfer to patient, or both but are
limited by weather
a university hospital (INTER). This showed that conditions and visibility
(Table 3). It is likely
mortality of the AMB-REG group was almost that pre-hospital
emergency medical services,
double that of the HEMS-UNI group. There was operating in different
trauma systems, with dif-
no difference in mortality between the AMB-UNI ferent terrain and
geographical arrangements of
and HEMS-UNI group after adjustment. The dif- hospital facilities will
come to different conclu-
ference in mortality rate between the HEMS-UNI sions about the ideal
structure of pre-hospital
and AMB-REG group was considered a result of trauma care. Such
conclusions should be based
the receiving facility and not the transport on event incidence
modelling, accrued outcome
method. This supported the concept that transport data and should aim to
result in a service that can
of the patient to a dedicated trauma centre was deliver the required care
at all times of the day
most important. The use of helicopter transport and night.
makes this achievable when large distances
between the scene of injury and tertiary facility
are encountered, but when smaller distances are Trauma Systems
expected, GMT of the patient to the trauma centre
is equally satisfactory or quicker. The benefit of a
systematic approach to trauma
The structure and triage protocols for pre- care on a large scale was
first recognised in the
hospital care in modern trauma systems will con- military setting. During
the First World War,
tinue to develop and become more responsive. In faced with huge numbers of
wounded soldiers
the design of regional trauma networks there and limited resources,
military medical planners
should be a needs assessment for pre-hospital developed a process
whereby injured men
106
I. Anwar et al.
systematically passed through echelons of party group from The Royal

College of Surgeons
increasingly specialised medical care, from of England (RCSEng) reviewed
the care pro-
immediate treatment on the battlefield to vided to major trauma patients
and drew atten-
specialised hospitals remote from the fighting tion to serious deficiencies.
The report based its
[60]. This system was developed further in sub- recommendations on the outcome
of a study of
sequent conflicts and formed the model for mod- 1,000 deaths following trauma.
Of those patients
ern trauma care systems. who reached hospital alive and
later died, one
Much of the historical development of trauma third of deaths were deemed to
have been
systems in the civilian setting occurred in the preventable. There were calls
for better organi-
United States, triggered by a 1966 report from sation of trauma services,
improvements in pre-
the National Research Council highlighting hospital care, increased
investment in trauma
inadequacies in the care provided to seriously- research and better training
for staff dealing
injured patients. That report made a number of with trauma [64]. Successive
reports from the
recommendations for action and strongly British Orthopaedic
Association (BOA) in 1989,
emphasised the need to improve the funding 1992 and 1997 re-iterated this
message, showing
and organisation of trauma care services nation- that many hospitals in the UK
were unable to
wide [61]. Legislation was quickly introduced maintain acceptable standards
of care for injured
and public funds allocated to develop the whole patients due to lack of senior
staff, resources and
spectrum of trauma care from injury prevention experience in dealing with
major trauma
and the pre-hospital phase through to post- [6567]. There have since been
initiatives
hospital rehabilitation programmes. The Ameri- which have resulted in
improvements in pre-
can College of Surgeons Committee on Trauma hospital care, better
facilities for trauma care in
(ACSCOT) played a leading role in the subse- individual large hospitals and
the introduction of
quent evolution of trauma systems. In 1976 it improved data collection and
research into
published Optimal Hospital Resources for Care trauma outcomes, such as the
Trauma Audit
of the Seriously Injured, in which it defined the Research Network (TARN).
However, perhaps
essential characteristics of a specialized trauma due to a lack of political
will and a fear of the
centre, and proposed that such centres should large potential costs of
implementing trauma
ideally be organised in the context of a regional systems, there has been little
progress in devel-
system [3]. oping a unified system of
trauma care in the UK.
In the late 1970s Orange County in California, The potential financial
implications can be put in
USA, implemented a trauma system which perspective by the fact that
in the mid-1990s
resulted in a significant reduction in preventable there were only six hospitals
in the UK where
deaths following injury [62]. Over the next two all the surgical specialties
necessary for desig-
decades the concept gained momentum and many nation as a Level I Trauma
Centre based on the
other regions introduced trauma systems. A 1999 US system were present [68].
review of all the then available evidence from The issue was highlighted
again in 2000, in
population-based studies concluded that the a joint report published by
the RCSEng and the
implementation of trauma systems resulted in an BOA [69]. This report made a
number of recom-
improved survival rate of 1520 % among mendations, including
systematic auditing of
seriously-injured patients [63]. Regionalised trauma outcomes and the
national co-ordination
trauma systems have now been successfully of standards of care. A report
by the National
implemented across the United States, Canada, Confidential Enquiry into
Patient Outcome and
Australia and many European countries such as Death (NCEPOD) in 2007
recommended the
Norway and Denmark. integration of all components
of trauma care
In the United Kingdom there have been calls into a regionalised system
[70], and the govern-
for reorganisation of trauma services nationally ment has committed itself to
implementing such
for more than two decades. In 1988 a working a system in England.
107
Primary - pre-injury
Injury
Secondary-at time of injury

prevention
State
legislation
Tertiary-post-injury
Triage and transport to appropriate

Finance
facility for definitive management
Pre-hospital
care
Effective communication systems

Leadership
INTEGRATED
TRAUMA
Designated regional trauma centres
SYSTEM
Community
partnership
Acute care
Role for all acute care facilities
Use of
information
Effective inter-facility transfer
technology
processes
Quality assurance
Rehabilitation - physical and

and performance
psychological
improvement
process
Post
Data collection for research and
discharge
quality assurance
Education and training

Fig. 2 The essential elements of an integrated trauma system
Optimal Elements of a Trauma System the UK than in the US,

with by far the main cause
of severe injury in the
UK being road traffic
A trauma system has been defined as a system accidents (RTAs) [68].
Funding of the health
which is able to provide a co-ordinated and sys- service too, is very
different between counties
tematic means of delivering trauma patients rap- and so the cost
implications of trauma system
idly to definitive care [71]. In order to achieve implementation need to be
carefully considered.
this ultimate goal, health planners in different Professional boundaries
and practices also vary
regions have adopted different approaches when significantly.
implementing trauma systems. Figure 2 shows Despite the
differences between trauma sys-
the essential elements of an integrated trauma tem requirements in
different states and coun-
system. tries, there are certain
common elements and
The optimal components for a system are dif- lessons that can be drawn
from the available
ficult to define, because different regions have research.
differing requirements dependent on local factors
such as geography, population, patterns of injury,
siting of pre-existing facilities, availability of Inclusive/Exclusive
Systems
expertise and resources. For example, the inci-
dence of polytrauma and that of penetrating inju- Trauma systems have
traditionally been
ries secondary to personal violence is far lower in categorised as being
inclusive or exclusive.
108
I. Anwar et al.
Some early trauma systems consisted of one or must admit a minimum of 1,200
trauma patients
two dedicated trauma centres to which all per year of which 240
patients, or an average of
major trauma patients in the region were 35 patients per trauma
surgeon, must be major
transported, by-passing any closer facilities trauma cases (Injury Severity
Score >15) [5].
which were not designated to deal with severe These numbers were based on
the study by
injury. Hospitals, which were not equipped to Konvolinka et al., who used a
stepwise regression
serve as regional trauma centres, were thus model to calculate the optimal
number of patients
excluded from the system. Although these per surgeon [74].
exclusive systems did reduce injury mortality However, the studies
supporting a directly
in the regions where they were implemented, it proportional relationship
between patient volume
became evident that such systems did not best and outcome vary in terms of
the methodology
serve the needs of the entire population in those used to reach their
conclusions, and the findings
regions, as those patients in suburban or rural of subsequent studies have
questioned whether
areas geographically distant from a trauma cen- volume really does matter [78
80]. The issue
tre were at a disadvantage. There were calls for continues to be a source of
debate but most
trauma systems to be more inclusive, i.e. to would agree that a minimum
volume of patients
include all acute care facilities within a region should be specified for
designated trauma facili-
as part of the co-ordinated response to trauma ties in order to ensure that
clinical expertise and
and thus to better serve all trauma patients quality of care is maintained.
The Royal College
[72]. In an inclusive system the resources of of Surgeons of England has
stated that,
all individual facilities within a region are as a minimum, major trauma
centres should
taken into consideration, and patients can be admit more than 250 critically
injured patients
stabilised at the nearest appropriate facility a year [81].
before, if necessary, being transferred to
a definitive trauma centre. The available evi-
dence suggests that inclusive systems result in Provision of Specialties
better patient survival than exclusive systems
[73], and most modern trauma systems are now In order to be designated a
major trauma centre,
based on an inclusive model. The inclusion of a hospital would have to
provide all acute surgi-
all hospitals in a trauma network also carries cal specialties on-site or
have access to those
considerable advantage in facilitating repatria- specialties at short notice 24
h a day. The 2007
tion and local rehabilitation. NCEPOD report Trauma: Who
Cares? pro-
vided an overview of the
distribution of UK
hospital specialties [70]. Of
183 hospitals in the
Patient Volume study, only 17 (9 %) were able
to provide the full
complement of acute surgical
specialties neces-
A concern about inclusivity was the fear that such sary for designation as a
trauma centre and only
systems may dilute the volume of patients seen at 31 (17 %) had on-site
Neurosurgery department.
trauma centres. A number of studies have shown This is of particular concern,
as 62 % of the 795
that centres which treat a higher volume of patients studied as part of
that report had suf-
patients have better patient outcomes, and the fered neurotrauma and
traumatic brain injury
effect is most evident when considering patients accounts for the largest
single cause of death.
with the most severe injuries [7477]. Attempts Several studies have clearly
demonstrated the
have also been made to define what constitutes an importance of early
neurosurgery in a specialist
appropriate volume of patients for a Level I centre to improve survival in
patients with head
trauma centre. The 1999 ACSCOT document injury [8284]. Access to
neurosciences special-
Resources for the Optimal Care of the Injured ist care is critical in
network planning for major
Patient specified that Level I trauma centres trauma.
109
Integration of all Aspects of Implementation of a regional

trauma system
Trauma Care will require further
reorganisation of the service
to ensure unambiguous
coordination with the
A fully integrated trauma system consists of sev- hospitals in the region. In
addition, the use of
eral essential components that work together in predominantly charity-run
helicopter emergency
a co-ordinated manner to ensure the patient safely services (HEMS) has increased
across the UK
reaches the right hospital at the right time in the and they are likely to play
some role in trauma
best condition. This approach encompasses all networks.
aspects of injury care, including pre-injury pre- The role of an effective
trauma system does
vention strategies, pre-hospital emergency ambu- not end with the patients
discharge from the
lance systems, in-hospital care and post-hospital major trauma centre. Post-
operative rehabilita-
rehabilitation programmes. tion strategies should
equally be an integral part
Examples of injury prevention strategies of the networks and should be
regularly assessed
include road and fire safety, environment inter- to ensure their effectiveness
within the clinical
ventions, supporting legislation on alcohol, vehi- governance structure. The
responsibility of con-
cle design, speed and seat belts, and educational tinuously auditing patient
outcomes and
initiatives to prevent youth and gang-related vio- maintaining highest standards
of care also rests
lence. In the UK, the prevention strategies aimed with the regional trauma
network. Regular
at reducing injury from RTAs in particular have assessment of the quality of
all phases of patient
had a dramatic effect. Deaths from RTAs in the care, from injury prevention
right through to
UK have been steadily declining over recent post-hospital rehabilitation,
is an essential com-
decades and are now amongst the lowest in ponent of the trauma system
[87]. The World
Europe [68]. However, there is no room for com- Health Organisation (WHO) has
recently
placency, as the trend towards lower mortality published useful guidance on
implementing
rates is not equally distributed across society. effective trauma
quality improvement
Rates of death amongst young people and programmes. It provides
strong evidence that
amongst deprived sections of the community are the introduction of such
programmes, or increas-
falling more slowly [85], and any new prevention ing the effectiveness of
existing processes, by
strategies forming part of a trauma system should structuring morbidity and
mortality meetings
focus on this. and preventable death panels,
significantly
Integration of emergency ambulance services improve trauma outcomes [88].
is an essential part of any trauma system. Ambu- There remains a paucity of
evidence on the
lance services should have clear protocols with effect of trauma systems on
the quality of life
regards to triage and immediate medical care at post-injury of those who
survive. Future trauma
the scene, should be able to identify the most systems development should
take the opportunity
appropriate facility for the patients care and to fill this gap in our
knowledge. The developed
should ensure rapid transport. Network co- trauma registries (such as
the Trauma Audit and
ordination between the receiving hospital and Research Network (TARN) in
the UK) have pre-
the paramedics at the scene is important and dominantly collected data on
mortality and pro-
communication procedures should be effective. cess measures but are now
increasingly focussing
In the past, wider co-ordination of UK ambulance on trauma outcomes relating
to disability.
services was hampered by a lack of commonality
in protocols, documentation and organisational
structure in the regional ambulance services. Trauma Registries
From 2001 a programme for modernising emer-
gency services, has resulted in greater investment An essential component of any
trauma system is
in equipment and vehicles, as well as better train- the incorporation of a data
collection process that
ing and recruitment of paramedics [86]. enables audit of clinical
outcomes, facilitating
110
I. Anwar et al.
quality assurance and performance improvement. a voluntary basis but this

is increasing with the
Such trauma registries should provide a compre- planning for trauma networks
in England. There
hensive record of the care received by each is an opportunity to expand
the role and functions
injured patient, including details such as patient of TARN to suit the needs of
the new system and
demographics, mechanism of injury, pre-hospital incorporate a national
registry system as an
care and transport, hospital treatment, anatomical essential component of the
service [93]. Registries
description of the injury, physiological mea- provide a useful resource
for clinicians in partici-
surements, surgeries and interventions, com- pating hospitals, who can
assess the performance of
plications, outcomes and discharge destination their own and other
hospitals in the form of regular
[89]. Personnel trained in data coding, using reports and on-line
analyses. These can be used for
specialised software usually collect the relevant quality assurance and local
audit purposes.
information from patient case notes. In addition to their use
for quality assurance,
Early trauma registries were set up by individ- trauma registries provide an
invaluable research
ual hospitals for local assessment of the quality of tool and indeed much of the
evidence supporting
care and to monitor improvements in performance the implementation of
regionalized trauma sys-
[90]. As a result of increased co-operation between tems comes from registry-
based comparisons
hospitals, and the emergence of trauma systems, [2, 94]. Most registry
systems also record
these individual hospital registries coalesced to information on the pre-
hospital phase of injury
form much larger, more powerful Regional and care, and analysis of this
data can help to plan
National databases. The potentially huge size of ambulance services and
optimize pre-hospital
such databases means that they can be extremely care and triage protocols
[82]. The large size of
useful tools for evaluating and benchmarking qual- registry databases means
that they can help to
ity of care and assessing the impact of interven- answer many clinical
questions that would other-
tions or developments aimed at improving patient wise require large multi-
centre trials to address.
outcomes. For example, in the United States the Given that all patients
meeting the inclusion
National Trauma Data Bank (NTDB) set up by the criteria for the registry
are included, this may
American College of Surgeons Committee on reduce the potential
selection bias encountered in
Trauma (ACSCOT) contains over three million clinical trials. Large sets
of data are also more
records. In 2008 it collected data from over likely to provide sufficient
numbers of cases of
627,000 trauma admissions from 567 participating rare types of injury for
research purposes. Another
hospitals [91]. The NTDB, like most other registry example of the use of trauma
registries include
systems in use, relies on information provided by comparing patient
characteristics such as demo-
participating hospitals on a voluntary basis. In graphic information and pre-
existing conditions to
some areas however, the introduction of regional evaluate risk and predict
outcomes following dif-
trauma systems has included mandatory participa- ferent types of injury. Many
contemporary injury
tion in a regional trauma registry database as an severity scoring systems owe
a lot to data obtained
essential requirement. An example is the Victoria from such trauma registries
[89].
State Trauma Registry (VSTR) in Australia, which There are, of course,
potential limitations to
is funded by local government and collects data the use of trauma
registries. The accuracy of data
from all 139 hospitals providing trauma services in coding is central to the
reliability of trauma reg-
the region. That registry has demonstrated signif- istries, and there should be
processes in place to
icant improvements in patient outcome and reduc- minimise errors and to
assess data quality. The
tions in mortality in the first 7 years since tasks of data collection,
coding, processing and
introduction of the state-wide trauma system [92]. analysis all require well-
trained individuals
In the UK, TARN collects and disseminates whose work should be
overseen by a data quality
information comparing trauma care between group responsible for
ensuring there is on-going
hospitals and nationally. Currently 70 % of UK data validation. Potential
problems can arise for
hospitals contribute data to the TARN registry on example when a patient has a
diagnosis for which
111
there is no specific data coding value, creating organisation of the

individual elements that
gaps in the registry [95]. Coding errors and gaps make up the service are
common to all societies.
can also occur when different hospitals contrib- With the advent of
regionalised trauma systems
uting to a pooled national or regional registry in the late 1960s, the
benefits of hospitals, para-
have different coding processes. The NTDB medic and transport
services working in
report for 2006 excluded 25 % of all cases from a network are proven.
Strengthening data collec-
statistical analysis because of data coding errors tion and the development of
trauma outcome
and gaps [96]. The introduction of standardised measures interpreted
through robust clinical gov-
coding practices and software has since helped to ernance structures are the
next priorities to
minimise such problems. False negative coding improve the care of the
seriously-injured patient.
errors are the most frequently occurring type, Over the past few
decades, we have learned
particularly for diagnoses which are less com- a great deal about what
constitutes an effective
monly encountered [97]. trauma system. Patient
triage criteria have
The cost of maintaining, analysing and dis- become more refined,
resulting in more effective
seminating information has historically been decision-making at the
scene. Transport services
seen as an obstacle to the creation of trauma have evolved, and in many
scenarios patients are
registries. However, the many potential benefits no longer routinely
transported to the nearest
to public health that have been demonstrated by hospital, but to the
nearest facility appropriate
existing registries provide a powerful argument for their specific clinical
needs. Research studies
in support of the use of health-care funding to have started to unravel the
question of when it is
expand the use of registries [98]. better to stay and play
rather than scoop and
Trauma registries worldwide have been shown run but much remains
unclear.
to be invaluable resources for quality assurance, A variety of scoring
systems are now widely
performance improvement, research and to guide used to better categorise
injured patients, helping
healthcare policy. Many large registries such as the to guide clinical and
triage decisions on immedi-
NTDB now provide information to clinicians and ate and, later, definitive
management.
researchers worldwide free of charge, and this is Helicopters and EMS
services are now used in
likely to result in even greater use and support many parts of the world,
but the evidence regard-
for the creation and expansion of registry ing their effectiveness at
reducing mortality
programmes. Future trauma registries are likely remains inconclusive and
the cost-effectiveness
to be better-funded as healthcare commissioning is in doubt in smaller
countries. There is however
becomes increasingly targeted at quality measures; strong evidence for the
effectiveness of inte-
for trauma care the obvious partner for this are the grated trauma systems in
reducing preventable
national clinical audits and registries. Their poten- trauma deaths. Healthcare
policy makers have
tial scope is also likely to expand beyond discharge taken note, and trauma
systems are now
or mortality as endpoints, following the example established in many
countries and that process
of the Victorian State Trauma Registry (VSTR), continues to spread. Over
the coming years we
which has successfully implemented processes to will see further research
in this area to refine the
assess quality of life and functional outcome up to concepts of triage, timing
and appropriateness of
6 months after hospital discharge [99]. interventions and network
organisation - to
establish what makes the
most successful trauma
system - rather than to
prove their effectiveness.
Summary An important resource in
this regard will be
trauma registries, which
having developed as
The burden of morbidity and mortality from audit tools will become
powerful databases to
trauma continues to increase worldwide. The be interrogated to the
benefit of the seriously-
greatest need is in evolving countries but the injured patient and drive
quality improvement
demand for trauma services, and the effective through targeted
commissioning of services.
112
I. Anwar et al.
17. Osler T, Baker

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Classification of Long Bone
Fractures
Thierry Rod Fleury and Richard

Stern
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 115
Characteristics and statistics # Classification
# Fractures (long bones) # Future trends #

Classification Systems: What are They
History # Limitations-complexity, reliability,

Used
For? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 116
usefulness # Types-fracture-specific, patient-

A Little Bit of History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
117 specific, generic (universal), soft tissue based
Types of Fracture Classification Systems . . . . . . . .
118
Fracture-Specific Classification Systems . . . . . . . . . . .
118
Patient-Specific Classification Systems . . . . . . . . . . . . .
120
Generic or Universal System . . . . . . . . . . . . . . . . . . . . . . . .
121
Introduction
Soft-Tissue Injury Classification Systems . . . . . . . . . .
124
Since human beings acquired speech, they named

Fracture Classification Systems:
Characteristics and Statistics . . . . . . . . . . . . . . . . . . 125
things. Immanuel Kant thought that the adult
human mind naturally organizes its knowledge

Limitations and Flaws of Current Fracture
Classification Systems . . . . . . . . . . . . . . . . . . . . . . . . . .
128
of the world in groups of objects sharing the same

Classification System Flaws . . . . . . . . . . . . . . . . . . . . . . . . .
130 name. The purpose of such organization is to
Experience of the Observer . . . . . . . . . . . . . . . . . . . . . . . . .
131 simplify the surrounding world in order to better
Radiographic Images: Their Quality, the
understand it, communicate with others, and
Difficulties of Identifying Fracture Lines,
and the Role of New Technologies . . . . . . . . . . . . . .
131
guide actions.
Complexity of Fracture Classification Systems . . . .
132 Taxonomy is the science of naming and clas-
Reliability of Reliability Studies . . . . . . . . . . . . . . . . . . . .
133 sifying items, originally concerning only organ-
Current Usefulness and Qualities of Fracture
isms but later extended to the classification of any
Classification Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 133
concept or thing that can be classified. The basic
Considerations for the Future . . . . . . . . . . . . . . . . . . . . . 134
unit is named taxon, and these units are arranged
in a hierarchical structure, usually with a

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 134
typesubtype relationship. The subtype has all
the properties of the parent type, plus one or
more additional properties characteristic of itself.
For example, the living world could be divided
into three kingdoms: animals, plants, and bacte-
ria. A mammal is an animal but not all animals
are mammals, and a cow is a mammal but not all

T. Rod Fleury (*) # R. Stern
mammals are cows.
Division of Orthopaedics and Trauma Surgery, University
Hospitals of Geneva, Geneva, Switzerland
Fracture classification systems based on the
e-mail: richard.stern@hcuge.ch
same reasoning have probably existed for nearly

115
DOI 10.1007/978-3-642-34746-7_5, # EFORT 2014
116
T. Rod Fleury and R. Stern
as long as people have identified fractures. upon similarities and

differences in their physical
This chapter reviews the concept of fracture clas- and/or genetic
characteristics. Fracture classifica-
sification, with the history, purposes, types, tion systems are often
based on the same princi-
strengths, and limitations of the current classifi- ple. The choice of the
characteristics of each
cation systems. group can also be
empirically based upon physi-
cal properties like
fracture lines or fracture pat-
terns, or it can fit with
scientific data like outcome
Classification Systems: What are They prognosis or biomechanics.
Examples are the
Used For? Schatzker classification
of proximal intraarticular
tibia fractures which is
based upon fracture lines
In all its fields of application, scientific or other- and patterns, and the
Danis-Weber classification
wise, the first purpose of taxonomy is to describe of malleolar fractures
which was developed
and name things. A name permits the differenti- according to the fracture
mechanism.
ation of one object from another, and to identify A third purpose of
fracture classification sys-
it in order to work with it. In a fracture classifi- tems is to predict
outcomes. This was one of the
cation system, the beginning is also the setting principles that led to the
development of the
of names in order to understand what we are Comprehensive
Classification of Fractures by
talking about. Professor Maurice Muller
in 1990 [3]. Unfortu-
The second purpose is to group and order the nately, at present, no
objects. Groups are defined according to their tem can reliably assist in
predicting outcomes
description and to a choice of common charac- following the most common
fractures. This is
teristics of the objects composing them. The explained by many factors:
The natural outcome
choice of the common descriptors of the group of a fracture must be
known, the impact of dif-
can be completely empirical, or it can obey some ferent interventions on
the natural outcome must
logical or scientific criteria. The interesting point be studied, and above all
the classification has to
is the variable nature of these groups which can prove itself to be valid,
reliable, and reproducible.
be modified according to scientific progress or Theoretically, a
classification system which had
expert opinion. For example, the classification all these qualities would
be of tremendous benefit
of nature (Systema Naturae) by Carolus Linnaeus to patient and surgeon for
it would allow for an
in 1735 [1] included three kingdoms (mineral, expectation of the outcome
at the time of fracture,
vegetable, and animal) with organisms classified and thus help decide upon
the most effective
by shared physical characteristics. One of the treatment.
most recent systems was invented in 1990 by That leads to the
fourth purpose of classifica-
C. Woese [2] and includes three domains (bacte- tion systems guiding
actions. This feature is not
ria, archaea, and eukaria) according to the Dar- common to all
classification systems, but only to
winian principle of evolution. Fungi were part of those implying an action
in reaction to
the kingdom of plants in Linnaeus system, but a diagnosis. Descriptive-
only systems are devoid
they are now a kingdom themselves, included in of this feature as there
is no consequence to
the domain of eukaria. a description. For
example, the Thorne system
The defined groups are then ordered in a hier- of plant classification is
a purely descriptive clas-
archical manner, usually with increasing com- sification system, and no
specific action is
plexity of characteristics as the progression goes suggested in reaction to
the position of a plant
down along the branches of the tree-diagram in the system. In
contrast, most fracture classifi-
drawn by this classification, the typical example cation systems were
designed by their inventors
being the phylogenetic Tree of Life. This is in order to guide
practicing orthopedic surgeons
a branching diagram or tree showing the in the treatment of their
patients, based upon the
inferred evolutionary relationships among vari- severity, complexity,
mechanism of injury, or
ous biological species or other entities based outcome of the fracture.
Such classifications
Classification of Long-Bone Fractures
117
have also to be valid, reliable, and reproducible for treatment are provided
for each situation. He
because the absence of these qualities implies an differentiates between
undisplaced and displaced
unpredictability of the outcome, and so the sys- fractures, diaphyseal
fractures and fractures of the
tems become useless. extremities of the bone
(which are more painful
and more difficult to cure),
simple and transverse
fractures which are
considered less severe than
A Little Bit of History oblique or comminuted ones,
and closed and open
fractures which are treated
in different ways. Their
Fractures have existed for as long as human prognoses are discussed. In
the forearm and the leg,
beings have sustained trauma. There is no doubt he differentiates single-
bone fractures from two-
that shamans and healers in the prehistoric ages bone fractures. He mentions
also limb shortening
knew how to recognize fractures and thus and soft-tissue problems
associated with the frac-
attempted to treat them with their limited ture. Celsus writings were
in use for many centu-
means. The most ancient text about general and ries, in fact until the end
of the Renaissance.
osteologic surgery known today is the Edwin In the modern era, still
before the advent of
Smith Papyrus [4], which is dated from the roentgenography, some
authors designed their
beginning of the XVIIIth Egyptian Dynasty own fracture classification
systems based on the
(about 1567 BC). The author (some think Imhotep clinical appearance of the
affected limb. In the
himself was the author, although others have eighteenth century, the
Potts fracture [7] described
claimed they were written and edited by at least a distal tibia and fibula
fracture with a varus defor-
three different authors) describes 48 cases of con- mity. In the nineteenth
century (1814) Giovanni
tusions, wounds, and fractures ordered by topogra- Batista Monteggia described
a fracture of the prox-
phy from the head and face to spine and long imal third of the ulna in
association with an anterior
bones. Treatments are advocated for each ailment, dislocation of the radial
head [8]. At the same time,
according to ancient Egyptian medical principles. any fracture of the distal
radius with a dorsal defor-
The skillful Egyptian healer knew the natural out- mation in a dinner fork
shape was classified as
come of the diseases; those that had a good natural a Colles (Colles-Pouteau)
fracture [9], and was
outcome were to be treated, those that were treated according to Colles
advice: correct the
uncertain had to be fought, and those that had deformity and immobilize the
limb.
a bad natural outcome with or without treatment With the advent of
radiography at the end of
were not to be treated. In the Edwin Smith Papy- the nineteenth century,
orthopedic surgeons had
rus, the closed fractures (ailments to be treated) an almost direct view on
their subject: the bone.
are clearly distinguished from open fractures Fracture classification
systems multiplied and
(ailments not to be treated), as open fractures came into common usage,
especially in the med-
were synonymous with early death in ancient Egypt. ical literature. The changes
that took place with
In his book On fractures [5], Hippocrates a better understanding of
fractures brought by
(ca. 460 BCca. 370 BC) shows that the ancient radiographs dramatically
altered the way of clas-
Greeks also distinguished between closed and sifying fractures. The
patient and clinical status
open fractures, and the guidelines of treatment were disregarded, and almost
all systems of clas-
depending upon this classification. He also com- sification developed from
that time were based
pares elbow with knee dislocations, and gives exclusively on fracture
characteristics that were
different methods of reduction for each type of visible and measurable on
plain radiographs.
dislocation. In his treaty De Medicina [6], the Countless fracture
classification systems have
Roman encyclopedist Aulus Cornelius Celsus been described, and most of
them have been
(ca. 25 BCca. 50 AD) demonstrates an astonish- forgotten. For example,
Schepers found 49 sys-
ingly wide knowledge of long-bone fractures. tems of calcaneal fracture
classification based
The fractures are classified in degrees of severity upon plain radiographs, of
which 30 were deter-
based on several characteristics, and guidelines mined to be of historical
significance only [10].
118
But some old fracture classification systems are a precise and exclusive
skeletal location. For
still in common use, such as the Garden classifi- example, radial head
cation of femoral neck fractures [11] and the Neer tems apply only to the
radial head. (2) Patient-
classification of proximal humerus fractures [12] specific systems apply only
to a certain category
being among the most famous. of patients, such as
children, or patients with
In the last 30 years, the development of new cancer, but are not
restricted to a specific bone.
radiologic technologies, principally computed (3) The aim of generic or
universal classification
tomography (CT), ushered in a new era in fracture systems is to classify any
fracture of any bone by
classification systems. Initially, most investiga- always applying the same
logical methodology.
tors tried to apply CT data to existing fracture This is basically a
numerical coding system.
classification systems previously designed for (4) The fourth group of
classification systems
plain radiographs only, in order to improve the deals with the soft-tissue
injury associated with
performance of these systems. However new the fracture, rather than
with the fracture itself.
classification systems based on CT technology The objective of this
chapter is not to describe
itself have also been designed, perhaps the most every possible fracture
classification system. The
famous are the Sanders [13] and the Zwipp [14] most common and useful
systems will be discussed
classifications of calcaneal fractures. As of the in every fracture-dedicated
chapter. However,
present day there is no publication of a classifica- some examples of every kind
of system will be
tion system of long-bone fractures based specifi- useful to understand the
following discussions.
cally on magnetic resonance imaging (MRI).
Some authors also returned to consideration of
the patient as a whole, and to examine non- Fracture-Specific
Classification
radiographic factors that could influence the Systems
choice of treatment and the outcome of the frac-
ture [1518]. The extent of soft-tissue injury, the The Neer classification of
proximal humeral frac-
patients age and comorbidities, the presence of tures [12] is a descriptive
classification system
other traumatic injuries (musculoskeletal or not), described by Charles Neer in
1970. It is still
and even the social and psychological status widely used by orthopedic
surgeons around the
of the patient are some of these factors. Some of world, and is one of the
most studied fracture
them, like soft-tissue injury, are the subject of classification systems. The
classification is
separate classification systems. However, none based on the number of
fracture parts on plain
of these factors are part of a radiological fracture radiographs (Fig. 1). A part
is defined as a bone
classification system. fragment that is displaced
more than 1 cm or
Recently some authors have reasonably angulated greater than 45# .
Neer grouped frac-
questioned the validity and the usefulness of the tures into five categories:
one-part (non-displaced
fracture classification systems in use at present fractures, meaning that no
fragment meets the
[19]. Currently, research is oriented toward veri- criteria to be a part
whatever the number of frac-
fying the validity of the classification systems, ture lines), two-parts
(usually the head separated
improving existing systems, and developing from the shaft, or a greater
tuberosity fracture),
brand new valid tools. three-parts, four-parts, and
articular surface frac-
tures (usually the head-
split type). The challenge
of the Neer system is for
the observer to correctly
Types of Fracture Classification and precisely identify every
fracture fragment
Systems and measure their linear and
angular displace-
ments in order to determine
which ones are con-
Fracture classification systems can be grouped sidered as parts.
into four main categories: (1) Fracture-specific The Garden
classification of femoral neck
systems are designed to describe fractures of fractures [11] was
originally published in 1961.
119
Fig. 1 Neer classification I

of proximal humerus MINIMAL DISPLACED FRACTURES
fractures (Source: DISPLACEMENT
Neer [12])
2 3
4
PART PART
PART
II
ANATOMICAL
NECK
III
SURGICAL
NECK
B
A C
IV
GREATER
TUBEROSITY
V
LESSER
TUBEROSITY
ARTICULAR
SURFACE
VI
FRACTURE
DISLOCATION
ANTERIOR
POSTERIOR
It is based on the anteroposterior radiographic stages of fractures are

ordered in increasing
appearance of femoral neck fractures in varying severity of displacement
and of expected diffi-
stages of displacement before reduction. culty in reduction. For
each stage of fracture,
A correlation is made between the radiographic specific guidelines were
proposed on how to
appearance and the anatomic reality of the frac- achieve a reduction. At
that period, internal fixa-
ture, which is then grouped into four stages. Stage tion was the proposed
treatment for every frac-
I are incomplete fractures; Stage II are complete ture. Common use of this
classification altered it
fractures without any displacement; Stage III are in some ways. Most of the
fractures currently
complete fractures with partial displacement, the classified as Grade I are
complete fractures with
fragments still being attached by the posterior valgus impaction, but
according to Garden these
capsule; and Stage IV which are complete frac- fractures should be
considered as Grade III (com-
tures with full displacement. These descriptive plete fracture with partial
displacement) since
120
Grade I are only incomplete fractures. It is the foot. The extreme

example of a Weber
unclear from the literature when and how this C fracture is the
Maisonneuve fracture, in
complete valgus-impacted fracture came to be which the fracture line is
located right below
classified as a Garden stage I [17]. The notion of the head of the fibula.
fracture stability and risk of femoral head The Vancouver
classification of periprosthetic
osteonecrosis also changed. Garden considered proximal femoral fractures
[23] is peculiar in that
only stage IV fractures as unstable (stability was it concerns fractures of
the proximal femur in
assured in stage III by the posterior capsular patients with an
ipsilateral hip arthroplasty. It
attachment), and linked the risk of complications describes the location of
the fracture line in rela-
with the quality of the reduction. In present day tion to the prosthesis, and
takes account of the
usage, Garden stage III and IV are considered stability of the femoral
component and of the
unstable with a high risk of avascular necrosis, quality of the surrounding
bone stock, in order
and thus are commonly treated by arthroplasty in to guide treatment
decisions. The femur is
elderly patients. divided into three zones:
Zone A is the proximal
The Schatzker classification of tibial plateau metaphysis, Zone B the
diaphysis around the
fractures [20, 21] is one of the most widely used femoral component, and Zone
C is the distal
descriptive classification system for intraarticular diaphysis below the femoral
component. Van-
proximal tibia fractures. The fractures are distrib- couver A fractures involve
the greater or lesser
uted in six types in accordance with the location trochanters, but do not
extend into the diaphysis.
of the fracture lines and the presence or absence Vancouver C fractures occur
distally remote from
of a depression of the articular surface. The the implant. Vancouver B
fractures are located at
amount of displacement or depression is not the level of the implant,
and are subdivided into
taken into account to classify fractures. Type 1 three types: B1 are
fractures with a stable
are pure split fractures of the lateral plateau. Type implant, B2 are fractures
with a loose implant,
2 are spilt fractures of the lateral plateau associ- and B3 are fractures with a
loose implant in the
ated with a depression fracture of the lateral artic- presence of severe loss of
bone stock.
ular surface. Type 3 are pure articular depression
fractures of the lateral plateau, without a split
fracture. Type 4 are medial plateau fractures, Patient-Specific
Classification Systems
either split or depression, with or without
a fracture of the tibial spines. Type 5 are The Salter-Harris
classification [24] was
bicondylar fractures, with continuity between designed to classify
pediatric fractures occurring
the diaphysis and the central metaphysis. Type 6 around the growth plate of
almost any bone. It
are tibial plateau fractures with dissociation consists of five types of
fracture patterns (Fig. 2),
between the tibial metaphysis and diaphysis. ordered by increasing
severity of the injury
The Danis-Weber classification (commonly sustained by the growth
plate. Type I is a com-
called simply Weber) of ankle fractures [22] plete separation of the
epiphysis from the
describes malleolar fractures according to the metaphysis without any
fracture. In Type II, the
location of the fibular fracture line, from which fracture line extends along
the epiphyseal plate to
the mechanism of injury and the damage to the a variable distance and
then goes through a por-
syndesmosis can be deduced. Weber A fractures tion of the metaphysis,
thus producing a typical
are located distal to the syndesmosis, and are triangular-shaped
metaphyseal fragment. Type
typically supination injuries. Weber B fractures III is an articular
fracture, where the line of cleav-
are located at the level of the syndesmosis, age extends from the joint
surface to the weak
and are usually pronation injuries. In Weber zone of the epiphyseal
plate, and then extends
C fractures, the fracture line is proximal to the along the plate to sever it
from the metaphysis.
syndesmosis; the mechanism of injury is Type IV is also articular,
but here the fracture line
thought to be pronation and external rotation of extends from the joint
surface of the epiphysis,
121
I II III IV
V
Fig. 2 Salter-Harris classifi cation (Source: Salter and Harris [24])
across the full thickness of the epiphyseal plate Table 1 Mirels

scoring system for impending patholog-
and through a portion of the metaphysis, thereby ical fractures
(Source: El-Husseiny and Coleman [77])
producing a complete split. Type V is a crush Variable Score 1
Score 2 Score 3
injury of the growth plate; as no clear fracture Site Upper
Lower Peritrochanter
line is visible, it is often discovered late when limb
limb
growth disturbances occur. The classification Pain Mild
Moderate Functional
gives some prognostic indications according to Lesion Blastic
Mixed Lytic
the type of fracture. Types I and II typically have Size <1/3
1/32/3 >2/3
a good prognosis as the growing cells that remain
with the epiphysis are not injured. Type III, and
even more so Type IV, may present with growth can be fairly
subjective: the patients pain must
disturbances if the reduction is not perfect, since be given a score,
and the nature of the lesion
the growing cells may be damaged by the fracture (lytic, blastic, or
mixed) must be evaluated on
line passing through them. The worst prognosis is a plain radiograph.
associated with the Type V in which the growing
cells are destroyed by the crush mechanism.
Mirels scoring system [25] is a classification Generic or
Universal System
system of metastatic lesions of long bones. It was
designed to predict the risk of pathologic fracture In order to further
investigation, evaluation,
in any long bone, and thus evaluate the necessity learning, and
teaching, the Arbeitsgemeinschaft
for prophylactic surgery. It is therefore a kind of fur
Osteosynthesefragen (AO) group sought from
prophylactic classification system for pathologic its early days to
document the fracture cases
fractures. Four characteristics of a metastasis are treated by their
members. The sheer amount of
evaluated, each one receiving a score between 1 information, and
the countless uncoordinated
and 3 (Table 1). The final score is therefore a sum fracture
classification systems that existed,
between 4 and 12. Lesions scoring #7 are at low made them realize
that a universally applicable
percentage risk for fracture, so nonoperative and acceptable
system was needed. The develop-
treatment is advocated for those patients. For ment of such a
system, the special project of Prof.
scores of >8, the risk of fracture is considered Maurice Muller,
took many years and the classi-
sufficiently elevated to advocate prophylactic fix- fication system was
finally published in 1990,
ation prior to other treatment such as irradiation. with subsequent
modifications and additions
This is a good example of a classification system [3, 26]. The AO
comprehensive classification of
that has direct implication on the treatment of the fractures of the
long bones is the only generic or
patient, especially since it concerns prophylactic universal system in
use today. Universal means
surgery. The difficulty with this scoring system that the same
descriptive coding system of
for the observer is that the features of a metastasis this classification
can be applied to any bone
122
1 2 3
4
proximal 11- 21- 31- 41-
diaphyseal 12- 22- 32- 42-
distal 13- 23- 33- 43-

44-
Fig. 3 Numbering of bones and bone segments. The first by a square whose
sides are the same length as the widest
number designates the bone (the radius-ulna and the tibia- part of th e
epiphysis (exceptions: 31- and 44-) (Copyright
fibula are considered as one bone). The second number by AO Foundation,
Switzerland, www.aosurgery.org.
designates the segment: 1 for proximal, 2 for diaphyseal, Source: AO
principles of fracture management. Kellam
and 3 for distal. The malleolar segment is an exception, et al. [26])
noted 44-. The proximal and distal segments are defined
of the skeleton. The AO classification of a frac- widest part of the

epiphysis. An exception is
ture is a methodological process in five steps, the malleolar
segment of the ankle which
corresponding to the answer to five questions: received the
special code 4.
Which bone? Numbers are attributed to the bones Which fracture type?
Fractures can be of three
or limbs. 1 is for the humerus, 2 is for the types: A, B, or C.
In the diaphysis (bone seg-
forearm, 3 is for the femur, 4 is for the leg, ment 2) the type A
are simple two-fragment
etc. (Fig. 3). fractures, the
type B are wedge fractures with
Which bone segment? Each bone has three one or more
intermediate fragments but with
segments: the proximal segment is coded as some contact
between the main fragments after
1, the diaphyseal segment is 2, and the distal reduction, and the
type C are complex fractures
segment is numbered 3. The proximal and the with more than one
intermediate fragment and
distal segments of long bones are defined by a no contact between
the main proximal and distal
square whose sides are the same length as the fragments after
reduction. At the ends of the
123
Fig. 4 Description of the Type

Group Subgroup
morphology of the fracture,
expressed in types, groups,
A1.1
and subgroups according to
A1 A1.2
the level of complexity of
A1.3
the description. The types,
A2.1
A
A2 A2.2
groups, and subgroups are
A2.3
ordered in theoretical
A3.1
ascending severity
A3 A3.2
A3.3
according to the
morphological complexity
B1.1
of the fracture, the expected
B1 B1.2
B1.3
difficulty of treatment and its
B2.1
prognosis (Copyright by AO B
B2 B2.2
Foundation, Switzerland,
B2.3
www.aosurgery.org. Source: Bone
B3.1
B3 B3.2
AO principles of fracture segment
B3.3
management. Kellam et al.
[26])
C1.1
C1 C1.2
C1.3
C2.1
C
C2 C2.2
C2.3
C3.1
C3 C3.2
C3.3
long bone (bone segments 1 and 3), the type A As can be seen in Fig.
4, for each bone seg-
are extra-articular fractures, the type B are partial ment there are 27
possibilities of fracture classi-
articular fractures where a part of the articular fication at the subgroup
level. The fracture types,
surface is preserved and remains in continuity groups, and subgroups are
arranged in a theoret-
with the diaphysis, and type C are complete ical ascending order of
severity of the fracture.
articular fractures with complete disruption of For example, a C fracture
is theoretically more
the articular surface from the diaphysis. severe than an A
fracture, and a B1 fracture is less
Which group? Each type of fracture is then severe than a B2
fracture. The principle stated
divided into three groups (coded 1, 2, and 3) during the design of the
AO Comprehensive
according to relevant details of the fracture, Classification was that
the maximum amount of
such as the angle of the fracture line or the detail about a fracture
would lead to more accu-
degree of comminution. However, the defini- rate description and
classification, which would
tion of each fracture group is not constant and in turn lead to a better
understanding of the
varies with the fracture types. essence of that
fracture. The result could then
Which subgroup? Finally, each group of a be a guide to treatment,
improve research capa-
fracture is divided into subgroups (coded bilities, and provide a
prognostic outcome of the
.1, .2, and .3) according to key features of the treatment. The AO
classification is still in con-
fracture, in order to get the most precise stant evolution. It is
continually evaluated by the
description possible. AO group, changes are
made according to evi-
dence-based data, and new
sections are devel-
The result is a five-element alphanumerical oped. For example, a
classification of long-bone
code for the fracture. For example: a distal fractures in children was
published in 2006. The
humeral fracture, complete articular and Orthopaedic Trauma
Association (OTA) has
multifragmentary joint surface, and metaphyseal adopted the AO
classification system [27], and
complex would be coded 13-C3.3. for most surgeons it is
now known as the
124
AO/OTA classification. Some journals, such as Until recently, the only

published classifica-
the Journal of Orthopaedic Trauma, have also tion of soft-tissue injury
associated with closed
decided to restrict the classification of fractures fractures was the one
described by Tscherne [30].
in their pages to the AO/OTA classification. There are four grades of
increasing severity:
Grade 0 are simple fractures
with no or minimal
soft-tissue injury, usually
resulting from an indi-
Soft-Tissue Injury Classification rect low-energy mechanism.
Grade 1 includes
Systems fractures of mild to medium
severity with super-
ficial contusions or
abrasions. The soft-tissue
Fractures associated with soft-tissue injuries are damage usually occurs
through pressure from a
much more complex to treat than low-energy bone fragment on the soft
tissues from the inside.
fractures without soft-tissue concerns. For two Grade 2 fractures present
deep contaminated
equivalent fractures, the management protocol abrasions with localized
skin or muscle contu-
can be completely different in the setting of a sion. They usually result
from a direct blow
soft-tissue injury. Typical fracture classification (such as a car bumper
injury) causing a
systems consider only the bone lesions and do medium to severe fracture
pattern. A fracture
not include the soft-tissues. Few authors have with an impending
compartment syndrome is
published classification systems for soft-tissue also part of Grade 2. The
hallmarks of Grade 3
injury. injuries are extensive skin
contusion or crush,
Gustilo and Anderson developed a classifica- severe muscle damage and
subcutaneous tissue
tion system of open fractures on the basis of retro- avulsion. The fracture is
usually severe and
spective and prospective analysis of 1,025 patients multifragmentary. Overt
compartment syndrome
[28]. Further clinical experience led Gustilo to or vascular injuries also
belong to Grade 3.
modify it to its present version [29], and this is Knowing quite well the
major importance of
the most widely used classification system of open soft-tissue injuries
associated with fractures, the
fractures around the world. The classification inte- AO group developed a soft-
tissue grading system
grates the severity of the fracture with the skin with alphanumerical codes
which completes
wound, the extent of soft-tissue (muscles, perios- their Comprehensive
Classification of fractures
teum and vascular elements) injury, and the [31]. Three characteristics
of soft-tissue injury
degree of contamination. Gustilo type I fractures are described: skin
(fracture is either closed or
are associated with a clean wound of less than open), muscle/tendon damage,
and neurovascular
1 cm long. They are usually the result of a perfo- injury. Each one is coded
separately in increasing
ration from the inside out made by a sharp fracture order of severity (Fig. 5).
Skin lesions in closed
fragment. Gustilo type II fractures are associated fractures are coded as IC
15, skin lesions in
with a skin wound larger than 1 cm, but without open fractures are noted as
IO 14, muscle/
extensive soft-tissue contusion, periosteal strip- tendon injury is classified
as MT 15, and
ping, necrosis, flaps, or avulsion. Gustilo type III neurovascular injury is
coded as NV 15
are either open segmental fractures or fractures (Fig. 6). The final result
is a three-element code
associated with extensive soft-tissue damage, that is added to the AO
classification of the frac-
with or without gross contamination. They are ture under consideration.
For example, a closed
subdivided in three types: type III-A are usually simple transverse midshaft
tibial fracture with the
high-energy injuries, with extensive soft-tissue fibula fractured at the same
level, associated with
damage but with still enough soft-tissue coverage skin contusion, a one-
compartment muscle
of the fractured bone. Type III-B fractures present injury, and no neurovascular
injury would be
massive soft-tissue loss, periosteal stripping and classified as 42-A3.3/IC2-
MT2-NV1.
bone exposure, with no possibility of coverage. However, as useful as
these classifications are,
Type III-C defines any open fracture with associ- some surgeons think that the
increasing complexity
ated vascular injury that requires repair. of these classification
systems only shows that each
125
IC1 Skin lesions IC

Skin lesions IO
(dosed fractures)
(open fractures)
IO1
IC2
IO2
IC3
IO3
IC4
IO4
IC5
MT1 MT2 MT3 MT4 MT5
Musde/tendon injury (MT) and neurovascular injury (NV).
NV1 NV2 NV3 NV4 NV5
Fig. 5 The soft-tissue classification of the AO (Copyright by AO Foundation,

Switzerland, www.aosurgery.org.
Source: AO principles of fracture management. S
udkamp NP and The AO [31])
major injury involving the soft tissues has its these injuries in the
first days of management
own and unique personality. The classification following the fracture
[32].
systems are useful for documentation, but in the
setting of the emergent treatment demanded
by fractures associated with soft-tissue injury, Fracture
Classification Systems:
the initial task for the surgeon is not to classify, Characteristics and
Statistics
but to describe the lesions as well as possible.
Moreover, the assessment of soft-tissue damage In the December 1993
edition of the Journal
is a dynamic process that requires frequent of Bone and Joint
Surgery (American),
reevaluation because of the evolutionary nature of Dr. Albert H. Burstein
wrote a famous editorial
126
Skin lesions IC (closed fractures) Muscle/tendon injury (MT)

IC 1 No skin lesion MT 1 No muscle injury
IC 2 No skin laceration, but contusion MT 2 Circumscribed muscle
injury, one compartment only
IC 3 Circumscribed degloving MT 3 Considerable muscle
injury, two compartments
IC 4 Extensive, closed degloving MT 4 Muscle defect, tendon
laceration,
IC 5 Necrosis from contusion extensive muscle
contusion
MT 5 Compartment
syndrome/crush syndrome
with wide injury zone
Skin lesions IO (open fractures) Neurovascular injury (NV)

IO 1 Skin breakage from inside out NV 1 No neurovascular injury
IO 2 Skin breakage from outside in <5 cm, NV 2 Isolated nerve injury
contused edges NV 3 Localized vascular
injury
IO 3 Skin breakage from outside in >5 cm, NV 4 Extensive segmental
vascular injury
increased contusion, devitalized edges NV 5 Combined neurovascular
injury, including subtotal
IO 4 Considerable, full-thickness contusion, or even total
amputation
abrasion, extensive open degloving,
skin loss
Fig. 6 Description of the components of the AO soft-tissue injury classification

(Copyright by AO Foundation,
Switzerland, www.aosurgery.org. Source: AO principles of fracture management. S
udkamp NP and The AO [31])
about fracture classification systems. As he said, made unreachable by the

unavoidable observer
fracture classification systems are, indeed, tools. interpretation. In a
system based on fracture lines,
The main purpose of these tools is to help the a gold standard could be
an intraoperative assess-
orthopedic surgeon choose an appropriate ment of the fracture
lines. The problem in our era
method of treatment for each and every fracture of indirect reduction and
percutaneous fixation or
in their practice. They should also provide a minimally invasive
approaches is that finding and
reasonably precise estimation of the outcome measuring a gold standard
is usually very diffi-
of that treatment [19]. Other authors have cult, and thus also the
measure of validity.
also added that classification systems should Reliability (also
referred to as reproducibility)
facilitate and clarify communication between is defined by the fact
that a given fracture is
physicians, and assist the documentation, classified as the same by
several observers. This
research, and comparison of published results is known as the
interobserver agreement. How-
[3336]. ever, reliability is not
synonymous with validity.
However, we all like our tools to be of the finest For example, if an ankle
fracture is classified as
quality. That is, they should do the proper work Weber B by all observers,
the measurement is
they were designed for with constancy over time reliable. But if the
intraoperative findings are of
and that we can trust the information they give us. a Weber C fracture, then
the classification was
In order to be the best of tools, the ideal classifi- not valid.
cation system must have seven qualities: validity, The repeatability of a
classification implies
reliability (reproducibility), repeatability, all- that the same observer
classifies a given fracture
inclusiveness, mutual exclusiveness, logic, and always the same on several
different occasions.
clinical usefulness [19, 33, 34, 37]. This is known as the
intraobserver agreement.
Validity is the capacity of the system to pre- All-inclusiveness and
mutual exclusiveness
cisely describe the true state of the pathologic means that every possible
fracture of a given
process. It is the correlation between the classifi- anatomical region must fit
one and only one cat-
cation system and the reality. To quantify its egory of the related
fracture classification. In
validity, the tool in question must be compared a study by Maripuri, a
high number of proximal
to some gold standard, as the true reality is tibia fractures were
unclassifiable with the Hohl
127
Observer 1
Observer 2 A B
total
A 50 20
70
B 10 20
30
total 60 40
100
50+20
Observed agreement: = 0.7
100
6070 3040
+
expected agreement for A + expected agreement for B
100 100
Chance agreement:
= = 0.54
total
100
observed agreementchance agreement

0.70.54
Agreement beyond chance: k =
= = 0.34
1-chance agreement
10.54
Fig. 7 Calculation of the Kappa statistic. Example with observers agreed,

divided by total number of observations
the simplest situation: two observers doing 100 observa- (in this case
agreement of 0.7, or 70%). Chance agreement
tions with a clear-cut A or B choice (which could be is calculated. Then
the k statistic can be calculated,
fracture or no fracture, for example). The observed expressing the
agreement between both observers beyond
agreement is the total of the observations on which both chance only
and Moore system, thereby showing that this to what part of the
observers agreement is made
classification system is not all-inclusive [38]. by chance only. To
assess agreement that
Logic and clinical usefulness are self-defined. occurred above and
beyond that related to chance
A classification system which is not logical is only alone, Cohen
introduced the Kappa statistic (k) in
a source of confusion, misinterpretation, and mis- 1960 [40]. The Kappa
statistic provides a pair-
use. And a classification system that is not useful in wise proportion of
agreement between observers
everyday orthopedic clinical practice is of no use corrected for chance.
It is expressed mathemati-
at all, and should be quickly forgotten. Some cally as the observed
agreement minus expected
authors even think that the clinical issue of agree- chance agreement,
divided by the maximum pos-
ing on a treatment plan is the most important goal sible agreement not
related to chance (Fig. 7).
of a fracture classification system [39]. The expected chance
agreement is the percentage
Because of the difficulty of measuring valid- of agreement
attributed to chance alone. It is
ity, a fracture classification system should have at a statistical
calculation that is dependent upon
least high degrees of reliability and repeatability the number of
observers, the number of choices
[19, 34]. The basic method of evaluating these in each assessment,
and the number of assess-
two parameters is to measure the raw observed ments [41].
agreement, expressed as the percentage of times The k value was
designed to analyze categor-
that different observers agreed on their assess- ical data, which have
to be divided into two types.
ments. For example, if observers agreed on 75 Nominal (unranked)
data are given equal impor-
of 100 assessments, the observed proportion of tance between all
categorical differences. For
agreement would be 0.75, or 75 %. The limitation example, there is
equal importance between
of this method is that the chance factor is not blue and brown eyes,
and between blue and
taken into account, so there is no indication as green eyes; none is
better or worse than
128
the others. In ordinal (ranked) data, the difference should be clearly indicated,
which is in fact
between some categories is given more credit, or rarely done.
more weight, than the difference between some In the case of numerical
variables (data fall-
other categories. For example, the difference ing on a continuum; e.g.,
the amount of displace-
between Gustilo 1 and Gustilo 2 open fractures ment in millimeters), an
index of reliability
is less important than between Gustilo 1 and commonly used to measure
reproducibility and
Gustilo 3 open fractures, as they are ranked repeatability is the
Intraclass Correlation Coef-
according to an increase in severity. To analyze ficient (ICC), where values
range from 0 (no
ordinal data, Fleiss introduced the weighted agreement) to 1 (perfect
agreement) [45]. How-
k statistic [42] in which a weight modifier ever the ICC is of limited
use as it is not related
gives some credit to partial agreement in order to the size of the error
which is clinically accept-
to reflect the inequality between the different able, and its values should
not be compared
categories. While unweighted k must always be between different sets of
data as the ICC is
used for nominal data, a choice must be made influenced by features of
the data (e.g., the ICC
whether or not to use weighted k for ordinal data will be higher if the
observations are more
[34]. Weighting k values gives rise to two prob- variable).
lems. As the chosen weights can greatly alter the
k values, it is mandatory that the weighting plan
is clearly defined in advance. And without uni- Limitations and Flaws of
Current
form weighting schemes, no comparison between Fracture Classification
Systems
studies is possible if the used scheme is not pre-
cisely described. Since Bursteins editorial,
many authors have
Although most authors have now accepted the evaluated the functionality
of the most common
k value as a method to measure observer agree- fracture classification
systems in terms of
ment, its interpretation is somewhat difficult. intraobserver and
interobserver reliability.
Values obtained range from #1 to +1, where #1 Unfortunately the next step
in the process proving
corresponds to perfect disagreement, +1 is a per- the usefulness of these
tools has not been
fect agreement, and 0 corresponds to agreement achieved because most of the
classification sys-
due to chance only. Between these reference tems show disappointing
reliability. One of the
values, no statistically defined cutoff values few fracture classification
systems considered
express the level of agreement between good and clinically useful
on the basis of scien-
observers, even if it seems logical that the higher tific testing is the Weber
classification of ankle
the value, the more reliable the classification fractures. A study by Malek
et al. [35] showed
system. The two most widely used scales of substantial interobserver
(raw agreement of
k level of agreement published are those of Lan- 78 %, mean k 0.61) and
intraobserver (raw
dis and Koch [43] and Svanholm [44] (Fig. 8). agreement of 85 %, mean k
0.74) reliability.
Despite their widespread acceptance and use, it is A second one is the
Vancouver classification of
important to note that the cutoff values of these periprosthetic fractures,
where the European val-
two guidelines were chosen arbitrarily. It is also idation study of Rayan et
al. [46] showed sub-
important to note that k is dependant both on the stantial agreement for all
observers with
number of categories (i.e., its value is greater if a maximum k of 0.74. And a
third one is the
there are less categories) and the prevalence of Letournel classification of
acetabular fractures.
the condition [45]. For example, a category with a Beaule [47] demonstrated a
substantial
high prevalence can give rise to a high raw interobserver and
intraobserver reliability, with
interobserver agreement but with a very low k. k values of 0.69 and 0.77,
respectively.
Therefore care must be taken when comparing Almost every other
k from different studies, and the prevalence of tested shows unsatisfactory
reliability, whether
the analyzed conditions (fracture categories) they are commonly or rarely
used, simple or
129
Fig. 8 Guidelines used for

the interpretation of the
Kappa coefficient (Adapted
from: Audige [75])
Perfect
1.00
t Very or
Excellent
ll
en od t
ce
good Go ellen
Ex
exc
0.80
al
ta
nti Good
bs
Fair Good
Su
Kappa coefficient scale
Fair to
0.60
good
Moderate
0.40
Fair
0.20
POOR
0.00
Slight
<0
Landis & Koch
1977
Svanholm & al 1989
Martin & al. 1997
Brage & al. 1998
Altman 1990
Fleiss 1981
Authors of guidelines
complex. Examples are numerous. In two stud-

of their questionable reliability and reproduc-
ies, a total of five classification systems of distal
ibility. Two classifications of radial
radius fractures were reviewed by Ploegmakers
head fractures were tested by Sheps et al. [50].
et al. [48] and Belloti et al. [49]. The
The Hotchkiss modification of the Mason clas-
interobserver agreement was unsatisfactory in
sification showed only moderate interobserver
all of them. They concluded that the use of the
reliability, confirming the results of Morgan
AO, Frykman, Fernandez, Older, and Cooneys
et al. [51]. The interobserver reliability for the
Universal classifications cannot be
AO classification was only fair at the subgroup
recommended for clinical application because
level (rising to moderate without subgroups),
130
with the major concern that this classification also agreed that there was
difficulty in
was unable to differentiate fractures needing determining preoperatively
the stability of the
operative versus conservative treatment. As prostheses and the quality
of the bone stock,
regards trochanteric fractures, neither the AO and thus to establish the
diagnosis of a B1-
classification [5254] nor the Jensen classifica- versus a B2-fracture. The
repercussion is
tion [52, 54] met acceptable thresholds for reli- a lower interobserver k in
the B subgroup
ability. van Embden [54] and Fung [52] also (k 0.67) compared to the
whole interobserver
showed that surgeons were unable to reliably k of 0.74.
determine fracture stability or instability, thus Some fractures are
commonly evaluated on
raising concerns about previous studies that the basis of their assumed
stability or instability,
recommended implant choice on the basis of the most famous example
being proximal femur
fracture stability. Primarily two classification fractures. Fracture
stability is in fact very difficult
systems of tibial plateau fractures have been to evaluate on the basis of
static radiographs. As
examined. Walton et al. [36] found the AO clas- was previously mentioned,
the study of Fung
sification to be slightly superior to the Schatzker et al. [52] where 12
reviewers evaluated 56
classification in terms of interobserver reliabil- radiographs of
intertrochanteric fractures showed
ity, but Maripuri et al. [38] found the opposite. unacceptable reliability
for both AO/OTA and
However both authors agree that neither classi- Evans/Jensen
classification. In addition, surgeons
fication system is good since the interobserver were unable to determine
fracture stability when
reliability is at best moderate with a mean k of specifically asked to do
so. The study of van
0.47. Where does the problem lie, and why are Embden et al. [54] obtained
the same results
there so few reliable and repeatable fracture with 10 reviewers examining
50 trochanteric
classification systems? fractures, with the
additional result that after con-
sidering the postoperative
radiographs, the
reviewers concluded that
1518 % of the
fractures were treated with
an inappropriate type
Classification System Flaws of implant. Thus, basing a
and the choice of treatment
on the aspect of
Some fracture classification systems have inher- fracture stability seems to
be a mistake. In fact,
ent flaws which make them inevitably unreliable. a problem with evaluation
of fracture stability is
In their study of tibial plateau fracture classifica- the complete lack in the
literature of a clear and
tion systems, Maripuri et al. [38] showed that the consensual definition of
what is stable or
Hohl and Moore system was not all-inclusive unstable. Interestingly,
11 observers classify-
since many fractures were unclassifiable. When ing 34 subcapital hip
fractures obtained only fair
trying to classify fractures with this system an results with the Garden
classification, but dem-
observer would be forced to choose the least onstrated almost perfect
agreement between the
wrong category instead of the best one, thereby most experienced of them
when they classified
leading to imprecision and variability between the same fractures as
stable or unstable
observers. according to the precise
definition established
Another common problem arises when the by the study authors [55].
Beimers et al. then
classification is based on non-radiological concluded that the Garden
classification is
factors, such as bone quality, implant stability, unreliable and should be
abandoned in favor of
or fracture stability. These are clinical categorizing these
fractures as stable versus
and dynamic factors which are very hard to unstable. Probably when a
clear consensus-
evaluate on a static radiograph which is only based definition of
fracture stability is published,
a glimpse in the life of a fracture. Although the new studies will determine
if the concept of sta-
study of Rayan et al. [46] showed the validity bility is effectively a
source of imprecision and
of the Vancouver classification, the authors variability.
131
Experience of the Observer Even with good-

quality radiographs, it may
be sometimes difficult
to identify the fracture
Some authors have postulated that the level of lines, notably in the
context of articular frac-
professional experience of the observer could be tures with multiple
overlapping fragments, fac-
an important factor affecting the reliability of tors related to the
complex three-dimensional
fracture classification [53]. Experienced (3D) shape of the bone,
or with osteoporotic
observers are supposed to be well informed bone. In the above-cited
study [59], Dirschl
about classification diagrams and accustomed to et al. asked observers
to identify and mark the
classifying fractures, and thus should be more fragments of tibial
pilon fractures before clas-
accurate and less variable in their classification sifying them, which did
not improve the
process than inexperienced observers. This the- interobserver
reliability over that from
ory has only rarely been proven, as with the a previous session
without drawings. However,
Vancouver classification of periprosthetic femo- when the fragments were
identified and marked
ral fractures [46] or with the Letournel classifica- beforehand by the senior
author of the study,
tion of acetabular fractures [47]. Actually, many the interobserver
reliability was significantly
studies about classification of long-bone fractures improved, but only to a
moderate level of
have demonstrated that the experience of the agreement (k 0.54).
These results show that
observer has no influence on reliability, whether the identification of
fracture lines and fracture
it be fractures of the proximal humerus [56], the fragments is difficult.
However, it is only one
distal radius [48, 49], the proximal femur [54], factor in interobserver
variability since when
the tibial plateau [36], or the distal tibia [57], or in this factor was removed
by pre-marking the
the setting of the general AO classification [58]. fragments, the agreement
did not rise to an
almost perfect level.
Another study [41] con-
firmed these facts in
the context of tibial plateau
Radiographic Images: Their Quality, fractures, where the
authors concluded that the
the Difficulties of Identifying Fracture reliability of fracture
classification is limited by
Lines, and the Role of New the observers ability
to agree on basic radio-
Technologies graphic assessments such
as the location of
fracture lines or the
amount of displacement
The quality of fracture radiographs can vary and comminution.
because of a number of factors, including the Although most
classification systems were
type of radiographic machine, the skill of the designed on the basis of
plain radiographs, the
radiologic technician, or the physical characteris- advent of new imaging
technologies, especially
tics of the patient. It would seem logical that CT, ushered in the hope
of increasing classifi-
poor-quality radiographs may affect the observers cation reliability
largely due to the improved
ability to accurately and reliably classify fractures, detail and specific
information that they could
especially if the fracture lines are difficult to see. provide. Unfortunately
many studies have
However, a study specifically evaluating the shown that two-
dimensional (2D) CT scans do
impact of the radiographs quality did not show it not improve the
intraobserver and interobserver
to be a significant source of interobserver vari- agreement on fracture
classification [39, 41, 47,
ability [59]. Actually, interobserver agreement on 57, 6062].
Paradoxically, one explanation could
the adequacy of the radiographs was poorer than be the increased
difficulty for the observer to ana-
agreement on the classification of the fractures lyze the huge amount of
information provided by
themselves. It therefore appears that improving CT with its multiple
imaging planes, to follow the
the quality of plain radiographic images is fragments from one image
to another, and to ima-
unlikely to improve the reliability of classifica- gine a complex 3D volume
like an articular surface
tion of fractures, at least in the case of tibial with 2D images slices
[61, 63]. However, standard
plafond fractures. 2D CT still has
advantages for the characterization
132
of the fracture in terms of better quantification of Complexity of Fracture

Classification
articular surface incongruity [64, 65], and also for Systems
increasing observers agreement on treatment plan
[39, 66]. To make a fracture
classification work, one must
Recent studies have evaluated more sophis- keep it simple, said Dr
Sanders [70]. It could
ticated post-acquisition treatment of CT images effectively seem reasonable
that a very complex
with promising results. Harness et al. [63] classification system would
lead the observer
found that in comparison to 2D CT, 3D recon- either to difficulties in
understanding the basic
struction of CT scans improved both the reli- system or to hesitation
between too many cate-
ability and the accuracy of radiographic gories, thus resulting in
uncertainty and variabil-
characterization of articular fractures of the ity of classification. For
example, in the AO
distal part of the radius as well as treatment fracture classification
system, a given fracture
decisions, but without knowledge whether this can belong to one of 3
types, or one of 9 groups,
would have resulted in better patient outcomes or one of 27 subgroups,
depending upon the
or more cost-effective treatment. Hu et al. [67] amount of detail of the
description. Several stud-
showed that the interobserver reliability for ies have shown that
observers reliability drops
both the AO and Schatzker tibial plateau clas- with every increase in the
classifications com-
sification systems improved from substantial plexity (from type to
group, and from
with the use of plain radiographs combined group to subgroup) [36,
53, 57, 71], leading
with 2D CT images, to almost perfect with to the conclusion that
acceptable reliability was
the use of plain radiographs and associated 3D only achieved at the type
level. Thus, drawing
CT images. In another study, Doornberg et al. guidelines concerning
fracture management
[68] showed that 3D CT significantly improved based on patterns more
complex than the
both the intraobserver and the interobserver broad AO-type fracture
classification was mean-
agreement for the characterization, classifica- ingless [70].
tion, and treatment of distal humeral fractures, However, the complexity
of the AO classifi-
but only to a moderate maximal level of cation is probably not the
only factor that
agreement. This led them to conclude that explains its poor
performance at higher levels of
there is substantial disagreement among quali- detail description. Two
studies tried to improve
fied observers that cannot be resolved even with the reliability of the AO
classification within the
more sophisticated imaging techniques. In an setting of tibial pilon
fractures [59] and ankle
example of proximal humerus fractures, Sjoden fractures [72] by
simplifying the diagnostic pro-
et al. [69] showed unsatisfactory reliability of cess with a binary decision-
making protocol.
both the AO and Neer classification systems, When evaluating the
radiographs, the observers
with absolutely no improvement with 2D or 3D could not jump directly to
the diagnosis but were
CT imaging. Pushing the technological sophis- forced to follow a path of
thought by answering
tication even further with the use of 3D-volume sequential binary questions
(whose answers
rendering and special stereo-visualization could be only yes or no)
which led them
workstations, Brunner et al. [56] improved to the final classification
code. In both studies
both intraobserver and interobserver reliability there was no statistically
significant difference
of these classifications to good and even in reliability between the
original and binary
excellent. Thus, while it seems that in the classification systems.
Moreover, apparently
present era of high-definition video and three- more complex systems like
the Letournel classi-
dimensional cinema these new radiographic fication for acetabular
fractures perform better
imaging technologies could help us to better in terms of reliability than
simpler classification
evaluate and classify fractures, the questions systems [47]. The
simplification of the clas-
remain as to the increased cost and time for sification process or the
application of binary
such imaging studies. decision-making does not
appear to be effective
133
in improving interobserver reliability in fracture results and conclusions of

these reliability stud-
classification. ies should be interpreted in
the light of their
Simplicity still has its advantages in everyday methodological strength.
They also pointed out
clinical practice notably for ease in communica- the need for methodological
standards for reli-
tion, but lacks the level of detail necessary for ability studies.
research purposes which is in turn too cumber-
some to be used in clinical practice. Therefore,
Bernstein advocated that two classification sys- Current Usefulness and
Qualities of
tems be used for every fracture: one simple and Fracture Classification
Systems
succinct for clinical use and another detailed
enough for research purposes [73]. Such a dual Classification systems have
four purposes: nam-
system would probably add to the confusion ing things, grouping objects
of the same cate-
rather than solve the problem of reliability [74], gory, predicting outcomes,
and guiding actions.
which is why Colton advocated the use of Almost every possible
fracture fits into at least
a multilayer system, with increasing details one classification, and thus
has a name that is
about the personality of the fracture as the clas- usually an eponym. The
usefulness for commu-
sifier descends through it, and with an upper layer nication between orthopedic
surgeons in every-
serving as an everyday working tool for the sur- day practice is obvious, for
even without
geon. A compromise like this would not be a radiograph one can have
quite a good
a weakness, but a foundation on which to build. mental image of a fracture
just by its name.
However, the classification
must be well-
known by both users, and
some communication
Reliability of Reliability Studies problems and confusion could
arise with the
multiplicity of
classification eponyms for the
Although some fracture classification systems same fracture.
appear better than others, and some should no More than easing
communication and passing
longer be used because of their evident flaws, on knowledge to trainees,
care should be taken before recommending or also have an educational
role. In order to cor-
discarding a classification system. While rectly classify a fracture,
the bony anatomy
a number of studies have been conducted to eval- must be well-known, the
mechanism of injury
uate the reliability of many fracture classification must be understood, and the
different character-
systems, the quality of these studies was not istics of the fracture
itself must be established,
always optimal. Audige et al. [75] reviewed 44 which implies a certain
discipline of thought.
studies assessing 32 fracture classification sys- Nonetheless, we agree with
Smith [76] that in
tems and found considerable variation in their practice, most surgeons
classify occasionally (on
methodologies. For example, in these 44 studies, courses), a few formally and
even fewer have
the study population was clearly defined by the protocols which plan
management around
inclusion/exclusion criteria in only 59 %, the a classification system. For
the most part we
selection of cases was considered representative continue to describe a
fracture in longhand
of the study population in only 39 %, not a single with regard to its site,
pattern, displacement and
study justified the size of the sample chosen, the complicating features. Even
if this longhand
participating raters were judged representative method probably gives rise
to inaccuracies,
of the eventual users of the classification in only many formal classification
systems cannot claim
9 %, and the number of raters was appropriate in to be more accurate or
reliable.
23 %. The statistical analyses, with the Kappa Because of their
limitations in interobserver
coefficient used in 88 % of the studies seemed and intraobserver
reliability, current classification
adequate for the study objectives in only 39 % of systems probably fail in
their last two purposes,
the studies. Audige et al. thus recommended the predicting outcomes and
guiding actions.
134
This substantial variability casts doubt on compar- a huge amount of new or

improved information
ative studies that have inferred a best treatment with the same raw data as
that in the past. One
(or implant) choice on the basis of the fracture could even envisage the
development
classification. In the same way, there is nothing of computer algorithms that
could automatically
in orthopedic literature to date that validates an recognize the fracture
patterns on digital images
outcome prognosis with a fracture classification. and classify them according
to a selected classi-
Only one study [18] of isolated unilateral lower fication system, in the
same way that today com-
limb fractures was specifically designed to evalu- puters read
electrocardiograms.
ate the outcome prognosis of the AO classification, Some characterizations
about the basic fea-
and found no correlation between the alphanumer- tures of fractures are
still missing. Experts
ical code and 612 month functional performance should work together and
set precise definitions
and residual impairment. of, for example, fracture
stability, displace-
ment, and comminution. They
should also
agree on precise
methodologies for studies
Considerations for the Future that evaluate the
classification systems, and
define the statistical
cutoff of what is an accept-
There is still much work to do to find the opti- able or unacceptable
reliability. In addition to
mal fracture classification system which will the technical feats that
show promising results
reliably guide the orthopedic surgeons deci- but also limitations, there
are two ways of
sion as to best treatment, as well as predict improving fracture
classification. Existing sys-
outcomes. Precise classification is mandatory tems can be modified or
brand-new systems can
in order to improve patient care, as well as for be created. Audige et al.
[33] defined a precise
hospital managers and administrators who need method to modify or create
a fracture classifi-
accurate information to recover the appropriate cation system in the most
efficient way, which
costs for treatment. Improvements in the con- includes three phases of
validation: a pilot
cept of fracture classification have to be global phase based on expert
consensus, a second
and not only centered on bone radiography. phase of multicenter
consensus, and a third
Before deciding upon a course of treatment, phase of prospective
clinical study. Although
one must be aware of the many variables that time- and resource-
consuming, this rigorous
make up the personality of the injury and need method is probably the best
way to achieve
to be included in any classification system. the creation of valid,
useful, and reliable clas-
These are not only the specific musculoskeletal sification tools for our
orthopedic practice.
trauma involving bone, cartilage, and soft tis- The classification of
long-bone fractures is
sue, they also include the patient and factors currently undergoing a
revolution. What will
such as age, occupation, medical condition, emerge from this will
probably change
needs, expectations, motivation, psychological completely our practice
habits, but will also
status, level of education, and socioeconomic greatly advance our
understanding of specific
status. fractures and thus improve
the quality of care
New imaging technologies like 3D CT volume we render our patients.
rendering with stereo visualization will probably
help us to better understand and categorize frac-
tures, hopefully in a more reliable way. Improved References
complementary imaging modalities with MRI
and ultrasound should further provide us with 1. Linnaeus C. Systema
naturae in quo naturae regna tria,
more information about possible soft-tissue and secundum classes,
ordines, genera, species,
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Non-Operative Treatment of
Long Bone
Fractures in Adults
J. Fabry and Pierre-Paul

Casteleyn
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 140 This chapter describes the possibilities of
no-touch fracture healing by closed manipula-

Specific
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
tion in aldult long shaft bones. The clinical

Specific Treatments: Tibia-Humerus-Femur-
part is out of necessity precided by
Radius/Ulna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 142 pointing out the biology of fracture healing.
Closed Treatment of Tibial Shaft Fractures
in
Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 142 Furthermore, we will draw attention to the
Closed Treatment of Humeral Shaft Fractures in
fracture anatomy and its deforming forces.
Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 146 The main goal of this text is to provide the
Closed Treatment of Femoral Shaft Fractures in
reader with a basic guidline for his personal
Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 151
Closed Treatment of Radial and/or Ulnar
practice. Hence, throughout the second and
Fractures in
Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
154 clinical part of the text, we will try to make a
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 157
clear distinction between suitable and non-
suitable fracture types for closed treatment.
Keywords
Adjacent joint motion # Angular deformity #
Callus # Closed treatment # Diaphysis #
Displacement # Distraction # Epiphysis # Frac-
ture haematoma # Fracture patterns # Intrinsic

fracture stability # Lamellar bone # Limb-
length # No-touch technique # Non-union #
ORIF # Plaster # Primary bone healing # Sec-
ondary bone healing # Three-point fixation #
Traction # Vascularity # Woven bone
J. Fabry (*) # P.-P. Casteleyn

Department of Orthopaedics and Traumatology,
University Hospital, Brussels, Belgium
e-mail: bea.pion@uzbrussel.be; cortorm@az.vub.ac.be

139
DOI 10.1007/978-3-642-34746-7_7, # EFORT 2014
140 J.
Fabry and P.-P. Casteleyn
a pins-in-plaster construct
providing correct
Introduction axial alignment.
Conservation of the local
vascularity in the
The following paper will discuss the conservative direct vicinity of the
fracture is the pre-requisite
care of diaphyseal fractures of long bones in for fracture healing. This
implies the preservation
adults. It combines basic biological knowledge of the vascularity of the
periosteum, the bone
of fracture healing and its direct implications for itself and the soft tissue
sheath around the
treatment. fracture.
This overview is far from complete. It wants to In the early stages of
spontaneous healing,
offer the reader insight into the mechanisms of woven bone is formed in the
fracture haematoma.
fracturing and its healing. Furthermore it wants to This process does not
require strict
provide the reader a sound strategy for treatment. immobilisation as long as the
bridging of the
Orthopaedic Surgeons trained in developed haematoma is not disturbed.
Later on this
countries progressively become out of touch woven bone is transformed
into lamellar bone.
with closed fracture treatment and the basic Woven bone is
radiographically visible and an
knowledge of it. Nevertheless, different countries important clinical landmark
for decision- mak-
take a different stand on the conservative- ing: early weight-bearing or
initiation of more
operative scale in their approach to resolve vigorous mobilisation.
problems. The fracture haematoma
forms a pathway for
By and large, there is a tendency in western the formation of the callus
around the fracture:
countries to gradually abandon these techniques a so-called cuff of woven
bone appears around
and lose knowledge of them. These are almost the fracture. This reaction
originates from
certainly lost in favour of expensive implantation the periosteal cells directly
neighbouring the
devices which are not available to every fracture site.
member of the public. This tendency does Woven bone begins to form
between the
not apply to colleagues in the Paediatric sub- periosteum and the bone
surface itself and
specialty. Certain situations, varying from grows, from both sides,
through the fracture
strictly patient-related (e.g. ASA III or NYHA haematoma. In the adult
population this takes
IV ratings) or situational (e.g. war theatres and place in the first 2 weeks
post-fracture and adds
disasters in developing countries) may still some degree of stiffness to
the fracture. In corti-
necessitate the use of these old-fashioned tech- cal bone healing we find
abundant woven bone
niques. We define conservative treatment essen- formation.
tially as a no-touch technique of the fracture Trabecular bone healing
(in metaphyseal
haematoma. This does not necessarily exclude areas), on the contrary,
takes place at the contact
operative treatment: pins-in-plaster techniques surface. In this type of
healing stability and inti-
and external fixation are also covered by this mate contact between the bony
ends are impor-
definition. tant. Hence callus formation
is less visible on
On the other hand, (reamed) intramedullary radiographs.
nailing, seriously interferes with the fracture Here the woven bone
formation only takes
haematoma and endosteal vessels, though the place at the contact surfaces
in the meta/epiphy-
fracture site is not opened from outside. seal area and does not
surround the fracture site as
Hence nailing will not be discussed, but men- in cortical fracture healing.
A certain degree of
tioned only to compare functional results. guided collapse with early
partial weight-
In fractures with a high degree of comminu- bearing can propagate this
process, but can also
tion, it is often better to leave the fracture site result in shortening or
angulation of the lower
untouched, and add stability with a bridging limb. Therefore good clinical
follow-up is
technique such as an external fixator or mandatory.
Non-Operative Treatment of Long Bone Fractures in Adults
141
Next, lamellar bone is formed in the woven degree of internal soft

tissue injury and some-
callus. Clinically it is important that the woven times the type of fracture.
callus completely bridges both fracture ends: Apart from these
strictly injury-related
continuous disruption by motion, infection or factors, general factors
like poor nutritional sta-
surgical dissection, can result in a pseudarthrosis. tus, medicine intake (e.g.
steroids, NSAID and
Additional stability and/or addition of methotrexate) and smoking,
can seriously
a biological stimulus to bone formation is then compromise the fracture
healing process [13].
needed. These drugs sometimes
require adjustment or
Early weight-bearing, when early callus is abolition to create sound
healing conditions.
seen on x-rays, propagates maturation of the cal- The influence of
osteoporosis on fracture healing
lus (e.g. with transverse or short oblique fractures remains uncertain, and is
still under intense
of the lower limbs). investigation [4].
In summary, conservation of the vascularity Fracture patterns
should also be assessed by
around the fracture and providing a certain their intrinsic stability
after the dissipation of
degree of stability, are important conditions for the fracturing kinetic
energy. Fracture patterns
proper fracture healing. oriented strictly
perpendicular or only slightly
The amplitude of displacement (at the moment obliquely to the long axis
of a weight-bearing
of maximal energy absorption), is also an bone possess an inherent
stability, provided one
important determinant. It is directly proportional obtains excellent contact
during reduction and
to the degree of kinetic energy causing the the concave soft tissue
sleeve is still intact. This
fracture. It also correlates well with the applies mainly to the tibia
and to a lesser degree
disruption of the soft tissues (vascularity) to the mid- and distal
shaft of the femur. These
around the fracture. High energy impacts destroy fractures can be treated
with plaster-of-Paris to
more and can cause difficulties in the healing control angular alignment
with three-point
process. fixation.
The fracture haematoma should be seen as Distraction of the
fracture components after
a pathway for the woven bone formation in attempted reduction is
likely to cause
a closed envelope surrounding the fracture. a hypotrophic non-union.
Even cases with appar-
As mentioned before, this pathway for the ent sufficient contact, but
with point contact
woven callus can become interrupted, resulting between the highest
fracture spikes, can create
in disturbed healing. Hence one can understand a fair amount of
distraction, with disruption of the
why complicated fractures, insufficient immobil- local vascularity. Re-
manipulation or open
ity or distraction of the fracture can result in non- reduction techniques are
then mandatory. Spiral,
or delayed union. long oblique fractures or
those with a high degree
Immediate post injury x-rays may deceive the of comminution do not
possess much stability.
examiner about the amplitude of displacement Muscles that run across the
fracture have no
and the associated tissue injuries. Because the bony restraint and can
cause shortening, rotation
x-rays are taken at a moment when elastic recoil and angulation.
has already taken place, they therefore may show Preservation of length
by the use of traction or
less displacement. Elastic recoil is the tendency pull by gravity is
essential to counteract muscle
of the soft tissues to revert to their original shape action. External fixation
and pins-in-plaster can
(or position), once deformed by kinetic energy. also be effective in these
situations.
Therefore a detailed history and assessment, Short oblique fractures
can be treated by plas-
scrutinising the injury mechanism with regard to ter immobilisation and the
use of three-point
speed, height, type of impact and position of the forces around the fracture.
This mechanism relies
limb at impact, can give us an idea about the on the intact soft-tissue
hinge on the concave side
amplitude of displacement and the concomitant of the fracture.
142
J. Fabry and P.-P. Casteleyn
a
b
Specific Fractures
In the second part, we will discuss specific bone

fractures, their treatment and potential pitfalls.
Emphasis will be placed upon mechanical
factors that influence alignment and its correction
by the use of gravity, traction, or plastering
techniques.
In conclusion, in order to work out a treatment
strategy, it will be necessary to assess the dis-
placement mechanisms, the remaining stability,
and the intact soft- tissue hinges.
The main clinical goals in closed treatment
can be summarised as:
1. Obtaining accurate alignment,
2. Maintenance of that alignment, and
3. Preservation of adjacent joint motion by early
mobilisation.
The strategies used mainly rely upon whether (a) Only soft tissue support
the soft tissues (periosteum, muscle sheath) are
(b) Three point fixation:
action of plaster via soft tissue
preserved or not. Plastering techniques (hinge
technique) depend on the intact soft tissues on the Fig. 1 Principles of three-
point fixation in plastering
concave side of the fracture. Tensioning of these techniques
structures by three-point fixation can provide
a fair amount of stability until fibrotic callus or
early woven bone appears Fig. 1. especially in fractures
around the knee joint.
Another frequently-used reduction technique Notorious is the stiffening
of the knee in
when confronted with overlap (transverse fractures) conservative treatment of the
distal and middle
is done by initial exaggeration of the deformity femur by traction [5].
with the distal fracture fragment in order to hinge
it on the proximal fragment, thereby optimising
contact and regaining normal limb length. Often Specific Treatments: Tibia-
Humerus-
a plaster with three-point fixation is added. Femur-Radius/Ulna
Also gravity and traction by weights can be
used to restore length and correct angular defor- Closed Treatment of Tibial
Shaft
mity of a broken limb, especially for the middle Fractures in Adults
and distal thirds of the femur.
After initial successful reduction, loss of Closed treatment implies the
intent not to
reduction can be caused by gravity, resolution disturb or minimally disturb
the fresh fracture
of soft tissue oedema and volume reduction haematoma. Obviously this can
be obtained by
of the fracture haematoma. Consequently, plaster treatment.
undesired deformity may (re)appear. This should Fracture ends have already
become ischaemic
be anticipated by frequent fracture clinic visits due to the injury itself
(periosteal stripping and/or
and x-ray evaluations within the first 4 weeks tearing of the endosteal
arteries). This consider-
post-fracture. ation is certainly of
importance when judging
Prevention of joint stiffening by early and fractures extending distally
from the junction of
well-directed mobilisation is important, the middle and distal thirds
of the tibia, where the
143
afferent sources of blood supply to the bone a neurovascular injury. The

latter are best dealt
become fewer [6, 7]. with by external fixation:
one obtains immediate
In the tibia, the metaphyseal-epiphyseal areas stability and easy access to
the soft tissue prob-
are generously supplied by circumferentially lems. Immediate and correct
positioning of the
penetrating vessels. In the diaphysis, on the con- frame is best done in
concert with the vascular or
trary, the nutrient artery is the main blood source. plastic surgeons.
After entering the medullary cavity, the artery In addition to these
strictly injury-related mat-
gives off ascending branches that disperse widely. ters, there are also
important patient- related
The descending branch, on the other hand, issues to be taken into
account: age, mental sta-
remains a single vessel before it branches off tus, expected compliance,
general health condi-
more distally. These branches in their turn give tions (e.g. neuromuscular
disease and/or heart
off radial branches that anastomose with the failure) and history of
DVT/PE.
Haversian systems. Hence the blood supply here Cutaneous conditions
(steroid impregnation)
is more dependent on the finer anastomotic grids or venous insufficiency are
strong contra-
in the cortex. Nutrient arteries enter the bone at indications for prolonged
plaster treatment.
the level of muscle and tendon attachments, and Even psychological
conditions can be
therefore not at the anteromedial boundaries strong contra-indications
for plaster treatment:
which forms two-third of the circumference of ethylism, dementia,
depression, drug abuse and
the distal third of the tibia. psychotic conditions. The
nutritional status and
The periosteum has a copious vascular bed but risk for infection are to be
reckoned with when
delivers only a sparse contribution to capillaries faced with these conditions!
It is also imperative
of the cortical vascular system in a non-fractured to obtain a clear history
and assessment of the
situation! [8]. However Strachan et al. demon- fracture mechanism: low
energy versus high
strated the existence of periosteal vessel recruit- energy, because it provides
vital information
ment and increased blood flow in the bone about initial fracture
displacement and the con-
and callus, even after ligation of the nutrient comitant degree of soft
tissue injury, even for
artery! [9]. They also observed a progressive a closed fracture Fig. 2.
development of centripetal blood flow towards As mentioned before, the
immediate post-injury
the fracture. This observation reminds the sur- x-ray is often not a true
measure of the furthest
geon again to deal conservatively with the peri- point of displacement at the
time of maximal trau-
osteum when opening up a fracture in the distal matic energy absorption. The
elastic recoil of the
third of the tibia. soft tissues reduces the
amplitude of displacement
Venous drainage of the diaphysis goes largely after the traumatic energy
has dissipated into the
towards the endosteum. From here onwards, fracture. This displacement
compromises the vas-
veins accompany the course of the arteries. cularity around the fracture
site and can adversely
This pattern partially explains the existence of interfere with the healing
process [10].
a transitional area between the middle and lower Once the surgeon has
opted for closed treat-
thirds of the tibia which is prone to the development, sound knowledge of
potential complica-
ment of fracture healing problems. tions should be anticipated:
they are both
Generally, operative intervention is strongly fracture and plaster-related
[11, 12].
advised in the following circumstances: The surgeon needs a good
plaster technician or
1. unstable fracture patterns with displacement, should possess good
plastering skills. He has to
2. bilateral tibial fractures, be aware of the sequence of
application, the set-
3. polytrauma settings-fractures with displaced ting characteristics of the
plaster, the thickness
intra-articular extensions, and above all how to apply
the right forces into
4. open fractures and severe soft tissue loss. the right direction (three-
point fixation).
There is no place for closed treatment when In addition to this,
competence in wedging
suspecting a compartment syndrome or in case of techniques is desired [13],
Fig. 3a, b.
144
a b wedging
techniques. Many surgeons consider
this finding as an
indication for surgery.
Displaced
fractures of the upper one-third of
the tibia are best
treated by operative means,
because the thick
muscular mantle does not effi-
ciently transmit
corrective forces.
The treating
surgeon must associate certain
fracture patterns
with the condition of eventual
stabilising soft
tissues (muscles, periosteum,
interosseous
membrane and fibula). The degree
of damage to these
structures is, of course, closely
related to the
degree of initial displacement.
Mildly
displaced fractures usually possess an
intact
interosseous membrane and an intact peri-
osteal hinge on
the concave side of the fracture.
This could imply
that correction might be possi-
ble with three
point fixation.
Transverse and
short oblique fractures
(even with a
fractured fibula) are ideal
indications for
plaster treatment with three-point
fixation.
In (a), the stabilising soft tissue structures on the concave Spiral
fractures of the tibial shaft, with or
side of the fracture still have a certain degree of Integrety,
whereas in (b), the displacement suggests a total disruption without fibular
fracture, are also good indications
of the soft tissues including the interosseous membrane. for closed
treatment Fig. 4.
Fig. 2 Moderately- (a) and (b) severely-displaced tibial
fractures Unstable Fractures
Oblique fractures
with opening at the lateral side
and an intact
fibula or non-displaced fibular frac-
In the follow-up its important to see the ture, are not good
indications for closed treatment
patient in clinic every week during the first 34 Fig. 5, Table 1.
weeks in order to act quickly, when faced with These
configurations are prone to develop
looming complications. Understanding of the frontal varus
angulation and distraction. Here,
fracture anatomy is vital to predict whether con- ORIF is advised.
servative treatment will be successful: location, Residual
frontal plane angulations of >10# are
direction, degree of comminution, or the presence prone to develop
early post-traumatic arthritis in
of a butterfly fragment [10]. the tibio-talar
joint [17].
One needs to look for alignment in frontal and These might
necessitate further surgery ranging
sagittal planes, rotational deformity and shorten- from distal tibial
osteotomies to fusion depending
ing of the leg. A frontal plane deviation up to 5# on the extent of
the arthritic changes. Serious dis-
(valgus or varus), fracture overlap of minimally placement suggests
a complete rupture of the
50 % and shortening, not exceeding 1.5 cm, are interosseous
membrane and periosteal sheath
all acceptable limits for in situ casting and there- with no intrinsic
stabilising structures left. One
fore, need no further manipulation [1416]. should consider
surgery in these circumstances.
Hence these figures should be kept in mind Some fracture
characteristics like the degree
during treatment. of comminution,
presence of a butterfly fragment,
The intact fibula can cause varus mal- distraction of the
fracture on spikes, mediolateral
alignment of the distal tibia, which is difficult to displacement of
>50 % and bifocal fractures,
control by closed treatment even with additional are frequently
related with delayed union or
145
Fig. 3 (a) Principles of a

wedging technique, frontal
view. (b) Principles of
wedging technique,
transverse view
Hinge point (Hpf and Hps)
Insert plaster strut opposite of hinge point
Desired angle of correction
b
anterior
Hf
medial
lateral
Hs
Range of hinge point orientation depending
posterior
on relative degree of frontal and sagittal deformity
Hf: hingepoint for purely

frontal plane deformity (valgus)
Hs: hingepoint for purely
sagittal plane deformity (recurvatum)
non-union when treated by closed means [18, 19], The patient is

frequently followed in fracture
Fig. 5. clinic as an
outpatient, during the initial 34
They need open accurate reduction and weeks once every week
with an x-ray.
stabilisation Table 2. In the later stages
of follow-up the fracture
clinic intervals can be
progressively extended
Plastering Technique when felt safe.
In practice, plastering starts at the lower leg after Once there is
radiographic evidence of
manipulation. callus formation, the
plaster can be safely
The surgeon sits upright and the patients changed to a patellar
tendon-bearing device
lower legs hang over the edge of the table. (PTB).
This is a very comfortable position to apply The pace of weight-
bearing must be tailored
correcting forces in all planes and to assess rotation to the individuality
(inherent stability) of the
of the limb. After curing of the plaster at the level fracture and the
compliance of the patient, as
of the lower leg, it is extended above the knee, with discussed previously.
In this phase, it is advised
the knee in 05# flexion. X-rays are taken, and if to review the patient
again with short intervals to
necessary wedging techniques are used to correct avoid undesirable
angular deformation. The
unacceptable frontal or sagittal axes. enhancing effect of
cyclic loading and micro-
The patient is admitted overnight for close movement on fracture
healing is well-
neurovascular observation. documented [20].
146
a b Closed Treatment of
Humeral Shaft
Fractures in Adults
Of the five long bone

fractures we will discuss in
this overview, the
humeral shaft fracture remains
the only one where a
strong consensus exists in
favour of closed
treatment.
Ekholm et al.
studied the age incidence of
these fractures in the
Swedish population: in the
overall population they
reported an incidence of
14.5 % per 100,000
inhabitants. From the fifth
decade onwards, this
figure increases steeply to
60/100,000. Women are
more affected than men.
In the older age group
fractures are commonly
located at the middle
and proximal third of
the shaft.
Fractures through
the distal third (e.g.
Holstein type) are more
often encountered in the
younger population
[24].
Fracture patterns
are the result of indirect or
direct actions of force
and the subsequent muscle
actions Fig. 6a, b.
Indirect fracture
mechanisms with rotational
forces give rise to
long spiral or long oblique
fractures. When mildly
displaced, they allow
safe healing by closed
means because of the
large contact area,
though there is a greater
chance of soft tissue
interposition.
(a): transverse midshaft fracture with ample contact,
due to broken fibula. Direct impact
mechanisms give rise to trans-
(b): short obilque fracture with broken fibula
verse, short oblique
and comminuted fractures,
(counteracts distraction). frequently accompanied
by soft-tissue injury or
severe concussion.
Hence these fracture patterns
Fig. 4 Tibia, stable fracture patterns cause more non-unions.
Butterfly-type
fractures result from combined
fracture mechanisms
Table 3.
Most observational studies indicate a time to Contra-Indications

union variation from 2 to 14 months with an We will first mention
some circumstances in
average of 45 months. which closed treatment
would be disadvanta-
geous: radial nerve
injury after closed manipula-
Complications tion, second fracture
focus on the humerus,
The literature reports a re-fracturing rate of polytrauma setting,
floating shoulder/elbow.
12 %. In the setting of a
severe chest injury, with
Non-union is seen in 35 %. ventilation problems,
it is evident that thora-
Clinically significant mal-alignment is seen columbar fixation
methods (Dessault) should
in 38 %. not be applied.
Shortening more than 1 cm reaches an inci- When faced with a
brachial artery injury,
dence of 10 %! [18, 2123]. quick and safe fixation
(screw and plate, external
147
a b c
d
(a) Unstable bifocal fracture; (b) intact of undisplaced fibular fracture

with consequent lateral
opening of the tibial fracture (risk of varus deformity); (c) butterfly
fragment; (d) contact only by a
A few fracture spikes (distraction with non-union risk).
Fig. 5 Tibia, unstable fracture patterns that might necessitate surgical

stabilisation
Table 1 Overview closed treatment tibial fractures

Transverse fracture +/# fibula fracture
plaster with three point fixationa
Short oblique +/# fibula fracture
Spiral +/# fibula fracture
Oblique with lateral opening Intact or non displaced fibula
ORIF, risk of varus angulation
a
Low energy impact, with intact contralateral soft tissue hinge
Table 2 Indications for operative (open) treatment Generally,

polytrauma patients need good
High degree of communition (high energy impact) triceps function
(stable humerus) for early
Butterfly fragment mobilisation.
Continuing distraction on spikes (after reduction) Non-fracture
related contra-indications for
Mediolateral displacement >50 % plaster or brace
treatment are poor cutaneous
Bifocale fractures and/or vascular
condition, which can cause seri-
ous complications.
When opting for
closed treatment, the specific
fracture type (long
oblique, short oblique or
fixator) is mandatory to avoid re-injury of the transverse) will
indicate the specific type of
arterial reconstruction. The same applies to bra- immobilisation.
chial plexus injury, where rigid fixation favours A plaster U-slab
with collar and cuff or
rehabilitation. a Sarmiento co-
aptation brace is particularly
148
a b
M Pectoralis Major
M Deltoideus
M
Deltoideus
M Triceps
M Coracobrachialis
Fig. 6 (a) Deforming forces of humeral shaft fractures (above the insertion of the
Deltoid muscle). (b) Deforming
forces of humeral shaft fractures (below the insertion of the Deltoid muscle)
Table 3 Closed treatment of non-complicated, isolated fractures of the humeral

shaft
Fracture type Recommended treatment Remarks
Transverse Sugar tongue plaster with arm immobilised Support
elbow
to thoracic cage Beware of
distraction and consequent non-union
Later, change to Sarmiento splint Hanging cast
to be avoided
Spiral Sarmiento splint Beware of
distracton in case of initial hanging
cast
Proximal
extension to armpit, not in vicinity of
fracture
Long/short Sarmiento splint Beware of
distraction in case of initial hanging
oblique cast
Proximal
extension to armpit, not in vicinity of
fracture
Comminuted Sugar tongue plaster, with arm immobilised Support
elbow
to thoracic cage
Later, change to Sarmiento splint Beware of
distraction
Hanging cast
to be avoided
suitable for long oblique and more comminute self-supporting and,

more importantly, can
fractures Figs. 7 and 8. eliminate the
distraction action of gravity.
The slab is applied from above the shoulder, The arm is hanging
alongside the thoracic cage.
around the elbow, and finally directed towards Hanging casts are
generally disapproved of
the armpit. By so doing, the construct is when dealing with mid-
shaft short oblique or
149
Fig. 7 U-slab for humeral fractures Circumferential

pressure transmits
corrective forces
to the fracture site.
transverse fractures. However, they can Fig. 8 Co-aptation

(Sarmiento) brace for humeral
enhance closed reduction of sub-capital humeral fractures
fractures [25]. They elongate the arm, can cause
backward angulation at the fracture site and can
seriously threaten the skin on the posterior aspect To define a fracture as a
non- or delayed union,
of the upper arm. Most of all, distraction of the generally a waiting time of
1012 weeks is appro-
fracture can reduce the vascularity at the fracture priate [27].
site and prevent or decelerate the healing process. In order to decide
whether one uses a collar
Hence, transverse and short oblique and cuff or a sling, one
should consider whether
fractures should not be treated with distracting the action of gravity is
desirable. In other words is
techniques [26]. a certain degree of
elongation along the long axis
One should strive for a certain degree of over- of the humerus necessary?
riding in oblique fractures and not accept the A sling supports the
elbow and can cause
slightest degree of distraction. Even a moderate angulation and shortening.
degree of angulation and/or shortening is func- A collar and cuff which
is fixed at the distal
tionally well-tolerated because of the wide range forearm, on the contrary,
can cause distraction
of motion of the glenohumeral joint [2729]. and angulation. The pull of
gravity is not opposed
Practically, they need to be treated with as it can with a sling
incorporating the
a U-slab and a sling that supports the elbow. elbow. In comminuted and
certainly in two-part
The involved limb should be positioned on, and long oblique fractures, a
certain degree of
not alongside, the thoracic cage or abdomen to elongation can be desirable
to counteract the
eliminate the action of gravity. shortening action of the
unopposed muscles.
150 J.
Fabry and P.-P. Casteleyn
Therefore support of the elbow is not necessary Important non fracture-

related factors here
and a collar and cuff can be used safely. are smoking and malnutrition
[1, 2].
Since Sarmiento has given ample evidence of
the success of the co-aptation splint, this type of Radial Nerve Injury
treatment is still enjoying widespread popularity Around 18 % of the humeral
fractures are associ-
[3034]. It works via compressive forces, trans- ated with radial nerve injury
(RNI) [3537]. The
mitted by the soft tissues to the fracture parts. majority of these fractures
are located at the
Long oblique and comminuted fractures in distal third with
considerable varus angulation
particular, are very well-suited for this type of and/or medial translation of
the distal fracture
treatment. element [38]. Regarding the
onset of the palsy
Early mobilisation by active (assisted) exer- we can make a distinction
between acute and
cises avoids adjacent articulation stiffness. delayed.
Healing of the fracture with angulation, shorten- At the junction between
the middle and distal
ing or in bayonet position is generally well- thirds of the humerus, the
radial nerve is trapped in
tolerated. Several authors have demonstrated the intermuscular septum and
has no possibility to
that anterior angulation up to 20# and varus angu- move with the distal humerus
at the time of the
lation up to 30# do not cause significant func- initial displacement.
Consequently, the neural
tional impairment. lesion mostly consists of an
elongation
Excessive and progressive varus angulation (neuropraxia) with no
macroscopic loss of conti-
can result in tardy ulnar nerve palsybut definitive nuity. Often intraneural
haematoma formation is
shortening up to 2 cm is generally well tolerated. observed during exploration.
Knowledge of these figures provides useful Less often the nerve is
trapped scissor-like
guidelines for assessment of follow-up X-rays between the fracture
fragments.
and thereby avoids unnecessary re-manipulations An iatrogenic crush can
also happen after
and anxieties. attempts of closed
manipulation: open exploration
Short interval follow up is mandatory for early and fixation of the fracture
is then mandatory [37].
detection of distraction or excessive angulation. Axonotmesis and crush
have a poor prognosis
These features are best promptly corrected to for motor recovery.
avoid prolonged immobilisation times associated Secondary or delayed
palsy is frequently seen in
with adjacent joint stiffening. progressive varus of the
distal fracture fragment.
Open treatment should be initiated when Exploration, release,
straightening and stabilisation
closed treatment attempts have failed after by open means are required.
Rarely the nerve
12 weeks. Surgical treatment mostly consists of becomes trapped in the callus
mass itself.
femoral plate fixation with autologous bone As a consequence careful
radial nerve evalua-
grafting. tion remains important during
the complete treat-
ment of the lesion [38]. The
great majority of
Non-Union and Complications radial nerve injuries consist
of neuropraxial
Literature surveys demonstrate an overall inci- lesions with a spontaneous
recovery rate of
dence of non-union in closed treatment varying 7590 % within a time frame
of 34 months
between 4 % and 6 % [29, 33]. [38, 39]. As a result of
these observations, there
Risk factors for non-union are: transverse and exists no strong indication
for immediate explora-
segmental fractures; short oblique fractures; fraction of the radial nerve when
confronted with
tures with a high degree of displacement (>shaft symptoms of paresis [36]. On
the contrary, if
diameter); high grade of comminution; initial a RNI is observed after
closed manipulation,
treatment with hanging cast and infection of a strong indication for an
immediate exploration
a complicated fracture [27]. exists [37].
151
Closed Treatment of Femoral Shaft

Fractures in Adults
M psoas
Indications for traction have become progres- M gluteus medius
sively exceptional in the last 30 years.

Traction is used to counterforce the deforming
action by the hamstrings and quadriceps,
resulting in shortening and angulation of the
femoral shaft Fig. 9.
Adductor muscles
Not only the fractures of the proximal thir but
also those of the middle and distal thirds are
currently treated with invasive techniques
(intramedullary nailing), because of their supe-
4.Mm gastrocnemii: flexion
rior functional results following the operation
[4043].
Hence conservative methods have been
almost completely abandoned in adult Orthopae-
Fig. 9 Femoral Shaft
Fractures: deforming muscle
dics. Modern textbooks of adults Orthopaedics forces. (a) gluteus medius:
abduction; (b) psoas: flexion;
only mention them for historical reasons, though (c) adductors: adduction;
(d) gastrocnemii: flexion
in Paediatric settings they are still common
practice.
In the absence of advanced medical technol- pelvic ring instability,
which forms a contra-
ogy, or its failure, traction techniques can still be indication for this
treatment because of the appo-
very helpful [44]. sition of the proximal ring
in the groin. In those
The conservative alternatives consist of circumstances one should
opt for a Brauns sleigh
cast-bracing and the use of external fixation or Hamilton-Russell system.
Mechanically it is
[4547]. a system of traction and
counter-traction by body
However the use of external fixation in the weight. Traction is
provided by a construct of
proximal two-third (muscle mass) has become weights, pulleys and a
frame. The counter-
unpopular both for technical and aesthetic rea- traction consists of a
cushioned ring that apposes
sons. Motion restriction of the knee joint is against the groin. Distally
the traction can still be
a serious disadvantage of this type of treatment. adjusted by a simple system
of rope and spatula in
In secondary reconstructive surgery there are a twisting manner Fig. 10.
still applications for external fixation (Ilizarov). In the application
sequence, a Steinman pin is
The Thomas traction is by far the most used drilled through the tibial
tuberosity. To this pin
technique in the Anglo-Saxon world and less a small frame is attached,
reaching to the heel.
frequently in continental Europe Fig. 10. Then, the longer frame with
the ring (in the groin)
In comparison wit its alternatives (Russell- is threaded over the entire
length of the leg.
Hamilton traction and Brauns sleigh traction), A canvas sling is attached
over the greater and
the Thomas method of femoral traction has smaller frame to support
the limb. The length of
many advantages: it permits better fracture con- the canvas is determined by
the specific fracture
trol and fine adjustment Fig. 11. pattern in order to prevent
sagging of the distal
Early mobilisation of knee and hip joint are fracture parts.
possible and associated fractures of the tibia can In the course of the
first week, the reduction
be easily incorporated in the construct by calca- needs to be thoroughly
evaluated by radiographs
neal pin traction. One should exclude ipsilateral and promptly adjusted
before a fibrotic, less
152
Transtuberosity pin
with inner frame
Counterforce against groin
Proximal end of supporting canvas

(preventing posterior sagging)
Weight
Ring in groin
Fig. 10 Schematic principles of Thomas traction
F1
F2
Fig. 11 Femoral sleigh

according to Boehler: less
access points for further
adjustment
malleable, callus has formed. Weight, traction than a simple sleigh,

but rotation control remains
angle, position of the canvas, addition of addi- a flaw.
tional Steinman pins are all methods of Traction methods
only in the adult population
adjustment. entail a bedridden
period varying between 6 and
Alternative methods of traction like sleighs 12 weeks until callus
forms on the radiographs.
according to Braun and Boehler, more frequently The success of this
method was seen in the
used on the Continent but have less potential for observation of Wardlaw
et al. who compared
this fine tuning. traction only with
additional cast-brace methods:
The suspended traction system according delayed union and re-
fracturing was seen only in
to Russell-Hamilton gives more options the traction-only group
[5, 46, 48], Fig. 12.
153
correct initial
management, remains backward
angulation. It is the
result of the combined
action of gravity and
muscle force. It is important
to build a differential
force couple on the femur
by not supporting the
complete length of the
femur, but only the
proximal part of it by
a canvas sheath. This
counteracts the flexion
force by the gastrocnemii
on the distal fracture
element.
The same flexion force
can also be neutralised
by putting a Steinman pin
through the
epicondyles of the femur
and creating an oppos-
ing vertical force.
Hinge at epicondylar level Whenever possible this
technique should be
avoided because of post-
traction knee stiffness
[5, 49]. Length,
angulation and rotation control
need to be attended to
early and frequently. The
variation in loss of
length is reported between 1.0
and 3.0 cm [42, 43].
Avoidance of
angulation of the proximal one-
third remains difficult
with traction. Loss of
rotation is mostly seen
in a completely suspended
traction systems
(Russell-Hamilton). A daily
check up of the following
topics is important:
pressure sores, excessive
pressure of the ring in
the groin, pressure
neuropathy and infection of
Rocker bottom
the pin tracts.
Fig. 12 Femoral cast brace
Complications of Traction
Knee joint stiffness
remains an important draw-
Time to union (the day of full weight-bearing) back of traction.
was 17 weeks for the traction-only group and Middle-aged patients
see their knee function
15.1 weeks for the cast-brace group. functionally restored
only 18 months after the
As expected, the deformity of the proximal cessation of traction!
Daily practice teaches that
femur was poorly controlled in both groups. early mobilisation (even
in traction) is of utmost
Only in exceptional and temporary circum- importance to restore
knee function.
stances are traction methods and cast-bracing Definitive range of
motion remains limited in
used in the adult population nowadays. The tech- this method: 47 % of
traction patients have less
nique of applying traction remains an art and the than 90# of knee flexion.
mastering of it becomes more difficult in Ortho- Early instruction for
isometric quadriceps
paedic training as time passes. Nevertheless exercises in traction
should be given.
knowledge of the basic principles remains The use of a
transcondylar traction pin is to be
important. avoided when possible
because it leads to Peri-
Obtaining good alignment within the first 24 h articular fibrosis and
stiffening.
is an absolute priority, thereafter the fracture As mentioned before,
proximal one-third
haematoma begins to re-organise and displays fractures of the femur
are difficult to control by
more rigid mechanical properties. The most traction Table 4. The
deforming forces of the
frequently-encountered hazard of traction, after glutei (abduction) and
the psoas (flexion) cannot
154
Table 4 Femoral fracture patterns less suited for traction capacity will be
strongly reduced after the age
Transverse Establishing Risk for non or of 10. Hence this
method cannot be relied upon
midshaft sufficient contact in delayed union in adults. Only when
dealing with absolute contra-
fractures both ap and lateral indications for
surgery, undisplaced fractures or in
planes; applying
excessive the absence of
implants and proper theatre facili-
distractive forces ties, should closed
treatment be contemplated.
Fractures No effective means Serious Wherever possible,
there must be no hesitation
of proximal of counteracting distortion of the to treat these
fractures with open reduction and
1/3 deforming forces by weightbearing
internal fixation.
traction techniques axis
In spite of
abundant clinical evidence, there
exist reports which
claim that angular and rota-
tional deformities can
be accepted in adults up to
be neutralised adequately by a single longitudinal 10# without causing
functional impairment [51].
force vector (traction) Fig. 9. Certain pre-
operative considerations remain
When confronted with transverse or short of importance: is
there a direct or indirect fracture
oblique mid-shaft fracture, one should carefully mechanism; is it an
isolated radial or ulnar frac-
look for varus angulation caused by non-opposed ture; are there
luxations at the distal or proximal
action of the adductor muscles Table 4. Abduc- adjacent joints
(radio-capitatellar joint and distal
tion of the traction can be tried for control. Fixed radio-ulnar joint).
varus deformities can cause serious distortions of When confronted
with apparent isolated frac-
the mechanical weight-bearing axis of the lower tures, a full length
x-ray of the arm is necessary
limb with shortening and unequal loading of the with good quality
anteroposterior and lateral
knee and hind-foot joints. Early arthritis can views of the
neighbouring joints.
develop in these joints. The suspicion of a
conjoint lesion should
already be raised by
thorough history-taking and
examination.
Closed Treatment of Radial and/or Clinical
assessment of wrist (flexion/exten-
Ulnar Fractures in Adults sion; pro- and
supination) and elbow range of
motion are
indispensable. Moreover, one should
In this chapter Colles, Smith and radial head never accept
incomplete x-rays.
fractures will not be discussed. D. Ring et al.
studied 36 patients over a period
Bi-diaphysial fractures in adults are customar- of 6 months with an
apparently isolated fracture
ily treated by operative means. Closed treatment of the radius and
intact ulna [52]. Of these, 14
by plaster results in unsatisfactory results in more displayed associated
lesions elsewhere in the
than 70 % [50]. Foremost are rotational deformi- forearm: 9 had a DRUJ
dislocation; 4 had an
ties, which seriously interfere with forearm rota- ulnar styloid
fracture; one had displacement of
tion and wrist function. the proximal
radioulnar joint. In total 39 %
Children, on the contrary, possess around the displayed an
associated lesion!
diaphysis a strong periosteal sheath, which is not Early distinction
between a really isolated and
completely torn when injured, and hence pro- a Galiazzi-type
fracture is vital for functional
vides stability to the fracture. At the concave outcome Fig. 13.
side of the fracture, this untorn sheath can be Hughston et al.
report on cases with delayed
used as stabilising factor when applying a three- repair of DRUJ
dislocations with unsatisfactory
point fixation force. results. If these, in
essence ligamentous lesions,
In an adult fracture, the thinned periosteal are discovered late,
direct repair is no longer
sheath together with the rigid elastic features of a viable option [50].
Early and accurate reduction
the bone, will result in complete discontinuity and by operative means is
essential. Furthermore
instability. In addition to this, the remodelling there exists a
correlation between the relative
155
Fig. 14 Monteggias fracture

pattern
complete contact loss are

rotationally displaced
by specific action of the
pronator teres and the
relative position of its
insertion on the radius with
Note: elbow not included on this film! Overt regard to the location of
the fracture. A fracture
dislocation of distal radio-ulnar joint. that is located proximal to
this insertion results in
supination of the proximal
and pronation of the
Fig. 13 Galeazzis fracture pattern
distal fragment.
These displacements are
caused by the com-
location of the radial shaft fracture and the like- bined action of the
supinator, pronator teres and
lihood of a second lesion at DRUJ level. Frac- the pronator quadratus.
tures located less than 7.5 cm from the distal In fractures of the
middle or distal third, hence
radial articular surface showed, in 54 %, located distally from the
pronator teres insertion,
a DRUJ instability whereas radial fractures the proximal fragment
display remains in
located more than 7.5 cm from the distal articular a neutral to pronated
position Fig. 15a, b.
surface displayed in 18 % a DRUJ injury [53]. As a consequence,
proximal fractures are
Isolated ulnar shaft fractures are frequently the treated with the hand in
supination in an above-
result of a direct blow in a defence reaction. elbow plaster.
Moderately displaced isolated ulnar fractures in Distally located
fractures are plastered with
the distal shaft can be easily treated with a below- the forearm in mid-
pronation.
elbow plaster. This was confirmed by our own Reduction of these
fractures is usually done
experience: satisfactory outcome in 89 %. Only with the arm in a vertical
position. The patient is
two patients needed ORIF because of non placed in a recumbent
position with the arm ver-
union [54]. tical attached to Chinese
finger traps in the sec-
Suspicion of a Monteggia lesion should ond and third ray. A
counter-weight is attached to
increase as the location of ulnar pain becomes the elbow. This position has
the advantage that
more proximal Fig. 14. the arm can be approached
from all directions.
Therefore clinical examination of the entire Horizontal reduction
techniques often result in
length of the forearm including wrist and elbow sagging of the fragments and
loss of fracture
must be carried out. Monteggia himself described control. Furthermore, they
require a two-stage
the lesion accurately in 1814, in the pre-X-ray plastering technique with an
inherent risk of loss
era, solely on the basis of clinical examination! of reduction when the elbow
is brought in the 90#
His description corroborated well with findings position.
on early radiographs. Over-riding of the
fragments can be overcome
One should remain vigilant when faced with by initially exaggerating
the deformity to create
apparently isolated forearm fractures! contact. Subsequently the
arm can be placed in its
When diagnosed with delay, secondary recon- vertical position.
struction efforts frequently result in debilitating Thereafter the hand is
positioned in the
outcomes. Double forearm fractures with required rotation as
mentioned above. Now an
156
Fig. 15 (a) Deforming a b

rotatory forces in radial
shaft fractures (above M Biceps
insertion of pronator teres).
(b) Deforming rotatory M
Biceps
forces in radial shaft
fractures (below insertion
of pronator teres)
Mm Pronator Teres
M Pronator Teres
M Pronator Quadratus
M
Pronator Quadratus
assistant can easily apply the above-elbow plas- forearm in order to

prevent dropping of the cast
ter. A single layer of cotton wool is sufficient to with a bowing effect Fig.
16.
protect the skin and will allow good transmission From the very
beginning the support should
of reduction forces on the bones. be placed towards the
elbow to prevent this. It is
Extra padding over potential pressure areas of utmost importance to
apply a good primary
(styloid process of the ulna and medial plaster that can last for
the first 23 weeks!
epicondyle) can prevent early and undesirable A major disadvantage of
plastering techniques
removal of the plaster. is the real risk of loss
reduction after shrinkage
During the setting of the plaster, a squeezing of the soft tissue
swelling and the fracture
manoeuvre is exerted at the muscular level of the haematoma.
forearm. The pressure is applied maximally at the Radiographically,
rotation can best be appre-
fracture site. This creates a separating effect ciated by comparing the
cortical widths and by
between the radius and the ulna within the soft the projection of the
bicipital tuberosity on the
tissue envelope. The form of the plaster should anteroposterior X-rays.
not circular but oval because the bones move to When dealing with an
intact ulna, attention
the area of the least resistance. should be directed towards
the development of
In a circular plaster the bones move towards a concavity at the dorsal
radius with coupled
the centre of the plaster, resulting in a loss of supination. If not
addressed, this can lead to
reduction! a serious limitation in
pronation. Non-anatomic
Now the plaster can be completed to the reduction in plaster (loss
of bowing of the radius)
above-elbow level. It is important to incorporate often results in a
permanent loss of pronation and
the thumb up to the level of the interphalangeal supination with important
functional limitations.
joint to avoid pressure sores at its base and to Hence we advise close
observation of the patient
optimise the alignment of the distal radial frag- with x-rays weekly during
the first month, even in
ment. After complete setting of the plaster, the an undisplaced fracture.
arm is put in a sling that supports the elbow and The patient should be
cautioned that displace-
not a collar and cuff that only supports the distal ment is likely within the
first 3 weeks,
157
a b
Soft tissue
oedema
Sagging and rotation of plaster.
Full length support of forearm is
necessary.
Fig. 16 Loss of reduction after disappearance of soft tissue swelling
necessitating open reduction and internal fixation 9. Strachan RK,

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20.
External Fixation in Fracture
Management
Peter Calder
Contents
Surgical Choice: Wires or Pins? . . . . . . . . . . . . . . . . . . . . 171
Surgical Choice: Which Type of Frame? . . . . . . . . . . . 171

Introduction to External Fixation . . . . . . . . . . . . . . . . 160
Surgical Choice: How Stiff/Stable Should
Biomechanics of External Fixators . . . . . . . . . . . . . . . 160
the Frame Be? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 171
Mono-Lateral Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Clinical Indications for External Fixators . . . . . . . 171
Pin Placement: Operative Tips . . . . . . . . . . . . . . . . . . . . . . 162
Definitive Fracture Management . . . . . . . . . . . . . . . . . 172
Enhancing Stability in Mono-Lateral Frames . . . 162
Operative Tips: Fracture Reduction . . . . . . . . . . . . . . . . . 172
Mono-Lateral Fixator: Operative Tips to Enhance
Peri-Articular Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 162
Open Fracture Management . . . . . . . . . . . . . . . . . . . . . . 172

Circular Fixators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 164
Wire Placement: Operative Tips . . . . . . . . . . . . . . . . . . . . 164
Damage-Control Orthopaedics . . . . . . . . . . . . . . . . . . . . 173
Enhancing the Stability of Circular Frames . . . . .
166 Operative Tips: Bridging Fixator . . . . . . . . . . . . . . . . .
173
Ring Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 166 Open Fracture
Management . . . . . . . . . . . . . . . . . . . . . . . . .
173
Ring
Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 166 Femur and
Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
173
Ring Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 166 Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 174
Wire
Construct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 166 Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 175
Wire Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 167 Upper
Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 175
Wire Tension and Fixation . . . . . . . . . . . . . . . . . . . . . . . . . .
167 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 175
Wire
Configuration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
169 Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 177
Half-Pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 177
Half-Pin Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 169
Half-Pin Insertion: Operative Tips . . . . . . . . . . . . . . . . . .
170
P. Calder
The Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
e-mail: Peter.calder@rnoh.nhs.uk

159
DOI 10.1007/978-3-642-34746-7_18, # EFORT 2014
160
P. Calder
regeneration and active

growth of certain tissue
Keywords structures including bone,
blood vessels and nerve
Fractures # External fixation # Biomechanics # [13].
Mono-lateral frames # Circular fixators # The most recent
innovation is the Spatial
Wire placement, tension and fixation # Fixation Frame, a hexapod structure
invented by Charles
pins # Open fractures # Damage control ortho- Taylor based on the Stewart
Gough platform. Uti-
paedics # Surgical indications # Surgical lizing a web-based
programme deformity correc-
techniques tion can be calculated and
correction undertaken
by adjusting the length of
the struts. Correction can
take place in 6# of freedom
and can be repeated
Introduction to External Fixation without the need of frame
re-adjustment. The abil-
ity to place a virtual
hinge also enables frames to
Historically, the principles involved in be less bulky and thus less
heavy, and potentially
stabilising bone using a device placed externally more tolerable to the
patient who may need to
on a limb have changed very little since remain in the frame for
several months.
Malgaigne in 1843 used the Grippe, (Fig. 1) The external fixator is
therefore an extremely
a simple clamp, for patellar fractures. The spikes versatile tool for the
Orthopaedic surgeon for
passed through the skin proximally and distally several clinical
indications. This chapter will
with an external threaded rod between the two highlight the biomechanical
principles needed
parts to allow compression of the fracture frag- to produce a stable
construct and the clinical indi-
ments. Parkhill (1897). Lambotte (1902) intro- cations with operative tips
for the use in fracture
duced fixators for treating diaphyseal fractures management. Limb
reconstruction techniques
which are little different from modern day mono- involving distraction
osteogenesis, deformity
lateral frames. correction, lengthening and
the management of
In the early 1950s Gavril Ilizarov developed his non-union will not be
addressed.
circular transfixion-wire external fixator-system
(Fig. 2) which he applied clinically in the treatment
of fractures, deformity correction and limb- Biomechanics of External
Fixators
lengthening. After initial animal models he
published the concept of the tension-stress effect, Biomechanics by definition
is the mechanics of
where the gradual traction on living tissues creates movements in living
creatures. External
stresses that can stimulate and maintain the fixators, as their name
suggests, lie outside of
Fig. 1 Malgaignes Patella

clamp
External Fixation in Fracture Management
161
Fig. 2 An Ilizarov fixator
the tissues fixing the bone within the limb. The

main question to be answered is how to achieve Mono-Lateral Frames
clinical stability of the bone fragments by a frame
construct which prevents unwanted excessive The basic construct consists
of half-pins fixed to
movement in fracture management or allows the bone connected to bars by
clamps between the
accurate movement in deformity correction and/ pins. The bone is supported
by cantilever loading.
or lengthening. A cantilever is a beam
supported only at one end.
The two main types of fixator are Mono- This beam carries the load to
the area of support
lateral and Circular frames. A combination of where it is resisted by
moment and shear stress.
the two is known as a Hybrid configuration but An example is a diving board
where the moment
this term can also be used to describe force generated by the diver
at the end of the
a combination of fine-wire and half-pin fixation board is resisted at the
point of fixation to the
in a circular construct. tower (Fig. 3).
162
P. Calder
c L3
W U #
4#P
3pE d
U Deflection of a pin
mounted between two
clamps under the load P
L Free length of the pin
between the clamps,
bone clamp distance
d The diameter of the pin
E The modulus of
elasticity of the pin
c The bearing factor with
a theoretical value
WL
from 1 to 4 where 1 is
absolute rigidity of the
bar held with the clamp
and 4 where the rod is
Fig. 3 Mono-lateral frames Cantilever loading not held. In this case
every rod will have
a value from 1 to 4 and
is generally taken as
Pin Placement: Operative Tips a constant 2.5.
The half-pins are placed into pre-drilled holes

in the bone. 6070 % of the load is resisted at Mono-Lateral Fixator:
Operative Tips
the near cortex. to Enhance Stability
It is important to avoid heat generation during
drilling which can result in osteonecrosis, pin The bending rigidity of
the half-pin is propor-
loosening leading to loss of fixation and poten- tional to the fourth
power of its diameter.
tially increased risk of infection. Pulsed drilling Increasing the pin size
diameter increases
with saline flush can reduce heat formation. its stiffness. The
resistance to bending is
It is important to be aware of the pin thread twice increased by an
increase from 4 to
shape. Tapered threads require accurate place- 5 mm diameter and twice
again from 5 to
ment. Use image intensifier images to check 6 mm.
tapered pin insertion depth. If the pin is N.B. The pin diameter
should, however, not
inserted too far it is not possible to retract it exceed 20 % of the
diameter of the bone to avoid
as this will result in loosening. producing a stress riser
that may lead to fracture.
Increasing the number of
pins increases
stability.
Enhancing Stability in Mono-Lateral Increased rigidity
results with a larger
Frames working distance between
the pins. The pins
are placed with as large
a pin separation as
It is accepted that certain factors are beyond the possible. This is the
NEAR-FAR concept
surgeons control in determining the stability of (Fig. 4).
the fixator. These include the strength of the Placement of the pins
should be as near as
bone, for example in osteoporosis, and the mod- possible to the fracture,
as seen in Fig. 4b to
ulus of elasticity of the fixator components. Sur- produce the optimum
working length of the
gical choice includes half-pin size diameter, the fixator (This may be
dependent on soft tissue
distance between the pins along the bone, the and anatomical
constraints such as open
distance of the connecting bar from the bone, wounds or instruction
from Plastic Surgeons
the number and orientation of the pins and finally in order to allow a clear
operative field).
the number and orientation of the connecting The placement of the
connecting bar results
bars. The stiffness of the frame can be determined in a bending stiffness
proportional to the
by the following formula [4]: third power of the bone
rod distance.
163
Fig. 4 (a) Small a

separation between the pins
produces less stability of
the frame. (b) Near-Far
Concept. A stable frame
with wide pin separation
and pins placed as close as
possible to the fracture
Fig. 5 The closer the bar

to the bone the more stiff
the construct
Therefore the shorter the distance from the bar There is less resistance
to torsional and per-
to the bone the more stiff the construct (Fig. 5). pendicular forces. By
placing pins in different
Adding further bars increases resistance planes further stability
can be achieved.
to bending forces in the plane of the bar Further stability can be
achieved by orientat-
(Fig. 6). ing the connecting bars in
different planes and
Mono-lateral fixators have the largest resis- forming stable patterns.
Triangulation pro-
tance to forces in the plane of the fixator. duces excellent stability.
164
P. Calder
Fig. 6 Increasing the

number of bars increases
stiffness
Prior to passing the tip

of the wire down to the
Circular Fixators bone make a small stab
incision with a size 15
blade through the skin.
This prevents devia-
The basic components of circular frames consist tion of the wire by the
skin during insertion.
of complete rings, partial rings arches and spe- Blunt dissection using an
artery forceps can be
cific foot plates which are connected by threaded used to separate the soft
tissues especially if
rods, plates or, in the case of the Taylor Spatial using an olive type
wire.
Frame, struts which have universal hinges at each If movement of the wire
through soft tissues is
end. There are a multitude of other components expected, for example
during lengthening or
including posts, hinges, washers and bolts which deformity correction then
the skin can be pulled
enable individual constructs to be built for the taught in the opposite
direction before the wire
patients specific needs. is passed through the
skin. As the bone moves
The frame is attached to the bone by either so the tension in the skin
will be released and
half-pins, as used in the mono-lateral constructs, may prevent tearing of the
skin by the wire or
or tensioned fine wires. The wires pass through- need for a formal skin
release due to tethering
out the bone and soft tissues, exiting the skin on by the wire which can be
painful to the patient.
the opposite side. It is therefore fixed to the ring During wire insertion
avoidance of heat is
on either side of the bone. paramount. The end of the
wire should be
The wire supports the bone by beam loading bayonet in shape (rather
than a trochar tip
which provides a variable multi-modal (elastic) as seen in Kirschner
wires). The wire is cooled
support (Fig. 7). The stresses are absorbed by the with spirit-soaked gauze
used to hold the wire
cortical plates and distributed more evenly across during insertion. The
drilling is pulsatile in
the surface of the bone (compared to mono- nature, with long pauses
between the drilling
lateral frames and cantilever loading where to allow the wire to cool
down [6]. More fluid
most of the force is resisted at the near cortex). can be flushed over the
wire to aid this process.
The drill should be set at
a low revolution,
high torque.
Wire Placement: Operative Tips When passing the wire
through muscle com-
partments the muscles
should be kept at max-
When traversing the bone a knowledge of the safe imum stretch (Fig. 8).
This results in the wire
anatomical corridors is required in order to avoid fixing the muscle at its
maximum excursion,
hitting important structures such as nerves or otherwise tethering of the
muscle will restrict
blood vessels [5]. joint range of motion.
165
Fig. 7 The tensioned wire

supports the bone by beam
loading
Arrows represent tension in the wire
Fig. 8 Ensure maximum

stretch of muscle when
inserting wire
166
P. Calder
Once the wire passes through the opposite Ring Numbers

cortex further propulsion is achieved using
a hammer. This avoids snaring of structures Traditionally Ilizarov
advocated two rings per
such as nerves and blood vessels which segment of bone [1]. When
fractures are near
may be damaged by a spinning wire. With joints then consideration
may be given to place
gentle taps the wire will push these structures a ring across the joint to
offer more stability of the
aside as it passes through the relevant com- construct if only a single
ring can be placed. This
partment. This is especially important when often is the case when
dealing with a pilon-type
passing wires through the posterior fracture where a single ring
is placed in the distal
compartment of the thigh to avoid spinning tibail metaphysis and the
ankle is bridged with
the sciatic nerve. a foot frame. This may be
removed at a later stage
After wire insertion spiri-soaked gauze is when it is felt that a
single ring will offer enough
used to place pressure on the skin and stability to allow ankle
motion.
underlying tissues. This is to prevent
haematoma formation and reduce the risk of
infection. Ring Size
Pin-site dressings are generally performed once
per week if dry with a pressure dressing applied Gasser at al. [8]
demonstrated a 250 % increase in
constantly [6]. If there is oozing then they axial stiffness when
decreasing the ring size diam-
should be cleaned daily with re-application eter from 16 to 6.25 cm.
This is similar in principle
of pressure dressing. If pain and erythema to enhancing stability in
mono-lateral frames
develops oral antibiotics should be started where the working length of
the pins is reduced
immediately. If discharge continues a microbi- by placing the connecting
bars as close to the bone
ology swab is taken to check sensitivities. as possible. The diameter or
the ring should there-
In cases of continual purulent discharge fore be as small as possible
but the soft tissues of
unresponsive to oral antibiotics with radiolog- the patient have to be
considered. As a rule of
ical evidence of loosening then consideration thumb, leave approximately 2
cm between the
of pin removal may be required. In such cases skin and inner edge of the
ring. This should
the pin-site should be drilled and care taken allow for soft tissue
swelling. With femoral frames
not to leave potential sequestra which may the anterior edge of the
frame can be much closer
lead to further discharge. the skin as the swelling
tends to occur posteriorly;
therefore leave a greater
distance posteriorly and
laterally with femoral
frames. With tibial frames
a greater distance should
again be left posteriorly
Enhancing the Stability of Circular compared to over the
subcutaneous border of the
Frames tibia where minimal swelling
will occur.
Ring Material
Wire Construct
Initially the rings were made of stainless steel but
are now more-commonly a carbon fibre compos- The wires have two basic
forms, a smooth wire
ite. This has the benefits of being lighter for the and an olive type wire
(Fig. 9). The use of
patient and also more radiolucent enabling clearer opposing olives enhances
bending, torsional and
imaging of the bone. The carbon fibre rings are axial stiffness (Fig. 9b) by
minimizing translation
slightly thicker to offer the same mechanical of the bone along the wire
[9]. The olive also
stiffness; Kummer demonstrated 6590 % stiff- enables bone fragments to be
pushed or
ness when comparing 150 mm. carbon composite pulled into position which
can aid in fracture
rings with stainless steel [7]. reduction and compression
(Fig. 10).
167
Smooth Wires Olive

Wires
a b
Fig. 9 Wire construct
a Fracture with proposed b Olive wires

compressing
olive placement fracture
Fig. 10 The use of olives

to compress a fracture
Wire Size Wire Tension and Fixation
There are two sizes of wire; 1.8 mm diameter, Tension is required in the
wire to increase stabil-
which are generally used in lower limb and ity. Ilizarov [1] in his
animal experiments con-
humeral fixation, and 1.5 mm diameter wires firmed that the optimum
frame construct was two
used in Paediatric bone and forearm fixation. rings per segment with two
crossing tensioned
Podolsky and Chao [10] showed in a laboratory wires per ring in a
lengthening model.
testing that there was a 1020 % increase in all The wire is secured to
the ring using
stiffness parameters when comparing the 1.8 mm a wire fixation bolts
(Fig. 11) or a slotted threaded
to the 1.5 mm wires. Therefore the thickest wire rod and nut. During
tightening the wire
should be used where clinically possible. should never be pulled to
the ring, the ring
168
P. Calder
Hole Fixation Bolt Slotted

Fixation Bolt
a b
Fig. 11 Wire fixation bolts
should be built out to the ring using washers,

hinges or posts (Fig. 12). If the wire is
pulled down the ring, secured and tensioned,
this will cause potential deflection in the bone
which may displace after, for example, an
osteotomy where the wire will return to the
original plane. The wire is then tensioned
using a tensioner placed against the ring. In
cases where the wire is far from the ring
a socket can be placed against the fixation bolt
so that the tensioner pulls against this rather than
the ring. The tensioners are marked up to 130 kg.
Kummer [7] stated that the wires should be
tensioned to certain limits due to the yield point
of the stainless steel and potential slippage from
the fixation bolts. Tension limits recommended
were 90 kg for the 1.5 mm wires and 130 kg for
the 1.8 mm wires. Lower amounts should be
performed if the wires are away from the ring
as this can cause distortion in the ring or
Fig. 12 The ring is built
out to the wire to avoid distortion
fixation post. when the wire is tensioned
Aronson and Harp [11] showed that wire slip-
page between the fixation bolt was the primary when possible over the
holey type bolt as
reason for loss of tension in the wire. They stated these maintained the base
line tension better
that a torque of 20 Nm on the fixation bolt nut (Fig. 11). This was thought
to be due to an
avoided slippage. They also recommended the increase in surface area
between the bolt, wire
slotted type of fixation bolt should be used and ring.
169
Fig. 13 Wire
orientation A decrease in
AP stiffness by decreasing
the crossing angle (#). No
decrease in lateral bending
stiffness (#)
centered centered
off-centered
90/90 45/135
90/90
Wire Configuration during knee flexion. To

accept a narrower cross-
ing angle stability may be
maintained by placing
When placing the wires a crossing angle of 90# an anterior or anteromedial
half-pin which offers
between them is the optimum position. This how- similar stability properties
(Fig. 14).
ever is not always achievable due to the limitation When using the Taylor
Spatial Frame wire
of the safe anatomical corridors [5]. The greater placement needs consideration
due to the fixed
the angle the greater the resistance to bending and placement of the struts
attached to the tabs. The
shear forces [9]. Fleming et al. [12] performed crossing angles seen in an
anatomical model are
a biomechanical analysis of wire position and reduced when using this
system [14]. Operative
confirmed a decrease in frame stiffness in the tips include using a dummy
ring below the ring
AP plane when changing from a 90# crossing fixed to the bone. The dummy
ring has the struts
angle to 45# /135# (Fig. 13). There was however fixed to it. Half-pins can be
used especially in the
no decrease in lateral bending stiffness. They also diaphysis.
mimicked off-centre placement of the bone (seen
when fixing a tibia with the leg in the centre of
Half-Pins
a ring) and found that whereas axial compressive
stiffness increased, torsional stiffness was
Ilizarov traditionalists
often shunned the use of
reduced. There is therefore a compromise needed
half-pins which they felt
were biomechanically
on deciding the optimal size of ring to fit the
inferior to tensioned wires.
Green et al. [15] how-
lower leg accepting that the bone will not be
ever demonstrated good
clinical results using
central.
pins rather than wires to fix
the Ilizarov frame to
Axial compression and torsional stiffness
the bone. Their indication
was to improve
are also directly proportional to the number
implant tolerance and muscle
function by reduc-
of wires used [9]. Further resistance can be
ing muscle tethering and
impalement by
achieved using a drop-wire from the ring. The
wires crossing muscle
compartments. They
wire is deliberately placed away from the ring
recommended similar
principles for fixation sta-
(Fig. 12) and fixed to the ring using a post or
bility with two pins with
divergence and near-far
plate. For optimum stiffness the distance of
placement.
4 cm away from the ring is recommended.
Geller et al. [13] confirmed that increased
obliquity of the tensioned wires in the proximal Half-Pin Material
tibia reduced the AP displacement during
AP bending. Patients however often find the The main reticence to using
half-pins was due to
placement of the wire through the posteromedial the increased incidence of
loosening and hence
and posterolateral skin uncomfortable especially loss of fixator stability.
The introduction of
170
P. Calder
a Anteromedial pin placement b Anterior

pin placement
Fig. 14 Placement of an anteromedial or anterior half-pin produces an increase in

AP bending stiffness
hydroxyapatite coating has made the half- pin group. In the control
group 22 pins (13 %) loosened
more appealing. Moroni et al. demonstrated and there was infection
in 20 pins. They concluded
greater interface strength in a sheep model that HA-coated pins
reduce the rate of both loos-
[16]. In a randomised clinical study insertion ening and infection.
and extraction torque forces between standard
and HA coated pins were compared in patients
undergoing hemi-callotasis for osteoarthritis of Half-Pin Insertion:
Operative Tips
the medial side of the knee [17]. They found that
all the standard metaphyseal pins were loose on A longitudinal
incision is made slightly larger
removal compared to only one out of 20 HA- than the soft-tissue
guide.
coated. In the diaphysis none of the pins were The soft-tissues are
parted using forceps and
clinically loose but the torque required to blunt dissection down
to bone.
remove the pins was half the insertion torque The trocar and guide
are placed down to bone.
force in all but one of the standard pins whereas The drill is cooled
with saline placed in the
all the diaphyseal HA-coated pins were guide. A sharp drill
should be used, again to
well-fixed, prevent a build-up of
heat when drilling.
Pommer et al. [18] in a randomised trial of 46 After the drilling is
complete the swarf is
patients undergoing tibial segmental transport or washed away by
flushing with saline. This is
lengthening recorded no clinical or radiological to prevent potential
sequestra in the soft tis-
signs of pin loosening or infection in the HA sues and risk of
infection.
171
The pin is inserted and a dressing placed, bending and shear rigidity
was similar to bending
compressed against the skin with a clip to and torsional forces in
comparison to mono-
prevent haematoma formation. lateral frames [12]. Axial
motion was increased
in the Ilizarov frame, which
was reduced with
Surgical Choice: Wires or Pins? increasing wire tension.
Micro-motion has how-
ever been shown to be
beneficial in fracture
The fact that half-pins reduce the need to pass healing [19, 20].
through muscle components, and that this offers The Taylor Spatial Frame
has been shown to be
a clinical advantage for muscle and thus joint equal in mechanical testing
to axial compression
function, suggests that it would be understand- as a four-rod Ilizarov but
is twice as stiff in bend-
able to use only half-pin fixation in circular ing and 2.3 times more stiff
in torsion.
frames. There is however concern over potential
loosening especially in metaphyseal bone. Even
with HA-coating there was evidence of Surgical Choice: How
Stiff/Stable
a metaphyseal pin loosening [17]. Board et al. Should the Frame Be?
[19] in an experimental model measured the
distribution of pressure in cancellous bone sur- From above the surgeon has
many options in
rounding a tensioned wire under loading condi- increasing the stiffness of
the frame. This will
tions and compared this to a half-pin. In the wire result in reduced movement
of the bone frag-
group the pressure distribution was seen at three ments being stabilised. The
amount of stability
points, the first at the wire entry point, the sec- required is again debatable
and individual to each
ond with beam loading (1.5 mm from the wire) patient. If a frame is too
stiff with little movement
and the final uniform distribution of pressure at the fracture site then
callus formation may be
(approximately 4 mm from the wire). The pres- impaired, and vice versa if
there is too much
sure was mostly measured below 2 MPa (yield movement a fibrous
hypertrophic non-union
strength of cancellous bone is #7 MPa). The may occur.
half pin pressures measured 20 MPa and were Frame constructs also
will be determined by
much deeper in the bone. With cantilever load- their clinical indication. A
more robust frame will
ing it is hypothesised that the bone will deform, be required for definitive
fracture treatment for
as most of the force is resisted at the near cortex, potential weight-bearing, in
comparison to
and will result in pin loosening. a temporary bridging fixator
of a joint
Therefore ideally fine wire fixation is used in whose function is to prevent
major movement of
metaphyseal bone and HA-coated pins in the the joint and fracture
fragments, whilst
diaphysis. Exceptions are in children with a further planning of
definitive peri-articular fixa-
smaller diameter diaphysis where fine wires tion or general health of
the patient is optimised
are used. before further surgery, in
damage-control
Orthopaedics.
Surgical Choice: Which Type of Frame?
The choice of implant directly depends on the Clinical Indications for

External
surgical indication and clinical need for the exter- Fixators
nal fixator. It is clear that different frame con-
structs and types will offer different stability to External fixators can be
applied as temporary or
the underlying bone. definitive constructs.
Clinical indications include
Fleming et al. demonstrated that, in compari- definitive fracture
management, peri-articular
son to a standard four-ring Ilizarov construct with fractures, open fractures
and damage-control
two 1.8 mm wires per ring, the overall stiffness in Orthopaedics.
172
P. Calder
(i.e. deflection of the

wire from the natural
Definitive Fracture Management resting point), will pull
the bone to the level
of the new wire fixation
point. The wire is
General fracture management is determined tensioned at both ends
using two tensioners.
by patient age, the configuration and site of Once the fragment is in
the ideal position one
the fracture, whether it is open or closed, of the wire fixation
bolts is tightened and the
and ultimately by the surgeons preference. The opposite tensioner
released and the wire re-
use of external fixation has been shown to tensioned. If the
reduction is lost during this
be successful in the treatment of fractures [1922]. manoeuvre then the
process is repeated but
Gordon et al. compared mono-lateral to circu- once the fragment is
reduced a further ten-
lar fixation in unstable diaphyseal tibial fractures sioned wire is passed to
hold the position.
in children [21]. Their conclusions were that The initial wire is then
removed.
external fixators were a safe and effective method
of treatment and recommended circular fixators
in the child 12 year or over and/or with commi- Peri-Articular Fractures
nuted fracture patterns.
Kenwright et al. demonstrated fracture healing These fractures are
frequently high-energy inju-
using mono-lateral frames which allowed ries with comminution and
significant soft-tissue
axial movement, highlighting favourable condi- damage. Early definitive
fixation is often not pos-
tions for callus formation and fracture healing sible due to the poor
overlying soft tissues. Fur-
[19, 20]. ther imaging may also be
required due to the
In patients with a tibial fracture advantages multiple fracture fragments
to aid operative plan-
have been shown in using an Ilizarov frame ning. In order to await the
optimum surgical time
rather than an intramedullary nail [22]. Patients the limb-length should be
maintained. This is
with a closed tibial fractures (suitable for achieved by a bridging
external fixator, the
nailing) were randomised for treatment with SPAN, SCAN and PLAN
approach.
either an Ilizarov circular fixator or reamed
intramedullary nail. The mean frame time was
16 weeks. At 2 year follow-up 30 patients treated Open Fracture Management
by Ilizarov frame were found to have better phys-
ical function in comparison to 36 patients treated The latest Standards for
the management of
by intramedullary nail. Complication rates Open Fractures of the Lower
Limb [23] recom-
including non-union rate was comparable mends these complex injuries
should be treated
between the groups. The functional difference by a multi-disciplinary
team, including Ortho-
was explained by persistent knee pain in the paedic and Plastic surgeons,
in a specialist centre.
nail group. These centres are to be
organised in a regional
basis with arrangements for
immediate transfer
from local hospitals who do
not have the requisite
Operative Tips: Fracture Reduction expertise to treat these
fractures.
Prior to patient
discharge from the acute unit,
Olive wires can be used to manipulate fracture the limb is handled to
remove gross contamina-
fragments by pulling or pushing fracture frag- tion, photographed, sealed
from the environment
ments against the ring. with cling film, splinted by
the most appropriate
Opposing olives can be used to compress frag- means of immobilisation
(splint or plaster) and
ments after reduction (Fig. 10). transferred ideally from the
accident and emer-
Wires can be used to elevate fragments by gency department. Irrigation
and primary provi-
using the principle that a tensioned wire, sional external fixators are
not applied in these
when fixed in higher holes on the ring cases.
173
The transfer of the patient however is still deter- Stage 1 Temporary

stabilisation of unstable
mined by their general health. If the patient is not fractures and control
of haemorrhage.
fit for transfer then the local unit will be required Stage 2 resuscitation
of the patient in the inten-
to perform the primary surgical management sive-care unit.
(antibiotic and anti-tetanus administration, wound Stage 3 delayed
definitive management of the
debridement and initial fracture stabilisation). fracture when the
patient physiologically is
Stable fracture fixation remains paramount for able to undergo the
surgery [27, 28].
the recovery of the soft tissues. Provisional Rapid stabilisation of
fractures is achieved by
stabilisation is recommended incorporating applying bridging
fixators. The time delay
a spanning fixator when immediate wound between the initial
procedure and definitive fixa-
cover is not carried out at the time of immediate tion is slightly longer
than in the management of
debridement. Conversion from a temporary open fractures. Pape et
al. showed lower rates of
external fixator to definitive internal fixation is multi-organ failure in
those patients treated 58
recommended to be within 72 h of primary days after injury
compared to a comparable group
debridement in order to reduce the risk of deep treated at 24 days [29].
The debate whether
infection following pin site contamination. In further delay compromises
internal fixation due
those cases when this window is breached con- to possible increase risk
of infection from previ-
sideration of using a definitive fixator, circular ous pin placement will
always remain.
fixator, may be made. The decision on
whether a patient undergoes
ETC or DCO is based on
the physiological status
which may change rapidly
(Table 1). Therefore
Damage-Control Orthopaedics constant re-evaluation is
required as the manage-
ment strategy may change
at any time, even per-
This is a philosophy of treatment in the multiply- operatively.
injured patient presenting in an unstable or
extremis physiological state. With advances in
surgical treatment in this patient group, the initial Operative Tips: Bridging
Fixator
beneficial results of early stabilisation of fractures
(Early Total Care) presented a variety of unex- Open Fracture Management
pected complications [24]. These were thought to
be as a result of the operative procedure, predom- Avoid pin placement in
close proximity to
inantly intramedullary nailing [25]. Adverse out- wounds. This may in
principle mean an inabil-
comes involved pulmonary complications with an ity to have a near-
near, far-far placement.
increased incidence of adult respiratory distress Liason with the Plastic
surgeons is essential prior
syndrome and associated multi-organ failure. to pin placement and
constructing the frame to
The concept of damage-control surgery was avoid difficulties with
wound access and/or
proposed by Rotondo et al. in the treatment of compromised potential
flap reconstruction.
uncontrollable abdominal haemorrhage [26]. Always assume soft-
tissue swelling will occur
This consisted of three stages: and so do not place
connecting bars too close
Stage 1 immediate surgery for the control of to the skin.
haemorrhage and contamination.
Stage 2 involved resuscitation of the patient in the
intensive-care unit correcting hypovolaemia, Femur and Tibia
hypothermia and coagulation disorders.
Stage 3 definitive surgery following physiolog- When bridging mid-
diaphyseal fractures of
ical optimisation of the patient. the tibial pins are
placed into the anteromedial
Damage-control orthopaedics follows subcutaneous border in
a longitudinal
a similar strategy: alignment.
174
P. Calder
Table 1 Management strategy for decision making on ETC or DCO

Parameter Stable Borderline Unstable
In extremis
Shock Blood pressure 100 or 80100 6090
<5060
(mmHg) more
Blood units (2 h) 02 28 515
>15
Lactate levels Normal Around 2.5 >2.5
Severe acidosis
range
Base deficit Normal No data No data
>68
mmol/l range
ATLS I IIIII IIIIV
IV
classification
Coagulation Platelet count >110,000 90,000110,000 < 70,00090,000
< 70,000
(mg/ml)
Factor II and 90100 7080 5070
<50
V (%)
Fibrinogen (g/dl) >1 Around 1 <1
DIC
D-Dimer Normal Abnormal Abnormal
DIC
range
Temperature >34 # C 3335 # C 3032 # C
30 # C or less
Soft tissue Lung function; 350400 300350 200300
<200
injuries PaO2/FiO2
Chest trauma AIS I or II AIS 2 or more AIS 2 or more
AIS 3 or more
scores; AIS
Chest trauma 0 III IIIII
IV
score; TTS
Abdominal < or II < or III III
III or >III
trauma (Moore)
Pelvic trauma A type B or C C
C (crush, rollover abd.)
(AO class.) (AO)
Extremities AIS III AIS IIIII AIS IIIIV
Crush, rollover extrem.
Surgical Damage control ETC DCO if DCO
DCO
strategy (DCO) or uncertain
Definitive ETC if stable
surgery (ETC)
For femoral diaphyseal fractures the preferred Single Pin clamps

offer versatility in pin
pin alignment is along the lateral cortex. The placement.
pins may be sited below the mid-lateral line Proximal placement can
be inserted in the
from posterolateral to anteromedial in attempt saggital plane
approximately 1 cm medial to
to be below the ilio-tibial band. Tethering of the crest or directly
into the anteromedial sub-
this can result in limitation in knee flexion if cutaneous border of
the tibia.
the external fixator is used as the definitive A calcaneal pin can be
placed either lateral or
treatment. medially as an
individual pin or a Denham-
type pin can be placed
through the bone.
This allows fixation
with bars crossing both
Ankle sides of the hind-foot
with further increase in
stability.
The basic construct should ideally involve A pin is placed into
the first metatarsal to fix
triangulation to provide stabilisation (Fig. 15). the anterior aspect of
the foot. Rods can attach
175
Fig. 15 Bridging fixator across the ankle
this pin both to the tibial and calcaneal pins to crossing the knee will be
very close to the
form a stable triangle construct. Note that skin. The principle aim
of the fixator is to
a smaller diameter pin (4 mm or less) will be prevent knee movement
into flexion. This
required in the smaller metatarsal. frame is not as stable as
the straight anterior
construct.
Knee
Upper Limb
The knee can be spanned by two main
methods. Pin placement in the upper
limb requires
Pins may be placed into the femur in an care and attention due to
the underlying
anteroposterior direction directly through neurovascular structures
and an open
the quadriceps muscle. These are connected approach is undertaken in
most sites.
to pins placed in the saggital plane in the
tibia. The frame will be removed before
long-term damage or tethering of the quadri- Elbow
ceps occurs.
An alternative is to combine laterally-placed Proximal humeral pins are
placed in the lateral
pins on the femur connected with oblique rods plane. The humerus can be
palpated through
across the knee with anteromedial placed pins the skin. A small
longitudinal incision is made
on the tibia. Care must be taken when placing with blunt dissection down
to the bone to
the pins otherwise the connecting bars allow placement of the
soft-tissue guide.
176
P. Calder
The anatomical
course of the radial nerve
Radial
around the humerus
from posterior to anterior
nerve distally merits open
placement (Fig. 16). The
incision is extended
to allow clear placement
of the drill on the
bone to avoid risk of damage
Deep branch
of radial nerve to the nerve. The
area is proximal to the flare
(posterior of the lateral
epicondyle.
interosseous
nerve) Ulnar pin placement
is similar to the tibia as
Superficial
branch of
the bone is
subcutaneous. Care is needed not
Arcade of radial nerve to place the pins
too proximal to compromise
Frohse
wound access or
approach to the elbow region
at the time of
definitive surgery.
Once again the
connecting bars incorporate
Fig. 16 Avoid radial nerve when placing distal humeral triangulation to
achieve stability across the
pins elbow (Fig. 17).
Fig. 17 Elbow bridging fixator
a Pin placement in mid-diaphysis of b Open pin

placement in
radius and index metacarpal index
metacarpal
Fig. 18 Wrist bridging fixator

177
Wrist 6. Davies R, Holt

N, Nayagam S. The care of pin sites
with external
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Fractures with Arterial Injury
Panayotis N. Soucacos and Zinon

T. Kokkalis
Contents
Basic Microvascular Arterial Repair . . . . . . . . . . . . .
200
Microvascular Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . .
200
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 180 End-to-End Microvascular Anastomosis . . . . . . . . . . .
203
Open Fractures with Arterial Lesions . . . . . . . . . . . . 181
End-to-Side Microvascular Anastomosis . . . . . . . . . . .
204
Microvascular Vein Suturing and Grafting . . . . . . . . .

204
Closed Fractures with Arterial Lesions . . . . . . . . . . 182
Wound Coverage and Post-Operative

Pelvic
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
182
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
204
Antibiotic Prophylaxis and Therapy . . . . . . . . . . . . . . . . 205

Open Fractures of the Lower Extremity . . . . . . . . . 182
Post-Operative Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Open Fractures of the Upper Extremity . . . . . . . . . 185
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 206
Open Hand Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
185 Circulatory Compromise . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 206
Venous Congestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 206
Damage to the Vascular System in Orthopaedic
Management of Venous Congestion
Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 190 with
Leeches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
206
Prognosis of Fractures with Arterial Injury . . . . . 191
Arterial
Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
207
Prognostic Scoring Systems . . . . . . . . . . . . . . . . . . . . . . . . . 191
Other Intra-Operative Complications . . . . . . . . . . . . . . .
208
Other Post-Operative Complications . . . . . . . . . . . . . . . .

208
Clinical Signs and Assessment of
Arterial Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
192 Salvage and Re-Vascularization . . . . . . . . . . . . . . . .
. . 208
Repair Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 193
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 209
Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 194
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 195
Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 195
Skeletal Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 195
Vascular Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 196
Microsurgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . .
197
P.N. Soucacos (*)

School of Medicine, University of Athens, Athens, Greece
e-mail: psoukakos@ath.forthnet.gr
Z.T. Kokkalis
School of Medicine, University of Athens, Haidari,
Athens, Greece
e-mail: zinon.kokkalis@hotmail.com

179
DOI 10.1007/978-3-642-34746-7_19, # EFORT 2014
180 P.N.
Soucacos and Z.T. Kokkalis
Abstract
Introduction
The potential for serious vascular injury in frac-
tures is related to the site and mechanism of
Historically, there has been
an exceptionally high
skeletal injury. The vasculature of the extremi-
amputation rate in acute
traumatic arterial injury,
ties is vulnerable to trauma in fractures of the
particularly for certain
sites. For example, failure
skeleton, primarily because of the proximity of
to repair a damaged
popliteal artery will often
the vessels to the bones, their fixed placement
result in loss of the
extremity, and injury of the
around the joints, and their superficial position.
brachial artery even when
associated with
Thus, vascular injury should be anticipated
a forearm fracture-
dislocation will also jeopardize
with fractures and/or dislocations in vulnerable
the upper extremity. On the
other hand, it is rela-
anatomical areas, such as the knee, elbow and
tively uncommon for blunt
non-penetrating
shoulder. Fractures with arterial lesions run
trauma to be associated with
arterial injuries
a high risk for muscle necrosis, partial or com-
with fractures or
dislocations. In general, effective
plete amputation, or loss of extremity function.
management of these combined
injuries requires
In order to maximise outcome, it is paramount
recognition of the arterial
injury without delay and
that the surgeon recognises the implications of
appropriate orthopaedic
management of the frac-
the potential or actual vascular injury. Although
ture or dislocation. Limb
salvage in patients with
open fractures run the greatest risk of being
combined Orthopaedic and
vascular injuries is
combined with an arterial injury, closed frac-
highly dependent on the
severity of injury and
tures may also be associated with a significant
the expeditious diagnosis
and treatment of the
vascular lesion. Survival or not of a limb with
vascular trauma. In multiple
trauma cases, injuries
combined bony and vascular damage is closely
to other body systems may be
so severe that they
related to the severity of the injury and the
take precedence over the
vascular trauma.
timely diagnosis and treatment of the vascular
There are various
situations in which the
trauma. An important factor in the prognosis of
Orthopaedic surgeon may be
faced with serious
fractures with arterial lesions is ischaemia time.
arterial injuries. Vascular
trauma occurs relatively
Rapid and proper patient transport, with
infrequently in association
with general
a subsequent decrease in warm ischaemia time
Orthopaaedic trauma, but may
be seen more
are critical factors in decreasing the rate of
often in injuries involving
joint dislocations and
amputation. Measurements with Doppler or
areas in which vascular
structures are tethered at
duplex ultrasonography are valuable adjuncts
the fracture site. Among the
most common
in the rapid evaluation of patients with trau-
include complete or
incomplete non-viable ampu-
matic arterial injury. When unequivocal evi-
tations and open injuries /
fractures of the upper or
dence of arterial injury is present, and the
lower extremities, pelvic
fractures, knee fractures/
operative approach is established by the mech-
dislocations, as well as
shoulder and upper limb
anisms and site of injury, treatment should not
injuries. In addition,
injuries to major vessels dur-
be delayed by confirmatory arteriography. To
ing trauma or reconstructive
Orthopaedic proce-
avoid detrimental sequelae, it is better for the
dures (iatrogenic injuries)
are known to occur and
surgeon to presume a fracture is complicated by
need to be addressed
immediately by the operat-
vascular or nerve injury until proven otherwise.
ing team. Today, fractures
account for about 35 %
of non-fatal injuries. With
the increased incidence
Keywords of severe trauma related to
automobile accidents,
Assessment # Clinical features-upper limb, work-related trauma, etc.
Orthopaedic surgeons
lower limb, pelvis # Complications # Fractures, have also witnessed an
increase in vascular inju-
arterial injury # Ischaemia # Microsurgery # ries associated with limb
fractures.
Rehabilitation # Scoring systems # Thrombosis Fractures with arterial
injury that require vas-
# Vascular repair techniques # Wound closure cular repair are severe
injuries, as this type of
181
fracture is often associated with severe soft-tissue Type I open fractures have
a puncture wound
compromise. The goal in managing fractures is to with injury to the skin
(1 cm or less) from the
obtain union of the fracture in an anatomical posi- inside out.
tion that is compatible with maximal functional Type II fractures have a
larger skin
return. When surgical management of the fracture trauma (>1 cm) and
moderate soft tissue
is required, the method applied should minimize injury.
any additional soft-tissue damage or bony injury. Type III factures are the
result of a high energy
Successful treatment depends upon a thorough impact, such as those
produced in shotgun
evaluation of the patient, assessment and classifi- injuries, traffic
accidents and farming acci-
cation of the extent and type of fracture, and its dents. They have a skin
defect grater than
associated soft-tissue injuries. Amputation rates 10 cm, a comminuted
fracture with bone loss,
after these injuries varies greatly depending on extensive soft tissue and
possible vascular
the degree of skeletal and soft tissue destruction, injury and are associated
with the worst prog-
ranging from 4 % to 61 % [1]. nosis [3, 4].
With the increased incidence of vascular Type III open factures are
categorized into three
injury an attempt was made to quantitate the subgroups:
specific arteries most commonly involved in the Type IIIA fractures have
adequate soft tissue
extremities [2]. The authors reported a ratio of coverage despite the
extensive soft tissue
upper to lower extremity arterial trauma of injury. As such, local
flaps are adequate for
1286, respectively, with simultaneous injuries coverage.
to two or three extremity arteries in 13.3 % and Type IIIB and
particularly.
9.3 %, respectively. The most common arteries Type IIIC open fractures
of both the upper and
injured were the anterior tibial, femoral, peroneal lower extremities are
extremely severe
and popliteal arteries, with associated fractures in injuries that
frequently result in limb ampu-
86.7 % of the patients. Blood loss varies tation. High energy
impact in Type IIIB
according to the fracture site. Blood loss ranges fractures results in
extensive bony commi-
from 0.5 to 1 l. in fractures of the arm, 0.51.5 l nution or segmental
bone loss, pronounced
for the leg, 1.02.5 l for the thigh, and 1.04.0 l soft tissue injury,
including extensive skin
for pelvic fractures. Blood loss is up to two to loss, tendon and nerve
damage, and
three times greater for open fractures. muscular and
periosteal stripping from the
A high index of suspicion of arterial injury bone [3, 4].
should exist whenever arteries are in close prox- Type IIIC
fractures are characterized by
imity to bone and held in a semi-fixed position. severe circulatory
compromise of the
The arteries most frequently involved are the sub- extremity related to
complete ischemia sec-
clavian artery beneath the clavicle, the ondary to trauma of
the major vessels. The
brachial artery adjacent to the humeral shaft and severity of Type IIIB
and IIIC fractures is
supracondylar portion of the humerus, the femoral emphasized by the high
amputation rate.
artery near the femoral shaft, and particularly the Type IIIB fractures
associated with a rate
popliteal artery as it is stretched across the popli- of amputation of about
16 %, while the
teal space with both superior and inferior fixation. amputation rate of
Type IIIC fractures is
as high as 60100 %.
In type IIIB and
IIIC fractures, wound
coverage may neces-
Open Fractures with Arterial Lesions sitate the use of
vascularized or pedicled
fasciocutaneous flaps
or muscle graft.
Open fractures may be complicated by arterial The aim in treatment
today is not just to
lesions. Gustilo and Anderson [3] provided salvage the limb, but
to produce a func-
a prognostic classification system for open frac- tional, painless
extremity with protective
tures based predominately on wound size: sensation.
182 P.N.
On the other hand, arterial

hemorrhage is one of
Closed Fractures with Arterial Lesions the most serious problems
associated with pelvic
fractures, and remains the
leading cause of death
Although vascular damage occurring in conjunc- attributable to pelvic
fractures. Many suggest that
tion with fracture-dislocations of the lower external fixation is not
likely to be sufficient to
extremity is uncommon, various vascular injuries stop arterial bleeding, and
that urgent angiogra-
can occur from fracture-dislocations, including phy and subsequent
transcatheter embolization is
compression, puncture, laceration and transec- a more effective method for
controlling on-going
tion. Closed fractures can produce and arterial arterial bleeding [9].
lesion due to direct injury from the fracture The mortality following
pelvic fractures has
ends. Comminuted fractures may cause arterial declined somewhat as better
methods of control-
lesions by insertion of a bone spike in the artery at ling haemorrhage, such as
angio-embolisation to
the moment of fracture or later during transpor- control arterial bleeding,
have been introduced.
tation or during uncontrolled movements or None-the-less, about 10 %
of patients still die.
spasms as in drunken states or epileptic seizures. The majority of blood loss
derives from injured
The surgeon should remember that Doppler sig- retroperitoneal veins and
broad cancellous bone
nals and palpable pulses do not necessarily surfaces. Key questions
that exists in managing
exclude vascular injury, and that missed diagno- pelvic fractures are: which
patients are at highest
sis runs the risk of subsequent amputation, even risk for a life-threatening
bleed, in these patients,
in closed fractures. what is the exact
anatomical source of the bleed-
ing, and what is the best
way to stop it. Most
believe that bleeding is
most likely to occur
Pelvic Fractures with unstable fractures,
although is remains dif-
ficult to predict which
fractures will actually
Pelvic and acetabular injuries are fairly rare, and cause excessive bleeding.
Current treatment pro-
they often present with other associated injuries. tocols rely on angiographic
embolisation and
Their management can pose difficulties even to external fixation, either
alone or in combination.
the most experience trauma surgeon [5]. In the
management of multiply-injured patients the
question of the optimal time point for surgical Open Fractures of the Lower
Extremity
treatment of individual injuries is still an open
question, particularly for pelvic fractures. Open wounds have been
classified in several
Because of the extreme force needed to disrupt ways. Gustilo and Anderson
in 1976 described
the pelvic ring, associated injuries are common their treatment of open
fractures using a grading
and mortality is usually from uncontrolled system that provided
prognostic information
haemorrhage from extra-pelvic sources. about the outcome of the
infected fracture [3].
Pelvic fractures are reported in up to 9 % of In 1984, the system was
modified, basing the
patients with blunt trauma [6]. Although well- classification on size of
the wound, periosteal
organized trauma centres exist today, the soft-tissue damage,
periosteal stripping and vas-
mortality rate is still high in patients who have cular injury [4] (Table 1).
The classification by
hypotension attributable to pelvic fractures, with Tscherne and Gotzen is
widely used in Europe
rates ranging from 36 % to 54 % [7, 8]. Patient and divides open fractures
into four grades:
death related to hemorrhage of a pelvic fracture Grade 1 includes open
fractures with skin lacer-
often occurs within the first 24 h of injury. ations caused by bone
fragments from the
In pelvic fracture hemorrhage caused by inside, with little or
no contusion of the skin.
venous injury, the fracture site can be effectively Grade 2 includes any type
of skin laceration with
treated with external fixation by reducing circumscribed skin or
soft-tissue contusion
the pelvic volume and stabilizing the fracture. and moderate
contamination.
183
Table 1 Classification of open fractures The functional

outcome and success of pre-
Type Characteristics serving a limb
following the treatment of these
I Open fx with clean wound < than 1 cm long severe open fractures
is dependent upon sev-
II Open fx with clean wound > than 1 cm long and eral variables. These
include the extent and
with no extensive soft tissue damage, skin flaps severity of vascular
injury, the extent of bony
or avulsions
and soft tissue injury,
the duration and type
IIIA Open fx with extensive soft-tissue lacerations
or flaps, but maintain adequate soft-tissue of ischaemia to the
limb, age of the patient,
coverage of bone, or they result from high- time since the initial
injury and finally any
energy trauma regardless of the size of the concomitant organ
injuries which may be
wound. Includes segmental or severely present [3, 4].
comminuted fractures, even those with 1 cm
lacerations Microsurgical
techniques with the use of vein
IIIB Open fxs with extensive soft-tissue loss with grafts are able to
restore arterial blood flow in the
periosteal stripping and bony exposure. Usually injured limbs and,
thus, contribute in salvaging
severely contaminated the limb. On the other
hand, microsurgical
IIIC Open fx with an arterial injury that requires methods such as free
flaps, vascularized bone
repair regardless of the size of the soft tissue
grafts and nerve
grafting, utilized as secondary
wound
reconstructive
procedures have tremendously
Modified Gustilo and Colleagues classification (1976,
1984) [3, 4] helped in achieving
better results and in improv-
ing the functional
outcome of the severely injured
extremity, as well as
diminishing the need for
Grade 3 fractures have severe soft-tissue damage, secondary amputation.
Thus, microsurgery plays
often with major vessel or nerve injury or both. a decisive role in
augmenting the treatment of
Fractures accompanied by ischaemia, severe open type IIIb and IIIc
fractures by:
bone comminution or compartment syndrome (a) restoring the
circulation of the injured
are included in grade 3. extremity; and
Grade 4 includes incomplete and complete ampu- (b) by improving the
function of the limb using
tations, with any remaining soft tissue not free tissue
transfers such as nerve grafts, free
exceeding one-fourth of circumference of skin flaps and
vascularized bone grafts [12].
extremity. The treatment for
patients with Types IIIB and
Open type IIIb and especially type IIIc frac- IIIC open fractures is
an extremely demanding
tures of the upper and lower extremities are procedure that requires
a highly specialized med-
extremely severe injuries that can often lead to ical team and a
hospital centre with outstanding
amputation of a limb. These types of fractures are emergency and surgical
facilities. Even with
usually caused by high energy impact, resulting todays sophisticated
scoring systems for evalu-
in extensive bony communition or segmental ating the extent of
injury, it still is difficult for the
bone loss, as well as severe soft tissue injury surgeon to determine
which limb to preserve and
including, extensive skin loss, tendon and nerve which to amputate [12,
13]. The mangled extrem-
damage, muscular and periosteal stripping from ity syndrome and the
mangled extremity severity
the bone, and severe circulatory compromise sec- scores are scoring
systems designed to aid in the
ondary to heavy trauma of the major vessels decision-making process
by predicting the viabil-
(Fig. 1). The gravity of this fracture is empha- ity and salvageability
of the mangled limb part
sized by the high rate of amputation which has [12, 14, 15].
been reported to occur from 60 % up to 100 % For open fractures
of the lower extremity, the
[10, 11]. Today, efforts are no longer aimed at combination of damage
to both posterior and
simply salvaging the limb that has sustained anterior tibial
arteries and popliteal arteries at
a serious compound injury, but rather to produce the trifurcation level
that is often seen in open
a functional extremity free of pain which has, at tibial fractures
carries the worst prognosis [16]
least, protective sensation. (Fig. 2). In our own
experience, none of
184 P.N.
our patients with open Type IIIB injuries have as it doubles the surgical
time for vascular anas-
undergone amputation [12]. This must be attrib- tomosis. However, vein
grafting does offer the
uted, at least in part, to the use of microsurgical benefit of doing the vessel
anastomoses without
techniques which permit better restoration of the tension and on healthy
intima.
arterial damage; and to the fact that most of our Microsurgical techniques
and the use of vein
cases involved isolated arterial injuries, which grafts to restore arterial
blood flow in the injured
are know to have a better prognosis [17]. The extremities also are related
the relatively high
use of vein grafts is a time-consuming procedure, rate of limb salvage in
patients with Type IIIC
Fig. 1 (continued)
185
Fig. 1 Type IIIC open fracture of the distal third of the nerves. (b)
Stabilization was achieved with a external
tibia, equivalent to an incomplete, nonviable amputation. fixator system which
allowed for revascularization using
(a) Preoperative view shows that both posterior and ante- microvascular
anastomosis of both anterior and posterior
rior tibial arteries were severed, with severe soft tissue tibial arteries using
microvenous grafts. (c) Post-operative
injury, including deep venous system and peripheral appearance of the
distal tibial 30 months post-operatively
injuries. Microsurgical skills applied in second- hand still remains

controversial. In children, a
ary reconstructive procedures such as free flaps, persistently absent
radial pulse, obtained by Dopp-
vascularized bone grafts, and nerve grafting help ler ultrasound in the
form of absent or monophasic
to achieve better results and to improve the func- flow of the radial
artery, is a reliable indicator
tional outcome of the severely injured extremity. of vascular
compromise, indicating the need for
Microsurgery aids the treatment of these injuries surgical exploration
of the brachial artery (Fig. 3).
by improving the circulation of the injured
extremity using fine surgical techniques, restor-
ing function of the limb, and solving other com- Open Hand Injuries
plex problems such as replacing unstable scar
tissue with free skin flaps. It is widely accepted
that correct, early treatment
by surgeons well-
trained in hand surgery is of
paramount importance
for successfully managing
Open Fractures of the Upper Extremity complex open hand
injuries. Neglect by postpon-
ing treatment of the
hand to treat other trauma-
Comminuted fractures of the neck of the humerus tized sites, almost
always results in permanent
are a rare cause of injury to the axillary artery. disability of the
hand. Overall, open injuries of
Supracondylar fractures of the humerus are the the hand require
state-of-the-art methods
commonest upper limb fractures in children performed in a timely
fashion, as well as
accounting for up to 70 % of all paediatric elbow well-developed skills
in both skeletal and
fractures. Although acute vascular injury is a com- soft tissue
reconstruction. The initial treatment
mon complication in children with severely of open hand injuries
is of great importance.
displaced supracondylar humeral fractures, the It must involve the
management of all the
management of patients with a pink pulseless anatomical and vital
structures of the hand that
186 P.N.
have been involved in the injury. Secondary pro- managing these demanding and
complex injuries.
cedures include nerve grafting and two-stage Although the majority of these
are aimed at the
flexor tendon reconstruction, among others. appropriate treatment of the
anatomical struc-
Delay in the direct reconstruction of the injured tures involved, some are over-
simplified and
elements will virtually always result in severe lack the necessary, more
sophisticated methods
stiffness of the joints with subsequent functional of treatment, while others are
too complicated to
impairment of the hand. A variety of classifica- be followed by the average
surgeon. The S.A.T.
tions have been proposed to assist the surgeon in T. classification was designed
to assist the
a b
c d
Fig. 2 (continued)
187
Fig. 2 Severe open fracture of the proximal third of the microvascular

anastomosis of the popliteal artery to both the
tibial (Type IIIC). (a) The fracture was associated with posterior and
anterior tibial arteries. (e) The fracture was
extensive skin loss and soft tissue injury over the popliteal stabilized with the
aid of an external fixation system, and
fossa. (b) Arteriography demonstrated complete rupture of the wound was
successfully covered with the use of a split
the popliteal artery. Note the comminuted fracture of the thickness graft.
(f) The saphenous vein graft used for the
proximal tibia. (c) Microphotograph (via operating micro- microvascular
anastomoses was harvested by a second ortho-
scope) showing rupture of the popliteal artery paedic team from
the contralateral leg. The healed scar can
intraoperatively. (d) A saphenous vein graft was used for be seen on the
medial surface of the contralateral leg here
188 P.N. Soucacos and Z.T. Kokkalis
Fig. 3 (continued)
189
d e
Fig. 3 Severely contaminated open fracture Type IIIC of This was done to
allow for a fibular bone grafting proce-
both bones of the forearm in a 28 year old female farmer. dure in a second
stage. Note abnormal flexion of the
(a) Note the extensive skin loss, as well as the exposure of midshaft of the
forearm, as a result of the missing forearm
the forearm bones. Both ulnar and radial arteries were bony structures (d,
e) Radiograph shows good hypertro-
ruptured. (b) Radiograph showing removal of both fore- phy of the
vascularized fibular graft which was used to
arm bones. This was performed because they were avas- replace both
necrotic forearm bones. Reconstitution of the
cular and septic. (c) After multiple debridement blood supply along
with good wound coverage allowed
procedures, soft tissue and wound coverage was achieved for excellent
healing in both proximal (elbow) (d) and
with the use of a forearm flap from the contralateral arm. distal (wrist) (e)
junctions
surgeon in selecting the most appropriate means and selection of the

appropriate means of treat-
of management and is based on four major ment. In general the
first and foremost priority is
parameters: (S) severity of injury (viable vs assessment of the
quality of vascularity of the
nonviable injuries); (A) anatomic localization damaged segment and
areas distal to the site of
(isolated for extended injuries), (T) topography injury [18]. The
second concern is ensuring
(volar vs dorsal) and (T) type of injury (clean cut of skeletal
stabilization and rigid fixation of
or crush-avulsion) [18]. the de-stabilized
skeletal framework. Tendons
Prognosis for full functional recovery follow- and nerves are then
examined and the need
ing open hand injuries is dependent upon for primary or
secondary repair is explored
recognition of the presence and extent of damage according to the
type and extent of their damage.
to the various tissue components including, Finally soft tissue
reconstruction, particularly
neurovascular bundles, bone, tendons and skin, flap coverage of the
skin defects, is considered.
190 P.N.
Open hand injuries are complex injuries which a surgical scalpel, resulting
in massive bleeding
require technical expertise in both skeletal and [21, 24, 25]. These are very
serious intra-
soft tissue reconstruction. Trauma to the vascular operative vascular injuries
that may not only
system may produce vascular impairment, which jeopardize the viability of a
limb, but even the
may result in loss of the segment or skin necrosis life of the patient. In all
cases, further injury is
and is of primary concern to the hand surgeon. related to some extent to
varying degrees of
Most non-viable injuries due to the nature of their ischaemia and local bleeding.
vascular impairment require time-consuming The Orthopaedic surgeon
should be aware of
procedures for the restoration of an adequate potential complications
inherent to the procedure
blood supply. These must be done under brachial that they are performing.
This, along with sound
plexus block with an experienced anaesthetist. knowledge of the anatomy of
the area is the best
Stable bone fixation is also a key procedure and preventative factor. In the
face of these serious
is necessary to create a skeletal framework for complications, however, the
Orthopaedic sur-
early motion and function. In general, sharp lac- geon must have the skills to
recognize and
erations have a better prognosis compared to manage the emergency
promptly. If there is any
crush injuries. They are less demanding in both doubt concerning the extent
of the arterial com-
primary reconstruction and secondary proce- plication, a thorough
clinical examination of the
dures, such as free flaps, nerves, tendon or venous viability of the limb should
be performed without
grafts. Even though clean cut injuries are less hesitating to use objective
testing controls,
severe than crush injuries, when they occur in such as the Doppler
ultrasound or contrast
zone II they are demanding requiring fine micro- media for intra-operative
arteriography. No
surgical techniques in suturing tendons and digi- matter what the severity of
the complication, if
tal nerves. Most patients with open hand injuries it is treated promptly and
correctly, the devastat-
and particularly those with crush injuries ing potential for limb or
lift loss can be success-
require secondary procedures. These may include fully avoided.
reconstructive procedures to restore anatomical There are various
vulnerable anatomical sites
elements when primary reconstruction was susceptible to vascular
complications during
contra-indicated such as with flexor tendon rup- Orthopaedic procedures [25].
Among these
ture in zone II, digital nerves or to treat compli- include major vessels, such
as the femoral artery
cations secondary to the severity of the initial or popliteal artery which are
vulnerable to injury
injury, such as tenolysis, bone pseudoarthrosis during reconstructive
surgical procedures, like
or infection. total arthroplasties or
osteotomies, of the hip or
knee, respectively. Surgical
management of
pseudoarthrosis or
heterotopic ossification
Damage to the Vascular System around the hip, knee or elbow
joint is also asso-
in Orthopaedic Patients ciated with a high risk of
vascular injury.
Prior to the development
of microsurgery, vas-
Damage to major arterial structures during vari- cular surgeons were usually
called upon to take
ous orthopaedic procedures related to both over and manage these very
serious intra-
trauma and reconstruction is well-known and operative complications by
repairing the dam-
has been documented extensively in the Ortho- aged vessel either by end-to-
end anastomosis or
paedic literature [1925]. Injuries to the major interposition of a vein
graft. Today, these serious
vessels may be of several types, involving either vascular complications during
Orthopaedic pro-
partial or complete interruption of normal blood cedures can be met with a
successful outcome
flow. They can be the product of continuous when there is immediate
recognition of the com-
pressure resulting in thrombosis or false aneu- plication, and when there is
an Orthopaedic sur-
rysm [26] or the result of acute complete or par- geon present who is well-
trained in microsurgical
tial laceration from a sharp instrument, such as techniques who is able to
immediately manage
191
the emergency. The presence of a vascular sur- Prognostic Scoring Systems

geon or an Orthopaedic surgeon trained in micro-
vascular technique represents an invaluable With growing experience in
managing frac-
attribute to the Orthopaedic team, and minimizes, tures with vascular
lesions, surgeons now
if not eliminates the potentially disastrous out- realise that prognosis is
closely dependent
come from serious intra-operative vascular on injury to the vessels,
nerves, muscle and
complications. bone deep in the wound,
rather than surface
characteristics. Thus,
decisions regarding
salvageability and outcome
cannot accurately
Prognosis of Fractures with Arterial be made until the first
debridement is
Injury complete.
Orthopaedic surgeons are
occasionally
An important factor in the prognosis of the frac- confronted with extremities
that are so mangled
tures with arterial lesions is ischaemia time. In that salvage is
questionable. Attempts have been
general, the time limit for warm ischaemia in made to establish criteria
that surgeons can use to
parts with bulky muscles is about 6 h. This can determine which severely
injured limbs should be
be extended up to 12 h when the part is salvaged and which should
undergo primary
transported under conditions of cold ischaemia. amputation. Several
variables play a decisive
In cases of trauma to parts with little or no muscle, role in determining the
outcome and success of
such as the hand, fingers or foot, the time limit for preserving a limb,
particularly for open fractures.
warm ischaemia can be extended to almost 12 h, These include, the extent
and severity of vascular
and to 24 h or more for cold ischaemia. injury, bone and soft
tissue damage, type and
Rapid and proper patient transport with duration of limb ischaemia,
the patients age,
a subsequent decrease in warm ischaemia time, time elapsed since the
initial injury and surgery
are critical factors in decreasing the rate of ampu- and the presence of
concomitant organ injuries.
tation following severe trauma to the extremities. To help the surgeon
determine which limbs
For transport, a completely amputated part is should be salvaged and
which should be ampu-
wrapped in wet gauzes, enclosed in two plastic tated first, several scales
using a variety of criteria
bags and immersed in a mixture of water and ice have been proposed for
assessing the severity of
(three parts water to one part ice). For patients the injury. These include
the mangled extremity
who have fractures with arterial damage and syndrome (MES), the mangled
extremity severity
ischaemia of the peripheral part, the limb should score (MESS), and NISSA
(Nerve, ischaemia,
be re-positioned and immobilized with soft tissue injury,
skeletal injury shock and age)
a posterior splint. A plastic bag containing the [14, 15, 17].
water and ice mixture can then be placed around MESS takes into account
various important
the ischaemic part only. parameters for assessing
survival of an injured
Time limits refer to real ischaemia time: that lower limb, including age,
ischaemia time, local
is, the time from the accident (and not the time conditions and shock. The
sum of these parame-
the patient arrives at the hospital) to the time of ters is used to direct the
surgeon toward either
re-vascularization. It is of paramount impor- salvage procedures or
amputation. A MESS of
tance to give exact instructions for the cold 712 points is a strong
indication that the surgeon
ischaemia measures to be taken by those should proceed to primary
amputation. In gen-
transporting the patient. The importance of eral, the MESS scoring
system holds promise as
cold ischaemia should not be underestimated being a good, objective
scoring system for
and should be kept in mind throughout time- predicting poor outcome and
justifying amputa-
consuming procedures, including radiographic tion. Lange proposed
absolute and relative indi-
examination and other clinical tests and even cations which in
conjunction with the MESS
in the operating room. system, provide a helpful
guide to determine
192 P.N.
when to amputate in serious open IIIC tibial nerves. Careful neurovascular

examination is
fractures [27]. According to Lange, absolute imperative in the treatment
of open fractures or
indications for primary amputation include ana- shotgun injuries. The surgeon
must be aware that
tomically complete disruption of the posterior the absence of haemorrhage or
severe signs of
tibial nerve in adults and crush injuries with ischaemia do not necessarily
preclude serious
warm ischaemia greater than 6 h. Relative indi- vascular injury. Pulsatile
bleeding is a clear sign
cations include serious polytrauma, severe ipsi- of arterial injury, as is a
large or expanding
lateral foot trauma and anticipated protracted haematoma. Differences in the
colour of the
problems in obtaining soft tissue coverage. The extremities, such as a pale
colour of the injured
MESS system refers to the lower extremity and limb, must alert the surgeon
to establish
Lange to the open IIIC tibial fractures. For the a diagnosis rapidly.
upper extremity the tendency is more toward The pulse should be equal
in both extremities.
salvage. A diminished or absent pulse
strongly suggests
partial or complete
obstruction of normal blood
flow. When clinical
examination indicates an
Clinical Signs and Assessment absent or diminished pulse, a
thorough evaluation
of Arterial Trauma of the circulation in the
extremity should be
performed. This can be easily
done with
Early diagnosis and timely treatment of extremity a portable Doppler device, a
powerful tool for
vascular injuries are essential for limb salvage the rapid assessment of
arterial injury in trauma
and optimal limb function. Critical for early diag- patients. The detection of an
arterial signal sug-
nosis are careful and repeated clinical examina- gests limb viability.
However, it is important to
tion and Doppler indices. Thus, on admission, bear in mind that the
arterial signal confirms
a detailed clinical evaluation should be carried distal patency, and does not
exclude proximal
out. When there is clear evidence of arterial vascular injury. In addition,
the Doppler device
injury, the surgeon should not delay treatment is valuable when pulse
palpation is obscured by
by performing arteriography. hemorrhage or oedema.
On admission, all patients should be examined Measuring the ankle-
brachial systolic pressure
thoroughly with measures taken to stabilize their ratio has been found an
important tool. With the
general condition. They should be given tetanus normal ankle-brachial
systolic pressure ratio is
prophylaxis and started on antibiotics, as needed, >0.95, a difference of less
than 20 mmHg (ratio
after cultures have been obtained. A broad spec- <0.9) between the extremities
is indicative of
trum cephalosporin is usually sufficient for low vascular injury. Overall, the
ankle-brachial sys-
impact injuries, while an aminoglycoside (genta- tolic pressure index for
detecting arterial injury is
micin) is added for more severe wounds. In a fast and useful tool, with
a specificity of 97 %
severe crush injuries or those with vascular com- and an overall accuracy of 95
%. Duplex ultraso-
promise particularly when there is a high risk of nography can also reliably
detect injury to arter-
contamination, such as in farming injuries, peni- ies or veins, the presence of
arteriovenous fistulae
cillin G should be administered. and pseudo-aneurysms. Care
must be taken to
A detailed clinical evaluation for colour, tem- distinguish between arterial
and venous flow.
perature, pulsation mobility, sensation and This can be done by
differentiating between the
wound condition should be carried out. Culture magnitudes of the signal
produced by an artery
of the wound, radiographic analysis and Doppler compared to a vein (the
signal is greater for
control should be routinely performed. The arteries), with subtle
changes in the position of
severity of an arterial injury depends on the the probe.
extent of vessel damage, collateral circulation The Allen test should also
be applied for frac-
and the presence of shock. Every fracture must tures below the elbow
(bifurcation) in order to
be checked for additional injury to vessels or assess whether the lesion is
on the ulnar or
193
radial artery. The Allen test is performed by the Table 2 Indications for
arteriography
patient forming a tight fist. The surgeon then Indications
applies pressure and occludes both the ulnar and Multilevel trauma where
the exact site cannot be
radial arteries. The patient opens his hand the determined
surgeon then release one artery and observes the Knee dislocation or tibial
plateau fractures associated
with diminished or absent
pulse
blood return to the hand: the procedures is
Leg or forearm injury with
equivocal arterial injury
repeated for the other artery. If on releasing the
Suspected arteriovenous
fistulas
artery, the hand does not fill with blood quickly,
Contraindication
then there is vascular damage to that artery. History of allergic
reactions to contrast media
In some cases the limb may be in a position
where the bony ends of the fracture site are press-
ing against the vessel, resulting in a pulseless
extremity. The surgeon should proceed with gen- to produce occlusion during
the injection of 30 ml
tle reduction and immobilization of the fracture of contrast. When patients
are stable, they should
and the re-assess the circulation of the limb. If be evaluated in the
arteriography suite. Arterial
there is no return of the pulse, the surgeon should damage is indicated by an
arrest of contrast
proceed to the operating room without delay. media, irregular vessel
shape, abnormal luminal
When there is clear evidence of arterial injury or venous filling or the
expansion of a false
and the site and mechanism of injury have been aneurysm.
established, the surgeon should not delay treat-
ment by performing arteriography. Angiography
is recommended for patients with complete Repair Strategies
ischaemia when the limb is without pulsation, or
in patients with incomplete ischaemia and when The principles in the
management of acute vas-
Doppler control suggests major arterial compro- cular injuries involve
haemorrhage control,
mise. In a few select cases arteriography can be timely correction of the
ischaemia and careful
used to identify occult injury in patients with an prevention of potential
complications. Some sur-
abnormal physical examination or when the ana- geons contend that vascular
repair should precede
tomical localization of the injury is ambiguous. Orthopaedic stabilization,
particularly when crit-
For the most part, arteriography is rarely indi- ical ischaemia is present,
however, the optimal
cated. Diagnostic arteriography should be sequence of surgical repair
for lower extremity
reserved to selectively identify an occult injury injury with associated
vascular injuries still
in patients with an abnormal physical examina- remains unclear. Advocates
of performing the
tion or to establish the anatomy and precise loca- vascular repair prior to
lower extremity fixation,
tion of injury (Table 2). Displaced fractures of the believe that reversal of
ischaemia in the limb is
distal femur and proximal tibia, particularly knee the most important factor in
limb survival and
dislocations, have a high risk of concomitant should take precedence.
However, some sur-
vascular injury and poor collateral circulation to geons believe that lower
extremity fixation
support the distal limb. Angiography is highly should take place prior to
re-vascularization, as
recommended for these injuries. An absolute they are concerned that the
manipulation during
contra-indication to arteriography is a history of fixation could potentially
disrupt the vascular
allergic reactions to contrast media. For unstable repair.
patients, arteriography is best performed in the Primary vascular repair
in priority cases can
operating room by a direct needle injection into be performed when the
fracture is stable. How-
an arterial segment proximal to the injury site. In ever, with unstable bone
fractures, the bone fixa-
injuries of the lower limb when a pulse cannot be tion should be performed
prior to vascular repair.
clearly detected, the surgeon should expose the In injuries to the tibial
artery, bone fixation is
proximal superficial femoral artery and clamp it more frequently performed
before vascular repair
194 P.N.
because of the hazard of unstable fractures. The may increase distal

ischaemia. In general, tourni-
surgical sequence varies according to the time of quets are rarely required.
Surgeons should also
cold or warm ischaemia involved. If close to the avoid clamping of deep
bleeding vessels. It is
end of the permitted ischaemia time, the surgeon ineffective and may injury
adjacent nerves,
should proceed directly to re-vascularization. increase vascular injury
and ultimately compro-
Debridement is a critical factor for obtaining mise subsequent repair.
Surgical exploration is
good results, particularly for open fractures. The indicated with expanding
haematomas, which
4 Cs are a helpful rule of thumb for the surgeon are suggestive of
continuing arterial
during debridement: Contractility, Colour, Con- haemorrhage. If delayed,
shock, nerve compres-
sistency and Capacity to bleed. sion, compartment syndrome,
or false aneurysm
In many of the cases, external fixation may be formation may ensue.
preferred, as it requires less operative time for If the initial
examination suggests obstruction
immobilization, less tissue destruction, less of blood flow as indicated
by a diminished or
potential for infection in contaminated wounds, absent pulse, the initial
treatment should focus
and allows for debridement and irrigation of the on correction of
hypotension and shock. The per-
wound on a regular basis in cases with severe sistence of ischaemia after
management of shock
soft-tissue injury [1]. In most IIC fractures, exter- indicates arterial
obstruction. As the obstruction
nal fixation is recommended as initial treatment. of blood flow is probably
related to some form of
After 23 weeks, it can be changed to arterial interruption, the
surgeon should proceed
intramedullary nailing or plates and screws. with reduction of any
fracture-dislocation which
Often these injuries require concomitant venous may be the causative factor
for extrinsic arterial
injury repair, as this will assist in maintaining the obstruction or entrapment.
arterial repair open and prevent postoperative An abnormally harsh,
intermittent and oscilla-
oedema [28]. In addition, soft-tissue injuries tory Doppler signal (bruit)
is indicative of an
most also be managed. This may entail multiple abnormal arteriovenous
connection. The early
debridements to control infection and split- manifestations may include
distal ischaemia,
thickness skin grafts for final coverage. In gen- arterial thrombosis, false
aneurysm and limb
eral, early wound coverage by local flaps or oedema. The surgeon is
advised in these cases,
vascularised tissue transfer, minimizes infection to proceed with immediate
exploration and vas-
rate and hospital stay and promote early bone cular repair. This may be
delayed if the limb is
union. Fasciotomy is an important tool in manag- viable and treatment of
other injuries is more
ing fractures associated with arterial injury which pressing.
is related to the increased risk of compartment Blunt injury re-
vascularization following
syndrome associated with soft tissue trauma, prolonged ischaemia or deep
venous thrombosis
crush injury and venous injury or occlusion [29]. often produces a diffuse
swelling of the injured
extremity. Oedema may also
compress the vas-
cular system and soft
tissues resulting in further
Initial Treatment increase of ischaemia. It
is important to keep in
mind that compartment
syndrome can also
After the initial evaluation of the patient and develop in open fractures.
In these cases, com-
assessment of other injuries, the wound is dressed partmental pressure should
be measured to assess
using a sterile technique, the limb is splinted and the need for fasciotomy,
where incision of the
the patient is taken to the operating room. The muscle fascia decompresses
the affected muscle
extremity is cleaned and a final evaluation is compartment. A catheter
should be inserted into
made. During preparations, haemorrhage can be the muscle compartment to
determine pressure.
controlled by direct pressure on the arterial Normal compartment pressure
is less than
wound or proximal vascular structures. Care 10 mmHg. Fasciotomy is
indicated with compart-
must be taken if tourniquets are used, as they mental hypertension greater
than 40 mmHg.
195
Fasciotomy is performed with a wide incision Surgical enlargement of the

wound for an accu-
across the overlying skin and fascia. A lateral rate assessment of damage
should be done by
approach is preferred over the leg, where all extensile incisions. This
preserves skin viability,
four muscle compartments may have to be as well as allows bone
stabilization later. Before
decompressed. The surgeon must always be extending the incisions,
however, the surgeon
aware of compartment syndrome, particularly in needs to carefully consider
later wound coverage,
the sedated or unconscious patient. The criteria so that debridement can be
performed through
for fasciotomy in vulnerable areas (forearm, tibia incisions which can be
utilized for future pedicle
and foot) vary according to the method used for or fasciocutaneous flap
advancement in severe
measuring compartment pressure. With the older open injuries.
method of continuous infusion monitoring, After adequate exposure has
been achieved,
fasciotomy is recommended when tissue pressure the wound is irrigated
liberally (610 l) with
rises above 45 mmHg. If a self-contained needle Ringers lactate using a
pulsed lavage system.
manometer is used, fasciotomy should be Ringers lactate may be
combined with antibi-
performed when the compartment pressure rises otics. The surgeon should
begin debriding
to within 1030 mmHg of the patients diastolic wound edges and then proceed
to deeper tissues
pressure. When uncertain, it is better to perform until all necrotic tissue is
excised with care taken
an unnecessary fasciotomy than not to do one that not to harm intact
neurovascular structures. The
is needed. 4 Cs are a helpful rule of
thumb for the surgeon
during debridement:
Contractility, Color, Consis-
tency and Capacity to bleed.
Muscle tissue which
Treatment fails to contract when
pinched, is pale, disinte-
grates to the touch and fails
to bleed should be
The principles in the management of fractures excised. Skeletal injury
should also be assessed
with acute vascular injuries involve hemorrhage and the bone cleaned. Free
cortical and grossly
control, timely correction of the ischaemia and contaminated fragments need to
be removed,
treatment of fractures and soft tissue injury. while those with adequate soft
tissue attached
Often the treatment can be preformed by two should be kept. For severe
open tibial fractures,
Orthopaedic teams: a bone team and a vascular the availability of viable
soft tissues for bony
team. The bone group debrides the wound and coverage dictates the extent
of additional bone
fixes the bone, while the vascular group prepares debridement. Finally it must
be stressed that
the contralateral upper or lower limb for meticulous wound care is
essential for the suc-
a vascular graft. A shunt can temporarily restore cessful management of open
fractures, regardless
blood flow while fixation of the bone takes of the type of skeletal
fixation ultimately used.
place. In general, bone fixation is essential
because it stabilizes the bone and allows for the
fine manipulations necessary for performing Skeletal Repair
micro-anastomosis. In addition, further damage
to repaired arteries and veins by the gross move- Stabilization of the skeleton
right after debride-
ments often needed in bone fixation can be ment improves venous return
and local re-vascu-
avoided by microvascular repair after external larization, as well as
preventing additional soft
fixation of the bone. tissue damage from excessive
motion. Stable fix-
ation minimizes pain and
allows easier surgical
access, as well as patient
mobilization. However,
Debridement it is important for the
surgeon to keep in mind that
surgical sequence can vary
according to the
Debridement is a critical factor for obtaining ischaemia time. If close to
the end of the permit-
good results, particularly for open fractures. ted ischaemia time, the
surgeon should proceed
196 P.N.
directly to re-vascularization, either by vascular coverage and vascular

supply, plates and screws
repair or shunting techniques. and reamed intramedullary
nails are associated
The selection of the skeletal fixation (locked with an unacceptable high
rate of infection and
intramedullary nails, plates and screws or exter- should not be applied.
Initial bony stabilization of
nal fixation) depends on the location and extent of the tibia should be
achieved with external fixa-
the wound and the preference of the surgeon. tion. Although the bone is
stabilized without
Low velocity injuries can usually be managed risking further injury to
the blood supply, exter-
as closed fractures, while several factors should nal fixation is associated
with non-union, mal-
be considered in the skeletal fixation of high union, pin loosening and
pin tract infection.
velocity injuries. The vascularization of the Although axial control is
difficult, recent studies
bone is one such consideration. Types I, II, IIA indicated that
undreamed, interlocked,
open fractures should be managed as closed frac- intramedullary nails permit
excellent bony align-
tures with the method preferred by the surgeon. ment, union and low-to-
minimal infection rates
Types IIIB and IIIC are best treated with an for tibial fractures types
I, II, IIIA and in some
appropriate external fixator that allows stabiliza- cases IIIB. Type IIIC
fractures of the tibia require
tion and easy access to the wound. Good results initial external fixation.
have also been obtained by the primary use of
intramedullary nails, although this is still contro-
versial. For tibial fractures, external fixators are Vascular Repair
the only definitive method of treatment, as they
do not interfere with the mobilization of joints The aim of vascular repair
is to restore a normal
and muscle. After an initial use of the external blood flow by securing and
maintaining arterial
fixator (23 weeks) and when the soft tissue enve- and venous patency.
Collateral vessels in the
lope permits, fixation can be changed to either forearm and leg often
provide normal perfusion
intramedullary nails for most bones, or plate and when an isolated artery is
occluded. In these
screws for femur, humerus, radius and ulna. How- cases, reconstruction may
not be required. On
ever, in the presence of extensive soft tissue the other hand, when the
extremity is ischaemic,
injury (e.g., Type IIIB), bones such as the femur both arterial continuity
and venous outflow must
or humerus should also be managed initially with be restored to avoid early
thrombosis, limb loss or
an external fixator. The wound and joints can be chronic function ischaemia.
stabilized with minimal soft tissue compromise in The surgical sequence
varies according to the
open or de-gloved fracture-dislocations using time of cold or warm
ischaemia involved. If close
internal fixation with lag screws and external to the end of the permitted
ischaemia time, the
fixation away from the wound. surgeon should proceed
directly to revasculariza-
Fixation techniques for open fractures of the tion. This can be achieved
either by vascular
femur are more dependent on anatomical location repair or shunting
techniques. If the ischaemia
than on the type of wound in Type I, II, and IIIA time has been prolonged,
the surgeon may opt
fractures. Intertrochanteric and subtrochanteric to restore perfusion
promptly with a temporary
fractures can be effectively managed with intraluminal shunt, before
proceeding to more
a sliding hip screw or for the latter, second or time-consuming vascular
repair. Although in sit-
third generation intramedullary nails. A reamed, uations when no arterial
flow is detected by
interlocked intramedullary nail is appropriate for Doppler ultrasound testing
and when
femoral shaft or distal fractures without an a neurological deficit
secondary to ischaemia is
increase in infection. Type IIIB and IIIC fractures present, vascular repair
should be done, there are
should be managed initially with external cases where bony
stabilization may need to pre-
fixation. cede vascular repair. This
is when the bony skel-
In contrast to the femur, fixation of the tibia is eton is very unstable, the
joints are dislocated or
problematic. Because of the poor soft tissue the subsequent skeletal
manipulations required
197
risk disruption of any arterial reconstruction. In complete obstruction may not

occur for hours or
cases where skeletal repair should precede vas- days after injury.
Characteristic of a contused
cular repair, shunting techniques become an vessel is the bluish skin
discoloration.
invaluable tool. An intraluminal shunt can be Vascular repair require
microsurgical tech-
used to secure adequate blood flow to the limb nique, as described below.
When arterial injury
temporarily. is extensive, bridging the
defect with a vein graft
Once the extremity is prepped, adequate is the treatment of choice.
The great saphenous
exposure should be achieved to permit control vein of the uninjured leg is
preferred for venous
of vessels proximal and distal to the wound site. grafts. When not available,
the lesser saphenous,
A longitudinal incision over the vessel is pre- cephalic or basilic veins
are also appropriate.
ferred, as it allows extension in both directions These will avoid compromise
of venous return
to control bleeding. Only the popliteal artery in the injured extremity.
The use of vein grafts is
should be exposed, using medial transverse inci- a time-consuming procedure;
it doubles the sur-
sion to allow proximal and distal extension, as gical time for vascular
anastomosis. However, it
required. Until vascular control can be achieved, offers the benefit of
performing vessel anastomo-
the surgeon should not attempt to remove pene- sis without tension and on
healthy intima.
trating objects. Frequently, manual compression Once arterial repair has
been achieved, it is
of the brachial artery against the humerus or of usually advised to postpone
venous repair for
the femoral artery at the inguinal ligament is about 15 min. This allows
the blood flow to re-
sufficient to control bleeding and allow exposure vascularize the muscle
without introducing any
of a more distal arterial injury. Ligation of the residual metabolic waste
into the circulation.
collateral vessels should be kept to minimum and Upon completion of vessel
repair, the re-perfused
superficial veins should be preserved for possible muscles are evaluated. All
devitalized tissues are
use as vascular grafts. surgically debrided and
fasciotomies should be
Surgical treatment of the vascular injury performed at this point.
Arteriovenous fistulas
depends on the mechanism and type of injury should be repaired by
interrupting the fistula
(laceration, transection or blunt injury). tract and then restoring
continuity of the artery
A laceration injury to a vessel is caused by the and vein. This can be
achieved usually by local
impact and penetration of an object, such as debridement and direct
suture.
a bullet, glass or bone and is defined as a tear in
the vessel wall. The presence of an intact vessel
wall prevents retraction and closure of the wound Microsurgical Technique
and leads to persistent bleeding. Debridement of
the vessel wall followed by primary suture or Prior to the development of
microsurgery, vascu-
end-to-end anastomosis is usually sufficient to lar surgeons were usually
called upon to take over
manage a simple laceration. If a small segment and manage these very
serious limb, or even life-
of the vessel is resected (about 1 cm), proximal threatening injuries.
Microvascular repair by an
and distal mobilization (about 6 cm) is usually Orthopaedic team well-
schooled in microsurgical
sufficient to permit primary anastomosis. In sim- techniques enhances the
chances of limb salvage
ple laceration injuries, retraction and spasm of the with satisfactory function.
With the introduction
arterial ends and formation of a temporary throm- of the operating microscope
and other means
bus prevents persistent bleeding. Delayed bleed- of magnification (i.e.,
loupes) along with
ing may be observed in these injuries, due to micro-instruments and micro-
sutures, Orthopae-
spasm relaxation or dislodgment of the thrombus. dic surgeons were able to
achieve successful
A blunt injury may result in partial or complete anastomoses of small vessels
less than 1 mm in
transection of the intima, without medial or diameter, including the
digital arteries in
adventitial disruption, leading ultimately to pro- complete and incomplete non-
viable digital
gressive obstruction and thrombosis. Sometimes, amputations [30, 31].
198 P.N.
Fine work with reliable accuracy is made pos- anastomosis site. Interrupted
suturing is the tech-
sible in microsurgery with the aid of an operating nique of choice in contrast
to a running suture that
microscope or magnifying loupes, and the refined can cause unacceptable
constriction of the lumen.
techniques and skills can be acquired only by A few interrupted sutures are
preferable to an
many hours of practice. Magnification can be excessive number, as the
latter may produce
achieved with an operating microscope or ocular increased areas of vessel
wall necrosis that
loupes. Although several types and models of could subsequently lead to
scar formation and
operating microscopes are currently available, intimal proliferation and
necrosis (Fig. 4). Fur-
similar general principles apply to the use of thermore, excessive suturing
may cause added
most. In general, microsurgical repair of vessels deformation of the ends of
the vessel, causing
and nerves requires 16# and 25# magnification. exposure of more collagen of
the tunica media
While magnification from 16# to 40# is pro- to blood flow, and in turn,
producing clot aggre-
vided by the microscope and is essential when gation and thrombus formation
[33].
working with structures less than 1 mm in diam- Suturing of the vessels
must be done on
eter, many procedures may be performed using healthy tissue and under no
tension. In general,
magnifying loupes of up to 5#. Ocular loupes are correct tension can be
indicated by a small loop of
invaluable tools for anastomosis of large vessels suture visible through the
opposed vessel walls
(diameter 23 mm) or for the initial dissection. (Figs. 5 and 6). In addition,
the tension should be
Microvascular instruments are extraordinarily such that the suture does not
break while knot-
delicate so as to allow the surgeon to execute very ting. The diameter of this
loop should be equal to
precise procedures. Although a variety of special- the thickness of the wall
[32, 34]. Although per-
ized instrumentation exist, for the most part, fusion of the lumen of the
vessel is not always
microvascular procedures require three or more necessary since it may induce
damage to the
straight and curved jewellers forceps for manip- intima, irrigation of the
edges of the vessel to
ulating fragile tissues; fine suture, microscissors remove any residual traces of
blood is helpful.
with blunt edges for fine dissection; Interrupted suturing is
the technique of choice
microscissors with serrated blades for cutting in contrast to a running
suture which can cause
without crushing the intima of the vessel; and unacceptable constriction of
the lumen. A few
microvascular clamps with a closing pressure of interrupted sutures
symmetrically placed in both
less than 30 g per square millimeter to avoid the anterior and posterior
walls of the vessel are
damaging the vascular intima of small vessels preferable to an excessive
number, as the latter
and causing subsequent thrombosis. A tapered may produce increased areas
of vessel wall
point needle with a diameter less than 75 mm is necrosis which could
subsequently lead to scar
the most suitable for vessel anastomosis. The formation and necrosis of the
intima (Fig. 7).
cutting needle or the spatula type is inappropriate Furthermore, excessive
suturing may cause
for vessel anastomosis as they can produce added deformation of the ends
of the vessel,
trauma to the intima and consequently lead to causing exposure of more
collagen of the tunica
intimal proliferation and thrombus formation. media to blood flow, and in
turn, producing clot
The patency rate obtained in microvascular aggregation and thrombus
formation. A common
anastomosis is dependent upon the skills learned technical error is to
inadvertently suture a portion
in the laboratory and upon careful attention and of both walls of the vessel
together which will
awareness of factors that influence the success of cause anastomotic failure. As
the vessel wall,
patency [32]. Minimal, no more than 12 mm, particularly the intima, is
very susceptible to
advential stripping is recommended in order to injury particular care must
be taken in handling
visualize the lumen and avoid an excess of adven- the vessels. Thus, the
surgeon must avoid picking
titia that can invert and occlude the lumen. On the up the vessel edges with the
forceps during sutur-
other hand, extensive stripping of the adventitia ing, and stretching of the
vessel. Recently,
can lead to necrosis of the advential wall at the a micro-stapling technique
for anastomosing
Fractures with Arterial Injury 199
Fig. 4 (continued)
200
P.N. Soucacos and Z.T. Kokkalis
Fig. 4 Histological examination of the anastomosis site (H&E, 50#). (c)

Incorrect suturing technique of a vessel
has demonstrated unequivocally that extensive stripping under tension and on
unhealthy intima with 7-0 running
of the adventitia or suturing under tension can seriously suture seriously
damages vascular wall as seen in
damage the vascular wall. (a) The appearance of the this longitudinal
section of the rabbit femoral artery. (d)
normal lumen in longitudinal section of a normal, intact Histological
examination in cross section of the lumen
vessel as it appears under the operating microscope. (Sam- following incorrect
suturing shows extensive proliferation
ple from femoral artery of a rabbit). (b) Normal histolog- of the intima, with
complete occlusion of the lumen
ical vascular cytoarchitecture is shown in cross section (H&E, 50#)
vessels has been devised. This method, however, empty-and-refill or

milking test performed
is still in the trial stage. by clamping the artery
proximal to the anastomo-
Suturing of the vessels must be done on sis site with a
forceps and then milking the vessel
healthy tissue and under no tension. The distance distal to the
anastomosis site using another for-
between the edges of the anastomosis must not ceps, thus, creating
an empty vessel pocket. Once
exceed 12 mm or the transverse diameter of the an empty segment has
been obtained, then the
vessel. Breakage of the suture during knotting proximal forceps is
released. If the vessel is pat-
and pulling of the vessel ends together is indica- ent, then the empty
space should show blood flow
tive of excessive tension. On the other hand, and rapid filling.
sutures which are tied too loosely will project
into the lumen and will inevitably cause throm-
bus formation. In general, correct tension can be Basic Microvascular
Arterial Repair
indicated by a small loop of suture visible
through the opposed vessel walls. Microvascular
Dissection
Although perfusion of the lumen of the vessel
is not always necessary since it may induce dam- Careful microvascular
dissection under magnifi-
age to the intima, irrigation of the edges of the cation is used to
expose the selected vessel. Mag-
vessel to remove any residual traces of blood is nification by a
microscope is required when
helpful. Once anastomosis has been achieved, working with vessels
less than 2 mm in diameter,
patency is evaluated. A simple patency test is to while ocular loupes
are valuable for the initial
inspect the fullness and pulsation of the vessel or dissection and
anastomosis of vessels greater
to gently palpate the site of anastomosis. than 3 mm in diameter.
Proper exposure entails
However, the most reliable patency test is the clearing enough room
to perform the procedure
Fractures with Arterial Injury 201
Fig. 5 Microvascular
Anastomosis (a) The vessel
ends are first placed in a bar
clamp. Once the 2 stay
sutures have been placed
(preferable at 120# apart),
sutures are placed in-
between on the anterior
wall. (b) Once sutures have
been placed on the anterior
wall, the clamped vessel is
then flipped 180# to show
the posterior wall. A stitch
is place 120# from the
initial stay sutures, and then
this followed by evenly
spaced sutures in-between
a 120 2
3 3
1 1
Fig. 6 Suture placement.
(a) The first 2 sutures or
stay sutures (1) are placed
at 120# apart on the anterior
wall. Then a suture is
placed in-between the
2 stay sutures (2), followed
4
by even placement of
subsequent sutures (3). b
(b) Once the clamped
vessel has been flipped
180# to expose the posterior
wall, a stitch (4) is placed
120# between the first stay
sutures. This is followed by
even placement of
subsequent sutures
202 P.N. Soucacos and Z.T. Kokkalis
Fig. 7 Good suture a

technique involves
interrupted suturing on
healthy tissue with no
tension (a) Correct spacing
of sutures on the anterior
wall, after placement of
stay sutures. Note the
symmetrical placement of
the needle on both proximal
and distal ends of the
anterior wall.
(b) Appearance of the
vessel after it has been
flipped over to expose the
posterior wall and sutures
have been evenly placed.
(c) Following good suture
technique, good arterial
flow is noted once the
clamps are removed. Note
the absence of leaking,
even diameter and
b
appearance of proximal and
distal ends, and no pre-
anastomosis dilatation or
post-anastomosis stenosis
at the suture site
c
203
and to be able to visualize enough of the proximal trauma and de-vascularization

of the vessel
recipient vessel to verify its condition. This wall. Upon inspection of the
intima under high
allows the vessel to be placed in a better position magnification (2540#), the
vascular wall can be
for anastomosis and avoids technical errors cut until the normal tissue
ends appear. After-
attributable to unfavourable exposure. The prox- wards, the vessel ends can be
opposed with
imal and distal ends are examined, respectively, a clamp approximator. It
should be noted that
with care to avoid blind and extensive handling the dissection of a vein is
similar to that of an
which can cause further damage. If the lumen artery, but since it has a
thinner wall it requires
cannot be visualized, traction should be placed more cautious handling.
on the vessel stump with forceps and the vessel
transected about 0.30.5 mm from the end.
Inspection of the ends will assess the condition End-to-End Microvascular
Anastomosis
of the intima and media and determine their suit-
ability for anastomosis. Haemorrhage within the Careful microvascular
dissection under magnifi-
media, disruption of the intima and intimal tears cation is used to expose the
selected vessel. Mag-
are contra-indications for suturing and the dam- nification by a microscope is
required when
aged area should be excised. It is imperative that working with vessels less
than 2 mm in diameter,
the anastomosis is attempted only on healthy while ocular loupes are
valuable for the initial
tissue and without tension. dissection and anastomosis of
vessels greater
Once the loose connective tissue surrounding than 23 mm in diameter.
Proper exposure entails
the vessel has been removed with the jewellers clearing enough room to
perform the procedure
forceps and microscissors, each end of the vessel and to be able to visualize
enough of the proximal
is mobilized to obtain adequate length to approx- recipient vessel to verify
its condition. Once the
imate both ends with no tension. This can be loose connective tissue
surrounding the vessel
achieved by ligation or by bipolar electrocautery has been removed, each end of
the vessel is
of side branches which tether the vessel. mobilized to obtain adequate
length to approxi-
Branches are ligated or safely cauterized leaving mate both ends with no
tension. This can be
about a 0.5 mm stump. Most microsurgeons find achieved by ligation of side
branches that tether
that visualization is considerably augmented by the vessel. The area is
continuously irrigated with
placing a contrasting coloured plastic sheet heparinized lactated Ringer
solution throughout
underneath the vessel. The area should be contin- the procedure to keep the
vessel moist and pliable
uously irrigated with heparinized lactated Ringer and to prevent the suturing
material from becom-
solution throughout the procedure to keep the ing sticky. Adventitia is
removed from the vessel
vessel moist and pliable and to prevent the sutur- ends by circumferential
trimming or applying
ing material from becoming sticky. traction to the adventitia,
pulling it over the ves-
Adventitial tissue, or more specifically the sel stump and then
transecting it (sleeve ampu-
collagen fibres, tissue thromboplastin and tation). By doing this, all
layers of the vessel
Hageman factor which it contains, are highly wall should be exposed. Upon
inspection of the
thrombotic when intruding into the lumen and intima under high
magnification (2540#), the
needs to be excised in order to prevent clot for- vascular wall can be cut
until the normal tissue
mation and to promote visualization of the lumen. ends appear. Afterwards, the
vessel ends can be
Adventitia is removed from the vessel ends by apposed with a clamp
approximator.
circumferential trimming or by applying traction Interrupted sutures that
go through the full
to the adventitia, pulling it over the vessel stump thickness of the vessel wall
are used. The first
and then transecting it (sleeve amputation). By two sutures (stay sutures)
are placed about 120#
this all layers of the vessel wall should be apart on the vessels
circumference and the ends
exposed, although the surgeon should always are left long so that they
can be used for traction.
keep in mind that over-cleaning may lead to Once the clamp approximators
are rotated to
204 P.N.
expose the posterior wall, a stitch 120# from the grafts so that the graft can
approximate the diam-
initial two stitches can be placed. Additional eter of the recipient
vessel. Close approximation
stitches are placed in the remaining spaces. In of sizes between vein graft
and recipient avoids
general, arteries 1 mm in diameter usually need thrombosis resulting from
turbulence. Vein grafts
five to eight stitches, while veins need 710 are generally harvested from
the upper and lower
sutures. Once the anastomosis is complete, the extremities. Upper extremity
veins tend to be
clamp distal to the anastomosis is removed first, more flimsy because of the
lower muscle content
followed by the upstream clamp. Some minimal in the upper extremity
vessels, but as a result they
bleeding between stitches is of no concern. also demonstrate fewer spasm
problems. The foot
A patency test should be performed as described and forearm are sources for
veins 12 mm in
above, and soft tissues are closed over the diameter, although grafts
can frequently be
vessels so as to avoid exposure and drying of obtained from amputated
parts. The graft should
the vascular wall. be handled minimally during
harvesting.
When the vein is
harvested, the small side
branches are either ligated
or cauterized with
End-to-Side Microvascular bipolar cautery far from the
vein wall. A suture
Anastomosis is placed on the proximal
end, This provides an
arbitrary convention for the
surgeon to orient the
Dissection and vessel mobilization is performed graft knowing that the blood
flow is always in the
as for end-to-end anastomosis. Once dissection direction from the unmarked
end of the graft
and mobilization has been done, a small elliptical towards the end with the
suture. For arterial
portion is carefully excised from the recipient reconstruction using
interposition graft, the vein
vessel using microscissors. The vessel that is to graft should be reversed end
from end in order to
be connected is then cut at a 45# angle. Sutures avoid obstruction of blood
flow by the valves in
with long suture ends for traction are placed in the the veins. This is not
necessary for venous recon-
proximal and distal ends of the ellipse of the struction. The suturing
technique is similar to that
receiving vessel, followed by placing sutures used for end-to-end
anastomosis described
evenly between the traction sutures. Once anas- above, although often size
differences in the ves-
tomosis is complete, the procedures followed are sels diameter need to be
overcome by cutting the
similar to those described above. vessel ends obliquely or in
a fish-mouth pattern.
First the proximal
anastomosis is performed,
once the vein graft has been
gently perfused
Microvascular Vein Suturing and with heparinzed Ringer
solution. Afterwards,
Grafting the distal anastomsis can be
performed.
The techniques used for the suturing of a vein are

similar to those applied for suturing of an artery. Wound Coverage and Post-
Operative
However, as the vessel wall of the vein is consid- Management
erably thinner and more frail than that of the
artery, great care is necessary in handling the Skin should be re-
approximated, but never under
vein wall to avoid tearing. In addition, finer tension. Temporary coverage
can be obtained
suture material should be used when suturing with sterile dressing
sponges soaked in normal
veins. saline placed over the
wound. However, since
Vein grafting is performed when end-to-end this can lead to wound
dessication, a synthetic
microvascular anastomosis cannot be performed. biological dressing is
preferred. Post-operative
In re-vascularization and replantation proce- management should include
antibiotics, particu-
dures, this may also entail bone shortening. larly for open injuries. A
second generation ceph-
There are several candidate veins available for alosporin plus
aminoglycosides for 5 days are
205
adequate. These may be continued subsequently, congestion, although if the

part appears ischaemic
according to culture and antibiotic sensitivity it may be lowered to assist
arterial flow.
tests. Patients who have experience work-related
accidents, such as farmyard injuries or who have
severely contaminated open wounds should be Antibiotic Prophylaxis and
Therapy
also be given penicillin. Patients with open IIIB
or IIIC fractures should be brought into the oper- Broad spectrum antibiotic
(cephalosporins) are
ating room every 2nd to 3rd day for wound generally indicted for 510
days for patients
inspection and debridement until no necrotic tis- with open injuries.
Parenteral or oral route, and
sue remains. After subsequent debridements to the duration of antibiotic
treatment is dependent
ensure that the zone of injury is clean, closure upon the clinical situation
of the patient. For
of the soft tissue envelope should take place vessel repair in open
injuries, antibiotic adminis-
(ideally within 7 days). This can be achieved tration is considered
therapeutic and the duration
with split thickness skin grafting, local flaps or of administration can be
somewhat longer.
vascularized free tissue transfer, as determined Prophylatic antibiotics are
usually continued for
by the final defect size and composition. Bone about 3 days.
grafting and other secondary reconstruction pro- Sharp lacerations of
vessels usually require
cedures are recommended 48 weeks after minimal anticoagulant
therapy. In contrast,
wound closure. In cases of bone defects, these high energy crush or
avulsion injuries with
can be covered by conventional techniques extensive vessel damage
depend upon adequate
(spongiosa) if less than 5 cm, or by either bone anticoagulant therapy for
better patency. Among
transport or free vascularized bone transplanta- the agents commonly used are
heparin,
tion (free fibular grafts) for longer defects. aspirin and low molecular
weight dextran
Although post-operative treatment and com- (Dextran 40) [35].
plications are diverse and vary according to the Usually, heparin is
administered intra-
microsurgical procedure for which the microvas- operatively from the time
that the initial anasto-
cular anastomosis was used for, there remain mosis is performed until the
dressing is applied.
some general rules post-operatively. The A dose of 2,5005,000 units
of heparin is given
patients vital signs and vascularity of the area immediately after removal of
the clamp per anas-
should be monitored continuously and regularly. tomosed artery. The role of
heparin has dimin-
The part (e.g., arm) should be kept elevated in ished over the years, as it
has become clear with
a bulky dressing. Dressing changes should be experience that patency is
more a factor of sutur-
performed every other day, so as to avoid dried ing without tension and on
healthy tissue. The use
blood building up and constricting the replanted of heparin post-operatively
is also avoided
part or reconstructed tissue. The room should be because of potential excess
bleeding.
warm, as cooling can often lead to cold-induced
vasospasm. In addition, the patient should be left
in a quiet room with limited visitations, to avoid Post-Operative Monitoring
stress-induced vasospasm. Cigarette smoking by
the patients and visitors is strictly forbidden, as Several methods of
monitoring after microvascu-
nicotine is a potent inducer of vasospasm. lar surgery have developed
over the past decade.
Finally, cold drinks, as well as those with caffeine Despite the method used, the
most valuable and
are restricted. essential tool is the
regular clinical evaluation by
Patients are administered antibiotics, sedative the surgeon and nurses.
Clinical evaluation
and anagelsics depending upon each clinical case. should include colour,
capillary re-fill, tempera-
Anti-coagulation therapy includes low molecular ture and turgor. Clinical
evaluation should be
weight dextran, aspirin and thorazin, among performed continuously for
the first three 24 h
others. The area is kept elevated to avoid venous post-operatively.
206
Among the mechanical monitoring techniques operatively and shows the

tendency of becoming
now available include ultrasonic and Doppler gradually worse with time.
If venous insuffi-
probes and scanning, plethysmography, skin tem- ciency is suspected, the
area or part should be
perature probes, transcutaneous oxygen tension elevated to enhance
drainage. In patients treated
monitoring, radio-isotope clearance assays, fluo- with free flaps, the skin
of the flap develops
rescein perfusion, among others. Overall, skin a bluish discoloration in
the segment of a flap
temperature monitoring probes have been found which then rapidly spreads
over the rest of the
the simplest and most reliable adjunct to clinical flap. It also exhibits
rapid dark bleeding with
evaluation. Continuous temperature monitoring a pinprick. Congestion can
be relieved with
is now widely used to assess temperature changes the use of medicinal
leeches or with small pricks
in re-planted digits and vascularized free flaps. in the area which are
wiped with heparinized
This method which assesses the changes in rela- gauzes [3638].
tive and absolute temperature requires three Once a patient
demonstrated signs of venous
probes, one each placed on the re-vascularized congestion, leeches from a
commercial supplier
area, the normal adjacent area and the dressing. If can be applied. Before
leech application, the
the temperature of the re-vascularized area drops congested flap or digit is
thoroughly cleaned to
below 30 # C or more than 3 # C from the adjacent remove any antiseptics or
old blood. The region
normal tissue, then vascular compromise is likely should then surrounded
with gauze to inhibit the
present. leech from moving to other
areas. Gently han-
dling the leeches with
disposable gloves, they
should be applied to the
areas of skin with the
Complications greatest amount of venous
insufficiency, recog-
nized by the bluish
colour. To facilitate attach-
Circulatory Compromise ment, small nicks can be
made in the congested
region, producing a few
drops of blood to stimu-
Following microvascular repair the area must be late the leech to bite.
Once attached, the leech
closely monitored to detect signs of inadequate should be left undisturbed
until it detaches vol-
circulation before detrimental ischaemic changes untarily, usually after
about 20 min. Depending
develop. Following most microvascular proce- on its size, the leech
consumes approximately
dures used in replantation, free tissue transfer 515 ml of blood, although
blood can flow from
etc., the rule of thumb is that when the part or the site of the leechs
bite for 2448 h. In order to
area has developed pallor and loss of turgor (e.g., stimulate the egress of
blood from the congested
the area is pale with loss of capillary re-fill), then area, it is necessary to
wipe the wound area with
arterial insufficiency is present. On the other heparinized gauzes on a
regular basis (approxi-
hand, when the area is cyanotic, congested and mately every hour). The
estimated blood loss per
turgid, then venous insufficiency is present. If the each leech applied is
about 50 cc.
problem is minor, it sometimes can be managed
without having to re-operate. The means of man-
agement of circulatory compromise is strictly Management of Venous
Congestion
dependent upon whether arterial or venous insuf- with Leeches
ficiency is present.
Venous congestion is a
frequent and significant
problem of various
micosurgical procedures,
Venous Congestion including re-
vascularization and re-plantation,
as well as free skin
flaps. Venous congestion
The room would be warm following any type of can be the result of
various factors including an
microvascular surgery. Venous congestion is inadequate anastomosis of
a vein, an effect sec-
usually noted to gradually appear 612 h post- ondary to arterial
insufficiency, venous spasm,
207
venous occlusion and the absence of venous of blood lost is dependent

upon the number of
repair. It has been generally recognized that leeches applied and the
duration of their use.
venous congestion and engorgement can poten- However, the continuous
oozing of blood from
tially lead to necrosis of the replanted part or flap. the site of attachment
makes it difficult to pre-
In fact, clinical experience indicates that necrosis, cisely measure the total
amount of blood loss due
particularly in flaps, is more frequently associated to the leech. In general,
although each leech con-
with venous congestion than arterial insuffi- sumes only about 515 ml,
from the subsequent
ciency. The major therapeutic effect of the leech oozing from the leech
bite, each leech induces
is the relief of venous congestion. Recent recog- about 50 ml blood loss. In
this regard, it is essen-
nition of the clinical efficacy of leech, in this tial to closely monitor
the vital signs of the
regard, has produced a continuous increase in its patient, as well as
perform frequent blood and
use [37, 38]. Overall, venous insufficiency is the laboratory tests, since
any drop has detrimental
most important indication for leeching. effects not only for the
patient, but also for the
A state of venous insufficiency can be recog- survival of the free flap
and re-attached part.
nized by the bluish colour of the tissue, as well as Hence, the use of leeches
can result in
by tissue tension and oedema. In our experience, a significant loss of
blood which is directly
the leech was effective in the treatment of venous dependent upon the number
of leeches applied
congestion in skin flaps and trauma, in the treat- and the duration of their
use [37, 38].
ment of venous insufficiency following replanta- The use of medicinal
leeches can potentially
tion of digits and hands, and in distal phalanx have various complications
[39]. These include
replantation without venous drainage due to the persistent bleeding,
anaphylaxis and local aller-
absence of adequate veins for anastomosis. The gic reactions to
biological active substances
effectiveness of leech therapy becomes particu- within the leeches saliva
[40], transmission of
larly apparent in view of the extremely rapid viral-borne infections and
excessive scarring
change in colour of an engorged flap following from the leech bites. In
our own experience, we
the application of the leech. Relief is accom- have noted no significant
complications which
plished both immediately with the decongestion could be associated with
leech therapy [37, 38].
which is produced while the leech is attached, and Although the risk of
infection is always
afterwards due to the continued flow of blood there, in our experience
the use of leeches was
from the site of attachment. Bleeding can con- not associated with
infection in any patients.
tinue from the wound for as long as 2448 h. Studies indicate that
Aeromonas hydrophila is a
Ultimately, the venous decongestion produced predominant leech enteric
organism that is
by leeching acts to prevent any potential arterial responsible for digestion,
[41] and that there is
occlusion. The earlier that the diagnosis of always the concern for
infection [42, 43].
venous congestion is made, the better the result. However, it should be
noted that leeches have
The most significant contra-indication to been increasingly used
without report of infection
leeching is arterial insufficiency. It should be problems. We have found
that when
noted that in cases of arterial insufficiency the patients were treated with
a combination of
leech does not attach. Due to the relative aminoglycosides and third-
generation cephalo-
increased risk of bacterial infection, sporin antibiotics for
prophylaxis that infections
immunosuppressed patients are also not consid- can be effectively
avoided.
ered appropriate candidates for leech therapy
[39]. Thus, patients who are in an immunodefi-
cient state either primary or secondary to immu- Arterial Insufficiency
nosuppressive drug therapy should have venous
congestion treated with an alternative method. Once signs of arterial
insufficiency are present,
The application of leeches can potentially conservative and if
necessary, surgical measures
result in a significant loss of blood. The amount must be promptly
considered. Initially, several
208 P.N.
conservative measures can be taken. (1) The part area should be resected,
and the anastomosis
or area should be placed in a dependent position re-done. Histological
examination of the anasto-
(e.g., lowered) and (2) possible constriction by mosis site has
demonstrated unequivocally
splints and dressing should be examined and that extensive stripping
of the adventitia or
removed, accordingly. (3) Gentle milking of the suturing under tension can
seriously damage the
artery from proximal to distal may also be help- vascular wall [46, 47].
ful. (4) Heparin injected at a bolus of 3,0005,000 Systemic complications
which can occur
units may be required [44, 45]. (5) Vessel spasm intra-operatively
include hypothermia,
can be managed with the administration of about hypovolemia and acidosis.
These can result in
5 ml of 0.25 % bupivacaine or stellate sympa- excessive vasoconstriction
which, in turn, pro-
thetic block when catheters are still present. motes thrombus formation.
In these cases, hepa-
If these conservative measures fail to correct the rin has been found to be
an effective
problem and if signs of vascular compromise per- prophylactic. Vascular
spasm can be decreased
sist, then the anastomosis site must be explored in by bicarbonates (if
systemically induced), or by
a re-operation to assess patency. Exploration of the raising the room
temperature, warm saline baths
anastomosis site ranges from the removal of a few or adventitial stripping
(if secondary to local fac-
stitches, rinsing vessel ends and inspection for tors). Vasocontriction can
also be controlled by
thrombus formation in order to remove the throm- local or intravascular
agents, such as lidocaine,
bus to excision of the thrombotic area when exten- papaverine and
nitroprusside [47].
sive, and interpositioning of a vein graft. It is
important for the surgeon to check that a strong,
arterial pulse is present afterwards. If not, this may Other Post-Operative
Complications
lead to renewed thrombus formation.
Thrombosis of
microvascular repair can be attrib-
uted to various post-
operative causes including
Other Intra-Operative Complications environment, oedema,
haematoma, constriction
and infection. Peripheral
vasoconstriction or
Thrombosis following vessel reconstruction can vasodilation is intimately
effected by environ-
be attributed to intra-operative complications mental conditions, such as
cool air and anxiety.
including technical errors and systemic prob- A decrease in tissue
perfusion may be attributed
lems. Close inspection of vessels under high- to hypothermia, acidosis,
hypovolaemia and
power magnification will assist the surgeon in shock, amongst others.
Local pressure may
correctly judging the extent of damage to the increase from tight wound
closure, oedema and
vascular wall and avoid the repair of vessels external compression.
which are irreversibly damaged. Common tech-
nical errors during anastomosis include sutures
which catch the side or back wall of the vessel, Salvage and Re-
Vascularization
sutures which fail to penetrate the wall, uneven
opposition of the intima or spacing of sutures, Acute arterial thrombosis
or evidence of inade-
discrepancy in size, damage to the intima from quate tissue perfusion
indicates the need for
needle tears, false needle passes or probes and immediate re-exploration.
If the patient shows
clamps. Unintentional crushing of the vessels early evidence of
thrombosis following vascular
during the procedure by clamps frequently leads anastomosis, then the
wound is explored and the
to post-operative thrombosis. Overall, poor tech- anastomosis is re-
established after removal of
nique, including mal-alignment, intimal inver- the clot. Low molecular
weight dextran is
sion, twisted anastomosis and excessive tension administered post-
operatively at 20 ml/h for
require careful assessment by the surgeon intra- 15 days. During this
period the patient is also
operatively, to determine whether the repaired given oral salicylates
(325 mg twice daily).
209
Afterwards, the patient is advised to take 325 mg 11. Zehntner MK,

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Biologics in Open Fractures
Christian Kleber and Norbert P.

Haas
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 212 The successful management of open frac-
tures with high infection (<50 %) and non-

Diagnosis of Impaired Fracture Healing and
Infectious Complications . . . . . . . . . . . . . . . . . . . . . . . 212
union rate is a difficult clinical task. In the
last decade new biological methods (bio-

Management of Open Fractures and Clinical
logics) have been invented, assisting the
Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 213
Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 214 modern trauma surgeon in the treatment of
Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 214 open fractures. In this article we provide an
Infection-Associated Complications in Open
overview of the recent management algo-
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 215 rithms and individual treatment options for
Systemic Antibiotic Therapy . . . . . . . . . . . . . . . . . . . . . . . . 215
open fractures. Beside management of infec-
Local Antibiotic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . .
215 tion and associated complications, we focus
Bone Segmental Defects, Impaired Fracture
on the late complications, non-unions
and Bone Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
216 and bone segmental defects, and their man-
Autologous Bone Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
216
agement. Commercially available bone

Allogenic Bone Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
217
Xenogenic Bone Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
217 grafts and growth factors are discussed,
Synthetic Bone Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
217 summarized and future perspectives
Platelet-Rich Therapies (PLT) . . . . . . . . . . . . . . . . . . . . . .
217 mentioned.
Bone Morphogenetic Proteins (BMPs) . . . . . . . . . . . . .
217
Coated Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 218
Pulsed Electromagnetic Field (PEMF) and Low
Intensity Pulsed Ultrasound (LIPUS) . . . . . . . . . . .
218 Keywords
Summary Table of Biologics in Open Fractures . . .
219 Allografts # Autografts # Biologics # BMPs-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 219 Bone morphogenic proteins # Bone graft #
Bone segmental defect # Bone segmental
defects # Coated implants # Delayed union
and failure of healing # Diagnosis # Infection-
associated complications # LIPUS-low inten-

Previously published in G. Bentley (ed.), European
sity pulsed ultrasound # Management and
Instructional Lectures, European Instructional Lectures
guidelines # Open fracture # PEMFs-pulsed
13, DOI 10.1007/978-3-642-36149-4_6, # EFORT 2013
electro-magnetic fields # PLTs-platelet-rich

C. Kleber (*) # N.P. Haas
therapies # Pseudarthrosis # Synthetic grafts #
Center for Musculoskeletal Surgery,
Xenografts
Charite Universitatsmedizin Berlin, Berlin, Germany
e-mail: christian.kleber@charite.de;
norbert.haas@charite.de

211
DOI 10.1007/978-3-642-34746-7_199
212
C. Kleber and N.P. Haas
microbiological
contamination, compartment
Introduction syndrome, concomitant
vascular injury or periph-
eral vascular occlusive
disease, co-morbidities
The successful management of open fractures (diabetes, adiposity),
connective tissue diseases,
continues to represent a surgical and reconstruc- iatrogenic factors
(NSAID therapy,
tive challenge due to high rate of infection corticosteroid use),
smoking and social back-
(<50 %), poor soft tissue coverage, impaired ground [5]. Owing to
scientific progress new
fracture healing, non-union and secondary ampu- biologics, from debridement
devices to coated
tation [1]. Although open fractures are severe but implants and recombinant
growth factors are
rare injuries, the potential risk for detrimental available to positively
influence the clinical
consequences and serious handicaps, which in course of open fractures
and assist the surgeon
turn, cause major socio-economic costs, is high in order to fully
rehabilitate patients. In the fol-
[2, 3]. The two main problems in management of lowing sections we provide
an overview of
open fractures are infections and impaired frac- diagnosis, actual treatment
concepts and avail-
ture healing. Historically the treatment and major able biologics in the
treatment of open fractures.
clinical problems in open fractures changed from
infectious to reconstructive and bone healing
complications. Cornerstones of open fracture Diagnosis of Impaired
Fracture
treatment have been the invention of simple ste- Healing and Infectious
Complications
rility measures like hand disinfection
(Semmelweis 181865), skin disinfection by The initiation and
observation of the early bone
iodine solutions (Grossich 18491926), wearing healing process
(reactive/reparative phase) with-
of rubber gloves (Friedrich 18641916), sterili- out calcification is
difficult to diagnose and
zation of operation instruments (Schimmelbusch observe on conventional X-
ray or CT-scan.
(186095) and the invention of antibiotic agents New techniques like
ultrasound and MRI are
(discovery of Penicillin by Fleming and its appli- useful to assess the
granulation tissue, callus
cation by Florey and Chain (Nobel prize 1945). formation and lamellar bone
deposition. A test
Due to the improved methods of limb reconstruc- for early diagnosis of
deranged or impaired
tion the rate of secondary amputations after open fracture healing is not
available. Recent studies
fractures has decreased and reconstruction pro- try to understand the
regulatory mechanisms
tocols for non-unions and bone segmental defects (cytokines, adoptive immune
system, biome-
have improved over the last decade. The para- chanics) of the bone
healing process in order to
digm change, that not bone but soft tissue cover- predict impaired fracture
healing and develop
age, responsible for vascularity, microcirculation new targets to accelerate
bone healing.
and immune response are crucial for complete The early diagnosis of
infectious complica-
recovery, improved the outcome of open tions or impaired fracture
healing is difficult.
fractures in the last decades. Nevertheless, limb Beside clinical examination
with rubor, calor,
salvage in contrast to primary amputation is still dolor and pus, several
clinical tests assist in
associated with an increased rate of confirming infectious
complications. Despite
complications and sometimes large numbers of a high sensitivity all test
have a low specificity:
necessary surgeries [4]. Osteomyelitis and ostei-
Blood tests (CRP, 8090
% 60 %
tis are still the major factor for non-union and re- WBC)
sensitivity specificity
hospitalization after open fractures. 3-phase 100 %
25 %
Prognostically relevant are the amount of initial scintigraphy
bone loss, facture type, grade of soft tissue injury MRI 100 %
60 %
and defect, deficiency of bone vascularity, type of
213
a a
b
b c
Fig. 1 Male 23 year old cyclist overrun by train: subtotal (b) secondary
amputation toes free flap skin
amputation both legs open amputation left graft nailing
and plating fracture healing 1 year after
leg replantation, primary shortening, external fixator trauma (c)
In contrast sequestra and intra-/ tests may assist

in proving low-grade infections
extramedullary fat globules on MRI are and biofilm
pathogens in the future.
a specific signs of osteomyelitis [6, 7]. The com-
bination of microbiological wound swabs, tissue
tests, sonication of implants and prosthesis and Management of Open
Fractures and
histological investigations, normally acquired Clinical
Guidelines
while during interventions are the most reliable,
but are invasive diagnostics. But correct proce- In the following
two sections we outline the
dures to prove the presence of pathogens is cru- current clinical
practice and use of biologics in
cial. Specimens must be obtained under open fractures.
The major goals in treatment of
strict sterile conditions. Bearing and transporta- open fractures are
to prevent infectious
tion of the specimens must be organized. Large complications,
assure fracture healing and restore
probe volumes and numbers, no superficial function (Fig. 1).
swabs, sonication and short transportation time The Gold
standard for prevention of infec-
can increase the detection rate of pathogens. The tion after open
fractures is the combination of
specimens should be taken before administration radical surgical
debridement with initially
of antibiotic agents (except open fractures) or an empiric antibiotic
therapy. Due to changes in
antibiotic window (>24 h) should be the
microbiological spectrum, today we see
obtained. New highly specific bacterial PCR more Gram-negative
infections in open fractures
214
than 20 years ago, and therefore a combined additional soft tissue

injury due to hydrostatic
antibiotic therapy should be administered pressure and dissemination
of pathogens in
(section Systemic Antibiotic Therapy). Not deep, primary not
contaminated and infected,
only the incidence of infectious complications compartments.
Intramedullary reaming, with
after open fractures depends on the soft tissue a cortical window for
decompression and
injury severity and grade of open fracture (classi- decreased risk of septic
complications, is used
fications of Tscherne/Oestern and Gustilo/Ander- in septic non-unions with
an affected bone
son), but also the initial surgical treatment [814]: canal. The new RIA is an
elegant way to debride
1. Debridement, primary wound closure (if intramedullary long-bone
osteomyelitis because
possible) and definitive osteosynthesis of simultaneous suction
while reaming [15]. The
(grade I/II open fractures Tscherne/Oestern classical intra-operative
methylene blue applica-
and Gustilo/Anderson) tion is useful to label
fistulae for radical excision.
2. Staged therapy algorithm (grade IIIV open
fracture Tscherne/Oestern, grade IIIIIc
Gustilo/Anderson) with debridement, primary Wound Closure
shortening, temporary fracture stabilization
(external fixator), re-vascularization, tempo- The time point for wound
closure and successful
rary wound closure, programmed debridement soft tissue management are
crucial to prevent sec-
and soft tissue conditioning, plastic surgery ondary complications after
open fractures. In con-
and definitive osteosynthesis trast, ambitious wound
closure can provoke
3. In the subsequent phase of typical complica- secondary necrosis. Open
wound management
tions (septic/aseptic non-union) radical with sterile gauze has the
disadvantage of moist
debridement, removal of osteosynthesis milieu and danger of
secondary infections, espe-
implants, segmental resection, antibiotic- cially with hospital
pathogens. Therefore, we think
loaded bone cement (PMMA) spacer implanta- an individual concept of
wound closure should be
tion, reconstruction of bone segmental defects performed:
with bone substitutes and growth factors are In type I/II open fractures
we should strive for
needed (section Bone Segmental Defects, primary wound closure,
which according to
Impaired Fracture and Bone Healing). the literature, is
associated with lower infec-
tion rates.
In type IIIIV open
fractures primary wound
Debridement closure is normally not
possible. Temporary
soft tissue coverage
can be achieved by artifi-
Debridement is one of the cornerstones of limb cial skin (Epigard) or
negative pressure wound
salvage, wound and fracture healing in open frac- therapy (NPWT). NPWT
can reduce the infec-
tures. An open fracture is a traumatology emer- tion rate by up to 20 %
[16, 17]. NPWT in type
gency. The first surgical debridement should be IIIV open fractures
(negative pressure #50 to
performed within 6 h after trauma. Notably, the #150 mmHg) can reduce
the defect size and
radical surgical debridement in specialized cen- soft tissue oedema.
Furthermore, NPWT pro-
tres has had a stronger impact on the outcome tects the wound from
secondary contamina-
compared to the time-point of initial surgery. tion and hospital
acquired infections.
Serially-performed debridement every 48 h until Definitive wound
closure should be achieved
negative microbiological culture results pro- within 1 week for type
IIIIV open fractures.
duced decreased infection and complication Chronic wounds are a
domain of modern
rates. Additive tools like high pulsatile lavage wound management with
occlusive wound
(Jet-lavage) and the hydro-surgical scalpel are dressings, enzymatic wound
cleaning, secretory
reported controversially. Some publications absorption and facilitation
of granulation
report reduced infection rates, others fear tissue formation. Silver-
coated gauze has positive
215
effects on wound healing and protection from sec- Favour bactericidal

antibiotics
ondary infections. Silver is an antimicrobial agent Use antibiotics with good
bone and biofilm
which has been used for nearly 20 years. Nano- penetration:
crystalline silver dressing has been developed to Excellent:
fluoroquinolones, clindamycin,
prevent wound adhesions, control bacterial growth rifampicin, fusidic
acid, metronidazole
up to 7 days and improve healing of burn wounds. Fair: betalactam
antibiotics, gylcopeptides,
Furthermore, silver-coated sponges may reduce fosfomycin and
sulfonamids
Gram-positive infections. Poor: aminoglycosides
Some antibiotic agents
might have negative
impact on bone healing and
should be avoided
Infection-Associated Complications (e.g. fluoroquinolones).
Additionally to systemic
in Open Fractures antibiotic therapy another
from of systemic
antimicrobial therapy, the
hyperbaric oxygen
Systemic Antibiotic Therapy therapy (HBOT), can be
used. HBOT uses
oxygen in supra-atmospheric
pressure to treat
The early use of systemic antibiotic therapy bacterial infections.
Positive effects of HBOT
together with debridement is the cornerstone have been described for
necrotizing fasciitis,
of successful open fracture management osteomyelitis, skin grafts,
flaps and other forms
and prevention of secondary complications. of traumatic ischaemia
[22].
It can significantly reduce the soft tissue infection
rate up to 60 % in open fractures [18, 19]. The
empiric antibiotic therapy should start as soon as Local Antibiotic Therapy
possible after trauma, but at least within 3 h after
injury [20]. According to the severity of soft Local antibiotic
deliverance, e.g., sponge, fleece,
tissue injury, contamination, environment of the PMMA cement/chains/spacers,
has the advantage
injury and grade of open fracture, the antibiotic of high antibiotic
concentration at the infection
therapy should be chosen. focus and less systemic
complications [23]. Most
In type I/II open fractures short-term antibi- of the antibiotic carrier
systems (sponge) are bio-
otics for Gram-positive pathogens (Ampicillin/ degradable and must not be
removed. Soaking of
Sulbactam or Cephalosporin) is advised. antibiotic-loaded sponges
before implantations
Type IIIIV open fractures need additional precisely decrease the
antibiotic concentration
Gram-negative antibiotic therapy (Piperacillin/ in the sponge and should
not be performed [24].
Combactam or Ampicillin/Sulbactam + PMMA bone cement loaded
with antibiotics
Fluoroquinolones) due to high incidence of (tobramycin, gentamycin,
vancomycin) was able
Gram-negative pathogens. Therefore, calculated to reduce the infection
rate after open fractures
antibiotic therapy until positive culture results due to 1030-fold higher
local concentrations
and afterwards adaption according to compared to systemic
application [25]. But the
microbiogramme should be performed. release of antibiotics is
temporary. In some stud-
According to the EAST report antibiotic therapy ies, 34 weeks after
implantation, bacteria and
should be stopped 24 h after soft tissue coverage biofilm colonized the PMMA
spacer. Early infec-
in type I/II and 72 h after wound closure in type III tion of implants, in some
cases, have been suc-
open fractures. cessfully been treated by
debridement, local
For the duration of antibiotic therapy in antibiotic agents without
removal of the implant.
chronic infections and osteomyelitis no hard evi- To summarize, positive
effects for the treat-
dence exists [21]. But the principle of antibiotic ment of open fractures are
known but in general
therapy are: due to lack of randomized
trials the reduction of
Hit early and hard (high dose) infection and osteomyelitis
rate in open fractures
Use combination antibiotics is arguable.
216
spongy graft from resorption

and favours its vas-
Bone Segmental Defects, Impaired cularity and
corticalisation.
Fracture and Bone Healing The optimal bone
substitute to reconstruct
non-unions or bone segmental
defects is
Beside infectious complication the delayed- or controversial. Its
properties should be
non-union of open fractures is the second major osteoconductive, osteo-
inductive and biodegrad-
clinical task in open fracture treatment. Septic able to be replaced by
autologous bone [27].
versus aseptic and atrophic versus hypertrophic Osteoconductive means a
three-dimensional
non-unions are known. According to the individ- structure, which has
biomechanical properties
ual pattern of impaired fracture healing, specific and serves as a scaffold for
new bone ingrowth.
treatment should be performed. The bases for A synonym is osteo-
integration. Osteo-inductive
fracture healing are adequate cellular environ- means the promotion of
differentiation of
ment, vascularization, sufficient growth factors, osteoprogenitor cells into
osteoblasts and the
bone matrix, soft tissue coverage and mechanical acceleration of new bone
formation. BMP is the
stability. In delayed or non-union one of these most famous osteo-inductive
growth factor
factors is abnormal. The effectiveness of treat- (section Bone Morphogenetic
Proteins
ment depends on the detailed analysis of the (BMPs)). Osteogenesis
means the ingrowth of
impaired bone healing in order to reveal the fac- cells and guided tissue and
bone regeneration for
tor responsible. Mostly, the reason for aseptic optimal healing [28].
Recently, industrial part-
delayed or non-union is wrong osteosynthesis ners offer an array of
products with big regional
with no biomechanical stability leading to worldwide differences.
secondary aseptic pseudarthrosis. Hypertrophic
aseptic non-unions are treated with intra-or
extramedullary osteosynthesis. Atrophic non- Autologous Bone Grafts
union is more difficult to treat, because of a
poor biological environment. In cases of Autologous bone grafts are
taken from the patient
infection-associated pseudarthrosis a staged him/herself and transferred
to another anatomical
therapy algorithm with radical debridement, body region. Autologous bone
graft from iliac
segmental bone resection, temporary external sta- crest, rib, skull, mandible,
fibula are limited
bilization and secondary reconstruction of in supply, but are the only
bone substitute, which
the bone defect is recommended. Shortening is osteo-conductive,
inductive and
of the leg is a possibility but limited by vascular osteogenic. Autografts,
especially from the iliac
kinking. Another classical method to reconstruct crest, have a high co-
morbidity rate (24 % pain,
large bone segmental defects is bone 65 % haematoma) [29, 30].
Although, harvesting
segmental transport by Ilizarov or external fixator. bone from iliac crest is
time-consuming and
The disadvantages are pin-track infections, expensive, it is still the
gold standard for bone
discomfort and the long time period needed for substitutes in a bone
defects up to 3 cm in size
bone segmental transport (1 mm per day). A staged [31]. In autologous
grafting, de-fatting of the bone
approach to reconstruct large diaphyseal bone seg- chips (Jet-lavage) is
important to improve the inte-
mental defects (<25 cm) was described by gration rate. In the future
antibiotic or growth
Masquelet [26]. After initial resection of factor-loaded autologous
grafts might be avail-
pathological bone, an antibiotic-loaded PMMA able. Another elegant way to
harvest bone is the
cement spacer is inserted into the bone defect in reamer-irrigator-aspirator
(RIA). Developed to
order to induce a pseudosynovial membrane. In reduce fat embolism and
thermal necrosis after
a second operation the membrane around the reaming of long-bone
fractures, due to reduction
cement spacer is preserved, the cement spacer of intramedullary pressure,
RIA can harvest autol-
removed and the membrane fulfilled with ogous bone from long bones
together with mesen-
bone graft. The pseudomembrane protects the chymal stem cells [32].
Additionally, reaming
217
itself has been shown to improve bone healing in analogous to allografts

are processed to
tibial shaft fractures in some studies [31]. Large eradicate viruses, prions
or bacteria. Therefore,
bone defects (>3 cm) need primary mechanical xenogenic grafts have no
osteo-inductive and
stability and perfusion. Vascularized grafts (fib- comparable osteoconductive
properties to
ula), autologous/allogenic grafts (strut grafts), cus- allogenic bone grafts.
tom- made implant or bone segmental transport by
Ilizarov fixator, are possible solutions.
Synthetic Bone Grafts
Allogenic Bone Grafts Industry produces

synthetic bone grafts created
from calciumphosphate,
-sulphate, bioactive
Allografts are bone or bone substitutes from glass, polymers and
composites. Some products
another human, transferred to the patient. are loaded with
antibiotics or growth factors.
Allografts are used in up to 35 % of all bone Compared to synthetic bone
grafts 1020 years
transplantations [33]. Mostly, cadaveric bone or ago, the modern grafts are
osteoconductive and
donor bone from hip arthroplasty is obtained and biodegradable for 618
months whilst not weak-
stored in a bone bank. To avoid the transmission ening osteosynthesis or
grafting. Some studies
of e.g. HIV, hepatitis and prions, the allografts are report similar mechanical
properties to bone.
processed which weakens the osto-inductive Today, synthetic bone
grafts are used in joint
properties of the graft and maybe the mechanical reconstruction surgery
(tibial head fracture) with
stability. The limited osteoconductive capacity comparable biomechanical
and socioeconomic
leads to failure of ingrowth of the transplant in properties to autologous
and allogenic grafts.
1520 % [34]. In general, three different types of
allografts (fresh or fresh-frozen bone, freeze-
dried bone grafts (FDBA), demineralized Platelet-Rich Therapies
(PLT)
freeze-dried bone grafts (DFDBA)) in different
application forms (cancellous, corticocancellous, Platelet-rich therapies
are autologous blood prod-
structural cortical graft) are available. Irradiation ucts with enriched
concentration of platelets due
of bone grafts reduces the incorperation rate to a bedside
centrifugation process (platelet-rich
from 80 % to 100 % in non-irradiated grafts to plasma by gravitational
platelet separation) [35].
40 % irradiated grafts [34]. De-mineralized Furthermore, the processed
platelet concentrate
freeze-dried bone grafts lose their biomechanical can be in-vitro activated
by e.g. thrombin adjunct.
stability after processing. Allogenic strut grafts After intra-operative
preparation PLT is directly
(fibula) are used more seldom, especially in located to the critical
fracture site. PLT promotes
large bone segmental defects (>3 cm). Analo- bone healing via release
of various growth factors
gous to autologous grafts the future perspectives (PDGF, TGF-b) [36]. A
recent Cochrane
are antibiotic, chemotherapeutic or growth fac- database analysis revealed
only two trials with
tor-loaded bone grafts. Allogenic, compared to insufficient evidence to
recommend routine use
autologous bone grafts, are not limited in of PLT in non-union [35].
Actually, no controlled
size/amount but carry risks of transfection and study is available
investigating the application of
have lower osteo-induction properties. PLT in delayed- or non-
union after open
fractures.
Xenogenic Bone Grafts

Bone Morphogenetic
Proteins (BMPs)
Xenogenic bone graft is derived from animals,
mostly bovine or coral in origin. Due to transfec- BMPs. are members of the
TGF-b family.
tion issues the xenogenic bone substitutes, As growth factors with
osteoconductive and
218
osteo-inductive effects, BMPs. Induce bone and gentamycin. Early promising

results from
cartilage formation and play a key role in clinical trials are
published [1, 41]. In the future
osteoblast differentiation, accelerating bone this technology might give
us the opportunity to
regeneration and fracture healing. The clinical treat complications after
open fracture with
use and approval by the American FDA under- coated implants or even
prevent secondary
scores the effectiveness of BMP in problematic complications. Until then
much scientific and
bone healing situations. Mostly BMPs are used investigational work has to
be done.
in atrophic delayed or non-unions [37]. Com-
mercially available are BMP-2 and -7. The
application of recombinant BMP-2/7 in clinical Pulsed Electromagnetic Field
(PEMF)
studies showed enhanced fracture healing in and Low Intensity Pulsed
Ultrasound
scaphoid, fibula, distal tibial fractures and spine (LIPUS)
fusions. Due to short half-life the drug delivery,
actually a bovine collagen sponge or biodegrad- The indications for PEMP and
ultrasound are
able polyurethane scaffold, is a scientific task aseptic, atrophic delayed or
non-unions. Expo-
[38, 39]. Also the combination of BMPs with sure of bone cells to pulsed
electromagnetic field
new implants and autologous graft was shown induces intra-cellular
signalling cascades asso-
to be a safe procedure with good results [40]. ciated with anabolic bone
formation (PTH, insu-
With further scientific research new growth lin, IGF-2, LDL, calcitonin
receptors) similar to
factors like PDGF are potential targets for mechanical load [4244].
Osteoblasts are
clinical use in the future. simulated by PEMF and secret
BMP-2/-4 and
TGF-beta [45, 46]. The
success rate in healing
non-union was dependent on
the daily timespan
Coated Implants used. In 36 % of non-unions
treated with less
than 3 h a day with PEMF,
bone healing was
Osteosynthetic implants with the capability of observed, compared to 80 %
when the device
local, controlled drug release pose a feasible and was used for more than 3 h a
day [47]. Further-
logical way to solve the local and specific more, PEMF is an effective
tool in aseptic non-
problems of infectious or impaired bone healing unions after paediatric
osteotomies and adult
complications after open fractures. Some tibial fractures [48, 49].
Beside PEMF also low
titanium implants, especially tibial nails, are intensity pulsed ultrasound
healing gave rates up
covered with biodegradable polylactide and to 86 % [50, 51].
Table 1 Summary Table of Biologics in Open Fractures

Graft Osteoconductive Osteoinductive
Osteogenesis Stability
Autologous + + +
+
Allogenic + (+)
+
Xenogenic +
Synthetic +
RIA + + +
BMP-2/7 ++
PDGF +
PLT +
MSC +
BMA +
RIA reamer-irrigator-aspirator, BMP bone morphogenetic protein, PDGF platelet-
derived growth factor, PLT
platelet-enriched therapy, MSC mesenchymal stem cells, BMA bone marrow aspirate
219
Summary Table of Biologics in Open 14. Sirkin M, Sanders

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Compartment Syndromes
in the Lower Limb
Peter V. Giannoudis, Rozalia

Dimitriou, and George Kontakis
Contents
Post-Operative Care and Rehabilitation . . . . . . . . . 234
Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 235
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
222
Historical Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 222 Complications . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 236
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . . 223
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 238
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 223
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 238
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 224
Applied Anatomy and Pathology . . . . . . . . . . . . . . . . .
224
Compartments of the Thigh . . . . . . . . . . . . . . . . . . . . . . . . .
224
Compartments of the Leg . . . . . . . . . . . . . . . . . . . . . . . . . . .
224
Compartments of the Foot . . . . . . . . . . . . . . . . . . . . . . . . . . .
225
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 225
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 227
History and Clinical Examination . . . . . . . . . . . . . . . . . . .
227
Intra-Compartmental Pressure (ICP)
Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 228
Other Investigational Techniques . . . . . . . . . . . . . . . . . . .
229
Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 230
Differential
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
230
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Pre-Operative Preparation and Planning . . . . . . . . 231
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
231
Decompression of the Thigh . . . . . . . . . . . . . . . . . . . . . . . .
231
Decompression of the Leg (Tibia) . . . . . . . . . . . . . . . . . .
231
Decompression of the Foot . . . . . . . . . . . . . . . . . . . . . . . . . .
232
Decompression for Chronic Compression
Syndrome (CCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
234
P.V. Giannoudis (*) # R. Dimitriou

Academic Department of Trauma and Orthopaedics,
e-mail: pgiannoudi@aol.com
G. Kontakis
School of Medicine, University of Crete, Crete, Greece

221
DOI 10.1007/978-3-642-34746-7_69, # EFORT 2014
222
P.V. Giannoudis et al.
soft tissue trauma, burns and

reperfusion injury
Abstract
following acute arterial
obstruction [2, 3].
Compartment syndrome (CS) is the clinical
Although its incidence is
relatively low, clinical
condition characterised by raised pressure
awareness of this
complication, early recognition
within a closed, non-elastic muscle compart-
and appropriate treatment with
fasciotomies are
ment, and it represents a severe complication
of paramount importance to
minimise the risk of
caused by bleeding or oedema, occurring after
irreversible damage and
permanent disability [4].
fractures or soft tissue trauma, burns and re-
Overall, the development of CS
represents an
perfusion injury following acute arterial
Orthopaedic emergency and,
therefore, surgeons
obstruction. Although its incidence is rela-
dealing with musculoskeletal
trauma must be
tively low, clinical awareness of this compli-
familiar with its treatment.
Finally, CS is one of
cation, early recognition and appropriate
the more common sources of
medical litigation,
treatment as an emergency situation with
with significant malpractice
liability [5].
fasciotomies are of great importance, in order
Regarding the lower
extremity, compartment
to prevent morbidity and poor outcomes usu-
syndrome is most commonly seen
in the leg, but it
ally leading to permanent disability. The diag-
can also occur in the foot,
thigh, and gluteal
nosis of compartment syndrome is mainly
region [24, 6, 7].
based on clinical signs, but it can often be
difficult. Adjunctive use of compartment pres-
sure measurements is desirable, especially in
Historical Review
particularly difficult cases with inconclusive
clinical diagnoses (regional anaesthesia,
The earliest publication
regarding this clinical
unconscious or polytrauma patients). A high
entity is attributed to
Richard von Volkmann in
suspicion index should always be present.
1881. He published a case of
contracture of the
A Dp #30 mmHg is also an indication for
forearm muscles following a
supracondylar frac-
urgent surgical treatment. When the diagnosis
ture of the elbow and he
called attention to the
is made urgent fasciotomies with adequate
fact that the pareses and
contractures of limbs
decompression of all anatomic compartments
following application of tight
bandages are
at risk must be performed.
caused not by pressure
paralysis of nerves, as
formerly assumed, but by the
rapid and massive
Keywords deterioration of contractile
substance and by
Compartment syndrome # Lower extremity # reactive and regenerative
processes [8]. It was
Intra-compartment pressures # Anatomy # Hildebrand in 1906 who first
introduced the term
Classification # Pathology # Clinical diagnosis Volkmanns ischaemic
contracture, to describe
# I.C.P. measurement # Surgical indications the final result of any
untreated compartment
fasciotomies # Techniques # Complications syndrome. He suggested that
ischaemic contrac-
chronic.C.S ture might be the end-result
of elevated tissue
pressure [9]. In 1909, Thomas,
reviewing the
literature of Volkmanns
ischaemic contractures,
General Introduction found fractures to be the main
causative factor
[10]. Other predisposing
causes included arterial
Compartment syndrome (CS) is the clinical con- injury, embolus, and tight
bandaging. Rowlands,
dition characterised by raised pressure within in 1910, suggested that
reperfusion of a limb after
a non-expandable anatomical compartment: a prolonged ischaemia could
result in the devel-
the closed, non-elastic muscle compartment, opment of acute compartment
syndrome (ACS)
which is surrounded by fascia and bone [1]. CS [11]. In 1914, Murphy reported
that impeding of
is a severe complication caused by bleeding or venous flow due to
intramuscular haemorrhage
oedema and it can occur following fractures or which increases intra-
compartmental pressure
Compartment Syndromes in the Lower Limb
223
and was the first to suggest that a fasciotomy occlusion of the vessels in
the compartment will
might be effective for the prevention of occur, resulting in the
development of compart-
Volkmanns contracture [12]. Jepson in 1926 ment syndrome and inducing
ischaemic damage
was the first to perform a fasciotomy for to the nerves and muscles of
the compartment.
a compartment syndrome [13]. During World Musculoskeletal trauma
and various conditions
War II and subsequent years, many cases of are associated with the
development of compart-
Volkmanns contracture occurred as a result of ment syndrome. The average
annual incidence of
high-velocity gunshot wounds that caused frac- acute CS is 3.1 per 100,000
people (7.3 per 100,000
tures either of the upper or of the lower extremity. men and 0.7 per 100,000
women); and its most
Bywater and Beall in 1941 reported on the vic- common cause is the fracture
of the tibial diaphy-
tims of London Blitz, highlighting the systemic sis, with a reported
incidence of 2.711 % and with
consequences of severe crush injuries including the anterior and deep-
posterior compartments
renal failure and death [14]. Matsen and Clawson being most commonly affected
[16]. The second
in 1975 showed that compartment syndrome most common cause is blunt
and crushing soft-
caused a sequential progression of nerve dysfunc- tissue injury. Other causes
include operative treat-
tion. As nerve conduction velocity steadily ment of fractures especially
after intramedullary
diminished under prolonged pressurization, nailing, as well as elective
Orthopaedic procedures.
symptoms of paraesthesia and hypoesthesia Additionally, prolonged limb
compression after
occurred first, followed by motor weakness and drug abuse, or poor
positioning during prolonged
finally anaesthesia. They also showed that exces- surgical procedures
(lithotomy position), burns
sive elevation of a severely injured extremity causing scar formation and
interstitial oedema, as
might increase the risk of compartment syn- well as any
revascularisation procedure due to
drome, because elevation led to diminished arte- tissue swelling following
reperfusion can cause
riolar pressure and increased tissue hypoxia. ACS [17]. Other vascular
causes for ACS include
Moreover the same authors contributed to the arterial and venous
injuries. Moreover, it is impor-
development of guidelines for fasciotomy [15]. tant to know that CS may
develop even after open
fractures and penetrating
lower-extremity injuries,
mainly when the anatomic
location is the proximal
Aetiology and Classification half of the below-knee
segment [17, 18].
There are also
iatrogenic causes for the devel-
Aetiology opment of this complication,
such as casting, cir-
cular dressings and
pulsatile irrigation [17]. The
In the upper and lower extremity, non- use of military anti-shock
trousers (MAST) for
expandable anatomic compartments are created abdominal or pelvic
haemorrhage has been also
by the deep fascia, which forms a tough circum- associated with the
development of lower extrem-
ferential stocking-like structure that constrains ity compartment syndromes,
although the key fac-
the musculature. Septa pass from the deep surface tor seems to be the
inflation pressure rather than the
of this fascial sheath to the bones within, confin- time of duration [19].
Moreover, anticoagulation
ing the functional muscle groups within osteo- treatment utilised in
elective procedures has been
fascial compartments. Vessels and nerves run reported also to precipitate
ACS [20].
through all the osteo-fascial compartments and Particularly in the
foot, the most common
supply the muscles contained within them. The cause of compartment
syndrome is high-energy
fascial boundaries that limit the osteo-fascial trauma, including crush
injuries, calcaneal frac-
compartments are largely inelastic. Any condi- tures and disruption of the
tarsometatarsal joints
tion that leads to an increase in the volume of [18]. Finally, there are
other rare conditions like
the compartmental contents is likely to cause snakebite and overuse of
muscles or tendon rup-
an increase in intra-compartmental pressure. If tures that may be
responsible for the development
this pressure exceeds a threshold, compressive of compartment syndrome
[17].
224
Classification attachment for them. The

medial septum lies
between vastus medialis,
the adductors and
Compartment syndrome can be classified into pectineus. The fascia lata
is attached superiorly
incipient, acute, and chronic compartment syn- and posteriorly to the back
of the sacrum and
drome. Incipient means an impending compartment coccyx, laterally to the
outer margin of the iliac
syndrome. Intolerable pain can be present, but tis- crest, anteriorly to the
inguinal ligament and
sue pressure measurements may not be superior ramus of the
pubis, and medially to the
diagnostic. There is no irreversible neuromuscular inferior ramus of the
pubis, the ramus and tuber-
damage at this stage. If measures are not taken (for osity of the ischium, and
the lower border of the
example removal of a tight cast, prophylactic sacrotuberous ligament.
From the iliac crest it
fasciotomies after limp revascularization following descends as a dense layer
over gluteus medius
prolonged ischaemia) there is a high probability of to the upper border of
gluteus maximus, where it
development of compartment syndrome. Acute splits into two layers, one
passing superficial and
compartment syndrome is the most common type. the other deep to the
muscle, the layers re-uniting
In its early stage (<8 h from the onset of conditions at the lower border of the
muscle. There are three
that caused compartment syndrome) there is exces- functional groups of
muscles in the thigh: the
sive compartment pressure. The ischaemia, anterior (extensor),
posterior (flexors) and the
oedema, and cell death cascade has begun but medial. The anterior and
posterior groups occupy
extensive muscle and nerve necrosis is not yet separate osteo-fascial
compartments that are lim-
present. In its late stage (>8 h from onset of condi- ited peripherally by the
fascia lata and separated
tions that caused compartment syndrome) there is from each other by the
femur and the medial and
extensive and irreversible muscle and nerve dam- lateral intermuscular
septa. The adductor mus-
age. The end-stage of compartment syndrome is cles, though distinct in
terms of function and
characterised by muscle death and replacement of innervation, do not possess
a separate compart-
compartments with fibrous tissue. Development of ment limited by fascial
planes. Nevertheless it is
significant contractures and loss of function is the customary to speak of three
compartments: the
common end-point. Finally, chronic (or exertional) anterior (quadriceps),
posterior (hamstrings) and
compartment syndrome is a condition occurring in medial (adductors).
Adductor magnus, adductor
athletes during exercise (usually in the lower longus and pectineus could
each be considered to
extremity) and is characterised by increased com- be constituents of two
compartments, i.e. adduc-
partment pressures, loss of strength or sensation tor magnus in the posterior
and the medial com-
(during exercise), and subsidence of symptoms partments, and adductor
longus and pectineus in
with rest. Unlike acute compartment syndrome, the anterior and the medial
compartments [4].
this condition is usually not a surgical emergency.
Compartments of the Leg

Applied Anatomy and Pathology
Four compartments are
recognised in the leg: the
Compartments of the Thigh anterior, the lateral (or
peroneal), the deep posterior
and the superficial
posterior. Tibialis anterior,
The fascia of the thigh (fascia lata) yields two extensor hallucis longus
and peroneus tertius
intermuscular septa, attaching to the whole of the including the anterior
tibial neurovascular struc-
linea aspera and to its proximal and distal pro- tures comprise the anterior
compartment. Peroneal
longations. The stronger and thickest lateral sep- muscles and superficial
peroneal nerve occupy the
tum extends from the attachment of gluteus lateral compartment. In the
posterior compart-
maximus to the lateral femoral condyle, and lies ments, plantar flexors
including the gastrocnemius,
between vastus lateralis in front and the short soleus and plantaris with
the sural nerve constitute
head of biceps femoris behind providing partial the superficial
compartment, whereas tibialis
225
AT AT
EDL A EHL n. art & v. AT Tibia
IM
PT
FDL
L
DP
PT art & v.
PB
PTn.
PL
P art & v.
Fibula
FHL
SP
S
GL
GM
Fig. 1 Contents of the four compartments of the leg (AT S soleus, GM

gastrocnemius medialis, GL gastrocnemius
anterior tibialis muscle, AT art & v. anterior tibial artery lateralis, SP
superficial posterior compartment, P art & v.
and veins, AT n. anterior tibial nerve, EHL extensor peroneal artery and
veins, PT n. posterior tibial nerve, PT
hallucis longus, A anterior compartment, EDL extensor art & v. posterior
tibial artery and veins, DP deep posterior
digitorum longus, L lateral compartment, PB peroneus compartment, FDL
flexor digitorum longus, PT posterior
brevis, PL peroneus longus, FHL flexor hallucis longus, tibialis, IM
interosseous membrane)
posterior, flexors of the big and lesser toes, poste- osseofascial

tarsometatarsal structures dorsally
rior tibial nerve and vessels, and peroneal vessels and intermuscular
septa medially and laterally.
form the deep compartment [4], (Fig. 1). The lateral
compartment includes abductor digiti
minimi and flexor
digiti minimi brevis, and its
boundaries are the
fifth metatarsal dorsally, the
Compartments of the Foot plantar aponeurosis
inferiorly and laterally, and
an intermuscular
septum medially. The four
There are seven main compartments of the foot: interosseous
compartments contain the interossei
the medial, the central, the lateral and the four muscles and their
boundaries are the interosseous
interosseus [3, 4]. The medial compartment con- fascia and the
metatarsals. A calcaneal compart-
tains abductor hallucis and flexor hallucis brevis, ment that includes
the quadrates plantae muscle
and is bounded inferiorly and medially by the has also been
described [4].
medial part of the plantar aponeurosis and its
medial extension, laterally by an intermuscular
septum, and dorsally by the first metatarsal. The Pathology
central (or superficial) compartment contains
flexor digitorum brevis, the lumbricals, flexor The pathophysiology
of compartment syndrome
accessorius and adductor hallucis, and is bounded has been defined as
an insult to normal local
by the plantar aponeurosis inferiorly, the tissue homeostasis
resulting from the increased
226
tissue pressure within a confined tissue space. increasing tissue

pressure or decreasing arte-
Increased pressure is generated secondary to an riolar pressure), the
arterioles close (critical
increase of the content of the compartment and/or closing pressure [CCP]
is reached) and
a decrease of the intra-compartmental space [4]. ischaemia ensues.
The main causes for the development of CS sec- (c) The rising tissue
pressures cause collapse of
ondary to decreased size of the compartment is the veins as their
walls are thin and suscepti-
the external application of constrictive casts or ble. Initially the
unabated arterial flow
dressings, or the firm closure of fascial defects increases the venous
pressure which re-
especially in the anterior compartment of the leg. establishes the flow,
but the increased venous
On the contrary, an increase of the intra- pressures adversely
affect the arteriovenous
compartmental content is seen in case of bleeding gradient and results in
ischaemia.
or oedema within the compartment. The former is When the interstitial
pressure exceeds CCP,
mainly associated with fractures, vascular inju- the capillaries collapse and
no further blood
ries, extravasation of arthroscopic fluids or enters the capillary
anastomosis, resulting in
coagulopathy, whereas the latter with post- shunting within the
compartment. The decreased
ischaemic and post-traumatic swelling, increased perfusion causes ischaemia
and cell death. Hyp-
capillary permeability and reperfusion oxic injury of cells
releases vaso-active sub-
phenomenon. stances, which increase the
endothelial
Regardless of aetiology, distortion of the rela- permeability. Subsequently
unabated shift of
tion between intra-compartmental volume, space fluid occurs across the
capillary endothelium
and pressure interfere with the circulation, lead- into the extra-vascular
space, causing high tissue
ing to the development of CS initially with pressure [22]. Nerve
conduction slows down as
venous obstruction within a closed space and a result of ischaemia,
tissue pH falls and the tissue
decreased capillary blood flow, and ultimately degradation products
contribute to further
with local tissue necrosis caused by oxygen dep- increase in the tissue
pressure and a vicious
rivation [4]. cycle of increased tissue
pressure and ischaemia
Tissue metabolism normally requires an oxy- ensues. Myocyte necrosis
produces large
gen tension of 57 mmHg readily maintained by amounts of osmotically
active particles drawing
capillary perfusion pressure (CPP) of 25 mmHg large amounts of fluids into
the tissues [23].
that is well above the normal interstitial tissue The involvement of
neutrophils in arterial
pressure (IP) of 46 mmHg. The tissue perfusion occlusion models of
ischaemic skeletal muscle
pressure is the result of capillary perfusion pres- injury and acute,
experimental compartment
sure minus interstitial pressure. As compartment syndrome has also been
reported [24]. However,
pressure increases, progressive decrease in the the mechanisms by which
neutrophils contribute
perfusion leads to ischaemia and necrosis. Tissue to the microvascular
dysfunction and blood
necrosis also triggers a chain of events including flow distribution
abnormalities have not yet
increased permeability due to toxins [21]. Tissue been clarified. It is
believed that neutrophils
ischaemia, a direct result of increased compart- once activated can produce
large quantities of
ment pressure, is also compounded by the follow- oxygen metabolites, during
revascularization in
ing factors: experimental ACS.
(a) Arterial spasm directly due to increasing It appears that a
plethora of mechanisms are
interstitial pressure. involved in the pathogenesis
of this potentially
(b) The effect of critical closing pressures on the devastating condition.
Unfortunately, once the
arterioles. Due to small luminal radius and chain of events starts the
vicious cycle of swell-
high mural tension, arterioles naturally have ing, tissue death follows
and only immediate
high transmural pressure (arteriolar pressure decompression helps to break
the cycle. As soon
minus tissue pressure). When the transmural as prolonged ischaemia is
established, it leads to
pressure ceases to exist (either due to muscle infarct and
irreversible damage of the
227
intra-compartments contents resulting in fibrosis Some authors advocate

that the diagnosis of
and contractures (Volkmanns ischaemic con- compartment syndrome is
largely a clinical one
tractures). In an animal model, it has been and is based on signs and
symptoms. Yet, the role
shown that the extent of tissue damage depends of clinical findings is
questioned by others who
on pressure and duration of pressure applied [4]. debate that few criteria
are available to serve as
Overall, the importance of relative or differ- guidelines for making the
diagnosis of compart-
ential pressure levels is well established, since ment syndrome [26]. In
most conscious and alert
perfusion within a compartment can only occur patients, an early
diagnosis of acute compartment
when the diastolic blood pressure exceeds the syndrome can be made on
the basis of clinical
intra-compartmental pressure [3]. This different evaluation, provided that
the physician has a high
between the diastolic and the compartmental index of suspicion. The
classic clinical symptoms
pressure was labelled Dp and is currently one of and signs that include the
six Ps: pain, pressure,
the most important parameters to evaluate. It has pulselessness, paralysis,
paresthesiae, and pallor,
been reported that ischaemia begins when pres- are not always present,
they may be difficult to
sure rises to within 1030 mmHg of the diastolic assess, and when present
they are indicative of an
blood pressure. McQueen and Court-Brown advanced CS with most
likely irreversible
suggested that a difference between diastolic damage.
pressure and compartment pressure of less than In general, the most
reliable clinical symptom
30 mmHg has a high clinical correlation with the of ACS is pain. However,
pain is not easily
development of CS [25]. assessed in the sedated,
intoxicated, or head-
Finally, it is important to outline that the path- injured patient or in
patients after regional anaes-
ophysiology of the crush syndrome or crush thesia [4]. Nevertheless,
pain may be absent in an
injury is different to the pathophysiology of the established compartment
syndrome. Pain is
CS, and that for this reason fasciotomies are reproduced by palpation of
the swollen compart-
contra-indicated in crush syndrome and they ment or by passive
stretching, which has been
are associated with increased morbidity and described as a highly
sensitive indicator of com-
morbidity [4]. partment syndrome in the
lower leg. Pain with
In chronic compartment syndrome, exercise passive stretch may result
from ischaemia-
causes an increase in blood flow, which increases induced loss of
intramuscular high-energy phos-
the volume of the muscle. The muscle is typically phates or alterations of
intramuscular pressure
hypertrophied from repetitive exercise. This [27]. Pain is usual
disproportionate to the pain
increase in muscle volume leads to elevated expected from the initial
injury, and it is unre-
intra-compartmental pressures and a disturbance lenting and not improved
by immobilisation or
in the microvascular circulation. Associated mus- different positions of the
lower extremity. It is
cle and nerve ischaemia results in limb pain and usually exacerbated by
constriction casts and
paraesthesiae. dressings.
Paraesthesiae are also
a significant diagnostic
sign and a valuable
indicator for fasciotomy.
Diagnosis Neurological symptoms in
the early stages
include reduced vibratory
sensations, increased
History and Clinical Examination two-point discrimination,
paraesthesias-e, numb-
ness or tingling. Altered
sensation over the 1st
The mechanism of injury is the first indication web space (between the
first and the second toe)
that a patient may be at risk of developing com- may accompany the pain and
should alert the
partment syndrome. The more severe the initial clinician. Even though the
pulse status has
soft-tissue injury is; the greater is the probability a restricted diagnostic
value, since pulses are
that soft-tissue complications, including com- usually palpable until the
late stages of ACS,
partment syndrome, could develop. their absence should raise
suspicion for an
228
underlying arterial injury. The other classic Ps The intra-compartmental

pressure (ICP) of
like paralysis (e.g.: foot drop), pallor, as well as a normal muscle compartment
is less than
poikilothermia are not only unreliable but, more 10 mmHg. Monitoring of ICP
in patients at risk
importantly, they are late signs. In a meta- of developing ACS has no
significant complica-
analysis, Ulmer et al. showed that if two clinical tions, while the contrary
may lead to a missed
symptoms were positive, the probability of diagnosis. The critical
pressure that will lead to
compartment syndrome was 25 %, and if there microcirculatory failure
depends on the
were three positive symptoms, the probability patients blood pressure,
the duration of pressure
would rise to 93 %. They concluded that, elevation, and many other
local and systemic
even though association of clinical findings with factors. Although
controversy still exists regard-
compartment syndrome seems evident, the ing the identification of a
critical value in each
predictive value of the clinical findings for the anatomical region that will
lead to the develop-
diagnosis of compartment syndrome has yet to be ment of tissue necrosis, the
more reliable clini-
delineated [28]. cal indicator for pending CS
was found to be the
Finally, documentation of clinical findings is difference between blood
pressure and compart-
of great importance in patients with compartment mental pressure, or
differential pressure (P or
syndrome. Serial examinations are essential and Dp). A threshold of Dp # 30
mmHg was found
the findings over time must be compared. Unfor- to be the most reliable
value to decide when to
tunately, inadequate documentation in patients perform fasciotomies [25].
with suspected compartment syndrome has been Clinical assessment of
ICP must be repeated,
reported to be in up to 70 % of the patients; and preferably by the same
clinician, at frequent
this was identified as the most common cause intervals (30 min. to 2 h)
to detect an evolving
for paid claims in Orthopaedic malpractice compartment syndrome. There
are both continu-
cases [29]. ous and non-continuous
methods of monitoring
compartment pressure.
Continuous monitoring
can alter management and
allow early
Intra-Compartmental Pressure (ICP) fasciotomy, thereby avoiding
possible sequelae.
Measurement Besides the controversy
on the threshold pres-
sure for fasciotomy, there
is no consensus on the
Overall, the diagnosis of compartment syndrome ideal measuring device
either [32, 33]. The instru-
is mainly based on clinical signs. However, its ments that are currently
used are the needle
presentation can be clouded by altered mental manometer, the slit and the
wick catheter [4]. The
status, fluctuating physical signs or covered up latters consist of a fluid-
filled catheter attached to
by general or regional anaesthaesia. Adjunctive an extracorporeal
transducer. Whitesides and col-
use of compartment pressure measurements is leagues created the simple
needle manometry tech-
reasonable in the majority of patients. nique utilising an 18-G
needle and a pressurised
The measurement of the elevated intra- constant-infusion system
[31]. The drawback of
compartmental pressure was an unsolved prob- the infusion technique is
that the need for continu-
lem. In 1968 the wick catheter technique for ous infusion of saline may
lead to an increase of
pressure measurement was popularized by ICP to 24 mmHg. To avoid
problems associated
Owen et al. [30]. In 1975 Whitesides and Haney with fluid-filled systems
this, an electronic trans-
developed an infusion technique using a slit ducer-tipped catheter system
that allows direct
catheter [31]. Later on, Mc Queen and Court- measurements of intra-
compartmental pressure
Brown, in 1996, reported the role of Delta has been developed [32].
There are also other
pressure (difference between diastolic and intra- systems for ICP measurement
such as the STIC
compartmental pressure) as the critical determi- catheter system (by Stryker)
which is a hand-held
nant of need for decompression [25]. and easy to use device, the
microcapillary
229
a c
e
b d
Fig. 2 ICP measurement with the simple needle manom- compartments. Measurements
were made in all four com-
etry technique utilising an 18-G needle (a) and partments: the anterior
compartment (b), the lateral com-
a pressurised constant-infusion system is shown in partment (c), the
superficial posterior (d) and the deep
a patient after tibial nailing. ICP measurement was posterior compartment (e)
performed due to palpable hardness of the tibial
infusion technique (for chronic CS as it offers 3. Patients with an isolated

long-bone fracture
dynamic applications), and the arterial transducer in which it is difficult
to elicit an accurate
measurement [4]. history or clinical
evaluation, such as
Overall, because it is not feasible or cost- patients with drug
overdose, head injury or
effective to perform ICP measurement in regional anaesthesia.
all patients, the surgeon must decide which Finally, when measuring
ICP, it is important
patients should be monitored. In case of appar- to know that the results of
the measurements may
ent clinical signs of ACS, the patient must depend on the position of
the limb, the accuracy
be taken immediately to the operating of the device or the height
of the pressure trans-
theatre for fasciotomies and release of all ducer above the tip of the
catheter; and that all
compartments. The main indications for ICP compartments should be
carefully assessed, espe-
measurement in combination with the clinical cially at the level of the
fracture (Fig. 2).
experience and judgment of the clinician are
the following [4]:
1. Inconclusive clinical diagnosis: including Other Investigational
Techniques
cases with a suspected nerve injury, dispro-
portionate pain, in certain cases after Currently other non-invasive
investigational tech-
intramedullary nailing of the tibia or after niques are being evaluated
for their efficacy in
successful arterial repair and fasciotomy fol- improving the diagnosis of
compartment syn-
lowing a period of ischaemia. drome. These include
measurements of the surface
2. Polytrauma patients: ICP of all compartments hardness of the compartment,
transcutaneous
at risk should be measured and the catheter oxygen measurements,
measurement of mechani-
should be left in the compartment with the cal impedance, scintigraphy
with Tc-99 m,
highest pressure (usually in the forearm or thallium stress-testing and
laser Doppler flow
the lower leg) to allow continuous pressure measurements, but mainly for
chronic exertional
measurement. compartment syndromes [4].
The near-infrared
230
spectroscopy (NIRS) measure of tissue O2 satura-

tion is a non-invasive method of detecting varia-
tions in the level of muscle haemoglobin and
myoglobin, and it has been proposed as a means
of monitoring for compartmental syndrome in crit-
ically-injured, unstable patients as it can detect
muscle ischaemia caused by CS despite severe
hypotension and hypoxemia [34].
Magnetic resonance imaging (MRI) has
a wide variety of diagnostic applications in mod-
ern medicine and some encouraging results have
been obtained in studies examining its ability to Fig. 3 Severe swelling and
bruising after a closed tibial
diagnose both chronic exertional and acute com- shaft fracture (black arrow)
compared to the un-injured
left side with palpable
hardness of the tibial compartments
partment syndromes [35]. It has been observed
that the changes on MRI in an established com-
partment syndrome with swollen compartments
and loss of normal muscle texture Indications for Surgery
correlated well with both the intra-operative
findings and the tissue histology. MRI can help The main indications for
surgery for ACS are the
make the diagnosis of a manifest compartment presence of the aforementioned
clinical signs and
syndrome in clinically ambiguous cases symptoms of nerve and muscle
ischaemia. In
pointing out the affected compartments and particular this applies with a
painful
allowing the surgeon to split selectively the fas- swollen compartment (Fig. 3),
which is at risk
cial spaces. for the development of this
complication (after
high energy trauma,
polytrauma, IM nailing,
reperfusion of the
compartment, prolonged limb
Laboratory Findings compression, etc.) or
increased pain with
passive stretching of the
muscles in the involved
Elevation of serum CPK in isolated compartment compartment and/or a
differential pressure level
syndrome reflects the amount of muscular dam- (Dp) of 30 mmHg or less in
case of ICP
age. Lactate dehydrogenase (LDH) has also been monitoring.
shown to be elevated in patients with ACS, espe- Overall, the treatment of
an established ACS
cially secondary to ischaemia and crush syn- is operative. It represents
one of the few Ortho-
dromes. Steadily elevated levels of CPK after paedic Emergencies and it
should be treated
decompression denote insufficient decompres- promptly and effectively with
decompression
sion and on-going muscle necrosis [36]. by surgical fasciotomies,
before the develop-
Since coagulopathy has been described as ment of irreversible damage to
the anatomical
a risk factor for the development of compartment structure of the compartment.
Only in cases
syndrome, the coagulation status of the patient of an incipient CS, the
surgeon can implement
should be evaluated. a few conservative measures to
reduce
the chances of the patient
developing an
established CS. All tight
casts and constricting
Differential Diagnosis dressings should be removed.
The limb
should be kept at the level of
heart rather
The differential diagnosis of acute compartment than elevated, to maximise the
tissue perfusion.
syndrome includes crush injury, arterial occlu- Elevation of the limb was
found to reduce
sion, acute tendon rupture or injury to mean arterial pressure in the
arteries of
a peripheral nerve [4]. the lower extremity and the
blood flow to the
231
compartment [4]. Inadvertent pressure of the Decompression of the Thigh

patients torso on the extremity was also
shown to have dramatic effects on the compart- The surgical approach for
thigh fasciotomy
ment pressures. Adequate hydration and blood depends on the muscle
groups involved which
pressure maintenance also help the tissue per- can be determined by ICP
measurements [4].
fusion. However, close and serial clinical However, it has been
reported that all muscle
assessment with detailed documentation and/or compartments of the
involved limb must be
ICP monitoring should be performed to identify relieved at fasciotomy to
eliminate the risk of
early evolution into ACS. subsequent ischaemic
changes [6]. For decom-
pression of the anterior
and posterior compart-
ments a single lateral
incision is performed along
the entire length of the
thigh. The leg is prepped
Pre-Operative Preparation
from the iliac crest to the
knee joint. The skin and
and Planning
subcutaneous tissues are
incised beginning and
around the
intertrochanteric line and extending to
The aforementioned measures implemented in
the lateral epicondyle,
exposing the iliotibial
the incipient CS should also be applied pre-
band. The iliotibial band
and fascia over the
operatively while preparing the patient for
vastus lateralis are
divided along their length.
fasciotomy. Comprehensive knowledge of
The hamstring muscles
(posterior compartment)
the number of compartments of the specific ana-
may be accessed by
retracting the vastus lateralis
tomic location and the available decompression
and dividing the
intermuscular septum. Care
techniques is imperative, in order to
must be taken to avoid
injury of the perforating
decompress all compartments at risk. In cases
vessels. To decompress the
medial compartment
with associated fractures, these should be
of the thigh (adductors) a
separate longitudinal
stabilised by means of operative stabilisation
incision should be made
along the length of
(IM nail or external fixator) at the time of surgical
the femur, dividing the
medial intermuscular sep-
fasciotomies.
tum. Closure is usually by
interval closure until
wound edges can be
approximated. This takes
a minimum of 7 days.
Operative Technique
As a general rule, the purpose of fasciotomy is Decompression of the Leg

(Tibia)
prompt and adequate decompression to restore
the tissue perfusion. It entails incision of the Various fasciotomy
techniques have been
overlying skin and fascia of the compartment described to decompress the
four compartments
to relieve pressure. The surgeon should be famil- of the leg. This can be
performed by a single
iar with the recognition of necrotic tissue as lateral incision or by
combined anterolateral and
thorough debridement reduces the potential of posteromedial incisions;
but regardless of the
infection and improves the chances of tissue approach used, all four
compartments of the leg
recovery. Almost complete recovery of limb (anterior, lateral, deep
posterior, and superficial
function is possible if adequate fasciotomy is posterior) must be
thoroughly decompressed. In
performed within the first 6 h. Muscle necrosis most instances, the two-
incision technique
has been shown to occur after 6 h and irrevers- affords better exposure of
the four compartments
ible changes in the nerve tissues appear after and release of the soleus
from the fibula is not
1224 h. Therefore, the role of immediate sur- required. With this
fasciotomy technique, two
gical decompression is crucial. Adequate skin vertical skin incisions are
made, extending from
incision is necessary as the skin can be the head of the fibula to
the ankle. First, the lateral
a potentially limiting structure. skin incision is made over
the interval of the
232
anterior and the lateral compartments midway nerve should also be

identified and protected.
between the fibula and the anterior crest of the Fasciotomy for the anterior
and lateral compart-
fibula to decompress these two compartments ments is performed, as in the
lateral incision of
(Fig. 4a). The second (medial) incision is the two-incision technique.
The superficial pos-
performed 12 cm posterior to the posteromedial terior compartment is
identified and fasciotomy is
border of the tibia to decompress the two poste- performed. After identifying
the interval between
rior compartments (superficial and deep) the peroneal and the
superficial posterior com-
(Fig. 4b). Care must be taken so that the two partments, the peroneal
(lateral) compartment is
incisions are separated by a bridge of skin at retracted anteriorly and the
superficial posterior
least 8 cm wide. After the lateral skin incision, compartment posteriorly. The
interosseous mem-
sharp dissection is used to elevate the skin flaps brane from the posterior
surface of the tibia is
and expose the fascia of the anterior and lateral identified and followed to
access the deep poste-
compartments (Fig. 5). The lateral intermuscular rior compartment, which is
released from this
septum that divides these two compartments is membrane. With this
technique, especially in
identified and the superficial peroneal nerve is cases of trauma with severely
mangled extremity,
identified and protected to avoid iatrogenic it may be difficult to assure
complete decompres-
injury. The fascia of the anterior compartment is sion of all compartments and
the peroneal nerve
dissected 1 cm in front of the intermuscular may be injured proximally.
septum (Fig. 6) and the fascia over the Various authors also
support closed tech-
peroneal muscles is dissected 1 cm behind niques (small skin incision
or primary skin clo-
the intermuscular septum (Fig. 7). Next, after sure), subcutaneous
(limited skin incision and
the medial (posteromedial) incision, the saphe- secondary closure) or open
techniques (extensive
nous vein and nerve must be identified and skin incision and secondary
skin closure). How-
protected. The fascia overlying the gastrocne- ever, since small,
subcutaneous, and closed inci-
mius-soleus complex must be released in its sions may not decompress the
compartments
entire length, exposing the distal part of deep fully, and patients treated
in this way may need
posterior compartment. To decompress the prox- further intervention to
normalise ICP, open
imal part of the deep posterior compartment, part fasciotomy is overall
recommended for adequate
of the soleus bridge should be detached from the decompression. The skin
incision in the leg
back of the tibia. Thus, the fascia over the flexor should be approximately 16
cm; and long inci-
digitorum longus and the deep posterior compart- sions were not found to
influence either the com-
ment is exposed and incised (Fig. 8). This two- plication rate or the late
functional result.
incision technique for fasciotomy is relatively
easier to perform; but its disadvantages are that
it requires two incisions and it may result in Decompression of the Foot
exposed bone, nerve or vessels. After complete
fasciotomies of all four compartments, all Various techniques have been
proposed for
devitalised muscles are excised (Fig. 9). decompression of the foot
depending on the
A single-incision fasciotomy of the lower leg nature of the injury and the
objectives of the
is also known as perifibular facsiotomy. It allows treatment [3, 4]. Usually,
one or two dorsal inci-
access to all four compartments via one lateral sions to access to the
interosseus and adductor
incision, following the line of the fibula and compartments, and one medial
incision, to assess
extending from the fibular head to the ankle. the deep flexors and the
calcaneal compartment
After skin incision and sharp dissection of the (Fig. 10), are used [3].
subcutaneous tissue, the intermuscular septum In case of two dorsal
incisions, these are
between the anterior and the lateral compart- performed dorsally over the
second and fourth
ments is identified. The superficial peroneal metatarsals (Fig. 10a);
allowing direct access to
233
Fig. 4 (a) The lateral

a
incision is made over the
interval of the anterior and
the lateral compartments
midway between the fibula
and the anterior crest of the
fibula extending from the
head of the fibula to the
ankle (FH fibular head, LM
lateral malleolus). (b) The
medial incision is
performed 12 cm posterior
to the posteromedial border
of the tibia from the knee to
the ankle to decompress the
two posterior
compartments (superficial
and deep)
all compartments, and providing exposure for incision is performed medial to

the second meta-
open reduction and internal fixation in cases of tarsal and the lateral dorsal
incision lateral to the
Chopart or Lisfranc fracture- dislocations and fourth metatarsal. To minimise
the risk of skin
tarsometatarsal fractures. The medial dorsal bridge necrosis, these two
dorsal incisions are
234
compartment is
identified. Its decompression is
complete when the
abductor digiti quinti and
flexor digiti minimi
are visible and can be
identified.
Particularly in
cases of an isolated CS of the
calcaneal
compartment, usually after calcaneal
fractures, with
compression of medial and lateral
plantar nerves and
vessels, a single plantar inci-
sion can be used. The
incision is made following
the plantar aspect of
the first metatarsal. The
medial compartment
becomes visible and is
split longitudinally.
The abductor hallucis must
be retracted to reach
the other compartments.
Fig. 5 After the lateral skin incision, sharp dissection is However, through this
incision it is difficult to
used to elevate the skin flaps and expose the fascia of
the anterior and lateral compartments (black arrow). The decompress the
lateral compartments and thus the
superficial peroneal nerve is identified (white arrow) and single plantar
incision is not generally
protected to avoid iatrogenic injury recommended [3].
made through the subcutaneous tissue to preserve

perfusion and the superficial veins and nerves Decompression for
Chronic
should be preserved. For each interosseous com- Compression Syndrome
(CCS)
partment, the dorsal fascia is opened longitudi-
nally. In the first interosseous compartment, the The most commonly
seen CCS in the lower
muscle is stripped from the medial fascia and extremity is the
chronic anterior compartment
retracted medially. The white fascia of the syndrome of the leg.
CCS is usually exercise-
adductor compartment becomes visible and is related and dynamic
pressure measurements are
carefully spit. required for an
accurate diagnosis (elevated
For the medial plantar approach (Fig. 10b), the post-exercise
pressures and delayed restoration
incision begins at the origin of the abductor of normal
compartmental pressures). In this
hallucis (approximately 3 cm above the plantar case, decompression
of the anterior and the
surface and 4 cm from the posterior aspect of the lateral compartments
through a subcutaneous
heel) and is extended parallel to the plantar sur- fasciotomy using two
vertical incisions centred
face for 6 cm [3]. The fascia of the abductor over the anterior
intermuscular septum (1 cm in
hallucis muscle is visible and split in line with front and 1 cm behind
the septum) is sufficient.
the dermal incision. After release of the medial For the decompression
of chronic posterior com-
compartment, the abductor hallucis muscle is partment syndrome of
the leg, a posteromedial
detached from the fascia and retracted superiorly. subcutaneous
fasciotomy is preferred, and care
The barrier to the calcaneal compartment is the must be taken to
assure that the tibialis posterior
visible white fascia, which should be split longi- muscle is completely
decompressed [37].
tudinally. A blunt dissection can also be
performed, since it is more tissue-preserving.
After reflecting the medial compartment superi- Post-Operative Care
and
orly, the superficial compartment is identified Rehabilitation
lateral to the medial compartment and it is
decompressed via a longitudinal incision of the Adequate hydration
and maintenance of satisfac-
fascia. The flexor digitorum brevis is retracted tory blood pressure
post-operatively help the tis-
inferiorly and the medial fascia of the lateral sue perfusion. Any
dressings or casts should not
235
a b
c d
Fig. 6 The lateral intermuscular septum that divides the front of the septum
(ad). The bulking of the muscle is
anterior and the lateral compartments is identified and the noted (black arrows)
after dissection of the fascia due to
fascia of the anterior compartment is dissected 1 cm in raised ICP
be tight or constricting; and the limb should be Wound Closure

kept at the level of heart rather than elevated, to
maximise the tissue perfusion. Adequate analge- In general, all
fasciotomy wounds are left open to
sia and administration of antibiotics until wound obtain usually
secondary healing, skin graft, or
closure are also vital, and continuous vacuum-assisted
closure (VAC) [3]. Split-
clinical assessment should be performed to early thickness skin
grafting is usually performed
identify insufficient decompression of the after 721 days.
Delayed primary healing or flap
compartments. coverage may also
used in some cases. Delayed
The aftercare of fasciotomy wounds is impor- primary wound closure
after fasciotomy has been
tant in an effort to minimise infection and wound advocated for some
patients on the third or fourth
healing complications and optimise as possible day after operation,
but only with concurrent ICP
their aesthetic outcome. The initial bulky monitoring.
dressing of the wounds is usually kept until Another technique
with dermatotraction has
wound inspection at 48-h in the operating theatre also been proposed to
close fasciotomy wounds.
to remove if necessary any further necrotic tis- With this technique,
there is progressive closure
sues. Change of dressing is performed as per of wounds and
improved wound edge apposition
hospital protocols or when required, but under by continuous
traction on the skin margins,
aseptic conditions and adequate analgesia. reducing thus the
need for subsequent skin
236
a b
Fig. 7 (a) The fascia over the peroneal muscles is dissected 1 cm behind the
intermuscular septum. (b) After complete
fasciotomy of the anterior and lateral compartments of the leg
and mainly in
case of lower limb fractures, on
the fixation
method used.
Complications
GM
S
Complications of
ACS are common and poor
outcome with
serious morbidity can be expected,
Fig. 8 After the complete release of the fascia (black especially when
the diagnosis is missed and the
arrow) overlying the gastrocnemius-soleus complex decompression is
delayed. If left untreated, it can
(superficial posterior fasciotomy) is performed, the soleus
(S) and gastrocnemius medialis (GM) are retracted poste- even become a
limb-threatening or even a life-
riorly to expose the fascia over the flexor digitorum longus threatening
condition, when occurring in large
(white arrow) to enable fasciotomy of the deep posterior compartments,
leading respectively to amputa-
compartment tion and
excessive tissue necrosis, rhabdomyoly-
sis, acute renal
failure and death.
grafting. Examples are the shoelace or vessel- Once
ischaemia causes irreversible damage to
loop technique and the STAR (Suture Tension the intra-
compartmental nerves and muscles,
Adjustment Reel) [4]. neurological
deficits and muscle dysfunction are
There is little information in the literature expected,
leading to various degrees of perma-
regarding the use of VAC dressings after nent functional
impairment. The long-term
fasciotomies for compartment syndrome. It sequelae of
untreated or late diagnosed ACS usu-
seems though that the VAC dressing may be ally includes
permanent ischaemia, dyseasthesia,
useful after fasciotomy for compartment syn- chronic pain,
muscle weakness and muscle
drome, as it may allow earlier fasciotomy clo- ischaemic
contractures. Clawing of the toes is
sure and reduce the needs for skin grafting [4]. a typical
deformity seen in untreated deep poste-
The use of VAC in combination with simulta- rior ACS of the
leg. Such complications with
neous hyperbaric oxygen therapy has also been muscle
contractures or dysfunction may require
shown to reduce the oedema in a synergistic further
reconstructive procedures, the use of
fashion, permitting early closure of fasciotomy orthotic
devices, or even amputation.
wounds [38].
Unfortunately, despite the appropriate
Further requirements for rehabilitation fasciotomies and
the on-time intervention, com-
mainly depend on the associated injuries plications can
still occur. Such complications
237
a b
Fig. 9 After medial and lateral incisions and fasciotomies of all four
compartments, all devitalised muscles are excised
(black arrows)
a b
MT2
MT2
MT3
MT1
MT1 MT3
MT4
MT4
MT5
A MT5 A
S
M S L M
L
Fig. 10 Anatomical section views of the forefoot show- approach (b). (MT
metatarsal, M medial compartment,
ing the compartments accessible through the two longitu- A adductor
compartment, S superficial compartment,
dinal dorsal incisions (a) and through the medial plantar L lateral compartment)
include wound healing complications (up to to prevent further

damage and functional impair-
40 %), iatrogenic nerve (15 %) or vascular injury ment, complications
from the fasciotomy proce-
with excessive bleeding (up to 35 %), and chronic dure itself have been
reported, causing severe
venous insufficiency [39]. Wound infection rates long-term sequelae
such as cosmetic issues,
have been reported to be as high as 25 %. altered sensation and
dry, scaly skin with
Particularly, thigh compartment syndromes pruritus [40].
have a significant complication rate, as high as Finally, regarding
the impact of compartment
78 %. Wound infections may complicate as many syndrome on the
quality of patient life, it has
as 67 % of cases, and neurological deficits such as been shown that this
complication may be asso-
paraesthesia and muscle dysfunction commonly ciated with long-term
impact on health- related
occur [6]. In general, the use of broad-spectrum quality of life [41].
Patients with skin grafts
antibiotic prophylaxis and vacuum-assisted reported more problems
with pain and discom-
wound care techniques may help to reduce fort than patients
without skin grafts; and those
the incidence of septic complications of who stated that the
appearance of the fasciotomy
fasciotomy. wounds was a problem,
reported significantly
Although fasciotomies for ACS represent an poorer health-related
quality of life than
emergency procedure with an absolute indication those who had no
problem with the appearance.
238
Faster closure times of the fasciotomy wounds 7. Henson JT,

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21.
Management of Delayed Union,
Non-Union and Mal-Union of
Long
Bone Fractures
Gershon Volpin and Haim

Shtarker
Contents
Abstract
Fracture
Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Long bone fractures heal without complica-
tions in most patients. Only a small percentage

Delayed Union and Non-Union of Fractures . . . . .
242
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 242
of fractures, between 2 % and 10 %, result in

Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 246 delayed union or non-union. The process of
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 246 fracture healing involves several stages,
Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 249 including inflammatory reaction, production
Non-Surgical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
249
Surgical
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
250
of soft callus and then rigid bone, and

Bone Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 252 remodelling. Delayed union is defined as the
absence of radiographic progression of

Mal-Union of Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
255
General
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
255 healing or the instability of a fracture upon
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . . .
255 clinical examination between 4 and 6 months
Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 256 after injury. Non-union is defined as a fracture
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 256 that does not unite within 912 months. or the
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
256
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
259 extension of the healing process beyond the
expected rate. Mal-union refers to the healing

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 263
of a fracture with incorrect anatomical align-
ment. Various aspects of the stages of fracture
healing, aetiology and pathogenesis of
delayed union, non-union and mal-union and
the optional treatment modalities of these
pathologies are reviewed and discussed.
Keywords
Biology # Bonetransport # Deplayed-non-
and mal-union # Ex-Fixation # Grafting #
Fractures # Longbones # Plating # Treatment-
non-operative # Treatment operative
G. Volpin (*) # H. Shtarker

Department of Orthopaedic Surgery and Traumatology,
e-mail: volpinger@gmail.com; haimsh@netvision.net.il

241
DOI 10.1007/978-3-642-34746-7_10, # EFORT 2014
242
G. Volpin and H. Shtarker
rapidly mineralize to form

woven bone tissue
Fracture Healing [2, 3, 5]. Thus, the third
stage of the repair process
includes both enchondral
and intramembranous
Fracture healing is a process involving several bone formation and
requires mechanical stability,
stages, including inflammatory reaction, produc- bone contact, and adequate
blood supply. The
tion of soft callus and then rigid bone, and amount of cartilage
present in the callus of
remodelling. The first phase of fracture healing long bones is greater in
unstable experimentally-
occurs upon injury. Ruptured blood vessels produced fractures where
unrestricted movement
within the bone and tissues adjacent to the injury of the fracture fragment
was allowed, but minimal
site cause a hemorrhage into the fracture site in cases of anatomical
reduction with stable
[14]. The blood vessels soon constrict to stop fixation [13, 5, 13, 14].
further bleeding and a hematoma forms within The progressive
development of cartilage in the
a few hours (Fig. 1). Vascular congestion, callus is characterized by
successive stages of
oedema and leukocyte activity all signify phase proliferation and
hypertrophy of the chondrocytes
two inflammatory reaction 2448 h following together with synthesis,
secretion and organization
injury. This takes place at the fracture gaps with of collagen and
proteoglycans (Fig. 1c, d). At this
the invasion of macrophages, polymorphonuclear stage an intensive
reaction of alkaline phosphatase
leukocytes, and lymphocytes that secrete various is observed around the
cell membrane of
types of growth factors and pro-inflammatory hypertrophied chondrocytes
and the membrane
cytokines such as interleukin-1, interleukin-6 of the matrix vesicles
(Fig. 1c, d). The calcification
and tumour necrosis factor-a (TNF-a). At the of the cartilage takes
place by deposition of needle-
same time, peptidesignaling molecules such as like hydroxyapatite
crystals within and around
members of the transforming growth factor-beta extracellular membrane-
bound matrix vesicles
(TGF-b) super gene family, including bone (Fig. 1e, f). These
observations suggest that alka-
morphogenetic proteins (BMPs) as well as line phosphatase plays an
essential role in calcifi-
platelet-derived growth factor, are triggered cation of the
cartilaginous callus during fracture
[610, 1719]. Transforming growth factor-beta healing [2, 3, 15, 16].
The next stages of fracture
(TGF-b) is released by platelets during the initial healing consist of
resorption of the mineralized
stage of fracture healing. Bone morphogenetic cartilage and formation of
the new bony callus
proteins are associated with rapid proliferation between the bone
fragments, followed by
of mesenchymal cells in the early stages of the remodelling of the bone.
healing process [7, 8, 11, 18]. It seems that TGF-b
stimulates cells to make and react to BMPs and
other factors in a synergistic cascade which, in Delayed Union and Non-
Union
conditions of proper mechanical stability and in of Fractures
the presence of a new blood supply, lead to
regenerative bone repair [12]. Introduction
The next stage of bone healing consists of an
intense proliferative response in the cambium A delayed union is defined
as the absence of
layer of the periosteum, forming a collar-shaped radiographic progression
of healing or the insta-
soft primary callus around the fracture site [24]. bility of a fracture upon
clinical examination
At the fracture site and bone ends, osteoprogenitor between 4 and 6 months
after injury [2125].
cells of the periosteum differentiate into Non-union is defined as a
fracture that does not
chondrocytes which produce a cartilaginous matrix unite in 912 months or an
extension of the
(Fig. 1a, b). In the peripheral part of the callus the healing process beyond the
expected rate. There
cells of the cambium layer of the periosteum is a gap between the
fracture fragments with
differentiate into osteoblasts, which in turn produce sclerosis at the ends
either hypertrophic callus
an organic matrix composed of collagen fibres that or atrophic callus (Figs.
2 and 3). Delayed or
Management of Delayed Union, Non-Union and Mal-Union of Long Bone Fractures 243
b1 b2
c1 c2
c3 c4
Fig. 1 (continued)
244
d1 d2
e1 e2
f1 f2
Fig. 1 Stages of fracture healing (After Volpin G, Rees alkaline

phosphatase activity (c2) demonstrating intense
AJ, Ali SY, Bentley G: Distribution of alkaline phosphatase enzymatic
activities around cell membrane (arrows) and
activity in experimentally produced callus in rats. around matrix
vesicles (MV) before any signs of calcifica-
J Bone Joint Surg 1986;68B. 629634). (a) Radiograph of tion (c2). (d)
EM sections through the extracellular matrix of
experimental fracture of the radius (arrow) demonstrating the
cartilaginous callus showing initial (d1) and more
anatomical alignment of the fracture. (b) Histological advanced stages
(d2) of deposition of needle like crystals
sections through the callus after seven days of
hydroxyapatite inside matrix vesicles (arrows), scattered
(b1 haematoxyllin and neutral red #40) and after between the
collagen fibers (CF). (e) EM sections (e1, e2)
2 weeks (b2 azure A #40) demonstrating development demonstrating
advanced stages of deposition of needle like
of a collar shaped callus around the fracture site with prolif- crystals of
hydroxyapatite (arrows), only inside or around
eration of osteoprogenitor cells (OP) of the cambium layer matrix vesicles
(MV). (f) EM sections (f1 and f2) through the
of the periosteum (CP) with formation of cartilaginous callus showing
advanced stages of cartilage cells from
callus (CR) at the central part of the callus and across proliferation
(PC) to hypertrophied chondocytes (HC) and
fracture and new bone trabeculae (BT) at the peripheral advanced stage
of calcification of the matrix (CM) around
part of the callus. (c) EM sections through hypertrophied degenerated
cartilage cells (DC)
chondrocytes (c1) and through these cells stained for
Management of Delayed Union, Non-Union and Mal-Union of Long Bone Fractures
245
a1 a2 a3 a4
b1 b2 b3
b4
c1 c2 c3
c4
Fig. 2 (continued)
246
non-union of long bone fractures prolongs the 100 % [28, 29]. All
these should be investigated
patients disability, and his independence and in order to correct
the delay in fracture union.
quality of life is adversely affected by these No definite
timetable to define delayed union
complications. exists; therefore,
each case has to be reviewed
individually to
decide whether a fracture is
delayed union or non-
union. Considering
Aetiology a certain technique
as treatment for non-union
fracture necessitates
exclusion of diagnoses
Though fracture repair is a continuous process, such as delayed
union, established fibrous union
a delayed union, or prolongation of time needed and pseudoarthrosis.
for fracture union and healing, may occur [4, 20]. Non-union refers
to the failure of the ends of
Delayed union may be caused by inadequate a fractured bone to
unite by 9 months post-injury.
blood supply, infection, faulty immobilization The fracture repair
process may be halted due to
or reduction, by poor fixation, by lack of appro- instability, poor
blood supply, infection, nutrition
priate nutrients for bone healing and by high deficiency, or
weakening of the bone structure by
energy injuries. Delayed union of a fracture pathological
processes. A torn provisional callus
may be influenced by f the patients age and may prevent the
continuation of the fracture
constitution, or from the fracture type or repair process, or
fracture fragments may not
impaired blood supply. In the femoral neck, have covered enough
space to provide a bridge
carpal scaphoid bone and sometimes in fractures for the callus. It is
generally agreed that the most
of the shafts of long bones, inadequate blood important aetiologic
factors of non-union are
supply of one fragment may be the cause of instability and
impaired vascularity.
slow union. Excessive traction is a wellknown
cause of slow union, as the fractured surfaces are
separated and the fragments distracted. In the Classification
case of delayed union, a fracture line is visible,
but other factors that potentially complicate Non-union of long
bone fracture is classified
union, such as fragment gaps or separation, as non-infected and
infected, based on the
sclerosis, decalcification or pathological surface presence or absence
of infection. Non-infected
cavitation, are absent. Continued weight- non-unions are
categorized into hypertrophic or
bearing will most likely end in successful hypervascular non-
union and atrophic or avas-
union. Infection is an indirect cause of delayed cular non-union
(Figs. 2 and 3) by radiographic,
union [26, 27]. In some cases of infection, fre- scintigraphic, and
histological appearance,
quent disturbance of the wound for irrigation according to the
viability of the fragment ends
and dressing interrupts strict immobilization, and other specific
characteristics [3034]. Scin-
leading to delayed union or even non-union. tigraphy studies show
a rich blood supply in the
Delayed union in lower-grade open tibial-shaft hypertrophic types
and a poor blood supply to the
fractures (Gustilo types I, II and IIIA) varies fragment ends in the
atrophic types. In some non-
from 16 % to 60 %, while in higher grade open unions, callus
formation may be evident but car-
tibial-shaft fractures (Gustilo types IIIB and tilage is interposed
rather than bone, causing
IIIC) delayed union ranges from 43 % to some degree of
clinical stability.
Fig. 2 Hypertrophic non-union fracture of the distal tibia. correction of

alignment and fixation compression by
Demonstrating clinical and radiographic images of hyper- Ilizarov external
fixation system (b1b4). Two months
trophic non-union of the distal third of the left tibia later a solid bone
union in acceptable position with equal
(a1a4) treated by osteotomy of the fibula with gradual bone length was
observed (c1c4)
247
Fig. 3 Atrophic non-union

of fracture of the humerus.
a b
c
Demonstrating clinical and
radiographic images of
atrophic non-union of the
midshaft of the humerus
(ac)
In the case of hypertrophic non-union, a callus Atrophic non-union

fractures are often the
is formed and there may even be abundant bone result of open fractures,
impaired blood supply
formation, but the bone fragments of the fractures to bone fragments, or
metabolic complications
have not united (Fig. 2). This can be due to inad- from diabetes or smoking.
Failure of initial
equate fixation of the fracture and impaired union where inadequate or
no callus is formed
mechanical stability. Typically, hypertrophic non- and bone fragments are
separated by soft tissue
unions are biologically viable, blood supply is good may result in atrophic non-
union (Fig. 3). The
and there is potential for progress with treatment by regeneration process has
halted and there is
correct alignment and rigid immobilization, resorption of bone ends.
The fracture site may
allowing compression and preventing shearing. suffer from infection
and/or bone loss. In some
Therefore, in such cases the most important factor cases there is also an
extensive loss of bone
is to achieve mechanical stability without resection fragments with segmental
bone defects due to
of the viable hypertrophic non-union callus, render- the trauma itself. Atrophic
non-unions are usually
ing bone grafting unnecessary. Internal fixation by in need of both stability
and augmentation of
compression plating or by reamed interlocking bone grafts. Atrophic non-
union can be treated
intramedullary nailing, or Ilizarov external fixation by improving fixation,
opening the endosteal
systems are the most effective surgical immobiliza- canal, removing non-viable
scar tissue and
tion options. Hypertrophic non-unions were debriding bone ends to
provide healthy tissue
further subdivided by Weber and Cech [30] for healing. Bone grafts
are necessary, preferably
as follows: using autogenous cancellous
bone from the iliac
Elephant foot non-unions are highly hypertrophic crest. Allograft bone with
or without bone
and rich in callus, and occur after unstable marrow aspirate and other
bone graft substitutes
fixation or premature weight-bearing. are sometimes used.
Internal or external fixation
Horse hoof non-unions are mildly hypertrophic is then required for
mechanical stability.
and poor in callus, typically occurring after Oligotrophic unions combine
the less extreme
a moderately unstable immobilization. characteristics of both
atrophic and hypertrophic
Oligotrophic non-unions are not hypertrophic non-unions. There is some
callus formation but
with absence of callus, and generally occur the bone ends are healthy
and viable. Biological
after fracture displacement or distraction of augmentation and mechanical
fixation are usually
the fragments. necessary.
248
Multiple systemic or local factors may affect during reduction often

delays healing of
the union of a fracture and whether it will be fractures. Unstable
fracture fixation by plates
delayed or failed. Both delayed union and non- or intramedullary nails
may be a cause of
union of fractures may be caused by endogenous non-union. Some fractures
tend to unite despite
factors, those stemming from the location and the inadequate immobilization.
Some types of frac-
nature of the fracture itself. One example is the ture require minimal
fixation, while others
fracture site: the radial shaft fracture, in cortical require strict
immobilization for an extended
bone for instance, takes up to 16 weeks to period of time. Therefore,
unstable fixation
unite and its structure raises the risk for may result in some cases
in delayed union.
non-union to 7 %, while the Colles fracture, in Prolonged immobilization
is often the solution
cancellous bone, unites in 46 weeks, with for what may seem to be
non-union in fractures
little risk of non-union [34]. Intra-articular frac- complicated by poor blood
supply or gaps.
tures have a prolonged time of union, mainly Displacement of fracture
fragments, or commi-
due to the synovial fluid that curbs clot formation, nution of bone fragments,
synovial fluid inter-
thus hampering the development of the ference with blood clot
and osteoporosis may
connecting mesh among the fragments, one also result in delayed or
non-union. Infection
of the crucial initial processes in fracture acquired during treatment
of either an open frac-
healing [35]. ture or surgical treatment
of a closed fracture,
Age can make a difference to the rate of repair raises the rate of delayed
union considerably.
[36, 37]. For example, a fractured femur will Stable immobilization
maintained for a long
unite after 4 months in an adult, even in an elderly enough time can overcome
even non-union due
person, but it takes only 4 weeks in a young child. to infection.
Other systemic factors that may influence frac- Non-union should be
established only when
ture repair are the nutritional status of the patient, delayed union is not a
possible diagnosis. In the
presence of systemic diseases, metabolic diseases case of non-union,
continued immobilization
or tumours, neurological problems like syringo- and fixation will not
result in solid union and
myelia, spina bifida and paraplegia, treatment the fracture will never
unite by bone. Inade-
with corticoids, non- steroids anti inflammatory quate immobilization is
the most frequent
drugs (NSAIDs), anti-convulsants, chemother- cause of non-union of
fractures. In a case of
apy and chronic addiction of alcohol or tobacco non-union, movement
remains present at the
smoking [3133, 3842]. fracture site and there
may be pain or tender-
Local factors that may affect fracture healing ness. Non-union occurs
when movement of
are vascular supply, method of reduction and fragments still continues
after 912 months
immobilization, soft tissue injuries and infection. and the gap margins are
welldefined, or when
Repair may be delayed by impaired or inadequate cellular activity ceases
and sclerosis sets in.
blood supply caused by either the fracture itself Sometimes fractures of the
femur or tibia are
or by the surgical exposure that strips the perios- treated by traction
without immobilization,
teum and soft tissues from the bone. However, where weight is expected
to maintain length
good fixation post-operatively will most likely and alignment. In such
cases weight can lead
prevent non-union. Gaps in the haematoma or to distraction of
fragments and non-union. Cor-
a weak or disrupted provisional callus are also rection of this situation
by reduction of weight
reasons for non-union, ones that even prolonged can lead to angulation.
Traction without immo-
immobilization will not solve. Attenuation of the bilization may result in
non-union. Atrophic
haematoma may occur when traction causes non-union may require
surgery for fracture
a small fragment to be torn from a bone. The debridement and/or bone
grafting with internal
haematoma may be completely eliminated by fixation, while in the
case of hypertrophic non-
the interposed flap of tissue that seals the ruptured union, internal or
external fixation may lead
surface of one fragment. Excessive traction to union.
249
a b c
d
Fig. 4 Delayed non-union fracture of the femur. Demon- nail. After 5 months
there were not any signs of solid
strating a delayed union of a fracture of the right femur at union (a, b). The
distal interlocking screws were then
road traffic accident in a 24 year old male. The fracture removed. Four months
later a solid union of the fracture
was reduced and fixed by an interlocking intramedullary was observed (c, d)
Treatment Options Mechanical

Stimulation
Mechanical
stimulation with functional weight-
The treatment options for long bone non-union bearing can
accelerate bone-healing in delayed
can be divided into non-surgical and surgical. unions or even non-
unions. Removal of proximal
Non-surgical options consist of functional brac- or distal locking
screws in patients with
ing with weight- bearing and exercise, external delayed or non-union
following interlocking
bone stimulation, addition of bone graft and intramedullary nail
fixation of fractures of the
injection of bone marrow or other biological femur or tibia may
also enhance progressive
modifiers, such as growth factors. Surgical bone callus
formation with bone healing (Figs. 4
options consist of internal fixation by compres- and 5).
sion plating or locked reamed intramedullary
nailing, or by distraction osteogenesis and bone Biophysical
Stimulation
compression with external fixators such as the This form of
stimulation can be done with elec-
Ilizarov apparatus, combined in some cases with tromagnetic field
stimulation, electrical stimula-
addition of bone grafts- autogenous, allogeneic, tion, ultrasound
stimulation and extra-corporeal
or bone substitutes. shock waves,
sometimes combined with various
surgical modalities,
as follows:
Electromagnetic
Stimulation
Non-Surgical Methods Several reports have
described that electromag-
netic fields can
enhance fracture healing in
Non-surgical methods that can enhance fracture patients with non-
union of long bones, but the
healing may be mechanical, physical (electrical, exact mechanism is
still unknown [12, 4349].
ultrasound stimulation or extra-corporal shock
wave), or biological methods such as bone Electrical
Stimulation
grafting (autografts, allografts, or bone graft sub- Electrical
stimulation is a non-invasive method
stitutes), use of growth factors and osteogenic that has been
effective in cases of non-union,
cells and bioactive molecules produced by tissue though this
treatment must be implemented for
engineering techniques, or a combination of all 68 months and is
not appropriate for avascular
these options [57]. non-union.
Electrical stimulation is effective in
250
a b c
d
Fig. 5 Delayed non-union fracture of femur. Demon- were not any signs of
solid union and the distal
strating a delayed union of a fracture of the left femur interlocking screws were
then removed (a, b). Five
following a fall from 6 m height in a 48 year old heavy months later a solid
union of the fracture was observed
smoker male. The fracture was reduced and fixed by an (c, d)
interlocking intramedullary nail. After 8 months there
hypertrophic non-unions. The biologic principle Surgical Methods

is based on the observation that mechanically-
stimulated bone cells produce an electrical field, Several surgical
procedures have been used in
which mediates bone cell proliferation. However, order to treat long bone
non-unions by means of
electrical stimulation cannot be used to correct internal fixation or
external fixation, which may be
angular deformities or large bone defects combined with the use of
bone grafts, bone sub-
[5052]. stitutes, bone marrow
injection, and growth factors
or the use of non-
surgical therapies, such as elec-
Ultrasound Stimulation tromagnetic field and
ultrasound therapy.
Low-intensity pulsed ultrasound may accelerate There are different
surgical modalities for
healing of delayed union and non-unions, and treatment of non-union,
as follows:
increase calcium incorporation in both cartilage 1. Reamed intramedullary
nailing provides rigid
and bone cells. Ultrasound may increase blood and stable fixation
and also allows early partial
flow through the dilation of capillaries and the weight bearing.
Although reaming destroys the
enhancement of angiogenesis, thus optimizing endosteal blood
supply, blood flow is fully
the environment that is conducive to non-union restored in 12 weeks
[64, 65].
healing [37, 5456, 5961]. 2. Non-unions can also
be treated with compres-
sion plates that
provide mechanical stability,
Extracorporeal Shock Waves but bone grafting is
often recommended in
High-energy extra-corporeal shock wave therapy such conditions,
since the plate may damage
has been shown to be effective in the treatment of the periosteal blood
flow with osteopenia
non-unions [57, 58, 62, 63]. beneath [66].
251
a b c d
e f g
h i j
Fig. 6 (continued)
252
3. In recent years the use of a limited-contact In some cases with

large bone defects,
dynamic compression plate (LC-DCP) or osteotomy and
distraction osteogenesis or bone
locking compression plates (LCP), has been transport are required,
combined with stable
developed to minimize these complications external fixation by
Ilizarov or Taylor Spatial
([67, 68], Ring 2004). Frame systems [7181].
According to Rodriguez-
4. External fixators may also be used in cases of Merchan and Forriol
[37], non-unions of long bone
non-infected and infected non-unions. Exter- fractures can be
treated successfully with a single
nal fixators provide stable immobilization of operative procedure in
more than 90 % of patients.
bone fragments with preservation of blood In fact, 80 % of
patients can have good to excellent
supply, but there is a risk of pin tract infection final restoration of
mechanical axis alignment and
[69, 70]. Circular external fixation systems proper length. Patients
with infected non-unions
such as Ilizarov or Taylor Spatial Frame sys- may require more than
one procedure to overcome
tems have made significant progress in the infection and heal the
non-union.
treatment of non-infected non-unions associ-
ated with angular deformities, bone defects
and shortening, and in the treatment of infected Bone Grafting
non-unions with osteomyelitis combined with
debridement of the infected bone segment and The treatment of
delayed unions and non-unions
antibiotic therapy [7173, 76, 80]. requires restoration of
alignment, stable fixation,
The preferred surgical modality is chosen and, in many cases,
addition of bone grafts
according to the type of non-union hypertrophic or bone transport, or
use of bone-graft substi-
or atrophic and also according to the presence of tutes for stimulating
bone repair and filling
infection as follows: hypertrophic non-unions are bone defects [82].
Cancellous bone-graft mate-
viable, with an adequate blood supply and abun- rials usually have one
or more components:
dant callus formation but lack mechanical stability an osteo-conductive
matrix that serves as
and therefore often can be treated by stable fixation a scaffold which
supports the in-growth of new
with compression of the fragments alone (Fig. 2). bone, an osteo-
inductive protein that supports
Atrophic non-unions (avascular) are non-viable, mitogenesis of
mesenchymal osteoprognitor
with poor blood supply and therefore require cells, and osteogenic
cells (vital osteoblasts or
decortication of fracture fragments and biological osteoblast precursors),
that are capable of
stimulation by bone grafting or bone transport forming new bone in the
proper environment.
together with stable fixation (Fig. 6). In cases of Osteo-induction is
mediated by graft-derived
infected non-union, treatment consists of debride- growth factors such as
bone morphogenetic
ment of the infected area, application of antibiotic proteins, platelet-
derived growth factors, inter-
beads, and stimulation of bone healing by bone leukins, fibroblast
growth factors, and insulin-
grafting, combined with stable fixation and sys- like growth factors.
Local autologous bone
temic antibiotic therapy (Fig. 7). marrow provides a graft
that is osteogenic and
Fig. 6 Surgical treatment for atrophic non-union fracture femur for bone
lengthening and stabilization by knee
of the distal femur. Demonstrating a 54 year old male cross bridging by
hybrid LRS Orthofix combined
with stiff knee, shortening of 4.5 cm of the lower limb with Shefield rings for
stable compression at fracture
and atrophic nonunion 8 months following open site simultaneously
with bone transport and elongation.
comminuted fracture of the distal right femur at road (c, d, e). Six months
later a solid bone union was
traffic accident. He was treated initially elsewhere by observed (arrows f,
g) with remodeling of the new
excision of wounds and unilateral external fixation bone regenerate (arrows
h) and after additional
(a, b). The patient was treated by us by debridement 2 months the fixator
was removed. Clinical results
of fracture gaps with removal of fibrous tissues from after additional 12
months revealed equal limb length
fracture gaps and addition of iliac bone graft of the with full knee
extension and 80 degrees of flexion (i, j)
femur (arrow), followed by osteotomy of the proximal
253
potentially osteo-inductive through cytokines the patients own body. Such a

graft would
and growth factors secreted by the transplanted be both osteogenic and osteo-
conductive.
cells, and can stimulate healing of non-union Cortical allografts provide
structural strength,
[8488]. Injections of autologous bone marrow but their osteogenic properties
are limited. Cor-
provides a graft that is osteogenic and poten- tical bone grafts are mostly
osteo-conductive
tially osteo-inductive through cytokines and with few or no osteo-inductive
properties [82].
growth factors secreted by the transplanted Cortical bone grafts are
usually harvested
cells ([8386], Ring 2004). The technique is from the iliac crest, ribs, or
fibula and can be
simple: marrow is aspirated from the iliac wing transplanted with or without
their vascular ped-
and directly injected into the non-union site, icle, i.e. non-vascularized or
vascularized corti-
which should be stabilized by cast bracing or cal bone grafts [89]. Several
clinical and
by surgical fixation. experimental studies have
demonstrated the
Cortical and cancellous autologous bone superior biological and
mechanical properties
graft can be harvested from the iliac crest. of vascularized bone grafts as
compared with
Autogenous cancellous graft is always fresh non-vascularized bone grafts
[8995].
and most preferred as there is less risk of Allogenic bone grafts are
used in various
graft rejection since the graft originated from Orthopaedic procedures such as
bone tumour
a1 a2 b c
Fig. 7 (continued)
254
e f
g
h i
j
k
Fig. 7 Surgical treatment for infected non-union fracture osteomyelitis of

the femur, treated by multiple procedures
of the femur. Demonstrating a 51 year old male, 12 of incision and
drainage. The patient was treated by us by
months following open comminuted fracture of the distal resection of the
infected bone fragments with debridement
right femur at road traffic accident, with stiff knee, short- of fracture gaps
and removal of fibrous tissues, leaving
ening of 6 cm of the lower limb and infected atrophic a fracture gap of
about 8 cm, followed then by acute short-
nonunion (arrows in CT reconstruction a1, a2, b). He ening and closure
of gap. This was followed by osteotomy
was treated initially elsewhere by excision of wounds and of the proximal
femur for bone lengthening over
unilateral external fixation, but developed acute a retrograde
intramedullary nail (horizontal black arrow c)
255
surgery, spine surgery, and during revision involve flat bones such
as the pelvis or scapula;
arthroplasty. They may require more than one it may happen in short
bones such as scaphoid, as
procedure to overcome infection and heal well as in tubular
bones. What are the possible
the non-union. Bone allografts are harvested ranges of deviation
from anatomical parameters
from cadavers. They are usually stored in bone for normal fracture
healing? What is the border
banks by freezing, freeze-drying or irradiation line that divides
acceptable from unacceptable
sterilization procedures to avoid disease trans- positions of bone
segments after fracture healing?
mission [53]. Allogeneic bone as a treatment When is a condition
considered pathological?
modality for non-union can be used as The literature has not
given clear answers to
osteochondral segments, cortical or cortico- these questions.
cancellous grafts, morselized and cancellous
chips, or as demineralized bone matrix (DBM),
which has a greater osteo-inductive potential than
conventional allografts [82, 88, 9699]. Aetiology and
Classification
Another option is to use additional bone graft
substitutes that are biocompatible and have the Though many causes of
inappropriate bone
properties of osteo-conduction and osteo- healing are known,
three main aetiologic groups
induction, i.e., they can provide scaffolding for are recognized:
osteo-conduction, growth factors for osteo- 1. A fracture that was
left in an inappropriate
induction, and progenitor cells for osteogenesis position initially
and healed incorrectly;
[88, 100]. The currently available bone graft sub- 2. Inadequate fracture
fixation in a cast or by
stitutes include calcium phosphate ceramics such internal or external
fixation device;
as hydroxyapatite and tri-calcium phosphate, bio- 3. An anatomically-
reduced and well-fixed
active glass, biodegradable polymers, recombi- fracture in a
growing child with unpredictable
nant human BMPs (OP-1 and BMP-2), and bone alignment due
to growth arrest or
autologous bone marrow cells. Growth factors overgrowth.
are osteo-inductive and can be obtained by In long bones we may
categorize mal-union
means of recombinant synthesis, but they are according to anatomical
place. Intra-articular
expensive and not autologous. Autologous acti- mal-union, for example,
may be a condition
vated platelets may be used as a source of autol- after malleolar, tibial
plateau, or distal radius
ogous growth factor (AGF) that may stimulate fracture. Metaphyseal
mal-union is also not
osteogenesis in long bone non-unions. a rare circumstance,
especially after fractures
of proximal humerus,
proximal femur or tibia.
Deformity following
fracture of the diaphyseal
Mal-Union of Fractures part of the bone is
known as diaphyseal mal-
union. Mal-union may
occur as a result of rota-
General Introduction tional mal-alignment
following the fracture; this
situation may have
superior clinical importance
Mal-union of fracture refers to the healing of especially in the lower
limbs. A combination of
a fracture with incorrect anatomical alignment. planar and rotational
deformity in the same mal-
Mal-union is a widely-described problem, as it union is a common
occurrence; for example,
may occur in any part of the skeleton. It may tibial fracture may
heal with varus, procurvatum
Fig. 7 (continued) and bone transport toward the hip 14 months later a solid
bone union with acceptable align-
using the LRS Orthofix.- vertical arrow c). First signs ment was observed
together with remodeling of the new
of the new regenerate were visible after 2 months (white bone regenerate (e, f,
g). Clinical images taken 2 years
arrows- c). This combined system enabled bone transport later revealed equal
limb length with full knee extension
along the femoral axis combined with stable fixation (d). and 50# of flexion (h,
i, j, k)
256
and excessive internal tibial torsion. Each com- may be helpful, and it is
possible to perform a CT
ponent of this deformity must be recognized Rotational Mal-alignment
Test in addition to the
separately [101]. Plane Mal-alignment Test
[101]. CT may also be
helpful in measuring limb
length discrepancy.
In many cases even
minimal displacement of
Biomechanics a few millimeters will be
unacceptable in the
reduction of malleolar,
patellar, and other intra-
Significant deformity may influence function of an articular fractures. Intra-
articular mal-union is
impaired limb, causing restricted joint motion, itself an extensive field
in Orthopedics and often
especially in the case of intra-articular and related to the area of
joint surgery. In this chapter
metaphyseal mal-unions. In the lower limbs, we shall focus on mal-union
of long bones where
which have the task of weightbearing, even small the range of acceptable
displacement in fracture
deviations from proper anatomical position during healing varies, depending
on fracture location,
fracture healing will cause changes in normal limb patient age and involved
segment. Specifically,
axis, resulting in abnormal stress on adjacent joints we shall concentrate on
extra-articular mal-union
and increasing future possibility of osteoarthritis. of long bones.
In addition mal-union may cause limb length dis-
crepancy due to longitudinal translation of bone
fragments or deformity of the bone. All these Indications for Surgery
factors require careful investigation of each suspi-
cious condition for mal-union of fractures [102]. Approach to mal-position of
clavicular fracture
and mal-union of the
clavicle is still controversial
[104, 105]. Khan et al.
advocate intervention with
Diagnosis clavicular shortening of
more than 15 mm. Bulky
callus may be cosmetically
unacceptable or may
Diagnosis begins with careful history and exam- even cause pressure on
neurovascular structures,
ination of the patients limbs for range of joint providing relative
indications for surgery. At the
movement, tenderness, and presence of deformi- same time any range of
clavicular deformity may
ties. It is very important to check rotational be acceptable in a growing
child because of the
profile of the limb in order to exclude mal- huge potential for bone
remodelling [106].
rotation. In the case of single limb injury, the Mal-union of the humeral
shaft is more
results of a physical examination should be com- a cosmetic issue, as
Broadbent et al. [107] found
pared with the uninjured limb. At this point radio- that function was not
compromised in angula-
graphs should be examined. tions of up to 25# of
varus. The mal-union is
Sometimes bulky callus or presence of inter- usually a painless
deformity without impairment
nal fixation may complicate diagnosis, and sim- of shoulder and elbow
function. However,
ply viewing radiographs along with clinical recurvatum deformity of the
humerus, especially
examination of the patient may be not enough in distal third, may
imitate flexion contracture of
for proper diagnosis. In order to avoid the elbow, while
procurvatum may cause a sense
overlooking pathology, it is necessary to perform of over-extension in the
elbow.
a simple mal-alignment test. This method of The anatomical position
of forearm bones has
diagnosis, systematized by Paley, provides a higher functional
importance. Shortening of
the possibility of precise placement of one of these bones may
cause a pathological
mechanical and anatomical axis, joint lines and condition of the adjacent
joints. For example,
the measurement of their relationship on a considerable angulation of
the ulnar shaft will
radiograph [103]. cause shortening of the
ulna and may lead to
In order to investigate rotational mal- subluxation or even
dislocation of the humero-
alignment, computer tomography of the limb radial joint. This
condition is described as
257
neglected Monteggia fracture and requires surgi- wide use of intramedullary

nailing and locked
cal correction with restoration of alignment of the compressive plates. Precise
evaluation and
ulna and reduction of the radial head [108]. proper treatment of a
femoral shaft fracture
Isolated deformity of the radius may cause decrease the risk of such
complications. Conser-
dysfunction of the distal radio-ulnar joint vative treatment of a
femoral shaft fracture,
(DRUJ) and deformity of the wrist joint with however, will almost always
resolve with some
prominence of both distal and ulna. Because degree of mal-union. No
clear parameters of the
of precise synergism of two bones in one segment clinical significance of
femoral shaft deformity
of the forearm and a relatively wide range were found in the
literature [112]. Many authors
of motion, even small deformities will cause consider angulation and
mal-rotation of
restriction of forearm rotation pronation, more than 10# and
shortening of 2.5 cm as
supination or both. Nagy et al. found that the borderline of
acceptable alignment. Clinical
angulation of 10# of one forearm bone has little significance grows
progressively as angulation or
impact on motion, but combined deformities of mal-rotation increases
[113, 114].
10# of the radius and ulna toward the interosseous In small children
conservative treatment of
membrane considerably decrease supination femoral shaft fractures is
the method of choice;
[109]. Isolated 20-# angulation of the radius is as a result, some amount of
deformity always
usually accompanied by markedrestriction of the presents after fracture
healing. Wallace et al.
forearm rotation. (1992) found that in
children under 13 years of
The approach to treatment of forearm frac- age, mal-union of as much
as 25# in any plane
tures in children is less rigid. Good potential for will remodel enough to give
normal alignment of
bone remodelling allows conservative treatment the joints [115]. Davids
[116] reported that rota-
and followup with angulation of up to 30# in tional deformity of up to
25# is well-tolerated
children younger than 9 years old [110]. At the clinically, but found poor
remodelling potential
same time, mal-union with angulation of more of significant post-
traumatic torsional deformity
than 20# in a child older than 9 years is unlikely to of the femur in children.
be sufficiently remodelled and will most likely Tibial mal-union is a
much more common
need osteotomy and correction. pathology. Wade et al.
[117] testify to the
As we mentioned earlier, even a small defor- absence of consensus
concerning indications for
mity of the femur or tibia may influence lower correction of tibial
malunion, quoting both
limb function due to changes of vectors of weight Russell who maintains that
mal-alignment of
bearing [103]. Coxa vara is usually the mal-union more than 15# may require
corrective osteotomy,
of the proximal femur. Changes in the femoral and Apley and Solomon who
consider angulation
neck-shaft angle secondary to fracture will lead of more than 7# or any
rotation to be unaccept-
to limblength discrepancy, weakening of hip able. Mashru et al. [118]
found that 10# of coronal
abductors and restriction of hip motion. Patho- or saggital plane
angulation will remodel predict-
logic femoral torsion in trochanteric mal-union ably in children younger
than 8 years of age.
may cause mal-function of the distal joint of the Dwyer et al. [119] examined
children in
lower limb. Restoration of normal alignment is the 312-year age range,
concluding that
usually preferred in adult patients. Coxa vara, deformities that corrected
completely were 12#
defined as a femoral neck shaft angle of less of antecurvatum and 6# of
recurvatum. In
than 120# , is the second most common complica- the coronal plane,
acceptable critical angular
tion of hip fractures in children. In very young deformities were 10# varus
and 8# valgus.
children (03 years old) mild coxa vara may Most remodelling occurs in
the first 2 years
remodel if the neck-shaft angle is more than after injury. Rotational
mal-union does not
110# [111]. remodel with growth. Mal-
rotation beyond 10#
Mal-union of the femoral shaft is an uncom- may result in functional
impairment or unaccept-
mon pathology today since the introduction and able cosmesis.
258 G. Volpin and H. Shtarker
a b c d
e f
h i
Fig. 8 (continued)
259
Operative Techniques deformity will lead

to irreversible disability.
The main goals of
treatment are restoration of
After proper diagnosis, performance of mal- length and shape of
the ulna, as well as the resto-
alignment tests and reassurance of the parameters ration of a normal
relationship between radial
of mal-position, the surgeon should decide on head and capitellum
of humerus (Fig. 8ad).
a method of treatment. Modern Orthopaedics Open osteotomy of
the ulna at the proximal and
has disposed of many methods of mal-union cor- middle third level
with fixation by rigid
rection and fixation. Traditional open osteotomy intramedullary Rush
pin will restore normal anat-
and plate or rod fixation have been replaced by omy and reduce the
dislocated radial head
minimallyinvasive percutaneous osteotomies and (Fig. 8ei). Full
range of motion and absence of
external fixation, which have proven to be more pain were found
after fracture healing.
precise. Furthermore, treatment by external fixa- Another example
is the severe mal-union that
tion is dynamic and allows additional re-checking occurs following
lack of fixation of fracture in the
during treatment and performance of final tuning proximal femoral
shaft. Severe deformity of the
of deformity correction. right femur results
in angulation, translation and
Osteotomy may be carried out at the level of shortening of the
femur (Fig. 9). Severe
CORA as well as at another level. If the center of limblength
discrepancy exacerbates deviation of
deformity is located in a place suitable for mechanical axis and
stress of the joints. Interven-
osteotomy, it is preferable to use this point tional procedures
aim to restore normal anatom-
in order to avoid translation of bone fragments ical and mechanical
axis of femur and its length,
during correction. Sometimes CORA of defor- to correct mal-
rotation, and to achieve stable
mity locates in an anatomically-complicated fixation [121, 122].
The Ilizarov method was
place or even outside the operated segment, chosen to allow
maximum precision of correction
especially in the metaphyseal or peri-articular and stable fixation
which, in turn, allow early
non-unions; in such situations correction and weightbearing and
non-restriction of adjacent
translation of bony fragments should be precisely joints, and for
early physical therapy and avoid-
calculated [120]. ance of joint
contractures. Since severe deformity
One example is the condition that follows with established
mal-union of the femoral shaft is
neglected Monteggia fracture, where angular concerned, division
of mal-unated fragments and
deformity of the proximal ulna was overlooked their re-
canalization may be an overly traumatic
and caused dislocation of radial head (Fig. 8). procedure. We prefer
performing a resection of
This pathology frequently causes diagnostic the deformed part of
the femur, creating acute
problems, due to plastic deformity of the ulnar shortening with
simultaneous gradual lengthen-
bone rather than simple fracture. Pain in the ing through
additional osteotomy (Fig. 9). This
elbow joint and restriction of pronation and supi- method is described
as one of the ways to trans-
nation in the forearm are clinical signs presenting port bone. Stable
fixation by ring TrueLok
in the patient. Continuing neglect of the fixators is
achieved, bone shape is restored and
Fig. 8 Surgical treatment of neglected Monteggia frac- nail for restoration

of the ulnar bone alignment were done
ture with angulated ulna and dislocation of the radial head. and then the radial
head was reduced (e, f). Arthrography
Demonstrating neglected Monteggia fracture of forearm of the elbow
revealed anatomical alignment of the radial
of a 12 year old boy. The plastic deformity of the ulna head (g). Three
months later a solid bone union in ana-
causes dislocation of head of radius as observed in plain tomical alignment of
ulna and radial head were observed
radiographs and Tri-dimensional CT reconstruction (a, b, (h, i)
c, d). Ulnar osteotomy with insertion of intramedullary
260 G.
Volpin and H. Shtarker
additional osteotomy for lengthening is done. mal-rotation, with excessive

external or internal
The docking side of the resection and bone regen- tibial torsion, is a rather
common pathology.
erate healed without complications. Normal Good quality plane radiogram
with proper limb
length and axis of the lower limb were achieved. position in combination with CT
scan is essential
The Ilizarov method is especially effective in for pre-operative planning.
After calculation of
such cases as combined angular and rotational the extent of angulation and
its direction and the
deformities. Angular deformity of the tibia and amount of mal-rotation, frame
planning and
a b c d
e f
Fig. 9 (continued)
261
g h i
j k
Fig. 9 Surgical treatment for neglected sever mal-union 2 weeks, d- after 3

months). During the next 9 months of
of the proximal femur. A 42 year old male with an anam- femoral lengthening
a good quality of bone regenerate
nesis of closed fracture of the proximal third of right femur was observed
throughout the gap of the distraction with
that was treated elsewhere by splint. The fracture united development of
solid union in the compression site. The
with shortening of 5 cm and severe malaligment due to TroeLok external
fixator is very stable and allows full
complete translation and angulation (a, b). He was treated weight bearing (e,
f). Control radiographs after 9 months
by us by resection of the callus with malunion, followed revealed healing of
the femoral bone in normal alignment
by application of TroeLok Ilizarov external fixation sys- and restoration of
normal length. Bone regenerate was
tem for acute shortening in the fracture site by compres- maturated and
appeared as normal bone (g, h, i). Clinical
sion and by additional osteotomy in the distal femoral images taken 6
months later showed equal limb length
metaphysis for bone lengthening by distraction (c- after with full hip and
knee ROM (j, k)
262
a b c
d
e f g
h
Fig. 10 Surgical treatment for neglected sever mal-union by performance of

percutaneous proximal tibial
of the proximal tibia treated by Taylor Spatial Frame. A 48 osteotomy (c, d). Two
months later a restoration of normal
year old male with malunion of the proximal left tibia (a, alignment was
achieved, and the osteotomy healed with-
b) after inappropriate plating of a fracture dome elsewhere out complications (e,
f). 90# MPTA without deviation of
with severely decreased MPTA (Medial Proximal Tibial bone axis was noted.
Taylor Spatial Frame allows weight
Angle). He was treated by us by application of Taylor bearing and lives
free adjacent joints (g)
Spatial Frame applied for deformity correction followed
assembling begins. Gradual de-rotation and performed in a

minimally- invasive manner.
angular correction will help avoid possible trac- Osteotomies may be
performed percutaneously
tion of neurovascular structures. In the case of and only small
incisions will be necessary for
relatively small deformities, acute anatomical nail insertion and
its locking.
correction may be done by external fixation as Another
possibility is the use of external
a first stage of surgery, after which an fixation as a
definitive method of correction and
intramedullary nail with locking may be inserted fixation. The
Ilizarov external fixator offers more
in a precise, corrected position [123]. The exter- opportunities for the
experienced surgeon. The
nal fixator will be removed after completion of Taylor spatial frame
may simplify the construc-
locking, since the interlocking nail is a stable tion especially in
combined deformities. Special
enough fixation. This procedure may be software is designed
to calculate deformity
263
correction using virtual hinges. Other devices 16. Wuthier RE. A

review of the primary mechanism of
such as the Hexapod Frame may be used enchondral
calcification with special emphasis on the
role of cells,
mitochondria and matrix vesicles. Clin
for the same purpose in addition to the conven- Orthop Rel Res.
1982;169:21942.
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Gerstenfeld LC, Einhorn TA. Differential
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2009;468(5):135261.
Necrotising Fasciitis
Nikolaos K. Kanakaris and

Peter V. Giannoudis
Contents
Abstract
268 Despite the expanded understanding on the
pathophysiology of sepsis, the contemporary

sophisticated diagnostic methods, and the

Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 269 modern advanced antibiotics, surgical
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 270 debridement remains the cornerstone of treat-
Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 270 ment of necrotising fasciitis. The high mortal-
Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
271 ity and morbidity of the disease remains
Radiological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
271
Histological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
272
a significant concern, while its incidence and

Differential
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
273 microbiology appears to be evolving. Clinical
research on this rare and lethal disease lacks of

Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 273
high-level evidence, highlighting the neces-

sity of multicentre collaboration on this scien-
273 tific effort.
Post-Operative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
274
Antibiotic
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
274 Keywords
Supportive
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
276 Aetiology and classification # Complications #
Adjunctive
Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
276 Diagnosis # Management # Necrotising
Complications Outcome . . . . . . . . . . . . . . . . . . . . . . . . . 276
Fasciitis # Outcomes # Pathophysiology #
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 277 Pre-op planning # Rehabilitation # Surgical
technique
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 277
Abbreviations
ARDS Acute respiratory distress
syndrome
Atm Atmospheres
N.K. Kanakaris
CK Creatine kinase
CRP C-reactive protein
School of Medicine, Leeds General Infirmary, Leeds,
CT-scan Computed tomography scan
West Yorkshire, UK
ESR Erythrocyte sedimentation rate

e-mail: nikolaoskanakaris@yahoo.co.uk
Hb Haemoglobin
P.V. Giannoudis (*)
HBO Hyperbaric oxygen therapy

IL-1/6 Interleukin 1/6
IV Intravenous

267
DOI 10.1007/978-3-642-34746-7_73, # EFORT 2014
268 N.K.
Kanakaris and P.V. Giannoudis
IVIG Intravenous immunoglobulin G anticipated to gain

adequate experience in his
LFTs Liver function tests standard practice.
LRINEC Laboratory Risk Indicator for For yet undetermined
reasons the incidence
Necrotising fasciitis has increased the last
second decades. Possible
MOF Multiple organ failure explanations could be the
increased microbial
MRI Magnetic resonance imaging virulence and resistance
due to the excessive
MRSA Methicillin-resistant Staphylo- universal use of
antibiotics, the increased clinical
coccus aureus awareness, and the
establishment of international
NSTI Necrotising soft tissue infection reporting pathways [7].
SIRS Systemic inflammatory In a recent systematic
review [8] of the existing
response syndrome evidence, the male-to-
female ratio was 2/1 with
TNF-a Tumour necrosis factor a the age ranging from 5 to
88 years (average
WBC White blood cells 45 years). Ethnic
variations have been reported
[9], however they can
mostly be attributed to
differences in the
prevalence of contributing risk
factors, communication
issues, and causes of
General Introduction delayed presentation [10,
11]. The lower extremi-
ties are the most commonly
affected anatomical
The term Necrotising Fasciitis was introduced site, followed by the
perineum, the upper extrem-
in 1952 by Wilson [1] to describe an inflamma- ities, and virtually any
other body part in smaller
tory disease, caused by several microbes, located numbers [12].
at any anatomical site, resulting in necrosis of
the fascial planes and the subcutaneous fat with
usually devastating results.
Its basic clinical characteristics have been Aetiology and
Classification
described in the past, starting from Hippocrates
in the fifth century BC: . . . many were attacked Usually an injury near to
the affected anatomical
by the erysipelas all over the body when the site precedes the
development of this infection.
exciting cause was a trivial accident. . . flesh, The severity of this local
trauma may be minimal
sinews, and bones fell away in large quantities. . . and there are reported
cases associated with
there were many deaths [2]. minor blunt or penetrating
trauma and burns,
Since then, a number of authors have assigned needle biopsies, surgical
incisions, peri-rectal
to this clinical entity a variety of terms including: abscesses, childbirth, even
chicken pox. In
hospital gangrene, Fournier gangrene, a number of cases no
definite portal of entry to
phagedema, phagedema gangrenosum, pro- the patients skin is
identified or any trauma event
gressive bacterial synergistic gangrene, non- in the patients history.
clostridial gas gangrene, flesh-eating bacterium, Host conditions related
to immune deficiency
necrotising soft tissue infection (NSTI) [3, 4]. are considered as risk
factors for necrotising
Irrespective of terminology is considered as fasciitis. Diabetes
mellitus is present in
the most aggressive form of soft tissue infection, 1860 % of the cases [13,
14], while other risk
with a rapid life-threatening course, and still factors include obesity
[15], peripheral vascular
today with often a poor prognosis. disease [16], intravenous
drug / alcohol abuse
According to recent reports there are almost [16], malnutrition [17],
smoking [16], chronic
1,000 cases of necrotising fasciitis per year in the cardiac disease [16], the
continued or chronic
United States, or 0.40.53 cases per 100,000 of use of non-steroidal anti-
inflammatory drugs
population [5, 6]. The prevalence of this disease [18], chronic
corticosteroid therapy [19],
is such that the average clinician could not be cancer, gout [20], and
increased age [21].
269
Table 1 Classification of necrotising fasciitis according to the microbial cause

[12]
Type 1 [22] Type 2 [16, 22]
Type 3 [22, 64]
Aetiology Polymicrobial (45 species) Monomicrobial (Streptococcus
Marine vibrios, Gram-negative
(Gram-positive cocci, pyogenes, Staphylococcus,
rods (Vibrio Vulnificus %,
Gram-negative rods, Clostridia, MRSA, or other
Klebsiella, Escherichia coli,
Anaerobes) species)
et al.)
Incidence 5575 % 810 %
25 %
Anatomical % abdominal perineal Flesh eating of
Small wound from fish/cut/
site wounds extremities toxic shock
insect bite extremities %
Epidemiology % immunocompromised, % Healthy patients
Liver disease, chronic
diabetic patients
Hepatitis-B
Prognosis High mortality Moderate mortality
Highest mortality
Besides the numerous co-morbidities statisti- The speed of the

pathological sequel is depen-
cally related to an increased risk for necrotising dent on the
characteristics of the microbes, the
fasciitis, it should be emphasised that 2050 % local biology, and the
defences of the host.
of all cases were in previously healthy individ- The nowadays rare
Clostridium species produce
uals [12, 17]. an a-toxin that causes
extensive local necrosis
The responsible micro-organisms vary signif- and systemic shock.
Staphylococcus aureus and
icantly and may include aerobic / anaerobic, gram Streptococci species
express surface proteins
positive/negative, or even fungi (Candida, and toxins (M-1, M-3,
exotoxins A-B-C,
Aspergillus, Rhizopus species) [22]. Recently, streptolysin O, and
superantigen) that allow
community acquired methicillin-resistant staph- them to adhere to the
host tissues, escape the
ylococcus aureus (MRSA)-related necrotising defence mechanism of
phagocytosis, cause
fasciitis has been described in relatively high damage to the
endothelium, resulting in tissue
proportions [23, 24]. MRSA is currently cultured oedema and impairment
of the local blood flow.
in 40 % of necrotic wounds particularly in The stimulation of the
defence mechanisms
intravenous drug abusers, athletes, and (CD4 cells and
macrophages), and the produc-
institutionalised groups of patients [23, 25]. tion of cytokines of
the acute phase in large
A classification based on Gram stain and culture quantities (TNF-a, IL-
1, and IL-6) leads to
is often used [12] (Table 1). a systemic
inflammatory response (SIRS),
and/or septic shock,
and/or multi-system organ
dysfunction, and in
some cases eventually to
Pathophysiology death. The secretion
of the cytokines (TNF-a)
interacts also with
the vascular endothelium,
Following mostly external trauma, or more rarely, stimulating the
neutrophil degranulation,
direct spread from perforated visceral organs activating the
coagulation cascade (comple-
(lower gastro-intestinal or urogenital tract), ment, bradykinin /
kallikrein system), promot-
microbes invade the subcutaneous tissues. The ing small vessel
thrombosis (due to the local
secretion of endo- and exo-toxins is followed by hypercoagulable
state, platelet-neutrophil
tissue ischaemia and necrosis. Thrombosis of the plugging of small
vessels, and the increased
perforating vessels to the skin is the resulting key interstitial
pressure). Thus, tissue perfusion,
feature of necrotic fasciitis, which declares itself capillary blood flow,
and subsequently local
by a gradually increasing subcutaneous and skin distribution of
antibiotics are all diminished,
necrotic lesion. explaining the
mechanism of ischaemic necrosis
Infection can spread locally rapidly (1 cm/ h) and the
ineffectiveness of antibiotic therapy
without major skin findings at the early stages. alone [26, 27].
270 N.K.
Diagnosis
Clinical Presentation
The diagnosis should be based principally to the

clinical pre- and mostly intra-operative findings.
Any delay caused in order to attain radiological
or laboratory verification may be proven detri-
mental, and surgical debridement should be
performed early together with the initiation of
intravenous antibiotic therapy.
The typical presentation of necrotising fascii-
tis is usually a slightly inflamed area of soft tissue
that rapidly advances to fasciitis combined
with systemic toxicity. In the first stages, the
subtle clinical findings may be mistaken as sim-
ple cellulitis [11] (Fig. 1). In a percentage of
2040 % of the cases there is a clear history of
trauma, or a break of skin within 48-h from the
onset of symptoms. A high index of suspicion at
these early stages may be decisive for the final
outcome.
Fig. 1 Spontaneous type-2
necrotising fasciitis, rapidly
In this phase of acute inflammation which is expanding cellulitis (6 h
from initial marking)
excessive and disproportionate to the local find-
ings, pain and tenderness to palpation (almost in
all cases), and rapid expansion (may be >1 cm/h)
of non-specific skin findings (swelling, warmth,
erythema, wooden skin) should alert the drop of the level of
consciousness, accompanied
clinician to the seriousness of the patients by bacteraemia (50 %),
acute renal failure
condition [5, 28]. (35 %), coagulopathy (29
%), acute respiratory
As the disease progresses more classic distress syndrome (14 %)
compose the cardinal
signs develop, including blisters and cysts composites of a fast
multiple-organ failure
with serosanguinous or haemorrhagic fluid. The and a rapidly
deteriorating critically ill patient
skin passes stages from discoloration to black [29, 30].
necrotic sloughing eschars, surrounded by rap- The absence of any of
the above symptoms
idly increasing oedema. In the presence of gas may occur and should not
misguide the clinician,
(depending on the type of the responsible bacte- who should follow the
patient closely alerted by
ria) crepitus may develop. Analgaesia over the presence of
disproportionate, to the cellulitic
the necrotic skin areas is typical accompanying lesion, pain, and the
rapid deterioration of the
the destruction of cutaneous nerves. The subse- general condition [12,
31]. In fulminant cases
quent necrosis of the fat and fascia produce the (mostly type 3 Table 1)
it may be that cardio-
characteristic discharge of a greyish-watery-foul- vascular collapse precedes
the extensive soft tis-
smelling pus fluid [22]. sue and skin changes. The
reported average time
Gradually the patient develops an escalating from the first signs and
symptoms to the diagnosis
systemic state that leads to septic shock of the disease and the
escalation of the clinical
in over than 30 % of the cases. Fever-chills presentation varies from 2
to 4 days, while in rare
>38.5 # C (59 %), tachycardia, hypotension, cases may take weeks [32].
271
Laboratory Evaluation Table 2 Laboratory Risk

Indicator for Necrotising fasci-
itis score [35]
The related laboratory evaluation includes a full Variables
Value LRINEC score
blood count, biochemistry panel, as well as liver CRP
<150 0
function tests, and coagulation studies. Blood
#150 4
cultures should be always taken, are positive in WBC (cells/mm3)
<15 0
half of the cases, and, following the sensitivity
1525 1
>25 2
tests, guide the antibiotic therapy. However, their
Haemoglobin (g/dL)
>13.5 0
sensitivity can be low, down to 18 % [11]. In the
1113.5 1
presence of septic shock arterial blood gases are
<11 2
needed to monitor the acid-base balance and
Sodium (mmol/L)
#135 0
respiratory function [21]. Often, dependent on
<135 2
the phase of the sepsis and the immune response Creatinine (mcg/L)
#141 0
of the host, there are electrolyte deficits (Na, K),
>141 2
increase of creatine kinase, hypoalbuminaemia, Glucose (mmol/L)
#10 0
hypertransaminasaemia, thrombocytopenia,
>10 1
anaemia, raised ESR and CRP. The progress of
the observed laboratory parameters reflects the
decline of the patients condition, or the success-
ful response to the antibiotics and surgical
interventions. and this after the
necrosis has progressed signif-
In 2000 Wall et al. [33] described a diagnostic icantly and only in a
number of cases. Ultraso-
model able mostly to exclude the presence nography, a useful
diagnostic tool for abscesses
of necrotising fasciitis (sensitivity 90 %, and cellulitis, is not
considered sensitive or spe-
specificity 76 %, poor predictive value 26 %). cific enough for
differentiating necrotising fasci-
Simonart et al. [34] proposed that CRP levels itis [36].
>15 mg/dl have a sensitivity of 89 % and CT-scanning is more
sensitive as it can iden-
specificity of 90 %, while elevation of CK levels tify the pathological
signal of the affected subcu-
>600 U/L are highly specific (95 %) for taneous fat and deep
fascia in more than 80 % of
necrotising fasciitis in contrast to plain cellulitis. all necrotising fasciitis
cases, as well as thicken-
In the same year (2004), the Laboratory Risk ing and increased
enhancement of the affected
Indicator for Necrotising fasciitis (LRINEC) tissue planes,
subcutaneous gas collection, and
was developed (Table 2). It incorporates param- soft tissue oedema
defining accurately the extent
eters such as the CRP, WBC, Hb, serum Sodium, of the disease [32].
Nevertheless, there are
Creatinine, and Glucose levels to identify the rare described cases with
false-negative CT-scan
necrotising fasciitis cases fro other more frequent results, and reported
findings are not universal
soft tissue infections. The summation of the [5, 31].
sub-scores varies between 0 and 13. Above 6 MRI scans are
significantly more sensitive
(cut- off point) the probability of necrotising fas- (>93 %) even in the early
stages of necrotising
ciitis is >50 %, while the overall positive and fasciitis, while
specificity is lower (5085 %).
negative predictive values are 92 % and 96 % T2-weighted images detect
the thickening of
respectively [35]. soft tissues followed by
the high signal of
necrotic tissue and the
fluid accumulation follow-
ing the liquefaction of
subcutaneous fat and
Radiological Evaluation fascia layers. Contrast-
enhanced T1-weighted
images detect the
peripheral enhancement at
The only related finding on plain x-rays is the the margins of the lesion
as well as the oedema
presence of gas in the subcutaneous soft tissues of the deep fascial planes
[37]. Nevertheless, an
272
N.K. Kanakaris and P.V. Giannoudis
a b
c d
Fig. 2 Intra-operative photographs of initial debridement subcutaneous fat

(arrow), while the muscle groups appear
of necrotising fasciitis case affecting the left thigh. (a) unaffected. (c) Same
patient, following wide excision of
Extensive skin incision over left femur. (b) Elevation of infected layers to
healthy tissue. (d) Application of Vac-
affected fascio-cutaneous flap, marked necrosis of the Pac following initial
debridement
MRI scan may be impractical for critically ill dishwater pus,

absence of bleeding, and lack of
or unstable patients and should not delay the tissue resistance to
the insertion of the finger are
delivery of the necessary surgical treatment. considered to be
positive findings. At the same
time a frozen-section
biopsy can be taken via
a small elliptical
section of skin-fat-fascia of the
Histological Evaluation suspected area, as
well as from one at the periph-
ery of the affected
soft tissues.
Intra-operative biopsies provide the confirmatory Nevertheless, it
should be underlined that for-
diagnosis and are considered as the gold standard mal surgical
debridement and an open biopsy is
diagnostic modality (Fig. 2). There is no role for preferable whenever
the patient is unstable, or the
culturing superficial skin lesions and blisters, as the clinical suspicion
strong. The argument of
infection tracks at the subcutaneous level. attaining more
laboratory proof regarding the
The finger test is a procedure that can be establishment of a
safe diagnosis and delaying
used for pre-operative tissue-based diagnosis surgical
interventions should not be followed in
under local anaesthesia. Through a small skin the case of
necrotising fasciitis due to its rapid
incision a gloved finger is inserted down to the escalation and
detrimental effects locally and
deep fascia under sterile conditions. Drainage of systemically.
273
A Gram stain, microscopical analysis, and

a culture are able to provide early verification Management
of the clinical suspicion, as long as an
experienced pathologist is available to review Successful management of
this difficult clinical
the samples [3]. Typical histopathological find- condition requires a multi-
disciplinary approach,
ings are the necrosis of the superficial fascia, close collaboration of the
surgeon with the
subcutaneous fat and nerves with thrombosis intensivist, and above all
prompt action and
and suppuration of the vessels, mixed constant follow-up. In all
cases where the clinical
inflammatory-cell infiltration and early fibro- presentation points towards
this diagnosis,
blast proliferation. At the early stages superfi- operative treatment with
aggressive debride-
cial epidermal hyaline necrosis, dermal ments and supplementary use
of targeted antibi-
oedema, polymorphonuclear infiltration and otics and systemic
resuscitation of the patient are
obliterative vasculitis is followed by mandatory.
thrombosis of penetrating fascial-to-skin ves-
sels, and later by liquefactive necrosis of
all tissue layers and the production of Pre-Operative Preparation
and
a dense predominantly neutrophilic infiltrate Planning
[16, 31, 37].
The swiftness of spread of
the infection and the
proportionately rapid
deterioration of the general
Differential Diagnosis state of the affected
patient dictates the use of
standardised institutional
protocols that allow
This clinical syndrome (due to the array of prompt decision-making, co-
ordinated action of
its infectious aetiologies) especially at its different specialties
(surgeon, intensivist, micro-
early stages has mostly non-specific findings biologist), and close
monitoring of the patients
and symptoms. Due to the rapid escalation of response. Full blood
laboratory profile, availabil-
events and the severity of its prognosis, the ity of blood by-products,
senior surgical and
prompt differential diagnosis and subsequent anaesthetic input, intensive
care or high-
immediate surgical debridement is of paramount dependency bed
accessibility, and low thresholds
importance. for further aggressive
interventions are crucial,
In the early stages the most likely dia- especially at the early
stages of necrotising fasci-
gnosis is that of cellulitis, which is much itis management.
more frequent, has identical skin findings
(erythema, swelling), but in contrast only mild
pain / tenderness and normal-looking subcutane- Operative Technique
ous fat and fascia.
Myonecrosis should be also considered The effective minimisation
of the bacterial load is
in those cases where infection is excluded follow- achieved only by a thorough
surgical debride-
ing the debridement and the microbiology ment. This is essential in
the attempt to stop the
cultures. Comparatively, it affects deeper layers necrotic process and
represents the cornerstone of
of the soft tissues and is limited to muscle groups. necrotising fasciitis
management. It has been
Eosinophilic fasciitis, an even more rare proven to increase the
survival rate of the affected
entity, has in contrast a chronic course, affects patients and the timing and
adequacy of this
also the fascia layer, is sterile and responds to procedure have been
identified as the most impor-
steroids. Lymphoedema or Myxoedema are tant clinical variable
related to mortality [12, 21].
easierly distinguished by the absence of The consensus is that the
first debridement
systemic findings and the history of hypothyroid- should remove all necrotic
tissues including mus-
ism respectively. cle, fascia, fat and skin to
the extents of
274 N.K.
tumour-excision surgery [38]. Surgical approach of the VAC-PAC (Fig. 3).

At a later stage
is directed from the existing skin lesion, a number of cases undergo
reconstructive surgery
should be parallel to the local neurovascular bun- with appropriate full
thickness free or rotational
dles, or other vulnerable anatomical structures, flaps [16].
and down to the level of the deep fascia. The In the cases of
affected extremities an
margins of the resection should be to viable amputation represents a
radical option which
vascularised bleeding tissues, and all in-between is often life-saving and
mandatory. If the
necrotic or doubtful looking elements should be extent of the infection
is rapidly spreading
removed [16, 31]. proximally, or includes a
major joint, or has
Perineal and scrotal infections pose particular destroyed significant
muscle groups of the
surgical difficulties. In most cases at the time of the extremity then an
amputation should be
initial surgical debridement a diverting colostomy, considered and informed
consent should be
as well as suprapubic catheterization may be obtained. Amputations
have been reported to
needed to allow wound hygiene and settling of be performed in 20 % of
all cases, particularly
the inflammation of the rectum / anus or the ure- in IV drug users [3, 45].
thra. Surgical castration is not needed in most of
the cases and the exposed testicles after scrotal
resection are placed in the medial thighs [5]. Post-Operative Care
The steps following the initial debridement
include a re-evaluation of the wound on Antibiotic Therapy
a daily basis, with repeated debridement/s mostly
compulsory. It has been reported that optimally Antibiotic therapy
represents an essential adjunct
an average of 3 debridements within the first to surgical debridement.
Besides one report [46]
23 days are needed to control gross infection on a paediatric
population of solely conservative
[28, 39, 40]. In this process the wound should treatment for several
days with antibiotics, the con-
be protected against secondary infections, and sensus is that they
should not be used alone for the
also the formation of granulation tissue needs to treatment of necrotising
fasciitis due to the poor
be accelerated, as well as the exudates continu- vascularity of fasciae,
the poor blood supply of the
ously drained. In the first stages the wound should necrotic lesion, and thus
the poor delivery of the
be left open and treated with wet-to-dry dress- antibiotic agents
locally. Nevertheless, they assist in
ings. It appears that topical negative pressure the reduction of
bacterial and toxin load, preventing
therapy (VAC-PAC) represents a viable subsequent organ failure.
option for wound management following initial Intravenous broad-
spectrum antibiotics should
infection control [41, 42]. Although not well- be administered on first
presentation, optimally
studied in this particular clinical setting, other after microbial cultures
are obtained. This initial
forms of wound dressing (alginate and hydrogel, empirical therapy should
be efficient against
dilute sodium hypochlorite or iodine solution Gram-positive and
negative organisms, as well
dressings, enzymatic debriding agents), or der- as against anaerobes. In
the past it included
mal substitutes (Integra used mostly as dermal large doses of Penicillin
with Clindamycin (Gram-
regenerate template in burns) have been sporad- positive and anaerobe
coverage), and a third
ically described [43, 44]. antibiotic for Gram-
negatives. Due to the major
Once a healthy bed of granulation tissue is changes of microbial
flora and the development of
established, after the series of wound debride- resistant species,
currently the combination of
ment, and the general condition of the patient is Clindamycin with
Vancomycin, Imipenem,
improved, the wound may be grafted (skin flap or Meropenem, Ampicillin-
Sulbactam, Piperacillin-
split-thickness skin graft,) or left to complete its Tazobactam, Daptomycin,
Quinupristin / Dalfopristin
granulation by secondary intent with the help are preferred by most of
the authors as the initial
275
Fig. 3 Same patient 8 days later, following a series of debridements, now

clinically improved. Split skin grafting as
definitive coverage of the debrided left thigh
empirical regime to cover Anaerobes and doses) suffices.

Otherwise, if the gram stain iden-
Gram-positive microbes [5, 12]. The addition tifies a polymicrobial
flora or is inconclusive, the
of a Quinolone offers additional coverage for initial regime should
continue until the final
the Gram-negatives, as they have excellent soft results of the
cultures. Wound swabs should
tissue penetration [23, 25, 47]. be sent at each
debridement until final closure
Following the collection of samples from the of the wound in order
to identify early any sec-
wound and the gram stain of pus or of deep tissue, ondary contamination,
and adjust further the
adjustments to the antibiotic regime should fol- antibiotic therapy.
low. The presence of Gram-positive cocci in The duration of the
antibiotics is still debat-
clusters, as well as the increased prevalence of able and no proven time
frame could be
MRSA in many institutions dictates the use of recommended. It appears
sensible to continue
Vancomycin in combination to Clindamycin [12, the antibiotics until
no further debridement is
23, 48]. If the Gram-positive cocci are in pairs or needed, when healing
healthy granulation
chains then the combination of Clindamycin to tissue appears to cover
the created defect,
a b-lactam antibiotic (Ampicillin-Sulbactam or accompanied by settling
of clinical and labora-
Piperacillin-Tazobactam, or Penicillin in high tory inflammatory
markers.
276 N.K.
Supportive Therapy and tissue oxygen

pressure respectively at
normobaric conditions),
reverses the effect
The general condition of these patients is usually of bacterial infection,
and breaks the vicious
grossly affected and a large proportion of them triangle of infection-
ischaemia-reduced host
develop septic shock and multiple organ failure. defences. HBO also may
limit the expansion of
Thus, adequate resuscitation and support of the the necrosis and allow
marking its boundaries and
vital functions is crucial. Analgaesia is also essen- guiding the extent of
the necessary debridement
tial as well as supplementation of the extensive [56]. The typical HBO
regime consists of 23
fluid and electrolyte loss, and of the hypoalbu- Atm. of pressure for
0.52 h twice to four times
minaemia from the gross drainage of the large daily until the
progress of the infection is
surgical wound. In the acute catabolic phase the decreased or halted.
The reported results vary
caloric requirements of the patient are high and significantly between a
3 [57] to 11-fold [58]
total parenteral nutrition may be needed for those decreased mortality
rates and a significant
patients that enteral feeding is not feasible. decrease on amputation
rates, while others report
a non-effect of HBO
treatment on survival rates
and an increased risk
of tympanic membrane
Adjunctive Therapies rupture, seizures,
central nervous system oxygen
toxicity [21, 59]. It
appears to offer advantages on
Several authors have investigated the use of tissue preservation and
decreased mortality in the
adjunctive therapies in the difficult clinical clostridial infections,
which however, have
scenario of necrotising fasciitis in an attempt a steadily decreased
incidence in contemporary
to optimise the outcome. Intravenous necrotising fasciitis
cases, reflecting a decrease
immunoglobulin-G (IVIG) is a concentrated prod- on the potential
candidates for HBO treatment
uct from a pool of immunoglobulin-G isotypes of [60, 61].
human donors. It acts by inhibiting the activation of Lately, the use of
recombinant human-activated
T-cells and the activity of streptococcal antigens. protein C has been
described in a necrotising fas-
Theoretically, it can bind staphylococcal and strep- ciitis case-report
[55]. The authors advocated in
tococcal exotoxins limiting the systemic inflamma- favour of its
evaluation in the future in a clinical
tory response and its consequences specifically for trial focused on
necrotising fasciitis case with
necrotising fasciitis of this microbial aetiology involvement of group-A
streptococcus.
[49, 50]. The reported results of its use, in the typical
dosage of 12 g/kg of body weight for 15 days, are
conflicting, underpowered, and non-randomised Complications Outcome
[51, 52]. Some studies report decreased mortality
in patients with streptococcal toxic shock where The reported mortality
rates have a wide range
IVIG was administered [53, 54], while others report from 6 % to 76 % [12,
35]. The latest series report
no clear advantage of its use [55]. a somehow reduced
mortality around 20 %,
Hyperbaric oxygen therapy (HBO) has been reflecting the
importance of early diagnosis and
used sporadically in necrotising fasciitis cases, the advances of
critical care [62].
following its good results in cases of clostridial Necrotising
fasciitis of the perineum or
gangrene [55]. It is considered still an adjunct, abdominal wall have the
highest mortality rates
with a probable beneficial effect that should due to the inability
for drastic surgical debride-
never delay or hinder the primary treatment ment or amputation in
comparison to the cases
pillars of surgical debridement and intravenous where the extremities
are affected.
antibiotics. In principle the increase of partial In the series of
Golger et al. [63] it was proven
oxygen pressure (achieves arterial oxygen that the most important
clinical variable related
pressure of 2,000 mmHg, tissue oxygen pressure to mortality is the
time from admission to
of 300 mmHg vs. 300 and 75 mmHg of arterial surgical debridement,
highlighting the importance
277
of prompt diagnosis. Moreover they have found patient and subsequent

multiple organ failure
that for every year of life the risk of death is raised and death in over 20 %.
High clinical suspicion,
by 4 %. In general the extremes of age early diagnosis, and
aggressive surgical man-
(<1 and >60 years), streptococcal toxic shock agement in combination
with intravenous anti-
and immunodeficiency syndromes are also asso- biotic therapy and
intensive care support of the
ciated with worse prognosis, as well as thrombo- often critically-ill
patient, are of paramount
cytopenia, hypoalbuminaemia, abnormal LFTs, importance. Contemporary
protocols, diagnos-
acute renal failure, and elevated blood lactate tic algorithms, and
adjunctive therapies have not
levels [16, 21, 64]. yet been tested
adequately.
Nisbet et al. [11] in their large cohort of 82
cases, by means of logistic regression analysis
defined as independent predictors of mortality
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Osteoporosis, Fragility, Falls
and Fractures
Contents
Abstract
Osteoporosis: Pathophysiology . . . . . . . . . . . . . . . . . . . . 281
Fractures in the elderly are caused by
increased falling tendency and decreased

Osteoporosis: Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
bone mass which all develop with increasing

Osteoporosis: Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
age. Osteoporosis is defined as a systemic
Osteoporosis: FRAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
288 skeletal disease characterised by reduced
resistance of bone due to loss of bone tissue

Osteoporosis: Basic Treatment . . . . . . . . . . . . . . . . . . . . 289
and/or changed bone quality, which in turn

Osteoporosis: Pharmacological Treatment . . . . . . 289
pre-disposes a person to get a fracture. So
Agents Against Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . 290
there is low bone mass and deterioration in

Calcium + and Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . 290
the micro-architecture of bone tissue, leading
Bisphsophonates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 290 to increased risk of fracture. Diagnosis, pre-
Other Treatment Modalities . . . . . . . . . . . . . . . . . . . . . . 291
vention and treatment are described. When the
patient is admitted to hospital for operation

Osteoporosis: Secondary . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
and rehabilitation after hip fracture or other

Osteoporosis: Risk Factors for Fracture . . . . . . . . . 293
fragility fractures preventive action should be
Osteoporosis and Fall Prevention . . . . . . . . . . . . . . . . . 293
taken to avoid future fractures.
Osteoporosis: Operative Treatment . . . . . . . . . . . . . . 296
Vertebroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 296 Keywords
Definition # Diagnosis # Fall prevention #

Osteoporosis: Orthopaedic Surgeons . . . . . . . . . . . . . 297
Fragility, falls and fractures # FRAX (Fracture

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 298 Risk Assessment Tool) # Osteoporosis #
Pathophysiology # Risk factors # Secondary

osteoporosis # Treatment pharmacological
(calcium and vitamin D, bisphosphonates) #
Vertebroplasty
Osteoporosis: Pathophysiology
Fractures in the elderly are caused by increased

K.-G. Thorngren
falling tendency and decreased bone mass which

Department of Orthopaedics, Lund University Hospital,
Lund, Sweden
all develop with increasing age. Osteoporosis is
e-mail: Karl-Goran.Thorngren@med.lu.se
defined as a systemic skeletal disease characterised

281
DOI 10.1007/978-3-642-34746-7_13, # EFORT 2014
282
K.-G. Thorngren
Fig. 1 Normal (left) and

osteoporotic (right) bone
tissue. Note the fewer and
thinner bone trabecules in
the osteoporotic bone. The
continuity gaps will not
bridge again
by reduced resistance of bone due to loss of bone two million single

remodelling sites are active in
tissue and/or changed bone quality, which in turn the 220 bones that
constitute the skeleton. When
pre-disposes a person to get a fracture. So there is the remodelling process is
in balance the bone
low bone mass and deterioration in the micro- mass is maintained but
when more bone is
architecture of bone tissue, leading to increased resorbed than rebuilt
there is a net loss of bone
risk of fracture (Fig. 1). mass and changed bone
quality with thinner and
Throughout life there is an on-going process less abundant bone
trabecules. In the elderly the
of resorption and rebuilding of the skeleton called bone mass decreases more
quickly than the body
remodelling. This remodelling aims at adapting can replace it, making the
bones fragile. Even
the skeleton to mechanical load and to repair a slight low energy trauma
(a fall or a bump) can
small injuries. lead to a fragility
fracture. This imbalance is
Osteoporosis develops by imbalance in the called primary
osteoporosis where no external
functional result of the bone-forming cells (osteo- cause is known
(idiopathic), whereas secondary
blasts) versus the bone resorbing cells (osteoclasts) osteoporosis is due to
factors such as lack of
(Fig. 2). They are active on all bone tissue surfaces, exercise or pharmaceutical
agents such as corti-
cortical and trabecular (Figs. 3 and 4). The cells costeroids. Osteoporosis
has no signs or symp-
embedded within the bone tissue (osteocytes) take toms until a fracture
occurs.
no part in the remodelling process. The resorption The skeleton consists
of two different types of
phase takes around 24 weeks followed by the bone tissue, cortical bone
and trabecular bone.
rebuilding phase which lasts a considerably lon- The cortical bone is
situated in the shafts of the
ger time, around 24 months. Constantly on aver- long bones and also as a
shell around all bones.
age 10 % of the skeleton is undergoing The trabecular bone is
found in the inner parts of
remodelling. It has been estimated that one to the bones as for example
in the vertebral bodies
Osteoporosis, Fragility, Falls and Fractures
283
NORMAL BONE REMODELLING
RESORPTION
UNCHANGED
BONE MASS
BONE FORMATION
REMODELLING AT OESTROGEN DEFICIT
increased number of osteoclasts
OSTEOPOROSIS
Less active osteoblasts
Fig. 2 Bone remodelling by osteoclasts resorbing bone and osteoblasts building up

new bone, normally and at estrogen
deficit
and in the ends

of long bones. The cortical bone
constitutes 80
% of the skeleton whereas it only
contributes to
20 % of the bone surface. Each year
3 % of the
cortical bone is remodelled. The tra-
becular bone
constitutes 20 % of the skeleton, but
80 % of the
bone surface and 25 % of the trabec-
ular bone is
remodelled each year. The bone
losses appear
with different speed in the different
types of bone
tissue and also change during the
different
phases of life. During the early part of
the menopause
in women the loss of trabecular
bone tissue is
rapid which increases the risk of
wrist fractures
and later also vertebral compres-
sion fractures.
Loss of cortical bone has impor-
tance in older
age groups and is then contributing
to the
increased number of hip fractures.
The
skeleton is growing during childhood and
Fig. 3 Osteoclast visualized by electron microscopy youth until a
maximum bone mass has been
284
K.-G. Thorngren
a b
FcR DAP12
Cell nuclei
Osteoclast
Osteoclastprogenitor c-Fms
RANK
Iysosomes
RANKL
M-CSF
ruffled
border Sealing zone
proliferation, differentiation
Protonpump
Chloride ion channel
Release of proteolytic
enzymes
H+ Cl
pH 4,5
Fusion
Dissolution of Degradation of
mineral chrystals matrix proteins Osteoclast
Boneresorption
Fig. 4 Function and formation of osteoclasts
Bone mass peaks at age 25-35
Menopause
Bone Mass
Active Slow
Rapid Continuing
Growth Loss
Loss Loss
10 20 30 40
50 60 70 80 90
Fig. 5 Bone mass at
various ages
Age (Years)
achieved about age 2035 years, the so-called factors such

as smoking, physical activity and
peak bone mass (Fig. 5). The peak bone nutrition.
Women reach skeletal maturity some-
mass is mostly dependent on hereditary factors what earlier
than men. After the peak bone mass
(around 70 %) but is also influenced by lifestyle has been
achieved there is a plateau phase with
285
slow bone losses until the menopause at the age

around 50 years when the bone mass decreases
rapidly over 510 years due to diminishing levels
of oestrogen hormone. After 70 years of age dif-
ferent factors linked to age such as lack of vitamin
D, decreasing levels of other anabolic hormones
and decreased physical activity play an increasing
role in the bone loss, which then is similar in
magnitude for men and women and affects both
trabecular and cortical bone. The abundance of
osteoporosis and fragility fractures vary through-
Fig. 6 Bone densitometer.
Dual Energy X-ray Absorpti-
out Europe [38, 48, 49, 56]. (see Fractures of the ometry (DXA)
Femoral Neck and Proximal Femur).
the determination (Fig. 6).

As X-rays are used,
Osteoporosis: Definition also a low resolution
radiographic picture is
achieved to facilitate the
interpretation. The
The definition of osteoporosis is based on mea- measurement is usually
standardised to include
surement of BMD (Bone Mineral Density) also the lumbar spine (LI-LIV or
LII-LIV) and the hip
called BMC (Bone Mineral Content) [26, 40, 71]. (total hip or femoral neck)
(Figs. 7 and 8).
A DXA machine is used (DXA Dual X-ray In some instances also the
whole body BMD is
energy Absorptiometry) by which it is possible to measured and values are
given for total calcium,
calculate the BMD based on the difference in fat and water content of the
body.
absorption of two wave-lengths taken from sepa- To make the bone
densitometry measurement
rate parts of the X-ray spectrum having more or more available and less
expensive peripheral
less resistance for their penetration through the scanners have been
developed. BMD in the calca-
body as hindered by the skeleton or the soft neus can be used for
fracture risk assessment, with
tissues, respectively. A comparison with the predicted power similar to
measurements made in
BMD value of fully-grown young healthy per- the spine or hip. The
calcaneus has greater than
sons of the same sex is made (T-score). Z score 95 % trabecular bone by
volume and the
is the BMD compared to persons of the same age age-related bone loss in
this bone is similar to
and sex. Patients with osteoporosis have values in that of the lumbar spine.
Dual X-ray combined
the lower range of the normal distribution. Oste- with laser (DXL) used for
measurements on
oporosis is defined as a T-score less than #2.5 the calcaneus has been shown
to predict hip
standard deviations (SD). A BMD value above fractures and seems suitable
for diagnosing
#1 SD is considered normal. An intermediate osteoporosis and for
prediction of fracture risk
value is called osteopenia with BMD in the (Fig. 9). The equipment is
portable and easy
range of #1 to #2.5 SD. DXA scanning has a to handle in primary care
settings and the cost is
high specificity, but the sensitivity is low considerably lower than an
ordinary DXA
(around 50 %). machine [14].
In the early days of
bone mass determination
ordinary X-rays were
measured for cortical thick-
Osteoporosis: Diagnosis ness e.g., on the metacarpal
bones. Sometimes
even a visual impression of
a thin picture was
For DXA measurement the patient is positioned classified as osteoporosis.
on a table and the X-ray generator and the Other methods previously
used for bone min-
measuring device are passed along the body eral measurement have used
ionizing radiation
making repeated measurements as a basis for with one gamma radiation
source (single-photon
286
K.-G. Thorngren
Densitometryreference:
AP-spine L1-L4
BMD (g/cm2)
UVT-Score
1,42
2
Normal
1,30
1
1,18
0
1
1,06
2
0,94 Osteopenia
3
0,82
4
0,70
Osteoporosis
5
0,58
20 30 40 50 60
70 80 90 100
Age (years)
BMD Young Adult Age

matched
Region (g/cm2) T-Score z-
Score
L1 0,739 -3,3
-1,2
L2 0,693 -4,2
-2,2
L3 0,807 -3,3
-1,3
L4 0,773 -3,6
-1,5
L1-L2 0,715 -3,7
-1,7
L1-L3 0,749 -3,5
-1,5
L1-L4 0,756 -3,5
-1,5
L2-L4 0,760 -3,7
-1,6
Fig. 7 Example of DXA report
absortiometry, SPA) or two (dual-photon markers for bone

formation (bone specific
absortiometry, DPA). DPA has lower precision alkaline
phosphatase, osteocalcin, procollagen
than DXA and DXL. SPA can be used in regions extension peptides)
as well as for bone resorption
where there is less soft tissues such as at the distal (crosslaps CTx,
NTx). Patients with osteoporosis
radius and calcaneus. Quantitative ultrasound have increased bone
metabolism affecting both
(QUS) has been used at the calcaneus. It has the bone formation
and the bone resorption. The
been suggested that the broadband ultrasound bone resorption is
more increased than
attenuation (BUA) is not only influenced by the formation. With
pharmacological treatment
the amount of mineral in the bone but also by the the markers are
decreased both for formation
micro-architecture of bone, whereas the speed of and resorption.
Pharmacological treatment
sound (SOS) may vary with the elasticity of bone. which decreases the
resorption shows activity
Quantified computer tomography (QCT) has within 612 weeks on
the blood markers. The
been used for research purposes. It measures the markers have however
low specificity and sensi-
real volumetric bone density whereas the other tivity and are less
well-suited for diagnosis of
ionizing techniques measure the amount of min- individual cases. In
specific complicated bone
eral within an area. metabolic disorders
they can give additional
Blood tests can be used to exclude other types information. Markers
have proved to be useful
of diseases if needed. There are biochemical in epidemiological
and interventional studies in
287
Densitometryreference: Left femur Total
BMD (g/cm2)
UV T-Score
1,256
2
Normal
1,132
1
1,008
0
0,884
1
0,760 Osteopenia
2
0,636
3
0,512
4
Osteoporosis
5
0,388
20 30 40 50
60 70 80 90 100
Age (years)
BMD Young Adult
Age matched
Region (g/cm2) T-Score
Z-Score
Neck 0,719 -2,3
-0,4
Wards 0,487 -3,3
-0,8
Trochanter 0,493 -3,1
-1,5
Total 0,690 -2,6
-0,8
Fig. 8 Example of DXA report for hip
which groups of
patients are studied and in
patients with
metabolic diseases associated with
high bone turnover
such as Pagets disease.
DXA measurement
is indicated when there is
a high risk for
fracture (see section
Osteoporosis:
FRAX below) and for follow-up
of pharmacological
treatment. General screening
with bone
densitometry by DXA is not
cost-effective and
not recommended. The DXL
method seems
promising. Osteoporosis increases
with increasing
age. Age is the most important
risk factor for
fracture. The increase in the
Western World of
mean survival age leads to an
increase of the
population at risk. With
more elderly in
the population the number
of patients with
osteoporosis and various frac-
Fig. 9 Bone densitometry of the calcaneus with DXL
tures increases
(Fig. 10). Prospective studies
(dual x-ray laser) technique, combining DXA and heel have shown that
the fracture risk is increasing
thickness measurement with laser with lowered bone
BMD. Risk for fracture
288
K.-G. Thorngren
1900
1950
100
100
Men Women Men
90 Women
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
60 000 40 000
20 000 20 000 40 000 60 000
60 000 40 000 20 000 20 000 40 000 60 000
www.scb.se
2000
2050 Prognosis
100
100
Men Women Men
Women
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
60 000 40 000 20 000 20 000 40 000 60 000 60 000 40 000

20 000 20 000 40 000 60 000
Fig. 10 Demographic development in Sweden 19002050
is doubled for each standard deviation decrease of It is called WHO

Fracture Risk Assessment
the BMD. The decrease of BMD is seen earlier in Tool (FRAX). Data
from previously published
the spine than in the hip, probably due to more cohorts have been
analysed separately for
trabecular bone in the spine. The predictive different
countries so the specific risk within
value of a bone densiometry measurement a country can be
given [11, 15]. The calculations
for prognosticating future fracture is as good are based on
previously-established risk factors
as the blood pressure measurement is for the such as age, sex,
body weight, smoking, earlier
prediction of stroke. fracture, hip
fracture in the parents, cortisone
Osteoporotic vertebral compression fractures treatment,
presence of rheumatoid arthritis,
of the spine give a kyphotic stature and alcohol
consumption and secondary reasons.
decreased body height. A loss of height Also a value from
a bone densitometry can be
more than 3 cm should give suspicion of included in
separate calculations. A FRAX eval-
osteoporosis. uation should be
used to give indication if a bone
densitometry
should be performed or not.
A FRAX calculation
is free of charge and can
be done on the
web. Go to www.shef.ac.uk/frax
Osteoporosis: FRAX and chose the
country of interest. A percentage
risk within 10
years is calculated for the occur-
As the DXA measurement is resource-consuming rence of any
osteoporosis related fracture or of a
a clinical risk-evaluation based on clinical and hip fracture. If
the 10 year overall fracture risk is
epidemiological factors has been developed. over 15 % as
calculated by FRAX a DXA
289
Table 1 General actions for

osteoporosis and risk of
fracture
Nutrition analysis and
actions for adequate caloric intake
by food
Adequate daily intake
(including nutrition) of calcium
(5001,000 mg calcium) and
Vitamin D (800 IE)
Stop smoking
Weight-bearing physical
activities such as walking at
least 30 min per day
Fall prevention, training
of balance and co-ordination
according to ability and
age
Reconsider concomitant
medications
For patients with high
falling tendency prescribe hip
protectors in motivated
patients
To be continued throughout
life the activity
must be regarded as fun and
if it engages others
the motivation is usually
stronger. The use of hip
Fig. 11 Hip protector. Note the padding inlay in the protectors is a very
efficient and cost effective
trousers over the trochanteric area way to diminish the risk of
hip fractures in elderly
with especially high risk
for falls. The effect in
nursing home patients and
patients in homes for
the elderly has been shown
in several studies,
measurement of hip and spine should be whereas there is no proof
for effects in patients
performed. If the patient has very high living in own home. A hip
protector consists
fracture risk pharmacological treatment with of a plastic shield over
the hips which is mounted
bisphsphonates supplemented with Calcium + into special tight trousers
(Fig. 11). In a fall the
Vitamin D should be considered (see section energy of the impact is
distributed over a wider
Osteoporosis: Pharmacological Treatment). area and thereby protects
against a fracture.
The problem has been
compliance, as the elderly
have found these trousers
too tight and an obstacle
Osteoporosis: Basic Treatment at toilet visits. On the
other hand nowadays young
people practising roller
blades and mountain biking
Fundamental in all osteoporosis treatment is to have similar protective
dressings so it seems advis-
act on those risk factors that the individual patient able for elderly when going
outdoors on days with
has. Basic treatment is to influence those risk icy pavements to supplement
the spikes strapped
factors which are linked to life-style. on to the shoes also with
use of hip protectors.
Nutrition is important, especially the dietary Recommendations for
general actions when
intake of calcium and Vitamin D [9, 34]. a patient has osteoporosis
and risk of fracture
Training of balance and muscle strength, suit- are listed in Table 1.
able walking aids if needed, evaluation of the risk
of falling in the home environment, analysis of
medications and the nutritional status are impor- Osteoporosis:
Pharmacological
tant issues. Continued physical activity since the Treatment
youth prevents against osteoporosis [39]. The
skeleton responds to repetitive impacts by The pharmacological
treatment that has been
forming more bone. Brisk walks and sports with developed for prevention of
post-menopausal
weight-bearing on the legs is recommended. osteoporosis has shown good
effect also in
290
K.-G. Thorngren
elderly people. This is one of the few and decrease gastro-

intestional problems from
therapeutical areas where larger groups of elderly high oral calcium intake,
there has recently been
patients have been included in the studies which a shift in the substitution
recommendation towards
are the basis of demonstrating the effect of one daily tablet combining
higher vitamin
a pharmaceutical agent. It is not too late to treat D content (800 IE) with lower
calcium (500 mg).
patients even if they are older and already have Most of the patients with a
hip fracture have high
got a fracture. Indications for pharmacological age, bad nutritional status
and limited access to
treatment are osteoporosis and/or a previous sunshine (which produces
vitamin D in the skin)
fragility fracture. so treatment with calcium +
vitamin D seems
advisable.
Most of the additional
specific pharmacologi-
Agents Against Osteoporosis cal agents against
osteoporosis have been tested
in randomised studies
combined with calcium and
Bone resorbtion inactivators vitamin D, which therefore
always should be
Calcium and vitamin D given together with the
specific pharmaceutical
Bisphsophonates agent when preventing or
treating osteoporosis.
Calcitonin
Strontiumranelat
Oestrogen Bisphsophonates
SERM, Selective Oestrogen Receptor
Modulator Bisphosphonates are synthetic
pyrophosphate ana-
Bone formation stimulators logues which build into the
hydroxyapatite of the
Fluoride skeleton similarly to
calcium. Bisphosphonates
PTH, Parathyroid Hormone are the predominant first-
choice drugs for specific
GH, Growth Hormone treatment of osteoporosis
both in women and
IGF-I, Insulin-like Growth Factor I men. Bisphosphonates act
through preventing the
Anabolic Steroids osteclasts from resorbing
bone. Alendronate
Testosterone and risedronate are the
agents most studied
[6870]. They have
significant positive effect on
BMD in post-menopausal women,
especially after
Calcium + and Vitamin D a previous vertebral
fracture. The effect is also clear
concerning prevention of new
vertebral fractures in
Calcium should always be given together with this patient group, whereas
there is weaker evi-
vitamin D [64]. The elderly have low calcium dence for the decrease of
peripheral fractures
absorption if it is given alone. Meta-analysis of including hip fractures.
Possible very rare compli-
randomised studies have shown significant effect cations are slow healing
wounds in the jaw includ-
for prevention of osteoporotic fractures in ing some patients with jaw
osteonecrosis as well as
institutionalised patients, but not in those living strange transverse femoral
shaft fractures.
independently at home [7, 8]. There might be an Recently some cases have
been described with
effect on those above 80 years of age [2, 62]. transverse fractures of the
femoral shaft consid-
Calcium combined with vitamin D should always ered to be of insufficiency
type, as there is mini-
be given in connection with all other types of mal trauma involved [42, 51,
63]. Most cases have
specific pharmaceutical anti-osteoporotic treat- had long treatment periods
(average 57 years)
ment, especially the bisphosphonates, to prevent and a relative overdosage
(patients with low
increased secretion of parathyroid hormone which BMI). An incidence of 1/1,000
per year has been
otherwise could counteract the effect. Vitamin calculated which was 46 times
higher than for
D might also prevent the falling tendency in the those who had not received
bisphosphonate treat-
elderly above 80 years. To improve compliance ment. This was considered
acceptable in the
291
view of the total fracture-reducing effect of and aching muscles. It

quickly disappears and is
the treatment [63]. A general limitation of the easily prevented and
reversed by giving paraceta-
treatment period by bisphosphonates to 5 years mol orally before and after
the infusion. At the
is being discussed [12]. In all patients treated with second yearly infusion many
fewer patients get
bisphosphonates it is important to check the this reaction.
kidney function. A creatinine clearance above
30 mmol/min is mandatory. This is especially
important when giving the highly-potent
bisphosphonate Zolodronic acid intravenously. Other Treatment Modalities
Some patients cannot tolerate oral bisphosphonate
due to gastro-intestional problems or there is Raloxifen is a selective
oestrogen-receptor modu-
a lack of effect due to a combination of adminis- lating agent which gives an
anti-resorptive effect.
tration problems with low compliance as well as Raloxifen has shown effect
both on BMD and by
low uptake (only 1 % of the oral dose is ordinarily decreasing the vertebral
fracture incidence [22]. It
resorbed). The uptake of oral bisphosphonates is has mostly been used to
treat spinal osteoporosis.
influenced by concomitant intake of food and In studies Raloxifen has
shown reduction of the
other pharmaceutical agents especially calcium. incidence of mammary cancer
but increased
Therefore it is very important that the patient is occurrence of venous
thromboembolism similar
instructed to take the tablet fasting in the morning to ordinary oestrogen
treatment. Ordinary
together with a glass of water (to prevent oestrogen reduces bone loss
in post-menopausal
oesophageal erosion) and then wait at least half women mostly by inhibiting
bone resorption [3].
an hour, preferably 1 h with intake of food or other Fracture risk is diminished
with oestrogen treat-
pharmaceutical agents. The tablets are usually ment, but hormonal
replacement therapy has
taken once a week. The most common adverse many serious adverse
effects including vaginal
effects are problems from the gastro-intestinal bleeding, deep vein
thrombosis and pulmonary
tract, above all nausea. Aching muscles is also embolism, stroke, heart
disease, gall bladder
one of the more frequent adverse effects. disease and increased risk
of breast, endometrial
Slowhealing wounds after dental surgery and and ovarian cancer [61].
Oestrogen is not
osteonecrosis of the jaws appear very seldom [72]. recommended for prevention
of osteoporosis.
Other types of bisphosphonates are given Strontiumranelat is a
salt that is ionised in the
monthly as an oral tablet such as Etidronate gastro-intestinal tract. A
pulver is dissolved in
and Ibandronate. The compliance is increased water and should be
ingested every evening at
with one tablet once a month, but the clinical least 2 h after food intake
for best uptake. The effect
experience is still much lower for these agents. is given by the strontium
ion. It is built into the
For patients with gastro-intestinal problems or skeleton similarly to
calcium. Strontium affects
lacking effect after oral bisphosphonate adminis- both bone formation and
bone resorption. The
tration there is now the possibility of intravenous reduction of fractures is
similar to the
administration [13, 47]. Zolodronic acid is given effect achieved with
bisphosphonates. Some very
as an intravenous infusion (5 mg in 100 ml solu- rare but dangerous cases of
drug rash with eosino-
tion during minimum 15 min infusion) once philia and systemic
symptoms have been reported.
yearly. Randomised studies of Zolodronic acid Parathyroid hormone has
two different and
including up to 3 years treatment (three infusions) counteracting effects on
the bone metabolism.
have shown an effect of decreased new fractures In high doses as with
hyperparatyroidism the
including hip fractures. The patient should con- effect is bone resorption.
In lower doses of inter-
tinue daily oral calcium and vitamin D treatment mittent treatment by
injection the bone formation
during the whole year after the infusion. The day is stimulated which gives
an increased BMD,
after infusion 1020 % of the patients can get a above all in trabecular
bone. There is a possibility
reaction like starting an influenza with shivering of a coupling effect where
bone resorption is
292
K.-G. Thorngren
followed by bone formation. Parathyroid hormone about their effects before

they can be
can be synthesised. Teriparatide (PTH 1-34) recommended for the
prevention of osteoporotic
is a peptide identical with the N-terminal part fragility fractures.
of endogenous human parathyroid hormone.
PTH1-84 is a longer molecule. Both have shown
a decrease in fractures, especially vertebral Osteoporosis: Secondary
fractures [24, 33]. PTH is the only pure anabolic
pharmaceutical agent against osteoporosis avail- Certain diseases and
medications have been
able today. It is given as a daily subcutaneous shown to promote the
development of osteoporo-
injection and the treatment period is 18 months. sis. Some result in low
access of calcium to the
After this treatment it is recommended to con- skeleton through low intake
or decreased absorp-
tinue with some type of anti-resorptive treatment tion in the gut, whereas
others have been shown
e.g., bisphosphonates. The treatment gives to inactivate the
osteoblasts.
a good increase of bone density and a good Osteoporosis has a
higher prevalence in the
reduction of vertebral compression fractures following conditions:
and also peripheral fractures. The effect is Disturbances of eating,
above all anorexia
especially good in patients with very low bone nervosa. In some
elderly difficulties in
BMD and many earlier vertebral compression chewing and swallowing
pre-disposes as well
fractures. as their choice of
nutrition with low calcium
Calcitonin is produced by the thyroid C cells. It and vitamin D content.
reduces bone resorption by osteoclast inhibition. Endocrine disturbances such
as hyperparathyroid-
Oral administration breaks down the calcitonin, ism, hypothyroidism,
diabetes and Cushings
subcutaneous or intramuscular injections can syndrome.
give nausea, facial flushes and diarrhoea. Intra- Chronic disorders, some
with inflammatory
nasal administration has no such side effects. involvement such as
coeliac and inflammatory
A meta-analysis shows that calcitonin reduces the gut disease, rheumatoid
arthritis and other
risk of vertebral fractures in 54 % [25]. It has also inflammatory joint
diseases, kidney insuffi-
pain-reducing effect in fresh osteoporotic vertebral ciency, chronic liver
disease, chronic pulmo-
compression fractures [28]. nary disease and
malignancies.
A new principle for treatment is to block Neurological disorders with
decrease of locomo-
RANK/RANKligand which are involved in the tor function such as
stroke, Parkinsonism,
signal system of the osteoclasts. Denosumab is a multiple sclerosis and
spinal injuries.
recombinant antibody which gives the blocking, Disorders associated with
decreased levels
leading to an effect of fewer osteoclasts being of sex hormones such as
hypogonadism,
recruited and activated, resulting in decreased oligomenorrhea, the use
of gestagenes, anti-
bone resorption. Denosumab is administered oestrogen treatment,
aromatas inhibitors and
subcutaneously twice a year. An effect has been cytostatic treatment.
shown for all fracture types, especially vertebral Osteomalacia differs from
osteoporosis having
compression fractures [27, 50]. Treatment less calcium content in
the bone tissue and
of men with prostatic cancer has also resulted more osteoid
(osteoporosis is a disease of
in decreased risk for vertebral compression diminished bone mass
and different structure).
fractures. Osteomalacia patients
can also have an
Other agents such as fluoride, growth hor- increased fracture
risk.
mone, IGF-1, testosterone, anabolic steroids Pharmaceutical agents such
as cortisone,
and vitamin K have been tried to improve some anti-eptilectic
drugs and drugs for type
BMD but many studies are small and fracture 2-diabetes, high doses
of thyroxine, long-term
data is lacking. Sometimes the side-effects are treatment with drugs
such as heparin, low
undesirable. Further information is required molecular-weight
heparin and SSRI.
293
with age. The middle-aged

woman mostly falls
Osteoporosis: Risk Factors for Fracture forward, protects herself with an
outstretched
arm and gets a radius
fracture (Fig. 12). The old
Strong risk factors for fracture lady falls sideways, does
not react fast enough to
Advanced age protect the fall and gets a
hip fracture (Fig. 13).
Previous low-energy fracture after 50 years of Every third, community-
dwelling person above
age, particularly hip fracture, vertebral frac- the age of 65 falls at least
once yearly [46, 65], but
ture, wrist fracture, proximal humerus fracture there is evidence that the
fall rate is even higher.
or pelvic fracture A fall rate of about 50 %
was shown among
BMD < 2.5 SD women with a mean age of 80
[6]. People
Parents had hip fracture or vertebral fracture who live in residential care
fall more often com-
Systemic glucocorticoid treatment for more than pared with people who live
in their own home.
3 months (5 mg Prednisolone or more per day). Women tend to fall more
often than men, but at the
Treatment duration below 6 weeks seldom age of 80, the difference
levels out. Among the
gives osteoporosis. oldest persons living in
institutions, men fall more
frequently compared to women
[46, 66].
Weak risk factors for fracture Falls account for two-
thirds of home accidents
BMI less than 20 in older people aged 65 and
above [32]. At
Weight less than 55 kg if average tallness the age of 75 and older, 84
% of all injuries
Involontary weight loss were caused by a fall [41].
The fall risk factors
Menopause before 45 years of age in the community-dwelling
elderly have been
Increased falling tendency summarised by Lord et al.
[44] who classified
Smoking the risk factors as
psychosocial and demographic
Inactivity factors, postural stability
factors, sensory and
Alcohol neuromuscular factors,
medical factors, medica-
tion factors and
environmental factors.
Smoking is an independent risk factor for Injuries occur in
approximately half of the
osteoporotic fractures [43]. falls [6] and about one-
third of the falls lead to
BMD in smokers has been shown to be 2 % major injuries. Fractures
occur in between 4 %
lower for each 10 year after menopause which and 16 % of the accidental
falls [46, 55]. Cogni-
gives a difference of 6 % at 80 years of age. tive impairment, the
presence of at least two
Moderate alcohol consumption does not give chronic conditions and
impaired balance and
osteoporosis, whereas high consumers have higher gait are associated with
serious injury during
risk for hip fractures which may depend on bad a fall [67]. Women sutain
injuries more often in
nutritional status and increased falling. Alcoholic a fall compared with men.
Women are also more
men have five times higher risk for a hip fracture likely to sustain fractures
[6, 52].
compared to those who abstain from alcohol. It has now been
established that prevention
Women with high alcohol consumption have 1.4 can reduce falls in older
people [30, 57]. Reduc-
times (40 %) increase in the risk of a hip fracture. ing falls will also reduce
injuries [60]. Studies
in recent years have proven
that exercise to
increase muscle strength and
balance improves
Osteoporosis and Fall Prevention those functions and
therefore reduces the risk
of falling in the elderly
living in the community
A patient can have severe osteoporosis without [17, 18, 60].
any symptoms. When the patient falls and gets Good balance capacity is
a complex motor
a fracture the osteoporosis is revealed. skill and a pre-requisite
for many daily tasks
The fall rate increases with age. Also the fall such as walking and
transferring. With increasing
direction and the protective possibilities change age, balance capacity
decreases [35, 59] and may
294
K.-G. Thorngren
Fig. 12 Fall patter in middle aged women
Fig. 13 Fall patter in elderly women
result in deleterious falls [52]. Balance capacity maintenance of a position,

postural adjustment to
can be measured in various ways depending on voluntary movements and
reactions to external
population and purposes [4, 45]. Three levels of stress. The laboratory tests
aim at determining the
increasing balance capacity can be distinguished: underlying cause of balance
disturbances, while
295
VISION
Balance
monitoring
Ne
rv
e
VESTIBULAR INFO
sig
na
CNS
ls
o integration
inf
PROPRIOCEPTION
Biomechanics
Outer
limitations
info
SKIN - SENSITIVITY
t
m en
ve
Mo
Fig. 14 The balance is governed by signals from the vision, the vestibular system,
the proprioception in tendons and
muscles and the skin sensitivity which are all integrated in the brain which gives
motor signals to the muscles
the clinical, functional tests document the rising from a chair

without having support by
balance status and may reflect whether treatment the arms or walking up
several stairs carrying
is needed or not [36]. Commonly-used clinical shopping bags. The
balance reaction which
balance performance tests in elderly subjects con- means the ability to
modify movements
sist of single tasks such as one leg stance, tandem according to the
surroundings needs speed in the
stance, chair stand, functional reach and walking activity and with
increasing age all movements
speed, or a combination of several tasks such as become slower.
Difficulties in activating
the Berg Balance Scale [5] and timed Up & Go stabilising muscles also
increase the falling
[58]. Poor results in these tests are often associ- tendency. Vision,
hearing, skin sensitivity and
ated with an increased fall risk [20]. Although the vestibular organ are
all important for
many tests identify fallers, their prediction of maintaining body
posture. Decreased sensibility
falls is less accurate [37]. in the sole of the foot
gives a decreased ability to
Most falls in the elderly occur indoors on even compensate when walking
on uneven surface.
surface. To maintain body posture many systems Cognitive impairment in
the form of dementia
must work together. Not only the vestibular sys- or confusion as well as
diseases such as acute
tem, but also the eye-sight and the muscle and infection in the urinary
tract or chronic diseases
tendon sensory corpuscles are involved in the as Parkinsons disease
or stroke all become more
neuromuscular regulation, and muscle strength abundant with age and
all influence the balance
plays a role (Fig. 14). During aging muscle capacity.
strength, muscle endurance and range of motion A serious problem
after a fall especially after
in the joints decrease which leads to difficulties to a fall with fracture is
the risk that the elderly
maintain previous ordinary activities such as develop a fear of
falling. This is more abundant
296
K.-G. Thorngren
among women than men and increases with

increasing age. Fear of falling is more common
among people who have previously fallen, or
experience decreased health or quality-of-life as
well as those having many medicines, known
decreased balance capacity or those who are
depressed. People who have fear of falling are
more afraid of moving around and walk outdoors.
This initiates a vicious circle with less and less
activities and mobility. Muscle strength and bal-
ance get worse.
There is a possibility even in the elderly to
improve by training the strength of leg muscles,
balance and walking ability and thereby
prevent new falls. Studies have shown that
Vitamin D supplementation can decrease the
risk of falling in around 20 % [10]. Physical
activities such as walks outdoors improve the Fig. 15 Two vertebrae with
the marrow washed away.
balance. The lower vertebra has
compression fracture
Prevention of falls should be directed both
towards individual and environmental risk
factors [30] as well as towards the individual
behaviour [21]. According to Norton et al. [54] Osteoporosis: Operative
Treatment
prevention should be directed towards internal
factors in the elderly over 80 years of age and Fractures in osteoporotic
bone are abundant and
towards environmental factors in the younger. specific considerations are
necessary when
Osteoporosis and falls in combination strongly performing osteosynthesis
in this changed bone.
contribute to hip fractures. National guidelines Reduced bone mass,
increased bone brittleness
to prevent fall accidents in the elderly have been and structural changes such
as medullary expan-
published in England [29] and in the USA [1]. sion must be taken into
account in the osteopo-
Increased awareness is now emerging among sur- rotic patient when deciding
on the type of
geons that preventive measures should be aimed surgical method to be used.
Other chapters in
particularly at patients with identified risk factors this textbook give multiple
examples, as fractures
such as repeated fragility fractures. Patients with in the elderly now are the
major work-load for
a fresh hip fracture have an increased risk of Orthopaedic departments.
sustaining a hip fracture on the other side within
the next 2 years. This is a group of patients that
the surgeon can aid in preventativetive measures Vertebroplasty
either by himself or by referral to general
practitioners and physiotherapists. Exercise, A specific operative
treatment will be mentioned
calcium-rich diet and exposure to sunshine here because it has started
to be used as an adjunct
(vitamin D-production) are the basic recommen- and sometimes substitution
for pharmacological
dations followed by pharmaceutical prevention treatment in vertebral
compression fractures
or hip protectors. A summary of these possibili- (Fig. 15). Bone cement is
injected into the com-
ties is emerging in the Cochrane Library, which pressed vertebra, usually
methylmetacrylate of
contains evaluation and meta-analysis of all the type used for fixation
of arthroplasties. In
randomised trials for various aspects of fall pre- the so called
vertebroplasty the substance is
vention ([16, 31]). only injected, whereas in
kyphoplasty the
297
vertebra is first expanded by a balloon technique. with correlating signs and

symptoms suggesting
Recently clinical practise guidelines approved by an acute injury (05 days
after an identifiable
the American Academy of Orthopaedic Surgeons event or onset of symptoms),
and who are neuro-
(AAOS) in USA have been published [28]. They logically intact, could be
treated with Calcitonin
are based on a systematic review of published for 4 weeks. This
recommendation has moderate
studies on the treatment of symptomatic osteopo- strength. Calcitonin reduces
pain in four posi-
rotic spinal compression fractures in adults. The tions (bedrest, sitting,
standing and walking) as
purpose of the guideline is to help improved well as the number of bed-
ridden patients at 1, 2,
treatment based on the current best evidence. 3, and 4 weeks in a clinically
important manner.
They recommend strongly against vertebroplasty Also studies with Calcitonin
showed benefit at
for patients who present with an osteoporotic longer periods (312 months).
With weak
spinal compression fracture on imaging with cor- strength of recommendation
they recommend
relating clinical signs and symptoms and who are Ibandronate and
Strontiumranelate as options to
neurologically intact. Vertebroplasty randomised prevent additional symptomatic
fractures. They
with sham procedure reports no statistical signif- have evaluated the use in
patients with an existing
icant difference between the two procedures in fracture as well as prevention
in patients who
pain, using the visual analogue scale, and func- experienced symptomatic
fractures. Furthermore
tion using a disability questionnaire. Further they were unable to recommend
for or against
studies, without a sham procedure as control, bed-rest, complimentary
alternative medicine,
report similar results. By making a strong recom- or the use of
opioids/analgesics for patients who
mendation against the use of vertebroplasty the present with an osteoporotic
spinal compression
AAOS clinical practise guideline expresses con- fracture on imaging with
correlating clinical
fidence that future evidence is unlikely to over- signs and symptoms and who are
neurologically
turn the results of the referred trials. Based on intact. A support for root
injection at level LII for
what they call weak evidence they summarise that treating new-onset back pain
associated with LIII
kyphoplasty is an option for patients who present or LIV compression fractures
is weak and is
with an osteoporotic spinal compression fracture therefore, an option only for
temporary pain
on imaging with correlating clinical signs and relief. They were unable to
recommend for or
symptoms and who are neurologically-intact. In against treatment with a brace
for patients
the case of kyphoplasty the comparison to conser- with osteoporotic spinal
compression fracture
vative treatment resulted in possibly clinically and also unable to recommend
for or against a
important differences for critical outcomes up to supervised or unsupervised
exercise programme
12 months, whereas vertebroplasty compared as well as to recommend for or
against electrical
with conservative treatment showed possible clin- stimulation [28]. In
conclusion there is evidence
ically important differences for critical outcomes to leave a vertebral
compression fracture to
only at 1 day. Direct comparison between heal by itself and it will
eventually become
vertebroplasty and kyphoplasty showed a possi- pain-free.
bly, clinically important advantage in critical
outcomes for kyphoplasty at duration up to
2 years. They were unable to recommend for or Osteoporosis: Orthopaedic
Surgeons
against improvement of kyphosis angle in the
treatment of patients who presented with an When the patient is admitted
to hospital for
osteoporotic spinal compression fracture on operation and rehabilitation
after a hip fracture
imaging with correlating clinical signs and there is a golden opportunity
to take preventive
symptoms. measures to avoid future
fractures [19, 73].
The AAOS clinical practise guideline group Orthopaedic surgeons tend to
treat only the
suggests that patients who present with an osteo- current fracture. It seems
practical that the
porotic spinal compression fracture on imaging, Orthopaedic department should
develop routines
298
K.-G. Thorngren
to screen fracture patients for osteoporosis, even 9. Bischoff-Ferrari

HA, Kiel DP, Dawson-Hughes B,
though the treatment may be administered Orav JE, Li R,
Spiegelman D, Dietrich T,
Willett WC.
Dietary calcium and serum
elsewhere as well as the follow-ups. One 25-hydroxyvitamin
D status in relation to BMD
fracture is enough! [73]. Patients who have among U.S.
adults. J Bone Miner Res. 2009;24(5):
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medication to prevent further fractures [74]. 10. Bischoff-Ferrari
HA, Willett WC, Wong JB, Stuck
AE, Staehelin HB,
Orav EJ, Thoma A, Kiel DP,
There is an opportunity to optimise the whole Henschkowski J.
Prevention of nonvertebral fractures
patient with advice for nutrition, physical exer- with oral vitamin
D and dose dependency: a meta-
cise, osteoporosis prevention and fall prevention, analysis of
randomized controlled trials. Arch Intern
as well as optimize all medications, when the Med.
2009;169(6):55161.
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patient appears with their first fracture. Aware- ment tool for
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Schwartz AV, Ensrud KE, Cauley JA,
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SA, Satterfield S, Wallace RB,
Bauer DC, Palermo
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Management of Synovial
Disorders
Zois P. Stavrou and Petros Z.

Stavrou
Contents
Synovial Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 312
Pigmented Villonodular Synovitis (PVNS) . . . . . . .
302 Synovial Haemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . .
312
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 303
Synovial
Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 303
Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 303 Foreign-Body
Synovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Differential
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
303
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 303 Tuberculous
Synovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Radiological Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
304 Rheumatoid Arthritis Synovitis . . . . . . . . . . . . . . . . . . . 315
Echo and MRI Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
304
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 304
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 317
Synovial Chondromatosis . . . . . . . . . . . . . . . . . . . . . . . . . .
308
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 308
Radiological Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
308
Operative
Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
309
Arthroscopic Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
309
Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 309
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 309
Plica
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
310
Post-Traumatic Synovitis . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Haemophilic Synovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Z.P. Stavrou (*)
Henry Dunant Hospital, Athens, Greece
e-mail: zstavrou@gmail.com
P.Z. Stavrou
School of Medicine, Leeds General Infirmary, Clarendon
Wing, Leeds, UK
Evangelismos Hospital, Athens, Greece

301
DOI 10.1007/978-3-642-34746-7_15, # EFORT 2014
302
Z.P. Stavrou and P.Z. Stavrou
synovial joints are also

sometimes involved [1].
Abstract
It is a monoarticular joint
disease and synovial
Synovium lines the capsule of joints, tendon
bursae and tendon sheaths
are also affected.
sheathes and bursae. It is seen to differ from
Men and women are equally
affected. The
the outer thick layer of the capsule both macro-
patients are usually
adolescent with involve-
and microscopically. This capsular layer con-
ment of the lower limbs.
Bony involvement is
tains a rich network of blood vessels, lymphatic
rare and usually affects
the hip. Generally, in all
vessels and nerves, which penetrate the inner
types the fingers (tendons
and sheaths) are
synovial membrane. There are numerous cap-
affected in 60 % of the
patients and the knee
illaries on the surface of the synovial mem-
in 30 % [1].
brane and delicate capillary loops extend into
The disease was
probably first described by
the margins of the articular cartilage at the site
Chassaignac who, in 1852,
reported the nodular
of the insertion of the capsule. These are part of
form affecting the index
and middle fingers [2]. It
the vascular border of the joint which was
was considered to be a form
of synovial sarcoma.
termed by Hunter the circulus articuli
Dowd in 1912 considered it
to be a benign form
vasculosus (Jaffe HL. Metabolic degenerative
(villous arthritis) [3].
There has been some con-
and inflammatory diseases of bone and joints.
fusion with terminology and
several names have
Philadelphia: Lea and Febiger. 1972. p. 92).
been ascribed to the
condition such as xanthoma,
Synovium also covers intra-articular ligaments
myeloxanthoma, giant-cell
tumour, villous
and tendons and intracapsular areas of bone
arthritis and benign
synovioma. Two patients in
which are not covered by articular cartilage.
his series had recurrence
and repeated operations
The synovial membrane is involved in all dis-
were necessary, which led
to amputation. These
eases of joints and tendons. Villi are projections
two patients were still
alive 6 years after opera-
of the surface of the synovial membrane which
tion. It is well known that
synovial sarcoma has
consist of fibrils of collagen with lining cells.
a poor prognosis if
diagnosed late. Lichtenstein
They can be identified microscopically and
doubted that these two
patients had a synovial
vary in size, shape, and composition according
sarcoma. As a result of his
histological examina-
to the underlying pathological conditions
tion he stated that no case
of PVNS developed
which are considered here.
malignant change. Several
theories have been
proposed regarding the
aetiology of PVNS. In
Keywords
1941 Jaffe, Lichtenstein
and Sutro [4] termed it
Arthroscopic # Disorders # Foreign body
pigmented villonodular
synovitis implying
synovitis # Haemophilic Synovitis # Pigmented
a benign inflammatory
aetiology. Some authors
villonodular synovits # Plica syndrome #
considered the aetiology to
be repeated
Post-traumatic synovitits # Rheumatiod
microtrauma. Some of the
changes in PVNS are
arthritis synovitis # Synovectomy # Synovial #
similar to the synovial
changes which are seen in
Synovial chondromatosis # Synovial
haemophilia. Another theory
has suggested that it
haemangioma # Synovial lipoma # Total
is caused by changes in the
concentration of
joint replacement # Treatment-conservative #
lipids in the blood.
However, it is not reproduced
Tuberculous synovitis
by injecting lipid into
joints. The aetiology there-
fore remains unknown
although many authors
have reported it as a
benign neoplastic disorder
Pigmented Villonodular Synovitis which often occurs in
conjunction with abnor-
(PVNS) malities of chromosome 1
p11-13 [5, 6]. More so
there are immunophenotypic
differences in
This is a rare disease of joints. The knee is most giant cells between PVNS
and Haemosiderotic
commonly affected (80 %), followed by the hip Synovitis and the
expression of CD51 in PVNS
(15 %). The shoulder, ankle, elbow, and other giant cells only as well as
the higher ki-67 index
Management of Synovial Disorders
303
in PVS, effectively distinguishes these two the deposition of

haemosiderin. It can be classi-
conditions [7]. Immunophenotype, also, differs fied as PVN synovitis,
PVN bursitis or PVN
comparing to other inflammatory diseases. tenosynovitis according
to the site, and all may
Compared to Rheumatoid Arthritis with which be nodular (localized or
diffuse). The first is more
PVNS has histologically homogeneous appear- common in joints, and
the last in tendon sheaths.
ance, proliferating synovial cells display hetero-
geneous immunophenotype in both RA and
PVNS indicating functional properties of both Histology
macrophages and fibroblasts. Aneuploidy seems
to be a special feature of diffuse PVNS [8]. Histological examination
shows villous hypertro-
Furthermore malignant transformation and phy of the synovial
membrane in both types with
metastasis appear in some reports initially diag- active proliferation of
the synovial cells and var-
nosed as PVNS [911]. iable fibrosis. There
are stromal cells among
Several theories have been proposed to explain which can be found
multinuclear giant cells and
the formation of cysts in PVNS. These are rare but cells containing lipids.
Deposits of haemosiderin
it is postulated that in joints with limited possibility are prominent and may be
either extracellular or
of expansion such as the hip, the synovium within histiocytes. The
synovial membrane is
extrudes at the junction between the articular car- fairly vascular (Fig.
1a, b). When there is bony
tilage and bone, or through pressure within the involvement, similar
tissue can be found nearby,
bone where atrophy allows cysts to form within forming cysts (Fig. 2).
the Haversian systems. In several studies giant cells
in PVNS have been shown to express all the phe-
notypic features of osteoclasts including the ability Differential Diagnosis
to induce lacunar resorption which may account for
the bony lesions seen in this condition [12, 13]. Cases have been reported
which were
In conclusion the aetiology remains obscure. It misdiagnosed as
malignant synovioma and
seems as though that it is of inflammatory origin treated by amputation
[16]. The presence of
with a destructive course and high rate of recur- multinuclear giant
cells, cells containing
rence in the diffuse form and possibility to haemosiderin and the
absence of spindle cells in
metastasize very rarely to another joint or to the active proliferation,
distinguish the disease from
lungs [12]. malignant conditions.
The clinical, microscopic
and histological
appearances also distinguish the
condition from other
active inflammatory disor-
Incidence ders such as rheumatoid
arthritis, traumatic
haemarthrosis and
haemophilia.
After its onset PVNS progresses slowly. Flandry
et al [14] have estimated an incidence of between 1
and 3 per million of population. Dorfman and Symptoms
Czerniak [2] consider it to represent 5 % of benign
soft-tissue tumours. Biopsy of tissue from 1388 These include persistent
pain which gradually
total hip and knee replacements revealed one case increases, possible
locking of the joint in the
of PVNS and 12 of malignancy [15]. nodular form and
stiffness. When the shoulder
is involved, there may
be extension of the
synovium into the
subdeltoid bursa. In the knee
Classification and ankle, haemarthrosis
and swelling are the
usual characteristic
findings. In the fingers and
At operation the lesion presents as villous or toes there is irregular
swelling extending outside
nodular tissue which is yellow brown because of of the tendon sheath.
304
a b
Fig. 1 (a, b) Villous formation of the synovial membrane magnification multi-

nuclear giant cells and lipid-bearing
can be seen on histology with active proliferation of the cells can be seen.
Haemosiderin can be seen extra- or
synovial cells and variable fibrosis. On higher intra-cellular, while
the synovium looks vascular
Echo and MRI Findings
Both techniques may

delineate the lesion. This
is especially so with
MRI in which multiple
synovial lesions with
low or intermediate signal
intensity on T1-
weighted images or low
signal intensity on T2-
weighted and gradient
echo images can be seen
(Fig. 3). The use of
contrast medium can
enhance the lesions, being
non-diagnostic.
Treatment
Surgical treatment may

be open or
arthroscopic. Open
treatment applies to the dif-
fuse type of the
disease affecting the joint (more
so if there are exra-
articular masses), synovial
Fig. 2 Bone cysts in PVNS can be seen away from the
bursae and tendon
sheaths.
articular surface
Since the knee is
the major joint affected, the
surgical approach to
the knee will be described.
Radiological Findings The skin is
prepared and the tourniquet is
inflated. The joint is
approached through
If there is no bony involvement there will be no a straight midline
incision to the skin and
radiological abnormalities. In advanced cases a medial parapatellar
incision. The capsule is
there may be cysts at some distance from the separated from the
synovium (Fig. 4) and the
articular surface; they may be well-defined and hypertrophied synovium
can be seen protruding
the joint space relatively preserved (Fig. 2). In on incising the
synovial membrane (Fig. 5). Sub-
more advanced cases there may be secondary sequently the synovial
suprapatellar pouch is
degenerative changes. In cases affecting the fin- resected en bloc (Fig.
6) with the remaining
gers, pressure indentation of bone may be seen. synovium to the margins
of the articular cartilage
305
Fig. 3 MRI scans showing hypertrophied lobular synovium
Fig. 5 Hypertrophied
synovium can be seen protruding
Fig. 4 Synovium can be clearly dissected from the outer on incising the synovial
membrane with villus formation
fibrous or other structures
which is meticulously excised (Figs. 7, 8a, b). underlying remnants of

the synovium are
The synovial remnants which invade the cruciate curetted. The detached
menisci are repaired
ligaments are also removed. Then the menisci are with non-absorbable
sutures. If there are any
detached from the periphery and the possibly bony cysts, these are
evacuated by curettage and
306
filled with bone

graft. After suturing and vacuum
suction placement, if
there are lesions in the back,
either extra- or
intra-articular, the patient is
turned over. The
tourniquet is reinflated and the
posterior lesions are
approached through an
S incision. The extra-
articular lesions are excised
and the posterior
joint is approached after
dissecting the
peroneal nerve and detaching the
two heads of the
gastrocnemius protecting the
neurovascular
structures. The capsule is incised
with medial and
lateral incisions and the inside
tissue is excised.
After suturing and vacuum suc-
Fig. 6 Most of the synovial membrane including the tion placement the leg
is immobilized in a Robert
supracondylar pouch can be excised en-bloc Jones bandage and
continuous passive movement
and physiotherapy are
started from the first post-
operative day with
isometric exercises followed
by active assisted
exercises and gradual weight-
bearing. Postop pain
is controlled in the first
2 days by epidural
medication or PCA.
Arthroscopic
treatment of the knee is indi-
cated for the nodular
(localized) form and the
node or nodes are
removed through medial or
lateral portals
depending on their site. This treat-
ment gives equally
good results as the open pro-
cedure and better
rehabilitation. Postoperative
rehabilitation is
simple, as for other minor arthro-
scopic procedures.
Arthroscopic
synovectomy for the diffuse form
of PVNS has a high
incidence of recurrence, 14 %
Fig. 7 The remnants of the excised synovium can be in 42 months [17].
Recurrence-free survival is
meticulously be removed up to the borders of the articular 95 % for open
synovectomy and 62 % for
cartilage arthroscopic
synovectomy at 2 years and at 5 years
a b
Fig. 8 (a) The main part of the excised synovium with the supracondylar pouch. (b)
The inside of the pouch with the
nodular appearance
307
73 % for open and 48 % for arthroscopic [18].

Arthroscopic total synovectomy gives equally
good results as open total synovectomy, according
to some authors, [19] but it is a technically demand-
ing procedure and requires posterior portals and
experience with 70# scope. The same authors
reported five clinical recurrences in nine patients
in 1.8 years [20]. On the other hand, De Ponti et al
presented better results for the defuse PVNS
with extended arthroscopic synovectomy and the
recurrence rate was lower in comparison to the
partial synovectomy group [20].
In conclusion open total surgical synovectomy,
Fig. 9 Defuse PVNS of the
extensor tendons of the
as described, remains the most reliable and con-
thumb, totally excised
sistent method of treating all anatomic variations
of diffuse PVNS, especially in the extra-articular
form [12, 21]. Safe comparison between the
different studies is difficult because recurrence of the
synovitis, but does not prevent
many authors do not use MRI for the diagnosis the development of
secondary osteoarthritis [23].
of recurrences [12]. Total hip replacement in
diffuse PVNS is indi-
Total knee replacement (TKR) is indicated cated when there are
advanced O.A. changes.
in more advanced cases in conjunction with Gonzalez Della Vale et al
reviewed 117 cases
synovectomy when secondary O.A. changes have from the literature and
presented 7 new cases.
been established. The results are encouraging. In Among the new cases, 4
underwent synovectomy
18 patients followed for a mean of 10, 3 years after and primary total hip
replacement with no
TKR and synovectomy there was one case of recurrences detected after
an average follow-up
recurrence and three of aseptic loosening without of 13 years. One patient,
who underwent
recurrence [22]. Arthrodesis with synovectomy synovectomy, had a
recurrence 9 years later,
was the treatment of choice for advanced case requiring a total hip
replacement. Regarding the
previously before TKR became an established reviewed cases of PVNS of
the hip, 53 % did not
successful procedure. have enough information for
analysis. Of the
As mentioned before, hip joint is affected remaining cases 10 had
recurrence, 1 in
much less by diffuse PVNS. Synovectomy, as it the arthroplasty group (24
patients) and 9 in the
is generally accepted, is indicated in patients with synovectomy group (26
patients) [24]. Recently
preserved articular cartilage. Arthrotomy with Yoo et al reviewed 8
patients for 8.9 years
subsequent dislocation of the hip is necessary to following cementless total
hip arthroplasty
complete maximal synovectomy. Vastel et al (THA) combined with
synovectomy. None of
presented 16 patients, mean age 35 and 16 years the patients had clinical
or radiographic evidence
follow-up. All had synovectomy and in addition of PVS. Osteolysis occurred
in 4 hips and two
3 cup arthroplasty, 4 total hip replacement and revision surgeries were
performed [25].
1 monopolar replacement. Nine patients needed Open surgical treatment
is the only treatment
repeat surgery, but only one had recurrent syno- for PV bursitis and
tenosynovitis. In the former,
vitis 14 years after treatment with synovectomy excision of the affected
bursa and synovectomy
and cup arthroplasty. Secondary osteoarthritis are the recommended
procedures. In the latter,
developed in all 8 patients who had been treated total resection of the
hypertrophic synovium is
with synovectomy alone and 4 of them required indicated (Figs. 911).
Recurrence is the main
total hip arthroplasty within the follow-up period. complication. In the
diffuse form a rate of recur-
They concluded that synovectomy prevents rence of between 30 % and
46 % has been
308
Fig. 10 Defuse PVNS of the extensor tendons of the

thumb, totally excised
Fig. 12 X-Rays of the knee

of a 60 years-old woman with
Synovial Chondromatosis
gradually detached from

the synovium becoming
loose. Although rare it
presents between the ages
of 20 and 50 years,
usually occurring in men [30].
Approximately 70 % of
cases involve the knee.
Fig. 11 Defuse PVNS of the extensor tendons of the Other areas such as the
hip, shoulder, elbow, and
thumb, totally excised the temporomandibular
joint may be affected.
In contrast to PVNS, in 10
% of cases it may be
bilateral [2].
reported, and in the nodular form of between
27 % and 48 %.
Radiation therapy in PVNS has been used as Symptoms
adjuvant external beam therapy with no signifi-
cant advantage over surgical synovectomy alone. Pain and swelling are the
main presenting fea-
Arthroscopic synovectomy with adjuvant low tures with occasional
locking. They are usually
dose radiotherapy showed recurrence rate 14 % mild, insidious and
chronic until there is limita-
same as open synovectomy [26]. Possible compli- tion of movement of the
affected joint.
cations are reported; joint stiffness, skin reactions,
poor wound healing and possibly sarcomatous
transformation. The results are variable [2729]. Radiological Findings
There may be multiple

loose bodies, which if
Synovial Chondromatosis mineralized, can be seen
on plain radiographs
particularly in
longstanding cases (Fig. 12). In
This is a metaplastic disorder involving the syno- 10 % of the cases loose
bodies cannot be identi-
vial membrane of a joint, the tendon sheath or the fied on plain radiographs
[2]. MRI is of value in
bursa, producing nodules of cartilage which are early cases.
309
Fig. 15 The excised

synovium and loose bodies
Fig. 13 Same patient as Fig. 12. Multiple loose bodies
popping out of the joint on incising the synovium
Fig. 14 Hypertrophyed synovium with no pigmentation

can be seen
Fig. 16 Arthroscopic
picture in an early case of synovial
Operative Findings chondromatosis
These depend on the stage of the disease. In late

features (Fig. 17a). The
cellularity of cartilage
cases on opening the joint, multiple loose bodies are
nodules is often
increased. The loose bodies
seen (Fig. 13). The synovium resembles that of PVS
resemble hyaline cartilage
(Fig. 17b).
without pigmentation or villi (Fig. 14). The loose
bodies may be of many different sizes (Fig. 15).
Treatment
Arthroscopic Findings
Open surgical treatment is
indicated in
In early stages, loose bodies may be identified longstanding cases in
which there are multiple
and can be excised (Fig. 16). No macroscopic chondromatous loose bodies
and the synovium
synovial changes are seen in the early cases. appears to be
proliferative. All loose bodies are
removed and a synovectomy
is carried out as
Histology previously described.
After operation, the same
regime is followed as for
PVS. If there are sec-
The synovium in fully developed cases contains ondary symptomatic
degenerative changes, TKR
multiple nodules of hyaline cartilage of myxoid may be required.
310
a Arthroscopic
removal of loose bodies has
higher recurrence
rate than if it were combined
with arthroscopic
synovectomy (p 0.02) [32]. In
5 cases of shoulder
arthroscopy, removal of loose
bodies and partial
synovectomy, performed due to
synovial
chondromatosis, clinical results were
very good, whereas
radiological signs of
chondromata were
observed in 2 patients [33].
If secondary O.A.
develops in conjunction
with synovial
chondromatosis total knee or total
hip arthroplasty is
required. Ackerman D. et al
b from the Mayo Clinic
reviewed 11 patients
treated with total
knee or total hip arthroplasty
with mean follow-up
time after surgery of
10.8 years. Pain and
functional scores improved
in all patients.
There was only one recurrence of
the disease for the
knee and one for the hip group,
25 % and 14 %
respectively [34].
Plica Syndrome
Fig. 17 (a) The synovium in synovial chondromatosis
looks nodular on histology before the top ends become
Plicae in the knee
are some of the normal synovial
loose bodies. (b) Histologic picture of a loose body at the structures. They are
remnants of the mesenchymal
same patient with hyaline cartilage formation tissue that occupy
the space between the distal
femoral and proximal
tibial epiphyses in the
Arthroscopic treatment is recommended in 8 weeks-old embryo.
Under some circumstances
early cases in which there are a few loose bodies the incomplete
resorption leaves synovial pleats in
without proliferative synovial changes requiring most of the knee.
Plicae in the knee are classified
synovectomy. Synovial chondromata are those based on their
anatomical location; the infrapatellar
cases in which there is a single cartilaginous plica or ligamentum
mucosum, the suprapatellar
nodule within the synovial membrane. There is plica and the medial
patellar plica or medial
controversy as to whether it exists or reflects shelf. Lateral plicae
exist but rarely [35]. Dandy
synovial metaplasia. described several
variations of the most common
Synovial chondromatosis of the hip appears in medial plicae [36].
the literature in a few reports regarding the out- Plicae become
pathological when thickening
comes. Schoeniger R. et al reviewed 8 patients and fibrosis occurs
with subsequent inelasticity
who had joint debridement and total synovectomy that can lead in
snapping over the femoral condyle
performed through open surgery dislocating the causing synovitis,
chondral damage and pain [37].
hip and flip osteotomy of the greater trochanter. Pain is the most
common symptom. Swelling,
The mean follow-up was 6.5 years. No patient had pseudo-locking, and a
feeling of snapping are com-
recurrence of the disease at follow-up. Finally at mon symptoms as well.
Arthroscopy is of value in
5 and 10 years, 2 patients had developed O.A. diagnosis and the
reason for the symptoms may be
requiring total hip arthroplasty. Even these attributed to a plica
in the absence of other pathol-
2 patients did not show recurrence of the disease ogy such as meniscal
lesions, loose bodies etc.
on histologic examination of the synovial mem- Post-traumatic
synovitis after injury to a plica
brane. They concluded that synovectomy prevents may cause symptoms
and a plica may also cause
recurrence of the disease with no morbidity [31]. recurrent
haemarthrosis [38].
311
The treatment of synovial plicae is conserva- The sensitivity,

specificity and accuracy of MR
tive in the first instance with administration of imaging compared to
arthroscopy is 88 %, 95 %
non-steroid anti-inflammatory drugs, isometric and 95 % respectively
[41]. In late cases arthros-
quadriceps and hamstring exercises. If there is no copy can be difficult
because of lack of space for
symptomatic improvement arthroscopic removal expansion of the joint,
and several portals may be
of the plica after inspection of the entire joint is the needed.
treatment of choice [39]. Postoperatively, an
intense programme of physiotherapy is required.
The syndrome may recur and further arthroscopy Haemophilic Synovitis
may be needed if a new plica forms, which must
be removed. The routine medial and lateral arthro- Haemophilia is a sex-
linked inherited disorder,
scopic portals are used. transmitted as a
recessive Mendelian trait. It is
expressed by males and
transmitted by females,
who are not affected.
One of the main presenting
Post-Traumatic Synovitis symptoms is repeated
haemarthroses due to lack
of a clotting factor.
Successive haemorrhages
This refers to the reaction of the synovial mem- cause proliferation of
the synovial membrane,
brane after trauma. It can be at the site of injury to reactive inflammation
and eventually destructive
the synovium or secondary to an associated injury changes in the joint.
to ligament or bone. Immediately after the injury The initial symptoms
are pain, heamarthrosis
local haemorrhage or rupture of the synovial and impaired function.
The knee is the most com-
membrane may be distinguished arthroscopically. monly involved joint.
Repeated haemarthroses
Haematoma at the insertion of a ligament gives cause stiffness due to
initially reactive synovitis
the suspicion or rupture. If trauma to the synovium and subsequently to
arthrofibrosis. Contractures
is longstanding the reaction is generalized. The of the knee or other
affected joints usually
knee is the most commonly affected joint. appear as the condition
progresses and the devel-
Immediately after injury parts of the trauma- opment of secondary
degenerative changes is
tized synovium may protrude inside the joint and inevitable.
if devascularized may become loose and cause Initially,
radiographs are normal. Gradually,
locking. Subsynovial haematoma, hydrarthrosis due to disuse, bone
atrophy becomes evident and
and haemarthrosis may resolve with the passage later there are
secondary degenerative changes.
of time whereas deposits of haemosiderin may MRI may show
hypertrophy of the synovium
continue for many months and be mistaken for as in PVNS.
Histologically the synovial villi are
PVS. They differ, however, in that the changes in plump and matted
together. The cells of the syno-
post-traumatic synovitis are superficial. In case of vial lining contain
haemosiderin and are mostly
recurrent haemarthrosis a thick plica-like appear- macrophages [42].
ance of the synovium can be seen either Open synovectomy is
the established surgical
arthroscopically or histologically. Chronic syno- procedure after initial
conservative treatment
vial tears may become fibrotic and lead to with the administration
of the missing clotting
arthrofibrosis and stiffness. factor, immobilisation
and physiotherapy. Radio-
The indication for surgery is severe mechani- active synovectomy is
indicated in patients who
cal type of pain after injury non-responding to have inhibitors to the
clotting factor, immune
3 months of conservative treatment [40]. In pri- deficiency or advance
hepatitis [43, 44].
mary synovial injuries arthroscopy is of value Arthroscopic
synovectomy offers many
for removal of pieces of the injured synovium advantages, since the
disease is not proliferative,
and for washing-out the joint to avoid synovial and is preferable to an
open procedure in
inflammation. Arthroscopy is decided after MRI order to avoid
postoperative haemorrhage and
exclusion of other internal disorders of the joint. fibrosis. Synovectomy,
by either method, does
312
not arrest the development of degenerative

changes [45]. Synovial Sarcoma
With the availability of activated recombinant
factor VIII the possibility of total joint arthroplasty Synovial sarcoma is a
tumour the cells of which
was expanded in haemophilic patients with resemble those of normal
synovium. It accounts
inhibitors [46]. Total hip and knee replacement for 510% of soft-tissue
tumours. It is usually
in post-haemophilic degenerative arthritis have located in par-articular
or extra-articular tissues;
encouraging results [47, 48]. Latest techniques of 510% are intra-
articular. The knee is the most
continuous infusion of clotting factor have signif- commonly-affected joint
[31].
icantly helped to reduce the complication rates The tumour grows
slowly accompanied by
and have achieved results which match to those pain and tenderness. On
palpation a deeply
of the non haemophilic population undergoing located round or
lobulated mass can be identified
arthroplasties [49]. or in rare cases it may
present as chronic synovitis
or an internal
derangement.
Radiography shows
calcification or ossification
Synovial Lipoma within the tumour in 25%
of cases. On CT or MRI,
the tumour appears
inhomogeneous. T2-weighted
A lipoma very rarely rises from the synovial mem- images show intermediate
and high- intensity sig-
brane [2, 50]. Clinically it can cause locking, nals. Histologically the
tumour consists of epithe-
swelling, mass effect and synovitis. In rare cases, lial-like and fibroblast-
like cells [31].
concerning the knee, it can displace the patella due Arthroscopy has a
limited indication and only
to the mass-effect [51]. A lipoma also may arise in rare cases in which
the tumour is intra-articular.
from tendon sheaths of the hand. When found in It is used only for
diagnostic biopsy. Wide exci-
the knee it should not be mistaken for hyperplasia sion gives results
similar to those of amputation
of Hoffas fat pad. Histologically, it consists of with a survival at 5
years of 2560 % depending
adipose tissue and is identical to those found else- on the stage of the
tumour [55].
where. Arthroscopic excision is recommended.
Foreign-Body Synovitis
Synovial Haemangioma This condition is

identified as a result of wear mainly
in joint replacement. The
synovium reacts to wear
This is another rare lesion affecting the knee, particles by an
inflammatory mechanism with cen-
elbow and tendon sheaths. It may be either tral necrotic
hypertrophic synovium infiltrated by
localised or diffuse. The symptoms in the various cells.
Eventually, the implant becomes
localised form consist of pain, swelling and loose and revision is
necessary (Figs. 1820).
occasionally locking. In the diffuse form it
can cause a haemarthroses and even destruction
of the joint [52]. Histologically, it may be Tuberculous Synovitis
capillary or mixed type (capillary and cavernous
haemangioma) [2]. According to Campanacci The condition was common
before the
[31] the diffuse form may be confused with pasteurisation of milk.
Nowadays, it is seen in
PVNS if there are repeated haemarthroses. The old cases of pulmonary
tuberculosis which has
two conditions can be distinguished histologi- been either untreated or
incompletely managed or
cally. MRI is recommended. Arthroscopic treat- in immuno-suppressed
patients. Synovial joints,
ment should be used for the localised form tendon sheaths or bursae
can be affected as
whereas open synovectomy is needed for the a manifestation of the
tertiary stage of the disease
diffuse type [53, 54]. or in post-primary re-
infection.
313
Fig. 18 Loose Charnley total hip replacement in 82

years-old patient on the left side, after 18 years
Fig. 19 Foreign particle inflammatory reaction with infil-

tration by macrophages and histiocytes around the plastic
particle (same patient)
Fig. 20 After revision
surgery (same patient)
The condition can affect the spine in 2540 %
of cases, the hip in 25 % and the knee in MRI, echo studies
and CT may show synovial
20 % [42]. hypertrophy and bony
erosions or atrophy. A bone
The presenting symptoms are pain which is scan may show
increased uptake. The ESR and the
usually mild, effusion, synovial or peri-articular level of C-reactive
protein are increased. The
thickening, local mild heat but not redness (as in tuberculin test is of
value although if negative it
non-specific infections), limitation of movement, does not exclude
tuberculosis. PCR examination of
muscle spasm and eventually atrophy of the the joint fluid can
confirm the diagnosis. Nowa-
muscles and contractures with inability to walk if days, guinea-pig
inoculation is not used because of
the hip, knee or ankle are affected. In untreated the delay in obtaining
the result. Acid-fast bacilli
cases cold abscesses with chronic sinuses may may not always be
observed under microscopy.
develop. Arthroscopy is of
value at the onset of the dis-
The radiological findings in the early stages ease when it has not
eroded the bone and the diag-
are demineralisation of the joint resembling tran- nosis has not been
established. Biopsy will indicate
sient osteoporosis, bony erosions in late cases and villous proliferation
in the synovial membrane and
subluxation if a synovial joint is affected infiltration by
epithelial-like cells, Langhans-type
(Fig. 21a, b). giant cells and
lymphocytes (Fig. 22).
314
a b
Fig. 21 (a, b) The X-rays of a neglected case of tuberculosis of the right knee
with bone erosions and subluxation
Fig. 22 Microscopic view

of the previous patient,
showing Langhans-type
cells with infiltration of the
synovium by epithelial like
cells and lymphocytes
Open synovectomy may be performed in the age. This is combined

with anti-TB drugs for
early stages in order to prevent the progress of the the appropriate time
(Fig. 23).
disease locally. If this happens, the patient can In late cases open
surgery is the only treatment
undergo joint replacement at a later stage and for removal of all
infected synovium, bursae or
315
Fig. 25 Synovium in
rheumatoid arthritis infiltrated by
plasma cells,
lymphocytes and macrophages
Fig. 23 Fifty years-old patient with bilateral avascular

necrosis of both hips following bone marrow transplanta- cysts with curettage of
bony erosions and even-
tion for acute lymphocytic leukemia. The right hip was tually arthrodesis (Fig.
24).
complicated by tuberculosis. Reconstruction of the right
hip was undertaken in a two-stage procedure using allo-
graft, cage and cemented acetabulum. Six years post-op
X-ray Rheumatoid Arthritis
Synovitis
The aetiology of this

chronic systemic inflamma-
tory disease is multi-
factorial with genetic dispo-
sition and immunological
reactions leading to
generation of cytokines
due to an immune system
defect and inflammatory
reaction of the synovial
membrane. There is a
predilection for the
involvement of joints.
The arthritis is
initiated by non-suppurative
inflammation of the
synovial membrane. This
produces an effusion and
synovial hypertrophy
extends to the margin of
the articular cartilage
creating the so-called
pannus which gradually
erodes bone and
ligaments leading to distortion
of the joint. Extra-
articular manifestations are
characteristic such as
rheumatoid nodules, arter-
itis, scleritis,
pericarditis and splenomegaly.
Swelling, heat,
pain, morning stiffness
and deformities are the
usual symptoms.
Women are twice as often
affected as men.
There are also musculo-
skeletal, haematological,
lymphatic, pulmonary,
cardiovascular, immuno-
logical and neurological
manifestations.
Laboratory tests
show anaemia to some extend
depending on the stage
of the disease and a raised
ESR. Rheumatoid factor
is found in 80 % (non
Fig. 24 Post-operative X-ray of the performed arthrode- specific) of the cases
and ANA is present in
sis of the knee 2030%. Anti-CCP
antibodies are also found
316 Z.P.
Stavrou and P.Z. Stavrou
with specificity of 95 % and in combination with the possible damage to the

vessels and nerves in
RF of almost 100 %. the popliteal fossa [58].
According to other
Histological examination shows that the authors and as it was
mentioned in the Pigmented
synovium is infiltrated by lymphocytes, plasma Villonodular Synovitis
(PVNS) section, this
cells and macrophages. There is hyperplasia of method is technically
demanding and requires
the synovial cells (Fig. 25). posterior portals and 70#
scopes [20]. There are
Radiographs do not show specific indications no long-term results
available for arthroscopic
of the disease, but in early stages some osteoporo- synovectomy. The short-term
results are compat-
sis may be seen as in the early stages of other ible with those of open
synovectomy. In a recent
inflammatory conditions. As the process of the comparative study (13 years
follow-up) in
disease continues there is marginal erosion of 53 patients and 58
rheumatoid elbows, of which
bone leading to joint destruction and secondary 23 had been selected to be
treated by arthroscopic
osteoarthritis. In the early stages the arthritis is synovectomy (group 1) and
another 23 by open
atrophic and MRI and CT findings are not specific. synovectomy (group 2). 11 of
the 23 elbows of
Medication to control inflammation includes group 1 and 16 of the 23
elbows of group 2 were
disease modifying anti-rheumatic drugs, bio- mildly or not painful at
latest follow up examina-
logics, NSAIDs, including COX-2 inhibitors, tion and also there was no
significant difference
and corticosteroids. in the overall clinical
results with both methods
If the joint does not respond to the selected used. Open synovectomy
provides persistent
drugs, synovectomy may be necessary. It is gen- improvement in pain relief
and function, pro-
erally agreed in multi-centred studies that early vided that pre-operative
flexion is # than
synovectomy in the first 6 months can prevent or 90 degrees. If patients have
pre-operative
extend the time of appearance of bony erosions, stiffness they have higher
risk of post-operative
although this remains a matter of debate and there stiffness with open surgery.
Recurrent synovitis
may be no long-term benefit. was noticed in 21 % in the
arthroscopic group and
Open synovectomy of the knee as described in 10 % in the open group.
Fibrous ankylosis is
the section on Pigmented Villonodular Synovitis contra-indication for
arthroscopy [59]. Although
(PVNS) is a well-accepted procedure for rheuma- a real joint-preserving
effect has not been
toid arthritis, and it may be used in other joints demonstrated, pain reduction
and improvement
such as the elbow, wrist or MCP and PIPJs. Open of joint function recommend
arthroscopic
surgical synovectomy is the treatment of choice synovectomy as a substantial
treatment option
providing that there are no erosions of the artic- as described [60]. Open
synovectomy of the hip
ular cartilage. Post-operative physiotherapy is gives 85 % improvement of
function and 94 %
important to maintain the function of the joint. survival rate with 4 years
mean follow-up. In 65
Arthroscopic synovectomy has been intro- hip synovectomies (nine
required dislocation),
duced in recent years and seems to give better five hips required total hip
arthroplasty during
early results with regard rehabilitation and mobil- follow up. None showed
avascular necrosis [61].
ity of the joint. A disadvantage of the technique is After some years the
joint will become eroded
that hypertrophied synovium may impede the and unstable with secondary
osteoarthritis and
view of the joint. Multiple portals may be replacement is necessary.
The results of total
used [56]. The operating time is extended [57] hip and total knee
arthroplasties differ from oste-
and care must be taken to remove as much of the oarthritis, due to younger
age, osteoporosis and
synovium without damaging ligaments and other risk factors. In a recent
study, the overall infec-
structures. It is not recommended to remove tion rate was 3.7 % in 657
hip and knee replace-
synovium from the popliteal space because of ments (follow-up 4.3 +/# 2.4
years) [62].
317
during
primary hip and knee arthroplasty. J Bone
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Orthopaedic Management
of the Haemophilias
Richard Wallensten
Contents
Simultaneous Operations . . . . . . . . . . . . . . . . . . . . . . . . . . 326
320 Post-Operative Care and Rehabilitation . . . . . . .
. . 326
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 320
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 326
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 320 Economical Considerations . . . . . . . . . . . . . .
. . . . . . . . . . 328
Non-Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 321
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 328
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 329
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
321
Synovectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 321
Radiosynovectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 321
Open
Synovectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
322
Arthroscopic Synovectomy . . . . . . . . . . . . . . . . . . . . . . . . . .
322
Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 322
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 323
Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 323
Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 324
Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 325
Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 325
Resection of Osteophytes . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Pseudotumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 326
R. Wallensten
Department of Orthopaedics, Karolinska University
Hospital, Stockholm, Sweden
e-mail: richard.wallensten@efort.org;
richard.wallensten@karolinska.se

319
DOI 10.1007/978-3-642-34746-7_16, # EFORT 2014
320
R. Wallensten
the child and as a rule only

boys develop the
Abstract
disease whereas girl are
carriers. In 2530 % of
Haemophilia affects joints through repetitive
the patients no family
history can be traced and
bleeding that destroys the articular cartilage.
new mutations are the cause.
Thus prophylaxis with clotting factor treat-
Depending on the blood
level of the factor
ment is important. When patients have
concentration the patients
are classified as having
established arthropathy and need surgery it
mild (>5 % of normal),
moderate (25 %) or
is important to have co-operation with
severe haemophilia (<2 %).
Patients with mild
a haematology laboratory that can supervise
disease rarely bleed unless
there has been signif-
per- and post-operative factor substitution.
icant trauma whereas those
with severe
The joints most affected are knees, ankles,
haemophilia bleed
spontaneously as a result of
hips and feet and the most common proce-
minimal trauma or activities
of daily living. They
dures joint fusion or replacement. Since the
may have several such
episodes of bleeding every
arthropathy is advanced the operations may
month. Prophylaxis against
joint bleeding is
be technically difficult and the surgeon needs
important in order to
minimize damage to the
to be well-experienced in primary and revi-
articular cartilage [1, 2].
sion joint replacement. Successful surgery
can give these patients a large improvement
in pain relief, function and life quality and the
long-term results are good. If the patients Classification
need more than one operation it is advanta-
geous to perform them in the same session. The sub-committee on Factor
VIII and Factor IX
of the Scientific and
Standardization Committee
of the International
Keywords
Society on Thrombosis and
Haemostasis classifies
Arthrodesis # Arthropathy # Arthroplasty #
the haemophilia patients
into three forms [3]:
Coagulation # Factor deficiency # Haemophilia
# Joint deformities # Joint reconstructions #
Severe form factor level
<0.01 IU/mL
(<1 % of normal);
Multiple simultaneous joint reconstruction #
Moderate form
factor level
Pseudotumors # Von Willebrands disease
0.010.05 IU/mL (15 % of
normal); and
Mild form factor level
>0.050.40 IU/mL
(more than 540 % of
normal).
General Introduction
Haemophilia is a hereditary disease that

decreases the ability to form blood clots when Diagnosis
bleeding occurs. It occurs in all ethnic and racial
groups. The cause is absent or low concentration Suspicion of a bleeding
disorder should come
of one of the factors needed for normal coagula- from a history of abnormal
bleeding episodes,
tion. In 85 % of the cases the deficient factor is genetic background for
haemophilia or other coag-
factor VIII and the disease is classic haemophilia ulation defects and, if
present, joint deformities.
A. Less common is deficiency of factor IX or Of particular orthopaedic
interest are joint bleeds
Christmas factor, also called haemophilia B, and haemarthrosis. The
diagnosis is confirmed by
which accounts for about 15 %. Other coagula- laboratory tests where the
most important are
tion defects are caused by deficiencies of factors platelet count, bleeding
time, activated partial
V, VII, X or XI or by von Willebrands disease. thromboplastin time (aPTT)
and prothrombin
The defect in haemophilia A is linked to the time. Important tests also
are factor assays for
X chromosome and is carried from the mother to factors VIII and IX and the
von Willebrand factor.
Orthopaedic Management of the Haemophilias
321
Fig. 1 Distribution of 288

operations in patients with
coagulations disorders (%) Operations
Knee 45 %
3
Ankle 17
1
Hip 16 7
Foot 9 16
2
Elbow 7
Shoulder 3
45
Hand 2
Spine 1 17
Non-Operative Treatment Pre-Operative Preparation

and Planning
The basic treatment for haemophilia is prophy-
laxis with the appropriate factor. It should be Pre-operative planning for
surgery on
given to children and adults. haemophiliac patients consists
not only of plan-
ning the surgical intervention
but also of planning
the factor substitution
treatment [4, 5].
Indications for Surgery
Patients with haemophilia can have the Operative Techniques

same orthopaedic diseases and injuries as
patients with normal coagulation. Thus indica- Since the operative procedures
used on
tions for surgery are the same as for haemophiliac patients are
technically the same
non-haemophiliacs. as in patients without
coagulation defect they
Special indications caused by the coagulation are not described in detail in
this chapter. Only
defect are: special considerations and
advice particular to
Chronic synovitis with bleeding episodes haemophiliac surgery are
addressed.
that do not respond to pharmacological
treatment.
Pain and restricted ROM due to secondary Synovectomy
haemophilic arthropathy
Joint deformities Radiosynovectomy
Pseudotumours caused by repeated bleeding
into soft tissues. Synovectomy for haemophilic
synovitis has been
The joints most commonly affected by performed since the 1960s [6].
Initially open sur-
haemophilia and in need of surgery are knees, gery was used but in the 1970s
synoviorthesis was
ankles, hip, feet and elbows (Fig. 1). achieved using injection of
radioactive isotopes
322
R. Wallensten
such as gold (198Au), chromic phosphate (32P) or replacement are good and
few patients want to
Yttrium (90Y). Synoviorthesis is still used and, accept the disability of a
knee fusion. When it is
except for a few cases of necrotic needle tract from done today it is generally
after failure to recon-
extravasation of the radiocolloid, no distant radia- struct an infected
arthroplasty.
tion injuries have been reported. The long-term Knee fusion can be
achieved by external fixa-
results have been good in preventing bleeding epi- tion, intramedullary
nailing or plating. The exter-
sodes but the treatment has not been able to prevent nal fixation can be a
reliable method [11] which
progression of the arthropathy. It is, however, a safe however is uncomfortable
for the patient during
and inexpensive procedure that needs less factor the several months before
stable healing. Caution
substitution and does not require hospitalization as must be taken if bleeding
or infection occurs in
compared to open or arthroscopic synovectomy. the pin tracks.
Intramedullary nailing
needs either long nails
that go from the proximal
femur through the knee
Open Synovectomy down into the tibia or
shorter modular nails that
are introduced upwards and
downwards from the
Open synovectomy is the classical way of surgi- knee and then connected.
The long nails have to
cally-treating synovitis. In haemophilia it is best be measured and ordered
beforehand and can be
suited for larger joints such as the knee or elbow. tricky to get all the way
down into the tibia but
The drawbacks are that it is very invasive and that they are easy to remove if
needed. The short
it is difficult, if not impossible, to remove all of special modular nails for
knee fusion are easier
the diseased synovial membrane through one to insert but have the
great disadvantage of being
incision. It has now been replaced by very difficult to remove.
Should that become
arthoscopically-assisted synovectomy. necessary one has to take
down the fusion as
Technically the operation is performed as in well. IM nailing usually
results in a straight
rheumatoid arthritis. The synovial membrane is knee since the nails are
not bent to functionally
usually hypertrophied and brownish and should optimal flexion.
be removed as completely as possible. In the knee Plates are easy to
insert since the knee joint is
a mid-line skin incision with medial arthrotomy fully open when the
arthrodesis is performed.
and eversion of the patella is preferred. In the They can be adapted to the
contours of the knee
elbow the patient is put in the lateral decubitus and permit the desired
flexion, usually 20# , in the
position with the arm hanging over a roll for fused knee. Two plates are
recommended for
a straight posterior incision. This makes it possi- stable fixation if
external support (plaster or
ble to explore the elbow from the radial and ulnar brace) is to be avoided.
sides for a complete clearance of the synovium. Arthrodesis of the
ankle and sub-talar joints
are frequent operations in
haemophiliac patients
[12]. They can be fused
separately or simulta-
Arthroscopic Synovectomy neously depending upon the
situation. Since
radiological arthropathy
is common it is impor-
Arthroscopic synovectomy has been proven tant to analyze the pain
and range of motion in
effective for the knee joint with reduction in order to only address the
symptomatic joints.
bleeding episodes [710]. This can be done by good
physical examination
and sequential local
anaesthesic blocking intra-
articularly.
Arthrodesis Tibio-talar fusion can
be performed by resec-
tion of the remaining
cartilage through an ante-
Arthrodesis of the knee was earlier a common rior or lateral approach
and the fixation by screws
procedure in severe haemophilic arthropathy. or by a blade-plate. The
important thing is to
Today it is rarely used since the results of knee achieve good compression
to allow immediate
323
Fig. 3 Subtalar fusion
the ankle and then let the

screws from the tibia
continue down through the
talus into the
calcaneus.
Fig. 2 Ankle fusion It is uncommon for
haemophilia patients to
have symptomatic arthritis
in the talo-navicular
and calcaneo-cuboid joint.
Triple arthrodesis is
weight-bearing as tolerated in a cast or orthosis. thus a rare procedure in
bleeding conditions.
My preferred technique is a lateral incision with
osteotomy of the fibula just above the lateral
malleolus. This is then turned externally and Arthroplasty
split so that the inner half is removed. The joint
is then well exposed and can be cleaned out Joint replacement has become
a valuable solution
completely. Two half threaded cancellous screws for severe haemophilic
arthropathy [13].
are put across the joint into the talus through stab
incisions and cross the joint in a parallel fashion
which gives compression and absolute stability Hip
(Fig. 2). The lateral malleolus is put back as
a graft across the joint and can be fixed with Since arthropathy of the hip
is not more common
a separate screw. A below-knee plaster is used in haemophiliac patients
than osteoarthritis in
for three weeks and then stitches are removed and non-bleeders the need for
total hip replacement
the patient is supplied with a walker orthosis for is relatively rare in this
context.
another five weeks. Weight-bearing as tolerated Indications are the same
as for idiopathic oste-
is allowed from the start. oarthritis and the anatomy
of the joint is seldom
Fusion of the sub-talar joint is usually done out of the ordinary for an
arthritic hip. Both
through an incision in the sinus tarsi that cemented and uncemented
fixation can be used
allows for resection of the talo-calcaneal joint and the long term results
are the same [1416].
which is the fixed with a half-threaded cancellous There are usually no
technical difficulties
screw either from the heel upwards through when performing THR in
haemophiliac patients
the tuber calcanei or from the neck of the since the deformity of the
joint is usually moder-
talus down into the calcaneus (Fig. 3). When ate. The surgeon may use the
approach and
both the ankle joint and the sub-talar joint are to implant that he is familiar
with. Post-operative
be fused at the same time is suffices to resect rehabilitation follows the
routine for standard hip
the latter through the lateral approach for replacement.
324
R. Wallensten
Knee the lengthening of the tendon

creates an exten-
sion lag of which the patient
must be informed
The knee joints are very often affected by before the operation. Usually
the lag does not
haemophilia; probably since minor trauma with exceed 1015# and does not
impair walking but
accompanying bleeding into the joints occur fre- some patients prefer less
flexion in order to have
quently. Cartilage destruction happens early full extension.
unless factor prophylaxis is given and severe Osteotomy of the tibial
tubercle has the
deformity and stiffness is common. Thus many advantage of not compromising
the quadriceps
patients present at a relatively early age for muscles and gives as good
access to the joint as
arthroplasty. Since the haemophilic arthropathy the V to Y tenotomy. The
tubercle fragment
affects the whole joint there is no place for hemi- should be large and of
sufficient thickness to
arthroplasty. If the patient has no major not break when handled during
the operation.
deformity or severely restricted range of motion If possible one should try to
preserve a layer of
a standard total joint prosthesis can be cancellous bone between the
osteotomy site
used. Knees with deformities and/or severely and the medullary cavity.
After insertion of the
restricted ROM require special techniques prosthesis the tubercle is
re-attached to its orig-
[17, 18]. inal site and fixed with
cerclage wires
The surgical approach should be a midline that can pass around the
tibia or through drill
incision with medial parapatellar arthrotomy holes in the tibia. The
fixation should be stable
unless previous scars or poor skin conditions enough to allow immediate
post-operative
require otherwise. The haemophiliac patients mobilisation.
often have poorly-developed thigh muscles and Regardless of which
approach is used the
thin skin so great care must be taken to handle the joint must be cleared of all
adhesions and an
tissues in an atraumatic way. extended soft tissue release
performed. This
The synovium in the knee joint is usually includes extension under the
quadriceps muscle
discoloured by all the previous bleeding episodes to free this from the femur
in order to achieve as
and has a brownish colour from haemosiderin much knee flexion as
possible. It is very impor-
incorporation. The degree of active synovitis tant to have full extension
and flexion of the
varies but regardless of this a synovectomy knee and to correctany varus
or valgus defor-
should be performed which sometimes means mity before the bony
resections start, otherwise
extending the initial incision. correct implantation of the
prosthesis becomes
In the knee with pre-operative deformity and/ impossible. It is advisable
to deflate the thigh
or severely limited ROM it is not possible to get tourniquet when testing the
range of motion in
access to the joint unless an extended approach is order to be able to fully
estimate what has been
used. The options are an inverted V to achieved.
Y tenotomy of the quadriceps tendon or a tibial For the severely-affected
haemophilic knee
tubercle osteotomy. a stemmed, semi-constrained
prosthesis is
V to Y quadriceps tenotomy means cutting recommended since such soft
tissue releases are
the tendon in the fashion of an inverted V and necessary that not only both
cruciate ligaments
folding down the patella. This gives good access but also the collateral
ligaments are sacrificed.
to the knee and the possibility to suture the This also allows for
reconstruction of any bony
tendon in a Y manner so that an elongation is defects after resections with
the guide
achieved. The tendon tenotomy should be instruments.
sutured carefully so that active mobilisation of Using these techniques in
a personal series of
the knee can be started immediately post-opera- 67 TKAs followed for up to 17
years it has been
tively. For the patient with little flexion pre- possible to gain an average
of 55# of knee flexion
operatively this can be advantageous with (Table 1). These results are
in accordance with
increased flexion after the operation. However, other reports [19, 20].
325
Ankle was in a patient who had

a successful prosthesis in
one ankle and a fusion of
the other. The latter was
Total ankle replacement is an alternative in converted into an ankle
replacement but came
haemophilic arthropathy [21, 22]. However, one loose after 3 years and
had to be extracted.
must bear in mind that the long-term results are
still not as good as for hip, knee and shoulder
replacement and arthrodesis is an alternative with Elbow
life-long function.
If ankle replacement is considered the patient Total elbow replacement
can be performed in
should have a relatively well-preserved range of haemophilic arthropathy.
However, one must
motion since it does not usually increase post- bear in mind that the
long-term results are still
operatively. Also the skeletal anatomy of the not as good as for hip,
knee and shoulder replace-
distal tibia and particularly the talus must be ment. Arthrodesis of the
elbow is not compatible
reasonably intact. with good function and
neither is a resection
The author has done seven ankle replacements arthroplasty. Thus for
the elbow with great pain
(Fig. 4) in haemophilic patients. Six of them work from haemophiliac
arthropathy replacement can
well with a follow-up of 27 years. The one failure be indicated. The patient
must be informed that
such a prosthesis is not
suitable for heavy loads of
repetitive work.
Table 1 Pre- and post-operative ROM (arc of extension- The author has done
three total elbow
flexion) after knee arthroplasty in haemophilia
replacements (Fig. 5) in
haemophilic patients.
Pre-op. arc 35# 090# They all function well
with a follow-up of up to
Post-op. arc 80# 10120# 6 years.
DX
Fig. 4 Total ankle replacement in a patient with haemophilia

326
R. Wallensten
to map the vascular anatomy

pre-operatively.
Resection of Osteophytes Also it is recommended that
these operations
are done at major haemophilia
centres [24].
The arthropathy of haemophilia is character-
ized by formation of osteophytes. Quite often
these can cause restriction of motion in the Simultaneous Operations
elbow or ankle joints (Fig. 6). For the patient
for whom the decreased range of motion is Since operations on patients
with haemophilia
the major complaint removal of these requires factor treatment,
which are very expen-
osteophytes and debridement of the joint may sive, it is advantageous to
perform multiple pro-
be considered. cedures in the same session
when indicated. The
For the elbow the best approach is cost for factor treatment can
thus be decreased
a posterior incision where one can then open and the hospital stay and
post-operative rehabil-
both the radial and ulnar sides for a complete itation is shorter than if
the operations are done on
arthrolysis. The anterior joint capsule and the separate occasions. It is not
unusual for the same
radial head may be removed if necessary and patient to need operations on
more than one joint
the olecranon fossa cleared out. As in all and then they can safely be
addressed simulta-
elbow operations the ulnar and radial nerves neously. The author has over
the years done
must be protected. a variety of combinations
without any increase
Debridement of the ankle joint is best in complications (Table 2).
performed through an anterior approach, if nec-
essary combined with and incision behind the
posterior malleolus. Most of the obstacle to Post-Operative Care and
motion is from anterior osteophytes and removal Rehabilitation
of these may be quite rewarding.
Since joint debridement does not prevent pro- The post-operative factor
treatment should be
gress of the arthropathy the gain in motion continued until wound healing
has occurred. . . .
achieved is lost over the years and other proce- Since haemophilia patients
often have
dures may become necessary. severely compromised function
pre-operatively
they need structured
rehabilitation. Pre-operative
evaluation and education is
of value and post-
Pseudotumours operative rehabilitation
should start directly in
hospital and continue on an
out-patient basis
Pseudotumours (haemophilic cysts) are with a long-term perspective
[25].
haematomata resulting from spontaneous bleed-
ing episodes into the soft tissues [23]. The
haematomata increase and are organized into Complications
fibrous tissue and form tumours that can attain
considerable size (Fig. 7). Depending upon size In addition to the
complications connected to total
and localization they may be troublesome to the knee replacement in non-
haemophilic patients
patients and have to be removed. If they are large there are some problems
specific for those with
the excision can be difficult and principles of haemophilia. Due to treatment
with factors pro-
oncology surgery have to be applied although duced from HIV contaminated
blood many of the
a radical margin is not necessary and intra- haemophilic patients are HIV-
positive which is
lesional cuts do not matter. As a rule non- feeding a risk factor for post-
operative wound infections.
vessels can be identified but when planning to All prophylactic measures
against infection should
remove large pseudotumours it is advisable be taken when operating on
this group of patients
327
Fig. 5 Total elbow replacement in a patient with haemophilia
and under such conditions that the rate of post- of patients with severe
haemophila B. Surgery in
operative infection is acceptable [2629]. these patients requires a
more complicated and
Some patients with haemophilia develop neu- expensive factor
treatment as well as other measures
tralizing antibodies (inhibitors) to factor VIII or to control coagulation.
These resources exist only in
factor IX [30, 31]. This happens in 1030 % of major haematological
centres where haemophilia
patients with severe haemophilia A and in 25 % patients with inhibitors
should be referred.
328
R. Wallensten
Fig. 7 Large
pseudotumour in the right thigh of a patient
with haemophilia. A
similar one was previously removed
from the left thigh
Table 2 Combinations of
simultaneous operations in
patients with
haemophilia
Simultaneous operations
27
Bilateral TKR
15
TKR + ankle/subtalar
fusion 3
TKR + extraction of
implants 1
TKR + THR
1
TKR + pseudotumour
1
Bilateral THR
2
Bilateral hallux
valgus 1
Excision radial head
+ ankle fusion 1
Extr. of implants +
Achilles tendon repair 1
Fig. 6 Anterior osteophytes in a haemophiliac ankle joint
Excision of
osteophytes foot + knee artroscopy 1
haemophilia can, in
spite of high costs associated
Economical Considerations with the procedures, be
cost-effective [33].
The medical treatment of haemophilia patients is

very expensive and in addition these patient often Summary
also need support from society with physiother-
apy, occupational therapy, ergonomic adjustments Haemophilia affects
joints through repetitive
and other measures [32]. With surgical procedures bleeding that destroy
the cartilage. Thus prophy-
such as fusions and joint replacements long-term laxis with factor
treatment is important. When
pain relief and improved function can be achieved. patients have
established arthropathy and
These help the patients to achieve a better quality need surgery it is
important to have co-operation
of life and improves their ADL thus reducing the with a haematology
laboratory that can supervise
need for support from medical, paramedical and per- and post-operative
factor substitution. The
social carers. The surgery on patients with joints most affected
are knees, ankles, hips and
329
feet and the most common procedures are joint 12. Gambl JG, Bellah
J, Rinsky LA, Glader B. Arthropathy
fusion or replacement. Since the arthropathy is of the ankle in
haemophilia. JBJS. 1991;73-A:100815
13. Beeton K,
Rodriguez-Merchan EC, Alltree J. Total
advanced the operations may be technically dif- joint
arthroplasty in haemophilia. Haemophilia.
ficult and the surgeon needs to be well- 2000;6:47481.
experienced in primary and revision joint 14. Yoo MC, Cho YJ,
Kim KI, Ramteke A, Chun YS.
replacement. Successful surgery can give these The outcome of
cementless hip arthroplasty in
haemophilic hip
arthropathy. Haemophilia. 2009;
patients a large improvement in pain relief, func- 15(3):76673.
tion and life quality and the long-term results are 15. Habermann B,
Eberhardt C, Hovy L, Zichner L,
good. If the patients need more than one opera- Scharrer L, Kurth
AA. Total hip replacement in
tion it is advantageous to perform them in the patients with
severe bleeding disorders. Int Orthop.
2007;31:1721.
same session. 16. Rodriguez-Merchan
EC. Total joint arthroplasty: the
final solution
for knee and hip when synovitis
could not be
controlled. Haemophilia. 2007;13
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Orthop Traumatol Surg Res.
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Cappelli M, Hulet C, Canciani JP,
3. White 2nd GC, Rosendaal F, Aledort LM, et al. Letenneur J,
Burdin P, Societe dOrthopedie de
Definitions in hemophilia. Recommendation of the lOuest (SOO).
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scientific subcommittee on factor VIII and factor IX with greater than
20 degrees flexion contracture.
of the scientific and standardization committee of the Orthop Traumatol
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Kim HS, Song SJ. Total knee
Thromb Haemost. 2001;85:560. arthroplasty in
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4. Schulman S, Loogna J, Wallensten R. Minimizing J Arthoplasty.
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P, OShea E, Smith O. Total knee
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Economic evaluation of major knee
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1):10916. 2008;24:75368.
Infections in Orthopaedics
and Fractures
Eivind Witso
Contents
Keywords
Basic Science and Bacteriological Principles . . . .
331
Amputation # Antibiotic cement # Antibiotic

Bacteria Associated with Bone and Joint
prophylaxis # Antibiotic resistance # Biofilm
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 331 concept # Biopsy and culture # Classification-
The Biofilm Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
332 open fractures # Clinical features # Clinical
Antibiotic Prophylaxis in Orthopaedic Surgery . . . .
333
Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 335
features # Closed fractures # Diagnosis #
Diagnosis-sensitivity and specificity #

The Infected Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
336
Definition and classification # Epidemiology #

Open
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 336
Post-Operative Infection in Closed Fractures
Epidemiology # Imaging # M.R.S.A. # Molec-
Treated with Internal Fixation . . . . . . . . . . . . . . . . . . . 339
ular diagnostics # Orthopaedic bacteria #
Prosthetic Joint Infections . . . . . . . . . . . . . . . . . . . . . . . . .
340 Pathophysiology # Post-operative infections #
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 340 Serology # Sonication # Staged revision, ampu-
Definitions and Classification . . . . . . . . . . . . . . . . . . . . . . .
340 tation # Surgical treatment # Surgical debride-
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 340 ment # Treatment # Treatment-antibiotic #
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 341
The Sensitivity and Specificity of a Test . . . . . . . . . . .
341 Treatment-debridement
Pre-Operative Investigations . . . . . . . . . . . . . . . . . . . . . . . .
341
Diagnostic Tests During the Operation . . . . . . . . . . . . .
344
Treatment of Infected Joint Prostheses . . . . . . . . . . . . .
347 Basic Science and Bacteriological
Conclusions and Recommendations . . . . . . . . . . . . . . . .
351
Principles
The Infected Diabetic Foot . . . . . . . . . . . . . . . . . . . . . . . .
351
The Epidemiology of Diabetes Mellitus (DM),
Diabetic Peripheral Neuropathy,
Bacteria Associated with Bone

Diabetic Foot Ulcers, Diabetic Foot Infection
and Joint Infections
and Diabetic Lower Limb Amputations . . . . . . . .
351
Pathophysiology of Diabetic Foot Ulcers and
Bacteria belonging to the Staphylococcus genus
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 352
are the most frequent species encountered in

The Clinician Presentation and Diagnosis of the
Infected Diabetic Foot . . . . . . . . . . . . . . . . . . . . . . . . . . .
352 osteomyelitis and arthritis [9, 51]. In Europe,
Treatment of Diabetic Foot Infections . . . . . . . . . . . . . .
354 Mycobacterium tuberculosis is still rather
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 356 uncommon as the causative microbe in cases of
vertebral osteomyelitis [85]. The infection in the
diabetic foot and in open fractures are often
polymicrobial, with a mixture of Staphylococcus

E. Witso
aureus, Gram negative rods and anaerobes.
St. Olavs University Hospital, Norwegian University of
Science Trondheim, Trondheim, Norway
In patients with an infected Orthopaedic implant.
e-mail: eivind.witso@stolav.no
S. aureus and Staphylococcus epidermidis are

331
DOI 10.1007/978-3-642-34746-7_17, # EFORT 2014
332
E. Witso
Fig. 1 Tissue biopsies

from a patients with
a loosened hip prosthesis
were cultured on blood
agar. Apparently at least
four phenotypically
different Staphylococcus
sp. were identified.
Extraction of bacterial
DNA followed by pulsed
field gel electrophoresis
revealed that they all
belonged to the same strain
of a S. epidermidis
cultured in >50 % of the cases, and other Staph- Finally, particularly in

chronic infections and
ylococcus sp. such as Staphylococcus hominis in bone and joint infections
with overlying
and Staphylococcus haemolyticus also contribute wounds, the causative
bacterial flora should be
to these infections [9]. In chronic infected joint considered as dynamic.
Antibiotic pressure may
prosthesis S. epidermidis and Propionibacterium result in a transition from
Gram-positive bacteria
acnes are cultured frequently [137, 184]. Partic- to Gram-negative bacteria, and
from methicillin-
ularly in infected shoulder prosthesis, P. acnes sensitive to methicillin-
resistant bacteria [21].
has been identified as the causative microbe in up
to 40 % of the cases [131].
A special sub-population of Staphylococcus The Biofilm Concept
sp. called small colony variants (SCV) have
been associated with chronic and relapsing oste- In the early 1960s the term
biofilm is not men-
omyelitis and implant infections [134, 167]. tioned in the Orthopaedic
literature According to
Although most SCVs are sub-populations of PubMed 1.517 papers were
published from 1990
S. aureus, SCVs of S. epidermidis have also to 1999 where the term biofilm
is used, compared
been observed [13]. In Orthopaedic infections to 10.804 papers from 2000 to
2009. The com-
SCVs are cultured in patients exposed to genta- prehension that In nature
(but not in laboratory
micin, and the emergence of gentamicin-resistant cultures) bacteria are covered
by a glycocalyx
strains of SCV have been observed in in vitro, of fibres that adhere to
surfaces and to other
in vivo and in clinical studies [113, 167]. Due to cells. [45] represents a
paradigm shift in the
their slow-growing nature and their inconstant understanding of the nature of
human infectious
phenotype, the microbiological diagnose of disease in general, and bone
and joint infections
a SCV infection sometimes is difficult, and in particular. Bacteria adhere
and grow on
there is a risk that growth of SCV are a surface, and the surface of
bone tissue is not
misinterpreted as contaminant growth (Fig. 1). an exception [170]. A large
number of in vitro
Infections in Orthopaedics and Fractures
333
and in vivo experiments have been performed to to methicillin-sensitive S.

aureus, systemically
study the adherence of different bacterial species administered cephalosporins
have proved to be
on different surfaces of biomaterials used in effective as prophylaxis in
operative treatment
Orthopaedic surgery (such as titanium alloy and of closed fractures. In
fact, antibiotic prophy-
stainless steel), and the results of in vitro and laxis is so effective in
reducing infections after
in vivo studies have to some degree been contra- operative treatment of
closed fractures that fur-
dictory (Zalavras et al. 2009). So far, Orthopaedic ther studies where
antibiotics are compared with
implants with reduced affinity to bacteria have placebo are considered to
be unethical [69].
not been introduced as commercial products. The In hip prosthetic surgery,
the relative risk for
biofilm concept does explain the chronic nature a revision due to infection
is almost five times
of osteomyelitis in general and implant infections higher in patients who do
not receive any anti-
in particular, and why antibiotic therapy does not biotic prophylaxis,
compared with patients who
eradicate these infections. The biofilm concept received parenteral
cephalosporins combined
also indicates that local antibiotic treatment has with local gentamicin in
bone cement [59].
its limitations and the necessity of radical In countries with a high
prevalence of
debridement in cases of chronic infection. The methicillin-resistant S.
aureus, glukopeptides
poor results of soft tissue debridement and (teicoplanin) have been
combined with a cepha-
prosthetic retention in prosthetic joint infections losporin and given
successfully as prophylaxis
(PJI) that have lasted for more than 4 weeks is in operative treatment of
femoral neck fractures
consistent with the biofilm concept, and the bio- [147]. It is reasonable to
use systemic antibiotic
film concept it the theoretical background for prophylaxis in all types of
clean Orthopaedic
classifying acute PJI as an infection that occurs surgery with use of
implants. If possible the
<24 weeks after surgery antibiotic infusion should
start before surgery,
The biofilm concept has also been the theo- and there is no support for
the use of prophylaxis
retical background for the assumption that most for more than 1224 h after
surgery [147, 172].
prosthetic loosening is due to low virulent infec-
tion, i.e. aseptic loosening. The negative culture Antibiotics in Bone Cement
result has been explained by the existence In 1970 Buchholz and
Engelbrecht reported
of fastidious biofilm bacteria that are not readily on the sustained release of
antibiotics from
cultured on agar plates. The main problem antibiotic-containing
polymethylmethacrylate
so far is the lack of a universally accepted diag- (PMMA) bone cement [32].
Their initial reports
nostic gold standard with high sensitivity and were on the incorporation
of penicillin, erythro-
specificity when diagnosing an implant mycin and gentamicin in the
cement. Most anti-
infection. biotics can be mixed into
bone cement [168],
Different imaging techniques have been but the betalactams are not
used due to fear
employed when studying biofilms on Orthopaedic of hypersensitivity
reactions [174]. Today
implants (Figs. 2 and 3). So far these techniques aminoglycosides and
glycopeptides are most
are mainly used in research. frequently employed when
antibiotics are incor-
porated into bone cement.
The amount of antibi-
otics eluted from
antibiotic-impregnated bone
Antibiotic Prophylaxis in Orthopaedic cement shows a high early
release with exponen-
Surgery tial decay, in vitro and in
vivo [18, 87, 94, 97,
104, 126]. After the
initial phase of exponential
Systemic Antibiotic Prophylaxis decay, bone cement elutes
small amounts of anti-
Per definition, antibiotics are given systemically as biotic for many years in
vitro and in vivo, and
prophylaxis in cases of clean surgery to avoid post- gentamicin has been
recovered in urine 2 years
operative infections. In countries where hospital- post-operatively [155,
168]. Furthermore, in vitro
acquired post-operative infections mostly are due less than 20 % of the total
amount of antibiotic
334 E. Witso
Fig. 2 Biofilm on
gentamicin-containing
bone cement. A live/dead
stain is used (green
fluorescence viable
bacteria, red
fluorescence dead
bacteria, and blue
fluorescence EPS)
(Photo: Danielle Neut, with
permission)
Fig. 3 Electron-
microscopy of Staphylo-
coccus epidermidis biofilm
on stainless steel (Photo:
Kare E. Tvedt, with
permission)
335
mixed in bone cement is released [104, 129]. community isolates of S.

aureus were resistant to
The mechanism by which antibiotic is released penicillin as well [82].
from bone cement is still debated [165]. It has Methicillin was introduced
in 1961 as an anti-
been suggested that the initial release mainly is biotic that had antibacterial
effect against peni-
a surface phenomenon, while the sustained cillinase-producing S. aureus
[38]. However, in
release over months and years is a bulge diffusion the same year it was reported
that strains of
phenomenon [166]. S. aureus were resistant to
another penicillinase-
Bone cement-containing antibiotics are resistant penicillin, celbenin
[83], possible due to
widely used in Orthopaedic surgery. In Norway, naturally resistant organisms.
A survey from
more than 80 % of patients older than 60 years U.K. from 1960 to 1960 showed
an increased
operated with implantation of a primary hip pros- rate of methicillin-resistant
S. aureus (MRSA),
thesis in 2008 received antibiotic-containing probably due to the use of
methicillin [122]. In
bone cement [154]. 2004 the following rates of
methicillin resistance
Due to the relatively low incidence of pros- in S. aureus were encountered:
43 % (U.K.), 29 %
thetic revision due to infection, it has not been (France), 44 % (Greece), 40 %
(Italy) and 20 % in
clearly shown in any randomized study that Germany (European
Antimicrobial Resistance
PMMA with antibiotics is sufficient as prophy- Surveillance System,
www.rivm.nl/earss/).
laxis in primary prosthetic surgery. Data from As was observed in penicillin-
resistant S. aureus
the Scandinavian Arthroplasty Registers have in the sixties, methicillin
resistance in S. aureus is
presented the best results in patients who have today also community-acquired
[40, 63].
received PMMA with antibiotics combined with In Orthopaedic surgery,
infection with MRSA
systemic antibiotic prophylaxis [59, 60, 127]. has been identified as a risk
factor for treatment
The data used in these studies was not collected failure [142]. Vancomycin is
most often the drug
from an infection register, and soft tissue of choice in MRSA infection,
and treatment
debridement with retention of the prosthesis failure has been associated
with elevated minimal
(no parts exchanged) was not reported to the inhibitory concentration (MIC)
of vancomycin
register. [149]. From many European
countries are
reported cultures of MRSA with
reduced suscep-
tibility to vancomycin, and in
U.S.A. a significant
Antibiotic Resistance creep in vancomycin MIC to
S. aureus has been
observed during the last
years, from 0.5 mg/l in
Antibiotics and Antibiotic Resistance 2000 to 1 mg/l in 2005 [151].
From the time penicillin was introduced by In cases of chronic
Orthopaedic implant
Fleming in 1941 it took only 3 years until the infections, S. epidermidis is
probably the predom-
first report appeared on penicillinase-producing inant bacteria, and it is also
cultured in cases of
(penicillin-resistant) strains of S. aureus [86]. acute implant infections.
Compared to what
These strains were isolated from hospitalized we know about the emergence of
antibiotic
patients [14], while community isolates of resistance in S. aureus, less
information is
S. aureus were sensitive to penicillin. The available concerning
antibiotic resistance with
first thorough analysis of the epidemiology S. epidermidis. In Europe,
methicillin-resistant
of antibiotic resistance in S. aureus was S. epidermidis (MRSE) is
probably at least as
published in 1969: The examination of more frequent as MRSA in prosthetic
joint infections
than 2,000 blood cultures at Statens Serum insti- [36, 136]. In the term
difficult-to-treat micro-
tute in Copenhagen, Denmark, showed that organisms in Orthopaedic
infections have
8590 % of S. aureus strains isolated from hos- been included MRSA,
enterococci, quinolone-
pitalized patients were resistant to penicillin. resistant Pseudomonas
aeruginosa, small colony
It was rather unexpected that 6570 % of variants of staphylococci and
fungi [160].
336
E. Witso
In cases of chronic PJI, MRSE should probably

also be considered as a difficult-to-treat The Infected Fracture
bacterium.
In Europe, Staphylococcus sp. Are, at Open Fractures
increasing rates, resistant to aminoglycosides,
and 40 % of MRSA are resistant to gentamicin Classification of Open
Fractures
(European Antimicrobial Resistance Surveil- The modern classification of
open fractures was
lance System (www.rivm.nl/earss/)). In introduced by Gustilo and
Anderson in 1976
U.S. the rate of gentamicin and tobramycin [74]. The paper presented the
results of
resistance in S. epidermidis causing PJI is a retrospective study on 673
open fractures
40 % [7]. treated from 1955 to 1968, and
a prospective
Linezolid is an alternative to vancomycin in study on 352 open fractures
treated from 1969
infection due to MRSA and MRSE [101]. It to 1973, altogether 1,025 open
fractures. In the
can be administered orally and parenterally, prospective study the
fractures were classified
but long-term treatment with linezolid is associ- into three categories, type I,
II and III,
ated with risk of adverse effects as bone marrow depending on the severity of
soft-tissue damage,
suppression and neuropathy. In acute presence of vascular injury,
the fracture type and
Orthopaedic implant infections the cure rate is the mechanism of the injury.
In 1984 this clas-
high when patients are treated with linezolid, but sification was modified into
five categories:
the cure in cases of chronic implant infections Type I, II, IIIA, IIIB and
IIIC [76]. An overview
treated with linezolid is <50 % [148]. There of the Gustilo classification
of open fractures is
have been case reports on linezolid-resistant presented in Fig. 4.
Staphylococcus sp., and at a one hospital in The open fracture, Gustilo
type I and II, is
USA, 4 % of coagulase-negative Staphylococ- a low energy fractures, and in
these fractures the
cus sp. (mostly S. epidermidis) were resistant to treatment is similar to that
of closed fractures. In
linezolid [133]. a type IIIA fracture there is
a considerable
Daptomycin has a bactericidal effect on degree of soft-tissue damage,
but the soft-tissue
MRSA in vitro and in vivo. Further clinical coverage of the bone is
adequate. In a type IIIB
studies are needed to clarify the position of fracture either a local or a
free tissue transfer is
daptomycin as a drug of choice in cases of necessary for soft-tissue
coverage of the frac-
Orthopaedic infections [101]. tured bone, and in an open
fracture Gustilo type
Finally, to what degree the use of gentamicin- IIIC vascular surgery is
mandatory for salvage
containing bone cement per se has promoted of the extremity. The
association between the
the emergence of gentamicin-resistant Staphylo- Gustilo classification of open
fractures and rate
coccus sp. is still an issue that needs to be of infection has been
established, with less than
clarified. A few studies have associated the use 5 % infection in type I and II
fractures, less than
of bone cement containing gentamicin with the 10 % infection in type IIIA
fractures, and
emergence of gentamicin-resistant bacteria 3050 % infection in type IIIB
and IIIC fractures
[7, 78, 164]. Hope [78] reviewed 91 patients [26, 75, 76].
with an infected cemented prosthesis. However, objections to the
Gustilo classifica-
In 52 patients infected with gentamicin-sensitive tion have been that it is
difficult to reproduce
Staphylococcus epidermidis, four of them (Fig. 5), and even experienced
trauma
had previously been operated on with the use of surgeons to a considerable
degree classify
gentamicin-containing bone cement. In contrast, the same fracture into
different Gustilo types
of the 39 patients infected with gentamicin- [31, 153].
resistant S. epidermidis, 30 of them had The Trauma surgeon should
also be aware of
previously received bone cement containing other factors influencing the
rate of infections
gentamicin. that are not included in the
Gustilo classification:
337
Characteristics
Comments
Type I An open fracture with a wound less than one The wound has also
been characterised as a
centimetre long and clean. puncture wound
with minimal muscle damage.
Type II An open fracture with a laceration more than one In this fracture
type the soft tissue coverage of
centimetre long without extensive soft-tissue the bone is
adequate, and there is only minor
damage, flaps, or avulsions. comminution of the
bone.
Type IIIA An open fracture with adequate soft-tissue All open fractures
due to a high-energy trauma
coverage of a fractured bone despite extensive are classified as
Type III fractures. In a Type
soft-tissue laceration or flaps, or high-energy IIIA fracture the
wound is contaminated and
trauma irrespective of the size of the wound. the fracture is
comminuted or segmented.
Type IIIB An open fracture with extensive soft-tissue In a Type IIIB

fracture the soft-tissue coverage
injury with periosteal stripping and bony of the bone is
inadequate, and neither primary
exposure. This is usually associated with nor secondary
wound closure can be performed.
massive contamination. without a local or
free vascularised soft tissue
flap.
Type IIIC An open fracture associated with arterial injury Irrespective of

the size of the wound and the
requiring repair. severity of soft
tissue and bone damage,
vascular repair is
mandatory for limb salvage.
Fig. 4 The Gustilo classification of open fractures
Fig. 5 An open fracture of

the tibia. Gustilo type II,
IIIA or IIIB?
The Time Factor fractures, depending on

early/immediate soft-
As a general rule open fractures should be tissue coverage (type
IIIB1) or late soft- tissue
debrided as soon as possible [48]. A delay in tissue coverage after more
than 37 days (type IIIB2).
coverage in type IIIB fractures is associated with A Gustilo type IIIB2
fracture is associated
a poor result, and type IIIB fractures have been with infection and non-
union rates of more than
sub-divided into type IIIB1 and type IIIB2 50 % [41, 72].
338
E. Witso
The Location of the Fracture (a) Immediate debridement

and irrigation,
In the studies from 1984 and 1987 (Gustilo et al.) including repeated
debridement and irriga-
one-third of the fractures were located at the tion of type III
fractures at 2448 h intervals
humerus, femur and pelvis, and only one half of (b) Antibiotic therapy
the fractures were located at the tibia. The Gustilo (c) Secure fracture
stability
classification and recommendations for treatment (d) Wound coverage, either
by delayed primary
could be applied to every open fracture. How- closure or by local
or free flaps
ever, fractures of the lower leg and, in particular, (e) Early cancellous bone
grafting
open fractures of the distal one-third of the tibia (f) Make an early decision
on amputation.
have a higher rate of infection compared with The debridement of
open fractures should be
other open fractures [26, 125]. done in the operating
theatre, and should include
harvesting of tissue
biopsies for culture. In the
The Host low-energy Gustilo type I
and II open fractures it
An important contribution to treatment of adult is possible to do a
primary wound closure in most
chronic osteomyelitis is the Cierny-Mader cases. The biggest
challenges are the treatment of
classification [44], which is a combination of Gustilo type IIIB and IIIC
fractures, and particu-
a classification of the degree of bone involve- larly when these fractures
are located at the lower
ment and a classification of compromising leg. The treatment results
and prognosis of these
factors, local and systemic (host A, B and C). high energy fractures are
dependent on hospital
An A-host has good systemic defences, a normal admission to a qualified
surgical team, i.e.
local blood supply and no local compromising a trauma treatment centre
[48, 132]. It is of par-
factors. An B-host is local and/or systemically amount importance that in
the Gustilo type IIIB
compromised, as in a patient with diabetes fracture the trauma
surgeon and the plastic sur-
mellitus who has extensive local scarring or geon work together, and
that the fractured bone is
venous stasis. A C-host is by definition not covered with soft-tissue
in less than 1 week after
a candidate for surgery (in cases of chronic the injury. The soft
tissue problems in most open
osteomyelitis), and the treatment should lower leg type IIIB
fractures can be solved with
be very conservative. The clinical stage classifi- use of local flaps, but in
severe open factures of
cation constitutes the combined classification the distal part of the
tibia there will also be an
of bone involvement and compromising factors, indication for free
vascularised muscle transfer
and the treatment results and prognosis [123, 130].
correlates with the clinical stage of the The choice of fracture
stabilization device
disease [43]. depends on the location of
the fracture, i.e. if
As in cases of chronic osteomyelitis, the the fracture is
diaphyseal, metaphyseal or intra-
general condition of the host should also been articular.
taken into consideration in patients with open External fixation is
no longer the standard
fractures. It comes as no surprise that the treatment in cases of open
fractures, and even
presence of co-morbidities, for example tobacco Gustilo type IIIB
fractures of the tibia have been
use, is associated with infection in open successfully treated with
internal fixation [156].
fractures [26]. A primary amputation might be However, in severe
contaminated type IIIB frac-
the best option in patients with Gustilo type IIIB tures, external fixation
is still indicated, and the
and IIIC fractures who have severe systemic and experienced trauma surgeon
will use external
local compromising factors, i.e. a C-host. fixation to secure rapid
fracture stabilization in
the Gustilo type IIIC
fracture and in multi-trauma
Treatment of Open Fractures patients. A thorough
discussion on the use of
The basic principles advocated by Gustilo et al. reamed versus unreamed
nails, the use of locking
[75] for the treatment of open fractures are still, to plates and minimally-
invasive osteosyntheses is
an impressive degree, up-to-date: beyond the scope of this
presentation.
339
Although open fractures should be considered should be removed and the

fracture should
contaminated from the time of the injury, most be stabilized with an
external fixation device.
infections in open fractures are nosocomial [153]. As in acute post-operative
prosthetic joint
Typically, the infections is polymicrobial, includ- infections Staphylococcus
spp. are most often
ing Staphylococcus aureus and Gram-negative the causative bacteria, and
empirical antibiotic
bacteria [51]. Due to contamination antibiotics treatment should include
drugs active against
should be administered as treatment as soon as methicillin-sensitive S.
aureus, eventually
possible after the injury. In general a first, second methicillin-resistant S.
epidermidis and S. aureus.
or third generation cephalosporin will be ade- The evidence for treating
post-operative infec-
quate [182], or a betalactamase-stable penicillin. tions after osteosynthesis
with rifampicin in
The empirical antibiotic treatment should take combination with other
antibiotics is weak.
into consideration the mechanism of injury. In Previous studies on the use
of rifampicin combi-
typical agriculture injuries the wound may be nations have mainly
included prosthetic joint
contaminated with anaerobic bacteria, such as infections and only few
infected fractures.
Clostridium sp., and a penicillin should be However, the results have
been promising, and
added. In marine injuries the antibiotic treatment new studies are warranted
[161, 186].
should cover the possibility of infection caused Of particular interest
is the extremely high
by Vibrio sp., Pseudomonas sp. and Aeromonas rate of post-operative
complications in patients
hydrophilai, and either a third-generation cepha- with diabetes mellitus
operated on by internal
losporin or ciprofloxacin should be included or external fixation of
ankle fractures.
[116]. In the Gustilo type I and II fractures just The most feared of these
complications are
a few doses of antibiotic is adequate, while in the deep post-operative
infections and Charcot
type III fractures antibiotic treatment should be osteoarthropathy. In
general, the rate of deep
continued for days after wound closure [153]. infections after open
reduction and internal fix-
Further antibiotic treatment of the infected frac- ation of ankle fractures is
less than 1.5 % [146].
ture should be guided and modified after culture This is in contrast to
rates of 1020 % post-
results of tissue biopsies taken during revision. operative wound infections
in patients with dia-
betes mellitus operated on
for an ankle fracture
[46, 181]. The presence of
peripheral neuropa-
Post-Operative Infection in Closed thy in general is an
independent risk factor and
Fractures Treated with Internal predictor for infection,
and patients with
Fixation diabetes mellitus without
peripheral neuropathy
do not have more post-
operative complications
In theory, the principles for treatment of a post- than the non-diabetic
population. Patients
operative infection after internal fixation of with peripheral neuropathy
and a history of
a closed fracture are the same as the treatment a diabetic foot ulcer are
at a particular risk of
of prosthetic joint infections. The aim of the developing infection after
surgery for an ankle
treatment is to avoid a chronic infection where fracture [181]. A complete
evaluation of the
the bacteria have colonized the implant and neurological and vascular
status of the extremity
the bone (i.e. chronic osteomyelitis) and to is therefore mandatory in
every patient
avoid infected pseudarthrosis. In acute post- with diabetes mellitus with
an ankle fracture.
operative infections that occur less than 4 weeks If the ankle pulses are
absent, the vascular sur-
after surgery, adequate treatment includes radical geon should be consulted
before surgery.
soft-tissue debridement, harvesting of tissue The palpation of the
posterior tibial artery
biopsies for culture and wound closure. If the might be difficult due to
fracture haematoma
osteosynthesis is stable the implant should not and oedema, and the
vascular status of the
be removed. In late post-operative infections other ankle might help the
clinician in the pre-
(more than 4 weeks after surgery) the implant operative evaluation.
340
E. Witso
The following recommendations has been pro- infection. Stage III has
also been classified as
posed for treatment of ankle fractures in patients a late (>24 months after
surgery) infection
with diabetes mellitus: [185]. A positive culture of
intra-operative biop-
(a) Patients with diabetes mellitus but without sies in patients operated on
with a preliminary
peripheral neuropathy and peripheral vascu- diagnosis of aseptic
prosthetic loosening is clas-
lar disease are treated as are patients without sified as a fourth type of
infection [162].
diabetes. The clinical observation
that acute PJI
(b) Patients with peripheral neuropathy and non- becomes chronic after few
weeks has acted as
displaced fractures of the distal part of the an incentive to a revision
of the PJI classification
lateral malleolus or the medial malleolus can from 1975. Today there is no
consensus regarding
be treated non-operatively. the classification of a PJI.
The following classifi-
(c) Patients with peripheral neuropathy and only cation will be used in this
presentation:
minimal displacement should be treated oper- (a) Stage I PJI: An acute
post-operative infection
atively with a rigid osteosynthesis. It has been that occurs <4 weeks
after implantation.
recommended that multiple syndesmosis (b) Stage II PJI: A chronic
infection that occurs
screws are used, and that the internal fixation >4 weeks after
implantation.
is supplemented with external fixation for (c) Stage III PJI: A
haematogenous infection
trans-articular immobilization. [119, 171]. The
rationale behind this classifi-
(d) In every case a close follow-up is mandatory, cation is a correlation
between the classifica-
and the period of non-weight bearing and tion of PJI and
treatment of PJI. Today, many
immobilization should be increased two- or Orthopaedic surgeons
will do an exchange
three-fold compared to patients without revision if the
infection occurs more than
peripheral neuropathy [39, 46, 180]. 4 weeks after
implantation.
Prosthetic Joint Infections Epidemiology
Introduction The estimated incidence of

PJI varies in the
literature, depending on how
data are collected.
At present most of our knowledge concerning The incidence of PJI based
on data from hospital
prosthetic joint infections is based upon studies registers may differ from
the incidence that is
on infected hip and knee prostheses. There are based on retrospective or
prospective studies.
only a few studies on infected shoulder, ankle and Most arthroplasty registers
have previously not
elbow prosthesis [29, 70, 178]. If not specified registered acute PJI treated
with soft tissue
otherwise, the following presentation is related to debridement only, and the
incidence of PJI
bacterial PJI in general. may be underestimated in
these registers [169].
Since a radical soft-tissue
debridement also
includes the change (i.e.
revision) of exchange-
Definitions and Classification able parts of prosthesis
such as the heads of
modular femoral stems and
polyethylene liners
A prosthetic joint infection (PJI) is any infection of acetabular cups and knee
prostheses,
due to bacteria or fungi in a total or the quality of register data
concerning the inci-
hemi-arthroplasty. A classification of PJI was dence of PJI will probably
improve. Briefly, the
introduced in 1975 [47], and modified in 1977 incidence of infection has
roughly been esti-
[64]: Stage I infection (acute infection) occurs mated to 1 %, 2 % and 5 %
after a primary
within 3 months after implantation of the pros- total hip arthroplasty, a
primary total knee
thesis, Stage II (delayed infection) within 2 years, arthroplasty, and revision
prosthetic surgery,
and Stage III presents as a haematogenous respectively.
341
The relative incidence of the different types of most clinicians will

consider culture of intra-
infection (Stage I, II, III) is also presented at dif- operative biopsies as the
diagnostic gold
ferent rates in the literature. Today probably more standard, there is no
consensus regarding the
prosthetic loosenings are diagnosed as septic loos- diagnostic criteria of a
PJI.
ening due to better diagnostic tools, and chronic As mentioned above, a
positive culture of
PJI may account for up to 50 % of all PJI. intra-operative biopsies
in patients operated
Haematogenous infections is the least frequent with a preliminary
diagnosis of aseptic prosthetic
PJI of the three different types (<20 %) [162]. loosening is not extremely
rare and therefore
classified as a fourth
type of infection [162].
Every effort should be
made to avoid this
Diagnosis situation, and in each
Orthopaedic department
the quality of pre-
operative evaluation of the
The three different types of PJI (acute, chronic, patient is reflected in
the numbers of this
haematogenous) have different symptoms. An particular PJI.
acute infection, as the name implies, often has In the following
discussion, the different
the classical signs of an infection: rubor, calor, diagnostic modalities in
cases of a suspected
dolor, tumor et functio laesa. A few weeks after acute or chronic PJI will
be presented, as well as
surgery the wound is red, eventually with wound a discussion of the
recommendations of the best
drainage, and the patient has fever and pain. An diagnostic approach.
acute haematogenous infection also may present
as an acute infection with the above-mentioned
classical signs of an infection. The Sensitivity and
Specificity of a Test
In cases of chronic infection, however, the
symptoms of the infection may overlap with
other conditions, such as aseptic loosening. Sensitivity: True
positives/(True positives + false
The presentation of the infections may be negatives)
Specificity: True
negatives/(True negatives + false
innocuous, and easily mis-diagnosed. It has
positives)
been claimed that many patients with a pre-, A diagnostic test with
many false negative results
per- and post-operative diagnosis of aseptic will have poor
sensitivity, and a diagnostic test with
loosening in fact have a septic loosening caused many false positive
results will have poor specificity.
by low-virulence and fastidious bacteria. The
observation that the use of antibiotic-containing
bone cement reduces the rate of both aseptic and Pre-Operative
Investigations
septic prosthetic revisions has been used as an
argument for this point of view [60]. Clinical Presentation
An impressive number of studies have been Although the acute post-
operative PJI in most
performed with the intention of identifying the cases is not a diagnostic
challenge [117], it should
best methods and algorithm for diagnosing a PJI. not be underestimated how
difficult it can be to
This reflects the status of PJI as the most make a clear decision in a
patient who 2 weeks
devastating complication to prosthetic surgery, after the surgery has an
operation wound which is
and that PJI is a complication that should not be not completely healed, but
no other signs of
mis-diagnosed. Unfortunately, several studies on infection. Continuous
wound drainage should
the diagnosis of PJI do not make it clear whether always be considered as a
possible sign of
it is acute PJI, chronic PJI, or both conditions, a deep infection, even if
the patient has no
which is the focus of the study. Diagnostic fever, and CRP has fallen
to almost normal
parameters such as PCR and histology are values. In most cases the
only way to clarify
highly sensitive in cases of acute infections, but such a situation is to
take the patient to the
not so in chronic infections. Finally, although operating theatre (Fig.
6).
342
E. Witso
Fig. 6 The patient was

operated with implantation
of a primary hip prosthesis
16 days ago. The skin
stitches has just been
removed, the patient has no
fever and the CRP is 72,
compared to 68 five days
ago. This patient should be
treated as a deep
postoperative infection
In chronic infections the case history might

give the clinicians important information which
might help in differentiating PJI from other con-
ditions. Compared to other conditions leading to
a prosthetic revision, patients with a chronic PJI
have a shorter interval from the primary opera-
tion to the present revision, more previous revi-
sions and wound healing problems [112, 115].
Persistent pain without any other plausible expla-
nation, and particular pain at rest, should also be
considered as sign of a PJI [68]. The presence or
a history of a sinus or abscess should be consid-
ered as synonymous with a PJI (Fig. 6). However,
the presence of a sinus as a diagnostic test has
a sensitivity of only 10 % [19].
Imaging
A normal radiograph does not exclude the pres-
ence of any PJI, and the classical radiological
signs of a chronic osteomyelitis (subchondral
ossification and sequestration) is rare in cases of
PJI. Radiolucent lines, osteolysis and scalloping
are seen in both aseptic and septic prosthetic
loosening, but the progress over time will be
different in the two conditions [140]. Radio-
Fig. 7 Radiographic signs of
prosthetic loosening is not
graphic signs of a prosthetic loosening that are
specific for PJI. However, if
these radiographic changes
observed less than 5 years after the index opera- occurs less than 5 years
after the index operation, the
tion should raise the suspension of a PJI (Fig. 7). prosthesis should be
considered as infected
343
a b
Fig. 8 The patient had an acute postoperative PJI treated <10 mg/l. Six months
later a resorption of the calcar
with soft tissue debridement and antibiotics for 3 months. region was observed
(b), and culture of joint fluid revealed
One year later he complained of pain in the groin, but the the same bacteria as
was cultured 18 months earlier
x-ray (a) was considered as normal, and CRP was (Staphylococcus
epidermidis)
A series of radiographs taken at regular intervals However, at present

PET scan is only to
should help the clinician to evaluate the evolution a limited degree
available to the clinician [139].
over time (Fig. 8).
Radio-isotope scans are in general Blood Tests
unspecific. A Technetium 99 m bone scan will C-reactive protein
(CRP) is produced in the liver
be positive up to 2 years after implantation of as an unspecific
response to an inflammatory
a cemented prosthesis, and even longer when an stimulus. After
surgery it rises acutely, and after
uncommented prosthesis has been implanted. 4872 h it starts to
decline to normal values in
Although a negative bone scan cannot rule out 23 weeks. Hence, CRP
is useful when evaluat-
a PJI with 100 % certainty, the test is of value in ing complications in
the post-operative period.
patients with sudden onset of pain in a joint where Sedimentation rate
(ESR) is also a rather
a prosthesis was implanted more than 23 years unspecific test, but
in cases of chronic PJI, SR is
ago. probably a more
specific test than CRP [115]. In
Indium 111-labelled white blood cell scan has a study on all types
of PJI the combination of
a better specificity than a Technetium 99 m bone CRP < 10 mg/l and ESR
< 30 mm/h ruled out the
scan. However, this test is rather time-consuming possibility of a PJI
in all cases [150]. When only
and expensive, and not ideal for routine use. chronic PJI (septic
loosening) is studied the sen-
PET scan is a new diagnostic tool in cases of sitivity of CRP and
ESR (cut-off value 10 mg/l
PJI. The specificity and sensitivity of the test is and 30 mm/h) were 82 %
and 64 %, respectively
similar to Indium 111-labelled white blood cell [115]. Hence, although
a normal CRP or
scintigraphy, but compared to the radio-isotope normal ESR cannot rule
out the possibility of
scan, PET scan is much faster to perform. a chronic PJI, all
patients with any unspecific
344
E. Witso
complaint from a prosthetic joint should be Diagnostic Tests During the

Operation
screened by measuring CRP and ESR. Leukocyte
count in blood has limited value in the screening Gram Stain
of patients with symptoms from prosthetic It should be very simple:
In at least an acute PJI
joints [124]. microscopy of
periprosthetic tissue or joint fluid
should reveal the causative
bacteria. Why Gram
Culture of Joint Fluid and Leukocyte stain of peri-prosthetic
tissue or joint fluid is
Count in Joint Fluid negative in more than 70 %
of cases with PJI
Puncture of the knee joint and shoulder joint is in [111] is difficult to
explain. Probably the bacterial
most cases easy and can be done in the out-patient load in most cases is too
low for detection by
clinic. Puncture of the hip joint, however, is more routine microscopy. The
specificity of the test is
demanding and should be done with some imag- extremely high, but in fact
not 100 %. So, a neg-
ing guiding. The great advantage of culture of ative Gram stain of tissue
taken from the peri-
joint fluid in cases of suspected PJI is of course prosthetic tissue during
the operation does not at
that it makes it possible to identify the causative all exclude a PJI, but a
positive Gram stain will
micro-organism before surgical revision. Due to (almost always) confirm the
diagnosis of a PJI.
the emergence of multi-resistant bacteria, the
identification of the causative microbe has Intra-Operative Histology
become of utmost importance, and it should be (Frozen Section)
a pre-requisite for one-stage revisions (see later). The correlation between
frozen section and per-
The problem related to culture of joint fluid in manent histology of peri-
prosthetic tissue is
cases of suspected PJI is that a negative culture #95 % [1, 62, 118]. The
cut-off value used in
cannot rule out an infection, particularly in many studies when
diagnosing a PJI is >5 poly-
patients who have received antibiotics. In morphonuclear (PMN)
leukocytes per high-
a series of 67 patients (69 knees) with symptom- power field (#400) in at
least five different
atic total knee prosthesis, the sensitivity of joint microscopic fields [105].
When tissue is
fluid culture was 55 % [16]. Since the specificity harvested for frozen
section, the interface mem-
of the test is not 100 %, it is recommended brane has been of
particular interest, and
that aspiration and culture of joint fluid from a consensus for
classification of histopathological
prosthetic joints is done in patients where clinical changes in cases of septic
and aseptic prosthetic
findings (clinical presentation, radiograph revision has been proposed
[110]. In studies of
or blood tests) have raised the suspicion of different types of PJI,
frozen section of biopsies
a PJI [17]. Another problem is a dry tap, i.e. no from the neocapsule, the
interface membrane or
fluid is aspirated. In these cases normal saline any other inflamed tissue
has had a diagnostic
can be injected into the joint space and aspirated. sensitivity of 8090 % for
a PJI (cut-off 5 PMN
The value of this procedure has not been per high-power field, in 1
10 fields), and
validated. a specificity of 8796 %
[96, 118, 150]. However,
In addition to culture, leukocyte count and dif- frozen section is probably
of a more limited value
ferential leukocyte count in joint fluid are useful when the surgeon wants to
rule out the possibility
diagnostic tools. At a cut-off value of 1.7 # 103 of an infection in cases
where the pre-operative
leukocytes per ml, the sensitivity and specificity of diagnosis is aseptic
loosening of a prosthesis. In
the test is approximately 90 %, also in cases of a study on 61 patients with
a preliminary diagno-
chronic PJI [115, 157]. A differential leukocyte sis of aseptic prosthetic
loosening, 12 patients
count of >65 % neutrophils in joint fluid is also were found to have a PJI
with growth of the
a sensitive and specific test. The disadvantage, same micro-organism in at
least two tissue sam-
however, with leukocyte count and differential ples. Frozen section (cut-
off 5 PMN per high-
in joint fluid is that it does not provide power field in at least 5
fields) identified only
a microbiological diagnosis of the PJI. 6 of 12 (50 %) of these
infections, and the
345
specificity was 81 % [25]. Finally, the use of will help both to identify
the bacteria, and to
frozen section as a method for an intra-operative make a decision of a possible
contamination.
diagnosis of a PJI depends on the collaboration In cases of PJI the
classical definition of an
with an interested (and enthusiastic) pathologist, infection according to Kamme
and Lindberg
and optimal logistics. [84] was bacterial growth in
five out of five
tissue biopsies. Today this
definition is by most
The Surgeons Judgement investigators modified to
growth of bacteria in >2
The presence (more precisely: the surgeons or #2 out of at least five
samples [12, 21, 52, 103].
judgement of the presence) of macroscopic This definition should be
nuanced, since
gross purulence is often included as a criterion the growth of a high virulent
bacterium as
for the intra-operative diagnosis of a PJI. The S. aureus in just one out of
five tissue samples
evidence for this is poor, and so far it must be in most cases would be
considered as significant,
concluded that the presence or absence of gross whilst the sparse growth
(eventually after
purulence (as judged by the surgeon) can neither enrichment) of S. epidermidis
in just one
confirm nor rule out the possibility of a PJI sample, would not. A close
collaboration
[62, 124]. This may come as a surprise, but between the microbiologist
and the Orthopaedic
probably it is due to a high rate of low virulence surgeon is the best guarantee
for a proper deci-
infections in PJI which both locally and system- sion in these cases, and the
specificity of culture
ically lack the classical signs of a purulent as a diagnostic test thus is
influenced by this
infection. collaboration.
Although culture of
tissue biopsies is the gold
Culture of Tissue Biopsies standard when diagnosing a
PJI, the sensitivity of
These culture results are available for the surgeon culture of tissue biopsies in
cases of PJI is not
after the operation, and every effort should be 100 %. This is explained by
the fact that even in
made to classify the operation into either cases with an obvious PJI
(for example patients
a septic or an aseptic revision before surgery. with a sinus), culture might
be false negative due
Ideally, the causative microbe should also have to antibiotics administered
prior to tissue sam-
been identified before revision, but as has been pling [19]. The bacteria
causing a chronic PJI
mentioned above this is not always possible. might also be so fastidious
that routine culture
In acute and chronic PJI Staphylococcus will be negative, or the
bacteria are only present
sp. are isolated in >50 % of the cases in the biofilm on the surface
on the implant.
[112, 118, 121]. A number of other bacteria has These considerations do of
course interfere with
also been cultured in cases of PJI, such as strep- the use of tissue culture as
the gold standard in
tococci, enterococci, Enterobacteriaceae sp., and cases of chronic PJI. As a
preliminary conclusion
a number of other more uncommon species it must be stated that this
question at present is not
(Marculescu et al. 2006). In chronic PJI (septic clarified.
loosening) low virulence bacteria such as Staph- Fungal PJI are rare, and
papers on fungal PJI
ylococcus epidermidis and Propionibacterium are mostly case reports on
infections due to
acnes are cultured in >75 % of the cases Candida sp. The incidence of
fungal PJI is
[100, 115, 120]. S. epidermidis and P. acnes unknown, but it has been
estimated to 1 % of
belong to the normal skin flora, and there will all PJI [128]. In the
laboratory of microbiology,
be a risk that tissue samples taken for culture are fungi are cultured on agar
specialized for fungal
contaminated by these commensal bacteria. In growth. Fungal PJI is mostly
seen in cases of
the microbiological laboratory tissue biopsies chronic PJI, and in patients
who are immuno-
are processed and seeded onto agar plates, and suppressed. Hence, in these
cases the clinician
growth of bacteria is classified as abundant, mod- should specify the
possibility of fungal PJI when
erate or sparse. In cases of no or sparse growth on tissue specimens are sent to
the laboratory of
agar plates, bacterial growth in enrichment broth microbiology.
346
E. Witso
Culture of Sonicate Specimens primers are used to

identify the DNA. By the
In an ultrasonic bath biofilm bacteria will be technique called
polymerase chain reaction
detached from the surface of an implant, and the (PCR) bacterial DNA in
joint fluid, periprosthetic
fluid into which the biofilm is dissolved is called tissue or sonicate
sediment is augmented. After
the sonicate fluid. Either the sonicate fluid or its augmentation it is
possible to identify the PCR
sediment (after centrifugation) is called the son- product. PCR is extremely
sensitive, and the
icate specimen, and is the subject for culture or specificity of the test
depends on which primers
molecular diagnostics [23, 88, 106]. During the that are used. Specific
primers will for example
sonication process in plastic bags contamination identify only methicillin-
resistant S. aureus
has been a problem [61, 158], but after plastic (MRSA), with almost no
risk of false positive
containers have been introduced, the contamina- results. However,
universal (also called global)
tion problem has been minimized [159]. In primers are capable of
identifying the 16S rRNA
a study on 79 patients with PJI (the type of PJI gene, which is a highly
conserved gene in all
was not specified but 51 of 61 (84 %) had sign of bacteria. Even minute
amounts of contaminant
acute inflammation in tissue), culture of sonica- DNA in specimens or in
enzymes or reagents
tion fluid had, compared to culture of used in the PCR reaction
will give a false positive
periprosthetic tissue, a significantly better sensi- result. The PCR is not a
100 % sensitive test,
tivity in patients who had received antibiotics since large amounts of
human DNA, always pre-
414 days before surgery. In patients where anti- sent in tissue specimens,
may inhibit the PCR
biotic administration had been discontinued >14 reaction, and, unless
special techniques are
days prior to surgery, the sensitivity of culture of employed, PCR does not
readily identify more
periprosthetic tissue and culture of sonicate was than one bacterial species
in polymicrobial infec-
similar. Fourteen patients out of the 79 patients tions [107].
with a PJI had positive culture of sonicate fluid In a much cited study
from 1999 [163, 164],
and negative culture of periprosthetic tissue. it was reported that
culture of tissue biopsies in
However, if positive culture of synovial fluid 120 patients operated with
revision of
and previous positive cultures at other institutions a hip prosthesis showed
bacterial growth in
are included, only one patient with PJI had 5 of 120 (4 %) of the
cases. All patients had
positive culture of sonicate fluid and negative received antibiotic
prophylaxis prior to tissue
culture of periprosthetic tissue [159]. In a study sampling, and culture of
sonicate fluid was pos-
on infected shoulder prostheses, culture of tissue itive in 21 of 120 (18 %)
of the cases. Addi-
biopsies was positive in 18 of 33 cases, and tional investigations
showed that the majority
culture of sonicate sediment was positive in of the patients had an
infected implant: Immu-
22 of 33 of the cases [131]. nofluorescence microscopy
was positive in 71
Culture of sonicate fluid or sediment is of 113 (63 %) of the
cases, 16S rRNA gene
a promising diagnostic procedure, and could be amplification was positive
in 85 of 118 (72 %)
either a supplement or alternative to routine cul- of the cases, and
inflammatory cell infiltration
ture of tissue biopsies. Particularly in cases where (#1020 cells per HPF) was
positive in 59 of 81
bacteria in the periprosthetic tissue are difficult to (73 %) of the cases. The
authors concluded that
culture due to antibiotics administered before the incidence of PJI is
grossly underestimated,
tissue harvesting, culture of sonictate fluid or and that routine culture
is inadequate as
sediment could identify the causative organism. a diagnostic method in
cases of PJI.
So far, PCR has not
become a routine micro-
Molecular Diagnostics biological test in cases
of PJI. This is probably
Identification of bacterial DNA is the rationale of due to the contamination
problem related to the
molecular diagnostics. The keys to an under- use of universal (global)
primers. If specific
standing of the limits and possibilities of molec- primers are used, the
specificity of the test will
ular diagnostics is that either specific or universal increase, but not the
sensitivity. In 37 cases of PJI
347
(hip, knee, shoulder, elbow, and ankle prosthe-

ses) the sensitivity of periprosthetic tissue cul-
ture, sonicate fluid culture and multiplex
(specific) PCR of sonicate fluid was 24 of 37, 23
of 37 and 29 of 37, respectively [4]. The enthusi-
astic approach that all prosthetic loosenings are
septic, is today replaced by a more modest
approach. In a study on 176 patients with a pre-
operative diagnosis of aseptic loosening, only
7 (4 %) were finally classified as infected. The
criteria for the diagnose were that the same bac-
teria was identified either by PCR (16S rRNA
PCR with reverse line blot hybridization) or
culture in >2 samples [109].
Fig. 9 A transposition of the

medial and lateral gastroc-
Treatment of Infected Joint Prostheses nemius muscle will secure an
excellent soft tissue cover-
age of the ventral part of
the knee joint
Most of present knowledge about treatment of PJI
is interpreted from non-randomized studies
[140]. To randomize patients to different surgical reasonable to exchange
polyethylene liners and
procedures is of course much more difficult than the femoral heads of modular
femoral compo-
to randomize patients to for example different nents, if possible. The
debridement is followed
types of medical treatment for hypertension, and by antibiotic treatment,
intravenously for 24
blinding (at least double blinding!) would be weeks followed by oral
treatment for 23 months.
almost impossible in a surgical study. Analyses The result of soft-tissue
debridement in
of data from arthroplasty registers is a realistic Stage I PJI varies
considerably in the literature,
alternative to randomized trials, and many studies with a success rate from 20 %
to 100 %. In acute
on epidemiology and antibiotic prophylaxis in PJI caused by Staphylococcus
sp. much attention
prosthetic surgery are based on data from has been paid to rifampicin
treatment. Rifampicin
arthroplasty registers [59]. is active against most
staphylococci and in vitro
The different options for treatment of a PJI studies have shown that the
antibacterial effect of
is (a) soft tissue debridement, (b) one-stage rifampicin also includes
biofilm bacteria.
or two-stage prosthetic revision, (c) permanent In a clinical study, 18
patients (8 with PJI)
resection arthroplasty (Girdlestone) or were randomized to
rifampicin/fluoroquinolone
arthrodesis, (d) antimicrobial suppression therapy and 15 patients (7
with PJI) to placebo/
therapy, and (e) amputation. fluoroquinolone [186]. All
patients had an acute
In some cases of soft-tissue debridement, post-operative infection (<2
months after sur-
prosthetic revision or resection arthroplasty gery) or acute haematogenous
infection. Out of
either local or free muscle transposition is needed the 33 patients, 29 were, in
addition to antibiotic
to improve soft tissue coverage (Fig. 9). therapy, operated on with
soft-tissue debride-
ment. At a minimum of 15
months follow-up
Soft-Tissue Debridement the success rate was 12/12 in
the rifampicin
In acute post-operative PJI (Stage I) soft tissue group and 7/12 in the placebo
group (9 drop-
debridement and prosthetic retention should outs). In another study, 60
patients with an
always be considered. A pre-requisite for this infected hip or knee
prosthesis were treated with
procedure is that the prosthesis is well-fixed. soft-tissue debridement and
prosthetic retention
Although not supported by any study, it is followed by
rifampicin/levofloxacin for at least
348
E. Witso
6 weeks after resolution of symptoms [15]. infection (sinus, longer

duration of the infection
The success rate was 20/24 when duration of and loss of bone stock),
and they were more often
symptoms was #1 month, 15/23 when duration infected with MRSA compared
to patients treated
of symptoms was 26 months, and 4/13 when with a one-stage procedure
[90]. Hence, it has
duration of symptoms was >6 months. In been advocated that one-
stage revision should
a study of 18 patients with acute PJI (<3 months only be performed in
selective cases [81].
after surgery) the success rate was 89 % (16/18) However, the success rate
has been reported as
when treated with a mean of 2.2 (14) soft tissue rather good after both
procedures, with cure of
debridements and rifampicin/fusidic acid [3]. infection and acceptable
functional results in
Rifampicin should not be given as monotherapy 8590 % in one-stage
revision, and even >90 %
(due to risk of emergence of resistant strains), and in two-stage revision [91].
rifampicin treatment should be administered in
accordance with the guidelines of the infectious One-Stage Revision
disease specialist at the hospital. In larger patient Most Orthopaedic surgeons
would have
series with different antibiotic treatment regimes, a knowledge of the
causative bacteria, and its
the cure rate in cases of PJI treated with soft- antibiogram, before
performing a one-stage pro-
tissue debridement and prosthetic retention has cedure. This knowledge is
in many cases avail-
been 6080 % in patients operated after days or able by culture of joint
fluid, after any antibiotic
23 weeks after primary surgery, and #50 % cure treatment has been
discontinued for more than
rate in patients with a longer duration of infection 2 weeks. Culture results
from previous soft-tissue
([90], Marculescu et al. 2006). In cases of acute debridement or blood
culture are also informa-
PJI due to MRSA the cure rate in patients opertive, although not
completely reliable. A
ated with soft-tissue debridement and prosthetic one-stage revision should
be performed as two
retention has been much poorer (#20 %) [28]. In separate procedures. The
first procedure is to
cases of acute haematogenous PJI (Stage III) and remove the implant, to
harvest specimens for
a fixed prosthesis the cure rate in patients treated culture and to do an
extremely radical debride-
with soft-tissue debridement and prosthetic reten- ment of the soft tissue and
bone stock. The second
tion is probably <50 % [90]. If possible patients procedure is implantation
of the new implant.
treated with soft-tissue debridement should not The same surgical
instruments should not be
start treatment with antibiotics until tissue speci- used in procedure one and
two, and the two pro-
mens for culture have been harvested. In cases cedures should be
considered as two separate
with fulminant infection and systemic features of operations. A consequent,
but rather drastic
sepsis this can be difficult to implement. In these action, is to close the
wound after procedure
cases blood culture can provide the microbiolog- one, and then move the
patient into an operating
ical diagnosis. theatre for clean
operations. This procedure is of
course not possible to
implement in every case,
One-Stage or Two-Stage Prosthetic and at every hospital. A
radical debridement is of
Revision paramount importance, and
residual cement is
What we today know about the results of either associated with treatment
failure [34].
one- or two-stage prosthetic revision in cases of Another pre-requisite
for a one-stage proce-
PJI is mostly interpreted from analyses of retro- dure is the possibility of
local and systemic
spective case series. When the results of the two antibiotic treatment. Local
antibiotic treatment
surgical procedures are compared, it is important is possible when
antibiotics are eluted from anti-
to recall that patients treated with a one- or two- biotic-containing bone
cement. Many Orthopae-
stage procedure are not necessarily similar dic surgeons prefer
uncemented revisions,
regarding the risk factors. In a present study and in septic revisions
cancellous bone is
from France, patients treated with a two-stage a possible vehicle for
local antibiotic delivery
procedure more often had signs of a chronic [33, 175, 176].
349
Two-Stage Revision Permanent Resection

Arthroplasty
In many hospitals, countries and continents, (Girdlestone) and Arthrodesis
a two-stage procedure is the standard procedure. Indication for these
procedures are a previous
The best indication for a two-stage revision failed soft-tissue
debridement, one-stage or two-
is perhaps a previously failed one-stage stage revision (Fig. 10). In
patients with
revision due to a PJI. As mentioned above it protracted chronic infection
or in patients with
is considered that lack of knowledge of the caus- a general impaired function
these procedures are
ative microbe, chronic infection and PJI caused realistic options. In
particular, fungal PJI has
by MRSA, are indications for a two-stage been associated with
permanent resection
revision. arthroplasty [128]. Permanent
resection
The use of antibiotic-containing polymethyl- arthroplasty in the hip joint
results in limb-length
methacrylate (PMMA) spacers have probably discrepancy of at least 4 cm.
Although the joint
made a two-stage procedure more easy to per- may be pain-free, even during
full weight-bear-
form and has improved the results [141, 152]. For ing, the functional result is
not at all optimal.
the hip and knee joint there are prefabricated Some of these patients will
prefer to use
spacers or the spacers are made per-operatively a wheelchair. Particularly in
chronic cases, the
with the use of plastic moulds. It is also possible acetabular dead space should
be filled with either
to use custom-made spacers in the hip, knee or the gluteus muscle or the
vastus lateralis muscle.
shoulder joint. The different antibiotics used in Arthrodesis of the knee joint
after a failed knee
spacers are aminoglycosides, glycopeptides (van- prosthesis is performed with
either an external
comycin) and clindamycin. Compared to fixator or internal
osteosynthesis with a plate(s)
polymethylmethacrylate beads, the elution prop- or a nail (Fig. 11).
erties of gentamicin and vancomycin from In the shoulder and ankle
joint a permanent
PMMA spacers are inferior [6], and in particular resection and arthrodesis,
respectively, may be
if low-dose antibiotic bone cement is employed the best options.
[108]. The spacer may become a (new) infected
implant, and there is always the possibility of Antimicrobial Suppressive
Therapy
displacement of the spacer. Reports on such com- The indication for chronic
antibiotic therapy is
plications are sporadic, and at present it is cases where the infection is
not eradicated or the
unknown how frequent these complications are. risk of reinfection is
considered as very high. At
The interval between first and second stage in present, the knowledge on
this treatment is very
two-stage revision is at least 46 weeks. The limited. First and foremost
it is used in patients
evaluation of the appropriate time for re- with such an impaired general
condition that the
implantation is mostly done by a clinical evalua- risk of serious complications
during a new oper-
tion of the patient (including measurement of ation is considered as very
high (host C).
CRP and ESR). In some institutions the clinician
stops antibiotic treatment after 46 weeks, and Amputation
after 2 weeks aspiration of joint fluid is made for In patients where it is not
possible to eradicate the
culture. The sensitivity of this test is unknown, infection even after joint
resection, knee disartic-
but is expected to be rather low. The implantation ulation or trans-femoral
amputation is an option
of the new prosthesis is performed as a clean in infected knee prostheses,
hip disarticulation is
procedure. There is no consensus regarding the an option in infected hip
prostheses, and trans-
use of local antibiotic treatment (prophylaxis) tibial amputation is an
option in infected ankle
and the pre-operative, per-operative and post- prosthesis. The amputation is
either performed on
operative use of antibiotics in the stage two oper- life- or limb-threatening
indications in cases of
ation. However, the results of two-stage revisions a fulminant and aggressive
infection, or in very
are in general very good, and it is difficult to chronic infection where an
amputation is consid-
make the case for one specific procedure. ered as a better option than
chronic antibiotic
350
E. Witso
a b
c
Fig. 10 An uncemented prosthesis was implanted in a luxation of the

spacer (b), a resection arthroplasty was
62 years old female due to pain in the thigh while cross performed (c). Tissue
biopsies showed growth of methi-
country skiing (a). A soft tissue debridement was done cillin resistant S.
epidermidis, which also were resistant to
twice due to a postoperative infection with culture of gentamicin, and MIC
of vancomycin was 3 mg/l. So far
Staphylococcus aureus. A two-stage revision was the patient is
reluctant to any further operative treatment
intended, but due to continuous wound secretion and
a b c
d
Fig. 11 A 70 year old male was operated with implanta- biopsies showed
growth of S. aureus, methicillin resistant
tion of a knee prosthesis (a). Due to pain the prosthesis S. epidermidis and
Propionibacterium acnes. Continuous
was revised (b). Culture of tissue biopsies was negative. wound secretion made
it necessary to fill the joint
Due to postoperative wound infection a soft tissue revision space (dead space)
with the medial gastrocnemius muscle.
was performed before the revision prosthesis was An arthrodesis of the
knee joint was performed 6 months
removed (c). The tuberositas tibia was loose. Tissue later (d)
351
suppression therapy. Particularly in cases of increase [49]. Since the rate

of multi-resistant
chronic PJI and osteomyelitis due to methicillin- bacteria also increases the
total burden of PJI
resistant S. aureus and methicillin-resistant will increase and take a
larger part of the total
S. epidermidis the lack of oral antibiotics will resources of a department of
Orthopaedic sur-
strengthen the indication for amputation as the gery. Hence, to establish
specialized infection
definite treatment. There are very limited data on units is the best way to
secure a specialized and
how often amputation due to PJI is performed up-to-date treatment of PJI.
The antibiotic treat-
[177], but an infected knee PJI is probably the ment in cases of PJI is
associated with adverse
most common indication. Hence, due to the effects, and a specialist in
infectious diseases
increasing number of implanted knee prosthesis, should be included in the
multidisciplinary team
this dramatic outcome will probably not be that is responsible for the
treatment of PJI. Par-
a rarity in the future. ticularly in cases of infected
knee arthroplasties,
but also in cases of infected
hip prosthesis and
ankle prosthesis, soft-tissue
handling will include
Conclusions and Recommendations plastic surgery, such as
transposition of the gas-
trocnemius and the vastus
lateralis muscle, or
The Diagnosis a free gracilis muscle flap. A
plastic surgeon or
Prosthetic revision accounts for 15 % of all pros- a surgeon who master basic
plastic surgery tech-
thetic surgery [67], and every department of niques should be a member of
the multidis-
Orthopaedic surgery should have a strategy for ciplinary team. To what degree
chronic PJI
identification of septic revisions. The clinical should be treated with one- or
as a two-stage
presentation, including routine measurement of revision should be based on
the strategy for treat-
CRP and ESR, will be of importance in deciding ment of a PJI in each
particular department. In
which patients should be candidates for further cases of two-stage revision
the patient logistics
investigations, such as aspiration of joint fluid, are important, and in all
cases of PJI the follow-
cell count in joint fluid and imaging depending up routines should be
standardized.
on the resources of each hospital. To do routine Regarding antibiotic
treatment there are
joint fluid aspiration and culture in all patients extremely few randomized
trials from which the
with a loosened prosthesis is probably justified results could guide the
clinician in choosing the
only in prospective studies. The procedure best drug, and the most
effective administration
demands resources, the test will not rule out all of the drug. A close
collaboration with a special-
PJI and there are problems with false-positive ist in infectious diseases
with an interest in PJI
results. Each Orthopaedic department should will probably be a guarantee
for the best treat-
clarify with the respective departments of pathol- ment outcome.
ogy and microbiology the policy for the use of
histology (frozen section), PCR and sonication as
diagnostic tools. The Infected Diabetic Foot
Treatment The Epidemiology of Diabetes

Mellitus
The quality of the treatment of all types of PJI (DM), Diabetic Peripheral
Neuropathy,
depends on a thorough knowledge of the particu- Diabetic Foot Ulcers, Diabetic
Foot
lar pathophysiology characterizing implant infec- Infection and Diabetic Lower
Limb
tions. To what degree PJI should be treated by Amputations
specialized Orthopaedic surgeons depends on
the size of the respective department of Ortho- Almost six percent of the
world population has
paedic surgery. Either due to an increase in revi- DM; of which >97 % have DM
Type 2 [5]. On
sion surgery in general, or due to other factors, a global scale the number of
people with diabetes
it is to be expected that the rate of PJI will mellitus (DM) will rise from
170 millions in 2000
352
E. Witso
to 370 millions in 2030 [173]. Due to an increas- ischemia or gangrene [77].

This means that the
ing rate of overweight and obesity the number of indication for examination of
the arterial circula-
people with DM in 2030 might prove to be con- tion is not different in
diabetic subjects compared
siderable higher than the estimated 370 millions. to non-diabetic subjects.
Diabetic neuropathy is the most common of the DM is, per se, a risk
factor for having an
DM complications, and at the time of diagnosis, infectious disease. In a
Canadian cohort study
up to 50 % of people with DM Type 2 have more than 500 000 people with
DM were
neuropathy [79]. In people with DM, peripheral matched to a group of non-
diabetic subjects. Peo-
neuropathy is the main risk factor for diabetic ple in the diabetic group had
a higher risk of being
foot ulcers, and the lifetime risk for developing hospitalized for different
infectious diseases,
a foot ulcer in people with DM has been esti- including osteomyelitis
[145]. Compared to
mated at 1525 % [35, 66, 79]. A majority of non-diabetic subjects the
function of polymor-
the diabetic foot ulcers are infected, and phonuclear neutrophils is
abnormal in diabetic
1520 % of patients with a diabetic foot ulcer patients [53], and an
impaired function of the
have osteomyelitis in the skeleton of the foot immune system might partly
explain the high
[93, 135, 138]. Hence, diabetic foot osteomyelitis rate of infected diabetic
foot ulcers [35].
is probably the most common of all types of Finally, the chronic
infected diabetic foot
osteomyelitis. In Europe 3060 % of lower limb ulcer should be considered as
a typical biofilm
amputations (LLA) are associated with DM [71], infection where the biofilm
bacteria live in micro-
and LLA in patients with DM is preceded by colonies and have reduced
susceptibility to anti-
a foot ulcer in 85 % of the cases [79]. biotics [22, 50]. This is a
new approach to the
understanding of the extreme
chronic nature of
the diabetic foot ulcers.
Pathophysiology of Diabetic Foot
Ulcers and Infection
The Clinician Presentation
and
Diabetic peripheral neuropathy is the major risk Diagnosis of the Infected
Diabetic Foot
factor for a diabetic foot ulcer. The classical
manifestations of diabetic peripheral neuropathy There are several
classification systems for dia-
are loss of protective sensation, deformities due betic foot ulcers and
diabetic foot infections
to motor neuropathy, elevated plantar pressure [30, 35, 80]. For the
clinician it is practical to
and diminished ability to regulate skin perspira- classify the infection in the
diabetic foot as mild,
tion. An additional and independent risk factor moderate or severe [65, 66,
95]. A mild infection
for diabetic foot infection is peripheral vascular refers to a superficial
infected wound with no
disease [92], and the degree of peripheral vascu- ischaemia. These infections
should be considered
lar disease is the most important factor related to as non-limb-threatening and
the patient can be
the outcome of a diabetic foot ulcer. Histopatho- treated in an out-patient
clinic. Moderate to
logically, the atherosclerosis in diabetic subjects severe infections have to
varying degrees of
is similar to atherosclerosis in non-diabetic involvement of deep tissue,
and to varying
subjects, but there are several important clinical degrees ischaemia and
systemic toxicity. These
differences: Compared to the non-diabetic popu- infections are limb-
threatening and the patients
lation, peripheral vascular disease in patients should always be
hospitalized.
with DM is more common, it affects younger It is of paramount
importance to know that the
individuals and it is located more distally, i.e. classical systemic signs of
an infection might be
distal to the superficial femoral artery [77, 79]. absent even in cases of
severe infection in the
It should be stressed that the vascular changes in diabetic foot (Fig. 12). In
most patients with an
diabetic subjects are macrovascular, and that so- infected diabetic foot pain
is absent due to periph-
called small vessel disease does not cause eral neuropathy. Even
patients with a severe
353
Fig. 12 This patient was

a
encouraged by his wife to
contact the local diabetic
foot team (an outpatient
clinic) due to a very
unpleasant odour from the
foot. The patient himself
had no complaints. The
infection included a deep
abscess in the planta pedis
and osteomyelitis of the
fifth and fourth metatarsal
bones. The patient was later
transmetatarsal amputated,
followed by a transtibial
amputation
infection may have normal body temperature, signs which will lead the
clinician to the suspi-
blood cell count and erythrocyte sedimentation cion of a severe infection
[37, 66]. However,
rate [10, 57, 58, 73]. A general malaise (diabetic when increased body
temperature, sedimentation
foot flu) and hyperglycaemia might be the only rate and blood cell count are
present in cases of
354
E. Witso
diabetic foot infections, they should be consid- between ulcer swab cultures
and culture of bone
ered as alarming signs. biopsies is poor, and ulcer
swab cultures should
The clinical examination in any patient with be considered as unreliable
in the microbiologi-
DM and a foot ulcer should include ulcer classical diagnosis of diabetic
foot osteomyelitis
fication (i.e. superficial or deep) and evaluation of [56, 143]. If possible,
antibiotic therapy and pro-
the neurological status, the vascular status, and phylaxis should be withheld
for more than 1 week
the general status of the patient. The 10 g before biopsies are
harvested for culture. How-
Semmes-Weinstein monofilament and the ever, it is very common
that patients with an
128 Hz tuning fork are useful when testing the infected diabetic foot have
already started antibi-
level of foot sensation and vibration perception, otic treatment before being
referred to a hospital
respectively [80]. If the dorsalis pedis and tibialis [58]. This probably
explains the rate of false
posterior arteries are not palpable, a further vas- negative culture results in
otherwise obvious
cular examination has to be done. The only cases of diabetic foot
infections.
exception to this rule is in cases of lower limb At present, no gold
standard exist that could
amputation as an emergency procedure in help the clinician to
diagnose osteomyelitis in
a critically-ill patient. Depending on the local the diabetic foot. The
International Working
resources there are a number of non-invasive Group on the Diabetic foot
has proposed
techniques available to assess the vascular supply a scheme based on clinical,
laboratory and imag-
to the foot. It should be remembered that in ing results where the
likelihood of osteomyelitis
patients with peripheral neuropathy there is has been classified as
unlikely, possible, proba-
a risk of a false elevated (normal) ankle/brachial ble and definite [20]. So
far, this scheme has not
index due to medial arterial calcinosis [77]. In been validated.
patients with an infected diabetic foot ulcer it is
important to make a thorough investigation of the
wound, including deep exploration. Due to Treatment of Diabetic Foot
Infections
peripheral neuropathy this can be done in most
patients without anaesthesia. The degree to which Surgical Debridement
the infection affects muscles, tendons, joints and Surgical debridement should
be considered in all
bone must be evaluated. A radiological examina- patients with an infected
diabetic foot ulcer.
tion will give the clinician an indication of bone Superficial ulcers may be
debrided at the out-
destruction in cases of chronic osteomyelitis. patient clinic, while
deeper ulcers, and particular
These radiological changes are not pathogno- in cases with necrosis,
should be debrided in the
monic for osteomyelitis and might also be seen operating theatre. As in
other chronic infections
in a Charcot foot. However, in most cases the in the musculoskeletal
system, infected and
combination of a diabetic foot ulcer overlying necrotic tissue should be
radically resected.
a destroyed bone with signs of osteomyelitis Cases of chronic
osteomyelitis of the lesser digits
will leave little doubt concerning the diagnosis have been treated without
radical resection. How-
(Fig. 13). MRI is justified if there is an additional ever, the mean duration of
antibiotic treatment in
need to evaluate the extent of bone and soft-tissue these cases has been nearly
1 year [20]. If revas-
involvement [20]. The culture of bacteria, per se, cularization is considered
as necessary this
is not diagnostic for an infected diabetic foot. should be performed as soon
as possible after
Bacterial colonisation will occur in all wounds, the primary revision of the
infected foot, i.e.
and the diagnosis of infection is in principle before secondary wound
closure or minor
based on the clinical signs of infection. In patients amputation [77].
with local and/or systemic signs of an infection,
biopsies for culture should be taken per- Amputation
operatively from deep structures in general, and Indications for amputation
are life-threatening
bone tissue in particular. The concordance foot infections, systemic
toxicity despite radical
355
a b
Fig. 13 A thorough exploration of the wound (b) reveals there is little doubt
concerning the diagnose. The x-ray
communication to bone. Although the radiological will also be of value for
the surgeon in the preoperative
changes are not pathognomonic for osteomyelitis (a), planning
debridement, insufficient soft-tissue coverage deformity, and achilles

tendon lengthening
after debridement and the infected, ischaemic should be considered as
part of the amputation
foot with no possibility of revascularization. In procedure [27].
chronic infection of the lesser toes (II-V)
exarticulation is an option, while in chronic infec- Antibiotics
tion of the hallux as much length as possible Staphylococcus sp. are
the most frequent bacteria
should be preserved. If toes have been encountered in the
infected diabetic foot [55, 66],
exarticulated before or many toes are affected of which Staphylococcus
aureus are predomi-
by the present infection, it is not advisable to nant. Other Gram-positive
bacteria involved are
leave just one or two toes (except for the hallux). Streptococcus sp. and
Enterococcus sp. Com-
In these cases a proximal transmetatarsal ampu- pared to other types of
chronic osteomyelitis the
tation is an option. In transmetatarsal, Lisfranc osteomyelitis in the
diabetic foot is more often
and Chopart amputation it is important to opti- polymicrobial. In
addition to Gram-positive bac-
mize the vascular supply to the foot, and if nec- teria, Gram-negative
bacteria and anaerobes are
essary a vascular surgeon or a vascular laboratory cultured in bone biopsies
in 2050 % of the cases
should be consulted before the amputation. In [143, 144]. The empiric
antibiotic treatment of
foot amputations above the toe level there is the infected diabetic
foot should be administered
always a risk for a post-operative supination by an infectious disease
specialist in
356
E. Witso
collaboration with the Orthopaedic surgeon, and

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Thromboprophylaxis
David Warwick
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 365
Chemical prophylaxis # DVT-deep venous
thrombosis # Guidelines # Mechanical prophy-

Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 365
laxis # Pathogenesis # PE-pulmonary embolism

Risk
Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 366 # Risk factors # Timing of treatment
Risk in Orthopaedic Conditions . . . . . . . . . . . . . . . . . . 366

Fatal
PE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 366
Chronic Venous and Pulmonary Sequelae . . . . . . . . . . 366
Introduction
Prophylactic Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
367
General
Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
367 This is a controversial topic with different views
Mechanical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
367 across Europe. The scale of the problem is dis-
Chemical
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
368
When to Start Chemical Prophylaxis . . . . . . . . . . . . . . .
369 puted and the cost-benefit, risk-benefit and prac-
When to Finish Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . .
369 ticality of any particular protocol is uncertain.
Stacked and Combined Modalities . . . . . . . . . . . . . . . . . .
369 However, nowhere else in orthopaedics are
Knee Arthroscopy, Plaster Casts, Foot Surgery . . . .
369 there so many high quality clinical trials to
Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 369 guide practice [9]. These trials have been sum-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 372 marized by several groups to form guidelines.
This chapter is based upon the the advice from
various such groups.
Pathogenesis
Virchows triad of altered blood components,
venous stasis and endothelial damage is fully
represented in major trauma and orthopaedic
surgery. Injury or surgery to soft tissue but
especially bone provokes systemic hypercoa-
gulability and inhibition of fibrinolysis. After
injury or surgery, patients are likely to be
relatively immobile. During hip replacement,

D. Warwick
femoral vein blood flow is obstructed by the
Hand Surgery, University Hospital Southampton,
Southampton, UK
maneuvers required to expose the femoral
e-mail: davidwarwick@me.com
canal and acetabulum. This may damage

365
DOI 10.1007/978-3-642-34746-7_2, # EFORT 2014
366
D. Warwick
the endothelium in the proximal femoral vein, Table 1 Risk factors [7]
and also distends the veins in the calf, causing Personal VTE risk factors
damage to the calf endothelium and valve Active cancer or cancer
treatment
pockets; aggravated by the concentration of Age >60 years
clotting factors in the stagnant blood. Anterior Critical care admission
subluxation of the knee and the vibration may Dehydration
cause local endothelial damage during knee Known thrombophilias
replacement. Obesity (BMI >30 kg/m2)
One or more significant
medical comorbidities
Heart disease
Metabolic, endocrine
or respiratory pathologies;
Acute infectious
diseases
Risk Factors
Inflammatory
conditions
Personal history or
first-degree relative with a history
Each patient has his own personal risk (Table 1) of VTE
which is determined by their genetic predispo- Use of HRT
sition and by their medical co-morbidity. Use of oestrogen-
containing contraceptive therapy
A previous PE or DVT is the strongest individ- Varicose veins with
phlebitis
ual risk factor. Surgical risk factors
Superimposed onto the individuals own risk If total anaesthetic +
surgical time > 90 min or
is the mechanical and haematological risk of the If surgery involves
pelvis or lower limb and total
anaesthetic + surgical time
> 60 min or
injury or surgery. Some orthopaedic procedures
If acute surgical
admission with inflammatory or
are unlikely to predispose to thrombosis. intra-abdominal condition or
Most upper limb surgery and brief lower limb If expected to have
significant reduction in mobility or
operations probably carry no risk whereas If any VTE risk factor
present
procedures such as complex lower limb trauma
reconstruction or revision hip surgery carry
a particularly high risk.
but fatal PE is occasionally
seen after lower limb
trauma, pelvic trauma; there
are case reports after
ankle fracture, knee
arthroscopy and even elbow
Risk in Orthopaedic Conditions replacement.
The risk in some procedures is now fairly

well known whereas in others knowledge is Chronic Venous and Pulmonary
sparse (Table 2). Sequelae
The frequency of chronic

venous insufficiency,
Fatal PE an important longer-term
outcome, is unknown.
It is likely to be rare
after asymptomatic
With modern surgical and anaesthetic thrombosis (the majority of
thrombosis after
techniques, but without prophylaxis, the death orthopaedic surgery) but
common after symp-
rate from PE after hip replacement or knee tomatic thrombosis. Chronic
pulmonary hyper-
replacement is probably around 0.2 %; perhaps tension is a potential
sequel for those who
slightly higher after hip fracture. With 1.2 million survive a symptomatic PE.
arthroplasties per year in Europe, that equates to Most studies refer to hip
and knee arthroplasty
2,400 deaths a huge problem. The death rate patients; there are far
fewer data on other ortho-
after other orthopaedic procedures is unknown, paedic procedures.
Thromboprophylaxis
367
Table 2 Risk of VTE derived from International Consensus Statement [8] and ACCP
Guidelines [5]
Procedure or condition Fatal PE Symptomatic VTE
Asymptomatic DVT
Hip fracture ?1 % 4%
60 %
Hip replacement 0.20.4 % 34 %
55 %
Knee replacement 0.2 % 34 %
47 % (CI 4251)
Isolated lower limb trauma ? 0.42 %
1035 %
Spinal surgery ? 6%
18 %
Knee arthroscopy ? 0.2 %?
8 % (CI 610)
Major trauma ? ?
58 %
Spinal cord injury ? 13 %
35 %
hyperaemia on tourniquet
deflation probably bal-
Prophylactic Measures ances the accumulation of
clotting factors whilst
the tourniquet is inflated.
General Measures
Early Mobilization Mechanical Methods

This is to be encouraged for most orthopaedic
patients, to enhance functional recovery but also These include graduated
stockings and
to reduce the risk of VTE for which there is good mechanically-driven
rhythmic compression devices.
physiological premise, although rather weak sci- They have no bleeding side
effects, which
entific evidence. appeals to the surgeons
obligation to balance
risk and benefit in the
peri-operative period.
Neuraxial Anaesthesia A recent meta-analysis
through the UK NHS
spinal or epidural anaesthesia reduce mortality Health Technology
Assessment process reviewed
and enhance peri-operative analgesia as well as 17 GCS trials, 22 IPC
trials and 3 ft Pump trials.
reducing the risk of VTE by about 50 % There are Of these, 14 trials were in
hip and knee surgery.
concerns that a spinal haematoma could develop The review concluded a 72 %
odds reduction for
when chemical prophylaxis and neuraxial anaes- mechanical methods alone
[11].
thesia are combined and so guidelines should be
followed [12]. Graduated Compression
Stockings
They must be well-fitted,
properly woven, and
Surgical Technique remain in place. Meta-
analysis of studies in sur-
Careless tissue handling potentiates thrombo- gical patients suggests
modest benefit with either
plastin release. If retractors are used too aggres- above-knee or below-knee
stockings.
sively or for too long in hip or knee surgery
then there may be venous occlusion, as there Intermittent Pneumatic
Compression
may be with prolonged torsion of the dislocated Devices
hip whilst reaming during hip replacement, or These can either compress
the calf or the foot,
aggressive dorsal retraction of the tibia during enhancing venous blood flow
and promoting
knee replacement. fibrinolysis. The peak
venous flow is variable
depending on design; in
general these devices
Tourniquet are effective. However they
can be expensive,
There is no evidence that tourniquets increase the compliance can be an issue
and they are imprac-
risk of VTE. The fibrinolytic and valve-flushing tical for extended duration
use.
368
D. Warwick
IVC Filters
These umbrellas are inserted into the inferior Box 1: Drawbacks of
Warfarin and Aspirin
vena cava percutaneously through the femoral Drawbacks of Warfarin
vein. They merely catch an embolus and pre- Needs regular
monitoring, which is
vents it reaching the lungs but do not prevent expensive and time
consuming;
thrombosis in the leg. There is a high complica- If started too close
to surgery or at too
tion rate to include death and so their use should high a dose, there
will be a risk of
be restricted to very specific conditions where bleeding;
anticoagulation is contra-indicated yet the If started
judiciously later and at
risk of embolism is high (for example a pelvic a lower dose there
will be an interval
fracture patient who has already developed of several days
during which the patient
a leg DVT yet needs a major surgical will be unprotected
at their most
reconstruction). thrombogenic phase;
Interaction with many
drugs and
alcohol.
Chemical Methods Not as effective as
LMWH
Warfarin and aspirin have drawbacks (Box 1). Drawbacks of Aspirin

Injections (LMWH, pentasaccharide) [13] are
effective but are likely to be superseded by the Only weak
antithrombotic effect so lim-
newly available and equally effective oral direct ited efficacy
thrombin inhibitors and Factor Xa inhibitors Weak evidence base
[3, 4]. They can be used for an extended duration. GI bleeding, wound
bleeding
They are fairly inexpensive relative to the overall Not recommended by
NICE, ACCP (but
cost of surgery. The problem with drugs is that is by AAOS)
they all carry a risk of bleeding if used too close to Not licensed for
Thromboprophylaxis in
surgery. UK
Low Molecular Weight Heparins

This type of drug requires no monitoring as it has by differences in the
proximity to surgery when
readily bio-availability and a wide safety margin. drug is given. It is not
easily reversed and must be
They have been closely studied for many years avoided in those with poor
renal function.
and are effective (about a 66 % risk reduction
compared with placebo). Care must be taken Direct Anti-Xa Inhibitors
and Direct
with renal impairment (for which patients Thrombin Inhibitors
unfractionated heparin may be safer or a lower These newer class of drug
will transform
dose should be used). Platelet count should be thromboprophylaxis. Two
are currently available:
measured in those having extended duration a direct thrombin
inhibitor (Dabigatran, Boehringer
use because of the small risk of idiopathic Ingelheim) and an anti-Xa
inhibitor (Rivaroxaban,
thrombocytopaenia. Bayer). Others are due to
follow. The efficacy
is at least as good as
LMWH. The drugs are
Pentasaccaccharide taken by mouth so can be
used for as long as
These is a synthetic but injectible drug which the risk of thrombosis
persists which can be for
precisely inhibit Factor Xa. It is excreted renally several weeks after joint
arthroplasty and those
rather than metabolized by the liver. As it immobilised by lower limb
trauma or surgery.
has a long half-life (15 h), it requires only a Monitoring is not required
because of a broad
once-daily injection. Differences between therapeutic and safety
margin. However the
Pentasaccharide and LMWH are partly explained drugs are difficult to
reverse.
Thromboprophylaxis
369
When to Start Chemical Prophylaxis a particularly high bleeding

risk, mechanical
methods are used for longer
and chemical
Chemical thromboprophylaxis can be started methods delayed.
before or after surgery, probably with equal effi- In some patients
(especially hip fractures)
cacy. However if a chemical is given too close to there is an unpredictable
delay to surgery; it
surgery then there will be bleeding. If given too may be safer to avoid
chemical methods until
long before surgery then the drug will have been after surgery but cover the
risk with mechanical
metabolized and there will be no prophylactic methods started as close to
the moment of trauma
effect; if given too long after surgery then throm- as possible. If there is
likely to be a prolonged
bosis, provoked by intra-operative factors such as delay then a chemical can be
started if there is no
thromboplastins and interruption to venous flow significant bleeding risk
from the injury but the
or endothelial damage, will have already com- surgery must be then delayed
until the bleeding
menced. The drug should be administered just in risk from the chemical
itself has decayed.
time to avoid bleeding yet remain effective.
Knee Arthroscopy, Plaster

Casts, Foot
When to Finish Prophylaxis Surgery
Prophylaxis should be given for an appropriate The risk benefit and cost-
benefit ratios of prophy-
duration of time. The risk may persist for several laxis in these situations
has not been clearly
weeks after some injuries or surgical procedures, established Meta-analysis of
imaging studies in
especially if there is prolonged immobility. Sev- plaster casts and knee
arthroscopy [1, 10] show
eral sources show that half of symptomatic VTE that LMWH reduces the
incidence of DVT but the
after knee replacement and two-thirds after hip clinical benefit is unclear;
there is insufficient evi-
replacement and hip fracture occur beyond the dence that
thromboprophylaxis will effectively
first week. Clinical trials have clearly proven that and safely prevent VTE.
Because of this insecure
extending the use of prophylaxis beyond hospital evidence, some European
surgeons may use pro-
discharge can reduce the risk of later symptomatic phylaxis universally and
others may not use it at
VTE by about two thirds. The precise period all. A careful risk
assessment with prophylaxis
depends on many factors, but current evidence targeted to those with extra
risk is probably the
suggests 14 days for knee replacement and safest and most cost
effective approach [7].
2835 days for hip surgery [2, 15]. In European There is a risk of
bleeding with the use of
healthcare systems, patients are discharged from LMWH especially as in the
day case setting the
hospital earlier and earlier; the new oral agents first dose may be given too
close to surgery.
facilitate effective and simple extended duration There are also pragmatic
issues about how to
prophylaxis. give out-of hospital
prophylaxis; there are no
epidemiological data or
prophylaxis trial data to
guide the duration of
prophylaxis. The new oral
Stacked and Combined Modalities agents, used off-label and
subject to further
trial data, would offer a
practical solution.
To avoid bleeding yet optimise thrombopro-
phylaxis, a mechanical method is used to cover
the peri-operative phase and then a drug is started
only when the bleeding risk has decayed in the Guidelines
individual patient. For those with particularly
high risk of thrombosis, both mechanical and There have been several
guidelines produced
chemical methods can be used simultaneously across Europe and in North
America, based
for as long as possible. For those with apon a meticulous synthesis
of the data and
370
D. Warwick
a judgment on the reliability and clinical applica-

bility of those data. The International Surgical a wide therapeutic and safety
margin, and
Thrombosis Forum has suggested how an ideal be predictable in nearly all
patients
guideline should be interpreted [14]. (elderly, renal impairment,
liver impair-
The most comprehensive guidelines include ment) without interaction and
be monitored
the NICE guidelines from the United Kingdom with simple coagulation tests
in critically
[7], the International Consensus Statement [8] ill patients. The ideal
mechanical method
and the American College of Chest Physicians should be comfortable, quiet
and cost-
[5]. However, many European countries have effective. The guideline
should not con-
their own guidelines (Box 3). The guidelines strain the surgeon or
anaesthetist into
accept that hip fracture, hip replacement and a practice which is not
available, practical,
knee replacement patients are all at high risk affordable or deliverable.
All methods
and need prophylaxis. It is also generally should have an acceptable
compliance
accepted that aspirin and Warfarin are not when handled by the patients
themselves
appropriate (Box 1); some recommend universal (eg self-administered
pharmaceuticals,
prophylaxis for knee arthroscopy, lower limb mechanical devices).
trauma and ankle/foot surgery whereas others
recommend individualised risk assessment. In
some countries or centres guidelines are
followed, in others individual surgeons use Box 3 European Guidelines
their own protocols. British Recommendations
NICE Clinical Guideline 92

Reducing the
Box 2 The Ideal Guideline: International risk of venous
thromboembolism (deep
Surgical Thrombosis Forum vein thrombosis and pulmonary
embolism)
Recommendation [14] in patients admitted to
hospital Available at
For those with a demonstrable risk of
http://www.nice.org.uk/guidance/index
thrombosis, thromboprophylaxis should Elective knee replacement:
TED
be started with an effective dose as close stockings, Foot Pumps or Calf
compressors
to the thrombogenic insult as possible, on admission, continued until
tolerated.
without introducing a greater or equal risk Start chemical prophylaxis
(LMWH,
of alternative complications, and continued Dabigatran, Rivaroxaban or
Fondaparinux)
until the risk of thrombosis has reduced to post-operatively and continue
1014 days.
a clinically negligible rate, with due con- Knee arthroscopy etc.:
Consider offer-
sideration of cost and practicality [14]. Sur- ing combined VTE prophylaxis
with
geons also should consider their own mechanical and
pharmacological methods
threshold of comfort between thrombosis to patients having
orthopaedic surgery
and bleeding based on their patients indi- (other than hip fracture, hip
replacement
vidual risk factors when deciding the safe or knee replacement) based on
an assess-
proximity to surgery for chemical methods ment of risks and after
discussion with the
i.e. before or after the trauma. Individual patient. Start mechanical VTE
prophylaxis
patients may have their own risk for throm- at admission. Choose any one
of the fol-
bosis and bleeding as well as duration of lowing based on individual
patient factors:
risk for each. Initiation and duration of - anti-embolism stockings
(thigh or knee
prophylaxis should therefore ideally be tai- length), used with caution-
foot impulse
lored. The ideal chemical agent should be devices,, intermittent
pneumatic compres-
both injectable and oral, reversible, have sion devices (thigh or knee
length).
(continued)
Thromboprophylaxis
371
Box 3 European Guidelines (continued) Begin in elective patients the

evening before
Continue mechanical VTE prophylaxis until surgery and continue until POP is
removed
the patient no longer has significantly or until partial WB of 20 kg with
an AROM
reduced mobility. Start pharmacological of 20# in the ankle joint is
reached
VTE prophylaxis 612 h after surgery. Total knee replacement, LMWH or
Choose one of: LMWH or UFH (for patients Fondaparinux (in case of former
adverse
with renal failure). Continue pharmacologi- effects of LMWH). In case of
contra-
cal VTE prophylaxis until the patient no indication for LMWH/Fondaparinux
inter-
longer has significantly reduced mobility. mittent pneumatic compression is
recommended. Elective cases: VTEP
can
Dutch Recommendations be started preop. with LMWH.
Duration 1114 days
www.cbo.nl
Arthroscopically assisted
surgery of
Elective knee replacement: For
longer operation time in knee,
VTEP
thromboprophylaxis during hospitalization
should be given until normal AROM
and
for knee arthroplasty fondaparinux,
WB of 20 kg is reached, at least
for 7 days.
LMWH or a vitamin K-antagonist (VKA)
Pharmacological VTEP with LMWH or
are recommended (grade 1A ACCP).
Fondaparinux. Begin in elective
patients
Acetylic salicylic acid is not recommended
preaop. when time to surgery is
sufficient.
as monotherapy (grade 1A ACCP). Graded
(no definitive time given)
compression stockings or foot pumps are
not recommended as monotherapy for
French Recommendations
thromboprophylaxis in elective knee
arthroplasty (grade 1B ACCP). Intermittent European Journal of
Anaesthesiology
pneumatic compression is an alternative 2006; Venous thromboembolism
preven-
to fondaparinux, LWMH or VKA for tion in surgery and obstetrics:
clinical prac-
thromboprophylaxis in knee arthroplasty tice guidelines 23: 95116.
during hospitalization (grade 1A ACCP)
Major Orthopaedic Surgery
German Recommendations
LMWHs are the standard
preventive
European Journal of Vascular Medicine treatment after hip replacement,
knee
2009; Prophylaxis of venous thromboem- replacement, and hip fracture
surgery
bolism Volume 38 S/76 1132 (Grade A). UFH (even
aPTTadjusted)
Total hip replacement, hip fractures : and VKAs should not be used as
firstline
Basic prophylaxis, LMWH or Fondaparinux prophylaxis after major
orthopaedic sur-
(in case of former adverse effects of gery of the lower limbs (Grade
A). Aspi-
LMWH) In case of contraindications against rin should not be considered as
LMWH/Fondaparinux intermittent pneu- a prophylactic measure for VTE
matic compression is recommended. Begin (Grade B).
prophylaxis in elective patients on the eve- The three first-line
prophylactic agents
ning before surgery (LMWH), begin with for hip and knee replacement
surgery
first dose Fondaparinux 6 h postop.. Con- are LMWHs, fondaparinux and
tinue for 2835 days. melagatran/ximelagatran (Grade
A).
Immobilisation in POP, operations on Because danaparoid and desirudin
foot and ankle: LMWH/Fondaparinux (in are less easy to use and because
case of former adverse effects of LMWH). danaparoid development is less
well
(continued)
372
D. Warwick
Box 3 European Guidelines (continued) target INR 2.03.0). Aspirin

and mechani-
advanced, they should be considered as cal methods not recommended.
second-line prophylactic measures Knee arthroscopy: Nom
prophylaxis rou-
(Grade A). tinely. If risk factors then
consider LMWH.
Mechanical methods should not be
prescribed alone as first-line treatment Norway
in the absence of comparisons provid-
No current guidelines
ing level 1 evidence (Grade A), but
they are a preferred choice when
Sweden
antithrombotics are contraindicated
because of the risk of bleeding (Grade The Swedish Health
Department
A). Properly fitted ECS are an effective (Socialstyrelsen) has
published a priority
adjuvant therapy to pharmacological document on VTE prophylaxis
2004,
prophylaxis because they have no inter- which recommends for Knee
Arthroplasty
actions (Grade B). and hip arthroplasty 710 days
of VTE
prophylaxis. There is no
preference regard-
Trauma Surgery ing LMWH, fondaparinux, oral
factor Xa
Multiple trauma: LMWHs are the refer- inhibitors or oral direct
thrombin inhibitors
ence prophylactic treatment (Grade A). in this document.
In the case of a marked risk of bleeding,
mechanical methods, in particular IPC
(if applicable), are a first-line prophylac- References
tic measure (Grade B).
Trauma of lower extremities: In view of 1. Camporese G, Bernardi E,
Prandoni P, Noventa F,
Verlato F, Simioni P, Ntita
K, Salmistraro G, Frangos
the moderate VTE risk, and duration of C, Rossi F, Cordova R, Franz
F, Zucchetta P,
immobilization and thus prophylaxis Kontothanassis D, Andreozzi
GM. Low-molecular-
(on average 45 days), LMWH prescrip- weight heparin versus
compression stockings for
tion should be adapted to patient-related thromboprophylaxis
after knee arthroscopy:
a randomized trial. Ann
Intern Med. 2008;149(2):7382.
risk factors (Grade D). LMWHs could 2. Eikelboom JW, Quinlan DJ,
Douketis JD. Extended
be prescribed more routinely for frac- duration prophylaxis against
venous thromboembolism
tures (Grade B). after total hip or knee
replacement: a meta-analysis of
the randomised trials.
Lancet. 2002;358:915.
3. Erikkson B, Kakkar AK, Turpie
AG, et al. Oral
Knee Arthroscopy rivaroxaban for the
prevention of symptomatic venous
thromboembolism after
elective hip and knee replace-
In view of the low risk associated with
ment. J Bone Joint Surg.
2009;91b:63644.
this type of surgery, LMWH prescrip- 4. Eriksson BI, Dahl OE,
Rosecher N, et al. Dabigatran
tion should not be routine but should be etexilate vs subcutaneous
enoxaparin for the preven-
considered only if the patients have one tion of venous
thromboembolism after total hip
replacement. Lancet.
2007;370:94956.
or more additional risk factors
5. Geerts WH, et al. Prevention
of venous thromboembo-
lism. The 8th ACCP Conference
on Antithrombotic and
Italian Recommendations
thrombolytic therapy. Chest.
2008;133:381S453S.
Published by LAZIOSANITA ` AGENZIA 6. Mismetti P, Laporte S,
Zufferrey P, et al. Prevention of
` venous thromboembolism in
orthopaedic surgery with
DI SANITA PUBBLICA vitamin K antagonists- a
meta-analysis. J Thromb
Knee and hip replacement: LMWH Haemost. 2004;2:105870.
12 h pre-op or 1224 h post op; or 7. NICE Clinical Guideline 46.
Venous thromboembo-
Fondaparinux or Warfarin (dose adjusted, lism: reducing the risk of
venous thromboembolism
(deep vein thrombosis and
pulmonary embolism) in
Thromboprophylaxis
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inpatients undergoing surgery. 2007 Available at as

thromboprophylaxis. Health Technol Assess
http://www.guidance.nice.org.uk/CG46 2005;9(49):194.
8. Nicolaides AN, et al. Prevention and treatment of 12. Rodgers A,
Walker N, Schug S. Reduction of post-
venous thromboembolism. International Consensus operative
mortality and morbidity with epidural or
Statement (guidelines according to scientific evi- spinal
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9. Pellegrini Jr VD, Sharrock NE, Paiement GD, Morris 13. Turpie AGG,
Bauer KA, Eriksson BI, Lassen MR.
R, Warwick DJ. Venous thromboembolic disease after Fondaparinux vs
Enoxaparin for the prevention of
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thromboembolism in major orthopaedic sur-
a regulated environment. AAOS Instr Course Lect. gery. Arch Int
Med. 2002;162:183340.
2008;57:63761. 14. Warwick D, Dahl
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10. Ramos J, Perrotta C, Badariotti G, Berenstein G. 2007
thromboprophylaxis: limitations of Current Guide-
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Friedman RJ, Agnelli G, Gil-Garay E,
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Insufficient duration of venous thromboembo-
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Surgical Amputations
John C. Angel
Contents
Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 381
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 381
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 376 Osteoarthritis . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 381
Arterial
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
376
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 376 Types of Amputation . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 381
Venous
Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
376 Circular Open Amputation . . . . . . . . . . . . . . . . . . . . . . . . . .
381
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 376 Amputation of the
Toes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Re-Plantation/Transposition of Limb or Digits . . . . .
377 Transmetatarsal Amputation . . . . . . . . . . . . . . . . . . . . . . . .
383
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 377 Symes Amputation (Disarticulation at
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 377 the Ankle) . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 385
Transtibial Amputation (Below-Knee) . . . . . . . . . . . . . .

389
Pre-Operative Preparation . . . . . . . . . . . . . . . . . . . . . . . .
377 Disarticulation at the Knee . . . . . . . . . . . . . . . . . . . . . . . . .
. 392
Choice of Amputation Level . . . . . . . . . . . . . . . . . . . . . . . .
377 Gritti-Stokes
Amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . .
394
Second
Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
377 Transfemoral (Above Knee) Amputation . . . . . . . . . . .
397
Elasticity of Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 378 Disarticulation at the Hip . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 399
Marking the Limb or Digit . . . . . . . . . . . . . . . . . . . . . . . . . .
378 Upper Limb Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . .
401
Prophylactic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
378
Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 378 References . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 403
Surgical Technique-Handling of Tissues . . . . . . . . .
378
In
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 378
Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 378
Subcutaneous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
378
Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 379
Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 379
Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 379
Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 379
Skin
Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 379
Post-Operative Problems . . . . . . . . . . . . . . . . . . . . . . . . . .
379
Early
Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 379
Phantom
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 380
Neuromata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 380
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 380
Growing Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 380
Falls After Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
381
J.C. Angel
Royal National Orthopaedic Hospital, London, UK
e-mail: jc.angel@mac.com

375
DOI 10.1007/978-3-642-34746-7_191, # EFORT 2014
376
J.C. Angel
Diabetes
Keywords
Boyds amputation # Circular open amputation When gangrene appears in
diabetes the
# Complications # Disarticulation of hip #
situation is different.
Then, it is often due to
Disarticulation of knee # trans-femoral a combination of both a
proximal obstruction
(above-knee) amputation # trans-humeral and distal, involving the
small arteries and the
(above-elbow) amputation # trans-radial arterioles. Where the
distal involvement is patchy
(below-elbow) amputation # trans-tibial and the proximal relatively
mild, the gangrene
(below-knee) amputation # Gritti-Stokes represents a small mass of
disordered tissue with
amputation # Indications # Pre-operative well-perfused structures
close by. This allows a
preparation # Surgical technique-principles # brisk line of demarcation
to form and, depending
Surgical amputations # Symes amputation # on its location, it may
permit local amputation
Toe amputation with a reasonable chance of
success.
Peripheral neuropathy
is one of the commonest
complications of diabetes.
The motor paralysis
Indications leads to broadening of the
forefoot and clawing
of the toes producing an
abnormal pressure
Amputation is one of the oldest surgical proce- distribution on weight-
bearing. The autonomic
dures. Today, in a developed country in peace- involvement can lead to
cracked, dry, vulnerable
time, the amputation rate is approximately 1 in skin and the sensory
impairment allows tissue
10,000 of the population. In England and Wales damage to occur without the
patient being aware
(population 54,000,000), some 5,500 new ampu- of it. The sensory loss can
also manifest itself as a
tees are referred for prosthetic fitting annually. Charcot arthropathy, which
also adds to the defor-
The reasons for these amputations are as follows mity. All these factors
make the patient with dia-
(figures are approximate): betes vulnerable to skin
breakdown and infection.
In the earlier stages,
these problems can be
Arterial disease and diabetes 80 %
Trauma 10 %
successfully managed with
podiatric care,
Tumours 5% attention to footwear and
conservative surgery
Congenital deformity, infection, neurological 5% to remove dead bone, tendon
or fascia. Later,
the only solution may be an
amputation.
In developing countries, the figures for trauma
and vascular disease tend to be reversed, as there
are relatively few old people and more accidents. Venous Insufficiency
Venous insufficiency
associated with ulceration
Arterial Disease can sometimes be so
persistent as to warrant
a transtibial amputation.
Occasionally, venous
Arterial disease that is not associated with diabetes obstruction due to common
iliac vein thrombosis
(arteriosclerosis) tends to obstruct the proximal is also a reason.
part of the vascular tree. This means that many
amputations can be avoided using arterial proce-
dures at the level of the femoral artery or proximal Trauma
to it. If this approach has been exhausted, gan-
grene, by the time it appears, is usually part of Where there has been a
complete or partial limb
a large iceberg of disordered tissue that precludes avulsion and the
circumstances are unsuitable for
local amputation (for example, within the foot) implantation then the
decision to amputate is
and it is necessary to consider a higher amputation straightforward. An equally
common scenario
(here, transtibial). finds the surgical team and
the patient embarking
377
on a long and difficult programme of reconstruc- physical cause for it. When
it cannot be explained
tion. If the results are disappointing, the then amputation is often
disappointing.
decision to amputate after so much investment Rarely, patients seek
amputation for no other
of time and money can often be a very difficult reason than they want to be
amputees and wish to
one. In an effort to avoid this situation, a number exchange a perfectly good
limb for an amputation
of scoring systems have been devised to indicate stump. Such people may
consult large numbers of
which cases should be reconstructed and which surgeons in the hope of
finding one that will
would be more appropriately treated by amputa- acquiesce with their wish.
tion [1, 2]. Unfortunately, none of these has
received widespread acclaim.
Re-Plantation/Transposition of Limb Choice of Amputation Level

or Digits
Transtibial and transfemoral
amputations are the
Patients who have suffered a traumatic amputa- levels most commonly
performed and the ones
tion are sometimes brought to hospital accompa- with most reliable results.
Other levels can give
nied by the amputated limb segment or digit. better results in the right
circumstances but they
Successful re-plantation or transposition of can cause problems and so
need careful consid-
limbs or digits is now commonplace. The rate of eration. For example,
disarticulations are bulky
survival after re-plantation of amputated parts and may interfere with the
cosmesis and the
was reported as 72 % in children when the ampu- mechanics of the artificial
limb. However, they
tation was the result of a laceration rather than an are robust and may suit
young active people for
avulsion or crushing injury [3]. Excellent results whom function is a priority.
The Chopart ampu-
of re-planting the big toe [4] and fingers amputation through the mid-foot
may have great
tated distal to the proximal interphalangeal joint appeal to the patient and
the family, but it is
[5] have been reported. prone to equinovarus
contracture which, if it
Amputated limbs being considered for occurs, can be a great
problem to the patient, the
re-plantation should be handled in sterile condi- family and the unfortunate
prosthetist.
tions, photographed and x-rayed and wrapped in Before embarking on an
unfamiliar level, the
saline-soaked gauze before being immersed in surgeon should consider
consulting with the
iced water. If possible the limb should be prosthetic team.
perfused with a tissue perfusion fluid [6]. Clinical methods often
provide good clues as
to the appropriate selection
of amputation level.
Skin that that looks non-
viable, is pale and
Infection blue, or which displays a
palpable temperature
gradient should not be
included in the amputation
Amputation is still occasionally required for gas stump. A number of
investigations have
gangrene, actinomycosis and leprosy. In recent been shown to provide useful
information in
years, it has been increasingly required to deal determining amputation
level. For example,
with disseminated intravascular clotting associ- tissue oxygen saturation
[7], and radio-isotope
ated with meningococcal infection. washout [8].
Pain Second Opinion
It is reasonable to offer a patient an amputation Amputation can cause grief

and guilt within
for chronic, intractable pain if there is an obvious families and, in time, doubt
about the wisdom of
378
J.C. Angel
the original decision may arise. The surgeon epidural or regional

anaesthesia can be used.
may wish to bolster his or her position by The anaesthetized field
needs to include the site
seeking a second opinion before performing the of the tourniquet if one is
used.
operation.
Surgical Technique-Handling
Elasticity of Tissues of Tissues
The soft tissues are far more elastic in youth than In General
they are in old age. This is particularly apparent
in amputation surgery and much longer skin flaps Amputation wounds tend to be
large and are
are required in young people than they are in the frequently contaminated. Be
gentle! Do not
elderly. open up tissue planes
unnecessarily! Leave no
tissue with a compromised
blood supply! Keep
to a minimum the amount of
ligature and suture
Marking the Limb or Digit material left behind in the
wound!
The surgeon should personally mark the limb

with an arrow and the name of the amputation Incision
level. If individual digits are to be amputated they
should each be marked together with circumfer- Most amputations have two
flaps. The location of
ential line indicating the amputation level and the the cusps that mark the base
of each flap is impor-
number or name of the digit. tant and partly determines
the shape of the stump.
They need to be at the level
of bone section or
proximal to it, the distance
depending on how
Prophylactic Antibiotics much soft tissue needs be
removed to avoid
a bulbous shape in the
residual limb. Where the
All amputations through muscle should be cov- flaps are unequal, the
shorter flap should have the
ered by an antibiotic effective against Clostidium broader base to reduce the
mismatch between
welchii. This should be started 2 h before the edges when they come to be
sutured. The longer
operation and continued for 3 days. Penicillin flap should have a robust
blood supply, as in the
500,000 units twice daily is suitable. Other organ- calf or the plantar aspect
of a digit. The ends of
isms grown from contaminated areas distal to the flaps should always be
rounded, rather than
proposed amputation require additional antibiotic tongue-shaped.
cover. Amputation wounds are unique in the way As the knife is applied
to the skin, an amputa-
in which they can be contaminated from within as tion wound distorts in a
disorientating manor and
soon as the lymphatic channels passing through it is important that the
incision is always marked
them are severed. in ink beforehand. To ensure
that the skin edges
can be everted at closure
they must be cut
perpendicular to the skin
surface.
Anaesthesia
Patients with vascular disease or diabetes often Subcutaneous Tissue

present with complex medical problems that pre-
sent considerable challenges for the anesthetist The rest of the subcutaneous
tissue is cut with
and these may need thorough pre-operative a raked incision that moves
proximally as it goes
investigation. If the patients general condition deeper. This is especially
important when this
is not suitable for general anaesthesia, spinal, layer is in excess.
379
Muscle Skin Closure
The same remarks apply to the muscle. A raking Amputation wounds are
generally long and sta-
cut is the best way to avoid a bulbous stump in the ples have the advantages of
being quick and
early post-operative stages and redundant tissue everting the skin edges well.
They should be left
in the mature stump. for at least 2 weeks and up
to 3 in dysvascular
cases. Stitch or staple marks
are rarely to be found
in amputation stumps by the
time they have
Bone matured. Split skin grafting
may be necessary as
a temporary measure to obtain
closure. The skin
The periosteum is sectioned cleanly to avoid the should be taken from the
amputated part or
later formation of a bony spur. Cancellous another limb, not from the
residual limb where
bone can be cut safely with a powered saw. the donor area could rub
against the socket of the
Where it is important that the cut should be artificial limb.
accurately aligned, for example perpendicular to
the long axis of the limb, a tenon saw is some-
times preferable. Cortical bone is easily Post-Operative Problems
damaged by being overheated with a power saw
and saline cooling is important. It is also useful Early Stages
to check frequently that the teeth of the saw are
not jammed with bone dust. The soft tissues need In the early stages after an
amputation, it is
to be protected from bone debris with damp necessary to minimize the
accumulation of
swabs. A Gigli saw is often a convenient oedema fluid in the area of
the wound. The
instrument for dealing with cortical bone, inflammatory process causes a
build-up of
especially the tibia, where the main cut and the protein-rich interstitial
fluid, which overloads
bevel can be fashioned in the same action. the lymphatic channels, the
function of which is
Cortical bone is then smoothed with a mallet entirely dependent on the
activity of the muscles
and chisel and finished off with a rasp, used surrounding them. Until those
muscles have
transversely, making sure that the soft tissues gained re-attachment, the
protein lingers, draw-
are not accidentally dragged over the end of ing more fluid out of the
capillaries by osmosis.
the bone. Compression bandaging is
used to apply
a gradient of pressure,
decreasing proximally.
The laws of mechanics cause
the bandage to
Nerves tend to work its way distally
and it must be
suspended by a U slab of
adhesive tape
Nerves are carefully dissected from their (Mefix). After the first
week, elasticated stump
neurovascular bundles, pulled down gently and socks (Juzo) are a more
convenient way of apply-
cut high with scissors so that they retract into ing a pressure gradient.
Where the facilities are
their soft fatty tunnels. available, temporary
prostheses can be used after
710 days and this activity
is a further stimulus to
lymphatic flow.
Arteries Flexion contractures are
prone to develop in
the first week, sometimes as
a flexor response to
The major vessels should be individually double post-operative pain. These
are treated with
ligated with material that knots well. The more physiotherapy, stump
supports, prone lying,
distal vessels below the knee can be taken stretching and serial
casting.
as a bundle with a transfixion ligature using If the residual limb
remains painful and fails to
20 Vicryl. reduce in size after the
first few post-operative
380
J.C. Angel
days, suspect a haematoma, a fluid collection or neuromata to form and the

troublesome symp-
an abscess. Aspiration or surgical drainage may toms to develop. Neuromata
that adhere to scar
be needed as determined by an ultrasound tissue can be very tender
and, in my experience,
examination. the worst are those
adhering to periosteum. Most
can be treated by re-
sectioning the nerve under
tension, away from scar
tissue, or by burying the
Phantom Pain cut end inside the bone,
away from mechanical
interference.
Most adult amputees have an intermittent aware-
ness of the part of the limb that has been ampu-
tated (phantom sensation). Quite often, this is Infection
associated with an unpleasant sensation, such as
cramp or pain (phantom pain). It rarely comes on Post-amputation infection
commonly has an
before the end of the first week after amputation. insidious onset and becomes
apparent in the
For some 35 % of patients, this problem second or third week as a
discharge of thin pus
becomes a nightmare. The phenomenon is more and failure of part of the
wound to heal. It precludes
common with proximal amputations and is hardly the wearing of a
prosthesis. By 46 weeks a sinus
ever seen in children. It is not affected by epidural has usually formed. If this
is explored with
anaesthesia or cutting the nerve proximally, indi- a metal probe it commonly
leads down to the
cating its central origin. It is said to be more cut end of the bone which
has a stony feel when
common if there has been severe, prolonged tapped with a metal probe.
Part of the bone
pre-operative pain. becomes a sequestrum and no
longer has
Phantom pain is often provoked by other a covering of soft
periosteum. Hence, the
activities such as micturition or sexual inter- characteristic stony feel
or sound. Occasionally
course. Often it is brought on by a pain coming the source of the infection
is a thick non-absorbable
from another part of the body altogether, the braided ligature.
episodes receding as the other painful condition With an infected
amputation there is normally
heals. Phantom pain coming on some years after a brisk demineralisation
close to the bone end
amputation is uncommon and the clinician should with an associated increase
in blood supply. If
consider proximal involvement of the nerves, one waits 3 months from the
time of the amputa-
such as a prolapsed intervertebral disc or nerve tion it is possible to
revise the distal end of the
compression. stump using a wedge
resection. By then the cut
Attempts to reduce the sensory input for 2 or 3 end of the bone is soft and
vascular and capable of
days before the amputation, for example with resisting infection. The
wedge consists of an
epidural anaesthesia, were designed to reduce ellipse, which takes the
sinus margins and the
the pre-operative pain imprint on the cerebral sequestrum at the distal
end of the bone and the
cortex. Many methods of treatment have been wound can be closed either
immediately or by
devised for dealing with this disturbing condi- delayed primary closure
[10].
tion, none with regular success, unfortunately [9].
Growing Bones
Neuromata
In children, certain bones
have a tendency to
Neuromata form on the cut ends of all the nerves grow disproportionately
causing them to become
involved in an amputation. Most of them cause no prominent at the end of the
stump. This applies
trouble, being free to move in the soft fatty tun- particularly to the humerus
and the tibia and it
nels that envelop them. It usually takes until occurs through a process of
accretion at the distal
6 months after the amputation for these end of the bone rather than
bone growth at the
381
proximal epiphysis. A child having a diaphyseal showed that the need for hip
replacement was
amputation at the age of 1 year can expect to have doubled from that of the
general population of
three revisions before reaching maturity. If the the same age.
medullary canal is capped, using a primary autog-
enous epiphyseal transplant taken from the ampu-
tated limb, the problem can be prevented [11]. Types of Amputation
Circular Open Amputation

Falls After Amputations
Severe crushing injuries or
grossly contaminated
A significant number of patients fall and dam- wounds may be best treated by
an open circular
age their stump in the early stages after their amputation, especially if
there has been a delay in
amputation. This may occur during the day as treatment. In a part of the
limb where every
a result of the patient learning to walk, or at centimetre of bone should be
conserved, just
night when getting out of bed and forgetting proximal to a site of
election, for example, it
that the foot is no longer there. One study [12] might be wiser to fashion
simple, short flaps,
concluded that 18 % of amputees are likely to using whatever skin is
available. The intention
fall and injure themselves during their in- is to provide good drainage
locally and gain some
patient rehabilitation. Patients and carers need time while the patients
general condition
to be warned of this danger. improves. Later, a definitive
amputation is
performed. If the surgeon has
been able to
fashion skin flaps then it may
well be possible
Fatigue to close the wound by delayed
primary closure.
A circumferential skin
incision is made 2 cm
Amputees tire easily and it has been shown that distal to the level of bone
section. A slightly
they use extra energy to walk any given distance raked cut is then made through
the musculature,
compared to people with intact limbs. The higher meeting the bone at the
planned level of section.
the amputation, the greater the energy require- After dividing the bone, the
vessels are ligated
ment [13]. and the nerves are cut high
under slight tension.
The wound is then dressed
with fluffed gauze
soaked in aqueous proflavine
emulsion (Fig. 1).
Fractures The skin is then placed under
tension with
The body adjusts the strength of the bones to

match the mechanical requirements of everyday
use. The bones of the residual limb are subjected
to much reduced strain and so their mineral con-
tent diminishes [14]. This is not a problem when
walking in an artificial limb but it leaves the
bones vulnerable in the event of a fall and frac-
tures in the residual limb are common.
Osteoarthritis
Fig. 1 Circular open
amputation with skin flaps retracted,
Long-term follow up studies of amputees have dressing about to be applied
(With permission of Bohne,
shown an increased incidence of osteoarthritis in Walther HO: Atlas of
Amputation Surgery. Thieme
the contralateral hip and knee [15]. One study Medical Publishers, Inc., New
York, 1987)
382
J.C. Angel
Fig. 2 Circular open amputation with skin traction

applied to skin flaps (With permission of Bohne, Walther
HO: Atlas of Amputation Surgery. Thieme Medical
Publishers, Inc., New York, 1987)
stockinette stuck to the skin with a plastic wound

dressing. An appropriately placed knot can be
used to hold the dressing in place. Some traction
cord and a weight of 500G will prevent the skin
edges from retracting (Fig. 2).
Amputation of the Toes
Diabetes accounts for the majority of toe ampu-

tations, either through gangrene or deep infection
[16]. Other indications are trauma, deformity and
tumour.
Even the lesser toes cannot be removed without
consequences. Amputation of the second toe com- Fig. 3 Racquet incisions
required for toe amputations
monly leads to the development of a hallux valgus
deformity, despite efforts to fill the gap with a toe
spacer. Removal of the fifth toe leaves the head of loss tends to overload
the neighbouring metatar-
the fifth metatarsal exposed to pressure from the sal heads significantly
[17].
lateral side of the foot, sometimes with the forma- The toes are
amputated through a racquet inci-
tion of a tender bursa. Amputation of a lesser toe sion. This must clear
the webs sufficiently to allow
through or just proximal to the proximal lateral flaps to fall
naturally together (Fig. 3).
interphalangeal joint detaches both long flexor The flaps are taken
down to bone and dissected
tendons, creates a muscular imbalance. This off the phalanx,
maintaining the deep transverse
often results in elevation of the remaining proxi- intermetatarsal ligament
(Fig. 4).
mal phalanx. The ensuing pressure problems Haemostasis is
secured and, if possible, the
against the toe box of the shoe can cause pain somewhat elusive digital
nerves are sought and
and even ulceration. divided under slight
tension. The racquet inci-
Ray resection is sometimes necessary for vas- sions used on the hallux
and little toes are skewed
cular disease when the gangrene extends to the slightly to cause the
suture line to lie close to the
root of a toe. Commonly these amputations fail adjacent toe where it is
less likely to encounter
unless they are backed up by reconstructive arte- pressure from footwear
(Figs. 58).
rial surgery. Even if they do heal load is trans- More distal
amputations are performed with
ferred to the neighbouring metatarsal heads with a long plantar flap. A
bulbous appearance to the
the formation of painful callosities or ulceration. residual toe is avoided
by keeping the long flap
Because of the way the tendons are inserted in relatively narrow and
providing the short dorsal
the big toe, it can be amputated at any level flap with a wide base,
about three fifths of the
without risk of muscle imbalance. However, its circumference of the
toe.
383
Fig. 4 Amputation of the middle toe
Fig. 6 Skin closure

following amputation of the little toe
The procedure is best

carried out under thigh
tourniquet. A sandbag
under the ipsilateral
buttock is used to control
the position of the
foot and the operator sits
at the end of the table.
The proposed level of
bone section is marked
on the dorsum of the foot.
It should be a gentle
curve proximal to that of
the natural metatarsal
Fig. 5 Amputation of middle toe prior to skin closure heads, the level depending
on the extent of the
pathology. Two points are
then marked on the
Transmetatarsal Amputation medial and lateral sides
of the foot at the level at
which the first and fifth
metatarsal bones are to be
A transmetatarsal amputation is indicated in exten- resected. They are located
nearer to the plantar
sive forefoot trauma and in vascular disease where side of the foot, roughly
corresponding to the
it has been possible to restore the circulation to the inferior borders of the
two bones (Fig. 9).
area. It must be used with caution in diabetic A short dorsal flap,
some 2 cm long at its
patients complicated by neuropathy or nephropa- mid-point, is marked and a
long plantar flap which
thy, especially if the blood glucose is poorly con- needs to be longer towards
the medial side than the
trolled, as indicated by a glycosylated haemoglobin lateral to provide cover
for the greater thickness of
(HbA1c) level over 8 % (64 mmol/mol) [18]. the bone and soft tissues
on this side (Fig. 10).
With frostbite ample time should be allowed for With the more distal
transmetatarsal amputations
demarcation to appear. this will extend down to
the root of the toes.
384
J.C. Angel
Fig. 8 Skin closure

following amputation of the hallux
Fig. 7 Skin closure following amputation of the middle

toe
The plantar incision is carried down to bone and

the flap is raised back to the level of bone section.
The dorsal incision is also taken down to bone and
a small dorsal flap is raised. The level of section of
each bone is marked with diathermy and the bones
are divided with either a Gigli saw or a well-cooled
oscillating saw. The fifth metatarsal bone is
bevelled laterally. The tendons are then grasped,
pulled down and cut high. The remaining soft
tissues are trimmed to allow the flaps to fall
comfortably together. The metatarsal arteries and
other vessels are ligated and the tourniquet is
released. The plantar digital nerves are sought
and cut high under slight tension (Fig. 11).
The plantar fascia is sutured to the dorsal fascia
of the foot and the skin is stapled. The wound is
dressed with gauze and wool and lightly bandaged
(Fig. 12). The foot is elevated for the first few Fig. 9 Skin incision
required for transmetatarsal
days. After 48 h the patient is allowed up in amputation
385
Fig. 10 Dissection of dorsal flap of transmetatarsal

amputation
Fig. 11 Transmetatarsal
amputation: preparation of
plantar flap and bone
section
a below knee cast which maintains the ankle and
subtalar joints in a neutral position. hemimelia [21] and gross
leg-length discrepancy.
The staples are removed at 23 weeks. It is contra-indicated where
the heel pad is not
The most effective orthosis consists of a rigid intact. For cosmetic reasons
it may not be
rocker-soled shoe fitted with a total contact suitable for women.
Peripheral neuropathy is
insert and arch support and toe filler. In time, it not a contra-indication, and
a patient with
may be possible to dispense with all but the a totally anaesthetic stump
can function success-
toe filler. fully with prosthesis for
many years.
The operation is
performed with the patient
supine and a pneumatic
tourniquet is applied to
Symes Amputation (Disarticulation the thigh. The lower part of
the leg is supported
at the Ankle) on a support to allow the
ankle to be moved freely
and the surgeon seats
himself at the end of
The Symes amputation is indicated for major the table.
foot trauma, diabetes [19, 20], vascular disease The tips of the malleoli
mark the two cusps of
where there is residual gangrene following the incision. The edge of
the anterior flap takes
a vascular reconstruction, foot deformities that the shortest distance across
the front of the ankle,
are not amenable to correction, fibular and tibial passing directly over the
joint line. The plantar
386
J.C. Angel
Fig. 13 Skin incision for

Syme amputation
Fig. 12 Transmetatarsal amputation: wound closure
part of the incision is formed by two

lines dropping perpendicularly to the sole,
which are then joined together by a slightly
oblique line passing across the sole of the
foot. The plantar incision is taken down to bone
using a slightly raked cut (Fig. 13).
Anteriorly the incision passes through the skin
and subcutaneous fat and the extensor retinacu-
lum is divided transversely. This allows each of
the extensor tendons to be grasped in a forceps,
pulled down and divided as high as possible.
The distal stumps of the tendons are then put
under tension and cut distally as far as possible
to stop them getting in the way of the next part
of the dissection. The ankle joint capsule is
then divided transversely and the medial
and lateral ligaments are each sectioned (Fig. 14).
At this point attention is turned to the posterior
Fig. 14 Preparation of
anterior flap for Syme amputation
flap and a sub-periosteal dissection of the
calcaneum is commenced and continued posteri-
orly as far as it comfortably can be (Fig. 15). The dissection then
proceeds further posteriorly
Returning to the dorsal part of the incision the until the dorsal, medial
and lateral sides of the
posterior capsule of the ankle is divided exposing calcaneum are cleared of
soft tissue.
the dorsal surface of the calcaneum. A large, When the retrocalcaneal
bursa is entered the
sharp bone hook is then driven into the dome of bone hook can be
transferred into the back of the
the talus allowing it to be drawn forcibly forward. calcaneum and, once again,
traction is applied.
387
Fig. 15 Dissection of posterior flap for Syme amputation
Fig. 16 Bone section in

Syme amputation
Working down the back of the calcaneum the The medial and
lateral plantar neurovascular
Achilles is detached at its insertion. It should be bundles will be found
towards the medial side of
borne in mind that the skin of the back of the heel the posterior flap. The
arteries are ligated and the
is only millimeters away. At this point, it may be nerves divided under
slight tension. The anterior
necessary to return to the plantar part of the tibial neurovascular
bundle is treated in the same
incision before the calcaneum is finally released. way. The cut edges of
the bone are smoothed with
During this whole process it is essential to stay a rasp. The flexor and
peroneal tendons are pulled
close to bone to preserve the integrity of the fatty down and cut as high as
possible and loose pedi-
lobules that cushion the bone and providing com- cles of fibrous tissue.
The remains of the extensor
fortable walking later. digitorum brevis muscle
are preserved in order to
After removing the foot, the flaps are detached help fill some of the
dead space in the heel pad
from the periosteum up to the level of the tibial with living tissue. A
suction drain is passed up
plafond. The cut ends of the peroneal, flexor behind the inferior
tibiofibular joint and brought
hallucis and tibialis posterior and digitorum out on the lateral
aspect of the leg. The tourniquet
longus tendons are grasped with forceps and is released and
haemostasis is secured (Fig. 18).
used to retract the soft tissues proximally, expos- The plantar fascia
is sutured to the extensor
ing the malleoli and distal tibia. A single cut with retinaculum, making sure
that the heel pad is
a tenon saw is used to detach the malleoli together located centrally under
the cut surface of the
with a sliver of the interconnecting bone bone. The wound edges
are stapled. This must
(Fig. 16). The plane and level of this cut are be done accurately,
despite the difference in
very important. It must be perpendicular to the thickness of the two
flaps. The wound is dressed
long axis of the tibia as viewed in both the coronal with gauze and wool and
a rigid dressing of
and saggital planes. The specimen should appear plaster-of-Paris is
applied and moulded to hold
translucent when it is held up to the light. That the heel pad squarely
under the cut end of the
indicates that the cut is through the maximum tibia. The cast extends
to just below the
cross-sectional area of the tibia [22] (Fig. 17). tibial tubercle.
388
J.C. Angel
Fig. 18 Syme amputation

following skin closure
designed to carry full

body weight. It is therefore
very robust. It has
been shown to be superior to
Symes amputation when
dealing with longitudinal
deficiency of the
fibula [23] and is the better choice
Fig. 17 Syme amputation final preparation prior to skin for the completely
anaesthetic foot. It depends on
closure the success of a major
arthrodesis, so it should not
be used in the presence
of heavy contamination. It
Post-operatively the drain is removed after produces a longer stump
than the Syme and there-
48 h and at 5 days the cast is changed to allow fore is best used where
there is already shortening to
inspection of the wound. It is changed again avoid the need for a
raise on the contralateral shoe.
during the third post-operative week and at this Although it is
necessary to fashion the flaps
stage progressive weight-bearing can be com- longer than those for
the Syme, the first part of the
menced. The definitive prosthesis consists of dissection proceeds
similarly with an opening up of
a soft inner liner which is split to allow it to be the ankle and a
dissection of the soft tissues off the
pulled over the bulbous end of the stump. Its outer talus and the upper
part of the calcaneum (Fig. 19).
surface forms part of an inverted cone, which A disarticulation
freeing most of the foot
allows it to be pushed down into the rigid socket is performed through
the subtalar and
which is bolted to an artificial foot. This has to calcaneocuboid joints
and then the upper part of
have a low profile to avoid making the prosthetic the calcaneum is
removed together with a 2 cm
limb too long, which would necessitate an slice from the front of
the bone (Fig. 20).
embarrassing heel raise on the normal side. The distal tibia
and fibula are prepared, just as
in the Syme, and the
lower part of the calcaneum
Boyd Amputation is fixed to the tibia
with a wire mattress suture,
The Boyd amputation, similar to the Syme, pre- a screw or, if the bone
is very soft, an external
serves the plantar part of the calcaneum with its fixator. The post-
operative treatment is also
intact heel pad, a part of the body that is naturally similar to that for the
Syme (Fig. 21).
389
confusing when
translated into other languages
(ISO 8548-2:1993).
The most commonly
used technique
employs a long
posterior myocutaneous flap,
making use of the
better-perfused skin of the
back of the calf [24].
This method also gives
comfortable access to
the wound and minimises
the unnecessary opening
up of tissue planes.
Skew flaps have been
recommended on the
basis of thermographic
evidence of the optimal
blood supply. Equal
flaps, either saggital or
Fig. 19 Skin incision for Boyd amputation (With permis-
coronal, have also been
used and even a long
sion of Bohne, Walther HO: Atlas of Amputation Surgery.
Thieme Medical Publishers, Inc., New York, 1987) anterior flap. This
variety of design indicates
the range of options
available when dealing
with scarring or other
pathology close to the
site of amputation
[25].
The operation is
performed with the patient
supine. The use of a
tourniquet is helpful when
the arterial supply is
not a problem. The tradi-
tional site of
election is 15 cm below the joint
line or, as it is a
matter of proportion, the residual
tibia should measure
1/12 of the patients height.
Fig. 20 Diagram showing lateral and posterior views of This is marked on the
front of the shin. Two
the calcaneum and the planes of the saw cuts required for points on either side
of the limb indicate the
Boyd amputation bases of the flaps.
These are located 1 cm proxi-
mal to the level of
bone section and are arranged
so that the base of the
posterior flap is two-fifths
of the limb
circumference and the base of the
anterior flap three-
fifths. From these two points
the short, rounded
anterior flap extends 2 cm
distal to the level of
bone section and the lateral
sides of the posterior
flap are drawn in such a way
that, when the flap is
later laid flat on the operat-
ing table, the two
sides are parallel. That is to say,
the marking lines pass
slightly forwards as well as
distally. The distal
end of the flap need not be
marked since the flap
will be cut overlong,
initially (Fig. 22).
Where there is
insufficient tissue to fashion
Fig. 21 Diagram showing lateral view of completed a stump at the site of
election the following
Boyd amputation approach may be
helpful. A residual tibia of
1015 cm provides a
serviceable stump. The
minimum stump length is
7.5 cm.
Transtibial Amputation (Below-Knee) Where it is
practicable, a longer length than
15 cm gives a better
lever arm but the prosthetist
The precise term transtibial is preferred to may then struggle to
conceal the end of the stump
the widely used below-knee, which can really within the shape of the
artificial shank, especially
mean any level below the knee joint and is if there any alignment
difficulties or a knee
390
J.C. Angel
Fig. 22 Diagram showing

lateral view of transtibial
amputation indicating skin
incision and level of bone
section
Fig. 23 Transtibial
amputation prior to section of tibia
limb has been removed and

the soft tissues can
more easily be retracted.
The tibia is divided with
a Gigli saw, which is
less likely to cause thermal
damage than a power saw
and it can also be used to
bevel the front of the
bone in one action.
At this point a sharp
hook is inserted into the
medullary cavity of the
distal part of the tibia,
contracture. Where cosmesis is not a priority, an traction is applied and
the bone is pulled slightly
extra 23 cm in length can be beneficial. forwards to allow the
amputation knife to be
A bulbous calf may require later de-bulking of inserted over the back of
the fibula. The blade is
the muscle proximal to the level of bone section, then turned parallel with
the back of the bone and
using a proximal extension of the skin incision, it should be found that
the knife fits into the two
rather in the manner of a dart used in tailoring. incisions forming the
lateral sides of the posterior
An anterior flap consisting of skin and subcuta- flap. The knife is then
worked down the back of
neous tissue is raised up to the level of bone section. the fibula progressively
drawing the bone forward
The sides of the long posterior flap are cut straight away from the muscle
flap. When the knife
down to and including the deep fascia. reaches two-thirds of the
way down the back of
It is advisable to mark the level of bone section the calf it is withdrawn
and used to fashion the
directly on the subcutaneous surface of the tibia distal end of the
overlong posterior flap, using
using the ruler and diathermy since the original a transverse incision
from the back of the calf.
indicator on the skin may well have moved prox- This frees the amputation
specimen (Fig. 24).
imally (Fig. 23). The periosteum and the deep The bevelled distal
end of the tibia is
fascia of the anterior compartment is then cut at smoothed with a bone
rasp. The fibula is cut
the same level as bone section and, if a tourniquet with a powered saw in a
plane that passes from
is not being used, the neurovascular bundle of the posterolateral to
anteromedial at an angle of
anterior compartment is identified and the vessels about 45# to the long
axis of the bone. The cut
are clamped and tied. starts at a point a
centimetre and a half proximal
The muscles are then transected at the level of to the cut tibia (Fig.
25).
bone section and the fibula is divided with The structures in the
posterior flap are best
a powered saw. It is convenient to delay the defin- displayed by placing a
support under the upper
itive section of this bone until the distal part of the end of the residual
tibia. The soft tissues fall away
391
Anterior tibial
neurovascular
bundle
Posterior tibial
neurovascular
bundle
Fig. 24 Transtibial amputation, preparation of posterior

muscle flap Fig. 26 Completion of
posterior muscle flap in transtibial
amputation
this plane is easily be

developed by finger dissec-
tion although sharp
dissection may be required
laterally. The part of
the soleus lying distal to the
level of bone section is
then removed. If the
tourniquet has been
used, it is released at this
point and haemostasis is
secured (Fig. 26).
Four remaining nerves
need to be identified;
the anterior tibial,
peroneal, sural and saphenous.
Each is cut high under
mild traction.
The kidney dish
support is then removed to
allow the amputation
stump to lie flat on the table.
The long posterior
muscle flap is brought up
momentarily to meet the
anterior fascial flap
and a small incision is
made in the fascia to
mark the required
length. Then, with the flap
Fig. 25 Preparation of bone ends in transtibial
lying flat on the table
and under no tension, the
amputation fascia and gastrocnemius
is cut to length in
a gentle arc. At this
point the sides of the muscle
flap may also need to be
trimmed to avoid unnec-
from the bone and the posterior tibial and essary bulk. The fascia
is then sutured to the ante-
peroneal vessels can be found either side of the rior tibial periosteum
and the fascia of the anterior
posterior tibial nerve, behind the muscles of the compartment. It will be
necessary for the posterior
deep compartment but anterior to the soleus. flap to be supported by
an assistant while the first
The vessels are cut and ligated just proximal to few sutures are inserted
to avoid the risk of the
the level of bone section and the nerve is put sutures tearing out. If
a suction drain is to be used it
under mild tension, cut high and allowed to should be passed up the
peroneal compartment just
retract into its soft fatty tunnel. under the deep fascia
and brought out through the
The plane between the soleus and the gastroc- skin on the lateral
aspect of the stump. The perfo-
nemius is best identified with a finger tip at the rated part of the drain
is tucked behind the cut end
level of bone section on the medial side. Most of of the tibia (Fig. 27).
392
J.C. Angel
Fig. 28 Transtibial
amputation showing rigid
plaster dressing
Fig. 27 Completed transtibial amputation stump
Finally, the overlong posterior skin flap is too soon there may be a
powerful flexor with-
brought up to meet the anterior flap, trimmed to drawal response, which
could undo this work.
length so that it can be stapled under slight ten- The suction drain is
pulled out from the top
sion, the longer, posterior edge inevitably becom- of the cast at 48 h and
the cast itself is removed
ing slightly crenellated. This and the staple marks at 5 days. Then follows
the programme of
are rarely a problem in the mature stump. Any bandaging, elastic hose
and temporary prosthetics
floppiness in the soft tissues at this stage will lead described above.
to redundant soft tissue in the mature stump;
something to be avoided.
The wound is dressed with dry gauze and Disarticulation at the
Knee
plaster wool is wrapped up to the level of the
mid-thigh (Fig. 28). If a soft dressing is to be Pre-Operative
used a crepe bandage is applied and held in Knee disarticulation
provides a robust stump,
position with a U-slab of adhesive tape. A rigid capable of full end-
bearing and good suspension
dressing has the advantages of holding the knee through its bulbous shape
[27]. The disadvan-
joint in extension and keeping inquisitive eyes tages of this level are
the bulky appearance of
at bay as well as promoting wound healing the prosthesis and the
need to locate the axis
and controlling oedema [26]. Plaster-of-Paris is of the prosthetic knee
lower than normal, making
applied to the stump up to the mid-thigh level the thigh section too long
and the shank too short.
and moulded heavily over the femoral condyles to Before selecting this it
should be noted that the
hold it in position. The assistant holds the limb at skin flaps are only
slightly shorter than those
the knee, allowing the distal part of the cast to be required to fashion a
short but functional
applied first, before moving round to hold the transtibial amputation.
distal end so that the knee drops into extension The procedure is
indicated where there is inad-
while the cast is completed. As it sets the surgeon equate viable tissue for a
transtibial amputation or
moulds the cast with the heels of his hands, just where there is severe knee
instability or a severe
proximal to the supracondylar area, medially and contracture. The procedure
can also be useful in
laterally. If the patient wakes from the anaesthetic very ill patients, as it
can be performed rapidly,
393
2 cm
5 cm
2 cm
Fig. 29 Lateral view of the skin flaps required for a knee

disarticulation
if necessary, under infiltration anaesthesia. In

children, it should be used if at all possible in
preference to an above-knee amputation even
if it involves extensive skin grafting. Disarticula-
tion at the knee is contra-indicated when the
robust end-bearing qualities are outweighed by
Fig. 30 Anterior view
of the skin flaps required for a knee
cosmetic considerations; for example, in younger disarticulation
women.
the cruciate
ligaments. The popliteal vessels are
The Operation then identified and
ligated and the tibial and com-
The patient is placed prone on the operating table. mon peroneal nerves
are cut high under slight
The incision for the lateral flap starts midway tension. The
gastrocnemius is sectioned close to
between the lower pole of the patella and the its femoral origin.
The disarticulation is completed
tibial tubercle. It descends to a point 5 cm by dividing the
remaining soft tissues including
below the upper border of the tibial tubercle and the tendon of the
popliteus. The menisci are then
then ascends to the mid-line posteriorly, 2 cm excised. The
tourniquet, if one is used, is released
above the knee joint line (Fig. 29). and haemostasis is
secured (Fig. 31).
The medial flap is made slightly longer in Following the
advice of Burgess [28], the fem-
order to cover the larger medial femoral condyle oral condyles are
prepared by removing a
(Fig. 30). centimetre from the
distal surface using a tenon
The incisions are carried down to the perios- saw. It is most
important that the plane of this cut is
teum and the flaps are raised keeping close to the perpendicular to the
eventual line of weight bear-
periosteum, thus dividing the ligamentum patel- ing. The ligamentum
patellae is then sutured to the
lae and the medial and lateral hamstrings. With cruciate ligaments and
the retinacula either side of
the knee flexed to a right angle, the medial and the tendon are
stitched to the hamstrings (Fig. 32).
lateral ligaments are divided and the capsule is A suction drain is
passed through the lateral
freed from the margins of the tibia together with flap. The skin is
closed with staples (Fig. 33).
394
J.C. Angel
Gritti-Stokes Amputation
This is a controversial
amputation [29] through the
lower femur that has been
condemned in the past for
being too long. It left
insufficient space for
a mechanism to control the
prosthetic knee without
lowering its axis and
making the shank of the
artificial limb too short.
Today, improvements in
design have largely
overcome the problem. The
main advantages of this
amputation are that it is
creates a fully end-bearing
stump [30] and it
requires significantly
shorter skin flaps than a knee
disarticulation. It is
indicated in two contrasting
situations: a young man who
values function more
than appearance and who
does not have a need to
wear a cosmetic covering
over the knee and
a person who is not
suitable for prosthetic fitting
because of other mobility
problems.
Fig. 31 Knee disarticulation, posterior view, showing The level of bone
section is marked at the upper
muscle division pole of the patella and the
cusps of the skin incision
are marked just in front of
the mid-lateral and mid-
medial lines at a level 2
cm proximal to the femoral
condyles. The anterior flap
descends to the level
There should be no tension in the skin flaps, of the upper border of the
tibial tubercle and
the main cause of wound breakdown with the posterior flap is half
this length. The
this amputation. If there is real concern about skin incision is made and
the ligamentum patellae
this then the patella can be firmly anchored is detached from the tibial
tubercle and reflected
in the flexed knee position beneath the proximally, together with
the patellar retinacula
femoral condyles using a Steinmann pin. and the iliotibial tract
(Figs. 34 and 35).
This pulls down the anterior skin and soft tissues Posteriorly, the skin
flap is raised and the
and secures them against the pull of the hamstrings are divided
level with the knee joint
quadriceps. line. The popliteal vessels
are ligated at the level
of bone section and the
medial and lateral popli-
Post-Operative Care teal nerves are pulled down
gently and transected
The wound is covered with gauze and the stump at a higher level.
is bandaged with orthopaedic wool and crepe and The articular surface
of the patella is removed
held in place with a U- shaped slab with adhe- with an oscillating saw
leaving a smooth, flat
sive tape. The suction drain is removed after 48 h surface of cancellous bone.
and the sutures at 23 weeks. The femur is divided at
a level that provides an
The socket of the prosthesis consists of a soft equivalent surface area
(Fig. 36).
inner liner, which is split to allow it to be pulled The two cut surfaces
are compressed together
over the bulbous end of the stump. When in place by means of medial and
lateral wire mattress
the outer aspect of the liner is the shape of an sutures. This requires 24
gauge wire and a wire
inverted cone. The rigid outer socket is pulled tightener (Fig. 37).
on top of this. The knee joint is a polyaxial If the bone is too soft
to take a wire suture,
system that largely mimics the axis of the a firm fixation can be
achieved by wiring together
natural knee, even though it is located two transverse screws
passed horizontally
several centimetres below it. through each of the bones.
395
Fig. 32 Preparation of the

femoral condyles in knee a
disarticulation
The hamstrings, including the tendon of Prosthetic fitting can be

commenced at 6 weeks
adductor magnus, are then adjusted to length or so when the patella has
united. The weight is
and sutured to the ligamentum patellae, which carried largely on the
patella but also on the con-
by now has become a posterior structure. ical shape of the thigh on a
cork in bottle principle.
The skin is closed with staples. The The socket does not require a
tuber seating, as
wound is then dressed with gauze, wool and would an above-knee
prosthesis. The polycentric
crepe, and the whole suspended with an adhesive knee mechanism tucks the
shank behind the
stirrup. distal end of the femur on
flexions so that when
396
J.C. Angel
Fig. 33 Completed knee disarticulation showing skin

closure and location of suction drain
Fig. 35 Oblique view of

the skin flaps required for a
Gritti-Stokes amputation
(With permission of Bohne,
Walther HO: Atlas of
Amputation Surgery. Thieme
Medical Publishers, Inc.,
New York, 1987)
Fig. 34 Anterior view of the skin flaps required for a Fig. 36 Bone cuts required
in a Gritti-Stokes amputation
Gritti-Stokes amputation (With permission of Bohne, (With permission of Bohne,
Walther HO: Atlas of Ampu-
Walther HO: Atlas of Amputation Surgery. Thieme tation Surgery. Thieme
Medical Publishers, Inc., New
Medical Publishers, Inc., New York, 1987) York, 1987)
397
onto a knee-breaking
mechanism that controls the
knee in the stance
phase of gait. All this requires
bone section to be 15
cm above the knee joint
line. Any less is
likely to compromise the ease of
donning the
prosthesis, reduce the cosmesis and
increase the length of
the thigh section of the
prosthesis at the
expense of shortening the
shank section. In the
case of a thin, elderly patient
who has little soft
tissue at the end of the stump no
requirement for a
suction socket or a stabilized
knee, a clearance of
only 8 cm is required.
For the patient to
be able to control the
artificial limb
properly the residual femur needs
to measure at least 20
cm and in short, fat
Fig. 37 Wire fixation of patella to femur in Gritti-Stokes
amputation (With permission of Bohne, Walther HO: people there may have
to be a compromise
Atlas of Amputation Surgery. Thieme Medical Publishers, between stump length
and the space below it.
Inc., New York, 1987) A fixed flexion
deformity of the hip can be
a problem for the
prosthetist who accommodates
the patient sits down the knee does not protrude the deformity by the
angle at which he sets the leg
beyond its contralateral neighbour. To achieve this relative to the
socket. This makes the distal end of
it is best not to have a foam covering. The the stump protrude
anteriorly from the thigh
prosthesis is also equipped with a stabilised knee shape of the
artificial limb. In these circum-
mechanism and swing phase control. stances a longer
residual femur is more difficult
to accommodate than a
shorter one.
Transfemoral (Above Knee) Technique

Amputation The operation is
performed with the patient supine
under general or
regional anaesthesia. A high tour-
The transfemoral amputation is indicated when niquet is applied in
non-vascular cases. The level
there is insufficient tissue to construct a transtibial of bone section is
marked both medially and later-
amputation and none of the intervening levels are ally. Anterior and
posterior skin flaps are marked
either possible or suitable. The transfemoral ampu- marking sure that they
are rounded and not tongue
tation poses particular problems for children shaped. Their combined
length should be equal to
because most of the femoral growth occurs at the half a circumference
of the limb at the level of
distal epiphysis and the stump fails to lengthen in bone section. I prefer
the posterior flap to be
proportion with the rest of the body. slightly longer than
the anterior (Fig. 38).
The level of bone section is determined not Having incised the
dermis with the knife
only by the upper limit of pathological process perpendicular to the
skin the subcutaneous tissues
but also by the type of prosthesis that the patient are fashioned with a
raking cut directed towards
is likely to require. The axis of the artificial knee the level of bone
section. The muscles are cut in
will need to be located at the natural level, 2 cm a similar fashion. The
posterior muscle flap is cut
proximal to the original knee joint line. There slightly longer than
the anterior. The femoral
will, on average, be 3 cm of soft tissue covering vessels, deep to the
sartorius muscle, should be
the distal end of the stump and if a suction socket dissected cleanly and
ligated under good vision at
is to be worn, end-socket space is required to a level higher than
bone section. In shorter
manipulate the soft tissues fully into place. The stumps it is important
to retain the adductor
socket itself has a thickness and it has to be bolted magnus for suture to
the distal end of the stump
398
J.C. Angel

transfemoral amputation
Fig. 38 Diagram indicating the skin flaps required for

a transfemoral amputation
to counterbalance the powerful short hip abduc-

tors and prevent a hip abduction contracture.
Once the bone is exposed, the level of section
is re-measured and marked again directly on
the bone using diathermy. The periosteum is cut
circumferentially at the level of bone section and
further stripping is avoided to preserve the
blood supply of the residual femur. The bone
is cut with a Gigli saw (Fig. 39).
A sharp bone hook is inserted into the cut end
of the distal fragment and used to apply traction, Fig. 40 Preparation of cut
bone surface in transfemoral
while the remaining soft tissues are divided and amputation
the amputation specimen is freed.
The sciatic nerve is pulled down and cut high
bearing in mind that the arteria commitans nervi The anterior muscle
flap is trimmed for suture
ischiadici (the vestigial sciatic artery) can to the posterior and the
adductor magnus is used to
sometimes be large and cause troublesome re-inforce the first layer
of the repair on the medial
bleeding. The cut end of the femur is smoothed side. The importance of
attaching this muscle has
with a rasp and a slight bevel is created over been stressed [31]. The
myodesis is important in
the anterolateral aspect (Fig. 40). order to prevent the
muscles from abrading them-
The posterior muscle flap is fashioned to reach selves against the cut end
of the femur and gener-
the anterior edge of the cut end of the femur ating a painful blood-
filled bursa (Fig. 42).
where it is sutured using a small, anterior Subcutaneous sutures
are not necessary if the
drill hole through which are passed two flaps fall together
correctly. The skin is closed
non-absorbable mattress sutures (Fig. 41). with staples (Fig. 43).
399
Fig. 43 Completed
amputation stump in transfemoral
amputation
Disarticulation at the
Hip
Hip disarticulation is
indicated in malignant
disease, severe trauma,
vascular disease and occa-
sionally infection. This
amputation level is pre-
Fig. 41 Preparation for muscle suture in transfemoral
ferred to a very short
transfemoral amputation
amputation
because the hip in such
cases tends to develop
a flexion-abduction
contracture and the protruding
femur makes it impossible
to fit a prosthesis
satisfactorily.
Before the operation,
four to six units of
blood should be cross-
matched. The operation
is performed under
general anaesthesia with the
patient supine and a
large sandbag supporting
the sacrum. The incision
begins slightly proxi-
mal to the anterior
superior iliac spine and some
6 cm lateral to it. It
curves anteriorly and
then downwards following
a line parallel to the
inguinal ligament, some 2
cm below it.
Rounding the adductor
magnus it continues pos-
teriorly 5 cm below the
root of the limb. At the
ischial tuberosity it
begins to sweep upwards in
a broad curve crossing
the greater trochanter to
Fig. 42 Method of suturing the posterior muscle flap to
the femur
meet the earlier part of
the incision at an acute
angle close to the
anterior superior iliac spine
(Fig. 44).
The wound is dressed with dry gauze, a layer of The femoral vessels
are exposed and double
wool and then a crepe bandage. It is important that ligated, first the artery
and then the vein. The
this is held in place by means of a U-slab of adhe- femoral nerve and the
lateral cutaneous nerve of
sive strapping. After 2 days, exercises are begun to the thigh are each
divided under slight tension,
prevent a flexion contracture of the hip. After 57 allowing them to retract
out of the way. The
days the wound is checked and elasticated hose is flexor muscles are
detached from the superior
applied and at 1014 days partial weight-bearing and inferior iliac spines
and the pectineus is
can begin in a temporary prosthesis. divided in the line of
the incision. The lesser
400
J.C. Angel
Fig. 45 Handling of
anterior muscles in disarticulation of
the hip
short rotators are detached

from the region
Fig. 44 Diagram indicating skin incision required for
of the greater trochanter,
finally releasing the
disarticulation at the hip lower limb.
A large suction drain
is brought out through the
posterior flap, which is
then approximated to the
anterior. It will be
appreciated that if it is displaced
trochanter is brought into view by externally downwards it tends to
create a large dog ear flap
rotating the limb, allowing the iliopsoas tendon distally and, with upward
displacement, a similar
to be cut close to its insertion. The adductors are dog ear appears at the
proximal end of the wound,
cut close to their attachments to the pubis and but the latter is easier to
deal with. The muscle
ischium. The obturator externus is encircled and fascia of the posterior
flap is sutured to the
by the obturator artery close to its origin. It iliopsoas, pectineus and
the remnants of
is divided cautiously as the obturator artery has the adductor muscles. The
wound is dressed with
a tendency to retract into the pelvis if cut gauze and an absorbent pad
held in position
accidentally (Fig. 45). with adhesive plaster (Fig.
47).
The limb is then rotated medially allowing The prosthesis consists
of a close-fitting shell
gluteus medius and minimus to be detached enveloping the hemipelvis,
part of which is
from the greater trochanter. The fascia lata and a padded seat through
which weight is transmit-
distal fibres of gluteus maximus are cut in ted from the ischial
tuberosity. The hip joint is
the line of the skin incision and the gluteus located anteriorly, well in
front of the line of
maximus is also released from its attachment weight-bearing. It is
designed so that it locks
to the linea aspera. The sciatic nerve is divided when weight is applied to
the limb and releases
under slight tension (Fig. 46) and the during the swing phase of
gait.
401
Fig. 46 Handling of lateral and posterior muscles in

disarticulation of the hip Fig. 47 Diagram showing
completed disarticulation with
skin incision
Upper Limb Amputations function is very modest

and for these reasons
many prostheses are not
regularly worn once
General Remarks arm training has been
completed. The situation
In England and Wales some 5 % of the amputations is completely different
in bilateral upper extrem-
referred for prosthetic fitting involve the upper limb. ity amputees, who become
remarkably skilful in
The function and appearance, especially the using their artificial
limbs and very dependant
dynamic appearance, of upper limb prostheses upon them.
leaves a lot to be desired. Huge effort has been The main indication
for an upper limb ampu-
put into their development and great strides have tation is trauma but
occasionally the operation is
been made, but the goal seems impossibly diffi- required for tumour,
ischaemic gangrene, dis-
cult. An artificial arm has no feeling and its posi- seminated intravascular
clotting and congenital
tion has to be visualised for the wearer to locate it. abnormality. The
principle is to conserve length
The hand is one of the means by which we as far as possible,
although it may be necessary to
express ourselves and, though it is not as impor- trim uncomfortable
excrescences, such as styloid
tant as the face, a hand tends to attract our gaze processes, epicondyles
or, in the case of
and the artificial hand is often found wanting. a shoulder
disarticulation, a prominent acromion.
This is not so much because of its appearance Where there is severe
crushing, contamination or
but because of the way in which it moves. infection there should be
no hesitation at the
Almost all are cumbersome and while being initial debridement in
leaving the wound open
worn they mask what sensibility there is in the rather than performing
complicated procedures
residual limb. Compared to a normal limb their with the soft tissues.
402
J.C. Angel
Fig. 48 Incisions required for transradial amputation
The operation is performed either under gen-

eral anaesthesia or brachial plexus block. The
patient lies supine with the arm on a side-table,
elevated on a support placed just proximal to
the site of amputation. In the sections that follow
the measurements apply to a person of average
build.
transradial amputation
Transradial (Forearm) Amputation
In most cases it is possible to use a tourniquet.
The amputation is performed as distally as the
injury or pathology allows. The level of bone bones are smoothed with a
rasp. The cut ends
section is marked on the skin. The forearm is of the medial, radial and
ulnar nerves are
fully supinated before marking out the skin cut high under slight
tension. The anterior
flaps. The cusps of the incision are 1.5 cm prox- interosseous branch of the
median nerve passes
imal to the level of bone section on the medial down the forearm on the
interosseous membrane
and lateral aspects. Two well-rounded equal flaps between the flexor
digitorum longus and the
descend to 7 cm below the proposed bone section. flexor pollicis longus
(Fig. 49). The cut end is
The deep fascia is incised at a slightly more prone to becoming adherent
to the underlying
proximal level to the skin incision and the same membrane to form a
troublesome neuroma, so it
raked incision is carried through the muscle to meet too should be sought and
cut high under slight
the bone at the level of bone section. The radial and tension.
ulnar vascular bundles are ligated with a transfixion The tourniquet is
released, haemostasis is
ligature (Fig. 48). secured and the deep fascia
is closed over the
The bones are sectioned using a Gigli saw; the ends of the bones using a
20 absorbable suture.
ulna a few millimetres proximal to the radius, The skin edges are
approximated with staples
and its subcutaneous border is bevelled. Both (Fig. 50).
403
Fig. 50 Completed transradial amputation Fig. 52 Completed

transhumeral amputation showing
skin incision with
drain in-situ
Transhumeral (Above
Elbow)
Amputation
Equal anteroposterior
flaps are marked with the
cusps lying 2 cm
proximal to the level of bone
section. The well-
rounded flaps descend to 7 cm
below the bone. Raking
cuts are then made to
meet the bone as
described with above-knee
amputation (Fig. 51).
The brachial vessels
are individually ligated
and the bone is cut
with a Gigli saw and smoothed
with a rasp. The
tourniquet is then released and
haemostasis is secured.
The medial, radial and
ulnar nerves pulled
down and cut high. The
wound is dressed and
protected with wool and
bandage which is kept
in place with a stirrup of
adhesive strapping
(Fig. 52).
References
Fig. 51 Diagram indicating anterior and lateral views of
the upper arm showing the flaps required for transhumeral 1. Dirschl D. The
mangled extremity: when should it be
amputation amputated? J Am
Acad Orthop Surg. 1996;4(4):18290.
404
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2. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, patients with
diabetes mellitus who have forefoot
Webb LX, Swiontkowski MF, et al. A prospective sepsis
requiring hospitalization and presumed
evaluation of the clinical utility of the lower-extremity adequate
circulatory status. J Vasc Surg.
injury-severity scores. J Bone Joint Surg Am. 1999;30(3):509
17.
2001;83(1):3. 17. Quebedeaux TL,
Lavery LA, Lavery DC. The develop-
3. Saies AD, Urbaniak JR, Nunley JA, Taras JS, Goldner ment of foot
deformities and ulcers after great toe
RD, Fitch RD. Results after replantation and revascu- amputation in
diabetes. Diabetes Care. 1996;19
larization in the upper extremity in children. J Bone (2):1657.
Joint Surg Am. 1994;76(12):176676. 18. Younger AS,
Awwad MA, Kalla TP, de Vries G. Risk
4. Wolff GA, Posso C. One case of big-toe re-plantation: factors for
failure of transmetatarsal amputation in
a 13-year follow-up and a literature review. J Plast diabetic
patients: a cohort study. Foot Ankle Int.
Reconstr Aesthet Surg. 2010;63(5):83840.
2009;30(12):117782.
5. Li J, Guo Z, Zhu Q, Lei W, Han Y, Li M, et al. 19. Wagner FW. The
dysvascular foot: a system
Fingertip replantation: determinants of survival. Plast for diagnosis
and treatment. Foot Ankle.
Reconstr Surg. 2008;122(3):8339. 1981;2(2):64
122.
6. Lloyd MS, Teo TC, Pickford MA, Arnstein PM. 20. Pinzur MS,
Stuck RM, Sage R, Hunt N,
Preoperative management of the amputated limb. Rabinovich Z.
Syme ankle disarticulation in patients
Emerg Med J. 2005;22(7):47880. with diabetes.
J Bone Joint Surg Am. 2003;85-A
7. Dowd GS, Linge K, Bentley G. Measurement of trans- (9):166772.
cutaneous oxygen pressure in normal and ischaemic 21. Birch JG, Walsh
SJ, Small JM, Morton A, Koch KD,
skin. J Bone Joint Surg Br. 1983;65(1):7983. Smith C, et al.
Syme amputation for the treatment of
8. Stckel M, Jrgensen JP, Jrgensen A, Brchner- fibular
deficiency. An evaluation of long-term physi-
Mortensen J, Emneus H. Radioisotope washout tech- cal and
psychological functional status. J Bone Joint
nique as a routine method for selection of amputation Surg Am.
1999;81(11):15118.
level. Acta Orthop Scand. 1981;52(4):4058. 22. Harris RI.
Symes amputation; the technical
9. Mulvey MR, Bagnall A, Johnson MI, Marchant PR. details
essential for success. J Bone Joint Surg Br.
Transcutaneous electrical nerve stimulation (TENS) 1956;38-
B(3):61432.
for phantom pain and stump pain following 23. Fulp T, Davids
JR, Meyer LC, Blackhurst DW. Lon-
amputation in adults. Cochrane Database Syst Rev. gitudinal
deficiency of the fibula. Operative treatment.
2010;5, CD007264. J Bone Joint
Surg Am. 1996;78(5):67482.
10. Hadden W, Marks R, Murdoch G, Stewart C. Wedge 24. Burgess EM,
Romano RL, Zettl JH, Schrock RD.
resection of amputation stumps. A valuable salvage Amputations of
the leg for peripheral vascular insuf-
procedure. J Bone Joint Surg Br. 1987;69(2):3068. ficiency. J
11. Benevenia J, Makley JT, Leeson MC, Benevenia K. 25. Tisi PV, Callam
MJ. Type of incision for below knee
Primary epiphyseal transplants and bone overgrowth amputation.
Cochrane Database Syst Rev. 2004;1,
in childhood amputations. J Pediatr Orthop. CD003749.
1992;12(6):74650. 26. Honkamp N,
Amendola A, Hurwitz S, Saltzman CL.
12. Pauley T, Devlin M, Heslin K. Falls sustained during Retrospective
review of eighteen patients who
inpatient rehabilitation after lower limb amputation: underwent
transtibial amputation for intractable pain.
prevalence and predictors. Am J Phys Med Rehabil. J Bone Joint
Surg Am. 2001;83-A(10):147983.
2006;85(6):52132; quiz, 5335. 27. Batch JW,
Spittler AW, McFaddin JG. Advantages of
13. Genin JJ, Bastien GJ, Franck B, Detrembleur C, the knee
disarticulation over amputations through the
Willems PA. Effect of speed on the energy cost of thigh. J Bone
Joint Surg Am. 1954;36(5):92130.
walking in unilateral traumatic lower limb amputees. 28. Burgess EM.
Disarticulation of the knee. A modified
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Surg. 1977;112(10):12505.
14. Sherk VD, Bemben MG, Bemben DA. BMD and bone 29. Martin P,
Wickham JE. Gritti-Stokes amputation
geometry in transtibial and transfemoral amputees. for
atherosclerotic gangrene. Lancet. 1962; 2(7245):
J Bone Miner Res. 2008;23(9):144957. 1620.
15. Struyf PA, van Heugten CM, Hitters MW, Smeets RJ. 30. Yusuf SW, Baker
DM, Wenham PW, Makin GS,
The prevalence of osteoarthritis of the intact hip and Hopkinson BR.
Role of Gritti-Stokes amputation in
knee among traumatic leg amputees. Arch Phys Med peripheral
vascular disease. Ann R Coll Surg Engl.
Rehabil. 2009;90(3):4406. 1997;79(2):102
4.
16. Nehler MR, Whitehill TA, Bowers SP, Jones 31. Gottschalk FA,
Stills M. The biomechanics of trans-
DN, Hiatt WR, Rutherford RB, et al. Intermediate- femoral
amputation. Prosthet Orthot Int. 1994;
term outcome of primary digit amputations in 18(1):127.
Part II
Spine
Applications of Prostheses and
Fusion
in the Cervical Spine
Contents
Abstract
History of Spinal Fusion and Intervertebral
Cervical and lumbar fusions are well-
Disc Replacement in the Cervical Spine . . . . . . 408
established procedures for the treatment of
Prosthetic Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 410
a wide range of spinal disorders. Whilst both
have a good record of success, there are con-

Indications for Surgery in Cervical
cerns about the impact of spinal fusion on
Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 410
movement and the biomechanical effects

Evidence for Cervical Arthroplasty as an
upon the remainder of the spine, particularly
Alternative to Anterior Cervical Fusion . . . . . 411
Cervical Nerve Root Compression and
the levels adjacent to the fusion.
Radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 411 Although many indications for spinal fusion
Cervical Myelopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
413 would be contra-indications for intervertebral
The Evidence for Adjacent Level Disease After
disc arthroplasty, the particular indication of
Anterior Cervical Fusion . . . . . . . . . . . . . . . . . . . . . . 414
degenerative disc disease allows for both
Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
forms of treatment. Intervertebral disc replace-
Decompression and Disc Arthroplasty . . . . . . . . . . . . . . 415
ment is relatively new and as yet unproven in
The Alternative Procedure of Anterior Cervical
the long term, but there has been a great trend
Decompression and Fusion . . . . . . . . . . . . . . . . . . . . . . 419
towards arthroplasty in the last 1520 years.
Complications of Anterior Cervical Surgery . . . .
419 The history of spinal fusion is considered,
Approach-Related Complications . . . . . . . . . . . . . . . . . . .
419 the design and development of the prosthetic
Complications Specific to Cervical Disc
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 419
disc replacements described, and the current
Complications Specific to Anterior
evidence for both procedures outlined. The
Cervical Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 420 success rates, complications and impact upon
Conclusions Regarding Anterior Cervical
the spine as a whole will be compared.
Surgery: Disc Replacement or Fusion . . . . . . . . 420
The anterior surgical procedures for fusion
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 421
and arthroplasty are almost identical, but
fusion can also be performed through posterior
and posterolateral approaches. For the pur-
poses of this chapter only the anterior surgical
approaches will be covered.
Keywords
R.W. Marshall (*) # N. Raz
Adjacent Level Disease # Cervical # Compli-

Department of Orthopaedic Surgery, Royal Berkshire
cations # Fusion # History # Myelopathy # Pros-
e-mail: robmarshall100@hotmail.com
thesis # Prosthetic Design # Root Compression

407
DOI 10.1007/978-3-642-34746-7_215, # EFORT 2014
408
R.W. Marshall and N. Raz
and Radiculography # Spine # Surgical Indica- equivalent results and as

many as 75 % go on to
tions and Contra-Indications # Surgical spontaneous fusion [1420].
Laing [19] found
Technique that over 50 % of anterior
cervical discectomies
developed loss of the normal
cervical lordosis
and a third had a segmental
kyphus, but the clin-
History of Spinal Fusion and ical results were not
compromised in the short
Intervertebral Disc Replacement in term.
the Cervical Spine Long-term outcome after
anterior cervical
decompression alone revealed
excellent results
The limitations of posterior cervical surgery in initially (90 %), dropping
to 67 % at follow-up
treating the axial neck pain, nerve root and spinal (318 years) mainly due to
neck pain and degen-
cord compression syndromes resulting from erative change at other
cervical levels [20].
degenerative disc disease in the cervical spine A prospective randomised
controlled study
led to the development of anterior surgery in the from Finland found
equivalent results at
1950s. a minimum of 4-year follow-
up for anterior cer-
Using the anterior cervical spine approach vical discectomy alone,
autograft without plating
described by Southwick and Robinson in 1957 and autograft with plating.
It was concluded that
[1], Smith and Robinson [2] developed an effec- fusion was unnecessary [12].
tive decompression and fusion technique and However, Yamamoto found
that cervical
reported good results, but warned about the decompression with fusion
provided more reli-
potential for some specific complications such able relief of neck pain
[21]. Cases of
as oesophageal perforation, recurrent laryngeal pseudarthrosis were
associated with neck pain
nerve damage and Horners syndrome. At late in other publications [22,
23]. Re-operation to
follow-up the reproducibility of this technique ensure firm fusion can
improve the outcome of
was proven [3]. Other authors have reported cases where pseudarthrosis
was responsible for
excellent results using this technique. [46] continued neck pain [24]. In
another study, late
There was a reported incidence of pseudarthrosis results of cervical
discectomy alone were found
of 7 % per level with the technique and this was to be inferior to anterior
cervical fusion [25].
sometimes responsible for failure. Many alternatives to
iliac crest bone graft
Other techniques for anterior grafting and fusion have been tried and
they have been
fusion of the cervical spine were developed by reviewed very well by Chau
and Mobbs [26].
Cloward [7] in 1958 with a dowel grafting tech- Despite the drawback of
donor site complications
nique and Bailey and Badgeley [8] in 1960 with for iliac crest autograft
nothing else has produced
an intervertebral trench and shaped autograft. better results. Xenografts
(usually bovine) have
The Cloward technique became highly popular, produced worse fusion rates.
Allograft is expen-
but the late results were disappointing due to graft sive, carries a small risk
of disease transmission
collapse and failure of fusion. and gives an acceptable
fusion rate, but fusion
Cervical plating was introduced to support the rates are still inferior to
autograft. Ceramics have
autograft and immobilise the motion segment and been shown to be a very
reasonable alternative to
there were reports suggesting that the fusion rate iliac crest autograft.
Whilst bone morphogenic
improved considerably [9, 10]. protein (BMP) has powerful
osteo-inductive
However, others have not found much advan- properties, it is expensive
and has yet to be
tage in using a cervical plate [11, 12]. proven as a worthwhile
alternative.
Hankinson and Wilson introduced the treat- Based upon Bagbys
stainless steel fusion
ment of microscope-assisted discectomy without cage [27] invented to treat
wobbler syndrome
anterior cervical fusion and good results were in race-horses, stand-alone
cages were introduced
reported [13]. Others have also shown that for both lumbar spine and
cervical fusions to
decompression without fusion can produce avoid the need for iliac
crest autografts, which
Applications of Prostheses and Fusion in the Cervical Spine
409
Fig. 1 Evolution of the a b

Prestige intervertebral disc
(Medtronic Sofamor
Danek)
carried the disadvantages of donor site pain and

lateral cutaneous nerve damage. Good results
were achieved with a variety of cages made of
synthetic materials such as Titanium and
polyetherether ketone. Two prospective,
randomised controlled trials showed results of
cage fusions were equivalent to autogenous,
iliac crest tricortical grafts [28, 29].
The first attempt to maintain cervical mobility
by any form of arthroplasty was reported in 1966
by Fernstrom using a metal ball-bearing spacer,
but no late outcome or experience with other
cases was ever published [30].
No other attempts at disc arthroplasty were
published until the work of Cummins et al. from
Bristol, who reported 20 cases treated by the
Prestige disc with maintenance of movement in Fig. 2 The Bryan disc
(Medtronic Sofamor Danek)
the majority and satisfactory clinical outcome
[31]. The device consisted of two stainless steel The Bryan Cervical
Disc prosthesis (Fig. 2) is
plates which were fixed to the vertebral bodies by a low-friction
polyurethane nucleus surrounded
anterior screws. This design made the device by a polyurethane
covering, placed between two
incompatible with MRI and also meant that two titanium alloy shells.
There is a milling device for
adjacent discs could not be treated. Modifications preparation of the end-
plates to stabilize the
of the device included changing from a ball and prosthesis.
socket to a ball and trough design, changing from Since its first
description [32] this has become
a stainless steel to a composite of titanium and one of the most popular
disc prostheses.
ceramic (thus MRI compatible), and from screw It has been shown in
multi-centre randomized
fixation to the insertion of two serrated rails into trials to produce
clinical outcomes comparable to
prepared grooves within the bony end-plates anterior cervical
decompression and fusion
(Fig. 1). (ACDF) (see below).
410
Despite emphatic
claims by the manufac-
Prosthetic Design turers, no one design has
been proven to be supe-
rior to any other and
short term results are very
There are many different cervical arthroplasty satisfactory,
irrespective of the design or mate-
designs emerging with short-term evidence for rials used. This is not
at all surprising when one
some of them [3241]. The true place of considers the excellent
results achieved by ante-
arthroplasty, the ideal disc design and the salvage rior cervical discectomy
alone, i.e. without fusion
procedures to deal with failures have yet to be or insertion of any
prosthesis! [1220].
established. We must keep in mind
that the real benefits of
Some are modular, others non-modular, some anterior cervical fusion
or disc replacement
are constrained whilst others are unconstrained. come from the spinal cord
and nerve decompres-
Fixation can be by means of screws or by press-fit sion, the fundamental aim
of any such
designs. There are metal end-plates made of cobalt procedure.
chrome, stainless steel or titanium. Others are
ceramic or made of materials like polyetherether
ketone. Some have metal-on-metal articulation, Indications for Surgery
in Cervical
others employ polyethylene or polyurethane. Pros- Syndromes
theses can be porous- coated or coated with
hydroxyapatite or calcium phosphate [42] (Fig. 3). The consequences of
cervical disc degeneration
The use of cobalt chrome or stainless steel are the commonest reasons
for surgical treatment
prostheses makes interpretation of M.R.I. scans in the cervical spine
the degenerative process
difficult post-operatively because of the metal can lead to cervical disc
herniation with acute
artefact interfering with the image quality [43]. onset of neck pain,
radicular pain radiating
Others have shown that the artefact is dependent down the upper limb and
the neurological syn-
upon the strength of the magnet and is variable dromes of radiculopathy
or myelopathy, but usu-
[44] (Fig. 4). ally there is more
insidious development of
Fig. 3 Photographs showing some variety in design of cervical disc prostheses

411
Fig. 4 MRI T2 sagittal and axial images showing minimal artefact after
decompression and M6 (C.4-5) disc
replacement
similar syndromes due to uncovertebral joint and In a randomised

controlled trial Kuijper et al.
facet joint hypertrophy together with disc degen- showed no difference in
treated and untreated
eration and a circumferential rim of osteophyte groups of brachialgia at
6 months, but there were
around the disc space. some early benefits in
the treated group [46].
Remember that cervical disc and facet joint Surgery is only
indicated for the intractable
degeneration are extremely common and are cases of brachialgia and
persistent focal neuro-
often found incidentally on radiographs or mag- logical deficit or for
the much more serious
netic resonance imaging carried out for other condition of spinal cord
compression with mye-
purposes. Boden et al. showed that cervical lopathic features.
degeneration was present in 60 % of asymptom- Single or double level
disease can be treated
atic patients over the age of 40 years, 5 % had by anterior cervical
decompression and fusion or
disc herniation and 20 % appeared to have foram- by decompression and
insertion of a prosthetic
inal stenosis. In patients under 40 years of age disc replacement.
degenerative disc disease was seen in 20 % and
incidental disc herniation was found in 10 % [45]
(Fig. 5). Evidence for Cervical
Arthroplasty as
This means that cervical degeneration is an Alternative to
Anterior Cervical
a benign part of the natural ageing process, so it Fusion
is essential for the clinician to correlate clinical
features accurately with imaging information Cervical Nerve Root
Compression and
before embarking upon any invasive forms of Radiculopathy
treatment.
Treatment of acute neck pain and cervical In randomised controlled
trials for three different
nerve compression syndromes consists of tempo- intervertebral disc
replacements, the disc replace-
rary use of a soft collar, physiotherapy and x-ray- ment option has been
found to be at least equiv-
guided steroid injections. alent to anterior
cervical fusion at a follow-up of
412
Fig. 5 MRI T2 Sagittal and T2 axial images showing a left sided C5-6 intervertebral
disc prolapse with C6 nerve
compression (arrowed)
at least 2 years and in one study up to 5 years

[3338].
The arthroplasty patients had better clinical
outcome at 2 years. Device-related complications
were also lower in this group.
The favourable clinical and angular motion
outcomes that were previously noted at 1- and
2-years follow-up after cervical disc replacement
with the Bryan Cervical Disc Prosthesis appear to
persist after 4 and 6 years of follow-up [37].
Fig. 6 The Prodisc C
prosthesis (Synthes)
In assessing the Prestige II disc
(Medtronic) Burkus et al. started a randomised
controlled multicentre trial in 2002 of single level
total disc replacement or anterior cervical decom- of the ProDisc-C cervical
disc replacement with
pression and fusion with allograft and plate fixa- anterior discectomy and
fusion with allograft for
tion in 541 patients. single-level symptomatic
disease. There was
Five patients in the fusion group had re- a statistically
significant difference in the number
operations and the disc arthroplasty group had of revision procedures in
the two groups, 8.5 %
better clinical and neurological outcome at 24 (9 of 106) of the anterior
discectomy and fusion
months and this difference was maintained at 5 group and 1.9 % (2 of 103)
of the disc replace-
years. Re-operation was less common in the total ment group. The ProDisc-C
was successful in
disc replacement group [41]. 73.5 % (76 of 103) and
anterior discectomy and
In the United States, Food and Drug Adminis- fusion and plating in 60.5
% (64 of 106) at follow-
tration investigational device exemption study up of 24 months [39] (Fig.
6).
of the ProDisc-C prosthesis, Murrey et al. found From the above
evidence it can be concluded
that the Prodisc C was equal to or superior to that the three most
commonly used artificial discs
ACDF. The two-year prospective, randomised, are producing similar
results for treatment of
controlled multi-centre study compared the use cervical radiculopathy.
They are no worse than
413
anterior cervical fusion and there are some per- papers suggest that after
initial neurological
ceived benefits in terms of early return to work deterioration the
condition can stabilise and be
and initial clinical scores. No single device has followed by a long period
of clinical stability,
any clear advantage at this stage. especially if the
myelopathy is mild on presen-
tation [49].
Nurick later
confirmed this pattern [50]. How-
Cervical Myelopathy ever, both studies noted
that patients who were
older or had significant
progressive disability had
Brain et al. first described the syndrome of a worse prognosis.
myelopathy in 1952 [47]. Other studies that
the myelopathy may deteri-
Multiple factors play a critical role in the orate at a variable rate
and even if the neurolog-
development of cervical spondylosis and subse- ical condition stabilises
for some time, there is
quent cord compression and its consequences often a late
deterioration [5153].
of cervical myelopathy. The progression of In a series of 1,355
patients with cervical
spondylotic changes begins with cervical disc spondylotic myelopathy
treated conservatively,
degeneration. With aging, dehydration and Epstein et al. found that
64 % showed no improve-
disorganisation of the disc leads to disc height ment and 26 %
deteriorated [52]. Clark and Rob-
collapse. Increased mechanical stress on the end- inson, found that
approximately 50 % of patients
plates initiates osteophyte formation along the with cervical spondylotic
myelopathy treated
end-plates. These osteophytes serve to increase medically deteriorated
neurologically [53].
the load-bearing surface of the end-plates to com- Syman and Lavender
found that 67 % of their
pensate for spine hypermobility secondary to the patients with cervical
spondylotic myelopathy
loss of disc material. Compensatory bone growth experienced functional
deterioration [54].
due to uncinate process hypertrophy may also Some argue that
patients do badly with con-
occur. Ossification of the posterior longitudinal servative medical
management, and that surgery
ligament (OPLL) can develop and is a particular is preferable, even in
mild cases. They suggest
problem amongst Asians [48]. that early surgical
intervention can lead to
This condition is usually painless although improved neurological
outcomes [5557].
some have neck pain. There is a variable rate of Prognosis after
surgery was better for patients
neurological deterioration with the development with less than 1 year of
symptoms, younger age,
of upper motor neurone dysfunctional changes in fewer levels of
involvement, and unilateral motor
all four limbs. Patients may complain of numb- deficit.
ness of the fingers, loss of dexterity with impair- Phillips examined 65
patients treated surgi-
ment of fine tasks such as fastening buttons, cally and found that
symptoms of less than 1
writing or playing musical instruments. Later, years duration
significantly correlated with ben-
they may develop poor lower limb control, with efit from treatment [57].
walking difficulty and an obvious spastic Although patients
seldom have complete res-
paraparesis. olution of their
myelopathy and any improvement
Physical signs include sensory impairment, after surgery can be
modest, surgery usually pre-
weakness, brisk reflexes commensurate with the vents any further cord
deterioration. The outcome
level of the pathology, Hoffmanns sign and after surgery is superior
to procrastination and
dysdiadochokinesia in the upper limbs, further neurological
deterioration.
Rombergs sign, abnormal plantar responses and Surgical treatment of
cervical myelopathy has
ankle clonus. The tandem walking test is often historically been by
anterior cervical decompres-
a good way of observing impaired function in sion and fusion for one
or two levels of cervical
more subtle cases of myelopathy. stenosis or posteriorly
by cervical laminectomy,
The natural history of cervical myelopathy is laminoplasty or
laminectomy with lateral mass
not fully understood. Some of the early fusion for three or more
affected levels.
414
Surgical treatment should decompress the 25.6 % of the fusion patients

would develop
spinal cord adequately and prevent the develop- symptomatic adjacent segment
disease within
ment of a cervical kyphosis. The decompression 10 years. The chances were
even higher at the
should be carried out anteriorly in cases C5-6 and C6-7 levels.
However, longer con-
of kyphosis and where the main compressing structs were found to have a
lower incidence of
force lies anteriorly due to disc and osteophyte adjacent level degeneration,
this surprise finding
prominences, but posterior surgery is preferable has fuelled the debate about
whether adjacent
for multi-level disease, posterior compression level disease was caused by
deleterious biome-
or ossification of the posterior longitudinal chanical effects or was
simply the progression of
ligament. the natural history of
degenerative disc disease.
The anterior decompression and fusion as Goffin et al. [37] also
found a 92 % incidence
described by Smith and Robinson or Cloward of radiographic changes at
adjacent segments
has a proven record for this condition and many 5 years after anterior
cervical decompression
consider that it is important to fuse the spine to and fusion.
prevent the repeated irritation of the Robertson et al. studied
radiological changes
myelomalacic section of spinal cord that could and symptomatic adjacent-
level cervical disc
result from disc replacement and the preservation disease after single-level
discectomy and
of movement at the diseased level [28]. subsequent cervical fusion
versus arthroplasty
However, when the cohorts of myelopathic using the Bryan disc. New
radiographic changes
patients in the multi-centre trials of the Bryan were seen in 34.6 % of the
fusion cases and in
disc and Prestige discs in the U.S.A. were 17.5 % of the arthroplasty
group at 24 months.
analysed, the outcome of treating myelopathy Symptoms related to these
changes only devel-
by disc replacement was equivalent to the fusion oped in 7 % of the fusion
cases with none in the
cases with improved neurological status in arthroplasty cases [60].
approximately 90 % of cases. This suggests Although controversy still
exists regarding
that concerns of treating myelopathy by disc the role of natural
progression of degeneration
replacement are not justified in the case of versus the effects of spinal
fusion, there does
single level disease with anterior cord seem to be an undesirable
alteration of
compression [58]. biomechanics after fusion
that arthroplasty may
However, in cases with multi-level disease, avoid. Cervical arthroplasty
has not yet been
kyphosis or ossification of the posterior longitu- proven to reduce the rate of
adjacent segment
dinal ligament, cervical disc arthroplasty remains deterioration and longer term
follow up is neces-
contra-indicated. sary. However, it does seem
as if cervical
arthroplasty can restore
relatively normal biome-
chanical function [61].
The Evidence for Adjacent Level Indications for cervical
disc replacement or
Disease After Anterior Cervical Fusion anterior cervical discectomy
and fusion:
1. Decompression of one or
two level cervical
One of the prime motivations for the develop- degeneration between C3
and T1 with nerve
ment of cervical disc replacement has been the root compression without
instability or cervi-
desire to prevent the alteration of the spinal bio- cal kyphosis.
mechanics that would result from spinal fusion 2. Single level cervical
degeneration causing
and have been blamed for causing accelerated myelopathy due to anterior
pathology between
degeneration of adjacent spinal segments. The C3 and T1.
influential paper by Hillibrand et al. [59], 3. Adjacent level symptomatic
disc degeneration
reported the incidence of symptomatic adjacent after previous cervical
fusion.
segment disease as 2.9 % per year after anterior 4. Axial neck pain but this
is not well supported
cervical fusion and extrapolation suggested that by the literature.
415
Indications for anterior cervical fusion where

disc arthroplasty is contra-indicated:
1. Cervical nerve root compression at three
levels of the cervical spine
2. Cervical myelopathy at more than one
level better suited to anterior corpectomy
and fusion
3. Cervical kyphosis requiring neural
decompression
4. Cervical instability (demonstrated on flexion
and extension lateral radiographs)
5. Any situation with loss of structural integrity
of the anterior column e.g. infection or
Fig. 7 Photograph of
traction applied to a harness. Care-
tumour damage ful alignment of head and
neck with head support. Shoul-
6. Indications for decompression in cases with ders are taped down to
improve x-ray access
severe facet joint degeneration
7. Osteoporosis
8. Previous laminectomy thus accurate mid-line
placement of the
9. Rheumatoid disease prosthesis.
10. Conditions leading to ankylosis of the spine Intermittent calf
compression is continued
such as ankylosing spondylitis, ossification throughout the procedure
for prophylaxis against
of the posterior longitudinal ligament thrombo-embolism.
(OPPL) and diffuse idiopathic skeletal Some favour external
traction with a Mayfield
hyperostosis (DISH) [42]. support or a head harness
to which varying
weights can be attached
at different stages of the
procedure to allow
different degrees of
Surgical Management intervertebral
distraction.
Taping of the
shoulders to keep them down
Decompression and Disc Arthroplasty during the operation
enables better access for
intra-operative imaging
(Fig. 7).
During patient preparation the surgeon must Prior to commencement
of the operation the
ensure that the clinical picture is carefully surgeon should ensure
that good lateral and
correlated with the imaging findings (e.g. anteroposterior imaging
can be obtained using
Fig. 5) so that the surgeon is clear about the the biplanar image
intensifier.
level and extent of the nerve or cord com- A left-sided approach
is favoured to reduce the
pression. Sufficient time should have elapsed risk of recurrent
laryngeal nerve damage [1].
to ensure that conservative treatment has The level of the
intended operation can be
failed. marked on the skin so
that the skin incision can
Patient consent should be obtained after full be placed in an ideal
position. Infiltration of the
explanation about the risks and potential benefits skin and subcutaneous
tissues with Bupivicaine
of the procedure. 0.5 % and Adrenaline in a
solution of
Prophylactic antibiotics are administered 1 in 200,000 units can
cut down bleeding and
intravenously. reduce the post-operative
analgesic requirements.
Under general anaesthesia via endotracheal After antiseptic
preparation of the skin and
intubation, the patient should be placed supine application of sterile
drapes, a transverse skin
over the radiolucent end of the operating table crease incision is made
extending from the ante-
with a support behind the neck and the head in rior border of the left
sternocleidomastoid muscle
a neutral position to facilitate good imaging and to a point just across
the mid-line. Haemostasis is
416
Fig. 8 Blunt finger tip dissection to expose the vertebral Fig. 9 Southwick-
Robinson left-sided approach medial
column to the left
sternocleidomastoid muscle (SCM)
achieved by a combination of monopolar and

bipolar diathermy.
The approach is that described by Southwick
and Robinson [1]. Dissection is medial to the
medial border of the sternocleidomastoid
muscle and medial to the carotid sheath.
A combination of fine scissor and blunt dis-
section with a finger tip opens up the fascial
planes and allows direct access to the front of
the vertebral column (Figs. 810).
The discs, vertebrae and longus colli muscles
are thus exposed. The level of the disc is checked
with a needle in the disc space and the image
intensifier in the lateral position (Fig. 11).
The image intensifier is then placed in position
for anteroposterior imaging and the mid-line of Fig. 10 Dissection
continues medial to the carotid sheath.
the disc is marked using diathermy on the verte- The descending branch
of the hypoglossal nerve is seen
bra on either side of the disc space (Fig. 12). overlying the carotid
sheath
Although the external traction via the harness
can suffice, we prefer to insert parallel Caspar
distraction pins which are placed in the mid-line
of the vertebra on either side of the disc space Once the disc
space is distracted, the
(Fig. 13). It is important that the pin in the vertebra intervertebral disc is
excised. A high speed burr
above is placed in the superior part of the vertebra and fine Kerrison
cervical bone punches are used
and the lower pin in the lower part of the inferior to remove posterior
osteophyte. The posterior lon-
vertebra so that they are not in the way of the gitudinal ligament is
exposed and removed with
instruments for disc space preparation and the the fine punches until
the spinal cord and cervical
insertion of the artificial disc. nerve roots have been
fully decompressed.
417
Fig. 11 Exposure of the vertebral column with the longus

colli muscle (L.C.) on either side of the midline
Fig. 13 Caspar
distraction and retractors (Braun
Aesculap) in place
allowing excellent access for removal
of cervical disc and
posterior osteophyte. The spinal cord
and cervical nerves are
fully decompressed
Fig. 12 Diathermy is used to mark the mid-line
Up to this stage, the operation of cervical

discectomy and nerve decompression is the
same, but from now on, there are differences
depending upon whether the disc is to be
replaced by a cervical disc prosthesis or anterior Fig. 14 Trial implant is
used to obtain optimal implant size
cervical fusion is planned.
Cervical Disc Replacement procedure described

below. The trial implants are
For cervical disc replacement the end-plates of the used to obtain an
optimally-sized device and the
vertebral bodies are prepared in the manner dic- appearances checked on
lateral fluoroscopy
tated by the choice of artificial disc. The Prestige (Fig. 14). It is
important to remove the distraction
disc (Medtronic Sofamor Danek) is used in the at this stage so that
the tension in the disc space can
418
a b
Fig. 15 (a) Photograph, (b) Diagram, showing pinning of guide and drilling of four
holes to mark sites for rail slots for
the prosthesis
a b
Fig. 16 (a) Photograph, and (b) diagram, showing the insertion of the rail cutter
to create slots in the position dictated
by the drill-holes
be judged. If the distraction were left in place, there drain for the first
24 h to deal with any post-
would be a danger of using too large a prosthesis, operative bleeding.
Discharge from hospital is
which could impede movement and also interfere allowed after 2448
h.
with facet joint function (Figs. 1518). A soft collar is
recommended for 4 weeks to
The wound is closed with an absorbable con- allow for soft tissue
healing and to prevent
tinuous suture (Polyglycolic acid) suturing the extreme movement
initially.
platysma muscle and then a subcuticular layer to The patient is
followed at 6 weeks, 3 months
minimise scarring. The authors advise a redivac and then 6 months
with dynamic lateral
419
Fig. 17 Insertion of the Prestige prosthesis using the

introducer
radiographs at the final visit to confirm good

anchorage of the components and that the level
has remained mobile as intended.
The Alternative Procedure of Anterior

Cervical Decompression and Fusion
The approach is identical to that described above

up until the completion of the decompression.
Then, when fusion is preferred to disc replace-
ment (See indications and contra-indications
above) we favour decortication of the end-plates
using a high speed burr, followed by insertion of
a shaped tricalcium phosphate (TCP) block into
Fig. 18 (a) Photograph
showing appearances after disc
the disc space, and application of an anterior insertion and (b) x-ray
checking of disc position
cervical plate (Fig. 19).
Wound closure, drainage and post-operative infection, dysphagia,
hoarseness due to recurrent
care are the same as described for disc arthroplasty. laryngeal nerve damage
and Horners syndrome
due to disturbance of the
cervical sympathetic
nerves.
Complications of Anterior Cervical
Surgery
Complications Specific to
Cervical Disc
Approach-Related Complications Replacement
Most complications are related to the surgical Device related problems

with the Bryan disc
approach with possible damage to the soft tissues, were very rare [36].
Prostheses that were well
vessels and nerves. They include: haemorrhage, placed showed no tendency
to migrate and
420
in 3.2 % and an average of

6.5# of movement was
retained at the operated
level [41].
Longer follow up may be
associated
with prosthetic failure,
but no reports exist at
present.
Complications Specific to
Anterior
Cervical Fusion
Graft related
Donor site: Pain,
infection and damage to the
lateral cutaneous nerve of
the thigh with painful
neuroma formation.
Neck graft site:
Failure of fusion can
occur, especially where
alternatives to autograft
are used. If there is
a painful pseudarthrosis,
re-operation may be
required with re-grafting.
When internal fixation
is not used, migration
of the graft can occur.
Internal fixation related
Fig. 19 Lateral radiograph of TCP block and overlying
plate Devices such as cages
can subside through the
vertebral end-plates.
no device had to be explanted at 2 years of Anterior plates can
become displaced and
follow-up. screws may loosen.
An analysis of patients in the European Plates can also impinge
upon neighbouring
multi-centre trial on the Bryan disc revealed levels and lead to adjacent
level disease.
that prevertebral ossification at the operated Adjacent level
degeneration
level occurred in 17.8 % of cases and 11 % of Although fusions have
been incriminated in
cases had negligible movement on dynamic the development of
junctional changes at
radiographs (less than 2# ) [62]. Heterotopic neighbouring levels, it is
not definitely proven
bone was especially likely in older males. that the changes are in
excess of those that
Ossification after inserting the Prodisc C device would occur with the
natural history of cervical
was reported by Bertagnoli et al. in patients with a degeneration [59].
1 year follow-up without any appearance of fusion
[63]. Later, Bertagnoli observed a 9.4 % incidence
of heterotopic ossification among 117 patients Conclusions Regarding
Anterior
treated with Prodisc C and followed for more Cervical Surgery: Disc
Replacement or
than 2 years [64]. Fusion
In a 4 year follow up, Suchomel et al. found
heterotopic ossification (grade III) in 45 % of Current evidence suggests
that cervical disc
implants and segmental ankylosis (grade IV) in replacement is a safe and
good alternative to
another 18 %. This finding had no clinical conse- anterior cervical fusion.
Equivalent early results
quences and 92 % of patients were satisfied with can be achieved and
movement is preserved in
their results [65]. the majority, but not in
all cases.
At 5 year follow up after the Prestige disc Revision surgery for
anterior cervical surgery
implantation, complete ankylosis was only seen is feasible and not
particularly hazardous.
421
Disc replacement is a justifiable alternative to operations with

long-term follow-up: surgical fusion is
fusion, but the long-term results are not yet known. unnecessary.
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15.
Surgical Treatment of the Cervical
Spine in Rheumatoid Arthritis
Zdenek Klezl and Jan Stulik
Contents
Abstract
General Introduction and Classification . . . . . . . . . 426
Cervical spine involvement in rheumatoid
arthritis (RA) is common and can lead to

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 429
severe pain, irreversible neurological deterio-

ration and even death. It presents a challenge
to the treating physician as the pain, neurolog-
ical symptoms and instability cannot be

433
Posterior
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
equated with each other.
RA of the cervical spine follows the same

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 442 pathophysiology as in the peripheral joints and
leads to instability due to atlanto-axial sublux-

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 445
ation, mid- and lower cervical spine instability

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 445 and basilar invagination. The clinical presen-
tation is variable and neurological assessment
is difficult due to peripheral disease. Patients
with minimal symptoms can have major life-
threatening instability.
Treatment goals are to prevent irrevers-
ible neurological deficit, alleviate intracta-
ble pain and to avoid death due to cord
compression.
Timing of surgical interventions is extremely
important. It is generally recommended to
address the instability (usually C1/C2)
early in order to avoid more extensive
fixation and fusion. Surgical stabilization
is challenging because of suboptimal bone
quality, increased risks of infection and

Z. Klezl (*)
difficult post-operative rehabilitation but
Department of Trauma and Orthopaedics, Spinal Unit,
generally leads to favourable outcomes.

Royal Derby Hospital, Derby, UK
e-mail: zklezl@aospine.org
Referral of patients to specialist rheuma-
tology centres and screening of cervical

J. Stulik
Spine Surgery Department, University Hospital Motol,
spine with flexion-extension radiographs
Praha, Czech Republic
and MRI scans seems optimal to avoid

425
DOI 10.1007/978-3-642-34746-7_24, # EFORT 2014
426
Z. Klezl and J. Stulik
patients presenting with major deformity,

instability and advanced myelopathy. Sur-
gical treatment of the rheumatoid cervical
spine is very demanding and should
therefore be performed at centres where
cervical spine surgery is performed on
a regular basis. In our experience, even
advanced neurological deficit can signifi-
cantly improve following well-executed
surgery.
Keywords
Cervical spine # Classification # Diagnosis #
Indications for surgery # Posterior # Rehabili-
tation # Rheumatiod arthritis # Techniques:
fixation: -anterior, C1-2, occipito-cervical,
sub-axial, upper thoracic
General Introduction and

Classification
Rheumatoid arthritis (RA) is a progressive,

immunologically-mediated disease with serious
physical, psychological and economic conse-
quences and the aetiology is unknown [25, 29].
RA affects about 1 % of the world population,
more than 2.9 million Europeans and over 2 mil- Fig. 1 Significant deformity
of the ankle and foot
lion patients in the United States. The clinical
course of RA fluctuates and prognosis is
unpredictable [14, 15]. 70 % of patients with
Class I Complete ability
to carry on all usual duties
recent onset of RA show evidence of radio-
without handicap
graphic changes within 3 years of diagnosis Class II Adequate for
normal activities despite
[39]. 50 % of RA patients are unable to work a handicap of
discomfort or limited motion
due to disability within 10 years of disease onset at one or more
joints
[1, 3, 32, 42]. Class III Limited only to
few or none of the duties of
The disease usually starts at metatarso- usual occupation
or self- care.
Class IV Incapacitated,
largely or wholly bedridden
phalangeal and metacarpophalangeal joints
or confined to a
wheelchair; little or no self-
and is characterized by inflammation of the care.
synovial membrane, destruction of hyaline car-
tilage and peri-articular inflammation resulting It was observed that in the
last decade the
in bony erosions and formation of synovial incidence of the disease has
dropped significantly
cysts. [10, 20] These processes lead to joint with fewer total hip and knee
replacements
laxity, instability, subluxation and deformity performed on rheumatoid
patients compared
(Figs. 1 and 2). with previous years [9, 17,
41]. The treatment
RA is generally classified according to the has changed as well with the
use of new disease-
American Rheumatologic Association functional modifying anti-rheumatic
drugs, (anti-tumour
capacity score. necrosis factor and anti-
interleukin 1 agents)
Surgical Treatment of the Cervical Spine in Rheumatoid Arthritis
427
Fig. 3 Basilar
invagination caused by destruction of
Fig. 2 Status post multiple surgeries for deformity, insta- C0-C1 and mainly C1-
C2 joints
bility and pain in the area of both wrists and hands
which led to decrease in steroid use and better

treatment results.
Cervical spine involvement is common in RA
(up to 90 %) with neurological involvement
occurring in 713 % of patients and the patho-
physiology follows the same pattern as that of the
small peripheral joints.
Involvement of the cervical spine was first
described by British geneticist Sir Archibald
Garrod in 1890 in his study of 500 patients, of
whom 178 had the cervical spine affected [43].
The disease usually starts at the C1-C2 level as
erosive synovitis affecting the ligaments around
the dens and joint capsules in the area which leads
to hypermobility of C0-C1 and C1-C2 joints and
later mainly to atlano-axial anterior subluxations.
C1-C2 joints may be affected by erosions and
destruction of bone and cartilage resulting in
lateral subluxation or, as the joints are symmetri-
cally destroyed, the whole of C2 (including the
dens) migrates proximally into the foramen mag- Fig. 4 Massive panus
formation visible behind the dens,
num. This is also referred to as basilar invagina- which is eroded at
its base
tion, vertical subluxations of the dens or cranial
settling (Fig. 3).
Dens erosions are frequent and pannus may step deformity due
to subluxations (staircase or
form around the dens, narrowing the spinal canal stepladder appearance
of sub-axial spine).
significantly. In case of significant destruction of Conlon et al [8]
demonstrated that 50 % of
the anterior arch of C1 or the dens [which can patients with
cervical spine involvement had
fracture once weakened] rare posterior subluxa- radiological signs of
instability. Anterior atlanto-
tions of C1/C2 can occur (Figs. 46). Sub-axial axial subluxation
represents two-thirds of rheuma-
spine, intervertebral discs and facet joints can be toid cervical
subluxations (65 %), 20 % are lateral
involved in one or more levels usually leading to and 10 % posterior
[3, 10, 23].
428
The incidence of
lower cervical spine subluxa-
tion ranges between 20 %
and 25 %. Basilar invag-
ination with or without
atlanto-axial subluxation
occurs in approximately
20 % of patients. Neuro-
logical deficit varies
from 11 % to 58 % [7, 13, 36],
which is due to the
difficulty in detecting
subtle loss of strength
from spinal cord com-
pression in the presence
of weakness and dis-
use atrophy arising from
painful peripheral
joints (Figs. 1 and 2).
Neurological
deterioration can be irrevers-
ible and the presence of
myelopathy is an
indicator of significant
cord compression.
Patients with advanced
myelopathy have poor
prognosis. Typical signs
and symptoms of mye-
lopathy include weakness,
spasticity, bowel and
bladder dysfunctions,
loss of proprioception,
hyperreflexia, positive
Hoffmann sign, gait
disturbance, paraesthesia
and loss of dexterity.
In many older RA patients
these signs and
Fig. 5 Subsequent fracture of the eroded dens
symptoms can be difficult
to assess. Worsening
neurological deficit is
most frequently hidden in
the patients history in
expressions like: I can-
not unbutton my shirt; I
can no longer walk the
usual distance; I can no
longer walk; my gait is
very unstable; whenever I
bend my head I feel
electric shocks in my
arms and legs or I lose
consciousness. A careful
examiner should
focus on this highly
significant information.
Electrophysiological
examination is extremely
helpful in diagnosis of
early cord compression.
It can be performed as
dynamic examination in
extension and flexion of
the head. Pathological
potentials are frequently
recorded in flexion,
when the cord compression
occurs.
Up to 10 % of
patients with RA die of
unrecognized spinal cord
or brain stem compres-
sion. It usually takes
about 10 years for severe
instability to develop
but in patients with the
mutilating form of the
disease it can occur within
2 years of diagnosis.
Various functional scoring
systems have been used to
classify and monitor
neurological deficit.
The most frequent are
the Frankels classifica-
tion grading system for
acute spinal cord injuries
Fig. 6 Peridental panus causing cord compression at the (Table 1), Ranawats
classification of neurological
C1 level with high signal in the spinal cord present deficit [34] (Table 2),
Nuricks classification
429
Table 1 Acute spinal cord injury Frankel Classification system for

myelopathy on the basis of gait
grading system abnormalities [28]
(Table 3) and JOA or modified
Grade A Complete neurological injury no JOA systems [21].
motor or sensory function clinically
detected below the level of the injury.
Grade B Preserved sensation only no motor
function clinically detected below the Diagnosis
level of the injury; sensory function
remains below the level of the Diagnosis of
rheumatoid arthritis is by exclusion
injurybut may include only partial
of other
seronegative spondyloarthopathies such
function (sacral sparing qualifies as
preserved sensation). as ankylosing
spondylitis, systemic lupus
Grade C Preserved motor non-functional some erythematosis,
psoriatic arthritis, reactive arthritis
motor function observed below the (formerly Reiters
syndrome) and other poly-
level of the injury, but is of no practical arthropathies
associated with inflammatory bowel
use to the patient.
disease.
Grade D Preserved motor function useful
motor function below the level of the Laboratory tests
include ESR which is ele-
injury; patient can move lower limbs vated, rheumatoid
factor is positive in 7080 %
and walk with or without aid, but does of patients, anti-
nuclear factor is positive in
not have a normal gait or strength in all 3070 % of patients.
CRP is non-specific but
motor groups.
can be used as a
marker of the activity of the
Grade E Normal motor no clinically detected
abnormality in motor or sensory disease.
function with normal sphincter Cervical spine
involvement is seen well on
function; abnormal reflexes and plain radiographs,
which frequently show subtle
subjective sensory abnormalities may signs of atlanto-
axial instability. The full extent
be present.
of instability can
be appreciated on flexion and
extension views.
Plain radiographs provide little
information on real
space available for the spinal
cord (SAC) and MRI
scans are routinely used to
determine the SAC
which should ideally be more
than 14 mm in the
upper cervical spine. SAC less
Table 2 Ranawat Classification of Neurologic Deficit than 14 mm is
considered to be pathological
Class I Pain, no neurologic deficit
and if less than 10
mm is regarded as critical
Class II Subjective weakness, hyperreflexia, and usually with a
poor prognosis. MRI is
dyesthesias the examination of
choice for demonstrating pos-
Class III Objective weakness, long tract sible changes in the
spinal cord, ligamentum
signs transversum
atlantis, intervertebral discs of the
Class IIIA Class III, ambulatory sub-axial spine or
of the pannus, which may sig-
Class IIIB Class III, nonambulatory nificantly narrow
the spinal canal [11, 22].
Table 3 Nuricks classification system for myelopathy on the basis of gait

abnormalities
Grade Root signs Cord involvement Gait
Employment
0 Yes No Normal
Possible
I Yes Yes Normal
Possible
II Yes Yes Mild
abnormality Possible
III Yes Yes Severe
abnormality Impossible
IV Yes Yes Only with
assistance Impossible
V Yes Yes Chair bound or
bed ridden Impossible
430
Fig. 7 Different
measurements of cranial
migration of the dens
Yellow line: McRay line Blue line: Chamberlain

line
White line: McGregor line Red line: Redlund-Johnell
and Pettersson parameter
High resolution MRI scans may be useful in the

future [40]. MRI is a static examination and
although the SAC seems reasonable on scans
taken in the supine position, dynamic compression
may regularly occur with head flexion. CT scans
are valuable in assessing bone loss, rotatory and
lateral subluxation and play a major role in pre-
operative planning, determining the course of the
vertebral arteries and the dimension of structures
where we plan to introduce screws in the C1 and
C2 vertebrae.
Basilar invagination or cranial settling is mea-
sured using various methods and lines [35]
(Figs. 7 and 8).
McGregor line: Caudal part of occiput to hard
palate. When dens is 4.5 mm. above this line, it is
a pathological finding.
McRay [method or lines]: Occiput to clivus Fig. 8 Clarks station of
the atlas evaluating cranial
(foramen magnum diameter), tip of the dens migration of the dens
should not cross this line.
Redlund-Johnell and Pettersson parameter: Once the C1-C2 joints are
destroyed, the middle
Distance from middle of the bottom of C2 third of the odontoid
corresponds to the ring of
endplate to McGregor line which should be less atlas indicating mild to
moderate cranial settling
than 34 mm. in men and less than 29 mm. in and when the bottom third of
C2 corresponds
women. to the ring of atlas, there
is severe cranial
Clark station of the atlas: The Odontoid settling [6].
process is divided into thirds; 1st third (upper) Ranawat criterion: The
distance between the
should correspond to the anterior ring of atlas. centre of the second
cervical pedicle and the
431
transverse axis of the atlas is measured along the treatment results of a

surgically-treated group of
axis of the odontoid process. Once the distance 19 patients and
conservatively-treated group of
between these two lines is less than 15 mm in 21 patients, who were
treated in different hospital.
males and less than 13 mm in females, cranial Patients were observed
until death. The survival
settling is present. rate in the surgical
group was 84 % in 5 years and
Riew et al [35] found that none of the currently 37 % in 10 years, 68 % of
them improved clinically.
published lines and parameters used alone can There was no improvement
in the conservative
diagnose basilar invagination accurately. The group, 76 % worsened, all
patients were bedridden
highest accuracy was reached using a combination by 3 years and none
survived for longer than
of criteria by Clark [6], Redlund-Johnell, 8 years. Singh et al
looked at 50 surgically-treated
Pettersson and Ranawat. If any of these suggest patients with myelopathy
and compared this group
basilar invagination, CT or MRI should be to 34 patients who
declined surgery or were not fit
performed. This also demonstrates the need for for it, by using the
validated 30 m walking test.
a low threshold for requesting MRI scans in rela- The test confirmed
lasting improvement following
tion to possible pannus formation as described by surgery at 3 years.
Unoperated patients continued
Dvorak [11]. to deteriorate.
Interestingly, they noticed remark-
able improvement of
severe myelopathy in older
patients [37, 38]. This
was also our experience.
Indications for Surgery In the majority of
cases, the disease manifests
itself as atlanto-axial
instability with clinical
The major challenge is to have the right indica- symptoms varying from
very subtle to a severe
tions and to avoid unnecessary high risk surgery. myelopathic picture. If
detected early it is best
As discussed previously, pain cannot be equated treated by atlanto-axial
immobilization (fusion),
to instability, or instability to neurological symp- which eliminates severe
pain, further subluxa-
toms. Careful detailed follow up of rheumatoid tion and progressive
tissue destruction and cra-
arthritis patients leads to correct indications for nial settling. We try to
avoid fusion to the
surgery which are: occiput because this
leads to significant decrease
1. Intractable pain of flexion of the head,
which makes activities
2. Increasing neurological deficit (even sub-clin- of daily living difficult
e.g. eating or brushing
ical, documented on somatosensory or motor teeth.
evoked potential or both)
3. Posterior atlanto-dental interval (SAC) less
than 14 mm Pre-Operative Preparation
and
4. Cervicomedullary angle of less than 135# Planning
5. Lateral subluxation of more than 2 mm
6. Increasing instability (atlanto-axial or cranial Pre-operative assessment
should be elaborate,
settling). considering the systemic
nature of the illness,
Indications for surgery have changed in the increased incidence of
anaemia in chronic disease,
recent years with surgeons being more pro-active, increased risk of both
frequency and severity of
encouraged by the good results following surgery. post-surgical infections
(especially associated
Surgery for cervical myelopathy is no longer with immunosuppressive
agents) and significantly
considered as waste of effort and resources, but reduced bone quality.
has major role in treatment of this potentially Spinal instrumentation
for the upper and lower
lethal condition [17, 26]. There is currently no cervical spine has made
enormous progress since
level-one evidence on surgical treatment of mye- the time Gallie published
his C1-C2 simple
lopathy in rheumatoid arthritis patients. The best wiring technique in 1937
[12]. Double wiring
available evidence is documented in the study by technique was then
introduced by Jenkins and
Matsunaga et al [26]. They have compared Books. Sub-laminar wires
have been used for
432
Fig. 9 AP intraoperative view of transarticular screw Fig. 10 Lateral intra-

operative view of the same technique
fixation (Magerl)
many years to stabilize the spine together with using lateral and sagittal
CT reconstructions of
structural bone graft harvested from the pelvis or the C1-C2 is routinely
performed.
later with Luque or Ransford loops. The posterior approach
dominates surgical
Modern instrumentation started with first treatment of rheumatoid
patients. Indications for
universal system combining plate-rod screw the trans-oral approach are
extremely rare. The
fixation developed by Jeanneret in 1992. Wiring approach is no longer
indicated for pannus resec-
techniques are no longer used except as part tion as it resolves within
a few months of an
of transarticular screw fixation or in special atlanto-axial fusion (Figs.
11 and 12) [16, 22].
circumstances. There is very little room for Trans-oral decompression is
indicated in severe
non-instrumented posterior decompressions in cases of irreducible
cranial migration of the dens
RA patients. into the foramen magnum and
in cases of cervico-
Some of the commonly used techniques are: medullary compression.
1. Transarticular C1-C2 screw fixation (Figs. 9 Once the C1-C2
instability is combined with
and 10) as described by Magerl [16] cranial migration of the
dens, occipito-cervical
2. Lateral mass C1-C2 fixation described by fixation is used.
Unfortunately atlanto-axial insta-
Goel [11] and Harms and Melcher [18] bility with cranial
settling is frequently combined
3. Occipito-cervical stabilization with sub-axial instability
and subluxation. In these
4. Occipito-thoracic stabilization cases occipito-cervical
fixation is extended down
5. Anterior approach, placement of strut graft or to the upper thoracic spine
(C0-T1) to avoid junc-
cage and plate fixation. tional instability (Figs.
13 and 14).
All the posterior techniques carry the risk of Complex deformities
(Figs. 15 and 16), which
injury to the vertebral artery and require pre- involve both upper and
lower cervical spine,
operative imaging to minimize the risk. Solanki require a combination of
both anterior and poste-
and Crockard [27, 38] identified a frequent abnor- rior stabilization (Figs.
16 and 17). This is also
mal course of the vertebral artery in their exten- true for trans-oral
surgery. Once the anterior
sive work (22 % vertebral artery groove resection of the C1 arch is
performed, posterior
anomalies noted). Currently careful planning stabilization is
neccessary.
433
Fig. 11 Panus extent before surgery and after 5 months Fig. 12 Panus extent
before surgery and after 5 months
following C1-C2 fixation following C1-C2 fixation
bleeding at this stage.

Bony landmarks are iden-
Operative Techniques tified by palpation, the
occiput, usually bifid and
prominent spinous process
of C2 and the highest
Posterior Approach spinous process of T1.
The tubercule of C1 can
be palpated proximally to
the spinous process of
The patient is placed in prone position in reverse C2. However, sometimes it
cannot be palpated,
Trendelenbourg position (head up) with the head because it lies right
below the occipital bone
placed on a head-rest or in a Mayfield clamp. especially in cases of
cranial settling. Exposure
Positioning of the head is very important and of the bony elements in
the occipito-cervical
should be done by the surgeon himself or area should start in the
mid-line and expand
a qualified assistant. Maximum care should be laterally, symmetrically
on both sides. Sub-
taken to avoid injury to the eyes, which is an periosteal dissection of
muscle insertions leads
infrequently reported, but potentially cata- to less muscle damage and
facilitates later
strophic complication. Hair should be shaved reinsertion to C2.
above the external occipital protuberance to facil- Lateral fluoroscopy
is necessary, the C-arm is
itate sterile draping. A mid-line incision should located opposite the
surgeon.
be drawn on the skin to avoid oblique incisions. Exposure of the
occipital bone is not associ-
Identifying mid-line after the skin incision is not ated with any problems
but exposure of C1 can
easy and is best done at the distal part of the be. Exposure is carried
out from the tubercule of
incision, where the fibrous septum separating C1 which is in the
midline out laterally. The safe
the muscles on each side is better developed. zone is considered to be
1.5 cm to each side.
Dissection in this plane significantly reduces Further exposure should
be done with extreme
434
cable-wires or a non-resorbable
strong suture
need to be passed under the
arch of C1 (Magerl).
This should be done carefully
using a blunt nee-
dle or Dechamp suture-passer to
avoid CSF leak
or cord injury. In case of
lateral mass screw
insertion (Goel, Harms), the
entry point of the
screw is identified under the
C1 arch by strict
sub-periosteal dissection to
avoid injury to the
C2 nerve root and venous plexus
which may
lead to profuse bleeding. The
lamina of C2 is
exposed laterally to the edges
of the lamina, the
atlanto-axial membrane between
the arch of C1
and C2 is exposed and the
pedicle of C2 is iden-
tified by palpation from inside
the canal using
a Milligan dissector. Once all
the anatomical
landmarks are identified, screw
insertion can be
performed. A towel clip
attached to the spinous
process of C2 is helpful in
stabilizing it during the
exposure. Profuse bleeding is
sometimes encoun-
tered even with very gentle
dissection of the C1
lateral masses. Quick placement
of the partially-
threaded screw and tamponade of
the venous
Fig. 13 Pre-operative films showing dens erosion, plexuses by the screw head and
Surgicel will
atlanto-axial instability and lateral subluxation help.
Transarticular Screw Fixation

Screws are inserted from the
posterior aspect of
C2 lamina parallel to the
spinal canal across the
joints of C1-C2 into the
lateral masses of C1
(Figs. 1720) [16]. The screws
should avoid ver-
tebral arteries. It is
recommended to place the
screws as medially and as
proximally in the sag-
ittal plane as possible. This
technique includes
graft insertion in between the
arches of C1 and C2
which is secured in position by
wire, cable-wire
or suture. Well-positioned
graft provides 3-point
stable fixation. This technique
requires reduced
alignment of C1 and C2. Partial
reduction of
C1-C2 on the table can be
performed by pulling
Fig. 14 Pre-operative films showing dens erosion,
atlanto-axial instability and lateral subluxation
on the cable wire or strong
suture around the C1
arch, which is always
introduced first. It is some-
times difficult to follow the
trajectory of the
screw in the lateral view
because of the promi-
caution with a thin rasp or clamp-held peanut to nent back of the patient.
avoid vertebral arteries as they emerge from This requires:
the lateral masses of C1 and converge medially 1. enlarging the exposure to
the upper thoracic
on the proximal surface of C1. In case spine,
of transarticular screw placement, wires, 2. using a cannulated screw
technique,
435
Fig. 15 Transarticular fixation with bonegraft held in place between the arches of
C1 and C2 with cable wire
Fig. 17 Major atlanto-

axial subluxation on axial CT and
lateral X ray
3. using percutaneous
screw placement through
two stab incisions at
the level of T2-T4 with
normal exposure of C1
and C2 (preferred
option).
From our experience
as well as that of the
techniques author, we
do not advocate exposure
Fig. 16 Transarticular fixation with bonegraft held in and decortications of
the C1-C2 joints as origi-
place between the arches of C1 and C2 with cable wire nally recommended.
436
Fig. 20 CT sagittal and

coronal view of the same patient
available to avoid
irritation of the C2 nerve root
by the screw thread
which is a well-recognized
Fig. 18 Major atlanto-axial subluxation on axial CT and disadvantage of the
method. C2 crews are
lateral X ray transpedicular screws as
described by Judet in
1962. The screws used
have polyaxial heads and
allow reduction of
subluxation on the table,
which is a well-
recognized advantage of the
method (Figs. 2125).
The stability of the
two constructs is the same,
provided the Magerl
technique is combined with
the wiring. Sometimes
the arch of C1 is missing
and in that case the
Goel/Harms technique would
seem better. It has been
considered that the pedicle
screw fixation of the
Goel/Harms technique had
lower risk of intra-
operative injury of the vertebral
artery. However, in the
study by Makoto et al, the
risks were found to be
the same [24].
Sometimes pedicle or
transarticular screws
cannot be used in C2
vertebra because of
unfavourable vascular
anatomy. Wrights tech-
nique is a good option
[42]. Screws are placed
into the lamina of C2
which is well-developed
Fig. 19 CT sagittal and coronal view of the same patient and are connected to the
rest of the construct
(Figs. 2629).
C1-C2 Fixation In case of a
complication at C1-C2 level, the
Screws are placed into lateral masses of C1 either Gallies or Brooks and
Jenkins single or double
straight or slightly converging medially [13, 18]. wiring techniques or
occipito-cervical instrumen-
Special screws with partially threaded shafts are tation [30] can be used
as a secondary option.
437
Fig. 21 Lateral and AP X ray of posterior C1-C2 fixation according to Goel-Harms

with good reduction of the
subluxation
Occipito-Cervical
Fixation
Occipito-cervical
fixation is usually indicated in
advanced stages of the
disease which is associated
with cranial settling.
Sub-periosteal dissection of
the rectus capitis
posterior minor and major
exposes the occipital
bone. The bone is thicker in
the mid-line. Screws
should therefore be placed in
this area and not above
the inion, which could
result in profuse
bleeding from the intracranial
sinus. All currently
available instrumentations
have special occipital
plates which allow for inde-
pendent placement and
later connection with the
rods attached to the
upper or lower cervical spine.
The thickness of
occipital bone in the mid-line
varies from 10-16 mm.
Drilling the screw holes
should at all times be
done using a depth-
restricting sleeve to
avoid injuring the cerebellum.
Sometimes a CSF leak is
encountered, which is
Fig. 22 Patient with long-standing RA and major cervi- not a serious
complication. It is sealed by screw
cal spine involvement placement in the hole.
Three screws usually
438
Fig. 23 Patient with long-standing RA and major cervi-

cal spine involvement Fig. 25 Patient
underwent surgery using the Wright tech-
nique of anchoring
screws in the lamina of C2
provide enough
stability. If the older plate rod
systems are used, the
occipital plates should be
contoured towards the
midline and screw holes
should be drilled aiming
towards the mid-line of
the occiput. Rod
contouring is very important in
extensive fixations
extending to the thoracic spine.
Post-operative position
of the head should be
discussed with the
patient. The rods should be
contoured to
approximately 90# . A common mis-
take is excessive
flexion (group of mushroom
pickers) or rarely
exaggerated extension (group
of astrologers) (Figs.
3034).
Sub-Axial Fixation
In cases where sub-axial
fixation is necessary,
lateral mass screw
insertion is used in C3C7.
Two techniques were
described by Roy-Camille
and Magerl. The latter
is used widely because it
provides better screw
purchase in the bone, the
screw canal is longer
and purchase is bi-cortical.
The surgical technique
was recently simplified by
Fig. 24 Patient underwent surgery using the Wright tech- Bayley et al [2]. Their
investigation was based on
nique of anchoring screws in the lamina of C2 analysis of 80 digitized
cervical spine CT scans.
439
Fig. 28 Occipito-cervical
fixation was performed follow-
ing wide decompression of
the cord using independent
occipital plate in
combination with top loading polyaxial
Fig. 26 74 year old female, Ranawat 3B with cord com- screws
pression at foramen magnum and C3-C4 level
Fig. 27 Intra-operative confirmation of decompression

of the foramen magnum with ball tip hook
A virtual screw trajectory, 2 mm from and paral-

lel to the lamina was placed through the lateral
Fig. 29 Occipito-cervical
fixation was performed follow-
mass of C3 to C7 vertebrae and potential viola- ing wide decompression of
the cord using independent
tion of the transverse foramen was assessed and occipital plate in
combination with top loading polyaxial
was not found. The authors have been using this screws
440
Fig. 32 Flexion-
extension films demonstrating partial
mobility at the area of
destruction of subaxial spine and
atlanto-axial
subluxation as well
Fig. 30 Patient has regained sphincter control, self care

and mobilizing with an aid
Fig. 33 MRI view of the

critical spinal canal stenosis and
myelopathy at C4 level
laterally [2]. Apart

from lateral masses, pedicles
Fig. 31 Flexion-extension films demonstrating partial
mobility at the area of destruction of subaxial spine and
may be used as
anchoring points for screws.
atlanto-axial subluxation as well This especially applies
to the C7 level where
pedicle screw fixation
is frequently superior to
laminar guidance for the last 15 years without the lateral mass.
Confirmation of the absence of
injury to the vertebral artery. The technique usu- the vertebral artery
has to be done on pre-
ally requires resection of the bifid spinous pro- operative imaging. The
medial angulation of the
cesses in order to aim the drill sufficiently C7 pedicles can be
assessed. In case of any doubt,
441
very difficult and

therefore key-hole opening of
the spinal canal and
palpation of the medial bor-
der of the pedicle from
inside of the spinal canal
with a Milligan
dissector, as mentioned above, is
an option.
Anchoring individual
screws is critical, espe-
cially in osteoporotic
bone and multi-point fixa-
tion is usually
performed.
Performing posterior
cervical fusion remains
a controversial issue;
based on our good experi-
ence with fusion we
support fusion in rheumatoid
patients. Meticulous
decortication with a high-
speed burr creates an
ideal host bed for the
autologous locally-
harvested or iliac crest bone
graft. Bone graft is
carefully placed onto the
decorticated areas and
compressed to allow good
contact as osteoblasts
are very good climbers
but very bad jumpers.
Use of BMP-2 is also
a viable option. Bone
graft harvesting is
a separate surgical
procedure with associated mor-
bidity and complications
in up to 1520 % with
frequently wound healing
problems. Good results
have been reported
without fusion [27].
Anterior Approaches
Fig. 34 MRI scan following 1st stage of anterior surgery The trans-oral approach
was frequently used to
which helped to improve the sagittal alignment of the decompress the spinal
cord from peridental
cervical spine pannus. It has been
found to be unnecessary
because resolution
occurs with immobilization.
Trans-oral decompression
is indicated in cases of
small fenestration of the lamina enables direct fixed kyphotic deformity
and brain stem com-
palpation of the pedicle from inside the spinal pression. The
decompression usually involves
canal. Pedicle screw technique is not used rou- resection of the
anterior arch of C1, sometimes
tinely in other than C7 segment. Intra-operative also of the clivus.
Stabilizaton by anterior C1-C2
navigation makes the pedicle screw placement transarticular screws is
possible and usually pos-
safer and will probably lead to more frequent terior stabilization
follows.
use of the technique, especially in osteoporotic Although pre-
operative traction is seldom
bone. used in RA patients, it
is used in cases of major
basilar invagination of
the dens. Reduction of the
Upper Thoracic Spine Fixation invagination can be
achieved thus eliminating
Fixation to the upper thoracic spine is done by need for trans-oral
decompression.
inserting transpedicular screws into the T2, T3 or The anterior approach
to the sub-axial spine is
T4 pedicles. Another possibility is claw fixation same as for any other
pathology. We must stress
using laminar hooks. Use of polyaxial screw the presence of
suboptimal bone quality. Preser-
heads significantly simplified the fixation in tran- vation of intact bony
end-plates is essential for
sition of cervical to thoracic spine because con- force transmission to
the bone graft or mesh cage.
nection to the rods is much easier. Intra-operative Cement screw
augmentation is a viable option in
imaging of the upper thoracic pedicles may be cases of severe
osteoporosis (Figs. 3540).
442
Fig. 35 AP and lateral X rays demostrating 2nd stage

surgery from posterior approach, occipito-thoracic
stabilization
Fig. 36 AP and lateral X

rays demostrating 2nd stage
surgery from posterior
approach, occipito-thoracic
stabilization
Post-Operative Care and
Rehabilitation
simulate activities of daily
living like buttoning
Stable fixation of the cervical spine facilitates a shirt, locking-unlocking
doors, opening
post-operative care and subsequent rehabilita- a window, and handling cups
and cutlery.
tion. This is frequently very demanding espe- Recently the use of
electrical stimulation and
cially due to the advanced peripheral joint exercise to increase muscle
strength in patients
involvement. Fixation should be stable enough after surgery for cervical
spondylotic myelopathy
to enable patients to sit and walk within a few was reported by Pastor [31].
days. Successful post-operative rehabilitation
involves early mobilization, input from occupa-
tional therapists and provision of domestic after- Complications
care. In general, activity and exercise provoke
favourable responses in physical and psycholog- Intra-Operative
ical benefits. Dynamic (aerobic) exercises as well Most serious complications
with catastrophic
as hydrotherapy are used to enhance range of consequences involve the
spinal cord and the
motion in joints, muscle power and co-ordination vertebral arteries. The
spinal cord can be injured
and to prevent contractures. Because hand func- during positioning, so this
has to be done in a very
tion is frequently compromised in myelopathy careful and controlled way.
The spinal cord can
patients, specific long-term exercises concentrat- be injured by inserting
screws and wires into the
ing on fine movement of the hand and fingers spinal canal, and passing
wires under the arch of
are necessary. These focus on exercises which C1 may be difficult when
there is little space
443
Fig. 37 Major improvement in wound appearance with VAC dressing in 6 weeks
left for the dorsally-displaced spinal cord. Spinal which demonstrated equal
or smaller size of the
cord monitoring is extremely helpful when major ligated artery [19]. It
is important not to continue
instability or deformity is treated. with drilling C2 on the
other side once one artery
Even with adequate pre-operative planning, is already injured. The
other area where the artery
injury of the vertebral artery while drilling can be injured is at the
top of C1. Safe exposure of
transarticular or C2 pedicle screws may happen. C1 arch is considered to
be up to approximately
Wright and Lauryssen looked at risks of vertebral 15 mm on each side of the
arch from the mid-line.
artery injury in 2492 patients. They concluded In general, the vertebral
artery is difficult to ligate
that the risk of injury per patient was 4.1 %, unless an adequate
exposure is made. Therefore
neurological deficit at 0.2 % and mortality of balloon occlusion in case
of continuous bleeding
0.1 % [43]. The best way to control the bleeding is recommended [43].
is to insert a shorter screw. The authors have Profuse bleeding from
the venous plexuses
experienced 2 such episodes and know of further can be encountered while
preparing the entry
5 which all were treated in this way, luckily point for the C1 lateral
mass screws. It is best
without any major neurological consequences. treated by using Gelfoam,
Surgicel or Floseal and
This experience was confirmed by retrospective applying pressure on the
area by the polyaxial
evaluation of 15 patients who had one vertebral screw head.
artery ligated during cervical spine tumour resec- Post-operative early
complications: wound
tion. All patients had pre-operative angiography dehiscence and infection
are the most frequent
444
Fig. 38 Dislodgement of instrumentation following a fall Fig. 39 Progressive

junctional instability below the
from standing height instrumentation
post-operative complications, which require revi-

sions, re-drainage and re-suture. VAC dressing
(Fig. 41) is a major help in this area. Wound
healing problems may also occur at the occiput
right at the top of the cervical collar. A collar
should not be worn in the bed unless absolutely
necessary.
Post-operative late complications include:
dislodgement of instrumentation, non-union
and adjacent segment instability. Dislodgement
of instrumentation can be caused by sub-optimal
anchoring of screws in the bone due to poor
bone quality or surgical technique. Non-union
with progressive instability and adjacent
segment instability are late complications.
Although spinal surgeons fight for every
mobile segment, careful consideration has to
be made in RA patients. If subtle signs of insta-
bility are detected at other levels on pre-
operative imaging, extending fusion below
these segments is recommended even if this Fig. 40 Major extent of
cranial migration of the dens and
represents extending the fixation down to the sub-axial involvement of
the cervical spine, patient
upper thoracic spine. declined to have surgery
445
made in development of
spinal instrumentation,
polyaxial screw-rod
constructs, occipital plates
etc, which facilitate
more extensive fixation,
ranging from C1-C2 to
occipito-thoracic levels.
The vast majority of
interventions are by
a posterior approach.
Indication for a trans-oral
approach for pannus
resection no longer exists
since the pannus
resorbs well following stabiliza-
tion of the C1-C2
segment. The current strategy is
to address cervical
instability rather earlier than
later. Because it most
frequently involves atlanto-
axial area, C1-C2
fixation according to Magerl or
Goel-Harms is logical.
Careful pre-operative
planning is essential
when using both techniques
because of the possible
abnormal course of the
vertebral arteries. C1-
C2 fixation prevents further
destruction of the
atlanto-axial joints and pro-
gressive migration of
the dens proximally. It
also results in less
restricted movement than
Fig. 41 Major extent of cranial migration of the dens and
occipito-cervical
fixations. When dealing with
sub-axial involvement of the cervical spine, patient more advanced stages of
the disease more exten-
declined to have surgery sive surgery is
necessary including the occiput.
Adequate position of
head should be maintained
especially when the
fixation extends to the upper
thoracic spine. Minimal
sub-axial subluxations
should be considered
when planning shorter
Summary occipito-cervical
fixation, usually in young
patients. All
potentially unstable levels should
It is essential that the general medical Physicians be involved in the
instrumentation eliminating
and Rheumatologists are aware of the possible the need for revision
surgery for adjacent seg-
devastating effects RA may cause to upper and ment instability.
lower cervical spine. Regular follow- up and Surgical treatment
of cervical spine involve-
screening of RA patients using dynamic X rays ment in patients with
RA is associated with diffi-
and MRI in rheumatology centres is ideal to culties and
complications but is equally rewarding
avoid presentation of patients with major insta- to the patients and the
treating surgeons.
bility, deformity and late stages of cervical mye-
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Thoracic Outlet Syndrome
Henk Giele
Contents
Abstract
450 Thoracic outlet syndrome (TOS) in its sim-
plest form is postural compression of the

subclavian artery causing relative ischaemia

Relevant Applied Anatomy, Pathology
of the upper limb presenting as fatigue, clau-
and Basic Science: Biomechanics . . . . . . . . . . . . . 451
dication and pallor usually with overhead
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 453 activity or caudal depression of the shoulder.
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 453 The compression may become constant rather
Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 453
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 455
than postural, and the compression may
involve the nerves of the brachial plexus rather

Treatment and Indications for Surgery . . . . . . . . . . 456
than the artery. The classic neurological pre-

Non-Operative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 456
Operative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 456 sentation is of compression of the lower roots
or lower trunk of the brachial plexus

456
presenting with severe ulnar neuropathy but

Supra-Clavicular Exploration Technique . . . . . . . . 456
including wasting of abductor pollicis brevis
(the median nerve T1 innervated muscle) and
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 457
including sensory disturbance of the medial
forearm (the medial cutaneous nerve of the

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 458
forearm arises proximally from the medial

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 459 cord). However such obvious signs of severe
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 461 neuropathy are very rare and usually the
compression or irritation is mild, intermittent,
postural, and proximal leading to ill-defined
symptoms and signs. In these cases thoracic
outlet syndrome is a frustrating condition to
diagnose, leading many to ignore it or even
refute its existence.
This chapter aims to assist in the diagnosis
and treatment of thoracic outlet syndrome by
explaining both the classic and difficult pre-
sentations of the syndrome, the examination
manoeuvres, investigative techniques, the

H. Giele
Oxford Radcliffe Hospitals, Oxford, UK
indications for surgery, the operative
e-mail: henk.giele@mac.com
approach, outcomes and complications.

449
DOI 10.1007/978-3-642-34746-7_23, # EFORT 2014
450
H. Giele
Keywords Box 1 Synonyms for

Thoracic Outlet
Aetiology # Anatomy and biomechanics # Syndrome
Clinical diagnosis and tests # Complications # Thoracic Inlet syndrome
Non-operative treatment # Operative Scalenus Anticus syndrome
technique # Operative treatment # Results # Costo-clavicular
compression
Thoracic outlet Cervical rib syndrome
Nafzigger syndrome
Thoracic outlet syndrome like all syndromes is of an anomaly but the

presence of which indicates
a constellation of symptoms and signs that allow potential for enormous
variation in unseen soft
clinical diagnosis and treatment. However unlike tissue anomaly. To add
further complexity the
other syndromes the constellation of symptoms pathology in thoracic outlet
syndrome may be
and signs in thoracic outlet syndrome are so ill- positional and intermittent.
The pathology can
defined, that there are many doctors who doubt effect artery or vein or
both, or the pathology
the existence of the condition. may effect any or part of
the nerves of the bra-
The name of the condition [1, 2] refers to the chial plexus. Nerve
compression causes symp-
symptoms and pathology arising from compres- toms by ischaemia, and
proximal peripheral
sion or irritation of the vessels and nerves as they nerve lesions can be
difficult to diagnose due to
pass from the chest into the neck. However only the large quantity of neural
cross-over between
the sympathetic trunk, T1 nerve root and subcla- nerve branches and
fascicles. Complete inactivity
vian vessels pass through the thoracic outlet or of a brachial plexus root
may not manifest as
inlet (as some prefer to name it), and as such the weakness, palsy, altered
sensibility or numbness
name is a misnomer, as the actual syndrome but by pain, lack of
endurance, fatigue or by no
includes compression or irritation of all the lon- symptoms at all. Indeed in
most cases thoracic
gitudinal structures as they pass along the neck outlet syndrome presents as
a pain syndrome. To
and into the arm. For example, thoracic outlet best understand this
difficult syndrome, we
syndrome encompasses compression or other should examine and diagnose
those discrete
pathology except tumours, at any point along cases of vascular occlusion,
or definite neurolog-
the path of the brachial plexus from the exit ical loss that can be
localised to the neck gaining
of the nerves from their foramina to their entry experience before tackling
the more difficult
into the arm at the distal limits of the axilla, more common cases presenting
with poorly
clearly involving nerves that never pass through defined symptoms and signs.
the thoracic outlet. Compression can occur to the
vessels and nerves as they descend between the
scalenes, pass through the thoracic outlet if they
do so, or as they pass over the first rib, still Aetiology and Classification
between scaleneus anterior and scaleneus medius
muscles, pass under the clavicle and under Thoracic outlet syndrome can
be classified as
pectoralis minor and around the coracoid into vascular or neurogenic.
Vascular cases are gener-
the arm. Hence a large number of synonyms for ally arterial but rare cases
of venous compression
thoracic outlet syndrome exists (Box 1). are reported. Neurogenic
cases can be true neuro-
Apart from these normal anatomical structures genic with clearly
demonstrable neural lesions
the region is rich in anatomical variations, the localizable to the brachial
plexus or presumed
best known being the cervical rib. The cervical neurogenic as lesions cannot
be clearly demon-
rib represents the easily visualized bony evidence strable but are suggested to
arise from the plexus.
451
There are of course cases of involvement of both weight. Frequently there has
been a preceding
vessels and nerves complicating things further. history of carpal and/or
cubital tunnel release.
The pathology and symptoms can be static/ There is an association with
occupations that
constant or positional. Most commonly it is involve working with the
arms elevated such
a pain syndrome but can present as a sensory or as hair dressers, teachers,
brick layers and plas-
motor palsy, weakness or with claudication or loss terers, swimmers and weight-
lifters, either
of endurance. Thoracic outlet syndrome can also due to the provocative
postures these occupa-
be classified according to the site of presumed tions adopt or because these
postures cause
pathology. Three levels of TOS exist; inter- functional changes to the
scalenes or other
scalene, costo-clavicular and infra-clavicular structures provoking
thoracic outlet syndrome.
(also known as retro-pectoral). Finally it may be that an
element of trauma
The incidence of thoracic outlet syndrome is either acute or cumulative
may be necessary in
unknown, hardly surprising given the variation in some cases in order to
create fibrosis or muscu-
pathology and the difficulty in diagnosis. How- lar spasm or inflammation
before the symptoms
ever it has been reported to occur as commonly as arise. Contraction or spasm
of the scalene mus-
1 per 1,000 people. Thoracic outlet syndrome is cles resulting from
irritation of their nerve
more common in females, perhaps as much as supply from the brachial
plexus or other rea-
fivefold. It generally presents in the early sons, causes elevation of
the first rib, causing
twenties but can present in children and at older greater irritation and the
establishment of
ages. Up to 25 % can be bilateral. Most cases are a vicious cycle [4].
neurogenic, with 10 % being vascular and 5 %
being both.
The cause of thoracic outlet syndrome is an Relevant Applied Anatomy,
Pathology
anatomical arrangement that compresses or irri- and Basic Science:
Biomechanics
tates passing neurological or vascular structures.
The cause may often remain unknown. Why, if the The anatomy of the region is
the anatomy of the
cause is an anatomical arrangement or variation, posterior triangle of the
neck. The bony land-
do symptoms only arise later in life? If the anatom- marks are the first rib
extending from the trans-
ical arrangement partially compresses or just irri- verse process to the
manubrium, the cervical
tates the vessels then prolonged repetitive insults vertebrae especially the
foramen of the C5-8
must occur before intimal and structural changes and T1 nerves and the
lateral processes, the
become apparent in the vessel wall [3]. With clavicle and in the infra-
clavicular fossa, the
increasing age the tolerance of the peripheral coracoid. The roots of the
brachial plexus
nerves to ischaemia and irritation diminishes and emerge from the foramina
lying anterior to the
the adaptations and postural mechanisms to avoid scalenus medius, which runs
from origins on
compression become more difficult. The descent the transverse processes to
insertions on the
of the scapula is more common and marked in middle and posterior
portions of the cranial
women and, associated with age, increases the and lateral aspects of the
first and second rib.
tension in the plexus and reduces the costo- The long thoracic nerve
arising from C5, 6 and
clavicular space. These patients frequently have 7 merges within the scalenus
medius and travels
a slumped posture, steep supra-clavicular slopes, through it. Anterior to the
plexus and the sub-
a less concave supra-clavicular fossa, apparently clavian artery lies the
scalenius anterior
long necks and protracted shoulders. There is an inserting onto the anterior
portion of the first
association with large breasts perhaps as these rib. Anterior to this muscle
lies the phrenic
contribute to poor posture or by traction on the nerve, which is seldom
involved in TOS, and
shoulders producing acromio-clavicular descent. the subclavian vein. The
subclavian artery and
There may have been a recent increase in weight plexus to a lesser extent
cause a shallow groove
as there is a weak association with being over in the cranial surface of
the first rib called the
452
H. Giele
C7 vertebrae. Cervical ribs

occur in 0.20.5 %
of the population but are
over-represented in tho-
racic outlet syndrome
sufferers (10 %), either
because cervical ribs cause
thoracic outlet syn-
drome or because the presence
of the cervical rib
re-inforces the diagnosis.
The cervical rib can be
complete articulating with
the manubrium, com-
plete by articulating with
the first rib (usually by
a large tubercle at the level
of the interscalene
groove), or partial whereby
it does not articulate
but the anterior end of the
rib but is attached by
fibrous bands extending to to
the first rib or ster-
num. An over-long C7
transverse process may
represent a vestigial attempt
to develop a cervical
rib or be associated with
soft tissue anomalies
that may compromise the
passage of the nerves
and vessels into the arm. An
elongated C7 trans-
verse process, one which
extends beyond the
lateral limits of the T1
process, may be associated
with a scalenus intermedius
muscle. Clavicle dis-
tortion from osteoma or non-
or mal-union can
reduce the costo-clavicular
space producing
Fig. 1 Anatomy of the thoracic outlet symptoms particularly on
depression of the
shoulder. Bone tumours
affecting the first rib or
clavicle such as exostoses or
fibrous dysplasia
inter-scalene groove. The plexus is stacked ver- can compromise the space for
transit of the
tically as it passes between the scalenes over the structures.
first rib, so that the lower trunk has most contact The soft tissue anomalies
are more varied,
and deviation, hence the predominance of harder to identify and
difficult to detect pre-
symptoms in this distribution. The plexus and operatively. The scalenes may
hypertrophy in
artery as they pass over the rib emerging from response to exercise,
especially in weight-lifters
behind scalenus anterior are confined posteri- and swimmers. The scalenes
may have a common
orly and inferiorly by the scalenus medius- origin and only split late in
their descent down the
covered ribs, and anteriorly by the fat pad, and neck reducing the
interscalene space. The sca-
the clavicle. Depression of the clavicle or lenes may have well-developed
aponeuroses
abduction of the shoulder reduces this space that present sharp edges or
hard surfaces with
and can lead to compression of the structures. which to compress components
of the plexus or
Hence the exacerbation of symptoms when vessels. The scalenes may
have anomalous inser-
working with the arms overhead or when carry- tions on to the first rib
such that the inter-scalene
ing heavy objects. The structures then pass groove is obliterated or
narrowed. Roos described
under the clavicle medial to the coracoid and classified 9 different
anomalous scalene
under the insertion of pectoralis minor to enter bands that could cause TOS
[5]. Anomalous mus-
the arm. Here too, they can get compressed or cles such as the scalene
intermedius or minimus-
irritated in the relatively uncommon infra- that arises from the
transverse processes and
clavicular TOS (Fig. 1). inserts onto the dome of the
pleura, may occur
Common bone anatomical anomalies associ- and compromise the T1 root
[6].
ated with thoracic outlet syndrome are cervical The pathomechanics of
nerve compression
ribs, and long transverse processes of the are oedema,
ischaemia, demyelination,
453
Schwann- cell necrosis and axonal injury, the constant or intermittent,

burning or aching,
degree of which correlates with the severity and sharp or dull, provokable or
unchanging. There
chronicity of the compression. The peripheral may be associated pain
affecting the neck, shoul-
axons can be severely affected whilst those in der, para-scapular region,
back, face and descrip-
the centre or located away from the stimulus can tions of headache. Some of
these secondary pain
be unaffected. This particularly relative to the symptoms may be related to
mechanisms
size of the nerves, and the large number and employed to avoid vascular or
neural compres-
variety of inter-connections between nerves at sion such as elevating the
clavicles and
the brachial plexus level explain the vagueness protracting the shoulders to
enlarge the costo-
of symptoms and signs. clavicular space.
Vasomotor Symptoms
Diagnosis These symptoms are generally
not the main
presenting complaint but can
often be elicited.
Thoracic outlet syndrome is often said to be They reflect either the
involvement of the sym-
a diagnosis of exclusion and indeed one has to pathetic nerves or
disturbance of the neural
exclude other peripheral nerve compression dis- pathways of sweating,
temperature regulation,
orders and radiculopathy. Unfortunately carpal vascularity and permeability
of vessels. Either
tunnel syndrome can on occasions present with hypo- or hyperhidrosis may
occur, exaggerated
thoracic outlet syndrome-like symptoms. One cutaneous colour change in
response to ambient
must have an awareness of thoracic outlet temperature or emotion and
the hands may be
syndrome in order to consider it as part of the described as being constantly
cold or hot; there
differential diagnosis of a patient presenting with may be a complaint of
swelling. Other vascular
upper limb pain, paraesthesia, numbness, weak- symptoms are end-stage
presentations of digital
ness, or other vague symptoms. If you do not look gangrene, evidence of emboli,
or of venous
for TOS, you will never diagnose it. congestion.
Motor Symptoms
History Weakness or lack of endurance
are common fea-
tures of thoracic outlet
syndrome particularly
Pain with activities overhead or
carrying weights.
The common presentation is of arm pain. Classic Dropping objects and
clumsiness are recalled
vascular thoracic outlet syndrome presents with similar to carpal and cubital
tunnel syndromes.
claudication type aching associated with activity
especially with arm elevation. Classic neurolog-
ical thoracic outlet syndrome affecting the lower Examination
trunk presents with dull aching pain in the ulnar
nerve distribution but including the medial fore- Musculoskeletal
arm, often when carrying heavy objects or on arm Examination of the upper limb
should ensure
elevation. However the arm pain can be in any normal passive range of
motion of the joints,
distribution depending on which part of the absence of injuries that
might explain neurologi-
plexus is involved. Upper trunk TOS may present cal lesions, and exclude
disorders such as a frozen
with shoulder and lateral arm pain, and middle shoulder, medial
epicondylitis, or pisi-triquetral
trunk or posterior cord involvement with pain arthritis.
experienced at the back of the arm, elbow or
forearm. The pain or sensory symptoms may not Vascular
be in a known peripheral nerve distribution or Examine for venous distention
particularly in
dermatome. The pain could be described as postures such as arm
elevation or depression.
454
H. Giele
Venous engorgement, cyanosis and swelling may inspire deeply and hold their
breath. This elevates
indicate venous obstruction. In severe cases this the first rib and contracts the
scalenes. A positive
may indicate subclavian or axillary vein throm- test is one that elicits a
reduction or cessation of
bosis known as Paget-Schroetter syndrome. Feel the radial pulse or provocation
of the pain or
and compare the pulses between arms, and at sensory symptoms. The
pathogenesis of the
different sites of the upper limb. Embolic phe- positive test is thought to be
stretching of the
nomena such as nail bed infarcts, Raynauds scalenes and their aponeuroses
or anomalous
phenomenon and gangrene may rarely be associated bands compressing
the artery or
present. Bruits should be excluded by careful plexus.
auscultation. Reverse Adsons test [8]
involves the same
arm position, breath holding
and downward
Neurological retraction but the head and
neck are held flexed
Examination should include a complete upper and rotated away from the
affected side thereby
limb neurological examination. In classic TOS allowing the scalenes to
contract and bulge
there may be sensory disturbance in the ulnar compressing the plexus.
nerve distribution but in addition involvement Wrights hyper-abduction
test [9] assesses
of the medial cutaneous nerve of forearm indi- the radial pulse when the arm
is abducted. Loss
cating a proximal lesion (as this branch arises of the pulse is a positive test
but occurs in 25 %
from the medial cord of the plexus and indicates of asymptomatic people. The
mechanism is
thoracic outlet syndrome rather than ulnar thought to be compression of
the subclavian
neuropathy). Sensory disturbance can occur in artery as it courses around the
coracoid and
any distribution depending on the elements of may indicate an infra-
clavicular thoracic outlet
the plexus involved. There may be no sensory syndrome. However, imaging
studies show
disturbance present. In classic TOS, motor signs that the costo-clavicular space
and the retro-
may include intrinsic weakness or wasting pectoralis space are both
decreased with arm
involving both ulnar and median-innervated elevation.
intrinsics indicating a T1 or lower trunk lesion, Falconers test [10] or the
military brace posi-
but more commonly there are no such signs. tion or costo-clavicular
compression test, also
Fatigue and reduced endurance are difficult to sometimes called Halsteads
test, places the
assess. Carpal and cubital tunnel syndrome shoulders in an extended
retropulsed position
should be excluded using standard examination with slight downward traction
of the arms whilst
techniques for these conditions and their feeling the radial pulses. A
positive test is
provocative tests. a diminution or obliteration of
the pulse or prov-
ocation of the neurological
symptoms. This posi-
Neck tion probably exaggerates
costo-clavicular
The range of neck motion should be checked to compression. Narakass test
abducts the arm to
elicit any evidence of cervical arthropathy. 90# with traction and provokes
symptoms.
Spurlings test
differentiates radiculopathy
Provocative Tests from brachial plexopathy by
provoking symp-
The provocative tests for thoracic outlet syn- toms with compression on the
vertex either
drome are less sensitive and specific than those when the neck is laterally
flexed towards the
for carpal tunnel and cubital tunnel syndrome but affected side or away from the
affected side
are presented here for completeness. respectively.
Adsons test [7] involves adducting the arm, The cervical rotation
lateral flexion test [11] is
extending the neck and rotating it towards the positive when there is reduced
neck flexion when
affected side thereby stretching the scalenes. the head is turned away from
the affected side
The arm is gently retracted downwards depress- compared to when it is turned
towards the
ing the clavicle as the patient is requested to affected side. The mechanism of
this test is
455
suggested to be that subluxation of the first rib thoracic outlet syndrome the
neurophysiology
attachment to the transverse process reduces may demonstrate denervation
changes on elec-
flexion on rotation and displaces the brachial tromyography, and more rarely
with increased
plexus anteriorly thus reducing the space for its severity and duration of
compression there
passage through the neck. may be changes in F-latency
and SEP. Reduced
Roos elevated arm stress test (EAST) [12] is nerve conduction is a late
neurophysiological
non -specific with provocation of symptoms in sign usually correlating to
easily detected clinical
patients with carpal tunnel and cubital tunnel signs [15]. Localization of
the lesion can be help-
syndrome as well as in thoracic outlet syndrome. ful if nerve conduction
studies detect involve-
The Roos test is performed by abducting ment of the medial cutaneous
nerve of forearm
and elevating the arms in external rotation with in cases presenting as ulnar
neuropathy. However
the elbows flexed and then flexing and the main usefulness in TOS
for neurophysiolog-
extending the digits for 2 min and observing for ical studies is to exclude
carpal and cubital tunnel
pallor of the hand and provocation of syndromes.
symptoms including claudication of the forearm
muscles. Imaging
Gages test [13] detects tenderness of the sca- Part of the difficulty in
imaging this syndrome
lenes which are thought to be inflamed in cases of is that it is a dynamic
syndrome and that pos-
thoracic outlet syndrome. Gage went further in ture pays a large component.
Imaging is gen-
then injecting local anaesthetic into the scalenes erally static and performed
supine. MRI is the
which he considered indicative of thoracic main imaging technique in TOS
[16]. MRI
outlet syndrome if it resulted in temporary reso- should be arranged for the
cervical vertebrae
lution of symptoms. to exclude cervical causes of
the symptoms
Morleys compression test [14] is provocation such as disc prolapse with
root compression.
of the neurological symptoms when gently MRI of the brachial plexus
may demonstrate
compressing the plexus in the supra-clavicular deviation of the plexus over
or around anoma-
fossa. This test is the most compelling clinical lous structures, but rarely
shows the anomalous
sign of thoracic outlet syndrome in my experi- structures themselves. The
MRI may show
ence. The plexus may also be tender and Tinels compression of the subclavian
vessels and
test may provoke pain or paraesthesia. post-stenotic dilatation.
However, a negative
Though each test independently may be of MRI does not exclude TOS,
importantly
limited value due to low sensitivity and specific- though it will exclude a
tumour such as
ity, we have found that if a patient has three or a Pancoast-Tobias tumour of
the apex of the
more positive clinical signs they are more likely lung as the cause of
symptoms. Plain radio-
to benefit from surgery. I perform all the provoc- graphs of the chest and neck
should be
ative tests other than the injection of local requested as MRI may not
detect cervical
anesthesia. ribs, elongated transverse
processes or other
bony abnormalities. MRA may
be necessary
if vessel occlusion or
partial obstruction are
Investigations considered. CTA may allow
comparison
between different postures of
the arm. MRA
Neurophysiology and CTA in this region should
obviate the need
When thoracic outlet syndrome is suspected for angiography. Both can
detect occlusion but
nerve conduction studies including EMG should find it harder to
discriminate normal and
be requested asking the neurophysiologist to abnormal compression with
postural changes.
investigate for carpal and cubital tunnel syn- Ultrasound can be helpful as
a dynamic imag-
drome as well as for any evidence of ing technique as the plexus
can be viewed in
brachioplexopathy. In the classic true neurologic differing arm positions.
456
H. Giele
infra-clavicular, the
posterior and the axillary,
Treatment and Indications for Surgery along with combined approaches. The supra-
clavicular approach is the
preferred approach to
Non-Operative thoracic outlet syndrome,
and will be described in
detail below. The axillary
approach involves an
The initial treatment of thoracic outlet syndrome is axillary incision with the
patient in the lateral
always non-operative. This comprises analgesia, position and extra-
thoracically removing the cer-
relaxants, and physiotherapy. The therapy is vical or first rib. This
axillary approach does not
aimed at relaxing and stretching the scalenes, directly explore or release
the vessels or plexus.
strengthening the scapula muscles to increase Though this approach
delivers an increased
shoulder support, increase shoulder and scapula costo-clavicular space, this
approach fails to
mobility, increase the costo-clavicular space by address the possible
suspension of the plexus by
improvement of posture, elevation of the shoulder anomalous bands between the
scalenes or
acromio-clavicular joint and implementation of a scalenus minimus or allow
for a neurolysis
strategies to avoid provocative postures [17, 18]. and so is less useful for
neurogenic thoracic outlet
These strategies may show response within syndrome. The posterior
approach incises
3 weeks but if not, should continue to be trialled through the trapezius,
levator scapulae and
for 3 months. Analgesics are usually NSAIDs, scalenus medius to expose
the plexus from
and neuropathic pain medications such as behind.
gabapentin or pregabalin, coupled with anti-
depressants such as amitriptylene to aid sleep if
required. Recently botulinum toxin denervation of Supra-Clavicular Exploration
the scalenes has been reported to provide symp- Technique
tomatic relief for those waiting for surgery [19].
The procedure involves a
general anaesthetic.
The patient is positioned
supine, with the head
Operative turned away from the
affected side, and the neck
extended with a bolster in
the ipsi-lateral trape-
The indications for operative treatment are fail- zius region. The neck,
axilla and arm is prepped
ure of conservative non-operative management, leaving the sternal notch
and upper sternum
the absence or exclusion of other peripheral neu- exposed as well as the
clavicle, axilla, whole
ropathies or failure of resolution of symptoms upper limb including
shoulder. After infiltration
following surgical release of the carpal tunnel with local anesthesia with
adrenaline, a 57 cm.
and cubital tunnel, and continuing symptoms long supra-clavicular
incision is made above the
and signs diagnostic for thoracic outlet syn- mid-point of the clavicle.
This is deepened
drome. The operation offered is an exploration through platysma. The
lateral clavicular insertion
of the brachial plexus and subclavian artery, and of sternomastoid is divided,
leaving a cuff on
decompression and neurolysis depending on the clavicle to facilitate
later repair. The lateral
intra-operative findings. As such the patients border of sternomastoid is
released from the
should be informed that the chance of improve- fascia. The fascia is
incised just above and paral-
ment is only 50 %, though in reality with good lel to the clavicle,
exposing the supraclavicular
patient selection the outcomes are much better. nerves and external jugular
vein which are
retracted laterally.
Omohyoid is identified lying
a little more cranially and
medially. The medial
Operative Technique belly of omohyoid points to
the level of the C5
root. Omohyoid is retracted
superiorly and held
Various approaches described for thoracic there with a small self-
retainer. The deep fascia is
outlet syndrome, the supra-clavicular, the incised and the pre-plexural
fat pad is swept
457
cranially exposing the plexus. The transverse is filled with saline and
a Valsalva manoeuvre
cervical and dorsal scapular vessels may be within requested from the
anesthetist to check for
this fat pad and need to be divided but can some- a pneumothorax and air
leak. There is commonly
times be retracted intact. The divisions of the a parietal pleural hole
allowing fluid and air to
upper trunk of the brachial plexus lie most super- enter the thorax, but a
true air leak from a visceral
ficially and are the first exposed and, following pleural injury is
uncommon. If an air leak is
this, the middle and lower trunk. Scalenus anterior present a chest tube with
an underwater seal is
is identified medially, as is the phrenic nerve lying inserted through the
lateral fourth intercostal
superficially upon it, running from lateral to space. The fat pad is
replaced over the plexus,
medial as it courses towards the chest. The lateral and the omohyoid restored.
The sternomastoid is
border of the anterior scalene is incised freeing it repaired as well as the
platysma and skin. No
from the thin fascial sheet covering it and the drain is inserted as the
wound is usually dry.
plexus. Scalenus anterior is retracted medially The arm is placed in a
broad-armsling.
exposing the roots and the subclavian artery. The
relationship of the scalenes, artery and plexus is
explored. For example a frequent cause of thoracic Post-Operative Care
outlet syndrome is an anomalous insertion of and Rehabilitation
scaleneus medius onto the first rib extending too
far anteriorly inter-digitating with the anterior Regular analgesia is
prescribed. The patient is
scalene thus obliterating the inter-scalene groove, encouraged to mobilise the
shoulder and arm as
and causing the plexus to have to cross this comfort allows and to
remove the sling as soon as
part of the scalenus medius as well as the first possible. As in other
nerve decompressions,
rib as it traverses inferiorly. These anomalies are immediate mobilization of
the joints prevents
frequently fibrous or aponeurotic and have been adhesions of the nerve and
joint stiffness. Deep
described as bands. breathing exercises are
encouraged especially if
The lower insertion of scaleneus anterior to there is pleuritic pain.
The wound is reviewed at
the first rib is divided and the distal 12 cm of 2 weeks by which time the
sling should be
muscle excised to prevent its re-attachment, discarded. Discomfort
around the operation site
protecting the phrenic nerve (superficial) and is common for a few weeks
but should not pre-
the subclavian artery (deep) from injury. The vent full range of motion
of the shoulder and arm.
artery is released and the plexus is neurolysed.
If a cervical rib is present this is exposed superior
and inferior to the plexus and removed at this Outcomes
stage. The costo-clavicular space is assessed by
placing a finger under the clavicle over the plexus Outcomes of operative
exploration vary
and then abducting the arm. A tight space will according to the
indication. If definite neurolog-
pinch the finger preventing full abduction, indi- ical or vascular thoracic
outlet syndrome are pre-
cating that first rib excision is necessary. The first sent then relief of
symptoms is predictable;
rib is dissected by releasing the attachment of however in the majority of
indefinite cases symp-
scalenus medius superiorly and the intercostals tomatic relief is less
predictable. Similarly if
inferiorly. A Clowards punch is used to nibble identifiable anatomical
anomalies are detected
across the neck of the first rib and then across the pre-operatively there is a
greater chance of
body as far anterior as possible. The rib is then a successful outcome.
Reported outcomes are
removed, and the costo-clavicular space checked extremely variable,
ranging from 37 % to 90 %
again. If the finger is no longer squeezed between improvement [20, 21]. The
large variation in
clavicle and the second rib on abduction of the reported outcomes reflects
the difficulty in diag-
arm then sufficient space has been created for the nosis, assessment and
measuring symptoms, the
safe passage of the plexus and vessels. The cavity variation in patient
selection and surgical
458
H. Giele
procedure, and the variation in outcome mea- confirm or refute other

potential diagnoses. If
sures. It is most simple to report improvement there has been little or no
improvement with the
of symptoms on a grade as excellent to poor; operation then the diagnosis
is incorrect, the
a few report measures such as DASH or SF-12. nerves intrinsically injured
beyond recovery
Study numbers range from 700 or more to less (though this state should be
identifiable preoper-
than 20 [22]. For example, Scali [23] reported an atively by neurophysiology),
or incomplete
average 8 year follow-up on 26 patients with decompression performed.
neurogenic thoracic outlet syndrome diagnosed The second commonest
complication is recur-
by a positive Roos test or postive response to rence of symptoms. If this
occurs the history and
scalene block, treated by scalenotomy alone (2), examination and investigation
of the patient
scalenectomy plus cervical rib excision (6), should be repeated. Symptoms
may recur due to
scalenectomy plus first rib excision (18), eight scarring, progressive neural
changes from the
cases were done by the axillary approach and previous insult, recurrence of
the compression
the rest by the supra-clavicular. Two cases due to further descent of the
shoulder or loss of
(9 %) required further operations. Of the ability to compensate or
accommodate for the
26 patients 22 were followed up, 72 % returned compression. If other
diagnoses are excluded
to work, and 68 % reported their outcomes as and the diagnosis of thoracic
outlet syndrome is
good or excellent. 27 % still used narcotics secure then re-exploration of
the plexus and ves-
post-operatively. sels may be indicated. This is
particularly indi-
Outcomes are reported to be much worse cated if the initial procedure
involved either
if symptoms have persisted for greater then scalenus anterior release, or
cervical rib excision
24 months [24], or if the patients are involved in alone preserving the first
rib. It is for this reason
compensation [25]. Poorer outcomes were also that a complete release
comprising the above and
associated with acute ischaemia, sensory or first rib excision is
recommended by some sur-
motor deficit, poorly systematized neurological geons. Some surgeons excise
only a small middle
symptoms as presenting complaints, extended segment of the first rib but
then the remaining
resection of the first rib, and severe post- anterior or posterior segments
under the traction
operative complications [26]. The importance of of the scalenes can migrate
superiorly causing
complete posterior resection of the first rib was recurrent compression. First
rib excision should
emphasized by correlation of outcomes with be complete posteriorly and
extend sufficiently
length of posterior stump of first rib [27]. anterior such that upward
migration of any
Recurrent thoracic outlet syndrome occurs in remaining rib would be medial
to the passage of
up to 50 % of indefinite cases usually within the plexus and artery. Supra-
clavicular and retro-
2 years [28]. These may warrant re-exploration, clavicular decompression will
not be effective
but the outcomes are even less predictable, but for infra-clavicular thoracic
outlet syndrome
can be excellent. for which an infra-clavicular
exploration and
pectoralis minor release is
required. The possibil-
ity of infra-clavicular
thoracic outlet syndrome
Complications should be considered.
In recalcitrant thoracic
outlet syndrome with
The commonest complication is failure of reso- notable fibrosis around or
within the plexus, there
lution of all the symptoms. The patients fre- may be benefit in wrapping the
plexus in a well
quently report improvement but less commonly vascularised layer of fat in
order to protect it from
complete cure. In most cases the symptoms further injury and provide a
gliding layer under
recede to a level at which no further intervention the clavicle. This fat can be
transferred from the
is necessary. However, if symptoms fail to deltopectoral region obtained
through the same
resolve then the diagnosis should be re-examined supra-clavicular incision, or
as a free tissue trans-
and efforts made to re-investigate and again fer of omentum or groin fat.
Alternatively the
459
superficial fascia from pectoralis major can be of the operative site can
extend onto the anterior
transferred. chest wall down as far as
the nipples due to
Operative complications are bleeding, chyle injury to the
supraclavicular nerves that traverse
leak and seroma, pneumothorax, haemothorax the incision. Despite the
best attempts to preserve
or pleural effusion, numbness of the operative these supraclavicular
nerves, they frequently get
site extending onto the anterior chest, injury to stretched or divided. The
patient should be encour-
the phrenic nerve, brachial plexus, sympathetic aged to desensitize the
area to reduce the hyper-
chain or recurrent laryngeal nerve, shoulder stiff- sensitivity as neural
ingrowth from surrounding
ness, neural adhesions and recurrence. areas occurs.
Bleeding is usually minor but can be more
worrying wih rupture of the subclavian artery
from atheromatous plaques and post-stenotic Summary
aneurysmal dilation associated with compression
of the artery. Deaths have been reported from Thoracic Outlet syndrome
is a complicated nebu-
catastrophic hemorrhage. Prevent catastrophic lous syndrome as it
encompasses a diverse array of
bleeding by gentle retraction of the artery only if pathologies affecting the
subclavian artery, vein
necessary. Be prepared to split the chest to expose and brachial plexus
causing perplexing symptoms
the origin of the subclavian artery if uncontrolled and signs and only
corralled together by virtue of
bleeding occurs. Chyle leak and seroma result their anatomical
arrangement as they depart the
from injury to the thoracic duct as it enters the axial skeleton for the
upper limb. There are those
subclavian vein at the root of the neck. If injury to surgeons who doubt the
existence of such
the thoracic duct or its branches are seen at time of a nebulous condition, and
others who diagnose
operation then the leak must be ligated or clipped, every hand complaint as
thoracic outlet syndrome.
as diathermy is not effective. If a chyloma appears The truth must lie between
the two camps. If one is
post-operatively then the patient should be placed not aware of the
possibility of thoracic outlet syn-
on a low fat diet until the leak stops and the drome and how to diagnose
it, then one will never
swelling or drainage diminishes. Injury to the consider its diagnosis.
Careful diagnosis and
phrenic nerve may result in respiratory difficulties patient selection can
result in excellent resolution
requiring intensive care support for some days of symptoms either from
physiotherapy or follow-
post-operatively or leading to basal lung collapse ing surgical intervention.
The surgery is challeng-
and infection. Longer term shortness of breath ing but rewarding
technically and on outcomes.
from diaphragm palsy can result, necessitating
diaphragmatic plication. Pleural effusion or
haemothorax results from usually small quantities Box 2 Differential
Diagnoses for Symptoms
of blood or fluid tracking from the operative site of Thoracic Outlet
Syndrome
into the pleural space causing pleuritic pain. Very Carpal tunnel syndrome
rarely the pleural defect is made in the parenchy- Cubital tunnel syndrome
mal pleura leading to an air leak and requiring the Radial tunnel syndrome
placement of a chest drain. Injury to the brachial Parsonage Turner or
Amyotrophy
plexus from traction on retracting, is usually at Raynauds phenomenon
worst a temporary neurapraxia causing some dis- Vibration white finger
comfort and weakness, that recovers within Reflex sympathetic
dystrophy or chronic
a couple of months. Injury to the sympathetic regional pain
syndrome
chain results in a Horners syndrome for which Supra-scapular nerve
compression
no intervention is necessary other than reassurance Sub-acromial bursitis
as it usually resolves. Injury to the recurrent laryn- Rotator cuff injuries
geal nerve is mainly a theoretical possibility due to Cervical arthritis
its proximity to the operative site. The numbness
460
H. Giele
sympathetic
changes to the limb and
a Horners
syndrome, hoarseness,
change in
voice, scapula winging.
Early
Pleuritic pain
Chest infection
Hematoma and
wound infection
Shoulder
stiffness
Weakness
Chyle leak
Late
Numbness
or allodynia in
Fig. 2 The incision and exposure from the supra-
supraclavicular nerve distribution

clavicular approach. Note the mass in the wound
Recurrence
Shoulder
stiffness
Box 4 An
Illustrative Case
A 16 year-old girl
presented with
a 12-month history
of left arm fatigue,
and left para-
scapular and shoulder pain
and ache extending
down the lateral
aspect of the arm,
into the dorsum of the
forearm. There was
associated positional
global hand
paraesthesia. Her symptoms
were exacerbated by
arm elevation
Fig. 3 The mass is bony (dome-shaped protruding from the performed as part of
her training as
bottom of the wound) and displaces the upper trunk of the a hairdresser.
plexus anterior and superior (on the right of the wound) and On examination,
she had no sensory
the middle trunk cranially. Scalenus anterior lies medial.
Unseen, the subcavian artery is compressed between the loss, no motor
weakness, but fatigue on
mass and the posterior edge of scalenus anterior repetitive testing.
Examination showed
loss of her radial
pulse on arm abduction,
and some reduction
in pulse volume with
Box 3 Complications of Brachial Plexus Adsons test.
Palpation of her neck
Exploration, Artery and Neurolysis and revealed a palpable
mass in the left supra-
Excision of Cervical and First Rib clavicular fossa,
gentle pressure on which
Immediate provoked her
symptoms. Roos test also
Bleeding provoked her
symptoms.
Pleural hole leading to haemothorax Her cervical
radiograph showed the cer-
Pneumothorax vical rib. The MRI
showed the cervical rib
Injury to nerves-brachial plexus, but no anomaly to
the plexus. The neuro-
phrenic, sympathetic, recurrent physiological
studies were normal.
laryngeal, long thoracic, resulting in She had no
improvement with 3 months
palsy, numbness, raised diaphragm, of therapy and was
offered surgery. After
chest infection, dyspnoea,
(continued)
461
still tight and

hence the first rib was also
excised. The
resulting defect (Fig. 4)
allowed tension
free passage of the brachial
plexus through the
thoracic outlet, and
released the
subclavian artery, which had
a post-stenotic
dilatation. Reconstruction
of the cervical
rib and first rib articulation
on the table
demonstrates the space this
mass occupied
(Fig. 5).
Post-
operatively there were no compli-
cations and
complete resolution of her
Fig. 4 The scalenus anterior, cervical and first rib having symptoms.
been excised, the subclavian artery and the plexus can now
be seen passing unimpeded through the thoracic outlet
References
1. Peet RM, et al.
Thoracic-outlet syndrome: evaluation
of a therapeutic
exercise program. Proc Staff Meet
Mayo Clin.
1956;31(9):2817.
2. Roos DB.
Historical perspectives and anatomic con-
siderations.
Thoracic outlet syndrome. Semin Thorac
Cardiovasc Surg.
1996;8(2):1839.
3. Eden K. The
vascular complications of cervical ribs
and first
thoracic rib abnormalities. Br J Surg.
1939;27(105):111
39.
4. Ochsner A, Gage
M, DeBakey M. Scalenus anticus
(Naffziger)
syndrome. Am J Surg. 1935;28:
66971.
5. Roos DB.
Congenital anomalies associated with
Fig. 5 The excised specimen showing the cervical rib thoracic outlet
syndrome. Anatomy, symptoms,
superiorly, descending anteriorly to form a nodular artic- diagnosis, and
treatment. Am J Surg. 1976;132(6):
ulation with the first rib, which was the mass viewed in 7718.
Figs. 2 and 3. Orientation is vertebrae to the right of the 6. Lawson FL, Mc KK.
The scalenus minimus muscle.
picture and sternum to the left Can Med Assoc J.
1951;65(4):35861.
7. Adson AW, Coffey
JR. Cervical ribs:a method of
anterior approach
for relief of symptoms by division
of scalenus
anticus. Ann Surg. 1927;85:83957.
8. Adson AW.
Surgical treatment for symptoms
Box 4 An Illustrative Case (continued) produced by
cervical ribs and the scalenus
incision and exposure the prominent mass anticus muscle.
Surg Gynecol Obstet. 1947;85(6):
687700.
was confirmed to be the articulation 9. Wright IS. The
neurovascular syndrome produced by
between the cervical and first rib at the hyperabduction of
the arms. Am Heart J.
level of the scalene groove (Fig. 2). Closer 1945;29(1):119.
examination showed (Fig. 3) that the mass 10. Falconer MA,
Weddell G. Costoclavicular compres-
sion of the
subclavian artery and vein: relation to
was causing deviation of the plexus and the scalenus
anticus syndrome. Lancet.
compression of the subclavian artery. The
1943;242(6270):53944.
scalenus anterior was released with exci- 11. Lindgren KA.
Conservative treatment of thoracic out-
sion of the distal few centimetres. The cer- let syndrome: a
2-year follow-up. Arch Phys Med
Rehabil.
1997;78(4):3738.
vical rib was excised. Assessment of the 12. Roos DB.
Transaxillary approach for first rib resection
costo-clavicular space showed this was to relieve
thoracic outlet syndrome. Ann Surg.
1966;163(3):354
8.
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13. Gage M, Parnell H. Scalenus anticus syndrome. Am 21. Bhattacharya V,

et al. Outcome following surgery for
J Surg. 1947;73(2):25268. thoracic outlet
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14. Morley J. Brachial pressure neuritis due to a normal 2003;26(2):170
5.
first thoracic rib: its diagnosis and treatment by exci- 22. Hempel GK, et
al. 770 consecutive supraclavicular
sion of rib. Clin J. 1913;XLII(29):4613. first rib
resections for thoracic outlet syndrome. Ann
15. Passero S, Paradiso C, Giannini F, Cioni R, Burgalassi Vasc Surg.
1996;10(5):45663.
L, Battistini N. Diagnosis of thoracic outlet syndrome 23. Scali S, et al.
Long-term functional results for the
Relative value of electrophysiological studies. Acta surgical
management of neurogenic thoracic outlet
Neurol Scand. 1994;90:17985. syndrome. Vasc
Endovascular Surg. 2010;44(7):
16. Demondion X, et al. Imaging assessment of 5505.
thoracic outlet syndrome. Radiographics. 2006;26(6): 24. Cheng SW, et
al. Neurogenic thoracic outlet
173550. decompression:
rationale for sparing the first rib.
17. Aligne C, Barral X. Rehabilitation of patients with Cardiovasc
Surg. 1995;3(6):61723. discussion: 624.
thoracic outlet syndrome. Ann Vasc Surg. 1992;6(4): 25. Franklin GM, et
al. Outcome of surgery for thoracic
3819. outlet syndrome
in Washington state workers com-
18. Kenny RA, et al. Thoracic outlet syndrome: a useful pensation.
Neurology. 2000;54(6):12527.
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Reynaud C, Becquemin JP. Thoracic
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19. Jordan SE, et al. Selective botulinum chemodenervation Ann Vasc Surg.
2004;18(5):55865.
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al. Long-term outcome after
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14(4):3659. Surgery.
1995;118(5):8404.
20. Lepantalo M, et al. Long term outcome after resection 28. Altobelli GG,
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of the first rib for thoracic outlet syndrome. Br J Surg. of clinical
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1989;76(12):12556. J Vasc Surg.
2005;42(1):1228.
Conservative Management of
Spinal
Deformity in Childhood
Federico Canavese, Dimitri

Ceroni, and Andre Kaelin
Contents
Abstract
Conservative Treatment of Idiopathic
Casting and bracing for spinal deformities are
Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 463 very traditional ways of stabilizing or
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 463 correcting spinal deformities during growth.
When to Start Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .
464 There is still open debate about their influence
Method of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
465
Hours Per Day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 465 in positive outcome.
When to Stop Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .
465 Indications for bracing for scoliosis and
Complications of Brace Treatment . . . . . . . . . . . . . . . . .
466 kyphosis in the growing period depend on
Brace Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 466 accurate history and clinical examination, as
Other Conservative Treatments . . . . . . . . . . . . . . . . . . . . .
470
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 471 well as imaging and documentation of pro-
gression. Bracing systems must be effective

Conservative Management of Kyphosis . . . . . . . . . .
471
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 471
and tolerable for the patients. The team

Scheuermanns Kyphosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .
471 conducting the treatment must be convinced
Radiographic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . .
472 of its effectiveness and transmit this convic-
Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 474 tion to the patient and his family. These are the
Non-Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .
474
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 477
basic conditions for a successful treatment. In
the following paper, scoliosis treatment and

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 478 kyphosis treatment are discussed.
Keywords
Federico Canavese is the author of the section
Conservative Orthopaedic treatment # Idio-
Conservative Treatment of Idiopathic Scoliosis and
pathic scoliosis # Kyphosis # Physical therapy

Dimitri Ceroni is the author of the section Conservative
# Scoliosis # Spinal braces # Spine # Spine

Management of Kyphosis
deformities # Spine growth # Unbalanced spine

F. Canavese
Department of Pediatric Surgery, University Hospital
Estaing, Clermont Ferrand, France
e-mail: canavese_federico@yahoo.fr
Conservative Treatment of Idiopathic
D. Ceroni
Scoliosis
Department of Paediatric Orthopaedics, Childrens
Hospital and University Hospital Geneva, Geneva,
Switzerland
Introduction
e-mail: dimitri.ceroni@hcuge.ch
The strategy for the treatment of idiopathic

A. Kaelin (*)
Clinique des Grangettes, Chene-Bougeries, Switzerland
scoliosis depends upon the size and pattern of
e-mail: andre.kaelin@grangettes.ch
the deformity, and its potential for progression.

463
DOI 10.1007/978-3-642-34746-7_27, # EFORT 2014
464
F. Canavese et al.
During the past decade, several studies have When to Start Treatment
confirmed that the natural history of adolescent
idiopathic scoliosis can be positively affected Observation is appropriate
treatment for small
by non-operative treatment, particularly bracing curves, curves that are at low
risk of progression,
[16]. The primary objective of non-operative and those with a natural
history that is favourable
treatment is to successfully arrest progressive at the completion of growth.
Indications for brace
curves or correct curves that cause or may treatment are a growing child
presenting with
likely cause disability. Orthotic device selection a curve of 25# 40# or with a
curve less than 25#
is based on the type and level of the curve that has shown documented
progression. Curves
and the anticipated tolerance of the patient. of 20# 25# in those with
pronounced skeletal
Avoidance of unnecessary surgery, cosmetic immaturity (Risser 0, Tanner 1
or 2) should also
improvement, and an increase of vital capacity be treated immediately. By
contrast, contra-
as well as pain control, are also of major indications for bracing are
children who has com-
importance [714]. pleted growth, or growing
children with a curve
In 1985, the Scoliosis Research Society of over 45# , or under 25#
without documented
(SRS) initiated a controlled clinical trial study progression [2, 3, 6, 17].
True thoracic lordosis is
to investigate the effectiveness of bracing as also a contra-indication for
orthotic treatment due
treatment for scoliosis. Patients of the same to the effect of orthoses on
the thoracic spine.
age, curve pattern and curve severity were A child with a non-supportive
home situation or
divided into two groups, one treated with brac- who refuses to wear a brace
should not be con-
ing and one untreated. Results published in 1993 sidered for brace treatment.
demonstrated that brace treatment was effective Body habitus has been
found to be a predictive
compared with natural history [2]. In another factor of poor outcome in the
orthotic treatment
study [3], the records and radiographs of more of adolescent idiopathic
scoliosis. Overweight
than 1,000 scoliotic patients treated by bracing adolescent patients will have
greater curve pro-
were reviewed and compared with unbraced gression and be less
successful with bracing. In
patients [15]. This retrospective study confirmed addition, the ability of a
brace to transmit correc-
that bracing was an effective treatment to slow tive forces to the spine
through the ribs and soft
or arrest the progression of most spinal curva- tissue may be compromised in
these patients and
tures in skeletally-immature patients compared this factor should be taken
into account when
with those untreated by this method. Further- making treatment decisions
[18].
more, a meta-analysis of 20 studies showed A prospective, multi-
centre study conducted
that bracing 23 h per day was significantly by Nachemson et al. in several
countries showed
more successful than any other non-operative that the success rate of
bracing was significantly
treatment [4, 6]. Nevertheless, there are higher compared to observation
and surface elec-
some patients for whom brace treatment is not trical stimulation [2]. A
meta-analysis of 20 stud-
effective [16]. ies further supported this
finding and showed that
Other forms of non-surgical treatment, such the weighted mean proportion
of success was low
as chiropractic or osteopathic manipulation, for lateral electrical surface
stimulation and for
acupuncture, exercise or other manual treat- observation, and progressively
higher for bracing
ments, or diet and nutrition, have not yet been at 8, 16, or 23 h per day. The
study concluded that
proven to be effective in controlling spinal bracing 23 h per day was
significantly more suc-
deformities. cessful than any other
treatment [4]. Furthermore,
The purpose of this review is to summarize a recently published
systematic review concluded
the available knowledge related to the conser- that bracing adolescent
idiopathic scoliosis is
vative treatment of adolescent idiopathic effective in the long-term
[19]. However, it
scoliosis. remains controversial as to
whether or not
Conservative Management of Spinal Deformity in Childhood
465
a bracing program can decrease the frequency of Use of the brace part-time
or only at night has
surgery [20, 21]. A recently published systematic been advocated by some
physicians and is widely
review used the number of surgically-treated used in some institutions.
However, there is
patients as an indicator of failure of bracing and a paucity of long-term
follow-up data to prove
reported a broad spectrum ranging from 1 % to the effectiveness of this
wearing regimen in ado-
43 % [22, 23]. lescents, and all series on
effective orthotic treat-
ment were with full-time
wear.
Wiley et al. analysed the
results of bracing
Method of Treatment according to the wearing
regimen. Patients were
divided into non-compliant
(less than 12 h per
When patients are first fitted with a brace, there day), part-time (between 12
and18 h per day), and
is an initial adjustment period of usually 12 full-time brace wearing
(between 18 and 23 h per
weeks. Initially, the patient is prescribed to day). The initial curves were
similar in the three
wear the brace for a specific number of hours groups. Patients who wore the
brace less than
per day and the orthosis is left slightly loose to 12 h per day had an average
curve progression
allow the patient to gradually adjust to it. The from 41.3# to 56.3# , and
those who wore the brace
brace is increasingly tightened daily until the part-time progressed from
37.6# to 41.2# . Signif-
appropriate level of snugness is reached. If any icant curve improvement was
noted in the full-
areas of tenderness or skin irritation develop, the time patient group and curves
measured 35.7# at
brace is adjusted for optimal fit. Roentgeno- final follow-up compared to
39.3# at brace fitting.
grams are performed after 4 weeks with the In addition, the surgical
rate also depended on
brace in place to verify the fit and determine brace compliance with 73 % in
non-compliant
the degree of curve reduction. Repeated roent- patients compared to 9 % in
the fully compliant
genograms should be performed approximately group [24].
every 46 months with the brace removed to Green [25] reported that
16 h per day of brac-
follow the progression of the curve. No further ing was effective in slowing
curve progression.
roentgenograms are required with the brace in He studied a heterogeneous
group of patients
place as all reduction is achieved at the time of with curves between 23# and
49# and found that
the initial fitting. If any major adjustments are only 9 % curves progressed 5#
or more. However,
made to the brace, a roentgenogram is necessary both Boston and Milwaukee
braces were used for
to verify position. treatment and follow-up was
limited. Similarly,
Emans et al. [26] found part-
time brace wear to
be as effective as full-time
wear for smaller
Hours Per Day curves. Allington and Bowen
[27] reported no
difference in the efficacy of
full-time versus
Studies conducted on the number of hours per day part-time wear using the
Wilmington brace for
of brace wearing show that the more hours per curves of 30# 40# , but
observed that 58 % of
day the brace is worn, the better the result. The patients progressed more than
5# in the brace.
brace is usually prescribed for full-time wear with Peltonen et al. [28] also
noted that the results of
time out for bathing, swimming, physical educa- 12 h per day of bracing were
similar to the results
tion and sport. The child should be encouraged to of 23 h per day.
be active in sporting activities while continuing
to wear the brace if possible. Contact sports are
not allowed with the brace to protect other par- When to Stop Treatment
ticipants. These activities generally represent an
average of 24 h a day to ensure brace-wearing of Brace-weaning stops when the
patient reaches
2123 h daily. skeletal maturity, determined
as the finding of
466
F. Canavese et al.
a Risser sign of 4, i.e., more than 12 months post- a

b
menarche and lack of growth in height. Over
a period of 23 months, the time of brace wear
is decreased progressively and a roentgenogram
is then performed of the patient without the brace.
If the spine remains stable, brace weaning con-
tinues over another 23 months with a further
progressive decrease in brace wear. After the
second phase of weaning, another roentgenogram
without the brace is performed to verify the sta-
bility of the spine. If stability is maintained, the
weaning programme continues until the patient is
completely independent of the brace. If at any
time during the weaning process the stability of
the spine is in question, the bracing regime is
continued.
Fig. 1 Milwaukee brace. (a)
Front view, (b) back view
Complications of Brace Treatment

Blount and Schmidt in 1946
for post-operative
Problems encountered due to brace treatment care when surgery required
long periods of immo-
include skin irritation, a temporary decrease in bilization and it has
subsequently been used for
vital capacity, and mild chest wall and inferior rib thoracic and double curves.
Milwaukee braces are
deformation. Skin irritation is a common problem often custom-made from a
mould of the patients
and more frequent in warm climates and during torso. One anterior and two
posterior bars are
the summer months due to the increase in heat attached to a pelvic girdle
made of leather or
and sweat. To reduce the likelihood or occurrence plastic, as well as a neck
ring. The ring has an
of skin irritation, frequent changing of the cotton anterior throat mould and
two posterior occipital
undergarment is recommended, but discontinua- pads, which fit behind the
patients head. Lateral
tion of brace treatment due to skin irritation is pads are strapped to the
bars and adjustment of
uncommon. The vital capacity may be temporar- these straps holds the spine
in alignment.
ily reduced in patients treated with thoraco- Curve patterns that
should be treated in
lumbo-sacral orthosis and mild chest wall and a Milwaukee brace are
thoracic curves that have
inferior rib deformation can appear during treat- an apex at or above T8,
double thoracic, and other
ment. However, when brace use is discontinued, double curves when the apex
of the thoracic com-
the mild rib cage deformity disappears. No severe ponent is above T8, i.e.,
double thoracic and lum-
permanent chest wall deformities have been bar, or double thoracic and
thoracolumbar patterns.
described following brace treatment [714]. Success rate. Curves
between 20# and 29#
with a Risser sign between 0
and 1 progressed
28 % less than untreated
curves of similar mag-
Brace Types nitude (40 % vs. 68 %,
respectively). Treated
curves of similar magnitude,
but a Risser sign of
Cervico-Thoraco-Lumbo-Sacral Orthosis 2 or more, progressed 10 %
less than untreated
(Milwaukee Brace) curves (10 % vs. 23 %,
respectively). Similarly,
The Milwaukee brace (Fig. 1), also named curves between 30# and 39#
with a Risser sign
cervico-thoraco-lumbo-sacral orthosis (CTLSO), between 0 and 1 progressed
14 % less than
is a full torso brace extending from the pelvis to untreated curves of similar
magnitude (43 % vs.
the base of the skull. It was originally designed by 57 %, respectively). Treated
curves of similar
467
magnitude, but a Risser sign of 2 or more, provided opposite the

sites of corrective force to
progressed 21 % less than untreated curves allow the patient to
pull the spine away by active
(22 % vs. 43 %, respectively) [3, 15]. muscular effort [26].
The brace also has a 15#
lumbar lordosis built
into it. The brace runs from
Thoraco-Lumbo-Sacral Orthosis just above the seat of
a chair (when a person is
To improve patient compliance, substantially less seated) to around
shoulder blade height and is not
bulky and lightweight thoraco-lumbo-sacral particularly useful in
correcting very high curves
orthoses (TLSO) were developed. TLSO is the [5, 23, 24, 26, 29].
generic name for a group of orthoses character- Success rate. The
brace has been shown to be
ized by a pelvic portion similar to the pelvic particularly effective
for curves ranging from 20#
section of the Milwaukee brace and an upper to 59# between T8 and
L2. At the beginning
portion extending up to one or both axillae or of treatment, brace
correction is about 50 %
only to the lower thoracic area. Although there (Fig. 3), decreasing to
15 % by the time of brace
are many variations in their design, generally discontinuance. With
Boston brace treatment,
named after the city or centre of origin, they approximately half of
the curves (49 %) remain
all function on the same principle. This type of unchanged, 39 % are
stabilized with a final correc-
brace is generally prescribed for lumbar and tion of 5# 15# , 4 %
are stabilized with a correction
thoracolumbar curves, and thoracic curves with superior to 15# , 4 %
lose between 5# and 15# , and
an apex at or below T8. 3 % progress more than
15# . A study by Emans
et al. reported that 11
% of patients underwent
Boston Brace surgery during the
period of bracing [26].
Watson, Hall and Stanish first introduced the
Boston brace in the mid-1970s and reported on Wilmington Brace
its efficacy on 1977 [29]. The brace (Fig. 2) opens In the early 1970s,
Dean MacEwen developed the
at the back and corrects curvatures by pushing the Wilmington brace, also
known as the duPont
spine with small pads placed against the ribs, Brace. The Wilmington
brace is a custom-made,
which are also used for partial rotational correc- plastic, underarm
thoraco-lumbo-sacral orthosis.
tion. These pads are usually placed in the back The brace is a total
contact orthosis and is
corners of the brace so that the body is thrust designed as a body
jacket, which opens in the
forward against the front of the brace, which front for easy removal
and is held closed by
acts to hold the body upright. Areas of relief are adjustable straps.
Similar to the Boston brace, it
is not useful in
correcting very high curves [27].
a b Success rate.
Progression of the deformity by
5# or more is generally
observed in 36 % of
patients treated with
full-time bracing for
a curve of less than
30# compared to 41 % of
patients managed with
part-time bracing. Failure
rates are higher in
patients with curves between
30# and 40# managed
with both full-time (58 %)
and part-time bracing
(59 %) [27].
Lyon Brace
The Lyon brace (Fig. 4)
was designed by Stagnara in
1947. It is composed of
a pelvic section with axil-
lary, thoracic and
lumbar plates connected in units
by two vertical
aluminium rods, one anterior and
Fig. 2 Three-point Boston brace. (a) Front view, (b) back one posterior. The
pelvic section is composed of two
view lateral valves, one for
each hemipelvis. The valves
468
F. Canavese et al.
Fig. 3 Right thoracic

scoliosis. (a) Antero-
a b
posterior full spine
radiograph without brace,
(b) immediately post first
brace fitting
a b are connected by metal pieces to

the vertical alu-
minium rods. Forces are applied
at the two neutral
vertebrae and a counterforce is
applied at the apex of
the curve. It is usually
prescribed for progressive
scoliosis with lumbar or low
thoracolumbar curves
between 30# and 50# [30, 31].
Success rate. The overall
efficacy of the Lyon
brace is 95 %. However, it drops
to 87 % for thoracic
curves and to 80 % in patients
with Risser sign 0.
Cheneau Brace
Jacques Cheneau designed the
original Cheneau
brace in 1979. The brace is
commonly used
Fig. 4 Lyon brace. (a) Front view, (b) back view for the treatment of scoliosis
and thoracic
469
hypokyphosis in many European countries, Israel aluminium rods. It has two

lateral elements
and Russia. However, it is not commonly pre- that cover the back from the
pelvis to the
scribed in North America and the United Kingdom. armpits, and the abdomen.
These are linked to
The Cheneau brace utilizes large, sweeping pads to a posterior, centrally-
located, aluminium rod, and
push the body against its curve and into blown out the brace closes anteriorly
with straps on the
spaces and is usually coupled with the Schroth abdomen and another
transverse bar at the level
physical therapy method. The Schroth theory of the manubrium sterni. The
brace corrects hip
holds that the deformity can be corrected through misalignments through
padding. Large, sweep-
retraining muscles and nerves to learn what ing, thick pads push the
spine to a corrected posi-
a straight spine feels like, and by breathing deeply tion. To prevent
overcorrection, however, the
into areas crushed by the curvature to help gain brace also has stop pads
to hold the spine
flexibility and to expand [32, 33]. The brace from moving too far in the
other direction. This
helps patients to perform their exercises brace is used for all curve
patterns and types, even
throughout the day. It is asymmetrical and used for those ones considered as
too late for brace
for patients of all degrees of severity and matu- treatment by other schools.
It is typically worn
rity, and often worn 2023 h daily. The brace 22 h a day and often coupled
with a physical
principally contracts to allow for lateral and therapy program [36, 37].
longitudinal rotation and movement [34]. Success rate. In terms of
Cobbs angle,
most curves have been shown
to remain stable
Rigo-Cheneau System (RCS Brace) or to slightly improve. The
SPoRT brace
Rigo et al. have further developed the developing team found that
it is possible to
original Cheneau brace by designing the obtain scoliosis correction
similar to cast in
Rigo-Cheneau System (RCS) brace. The main the corrective phase of
adolescent idiopathic
indication are curves up to 60# (first grade scoli- scoliosis treatment [37].
osis: angle up to 40# , and second grade scoliosis,
between 40# and 60# , according to the Rigo Night Braces
classification [35]). Charleston Brace
The Charleston bending brace
(Fig. 5) was
Malaga Brace designed with the idea that
compliance would
The Malaga brace is a custom-made TLSO, increase if the brace was
worn only at night.
commonly prescribed in Southern Spain, but
relatively unknown outside that country. It is
a corrective spinal orthosis used in the treatment a
b
of coronal plane curves, but with no derotation
element incorporated in the brace.
The brace is of monovalve construction with
a posterior opening that closes with metal fas-
teners. The patient wears the brace for approxi-
mately 23 h per day and it is indicated for
progressive curves between 20# and 30# .
SPoRT Brace (also known as Sforzesco

Brace)
The SPoRT (Symmetric, Patient-oriented, Rigid,
Three-Dimensional active) brace is symmetrical
and built with a plastic frame re-inforced with Fig. 5 Charleston brace. (a)
Front view, (b) back view
470
F. Canavese et al.
Hooper and Reed collaborated in 1978 on the Soft Brace

early development of this new side-bending SpineCor Brace
brace for nocturnal wear. The orthosis is asym- The SpineCor brace was
developed by Coillard
metrical and fights against the bodys curve by and Rivard in the mid-1990s.
The brace has
overcorrecting the deformity. It grips the hips a pelvic unit made of
plastic, from which strong
much like the Boston brace and rises to approxi- elastic bands wrap around
the body, pulling
mately the same height, but pushes the patients against curves, rotations,
and imbalances. It is
body to the side. It is used in single, most successful when
patients have relatively
thoracolumbar curves in patients 1214 years of small and simple curvatures
and are structurally
age (before structural maturity) who have flexible young and compliant. The
SpineCor bracing
curves in the range of 2535# [3840]. method is an adjustable,
flexible, and non-
Success rate. Patients with a curve over 25# invasive technique providing
correction that con-
and a Risser sign between 0 and 2 showed a rate tinues as a child moves and
grows. The brace is
of surgery between 12 % and 17 % [38, 39, 41]. In usually worn 20 h a day and
the patient can
a 2002 study, it has been shown to be equally remove it for no more than 2
h a day.
effective as the Boston brace [41]. Success rate. A 2003
study reported that after
2 years, the SpineCor brace
is able to correct
Providence Brace scoliotic curves by 5# in 55
% of patients. The
The Providence brace was developed by remaining 45 % were
stabilized (38 %) or wors-
DAmato, Griggs and McCoy in the mid- ened by more than 5# (7 %).
However, recent
1990s. The brace works by the application of studies demonstrated a trend
different from the
controlled, direct, lateral and rotational forces findings of the SpineCor
developing team and
on the trunk to move the spine toward the mid- reported a lower success
rate than rigid spinal
line or beyond the mid-line. It does not bend the orthosis [4446].
spine as with the Charleston bending brace. The
goal is to use the centreline as a reference and
bring the apices of the scoliotic curve to that line Other Conservative
Treatments
or beyond through the application of lateral
forces. This involves the use of three-point- Opinions differ in the
international literature on
pressure systems and void areas that are located the efficacy of conservative
approaches to scoli-
opposite these pressures. Compared with natural osis treatment. Alternative
forms of non-surgical
history and the prospective study data of treatment, such as
chiropractic or osteopathic
Nachemson et al. [2], the Providence brace is manipulation, acupuncture,
exercise or other
effective in preventing curve progression of manual treatments, or diet
and nutrition, have
deformities less than 35# and low apex curves not yet been proven to be
effective in controlling
of over 35# . It is more successful in curves with spinal deformities.
apex curves at or below T9 compared to curves Although a subject of
debate, most experts
with apex cephalad to T8 [42, 43]. agree that physiotherapy
alone will not affect
Success rate. Recent studies showed that the the progression of a
structural scoliosis. How-
Providence night brace generally achieves an ever, there is agreement
that a selective physical
average of about 90 % for brace correction therapy program in
conjunction with brace treat-
of the primary curve and during follow-up, pro- ment is beneficial. The
triad of out-patient phys-
gression of the curve of more than 5# should iotherapy, intensive in-
patient rehabilitation, and
be expected in about 25 % of cases. The night bracing has proven effective
in conservative sco-
brace may be recommended for the treat- liosis treatment in central
Europe [32, 33].
ment of adolescent idiopathic scoliosis with Acupuncture involves
penetration of the skin
curves less than 35# in lumbar and thoracolumbar by thin, solid, metallic
needles that are stimulated
cases [42, 43]. either manually or
electrically and it is commonly
471
used for pain control throughout the world, kyphosis, idiopathic

kyphosis, osteochondral
although the putative mechanisms are still dystrophies and, above all,
Scheuermanns
unclear. To date, only one study has been kyphosis. The main purpose
of this review is
published and the effects of acupuncture in the to summarize the available
knowledge related to
treatment of patients with scoliosis require fur- the kyphotic deformities and
to their conservative
ther investigation [47]. treatment in the teenage
population.
Electrotherapy was hailed as a promising ther-
apy, but failed to alter the natural history of
idiopathic scoliosis. With electrotherapy, the lat- Scheuermanns Kyphosis
eral muscles on the convexity of the curve are
stimulated electrically. It has been shown that no Scheuermanns kyphosis is
the most common
benefit was observed in approximately half of the cause of hyperkyphosis in
adolescence; its
patients treated by nighttime electrotherapy and reported prevalence ranges
from 0.4 % to 8 %
that the difference in progression between brac- of the general population,
but its true prevalence
ing programs and electrical stimulation was not is probably understated
since it is either missed
significantly different [27, 48]. or attributed to poor
posture [5053] (Fig. 6).
Conclusions
Brace treatment is the only method that has been

proven to alter the natural history of idiopathic
scoliosis. However, different orthosis and many
bracing regimens exist. Observation is appropri-
ate for small curves, whereas bracing is generally
indicated for progressive curves or for curves
over 29# in a skeletally immature child. Braces
are generally prescribed for more than 20 h a day
and the results of brace treatment correlates to
treatment compliance. Problems encountered
with bracing are limited.
Conservative Management
of Kyphosis
Introduction
Kyphosis is an exaggerated outward curvature of

the spine in the flexion/extension axis, producing
a humpback appearance. Excessive kyphosis
can be associated with a variety of conditions,
such as congenital spinal anomalies, neuromuscu-
lar disease, bone dysplasia, trauma, infection, neo-
plasm, irradiation therapy, surgical laminectomy,
and metabolic disorders [49]. Most of these
kyphotic deformities require usually surgical
Fig. 6 A fourteen-year-old
male teenager presented to
treatment. In adolescents, many conditions our consultation with an
unaesthetic Scheuermanns
present with kyphotic curves such as postural kyphosis. He complained
about occasional low back pain
472
F. Canavese et al.
This affection has no specific gender prevalence theory of pathogenesis has

recently been
[5356]. The onset of Scheuermanns kyphosis described by Fotiadis and
al. According to
usually starts just before puberty, after ossifica- these authors, a smaller
length of sternum than
tion of the ring apophysis, as a structural kyphotic the normal may be correlated
with the appear-
deformity of thoracic or thoracolumbar spine. ance of thoracic
Scheuermanns kyphosis, since
The typical patient is between the late juvenile a smaller length of this
bone could increase the
to age 16 years, commonly between 12 and 15 compressive forces on the
vertebral end-plates
years [55]. anterioly, allowing uneven
growth of the verte-
The thoracic pattern is the most common and bral bodies with wedging
[61].
is associated, most of the time, with compensa- Disorganized enchondral
ossification similar
tory non-structural hyperlordosis of the cervical to Blounts disease, a
reduction in collagen, or
and lumbar spine [57]. The apex of the deformity an increase in
mucopolysaccharides in the end-
localized between T7 and T9. The thoracolumbar plate, are common
histopathological findings
pattern, whose apex localized between T10 and noted in adolescents with
Scheuermanns
T12, is less frequently encountered but it has the kyphosis [62, 63]. It is
readily differentiated
poor reputation being the most likely to progress from postural roundback
radiographically
after the end of skeletal growth [58]. The natural because of the presence of
vertebral bony wedg-
history of Scheuermanns in adolescents shows ing, vertebral end-plate
irregularity, diminished
that progression is faster when curves are large, anterior vertebral growth,
and premature disc
and during peak growth velocity [49]; however, degeneration [53]. Other
pathological entities
curves are generally considered to be stable that must be differentiated
include idiopathic
after maturity [49]. In the majority of patients, kyphosis, osteochondral
dystrophies, congenital
thoracic kyphosis is painless and partially flexible kyphosis, and spondylo-
epiphyseal dysplasias
[56]; when symptomatic, pain may be aggravated [55]. Currently,
Scheuermanns kyphosis is the
by physical exertion [55]. At clinical examina- more frequent affection
requiring a brace treat-
tion, the most common findings are forward ment in skeletally-immature
patients.
protruded position of the head, round anteriorly-
positioned shoulders, anterior flexion contrac-
tures of the shoulder joint, flexion contracture of Radiographic Evaluation
the hip joint, and hamstrings tightness. In the
Adams forward bend-test, the patients with How to do a Good Radiograph
Scheuermanns disease demonstrate an area of Initial evaluation for
kyphosis should include
angulation in a fixed or relatively fixed kyphotic anteroposterior (AP) and
lateral standing radio-
curve [55]. graphs, including the entire
spine, the cranium
At present, the aetiology of Scheuermanns and the femoral heads.
Careful attention should
kyphosis remains unknown, but several factors be paid to patient
positioning and radiologic tech-
seem important in the pathogenesis of this affec- nique in order to achieve
correct visualization of
tion, such as a genetic contribution [59, 60] or an the upper thoracic spine.
The optimal lateral
abnormal mechanical loading of the growing radiograph should be taken
in the standing posi-
spine [54, 56]. Scheuermanns disease is consid- tion with the arms
anteriorly flexed at 90# , and
ered hereditary, although the hereditary pattern resting on a support [64,
65] or in the clavicular
has not been clearly defined [55]. The mode of position [66, 67]. The
kyphosis can then be mea-
inheritance may be autosomal dominant, with sured from the uppermost
tilted vertebra to the
a high degree of penetrance and variable expres- lowermost tilted vertebra,
whatever these may be
sivity [59]. Reports suggest heritability of [65]. Nevertheless, some
radiographs may
identical radiological changes in monozygotic be somewhat indistinct in
the upper thoracic
twins, sibling recurrence, and transmission area and the end-plates
cannot be adequately
through generations [60]. An interesting new seen for a good measurement
[65]. This problem
473
can be often be overcome by re-creating the con-

tour by drawing a line along the anterior vertebral
body cortices [65]. Once this best-fit line
has been drawn, perpendiculars to that line
can be used to measure the kyphosis (unpublished
data by F. Takeuchi & F. Denis).
What is Normal
The measurement of thoracic kyphosis is confus-
ing, as some authors routinely measure T2T12,
T4T12, or T5T12, even if these are not the
maximally tilted vertebrae [65]. When the kypho-
sis is measured between the first and the twelfth
thoracic vertebrae, the mean thoracic kyphosis in
children and adolescents ranges from 33# [64] to
43# [68], with very large ranges and standard
deviations. There is still a controversy as to
what is the normal range of thoracic kyphosis.
The old statement found in many text, that normal
is from 20# to 40# is no more justifiable. Cur-
rently, curves ranging from 15# to 55# can be
considered as physiologic kyphosis [65].
Beyond this limit, kyphosis becomes abnormal,
which is confirmed by the fact that postural
roundback rarely exceeds 60# while
Scheuermanns typically does [49].
Radiologic Criteria of Scheuermanns

Disease Fig. 7 Radiographic
investigations demonstrated a 75#
The radiographic diagnosis of Scheuermanns Scheuermanns thoracic curve,
which was partially
disease requires anterior vertebral wedging reducible
more than 5# in at least three contiguous verte-
brae, as defined by Sorensen [69] (Fig. 7). Sec-
ondary radiographic findings included irregular
apical vertebral end-plates, anterior narrowing of thought to result in
increased stresses on the
disc spaces, and Schmorls nodes [49]. The pars interarticularis that
may account for the
anteroposterior view of the spine may show increased incidence of
spondylolisthesis reported
mild scoliosis, typically less than 20# and non- in adolescents with
Scheuermanns disease [55].
progressive [56, 70]. However, most of the time,
these curves are not real scoliotic curves; in Description of Sagittal
Spinal Imbalance
fact, vertebral rotation is often absent and appar- Radiographic evaluation does
not have to limit
ent scoliotic curves have to be attributed to non - itself to measure the
kyphotic deformation:
orthogonal view on the AP radiograph of the studying the global sagittal
balance has to be
thoracic kyphotic or lumbar lordotic curves. conducted taking into
consideration the position
Thoracic Scheuermanns kyphosis is usually of the spine, and that of the
pelvis and the hips.
compensated either by lumbar hyperlordosis Legaye et al. have
demonstrated the key impor-
(>50 %) or by thrusting the lumbar spine back- tance of the anatomical
parameter of pelvic
wards. These compensatory phenomenons are incidence in the regulation
of the sagittal curves
474
F. Canavese et al.
of the spine and in the individual variability of the Natural History

sacral slope and the lordosis curve [71, 72]. The
pelvic incidence is formed by the line connecting Before implementing any
treatment, the Ortho-
the centre of the upper end-plate of S1 to paedic surgeon should be
aware of the natural
the centre of the axis of the hips and by the line history of the disease,
specific criteria for initiat-
perpendicular to the tangent to the centre of the ing therapy and, above
all, must weigh the bene-
upper end-plate of S1. Pelvic incidence is a fixed fits against the
complications of the prescribed
anatomical value for each individual and corre- treatment. The natural
history of Scheuermanns
sponds to the sum of two postural parameters in teenagers shows that
progression is faster
called sacral tilt (ST) and pelvic tilt (PT) [71, 72]. during peak growth
velocity, especially when
Therefore any change in sacral tilt produces the curves are important
[49]. After the end of
a change in pelvic tilt, and vice versa. In children the puberty, the curves
will generally not
and adolescents with thoracic Scheuermanns increase [49]. Particular
attention should be paid
kyphosis, two mechanisms may be implemented to thoracolumbar kyphosis,
since these curves
to compensate the sagittal imbalance. First, pelvic have the poor reputation
to be the most likely to
tilt can increase by rotation of the pelvis around the progress after the end of
the growth [58]. Most of
line passing through the femoral heads. Rotating the patients with
Scheuermanns report greater
the pelvis forwards (classically called pelvic back pain, embarrassment
about their physical
anteversion) displaces the S1 end-plate anteriorly appearance which can
progress to psychological
and increases the sacral inclination (sacral tilt). distress, but do not
appear to be disabled by their
If the lumbar spine is mobile, the sagittal symptoms [54].
Nevertheless, patients with
balance will be ensured by increasing lumbar Scheuermanns
hyperkyphosis work usually in
lordosis (picture). When the pelvis appears lighter jobs and announce
interference with
backwards rotated (pelvic retroversion due to daily activities [54].
Most of the patients with
tight hamstrings), sacral inclination appears weak the lumbar or thoraco-
lumbar form of the disease
and, as a result, a second mechanism is called into present usually with more
important and perma-
play: in this situation, the sagittal balance is nent low back pain [59].
Neurologic complica-
ensured by thrusting the lumbar spine backwards tions secondary to severe
kyphosis, dural cysts, or
without using the natural lumbar lordosis. thoracic disc herniation
have been described in
This lumbar postural inversion is recognized a small number of patients
with untreated
to increase the facet joint pressure especially at Scheuermanns kyphosis
[7375]. The conse-
the level of L4L5 and L5S1, and to concentrate quences of kyphotic
deformity on pulmonary
sagittal shear-force at the level of the pars function remain unclear
since no correlation is
interarticularis, with the spondylolysis risk which found with cardiopulmonary
insufficiency,
results from this. except for the curves of
more than to 100# 110#
[54]. Unfortunately, there
is still a lack of litera-
Additional Investigations ture regarding the natural
history of
Additional imaging studies should include radio- Scheuermanns kyphosis and
there are therefore
graphs of the left hand and wrist (bone age), a few questions that still
need to be answered in
passive hyperextension views, and in many order to establish
guidelines for treatment.
cases magnetic resonance. Lateral hyperexten-
sion views give interesting information about
the flexibility of the kyphotic curves. Magnetic Non-Operative Treatment
resonance imaging is used in the evaluation of
neurological deficits, intervertebral disc degener- Indications
ation and disc herniation, for atypical forms During the past decade,
several studies have
of Scheuermanns disease with non-diagnostic confirmed that the natural
history of adolescent
findings in conventional radiographs [55]. kyphosis can be positively
affected by
475
non-operative treatment, particularly bracing 3-point corrective force to

the mid-thoracic
[7680]. Indications for conservative treatment spine and simultaneously
decreases the excessive
include pain, progression of deformity, neuropa- lumbar lordosis. The
Milwaukee brace is the pri-
thy, but also cosmesis, in Scheuermanns curves mary orthosis recommended
for kyphosis located
measuring 55# 75# . For curves measuring to the thoracic spine,
especially if the apex of the
beyond 75# , it seems legitimate to consider spinal deformity is located at or
cephalad to T6 and T8.
fusion even if brace treatment may be successful Consecutively, other types
of bracing have been
in several cases [79]. Braces are useful for manufactured to relieve the
psychological prob-
Scheuermanns kyphosis measuring 55# 75# , lems associated with the
Milwaukee braces
provided the patients still have significant growth occipital-chin ring to the
patient, and therefore
remaining. As spinal growth continues until the to improve patients
compliance to wear the
end of the puberty, it seems consistent to start brace. The polypropylene
thoracolumbosacral
with brace treatment even after the pubertal orthosis (TLSO) is a popular
3-point orthosis
growth peak. On this subject, teenagers with with an anterior sternal
extension or padded ante-
Rissers score less or equal to two require rior shoulder outriggers and
a posterior spinal
bracing (unpublished data by Richards B.S. and pad. Like the Milwaukee
brace, TLSO also
Katz D.E. Texas Scottish Rite Hospital). By con- diminishes the lumbar
lordosis. TLSO is indi-
trast, contra-indications for bracing are an ado- cated above all for kyphotic
deformities whose
lescent who has completed growth, or a growing apex below the eighth or
ninth thoracic vertebra.
child with curve of over 80# , especially if these Other braces, such as
polypropylene lumbosacral
are located in the upper part of the thoracic spine. orthosis (LSO) (Fig. 8) or
the active-passive
Teenagers with non-supportive home situations Gschwend erection corset,
reduce the lumbar
or who refuse to wear a brace should not be lordosis severely, and by
doing so, force the
considered for bracing. Finally, angular structural patient to actively right
himself out of the
kyphosis due to an anterior vertebral wedging has kyphotic thoracic posture.
These devices are effi-
to be considered as predictive factor of poor out- cient for curves with an
apex below T8T9, and
come in the orthotic treatment of Scheuermanns the indications for using
these braces are partially
kyphosis. flexible kyphotic curves.
More recently, Weiss
and al. suggested that
braces using only trans-
Types of Braces verse corrective forces may
achieve reduction
Currently, only bracing has demonstrated to be rates similar to those
obtained by Milwaukee
effective in decreasing or in stabilizing progres- brace. In the same way,
Riddle and al felt that
sion of kyphotic curves. The goal of the bracing is TLSO results were comparable
to those with the
not only to arrest progression but also to achieve Milwaukee brace. Currently,
computer-aided
permanent improvement in the thoracic kyphosis. design/computer-aided
manufacture (CAD/CAM)
This can result only if the anterior vertebral and other computer
technology had been intro-
height is restored by application of hyperexten- duced in order to eliminate
uncomfortable physical
sion forces (unpublished data by Richards B.S. contact for the teenagers,
as well as the orthotists
and Katz D.E. Texas Scottish Rite Hospital). skills. The first results
suggest that CAD/CAM
Without reconstitution of the anterior vertebral braces are more comfortable
and therefore better
height, the deformity will inevitably recur fol- tolerated by patients with
equivalent correction if
lowing bracings removal. In the past, many not superior.
braces have been described in the treatment of
Scheuermanns kyphosis. For many years, the Treatment Modalities
most commonly-used brace was the Milwaukee At the beginning of the
brace treatment, there is
brace [56, 76, 79], which acts as a three-point an initial adjustment period
of a few weeks.
orthosis promoting dynamic extension of the tho- Initially, the patient is
prescribed to wear the
racic spine; this brace effectively applies a brace for a specific number
of hours per day,
476
F. Canavese et al.
especially encouraged to
wear the chosen ortho-
sis until later
adolescence (Risser grade 5).
Unfortunately, this is
difficult to achieve as the
adolescents tend to
become less compliant with
bracewear over time.
Repeated roentgenograms
should be performed
approximately every 46
months with the brace
removed during the preced-
ing 24 h to follow the
improvement of the curve.
In the most severe or
stiff deformities, prepara-
tive cast treatment may
be considered to improve
the curves flexibility
before switching to a brace
[52, 55]. This effect
has been well demonstrated
using the methods of
Ponte & Stagnara.
Expectable Results of
Bracing
Whilst unlikely in
idiopathic scoliosis, brace
treatment often results
in some permanent reduc-
tion of spinal deformity
in Scheuermanns
kyphosis. In most
series, the results of bracing
are very interesting in
compliant patients, with
approximately 4050 % of
correction (Fig. 9). In
absolute values, final
mean improvement range
between 6# and more than
20# . In our hospital, we
analyzed the results in
20 patients who had used
a polypropylene
thoracolumbosacral orthosis and
had been followed for 45
months. The average
age of the patients at
the initiation of treatment
was 13 years and 6
months, the average duration
Fig. 8 The patient was prescribed to wear of the brace-wearing was
21 months, the mean
a polypropylene thoracolumbosacral orthosis (TLSO) improvement of kyphosis
was 22# , whereas the
with padded anterior shoulder outriggers and a posterior
mean improvement of the
posterior lumbar inver-
spinal pad
sion was 15 mm. In our
experience also, a 1# of
angular improvement of
the kyphosis per month
with the orthosis adjusted. When the patient is of brace-wearing was
noted.
accustomed to the brace-wearing, the brace may Parallel to the
reduction of the thoracic kypho-
be tightened until the appropriate level of sis, curve response to
Orthopaedic treatment was
snugness. Roentgengrams are performed during noted in the form of a
decrease of the vertebral
the first fitting with the brace correctly tightened, body wedging (Fig. 10).
Some studies also dem-
in order to check the degree of curve correction. onstrated that
correction of kyphosis was due to
To be effective, the brace should correct instan- a realistic partial
reconstitution of the anterior
taneously the deformity at least 50 %. Thereafter, vertebral height by the
application of extension
the compliant patient should wear the cast on forces [77, 81].
Flexible deformities seem to pre-
a full-time basis (2224 h daily) or at least 20 h dict best results after
brace treatment [78]. How-
per day for an average of 1218 months. Areas of ever, some authors
consider that initial maximal
skin irritation are treated with local application of wedging or initial
assessment of curve flexibility
medical alcohol or bepanthen lotion. Ideally, do not influence the
degree of improvement in the
bracing should be continued until skeletal matu- angular deformity [82].
As for scoliosis, bracing
rity to provide the best outcome. Males should be is less successful in
overweight teenagers, since
477
at night, until
maturity [56]. For patients
presenting at the post-
pubertal stage with little
or no growth remaining,
it is illogical and there-
fore not acceptable to
undertake brace treatment
[52, 55]. In fact,
after skeletal maturity, casting or
bracing cannot correct
the anterior vertebral
wedging and attempts to
use either technique are
probably not warranted.
Progression of the defor-
mity, requiring other
type of treatment, is more
likely observed in
patients with poor bracewear
compliance, in kyphotic
curves of more than 75# ,
in patients with severe
and rigid curves and in
atypical forms of the
disease [56, 79].
Other Conservative
Treatments
As for scoliose, there
is no consensus in the
international
literature on the efficacy of conser-
vative approaches to
kyphosis treatment. Other
forms of conservative
treatment, such as chiro-
practic or osteopathic
manipulation, acupuncture,
superficial electric
stimulation, exercise or other
manual treatments, or
diet and nutrition, have not
yet been proven to be
effective in controlling
spinal deformities. In
the same way, practice of
extension sports such
as gymnastics, swimming
and basketball are
usually advised but these rec-
ommendations raise more
of belief than of true
scientifically
established results [55]. Intensive
Fig. 9 Radiograph performed after the first brace wearing physiotherapy exercise
programs for postural
demonstrated that the brace was effective as it corrected improvement have been
tried for many years
instantaneously 50 % of the deformity but without any
conclusive data that physical
therapy alone can
benefit kyphotic improvement
the ability of the brace to transmit correctives [56]. Nevertheless,
long-term physical therapy,
forces to the spine through bony surfaces and osteopathy, manual
therapy, exercise program,
soft tissues may be compromised in these and psychological
therapy may be an interesting
patients. Following brace discontinuation, some alternative to control
the pain, even if no correc-
loss of correction may occur, but in the majority tion is expectable on
the deformity [83].
of cases, the deformity is improved and the curve
correction is maintained [53, 7779]. Usually,
larger deformities at the onset of the treatment Conclusion
show greater losses of correction after bracing is
discontinued. On the other hand, correction Brace treatment for
Scheuermanns hyperkyphosis
achieved in smaller deformities seems better is currently regarded
as the only effective treat-
maintained following brace discontinuation. ment approach that may
modify the natural history
This potential loss of correction occurring after of the affection.
Evidence about other forms of
braces removal is the reason why some authors conservative treatment
is scanty. Different orthosis
recommend that the patient continue the brace and many bracing
regimens exist; the current
treatment full time or at least part-time, usually belief among the
orthopedic surgeons is that
478
F. Canavese et al.
Fig. 10 The final

radiograph realized
24 months after the end of
treatment demonstrated
that a good correction
persisted even after
stopping bracewearing
results obtained with actual more comfortable 2. Nachemson A, Peterson

L, Members of the Brace
orthosis are comparable to those with the Milwau- Study Group of the
Scoliosis Research Society. Effec-
tiveness of treatment
with a brace in girls who have
kee brace. The brace should be worn ideally at adolescent idiopathic
scoliosis. J Bone Joint Surg Am.
least 20 h per day until skeletal maturity to provide 1995;77:81522.
the best outcome. Bracing is generally indicated 3. Lonstein JE, Winter
RB. The Milwaukee brace for the
for curves between 55# and 75# in skeletally imma- treatment of
adolescent idiopathic scoliosis: a review
of 1020 patients. J
Bone Joint Surg Am. 1994;76:
ture teenagers. As for scoliosis, results of brace 120721.
treatment are correlated to patients compliance 4. Rowe DE, Bernstein
SM, Riddick MF, Adler F, Emans
and problems encountered with it are limited. JB, Gardner-Bonneau
E. A meta-analysis of the effi-
cacy of non-operative
treatments for idiopathic scoli-
osis. J Bone Joint
Surg Am. 1997;79:66474.
5. Olafsson Y, Saraste
H, Soderlund V, Hoffsten M.
Boston brace in the
treatment of idiopathic scoliosis.
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New Surgical Techniques in
Scoliosis
Acke Ohlin
Contents
Keywords
A Brief Historical Review . . . . . . . . . . . . . . . . . . . . . . . . . 483
Scoliosis history # New techniques-contoured
rods, anterior and posterior approaches #

Later Innovation in Techniques . . . . . . . . . . . . . . . . . . . 484
Pedicle screws # Screw design # Endoscopic

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 484
techniques # Growing rods # Distraction sys-

Adult Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 487 tems # Guided-growth systems # Titanium
Screw Head Development . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
implants
Spinal Cord Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 489
Endoscopic Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
A Brief Historical Review

Growing-Rod Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
490
About 50 years ago Harrington introduced

Other Growing-Rod Systems . . . . . . . . . . . . . . . . . . . . . . 491
Distraction Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 492 a distraction system for scoliosis with one hook
Guided-Growth System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
at top and one at bottom of the spinal curvature
Titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 493 [1]. The principal diagnosis of his primary
patient cohort was post-polio-myelitis deformity.

The
Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 495
It was the first instrumentation for scoliosis and

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 495 it was used worldwide for at least three decades.
Almost 10 years later Dwyer employed an
anterior system with a cable connecting
vertebral bodies with anterior body screws made

from titanium which, after removal of the
intervertebral discs, enabled major correction.
He reported on the technique and his early
experience with the eight first cases in 1969 [2].
Zielke from Germany refined this system and
presented in 1976 an anterior system with a thin
threaded rod [3]. These two anterior systems
were however kyphogenic. Cable and rod break-
age were both common. In the early 1990s
Kaneda from Japan introduced an anterior
double rod system with which the surgeons also

A. Ohlin
Lund University, Sweden, Malmo, Sweden
could manage the sagittal plane deformity.
e-mail: acke.ohlin@med.lu.se
With this technique an excellent correction was

483
DOI 10.1007/978-3-642-34746-7_29, # EFORT 2014
484
A. Ohlin
frequently achieved, when performing correction pins are inserted at expected

entry points and
in the thoracolumbar and thoracic regions [4]. checked by X-ray or fluoroscopy
before pre-
However a non-reversible reduction of paring the screw tracts by
different
pulmonary function was regularly observed means a drill and/or a probe
[10]. Some
after surgery in the middle and upper thoracic surgeons prefer a direct
technique using
spine [5, 6]. This impairment is most often not a curette or burr to create a
wider entry and
clinically important when the patient still is then observe the wall of the
pedicle before
young, but eventually when the patient is making the channel for the
screw [11]. In
old, this reduction of pulmonary function may difficult circumstances, a
small fenestration
affect the general body function. to the epidural space can be
very helpful,
In the late1970s Luque reported a method of with the dural sac under direct
observation.
posterior spinal segmental instrumentation for These fenestrations are also
very useful in
deformities. This was based on rods connected rigid cases to create a
posterior release,
to the spine by multiple sublaminar wires [7]. removing the ligamenta flava
and capsular
Using this technique, patients with neurological structures and sometimes the
whole joint espe-
disorders other than poliomyelitis, also could be cially on the concave side. In
our experience
effectively instrumented. screws are inserted at every
level on the con-
In the mid 1980s Cotrel and Dubousset cave side of the curve, and at
almost all levels
introduced a multi-segmental double rod poste- on the convexity.
rior system (CD) with hooks. This method The current generally-
accepted technique for
addressed also the sagittal plane [8]. By the scoliosis correction was
originally developed by
advent of the transpedicular screw technique, Suk and is as follows:
introduced to the non-French- speaking world in A contoured rod is applied
into the screw
the early 1980s, the CD technique was further heads on the concavity, bent
or, preferably,
developed with screws in the lumbar spine and overbent depending on the
existing scoliotic
combined with wires and hooks in the thoracic curve (Fig. 1af). The next
step is the simple
region, creating the hybrid technique. rod de-rotation. The rod is
rotated 90# [10].
By this means a virtually
straight spine
may be created (Fig. 1af).
However the
Later Innovation in Techniques vertebral rotation may seem not
to be much
affected if not increased
during this phase.
A new approach, representing further Therefore a de-rotational
manoeuvre has been
development of the CD system and the hybrid developed DVR-direct
vertebral rotation [12].
techniques was presented by Suk from South By applying de-rotational
forces on screw
Korea in 1994 [9]. Initially he was considered handles attached to screw heads
on both sides
unorthodox because he introduced screws into in the apical region, the
rotation of the scoliotic
hypoplastic pedicles on the concave side of deformity can be reduced
significantly. Before
a scoliotic curve very close to the spinal cord. inserting the stabilising rod
on the convexity,
A few surgeons made study visits to Seoul and the joints and all posterior
cortical surfaces
introduced this technique to USA in the late are decorticated to induce a
fusion. With this mul-
1990s. This method has gained great recognition tiple-fixation technique, the
use of bone grafts
and is today accepted at many institutions. from iliac crest seems to be
unnecessary thus
avoiding donor site pain
problems [13]. Pain prob-
lems from iliac crest have been
recorded in up to
Technique 25 % of 2-year post-operative
follow-ups [14].
The use of transverse bars
between rods are prob-
After a standard posterior exposure, entry ably not necessary since the
vertebral bodies
points of the screws are identified. Guide work as connectors between
screws [15].
New Surgical Techniques in Scoliosis 485
a b
Fig. 1 (continued)
486
A. Ohlin
e f
Fig. 1 (a) A postmenarchial girl, 14 years of age with convex side to

inhibit further rotation. (e) Postoperatively,
AIS, preop PA. (b) Peroperatively, all screws are inserted, PA, at 6 months. (f)
Direct Vertebral Rotation (DVR) by
the concave rod is overbent. (c) The first rod is inserted. means of screw
handles attached to the screw heads in the
(d) Simple rod derotation, the assistants push at the apical area
New Surgical Techniques in Scoliosis
487
Transverse connectors at the top of a construct can

even be harmful in rare cases of progressive Adult Scoliosis
proximal junctional kyphosis a pull-out of upper
screws may occur. There are reports of late In adult scoliosis the same
instrumentation
compression of the spinal cord by ploughing methods are used as in
adolescents. A more
screws and the use of transverse connectors may aggressive posterior release
is frequently needed
play a role [16]. and sometimes also
osteotomies may be
Cantilever reduction techniques followed by necessary to achieve the
intended correction.
DVR can also be made to obtain correction in all Problems with sagittal
decompensation are
planes. With this technique two rods, pre-bent however frequent; Cho et al.
recently reported
for the estimated sagittal profile, are simulta- that up to 40 % of an adult
cohort operated upon
neously inserted into sequential screws heads experienced these problems,
especially in the
on both sides, either in a caudo-cranial or oppo- lower lumbar area [19].
site direction. Different methods to push the rods One probable reason for
this is a poor sagittal
into the screw heads can be used. This correction balance pre-operatively and
this must be
technique is especially useful in cases with corrected at the time of
scoliosis correction.
neuromuscular C-shaped scoliosis where the Screw loosening is another
problem evident in
simple rod rotation technique as described this group of older patients.
Solutions suggested
above, does not easily result in a good are techniques to introduce
bone cement into
correction. the screw channel, either
directly with a syringe
Fixation of the pelvis has been a matter of prior to inserting the screw
or by means of
continuous debate. In neuromuscular scoliosis a delivery system with
special screws with
with a pelvic tilt exceeding 20# there is a cement canal and
perforations at the shaft and
a general acceptance to also include pelvis in tip. No published results are
yet available for the
the instrumentation and fusion. The pelvis may latter technique. One series
from Belgium exists
however be considered as a part of the scoliotic utilising this technique with
poor resultsand
deformity and the necessity to include it in the remains unpublished [20].
Trials with
fusion construct may not be quite obvious. hydroxyapatite screws are in
progress and prom-
Some surgeons stop at L5, bearing in mind the ising results in human and
animal studies have
well developed ilio-lumbar ligamentous been published [21, 22].
Another line of develop-
apparatus [17]. Multiple observations show ment has been expandable
pedicle screws. Data
that there is a high incidence of loss of pelvic from biomechanical
laboratories have provided
fixation (windscreen-wiper sign). This is positive results, however no
convincing clinical
believed to be due to the long lever arms in success has yet been
presented [23, 24].
combination with a poor bone stock. Previously
the pelvic fixation was most often achieved by
the Galveston [18] technique, which is time- Screw Head Development
consuming and may be difficult to achieve.
The distal part of the longitudinal rod had to During the last 10 years a
significant develop-
be bent and inserted in to the ilium. Today, ment of screw head technology
in spine instru-
almost all manufacturers of spinal implants mentation has occurred.
Initially mono-axial as
provide the surgeon with connectors to attach well as poly-axial screws
were marketed. With
the long rods to iliac screws making this ilio- mon-axial screws a perfect
perpendicular fit
lumbar fixation easier and faster. These con- between rod and screw is not
always possible to
nections are however sometimes prominent obtain. This is because the
screw trajectory in the
and may be painful. There is also a higher risk thoracic spine is more
caudally-oriented due to
of deep infection when undertaking surgery in anatomical reasons. Some few
of our early
the pelvic area. patients when using the Suk
technique and
488
A. Ohlin
a b c d
e
Fig. 2 (a) Mono-axial screw. (b) Uni-axial screw, per- thread design reduces
head spread forces, which
mitting motion of the screw head in one plane. It gives occurred with earlier
screw designs. (e) Polyaxial
probably a better correction in the coronal plane. reduction screw,
enabling gradual correction, especially
(c) Polyaxial screw, the screw head permits a motion of useful in severe
deformities. Multiple subsequential
about 25# to facilitate rod insertion. When the inner screw screws are used
simultaneously to diffuse forces when
is fixed there is no more motion. (d) Innie screw the the rod is attached
titanium alloy implants reported noise from the tabs which are
removed at the end of the
back early post-operatively. Clinically, the backs procedure. This
creates the possibility of a cantile-
became silent about 6 months post-operatively but ver correction
manoeuvre by having a row of
the reason was obvious an imperfect fit permitted screws of this type
thus enabling delivery of the
some motion between screw heads and rods. For rod into multiple
screw heads by means of working
deformity correction, the poly-axial screw does on the inner screws
more evenly. This way of rod
not transmit the applied force to the spine but insertion or pushing
with more evenly-distributed
a great deal is lost in changing the screw head forces reduces the
risk of screw pull-out. This is
position. This means that extent of the correction particularly useful
in rigid neuromuscular cases
is somewhat lost [25]. One way to solve this prob- with an associated
poor bone stock.
lem was the development of uni-axial screws, We still observe
that the inner screws become
permitting a motion of the screw head in the loose but today it is
a rare occurrence. The reason
cranio-caudal direction thus improving the fit of is metallurgical
one cannot apply more force
the rod in screw head (Fig. 2ad). Clinically, the between the screw
driver tip and the inner
reporting of noisy backs is today very rare. The screw otherwise
screws can deform.
configuration of threads within the screw head has Recently a new
low-profile system with an
also undergone a further development from unconventional screw-
rod locking mechanism
wedge-shaped to right-angle threads reducing has been developed
The Range Spinal
the risk of having a head-spread. This means System-by the K2M
company. Until now no clin-
that the tulip-formed head wings were spread ical results have
been presented.
due to force vectors with the former configuration
of threads with subsequent poor fitting and
long-term reduction in stability. Poly-axial screws Spinal Cord
Monitoring
are still used in the ends of a construct where
stabilisation is the goal and not correction. Spinal cord
monitoring is today considered
Another development is the temporary mandatory during
deformity surgery, in
extensions of the screw head, by flanges or Scandinavia at least.
At present, motor evoked
489
potential monitoring (MEPs), which record the can actually be made with
correction values in
function of the spinal cord motor tract in real the range 57# [12, 29].
time, is to be preferred to the older and less Another issue is that
of economy. How many
reliable somato-sensory evoked potentials screws are needed to
achieve a satisfactory
(SSEP) [26]. Most units employ both. The correction? Clementz et al.
have shown, that for
Scoliosis Research Society now advises that a series of both hybrid and
all-screw constructs,
spinal cord monitoring is its preferred method the number of anchors
significantly improve the
of intra-operative spinal cord functional coronal correction when
assessed by means of
assessment [27]. conventional radiography
[35]. We have recently
observed, by means of low-
dose CT, that in
all-screw constructs, the
density of screws signif-
Results icantly affects the de-
rotation as well as the
re-creation of the thoracic
sagittal profile [36].
Since scoliosis is a deformity, not only in the With respect to coronal
correction and LEVT,
coronal plane, but also involves rotation and there was however, no
statistically significant
associated change in the sagittal profile; the association between screw
density and the result.
radiographic assessment of correction cannot be The use of screws is
not without risk for neu-
estimated only as a change of the Cobb angle. rological compromise and it
is, based on the
Several reports indicate a correction in the Scoliosis Research Society
Morbidity and Mor-
coronal plane (Cobb), when using Suks method, tality Committees data,
reported to occur in
in the range of 6575 % [21, 28, 29]. All-screw 1.75 % of cases operated on
for adolescent
construct were superior to hybrid instrumentation idiopathic scoliosis
posteriorly; no data on type
in adolescent idiopathic scoliosis, with reported of anchors was however
mentioned [37].
values of 70 % correction with screws versus The rate of mis-placed
thoracic pedicle screws,
56 % with a hybrid construct when measuring evaluated with CT, varies
widely from 6 % to 50 %
the Cobb angle [28]. [3840]. Different
definitions of mis-placements
The corrective effect in an adult population was probably contribute to this
variability in reported
also significantly better in all-screw than in hybrid figures [41]. There is also
a significant learning
instrumentation, 56 % versus 41 % Cobb correc- curve to achieve a low mis-
placement rate [42].
tion was reported by Rose et al. [30]. The true Computer-assisted
Orthopaedic surgery
degree of pre- and post-operative rotation can (CAOS), has been shown to
improve the position-
only be assessed by means of CT (or MRI) and ing of pedicle screws, at
least in the lumbar spine
measuring the most rotated vertebra [29, 31]. This [43]. A newer technique
(the O-Arm) utilising
vertebra is most often located at the apex of the a CT-like imaging intra-
operatively together with
curve or one segment above or below [29, 32]. The a navigation system
(Stealth Station) can hope-
reported de-rotational effect is in the range from fully be of benefit and
reduce the number of mis-
30 % to 60 % [12, 29, 33, 34]. placed screws. The
radiation dose, when following
Correction of the lower end vertebral tilt the manufacturers
recommendation, is at present
(LEVT) is of interest to reduce the risk of too high for young patients
in our opinion. Recent
progression in the lumbar area in the long term. studies indicate the
radiation dose can be reduced
The Suk technique is effective in reducing LEVT by 10 times when using the
O-Arm without
in 70 % of cases [12, 29]. compromising the required
image quality for opti-
With respect to ability to correct the often mal spinal surgery [44].
hypokyphotic or even lordotic thoracic spine the Trials with rods made
from memory metals
literature is confusing. There are reports indicat- have been completed in
Beijing, China, in the
ing that the Suk technique is inferior to hybrid 1980s. A recent report has
been published in the
constructs [33]. When using more rigid rods English literature. Wang et
al. used such rods
however, a re-creation of the thoracic kyfosis temporarily for the
correction and subsequently
490
A. Ohlin
replaced them with conventional rods. They a polymeric band under

compression. He has
reported corrections of a mean 71 % Cobb, reported promising results,
the number of which
which was similar to many following the Suk is unfortunately very low
[52]. Legislative
technique [45]. policies have however
stopped further trials in
human beings, at least in
the USA.
Endoscopic Techniques
Growing-Rod Systems
Jacobeus, a Swedish doctor of internal medi-
cine, published his early-experience of VEPTR
thoracoscopy as well as laparoscopy in 1910 In the late 1980s Campbell
in the USA, was
[46]. In the early 1990s, Regan from USA presented with a child
patient a little more than
re-introduced this approach, for spinal surgery 1 year of age, with aplasia
of five ribs on one side.
[47]. Blackman, Newton and Picetti, respec- This malformation resulted
in a severe scoliosis
tively, further developed this approach, for and the child needed a
ventilator. The patient was
endoscopic correction of thoracic scoliotic operated on with a
thoracotomy incision and
curves. By means of this technique, a very the contracted soft tissue
in the dysplastic region
good correction of moderate thoracic scoliotic was divided. After
distraction of the chest wall this
curves could be obtained without any signifi- was stabilised by two
Steinmann pins turned
cant respiratory deterioration, which is one of around the second and tenth
rib and the soft tissues
the drawbacks of the open anterior technique of the chest wall were
reconstructed. Soon the
[6]. These procedures are however very time- child was off the
ventilator. Today after repeated
consuming and therefore this technique is not surgical operations, the boy
is able to play football.
widespread today (Fig. 2ad). Further development of
this approach has
In the 1950s trials with stapling over discs on resulted in a new approach
to spine deformity
the convexity of a thoracic curve were surgery in children. This is
the extra-spinal
performed but it was abandoned due to poor technique for the management
of the deformed
results [48]. By the turn of the millennium, spine by VEPTR (Vertical
Expandable
Betz from Philadelphia presented endoscopi- Prosthetic Titanium Rib).
Much research in the
cally-inserted staples made from memory field of respiratory
disturbance due to spine and
metal, over the convex discs in the thoracic as chest wall deformities has
been stimulated due
well as the lumbar regions [49]. From the posi- to the dramatic effect of
this particular case,
tioning on the operating table, no significant and Campbell has then coined
the term Thoracic
corrective forces could be applied to the Insufficiency Syndrome, TIS
[53].
deformed spine. The presented results are com- The VEPTR technique is
at present
parable with these of brace treatment 30 % popularised worldwide and
used in cases of
need a further surgical treatment and 70 %were primary thoracic wall
disorders as well as in
apparently effective [49, 50]. The results of sta- cases of congenital
scoliosis. This includes
pling are not based on a prospective study and no several syndromes with
respiratory compromise
controls for comparison between groups exists. due to spinal deformities
such as myelodysplasia
Therefore no conclusion can be drawn. The lim- and many others. It has also
been used in cases
ited Malmo experience of Betz staples consists of of early onset idiopathic
scoliosis. The patient
12 cases that were stapled for idiopathic scoliosis has to be operated on
repeatedly and with
with similar inclusion criteria as Betzs [49]. Of lengthening usually every
6 months. Three
these more than six have undergone further and fixation methods can be
used. From the
definite surgery [51]. Lenke has presented a similar proximal ribs at the top,
instrumentation may be
technique, The Tetherconnecting endoscopi- made to more distal ribs, or
the vertebral
cally-inserted vertebral body screws with arches/pedicles or to the
pelvis (Fig. 3a, b).
491
a b c
Fig. 3 (a) A boy 4 years of age with collapsing spine due Peroperative blood loss
was 20 ml, postop PA.
to myelodysplasia, preop PA. (b) Surgery with subcuta- (c) A 5 year old girl
with congenital scoliosis, three
neous insertion of VEPTR rods, rib to pelvis. VEPTR devices were
inserted
Further developments with bilateral rods, conventional modern

spinal instruments. By
one on the corrective side and one on the means of this you can
create a distraction
stabilising side have been presented. Many between the lower spine
to the chest wall and
problems have been observed, e.g., migration there is no need for
special instruments during
of anchor sites and therefore a further develop- primary surgery or
lengthenings [56].
ment has been presented (VEPTR 2) this
new version has multiple cranial rib anchors.
In cases of kyphosis it must be used with great Other Growing-Rod
Systems
caution since severe deterioration of this cur-
vature has been observed repeatedly when In children with little
or no remaining
using VEPTR. growth potential left;
correction and fusion has
The expected effect of VEPTR on long-term been and still is the
gold standard in the
respiratory improvement assessed by pulmonary operative treatment of
scoliosis expected to exceed
function test is still unclear. However impressive 50# or more Cobb angle
at skeletal maturity.
clinical and radiographic results have been Recent advances in
the understanding of spine
presented [54, 55]. With this technique we can and thoracic cage
development have shown that
today provide many of our present patients fusing a spine too
early, not only results in
a therapy, for which we previously had no good a shorter stature but
also result in a reduced
management to offer. By means of this indirect volume of the thoracic
cage with detrimental
spine corrective surgery, one hasnt burnt ones effects on respiration
for the rest of the life. At
bridges. the age of 10 years,
the remaining growth of lung
Skaggs has recently presented a technique volume has been
considered to be 50 % [57].
similar to VEPTR where you can use Growth arrest of the
spine affects the growth of
492
A. Ohlin
the ribs and the thoracic cage [58]. These new A less invasive
technique has recently been
insights have resulted in the development and presented the Shilla
technique [62]. It was
popularisation of growing-rod systems, enabling proposed by Richard McCarty
who, according
a straightened spine to grow further. to the legend, had his idea
when waking up at
Growing-rod systems can be divided into a luxurious Shilla hotel in
South Korea
those based on distraction or those based on (Shilla was one of the
longest sustained dynas-
guided growth. ties in Korean history
650918 A.D.). It is
The VEPTR technique, presented above can based on an upper and a
lower foundation by
also be considered as a growing rod system but screw fixation. In the
apical region of the defor-
not principally necessarily anchored to the spine. mity, two to four pairs of
screws are inserted
where a deformity
correction is performed
locally. With a temporary
rod holding the apical
Distraction Systems correction, a long rod on
the opposite side is
inserted from below,
tunnelled to the middle
In the immature scoliotic spine one can create region where the rod is
loosely fixed to these
a cranial and distal anchor connected by rods, screws and further
tunnelled in the sub-fascial
which can be lengthened at different periods, usu- muscle layer to the upper
foundation.
ally, a 6 month interval being preferred. The anchors A stabilising rod is then
inserted on the opposite
to the spine at either end can be hooks, screws and side. Both rods are too
long at both ends. The
sublaminar wires or combination of these. There has inner-screws in the middle
are full fixed and here
been a discussion whether to use a single or double- a formal fusion is
performed; at the ends a special
rod system. At present there is evidence for the screw construct makes the
inner screw fixation not
double-rod construct being superior [59]. firmly fixed, permitting
the too long rods to
The place where distraction is applied can be slide in the end screws
(Fig. 4). Guided growth
at the ends of the rod, but the preference is the technique can also be
performed by the use of
middle where domino connectors are used or dual rods, i.e., implanting
a fully fixed thicker rod
specially made boxes containing parts of the rods. at the bottom and having
the thinner end of the
Experience has shown that the distractive too long rod passing
screw heads with the larger
effect of lengthening procedures often disappear diameter at top, enabling
growth.
after 6 lengthenings or more. Histological Problems identified are
many, e.g., loosening
examinations of specimens from facet joint in of end screws due to long
lever arms. In systems
such cases have revealed degenerative changes used for Shilla and when
utilising Titanium
in cartilage [60]. implants, wear in the
interface of screws and
rods may occur at the end
foundations due to
motion of Titanium implants
against each other,
Guided-Growth System giving rise to a foreign
body reaction with
synovial-like fluid
accumulation.
A system based on multiple sublaminar wires All these new growing
rod systems are
connecting contoured rods to the spine accompanied by many
problems. The founda-
(the Luque-trolley technique), but too long to tions at both ends are
exposed to great mechan-
permit growth was introduced in the early ical forces because of long
lever arms and
1990s. With this technique, exposure of perios- therefore they are at an
increased risk of
teal tissue was unavoidable which made sponta- mechanical loosening. The
repeated lengthen-
neous fusion frequent. The results of this ing operations are all an
infection and soft tis-
correction technique have not been as good as sue healing risk. An
infection can, in many
expected and at present this technique is used cases, be managed by
temporary removal of
infrequently [61]. the implants at the
infection site, which after
493
Fig. 4 (a) Shilla procedure a

in a 4 year old girl with b
syndromic scoliosis. Three
pairs of screws in the apical
area are locked, in either
end the screws are not fully
locked and the rods are
intentionally too long,
permitting growth. (b) PA
postoperatively
antibiotic therapy and after some time, can be Even pure titanium always
contains traces of
re-inserted with success. The whole process is iron, which creates disturbances
in imaging.
in most cases favourable in spite of these com- There have been some
retrospective studies
plications [63]. showing significantly lower
incidence of implant
associated infections when using
Ti or Ti-alloy
implants [64, 65]. Also Muscik et
al. showed
Titanium that it was possible to revise
late infected stainless
steel implants to titanium
implants without recur-
Titanium-alloy (Ti4V6Al) implants were rence of infection in 10
consecutive cases [66].
popularised in spine surgery primarily due to Interestingly there is a basic
atomic/molecular
their relative compatibility to MR-scanning. explanation for this. In the
sphere of researchers
494
A. Ohlin
around Branemark, who coined the term of inflammatory cells, e.g.,

leukocytes and macro-
osseointegration and successfully introduced Ti phages, to release peroxidase
enzymes (a more
jaw screws in odontology, there have been detailed explanation can be
found in the literature
reports published explaining why Ti implants of ROS, reactive oxidative
specimen, which are
not are subjected to infection in such a mileau out of the scope of the
present presentation).
as the mouth [67]. In this environment a Ti-
hydroxy-peroxide gel
These laboratory investigations are not easy to is formed. This gel will cover
the whole implant.
comprehend even by the well-read Orthopaedic It is subsequently degraded to
TiO2 and
surgeon! A brief explanation of the process is as during that process H2O2 as
well as oxygen
follows: radicals are released. No
bacteria will survive in
All Ti implants, pure Ti as well as its alloys, this particular environment.
The host cells are
are covered by a layer of TiO2 as soon as they are also at risk for the toxic
influence and go
exposed to the atmosphere. The inflammatory necrotic, however they are
soon replaced by
processes in the operative site induce new host cells in the
vicinity. In cases of
a b
Fig. 5 (a) Magnetic rod

(the French Phenix design).
The patient is a boy 9 years
of age, not tolerating brace
treatment, preoperative PA.
(b) Postoperative PA, the
caregiver apply and rotate
a magnet externally, with
an estimated extension of
0.1 mm every morning
495
hematogenous deposition of bacteria in the vicin- 4. Kaneda K, Shono

Y, Satoh S, Abumi K. New anterior
ity of implants, these are protected by a similar instrumentation
for the management of thoracolumbar
and lumbar
scoliosis. Application of the Kaneda two-
chain of events. rod system.
Spine. 1996;21:125061.
There is, as mentioned, a scarce literature on 5. Kim YJ, Lenke
LG, Bridwell KH, Kim KL,
the benefit of Ti implants for posterior implant Steger-May K.
Pulmonary function in adolescent idi-
instrumentation. In our own experience in opathic
scoliosis relative to the surgical procedure.
J Bone Joint
Surg Am. 2005;87:153441.
Malmo, after having made more than 700 poste- 6. Kishan S,
Bastrom T, Betz RR, Lenke LG, Lowe TG,
rior Ti-alloy constructs, we have observed only Clements D,
DAndrea L, Sucato DJ, Newton PO.
two cases of late infection [51]. This is in contrast Thoracoscopic
scoliosis surgery affects pulmonary
to our experience of a late infection rate of up to function less
than thoracotomy at 2 years postsurgery.
Spine.
2007;32(4):4538.
5 % when using stainless steel implants in poste- 7. Luque E. The
anatomic basis and development of seg-
rior spine surgery. The latter figures are in accor- mental spinal
instrumentation. Spine. 1982;7:2579.
dance with other reports [68]. 8. Cotrel Y,
Dubousset J. Nouvelle technique
doste
osynthe`se rachidienne segmentaire par voie
posterieure.
Rev Chir Orthopedique. 1984;70:48994.
9. Suk SI, Lee CK,
Min HJ, CHO KH, Oh JH. Compar-
The Future ison of Cotrel-
Dubousset pedicle screws and hooks in
the treatment of
idiopathic scoliosis. Int Orthop.
Regarding spinal instrumentation for 1994;18(6):341
6.
10. Suk SI, Kim WJ,
Lee SM, Kim JH, Chung ER. Tho-
Paediatric scoliosis we can expect that further racic screw
fixation in spinal deformities. Are they
development of the endoscopic techniques in really safe?
Spine. 2001;26(18):204957.
early progressive cases will be a reality. 11. Kim YJ, Lenke
LG, Bridwell KH, Cho YS, Riew KD.
For growing techniques there are lines of Free hand
pedicle screw placement in the thoracic
spine: is it
safe? Spine. 2004;29(3):33342.
developments of implantable devices whereby 12. Lee SM, Suk SI,
Chung ER. Direct vertebral rotation:
one can distract rod systems by means of energy a new technique
of the three dimensional deformity
transferred magnetically from an external source correction with
segmental pedicle screw fixation in
[69]. Hopefully this will reduce the number of adolescent
idiopathic scoliosis. Spine.
2004;29(3):343
9.
open distraction procedures all of which are 13. Betz RR, Lavelle
WF, Samdani AF. Bone grafting
expensive, time consuming and, of course, carry options in
children. Spine. 2010;35(17):164854.
a potential risk of infection (Fig. 5a, b). 14. Skaggs DL,
Samuelson MA, Hale JM, Kay R,
In general, further genetic and biomedical Tolo VT. Iliac
crest bone grafting in spine surgery in
children. Spine.
2000;25(18):24002.
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Personal Communication; 2008.
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Yazici M, Surat A. Late spinal cord
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Neuromuscular Scoliosis
J. Brad Williamson
Contents
Abstract
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 500 This chapter will discuss the problems associ-
ated with neuromuscular scoliosis in general,

General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
consider the more common diseases in which

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 501 scoliosis occurs, and mention the problems
Conservative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
501 associated with outcome measurement in this
Surgical
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
group of conditions.
Considerations in Specific Diseases . . . . . . . . . . . . . . .
507 Spinal deformity is a consequence of many
Duchenne Muscular Dystrophy . . . . . . . . . . . . . . . . . . . . .
507
Spinal Muscular Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . .
511
neuromuscular conditions and is the result of

Hereditary Sensory Motor Neuropathy
lack of muscular control and muscular
(Charcot-Marie Tooth Disease) . . . . . . . . . . . . . . . . .
513 weakness.
Friedreichs Ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 513 Although there are similarities between
Cerebral
Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
514
curve patterns in different neuromuscular dis-

Outcome Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
eases, each disease is unique and each brings its
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 516 own set of challenges. To speak of neuromus-
cular scoliosis as a single condition or disease
is to grossly oversimplify the situation and to
underestimate the consideration which needs to
be given in establishing a treatment path.
Keywords
Anaesthesia # Blood loss # Cardio-respiratory
assessment # Classification # Complications #
Conservative treatment # Neuromuscular-
Duchenne dysystrophy, spinal muscular atro-
phy, cerebral palsy # Operative techniques #
Outcomes # Radiology # Scoliosis # Surgical
treatment
J.B. Williamson
Division of Neurosciences, Salford Royal Hospital,
Salford, UK
e-mail: brad.williamson@srft.nhs.uk

499
DOI 10.1007/978-3-642-34746-7_32, # EFORT 2014
500
J.B. Williamson
I NEUROPATHIC
Classification A. Upper motor
neuron
1.
Cerebral palsy
2.
Spinocerebellar degeneration
The Scoliosis Research Society classification is a.
Friedreichs ataxia
b.
Charcot-Marie-Tooth disease
the most commonly used (Fig. 1). This divides c.
Roussy-Levy disease.
neuromuscular scoliosis according to diagnosis, 3.
Syringomyelia
4. Spinal
cord tumour.
the main division being into those caused by 5. Spinal
cord trauma.
disorders of the nerves neuropathic- and those
B. Lower motor
neuron
caused by disorders of the muscle myopathic. 1.
Poliomyelitis
This classification is widely used, particularly in 2. Other
viral myelitides
3.
Traumatic
the United States, but is imperfect and does not 4. Spinal
muscular atrophy
reflect contemporary knowledge of neuromuscu- a.
Wernig-Hoffman disease.
b.
Kugelberg-Welander disease.
lar conditions- for example Charcot Marie Tooth 5.
Dysautonomic (Riley-Day syndrome).
Disease is a disorder of peripheral nerve, rather
than a spinocerebellar condition as classified II MYOPATHIC
[1]. It does not serve to inform the surgeon
A.
Arthrogryposis.
about management, as the grouping does not con-
tain any commonality of surgical pathology, or B. Muscular
dystrophy
1.
Duchennes muscular dystrophy
indication of associated problems. European neu- 2. Limb-
girdle dystrophy
rologists and surgeons only regard curves caused 3.
Fascioscapulohumeral dystrophy
by diseases with progressive neurological deteri- C. Fiber-type

disproportion.
oration as being truly neuromuscular, with
D. Congenital
hypotonia.
those caused by static neurological lesions such
as cerebral palsy not being classified as neuro- E. Myotonia
dystrophica.
muscular. This chapter recognizes the European Fig. 1 Scoliosis Research

Society classification of
point of view, but also considers the problems of neuromuscular scoliosis
cerebral palsy scoliosis as it is numerically the
most common. thus becomes a functional
quadriplegic, with
only one useful hand (Fig.
2).
The systemic nature of
some neuromuscular
diseases means that co-
morbidities are common
General Considerations and often severe.
Respiratory function is affected
not only by the mechanical
effects of the scolio-
Neuromuscular scoliosis is generally of earlier sis, but also by the
muscular weakness and poor
onset and has a greater propensity to deteriorate co-ordination of the
respiratory muscles. Myop-
than idiopathic scoliosis due to the underlying athies also affect the
cardiac and respiratory mus-
neuromuscular mechanism. cles. These factors need to
be considered when
The functional reserve of the neuromuscular making a treatment plan.
patient is less, and the effects of the scoliosis may The risks of surgical
intervention are
be to impair the capacity for independent ambu- greater than in a non-
neuromuscular population.
lation or precipitate dependence on aids. Func- Prolonged peri-operative
intubation in those with
tional considerations are thus more important poor lung function makes
respiratory infection
than in idiopathic scoliosis. In those already con- more likely. Long operative
times and malnutri-
fined to a wheelchair increasing pelvic obliquity tion increase the chance of
wound infection and
may make seating difficult. Severe pelvic obliq- pressure area problems.
Cardiomyopathy and
uity may remove the use of one hand, the arm huge fluid shifts mean that
patients are often
being required to prop the child up in the chair in haemodynamically unstable
in the peri-operative
the face of a severe trunkal imbalance. The child period, mandating the
involvement of skilled
Surgical Management of Neuromuscular Scoliosis
501
a b
Fig. 2 Pre and post operative sitting posture of a boy with Duchenne Muscular
Dystrophy (case of Mr NJ Oxborow) (a)
Pre-operative, (b) Post-operative
anaesthetists and intensivists Disuse osteoporosis Wheelchair fitting

may also be regarded as an
means that meticulous attention to fixation aspect of conservative
treatment especially in
techniques and acknowledgment of the need for those for whom surgical
treatment is inappropri-
load-sharing is required. ate. Seating a child
with a severe curve is a task
not to be
underestimated. Off the peg chairs
may be modified by the
use of inserts and pads in
Treatment those with relatively
minor deformity, but those
with severe deformity
will require a custom
Conservative Treatment moulded seat.
Tightly fitting
lycra suits sleep suits, said
Conservative treatment of neuromuscular spinal to work by enabling
greater proprioceptive feed-
disorders is difficult. back by increasing
input from the skin, are often
Orthotic management, usually in the form of prescribed by
physiotherapists, but there is little
a custom moulded thoracolumbosacral orthosis high quality evidence
of their efficacy.
(TLSO), is often employed. It is suggested that
a TLSO may prevent or slow curve progression,
but the evidence for this is poor. In those with Surgical Treatment
flexible curves, a moulded orthosis may increase
functional capability by allowing a more upright Pre-Operative
Evaluation
posture. In those with more severe or rigid curves Radiology
this form of management produces little func- The radiological
assessment of neuromuscular
tional benefit, and is beset by skin problems. scoliosis is more
difficult than the assessment of
502
J.B. Williamson
idiopathic scoliosis. Consistent positioning of the specialist nurse or

physiotherapist who accom-
paralysed patient is difficult, and erect x-rays are panies the patient. Physical
examination may
often impossible to take. If standing x-rays are reveal signs of respiratory
failure.
not feasible then it is sometimes possible to take There are a number of
pathological processes
seated x-rays in the wheelchair, but this requires at the root of respiratory
insufficiency in neuro-
skilled technical staff. Often it is impossible to muscular scoliosis;
get the whole spine on such films and detail of the Firstly, chest wall
deformity and diaphrag-
pelvis is obscured by the shadow of the thighs. matic restriction by
thoracolumbar curvature
The use of a highly moulded wheelchair or matrix and pelvic obliquity
increase the work of breath-
seat precludes taking x-rays in the chair and we ing. This latter is
particularly important given the
must then use supine x-rays. Error may be intro- diaphragms major role in
quiet respiration.
duced by faulty or inconsistent positioning in Secondly, muscular
weakness secondary
those with a flaccid paralysis, and it is of course to the underlying pathology
hampers the
impossible to assess the sagittal plane deformity ability to breath. In
patients with some neuro-
from radiographs taken in the lying position. pathic conditions bulbar
problems lead to inco-
There are a number of different ways of mea- ordination of swallowing and
aspiration, with
suring the frontal plane spinal deformity, but frequent respiratory
infections lessening the
measurement of the Cobb angle has been shown respiratory reserve. The
cough is often weak,
to have the smallest inter-observer error, with due to a combination of
coordination and muscle
measurements being taken by multiple observers strength problems.
on the same radiograph [2]. Similarly a variety of The assessment of
cardiorespiratory status is
methods of measurement of pelvic obliquity fundamental to the
performance of safe surgery in
exist, but comparison of the intercristal line neuromuscular scoliosis.
Spinal corrective sur-
with the horizontal yields the most consistent gery is a huge physiological
stress, in a patient
measurements. who is already compromised
because of neuro-
Patients with severe deformities may require muscular disease. Even in a
heterogeneous group
imaging with CT scanning pre-operatively to of patients 38 %
neuromuscular lung function
assess the extent of secondary bony dysplasia declined by up to 60 % in
the immediate post-
and assess the pedicles or other anchor sites for operative period, recovering
only 2 months after
competency. Patients with intra-spinal problems surgery [3] It can be seen
that an adequate respi-
at the root of their diagnosis will need MR scan- ratory reserve is required
for safe surgery.
ning pre-operatively. It is clear that
assessment of respiratory func-
tion is important in the
assessment of fitness for
Cardiorespiratory Assessment surgery. Spirometry is often
performed, but in
Most patients being considered for corrective some conditions there are
technical issues which
surgery are already under the care of limit its usefulness. In
cerebral palsy poor co-
a paediatric neurological team. The importance ordination may give a
falsely pessimistic outlook,
of their input into the planning of surgery, pre- whereas in paralytic
conditions weakness of this
operative assessment and peri-operative manage- orbicularis oris may impair
the ability to make
ment cannot be overestimated. Many children a seal around the
mouthpiece, resulting in an
will already be having respiratory support, and inaccurate assessment.
Respiratory volume is
some will be on treatment and monitoring for indicated by the Forced
Vital Capacity (FVC)
their cardiomyopathy. Multi-disciplinary input which is usually reported as
a percentage of that
into the planning of peri-operative management predicted from the height
(arm span is often used
can result in a smoother passage for the patient, in the wheelchair bound or
scoliotic). The ability
and fewer unforeseen problems. A history regard- to generate an explosive
expulsion as in
ing respiratory problems, infections and manage- coughing is indicated by
the Forced Expiratory
ment can be obtained from the parents or Volume in 1 s (FEV1). Sniff
nasal inspiratory
503
pressure (SNIP) may give a good indication scoliosis only 25 % needed

ventilatory support
of this latter, and is technically easier in this post-operatively. Of this
25 %, no attempt was
population [4]. made to extubate in the
immediate post-operative
Percentage of predicted FVC gives a good period in half, ventilatory
support being
indication of the respiratory risk in a given pro- elective for patients with
prolonged surgery or
cedure. Generally an FVC of less than 30 % very high blood loss. Of
the boys with Duchenne
predicted gives cause for concern [5] but Muscular Dystrophy 40 %
were ventilated post-
with adequate cardiac function need not preclude operatively. Bach and
Sabharwal [6] presented
surgery by an experienced team. In our centre five patients with poor
lung function and a diag-
we have safely operated upon a boy with nosis of Duchenne Muscular
Dystrophy or spinal
Duchennes muscular dystrophy with only 17 % muscle atrophy, all of whom
were extubated to
of the predicted FVC. non-invasive positive
pressure ventilation post-
Many patients nowadays have active respira- operatively. However Yuan
et al. found that
tory management as part of their neurology treat- boys with neuromuscular
scoliosis and poor
ment. It is not uncommon for children to have FEV1 were most likely to
require post-operative
home oxygen or home respiratory support. Oxy- ventilation [7].
gen dependency or the use of nocturnal BIPAP
need not disqualify the patient from spinal sur- Anaesthetic Considerations
gery. Many of our patients with Spinal Muscular The peri-operative
management of children with
Atrophy are treated with nocturnal BIPAP. After neuromuscular scoliosis is
not a matter for the
surgery they are usually extubated in the recovery occasional anaesthetist. As
well as the general
area, and re-established on BIPAP before dis- requirement for familiarity
with the problems of
charge to the high- dependency unit. the various neuromuscular
diseases, some dis-
Some neuromuscular conditions such as eases are associated with
specific susceptibility
Duchennes Muscular Dystrophy and Friedreichs to anaesthetic agents. For
example Central Core
Ataxia are complicated by a progressive Disease shares an allele
with malignant hyperpy-
cardiomyopathy. In these patients a detailed rexia, and cross- reactions
are sometimes seen in
assessment of cardiac function is required pre- Duchenne muscular
dystrophy.
operatively. Electrocardiographic abnormalities Patients with myotonic
dystrophy are sensitive
are common, especially in myotonic dystrophy to suxamethonium, which can
cause ventricular
and Duchenne, but hard to quantify. All such tachycardia or fibrillation
with cardiac arrest. It is
patients should undergo echocardiography to wise to avoid the use of
suxamethonium in all
obtain a quantification of left ventricular function. cases of progressive muscle
weakness.
This is sometimes technically difficult because of
chest wall deformity secondary to the scoliosis. In Nutritional Status
these circumstances trans-oesophageal echocardi- There is a well-documented
relationship between
ography or even an isotope MUGA scan may nutritional status and
peri-operative complica-
be required. Generally speaking, those with tions in those undergoing
Orthopaedic surgery
a left ventricular ejection fraction of less than [8]. Protein depletion
correlates well with
50 % require medical assessment/treatment before increased mortality,
impaired wound healing,
consideration of surgery. and increased wound
infection rates. Given that
In spite of these acknowledged respiratory the metabolic stresses of
spinal reconstructive
difficulties there is ample evidence that with suit- surgery are perhaps greater
than any other form
ably skilled peri-operative care surgery in chil- of Orthopaedic surgery it
is sensible to optimize
dren with neuromuscular scoliosis can be nutritional status before
surgery. Nutritional
undertaken safely (Bentley et al. [64]). assessment can take the
form of BMI measure-
Almenrada and Patel [5] found that of their ment (bearing in mind that
obesity as well as low
population of patients with non-idiopathic BMI can be an indicator of
poor nutrition),
504
J.B. Williamson
assessment of serum protein and albumen levels. possible to apply

consistent corrective forces to
It has been shown that patients with a serum albu- the pelvis. The addition
of pedicle screw fixation,
min level of less than 3.5 g%. or a lymphocyte either in the sacrum or
L5 further increased the
count of less than 1,500 per cubic ml. have greater strength of the
construct and allowed the appli-
infection rates, periods of intubation and length of cation of greater
corrective forces. The Galveston
stay [8]. technique describes the
passage of a bone anchor
There are many reasons for nutritional down a thick tube of
iliac bone stretching from the
impairment in this group of patients. Inco- region of the posterior
inferior iliac spine, supe-
ordination of the muscles of mastication and rior to the sciatic
notch to the roof of the acetab-
swallowing may make eating difficult. Gastro- ulum (the Galveston
channel). The anchor
oesphageal reflux is common, leading to originally described was
the end of a spinal rod.
oesophagitis, vomiting and aspiration. Ideally This necessitated the
performance of a complex,
surgically-remediable factors should be three-dimensional
rod-bending manoeuvre
addressed prior to the consideration of spinal towards the end of a
procedure which was often
surgery, but one may find oneself in the situation long and tiring. The
technical difficulty of this
of balancing the sub-optimal nutritional state procedure should not be
underestimated.
against delaying surgery in a curve which More recently it has
been usual to fix to the
is progressing relentlessly. Laparoscopic pelvis using pelvic
screws or bolts. This is tech-
fundoplication will provide an answer to reflux nically much more
straightforward, and the
related problems, whilst mechanical problems resulting construct
performs as well as Galveston
with eating can be addressed by the insertion of rods in correction of
obliquity [10, 11].
a PEG gastrostomy. A co-ordinated, multi- Such pelvic fixation
is bulky, and the screw
disciplinary approach to children with neuro- heads sit in the
relatively superficial area of the
muscular scoliosis will enable the spinal posterior iliac crest.
In the poorly-nourished neu-
surgeon to be presented with the patient in the romuscular population
the screws can often be
best possible condition. felt, and serious skin
problems are not uncom-
mon. These can be
mitigated, but not abolished
Operative Techniques by meticulous attention
to detail countersinking
Although each neuromuscular diagnosis brings the screw head, the use
of as few bulky connec-
with it a unique set of challenges, there are tors as possible and
careful approximation of the
a number of common problems which face the thoracolumbar fascia
over the screw head.
surgeon. Once a secure ilio-
sacral foundation has been
established correction
of pelvic obliquity can be
Pelvic Obliquity accomplished by the
application of cantilever
The configuration of neuromuscular curves is dif- forces by means of
reduction of the (usually con-
ferent from that of non-neuromuscular curves. vex) rod to the curve.
This manoeuvre is aided by
The curves are longer, more C shaped and fre- the application of a
distraction force to the high
quently extend to the lumbar spine, involving the side of the pelvis.
sacro-pelvis. Pelvic obliquity is thus a common More severe pelvic
obliquity can be addressed
feature. The problems which follow from pelvic by the application of
corrective forces by intra-
obliquity are those of ischial pressure areas (espe- operative halo femoral
traction. In this technique
cially in thin patients), difficulty in seating, toilet/ a halo is applied to the
patients skull before
hygiene difficulty, and sometimes hip subluxa- prone positioning, and a
supracondylar pin or
tion. Correction of pelvic obliquity is therefore wire applied to the
femur ipsilateral to the high
an important part of deformity correction. side of the pelvis.
Traction is then applied to the
Although the L5 vertebra is firmly anchored to femur, and counter
traction to the halo. A little
the pelvis by the iliolumbar ligaments, only with anti-Trendelenburg
positioning is helpful. By this
the advent of the Galveston technique [9] was it method a good postural
correction of pelvic
505
In view of the
significant complication rate
associated with sacro-
pelvic fixation, and the
firm fixation of L5 to
the sacro-pelvis, some
authors have questioned
the need for sacro-pelvic
fixation, even in
patients with marked pelvic
obliquity. McCall and
Hayes [14] compared
patients fused to L5
with those fused to the
sacro-pelvis. Although
the groups were similar,
the method of allocation
was not stated. They
found that in both
groups the correction of pelvic
obliquity was good, but
slightly better and better
maintained in the sacro-
pelvic group.
Sacro-pelvic fixation
has a high complication
rate. Emami et al. [15]
performed a retrospective
review of 54 deformity
patients fused to the
sacro-pelvis. A variety
of fixation techniques
were used (11
Luque/Galveston, 36 Isola S1 and
pelvic bolts, 12 Isola
bi-cortical S1 screws) and
there was a complication
rate, mostly associated
with sacro-pelvic
fixation of almost 50 %. In
addition 10 patients
required further surgery for
pseudarthrosis, and 9
required removal of iliac
bolts.
Tsuchiya [16] also
found a significant
complication rate in
patients having sacro-pelvic
fixation a 6 %
lumbosacral pseudarthrosis
rate and a significant
rate of iliac fixation
problems [14].
Edwards et al. [17]
compared patients fused to
L5 and the sacro-pelvis.
The complication
rate was high in both
groups of 27 fused to
Fig. 3 Healing of supracondylar femoral fracture follow- L5, 22 had
complications, whereas the 12 fused
ing intra-operative traction
to S1 experienced 75
complications. Those fused
to the sacro-pelvis
underwent significantly
obliquity can be achieved, which can be devel- more procedures than
those fused to L5
oped further by the use of the surgical techniques (1.7 procedures per
patient in L5 group vs. 2.8
mentioned above. The utility of this technique in in the S1 group). There
was no difference in the
a group of 20 patients was reported by Takeshita clinical outcomes.
et al. [12]. Vialle et al. [13] reported better results, Modi [18] examined 55
patients and examined
and shorter operative times in patients who the correction of pelvic
obliquity and the rela-
underwent intra-operative traction than those tionship to pelvic
fixation. He found that if there
subjected to more traditional manoeuvres alone. was more than 15# of
pre-existing pelvic obliq-
Although intra-operative traction is a useful tech- uity and pelvic fixation
was not performed then
nique it is not without pitfalls. The insertion of there was a
significantly greater loss of correction
traction pins in those with osteoporotic bone is of pelvic obliquity with
follow-up. The func-
a cause for concern we have had one patient tional significance of
this loss was not clear.
who suffered an ipsilateral supracondylar frac- There is a trend to
question the need for com-
ture of the femur (Fig. 3). plex sacro-iliac
fixation. Bilateral fixation may
506
J.B. Williamson
not be required, unilateral fixation may suffice. In found that even when the
number of levels
view of the evidence above, the complication rate operated was controlled
for patients having
of sacro-iliac fixation may outweigh the potential surgery for
neuromuscular scoliosis had a seven
benefits. Further work is required. times greater chance of
having a blood loss of more
than 50 % of their
estimated blood volume.
Severe Curves
Because neuromuscular scoliosis is of earlier onset Complications of Surgery
than idiopathic scoliosis, and has a propensity to Complications are more
common in patients with
progress even after skeletal maturity, neuromus- neuromuscular scoliosis.
They have more co-
cular curves tend to be larger than idiopathic ones. morbidities and medical
complications are more
This tendency is exacerbated by having a higher common. Wounds are more
extensive and the
threshold for intervention in children with such patients are not well
nourished and to a degree
co-morbidities. Correction of the deformity is immuno-compromised.
Children with neuromus-
therefore more challenging, and specialized tech- cular scoliosis tend to
have a higher length of stay
niques are often appropriate. Segmental fixation and hospital mortality
than those with other
with Luque wires gained widespread acceptance diagnoses [22].
in neuromuscular scoliosis before idiopathic sco- Mohamad et al. [23]
in a review of 175
liosis, and it is fair to say that radical destabilizing patients, predominantly
with cerebral palsy
surgery, such as total spondylectomy and posterior (129/175) found that
complications were com-
vertebral column resection (PCVR), were mon. In his group there
were 96 complications in
adopted for neuromuscular curves before gaining 58 patients. Nine
percent of the patients had respi-
widespread acceptance in idiopathic curves. ratory complications and
8 % wound infections.
Pedicle screw fixation was adopted as the gold 4 % had cardio-vascular
complications mainly
standard for fixation of neuromuscular curves coagulopathy secondary
to bleeding. A higher
long before its almost universal prevalence in rate of complications
was associated with seizure
idiopathic scoliosis. Modi et al. [19] reviewed disorder, longer
operations, increased estimated
52 patients with Cerebral Palsy (CP) scoliosis. blood loss and sacral
pelvic fixation.
They found good correction of scoliosis, but Sarwark and Sarwahi
[24] looked at the deter-
one patient had a temporary paresis secondary minants of survival in
their population of patients
to a misplaced screw. There were also with neuromuscular
scoliosis. If their kyphosis
2 haemothoraces it is not clear if these were was more than one
standard deviation above the
due to screw malposition The same author [20] mean (the mean was 56# ,
one standard deviation
found that the use of pedicle screws enabled above was 86# ) there
was an excess mortality of
a modest (25 %) correction of rotatory deformity. 122 %. Similarly those
who spent more than
The mechanism of reduction of the deformity was 30 days on the Intensive
Care Unit had
not specified in his paper. However the reduction a mortality of ten times
those who did not.
in rotation was independent of diagnosis. Vitale et al. [25]
found that the length of stay
and complications were
higher in patients whose
Blood Loss treatment was funded by
Medicaid than private
Blood loss is a particular issue in surgery for neu- insurers. Whether this
was due to societal factors
romuscular scoliosis. Patients with neuromuscular or factors in the
delivery of care is not clear. They
scoliosis have more extensive surgery than patients also found a
relationship between the outcome
with idiopathic or congenital scoliosis, with more and the volume of
surgery undertaken at a given
levels being fused. The curves are often worse; the institution, but this
effect had a very low floor,
surgery is technically difficult and takes longer. with no additional
benefit being perceived for
However, even when these factors are controlled operating on more than
five cases per annum.
for the blood loss in patients with neuromuscular Tsirikos et al. [26]
examined life expectancy
scoliosis is considerably higher. Edler et al. [21] after surgery for
cerebral palsy. They found that
507
a number of surgical variables (as well as for force transduction by

linking the contractile
a number that correlated directly with disease mechanism to the
extracellular matrix.
severity) correlated with length of post-operative About two-thirds of boys
with DMD have a
survival. These included spinal deformity, intra- gross rearrangement
deletion, whereas the other
operative blood loss, operative time, length of third have duplications (10
%) or smaller point
ICU stay and length of hospital stay. Whilst it mutations (10 %). The
smaller mutations may
could be argued that these variables are surro- lead to a reduction rather
than complete absence
gates for disease severity, the importance of the of dystrophin, leading to a
milder phenotype (for
avoidance of complications is highlighted. The example Becker Muscular
Dystrophy) rather
mean survival time for globally affected children than the more severe
Duchenne. Boys with
was 11 years 2 months. Duchenne generally have
absence of dystrophin
in skeletal and cardiac
muscle. Some isoforms of
Spinal Cord Monitoring dystrophin are also
expressed in the brain and
Spinal cord monitoring is possible in patients absence of these isoforms is
responsible for the
with neuromuscular scoliosis. In our own series low intellect which
complicates a proportion of
using epidural electrodes we found that it was cases of Duchenne.
possible to monitor consistently except in Only one-third of cases
are due to transmis-
patients with neurodegenerative diseases. [27]. sion from the mother.
Advances in molecular
The findings of Tucker et al. were similar [28]. genetics now allow precise
evaluation of carrier
Both of these authors reported series using status of females in the
family of an affected
epidural electrodes. individual. Determination of
carrier status is
The situation with respect to cortical evoked important, because as well
as for reasons of
potential monitoring is more difficult, and it may counselling and ante-natal
diagnosis, carriers
be harder to monitor in conditions affecting the have a 10 % lifetime risk of
developing cardio-
cerebral pathways. myopathy and appropriate
surveillance is clearly
important [30].
Late diagnosis of
Duchenne continues to be
Considerations in Specific Diseases a problem [3134], The
reason for this delay may
be that healthcare workers
do not see children
Duchenne Muscular Dystrophy performing high demand
activities such as run-
ning and rising from the
floor which require well
Duchenne Muscular Dystrophy is the commonest developed muscle power. Late
motor develop-
muscular dystrophy, affecting about 1 in ment, frequent falls,
waddling gait, persistent
3,500 6,000 male live births. It leads to progres- toe walking and difficulty
running may be
sive disability and although advances in treat- presenting features to the
Orthopaedic surgeon.
ment have seen life expectancy extended, boys The first investigation
in such children should
with Duchenne Muscular Dystrophy usually die be a serum creatinine kinase
(CK) which is
in their third decade [29]. always extremely elevated
(10100 x normal) in
Duchenne is inherited in an x-linked recessive Duchenne. A high CK should
instigate a referral
manner but a third of cases are caused by new to a specialist
neuromuscular clinic for diagnosis.
mutations. The locus of the genetic defect in A normal CK at presentation
excludes the
Duchenne is Xp21. This is the dystrophin locus diagnosis.
where dystrophin, a large but uncommon protein Scoliosis is common in
boys with Duchenne,
is encoded. but only progresses once
they become dependent
Dystrophin is active in the cell membrane of upon a wheelchair [35].
all muscles. It connects the sarcolemma to the There are a number of
issues for the spinal
muscle protein actin. Dystrophin is important in surgeon which are unique to
patients with
calcium transport and is thought to be essential Duchenne Muscular Dystrophy.
508
J.B. Williamson
Natural History King et al. [45] in a

study of a large number of
Scoliosis is very common in boys with Duchenne patients found that the use
of steroids delayed the
Muscular Dystrophy once they are wheelchair- age at which boys became
wheelchair dependent
bound. Scoliosis in wheelchair-bound boys by some 3.5 years. The
prevalence of scoliosis
with Duchenne Muscular Dystrophy may be was decreased from 91 % to 31
%, and when
invariable if they are followed until death [36]. scoliosis occurred it was
less severe (average
Galasko quotes the incidence to be over 90 %. Cobb angle of 11# against 32#
). However 32 %
[35, 37] Rideau [38] recognises different of the treated group had
concomitant vertebral
categories of severity of scoliosis in Duchenne fractures (none in the
control group) and long
Muscular Dystrophy, however all who were bone fractures were 2.6 times
more frequent.
followed until death developed some degree of The boys treated with
steroids were 13.9 kg
scoliosis. At the other end of the spectrum heavier than those not
treated with steroids. Over-
Brooke [39] found that almost 25 % of patients all they found that the risk
of scoliosis surgery
had a relatively straight back. Factors which was reduced to one-third of
the risk in the
may modify the progression of scoliosis include untreated group. However it
would be clear to
prolongation of walking in long-leg callipers all surgeons that boys with
Duchenne Muscular
[35, 40] and prolongation of walking by the use Dystrophy have a degree of
osteoporosis, even
of steroids [41]. without steroid treatment.
The technical diffi-
A number of authors have reported the natural culty of spinal surgery in
those who have had
history of scoliosis in Duchenne Muscular Dys- prolonged steroid treatment
is greatly increased.
trophy. Although most boys with DMD develop
a scoliosis, and it is progressive in most, some do Blood Loss
not progress. Those familiar with spinal
surgery in Duchenne
Kinali et al. [42] reported their experience in Muscular Dystrophy will be
aware of the techni-
a large neuromuscular clinic. This unit had the cal difficulty of all aspects
of the surgery. The
policy of only offering surgery to those who dissection is difficult with
the paraspinal muscles
developed curves of more than 50# . The authors being replaced by a dense
fibrotic mass, making
question the need for spinal fusion in all who dissection down to the
posterior elements more
have a scoliosis, saying that perhaps 35 % do difficult. Even with
painstaking technique, the
not need spinal surgery. However it is clear blood loss in boys with
Duchenne Muscular Dys-
from their paper that a significant number of trophy is higher than for
other forms of posterior
their patients with a larger scoliosis were not spinal surgery. Noordeen et
al. [46] compared the
suitable for surgery because of lack of fitness. blood loss in patients with
Duchenne Muscular
The current guideline [43] is that scoliosis sur- Dystrophy with other
neuromuscular groups and
gery should be considered for patients whose found a significantly higher
blood loss in boys
curve reaches 2040# . with Duchenne, even when
other variables were
The natural history of the Orthopaedic prob- corrected for. He
hypothesised that this was due
lems in Duchenne Muscular Dystrophy can be to a lack of dystrophin in
the smooth muscle of
improved by the use of steroids. Houde et al. the vessel walls, impairing
the contractility and
[44] found significant differences in patients preventing haemostasis.
treated with steroids when compared with those Turturro [47] found that
boys with Duchenne
who were not. They found improved cardiac Muscular Dystrophy had a
higher peri-operative
function, prolonged walking time and blood loss, independent of
all other surgical vari-
a decreased incidence of scoliosis. They ables. They found an
increased bleeding time in
hypothesise that the use of steroids may eliminate Duchenne Muscular Dystrophy
and examined the
the need for spinal surgery. However vertebral platelets of control patients
who did not have
crush fractures and stunted spinal growth were DMD. No dystrophin was found
in these non-
much more common in the steroid-treated group. Duchenne platelets and the
suggestion that there
509
may be a defect in platelet function was not a relatively low risk

population with an average
supported. The authors suggested a primary 44# pre-operative Cobb angle
and an average pre-
defect of haemostasis possibly due to impaired operative forced vital
capacity of 55 % of
vessel reactivity. predicted. Notwithstanding
this they had a 77 h
The measures which the surgeon can take to intensive care length of
stay and one intra-
alleviate this effect, apart from meticulous atten- operative death. Similarly
Mehta et al. [52] had
tion to surgical detail and careful positioning, a policy of pelvic fixation
for pelvic obliquity of
include the use of pharmacological anti- more than 15# . They also
had one peri-operative
fibrinolytic agents. Aprotonin has been shown to death. Takaso et al. [53]
examined 28 patients
be extremely efficacious in this regard. Its main with large (75# ) curves.
All were fused to L5
use was in cardiac surgery and unfortunately with pedicle screws. All had
a curve apex caudal
because of problems in cardiac surgery its use to L2 though they found that
an L5 tilt of less than
has been discouraged. We no longer use aprotonin 15# prognosticated for a
good correction of pelvic
for patients with idiopathic scoliosis, but as it is obliquity. However if the L5
tilt was greater than
still available on a named patient basis in the UK, 15# there was significant
residual pelvic obliquity.
we use it in patients with neuromuscular scoliosis The functional significance
of this is not clear.
However tranexamic acid has also been shown to Alman & Kim [54]
reduce the blood loss significantly in patients with treated by Luque Galveston
surgery. 38 were
Duchenne Muscular Dystrophy [48]. fused to L5 and 10 with more
pelvic obliquity
were to the sacrum. They
found that those whose
Operative Technique and Fusion Levels curve apex was caudal to L1,
if only fused to L5,
There remains debate as to the type of surgery to had a much greater increase
in pelvic obliquity
be performed in boys with Duchenne Muscular when compared to those fused
to S1. It can be
Dystrophy. All are agreed that a posterior spinal argued that this paper
examines historical surgi-
fusion is the operation of choice, with anterior cal methodology which may
not be directly appli-
surgery being precluded by the patients respira- cable to the use of pedicle
screw instrumentation.
tory function. Segmental fixation is universally Sengupta [55] compared
two groups of patients,
accepted. one group being operated
early, the other late. The
Gaine et al. [49] compared the use of Luque earlier operated group were
treated by pedicle
sublaminar wires with Isola hybrid instrumenta- screws down to L5 whereas
the later group were
tion, with pedicle screws being used in the lumbar treated by Luque Galveston
instrumentation down
spine. They found that not only did the Isola to the sacral pelvis. They
found equally satisfactory
instrumentation produce a better correction but results in terms of pelvic
obliquity in those treated
there was less loss of correction post-operatively. early and fused down to L5.
There is much debate about the caudal extent of It is our experience
that fusion to L5 with
spinal fusion in Duchenne Muscular Dystrophy. pedicle screw
instrumentation leads to a satisfac-
Some authorities maintain that it is not necessary tory result in all but those
with the most severe
to fuse past L5 whereas others argue that fusion to pelvic obliquity (Fig. 4).
the sacro-pelvis produces better outcomes.
Mubarak et al. [50] examined 22 patients, of Lung Function
whom 12 were fixed to the pelvis and 10 to L5. A number of authors have
examined the effects of
All patients had small curves and pelvic obliquity spinal surgery on lung
function in Duchenne
was assessed clinically. No difference was seen Muscular Dystrophy.
Untreated the respiratory
between the two groups. function of boys with
Duchenne progressively
There are a number of papers which report worsens as they age.
good results in patients having long spinal fusions Galasko et al. [37] found
that the performance
from the upper thoracic spine to the pelvis. How- of spinal stabilisation
produced a 3 year plateau
ever, Hahn et al. [51] were operating on in the decline of forced
vital capacity when
510
J.B. Williamson
a b
Fig. 4 Pre- and post-operative photographs of a boy with Duchenne Muscular

Dystrophy showing satisfactory
correction of pelvic obliquity with instrumentation to L5. (a) Pre-operative, (b)
Post-operative
compared to an un-operated, and seemingly iden- and surgery survived to 30

years, compared
tical, cohort of patients who declined the offer of with 22.2 years for those who
only had ventila-
surgery. They also found that significantly more tion. Those who had neither
lived to 17.2 years.
of the boys who accepted the offer of surgery Galasko et al. [35]
demonstrated that a stand-
were alive 5 years from the date of the offer. ing regimen protected lung
function and delayed
Kennedy [56] examined 17 patients, some of the onset of progression of
scoliosis. They
whom had surgery and some of whom did not reported a large series of
patients who had no
they found no difference in the rate of decline of major complications from
spinal surgery. Once
respiratory function. again they reported that the
forced vital capacity
A number of other authors have found no remained static for 36 months
after spinal sur-
difference in lung function between those oper- gery. Significantly they
found that 61 % of the
ated and those not [57, 58] However Velasco [59] cohort who accepted the offer
of spinal surgery
in a more recent paper concluded that posterior was alive at 5 years compared
with 23 % of the
spinal fusion slowed the rate of respiratory matched cohort who declined
the offer.
decline in boys with Duchenne Muscular Dystro- A number of papers have
examined the effect
phy. Eagle et al. [60] found that the effects of of lung function on surgical
prognosis. It is often
spinal surgery and nocturnal home ventilation quoted that spinal surgery
should not be performed
were additive. Patients having both ventilation in boys with an FVC of less
than 30 %.
511
Takaso et al. [61] examined 14 patients, all of this site is the survival
motor neurone gene
whom had an FVC of less than 30 %. All had (SMN1). This gene has
deletions in greater than
pedicle screw fixation with no complications. 98 % of patients with SMA
[66] The function of
All of the patients and their parents thought that the gene product encoded by
the SMN1 gene is
there was an appreciable quality of life gain. not clear.
Marsh et al. [62] compared two groups of patients, SMA is characterised
clinically by symmetri-
one of whom had an FVC of greater than 30 % and cal muscle weakness
affecting the legs more than
one had an FVC of less than 30 % and found no the arms, proximal muscles
more than distal ones
difference in the surgical outcomes or rate of and affecting the axial
muscles and the intercos-
complications. Harper et al. [63] again compared tals selectively. The
diaphragm is relatively
those with an FVC of greater or less than 30 %. spared, but bulbar
involvement is common.
They found no difference but did suggest that in Byers and Banker [67, 68]
based their classi-
the group with the worst lung function weaning fication on severity of
disease and age of clinical
onto non-invasive ventilation may smooth the onset. Type 1 is usually
diagnosed in the first few
post-operative course. Bentley et al., in a seies of months of life. The child
has little useful motor
64 patients with Duchenne Muscular Dystrophy function and death from
respiratory failure is
with a range of 1863 % forced vital capacity, early. Type 2 is diagnosed
later and children
found no influence on outcome [64]. may sit without support.
They rarely stand.
In conclusion therefore spinal surgery in boys Many patients now survive to
the third or fourth
with Duchenne Muscular Dystrophy with scolio- decade. Type 3 is the
mildest form and patients
sis produces an appreciable quality-of-life gain can often walk unassisted.
They may lose the
and may well have a protective effect on respira- ability to walk as they grow
older.
tory function. It would seem to be advantageous Many paediatric
neurologists use a pragmatic
to operate early, when the curve is 2040# when classification [69] based on
the onset of symp-
respiratory and cardiac function are good. In this toms, with Type 1 patients
seeing an onset before
group, before significant pelvic obliquity has 6 months of age, and never
sitting. Type 2 has an
developed, fusion down to L5 with a pedicle onset between 7 and 18
months of age and
screw system is probably adequate. patients are able to sit.
Type 3 has an onset
Boys with Duchenne Muscular Dystrophy older than 18 months, and
these children can
have considerable co-morbidities and their safe walk. Type 4 has an onset in
adult life, usually
management requires an experienced multi- the second or third decade.
disciplinary team. Such surgery should probably Spinal Muscular Atrophy
has a spectrum of
only be undertaken in centres which perform severity. Survival depends
on the degree of bul-
surgery for neuromuscular scoliosis regularly. bar and respiratory
involvement, which largely,
but not completely mirrors
the motor function on
which the disease is
classified.
Spinal Muscular Atrophy There is no curative
medical treatment for
SMA but palliative methods
such as nutritional
Spinal Muscular Atrophy (SMA) was first and respiratory support have
seen a significant
described independently in the early 1890s by improvement in quality of
life and survival [70].
Werdnig and Hoffman. It is a genetic disorder Scoliosis is the main
functional problem of
with a prevalence of 8 in 100,000 live births. It patients with SMA. Its
prevalence and severity
is the commonest fatal neuromuscular disease of mirrors the severity of the
disease [71, 72]. The
infancy. onset of the scoliosis is
earlier in patients with
Spinal Muscular Atrophy has an autosomal more severe disease, and
once established the sco-
recessive pattern inheritance with a slight male liosis is relentlessly
progressive. A severe kypho-
preponderance. Gilliam et al. [65] identified the scoliosis with marked pelvic
obliquity and painful
gene locus in 1990 as 5q 11.2 13.3. The gene at costo-iliac impingement is
very common.
512
J.B. Williamson
a b c
d
Fig. 5 Pre- and post-operative xrays of a child with Spinal Muscular Atrophy with
growing rods (Case of Mr Rajat
Verma). (a) A-P view, (b) lateral view, (c) A-P view, (d) lateral view
A number of authors have reported good surgi- They found an inverse

relationship between the
cal results in patients with SMA. Aprin et al. [73] Cobb angle and percentage
lung function. They
operated on 15 patients. They concluded that short reported good results in
16 patients operated.
segment anterior fusion had a high respiratory com- Chng et al. [81] studied 8
patients. They found a
plication rate and was accompanied by progressive continuing decline in lung
function even after
deformity. Posterior spinal fusion seemed to reduce spinal fusion, but the
decline was slower than
the rate of pulmonary deterioration but did not pre-surgery.
stop it. A number of other papers have reported The dilemma now faced
by contemporary
good results of spinal surgery in patients with Spi- surgeons is that medical
advances have increased
nal Muscular Atrophy. [7479] All of the patients life expectancy of
patients with what would have
in these cohorts were relatively mature, being previously been a poor
prognosis Spinal Muscular
largely in their teens with an occasional patient in Atrophy. They are
therefore presented with
childhood. Bentley et al., in a study of 33 patients increasingly younger
patients with severe scoliosis.
with Spinal Muscular atrophy, reported good out- Anterior surgery is
precluded because of poor lung
comes over a 13-year period. They noted that it is function whereas posterior
only surgery invariably
necessary to avoid fusion below L.5 in ambulant results in a recurrence of
deformity, due to anterior
patients because fixation of the pelvis could prevent spinal overgrowth
(crankshaft effect).
the pelvic tilt required for walking [64]. These patients present
a therapeutic dilemma.
A number of authors have examined lung Conservative treatment in
the form of corsetry or
function in Spinal Muscular Atrophy. Robinson bracing is ineffective and
has an inhibitory effect
et al. [80] found that the scoliosis in patients with on lung function, whereas
conventional surgical
SMA deteriorated in patients once they stopped techniques will yield a
poor result. In this cohort
standing. Even if they stood in orthoses scoliosis we have operated a number
of patients by the use
was prevented and lung function protected. of growing rods (Fig. 5).
This technique has been
513
evaluated by other authors but no comprehensive scoliosis, 31 % kypho-

scoliosis and 11 % an
follow-up is yet published [82, 83]. It is our isolated hyper-kyphosis.
Interestingly hyper-
experience that this is an efficacious means of kyphosis was more common in
patients with
controlling the curve in an otherwise difficult the MPZ mutation than PMP22
abnormalities.
population. Clearly in commencing this treatment Karol & Ellison [87]
one is committed to a programme of treatment with Charcot-Marie Tooth
Disease. 1 in 6 of
and in this population and multi-disciplinary these developed a scoliosis
and of those followed
approach is paramount. The decision to offer two-thirds progressed.
Progression was more
definitive spinal fusion is frequently made on the common in those with a large
curve at presenta-
advice of the chest physician or neurologist tion and in those with
hyper-kyphosis.
because the childs lung function has declined Of those treated
surgically a long posterior
sufficiently that the window for further surgery spinal fusion with
instrumentation was performed.
will soon close. Nonetheless we have found this It was not possible to get
consistent SSEP moni-
to be a useful way out of a difficult situation. toring and this latter
coincides with our own
findings [27].
Hereditary Sensory Motor Neuropathy

(Charcot-Marie Tooth Disease) Friedreichs Ataxia
Charcot-Marie Tooth Disease (CMT) is the most Friedreichs Ataxia is a

spinal cerebellar disease
common inherited sensory neuropathy with an or hereditary ataxia. It is
usually inherited as an
incidence rate of between 1 in 2,500 and 1 in autosomal recessive trait,
due to mutations in the
5,000 [1, 84]. The common orthopaedic manifes- frataxin gene. Inheritance
is variable. Patients
tation is of cavovarus feet, but hip dysplasia is with Friedreichs Ataxia
usually present in early
also more common. Scoliosis occurs in CMT with adolescence with an ataxic
gait but may also
a higher prevalence than in the general popula- present with scoliosis or
foot deformity. The dis-
tion. The nature of the scoliosis is different from ease is generally
progressive with increasing loss
idiopathic scoliosis and the scoliosis is associated of mobility and eventual
death from cardiomyop-
with some genotypes more than others. Walker athy. The genetic defect has
been identified on the
et al. [85] reviewed 100 patients with electrophys- locus 9q13. The absent gene
product allows the
iologically proven Charcot-Marie Tooth Disease. accumulation of
intramitochondrial iron and cell
Of these, 89 had spinal x-rays with 37 having death [88, 89]. Cady and
Bobechko [90] exam-
a spinal deformity. Of the 37, 17 had a kyphotic ined 42 patients. Of 34 for
whom complete data
deformity with or without scoliosis. were available 30 developed
a scoliosis.
Scoliosis seems to have been mild as only Daher et al. [91]
examined 19 patients with a
2 patients underwent surgical treatment. Of diagnosis of Friedreichs
Ataxia and a scoliosis.
those with x-rays at skeletal maturity 50 % had Of these 8 had a degree of
hyper-kyphosis and 12
some degree of spinal deformity. Horacek [86] came to surgery.
reviewed 175 patients with HSMN. They found Labelle examined 56
patients with
that the incidence of scoliosis depended on the Friedreichs Ataxia [92].
All developed
genotype. Those with deletional duplication at a scoliosis of more than 10#
by the end of fol-
the PMP22 gene on chromosome 17 had a 56 % low-up and of these two-
thirds had some degree
chance of spinal deformity. Those with a Cx32 of hyper-kyphosis. Of those
with long term fol-
gene mutation (typically CMTX) had an 18 % low-up [36] 20 proved to
have progressive
chance of scoliosis whilst those with the MPZ curves. The authors found no
correlation of the
gene mutation, including those with Dejerine- risk of progression with
disease severity but
Sottas syndrome, had a 13 % chance of scoliosis. did find a correlation with
the age of onset of
Of those with spinal deformities 58 % had scoliosis. They suggested
that as the curve
514
J.B. Williamson
patterns resemble those of idiopathic scoliosis The incidence of scoliosis

is greater in those
rather than neuromuscular scoliosis that scoliosis with the greatest
neurological affliction.
in Friedreichs Ataxia behaves more like idio- Like other neuromuscular
scolioses cerebral
pathic scoliosis than neuromuscular scoliosis. palsy scoliosis has a
propensity to deteriorate.
Milbrandt et al. [93] found that 49 of the 77 Saito et al. [95] found that
patients whose curves
patients whom they observed developed a scoliosis were 40# by the age of 15
years invariably
(63 %). Of these 49, 24 progressed and a third had progressed to more than
60# . Those with whole
come to surgery by the time the paper was written. body cerebral palsy were
more likely to deterio-
Like Labelle these authors found that double major rate. These findings were
confirmed by Majd et al.
curve patterns predominated, but in contrast to [96] who found that many
relatively small (less
Labelles findings they found no relationship than 50# curves) progressed
after skeletal matu-
between the age at diagnosis of the scoliosis or rity, linking an increasing
scoliosis to a decline in
curve magnitude and the risk of progression. physical function. A number
of the patients in
Furthermore, the authors illustrated their their study went from being
assisted sitters to
belief that these curves do not behave like idio- being bed-bound as their
scoliosis progressed.
pathic scoliosis using two examples. One had The effect of scoliosis
in cerebral palsy is
a selective thoracic fusion for a double major functional. Loss of trunkal
balance may deprive
curve which was followed by severe progression the ambulant patient of his
ability to walk. The
of the lumbar curve and the other had severe non-ambulant may lose their
ability to sit, or need
proximal junctional kyphosis after a short fusion. to use the arms to arrest
declining sitting balance,
They found that somatosensory evoked poten- rendering the patient a
functional quadriplegic.
tial monitoring was not possible. An increasing scoliosis and
pelvic obliquity may
make sitting impossible.
Pelvic obliquity leads
to an increasing likeli-
Cerebral Palsy hood of development of
pressure sores over the
dependent ischial
tuberosity, greater trochanter
Cerebral palsy (CP) is a neurological condition or sacrum. Once established
it is very difficult
which results from a static lesion in the brain of to treat a decubitus ulcer
without treating the
a growing child. Cerebral palsy is the commonest underlying pelvic obliquity.
Skin problems in
cause of neuromuscular scoliosis. the costo-iliac angle are
also difficult to treat.
It is hard to estimate the prevalence of scolio- The scoliosis associated
with cerebral palsy is
sis in cerebral palsy because cerebral palsy is sometimes painful. Pain is a
frequent concern of
a protean condition with manifestations ranging the care givers but seems to
be less prevalent than
from the severely disabled child with whole body is sometimes imagined. Most
children severely
spastic cerebral palsy to those who are minimally affected by cerebral palsy
and scoliosis can com-
affected whose problems can only be properly municate their discomfort to
the care givers.
diagnosed by a skilled physician. Most estimates The aims of treatment in
cerebral palsy are to
of the prevalence of cerebral palsy are based on maximize function, even in
severe whole body
severely affected individuals. For example, the CP. This is best done by
minimizing trunkal
incidence of scoliosis in the institutionalized pop- imbalance. This can
sometimes be achieved by
ulation is some 60 % or 70 % [94]. Cerebral palsy the provision of a rigid
polythene TLSO or by
has different manifestations. Spastic cerebral seating adaptations. The
benefits which accrue to
palsy is the most common but cerebral palsy the patient from wearing a
brace are immediate
may also cause movement disorders such as and functional. There is no
convincing evidence
ataxia and athetosis. Madigan and Wallace [94] that brace treatment in
cerebral palsy affects the
found a 69 % incidence of cerebral palsy in those natural history of the
condition.
with a spastic condition, 50 % in those with Surgical treatment has
the ultimate aim of
ataxia and 39 % of their dyskinetic group. restoring a balanced trunk
over a level pelvis.
515
Scoliosis in cerebral palsy is often very severe and the Low Back Outcome
Score) or the general
before treatment and consideration is frequently health-related quality-of-
life questionnaire (e.g.,
given to destabilizing surgery to allow a better SF36). The best assessment of
outcome can be
correction of the deformity. obtained by using a
combination of a generic
This may take the form of an anterior release health-related outcome,
condition-specific mea-
or more recently surgeons have used posterior sures and a measurement of
function.
vertebral column resection as a way of inducing A number of authors have
developed question-
flexibility in the spine [97]. With preliminary naires for use in patients
with neuromuscular
anterior surgery debate remains as to the pros. conditions. Bridwell et al.
[99] evaluated 48
and cons. of sequential (that is to say under the patients with SMA and DMD
using a structured
same anaesthetic) anterior and posterior spinal questionnaire of twenty
questions covering the
surgery compared with staged (that is to say domains of function,
satisfaction, quality of life
under two anaesthetics) surgery. This was exam- and cosmesis. The
questionnaire covered a range
ined by Tsirikos et al. [98]. They found that of issues specific for
progressive flaccid neuro-
sequential procedures were associated with an muscular scoliosis including
questions from the
increased intra-operative blood loss, prolonged SRS and American Academy of
Orthopedic Sur-
operative time and an increased incidence of geons questionnaires.
medical and surgical complications in a group Wright et al. recently
developed a muscular
of 45 patients. They concluded that staged sur- dystrophy spine questionnaire
[100] In cerebral
gery provided safer and more consistent results. palsy. Narayanan et al. [101,
102] developed a
questionnaire from interviews
with health care
providers and the care givers
of children with cere-
Outcome Measurement bral palsy. The final
questionnaire had 36 items in
six domains, (personal care,
position in transfer
The concept of measurement of outcome is essen- and mobility, communication
and social interac-
tial to the science of surgery. In spinal deformity tion, comfort in motions and
behaviour, health and
surgery the earliest outcomes measured were quality-of-life). Reliability
was established by
radiographic. However correction of Cobb a test/re-test performance
with a very high corre-
angle has been shown to have a poor relationship lation coefficient. A number
of authors have used
with patient satisfaction and this has prompted such outcome measures to
assess the effects of
the search for outcome measures which are scoliosis surgery. Watanabe
et al. [103] examined
more relevant to the patient. The Scoliosis 84 patients with cerebral
palsy who underwent
Research Society (SRS) questionnaire is now spinal fusion, Of 142
patients undergoing surgery
accepted as a reliable and valid measurement of 18 had re-located and a
further 40 did not return the
outcome for patients with adolescent idiopathic questionnaires (10 of this 40
did not return the
scoliosis. questionnaire because the
child had died).
In assessing outcome in neuromuscular scoli- The questionnaire used
was a version of that
osis, function is of prime importance. Functional developed by Bridwell et al.
[99] addressing
outcomes, or their surrogates have been used expectations, cosmesis,
function, patient care,
rather than cosmesis or deformity. As has been quality-of-life, pulmonary
function, pain, co-
seen in this chapter respiratory function is fre- morbidity, self-image and
satisfaction. Families
quently used as an outcome measure in neuro- of patients were given the
questionnaires and
muscular scoliosis. Similarly, walking status may asked to remember the childs
pre-operative
be used in the ambulant patient. A number of state. The authors results
indicated that spinal
authors have made moves towards developing deformity surgery was
beneficial and that
patient-related outcome measures. These may cosmesis improved
dramatically after surgery.
be condition specific (examples in low back sur- Interestingly, only 40 % of
patients saw an
gery for example the Oswestry Disability Index improvement in function from
surgery, whereas
516
J.B. Williamson
72 % of the patients or carers reported an 12. Takeshita K, et

al. Analysis of patients with
improved quality of life. nonambulatory
neuromuscular scoliosis surgically
treated to the
pelvis with intraoperative halo-femoral
Larsson et al. [104] performed a functional traction. Spine
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Outcome and complications of long
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spastic cerebral palsy truly beneficial?:
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2009;34(20):222232.
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tion of the care giver priorities in child health index 214552.
Surgical Management of Adult
Scoliosis
Norbert Passuti, G. A. Odri,

and P. M. Longis
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 521
Adult # Aetiology # Classification # Complica-
tions # Diagnosis # Pathomorphology # Pre-

Aetiology, Classification and
operative preparation # Scoliosis # Surgical

Pathomorphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
522
techniques
Diagnosis and Pre-Operative Preparation for
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 523
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
527 Introduction
Summary for Surgical Strategy . . . . . . . . . . . . . . . . . . . . .
528
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 528
Case Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 531 The natural course of idiopathic scoliosis during
adult life is neither static nor benign. As the

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 531
patient gets older, the deformed spinal column
may show aggravation of the curves, increasing
kyphosis, decompensation, and spondylotic
changes. These pathologic changes may cause
back pain, radiculopathy, cosmetic, and psycho-
logical problems, and cardiopulmonary compro-
mise, possibly leading to increased mortality.
The prevalence of adult scoliosis in the gen-
eral population has been reported as ranging from

1 % to 4 %. Physical deformity, significant pain
and disability can develop. With the demographic
shift involving an ageing population in the West-
ern World and increased attention to quality of
life issues, adult scoliosis is becoming
a significant health-care concern. The progres-
sion of spinal deformities in the adult population,
treatment approaches for adult scoliosis, and sur-
gical techniques have consequently been reported
frequently in the literature.
Adult scoliosis can be defined as a spinal defor-
mity in a skeletally-mature patient with a Cobb

N. Passuti (*) # G.A. Odri # P.M. Longis
Faculte de Medecine, Nantes, France
angle greater than 10# . Although there are many
e-mail: norbert.passuti@chu-nantes.fr
known causes of spinal deformity in the adult, two

521
DOI 10.1007/978-3-642-34746-7_34, # EFORT 2014
522
N. Passuti et al.
categories embrace the largest number of scolioses. Type 2: Progressive

idiopathic scoliosis in adult
The first category includes patients with scoliosis life of the thoracic,
thoracolumbar, and/or
during childhood and adolescence that may pro- lumbar spine.
gress or become symptomatic as the patient ages. Type 3: Secondary
degenerative scoliosis.
This type of scoliosis is often idiopathic and can be (a) Scoliosis following
idiopathic or other
termed adolescent scoliosis of the adult (ASA). forms of scoliosis
or occurring in the con-
The second category includes patients in text of a pelvic
obliquity due to a leg-
whom a the spinal deformity developed after length discrepancy,
hip pathology or
skeletal maturity. This type of scoliosis is often a lumbosacral
transitional anomaly,
termed DDS. Although the causes of ASA and mostly located in
the thoracolumbar, lum-
DDS appear quite different, they may share bar or lumbosacral
spine.
a common pathway in symptomatic patients: (b) Scoliosis secondary
to metabolic bone dis-
gradual loss of intersegmental stability with age- ease (mostly
osteoporosis) combined with
ing and consequent progressive deformity and asymmetric
arthritic disease and/or verte-
pain. Certainly, some adult deformities may not bral fractures.
fit clearly into the categories of ASA or DDS, Therefore, scoliosis
can be present since child-
such as traumatic, metabolic, osteoporotic, or hood or adolescence and
become progressive
iatrogenic deformities. and/or symptomatic in adult
life; or scoliosis
Progress in surgical techniques and technol- may appear de novo in
adult life without any
ogy has been significantly supported by progress precedence in earlier life.
in anaesthesia for spinal surgery and by more Clinically, the most
prominent groups are sec-
sophisticated and precise diagnostic imaging ondary (type 3) and primary
(type 1) degenerative
and differentiated application of invasive and adult scoliosis. In elderly
patients, both forms of
functional diagnostic tests. Increased patient scoliosis may be aggravated
by osteoporosis,
awareness, the patients unwillingness to accept which also holds true for
the type 2 scoliosis.
their limitations and pains, and the gradual shift All three types of
scoliosis may appear at
in the demographics towards a grey society, a certain stage as
degenerative scoliosis, and
make adult scoliosis with all of its different degenerative scoliosis is
therefore the main bulk
forms and clinical presentations a much more of adult scoliosis. Beyond
the above classifica-
frequent problem in a general spine practice tion, the degenerative
adult scoliosis can also be
than the scoliosis of children and adolescents. sub-divided into scoliosis
which has its aetiology
This trend is likely to continue when we consider in the spine itself and
scoliosis with an aetiology
the fact that in 25 years from now, a significant elsewhere. Schwab et al.
proposed recently
part (more than 10 %) of the population in the a radiographic
classification including type IIII
industrialized societies will be over 65 years old. scoliosis, characterized by
the a/p and lateral
views in standing position.
They correlated the
classification IIII with
increasing severity of
Aetiology, Classification and self-reported pain and
disability. Boachie-Adjei
Pathomorphology considered specifically the
idiopathic adult scoli-
osis (our type 2 scoliosis)
and uses the age as
Aebi [1] described 3 types of adult scoliosis. a classifying criterion
combined with degenera-
A scoliosis is diagnosed in adult patients when tive changes, that is,
patients with idiopathic
it occurs or becomes relevant after skeletal matu- adult scoliosis below and
above 40 years of age.
rity with a Cobb angle of more than 10# in the Degenerative adult
scoliosis, specifically in
frontal plain. the lumbar spine, is
characterized by quite
Type 1: Primary degenerative scoliosis (de a uniform pathomorphology
and patho-
novo form), mostly located in the mechanism. The asymmetric
degeneration of
thoracolumbar or lumbar spine. the disc and/or the facet
joints leads to an
Surgical Management of Adult Scoliosis
523
asymmetric loading of the spinal segment and Pain that localizes over
the convexity of the
consequently of a whole spinal area. This again curve is often axial and
diffuse in nature; it is
leads to an asymmetric deformity, for example, believed to be the result of
muscle fatigue and/or
scoliosis and/or kyphosis. Such a deformity again spasm of the paraspinal
musculature. However,
triggers asymmetric degeneration and induces pain on the concavity of the
curve may be localized
asymmetric loading, creating a vicious circle to the back and nerve roots.
This may be the result
and enhancing curve progression. On the one of disc rupture or facet
hypertrophy narrowing
hand, the curve progression is caused by the nerve roots and a subsequent
radiculopathy.
pathomechanism of an adult degenerative curve, Pulmonary compromise with
severe thoracic
and on the other hand by the specific bone metab- scoliosis (curve >80# ) is
well-recognized, due to
olism of the post-menopause female patients with loss of lung volume and
inability to expand the
a certain degree of osteoporosis, who are most thorax with inspiration.
However, it is the excep-
frequently affected by the degenerative form of tion for these patients to
present to the spine
scoliosis. The potential of individual asymmetric surgeon because of
respiratory issues and, in
deformation and collapse in the weak osteopo- fact, they typically present
before the scoliosis
rotic vertebra is clearly increased and contributes is this severe. As discussed
earlier, some adoles-
further to the curve progression. cent idiopathic scoliosis
patients will experience
The destruction of discs, facet joints and progression of their curve
even after skeletal
joints capsules usually ends in some form of maturity and present for
evaluation.
uni-or multi-segmental sagittal and/or frontal In addition to a complete
history and physical
latent or obvious instability. There may be not examination, there are
additional areas that
only a spondylolisthesis, meaning a slip in the should be specifically
reviewed when evaluating
sagittal plain, but also translational dislocation. a patient with a spinal
deformity. The aetiology of
The biological reaction to an unstable joint or, the patients pain needs to
be interpreted as
in the case of the spine, an unstable segment, caused by the progression of
the deformity, neu-
with the formation of osteophytes at the facet rological compromise, or de-
conditioning.
joints (spondylosis), both contributing to the Details of the axial pain
should include location,
increasing narrowing of the spinal canal radiation, aggravating and
alleviating factors, as
together with the hypertrophy and calcification well as the time course;
specifically, nocturnal
of the ligamentum flavum and joint capsules, pain may suggest a neurogenic
source (e.g., spi-
creating central and lateral recess spinal nal cord tumour). It is
important to rule out other
stenosis. sources of axial spinal pain,
such as pathological
The osteophytes of the facet joints and the fractures or infection.
Family history and social
spondylotic osteophytes, however, may not suffi- history are relevant because
patients with depres-
ciently stabilize a diseased spinal segment; such sion, nicotine use, and
substance abuse have an
a condition leads to a dynamic, mostly foraminal increased risk for worse
outcomes. In addition,
stenosis with radicular pain or claudication-type physicians must be cautious
in the patient with
pain. a rapidly-progressing curve
because it may sug-
gest an underlying
neurological condition. Simi-
larly, on physical
examination, cafe au lait spots,
Diagnosis and Pre-Operative naevi, skin dimpling, and
hairy patches may all
Preparation for Surgery be hallmarks of an underlying
neurogenic abnor-
mality therefore
necessitating a detailed imaging
The adult scoliosis population is similar to most of the neuroaxis. If the
patient has an abnormal
spinal disorder populations in that pain is the neurological examination
(e.g., radiculopathy,
most common presentation, with reports of myelopathy), magnetic
resonance imaging
approximately 90 % of patients reporting pain should be considered to
determine any neuro-
as their primary complaint [3,8]. genic cause of the scoliosis.
524
N. Passuti et al.
Perhaps the single most important principle in apical vertebral

translation of the thoracic and
the surgical treatment of adult scoliosis is achieving lumbar curves should be
measured. Radiographic
and maintaining a proper sagittal and coronal bal- signs of degenerative
disease are categorized, and
ance such that the spine is oriented to have the listhesis (rotary and
lateral) are noted. Degenera-
cranium placed over the pelvis. Such a balanced tive segments often are
associated with stenosis
spinal posture provides for decreased energy and this must be
considered as well in the treat-
requirements with ambulation, limits pain and ment algorithm.
fatigue, improves cosmesis and patient satisfaction, One very important
parameter is to precisely
and limits complications associated with define the lumbo-pelvic
parameters and particu-
unresolved (or new) deformities. The sagittal- larly the pelvic
incidence which is normally
vertical axis is determined and defined by around 50# . The amount
of sagittal correction
a plumb line from the mid-C7 vertebral body on will be correlated to
the degree of the pelvic
a lateral x-ray in the standing position. If this line incidence which links
to the sacral slope and the
falls anterior to the ventral S1 vertebra, it is referred pelvic tilt (Figs. 1
and 2).
to as positive (+) balance and if the line falls pos- The importance of
sagittal plane deformity has
terior it is called negative (#) balance. In a patient been well documented,
particularly with reference
with a normal sagittal-balanced spine, the plumb to post-surgical flat
back syndromes and post-
line should pass 24cm posterior to the ventral S1 traumatic kyphosis.
Symptomatic deformity is
vertebra (negative 24 cm) or 1 cm posterior to the often unresponsive to
non-surgical treatment, and
L5/S1 disc space. Any spine with a positive value is surgical treatment is
complex. Several studies
thought to be out of sagittal balance [4]. have shown that
adequate restoration of sagittal
The centre sacral line is used to assess coronal plane alignment is
necessary to improve signifi-
balance. The centre sacral line is a line that cantly clinical outcome
and avoid subsequent
bisects a line passing through both iliac crests pseudarthrosis.
Positive sagittal balance has also
and ascends perpendicularly. The vertebrae been identified as the
radiographic parameter most
bisected most closely by this line are known as highly correlated with
adverse outcome measures
the stable vertebrae. in unoperated adult
spinal deformity.
The apical vertebra is the vertebra associated Despite this
reported data, sagittal balance,
with the greatest segmental angulation at both its like many radiographic
measures, is still an
rostral and caudal disc interspaces, compared inconsistent predictor
of clinical symptoms.
with all other disc interspaces in the curve. Studies in asymptomatic
volunteers have shown
In general, it is located in the mid-portion or that progressive
positive sagittal balance is asso-
apex of the curve. Conversely, the neutral verte- ciated with normal
ageing. In some instances,
bra is the vertebra associated with little or no effective compensation
mechanisms may
angulation at the rostral and caudal disc spaces develop in patients,
which generate a more
of the curve. In general, an instrumentation con- acceptable functional
sagittal balance. Although
struct should not terminate at or near an apical some of these patients
eventually decompensate,
vertebra and should extend to a neutral vertebra more sophisticated
evaluation techniques, such
to balance forces on the deformity. as gait analysis, may
be necessary to understand
Standing 36-in. x-rays (posteroanterior [PA], better the progression
of these deformities [3,7].
lateral and bending) can aid in determining the These findings
emphasize the importance of
main or major curve, which is by definition thoroughly accessing
sagittal plane alignment in
a structural curve. Typically, a Cobb angle the treatment of spinal
deformity. Although the
greater than 25# on lateral-bending x-rays defines response to non-
operative treatment has not been
a structural curve. systematically studied,
the research suggest that
Additionally, structural curves are of greater methods directed at the
improvement in standing
magnitude and less flexible than compensatory balance might be
beneficial. With surgical treat-
curves. Curve magnitude, flexibility, and the ment, maintenance or
restoration of lumbar
525
Fig. 1 Pelvic parameters
Pelvic parameters
Pelvic incidence 55 +/- 106

Sacral slope 41 +/- 84
Pelvic tilt 13 +/- 6
Lumbar lordosis 60 +/- 10
Strong correlation between:
- sacral slope and pelvic incidence
- Lumbar lordosis and sacral slope
- Pelvic incidence and pelvic tilt
- Maximum lumbar lordosis and pelvic incidence,
pelvic tilt, and
maximum thoracic kyphosis
Duval beaupre, Legaye and all, Vaz and all,

Vialle and all,
Roussouly and all
PELVIC INCIDENCE
Anatomical factor genetically determine
G. Duval Beaupre and all
I= SH + PT
Sacro-horizontal angle
Pelvic tilt
Incidence
Fig. 2 Pelvic Incidence
lordosis appears to be critical, particularly for and clinical outcome

measures such that our
patients with a positive sagittal balance before clinical experience can
lead to more effective
surgery. Most important, the literature empha- treatment paradigms for
patients with adult
sises the vital role of reproducible radiographic deformity (Fig. 3).
526
N. Passuti et al.
Sagittal Balance
C7PL B
C7
C7PL
Negative
Sagittal
Positive Balance
Sagittal
Balance
C7PL
Lateral C7 to Sacrum
(Sagittal Balance = B - A)
Line A is drawn from the posterior-superior corner of

S1 and is perpendicular to the vertical edge oft
the radiograph. its length is measured in milimeters
from the lefthand edge of the radiograph.
Line B is drawn from the center of C7 and is perpen- A
dicular to the vertical edge of the radiograph. Its
length is measured in millimeters from the lefthand
edge of the radiograph.
Neutral Balance : B=A
+X
Negative Balance : B < A
Positive Balance : B>A

0 +
Negative
Neutral Positive
Fig. 3 Vital role of reproducible radiographic and clinical outcome measures for
efficient treatment paradigms for
patients with adult deformity (From S.D. Glassman [4])
527
a double major curve in

adult scoliosis that is
Surgical Techniques progressive in nature often
requires anterior and
posterior procedures. A
long, relatively inflexible
Once surgery is decided as the optimal treatment deformity may require
anterior releases to
option, the correction of the deformity with incor- accomplish effective
reduction and fusion with
poration of proper sagittal balance should be posterior surgery. However,
with the increased
assessed because the loss of lumbar lordosis has ability to manipulate a
curve with modern instru-
been shown to be associated with poor outcomes. mentation through a
posterior approach, this may
Glassman et al. also confirmed that restoration of lessen the need for anterior
releases. The curve
proper sagittal balance is the most important fac- stiffness is related to both
patient age and curve
tor associated with a good clinical outcome. The magnitude. Flexibility
decreases by 10 % with
use of an operating table that produces extension every 10# increase and by 5
10 % with each
of the hips and maximizes lumbar lordosis (e.g., decade of life.
Jackson) is biomechanically advantageous, par- The primary structural
goal is achieving
ticularly when fusing more than one lumbar seg- a proper sagittal balance.
Reduction of the coro-
ment. The ultimate choice of surgical approach nal and rotational
deformities follows in priority,
for the treatment of lumbar adult scoliosis with the goal of
establishing coronal balance and
depends on the levels of the pain-generating seg- reduction of rib asymmetry
for enhanced
ments, the flexibility of the curve, the tilt of the cosmesis and patient
satisfaction. Shoulder bal-
distal vertebrae, and the extent of the curve. ance is particularly
concerning for patient
The aim of surgical treatment is correction and cosmesis and should be
considered in deformity
stabilization of the deformity and, therefore, an corrections.
in-situ or on-lay fusion is an option for a minority The rostral construct
should include the tho-
of patients since this will not correct the defor- racic curve and should not
stop caudal to any
mity and lessens the chance of an arthrodesis. For structural aspect of this
portion. Adult thoracic
example, it may become an option for an elderly deformity curves tend not to
be flexible enough to
patient with a small curve or deformity and poor correct significantly as
opposed to the adolescent
bone quality. Therefore, an arthrodesis and cor- patient.
rection of the deformity may be accomplished Therefore, all fixed
deformities and subluxa-
with a variety of methods, many of which require tions should be included in
the fusion. For rela-
restoration of anterior column height. A lumbar tively flexible rotational
deformities, however,
interbody fusion (transforaminal lumbar reduction can be achieved
with effective
interbody fusion or posterior lumbar interbody improvement in trunk
symmetry, which can sig-
fusion) may achieve these goals through nificantly improve patient
satisfaction. One tech-
a posterior-only approach. To further assist in nique is to use mono-axial
or uni-axial screws,
correction of the deformity, the cage may be which are placed into the
pedicles of the vertebra
biased to the concavity of the scoliosis deformity of the vertebrae that will
be manipulated at the
to address the coronal plane. convexity.
The double major curve describes After one pre-bent rod
is placed and rotated in
a scoliosis in which there are two structural the usual manner to reduce
the coronal deformity
curves which are usually of equal size. Patients at the convexity and attain
a proper sagittal rela-
with double major adult scoliosis (most often tionship, it is secured and
the contra-lateral rod is
a right thoracic curve in conjunction with a left placed. The strength of the
construct can be aug-
lumbar curve of equal magnitude) may present mented with the use of rod
cross-links since they
with axial skeletal pain. However, the typical can increase the stiffness
of long constructs.
presentation is one of progression of the defor- Additional release
manoeuvres may be necessary
mity manifested as changes in balance, ambula- in stiff curves including
thoracoplasty, concave
tion, and cosmesis. The surgical treatment of rib osteotomies, and
aggressive facetectomies.
528
N. Passuti et al.
The correction of a deformity is therefore posterior lumbar interbody

fusion (PLIF) tech-
achieved after an appropriate release either by nique using specifically-
designed cages has
step-wise correction though segmental instru- become a well-controlled
procedure [7].
mentation or by one or more segmental
osteotomies for the frontal or sagittal re-
alignment of the spine. Summary for Surgical Strategy
In case a lumbar curve is still flexible, which
can be assessed by side-bending and flexion/ The complexity of the
relationship between clin-
extension views, and a certain compensation of ical signs, symptoms and
pathophysiology of
the thoracic counter curve can be anticipated, adult scoliosis remains a big
challenge in spinal
a posterior correction, stabilization and fusion surgery. Radiographic
correction is more effec-
with or without decompression are sufficient. tive in younger adults
patients, pain improvement
This is also done when a curve is clearly is a more reliable outcome in
older patients,
progressive. although younger patients
rarely have severe
If back pain is a leading symptom, with or pain symptoms, older patients
may require exten-
without leg pain, a fusion is usually indicated. sion of the fusion to lower
segments because of
The levels to be included in the fusion can be a higher prevalence of
degenerative changes but
difficult to determine. two problems could be
encountered. First the risk
Generally speaking, it is unfavourable to stop of pseudarthrosis at level
L5-S1 and the risk of
a fusion at L1 or even L2, i.e., below the proximal junctional kyphosis
above the superior
thoracolumbar junction, because it may easily level of fixation. The
strategy may be a more
lead to decompensation above the fusion, reliable technique for
restoring sagittal balance
with localized disc degeneration, segmental which is the most significant
parameter combined
collapse, translational instability and secondary with functional outcomes but
medical complica-
kyphosis [6]. tions are a frequent
occurrence with adult defor-
The most critical segment to consider whether mity spinal surgery.
Pulmonary complications
or not to include in a fusion is the lumbosacral are among the most common
life-threatening
junction. It takes all the movement from the lum- complications that occur.
Awareness of the pre-
bar spine and is the most difficult fusion to be sentation, treatment and
prevention of medical
achieved. A high percentage may remain with complications of deformity
surgery may allow
a non-union due to the unfavourable mechanical the spine surgeon to minimize
their occurrence
conditions of this junction between the two major and optimize treatment.
lever arms of the fused spine and the rigid pelvis.
The incidence of the non-union varies quite
remarkably in the literature (530 %). Various Complications
types of instrumentation have been designed to
enhance the fusion healing to the sacrum. They The two most common
mechanisms of failure
are mostly based on an increasingly more solid are:
anchorage in the sacrum, or in the sacrum and iliac 1. Fracture or late screw
loosening of rostral
wings at the same time. None of these instrumen- instrumentation and
tations have been clinically demonstrated to sig- 2. Late progressive kyphosis
again at the rostral
nificantly overcome the problem of non-union in aspect of the construct.
This risk of progres-
the complex pathology of degenerative scoliosis. sive post-operative
kyphosis may be mini-
The most certain approach to eliminate the prob- mized by not ending the
construct within
lem of non-union is a 360# circumferential fusion a kyphotic or apical
region of the spine. In
at the lumbosacral junction. In order to avoid the addition, longer
constructs over the
anterior approach, unless needed for an extensive thoracolumbar junction or
apex of the kypho-
release, the refinement and standardization of sis are preferred to avoid
this phenomenon.
529
Fig. 4 A 56 year old

female patient presented
with a severe progressive
adult scoliosis with frontal
imbalance (6 cm right side)
and sagittal imbalance
(positive C7-plumb line +7
cm) and high pelvic
incidence PI: 65
These longer constructs therefore, should not proceeding with the second stage
because
be presumed to be overly aggressive, partic- the patient can become
malnourished if the
ularly in the osteoporotic spine. However, interval is too great. In a
study by Dick et al.,
each patient must be individually evaluated 7 of 11 staged procedure
patients and 10 of 13
and the specific construct modified to meet combined procedure patients
developed post-
the goals of the procedure. Many adult defor- operative malnutrition. However,
the only
mities are rigid and therefore require com- infections occurred in the
staged patients.
bined surgical approaches. Same-day or Therefore, the combined group
had 30 %
combined procedures may be preferable less hospital costs and a
shorter hospital
to staged procedures if they can be stay; Furthermore, all patients
reported that
performed within a reasonable time period they would prefer to have both
operations
such as less than 12 h. If staged procedures performed on the same day as
opposed to
are performed, care must be taken in staged operations [2].
530
N. Passuti et al.
Fig. 5 C7-plum line was

achieved with an excellent
clinical result at 3 years
post-operatively
Lenke et al. prospectively demonstrated that it Pseudoarthrosis is

another serious adverse
takes 612 weeks to return to baseline nutritional consequence of an
arthrodesis procedure that
status and that as the number of fusion levels may require revision surgery
if symptomatic.
increase, the time to return to nutritional baseline Weiss et al. reported a 38 %
pseudoarthrosis
increases. Therefore, if a surgical procedure rate at 37 months follow-up
that increased
needs to be staged, there should be supplemental to 64 % if the sacrum was
included in the
nutrition between the stages to reduce the risk of fusion. Others have
documented that
malnutrition-related complications. posterior instrumentation
and fusion alone to the
Infection rates depend on the approach and the sacrum carries a 1520 %
rate of pseudoarthrosis
age of the patient. Overall, infection rates in even with newer, stiffer
instrumentation
scoliosis surgery are reported at 35 %. Infection constructs.
rates after anterior surgery alone is reported to be Although major
complications can occur,
approximately 1 %. Despite a low rate of infec- fortunately, neurological
injury occurs in less
tion, a deep infection can have significant than 15 % of cases.
Significant risk factors for
sequelae and may require multiple operations to major intra-operative
neurological deficits
eradicate the infection. include hyperkyphosis and
combined surgery.
531
Neurological deficits can manifest in a delayed Good correction frontal

balance and negative
manner. In fact, delayed paraplegia has been C7-plum line was achieved
with an excellent
well-described and can occur several hours clinical result at 3 years
post-operatively
after spinal reconstruction surgery. Post- (Fig. 5).
operative hypovolemia and mechanical tension
on spinal vessels along the concavity of the
curve have been implicated as the cause of
spinal cord ischaemia which leads to delayed References
post-operative paraplegia. Therefore, it is impor-
tant to maintain adequate volume and blood pres- 1. Aebi M. The adult
scoliosis. Eur Spine J. 2005;
sure in the patients during the post-operative 14:92548.
2. Baron EM, Albert TJ.
Medical complications of surgi-
period. cal treatment of adult
spinal deformity and how to avoid
them. Spine.
2006;31(19):S10618.
3. Birknes JK, White AP,
Albert TJ, et al. Adult degener-
ative scoliosis a review.
Neurosurgery. 2008;63(3):
A94103.
Case Report 4. Glassman SD, Bridwelle K,
Dimar JR, et al. The impact
of positive sagittal
balance in adult spinal deformity.
A 56 year old female patient presented with Spine. 2005;30(18):20249.
a severe progressive adult scoliosis with frontal 5. Kim YJ, Bridwell KH, Lenke
L, et al. Sagittal thoracic
decompensation following
long adult lumbar spinal
imbalance (6 cm right side) and sagittal imbal-
instrumentation and fusion
to L5 or S1: causes, preva-
ance (positive C7-plumb line +7 cm) and high lence and risk factors
analysis. Spine. 2006;31(20):
pelvic incidence PI: 65# (Fig. 4) 235966.
There was severe lumbar pain in the standing 6. Kim YJ, Bridwelle KH, Lenke
LG, et al. Proximal
junctional kyphosis in
adult spinal deformity after seg-
position and radicular pain at the L4-L5 level on
mental posterior spinal
instrumentation and fusion.
the right side. Spine. 2008;33(30):217984.
Through a posterior approach: 7. Schwab FJ, Lafage V, Forcy
J-P, et al. Predicting out-
Instrumentation from T3 to S1 was performed. come and complications in
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Segmental screw fixation and Smith Petersen
8. Takahashi S, Delecrin J,
Passuti N. Surgical treatment
osteotomies at levels L3-L4 and L5 were of idiopathic scoliosis in
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Spondylolysis With or Without
Spondylolisthesis
Philippe Gillet
Contents
Spondylolysis With Associated Disc Disease and
Grade 4 Spondylolisthesis or
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 534
Spondyloptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 553
Lysis at the Level of the Pedicle . . . . . . . . . . . . . . . . . . . .
554
Natural History of Spondylolysis . . . . . . . . . . . . . . . . . . . 535
Dysplasic Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . .
554
Degenerative Spondylolisthesis . . . . . . . . . . . . . . . . . . . . .
554
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 536
Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 536
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 554
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 536
General Principles for Treatment . . . . . . . . . . . . . . . . . . . 538
Authors Pre-Operative Imaging Strategy . . . . . . . . . . 538
538
Patient Positioning and Approaches to the Spine . . .
538
Decompression Procedures . . . . . . . . . . . . . . . . . . . . . . . . . .
539
Stabilisation Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
540
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 551
Length of
Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
551
The Use of Interbody Fusion and Posterior
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
552
Summary: Suggested Choices . . . . . . . . . . . . . . . . . . . . .
553
Spondylolysis Without Associated Disc Disease and
Without Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . .
553
Grade 0 or 1 Spondylolisthesis . . . . . . . . . . . . . . . . . .
553
Grade 2 or 3 Spondylolisthesis . . . . . . . . . . . . . . . . . .
553
P. Gillet
Centre Hospitalier Universitaire, Lie`ge, Belgium
e-mail: philippe.gillet@chu.ulg.ac.be

533
DOI 10.1007/978-3-642-34746-7_28, # EFORT 2014
534
P. Gillet
When spondylolisthesis
is due to dysplasia of
Abstract
the lumbosacral facets or
to degenerative condi-
Spondylolysis with or without spondylolisthesis
tions the whole vertebra
including the posterior
is an often well-tolerated situation. However,
arch slips forward,
causing central canal stenosis
growing or adult patients may experience severe
in addition to foraminal
stenosis. Multiple root
back pain, referred pain or even neurological
compromise can occur and
may be severe. When
compromise that justifies surgical treatment.
a spondylolysis exists,
associated or not with
During growth, exceptionally in adult life, true
spondylolisthesis, back
pain and referred leg
instability with increase of the spondylolisthesis
pain, true sciatica or
even neurological deficit
may also require stabilisation, in situ or after
and progressive deformity
of the spine in the
reduction of the deformity. Posterior, anterior
sagittal plane may occur.
Multiple root compro-
and combined approaches intended to obtain
mise is exceptional but
foraminal entrapment
correction and fusion have been described, the
can occur. The condition
is often well tolerated
choice between available options remains diffi-
during lifetime and
surgery is needed in a very
cult. The recent literature does not necessarily
restricted number of
patients. In spondylo-
support procedures that seem more logical but
listhesis due to
spondylolysis, many patients
are more invasive than others. While the impor-
presenting with thigh or
even leg pain do not
tance of maintaining or restoring an adequate
really suffer from root
entrapment but from
sagittal profile of the lumbar spine is universally
referred pain. Even in the
case of true radicular
well-accepted, the importance of slip correction
pain, it does not imply
that a true decompression
is considered less important. This chapter
of the nerve root must
necessarily be carried out.
intends to help the surgeon dealing with differ-
Root pain can be initiated
by local inflammatory
ent situations encountered in spondylolysis and
conditions due to
excessive motion of the
spondylolisthesis patients by first exposing the
mobile segment. Fusion
without decompression
different techniques currently in use with their
can lead to disappearance
of radicular symptoms
respective advantages and disadvantages and by
as well as back pain and
muscle contracture.
considering the proper matching of the most
True entrapment of nerve
roots may exist
logical procedure theoretically required by the
in severe slips and severe
disk narrowing
anatomical situation and the functional expecta-
deforming the neural
foramen or in the case of
tions of the particular patient.
associated herniated
discs.
Keywords
Anterior interbody fusion # Diagnosis #
Aetiology and
Classification
Imaging-radiographs, C-T scanning, NMR #
Natural history # Posterolateral fusion # Reduc-
A spondylolysis is a
fatigue fracture thought to be
tion of spondylolisthesis # Spondylolisthesis:
the result of repetitive
microtrauma. In some cases,
aetiology and classification # Spondylosis #
the pars interarticularis
can fracture and heal several
Surgical indications
times, leading to an
elongated pars. Spondylolysis
usually occurs in the
youth. Male to female ratio is
about 2:1. Spondylolysis
is not accepted as a con-
Introduction genital disease, however
genetic factors can influ-
ence the occurrence of
isthmic spondylolisthesis
Spondylolisthesis is the anteroposterior displace- but in a far lesser degree
than in dysplastic types.
ment of a vertebra with regard to the lower A genetic influence is
illustrated by a different prev-
vertebrae. It can be the result of a pars alence of the disease in
different races and greater
interarticularis defect called spondylolysis, prevalence in certain
families. Repetitive stress on
degenerative disorders of the spine, dysplasia of the pars, especially in
extension, and hyperlordosis
posterior facet joints or severe trauma. favour impingement on the
affected pars by the
Spondylolysis With or Without Spondylolisthesis
535
distal aspect of the lower articular facet of the upper in a perfectly smooth
sagittal alignment. The term
vertebrae. Adolescents practising sports involving spondylolisthesis should
not be used in such cases
hyperextension are at risk with up to 47 % of paedi- since it can lead to
misinterpretation of the local
atric patients involved in comparison to a 5 % stability conditions of
the lumbosacral junction.
occurrence in the general adult population. The Such patients illustrate
the role of genetic factors
occurrence of spondylolysis is probably multi-fac- in the occurrence of
isthmic spondylolysis since the
torial. Radiological peculiarities such as dysplasia vertebral body changes
are not due to secondary
of the vertebral body show that there can be remodelling as proved by
the normal positioning
a predisposition that weakens the pars, probably of the vertebral body in
regard to adjacent vertebrae.
from genetic origin and further local repetitive The kyphotic angle
can be measured in differ-
microtrauma leads to the fracture. ent ways, e.g. between a
line drawn tangential to
A spondylolysis can lead to spondylolisthesis the posterior wall of S1
and the upper vertebral
because of mechanical failure of the posterior arch plate of L5 (slip
angle).
andtheoverloadeddiscandligaments.Spondylolysis It must be stressed
that there is no relation
with or without spondylolisthesis occurs mostly at between the importance
of a slip and the mechan-
L5, followed by L4 and rarely more proximally. ical or neurological
symptoms in spondylolitic
A degenerative spondylolisthesis is the result of cases. Kyphotic
spondylolitic spondylolisthesis is
failure of the disc and ligaments, moreover, often more symptomatic.
In degenerative cases and
it produces severe alteration of the articular dysplasic cases, when
the whole vertebra slips,
cartilage and deformation of the posterior facets neurologic compromise is
often related to the
leading to segmental hypermotion. Degenerative severity of the
stenosis.
spondylolisthesis usually occurs at the L4-L5 level.
A dysplastic spondylolisthesis is the result of
developmental malformation of the posterior Natural History of
Spondylolysis
facets, consisting of sagittal orientation of the artic-
ular processes with loss of their buttress effect or A spondylolysis can heal
without sequelae or can
hypoplasia or aplasia of the facets. This condition persist until adulthood,
with progressive pain
occurs mostly at the lumbosacral junction. presenting after decades
of asymptomatic existence.
A traumatic spondylolisthesis is the result of Late onset symptoms can
occur as the result of stress
severe lesions of the posterior arch associated imposed on the various
ligamentous structures
with disco-ligamentous injuries. because of the motion
segment instability induced
The importance of spondylolisthesis is by the pars fracture.
Potential intervertebral instabil-
described according to the Meyerding classification: ity is theoretically
greater for L4 or L3 spondylolysis
grades 1, 2, 3, 4 correspond to more or less 25 %, than for L5
spondylolysis because of the absence of
50 %, 75 % and, 100 % of anterior slip. When the anatomical links such as
the ilio-lumbar ligaments.
slipped vertebra is anterior to the sacrum and usually Most of the slips are
less than 3050 %. Progressive
tilted in kyphosis, the term spondyloptosis is used to slips are more often
associated with local anatomical
describe the condition. A certain degree of kyphotic peculiarities such as a
vertical sacrum, a dome-
tilt can occur in grades 3 and 4 spondylolisthesis and shaped sacrum, or a
trapezoidal-shaped L5 with
must ideally be corrected more than the slip itself. a short anteroposterior
diameter of the vertebral
A false L5-S1 spondylolisthesis is often described body. A local kyphosis
is more troublesome than
because of dysplasia of the L5 vertebral body: some the amount of slip.
Progressive slip is unusual in
patients show a trapezoidal-shaped vertebral body adulthood but can be the
result of degenerative disc
with a reduced anteroposterior diameter. This leads disease with disc
collapse leading to an added slight
to the description of a spondylolisthesis because the amount of
spondylolisthesis. Important slips
posterior walls of L4, L5 and S1 are not aligned. presenting in adult
patients are generally present
However, the author has often noticed in such cases since adolescence. Early
onset of pars fracture can
that the anterior borders of the vertebral bodies are increase the risk for
progressive spondylolisthesis.
536
P. Gillet
Progression of the slip usually occurs during the In degenerative

spondylolisthesis and dysplas-
growth spurt. The more the slip is important during tic spondylolisthesis,
leg weakness can be
the growth period (more than grade 2), the more observed on top of back
pain and referred pain,
the patient is at risk for further displacement until true sciatica is also
more common than with
skeletal maturity. A high slip angle is also associated spondylolytic slips.
with a risk of progression. Therefore, even in
asymptomatic patients, there may be an occasional
indication for fusion in severe spondylolisthesis. Imaging
Spondylolisthesis occurs two times more often in
males but the risk of increasing spondylolisthesis is Plain lateral, ap. and
oblique radiographs are the
four times greater in female than male patients. first step in the
evaluation of spondylolisthesis.
If not the cause of spondylolysis, trauma can Ideally, standing films
should be obtained,
increase symptoms related to the anomaly and centred on the
lumbosacral area and not the
favour increase of the slip. lumbar spine.
Spondylolysis can be missed on
From a personal experience, spondylolysis with lateral views, oblique
views centred on the
or without spondylolisthesis ultimately requiring pathological vertebra
must be obtained
surgical management is a problem of the young when the abnormality is
suspected. Even
adult. In a series of 276 patients from 1986 to 2006, with perfect quality
plain radiographs,
the mean age was 37 years with a range from 13 to spondylolysis, especially
in the early stage,
70 years; 75 % were between 20 and 50 years old. can be missed. CT scan,
using particularly
the reversed gantry
technique, can be necessary
to show the defect but is
of low interest in
Diagnosis the general set-up except
in dysplastic and
degenerative conditions.
Bone scans are helpful
Clinical Findings to make the diagnosis of
a pars defect at an
early stage.
Spondylolysis and even spondylolisthesis are Dynamic lateral views
can be helpful to
often diagnosed incidentally because they are evaluate the mobility of
the abnormal vertebra.
asymptomatic. However, the patient, either A lateral full-length
standing film is
child, adolescent or adult may present with com- recommended to judge the
global sagittal
mon or acute back pain, thigh or leg pain the alignment and balance of
the spine, especially
latter can be mechanical pain radiating to the when a severe
spondylolisthesis or lumbosacral
lower limb or true radicular pain- lumbar scolio- kyphosis is present
sis, paravertebral muscle spasm, abnormal stance The regular pre-
operative imaging set-up for
or gait. If symptoms are important, other patho- a spondylolysis with or
without spondylo-
logical conditions of the spine should be ruled listhesis requires NMR.
It will give the necessary
out since spondylolysis is often poorly information on the
presence of and on the
symptomatic. Symptoms are not proportional to indication for removal of
a intraforaminal her-
the importance of the pathological condition, niated disc, on the
possible choice between
spondylolysis without slip can be more painful a reconstruction
procedure of the pars if there
than spondylolysis with obvious spondylo- is no degenerative disc
disease at the level of the
listhesis. Moller and co-workers found that symp- spondylolysis or some
kind of intervertebral
toms were similar in adult patients with fusion if degenerative
disc disease is present,
spondylolisthesis or with chronic non-specific and finally on the
necessary length of such
low back pain probably related to degenerative a fusion to stop it
ideally at the level of an intact
conditions; however they found that the chronic disc space (Fig. 1). If
NMR gives doubtful
low back pain group reported greater functional results, a provocative
discography can be
disability [17]. performed, the procedure
does however not
537
Fig. 1 Pre-operative NMR imaging is essential to evaluate the status of the neural
foramina (a) and the discs (b)
seem innocuous [3]. NMR is the best procedure spinal canal, the
possible root impingement is
to evaluate central root compromise in far lateral, in an area
the contrast does not
degenerative and dysplastic spondylolisthesis reach. Dynamic
myelography is the sole
but lacks dynamic information as does CT dynamic procedure to
date and may be useful
scanning. in degenerative
conditions when the impor-
Myelography has been and is still used by tance of the slip can
be underestimated by the
some teams to evaluate possible root compro- supine position needed
for CT and NMR. The
mise. In spondylolytic spondylolisthesis association of NMR and
dynamic plain films
myelography is commonly normal: since the gives however the
possibility to assess the pos-
posterior arch remains in place, there is an sible neurological
compromise occurring in
increase in the anteroposterior diameter of the dynamic conditions.
538
P. Gillet
Radiological Peculiarities degenerative disc disease

and the presence of
In unilateral spondylolysis, a hypertrophy of the a true local instability.
Where some kind of
opposite pars or pedicle may occur due to by-pass stabilization procedure is
performed the possi-
of the loads through these structures. Differential bilities include pars
repair with no fusion of
diagnosis from osteoid osteoma must be made, a motion segment, different
posterior fusion pro-
especially if the patient has persistent pain. cedures and interbody
fusion by posterior or
Unilateral pars defect with opposite pedicle anterior approach. The
number of motion seg-
lysis can be observed. ments to be fused must be
estimated. The need
for decompression of the
nerve roots must be
assessed but differential
diagnosis between
Indications for Surgery referred pain and true
radicular symptoms is
sometimes difficult.
Reduction or not of an asso-
General Principles for Treatment ciated spondylolisthesis or
lumbosacral kyphosis
and the role of internal
fixation must be
Asymptomatic patients presenting with a discussed for each
individual patient.
spondylolysis and grade 02 spondylolisthesis
should not be prevented from sports activities and
strenuous work as long as such activities do not Authors Pre-Operative
Imaging
induce pain. In symptomatic patients without neu- Strategy
rological compromise, adaptation of the lifestyle,
which can mean change of work and refraining The regular imaging set-up
for spondylolysis
from sports, in association with conservative treat- with or without
spondylolisthesis will require
ment, is the cornerstone of treatment [6, 19]. Fusion plain radiographs and NMR.
procedures should only be performed in the In dysplastic cases, an
additional CT scan may
unusual cases where a great risk of increased be performed to perfectly
assess the posterior
spondylolisthesis is present, whether the patient is arch anomalies.
symptomatic or not, and in cases where conserva- In degenerative cases,
plain radiographs with
tive treatment has failed to relieve symptoms. additional dynamic lateral
views and NMR are
There is a place for surgery in patients who are performed.
relieved by adaptation of their lifestyle but who
want to regain normal work or sporting possibili-
ties. If a reasonable surgical procedure can be pro- Operative Techniques
posed, surgical treatment, although invasive, may
be considered in selected patients capable of mak- The techniques are
described for spondylolysis
ing a well- understood decision with the surgeon. cases with or without
spondylolisthesis; particu-
Decompression procedures are usually associ- larities for dysplastic and
degenerative cases will
ated with fusion, however, in a symptomatic ste- be highlighted.
nosis due to degenerative spondylolisthesis,
isolated fenestration may be contemplated if
instability is low and will not be worsened by Patient Positioning and
Approaches to
the decompression procedure. the Spine
Approaches are described in

another section of
Pre-Operative Preparation and this treatise. While the
posterior approach carries
Planning few risks, except when
penetrating the spinal
canal and performing the
reduction, the anterior
Surgical options depend on the age of the approach carries specific
risks because of the ana-
patient, the existence or not of an associated tomical structures that lie
in front of the spine.
539
Patient positioning is important according to the much lordosis can tighten

the abdominal wall and
specificity of the disease. pre-vertebral vascular
structures, making retrac-
tion of these tissues more
difficult. A neutral posi-
Patient Positioning for the Posterior tion of the spine may be
preferred. A slight
Approach Trendelenbourg positioning
is favourable to clear
The patient can be positioned on any operating the bowels from the
lumbosacral area.
table the surgeon is familiar with. However the Possible complications of
the anterior
sagittal alignment of the lumbosacral spine is approach to the lumbosacral
spine include vas-
important during a posterior approach. cular, bowel and urogenital
injury [1, 20, 26].
A decompression procedure and the access to Anterior approaches should
only be performed
the disc are easier with the patient in slight by properly trained
Orthopaedic surgeons and
kyphosis. If a posterolateral fusion is performed with the assistance of a
vascular surgeon if
without instrumentation, the sagittal alignment needed. The true frequency
of urogenital compli-
can correct itself in the post-operative brace to cations (retrograde
ejaculation and sterility)
restore lordosis. If an instrumentation is related to the anterior
approach of the lumbosa-
performed or if interbody bone blocks or cages cral junction is difficult
to evaluate; meticulous
are inserted, a permanent sagittal mal-alignment surgical technique and
avoidance of monopolar
of the lumbosacral spine may result from posi- electrocautery should keep
this risk to
tioning the patient in a flexed position. When a minimum [12, 15].
performing a procedure that fixes the spine in
a definite position, one must ascertain that the
patients sagittal profile is adequate at the end of Decompression Procedures
this procedure. Sagittal imbalance of the spine,
especially in the lumbosacral area can be badly If true neurological
compromise is present, com-
tolerated. The author uses a regular Hall frame pression usually occurs at
the level of the
with the hips slightly flexed at about 20# . This deformed foramina.
Therefore, posterior decom-
provides a slight amount of lordosis, usually not pression of the nerve roots,
when necessary, is
interfering with the decompression procedure if a more complete procedure
than the usual
the latter is necessary while offering great ease to laminectomy or fenestration
for spinal degenera-
achieve adequate lordosis by simply fixing the tive stenosis. It includes
the removal of the entire
spine in that position or by putting some com- posterior arch and all bulky
fibrocartilaginous
pression between pedicle screws or by contouring tissue present at the level
of the pars defect. It is
the rods if more lordosis is desired. Another way indeed this fibrous tissue,
in association with the
to position the patients adequately is to put them slip, if present, that
compresses the nerve roots.
in a kneeling position, taking care that the pelvis The procedure is known as
the Gill procedure.
remains free to rotate around the hip joints. This Louis has described the most
offending structure
position gives more freedom for reduction which is in fact the
proximal pars remnant, it is
manoeuvres, allowing true anterior tilt of the called the crochet
isthmique or isthmus hook,
pelvis and sacrum while pulling back the slipped this particular structure
may be responsible
vertebra. In any case abdominal pressure must be for stretching the nerve
root when
avoided to lessen epidural bleeding. a spondylolisthesis is
present. The decompres-
sion procedure must include
thorough removal
Patient Positioning for the Anterior of this structure. It is
preferable to remove it
Approach with a chisel than with
Kerrisson rongeurs since
The patient is positioned supine on the operating the latter can compress the
already compromised
table. Traction and lordosis have been advocated nerve root. Removal of all
offending tissue is
to obtain partial slip correction if needed and to necessary flush with the
inferior and internal bor-
facilitate exposure of the spine [15]. However, too der of the pedicle at the
end of the procedure.
540
P. Gillet
En bloc resection of the posterior arch is aspect of the transverse

processes or the ala of
advised to obtain a bony structure from which the sacrum are decorticated
down to bleeding
cortico-cancellous bone blocs can be trimmed cancellous bone first with a
rongeur and then
when interbody fusion is contemplated. If with a large curette; care
must be taken not to
a posterolateral onlay graft or if cages are break the transverse
processes which can be very
planned, the posterior arch may be removed thin (Fig. 2ad). The
strongest part of the trans-
piecemeal with rongeurs. verse processes where most
of the graft material
An isolated Gill procedure, without should be laid is close to
the articular processes
stabilisation, can increase the risk of progression (Fig. 2e). If an
instrumentation is performed the
and is not recommended, except in some elderly bone chips can be inserted
while the instrumen-
patients where degenerative disc space tation is already in place,
but it is strongly
remodelling has re-established some local stabil- advised to make the
decortication before putting
ity. If a herniated disk is present and is responsi- the implants, as these can
hinder adequate access
ble for root compression, it should be removed; to the bone and lead to
inadequate preparation of
an isolated discectomy in a patient presenting the fusion bed, thus
favouring non-union. It may
with an otherwise asymptomatic spondylolysis be easier however to mark
the insertion points
may be considered. for the implants before
starting the decortica-
tion. During the
decortication procedure as
well as the introduction of
pedicle screws, the
Stabilisation Procedures articular capsules of the
adjacent free motion
segment must be preserved to
lower the risk of
The various stabilisation procedures will be secondary degenerative
changes. Autologous
described here, their indications will be discussed bone graft can be harvested
from the iliac crest,
at the end of this chapter. which is the gold
standard, either by a separate
incision or through the mid-
line approach. If
Posterolateral Fusion With and Without a Gill procedure is
performed, sufficient bone
Instrumentation chips can often be trimmed
from the posterior
Posterolateral fusion is a common fusion proce- arch to perform a one level
fusion. Bank bone or
dure in the lumbosacral area, bone graft is packed bone substitutes can be used
as an adjunct to
against the lateral aspect of the articular pro- autologous bone.
cesses, the posterior aspect of the transverse pro-
cesses and the sacral ala. In spondylolysis and In Situ Posterolateral
Fusion
spondylolisthesis, it can be performed either in In situ posterolateral
fusion, i.e. without any
situ or after reduction of the slip. attempt to improve the
sagittal alignment of the
lumbosacral junction, has
been described as
General Principles for Posterolateral Fusion a functionally successful
treatment even in high
The posterior aspect of the spine is exposed grade spondylolisthesis in
adolescents and even
through a standard mid-line approach and when mild nerve root
irritation was present
subperiosteal muscle stripping. The exposure [11, 13, 21]. In situ fusion
can be associated
must extend to the tips of the transverse pro- with posterior
decompression. In the case of
cesses and to the ala of the sacrum. The small a narrow degenerative disc
space, in situ postero-
arterial branches close to the pars interarticularis lateral fusion can lead to
secondary spontaneous
are regularly sacrificed. The mid-line approach fusion of the disc space
(Fig. 3).
enables the surgeon to perform a decompression
procedure if needed. If no decompression is After-Treatment and Role of
the Instrumentation
contemplated, the Wiltse paraspinal approach The use of a solid rod-screw
type instrumenta-
is an option. The lateral extra-articular aspect tion spares the need for
post-operative bracing
of the articular processes and the posterior in the authors experience.
When no
541
a b c
d e
Fig. 2 Posterolateral L5-S1 fusion: the bone graft must decortication has
been performed, pre-positioning the
be placed in a carefully decorticated area, using rongeurs, screws can hinder
adequate fit of the bone graft; the
curettes and bone chisels (ad). Pedicle screws must only direction of pedicle
screws must follow the natural orien-
be placed after proper bone grafting or at least tation of the
pedicles (e)
a b
Fig. 3 Grade 2 spondylolisthesis in an adult patient. posterolateral L5-S1

fusion was performed associated
Severe back and buttock pain, no radicular pain though with a Gill
procedure. Radiographs at 1 month (a) and
severe remodelling of the neural foramen. In the absence 2 years post-
operative: (b) spontaneous fusion of the disc
of no true instability at the L5-S1 level an in situ space
instrumentation is used, permanent rigid brac- encouraged to walk

frequently but no specific
ing, preferably including one thigh is rehabilitation is
performed, it is even discour-
recommended for 3 months. In any case, during aged. Return to light
work is allowed after 612
the first 3 months after a posterolateral fusion, weeks, strenuous work
is discouraged before
bending of the trunk is prohibited. Patients are 46 months [18].
542
P. Gillet
Posterolateral Fusion with Reduction The spine is exposed through a

standard posterior
of the Spondylolisthesis approach. The posterior arch
is removed -en bloc
Reduction may be desirable if the slip is signifi- to provide bone graft- as well
as the fibrous tissue
cant and especially if lumbosacral kyphosis is and all other potentially
offending structures at the
present. Techniques of reduction are described level of the pars
interarticularis and the neural
further in this chapter. Posterolateral fusion is foramen. The nerve roots must
be free of any
performed after reduction in the same way as compression. The disc is
excised completely, the
described above. dural sac being retracted
alternatively to the
left and right (Fig. 4ad).
Adequate decortication
After-Treatment and Role of the Instrumentation of the end-plates is carried
out with rongeurs,
After reduction of the spondylolisthesis, the curettes, side cutting
spreaders in 1 or 2 mm incre-
mechanical stress on the healing postero-lateral ment sizes and rarely bone
chisels in the case of
bone graft and the posterior instrumentation is dense cortical bone (Fig. 4e).
Deep penetration
much greater than with in situ fusion, this can down to cancellous bone must
be avoided because
augment the risk for non-union and lead to loss it can lead to sinking of the
bone grafts in the
of correction. Post-operative immobilisation vertebra; subchondral end-
plates should be
should be more rigorous. A semi-rigid or rigid respected while some bleeding
of the end-plates
brace may be considered; it has been the must be obtained to ensure an
ideal bed for the
authors practice not to use bracing with the graft. Distraction between the
end-plates must be
strong rod-screw instrumentations but to ensure maintained during the
insertion of the grafts. This
strict respect for lumbosacral bolting by the can be obtained by using the
side-cutting
trunk musculature during the first 3 months. intradiscal spreaders actually
offered by most
Return to work follows the same rules as instrumentations. Distraction
can also be obtained
with in situ fusion. Though correction and maintained by pedicle
screws and rods or
of the spondylolisthesis associated with pos- plates. Since the distraction
obtained with the pos-
terolateral fusion is a classic procedure, terior instrumentation can
lead to segmental
the author favours interbody fusion when kyphosis, even with strong
pedicle screws and
correction of the slip is performed to avoid rods, because the distraction
force predominates
excessive stress on the posterior graft and at the posterior aspect of the
spine (Fig. 5d), the
instrumentation. author does recommend the use
of incrementally-
sized intradiscal speaders to
obtain most of the
Interbody Fusion distraction. The size of the
last spreaders is
Posterolateral fusions are submitted to tension slightly superior to the
height of the future
and bending stresses, reduction creates a new bone grafts, the distraction
is then only
unstable condition until bone healing. Interbody maintained by the posterior
instrumentation
fusions are more logical from a biomechanical (Fig. 5ac) and the
corticocancellous bone
point of view. They are submitted to blocs, or the cages filled
with bone graft are
a compression stress favourable to stability and alternatively placed at the
left and right sides
fusion but some shear stress persist if the lumbo- after the intradiscal speaders
have been removed
sacral junction is very oblique. Compared to pos- (Fig. 4f). Before placing the
grafts, it is advised
terolateral fusion, the increased bony surface and to take advantage of the
distraction to improve if
superior vascularity of the interbody space pro- necessary the removal of all
potential neurolog-
vides a potentially superior biological environ- ically offending structures,
especially in the
ment for fusion [8, 14, 22, 25]. foraminal area. When the bone
grafts or cages
have been placed in the
intervertebral space, the
Posterior Lumbar Interbody Fusion (PLIF) locking nuts of the proximal
of distal pedicle
PLIF offers the opportunity to perform the whole screws are released and
compression is applied;
surgical procedure through one single approach. finally all the locking nuts
are tightened again.
543
a b
c
d e
f g
Fig. 4 Basic principles to perform posterior lumbar epidural veins

are difficult to control (c). The disc is
interbody fusion. The level of the disc spaces with regard removed and the
end-plates are decorticated using specific
to the posterior arch is showed (a). After removal of the instruments (d,
e). Corticocancellous bone blocks from the
posterior arch, the nerve roots are thoroughly decompressed iliac crest (g),
from the posterior arch (h) or cages filled with
and the disc exposed (b), bi-polar electrocautery is used to autologous bone
(i) are placed in the disc space; at least
perform haemostasis at the level of the disc space; at the three bone
blocks are put in place or two cages and one bone
level of the vertebral body, especially at the area of the slip, block in between
(f)
This locks the grafts or cages in place and revascularistion

and healing at mid-height of
improves the lumbosacral lordosis (Fig. 5e, f). the graft and to
a locked non-union.
Adequate bending of the rods in the sagittal
plane is mandatory. Corticocancellous bone Drawbacks and
Possible Complications
grafts can be obtained from the posterior iliac The anterior
longitudinal ligament and anterior
crest or the removed posterior arch if the latter is border of the
disc should be respected to avoid
large (Fig. 4g, h); cages filled with autologous great vessel
injury [9, 19]. The dural sac and the
bone graft are an option to diminish the removal nerve roots are
at permanent risk throughout the
from the donor sites (Fig. 4i). When using cages, procedure. The
use of adequate retractors and
it is recommended to pack bone also between the cautious
manipulation of the nerve roots while
cages to augment the local bone stock and performing the
discectomy and inserting the bone
favour solid fusion (Fig. 4f). About a 1 cm grafts or cages
is mandatory to limit the risk for
height for the bone grafts seems necessary to dural leaks. To
facilitate haemostasis of the epi-
avoid crushing and failure. When using cages, dural plexus, it
is advised to stay at the level of the
a greater height may lead to inadequate disc space since
profuse bleeding usually occurs
544
P. Gillet
a b
c
d e
f
Fig. 5 Method to obtain distraction and perform With the spreaders

and posterior instrumentation, the
interbody fusion by posterior approach. Using intradiscal desired
intervertebral space and reduction is obtained
spreaders, the disc space is restored, this also leads to (c). After removal
of the intradiscal instruments, the disc
partial reduction of the slip when present by tightening height is maintained
by the posterior instrumentation (d),
of the residual soft tissues surrounding the adjacent verte- the bone grafts or
cages are placed, compression is finally
brae (a, b), distraction using pedicle screws can also open put on the pedicle
screws to lock the grafts and improve
the disc space but carry the risk of inducing kyphosis (d). the lumbosacral
lordosis (e, f)
from veins at the level of the vertebral body compromised by bad

bone quality. With the
(Fig. 4c). If bi-polar coagulation is insufficient, exception of
walking, exercises are however not
compression by gelfoam# or surgicel# is recommended during
the healing process of the
recommended. Controlled hypotension is a pre- graft for
approximately 3 months. Return to phys-
requisite to perform this procedure safely. Ade- ical work is allowed
36 months after surgery,
quate decortication of the vertebral end-plates is according to the
radiological appearances and the
difficult because the view is limited by the dural type of work and
earlier in sedentary occupations.
sac and any bleeding. Specific instruments such If PLIF is performed
without posterior instrumen-
as lateral cutting shapers and broaches like those tation, caution must
be observed in mobilisation
designed for the placement of cages help to per- and rigid bracing is
mandatory for 3 months. This
form the procedure safely, even if only procedure is not
recommended by the author.
corticocancellous bone blocks are used.
Anterior Lumbar
Interbody Fusion (ALIF)
After-Treatment Anterior interbody
fusion can be performed by
In the authors experience, thanks to the stability transperitoneal or
retroperitoneal approach. The
of interbody bone grafts in combination with pos- disk space can be
exposed with greater facility
terior instrumentation in compression, patients are than through the
spinal canal, allowing the place-
allowed to ambulate immediately, according to ment of multiple
corticocancellous bone grafts
post-operative pain, without a brace except if after discectomy and
decortication of the end-
bone purchase of the pedicle screws is plates with
rongeurs, curettes and bone chisels.
545
A technique using a fibular peg from the the operated mobile

segment. The anterior approach
anterosuperior border of L5 down to the S1 ver- is used to perform the
interbody bone fusion, some-
tebral body through the disc space has been times also the reduction
with specific reduction
described [15]. instruments [20]. All
these combined procedures
can be performed in one
operative setting or as
Drawbacks and Possible Complications staged operations,
depending on the severity of the
Isolated anterior interbody fusion plays a small case, the surgical team
and the general health status
role in the surgery for spondylolisthesis. It gener- of the patient.
ally does not allow a safe reduction of the slip if no The author often uses
the combined approach
preliminary decompression of the nerve roots has in one operative setting
in degenerative
been performed. If a nerve root entrapment is spondylolisthesis when
instability is significant.
present, an isolated anterior interbody fusion may After completion of the
posterior L4-L5 decom-
not be able to obtain decompression. However, if pression and
instrumentation, the patient is
the entrapment is only present at the level of the placed in right side
decubitus and a small
foramina, the restoration of the normal disc height minimal invasive approach
is performed
by the interbody graft may theoretically suffice to anterolaterally by muscle
splitting and retroperi-
decompress the nerve root without a complemen- toneal approach to put an
interbody bone graft or
tary posterior approach, but the risk of mobilising cage in the disc space.
Other authors favour
more disc in the foramen with increased root com- a TLIF procedure in such
cases which has the
pression is present during reduction of the slip. theoretical advantage of
keeping the patient in
Immediate intervertebral stabilisation is not a prone position. The
combined approach is
obtained because of the vessels that almost pre- somewhat longer due to the
two consecutive posi-
cludes strong anterior internal fixation at the lum- tionings of the patient
but it gives a better view of
bosacral level which carries the risk of bone graft the disc and favours a
thorough debridment.
mobilisation. Anterior in situ fusion may be con- Moreover, fluoroscopy is
kept to a minimum.
sidered when the lumbosacral junction remains
well balanced and no decompression or reduction Drawbacks and Possible
Complications
is desired. Complications due to the anterior The potential
insufficiencies of an isolated poste-
approach have been described earlier. rior or anterior approach
may be compensated for
by the combination with
other procedures. How-
After-Treatment ever, the possible
complications linked to the spe-
Rigid bracing and avoidance of physical exercise cific techniques described
earlier are cumulative.
during the healing period of an isolated anterior
intervertebral fusion is mandatory. After-Treatment
The immediate stability
obtained with these tech-
Combined Anterior and Posterior Fusion niques is usually
excellent, the same post-operative
These procedures combine the techniques rules as for instrumented
PLIF are recommended.
described above. Several authors [6, 11, 20, 26]
have reported on combined or staged anterior and Techniques of Reduction of
the
posterior approaches for spondylolysis with Spondylolisthesis
spondylolisthesis, usually for severe slips. The aim It seems logical that
anatomical and biomechan-
of this two or three-stage surgery is generally to ical restoration of the
lumbosacral sagittal bal-
obtain correction of the slip while improving the ance should lead to better
long-term results as far
chances for solid fusion. The posterior approach as back and thigh pain are
concerned and that it
permits adequate decompression of the nerve roots should lessen the risk for
a junctional-segment
before any attempt at reduction, and a posterolateral syndrome. Correction of
the slip puts the postero-
fusion and pedicle screw instrumentation can help to lateral bone grafts in
better mechanical condi-
obtain the reduction and promotes early stability of tions to ensure solid
fusion. Restoration of
546
P. Gillet
normal or close to normal anatomical relation- questionable if there remains

an adequate lum-
ships also favours radicular decompression by bosacral lordosis. If
reduction is desired, it is
opening the neural foramina. Lordosis is the easily obtained by putting
pedicle screws in L5
aim, and correction of the kyphotic deformity, if and S1, fixing rods to the S1
screws and bringing
present, is more important than the slip. the L5 pedicle screws and the
L5 vertebra back-
Reduction of the spondylolisthesis may be ward against the rods with
the help of levers, rod
obtained pre-operatively or post-operatively pushers and rod introducers
from the ancillary
using traction tables, halo-pelvic or halo-femoral instrumentation. Partial re-
alignement is often
traction. These procedures have the advantage of already obtained by the use
of intra-discal
offering close neurological monitoring but are spreaders: the spreaders not
only restore the
uncomfortable for the patient [5]. Correction of height of the disc space.
Thanks to the remaining
the deformity is generally obtained intra- ligamentous structures and
lateral and anterior
operatively using some kind of instrumentation. parts of the annulus, there
is a combined back-
The instrumentation has two aims: to obtain the wards movement of the upper
vertebra while the
desired reduction and to provide post-operative disc space is distracted
(Fig. 5ab). Pulling the
immobilization. In severe instability supplemen- screws back against the rods
or plates while
tary post-operative bracing must be considered. pushing the sacrum under L5
to induce lordosis
All techniques using distraction only favour loss finalizes the reduction (Fig.
5c). The L5 rod
of lumbosacral lordosis and must be abandoned. screw fixations are tightened
and a interbody or
Pedicle screw fixation with plates or rods can be posterolateral bone fusion is
performed. An
used to obtain and maintain correction while keep- interbody fusion is advised
to minimise the risk
ing the length of fusion to a minimum [2, 18]. of deformity recurrence if
slip reduction
A pre-requisite to obtain and maintain reduc- has been obtained, even if a
strong posterior
tion is a firm fixation in the sacrum as well as in instrumentation is used in
combination with
the slipped vertebra. Pedicle screws are the safest posterolateral fusion.
and strongest fixators. To improve the sacral fix- In severe slips, the
correction is more difficult
ation, another pair of pedicle screws can be put in to obtain. In any case, a
thorough decompression
the S2 pedicles, in the sacral ala and even in the of the nerve roots must be
obtained before any
iliac crest using special connectors. The different attempt of reduction. The
disc space must be
sacral fixation options are too numerous to be recognised, if necessary with
the help of an
completely described in this chapter. image intensifier. Resection
of the dome of the
The sacrum is considered as the reference sacrum may be necessary to
enter the disc space
vertebra with regard to which the slipped vertebra and perform the resection of
the residual disc tis-
must be reduced. The sacrum can be vertical in sue. A spatula or the disc
spreaders may be intro-
association with lumbosacral kyphosis in severe duced in the disc space and
used as a lever to
slips. Reduction of the slip must not re-align the disengage the slipped
vertebra from its position
posterior aspects of the vertebral bodies but (Fig. 5a). While doing this,
some kind of the ancil-
above all correct the lumbosacral angle by tilting lary instruments such as rod
introducers are used to
the sacrum forward and downwards under the try to pull the slipped
vertebra backwards while
lumbar vertebra while the latter is pulled back- tilting the sacrum forwards
thanks to the screws
wards and in lordosis. Beforehand, a slight dis- and rods fixed to the
vertebrae (Figs. 5c, 6).
traction may be necessary to de-co-apt the The correction may be stopped
when an adequate
adjacent vertebrae and give the mobile segment lordosis of the lumbosacral
area has been obtained.
the necessary freedom before correcting the slip Complete reduction of the
slip is not the aim and
and the kyphosis. Resection of the dome of the produces a greater risk of
root tethering than angu-
sacrum is sometimes required. lar correction.
Posterolateral fusion, PLIF or ALIF
In low grade, i.e. grade 1 or 2 spondylo- is performed after the
instrumentation has been
listhesis, the usefulness of reduction is tightened in place. If there
is a contact between
547
a b
c
d e
f
Fig. 6 Reduction of severe slips. A thorough posterior such as rod

introducers, trying to pull and tilt L5 and S1
decompression is performed, pedicle screws are fixed in in relationship to
each other (c, d), the arrows show the
the sacrum and the slipped vertebra. The disc space is resulting correcting
forces that should be obtained. When
recognized with the help of an image intensifier and after correction of the
slip is satisfactory, sagittal profile can be
resection of the dome of the sacrum if necessary (a, b). further increased by
compression between the body of the
After removal of the disc, a lever is introduced in the disc screws, if adequate
anterior bone support is present (e, f).
space to de-coapt the adjacent vertebrae and induce cor- The use of polyaxial
screws at the lumbar level is neces-
rection of the lumbosacral deformity in combination with sary to obtain
adequate fit and secure tightening between
the posterior instrumentation and ancillary instruments the screws and the
rods
the decorticated adjacent end-plates after the When the desired

reduction is obtained there
reduction while there is no root compromise, can still be an
great angulation between the
a posterolateral fusion may be sufficient but if screws and the rods
making it impossible to
there is an anterior gap, it should be filled with assure solid
tightening using the locking nuts.
an interbody fusion to avoid late recurrence of The use of polyaxial
screws may help since the
the deformity. body of the screw
may move to maintain ade-
Because of the angular deformity, the use of quate alignment with
the rods during the whole
regular monoaxial screws can be difficult phase of the
correction. In the beginning, there
because there will be a great sagittal angulation will be a flexion
tilt between the core of the screw
between the L5 screws and the rods fixed to the and the body of the
screw, while the reduction
S1 screws before reduction is attempted. improves, this angle
will lessen (Fig. 6bd),
548
P. Gillet
a b
c d
e
Fig. 7 Posterior lumbar interbody fusion with reduction pain, after return to
full work (ad). Slight residual slip
in a patient with grade 2 L5-S1 spondylolisthesis in slight remains but there is
adequate sagittal profile
kyphosis, suffering from associated back and radicular
finally compression between the body of the instrumentation he

intends to use because its
screws to improve lordosis may even reverse reliability can be
highly manufacturer-related.
the angle between the core and the body of the When polyaxial screws
are not really needed,
screw while maintaining adequate fit between the use of monoaxial
screws remains
the body of the screw and the rod (Fig. 6e, f). recommended. When
anterior interbody fusion
However, one must be aware that by using the is needed, it can be
performed either by an ante-
mobility of polyaxial screws, there can be a risk rior approach or by a
posterior approach using
of secondary loss of lordosis if there is no ade- the specific
instruments described in the para-
quate anterior support or if the tightening of the graph on posterior
interbody fusion (Fig. 7).
screws against the rod is not perfect. Final com- In some cases, a
supplementary L4 fixation
pression between the screws should be can be useful to
obtain reduction [23]. If the
performed after the interbody grafts or cages L4-L5 disc is intact,
the rod may be cut between
have been put in place, using the procedure L4 and L5 and the L4
screws removed after
with the spreaders in combination with the pos- L5-S1 fixation to
regain the mobility of the
terior instrumentation described above. The sur- L4-L5 segment. It may
happen that the L5 pedi-
geon is encouraged to critically evaluate the cles are weak and in
this case, temporary fixation
549
without fusion to L4 can prevent screw pull-out at The L5 vertebral body is

excised with the two
L5. The L4 fixation may be removed 6 months adjacent disks and the
lower L4 cartilage end-
later. If the L4-L5 disc space remains very plate is removed
maintaining the subchondral
oblique or if L5-S1 sagittal alignment is unsatis- bony end-plate. No attempt
is made at that stage
factory after L5-S1 fixation only, lengthening the to reduce the deformation.
The second, posterior
fusion and instrumentation up to L4 may improve stage consists in the
removal of the L5 posterior
the global lumbar lordosis by adequately arch, the positioning of
pedicle screws in L4 and
contouring the rods and compressing the poste- S1 and the progressive
reduction of L4 on the
rior L4-L5 elements. A L4-S1 fusion may be sacral plateau which has
been decorticated. Bone
preferable to a shorter L5-S1 fusion if the result fragments obtained from the
removed vertebral
is a better sagittal spine balance. body are used to perform
supplementary postero-
lateral fusion and to
improve bone contact between
Drawbacks and Possible Complications the end-plates if
necessary. Gaines observed no
In severe slips, there can be a shortening of the L5 serious permanent root
damage with this method
roots and these may be stretched during the but other authors reported
complications [9].
reduction procedure, either closed or open, lead-
ing to severe deficit. Partial reduction of the Drawbacks and Possible
Complications
deformity is often the safest procedure. Correc- The risks for complications
are those of all com-
tion of the kyphosis, when present, is more bined procedures, with the
increased difficulty to
important than reducing the translational slip. recognise anatomical
elements such as the ves-
One must be aware that when the reduction of sels and nerve roots due to
the severe deformation
a spondylolisthesis is obtained, this creates a new of the lumbosacral area.
temporary unstable situation that is generally even
worse than the one before the surgical procedure. After-Treatment
The posterior instrumentation is submitted to A 46 weeks bed rest in a
crutch-type brace with
a tremendous stress before bone fusion occurs. leg extension is advised
before the patient starts
This carries the risk of slip recurrence depending walking. Surgical
inspection of the fusion mass
of the type of bone graft, the strength of the inter- and implant removal are
usually performed at
nal fixation and the post-operative behaviour of 46 months.
the patient. Reduction by posterior instrumenta-
tion and posterolateral fusion only is at risk for Pars Defect Reconstruction
Procedures
secondary loss of correction because of the lack of A spondylolysis can induce
pain even without asso-
an anterior weight-bearing bone graft. In situ ciated degenerative disc
disease, the hypermobility
fusion, even for high slips must be considered as of the loose posterior arch
stimulates the defect
a viable option [11, 13]. tissue which seems rich in
nocioceptive nerve end-
ings and the relative
instability of the vertebral body
L5 Vertebrectomy and L4-S1 Fusion in High induces excessive stress to
the underlying
Grade Slips disc. Removal of the soft
tissue and bone grafting
Gaines has advocated a combined approach with of the defect to restore
the stabilising role of the
removal of the L5 vertebral body and posterior posterior arch seems a
logical form of treatment in
arch and L4-S1 fusion in spondyloptosis [9]. this small group of
patients, the theoretical advan-
The first stage is performed by an anterior retro- tage being the avoidance of
any sacrifice of
peritoneal approach using a transverse skin and a motion segment. The
procedure can be described
rectus abdominis muscle incision. Great care as isthmic reconstruction
or direct repair of the
must be taken to control the vascular structures pars interarticularis. Most
procedures include some
including exiting epidural veins at the level of the sort of internal fixation
in order to improve the
L4-L5 and L5-S1 foramina. The L5 pedicles define fusion rate and favour more
rapid return to active
the posterior border of the anterior stage resection. life without external
support: a screw across the
550
P. Gillet
pars, techniques using the passage of wires under screws are placed with
their grooves oriented
the laminae and transverse processes, special 3045# to the
longitudinal axis of the patient.
screw-hook constructs or special plates. We Finally, the blocking
elements are firmly tightened
described a technique using a V-shaped rod and against the rod to fixed
to the pedicle screws. Care is
pedicle screws, associated with direct bone grafting taken to avoid any
impingement between the rod
of the pars defect using a rod-screw instrumentation and the superior aspect
of the S1 spinous process
[10]. The optimal indication for pars defect recon- during extension of the
spine (Fig. 8).
struction is isolated spondylolysis, pars reconstruc- The same technique
may be used at the L4 level.
tion is not recommended if underlying disc
degenerative disease is present. The following After-Treatment
three methods have been used by the author. Patients are allowed to
sit and walk 1 or 2 days after
surgery and are usually
discharged at day 4. No
V-Rod and Pedicle Screw Technique brace is recommended.
Return to work is allowed
By a posterior mid-line approach, the lumbosacral between 6 and 12 weeks,
sports after 3 months.
junction is exposed from the L4 to S1 spinous pro-
cesses and laterally to the tips of the L5 transverse Limitations of the
Technique
processes. To avoid stress being put on the isthmus The presence of a spina
bifida precludes the use
of L5 by the overlying inferior L4 facets which of this technique.
could possibly lead to recurrence of the
spondylolysis, [16], two or 3 mm of the distal aspect Morscher Hook-Type
Techniques
of these facets are removed with an osteotome, The spine is exposed and
the pars defect is dis-
taking care to remove as little capsular structure as sected as with the
previous technique. After iliac
possible. The soft tissue situated in the pars defect is bone blocks have been
put in the defect, pedicle
removed with rongeurs. If the pre-operative MRI screws are fixed and the
hooks are slid onto the
has shown the absence of any root impingement, rods and tightened
against the inferior aspect of
which is usually the case, a very thin layer of soft the laminae (Fig. 9).
tissue is preserved at the bottom of the defect to
avoid migration of the bone graft in the foramen. After-Treatment
The sides of the defect, the upper half of the laminae The original Morscher
instrumentation is somewhat
and the lateral, extra-articular aspect of the upper delicate and a brace is
recommended for about 34
zygapophyseal joint are exposed down to bleeding months. Stronger
implants from most universal rod-
bone. Lumbar screws, about 35 mm. in length and screw-hook
instrumentations may be used; the use
5 mm. in diameter, are inserted in the L5 pedicles, of post-operative
bracing is then optional [4].
avoiding violation of the L4-L5 joint. Iliac bone
graft is harvested and trimmed to be placed in the Limitations of the
Technique
defect and on the posterior aspect of the laminae and The presence of a spina
bifida precludes the use
lateral aspect of the zygapophyseal processes. A rod, of this technique.
usually 810 cm. in length, is bent in a V-shape and
inserted under the L5 spinous process, after the L5- Butterfly-Plate Type
Technique
S1 interspinous ligament has been removed. The rod The techniques described
above carry the theo-
is firmly fixed against the spinous process and the retical risk of
shortening the posterior arch and
laminae, offering the possibility of compressing the creating mal-alignment
of the L5-S1 articular
graft in the defect and to stabilise the posterior arch. facets. Louis
recommended bone grafting of the
A slight bending is made in the sagittal plane if pars defect followed by
temporary fixation of the
necessary to achieve proper fit against the posterior L5-S1 segment with a
butterfly plate. This tech-
arch of the vertebra and the grooves of the open nique can be used in the
case of associated spina
pedicle screws; postero-anterior compression on bifida occulta and the
mid-line defect is also
the L5-S1 joints must be avoided. The pedicle grafted. Since the
butterfly plate is not any more
551
Fig. 8 Pars reconstruction with the V-rod technique immobilisation of the

isthmic bone graft. Supplemen-
which can be performed with any universal rod- screw tary graft may be put on the
lateral aspect of the facet
instrumentation. Mono-axial screws must be used and down to the lamina. Care
must be taken not to injure
adequate bending of the rod must be performed to the nerve root in the
foramen when fitting the bone
obtain close fit on the posterior arch and graft in the decorticated
defect
available, a temporary fixation of the L5-S1 seg- Indisputable data remain

scarce; a recent study
ment may be performed with any instrumentation however showed that surgical
treatment can
but taking care to stabilise the loose posterior improve pain status and
allow for a more active
arch, for instance, with supplementary wires [16]. lifestyle [19]. The role of
instrumentation still
remains a matter for debate,
at least in posterolat-
After-Treatment eral fusions [18]. On
theoretical grounds its useful-
A light brace is recommended for 3 months. ness seems undisputable in
severe unstable
Secondary removal of the instrumentation is conditions, it also favours
more comfortable post-
required, usually at 6 months, which is not an operative conditions through
the avoidance of cum-
obligation with the other techniques. bersome braces.
Discussion Length of Fusion
The usefulness and indication for surgical The length of the fusion is
important to consider
stabilisation in spondylolysis and spondylolisthesis with regard to the
activities the patient contem-
have been questioned by many authors. plates after the operation.
It is reasonable to
552
P. Gillet
Fig. 9 Unilateral spondylolysis at L5 treated with a Morscher hook-type

instrumentation using a custom made device
constructed with a universal posterior instrumentation
assume that the longer the fusion, the more the respective role of
spondylolysis, spondylo-
residual free motion segments are at risk for junc- listhesis and
degenerative disc disease,
tional segment disease, a problem well- discograms of the
different motion segments
recognized in degenerative spine fusions [7]. can be of help, not so
much by the radiological
Work and sport expectations of the patient must image but more by the
accompanying provoca-
be considered to see if the length of fusion which tive pain test. In
carefully selected cases and with
appears necessary is compatible with such expec- a good understanding by
the patient of
tations. If the fusion involves only one motion a potentially less than
optimal result, compro-
segment (the lumbosacral or a floating lumbar mise reconstruction
procedures or short fusions
segment), all types of work or sports may be may be considered, as
they may represent a more
allowed, as with a reconstruction procedure. satisfactory surgical
option than a fusion involv-
A fusion length that does not exceed two levels ing a great number of
lumbar motion segments.
is considered an acceptable procedure in most
cases. However, strenuous work or sport should
be discouraged. If more than two motion seg- The Use of Interbody
Fusion
ments are involved with degenerative changes, and Posterior
Instrumentation
decision- making becomes very difficult. Surgi-
cal treatment would not be advised except if Posterior or anterior
interbody fusion is
unbearable pain is present and indisputably recommended if anterior
bone support is
linked to the abnormalities. To evaluate the required: in heavy
patients, when strenuous
553
physical activity is anticipated, with normal or Spondylolysis With Associated

Disc
near-normal disc height, and after reduction of Disease and Grade 0 or 1
a spondylolisthesis since this creates an even Spondylolisthesis
greater, though temporary, unstable situation
than pre-operatively. A posterolateral in situ
fusion with or without
Uninstrumented PLIF has been proposed posterior instrumentation is
the classical proce-
but most authors have combined pedicle fixation dure; reduction of a grade 1
slip is optional. If
and rods or plates with interbody fusion root entrapment is present,
resection of the pos-
[8, 22, 25]. It is logical to perform posterior terior arch should be
performed and, if needed,
instrumentation in combination with posterior removal of a herniated disc.
interbody fusion because facet joints must be In heavy patients, if
strenuous work is antici-
largely resected to avoid root injury during pated, if disc material has
been removed or if the
the introduction of the bone blocks or cages; disc space is high, a PLIF
with posterior instru-
this leads to marked weakening of the posterior mentation is a recommended
option.
supportive structures. Since the posterior longi-
tudinal ligament and the disc are also largely
excised, the motion segment becomes highly Spondylolysis With Associated
Disc
unstable, and there is a real risk of secondary Disease and Grade 2 or 3
mobilisation of the grafts into the neural canal if Spondylolisthesis
the operated segment is not kept perfectly
immobile until biological fusion is obtained. A PLIF with partial or total
reduction of the slip
However the usefulness of internal fixation asso- and restoration of an
adequate lumbosacral lor-
ciated with interbody fusion to improve fusion dosis combined with posterior
instrumentation is
rate and clinical results remains a matter for recommended. If the disc
space is very narrow, if
debate because few comparative studies have there is no significant loss
of lumbosacral lordosis
been reported. Though some authors have and if no neurological
symptoms are present,
shown improved results using instrumentation, a posterolateral in situ
fusion with posterior
its use is mostly justified on theoretical grounds. instrumentation would be an
option, especially
in grade 2 slips.
Summary: Suggested Choices

Spondylolysis With Associated
Disc
Spondylolysis Without Associated Disc Disease and Grade 4
Spondylolisthesis
Disease and Without Spondylolisthesis or Spondyloptosis
A pars defect reconstruction is advised whenever A posterior reduction with a
PLIF, or a combined
possible to avoid loss of mobile segments and anterior and posterior
approach with ALIF, pos-
increased stress on adjacent structures. On occa- terolateral fusion and
posterior instrumentation
sions, when a L5 spondylolysis was present with should be considered,
remembering that correction
an intact L5-S1 disc but with degenerative disc of the lumbosacral kyphosis
is more important than
changes at L4-L5, isthmic reconstruction of L5 correction of the slip. If
true spondyloptosis is
has been attempted to avoid L4-S1 fusion, hoping present, the Gaines procedure
may be an option.
that in such cases, the L5 spondylolysis was the However, it must be stressed
that in situ L4-L5-S1
main cause of back pain. Results were satisfac- posterior fusion remains a
neurologically safe and
tory but inferior to those in the isolated valid option. It is
recommended to obtain an ade-
spondylolysis cases. Such a therapeutic option quate lordotic angle between
the first upper free
should be considered with caution and only in mobile segment and the sacrum
at the end of the
carefully selected cases. procedure to avoid junctional
breakdown.
554
P. Gillet
Lysis at the Level of the Pedicle lumbar disc: a

ten year matched cohort study. Spine.
2009;34:2338
45.
4. Debusscher F,
Troussel S. Direct repair of defects in
If a unilateral pedicle lysis associated with con- lumbar
spondylolysis with a new pedicle screw hook
tralateral spondylolysis or if a bilateral pedicle fixation:
clinical, functional and CT assessed study.
lysis is present, the only option is an interbody Eur Spine J.
2007;16:16508.
fusion since a posterolateral bone graft will not 5. Dubousset J.
Treatment of spondylolysis and
spondylolisthesis in children and adolescents. Clin

stabilize the vertebral body and the motion seg- Orthop.
1997;337:7785.
ment; a PLIF would be our procedure of choice. 6. Ekman P,
Moller H, Hedlund R. The long term effect
of
posterolateral fusion in adult isthmic spondylo-
listhesis: a
randomized controlled study. Spine J.
2005;5:3644.
Dysplasic Spondylolisthesis 7. Ekman P,
Moller H, Shalabi A, Yu YX, Hedlund R. A
prospective
randomised study on the long term effect
A thorough posterior mid-line and lateral decom- of lumbar
fusion on adjacent disc degeneration. Eur
pression must be performed, keeping in mind that Spine J.
2009;18:117586.
8. Enker P,
Steffee A. Interbody fusion and instrumenta-
severe narrowing of the spinal canal may be pre- tion. Clin
Orthop. 1994;300:90101.
sent with severe compromise of the cauda equina. 9. Gaines RW. L5
vertebrectomy for the surgical treat-
Further injury of the nerve roots must be avoided ment of
spondyloptosis: thirty cases in 25 years.
during the intra-canalicular use of surgical instru- Spine.
2005;30:S6670.
10. Gillet P, Petit
M. Direct repair of spondylolysis without
ments. Reduction and fusion are performed
spondylolisthesis using a rod-screw construct and bone
according to the above-mentioned rules. grafting of the
pars defect. Spine. 1999;24:12526.
11. Grzegorzewski
A, Kumar J. In situ posterolateral spine
arthrodesis for
grades III, IV and V spondylolisthesis
in children and
adolescents. J Ped Orthop.
Degenerative Spondylolisthesis 2000;20:50611.
12. Johnson R,
McGuire E. Urogenital complications of
In symptomatic degenerative spondylolisthesis, anterior
approaches to the lumbar spine. Clin Orthop.
spinal stenosis is the rule and the main or the 1981;154:1148.
13. Lamberg T,
Remes V, Helenius I, Schlenzka D,
sole indication for surgical treatment is often the Seitsalo S,
Poussa M. Uninstrumented in situ fusion
neurological deficit. In the event of primary for high-grade
childhood and adolescent isthmic
severe instability or post-laminectomy instabil-
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ity, a posterolateral fusion, instrumented or not, Surg Am.
2007;89:5128.
14. Lin P.
Posterior lumbar interbody fusion technique:
a PLIF or a lateral retroperitoneal ALIF since complications
and pitfalls. Clin Orthop. 1985;
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L4-L5- should be considered. The aim of the 15. Louis R. Fusion
of the lumbar and sacral spine by
fusion in this specific indication is more often to internal
fixation with screw plates. Clin Orthop.
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avoid iatrogenic secondary increase of the 16. Louis R.
Reconstruction isthmique des spondylolyses
spondylolisthesis than to treat back pain. par plaque
vissee et greffes sans arthrode`se (Pars
interarticularis reconstruction for spondylolysis by

plate and
screws with grafting without arthrodesis).
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Orthop. 1988;74:54957.
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Sundin A, Hedlund R. Symptoms, signs and
functional
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cations of anterior intervertebral grafting. Clin Orthop. 18. Moller H,
Hedlund R. Instrumented and
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posterolateral fusion in adult
2. Boos D, Marchesi D, Zuber K, Aebi M. Treatment of
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severe spondylolisthesis by reduction and pedicular 19. Moller H,
Hedlund R. Surgery versus conservative
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adult isthmic spondylolisthesis.
3. Carragee EJ, Don AS, Hurwitz EL, Cuellar JM, Spine.
2000;25:17115.
Carrino JA, Hertzog R. Does discography cause accel- 20. Rajaraman V,
Vingan R, Roth P, Keary R, Conclin L,
erated progression of degenerative changes in the Jacobs G.
Visceral and vascular complications
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V, Helenius I, Lamberg T,
Neurosurg: Spine. 1999;91:604. Tervahartiala P,
Yrjonen T, Tallroth K, Osterman K,
21. Remes V, Lamberg T, Tervahartiala P, Helenius I, Seitsalo S, Poussa
M. Direct repair for treatment of
Schlenzka D, Yrjonen T, Osterman K, Seitsalo S, symptomatic
spondylolisis and low-grade isthmic
Poussa M. Long-term outcome after posterolateral, spondylolisthesis
in young patients: no benefit in
anterior and circumferential fusion for high grade comparison to
segmental fusion after a mean follow-
spondylolisthesis in children and adolescents: up of 14.8 years.
Eur Spine J. 2006;15:143747.
magnetic resonance imaging findings after average 25. Suk S, Lee C, Kim
W, Lee J, Cho K, Kim H. Adding
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interbody fusion to pedicle screw
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posterolateral fusion after decompression
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23. Ruf M, Koch H, Melcher RP, Harms J. Anatomic reduc- 26. Watkins R. Anterior
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Microdiscectomy
Trichy S. Rajagopal and

Robert W. Marshall
Contents
Abstract
Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
558 Microdiscectomy is the commonest spinal
operation and the one that produces the most

Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 558
reliable outcomes from spinal surgery. The

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
558 origins of the procedure are discussed from
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 559 the time that disc herniations were mistaken
for some form of chondral tumour to the

Non-Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
proper identification of the pathology by

Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
560 Mixter and Barr in 1934. The natural history
Microdiscectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 560
of disc herniations is outlined together with

Surgical Technique of Microdiscectomy . . . . . . . . .
561 the clinical syndrome of back pain, sciatica
Check the Side and Level of the Disc Herniation
and Correlate with MRI Findings . . . . . . . . . . . . . . .
561
and neurological dysfunction. As sciatica can

Positioning of the Patient on the Operating
resolve spontaneously with resorption of the
Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 561 herniated disc material a conservative
Use of Fluoroscopy to Identify and Mark
approach to treatment is often possible with
the Level of the Relevant Intervertebral Disc . . .
561
Skin Incision and Retraction of Soft Tissues . . . . . . .
561
medications, perineural steroid injections and

Use of the Operating Microscope . . . . . . . . . . . . . . . . . . .
562 physiotherapy providing enough comfort to
Fenestration of the Ligamentum and Laminae . . . . .
562 help the patient to manage the condition whilst
Location, Protection and Gentle Retraction of the
buying time for the natural healing process to
Compressed Nerve Root . . . . . . . . . . . . . . . . . . . . . . . . .
564
Intervertebral Disc Incision and Discectomy . . . . . . .
564
occur. There are absolute and relative indica-

Post-Operative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 569 tions for surgical intervention. Details of sim-
ple microdiscectomy techniques are shown,

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 578
which are highly effective without the need
for sophisticated instrumentation. Tips are
given to improve level localisation and ensure
that the procedure can be carried out safely
through a small approach with minimal
retaction. Complications and their avoidance
are discussed.
Keywords
T.S. Rajagopal # R.W. Marshall (*)
Alternative treatment # Complications # Far

lateral disc # History # Lumbar intervertebral

557
DOI 10.1007/978-3-642-34746-7_89, # EFORT 2014
558 T.S.
Rajagopal and R.W. Marshall
disc herniation # Microdiscectomy # Natural

history # Post-discectomy back pain # Surgical Natural History
technique
The natural history of lumbar
disc herniation is
not well understood. However
in the majority of
Historical Perspective patients this follows a
favourable course. There
are a few observational
reports in the literature
The surgical treatment of lumbar disc herniation about the natural history of
lumbar disc
has gradually evolved over the last century. herniation especially in
relation to surgical and
Oppenheim and Krause were credited with the non-surgical intervention.
There are no conclu-
first report of surgery for lumbar disc herniation sions about the duration or
average course of the
in 1909 [1]. The German surgeon, Fedor Krause, disease [9].
operated on a patient who had severe sciatic pain Usually the onset of
sciatica correlates with
for many years, and presented with an acute the period of most intense
pain. In the first 6
cauda equina syndrome. The operation consisted weeks the leg pain diminishes
in about 70 % of
of laminectomy from L2 to L4, a transdural the patients [10]. The
residual pain remains more
approach to the intervertebral disc and removal or less the same, or improves
gradually for 13
of a small mass, which was erroneously believed months. Symptoms gradually
subside after a few
to be a spinal tumour at that time. Similar reports months and almost disappear
in 7090 % of the
were published by Steinke in 1918 [2], Adson in patients [1113].
1922 [3], Stookey in 1922 [4] and Dandy in 1929 The natural course does
not seem to be
[5]. In 1934 American Neurosurgeon, William influenced by age or sex
[14]. However co-
Mixter and Orthopaedic Surgeon, Joseph Barr existing spinal pathologies
such as spinal canal
described the rupture of the intervertebral disc stenosis or spondylolisthesis
seem to influence it
in their historic paper where they reviewed the [13]. Smoking [15],
psychosocial factors [14],
previous case reports and added 11 cases of their repetitive heavy lifting
[15], sedentary life style
own. They described the pathophysiology of disc and obesity have been cited
as important risk
herniation and suggested surgical treatment by factors. The number of months
required for spon-
extensive laminectomy and removal of the rup- taneous recovery from
sciatica is variable and
tured disc by a transdural approach. therefore uncertain.
With the advent of the operating microscope, There are a few
randomised trials comparing
application of microsurgical techniques to the surgical and non-surgical
intervention for lumbar
treatment of lumbar disc herniation became popu- disc herniation [1619].
These studies seem to
lar. In 1977, Yasargil from Switzerland and Caspar indicate that the patients
undergoing surgery
from Germany reported their experience in using achieve greater improvement
than non-opera-
the operating microscope for lumbar disc surgery tively treated patients in
all primary and second-
[6, 7]. In the following year Williams who ary outcome measures. However
the relative
popularised microdiscectomy in the United States benefit of surgery decreases
over time.
reported on a series of 532 patients [8]. Generally
any new procedure is met with initial scepticism
and microdiscectomy was no exception. However, Clinical Presentation
the pioneering work of Caspar, Yasargil, Wil-
liams, Wilson and Goald confirmed the efficacy ....... surgical treatment
of spinal disorders pro-
of microdiscectomy in reducing the incision size, duces the best results
when clinical signs and
symptoms are congruous and
confirmed by care-
soft-tissue disruption and morbidity. The vast fully selected imaging
studies, and when they have
majority of spinal surgeons now perform lumbar resulted in an unequivocal
diagnosis amenable to
disc surgery with an operating microscope. surgical management......
(Frymoyer [81])
Microdiscectomy
559
Most lumbar disc herniations occur between 30

and 50 years of age. Patients usually present Investigations
with a history of low back pain which over a
period of time radiates increasingly into Water-soluble contrast
myelography and
one leg. Unilateral leg pain becomes the computerised axial tomography
were of great
dominant complaint and radiates from value historically and are
still used in cases
buttock to calf (S1 nerve) or buttock to lateral where magnetic resonance
imaging (M.R.I.) is
aspect of the leg and ankle (L5 nerve) The contra-indicated, but the
investigation of
cardinal symptoms of lumbar disc herniation choice is undoubtedly M.R.I.
However, M.R.I. is
include radicular leg pain, sensory loss and a very sensitive test and
Boden et al. warned of the
muscle weakness. These symptoms usually cor- high incidence of lumbar disc
abnormalities seen
respond to the sclerotome (dermatome and in asymptomatic individuals so
the MRI will often
myotome) of the compressed nerve root [20]. reveal incidental pathology
that has nothing to do
It is important to ask specifically about symp- with the patients symptom
complex [24].
toms of cauda equina syndrome which include
severe or incapacitating back or leg pain, bilat-
eral numbness or weakness, urinary retention or Non-Surgical Treatment
incontinence, faecal or flatulent incontinence
and reduced perineal sensation. Other pertinent The natural course of disc
herniation involves
symptoms relating to lumbar disc herniation a gradual process of
spontaneous resolution,
include radicular pain provoked by coughing with respect to the symptoms
and the volume
and sneezing, paraesthesia in the affected der- of the disc herniation itself,
justifying a
matome and previous episodes of acute back conservative approach in the
vast majority of
pain. Children and adolescents with lumbar patients. The goals of
conservative management
disc herniation usually present with back pain include [25]:
and hamstring tightness rather than characteris- Relief of pain
tic sciatica. Reduction of disability
Physical signs include alteration of the sag- Restoration of pre-morbid
level of spinal
ittal lumbar curve (flattening of the lordosis), motion
a scoliotic list and painful restriction of spinal Regaining activities of
daily living
mobility especially forward flexion. A positive Return to work and leisure
activities
ipsilateral straight leg raising test with radiat- Several factors have been
associated with
ing pain below knee level seems to be associ- a favourable outcome in
patients having non-
ated with good sensitivity (7297 %) but lower operative treatment for lumbar
disc herniation.
specificity (1166 %) [2022]. Restriction of These include [20]:
the contralateral straight leg raise with cross- Young age
legged pain is more specific for a large disc Small disc herniation
herniation [23]. For the rarer syndromes of Minor neurological
compromise
upper lumbar disc herniations affecting L2 to Mild disc degeneration
L4 nerve roots, the femoral nerve stretch test is Mild to moderate sciatica
often positive. Careful neurological examina- The non-operative treatment
options include
tion including precise testing of dermatomal A short period of bed rest
limited to under 3
sensation and muscle power of the local days during the acutely
painful phase
extremities is of paramount importance. Neu- Analgesia and anti-
inflammatory medication
rological examination should also include test- Physiotherapy including
exercise prescrip-
ing of perianal sensation and the tone of the tion, manual therapy and
pain management
anal sphincter. Epidural and periradicular
steroid injections
560 T.S.
Rehabilitation strategies including Cognitive herniation are favourable

when there is good cor-
Behavioural Therapy relation between clinical
symptoms, physical
During the acute period of sciatica, pain may signs and radiological
evidence of disc herniation.
be so severe that the patient cannot be mobilised. Even though there is
controversy over the
The primary goal at this stage is to control pain choice of treatment between
non-operative and
effectively and increase the physical activity. operative treatment, it is
generally agreed that
With regard to physiotherapy, specific supervised absolute indications for
surgery include cauda
retraining of trunk stabilising muscles appears to equina syndrome and severe
neurological deficit
be superior to general exercise programme in with weakness of MRC grade
<3.
restoring spinal function [26, 27]. Relative indications
include the presence of
Epidural corticosteroid injections are still used severe sciatica, persistent
or progressive sensori-
in patients with radicular pain due to lumbar disc motor deficit, persistent
radicular leg pain
herniation but scientific evidence is lacking for the unresponsive to
conservative treatment for 612
long-term effectiveness of this treatment [28]. Epi- weeks and presence of
concomitant spinal canal
dural corticosteroid injections were evaluated for stenosis. The surgical
techniques available in the
the treatment of sciatica due to lumbar disc herni- treatment of lumbar disc
herniation include:
ation in a randomised double-blind trial. The Microdiscectomy
results showed that the epidural corticosteroid Open discectomy
(laminotomy)
injections provided improvement in the leg pain Chemonucleolysis
and sensory deficit and reduced the need for anal- Minimally invasive
techniques (Automated
gesia in the first 612 weeks but after 3 months percutaneous discectomy
and Endoscopic
there was no difference between the patient discectomy)
groups. At 1 year there was no difference in the
need for surgery [29]. Another prospective
randomised study compared epidural corticoste-
roid injections and discectomy after 6 weeks of Microdiscectomy
non-invasive treatment. Patients who underwent
discectomy had better results (9298 % effective) Advantages of
microdiscectomy include [3234]:
than patients in the epidural group (4256 %). Smaller skin incision
Selective nerve root injections of corticoste- Reduced trauma to soft-
tissues
roids have also been shown to be effective in the Improved illumination and
magnification
short term providing relief of symptoms [30]. Provision of binocular
vision
A systematic review showed there is strong evi- Better haemostasis due to
meticulous prepara-
dence that the selective nerve root block may tion of epidural veins
relieve radicular nerve root pain in the short Less post-operative pain
term [31]. The available literature is supportive Rapid mobilisation
of selective nerve root block as a diagnostic tool, Reduced hospital stay
especially in the presence of negative or incon- Less scarring
clusive imaging studies. Disadvantages and
potential pitfalls include:
Limited exposure making
it easier to operate
at the wrong level
Operative Treatment Possibility of
overlooking free fragments
Inadequate decompression
The objectives of surgery in lumbar disc hernia- Learning curve involved
in microsurgery
tion include decompression of neural structures, Inadvertent neural or
vascular injury
removal of mechanical pressure and chemical irri- The indications for
microdiscectomy are similar
tation to the nerve root by excision of the disc to those of open discectomy
and both techniques
material. Results of surgery for lumbar disc are suitable for all forms
of lumbar disc herniation.
Microdiscectomy
561
Use of Fluoroscopy to
Identify and
Surgical Technique of Mark the Level of the
Relevant
Microdiscectomy Intervertebral Disc
Check the Side and Level of the Disc Two of the uncommon but
serious errors in
Herniation and Correlate with MRI disc surgery include
operating at the wrong
Findings level and operating on the
wrong side. When
the wrong level is operated
upon, it is usually
Pre-operatively the surgeon should check the the level above the intended
one [34]. Therefore,
scans and investigations, to confirm the level it is imperative to have an
on-table level
and side of the surgery (Fig. 1). It is also imper- check with an image
intensifier. Besides ensur-
ative to check the date of the MRI. Disc pathol- ing that the correct level is
treated, the x-ray
ogy evolves so if the scan is more than 6 months guided marker will also allow
optimal place-
old the operative findings may be very different ment of the small skin
incision (Figs. 5 and 6).
from those predicted by the scan. We recommend
a new MRI if the original is greater than 6 months
old. One should also make a careful assessment Skin Incision and Retraction
of segmentation anomalies of the vertebrae to of Soft Tissues
avoid operating at the wrong level. Then the
patients signed consent to the procedure is Once the disc level is
identified radiologically the
checked. skin incision is made,
bearing in mind that the
disc space at L5-S1 is inter-
laminar in location; at
L4-5 the disc is partially
covered by the L4 lam-
Positioning of the Patient on the ina and at proximal lumbar
levels, the disc space
Operating Table is almost completely covered
by the superior
lamina [33]. The skin
incision is carried down
Microdiscectomy is usually performed under to the lumbar fascia, which
is then incised close
general anaesthesia. The procedure is most com- to the midline. When
operating in the lateral
monly performed in the prone position with flex- position it is particularly
important to ensure
ion of the lumbar spine (Fig. 2). that no fascia or muscle is
left medially, obscur-
Some prefer a lateral position with flexion of ing access to the medial
portion of the
hips and knees to induce flexion of the lumbar interlaminar area. The
fascial incision is usually
spine (Fig. 3). Patient supports allow good flexion longer than the skin incision
to allow tension-free
of the lumbar spine and do not interfere with the retraction of the paraspinal
muscles. A Cobb ele-
surgical approach (if placed over the upper lum- vator is used to reflect the
muscle off the laminae
bar spine and upper tibiae). and ligamentum flavum.
While most surgeons prefer the familiarity of Once this soft tissue has
been cleared a retractor
the prone position, the lateral position allows is inserted. Retractors vary
in design and sophisti-
optimal exposure of the interlaminar space and cation. Some of the tubular
systems are quite
ligamentum flavum so that the fenestration into constraining and can
interfere with access for
the canal can be made with minimal resection of instruments, so there are
advantages to the simple
the bony lamina. Another advantage is that the but effective method of a
curved Trethowan bone
surgeon is seated upright, can see into the wound lever attached to a Charnley
chain and weight
clearly with the microscope facing due laterally (Fig. 7). The tip of the
lever is inserted over the
and can use instruments easily in this ergonomic facet joint at the operated
level and, once the
posture (Fig. 4). The table can be tilted away from weight and chain are
attached, the soft tissues are
or towards the surgeon to improve the view as tented laterally, giving the
surgeon a triangular
required. field of exposure that allows
excellent
562 T.S.
a b
Fig. 1 Sagittal and axial T2 weighted images showing L5-S1 disc herniation
Fig. 2 Patient positioned

prone on Wilson Frame
with abdomen free of
pressure. The frame is
adjusted to allow flexion of
the lumbar spine
visualisation of the anatomy with complete free- surgeon sits facing the
exposed back and the
dom to insert the operating instruments (Fig. 8). microscope is placed on
the opposite side and
brought across the
operating table.
Use of the Operating Microscope

Fenestration of the
Ligamentum and
The microscope is moved into position and Laminae
focussed through the incision and onto the lami-
nae and ligamentum flavum. If the patient is Any remaining muscle
fibres are removed off the
prone, the microscope is usually positioned on ligamentum flavum with
pituitary rongeur for-
the far side and the surgeon stands on the near ceps so that a clear view
of the ligamentum and
side (Fig. 9). If the lateral position is used, the laminae is obtained (Fig.
10).
Microdiscectomy
563
Fig. 3 Patient in the lateral

position between hip a
supports to create flexion of
hips, knees and lumbar
spine
The ligamentum flavum is then incised quite the theoretical benefit of less
scarring and easier
medially and 2 or 3 mm inferior to the superior revision surgery if required.
We prefer
lamina. The medial entry point is chosen as there a flavectomy. Once an opening
is made, this is
is more space here between the ligamentum and carefully enlarged with
Kerrison bone punches
the nerve than out laterally where the nerve and a laminotomy is made to
complete the fenes-
would be more vulnerable to injury (Fig. 11). tration. A cottonoid neuro-
patty can be placed
Once the entry point is made the ligamentum through the small fenestration
to protect the
is cleared away, either by a flavectomy or by nerves and dura while the
opening is enlarged
raising a medially based flaval flap, which has with Kerrison bone punches. It
is important to
564 T.S.
Fig. 4 With the patient in

the lateral position the
seated surgeon has a good
ergonomic posture
make a big enough window to see the nerve retained ligamentum can
sometimes prevent
clearly and retract it. The window will be medial retraction of the
nerve.
a square shape approximately 1 cm2 but the open- Once the nerve root is
adequately exposed the
ing may need to be larger in cases where the anterior epidural space is
then prepared for
surgeon has to reach disc material that has discectomy. We recommend the
use of two
become sequestrated higher or lower than the neuro-patties placed into
the lateral recess, one
disc space itself (Figs. 12 and 13). packed superior to the
nerve, and the other placed
inferiorly to act as a
gentle nerve retractor. These
neuro-patties protect the
nerve and dura mater,
Location, Protection and Gentle pack away the epidural veins
and tamponade any
Retraction of the Compressed bleeding (Fig. 14a).
Nerve Root Metal nerve root
retractors can be used, but
we prefer to avoid this
unnecessary trauma to
Lateral extension of the fenestration allows good the nerve. In the case of
large disc herniations,
exposure of the nerve root. the nerve root is carefully
mobilised over the
The nerve roots can be anomalous (conjoined) protruding disc to ensure
that the disc fragments
so there may be more than one nerve traversing are not removed through the
axilla of the
the space. In order to avoid inadvertent damage to nerve root.
a second nerve, the Watson-Cheyne dissector is
used as a probe to feel the pedicle and ensure that
the lateral edge of the most lateral neural struc- Intervertebral Disc Incision
and
ture (usually the single traversing nerve) is visu- Discectomy
alized and carefully retracted. If the nerve cannot
easily be retracted medially the fenestration is too The posterior annulus of the
intervertebral disc
small and more of the overhang should be may have been perforated by
the herniating
removed inferolaterally, but also medially as nucleus pulposus, extruding
into the epidural
Microdiscectomy 565
Fig. 5 Lateral imaging

with a metal marker shown a
in the prone and lateral
positions
b
566 T.S.
Fig. 6 The level of the

posterior edge of the disc
space is marked on the skin
space, in which case the opening can be stretched It is important at this

stage to ensure that the
with the jaws of the pituitary rongeur forceps and nerve root is adequately
decompressed and that
the space entered by removing degenerate disc there are no free fragments
of disc lying seques-
material, but if the disc is bulging and not perfo- trated in the spinal canal.
rated it will be necessary to incise the annulus and It must be remembered
that the left common
then enter the disc space to remove the loose and iliac artery runs across the
anterior aspect of the
degenerate nucleus pulposus (Fig. 14b). L4-5 intervertebral disc and
care should be taken
Fine tipped, straight and angled pituitary for- while using the pituitary
rongeurs to avoid
ceps are used to remove loose fragments of a vascular injury,
especially at this level. On occa-
nucleus pulposus from the disc space (Fig. 15). sions a pre-existing defect
may be present in the
How much to remove is the vexed question. anterior annulus and this
provides a significant haz-
Some favour minimal trauma to the disc, but ard [34]. Haemostasis of the
epidural venous bleed-
evidence for worsening of disc function and ing is achieved by bipolar
diathermy or packing
back pain is lacking, so a careful but thorough with neuro-patties. There is
no convincing evidence
disc clearance does not seem to have a worse in the literature regarding
the efficacy of materials
long-term prognosis than the natural history of to reduce epidural fibrosis
after disc surgery. Their
the disease. We favour removal of all loose frag- routine use is not
recommended.
ments of nucleus pulposus, but do not advocate We use intrathecal
injection of morphine
curettage of the end plates of the vertebrae. Once (300 mg) and 2 ml of 0.125 %
bupivacaine for
the disc space has been emptied with the pituitary post-operative analgesia.
This analgesic cocktail
rongeur forceps it can be washed out by flushing is injected into the
cerebrospinal fluid through
saline from a syringe with a blunt metal cannula a very fine (25 gauge)
spinal needle. A small
placed through the opening in the annulus. This piece of calcium alginate
can be left overlying
has the dual effect of flushing out any remaining the fenestration to promote
haemostasis, but
small disc fragments and diluting the effects of beware some haemostatic
materials such as
the inflammatory chemicals that are contained oxidised cellulose have been
blamed for post-
within the nucleus pulposus. operative cauda equina
syndrome.
Microdiscectomy 567
Fig. 7 Curved Trethowan

bone lever with its insertion a
and attachment to
a Charnley weight (Prone
position). The surgeon
stands on the side of the
disc pathology
b
568
T.S. Rajagopal and R.W. Marshall
Fig. 8 In the lateral position the affected side is placed uppermost and the
Trethowan bone lever is attached to the
weight which is suspended over the far side of the operating table
Fig. 9 Prone
position surgeon nearside
and microscope across
from the far side
Microdiscectomy
569
Fig. 10 Operating microscope view of ligamentum Fig. 12 Kerrison bone punches

are used to create
flavum. The white line shows the position of the a laminotomy. A neuro-patty
has been placed through
lamina the small opening for safety
Fig. 13 Intervertebral disc

is exposed as the nerve
(arrowed) is retracted
The wound is closed in

layers of absorbable
suture material.
Post-Operative Care
Post-operatively the patients

can be mobilised on
recovery from anaesthesia and
discharged
Fig. 11 (a) Incision of ligamentum flavum close to
midline and just beneath the upper lamina. (b) The
home within 2 days. There are
reports in the
epidural fat can be seen through the flaval opening literature confirming the
safety of day case
(arrowed) microdiscectomy, but this is
not widely practised.
570
b Fig. 15 Pituitary
rongeur forceps teasing disc material
through the annular
opening
headlight are used

by some surgeons to improve
the visibility. The
ideal magnification would be
34 times and the
optimal focal length (working
distance) would be
around 400 mm.
In cases of
cauda equina syndrome, some sur-
geons employ a more
extensive exposure with
either a central
approach removing the spinous
process and laminae
or a bilateral approach with a
hemilaminectomy
either side of the spinous
Fig. 14 (a) Disc pathology isolated by using neuro-
process.
patties as retractors. (b) Transverse incision of the bulging
annulus of the disc Review of early
literature comparing open
discectomy and
microdiscectomy based on
retrospective case
series seems to indicate
The patients are encouraged to make a graduated that
microdiscectomy could provide a better
return to normal activities with return to sedentary outcome [3638].
These reports also
work by 4 weeks and to manual work after 6 weeks. showed reduced
blood loss, faster rehabilitation
There is no rational basis for imposing or lifting and improved
functional results with
restrictions after lumbar disc surgery [35]. microdiscectomy. In
contrast, prospective clini-
cal trials (some
randomised) have failed to show
Open Discectomy any significant
differences between the two sur-
Open discectomy is generally preferred in the gical procedures
including pre and post-
following circumstances: operative pain
scores, operative time, blood
Concomitant spinal stenosis loss and functional
outcome [3942]. However
Revision surgery one trial showed
reduced hospital stay following
Multi-segmental disease microdiscectomy
(mean 2 days) compared to
Open discectomy involves unilateral open discectomy
(mean7 days) [41].
laminotomy to create an inter-laminar window
followed by flavectomy to expose the dura and Far Lateral Disc
Herniation
the nerve root. While the procedure is similar to The term far
lateral applies to a lumbar disc
microdiscectomy, more lamina may be removed herniation which
compresses the nerve root
to improve the exposure; however this may not exiting at the same
level, irrespective of its loca-
be always needed. A magnifying loupe and tion. This is in
contrast to classic posterolateral
Microdiscectomy
571
disc compression which affects the nerve root With the patient prone a
guide wire is
leaving at the level below. For example an L4-5 passed obliquely from a
paramedian position
far lateral disc herniation would result in com- 5 cm from the midline and is
directed into the
pression of the L4 nerve root as opposed to intertransverse area under
fluoroscopy. A series
a posterolateral disc herniation which would of dilators are passed over
the guide wire until the
result in L5 nerve root compression. The site of retractors can be inserted
into the small incision
herniation is usually lateral to the pedicle in the (Fig. 18a, b) and expanded
(Fig. 19).
region of the intervertebral foramen (Fig. 16). The retractors expose the
intertransverse
Failure to recognise its presence has often been space and allow the surgeon
to work under the
responsible for a poor outcome and persistent lateral aspect of the pars
interarticularis and supe-
sciatica after operation. Far lateral disc hernia- rior facet joint so that the
intertranverse muscle
tions account for between 6 % and 10 % of all and aponeurosis can be
reflected. This reveals the
lumbar disc herniations (Fig. 17) [43]. much deeper position of the
exiting nerve and its
Foraminal steroid injections are often effec- dorsal root ganglion. Venous
bleeding is fre-
tive, but surgical treatment of a far lateral disc quently encountered during
this dissection and
herniation involves a muscle splitting, inter- should be controlled by
packing with neuro-
transverse approach through a paramedian inci- patties and bipolar
diathermy. Gentle lateral
sion. The alternative is an inter-laminar retraction of the nerve
exposes the intervertebral
approach, but full exposure of the nerve root disc herniation. By working
in the axilla of the
requires total resection of the facet joint and this nerve the disc space can be
opened and emptied
may prejudice the subsequent stability of the of the herniating disc
material. Because one is
spine. The advantages of the inter-transverse starting very laterally, it
is important to direct the
approach include direct access to the herniated pituitary rongeur forceps
medially when clearing
disc, minimal soft tissue traumatisation and min- the disc (Fig. 20).
imal resection of bone. The bony resection is
usually limited to hypertrophied facets and to Chemonucleolysis
the L5-S1 level. The medial branch of the poste- Chemonucleolysis involves
intra-discal injection
rior primary ramus of the spinal nerve is a useful of a proteolytic enzyme,
usually chymopapain to
anatomical landmark in this approach, allowing dissolve the nucleus
pulposus of the intervertebral
early identification of the spinal nerve and dorsal disc. Chymopapain is a
sulfhydryl protease
root ganglion and safe dissection of the inter- obtained from the purified
extract of the papaya
transverse space. The use of an operating micro- fruit [46]. Smith et al. in
1963 first reported the
scope helps to identify the posterior primary use of chymopapain injection
into the intervertebral
ramus of the spinal nerve where it passes through disc to treat intervertebral
disc prolapse [47]. Since
the medial aspect of the inter-transverse mem- then it has been the subject
of a number of
brane, before distributing its branches to the dor- randomised controlled
trials.
sal musculature. In general the
indications for chemonucleolysis
OHara and Marshall reported their results are the same as those for
discectomy for
using the muscle splitting, inter-transverse intervertebral disc
prolapse. McCulloch published
approach, which were excellent in 60 %, good his criteria for selection
of patients in 1977 [48].
in 30 %, no improvement in 5 % and poor in 5 % These included unilateral
leg pain, specific neu-
[43]. Similar results have also been reported by rological symptoms involving
a single nerve,
other authors in the literature [44, 45]. limitation of straight leg
raise with leg pain,
Modern designs of retractors for minimally neurological signs and a
positive myelogram,
invasive surgery such as the In-sight retractor which can be reasonably
substituted by mag-
of Synthes or the Quadrant retractors of netic resonance imaging
confirmation of disc
Medtronic allow very good access for micro- prolapse. If the patient has
three or more of
scopic far lateral discectomy as follows: these criteria then he or
she should be considered
572 T.S.
Fig. 16 Emptied disc space and decompressed nerve root (white arrow)
as a candidate for chemonucleolysis. The of which was transverse

myelitis with paraplegia.
contraindications include sequestrated discs, Various other reports
estimate that allergic reac-
hard discs, lateral recess or foraminal stenosis, tions occur in 212 % of
patients.
fibrosis due to previous surgery, cauda equina Chemonucleolysis is one
of the most investi-
syndrome and known chymopapain or papaya gated interventions for the
treatment of
allergy. intervertebral disc
prolapse. More than 20
A posterolateral approach is generally used randomised trials evaluated
chemonucleolysis.
under local anaesthesia with sedation or general Gibson and Waddell
published a Cochrane
anaesthesia. A transdural approach is strongly review, which included a
systematic review of
contraindicated. It is generally advisable to use the chemonucleolysis [50].
Trials which com-
discography to confirm the position of the pared chemonucleolysis and
placebo injection
needle before injecting the enzyme. The dosage consistently reported that
chemonucleolysis was
has reduced from about 3,0004,000 units superior to placebo
treatment [5153]. Another
down to 5002,000 units. The disc height trial found collagenase
chemonucleolysis supe-
reduces by about one fourth after chymopapain rior to placebo [54].
Trials comparing
injection. It may gradually recover over a period chemonucleolysis against
either open surgery or
of 1 year. microdiscectomy showed
slightly less efficacy
Potentially serious complications are rare. for chemonucleolysis
compared to surgery in
Norby et al. examined the safety of the short term, but fewer
complications and
chemonucleolysis reviewing the adverse effects long-term recurrences. The
long-term results
reported in the United States between 1982 and were comparable [5557].
The results of surgery
1991 [49]. There were seven reported cases of after failed
chemonucleolysis are similar to those
fatal anaphylaxis in 135,000 patients (0.0005 %); obtained after primary
discectomy, indicating
other complications included infection (24 that failure to respond to
chemonucleolysis does
patients), haemorrhage (32 patients), neurologi- not compromise surgical
discectomy. In spite of
cal complications (32 patients), the most serious the favourable evidence for
chemonucleolysis,
Microdiscectomy
573
been investigated most

include automated percu-
a
taneous lumbar
discectomy and endoscopic
discectomy.
Automated Percutaneous
Lumbar
Discectomy (APLD)
Automated Percutaneous
Lumbar Discectomy is
a procedure that
involves percutaneous insertion
of a cannula under
fluoroscopic guidance using
a posterolateral
approach. A probe is then
connected to an
automated cutting and aspiration
device, which is
introduced through the cannula
[58]. The disc is
aspirated until no more nuclear
material can be
obtained. The procedure is
performed under local
anaesthesia with or with-
out sedation. The
indication for the procedure
b primarily involves
patients with contained disc
herniations or
protrusions.
One randomised
controlled trial compared
automated percutaneous
lumbar discectomy with
microdiscectomy. This
reported 29 % successful
outcome with automated
percutaneous lumbar
discectomy compared with
80 % of patients with
microdiscectomy, and the
difference was statisti-
cally significant [59].
Another randomised con-
trolled trial compared
automated percutaneous
lumbar discectomy with
chemonucleolysis and
found that significantly
more patients had success-
ful results after
chemonucleolysis [60]. Grevitt
et al. reported on 137
patients who had automated
percutaneous lumbar
discectomy. 52 % of patients
had excellent or good
outcome after a mean fol-
Fig. 17 M.R.I. T2 and T1 Axial images show a left sided,
far lateral disc prolapse (arrowed) causing L4 nerve
low-up of 55 months
[61]. However, with the
(exiting) compression advent of endoscopic
procedures the popularity
of automated
percutaneous lumbar discectomy
has declined.
its use has been thwarted by worldwide shortage Endoscopic Discectomy

of the enzyme due to lack of production. There is Percutaneous endoscopic
removal of the herniated
a real opportunity for someone to resume man- lumbar disc can be
performed through a midline
ufacture and marketing of this useful agent. posterior,
posterolateral or transforaminal
approach. Kambin is
credited with the description
Minimally Invasive Techniques of the first discoscopic
view of a herniated disc,
The perceived advantages of percutaneous even though percutaneous
techniques of disc
techniques over those of open procedures include removal have been
described earlier. The develop-
less damage to the soft tissues, shorter hospital ment of appropriate
surgical instrumentation and
stay and less scar formation. There are a number the description of a
triangular working zone by
of techniques described but the ones that have Kambin were the basis
for all further progress.
574
a b
Fig. 18 (a) Serial dilators over a guide-wire. (b) Quadrant retractors inserted
(Pictures with permission of Medtronic)
Fig. 19 Medtronics
Quadrant retractors in
place (dilators removed)
He reported a favourable outcome in 87 % of the for lumbar disc

herniation. 90.7 % of the patients
cases; a similar rate to open disc surgery [62]. were satisfied at the
end of 1 year and he concluded
Yeung reported on a series of 307 patients who that percutaneous
endoscopic discectomy has com-
underwent percutaneous endoscopic discectomy parable results to
open microdiscectomy [63].
Microdiscectomy
575
intra-operative,
early or late complications. Intra-
operative
complications include those complica-
tions which are
evident during the surgery or
become apparent
immediately afterwards. These
include epidural
bleeding, dural tears, nerve root
injury and vascular
injury.
Epidural Bleeding
Epidural venous
bleeding may be minimised by
positioning the
patient prone with the abdomen
hanging freely.
Experienced surgeons feel that
epidural venous
bleeding usually stops when the
disc fragment is
removed and after the wound
closure. Tamponading
the epidural veins with
Fig. 20 Operating microscope view of emptied disc neuro-patties is
useful to reduce the bleeding;
space in the axilla of the exiting nerve (arrowed) which
is being retracted by the sucker tip. The broken white line however the use of
bipolar diathermy may be
indicates the overhanging bone of the pars interarticularis required to stop the
bleeding. Excessive use of
and superior facet joint diathermy may be a
cause of epidural fibrosis and
post discectomy
syndrome.
Dural Tears
Ruetten et al. reported on a prospective series of Inadvertent injury to
the dura with loss of cere-
463 patients who underwent full endoscopic brospinal fluid can
occur during any form of
uniportal transforaminal approach using an spinal surgery. When
a dural tear is recognised
extreme lateral access for lumbar disc herniation. it is important to
localise and repair the defect.
They reported that 81 % of their patients had com- Usually it is
necessary to enlarge the fenestration
plete resolution of leg pain [64]. laminotomy to carry
out a repair. Small punctures
There has been a recent surge in the literature can be left alone. If
dural repair is performed we
on endoscopic discectomy as a result of improve- prefer 60 Prolene
sutures and a small fat graft
ment in endoscopic techniques. The reported from the subcutaneous
tissue can be tied over the
outcomes with endoscopic discectomy continue suture line to seal
the leak. If light-headedness
to improve and are equal to those of and headache result,
the patient may need to be
microdiscectomy. The advantages of endoscopic kept in bed for 2448
h until the cerebrospinal
discectomy include outpatient surgery, less sur- fluid volume
increases.
gical trauma and early functional recovery. How- Various reports
in the literature quote an inci-
ever, although the 2 year results were similar for dence of 0.87.3 % of
dural tears during
the three groups in a prospective, randomized discectomy.
Consequences of dural tear include
trial of 240 patients comparing endoscopic headache,
cerebrospinal fluid fistula and post-
discectomy with microdiscectomy and conven- operative
pseudomeningocele which may require
tional discectomy, the costs and complications re-exploration and
repair of the defect.
were higher in the endoscopic group. Complica-
tions included dural tears, nerve injury and recur- Nerve Root Injury
rent disc herniation [65]. The incidence of
nerve root injury during surgery
has been estimated to
be 0.21 %. Poor visibility,
Complications perineural adhesions,
and congenital abnormali-
Complications following microdiscectomy are ties of the nerve
roots such as conjoined
generally rare but some can be serious and nerve roots are the
most common causes of
devastating. Complications can be classified as nerve root injury.
Good lighting and visibility
576 T.S.
during microdiscectomy help to reduce the Early recurrent disc

herniation
incidence of this complication. Unrecognised
additional nerve root
compression
Vascular Injury Inadequate decompression
of concomitant
Vascular injury is fortunately rare, but can be spinal stenosis
devastating. This happens when pituitary rongeurs Extra-foraminal nerve
compression
penetrate the anterior annulus fibrosis inadver- Intrinsic neuropathy such
as diabetes
tently during removal of the disc. The most com- If present, persistent
sciatica should be inves-
mon vessel involved is the left common iliac artery tigated with further
magnetic resonance imaging.
during right-sided L4-5 microdiscectomy. The
reported incidence of these injuries is in the order Cauda Equina Syndrome
of 0.003 %. Some reports indicate that the mortal- Cauda equina syndrome can
result from an epi-
ity is about 50 %. Any dramatic unexplained fall in dural haematoma or from
intra-operative nerve
blood pressure and excessive haemorrhage from injury. If there is a
concern about cauda equina
the disc should alert one to the possibility of injury, a thorough
neurological examination
unrecognised vascular injury. This should be should be carried out and
immediate imaging
treated with rapid wound closure, intravenous performed. If a compressive
lesion is identified
fluids and blood, and repositioning the patient for immediate surgical
decompression is indicated.
a trans-abdominal approach for a vascular repair.
Some surgeons prefer to use rongeurs that have Recurrent Disc Herniation
stops to prevent deeper insertion. The incidence of recurrent
disc herniation after
primary discectomy has been
reported as 511 %
Wrong Level Surgery [6668]. Gaston and Marshall
showed that sur-
Wrong level exploration is most likely to occur at vival analysis is a better
method of estimating the
L4-5 level or higher and is usually rare at L5-S1. recurrence [69]. In their
series the rate continued
It is therefore important to use x-ray confirmation to rise steadily with each
year of follow-up; it was
pre-operatively and well as intra-operatively. only 1.1 % at 1 year, 5.0 %
at 5 years and 7.9 % at
8 years. No recurrences
occurred after 8 years
Infection from the primary operation.
The majority of
The reported rate of infection varies between recurrences occurred on the
same side as previous
0.2 % and 1 %. Treatment of disc space infection discectomy with relatively
few occurring on the
involves aspiration of the disc to identify the contralateral side.
organism and the use of appropriate antibiotics As in primary disc
herniation, the extent of
for a minimum of 6 weeks, or until the infection clinical symptoms is a
critical determinant in
markers return to normal. In spite of successful deciding on surgical
management. Persistent
treatment of infection, some patients end up radicular pain in the
distribution consistent
with chronic back pain and require a surgical with previously operated
level, severely reduced
fusion later. walking ability, straight
leg raising test positive
at less than 30# and pain-
free interval of at
Persistent Leg Pain least a few months after
prior discectomy
Presence of persistent or residual leg pain increase the likelihood of
true recurrent disc
after discectomy is uncommon; however if herniation [70].
present one should look for a specific cause. Magnetic resonance
imaging with intravenous
Frequent causes of persistent sciatica after gadolinium contrast is the
imaging modality of
discectomy include: choice to study recurrent
disc herniation by com-
Wrong level surgery paring T1-weighted images
before and after
Residual disc fragment injection of the contrast.
Gadolinium enhances
Nerve root injury the vascularised soft tissue
structures including
Microdiscectomy
577
epidural fibrosis and scar formation, which can syndrome is loosely used,
but this condition is not
be readily distinguished from a recurrent disc clearly defined. Review of
the literature suggests
herniation that does not enhance. At the same that the incidence of
recurrent or persistent back
time, conventional T2 weighted sequences give or leg pain varies from 7 %
to 37 % depending
information on disc herniation at another level, on the criteria used [75].
Management of this
associated spinal stenosis or any other cause of group of patients is quite
complex requiring
sciatica. a multidisciplinary approach
including physio-
The indications for surgery are similar to therapists, psychologists
and pain management
those for primary disc herniation. However it services.
has been stated that a relatively smaller degree In considering surgical
management, it is
of disc herniation could cause severe symptoms important to take into
account a number of
in the presence of epidural fibrosis which might factors. It is also
important to identify the pain
limit the mobility of the affected nerve root. generator, i.e. if the pain
is arising from the
The presence of epidural fibrosis on its own is degenerative disc or the
facet joints, presence or
not an indication for surgery, as the results of absence of any neural
compression and
outcome for surgery on epidural fibrosis are not perineural or epidural
fibrosis. The presence or
rewarding [71]. absence of segmental
instability also influences
In terms of surgical technique, a wider surgical the choice of surgical
treatment.
exposure is required compared to primary Non-operative treatment
involves an aggres-
discectomy. A wider laminotomy or even sive regimen of
physiotherapy and aerobic con-
a partial laminectomy may be required to enter ditioning, involvement of
pain specialists and
the spinal canal through virgin territory and then cognitive behavioural
therapy. Before consider-
work a way through the scar tissue. Using a high ing any surgical
intervention it is important to
speed burr to thin the lateral aspect of the lamina exclude infection by blood
tests including full
can be a good way of approaching the lateral blood count, erythrocyte
sedimentation rate and
aspect of the nerve and then freeing the nerve in C-reactive protein. Standing
flexion and exten-
its bed of scar tissue and retracting it medially to sion lateral radiographs are
taken to assess the
expose the recurrent disc hernia. The use of an presence or absence of
segmental instability.
operating microscope assists this soft tissue dis- The presence of any
significant translation or
section. Any lateral recess stenosis should be angulation in the motion
segment indicates
addressed by undercutting of the facet joint instability.
(partial medial facetectomy). The chance of The choice of surgical
treatment is usually
a successful outcome is good after recurrent between fusion and disc
replacement. There are
discectomy, provided that the patient has had very few reports in the
literature that address the
a pain-free period of several months or years problem of post-discectomy
back pain. The
before recurrence. Review of literature suggests sparse literature indicates
that successful func-
that the improvement of radicular leg pain, back tional outcome does not
depend on the choice of
pain and functional outcome is almost similar to surgical technique or the
type of fusion [76, 77].
that of primary discectomy [66, 7173] The risk Various techniques such as
anterior, posterior
of yet another disc herniation at the same level is and trans-foraminal lumbar
interbody fusion and
not clearly known [73, 74]. posterolateral fusion have
been successful in
achieving a good outcome.
Chitnavis et al. have
Post-Discectomy Back Pain: Spinal reported on the use of
posterior lumbar interbody
Fusion and Disc Replacement fusion and were able to
achieve 92 % improve-
Microdiscectomy and open discectomy are effec- ment and 95 % radiological
fusion rate [78].
tive in relieving radicular leg pain, but Similar results have been
reported with trans-
a significant proportion of patients continue to foraminal [79] and anterior
lumbar interbody
have axial back pain. The term post-discectomy fusion [80].
578
With regard to lumbar disc replacement, in 14. Rasmussen C.

Lumbar disc herniation: social and
one series 36 % of patients undergoing lumbar demographic
factors determining duration of disease.
Eur Spine J.
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MH, Clements JH, Wilder DG,
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Ashikaga T. Risk factors in low-back
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Spine (Phila Pa
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Applications of Lumbar Spinal
Fusion
and Disc Replacement
Contents
Clinical Outcomes After Lumbar Disc
Replacement and Lumbar Fusion . . . . . . . . . . . . 592

Applications of Lumbar Spinal Fusion and Disc
Transperitoneal Approach to L5-S1 . . . . . . . . . . . . . . . . . 595
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 582
Retroperitoneal Approach to L4-5 . . . . . . . . . . . . . . . . 599

History of Fusion of the Lumbar Spine . . . . . . . . . . 582
Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 603
Anterior Lumbar Interbody Fusion . . . . . . . . . . . . . . 584
Post-Operative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 603
Lateral Transpsoas Interbody Fusion
Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . 604
(Extreme Lateral Interbody Fusion XLIF) . . . . 584
Spinal Fusion for Degenerative Disc Disease . . . . . . 584
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 605
Lumbar Intervertebral Disc Replacement . . . . . . . 585
History of Lumbar Disc Replacement . . . . . . . . . . . . . . 585
Indications for Lumbar Disc Replacement . . . . . . 586
Manifestation and Diagnosis of Discogenic
Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 587
Treatment Options for Discogenic Back Pain . . . 587
Motion Preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
588
Adjacent Segment Degeneration . . . . . . . . . . . . . . . . . .
589
General Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 589
ASDeg and ASDis Following Lumbar Fusion . . . . . .
589
Complications of Lumbar Disc Arthroplasty . . . . . . .
590
Relative Safety of Spinal Fusion and Lumbar Disc
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 592
R.W. Marshall (*)

N. Raz
Bnai Zion Medical Center, Haifa, Israel

581
DOI 10.1007/978-3-642-34746-7_214, # EFORT 2014
582
interbody fusion and lumbar

disc replacement
Abstract
the operative anterior
approach to the spine will
Spinal fusion has been the operation of choice
be outlined in detail.
for degenerative back pain for almost a century.
However, the desire to maintain movement and
minimise the risk of biomechanical disturbance
History of Fusion of the
Lumbar Spine
of adjacent levels has led to the development of
intervertebral disc arthroplasty. Artificial disc
The first published
accounts of posterior lumbar
replacement has increased in popularity, but
fusions appeared in 1911
when Hibbs [1] devised
the long term consequences are not yet known
a method of fusion for
spinal deformity that
and the intended benefits are still to be proven.
involved excision of the
facet joints and decorti-
We trace the history of spinal fusion, including
cation of the laminae and
spinous processes
the many different ways to achieve arthrodesis
and later the same year
Albee used tibial strut
of the diseased levels. The evidence for spinal
grafts placed between
clefts created in the spi-
fusion and disc arthroplasty together with the
nous processes, initially
in the treatment of spinal
detailed results of existing clinical trials are
tuberculosis [2] (Potts
disease).
considered. Surgical techniques are compared
Hibbs extended the
indications to include
and contrasted.
treatment of back pain in
1914 and by 1929
he published his experience
in 147 cases [3].
Keywords There were also
publications on posterior
Adjacent segment degeneration # Anterior # fusion for poliomyelitis
and scoliosis [4, 5],
Complications # Fusion-posterior # Lateral # but tuberculosis remained
the commonest
Lumbar # Lumbar disc replacement-indica- indication [6].
tions # Motion preservation # Outcomes # The indications for
posterior fusion in the
Spine # Surgical techniques # Spine # Cervical absence of deformity or
chronic infection were
# Anterior fusion # Prosthetic disc replacement more controversial and
usually included persis-
# History # Prosthetic design # Surgical indica- tent back pain refractory
to conservative
tions # Fusion and disc replacement # Surgical treatment in the presence
of radiographic changes
management # Anterior decompression and of degeneration. The pain
source was uncertain
fusion # Complications # Conclusions as were the number of
levels that required to
be fused. There was even a
vogue for
trisacral fusion from L4
to the sacrum
Applications of Lumbar Spinal Fusion with additional arthrodesis
of the sacro-iliac
and Disc Replacement joints [7]!
When Mixter and Barr
published the evidence
In this section, the history of spinal fusion will be for herniation of lumbar
intervertebral discs [8]
discussed, posterior un-instrumented fusions, the posterior lumbar fusion
operations were used
later addition of instrumentation, anterior and even more freely,
especially after their long fol-
posterior lumbar interbody fusions, the more low-up study suggested that
the outcome was
recent development of the transforaminal lumbar slightly better after
discectomy and fusion than
interbody technique and finally lumbar disc after discectomy alone [9].
replacement. Indications, clinical results and The various posterior
methods of fusion, espe-
complications of the different methods will be cially the Hibbs method
were found to be associ-
considered and the comparative studies of spinal ated with a pseudarthrosis
rate of 2040 % and
fusion with lumbar disc arthroplasty will be 50 % in two level fusions
[1013].
analysed. Because of the strong similarity in sur- In an attempt to
improve the fusion rate alter-
gical approach between anterior lumbar native methods were
developed e.g. the
Applications of Lumbar Spinal Fusion and Disc Replacement
583
intertransverse fusion of Watkins [14] and an acceptable complication

rate and low inci-
Adkins [15], posterior lumbar interbody fusion dence of neurological
damage.
by Cloward 1953 [16], James and Nesbit 1953 Although internal
fixation became increasingly
[17], and Adkins 1955 [15] and anterior lumbar sophisticated and reliable
there are a number of
interbody fusion by Mercer 1936 [18], Harmon studies showing that the
addition of internal fixa-
1960 [19], and Freebody 1964 [20]. tion produced a higher rate
of fusion, but this did
Internal fixation was introduced in an attempt not necessarily equate to an
improved clinical out-
to improve the fusion rate and also shorten come in patients treated for
degenerative disc dis-
the period of immobilisation. (King 1948 [21], ease and chronic back pain.
Internal fixation
Boucher 1959 [22]). Originally the internal fixa- increased the cost of the
procedure and the com-
tion methods were not suitable for spondylo- plication rate, but did not
always produce improve-
listhesis despite some attempts at stabilization ment in outcome [33, 34].
However, instrumented
involving support of the transverse processes of fusion at the time of
posterior decompression for
the displaced vertebra (Nelson [23]). stenosis and degenerative
spondylolisthesis pro-
A large series of uninstrumented posterolat- duced better fusion rates.
It was originally thought
eral fusions with iliac crest autografts and that the results were no
better than with
long follow-up was reported from the Mayo uninstrumented
posterolateral fusion [35], but
Clinic with a radiographic fusion rate of 80 % later follow-up showed
improved long term out-
which correlated with a similar rate of clinical come [36] when fusion was
achieved.
success [24]. Besides posterolateral
fusion, there was
Internal fixation devices for correction and a vogue for posterior lumbar
interbody fusion
fusion of scoliosis were developed [2527] and The posterior lumbar
interbody fusion (PLIF)
whilst these could be used as supportive treat- procedure was first
described in 1944 by Briggs
ment for spinal fractures and after spinal tumour and Milligan [37], who used
laminectomy and
resections, they were not usually appropriate for bone chips in the disc
space. In 1946, Jaslow
back pain fusions for degenerative disc disease, modified the technique by
positioning an excised
which usually only involved one or two motion portion of the spinous
process within the
segments. intervertebral space [38].
Adaptations were introduced to make the Although Cloward used
the technique of
Luque wiring method more appropriate for lum- interbody fusion using iliac
crest autograft blocks
bar fixation, resulting in the Hartshill Rectangle as early as 1940, it took
him until 1953 to publish
[28] with sublaminar wire fixation. his experience [16]. His
extensive use and
Cotrel and Dubousset designed special rods expanded indications of the
PLIF technique led
and hooks that allowed rotational control of the to further publications of
large series over the
spine in the treatment of scoliosis [29]. next 30 years [39, 40].
Although a better rate of
Transpedicular screws and plate systems (later spinal fusion was achieved,
the increased com-
screws and rod fixation) revolutionised the inter- plexity of the PLIF approach
was associated with
nal fixation of the spine and allowed much stron- higher rates of dural and
nerve injury. The higher
ger fixation than with any other fixation system complications discouraged
many surgeons until
[3032]. These allowed stabilization, even when the advent of interbody,
moulded fusion cages,
the spinous processes and laminae were missing. made either of carbon,
stainless steel, titanium or
They allowed improved correction of spinal polyether ether ketone
(PEEK) and more sophis-
deformity, better reduction and stabilization of ticated instrumentation to
allow safer insertion of
spinal fractures, spinal support after resection of the interbody devices [41
43].
primary tumours and spinal metastases, treatment The cages were based
upon a precursor used to
of high grade spondylolisthesis, spinal instability fuse the cervical spine in
horses with wobbler
and back pain due to degeneration all these with syndrome [44].
584
A modification of the lumbar interbody a 44 % pseudarthrosis rate

was reported.
fusion technique- transforaminal lumbar inter- In addition to the
unimpressive results, compli-
body fusion was introduced by Harms and cations included
thromboembolism, graft
Jeszenszky in 1998 191 cases were treated in extrusion, paralytic ileus,
cardiac arrest and
this way over a 4 year period with very satisfac- infection.
tory results in spondylolisthesis, post-discectomy Mayer re-kindled the
interest in anterior lumbar
syndrome, degenerative scoliosis and spinal interbody fusion by devising
a less invasive mini-
stenosis [45]. The approach was unilateral with ALIF approach with excellent
results and low
partial or total excision of the facet joint which morbidity [50]. This approach
was often used in
allowed access to the foramen for the exiting conjunction with posterior
instrumentation in
nerve and a lateral entry point to the the form of pedicle screws or
translaminar screw
intervertebral disc for discectomy and prepara- fixation, but there is
evidence that stand-alone
tion of the vertebral end-plates with insertion of anterior lumbar fusions are
just as good and there
a single cage packed with bone graft. The lateral is probably no need for
posterior fixation [51].
approach increased the safety of the procedure Some advocated revision
surgery with anterior
and reduced the incidence of nerve damage and fusion in patients with
persistent pain despite
dural tears. sound posterior fusions [52].
There was a percep-
The transforaminal approach allows excellent tion that discogenic pain
was not addressed
decompression of the exiting nerve in the fora- fully by posterior surgery.
This in turn increased
men and restoration of disc space height with the vogue for 360#
(Anterior,lateral and
concomitant enlargement of the foramen which posterior) fusion surgery.
makes it an ideal treatment for the lytic spondylo-
listhesis with nerve entrapment in the foramen.
The unilateral approach carries the additional Lateral Transpsoas Interbody
Fusion
advantage of preserving the anatomy on the con- (Extreme Lateral Interbody
tralateral side. Fusion XLIF)
The trans-psoas approach to

the lateral aspect of
the spine employs
sophisticated retraction and
Anterior Lumbar Interbody Fusion instrumentation systems that
allow interbody
fusions to be carried out
through very small
The anterior approach to the lumbar spine was incisions with minimal soft
tissue trauma [53].
first used in the treatment of spondylolisthesis The technique seems to be of
particular value in
[18, 46, 47]. the correction and fusion of
adult degenerative
Case reports or small series of anterior scoliosis, but it is not
without complications.
interbody fusions prevailed until enthusiasts Damage to the lumbar plexus
can occur so that
began to report much larger series with the psoas weakness and thigh
numbness are not
extended indication of treating back pain due to uncommon. The precise place
of this procedure
degenerative disc disease [20, 48]. Improvement is still uncertain.
was reported in 90 % of cases and similar rates of
sound fusion were found radiographically.
Despite these favourable reports the anterior Spinal Fusion for
Degenerative
lumbar fusion approach was discredited by Disc Disease
review of a large series from the Mayo Clinic
by Stauffer and Coventry [49]. They found The surgical treatment of
chronic back pain due
improvement in only 36 % of patients and to degenerative disease of
the spine has become
585
the commonest indication for spinal fusion sur-

gery. Despite the enthusiasm for this treatment,
favourable outcome is only achieved in around
6070 % of cases and, in a multicenter
randomised controlled trial, spinal fusion was
no better than a structured functional restoration
programme consisting of education, physio-
therapy and the contribution of a clinical
psychologist [54].
In analysis of outcome from the Swedish
Spine Registry the results were equivalent for
surgery undertaken posteriorly, posteriorly with
instrumentation or through combined anterior
and posterior surgery (circumferential or 360#
Fig. 1 The Charite III
prosthesis. Reproduced with per-
fusion) [55].
mission and copyright # of
the British Editorial Society
of Bone and Joint Surgery
(Mayer HM. Total lumbar disc
replacement. J Bone Joint
Surg [Br] 2005;87-B:
1029-1037 Fig. 4)
Lumbar Intervertebral Disc
Replacement Although initial reports
were favourable the tech-
nique never progressed,
probably because of end-
Lumbar disc replacement or arthroplasty surgery plate penetration by the
stainless steel spheres and
developed for three reasons: inevitable subsidence [59].
1. Dissatisfaction with the unpredictable results At the Charite Hospital
in East Germany
of spinal fusion for degenerative back pain. a disc replacement was
developed by Schellnack
2. The desire for preservation of motion in the and Buttner-Janz in 1982
and modified to
diseased segment. the type II in 1984 and
Charite III version
3. An attempt to reduce the potential for adverse in 1987 [60, 61]. This is an
unconstrained
biomechanical effects of fusion upon adjacent prosthesis consisting of
metallic end-plates
segments of the spine. (Cobalt Chrome Molybdenum)
lined by plasma
sprayed Titanium and a
coating of calcium phos-
phate to promote bone
ingrowth. The core con-
History of Lumbar Disc Replacement sists of biconvex ultra-high
molecular weight
polyethylene with freedom to
move on the
There are currently large numbers of different biconcave end-plates. Tooth-
like projections
lumbar disc replacement prostheses, but many allow primary stability
whilst secondary stability
only have very short follow-up and remain results from bone ingrowth
into the porous
unproven. Therefore only three will be men- coating (Fig. 1).
tioned as they have had longer follow-up and The Prodisc L prosthesis
(Synthes, Paoli,
have been subjected to greater scrutiny. Pennsylvania) was developed
in France in the
An excellent review of this topic was published 1980s and was reported by
Marnay [62, 63].
by Mayer in 2005 [56]. This is a semi-constrained
device consisting
The first attempt at disc replacement involved of two Cobalt Chrome
Molybdenum alloy
the use of stainless steel balls placed between the end-plates with an insert of
UHMWPE
vertebral bodies. They were devised by Fernstrom inlay which clips into a
fixed position during
and first implanted by Harmon [57, 58]. the procedure. The shape of
the insert and the
586
Fig. 3 The Maverick disc

prosthesis (Reproduced with
permission and copyright
# of the British Editorial Soci-
ety of Bone and Joint
Surgery (Mayer HM. Total lumbar
disc replacement. J Bone
Joint Surg [Br] 2005;87-B:1029-
1037 Fig. 6))
Fig. 2 The Prodisc-L Prosthesis (Reproduced with per-

mission and copyright # of the British Editorial Society
of Bone and Joint Surgery (Mayer HM. Total lumbar disc disease, recurrent disc
herniation and post-
replacement. J Bone Joint Surg [Br] 2005;87-B:1029- discectomy back pain.
1037 Fig. 5) Between 70 % and 85 %
of the population
suffer from low back
pain at some time in
their lives. The annual
incidence of back pain
fact that it is not free to move mean that the in adults is 15 % and
its point prevalence is
axis of flexion and extension is fixed and approximately 30 %. Low
back pain is the primary
the movements are semi-constrained. The device cause of disability in
individuals younger than
has central, sagittally-orientated keels which 50 years [65].
fit into slots created in the vertebrae by the Potential sources of
low back pain include
specific instrumentation. This provides primary the intervertebral
discs, facet joints, vertebrae,
fixation and the plasma sprayed titanium coating neural structures,
muscles, ligaments, and
allows for secondary fixation through bone fascia.
ingrowth (Fig. 2). Changes in disc
volume and shape occur
The Maverick disc prosthesis (Medtronic almost universally with
aging. In as many as
Minneapolis Minnesota) is a metal-on-metal 90 % of individuals, the
lumbar discs may
implant with a ball and socket design and develop degenerative
changes by the age of
a posteriorly situated, fixed axis of flexion and 50 years.
extension (semi-constrained). Good preliminary Fissures and cracks
usually develop between
results were reported in 2004 [64] (Fig. 3). the lamellae and may
establish channels of com-
munication between the
peripheral layers of the
annulus and the nucleus.
Disc tissue can herniate
Indications for Lumbar Disc through these cracks.
Replacement The relationship
between intervertebral disc
degeneration and low
back pain is not clearly
Whereas spinal fusions can be used to treat infec- understood. It appears
that alteration in biome-
tion, spinal deformity, spondylolisthesis, tumour, chanical properties of
the disk structure, sensiti-
fractures and degenerative back pain, the indica- zation of nerve endings
by neurovascular
tions for disc replacement are much more ingrowth into the
degenerated disks all
restricted and are confined to degenerative disc may contribute to the
development of pain.
587
There is also a biochemical basis for discogenic Traditionally, fusion has

become the gold
pain with abnormal release of cytokines from standard in the surgical
treatment of degenera-
degenerate discs These are pro-inflammatory tive disease in the lumbar
spine, but in the light of
mediators [66, 67]. unpredictable outcome after
fusion, this accolade
would seem unduly
flattering.
Spinal fusion is an
expensive procedure
Manifestation and Diagnosis which can involve a long
hospital stay. It has
of Discogenic Back Pain a significant rate of
complications and consider-
able morbidity.
Discogenic low back pain is non-radicular Recuperation is lengthy
and return to work can
and occurs in the absence of spinal deformity, be delayed.
instability and signs of neural tension [68]. The posterior approach to
the spine inevitably
In the absence of evidence of disc pathology causes damage to the
paravertebral muscles which
on radiological images, it may be impossible are so important in
subsequent functional recov-
to localise a painful disc from the symptoms and ery. Failure of fusion
remains a problem even with
the signs elicited on physical examination. the use of sophisticated
instrumentation.
Although MRI may identify a degenerative The use of screws and
cages tends to increase
disc (a black disc), it will not differentiate neurological and vascular
risks. The reported inci-
between a disc which is pathologically painful dence of these complications
varies, but a meta-
and one which is physiologically ageing. analysis of 47 publications
found a 9 % risk of
Moreover, intervertebral disc degeneration is significant donor site pain
and a pseudarthrosis
commonly seen on MRI in asymptomatic rate of 14 % [71].
subjects [68]. A particular concern with
rigid fusion is the
Discography is used in diagnosing discogenic transfer of stress to
adjacent segments.
back pain, but its reliability is questionable. This may cause
symptomatic degenerative
The key feature of discography is the reproduction disease in the long term and
may require further
of the pain felt by the patient on stimulation surgery in up to 20 % of
patients in 5 years and
of the disc. Some claim high accuracy perhaps even 37 % within a
decade following
and specificity of discography [68], but successful lumbar fusion.
Carragee assessed the outcome of fusion spinal This risk may lead to the
exclusion of many
surgery in patients with single level discogenic very deserving patients from
consideration for sur-
pain as confirmed by discography and con- gery if the adjacent
segments show any existing
cluded that discography failed to identify a sign of degeneration, even
if this is asymptomatic
single segment pain generator in 50 % of [7274].
patients [69]. An association has been demon- An alternative surgical
procedure, total disc
strated between high intensity zones visible replacement, has increased
in popularity.
on MRI and the incidence of discogenic back The purpose of this
technique is to restore and
pain [70]. maintain spinal segment
motion, which is pre-
sumed to prevent adjacent
level degeneration at
the operated levels, while
relieving pain [75].
Treatment Options for Discogenic The design of total disc
prostheses needed to
Back Pain take into account the aims
of total disc arthroplasty:
1. Restoration of
physiological kinematics
Most of these individuals can be treated success- and mobility, whilst
avoiding segmental
fully without recourse to surgery, but some have instability;
persistent back pain which may be amenable to 2. Restoration of correct
spinal alignment and
surgical treatment. sagittal balance;
588
3. Protection of the biological structures, such In a prospective

randomized trial FDA-
as the adjacent intervertebral discs, the supported multi-center
study in the USA [78],
facet joints and the ligaments, from increased 304 patients with DDD who
failed conservative
loading which could lead to rapid treatment were randomised
for either lumbar
degeneration; total disc replacement with
Charite disc or ALIF
4. Device stability and wear properties [76]. surgery using the BAK cage
and iliac crest bone
Significant facet joint osteoarthritis is a graft, and followed for 24
months. The range of
contra-indication to the procedure and yet, it is motion in the operated
level of the arthroplasty
difficult to identify in its early stages. The use of group gradually increased
to a level of 113.6 %
total disc replacement may be limited to the compared to pre-operative
range of motion (final
treatment of early degenerative disc disease range of motion exceeded
the pre-operative range
with preservation of disc height thereby eliminat- by 13.6 %).
ing its uses in the majority of patients [75]. There was a mean range
of motion of 7.5# at
The fate of facet joints following a total disc 24 months, including
subjects with suboptimally-
replacement is unknown and facet joint hypertro- placed prostheses.
phy, which accelerates spinal stenosis, may be a A prospective Canadian
study that followed
potent long-term complication. 57 patients with
degenerative disc disease who
Anterior revision procedures are bound to underwent disc replacement
with the Charite III
be technically difficult with a significant prosthesis with average
follow-up of 55 months
risk of vascular injury, particularly at the L4/5 (27 years) showed that
motion was maintained
level. at the replaced segment
with a mean flexion-
A summary of the indications and contra- extension range of 6.5#
that compares favourably
indications for disc replacement is as follows: with the sagittal rotation
reported in the
Young, active patients with chronic dis- literature [79].
cogenic low back pain, reproduced by discogra- Cinotti et al. reported
46 patients undergoing
phy, little facet disease, and good bone stock, are artificial disc replacement
with Charite SB III
the ideal candidates for arthroplasty. disc prosthesis with a mean
follow-up of 3.2
Instability and deformity are strong years (range 25 years).
contra-indications to lumbar arthroplasty, partic- The vertebral motion
averaged 9# (range
ularly with an unconstrained prosthesis design. 015) at the operated level
with four patients
Although there are proponents of expanded developing spontaneous
fusions [80].
indications for semi-constrained prostheses, evi- Tropiano et al.
reported on 53 patients who
dence of safety and effectiveness in these patients underwent Pro-Disc II
lumbar disc replacement
has not been proven [77]. [63]. Forty patients had
surgery at one level,
11 patients at two levels
and two patients at
three levels. The mean
follow-up time was
Motion Preservation 1.4 years (range 12
years).
At L5S1, the
flexion/extension range of
The whole concept of disc arthroplasty is based motion averaged 8# (range
212) at the operated
upon preservation of motion of the operated level level. At L4-5, the range
of motion averaged 10#
so it is important to consider the evidence for (818) at the operated
level.
motion preservation. Bertagnoli and Kumar
reported on 108
Many studies show results of relatively short patients undergoing total
disc replacement with
follow-up with significant improvement and even the Pro-Disc II implant
[81]. Ninety-four patients
restoration of a normal range of motion in the underwent surgery at one
level, 12 at two levels
operated level. and two at three levels.
589
Range of follow-up time varied from 3 months

to 2 years, with 54 patients (50 %) having more Adjacent Segment
Degeneration
than 1-year follow-up.
There were no implant failures and the aver- The second main theoretical
benefit behind disc
age range of motion at L5S1 was 9# (range replacement is preservation
of the adjacent
213) and at L4-5 was 10# (range 815). segment.
The above studies had the limitation of a Maintaining motion at
the operated segment
short follow-up. By contrast, Putziers is the can theoretically reduce the
over-loading and
only long-term follow-up study and yielded subsequent rapid
degeneration of the adjacent
much less favourable results with regard to motion segments.
motion preservation [82]. In this retrospective One should remember that
it is difficult to
clinical and radiological analysis of 84 Charite differentiate between true
surgery-related adja-
discs (71 patients, operated between 198489) cent segment degeneration
and the natural pro-
after an average follow up of 17.3 years cess of spinal degeneration.
(14.519.2 years) a segmental mobility of 3# or There is considerable
debate in the available
less was graded as Ankylosed whilst a segmen- literature regarding the
definition and pre-
tal mobility of more than 3# was graded as valence of adjacent segment
degeneration
mobile. (ASD) following spinal
fusion and disc
The results of this study are not favourable and arthroplasty and the actual
clinical significance
show that 60 % of the patients had definitive of the changes.
ankylosis at long term follow-up due to
high grade anterior heterotopic ossification. One
of the possible explanations for this high rate General Definitions
of heterotopic ossification is the surgical
technique which included repair of the anterior After lumbar spinal surgical
intervention such as
longitudinal ligament, now known to trigger arthrodesis or arthroplasty,
the radiographic
ossification. presence of disc
deterioration adjacent to the
There are two French studies with 10-year surgically-treated disc is
referred to as: Adjacent
follow up where motion was preserved. Segment Degeneration
(ASDeg).
In Thierrys series of 106 patients, seven cases This must be
differentiated from Adjacent
of ossification were found, four of them partial and Segment Disease (ASDis)
which is the
asymptomatic. Mean range of motion at the oper- development of clinically
symptomatic junctional
ated level at the end of follow up was 10.1# of degeneration [84]. ASDis may
lead to additional
flexion-extension and 4.4# of lateral bending [77]. surgery and thus impact
negatively on functional
Lemaire et al, retrospectively reported on outcome, as opposed to ASDeg
which is
107 patients (147 implants) following Charite purely a radiographic
finding without associated
disc replacement between 1989 and 1993 and symptoms.
followed for an average of 11.3 years [83].
Three cases of heterotopic ossification were
noted, 2 of them affecting the implant mobility. ASDeg and ASDis Following
Lumbar
Mean range of motion was 10.4# of flexion- Fusion
#
extension and 5.4 of lateral bending.
The differences in these series raise questions There is wide variation in
the reports regarding
about prosthetic design and the influence of sur- the incidence of lumbar
ASDeg (5.2100 %)
gical technique upon the rate of heterotopic and ASDis (5.218.5 %)
following lumbar
ossification. arthrodesis [84].
590
Ghiselli et al reported the largest single series disc degeneration correlated

with a decreased
of patients managed with a posterior lumbar overall lumbar range of
motion. Patients with
arthrodesis in which junctional degeneration was motion of 5# or greater had
a 0 % prevalence of
assessed. 215 patients were assessed at an average ASD degeneration, whereas
patients with less
follow up of 6.7 years. They found an incidence than 5# motion had a 34 %
prevalence of ASD
of ASDis of 16.5 % at 5 years and 36.1 % at degeneration. However,
despite these radiographic
10 years. Perhaps surprisingly, there was no changes there was no
significant correlation with
correlation between the number of levels of clinical outcome.
fused, i.e. the length of the lever-arm and the Putzier reported on 53
patients that underwent
degree of degeneration at adjacent levels [74]. a Charite I to III disc
arthroplasty procedure with
In Brantigans study adjacent segment degenera- a follow up over 17 years
and found a 17 % (9/53)
tion occurred in 61 % of patients, but was incidence of ASDeg changes
[82]. However, in
clinically significant only in 20 % at 10 years keeping with Huangs
findings, the degenerative
after lumbar fusion [85]. changes only occurred in
arthroplasty cases which
The systematic literature review by Harrop had ankylosed and had
limited motion.
et al calculated the incidence of ASDeg to The arthroplasty
patients that maintained their
be around 34 % and the incidence of ASDis motion (40 %) did not
develop any evidence of
to be approximately 14 % following a lumbar adjacent segment
degeneration.
arthrodesis [84]. Whilst lumbar disc
replacement reduces
In an attempt to evaluate the rate of natural the load on adjacent
segments of the spine,
ageing process of the non-operated spine, it is known to increase the
load on the facet
Hassett et al assessed the incidence of degenera- joints at the operated level
(which are off-loaded
tive spinal disease in a population of women over following successful fusion
surgery), and
a 9 year period and found it to progress at an that is why facet
arthrosis is considered to be
incidence of 34 % per year. This seems a contra-indication to disc
replacement.
similar to the spinal fusion population and sug- A 2.5-fold increase in facet
joint loading was
gests that ASDeg following spinal fusion is not measured following lumbar
total disc
significantly different from the natural ageing replacement [88, 89].
process of the non-operated spine [86].
Adjacent segment degeneration and adjacent
segment disease following lumbar disc Complications of Lumbar Disc
replacement. Arthroplasty
Most studies involve short follow-up and
cannot address the long term process of ASD. Complications can be divided
into:
The available data are products of the few 1. Those related to surgical
approach;
long-term studies. The systematic liter- 2. Those related to implant
survival and function.
ature review by Harrop et al. found that 9 % The complications of the
surgical app-
of arthroplasty patients were noted to have roach should be the same for
lumbar disc
ASDeg and only 1 % clinically symptomatic replacement and anterior
lumbar fusion as
ASDis. the surgical technique is
virtually identical.
This low level of symptomatic disease was also They include the risk of
bleeding from
reported by David -100 single level (L4L5 or the iliac vessels (the
bifurcation of the aorta
L5S1) arthroplasty patients with a 13.2 year aver- and vena cava is located
just anterior to the
age follow-up and 2.8 % incidence of ASDis [87]. vertebral column at L4-5
level), injury
Huang et al, using graphic motion analysis to the superior hypogastric
plexus of nerves
found 24 % of patients developed radiographic which in males can lead to
retrograde
evidence of ASDeg [87]. The authors noted that ejaculation.
591
Poor positioning of the implants or over- In the second series (75

patients) [91] the
distraction of the disc space can endanger the causes of persisting pain
were thought to be
nerve roots. related to the following
late-complications:
Post-operatively, the circumstances are differ- subsidence (39 cases),
adjacent degeneration in
ent as fusion involves a static implant and the various combinations (36
cases), facet joint
main anticipated complication is failure of fusion degeneration according to CT
scan (25 cases),
(pseudarthrosis) that could lead to pain and even prosthesis migration(6
cases) and wear of the
implant failure. disc prosthesis (5 cases).
When solid fusion is achieved the Van Ooij et al pointed
out that whilst
implant is off loaded, leaving mainly the degenerative disc disease is
supposed to be the
adjacent segment degeneration as a continuing main cause of the symptoms,
it is possible that
concern. the facet joints play a role
in the pain syndrome
Lumbar disc replacement employs a dynamic of most of these patients
[60]. Obviously,
implant, and with time there is an increased replacing only the
intervertebral disc would not
likelihood of implant failure or even address this pain source. A
normal intervertebral
unintended ankylosis of the treated motion disc has a shock-absorbing
function. The current
segment. prostheses, made from metal
and polyethylene
The relative impact of the two treatments upon or from metal alone, have
little shock-absorbing
adjacent segment degeneration has been capacity, and this should be
a matter of concern.
discussed above and is more favourable for the The fixation of a disc
prosthesis onto the ver-
motion-preserving arthroplasty. tebral end-plates is
questionable and some
In a meta-analysis of 47 papers on lumbar suggest that press-fit
fixation components with
fusions the most common problems following spikes, pegs, and posts are
inadequate after ten-
spinal fusions were: Pseudo-arthrosis (14 %) sile loading and may be
effective only for the
and chronic pain at the iliac crest bone graft relatively short term [92].
Subsidence of prosthe-
donor site. Less frequent complications were ses is encountered and it is
known that the central
venous thrombo-embolism (3.7 %) and neurolog- end-plate is relatively weak
and that only
ical injury (2.8 %) [71, 90]. the outer rim of the end-
plates contains
Implant failure: stronger bone. This implies
that the metal plates
In the 17-year follow up study after disc must be large enough to rest
on the periphery of
arthroplasty 23 % needed fusion surgery for the end-plates. A
disadvantage of larger plates
implant failure or pain [81]. is that they carry more risk
for compression
There were two reports of cohorts of patients of the exiting nerve roots
posterolaterally
referred to a tertiary center in the Netherlands and on the great vessels
ventrally.
following an unsuccessful lumbar disc replace- In males, temporary or
permanent retrograde
ment [59, 92]. ejaculation can result from
damage to the supe-
In the first series of 27 patients [59], early rior hypogastric plexus of
nerves on the
complications included 2 cases of early prosthe- anterior aspect of the
lumbosacral spine. This
sis dislocation, 2 cases of erectile dysfunction risk has been reported in
from 27 %
and retrograde ejaculation and 4 cases of [93]. Sasso et al found that
the risk was substan-
abdominal wall or retro peritoneal hematomas. tially greater with
transperitoneal compared to
Late complications included: degeneration of retroperitoneal approaches
[94].
facet joints at the same level, degeneration of The problems of
polyethylene and metal
facet joints and discs at neighboring levels, as debris caused by wear have
been investigated
well as subsidence and migration of the prosthe- extensively in hip and knee
replacements,
sis. In one patient, signs of polyethylene break- but little evidence exists
regarding these issues
down were seen. following lumbar disc
arthroplasty.
592
Although the clinical significance is

not yet known, a recent study on metal-on- Clinical Outcomes After
Lumbar Disc
metal disc replacements showed cobalt and Replacement and Lumbar Fusion
chromium levels that were elevated at all
post-operative time points, and similar in In the randomised controlled
trial that com-
magnitude to those seen in well-functioning pared the 2 year results of
304 patients with
metal-on-metal surface replacements of degenerative disc disease
randomised for either
the hip and in metal-on-metal total hip replace- Charite lumbar disc
replacement or anterior
ments [95]. lumbar interbody fusion using
the BAK cage
Reports of osteolysis after disc arthroplasty packed with iliac crest bone
graft both
exist [60, 96], but Lemaire et al in a pro- patient groups demonstrated
significant improve-
spective report of 100 followed for a mean of ment in the Oswestry
Disability Index (ODI,
11.3 years after implantation of Charite disc functional self assessment)
and the pain
replacements noted no patients with signs of levels determined by the
visual analogue
osteolysis [83]. scale [97].
The disc replacement
group demonstrated bet-
ter results at all stages of
follow-up. Patient satis-
Relative Safety of Spinal Fusion faction was also higher in
the LTDR group
and Lumbar Disc Replacement (73 % vs. 59 %) and when
asked whether
they would have the same
treatment again the
Comparative studies show a similar rate of com- answer at the end of follow-
up was positive in
plications for lumbar fusion and arthroplasty at 69.9 % of the patients in the
disc replacement
2 and 5 years group but only in 50 % of the
ALIF group
A prospective, randomized, multicenter (p 0.006) [97].
FDA study of 304 patients who underwent The need for narcotics
for pain control was
either lumbar total disc replacement with the lower in the disc replacement
group compared
CHARITE artificial disc or ALIF surgery, to the ALIF group at all
stages of follow-up
with 2 year follow-up, showed the following (at 24 months: 64 % vs. 80 %,
p 0.004) [97].
results: Assessment of the work
status before and after
1. Neurological complications were the same in surgery showed no significant
difference between
the two groups. the groups.
2. Pain at the bone graft donor site occurred in 18 At the end of follow-up
the clinical success
(18.2 %) of the ALIF patients. rate at the lumbar disc
arthroplasty group was
3. Device failures necessitating re-operation, 63.9 % compared to 56.8 % in
the ALIF group
revision, or removal occurred in 11 (5.4 %) (p 0.0004) [97].
patients in the disc replacement group and 9 In a prospective study of
57 patients who
(9.1 %) patients in the ALIF group. underwent disc replacement
(Charite III) and
4. There were no catastrophic device fail- followed for an average of 55
month (27 years)
ures resulting in death or injury in either an improvement of 50 % in
ODI, VAS and
group. SF-36 was achieved compared
to pre-operative
5. Approach-related complications occurred in scores [79].
20 (9.8 %) of the disc arthroplasty patients In Lemaires prospective
report of 100
and 10 (10.1 %) of the ALIF patients. patients followed for a mean
of 11.3 years excel-
6. The overall complication rate was similar. lent clinical outcome was
achieved in 62 % of the
7. The short follow up did not permit patients, good in 28 % and 10
% of patients
assessment of the impact of the pro- experienced a poor outcome
[83].
cedures upon the adjacent segments of the In four published
randomised studies compar-
spine [97]. ing disc prosthesis with
fusion, the clinical
593
Fig. 4 Supine,
Trendelenburg position
with pillow to flex knees
and hips. A urinary catheter
and intermittent calf
compression are in place
Fig. 5 A gel pad is placed beneath the spine for posterior

support
Fig. 7 A metal
marker is used with fluoroscopy to mark
the ideal skin
incision for access to the correct level of the
spine in this
case L5-S1 with lytic spondylolisthesis
Fig. 6 A metal marker is used with fluoroscopy to mark Fig. 8 A metal

marker is used with fluoroscopy to mark
the ideal skin incision for access to the correct level of the the ideal skin
incision for access to the correct level of the
spine in this case L5-S1 with lytic spondylolisthesis spine in this
case L5-S1 with lytic spondylolisthesis
594
Fig. 9 The surgeons attach

the synframe and make sure
that there is no pressure
upon the patient
outcome of disc prosthesis was at least equivalent Abdominal surgery should

be accompanied by
to that of fusion [97100]. effective thromboprophylaxis
using the combina-
A recent Norwegian study has shown tion of intra-operative and
post-operative inter-
better improvement of function (measured mittent calf compression
boots and low molecular
by the Oswestry Disabiity Index) after disc weight heparin administered 6
h after completion
replacement in comparison to a rehabilitation of the operation and
continued until the patient is
programme involving a multidisciplinary team discharged from hospital.
using cognitive therapy and physiotherapy [101]. The position on the
operating table is
Operative techniques for lumbar disc replace- supine with a pillow beneath
the lower limbs to
ment and spinal fusion keep the hips and knees
slightly flexed (Fig. 4).
We will concentrate upon the similarities of This takes the tension off
the iliac vessels
the anterior approach for the two operations. and lumbosacral plexus, thus
making retraction
The surgical approach is usually retroperitoneal safer [102]. The
Trendelenburg position is
for the L4-5 and higher lumbar levels, but the helpful in keeping the small
bowel retracted
L5-S1 level can be approached retroperitoneally during a transperitoneal
approach.
or transperitoneally. For the purposes of illustra- In order to provide
posterior support
tion only, we shall describe the transperitoneal and prevent sagging of the
vertebral column,
access to L5-S1 for an anterior lumbar a gel pad can be placed
beneath the patient.
interbody fusion using a Synfix cage (Synthes) (Fig. 5)
and graft and the retroperitoneal approach to the By placing a metal marker
on the anterior
L4-5 level for a Prodisc II (Synthes) lumbar disc abdominal wall and using
fluoroscopy the ideal
replacement. location of the skin incision
can be marked.
For both procedures a general anaesthetic is (Figs. 68).
administered via a cuffed endotracheal tube. The synframe retractor
(Synthes) is attached
Prophylactic antibiotics are administered with to its table mountings and
placed carefully in
the induction of anaesthesia and currently we use order to avoid pressure upon
the patients
the combination of Teicoplanin and Gentamicin. abdomen (Fig. 9).
595
W X
Left triangular ligament of liver
Upper recess of omental bursal

A
A
Coronary ligament of liver
Oesophagus
Left gastric artery
Spiencrenal ligament
Right triangular ligament of liver
Epiploic foramen
B
B
Cut edge of lesser omentum
Common hepatic artery
C
C
Root of transverse mescoolon
adherent to posterior layers
of greater omentum
Root of the mesertery
Root of sigmoid mescoolon
W X Y
Fig. 10 Transperitoneal approach directly between iliac vessels. (reproduced from

Grays Anatomy with kind
permission from Elsevier)
Transperitoneal Approach to L5-S1
The spine at L5-S1 can be approached retroperi-

toneally or transperitoneally. As the procedure is
carried out in the mid-line between the iliac ves-
sels, the transperitoneal approach gives rapid,
direct access to the anterior aspect of the lumbo-
sacral junction (Fig. 10).
Through a vertical mid-line skin incision
below the umbilicus, the rectus sheath is
exposed and the linea alba incised in the mid-
line. This allows access to the peritoneal sac
which is elevated on a clip and incised
(Figs. 1113).
Moist packs are used to keep the small
bowel retracted and expose the posterior
peritoneum overlying the spine (Fig. 14). After
incising the posterior peritoneum, it and the auto-
nomic nerves of the superior hypogastric plexus Fig. 11 Midline sub-
umbilical incision with incision along
are carefully peeled away from the spine and the linea alba to part the
rectus abdominis muscles. The
retracted gently (Fig. 15). peritoneum is picked up
and opened with dissecting scissors
596
Fig. 12 Midline sub-umbilical incision with incision along

the linea alba to part the rectus abdominis muscles. The Fig. 14 Moist swabs
pack the loops of small bowel away
peritoneum is picked up and opened with dissecting scissors and the posterior
peritoneum is exposed overlying the disc
Fig. 15 The posterior

peritoneum is incised and carefully
cleared using a Lahey
swab to expose the anterior longi-
tudinal ligament and
intervertebral disc
Fig. 13 Midline sub-umbilical incision with incision along

the linea alba to part the rectus abdominis muscles. The With the bone
levers placed laterally, the
peritoneum is picked up and opened with dissecting scissors Synframe retractors
are inserted superiorly and
inferiorly to allow
good access to the disc space
(Fig. 16).
Once the vertebral column is well visualized When safe access
is established, the
the synframe bone levers can be placed either side intervertebral disc
can be excised and removed
of it and attached to the synframe. Because they (Figs. 17 and 18).
have sharp points that can find their way into the The vertebrae are
distracted by insertion of a
spinal foramina, it is neccessary to wrap some spreader and this
allows thorough curettage of the
Surgicel around the tips of the levers to prevent end-plates to remove
all disc remnants and the
damage to the exiting spinal nerves. end-plate cartilage
(Figs. 19 and 20).
597
Fig. 16 A Synframe bone lever is placed on either side of

the intervertebral disc and synframe retractor blades
placed superiorly and inferiorly
Fig. 19 Using an
intervertebral spreader and curettes, the
cartilaginous end-
plates are removed to expose bleeding
bone
Fig. 17 The intervertebral disc is incised and removed

with rongeurs
Fig. 20 Using an
intervertebral spreader and curettes, the
cartilaginous end-
plates are removed to expose bleeding
bone
When the disc space

has been cleared the
Synfix trial can be
used to judge the optimal
size of cage to be
used. As large a footprint as
possible should be used
and at L5-S1 angled end-
plates are necessary
usually requiring a 12#
cage. Fluoroscopy is
used to help judge the
choice of cage (Figs.
21 and 22).
The Synfix cage is
filled with bone graft.
This can be autogenous
or allograft bone,
Fig. 18 The intervertebral disc is incised and removed but we prefer synthetic
bone in the form of
with rongeurs tricalcium phosphate
granules in a conformable
598
Fig. 21 Trial Synfix cage introduced with fluoroscopy to

check ideal size and placement
Fig. 23 The squid is
used to introduce the Synfix cage
containing bone graft
Fig. 22 Trial Synfix cage introduced with fluoroscopy to

check ideal size and placement
Fig. 24 The squid is
used to introduce the Synfix cage
containing bone graft
gel (Actifuse ABX). The specially designed

squid introducer allows ready insertion of the
device into the disc space (Figs. 23 and 24). which engages firmly
into the threaded
The well-seated cage is fixed into place holes in the cage (Fig.
25). Radiographic confir-
using four cancellous screws which anchor mation of position and
fixation is important
the cage securely and also have a thread (Figs. 26 and 27).
599
Fig. 25 Synfix cage fixed in place with 4 cancellous

screws
Fig. 27 Show radiographic

appearances lateral and
anteroposterior views
favoured. This is done on

the left side to allow
the peritoneum and
peritoneal contents to be
retracted to the right (Fig.
28).
Through the transverse
skin incision, placed
optimally after fluoroscopic
marking, the rectus
sheath is exposed in the
mid-line and to the left
side. Then the left anterior
rectus sheath is
exposed vertically (Figs. 29
and 30).
The left rectus is freed
from the anterior sheath
and retracted medially.
(Figs. 31 and 32). The
posterior rectus sheath is
thus exposed.
By going below the
arcuate line of the poste-
rior rectus sheath, the
peritoneum can be sepa-
rated off the sheath. Then
the arcuate line and
posterior sheath itself are
incised to allow better
Fig. 26 Show radiographic appearances lateral and
access (Fig. 32).
anteroposterior views
The peritoneal sac and
its contents can be
reflected medially until the
vertebral column is
exposed (Figs. 33 and 34).
It is important to
Retroperitoneal Approach to L4-5 retract the left common
iliac vessels carefully
to avoid damage to them and
particular to the
The anaesthetic and positioning are identical to iliolumbar veins which have
variable anatomy
the transperitoneal approach described above. and, if torn, can lead to
brisk haemorrhage.
However, for the retroperitoneal approach to the In dealing with these veins
it is also possible
higher levels, a transverse skin incision is for them to pull off the
iliac vein resulting in
600
W X Y
Left triangular ligament of liver
Upper recess of omental burse

A
A
Oesophagus
Coronary ligament of liver
Left gastric artery
Splenorenal ligament
Right triangular ligament of liver
Epiptoic foramen
B
B
Cut edge of lesser omentum
Common hepatic artery
C
C
Root of transverse mesccolon
adherent to posterior layers
of greater omentum
Root of the mesentery
Root of sigmoid mesccolon
W XY
Fig. 28 Peritoneal reflections arrow indicates retroperitoneal access.

(Reproduced from Grays Anatomy with kind
permission from Elsevier)
Once the spine is

exposed, fluoroscopy in the
anteroposterior plane
is used to locate the mid-
line with an
injection needle. Then, an osteotome
is used to mark the
mid-line across the adjacent
vertebrae (Figs. 35
37).
Then the
intervertebral disc is totally excised
(Fig. 38).
Once the disc has
been excised and the end-
plates cleared of all
disc and cartilage it is
important to release
the posterior longitudinal
ligament all the way
across using fine
Kerrison rongeur
punches (Fig. 39). Without
this step the
prosthesis will be under posterior
tension, cannot
articulate properly and tends to
be extruded.
Fig. 29 A transverse skin incision is followed by
a vertical splitting of the left anterior rectus sheath Trial implants
are used to determine the ideal
size for the patient
(Fig. 40). Then the trial is placed
an even more major bleed from the common iliac with a stop to
prevent it extending too far posteri-
vein itself. A cadaveric study has highlighted the orly while the chisel
is passed through the slot in the
hazards of variable anatomy and the proximity of trial. This cuts the
slots in the vertebral end-plates
the lumbosacral plexus to these veins [103]. for the keels on the
prosthesis (Figs. 41 and 42).
601
a b
Fig. 30 Transverse skin incision is followed by a vertical splitting of the left

anterior rectus sheath
Fig. 31 After opening the left rectus sheath the left rectus
abdominis muscle is retracted medially to expose the Fig. 33 The
peritoneal sac and contents are reflected off
posterior rectus sheath the posterior
abdominal wall revealing the psoas muscle
Fig. 32 Arrow shows arcuate line of posterior rectus Fig. 34 Retraction

medially allows exposure of the
sheath incised after separating it from the peritoneum intervertebral disc
602
Fig. 35 The mid-line is determined with an injection

needle and fluoroscopy
Fig. 38 Shows excision
of the intervertebral disc
Fig. 36 The mid-line is marked on the adjacent vertebral

bodies using an osteotome Fig. 39 Disc clearance
and division of the posterior lon-
gitudinal ligament
Fig. 40 Shows insertion

of trial implant with adjustable
stop
Fig. 37 Shows mid-line marking
The end plates of the Prodisc C prosthesis are with a mallet. This
process must be done with
fitted onto the introducer and locked in place. fluoroscopic control.
Once the end-plates of the
After engaging the keels in the vertebral end- prosthesis are securely
fixed within the vertebral
plate slots the prosthesis is tapped into place bodies, the polyethylene
insert is passed along
603
Fig. 41 Chisel inserted to cut the slots for the keel
Fig. 44 Polyethylene insert

sliding down introducer
Fig. 42 End-plates of the prosthesis on inserter Fig. 45 Prodisc C

prosthesis and insert in place
Wound Closure
The wound is closed in

layers with synthetic,
absorbable sutures
(Polyglycolic acid), taking
care to close any
inadvertent openings in
the peritoneum and both
layers of the rectus
sheath are repaired. After
the mid-line approach
a strong loop PDS suture is
used for a mass
closure of the anterior
abdominal wall. The
skin is approximated with a
subcuticular stitch
and steristrips.
No drains are necessary.
Fig. 43 Prosthesis inserted
Post-Operative Care
grooves in the introducer and clicked into place
(Figs. 4345). The patient receives opiate
analgesia which can
Satisfactory seating of the device is confirmed be in the form of patient
controlled analgesia via
on fluoroscopy (Figs. 46 and 47). an intravenous line and
infusion pump, but we
604
favour the use of a small

dose of morphine and
Bupivicaine injected into
the CSF via a a 25
Guage spinal needle. This is
given at the end of
the operation and provides
excellent analgesia for
the first 1224 h.
Sometimes a paralytic
ileus occurs post-oper-
atively, but is usually of
short duration so we do
not restrict fluids or food
intake for more than
a few hours after surgery.
The patient sits out and
walks on the first post-
operative day and when they
can manage to visit
the bathroom the urinary
catheter is removed.
The low molecular weight
heparin injections
and mechanical DVT
prophylaxis (calf compres-
sion) continue until the
patient is fully mobile and
ready for discharge from
hospital. They are usu-
ally ready for discharge
after 34 days.
For fusion or disc
replacement we use a lum-
bar support for the first 4
weeks after which
physiotherapy exercises
commence. Activities
are increased according to
comfort.
Post-operative
radiographic and clinical
Fig. 46 A-P and lateral radiographs post-operatively checks are at 6 weeks, 3
months and 6 months.
Times to return to work
and to active sport
vary according to the
patient and their perceived
progress. We impose as few
restrictions as possi-
ble and encourage resumption
of all activities in
a graduated way.
Summary and Conclusions
1. Spinal fusions have been

carried out in various
forms for over 100 years
and have a proven
record in dealing with a
whole range of spinal
pathology.
2. Lumbar disc arthroplasty
is a more recent
development with
restricted indications includ-
ing degenerative disc
disease, post- discectomy
back pain and recurrent
disc herniation.
3. Comparative randomised
controlled trials
have shown that lumbar
disc arthroplasty is
at least equivalent to
spinal fusion after fol-
low-up for 5 years.
4. Both procedures can be
carried out anteriorly
through a retroperitoneal
approach so the
complications are similar
and mainly
Fig. 47 A-P and lateral radiographs post-operatively approach-related.
605
5. The long term effects of polyethylene 18. Mercer W.

Spondylolisthesis. Edinburgh Med J NS.
and metal wear debris remain uncertain, but 1936;43:545.
19. Harmon PH.
Anterior extraperitoneal lumbar disk
may produce late complications of disc excision and
vertebral body fusion. ClinOrthop.
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Bendall R, Taylor RD. Anterior
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Spinal Osteotomy Indications
and Techniques
Enric Caceres Palou
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 610 Corrective osteotomies are used to treat sagit-
tal and coronal imbalance of the spine in

Sagittal
Imbalance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
patients with a variety of spinal deformities.

Initial Work-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 610 It is important to be able to recognize the type
Assessment of Correction . . . . . . . . . . . . . . . . . . . . . . . . . . 612
and underlying cause of the deformity so that
the most appropriate osteotomy can be chosen.

Deformity Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
613
Smith-Petersen Osteotomy (Posterior Element
The Smith-Petersen osteotomy is relatively
Wedge Resection) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
613 simple compared with the other osteotomies and
Pedicle Subtraction Osteotomy . . . . . . . . . . . . . . . . . . . . .
614 can typically be used to treat type-1 deformities.
Vertebral Column Resection . . . . . . . . . . . . . . . . . . . . . . . .
617
Also, curves that have a relatively smooth

Selection of the Appropriate Osteotomy
kyphosis instead of a sharp angular kyphosis
and Spinal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
617 can be treated with a Smith-Petersen osteotomy.
Indications for Specific Osteotomies . . . . . . . . . . . . . . 621
Multiple Smith-Petersen osteotomies can be
Complications with Osteotomies . . . . . . . . . . . . . . . . . . 621
used to achieve the necessary amount of
correction.
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 622
Pedicle subtraction osteotomy is typically

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 623 used in patients with greater imbalances in the
sagittal plane of the spine and when
a minimum of 30# of correction is needed.
Vertebral column resection is reserved for

deformities, such as those in both the sagittal
and the coronal plane, that are not amenable to
treatment with either a Smith-Petersen
osteotomy or a pedicle subtraction osteotomy,
or a combination of the two.
Recent results have shown high patient sat-
isfaction rates and good functional outcomes
after spinal osteotomies done to treat a variety
of disorders. As the level of complexity of the
osteotomy increases, so does the potential for

E.C. Palou
complications.
Department Hospital Vall dHebron, Autonomous
e-mail: ecaceres@vhebron.net

609
DOI 10.1007/978-3-642-34746-7_223, # EFORT 2014
610
E.C. Palou
the plumb line falls through

the lumbosacral
Keywords disc. If the C7 plumb line
falls behind the
Complications # Indications # Osteotomy- lumbosacral disc; sagittal
balance is defined
Smith-Peterson, pedicle subtraction, vertebral as negative, whereas if it
falls in front of the
column resection # Spine # Techniques lumbosacral disc it is
positive. The most com-
monly used specific reference
point for the C7
plumb line is the posterior
aspect of the L5-S 1
Introduction disc. Most investigators
consider normal sagit-
tal balance as the C7 plumb
line falling
Most patients with spinal sagittal imbalance through disc or 2 on in front
01 behind it.
have a fusion mass that is either kyphotic or It is known that the C7 plumb
line and the
hypolordotic, with segments above or below centres of gravity are not
identical. In most
the fusion that have subsequently degenerated. circumstances the centre of
gravity falls in
The four most common presentations include front of the C7 plumb line
and slightly behind
a patient who had a long fusion for adolescent the hip joints. There is a
range of sagittal
idiopathic scoliosis with subsequent degenera- imbalance (Fig. 1). Booth and
associates [1]
tion distally; a patient with degenerative sagittal refer to a type 1 imbalance
as a segmental
imbalance in whom fusions have initially kyphosis, with global balance
in which the C7
been performed in the distal lumbar spine in a plumb line (on a long
cassette standing radio-
somewhat hypolordotic or kyphotic position graph) falls over the
lumbosacral disc. Patients
with subsequent degeneration of segments with this type of imbalance
frequently have to
above the fusion; a patient with post-traumatic hyperextend segments above or
below the
kyphosis; and a patient with an ankylosing kyphosis to maintain balance.
It is believed
spondylitis. that this compensatory
mechanism predisposes
The surgical solutions usually involve a com- the patient to accelerated
disc degeneration. In
bination of osteotomies through the fusion mass a type II sagittal imbalance,
the C7 plumb is so
and extension of the fusion to include degenerated far anterior to the
lumbosacral disc that the
segments. patient is not able to
compensate to maintain
The usual goal is to normalize the regional global balance. In this
situation, there is usu-
segmental spinal alignment as much as possible ally substantial disc
degeneration above or
and to achieve global balance. Global balance is below an area of prior fusion
or pathology
confirmed when the C7 plumb line falls over the that makes it impossible for
the patient to
lumbosacral discon a standing long lateral hyperextend segments enough
to maintain bal-
radiograph. ance. Sagittal imbalance is
the most poorly
Most patients should have at least 1020# tolerated and debilitating
form of adult defor-
more lumbar lordosis than thoracic kyphosis. mity. The intersection
between this line and
Usually a Smith-Petersen osteotomy will achieve a line that is perpendicular
to the L5-S 1 end-
10# of correction and a pedicle subtraction plate determines the pelvic
incidence.
osteotomy will produce 3035# of lordosis of
the spine.
Initial Work-Up
Sagittal Imbalance When a patient has a

substantial deformity, the
initial work-up always
includes an assessment
Sagittal balance is most frequently defined by of flexibility of the spine.
This can be deter-
the position of the C7 plumb line on a standing mined both clinically and
radiographically.
lateral radiograph (Fig. 1). When a C7 plumb At times, if a patient stands
with a sagittal imbal-
line is dropped, neutral balance is suggested if ance, the surgeon may find
that if the patient
611
a b c
C7
C7
C7
C7PL
C7PL
Fig. 1 (a) The spine is sagittally balanced when the plumb line from C7 touches the
posterior edge of S1. (b) Spinal
imbalance is positive when the line falls in front of this point. (c) It is
negative when the plumb line falls behind this point
lies supine or prone, this imbalance corrects lateral

radiographs to either long-cassette
to some extent through mobile segments. anteroposterior
and lateral supine or prone
Therein, part of the assessment is to compare radiographs. The
patients spine will fall into
standing long-cassette anteroposterior and one of three
categories:
612
E.C. Palou
1. Totally flexible, meaning that the spinal defor-

mity corrects simply by being in a supine or
prone unweight position;
2. A deformity that partially corrects through
mobile segments, but not entirely.
3. A totally inflexible deformity with no correc-
tion in the recumbent position, meaning that
the spine is entirely fused throughout the tho- b
a
racic and lumbar spine.
c
Fixed sagittal imbalance (a syndrome in which
the patient is only able to stand with the weight-
bearing line in front of the sacrum) has many PI
aetiologies. The most commonly reported tech-
o
nique for correction is the Smith-Petersen
osteotomy. Few reports on pedicle subtraction
procedures (resection of the posterior elements,
pedicles, and vertebral body through a posterior
approach) are available in the peer-reviewed lit-
erature. We are aware of no report involving Fig. 2 Pelvic incidence (PI)
is defined as the angle
a substantial number of patients with co-existent subtended by a line that is
drawn from the centre of the
femoral head to the mid-point
of the sacral end-plate and
scoliosis who underwent pedicle/vertebral body
a line perpendicular to the
centre of the sacral end-plate
subtraction for the treatment of fixed sagittal
imbalance.
Treatment of fixed sagittal imbalance involves
performing osteotomies to shorten the spine. One
option is to perform multiple Smith-Petersen pro- associated with a more
horizontal sacrum: the
cedures, which do not directly address the ante- hip joints are situated
more anterior to the
rior column of the spine. L5-S1 disc. The
measurement of pelvic inci-
Many factors contribute to fixed sagittal dence is made by drawing a
line between the
imbalance. A hypolordotic or hyperkyphotic mid-point of the L5-S1
disc connecting the
fusion mass with subsequent disk degeneration mid-point of the femoral
heads.
above or below the fusion is common. Subse-
quent disc degeneration leads to loss of anterior Thoracic kyphosis relative to
lumbar lordosis
column height and increased kyphosis. In most There is a wide variation
in the normal range
patients, both ageing and iatrogenic factors con- of the measurements of
thoracic kyphosis and
tribute to fixed sagittal imbalance. lumbar lordosis. The middle
of the bell-shaped
curve is 3035# of thoracic
kyphosis measured
from T5 to T12 and 5560#
of lumbar lordosis
Assessment of Correction measured from T12 to the
sacrum. Lumbar
lordosis usually begins at
T12-L1. Between
Pelvic incidence two-thirds and three-
fourths of lumbar lordo-
Duval-Beaupe`re and associates defined the sis is located in the
distal two discs. However,
term pelvic incidence (Fig. 2). Pelvic inci- there is substantial
individual variation. If
dence measures a combination of pelvic tilt and a patient has only 10# of
thoracic lordosis,
sacral slope. The higher the pelvic incidence then less lumbar lordosis
is required to main-
the more lumbar lordosis a patient needs to tain balance. One guideline
is that the mea-
maintain balance. A higher pelvic incidence is surement of lumbar lordosis
from T12 to S1
613
should exceed the measurement of thoracic provisional stabilization

prior to completing the
kyphosis from T5 to T12 by at least 1020# . osteotomy can help to reduce
the risk of
uncontrolled translation of
the spine with
The C7 plumb line corresponding neurologic
injury.
The C7 plumb line will be affected by the
patients positioning. When a long cassette
lateral radiograph is taken, the patient is usu- Smith-Petersen Osteotomy
(Posterior
ally asked to extend the shoulders and arms Element Wedge Resection)
out in front of the trunk to allow the spine to be
seen on the radiograph. This positioning may Smith-Petersen et al. first
described this
have a tendency to posteriorly displace the C7 osteotomy as an operative
technique for the treat-
plumb line. The effect of arm position on the ment of kyphotic deformity
caused by ankylosing
C7 plumb line was studied and it was con- spondylitis [4] (Fig. 3).
Smith-Petersen et al.
cluded that a position in which the shoulders recommended a single-stage
posterior wedge
are flexed approximately 30# and the fists are resection of the mid-lumbar
spine in a chevron
placed in the supraclavicular fossa was the arrangement with controlled
fracturing of the
most desirable position to allow for visualiza- ossified anterior
longitudinal ligament.
tion of the anatomical landmarks. The C7
plumb line is the best assessment for sagittal Surgical Technique
balance, but it is not perfect because it does not Like all osteotomies, the
Smith-Petersen
always directly correlate with the centre of osteotomy can be performed
on an open-frame
gravity, which is the element that is actually spine table and should take
advantage of any
being assessed. A patients centre of gravity flexibility in the
deformity. The hips of the
should always fall either through the hip joints patient may need to be
flexed initially and
or somewhat behind it. then extended to help close
the osteotomy site.
Once the appropriate level
for the Smith-
Petersen osteotomy is
identified, the lamina,
Deformity Correction ligamentum flavum, and
superior and inferior
articular processes are
removed bilaterally.
Most spinal osteotomies are based on Typically, the width of the
osteotomy is
a combination of two traditional osteotomies: 710 mm. A rough guideline
to follow is that
the Smith-Peterson and the pedicle subtraction every 1 mm. of resection
results in 1# of cor-
osteotomies. Both techniques were originally rection, resulting in
approximately 10# of
described for the management of flexion correction at each level at
which the Smith-
deformities that occurred in rheumatoid and Petersen osteotomy is
performed. An open
ankylosing spondylitis patients and have since disc space is a prerequisite
for closure of the
been extensively modified. Frequently, as in Smith-Petersen osteotomy
site. If the disc is
patients with unsegment bars; an asymmetric collapsed, then it may limit
the amount of cor-
osteotomy aimed at addressing the specific ver- rection that can be
obtained. Additionally,
tebral anomaly should be designed as necessary. a Smith-Petersen osteotomy
cannot be done at
A thin-slice or spiral CT scan is essential for pre- a level at which a spinal
arthrodesis has been
operative surgical planning, which can be previously performed, since
the disc is no lon-
performed through either a single posterior ger mobile. Once the
osteotomy site has been
approach or a combined approach. The inherent closed with the aid of rods
and pedicle screws,
neurologic risks of such techniques must be well through gradual compression,
it is important to
understood before undertaking such a procedure. ensure that the neural
elements are free and not
Placement of segmental instrumentation for compressed in the osteotomy
site.
614
E.C. Palou
Fig. 3 Smith-Petersen osteotomy
The lumbar region is more favourable than the the osteotomy is completed,
there is bone-on-
thoracic, since the latter commonly presents bone contact throughout all
three columns of
ankylosedcostovertebral joints rendering correc- the spine.
tion difficult, if notimpossible. Selection of the
lumbar level or levels at which the osteotomy is Surgical Technique
to be performed depends on the roentgenographic Step 1: Prior to the
initiation of the osteotomy, the
findings; the less marked the ossification, the fixation points should be
placed (Fig. 5). Next,
better the chanceof correction. a laminectomy is performed
and the necessary
posterior elements are
resected. If there is no
coronal plane deformity,
the wedge should be
Pedicle Subtraction Osteotomy made symmetrically on both
sides. When
resecting the posterior
elements, the surgeon
Another option is to perform a pedicle subtraction should start off using hand
instruments such as
osteotomy, which usually achieves about 30# of Leksell rongeurs,
osteotomes, and curettes to
lordosis (Fig. 4). Performance of that procedure try to retain as much bone
graft as possible.
amounts to performing two Smith-Petersen Then, if needed, a high-
speed air-drill is used
osteotomies as well as resection of the pedicles to thin the posterior
elements. Finally,
and vertebral body bilaterally from a posterior a Kerrison rongeur is used
to surround the
approach. This accomplishes approximately pedicles. The first step of
surrounding the ped-
as much correction as can be achieved with icles is to resect bone
centrally and then to
three Smith-Petersen osteotomies, but it is tech- perform, in essence, a
Smith-Petersen
nically much more demanding. The advantage of osteotomy both cephalad to
and caudad to
the pedicle subtraction osteotomy is that, when the pedicles on both sides.
This involves
615
Fig. 4 Pedicle Substraction Ostetomy (PSO)
exposing the nerve root caudad to the pedicle, This is done with a
combination of a Kerrison
which, in the case illustrated, is the L3 nerve rongeur from within the
pedicle and a thin
root. As the pedicles are circumferentially Leksell rongeur from
without. Care should
surrounded, they are detached from the trans- be taken to retract the
neural elements so that
verse processes. the exiting nerve root is
not injured during the
Step 2: The next step is to decancellate the process.
pedicles and vertebral body (Fig. 2). The Step 4: The next step is to
finish the resection of
medial wall of the pedicle is identified, and the posterior wall of the
vertebral body. Work-
the thecal sac and the nerve root are retracted ing underneath the
posterior vertebral cortex,
with a Penfield retractor to identify the poste- the surgeon thins the
cortex as much as possi-
rior wall of the vertebral body. It is helpful to ble with curettes and
Woodson elevators.
move straight and curved curettes and Once the posterior wall
of the vertebral body
Woodson elevators back and forth from one is thin enough, a Woodson
elevator or
side to the other until the resection of the a substantial reverse-
angled curette is placed
vertebral body connects one side to the other. between the anterior dura
and the posterior
If there is bleeding from epidural vessels ceph- vertebral cortex and
pushed anteriorly to cre-
alad and caudad to the pedicles, it is best ate a greenstick fracture
of the posterior ver-
controlled with a surface haemostatic agent tebral cortex. The
fractured posterior cortex is
and packing with cottonoids. At this point then removed. At this
point, the osteotomy is
of the procedure, one should try to preserve the still stable because the
lateral vertebral body
medial wall of the pedicle. walls remain intact. The
amount of the poste-
Step 3: Next, the pedicle stump is resected rior wall that is removed
should be
on both sides flush with the vertebral body. asymmetrical.
616
E.C. Palou
Fig. 5 (a) The initial resection of the posterior elements (c) Resection of the
lateral walls and central canal enlarge-
and surrounding of the pedicles. The amount of bone ment (d) Closure of
the osteotomy and final
resected is demonstrated in the lateral view in this figure instrumentation
(b) Decancellation of the pedicles and the vertebral body.
Step 5: Next, the spinal canal is enlarged centrally The lateral

vertebral cortex should be hugged
somewhat more with use of Kerrison during the
dissection so that the segmental
rongeurs, but the surgeon must be sure that vessel is not
injured. Then, a rongeur is used
the lateral masses remain symmetrical. In to resect the
lateral vertebral body walls down
preparation for resection of the lateral verte- to, but not
through, the anterior cortex. Once
bral body walls, the surgeon first dissects them this is
accomplished on both sides, the
with a small Cobb or Penfield elevator. osteotomy is
complete.
617
Step 6: The final step is to close the osteotomy. performed more cephalad than
L2 and prevent
Depending on the circumstances, this can excessive retraction on the
thecal sac when it is
be accomplished by either applying compres- performed caudad to L2. In
the thoracic spine,
sion or cantilevering the spine. Also, costotransversectomies are
performed to facili-
hyperextending the patients chest and lower tate removal of the vertebral
body. Unlike
extremities may accomplish closure. Some- the previously discussed
osteotomies, bone-on-
times, when this step is performed, subluxa- bone contact is not achieved,
as the vertebral
tion occurs, most commonly with the proximal body is completely removed.
Therefore, re-
elements subluxating dorsally on the distal construction of the spinal
column is needed
elements. If this does occur, the subluxation after the deformity is
corrected. A metal cage,
needs to be reduced anatomically as the final structural autograft, or
allograft may be used to
implants are placed. When the construct is reconstruct the vertebral
column after correction
complete and the osteotomy is closed on both of the deformity. This
reconstruction of the ver-
sides, the spinal canal is dissected, first with tebral column is supplemented
with pedicle
a nerve hook and then with a Woodson eleva- screws and rods. The
instrumentation also
tor to confirm that there is no dorsal compres- helps to achieve the desired
deformity correc-
sion of the dural sac. The lateral masses should tion once the vertebral
column resection is done.
be squeezed together very tightly to promote Finally, an arthrodesis of
the spine that is equal
stability and osteogenesis. to the length of the
instrumentation is done to
further stabilize the spine.
In the Fig. 7 we can
observe a PSO for
Vertebral Column Resection a severe cervico-thoracic
post-traumatic spine
deformity.
Vertebral column resection has been described
for the treatment of spinal column tumours
(Fig. 6), spondyloptosis, and congenital kypho- Selection of the Appropriate
sis as well as for hemivertebrae excision. It is Osteotomy and Spinal Level
defined as a resection of one or more vertebral
segments, including the posterior elements (spi- Selecting the appropriate
osteotomy and level at
nous process and lamina), pedicles, vertebral which to perform it is
critical to the success of the
body, and discs cephalad and caudad to the ver- procedure. The osteotomies
are typically
tebral body. Vertebral column resection has performed in the region of
the relative kyphosis
been suggested for use in deformity-correcting and maximal deformity, which
can be in the
operations when the deformity is not amenable cervical, thoracic, or lumbar
spine [15]. The
to other osteotomy techniques such as the Smith- amount of correction needed
can be estimated
Petersen osteotomy or the pedicle subtraction from the pre-operative
radiographic measure-
osteotomy. The vertebral column resection is ments indicating the degree
of curvature in the
performed either through a combined anterior sagittal plane [6]. A Smith-
Petersen osteotomy
and posterior approach or through a posterior can be used if <30# of
correction is needed.
approach only. A sagittal deformity that is
combined with coro-
nal imbalance is better
treated with an asymmet-
Surgical Technique ric pedicle subtraction
osteotomy or even
First, the posterior elements (spinous process a vertebral column resection
so that the coronal
and lamina), including the pedicles, are deformity is corrected rather
than exacerbated.
removed. A wide lateral dissection to the trans- The Smith-Petersen osteotomy
or a symmetric
verse processes is done to facilitate the vertebral pedicle subtraction osteotomy
will correct
body resection. This wide lateral resection will the sagittal deformity and
allow the coronal
avoid violation of the thecal sac when it is deformity to decompensate as
these osteotomies
618
E.C. Palou
a b c
d
4-5
rib cm
m
4-5c rib
e f g
Fig. 6 Vertebral column resection. (a) In order to address (d) Image of

impactation of vertebral body after bone
the vertebral body above we resect about 35 cm. bilateral resection (e)
Concavity rod compression (f) Placement
rib (b) Image of vertebral body resection by posterior of an interbody cage
(g) Final correction
approach (c) Discectomy above and below the osteotomy
cannot correct a coronal deformity. The level of Once the selected

osteotomy is done, an
the osteotomy is also important in that the more adequate number of
vertebrae need to be
caudad the osteotomy, the fewer vertebrae there included in the
instrumentation and arthrodesis.
are for fixation, placing greater stress on the Instrumentation that
is too short (encompassing
instrumentation and potentially leading to hard- two or three
vertebrae) may result in junc-
ware failure prior to osseous union. tional kyphosis
cephalad or caudad to the
Spinal Osteotomy Indications and Techniques 619
a b
Fig. 7 (continued)
620
E.C. Palou
Fig. 7 (a) Clinical photograph of a 72 year old patient Three-dimensional CT

reconstruction of the cervico-
with severe cervico-thoracic coronal and sagittal defor- thoracic deformity (e)
Intra-operative image of the pedicle
mity after polytrauma injury (b) Radiological image of the subtraction osteotomy
at T2 (f) Post-operative appearance
cervico-thoracic deformity (c) CT scan sagittal view (d) after osteotomy
operative construct. Additionally, the operative construct should end,

if possible, cephalad to
construct should not end at the apex of the the L5 vertebra, with
the L4-L5 and L5-S1 disc
curve as this may exacerbate the curve or lead spaces left open. A
construct that ends at L5
to loss of fixation. The caudad end of the may accelerate
degeneration of the L5-S1 disc.
621
performance of a Smith-
Petersen osteotomy
Indications for Specific Osteotomies since osteoclasis cannot be
done through
a fused intervertebral
disc.
Smith-Petersen osteotomy
Indications for the Smith-Petersen osteotomy Vertebral column resection
depend on the extent of the deformity, Patients with a severe and
rigid imbalance in
the degree of functional impairment of the the sagittal plane of the
spine that is not
patient, the age and condition of the patient, amenable to treatment with
a Smith-Petersen
and the feasibility of correction. The Smith- osteotomy or a pedicle
subtraction osteotomy
Petersen osteotomy is typically performed in are candidates for a
vertebral column resec-
the thoracic spine. In addition, multiple tion. A type-II sagittal
deformity with coronal
Smith- Petersen osteotomies can be done imbalance of the spine
requires a vertebral
throughout the thoracic spine, and even column resection, as an
asymmetric pedicle
the lumbar spine, to achieve the desired subtraction osteotomy would
not fully cor-
correction. rect the coronal deformity.
Additional indi-
Multiple Smith-Petersen osteotomies are cations for a vertebral
column resection
very useful for treating a fixed imbalance in include congenital
kyphosis, a hemi- verte-
the sagittal plane of the spine caused by a loss bra, L5 spondyloptosis, and
resection of
of lumbar lordosis following operative treat- a spinal tumour.
ment of spinal deformities, particularly idio-
pathic scoliosis. These patients were
typically treated with a posterior distraction Complications with Osteotomies
instrumentation system such as the Harring-
ton rods [25]. Smith-Petersen osteotomies are Spinal osteotomies are
extensive and complex
also beneficial for patients with a degenera- procedures. As the level of
complexity increases,
tive imbalance in the sagittal plane of the so does the risk of
complications. As in any spinal
spine. This condition typically occurs in the procedure, major neurologic
problems can occur,
lumbar spine in older individuals (more than especially when there is
manipulation of the
50 years of age). These patients typically foraminal space, retraction of
the thecal sac and
have substantial intervertebral disc collapse, nerve roots, and shortening of
the spinal column
facet arthropathy, and vertebral end-plate and segments. Therefore, it is
important to per-
osteophytes causing the deformity. form proper spinal cord
monitoring. A wake-up
test after the osteotomy site
has been closed may
Pedicle subtraction osteotomy be the most accurate way to
assess spinal cord
The pedicle subtraction osteotomy is useful and nerve root function.
for treating patients with ankylosing spondy- A Smith-Petersen osteotomy
shortens the
litis and an imbalance in the sagittal plane posterior column while
lengthening the anterior
of the spine. Unlike the Smith-Petersen column. There is a concern
that this could result
osteotomy, the pedicle subtraction osteotomy in injury of the major
vessels, particularly the
is mainly useful for deformities with an apex abdominal aorta, although we
are not aware of
in the lumbar spine. The pedicle subtraction any reported case of an aortic
injury. Specific to
osteotomy is historically performed at L2 the Smith-Petersen osteotomy
are complica-
or L3, and an ideal candidate for the tions such as intraspinal
haematoma and intes-
procedure typically has a positive sagittal tinal obstruction or superior
mesenteric artery
imbalance of >12 cm. The pedicle subtrac- syndrome. Cho et al. found
that the most fre-
tion osteotomy is also indicated for patients quent complications after a
Smith-Petersen
who have had a circumferential fusion along osteotomy were superficial
wound infections
multiple vertebrae, which prevents the and substantial coronal
imbalance of >4 cm.
622
E.C. Palou
when three or more Smith-Petersen osteotomies foramen if not enough bone

was removed from
had been done. the pedicles cephalad and
caudad to the
Pedicle subtraction osteotomies are techni- osteotomy. In addition,
instability and subluxa-
cally demanding and involve substantial mobili- tion at the osteotomy site
may lead to neurologic
zation of the dura, and the blood loss is greater complications. If
subluxation occurs, there is
than that associated with the Smith-Petersen a high probability that it
will lead to non-union
osteotomy. A retrospective analysis of data at the osteotomy site,
which may require an ante-
obtained prospectively in a study of 46 patients rior spine arthrodesis [1].
who were 60 years of age or older showed that Suk et al.
retrospectively evaluated the com-
patients who underwent a pedicle subtraction plication rate following a
vertebral column
osteotomy were seven times more likely to have resection in 16 patients
with rigid scoliosis
at least one major complication compared with [30]. Complications,
including one complete
patients who underwent a different spinal proce- paralysis, one haematoma,
one haemopneu-
dure (odds ratio, 6.96; 95 % confidence interval, mothorax, and one proximal
junctional kypho-
1.1079). Major complications included neurosis, developed in four of
these patients. In
logic deficits; deep wound infection, pulmonary another retrospective
study, a complication
embolus, pneumonia, and myocardial infarction. developed in 20 % (five) of
25 patients who
Increasing age was a significant predictor of had had a vertebral column
resection to treat
a complication (p < 0.05). The investigators con- a fixed lumbosacral
deformity.
cluded that the age at which patients are able to The complications
included two cases of
tolerate a major procedure such as a pedicle sub- radicular pain that
resolved in 6 months, two
traction osteotomy might be lower than the age at compression fractures, and
one pseudarthrosis.
which they can tolerate other common spinal The investigators reported
a mean blood loss of
procedures. Buchowski et al. reported the preva- 2,810 mL (range, 3205,460
mL), indicating that
lence of intra-operative and post-operative neu- a substantial amount of
blood loss can occur in
rological deficits to be 11.1 % and the prevalence association with this
procedure.
of permanent deficits to be 2.8 % in a study of
108 patients who had undergone a pedicle sub-
traction osteotomy [3]. In a study by Bridwell Conclusions
et al., five (15 %) of 33 patients who had undergone
a pedicle subtraction osteotomy for the treatment Spinal deformities can
result in increasing tho-
of an imbalance in the sagittal plane experienced racic kyphosis or loss of
lumbar lordosis, leading
a transient neurological deficit. In a recent retro- to imbalance in the
sagittal plane. Such deformi-
spective study, Yang et al. found the prevalence ties can be functionally
and psychologically debil-
of intra-operative or post-operative neurological itating. The Smith-Petersen
osteotomy can
deficits to be 4 % (1 of 28 patients) after lumbar achieve approximately 10#
of correction in the
or thoracic pedicle subtraction osteotomy for the sagittal plane at each
spinal level at which it is
treatment of an imbalance in the sagittal plane [42]. performed. This osteotomy
is beneficial for
This single deficit was thought to be most likely patients who have a
degenerative imbalance
due to nerve root compression. in the sagittal plane. The
pedicle subtraction
In a cervical extension osteotomy, neurologic osteotomy can achieve
approximately 3040# of
complications can arise from a variety of causes. correction in the sagittal
plane at each
When the osteotomy site is closed, neural ele- spinal level at which it is
performed. It is the
ments including the spinal cord and nerve roots preferred osteotomy for
patients with ankylosing
may be compressed if enough bone was not spondylitis who have an
imbalance of the spine in
removed from the posterior elements (spinous the sagittal plane. The
cervical extension
process and lamina). Also, the C8 nerve roots osteotomy is performed in
the cervical spine, at
may be compressed in their intervertebral the cervico-thoracic
junction, in patients who
623
have a cervical flexion deformity that impedes 10. McMaster MJ.

Osteotomy of the cervical spine in
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Posterior Decompression
for Lumbar
Spinal Stenosis
Franco Postacchini and

Roberto Postacchini
Contents
Keywords
Definition of Lumbar Stenosis . . . . . . . . . . . . . . . . . . . . . 625
Definition and classification # Microsurgery #
Posterior decompression # Spinal stenosis #

Classifications of Lumbar Stenosis . . . . . . . . . . . . . . . 626
Surgical indications # Surgical treatment-

Site of
Constriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
626
Types of Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 627 decompression, laminectomy, laminotomy,
spinal fusion
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .
628
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 629
Co-
Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 629
Type and Level of Stenosis . . . . . . . . . . . . . . . . . . . . . . . . .
629 Definition of Lumbar Stenosis
Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
630
Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 630 Lumbar spinal stenosis can be defined as an abnor-
Operative
Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
630 mal narrowing of the osteoligamentous vertebral
Methods of Decompression . . . . . . . . . . . . . . . . . . . . . . . . .
632
canal and/or the intervertebral foramina, which is

Spine
Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 632
responsible for compression of the thecal sac and/

Surgical
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
or the caudal nerve roots; narrowing of the verte-
Total Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 635
Laminotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 637 bral canal may involve one or more levels and, at
a single level, may affect the entire canal or a part
Interspinous Distraction Devices . . . . . . . . . . . . . . . . . . 639
of it [1]. Thus, abnormal narrowing of the

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 640 spinal canal may be considered as stenosis if two
criteria are fulfilled: the narrowing involves
the osteoligamentous spinal canal and causes
compression of the neural structures.
If the concept of stenosis is not limited to the
osteoligamentous canal, even disc herniation in
a normally-sized spinal canal might be consid-
ered a stenotic condition because it causes
a pathological narrowing of the canal.

F. Postacchini (*)
The second criterion emphasizes the concept of
Department of Orthopaedic Surgery, University
compression of the thecal sac and nerve roots. The
Sapienza, Rome, Italy
term stenosis indicates a disproportion between
e-mail: franco.postacchini@hotmail.com
the calibre of the container and the volume of the

R. Postacchini
content. If the content is solid or semi-fluid, as in
Department Orthopaedic Surgery Israelitic Hospital,
IUSM, Rome, Italy
the vertebral canal, the dimensional disproportion
e-mail: robby1478@hotmail.com
results in compression of the content by the walls of

625
DOI 10.1007/978-3-642-34746-7_37, # EFORT 2014
626 F.
Postacchini and R. Postacchini
the container. If the narrowing is not severe enough

to cause compression of the neural structures, the
spinal canal should be considered narrow but not
stenotic. Therefore, the diagnosis of stenosis cannot
be based on measurements of the size of the verte-
bral canal or the area of the thecal sac in the axial
sections. Diagnosis can be based only on the evi-
dence of compression of the neural structures
(symptomatic or asymptomatic) by an abnormally
narrow osteoligamentous spinal canal (Fig. 1).
Classifications of Lumbar Stenosis
Site of Constriction
Lumbar stenosis can be distinguished as stenosis of

the spinal canal, isolated stenosis of the nerve root
canal, and stenosis of the intervertebral foramen [2].
In stenosis of the spinal canal, both the central
portion of the canal and the lateral parts occupied
by the emerging nerve roots, are usually
constricted. Therefore, the expression stenosis of
the spinal canal is more correct than that of central
stenosis, which would indicate constriction only of
the central area. However, the expression central
stenosis will be used because it has become the one Fig. 1 T-2 weighted MR
midsagittal scan showing spinal
generally adopted. As a rule, central stenosis is stenosis at L4-L5 and L3-
L4. The thecal sac is compressed
by the posterior elements
of the spinal canal, namely the
located at the level of the intervertebral space, posterior joints and the
ligamentum flavum (arrows)
where there are the anatomical structures, such as
the intervertebral disc, the apophyseal joints and
the ligamenta flava, which can change with ageing
or disease.
In isolated stenosis of the nerve root canal,
or radicular canal, only this part of the spinal
canal is constricted (Fig. 2). This canal (more an
anatomical concept than a true canal) is the
semi-tubular structure in which the nerve
root exiting from the thecal sac runs before enter-
ing the intervertebral foramen Similarly to the
central form the term lateral stenosis has
become the most widely used for this type of
stenosis.
The intervertebral foramen, which begins and
ends at the level of the medial and the lateral
border of the pedicle, respectively, should Fig. 2 Axial MR scan of
isolated stenosis of the nerve
be considered as a distinct anatomical entity com- root canal at L4-L5. The
articular processes encroach only
pared to the spinal canal. Therefore, stenosis of on the lateral portions of
the spinal canal
Posterior Decompression for Lumbar Spinal Stenosis
627
the foramen should be differentiated from the Secondary Forms

other two forms of stenosis, although it can be Central Stenosis
associated with them. If the dimensions of the
spinal canal are primarily
normal, or at the lower
limits, compression of the
caudal nerve roots is the
result of one or more
Types of Stenosis acquired conditions, such as
spondylotic changes
of the facet joints, abnormal
thickening of the
Three aetiological forms of stenosis can ligamenta flava and bulging
of the intervertebral
be identified: primary, secondary and discs. We define this form as
simple degenerative
combined [2]. stenosis (Fig. 1).
Very often, however,
degenerative spondylo-
Primary Forms listhesis of the cranial
vertebra of the
Central Stenosis motion segment is also
present, at one or, occa-
This form includes congenital and developmental sionally, two or more levels.
Degenerative
stenosis. Congenital stenosis, which is exceed- spondylolisthesis is mostly
responsible for spinal
ingly rare, is due to congenital malformations of stenosis (Fig. 3). However it
may cause
the spine. narrowing of the spinal canal
with no neural
Developmental stenosis, a term introduced by compression. This is because
the presence, type
Verbiest [3], includes achondroplastic and consti- and severity of stenosis is
related to several fac-
tutional forms [4]. In achondroplasia, stenosis is tors, such as the
constitutional dimensions of the
due to abnormal shortness of the pedicles. In spinal canal, the orientation
(more or less sagittal)
constitutional stenosis, in which the cause of the and the severity of
degenerative changes of the
defective vertebral development is unknown, two facet joints, and the amount
of vertebral slipping,
types of anatomical abnormality may be identified: which however may play no or
a minor role.
(a) A short mid-sagittal diameter of the spinal The type of stenosis, central
or lateral, depends
canal. on the orientation of the
articular processes, and
(b) An exceedingly sagittal orientation of the length of the pedicles.
Usually stenosis is
the laminae and/or shortness of the lateral initially, and
central in later stages. What-
pedicles. In the latter type, the spinal canal ever the type, we call this
form of stenosis degen-
is abnormally narrow, mainly or only, in the erative stenosis associated
with degenerative
interarticular diameter. spondylolisthesis.
Instability, that is
hypermobility on flexion-
Lateral Stenosis extension radiographs, is one
of the main
This may result from abnormal shortness of the characteristics of
degenerative spondylo-
pedicles, even more so if associated listhesis; in these case, we
define instability
with a trefoil configuration of the spinal canal as actual. When there is no
appreciable
or anomalous orientation and/or shape of the hypermobility of the slipped
vertebra, we con-
superior articular process. In this form, sider the condition as a
potential instability
a primary role may be played by the of the slipped vertebra,
which can become
intervertebral disc because even a mild bulging unstable as a result of
surgery with removal
of the annulus fibrosus may be enough to of a large part of the facet
joints or disc exci-
cause symptoms. sion. In degenerative
spondylolisthesis, the
intervertebral disc often
bulges into the
Stenosis of the Intervertebral Foramen intervertebral foramen
causing constriction of
Primary forms are found almost exclusively the foramen. However, true
stenosis is rarely
in the presence of abnormally short pedicles present as the foramen
becomes larger in the
associated with decrease in height of the sagittal dimensions in the
presence of slipping
intervertebral disc [5]. of the cranial vertebra [5].
628
F. Postacchini and R. Postacchini
a b c
Fig. 3 Degenerative spondylolisthesis of L4. (a) Lateral compression of the

neural structures (arrow). (c) Axial
radiograph of the lumbar spine showing slipping of the L4 MR scan shows severe
central spinal stenosis
vertebra (arrow). (b) Midsagittal MR scan showing
A particular form of degenerative stenosis Combined Forms

is that associated with degenerative scoliosis, These forms occur when
primary narrowing of
in which a role may be played by the scoliotic the spinal canal, the
nerve root canal or the
curve as well as the degenerative changes intervertebral foramen,
is associated, at the
of the facet joints, particularly on the concave same vertebral level,
with secondary narrowing
side. due to spondylotic
changes.
Other forms of secondary stenosis include late
sequelae of fractures or infectious diseases of the
spine, and Pagets disease.
Lateral Stenosis
Most often, this form of stenosis is degenerative Decompressive surgery
is contra-indicated for
in nature. Usually degenerative stenosis involves a narrow spinal canal,
not causing any compression
the lateral portions of the spinal canal in the of the neural
structures. In these cases, in the
initial stages and becomes central in more presence of a herniated
disc, only discectomy
advanced stages. A particular form of lateral ste- should be performed.
Generally, decompressive
nosis is that due to a cyst of the facet joint, surgery is not
indicated in patients who complain
compressing the emerging root in the nerve root only of back pain, in
the absence of deformities,
canal. such as degenerative
spondylolisthesis or scoliosis.
In patients with an
unstable motion segment who
Stenosis of the Intervertebral Foramen have only back pain it
is usually sufficient to per-
This is rare especially as an isolated condition. form a fusion alone if
stenosis is mild, because it is
In most cases, foraminal stenosis is associated unlikely that neural
compression will significantly
with central or lateral stenosis. At times, root increase and become
symptomatic over time after
compression occurs when there is a lateral disc fusion. Neural
decompression may instead be
herniation or disc bulge in the presence of performed if stenosis
is severe, because it can be
advanced degenerative changes of the articular responsible for the
onset of radicular symptoms in
processes. the months or years
following surgery.
629
In patients with leg symptoms, surgery is indi- older than 70 years, provided
the patients
cated when conservative management carried out general health is
satisfactory [6, 7]. There is no
for 46 months has led to no significant improve- significant difference in the
results of surgery
ment. The exception is the patient with severe between patients in early
senile age and those
motor and/or sensory deficit in the lower limbs aged 80 years or even more.
or a cauda equina syndrome,wich requires emer-
gent neural decompression.
In the presence of fixed motor deficits only Co-Morbidity
(with no radicular pain), surgery is usually indi-
cated when stenosis is marked, the deficits are A high rate of co-morbid
illnesses was found to
severe and their duration is less than few months. be inversely related to the
rate of satisfactory
In the presence of severe paresis or paralysis results following surgery [8]
In one study, com-
lasting more than 68 months there can be no paring the long-term results
of surgery in 24
indication for decompression because there are diabetic and 22 non-diabetic
patients, the rate of
few or no chances of improvement of muscle satisfactory outcomes was 41
% in the diabetic,
function. compared to 90 % in the non-
diabetic, group [9]
The best candidates for surgery are those However, different results
were observed in
patients who have no co-morbid diseases, a similar study [10], in
which the outcome was
a severe or very severe stenosis, long-standing satisfactory in 72 % of the
diabetic and 80 % of
leg symptoms and severe intermittent claudica- the non-diabetic patients.
Neither the duration of
tion, moderate or no motor deficits, and mild or the diabetes before surgery
nor its type correlated
no back pain. This is in contrast to patients who with the outcome. A mistaken
pre-operative diag-
have mild stenosis, mild or inconstant leg symp- nosis was the main cause of
failure in diabetic
toms with no precise radicular distribution, patients, in whom diabetic
neuropathy or
a history of claudication after many hundreds angiopathy may mimic the
symptoms of stenosis.
metres, no motor deficit and back pain of similar It is thus mandatory to carry
out electrophysio-
severity to, or more severe than, leg symptoms. logical studies in diabetic
or non-diabetic patients
A less predictable outcome is associated with who have symptoms in the
lower limbs not typi-
surgery in this group. cal of lumbar stenosis to
exclude a peripheral
In patients with no degenerative spondylo- neuropathy.
listhesis or other forms of actual or poten-
tial instability before surgery, there is usually
no need for spinal fusion. However, arthrodesis Type and Level of Stenosis
should be planned when, prior to surgery, wide
surgical decompression risking the development There is no significant
difference in the outcomes
of post-operative instability, is previewed. between the various types of
central stenoses.
Spine fusion, or some form of stabilization, However, patients with
degenerative or com-
may be indicated for patients with chronic bined stenosis at a single
level are the best can-
back pain and severe degeneration of the disc didates for surgery because
they tend to have
(s) or facet joints in the area of decompression. better results than those
with stenosis at multiple
levels. In patients with
constitutional stenosis, the
intervertebral disc may play
a significant role in
Age the compression of the neural
structures. When
the disc bulges considerably
in the spinal canal,
Lumbar stenosis is usually diagnosaed and but it is not truly
herniated, it may be difficult to
treated surgically betwen 50 and 70 years. eliminate the anterior
compression of the neural
However, surgical decompression may offer structures and this may lead
to less satisfactory
significant relief of symptoms also to patients results than in the cases in
which the neural
630 F.
with a laminotomy, also

called keyhole
laminotomy or
hemilaminectomy or partial
hemilaminectomy.
Laminotomy consists in the
removal of the caudal
portion of the proximal
lamina, the cranial
portion of the distal
lamina and a varying
portion of the articular
processes, which should
not usually exceed the
medial half, and
ligamentum flavum on the side
of surgery. Laminotomy
can be performed
at a single level on one
side or both sides
(Fig. 5). When necessary,
it is performed at
multiple levels. An
alternative to bilateral
laminectomy or bilateral
laminotomy is bilateral
decompression by a
unilateral approach,
performed with the use of
the operating micro-
scope (Fig. 10).
The term foraminotomy
indicates removal
of a part of the
posterior wall of the
intervertebral foramen,
while the term
foraminectomy refers to
complete excision of
the wall of the foramen.
Fig. 4 Anteroposterior radiograph showing total

laminectomy from the caudal border of L3 to the cranial
part of L5 for severe central stenosis at L4-L5 Operative Planning
General Concepts
compression is caused exclusively by the poste- Surgical treatment is
aimed at decompressing the
rior vertebral arch. Nevertheless, discectomy neural structures by
means of a bilateral
should not usually be performed in these cases laminectomy or laminotomy
at one or more ver-
because the intervertebral disc is an important tebral levels.
stabilizing structure and removal of a not herni- It is crucial to plan
accurately the extent of
ated nucleus pulposus exposes more to the risk of decompression before
surgery because during the
recurrent herniation. operation it may be
difficult to determine whether,
Patients with lateral stenosis, particularly at at a given level, the
central or lateral canal is
a single level, tend to have better results than stenotic, particularly if
stenosis is mild. Lack of
those with central stenosis, provided the nerve- sufficient care in
planning the operation may give
root compression is severe and the leg symptoms rise to inadequate
decompression, which can leave
have a precise dermatomal distribution. areas of stenosis, or a
too wide decompression,
which may cause
iatrogenic instability.
Surgical Management Types of Stenosis

Stenosis with no
Degenerative
Definition of Terms Spondylolisthesis or
Scoliosis
Central Stenosis
Decompression of the lumbar spinal canal can be Number of levels to
decompress. The stenotic
carried out by bilateral laminectomy, also levels should be
distinguished accurately as
defined as total laminectomy (Fig. 4). More levels at which the need
for decompression is
focal decompression can be accomplished absolute and levels where
the need is relative.
631
a b
Fig. 5 (a) Anteroposterior radiograph showing L4-L5 unilateral laminotomy (arrow)

in a patient with lateral stenosis.
(b) Bilateral laminotomy at the same level (arrows) for central stenosis at L4-L5
In the former case, compression of the neural fusion represents a

guarantee against post-surgical
structures is marked or, regardless of the severity, instability, which may
be worrying when decom-
is responsible for clinical symptoms and signs. In pression has to be
carried out at high lumbar levels.
the latter case, neural compression is mild and At these levels, in
fact, a larger removal of the
asymptomatic. In many instances, there are one articular processes in
the transverse plane is
or two levels contiguous to the area of symptom- needed to decompress
the lateral part of the spinal
atic stenosis. canal since the facets
are orientated more sagittally
The usefulness of prophylactic surgery at than at the lower
lumbar levels.
the levels at which there is a relative need for Unilateral or
bilateral decompression. For
decompression stems from the evaluation of sev- the intervertebral
levels at which the need for
eral factors, such as the patients age, the amount decompression is
absolute and stenosis is bilat-
of constriction, the site of stenosis (central or eral, the decompression
should be performed
lateral), the presence of disc abnormalities and bilaterally either in
patients with bilateral leg
the vertebral stability. symptoms and/or signs,
and in those with uni-
In patients aged over 75 years the need for lateral symptoms. When,
at a given level, ste-
a prophylactic decompression is less than in mid- nosis is severe and
symptomatic on one side
dle-aged patients. Posterior compression of the and milder and
asymptomatic on the other,
thecal sac due to mild central stenosis is less likely unilateral
decompression may be considered,
to become symptomatic than constriction of the particularly when
operative time should be
lateral spinal canal where the nerve roots run close limited due to the old
age or co-morbidities
to the facet joints. Marked bulging of the annulus of the patient, or
discectomy has to be
fibrosus, which may become symptomatic over performed.
time, may represent an indication for prophylactic For levels with
relative stenosis, the choice
decompression. The presence of intersomatic between unilateral or
bilateral decompression
osteophytes producing spontaneous vertebral should be made taking
into consideration the
632 F.
severity of stenosis on the two sides, and the neural structures and often
implies a shorter oper-
factors considered in determining the number of ative time compared to the
other decompressive
levels to decompress. methods. It should be taken
in to account, how-
Extent of decompression. The long-term ever, that re-growth of
posterior vertebral arch,
results of surgery may deteriorate with time which tends to occur over
time, may re-stabilze
because of re-growth of the resected portion of partially destabilized
motion segments [13]
the posterior vertebral arch [12]. This is more (Fig. 6).
likely to occur when a narrow decompression is Multiple laminotomy is
the treatment of choice
performed. We believe that decompression for constitutional stenosis
because the patients are
should be as wide as possible in the lateral por- usually middle-aged, the
stenosis is rarely severe,
tion of the spinal canal, while preserving at the and disc excision may be
necessary [12]. Multiple
same time vertebral stability. The optimal laminotomy is also
preferred for degenerative or
facetectomy is that in which the medial two- combined stenosis when
narrowing of the spinal
thirds of the superior and inferior articular pro- canal is mild or moderate,
particularly if disc exci-
cesses are removed. An important concept is that sion has been planned. The
same is true for bilat-
in lumbar stenosis radicular symptoms usually eral decompression with
unilateral approach,
originate from compression of the nerve root which is also indicated for
simple degenerative
after it has emerged from the thecal sac, that is stenosis of moderate
severity, particularly in
in the radicular canal, rather than within the those patients in whom leg
symptoms prevail on
thecal sac. one side, or in the
presence of mild degenerative
Compression of the thecal sac and nerve roots spondylolisthesis when the
surgeon decides
usually occurs at intervertebral level. To be ade- against a concomitant spine
fusion because the
quate, decompression should involve the whole slipped vertebra shows no
or very mild
area facing the intervertebral disc. That is, hypermobility on pre-
operative flexion-extension
decompression should extend as far as half of radiographs. Total
laminectomy is usually indi-
the height of the vertebrae above and below the cated for very severe
stenosis in patients with
stenotic area. bilateral leg symptoms,
providing that the
involved segments are
stable pre-operatively, or
when a fusion has been
planned due to a clear-cut
Methods of Decompression vertebral instability.
Surgery for lumbar stenosis is aimed at ade-

quately decompressing the neural structures, par- Spine Fusion
ticularly the nerve roots in the extrathecal course,
with no significant compromise of vertebral sta- In addition to degenerative
spondylolisthesis
bility, whilst not causing or worsening back pain with moderate or severe
instability of the slipped
after surgery. vertebra and to
degenerative scoliosis, spinal
In the last two decades, the technique of mul- fusion should be planned if
the area to be
tiple laminotomy has become widely used in the decompressed is unstable or
when total
treatment of central spinal stenosis because it laminectomy and bilateral
discectomy are to be
preserves vertebral stability better than central performed. Spine fusion
should also be planned
laminectomy [11, 12]. More recently, bilateral when there are high chances
that, at surgery, the
decompression with unilateral approach has articular processes will be
completely removed
gained popularity because it allows even better on both sides or they will
be excised on one side
preservation of the facet joints contralateral to the and discectomy performed
bilaterally, and in
side of direct approach. However, a major role is patients complaining of
severe chronic back
still played by total laminectomy, which may pain determined to
originate from the
allow a more effective decompression of the motion segment needing
decompression.
633
Fig. 6 (a) Anteroposterior

radiograph taken a few a b
weeks afte total
laminectomy performed
from L2 to L5 for central
stenosis at L2-L3, L3-L4
and L4-L5, with generous
resection of the facet joints.
(b) Radiograph obtained
after 4 years of the
operation. The posterior
verbral arch has undergone
partial regrowth, thus
restabilizing the operated
vertbral segments
Except for these situations there is no need for If pre-operative MRI shows
a bulging disc at
spinal fusion in stenotic patients [2, 14]. the stenotic level, a possible
discectomy has to be
planned. However, the final
decision should be
taken intra-operatively based
on the severity of
Isolated Lateral Stenosis bulging and the degree of
softness of the disc on
Usually a single vertebral level is involved. pressure by a blunt probe. A
hard disc should not
In patients with radicular symptoms on generally be excised unless
there is a clear evi-
both sides, bilateral decompression should be dence that it contributes to
compression of the
carried out, even if on one side leg symptoms neural structures.
are mild and no neurological abnormalities Generally there is no
indication for spinal
are present. fusion, unless bilateral
decompression is
When stenosis is bilateral and the patient performed at a pre-operatively
unstable level,
complains of radicular symptoms on only one particularly when disc
excision is carried out, or
side, bilateral decompression is usually indicated the patient complains of
chronic low back pain
particularly in middle-age patients or in those due to disc degeneration.
with electrophysiological evidence of nerve-root
deficit on the asymptomatic side. However, in the Stenosis of the Intervertebral
Foramen
elderly patient, a unilateral decompression MRI or CT often show narrowing
of the
may be indicated if the surgical procedure neuroforamen. However, in the
vast majority
should preferably be rapid due to co-morbid of these cases the nerve
running in the foramen
diseases. is not compressed.
Decompression of the
634
neuroforamen is rarely needed unless the Patients with severe

central stenosis and
narrowing is associated to a severe annular bulg- severe leg symptoms
usually need total
ing or a herniated disc. laminectomy which
allows the neural structures
to be decompressed as
widely as necessary. In
Stenosis with Degenerative these cases a pedicle
screw instrumentation and
Spondylolisthesis a vertebral fusion is
usually needed, particularly
In this type of stenosis, like that with no degen- if the olisthetic
vertebra is hypermobile on
erative olisthesis, decompression of the neural functional radiographs
and/or in the presence of
strucures may be carried out by unilateral or a history of chronic
low back pain (Fig. 7).
bilateral laminotomy, bilateral decompression However, in elderly
patients with co-morbid
by unilateral approach or total laminectomy. diseases, fusion may be
avoided especially
Furthermore, the presence of degenerative when the olisthetic
vertebra shows no
spondyolisthesis does not necessarily require hypermobility on
functional radiographs
a spinal fusion. (Fig. 8). An
alternative, in these cases, is to per-
The indications for unilateral laminotomy form a unilateral
instrumentation with unilateral
with no fusion are: moderate central stenosis in intertransverse fusion.
elderly patients with unilateral symptoms; lateral
stenosis only on one side; an additional condition, Stenosis and
Degenerative Scoliosis
such as a synovial cyst, on the side of the radic- When lumbar
degenerative scoliosis is associ-
ular symptoms; and no chronic back pain. Bilat- ated with spinal
stenosis, decompression of the
eral laminotomy may be carried out with no nerural structures may
lead to aggravation of the
concomitant fusion in the presence of mild curve or an increase of
lateral vertebral slipping
olisthesis, no vertebral hypermobility on func- where this is present.
This may occur if total
tional radiographs, moderate central stenosis or laminectomy is
performed, but also when bilat-
any degree of isolated lateral stenosis, and mild or eral, or even
unilateral, laminotomy is carried
no back pain. In these cases, bilateral decompres- out. The increase in
amount of the curve is
sion by a unilateral approach, rather than bilateral responsible for
worsening of the back pain,
laminotomy, has the advantage of preserving which usually is a
prominent component of the
better vertebral stability. patients symptoms.
a b c
Fig. 7 Spine fusion at L4-L5 carried out by pedicle screw stenosis and chronic
low back pain. (a) Preoperative MR
instrumentation and PLIF with blocks of trabecular metal scan, the arrow
pointing to constriction of the neural
in a patient with degenerative spondylolisthesis, central structures. (b) and (c)
Postoperative radiographs
635
Fig. 8 Postoperative anteroposterior and lateral radio- instrumentation was

applied and interspinous stabilization
graphs of a 76-year-old man with spinal stenosis and was performed with a
system of two interconnected plates
degenerative spondylolisthesis of L4 whose functional (Aspen) fixed to the
spinous processes of L4 and L5
radiographs showed no hypermobility of the slipped (arrows)
vertebra. After bilateral laminotomy, pedicle screw
In the presence of mild scoliosis and bilateral Dermal and subdermal

vessels may be cauterized
symptoms, there may be an indication for or clamped, together with
a small portion of super-
bilateral decompression by unilateral approach ficial subcutaneous
tissue; clamps are turned out-
and no fusion. On the other hand, when scoliosis wards of the wound and
held together with an
is severe, total laminectomy performed at elastic band for 1520
min. This method makes
the stenotic levels should be associated with haemostasis of the
superficial vessels very rapid.
spinal fusion after correction of the curve using
pedicle screw instrumentation. The latter should Dis-Insertion of
Paraspinal Muscles
often be extended to the lower thoracic spine The thoracolumbar fascia
is incised, starting on
when scoliosis involves the entire lumbar spine. the side of the surgeon,
immediately adjacent and
parallel to the spinous
processes using an electric
cautery knife.
Surgical Technique Dis-insertion of the
paraspinal muscles starts
from the most caudal of
the exposed vertebrae
Total Laminectomy [2]. A periosteal
elevator is introduced deep to the
muscle mass and allowed
to slip along the outer
Skin Incision and Superficial surface of the spinous
process and lamina
Haemostasis to detach the paraspinal
muscles from the bone
The skin incision extends from the cranial edge of surface until the lateral
border of the facet joints.
the spinous process above to the caudal edge of the Dry sponges are packed
beneath the muscle mass
spinous process below that of the vertebra, or the to arrest bleeding. The
sponge packed at one
group of vertebrae, needing decompression. extremity of the motion
segment is then removed
636 F.
and, while retracting the muscle mass, the resid-

ual musculo-tendinous attachments to the base of
the spinous processes and interspinous ligaments
are sectioned. The other sponge is then removed
and haemostasis is completed. When decompres-
sion is needed at more than one motion segment,
dry sponges are again packed into the depth of the
wound and the vertebrae and intervertebral
spaces are exposed. The manoeuvres described
above are then performed on the opposite side.
One or two self-retaining retractors are
applied and remnants of muscle and fat tissue
still adherent to the laminae, facet joints and
ligamentum flavum are removed using a large
curette or a bone rongeur.
Fig. 9 Drawing showing how the
chisel should be ori-
ented to carry out the
undercutting facetectomy
Opening of the Spinal Canal
After exposure of the ligamenta flava and
interspinous ligaments, the vertebrae included in extensively as possible. The
lateral portion of
the operative field are identified by locating the the laminae and the inferior
articular processes
lumbosacral interspace, when exposed. In the are removed using a bone
rongeur or Kerrison
doubt, the level or levels to be decompressed punches.
should be identified using fluoroscopic imaging An alternative technique,
that we prefer, is to
after inserting a spinal needle into one, or two perform lamino-arthrectomy
using chisels.
contiguous, interspinous spaces. After removal of the spinous
processes and
When a single intervertebral level has to be detachment of the ligamentum
flavum from the
decompressed, the cranial half of the spinous laminae of the proximal
vertebra, a chisel is
process of the distal vertebra and the caudal half used, on each side, to remove
the caudal half of
or two-thirds of the spinous processes of the the lamina of the proximal
vertebra and the
proximal vertebra together with the interspinous medial half of the inferior
articular process of
ligament are resected as far as their base. the same vertebra. The
proximal portion of the
For decompression of a motion segment, the lamina of the distal vertebra
can be removed
ligamentum flavum is detached from the deep partly by a chisel and partly
using Kerrison
surface of the proximal laminae using a small rongeurs. After removal of the
ligamentum
curette. Laminectomy is started in the central flavum and exposure of the
thecal sac, the resid-
portion of the laminar arch, that is, at the level ual lateral portions of the
articular processes are
of the posterior angle of the spinal canal, not removed using either chisels
or punch rongeurs.
occupied by the thecal sac. The lamina on each When using chisels,
undercutting facetectomy
side can be removed using a bone rongeur or can be performed by orienting
the instrument
small or medium-bite Kerrison rongeurs. at 45# in a medio-lateral and
postero-anterior
Laminectomy is then continued, alternately on direction to undermine the
articular processes,
one side and the other, after further detachment that is to remove only the
ventral portion of the
of the ligamenta flava from the ventral aspect of bone in order to preserve
vertebral stability
the laminae. The ligaments are then detached (Fig. 9) [15].
from the proximal border of the laminae of the If total laminectomy has to
be performed at
distal vertebra. The cut edge of the ligament is multiple contiguous levels the
spinous processes
picked up with a forceps, sectioned longitudi- located between the most
proximal and distal
nally using a thin scalpel, and removed as vertebra is excised
completely. Since stenosis
637
occurs at the intervertebral level, when symptomatic side just

laterally to the spinous
performing decompression at multiple levels, processes. The paraspinal
muscles are detached
laminectomy is extended, proximally and dis- from the spinous
processes, the laminae and the
tally, beyond the intervertebral discs located at facet joint. Bleeding can
be controlled using
the extremities of the stenotic area. small dry sponges packed
in the osteo-muscular
space. After a few
seconds, one of the sponges is
Exploration of Intervertebral Discs and removed and bleeding
vessels are coagulated by
Spinal Nerve Roots bi-polar cautery. The
same is done for the other
The spinal canal is opened laterally until the nerve sponges.
root emerging from the thecal sac is visualized. For retraction of the
paraspinal muscles, we use
The emerging root and the thecal sac are then a Taylor retractor of
appropriate width, installed
retracted medially and the disc is exposed at each against the lateral
aspect of the articular processes
of the intervertebral levels included in the area of and held by a metal
weight of two kilograms or
laminectomy. Consistency of the annulus fibrosus less. A large curette is
used to clean up the proxi-
is tested with a blunt probe. If the annulus is hard in mal and distal lamina and
the ligamentum flavum.
consistency, the disc should not be excised. The ligament is detached
from the deep surface of
A right-angled blunt probe is used the proximal lamina using
a small curette, and the
to evaluate the width of the intervertebral distal one-third to half
of the lamina is excised
foramen. If this is constricted, foraminotomy is using a Kerrison rongeur.
The ligamentum flavum
continued until complete decompression of is dis-inserted from the
proximal border of the
the root is obtained. However, foraminectomy distal lamina to allow
removal of the proximal
is very rarely necessary. If bilateral foramin- one-third of that lamina
with a Kerrison rongeur.
ectomy is performed, spine fusion may be The medial one-third to
half of the facets are
necessary, especially when the disc has been excided together with the
ligamentum flavum
excised. using Kerrison rongeurs.
When the interlaminar
space is very narrow,
Wound Closure the inferior articular
process of the proximal ver-
At the site of laminectomy, the paraspinal mus- tebra can be intially
removed with a chisel, until
cles of the two sides are sutured by interrupted the superior articular
process of the vertebra below
sutures. The thoracolumbar fascia is closed with is exposed. The chisel
can be replaced by a high
a continuous suture. Where the spinous processes speed microdrill. The
ligamentum flavum is then
have not been resected, the fascia is anchored to detached from the border
of the distal lamina to
the supraspinous ligament. allow a small-bite
Kerrison to be inserted under the
Post-operative haematoma between the subcu- lamina to initiate
removal of the proximal part of
taneous tissue and thoracolumbar fascia is it. The remaining
ligament is then removed in
avoided by passing a few sutures both in the a caudo-cranial direction
using Kerrison rongeurs.
deep subcutaneous layer and the fascia. Alternatively, a thin
dissector is carefully intro-
duced between the layers
of the central part of
the ligament to
progressively dissect them until
Laminotomy the thecal sac is
exposed. A Kerrison rongeurs
is then inserted between
the sac and the ligament
Single Level and the latter is
gradually and carefully removed.
Skin incision extends from the cranial border of Afterwards, the remaining
lateral part of the liga-
the spinous process of the proximal vertebra to ment is excised together
with the medial part of the
the caudal border of the spinous process of the articular processes by
inserting Kerrison rongeurs
distal vertebra. beneath the facets.
When performing unilateral laminotomy, the Facetectomy should be
extended laterally to
thoracolumbar fascia is incised only on the expose the emerging nerve
root. By retracting the
638 F.
sac and the root medially, the intervertebral disc The microscope provides
excellent lighting,
is exposed and the degree of its prominence and regardless of the extent of
surgical exposure,
consistency is evaluated. Disc excision should be which is 23 or 46 cm long
for one or two
done only when the disc is prominent and soft in levels, respectively.
Furthermore, by slanting
consistency, and appears to contribute signifi- the objective, any part of
the operative field can
cantly to compression of the neural structures. be illuminated. Thus,
surgical manoeuvres can be
Lamino-arthrectomy of the cranial vertebra performed with greater
precision, the causes of
should be continued proximally as far as a few compression of the neural
structures can be more
millimetres cranially to the disc. Laminotomy of easily identified and fewer
risks are run of causing
the distal vertebra should proceed until the caudal undue trauma to the
emerging nerve root or thecal
part of the pedicle. A blunt probe can then be used sac. Moreover, only
occasionally is an excessively
to assess the width of the neuroforamen. Gener- large portion of the
articular processes excised or
ally the latter is not constricted. In the rare cases a complete facetectomy
inadvertently performed.
in which it appears stenotic, formaninotomy is Laminotomy using the
microscope is
performed until complete decompression of the performed with the same
instruments used for
nerve root is achieved. the naked eye procedure.
The exception is the
For bilateral laminotomy at a single level, the paraspinal muscle
retractor, which should be as
procedure described above is then performed on narrow as possible, at
least for one level
the opposite side. laminotomy. Many surgeons
use the Caspar
retractor. We use a Taylor
retractor about one-
Multiple Levels third in width of the
standard instrument. Even
Unilateral or bilateral laminotomy can be the chisel or a bone
rongeur can be used for
performed at two or more adjacent intervertebral removal of the inferior
articular process of the
levels. The surgical technique is similar to that proximal vertebra. However,
many surgeons use
described for single level laminotomy. However, high speed microdrill to a
large extent to perform
when performing laminotomy at two adjacent the lamino-arthrectomy.
levels on the same side, care should be taken to The operating microscope
is indispensable
leave intact, for at least five millimeters, the lam- to carry out bilateral
decompression with
ina between the two motion segments. a unilateral approach (Fig.
10). After laminotomy
Laminotomy at multiple levels may be indi- has been performed on one
side (usually the one in
cated for any type of stenosis, but particularly for: which the radicular
symptoms are more severe)
(a) Constitutional stenosis in which constriction with the operating table
placed parallel to the floor,
of the spinal canal is usually moderately decompression is continued
towards the opposite
severe and disc excision is often necessary, side after inclining the
table and slanting the
(b) Isolated lateral stenosis at multiple levels, microscope towards that
side by some 10# . The
(c) Simple degenerative central stenosis when base of the spinous
processess and the most medial
constriction of the spinal canal is not partic- part of the laminae is
removed with a Kerrison
ularly severe, rongeur or a high speed
microdrill. This allows the
(d) Degenerative spondylolisthesis when spinal surgeon to see the top of
the thecal sac. The table is
fusion has not been planned. further inclined by some
25# with respect to the
floor and the microscope is
slanted enough to
Microsurgery see the medial part of the
articular processes
One of the main difficulties in performing which are removed until the
contra-lateral border
laminotomy, particularly at a single level, is of the the thecal sac is
clearly visible and the
related to poor lighting of the deep operative emerging nerve root is at
least glimpsed.
field when using a short skin incision. These The articular processes of
the contra-lateral side
difficulties may be overcome with the use of the are removed using a
kerrinson punches,
operating microscope. a microdrill or a thin
chisel (Fig. 9).
639
a b
Fig. 10 Bilateral decompression by unilateral approach. side. (c)

Postoperative CT scans showing the decompres-
(a) Photograph of the use of the operating microscope to sion performed for a
central stenosis; the lamina and
perform the procedure. (b) Scheme of the surgical proce- articular processes
are partially resected also on the left
dure: on the right side a laminotomy is performed and then side, thus
decompressing the central area of the spinal
the decompression is carried out obliquely on the opposite canal and the lateral
canal
applied
percutaneously, i. e. through a 23 cm.
Interspinous Distraction Devices skin incision carried
out 810 cm. from the spi-
nous processes (Fig.
11).
In the last few years several interspinous devices Recently there has
been a widespread use of
have been developed to obtain indirect decom- interspinous
distraction devises in patients with
pression of neural structures by posterior seg- central or lateral
lumbar stenosis of any severity.
mental distraction. The implant most often used However, the clinical
results of these devices,
has been the X-Stop, which is inserted by open evaluated in all
studies by the Zurich Claudica-
surgery, through an approach centred on the tion Questionnaire
(ZCQ), are contrroversial. In
interspinous space to be treated. Successively, a multi-centre study
on patients followed-up for
other devices haved been introduced that can be 2 years, a clinically
significant improvement in
640
Fig. 11 Posterior segmental distraction carried out with the Aperius implant
inserted percutaneously in a patient with
moderate central stenosis at L4-L5 level
the Symptoms Severity and the Physical Function asymptomatic) located

above or below levels
domains of the ZCQ was found in 60 % and 57 % undergoing laminotomy
or laminectomy for
of patients, respectively, while 73 % were at least symptomatic stenosis.
somewhat satisfied in the Patient Satisfaction
domain [16]. By contrast, in another study [17]
a good outcome, when considering all three
domains of the ZCQ, was obtained only by 31 % References
of patients 1 year on average after operation.
Only one study compared the result of operation 1. Postacchini F.
Lumbar spinal stenosis and
after a mean of 2 years in a group of patients who pseudostenosis.
Definition and classification of of
pathology. Ital J
Orthop Traumatol. 1983;9:33951.
had a distraction device inserted percutaneously
2. Postacchini F.
Lumbar spinal stenosis. Wien/
and a group submitted to open surgical decompres- NewYork: Springer
Verlag; 1989.
sion (laminotomy or total laminectomy) [18]. 3. Verbiest H. A
radicular syndrome from developmental
In the former group, a good outcome was found narrowing of the
lumbar vertebral canal. J Bone Joint
Surg Br. 1954;36-
B:2307.
in 60 % of patients with moderate stenosis and
4. Postacchini F.
Management of lumbar spinal stenosis.
only in 31 % of those with very severe stenosis, J Bone Joint Surg
Br. 1996;75-B:15464.
while in the open decompression group the out- 5. Cinotti G, De
Santis P, Nofroni I, Postacchini F.
comes were satisfactory in 69 % of moderate ste- Stenosis of the
intervertebral foramen. Anatomic
study on
predisposing factors. Spine. 2002;27:2239.
noses and 89 % of severe stenosss. These findings
6. Herron LD,
Mangelsdorf C. Lumbar spinal stenosis:
suggest that, at present, interspinous distraction results of surgical
treatment. J Spinal Disord.
devices are poorely indicated in patients with 1991;4:2633.
severe stenosis. 7. Sanderson PL, Wood
PLR. Surgery for lumbar spinal
stenosis in old
people. J Bone Joint Surg Br.
However, they may represent an alternative
1993;75B:3937.
to open decompression as a preventive measure 8. Katz IN, Lipson SJ,
Larson MG, et al. The outcome
in patients with relative stenosis (mild and of decompressive
laminectomy for degenerative
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lumbar stenosis. J Bone Joint Surg Am. 15. Getty CJM. Lumbar
spinal stenosis. The Clinical spec-
1991;73A:80911. trum and the
results of operation. J Bone Joint Surg Br.
9. Simpson JM, Silveri CP, Balderstone RA, et al. The 1980;62B:4815.
results of operations on the lumbar spine in patients 16. Zucherman JF, Hsu
KY, Hartjen CA, Mehalic TF,
who have diabetes mellitus. J Bone Joint Surg Am. Implicito DA,
Martin MJ, Johnson 2nd DR,
1993;75A:18239. Skidmore GA,
Vessa PP, Dwyer JW, Puccio ST,
10. Cinotti G, Postacchini F, Weinstein JN. Lumbar Cauthen JC, Ozuna
RM, Zucherman JE, Hsu KY,
spinal stenosis and diabetes. Outcome of surgical Charles A. A
multicenter, prospective, randomized
decompression. J Bone Joint Surg Br. 1994;76B:2159. trial evaluting
the X STOP Interspinous process
11. Aryanpur J. Ducker T: multilevel lumbar laminotomies: decompression
system for the treatment of neurogenic
an alternative to laminectomy in the treatment of lum- intermittent
claudication: two-year follow-p results.
bar stenosis. Neurosurgery. 1990;26:42933. Spine.
2005;30:3511358.
12. Postacchini F, Cinotti G, Perugia D, Gumina S. The 17. Brussee P, Hauth
J, Donk RD, Verbeek AL, Bartels
surgical treatment of central lumbar stenosis. Multiple RH. Self-rated
evaluation of outcome of the
laminotomy compared with total laminectomy. J Bone implantation of
interspinous process distraction
Joint Surg Br. 1993;75B:38692. (X-Stop) for
neurogenic claudication. Eur Spine J.
13. Postacchini F, Cinotti G. Bone regrowth after surgical 2008;17:2003.
decompression for lumbar spinal stenosis. J Bone Joint 18. ostacchini F,
Ferrari E, Faraglia S, Menchetti PPM,
Surg Br. 1992;74-B:8629. Postacchini R.
Aperius interspinous implant versus
14. Grob D, Humke T, Dvorak J. Degenerative lumbar open surgical
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spinal stenosis. decompression with and without sis. Spine J.
2011;11:9339.
arthrodesis. J Bone Joint Surg Am. 1995;77A:103641.
Minimally-Invasive Anterior
Lumbar
Spinal Fusion
H. Michael Mayer
Contents
Abstract
643 Less invasive anterior approaches to the lumbar
spine have been developed and become popular

General
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
Indications and Patient Selection . . . . . . . . . . . . . . . . . . . 644
within the last 20 years. Although the influence

Minimally-Invasive Anterior Approaches for
of mid-term and long-term outcomes is yet
Interbody Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 645 unclear, they have significantly reduced
645 peri-operative morbidity such as tissue trauma,
Lateral Retroperitoneal Approaches (L2-L5) . . . . . . . 645
blood loss, hospitalisation time and post-
Mid-Line Approaches to the Levels L2/3, L3/4,
operative pain. This chapter describes the
L4/5, L5/S1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 649 retroperitoneal lateral approaches as well as
Hazards and Complications . . . . . . . . . . . . . . . . . . . . . . . 658
anterior retroperitoneal midline approaches to
Lateral Approach L2-L5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
658 the lumbar levels L2-S1. These approaches can
Transperitoneal Approach to L5-S1 . . . . . . . . . . . . . . . . . 659
be used for various type of interbody fusion as

Critical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 659 well as for total disc replacement. They require
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 659
a detailed knowledge of the individual topo-

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 660 graphic anatomy of and around the lumbar
spine. With this information, individualized
approaches can be planned and performed,
which employ the most convenient access with
the least risk potential in each individual case.
Keywords
Anatomy # Anterior fusion # Complications #
Critical evaluation # Indications # Lumbar
spine # Minimally-invasive # Operative
techniques-L4-5 disc, L5-S1 disc # Principles
The term minimally invasive has been used in

H.M. Mayer
the surgical scientific literature since the intro-

Spine Centre Munich, Schon Klinik M
unchen Harlaching,
Munchen, Germany
duction of microsurgical and endoscopic surgical
e-mail: MMayer@schoen-kliniken.de
approaches. It has been applied in various fields

643
DOI 10.1007/978-3-642-34746-7_33, # EFORT 2014
644
H.M. Mayer
mainly in abdominal surgery, gynaecological or back pain due to disc

degeneration is in most
thoracic surgery [9, 18, 21]. Although arthroscopic cases multifactorial.
Whereas pure discogenic
techniques in the peripheral joints or microsurgical back pain is mainly found
in a younger patient
techniques for discectomy or decompression have population, the majority of
patients presents
been used for many years in Orthopaedic surgery, with a mixture of
discogenic, arthrogenic
the term minimally-invasive was very rarely and musculo-ligamentous
symptoms. Surgical
used or associated with these procedures. In fact, procedures to deal with
these symptoms
it has only come to our perception in the last years, have different goals in
common: the excision or
when it was increasingly used to describe or elimination of pain
source(s), the elimination
characterize procedures or surgical approaches of pain-generating
biomechanical mechanisms,
for the treatment of degenerative disc disorders the restoration and
retention of the physiological
of the lumbar spine. segmental curvature as well
as the restoration
For the surgical treatment of degenerative dis- of disc and foraminal
height especially
orders of the lumbar spine a variety of minimally- in cases with lateral
recess and/or foraminal
invasive techniques have been developed in the stenosis. There is no
doubt, that all these goals
last 15 years. All these techniques have in com- can best be achieved by
360# or 270# fusion
mon to represent surgical approaches which are of one or several lumbar
segments. Using this
less invasive than the standard approaches which technique, the pain sources
(disc, end-plates,
have been used hitherto [12]. facet joints, facet joint
capsules) are excised.
This leads us to a very fundamental but impor- Pathologic load patterns
due to loss in disc height
tant statement to avoid misunderstandings and as well as macro-
instabilities (e.g., degenerative
misinterpretations: whenever we talk about min- spondylolisthesis) are
eliminated by the fusion.
imally-invasive surgery for the curative treatment Disturbances of lumbar
curvature in the
of segmental lumbar disc degeneration we talk sagittal (kyphosis,
hyperlordosis) as well as
about minimally-invasive approaches to perform frontal (degenerative
lumbar scoliosis, segmental
target surgery such as disc excision, fusion or tilt) planes can be reduced
and retained by
disc replacement which in all cases is still as posterior instrumentation.
Disc height as well
(maximal) invasive as it ever was. as foraminal height can be
restored in cases
Wrong indications for surgery, undesired with root symptoms
associated with low back
side effects, complications and bad results are pain. Thus spinal fusion is
the only curative
strongly determined or influenced by the surgical salvage procedure to treat
degenerative low
approach to the target area [2, 13]. Less invasive back pain.
techniques in general decrease the degree of
iatrogenic surgical trauma. They ameliorate
early post-operative morbidity and enable early
and aggressive rehabilitation of the patient with- Indications and Patient
Selection
out an increase in complications. The following
chapter describes the rationales and goals of fusion There is consensus that
spinal fusion in degener-
surgery for degenerative lumbar spine disorders, ative conditions of the
lumbar spine should be the
and the implementation of minimally-invasive last therapeutic step when
non-invasive or semi-
techniques into the surgical standard strategies. invasive conservative
measures have failed or in
cases where total disc
arthroplasty or other
motion-preserving
techniques are contra-indi-
General Principles cated. However, there is no
international consen-
sus on the type of fusion
which should preferably
Disc degeneration is a key pathomechanism be used in different
pathologies [3, 4, 6, 8, 11].
which, per se, can lead to clinical symptoms The most often-used
techniques are listed in
(discogenic low back pain). However, low Tables 1 and 2.
Minimally-Invasive Anterior Lumbar Spinal Fusion
645
Table 1 Minimally invasive access surgery for fusion

and disc reconstruction
Laparoscopic anterior interbody fusion [18, 19]
Percutaneous posterolateral interbody fusion [8]
Mini-open microsurgical posterolateral fusion [15]
Mini-ALIF [10]
Mini-open total disc replacement [14]
Table 2 Spinal fusion techniques

Posterolateral (intertransverse) 180# post
TLIF/PLIF 270# post
Percutaneous PLIF 180# ant
ALIF 180# ant
Post/ALIF 270# post/ant
Fig. 1 Tradtional
anterior approach for lumbar
interbody fusion [7] (1
external oblique muscle, 2 quadratus
Minimally-Invasive Anterior lumborum muscle)
Approaches for Interbody Fusion
In 1990 Obenchain first described a laparoscopic the abdominal muscle

layers were cut irrespective
approach to the L5/S1 disc [16]. This key publi- of their orientation and
the lumbar segment(s)
cation triggered the development of a variety of were approached anterior
to the psoas muscle
less invasive anterior accesses to the lumbar spine, [7] (Fig. 1).
which dominated the 90s of the last century.
Laparoscopic surgery soon turned out to be
associated with a variety of technical pitfalls and The Microsurgical (Mini-
Open) Access
hazards and has never reached the status of a Pre-Operative Planning
and Preparation
routine-procedure in spine centres around the of the Patient
world [17, 19, 20]. However, the need for less The surgical approach is
performed from the left
invasive anterior approaches was obvious since side. Thus,
topographical anatomy of the ante-
360# or 270# fusion seemed to achieve the highest rior-lateral
circumference of the target segment
fusion rates of all fusion techniques used hitherto must be studied
carefully before the operation. In
[5, 11, 14]. In 1997, the author described two addition to information
about the underlying
mini-open access-techniques to the lumbar levels pathology, MRI of the
lumbar spine and its sur-
for anterior interbody fusion [10]. They were based rounding structures
gives all the anatomical
on the application of microsurgical philosophy to information which is
needed to perform meticu-
the well-known standard anterior approaches. lous pre-operative
planning (Fig. 2).
It facilitates the
operation if the surgeon is well
informed and aware of
the size, shape, and local-
Operative Techniques ization of the psoas
muscle in relation to the
anterior lateral
border of the lumbar spine, and
Lateral Retroperitoneal Approaches the size and course of
the retroperitoneal vessels.
(L2-L5) For the approach to
L4/5, MRI examination
should be focused, in
particular, on the size and
Mono- as well as multi-segmental anterior fusion shape of the common
iliac vein as well as on the
is performed through a standard anterior approach presence and size of an
ascending lumbar vein on
to the lumbar levels L2-L5. With this technique, the left side.
646
H.M. Mayer
M. psoas
Ascending lumbar vein
Common iliac vein
Fig. 2 MRI T2-axial view of the disc space level L4-5. Watch the surrounding
anatomic structures retroperitoneal
vessels, Psoas
Pre-operative conventional X-rays of the lum-

bar spine in two planes are mandatory in order to
gain enough information on the spine curvature as
well as the height of the intervertebral space to be
approached. Additional information on the shape
of the inferior borders of the rib cage, which is
important for the approach to L2/3, can also be
obtained. It is important to notice that there might
be huge lateral osteophytes of the vertebral bodies
adjacent to the segment which is to be fused.
Starting 24 h prior to surgery, the patients are
treated with routine mechanical large bowel
preparations to empty the colon.
Anatomical Considerations
The disc spaces L2/3, L3/4, and L4/5 are reached
through a left-sided retroperitoneal approach.
The disc space is reached through an antero-
lateral route along the medial border of the
psoas muscle. A trans-psoas approach, has Fig. 3 Psoas thickness in
a young athlete. High risk of
a significantly higher risk for damaging of lumbar muscular damage or lumbar
plexus damage if a transpsoas
approach would be used
plexus nerves within the psoas muscle. Espe-
cially in young athletic patients the psoas muscle
reaches a thickness of more than 57 cm, which To facilitate the
surgical preparation (espe-
makes it difficult to cross it (Fig. 3). The other cially in obese patients),
the patient is placed in
advantage of this antero-lateral dissection is that a right lateral decubitus
position. In contrast to
no nerve monitoring is necessary. the conventional macro-
surgical approach, the
647
a b
Fig. 4 (a) and (b) A surgical microscope or loupes should be used in difficult
anatomic situations
segmental lumbar arteries and veins are not rou- all the abdominal
contents fall away from the
tinely exposed nor do they need to be dissected in surgical field making
way for the approach
the majority of cases. However, one has to be corridor (Fig. 5).
aware of the segmental vessels since they are at According to the
level to be approached, the
risk for indirect tension due to retraction of table is then tilted
backward 20# in the axial plane
their mother vessels (vena cava, aorta, common for (L4/5), 30# (L3/4),
or 40# (L2/3). The orien-
iliac vein). tation of the lumbar
motion segment is then
checked with lateral
fluoroscopy. If necessary,
Optical Aids the tilt of the table
is adjusted in order to achieve
The use of a bright head lamp (Xenon Light a parallel projection
of the vertebral end-plates of
source) and optical aids (surgical microscope; the level to be
approached. The orientation of the
loupes) is recommended especially in difficult disc level
(orientation line), as well as the cen-
anatomic situations (obese patients, re-opera- tre of the disc space
(centre line), are marked
tions, difficult vascular situation in the retroperi- on the skin. The line
of the skin incision is centred
toneal space) (Fig. 4). over the target point
(intersection of the orienta-
tion and centre lines)
in an oblique direction
Positioning (parallel to the fibre
orientation of the external
The operation is performed with the patient in a oblique abdominal
muscle) (Fig. 6).
right lateral decubitus position on an adjustable
surgical table. The table is slightly tilted (legs Surgical Steps
down) to increase the distance between the iliac Skin to Retroperitoneal
Space
crest and the inferior border of the rib cage. A 4-cm skin incision is
sufficient for the exposure
Due to this positioning, the surgical approach of one segment. The
retroperitoneal space is
is facilitated especially in obese patients since exposed through a
blunt, muscle-splitting approach.
648
H.M. Mayer
Fig. 5 Positioning of the

patient (right lateral
decubitus for left lateral
approach)
enough retroperitoneal fat

tissue beneath the lat-
eral part of the
transversus muscle and the peri-
toneum, which is more
adherent to the inner
fascia of the medial part
of this muscle.
Retroperitoneal Space to
Intervertebral
Region
Blunt dissection is
continued in the retroperito-
neal space using peanut
swabs and modified
Langenbeck hooks for
preparation. Small bridg-
ing veins between the fat
tissue and the inner wall
Fig. 6 Localization of target segment of the lateral abdomen are
closed with bipolar
coagulation and dissected.
The anterior and
Each muscular layer (external oblique, internal medial circumference of the
psoas muscle is
oblique, transverse abdominal muscle) is dissected identified. The peritoneal
sack as well as the
in the direction of their fibre orientation (Fig. 7). ureter and the common iliac
artery at L4/5 are
The branches of the intercostal nerves 1012 gently retracted toward the
midline using the
as well as the iliohypogastric/ilioinguinal nerves, blunt hooks. Anteromedial
attachments of the
which occasionally cross the surgical field at the psoas muscle to the lumbar
spine can be identi-
level of L4/5 between the layers of the internal fied and incised and
sharply dissected from the
oblique and transverse abdominal muscles, are anterolateral circumference
of the disc space and
the only structures at risk during muscle splitting. adjacent vertebral body
borders after bipolar
They must be preserved in order to maintain coagulation. Dissection
should not be extended
innervations of the rectus abdominis muscle. posterior to the pedicle
entrance in order to avoid
Blunt splitting of the transverse abdominal mus- irritation of the lumbar
nerve roots. Very rarely
cle should be performed as far lateral as possible the segmental vessels of
the inferior vertebral
to avoid accidental opening of the peritoneum. body need to be ligated
with clips, cut, and dis-
Even in very slim patients, there is usually sected from the vertebral
surface.
649
Retractor blades are

attached to a self-retaining
frame-type retractor
(Synframe; SynthesOberdorf,
Switzerland). The
retractor ring is fixed to the
surgical table, and the
retractor blades can be
adjusted according to
the individual anatomical
situation (Fig. 8).
Interbody Fusion
Discectomy and
Preparation of Graft Bed
The annulus fibrosis is
incised from the middle of
the anterior
longitudinal ligament to the medial
border of the incised
psoas muscle. The
anterolateral annulus as
well as the nucleus
pulposus are removed
with curettes and rongeurs.
In patients with
inferior bone quality due to oste-
oporosis, care must be
taken not to injure the
subchondral bone. The
cartilaginous end-plates
are removed carefully
with curettes. The
subchondral bone is then
smoothed with a high-
speed drill. The height
and depth of the graft or
cage needed is measured
with a sliding caliper
after completion of
graft bed preparation.
The type of anterior
fusion is optional once the
target area is exposed.
All types of fusion tech-
niques are possible
(autologous bone graft; cages
(PEEK, Titanium)
combined with bank bone,
autologous bone; femoral
ring grafts or BMP,
stand alone ALIF cages
etc.) (Figs. 9 and 10).
Fig. 7 Blunt, muscle-splitting access to retroperitoneal Wound Closure

cavity
At the end of the
operation, the interbody space is
covered with surgicell.
A drain usually is not
At L4/5, the common iliac vein may cover the necessary. The muscle
layers are re-co-apted
mediolateral aspect of the intervertebral space. The with resorbable sutures.
The skin is closed with
vein can be gently retracted after mobilization in resorbable sub- and
intra-cutaneous sutures.
most of the cases. However, this may be a very Since all patients
are treated either with addi-
difficult task in patients with spondylitis/spondylo- tional posterior
fixation or with stand-alone anterior
discitis since there are often adhesions between the constructs, they are
allowed to mobilize 812 h
vessel and the infectious granulation tissue. The use after surgery. A brace
is recommended for 12
of the surgical microscope is helpful in such situa- weeks post-operatively
(Fig. 11).
tions. The main branch of the sympathetic chain
can now be identified. It can occasionally be mobi-
lized and preserved; however, in the majority of Mid-Line Approaches to
the Levels
cases cauterization and dissection is necessary. L2/3, L3/4, L4/5, L5/S1
The lateral border of the anterior longitudinal
ligament is now visible and blunt dissection is There are no general
contra-indications for mini-
completed when 510 mm of the adjacent verte- open anterior mid-line
accesses, however for the
bral bodies are exposed. levels L4-5 and higher,
they are only used as an
650 H.M. Mayer
Fig. 8 Synframe (Synthes,

Oberdorf, Switzerland)
ring-retractor
PEEK
Carbon
Titanium
Fig. 9 Different types of anterior interbody cages

651
Fig. 11 Typical post-

operative lumbar brace
information about the

curvature, disc space
height as well as about the
anterior bony circum-
ference of the disc space to
be approached.
The pre-operative
planning should also
Fig. 10 Anterior lumbar interbody fusion L4-5. X-ray
lateral projection post-operatively include MRI investigation of
the lumbar spine
to show the target
pathology, the surrounding
structures in the spinal
canal, the degree of disc
alternative to the lateral approach in case degeneration as well as the
type of degenerative
stand-alone cages or total disc replacement is changes in the adjacent
vertebral bodies.
performed which, for technical reasons, usually The knowledge of the
vascular topography of
requires a mid-line approach (Fig. 12). For the the retroperitoneal blood
vessels allows the
level L5-S1 we use this approach as a standard. planning of individualized
approaches. We thus
This type of mini-open access may be modi- routinely include a 3-D-CT
angiography to eval-
fied in patients with difficult vascular situations uate the size, shape and the
topography of the
or severe intra-abdominal scarring following pre- retroperitoneal blood
vessels (Fig. 13). Venous
vious abdominal operations. and arterial bifurcation can
be clearly visualized
as well as the entrance and
topography of
the ascending lumbar vein
and the segmental
Pre-Operative Work-Up arteries and veins. The
topographical relationship
Meticulous pre-operative planning is necessary between the arterial and
venous branches and the
to avoid vascular complications. underlying lumbar spine can
be shown. The
knowledge of the individual
vascular situation of
Imaging the patient influences the
surgical technique and,
Plain x-rays of the lumbar spine including in rare cases, might lead to
a contra-indication
flexion-extension views are standard. They give for disc replacement (e.g.,
venous bifurcation
652
H.M. Mayer
a b
Fig. 12 Implants requiring mid-line approaches: (a) stand-alone cage L5-S1 (Synfix,
Synthes, Siwtzerland) (b) total
disc replacement L4-5 (prodisc L, Synthes Switzerland)
covering completely the

anterior circumference of
the target disc space).
It also helps to decide,
whether the help or the
availability of a vascular
surgeon is necessary
during the operation to avoid
medico-legal problems in
case of complications.
Patient Positioning
The patients are placed
in a Da-Vinciposition
(supine, arms abducted
90# , legs abducted 25#
each) (Fig. 14). The
supine-position should be
neutral, hyperextension
of the lumbar spine should
be avoided. A surgical
table, which allows intra-
operative tilting of the
legs, is recommended. The
orientation of the disc
space can then be adjusted
to fit the visual axis
of the surgeon.
Localization
Fig. 13 3-D-colour-coded CT angiography. Note the The target level is
localized under a.p. and lateral
ascending lumbar vein fluoroscopic control and
marked on the skin.
653
In slim patients, the abdominal wall is slightly the level L4-5

(e.g., in adjacent level degener-
indented with a metal marker to show the position ation requiring an
anterior approach).
of the marker on the skin surface in relation to the 2. The second choice is
retroperitoneal from the
anterior border of the target disc space (Fig. 15). left side. This
approach is alternatively chosen
All implantations are performed through small in cases with
previous abdominal surgery in
45 cm. transverse skin incisions Because of the lower right
quadrant (e.g., appendectomy,
anatomical and topographical details each level gynaecological
operations, operation for
has very specific technical demands. abdominal hernia).
3. The third choice is
transperitoneal, which we
L5/S1 prefer in extremely
obese patients (see below).
There are three options to approach the L5-S1 The skin incision
is either placed in the mid-
disc space (Fig. 16): line in slim patients
or slightly asymmetric to the
1. The first choice of access to the L5-S1 disc is approach side in obese
patients or in patients with
retroperitoneal from the right side. The right a very wide stature
(Fig. 17).
side is chosen to decrease the risk of injury to This is the easiest
segment to approach. After
the superior hypogastric plexus in men and exposure of the
anterior rectus fascia, the linea
women and to leave the left approach-side alba is split in the
mid-line. The rectus abdominis
untouched for a potential future approach to is then visible on both
sides. Sometimes there are
adhesions between the
ligamentum urachi and the
pre-peritoneal fat pad,
which have to be dissected
sharply. A soft tissue
spreader with blunt blades
is then inserted to
retract both rectus muscles
from the midline. This
leads to exposure of the
peritoneum.
Retroperitoneal
access from the right side:
The peritoneum is
bluntly detached from the
inner abdominal wall on
the right side. The trans-
verse fascia has to be
incised to mobilize the
abdominal contents
adequately. The psoas mus-
cle, as well as the
common iliac artery with the
Fig. 14 Da-Vinci-position ureter, are identified.
Preparation is continued
a b
Fig. 15 (a and b) Localization of disc space with lateral fluoroscopic control

654
H.M. Mayer
fat tissue including

the plexus exposes the medial
sacral artery and vein,
which can then be clipped
or coagulated and
dissected. Thus L5/S1 can be
exposed easily. The
left common iliac vein can be
retracted carefully to
the left. This is the safest and
easiest 3.2.4 Approach
to L5/S1 Disc.
Retroperitoneal
access from the left side:
Dissection process is
the same as on the right
side. Dissection is
performed across the common
iliac vein to the disc
space L5/S1. This can be
difficult especially if
the vein has a large diameter
and covers part of the
disc space. The superior
hypogastric plexus has
to be pushed medially
Fig. 16 Three approaches to L5-S1 with care avoiding any
coagulation. These two
factors make this
approach the second-choice-
approach; however,
exposure of L5/S1 can be
achieved as properly as
from the right side.
Transperitoneal
access: The fat pad in front of
the peritoneum is
mobilized from lateral to
medial in order to
expose the peritoneum and to
facilitate laparotomy.
The peritoneum is then
opened and armed with
four sutures placed at
the cranial and caudal
edges. The mesentery
with the ileum is
carefully pushed into the upper
left abdominal cavity
using the Langenbeck
hooks for blunt
dissection and small abdominal
towels to hold the
abdominal contents in place.
The same is done to the
sigmoid colon, which
is carefully retracted
to the left. A soft tissue
retractor with blunt
blades is inserted in order to
retract the bowel to
the right and to the left after
identification of the
common iliac artery and the
retroperitoneal course
of the ureter on the right
side. Thus, the
promontory is exposed. The
retractor is then
completed with two other blades.
Once these are
positioned between the bifurca-
tion in front of the
lower anterior part of the
L5 vertebral body,
the other one is centred in
Fig. 17 Skin incisions for different levels L2-3 to L5-S1 the pre-sacral space.
Now, the corridor to the
anterior circumference
of L5/S1 is free.
The peritoneum in
front of the promontory is
towards the mid-line between the ureter incised with micro-
scissors. The incision is made
(displaced medially) and the artery. Medial to about 2 cm. lateral to
the mid-line on the right
the common iliac artery, the lateral circumference side and completed in a
semi-circular manner.
of L5/S1 can be exposed. In this area, the superior The reason for this is
the fact, that the main
hypogastric plexus is very thin with rare and small branches of the
superior hypogastric plexus usu-
branches, which decreases the risk of damaging ally are located in the
medial and left aspect of the
this plexus. Blunt dissection of the pre-vertebral pre-vertebral space at
L5/S1. On the right lateral
655
side, you can only find very small fibres of the

plexus, which can be identified easily under the
surgical microscope. Dissection is performed
bluntly and the pre-vertebral fat tissue including
the superior hypogastric plexus is gently pushed
away from the anterior disc circumference from
the right to the left using cotton wool pads. Only
bi-polar coagulation is allowed. Thus, the ante-
rior circumference of L5/S1 as well as the median
sacral vessels are exposed. The vessels are closed
with vascular clips, dissected and retracted from
the disc surface.
The retractor blades can now be re-adjusted
underneath the peritoneum in order to retract the
peritoneum and the pre-vertebral tissues from the
surgical field.
In very obese patients, in patients who have
had conventional abdominal surgery and in revi-
sion cases, the transperitoneal minimally-invasive
approach is the adequate technique. It is the most
direct way to L5/S1 and can be performed easily
even in obese and previously-operated patients.
Approach to L4/5 Disc

The anterior access to L4-5 is from the right side.
A retroperitoneal approach is the first choice.
This is the most difficult level to access because
of the vascular anatomy. The disc space is, in
most cases, covered by vascular structures. Vas-
cular anatomy thus determines the approach to Fig. 18 Oxytip on the left
big toe to continuously
L4/5. Due to the venous anatomy, the retroperi- measure the oxygen-saturation
in the left leg
toneal approach from the left side has been pre-
ferred in conventional anterior approaches.
However, vascular mobilization across the of oxygen saturation in the
left big toe to avoid
mid-line has its limitations using a minimally- prolonged ischaemia of the
leg due to retractor
invasive approach. Mobilization of the abdomi- pressure on the arteries
(Fig. 18).
nal contents is more difficult through a 45 cm. After localization of the
level of the skin inci-
skin incision. The same is true for preparation and sion it is placed slightly
paramedially to the left
retraction of the blood vessels. Since vascular side (Fig. 17). The rectus
fascia is exposed from
injury or arterial occlusion can result in a the linea alba to its lateral
border. It is then
life-threatening situation, all efforts should be incised transversely to allow
mobilization of the
directed to avoid such type of complication. rectus muscle (Fig. 19).
An individualized access, which considers the The muscle belly is then
mobilized medially to
individual vascular topography is recommended expose the posterior rectus
sheath and the linea
to access the L4-5 disc space. Pre-operative arcuata. The posterior rectus
sheath is the incised
3-D-CT angiography determines the individual longitudinally and the
peritoneum is exposed
mobilisation of the blood vessels. Intra-operative (Fig. 20). Care has to be
taken not to open the
monitoring includes the continuous measurement peritoneum. The
retroperitoneal space is entered
656
H.M. Mayer
L4-5 is then identified.

The next surgical target is
the lateral border of the
common iliac vein and
the entry of the
iliolumbar and ascending lum-
bar venous branches. It is
essential to first identify
these venous branches.
They have to be occluded
with sutures or vascular
clips and dissected. This
surgical step is paramount
since in the majority of
the cases, the common
iliac vein cannot be mobi-
lized without the risk of
a tear injury to the
iliolumbar and ascending
lumbar branches. The
mobilization of the common
iliac artery is simple,
since there are no exiting
branches in this region.
Once this step is
completed, the retroperito-
neal space lateral to the
rectus muscle is left and
is entered again medial to
the muscle belly.
Further mobilization
of the vascular structures
should follow the
individual vascular anatomy.
Although, 3D-CT
angiography shows a great
Fig. 19 Incision of the anterior rectus sheath
variety of vascular
situations in front of the
L4-5 disc space, there are
three variations of
vascular mobilization
which are recommended.
Variation 1
If venous and arterial
bifurcation are located cra-
nial to the superior
border of the L4-5 disc space,
the access can be between
the bifurcations. In this
situation, mobilization
and dissection of the
ascending lumbar veins is
not necessary. The
median sacral vessel
however should be ligated
and dissected. This is a
rare situation at the level
L4-5 (Fig. 21a).
Variation 2
If the arterial
bifurcation is located on the level of
Fig. 20 Incision of the arcuate line (posterior rectus
sheath) the disc space, it should
be mobilized together
with the venous structures
across the mid-line.
However, it is recommended
to carefully monitor
the oxygen saturation in
the left big toe and,
lateral to the rectus muscle, to facilitates vascular if necessary, to relieve
the pressure of the retrac-
preparation and dissection in the lower left quad- tor blades on the artery
every 3040 min.
rant with only low retraction pressure on the With this type of
mobilization, ligature of the
rectus muscle. The peritoneum is then mobilized left segmental artery and
vein L4 is mandatory
from the lateral abdominal wall and the psoas (Fig. 21b).
muscle is identified. Medial to the psoas muscle,
the common iliac vein and artery are exposed. Variation 3
The ureter is dissected from the common iliac If the arterial
bifurcation alone is well above the
artery and mobilized medially together with the disc space L4-5, a
dissection between the arteries
peritoneum. The lateral border of the disc space is recommended. Only the
common iliac vein
Minimally-Invasive Anterior Lumbar Spinal Fusion 657
Fig. 21 Low-risk vascular

a
mobilization in minimally-
invasive mid-line
approaches (a) left-to-right:
if aorta is close to the mid-
line and vena cava right to
the mid-line (b) between
aorta and vena cava: if aorta
far left and vena cava close
to the mid-line (c) below
bifurcation: if arterial and
venous bifurcation are
above L4-5 disc space level
L3
L4
L5
L3 L3
L4
L4
L5
L5
658
H.M. Mayer
or the inferior cava vein is mobilized across the

mid-line, whereas the common iliac arteries are
slightly pushed to both sides of the disc space.
Ligature of the segmental vein L4 on the left side
is necessary (Fig. 21c).
A direct, transperitoneal approach would be
the second-choice approach. The superior hypo-
gastric plexus and the perivascular tissues have to
be dissected carefully. The mobilization of the
blood vessels will be the same as described
above.
Approach to L 2/3/4 Disc

The approach to L3/4 and L2/3 needs modifica-
tions on the skin-to-spine-route. The skin incision Fig. 22 Exposure of the disc
space (L4-5). Synframe
is usually at the level or above the umbilicus retractor in place
(Fig. 17). If it is at the umbilical level, a small,
longitudinal paramedian incision on the left side
is preferred. Retroperitoneal exposure is much
more difficult at these levels, since the perito-
neum is adherent to the posterior rectus sheet. Hazards and Complications
Innervation of the rectus muscle must be pre-
served and the integrity of the fascial indentations Lateral Approach L2-L5
at these levels must be respected. It is thus
recommended to expose the retroperitoneal There are a variety of
potential complications,
space in two steps: Longitudinal midline incision pitfalls, and hazards which
can arise at various
of the anterior rectus sheet 5 mm lateral to the steps of the operation:
linea alba and exposure of the left rectus muscle. Wrong positioning of the
patient: It is com-
Then, dissection from anterior to the muscle to its mon to all microsurgical
procedures that posi-
lateral border and opening of the retroperitoneal tioning of the patients
significantly contributes
space is performed. to the success of the
operation. The patient should
Thus, the peritoneum can be detached from be positioned as described
above. Special atten-
the posterior rectus sheet from left- lateral to the tion must be made to the
parallel orientation of
mid-line. The exposure is then continued by the disc space borders as
well as to the tilt of the
opening of the posterior rectus sheath close to surgical table. This is
emphasized because all
the mid-line and retroperitoneal dissection from anatomical landmarks (iliac
crest, psoas muscle,
the left to the right. In obese patients again, anterior longitudinal
ligament) are helpful and
a transperitoneal route is recommended. valid only when they are
oriented the right way.
At the level L2-3, care should be taken for Take care that the end-
plates are in a parallel
the renal vessels to avoid tethering or indirect projection. If there is a
tilt which cannot be
rupture. corrected it is necessary to
modify the insertion
of the anchoring screws in a
way that perforation
Exposure of the Disc Space of the tip of the anchoring
screw into the
Once the peritoneum and the vascular structures intervertebral space is
avoided.
are shifted away from the anterior circumference Skin incision too close
to iliac crest: This can
of the spine, the disc space can be exposed happen in patients with
high iliac crests. If this
(Fig. 22). The approach corridor is then secured situation occurs during
localization of the skin
by the insertion of a frame-type retractor. incision (usually at L4/5),
I recommend to tilt
659
the table slightly more backward which will shift a Trendelenburg positioning
the angle between
the incision line more anteriorly. The same is valid the L5/S1 interspace and the
surgeons visual axis
for patients with hypertrophy of the psoas muscle. increases and might make it
impossible to have
High muscle tension due to insufficient a good insight into the disc
space.
relaxation of the patient: Note that the patient Exact localization of
the corridor line is para-
has to be completely relaxed otherwise high mount since mobility of the
skin of the patient is
forces are needed to retract the abdominal limited once the surgical
approach is too far cra-
muscles. nial or caudal.
Ureter: The ureter is rarely seen during Retraction of the
abdominal contents gets
exposure of the target area. It usually courses in extremely difficult if the
bowel is not empty and
the retroperitoneal fat, which is mobilized relaxed. So pre-operative
bowel preparation is
anteriorly. one of the keys to a
successful operation.
Common iliac artery: The left common iliac Microsurgical dissection
in front of the peri-
artery can only be exposed at L4/5. In patients toneum is safe. However it
should be performed
with severe arteriosclerosis, the vessels might bluntly with small swabs,
the use of bipolar coag-
kink laterally and thus reach into the approach ulation must be restricted
to a minimum.
corridor. It is not a problem to retract the vessel. Dissection in the
retroperitoneal space in front
However, if there are calcifications the retraction of the promontory must start
from the right side in
should be very gentle in order to avoid lesions to order to decrease the risk
of injury to the superior
the calcified wall of the vessel. hypogastric plexus.
Genitofemoral nerve: This nerve courses on The opening of the
retractor in the retroperi-
the medial surface of the psoas muscle. It is toneal space must be
performed very gently in
exposed to damage by pressure of the retractor order to avoid over-
distraction of the venous
blade or by bipolar coagulation. The nerve should bifurcation. If there is an
overlap of the medial
be preserved since irritation causes post- aspect of the left common
iliac vein with the
operative paresthesias, pain, and discomfort L5/S1 disc space, the vein
should be retracted
projecting into the groin and medial thigh. gently by the assistant.
Donor site complications: The most common There is sometimes
bleeding from intra-
post-operative complications at the iliac crest osseous veins of the sacrum,
which might occur
are pain, irritation of the lateral femoral cuta- after resection of the end-
plate. This can be con-
neous nerve, haematoma, and fatigue fracture trolled with bone-wax, which
is distributed on the
of the anterior superior iliac spine. Most of bony surfaces with the high-
speed diamond burr.
these complications can be avoided if the The peri-operative
complication rate is less
graft is taken at least 4 cm. lateral to the than 10 %.
anterior superior iliac spine. This helps to pre-
serve the lateral femoral cutaneous nerve,
decreases the risk of fatigue fracture as well
as post-operative pain. Haematomata can be Critical Evaluation
avoided by meticulous haemostasis, including
the use of bone wax, as well as by sufficient Results
wound drainage.
Results of Mini-open
anterior fusion have already
been described [10, 11, 14].
The combination of
Transperitoneal Approach to L5-S1 mini-open anterior fusion
with pedicle instru-
mentation leads to excellent
and good results in
Approach: Pitfalls might be wrong positioning of 7585 % of the patients. The
pseudoarthrosis rate
the patient and inadequate localization of the is 3 % and the rate of
complications due to
corridor line. If the patient does not have the anterior approach is 5.2
%. Decrease in
660
H.M. Mayer
peri-operative morbidity however seems to be the and

intertransverse process arthrodesis. J Bone Joint
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WH. Present role of thoracoscopy
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surgical techniques and, if necessary for medico- Spine.
1997;22:691700.
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Livingstone; 1967.
Sub-Total and Total Vertebrectomy
for Tumours
Stefano Boriani, Joseph Schwab,

Stefano Bandiera, Simone
Colangeli, Riccardo Ghermandi,
and Alessandro Gasbarrini
Contents
Abstract
662 En bloc resections in the spine involve sub-
total and total vertebral body excision

depending on the location of the tumour. The

goal of these procedures is to obtain tumour-
and/or Basic Science, e.g., Biomechanics . . . . . 663
free margins and conform surgical planning to
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 664 the oncological indications proposed by
Enneking and validated later in the treatment
of primary tumours. The spine imposes signif-

icant anatomical constraints which make wide

665 margins more difficult to achieve when com-
Vertebrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 665
Sagittal
Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
668
pared to extremity surgery.

Posterior Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 671 There are three techniques one can use:
The first is a combination of anterior and

posterior approaches to perform the en bloc

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 672 resection of the vertebral body/ies In
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 674 selected cases -when the tumour is not
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 674 expanding anteriorly- this procedure can
be performed by posterior-only approach.
The second is an anterior and posterior

approach (or posterior approach alone if fea-
sible) to perform a sagittal resection of the
vertebrae.
The third is the resection of posterior ele-
ments by posterior approach alone. All
three are technically challenging and com-
plications should be anticipated.

S. Boriani (*) # S. Bandiera # S. Colangeli #
The Weinstein, Boriani, Biagini staging
R. Ghermandi # A. Gasbarrini
system can be used to help assess spine
Department of Oncologic and Degenerative Spine
tumours as well as to plan the resection.

e-mail: stefanoboriani@gmail.com
The epidural extension of a tumour may
prevent the obtaining of negative margins.

J. Schwab
Department of Orthopedic Surgery, Massachusetts
A very morbid choice like dura resection and
General Hospital, Boston, MA, USA

661
DOI 10.1007/978-3-642-34746-7_38, # EFORT 2014
662
S. Boriani et al.
inclusion in the specimen can be considered such procedures must be

considered in terms of
and weighed against the risks. the margin they provide.
The risks of surgery must always be An oncologically
appropriate surgery in
balanced against the risks of avoiding surgery. primary bone tumours of the
spine should be
When non-oncologically appropriate treat- accomplished by planning
surgery based on
ment is performed most of these patients will oncological and surgical
staging. Following
experience local recurrences and undergo fur- appropriate guidelines
allows one to achieve a
ther surgery and possibly die of the disease. margin that is oncologically
sound for each tumour
as dictated by its
aggressiveness [1]. Many exam-
Keywords ples are reported in the
most recent literature of
Aetiology and classification # Anatomy and highly technically-demanding
surgical procedures
pathology # Complications # Diagnosis # Indi- performed either in tumours
of the cervical or
cations for surgery # Operative techniques- cervico-thoracic spine [26]
or including the
vertebrectomy-posterior approach, sagittal dural sac and neurological
structures in order to
resection, combined approach # Spine # Sub- obtain an appropriate
oncological margin [7, 8].
total and total vertebrectomy # WBB Staging Several different
techniques are therefore
described and detailed in
this chapter together
with the basic principles of
surgical staging and
General Introduction planning. Using these
principles one can adapt
the techniques described to
each individual case
Primary tumours of the spine are exceedingly as the tumour demands.
Furthermore, we have
rare. Owing to their rarity, few surgeons had also included tips that can
be used to avoid prob-
gained enough experience and insight into their lems and thereby reducing
morbidity.
management until the 1970s when B. Stener first
applied oncological criteria to the resection of
spinal tumours. Spinal tumours had been treated Aetiology and Classification
with intra-lesional curettage prior to this period.
It is important to acknowledge that Stener was the Fewer than 5 % of the 2,500
primary malignant
first to plan and perform en bloc tumour resec- bone tumours that present
each year in the United
tions in the spine using oncological principles States occur in the spine
[911]. For that reason,
previously outlined in tumours of the gastro- there are few centres that
gained a critical level of
intestinal tract. His works are still an unsurpassed experience in the management
of these tumours.
example of adapting surgery to tumour size and Furthermore, the terminology
utilized to describe
anatomical constraints to achieve an en bloc these tumours had tended to
vary considerably
resection with negative margins. from one region to the next.
In addition, there
Later on R. Roy Camille popularized were no staging systems that
helped one decide
a technique to standardize en bloc resection in which type of surgery to
perform. All of these
the thoracic spine using a posterior approach and reasons entered into our
decision to help develop
in the lumbar spine by combined posterior and the Weinstein, Boriani,
Biagini (WBB) surgical
anterior approach. Some years later K. Tomita staging system. This system
is designed to unify
proposed a similar technique that entailed remov- the ways by which tumours
are described in order
ing the posterior arch en bloc followed by remov- to facilitate communication
between physicians.
ing the vertebral body en bloc using a saw finer In addition, once a common
descriptive language
than the Gigli saw. However what is missing in is accepted it helps to
facilitate research efforts.
those excellent contributions, which represent the Finally, the WBB system
helps guide the surgeon
foundations upon which other surgeons have fur- with regard to what type of
resection is possible.
ther advanced, is any consideration to the mar- The WBB divides the axial
presentation of the
gins to be achieved. The oncological value of vertebrae involved with
tumour into 12 zones
Sub-Total and Total Vertebrectomy for Tumours
663
Fig. 1 WBB Staging

System. The transverse 12 1
extension of the tumour is
described with reference to
12 radiating zones 11
2
(numbered 112 in anti-
clockwise direction starting
from the left half of the
spinous process) and to five
concentric layers (AE)
10
3
E
C D
B
A
9
4
8
5
7 6
similar to a clock face (Fig. 1). Position number 1 the WBB staging system as
involving zones 4
begins at the left half of the spinous process and through 8 with extension into
zones A and D.
position 12 ends at the right half of the spinous
process. Zones 4 and 9 are particularly important
to know because they define respectively the left Relevant Applied Anatomy,
Pathology
and the right pedicle. Vertebrectomy with ade- and/or Basic Science,
quate surgical margins depends upon one of these e.g., Biomechanics
two zones to be free of tumour. The vertebra is
further divided into radial zones. The radial zones Fundamental knowledge of the
relevant anatomy
define the depth of tumour invasion. For instance, for each region of the spine
is imperative when
zone A represents a soft tissue mass extending planning en bloc excision of
tumours. The
beyond the confines of the bony cortex. Zone tumour leads the surgeon into
areas of the spine
B describes tumour within the superficial bony that are not often
encountered in the average
vertebrae, whereas zone C defines tumour within practice of degenerative
spine surgery. Each ver-
the deep bony vertebrae. Zone D describes epi- tebrae receives segmental
arterial contributions
dural tumour involvement and zone E is from two vessels. These are
matched by two
intradural. It is also important to describe the veins leading to the azygos
or hemi-azygos in
longitudinal extent of the tumour. the chest and the vena cava
in the abdomen.
As an example, a tumour of a lumbar vertebra While the artery is often
considered, avulsion of
involving the left pedicle and the vertebral body, a vein is more likely and
more difficult to man-
extending into the psoas and the epidural space age. The vessels travel from
the aorta towards the
can be described based on the distribution within neural foramina along the
osseous portion of the
664
S. Boriani et al.
vertebral leaving the disc spaces relatively free of imaging is imperative for
surgical staging and
major vessel attachment. The blood supply to the planning. A tissue sample
is also crucial.
spinal cord enters through the neural foramina, CT-guided biopsies have
become more accurate
inside the nerve roots (radicular artery) and and are the procedure of
choice for obtaining
reaches the terminal territory by the so called a tissue diagnosis [17].
However, they carry
artery of Adamkiewicz (radiculare magna a.) a non-diagnostic rate of
nearly 10 % and they are
Some segmental contributions are more vigorous inaccurate in about 2 % of
cases [17]. In cases
than others, and the major supply to the lower where the diagnosis is in
question, an open biopsy
thoracic/lumbar spine is classically described as is warranted. In general, a
transpedicular approach
arising from one segmental artery. This view is is best. The entry site can
be filled with
not confirmed by dynamic angiographic and MRI methylmethacrylate to help
mitigate tumour spill-
studies. There are animal data that suggest that age. An open biopsy can
also be performed at the
ligation of fewer than four segmental vessels time of surgical resection
by frozen section. How-
inclusive of the arteria radicularis magna does ever, the surgeon should
exchange the instruments
not result in spinal cord dysfunction [1214]. used for biopsy with new
ones. In addition, the
Furthermore, Kawahara et al. reported the liga- surgeons should change
their gown, gloves and
tion of the arteria radicularis magna in 14 patients re-drape prior to
proceeding with resection.
without neurologic compromise [15]. However,
it is commonly accepted that there is an increas-
ing risk of spinal cord injury when the arteria Indications for Surgery
radicularis magna as discovered on angiogra-
phy- is injured or ligated. This must be discussed Surgery is indicated when
one is attempting to
with the patient prior to surgery. cure a patient for their
primary sarcoma. Surgery
The specific type of tumour also has an impact may also be indicated for
palliative treatment due
on surgical preparation. For instance, Ewings sar- to the ability to allow a
long time for local control
coma and osteosarcoma are often treated with neo- of the disease, but, in
general, en bloc surgery
adjuvant chemotherapy. These patients are often should be reserved for
those patients who have
mal-nourished and immuno-compromised which a meaningful chance of
long-term survival. The
makes their ability to heal and recover from sur- morbidity associated with
en bloc resection is not
gery sub-optimal. It is imperative to consider in keeping with the goals
of palliation.
nutritional optimization of these patients prior to A frank discussion must
occur with the patient
surgery. In addition to chemotherapy, it is impor- prior to proceeding with
surgery. The goal of
tant to determine whether the patient has received surgery is to remove the
tumour with an
radiation therapy previously. Radiation therapy oncologically-acceptable
margin. For malignant
given pre-operatively has been shown to increase tumours this means removal
of tumour with
the rate of wound complications in extremity sar- a layer of normal tissue
surrounding it. In cases
coma [16]. Furthermore, a remote history of radi- where nerve root resection
will lead to significant
ation should signal to the surgeon that a significant motor deficit, the patient
must be made aware.
amount of scar tissue may be encountered making Furthermore, there may
arise a situation where
dissection much more dangerous, with risk of a meaningful surgical
margin is not possible
injury to the vessels, the dura, and the ureters. without transaction of the
spinal cord. This option
must be discussed with the
patient. For some
patients, the idea of
paralysis is not worth con-
Diagnosis sidering, however there are
others who may wish
to accept paralysis in
exchange for possible cure.
A differential diagnosis for primary malignant This is clearly a decision
that only a patient
bone tumours of the spine can be made based on should make in conjunction
with the counsel of
the patients history and plain radiographs. Axial their surgeon.
665
oncological margin only for

tumours without
Pre-Operative Preparation and extension into zone A. For
all tumours that extend
Planning into zone A we recommend a
staged posterior
followed by anterior
procedure, or an anterior
As mentioned above, the WBB system is helpful release as first step It is
our opinion that the staged
in planning for surgery. A pre-operative MRI is approaches are safer and
allow for best oncolog-
an important part of the WBB system as it pro- ical margins. For this
reason we generally stage
vides the necessary image quality used in the our anteriorly and
sagittally-based tumours. We
WBB staging system. The goal of surgery should will describe our technique
for removing these
be to obtain a negative margin. This is possible tumours as well as our
technique for removing
when the tumour spares at least one pedicle a sagittally-based tumour
and tumours of the
(zones 4 or 9). Extension into zone D may pre- posterior elements. It is
important to remember
clude the obtaining of a negative margin unless that these techniques were
first described by
a layer of healthy tissue (pseudocapsule) exists Stener and Roy Camille [18,
19].
between the tumour and the dura. It is not always
possible to know this until the time of surgery.
Close attention should be paid to zone
A extension. The anterior approach should be Operative Technique
directed towards the side with maximum zone
A involvement to allow for best visualization. In Vertebrectomy
addition, one must pay close attention to the
cephalo-caudal extent of the tumour. This will Posterior Approach for a
Vertebrectomy
help determine whether the transverse cuts The patient is placed in
the prone position with
should occur through a disc or vertebrae. If both the hips and the knees
flexed. Care is taken
a foramen is involved, then the nerve root in to avoid compression of the
abdominal compart-
that foramen will need to be taken with the ment. The shoulders and
iliac crests must be
tumour in order to obtain a tumour-free margin. protected to avoid skin
breakdown.
Furthermore, it may be necessary to remove A standard mid-line
incision is utilized to ele-
a nerve root to facilitate tumour exposure even vate the paraspinal muscles
for at least two levels
on the non-tumour side of the vertebrae. This is above and below the site of
the tumour (Fig. 2).
generally done in the thoracic spine. For low lumbar tumours this
includes exposing
It is imperative to plan ahead when en bloc the sacrum.
resection is entertained. A team must be assem- Prior to addressing the
tumour, spinal instru-
bled in order to perform this procedure. This team mentation is inserted (Fig.
3). In general we insert
may include a thoracic surgeon, vascular surgeon pedicle screws two levels
above and two below
and/or general surgeon among others. Skilled the affected vertebra.
However, hooks can also be
anaesthesia is critical and post-operative inten- used. One of the advantages
of pedicle screws,
sive care should be anticipated. Blood products aside from providing more
rigid fixation to bone,
must be at the ready in case rapid infusion is is that the pedicle screws
can be inserted into the
necessary to counteract hypovolaemia. anterior construct. This is
particularly true when
There are four general types of en bloc resection carbon fibre cages are
used.
in the thoracic and lumbar spine. There is the We usually instrument
two levels above and
posterior-only approach for anterior vertebral two below, but there are
exceptions to this rule.
tumours, a staged approach for anterior vertebral We avoid ending our
instrumentation at the apex
tumours, a staged sagittal resection and a posterior- of a curve. The apex must
be assessed on pre-
only resection for posteriorly based tumours. operative standing
radiographs. If a hook con-
While en bloc excision from a posterior only struct is utilized in the
thoracic spine, we may
approach is possible, it provides an adequate extend the fixation upwards
by a level or two.
666
S. Boriani et al.
In the thoracic
spine we remove ribs from
a
a level above and
below the tumour. The ribs
are also removed from
the level of the tumour if
they do not have
tumour involvement. We gener-
ally remove about 10
15 cm. of the rib from the
rib head distally. The
pleura is carefully dissected
and pushed anteriorly.
Once the posterior
elements are removed, then
the lateral aspects of
the vertebral bodies must be
bluntly dissected.
Again, if one side of the vertebral
body has a soft tissue
extension, then the opposite
side should be
approached from posteriorly. The
side with the soft
tissue mass will be approached
anteriorly. Blunt
dissection of the lateral aspect of
the vertebral body
necessarily involved identifica-
tion and ligation of
the segmental blood vessels.
Remember that they
course along the sides of the
vertebral body towards
the neural foramina. It is
b important to ligate
the vessels on the uninvolved
side of the vertebrae.
This will be the blind side
when the anterior
approach is carried out. Once this
dissection has taken
place, then sponges can be
packed into the dead
space created. These will be
removed on the
anterior approach.
Fig. 2 Lumbar vertebrectomy (L3). Posterior approach. Prior to beginning
the osteotomy, it is wise to
Patient prone. Midline posterior skin incision extending place a rod on the
side opposite to that on which
3 levels above and below the affected vertebra. (a) Poste-
rior view. Exposure of the posterior elements and removal
the bone is being cut.
When one moves to the
of all the posterior elements not affected by the tumour. other side for the
osteotomy, then the rod can be
(b) Transverse view. A dissection of muscle connections placed on the opposite
side again. This is to
from the vertebral body opposite to the tumour expansion prevent any sudden
movement if the spine were
is then performed and haemostatic sponges are left (see
also Fig. 7). Avoid any digital or instrumental manoeuvres
to fracture through
the osteotomy. Now the
in the area occupied by the tumour growth to avoid enter- osteotomy can begin.
Abundant bleeding should
ing the mass and producing tumour contamination of the be anticipated during
osteotomy. One should
surrounding tissue communicate with the
anaesthesiologists that
blood loss is
expected. The decision whether to
Once the instrumentation is inserted, then one make the cut through
the discs or through the
can begin excision of the posterior elements. All vertebral body will
have been made based on
the posterior elements not involved with tumour the pre-operative
imaging. If the discs are the
are removed. This is necessary to allow visuali- site of the cut, then
the discs are removed in
zation of the structures anterior to the spinal cord their entirety. It is
particularly important to
(Fig. 3b). Obviously, if tumour involves a portion remove the annulus
fibrosis form the blind
of the posterior elements such as a pedicle, then it side. This is the
side opposite where the anterior
is left untouched to be removed during the ante- approach will occur.
If an osteotomy is chosen,
rior approach. If both pedicles are involved with then the cuts should
be made most aggressively
tumour, it is still possible to remove the tumour on the blind side.
en bloc, but it is less likely that an appropriate The posterior
longitudinal ligament (PLL)
margin will be obtainable. The uninvolved pedi- must be transected at
the level of the osteotomy.
cle is removed with a rongeur or high speed burr. In addition, the
potential space between the dura
667
a b
Fig. 3 Lumbar vertebrectomy (L3). Posterior approach. pre-operative plan

requires section of the vertebral body,
(a) The posterior elements have been removed and the the selected area for
performing the osteotomy will be
pedicular screws introduced. (b) The dural sac is separated isolated. The nerve
roots will be sacrificed if included in
from the tumour, if growing in the epidural space. the tumour mass or if
preventing a complete separation of
Section of the annulus and longitudinal ligament. If the the dura from the
tumour
and the PLL should be developed in order to approach (Fig. 7) is

used. The soft tissues are
allow a sheath to be placed. This sheath will be identified and
retracted away from the tumour.
helpful during the anterior approach as it will Segmental vessels are
identified and ligated.
help to identify the dura. It will be removed A malleable retractor
is placed between the
during the anterior approach. large vessels and the
vertebral body (Fig. 8).
At this point the rods are place into the screws Now the posterior
incision is re-opened. Nearly
and the screw caps are positioned and hand- two-thirds of the
vertebral body/tumour can now
tightened (Fig. 4). They are not tightened with be visualized. The
blind side is not visualized,
the torque wrench as the rods will be removed but the dissection
from the posterior approach has
during the anterior approach. The wound is addressed this. The
sheath between the dura and
closed loosely. vertebral body is
identified and removed. The
spinal cord is
protected.
Anterior Approach for a Vertebrectomy The remaining disc
or bone can now be cut or
The patient is placed on the side in a secure removed. The
osteotomy is finished with an
position (Figs. 5, 6). A posterolateral skin inci- osteotome, burr or
gigli saw. Copious bleeding
sion is performed. Depending on the level, should be anticipated
during osteotomy. The
a thoracotomy, throracolumbar or retroperitoneal tumour is now
delivered en bloc (Figs. 9, 10, 11).
668
S. Boriani et al.
Fig. 6 Thoracic
vertebrectomy. Stage 2. Patient in
a lateral position.
Skin incisions: the posterior midline
approach is opened
again after the change of position.
The thoracotomy is
classically performed one level
above the lesion. A T
shaped incision is advised whenever
the tumour grows
posteriorly, to include a muscle shell
around the tumour
mass
Reconstruction of
the defect can now ensue.
The size of the
defect can be measured, and
appropriately-sized
cage can be inserted. The
Fig. 4 Lumbar vertebrectomy (L3). End of the posterior cage is filled with
local bone obtained during
stage. A posterior stabilisation system has been implanted.
Haemostatic sponges are positioned to fill the defect and
the previous
exposure. Note, if iliac crest bone
around the dura is to be used, then a
separate set of instruments
and drapes should be
used. We often use a carbon
fibre cage, because
we like to connect the screws
from the posterior
construct into the cage
(Fig. 12). Once the
cage is secure and the rods
are again in place
posteriorly, then the screw caps
are tightened with a
torque wrench.
Sagittal Resection
Posterior Approach
for a Sagittal
Resection
One of the key
differences between the sagittal
resection and the
vertebrectomy is that the neural
foramina are usually
involved with tumour and
Fig. 5 Lumbar vertebrectomy (L3). Stage 2. Patient in the corresponding
nerve root will need to be
a lateral position. An anterolateral retroperitoneal sacrificed in order
to obtain a tumour-free
approach is performed which, in selected cases, can arrive margin. The
positioning is similar to that for
at the midline approach forming a T shaped incision. The
T incision should be limited to those cases in which the the posterior portion
of the vertebrectomy. The
tumour is growing in the spinal muscles, to resect such posterior dissection
is also performed in
structures en bloc. The posterior approach is opened again a manner similar to
the posterior portion of the
669
Fig. 8 Lumbar
vertebrectomy (L3). Stage 2. Anterior
retroperitoneal
approach. Segmental vessels sectioned
between ligatures.
Malleable retractors positioned around
the vertebral
body. The psoas is left over the tumour mass
and the level of
osteotomy is decided according to pre-
operative
planning. Section of the discs above and below
the tumour, when
located inside the vertebral body
Fig. 7 Lumbar vertebrectomy (L3). Stage 2. Anterior ret-

roperitoneal approach. Note the haemostatic sponges posi-
tioned around the dura and between the vertebral body and
the muscle insertion on the contralateral side to the approach
vertebrectomy with one exception. The tumour

often involves a portion of the posterior elements
on one side and so the posterior dissection must
respect this area and leave it untouched in order to
obtain a margin. This may require that a cuff of
muscle be left on the transverse process or ribs if
Fig. 9 En bloc
removal of L3 vertebral body
there is a soft tissue mass extending posteriorly.
The uninvolved posterior elements are removed.
The dura needs to be exposed on the side opposite thoracic spine the
rib above and below must be
the tumour as well as the entire dura above and prepared for
excision. The ribs should be cut
below the level of the tumour. A plane must be distal to the
extent of the tumour on the involved
developed between the tumour and the muscles of side (Fig. 13).
the lumbar spine on the side of the spine with the Pedicle screws
should be placed into two
tumour. At least one nerve root will be taken with levels above and
below the site of resection.
the specimen and it should be identified as it The osteotomes
will often be placed between
leaves the mass so that it can be ligated. In the the tumour and the
dura on the side of the spine
670
S. Boriani et al.
Fig. 10 Thoracic vertebrectomy. Stage 2. Patient in

a lateral position. Combined posterior and anterior
approach through the T shaped incision (horizontal inci-
sion over the midline, transverse incision over the 9th rib).
A couple of malleable retractors (arrows) displace and
protect the mediastinum structures and the lung.
A couple of chisels (arrow head) are used to complete
the resection
Fig. 12 Carbon
fibre cages are stacked together
according to the
required length and filled with autoge-
nous cortico-
cancellous bone. A circumferential recon-
struction of the
spine by connecting the prosthesis with
the posterior
stabilisation system is performed
remove the
contralateral pedicle so that the dura
is not retracted
into its hard surface. Rods are
Fig. 11 Thoracic vertebrectomy. Stage 2. Transverse placed into
position, but the screw caps are only
section of Fig. 10. A malleable retractor not illustrated in
Fig. 10 is introduced between the posterior wall and the tightened manually
without the use of the torque
dura to protect from the chisels (arrow). Note the circum- wrench. The wound
is closed loosely in prepara-
ferential protection obtained by the malleable retractor tion for it to be
re-opened.
displacing the viscerae (arrow, see Fig. 10)
Anterior Approach
for a Sagittal
involved. Haemostasis is critical and bi-polar Resection
cautery is often very helpful. Gelfoam mixed The positioning is
similar to that for the anterior
with thrombin and/or fibrin glue can also be help- approach. The
incision is made and planes of
ful. The dural sac will necessarily be moved dissection chosen
based on the location of the
slightly to place the osteotome. It is critical to tumour. The same
T incision is made to
671
a b
Fig. 13 Sagittal resection of a thoracic vertebra. space and dissect the

dura from the tumour
Stage 1. Posterior approach. Removal of the healthy pseudocapsule, if
required. (a) Posterior view.
elements of the posterior arch, to visualise the epidural (b) Transverse section
connect with the posterior incision. The lung is Reconstruction of

the spine can be as simple as
collapsed and the pleura is incised around the removing remaining
discs and placing intebody
tumour mass to be used as a margin. The ribs cages filled with bone,
or a reconstructive cage
will be cut at this time if they have not already can be used if more
than 1/3 of the vertebral body
been cut on the posterior approach. In the lumbar has been taken. When we
use a cage that is not
spine the soft tissues around the tumour are sec- connected to the
posterior hardware, we will use
tioned including the psoas or portions of the dia- a plate along the sides
of the vertebrae for extra
phragm. The segmental vessels are ligated which support. The rod is now
replaced back into the
will allow for a malleable retractor to be placed posterior screw heads
and the screw caps are
between the large vessels and the spine. tightened with a torque
wrench.
The posterior incision should be re-opened.
An osteotome can now be placed between the
dura and the tumour. The direction of the Posterior Resection
osteotome will be determined based on the extent
of vertebral body involvement with tumour. The posterior resection
requires that both pedi-
The malleable retractor should serve as cles are free of tumour
in order to obtain
a barrier between the osteotome as it comes out a margin. The patient
is placed prone as described
the cortex and the vessels (Fig. 14). Once the above. A cuff of normal
tissue is left over the
vertical cut has been made, then two horizontal tumour in the posterior
elements (Fig. 15). The
cuts are made at each end of the vertical cut to spine is exposed
subperiosteally above and below
complete the osteotomy. The tumour is removed this level. The spine
must be exposed lateral to
in one piece. the end of the
transverse processes in the lumbar
672
S. Boriani et al.
a b
Fig. 14 Sagittal resection. Stage 2. Combined posterior A couple of chisels

cut the spine above and below the
and anterior approach through a T shaped incision which tumour. A chisel
directed posterior to anterior according
is always required for leaving an appropriate shell of to the pre-
operative planning completes the resection.
healthy tissue around the tumour. (a) Posterior view. The (b) Transverse
section. A malleable retractor protects the
dural sac is carefully retracted. The section of at least two mediastinum
structures from the chisel (arrow) directed
nerve roots prevents excessive traction on the cord. posterior to
anterior
spine and lateral to the angle of the ribs in the

thoracic spine. The dura must be exposed above Post-Operative Care
and
and below the level of the tumour. Both pedicles Rehabilitation
must be exposed without contaminating the field.
The pedicles must be transected (Fig. 16). There The vertebrectomies
and sagittal resections
are several ways to do this. One way is to require a stay in
the intensive care unit post-
use the T saw. The saw must be passed around operatively. This
is usually not the case for pos-
the pedicle with the use of a guide. Once the saw is terior-only
resections. Once the patient is out of
in place, the bone is cut by using a back and forth the intensive care
unit, we allow them to bear
motion with the saw. This technique was described weight. In many
cases we use a 3-point orthosis.
by Tomita [20]. Alternatively, a high speed burr This is
discontinued at about 2 months.
can be used. We prefer a diamond burr as it is less
likely to injure the dura as long as it is kept cool
with irrigation. Curved rongeurs can also be used Complications
to cut the pedicles. The tumour can be lifted away
and any further soft tissue attachments can be Complications are
very common after en bloc sur-
removed bluntly or sharply as required (Fig. 17). gery in the spine.
We have a team dedicated to the
The spine is reconstructed with posterior instru- management of spine
tumours, and 1 out 3 patients
mentation as described above. in our series
sustained a complication [21].
673
Fig. 15 Posterior resection. Patient prone. Midline

approach. A muscle shell is left over the tumour
Fig. 17 Posterior
resection. Final stage of resection in
the lumbar spine
(sectors 10 to 12). (a) Transverse view.
(b) Posterior view
The rate of complication

goes up with when sur-
gery is for a recurrence
or if more than one level is
involved. Staged
procedures had a higher rate of
complication when
compared to single-stage
approaches [21]. This
reflects the more techni-
Fig. 16 Posterior resection. Circumferential dissection cally-challenging cases
since they are most likely
around the tumour in the lumbar spine (sectors 10 to 12) to require staged
approaches.
674
S. Boriani et al.
The technical challenges of these procedures tumour. We have described

the details of three
cannot be emphasized enough. Some of these major types of en bloc
resections in the thoracic
tumours are quite adherent to the dura making and lumbar spine. The
purpose of removing
dural tear more likely. Previously irradiated tis- tumours en bloc is to obtain
an oncologically-
sues have a higher rate of complications. In this sound margin. While
complications remain high
setting, a dural tear may not heal even with pri- for these resections, one
must remember that the
mary closure of the durotomy. A lumbar drain is tumour itself will cause
its own set of complica-
sometimes necessary to help with closure. tions if untreated.
A blood patch can also be utilized. Dural tears
can lead to C.S.F. leak and depletion with possi- Acknowledgments We are
deeply indebted to
ble subdural hematoma. Infectious meningitis is Prof. M. Campanacci, who
spent a long time teaching us
how to understand the
biological behaviour of bone
another possible sequel.
tumours and how to establish
the treatment strategy on
Damage to the large vessels in the abdomen or the complete analysis of
each single case. To his memory
chest can lead to rapid blood loss and death. It is this work is dedicated.
wise to consider having a vascular surgeon avail- A special thank to Carlo
Piovani for his assistance in
preparing the preliminary
drawings and for the daily work
able to help with large vessel management.
of imaging elaboration and
archive.
Infections are a problem in part due to the long
operative times as well as to the tissue that is
necessarily removed leading to a potential dead
space. This is made worse in patients who have References
been treated with chemotherapy or who are mal-
1. Talac R, Yaszemski MJ,
Currier BL, et al. Relation-
nourished.
ship between surgical
margins and local recurrence in
Non-union and hardware failure are also prob- sarcomas of the spine.
Clin Orthop Relat Res.
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making fusion more difficult. It is important to 2. Fujita T, Kawahara N,
Matsumoto T, Tomita K.
Chordoma in the cervical
spine managed with en
have very stable anterior and posterior stabiliza-
bloc excision. Spine.
1999;24(17):184851.
tion to help mitigate the loss of bone. 3. Rhines LD, Fourney DR,
Siadati A, Suk I, Gokaslan
Our mortality rate from these surgeries is 2 % ZL. En bloc resection of
multilevel cervical chordoma
[21]. Unfortunately, these tumours will eventu- with C-2 involvement.
Case report and description of
operative technique. J
Neurosurg Spine. 2005;2(2):
ally cause the demise of most of these patients if
199205.
they are not removed. This is a critical point to 4. Bailey CS, Fisher CG,
Boyd MC, Dvorak MF. En bloc
remember. Local recurrence, metastases and marginal excision of a
multilevel cervical chordoma.
death are all the enemies of these patients. The Case report. J Neurosurg
Spine. 2006;4(5):40914.
5. Currier BL,
Papagelopoulos PJ, Krauss WE, Unni KK,
surgeon carries a large burden when he attempts
Yaszemski MJ. Total en
bloc spondylectomy of C5
to remove a spine tumour en bloc. The surgery is vertebra for chordoma.
Spine. 2007;32(9):E2949.
extensive and death is a possibility from the sur- 6. Leitner Y, Shabat S,
Boriani L, Boriani S. En bloc
gery itself. The patient, and the surgeon, must resection of a C4
chordoma: surgical technique. Eur
Spine J.
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7. Biagini R, Casadei R,
Boriani S, et al. En bloc
vertebrectomy and dural
resection for chordoma:
a case report. Spine.
2003;28(18):E36872.
Conclusions 8. Keynan O, Fisher CG,
Boyd MC, OConnell JX,
Dvorak MF. Ligation and
partial excision of the
cauda equina as part of
a wide resection of vertebral
Subtotal and total vertebrectomies are technically osteosarcoma: a case
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challenging procedures. They require careful technique. Spine.
2005;30(4):E97102.
planning. Current staging systems are available 9. American Cancer Society.
Facts and figures 2008. http://
www.americancancersociety.org. Accessed 2008.

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10. Dahlin DC, Unni KK. In
Bone tumors. General aspects
cedures are often necessary and the specific type and data on 8,542 cases.
4th ed. Springfield: Charles
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12. Woodard JS, Freeman LW. Ischemia of the spinal cord; 17. Yang J, Frassica
FJ, Fayad L, Clark DP,
an experimental study. J Neurosurg. 1956;13(1):6372. Weber KL.
Analysis of nondiagnostic results after
13. Fujimaki Y, Kawahara N, Tomita K, Murakami H, image-guided
needle biopsies of musculoskeletal
Ueda Y. How many ligations of bilateral segmental lesions. Clin
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arteries cause ischemic spinal cord dysfunction? An 18. Roy Camille R,
Mazel CH, Saillant G, Lapresle Ph.
experimental study using a dog model. Spine. Treatment of
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2006;31(21):E7819. terior
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14. Kato S, Kawahara N, Tomita K, Murakami H, Demura HH, Schiller AL,
Rosenthal DI, editors. Tumours of
S, Fujimaki Y. Effects on spinal cord blood flow and the spine.
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neurologic function secondary to interruption of bilat- 19. Stener B, Johnsen
OE. Complete removal of three
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Adamkiewicz: an experimental study using a dog 1971;53(2):278
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Kawahara N, Baba H, Tsuchiya H, Fujita T,
15. Kawahara N, Tomita K, Murakami H, Demura S. Toribatake Y.
Total en bloc spondylectomy. A new
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Bandiera S, Donthineni R, et al. Morbidity
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tive versus postoperative radiotherapy in soft-tissue J;19(2):23141.
Computer-Aided Spine Surgery
Teija Lund, Timo Laine, Heikki

Osterman, Timo Yrjonen, and
Dietrich Schlenzka
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 677 Recent literature has shown that computer-
aided techniques increase the accuracy of ped-

Basic Principles of Computer-Aided Spine
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 678
icle screw insertion. In the past 1015 years,
various navigation systems have been intro-

Technique of Computer-Aided Pedicle Screw
duced to clinical practice. Each computer-
Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 679
aided technique has its advantages and

Pitfalls of Computer-Aided Spine Surgery . . . . . . . 686
disadvantages, but the theoretical principles
Is Computer-Aided Pedicle Screw Insertion
remain the same. Thorough understanding of
Justified? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 689 and adherence to these principles is mandatory
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 692 for successful application of computer-aided
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 692
technology in the operating theatre. The present
chapter outlines the theoretical basis of com-
puter-aided spine surgery, as well as the princi-
ples of applying this technology in the clinical
setting to avoid any possible pitfalls. The spe-
cific features of different navigation techniques
are discussed, and the justification of computer-
aided spine surgery is addressed based on avail-
able evidence.
Keywords
Computer-aided # Computer-assisted # Navi-
gation # Pedicle screw # Spine # Surgery-
indications, techniques and rehabilitation
Introduction
The basic principles of computer-aided surgery

T. Lund # T. Laine # H. O sterman # T. Yrjonen #
(image guidance, navigation) date back to early

D. Schlenzka (*)
ORTON Orthopaedic Hospital, Helsinki, Finland
1900s, when Clarke and Horsley introduced an
e-mail: dietrich.schlenzka@invalidisaatio.fi
apparatus for precise location of intracranial

677
DOI 10.1007/978-3-642-34746-7_25, # EFORT 2014
678
T. Lund et al.
lesions during surgery [1]. The three components and tools are assumed to
be rigid bodies, i.e. they
of their device were similar to any modern com- should not deform during
the procedure. Despite
puter-aided surgery system: the surgical object apparent differences
between various navigational
(herein a brain tumour), the virtual object systems available to
date, they are all based on
(a brain atlas), and a navigator (an outer frame these fundamental
principles.
attached to the patients head). While these Although the vertebra
with its distinctive ana-
frame-based techniques are still used in neurosur- tomical features is an
ideal object for stereotactic
gical procedures, it was not until frameless tech- surgery, the concept was
introduced to spine sur-
niques became possible, that computer-aided gery only after a
functional alternative for a frame
surgery was introduced to orthopaedics, and spe- of reference, and modern
motion analysis systems
cifically to spine surgery. Pedicle screw insertion, were available for
clinical use. The navigator of
a technically demanding procedure with the risk the stereotactic
apparatus is basically a position-
of significant neurologic, vascular or visceral tracking device with an
ability to determine the
injury, was chosen as the first clinical application. three-dimensional co-
ordinates of the surgical
In the mid-1990s several research groups inde- object (the vertebra) and
the surgical tools in the
pendently published their first laboratory and space. From various
available methods, opto-
clinical results using computer-aided techniques electronic tracking based
on a camera system reg-
for pedicle screw insertion [25]. istering the position
data of the surgical object and
While several additional applications for com- tools remains the most
widely used. For the cam-
puter-aided techniques have been introduced in eras to be able to track
the location and orientation
spine surgery, pedicle screw insertion remains of the tools used in
surgery, the tools need to be
the most widely used. Hence, this chapter con- equipped with either
infra-red light emitting
centrates on computer-aided pedicle screw inser- diodes (LEDs) in systems
using active markers,
tion. First, the basic principles of computer-aided or passive light-
reflecting spheres. In the latter,
surgery will be discussed. Second, the clinical LEDs emitting infra-red
light are positioned
application of computer-aided pedicle screw around the camera; this
light is then reflected by
insertion is described, along with the possible the spheres, and further
registered by the opto-
pitfalls of the technique. Finally, a discussion on electronic camera. For
reasons of simplicity, this
the justification of computer-aided spine surgery, chapter will concentrate
on active navigation sys-
based on existing literature, will be conducted. tems, but the same
principles apply for passive
systems as well. For the
opto-electronic camera
to be able to register
the position of the vertebra to
Basic Principles of Computer-Aided be instrumented, the
vertebra needs to be equipped
Spine Surgery with a frame of
reference. Therefore, a bone clamp
mounted with LEDs
(dynamic reference base,
The navigation apparatus of Clarke and Horsley DRB) needs to be attached
to the spinous process
was based on the principle of stereotaxis, a method of the vertebra in
question. Rigid fixation of the
of localizing surgical objects within the body with- DRB to the surgical
object compensates for the
out direct access to its interior. The stereotactic motion of both the
patient (e.g. due to ventilation)
concept consists of the three above-mentioned and the opto-electronic
camera during the subse-
basic components: the surgical object (e.g. the ver- quent procedure. Finally,
the central control unit
tebra to be instrumented), the virtual object (e.g. the (CCU) of the navigational
system is used for stor-
CT image of that vertebra), and a navigator to link age and reconstruction of
image data to create
these two objects. In addition, conventional surgi- the virtual object, as
well as real-time visualization
cal tools slightly modified to fulfill the require- of the surgical tools
based on position data pro-
ments of computer-aided surgery are needed for vided by the opto-
electronic camera. The basic
execution of surgical procedures. In stereotactic components of a
navigation system are illustrated
surgery, all surgical objects (e.g. the vertebrae) in Fig. 1.
679
Fig. 1 Navigation set-up

in the operation theatre.
The opto-electronic camera
(a) positioned to the foot
end of the operation table
such that direct line of sight
between the camera and the
navigational tools is
maintained throughout the
navigation, and the
computer screen of the
central control unit (b) with
real-time display of the
navigational instruments
superimposed on the virtual
image of the vertebra are
the basic hardware
components of all currently
available systems
Skeletal registration (matching) is the pro- enabling navigation with 2D

and/or 3D recon-
cess linking the real surgical object (the structions of the vertebrae
was introduced.
vertebra) to its virtual representation (e.g. a CT For CT-based computer-
aided pedicle screw
image of that particular vertebra) by means of insertion, pre-operative CT
images of the area to
the navigators co-ordinate system. This is the be operated on are acquired
using a specific imag-
most crucial phase of any computer- aided suring protocol, and transferred
to the central control
gery, and allows for the determination of the unit of the navigation system.
The software of the
location of the various surgical instruments in system then reconstructs and
displays 3D images
reference to the patients anatomy. The most of the surgical object, as
well as multiple 2D
frequently used options for skeletal registration views, usually in frontal,
sagittal and axial planes.
in spine surgery are discussed in the next chapter These reconstructions are used
for the pre-
on the technique of computer-aided pedicle operative planning of the
computer-aided pedicle
screw insertion. screw insertion. For skeletal
registration, three to
six distinctive anatomical
landmarks are identi-
fied from each vertebra to be
instrumented. These
Technique of Computer-Aided Pedicle landmarks need to be easily
identifiable from the
Screw Insertion patients anatomy during the
surgery; the authors
recommend one to two points
from the tip of the
The ultimate aim of computer-aided surgery is to spinous process, the most
dorsal points of the
give the surgeon the possibility to follow his/her superior articular processes,
and the tips of
actions in real time on a computer screen. The the transverse processes. The
pre-operative plan-
navigation systems used in spine surgery are ning also allows for
definition of ideal pedicle
based on imaging of the area to be operated on, screw trajectories, as well as
careful analysis of
either pre-operatively or intra-operatively. The the patients surgical
anatomy.
first clinical applications of computer-aided All available computer-
aided navigation sys-
spine surgery relied upon pre-operative imaging tems aim to interfere with the
surgical procedure
of the relevant anatomy, usually with computed as little as possible. For CT-
based navigation, it is
tomography (CT) for a so called CT-based important to preserve the bony
surfaces during
navigation. Later, intra-operative fluoroscopy exposure for subsequent
skeletal registration.
680
T. Lund et al.
The dynamic reference base (DRB) is fixed to the matching). Based on this
crucial phase of any
the spinous process of the vertebra to be navigation procedure the
surgeon decides either to
instrumented. Stable fixation of the DRB is essen- continue with screw tract
preparation or to further
tial, as its position in space is the only means for improve the matching with a
surface matching for
the navigation system to see the vertebra of better clinical accuracy.
The surface matching
interest. The required connection between the implies digitizing a minimum
of 2030 random
patients real anatomy and the virtual images points from the bony
surfaces of the vertebra of
stored in the CCU is established through a specific interest. For this purpose,
the posterior surfaces of
registration process (matching). For the paired- the laminae and both sides
of the spinous process
point matching, all the anatomical landmarks usually provide sufficient
data [6]. The surface
selected from the pre-operative CT are identified matching algorithm of the
navigation system
from the actual vertebra, and digitized with then fits this acquired
cloud of points to the virtual
a pointer. The navigation system then finds the representation of the
vertebra. The time required
best fit for these two sets of points, the selected to register one vertebra
using both paired-point
points on the virtual image, and the real points and surface matching
techniques averages close
from the patients anatomy for a mean registration to 2 min [7]. After a
repeated confirmation to
error (MRE). It is important to realize that this is exclude any translational or
rotational inaccura-
a mathematically calculated figure, and does not cies, the surgeon can
proceed to the actual screw
necessarily correlate to the clinical accuracy of tract preparation. The
location of the tip and the
the navigation system in that particular case. To orientation of the surgical
tools in reference to the
ensure the clinical accuracy of the navigation patients anatomy are now
displayed in multiple
system, the surgeon selects random points from planes on the computer
screen. Figure 2 (a)
the vertebra with the pointer to confirm that the through (e) illustrate the
different stages of
computer screen display corresponds to the anat- computer-aided pedicle screw
insertion using the
omy of the patient (confirmation or verification of CT-based technique.
a
Fig. 2 (continued)
681
In 2000, Nolte et al. published the first report fluoroscopic images. Hence, a
calibration ring
on computer-aided spine surgery based on con- equipped with LEDs needs to
be fixed to the C-
ventional 2D fluoroscopy, also called virtual fluo- arm. Like CT-based
navigation, virtual fluoros-
roscopy [8]. For fluoroscopy- based surgical copy begins with securing the
DRB to a vertebra.
navigation, calibration of the C-arm is required Fluoroscopic images are then
acquired and auto-
to track its position and orientation during the matically registered by
simultaneous tracking of
image acquisition, and to eliminate the problem the DRB and the calibration
ring attached to the
of distorsion associated with standard C-arm. Adherence to a strict
imaging protocol
Fig. 2 (continued)
682 T. Lund et al.
Fig. 2 (continued)
683
is of highest importance for successful naviga- provide the information

needed for the location
tion. True antero-posterior (spinous process of the surgical object;
likewise, the iso-centric
centered between the pedicles) and lateral C-arm needs to be fitted
with a calibration ring.
(parallel end-plates and pedicles) images are For image acquisition and
registration purposes
a minimum requirement, additional oblique the C-arm rotates
continuously around the patient,
views are optional. After image acquisition the at the same time keeping the
relevant area (the
C-arm can be removed to provide the surgeon vertebral levels of
interest) in the centre of the
with an unrestricted access to the operative rotating motion. By
definition, multiple vertebral
field. The need for intra-operative anatomic reg- levels can be registered
simultaneously, averaging
istration is eliminated, as the registration process three lumbar and six
cervical levels per spin of the
is entirely automatic. The acquired images can be C-arm [9]. The image
acquisition, automatic
used for screw tract preparation in a way compa- registration, and
reconstruction of the images
rable to continuous fluoroscopy. Figure 3 illus- take on average 8.5 min [9].
The continuous iso-
trates the display and the principle of 2D centric rotation of the C-
arm creates a set of 2D
fluoroscopy-based pedicle screw insertion. projections of the anatomy,
out of which the
Intra-operative 3D fluoroscopy provides us software reconstructs a 3D
image dataset with
with another technique of computer- aided ped- additional axial, frontal
and sagittal planes.
icle screw insertion with automatic registration. The actual surgical
procedure is then similar to
Again, a DRB rigidly fixed to a vertebra will that of CT-based navigation
described earlier.
Fig. 2 (continued)
684
T. Lund et al.
Figure 4 (a) and (b) illustrate some specific virtual fluoroscopy and CT-based
navigation
features of the 3D-fluoroscopy navigation. than on 3D-fluoroscopic
navigation [10]. The
Direct comparison of the different navigation clinical accuracy of the
navigation techniques
techniques is difficult. A recent systematic available to date will be
discussed in the chapter
review and meta-analysis found more data on on the justification of
computer-aided pedicle
Fig. 2 (continued)
685
Fig. 2 (a) The dynamic reference base (DRB) rigidly screen display, the
tip of the surgical instrument is on the
attached to the vertebra to be instrumented. The DRB bony surface of the
right transverse process. (d) In the so
consists of a clamp equipped with a probe mounted with called surface
matching, 2030 random points from the
at least three non-collinear light emitting diodes (LEDs). bony surface of the
vertebra are selected to create a cloud
(b) In CT-based navigation, the anatomical landmarks of points which is
then matched to the virtual images from
selected from the pre-operative CT-images (here the tip the same vertebra.
The example herein shows verification
of the left transverse process) are identified from the after surface
matching for the S1 vertebra. The green dots
patients real anatomy and digitized. Based on these dig- on the display
represent the points selected randomly by
itized points the system performs the so called paired- the surgeon. (e)
After registration and verification the
point matching. (c) Confirmation of the registration system is ready for
screw tract preparation, here for the
includes selection of several random points from the right-sided L4
pedicle screw. The light blue graphic screw
patients anatomy to verify that the computer display corresponds to the
planned screw trajectory, and the green
corresponds to the real anatomical situation. The green bar represents the
orientation and location of the surgical
line represents the axis of the instrument. On the computer tool superimposed on
the virtual image
screw insertion. As far as CT-based navigation is comparison on

artificial models of the lumbar
concerned, experimental studies have evaluated spine, paired-point
matching proved to be more
the accuracy of the different registration precise than a
modified surface matching tech-
(matching) methods. Holly et al. found that nique [12]. In vitro
studies comparing the three
although paired-point matching combined with navigation techniques
suggest that CT-based
surface matching significantly improved the navigation provides
better accuracy than virtual
calculated accuracy compared to paired-point fluoroscopy [13, 14],
but no significant difference
matching alone, the clinical accuracy of the two exists between CT-
based and 3D-fluoroscopy-
techniques was equivalent [11]. In another based navigation
[15].
686
T. Lund et al.
Fig. 3 Example of a computer screen display from 2D are available, but

medial perforation of the pedicle cortex
fluoroscopy based navigation for upper lumbar spine pedis unlikely if the
tip of the instrument on the antero-
icle screw insertion. True lateral and antero-posterior posterior view does
not cross the medial limit of the
fluoroscopy images are paramount for this technique. pedicle when the tip
of the instrument on the lateral view
The light blue line represents the position and orientation is just entering the
vertebral body. This situation is illus-
of the surgical instrument. By definition, no axial views trated herein
The advantages and disadvantages of the dif- lumbar spine models

and animal models are
ferent navigational techniques are summarized in pre-requisites for a
successful introduction of
Table 1. computer-aided spine
surgery into the clinical
setting. The
following paragraphs discuss the
additional pitfalls
of computer- aided spine sur-
Pitfalls of Computer-Aided Spine gery concentrating on
the clinical aspects of
Surgery navigation. It is
important to bear in mind that
any inaccuracies of
navigation are always
As with any new surgical technique, the intro- a combination of
technical and human (surgeon
duction of computer assistance to the operation dependent) factors,
out of which the latter are
theatre involves a certain learning curve, even usually more
relevant.
for experienced spine surgeons [16]. In one clin- Any image-based
navigation technique relies
ical series on the introduction of 3D fluoroscopic upon good-quality
medical imaging of the surgi-
navigation into the clinical practice, a sharp cal area. No surgery
should be conducted based
decrease in the mean operative time and pedicle on less than optimal
imaging. The quality of the
screw misplacement rate was noticed after fluoroscopically-
generated 2D imaging may vary
6 months of experience [17]. Thorough under- significantly from
one fluoroscope to another.
standing of the underlying theoretical princi- Moreover, in both 2D
and 3D fluoroscopy, the
ples, and in vitro practice with e.g. artificial acquired images in
especially obese or
687
Fig. 4 (a) An iso-centric

3D image intensifier. When
a
the C-arm is used for
computer aided surgery, it
needs to be equipped with
an additional calibration
ring. For image acquisition,
the C-arm rotates
iso-centrically around the
patient, after which the
acquired images are
reconstructed and
automatically registered
such that computer aided
pedicle screw tract
preparation is possible in
axial, sagittal and frontal
views (b) (Pictures
courtesy of Dr. X. Ma,
Shanghai, China)
osteoporotic patients may not be sufficient for to the camera. This may cause
some changes to
navigation purposes. the traditional layout of the
operation theatre,
Navigation technology based on opto- which are to be taken into
account when position-
electronic tracking requires direct line of sight ing the camera. In case of a
passive navigation
at all times from the DRB and the surgical tools system based on reflective
spheres, any
688
T. Lund et al.
Table 1 Advantages and disadvantages of the different computer-aided techniques

Computer-aided technique Advantages
Disadvantages
2D fluoroscopy-based No pre-operative preparation needed No
possibility for precise
(Virtual fluoroscopy)
pre-operative planning
Virtual images obtained intra-operatively with
Inferior image quality in obese and
the patient in the prone position
osteoporotic patients
Suitable for minimally- invasive procedures
Accuracy sufficient for lower
thoracic and lumbar spine only

Automatic registration No
axial images available
Reduced radiation exposure
3D fluoroscopy-based No pre-operative preparation needed No
possibility for precise
pre-operative planning
Virtual images obtained intra-operatively with
Inferior image quality in obese and
the patient in the prone position
osteoporotic patients
Automatic registration
Expensive equipment
Multiple levels registered simultaneously
Suitable for minimally- invasive procedures
Possibility for post-procedure imaging before
wound closure
Reduced occupational radiation exposure
CT- based Possibility for precise pre-operative planning
Requires pre-operative CT imaging
with a specific protocol

Strict adherence to the principles of navigation
Surgeon-dependent registration
possible
process (learning curve)
Optimal quality of imaging
Separate registration usually needed
for
every level
Not
ideal for minimally- invasive
applications
contamination of the spheres with blood or irri- in navigation [18]. The

former of course applies
gation fluid may change their reflective qualities, as well to fluoroscopy-
based navigation. Thus,
and thus induce inaccuracies into the procedure. selecting a position for
the DRB such that it will
Computer-aided techniques in general cannot not interfere with the
surgical instruments, as
ensure that the surgery is performed at the right well as protecting this
position throughout the
levels. If the posterior anatomy from vertebra to navigation phase, is
mandatory. Frequent accu-
vertebra is almost identical, it is possible to obtain racy checks during the
surgery, especially if
satisfactory accuracy by chance with anatomical movement of the DRB is
suspected, are strongly
landmarks from the adjacent vertebra. Thus, the recommended.
surgeon needs to use other measures to verify the CT-based navigation
technique, by definition,
correct levels before starting with navigation. is based on pre-
operative CT images acquired
In CT-based computer-aided surgery, meticu- with the patient lying
supine. Relative motion
lous attention has to be paid to the registration between the vertebrae
from this position to the
(matching) process to avoid any inaccuracies in prone position during
the operation may lead to
the actual navigation procedure. Fixation of the navigational errors if
it is not accounted for. For
DRB to the vertebra in question needs to be stable this reason adherence to
the rigid body principle,
such that there is no relative motion between the i.e. registration of
each vertebral level separately
vertebra and the DRB. Further, any undetected and fixation of the DRB
to the level in question, is
change in the relative position of the DRB after strongly recommended for
improved accuracy
the registration is completed leads to inaccuracies [19]. Sometimes it is
not possible to fully follow
689
the rigid body principle, e.g. if the posterior ele- adherence to the
underlying principles is the only
ments of the vertebrae are missing due to previ- means to avoid these
mistakes. Furthermore, to
ous surgery. In such cases the DRB needs to be assure adequate skill
level in handling the navi-
fixed to the nearest possible vertebra, and the gation system by all
members of the operation
deviation from the principles reckoned. If no team, the technique should
be used on a regular
relative intervertebral motion has occurred from basis, and not reserved
only for the more difficult
the pre-operative to the intra-operative situation, operations [21].
it is possible after verification of the matching
accuracy to operate on adjacent vertebrae with
one single registration. However, in one clinical Is Computer-Aided Pedicle
Screw
series, adequate navigation accuracy was con- Insertion Justified?
firmed in only 13 % of the adjacent vertebral
levels [7]. The surgeon-dependent registration Although computer-aided
spine surgery has been
procedure shows a considerable learning curve a clinical reality for
more than 15 years, its rou-
over time [5]. tine use has not gained
widespread acceptance
In either 2D- or 3D-fluoroscopy-based naviga- amongst spine surgeons
[14, 20, 22]. When
tion, the DRB often is attached to a vertebra other inserting pedicle screws,
spine surgeons have
than that to be instrumented, or e.g. to the posterior traditionally relied upon
anatomical landmarks,
iliac crest for minimal invasive surgery. In 2D- the tactile feedback of
probing the prepared
fluoroscopic navigation this has proven highly screw channel, and
confirmation by conventional
inaccurate. In a cadaveric study with thoracic fluoroscopy. Especially in
the lumbar spine the
spine specimens, significantly better accuracy routine use of computer-
aided surgery is deemed
was achieved by adhering to the rigid body prin- unnecessary because of the
relatively consistent
ciple, i.e. acquiring several sets of fluoroscopic anatomy of that region
[14]. On the other hand,
images for navigation with the DRB attached to wide variance in the
three-dimensional anatomy
the index level [20]. Furthermore, fixation of the of the vertebrae has been
shown [2325], making
DRB to the vertebra in question excludes inaccu- pedicle screw insertion
based on anatomical land-
racies due to intra-operative motion between the marks unreliable.
vertebrae. If the DRB is attached to a remote ver- Pedicle screw
misplacement rates with the
tebra, and excessive manipulation of the vertebra conventional insertion
technique and adequate
is unavoidable due to sclerotic bone, significant post-operative CT
examination have ranged
differences between the reality and display on the from 5 % to 29 % of the
screws in the cervical
computer screen may exist, even though the spine [2632], from 3 % to
58 % in the thoracic
images have been acquired intra-operatively spine [3345], and from 6
% to 41 % in the
using 2D or 3D fluoroscopy. lumbosacral region [46
58]. Despite these rela-
In the stereotactic concept, all navigated sur- tively high pedicle
perforation rates, the inci-
gical tools are treated as rigid bodies, i.e. the dence of screw-related
complications in the
navigation system assumes the instruments do above mentioned studies
has remained low. Inter-
not bend. However, tension from paraspinal mus- estingly, the highest
rates of neurovascular inju-
cles or space constraints by retractors may cause ries have been reported
from the lumbosacral
bending of the tools. In these instances, the infor- spine in up to 17 % of the
patients [48].
mation displayed on the computer screen does not In their clinical
study on accuracy of pedicle
correspond to reality, and care must be taken to screw insertion, Gertzbein
and Robbins introduced
evaluate the situation based on those views only a hypothetical 4-mm safe
zone in the
where the instrument is not manipulated. thoracolumbar spine for
medial encroachment,
Inept use of navigation in the operation theatre consisting of 2-mm of
epidural and 2-mm of sub-
is associated with significant risks and less than arachnoid space [49].
Later, several authors have
ideal results. Thorough understanding and strict found the safety margins
to be significantly
690
T. Lund et al.
smaller [5962], suggesting that the safe zone controlled trials have
compared the accuracy of
thresholds of Gertzbein and Robbins do not apply computer-aided pedicle
screw insertion to the
to the thoracic spine, and seem to be too high even conventional technique [76,
86]. Rajasekaran
for the lumbar spine [20]. The mid-thoracic and et al. inserted 236
thoracic pedicle screws under
mid-cervical spine, as well as the thoracolumbar fluoroscopic control, and
242 screws using a 3D
junction set the highest demands for accuracy in fluoroscopy-based
navigation system for defor-
pedicle screw insertion, with e.g. no room for mity correction [76]. Post-
operative CT exami-
either translational or rotational error at T5 [63]. nation showed a
misplacement rate of 23 % in the
Although the reported incidence of pedicle conventional group and 2 %
in the navigation
screw-related complications remains low, every group. In the study of
Laine et al., 277 pedicle
pedicle screw violating especially the inferior or screws were inserted using
the conventional tech-
medial pedicle cortex increases the risk of neuro- nique with anatomical
landmarks, and 219
logic injury. Moreover, it only takes one cortical pedicle screws with
navigation based on pre-
breach per individual patient for a potentially operative CT imaging [86].
Post-operative CT
catastrophic complication to occur. Studies on control showed a
significant reduction of screw
the proportion of patients having misplaced ped- misplacement rate in the
navigation group: 4.6 %
icle screws have reported alarming results: up to of the navigated pedicle
screws violated the ped-
72 %, 54 %, and 80 % of patients with cervical, icle cortex, as opposed to
13.4 % of the screws
thoracic and lumbosacral pedicle screws, respec- in the conventional group.
In addition to
tively, have at least one misplaced pedicle screw, a quantitative difference,
these two studies dem-
and thus are at risk of neuro-vascular complica- onstrated a qualitative
difference in the place-
tions [28, 44, 51, 56]. ment of pedicle screws.
Laine et al. reported
Clinical studies on the accuracy of computer- a medial or inferior
misplacement of pedicle
aided pedicle screw insertion have reported mis- screws in 10.1 % and 0.4 %
of their patients in
placement rates ranging from 0 % to 34 % of the the conventional and
navigation group, respec-
screws in the cervical spine [6472], from 2 % to tively. This corresponded
to 40 % of the patients
19 % in the thoracic spine [7379], and from 0 % in the conventional group,
and 2.4 % of the
to 23 % in the lumbosacral spine [8095]. Com- patients in the navigation
group having a pedicle
paring the results from these studies is, however, screw perforation into
these more hazardous
difficult, as different criteria for accurate and directions. A significant
reduction in inferior,
acceptable screw position have been used. medial and/or anterior
misplacement was
With CT-based and 3D fluoroscopy based navi- reported by Rajasekaran et
al. as well. Finally,
gation some of the lateral pedicle perforations are several meta-analyses from
the existing literature
likely intentional, e.g. in an effort to protect the have demonstrated a higher
accuracy of pedicle
upper facet joint. Moreover, in the thoracic spine, screw insertion with
computer-aided techniques
the in-out-in technique of pedicle screw inser- compared to conventional
methods [10, 9698].
tion is clinically acceptable, although it results in Some specific
circumstances exist for
lateral perforation of the pedicle cortex reported computer-aided surgery in
the different regions
in some of the above-mentioned studies. Very of the spine. Irrespective
of the technique used,
few screw-related neurovascular injuries have highest precision in
pedicle screw insertion is
been published: none in the cervical or thoracic needed when the screw
diameter approximates
spine, and in up to 1.4 % of patients in the lum- the dimensions of the
pedicle. Thus, cervical
bosacral spine [89, 94], even if one clinical series pedicles can be regarded as
objects of marginal
on percutaneous placement of lumbosacral pedi- size for any computer-aided
system available to
cle screws with 2D virtual fluoroscopy reports date [99]. In one
experimental study on human
a significantly higher pedicle perforation rate of cadaveric cervical spines,
greater risk of injuring
23 % and a 10 % incidence of screw-related a critical structure with
either conventional tech-
neurological injury [91]. Two randomized nique or CT-based
navigation was demonstrated
691
if the pedicle screw was placed in a pedicle less but this did not reflect to
the total operative time
than 4,5-mm in diameter [100]. The C3 to C5 [86]. Rajasekaran et al., on
the other hand, could
pedicles have the smallest diameter and largest demonstrate in a randomized
setting that the
transverse angle in the cervical spine, and the time required to insert
pedicle screws in defor-
importance of precise registration and extreme mity patients was
significantly shorter in the
caution in applying computer-aided techniques navigation group than in the
conventional
in this region cannot be overemphasized [23]. group [76]. Our clinical
experience further con-
At the mid-thoracic spine (T3-T7) extremely firms that especially in
those patients with sig-
small translational and rotational error margins nificant deformities or
altered posterior anatomy
for the placement of pedicle screws have been e.g. due to previous fusion,
computer-aided
demonstrated [63]. The accuracy requirements at technology reduces the
operative time. More-
these levels may well be beyond the clinical over, with experience the
time needed for
accuracy of current computer-aided systems. computer-aided pedicle screw
insertion
Thus, expecting the navigation systems to per- decreases significantly
[17].
form with absolute accuracy is not realistic or Introduction of computer-
aided techniques
feasible. into clinical practice have
decreased the radiation
Some studies have specifically compared the exposure for both the
patient and the surgical
different available computer-aided techniques team. Significantly lower
radiation doses and
for pedicle screw insertion accuracy. In the fluoroscopy times have been
shown with fluoros-
cervical spine, pedicle screw misplacement copy-based computer- aided
pedicle screw inser-
rates seem to be significantly higher with vir- tion techniques compared
with the conventional
tual fluoroscopy (based on 2D fluoroscopy) technique using repetitive
fluoroscopic imaging
than with either 3D fluoroscopy or CT-based [101104]. In the CT-based
computer-aided tech-
navigation; between the latter two no signifi- niques, however, higher
organ and effective
cant difference was noticed [69]. No significant doses for the patient have
been reported com-
difference between 2D and 3D fluoroscopy pared to the fluoroscopy-
based computer-aided
navigation could be shown in pedicle screw technology [105]. Although
the radiation dose
insertion accuracy in the thoracic spine [75]. from CT imaging for
computer-aided surgery is
A recent meta-analysis, however, concluded well below that of the
diagnostic examinations,
that CT-based computer-aided technology is close attention to the
imaging protocol is
associated with a reduced risk of pedicle recommended with
modifications to reduce the
screw misplacement compared to the 2D fluo- radiation dose to the
patient [106].
roscopy- based technique at the thoracic level Computer-aided spine
surgery involves
[97]. At the lumbar level no significant differ- expensive equipment. In an
era of continuously
ences between the different computer-aided increasing health-care costs
and funding prob-
techniques were noticed. Not surprisingly, the lems, it may be difficult to
justify acquisition of
accuracy of 2D fluoroscopy-based navigation is such costly technology. No
evidence exists to
better in the sagittal than in the axial plane [82]. suggest better functional
outcomes after
Thus, the use of this navigation technique computer-aided spine surgery
compared to con-
should probably be limited to the lower tho- ventional techniques [98].
But evidence does
racic and lumbar spine in patients with no ana- show computer-aided pedicle
screw insertion to
tomic abnormalities. be more accurate than the
conventional tech-
Added operative time is one of the concerns nique. The low incidence of
clinical complica-
associated with computer-aided pedicle screw tions with the latter,
however, may give a false
insertion. In the randomized controlled trial of sense of security with no
need for added effort to
Laine et al., the average time needed to insert ensure better performance.
Safer surgeries with
one pedicle screw was significantly longer in the computer-aided technology
may well be worth
navigation group than in the conventional group, the financial investment.
692
T. Lund et al.
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Crosby TL. Timing of paired points
Summary and surface
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General Management of Spinal
Injuries
Cesar Vincent and Charles

Court
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 698 Spinal trauma is a serious issue with a tremen-
dous impact in western countries. Patients are

General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 698
usually very young, involved in high energy

Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
698 trauma but spinal trauma is more and more
Neurological Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
frequent in the elderly. Sequelae can be dev-
astating and irreversible. The social impact of

Neuro-Protective Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 702
spinal trauma is considerable. Efforts are

Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 702 being made in prevention and in managing
Plains
Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
702
CT Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 703 patients with spinal injuries. Many studies
Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . .
704 tried to evaluate neuro-protective agents to
Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 704 enhance recovery. Although the AO classifi-
Biomechanics and Classification . . . . . . . . . . . . . . . . . . 705
cation is being widely used in Europe, new
classifications have been published to help

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 708
physicians in understanding mechanisms and

Timing of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 709 treatment rationales. Conservative treatment
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 710 can give good results mainly with low energy
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 711 trauma and no neurological impairment. Sur-
gery is being indicated to ensure good fracture
reduction and neural decompression. Surgical
techniques are based on fusion by posterior or

anterior approaches. No approach has proven
to give better long-term results and no consen-
sus has been found with respect to posterior
fusion or fixation extent. New minimally-
invasive techniques have recently emerged in
an effort to decrease surgical morbidity
especially in elderly and polytrauma patients.
These techniques need to be confirmed by

C. Vincent # C. Court (*)
large prospective randomized studies with
Spine Unit, Orthopaedic Department, Bicetre University
long-term follow-up.
Hospital, AP-HP Paris, Universite Paris-Sud ORSAY,
Le Kremlin Bicetre, France
e-mail: cesar.vincent@bct.aphp.fr;
charles.court@bct.aphp.fr

697
DOI 10.1007/978-3-642-34746-7_30, # EFORT 2014
698
C. Vincent and C. Court
risk of injury to drivers and

passengers. Not only
Keywords have restraints and airbags
diminished the sever-
Biomechanics and Classifications # Clinical ity of injuries, but also they
changed the pattern
assessment # General Management # Imaging- of thoraco-lumbar fractures in
patients involved
radiographs, CT Scanning, MR Scanning # in car accidents [1215].
Injuries # Neurological assessment # Neuro- In a multi-centre study of
the Scoliosis
protection # Spine # Treatment-non-operative, Research Society including
1,019 patients, 16 %
operative of injuries occurred between
T1 and T10, 52 %
between T11 and L1, and 32 %
between L1
and L5 [16]. Multi-level
fractures occur in up to
Introduction 25 % of patients [17, 18]. Any
spine fracture can
be associated with another
non-contiguous spine
Spinal trauma can lead to dramatic functional fracture in up to 15 % of
cases [17], so these
sequelae when neurological lesions are present. fractures can be overlooked if
not systematically
In treating such lesions, the surgeon must looked for, and consequently
thoraco-lumbar
conduct a general examination to look for fractures are missed more
frequently in
associated lesions, as well as a precise polytrauma patients [14].
neurological examination. Imaging studies are
warranted and are oriented by the physical
findings. CT scan is the gold standard in Clinical Assessment
assessing the entire spine, fractures lines and
spinal canal compromise. Magnetic resonance In high-energy trauma
patients, life-threatening
imaging is of value to look for ligamentous lesions should be suspected
and actively looked
injuries and medullar lesions. Classifications for. These include abdominal,
thoracic, head and
are derived from imaging studies. Numerous vascular lesions. Polytrauma
patients with severe
classifications exist based on the anatomical lesions are usually admitted
to resuscitation areas
lesion, mechanism lesion or the clinical and which have been developed in
an effort to mini-
mechanical lesion. Their use is necessary to mize the adverse effects of
major trauma [19, 20].
determine spine stability and decide treatment. Management is usually
conducted by a multi-
The choice between Orthopaedic conservative disciplinary trauma team where
the spine surgeon
or surgical treatment is not straightforward as plays a key role.
guidelines are lacking. On admission, the patient
is usually placed
on a hard spinal board and the
cervical
spine is immediately
immobilized with a rigid
General Considerations Philadelphia collar if it has
not been done earlier.
It is important to limit the
time on the rigid
Injuries of the thoracic and lumbar spine occur in backboard to avoid the
development of skin
two categories of patients. In the first one, breakdown [21].
patients are mainly young and active people The ABC rules (ensuring
airway, breathing
and injuries are caused by high-energy trauma, and circulation) should be
applied. Airway
while in the others, spine injuries are related to clearance should be assured by
removing any
low-energy trauma in patients with altered bone mechanical obstruction (teeth,
tongue, clots. . .),
density and involve older patients especially and performing intubation if
necessary. The team
post-menopausal women. should have a good experience
with intubation
High energy trauma is caused mainly by motor techniques [22] which can be
more challenging
vehicle accidents (drivers, passengers and pedes- with an immobilized spine.
trian) [13], falls [4], gunshots [5] and sports Breathing can be
jeopardized in thoracic
[611]. Efforts have been made to diminish the trauma (lung contusion and
alveolar bleeding,
General Management of Spinal Injuries
699
haemothorax, tension pneumothorax, flail chest). 0.93 for intra-abdominal

lesions and is present
Haemothorax and tension pneumothorax, interfer- in around half of flexion-
distraction injuries
ing with ventilation, should be drained urgently. [26, 27]. Abdominal injuries
including solid
To ensure normal breathing, mechanical ventila- organs (liver, kidney,
spleen. . .) or hollow viscus
tion may be necessary especially in thoracic (bowel, stomach and
mesentery) are associated
trauma and comatose patients. Intubation and with lumbar flexion-
distraction in up to 55 %
sedation could be also indicated secondarily for of patients [26]. The
thoracic wall should
pain management. In case of sternal fracture and be examined for deformity,
bruising or signs of
great vessels injury should be ruled out. flail chest. A special search
should be made to
Circulation is monitored by heart rate and look for sternal fracture
(swelling, deformity or
arterial blood pressure. In 2003, French experts pain) and anterior shoulder
bruising since it can
[23] recommended the correction of any systolic be associated with unstable
upper thoracic spine
pressure below 90 mmHg and the maintenance of fractures. Many authors have
highlighted the
a mean blood pressure greater than 80 mmHg. need to have a high index of
suspicion not to
They also pointed to the fact that a mean blood overlook these fractures [28,
29].
pressure greater than 110 mmHg should be Patients with normal
neurological examina-
controlled to avoid spinal cord oedema. tion are carefully log-
rolled into the lateral
A femoral catheter is usually used for position with the cervical
spine protected by
precise pressure monitoring and drug administra- a rigid collar [3032]. In
cases of neurological
tion. Shock in polytrauma patients is usually impairment, log-rolling of
the patient may be
hypovolaemic due to bleeding but may be of car- postponed after obtaining X-
rays to evaluate
diogenic or neurogenic origin. Shock may lead to spine stability.
prolonged severe hypotension which can worsen The posterior chest wall
should be inspected
traumatic spinal cord damage. for bruising, wounds or skin
lacerations, cerebro-
Haemorragic shock should be treated initially spinal fluid leakage,
haematomata, contusions
by colloid perfusion. If necessary, blood should and subcutaneous degloving
(Morel Lavallee
be transfused as soon as possible to minimize syndrome, in which the skin
is separated from
hypoxaemia especially in spinal cord trauma fascia), especially in falls,
since it can interfere
[21]. Arterial embolization may be indicated in with surgical approach. The
spinous processes
case of continuous arterial bleeding especially for should be palpated
systematically to detect any
pelvic or spine lesions. Cardiogenic shock should abnormal spacing or palpable
step. In the case of
be suspected in association with thoracic trauma. an alert patient, the surgeon
should look for
Tamponade should be ruled out and immediately pain over the midline. Pain
can be spontaneous
addressed by aspiration. Shock could be also or caused by palpation over
mid-line. Hsu
caused by cardiac contusion with myocardial et al. [33] assessed the
value of clinical examina-
function. Neurogenic shock usually responds to tion in detecting spine
fracture. They found
perfusion and vasopressive drugs. pain to be the most sensitive
sign (sensitivity
Once the patient is haemodynamically stable, of 62 %) and palpable mid-
line step being
secondary assessment is made. the most specific sign
(specificity of 100 %).
In case of head or facial trauma, cervical The spine surgeon should keep
in mind that
fracture is found in up to 10 % of cases [24, 25]. cervico-thoracic lesion
causes pain in the
The anterior wall of the abdomen and chest are interscapular region.
Unsurprisingly, clinical
inspected. The spine surgeon should look for examination is less reliable
in the case of patients
abdominal wall contusion, bruising over the with altered Glascow score,
drug or alcohol
iliac crest and seat-belt sign for their associa- intoxication, and a major
painful distraction
tion with spinal injuries. Chapman et al. found lesion. In these cases, the
surgeon should have
that seat-belt sign has a positive predictive a high index of suspicion and
get radiographic
value of 0.59 and a negative predictive value of examinations to clear the
spine.
700
the anal wink (S2-S4)

and bulbocavernosus
Neurological Assessment reflex (S3-S4). The
bulbocavernous reflex is the
most distal reflex. Spinal
shock is a kind of spinal
Neurological examination is conducted and may cord impairment after
trauma which can last up to
be difficult depending on the patients level of 48 h in most cases. The
neurological examination
consciousness. in this period is not
reliable. The bulbocavernous
In patients with head trauma or multiple inju- reflex being the most
distal, is the first to be active
ries or in those who are sedated for any reason, after spinal shock but
this concept has been
the motor function cannot be assessed reliably. recently questioned [38].
Reflexes of the abdom-
Sometimes, curare action can be reversed to test inal wall and limbs are
tested systematically.
motor function but examination is less reliable. Several grading
systems for neurological status
In confused unresponsive patients, the spine have been described.
Frankel [39] described a
surgeon should observe the patients spontaneous system in 5 grades which
has been widely used in
movements and detect any reluctance in moving the evaluation of
neurological recovery [40, 41].
a limb. This raise the possibility of neurologic In the early 1990s, the
American Spine Injury
impairment, but bearing in mind that this can also Association (ASIA) along
with the International
be due to associated limb skeletal trauma. Medical Society of
Paraplegia (IMSOP) published
The tone of the anal sphincter should be assessed the International
Standards for Neurological and
in all cases as it can be the only indication of Functional Classification
of Spinal Cord Injury
spinal damage. which clarified the
incomplete lesions described in
In alert patients, neurologic examination should the Frankel grading system
in an effort to improve
include sensory, motor, reflex and pelvic examina- reliability [34, 42]. With
the new ASIA/IMSOP
tion according to the ASIA score (Fig. 1). International Standards
for Neurological and
Sensory examination tests both dorsal Functional Classification
of Spinal Cord Injury
columns (light touch,) and spinothalamic tract (ISCSCI), Grade A is a
complete injury with
(pain). Sensory examination should proceed by no motor or sensory
function preserved below
dermatomes (key dermatomes are T4: nipples, the level of injury
including most caudal sacral
T6: xyphoid, T10: umbilicus, T12: groin). segments. Grades B, C, and
D are incomplete
Motor function is assessed in the upper and injuries. In grade B,
sensory but not motor function
lower limbs by testing key muscles [34]. Muscles is preserved below the
neurologic level. In grade C,
are tested bilaterally against resistance and gravity. motor function in the
majority of key muscles
Force is quoted using the Medical Research below the neurological
level has a muscle grade
Council grading system as follows [3537]: less than 3 (this is
replacing useless function
0: Absent Total paralysis in the Frankel system)
while in grade D motor
1: Trace of palpable or visible contraction function is greater than 3
(replacing useful
2: Poor Active movement through a range of function in the Frankel
system). In grade E, the
motion with gravity eliminated neurologic examination is
normal.
3: Fair Active movement through a range of Moreover, incomplete
injuries may be distin-
motion against gravity guished in clinical spinal
cord syndromes: central
4: Good Active movement through a range of cord syndrome (CCS),
anterior cord syndrome
motion against resistance (ACS), posterior cord
syndrome and Brown-
5: Normal power Sequard syndrome.
Moreover, two syndromes
In all patients, assessment of sacral roots is (not purely spinal cord)
are well-known in spine
performed by testing the anal tone. In alert trauma: conus medullaris
syndrome and cauda
patients, anal contractility should be tested for equina syndrome [43].
intensity and symmetry. Sensory loss of the per- Central Cord Syndrome,
first described
ineum is assessed and urinary retention is looked by Schneider in 1954 [44],
is the most common
for in alert patients. Reflexes should be obtained- incomplete spinal cord
injury syndrome.
701
Fig. 1 The ASIA/ISCOS classification
It is characterized by more severe motor impair- associated with penetrating

trauma (gunshots or
ment of upper limbs, bladder dysfunction and stab wounds) [46] or
rotational injury. Its
variable sensory impairment. This syndrome is characterized by ipsilateral
proprioceptive
seen after cervical trauma with hyperextension and motor loss and
contralateral loss of sensitiv-
mechanism in older patients. It can be seen also ity to pain and temperature
below lesions
in immature patients (known as SCIWORA spi- level. Brown-Sequard syndrome
carries the
nal cervical injury without radiological anoma- best prognosis of the SCI
clinical syndromes
lies) with a congenital or acquired narrow (up to 90 %).
cervical spine canal. It is very rare in thoracic Posterior cord syndrome is
a selective lesion
spine trauma in mature patients and vascular to the posterior neurologic
columns (light touch,
injury should be ruled out [45]. 2-point discrimination,
vibration) and is the least
In ACS, the lesion affects the two anterior common of the SCI syndromes
[43].
thirds of the spinal cord, with paralysis, loss of Conus Medullaris Syndrome
is an injury
temperature and pain sensation. Dorsal column of the ending of the spinal
cord at thoraco
function is preserved (light touch, 2-point lumbar junction (T10-L1). Its
characterized
discrimination, vibration) [43]. Its mostly seen by a combination of lesions in
the spinal cord
in flexion injuries of thoracic spine or vascular and nerves roots. Clinical
manifestations
injuries. The prognosis is usually poor. include saddle anaesthesia,
bladder and bowel
Brown-Sequard syndrome is defined as dysfunction, lower limbs
paralysis or paresis
a hemi-section of spinal cord and is usually [40, 43, 47].
702
Cauda equina syndrome is not a spinal cord under massive dosage of

methylprednisolone in
syndrome since its an injury of the lumbar closed injury [59, 60] while
showing deterioration
and sacral nerve roots (lower motor neurons). of neurologic function or
increased infectious
It presents like Conus Medullaris Syndrome complications in penetrating
trauma [6163].
(saddle anaesthesia, bladder and bowel dysfunc- The third NASCIS III [64,
65] compared methyl-
tion, variable lower extremity involvement) but prednisolone for 24 h to
methylprednisolone for
with no upper motor neuron signs. It may have 48 h at the same dosage of
30 mg/kg in 1 h then
a better prognosis for neurological regeneration 5.4 mg/kg/h and to tirilazad
mesylate. Authors
than spine cord injuries [43, 48, 49]. concluded that
methylprednisolone should be
maintained for 24 h if begun
in the first 3 h after
trauma and for 48 h if begun
between 3 and 8 h.
Neuro-Protective Therapy The statistical methods of
these studies were
criticized and there were
concerns about random-
Secondary neurological damage is thought to be ization and clinical end-
points, to a such point that
caused by ischaemic and inflammatory mecha- many authors rejected or
questioned methylpred-
nisms and may cause secondary deterioration of nisolone protocols as
standard of care [6672].
neurological status [50]. Many drugs have been In Europe, the use of
methylprednisolone is
investigated in an effort to limit secondary still controversial and not
accepted as standard
damage and to enhance recovery. of care [73]. In France,
experts report have not
Corticosteroids have been largely used in recommended the use of
methylprednisolone until
acute spinal damage. Three prospective random- it is proven safe and
efficient [23].
ized studies have been conducted to attempt to
prove their efficiency (National Acute Spinal
Cord Injury Study NASCIS) and patients have Imaging
been followed for 1 year. In the first NASCIS
[51], 100 mg daily for 10 days was compared to Several imaging methods are
available for use to
1,000 mg. daily for 10 days in 330 patients. depict thoraco-lumbar
traumatic injuries. Plain
No difference in neurological recovery between radiographs, computed
tomography scan, magnetic
both groups was noted. resonance imaging and
sonography have been used
The second NASCIS [52, 53] was a random- in the emergency setting.
ized, double-blind, placebo-controlled trial includ-
ing 487 patients in three groups: the first had been
given methylpredinsolone (30 mg/kg in 1 h then Plains Radiographs
5.4 mg/kg/h for 23 h), the second received nalox-
one (5.4 mg/kg iv in 1 h then 4 mg/kg/h for 23 h) They have been the mainstay
of the radiographic
and the third group received placebo. Only patients assessment of trauma
patients in the emergency
treated by methylprednisolone in the first 8 h after department. In a review of
literature in 2005,
trauma showed improved neurologic recovery. France et al. [74] stated
that surgeons agreed
The three groups showed equal mortality and the that the mainstay of initial
radiographic evalua-
steroid treatment was considered safe by authors tion of the spine after
acute trauma remains plain
[54]. Authors recommended the usage of high radiographs.
dosage of methylprednisolone only if it could be In 1994, Frankel et al.
[75] defined their
started in the first 8 h after trauma. While this indications for obtaining
thoracic and lumbar
study aroused enthusiasm among physicians and spine radiographs: back
pain, fall of more than
surgeons dealing with spinal cord trauma, its meth- 3 ft, ejection from
motorcycle or motor vehicle
odology was largely debated [5557] and concerns crash of more than 50 mph,
Glascow score #8,
were aroused about infectious complications and neurologic deficit. They
stated as well that
[58]. Other studies failed to show improvement the absence of back pain
does not exclude
703
significant thoraco-lumbar fracture. In cases of CT Scan

spine trauma, plain radiographs are sometimes
difficult to obtain, especially in polytrauma More recently, trauma teams
use helical CT
patients and are often of poor quality. One of Scanning as a tool for
injury screening in high
the most difficult areas to assess with plain radio- energy trauma. Helical CT
Scans reduce the time
graphs is the cervico-thoracic junction and the needed to get a total body
examination including
upper thoracic spine down to T5. In this region, mainly head, thorax,
abdomen, cervical and
the shoulders projection makes the vertebral thoraco-lumbar spine and
pelvis. Many investi-
bony contours less visible [28, 76, 77]. Fractures gators reported the
usefulness of such screening
in this region should suspected especially in case tools: Sampson et al. [80]
reported on over
of associated sternal fracture [76]. a 7-year period 296 multi-
trauma CT scans with
In a review of the literature and according to positive findings in 86.2 %
of cases. They also
the opinion of an experienced group of spine found 19 cervical spine
fractures and 26
surgeons, Keynan et al. [78] listed the parameters pneumothoraces not detected
on plain radio-
to use for vertebral assessment: graphs. Antevil et al. [81]
compared spiral CT
1. The Cobb angle, to assess sagittal alignment; scan with plain radiographs
to evaluate spine
2. Vertebral body translation percentage, to trauma. They concluded that
spiral CT Scan is
express traumatic anterolisthesis; a more rapid and sensitive
modality than plain
3. Anterior vertebral body compression percent- radiographs. It delivers
less radiation than plain
age, to assess vertebral body compression; radiography in thoraco-
lumbar spine evaluation
4. The sagittal-to-transverse canal diameter ratio, but with a higher cost.
Based on these facts, they
and canal total cross-sectional area (measured concluded that spiral CT
scan may replace plain
or calculated); radiography as the standard
of care for evaluation
5. The percentage canal occlusion, to assess of the spine in trauma
patients. Campoginis et al.
canal dimensions. [82] reported on motorcycle
accident victims and
Daffner [79] identified many signs of found that more than half
with significant CT
instability: scan findings had normal
physical examination,
1. Displacement implies injury to major liga- thus recommending lower
thresholds for CT scan
mentous and articular structures; use in blunt trauma. Other
authors [83] reported
2. A wide interlaminar space implies injury to on usage of spiral CT scan
in initial evaluation of
the posterior ligamentous structures and the spine trauma. Brown et al.
[84] identified 99.3 %
facet joints; of spine fractures using
spiral CT Scan and they
3. Wide facet joints imply injury to the posterior stated that plain
radiographs are no longer neces-
ligamentous structures; sary for blunt trauma.
Brandt et al. [85] found that
4. A disrupted posterior vertebral body line using CT Scan images of
chest, abdomen and
implies burst injury with disruption of anterior pelvis obtained to evaluate
visceral injuries are
bony and posterior ligamentous structures; sufficient to rule out spine
injuries.
5. A wide vertebral canal implies injury to the The fine analysis of
fracture line and the exis-
entire vertebra in the sagittal plane. tence of spinal canal
narrowing are important in
Many trauma centres have protocol imaging choosing the treatment
modality. The ability of
for polytraumatized patients including an AP plain radiograph to
differentiate compression
view of pelvis and a lateral view of cervical fracture from burst fracture
was questioned.
spine. The first will detect displaced fractures In 1992, Ballock et al. [86]
studied the sensitivity
of the pelvis which could be a possible cause of plain radiographs in
detecting burst fracture
of major bleeding. The second will help in comparing with CT Scans and
found that
managing the immobilization of the cervical a quarter of burst fractures
would have been
spine and the attention that should be paid mis-diagnosed relying solely
on plain radio-
to intubation. graphs. In an effort to
increase the sensitivity of
704
plain radiographs in detecting burst fractures, usefulness of

complementary MRI for ligamen-
McGrory et al. [87] used the posterior vertebral tous injuries to the
cervical spine and found that
body angle and found a sensitivity of 75 %. all unstable lesions were
correctly detected by CT
Bernstein et al. [27], in their review of 53 patients Scan and that 18 % of disc
and ligamentous
with Chance-type fractures, found that the lesions were missed by CT
Scan comparing
fracture line in posterior elements may be very to MRI. Other authors
recommended the
subtle on plain radiographs and that there was an association of CT scan and
MRI for cervical
associated burst fracture in nearly half of the cases. spine clearance [91], but
such recommendations
Dai et al. [88] evaluated the role of CT Scans were not formulated for
thoraco-lumbar trauma.
in treatment planning of thoraco-lumbar frac- Dai et al. [92] found
that MRI was reliable in
tures. They found that treatment planning with detecting posterior
ligamentous injuries in
plain radiographs remained unchanged in only burst fractures but that
these injuries were
56 % of cases when using CT Scans for same not correlated with the
fracture severity nor
cases. In fact, plain radiographs were less reliable with the neurological
status thus making MRI
for the evaluation of vertebral body comminution unnecessary in treatment
planning. Lee et al.
and thus for assessment of vertebral stability. [93] suggested that signal
modification of fat-
Fontijne et al. [89] studied the usefulness of suppressed sequences
correlated with ligament
CT Scan in predicting neurological impairment disruption. Thereafter,
many authors pointed to
in burst fracture. They found that high level of the fact that relying
solely on MRI to define
fracture and increased amount of spinal canal stability of fractures may
lead to unnecessary
narrowing were correlated with the presence surgery [94]. In fact, it
seems that many false
of neurological abnormalities but not with the positive results are
associated with MRI evalua-
severity of neurological impairment. tion of ligamentous
injury, perhaps due to liga-
The CT Scan is the gold standard for ment elongation and not
rupture. In a survey of
measuring spinal cord narrowing, to find and to the members of the Spine
Trauma Group, sur-
study fractures lines. Reconstructed slices are geons considered signs on
plain radiographs to
especially useful to measure spinal canal dimen- be the most useful for
diagnosing PLC injury,
sions in different plane inclinations. CT scan can ranking them higher than
other radiological
study the entire spine looking for multi-level modalities and physical
signs [95]. The
injuries. same group considered MRI
more useful
than CT Scan in detecting
PLC lesion [96].
More recently, Vaccaro et
al. [97] found
Magnetic Resonance Imaging little correlation between
MRI findings and
intra-operative findings,
concluding that MRI
MRI is known for its high sensitivity in soft tissue should not be used in
isolation to diagnose
imaging. In spine trauma, MRI is the best tool to the PLC injury,
contradicting the former findings
evaluate discs, ligaments and neural elements, of Haba et al. [98].
but it is not routinely used because of the time
necessary to complete examination, examination
availability and cost considerations. In their Ultrasonography
review on management of spine trauma
with associated injuries, Harris et al. [21] stated Ultrasonography is a tool
used regularly in soft
that MRI is most useful in patients whose tissue investigation. It
has been used in spine
plain radiographs or CT results fall short of as well [99] to look for
posterior ligamentous
explaining their full clinical picture. This result complex lesions in
thoraco-lumbar trauma.
is most common in the neurologically-impaired Although it is less
reliable than MRI, it is a
victim with normal appearing plain films. useful tool in cases when
MRI is contra-indicated
Schoenwaelder et al. [90] evaluated the [100, 101].
705
This concept highlighted

the importance of the
Biomechanics and Classification middle column for
mechanical stability. The frac-
ture severity was
correlated to the number of injured
Several authors have described classifications for columns. A long time
before, in 1958, Decoulx and
thoraco-lumbar fractures in an effort to simplify Rieunau [106] had pointed
out this middle column,
the understanding of these complex lesions. which they called the
posterior wall, as a key factor
Classifications aim to make reporting on these for stability. Denis
defined four distinct fractures
fractures easier and treatment decisions more types: I- compression
fractures (anterior column),
straightforward. II- burst fractures
(anterior and middle columns),
In the third decade of last century, Bohler III- seatbelt injuries and
fracture-dislocations
classified thoraco-lumbar injuries into five injury (all columns) with 16 total
groups after
types taking into consideration anatomic defini- subclassification.
tion and mechanisms of injury: compression Several authors
criticized this classification.
fractures, flexion-distraction injuries, extension Lee et al. pointed out the
inaccuracy of
fractures, shear fractures and rotational injuries. oversimplifying the concept
of stability of the
In the 1960s, Holdsworth [102, 103] intro- lesion of more than one
column, which could
duced the concept of spine columns describing lead to indicate surgical
treatment for all burst
the spine as including two columns: an anterior fractures. In fact, many
authors reported good
column formed by vertebral bodies and discs results for burst fracture
treated solely with
acting in compression and a posterior column bracing. Guigui et al.
[107] underlined the fact
formed by pedicles, pars interarticularis, facet that this classification is
confusing with respect to
joints, laminae, spinous processes and ligaments, the mechanism of injury.
For these authors, a same
acting in tension. For Holdsworth, the posterior fracture (e.g. a burst
fracture of the vertebral body
column is sufficient to maintain stability, thus he (type IIB)) could be the
consequence of different
described burst fractures as stable fractures. mechanisms thus having very
different progres-
In the 1970s, Louis [104] described the sion prognosis depending on
associated posterior
concept of three columns: one anterior column lesions.
composed of vertebral bodies and discs, and two In 1984, Ferguson et
al. [108] described a
posterior columns each composed of pars mechanistic classification
of spinal fractures
interarticularis and intervertebral articulations. with seven categories based
on the mechanical
Pedicles and laminae are described as structures mode of failure of
vertebral bodies.
linking these columns (the anterior with each In 1994, Magerl et al.
[109] published what is
posterior and the posterior with each other). now known as the AO
(Association for Orthopae-
With the development of imaging technolo- dics) classification. This
classification appeared
gies, CT Scan gave surgeons a new look as the most inclusive of
all classifications yet
for spine fractures by allowing fine analysis of published with a total of
218 lesion types.
fracture patterns. The AO classification is
based on mechanism of
In 1983, Denis [105] published his now world- injury with three main
groups: A- Compression
wide-used classification based on a new concept of fractures, B- Flexion-
Distraction fractures,
the three-column model: the anterior column is C- Translation/rotation
fractures (Fig. 2). Each
composed of the anterior longitudinal ligament group is then sub-divided
in sub-groups with
and the anterior half of the intervertebral discs and sub-divisions (Fig. 3). The
AO classification has
vertebral bodies, the middle column is composed of the advantage of serving as
a guide for treatment
the posterior half of the intervertebral discs and indications since the
grading system is correlated
bodies and the posterior longitudinal ligament, the with lesion severity.
Indeed, the higher a fracture
posterior column includes the neural arc, posterior is graded, the higher is
the risk for neurological
ligaments (ligamentum flavum, articular com- injury or for instability.
This classification
plexes, posterior spinous ligamentous complex). was widely accepted
especially in Europe [110].
706
Fig. 2 The Magerl classification (AO classification): A-type compression fracture;

B-type flexion-distraction fracture;
C-type rotational component fracture
Fig. 3 AO classification A-type sub-groups: A1, A2, A3
In daily practice and for treatment decision, it is (thoracic level) in

levels adjacent to the fracture
sufficient to use the three main groups and only level, rotational
displacement of vertebral bodies
few sub-groups (especially for burst fractures). on CT scan transverse
view, asymmetrical
In classifying fractures using the AO classifi- vertebral body
fracture with lateral bony fracture
cation, it is essential that surgeon treating spine detached from the
vertebral plateau and neural
trauma be familiar with the algorithm used in this arc asymmetrical
fracture[107]. If such radiolog-
classification. When analyzing the images the, ical signs are lacking
a type C fracture is ruled
surgeon should look first for signs of rotation or out. Then the surgeon
should search for signs of
translation (type C fractures): spinous process anterior compression
and posterior distraction
step-off, unilateral facet joint fracture with corresponding to a
type B fracture. Distraction
contralateral facet joint dislocation, multiple signs are found on
reconstructed sagittal CT Scan
transverse process fractures (lumbar level views: increased
interspinous space, facet joint
fractures) or multiple rib fractures or dislocations incongruity,
horizontal fracture lines of laminae
707
or pars interarticularis or facets joint. Anteriorly Table 1 Thoracolumbar Injury

Classification and
the vertebral body is compressed. Depending Severity Score (TLICS) [114]
on the posterior lesion, the fracture is further Injury Morphology
classified as type B1 if the posterior lesion is Compression
1
predominantly ligamentous or B2 if this lesion Burst
2
is mainly osseous (the so-called Chance fracture Rotation/translation
3
is a typical B2 fracture). Inversely Type B3 Distraction
4
Integrity of Posterior
Ligamentous Complex
corresponds to anterior distraction, identified
Intact
0
by anterior disk space widening, and posterior
Suspected/Intermediate
2
compression. If no sign of distraction is found
Injured
3
then fracture is classified as a compression
Neurological Status
fracture (type A). With new imaging techniques Intact
0
the posterior lesions are detected more frequently. Root injury
2
At the same time, in 1994, McCormack et al. Complete cord/conus
medullaris injury 2
[111] reviewed retrospectively 28 patients with Incomplete cord/conus
medullaris injury 3
failure of short segment fixation and described a Cauda equina
3
new classification to assess the anterior column
10
integrity. This classification, based on post oper- Scoring #3 non-operative
treatment should be considered
ative CT Scan, is known now as the Load Shar- Scoring #5 operative
treatment should be considered
ing Score and is based on granting points to Scoring ranging from 3 to 5
both treatments can be
considered
1: Amount of damaged vertebral body,
2: The spread of fragments in the fracture site,
3: The amount of corrected trauma. This
classification appears to be reliable with good treatments can be applied
[116]. This system
reproducibility [112] and useful in assessing the has the advantage over other
systems of taking
acute instability of thoraco-lumbar fractures [113] into consideration clinical
findings and the neu-
and the need for anterior column graft or augmen- rological status. Including
PCL in point-granting
tation after posterior stabilization and reduction. has the advantage of
underlining its importance
More recently, Vaccaro et al. [114] described in stability. Rotation or
distraction highly
a new classification system, the thoracolumbar suggests that PCL is
injured, so giving PCL
injury classification system (TLICS) (Table 1). points in this case may be
questionable. In case
The aim of the author is to describe an easy-to- of burst fracture, PCL
status is of high importance
use system oriented toward clinical decision. and would influence the
indication for surgery.
The system is based on three determinants: But it is in this case that
PCL assessment is the
fracture morphology, neurological status and most difficult [92, 95, 97,
98, 101, 117].
posterior ligament complex integrity [115]. Many investigators
assessed the reliability
Each determinant is given points and a score is of TLICS. Many authors found
the TLICS
computed. The higher points are given according user-friendly, reliable and
useful [116], with
to severity of injury and/or emergency character good intra-observer and
inter-observer reliability
of treatment. With respect to morphology of the both in US and non-US
surgeons [118120].
lesion, distraction is given 4 points while rotation The ability of TLICS to
predict surgery
or translation are given three points, with respect was found good in a
retrospective study and was
to neurological status, the higher points are given correlated to the AO
classification [121].
to incomplete cord syndromes or cauda equina TLICS showed limitations in
predicting surgery
syndromes. A score less than or equal to 3 sug- in cases of multiple
contiguous fractures or frac-
gests that patient may treated non-operatively, tures in the ankylosed spine
[122]. In a review of
while a score greater or equal to five suggests the literature, Oner et al.
[123] considered TLICS
operative treatment and in between both to be the most useful system
for therapeutic
708
decision-making in thoraco-lumbar spine injuries. with good results. They

stated that posterior
In comparing three classification systems, TLICS column disruption was not a
contra-indication to
showed good reliability when compared to AO or non-operative treatment.
Mumford et al. [132]
Denis classifications [124]. reported good results in
burst fractures treated
non-surgically. McEvoy et al.
[133] reported on
a series of burst fractures
and concluded that
Treatment non-operative treatment was a
sound choice
for neurologically-intact
patients, but in cases of
Several treatment modalities have been described neurological impairment,
improvement is unlikely
in the literature: functional treatment with early with non-operative treatment
and that deteriora-
ambulation, Orthopaedic treatment with bracing tion could occur. Tezer et
al. [134] recommended
or casting (Fig. 4), surgical treatment with poste- conservative treatment in
cases with no neurologic
rior or anterior or combined approaches and involvement and no posterior
column disruption
more recently less invasive anterior or posterior (MRI to define in cases with
kyphosis greater than
fixation techniques are all being investigated. 30# ). Moller et al. [135]
retrospectively evaluated
Several authors compared non-operative to 27 patients at a mean follow-
up of 27 years and
operative treatment trying to define clearly the found that results are stable
in time but with
indications for surgery. reduction of height of
adjacent discs. Agus et al.
In 1975, Bedbrook et al. [125] stated that [136] treated successfully
two- and three-columns
ninety percent of thoracic and lumbar spine frac- fractures non-surgically.
Shen et al. [137] reported
tures with paraplegia or paraparesis could be a case of a three columns
ankylosed spine fracture
treated and reduced by closed methods. Harris treated successfully by non
surgical treatment,
[126] stated that the natural course of thoraco- introducing the concept of a
fourth column
lumbar fracutes is usually benign and the consisting of sternum and
ribs. Tropiano et al.
non-surgical methods should be the standard [138] reported on a series of
thoraco-lumbar
treatment with few exceptions. fractures treated by
reduction and casting (Bohler
Many regimens for non-operative treatment technique) with good
functional results. Kyphosis
exist but most of them include an initial period recurred at fourth months but
lesser than the
of bed rest (which can be as long as 3 months in amount before reduction. In a
survey for Canadian
some cases) with special attention to lordotic spine surgeons in 1994,
Findlay et al. reported
posture to reduce or limit kyphosis, followed by that the treatment of choice
for burst fractures
ambulation with a cast or plaster. No study has in Canada was essentially
surgical [139].
compared different regimens so treatment Post et al. [140] reported
good functional
protocol is chosen according to the surgeons results of non-surgical
treatment for compression
estimation of fracture stability, the patients fractures (AO
classifications type A) at 4 and
characteristics and his/her ability to comply 10 years follow-up.
with the treatment plan. The need for an orthosis Many authors compared
conservative and
is not very well proven [127, 128] and some surgical treatment. Knight et
al. [141] found no
authors did not find any difference in stable difference in functional
results between
burst fractures treated with or without orthosis non-operative and operative
treatment for
[129]. Cantor et al. [130] reported on a series of two- or three-column burst
fractures. Buttler
fractures without posterior column disruption et al. [142] compared
retrospectively two groups
with good functional results from early ambula- of L1 burst fractures and
found that burst
tion with total contact orthosis. They attributed fractures managed
conservatively had better
their good results to the fact that the posterior functional results than those
treated surgically,
column was intact. Chow et al. [131] disagreed and that clinical outcome was
not correlated
with this conclusion and reported on a series of with vertebral collapse,
kyphosis or canal
burst fractures treated by hyperextension cast narrowing. In a prospective
randomized study
709
Fig. 4 Orthopedic treatment with brace
comparing operative and non-operative treatment operation or whether its

advantages outweigh the
for stable burst fractures, Wood et al. [143] found risks have been largely
debated. Krengel et al. [145]
no long term advantage for operative treatment. In found that early
decompression and fixation for
a systematic review of the literature, Thomas et al. thoracic fracture with
incomplete neurologic
[144] concluded that there is no evidence proving impairment was safe and
improved neurologic
superiority of one treatment for burst fractures recovery. In a review of
literature conducted in
without neurological deficit. More studies are 1999, Fehlings [146]
concluded that animal studies
still needed to establish treatment guidelines. suggested a benefit of early
decompression for
neurologic recovery but that
solid proof in human
studies was lacking. Many
authors [147] found no
Timing of Surgery correlation between initial
spinal canal narrowing
and neurological recovery
and that remodelling of
Urgent surgery was proposed to enhance neurologic the canal diameter was seen
in patients many years
recovery or to limit morbidity in polytrauma after trauma [148], thus
questioning the utility of
patients. Questions concerning the risks of urgent surgical decompression
[149].
710
Zelle et al. [150] in a small series of patients patients operated in the

first 3 days had better
suffering neurological impairment from sacral outcome that those operated
later on and
fracture, found that decompression gave better reduced mortality. In a
recent review of
neurological recovery and better physical function. English literature,
Bellabarba et al. [161] drew
Rath et al. [151] reported a series of 42 patients the same conclusions,
recommending that
treated by open fixation and fusion and decom- patients with unstable
thoraco-lumbar fractures
pression. They found significantly better results be operated within 3 days
from trauma
in neurological outcome in patients treated by to decrease respiratory
complications, ICU and
very early decompression (less than 24 h). hospital stay for thoracic
fractures and hospital
Muchaty et al. [152] reported satisfactory stay for lumbar fractures.
The effect of
results with a specific protocol for patient early stabilization on
mortality was less clear.
selection: ASIA B, C, D, and ASIA A below Kerwin et al. [162]
reported better results for
T10 patients were operated within 8 h as surgical early surgery (before 3
days) in majority of
emergencies, and ASIA A from T1 to T 10 and patients but some of them
operated on early
ASIA E were operated on a regular schedule. had poorer outcome. These
authors do not
In 2006, Rutgers et al. [153] reviewed the recommend rigid protocol
for polytrauma
available data on timing of surgery for spinal cord patients but a protocol
that can be tailored for
injury in thoraco-lumbar fractures. They found that every specific patient.
the studies results with respect to neurological In conclusion, it
appears that polytrauma
outcome are contradictory so no conclusion can patients with or without
neurologic involvement
be drawn. On the other hand, early surgery was benefit from early
stabilization in the first
shown to be beneficial for respiratory complica- 3 days after trauma to
facilitate nursing and
tions and hospital stay in trauma patients. patient mobilization. Even
though there is no
Cengiz et al. [154] prospectively followed two strong proof, most spine
surgeons recommend
groups of thoraco-lumbar fracture patients with operating on patients with
incomplete neurologic
neurological impairment: 12 patients were impairment within 24 h and
some of them
operated within 8 h and 15 patients between within 8 h.
3 and 15 days. They found better neurologic
recovery in the group with early surgery.
More recently, in a prospective survey Summary
of 971 spine surgeons investigating timing
of surgery in spinal cord injury, Fehlings Injuries to the thoracic
and lumbar spine are
et al. [65, 155] found that the majority of spine frequent and can be
devastating. It happens
surgeons prefer to decompress the injured spinal mainly in young patients
due to falls, sport or
cord within 24 h. traffic accidents. They can
be associated with
Early surgical fixation, with or without other vital system
injuries. Their management
decompression, was also advocated to limit often needs a
multidisciplinary team. The initial
morbidity [156, 157] and respiratory complica- medical management is
described in this chapter.
tions (more prevalent in upper thoracic injuries in The main classifications
are discussed and the
comparison to lower injuries [158]). treatment orientation is
described. Physicians
Kerwin et al. [159] reviewed retrospectively taking care of trauma
emergencies, and espe-
the records of 16,812 patients who underwent cially orthopedic surgeons,
need to have good
surgical fixation for thoraco-lumbar fractures knowledge of clinical
examination, radiologic
(National Tauma Data Bank). They found that assessment and the main
treatment options.
patients operated within 3 days from trauma had When surgery is indicated
and the timing is
less complications than those operated later. discussed in this chapter.
The different surgical
Schinkel et al. [160] reviewed the German options and techniques are
discussed in detail in
National Trauma Database and concluded that an another chapter.
711
20. Nirula R,
Brasel K. Do trauma centers improve func-
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145. Krengel 3rd WF, Anderson PA, Henley MB. Early tion in
trauma patients: impact on clinical course
stabilization and decompression for incomplete and outcome.
J Trauma. 2006;61(1):15660;
paraplegia due to a thoracic-level spinal cord injury. discussion
160.
Spine (Phila Pa 1976). 1993;18(14):20807. 161. Bellabarba C,
et al. Does early fracture fixation of
146. Fehlings MG, Tator CH. An evidence-based review thoracolumbar
spine fractures decrease morbidity or
of decompressive surgery in acute spinal cord injury: mortality?
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rationale, indications, and timing based on experi- S13845.
mental and clinical studies. J Neurosurg. 1999;91 162. Kerwin AJ, et
al. The effect of early spine fixation on
Suppl 1:111. non-
neurologic outcome. J Trauma. 2005;58(1):1521.
Injuries of the Cervical Spine
Spiros G. Pneumaticos, Georgios K.

Triantafyllopoulos,
and Peter V. Giannoudis
Contents
Abstract
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 717 The incidence of cervical spine injuries ranges
from 2 %4.2 % among polytrauma patients.

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 718
They may be accompanied with significant

Initial Evaluation and Management . . . . . . . . . . . . . . 719
neurological impairment due to spinal cord
Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 722 involvement. High-energy trauma is the main
cause of cervical spine injuries in younger

General Considerations Regarding
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 724 populations, while falls are recognized as the
Non-Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
main cause in older patients. The cervical
Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 727 spine is divided into two functional units, the
Specific Injuries of the Cervical Spine . . . . . . . . . . . . 727
upper or axial and the lower or sub-axial cer-
Upper Cervical
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
vical spine. In the following chapter, the gen-
Lower Cervical Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
735 eral approach for a patient with cervical spine
Paediatric Cervical Spine Injuries:
trauma is discussed and specific injury types
SCIWORA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
739 of both the upper and lower cervical spine are
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 740 overviewed, with regards to clinical presenta-
tion, classification and treatment.
Keywords
Anatomy and Epidemiology # Cervical spine
injuries # Classification # Conservative treat-
ment # Neurological and imaging assessment #
Operative techniques for 11 specific injuries #

Operative treatment-goals
Epidemiology
S.G. Pneumaticos # G.K. Triantafyllopoulos
Cervical spine trauma represents only a small per-
3rd Department of Orthopaedic Surgery, School of
centage of all skeletal injuries, with an incidence

Medicine, University of Athens, Athens, Greece
ranging from 2 %4.2 % among patients with

P.V. Giannoudis (*)
blunt trauma [1, 2]. However, it poses

a significant socio-economic problem, due to com-
plications and sequelae related to spinal cord

717
DOI 10.1007/978-3-642-34746-7_39, # EFORT 2014
718
S.G. Pneumaticos et al.
involvement. Injuries of the cervical spine affect facets, and a pedicle and
lamina bilaterally. The
predominantly men, with the age distribution laminae converge
posteriorly in the midline to the
curve showing a double-peak pattern, in the third spinous process, forming
the spinal foramen.
and sixth decades of life. High-energy trauma, The C3C7 vertebrae
have similar anatomic
including motor vehicle accidents, sports injuries, features, consisting of a
vertebral body, two lat-
diving injuries, falls from heights and gunshot eral masses and one
pedicle and lamina on each
injuries are the most common causes of cervical side, which form the
neural arch and surround the
spine trauma in young populations [1, 35]. On the spinal foramen. The
spinal foramina of all cervi-
other hand, falls, even from the standing or sitting cal vertebrae form the
cervical spinal canal,
position, are implicated as the major cause of within which lies the
cervical spinal cord. Each
cervical spine trauma in the elderly [1, 35]. lateral mass exhibits
superior and inferior facets,
Hence, in younger patients, injuries of the cervical with a 45# inclination
from the horizontal plane.
spine are more likely to be related with concomi- The transverse processes
project laterally from
tant injuries [4]. Among patients with spinal cord the pedicle on each side,
while posteriorly, the
injury, trauma to the cervical spine is identified as spinous process is formed
in the mid-line by the
the cause in approximately 53 % of cases, with the convergence of the
laminae. The inferior pedicle
majority involving the C5 level [6]. In these surface of the overlying
vertebra and the superior
patients, pulmonary complications are an impor- pedicle surface of the
underlying vertebra form
tant factor in morbidity [5]. the intervertebral
foramen, one on either side,
through which the
corresponding nerve root
exits the spinal canal.
Anatomy In the upper cervical
spine there are six joints,
two atlanto-occipital
(one on each side) and four
The cervical spine is made up of seven vertebrae atlanto-axial. Each
atlanto-occipital joint is
(C1-C7) and can be divided into two functional formed by the concave
superior facet of the
units, the upper and lower, or sub-axial, cervical atlas and the
corresponding occipital condyle,
spine. The upper cervical spine consists of the C1 an anterior and posterior
capsule and the tectorial
vertebra, or atlas, and the C2 vertebra, or axis, and membrane. The atlanto-
axial articulations
includes the complex occcipito-cervical junction, include the two facet
joints laterally, between
by which the cervical spine articulates with the the inferior facets of
the atlas and the superior
occipital condyles of the cranium. The atlas and facets of the axis, and
the median atlanto-axial
the axis exhibit unique anatomic characteristics joints, one between the
anterior surface of the
when compared to the vertebrae of the sub-axial dens and the posterior
surface of the anterior
cervical spine. The atlas lacks a vertebral body, is arch of the atlas, and
another between the poste-
ring-shaped and consists of the anterior and posterior surface of the dens
and the transverse liga-
rior arch and two lateral masses, surrounding the ment. The apical and alar
ligaments provide
spinal foramen. The lateral masses have superior further stability through
their attachment to the
and inferior articular surfaces, which articulate with apex of the dens. There
is no intervertebral disc
the oval occipital condyles and the superior facets between the atlas and the
axis. The atlanto-axial
of the axis, respectively. The axis is the thickest and articulation is
responsible for 50 % of total rota-
strongest of the cervical vertebrae. Its main charac- tion of the cervical
spine. In the sub-axial cervical
teristic is the odontoid process or dens, spine, intervertebral
discs are interposed
a cylindrical cephalad projection of the anterior between the vertebral
bodies, which also articu-
aspect of the body, 1216 mm in length. The ante- late with the
uncovertebral joints (joints of
rior surface of the dens articulates with the anterior Luschka), on the
posterolateral aspect. The
arch of the atlas, while posteriorly lies the trans- facet, or zygoapophyseal,
joints are formed on
verse ligament. The atlas also exhibits a vertebral each side by the inferior
facet of the overlying
body, two lateral masses with superior and inferior vertebra and the superior
facet of the underlying
719
vertebra. Even though these joints allow little immobilization of the

cervical spine with a rigid
movement between two consecutive vertebrae, collar, a spine board and
tapes, sandbags or rolled-
the cervical spine as a functional whole is the up pieces of clothing must be
performed at the site
most mobile part of the spine. of injury and discontinued
only when, after com-
The anterior longitudinal ligament (ALL) and plete evaluation, an injury
of the cervical spine is
the posterior longitudinal ligament (PLL) attach excluded. Flexion, extension
or rotation of an
on the anterior and posterior surface of the verte- unstable cervical spine can
cause secondary dam-
bral bodies and resist hyperextension and age to the spinal cord,
resulting in quadriplegia or
hyperflexion, respectively. The proximal exten- even death. The National
Emergency X-ray Utili-
sion of the PLL is the tectorial membrane. The zation Study (NEXUS) [7] has
provided low-risk
facet joints are surrounded by a capsule and lig- criteria for the diagnosis of
cervical spine trauma.
aments. The ligamentum flavum connects the A patient without posterior
mid-line cervical spine
laminae, while between the spinous processes tenderness, without evidence
of intoxication, with
lie the interspinous ligaments. The ligamentum a normal level of alertness,
without focal neuro-
nuchae extends from the occiput and dorsal to the logical deficit and painful,
distracting injuries can
spinous processes, and below C7 continues as the be safely cleared from
cervical spine trauma, with-
supraspinous ligament. out imaging studies. However,
this tool cannot
The spinal cord is constituted by H-shaped determine the best imaging
modality for diagno-
grey matter, with anterior and posterior horns, sis, in a patient not
fulfilling these criteria.
surrounded by white matter. Grey matter mainly In a patient with blunt
trauma, a hierarchical
includes neuronal bodies, while white matter is evaluation of the airway,
breathing and circulation
made up of axons. Within the white matter, the is performed. Hypoxia and
hypotension should be
axons are organized in distinct tracts, both avoided, especially in
patients with suspected spi-
ascending and descending. These include the nal cord injury, as they can
both further impair
ventral and lateral spinothalamic tracts, which spinal cord function [8].
High level spinal cord
transmit pain and temperature sensation, the lat- injuries (higher than C5) can
cause respiratory
eral corticospinal tracts, which transmit motor failure, due to paralysis of
the intercostal muscles
signals from the brain, and the posterior columns and diaphragm. These patients
should be closely
(fasciculus cuneatus and fasciculus gracillis), monitored, as they may
require early intubation.
responsible for deep sensation, vibration and sen- Concomitant injuries of the
head and chest may
sation of the body position in space (propriocep- further compromise the airway
and respiratory
tion). There are eight pairs of spinal nerve roots, function, and must be
appropriately evaluated
exiting the spinal canal from the corresponding and treated. Generally,
intubation and mechanical
intervertebral foramina. The C1 root exits above ventilation can secure both
the airway and respi-
the C1 vertebra, the C2 exits below the C1 verte- ration. Major abdominal or
chest trauma may
bra and the C8 exits below the C7 vertebra. The cause hypovolaemic shock,
which must be
C5-T1 roots form the brachial plexi bilaterally, addressed. However, one
should keep in mind
which innervate the upper extremities. that, in case of spinal cord
injury, hypotension
may occur even with normal
blood volume. This
is called neurogenic shock,
it is caused by sympa-
Initial Evaluation and Management thetic impairment, and is
further distinguished
from hypovolaemic shock by
the accompanying
The correct and timely treatment of the patient bradycardia. It has been
suggested that, in patients
with cervical spine trauma is very important, as it with spinal cord injury, the
mean arterial pressure
can diminish complications and sequelae related should be kept >90 mmHg [8].
This can be
with these injuries. Every patient suffering from accomplished by
administration of crystalloid
trauma must be considered as having a cervical and colloid solutions, as
well as blood, while in
spine injury, until proven otherwise. Thus, case of neurogenic shock,
vasoconstricting agents
720
Fig. 1 The American Spinal Injury Association (ASIA) evaluation sheet
may also help. Examination of the spine takes 4, active movement with
full range of motion
place during secondary survey, with inspection against moderate
resistance; 3, full range of
and palpation. In up to 11 % of polytrauma motion against gravity; 2,
patients, cervical injury may be associated with with gravity neutralized;
1, palpable or visible
concomitant thoraco-lumbar injuries [9]. contractions; and 0, total
paralysis. Voluntary
A thorough neurological examination is also contraction of the anal
sphincter should always
necessary. Light touch and pin-prick sensation be included in the
examination. Neurological
are tested in each dermatome and the result is examination should also
include superficial and
graded as 2 (normal), 1 (impaired) or 0 (complete deep reflexes, as well as
search for pathological
loss). The last normal dermatome is noted on reflexes (e.g. Babinskis
sign). The American
each side. Examination of the sacral dermatomes Spinal Injury Association
(ASIA) evaluation
and determination of peri-anal sensation should sheet aids in obtaining a
rapid, yet thorough
not be missed. Sensory examination can provide assessment of a spinal
cord injury (Fig. 1).
a quick overview of the patients neurological Spinal shock is a
transient state of complete
status and the level of injury, but on the other loss of neurological
function, characterized by
hand it is highly subjective, as it depends greatly areflexia below the level
of injury, along with
on the patients perception of stimuli. flaccid paralysis and loss
of sensation. The dura-
Motor function is evaluated by testing strength tion of spinal shock
ranges from hours to days and
of certain key muscles that are predominantly its end is marked by the
re-emergence of the
innervated by the corresponding nerve roots. reflex arcs below the
level of injury, classically
Each muscle receives a grade from a six-grade including the
bulbocavernosus reflex. After spi-
system, with 5 being normal muscle strength; nal shock has resolved,
the degree of the patients
721
Table 1 The Frankels grading system and the ASIA impairment scale are used to
determine the neurologic status of
a patient with a spinal cord injury
Grade
A B C D
E
Frankels Complete Preserved sensory but Preserved sensory
Preserved sensory Normal
grading paralysis not motor function function, non-
function, useful sensorimotor
system below the level of useful motor
motor function function
injury function (grade
(grade 4/5) below
2/5-3/5) below the the
level of injury
level of injury
ASIA No sensory Sensory function Preservation of
Preservation of Normal
Impairment or motor preserved below the motor function
motor function sensorimotor
Scale function level of injury below the
below the function
preserved (including the S4S5 neurological level,
neurological level,
in the segments). Absence with >50 % of key with
at least 50 %
S4S5 of motor function muscles with of
key muscles
segments more than three a grade less than with
a grade #3/5
levels below the 3/5
motor level on either
side of the body
neurological impairment can be determined, tracts responsible for

upper extremity function lie
using either the Frankels grading system, or the more centrally in the
spinal cord, than those des-
ASIA Impairment Scale (Table 1). Frequent ignated to more distal
parts of the body. Finally,
serial neurological evaluations should be the Brown-Sequard
syndrome is caused by uni-
performed, in order to document any improve- lateral injuries
(typically penetrating trauma) and
ment of patients neurologic status over time. is characterized by
ipsilateral paresis, ipsilateral
The topography of spinal cord injury deter- loss of position and
vibratory sensation and con-
mines clinical presentation, according to the tralateral loss of pain
and temperature sensation,
affected spinal tracts. At the level of the cervical three dermatomes below
the affected level. This
spinal cord, four distinct syndromes may be clinical presentation
is due to the different decus-
encountered, including the anterior, the posterior sation patterns of the
sensory and motor tracts, as
and the central cord syndrome, as well as the the spinothalamic
tracts decussate three levels
Brown-Sequard syndrome. after entering the
spinal cord, while the
The anterior cord syndrome is caused by inju- corticospinal tracts
decussate at the medulla
ries of the anterior two-thirds of the spinal cord, oblongata (pyramidal
decussation).
commonly by a combination of flexion and com- The National Acute
Spinal Cord Injury Study
pression forces. It is characterized by loss of (NASCIS) II and III
trials showed improved
motor function and pain and temperature sensa- prognosis in patients
with incomplete spinal
tion, but preservation of position and vibratory cord injury, after
administration of high doses of
sensation. In case of a posterior spinal cord syn- methylprednisolone
[10]. If the patient is admit-
drome, the damage involves the posterior col- ted within 3 h after
injury, an initial bolus dose of
umns, with subsequent loss of deep sensation. 30 mg/kg of
methylprednisolone is administered
A central cord syndrome, most frequently caused within 15 min, followed
by a 45-min pause, and
by hyperextension injury of a spondylotic cervi- a 23-h continuous
infusion of 5.4 mg/kg/h. If the
cal spine, involves the central portion of the cord patient is admitted
between 3 and 8 h after injury,
and presents with paresis, which is more severe in infusion is continued
for 48 h. Recently, how-
the upper extremities, as the efferent and afferent ever, the efficacy of
this therapeutic scheme has
722
been questioned [11]. Gangliosides(GM-1) have view, either in the erect or

the supine (cross-
been also suggested as a potential treatment to table) position, can identify
most fractures and
improve recovery, but clinical trials failed to dislocations of the cervical
spine. In the upper
prove their effectiveness [12]. The effectiveness cervical spine, the
relationships between the
of other proposed agents, including naloxone, skull, the atlas and the axis
can be evaluated,
thyrotropin-releasing hormone and erythropoie- whereas the atlas and the
axis can be fully visu-
tin has not been confirmed in clinical trials [8]. alized. In the lower cervical
spine, the vertebral
bodies, the intervertebral
disc spaces, the facet
joints, and the spinous
processes can be identi-
Imaging Studies fied. Furthermore, the four
contour lines of the
cervical spine can be
evaluated (Fig. 2).
It has already been stated that the NEXUS criteria A lateral view without
depiction of the C7
do not determine the ideal imaging method for vertebra must not be
accepted, as injuries at this
the diagnosis of cervical spine trauma. Plain radi- level can frequently be
missed. In the
ography is the most widely available modality anteroposterior view, the
vertebral bodies of C3
and, in most circumstances, is the first imaging to C7 can be visualized, as
well as the Luschka
study a patient with blunt trauma will undergo, if joints, the disc spaces and
the spinous processes.
cervical spine injury is suspected. The lateral The open-mouth view is an
anteroposterior view
Fig. 2 Lateral radiograph

of the cervical spine in a
23 year-old female with
a fracture of the C2
odontoid process. The four
contour lines include A: the
anterior vertebral line along
the anterior margins of the
vertebral bodies, B: the
posterior vertebral line
along the posterior margins
of the vertebral bodies,
C: the spinolaminar line
which outlines the posterior
border of the spinal canal
and D: the posterior
spinous line along the tips
of the spinous processes
through C2C7. The
retropharyngeal space (I)
should be #7 mm, while
the retrotracheal space (II)
should be <22 mm in adults
and <14 mm in children. In
this case, disruption of the
A, B and C lines can be
noted
723
and the occipital condyles.

Moreover, it can pro-
vide valuable information
about soft-tissue inju-
ries, clinically
insignificant injuries that require
only symptomatic treatment,
as well as the involve-
ment of the spinal canal. CT
is more sensitive than
plain radiography in
detecting cervical spine frac-
tures, with a sensitivity of
up to 98 %, versus 52 %
for plain X-rays [16].
However, this does not jus-
tify the routine use of CT
scanning for the screen-
ing of all patients with
suspected cervical spine
injury, as it is related to
higher doses of ionizing
radiation, with special
consideration of the thyroid
gland, and is a more
expensive procedure. Hence,
efforts have been made to
establish clinical criteria
for selecting those patients
who would benefit from
CT scanning of the cervical
spine [17, 18]. Never-
Fig. 3 Open-mouth view of the upper cervical spine theless, the development of
newer and faster,
multi-detector scanners has
led many authors to
of the cervical spine, centred over the first two reconsider these limitations
[16].
vertebrae. It provides full visualization of the Magnetic resonance
imaging (MRI) is
dens, the body of the axis, the lateral masses of a valuable adjunct to
cervical spine trauma eval-
both the atlas and the axis and the lateral atlanto- uation, as it can accurately
depict soft-tissue and
axial joints (Fig. 3). The lateral, anteroposterior spinal cord injuries. MRI
can provide multi-
and open-mouth views are included in the stan- planar images, revealing
even minimal trauma
dard radiographic imaging of the patient with of the spinal cord and the
ligamentous structures
suspected cervical spine injury. If they are nega- (Fig. 5). It is also useful
in cases of Spinal
tive and there is still high suspicion of injury, Cord Injuries Without
Obvious Radiological
several other projections may be used, including Abnormalities (SCIWORA), as
all other imag-
the pillar view, the oblique view and the swim- ing modalities are negative
[19]. It is interesting
mers view (Fig. 4). Dynamic radiographs in that, in patients with
neurological deficit, MRI
flexion and extension may reveal instability that findings are well correlated
with long-term out-
cannot be identified in standard views. They are comes [6, 20]. On the other
hand, MRI requires
indicated in conscious, co-operative patients, time, which may not be
available in the case of
who can actively flex and extend their neck. The a yet unstable patient.
Furthermore, patients are
presence of more than 3.5 mm of intervertebral quite often immobilized with
metallic traction
translation or 11# of angulation is indicative of devices, which are not
compatible with a strong
instability. Passive flexion-extension radiographs magnetic field. Finally, it
is an expensive
in the unconscious patient should generally be method and, as plain X-rays
and CT can better
avoided, as they may result in secondary neuro- visualize bony structures,
it is usually used in
logical sequelae [13]. Despite its simple nature cases of neurologic
impairment, in order to
and widespread availability, plain radiography define the extent of spinal
cord injury.
may be time-consuming [14] and inadequate in Myelography is another
modality widely
detecting all cervical spine injuries [15], while used in the past. However,
as novel techniques
repeated imaging is frequently required, because were developed, including CT
and MRI,
of poor visualization. myelography is now rarely
used in acute
CT scanning is commonly used in the evalua- cervical trauma and mostly
serves as an adjunct
tion of cervical spine trauma, as it can more accu- to CT scanning, if the
patient is unable to
rately detect fractures of the C1 arches, the dens undergo MRI.
724
a b
c d
Fig. 4 (a and b) Lateral and AP views of the cervical decreased height of the C6
vertebral body raises sus-
spine of a 26 year-old male involved in a motor vehi- picion of a fracture.
Subsequently, left (c) and right
cle accident, who presented with complete C5 quadri- (d) oblique views were
obtained, demonstrating a burst
plegia. The lateral view failed to demonstrate the fracture of the C6 vertebra
with spinal canal
vertebrae below C5, while in the AP view, only the compromise
Non-Operative Treatment
General Considerations Regarding
Treatment Non-operative measures
include immobilization
with skeletal skull
traction, semi-rigid and rigid
Treatment of cervical spine fractures can be collars, cervico-
thoracicorthoses and the Halo vest.
either non-operative or operative, depending on Skeletal skull traction
involves applying weight
the type of injury, the degree of instability and the traction to the skull, via
tongs (Crutchfield or
presence of neurological deficit. Gardner-Wells) placed 1 cm
above the pinna,
725
standard for the

total weight that may be applied.
After reduction,
however, it is limited to 1020 lb.
Moreover,
distraction of a disc level for more than
1 cm precludes
further weight application. If the
patient is
unconscious, closed reduction with skull
traction should not
be attempted without previous
MRI. This is to
exclude a protruding herniated disc
at the level of the
dislocation, which could result in
post-reduction cord
compression and quadriple-
gia. A CT scan or an
MRI is done after successful
reduction.
Semi-rigid and
rigid collars are usually the
first measure for
cervical spine immobilization
at the site of
injury. When combined with sand-
bags and tapes, they
provide optimal immobili-
zation for patients
transfer. They include the
Philadelphia collar,
the Miami collar, the Aspen
collar etc., and may
be used in the treatment of
stable cervical
spine fractures. However, stand-
alone semi-rigid
collars still allow significant
motion of the
cervical spine, especially lateral
bending and
rotation. By incorporating the tho-
Fig. 5 Sagittal T2-weighted MRI of a patient with frac- rax, cervico-
thoracic orthroses (e.g. the sterno-
tures of the C4 and C5 vertebrae and quadriplegia. Abnor- occipito-mandibular
immobilizer SOMI and
mal signal is noted within the substance of the spinal cord. the Minerva brace)
provide better immobilization
The presence of haematoma between the anterior longitu-
dinal ligament and the anterior margins of the vertebrae is
than collars,
especially to the lower cervical spine
demonstrated, while significant edema and injury of the and cervico-
thoracicjunction. They are usually
posterior ligamentous structures can also be identified used in the
treatment of stable fractures of the
lower cervical
spine. Collars and cervico-
thoracic orthoses
are mainly associated with
skin complications,
including ulcerations and
below the skull equator. A Halo ring may be used allergic reactions,
but they may also be related
as well, especially if the Halo vest is planned to be with muscle atrophy
and pain.
the definitive treatment. Skeletal skull traction is The Halo vest
represents the stiffest means of
used for reduction of acute dislocations and sub- external
immobilization and can be used either as
luxations, as well as for immobilization of the a stand-alone
treatment, or as an adjunct to cervi-
cervical spine in critical care patients with upper cal spine surgery.
It consists of a ring, secured to
or lower C-spine fractures. It is contra-indicated in the skull with pins
and connected with rods to an
patients with skull fractures. The patient is placed upper torso vest.
The ring is selected to the appro-
in a reverse Trendelenburg position and should priate size and
connected with four pins, two ante-
ideally be conscious, in order to immediately rec- rior and two
posterior. The patient is supine, with
ognize any acute deterioration in the neurological the cervical spine
provisionally immobilized with
status during the procedure. Initially, a weight of a collar. Under
local anaesthesia, the pins are
10 lb is placed, which is increased by 5 lb per level inserted into pre-
defined sites of the skull and
in 2030 min intervals, in order to allow for mus- below its equator,
with the use of a torque screw-
cle spasm subsidence. After each increase, driver in order to
perforate only the outer cortex of
a lateral radiograph is taken and a full neurological the skull. The
anterior pins are placed within a safe
examination is carried out. Generally, there is no zone >1 cm above the
orbital rim and along its
726
Fig. 6 Application of the Halo. The safe zones for pin junction. Posteriorly,
the safe zone lies over the thick
insertion are shaded. Anteriorly, an area 10 mm above the bone of the external
occipital protruberance, avoiding
lateral third of the eyebrow will avoid the cutaneous branches of the
occipital nerve posteriorly, and branches
nerves and frontal sinuses medially, and will be over the of the auricular nerves
more anteriorly
relatively thick plate of bone at the fronto-temporal
lateral two thirds, where important structures,

including the frontal sinus, the supra-orbital and
supra-trochlear nerves, and the temporal artery are
avoided (Fig. 6). During anterior pin placement,
the patient should keep his/her eyelids closed, to
avoid skin tethering. The posterior pins are placed
opposite to the anterior pins. A vest of the appro-
priate size is applied and connected symmetrically
to the ring with rods (Fig. 7). Before securing the
rods to the vest, the alignment of the cervical spine
to the head and chest is checked, in order to con-
firm proper fracture reduction. Moreover, mal-
alignment could result in swallowing and eating
problems, as well as ambulation difficulties, as the
patient cannot see his/her feet. Pins and screws are
re-tightened 24 h and 1 week after Halo vest
placement, and weekly thereafter, while pin inser-
tion sites are cleaned with hydrogen peroxide
twice a day and observed for signs of infection.
In paediatric patients, up to ten pins may be
required to obtain stable fixation of the ring to
the skull. Pin site infection, pin loosening, ring
migration and pin discomfort are the most frequent Fig. 7 Application of
an appropriate size Halo-vest is
complications of this method [21]. illustrated
727
Operative Treatment nerves IX, X, XI and XII

(Collet-Sicard
syndrome) [23]. Late
neurologic deficit may
The goals of operative treatment include restora- be observed, due to fragment
displacement,
tion of alignment, stabilization of the C-spine, fibrosis or nerve edema.
Plain X-rays are
and decompression of neural elements. It usually insufficient for
diagnosis and, in case
includes anterior and posterior procedures. Ante- of a patient with a suspected
occipital
rior procedures are indicated in cases of anterior condyle fracture, CT scanning
should be
column insufficiency or anterior spinal cord com- performed. Anderson and
Montesano proposed
pression (e.g. burst fractures). On the other hand, a classification for
occipital condyle fractures
in the presence of facet dislocations or trauma based on CT scan findings,
recognizing three
with significant posterior element compromise, different types:
posterior surgery is usually preferred. The Type I includes comminuted
fractures, with min-
detailed description of each surgical technique imal or no displacement
into the foramen mag-
is beyond the scope of this chapter, however num. The contra-lateral
alar ligament and the
general points are discussed in the corresponding tectorial membrane are
intact, thus these frac-
sections for specific C-spine injuries. The timing tures are considered
stable.
of surgery depends on the type of injury and the Type II fractures are
typically an extension of
presence and progression of neurologic deficit. a basilar skull fracture
to the base of the con-
For example, a progressive neurological deficit dyle. Stability is
maintained by the intact lig-
in a patient with a fracture causing compression amentous structures.
to the spinal cord requires surgical intervention. Type III fractures are
avulsion fractures of the
On the contrary, surgery could be delayed in occipital condyles, and
are considered poten-
patients without neurological impairment. How- tially unstable. Treatment
is in the majority of
ever, early surgery permits patient mobilization cases non-operative and
includes immobiliza-
and decreases morbidity related to prolonged tion with the use of a
semi-rigid or rigid collar.
recumbency. If the fracture is
considered unstable, then
A suggested treatment algorithm for cervical a Halo vest may provide a
more rigid immo-
spine injuries is provided in Fig. 8. bilization (Table 2).
Occipito-Atlantal Dislocation
Specific Injuries of the Cervical Spine Occipito-atlantal dislocation
is recognized as
the cause of 68 % of deaths
among motor
Upper Cervical Spine vehicle accident victims and
accounts for
2030 % of deaths from
cervical spine injuries
Occipital Condyle Fractures [24, 25]. In the past, these
injuries were infre-
Occipital condyle fractures are classically quently reported, but with
the improvement of
described together with other injuries of the pre-hospital care, diagnostic
modalities and
cervical spine. Typically, they result from management over the years, an
increasing
axial compression or lateral bending forces to number of patients with such
injuries subse-
the head. They may be accompanied by head quently survived and were
diagnosed. Clini-
injuries, as well as fractures of the upper and cally, patients usually have
concomitant
lower cervical spine, which can make clinical injuries to other organs, as
occipito-atlantal
diagnosis difficult. Clinical presentation is dislocation results from
high-energy trauma.
non-specific and may include pain and tender- The vertebral arteries,
cranial nerves, brainstem
ness at the occipito-cervical region and torticol- and spinal cord are also in
danger. However, the
lis [22]. The presence of neurological deficit is absence of neurological
deficit is also
variable and mostly involves the lower cranial possible [26]. Occipito-
atlantal dislocations
728
Polytrauma patient
C-spine precautions untill further

evaluation excludes injury
Yes
Life-threatening injuries
No
Treatment
Neurological examination
plain radiographs
CT scanning
Stable injury Unstable injury

patient neurologically intact patient with neurologic
deficit
Non-opreative treatment
Cervical orthosis
Dislocation
Other
GCS<15
GCS = 15 Neurological
patient neurologically deficit MRI
intact
MRI
Failure Open reduction
Closed reduction
posterior fusion
Non-operative Operative
treatment treatment
Cervical orthosis vs Anterior vs
Halo vest Posterior vs

Patient unable to undergo
circumferential
surgery Posterior fusion
fusion
Traction
Fig. 8 Treatment algorithm for cervical spine injuries
are classified according to Traynelis into three classification,

as small changes in neck
types: position may
result in a totally different
Type I involves anterior translation of the occiput occipito-
atlantal pattern.
in relation to the atlas. In plain X-rays,
several measurements have
Type II result from vertical distraction forces. been proposed for
determination of occipito-
Type III are characterized by posterior dislocation cervical
dissociation. The distance from the basion
of the occiput over the atlas. Nevertheless, to the posterior
arch of the atlas, divided by the
the relationship of the occiput to the atlas is distance between
the opisthion to the anterior
highly dependable on the position of the arch of the atlas
is called Powers ratio, with
patient, limiting the accuracy of the Traynelis normal values less
or equal than 1.0 (Fig. 9a).
729
The basion-dens interval can also be measured, method involves drawing

two lines, one from the
with a distance of more than 10 mm in adults or basion to the C2
spinolaminar junction, and another
12 mm in children being abnormal (Fig. 9b). A con- from the opisthion to
the postero-inferior corner of
dyle-C1 interval of more than 2 mm in adults or the C2 body. Normally,
the first line intersects C2
more than 5 mm in children is also indicative of and the second
intersects C1 (Fig. 9d). CT imaging
occipito-atlantal dislocation (Fig. 9c). The X-line can be further used to
evaluate occipito-atlantal
Table 2 Summary of treatment options for specific cervical spine injuries

Treatment Modality
Type of Injury Non-Operative Operative
Upper cervical spine
Occipital condyle fractures Semi-rigid or rigid collar
immobilization
Halo vest immobilization may
be considered in certain Type
III fractures
Occipitoatlantal dislocation
Occipitocervical fusion with wiring, rod and
wire
fixation and rod and screws (posterior
approach),
after initial skeletal skull traction
Fractures of the Transverse Semi-rigid or rigid collar
atlas ligament immobilization
intact
Transverse Bony Halo vest
ligament avulsion immobilization
disrupted Non
Occipitocervical fusion (posterior approach)
bony
avulsion
Rotatory atlantoaxial dislocation Closed reduction with skeletal Open
reduction and posterior C1C2 fusion
skull traction + Halo vest with
wiring techniques or transarticular
immobilization screws
Fractures of the Odontoid Type I Semi-rigid or rigid
axis process collar
(dens) immobilization
fractures Type II Halo vest Odontoid
screw fixation (transoral
immobilization approach)
(high rates of non- C1C2
fusion (posterior approach) with the
union) use of
wires or cables, interlaminar clamps,
transarticular screw fixation, crossed C2

intralaminar screws and rod and screw
fixation
Type III Halo vest
immobilization
Traumatic Type I Rigid collar immobilization
spondylolisthesis Type II Halo vest immobilization
of the axis Type III Open
reduction C2-C3 fusion (posterior
approach)
Lower cervical spine
Burst fractures Anterior
decompression and fusion vs.
combined
procedures (in case of posterior
elements
injury)
Flexion teardrop fractures Anterior
decompression and fusion vs.
posterior
fusion vs. combined procedures
(continued)
730
Table 2 (continued)
Treatment Modality
Type of Injury Non-Operative Operative
Facet fractures Undisplaced Semi-rigid or rigid collar
and dislocations unilateral immobilization
facet
fractures
Bilateral Semi-rigid or rigid collar Anterior
vs. posterior fusion in case of
facet immobilization translation
>3.5 mm
fractures
Lateral mass Anterior
vs. posterior fusion
fracture
separations
Unilateral Immobilization with a cervical Open
reduction and posterior fusion with
facet orthosis may be considered in screws and
rods
dislocations case of stable injuries, without
neurologic deficit
Bilateral Closed vs.
open reduction and posterior
facet fusion with
screws and rods
dislocations
dislocation in multiple planes. MRI is very useful are the main causes of
atlas fractures, with
for evaluation of ligamentous and neural tissue a combination of axial
loading, flexion, extension
injuries, and can reveal abnormalities indicative and lateral bending
forces resulting in compres-
of instability, even in the setting of normal radio- sion of the atlas
between the occiput and the axis.
graphic or CT findings. Atlas fractures are
therefore frequently accompa-
Treatment of these injuries includes initial nied with head injuries
and other fractures of
immobilization by skeletal skull traction or the cervical spine. The
areas of transition between
a Halo vest. Skull traction is however contra- the lateral masses and
the anterior and posterior
indicated in type II injuries. The Halo vest may arches represent the
weakest points of the
also be the definitive treatment in patients with vertebra and it is at
these sites that fractures
normal CT findings and a borderline MRI [27]. occur during axial
compression. If axial compres-
However, in the vast majority of cases, instability sion is combined with
lateral bending, the result is
is addressed with occipito-cervical fusion usually a fracture of
the lateral mass. Clinically, an
(Table 2). This can be achieved with different atlas fracture presents
with pain, tenderness and
techniques, including wiring, rod and wire fixa- muscle spasm. Symptoms
from injury of the C2
tion and rod and screws fixation. Wiring tech- nerve root and the
vertebral artery may also be
niques require post-operative use of a Halo vest encountered. As
fractures of the atlas usually
for additional immobilization. Screws to the occi- cause the spinal canal
to expand, neurological
put are placed in the midline and have preferably deficit is unusual in
cases of isolated atlas frac-
bi-cortical purchase, while trans-articular screws tures. Jeffersons
classification includes five types
are used for C1-C2 fixation and lateral mass of fractures:
screws for sub-axial vertebrae, if fusion must Type I and type II are
isolated fractures of the
extend below C2. posterior and
anterior arch respectively.
Type III fractures are
the classic Jefferson burst
Fractures of the Atlas fractures of the
atlas, involving bilateral pos-
Fractures of the atlas represent 313 % of terior arch fractures
and unilateral or bilateral
injuries to the cervical spine in adults and 3.5 % fractures of the
anterior arch.
in children [28]. Motor vehicle accidents and falls Type IV fractures
involve the lateral mass.
731
a b
c d
Fig. 9 (a) Powers ratio ab/dc. Normal values #1. (b) values <2 mm in adults,
<5 mm in children. (d) The
Basion-dens interval. Normal values <10 mm in adults, X line method
<12 mm in children. (c) Condyle-C1 interval. Normal
Type V include transverse fractures of the ante- be treated with a

cervical collar. After removal of
rior arch. the Halo vest, stability
is confirmed with flexion
Plain X-rays may demonstrate fractures of the and extension X-rays.
Operative treatment is
posterior and anterior arch, while in the open- indicated in cases of
non-bony avulsion of the
mouth view, fractures and displacement of the transverse ligament or if
residual instability is
lateral masses may be noted. A sum of lateral present after
immobilization and includes poste-
mass diastasis of more than 6.9 mm is suggestive rior Occ-C1 and C1-C2
fusion.
of transverse ligament insufficiency [29]. Flexion
and extension X-rays can rule out instability. CT Rotatory Atlanto-Axial
Dislocation
scanning provides a more detailed evaluation of Traumatic rotatory
atlanto-axial dislocation,
the bony injuries (Fig. 10), while MRI may be although common in
children, is rarely described
used in order to evaluate the transverse ligament. in adults. The main cause
is motor vehicle acci-
Treatment of atlas fractures consists of exter- dents. Pain and
restriction of necks range of
nal immobilization with a Halo vest for 12 weeks motion are the main
clinical findings. Neurologic
(Table 2). Isolated posterior arch fractures may deficit may also be
present, even though injury to
732
immobilization for
12 weeks. If closed reduction
is not possible,
open reduction and C1C2 fusion
is indicated, with
the use of wiring techniques or
C1C2 trans-
articular screws (Table 2).
Fractures of the
Axis
Odontoid Process
(Dens) Fractures
Dens fractures are
the most common fractures of
the axis and result
from flexion or extension
forces, due to falls
or motor vehicle accidents.
Their sole clinical
manifestation may be pain,
making their
diagnosis difficult. In the setting
of an emergency
department, these injuries are
quite often missed.
Anderson and DAlonzo pro-
posed the most
widely-used classification of
Fig. 10 Axial CT image of the C1 vertebra in a 74 years- dens fractures,
which includes three types:
old female who sustained a fall from a height. A fracture of
the anterior arch of the C1 is demonstrated Type I represents
avulsion fractures of the tip of the
dens, where the
alar ligaments are attached.
Type II fractures
occur at the junction of the dens
the spinal cord at this level is frequently lethal. to the C2 body
(Fig. 11).
Rotatory atlanto-axial dislocation may be accom- Type III fractures
include injuries where the frac-
panied by rupture of the transverse ligament. The ture line extends
to the body of the axis
latter is classified into two types according to (Figs. 2 and 12).
Dickman et al. [30]: type I includes rupture at Diagnosis can be
made with plain X-rays, but
the mid-portion of the transverse ligament or at CT scanning provides
multi-planar images and
its insertion point, while type II injuries represent a more thorough
evaluation of the fracture.
bony avulsions of the ligament. Fieldings classi- Treatment depends
on the type of fracture
fication describes four patterns of rotatory (Table 2).
atlanto-axial dislocation: type 1 includes rotatory Type I fractures
are treated non-operatively,
displacement without shift, with the transverse with external
immobilization in a cervical collar.
ligament intact; type 2 involves 35 mm anterior However, in some
cases, type I fractures may be
displacement of the anterior arch in relation to the associated with
occipito-atlantal instability,
dens, with a lateral mass pivot; in type 3 injuries, which should always
be evaluated. Non-
displacement is more than 5 mm; finally, type 4 operative treatment
of type II fractures is related
dislocations include posterior translation of the with high rates of
non-union [31]. This is mainly
atlas in relation to the axis. Type 2 and 3 injuries due to the
relatively poor blood supply of the dens
are characterized by insufficient transverse and base. Other factors
include the lack of periosteal
alar ligaments, while type 4 is associated with blood supply to the
dens and the distractional
odontoid process fractures. forces applied by
the intact alar ligaments. Exter-
In plain X-rays, the atlanto-dens interval can nal immobilization
in a Halo vest is a reasonable
be measured, with values >5 mm being indica- option, with total
non-union rates ranging from
tive of instability. CT scanning is the diagnostic 26 % to 29.7 % [32
35].
method of choice, as axial images can accurately A displacement of
6 mm or more and an age
depict C1C2 rotatory translation. Again, MRI is #50 years are
related with higher rates of non-
useful in evaluation of ligamentous injuries. union with Halo vest
immobilization [35, 36]. In
Non-operative treatment includes skeletal these patients,
surgical management is the treat-
skull traction for up to 3 weeks, in order to ment of choice.
Operative treatment includes
achieve reduction, followed by Halo vest odontoid process
osteosynthesis and C1C2
733
a b
Fig. 11 (a) Lateral radiograph and (b) sagittal CT reconstruction image of a 19

year-old male with a type II fracture of
the odontoid process, after a motor vehicle accident
fusion. Odontoid screw

fixation has the theoreti-
cal advantage of
preserving rotation between the
atlas and the axis.
Reported fusion rates are up to
88 % [37]. Contra-
indications to this technique
include disruption of
the transverse ligament
(absolute contra-
indication), osteopenia, frac-
tures older than 6
months, fractures with
a direction from
antero-inferiorly to postero-
superiorly and poor
general health. Moreover,
the transoral approach
is associated with high
rates of
complications. C1C2 fusion may be
achieved with several
techniques, including use
of wires or cables
(Gallie fusion, Brooks and
Jenkins fusion),
interlaminar clamps, trans-
articular screw
fixation, crossed C2 intra-laminar
Fig. 12 Type III fracture of the odontoid process in a 34
year-old male who sustained a motor vehicle accident. The
screws [38] and rod
fixation with C1 lateral mass
patient was neurologically intact and was treated non- screws and C2 pedicle
screws (Harms and
operatively, with Halo-vest immobilization Melcher fixation
[39]). Fusion rates up to 100 %
734
a b
Fig. 13 (a) Lateral radiograph and (b) axial CT image of a 28 year-old male patient
with a type I traumatic
spondylolisthesis of the axis
have been reported [39], however C1-C2 fusion Type I fractures show
displacement less than
sacrifices 50 % of cervical spine rotation. 3 mm without angulation,
caused by a combi-
Type III injuries are typically treated with nation of hyperextension
and axial loading.
Halo vest immobilization, with bony union Type II refers to fractures
with displacement
rates ranging from 84 % to 100 % [32, 33]. more than 3 mm and
angulation more than
Failure of non-operative treatment, defined as 10o, caused by a sequence
of hyperextension-
mal-union or non-union, requires surgical axial loading and
flexion.
intervention. Type IIa is a sub-group of
type II fractures caused
by flexion and
distraction and characterized by
Traumatic Spondylolisthesis of the Axis widening of the posterior
intervertebral space
(Hangmans Fracture) between C2 and C3. Type
III fractures are
The incidence of traumatic spondylolisthesis of additionally accompanied
by unilateral or
the axis varies and has been reported up to 38 % bilateral facet
dislocation.
[40]. This pattern of axis fracture was first Treatment of type I
fractures consists of rigid
described in death-sentenced convicts, who cervical collar
immobilization for 12 weeks. Halo
were executed by hanging. Today, motor vehicle vest immobilization is the
treatment of choice for
accidents and falls from height are the primary type II fractures. On the
other hand, type IIa and
causes (Fig. 13). Levine and Edwards [41] mod- type III fractures are best
treated surgically, with
ified the Effendi [42] classification and described open reduction of the
dislocation (type III) and
three types of fractures: posterior C2-C3 fusion
(Table 2).
735
Lower Cervical Spine are characterized by marked

instability. They
most often involve C4, C5
and C6 vertebrae.
The Allen-Ferguson classification [43] divides Typically, the vertebral
body presents with
injuries of the lower (sub-axial) cervical spine a coronal fracture line,
leading to a smaller, ante-
into six categories, according to the mechanism rior fragment and a larger
posterior fragment. The
of injury: extension-distraction, extension-com- typical teardrop
appearance of the fracture in
pression, compression, flexion-compression, the lateral radiograph is
attributed to the anterior
flexion-distraction injuries and lateral flexion fragment. Frequently, the
posterior fragment
injuries. Each of these categories is further sub- splits sagittally and
protrudes into the spinal
divided in stages of increasing severity. Recently, canal, compromising the
spinal cord [46]. In
the Cervical Spine Injury Severity Score (CSISS) addition to the vertebral
body fracture, the poste-
[44] and the Sub-axial Cervical Injury Classifica- rior elements are disrupted,
resulting in spinous
tion System (SLIC) [45] have been proposed, in process diastasis or even
facet dislocation. Plain
order to guide therapeutic decision-making. The radiographs show the typical
signs of a flexion
CSISS is obtained by the sum of analog scale teardrop fracture, including
the triangular ante-
points representing the degree of osseous and rior fragment, the posterior
translation of the cer-
ligamentous injury of each of the four cervical vical spine cephalad to the
fracture and facet joint
spine columns (anterior, posterior, left and right and interspinous space
widening. Axial CT
pillar). A total of points #7 is suggestive for images can accurately depict
the characteristic
surgical management. The SLIC takes into pattern of vertebral body
fracture, as well as
account the injury morphology, the extent of spinal canal narrowing. MRI
can demonstrate
disco-ligamentous complex involvement and the the extent of spinal cord
and ligamentous injury
neurological status of the patient. If the score is (Fig. 15).
#5, then operative treatment is recommended. The treatment of these
significantly unstable
injuries is mainly
operative, especially in cases of
Burst Fractures complete or incomplete
neurologic deficit
Burst fractures of the cervical spine result from (Table 2). Nevertheless,
non-operative treatment
vertical compression loads applied to the head, with Halo vest
immobilization has also been pro-
with the cervical spine in the neutral position. posed [47], but its results
are less predictable.
This leads to comminution and loss of height of Surgical treatment includes
anterior decompres-
the vertebral body. Retropulsion of bone fragments sion and fusion, posterior
fusion or combined
into the spinal canal may provoke spinal cord techniques.
injury, with varying degrees of neurologic deficit,
usually presenting as an anterior cord syndrome. Facet Fractures and
Dislocations
Plain X-rays and CT scanning are the initial diag- Facet injuries range from
unilateral undisplaced
nostic modalities, with MRI being of vital impor- fractures to complete
bilateral dislocations. Uni-
tance in case of neurologic deficit (Fig. 14). lateral facet injuries
account for approximately
Cervical burst fractures are treated opera- 6 % of all cervical spine
injuries [48]. Facet frac-
tively, with anterior decompression and fusion tures usually involve the
superior facet, but the
being the procedure of choice. However, in cer- inferior facet may be
affected as well. Although
tain circumstances, a burst fracture can be accom- unilateral facet fractures
are generally considered
panied by significant posterior element injury, as stable injuries, they may
be accompanied by
and circumferential fusion may be indicated ligamentous injury of the
contralateral facet joint
(Table 2). capsule, as well as injury
of the posterior portion of
the annulus fibrosus. This
is a result of the mech-
Flexion Teardrop Fractures anism of injury, which
involves lateral bending or
Flexion teardrop fractures are the result of flexion extension and rotation of
the cervical spine. Bilat-
and compression forces to the cervical spine and eral facet fractures
represent a more unstable
736
a c
Fig. 14 (a) Lateral radiograph of a 27 year-old male with and spinal canal
compromise. (c) T2-weighted sagittal
a burst fracture of the C6 vertebra and complete quadri- image showing extended
spinal cord injury at the levels
plegia, after a motor vehicle accident. (b) CT scanning from C5 to C7
demonstrates in detail the vertebral body comminution
entity and are associated with a higher incidence of rotation. Plain

radiographs may not be conclusive.
intervertebral disc injury. Fracture separations of On the other hand, CT-
scan can demonstrate the
the lateral mass (floating lateral mass) result from fracture pattern in
detail. Undisplaced unilateral
a concurrent fracture of the pedicle and the ipsi- facet fractures are
usually treated conservatively,
lateral lamina, usually due to extension and with the use of a semi-
rigid or rigid collar.
737
a b c
d e
Fig. 15 A 36 year-old male, victim of a motor vehicle fracture, with a fracture

line in the coronal plane and
accident, was admitted with complete quadriplegia. another fracture line in
the sagittal plane. (d) The MRI
(a) Lateral radiograph showing fracture of the C6 shows extended injury and
oedema to the spinal cord.
vertebra. (b) Axial and (c) sagittal CT images, dem- (e) The patient underwent
anterior C6 corpectomy and
onstrating the typical appearance of a flexion teardrop C5C7 fusion
However, when significant rotational instability facet joint and

subluxation or dislocation. The
is present, operative management with anterior anterior and posterior
longitudinal ligaments
or posterior fusion is indicated. Bilateral facet remain intact. On the
other hand, bilateral facet
fractures may also be treated with conservative dislocations are caused
from flexion and distrac-
measures, except for those exhibiting translation injuries, without a
rotational component, and
tion greater than 3.5 mm. Fracture separations are characterized by
initial disruption of the pos-
of the lateral mass create instability over terior ligamentous
structures, followed by injury
two vertebral levels and thus are best treated of the middle and
anterior ligaments in more
surgically, with anterior or posterior fusion severe cases. The
anterior translation of the ceph-
(Table 2). alad vertebra may reach
or even exceed 50 % of
Unilateral facet subluxations and dislocations the superior end-plate of
the caudal vertebra. The
result from concurrent flexion-distraction and neurological status of
patients with facet sublux-
rotation of the cervical spine. The axis of rotation ations or dislocations
ranges from normal to com-
is centred over a facet joint, thus provoking injury plete quadriplegia.
Radicular symptoms are
of the capsule and ligaments of the contra-lateral usually related with
unilateral dislocations.
738
a b
c d
Fig. 16 A 46 year-old male was involved in a car acci- spinal cord,

consistent with the patients clinical presen-
dent and presented with a complete quadriplegia. (a) Axial tation. (d) The
patient underwent open reduction and
and (b) sagittal CT images, demonstrating a C6C7 bilat- posterior C4-T1 fusion
eral facet dislocation. (c) The MRI revealed injury of the
Radiographic evaluation consists of lateral, includes CT scanning,

with a high sensitivity in
anteroposterior and oblique views, where detecting facet
subluxations or dislocations, and
perching or locking of the facets may be identi- MRI, particularly in
cases with neurological def-
fied, with concomitant anterior translation of the icit (Figs. 16 and
17). Reduction and surgical
overlying vertebra and kyphosis. Imaging also stabilization are the
treatment principles of
739
a b
Fig. 17 A 71 year-old male with a history of ankylosing treated with a Halo-

vest for 12 weeks. (a) Axial and (b)
spondylitis sustained a C6C7 fracture-dislocation with- sagittal CT images of
the patients C-spine at 12 weeks,
out neurologic deficit, after falling from height. He was demonstrating C6-C7
spontaneous fusion
bilateral facet dislocations (Table 2). Stable uni-

lateral injuries without neurologic deficit may be Paediatric Cervical
Spine Injuries:
treated with external immobilization [49]. How- SCIWORA
ever, conservative treatment has been associated
with poor outcomes [50, 51]. The closed reduc- The paediatric cervical
spine exhibits distinct ana-
tion technique with skeletal traction has been tomic features. The
presence of synchondroses
described previously in this chapter. The neces- and ossification
centres may confuse the radio-
sity of obtaining a pre-reduction MRI to graphic evaluation of a
child with cervical spine
demonstrate a herniated disc at the level of dislo- injury. Moreover, the
increased elasticity of the
cation remains a topic of controversy [52]. Gen- spinal ligaments and
overall cervical spine mobil-
erally, in the conscious, co-operative patient, ity lead to unique
injury patterns [56]. Spinal Cord
closed reduction may be performed safely with- Injury Without Obvious
Radiologic Abnormalities
out previous MRI imaging [5254], provided that (SCIWORA) represents up
to 38 % of cervical
an accurate and detailed neurologic evaluation is spine injuries in
children [56]. Clinically,
done after each increase of the weight applied. a paediatric patient
with SCIWORA presents
Open reduction is indicated in concussed with neurologic deficit
of variable severity, but
patients, as well as in patients with failed attempts plain radiography fails
to demonstrate any pathol-
of closed reduction [52]. Surgical stabilization is ogy. The extent of
spinal cord injury and soft-
done through a posterior approach, with tissue trauma can be
evaluated with the use of
instrumented fusion and/or decompression. How- MRI. Treatment of
SCIWORA consists of sup-
ever, anterior fusion has also been reported in portive measures and
external immobilization,
cases of unilateral dislocations without neuro- with prognosis
depending on initial neurologic
logic deficit [55]. presentation [57].
740
16. Holmes JF,

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29.
Treatment of Thoraco-Lumbar
Spinal
Injuries
Antonio A. Faundez
Contents
Recent Developments in Computer-Assisted
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 754
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 744 Navigation for Percutaneous Pedicle Screw
Epidemiology of Spinal Injuries . . . . . . . . . . . . . . . . . . 744
Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 754
Navigation for Combined Approaches in

Initial Management of Polytrauma Patients
Thoraco-Lumbar Fractures . . . . . . . . . . . . . . . . . . . . . .
757
with an Associated Spine Injury . . . . . . . . . . . . . . 744
Surgical Technique for Combined
Anterior-Posterior Approach of Thoraco-Lumbar

Thoraco-Lumbar Trauma Imaging . . . . . . . . . . . . . . 745
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 758
Classification Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
745
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 759
Evolution of Classification Systems . . . . . . . . . . . . . . . .
746
Denis Classification (1983) . . . . . . . . . . . . . . . . . . . . . . . . . .
747
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 759
The Load-Sharing Classification (1994) . . . . . . . . . . . .
747
The AO Classification (1994) . . . . . . . . . . . . . . . . . . . . . . .
747
The Thoraco-Lumbar Injury Classification and
Severity System (TLICS, 2005) . . . . . . . . . . . . . . . . .
747
Non-Surgical Treatment of Thoraco-Lumbar
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 749
AO Types A1 and A2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
749
Burst Fractures (AO Type A3) . . . . . . . . . . . . . . . . . . . . . .
749
AO Fractures Type B and C . . . . . . . . . . . . . . . . . . . . . . . . .
750
Surgical
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750
Surgical Treatment for Fractures with Neurological
Deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 750
Surgical Treatment for AO Type A and B
Fractures Without Neurologic Deficit . . . . . . . . . . . 750
Less-Invasive and Recent Surgical
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 754
A.A. Faundez
Department of Surgery, Service de Chirurgie
Orthopedique et Traumatologie de lAppareil Moteur,
University of Geneva Hospitals and Faculty of Medicine,
Geneva, Switzerland
e-mail: antonio.faundez@hcuge.ch

743
DOI 10.1007/978-3-642-34746-7_9, # EFORT 2014
744
A.A. Faundez
only then to neurologic

functions. The trauma-
Abstract
tized spine is assessed
using standard radiologic
Non-osteoporotic thoraco-lumbar fractures
imaging, as well as CT scan.
MRI can provide
result from high energy trauma and affect
valuable information about
neural tissue and
mainly young people. Whereas the treatment
disco-ligamentous injuries.
Specific treatment
management of fractures with neurologic deficit
decisions will then rely on
both intrinsic (e.g.,
does not usually pose decisional issues, much
fracture morphology,
neurologic status, mechan-
more controversy surrounds fractures without
ical instability) and
extrinsic factors (e.g., age,
neurologic deficit. It should be recalled that
occupation, level of
physical activity). The main
non-surgical treatment can still be applied to
goal of surgical treatment
is to protect the neural
most of the thoraco-lumbar fractures diagnosed.
tissue by mechanically
stabilizing the spine and
On the other hand, marked improvements have
additionally decompressing
the spinal canal if
been made in the development of less invasive
necessary. We present here
an overview of cur-
surgical techniques in an effort to provide the
rent treatment options
available to surgeons for
best possible care to a usually young active
the treatment of thoraco-
lumbar fractures.
population that requires to resume normal activ-
ity as soon as possible. There also is a trend in
the literature to define more accurately the opti-
Epidemiology of Spinal
Injuries
mal treatment of fractures without neurologic
deficit in light of sagittal spino-pelvic balance
Thoraco-lumbar fractures
affect mostly males
parameters, as well as from an economic point
between 20 and 30 years old
and are due to high
of view. An overview of current treatment
energy trauma, mostly motor
vehicle accidents
options available is presented in this article.
(4050 %) and falls (around
20 %) [2]. It is
difficult to present exact
numbers for the inci-
Keywords dence of spine fractures
because of inconsistent
Classification types # Epidemiology # Fractures data collection amongst
Trauma centres. In
# Imaging # Minimally -invasive techniques # a recent epidemiological
review, it was estimated
Recent advances # Surgical treatment # that the incidence of adult
thoraco-lumbar frac-
Thoraco-Lumbar Spinal injuries # Spine # tures in the United Kingdom
is around 117/105
Epidemiology # Initial management # Imaging inhabitants/year [3]. The
incidence of spinal cord
# Classification # Non-operative treatment # injuries is better
documented and is reported to
Surgical treatment # Recent techniques range between 27 and 47 per
million population
in North America, with an
acute mortality rate
that has dramatically
decreased from 38 % to
Introduction 15.8 % over the past 30
years [1]. Major improve-
ments have been made in pre-
and in-hospital
Thoraco-lumbar fractures (Th10-L2) in young spinal cord injury
management, as well as in
adults are common and often associated with surgical implants and
techniques, thus allowing
profound socio-economic consequences [1]. provision of better trauma
care today.
Most of these result from motor vehicle acci-
dents and falls from heights, which involve
high kinetic energy and affect mainly males. Initial Management of
Polytrauma
Very often, patients are polytraumatized and Patients with an Associated
present with associated thoracic and/or abdomi- Spine Injury
nal injuries. Initial in-hospital management is
carried out following the Advanced Trauma Patients with spine injuries
are often
Life Support (ATLS) guidelines, where priority polytraumatized. Strict
adherence to ATLS
is given to stabilization of vital functions and guidelines is required
before and upon arrival
Treatment of Thoraco-Lumbar Spinal Injuries
745
to the trauma centre [4]. Taking pictures of provides an aerial view of

the osseous lesions of
the scene of the accident can be very useful the spine that cannot be
completely replaced yet by
to determine the mechanism of trauma and the CT scan. Several basic
pathomorphologic signs
is a current practice now in several paramedic can already be identified on
plain radiographs, such
teams. The patient should be adequately venti- as the amount of height loss
of the vertebral body,
lated and oxygenated and the cervical spine the interpedicular distance
on antero-posterior
immediately immobilized in a rigid collar. In views, interspinous distance
and interruption of
the emergency room, after vital functions have the posterior wall on lateral
views, and the amount
been stabilized, a detailed physical examination of kyphotic deformity. CT
scan is useful to pre-
and a thorough neurologic clinical assessment is cisely analyze the bony
contour of the spinal canal,
performed in the conscious patient. As but also the amount of
vertebral body destruction,
polytrauma patients frequently present with comminution and spread of
fragments.
altered consciousness, they are usually immedi- MRI is another important
tool for the analy-
ately screened with a total body CT scan that sis of spinal cord and
ligamentous injuries that
also allows detection of occult fractures of the cannot readily be detected on
plain radiographs
spine, which are frequently overlooked in this or CT scan, and often shows
the real extent of
category of patient [5]. If a spinal cord injury is vertebral injury by detecting
changes of
diagnosed, neurologic impairment is evaluated bone marrow signal intensity.
It has been eval-
according to the American Spinal Injury Asso- uated for the
characterization of spine injuries
ciation (ASIA) classification (Fig. 1). Mean since 1989 [9] and proposed
for inclusion in
blood pressure should be maintained above future spine trauma
classification schemes as
90 mmHg to protect the cord from secondary early as 1995 [10]. Only more
recent studies
ischaemic injury [2]. Until relatively recently, have investigated its
clinical validity in the
the administration of steroids was also consid- management of thoraco-lumbar
fractures
ered as a standard of care [6]. However, various [1113]. However, in an
article by Dai and
methodological flaws of the clinical trials colleagues published in 2009,
the practical
conducted by the National Acute Spinal Cord role of MRI in clinical
decision-making was
Injury (NASCIS) Study Group have seriously questioned, in particular for
burst fractures
questioned the validity of their conclusions, and [11]. The authors argued that
although it may be
because of possible serious adverse effects, ste- a reliable instrument for the
assessment of
roids should no longer be administered without ligamentous injuries, it did
not correlate with
further clinical research [7, 8]. A more detailed neurologic status or fracture
severity, and as such
description of the medical management of spi- should not be used routinely.
Further studies are
nal cord injury is provided in the article by awaited to better define
indications for MRI inves-
Bernhard and colleagues published in 2005 tigation of non-osteoporotic
spinal fractures.
[2]. Once urgent care has been delivered, treat-
ment strategy decisions for the spinal injury
need to be developed, also including possible Classification Systems
fractures of the appendicular skeleton.
A variety of thoraco-lumbar
fracture classifica-
tions have been described in
the literature, but
Thoraco-Lumbar Trauma Imaging none has reached a consensus
amongst Spine and
Trauma surgeons. The most
frequently cited clas-
Polytraumatized patients are often immediately sifications systems are the
Denis classification
taken to the radiology departement for a total (three-column theory), the
load-sharing classifi-
body CT scan once vital functions have been sta- cation, and the AO
classification (named after the
bilized. However, standard radiologic imaging founding Swiss group
Arbeitsgemeinschaft fur
must still be part of the initial assessment as it Osteosynthesefragen).
746
A.A. Faundez
Fig. 1 The ASIA scale of neurologic impairment. The motor and sensory deficits are
recorded on the data sheet left.
The scale of impairment (A, B, C, D, E) is detailed on the right
Evolution of Classification Systems His seminal work on the

treatment of fractures
was first published in
1929 [14]. Despite difficul-
Lorenz Boehler (18851973) was one of the ties to achieve
publication, the book encountered
first Trauma surgeons in Europe, and head of an important success and
was soon translated
the first hospital for labourers, based in Vienna. into English and later
into other languages.
747
Boehlers book is richly illustrated with drawings the surgeon to predict the
risk of implant failure
and pictures of various thoracic and lumbar frac- in short-posterior segment
constructs, such as the
ture types and their long-term deformity if not ones obtained using the AO
internal fixation
treated appropriately. He described five categories device [22] (Fig. 2). They
proposed a decisional
of thoracolumbar injuries which served later as algorithm to decide whether
an additional recon-
a basis for the Watson-Jones classification in struction of the anterior
column was necessary in
1938 [15]. Holdsworth was the first to use the burst fractures based on
three criteria: comminu-
term burst fracture [16]. He also introduced the tion of the vertebral body;
apposition of frag-
concept of column, dividing the spine into an ments of the vertebral
body; and reducibility of
anterior (vertebral body and disc) and a posterior sagittal deformation.
Although a few studies have
column (posterior facet joints and posterior liga- reported its validity in
clinical decision-making
mentous complex [PLC]) Some of the aspects of [2426], the disadvantage
of this algorithm is that
Holdsworths classification were later redefined it does not take into
account the neurologic status
by Kelly and Whitesides [17] and served as the of the patient, which is a
major drawback in
basis of the more recent AO classification clinical care.
published in 1994 by Magerl and colleagues [18].
The AO Classification
(1994)
Denis Classification (1983)
In 1994, Magerl and
colleagues proposed the AO
A major stage was reached in the management of classification of thoraco-
lumbar fractures follow-
spine trauma with the advent of CT scan imaging ing a review of 1445 cases
[18]. Fractures are
in the eighties. Using this new radiologic tool, classified according to
three pathomorphologic
Denis reviewed 412 patients with thoraco-lumbar types: type A (flexion-
compression fractures);
fractures and published in 1983 one of the most type B (distraction); and
type C (rotational-
frequently-cited thoraco-lumbar fracture classifi- shearing) (Fig. 3). In an
attempt to design a system
cation systems today [19]. The results of this describing every possible
fracture, the authors
study and the concept of middle column further divided each type
into sub-groups,
originated from the observation that during sub-types and sub-
divisions, resulting in a total
scoliosis surgery, where he would release both of 53 patterns.
anterior and posterior columns, he did not observe
any major mechanical instability as defined in
Holdsworths classification. Denis concluded that The Thoraco-Lumbar Injury
the middle column had to be disrupted to result in Classification and Severity
System
a clinically significant instability. Four major (TLICS, 2005)
types were defined: compression fracture, burst
fracture, seat belt fracture and fracture-dislocation At present, none of these
classifications has been
(flexion injury). It is often claimed that Denis adopted as a universal
reference, mainly because
classification is incomplete, and does not describe of their poor intra- and
inter-observer reliability
other pathomorphologic fracture types, e.g., the [28]. The latest
classification system described in
lumberjack fracture type, which was however the literature is the
Thoraco-lumbar Injury Clas-
described by himself later in 1992 [20, 21]. sification and Severity
System (TLICS) [29, 30]
that results from another
initially called the
Thoraco-lumbar Injury Sever-
The Load-Sharing Classification (1994) ity Score (TLISS). TLICS is
a spine trauma eval-
uation score that considers
three parameters:
In 1994, McCormack and Gaines described their (1) the fracture
morphology, based on the main
load-sharing classification in an attempt to help mechanisms described in the
AO classification;
748
A.A. Faundez
Comminution/Involvement (A1-3)
A1
B1
1 Little = <30% comminution on sagittal
section CT
2 More = 30%-60% comminution
3 Gross 60% comminution
Apposition of fragments (B1-3)
1 Minimal displacement on axial CT scan

2 Spread = At least 2mm displacement of A2
B2
<50% cross section of body
3 Wide = At least 2mm displacement of
>50% cross section of body
Deformity correction
1 Little = Kyphotic correction 3 on

lateral plain films A3
B3
2 More = Kyphotic correction 4-9
3 Most = Kyphotic correction 10
Fig. 2 The load-sharing classification of Burst fractures (3) reducibility of the

deformity. Each item is given
(Adapted from [22, 23]). The classification was proposed a numerical value.
Originally, the authors concluded that
in an attempt to predict the risk of implant failure in a score equal or
greater than seven represented a high risk
short-posterior segment constructs. Three items are con- of failure of short
segment fixations
sidered: (1) comminution; (2) apposition of fragments;
a b
c
Fig. 3 The AO classification of fractures (with permis- hyperextension; C.

rotational-shear fractures. There is
sion from Aebi et al. [27]). Three major traumatic mech- a progressive scale of
severity of the injury from type
anisms were described: A. flexion-compression fractures; A to type C with a
reported frequency of neurologic deficit
B. distraction injuries, either in hyperflexion or of 14 % in type A, 32 %
in type B and 55 % in type C
(2) the neurologic status; (3) the integrity of the a surgical treatment; a
score of 3 or less,
PLC, inferred by clinical and radiologic exami- a conservative
treatment. For a score of 4,
nation, including MRI (Fig. 4). A numerical either surgical or
conservative treatment can
value is assigned for each injury subcategory, be recommended, also
based on other
depending on the severity of injury. The sum of confounding factors,
such as the age of the
each numerical values is used to guide the treat- patient, amount of
kyphosis, quality of bone,
ment decision: a score of 5 or more suggests etc. [29]. TLICS has
shown improved intra- and
749
Fig. 4 The Thoraco-

Lumbar Injury Category
Points
Classification and Severity
System (TLICS adapted injury morphology
from [29]). The compression
1
classification is based on
three items: (1) Injury burst
+1
morphology;
(2) Neurological status; translational/rotational
3
(3) Integrity of PLC.
distraction
4
A numerical value is
attributed to each item and neurological status
a total score is calculated: if
#3, non-surgical treatment intact
0
is advocated; if #5,
surgical treatment is nerve root
2
recommended; for a score
cord, conus medullaris
of 4, either non-surgical or
surgical treatment can be incomplete
3
decided based on other
confounding factors complete
2
cauda equina
3
PLC
intact
0
injury suspected/indeterminate
2
injured
3
interrater reliability in recent studies, but only applied for AO

fractures of type A1 (impaction
within the group of physicians who developed and wedge
fractures, 5# vertebral kyphotic angu-
the system [30, 31], and further studies are lation). For most
of type A2 (split fractures), we
needed to more widely validate this promising recommend bracing,
usually a three-point
classification system. thoraco-lumbar
orthosis, for 612 weeks,
depending on the
radiologic follow-up. As
already pointed out
by Boehler at the beginning
Non-Surgical Treatment of of the twentieth
century, intensive and immediate
Thoraco-Lumbar Fractures physical therapy
with the brace in place should be
an integral part of
the treatment plan [14]. In the
AO Types A1 and A2 particular case of
the pincer-type fracture (A2.3),
surgical treatment
is recommended because of
With the advent of less-invasive surgical tech- a high risk of non-
union [18].
niques, there will probably be a future shift
towards surgical treatment for lesions that
would have been classically treated conserva- Burst Fractures (AO
Type A3)
tively. Nevertheless, conservative treatment of
thoraco-lumbar fractures still has a role to play There is no
consensus in the literature on the
at present. It can be divided into functional treat- treatment of burst
fractures [23, 32]. In our
ment or bracing with or without external reduc- institution, mainly
complete burst fractures (AO
tion manoeuvres. In our institution, functional A3.3) are treated
surgically. Incomplete burst
treatment (isometric muscular exercises) is fractures with
acceptable sagittal deformity, up
750
A.A. Faundez
to 15# in the thoraco-lumbar junction, can be

handled with a custom-made brace. However, Surgical Treatment
despite an ongoing debate for years over the
amount of tolerable kyphotic deformity of the Surgical Treatment for
Fractures
thoraco-lumbar junction, it is interesting to with Neurological Deficit
note that only recent studies have started to
focus on global sagittal balance and thoraco- As mentioned above, type B
and C injuries usu-
lumbar fractures. Koller and colleagues published ally require surgical
treatment and are character-
a retrospective study analyzing the long-term ized by serious
biomechanical instability and
radiologic and clinical outcome for regional deformity, frequently
accompanied by neural tis-
post-traumatic kyphosis of conservatively-treated sue damage. A treatment
strategy is quite simple
thoraco-lumbar and lumbar burst fractures to define for patients with
immediate and com-
according to the global spino-pelvic alignment plete spinal cord damage. If
any intervention is to
of each patient [33]. They concluded that the be planned, it should be
carried out only once
patients global spine compensates for the vital functions have been
stabilized, keeping in
post-traumatic regional kyphosis within the limits mind that the primary goal
of surgery is to
dictated by their pelvic geometry, in particular the enhance nursing care and
rehabilitation [37, 38].
pelvic incidence. They also found that clinical For incomplete or
progressive lesions, it is
outcome correlated with regional kyphosis. accepted that surgical
decompression and stabili-
Finally, the authors recommended that fractures zation should be performed
within 6 to
with a load-sharing classification score of more a maximum of 24 h from
injury [39]. Posterior
than 6 should be treated by aggressive surgical decompression and
stabilization can be
reconstruction. recommended as a first
emergency procedure.
However, it is not mandatory
that any residual
anterior compression be
relieved as an emer-
AO Fractures Type B and C gency. Even if it is now
suggested that the amount
of canal narrowing is
strongly associated with
Except for type B2.1, also known as Chance severity of the neurologic
deficit [40, 41], it
fracture [34], which can be successfully does not correlate with the
prognosis of func-
treated by bracing, surgical treatment is tional recovery. In other
words, the removal of
recommended for most type B as well as a large intra-canalar bone
fragment will not nec-
type C injuries. Type B and C fractures essarily improve the chances
of neurologic
result from very high energy trauma and recovery.
usually include ligamentous disruptions that
have a very poor healing potential. These
fracture types are also associated wtih neuro- Surgical Treatment for AO
Type A and
logic symptoms in 32 % and 55 % of patients, B Fractures Without
Neurologic Deficit
respectively [18]. As for the strategy of
stabilization and reconstruction, the same The treatment decision for
principles of amount of kyphosis and vertebral tures of AO types A and B
(predominantly osse-
body destruction apply (see chapter Fractures ous injury) without
neurologic deficit remains
with Arterial Injury). It is important to recall, very controversial and it
must recalled that there
however, that not all neurologic symptoms imply is a very real risk to end
up with irreversible
surgical treatment. In a well-done Instructional iatrogenic nerve tissue
damage. However, as
Lecture course, Rechtine lists other similar myths described by Boehler and
others [14, 23, 33],
around treatment indications for thoraco-lumbar there is a rationale to
treat these patients surgi-
fractures [35, 36]. cally given the risk of mid-
to late onset deformity
751
b c
Fig. 5 Chance fracture of L2 (AO type B2.1) in a young avoid external

reduction and bracing. At 2 year follow-up,
male patient involved in a car accident, without neurologic the patient was
symptom-free and the fracture radiologically
deficit. Decision was taken with the patient to surgically healed. (a) Pre-
operative Xray. (b) Post-operative Xray. (c)
treat the fracture using a minimally-invasive technique to Skin incisions at 2
years follow-up
and its possible progressive cord compression the thoraco-lumbar

junction, a maximum of 15#
and/or chronic disabling pain. Indications for sur- of regional kyphosis
(measured between the
gical treatment of fractures without neurologic upper end-plate of
the vertebra above and the
deficit should be based on the amount of defor- lower end-plate of
the vertebra below) is
mity and weighed against its anatomical location, usually tolerated for
non-surgical treatment.
and on the amount of mechanical instability However, it will also
depend on the amount of
inferred by the analysis of radiologic documen- destruction of the
vertebral body. An incomplete
tation, including MRI (fracture classification). As burst fracture (AO
3.1) with 1015# of regional
an example, for burst fractures (AO type A3) of kyphosis will be
treated by external reduction
752 A.A. Faundez
a c
Fig. 6 (continued)
753
and bracing in our institution. But if the burst is and that the cross-
sectional area of the spinal
complete (AO 3.3), reaching a high level of insta- canal recovers up to 87
% of its normal value
bility in compression, we will treat it surgically without surgery [46]. If
an anterior vertebral
[23, 33]. reconstruction is deemed
necessary, it can be
A further decision, even more controversial, done by a classic open
approach, for example
has to be made for complete burst fractures, i.e., the extra-pleural
approach of the thoraco-lumbar
whether a short posterior fusion will be enough or junction, or by a video-
assisted, less invasive
if an anterior approach and vertebral body recon- approach [47]. More
recently, vertebral body
struction is needed, according to the load-sharing augmentation with
calcium-phosphate cement
classification [22]. We continue to use the AO has gained popularity
and might be an alternative
fixateur interne as a posterior stabilization to more aggressive
surgery in fractures without
implant. The technique is based on the principles neurologic injury, but
the risk of intra-canalar
of posterior short segment stabilization and cement extravasation has
to be assessed. In addi-
ligamentotaxis: the indirect reduction of sagittal tion, improvements in
cement resistance are
deformity and intra-canalar bone fragments of the required before it can
be recommended as
posterior wall through posterior longitudinal lig- a routine procedure.
ament (PLL) retensioning [42, 43]. The success Some AO type B
fractures can also be treated
of the technique obviously relies on the integrity either surgically or
non-surgically. Figure 5 pre-
of the PLL. The reverse cortical sign is sents a typical case of
a young male patient who
a radiologic sign corresponding to a 180# flip of suffered a bi-column
fracture (AO type B2.1 or
the postero-superior wall fragment and Chance type). The
accident occurred in an old car
a consequent rupture of the PLL [44]. If present, with only two- point
seat belts and he suffered
this sign normally precludes any efficiency of from splenic and hepatic
contusions, in addition
ligamentotaxis alone for reduction of the frag- to a hyperflexion
fracture. It is known that these
ment and an additional anterior approach for types of fractures with
a predominant osseous
direct decompression should then be considered. instability respond very
well to external reduction
Of note, despite previous recommendations to and bracing [18]. For
various reasons, bracing can
remove intra-canalar bone fragments [45], the be very impractical (hot
weather, very active
compromise of the spinal canal is not in itself an patient, overweight
patient, etc.) and surgery can
indication for surgical treatment in the absence of reasonably be proposed.
However, it is of the utmost
neurologic symptoms [35]. In a mimimum 5-year importance that the
decision is taken together with
follow-up study, Wessberg and colleagues have the patient, and not by
the surgeon alone. As for any
confirmed that intra-canalar fragments stemming other treatment, risks
and benefits have to be
from the posterior wall are subject to remodelling discussed and weighed
against each other.
Fig. 6 A two-level fracture (Chance type of Th7 with discharged from the
intensive care unit, the patient
also some amount of height loss and compression frac- eventually declined to
undergo the cementoplasty and
ture of Th8) in a 57-year-old male patient involved in at 3-month follow-up we
did not observe further verte-
a motorcycle accident. He also sustained multiple rib bral collapse on
radiographs; the patient was also symp-
fractures and a haemo-pneumothorax precluding any tom-free. (a) Pre-
operative CT scan re-formatting
bracing technique. To stabilize the fractures while eas- showing the hyperflexion
type of injury with fracture
ing nursing care, we performed a multiple-level percu- of posterior elements.
(b) Intra-operative picture of
taneous pedicle screw fixation. Blood loss was minimal percutaneous pedicle
screw and rod insertion. The frac-
and the patient recovered from surgery uneventfully. ture was stabilized in
situ. No additional fusion was
Initially, we had planned to also provide a cement aug- necessary as the lesion
was predominantly osseous. (c)
mentation to the vertebral bodies, but for technical Post-operative lateral
X-Ray at 3 months. The patient
reasons it could not be done simultaneously. Once was symptom-free
754
A.A. Faundez
Less-Invasive and Recent Surgical Recent Developments in

Techniques Computer-Assisted Surgery
Major improvements have been made during Development of less invasive

surgical treatment
the past decade in spine surgical techniques techniques for thoraco-lumbar
fractures is
and new instruments have been developed to appraisable for
polytraumatized patients, to
insert implants through small incisions. For decrease further tissue trauma
and bleeding for
instance, surgeons have acquired an expertise instance. Less invasive
techniques have also
in endoscopic treatment of vertebral fractures broadened the spectrum of
treatment possibilities
and extensive exposure of the thoraco-lumbar for fractures without
neurological deficit, which
junction is no longer necessary to perform were usually treated
conservatively. But proce-
corpectomies and vertebral reconstructions dure safety becomes a major
concern with
with structural allografts or cages [47]. Pedicle narrowing of the surgical
field and use of indirect
screws can also be inserted percutaneously, with techniques.
the consequence of lowering blood loss and Thus additional intra-
operative imagery
operative time. An example of a fracture treated becomes mandatory. It has to
be accurate, reli-
by percutaneous pedicle screws and rod place- able, but not expose the
patient to increased radi-
ment is shown in Fig. 6. A technique that has ation doses.
recently gained popularity is cement augmenta- Improved computer-assisted
surgery (CAS)
tion of the vertebral body. It has been used for tools have emerged in recent
years meeting
treatment of osteoporotic fractures for a long these goals. In our
institution, acquisition of an
time, but only more recently for high energy O-ARM (Medtronic, Memphis,
USA), which
spine fractures [48]. A few prospective non- allows us to perform an intra-
operative CT-scan
randomized and non-controlled studies have and traditional scopic images,
profoundly
been published and suggest that stand-alone ver- changed our surgical practice
in spinal trauma.
tebral body augmentation with calcium phos- Surgical navigation with
modern infra-red cam-
phate cements might become an alternative to eras, to insert pedicle screws
has become much
bracing in non-osteoporotic AO type A1 up to easier. Immediate verification
of screw position
A3.1 fractures [49, 50]. Bone resorption around and. fracture fragments
reduction also represents
the calcium phosphate cement has been reported a major breakthrough.
in type A3.2 and A3.3 fractures and, for this In addition, these new
navigation tools allow
reason, it probably should not be recommended us to better plan and perform
tumoural resections,
in these types as a stand-alone technique. An whether primary, like osteoid
osteomata, or
additional posterior short segment construct could metastases.
be added percutaneously to increase stability
and avoid possible complications from cement
resorption [51]. Other cement compositions are Navigation for Percutaneous
Pedicle
being currently tested, for instance, calcium Screw Placement
phosphate cements with various Amounts of
poly-methyl-methacrylate (PMMA) as well as Percutaneous pedicle screw
stabilization of
ceramic cements. However, at present, there are a thoracolumbar fracture
follows the principle
not sufficiently clear data in the literature to of internal splinting. This
means, that fusion
recommend cement augmentation as a routine is usually not the goal,
otherwise either a larger
procedure for non-osteoporotic thoraco-lumbar classic incision is to be
done, or an additional
fractures. mini- invasive technique has
to be performed to
755
fuse the posterior facet joints. pedicle screw ligament and if the images are
equivocal, we
insertion should be limited to fractures without would not recommend
stabilization without fusion.
posterior ligament complex (PLC) injury. Typical indications for
percutaneous pedicle
Because fusion is not possible, indications for screw stabilization would be
percutaneous, MRI is thus mandatory to exclude tures AO type A3.2 and A3.3,
in combination with
complete rupture of especially the supraspinous cement vertebral body
augmentation [51].
Fig. 7 (continued)
756 A.A. Faundez
Fig. 7 (continued)
757
Navigation for Combined Approaches simultaneous posterior and

anterior approaches
in Thoraco-Lumbar Fractures for AO type A3.3 thoracolumbar
fractures with
indications for a corpectomy.
With a dynamic
Surgical navigation and intra-operative imaging reference base attached to a
spinous process of
are extremely helpful tools to optimize surgical the patient, as close as
possible to the fracture,
technique safety. For some time now, we navigation can first be used to
insert pedicle
have been using surgical navigation to perform screws, percutaneously or by an
open technique.
Fig. 7 (continued)
758
A.A. Faundez
Fig. 7 (ad): patient is placed in right lateral position. percutaneously. (e

g): exposure of the anterior approach
The reference frame is attached to the spinous process of is planned with the
help of navigation. Intra-operatively,
L3, the fracture is at the level L2 (Burst fracture, patient navigation is also
used to locate the intra-canicular frag-
had some left leg paresthesia). Pedicle screws are inserted ments and ease
removal
At the same time, after having planned the posi- distal to the
fractured vertebra. For fractures
tion,a second surgeon can start the anterior below L4, the sacral
pad and the lumbar lordosis
approach and length of the incision using the could hide the the
reference frame from the infra-
projection of a navigated pointer on the intra- red camera, impeding
accurate navigation. The
operative CT scan images (Fig. 7). frame can be placed
on the posterior iliac crest,
The most efficient way to reduce a kyphotic but this could
decrease accuracy because of the
deformity is by blocking the sliding of the pedicle distance from the
fracture. Navigated instruments
screws on the rod and sagittaly diverging them, are calibrated, the
CT scan is done and the
which is usually referred to as ligamentotaxis. OARM is pulled out
during the surgery. Pedicle
Different sets of tools to achieve this goal are screws are inserted
percutaneously, any kyphosis
available, according to the rod and screw system reduced by shaping
the rod adequately or by
used by the surgeon. If an significant reduction ligamentotaxis when
possible. The reference
has been obtained, it would be recommended frame is left in
place and the anterior surgical
to repeat the intra-operative CT scan before incision drawn by
using the navigated pointer to
carrying on with the anterior approach and aim at the fracture
and thus planning the adequate
corpectomy, as the accuracy of navigation could surgical incision
and exposure. In the example
be challenged. shown, the fracture
was at the level L2 in a male
patient with a very
large psoas muscle. After
placing retractors,
navigation was very helpful
Surgical Technique for Combined to dissect the
muscle while taking care of the
Anterior-Posterior Approach of lumbar nerve plexus.
Navigation was again effi-
Thoraco-Lumbar Fractures cient in helping to
perform the corpectomy in
a narrow surgical
field.
We start with pedicle screw insertion. The patient For fractures at
the level L1 or T12, we
is placed in a right lateral position on a Jackson approach the
fracture through an extrapleural
table. We use pubic and sacral pads to stabilize phrenectomy. Theres
thus no need for a chest tube.
the patient and an inflatable cushion under the The surgical
technique for this combined
right axilla. The dynamic reference frame is approach shown here
is for treating fractures
attached to the spinous process immediately from T5 to L3 (Fig.
7).
759
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compared with optimal pain medication
with nonoperative treatment of a thoracolumbar burst treatment:
short-term clinical outcome of patients with
fracture without neurological deficit. A prospective, subacute or
chronic painful osteoporotic vertebral
randomized study. J Bone Joint Surg Am. 2003;85-A compression
fractures. The VERTOS study. AJNR
(5):77381. Am J
Neuroradiol. 2007;28(3):55560.
33. Koller H, Acosta F, et al. Long-term investigation of 49. Maestretti G,
Cremer C, et al. Prospective study of
nonsurgical treatment for thoracolumbar and lumbar standalone
balloon kyphoplasty with calcium phos-
burst fractures: an outcome analysis in sight of phate cement
augmentation in traumatic fractures.
spinopelvic balance. Eur Spine J. 2008;17(8):107395. Eur Spine J.
2007;16(5):60110.
34. Chance GQ. Note on a type of flexion fracture of the 50. Schmelzer-
Schmied N, Cartens C, et al. Comparison
spine. Br J Radiol. 1948;21(249):452. of kyphoplasty
with use of a calcium phosphate
35. Rechtine GR. Nonsurgical treatment of thoracic and cement and
non-operative therapy in patients with
lumbar fractures. Instr Course Lect. 1999;48:4136. traumatic non-
osteoporotic vertebral fractures. Eur
36. Rechtine 2nd GR. Nonoperative management and Spine J.
2009;18(5):6249.
treatment of spinal injuries. Spine (Phila Pa 1976). 51. Verlaan JJ,
Dhert WJ, et al. Balloon vertebroplasty in
2006;31(11 Suppl):S227; discussion S36. combination
with pedicle screw instrumentation:
37. Capen DA. Classification of thoracolumbar fractures and a novel
technique to treat thoracic and lumbar burst
posterior instrumentation for treatment of thoracolumbar fractures.
Spine (Phila Pa 1976). 2005;30(3):E739.
fractures. Instr Course Lect. 1999;48:43741. 52. van der Roer
N, de Bruyne MC, et al. Direct medical
38. Harris MB, Sethi RK. The initial assessment and costs of
traumatic thoracolumbar spine fractures. Acta
management of the multiple-trauma patient with an Orthop.
2005;76(5):6626.
Kyphoplasty - the Current
Treatment
for Osteoporotic Vertebral
Fractures
Guillem Salo
Contents
Abstract
761 Vertebral osteoporotic fractures are the most
frequent fractures in older patients with low

Indications for Kyphoplasty . . . . . . . . . . . . . . . . . . . . . . . 762
mineral bone density. Kyphoplasty is

a technique that tries to recover the height of
765 the fractured vertebral body and support this
fracture with the injection of cement into the

vertebral body. This procedure is usually

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 771 performed percutaneously and requires appro-
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 772 priate training so as to avoid potential compli-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 773 cations. This chapter reviews the indications,
pre-operative preparation and planning,
operative technique guidelines, post-operative
care and rehabilitation and the complications
that might appear during and after this
procedure.
Keywords
Complications # Indications for surgery #
Kyphoplasty # Minimally-invasive surgery #
Osteoporotic vertebral fractures # Oper-
ative technique-inflatable bone tamps #
Rehabilitaion # Vertebral augmentation

Osteoporosis is the most common metabolic bone
disorder. It affects two hundred million individ-
uals worldwide [1]. Vertebral compression frac-
tures are a frequently encountered clinical

G. Salo
problem in these patients and are becoming

Orthopaedic Department, Spine Unit, Universitat
Auto`noma de Barcelona, Barcelona, Spain
increasingly more important as the median age
e-mail: Gsalo@hospitaldelmar.cat
of the population continues to rise. Patients with

761
DOI 10.1007/978-3-642-34746-7_26, # EFORT 2014
762
G. Salo
painful vertebral compression fractures may have Table 1 Summary of

guidelines for percutaneous
severe pain for prolonged periods of time. When vertebroplasty and
percutaneous kyphoplasty according
to the Society of
Interventional Radiology and Cardiovas-
such a fracture does cause pain, it can usually be cular and Interventional
Radiological Society of Europe
successfully managed with a combination of
Indications
medications, activity modification, and occasion-
Painful osteoporotic VCF
refractory to 3 weeks of
ally bracing [2]. In a patient who does not analgesic therapy
respond to this initial treatment, an internal Painful vertebrae due to
benign or malignant primary
splinting of the vertebral body with percutane- or secondary bone tumours
ously injected methylmethacrylate may provide Painful VCF with
osteonecrosis (Kummells disease)
adequate pain relief that allows the patient to Re-inforcement of
vertebral body before surgical
return to his or her previous level of functioning. procedure
Chronic traumatic VCF
with non-union
In this way, the key principles of the percutane-
Absolute contra-indications
ous cement augmentation techniques are the
Asymptomatic VCF
immediate stabilization of vertebral body frac-
Patient improving on
medical therapy
tures to decrease pain or prevent further collapse
Active infection
of the vertebral body. Prophylaxis in
osteoporotic patient
Percutaneous kyphoplasty is the placement of Uncorrectable
coagulopathy
balloons in the vertebral body with a one-off Myelopathy secondary to
retropulsion of bone/canal
inflation/deflation sequence that creates a cavity compromise
before the cement (generally polymethyl- Allergy to PMMA or
opacification agent
methacrylate) is injected. This procedure is Relative contra-indications
most often performed percutaneously on an out- Radicular pain
patient (or short-stay) basis. Kyphoplasty was VCF > 70 % height loss
developed in an attempt to reduce the deformity Severe spinal stenosis,
asymptomatic retropulsion
of the vertebral body and subsequent kyphosis Tumour extension into
canal/epidural space
while providing pain relief similar to that pro- Lack of surgical backup
vided by vertebroplasty [212]. This should
decrease the associated risks related to the defor-
mity, increase filling control, stabilize the verte-
bra and, thereby safely decrease pain and [1621] or lytic tumours,
such as plasmocytoma
improve mobility [12]. or multiple myeloma [22],
metastasis [23] and
The exact mechanism of the analgesic effect painful hemangiomata [24].
Evidence favours
of vertebral augmentation remains unclear. Some the use of this procedure
for the pain associated
investigators attribute the reduction of pain to the with these disorders. The
indications and contra-
toxic and/or thermal effect of the polymethyl- indications of this
procedure are summarized in
methacrylate (PMMA) cement by the destruction Table 1. Indications for
kyphoplasty in osteopo-
of nerve fibres [13, 14]. A more mechanical view- rotic fractures extend to
vertebral fractures of
point attributes the effect to the fixation of less than 8 weeks with an
increasing deformity
fragments and reduction of micro-motion and of the vertebra. This is so
even in cases of sig-
the associated irritation of periosteal nerve nificant posterior wall
disruption as well as in
fibres [15]. fractures with non-union
with an intravertebral
vacuum phenomenon [25, 26].
In the classifica-
tion by Magerl, the
fractures thereby suitable for
Indications for Kyphoplasty augmentation are the A1.1
(end-plate impres-
sion), the A1.2 (wedge
fracture), the A1.3 (ver-
Percutaneous vertebral augmentation (verte- tebral collapse) and the
A3.1 (incomplete
broplasty or kyphoplasty) is indicated for pain- burst fracture) types. A new
indication for
ful osteoporotic vertebral compression fractures kyphoplasty in combination
with posterior
Kyphoplasty - the Current Treatment for Osteoporotic Vertebral Fractures
763
short-segment instrumentation has recently been

described for the treatment of patients with trau- Pre-Operative Preparation
matic burst fractures (non-osteoporotic). This and Planning
combination has proven to provide good results
[2732]. Patients with a
symptomatic vertebral fracture
The exclusion criteria for balloon typically present with
severe back pain following
kyphoplasty include vertebral fractures that a minor injury [37]. The
pain is made worse by
are not painful or that are not the primary standing erect and
occasionally even by lying flat.
source of pain, the presence of local or sys- The spine shows
exaggerated thoracic kyphosis
temic infection, arterio-venous malformations, and the pain is typically
reproduced by deep
bone fragments retropulsed into the vertebral pressure over the spinous
process at the involved
canal or an epidural extension of a tumour level. Neurological
deficits are rarely associated
[26]. Balloon inflation for the kyphoplasty with these fractures, but
they must always be
procedure might force material into the spinal ruled out [37, 38].
canal and thus cause cord compression. Pre-operative planning
includes obtaining
There are also relative contra-indications to a detailed history and
performing a thorough
kyphoplasty. physical examination [39].
The proper identifica-
First, there must be sufficient residual height tion of the painful
vertebrae can sometimes
for the instruments used with kyphoplasty to be be difficult and the
patients symptoms need
inserted in the compressed vertebral body. to be linked to the
vertebral compression
Second, small pedicles may also be a limiting fracture. Diagnostic
studies usually include
technical factor. When the pedicles appear to be anteroposterior and
lateral plain X-rays of
too small to accommodate the instruments, the spine and magnetic
resonance imaging
a parapedicular approach can be utilized. (MRI) [39].
Kyphoplasty can be performed safely from L5 Radiographs show the
osteopenia characteris-
to T7 in most patients [33]. tic of these patients
[40]. The vertebral body
Third, this technique is not recommended shows a fracture with loss
of height and wedging
in high-energy injuries with concomitant ligamen- and occasionally
retropulsion of osseous frag-
tous or posterior element injury. In this case, ments into the spinal
canal. Fractures commonly
posterior instrumentation should be added. occur in the thoracolumbar
region, but they may
Controversy exists concerning the be present anywhere in the
spine [40]. If non-
specific indications for kyphoplasty as opposed union of a fracture is
suspected, flexion and
to vertebroplasty [34]. As a review of the extension lateral X-rays
can be helpful in
literature shows, the pain relief and assessing the degree of
fracture healing and
biomechanical stability resulting from both mobility. Magnetic
resonance imaging of the
procedures are comparable [35] although other spine is probably the
single most useful test for
factors need to be taken into account in determining fracture age,
the ruling out of
choosing one of these techniques over the a malignant tumour and
selection of the appro-
other. Fracture reduction and restoration of ver- priate treatment [41]. MRI
has the advantage of
tebral body height may be achieved through revealing additional
spinal conditions that may
kyphoplasty. However, severe loss of height contribute to the pain
syndrome; in particular
and an older fracture age may limit the afore- degenerative spinal
disease, infections, injury
mentioned effects to a minimum [35]. The of the disk or ligaments.
In the acute
most valuable effect achievable through period following a
vertebral fracture, magnetic
kyphoplasty is the markedly reduced rate of resonance imaging shows a
geographic pattern
cement leakage [36] through the injection of of low-intensity-signal
changes on T1-weighted
high-viscosity bone cement into the cavity that images and high-intensity-
signal changes on
is created. T2-weighted images [41].
In addition to that,
764
G. Salo
Fig. 1 T1-weighted,
T2-weighted and Short Tau
Inversion Recovery (STIR)
magnetic resonance image
showing increased signal
through the L2 vertebrae,
suggesting a recent fracture
fat-signal suppressing STIR (short tau inversion anterior vertebral cortex

and a burst fracture
recovery) of the MRI is particularly helpful in in that the posterior wall
is fractured as
differentiating between fresh and healed fractures well [43].
[41] (Fig. 1). The character of the
fracture and bone quality
Scintigraphy in combination with CT can also must be assessed during the
pre-operative evalu-
be used as an alternative to locate the affected ation [21]. In the
osteoporotic vertebrae with
vertebrae in patients with a contra-indication to a rarefied trabecular
structure, fractures tend to
MRI, such as brain aneurysm clips or cardiac result in varying degrees of
vertebral body col-
pacemakers [42]. Scintigraphy provides useful lapse with possible
retropulsion of the posterior
information about bone turnover and thereby iden- wall into the spinal canal.
In contrast to fractures
tifies any vertebral fracture that has an on-going in non-osteoporotic
vertebrae, splitting or severe
healing process. Bone scans are sensitive enough fragmentation occur less
frequently. A secondary
for the detection of fractures, but they have low indicator of posterior wall
compromise is the
specificity for the diagnosis of another underlying presence of an epidural
haematoma. This sug-
disease. An additional limitation of bone-scanning gests that the fracture
communicates directly
is that increased bone turnover can be detected as with the epidural space and
thus may be
long as 2 years following a vertebral fracture [42]. a conduit for cement
leakage. Percutaneous
The long term bone turnover period shown on kyphoplasty should only be
pursued with great
scintigraphy limits the ability of a bone scan to caution. The likelihood of
restoring vertebral
demonstrate the acuity of an osteoporotic vertebral body height depends largely
on the density of
fracture and is not helpful in determining the the bone and the acuteness
of the fracture [18].
source of the pain or the predictability of the Fractures treated within 13
weeks of the event
response to treatment. are much less likely to have
experienced substan-
Computed tomography (CT) scan provides tial healing and provide the
best opportunity for
excellent detail of the bony structures and is the height restoration.
best imaging procedure for assessing the verte- Vertebral compression
fractures can be
bral body deformity and the posterior wall and caused by pathological
conditions. Unless the
end-plate involvement. Furthermore, it is neces- diagnosis of osteoporosis is
well-established,
sary to precisely classify the fracture type. a biopsy is recommended. In
patients who have
It is also important to distinguish between a dual-energy x-ray
absorptiometry (DEXA)
a compression fracture with a collapse of the study consistent with
osteoporosis, no history
765
of malignancy, and a previously known osteopo-

rotic vertebral compression fracture, a biopsy is not
necessary.
Operative Technique
The patient should be placed in a prone position

on a radiolucent surgical table. Gentle lordotic
positioning allows some postural reduction
in certain fractures. The procedure can be
performed with local anaesthetic in many
patients, but the patient should be able to lie
prone for at least 1 h without significant pain or
respiratory difficulties [44]. The anaesthetic
injection under the periosteum at the entry point
decreases pain during trocar insertion and is
recommended even in patients under general Fig. 2 Operative set-up
for the percutaneous
anaesthesia for peri-operative and post-operative Kyphoplasty under bi-
planar fluoroscopic guidance, with
positioning of the patient
and typical arrangement of the
pain control. A gentle intravenous sedation can both C-arms
be added to decrease pain during the procedure. If
general anaesthesia is utilized, the patient must be
handled gently. Rib fractures may occur as vertebral body should be
equidistant from both
a result of undue pressure in the course of patient pedicles and the spinous
process should be
positioning and during impacting manoeuvres to centred between the
pedicles (Fig. 3). Caution
insert the trocar into the thoracic vertebral body should be exercised when
using the spinous pro-
[45]. During multi-level injections, the cement cess to obtain a true AP
image because there is
load is greater. Toxic monomeric constituents a significant anatomical
variation in the shape of
have the potential to cause cardio-respiratory the spinous process [49].
Intra-operative fluoro-
collapse. The anaesthetist must be alert at the scopic imaging of the mid-
thoracic spine can be
time of each injection procedure. Vasoactive sub- challenging in the severe
osteoporotic patient. The
stances to treat sudden hypotension must be read- image can be improved by
halting respiration and
ily available [14, 4446]. bringing the x-ray tube
closer to the patient. This
The use of bi-planar fluoroscopy greatly magnifies the image and
decreases beam scatter.
aids cannula insertion and cement injection The entry point to the
pedicle is marked using
[44, 47, 48]. Bi-planar fluoroscopy is readily high-quality bi-planar
images. It is necessary to
obtained by using two separate C-arms (Fig. 2). obtain a true AP view of
the pedicle with an oval
The lateral image is bought over the top and the shape in order to avoid
lesions of the surrounding
arc, leaning away toward the patients head. The neural structures (Fig.
4). A trocar needle is
anteroposterior image is brought in diagonally inserted into the
vertebral body either with
with the image intensifier directly over the target a transpedicular or
extrapedicular approach
site. It is most convenient to obtain a true (Fig. 5). The
transpedicular approach is best
anteroposterior image first because the diagonal suited for large pedicles
such as those in the
entry makes this process challenging. Meticulous lumbar and lower thoracic
spine. Localization
attention should be paid to obtaining true of the pedicles is
performed in a manner similar
anteroposterior and lateral images of the target to that used for
vertebroplasty. A posterior
vertebrae. On the AP plane, the pedicles should approach with a slight
ipsilateral obliquity
be symmetrical in shape. The lateral edge of the of 1025# is preferred
[4951]. The medial wall
766
G. Salo
Fig. 3 Intra-operative
fluoroscopy. The AP view
is adjusted with the spinous
process of the targeted Pedicles in the
vertebral body in the exact superior area
mid-line, end-plates of the
parallel and pedicles placed vertebral body
Parallel
symmetrically in the upper
vertebral
lateral quadrant of the
endplates
projection of the vertebral
body. The lateral view is Spinous
adjusted with pedicles apophysis
superimposed, end-plates equidistant
parallel and the posterior to both
wall aligned with a single pedicles
contour
Parallel
vertebral
endplates
Superimposed
pedicles
of the pedicle must be well visualized. The First, is necessary to

place the needle (usually
extrapedicular approach is best suited for an 11-G Jamshidi needle) at
the pedicle entry site
the mid-thoracic spine. The entry point for at the angle between the
upper articular process
the extrapedicular approach lies between the and the transverse process
[44]. The needle tar-
lateral edge of the pedicle and the costovertebral gets a starting point just
superior and lateral to the
joint [44, 45, 48]. The rib head helps pedicle. One must be
cautious to avoid injuring
direct the needle into the vertebral body. the exiting nerve roots and
the beginning point
The extrapedicular approach allows a trajectory must not be so far lateral
as to puncture the bowel
more latero-medial, thereby accessing the central or kidney [45]. Oblique
views should also be used
portion of the vertebral body. The approach is to confirm proper
positioning. The needle should
usually bilateral. However, adequate cement pass through the pedicle
centre without perforat-
distribution into the vertebral body can be ing the medial pediclar
cortex, and go on to enter
accomplished through a unilateral injection site the vertebral body. Only now
does the tip of the
with this technique. needle cross the projection
of the medial pediclar
The kyphoplasty procedure requires an 11- cortex, as viewed from the
rear. The optimal final
or 13-gauge bone entry needle, a scalpel, placement of the needle
should be in the anterior
a kyphoplasty kit, inflatable balloon tamps, sterile third of the vertebral body
[47].
barium sulphate or another opacifier, and After needle insertion,
the trocar is removed.
bone cement. The surgical steps involved in A Kirschner wire is then
directed through the
transpedicular placement of a kyphoplasty bal- needle and into the bone to
act as a guide-wire.
loon are shown in Fig. 6. The cannula is inserted over
the guide-wire and
767
a b c
Fig. 4 (a) X-ray of a patient with a good visualization a bad visualization of

the cross section of the pedicles in
of the cross-section of the pedicles in the AP view. the AP view. In this
case, is not possible to perform
(b) Anatomical coronal cut across the pedicles, showing a safe technique and we
recommend that the procedure
the neural structures around the pedicles that we must be aborted because there
is a high risk of neurological
avoid during the procedure. (c) X-Ray of a patient with injury
a b
Fig. 5 Axial view demonstrating the trajectory of the approach, the needle
follows the junction of the rib and
needle in a transpedicular approach (a) and in transverse process of the
vertebra and enters the vertebral
a parapedicular approach (b). In the parapedicular body along the lateral
margin of the pedicle
768
G. Salo
a b
c d
e f
Fig. 6 Schematic diagram of a transpedicular cannulated trocar via

guide-wire. (e) Positioning the
kyphoplasty of a lumbar vertebral body. The surgical kyphoplasty balloon
in the drilled channel in the fracture
steps involved are: (a) placing the biopsy needle at the zone. Pressure-
controlled inflation of the kyphoplasty bal-
pedicle entry site at the angle between the upper articular loon and the
simultaneous gain in height of the vertebral
process and the transverse process. (b) Kirschner wire fed body. (f) The cavity
that remains after the kyphoplasty
through the biopsy needle and acting as a guide. (c) The balloon has been
removed is filled with high-viscosity
biopsy needle is removed. (d) Introduction of the augmentation material
through the cannula
into the vertebral body. The operating surgeon a mallet can be used
to tap the plastic handle,
should always have control of the proximal end driving the cannula
into the vertebral body [47].
of the Kirschner wire because the sharp tip could The cannula is
inserted approximately 23 mm.
easily and inadvertently penetrate soft bone and past the posterior
vertebral body wall. If there is
breach the anterior vertebral cortex [44]. A skin considerable
resistance to placing the working
incision is then made to accommodate the work- cannula, the cannula
handle can be rotated in an
ing cannula, which is advanced through the soft alternating
clockwise-counter clockwise motion
tissues and through the pedicle to rest at the to help breach the
cortex and facilitate advance-
posterior aspect of the vertebral body. A plastic ment [46, 49]. The
guide-wire is removed and
handle can be placed on the hub of the cannula to a drill is used to
create a path for the inflatable
advance it manually into the vertebral body, or balloon tamp. If a
biopsy is needed, a biopsy
769
trocar is used to sample the vertebral bone prior to Table 2 End-points of

balloon inflation during
drilling the vertebral body. A 3 mm. drill is kyphoplasty
advanced through the cannula and multi-planar 1. Restoration of the
vertebral body height to normal
fluoroscopy is used to re-check the orientation of position
2. Flattening of the
balloon against an end-plate without
the working cannula. The drill is then ideally
accompanying height
restoration
directed along a slightly posterolateral to 3. Appearance of a small
outward bleb in the balloon
anteromedial trajectory into the vertebra until 4. Contact with a lateral
cortical margin
the tip of the drill is 3 mm. posterior to the 5. Inflation without
further pressure decay
anterior margin of the vertebral body [47]. 6. Reaching the maximum
volume of the balloon
Extreme caution should be used to avoid 7. Reaching the maximum
pressure of the balloon
breaching the anterior cortex of the vertebral
body with the drill. For bilateral transpedicular
or extrapedicular approaches, the sequence of
events is repeated on the contralateral side [47]. a practical maximum of 220
psi. The possible
After this, the kyphoplasty balloon is posi- end-points of inflation
are shown in Table 2.
tioned in the drilled channel in the fracture The operating surgeon must
maintain both visual
zone. If the clinician feels resistance in the pas- and manual control
throughout the entire inflation
sageway of the drilled hole, perhaps secondary to process and should record
the amount of fluid
small shards of bone, the drill or bone filler device used to inflate the
balloon when the end-point
can be inserted and withdrawn once or twice has been achieved [47].
This volume indicates
along the path to clear it of debris. Thereupon, the size of the cavity
that has been created and it
the balloon tamp can be inserted without will serve as an estimate
of the amount of cement
difficulty. The inflatable balloon tamp is avail- to be delivered. In some
cases, reduction of the
able in different sizes. Each balloon has markers vertebral body can be
accomplished. If substan-
to delineate its distal and proximal extents. Once tial height restoration
has not been achieved,
both balloons are in the vertebral body, they are careful repositioning of
the bone tamps and re-
pressure-controlled inflated with a radio contrast inflation can be helpful
[45]. The reduction
medium (for visualization) simultaneously under manoeuvre is best
accomplished when the
bi-planar fluoroscopy so as to gain height of the balloon pushes up against
the end-late and
vertebral body. The inflatable bone tamp com- shows a flattened
appearance on fluoroscopic
pacts the cancellous bone and re-expands image. When positioned
properly, this technique
the body. Before inflation, air is purged from the elevates the end-plates
without expanding
balloons, and the reservoir of an angioplasty the fractured vertebral
body laterally or posteri-
injection device (incorporating a pressure moni- orly. Two balloons are
generally used to provide
tor) is filled with 10 ml. of diluted iodine contrast a greater reduction.
Rupture of the balloon
material. Inflation via the injection device is (who rarely occurs) is not
a hazard, other than
begun under continuous fluoroscopy, increasing that of exposure to small
volumes of radio con-
balloon pressure to approximately 50 psi. to trast medium. If a balloon
ruptures, it is simply
secure the balloon in position. Balloon inflation withdrawn through the
working cannula and
should be performed slowly and progressively by replaced. The inflation of
the balloon should be
half-millilitre increments. There should be fre- stopped before causing a
cortical fracture, which
quent pauses to check for pressure decay, which is revealed by the
appearance of a small outward
occurs as the adjacent cancellous bone yields and bleb in the balloon [44].
compacts [49, 50]. If the bone is osteoporotic, The cavity that
remains after the kyphoplasty
pressure decay may be immediate. If the bone is balloon has been removed
is filled with high-
quite dense, there may be little or no pressure viscosity augmentation
material through the can-
decay, even at pressures up to 180 psi. nula and the cement can be
deposited under low
The balloon system is raised to 180 psi., with pressure. Once adequate
inflation has been
770
G. Salo
achieved, the cement is mixed in a manner simi- then drilled, the balloon
tamp deployed, and the
lar to that for vertebroplasty. The cement mixture cement injected. The next
level is then drilled,
is transferred to a bone filler device [14]. Once the treated with the balloon
tamp, and subsequently
bone cement has undergone transition from injected. A third site
can be treated thereafter in
a liquid to a cohesive, doughy consistency the same sequence. This
step-wise sequence allows
(about 5 min after mixing, depending on the use a single pair of
balloon tamps for the treatment
cement), the bone filler devices are passed multiple levels. The
limitation of the number of
through the working cannula and into the anterior levels is dictated by the
cement load. The risk of
aspect of the vertebral cavities. Small volumes of cement toxicity increases
with the number of levels
cement (about 0.5 cm [3]) are injected in a step- treated. As a general
rule, no more than three levels
wise fashion with fluoroscopic visualization. The should be treated during
a single procedure [44].
volume of cement for injection is approximately Maintenance of
reduction can be difficult in
1 ml. more than the volume of the cavity created certain fractures,
particularly in fractures with an
by each inflatable balloon tamp [52]. In addition intravertebral vacuum
phenomenon. Once
to filling the void created by the ballon tamp, a balloon is deflated,
the fracture may collapse
additional cement is needed to allow integration again. The reduction can
be maintained by the
of the cement into the surrounding trabecular eggshell technique
[44]. A small amount of
bone. This serves to lock in the cement. cement (0.51 cm3) is
injected into the cavity.
If a quantity of cement is equal to or less than The balloon tamp is re-
inserted and gently re-
the volume of the cavity, the vertebra will not be elevated. The small
cement bolus is then spread
re-inforced and may lead to further re-collapse of around the balloon to
create a thin eggshell of
the surrounding bone due to excessive motion at cement. When the balloon
is removed, the egg-
the bone-cement interface. The cement should shell mantle holds the
reduction until the remain-
be injected into the anterior two-thirds of the der of the cement is
injected. This technique can
vertebral body and the cavity should be filled also be utilized to
control cement leakage [44].
from the anterior to the posterior aspect of When cement filling
of the cavity has been
the vertebra. By avoiding the posterior one confirmed
fluoroscopically from both the lateral
third, the risk of cement leakage into the spinal and anteroposterior
views, the bone filler devices
canal is minimized [46]. Continuous fluoroscopic are partially withdrawn
to allow complete filling
monitoring is maintained to identify leakage of of the cavity. They are
then used to tamp the bone
cement into the spinal canal, paraspinous veins, cement in place before
being completely with-
inferior vena cava, or disc space [49]. When drawn. The patient
remains prone on the table and
cement leakage is observed, injection should be is not moved until the
remaining cement in the
halted immediately. The cannula is re-positioned mixing bowl has hardened
completely [15].
to another location and another attempt at injec-
tion may be pursued after adequate time has
passed to allow the first injection to polymerize. Post-Operative Care
In most cases, cement leakage is clinically incon- and Rehabilitation
sequential. If a significant leak is suspected,
a wake-up test is performed prior to departing The patients can be
mobilized immediately after
the operation room. If there are clinical signs and surgery without
restrictions and without external
symptoms of neurologic compromise, emergency support. When calcium
phosphate has been used,
decompression should be considered. we prescribe 12-h bed-
rest as the process of hard-
Treatment of multiple levels can be performed ening takes longer [44].
using a single batch of cement. The cement is Pain relief occurs
within 1 or 2 days in most
stored in a sterile ice-water bath to slow the poly- cases and it has been
correlated with fracture reduc-
merization process. The guide-wires are inserted tion. The patient is
dismissed with routine pain
into all the target vertebral bodies. The first site in medications and a
graduated resumption of activity.
771
Discharge instructions for the patient should Complications related

to the technique
include: a call to the physician for the onset include, post-operative
epidural bleeding, injury
of new back pain, chest pain, lower extremity to the neural elements,
temporary radicular pain,
weakness or fever. The first follow-up after the vascular injuries, dural
tears and rib, pedicle or
procedure is at 1 week [47] and after this the sternum fractures. Rib
fractures are also known to
patient should come back to the office at happen as a result of
pressure on the back and
1 month and at 3 months after the procedure. chest occurring during
needle placement while
Six months after the procedure the patient can the patient is prone [58].
New osteoporotic rib
be definitively discharged. fractures are thought to
occur when the patient is
As vertebral augmentation techniques cannot placed in prone position
on the table for and
be shown to reduce the rate of further vertebral during the procedure.
However, they might sig-
fractures, additional medical treatment for osteo- nificantly bias the
clinical outcome relative to
porosis and physiotherapy are required [49]. pain relief and should be
treated with analgesic
medications for an
appropriate period. Pedicle
fractures may be a primary
finding of the verte-
Complications bral compression or might
be induced by the
passage of the cannula
during the procedure.
The overall risks of the procedure are low, but Complications resulting
from improper needle
serious complications (including spinal cord placement or inattention
to fluoroscopic patterns
compression) can occur. With good patient selec- of cement distribution
during injection are depen-
tion and careful technique, these complications dent on operator training
and experience.
are avoidable and make the risk-to-benefit ratio Complications
secondary to extrusion of
highly favourable [53, 54]. cement include pulmonary
embolism and nerve
Early complications of kyphoplasty are or spinal cord compression
by cement. The most
divided in three groups: frequent problem is a
transient radicular pain due
(a) systemic complications to cement leakage into the
radicular veins in
(b) local complications related to the technique proximity to the vertebral
foramina. Cement
or to the placement of hardware in an incor- leakage into peridural
veins can, in the worst
rect location case, lead to para- or
tetraplegia by compression
(c) local complications due to extrusion of of the thecal sac and its
contents. In a group of
cement outside of the vertebra. thirty patients who
underwent kyphoplasty,
Delayed complications include a re-fracture or Lieberman et al. reported
cement leakage into
an insufficiency fracture of the cemented verte- the epidural space in one
patient, into a disc
brae, fractures of the adjacent level and delayed space on two occasions,
and into the paraspinal
dislocation of the cement [14, 5557]. tissues in three patients
[33]. Cement leakage can
Early systemic complications include cardio- occur less often in
kyphopasty than
vascular changes, fat embolism and fever that are vertebroplasty. The
incidence of cement extru-
usually resolved in 24 days. It may occur as sion outside of bone
occurring during
a result of inflammation or infection at the site kyphoplasty has been
reported to be 8.633 %.
of injection or as a result of exothermic effects of In contrast to this,
cement extrusion with
the cement [58, 59]. Unreacted monomer from vertebroplasty has been
reported to occur in
the cement can have systemic cardiopulmonary 370 % of cases [59].
effects resulting in hypoxia and embolism. Cement leakage into
the paravertebral soft
Infectious complications, although rare, have tissues or veins is
generally asymp-
been reported. There are several reports of osteo- tomatic. Cement leakage
into the disc space is
myelitis requiring corpectomy [53]. Meticulous controversial because some
studies have shown
attention to sterile technique is warranted, including an increased risk for
subsequent fractures of adja-
pre-operative intravenous antibiotic administration. cent vertebral bodies [60
62], whereas others
772
G. Salo
have claimed that cement leakage into the disc In addition to the short-
term peri-procedural
space is of no clinical significance [54, 57]. The risk of kyphoplasty, there can
be an additional
incidence of cement leakage following either risk of new fracture
development subsequent to
procedure can be higher than that seen on radio- the treatment. New vertebral
fractures are
graphs. Yeom et al. found that computerized reported in numerous patients
subsequent to
tomography revealed cement leakage 1.5 times kyphoplasty. They usually
occurred within the
more frequently than did radiographs [63]. Garfin first year after treatment
[68]. The hypothesis is
et al. reported on two patients with spinal cord that the restored stiffness of
the augmented
injury following kyphoplasty [17]. Phillips et al. vertebra itself might
propagate secondary frac-
evaluated whether the creation of a bone void tures in adjacent non-
augmented vertebrae.
during kyphoplasty reduced the risk of cement Because new vertebral
fractures can occur in
leakage [36]. Under fluoroscopic control, they osteoporotic patients simply
secondary to
injected radiopaque contrast material into the disease progression rather
than as a result of
vertebral body prior to and following the creation vertebroplasty or kyphoplasty
[69, 70], it is diffi-
of a void within the vertebra. There was less cult to determine the added
risk of fracture
extra-vertebral leakage of the contrast material resulting from these
procedures.
into the epidural vessels, inferior vena cava and In general, kyphoplasty is
a relatively safe
transcortically following the creation of the procedure when performed by
skilled operators.
cavity, suggesting that cement leakage may be The overall symptomatic
complication rate
less likely following kyphoplasty [64]. Because reported for kyphoplasty as a
treatment for oste-
cement extrusion outside of the vertebral body is oporotic compression fractures
is less than
usually asymptomatic with either vertebroplasty 16 %. They mostly consist of
minor complica-
or kyphoplasty, it makes more sense to monitor tions such as rib fractures
and temporary radicu-
and compare symptomatic complications rather lar pain [19, 45, 47]. Major
complications, such
than the incidence of cement extrusion. as permanent neurological
injury or serious pul-
Cement propagation via paravertebral veins monary embolism are rare. They
occur in less
into the inferior vena cava and pulmonary embo- than 1 % of cases [45].
lism has been described in several case reports A prospective, randomized
trial directly
as a possible cause for hypotension, arrhythmia, comparing outcomes of
kyphoplasty and
and hypocapnia [65, 66]. In a retrospective anal- vertebroplasty would be
necessary to
ysis, pulmonary cement embolism has been accurately compare the
relative safety of both
described in 4.68.1 % of the cases of procedures.
vertebropasty, with 1.1 % of patients being
symptomatic [67]. Experimental data have dem-
onstrated that high-viscosity cements might Summary
probably reduce the leakage rate to avoid those
complications completely in future. A decrease In conclusion, kyphoplasty is
a good technique
in the potential for cement extrusion with for the treatment of
osteoporotic vertebral frac-
kyphoplasty has been suggested because of the tures in order to relieve pain
and restore verte-
cavity formed and a more viscous cement that bral body height. On the other
hand, this
results in the need for less injection pressure procedure has serious
potential complications
[67]. Highly vascular lesions and a liquid con- that can lead to irreversible
consequences
sistency of cement may also cause leakage of for the patient, even to
death. Following the
methylmethacrylate into perivertebral veins. In guidelines set out above along
with proper
such cases, injection should immediately be training allows for the
carrying out of this tech-
discontinued so as to avoid pulmonary embo- nique with a low complication
rate and with
lism from the cement. good results.
773
15. Armsen N,
Boszczyk B. Vertebro-/kyphoplasty: his-
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Strategies for Low Back Pain
Richard Eyb and G. Grabmeier
Contents
Keywords
Strategies and Management . . . . . . . . . . . . . . . . . . . . . . . 777
Clinical assessment # Diagnostic strategies #
Imaging # Low back pain # Natural history #

Diagnostic Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
777
Risk factors # Therapy-activity and physio-

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 777
therapy, surgery
Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
778
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 779
Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 779 Strategies and Management
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 779
Non-specific low back pain is second to upper

Conclusions and Future Perspectives . . . . . . . . . . . . . 781
respiratory problems as a reason to visit general
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 782 physicians and the first to visit an Orthopaedic
Surgeons office. The reported prevalence is as
high as 73 % [1]. For active adults not seeking
medical attention, the annual incidence of signif-
icant low back pain (visual analogue scale VAS 4
on a ten-point scale) with functional impairment
ranges between 10 and 15 % [2]. These numbers
are for low back pain without sciatica, stenosis,
instability or deformity. If low back pain occurs
acutely (36 weeks previously), it usually
resolves after several weeks [3]. The problem is
the persistent or chronic disabling back pain.

Diagnostic Strategies
History
Before starting an exhaustive diagnostic proce-
dure it is useful to address three questions

R. Eyb (*) # G. Grabmeier
1. Is a systemic disease causing the pain?
Orthopadische Abteilung, Sozialmedizinisches Zentrum
Ost Donauspital, Wien, Austria
2. Are there social or psychological disorders?
e-mail: richard.eyb@wienkav.at
3. Is there neurological compromise? [4]

777
DOI 10.1007/978-3-642-34746-7_35, # EFORT 2014
778
R. Eyb and G. Grabmeier
Table 1 Differential diagnosis of low back pain [4]

Mechanical (97 %) Non mechanical (1 %)
Visceral disease (2 %)
Unspecific LBP 80 % Neoplasia 0.7 %
Disease of pelvic organ
Degenerative Discs and facets 10 % Multiple myeloma
Prostatitis
Disc herniation 4 % Metastasis
Endometriosis
Spinal stenosis 3 % Retroperitoneal tumours
Renal diseases
Osteoporotic fracture 4 % Primary vertebral tumours
Nephrolithiasasis
Olisthesis 2 % Infection 0.01 %
Pyelonephritis
Traumatic fracture <1 % Osteomyelitis
Aortic aneurysm
Congenital deformity <1 % Discitis
Gastro-intestinal diseases
Kyphosis, scoliosis Epidural abscess
Pancreatitis
Rheumatoid arthritis 0.3 %
Cholecystitis
Ankylosing spondylitis
Gastric ulcer
Psoriatric arthritis
Reiter syndrome
Scheuermann disease
Pagets disease
With these questions the medical history can If dealing with older
adults the diagnosis
be briefly elicited: probabilities change:
cancer, compression frac-
Systemic diseases include the history of can- tures, spinal stenosis and
aortic aneurysm
cer, chronic infection or chronic polyarthritis. become more common.
Osteoporotic fractures
Neurological involvement includes usually may even occur in the
absence of a recognised
sciatica or spinal claudication combined with trauma.
paraesthesia and numbness of one or both legs. An overview of
differential diagnosis of low
Disc herniation with neurological impairment back pain is shown in
Table 1.
usually increases with sneezing, coughing or
abdominal pressure. A massive mid-line herni-
ation can lead to a cauda syndrome with bladder Clinical Examination
or bowel dysfunction and sensory loss in
a saddle distribution and bilateral gait 1. Muscle tenderness is
almost always found but
weakness. without specificity and
is not reproducible.
Psychosocial reasons maybe found in depres- 2. Spinal stiffness is not
sion, job or family problems, somatisation, litiga- any diagnosis, but may
help in monitoring
tion involvement and/or disability compensation physical therapy [6].
issues. 3. Lasgues test can be an
indicator of nerve
If dealing with low back pain in adolescence root irritation
(straight-leg rising with symp-
the following risk factors have been pointed toms of sciatica if
elevation is less than 60# ).
out [5]: Crossed Lasegues test
is sensitive but highly
1. Rapid growth specific [7].
2. Smoking 4. Further examination
should include hip
3. Tight quadriceps femoris motion and tests of the
sacro-iliac joint
4. Tight hamstrings (Menell and Patricks
test), to exclude possi-
5. Working during the school year ble L3 symptoms.
6. Poor mental health (but no correlation to 5. Motor weakness of L5
and S1 nerve root
Schober sign). (great toe dorsiflexion
and plantar flexion).
779
Table 2 Red flags [8] over-diagnosis, dependence on

medical care and
Red flags indicate possible underlying spinal unnecessary treatment, and
even to surgery.
pathology [8] Only in cases with red
flags are these imag-
1. Onset age <20 or >55 ing tests are indicated, but
the prevalence of these
2. Non-mechanical pain specific pathologies is low.
3. Previous history of carcinoma, steroids, HIV
4. Thoracic pain
5. Feeling unwell
Natural History
6. Weight loss
7. Neural symptoms
Prognosis of unspecific low
back pain is that
8. Structural deformity
about one-third of patients
substantially recover
within 1 week, two-thirds at 7
weeks [12]. Forty
percent suffer recurrences
within 6 months. Most
6. Dermatomal sensory loss indicative of L5 or of these recurrences are not
disabling, but the
S1 nerve root lesions, which are approxi- result is frequently that of a
chronic problem
mately 95 % of lumbar disc herniations [4]. with intermittent acute
phases. Low back pain is
7. Reflexes of the patellar tendon (L4) and rarely permanently disabling
[13].
Achilles tendon (S1) conclude the neurologic Nevertheless there is a
certain risk of chronic-
overview to exclude serious neurological ity and on-going research is
looking for the iden-
pathology (Table 2). tification of patients with
acute low back pain
who are individuals with high
likelihood to
become chronic low back pain
patients. Certain
risk factors can be worked out
(Table 3).
Imaging
Plain radiography should be limited to patients Therapy

with:
1. Suggestion of systemic disease Non-steroidal anti-
inflammatory drugs are
2. History of trauma effective for symptom relief,
the evidence com-
3. Weight loss pared to placebo is strong.
The same is true for
4. Fever muscle relaxants but with side
effects which are
5. History of cancer drowsiness and sedation.
Medication should be
6. Age over 50 taken regularly rather than on
an as needed
7. Alcohol, drug abuse, HIV basis [14].
8. Neural deficit Spinal manipulation and
physical therapy
9. Pain duration >6 weeks [9]. have limited effects [15],
strong evidence shows
CT and MRI should be reserved for patients that bed rest and specific
back exercises
with strong clinical suggestion of infection, (strengthening, flexibility,
stretching, flexion
cancer and neurological pathology. Both CT and and extension exercises) are
not effective in the
MRI are equivalent for detecting spinal stenosis acute phase. For most patients
the best recom-
and disc herniation, but MRI is more sensitive for mendation is rapid return to
their daily activities
cancer, infection, neural tumours and fracture with neither exercises nor bed
rest in the acute
(bone marrow oedema) [10]. phase, but heavy lifting,
trunk twisting and
On the other hand these techniques show vibrating work should be
avoided. Back exercises
often false positive results: herniated discs are useful for later
preventing recurrences and for
are frequently seen especially in older patients treating chronic low back pain
[16] (Table 4).
who are asymptomatic [11]. In symptomatic If low back pain becomes
chronic, exer-
individuals with low back pain this may lead to cise and intensive multi-
disciplinary pain
780
Table 3 Risk factors for LBP (van Tulder 1997)

Risk factors Occurrence Chronicity
Individual Age, physical fitness Obesity
Low educational
level
High level of pain
and disability
Psychosocial Distress
Negative emotions Depressive mood
Poor cognitive function Somatisation
Pain behaviour
Occupational Manual material handling Job dissatisfaction
Bending and twisting Unavailability of
light duty on return to work
Whole body vibration Heavy lifting work
Job dissatisfaction
Monotonous tasks
Poor work relationship
Table 4 Recommendations for acute LBP [8] moderately more effective in

reducing pain
Recommendations clinical guidelines for acute LBP and disability than is a
single method of
1. Re-assure patients treatment.
2. Advise patients to stay active For patients with chronic
low back pain inten-
3. Prescribe medication (preferably) at fixed time sive exercises improve
function and reduce pain
intervals: [19, 20]. It is however
difficult to maintain these
Paracetamol exercise regimes for a long
period of time.
NSAIDs
Antidepressant drug
therapy is useful for one-
Muscle relaxants or weak opioids
third of patients with low
back pain and depres-
4. Discourage bed rest
sion. Conflicting evidence is
found for patients
5. Consider spinal manipulation
without depression [21].
6. Do not advise back-specific exercises
Opioids are also proposed
and may have
a greater effect on pain and
mood than NSAIDs,
but they seem not to raise
the activity level and
treatment have been shown to be effective. cause side-effects such as
headache, nausea and
Some evidence supports the effectiveness of constipation.
behaviour therapy, analgesics, antidepressive Referral to multi-
disciplinary pain centre
medication, NSAIDs, back school and may be appropriate for
patients with chronic
manipulations. low back pain. These centres
combine cognitive
No evidence was found for steroid injections, behaviour therapy patient
education, supervised
traction and lumbar support. exercise, selective nerve
blocks and other
But many commonly used therapies lack suf- strategies to relieve pain
and improve function.
ficient evidence of clinically relevant long-term Complete relief is
unrealistic and therapeutic
effects [17]. goals are necessary to be re-
focussed to
Acupuncture, spinal manipulation and mas- keep the level of function
obtained in these
sage are popular alternative therapies. Systemic centres [4].
reviews have found little positive effect from Even for effective
treatment, the effects
acupuncture [18], but some support for massage are usually small and short
term. Many
and spinal manipulation [15]. commonly-used therapies lack
sufficient evi-
Available data suggests that a combination dence for clinically relevant
long term effects
of medical care with physical therapy may be [17] (Table 5).
781
Table 5 Recommendations for Chronic LBP [8] who had been managed with
spinal fusion [27].
European clinical guidelines for chronic LBP The study showed no clear
benefit of fusion sur-
Recommended: gery 5 years post-
operatively.
Cognitive behaviour treatment The outcome of spinal
fusion surgery can be
Supervised exercise therapy improved for patients with
isolated one- or two-
Brief educational interventions level degenerative disc
diseases, if patients are
Multi-disciplinary (biopsychosocial) treatment carefully selected and only
individuals without
Short-term use of NSAID and weak opioids co-existing psychosocial
disorders, distress or
Consider: other chronic pain are
identified [27].
Short courses of manipulation and mobilisation The expectations of the
patient about the ben-
Antidepressants
efit of surgery should be
discussed in advance. In
Muscle relaxants
a study of patients scheduled
for fusion surgery
Not recommended:
due to degenerative disc
diseases, 90 % indi-
Passive treatment (ultrasound, short wave)
cated as an acceptable
outcome: return to some
Gabapentin
Invasive treatment
gainful work, no more use of
analgesics and
a high level of physical
function [28]. These
expectations are not
realistic and patients should
be informed that pain
reduction will be at about
Invasive treatments for chronic low back pain 50 %, recurrent back pain
will be common and
reveal a wide variability of techniques such as further activity will be
necessary to keep their
facet joint, epidural, trigger point and sclerosant function level acceptable.
injections.
In randomized trials however they have not
clearly improved outcomes, if the patient had no Conclusions and Future
Perspectives
radiculopathy. Radio-frequency ablation of the
small nerves of facet joints showed at best Treatment should mainly be
distinguished
a moderate effect which lasted only for 4 weeks between acute and chronic
back pain patients.
[22]. It may have possible benefit in patients with For both, natural history is
favourable and
low back pain who respond to placebo-controlled patients need this
reassurance. In the case of
anaesthetic blocks [23]. acute low back pain
pharmacologic treatment
Other techniques advocated include percuta- should be recommended. The
patient should
neous heat or radiofrequency application directly know that there is no danger
of serious neurolog-
at the disc altering the internal mechanics or ical injury, bed rest will
not help, and return to
innervation. Data supporting their use are lacking daily activity as soon as
possible will be the best
Randomized trials showed no effect [24] or course.
a benefit in only a small proportion of highly In cases of chronicity
again pharmacological
selected patients [25]. treatment in combination with
intensive multidis-
The role of surgery for chronic low back pain is ciplinary exercise and
cognitive behaviour ther-
under debate. The most common surgical treat- apy is the best choice. The
patient should
ment for persistent low back pain with degenera- understand that the primary
goal of treatment is
tive changes is spinal fusion. One randomized trial to maximize function and that
some on-going or
comparing spinal fusion versus a rehabilitation recurrent back pain is likely
but not dangerous.
programme showed no difference at 1 year in Imaging like plain
radiography should only be
back pain, function, use of medication, working performed if there is
suspicion of an underlying
status and general satisfaction [26]. systemic disease. Advanced
imaging can be
Another randomized study revealed better reserved for potential
candidates for surgery.
results in the level of back pain and improvement Generally, imaging is of
little help due to the
of function after 2 years in the group of patients poor association between
symptoms and
782
morphologic findings. In the absence of severe spine in

asymptomatic subjects: a prospective investi-
spinal disease or radiculopathy, surgery should gation. J Bone
Joint Surg Am. 1990;72:4038.
12. Cherkin DC, Deyo
RA, Street JH, Barlow W.
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On-going research focuses mainly on possible primary care
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7.
identifying sub-groups of patients, for whom spe- 13. Carey TS, Garrett
JM, Jackman A, Hadler N. Recur-
rence and care
seeking after acute back pain: results of
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Brockway JA, Bergman JA, Spengler D.
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15. Andersson GB,
Lucente T, Davis AM, Kappler RE,
Lipton JA,
Leurgans S. A comparison of osteopathic
spinal
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Ostelo R, Vlaeyen JW, et al. Behav-
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Hesselse G, Bentzen L, Christensen I,
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Treatment of the Aging Spine
Max Aebi
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 785
Aging # Osteoporosis # Spine # Spine and I.V.

Ostoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 786 disc degeneration
Spinal and I.V. Disc Degeneration . . . . . . . . . . . . . . . . . . 786
Typical Disorders of the Aging Spine . . . . . . . . . . . .
788
Disc Degeneration, Osteochondrosis, Disc
Herniation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 788 Introduction
Spinal Stenosis in the Elderly . . . . . . . . . . . . . . . . . . . . . . .
790
Degenerative Spondylolisthesis . . . . . . . . . . . . . . . . . . . . .
793
Degenerative Deformity (Scoliosis and/or
The aging of the population in the industrialised
Kyphosis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 793 countries appears to be a non-reversible phenom-
Vertebral Compression Fractures . . . . . . . . . . . . . . . . . . .
794 enon. Increasing life expectancy, due in a great
Other Typical Disorders of the Spine in Elderly
part to the improvement of healthcare, combined
Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 796 with a drastic decrease in birth rate, has led to this
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 797 situation [41]. The world demographic situation
has shifted from a pattern of high birth rates and

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 798
high mortality rates to one of low birth rates and
delayed mortality [23, 41]. In Europe, the propor-
tion of subjects over 65 was 10.8 % in 1950, 14 %
in 1970, 19.1 % in 1995 and is projected by some
sources at 30.1 % in 2025 and 42.2 % in 2050
[20]. The proportion of subjects over 75 has
grown from 2.7 % in 1950 to 5.2 % in 1995 and
is projected at 9.1 % in 2025 and 14.6 %

in 2050 [20]. However, this trend is not limited
to industrialised countries: The developing
countries share of the worlds population above
65 is projected to increase from 59 % to 71 %.

Previously published in G. Bentley (ed.), European
The global consequences of this distortion of the
Instructional Lectures, European Instructional Lectures 13,
age pyramid on healthcare development, access
DOI 10.1007/978-3-642-36149-4_11, # EFORT 2013
and costs are huge [29]. For instance approxi-
M. Aebi
mately 59 % of US residents over 65 are affected
MEM Research Center, University of Bern and
by osteoarthritis, which is the main cause of dis-
Orthopaedic Department, Hirslanden-Salem Hospital,
Bern, Switzerland
ability. Back and neck pain are amongst the most
e-mail: max.aebi@MEMcenter.unibe.ch
frequently encountered complaints of all people

785
DOI 10.1007/978-3-642-34746-7_203
786
M. Aebi
and the nature of the spine renders those problems to exposure of the disc to
repetitive mechanical
highly complex to investigate and to treat. loads [2, 35]. This leads
to a loss of extracellular
matrix with proteoglycans
degrading and
decreased capability to
bind water. The collagen
Ostoporosis organisation is dissociated
which leads to a loss
of the height of the disc.
This is always combined
Furthermore, osteoporotic compression fractures with a secondary
deterioration of the facet joints,
of vertebral bodies is another increasing problem ligaments and muscles.
Through this process,
due to aging of the Western population as well as the boundaries between the
annulus and nucleus
the Japanese and Chinese population, with an are less distinct and the
collagen is increasing
increasing number of severely osteoporotic sub- in the nucleus and
replacing the proteoglycans.
jects, mostly women. Recent studies have shown With that we see concentric
fissuring at radial
that osteoporotic vertebral fractures are associ- tears which weakens the
disc, starting in
ated with an increased risk of mortality and the third and fourth decade
of life. However,
a decreased quality of life. The prevalence in there are substantial
differences in this whole
those fractures is around 39 % in subjects over cascade of events. These
changes have clearly
65 years (National Center for chronic disease biomechanical consequences
for the motion
prevention, [31]). segment [2].
The role of
vascularisation in the aging spine
is most crucial: The
nutritional supply of the cells
Spinal and I.V. Disc Degeneration in the disc diminishes
because the adjacent
vertebral end-plate
permeability is decreasing,
Degeneration of the spinal structures leading to a blood supply
decrease with
induces interactive alterations at many levels: a secondary tissue
breakdown, which starts in
bones, discs, facet joints, ligaments. Some the nucleus, and a
mechanical impact on
of these degenerative lesions can be responsible the cells (sensitive to
mechanical sickness)
for compressive damage to the neural ele- which leads to a
qualitative and quantitative mod-
ments as in the case of disc herniations or spinal ulation of the matrix
proteins [10, 19, 43]. The
stenosis. variation of the
proteoglycan content as well as
Disc degeneration begins when the balance the water content is age-
dependent and runs in
between synthesis and degradation of the matrix parallel: more degradation
of the proteoglycans,
is disrupted; i. e., at the microscopic level, disc less water content and
higher probability of dis-
degeneration includes a net loss of water as integration of the disc
(Fig. 2).
a consequence of a breakdown of proteoglycans The aging of the spine
is characterised by
in so-called short chains, which are unable to bind two major parallel, however
(at least at the
water [30, 35]. Furthermore, there is disruption of beginning), independent
processes, which lead
collagen fibre organisation, specifically in the to different clinical
pictures:
annulus, and increased levels of proteolytic 1. The reduction of bone
mineral density, hence
enzymes. Disc degeneration can be seen in bone mass.
20 year-old people in about 16 %, whereas this 2. The development of
degenerative chan-
phenomenon is found in 98 % in 70 year-old ges of the
discoligamentous complex
people and older [8, 9] (Fig. 1). (discs, ligaments,
facet joint capsules and
Women reach the same level of degeneration facet joints) with
consequences of instability,
about 10 years later than men (Fig. 1). In the deformity and narrowing
of the spinal
aging of the spine there is a predetermined cell canal and the exit of
the nerve roots
viability (endogenous genetic) and/or decreas- (spinal and foraminal
stenosis) with second-
ing cellular activity in the disc over the years due ary neurological
problems such as
787
Fig. 1 The prevalence of Male

Female
macroscopic disc N= 25 33 35 76 52 7 28 32 35
54 85 38
degeneration based on 100%
autopsies by age for men
and women. The women
reach the same level of 75%
degeneration about a
Healthy
decade later than the men.
(based on data from the
Slight
50%
study of Heine (8a), cited
Moderate
from Battie MC et al. Spine
Severe
2004; 29, Nr. 23 (8)
25%
0%
39
49
59
69
79
85
39
49
59
69
79
85
15
40
50
60
70
80
15
40
50
60
70
80
Age groups
Aging of the spine
The cellular
activity in the
disc is
decreasing
Extracellular matrix is
decreasing,
i.e. proteoglycans are degrading
and water and collagen
organisation are decreasing
Disc
height is
decreasing
This initiating
Fig. 2 Aging of the
event is resulting
spine cascade of the
in secondary
intervertebral degeneration
deterioration
(see text)
myelopathy, cauda equina and radicular syn- a variety of lesions

and often to a number of
dromes and disability. Hence, degeneration painful and
invalidating disorders.
alone, or in combination with bone mass From this short
introduction it can be
reduction by osteoporosis and/or metastatic concluded that
Orthopaedic surgeons and
tumour involvement, contributes to musculoskeletal
specialists as well as dedicated
a different degree to the development of spine specialists are
going to face huge problems
788
M. Aebi
in treating the numbers of patients affected with significant radicular

pain and/or sensomotor
by diseases which are typical for the aging of deficit.
the musculoskeletal system. This pathology can occur
in the context of
previous surgery in the
lower lumbar spine
which led to a fusion or at
least poorly mobile
Typical Disorders of the Aging Spine spinal segment with an
overload and stress aris-
ing in the adjacent superior
or inferior segment
Typical disorders of the aging spine are: with a rapid degeneration of
the disc with poten-
Degenerative disease of the disc(s), tial instability, spinal
stenosis and possible extru-
osteochondrosis and disc prolapse sion of major disc
fragments. This can occur as an
Degenerative disease of the facet joints with acute event in almost all
those decompressions of
joint incongruences and arthritis, secondary the segment and a
stabilisation may become nec-
instability and deformity. essary [7, 16, 26].
Degenerative spondylolisthesis with or with- Asymmetrical
degeneration of the disc may
out spinal stenosis and instability. lead to a further
deterioration of adjacent motion
Spinal stenosis, foraminal stenosis due to segments and may end with a
progressive degen-
a narrowing of the spinal canal following erative scoliosis [4], which
may need surgical
hypertrophy of the ligamentum flavum treatment (see below).
and the joint capsules and the facet joint by Sometimes it is
difficult to differentiate the
itself. subchondral bony damage from
osteoporotic
Spinal deformities: Scoliosis and/or kyphosis compression fractures. The
precise history and
and concomitant secondary instability. clinical examination may
lead to a diagnosis as
Osteoporosis with vertebral compression frac- well as STIR sequences of
the MRI, CT-Scan
tures (VCF) alone or in combination with and/or bone scintigraphy.
degenerative defects. Symptomatic isolated or
multi-level disc
Pathological fractures of the vertebrae due to degeneration can be seen in
the lumbar
metastatic disease. spine as well as in the
cervical spine. This disc
Infection of the spine, spondylodiscitis and degeneration with
osteochondrosis and some-
spondylitis in the elderly. times significant
subchondral oedema, as expres-
sion of inflammation, and
occasionally combined
with significant disc
protrusion, can occur in
Disc Degeneration, Osteochondrosis, elderly people primarily
without relevant
Disc Herniation deformity or instability.
This degeneration can
start in younger age and can
be asymptomatic or
Symptomatic, isolated or multi-level disc can be combined with
intermittent back pain
degeneration can be seen in the lumbar spine as affecting people sometimes
over years and even
well as in the cervical spine [13]. The clinically decades [13].
most relevant disc degeneration with sub- For some reason, mostly
mechanical, disc
chondral oedema, possible secondary spondylo- degeneration can aggravate
and become highly
listhesis and/or translational, rotatory dislocation symptomatic, specifically
when there is
and consecutive spinal deformity is most fre- a combination with a
segmental instability and
quently seen in the lumbar spine at the level of osteochondritis (Fig. 3).
Since these discs are
L3/4 > L2/3 > L4/5 > L1/2. The asymmetrical severely degenerated and
dehydrated over many
degeneration may lead to a disc herniation with years, a herniation consists
almost always of
major or mass dislocation of whole disc frag- a big, combined annulus and
fibrotic nucleus
ments (annulus and nucleus parts) leading usually sequestrum. The consequence
of this disc degen-
to at least a major neurological complication, eration may be a secondary
deformity, with typ-
such as root compression or cauda compression ical translatory dislocation
of vertebrae in
789
Fig. 3 Multi-level
degenerated discs with
secondary flat back and
degenerative scoliosis,
spinal stenosis and
mechanical instability in
extension at L2/3 (air
inclusion in the disc)
a segment or several segments, rotation and sco- from L3/4, L4/5 and L5/S1, i.
e. in the lower
liosis and/or kyphoscoliosis [4, 13]. It is also lumbar spine. In cases where
the patient has had
possible that disc degeneration and facet joint abdominal surgery or is
adipose, it is advisable
arthritis can lead to a degenerative spondylo- not to do an anterior surgery,
but rather
listhesis [27, 32, 38]. As long as the disc degen- a posterior surgery with
pedicle fixation and
eration is isolated to one or two or three levels PLIF or TLIF procedure.
without a major deformity, a typical axial insta- In recent years,
specifically in elderly people
bility pain occurs, mostly in rotational move- who are frail and where
surgery is only an option
ments or lifting when upright or when turning if everything else does not
work, surgery should
in bed during sleep. If conservative treatment be limited to a minimum:
little blood loss and
with isometric re-inforcement exercises of the little surgical trauma and
short anaesthesia time.
abdominal and paravertebral muscles is not A far lateral approach (XLIF)
may fulfil these
successful, surgery may be necessary [32, 33, requirements [6, 21, 25, 34].
However, to avoid
37, 39, 42]. posterior surgery, stand-alone
cages need to be
There are several surgical options available: used which can be fixed either
by an additional
1. Minimally invasive, retroperitoneal anterior, plate or with the plate
incorporated with the cage
2. Posterior, as well as (Fig. 4).
3. Far lateral approach surgery as well as However, ALIF and XLIF
surgery is contra-
combinations. indicated in osteoporotic
bone, because there is
Anterior surgery with stand-alone cages a high probability that the
cages will sink into the
(ALIF), fixed with screws is straight forward in vertebral bodies [24, 25]. In
these cases it is
not too adipose patients, and is quite feasible sometimes necessary to do a
posterior pedicle
790
M. Aebi
Fig. 4 68 year-old female patient with degenerative sco- instability at L3/4

with relatively rigid adjacent segments
liosis and severe motion and activity dependent left leg above and below. Far
lateral approach and isolated stabi-
pain and blocking back pain due to a rapidly progressing lization and partial
correction of the segment
osteochondritis and total disc destruction with secondary
screw fixation with cement re-inforcement and central stenosis,

lateral or root canal stenosis,
even to fill the intervertebral space after remov- a combination of those
two and a combination
ing the disc with cement, i. e., a so-called with or without
degenerative spondylolisthesis.
discoplasty. In some cases where the disc height There are of course
other conditions like the
is significantly reduced and there is significant Pagets disease, then
degenerative disease,
concomitant facet joint arthritis which partici- which may cause spinal
stenosis with or without
pates in the pain generation and if the patient is neurological
complications. There is also second-
old with possibly reduced life expectancy and ary spinal stenosis due
to fracture, mostly osteo-
with little demand for physical activity, an porotic fracture, and
due to tumour compression
interlaminar microsurgical decompression with of the spinal canal,
mostly metastatic disease.
resection of flavum, capsule and partial Finally, there is
iatrogenic stenosis, which can
arthrectomy, combined with a translaminar facet occur as a late result
after any spinal surgery at
screw fixation may be sufficient (Fig. 5). This any age. In these
cases, spinal stenosis may occur
is an atraumatic surgery suitable for very elderly as so-called adjacent
segment problem after
patients with high morbidity and reduced fusion surgery or be a
part of a degenerative
life expectancy and little demand for physical deformity (scoliosis
and kyphosis) [40].
activity, with little blood loss and with one In most cases,
spinal stenosis is due to degen-
of the major purposes to control erative changes and/or
a pre-existing narrow
pain fulfilled by immobilising the facet joints canal. These changes
can lead to symptoms, how-
with a screw each. ever, it must be
stressed that so-called stenotic
images sometimes are
present on imaging
studies in a number of
symptom-free individuals
Spinal Stenosis in the Elderly and that the
relationship between degenerative
lesions, importance of
abnormal images and
Spinal stenosis is a very common condition in the complaints is still
unclear. Lumbar stenosis
elderly and we have to differentiate between with a claudication
symptomatology is also
791
Fig. 5 79 year-old
polymorbid, adipous
female patient with
degenerative scoliosis and
spinal stenosis. Because of
the medical risks a very
limited microsurgical
decompression and
localized stabilization at
the apex of the curve has
been done
a common reason for decompressive surgery and/ degenerative

spondylolisthesis, simple decom-
or fusion. The investigation of stenotic symptoms pression without
instrumentation may be suffi-
should be extremely careful and thorough and cient. If there is a need
for significant resection
should include a choice of technical examina- of hypertrophic facet joint
parts to decompress
tions including vascular investigation. This is of the dural sac as well as
the exiting roots, it may be
utmost importance, especially if a surgical action necessary to stabilise the
segment either by sim-
is considered, to avoid disappointing results [28]. ple
translaminar/transarticular screw fixation
Surgical management of spinal stenosis can (Fig. 5). This is a less
rigid fixation than the
consist of purely decompressive surgery: Here alternative with pedicle
fixation. The risk of the
different techniques are available, like classical pedicle fixation in spinal
stenosis without any
laminectomy, laminotomy, partial laminectomy, deformity and obvious
instability is to generate
resection of ligamentum flavum and scar tissue, a rigid spine section with
a relevant impact on the
simple foraminal decompression. In recent years adjacent segments,
including the discs as well as
it has been suggested in some cases to use the vertebral bodies [7,
12, 16, 17, 36]. This
a so-called interspinous process distraction. The increases the risk of
fatigue fractures in these
idea is that with this distraction the foramina are vertebral bodies and a
disruption of the posterior
opened and the canal is widened and indirectly ligament complex as an
expression of the aging
decompressed [28, 33]. The interspinous process of ligaments and muscles
(Fig. 6a).
distraction also unloads the discs as well as the Obviously, in a
severely degenerated cervical
facet joints. The best patients who are fit for this spine with spinal stenosis,
we may deal
surgery are those with increasing symptoms with compression of the
cord with consecutive
when doing lumbar extension movements. myelopathy and/or root
compression. The spinal
There is still a quite significant debate whether stenosis of the cervical
spine often goes together
a decompression needs to be accompanied by with a deformity usually in
kyphosis and some-
instrumentation [28, 33]. Depending on the times in little scoliotic
deformity in the frontal
osteophyte formations in the anterior column as plane. In case there is
relevant deformity of the
well as the osteoarthritis of the facet joints and in cervical spine combined
with a narrow spinal
the absence of any instability, such as canal, diagnostic traction
may be applied to
792
M. Aebi
a c
b d
Fig. 6 72 year-old female patient of 101 kg with spinal back and irradiating
into the legs: c) compression fracture
stenosis at L2/3 and L3/4, here with degenerative of L4 with secondary
instability in the functional
spondylosithesis, osteoporosis and massive claudication myelogram (supine and
upright position) d) Reoperation
symptomatology as well as back pain. a) She was operated with Fixation from L2 to
L5 with cement enhancement of
with wide decompression and pedicular stabilization. b) the screws and
kyphoplasty with stents of the fracture
For 5 weeks she did very well, then suddenly pain in the vertebra L4
explore how far the deformity can be reduced and multi-level discectomy
and resection of the pos-
the cervical spine can be re-aligned. In cases terior inferior and
superior corner of the adjacent
where this is possible, surgery may be done vertebra to do a
unisegmental anterior decom-
under traction in the reduced position. In this pression. In cases where
the compression of the
case there is no manipulation to achieve reduc- spinal cord is mainly
due to disc on several levels,
tion necessary during the surgery but only the then this technique can
be applied on each indi-
decompressive, and if necessary, the stabilisation vidual level by
maintaining the main part of the
part. vertebral body. The
latter is helpful to place
Again, also in the cervical spine, there are intervertebral spacers
and to restore the cervical
different ways to address the spinal stenosis . It lordosis. In case there
is more compression due
can be done by an anterior surgery, either by to relevant osteophytes,
extension of the
793
compression beyond the disc space and in case with a secondary narrowing
of the spinal canal.
there is concomitant OPLL, one or even two level It is still debated whether
this pathology needs to
vertebrectomies may be necessary with an ante- be decompressed and
stabilised or whether sim-
rior reconstruction with (expandable or rigid) ple decompression is
sufficient [1, 27, 32]. If
cages or bony struts (fibula or iliac crest) and instability can be
demonstrated in functional
plate fixation. If this stabilisation seems to be X-rays with maximal bending
and maximal
insufficient and specifically is not really restoring extension over a hypomotion
of the lumbar
lordosis, a combined posterior fixation with ten- spine in supine position
and accompanying low
sion-banding and re-aligning of the cervical spine back pain in combination
with irradiation into the
in lordosis may be necessary. There is of course legs, a stabilisation may
well be indicated.
the option left of posterior surgery through Here again, there is a
debate whether this should
laminectomy, laminotomy on several levels or be a pedicle fixation alone
or in combination
laminoplasty. In case there is insufficient physi- with an interbody fusion,
like PLIF or TLIF
ological lordosis (in fact kyphosis), then [9, 27, 32, 37, 42].
a simultaneous fixation of the decompressed According to the
guidelines of NASS [27],
cervical spine along with the decompression there is very little
evidence, whether a spondylo-
may be necessary. In this case, today, most of listhesis is to be operated
with decompression
the time lateral mass screws combined with rod alone, in combination with
fusion with or without
systems is the technique of choice. This surgery is implant (screws and cages)
and whether
combined with a posterolateral fusion, either by a reduction is necessary or
not.
bone substitutes or with cancellous bone from the
iliac crest. Since the cervical spine surgery is not
as invasive as the lumbar spine surgery, also Degenerative Deformity
(Scoliosis
elderly people with significant co-morbidities and/or Kyphosis)
can be treated specifically by anterior surgery
under neuromonitoring, since there is relatively The degenerative deformity
mainly of the lumbar
little blood loss to be expected and the surgical spine and the thoracolumbar
spine is a typical
trauma is more or less local, not involving the disease of the elderly,
specifically women. This
whole homeostasis of the body as in a surgery of is basically a disc disease
with the whole cascade
the lumbar spine in prone position over longer described before: disc
degeneration as the initial
time period. starting point, usually
unilateral or asymmetrical,
incongruence of the facet
joints with subluxation
and rotatory deformity,
which appears in the
Degenerative Spondylolisthesis AP-view as a translational
dislocation, mostly at
the level of L2/3 or L3/4
[4]. The deformity in the
Degenerative spondylolisthesis occurs usually at frontal plane (scoliosis)
is practically always
the level of L4/5, less frequently at the level of combined with a lumbar
kyphosis, and this defor-
L3/4 and L5/S1. Very often, this degenerative mity very frequently is
combined with recessal or
spondylolisthesis is combined with spinal steno- foraminal stenosis,
occasionally appearing as
sis. The spondylolisthesis is a consequence of a so-called dynamic
stenosis, only being clini-
a disc degeneration and insufficiency of the cally relevant when the
patient is in upright posi-
facet joints to maintain the stability of the seg- tion or in a certain
position while lying or sitting
ment. In these cases very often the facet joint (de novo scoliosis) [4].
The clinical appearance
effusion can be demonstrated, as well as air inclu- of the degenerative
deformity is pain, mostly
sion in the disc as well as in the facet joints. The back pain, with frequent
irradiation into the
spondylolisthesis can also be combined with legs, be it a so-called
pseudoradicular irradiation
a facet joint synovial cyst, which may add to or as a real radicular
irradiation and claudication
the compressive effect of the spondylolisthesis symptomatology. Therefore,
the clinical problem
794
M. Aebi
to be addressed is the progressing deformity, i.e., the parts of the

spine are opened portion by
the instability of one or several segments, the portion, then instrumented
and finally corrected
neurocompression in the spinal canal, be it and stabilised. This
reduces the exposure field of
centrally or laterally, and very frequently the the wound and therefore the
potential blood loss.
combination with osteoporosis. These patients In most of these
degenerative scoliosis or defor-
are usually unbalanced, not only in the frontal mities, if they need
surgery, a pedicle fixation is
plane but more importantly in the sagittal plane. indicated to develop the
power to correct to
There is very little substantial non-surgical treat- a certain degree the
deformity, specifically in
ment for these patients. Occasionally, a brace can the sagittal plane.
be tried and a walker or canes may be used to Whether cages need to
be placed interver-
maintain balance. tebrally in these elderly
people, usually with
These patients are generally much better while concomitant osteoporosis,
is certainly a question
walking in water, since the water carries them of debate. By correct
restoration of the lordosis
by the buoyant force of the water. The only effi- and establishing the plumb-
line out of C7 behind
cient treatment, however, although tainted by the hip joint, the force
transmission goes through
complications and relevant risks, is the surgical the posterior elements and
therefore a disc ante-
treatment. rior support with cage may
not be necessary.
Surgical treatment is almost always indicated To avoid cage surgery in
these elderly patients
when progression of the curve can be demon- is a major element to
reduce blood loss and
strated over time, and in case of relevant central, surgical risk. As a result,
depending on the prob-
recessal and/or foraminal stenosis with signifi- lem of the patient, the
demands of these patients
cant radicular pain and/or neurological deficit. and of course the co-
morbidities, different sur-
There is not only a segmental instability, visible gical options in terms of
invasiveness may be
in many of these deformities, but there is also applicable. Again, in
recent years, the applica-
a global instability of the spine which means tion of the far lateral
trans-psoas approach with
that the spine is collapsing along the sagittal selected correction of the
most severely
axis which increases the deformity when upright involved segments may be a
solution to diminish
and decreases the deformity when the patient is the surgical trauma in
these frail patients (Fig. 4)
prone [4]. [6, 14, 15, 36].
In general, this surgery is demanding, not only
for the patient but also for the surgeon. Since
many of these patients are beyond 65 and usually Vertebral Compression
Fractures
have several risk factors due to polymorbidity,
such a surgery needs to be well prepared and In recent years different
options have been pro-
thoroughly discussed with the patient and the posed to treat vertebral
compression fractures in
family, also pointing out risks and consequences elderly people and there is
still continuous con-
in further life. The patients have to understand, troversy about these
different methodologies.
together with their family, that such a surgery Essentially, several
technologies have been
could finally end up lethally. For this exact rea- developed to augment
compressed vertebrae
son, a lot has been done in the last few years to as a consequence of
osteoporotic fractures. The
facilitate and to reduce the risk of this surgery for simplest one is the so-
called vertebroplasty,
these elderly patients. One of the key issues is the where transpedicular
injection of cement into
blood loss and therefore there are different tech- a fractured vertebral body
can stabilise this ver-
niques to be applied to reduce the blood loss, to tebral body. There is,
however no relevant poten-
return the blood with cell saver and to lower the tial to reduce a fracture
with this technique,
blood pressure as far as possible. Also the staging except by positioning of
the patient. There are
of the incision during a surgical procedure from several risks involved in
this treatment and there
the back can help to diminish the blood loss [37], is still an on-going debate
whether in randomised
795
clinical trials the surgical augmentation really has catheter or the cement
applicator (in case of sim-
a benefit over conservative treatment of these ple vertebroplasty).
Through this working chan-
fractures [11, 22]. The major risk of this treat- nel also biopsies can be
taken. In case of an
ment is cement leak, most relevantly leak of additional kyphoplasty, the
balloon catheter can
cement into the spinal canal through the posterior be driven into the working
cannula and the bal-
wall, less problematically leak to the side or to the loon can be placed in the
prepared seat in the
front, as long as it is only a small amount of vertebral body. The same is
true for the balloon
cement. The second relevant risk is that cement catheter, which is armed
with a stent, which then
can go into the venous sinuses of the vertebral is inflated by the balloon
and expanded as verte-
body and from there into the venous system with bral body supporter and
partial corrector of the
cement thrombosis and/or embolism in the lung compression fracture (Fig.
6d). It is obvious that
[19]. There has been significant progress in with the simple
vertebroplasty there is almost no
cement technology to diminish cement risk to correction which can be
done directly with the
a minimum. Performance of vertebroplasty cement. In an early stage
of fractures with the
includes a third risk, which is the placement of kyphoplasty balloon as well
as the kyphoplasty
the working tubes through the pedicle into the balloon combined with a
stent, a certain reduction
vertebral body. Obviously, there is the risk that of the impressed end-plate
can sometimes be
this tube can be placed into the spinal canal or acheived. The introduction
of the balloon
outside the pedicle into the lateral paravertebral kyphoplasty and stent
kyphoplasty technology
area with vascular damage. Just as in has made this procedure of
cement augmentation
pedicle screw placement, however, with todays safer. According to some
meta-analysis, the mor-
X-ray technology, percutaneous placement of bidity as well as the
mortality and the cement
a cannula into a pedicle has become a standard complications are
significantly lower with
procedure and it should not be a major obstacle to kyphoplasty procedure
compared to the simple
do this procedure when adhering to the proper vertebroplasty [19]. The
augmentation technol-
recommendations of the technique. The pedicle ogy, however, has failed
until today to prove
projection has to be visualized carefully in the superior to conservative
treatment in randomised
AP-view and the guiding K-wire has to be placed clinical trials [11, 22];
however, there are several
in a way that it is projected completely within the flaws in these prospective
trials which are basi-
oval contour of the pedicle in the frontal plane. cally contradictory to the
everyday clinical expe-
The K-wire is slightly convergent towards the rience [5]. From
prospective case series it has
mid-line and it can cross the inner wall of the been learned, that this
augmentation surgery is
pedicle projection contour when at this point in very beneficial and
successful for patients in
the lateral view the K-wire tip is already in the severe pain in combination
with vertebral body
vertebral body. Therefore, it is important to compression fractures. The
indication for such
observe the forward drilling K-wire in the pedicle augmentation surgery should
be primarily pain
projection in the AP-view by checking quickly at in still active fractures,
i. e., fractures, which are
each step the lateral view to understand the pro- not healed and are
represented in the so-called
gress of the tip in the depths of the vertebral body. STIR sequences in the MRI
as white vertebrae.
Once the K-wire is placed properly, the Jamshidi Usually, the concept is to
apply an augmentation
needle or an analogue instrument can be intro- surgery not before 6 weeks
after the fracture, with
duced over the K-wire and progressed into the all the correct attempts of
conservative treatment.
vertebral body. This opens the pedicle for the The second benefit,
namely the correction
working tube, which is then introduced after of the vertebral body wedge
shape and
removing the Jamshidi needle. Once the working indirect correction of a
secondary kyphosis, is
cannula is positioned properly into the posterior less well supported.
However, if there are several
one third of body, the vertebral body can be fractures with wedge
deformity of vertebral
drilled in preparation of the seat for the balloon bodies, it can lead to a
significant kyphosis with
796
M. Aebi
a significant disturbance of the sagittal balance, managed today without

surgical treatment.
which is detrimental in a long term for an However, there are still
patients left with signif-
elderly patient. In such cases, the surgical treat- icant pain due to metastatic
pathological fractures
ment with augmentation of the vertebral body to of the spine or compression
of the spinal canal
avoid further progression of kyphosis may be due to tumour expansion into
the spinal canal.
extremely beneficial and important for the patient The most frequent tumours are
metastasis of
(Fig. 7). breast cancer in women and
prostate cancer in
men as well as the multiple
myeloma disease of
the spine [3].
Other Typical Disorders of the Spine With todays available
minimally- invasive
in Elderly Patients technology, there is often a
combination possible
of so-called augmentation
technologies described
As the treatment options for cancer pathology are above with less invasive
stabilisation technology,
getting more and more sophisticated with an as palliative procedures in
this kind of elderly
increase of survival time, there is also a higher patients who suffer from the
consequences of
probability that elderly patients develop metasta- spinal metastasis.
ses in the spine [3]. Many of those metastases, Spinal infections in
elderly people are again
due to chemotherapy and local irradiation, can be getting more frequent, too.
The spondylodiscitis
new
new
o ld
Old
fx
fx
new
new
T2
T1
STIR
Fig. 7 (continued)
797
POSTOP.
Fig. 7 82 year-old female patient with old kyphosing compression and

slightly wedging. This spine does not
osteoporotic fractures at Th 11 and Th10 and new frac- tolerate further
kyphosis and the pending collaps needs to
tures at Th 5 and Th12 (6a) with the tendency to collaps in be stopped by
kyphoplasty at Th 5 and Th12. (6b)
and the spondylitis can be quite a destructive a secondary infection

of an infection somewhere
disease with an interruption of the anterior col- else in the body
(bladder, lungs, lower limbs,
umn and secondary kyphosis. The early stage of skin), is high for
septic complications and surgery
spondylodiscitis can be treated with antibiotics should only be
considered when the above-
and partial immobilisation. The indication for mentioned criteria
are fulfilled.
surgical treatment is unrelieved pain in spite of
proper pain medication, persistent high infection
parameters in the blood (CRP, blood sedimenta- Summary
tion rate, leucocytes) and increasing secondary
deformity and neurological deficit. The proce- Spinal disorders in
elderly and usually frail
dures are very similar as for tumour surgery. patients with
polymorbidity have become
The risks of surgery in frail elderly patients with a major challenge in
spinal surgery. It is not
an infection of the spine, which is mostly only a major
challenge in terms of technical and
798
M. Aebi
surgical demands, but also a major challenge in 11. Buchbinder R,

et al. A randomized trial of
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for painful osteoporotic vertebral frac-
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FX, Ueyama K, Xie DH, Sannohe A,
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Adjacent segment degeneration after single-
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the risk factor for degeneration and its
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Samartzis D, Karppinen J, et al. Are
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Park SR, Kim JH, Choi SW, Yoon
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Arthrodesis to L5 versus S1 in long
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Rohrbach N, Berlemann U. Seg-
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Infections of the Spine
Jose Guimaraes
Consciencia, Rui Pinto, and Tiago Saldanha
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 801 Spondylodiscitis, tuberculosis and peri-
operative infections are different sub-groups

Discitis/Spondylodiscitis . . . . . . . . . . . . . . . . . . . . . . . . . . .
802
Aetiology and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . .
802
of the same problem that require specific

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 802 attention. There are patient-related and case-
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 803 specific risk factors for a spine infection that
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 804 although well-documented and significant are
Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 806 unfortunately not generally recognized. In
Aetiology and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . .
806 each pathological presentation of the disease
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 807 the relevance of aetiology, epidemiology,
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 808
diagnostic tools, as well as treatment modali-

Post-Operative Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
ties have to be well-established to clarify the
Aetiology and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . 809
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 810
differences between them. The costs of
treatment and its failure have to be carefully

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 811
evaluated. We must emphasise that a spinal

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 811 infection is usually a treatable condition
depending on the patients immunological
defences, the aggressiveness of the infecting
agent, elapsed time to diagnosis, and the
efficacy of the chosen treatment.

Keywords
Diagnosis, Imaging, Conservative treatment #
Discitis/Spondylitis # Infections #
J. Guimaraes Consciencia (*)
Orthopaedic Department, FCM-Lisbon New University,
Post-operative infection # Spine # Surgical
Lisbon, Portugal
indications # Surgical techniques #
e-mail: josegconsciencia@yahoo.com
Tuberculosis
R. Pinto
o Hospital, Porto,
Orthopaedic Department, S. JoA
Portugal
e-mail: ruialexpinto@yahoo.com
Introduction
T. Saldanha
Throughout history the spinal column has under-

Giology Department, EGAS Moniz Hospital - CHLO,
Lisboa, Portugal
gone changes, making the necessary adaptations
e-mail: tffaqs@gmail.com
to allow us to stand and walk, providing support

801
DOI 10.1007/978-3-642-34746-7_205, # EFORT 2014
802 J.
Guimaraes Consciencia et al.
to muscles or ligaments, to protect the neural dissemination through the

blood stream is usually
structures and to facilitate daily living activities the way pathogens reach the
infection site.
[13]. Pathological diseases such as spine infec- Staphylococcus aureus is
often the infecting
tion can break this balance producing discomfort, agent although other very
rare organisms such
pain and deformity. Also they can really endan- as mucormycosis or even the
Lactococcus
ger the patients either locally or systemically and garvieae might be involved
[11, 12]. It represents
thus become an important generalised disease. around 27 % of all
pyogenic osteomyelitis with
It is normally recognized that a haematogenous an incidence reported from
1 per 100,000 to 1 per
spine infection usually starts in the vertebral end- 250,000 a year [6] which
makes it an uncommon
plate area but it can spread from there to either the condition and about 1 % of
all bone infections
disc or the vertebral body [4, 5]. Several different [13]. Its a very rare in
children less than 1 year
infecting agents have been isolated including the old (Fig. 1) and although
it peaks in childhood it
most frequent staphylococcus aureus, mycobac- seems to be more common in
the elderly and in
terium tuberculosis and even rarely documented the lumbar spine rather
than the cervical or the
fungi. The literature indicates that old age can thoracic spine. It has been
noted that 95 % of
facilitate disease appearance, that there is no gen- these infections involve
the vertebral body,
der difference and also that, in spite of being while only 5 % reach the
posterior area of the
a treatable condition, it might become a life- spine [14, 15]. An epidural
abscess is a possible
threatening situation especially if not properly complication in around 90 %
of the cervical cases
treated [6, 7]. Diagnosis is often delayed and as well as 33.3 % of
thoracic and 23.6 % of
becomes a real challenge as the patients symp- lumbar cases and we must
bear in mind that it
toms and physical findings are often not severe. might also present as the
primary lesion [5, 16].
So early recognition becomes paramount in
decreasing morbidity and mortality rates. For
this purpose an exhaustive clinical examination Diagnosis
complemented by an appropriate imaging evalu-
ation is essential. As far as imaging is concerned At an early stage of a
spinal infection the incon-
PET scanning has 86 % accuracy and 100 % clusiveness of either
physical examination or
negative predictive value but MRI, on the other symptoms can make diagnosis
difficult (Fig. 2).
hand, has twice the sensitivity of a plain X-ray Nevertheless clinical
symptoms usually begin
and can detect early changes, thus making both from 4 to 10 weeks before
hospital admission
quite effective as diagnostic tools [4, 79]. The and often the time between
diagnosis and disease
imaging potential of radio-labelled antimicrobial presentation can reach as
much as 3 weeks or
peptides, antibiotic peptides or chemotactic even 6 months. Therefore
the spine surgeon
peptides have also been studied and they seem should suspect a spinal
infection whenever
to have some advantage over the classic a patient complains of
persistent pain specially
methods which might increase their role in the if accompanied by systemic
features like fever
near future [10]. and unexplained weight loss
as well as positive
laboratory findings like C-
reactive protein
changes, increased
erythrocyte sedimentation
Discitis/Spondylodiscitis rate or raised white cell
count [5, 7, 14]. Although
many authors would consider
these inflammatory
Aetiology and Epidemiology parameters very useful
others refer to their lack of
sensitivity as well as
specificity [8]. Therefore
Discitis is an infection of the spine localized in percutaneous biopsy remains
an effective diag-
the disc area but also simultaneously in bone and nostic tool in 60 % of all
cases, whilst open
therefore the term spondylodiscitis is the most biopsy is the chosen
technique whenever the
appropriate definition. Percutaneous spread or percutaneous route fails.
It is also useful when
803
Fig. 1 MRI scan in C6-7

spondylodiscitis of
9 month-old child treated
conservatively
the affected area is otherwise inaccessible with- resonance imaging, but they
all become more
out an open approach [14]. For this purpose it is useful in advanced stages.
Nuclear medicine
important to note that sometimes histology can in evaluation, which at an early
stage allows us not
fact produce a diagnosis even when no specific only the visualization of the
inflammatory pro-
infective agent has been isolated [17] and that cesses, but also the
localization or the number of
a percutaneous biopsy seems to be a more inflammatory foci, becomes
much more relevant
effective tool in diagnosing bacterial rather than at that stage (Fig. 3). The
radio-isotopic methods
fungal infections [18]. also help to detect either
physiological or bio-
chemical changes and thus
facilitate the
differential diagnosis from
sterile inflammation
Imaging [10]. However, they are not
always readily
available. Since they are
expensive and consider-
Knowing that an exhaustive clinical observation ing that a plain X-ray can
give some degree of
as well as an appropriate imaging study can give useful information, although
not at a very early
the correct diagnosis even before microbial con- stage, we really must define
clearly what is
firmation is obtained, the clinician should use the role of MRI or
scintigraphy in detecting
a wide variety of laboratory and clinical tests a spine infection?
complemented by different types of imaging to MRI is especially
important in un-operated
confirm the diagnosis. We know that the insignif- cases but is currently of
limited value to
icant anatomical changes inherent to the early differentiate between oedema
and active infection
stages of the disease significantly reduces the immediately after a surgical
procedure or in the
relevance of X-rays, ultrasound, computerized presence of metallic hardware.
In fact this is also
tomography and even sometimes magnetic a problem, even when using
nuclear medicine
804 J.
Fig. 2 (a) Adolescent

a b
patient with an early stage
spondylodiscitis T12-L1.
No major changes in X-ray
appearances. (b) MRI scan
3 months later showing
extensive changes at the
same level
techniques, where specificity also decreases Treatment

immediately after a surgical approach. One might
think that those problems could be overcome using The correct treatment for
spondylodiscitis
labelled leukocyte scanning. Unfortunately it is remains a matter of
debate. Nevertheless delayed
useless to evaluate the spine due to high uptake or inappropriate treatment
can be quite trouble-
of labelled leucocytes in hematopoietic active some leading to widespread
sepsis and subse-
bone marrow [8]. quent organ failure with
inherent higher
PET-scanning, on the other hand, has excel- morbidity and mortality.
If we can achieve
lent accuracy providing rapid results and some a correct assessment along
with an early diagno-
authors presently consider it the best option espe- sis we facilitate an
adequate treatment for the
cially in difficult cases [8, 9]. There is not a clear disease which is crucial
for its effective manage-
option that applies to each and every case so we ment. It has been said
that spondylodiscitis might
must realize that different types of image are in sometimes be a self-
healing disease but even in
fact quite important but they have to be used such cases the possible
remaining bone destruc-
according to the disease staging or its specific tion can produce
significant instability requiring
presentation otherwise misdiagnosis may occur. further treatment [19]. In
the absence of
805
Fig. 3 Scintigram
showing significant
changes in the upper
cervical spine of a patient
with C2 infection and large
abscess
neurological deficits or progressive symptoms and we know that even with

appropriate manage-
spondylodiscitis will sometimes respond to non- ment 14 % may experience
late recurrence [7]. On
surgical treatment, but otherwise surgery is the the other hand, we should
note that difficult cases
option. A wide number of treatment modalities will usually require
prolonged treatment for some-
for spinal infection have been suggested, from the times as long as 30 weeks
[7] and conservative
non-surgical such as antibiotics and bracing to treatment can only remain an
option if theres no
different types of surgery with anterior, posterior neurologic deficits, no
significant instability or
or combined approaches (Fig. 4). As we seldom deformity and no other
symptoms. Otherwise, sur-
find a corresponding clear indication for each one gery is indicated [4, 5, 7,
16]. When compared
of them, at the end of the day the specific features with surgically-treated
patients, conservatively-
of the cases will probably define treatment strat- treated ones seem to have
higher incidence of
egy. Even so, the option will often be aggressive disabling back pain and
worse functional and
treatment considering that a spinal infection radiological outcomes.
Surgery can in fact be the
might be the source of a generalised infection. best option and some would
consider that an ante-
rior debridement is a better
solution [15] whilst
Conservative Treatment others would claim that a
simple direct discectomy
When conservative treatment is indicated intrave- or even a transpedicular
discectomy are the best
nous antibiotics given for at least 10 weeks, [14] techniques. However surgery
is definitely the
sometimes in association with percutaneous drain- choice whenever we need to
reduce deformity or
age under imaging control, might still be the first stabilize the spine [20] and
then we often also need
option. Nevertheless 4357 % of the conserva- additional instrumentation
which has long been
tively-treated patients end up needing surgery, considered controversial in
active spine infections.
806 J.
Fig. 4 C2 infection and significant abscess treated with transoral dens removal and
occipito-cervical
instrumented fusion
Not using instrumentation is not the absolute solu- significant. There are
approximately 3.8 million
tion as poor sagittal correction has been reported new cases reported each
year around the
after non-instrumented fusions [15]. This fact world and probably a very
significant number
leads many surgeons to clearly recommend not reported or mis-
diagnosed. The so called
instrumented fusion, but the exact role of instru- re-appearance of the
disease might somehow
ments as well as graft material remains also be related not only to the
increased immuno-
a matter of debate [4, 19, 21]. Some [5, 13] compromised patients but
also to the multiple
would support the efficacy of aggressive debride- drug-resistant strains and
of course different
ment, anterior bone grafting and posterior stabili- socio-economic factors
[24].
zation (Fig. 5). If there is not significant vertebral
body destruction others would suggest that an ante-
rior titanium mesh cage filled with bone graft and Aetiology and Epidemiology
combined with anterior plating is an acceptable
solution [15, 20, 22]. In low risk patients there are When we consider
tuberculosis the Koch bacilli
also favourable reports on the use of PEEK cages are the infecting agents
and the infection can
without additional instrumentation to treat pyo- be localized in different
body areas as is well-
genic discitis in the cervical spine [22, 23]. But of recognized. Coming from
either the bloodstream
course the state of the art as far as surgery is or the lymphatic supply
the bacilli may reach the
concerned is to debride the infected area and stabi- anterior portion of the
vertebral body and then,
lize the spine in the best way but always bearing in with a high probability,
develop spinal tubercu-
mind that no matter what operation you perform losis. Nevertheless, it
will only happen in less
you will have to employ intravenous antibiotics for than 1 % of all
skeletally-infected patients. Espe-
no less than 6 weeks [16]. cially in uncontrolled
patients neurological defi-
cits and deformities such
as localized kyphosis
are sometimes observed and
need to be aggres-
Tuberculosis sively addressed. We must
realize that even when
using histology or culture
it is sometimes difficult
Tuberculosis seems to be increasing everywhere to differentiate between
tuberculosis and
and not only in developing countries where a pyogenic infection, in
fact it can only be
nevertheless the problem is definitely more achieved in around 62.2 %
of cases [24].
807
Fig. 5 Lumbar infection and vertebral destruction treated with anterior

decompression and fusion associated with long
Diagnosis diagnosis can become a

relevant factor consider-
ing shortening of the
elapsed time between symp-
In spite of only being diagnostic in around 2/3 of the toms and treatment. The
physician must carefully
cases, histology and culture are still indispensible identify all the
patients symptoms related to the
as diagnosis is often not an easy task. The delay in clinical picture and of
course even more so if the
808 J.
patient already has the disease diagnosed else- by decompression, exhaustive

debridement, re-
where. Some authors will claim that even in the alignment of the spine,
stabilization and fusion.
presence of a low-virulence pyogenic infection It has been mentioned that a
simple posterior
one must suspect co-existent tuberculosis if the decompression and
instrumented fusion can
disease is not responding as expected to the pre- effectively solve an early
stage, small bone
scribed normal antibiotics, or if the patient is destruction and mild kyphosis
case [25]. Nev-
immunocompromised or if a psoas calcification ertheless these results seem
to be comparable
is identified [24]. with those obtained after an
anterior approach
and, even if both approaches
can significantly
address the kyphosis, both
will also allow some
Treatment degrees of correction loss
that has to be taken
into consideration. Bezer et
al. [26] also dem-
Treatment in spinal tuberculosis is chosen onstrated that it was
possible to do an anterior
according to the patients symptoms as well as decompression and fusion
through a posterior
disease involvement and all this after careful approach preventing lumbar
kyphosis and
evaluation of any neurological deficits, existent maintaining sagittal balance
which is quite
deformity or instability, addressing each one of important considering this is
a less aggressive
these problems by itself in an overall perspective, technique. Other authors
[27], specifically at
looking for total disease control. At the present L5-S1, also reported good
results doing
time we can usually achieve an early diagnosis a TLIF (Transforaminac Lumbar
Interboy
and this can make a difference as far as treatment Fusion) to handle patients
with failure of con-
effectiveness is concerned. The new drugs and servative treatment,
localized kyphosis, neural
more effective types of instrumentation allow us compression and limited
destruction of the disc
also to achieve better results from the prescribed as well as adjacent vertebral
bodies. So in gen-
treatments. The assessment of the levels eral it seems that surgery
must be chosen in an
involved, the existence and location of an abscess individual manner depending
on disease
or bone destruction must be made in selecting specificity, patient
characteristics and the
adequate treatment. Minor cases can be surgeons ability to perform
each technique.
controlled conservatively with anti-tuberculosis As with other pathologies our
spinal tuberculo-
drugs, and this should probably be always a first sis patients should be
treated with the least
choice, but more severe cases will definitely aggressive, most effective
and long-lasting
need additional surgery and the infection site technique but this,
unfortunately, cannot be
must of course be thoroughly cleared. systematically applied all
the time.

As is well-recognized, surgery is indicated Post-Operative Infection
whenever there are significant deformity,
major instability, important neurological Post-operative infections are
sometimes very
deficits, large abscesses or failure of conserva- problematic and troublesome
complications of
tive treatment leading to either progression spine surgery. They can be
diagnosed immedi-
of symptoms and signs, or increased bone ately after surgery but
sometimes even several
involvement. There is no single generalized years later (Fig. 6). We must
always be aware of
technique for all patients. A wide anterior this possibility and take all
measures to avoid it
debridement and fusion, a front and back by meticulous techniques. We
also have to realize
fusion, either in one or in two procedures and that the use of a simple
dilute betadine solution
a posterior-alone fusion have all been can moderately reduce the
risk of infection.
suggested and all aim to achieve surgical treat- Meanwhile pursuing an
understanding of what
ment goals. These are; controlling the disease can facilitate infection, why
some patients are
809
Fig. 6 Late infection with

wound discharge after
scoliosis surgery (3 years
later)
more prone to it as well as how we can prevent it sterile technique of the team
also influence infec-
or safely treat it, are crucial steps. We sometimes tion rates and this in spite
of some reports that
assume this diagnosis based only on local pain, question whether post-
operative infections are
inflammatory changes or wound discharge and related to the experience of
surgical staff [29].
this is not reliable [28]. Although we know that
staphylococcus aureus or
epidermidis are the most
common infecting
agents a significant number
of cases still remain
Aetiology and Epidemiology without an isolated agent and
of course this
creates additional
difficulties [30]. Risk factors
Many surgeons would agree that post-operative have to be carefully
identified which seem to be
infections are mainly the result of a surgical multi-factorial and may be
case-specific or
wound contamination inside the operating room patient-related ones. Obese
people seem to be
or in the ward immediately after surgery and that more prone to infection,
wound drainage has
the infecting agent often comes from the a minor role and there is
only indefinite evidence
patients own flora. The skin of all individuals suggesting that pre-operative
prophylactic anti-
accessing the operating room as well as the ward biotics might improve
infection rate even if we
is generally recognised as a main source of all are not able to identify the
most effective one or
airborne organisms, so the more people we have the right dosage [31].
Operative time, previous
inside the operating theatre the more organisms spine surgery, blood loss,
tissue damage, diabe-
will be circulating. The surgical ability and tes, smoking, old age,
rheumatoid arthritis,
810 J.
Fig. 7 Early infection and wound discharge after long spine stabilization in trauma
patient treated with wide
debridement and instruments preservation
steroid use or previous infection are all consid- and that is important, as
the consequences
ered contributory [29, 3133]. The use of of a spinal infection
include longer and
implants might also incur in additional risk of more expensive hospital
stays, a two-fold
wound infection at the insertion level [34] or increase in mortality, a
five-fold risk of hospital
even at the level above [35]. re-admission, and a 60 %
greater chance of
Spinal surgery has a higher infection rate then intensive care unit
admission [29].
other surgeries such as total hip arthroplasty.
However there is a wide variation (0.320 %)
in reported infection rates after spine surgery Treatment
[30, 34] and in the incidence of delayed infection
which varies from 0.2 % to 6.7 % [28]. So there Usually a post-operative
spine infection is treated
might be a correspondence between the with multiple wide
debridement primary or
complexity or increasing number of invasive delayed wound closure and
antibiotics for no
surgical procedures and higher infection rates. less than 6 weeks.
Different options have been
We consider that revision surgery is more prone suggested and the use of a
vacuum-assisted
to infection than implant use and, on the other wound closure is a
possibility as it exposes the
hand, minimally-invasive surgery is associated wound to negative
pressures, removes fluid,
with less infection [30], although it takes more improves blood supply and
stimulates granula-
operative time. Since the cost of spinal tion tissue appearance
providing good results in
treatments is always increasing, a significant association with surgical
debridement [37].
reduction in risk factors would prove valuable, In the early stages implant
removal is seldom
allowing surgeons to carefully identify them and necessary (Fig. 7) since
implants can
act accordingly. There are inherent differences promote fusion and their
removal might result
in hospital rates for per-operative spine infection in spinal instability and
pseudarthrosis [32, 38].
across teaching and non-teaching hospitals [36] Collins et al. [28]
mentioned that there was
811
a confirmed 60 % deep wound infection on 3. Richmond BG, Strait

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E, Schon R. Septic hematog-
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in the cervical spine: a minimum
with wide debridement was an effective option as 2-year follow-up.
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Surgical Management
of Spondylodiscitis
Maite Ubierna and Enric Ca

ceres Palou
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 814 Vertebral osteomyelitis or spondylodiscitis
is an uncommon, mainly haematogenous,

Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 814
disease that usually affects the adult. The

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 814 incidence of this condition has steadily risen
Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 814 in recent years because of the increase in spinal
Micro-Organisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 814
surgery and nosocomial bacteraemia, aging of

Pyogenic Vertebral Osteomyelitis . . . . . . . . . . . . . . . .
814 the population and intravenous drug addiction.
Pathophysiology of Bacterial Spinal Infection . . . . .
814
Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 815
Pyogenic infection due to Staphylococcus

Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 816 aureus is the most frequent form of the disease
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 816 but tuberculosis is still a common cause of
Spinal Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
818 spondylitis. The clinical presentation is
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 818 non-specific and the diagnosis is often delayed.
. . . 818 Magnetic resonance imaging is the most sen-
. . . . 819
sitive radiological technique for this disease.

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 820
Blood cultures are sometimes positive but

Treatment of Spinal Infection . . . . . . . . . . . . . . . . . . . . . 820
computed tomography-guided needle biopsy
Medical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 820
is sometimes required to achieve a microbio-

Surgical
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
821 logical diagnosis. Prolonged antibiotic therapy
Double Approach Anterior and Posterior . . . . . . . . . . .
821
Posterior
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
825
and occasionally surgery are essential for cure

Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 825 in most patient, and both factors have contrib-
uted to a reduction in the morbidity and

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 826
mortality of the disease in recent years.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 826
Keywords
Anterior # Classification # Clinical features #
Diagnosis # Epidemiology # Indications #

M. Ubierna (*)
Medical treatment # Microbiology # Posterior
Spine Unit, Hospital Germas Trias i Pujol Badalona,
# Pyogenic vertebral osteomyelitis # Radiology
Barcelona, Spain
and scanning # Results # Spine # Spondylo-

e-mail: Maiteubi8587@gmail.com
discitis # Surgical approaches-anterior and

E.C. Palou
posterior # Techniques # Tuberculosis

Department Hospital Vall dHebron, Autonomous
e-mail: ecaceres@vhebron.net

813
DOI 10.1007/978-3-642-34746-7_219, # EFORT 2014
814 M.
Ubierna and E.C. Palou
be present in all cases of

vertebral body bone
Introduction involvement [25]. Finally,
it is very exceptional
to see isolated posterior
arch involvement, of
The spine is the most common site of which there are only16
documented cases in the
haematogenous bone infection in adults. At pre- literature [6].
sent, the sensitivity and specificity of imaging
techniques, the versatility of the spinal instru-
mentation and decreased surgical morbidity Micro-Organisms
allow healing in these patients. Despite this,
diagnosis and treatment remain as major chal- It is possible to
differentiate between bacterial,
lenges for the Orthopaedic surgeon. Selective granulomatous and fungus
infections with very
antibiotic therapy, early techniques combined different clinical behaviour
and histopathological
with spinal stabilization and biological input appearances.
if necessary, have reduced mortality from The route of spread can
differentiate between
5 % to 15 % [1]. hematogenous, direct
inoculation (post-operative)
and propagation by continuity
(from vascular
urological, or gastro-
intestinal surgery).
Epidemiology Depending on the age of
presentation can
speak of spinal infection in
children and in adults.
Spinal infection represents between 2 % and 5 % The behaviour and the
potential consequences are
of bone and joint infections. Among the risk very different.
factors listed are age, obesity, malnutrition, In the next pages we
could will divide the
diabetes, immunodeficiency, previous infection description into two sections
, pyogenic vertebral
and prior surgical procedures. If we compare the osteomyelitis and secondly
vertebral tuberculosis.
epidemiological data of vertebral infection with
osteomyelitis in the extremities there are clear
differences. The average age of patients with Pyogenic Vertebral
Osteomyelitis
spinal infection is 66 years while that in limb
infection is 16 years. The male/female ratio is Pathophysiology of Bacterial
Spinal
1:12:1 infection in spine and limbs. Infection
The haematogenous route is

the usual route of
Classification infection in the infection of
the column from a
septic focus such as
infection of the skin or soft
Classifications are related to the location of the tissues, urinary tract or
respiratory tract, which
infection and the aetiological organism. are among the most common.
There are two
main theories that could
explain haematogenous
seeding,
Location (a) spread via Batsons
venous plexus (Fig. 1) or
(b) spread by the venous
drainage of the pelvis,
Spondylodiscitis is present when the infection which pre-supposes the
existence of pres-
settles in the vertebral body and spreads to the sures sufficient to
cause retrograde flow to
adjacent disc; discitis is a term used for the iso- direct the bacteria
released from the bowel
lated disc space infection secondary to disc sur- manipulated in the
abdomino-pelvic area to
gery, discography or percutaneous nucleotomy. the spinal column.
Currently the existence of isolated hematogenous Currently, most authors
seem to favour the
discitis in children is being discussed because arterial system as the route
for the transmission
several authors suggest that MRI evidence must of infection. The arteriolar
theory described by
Surgical Management of Spondylodiscitis
815
the spread of the

infection to the spinal canal may
cause an epidural
abscess. The aggressive
osteolytic bone
infection causes bone destruc-
tion, leading to
compression fractures or fracture
with neurological or
mechanical instability.
In children, the
behaviour is different. Vascu-
lar channels
traversing the end-plate to irrigate
the nucleus pulposus
allow direct haematogenous
spread to the
intervertebral disc in this popula-
tion. Some cases
progress rapidly to neurological
deterioration. The
causes include: the formation
of an epidural
abscess by posterior common lig-
ament detachment, a
bone fragment posteriorlt
impinging on the
spinal cord or the development
of severe deformity
due to bone destruction.
Risk factors for
neurological injury have been
described: diabetes,
rheumatoid arthritis, steroid
treatment, advanced
age and location in the cer-
vical or high
thoracic spine [8].
Clinical Features
The mode of
presentation of a spinal infection is
highly variable. The
symptoms depend on host
immunity, the
aggressiveness of the organism
and the duration of
the process. The clinical picture
Fig. 1 Batsons paravertebral venous system. It is a set of
can be acute,
subacute or chronic. Overall there is a
veins, which anastomose and extra-abdominally commu-
nicate with the main intra-abdominal venous system. variable interval of
time (115 months) to reach
1 paravertebral venous plexus, 2 inferior vena cava, the diagnosis. This
due to the association in elderly
3 inferior mesenteric vessel, 4 iliac vein, 5 pelvic plexus patients with common
symptoms of spinal pain
(From Vider et al. 1977 [31])
(degnerative changes
and arthritis). MRI imaging
early greatly
accelerates the diagnostic process.
Wiley and Trueta [7] suggests that bacteria reach Always spinal
pain is present (90 % of cases).
the area located in the subchondral vertebral plate It is an inflammatory
pain, not relieved and even
arterial anastomosis which form septic thrombus. accentuated with
rest. There is intolerance for
This triggers a rapid inflammatory response sitting. Pain
radiating to the extremities can
which, together with the lysosomal activity, causes occur when there is
root compromise. Fever is
weakening and destruction of the subchondral only present in 50 %
of cases [9].
zone and penetrates the disc and adjacent vertebral In advanced
stages of the disease with signif-
body. (Fig. 2). The disc is rapidly destroyed with icant bone
destruction, segmental mechanical
a sudden loss of intervertberal space height. instability clearly
increases pain and function of
In the cervical spine, the prevertebral fascia the patient. The most
common location is in lum-
can spread the infection into the mediastinal bar spine, around 50
%. while only 10 % are
space or supraclavicular fossa aggravating the located in the
cervical spine.
clinical situation. In the lumbar spine infection Neurological
involvement appears in between
may go the way of the psoas sheath to the 10 % and 20 % of
patients, depending on the
piriform fossa or to the hip area. In some cases different series, in
the form of paraesthesiae,
816
M. Ubierna and E.C. Palou
a b c
d
Fig. 2 The most common pathophysiology of spinal infection. Showing septic

subchondral bone end-plate. Propaga-
tion later to the disc space and adjacent vertebral body
cramps, neurological claudication, motor deficit It is essential to

order appropriate diagnostic
and even early onset paraplegia [10]. The most and laboratory
investigations that will lead to the
common cause is a secondary epidural abscess diagnosis:
(27.5 %) followed by inflammatory tissue in 6.1 %.
History
The patient can come from
different medical
Microbiology specialties-
rheumatology, Orthopaedics, internal
medicine and general
surgery because the symp-
Staphylococcus aureus remains the most com- toms are often confusing.
In many cases, patients
mon pathogen (4255 % in adults and 8090 % have come to the
emergency room on more than
in children [1115]. Streptococcus occurs in one occasion and almost
always are labelled
19.6 % and in the last decade there has been an mechanical pain or
degenerative. Focussed
increased incidence of gram-negative bacilli such questioning can
distinguish the chronic degener-
as Escherichia coli, Pseudomonas and Proteus ative symptoms from a
subacute spinal pain that
microorganisms from the urinary tract, respira- does not respond to
standard treatment and is
tory tract, soft tissue infections or from normal accompanied by malaise
and sometimes gait
flora in immunocompromised patients. Patients claudication.
addicted to intravenous drugs have a higher It is important to
find a previous infectious in
incidence especially Pseudomonas and diabetic another location, which
is responsible for
patients to anaerobes. Microorganisms like haematogenous sepsis.
Sometimes a wound or
Staphylococcus plasmacoagulase-negative were skin erosion may be the
gateway in the immuno-
the cause in 14.7 % of cases in the series compromised patient.
published by Hadjipavlou [1618].
Radiology
Radiological images are
often inconclusive dur-
Diagnosis ing the first 2 or 4
weeks after onset of the disease.
The first visible change
is usually the loss of disc
Diagnostic delay is a characteristic feature of space height. Then
osteolytic lesions appear in the
spinal infection despite having tools for identify- vertebral body adjacent
to the end-plate zone may
ing pathology with certainty in the short term. We progress to destruction
of both vertebral bodies
just need to know how to use them and be able to (Fig. 3). In advanced
stages of the disease it is
differentiate between: granulomatous infection, easy to see wedge
kyphosis deformity, sometimes
bacterial infection, metastases, myeloma, osteo- severe, from destruction
of the entire vertebral
porotic fracture, degenerative disease, and pri- segment. The soft tissue
extension usually is due
mary neoplasm pseudodiscitis. to prevertebral oedema
and inflammation of the
817
a b
Fig. 3 Differences in behaviour in the initial phase of tuberculous infection.

(b) Pattern in both aggressive
tuberculosis and bacterial infection. (a) Minimal loss of osteolytic vertebral
bodies and kyphosis with disc collapse
disc space height without visible bone lesion is seen in in pyogenic infection
psoas muscle may cause psoas enlargement CRP is a more sensitive

and specific parameter,
and detachment in the lower back. A widened is increased in most
cases in the acute or subacute
mediastinum in the thoracic spine and increased phase, and returns to
normal quickly with effec-
shadow in the retropharyngeal space indicate tive treatment.
infection at the thoracic and cervical levels.
Bone Scanning
Laboratory Bone scanning is more
sensitive than radiography
Very often laboratory results are non-specific. although is not
specific to bone infection. It has
There is leukocytosis in 1360 % of cases, how- a role as skeleton
tracker to identify septic foci at
ever, chronic infections in elderly patients with different levels, a
situation described in 35 % of
poor nutrition often have normal blood markers. occasions. The combined
results of the study
The sedimentation rate is increased in 90 % of with 99Tch and Ga 67,
provide a sensitivity
cases between 50 and 55 mm/h. In the series of of 90 % and an
efficiency of 85 % for the
101 cases of bacterial infection collected by diagnosis of infection.
The specificity of gallium
Hadjipavlou [16] leukocytosis as statistically sig- Ga 67 is 85 %, slightly
higher than the 99 m Tc
nificant indicator of epidural abscess, and ele- Technecio 78 %.
Moreover, the Ga 67 can be
vated ESR were associated with a strong normalized in a few
weeks if the clinical course
tendency to epidural abscess. Both parameters is favourable, while
Tc99m remains positive for
are a red flag for possible complications. about a year.
818
MRI Scanning causes: antibiotic therapy

before biopsy, insuffi-
MRI is the technique of choice at present for the cient material and a
natural ability for healing
diagnosis of infection of the spine. It provides disc as Fraser had
described [21, 22].
excellent images of the extension of the process Open biopsy is
restricted to cases in which
in bone, disc, nerve and soft tissue adjacent struc- the needle biopsy has
failed, when the location
tures. It provides a very high sensitivity and spec- is inaccessible to closed
techniques or when the
ificity, 93 % and 96 % respectively in the symptoms of the infection
require surgical
diagnosis of bone infection [3]. treatment.
T2-weighted sequences show hyper-intense
signal attributable to oedema of the disk and the
vertebral body and in T1-weighted images Spinal Tuberculosis
the signal is decreased in both the disk and the
vertebral body due to replacement of the fatty Tuberculous spinal
infection is also known as
tissue of the bone marrow. T1 characteristically granulomatous infection.
This terminology
shows the loss of boundaries between the disc refers to organisms that
cause an immune response
and the endplate. The paramagnetic contrast in the host characterized
by the formation of gran-
injection, gadolinium, is useful in differentiating ulomata. Histologically,
these granulomata are
bone infection of post-surgical origin [19]. MRI chronic inflammatory foci
with nodular appear-
allows for the differential diagnosis of bone ance, with a central area
of necrosis surrounded
infection and neoplasia, as the latter does not by Langhans giant cells.
The most frequent gran-
extend to the intervertebral disc. ulomatous infection is
caused by Mycobacterium
Tuberculosis organisms
responsible for spinal
CT Scanning tuberculosis, described by
Sir Percival Pott
CT scanning has been displaced by the MRI from in 1779.
the point of view of specificity and diagnostic
sensitivity. However CT scanning is the best
tool to assess the degree of bone destruction and Epidemiology
can be of great help in deciding the type surgery
that is performed. Tuberculous spinal
infection is the most common
form of extrapulmonary
Mycobacterium tubercu-
Isolation of Aetiologic Bacteria losis. Its incidence ranges
from 1 % in developed
It is essential to identify the bacteria responsible countries to 10 % in
endemic areas. In the
for spinal infection to confirm the diagnosis. As a last decade, the incidence
has increased in
protocol, blood and urine cultures are needed in developed countries
attributed to increased
all cases. If fever is present blood culture perfor- immunosuppressed patients
and bacterial mutations
mance is of greater value. leading to increased
virulence and resistance to
In patients in whom we have not succeeded in drug treatment.
isolating the bacterium, we recommend performing An estimated 1.7
billion people, one-third of
a spinal puncture biopsy. The effectiveness incre- the population of the
earth, are or have been
ases if performed by percutaneous CT-guided infected with TB. Of all
patients with TB, 10 %
puncture. The technique increases success if mate- had musculoskeletal
involvement and of these
rial is referred to microbiology and pathology in all 50 % were of vertebral
location.
cases. the results are positive in between 70 % and
88 % for the diagnosis of infection [20]. Histopa-
thology can differentiate acute chronic pyogenic Pathophysiology
infection from granulomatous infection.
In the series of Hadjipavlou et al. they found The vertebrae are usually
infected secondarily to
24.4 % of negative cultures and suggested three haematogenous spread from a
pulmonary focus.
819
a b
Fig. 4 Formation of paradiscal tuberculosis infection. In the sagittal (a) and

frontal plane (b) the vertebral body
involvement and spread to the adjacent vertebra through the anterior common
ligament occurs
In some cases it is due to direct expansion Clinical Features

or lymphatic spread from a renal focus.
Currently, most cases of spinal tuberculosis in The thoracic location is
the most common
adults are silent re-activations of lung foci. followed closely by the
lumbar location
Three forms of vertebral involvement are and more infrequent
cervical involvement.
described: paradiscal, anterior and central Multi-segment
localization occurs between 1 %
(Fig. 4). Dobson, in a review of 914 cases, and 24 % depending on
nutritional status and
showed 33 % paradiscal, 12 % central and 2 % immunosuppression.
anterior. Involvement of the posterior structures The clinical
presentation of tuberculosis infec-
is less than 10 % [23]. tion is much more
insidious than the bacterial
The paradiscal form, the most common, shows infection leading to
frequent diagnostic delay.
haematogenous seeding located at the end-plate. According to different
publications, there is an
Slowly the infection spreads through the interval ranging from
between 3 months to 18
adjacent ,vertebra, the anterior vertebral common from the start of
symptoms to diagnosis.
ligament in most cases and sometimes through The common onset
symptom is slow but pro-
the posterior common ligament. The disc, in gressive spinal pain,.
The long duration of symp-
incipient forms, is not involved in many cases, toms makes the diagnosis
at the time associate to
unlike pyogenic infection when almost always other problems: epidural
abscess, angular kypho-
disc destruction is present. Bone destruction is sis deformity and
neurological impairment.
slow but progressive, with a kyphotic deformity About 40 % of patients
develop sensory-motor
at advanced stages. deficit more often in
the thoracic and cervical
The central form affects only the vertebral location. In the
cervical spine there have been
body, without involvement of the disc and adja- reported up to 80 % of
cases with neurological
cent vertebra. The destruction of bone tissue deficit. Advanced age
and diabetes have been
causes an isolated vertebral body wedging, show- described as risk
factors for developing neurolog-
ing an image that will appear like a fracture or a ical complications.
tumour. The differential diagnosis is more Paravertebral
abscess formation is not rare in
difficult. large tuberculosis
infection. In the cervical region
820 M.
Ubierna and E.C. Palou
in children retropharyngeal abscess is more com- Magnetic resonance

imaging is the investiga-
mon and may displace and compress the trachea tion of choice and probably
the most effective.
and oesophagus. In the thoracic region the The amplitude of the
explored area allows us to
abscess causes adhesions between pleura and obtain complete information
on the extent of
diaphragm. The abscess located in the lumbar bone involvement, soft
tissue and neurological
region is more frequent. Large abscesses can damage. Signal changes are
similar to those
descend in the psoas sheath to the region where described in bacterial
infection as opposed to a
they present at the adductors muscle site. lesser involvement of the
intervertebral disc. The
The kyphosis deformity at the time of diagno- MRI also allow us to
differentiate between dif-
sis is also a characteristic of tuberculosis infec- ferent types of anatomical
involvement (Fig. 2).
tion due to severe spinal vertebral destruction. It The use of paramagnetic
contrast agent, Gadolin-
is accompanied by severe mechanical instability ium, allows better
visualization of abscesses.
especially in the thoracolumbar junction which If you draw a contrast
capture peripheral ring
often aggravates the already existing neurologi- indicating the boundaries of
the abscess, and if
cal instability. instead it displays a large
mass with contrast
enhancement, it is probably
tissue granulation.
CT-guided byopsy will
give a definitive diag-
Diagnosis nosis. Microbiological study
will be conducted
by Loweinstein culture and
histopathology for
The diagnostic strategy in TB infection follow the presence of granulomas
that will support the
the same criteria as described for bacterial infec- diagnosis and initiate
specific treatment pending
tions, with the differences in clinical behaviour culture results.
and characteristic: slow onset and late diagnosis.
The laboratory studies will include the search
for the Kochs bacillus in gastric juice, sputum
and urine. Mantoux or PPD testing , which detect Treatment of Spinal
Infection
active TB or old exposure are useful. Acute phase
reactants are still less sensitive than in bacterial The goals of treatment of
spinal infection are:
infection due to the chronicity of the process. cure the disease, decrease
pain, preserve or
The polymerase chain reaction is a promising improve neurological
function and maintain
technique for the rapid detection of tuberculosis mechanical balance of the
spine (sagittal and
infection. frontal) and prevent disease
recurrence.
Radiology can be valuable at the first visit of Basically the treatment
of spinal infection is
the patient due to the duration of symptoms. pharmacological. Surgical
treatment is associ-
Bone destruction is visible with involvement of ated with the presence of
complications such as
two adjacent vertebral bodies. If diagnosed at neurological deficit,
epidural abscess or mechan-
an early stage the only radiographic sign is loss ical disruption in those
cases where specific med-
of disc height since it takes time to see the ical treatment can not cure
the disease.
signs of bone destruction (Fig. 3). Careful exam-
ination of the junctional zones, thoracolumbar,
lumbosacral and cervicothoracicis necessary
since in these areas, that are difficult to display Medical Treatment
in standard emergency radiology and destructive
infectious lesions, may go unrecognized. The Pyogenic Infection
chest X-ray should be part of the study protocol. Once identified the
causative organism should be
The bone scan is less sensitive than in bacterial treated according to the
antibiogram. Full doses
infections, with up to 40 % false negative Tch 99 intravenously should be the
choice. This should
and up to 70 % false negative Gallium 67 Ga. be maintained between 3 and
6 weeks and then
821
move on to oral if the response has been clinically This, today can be improved
through the use
and biologically positive. PCR repeated during of specialized surgical
techniques to support
the evolution of the disease reflect the response to advances in anesthetics and
new instrumenta-
treatment. The duration of oral antibiotic therapy tion devices.
will depend on the organism, the immune system
of the patient and other factors such as the pres-
ence of implants.
Contact orthoses are useful in the lumbar Surgical Treatment
region, while the cervical region may require
immobilization with a rigid cervicothoracic halo At present the surgical
treatment in spinal infec-
or brace. Mechanical restraint is intended to tion has a clear role in
promoting bone healing
relieve pain and prevent deformity. and preventing devastating
consequences. There
Prevention and recurrence is important in mal- are absolute [27] and
relative indications: Among
nourished hospitalized patients, such as elderly, these are absolute
indications for surgery are:
patients with chronic disease in whom there are open abscess drainage not
percutaneous drain-
increased metabolic needs secondary to fever, age; neurological deficit
secondary to compres-
severe infection or surgical treatment. The goal sion or bone destruction,
severe kyphosis that
is to restore satisfactory nutritional status in the imbalances the spine.
Relative indications are:
patient. The aim is to achieve a serum albumin absence of a causative
organism, failure of med-
>3 g/dl, absolute lymphocyte count >800/ml, ical treatment to control
the symptoms and lack
blood transferring >1.5 g/l and creatinine excre- of fusion, pseudarthrosis
and segmental pain.
tion in 24 h >10.5 mg in men and 5.8 mg in There are considerable
risks associated with
women [24]. this surgery. Patients older
than 60 years, diabetes,
immunosuppression and
malnutrition but should
not be considered contra-
indications. The timing
Tuberculosis Infection of the surgery will be
performed as early as pos-
Due difficulties in isolating the organism the sible from the moment that
the patient matches the
pharmacological treatment should be long and criteria indicated for
surgical treatment.
well-tracked for eradicating the disease and not The type of surgery will
depend on the
create drug resistance. affected segment and the
goal of surgery in each
Chemotherapy is the primary treatment case. There are three main
surgical techniques
for bone tuberculosis eradication. The British required with different
clinical situations.
Medical Council group has carried out numer-
ous works since 1963 to understand the behav-
iour and response of bone tuberculosis to
various drug treatments. Their results show Double Approach Anterior
that specific medical treatment for a period of and Posterior
6 months is enough to cure bone TB [25]. In the
first 2 months, 3 drugs: isoniazid, rifampicin This is the most aggressive
but also the safest
and pyrazinamide are used and in the remaining technique. Preferably it is
indicated in cases
4 months, 2 drugs, isoniazid and rifampicin. It with: spinal cord
compression, and severe
is important to monitor the compliance of drug kyphotic deformity and psoas
abscess. They are
treatment by a TB infection specialist. Changes usually advanced cases of
the disease in which
may be needed depending on treatment resis- there is severe destruction
of the anterior column
tance or intolerance. However the published with or without neurological
involvement. Nor-
results showed that long-term healing of the mally, it takes an anterior
approach first to allow
disease was accompanied by residual kyphosis extensive clearing of the
disc-vertebral segment,
or lack of fusion in about 40 % [25, 26]. spinal decompression and
reconstruction of
822
a b
c d
Fig. 5 76 year-old patient with long-standing back pain T2 hyperintense disc

and spinal cord compression. (c)
and paraparesis (Frankel C). (a) Radiology with involve- MRI coronal
paravertebral abscess. (d) Spinal CT-guided
ment T10-T11 and kyphosis angle of 20# . (b) MRI sagittal biopsy gave the result-
of tuberculosis infection
bone stock from the anterior column by bone pedicled-vascularized

rib in the case of the tho-
grafting as described by the Hong Kong school racic spine which
provides support and
in 1964 [2]. immediate vascular
supply, resulting in a shorter
We recommend using structural autologous integration time.
Allograft bone will be used
graft from iliac crest preferably tri-cortical or rarely in septic
processes, as it is associated
823
a b
c d
Fig. 6 The same patient was operated on by a double approach with pedicle rib graft
and posterior instrumentation.
(a, b) Radiology infectious focus fusion. (c, d) CT reconstruction- previous graft
incorporated
with a higher percentage of fracture and delayed stabilized by pedicle

instrumentation and postero-
union [29]. Recently titanium mesh filled with lateral arthrodesis is
performed. Immediate sta-
bone to reconstruct the anterior column has been bility is achieved by
promoting the incorporation
used. We prefer not to use metal implants unless it of the graft and the
improved fusion rate allows
is strictly necessary. In the second stage a poste- early rehabilitation of
the patient. (Figs. 5 and 6).
rior approach through which correction of the This second approach can
be performed in a
deformity of the posterior column can be single procedure or
staged at 2-week intervals.
824
a b
c d
Fig. 7 68 year-old patient diagnosed with vertebral uptake. (c) T2-

hyperintense sequence disc. (d) T1-weighted
bacterial infection by gram-negative organism. (a) Involve- sequence shows
diagnostic hypo-signal affecting vertebral
ment of levels T12-l1-l2 with bone injury and disc space at bodies and disc
spaces supporting the diagnosis
both levels. Angular kyphosis. (b) Positive scintigraphic
825
a b
Fig. 8 Same patient who underwent instrumented posterolateral fusion in the absence
of complications. (a) Immediate
post-operative control radiograph. (b) 2 years post-operatively showing complete
healing of the disease
In cases where there were contra-indications to of the infection site.

The results have been very
the anterior approach, costotransversectomy can satisfactory at
intermediate stages of the disease
be used for access to the anterior column and or cases with sequelae
without major complica-
allows radical, clearing and drainage of abscesses. tions. The technique
acts as an internal immobi-
The double approach is the most commonly lization system that
favours the fusion and
used and especially in cases where there is reduces the risk of non-
union (Figs. 7 and 8).
involvement the thoracolumbar junction, because The indication of choice
is: the persistence of
a highly unstable transition area between thoracic pain at the end of
medical treatment, the tendency
kyphosis and lordosis exists. Despite the potential to segmental interbody
fusion and when there has
morbidity of this surgery, it has provided excel- been no isolation of the
pathogen.
lent results in the literature and this is confirmed
by our own experience.
Anterior Approach
The isolated anterior

approach technique was first
Posterior Approach described by Hodgson in
1964 for the treatment
of tuberculosis
infection. Currently performed
This is a common technique using spinal instru- as an isolated technique
is exceptional in the
mentation with pedicle screws or laminar hooks thoracic and lumbar
spine. It is most appropriate
and provides sagittal deformity correction, mod- in rare cases of
cervical infection. It can be a
erate posterolateral biological contribution and valuable in cases where
only drainage and bone
perhaps most important immediate stabilization grafting is sought for
the lumbar lordosis.
826
Yilmaz et al. [30] study showed how infection 6. Ergan M, Macro

M, Benhamou CL. Septic arthritis of
could be treated by anterior approaches over lumbar facet
joints: a review of six cases. Rev Rhum
Engl Ed.
1997;64:38695.
previous spinal instrumentation, avoiding subse- 7. Wiley AM,
Trueta J. The vascular anatomy of the spine
quent second approach. It is imperative to have an and its
relationship to pyogenic vertebral osteomyekitis.
intact posterior column to carry on this technique. J Bone Joint
Surg Br. 1959;41:796809.
In general, surgery is more common in cases 8. Eismont FJ,
Bohlman HH, Soni PL, Goldberg VM,
Freehafer AA.
Pyogenic and fungal vertebral osteo-
of tuberculous spinal infection than in bacterial myelitis with
infection. The clinical behaviour of tuberculosis 1983;65:1929.
infection with slow and subacute development. 9. Torda AJ,
Gottlieb T, Bradbury R. Pyogenic vertebral
implies that at the time of diagnosis a big imbal- osteomyelitis:
analysis of 20 cases and review. Clin
Infect Dis.
1995;20:3208.
ance deformity exists or neurological compro- 10. Emery SE, Chan
DP, Woodward HR. Tratment of
mise which require more aggressive treatment hematogenous
pyogenic vertebral osteomyelitis with
for healing. In our experience over 50 % of anterior
debridement and primary bone grafting.
patients with spinal tuberculosis underwent sur- Spine.
1989;14:28491.
11. Hadjipavlou AG,
Crow WN, Borowski A, Mader JT,
gical treatment. Adesokan A,
Jensen RE. Percutaneous transpedicular
discectomy and
drainage in pyogenic spondylodiscitis.
Am J Orthop.
1998;27:18897.
Conclusions 12. Kemp HBS,
Jackson JW, Jeremiah JD, Hall AJ. Pyo-
genic
infections occurring primarily in intervertebral
Infections are the most common vertebral discs. J Bone
Joint Surg Br. 1973;55:698714.
13. Rath SA, Neff
U, Schneider O, Ritchter HP. Neuro-
haematogenous bacterial and tuberculous infec- surgical
management of thoracic and lumbar vertebral
tions. Early diagnosis and specific medical treat- osteomyelitis
and discitis in adults: a review of 43
ment can cure the disease. Surgery is has specific consecutive
surgically treated patients. Neurosurgery.
indications which greatly enhance therapeutic 1996;38:92633.
14. Sapico F,
Montgomerie JZ. Vertebral osteomyelitis.
healing. Faced with a poor response to drug treat- Infect Dis Clin
North Am. 1990;4:53950.
ment or in the presence of complications surgical 15. Waldvogel FA,
Papageorgiou PS. Osteomyelitis: the
treatment should not be delayed. The results are past decace. N
Engl J Med. 1980;303:36070.
excellent in the revised series despite with 16. Hadjipavlou AG,
Mader JT, Necessary JT,
Muffoletto AJ.
Spine. 2000;25:166879.
aggressive surgery and even in elderly patients. 17. De Witt D,
Mulla R, Cowie MR, Mason JC,
Do not forget to maintain a satisfactory nutri- Davies KA.
Vertebral osteomyelitis due to Staphylo-
tional status; it will determine much of the coccus
epidermidis. Br J Rheumatol. 1993;32:23941.
success of treatment. 18. Darouchi RO,
Hamill RJ, Greenberg SB, Weaathers
SW, Musher DM.
Bacterial spinal epidural abscess:
review of 43
cases and literature survey. Medicine.
1992;71:36985.
References 19. Lang IM, Hughes
DG, Jenkins JP, St Clair Forbes W,
Mc Kenna F. Mr
imaging appearances of cervical
1. Carregee EJ. Pyogenic vertebral osteomielitis. J Bone epidural
abscess. Clin Radiol. 1995;50:46671.
Joint Surg Am. 1997;79:8748800. 20. Kornblum MB,
Wesolowski DP, Fischgrund JS,
2. Ring D, Wenger DR. Pyogenic infectious spondylitis Herkowitz HN.
Computed tomography-guided biopsy of
in children: the evolution to current Thought. Am the spine: a
review of 103 patients. Spine. 1998;23:815.
J Orthop. 1996;25:3428. 21. Fraser RD, Osti
OL, Vernon-Roberts B. Iatrogenic
3. Modic MT, Feiglin DH, Piranio DW, et al. Vertebral discitis: the
role of intravenous antibiotics in preven-
osteomyelitis: assessement using MR. Radiology. tion and
treatment: an experimental study. Spine.
1985;157:15766. 1989;14:1025
32.
4. Post MJD, Quencer RM, Montalve BM, Katz BH, 22. Stoker DJ,
Kissin CM. Percutaneous vertebral
Eismont FJ, Green BA. Spinal infection: evaluation biopsy: a
review of 135 cases. Clin Radiol. 1985;36:
with MR imaging and intraoperative US. Radiology. 56977.
1988;169:76571. 23. Dobson J.
Tuberculosis of the spine. An analysis of the
5. Gorse GJ, Pais MJ, Kusske JA, Cesario TC. Tubercu- results of the
conservative treatment and of the factors
lous spondylitis: a report of six cases and review of the influencing the
prognosis. J Bone Joint Surg Br.
literature. Medicine. 1983;62:17893. 1951;33:517.
827
24. Tay BKB, Deckey J, Hu SS. Infections of the spine. management of

spinal tuberculosis in children:
J Am Acad Orthop Surg. 2002;10:18897. Hong-Kong
operation compared with debridement
25. Medical Research Council Working Party on tubercu- surgery for
short and long term outcome of deformity.
losis of the spine. A comparison of 6 or 9 months course Spine.
1993;18:170411.
regime of chemotherapy in patients receiving ambula- 29. Govender S,
Parbhoo AH. Support for the anterior
tory treatment or undergoing radical surgery for tuber- column with
allografts in tuberculosis of the spine.
culosis of the spine. Indian J Tuberc. 1989;36(suppl):1. J Bone Joint
Surg Br. 1999;81:1069.
26. A controlled trial of anterior spinal fusion and debride- 30. Yilmaz C, Selek
HY, Gurkan I, Erdemli B, Korkusu Z.
ment in the surgical management of tuberculosis of the Anterior
instrumentation for the treatment of
spine in patients on standard chemotherapy: a study in spinal
tuberculosis. J Bone Joint Surg Am.
Hong-Kong. Br J Surg 1974;61:85366. 1999;81:12617.
27. Moon MS. Tuberculosis of the spine: controversies 31. Vider M,
Maruyama Y, Narvaez R. Significance of the
and a new challenge. Spine. 1997;22:17917. vertebral
venous (Batsons) plexus in metastatic
28. Upadhyay SS, Sell P, Saji MJ, Bell B,Yau AM, Leong spread in
colorectal carcinoma. Cancer 1977;40:
CYC. Seventeen year prospective study of surgical 6771.
Tuberculosis
of the Spine
Ahmet Alanay and Deniz Olgun
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 830 Although an old ancient disease, tuberculosis
is still a major public health problem

Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 830
that affects both developing and developed

. . 831 countries. With the increase in immuno-
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 831 compromised states, it has become a larger
problem which is growing ever more difficult

to treat. The most common site of

Pre-Operative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833
extrapulmonary tuberculosis is the spine, and
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
834 here it causes destruction and deformity which
Non-Instrumented Posterior Fusion . . . . . . . . . . . . . . 834
may lead to kyphosis and paraplegia. The nat-
ural history of tuberculous spondylitis has

Anterior Radical Resection and Bone
Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 834
been defined in great detail owing to its fre-
quency in the years preceding the advent of

Debridement (Anterior or Posterior) and
anti-tuberculous drugs and effective surgical

Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
834
treatment options. Today the treatment of spi-

Late
Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
837 nal tuberculosis begins with diagnosis, which
Minimally-Invasive Techniques . . . . . . . . . . . . . . . . . . . 840
can be still a difficult one. This includes a
careful history, physical examination, x-rays
and, most importantly, MRI.scans However,
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 840
often, tissue diagnosis is necessary and cul-

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 840 tures, though generally reliable, are often slow
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 841 to yield results. Surgical treatment can
commence after obtaining tissue for diagnosis
and addresses removal of necrotic tissue at
the affected segments, instability and, if it

A. Alanay (*)
already exists, deformity. The use of implants
in tuberculous spondylitis has been shown to
Comprehensive Spine Center, Acibadem Maslak
be safe, and necessary in specific cases owing
Hospital, Istanbul, Turkey
to unacceptable kyphosis as an outcome after

e-mail: aalanay@hacettepe.edu.tr
exclusively conservative treatment. Today,

D. Olgun
the preferred form of treatment is debridement

Hacettepe University, Ankara, Turkey
and instrumented fusion, and depending
e-mail: aalanay@hacettepe.edu.tr
on the stability of fixation, post-operative

829
DOI 10.1007/978-3-642-34746-7_36, # EFORT 2014
830
A. Alanay and D. Olgun
immobilization. The mainstay of treatment, as Extrapulmonary tuberculosis

seems to be
it was 50 years ago, is still anti-tuberculous increasing worldwide [8, 9].
With the increasing
medical therapy. number of immune-compromised
patients due to
AIDS, auto-immune disease,
cancer therapy and
Keywords organ transplantation, the
incidence of diseases
Complications # Diagnosis # Late deformity # caused by atypical
mycobacteria has also
Operative techniques # Pathophysiology # increased. Atypical
mycobacteria and fungi con-
Spine # Surgical indications # Tuberculosis stitute a small percentage
of the causes of spinal
infection, but their
clinical and radiologic appear-
ances resemble those of
Mycobacterium tubercu-
Introduction losis spondylitis. The most
common atypical
mycobacterium isolated from
vertebral osteomy-
Tuberculosis of the spine is one of the most elitis in one series was
found to be mycobacte-
ancient diseases known to mankind, with reports rium avium-intracellular
complex [10].
of it dating back 5,000 years [1]. Despite the Although anti-
tuberculosis drugs provide an
advances in the previous century, tuberculosis effective weapon in the
treatment of tuberculous
remains an important public health problem spondylitis, the emergence
of multi-drug resis-
with close to ten million new reported cases in tant strains has caused a
setback. Tuberculosis
2008 [2]. First characterized by Pott in the late treatment is started with
four so-called first-line
eighteenth century as Potts distemper of drugs: isoniazid,
rifampicin, pyrazinamide and
the spine, it still represents one third of spinal ethambutol. Multi-drug-
resistant tuberculosis is
infections today. Owing to the advent of effective defined as that resistant to
isoniazid and rifampi-
public health measures, anti-tuberculous cin [1113]. The term
extensively drug- resis-
drugs and, although controversial, the Bacille- tant tuberculosis has been
coined by the US
Calmette-Guerin vaccine, the incidence of tuber- CDC and the WHO to describe
tuberculosis resis-
culosis has been declining steadily in the latter tant to at least isoniazid
and rifampicin and
half of the twentieth century. However, with the several second-line drugs
[14, 15]. Multi-drug
emergence of first the AIDS and then the diabetes resistant spondylitis has
been reported [16, 17].
epidemics, tuberculosis is back on the rise even Multi-drug and extensively
drug resistant tuber-
in developed countries. Today, patients with culosis represent failures
of the aforementioned
co-morbidities make up the bulk of cases, public health measures to
control the disease
while antibiotic therapy remains the mainstay of and emphasizes the necessity
of a proper drug
treatment. Although spinal tuberculosis remains regimen of appropriate
duration and complete
an uncommon diagnosis, it must yet be kept in patient compliance. The
incidence of these
mind in patients with spinal complaints whose problems have been on the
rise as well [18].
aetiology is not readily apparent. Before the discovery of
anti-tuberculosis
drugs and modern surgical
techniques, bed-rest
and conservative
immobilization were the main-
Aetiology stays of treatment of
tuberculous spondylitis.
This led to an extensive
knowledge regarding
Tuberculosis is caused by the pathogen Myco- the natural history of the
disease [19, 20].
bacterium tuberculosis. It is transmitted mainly Untreated tuberculosis of
the spine has three
through inhalation or ingestion of the bacterium. stages. The first is the
stage of onset, lasting
Less than 10 % of tuberculosis patients have from 1 month to 1 year, the
second the stage of
musculo-skeletal involvement, yet 50 % of these destruction which can go on
for up to 3 years and
have involvement of the spine [36]. Neurologi- the last stage, the stage of
repair and ankylosis.
cal deficit at the time of presentation is also com- Abscess formation and
destruction are seen in the
mon, reported to be between 10 % and 60 % [7]. second stage, which a third
of the patients do not
Surgical Management of Tuberculosis of the Spine
831
survive, while in the third stage, the joint or spine [25, 26], but this
definition is not as clear-cut as
heals with bony ankylosis or fusion. Non-union is in the case of acute
fracture. Inflammation and
associated with recurrences and super-infections destruction in tuberculosis
co-exist with repair
with pyogenic bacteria, generally, an unfavorable and fibrosis. Yet, the
occurrence of a pathologic
outcome. Historic treatments of tuberculosis fracture or global disease
affecting posterior ele-
included bed rest, heliotherapy and sometimes ments as well may lead to
the loss of stability
plaster immobilization in order to pre-empt spi- [27]. With the loss of the
support of the anterior
nal deformity. Despite these measures, kyphosis column, acute kyphosis
develops. Once the dis-
still was a problem, many times accompanied by ease reaches the healing
stage, bony ankylosis is
paraplegia as described by Pott [20, 21]. complete and the kyphosis
is rigid.
Spinal tuberculosis most commonly affects Once the pathogen is
safely ensconced in liv-
the thoracic or thoraco-lumbar spine, although ing tissue, the
inflammatory response of the
cervical and lumbo-sacral involvement has been immune system causes pus
and debris to accumu-
reported [22]. Spinal involvement has been clas- late, forming abscesses and
fluid collection.
sified by Mehta et al. according to anterior and In contrast to pyogenic
infection where proteo-
posterior column involvement into four groups: lytic enzymes cause most of
the destruction, in
anterior involvement only, anterior and posterior tuberculosis the delayed-
type hypersensitivity
involvement, anterior or global with thoracotomy reaction of the body itself
is the culprit [28].
presenting grave risk, and posterior involvement Bone resorption follows.
This may take place
only [23]. The most common is anterior anterior to the anterior
longitudinal ligament,
involvement with destruction of the disc space extending downward to the
psoas sheath and
and loss of anterior stability, making posterior causing the well-defined
psoas-abscesses of
laminectomy a greater destabilizing factor, Potts disease. It may also
end up in the spinal
should it be chosen as the method for treatment. canal, causing compression
of the spinal cord.
The neural structures may
also be affected
directly by tubercle
formation, leading to neuro-
Pathophysiology logic deficit and even
paraplegia. Causes of neu-
rologic deficit include
direct involvement of
Tuberculosis reaches the spine either through neural structures with the
disease, compression
direct extension through the lungs or haematologic by abscess and fluid
formation, vascular compro-
dissemination from a pulmonary or genitor- mise and compression by
bony debris left over
urinary source. Direct extension is rare, whereas from the destructive
process.
the haematologic form of dissemination is far
more common. The infection can appear in
three distinct patterns: peri-discal, central and Diagnosis
anterior [24], the most common of which is
peri-discal involvement. The disease begins in The presentation of
tuberculosis of the spine can
the vertebral end-plate adjacent to the disc, be variable. It depends on
the extent of the dis-
extends anteriorly underneath the anterior longi- ease, the nutritional
status of the patient and the
tudinal ligament and in this way multiple levels time that has elapsed since
the onset of disease.
are infected while the intervertebral discs are Back pain is a common
presenting symptom. The
spared. This presents a contrast to pyogenic spi- pain is less severe than in
pyogenic infection [24],
nal osteomyelitis where the disc is involved. Cen- follows an indolent course,
often waxing at night
tral involvement can lead to deformity. Anterior and increases as
instability progresses. Potts
involvement can lead to spinal abscesses that paraplegia, the gravest
complication of the
span many levels. Primary posterior involvement disease, is a presenting
symptom in nearly 10 %
is rare. As in spinal trauma, stability of the spine of the patients [29, 30].
Constitutional symptoms
is lost if two or more columns are affected are also common such as
fatigue, malaise,
832
low-grade fever, weight loss and the anaemia of deformity or, more commonly,
as a guide for
chronic disease. Acute phase reactants such as needle biopsy in order to
achieve tissue diagno-
white blood cell count, sedimentation rate and sis. Bone scanning can be
performed but cannot
c-reactive protein may be elevated, but normal differentiate tuberculous
spondylitis from other
values do not rule out the disease. The patient causes of infectious disease
and although it can
may or may not have a history of pulmonary be helpful in some cases, its
use is limited. MRI
tuberculosis. Immunosuppression is a risk factor remains the most helpful
imaging modality in the
for the development of tuberculous spondylitis. diagnosis of tuberculosis,
showing abscess for-
In underdeveloped countries, patients may mation, epidural involvement
and involvement of
present with obvious deformity, sinus tract the spinal cord as well as
bony destruction.
formation and even neurological deficit and MRI is the modality of
choice in vertebral
paraplegia. Elderly patients are more likely to osteomyelitis of any kind as
it has very high
present with neurologic deficit. sensitivity and specificity
[33]. Also, MRI is
Late-onset paraplegia is defined as new-onset non-invasive and has
unequalled resolution for
neurologic deficit after the first spinal infection soft, especially neural
tissues. MRI is the only
has healed. It can occur many years after soft- modality to distinguish
spondylitides of different
tissue and bony healing have been completed. aetiology [7, 3437]. The
earliest finding is end-
The reasons for late-onset paraplegia are numer- plate oedema, which appears
as a decreased
ous, some of which are re-activation, develop- T1-weighted signal and
increased T2-weighted
ment of anterior bony ridges and subsequent signal. Short-tau inversion
recovery images are
cord compromise, chronic instability, increase usually superior to other
modalities as they allow
in kyphotic deformity and rarely, degenerative the suppression of the bright
fat signal of the bone
changes in segments adjacent to those that have marrow [38]. If the disc
space is found to
healed with significant deformity [31]. be preserved, the diagnosis
of tuberculosis
Radiographs in early disease are most com- will become more than likely,
as it is
monly normal. Osteoporosis is the first sign that a pathognomonic finding of
this disease.
can be noted in x-ray studies, with loss of defini- This relative sparing of the
disc space is what
tion at the end-plates and only slight narrowing of differentiates it most from
pyogenic infection.
the disc space [32]. These changes progress to The infection progresses into
the retropharyngeal
loss of vertebral body height. Disk space is pre- soft tissue or sub-
ligamentously to involve
served until the disease progresses. Fusiform further spinal levels and the
paraspinal areas.
soft-tissue swelling in the thoracic region and Abscesses show rim-
enhancement with the
the darkening of the psoas shadow in the lumbar addition of Gadolinum-
containing contrast mate-
region are other radiological changes that have rial, and therefore, cases
with suspicion for spinal
been previously defined. The destruction of the infection should always be
examined with
anterior portions of multiple levels with sparing contrast unless otherwise
contra-indicated [32].
of the posterior elements will lead to This abscess wall in
tuberculous is thick, and
a progressively worsening kyphotic deformity calcifications, though not
always present, are
[28]. This kyphosis will progress until the last also characteristic of the
disease.
stage of the disease if it is left untreated. Sinus Tuberculosis is known to
mimic other condi-
tract formation can occur during this process, and tions of the spine. One of
these is metastatic
lead to pyogenic super-infection, which will in disease, which can be
differentiated from tuber-
turn increase bony destruction and worsen defor- culosis of the spine by the
absence of paraspinal
mity. Plain radiographs usually do not usually and other abscesses. Fungal
spondyliitis and
indicate the extent of the disease. Further imag- spondylitis caused by
atypical mycobacteria are
ing, preferably with MRI, is always necessary. far more difficult to
differentiate by imaging
CT scanning shows bony destruction and can findings alone and require
tissue diagnosis.
be used for pre-operative planning of complex Radiographic changes may
progress with the
833
initiation of medical treatment for more than

a year and should not be mistaken for the failure Indications for Surgery
of treatment [39].
Gibbus formation (sharp kyphosis at affected Today, the mainstay of
treatment for tuberculous
levels), due to anterior column destruction is, seen spondylitis is medical.
Shortened time to disease
in late untreated disease and conservatively- onset and diagnosis have
allowed tuberculous
treated disease. This deformity may progress spondylitis to be caught
before the development
despite skeletal maturity and lead to late paraple- of complex spinal deformity.
However, medical
gia. However, the increase in deformity is not the therapy alone has been shown
to increase healing
only cause of late paraplegia in healed disease. with kyphosis and deformity
in many cases. The
Other causes are compression of the spinal addition of bed rest and/or
cast or brace immobi-
cord by bony bridges, calcified caseous material, lization was found to be
ineffective in the devel-
fibrosis and disease re-activation [28]. opment of kyphotic deformity
in the British
Laboratory diagnosis is difficult. Purified pro- Medical Research Council
Working Party on
tein derivative (PPD) or tuberculin skin testing Tuberculosis of the Spine
reports [4245].
has lost importance in the passing years. It is Multi-drug regimens
(three or more drugs) of
especially non-specific in areas where tuberculo- at least 6 months duration
showing good healing
sis is endemic, BCG vaccination is routine, or the responses, and advancement
in minimally-inva-
population is frequently exposed to sub-clinical sive techniques to evacuate
huge abcessess led to
disease [28]. A new blood test measuring re-definition of surgical
indications. These are:
interferon-gamma response after in vitro stimu- Lesions not healing after
6 months of anti-
lation of the patients T-cells with tuberculosis tuberculosis therapy
antigens is being developed and could replace the Lesions developing after 6
months of anti-
less specific tuberculin skin testing and provide tuberculosis therapy
a tool for the detection of latent tuberculosis. Gross instability of the
spine
There are also studies attempting to increase New-onset neurologic
deficit or worsening
the specificity of the tuberculin skin test [40]. of prior neurologic
deficit while under anti-
Sputum smears for acid-fast bacilli are one of tuberculosis therapy
the primary methods of laboratory diagnosis but Unacceptable or impending
deformity
are negative in patients without pulmonary tuber-
culosis and in a significant portion of patients
with it. Although mycobacterial culture is quite Pre-Operative Planning
sensitive, it requires direct tissue sampling in the
case of spinal tuberculosis and is slow to yield Once the diagnosis of
tuberculosis of the spine
results. Newer liquid culture systems such as has been established, the
patient should be started
BACTEC have reduced this delay to days rather on anti-tuberculous therapy
as soon as possible,
than weeks with conventional methods and have preferably under the
supervision of an infectious
been found to be more sensitive as well [41]. diseases specialist. Drug
regimens based on iso-
Diagnostic tests using nucleic acid amplification niazid and rifampicin for at
least 6 months have
techniques and polymerase-chain reaction methods shown good results [46].
According to the recom-
have been developed and show high specificity for mendations issued by the
United States Centers
tuberculosis, yet their cost and requirement for for Disease Control, a four-
drug regimen should
high-technology laboratory facilities coupled with be used to treat Potts
disease. Rifampin and
their modest sensitivity have precluded widespread isoniazid should be
administered during the ther-
use [40]. Direct visualization of the granulamatous apy and another first-line
drug chosen for the first
reaction and the presence of intracellular pathogens 2 months along with one
second-line drug. The
(acid-fast bacilli) under direct microscopy are duration of therapy should
be at least 6 months,
the gold standard methods of diagnosis. but as studies concerning
special circumstances
834
such as neurologic deficit and the involvement of

multiple vertebral levels are scanty, some spe- Anterior Radical Resection
and
cialists still recommend therapy to last for 912 Bone Grafting
months. In the case of suspicion of multi-drug or
extensively drug-resistant tuberculosis, proper The Hong Kong operation was
described by the
consultations should be obtained. British Medical Research
Council Working Party
on Tuberculosis of the Spine.
It is the radical
removal of all affected
tissue until healthy, bleed-
ing bone is encountered and
subsequent recon-
Surgical Techniques struction with bone graft
with or without internal
fixation, a modification of
the original technique
Many approaches to tuberculous spondylitis have of Hodgson [4951]. The
reports on the Hong
been described. Before the advent of effective Kong operation, which does
not employ instru-
anti-mycobacterial therapy, surgery carried mentation, are favourable in
the long-term with
the quite large risk of sinus tract formation, very little loss of
correction of kyphosis. However,
leading to pyogenic infection and death of the there is a need for external
bracing at least for 36
patient. For this reason, indirect operations were months until bony healing and
incorporation of
favoured in order to increase stability and the graft material. On the
other hand, it may be
decrease recurrence, leading to the description difficult to preserve the
sagittal plane correction
of posterior fusion techniques. when more than one vertebral
level has to be
After effective anti-tuberculous therapy was resected and either anterior
or posterior instru-
shown to heal sinus tracts and ulcers, surgical mentation should be added
when reconstruction
therapy could directly deal with the problem at spans more than one vertebral
body. Debridement
hand. Many techniques were described, most of of all the necrotic and
diseased segments and
them including radical resection of diseased tis- reconstruction of the
anterior defect is still the
sues and massive reconstruction using structural key surgical principle for
the treatment of tuber-
grafts or cages. culosis. However, surgeons
nowadays prefer to do
either anterior or posterior
instrumentation in
addition to the Hong-Kong
procedure to increase
stability, preserve the
correction in sagittal plane
Non-Instrumented Posterior Fusion and to obviate the need for
external braces (Fig. 1).
Posterior fusion was the preferred method of treat-

ment in many centres before anterior spinal Debridement (Anterior or
Posterior)
surgery was found to be safe and effective. and Instrumentation
The rationale behind posterior fusion is the
achievement of a stable spinal segment in order The study by Oga et al.
reporting the lack of
to hasten healing and decrease the progress of glycocalyx capsule formation
by tuberculosis
kyphotic deformity. However, results of this bacilli has been a
revolutionary step in the surgical
technique were disappointing. Kyphotic deformity treatment of tuberculosis
spondylitis [52]. Many
increased despite posterior fusion and prolonged studies in the recent years
have shown successful
immobilization, pseudarthrosis was common use of implants either
anteriorly or posteriorly
and healing was not found to be more rapid after debridement of necrotic
tissues with no recur-
in several published series [47, 48]. Today, non- rence and exacerbation of the
infection [5053].
instrumented posterior fusion has been abandoned Both anterior and
in the treatment of tuberculous spondylitis. have been used in tuberculous
spondylitis with
835
success. Many combinations of the aforemen- be indicated in severe

osteoporotic patients where
tioned approaches exist and should be chosen anterior instrumentation may be
unsafe and can be
according to the patients special features, an alternative for combined
anterior debridement
the resources available and Surgeon preference. and posterior instrumentation
surgery.
Staged operations beginning with anterior The postero-lateral approach
as used for
debridement and continuing with posterior posterior vertebral column
resection provides ade-
instrumentation, anterior debridement, posterior quate exposure and allows the
insertion of cages
instrumentation and subsequent anterior instru- and other anterior struts. This
is performed by a
mentation, and simultaneous anterior and poste- posterior approach. The upper
and lower end
rior debridement and instrumentation have been levels are instrumented using
pedicle screws.
defined and used with success [52, 54]. Once this is performed, one rod
is inserted in
The thoracic vertebral column can be order to prevent accidental
movements. On the
approached by an anterior trans-thoracic or other side, costo-
transversectomy is performed
posterior extra-pleural method. While the trans- on as many levels as necessary.
Nerve roots and
thoracic method is straightforward, it may be intercostal veins are
visualized, tied and then cut.
associated with pulmonary complications post- Using a periosteal elevator,
the exposure is
operatively. The pulmonary condition of the extended to cover the entire
circumference of the
patient before the operation should be carefully vertebral body. Once the
anterior column is visu-
assessed and the risks weighed. The posterior alized, debridement is
commenced. Debridement
extra-pleural method requires more surgical should remove all necrotic
tissue, pus and loose
finesse, but may prevent further deterioration in bone fragments, but viable bone
is not resected.
patients with pulmonary co-morbidity. It also may Tissue sampling should be
performed, with
Fig. 1 (continued)
836
Fig. 1 (a) A-P and lateral x-ray of a 42 year-old male demonstrate the abcess
at T9 vertebral body and epidural
patient suffering back pain and neurological symptoms. compression due to
abcess. (c) Follow-up A-P and lateral
Patient had a pathologic compression fracture of T9 ver- x-rays. Anterior
debridement, reconstruction with allo-
tebrae due to tuberculosis. (b) Sagittal MRI views graft and
instrumentation was performed
837
mycobacterial cultures and specimens for patho- As deformity is often a

result of tuberculous
logical study. After debridement and decompres- spondylitis, the necessity for
instrumentation
sion anterior structural bone graft is placed and should be carefully evaluated.
rod is placed on the costo-transversectomy side
and pedicle screws are compressed to increase the
stability of the anterior graft. Authors have Late Deformity
reported good results in tuberculosis as well with
this technique [55]. Good results were achieved With recent advances in
surgical implants and
with the use of the posterior approach alone [53] techniques, the contemporary
approach to severe
(Fig. 2). kyphotic deformity includes
instrumentation and
Fig. 2 (continued)
838 A. Alanay and D. Olgun
Fig. 2 (continued)
839
Fig. 2 (a) A-P and lateral x-ray of a 60 year-old male who (c) Figures
demonstrating the technical steps of decom-
had tuberculosis at T9 and T10 vertebrae. P. (b) Sagittal pression, fusion and
instrumentation via a single posterior
MRI scans demonstrating the abcess at T9-T10 vertebral approach. (d) Follow-
up A-P and lateral x-rays (Images
bodies and the disc space. There is also epidural abcess. and diagrams courtesy
of Azmi Hamzoglu, MD)
spinal osteotomy, which can be done in an effective in the

treatment of most forms of kypho-
anterior-posterior-anterior fashion, simultaneous sis, although
spondylectomy is more appropriate
anterior surgery or posterior vertebral column for sharp, angular
kyphosis as occurs following
resection (PVCR). These procedures, although tuberculosis [59].
Previous studies have found that
challenging and prone to severe complications, instrumentation of the
spine afflicted with tuber-
have been used successfully for the treatment of culosis is safe [52]
and that titanium mesh cages
late deformity [5659]. Following spondy- can safely be used in
pyogenic infection as well.
lectomy, the resulting bone defect is filled with Fusion rates with any
approach are acceptable and
autograft or titanium mesh cages. Pedicle screw deformity correction
is best with spondylectomy
instrumentation and vertebral osteotomy are and pedicle screw
instrumentation.
840
Kyphosis may increase with

age despite fusion.
Minimally-Invasive Techniques Recurrence and re-activation
of the disease if not
treated properly with anti-
tuberculous medication
Video-assisted thoracoscopic techniques have is also possible. Pyogenic
infection may supervene
been described in the treatment of tuberculosis in a spine already de-
stabilized by tuberculosis and
of the spine. They are especially appropriate for open to the exterior by sinus
tracts.
the procurement of tissue material for biopsy and Complications of surgery
include pulmonary
culture, and mid-thoracic disease affecting few complications especially for
the anterior
levels which is unrelated to pulmonary tubercu- approach. Vessel injury and
epidural bleeding
losis [60, 61]. can also be encountered
during debridement due
Complications of tuberculosis of the spine, to the ossification and
fibrosis of the tissues.
such as discrete abscesses and collections, can Pedicle screw
instrumentation is a safe and
be successfully treated by percutaneous drainage effective technique for the
treatment of spinal dis-
placed under ultrasound or CT guidance [62]. orders. Complications related
to the use of pedicle
screws can be related to the
mal-positioning and
faulty technique. Pull-out in
osteoporotic bone has
Post-Operative Care and been reported and can be
avoided in most cases
Rehabilitation with careful pre-operative
planning. Neurological
injury during the placement
of pedicle screws is
The post-operative care for a tuberculosis patient rare but catastrophic. The
use of motor and
is no different than for any other spine patient, sensory-evoked potential
monitoring has been
except for the obvious need for anti-tuberculous revolutionary in the safety
of deformity surgery.
therapy. Anterior transthoracic approaches are Patients presenting with
neurological deficit at the
involved with a high degree of pulmonary com- time of diagnosis usually
have a favourable out-
promise and may necessitate intensive care and come with decompression and
medical therapy.
prolonged intubation. Once the patients general With better supportive
care, intensive-care
condition permits, the patient may be mobilized facilities and the better
nutritional status of the
according to the rigidity achieved by the patients, post-operative
mortality has decreased.
instrumentation. Routine immobilization is not Miliary tuberculosis
following surgery is rare
required with posterior pedicle screw fixation. with concomitant medical
therapy.
Orthoses can be used for 612 months in those Non-union and mal-union
are uncommon.
in whom a spondylectomy has been performed. Fusion rates in surgery for
the tuberculosis of
The physical therapy regimen should follow the the spine have been
favourable even in historical
standards for spine patients. reports where instrumentation
was not available.
Loss of correction is also a
minor concern.
Complications
Summary
The complications that can be encountered
depend on the extent of the disease, previous Tuberculosis of the spine is
an ancient disease that
neurological deficit, the surgical approach as a large public health
problem has inspired
selected, the type of graft used and the presence research, the development of
many surgical tech-
or absence of instrumentation. niques and new drugs. While
poor living conditions
In patients with neglected disease, deformity is nurture the disease in
developing countries, the
common. The spine usually heals in a kyphotic falling incidence in
developed countries following
position. Kyphotic deformity in excess of 60 is the discovery of effective
anti-tuberculosis
associated with late paraplegia even in healed dis- drugs has been pre-empted by
the appearance of
ease. Pain and cosmetic problems can also be seen. modern epidemics leading to
overt or functional
841
immuno-compromise. Starting in the pulmonary 9. Peto HM, et al.

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kyphotic deformity. Eur Spine J. 2009;18(10):143641. 62. Pieri S, et al.
Percutaneous management of complica-
59. Macagno AE, OBrien MF. Thoracic and tions of
Tuberculous spondylodiscitis: short- to
thoracolumbar Kyphosis in adults. Spine. 2006;31: medium-term
results. Radiol Med. 2009;114(6):
16170 (Phila Pa 1976). 98495.
Part III
Shoulder
Biomechanics of the Shoulder
David Limb
Contents
Abstract
Relevant
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
848 The shoulder permits a wide range of humeral
Sternoclavicular
Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
848 movement which, coupled with hinge move-
Acromioclavicular Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
848 ment at the elbow joint to regulate distance
Scapulothoracic Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 849 from the body, permits the hand to be placed
Glenohumeral
Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
850
The Rotator
Cuff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
852 into an almost spherical potential space. The
glenohumeral joint is the articulation that

Movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 852
Measurement of Movement . . . . . . . . . . . . . . . . . . . . . . . . . 853
primarily endows the shoulder with its huge
range of movement, but this is achieved

Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 856 by trading off inherent stability. The
Static
Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 856
Dynamic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 858 glenohumeral joint itself has to be positioned
and stabilised in relation to the trunk by the

Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 859
Forces Across the Glenohumeral Joint . . . . . . . . . . . . . . 859
scapulothoracic joint, which functions by sus-
pension of the scapula from the trunk with

Clinical
Relevance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
a system of muscles. The only synovial joints

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 862 linking the scapula to the axial skeleton are
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 863 the acromioclavicular and sternoclavicular
joints, at either end of the clavicle. There
is a finely-tuned neuromuscular control
mechanism that ensures that scapulothoracic
and glenohumeral joints work in concert and
are protected from injurious forces. However,
the glenohumeral joint is more likely than any
other joint in the human body to dislocate and
the associated rotator cuff tendons almost
inevitably degenerate and develop tears if the
individual lives long enough. The effects of
these pathological changes, and others, are
predictable by consideration of natural joint
anatomy and biomechanics of the joint.
D. Limb
Chapel Allerton Hospital, Leeds, UK
e-mail: d.limb@leeds.ac.uk

847
DOI 10.1007/978-3-642-34746-7_58, # EFORT 2014
848
D. Limb
Knowledge of the biomechanics is therefore apposed bone surfaces are

saddle- shaped (the
essential if one is to properly assess and treat sternal surface pointing
posterior, lateral and
shoulder pathology. upwards) but are separated
by an articular disc
and observation of any
skeleton reveals minimal
Keywords co-aptation of the
reciprocal surfaces. Stability
Anatomy # Biomechanics # Clinical applications relies in large part on
strong ligaments in front,
# Forces # Kinematics # Shoulder # Stability behind, above and below
the joint augmented by
muscle attachments (Fig.
1).
Above is the
interclavicular ligament, which
Relevant Anatomy connects the superomedial
aspects of both clavi-
cles and is taut when the
shoulder is depressed. It
The articulation between the upper limb and the shows considerable
variation between individ-
trunk at the human forequarter is referred to as the uals. Below is the strong,
short, costoclavicular
shoulder, though in reality this is a complex link- ligament, coursing from
the medial end of the
age of joints, of which the glenohumeral joint is first rib to the medial
clavicle where it attaches
only one component. The glenohumeral joint is at the costal tuberosity.
The anterior part of this
the last link in the chain between trunk and arm ligament limits upward
movement of the
and is a ball and socket joint that allows an clavicle, whilst the
posterior part blends with
enormous range of movement between the the posterior
sternoclavicular ligament and resists
humerus and scapula, with six degrees of free- posteroinferior
dislocation of the sternoclavicular
dom. However, for the joint to work effectively joint. Anterior and
posterior to the joint are the
the scapula, which bears the socket, must itself be respective
sternoclavicular ligaments. The joint
moved into a complementary position to accept allows four movements
(elevation, depression,
the resultant force vectors from the humerus. protraction and
retraction) and two rotations
Furthermore it must be held in this position with (upward and downward) [5].
Up to 50# of these
sufficient stability to support forces that can be axial rotations can occur,
facilitated by the artic-
multiples of body weight, yet be dynamic enough ular disc, which attaches
peripherally to the cap-
to move rapidly to counter changes in the direc- sule that is thickened by
the restraining ligaments
tion of resultant force. Thus in discussing the described above.
shoulder we must not only consider the
glenohumeral joint but also the scapulothoracic
articulation and the skeletal linkage of the scap- Acromioclavicular Joint
ula to the trunk, via the clavicle, involving
the acromioclavicular and sternoclavicular The acromioclavicular
joint is a plane joint,
joints. The functions of the clavicle and its asso- though the articular
surfaces are not perfectly
ciated joints, however, can be very difficult to congruent and in childhood
there is usually an
elucidate, particularly since some patients with intra-articular disc,
which remains only as
cleidocranial dysostosis have been noted to have meniscus-like remnants
extending down from
gone through life in manual jobs unaware that the superior capsule in
most adults [6]. The joint
they were without their clavicles. is vertically orientated,
but often tilted so that the
articular surface on the
acromion faces somewhat
superiorly and anteriorly,
or less commonly infe-
Sternoclavicular Joint riorly. Reviewing the
slope of the joint on plain
radiographs can help plan
the correct needle
The sternoclavicular joint is the only synovial insertion trajectory for
intra-articular injections.
joint connecting the upper limb to the torso but The capsule of the
acromioclavicular joint is
it is clear to see that it is not anatomically adapted thickened superiorly to
form the acromioclavicular
to withstanding enormous forces the two ligament, which can be
preserved in arthroscopic
849
Fig. 1 A diagrammatic
representation of the
F
sternoclavicular joint, in
cross section on the left. A
A articular disc,
B Subclavius,
C Costoclavicular
ligament, D Anterior
sternoclavicular ligament,
E First costal cartilage,
D
F Sternomastoid,
G First rib B
C
G
E
allow the scapula to rotate

around the
B C acromioclavicular joint in
the anteroposterior
A plane, the superoinferior
plane and around the
axis of the clavicle itself
[5]. Rotation around the
axis of the clavicle is
important in elevation of the
arm and without it, this
movement is limited to
about 110# [13]. There is
significant variation in
the anatomy of the conoid
and trapezoid ligaments
A Acromion and there is often a bursa
between the two. This
B Trapezoid ligament
C Conoid ligament
bursa can intervene between
the horizontal part of
the coracoid and the
lateral edge of the subclavius
attachment to the clavicle,
forming an
articulation the
coracoclavicular joint [20].
Scapulothoracic Joint
The scapula bears the

socket of the glenohumeral
Fig. 2 Ligaments attached to the coracoid joint and is suspended in
position, and moved
accordingly, by muscle
attachments. It does
excision of the distal clavicle but usually has to be articulate with the
clavicle at the synovial
divided in open excision. It merges with the acromioclavicular joint,
but this can be excised
deltotrapezial fascia at the anterosuperior aspect with no alteration in
shoulder biomechanics pro-
of the joint. The distal clavicle is bound to the vided that ligaments are
preserved. As noted, the
coracoid process by the conoid and trapezoid com- coracoid process of the
scapula is attached to the
ponents of the coracoclavicular ligament (Fig. 2). clavicle by the conoid and
trapezoid components
These ligaments limit the range of motion at of the coracoclavicular
ligament and acute rup-
the acromioclavicular joint, which can therefore ture of these, with
acromioclavicular dislocation,
850
D. Limb
Distal
Humerus
Retroversion
Scapula
Fig. 3 A patient with right scapular winging secondary to

intra-articular pathology of the glenohumeral joint
Fig. 4 The glenohumeral

joint viewed from above, with
does lead to depression of the scapula to the elbow joint seen
beyond, in neutral alignment. The
a variable degree, which can be misinterpreted retroversion of the
humeral head matches the anterior
as elevation of the clavicle. However, if neuro- angulation of the
scapula on the thoracic cage
muscular control of the scapula is retained then
very good shoulder function can be maintained.
The muscles that suspend and control the The scapula itself
gives rise to muscles that
scapula on the axial skeleton are the axoscapular provide the motors for
arm and forearm move-
muscles and these are arranged to elevate, ment (the
scapulohumeral muscles and biceps/
depress, protract, retract and rotate the scapula. triceps, which cross
both glenohumeral and
Proper scapula positioning requires co-ordination elbow joints), and the
axohumeral muscles
of multiple muscles, some contracting isometri- which span from the
torso to the humerus, cross-
cally, some concentrically and some eccentri- ing the scapulothracic
and glenohumeral joints. It
cally and the whole under constant flux. It is is perhaps more of a
surprise that the neuromus-
perhaps not surprising that almost any painful cular control of this
arrangement works at all than
shoulder condition can result in pain inhibition that it occasionally
malfunctions.
of some of these muscles, leading to slight tilting Biomechanical
analysis of shoulder girdle
of the scapula on the chest wall (scapular function has been
extensive, but the inroads we
winging) (Fig. 3). Such winging does not always, have made to a full
understanding are limited.
therefore, indicate a neurological lesion, such as Thus we often consider
the function of large
can occur in long thoracic nerve or accessory groups of muscles when
discussing clinically rel-
nerve palsy, though clinical examination should evant biomechanics,
such as the scapular
still rule out such causes. stabilisers and the
rotator cuff. There is still
In the resting position the scapula sits on the extensive scope for
further work in this
chest wall and is rotated anterior to the coronal complex field.
plane by approximately 30# [18], as viewed
from above. This matches the retroversion of
the humeral head with respect to the axis of the Glenohumeral Joint
elbow joint, bringing that axis parallel to the
coronal plane when the humeral head directly The glenohumeral joint
(Fig. 5) is the most
faces the glenoid (Fig. 4). extensively studied
component of the shoulder
851
Acromion
SS
LHB
IS/T
SGHL
SubS
MGHL
IGHL
Fig. 6 The glenoid

fossa with the humeral head removed.
IST/T Infraspinatus
and teres minor, SS Supraspinatus,
Fig. 5 The glenohumeral joint from in front A the
LHB Long head of
biceps tendon, SGHL superior
greater tuberosity, B the lesser tuberosity, C the
glenohumeral ligament,
SubS subscapularis, MGHL mid-
coracoid process, D the acromion, E the scapular notch
dle glenohumeral
ligament, IGHL inferior glenohumeral
ligament (arrow
indicates thicker anterior band)
and for good reason it is the component that

most often causes clinically relevant problems Compared to a line
drawn from the centre of the
and it is most susceptible to trauma. As noted, it glenoid to the base of
the scapular spine at
is a ball and socket joint, and a huge range of the medial border of
the scapula the glenoid
movement is facilitated at this joint by the sig- is slightly
retroverted in most individuals though
nificant mis-match between the size of the the range is
considerable amongst individuals,
humeral head and the size of the socket. The between 12# of
anteversion and 14# of retrover-
glenoid fossa has an area that is typically less sion. Furthermore this
angle may vary from
than 10 cm2 yet the humeral head articular car- one part of the
glenoid fossa to another [23].
tilage covers typically more than 50 cm2 the The soft tissue
structures that deepen the
analogy of a golf ball balancing on a tee is not socket of the
glenohumeral joint are the labrum
a bad one and emphasises that the problem asso- and its attached
structures the shoulder capsule,
ciated with this mismatch is that stability is its thickenings (the
ligaments) and the long head
compromised. Ball and socket joints with less of the biceps tendon
(Fig. 6). Outside this layer
of a mis-match, such that the socket encloses are the rotator cuff
tendons, which merge with the
more of the ball (as seen in the natural hip) rarely capsule laterally.
Thus one can see that the socket
dislocate, whilst the glenohumeral joint is the of the shoulder
becomes a dynamic structure and
most commonly dislocated joint in the human the biomechanics can
be influenced by tension
body. However this analogy ignores the fact that and other forces in
the ligaments and tendons,
in the shoulder the tee is significantly deep- which form part of the
containment of the
ened by soft tissue structures and the socket of humeral head. One does
not have to observe
the glenohumeral joint can more correctly be many shoulder
arthroscopies to realise that the
considered to be an osseoligamentous structure, anatomy of the
shoulder capsule and ligaments
the base of which is formed by the bone of the varies enormously
between individuals and
glenoid fossa. therefore any study of
shoulder biomechanics
The glenoid fossa itself has a slight upward tilt may not give results
that reflect the environment
with respect to the medial border of the scapula [1]. of every shoulder.
852
D. Limb
Fig. 7 The rotator cuff contraction compresses the

humeral head into the concavity of the glenoid, making
translation into a position of subluxation or even disloca-
tion much more difficult. The contracting muscle masses
themselves resist displacement of the humeral head away
from the glenoid Fig. 8 The
suprascapular nerve is susceptible to com-
pression where it
passes under the transverse scapular
ligament, in which
case both supraspinatus and
infraspinatus are
affected. It can also be compressed
The Rotator Cuff where it winds around
the base of the scapular spine, at
the spinoglenoid
notch, resulting in wasting and weakness
The rotator cuff tendons mentioned above are of infraspinatus
alone
both biomechanically and clinically important.
These tendons form a sleeve that, on contraction
of the associated muscle bellies en masse, com- labrum) affects
infraspinatus alone. Teres minor
presses the humeral head into the glenoid (Fig. 7), is served by the
axillary nerve and may be
being ideally aligned to provide such compres- affected by lesions
that occur, for example, after
sion in all shoulder positions [19]. Individually shoulder dislocation.
The nerve to subscapularis
the cuff tendons can internally rotate is much less commonly
affected by such patho-
(subscapularis), abduct (supraspinatus) or exter- logical lesions.
nally rotate (infraspinatus and teres minor) the
proximal humerus and this forms the basis for
clinical tests of cuff integrity. All of the cuff Movements
muscles are served by the C5 nerve root and
global wasting of all cuff muscles, plus deltoid, The shoulder joint,
through its constituent link-
occurs in brachial plexus lesions that involve the ages, allows an
enormous range of humeral
fifth cervical root. However, the route of nerve movement which, with
the elbow modulating
fibres to individual cuff muscles varies from mus- distance between the
distal radius and the torso,
cle to muscle and this may help identify the site of allows the hand to be
positioned within an almost
nerve pathology giving rise to localised cuff spherical field
around the glenohumeral joint.
wasting (Fig. 8). Any movements that we
care to measure and
The suprascaplular nerve is particularly prone record are therefore
rather artificial descriptions
to compression and it serves the supraspinatus of positioning that
do not always give a full pic-
and infraspinatus. Compression at the scapular ture of the
capability or limitations of the shoul-
notch in relation to the transverse scapular der. For convenience
we refer to orthogonal
ligament, causes pain and wasting of both planes in relation to
the torso to describe shoulder
supraspinatus and infraspinatus, whilst compres- movement
flexion/extension in the sagittal
sion at the spinoglenoid notch (for example by plane,
abduction/adduction in the coronal plane
a degenerative cyst connected to the posterior and internal/external
rotation in the transverse
853
plane. However it is also possible to refer instead The same technique can be
used to measure
to the scapular plane (which is 3040# forwards adduction, by first flexing
the glenohumeral
of the coronal plane) and describe flexion and joint to 90# then measuring
cross-chest adduction
abduction in relation to this, as may be reported (this being limited in this
position by tension in
in basic science research in which the scapula is the posterior shoulder
capsule).
isolated. Furthermore these planes do not include These movements
are not simply
the direction of movement that the humerus glenohumeral movements
however if the scap-
tracks out when reaching overhead, for example. ula is fused to the thoracic
wall then significant
The plane of functional elevation is approxi- limitation of shoulder
movements occurs.
mately 30# lateral to the sagittal plane and Shoulder movements are a
composite of
patients may achieve more in this range than in glenohumeral and
scapulothoracic movement,
conventionally measured flexion or abduction. the scapula rotating to
point the glenoid superi-
Note that the bone, muscle, tendon and ligament orly in abduction and in
flexion. The relative
conditions in any position of the arm are affected contribution of these two
components, and the
by how the arm came to be in that position. fluidity with which they are
combined, is
Codmans paradox describes the observation described by the term
scapulothoracic
that if the arm is by the side then the shoulder is rhythm. Ordinarily both
scapulothoracic and
fully flexed, the palm ends up facing towards the glenohumeral movements occur
together, though
head but if the arm is abducted fully to the same the contribution of the
glenohumeral overall is
position the palm is facing away from the head. approximately twice that of
the scapulothoracic
Essentially the humerus rotates about its long axis [13, 18, 27]. The relative
contributions in the first
by 180# between these movements, emphasising 30# of elevation appear to
vary between individ-
the interdependence of rotations about the uals and the sexes [7].
Indeed this may even vary
glenohumeral joint. within the same individual
and with disease. If
the glenohumeral joint
becomes very stiff, for
example in osteoarthritis,
the scapulothoracic
Measurement of Movement range may still be
preserved. In such patients
abduction may be associated
with shoulder
The range of movement is measured in degrees, hunching due to scapular
elevation; the relative
the zero position being with the arms by the side contributions of the
scapulothoracic and
and palms facing the thigh. Whilst this is satis- glenohumeral joints are
reversed so called
factory for flexion, extension, abduction and reversal of scapular rhythm.
Note that this com-
external rotation, it cannot apply to internal rota- posite movement has been
studied in the coronal
tion or adduction, as the torso prevents these plane and in the scapular
plane. However neither
movements from this starting point. Functionally, of these reference planes
adequately describes the
therefore, internal rotation is measured as path of the scapula around
the chest wall as it both
the highest spinal level that can be reached with translates and rotates to
contribute to elevation of
the ipsilateral thumb (marked restriction means the arm.
the thumb can reach only the trochanter, buttock The role of the clavicle
and its associated
or sacro-iliac region, whilst most individuals can joints in shoulder movement
is not fully eluci-
usually reach T8 T6) (Fig. 9a, b). The alterna- dated. As noted, the
shoulder can function very
tive is to measure in degrees with the arm at 90# well, or even normally, with
an incompetent clav-
of abduction. External rotation can also be icle or without the joints
associated with the
measured in this position but the conditions clavicle. Intuitively the
clavicle seems to act as
must be specified when the measurement is a strut between the scapula
and the torso. If this is
recorded external rotation measured with the so, then it is not a
significant load-bearing strut as
arm by the side and measured again in 90# of in these circumstances the
scapula would col-
abduction will be different in the same individual. lapse in towards the torso
with a dislocated AC
854
D. Limb
Fig. 9 (a) external rotation can be measured with the commonly recorded as the
highest vertebral level that
elbows tucked into the side, using a goniometer to give can be reached with the
thumb
an angular measurement. Internal rotation (b) is more
joint or un-united clavicle fracture. Instead it may So what movements are

possible at the shoul-
function co-operatively with the scapula suspen- der joint? As is the case
in most other joints, there
sory mechanism, perhaps providing propriocep- is no normal range.
This is quickly confirmed
tive feedback into the system. Note that the by asking a small group
to compare external
clavicle rotates around its long axis with arm rotation with the arms
held into the torso it is
elevation, particularly in high degrees of eleva- not uncommon to observe
maximal external rota-
tion. Plates and screws applied in one plane are tion to vary between 40#
and 100# in this situa-
not good at resisting rotation about an axis paral- tion. Other movements are
perhaps less
lel to the plate, therefore one must consider when susceptible to variation,
largely because the
to allow patients to regain full overhead range end-points are not
determined by soft tissues as
after internal fixation of the clavicle. is the case with external
rotation. Accurate
855
a b
Fig. 10 Shoulder abduction at the glenohumeral joint rotation increases

this to about 120# (b). However, exter-
without humeral rotation is limited to about 80# by nal rotation of
the humerus clears the greater tuberosity
impingement of the greater tuberosity (a), though scapular from beneath the
acromion and allows full abduction (c)
measurement is easily confounded in the case the zero position

described above, as the greater
of flexion the acromion will usually prevent flex- tuberosity and
attached supraspinatus impinge
ion beyond 160# but most individuals can flex against the
glenoid. Scapular rotation can allow
until their humerus points directly up, as they abduction to
around 120# but it is only by external
lordose the thorax and extend the lumbar spine rotation [16],
which brings the greater tuberosity
to tilt the scapula back. Abduction at the away from the
glenoid, that allows full abduction
glenohumeral joint is limited to about 80# from of about 180#
(Fig. 10ac). The experimental
856
D. Limb
study of shoulder movement in three dimensions that could be smaller, the

same or greater in
demands that three linear and three angular co- different people [31].
However it appears that
ordinates are recorded to sufficiently describe the this observation may be
attributable to experi-
starting and finishing positions where six degrees mental error. The articular
cartilage of the
of freedom exist. The two most commonly glenoid is thinner centrally
than peripherally,
described techniques are Eulerian angle and whist the reverse is true
for the humeral head.
screw displacement methods. Analysis of these Recent studies suggest that
the humeral head and
is outside the scope of this chapter, though for the glenoid are fully congruent
in all positions [34],
upper limb joints the methods are summarised in and this facilitates fluid-
film adhesion between
standard texts [24, 30]. the two, which enhances
stability by generating
During glenohumeral joint movement the a negative pressure if there
is any attempt to
humeral head is retained in the glenoid fossa by separate the joint surfaces
[14, 17]. When this is
the balance of muscle forces (and capsuloli- broken by introducing a
needle into the shoulder
gamentous restraining forces at the extremes of joint and allowing air to
ingress a soft pop is
range). Although the articulation of the humeral often heard as the fluid
film breaks and admits air.
head on the shallow glenoid can incorporate ele- Although the humeral head
and glenoid cannot be
ments of spin, roll and glide, studies suggest that distracted directly apart in
the anaesthetised
in normal movements of the shoulder the instant patient this becomes very
easy once air or fluid
centre of rotation varies little from a locus within are introduced between the
joint surfaces.
the humeral head and any translation on the The glenoid itself
encloses less than one-third
glenoid is limited to a few millimetres. of the humeral head
articular surface an arc of
about 75# in the coronal
plane and 60# in the
transverse plane. Saha
showed that if the glenoid
Stability is relatively small its
vertical height enclosing
less than 75 % of the
humeral head or its trans-
As noted, the glenohumeral joint is the most verse dimension less than 57
% of the humeral
commonly dislocated joint in the human body. head diameter, then the
shoulder was more likely
As a ball and socket joint, it is characterised by to be unstable. Furthermore
there is some evi-
the shallowness of its bony socket and therefore dence that the degree of
ante- or retroversion of
the soft tissues are primarily responsible for keep- the glenoid fossa can
increase the susceptibility
ing the ball in the socket. At rest and under to dislocation, those with
relative anteversion
anaesthesia the shoulder does not dislocate, how- being more prone to anterior
dislocation and
ever, so there are static restrains to dislocation vice versa. Again this is an
area for investigation
that operate even when the patient is paralysed. and it seems that the
glenoid may not be
However these mechanisms are amplified by so- a particularly even-sided
cup, the degree of
called dynamic factors, which increase the anteversion and retroversion
varying within the
compression force of ball into socket under the glenoid depending where it
is measured [23].
influence of muscle contraction. This shallow fossa is
deepened, however, by
the glenoid labrum to which
the capsule of
the shoulder joint and its
thickenings the
Static Factors glenohumeral ligaments are
attached. As the
concavity is deepened, the
joint is stabilised, but
Glenoid Fossa and Labrum note that if the glenoid
labrum were to be
The glenoid fossa forms a shallow concavity at detached from the margin of
the glenoid then
the base of the osseoligamentous socket of the this would abolish the
deepening effect and
glenohumeral joint. It was thought that the detension the glenohumeral
ligaments, signifi-
humeral head could be incongruent with respect cantly compromising their
functions. The depth
to the glenoid fossa, with a radius of curvature of the glenoid fossa in the
transverse plane is only
857
2.5 mm, but an equivalent depth is added by the ligament (SGHL) and
coracohumeral ligament
labrum. On the whole, however, it is agreed that (CHL) have a role to
play in preventing inferior
static constraints related to the shape of the artic- subluxation [26]. The
SGHL is put under tension
ulation contribute little to the overall stability of by external rotation of
the shoulder with the arm
the joint, though deficiencies of glenoid bone can by the side. Thus a
sulcus sign, indicating inferior
permit escape of the humeral head if combined subluxation, that
disappears on external rotation
with capsulolabral abnormalities [35]. Although of the arm indicates
that the SGHL is competent.
the possibility of abnormal humeral head If the sulcus sign
persists in external rotation this
anteversion has previously been considered as a suggests that the SGHL
and its adjacent capsule
cause for anterior instability, it is felt to be rarely, (the rotator interval
capsule and the extra-
if ever, a significant contributory factor [29]. articular CHL in the
same location) are incompe-
tent. The rotator
interval capsule also has a role in
Capsule and Ligaments controlling posterior,
as well as inferior, transla-
The capsule of the glenohumeral joint is thin and tion [10].
elastic with a high type 1 collagen content. It has The middle
glenohumeral ligament (MGHL)
a volume approximately three times that of the comes under tension with
external rotation, par-
humeral head, which is necessary in order to ticularly in the lower
range (less than 45# ) of
allow the enormous range of movement abduction [26]. At
higher degrees of abduction,
described above. Anything that diminishes the particularly in external
rotation, the inferior
volume of the shoulder capsule, such as scarring glenohumeral ligament
(IGHL) is the predomi-
after trauma or the histological change and con- nant restraint, as
documented in numerous stud-
tracture that occurs with frozen shoulder, ies [3, 9]. The IGHL
forms a hammock-like
causes a restriction of glenohumeral movements. structure from the
inferior glenoid to the
The ligaments of the glenohumeral joint are humeral head. The
posterior and, particularly,
very variable, as is demonstrated by observing the anterior margins of
this hammock are
only a few shoulder arthroscopies. Because the thickened. The anterior
band of the IGHL
volume of the shoulder capsule is so much greater comes under tension in
full abduction and
than the volume of the humeral head it is also true external rotation. In
this position it strongly
that the ligaments are not under tension, therefore resists anteroinferior
dislocation of the humeral
are contributing nothing to stability, except when head. If dislocation
does occur then a structural
the humerus is rotated to an extreme position alteration occurs
usually avulsion of the
which will put one region of the capsule, and anteroinferior labrum,
but also stretching of
any ligament in that region of capsule, under the ligament and/or,
less commonly,
tension. Thus at rest and in close range movement avulsion of the ligament
from its humeral inser-
the glenohumeral ligaments have no role to play tion (Humeral Avulsion
of the Inferior
in stabilising the shoulder. The patient who Glenohumeral Ligament
HAGL lesion).
subluxes or dislocates whilst in a sling will not
be prevented from dislocation by an anterior Muscles
repair unless this significantly shortens the loose The glenohumeral joint
is surrounded by the thick
capsule and ligaments, in which case external tendons of the rotator
cuff, with which the cap-
rotation of the shoulder will be lost. At the end- sule of the joint merges
laterally. Indeed, in engi-
range of movement, however, the ligaments do neering nomenclature the
glenohumeral joint is
come under tension and provide passive restraint a force-closed joint,
dependant on balanced mus-
to glenohumeral translation over the glenoid mar- cle activity to centre
the humeral head in its
gin in the direction of capsular tightening [3]. articulation on the
glenoid fossa [21]. The cuff
The only part of the shoulder capsule that is tendons are very thick
and, by their very presence
under tension in the erect posture is the superior around the humeral head,
and with their attach-
capsule. Thus the superior glenohumeral ments medially to the
scapula and laterally to the
858
D. Limb
tuberosities of the humeral head, will resist dis-

placement of the humeral head out of the glenoid
fossa. Thus it has been shown experimentally that
dividing the rotator cuff tendons in a cadaver
significantly reduces resistance to displacement
of the humeral head out of the fossa, even if the
muscles are not contracting. Contraction of the
cuff muscles put the tendons under significant
tension, which provides a substantial block to
humeral dislocation. Experimentally a 50 %
reduction in the force in the cuff muscles results
in an almost 50 % increase in displacement of the
humeral head in the glenoid in response to exter-
nal loading [36].
Dynamic Factors
As noted above, the glenoid labrum deepens the

socket of the glenohumeral joint and in doing so Fig. 11 With an intact bony
rim and glenoid, it is neces-
increases the force required across the face of sary to distract the humeral
head away from the line of
the glenoid to displace the humeral head towards action of the rotator cuff
(arrow), in addition to translating
the head away from the
glenoid, to bring about dislocation.
the joint margins. Any force compressing
Deficiency of the labrum
and/or bony glenoid rim means
the humeral head into the glenoid further that only translation is
needed, without having to provide
increases the resistance to lateral translation any distraction against a
contracting muscle mass
[21] in effect the humeral head would have to
totally overcome the compressive force to move
away from it in order to climb over the glenoid needed to set the supporting
core muscles of the
rim. Thus the resultant force in shoulder move- legs and trunk, position the
scapula on the torso,
ment, which should always be directed towards and fine tune shoulder
girdle muscle tensions to
the bony glenoid, acts to deter dislocation. direct the force transmitted
through the humeral
Furthermore the greater the joint reaction force, head directly onto the bone
of the glenoid
the greater the force required to overcome fossa. We are beginning to
understand the contri-
this concavity compression effect and create a butions of neuromuscular
control to stability,
dislocation (Fig. 11). In effect it is only by but beginning is the
important word. However
creating conditions where the resultant force is this is beginning to shape
our concepts of shoulder
no longer directed into the glenoid fossa that stability, recognising a
triad of interplaying
dislocation can occur [11]. factors shoulder anatomy
that predisposes to
This simple explanation masks the complexity instability (laxity,
variations in anatomy not
of the real situation, where the resultant force is resulting from trauma etc.),
traumatic structural
achieved by individual contributions from 18 to 26 lesions and neuromuscular
control [15].
muscles (depending on how these are counted). Concavity compression is
also enhanced as
Furthermore these are in a constant state of change, the glenohumeral joint moves
to an extreme posi-
accommodating variations in the applied load and tion of movement. As the
humeral head rotates
executing planned movement whilst responding towards the limit of motion
the capsule and liga-
to unpredictable changes in the resistance met. ments associated with it
become tight. As the
A very fine system of neuromuscular control is humeral head attempts to
rotate further the
859
and surrogate
measurements and still have a lot to
learn. For any
position of the upper limb it is
possible to
estimate the force that a muscle is
capable of
generating, its line of action and the
activity of the
muscle. From these, the net force
across a joint can
be computed, remembering
that in the case of
the glenohumeral joint up to
26 muscles can be
involved.
The force a
muscle is capable of generating
relates to the
cross-sectional area of all of the
muscle fibres in a
muscle (not necessarily there-
fore the cross-
sectional area of the muscle) and the
total length of the
fibres, and this has been calcu-
lated for certain
positions of the glenohumeral
joint. In abduction
and external rotation, for exam-
ple, the greatest
contribution to forces acting
across the
glenohumeral joint comes from the
deltoid,
subscapularis, infraspinatus/teres minor,
pectoralis major
and latissimus dorsi, with contri-
butions declining
from the deltoids 18 % to the
12 % contribution
of latissimus [2]. This is a static
analysis in one
position and simply has not been
repeated for most
possible positions of the joint.
Fig. 12 As the head rotates to the end of the available The orientation of
the line of action of a muscle
range of motion the relevant ligament comes under ten- may be extremely
difficult to define and during
sion, which is countered by increased concavity compres-
sion of the humeral head into the glenoid. As the head is a movement the line
of action may cross the axis of
forced into further rotation the tension in the ligament rotation,
completely reversing the action of the
increases, effectively increasing the stability of the joint, muscle [13]. The
activity of a muscle can be esti-
until ligament failure occurs mated by EMG
studies [32, 33], but these are
susceptible to
numerous sources of error. We
tension in the ligaments increases and this is have the ability to
derive the order of magnitude
directed to compress the humeral head into the of the forces
crossing the shoulder and estimate
glenoid (Fig. 12). Thus the stability of the joint how the force
vectors alter with some movements,
increases until the tension in the capsule and and this
information has informed the develop-
ligaments can no longer be sustained and soft ment of joint
replacements and reconstructive
tissue rupture occurs the capsule stretches or devices. However,
it is apparent that we are
tears, avulses its attachment to the glenoid or lacking in detailed
knowledge.
avulses from the humeral head, a predictable
range of pathology that is observed in patients
after shoulder dislocation. Forces Across the
Glenohumeral Joint
Most research has

been directed to determining
Forces the forces acting
across the glenohumeral
joint far more is
known about this, for example,
We can estimate forces acting across the shoulder than the forces in
the scapular stabilisers as they
girdle, and this suggests that the shoulder trans- rotate the scapula
and position it to stabilise the
mits the equivalent of body weight, or even mul- muscles that rotate
the humerus in the glenoid.
tiples of this. However we rely on assumptions This is driven by
need, as it is the glenohumeral
860
D. Limb
Fig. 13 A simple free-

body calculation of the
F2
order of magnitude of
D2
forces required simply to
abduct the arm, with no
D1
weight being lifted against
resistance. In the loaded
arm joint reaction forces
can be multiples of body F1 x D1 = F2 x D2
weight F1
0.05(BW) x 0.3 = F2 x 0.03
F2 = 0.05(BW) x 0.03
0.3
F2 = 0.5(BW)
joint that most commonly develops pathology joint replacements.

Although we have stated that
and the pathology is often amenable to recon- the scapular stabilisers
rotate the scapula to
structive surgery. Knowledge of the mechanical accept the resultant force
from the humerus onto
environment of the glenohumeral joint is there- the bony glenoid, this
resultant force is not
fore essential not only in developing adequate always central in the
fossa. It seems that even
joint replacement components, but also in design- the straightforward act of
initiating a simple
ing reconstructive procedures for fractures and movement such as abduction
causes significant
soft tissue injuries sufficiently robust to permit forces to sweep up and down
the glenoid, testing
the return of joint function. the fixation of any glenoid
component in
A simple free-body diagram can be constructed arthroplasty in the short
term and threatening it
to help calculate forces across the glenohumeral with loosening in the long
term. If the abductors
joint. With the arm held in 90# of abduction contracted to initiate
abduction and nothing else
moments acting to return the arm to the side are occurred, the scapula would
be pulled into down-
a result of the effect of gravity: the weight of the ward rotation by the weight
of the arm and the
arm through its centre of gravity a fixed distance effort available to abduct
the arm would be
from the glenohumeral joint (around 3035 cm). wasted. The movement
pattern of abduction
At equilibrium this is balanced by the action of the therefore demands that the
brain first pre-sets
abductors (deltoid and supraspinatus) whose line the scapula, fixing it to
the trunk. More than
of action passes only 23 cm from the axis of this, the trunk itself has
to be stable, so activity
rotation in the humeral head (Fig. 13). From this in the shoulder abductors
is in fact preceded, by
it can be estimated that even with no weight in the milliseconds, by
contraction of the leg and trunk
hand, there is a force equivalent to half body- muscles and scapular
stabilisers. The inferior cuff
weight acting through the humeral head onto the then contracts to pull the
humeral head down an
glenoid fossa. This multiplies to forces far exceed- instant before the
abductors kick in to rotate the
ing body-weight when the hand is significantly humerus up [28] the
result is that the joint
loaded, and this includes unexpected loads such reaction force momentarily
swings to the inferior
as breaking a fall with the outstretched glenoid as pre-setting
occurs then up to the supe-
hand a common scenario for rotator cuff tear. rior glenoid as deltoid and
supraspinatus initiate
Free-body diagrams such as this tell us basic the upward rotation of the
humerus, finally set-
information about static events, but dynamic tling in the central
glenoid as the humeral abducts
analysis adds important information that is cru- and the scapula rotates
upwards, contributing the
cial in understanding the long-term behaviour of scapulothoracic share to
the movement. In the
861
absence of the superior rotator cuff, as occurs

with a supraspinatus tear, this cycling of the Clinical Relevance
resultant force from inferior to superior glenoid
is magnified and, in the presence of a glenoid An appreciation of the
biomechanical environ-
replacement, can lead to early loosening of the ment of the shoulder is
essential to the successful
interface between component and bone the so management of the range of
pathology that can
called rocking horse glenoid. present to the shoulder
clinic. The delicate bal-
If the deltoid is acting alone, or is dominant, ance of muscle forces and
neuromuscular control
then simple consideration of its origin and inser- helps us to understand why
instability can easily
tion with respect to the glenoid reveals that shear result from abnormalities
in the anatomy of the
forces across the glenoid will occur with deltoid shoulder or in its
controlling mechanism. Ana-
contraction. The supraspinatus, however, and tomical problems can be
reconstructed by appro-
indeed the other cuff muscles, acts almost parallel priate ligament or labral
repair, or even bony
to the scapular plane, the force it generates being reconstruction, but
abnormalities of neuromuscu-
directed towards the glenoid with little shear com- lar control could be made
worse by the same
ponent. With normal muscle-tendon units across procedures. The
elucidation of the underlying
the shoulder the shear forces are balanced and the biomechanical cause of
instability is key to suc-
resultant force is directed into the concavity of the cessful management of the
patient with recurrent
glenoid. Loss of any component, and it is most dislocation or
subluxation. Examples of improve-
often the superior rotator cuff that is lost, disrupts ments in technique that
have resulted from con-
the normal control mechanism and allows eccen- sideration of normal
biomechanics include
tric joint reaction forces that are more difficult for fixation of the labrum
onto the face of the glenoid
the neuromuscular control mechanisms to contain. rather than its neck,
restoring an anterior buffer,
However it is clear that some patients develop and the realisation that
bone defects (the
good compensation, generating appropriate force inverted pear glenoid)
require bone reconstruc-
couples to maintain a well-centred joint reaction tion in the way of a
Latarjet repair or similar.
force despite apparently significant pathology. Neuromuscular control
and the creation of
Why some patients adapt in this way, with or balanced force couples is
essential to normal
without physiotherapy to assist, yet others develop shoulder function. There
is much to be learned
significant dysfunction with relatively small cuff about how disorders of
control can be managed if
tears, is not known. they occur with no
abnormality of the gross
One advantage that the anatomy of the shoul- shoulder anatomy. However
our understanding
der presents to the implant designer relates to this of neuromuscular control
in the face of an obvi-
discussion on shoulder movements and forces. ous anatomical lesion,
such as a rotator cuff tear,
We have already noted that the centre of rotation is also far from complete.
The biomechanical
of the glenohumeral joint is contained in analysis that we can
perform explains how we
a relatively small locus only a few mm across. can improve the symptoms,
range of movement
The humeral head itself rotates around a point at and strength by repairing
a rotator cuff tear. How-
the projected centre of a sphere of which it forms ever, it is not always
clear or explainable why
a segment. This lies within the metaphysis of the some people with very
large tears have excellent
humeral head and consequently the forces acting function and no pain [22],
whilst others have
on a prosthesis push it into a stable position and symptoms that improve with
non-operative treat-
provide little stress at the fixation interface of the ment [9]. However, even in
those that do not
stem. Thus humeral stem loosening is rare (even present for treatment,
function is poorer and
in uncemented stems that do not have any sort of symptoms more significant
in the presence of
bio-active coating) and resurfacing prostheses are a cuff tear [8].
Furthermore, most patients with
durable with very few reported complications of a bald humeral head due to
a massive rotator cuff
humeral component fixation. tear do go on to develop
rotator cuff arthropathy.
862
D. Limb
The shoulder is a weight-bearing joint in projected centre of a

sphere of which a humeral
normal activities loads exceeding body weight head component is a
segment. The result is that
are regularly transmitted across the glenohumeral the centre of rotation is
medialised by 3 cm or so,
joint. Even simple movements against gravity more than doubling the
distance between the line
result in the generation of large forces in the of action of the deltoid
muscle and the centre of
rotator cuff tendons. When shoulder fractures rotation. Consequently the
moment arm of the
involve the greater and lesser tuberosities it deltoid is significantly
increased and portions of
should not be forgotten that during rehabilitation the anterior and posterior
deltoid are recruited as
one is aiming for restoration of normal function, abductors. Upward migration
of the humerus is
which means a normalisation of the forces gen- prevented by articulation
with the glenosphere
erated by the cuff muscles and exerted on the and indeed the humerus is
lowered with respect
tuberosity fragments. Even modern locked- to the acromion, re-
tensioning or increasing ten-
plating systems do not usually provide stable sion in the deltoid [4]. As
a result the prosthesis is
fixation for the tuberosity fragments by screws not at all reliant on
rotator cuff function, making
engaging the plate. Additional fixation, com- it suitable for use when
the cuff is absent or
monly by suture material passing through the unreconstructable. Without
a working cuff there
plate, is required and one has to be aware of are significant limitations
in both internal and
the potentially destructive forces to which the external rotation, and the
importance of external
fixation will be subjected. rotation to shoulder
function has already been
The same applies to fixation of tuberosity frag- noted. This may be
addressed by concurrent
ments when hemi-arthroplasty is used for the transfer of latissimus
dorsi as a motor for external
reconstruction of complex fractures and fracture rotation, though the long-
term results of such
dislocations of the shoulder. One of the procedures are not yet
available.
commonest reasons for poor results of hemi-
arthroplasty for fractures is migration of the
greater tuberosity, and one of the most critical Summary
steps in surgery is the re-attachment in a position
that allows anatomical lines of action for cuff The articulation between
the thorax and arm
muscles that can withstand physiological forces. includes scapulothoracic
and glenohumeral joints,
Furthermore the biomechanical environment can the clavicle providing a
strut between the scapula
only be re-created by careful positioning of the and thorax through its
synovial acromioclavicular
prosthesis to re-create the correct length and and sternoclavicular
joints. The scapula is slung
humeral retroversion. Experimentally it has been on to the axial skeleton by
muscles and these
shown that mal-positioning of the humeral and/or control scapular
positioning, directing the glenoid
glenoid components in total shoulder replacement fossa to accept the joint
reaction force from the
adversely affects the kinematics, range of move- humeral head and
substantially increasing the
ment and stability of the shoulder [12]. range of shoulder movement
by its elevation,
However this is one situation where knights depression, protraction,
retraction and rotation
move thinking has lead to the development of on the ribcage. There is a
complex and, as yet,
a prosthesis specifically designed to work better poorly understood system of
neuromuscular con-
when the natural environment of the shoulder trol which is linked to the
system providing core
cannot be restored. The reverse geometry designs stability to the trunk,
providing the platform from
of shoulder prosthesis attach the ball, in the which the shoulder can
function.
form of a glenosphere, to the scapula. The The glenohumeral joint
in particular has
socket is then fixed to the proximal humerus, evolved to allow an
enormous range of motion
usually with a stem to stabilise it within the shaft. and this is at the cost of
inherent stability. Disor-
The centre of rotation becomes the projected ders in the natural anatomy
or lesions affecting
centre of the glenosphere rather than the the bone, ligaments,
tendons and other soft tissue
863
structures can each, alone or in combination, 5. Dempster WT.

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shoulder joint. Am J Sports Med. 1990;18:57984. 35. Stevens KJ,
Preston BJ, Wallace WA, Kerslake RW.
27. Poppen NK, Walker PS. Normal and abnormal motion CT imaging and
three dimensional recosntructions of
of the shoulder. J Bone Joint Surg. 1976;58A:195201. shoulders with
anterior glenohumeral instability. Clin
28. Poppen NK, Walker PS. Forces at the glenohumeral Anat.
1999;12:32636.
joint in abduction. Clin Orthop. 1978;58:165. 36. Wuelker N,
Korrell M, Thren K. Dynamic
29. Randelli M, Gambrioli PL. Glenohumeral osteometry glenohumeral
joint stability. J Shoulder Elbow Surg.
by computed tomography in normal and unstable 1998;7:4352.
shoulders. Clin Orthop. 1986;208:1516.
Principles of Shoulder
Imaging
S. Shetty and Paul

ODonnell
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 865
Anatomy # Arthrography # CT and CT
arthrography # MR & MR arthrography #

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 866
Radiographs # Ultrasound
Biceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 866
Deltoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 866
Rotator Cuff Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
866
Gleno-Humeral Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
866 Introduction
Acromioclavicular Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
867
Sternoclavicular
Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
867
Coraco-Acromial Arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
867 Radiographs, fluoroscopy, ultrasound (US), com-
puted tomography (CT) and magnetic resonance

Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 868
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 868 imaging (MRI) are the modalities most frequently
used in investigating the shoulder. US and MRI are

Arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 868
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 868
most often used for evaluating the rotator cuff.

Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 869 The need for imaging of the shoulder,
Posterior
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
870 particularly the rotator cuff, has increased over
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 870 the last few years, probably related to the ageing
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 870 population and an increase in sport-related injury.
Ultrasound Examination of the Shoulder . . . . . . . . . . . 872
The first publication regarding the use of US for
Computed Tomography (CT) and Computed
the evaluation of the rotator cuff was by
Tomography Arthrography (CT
Seltzer et al., published in 1979 and for MRI
Arthrography) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
875 was by Kneeland et al. in 1986. In the ensuing
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 875
years advances in imaging technology and

MR and MR Arthrography . . . . . . . . . . . . . . . . . . . . . . .
876 extensive research have improved understanding
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 876
of rotator cuff pathology. At present both these

Normal Anatomical Variants . . . . . . . . . . . . . . . . . . . . . . . .
876
MR
Sequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 877 modalities still have limitations and a rotator cuff
Post-Surgical Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
879 imaging gold standard is yet to be realised.
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 879 CT and MRI arthrography have significantly
improved the imaging of the labrum and ligamen-
tous structures of the gleno-humeral joint.
Conventional arthrography is currently not used
in isolation for diagnostic purposes. In this

S. Shetty (*) # P. ODonnell
chapter we aim to provide the reader with

Department of Radiology, Royal National Orthopaedic
a comprehensive overview of the imaging
e-mail: paul.odonnell@rnohnhs.uk
modalities for investigating shoulder pathology.

865
DOI 10.1007/978-3-642-34746-7_40, # EFORT 2014
866
S. Shetty and P. ODonnell
Infraspinatus
Anatomy The infraspinatus arises
from the medial aspect of
the infraspinous fossa of
the scapula and inserts
An in-depth knowledge of the anatomy of the onto the middle facet of
the greater tuberosity of
shoulder is key to the interpretation of any shoul- the humerus.
der imaging. Below is a short overview.
Teres Minor
The muscle arises from
the lateral margin of the
Biceps scapula and inserts onto
the inferior facet of
the greater tuberosity of
the humerus (Table 1).
The biceps has two heads: the short head of
biceps, which arises from the coracoid process,
and the long head of the biceps, which arises from Gleno-Humeral Joint
the supraglenoid tubercle and superior labrum.
The long head of biceps follows an intra-articu- This is the most mobile
and the least stable of
lar, intrasynovial path to descend into the the joints in the body.
This is because the articular
intertubercular groove, between the greater and surfaces are asymmetrical
in size and morphology,
lesser tuberosities. It is one of the structures in the with the small and
relatively flat glenoid surface,
anterior (rotator) interval of the rotator cuff along articulating with the
large, round articular surface
with the coraco-humeral ligament and the of the humeral head,
within a lax joint capsule.
superior gleno-humeral ligament. The anterior This laxity of the
capsule allows for a greater range
interval is located between the subscapularis of movement at the
shoulder joint, but makes the
and supraspinatus tendons. The biceps tendon shoulder inherently
unstable and prone to sublux-
inserts into the radial tuberosity of the radius, ation and dislocation.
The fibrocartilaginous
with an additional aponeurotic insertion into the labrum at the periphery
of the glenoid deepens
lacertus fibrosus. and widens the shallow
glenoid.
The articular
surfaces of the humeral head and
glenoid are covered by
hyaline cartilage. Humeral
Deltoid articular cartilage
extends to the anatomical neck,
which is also the lateral
attachment of the joint
The deltoid arises from the lateral clavicle, the capsule. Medially the
capsule is attached to the
acromion and the lateral scapular spine and margin of the glenoid
just medial to the labrum,
inserts into the deltoid tubercle of the humerus. posteriorly and
inferiorly. Inferiorly, it is lax and
this is the weakest part
of the capsule. Anteriorly,
based on the attachment
of the capsule in relation to
Rotator Cuff Tendons the glenoid labrum, it is
classified into three types:
Type 1. Capsule inserts
onto the labrum
Subscapularis Type 2. Capsule inserts
onto the scapular neck,
The subscapularis arises from the anterior aspect within 1 cm of the
labrum
of the scapula and inserts into the lesser tuberos- Type 3. Capsule inserts
onto the scapular neck,
ity of the humerus. greater than 1 cm
from the labrum.
Superiorly it extends
to the root of the cora-
Supraspinatus coid and contains the
supraglenoid origin of the
The supraspinatus arises in the suprascapular long head of the biceps.
fossa of the scapula and inserts into the There are two
apertures in the capsule, one
superior facet of the greater tuberosity of the between the humeral
tuberosities, which allows
humerus. the passage of the biceps
tendon, and the other is
Principles of Shoulder Imaging
867
Table 1 Anatomy of the rotator cuff muscles

Muscles Origin Insertion Action
Nerve Supply
Subscapularis Anterior aspect of body of Lesser tuberosity
Adduction & Upper and lower
scapula
internal subscapular nerves
rotation
Supraspinatus Supraspinous fossa of the Superior facet of the
Internal Suprascapular
scapula greater tuberosity
rotation & nerve
abduction
Infraspinatus Infraspinous fossa of the Middle facet of the greater
External Suprascapular
scapula tuberosity
rotation nerve
Teres Minor Lateral border of the Inferior facet of the
External Axillary nerve
scapula greater tuberosity
rotation
Biceps Short head: coracoid Radial tuberosity of the
Supination & Musculocutaneous
process radius and lacertus
flexion nerve
Long head: supraglenoid fibrosus
tubercle & superior labrum
Deltoid Lateral clavicle, acromion Deltoid tubercle on the
Abduction Axillary nerve
and scapular spine shaft of the humerus
the subscapularis recess in the sub-corocoid a fibrocartilagenous

disc. The coracoclavicular
region, which connects the subscapular bursa ligament, consisting of
the trapezoid component
with the synovial space. laterally and the conoid
component medially also
Synovium lines the fibrous capsule and forms aid in stabilizing the
joint.
a tubular structure around the biceps tendon
as it passes through the intertubercular groove,
extending to the surgical neck of the humerus. Sternoclavicular Joint
Multiple ligaments (coraco-humeral and the
superior, middle and inferior gleno-humeral) This joint lies between
the medial inferior
re-inforce the capsule. The gleno-humeral aspect of the clavicle
and the superolateral
ligaments extend from the anterior margin of the aspect of the manubrium.
It is lined by
glenoid to the lesser tuberosity. These, especially fibrocartilage and also
has a fibrocartilage disc.
the anterior band of the inferior gleno-humeral This joint can be
difficult to evaluate with radio-
ligament, limit external rotation and anterior graphs. Thin section CT
or MRI, with the patient
translation of the humeral head. The coraco- prone to stabilise the
sternum, provides better
humeral ligament arises from the coracoid and quality imaging.
inserts into the lesser and greater tuberosities,
re-inforcing the capsule over the biceps tendon.
Coraco-Acromial Arch
Acromioclavicular Joint This is formed by the

anterior acromion, the
coraco-acromial ligament
and coracoid process.
This joint lies between the medial aspect of the The coraco-acromial
ligament extends from the
acromion and the lateral aspect of the clavicle. It is anterior acromion to the
coracoid process and
a synovial joint and is therefore prone to inflam- measures between 2 and 5
mm. in thickness.
matory athritis. Osteophytes projecting inferiorly The subacromial space
lies between the
can cause rotator cuff pathology. The joint is coracoacromial arch and
the humeral head. The
re-inforced by strong acromioclavicular ligaments, contents of this space
are the subacromial bursa,
which limit joint movement, and contains the supraspinatus and
infraspinatus tendons and
868
the joint capsule. Thus, any narrowing of this

space can cause impingement of the rotator cuff
and the other constituents of the subacromial
space. Bigliani has classified the under surface
of the acromion into three types:
Type 1 (flat), Type 2 (concave) and Type 3
(anterior down slope, or hook, which can narrow
the subacromial space).
Radiographs
Despite the advances in imaging technology, stan-

dard radiography is still the mainstay of shoulder
imaging and is usually the first investigation.
Fig. 1 AP radiograph of the

shoulder
Indications
Any acute or chronic shoulder pathology: trauma,

including fractures, dislocations (acute or chronic
and the resulting bony injury); bony anatomy in
chronic shoulder pain (morphological variants
that may predispose to dysfunction, extent of
arthropathy); radiographic features of rotator
cuff disease; calcific tendonosis. Due to the com-
plex anatomy of the scapula, fractures may be
poorly demonstrated.
The most frequently used radiographic
projections are:
Anteroposterior (AP) view (Fig. 1)
Gleno-humeral (GH) view (Fig. 2)
Lateral (trans-scapular or Y view) (Fig. 3);
with caudal angulation to show outlet
Axial views (including axillary (Fig. 4) and var-
iants: Stripp [1], Bloom Obata [2]) (Figs. 5, 6)
Acromioclavicular Joint Fig. 2 AP radiograph of the
glenohumeral joint
Stryker notch view (Fig. 7a, b)
See Table 2 injection. Confirmation of
intra-articular
injection allows specific
assessment of the
effect of the injection;
alleviation of pain
Arthrography post injection localises
the pain to the shoulder
joint.
Indications As part of a CT arthrogram
or MR arthrogram
with either iodinated
contrast (CT) or gadolin-
As a therapeutic (long-acting local anaesthetic ium (MRI) injection into
the joint.
agent (LA) combined with corticosteroid) or Therapeutic hydrodilatation
as treatment of
diagnostic (with long-acting LA only) adhesive capsulitis. A
large volume injection
869
Fig. 5 Stripp (inferosuperior)

axial radiograph
Fig. 3 Lateral scapular Y view radiograph
Fig. 6 Bloom Obata

(superoinferior) axial radiograph
Anterior Approach
Patient lies supine with arm in

external rotation
(this moves the biceps tendon
lateral to the
puncture site and also allows
maximum
exposure of the humeral
articular surface for
puncture). The fluoroscopic
beam is perpendic-
ular to the table. This is the
most common
approach used by musculo-
skeletal radiologists.
The puncture site is variable
[3], but usually
Fig. 4 Axial radiograph immediately vertical to the
medial cortex of
the humeral head, where the
skin is marked,
cleaned and local anaesthetic
administered.
(typically consisting of iodinated contrast, A 21 or 22G needle are suitable
for joint
corticosteroid, local anaesthetic and normal puncture. The needle is
introduced vertically
saline) is injected under fluoroscopic control and, when intra-articular,
contrast medium is
to disrupt adhesions in the joint. administered to confirm
position of the
870
a b
Fig. 7 (a) Stryker view (normal) (b) Stryker view Hill-Sachs defect (arrow)
needle (Fig. 8). If this is a therapeutic or a diag- of the biceps tendon;

joint and bursal effusions;
nostic injection, a mixture of steroid and local muscle, bone and
articular cartilage lesions
anaesthetic or just local anaesthetic respectively variably demonstrated;
paralabral cysts
is injected into the shoulder joint. If this is (suggesting possibility
of labral tear);
part of a CT or MR arthrogram intra-articular suprascapular and
axillary nerve pathology;
contrast medium is administered. A total of AC and sternoclavicular
joint. It also allows for
1015 ml is can be injected, but lax joints dynamic assessment of
impingement and for
will be able to accommodate a larger volume. ultrasound-guided
interventional procedures.
With adhesive capsulitis, the joint capacity is Ultrasound (US) has
the advantages of
much reduced. being dynamic, with good
spatial and contrast
resolution, while
remaining non-invasive and
inexpensive. With good
equipment and a skilled
Posterior Approach examiner, US enables
assessment of partial
and complete tears of
the rotator cuff with high
The advantage to this approach is that it prevents sensitivity and
specificity. Many patients prefer
inadvertent contamination of the anterior struc- US to MRI, as it is
quicker and better tolerated.
tures by contrast medium. Linear ultrasound
probes or transducers
Patient is in the prone oblique position. A 21G use a range of high of
frequencies, providing
needle is aimed at the inferomedial quadrant of high resolution images.
Broadband transducers
the humeral head. use a spectrum of
frequencies, for example
125 MHz, rather than a
single frequency.
High frequency
components provide greater
Ultrasound spatial resolution but
limited depth penetration,
whereas low frequency
components extend
Indications the penetration depth
[4]. Other ultrasound
functions, which are of
use in musculo-skeletal
Identification of tendinosis and tears of the rota- ultrasound, include
Doppler, compound imag-
tor cuff (partial and complete tears can be dif- ing, extended field-of-
view imaging and
ferentiated); tendinosis, rupture and subluxation beam steering.
871
Table 2 Radiographic assessment of the shoulder

Radiographic Technique/
positions Patient position Centring
Indications
Anteroposterior Patient standing, sitting or supine, Coracoid process
Acute trauma of shoulder and
(AP) view with back against film (Fig. 1)
proximal humerus (less patient
discomfort); acromioclavicular
joint. Gives an oblique projection
of the gleno-humeral joint

Glenohumeral Patient standing, sitting or supine, Coracoid process
Chronic (occasionally acute)
view (true AP of with back against film. Turn the
glenohumeral joint pathology
the shoulder patient toward the affected side to
(previous dislocation, arthropathy)
joint) get the glenohumeral joint in
demonstrates the gleno-humeral
profile (blade of scapula parallel to
joint in profile
film) (Fig. 2)
Lateral (Y) Patient erect (standing or sitting), Humeral head
Subluxation of humeral head;
view affected shoulder rotated 45#
alternative second view in acute
(posteroanterior) anteriorly, placed against the film
trauma
(blade of scapula perpendicular to
film) (Fig. 3)
Outlet view As for Y view, with 15# caudal Glenoid fossa
Contour of coraco-acromial arch,
(posteroanterior) angulation
subacromial space
Axial view Patient standing (generally IS), Middle of GH joint
Acute trauma (limited by patients
(superoinferior sitting (SI) or supine (IS), film through axilla
ability to move); chronic shoulder
[SI], against superior aspect of GH joint
pain; (Os acromiale)
inferosuperior (IS) or curved cassette in axilla
Can be performed erect with
[IS]) (SI), with arm abducted. Tube
limited abduction in severe pain/
angulation away from (SI) or
acute trauma
towards the trunk (IS) (Fig. 4)
Stripp Axial The patient sits on a stool with Vertical, central ray
Provides an axial view without the
(inferosuperior) back to the x-ray tube. The x-ray directed through
need to abduct the arm in a painful
tube is inverted such that the the axilla
or immobile shoulder
central ray is directed vertically
upwards. The cassette placed over
the affected shoulder, kept in place
by the patients other hand. The
patient leans back slightly (Fig. 5)
Bloom-Obata Patient on stool, leaning back onto Vertical, central ray
Provides axial view of the
Axial table, such that shoulder is directed to the
glenohumeral joint. Again useful
(superoinferior) vertically above cassette on lateral tip of the
when abduction is limited
tabletop. X-ray tube positioned clavicle
such the central ray directed
vertically downwards (Fig. 6)
AC Joint The patient with back to film Horizontal ray
Demonstrates subluxations. Both
centred at midline
sides on same film for comparison
at level of head of
humerus
Stryker (notch) Patient supine, hand behind head Central ray directed
Shows humeral head contour
view with shoulder externally rotated to coracoid process
(useful in chronic anterior
and abducted (Fig. 7a, b) with 10# cranial
dislocation to show presence of
angulation
Hill Sachs deformity)
The patient is positioned on a stool with the All tendons are

examined in their
examiner standing either in front or behind, long and short axis,
for example, in the follow-
depending on individual preference. A posterior ing order: the biceps,
the subscapularis,
approach allows for easy access to the US the supraspinatus, the
infraspinatus and teres
keyboard and the patients shoulder. minor. A systematic
approach, even for
872
Fig. 9 Position of the probe

for examination of the long
head of biceps tendon in short
axis (elbow flexed to 90# ).
Turn the probe through 90# to
visualise the biceps in the
Fig. 8 Fluoroscopy guided needle placement for long axis
arthography
should always be sought in a
more medial
location. Tendon (tendonosis,
partial and
experienced examiners, will ensure that less complete tears, instability)
and tendon sheath
obvious findings are not overlooked. (synovitis, synovial bodies)
pathologies should
It is important that the US transducer is be assessed.
always orientated perpendicular to the Patient position. The
patient is seated comfort-
tendon; this avoids the loss of echogenicity, ably on a stool, with the arm
to be examined in the
which can simulate a tendon tear. This is neutral position (arm against
trunk, elbow bent
apparent hypo-echogenicity of the tendon to 90# , forearm supinated), or
in slight internal
is called anisotropy and can be overcome rotation (Fig. 9).
by slight rotation/angulation of the transducer. The bicipital groove is
identified between the
If this is due to real pathology, the hypo- lesser and greater tuberosities
of the humerus.
echogenicity will persist. However, if it is Within it, the arcuate artery
may be identified
due to positioning, the hyper-echoeic tendon lateral to the tendon. The
biceps tendon is
fibrils will be visualised again on proper visualised in both the short
(Fig. 10) and long
positioning of the transducer perpendicular to axis (Fig. 11). Slight cranial
angulation of the
the tendon [5]. probe is usually required in
both planes to abolish
anisotropy. The myotendinous
junction is at the
level of insertion of the
pectoralis major muscle
Ultrasound Examination of the into the lateral lip of the
intertubercular groove.
Shoulder From the neutral position the
arm is moved
from internal to external
rotation to check for
Long Head of Biceps subluxation/dislocation.
The normal biceps tendon has a fibrillar
appearance. A non-fibrillar appearance is Rotator Cuff
abnormal and would suggest degeneration On US the rotator cuff is
variably hyper-echoic
(tendon tissue still visible) or rupture (tendon when compared to the overlying
deltoid muscle.
not visible). An additional reason for non- However this echogenicity is
age-related and the
visualization of the tendon is subluxation/dislo- rotator cuff may not be as
hyper-echoeic in older
cation from the bicipital groove and the tendon patients.
873
Fig. 10 The long head of biceps short axis (arrow),

with a small surrounding tendon sheath effusion
Fig. 12 Position of the
probe for examination of the
subscapularis tendon in
long axis. The patients shoulder
is externally rotated
(varying the position allows exami-
nation of the whole
tendon), the elbow remains against his
side. Turn probe through
90# to examine tendon in the
short axis
Fig. 11 The long head of biceps long axis (arrows).

Note the normal fibrillar pattern
Subscapularis
The patient is then asked to externally rotate the Fig. 13 Short axis view of
the multipennate subscapularis
tendon (arrows). Lesser
tuberosity (asterisks)
arm (from the neutral position for examination
of the biceps tendon), which allows more
complete evaluation (Fig. 12). Varying the Supraspinatus
degree of external rotation allows visualization The patient is then asked
to position himself
of the entire tendon. with the arm to be examined
behind his back
The short axis view shows the normal or with the hand in/on his
back pocket (Fig. 15).
multipennate appearance (Fig. 13), which could This moves the
supraspinatus from under
be mistaken for a tear by the uninitiated. The long the acromion. In the short
axis, the biceps
axis view demonstrates the insertion into the tendon marks the anterior
aspect of the
lesser tuberosity (Fig. 14). Dynamic assessment supraspinatus tendon in the
rotator interval
during internal/external rotation is used for (Fig. 16); extend this view
in the same plane
subcoracoid impingement. (cranial movement of the
transducer) to visualise
874
Fig. 14 Long axis view of the subscapularis tendon

(arrow); lesser tuberosity (asterisk). Tendon passes from Fig. 17 The
supraspinatus tendon long axis (arrow);
medial (on the left) to lateral (on the right) over the subacromial bursa
(arrowheads), greater tuberosity
humeral head (arrowhead) (asterisk)
the entire tendon in

short axis. It is important to
visualise the biceps
tendon in this view. In the long
axis, the insertion
into the greater tuberosity is
demonstrated (Fig. 17).
Partial thickness tears at
the bursal surface are
identified more clearly, due
to abnormal contour of
the usually smooth, convex
bursal surface of the
tendon. Early calcification
within the tendon is
identified more sensitively
than on standard
radiographs; evaluation of the
subacromial-subdeltoid
bursa is possible simulta-
neously (may be
thickened or contain a fluid col-
lection suggesting
bursitis).
Fig. 15 Position of the probe for examination of the
supraspinatus tendon in short axis. The patients hand is Infraspinatus
placed over his back pocket
The patient is asked to
place the ipsilateral hand
on the contralateral
shoulder (Fig. 18), allowing
better visualisation of
the tendon in the short and
long axis (Figs. 19,
20). The muscle is examined
and fatty atrophy can
be clearly seen. The tendon
merges posteriorly with
teres minor without clear
differentiation
distally, but the morphology of
the muscle belly and
separation of the tendons
more proximally allows
the individual tendons to
be evaluated.
Acromio-Clavicular
joint AC joint
Examination is also
possible in two planes, plac-
ing the transducer
anteriorly and superiorly
over the
acromioclavicular joint. Osteophytes,
Fig. 16 The supraspinatus tendon short axis (arrows); subchondral cysts,
synovitis, capsular hypertro-
long head of biceps (arrowhead) phy and ganglia may be
seen. The articular disc is
875
Fig. 18 Position of the probe for examination of the

infraspinatus (long axis). The patients hand is placed on
the contralateral shoulder
Fig. 21 CT of the
shoulder, axial reconstruction. There is
an anterior glenoid
fracture
particularly well
demonstrated in the short axis of
the joint (sagittal
probe position).
Gleno-Humeral joint
A limited evaluation
is possible with ultrasound.
The transducer is
placed posteriorly over the joint
with an increased
field of view. Large gleno-
humeral joint
effusions/synovitis may be seen.
Computed Tomography
(CT) and
Computed Tomography
Arthrography
Fig. 19 The infraspinatus tendon short axis (arrows); (CT Arthrography)
humeral head (asterisk)
Indications
Provides high
resolution assessment of bone (qual-
itative, quantitative
and morphological) (Fig. 21).
Useful for the
characterisation of fractures; assess-
ment of the morphology
of the glenoid and humeral
head, for example
humeral torsion, glenoid ver-
sion; further
characterisation of focal bone lesions
demonstrated by other
imaging techniques (radio-
graphs, MRI), for
example the nidus in osteoid
osteoma and sequestrum
in osteomyelitis; assess-
ment pre- and post-
shoulder arthroplasty.
CT arthrography
has two parts:
Fig. 20 The infraspinatus tendon long axis (arrows); (A) The arthrogram
and (B) The CT. The
greater tuberosity (asterisk) indications are
similar to MR arthrography but
876
particularly useful for

assessment of articular
side partial thickness
tears, joint surfaces and
intra-articular bodies
and the labro-ligamentous
complex/capsule.
Conventional shoulder MR
provides accurate
diagnosis of full thickness
tears of the rotator
cuff, however it is less
sensitive in the
diagnosis of partial thickness
tears. Both US and MRI
evaluate cuff
tendons accurately, but
with full-thickness
tears, cuff muscle
atrophy (originally studied
using CT [6]), crucial
in the long-term functional
outcome post-surgical
repair, can be assessed and
graded more easily (and
with less operator-
dependability) using
MRI [7]. MRI also has the
Fig. 22 CT arthrogram, axial reconstruction. There is
advantage of giving a
more global assessment of
osteoarthritis, posterior subluxation of the humeral head
and an ossified intra-articular body (arrow) next to the the shoulder region.
coracoid process. The glenoid appears retroverted
Normal Anatomical
Variants
it can be performed in patients with absolute
contra-indications (e.g. pacemaker) and relative There are some normal
variants in relation to the
contraindications to MRI (e.g. post-arthroplasty). glenoid labrum that
must not be confused with
CT arthrography assesses the labrum, articular labral tears. If the
glenoid articular surface is
cartilage, joint capsule, rotator cuff tears and viewed as the face of a
clock most normal vari-
intra-articular bodies. ants occur in the 113
o clock position
A. Arthrogram: Refer to the arthrogram section (anterosuperior
quadrant) [8].
for the procedure. Once the intra-articular
position of the needle is confirmed, 1015 ml Sub-Labral Foramen
of iodinated contrast media is administered to A localised detachment
of the anterosuperior
distend the joint (single-contrast arthrography) labrum from the glenoid
at the 2 o clock posi-
or 23 ml contrast followed by air (double- tion, anterior to the
biceps tendon attachment [9].
contrast). Passive movement of the shoulder It can be difficult to
differentiate from an
helps the contrast spread evenly through the anterosuperior labral
tear.
joint. The patient should keep the arm close to
the body with minimal movement to prevent Sub-Labral Recess
dissipation out of the joint. A synovial reflection
between the cartilage of the
B. CT scan: Multi-planar reconstruction enables glenoid cavity and the
superior labrum. It is
full appraisal of the labrum and joint in mul- located at the 12 o
clock position at the site
tiple planes (Fig. 22). of attachment of the
biceps tendon. It can com-
municate with the sub-
labral foramen. This
may be misinterpreted
as a superior labral
MR and MR Arthrography anteroposterior (SLAP)
tear [9].
Indications Buford Complex

The antero superior
labrum is congenitally absent
Shoulder MR is used to assess the integrity and is associated with
a thickened cord like mid-
of the rotator cuff tendons, the muscles of the dle gleno-humeral
joint. This can simulate an
rotator cuff, with additional arthrography avulsed anterior labral
fragment [10].
877
a b
Fig. 23 (a) MRI shoulder. Coronal proton density, showing the supraspinatus tendon
(arrow) (b) MRI shoulder.
Coronal proton density with fat saturation, showing the supraspinatus tendon
(arrow)
MR Sequences subscapularis tendon in the

long axis, the long
head of biceps tendon in the
bicipital groove and
Coronal Oblique Images labral pathology is
occasionally seen (better eval-
These are obtained parallel to the supraspinatus uated with intra-articular
contrast). Common
tendon, in the coronal oblique plane. Multiple sequences include T2-
weighted gradient echo
sequences may be used: the authors preference (T2*) and fat-saturated
proton density (Fig. 25).
is proton density (PD) and PD with fat saturation MR arthrography has been
found to be more
(FS) or inversion recovery sequences (STIR). sensitive than conventional
MR for labral tears and
A high resolution, fluid-sensitive sequence, usu- is considered to be the
imaging gold standard for
ally with fat-saturation, gives accurate assess- the detection of labral
pathology. It is also better at
ment of full-thickness tears of the cuff (Fig. 23). detection of partial
(articular surface) supraspinatus
Fat suppression techniques improve the ability to tears, gleno-humeral
articular cartilage deficiency
diagnose full and partial thickness rotator and intra-articular bodies
than conventional MR.
cuff tears [11]. 3 T MRI has recently been
shown to improve the
demonstration of some of
these lesions without
Sagittal Images contrast injection. MR
arthrography is certainly
These are obtained in a plane perpendicular to the not required in all patients
and should be restricted
long axis of the supraspinatus tendon. They are to those with appropriate
indications, often
useful for assessment of the rotator cuff tendons instability, in view of the
additional time required
in short axis, cuff muscle bulk and signal, the sub- to perform the arthrogram,
the small risk of com-
acromial subdeltoid bursa and the acromio- plications and the limited
additional information
clavicular joint. Useful sequences are proton den- obtained in some cases.
sity (with or without FS) or T2-weighted fast spin MR arthrography, similar
to CT arthrography,
echo (Fig. 24). has two components: (A) The
arthrogram and
(B) MR:
Axial Images A. Arthrogram: Refer to the
arthrogram section
These evaluate the AC and gleno-humeral joints for the procedure. Once
the intra-articular posi-
for arthropathy; useful for visualising the tion of the needle is
confirmed using iodinated
878
a b
Fig. 24 (a) MRI shoulder. Sagittal proton density image density image with
fat saturation, obtained more laterally
with fat saturation at the level of the glenoid, to show cuff for visualisation
of the tendons close to their insertions.
muscles and forming tendons. Subscapularis- short arrow, Subscapularis-short
arrows, supraspinatus- long arrow,
supraspinatus- long arrow, infraspinatus- curved arrow, infraspinatus-
curved arrow, teres minor- arrowhead,
teres minor- arrowhead (b) MRI shoulder. Sagittal proton long head of
biceps- block arrow
contrast, either
dilute gadolinium or saline is
injected into
the shoulder joint. Passive move-
ment of the
shoulder helps the contrast spread
evenly through
the joint. After this the patient
should keep the
injected arm close to the body
with minimal
movement to prevent dissipation
out of the
joint. Care should be taken to avoid
injection of
even small quantities of air.
B. MRI: The patient
then has a shoulder MRI.
Depending on
whether gadolinium or saline is
injected the
imaging obtained is either
T1-weighted with
fat-saturation (with
gadolinium) or
proton density/T2-weighted.
Following
injection, MRI should be
performed
without delay while there is
maximal joint
distension [12] (Fig. 26).
Indirect MR
arthrography is less invasive than
direct MR
arthrography. This technique involves
Fig. 25 Axial MR (proton density) image.
an intravenous
injection of gadolinium, followed
Subscapularis-short arrows, infraspinatus- curved arrows, by gentle exercise
and delayed imaging
long head of biceps- block arrow (1520 min). This
results in contrast in the joint
879
a b
Fig. 26 (a) MR arthrogram: axial proton density image (same patient as Fig. 21,
anterior glenoid fracture). (b) MR
arthrogram: axial T1-weighted image with fat saturation (same patient as Fig. 21,
anterior glenoid fracture)
secondary to diffusion across the synovium [13]. sequences can be helpful

in these situations [14].
There is no significant joint distension from MR arthrography can be
useful in the
injected contrast and intra-articular structures post-operative shoulder
by distending the joint,
are consequently less well shown it may be of which provides improved
delineation of the rotator
use if an arthrogram cannot be performed. cuff, capsule-labral
structures and tendons [15],
but CT arthrography is
often more appropriate
for evaluation of the
cuff following shoulder
Post-Surgical Shoulder arthroplasty.
The post-surgical shoulder is imaged using the

various imaging modalities previously described References
(radiographs, ultrasound, CT (+/# arthrogram)
and MRI), each of which have advantages and 1. Stripp W. Special
techniques in orthopaedic radiogra-
disadvantages. phy. In: Murray O,
Jacobson HG, editors. The radiology
The challenges to imaging the post-operative of skeletal
disorders. 3rd ed. Edinburgh: Churchill
Livingstone; 1990.
shoulder come from the altered anatomy, post- 2. Bloom M, Obata W.
Diagnosis of posterior dislocation
operative scarring and, on CT and MRI, from the of the shoulder with
use of Velpeau and angle-up
artifacts due to ferromagnetic screws, staples and roetgenographic view.
J Bone and Joint Surg Am.
metal shavings. Use of titanium and non-metallic 1967;49A:9439.
3. Shortt C, Morrison W,
Roberts C, Deely D, Gopez A,
fixation help reduce these artefacts. Also, use Zoga A. Shoulder, hip
and knee arthrography needle
of specific sequences such as turbo-spin echo placement using
fluoroscopic guidance: practice
(TSE) and fast-spin echo (FSE), as an alternative patterns of
musculoskeletal radiologists in North
to conventional spin-echo and gradient-echo, help America. Skeletal
Radiol. 2009;38:37785.
4. Whittingham T.
Broadband transducers. Eur Radiol.
reduce the susceptibility artefact. Fat suppression 1999;9 (Suppl
3):S298303.
sequences are more prone to disruption and 5. ESSR Ultrasound Group
Protocols. Available at www.
fast-spin echo inversion recovery (STIR) essr.org (educational
material)
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6. Goutallier D, Postel J, Bernageau J, Lavau L, Voisin M. 11. Reinus W, Sady K,

Mirowitz S, Totty W. MR diagno-
Fatty degeneration in cuff ruptures. Pre and postopera- sis of rotator
cuff tears of the shoulder: value of using
tive evaluation by CT scan. Clin Orthop. T2-weighted fat
saturated images. AJR Am
1994;304:7883. J Roentgenol.
1995;164:14515.
7. Zanetti M, Gerber C, Hodler J. Qualitative assessment 12. Andreisek G, Duc
S, Froehlich J, Hodler J, Weishaupt D.
of the muscles of the rotator cuff with magnetic reso- MR athrography of
the shoulder, hip and wrist.
nance imaging. Invest Radiol. 1998;33:16370. Evaluation of
contrast dynamics and image quality
8. McCarthy CL. Glenohumeral instability. Imaging. with increasing
injection to imaging time. AJR Am
2007;19:2017. J Roentgenol.
2007;188:10818.
9. De Maeseneer M, Van Roy F, Lenchik L, et al. CT and 13. Bergin D,
Schweitzer M. Indirect magnetic resonance
MR arthrography of the normal and pathological arthrography.
Skeletal Radiol. 2003;32:5518.
anterosuperior labrum and labral bicipital complex. 14. Wu J, Covey A,
Katz L. MRI of the postoperative
Radiographics. 2000;20:S6781. shoulder. Clin
Sports Med. 2006;25:44564.
10. Tirman P, Feller J, Palmer W, et al. The Buford com- 15. MohanaBorges AV,
Chung CB, Resnick D. MR
plex- a variation of normal shoulder anatomy: MR imaging and MR
arthrography of the postoperative
arthrographic imaging features. AJR Am shoulder:
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J Roentgenol. 1996;166:86973. Radiographics.
2004;24:6985.
Outcome Scores for Shoulder
Dysfunction
Simon M. Lambert
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 881
Constant-Murley score # End-result # EQ-5D #
Oxford shoulder score # Shoulder assessment #

Which Score for Which Purpose? . . . . . . . . . . . . . . . . 882
Shoulder outcomes # Shoulder score # SPADI #

Health Status Measures: The EQ-5D . . . . . . . . . . . . . 883
Subjective shoulder value
Shoulder-Specific General Functional Scores:
The Constant Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
Shoulder Pathology: Specific Scores . . . . . . . . . . . . . . 884
Introduction
Shoulder Pain Scores: SPADI, OSS . . . . . . . . . . . . . . 884
A compendium of classifications and scores [8]

Simple Shoulder Tests: Subjective
for the shoulder, published in 2006, describes
Shoulder Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
887
105 classifications (based on anatomical site,

Assessing Shoulder Function . . . . . . . . . . . . . . . . . . . . . . 888
pathological process, surgical intervention) and
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 888 22 scores for function (site-dependent and site-
independent) and yet admits to being incomplete.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 888
A more recent similar compendium, less exhaus-
tive, describes the value of commonly-used
measures and instruments for the assessment of
shoulder conditions and interventions, and
weights the scores helpfully for methodological
and clinical utility [17]. An evaluation of the
accuracy with which scores are used in shoulder
surgery was published from Oxford, UK [9]: 44

scores were evaluated. 22 were clinician-based,
21 patient-based, and 1 used both clinician- and
patient-based scoring methodology. This evalua-
tion concluded that patient-related outcome
scores (PROMs) were valid, reliable, reproduc-
ible, could be conducted remotely and over time,
and likely to be the chosen method by which
funding bodies could give value to the outcome

S.M. Lambert
of interventions in health-care. More recently,
The Shoulder and Elbow Service, Royal National
still the same group warned against using
e-mail: slambert@nhs.net
PROMs as a means to define the level of

881
DOI 10.1007/978-3-642-34746-7_57, # EFORT 2014
882
S.M. Lambert
disability required to access specific heath-care

interventions [10]. PROMs are not designed to Which Score for Which
Purpose?
determine a set of population-based criteria for
the level of disability required before intervention A relevant and useful
study from the Schulthess
could be sanctioned: PROMs are disease- or inter- Klinik, published in 2008
[2], compared the sensi-
vention- specific subjective evaluations which can tivity to change
(responsiveness) of six outcome
be followed to determine the value, over time, of an assessment tools in 153
patients undergoing total
intervention in the specifc population. PROMS, in shoulder arthroplasty
(TSR) for a variety of rea-
themselves, do not help a clinician to understand sons, but most commonly
for osteoarthritis. The
what change to effect for improvement to occur in Short Form 36 (SF-36),
Disabilities of the Arm,
outcomes for a particular condition. The challenge Shoulder and Hand
questionnaire (DASH), Shoul-
for the clinician is to match objective data about der Pain and Disability
Index (SPADI), American
pre-intervention and post-intervention status, and Shoulder and Elbow
Surgeons questionnaire
patient derived (subjective) data. There is no (ASES), and the Constant
Score (CS) were evalu-
current system for the shoulder, for any condi- ated before and 6 months
after TSR. This study
tion or any intervention, that helps the clinician concluded that the CS and
SPADI were the most
in this way. The multiplicity of scoring systems suitable for short,
responsive, shoulder-specific
for function of the shoulder reflects the difficulty assessment, while the
SPADI was the most respon-
of encoding precisely what is important for the sive for pain. The
subjective (patient-based) part of
outcome of an intervention from the perspective the ASES questionnaire
was considered the most
of the patient, the clinician, and the health-care responsive shoulder-
function assessment. The
system. authors considered the
addition of the DASH or
Scores have, historically, been derived from SF-36 to gain a
comprehensive assessment of
the population set treated by interested clinicians. It health and quality of
life. In summary, scores for
is only lately that epidemiologists and biostatisti- pain, function, and
overall health status appeared to
cians have been instrumental in designing tools for be best treated
separately. Biophysical measures
understanding outcomes in shoulder conditions. (such as range of motion)
may correlate weakly
Most simple biological phenomena are more with patients perception
of outcome, but may
or less normally distributed at population level correlate with some
aspects of the functional
(e.g., humeral head size) and so can be dealt scores; composite scores
(scores which aggregate
with using parametric tests for small and large assessment of pain,
function, and biophysical
samples. Composite (multi-factorial) or complex parameters) may be the
least useful in terms of
(interdependent) phenomena are not necessarily responsiveness to change;
most scores can differ-
normally distributed so have to be analysed with entiate between the
outcome of slightly better
non-parametric tests: the differences between and slightly worse.
samples is now more complex with greater chance Scores serve several
purposes. A shoulder
of overlapping (confounding) factors. Within intervention can be
assessed from the perspective
scoring systems some apparently independent of the patient, the
clinician, and the health-care
variables may be dependent or surrogate variables: system. The patient is
interested in the likely
this makes the sensitivity of a score to change value, the improvement in
quality of life, that he
less accurate or discriminatory. The AO publication might expect from an
intervention; the clinician
has useful comparisons of methodological evalua- is interested in the
effect of the intervention and
tions: validity (content, construct, and criterion how the improvement on
quality of life might be
validity) and reliability (internal consistency, repro- explained by the
intervention; the health-care
ducibility, and responsiveness), and clinical utility system needs to know that
it is gaining value for
(patient-friendliness and clinician friendliness, money. To do this the
health-care system uses
both of which are valued as limited, moderate or comparators with similar
systems or groups of
strong). users. There are
therefore patho-biomechanical
Outcome Scores for Shoulder Dysfunction
883
scores of specific diagnoses or interventions

(objective clinician-based scores) and subjec- Shoulder-Specific General
Functional
tive patient-based scores both of which aim to Scores: The Constant Score
distinguish the decrement in function from nor-
mal and how closely an intervention restores The Constant Score was
described by Constant
the shoulder to normal, and biometric quality- and Murley in 1987 [6] and
was the result of
of -life scores for the better understanding of the a survey of the function of
the shoulders of
burden of disability due to shoulder problems a normal population in a
provincial market town
and for the improved distribution of resources near Cambridge, East
Anglia, Great Britain. The
for preventing and treating shoulder problems. population was skewed
towards older people, and
Of the latter the SF-36 and the EQ-5D are in showed a decline in
function with age. This in
common use. The EQ-5D is probably the most itself was not surprising,
but the simplicity of the
useful of these. method was attractive. The
score is given as
a percentage with 100 %
being the best score
possible, and comprises
four domains: pain, func-
Health Status Measures: The EQ-5D tion of daily life
including sleep and recreation,
strength, and range of
motion. The value of each
Very few scores for the shoulder fulfill the criteria domain as a component of
the score was 15 %,
commonly cited as important for understanding 20 %, 25 % and 40 %
respectively. Since pain
outcomes [14]. Methodological criteria such as was not a common experience
in normal shoul-
reliability, reproducibility, and validity are all ders it was afforded only a
small proportion of the
relevant but the score should also be easy to total (15 %), and is
categorised as absent (15
administer and simple for the patient to under- points), mild (10 points),
moderate (5 points),
stand: not all scores translate accurately into dif- and severe (0 points). Pain
scores within the CS
ferent languages. The EQ-5D is almost unique in are often quoted as means
with standard devia-
this regard, having been translated from the tions and compared to two
decimal points. This is
English into Germanic, Baltic, Central European not statistically
consistent. This categorisation of
(Slavic), and Southern European languages while pain is not compatible with
more accepted
retaining its statistical value. In its present form methods of scoring pain
(such as the linear scale
the EQ-5D method is increasingly used for com- or numeric analogue
scores). Pain is therefore not
parison of interventions in a wide variety of discriminated well in the
CS. The method of
health related activities, including surgery. evaluating strength follows
a strict definition, in
The EQ-5D is a score of current health status which the arm must be able
to be held at the level
self-administered by the patient. It comprises of the shoulder in the
scapular plane (90# abduc-
five items (mobility, self-care, usual activities, tion): if this position is
not possible then by def-
pain/discomfort, and anxiety/depression), with inition the score for
strength is zero. This vastly
a 3-point categorical response scale (a score of 1 underestimates the value of
interventions which
means no problems, 2 means some/moderate give patients pain-free use
below shoulder level,
problems, and 3 means extreme problems). such as shoulder
replacement in many patients
A unique score is calculated by a weighted with rheumatoid arthritis,
who might rate their
regression-based algorithm, with good reliability, shoulder value much higher.
To overcome this
validity, and responsiveness. In addition, overall many observers use what is
called a modified
functional capacity is self-assessed on a linear CS, which excludes
strength measurement.
rating scale. It is simple to administer, and is an Whenever a score is
modified it becomes invalid.
effective general health PROM. Users of the Modification should not be
accepted. Strength has
EQ-5D are required to register their project with been measured with a hand-
held fishermans
the Euroqol group, which offers support for the balance, which simply
compares the strength of
project. the observer with the
subject, and with electronic
884
S.M. Lambert
dynamometry. Both methods have been shown to (and so greater muscle

strength and better activa-
be comparable [3]. The range of motion at waist tion), and greater range
of motion. It is not
level includes functional internal rotation in a feature of the
arthroplasty itself, so unless the
which the thumb is taken as high up the back as biomechanical
characteristic of an arthroplasty is
possible, giving the spinal level achieved as the very different from
another with which it is being
functional range. In some conditions, e.g. rheuma- compared it is unlikely
that the CS will show a
toid arthritis, in which many other upper limb joints substantial difference
between two arthroplasties
(particularly the elbow) are affected, the spinal given similar rotator
cuff function. Scapular
level of achievement may be adversely affected motion is never assessed
independently of
by a joint other than the shoulder. The shoulder glenohumeral motion. A
shoulder arthrodesis
score may then be downgraded by the effect of (dependent on scapular
motion) may only
another joint. The subjective component of func- achieve a moderate CS yet
be transformative for
tional activities of daily living is afforded only 20 the quality of daily life
for the patient through
points, and gives points for sleep (no disturbance, pain relief, which is
poorly measured by the CS.
some disturbance, nightly disturbance), and recre-
ational activities, including sports. The functional
score therefore measures ability as opposed to Shoulder Pathology:
Specific Scores
decrement (disability), which introduces more
problems of subject bias. Since the subjective part There are many shoulder-
pathology specific
of the CS is at best only 35 % of the entire score, the scores, such as those for
instability (e.g., Walch-
value of this score as a PROM is limited. Over time Duplay, Rowe, Western
Ontario Shoulder Insta-
the CS has been strongly correlated with other bility index, WOSI),
osteoarthritis (e.g., Western
scores (i.e., the scores are consistent) and has Ontario Osteoarthritis of
the Shoulder index,
been found to be reliable and responsive for the WOOS), and rotator cuff
disease (e.g., Western
detection of improvement after shoulder surgery in Ontario Rotator Cuff
index, WORC). These are
a variety of shoulder pathologies [16]. valuable in the specific
pathologies for which
The European Society for Surgery of the they have been designed,
but should not be used
Shoulder and Elbow (ESSSE/SECEC) has, for for other pathological
conditions i.e., they are not
some years, adopted the Constant Score (CS) as transferable. The WOSI,
WOOS, and WORC
the preferred method for reporting outcomes for have been validated for
the conditions they rep-
interventions in the shoulder, excluding those for resent, and are therefore
the more valuable
instability. Attempts have been made to adapt the assessment tools. For a
detailed analysis of the
CS for use as a remotely-administered outcome application of these
tools the reader is directed to
measure to enable long-term review without the references [8, 17].
expense of multiple clinic visits, which the cur-
rent fiscal climate inhibits. These have proven
difficult. The scores have been ponderated or Shoulder Pain Scores:
SPADI, OSS
weighted against age-and gender-matched equiv-
alent normal scores (the so-called ponderated The SPADI (Shoulder Pain
and Disability Index,
CS), and against the contra-lateral shoulder [15]) was initially
derived from a very small
(the relative CS) which is assumed to be group of patients with
shoulder pain from
normal. a variety of causes, and
developed in an iterative
The essence of the CS is that it measures the manner. It comprises two
domains: pain (5 items)
decline in function of the rotator cuff over time. and disability (8 items),
which are treated equally
For instance, the benefit of total shoulder replace- from a statistical
perspective. The index has been
ment as measured by the CS is a function of the used (and validated as a
reliable instrument) for
improvement in the aptitude of the rotator cuff patients undergoing non-
operative therapy as
to do work in a joint with less friction, less pain well as for surgical
treatment, and is correlated
885
The assessment of shoulder dysfunction and the outcome of shoulder interventions

should reflect the following:
1. Items essential for Activities of Daily Living (ADL).
This element of a score system should reflect the patients ability to engage with
the internal or personal world
space, and the maintenance of independence. This could be expressed as the ability
to achieve a functional
triangle of face (mouth) - opposite axilla - perineum. This is equivalent to a
range of motion defined as an "inner cone"
of movement in which internal rotation / adduction / low-level flexion and
extension motions dominate. Pain will
modify this achievement.
2. Items not essential to, but enhancing, ADL.
This element describes the ability to engage with the external world space, and,
often, the maintenance of supported
locomotion. This is equivalent to a range of motion defined as an "outer cone" of
movement in which more external
rotation is involved, and high-level flexion is more valued than extension. Pain
and weakness will modify this
achievement.
3. Items not essential for ADL but which enhance the quality of life.
This reflects the patients ability to engage in cultural activities e.g. sport,
and assesses the impact of the
shoulder condition on the quality of daily life interactions. Since emotional,
psychological and physical factors
are involved, a general health score is relevant: in Europe the EQ-5D is the most
universal instrument. This also
indirectly indicates the decrement of function as an economic burden to the
population as a whole ie what extra
resources might be required to permit a patient with shoulder disability to
function within their cultural context.
Fig. 1 Hierarchy of information about an individual which might be helpful in

understanding decrement of function and
response to intervention
1. Pain assessment:
SPADI or VAS (or equivalent)
2. Shoulder-specific
function: OSS, SPADI (or equivalent)
3. Biophysical
assessment (figure 1): ROM
4. General health
status: eg. EQ-5D
5. Subjective
shoulder assessment: eg. SPONSA
Key
SPADI: Shoulder Pain

and Disability Index
VAS: Visual Analogue
Score
OSS: Oxford Shoulder
Score
ROM: Range of Motion
Fig. 2 The suggested EQ-5D: see text
elements of a shoulder SPONSA: Stanmore
Percentage of Normal Shoulder Assessment
scoring system
with changes in active range of motion [4]. In a point score in the

range 12 (normal) to 60
Europe the SPADI has been validated in English, (completely
abnormal). Importantly, the score is
German [1] and Norwegian languages. not used as a
percentage. Latterly, to align the
The Oxford Shoulder Score (OSS) [7] was OSS with the Oxford
Hip Score and the Oxford
developed as a method of evaluating patients Knee Score
(currently the preferred PROM
perception of pain following shoulder procedures scores utilised in
the UK National Joint Registry)
in a busy University clinic, using an iterative the range of
outcomes has been inverted to give
process which was the most statistically precise a range from 0
(completely abnormal) to 48 (nor-
of any score used in the shoulder at the time. The mal). The questions
are independently adminis-
involvement of statisticians and epidemiologists tered by the
patient, and so the OSS can be used
was a key advantage in this process. The score as a remote review
method. It is quick, requires
comprises 12 questions each having 5 responses, no special
instruments, and universal in that any
from 1 (the best outcome or effect) to 5 (the worst shoulder condition
can be assessed. The sensitiv-
outcome or effect) and was therefore given as ity to change is not
understood completely.
886
S.M. Lambert
a Pain
assessment
Shoulder-specific
function Time
Subjective shoulder
assessment
Biophysical
assessment
General
health status
b VAS / SPADI
SPADI / OSS Time
SPONSA
ROM % of normal
EQ-5D
outcome
c
ingo
VAS / SPADI
Time
SPADI / OSS
SPONSA
ROM % of normal
intervention
EQ-5D
Fig. 3 (continued)
887
d
outcome
ingo
VAS / SPADI
Time
SPADI / OSS
SPONSA
ROM % of normal
intervention
EQ-5D
Fig. 3 (a) Suggested graphic representation of a shoulder patient. (d) The

change in area represented by the shoulder
outcome tool. Each radius represents an instrument for outcome tool
describes the effectiveness (value) of the
measuring an attribute or condition. Better scores occur intervention; the
shape of the area describes what each
closer to the perimeter of the area of the shoulder outcome component has
contributed to the outcome. In this example
tool. Other scores (more radii) could be added if desired: case the intervention
has contributed by pain relief more
this might accuracy. (b) Graphic representation of shoulder than improvement in
range of motion, while the subjective
outcome tool with scores. See Fig. 2 for key. (c) Graphic shoulder value has
greatly improved, contributing to a
representation of shoulder outcome tool for an exemplar perceived improvement
on general health status
As previously noted it is not an instrument for administer than the

CS and as responsive as the
deciding when ability becomes disability and OSS. The SPONSA
requires the patient to con-
therefore should not be used to discriminate which sider the question:
A normal shoulder is one
patient receives treatment and when. The OSS is which, during a
normal day, is painfree, with
not valid for use in patients with glenohumeral a full range of
movement, normal strength and
instability due to capsulo-labral pathology. stability, and allows
you to do what you feel your
shoulder, if normal,
should allow you to do.
A normal shoulder is
scored at 100 % while
Simple Shoulder Tests: Subjective a completely useless
shoulder is scored as 0 %.
Shoulder Values Overall, where would
you rate your shoulder
between 0 and 100 %
at this present time? The
The simple expedient of asking the patient how question assumes an
appreciation of the concept
he/she feels the shoulder is behaving has received of ratio, percentage
or proportion; this does
increased interest since subjective shoulder exclude some
patients, who find such abstraction
scores have been shown to be correlated with difficult. Patients
personal expectations and
both the CS and the OSS [see 13]. The Stanmore values are
incorporated in this question: the out-
Percentage Of Normal Shoulder Assessment come of any
intervention is only relevant in the
(SPONSA, [13]) has been evaluated and shown context of patients
concerns, so this way of eval-
to be responsive to change, valid, reliable, repro- uating outcome is
more useful than others as
ducible, and accurate, while being easier to a PROM. The SPONSA
can be delivered
888
S.M. Lambert
remotely and is therefore useful for long-term

distant review. Summary
Scores are useful, and we

should not discard the
Assessing Shoulder Function admonition of Ernest Amory
Codman who, in
1913 [5], described the end-
result model and
All current shoulder scores which attempt to encouraged the measurement of
outcome as the
combine biophysical, subjective, and health- best way of improving
outcome. However scores
related questions have methodological problems can also be mis-used and mis-
interpreted. Scores
(Figs. 1 and 2). A score should measure a specific can also measure apparent or
surrogate outcomes,
attribute, and different components of an inter- and may not be sensitive
enough to accurately
vention may require different measurements describe the value of
interventions. Nevertheless
or scores. Each intervention should therefore we must measure outcome, and
therefore we need
be treated as a composite of patient-specific, to know ingo i.e., status
before intervention or
clinician-specific, and health-status outcomes. observation, to understand
how much difference
Patient-specific outcome and health status can was gained or lost and how it
was achieved. The
be combined in a subjective evaluation of shoul- multiple factors involved in
achieving an out-
der function. Factors other than the status of the come make a combination of
items into a single
shoulder (such as cardiac status, metabolic dis- score unlikely to measure
true value. It seems
ease, neurological deficit, psychiatric disorder) more likely that
combinatorial methodologies
influence the patient-specific and health-status might provide a mechanism for
using different
outcomes. While it is difficult to correlate objec- but comparably-valid scoring
systems to give
tive data with subjective data in an attempt to useful information about
burden of disease, inter-
understand the relationship between the specific vention, and improvement
(value) of intervention
intervention or problem and the patients sense of (Fig. 3ad).
achievement it is important to do so: the value of
a procedure may be much underestimated by the
subjective assessment [11]. References
The future for shoulder scores, and other
assessments, may be in combinations of ana- 1. Angst F, et al. Cross-
cultural adaptation, reliability
lyses, in which several sets of information are and validity of the
German Shoulder Pain and
Disability Index (SPADI).
Rheumatology (Oxford).
combined to give a descriptor of outcome.
2007;46(1):8792.
Bayesian statistics could be used to permit the 2. Angst F, et al.
Responsiveness of six outcome assess-
understanding of how the addition of one or ment instruments in total
more sets of information influences the accuracy Arthritis Care Res.
2008;59(3):3918.
3. Bankes MJ, et al. A
standard method of
and predictability of outcomes [12]. The ele-
shoulder strength
measurement for the constant score
ments which might be considered are shown in with a spring balance. J
Shoulder Elbow Surg.
Figs. 1 and 2. Figure 1 summarises a hierarchy of 1998;7(2):11621.
information about an individual which might be 4. Beaton D, Richards RR.
Assessing the reliability
and responsiveness of 5
shoulder questionnaires.
helpful in understanding decrement of function
J Shoulder Elbow Surg.
1998;7(6):56572.
and response to intervention. To measure these 5. Codman EA, et al.
Standardisation of hospitals: report
attributes a number of tools might be combined of the committee
appointed by the Clinical Congress
(Fig. 2). In this way each individual could of Surgeons of North
America. Trans Clin Cong Surg
North Am. 1913;4:28.
be described in a co-ordinate system, one axis
6. Constant CR, Murley AHG.
A clinical method of
of which is time. This is illustrated graphically functional assessment of
the shoulder. Clin Orthop
in Fig. 3. Relat Res. 1987;214:160
4.
889
7. Dawson J, et al. Questionnaire on the perceptions of Cardiothoracic

Surgeons of Great Britain and
patients about shoulder surgery. J Bone Joint Surg Br. Ireland.
1996;78-B(4):593600. 13. Noorani A, et al.
Validation of the Stanmore
8. Habermeyer P, et al. Classifications and scores of the percentage of
normal shoulder assessment. Accepted
shoulder. Berlin/New York: Springer; 2006. ISBN 13 for publication,
Int J Orth. 2011.
978-3-540-2430-2. 14. Rabin R, de
Charro F. EQ-5D: a measure of health
9. Harvie P, et al. The use of outcome scores in surgery status from the
EuroQol Group. Ann Med. 2001;33(5):
of the shoulder. J Bone Joint Surg Br. 2005;87-B: 33743.
1514. 15. Roach KE, et al.
Development of a shoulder pain
10. Judge A, et al. Assessing patients for joint replace- and disability
index. Arthritis Care Res. 1991;
ment. Can pre-operative Oxford hip and knee scores 4(4):1439.
be used to predict patient satisfaction following joint 16. Roy JS, et al. A
systematic review of the psychometric
replacement surgery and to guide patient selection? properties of the
Constant-Murley score. J Shoulder
J Bone Joint Surg Br. 2011;93-B:16604. Elbow Surg.
2010;19(1):15764.
11. Kay P. Patient reported outcomes measurement data 17. Suk M, et al.
Musculoskeletal outcomes measures and
(PROMs). BON. 2011;49:12. instruments,
Selection and assessment. Upper extrem-
12. Keogh B, Kinsman R. Fifth national adult cardiac ity, vol. 1. New
York: Thieme; 2009. ISBN 978-3-13-
surgical database report 2003. The Society of 141062-7.
Traumatic Lesions of the
Brachial Plexus
Rolfe Birch
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 892 Traumatic lesions of the brachial plexus cause
pain, paralysis and loss of sensation. The sub-

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 892
clavian-axillary artery is injured in one third of

Open Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 893 open wounds from knife or missile. Injuries to
The Closed Infraclavicular Lesion . . . . . . . . . . . . . . . . . .
894 head, spine, chest or viscera occur in 40 % of
Principles of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
896
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 897 closed traction lesions. Whenever possible
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 898 nerves and arteries should be repaired together
The Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 899 at urgent operation. Results of early repair by
Strategies of
Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
899 graft are decisively better. Reconnection to the
The Complete Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
902
spinal cord or repair, by transfer, of the

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 902 avulsed ventral root is possible only in early
Neurological Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
902
operations. Pain is usually improved by regen-

Relief of Pain by Repair . . . . . . . . . . . . . . . . . . . . . . . . . . .
905 eration and by successful rehabilitation. Reha-
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 907
bilitation is the central core of treatment.

The Birth Lesion of the Brachial
Plexus
(BLBP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
907 The incidence of birth lesion of the brachial
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 908 plexus (BLBP) in the UK is 0.42 per 1000 live
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 912 births. Serious secondary deformities are com-
The Indications for Operation . . . . . . . . . . . . . . . . . . . . 913
mon. Posterior dislocation or subluxation of
Principles of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
914 the shoulder occurs in about 25 %. Repair is
Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 915 justifiable in severe ruptures of C5 and in
Posterior Subluxation (PS) and Posterior
preganglionic injuries of the other nerves.
Dislocation (PD) of the Gleno-Humeral
Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 916
Keywords
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 918
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 919 Anatomy # Associated injuries # Birth Injuries-
aetiology and incidence, prognosis and treat-

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 921
ment, indications for surgery, late deformity,

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 921 posterior gleno-humeral disclocation # Closed
injuries-infraclavicular, traction # Examina-
tion # Incidence # Indications for surgery #
Investigations # Open injuries # Results-relief

R. Birch
of pain,functional recovery # Surgical strate-

War Nerve Injury Clinic at Defence Medical
Rehabilitation Centre, Epsom, Surrey, UK
gies for different injuries # Treatment
e-mail: m.taggart@hotmail.co.uk
principles

891
DOI 10.1007/978-3-642-34746-7_44, # EFORT 2014
892
R. Birch
Introduction
Rupture of the spinal nerves of the brachial plexus

leads to changes in the cell bodies of the ventral
horn which culminate in their death. These changes
are more extreme when the roots of the spinal
nerves are interrupted. Carlstedt (2007) [19] esti-
mates that 80 % of motor neurones in the anterior
horn disappear by 14 days after avulsion of the
ventral root. Cell death in the spinal cord and in
the dorsal root ganglia is even more severe in the
immature nervous system [33]. These changes are
diminished, or even prevented, by urgent
reconnection between the cell body and the periph-
eral tissues, above all, by reconnection with the
distal Schwann cell columns. This chapter is
based on studies extending for over 45 years of
approximately 2,300 cases of lesions of the brachial
plexus in the adult including about 1,500 closed
injuries to the supraclavicular plexus, and of some
1,800 cases of birth lesion of the brachial plexus.
Fig. 1 The 5th, 6th cervical

nerves avulsed from the
spinal cord. The ventral
root is easily distinguishable
Anatomy from the dorsal rootlets.
Note the dorsal root ganglion,
the dural sleeve merging
into the epineurium and the
The spinal nerves leave or enter the cord by spinal nerve itself. The
small pieces of tissue on the
ventral, largely motor, roots and dorsal sensory proximal ends of the dorsal
rootlets (below) are probably
portions of the spinal cord
roots. This junction is the weakest mechanical
link in the long chain between the central ner-
vous system and the periphery (Fig. 1). The
anterior primary rami of the lowest four cervical surface of scalenus
anterior. The transverse cer-
nerves and most of that of the first thoracic nerve vical and greater auricular
nerves wind round
enter the posterior triangle of the neck between the posterior border of the
sternomastoid no
scalenus anterior and scalenus medius to unite more than 1 cm. cephalad,
the spinal accessory
and branch to form the brachial plexus in the nerve emerges from deep to
the sternoclei-
lower part of the neck and behind the clavicle domastoid about 5 mm.
further cephalad. A sig-
(Fig. 2). The first thoracic nerve passes upward nificant branch from C4 to
C5 or to the upper
round the neck of the first rib, behind the pleura trunk is encountered in
between 2 % and 3 % of
and behind the vertebral artery and the first part operated cases.
of the subclavian artery. The formation of the Three significant nerves
pass from the brachial
trunks of the brachial plexus is fairly consistent. plexus within the posterior
triangle:
C5 and C6 form the upper trunk, the middle 1. The nerve to serratus
anterior is formed by
trunk is a continuation of C7, the lower trunk rami from C5, C6 and C7.
from C8 and T1. These lie in front of one another 2. The dorsal scapular nerve
leaves C5 within the
rather than side by side, with the subclavian foramen lying posterior
to the main trunk.
artery passing antero-medially. The phrenic 3. The suprascapular nerve
passes away from
nerve crosses C5 to pass antero-medially on the C5, or from the proximal
part of the upper
Traumatic Lesions of the Brachial Plexus
893
Fig. 2 The right brachial

plexus. Note the sequence:
the anterior primary rami;
C3
trunk; divisions; cord;
nerves. Note that the trunks
C4
are upper, middle and
C5
lower, and that the cords are Supraclavicular n.
lateral, medial and
C6
Upper trunk
posterior from their Dorsal scapular n.
C7
position in relation to the Middle trunk
C8
axillary artery which is, in Suprascapular n.
fact, variable Lower trunk
T1
Lateral cord
Phrenic n.
Posterior cord
Medial cord
Nerve to serratus
Lateral pectoral n.
anterior
Circumflex n.
Medial pectoral n.
Axillary a.
Thoracodorsal n.
Medial cutaneous n.
of forearm
Radial n.
Musculocutaneous n.
Median n.
Ulnar n.
trunk, a fingers breadth above the clavicle repair within hours or

days of injury is grasped,
passing laterally and then posteriorly through the results for C5, C6
and C7 wounds are
the suprascapular notch. excellent; better by far
than equivalent results
The divisions of the brachial plexus lie deep to even for early repair of
more distal nerve trunks
the clavicle and their display in a scarred field can ruptured by traction
injuries; they are worth-
be particularly tedious. The posterior division of while for C8 and T1 too.
In virtually no other
the upper trunk is consistently larger than the nerve laceration is the
harmfulness of procras-
anterior; this is true also for the middle trunk. In tination so clearly shown
as in the
some 10 % of cases there is no posterior division supraclavicular stab
wound. On the other hand
of the lower trunk. The formation and relations of the nature of the wound
is such that other and
the three cords are variable and indeed their des- more pressing problems
frequently arise. If the
ignations somewhat misleading. Immediately blade or bottle is thrust
from above down the
inferior to the clavicle the posterior cord lies lower trunk, subclavian
vessels and lung are
lateral to the axillary artery, the medial cord damaged. When the blade
is thrust towards
behind, the lateral cord in front. The cords the face or neck the 5th,
6th and 7th cervical
assume their appropriate relations about the axil- with phrenic nerves are
damaged: in addition to
lary artery deep to pectoralis minor. the jugular and carotid
vessels, the trachea and
the oesophagus are at
risk. The lateral thrust
divides the upper and
middle trunks, the nerve
Open Injuries to serratus anterior and
the accessory nerve
(Fig. 3).
The tidy wounds from knife, glass and scalpel Penetrating missile
wounds commonly
are amongst the most rewarding of all nerve involve the viscera, the
great vessels, and the
injuries to repair. When the opportunity for spinal cord. Wound
contamination is usual.
894
R. Birch
Fig. 3 The outcome 3 years after repair of stab wound of right C5, C6 and C7 and
the phrenic nerve
Stewart and Birch (2001) [74] recognised proven arterial

injury or false aneurysm or
three wound types: fistula, and the
failure of progression towards
1. Fragment recovery for lesions
of C5, C6 and C7 or their
2. Bullet derivatives.
3. Bomb blast or close-range shotgun. The
lesions were explored in 51 of 58 patients.
Correction of false aneurysm or arterio- The Closed
Infraclavicular Lesion
venous fistula (16 cases) led to dramatic relief
of causalgia and improvement in nerve func- Two patterns can be
discerned.
tion. Nineteen patients with neurostenalgia, The first, which is
more common, is caused by
pain arising from an intact nerve which is violent hyperextension at
the shoulder. There is
strangled, compressed, tethered or ischaemic almost always a fracture
of shaft of the humerus or
[7] were cured by operation. Main nerves were injury to the gleno-
humeral joint; the axillary
repaired in 36 patients, results were good or artery is ruptured in 30
% of cases, the level of
useful in 26 of them, including three repairs of proximal rupture is deep
to pectoralis minor which
the medial cord or ulnar nerves. The results of acts as a guillotine on
the neurovascular bundle.
repair, although inferior to those seen in tidy The second pattern is
even more severe and
wounds, are certainly worthwhile (Fig. 4). dangerous. The
forequarter is virtually avulsed
Kline and his colleagues [42, 43] define indi- from the trunk. The
subclavian artery is usually
cations for operation as : the presence of cau- torn. There is usually
avulsion of the 8th cervical
salgia or other severe pain; suspected or and 1st thoracic nerves
which is combined with
895
complication of severe
pain. In many cases the
damage lies between
the dorsal ganglion and the
spinal cord. To these
intradural injuries Bonney
(1954) [15] applied
the term preganglionic. The
lesion was intradural
in about one half of the 7,500
spinal nerves exposed
at operation in 1,500
patients since 1966;
the incidence of intradural
lesion is highest in
C7. There are two types of
preganglionic injury:
intradural rupture peripheral
to the transitional
zone (TZ) and avulsion central
to it [70]. The lesion
may be confined either to the
ventral or the dorsal
roots, The extent of displace-
ment of the dorsal
root ganglion and the level of
ruptures of the dura
varies. The spinal cord is
directly injured in
avulsion lesions, an effect wors-
Fig. 4 Shot gun blast to the neck. Bleeding from the first ened by rupture of the
subclavian and vertebral
part of the subclavian artery was controlled through the arteries. A partial
Brown Sequard syndrome was
transclavicular exposure
identified in 11.8 %
of patients with three or more
avulsions [9] (Fig.
6). It is very important to search
for even subtle signs
of disturbance of the spinal
cord at the first and
subsequent examinations. Late
onset symptoms must be
fully investigated to
ascertain cause [9,
56].
Incidence Associated
Injuries
and Referral Patterns
The 1987 survey by
Goldie and Coates 1992)
[31] uncovered 328
patients with complete or
partial lesions. The
subclavian artery was rup-
tured in 5.5 %, and 40
% had other major injuries.
Rosson (1987, 1988)
[66, 67] found an average
Fig. 5 Rupture of the axillary artery,1, and the radial age of 21 years,
injury to the dominant limb in
nerve,2, associated with closed fracture of the upper 65 % and severe
injuries to the head, the chest, the
humerus. Both were repaired (George Bonney 1962)
viscera or other limbs
in one half of patients. By
one year after injury
more than two thirds of
ruptures of the cords of the plexus more distally. patients remained in
significant or severe pain and
There is, almost always, a phrenic nerve palsy. over one third were
still unemployed. The severity
The immediate treatment of these limb- and of the injury may have
diminished over the years:
life-threatening injuries includes restoration of 48 from 210 (33 %)
patients operated in the years
ventilation, control of bleeding, stabilisation of 1966 1984 sustained
avulsion of C5, compared
the skeleton, repair of the main artery and,if cir- with 26 from 320 (8 %)
operated between 2003
cumstances permit, of the nerves [9,22] (Fig. 5). and 2006. Although
motor cycle accidents remain
the chief cause other
mechanisms were responsible
The Closed Traction Lesions of the for 30 % of the
injuries in the most recent group.
Supraclavicular Brachial Plexus Severe associated
injuries impose delay beyond the
Perhaps these are the worst of all peripheral nerve ideal time for
operation, that is beyond 7 days, in
lesions because of the frequency of associated one third of patients.
Over the years many patient
injury to the spinal cord and the common have been referred
urgently. In the 249 patients
896
R. Birch
Fig. 6 Wasting of right arm and of muscles in the right cold, pinprick and light
touch. The MR scan (right) shows
lower limb 13 years after preganglionic injury of C7, C8 deviation of the spinal
cord [By courtesy Editor Journal of
and T1. Sensory levels marked are (top to bottom) warm, Bone and Joint Surgery
(British)]
operated between 2000 and 2004 nearly 90 % were rehabilitation.

Potentially life-threatening associ-
referred by Orthopaedic surgeons, within 7 days of ated injuries, damage to
the spinal column and the
injury in 98 cases and in another 27 during the spinal cord must take
priority over the nerve
second week. injury. Fractures of the
long bones are not
a contra-indication to
urgent exploration; arterial
injury is a powerful
indication.
Principles of Treatment The proposition that
damage to the proximal
limb of the axon of the
dorsal root ganglion
Over the last 40 years we have followed a policy would not affect the
distal axon or its myelin
of early exploration and repair especially in arte- sheath was confirmed by
studies of the axon
rial injury. An accurate diagnosis is essential in reflex (Bonney 1954)
[14] and by the demonstra-
determining prognosis; all reasonable attempts tion of persisting
conduction in the afferent fibres
should be made to improve that prognosis. This of peripheral nerves in
cases of preganglionic
enables the patient to start the difficult, injury (Bonney and
Gilliat 1958) [18]. Bonney
prolonged, and, at times, painful process of (1959) [16] established
that there was no
897
Table 1 Qualities of pain described by 198 patients 20002004

Interval (days) Burning Crushing Electrical Lightning Bursting
In a vice Cold Total
07 65 60 47 34 16
10 1 233
814 3 3 4 3 1
2 16
1528 4 6 7 4 4
1 26
Over 28 11 8 17 14 4
1 55
Total 83 77 75 55 25
14 1 330
1. Many patients describe more than one quality of pain
recovery in nerves which had been injury; in others it

becomes apparent at intervals
avulsed, scarcely any through ruptures and that ranging from 14 h to
more than 4 weeks after
recovery through less severe lesions in continuity injury (Table 1).
was often complicated by cocontraction. Patients
with no recovery experienced intractable pain. Inspection
This work stimulated a profound and lasting One important physical
sign is the presence
interest in conduction in the central pathways, of linear abrasions on
the chin and on the face
between the spinal nerve, the spinal cord and with corresponding
abrasions and bruising at
the brain. Jones (1979) [39] provided the first the tip of the shoulder.
Deep bruising on the
detailed analysis of peripheral, spinal and cortical point of the shoulder
confirms that the limb
sensory evoked potentials. Landi, Copeland, was violently arrested.
Deep bruising in the
Wynn Parry and Jones (1980) [44] compared posterior triangle of
the neck suggests rupture
pre- and intra-operative somatosensory evoked of the subclavian
artery. An increasing swelling
potentials (SSEPs) with surgical findings. in the posterior
triangle of the neck indicates
either collection of
cerebro-spinal fluid or
expanding haematoma or
both. Linear bruising
Diagnosis in the arm suggests
rupture of a nerve trunk or
main artery at that
level.
The History
One common element underlies closed Examination
supraclavicular traction lesions and that is the It is very important to
conduct a systematic exam-
violent distraction of the forequarter from the ination of the whole
patient. Significant injuries
head, neck and chest so that the angle between may be missed even in
the very best accident
the head and shoulder is opened. A description department. Rupture of
the ipsilateral hemi-
of the shoulder being violently arrested by an diaphragm may be
confused with phrenic nerve
object, stone, tree, kerbstone or vehicle whilst palsy. The severity of
an injury to the lung may
the body is flying through the air is associated not be apparent at first
examination. An MR scan
with severe stretching of the structures in the of the head and of the
whole of the spine is
posterior triangle of the neck. advisable when there is
the slightest suggestion
Severe pain within the paralysed and anaes- of upper motor neurone
lesion or other abnormal-
thetic upper limb indicates serious injury. There ity of the central
nervous system. It is important
is constant crushing, burning and intense pins and also to be on the alert
for fractures of the spine
needles in the forearm and hand. Two-thirds of and the pelvis.
conscious patients who experience this pain do so The patient who is
not unconscious will be in
on the day of injury. Superimposed electrical or pain and distress. Even
so it should be possible to
lightning shoots of pain coursing into the derma- find loss of sensation
of the skin above the clav-
tome of a spinal nerve signify preganglionic icle (C4) which is
associated with intradural
injury to that nerve. More than one-half of con- injury of, at least, the
upper nerves, C5 and C6
scious patients experience this pain on the day of (Fig. 7). It should be
possible to ascertain whether
898
R. Birch
aspect of the arm and

the proximal forearm; of
C6 when they extend to
the lateral aspect of the
forearm and the thumb;
and of C7 when radiation
extends to the dorsum
of the hand. Radiation to the
outer aspect of the
shoulder and the upper part of
the arm signifies a
lesion of C4. Absence of the
sign in a complete,
deep lesion accompanied by
pain suggests
intradural injury (Table 2).
Investigations
The diagnosis of the

injury to the nerves is made
on clinical grounds.
The purpose of supplemen-
tary investigations is
to clarify that diagnosis but,
of even greater
importance, to detect associated
injuries.
Plain Radiographs
Tilting of the spine
away from the side of injury,
opening of the
intervertebral spaces, avulsion
fractures of the
vertebral tubercles, and fracture/
dislocations of the
first rib suggest severe inju-
ries. Some important
findings from radiographs
of the chest include:
a fluid collection at the apex;
elevation of the
ipsilateral hemi-diaphragm; rib
Fig. 7 Linear abrasions in the neck indicate separation of
the forequarter from the trunk. The abrasion at the tip of fractures which may be
associated with haemo-
the shoulder marks the point of impact against a road side or haemopneumothorax,
and lateral displacement
kerb. Rupture of C5, preganglionic C6 to T1 of the shoulder
girdle.
Imaging
Early myelography is
unpleasant and potentially
trapezius and serratus anterior are functioning. hazardous in those who
have suffered a head injury.
Amongst the 72 patients with intradural injury Marshall and de Silva
(1986) [49] showed that
to C5, C6 and C7 operated in the years computerised
tomographic (CT) scanning with con-
20002004 serratus anterior was paralysed in trast enhancement was
a good deal more accurate
65, 28 had phrenic palsy and C4 was involved than standard
myelography, especially for C5 and
in 23. A Bernard Horner sign suggests intradural C6, findings confirmed
by Nagano et a.l (1989a)
lesion to C8 and T1 [16]. [52], Carvalho et al.
(1997) [21] and Oberle et al.
Tinels sign is invaluable in the early detection (1998) [57]. The early
investigation may detect
of ruptures. It should be emphasised that Tinels interruption of a
ventral or dorsal root and
sign is detectable in a conscious patient on the a residual stump
Tavakazolledah et al. (2001) [78].
day of injury. It is important to advise the patient Magnetic resonance
imaging (MRI) reveals bleed-
that percussion in the posterior triangle of the neck ing within the spinal
canal and displacement of the
may be painful, and they should be asked to indi- spinal cord. The
characteristic features of intradural
cate into which regions they experience radiation injury have been
summarised by Hems et al.
of intense pins and needles. Rupture of C5 is likely (1999) [35]. Digital
subtraction, or MR angiography
when these sensations extend down the outer are required when
there is suspected arterial injury.
899
Table 2 Tinels sign in closed traction lesions of the brachial plexus in 100 adult
patients examined and operated
20042005
Tinel sign present (142 nerves). Findings at operation Tinel sign absent (358
nerves). Findings at operation
Spinal nerves Intact Rupture Avulsion Intact
Rupture Avulsion
C5 1 58 4 0 10
27
C6 0 41 5 10 6
38
C7 0 24 0 40 2
34
C8 0 4 0 45 0
51
T1 0 4 1 52 1
42
Total 1 131 10 147 19
192
Ultrasonography will prove particularly valu- cervical nerve has

been sheared from its junc-
able if done early before tissue planes are oblit- tion with the trunk.
erated by fibrosis. 6. Intra-operative
studies of motor and sensory
conduction evaluate
the central integrity of the
proximal stump, enable
mapping of the bun-
The Operation dles within the distal
stump and detect even
more distal rupture or
ischaemic conduction
The arguments in favour of urgent operation in cases block. Haematoma
causes proximal conduc-
where rupture or avulsion is suspected include: tion block. Central
conduction studies may not
1. The biological imperative. The cell bodies of detect intradural
injury confined to the ventral
the neurones must be reconnected with the dis- roots. It is important
to remember during oper-
tal Schwann cell columns as soon as possible. ations performed
within 2 or 3 days of injury
2. It is easier to detect rupture and to resect nerves that avulsion of
ventral roots may not be
to a recognisable architecture. This is helped by recognised because the
spinal nerves continue
detecting conduction centrally and distally. to conduct. The method
is not quantitative
Only rarely is it necessary to resect more than (Fig. 8).
5 mm. of the proximal or distal stump and even Injuries of the spinal
nerves are classified in
less than this when preparing the tips of the Table 3.
ventral roots. Few things are more
disheartening than to come to the field where
the normal tissue planes are replaced by scar Strategies of Repair
tissue with the consistency of concrete. Accu-
rate diagnosis may be impossible in such cases. The most important
distinction lies between those
3. The retracted ruptured nerves can be drawn cases where some spinal
nerves are intact or
back, so reducing the gap. recovering from those
where all roots are
4. Repair of avulsed roots, or re-implantation is damaged (Table 4).
generally possible only in the early days after
injury. Lesion at C5, C6 (C7),
intact (C7), C8, T1
5. It is important always to examine the distal This common pattern is
most favourable
stumps, after pulling them back from their because there is useful
hand function and
displaced position. Demonstration of the dor- there is usually at least
one rupture of the upper
sal root ganglion is absolute proof of avulsion nerves. Arterial injury
is rare. Urgent repair can
but the level of rupture of the ventral root may produce outstanding
results. The situation is
open the opportunity for direct repair. It is not more difficult when the
upper nerves have
uncommon to find C6 avulsed whilst the 5th been avulsed.
900
R. Birch
Fig. 8 Ischaemia and conduction. Traction lesion of the ischaemia within

the limb nor that there was a second,
brachial plexus was accompanied by rupture of the subcla- more distal,
lesion. Strong SSEPs were recorded from the
vian artery. There was a weak pulse. At operation, 54 h after stumps of C5 and C6
(1). The dorsal root ganglia of C7, C8
injury, stimulation of the avulsed ventral roots of C7, C8 and T1 (2) and
their ventral roots (3) are shown. An exten-
and T1 evoked strong contraction in the relevant muscles sive repair was
done(Case investigated and referred by Mr
distally. This showed that there was neither critical Tanaka and Mr
Shandall, Royal Gwent Hospital)
Intradural C5 and C6. Conventional nerve, that of C7

onto bundle in C8. Nerve
transfers to the suprascapular and circumflex transfer to the
nerve to biceps is successful in
nerves and to the nerve to biceps are reliable about 60 % of
patients. Intercostal nerves and
[46] although re-innervation of the avulsed the medial
cutaneous nerve of forearm may be
ventral roots using the spinal accessory nerve transferred to the
lateral root of the median nerve.
and one or two bundles within the intact C7 is Extension of the
digits and of the wrist is reliably
also effective. restored by
subsequent flexor to extensor transfer
Intradural C5, C and C7 is much more serious (Fig. 9).
because of the deep paralysis of the thoraco- Preganglionic
C5, C6, C7, C8, intact T1.
scapular and thoraco-humeral muscles. The loss These patients have
extremely poor function.
of cutaneous sensation is extensive and severe The hand is
insensate. Repair of avulsed ventral
pain is usual. C8 usually innervates the radial roots has improved
the outlook and significant
head of triceps and in about 30 % of cases the improvement has
been achieved in selected
extensor muscles of the digits. The ventral root of patients by re-
implanting the avulsed spinal
C5 may be transferred to the spinal accessory nerves into the
spinal cord.
901
Table 3 Characteristics of lesions of the spinal nerve

Conduction
between
spinal nerve
CT
Tinels and spinal Peripheral Conduction
Myelography
Type of lesion sign cord conduction across lesion
MRI Appearance
1. Intact Absent Intact Intact Not
Normal Normal
applicable no
lesion
2. Recovering Absent Intact Intact or Intact or
Normal Bundles intact.
stretch or weak diminished diminished
Epineurium
stretched or even
torn
3. Rupture Strong Intact Absent Absent
Normal Clear separation
of stumps (early
cases). Good
architecture of
proximal stump
4. Rupture Present, Diminished Absent Absent
Usually Clear separation
with but
normal of stumps. The
intradural weaker
proximal stump
component than in
abnormal, even
type 3
close to foramen
5. Intradural Absent Absent Sensory N/A
Separation of Normal(early).
with no conduction
roots may be Atrophy,
displacement preserved
seen sometimes gray-
of DRG
yellow colour
(late)
6. Rupture or Absent Present if Sensory N/A
Separation of Normal or mild
avulsion of dorsal root conduction
root(s) may atrophy
dorsal or intact preserved
be seen
ventral root
7. Intradural Absent Absent Sensory N/A
Clear DRG Visible, with
with conduction
abnormality the ventral and
displacement preserved
with CSF dorsal roots
of DRG
Leak
Note The timing of peripheral conduction studies is critical. Motor conduction can
be detected for up to 4 days after rupture
or intradural injury. Sensory Conduction persists for up to 7-10 days after rupture
and indefinitely after intradural injury
Table 4 Patterns of injury in 301 consecutive operated supraclavicular lesions (By

number of patients 19891993)
Complete lesions: pre-and postganglionic injury.
148 cases
Ruptures upper nerves C5 (C6,C7)
83
Intradural lower nerves (C6,C7, C8) T1
Ruptures middle nerves (C6) C7 (C8)
5
Intradural above and below
Ruptures lower nerves C8, T1
1
Intradural upper nerves C5, C6, C7
Total intradural C5-T1
52
Incomplete lesions: some roots intact.
153 cases
Damage C5, C6 (C7)
117
Recovering or intact (C7) C8, T1
Damage C6, C7, C8
23
Recovering or intact C5, T1
Damage C7, C8, T1
13
Recovering or intact C5, C6
902
R. Birch
Fig. 9 A 31 year old man:

left-sided lesion: rupture
C5, preganglionic C6, C7.
Operation on the day of
injury: accessory to
suprascapular, the VR
(Ventral root) of C6 and C7
were transferred to the
anterior face of proximal
C5, the rupture of that nerve
was grafted. Function at 28
months
Intact C5 and C6 (C7), C8, T1. These (C4), C5-T1 Avulsion

patients are much better off than those with Conventional nerve
transfer offers only paltry
lesions of the upper nerves because function mitigation in these, the
worst cases, and the only
at the thoraco-scapular, glenohumeral, and realistic prospect for
useful function by means of
elbow joints is good, pronosupination and flex- nerve repair lies in
reconnection between the
ion and extension of the wrist is usually pre- avulsed spinal nerves and
the spinal cord.
served and there is good sensation in the
thumb, the index and the middle fingers.
There are opportunities for palliation by Results
musculo-tendinous transfer. Repair of the
lower roots of the plexus is often worthwhile Results are considered by
neurological recovery,
if performed within days of injury. by relief of pain and by
return to work or study.
The Complete Lesion Neurological Recovery
These are devastating injuries and it is extremely A good result for repair
of a spinal nerve or an
important that the patient is approached in an open element of that nerve
means the return of move-
and positive manner. It is as bad to give the patient ment against resistance in
one axis of a joint of
a hopeless prognosis as it is to offer one which is two-thirds or more of
normal range. Earlier data
over-optimistic. Every reasonable effort should be has been set out in
Surgical Disorders of the
made to find proximal stumps of ruptured spinal Peripheral Nerves (1998,
2011) [7, 9]. Recovery
nerves and to repair these as soon as the patients of function in 360
patients operated between
condition allows. Return of function is usually 1990 and 1996 is
summarised in Table 5, and
only modest and confined to the upper segments that in 228 patients
operated between 2000 and
of the limb but some patients achieve much more. 2004 in Table 6.
Dickson and Biant (2009) [25] described extensive Grafts remain the
mainstay of repair, nerve
recovery of function, extending to the hand, in two transfers supplement them.
Addas and Midha
young adults with complete lesions. The repairs (2009) [1] point out, in
an excellent review of
were performed 6 days after injury. In both nerve transfers, that
surgeons must not turn away
patients continuing improvement in power, co- from the difficulties of
exploring the lesion itself.
ordination, and cutaneous sensation was detectable Some conclusions may be
drawn:
for up to 10 years and the rate of recovery was 1. The outcome is better
when repairs are
faster in the large myelinated efferent fibres than it performed within 7 days
of injury, especially
was in the A-delta and C fibres (Fig. 10). so in the presence of
arterial injury.
903
Fig. 10 Left sided lesion.

Rupture C5, C7, C8 T1,
avulsion C6. Function at 96
months after repair in
a nurse aged 28 at the time
of injury. Wrist extension
was regained by transfer of
FCU to ECRB
2. Preganglionic lesions exert a depressing effect 4. Lateral rotation at the

shoulder and extension
upon recovery. Good results were recorded in of the elbow and wrist was
regained in
63 % of repairs in patients without any pre- between 30 % and 40 % of
grafts compared
ganglionic injury compared with 40 % of all to 6070 % of nerve
transfers or VR repair.
repairs in patients with one or more intradural
lesion. Conventional Nerve Transfers
3. The decline in outcome with increasing The phrenic nerve should not
be used. Transfer
delay is most marked for grafts. Of those from the contra lateral
brachial plexus is reserved
performed within 7 days of injury, 52.5 % for rare cases of complete
bilateral lesion where
achieved a good result but the success rate one limb is so badly damaged
that no useful
for all grafts was 35.5 %. The success rate recovery can be anticipated.
For these nerve
for conventional transfers was 42.3 % and transfers may be used to ease
pain in the worst
65 % in the ventral root (VR) repairs. How- limb. Some conclusions drawn
from the study of
ever, the average number of function 958 nerve transfers follow:
regained through a successful graft was 3.2 1. Transfer of deep divisions
of intercostal
compared with 1.9 for the VR repairs and 1.6 nerves to the nerve to
serratus anterior is the
for conventional transfers. The admittedly most successful of all
nerve repairs with 76
few cases of recovery of useful cutaneous from 92 patients (83 %)
regaining powerful
sensation and motor function in the hand protraction of the scapula.
followed urgent grafts of ruptured spinal 2. Accessory nerve to
suprascapular nerve trans-
nerves. fer is useful in upper
lesions and when
904
R. Birch
Table 5 Results of repairs, in 360 patients, performed between 1990 and 1996 (By
interval and by severity of lesion)
Timing of repair
Functions attributed to the repair Within To To
More than Total
14 days 3 months 6 months
6 months
No % No % No %
No % No %
0 8 11.8 10 15.6 8 28.6
20 58.8 46 23.7
1 10 14.7 22 34.3 8 28.8
8 23.5 48 25
2 14 20.6 20 31.2 8 28.8
6 17.6 48 25
3 20 29.4 4 6.2 2
7.2 0 0 26 13.5
4 or more 16 23.5 8 12.5 2
7.2 0 0 26 13.5
Total 68 64 28
34 194
Complete lesion
0 15 16.9 18 41.9 8 36.4
8 66.7 49 29.5
1 15 16.9 10 23.2 4 18.2
2 16.6 31 18.6
2 19 21.3 12 27.8 8 36.4
2 16.6 41 24.6
3 23 25.8 2 4.6 2 9.1
0 0 27 16.2
4 6 6.7 1 2.3 0 0
0 0 7 4.2
5 4 4.9 0 0 0 0
0 0 4 2.4
6 or more 7 7.8 0 0 0 0
0 0 7 4.2
Total 89 43 22
12 166
Overall totals (%)
0 23 14.6 28 26.2 16 32
28 60.9 95 25.1
1 25 15.9 32 29.9 12 24
10 22 79 20.5
2 33 24.1 32 29.9 16 32
8 17.6 89 22
3 or more 76 48.6 15 13.6 6 12
0 0 97 25.2
157 107 50
46
1. This excludes patients with planned, late operations designed to relieve pain.
2. Incomplete lesions: at least one nerve intact or recovering
3. Regeneration did not restore useful function in 91 patients and in 38 of these
there was no detectable regeneration
Table 6 Results of repairs in 585 elements in 228 patients operated between 2000
and 2004 by interval between injury
and operation
Results (excluding
ventral root
Number Results of repairs repairs)
Average number of Average number of
Interval in of Good/ Good/
elements repaired functions regained in
days patients Total % Total % in
each patient each patient
07 52 114/175 65.1 86/40 61 3.4
5.4
814 25 41/72 57 21/45 46.7 2.9
3.8
1528 31 48/87 50.1 34/73 46.6 2.8
3.3
2956 32 25/74 33.8 21/68 30.1 2.3
1.6
5784 31 31/67 46.2 30/65 46.2 2.2
1.8
85112 16 13/35 37.1 12/33 36.4 2.2
1.9
113182 22 8/34 23.5 7/33 21.2c 1.5
1.1
More than 19 12/41 29.3 11/39 28.2 2.2
1
182
228 288/585 49.2 222/496 44.8
1. The average numbers of repairs for each patient was 2.6
2. The average number of functions regained in each patient was 2.9; the total of
functions regained was 658
905
combined with grafts often restores excellent medial rotation, with about
20# of forward flexion
abduction and lateral rotation [60]. From 280 at shoulder, in 35 of 49
roots. Elbow extension
transfers in upper plexus lesions 60 patients was regained in 29 patients
and useful extension
(21.5 %) regained abduction of 120# or more of the wrist in 10.
and lateral rotation of 40# or more. In 75
(26.8 %) abduction was 60# or better and lat- Re-Implantation of Avulsed
Spinal
eral rotation at least 30# . In 83 patients Nerves into the Spinal Cord
(29.6 %) either useful abduction or lateral The first case was operated
by George Bonney
rotation was regained. It is important to in 1979 [7]and the method has
been greatly
exclude rupture of the rotator cuff or damage developed by Thomas Carlstedt
who has
to the suprascapular nerve.The operation will described extensive
experimental work, indica-
fail if serratus anterior remains paralysed. tions, contra-indications and
results in his impor-
3. Ulnar nerve to nerve to biceps transfer [58] tant monograph [19].
has been used in 103 patients, of whom 45 The method may be
considered in cases of
(43.6 %) regained elbow flexion to MRC complete lesion with four or
five avulsions. Oper-
Grade 4 and a further 43 (41.7 %) achieved ation must not be undertaken
in patients with
elbow flexion of MRC Grade 3 or 3+. The rupture of the subclavian or
vertebral arteries,
principle has been extended to re-innervate nor in any patient showing
any sign of affliction
nerves to the extensor muscles of the wrist, of the spinal cord.
Transforaminal endoscopic
using bundles from the median or the examination of the cord is
helpful: methods of
ulnar nerve and also to the repair of the measuring the perfusion of
the cervical spinal
suprascapular nerve or an avulsed ventral cord need to be developed.
Regeneration into
root by transfer to a bundle within an adja- proximal muscle, notably
pectoralis major, has
cent spinal nerve. been confirmed in all
patients. Adduction, medial
4. Just over one half (52 %) of patient with rotation and forward flexion
at the shoulder and
lesions of C5, C6 and C7 regained useful flexion and extension at the
elbow have been
elbow flexion by intercostal transfer. Only regained in 21 patients. Some
have done rather
one third (34 %) with complete lesions did better than this. Carlstedt
et al (2009) [20] report
so, but see Nagano et al (1989) [53]. the case of a 9 year-old boy
who sustained com-
plete avulsion of his right
brachial plexus and he
Ventral Root Repair experienced severe,
spontaneous, constant and
The roots of the spinal nerves contain far less shooting pain. All five
spinal nerves were re-
connective tissue than the peripheral nerves and connected by interposed
grafts at operation
there is a dense concentration of motor axons in which was performed 4 weeks
later. Recovery
the VR. The specificity of Schwann cells related of muscles at the shoulder
girdle was evident by
to the large efferent axons may actively encour- 10 months and at the elbow by
1215 months by
ages the re-entry of new motor axons [34, 51]. which time his pain had
completely resolved.
Most repairs were performed within a few days of Muscle recovery in the
forearm, wrist and hand
injury; only then can the dorsal root ganglion be was apparent by 2 years. He
recovered useful
displayed with ease and the ventral root separated function throughout the
damaged upper limb
from the spinal nerve. The VR may be re- and he could grip and carry
objects (Fig. 11).
innervated by the spinal accessory nerve, by an
adjacent ruptured spinal nerve or by a bundle
within an adjacent intact spinal nerve. Interposed Relief of Pain by Repair
grafts are rarely necessary. Since the first repair
of a VR in 1992 [7] there have been 111 more in The pain of intradural injury
is caused by dam-
the adult. Results were good in 65 %. Repair of age, and subsequent gliosis,
in the transitional
the VR of C7 restored powerful adduction and zone at substantial
gelatinosa and by disinhibition
906
R. Birch
and spontaneous firing of cell bodies within the constant pain. The
intensity of pain was closely
deeper laminae of the dorsal horn of the spinal related to the extent
of de-afferentation of the
column [17, 59, 81]. These events occur rapidly spinal cord [37]. A
measurable decrease in pain
[45, 82]. was noted at a mean
time of about 6 months after
Berman, Taggart and colleagues (1995) [4] operation. In 34 % of
cases pain remained mod-
studied 116 patients with proven root avulsions, erate or severe at 3
years or more. Berman et al
in all of whom nerve transfer or graft had been (1998) [6] went on to
show that pain relief coin-
performed. All patients experienced pain which cided with, or
preceded by a few days, the return
was severe in 88 % of patients at some time of muscle activity.
The correlation between pain
during their course. Pain began within 24 h of relief and the return
of function was highly sig-
the injury in 62 %: pain was at its most intense at, nificant; there was no
such relation in those
on average, 6 months from injury. Paroxysmal patients with poor or
no recovery. However,
pain was never experienced in the absence of Berman and his
colleagues (1996) [5] also
found striking pain
relief following late intercos-
tal transfer. The
mechanism underlying this
remains obscure. Kato
and his colleagues
(2006) [41] studied
148 patients. The onset, pat-
terns and important
mitigating factors were sim-
ilar to those
recognised in the earlier series. Pain
relief was most
striking after early operations
(Table 7).
The evidence
showing that repair offers
a good chance of
easing pain is strong and the
earlier the operation
is done the higher the chance
of pain relief. These
facts provide the strongest
indication for
operation and repair by one
means or another even
in the most severe case.
Fig. 11 A 9 year-old boy. Right-sided lesion. Avulsion
C5,C,C7,C8,T1. Re-implantation of all five spinal nerves. Sadly, there are still
some patients whose pain
The hand at 6 years showing useful pinch grip function remains intractable
and for these interventions
with some recovery into the small muscles (Courtesy of upon the central
nervous system must be
Thomas Carlstedt)
considered [9].
Table 7 Improvement in pain against delay before repair. 148 patients studied by
Kato et al. (2006) [41]
Worst pain by visual Final pain by
visual Mean of improvement
Interval between analogue scale analogue scale
in PNI scale (ranging
injury and repair Number Mean Median Mean
Median from 0 to 4 maximum)
Less than 1 month 61 8.2 (SD0.3) 9.0 (310) 2.6 (SD0.3)
2.0 (010) 2.2 (SD 0.1)
Group 1
From 1 to 3 months 29 9.1 (SD 0.2) 9.0 (310) 3.7 (SD0.4)
3.0 (010) 1.8 (SD 0.2)
Group 2
From 3 to 6 months 32 8.5 (SD 0.3) 9.0 (310) 4.0 (SD0.5)
4.0 (010) 1.3 (SD 0.2)
Group 3
After 6 months 26 9.0 (SD 0.3) 9.0 (310) 5.3 (SD 0.6)
6.0 (010) 1.1 (SD 0.2)
Group 4
The changes were statistically significant taking p 0.05: group 1 and group 3 p <
0.01; group 1 and group 4 p < 0.01;
groups 2 and group 3 p < 0.05
Drawn from Kato et al. 2006 [41]
907
Table 8 Return to work,

retraining, further study, with
interval before re-
entry. Minimum follow-up of 36 months
Years of study.
Years of study. 2000-
19861993 324 patients
2004 238 patients
Same occupation
54 86
(often with
modification)
Different occupation
195 63
Formal retraining or
81 65
return to study
Did not return to work
75 24
Return to Work
The rate of return to
work after serious injury to
the brachial plexus is
encouragingly high but the
finding that four out of
five patients return to
a different job [7]
indicates the importance of
retraining and
information about employment
(Table 8). The recent
findings from patients oper-
Fig. 12 Right-sided lesion in a 70 year old man. Rupture ated between 2000 and
2004 appear similarly
of C5, C6. Operation at 10 days: accessory to
suprascapular, graft of C5 and C6. Function at 15 months encouraging but there
has been a serious decrease
in the rate of return to
work since. We attribute
this to the collapse of
rehabilitation services
Age within the National
Health Service with the out-
standing exception of
certain specialist units. The
Now is as good a time as any to dispel the notion abolition of the post of
Hospital Employment
that nerve injuries will not recover after a certain Advisor was a grievous
error (Fig. 13).
age. Indeed, the effects of age suggests that there
may be increasing vulnerability to pain, because
of the diminishing threshold to noxious stimuli The Birth Lesion of the
Brachial
[23]. Repairs were performed in 38 patients aged Plexus (BLBP)
45 years or more in the years 19882004. Useful
recovery was observed in 25 (Fig. 12). The traction and
compression forces which are
The falsity of that assumption that nerve inju- responsible for the
birth lesion of the brachial
ries in children do better than in the adult is plexus may be less
considerable than those caus-
nowhere better seen than in the outcome of the ing the most severe
injuries in the adult but they
complete closed traction lesion. The immature are active upon the
nerves for several hours
neurones are even more vulnerable to proximal during a prolonged and
difficult delivery. The
axonotomy. The disturbance of growth and response of the neonatal
nervous system to
deformity provoked by muscular imbalance is injury is profoundly
modified by a number of
particularly severe in the younger child. Recov- qualities:
ery of cutaneous sensation is certainly better 1. The density of
conducting tissue is higher; so
than in the adult but this may not be true for is nerve blood flow
which increases the sus-
motor recovery. No child aged less than 15 ceptibility to anoxic
conduction block.
years complained of the classical pain of avul- 2. The cell bodies of
the neurones in the spinal
sion injury, but several developed this as they cord and in the
dorsal root ganglion are depen-
approached later adolescence. dent on neurotrophins
for their development,
908
R. Birch
Fig. 13 Distraction or destruction! The patients own repaired. No nerve

repair was performed. He returned to
motto. Right-sided lesion in a 21 year-old man. Pregan- work at 3 months
rising to a senior position working with
glionic injury C5 to T1 with rupture of subclavian artery. the disabled. Whilst
he found the flail arm splint useful he
Operation at 4 days. There was one branch from C4 discarded it because
it made him feel disabled. Free func-
passing to the suprascapular nerve and another passing tioning muscle
transfer (latissimus dorsi)- Professor Roy
to the nerve to serratus anterior. The subclavian artery was Sanders- was
innervated by the accessory nerve
maturation and survival and are more likely to adult and it is

superior to somatic and sympa-
die after proximal axonotomy or avulsion. thetic motor
recovery [3].
3. Interruption of afferent impulses through the
somatosensory pathways delays the develop-
ment of patterns of function and the integra- Epidemiology
tion of the injured limb. Change in limb
dominance away from the injured side is strik- Incidence
ing: only 17 % of children with right sided The British Isles
census conducted by Evans-
BLPP showed right hand preference [84]. Jones and his
colleagues (2003) [26] found 323
4. Avulsion pain appears to be absent in infants confirmed cases, an
incidence of 0.42 per 1,000
and in young children. It is possible that the live births or 1 in
2300. Fifty-three per cent of the
absence of a nociceptor associated voltage infants were male
and there was a slight prepon-
gated sodium ion channel is contributory [85]. derance of right-
sided injury. The injury was
Spontaneous regeneration through lesions in partial in 91 % of
infants. There were only 10
continuity or neuromas is chaotic and disorderly cases caused by
breech delivery. The incidence in
and this contributes to co-contraction between the Netherlands may
be a little higher [14].
the muscles of the shoulder girdle, which is at
times so severe that the gleno-humeral joint acts Risk Factors
as an ankylosis. Recovery of the afferent path- The direct physical
cause of the lesion is the forced
ways is defective. Fullerton et al (2001) [28] separation of the
forequarter from the axial skele-
noted a selective failure of regeneration of the ton caused by
obstruction at the narrowest part of
largest diameter proprioceptive fibres. This the birth canal. In
breech deliveries the upper
contributes to the clumsiness of the injured spinal nerves and
the phrenic nerve are particu-
limb which is noticeable even when neurological larly at risk and
lesions may be bilateral. In diffi-
recovery has been good. However recovery of cult cephalic
deliveries nerves are stretched,
cutaneous sensibility is far better than in the ruptured or avulsed
as the angle between the
909
Table 9 Significant relative risks 1,060 cases

Dystocia 180.3
Asphyxia 10.8
Gestational diabetes 10
No Caesarean 9
Birth weight > 3.4 kg 8.5
Forceps assisted delivery 6.9
No episiotomy 5.2
Breech 3.6
Not induced 2.8
Ventouse assisted delivery 2.6
Age of mother > 30 2
Hypertension 1.4
By kind permission of Adel Tavakkolizadeh, Thesis 2007
[79]
delivered head and the obstructed shoulder

widens. In our earlier study [29] the mean birth
weight of the babies was 4.5 Kg against the con-
temporary mean for the North West Thames
region, of 3.88 Kg. There was a co-relation
between more severe lesions and higher birth
weight. Shoulder dystocia was recorded in over
60 % of deliveries. A trend was found towards the
mother being heavier and shorter than the national
Fig. 14 Lesion of C5, C6
and C7 Narakas group II
average, and also to excessive maternal weight
gain. There was no significant co-relation with
social class. The later report, extending to more
than 1,060 babies, comes from Tavakkolizadah The differential
diagnosis includes: fractures
(2007) [79] (Table 9). The older mother, with of the clavicle or
humerus; neonatal sepsis
a high body mass index (BMI) giving birth to of the gleno-humeral
joint; cerebral palsy;
a large baby by instrumental delivery, presents arthrogryposis; ischaemic
cord injury and even
the greatest risk. The continuing debate about trigger thumb. Any of
these may co-exist with
elective Caesarean section is illuminated by BLBP. Posterior
dislocation of the shoulder at, or
a frequency of LSCS at 2 % in the BLBP group, soon after birth, is
frequent.
against the national rate of 18 %. The Narakas
Classification (1987) [54] is not
applicable to the breech
delivery. It is useful at
Diagnosis and Classification about 4 weeks after
birth.
The characteristic posture of the upper limb in the Group 1 (C5,6) There is
paralysis of
partial injury is caused by injury to C5, C6 and C7 supraspinatus,
infraspinatus, deltoid and
(Fig. 14). The elbow is extended, the forearm biceps muscles. The
upper limb lies in medial
pronated and the wrist flexed. In the complete rotation with the
elbow extended.
lesion the arm lies flaccid. A Bernard-Horner Group 2 (C5,5,7): There
is also weakness or
syndrome suggests serious injury. Discrepancy paralysis of triceps
and of the extensors of
in the size of the digits is evident from about the wrists. The hand
is clenched into a fist
6 weeks of age. A lesion of the spinal cord usually with flexion at the
wrist.
passes unnoticed until the child starts to walk, Group 3 (C5-T1): The
paralysis is virtually com-
when the parents observe unsteadiness of gait plete. There may be
some weak flexion of the
and disparity in the size of the foot. fingers at, or
shortly after, birth.
910
R. Birch
Table 10 Outcome of 74 Persisting Operation

for Operation
children entered into the 12 Narakas Full defect. posterior
dislocation on brachial
month National Census group recovery No operation of
shoulder plexus
(Mean follow-up 32 months)
Group 1 21 4
3 0
(n 28)
Group II 14 5
16 5
(n 38)
Group 111 4 0
1 1
(n 5)
Group IV 0 0
0 3
(n 3)
Total 39 9
20 9
Drawn from Bisinella and Birch 2003 [10]
Group 4 (C5-T1): The paralysis is complete. The signed and dated with that
colour. This record can
limb is flaccid; there is a Bernard-Horner be completed in no more
than 1 min in most chil-
syndrome. dren aged 18 months or
above. The Mallet score
Neurological recovery is usual in Group 1, it is has proved to be a useful
indicator of overall
generally poor in Group 4. We have seen only one function within the upper
limb. Yang (2005) [84]
example of a lesion confined to C8 and T1. found that it strongly
correlated with both gross
and fine movements. The
inferior and posterior
Natural History scapulohumeral angles
(SHA) detects effects of
Recovery at 6 months after birth was studied in weakness, of contracture
and of bone deformity at
276 of the infants entered into the British Isles the gleno-humeral joint
(Fig. 16). Posterior dislo-
census. It was complete in 143 babies (52 %). cation of the head of the
humerus must be
Seventy four (26.8 %) of the census cases were suspected when a child
presents with a pronated
followed for a minimum of 2 years in our Unit. Of forearm who is unable to
supinate even though
these recovery was incomplete in just under one biceps is strong.
half of the children and more than one quarter of
them required operation for posterior subluxation Shoulder and Hand Function
in 1,320
or dislocation of the shoulder during the period of Children Studied
Prospectively Between
study [10] (Table 10). Pondaag and his colleagues 1992 and 2007
(2004) [63] studied 1020 articles and concluded 1. 252 children were seen
only once because
that persisting residual defects could be identified their function was so
good. The results for
in between 20 % and 30 % of children. Strombeck the Mallet score against
the Narakas grade in
et al (2007a, b) [76, 77] studied 70 cases from the remaining 1,128
children is set out in
birth to adolescence or early adult life. One quarter Table 11. Most children
showed a perceptible
had measurable difficulties in normal daily activ- and, at times
significant defect. Just over
ities. Strombeck and her colleagues suggest that one-third of all of the
children were given the
there is a progressive loss of motor neurones maximum Mallet score of
15 but this does not
which may explain the deterioration in shoulder necessarily signify a
normal shoulder.
function which is so common in late adolescence. 2. Of the 291 children
presenting with complete
For a full account of the systems used in pro- lesions (Narakas 3 and
4), 89 (30.6 %) went on
spective collection of data the reader is referred to to exploration and
repair of the brachial plexus
Birch 2011 [9]. The modified Mallet [48] system is and 193 (66.3 %)
required operations for pos-
valuable (Fig. 15). The five movements are scored terior dislocation of
the shoulder whilst 197
on a scale in range from 1 to 3. A different coloured (67.7 %) required
operations to improve func-
pencil is used at each attendance and the record is tion of the forearm,
wrist, and digits.
911
Fig. 15 The Mallet chart
Spontaneous Recovery of Hand Function 108 children and simple

musculo-tendinous trans-
in the Complete Lesion fers improved function to a
useful level in 28 more.
Good spontaneous recovery can occur in some The first signs of recovery
included improvement
infants presenting with a Narakas Type 4 lesion. in texture and colour and the
temperature of the
Of 200 such infants seen in the years 19842007 skin suggesting early recovery
of vasomotor tone,
the plexus was repaired in 92 (46 %). Operations changes which usually preceded
active movement
were not performed in 108, either because there by some weeks.
Neurophysiological investigations
was recovery or because the children presented too suggesting post ganglionic
injury for C8 and T1
late. Hand function was graded good in 63 of these were consistent favourable
findings.
912
R. Birch
advised of the risks of

contracture, above all at
the shoulder. It is
extremely important that
all those involved in
the care of the child
avoid giving
conflicting information. After
operation, it is for
the surgeon to explain what
was found, what was
done, why it was done
and what may follow.
Parents are
involved in the treatment of the
child from the outset.
Regular and gentle exercises
may prevent fixed
deformity. If gentle stretching
movements cause pain
then there must be either
fracture or posterior
dislocation of the shoulder.
The role of the
therapist and attending doctor is to
teach and then to
monitor progress. We have seen
too many examples of
fixed deformity resulting
from parents sitting
passively at home awaiting the
occasional visit by the
community physiothera-
pist. Exercises must be
performed, gently, for
2 or 3 minutes before
every feed. Both upper
limbs are worked
simultaneously. For medial and
lateral rotation the
arms are held against the side,
with the elbow flexed
to 90# . The forearms are
Fig. 16 Both the passive and active inferior scapulo
humeral angles were reduced by cocontraction and then brought onto the
childs body and then moved
contracture into full lateral
rotation. Then, the upper limbs are
brought gently into
full elevation. This manoeuvre
is repeated with the
arms at 90# of abduction. The
Table 11 The initial and final Mallet score in 1,128 inferior SHA is
maintained by holding the scapula
children seen in the years between 1992 and 2007. The
results are given by median and (mean). The median age at against the chest
whilst abducting the arm; the
the first record was 13 months. The median and (mean) posterior SHA by
holding the scapula against the
length of follow-up is given in months ribs whilst flexing and
medially rotating the arm.
Number Much fixed deformity
can be prevented by this
Narakas of Initial Final Duration of simple regime. It is
essential to warn parents
Group children score score study
I 249 8 (8.1) 13 (12.8) 43.5 (53.3) about the significance
of pain for this may be the
II 518 8.5 (8.6) 13 (12.5) 44 (62.3) first indication that
the gleno-humeral joint is no
III 217 7 (8) 13 (12.2) 41.5 (51.2) longer congruent.
IV 144 7 (7.3) 11 (10.9) 55.5 (63.3)
Investigations
Neurophysiological
Investigations (NPI)
Treatment Neurophysiological
investigations have been
used in nearly 1,000
children since 1980 and
The first step is to provide the parents with they are particularly
valuable in partial lesions
information about the nature and the extent of where recovery of
shoulder abduction and
lesion and of the likely outcome. Parents appre- elbow flexion is slow
and also in apparently
ciate a simple diagram showing the brachial unfavourable Group 4
lesions [73].
plexus and outlining the nature and level of the The clinician using
information provided by
lesion, which is written out for them by the neurophysiological
investigation (NPI) needs to
doctor. This is far preferable to an anonymous understand the method;
their interpretation must
hand out of printed paper. The parents are always consider
clinical findings. Nerve action
913
Table 12 The clinical interpretation of electrodiagnostic findings

Grade NAP EMG
Lesion
A Normal No spontaneous activity. Reduced
Conduction block
number of normal motor units.
Increased firing rates
B favourable Normal or > Relatively good motor unit recruitment.
Modest axonopathy consistent with
50 % of uninjured Mixture of normal and polyphasic units
useful recovery
side suggesting some collateral re-
innervation
B Absent or < 50 % Normal units few or absent.
Significant axonopathy. Recovery
unfavourable of uninjured side Widespread polyphasia indicating
particularly poor for C5
collateral reinnervation. No
spontaneous activity
C Absent; if present Extensive spontaneous activity.
Severe axonopathy consistent with
indicative of Sometimes poor recruitment of nascent no,
or poor, recovery. Preserved
preganglionic or small polyphasic units NAP
suggests preganglionic injury
injury
Drawn from Smith 1998 [73], and from Bisinella Birch and Smith 2003 [11]
potentials are measured from the median and ulnar was no recovery of
elbow flexion by the age
nerves by stimulating at the wrist and recording at of 3 months. The
lesions were graded by NPI
the elbow. The deltoid (C5), biceps (C6), triceps or as grades A or B and
the predictions were
forearm extensors (C7) forearm flexors (C8) and confirmed in 92 % of
C6 lesions, and in
1st interosseous (T1) muscles are sampled by 96 % of C7 lesions.
The accuracy of predic-
EMG. The lesion is graded for each spinal nerve, tions for C5 (78 %)
was lower because of the
according to the degree of demyelination and inability to record
compound nerve action
axonopathy (Table 12). A prediction is made potentials for this
nerve and also by the com-
about the likely extent of recovery on the basis of plication of
posterior dislocation. The NPI
the neurophysiological grade. predictions were
accurate in children with
Some conclusions may be drawn: congruent shoulders,
whereas recovery was
1. NPI performed during the first 8 weeks of life good in only 34 % of
those with Type A or
may prove unduly pessimistic. B lesion but in whom
relocation of the shoul-
2. Significant axonopathy in C5 is a sure der proved
necessary.
indicator that recovery at the shoulder will 7. Pre-operative NPIs
are more reliable than intra-
be poor. operative
investigations in determining progno-
3. Spontaneous recovery in Type B lesions of C6 sis for the injured
nerves; they also inform about
and C7 usually matches that seen after suc- the extent of
recovery after repair [8].
cessful repair.
4. Proof of post ganglionic injury at C8 and T1 Imaging
offers a high chance of considerable spontane- Magnetic resonance
imaging has replaced
ous recovery. myelography in the
diagnosis of avulsion. Ultra-
5. Pre-operative NPI predictions correlated with sonography in the first
few days of life may prove
the findings at operation. Rupture, avulsion, or valuable.
a mixture of both was confirmed in 94 % of
Type C lesions.
6. The predictions for recovery were matched The Indications for
Operation
against the outcome at a mean of 4.3 years
in 73 children (199 nerves) in whom opera- These revolve around
the cause of the lesion, its
tions were not performed even though there extent, and the tempo
of recovery.
914
R. Birch
There are a number of pitfalls lying in wait for potentials are recorded from
the median and
those who rely on late return of elbow flexion: ulnar nerves at both wrists.
Scarring in the infant
1. Prolonged conduction block underlies neck is often severe, blunt
dissection is danger-
prolonged paralysis in as many as 15 % of ous. The most serious
immediate complication is
spinal nerve lesions. venous bleeding and
superficial veins must be
2. The biceps muscle may be damaged or even ligated with great care
because of the proximity
torn apart during difficult delivery. of subclavian vein.
Laceration of the phrenic
3. Shoulder movement is the key to function in nerve is an extremely serious
complication,
the upper limb and poor recovery into the joint the nerve must be protected
for it is often deviated
is more important than elbow flexion. Too laterally and involved in the
neuroma of the upper
many cases of posterior dislocation have and middle trunks. Once the
lesion has been
remained undetected for months or even years! exposed further conduction
studies are made of
The Toronto scoring system [24, 50] measures the pathway between the
spinal nerve and the cen-
recovery at different segments of the upper limb. tral nervous system and that
traversing the lesion.
Combining the scores for return of elbow flexion
with extension of the elbow, wrist, thumb and The Principles of Repair
fingers provides an accurate prediction of recov- 1. Repair of ruptures by
grafts is the mainstay of
ery. Nehme et al (2001) [55] showed that the repair. Avulsed nerves
should always be re-
prognosis is reliably predictable by three factors: innervated, either from an
adjacent postgan-
birth weight, involvement of C7 and the tempo of glionic stump, or by
selective graft or transfer
recovery in biceps. to the ventral root and to
the dorsal component
Our indications have been narrowed by the of the spinal nerve after
resection of the dorsal
study of the outcome of repairs in 250 children: root ganglion.
1. Operation should be done as soon as is possible 2. The phrenic nerve should
never be used.
in breech lesions with phrenic palsy and also in 3. Hypoglossal nerve transfer
leads to unaccept-
those complete lesions where neurophysiolog- able deficit and poor
recovery [13].
ical and radiological evidence provides clear 4. Transfer of the spinal
accessory nerve leads to
evidence of preganglionic injury. measurable defect in
control and growth of the
2. Type B Unfavourable or Type C lesions in C5 scapula. Results are
inferior to those seen in
predict poor recovery at the shoulder. the adult [12, 64].
3. A Type B unfavourable lesion in C6 and 5. End-to-side transfer, in
which one bundle
in C7 is consistent with useful spontaneous is sectioned from within
an intact nerve
recovery. We no longer believe that repair of either in the neck or from
an intact peripheral
a rupture of C6 and C7 materially improves nerve, such as the ulnar
or median is very useful
the outlook. Exploration in these nerves is for the suprascapular
nerve or the nerves to
indicated in a Type C lesion. biceps, triceps, or wrist
extensors.
4. Repair of C8 and T1 is justified only with 6. In cases of avulsion of C8
and T1 it is
proof of avulsion. preferable always to re-
innervate the lower
trunk and the ulnar nerve
rather than use it
as a graft in contra-
lateral C7 transfer
Principles of Operation (Fig. 17).
The reader is referred to Birch 2011 [9] for a full Results of Repair
account of methods of exposure and techniques The results of 247 spinal
nerve repairs in 100
of repair. After induction of anaesthesia, record- consecutive babies performed
between 1990 and
ing electrodes are attached to the skin of the 1999 [8] were graded by
strict criteria. One-fifth
scalp and neck and somatosensory evoked failed. Results were graded
good in about
915
Fig. 17 A 5 year-old boy

with a group 4 lesion. At the
age of 7 weeks ruptures of
C5,6, 7 and C8 were
repaired using 16 grafts.
The avulsed T1 was
repaired by intraplexual
transfer and the
suprascapular nerve by
transfer to accessory nerve.
Shoulder 3+,14; elbow 4;
hand 4
one-half. The effect of the associated dislocation and arm after a difficult
delivery. This causes
of the shoulder was severe. The mean Mallet fibrosis of the muscles of
the shoulder, espe-
score in children without dislocation was 12.4; cially the subscapularis.
The pseudo-tumour
it was 10.8 in those children who came to opera- of the biceps muscle is
caused by damage to
tion for relocation of the shoulder. Grossman and the muscle at birth [47].
Posterior dislocation
his colleagues (2003) [32] are surely right when occurs at or very shortly
after birth in about
they recommend re-innervation of the shoulder one case in 4 (Fig. 18).
with correction of any existing shoulder defor- 2. Denervation of the Limb.
There is atrophy of
mity at the same operation. As Gilbert (2005) the denervated target
organs; atrophy of the
[30] points out secondary operations including skin and of the finger
nails. Bone growth is
musculotendinous transfer can bring about con- impaired in all but the
mildest case. Shorten-
siderable improvement. ing of the clavicle, caused
by paralysis of the
Anand and Birch (2002) [3] studied 24 patients deltoid, the subclavius and
the clavicular head
with a Narakas Group 4 lesion by quantitative of pectoralis major
distorts the posture and
sensory testing and measurement of cholinergic development of the scapula.
sympathetic function, Recovery of sensibility 3. Persisting muscular
imbalance is a potent
was far better than somatic and sympathetic cause of deformity. Poor
recovery in C5
motor function. There was accurate localisation leads to an imbalance
between the weak lateral
in the dermatomes of avulsed spinal nerves and the strong medial
rotators at the shoulder
which had been re-innervated by intercostal nerves and this contributes to
many gleno-humeral
transferred from remote spinal segments. dislocations. Bad lesions
of C7 cause weak
medial rotation at the
shoulder and supination
deformity of the forearm;
if C8 is also
Deformity involved then ulnar
deviation at the wrist
and thumb-in-palm deformity
will ensue
There are four main causes of deformity: [2, 83]. Poor recovery in
T1 causes intractable
1. Injuries Inflicted During Birth. Parents often extension deformity at the
metacarpo-
describe severe bruising around the shoulder phalangeal joints.
916
R. Birch
have matured and the extent

of weakness and
cocontraction will be very
plain. Careful,
prolonged, functional
splinting, particularly at
the wrist and thumb, enables
recovery in many
children. These are used in
the years before
planned muscle transfer and
often recovery is
good enough for the
operation to be cancelled.
These splints must be
changed regularly and
adjusted for comfort and
growth. They are re-
applied after operation, and
retained during the
period of post-operative
rehabilitation. Only
rarely do children reject
the splints; in these the
matter is not pressed.
Posterior Subluxation (PS)

and
Posterior Dislocation (PD)
of the
Gleno-Humeral Joint
More than 500 children with

posterior subluxa-
tion or dislocation have
come to operation since
1986. The finding that
dislocation complicates
about one quarter of birth
palsies suggests that
there will be about 70 new
cases every year in the
British Isles [10] About one
quarter of disloca-
tions occur at birth or
within the first 12 weeks of
life. About one half of
cases develop in the first
3 years, the remainder occur
after neurological
Fig. 18 Biceps pseudotumour in 9 year old boy. The recovery [40].
shoulder is dislocated The ease of clinical
diagnosis, the affect
of the dislocation upon the
posture of the
4. Some Deformities are Provoked by Treat- scapula and upon function of
the upper limb,
ment. Overzealous manipulation of the incon- and also an explanation for
the lack of active
gruent shoulder damages the head of humerus supination were all
described by Fairbank in
and glenoid. Incorrect muscle transfers 1913 [27]. Scaglietti (1938)
[69] reporting
replace one imbalance with another, notably Puttis work [65] thought
that epiphysiolysis
at the shoulder and wrist. Damage to the was often seen and that it
was the: hallmark of
medial epicondyle during Steindlers elbow a complicated obstetrical
trauma of the shoulder
flexorplasty leads to dislocation of the elbow. joint. He also described
retroversion of the
Arthrodesis in the growing skeleton should head upon the humeral shaft,
one of the most
never be performed until muscular imbalance important elements which
must be corrected
has been corrected. Joints should be congruent before secure congruent
reduction can be
before muscle transfers are performed. achieved.
With the exception of posterior dislocation The deformity is a very
complex one. To the
of the shoulder which should be corrected as violence of delivery is
added imbalance between
soon as is reasonable, it seems generally best to the powerful and active
medial rotators and the
defer musculo-tendinous transfer until the age of weak, or paralysed, lateral
rotators. The changes
5 years by which time regenerating nerves will in the glenoid occur early
[36, 61, 62, 71, 72].
917
Retroversion of the glenoid improves after as a double facet or a double

socket with the true
relocation of the head of the humerus [38]. glenoid lying above and
anteriorly and articulat-
The medially-rotated head of humerus is thrust ing with the lesser tuberosity,
and a postero-
against the posterior and inferior margin of the inferior facet which soon
becomes larger. The
cartilage of the glenoid which begins to deform head of the humerus lies in the
postero-inferior
so that it becomes convex. The deformity evolves facet. The head of the humerus
may progress to
Fig. 19 (continued)
918
R. Birch
Fig. 19 (a) Antero-posterior and axial radiographs show radiographs taken 5

years after reduction showing
overgrowth of the coracoid and downward displacement remodelling of the
head of the humerus and glenoid. The
of the acromion and lateral clavicle. There is a double humeral head shows
some signs of earlier vascular
facet glenoid and a cone-shaped head. Shoulder scores change. (c) Function
at 5 years from reduction. The shoul-
were 1+, 12. Active forward flexion and abduction was der scores were
5+,15. Active abduction and forward
180# ; active lateral rotation was minus 40# and the passive flexion was 170# ;
active lateral rotation 30# ; active medial
range was minus 20# . Active medial rotation was 90# , the rotation 90# ; and
pronation and supination 90# . The pos-
passive range was 110# . Active pronation was 90# and terior scapulo-
humeral angle was 90# (By kind permission
active supination 40# . (b) Antero-posterior and axial editor of J. Bone
Jt. Surg. 88B: 213219)
dislocation. In some cases the head of the simultaneously,

initially with the examiners
humerus was never in the glenoid. The eyes closed. Any
asymmetry between the shoul-
displacement of the head of the humerus leads ders indicates an
incongruent joint until proven
to mal-development of the lateral clavicle and the otherwise. Diagnosis
is confirmed by reduction
acromion and even to subluxation or dislocation in the passive range
of medial rotation measured
of the acromioclavicular joint. The abnormal with both arms
adducted to the side. In the older
position of the scapula and the dorsal displace- child the posture of
the limb and the awkward
ment of the coracoid is worsened by the shorten- elevation at the
shoulder with fixed medial rota-
ing of the clavicle. In a few cases the tional deformity are
characteristic.
subscapularis was severely fibrosed suggesting Three features
are important:
compartment syndrome at birth. 1. The coracoid is
nearly always displaced pos-
teriorly,
inclined vertically and elongated.
2. The clavicle is
shorter on the affected side, by
Diagnosis as much as 25 %
in the more severe cases.
3. The
acromioclavicular joint may be dislocated.
It is difficult to overstate the requirement for Ultrasound
scanning is useful [68]. Radio-
scrupulous clinical examination which is reli- graphs in the
antero-posterior, and in the axial
able in the detection of early incongruency. plane [75] confirm
the diagnosis. MR scanning is
Both shoulders must be examined reserved for cases
of unusual complexity.
919
Table 13 Results in 183 shoulders treated by reduction by the anterior approach.

Retroversion of head of humerus was
corrected by medial rotation osteotomy of humeral shaft in 70 cases
Pre-
operative Mallet Final Mallet score
Deformity Number of cases (183) Number of failures (20) score (183
shoulders) (183 shoulders)
SS 37 0 10.4
13.4
SD 24 0 7.8
12.4
CS 64 5 9.5
13.2
CD 58 15 9
12.7
Narakas Group
I 35 3
10.8 13.6
II 110 13 9
13
III 38 4
8.9 12.5
Based on Kambhampati et al. 2006 [40]
Fig. 20 AP and axial radiographs 24 months after glenoplasty in a 4 year-old child
Treatment contracted
subscapularis, the coracoid deformity
and the retroversion of
the head but did not address
The early onset of glenoid deformity indicates that the deformity of the
glenoid nor the abnormality of
temporary paralysis of the medial rotator muscles the acromioclavicular
arch (Fig. 19a, b, c). Dislo-
using botulinum is unlikely. Kambhampati et al cation recurred in 20
children with more advanced
(2006) [40] prospectively studied 183 children in bone deformity (Table
13). Currently, glenoplasty
whom an operation was used which corrected the is added when the head
appears to drop out of the
920
R. Birch
Fig. 21 Shoulder function

5 years after reduction and
glenoplasty on the right
side
antero-superior true facet into the larger postero- posterior face of the
scapula. A radial incision
inferior false facet after re-location and de-rotation into the capsule permits
identification of the pos-
osteotomy. With the first stage of the operation terior labrum and the edge
of the hyaline cartilage
complete the child is placed prone and the poste- of the inferior facet.
Fine osteotomes elevate the
rior face of the scapula is displayed between the posterior and inferior
walls of the glenoid so that it
infraspinatus and the teres minor. The relocated abuts the reduced head of
the humerus. The gap is
head of the humerus leaves behind a mass of wedged open with the
excised coracoid. The flap
redundant capsule which is elevated from the consists of the posterior
and inferior labrum, the
921
inferior (false) socket of the glenoid, the overlying 4. Berman JS,

Taggart M, Anand P, Birch R. The effect
capsule and corticocancellous strips petalled of surgical
repair on pain relief after brachial plexus
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Brit Neurol Proc. 1995;44(abs).
from the posterior face of the scapula. In older 5. Berman J, Anand
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6. Berman JS, Birch
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The early results of this procedure are promising brachial plexus
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[9, 80] (Figs. 20, 21). The problems caused by the and the effect
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deformity of the acromio clavicular arch and the 7. Birch R, Bonney
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Kono H, Smith S. Repair of obstetric
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Surgical disorders of the peripheral nerves.
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function in the upper limb in cases of BLBP, a study of 74
children registered with the British Sur-
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J Hand Surg. 2003;28B:405.
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Scapular Dysplasia
Tim Bunker
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 925
Aperts syndrome # Dysplasia # Embryology
and genetics # Obstetric brachial plexus palsy #

Primary Glenoid Dysplasia . . . . . . . . . . . . . . . . . . . . . . . . 926
Posterior-inferior dysplasia # Primary and sec-

Secondary Glenoid Dysplasia . . . . . . . . . . . . . . . . . . . . .
927 ondary dysplasia # Scapula # Snapping scapula
Obstetric Brachial Plexus Palsy (OBPP) . . . . . . . . . . . .
927 # Sprengels deformity-surgical correction
Aperts
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
928
Postero-Inferior Glenoid Dysplasia and
Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 928
Snapping
Scapula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
930 Introduction
Sprengels
Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
931
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 932 We are just beginning to understand that glenoid
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 932 version, depth and shape may have an important
bearing upon shoulder instability, and in particu-
lar posterior positional instability, the develop-
ment of arthritis, and shoulder replacement. On
top of this, primary glenoid dysplasia, secondary
glenoid dysplasia from obstetric brachial plexus
palsy (OBPP) as well as Aperts syndrome,
snapping scapula and finally Sprengels shoulder
are rare but challenging conditions.
The definition of dysplasia is abnormal
development, growth or absence of a structure.

In order to understand scapula dysplasia we need
to understand the normal development of the
scapula and its constituent parts. Fortunately
recent research in genetics has begun to enlighten
us and bring our understanding of scapula
dysplasia into the twenty-first century. Research
on the genetics and embryology of the scapula
reveals that the blade of the scapula and
the glenoid develop from completely different
tissues. The blade of the scapula seems to be an

T. Bunker
Princess Elizabeth Orthopaedic Centre, Exeter, UK
ossified muscular attachment whose develop-
e-mail: Tim.bunker@exetershoulderclinic.co.uk
ment is moulded by its environment. The glenoid,

925
DOI 10.1007/978-3-642-34746-7_81, # EFORT 2014
926
T. Bunker
coracoid and acromion have separate ossification The large coracoid base
secondary centre appears
centres, and it is genetics rather than external at 1 year of age and closes
at 1821 years. There
pressures and forces that determine their eventual are two secondary centres of
ossification for
morphology. the glenoid, the first
appears at the base of the
The scapula differentiates between the 5th and coracoid at the age of 10
and fuses at 18. There is
6th weeks of intra-uterine life as a hyaline a far smaller horseshoe-
shaped inferior centre
cartilage model at the level of the 4th to 6th that appears briefly at age
18 and fuses at 19.
cervical vertebrae. By the 7th week the shoulder The acromial apophysis
appears at age 15 and
is well formed and the scapula moves caudally usually fuses at age 1819.
Failure of fusion
to assume its adult position between the second to leads to the Os Acromiale
that occurs in 4 % of
seventh thoracic ribs. the population and may be
associated with some
In Sprengels shoulder there is failure of rotator cuff tears.
descent. There is also failure of remodelling The scapula can
therefore be looked at as
from the short wide scapula to the adult shape a modular bone. It is like a
Lego model
of the longer, thinner scapula. Since the scapula is compromising the
glenoid/coracoid block,
so high it conforms to the shape of the dome of the spine/acromion block and
the blade. These
the thoracic cavity, and is therefore more concave blocks can be assembled in
different ways so that
on its deep surface than if it had formed in the the glenoid may be
translated forward or back-
adult position of T2 to T7. wards on the blade. It can
be assembled anteverted
The Pax1 gene has been shown to control or retroverted to the blade.
The blade itself can be
development of the acromion and scapular flat or curved. All these
factors combine to create
spine. Knockout mice lacking the Pax1 gene are a bone that can be very
variable in its shape and
found to have the acromion and part of the scap- this can have implications
in terms of pathology,
ular spine missing. stability and degenerative
change.
The Emx2 gene controls development of the
scapular body. Knockout mice lacking the Emx2
gene have absence of the body of the scapula and Primary Glenoid Dysplasia
the majority of the ileum, but have a normal
acromion that articulates with the clavicle, and In 1981 Petterson suggested
that glenoid dyspla-
a normal glenoid that articulates with the sia might be more common
than previously
humerus. Pelviscapular agenesis has been thought. My experience would
support this
recorded in humans. for in 2001 we published 12
cases seen over an
The Hoxc6 gene controls the development of 8-year period. There may be
minimal symptoms
the coracoid and glenoid. Expanding expressions or the condition may be
asymptomatic making
of Hoxc6 genes in chick embryos results in dupli- under-diagnosis inevitable.
cate coracoid and acromion formation in the The term primary glenoid
dysplasia refers to
chick. This has been seen clinically in humans. an uncommon condition
characterised by incom-
The scapular body forms in a different way plete ossification of the
lower two-thirds of the
and is probably not a skeletal element proper, but cartilaginous glenoid and
adjacent neck of the
an ossifying muscle attachment. This might scapula (Fig. 1). The
aetiology and inheritance
account for differences in the shape of the scapula are poorly understood. The
pathogenesis appears
from flat to curved according to the underlying to be a failure of
ossification of the inferior
thoracic shape that provides the environment glenoid pre-cartilage.
Previous theories
around the developing scapula. concerning a failure of
development of the pre-
Its secondary centres of ossification define cartilage of the inferior
apophysis of the glenoid
post-natal development of the scapula. At are not supported by
findings on CT
birth the body and spine of the scapula have arthrography, plain
radiography, and arthros-
already ossified by intramembranous ossification. copy, which show that the
inferior glenoid
Scapular Dysplasia
927
if so how many are

due to errors in the same gene.
However it is likely
that some apparently isolated
cases without a
family history (due to new spon-
taneous mutations)
will also be at risk of having
an affected child.
Definition of the condition at
the molecular genetic
level will help address
these questions in
the future.
The clinical
findings may be very varied.
Most children are
asymptomatic, and relatively
few symptomatic
children have been described.
Children are more
likely to be diagnosed by ser-
endipity. We found a
bi-modal presentation, the
Fig. 1 In primary glenoid dysplasia the glenoid is flat and first peak at age 12
24 with clicking, instability
underdeveloped and the clavicle is bossed or pain, and the
second group presenting with
degenerative changes
aged 4869.
pre-cartilage is present, but unossified. The outline Changes in
morphology are always bilateral.
of the glenohumeral joint lines on radiographs If unilateral then
another cause should be sort for.
demonstrating the vacuum phenomenon also The inferior pole of
the glenoid is elongated,
supports the view that the radiological glenoid flattened and
medialised and often severely
deficiency compromises unossified cartilage. retroverted. There is
also bossing of the lateral
The underlying cause of this failure of ossification third of the clavicle
and an enlarged and inferi-
is not established. orly pointing
acromion.
Primary glenoid dysplasia often occurs spo- Shoulder
replacement is very difficult in
radically but there have been reports of familial primary glenoid
dysplasia as the socket is
occurrence consistent with autosomal dominant extremely retroverted
and access to ream and
inheritance. In one of these families, a young prepare this socket
is difficult. For this reason
woman with normal scapulae had an affected the surgeon might be
tempted to perform
son, daughter and brother. The observation that a hemi-arthroplasty,
but the Mayo Clinic experi-
obligate gene carriers can be clinically unaffected ence shows this is a
disaster for the patients
suggests that this gene may have variable pene- continue to have
disabling pain from the socket
trance within families. In 2009 I described an and most require a
second, and more difficult
affected son and father (and possibly grandfa- revision to
eventually implant a socket. This has
ther), providing further evidence that (at least in also been my
experience.
some cases) this is a single gene disorder with
autosomal dominant inheritance. At present the
gene is unknown and the linkage analysis (to Secondary Glenoid
Dysplasia
locate the gene) has so far been precluded by
the relatively small number of families reported. Obstetric Brachial
Plexus Palsy (OBPP)
It is interesting that this gene seems to have
a localised effect on the development of the scap- The lesson of OBPP is
that changes in glenoid
ula especially the glenoid fossa. morphology can be
aquired, and this may have
These familial cases emphasise the impor- relevance when we
come to discuss instability.
tance of taking a family history in this condition. Pearl and Edgerton
looked at 25 infants with
If there is already an affected parent and child OBPP. Seven had
normal glenoids but 18 had
within a family, the risk of another child (male or abnormal glenoids,
five being flattened, seven
female) inheriting the gene is 50 %. At present it bi-concave and six
dislocated with a pseudo-
is unknown what percentage of cases of primary glenoid formed
posterior to the original glenoid.
glenoid dysplasia are genetically determined and The severity of
glenoid change was proportional
928
T. Bunker
to the degree of internal rotation contracture. and dislocation are usually

silent the posterior
In another study Waters studied 94 children thrust of the humeral head
against the inflamed
with OBPP, 42 with persistent weakness and stretched posterior
capsule will cause pain.
were followed with CT and MRI. The bony anat- In posterior positional
dislocation the humeral
omy of the glenoid was typically normal head slips silently backwards
when the arm is
on the true AP radiographs, but scanning showed elevated in the adducted and
internally rotated
the affected side to be 20# more retroverted position. This is why patients
will present with
than the unaffected side, implying that the pain on swimming or with
overhead sports and
growth disturbance is an impairment of the carti- throwing. The patient can
often demonstrate
laginous development of the posterior glenoid. re-location (note this is re-
location and not
Ten years later Waters looked at the effect on dislocation), and when young
may even have
glenoid development following reconstruction used this as a party trick.
This does NOT mean
with the QUAD procedure. The QUAD proce- that they are insane and is
not, in itself, an
dure is a transfer of latissimus dorsi and Teres argument for a nihilistic
approach to their
major, release of the contracted subscapularis and management. Just because we as
doctors have
pectoralis major plus neurolysis of the axillary not found an effective and
reliable cure for
nerve. They demonstrated that early and effective a condition is no excuse for
labelling the teen-
surgery could remodel mild to moderate second- ager as abnormal. The
condition is entirely
ary dysplasia. This is confirmation that morpho- separate from muscle
patterning where the
logical changes to the socket can be acquired. patient demonstrates
dislocation with the
elbow at the side effected by
active muscle
contraction.
Aperts Syndrome Typically the teenager
will have joint laxity.
This may exhibit as
hyperlaxity (external rotation
This is an unusual condition of acrocephalo- of 85# or more), a positive
sulcus sign, positive
syndactyly. This syndrome is a variant of multi- Gagey sign, and laxity both
forwards and back-
ple epiphyseal dysplasia. The skeletal changes wards on unlocked stoop
testing. In other words
show dysplasia of the glenoid, short humeri, they have a capacious, high
volume loosy
elbow dysplasia, syndactyly, hip dysplasia, genu goosy shoulder. There are two
pathognomonic
valgum with knee dysplasia and changes in the tests of posterior positional
instability.
ribs and spine. These patients may also have The first is the Posterior
Jerk Test (Fig. 2).
subacromial dimples in the skin. Subacromial This is a demonstration of the
clunk of re-location
dimples are also seen in posterior positional from the postero-inferiorly
subluxed or
dislocation. dislocated position. Elevating
the arm in adduc-
tion and internal rotation
silently dislocates the
arm. The humeral head will be
felt to thrust out
Postero-Inferior Glenoid Dysplasia and posteriorly. Now the arm is
brought from the
Instability adducted elevated position out
into an abducted
elevated position and the
humeral head can be felt
Posterior positional instability is being to reduce with a pop, clunk or
snap that is often
recognised as a common cause of disability painful.
in young people. The patient usually presents The second test is the Kim
Test. This is
with a history of shoulder pain. Often there is a provocative test that
thrusts the humeral head
no true history of dislocation, for in these in a postero-inferior
direction against the
patients dislocation is both atraumatic and inflamed and stretched
posterior capsule,
asymptomatic. What the patient may notice is eliciting pain and
apprehension.
the clunk of relocation that may be asymptom- The pathology of posterior
positional disloca-
atic, but is often painful. Although subluxation tion is disputed. Some feel
that this is a condition
Scapular Dysplasia
929
a c
Fig. 2 The posterior jerk test. In posterior positional instability the humerus is
elevated in internal rotation (a) and
thrusts backwards behind the glenoid (c) then as the arm is externally rotated (b)
the head jerks back into joint (d)
brought on by a high volume stretched out capsule,

implying that treatment should be through a shift,
plication or remplissage of the capsule. The other
school of thought, championed by Kim, is that this
is caused by hypoplasia and retroversion of the
postero-inferior bone/cartilage/labrum complex
(Fig. 3), implying that treatment should be by
correcting the retroversion or increasing the con-
cavity compression containment of the head by
moving the labrum so that it acts as a more effec-
tive chock-block.
The idea that retroversion of the glenoid may
play a significant part in posterior positional
instability is not new. Edelson examined 1,150
dried scapulae and found quite a high incidence
of postero-inferior hypoplasia of the bone, vary-
ing from 19 % amongst the Negev desert Bedouin
Fig. 3 A J-shaped
inferior glenoid with postero-inferior
to 35 % amongst Mexican Indians. He then hypoplasia
looked at 300 CT and MRI scans and found that
the postero-inferior glenoid was convex rather of 12 patients with
posterior dislocation
than concave in 18 %. He termed this the lazy and found that 9/12
had such a deficiency.
J appearance. Finally he looked at the scans However the problem
has been that methods of
930
T. Bunker
of course they could

be acquired by recurrent
posterior dislocation,
just as the changes occur
in OBPP.
Chondrolabral
containment has been shown in
laboratory models to
account for 65 % of stabil-
ity, although in
Lazarus and Harrymans
study the containment
effect of the labrum was
more important at the
front of the socket than at
the back. Based on
these findings Kim
Fig. 4 Some patients with posterior positional instability has devised a
procedure of capsulo-labral poste-
have a characteristic dimple on the back of the shoulder rior re-positioning
and repair with a 7.5 % recur-
rence rate.
measuring retroversion from radiographs have Snapping Scapula

been shown to be invalid. Even measurement
from CT and MRI scans can be invalid for the The snapping scapula
is a rare condition that
scapula has great variability in terms of its shape. presents as a
distressing tactile acoustic phe-
Using the medial border can be unreliable as the nomenon consisting of
medial scapular pain
glenoid may be translated on the body rather than and grating on
movement. It was first described
retroverted, and the scapula blade itself varies in 1867 by Boinnet who
described three types of
from flat to curved. noises, fraissement
(gentle friction), frottement
Accepting these reservations in terms of (louder friction) and
craquement (a pathological
measurement Innui et al found that there was snap). In this
condition the superomedial corner
a significant difference in retroversion between of the scapula can be
more curved than the
patients with and without posterior dislocation. adjacent rib cage or
have a bony nodule on the
They also demonstrated differences in surface superomedial corner
that is called Lushkas
shape with some glenoids being concave, some tubercle (Fig. 5).
Edelson has described an
flat and some convex. abnormal protuberance
at the inferomedial cor-
Interestingly we have described the associa- ner of the scapula
that he called the rhino horn.
tion of a subacromial dimple with posterior po- This rhino horn seems
to develop within the
sitional instability (Fig. 4), and dimples have also origin of Teres Major.
Examination of historical
been seen in Aperts syndrome that is known to bone specimens has
shown that the body of the
be associated with glenoid dysplasia. scapula can be flat or
markedly angled and it
Kim examined not only the bone shape, but may be that these
angled scapulae have taken
also the combined shape of the bone, cartilage on the shape of the
more angled dome of the
and labrum on MRI scans. What he found was thorax and fail to
remodel on descent to the adult
that shoulders with posterior positional instability position. However it
is far more difficult to mea-
had greater retroversion of both the bony and sure this curve or
mis-match between the deep
chondrolabral portion of the glenoid in the mid- surface of the scapula
and the thorax in life,
dle and inferior planes. The height of the postero- than it is in death,
and even with 3D CT and
inferior labrum was decreased and the depth of MRI scanning it is
difficult to quantify this
the labral containment was decreased in patients mis-match.
with instability. At arthroscopy he found that Diagnosis is
difficult, and often depends on
although the postero-inferior labrum looked exclusion of other
conditions. Medial scapula
normal, when it was probed it was found to pain is far more
likely to be referred from the
be torn interstitially. These labral changes could cervical or thoracic
spine. Other tactile acoustic
be due to localised chondrolabral hypoplasia, but phenomena can be
caused by osteochondromata
Scapular Dysplasia
931
trapezius. Supraspinatus
is now lifted off the
superomedial border and a
subperiosteal excision
of the superomedial angle
of the scapula is
performed. The periosteal
sleeve remains as an
anchor for levator
scapula.
Arthroscopic bone
resection has been
performed, but is fraught
with difficulty and is
a procedure for
experienced experts only.
The reason for this is
that there are no clear
landmarks for the
arthroscopic surgeon. The sur-
gery is performed in
distended tissue planes
rather than true surgical
spaces and the spinal
accessory nerve, dorsal
scapular nerve,
suprascapular nerve,
brachial plexus and
Fig. 5 This patient with snapping scapula has an abnor- dorsal scapular artery
are all at risk. Bell has
mal shape to the supero-medial angle of the scapula
termed the tubercle of Luschka
described a superior
portal for resection of
the superomedial scapula
that is on average
2 cm from the
suprascapular nerve in one
direction and 3.5 cm from
the dorsal scapula
on the deep surface of the scapula, and even nerve in the opposite
direction. The results
posterior positional dislocation can mimic the are not as good as the
open technique.
clunk of a snapping scapula. One study on six patients
showed that in none
Conservative management is the mainstay of did the pain completely
resolve, surgery was
treatment but effectively this means re-assurance abandoned in one patient
and another developed
and anti-inflammatory analgesia when necessary. a superficial infection.
Physiotherapy is useful if the patients posture is
abnormal, or if they have scapula dyskinesia or
winging that is leading to a secondary snapping Sprengels Deformity
phenomenon. Most patients only present to the
Orthopaedic surgeon after some years of failed Congenital elevation of
the scapula is a rare con-
conservative management. Milch wrote, Even genital anomaly. Sprengel
(1891) recognized that
Thoroughly Competent Orthopaedic Surgeons the deformity was caused
by failure of the scap-
Have Expressed Surprise at the Possibility and ula to descend. In this
condition the scapula lies
Consequences of Surgical Therapy. In 1933 he higher than normal, is
broad in shape and deeply
described six cases of disabling pain caused by dished.
excessive forward curvature of the superior angle The disability is
dependent on the severity of the
of the scapula and stated resection resulted in deformity. In mild cases,
the scapula is only
prompt cure. More recently Richards and slightly elevated and
smaller than normal with
McKee reported on painful scapula thoracic minimal loss of function.
In the severe cases it
crepitus and an asymmetric scapula on CT in creates an ugly deformity
with widening of
three cases that were successfully treated by sur- the base of the neck.
Occasionally the scapula can
gical excision. Open surgery is relatively be so elevated that it
almost touches the
straighforward. A short horizontal incision is skull. Movement is
limited and function poor.
made over the superolateral scapula, splitting Other congenital
anomalies, such as scoliosis,
trapezius making sure that the split does not cervical ribs, and
anomalies of the cervical
extend more than a centimetre medial to vertebrae (KlippelFeil
syndrome), are com-
the medial border of the scapula so as to protect monly present; rarely,
one or more scapular
the spinal accessory nerve supplying the inferior muscles are partly or
completely absent.
932
T. Bunker
Radiographs of the neck should be taken to the aponeuroses of the

trapezius and rhomboids
identify these changes. An omovertebral bone are re-attached to the
spinous processes at a more
together with a very straight clavicle is found in inferior level.
between a third and half of patients. A simpler alternative is
to lower the scapula by
Surgery should only be undertaken at osteotomy. The patient is
placed semi-prone with
a recognised Paediatric Orthopaedic unit, the affected side uppermost.
A vertical incision is
between the ages of 3 and 8 years, and only for made over the medial border
of the scapula. The
severe deformity. The earlier surgery is per- scapula is exposed by
incising the periosteum
formed the better the results. In children older along the medial part of the
origin of
than 8 years surgery may seriously stretch and supraspinatus and
infraspinatus, which can be
damage the brachial plexus. Limited resection of swept laterally. An
osteotomy is made 1 cm
the prominent superomedial angle may be con- from the vertebral border
with an oscillating
sidered after this age. It must be made clear to the saw passing through the base
of the spine. The
parents that the deformity is never simply eleva- superomedial, deformed part
of the scapula is
tion of the scapula alone, but always complicated excised subperiosteally,
allowing removal the
by malformations and contractures of the soft omovertebral bone (if
present) or any fibrous
tissues and that the results of surgery may not bands. When the scapula is
completely mobile,
be all that they were hoping for. the lateral portion is
rotated downwards and
stabilized with sutures
passing through the
Surgical Technique periostium and bone of the
medial fragment.
Woodward described transfer of the origin of the Both these procedures run
the risk of injury to
trapezius muscle to a more inferior position on the brachial plexus, or the
spinal accessory nerve
the spinous processes. This is performed through and this risk is greater in
the more severe
a mid-line approach from the spinous process of deformities.
C5 to the T9 vertebra. The patient lies prone and
is draped so that the shoulder girdle and arm can
be moved freely. The skin and subcutaneous tis- Summary
sues are undermined laterally to the medial bor-
der of the scapula. The lateral border of the The scapula is a complex
bone with a variable
trapezius is identified distally and separated by shape. Understanding the
development of the
blunt dissection from the underlying latissimus glenoid can help in our
understanding of some
dorsi muscle. The origin of the trapezius is cases of instability and
arthritis as well as in the
released from the spinous processes all the way management of those rare
conditions such as
up to C5. The rhomboids are similarly freed and primary glenoid dysplasia,
snapping scapula and
separated from the muscles of the chest wall. Sprengels shoulder.
These muscles can be retracted to expose an
omovertebral bone or fibrous bands attached
to the superior angle of the scapula and these
are freed, avoiding injury to the spinal accessory References
nerve, the nerves to the rhomboids or the
1. Capellini T, Vaccari G,
Feretti E, et al. Scapula devel-
transverse cervical artery. The superomedial opment is governed by
genetic interactions of the Pbx1
scapula is often deformed and is excised gene. Development.
2010;137(15):255969.
subperiosteally thus releasing the levator scapu- 2. Andrews S, Bunker T.
Dominant familial inheritance
lae. The scapula can be displaced inferiorly with in primary glenoid
dysplasia. Should Elbow.
2009;1(2):934.
the attached sheet of muscles until its spine lies 3. Smith S, Bunker T.
Primary glenoid dysplasia;
at the same level as that of the opposite a review of twelve
patients. J Bone Joint Surg.
scapula. With the scapula in this position, 2001;83(B):86872.
Scapular Dysplasia
933
4. Sperling J, Cofield R, Steinman S, et al. Shoulder 10. Van Riebrox A,

Campbell B, Bunker T. The associa-
arthroplsaty for osteoarthritis secondary to glenoid tion of
subacromial dimples with recurrent posterior
dysplasia. J Bone Joint Surg. 2002;84(4):5416. dislocation of
the shoulder. J Shoulder Elbow.
5. Pearl ML, Edgerton BW. Glenoid deformity second- 2006;15(5):591
4.
ary to brachial plexus palsy. J Bone Joint Surg. 11. Lazarus M,
Sidles J, Harryman D. The effect of
1998;80(5):65967. chondrolabral
defects on glenoid concavity and
6. Waters PM. Effect of tendon transfers on obstetric bra- glenohumeral
stability. J Bone Joint Surg
chial plexus palsy. J Bone Joint Surg. 2005;87(2):3205. Am.
1996;78(1):94102.
7. Kim SH, Ha K, Yoo J, Noh K. Kims lesion; an 12. Edelson JG.
Variations in the anatomy of the scapula
incomplete and concealed avulsion of the postero- with reference
to the snapping scapula. Clin Orthop
inferior labrum. Arthroscopy. 2004;20(7):71220. Relat Res.
1996;322:1115.
8. Kim SH, Noh KC, Park JS, et al. Loss of chondro- 13. Milch H. The
snapping scapula. Clin Orthop.
labral containment in atraumatic posteroinferior 1961;20:13950.
multi-directional instability. J Bone Joint Surg. 14. Bell S, Van Riet
PR. The safe zone for arthroscopic
2005;87(1):928. resection of the
scapula. J Shoulder Elbow Surg.
9. Edelson JG. Localized glenoid hypoplasia. Clin 2008;17(4):647
9.
Snapping Scapula
Roger J. H. Emery and Thomas M.

Gregory
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 935
Clinical features # Radiological assessment #
Results # Scapula # Snapping # Treatment-

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 936
non-operative, open operative, endoscopic

. . 936
Anomalies and Radiological Presentation . . . . . . . 937
Introduction
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 938
Non-Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 938
Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 939 Snapping scapula is an uncommon and largely
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 941
under-recognised phenomenon that combines
a tactile and acoustic clunk localised at the

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 941
superomedial corner of the scapula. It usually
occurs in the third decade and normally only
requires treatment if painful. The differential
diagnosis is extensive [13]. The first description
was published in French by Boinet in 1867 [4]
and a more comprehensive review was published
by Milch and Burman in 1933 [5]. Mauclaire [6]
first described surgical treatment of snapping
scapula using a muscle transfer technique in
1904. In 1950 Milch et al. [7] reported partial

scapulectomy which although modified from
its original description is still in current practice.
More recently with the development of
endoscopy, Ciullo [8] published a series of nine
endoscopic resections of the scapulo-thoracic
bursa. Although most patients require non-

R.J.H. Emery (*) # T.M. Gregory
operative treatment, surgical intervention is
St. Marys Hospital, Imperial College NHS Trust,
London, UK
a proven modality. The most common procedure
is resection of the superomedial angle of the

Department of Mechanical Engineering, Imperial
College, London, UK
scapula. However, painful snapping scapulae
are not always associated with scapula supero-

European Hospital Georges Pompidou, APHP, University
Paris Descartes, Paris, France
medial angle anomalies. Therefore along with
e-mail: roger.emery@o2.co.uk
a comprehensive knowledge of the anatomy,

935
DOI 10.1007/978-3-642-34746-7_43, # EFORT 2014
936
R.J.H. Emery and T.M. Gregory
accurate clinical and radiological assessment

is essential for choosing the most appropriate
procedure among the many described.
This chapter will give insight into the anat-
omy, the clinical features, the various associated
anomalies and radiological presentation of snap-
ping scapula followed by a review of surgical
procedures and specific indications.
Anatomy
The superficial muscle layer includes trapezius

and latissimus dorsi. Levator scapulae, and
major and minor rhomboids that are attached to
the supero-medial angle form the middle layer, Fig. 1 Axial view of a left
shoulder. RC, Rib cage; SA,
Serratus anterior; Sca,
Subscapularis; S-S, Supraspinatus;
and the deepest layer includes subscapularis and
T, Trapezius; D, deltoid; Sb,
Scapula blade; S, Spine of the
serratus anterior. There is one constant bursa, scapula; 1, Scapulo-thoracic
bursa; 2, Subscapularis
the scapulo-thoracic bursa, located between bursa; 3, Scapulo-trapezial
bursa
the rib cage and the serratus anterior (Fig. 1,
number 2; Fig. 2, number 1). Wallach et al.
[9, 10] also identified three inconsistent bursae: reproduced. A wide range of
terms is used to
the subscapularis bursa, located between the describe it: Single snap,
intermittent clunks, con-
serratus anterior and the subscapularis (Fig. 1, tinuous grating of muscles,
clicking, crunching,
number 1), existing in only 40 % of cases; the and snapping sensations [3, 7,
1113]. Pain is
scapulo-trapezial bursa, located between trape- often difficult to localize
but is mostly at the
zius and the scapula blade (Fig. 1, number 3; superomedial corner or
inferior pole of the scap-
Fig. 2, number 2); and the third bursa is located ula [1416] and is triggered
by shoulder motion
between latissimus dorsi and the inferior tip of or shrugging of the shoulders
[17, 18]. It can
the scapula (Fig. 2, number 3). interfere with sports
activities, particularly rapid
The spinal accessory nerve runs at the deepest overhead movement (swimming or
throwing for
aspect of the trapezius, bends over to follow the example). A history of trauma
or less commonly
medial edge of the scapula and along the inferior fractures of the scapula and
ribs are noted [2, 11,
edge of the trapezius. 14, 16, 1921], although the
onset of symptoms is
The dorsal nerve of the scapula, which has one usually gradual. Examination
may demonstrate
or two divisions, runs under the levator scapulae winging of the scapula, an
asymmetry of the
and the rhomboids. It is located medially and static position of both
shoulders, a spine or rib
deep to the spinal accessory nerve. The cage deformity, and sometimes
visualisation of
suprascapular nerve is located in a more lateral the snap is possible. Crepitus
at the superomedial
position, crossing the supra-clavicular fossa to angle, the inferior pole of
the scapula or along the
the spino-glenoid notch. medial border [3, 16] is
palpated in the lateral
decubitus position, with the
upper limb in neutral
whilst pushing the
superomedial angle in
Clinical Features a cranio-caudal direction
[10]. Crepitus is also
easily reproduced during
abduction, accentuated
Presentation of symptoms ranges from annoying when the superior angle of the
scapula is being
to disabling [2]. Patients describe a tactile and pressed against the chest wall
[1, 22]. Con-
acoustic clunk that can often be voluntarily versely, lifting the scapula
from the rib cage by
Snapping Scapula
937
Fig. 2 Posterior view of

the shoulder: Superficial
plane (D deltoid, T
trapezius); deep plane
(LS levator of the scapulae,
Rm rhomboid minor, RM
rhomboid major, LD
Latissimus dorsi, S-S
spraspinatus, I-S
infraspinatus, TM terres
minor); nerve course
(a accessory spinal nerve,
b dorsal scapular nerve,
c suprascapular nerve);
artery course (d dorsal
scapular artery); Bursae
(1 Scapulo-thoracic,
2 Scapulo-trapezial, 3 bursa
between latissimus dorsi
and inferior extremity of
scapula)
positioning the hand of the affected upper limb on bony excresences; prominent
supero-medial
the opposite shoulder decreases pain and snap- tubercle (Luschkas tubercle)
or inferior tubercle
ping [23]. Muscular assessment is essential as (Fig. 3). In these patients,
the condition is most
well as an examination of the gleno-humeral often located at the infero-
medial angle of the
joint and subacromial space. Bursitis presents scapula. Functional causes are
associated with
with fullness over the bursa and palpation of the anatomic anomalies: rib or
scapula fracture mal-
bursa elicits pain [2]. Pain can limit shoulder union, dorsal spine deformity
(scoliosis and
motion or lead to a compensating pseudo- kyphosis), and excessive
forward curvature of
winging of the scapula [1]. the superomedial border. Other
known causes
are muscle detachment,
serratus calcific tendon-
itis, malignant or benign
(elastofibroma) tumours
Anomalies and Radiological of the scapulo-thoracic space,
and muscle atro-
Presentation phy narrowing the scapula-to-
rib cage distance.
Extrinsic aetiologies include
overuse of the
Snapping scapulae are due to a disrupted gliding scapulo-thoracic gliding space
due to pathology
of the concave anterior aspect of the scapula over in another joint of the
shoulder girdle: acromio-
the convex thorax. A variety of causes have been clavicular arthritis, gleno-
humeral arthritis or
reported but the condition remains poorly stiffness, or rotator cuff
tendinopathy.
understood. Definitive causes are
comparatively rare and
The causes can be classified as follows [10]: the majority of patients
present with poor posture
Local due to bursitis, which may be structural or and sagging of the shoulder
girdle such that the
functional. Structural causes include bone anom- superomedial corner descends
and impinges on
alies, such as scapular osteochondromata [15, 24] the chest wall. The pain is
probably mediated by
or as bony deformity following either/or scapula localized inflammation in the
scapulo-thoracic
and rib fractures. Repetitive micro-trauma mostly bursa and leads to chronic
thickening of the
described in throwing sports activities can create subscapular tissues [25].
938
Fig. 3 Anterior view and inferior view of a left scapula responsible for snapping
scapula, due to two tubercules, one
superior, and the other inferior (Thin arrow: superior tubercule, wide arrow:
inferior tubercule)
Radiological assessment should include plain CT-scan [28, 29]. MRI

is not recommended,
radiographs of the scapula, especially a care- with the exception of
defining bursitis or the
fully positioned lateral view, which will assess rare case of tumour.
Injection of local anaes-
the shape of the scapula and exclude an exosto- thetic is sometimes
valuable to confirm clinical
sis or obvious bony cause. Plain gleno-humeral interpretation [1, 10].
Differential diagnosis
or chest radiographs should be included if should also consider
cardiothoracic diseases,
clinically indicated. Routine CT is of limited disc protrusion and
lung neoplasia.
value and is difficult to interpret [26]. The radi-
ation exposure of CT must also be considered
and is therefore limited to patients with normal Treatment
radiographs but suspicion of osseous lesions or
fractures. Occasionally narrowing between the Non-Operative Treatment
superomedial corner and the chest wall can be
demonstrated when compared to the contralat- Treatment of snapping
scapula is usually non-
eral side [26, 27]. Modern CT-scan that provides operative, based on
careful assessment and cor-
high quality CT 3D reconstruction (Fig. 3) of the rection of abnormal
posture plus training of the
scapula and chest is indicated as it shows the scapular muscles [16,
30]. The snapping or grat-
accurate location of the snapping site, and ing often disappears
when the scapula is pas-
superomedial scapula angulation. It is more sen- sively elevated and
retracted. This can be
sitive than plain radiographs and regular demonstrated to the
patient and is helpful in
Snapping Scapula
939
Fig. 4 Chicken-wing
position that places the
shoulder in a position of
extension, external rotation
and adduction
increasing the patients understanding of the reha- Operative Treatment

bilitation program. Scapula position is responsible
for the static positioning of the shoulder girdle. Open Surgical Technique
Therefore, endurance training of the scapula An open surgical procedure
is a valid option for
musculature is crucial, particularly of the serratus treating painful, audible
and palpable crepitus
anterior and subscapularis [31]. Postural training is resistant to non-operative
treatment [2]. Neuro-
required in the presence of Kyphosis and is logic deficit in the limb
or wasting of periscapular
based on promoting upright posture and strength- musculature are contra-
indications to surgery
ening upper thoracic musculature. To reduce the [1, 27]. The goal of
surgical treatment is to
bursitis, non-operative treatment is often initiated remove the anatomical cause
of the clunk, the
by rest or modification of activities. A course location of which must be
accurately determined
of non-steroidal anti-inflammatory medications pre-operatively [7].
can help decrease inflammation [2]. In the The surgical options
vary from open
presence of uncontrolled pain, corticosteroid bursectomy (at the
superomedial angle and or
injection is warranted [2, 13, 21]. The injection the inferomedial angle,
which are the two most
is given with the patient lying prone with the common locations for
scapulo-thoracic bursitis)
arm in the chicken-wing position (Fig. 4), and to partial scapulectomy.
the hand behind the back. Before abandoning Surgery at the inferior
bursa is approached
these measures in favour of surgery it is impor- through an oblique incision
distal to the inferior
tant to consider the natural history and the angle of the scapula. The
trapezius and latissimus
not infrequent association with psychological dorsi are split in line
with the muscle fibres to
disorder. It is interesting to note that very expose the bursa. The
bursitis must be thoroughly
few cases fail to resolve with time, and therefore debrided and ensure all
osteophytes on the scap-
non-operative treatment must be pursued for ula are removed. For
superomedial bursitis, the
at least 6 months to 1 year. Beyond this skin is incised medially to
the medial border of
if symptoms continue to be disabling the scapula. The trapezius
is dissected free and
surgical resection of the scapula may be indicated retracted superiorly from
the scapular spine. The
[3, 19, 22]. levator scapulae,
subscapularis and suprapinatus
940 R.J.H.
Emery and T.M. Gregory
are subsequently dissected and retracted proxi- earlier rehabilitation and

cosmetic advantages
mally through sub-periosteal dissection. The [27, 3436].
bursa can then be resected and any osteophytes Under general
anaesthesia, the patient is
removed. The muscles are re-attached anatomi- positioned in the lateral
decubitus position or
cally at the end of the procedure. Bony resection prone position, with upper
limbs free to move.
is performed if necessary as determined pre- First, the scapulo-thoracic
tactile and acoustic
operatively. clunk is reproduced by
positioning the upper
Some authors have suggested [1, 32] when no limb in maximal internal
rotation, with the
obvious bony lesion is noted, removal of the hand on the back (Fig. 4).
The surgeon draws
medial 2 cm of the scapula allows a more natural landmarks on the patients
skin: posterior pro-
articulation of the scapulo-thoracic joint when cesses of spine, scapular
spine, lateral border of
the muscles are re-attached. However, care must acromion, and inferior
border of the trapezius.
be taken not to disrupt the muscles inserting on Three arthroscopic portal
sites are also drawn.
the medial border of the scapula. The medial The entire upper limb is
draped. Two portals are
border of the scapula contains the origin of placed on the medial border
of the scapula
subscapularis, suprapinatus, infraspinatus, approximately 3 cm medial to
the border and
serratus anterior, rhomboid and levator scapulae below the level of the
scapular spine [11, 13,
muscles. Significant post-operative disability can 27, 31] to avoid injury to
the dorsal scapular
be caused by disruption of these muscles through nerve and artery, and the
accessory nerve
resection of the entire medial border [28, 33]. (Fig. 5). The superior
portal [31] is located one
More recently, authors have published successful third of the distance from
the medial scapular
treatment of snapping scapula with excision of border, between the superior
medial angle of the
only the superomedial border, thus avoiding scapula and the lateral
border of the acromion, to
these negative outcomes [1, 2]. avoid the neurovascular
structures (namely,
To perform the superomedial scapular resec- accessory nerve,
suprascapular nerve, dorsal
tion, the patient is placed in the prone position, scapular nerve and artery,
coursing nearby).
and an incision over the medial scapular One of the medial portals is
made first, without
spine is made with dissection through the soft prior inflation of the
bursa. The scope is pushed
tissue to expose the scapular spine. The perios- forward to the deepest and
most anterior aspect
teum is incised with subperiosteal elevation of the scapula. Then a
second medial portal is
of the medial periscapular muscles, including made (first instrument
portal). The superior por-
the supraspinatus, subscapularis, rhomboid, and tal (second instrument
portal) is created from
levator scapulae, which are retracted proximally. inside to out.
The trapezius is retracted superiorly. The The potential
complications include penetra-
superomedial angle of the scapula is resected tion of the thoracic cavity,
penetration through
with an oscillating saw in the shape of an equi- the serratus anterior muscle
into the axillary
lateral triangle extending to the medial base of the space or penetration through
the scapular blade
scapular spine. Elevated muscles are sutured to into the supraspinatus fossa
[27, 34, 37]. Cannu-
the spine of the scapula by drill holes. The lae are not usually required
and a 4.5 mm 30#
affected arm is mobilized during surgery to con- scope is preferred. Exposure
is initially gained
firm relief of the snapping. by gradual debridement of
the bursitis with
a shaver or radio-frequency
probe. The inflow
Endoscopic Procedure pressure is set at 50 mm of
Hg. Needling is
An endoscopic technique for snapping scapula is useful to check the position
of the scope and
an alternative to an open approach for instruments [21]. There is
no established crite-
bursectomy and resection of the superomedial rion for ensuring a thorough
bony resection
corner of scapula, with the same indications and (Fig. 6). However peri-
operative examination
limitations. The morbidity is decreased with combined with arthroscopic
visualisation can
Snapping Scapula
941
Fig. 5 Endoscopic portals, patient in prone position (Ref- medial border of the
scapula, SpS spine of the scapula);
erence plane. I inferior, S superior, M medial, L lateral); Right figure:
Instrumental portals (1 and 3) and scope
Left figure: Portal skin drawings related to scapula and portal (2)
spine landmarks (Sp posterior processes of the spine, MB
series and the wide

range of causes associated
with snapping
scapulae. However, the literature
suggests successful
non-operative treatment is as
high as 80 % [8, 23].
Operative treatment, either
arthroscopic or open,
is also successful with
appropriate pre-
operative planning as the
aetiology of the
clunk is identified and then sur-
gically removed.
Acknowledgments This
review article was inspired by
the work of
Demoisnault et al. and Kuhne et and therefore
we would like to give
special acknowledgment to these
authors.
Fig. 6 Endoscopic view of scapulothoracic bursitis References

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Fractures of the Scapula
Norbert Suedkamp and Kaywan

Izadpanah
Contents
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 958
944
960
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . .
944 Scapular Body Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 960
Scapula
Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 944 Glenoid Neck Fractures (incl. Floating
Glenoid Neck Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
945 Shoulder) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 960
Glenoid Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 948 Glenoid Cavity
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
961
Coracoid
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
948 Acromion
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
962
Fractures of the Acromion . . . . . . . . . . . . . . . . . . . . . . . . . . .
949 Coracoid
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
963
Scapulo-Thoracic Dissociation . . . . . . . . . . . . . . . . . . . . . .
949 Principles of Post-Operative
Relevant Applied Anatomy . . . . . . . . . . . . . . . . . . . . . . . . 949
Treatment/Conservative Treatment . . . . . . . . . . . . .
963
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 949 Complications . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 965
Superior Suspensory Complex . . . . . . . . . . . . . . . . . . . . . . 952
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 966
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 952
. . . . 952
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 966
Radiographic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . .
952
Frequently-Associated Injuries . . . . . . . . . . . . . . . . . . . . . .
953
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .
953
Scapular Body Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
953
Glenoid Neck Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
954
Glenoid Cavity Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
955
Acromion
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
956
Coracoid
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
956
Combined Fractures (Some Frequent
Combinations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
956
N. Suedkamp (*) # K. Izadpanah

Department for Orthopedic Surgery and Traumatology,
Freiburg University Hospital, Freiburg, Germany
e-mail: norbert.suedkamp@uniklinik-freiburg.de;
kaywan.izadpanah@uniklinik-freiburg.de

943
DOI 10.1007/978-3-642-34746-7_242, # EFORT 2014
944 N.
Suedkamp and K. Izadpanah
decision-making and planning

of operative treat-
Keywords ment are proposed.
Aetiology # Anatomy # Classification #
Clinical features # Complications # Imaging #
Results # Scapular fractures # Surgical indica- Aetiology and Classification
tions # Techniques # Treatment-conservative,
Surgical Eighty to Ninety percent of
all scapular fractures
occur during high-energy
trauma such as motor
General Introduction vehicle collisions or falls
from great height [30, 40].
Scapular fractures are uncommon injuries and

account for only 1 % of all fractures [5], approx- Scapula Body
imately 5 % of all fractures of the shoulder girdle
and 3 % of all injuries to the shoulder [41]. The majority of scapular
body fractures result
Scapular fractures occur preferentially in young from direct, blunt trauma.
Forces have to be
males (m/f 6/49) between 25 and 50 years great to cause a fracture of
the scapula body due
[3, 40, 60, 66]. 45 % of all scapula fractures to its great mobility, the
thick surrounding deep
occur in the body, 35 % involve the glenoid pro- and superficial muscles
layers and the flexibility
cess (25 % Glenoid neck, 10 % Glenoid cavity), of the chest wall (recoil
mechanism of the chest
8 % the acromion and 7 % the coracoid process. wall) [53].
Only 10 % of the fractures to the scapular Some cases report
scapular body fractures
body and the glenoid neck show significant after electric shock [8, 58]
or after seizures with
displacement [52]. osteodystrophy [38].
Scapula fractures are frequently acquired dur- Nevertheless, there is a
huge variety of
ing high-energy trauma and therefore patients fracture patterns existing.
The OTA proposed
suffer a mean of 3.9 associated injuries, predom- a classification system in
two levels. Level 1
inantly of the chest, the ipsilateral upper extrem- as a basic system for all
trauma surgeons and
ity and to the skull or brain. All of them are Level 2 for specialized
Shoulder Surgeons.
potentially life-threatening. Therefore, patients In Level 1 the scapula
is divided into three
with scapular fractures should, where possible, regions:
be managed in trauma centres. 1. The articular segment
(Coded F) which is the
For a long-time scapular fractures have been area involving the
glenoid fossa and the artic-
treated nearly always conservatively. However, ular rim, limited
dorsally by a line joining the
fractures of the scapula have received more consid- dorsal articular rim to
the suprascapular notch,
eration in the recent literature and many papers are distally by the
articular rim and medially by
dealing with specific issues. With increasing knowl- a line joining the
suprascapular notch to the
edge about biomechanics of the upper extremity distal articular rim.
and invention of modern implants there is evidence 2. The Processes (Coded P)
the coracoid is
that some injuries deserve operative treatment to defined by the dorsal
limit of the articular
assure good functional outcome. Therefore, Treat- segment, the acromion is
lateral to the plane
ment of scapular fractures belongs in the hands of of the glenoid fossa and
an experienced Orthopaedic or Trauma surgeon. 3. The Body (Coded B) the
rest of the scapula
This chapter gives a comprehensive overview bone
of current classification systems, standards of Articular fractures are
subdivided into three
treatment and the latest operative techniques for groups:
treatment of scapular fractures. F0 are Fracture of the
articular segment, that do
Important biomechanical theories of the scap- not pass through the
fossa glenoidalis/glenoid
ular suspensory system and simple strategies for rim at all.
945
Processes Processes
Articular
segment
Body
Body
Fig. 1 Classification scheme of the OTA-classification system of the AO/OTA
F1 fractures have a simple articular fragment pat- B Fx

located within the Body
tern. They are rim or split fractures that involve B1 Simple
(Two or less body fracture
the glenoid fossa. Very small fragments less than exits)
2 mm should not be considered for classification. B2 Complex
body involvement (Three or
more
body fracture exits)
F2 fractures are real multi-fragmentary joint
P Process
fracture
fractures.
P1 Coracoid
fracture (Separate
Body fractures can be divided into simple fracture
line not affecting the
indention fractures (B1) with two or less main glenoid
fossa nor any part of the
fragments and complex body fractures (B2) with body)
3 or more fragments. Fractures of the coracoid P2 Acromion
fracture (Fracture line
process (P1) do not affect the glenoid, as they are lateral
to the plane of the glenoid
fossa)
articular fractures. Fractures of the acromion are
P3 Fracture
of both coracoid and
Type A2 fractures and fractures of both processes acromion
are A3 fractures. For further details of the level two
classification system please see the AO webpage
(Figs. 1 and 2).
F Fx of articular segment Glenoid Neck Fractures

F0 Fracture of the articular segment, not
through the fossa glenoidalis/glenoid Fractures of the
Glenoid neck may be caused
rim by
F1 Simple pattern with two articular impactation of the
humeral head against the
fragments: rim or split fracture
(Fracture involves the Glenoid Fossa) Glenoid process or
(Ignore small fragments up to about a blow over the
anterior or posterior aspect of
2 mm) the shoulder,
F2 Multi-fragmentary joint fracture fall on the
outstretched arm, when the humeral
(Fracture involves the Glenoid Fossa) had is impacted
against the glenoid process or
(Three or more articular fragments)
in rare cases by
fall on the superior aspect of
Fx .1 without body involvement
.2 with simple body involvement
the shoulder complex
[52].
.3 with complex body involvement There are three
types of glenoid neck
(continued) fractures [20].
946
N. Suedkamp and K. Izadpanah
F0
F1
Rule = The presence of only a small

(up to 2mm) fracture fragment in the
F2 glenoid fossa does not make a
fracture as multifragmentary
F = fx of articular segment
1 = without body involvement

(Body involvement = fracture line
located outside the articular segment)
2 = with simple body involvement

(none or one body fracture exit)
3 = with complex body involvement

(two or more body fracture exits)
Fig. 2 (continued)
947
B = Fx located within the Body

(extra-articular fracture with no Glenoid Fossa involvement)
B1 = Simple
(two or less body fracture exits)
B2 = Complex body involvement

(Three or more body fracture exits)
Note this fracture is NOT
a coracoid fracture as it enters
the glenoid fossa

P = Process fracture
(seperate coding)
P1 = Corecoid fracture
(Seperate fracture line not affecting the glenoid fossa not
any part of the body)
P2 = Acromion fracture
(Fracture line lateral to the plane of the glenoid fossa)
P3 = Fracture of the both coracoid and acromion
Fig. 2 Classification system of scapular fractures according to OTA/AO
One incomplete neck fracture, with the fracture One fracture along
the surgical neck and the
line entering at the inferior border of the glenoid other along the
glenoid neck fractures, anatomic
neck, running along the scapular spine and exiting neck.
at the medial border. Furthermore there exist two To be complete the
fracture lines have to exit
types of complete glenoid neck fractures: the lateral and the
superior border of the scapula.
948 N.
Fractures of the surgical neck extend medial to glenoid rim occurring

during dislocation of the
the coracoid process and those of the anatomic humeral head [65]. In the
latter, forces meet the
neck lateral to the coracoid process. A clinical peri-articular soft tissue
[11]. An avulsion frac-
treatment-based classification of glenoid neck ture of the glenoid rim
results from traction-
fractures is based on the extent of the glenoid forces of the surrounding
soft tissue. Fractures
fragment dislocation: of the Glenoid fossa
result from a lateral impact
Type I Fractures are insignificantly or undisplaced. to the humeral head [18],
which is then driven
Type II fractures are significantly displaced [20]. into the centre of the
glenoid cavity.
Zdravkovic and Damholt [69], Nordqvist and A transverse fracture
line develops. This
Petersson [45] and Ada and Miller [44] mechanism is supported,
according to the litera-
defined a major displacement of the glenoid ture [18, 21] as follows:
fragment as more than 1 cm or greater than 40# 1. The concave shape of
the glenoid fossa.
of angulation. Therefore, forces
concentrate in the centre of
Blauth, Suedkamp and Haas [9] provided the glenoid.
a more detailed classification, including the frac- 2. The transverse
orientation of the subchondral
ture pattern and criteria of stability (Figs. 3 and 4, trabeculae. Therefore,
forces can spread easily
Table 1). along this orientation.
3. A Crook along the
anterior rim, which is
Combined Glenoid Neck and Clavicle a stress-riser.
Fractures tend to originate there.
Fractures (Including Floating Shoulder) 4. The fact that two
ossification centres form the
Fractures of the clavicle are accompanied with glenoid cavity.
Therefore, the centre region
glenoid neck fractures in about 2050 % [1, 3]. might remain as a
relative soft spot.
Mechanisms of injury are a fall onto the Depending on the sub-
direction of the applied
outstretched arm, a fall onto the shoulder tip or force to the humeral head
a developing fracture
a direct blow [52]. Ganz and Noesberger [15] line will propagate.
Violent forces can lead to
were the first to describe an altered stability of a comminute fracture of
the glenoid fossa [18]
the glenoid fracture component in cases of addi- (Table 2).
tional ipsilateral clavicle fracture. Hersovici and
co-workers [28] introduced the term floating
shoulder for the combination of these fractures. Coracoid Process
However, biomechanical testing revealed that
only an additional disruption of the coraco- Ogawa et al. [49] proposed
a classification for
acromial or acromio-clavicular ligaments alter fractures of the Coracoid
process that divides
the stability of the glenoid. Goss [19] and them in two Groups:
co-workers therefore introduced the concept of Type 1 with the fracture
line proximal to the
a double disruption of the superior suspensory coraco-clavicular
ligaments and
complex (SSSC) for the definition of a floating Type 2 with the fracture
line distal to the
shoulder injury. coraco-clavicular
ligaments.
Type 1 fractures are
avulsion fractures that are
acquired during
indirect trauma. Type 2 frac-
Glenoid Fossa tures can be treated
conservatively when not
significantly
displaced. They are caused
Fractures of the Glenoid rim are caused by an either by direct blow
or indirectly by
impact of the humeral head against the periphery a dislocating humeral
head. Treatment of
of the glenoid cavity [27]. These fractures have to Type 1 fractures
depends on the concomitant
be distinguished from avulsion fractures of the injuries. In cases of
an additional alteration
949
Fig. 3 Illustration
depicting three basic
fracture patterns involving
the glenoid neck: A fracture
through the anatomical
neck, B fracture through the
surgical neck, and C
fracture involving the
inferior glenoid neck,
which then courses
medially to exit through the
scapular body (this type is
managed as a scapular body
fracture) (From [20])
of the scapular connection, i.e. the acromio- operatively. However there was
a certain criticism
clavicular joint, an operative refixation is to this classification scheme
[43, 59] (Table 4).
recommended. Isolated injuries can be
treated conservatively (see Table 3). Scapulo-Thoracic Dissociation
Only exceptional forces can

lead to a scapulo-
thoracic dissociation (a closed
avulsion of the
Fractures of the Acromion scapula) [13, 50, 70]. This
injury is associated
with a large spectrum of
concomitant osseous,
Acromial fractures are caused by direct trauma to vascular and neurological
injuries.
the acromion or the humeral head directed The scapula is dislocated
posteriorly from the
towards the acromion. Avulsion fractures chest-wall. This can best be
diagnosed in coronal
arise from indirect trauma while tensioning of CT-Scans of the chest, by
determining the dis-
the coraco-acromial and acromio-clavicular tance between the medial border
of the scapula
ligaments or the deltoid and trapezeus muscle. and the spinosus process on the
healthy and
Some cases of stress or fatigue fractures have injured side. These patients
are always multiple
been reported [22]. Kuhn et al. [36] proposed a and severely injured. This
injury is also called an
classification of the Acromion in 1994. Non- internal forequarter
amputation.
displaced Fractures (Type 1) were divided
into Avulsion (Type 1a) or Complete (Type 1b)
fractures. They can be treated conservatively as Relevant Applied Anatomy
no alteration to subacromial space develops.
Type 2 fractures of the acromion are displaced Anatomy
but do not reduce the subacromial space. They
can predominantly be treated conservatively The scapula is a large flat
bone. It has a triangular
as well. shape and four major processes:
the spine, the
If an inferior displacement of the acromion acromion, the glenoid process
and the coracoid
appears (Type 3a) or a combined fracture of the process. The scapular body
thickness can become
Acromion with a fracture of the glenoid neck less than 2 mm in its central
part. The superior,
(Type 3 b) a narrowing of the subacromial lateral and medial border is
thickened as greater
space develops. These fractures should be treated muscles insert here. At the
base of the coracoid
950
lies the suprascapular

notch. The greater scapular
notch or
spinogelnoidal notch is at the base of the
Bony Ring spine. Fractures of
the glenoid neck that occur in
this notch can be
associated with suprascapular
nerve palsy. From the
anterior fasciae of the scap-
Intact Double break
ula the subscapularis
muscle, the omohyoid and
the serratus anterior
muscle originate. From the
posterior fascia the
levator scapulae, the major
and minor rhomboid,
the supraspinatus and the
infraspinatus the
latissimus dorsi and the teres
major and minor
muscles originate (Fig. 11). The
coraco-acromial and
the transverse scapular
Soft tissue-bony ligaments are two
ligaments that insert and
originate at the same
bone, the scapula. The
Intact Single disruption coraco-clavicular the
acromio-clavicular, the
Break Torn glenohumeral and the
coracohumeral ligaments
are the major
ligaments of the scapula. The
coraco-clavicular
ligament is divided into the
conoid and trapezoid
ligament which form
the suspension of the
scapula. The surrounding
soft tissue offers
strong protection and therefore
fractures of the
scapula body only occur during
high-energy traumas.
Double disruptions
The coracoid
process is a hook-like structure,
Double Torn Double Break Torn/Break pointing laterally
forward. Its base begins between
the glenoid process
and the anterior margin. It has
great clinical
relevance as Surgeons Lighthouse
during operative
procedures. All major
neurovascular
structures of the upper limb lie
medial to this easy-
to-identify landmark. Staying
lateral to the
coracoid process during surgical pro-
cedures avoids
neurovascular damage.
The pectoralis
minor muscle, the biceps
Soft tissue/ bony ring/struts brachii and the
coracobrachialis muscle originate
from the coracoid
process. The latter two form
Double Break Torn/Break
the so-called
conjoined tendon.
The coraco-
acromial and coraco-clavicular
ligaments (formed by
the conoid ligament and
trapezoid ligament.)
insert at the coracoid pro-
cess. The latter
participate in the ClavicularCC-
ligamentous-coracoid
(C4)-linkage, the major
suspension system of
the scapula (see below).
Anatomic abnormalities
of the coraco-clavicular
connection have been
described in 1 % of all
Fig. 4 Illustrations depicting the many possible traumatic humans, such as a
joint or bony connection.
ring strut disruptions (From [19]. e Raven Press, Ltd.,
There are some cases
of coracoid impingement
New York)
syndrome reported [12,
17, 51].
951
Table 1 Classification of glenoid neck fractures according to Blauth, Suedkamp and

Haas [9]
Classification of scapular neck fractures
I Fractures of the anatomic neck
IA Non-displaced fractures Medial compression
Stable Conservative treatment
IB Displaced fractures Dist. and lat. glenoidal dislocation
Unstable ORIF
II Fractures of the surgical neck
II A Non-displaced fractures Clavicle and cor-cor.-lig. not injured
Stable Conservative treatment
II B Displaced fractures Clavicular fracture
Unstable ORIF of the clavicle
Ruptured cc-lig. (Floating shoulder)
Unstable ORIF of glenoid neck
Table 2 Ideberg classification scheme Table 4 Classification

system of acromion fractures
Classification of glenoid fractures according to Ideberg/ Classification
according to Kuhn [36]
Goss TP I Non-displaced
fractures of the acromion
I Fractures of the glenoid rim Ia Avulsion
fracture
IA Anterior Ib Complete
fracture
IB Posterior II Displaced
fractures of the acromion, but not
II Transverse or oblique fracture through the reducing the
subacromial space
glenoid fossa III Displaced
fractures of the acromion with
II A Transverse fracture through the glenoid fossa, reduction of
the subacromial space
with an inferior triangular fragment displaced III a Inferior
displacement of the acromion
with the subluxated humeral head III b Superiorly-
displaced glenoid neck fracture
II B Oblique fracture through the glenoid fossa, with
an inferior triangular fragment displaced with
the subluxated humeral head
III Oblique fracture through the glenoid exiting at it bends over
anteriorly, forming the summit of
the mid-superior border of the scapula the shoulder and
overhanging the glenoid cavity.
IV Horizontal fracture, exciting through the medial Moreover the
acromion contributes to the
border of the blade acromio-clavicular
joint. It is an important
V Combination of type IV with a fracture component of the
superior suspensory complex-
separating the inferior half of the glenoid
forming the acromial
strut (see below). An unfused
VI Severe comminution of the glenoid surface
acromion (os acromiale)
has to be distinguished
from a true acromial
fracture. The acromion gives
posterosuperior
stability to the glenohumeral joint.
The glenoid neck is
the portion between the
Table 3 Classification system of coracoid fractures
according to Ogawa et al. scapular body and the
glenoid cavity. From its
superior aspect the
coracoid process arises. Its
Classification according to Ogawa [49]
stability depends on
the osseous connection
Type I Proximal to the coraco-clavicular ligaments
Type II Distal to the coraco-clavicular ligaments
with the scapular body
(1) and its superior
suspension through the
coracoid process and
the coraco-clavicular
ligaments (2) to the
clavicle
acromioclavicular jointacromial strut.
The scapular spine is a bony prominence that If, in addition to the
scapular body junction, the
starts at the medial margin and ends in the superior suspension is
altered, fractures are
acromion. It gives insertion to the trapezeus mus- defined as unstable or
have a high likelihood to
cle and the posterior deltoid muscle originates dislocate. From the
supra-genoidal tubercle the
here. Because of its prominence it gives relevant long head of the biceps
brachii muscle originates
contribution to the lever arm of these muscles. and from the infra-
glenoidal tubercle the
The acromion is the continuation of the spine and coracobrachial muscle.
952 N.
Superior Suspensory Complex Table 5 Radiographic

evaluation of the scapula Trauma
series
The glenoid process, the coracoid process, the Radiological view
Check for
acromion, the acromio-clavicular joint, the lateral True anteroposterior
Glenoid
(AP)
Scapula neck
clavicle and the coraco-clavicular ligaments
together form the superior suspensory complex.
Scapula body, medial part
It consists of two bony struts and a bone-soft-
Medial margin
Scapular spine
tissue ring. The superior strut is the lateral clavicle
Lateral view
Scapular body
and the inferior strut is the changeover from the
True axillary
Acromion,
glenoid process to the scapular body. The complex
AC-joint
can be sudivided into three further partitions:
Coracoid process
The clavicular- acromioclavicular joint-
Glenoid, anterior and posterior
acromial strut
borders
The three-process-scapular body junction and
last but not least
The C-4 linkage (Clavicle, coraco-clavicular of the coracoid process
might indicate prior
ligaments and the coracoid process). (sub-) luxation of the
glenohumeral joint [14]
The SSSC is of extreme importance with or, in association with
glenoid neck fractures,
regard to the biomechanics of the shoulder joint. a double disruption of
the superior suspensory
It enables the very limited but crucial movement complex. Therefore
treatment of scapular frac-
and changes of the acromio-clavicular joint and tures belongs in the
hands of an experienced
the coraco-clavicular distance. The clavicle is the Orthopaedic surgeon.
only bony connection of the upper extremity to
the skeleton and the scapula is suspended to the
clavicle through the coraco-clavicular ligaments Clinical Features
(C4 linkage). Goss et al. [19] presented the
double disruption concept of the SSSC. Patients suffering a
scapular fracture regularly
Following this very simple idea one can under- complain of local pain or
tenderness. The reliev-
stand the diversity of complex injury combina- ing posture of a patient
presenting in the emer-
tions of the shoulder girdle and perform correct gency department is an
adduction of the
decision-making even in rarely encountered ipsilateral arm, because
tenderness and pain
injuries. increases during arm
abduction. Local signs
might be crepitus and
swelling, however due
to the compact
surrounding muscles and com-
Diagnosis partments they may be
minor. Before the era
of CT-scanning in
polytraumatized patients
Scapular fractures are predominantly acquired in these fractures where
overlooked in up to
high-energy trauma [29]. The primary treating phy- 30 % [60].
sician should therefore be aware of the frequently
associated injuries that can potentially be life-
threatening. i.e., thoraco-scapular dissociations are Radiographic Evaluation
regularly associated with disruptions of the subcla-
vian or axillary vessels [70]. All scapular fractures
can be identified in con-
Moreover the treating surgeon should be ventional radiographs.
For correct diagnosing of
aware of the complex function of the scapula the injury pattern all
four processes of the scapula
and its process during arm movement. Diagnosis have to be displayed (see
Table 5). The complex
of scapular fractures should increase awareness interaction of the
scapula, a careful evaluation of
of functionally associated injuries, i.e. a fracture the glenohumeral joint,
the acromio-clavicular
953
joint and the scapulo-thoracic articulation have to associated injuries [3].

Lantry and co-workers
be performed. Complex injury patterns such as found head injuries to be
associated to scapular
a double disruption of the superior suspensory or fractures in 20 % [23,
37]. The presence of scap-
alteration to the C4 linkage should be actively ular fractures in
polytraumatized patients corre-
excluded in all cases. If any doubts remain lates with a greater
severity score [63] but they
weight-bearing AP radiographs of the AC- joint are no marker for greater
mortality or
or if available weight-bearing MRI of the neurovascular morbidity
[56].
shoulder should be performed.
A scapula trauma series should include a true
anteroposterior (AP), view a lateral view and Indications for Surgery
a true axillary view of the glenohumeral joint.
McAdams and co-workers did not find an Scapular fractures are
predominantly acquired dur-
improvement in evaluation of scapular neck frac- ing high-energy trauma and
are regularly associ-
tures by performing a CT-scan [39]. However, ated with other severe or
life-threatening injuries.
they did point out that associated injuries to the However, the scapular
fracture itself is rarely
SSSC can be detected more easily. The authors a surgical emergency
except for cases with thoracic
belief is that CT-scans should regularly be penetration or exceptional
dislocation of fracture
performed in cases of scapular neck fractures components [10, 24]. Thus,
surgical management
to determine if they are indeed complete of the scapular fracture
should be performed during
and define associated injuries. Using modern reconvalescence of the
polytraumatized patient.
post-processing software solutions and 3-D Because of the complex
interactions of the scapula
reformatting can provide substantial information and its importance for
adequate movement of the
of operative planning [2]. Moreover, the use of whole upper extremity
meticulous diagnostics
routine CT-Scans in the diagnostics of should be performed. An
experienced Trauma or
polytraumatized patients will probably reduce Orthopaedic surgeon should
decide on surgery or
the former high rates of overlooked scapular conservative treatment.
fractures [37].
A general surgical
directive
Surgery is always
recommended if there is a relevant
alteration to the
Frequently-Associated Injuries
1. Scapula suspensory
system (SSSC; C4-linkage)
2. Position and integrity
of glenoid (articular surface)
About 6188 % of all patients, suffering a scapular
3. Lateral column
displacement is present
fracture, present with associated injuries [37, 54].
Relevant decision points
are
Thompson et al. described an average of 3.9 asso- 1. Is the SSSC (cor-CCL-
clav-ACJ-spine) intact?
ciated injuries [29] per patient. Chest trauma was 2. Is the glenoid fossa in
continuity with the SSSC?
found to be the most common site of concomitant 3. Is the glenoid fossa
intact?
injury. Rib fractures occurred in 3245 % [37] and 4. Is the lateral column
(scapular shape) intact?
accompanying pulmonary contusion or pneumo-
haemato-pneumothorax was found in 1550 % of
these patients [42]. Fractures of the ipsilateral limb Scapular Body Fractures
can be found regularly: 1540 % suffer concomi-
tant ipsilateral clavicular fractures and 12 % ipsi- Isolated fractures of the
Scapular body can appear
lateral humeral head fractures. Five to ten percent alarming on the x-rays.
However, the scapulo-
suffer injuries to the brachial plexus or the thoracic articulation can
largely compensate for
subclavian or axillary arteries [13, 23, 46, 61]. deformation of the
scapula. The surrounding
Neurovascular Injuries significantly determine thick soft-tissue layer
prevents further dislocation
the patients morbidity after treatment. In general of the fracture components
[31]. Nordquist and
morbidity of the patient highly correlates with the Petersson found functional
impairment of patients
954
a b
ACL
Clavicle
Clavicle
ACL
CCL
Acromion CCL
CP CP
Glenoid
Glenoid
Fig. 5 Illustrations depicting the superior shoulder sus- view of the bone
soft tissue ring (From [19]. e Raven
pensory complex. (a) AP view of the bone soft tissue Press, Ltd., New
York)
ring and the superior and inferior bony struts. (b) Lateral
with fracture-dislocation greater than 1 cm [45]. margin either lateral

(anatomical neck) or medial
The authors believe that operative treatment should (surgical neck) to
the coracoid process.
be considered on a case-based decision with regard Fractures along
the anatomical neck occur
to the degree of fracture component dislocation. only occasionally [4,
24] but have to be consid-
In cases of a dissociated suspensory system ered as inherently
instable. The glenoid cavity
surgery is always indicated (See Fig. 5 white has completely lost
it suspension and it is usually
arrow). In a systematic review of 520 scapula displaced distally
and laterally, due to the pull of
fractures Zlowodki and co-workers [71] found the long head of the
triceps muscle. These frac-
that 99 % of all isolated scapula body fractures tures always need
open reduction and internal
were being treated conservatively and in 86 % a fixation of the
glenoid.
good to excellent functional outcome was Type 1 glenoid
neck fractures of the surgical
achieved. It has to be pointed out, that in this neck are only
minimally displaced (<1 cm) or
review all operatively-treated patients showed show angular
displacement less than 40# . About
excellent functional outcome. Therefore, surgery 90 % of all scapular
neck fracture account for this
should not be avoided if indicated. In the literature entity. The
management is conservative and good
one case is reported with a fracture spike entering to excellent
functional results can be expected.
the glenohumeral joint [24] and two cases of intra- Type 2 glenoid
neck fractures showing signif-
thoracic penetration of fracture fragments [10, 26] icant displacement of
the glenoid and require
requiring surgical management. operative
stabilization. The glenoid predomi-
nantly presents with
medialization and long
head overturning.
This is due to the pull of the
Glenoid Neck Fractures long head of the
triceps muscle. Significant dis-
placement was
described as greater than 1 cm
Complete glenoid neck fractures cross along the independently by
Zdravkovic [69], Nordqist
lateral margin of the scapula and the superior [45] and Ada and
Miller [1]. This degree of
955
Fig. 6 Illustrations a b
depicting a transverse
disruption of the glenoid
cavity and the factors
responsible for this
orientation. (a) The
concave shape of the
glenoid concentrates forces
across its central region
(arrow). (b) The
subchondral trabeculae are
oriented in the transverse
plane. (c) A crook along the
anterior rim (arrow) is
a stress riser where c d
fractures tend to originate.
(d) Formed from a superior
and an inferior ossification
centre, the glenoid cavity
may have a persistently
weak central zone
(From [21])
Transverse
displacement leads to an interference of the CC-ligaments scapular neck

osteosynthesis
humeral head with the coraco-acromial arc dur- is indicated if significant
displacement of the
ing arm abduction [24]. A rotator cuff dysfunc- glenoid fragment (>2,5 cm
medial or >40#
tion, predominantly of the abduction can be dysangulation) is present.
expected, leading to subacromial pain and Isolated clavicle
osteosynthesis should be
reduced range of motion. Ada and Miller addi- performed if only the clavicle
is displaced or
tionally stated that angular displacement greater shortened. If the coraco-
clavicular ligaments
than 40# is not tolerable, either in coronal or remain intact repositioning of
the moderately-
sagital plane. Inferior angulation greater than displaced glenoid fracture
component through
20# was defined as intolerable by van Noort and re-positioning of the clavicle
might occur [25].
Kampen [62]. However these angulatory dis- However, reorientation of the
glenoid fragment is
placements are difficult to detect in conventional crucial for the clinical
outcome and should be
radiographs and the authors recommend achieved in all cases.
Internal fixation of the
performing CT-scans for decision-making. In clavicle and the scapula is
recommended if both
these cases open reduction and internal fixation fractures show significant
dislocation (Fig. 6).
of the glenoid has to be performed to prevent
persistent pain and impaired arm movement.
Glenoid Cavity Fractures
Combined Glenoid Neck and Clavicle
Fractures (Including Floating Shoulder) Glenoid fractures were divided
by Goss and
Combinations of a glenoid neck with a clavicle Ideberg into glenoid rim
fractures (type 1),
fracture can occur with or without a rupture of Glenoid fossa fractures (type
25) and commi-
the coraco-acromial ligaments. Whenever nuted fractures of the glenoid
(Type 6) [18]
the CC- ligaments are torn internal fixation (details see below). Most
fractures of the glenoid
of the glenoid is indicated. In case of intact cavity (90 %) can be treated
non-operatively.
956 N.
Operative treatment is recommended in Acromion Fractures

Type 1 fractures associated with a persisting
instability of the glenohumeral joint and all frac- Kuhn et al [36] proposed a
classification of
tures with an intra-articular displacement greater acromial fractures that
underwent intensive dis-
than 5 mm [34]. In Type 1 fractures persisting cussion in the literature.
They proposed conserva-
instability can be assumed in fractures displaced tive treatment for all
fractures with non, minor or
greater than 1 cm or if the posterior rim compo- superior displacement.
Fractures with inferior or
nent is greater than a fourth of its cavity and major displacement should be
treated operatively
posterior fracture components. As secondary sub- because of narrowing of the
subacromial space
luxation or luxation can happen unnoticed Indi- and possible development of
an impingement syn-
cation for operative treatment should be followed drome. An os acromiale might
complicate evalu-
generously. Yamamoto and co-workers [68] ation. In these cases CT-
scans should be
suggested that operative stabilization of the performed to identify the
injury to its full extent
glenoid should be performed if the anterior and distinguish between
fractures from os
glenoid rim fragment is larger than 20 % of acromiale. Recent work
proposes surgical treat-
the glenoid length because of the development ment in young patients with
high activity level,
of an anterior instability. and the early need for
crutches [35].
Type 2 fractures should be treated surgically if
an intra-articular gap greater than 5 mm exists or Coracoid Fractures
an inferior subluxation of the humeral head is
present. These injuries are associated with a Fractures of the coracoid
process are divided into
significant amount of glenohumeral arthrosis or fractures of the coracoid
base, the coracoid-tip
instability [18]. and the inter-ligamental
(coracoid ligaments)
Type 3 fractures exit medial to the coracoid area. Fractures to the tip of
the coracoid appear
process. They can be predominantly treated minimally and largely
displaced. However, con-
conservatively, if displaced less than 5 mm. servative treatment can be
generally performed.
However, attention should be drawn to secondary In athletes or patients
performing heavy manual
injuries to other parts of superior suspensory labour, open reduction and
internal fixation
complex, C4-linkage or the clavicular- can be recommended [48].
Fractures of the
acromioclavicular joint-acromial strut. If they inter-ligamental area are
regularly acquired
are present operative stabilisation is indicated. during indirect trauma as
well. They can be
A suprascapularis nerve palsy can be present treated conservatively. In
case of symptomatic
when the fracture line exits the suprascapular local irritation secondary
osteosynthesis should
notch. In doubtful cases electromyography be performed. Again, in
athletes or patients
should be performed and early exploration is performing heavy manual
labour, open reduction
recommended [55]. and internal fixation is
recommended.
Type 4 and 5 fractures are treated operatively Fractures of the coracoid
base should be
when persisting instability of the glenohumeral treated operatively only when
significantly
joint or an intra-articular displacement greater dislocated. However if pain
persists or movement
than 5 mm exists. is impaired secondary
operative procedures lead
Type 6 fractures are treated mainly conserva- to gratifying outcomes [48].
tively as these cases often maintain an adequate
secondary congruency. However, surgery
carries the danger of disrupting the soft tissue Combined Fractures (Some
Frequent
support and often does not allow adequate Combinations)
reduction of the fracture. In rare cases of second-
ary displacement prosthetic replacement must be As a treatment principle
combined fractures of
performed. the scapula and the shoulder
girdle should be
957
primarily analyzed for each injury pattern sepa- intact, due to the pull of
the trapezius muscle.
rately. If operative treatment is indicated, after- Operative stabilization of
the coracoid process is
wards the impact of the underlying injury indicated. If disruption
of the coraco-clavicular
combination on the SSSC and the C4 linkage ligaments is present only
displaced fractures
should be evaluated. of either the clavicle or
the coracoid process
have to be fixed. In cases
of a combined clavicle
Ipsilateral Coracoid and Acromial fracture, medial to the
coraco-clavicular ligaments
Fractures and a coracoid process
base fracture surgery is
Isolated fractures of the coracoid process or the only indicated in
displaced fractures.
acromion can be treated conservatively if not
displaced significantly (see above). However, Fracture
Indications for surgery
combined acromion and coracoid fractures Isolated body
Displacement greater than 1 cm
fracture [45]
medial to the coraco-clavicular ligaments
Dissociated suspensory system

(Ogawa Type 2) represents a double disruption
Surgical glenoid
Displacement greater than 1 cm
of the superior suspensory complex (SSSC). For neck
Angular displacement greater
reconstruction of the ring at least one surgery than
40# in coronal or sagital
is indicated, usually the coracoid process. If one plane
of the fractures is displaced significantly it should
Inferior angulation greater
be addressed. than
20#
Anatomic glenoid All
fractures of the anatomic
neck neck
have to be considered as
Fractures of the Acromion and Grade 3
inherently instable and should be
Acromio-Clavicular Joint Disruptions
treated operatively
Combination of an acromion fracture and Glenoid cavity Type
1 fractures associated with
a fracture of the acromio-clavicular-joint creates a
persisting instability of the
a free acromial fracture component. To prevent
glenohumeral joint
non- or mal-union of the fragment and or the All
fractures with an intra-
articular displacement greater
acromio-clavicular-joint the authors recommend than
5 mm [34]
surgical treatment of both ACJ and the acromion. Type 3 Glenoid With
associated alteration of the
Cavity SSSC
Coracoid Process and Glenoid Neck With
nerve palsy of the
A complete fracture of the glenoid neck and a
suprascapular nerve
fracture of the coracoid process medial to the Acromial fractures
Fractures with inferior or major
displacement or accompanied
coracoclavicular ligaments denotes a separation ACJ
disruptions grade 3
of the glenoid fracture component to the C4 link-
(Rockwood) or higher.
age. Secondary displacement of glenoid is very Coracoid tip-
Athletes or patients performing
likely and surgery is indicated. Open reduction interligamental heavy
manual labour- open
area
reduction and internal fixation is
and internal stabilization of the glenoid fracture
recommended
should be performed. Reduction of the coracoid
Coracoid base When
significantly dislocated or
process should only be performed if significantly
symptomatic
displaced.
Coracoid Process and Distal Third of the

Clavicle Pre-Operative Preparation
Fractures of the distal third of the clavicle, lateral and Planning
to the coraco-clavicular ligaments in combination
with a fracture of the base of the coracoid process Scapular fractures are
generally acquired
can lead to a significant dislocation of the coracoid during high-energy
traumata and patients are
process if the coraco-clavicular ligaments stay often polytraumatized.
Before planning operative
958 N.
treatment all concomitant injuries have to be above the coracoid process.

The conjoined ten-
identified and patients should be stabilised. don should be retracted
medially and the deltoid
If surgery is indicated precise radiological muscle laterally. The
subscapularis muscle is
evaluation of all fracture patterns is essential exposed and its tendon
incised 2 cm medial to
for successful treatment. A true anterior and biceps groove. Tendon and
glenohumeral capsule
posterior, a trans-axillary and a lateral scapular are separated and the latter
is turned back medi-
view should be taken as minimum. Glenoid dis- ally after incision about 5
mm medial to the
placement in the coronal and sagittal plane has to humeral neck. The whole
glenohumeral cavity
be evaluated. In case of a scapular neck or and the anterior rim of the
glenoid can be
glenoid fracture additional CT-scans and 3-D inspected now. One has to
take care of the axil-
reconstructive views enable measurements of lary nerve passing nearby.
the degree of displacement and fracture size.
This is crucial information for the surgeon to Posterior Approach
choose the right surgical approach and operative Extended posterior approaches
should be chosen
technique. only if truly necessary
because extensive tissue
scarring can be expected.
Especially the dorsal
approach from Judet is hardly
used apart from
Approaches tumour surgery or scapular
body fractures with
relevant displacement of the
medial margin of the
There are 4 standard approaches to the scapula: scapula or the scapular
spine.
Anterior, posterior, superior, and lateral.
Selection of the appropriate approach should Rockwood (Basic Posterior)
Approach
be based on the fracture morphology. The patients are placed in
prone position with the
The authors recommend an anterior approach arm at 90# abduction [67].
The incision is
for treatment of: Ideberg Ia fractures (bony performed from the posterior
aspect of the
Bankart fractures) Ideberg III fractures with acromion over the lateral
third of the scapular
clavicular fractures and a posterior approach in spine and then down distally
in the mid-lateral
cases of Ideberg Ib fractures Ideberg II-V line for 2.5 cm. The deltoid
muscle is dissected
fractures, scapula neck and scapula body sharply off the acromion and
the scapular
fractures. In cases of a coracoid or an acromion spine and than split along
its fibres for about
fracture a superior approach is indicated. The 5 cm. After separation of the
deltoid muscle
lateral approach is well suited for fractures of from the underlying
infraspinatus and teres
the lateral Margin and inferior aspects of the minor muscles the
musculotendinous units
glenoid [65]. are retracted downwards. Any
further operative
development should carefully
protect the
Anterior Approach closely-related axillary and
suprascapular
There is a choice of anterior approaches to the nerves. The infraspinatus
tendon is incised
scapula: along its superior and
posterior borders and
A delto-trapezoideal approach and dissected from the underlying
posterior
An anterior deltoid split (superior extension to glenohumeral capsule. After
incision of the cap-
the delto-trapezoideal approach). sule the entire glenoid
cavity can be inspected.
Alternatively the interval
between the
Anterior Deltoid Split infraspinatus and teres minor
muscle can be
The incision is performed above the exposed. After detachment of
the long head of
glenohumeral joint from the superior to the infe- the triceps muscle the
inferior aspect of the
rior margin of the humeral head. The deltoid glenoid process and the
lateral border of the
muscle is exposed and split in line with its fibres scapular body can be exposed.
959
Ideberg 1 a Ideberg 1 b Ideberg 2

Ideberg 3
Ideberg 4 Ideberg 5a Ideberg 5b

Ideberg 5c Ideberg 6
Fig. 7 Ideberg classification scheme for fractures of the glenoid cavity (From
[18])
Extended Judet Approach along their fibres

between the clavicle and the
The patient is placed in a prone position [6, 33]. acromion. Depending
whether one aims at the
A boomerang skin incision along the scapular ventral or posterior
aspects of the upper glenoid
spine and along the medial margin of the scapular the supraspinatus
muscle is prepared more ven-
body is performed (see Fig. 7). The deltoid is than tral or dorsal.
dissected off from the scapular spine. Afterwards The superior
aspect of the coracoid process is
the infraspinatus muscle is reflected proximally identified. Here one
has to take care and
after careful mobilization. One has to carefully avoid injury to the
suprascapular nerve and
avoid damage to the neurovascular bundles while accompanying vessels
medial to the coracoid
mobilizing the infraspinatus muscle in the process. The scapular
notch should always be
spinoglenoid notch. identified to avoid
injury to the suprascapular
nerve.
Superior Approach Lateral Approach

In cases where it is difficult to stabilize a superior The lateral approach
is less popular but
glenoid fragment a superior approach can be very suitable for
treatment of fractures of the
performed or added to a posterior or anterior lateral margin and
inferior aspects of the
approach. If needed either incision can be glenoid.
extended over the tip of the shoulder. The supe- The Patient is
placed in the prone position
rior aspect of the clavicle and the AC- Joint and and with the arm
abducted at 90# . The incision
the acromion are exposed. The trapezius muscle is starts in the mid-
line but slightly caudal of
and the supraspinatus muscle underneath are split the scapular spine.
It runs parallel to the
960 N.
ribs along the muscle fibres of the infraspinatus clamps. Fracture reduction
and osteosynthesis
muscle and the teres minor muscle to the should be applied at the
scapular ring if possible
lateral margin of the scapula. With preparation as the bone is thicker here.
2.7-mm and 3.5-mm
cranial along the margin one can identify the dynamic, compression plates
are used for defini-
inferior border of the glenoid. During preparation tive fixation.
one has to identify and avoid injury to the
axillary nerve. Now the axillary recesses
can be exposed and the glenohumeral joint can
be opened to expose the dorso-inferior aspects of Glenoid Neck Fractures
(incl. Floating
the glenoid. Shoulder)
The glenoid neck is best

reached through a
posterior approach. As with
scapular body
Operative Technique fractures the smallest
possible approach should
be favoured. Van Noort and
Obremskey
Scapular Body Fractures described modifications of
posterior approaches
for open reduction and
internal fixation of
Surgical management of a scapular body is the glenoid neck fractures
[32, 47]. The
performed through a posterior approach interval between the
infraspinatus and the teres
(see Fig. 8). The extent of exposure has to be minor muscle is entered to
expose the lateral
chosen depending on the fracture type. However, scapular border as well as
the postero-inferior
the limited window technique should be favoured, aspects of the glenoid neck.
In difficult to
whenever possible. Using limited windows frac- control cases, of superior
fracture components,
tures at the lateral border, the acromial spine, and an extension to a superior
approach can
the vertebral border can be accessed. Whenever be performed. 2.7 mm and 3.5
mm malleable
there are more than three exit points of the reconstruction plates are
particularly helpful to
fractures in the scapular ring extensive exposure constitute firm
stabilization. Additionally lag
might be indicated to gain full control of screws can be placed. In
case of severe
these complex fracture patterns. There exist no comminution of the scapular
neck and body,
specific reduction tools for the scapular body. making plate fixation
impossible, k-wire or lag
The authors preferably use small pointed reduction screw fixation can be used.
Fig. 8 Classification
scheme of coracoid
fractures according to
Ogawa et al. Type 1
fractures include the
coracoid base and Type 2
fractures the coracoid tip
[49]
961
1a 1b 2
3a
Fig. 9 Classification scheme of acromion fractures according to Kuhn et al. (From

[36])
a b
Levator
Trapezius
Biceps
scapula
Pectoralis
Coraco-
Supraspinatus
minor humeral
Deltoid
Rhomboid
minor
Triceps Infraspinatus Seratus
Subscapularis Triceps
anterior
Teres
Minor Rhomboid
major
Teres major
Latissimus
dorsi
Fig. 10 Anatomy of the scapula with insertion points of the originating muscles
(Modified from: http://img.medscape.
com/pi/emed/ckb/orthopedic_surgery/1230552-1263076-111.jpg)
In case of an additional ipsilateral clavicle Glenoid Cavity

Fractures
fracture osteosynthesis of the scapular neck
should be performed if significant displacement Glenoid cavity
fractures are treated surgically if an
(>1 cm) or dysangulation (>40# ) is present. articular step >1 cm
or persistent instability of the
In case of an additional disruption of the C4-link- humeral head is
present. Type 1a fractures are
age. reduction might be achieved by reduction- approached anteriorly
or arthroscopally [7, 57].
fixation of the glenoid neck. However, if not The displaced
fragment is fixed, if large
achieved additional osteosynthesis should be enough, with two
cannulated interfragmentary
performed (see Fig. 9). compression screws to
guarantee rotational
962
a b
c
the clavicular - acromioclavicular joint - the clavicular - coracoclavicular
the three-processscapular
acromial strut ligamentous - coracoid (C-4) linkage
body junction
Fig. 11 The three components of the superior shoulder coracoclavicular

ligamentous coracoid (C-4) linkage;
suspensory complex: (a) the clavicular (c) the three-
process scapular body junction
acromioclavicular joint acromial strut; (b) the clavicular
stability. Type 1b fractures are approached poste- of the glenoid the

k-wire is then driven across the
riorly and treated in the same way. If fracture fracture and can be
used to place a cannulated
components are comminuted but glenoid cavity screw.
defect demands operative treatment, a tri-cortical Type 5a
fractures are treated as type 2 fractures
graft harvested from the iliac crest can be used to and Type 5b and c
fractures as Type 3 fractures.
fill the defect (Fig. 10). Type 6 fractures are
rarely treated surgically.
Type 2 Fractures are treated using a posterior
Surgical approaches
to glenoid fractures
approach. The inferior fragment is exposed
Anterior approach:
through the infraspinatus-teres minor interval.
Ideberg I Fractures
(bony Bankart Fractures)
Reconstruction plates or cannulated compression
Ideberg III
Fractures with Clavicular Fractures
screws are used for internal fixation after
Posterior approach:
reduction (see Fig. 11). Ideberg II-V
Fractures
Type 3 fractures can be treated either by an Basic posterior
approach (extended posterior approach
anterior, posterior or arthroscopic approach. For (Judet))
an anterior approach the rotator interval has to be Arthroscopic
approach:
incised. In case of an additional injury of Ideberg I Fracture
(bony Bankart Fx)
the superior suspensory complex (SSSC) this Ideberg III Fracture
injury might be reduced by reduction of the
glenoid fragment (see below). If secondary
reduction cannot be achieved additional open Acromion Fractures
reduction and internal fixation of the injury has to
be performed. Acromial fractures
are treated surgically if sig-
For surgical treatment of Type 4 an nificantly displaced
or inferior displacement
anterosuperior or a combined anterior and occurs. Distal
disruptions are treated with tendon
posterior approach should be chosen. A K-wire band construct.
Proximal fractures can be treated
placed into the superior fracture component can using a dorsal
radial plate fixation (regular or
be used as a handle and after successful reduction angle-stable).
963
Fig. 12 Operative treatment of the scapular body fracture is indicated due to an

alteration of the scapular suspensory
system (white arrow) and significant fracture dislocation in a multi-fragmentary
situation (blue arrow)
a b c
Fig. 13 Case of a combined glenoid neck (blue arrow head) and clavicle fracture
(white arrow head). Because of
significant dislocation of the glenoid fragment a scapular osteosynthesis was
performed
Coracoid Fractures fragment. In comminuted

fractures a suture fixa-
tion of the conjoined
tendon is performed (see
An anterior deltoid-splitting approach is used in all Fig. 12).
coracoid fractures. In cases of Ogawa Type 1 frac-
ture the rotator interval is opened if needed. Com-
pression screw- fixation is performed. Type 2 Principles of Post-
Operative
Ogawa fractures are treated surgically if the bony Treatment/Conservative
Treatment
fragment is dislocated significantly or becomes
symptomatic [16]. An anterior approach is All operative
procedures and fractures treated con-
performed and whenever the bony fragment is servatively should be
protected from physiological
large enough cannulated 3.5-mm or 4.0-mm com- stress. Early motion is
of crucial importance
pression screws are used for refixation of the to prevent shoulder
stiffness. After post-operative
964
Supraspinatus m.
Deltoid m.
Infraspinatus m.
Teres Minor m.
Teres Major m.
Fig. 14 Stages of the extended posterior approach after Careful attention has
to be performed to avoid
Judet. A boomerang incision is performed (a, b). The suprascapular nerve
damage
infraspinatus muscle is mobilized an retracted laterally.
Fig. 15 Open reduction and internal fixation of a scapular body fracture using 3.5-
mm dynamic compression plates
pain has subsided it is the aim to achieve a good (12 weeks). Patients
with associated brachial
range of motion, if tolerable for the patient. plexopathy need special
treatment. They might
Continuous passive motion (CPM) therapy benefit from additional
operative strategies such
should be applied additionally. as brachial plexus
exploration and nerve grafting.
All patients should be encouraged to fulfill easy Glenoid fractures
with or without anterior
activities of daily living. Lifting of weights should instability acquire an
after-treatment comparable
not be performed until bony healing has occurred to that of operations
for shoulder instabilities.
965
Fig. 16 Complex scapular body and neck fracture with an associated clavicle
fracture. Both clavicle and scapular neck
fracture are significantly displaced and therefore treated operatively using 3.5 mm
LCPDCP malleable plates
Fig. 17 Operative set up for arthroscopic treatment of glenoid rim fractures
Many infections can be

treated successfully
Complications with antibiotics and
superficial drainage. Post-
operative injuries of
neural structures appeared
Lantry and co-workers presented a meta-analysis in 2,4 %. In one case
(of 212 scapular fractures) and described led to a nerve palsy.
Implant failure occurred
a mean of 4,2 % of post-operative infections in 7.1 %. Post-
traumatic arthritis developed
being the most common complication [37]. in 1.9 %
966
Fig. 18 Operative treatment of an Ideberg 2 glenoid cavity fracture using a 2,5 mm

reconstruction plate using a posterior
approach
Fig. 19 Surgical management of an coracoid fracture 3,5 mm compression

screw. Additionally a suture fixation
(Ogawa Type 2) because of significant fracture displace- of the conjoined
tendon is performed
ment. The bony fragment is fixed using a cannulated
the position or
integrity of the glenoid fragment
Summary (articular surface)
or if the lateral column is
displaced.
Fractures of the scapula are uncommon
injuries resulting predominantly from high-
energy trauma. Patients suffering a scapular References
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Scapulothoracic Arthrodesis
Deborah Higgs and Simon M. Lambert
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 969
Shoulder arthrodesis # Long thoracic nerve #
Muscular dystrophy # Nerve palsy # Scapular

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 969
winging # Scapulothoracic
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 970
Biomechanics of Scapulothoracic Motion . . . . . . . . 970
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 971
Introduction
Scapulothoracic Arthrodesis . . . . . . . . . . . . . . . . . . . . . . 972
The most common manifestation of
Surgical
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 972
Post-Operative Management . . . . . . . . . . . . . . . . . . . . . . . . 972
scapulothoracic dysfunction is symptomatic
scapular winging (scapulothoracic instability).

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 973
Most cases can be treated with physiotherapy,

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 974 using subscapular injection of steroid and local
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 974 anaesthetic to facilitate therapy when needed.
Persistent painful scapular dyskinesia may require
scapulothoracic arthropexy (soft tissue stabiliza-
tion or augmentation) for partial palsy or limited
winging, but scapulothoracic arthrodesis (fusion)
is a reliable and safe intervention when indicated
for irreversible neuromuscular disease.
Classification
Scapulothoracic instability is classified as
traumatic structural (type I), atraumatic structural
(type II), and neuromuscular (type III), using the
same concept as described for glenohumeral

D. Higgs (*)
instability. Three common patterns of instability
Royal National Orthopaedic Hospital, Stanmore,
are seen in clinical practice: superior

Middlesex, UK
polar, medial border, and inferior polar.

S.M. Lambert
Complex combinations of these are seen with

The Shoulder and Elbow Service, Royal National
glenohumeral instability, and patterns of
e-mail: slambert@nhs.net
scapoluthoracic instability may vary in ascent

969
DOI 10.1007/978-3-642-34746-7_261, # EFORT 2014
970
D. Higgs and S.M. Lambert
and descent of the arm at the shoulder. diltiazem may be effective

in delaying progres-
The commonest causes include injury to the dor- sion [4]. Initial studies
looking at prednisolone to
sal scapular nerve (to the rhomboid muscles), the halt or retard the muscle
weakness were unsuc-
long thoracic nerve (to serratus anterior) or the cessful [5] however some
benefit was seen with
spinal accessory nerve (to trapezius) singly or in albuterol, a beta-2-
adrenergic agonist [6] and this
combination. Scapular fractures, scapular may prove to be useful
following surgery.
tumours, rib fractures or chest wall deformity
can also cause scapular winging. Glenohumeral
joint pathology, particularly posterior Biomechanics of
Scapulothoracic
glenohumeral instability and large rotator cuff Motion
tears are often associated with scapular instabil-
ity. The commonest indication for arthrodesis of The nomenclature of
scapular instability is vari-
the scapulothoracic joint at the Royal National able in literature. No more
than 120# of abduction
Orthopaedic Hospital, UK is primary neurologi- is possible at the
glenohumeral joint, and further
cal or muscular disease, including sporadic and abduction at the shoulder
joint requires the scap-
familial fascioscapulohumeral dystrophy and ula to rotate. Scapular
rotation tilts the glenoid
muscular dystrophies (Duchenne and Spinal fossa forward and upwards.
After the initial 30#
Muscular Atrophy) of abduction, which occurs
without scapular
rotation, abduction occurs
due to a combination
of glenohumeral joint
motion and scapular
Aetiology rotation, at a ratio of 21
(Fig. 1).
Injury to the long
thoracic nerve results in
The spinal accessory nerve is a small nerve paradoxical movement of the
scapula away from
(2 mm in diameter), which crosses the posterior the chest wall, because of
the unopposed action of
triangle of the neck. It is vulnerable to injury by trapezius, levator
scapulae, and the rhomboid
inadvertent division during neck dissection, by muscles. The scapula
assumes a higher position,
irradiation, and by traumatic laceration. Scapular the inferior angle of the
scapula rotates towards the
instability is due to injury of this nerve if surgery midline and the medial
border of the scapula
has been undertaken previously. becomes more prominent. The
biomechanical result
The natural history of facioscapulohumeral is to reduce the arc of
motion available to the
dystrophy has only recently been studied glenohumeral joint because
of loss of the mechani-
prospectively [1, 2]. Genetic transmission is auto- cal advantage of the
deltoid and rotator cuff.
somal dominant with variable expression and Injury to the spinal
accessory nerve results in the
penetrance, but can be sporadic. Initially it scapula sitting lower, with
rotation of the inferior
involves the muscles of the face, shoulder girdle pole laterally and the
upper medial pole medially,
and upper limb. Involvement is bilateral but often due to the paralysis of
trapezius and unopposed
asymmetrical. Typically there is asymmetrical action of serratus
anterior. This places the rhom-
involvement of serratus anterior, rhomboids, boids and, to a lesser
extent, the levator scapulae at
trapezius, teres major and minor muscles. The a biomechanical
disadvantage, so that whilst eleva-
pectoralis minor and major, the biceps, and tion above the horizontal
plane is possible, the force
triceps, are also often involved. Deltoid is usually generated is compromised.
spared, and becomes the principle muscle that Injury to the dorsal
scapular nerve (levator
moves the shoulder. It appears to be slowly pro- scapulae and rhomboids) can
result in winging
gressive and may include the lower limbs with that is milder but similar
in pattern to that seen
eventual wheelchair dependence in up to 19 % of with trapezius muscle
paralysis.
patients [3]. It has been hypothesized that the In fascioscapulohumeral
dystrophy the deltoid
pathology is related to calcium regulation in the becomes the principle
muscle that moves the
muscle cells and that calcium antagonists such as shoulder. The effect of the
cantilever of the arm
971
a b
T
D
Ssp
Ssp
SA
c d
T
D
T
D
Ssp
T SA
SA
SSp
Fig. 1 Abduction of the shoulder joint, a combined acromion and further

abduction is achieved by scapular
glenohumeral joint motion and scapular rotation (ac). rotation. Ssp
supraspinatus, T trapezius, D deltoid, SA
At 120# (d) the greater tuberosity impinges on the lateral serratus anterior
and unopposed use of deltoid along with the loss In serratus

anterior weakness patients often
of the scapular stabilisers causes winging of the simply complain of
pain and/or weakness
scapula and a reduction in forward flexion affecting activities
of daily living. Pain is often
and abduction. located over the
scapula. There may be
symptomatic impingment
in the subacromial
space. Muscle atrophy
is not usually a feature.
Diagnosis At rest the scapula
may lie in a winged position.
In neuralgic
amyotrophy the patient may present
The position of the winged scapula depends on with a history of
pain, a fever, and then weakness
the specific nerve injury and the resulting pattern of one or more muscles
around the shoulder.
of muscle paralysis as described. The scapula
stabilisation test can be used to
972 D.
Higgs and S.M. Lambert
predict the value of physiotherapy or whether The infraspinatus is

elevated from the medial
scapulothoracic arthrodesis might improve the scapular border as a strip
about 1.5 cm wide.
patients function. This is performed by stabilising The medial extent of the
spine of scapula is
the scapula against the chest wall with one burred to allow seating of
the re-inforcing plate
hand, and providing counter-pressure over the (see below). The
subscapularis and serratus
coracoid with the other hand. If there is anterior are elevated from
the deep surface of
improved range of movement and symptomatic the medial border and
partially excised.
relief during active forward elevation then The posterior angle of the
second or third to
scapulothoracic arthrodesis should be sixth ribs are exposed sub-
periosteally and the
predictably beneficial. external surface partially
decorticated with a
An electromyographic study should be burr. Four or five 12G
stainless steel or titanium
performed to help establish the diagnosis, but not cables are passed sub-
coastally (Fig. 3) and
all patients with obvious winging secondary to through the scapula
supported on its dorsal
serratus anterior dysfunction will have abnormal surface by a nine or ten-
hole stainless steel one-
electromyographic findings. A period of conser- third semi-tubular plate.
The scapula is then
vative treatment (generally up to 1 year) should be brought to its desired
position and the cables
allowed for nerve recovery before considering provisionally tensioned.
Cancellous bone,
scapulothoracic arthrodesis. harvested from the posterior
iliac crest, is packed
In patients with scapular winging due to under the medial border and
the cables
paralysis of trapezius there is drooping of the sequentially and
definitively tensioned to
shoulder and limited active shoulder movements. achieve stability (Fig. 4).
The operative site is
If the spinal accessory nerve has been divided the then filled with crystalloid
solution to detect
patient usually has severe pain in the any tears in the pleura,
followed by a layered
shoulder girdle. closure over a suction
drain.
Patients with fascioscapulohumeral dystrophy A thoracobrachial spica
is applied post-
present with bilateral weakness, which may be operatively with the
shoulder in neutral rotation
asymmetrical, with restricted shoulder movement and 20# abduction and 20#
internal rotation.
and marked winging of the scapula, in association Post-operative radiographs
are taken to assess
with the classic facies. scapula and implant
position, and a chest
radiograph to assess for
pneumothorax.
Post-Operative Management
Surgical Technique
The shoulder is supported in
the spica for 3
In our preferred technique, the patient is months, at which point the
spica is replaced by a
positioned prone, on a padded Montreal mattress bolster cushion, and
physiotherapy with
with particular care of the skin overlying the hydrotherapy instituted.
prominent bones of the pelvis. The arms are In the literature other
authors have described
placed in elevation supported on a transverse rigid bracing [7],
immobilisation with sling
arm board. The patient is prepared and draped and swathe [8, 9], bandaging
the elbow
so that the mid-line is exposed together with the against the body for 2
months [10], simple sling
entire shoulder on the affected side. The posterior and early movement [11], and
figure-of-eight
superior iliac spine from which autologous bandaging. We advocate
relative immobilisation
graft is to be taken (usually the same side) is left in a spica cast for 12
weeks. The fusion surfaces
exposed. The skin is incised at 20# to the are narrow and any movement
of the arm
midline in line with the posterior angle produces a substantial
rotational force at the
of the ribs (Fig. 2). fusion site [1215].
973
Fig. 2 Prone patient with

mid-line and skin incision
marked for left
scapulothoracic
arthrodesis. The head is to
the left of the photograph
Fig. 3 Sub-costal
positioning of the cables
around the partially
decorticated ribs. Note the
posterior angle of the ribs,
used as a guide to the angle
of fusion
Krishnan et al. [7] reported

on 24
Complications scapulothoracic fusions in 22
patients
with various clinical disorders.
Of these,
Scapulothoracic arthrodesis has been associated 20 patients reported their pain
had improved
with a variety of complications including following surgery. However they
reported a
haemothorax [16], pneumothorax, rib fractures, complication rate of over 50 %
including pulmo-
brachial plexopathy [17] and other neurovascular nary complications, hardware
failure,
complications [18]. pseudarthrosis, and persistent
pain. We have not
974
D. Higgs and S.M. Lambert
Fig. 4 The plate and

cables after definitive
tensioning
experienced any of these with the surgical

technique described in this chapter. References
There is a theoretical risk of reduced
respiratory function in cases of bilateral fusion 1. A prospective,
quantitative study of the natural history
of facioscapulohumeral
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1997;48(1):3846.
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King WM, Tawil R,
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Facioscapulohumeral dystrophy
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cause for concern in patients with fascioscapu- 3. Lunt PW, Harper PS.
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64.
reported by Diab et al. deltoid weakness
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Michelotti JD, Litchfield
The aim of performing a scapulothoracic R, Willis RB, Kim YK.
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Sternoclavicular Joint and
Medial
Clavicle Injuries
Alistair M. Pace and Lars

Neumann
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 977
Aetiology # Anatomy # Classification # Clinical
signs # Imaging # Instability-Sterno-Clavicular

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 977
joint, medial clavicle # Mechanism of injury #

Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 978 Medial clavicle fractures # Physeal injuries #
Mechanisim of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
979 Results and complications # Treatment-closed
and surgical
Classification of Sternoclavicular Joint
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 979
Anatomic Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
979
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 980 Introduction
Physeal
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 981
Fractures of the Medial Clavicle . . . . . . . . . . . . . . . . . . . .
982
Traumatic and atraumatic pathology of the

Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
982 sternoclavicular joint (SCJ) is rare. It is difficult
Radiographic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 983
to achieve useful plain imaging of this joint and as
Treatment Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
985 a result an accurate diagnosis is often missed in
Traumatic
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985
Accident and Emergency departments. The treat-
Spontaneous Subluxation and Dislocation . . . . . . . . . . 986
ment may include non-operative or surgical inter-
Closed Treatment of Anterior Dislocation . . . . . . . 986
ventions. The operative techniques involved are
technically difficult with a high risk of complica-

Closed Treatment of Posterior Dislocation . . . . . . 987
tions. When mismanaged however, SCJ pathology
Open Treatment of Anterior and Posterior
can produce significant morbidity and mortality.
Sternoclavicular Joint Dislocation . . . . . . . . . . . . 988
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 990
Anatomy
The clavicle forms from two primary centres of
ossification that fuse in utero, making the clavicle
amongst the first long bones to become radiologi-

A.M. Pace (*)
cally visible [1]. The two ossification centres sub-
York Teaching Hospital NHS Foundation Trust,
sequently fuse leaving a medial epiphysis. It is the
York, UK
e-mail: alistairpace@hotmail.com
last bone in the body to have its epiphysis close at
a mean age of 25 years. Hence there is a potential

L. Neumann
Nottingham University Hospitals, Nottingham, UK
for traumatic Salter-Harris type fractures involving
e-mail: larsneumann@me.com
the physis at the medial clavicle up to this age [2].

977
DOI 10.1007/978-3-642-34746-7_50, # EFORT 2014
978
A.M. Pace and L. Neumann
The sternoclavicular joint is the only real joint 2. The rhomboid ligament
is also vital to the
connecting the arm to the axial skeleton. It is stability of the
joint. It is composed of two
a true synovial joint with both the sternal and fasiculi (anterior
and posterior bands) and
clavicular sides of the joint being lined by has an interlaced
appearance. It is attached
fibrocartilage. It has been described as the most to the upper surface
of the first rib and to
incongruous joint in the body [3]. the impression on the
inferior aspect of the
The sternoclavicular joint is a saddle-shaped medial end of the
clavicle. The anterior
diathrodal double-plane joint with the clavicular fasiculus of the
ligament allows for
end being bulbous in shape and the clavicular stability in upward
rotation and lateral
notch of the sternum being curved. In 2.5 % of displacement of the
clavicle and the posterior
cases there is an additional small facet on the fibres resist
downward rotation and medial
inferior aspect of the clavicle that forms a joint displacement.
with the superior aspect of the first rib [4]. 3. The interclavicular
ligament binds the super-
Movement at the joint can occur passively in omedial aspects of
both clavicles with the
three planes and is usually produced by transmis- upper margin of the
sternum. They aid
sion of movements of the scapula on the chest the capsular
ligaments in holding up the
wall. During abduction of the shoulder the shoulder girdle.
sternoclavicular joint can elevate 35# in the 4. The capsular ligament
is composed of the
coronal plane and has a range of movement anterior and
posterior portions and covers
of 70# around neutral in the antero-posterior the anterosuperior
and posterior aspects
plane [5]. Biomechanical studies have documented of the joints. It
represents a thickening of the
significant motion in the SCJ with shoulder capsule and is the
strongest ligament
activities. Indeed the SCJ allows 35# of flexion supporting the joint,
resisting superior dis-
and extension and 45# of rotation around its placement of the
medial clavicle together
longitudinal axis when the arm is elevated. Most with the intra-
articular disc when the lateral
of the SCJ motion occurs between the articular clavicle is pulled
inferiorly. The ligament is
disc and the clavicle [6]. The stability of joint relies attached to the
epiphysis of the medial clavicle
on both bony and soft tissue structures. The and is vital in
maintaining normal shoulder
sternoclavicular joint is shallow and has very poise [7] (Fig. 1).
little bony stability due to the paucity of contact The sternoclavicular
joint is subcutaneous and
between the sternal and clavicular sides of the the thoracic inlet lies
posteriorly. The great
joint making the joint incongruent. The stability vessels of the superior
mediastinum, trachea,
of the joint is thus highly dependant on the oesophagus, vagus and
phrenic nerves lie very
surrounding ligaments, the intra-articular disc and close to the joint.
Posterior dislocation of
the subclavius muscle. the SCJ can damage these
structures causing
1. The intra-articular disc absorbs energy on serious injury. The
proximity of these structures
impact to the shoulder and is a thick fibrous to the joint also places
them at risk during
structure dividing the joint into two separate surgery [8] (Fig. 2).
compartments. The disc may be incomplete in
6 % of individuals. It is attached from the
postero-superior aspect of the medial clavicle Epidemiology
at the junction of the first rib to the sternum
and usually blends in with the capsular liga- Dislocations of the
sternoclavicular joint are
ments. Occasionally this disc may be perfo- far less common than the
glenohumeral and
rated. The discs role is to act as a soft tissue acromioclavicular joint.
They comprise 1 % of
cushion as well as preventing the clavicle all joint dislocations
in the body and 3 % of upper
displacing medially. limb dislocations. They
frequently occur in active
Sternoclavicular Joint and Medial Clavicle Injuries
979
Fibrocartilages
Anterior
sternoclavicular
Articular Interclavicular
ligament
disc ligament
Costoclavicular
ligament,
Costoclavicular
posterior fibres First costal
ligament
cartilage
Fig. 1 Diagram illustrating the anatomy of stern- are attached from

the first rib to the medial clavicle.
oclavicular joint and surrounding stabilizing structures The interclavicular
ligaments bind the superomedial
including the rhomboid, interclavicular and capsular aspects of both
clavicles with the upper margin of the
ligaments. The rhomboid ligament has two bands that sternum
young males and as a result of high energy

injuries [9]. Minor sprains and medial physeal Classification of
Sternoclavicular Joint
injuries are more common but rarely do patients Injuries
seek medical advice for these conditions.
The joint may
become partially incongruent
with some of the
joint surface remaining
Mechanisim of Injury in
contact(subluxation) or fully incongruent
when there is no
contact remaining between
In spite of the sternoclavicular joint being a small the two joint
surfaces (dislocation). These
and incongruent joint, the ligamentous structures injuries may be
classified according to the
are strong and hence it rarely dislocates. anatomic position
of dislocation or the cause of
The sternoclavicular joint most commonly dislocation.
disloclates either anteriorly or posteriorly although
superior and inferior dislocation of the joint has
been described. When it does, it usually follows Anatomic
Classification
a high energy force and this may be directly
onto the sternoclavicular joint region such Anterior
Dislocation
as when a force is applied to the clavicle This is the most
common type with the
in an anterior-posterior direction or indirectly medial end of the
clavicle being displaced
to the shoulder joint by a fall on a outstretched anteriorly or
anterosuperiorly to the margin of
hand [10]. The most common causes of the sternum. This
usually results from a direct
sternoclavicular joint dislocation are motor lateral blow to the
shoulder with the shoulder
vehicle accidents and sports injuries. retracted [1].
980
Oesophagus
Vertebral
artery
and trachea
and
vein
Scalenus anterior
and phrenic nerve
Thyrocervical
trunk
Right subclavian
Thoracic duct
artery
Left subclavian
Right common
artery
carotid artery
Left internal
and vagus nerve
jugular vein
Internal thoracic
Left subclavian vein

artery
Brachiocephalic
trunk
Internal thoracic Superior vena Arch of Ligamentum

Left common
vein cava aorta arteriosum
carotid artery
and Left
recurrent
Thymic vien laryngeal nerve
Fig. 2 Diagram illustrating the mediastinal structures in close proximity to the

sternoclavicular joint and at risk of
injury. Posterior dislocation of the sternoclavicular joint can compress the aorta
as well as subclavian artery and vein
Posterior Dislocation levered out by a

posteriorly-directed force. If the
This is less common with the medial clavicle acromion is
posterior to the manubrium at
displacing posteriorly or postero-superiorly with the critical point
of impact then the joint
respect to the sternum. The ratio of anterior dislocates
anteriorly. The acromion is usually
to posterior dislocation is 20:1 [11]. Posterior situated
posteriorly relative to the manubrium
dislocation most commonly results from indirect explaining why
anterior dislocations are
forces imparted to the shoulder girdle with more common.
Moreover the posterior capsule
the shoulder adducted and protracted. The force is much more
substantial than the anterior
is applied laterally and indirectly, transmitted capsule further
increasing the propensity to
along the long axis of the clavicle. The force anterior
dislocation [13, 14].
can be applied by a lateral blow to the ipsilateral
shoulder. Alternatively, force applied to the
contralateral shoulder can yield the same effect Aetiology
when the ipsilateral shoulder is braced against
an immobile object. Less commonly the joint Traumatic
may be dislocated posteriorly with posteriorly Sprain
directed blow to the medial clavicle [12]. When the joint is
sprained, the stabilizing liga-
The direction of the dislocation depends on the ments are damaged
but there is no instability and
relation of the acromion to the manubrium at the the joint remains
congruent. This may be mild,
time of impact. If the acromion is anterior then moderate or severe
with increasing damage to the
a posterior dislocation will occur as the clavicle is stabilising
ligaments [12].
981
Subluxation There can be a painless

subluxation of one or
With further damage to the stabilizing structures both joints during overhead
activities however
of the joint, relative movement between the there is usually no danger to
mediastinal struc-
joint surfaces may occur, however the joint tures [15] Spontaneous
posterior dislocation
usually spontaneously reduces. The joint may occur but this is very
rare and can be treated
sufaces may sublux so that the joint surfaces similarly to a traumatic
dislocation [3].
are temporarily out of place and non-congruent.
The patient may experience a clicking sensation Congenital Subluxation or
Dislocation
resulting from the abnormal joint surface move- This has been reported as far
back as 1841.
ments or from an associated intra-articular There is usually loss of bone
stock of the medial
meniscal tear. clavicles causing instability
with subluxation or
dislocation. The condition
can also occur in
Acute Dislocation patients with severe
scoliosis causing anterior dis-
If the capsular and intra-articular ligaments are placement of the shoulder
girdle and hence poste-
completely disrupted a full joint dislocation can rior dislocation of the
strernoclavicular joint. The
occur and the joint surfaces lose contact and condition is usually
hereditary and are treated con-
remain in a dislocated position. The joint may servatively unless the
dislocation is posterior [16].
dislocate anteriorly or posteriorly. In some cases
the costoclavicular ligaments may simply be
stretched and not completely disrupted. Full dis- Physeal Injuries
locations need to be distinguished from very
medial fractures and epiphysiolysis particularly Salter-Harris type epiphyseal
fractures may
in young adults. involve the medial clavicle
and they are often
difficult to distinguish from
simple dislocations.
Recurrent Dislocation As the medial clavicle
epiphysis is the last physis
In these patients there is a history of an acute to close at around the age of
25 years, this diagno-
dislocation when, after reduction, the ligament sis must be considered in a
patient below this age
damage does not heal and subsequently disloca- who present with traumatic
pathology of the
tions may occur with minimal or no trauma. medial clavicle. The
principles of managing
These recurrent dislocations may be painless or these injuries differs from
simple sternoclavicular
painful and associated with clicking as the joint joint dislocations. Most of
these injuries have the
dislocates recurrently. potential to remodel and
hence surgical interven-
tion is rarely indicated. The
ability for these inju-
Atraumatic ries to remodel is
illustrated by several case reports
These occur particularly in children and adoles- in the literature [17].
However some authors have
cents and the natural history and results of treat- argued that significantly
displaced physeal injuries
ment are quite different to the traumatic cases. should be treated operatively
as the potential for
These may be of two types. remodelling in these cases is
limited.
Whilst conservative
treatment is advocated
Spontaneous Subluxation and Dislocation with anterior physeal
injuries, it is vital that
In this type of subluxation and/or dislocation patients with posterior
physeal injuries are inves-
there is no history of injury. tigated radiologically to
assess any potential
These patients are usually young or middle- compression of mediastinal
structures. Only
aged females presenting with a palpable once this has been excluded
can these injuries
deformity over the medial clavicle. Clinically be safely treated
conservatively. If there is
patients usually have features of generalized evidence of compromise the
injury must be
joint laxity and the episodes of dislocation reduced. This may be achieved
by closed
typically occurs on the dominant side. methods or operatively if
this fails [18].
982
Fig. 3 Antero-posterior radiograph of the proximal clav-

icle showing fractured medial end of the right clavicle
Fractures of the Medial Clavicle
Fractures of the medial third of the clavicle are

rare, accounting for between 2 % and 9.3 % of all
clavicular fractures (Fig. 3). These fractures are Fig. 4 Clinical
photograph demonstrating a patient with
often sustained in high-speed motor-vehicle colli- an right anterior
sternoclavicular joint dislocation. The
anterior bulge is the
medial clavicle end
sions, and seat belt use, while life-saving, may
have a role in the production of these injuries [19].
Typically, patients with a fracture of the medial be swelling and
tenderness but no evidence of
third of the clavicle also have severe thoracic inju- instability as the joint
surfaces remain continu-
ries including pneumothorax and/or pulmonary ally in congruous
contact. In more severe types of
contusion, with respiratory failure occurring in injury when the
stabilizing ligaments have been
nearly half of the patients. Other injuries include damaged, swelling and
pain with movement is
rib fractures, head injuries, and cervical spine and usually more marked and
there may be subluxa-
other upper-extremity injuries. The mortality tion or instability,
when the joint is stressed. In
rate is as high as 19 % for patients with these patients with
ligamentous laxity and multi-
fractures [20]. The fractures are classified directional instability,
there may be no history
according to their configuration, with transverse of injury but the
patient may be aware of
and comminuted fractures presenting most a painful or painless
lump presenting intermit-
commonly. Non-operative treatment is most often tently at the
sternoclavicular joint as the medial
recommended, but an open fracture is an indication clavicle translates in
and out of the joint (Fig. 4).
for operative fixation. Many patients have residual When the capsular
and disc-stabilising liga-
pain, and the non-union rate may approach 15 %. ments of the joint have
been disrupted the medial
Some authors have reported success with surgical clavicle end may
displace anteriorly or posteri-
reduction and internal fixation [21]. orly. The patient
complains of severe pain exac-
erbated by movement of
the arm particularly
when the shoulders are
pressed together by
Signs and Symptoms a bilateral force. The
patients may protectively
take the weight of the
affected arm by supporting
If the sternoclavicular joint has suffered a sprain it across the chest. The
discomfort may be worse
then the stabilising ligaments of the joint are on lying flat. The neck
may be be tilted toward the
structurally intact and the patient complains of dislocated side to
minimize the painful traction
varying amounts of pain around the area with on the clavicle provided
by the sternoclei-
movement of the upper limb girdle. There may domastoid muscle [22].
983
If the dislocation is chronic, the patient may be sternoclavicular joint had

complications of the
pain-free. Clinically, there is shortening and pro- trachea, oesophagus or
great vessels. The major-
traction of the shoulder with tilting of the head ity of these complications
were noted at the time
towards the affected side. A common pitfall lies of injury but later
complications including
in diagnosing an anterior SCJ dislocation because thoracic outlet syndrome,
subclavian artery
of a palpable, tender swelling at the medial clavicle compression, exertional
dyspnea and fatal sepsis
when in fact it is posterior. This may simply after the development of a
tracheo-oesophageal
be from palpating the swollen joint capsule, fistula have been recorded
[25]. Other authors
which can be prominent even if the displacement have reported mediastinal
injuries in 30 % of
is posteriorly [23]. Chronic anterior instability is a cases. It must be
emphasised that these compli-
rare problem and usually presents with pain, cations are rare but when
they do occur are seri-
clicking, crepitus or popping with shoulder ous and require the
expertise of a cardiothoracic
motion. There may be limitation in use when surgeon usually
necessitating a thoracotomy [26].
attampting activities away from body or overhead.
In anterior dislocation the medial end of the
clavicle is very prominent and may be palpated Radiographic Evaluation
anterior to the sternum. The dislocation may be
fixed or reducible. Patients with posterior dislo- Radiographic evaluation of
the sternoclavicular
cations are often in more pain than those with an joint can be difficult due
to its anatomy as well as
anterior dislocation. In these patients the medial its relationship to
overlying and adjacent struc-
end of the clavicle may be felt to be located tures. A chest radiograph
may occasionally
posteriorly and the anterior margin of the sternum reveal asymmetrical
clavicle lengths and abnor-
may be easily palpated. The medial end of the mal joints but these
finding are usually subtle.
clavicle may compress the large veins of the neck A number of dedicated
radiographic views for
causing venous congestion or decreased circula- the sterno-clavicular
joint have been developed
tion. There may be anterosuperior fullness of the as the standard clavicle
diaphyseal radiographs
chest. If the respiratory system is compressed often fail to reveal the
necessary detail. Heinig
the patient may show signs of breathlessness, proposed a tangential
radiograph of the SCJ with
choking or shortness of breath. The patient the patient supine and the
cassette placed behind
may have difficulty swallowing or he/she may be the opposite shoulder. The
beam is angled in the
complaining of a tight feeling in the throat. It is coronal plane, parallel to
the longitudinal axis of
thus vital that patients presenting with SCJ pathol- the opposite clavicle,
providing a profile of the
ogy are thoroughly assessed. The pulses should be affected sternoclavicular
joint [27]. Hobbs has
palpated, the upper extremity neurologically tested proposed a 90#
cephalocaudal lateral, taken
and the venous return assessed [24]. with the patient seated
and flexed over a table.
In patients where the diagnosis of The cassette is placed on
the table, against
sternoclavicular joint subluxation is not obvious the chest wall, and the
beam is directed
the joint may be assessed by placing a finger or a through the cervical spine
[28] (Fig. 5). The
hand on the joint anteriorly whilst the patient serendipity view
proposed by Rockwood
circumducts and extends the shoulder. In cases involves the cassette
being placed behind the
of subluxation, displacement of the medial chest and the radiographic
beam angled at 40#
clavicle may cause a simple click or abnormal cephalad centred on the
sternum, allowing for
movement may be felt as the joint is axially loaded. the visualisation of both
SCJs. In cases of
Sternoclavicular joint dislocations are usually anterior dislocation, the
affected clavicular
high energy injuries and there may be associated head will appear
superiorly compared with
haemothorax or pneumothorax. Worman and the unaffected side.
Conversely, with posterior
Leagus have reported that 16 out of 60 patients displacement, the medial
clavicle will appear
they reviewed with posterior dislocation of the inferior [29] (Figs. 6 and
7).
984
Fig. 7 Rockwoods
Serendipity radiographic view
illustrating clearly
the sternoclavicular joint
Fig. 5 Patient positioning when performing the Hobbs

radiographic view of the sternoclavicular joint. A 90#
cephalocaudal lateral, taken with the patient seated and
flexed over a table. The cassette is placed on the table,
against the chest wall, and the beam is directed through the
cervical spine
Fig. 8 Three
dimensional CT scan demonstrating poste-
rior dislocation of
left sternoclavicular joint. This image is
particularly useful
for assessing how much clavicle dis-
placement is present
and which structures are being com-
pressed by the
clavicle
unremarkable plain
views, then computed tomog-
Fig. 6 Patient positioning when performing the Seren- raphy should always
be performed.
dipity radiographic view of the sternoclavicular joint. Three-dimensional
computer-aided tomogra-
involves the cassette being placed behind the chest and
the radiographic beam angled at 40# cephalic centered on
phy is now being
increasingly used and improved
the sternum, allowing for the visualisation of both SCJs. In resolution helps
distinguish different SCJ injuries
cases of anterior dislocation, the affected clavicular head including physeal
fractures and true dislocations
will appear superiorly compared with the unaffected side (Fig. 8). In
patients with a past history of trauma
or long history of
joint instability, swelling at
It must be emphasized that there are reported the sternoclavicular
joint may be related to
cases of reducible dislocations, which are difficult degenerative changes
rather than subluxation or
to visualize with plain radiology. Therefore, if dislocation of the
joint. Swelling in this area may
a disruption is clinically suspected despite more commonly be
related to degenerative joint
985
Fig. 11 Clinical
photograph demonstrating an old
fracture/dislocation of
the right sternoclavicular joint
Fig. 9 CT scan demonstrating normal sternoclavicular
joint
Treatment Principles
Traumatic Injuries
Mild Sprain
In this injury the joint
is stable but painful.
These are treated
conservatively with rest, analge-
sia and ice packs
alternating with heat packs.
The shoulder is rested in
a sling for 57 days and
then gradual mobilization
is commenced.
Subluxation
This injury is also
treated like a soft tissue sprain
injury with ice and heat.
The subluxation may
occasionally need to be
reduced by manipulating
Fig. 10 CT scan demonstrating right posterior disloca- the shoulder girdle. A
clavicle strap may be applied
tion of the right sternoclavicular joint to aid maintainence of the
reduction and a sling to
prevent excess arm
movement. This should be kept
disease, medial clavicle osteitis, joint sepsis or on for 6 weeks. DePalma
suggests the use of plaster
aseptic inflammatory reaction of the joint. The figure-of-eight dressings
[31] whilst Allman pre-
CT scan is particularly useful in distinguishing fers the use of a soft
figure-of-eight bandage with
these different pathologies (Figs. 9, 10 and 11). a sling [32]. In cases
where the subluxation cannot
Concomitant angiography should be performed be reduced or improved by
if obstruction of the thoracic outlet or vascular open reduction and
subsequent repair of the liga-
injury is suspected. MRI may also be useful in ments and stabilization by
internal fixation using
assessing associated soft tissue damage after sternoclavicular wires
across the joint has been
injury. Some authors also recommend the use of suggested. The use of
wires across this joint how-
stress views to exacerbate the deformity on plain ever are fraught with risk
and possible complica-
radiographs and others suggest the use of tions most notably wire
migration. However in
ultrasound to assess bony displacement and most cases the patient may
simply chose to ignore
associated soft tissue injury. However both the pathology particularly
if painless and prefer it
these modalities are not widely used [30]. to be treated by
physiotherapy [33].
986
Dislocations a contracture making closed

reduction difficult.
A number of principles guide the treatment of In these circumstances
there should be a low
SCJ fracture-dislocations: threshold for open
reduction and reconstruction
1. The time from initial injury. Non-operative or of the joint [34]. Anterior
dislocations are usually
surgical treatment options must be considered unstable and should be
reduced under general
depending on the chronicity of the injury. anaesthesia if diagnosed
early. This is simply
A chronically dislocated joint may be treated achieved by direct pressure
over the medial por-
non-operatively particularly if painless. An tion of the clavicle of a
supine patient with a solid
acutely posterior dislocated sternoclavicular pad placed between the
shoulders. Successful
joint however may require emergency surgery reduction has been reported
up to 510 days
particularly if it compresses the mediastinum. after dislocation however
early reduction within
2. Anterior dislocations may produce little in 72 hrs is advocated. The
patient should be
terms of pain or functional compromise. Poste- immobilized in an arm sling
for 36 weeks and
rior dislocations however are more serious and physiotherapy commenced
thereafter. Pure
can result in life-threatening complications. sternoclavicular
dislocations often are stable
3. The risks and benefits of the interventions once reduced in a closed
fashion. The fracture-
must be considered in relation to the severity dislocation pattern of the
injury, however is
of symptoms inherently unstable,
because the high energy
4. Patient expectations. In elderly patients imparted to the shoulder
girdle had stripped the
with minimal demands, an acutely majority of the soft
tissues that normally would
dislocated sterno-clavicular joint may be stabilize the clavicle once
reduced [35]. The
accepted and treated non-operatively. In high long-term success of closed
reduction is limited
demand patients, particularly athletes, a and a proportion of
patients may have chronic
dislocated stenoclavicular joint may result in anterior dislocation due to
incomplete capsular
persistent pain and disability if not addressed healing. Nettles reported
on 14 cases of acute
surgically. anterior dislocation
treated with early closed
reduction. In 3 cases there
was persistent insta-
bility of the joint [7].
Moreover Eskola reported
Spontaneous Subluxation and on a series of eight
patients treated by closed
Dislocation reduction and five had
recurrent dislocation.
Recurrent anterior
instability following an acute
Rockwood and Oder have suggested the benign anterior dislocation rarely
results in functional
course of this condition and treatment including deficit. Moreover, some
anterior dislocations are
patient education and reassurance usually occurs irreducible and in both
cases these can be
in an unaltered lifestyle with little discomfort. accepted and treated with
physiotherapy and
Rarely the condition however may be painful slings [36]. According to
Miller the surrounding
enough to restrict activities. The problem may shoulder muscles including
trapezius and
be secondary to condensing osteitis affecting the sternocleidomastoid
compensate for maintaining
medial clavicle [3]. shoulder poise [37]. A
study by Savastano and
Stutz reported the results
of 12 patients treated
closed and open. They
concluded that reduction
Closed Treatment of Anterior and stability of the SC
joint is not necessary to
Dislocation ensure normal function of
the involved limb.
They also found that
residual prominence of the
Closed treatment of sternoclavicular joint dislo- medial portion of the
clavicle does not cause pain
cations is usually only effective in the acute stage. and does not interfere with
function of the shoul-
In the chronic stage the joint scars and develops der. Operative intervention
in these cases should
987
be considered only if there is persistent pain

and functional disability. In young patients a
substantial degree of remodelling may occur
during growth and the functional deficit with
skillful neglect is often minor [38].
Closed Treatment of Posterior

Dislocation
This can be achieved by abducting the arm and

applying traction whilst the shoulder is moved
into an extended position. If this fails or the
dislocation is more than 48 h old then an Fig. 12 Post-operative
radiograph demonstrating the
anteriorly directed traction may be applied to anchors utilized in achieving
stabilization of the
the medial clavicle with sterile reduction sternoclavicular joint using
the technique described by
forceps clipped percutaneously into the bone. Frostick et al
Alternatively, reduction may be achieved by
adducting the arm at the affected side and to a chronically dislocated
degenerate joint [39].
apply traction to the arm at the same time as Reconstruction of a
chronically dislocated
applying a posteriorly directed pressure on the sternoclavicular joint is
usually more
glenohumeral joint. The procedure should technically difficult to
perform and the risks
be performed under anaesthesia both to provide are greater than an acute
joint reconstruction.
pain relief and muscle relaxation, but also to Buckerfield and Castle
reported successful
allow an EUA (examination under anaesthesia) closed reduction of a
traumatic posterior
to be performed and hence assess the stability of sternoclavicular dislocation
or a posterior
the joint after reduction and the likelihood of physeal fracture- dislocation
in six of seven
re-dislocation (Fig. 12). In all cases of closed patients ranging from 13 to
26 years of age.
relocation, the patient should be admitted to Their technique involved
retraction of the
hospital and monitored for signs of mediastinal shoulders with caudal
traction on the adducted
obstruction. The arm should be immobilized arm with an interscapular
bolster supporting the
after reduction in a sling. Posterior dislocations patient. 1 patient with
persistent post-reduction
are usually stable once reduced unlike instability was treated by
holding the shoulders
anterior dislocations. This results from the in full retraction with a
figure-of-8 clavicular
more substantial posterior sternoclavicular strap [40]. Lafosse recently
reported that in
joint stabilising structures as compared to the a series of closed early
reduction of posterior
anterior structures. These thick stabilising dislocations only half were
successfully reduced
ligaments are only mildly stretched and only [41]. Rockwood et al. have
also reported similar
rarely disrupted with a posterior dislocation. findings. In their series one
patient underwent
Anterior dislocations unlike posterior disloca- successful reduction 10 days
following injury
tions frequently disrupt the anterior less which suggests that in some
cases, it may be
rigorous structures and hence the joint is not as still possible to reduce
these injuries even after
stable when reduced. Posterior dislocations may 10 days [42]. The use of
external splints, figure-
be accepted and treated conservatively but late of-eight bandages and local
pressure dressings
thoracic outlet syndrome, exertional dyspnoea only provide symptomatic
support and have not
and chronic vascular insufficiency have been proven to have any
influence in preventing
been described as has pain arising from redisplacement of unstable
reductions.
988
the sterno-clavicular
joint is not recommended
Open Treatment of Anterior and because of the serious
complications that can
Posterior Sternoclavicular Joint occur with this technique.
There is a risk of
Dislocation migration of intact or
broken wires into the
heart, pulmonary artery,
innominate artery or
This may be required in patients where closed aorta. Seven deaths and
three near deaths have
reduction of anterior and posterior dislocations been reported in the
literature from complications
has failed or when there is persistent painful of transfixing the
sternoclavicular joint with
instability of the joint possible, or if there is risk Kirschner wires or
Steinmann pins [46]. The use
of skin compromise in an anterior dislocation. of more stable implants
such as Balser plates
The latter may follow trauma or occur in individ- have been advocated
although not widely used
uals with generalized joint laxity. A number of or tested. These plates
allow early mobilization
studies have reported the outcome of treatment of but require removal at
about 3 months post-
acute dislocation [43]. The proximity of the operatively. The series
presented on 10 patients
adjacent vessels dictates that a cardiothoracic had a Constant score of
90.2 +/# 6.6 with no
surgeon should always be present in theatre ongoing instability [44].
Although these implants
when open surgical treatment of a posterior dis- also are at risk of
breakage and loosening with
location is attempted. Approximately 30 cases of subsequent migration this
complication was not
iatrogenic lesions of the heart, lungs or large reported. Brinker et al.
reported the use of two
mediastinal vessels (thoracic aorta, pulmonary large-bore cannulated
screws in conjunction
artery, brachiocephalic vessels) have been with open reduction to
stabilize an unstable
reported in the French-, English-, and German- sternoclavicular joint.
The patient was
language literature. A skin crease incision is immobilized post-
operatively and the metalwork
made centred on the joint and forceful traction was removed after 3 months
[47]. Suture anchors
may need to be applied to the abducted shoulder and capsulorrhapy, as
described by Frostick et al.,
to reduce the clavicle from the retrosternal does not involve exposure
of the first rib and
position under direct vision. Reduction may be 7 year results have been
reported with good sta-
facilitated using a reduction forceps on the bility. The technique is
simple, anatomic and has
medial end of the clavicle [44]. If open reduction low complication rates.
This technique is the
of the joint on the table is not stable then double preferred method of
sternoclavicular joint recon-
breasting of the anterior or posterior capsule struction by the senior
author. The technique is
(open reduction and capsulorraphy) and re- particularly useful in
patients with subtle insta-
inforcing it with sutures passed through the bility and clicking [48]
(Fig. 12). Tendon grafts
bone and fixed either with anchors on one side are usually looped through
drill holes in the
or through drill holes on both sides has been manubrium and medial
clavicle. The soft tissue
described. This is usually all that is required in reconstruction is then
secured and augmented
the acute situation [45]. In cases of recurrent with strong non-absorbable
sutures. The results
instability or persistent dislocation, various of stabilization using
ligament substitution have
surgical procedures have been suggested in the been mixed with a high
prevalence of soft-tissue
literature. These include open reduction and complications and failure
of the reconstruction
stabilization with wires, k- wires, plates, screw resulting in recurrence of
the deformity. The
fixation, external fixator, reconstruction with fas- best outcomes were shown
with the use of
cial loops and tendon grafts (fascia lata, Palmaris a semi-tendinosis graft
configured in a figure-of-
longus and semi-tendinosus tendon), tenodesis, eight arrangement through
two pre-drilled holes
stabilization with Polydioxonone (PDS) cord in the clavicular head and
manubrium [49]
and excision of the medial end of the clavicle (Fig. 13). Synthetic
material has been used in
(medial clavicular resection arthroplasty) and reconstructing the
sternoclavicular joint but
arthrodesis of the joint. The use of pins across results have been poor
with erosion and
989
Fig. 13 Peri-operative picture of the right sternoclavicular

joint being stabilized using a semi-tendinosis graft. The
picture shows the semitendinosis graft channeled as
a figure of 8 through intraosseous drill holes in the medial
end of clavicle and sternal end stabilizing the joint
Fig. 15 Peri-
operative arthroscopic picture of the
sternoclavicular
joint following resection. The degenera-
tive meniscus has
been resected and the medial end of the
clavicel shaved by
about 10 mm with an arthroscopic
shaver allowing an
excision arthroplasty to be created
(Acknowledgments to
Mr. G. Tytherleigh-Strong.
Consultant
Orthopaedic Surgeon)
using a procedure
involving decompression of
the mediastinum by
excision of the medial
clavicle. The
residual clavicle was then stabilized
to the costo-
clavicular ligament and the perios-
teum of the first
rib [51]. Eskola et al. however
has reported poor
results in patients treated with
resection for old
traumatic dislocations and
reported good
results with tendon grafts and
fascial loops [36].
Medial resection arthroplasty
(12 cm) is mostly
indicated in the setting of bony
Fig. 14 Peri-operative arthroscopic picture of a torn
changes and joint
arthrosis or if a ligament recon-
degenerate intra-articular meniscus of the sternoclavicular struction cannot be
performed because of absent
joint. The degenerative medial end of the clavicle is to the residual soft tissue
attachments. It is important
left of the picture and the degenerative sternal end to that the remaining
medial clavicle is stabilized by
the right. The arthroscopic hook in the background is in
contact with the pathological fibrocartilage meniscus
ligamentous repair
or augmentation of the costo-
(Acknowledgments to Mr. G. Tytherleigh-Strong. clavicular ligaments
as the results of resection
Consultant Orthopaedic Surgeon) arthroplasty are
poor without this soft tissue
stabilization.
Arthroscopic sternoclavicular joint
non-union of the first rib. Carbon fibre ligament resection can be
indicated in degenerate
has been used to reconstruct the sternoclavicular sternoclavicular
joints. The technique is develop-
joint together with Kirschner wire temporary ing but excellent
results have been reported [52]
fixation. Dacron has also been used as a suture (Figs. 14 and 15).
Arthrodesis is contra-indicated
material but there are reports of bone erosion [50]. due to the marked
restriction in shoulder move-
Rockwood et al. have described good results ments it produces
[53].
990
posterior
displacement in sports participants. J Bone
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80.
Fractures of the Shaft of the
Clavicle
Iain R. Murray, L. A. Kashif

Khan, and C. Michael Robinson
Contents
Neurovascular Complications . . . . . . . . . . . . . . . . . . . . 1011
Re-Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1011
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 994
Other Complications of Operative

Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 994 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 1012
Clinical and Radiological Assessment . . . . . . . . . . .
994 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 1012
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 996 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 1012
Surgical and Applied Anatomy . . . . . . . . . . . . . . . . . .

997
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1012
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 999
Non-Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . .
999
Primary Operative Treatment . . . . . . . . . . . . . . . . . . . 999
Plate
Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1001
Intramedullary Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1003
Other
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1004
The Floating Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1004
Complications of Mid-Shaft Clavicular
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1006
Non-Union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1006
Mal-Union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1010
I.R. Murray
Department of Trauma and Orthopaedics, The University
of Edinburgh, Edinburgh, UK
e-mail: Iain.Murray@ed.ac.uk
L.A.K. Khan # C.M. Robinson (*)
The Edinburgh Shoulder Clinic, Royal Infirmary of
e-mail: kashkhan@doctors.org.uk;
c.mike.robinson@ed.ac.uk

993
DOI 10.1007/978-3-642-34746-7_48, # EFORT 2014
994
I.R. Murray et al.
Keywords age (Fig. 1). These fractures

tend to result from
Classification # Clavicle # Clinical signs # a direct force applied to the
point of the shoulder
Complications-non-union, mal-union, during sport [6]. Equestrian
sports and cycling
neurovascular # Epidemiology # Floating account for a large number of
injuries, when, as
shoulder # Imaging # Shaft # Technique # a result of inertia when the
horse or bicycle stops
Treatment-non-operative, surgical suddenly, the rider is thrown
forward and lands
on the unprotected shoulder.
High-energy clavic-
ular fractures with
comminution, displacement,
Introduction and shortening are increasing
[1]. A second,
smaller peak of incidence
occurs in elderly
The traditional view that the vast majority of patients (over 80 years of
age), with a slight
mid-shaft clavicular fractures heal with good female predominance. The
majority of these
functional outcomes following non-operative are related to osteoporosis,
sustained during
treatment is now contested. While there is low-energy falls in the home.
a general concensus that undisplaced fractures
are best treated non-operatively, there is growing
evidence of a higher rate of non-union and poorer Clinical and Radiological
Assessment
functional shoulder outcome in subgroups of
patients with clavicular fractures. These fractures The history should explore
standard demo-
can no longer be viewed as a single clinical entity graphic information and the
mechanism of
which should always be treated non-operatively, injury. A clavicle fracture
which results from
but as a spectrum of injuries with diverse func- a simple fall is unlikely to
be associated with
tional outcomes, each requiring individualized other significant injuries.
However, fractures
assessment and treatment. occurring in the context of
high velocity road-
traffic accidents should
prompt a thorough search
for concomitant injuries. The
majority of frac-
Epidemiology tures result from direct
force to the point of the
shoulder, although fractures
can also result from
The clavicle is one of the most commonly frac- a traction injury [13]. These
injuries often occur
tured bones, accounting for 2.64 % of adult in industrial settings such
as where the arm
fractures and 35 % of injuries to the shoulder becomes entangled in
machinery and is pulled
girdle [13]. The incidence of clavicular fractures from the body. If the
clavicle fractures with
is estimated to be between 29 and 24 per 100,000 minimal force, the
possibility of pathologic frac-
population per year [1, 3, 4]. The majority of tures secondary to metabolic
processes and
clavicular fractures (6982 %) occur in the tumours must be considered.
Information that
shaft, where typical compressive forces on the may influence the
risk/benefit analysis when
point of the shoulder combine with the narrow considering surgery should
also be sought when
bone cross-section result in failure [2, 3, 5, 6]. taking a history [13].
Distal third fractures are the next most common Mid-shaft clavicular
fractures typically pro-
type (20 %), with medial third fractures rarest duce swelling and bruising at
the fracture site
(5 %) [712]. Shaft fractures occur most com- with displaced fractures
resulting in obvious
monly in young adults, whereas lateral and deformity. An abrasion over
the point of
medial-end fractures are more common in the shoulder is suggestive of
a direct blow, with
the elderly [1, 3, 4]. The majority of shaft abrasions over the mid-line
indicating a shoulder
fractures are displaced, unlike most lateral end strap or seatbelt injury
[14]. There is often down-
fractures [3]. ward displacement of the
lateral fragment and
The first and largest peak incidence of clavic- elevation of the medial
fragment [15].
ular fractures is in males under 30 years of A droopy, medially-driven,
and shortened
Fractures of the Shaft of the Clavicle
995
Fig. 1 The incidence of 150

clavicular fractures in
Male
relation to age and sex
Female
cohorts (Reproduced with
Incidence/100,000 popn/year
modification, with
permission and copyright 100
# of the British Editorial
Society of Bone and Joint
Surgery [Robinson CM.
Fractures of the clavicle in
the adult. Epidemiology
and classification. J Bone 50
Joint Surg [Br]
1998;80-B:476-484])
0
1319 2029
3039 4049 5059 6069 7079 >80
Age cohorts (Years)
shoulder in completely displaced fractures has

between upper extremities is suggestive of vascu-
been described as shoulder ptosis [16, 17].
lar injury. Duplex scanning and arteriography
Prominence of the displaced fracture fragments,
should be undertaken when the diagnosis is in
which button-hole through the platysma muscle
any doubt [22, 23].
can occur with severely angulated or comminuted
The diagnosis is usually made radiographi-
fractures [18]. Despite the superficial position of
cally on the basis of a single anteroposterior
the clavicle, open fractures or soft-tissue tenting
(AP) view (Fig. 2) [18]. In an urgent trauma
sufficient to produce skin necrosis are uncommon
setting the diagnosis is often made on a chest
[3]. Shortening of the clavicle should be mea-
radiograph, which can also be used to evaluate
sured clinically. The difference between the
the deformity relative to the normal side. Radio-
involved and normal shoulder girdle can be
graphs should be taken in the erect position where
calculated by measuring the distance between
gravity will demonstrate maximal deformity of
the suprasternal notch and the palpable ridge of
the clavicle, particularly when considering sur-
the AC joint.
gery. Some authors advocate the use of a 15#
A thorough examination should be performed
posteroanterior (PA) radiograph to assess the
to exclude co-existing injuries, particularly as a
degree of shortening [24]. Three per cent of
result of high-energy trauma. Fracture-dislocations
patients [25] have an associated chest injury
of the AC and SC joints and physeal injuries in
requiring radiological investigation, such as a
younger patients should be excluded. The entire
pneumothorax or haemothorax. These injuries
limb distal to the fracture should be assessed to
are almost universally associated with multiple
exclude brachial plexus or vascular injury. Any
rib fractures [26]. Evidence of an ipsilateral
deficit not noted pre-operatively may be falsely
shoulder girdle injuries including a double dis-
blamed on surgery with significant prognostic
ruption of the superior shoulder suspensory com-
and medico-legal implications [13]. The risk of
plex [27], should be sought on the initial trauma
neurovascular injury increases with high-energy
series radiographs.
trauma and marked fracture displacement or
Computed tomography (CT) scanning of mid-
comminution. Generally, deficits result directly
shaft clavicular fractures can demonstrate the
from displaced fracture fragments or by stretch or
complex three-dimensional deformity that affects
blunt injuries associated with overall injury of
the shoulder girdle with clavicular fractures but
the arm [1921]. A blood pressure discrepancy
is rarely performed as a primary investigation.
996
I.R. Murray et al.
Fig. 2 Plain radiograph of

a displaced, comminuted
a
mid-shaft clavicular
fracture (a). This fracture
was treated with open
reduction and plate
fixation (b)
CT is useful for delineating associated glenoid of the Orthopaedic Trauma

Association separates
neck fractures in cases of floating shoulder diaphyseal clavicular
fractures into three types:
[2830]. Spiral CT with three-dimensional recon- 06-A (simple), 06-B (wedge)
and 06-C (complex)
struction allows the best assessment of displace- [31]. Each type is further
divided into three
ment and can be useful in evaluating fracture groups.
union (Fig. 3). The Robinson
Classification [3] is based on an
analysis of 1,000 clavicular
fractures, and was the
first system to sub-classify
shaft fractures
Classification according to their
displacement and degree of
comminution (Fig. 4). Mid-
shaft clavicular frac-
A number of classification systems have been tures are divided into type
2A (cortical alignment
described that delineate mid-shaft fractures of fracture) and type 2B
(displaced fracture).
the clavicle. The classification proposed by Further division is made into
sub-group types
Allman [5] is based solely on the anatomic loca- 2A1 (nondisplaced), 2A2
(angulated), 2B1 (sim-
tion of the fracture and numbered according ple or wedge comminuted), and
2B2 (isolated or
to fracture incidence (mid-shaft I, lateral II, comminuted segmental)
fractures. These guide
medial III). Recognising that this basic system treatment and prognosis.
These parameters are
does not consider factors influencing treatment independently predictive of
non-union after oper-
and prognosis such as fracture pattern and short- ative treatment [32]. The
Robinson Classification
ening, further classifications have been refined to has been shown to have
acceptable levels of inter-
include other variables. The classification system observer and intra-observer
variation [3].
997
a c
Fig. 3 Hypertrophic non-union following a fracture of the mid-shaft of the clavicle

seen on AP plain radiograph (a),
computed tomography (b) and following open reduction and plate fixation (c)
clavicle articulates
laterally with the acromion,
Surgical and Applied Anatomy where it is held by the
acromioclavicular (AC)
and coracoclavicular
ligaments. The superior
The clavicle is the first bone to ossify at 5 weeks shoulder suspensory
complex (SSSC) is anal-
gestation [14], with initial growth arising from ogous to the pelvic ring
and comprises the
the ossification centre in the central portion of laterally-placed
structures in the shoulder
the clavicle up to age five. Further growth then girdle the glenoid
neck, the lateral clavicle,
occurs at the medial and lateral epiphyseal plates coracoid and acromion
and the ligaments
[14]. The medial growth-plate accounts for the which connect them.
majority of longditudinal growth and is gener- The clavicle lies
subcutaneously, with only the
ally the only plate seen radiographically. It is supraclavicular nerves
crossing the bone superi-
also the last physis to close, between ages 22 and orly. A number of
fascial layers, muscles and
25 [14]. The clavicle is S shaped with ligaments attach to the
clavicle and are responsi-
a cephalad-caudad curvature [33, 34]. It is rel- ble for the predictable
deformities associated
atively thin, and is widest at its medial and with fracture [14].
Sternocleidomastoid is
lateral expansions where it articulates with the attached to its medial
border and pulls proximal
sternum and acromion. The bone in the rela- fragments superiorly and
posteriorly. On the lat-
tively thin diaphysis is typically hard cortical eral side, part of the
deltoid and pectoralis major
bone best suited for cortical screws, unlike muscles are attached.
Due to the weight of the
the softer bone in the medial and lateral upper extremity and the
pull of pectoralis on the
expansions where larger pitch cancellous humerus, distal
fragments tend to sag forward
screws are more suitable. The clavicle articu- and rotate inferiorly.
lates medially with the sternum and is securely The mid-shaft of the
clavicle forms
fixed to the first rib by the costoclavicular a transition zone
between the flattened lateral
ligaments, subclavius and the intra-articular part and the tubular-to-
triangle medial pole
sternoclavicular (SC) joint cartilage. The [35]. The relatively
thick and strong medial
998
I.R. Murray et al.
Fig. 4 The Robinson Undisplaced Fractures (Type 1A)

Displaced Fractures (Type 1B)
classification of clavicular
fractures (Reproduced with
modification, with
permission and copyright
# of the British Editorial
Society of Bone and Joint
Extra-articular (Type 1A1) Extra-
articular (Type 1B1)
Surgery [Robinson CM.
Fractures of the clavicle in
the adult. Epidemiology
and classification. J Bone
Joint Surg [Br]
1998;80-B:476-484])
Intra-articular (Type 1A2) Intra-
articular (Type 1B2)
Cortical Alignment Fractures (Type 2A)

Undisplaced (Type 2A1) Simple

or wedge comminuted (Type 2B1)
Angulated (Type 2A2) Isolated

or comminuted segmental (Type 2B2)
Cortical Alignment Fractures (Type 3A)

Extra-articular (Type 3B1)
Extra-articular (Type 3A1)
Intra-articular (Type 3B2)

Intra-articular (Type 3A2)
clavicle protects the underlying neurovascular curve of the S-shaped

clavicle and travel
structures. The area of biomechanical weak- from superomedial to
inferolateral [35]. The
ness lies laterally, protecting these structures neurovascular bundle
is further protected by
during fracture [36]. Cadaveric studies have the subclavius muscle
and the costocoracoid
demonstrated that the axillary vein and membrane, lying on the
inferior surface of
artery lie under the apex of the anterior the clavicle.
999
simple sling was

demonstrated in a comparative
Management study, but with identical
functional and cosmetic
results [37]. The sling can
normally be discarded
There is currently considerable debate about the once the acute pain has
subsided, with patients
most appropriate treatment for midshaft clavicular encouraged to undertake
normal activities as far
fractures. Undisplaced fractures of the diaphysis as pain allows. If the
fracture heals, range of
(Robinson Type 2A) have a high rate of union and motion and shoulder function
are restored
are associated with good functional outcomes rapidly. Patients rarely
require supervised phys-
when treated non-operatively. Until relatively iotherapy, and generally
progress well with self-
recently, even displaced fractures were rarely directed range-of-motion and
strengthening
stabilised operatively. Early studies evaluating exercises.
complications in clavicular fractures managed
non-operatively reported a rate of non-union of
<1 % [6, 25, 3740], higher than after primary Primary Operative Treatment
open reduction and internal fixation [25, 39].
A number of other early studies have reported There is growing evidence to
support early oper-
high levels of patient satisfaction after ative treatment of displaced
clavicular fractures,
non-operative treatment [37, 38, 41]. However, with an increasing number of
studies demonstrat-
more contemporary studies have demonstrated ing benefit when compared
with non-operative
increased rates of non-union and poorer functional management [25, 32, 53, 68
70]. In a retrospec-
outcomes after non-operative treatment, with tive clinical series of 52
displaced fractures
results of primary operative reduction and fixation treated non-operatively,
initial shortening of
improving considerably (Table 1) [31, 57, 59]. #20 mm was associated with a
greater risk of
Compliant patients in the 1660 age group, who non-union and a poor
clinical outcome [71].
have physically-demanding occupations or active Another study reporting
patient-centred outcome
physical lifestyles are candidates for primary oper- measures in fractures
treated non-operatively
ative repair if they are medically fit and have demonstrated significant
deficits in shoulder
completely displaced fractures with good bone strength and endurance in
those with initial dis-
quality [51, 57, 6062]. Drug and alcohol abuse, placement [59]. A large
multi-centre trial com-
untreated psychiatric conditions, homelessness and paring non-operative
treatment with primary
uncontrolled seizure conditions are associated with plate fixation in 138
patients with displaced
non-compliance and fixation failure and are there- fractures reported better
functional outcomes,
fore considered as contra-indications for primary lower rates of mal-union and
non-union, and
operative repair of clavicle fractures [53]. a shorter time to union in
those undergoing plate
fixation [57]. Although, the
operative group
had a complication rate of
34 % and a high
Non-Operative Treatment re-operation rate (18 %),
the majority of these
were for hardware removal.
Significant benefits
The simple sling and figure-of-eight bandage in functional scores were
demonstrated with plate
(Fig. 5) are the most widely-used methods of fixation (p 0.001 for the
Constant score [72]
conservative treatment, although many and p < 0.01 for the
Disabilities of the Arm,
immobilising techniques have been described Shoulder and Hand [DASH]
score [73]). These
[63]. Neither technique reduces a displaced frac- results must be interpreted
with caution, as
ture [37]. The risk of axillary pressure sores, a minority of outlying
patients with poor scores
neurovascular compromise secondary to com- due to non-union may have
contributed to the
pression, and non-union are higher in patients poorer overall scores in the
non-operative
treated with the figure-of-eight bandage [24, 37, group. The authors of this
trial support the use
40, 6467]. Better patient satisfaction with the of primary plate fixation of
displaced fractures in
1000
I.R. Murray et al.
Table 1 Results of acute fixation of clavicle shaft (Edinburgh Type 2) fractures

with reported rates of complications
and functional resultsa
Method of Number Nonunions
Functional
Technique Authors fixation treated (%)
Complications results
Wiring Ngamukos K wires 99 0 (0) 3
wire migration Not given
Techniques et al. [42]
Total 99 0 (0)
Nailing Grassi 2.5 mm 40 2 (5) 3
refractures, 2 Mean Constant
techniques et al. [43] threaded pin
breakage score 82.9, 75 %
intramedullary
satisfied with
pin
treatment
Chu Knowles pin 75 1 (1.3) Pin
migration 70/75 (93.3 %)
et al. [44]
good/excellent
(constant>80)
Jubel Titanium nail 58 1 (1.7) 12
hardware Mean Constant
et al. [45]
removals score 97.9
Meier Elastic nailing 14 0 (0) 1
secondary Mean Constant
et al. [46]
fracture score 98 at
displacement 6 months
Lee Knowles pin 32 0 (0) 20
et al. [47]
removals score 85
Strauss Hagie pin 14 0 (0) 3
skin breakdown, 93 % symptom
et al. [48] 2
breakages free
Kettler Titanium nail 87 2 (2.3) 4
nail migration, 2 Mean Constant
et al. [49]
revisions for poor score 81
position
Mueller Titanium nail 32 0 (0) 8
nail migration, 2 Mean Constant
et al. [50] nail
breakage, 29 score 95
nail
removal
Total 352 6 (1.7)
Plating Poigenfurst Plate fixationb 110 5 (4.5) 2
deep infections, Not given
techniques et al. [51] 4
refracture
Faithfull Plate fixation 18 0 (0) 14
plate removal Full range of
et al. [52]
movement
Bostman Plate fixation 103 2 (1.9) 5
deep infections, Not given
et al. [53] 3
plate loosening,
3
plate failures, 1
refracture
Shen Plate fixation 251 7 (2.8) 1
deep infection, 94 % satisfied
et al. [54] 171
hardware
removals
Coupe Reconstruction/ 62 0 (0) 1
deep infection, Not given
et al. [55] DCP plates 19
plates removed
Collinge Plate fixationc 42 1 (2.4) 1
fixation failure, American
et al. [56] 3
infections, 2 Shoulder and
removal of Elbow Score 93
metalwork
Lee Plate fixationb 30 1 (3.3) 22
et al. [47]
removals score 84
COTS [57] Plate fixationd 62 2 (3.2) 3
wound Mean Constant
infections, 5 score 98
metalwork
removal, 1
mechanical
failure
(continued)
1001
Table 1 (continued)
Method of Number Nonunions
Functional
Technique Authors fixation treated (%)
Complications results
Russo et al. Mennen plate 43 2 (4.7) 10
hypothesia Mean Constant
[58] fixation
score 96
Total 721 20 (2.7)
COTS Canadian Orthopedic Trauma Society
a
Only English-language studies, or studies with an English-language translation,
appearing in peer-reviewed journals
during the last 20 years are shown
b
Plates used included one-third-tubular, reconstruction (2.7 and 3.5 mm),
semitubular and dynamic compression
c
Plates used included 3.5 mm reconstruction, dynamic compression or fibular
composite
d
Plates used included low-contact dynamic compression, 3.5 mm reconstruction, or
precontoured
a b
Fig. 5 The figure-of-eight bandage (a) and simple sling (b) are the most widely-
used methods of non-operative
management for mid-shaft clavicle fractures
active adults on the basis of this evidence. Inter- Increasing numbers of

young, active patients are
estingly, number-needed-to-treat analysis reveals seeking operative
treatment in the hope that
that operative fixation of nine fractures would be better functional
outcome and an earlier return
required to prevent one non-union, and fixation of to contact sports can
be achieved. Following
3.3 fractures would be required to prevent one adequate counselling
about the risks of surgery
symptomatic mal-union or non-union [74]. The and likely outcomes, we
believe that these
results of other ongoing randomised controlled patients should be
offered the option of operative
trials are eagerly awaited. treatment. In such
cases, there are a wide
Potter et al. [75] demonstrated no significant variety of methods
available for the operative
difference in DASH scores when they com- fixation of shaft
fracture including plate fixation,
pared acute operative treatment with delayed intramedullaryfixation
and Kirschner wires
treatment of established non-unions and mal- [25, 4258, 70, 7678].
unions of mid-shaft fractures. A significant
difference (p 0.05) was evident in only
one of the six strength and endurance vari- Plate Fixation
ables studies [75]. Although, there was
a significant difference (p 0.02) of 6 points Open reduction and
plate fixation enables imme-
in the Constant score, all patients reported diate absolute
stability, controlling pain and facil-
a high level of satisfaction. itating early
mobilization [60, 68, 71, 7981]. With
There is no current agreement on which displaced mid-shaft
fractures, the skin is typically
displaced fractures should be treated operatively. bruised and swollen. It
may be advantageous to
1002
I.R. Murray et al.
delay operative intervention until the surrounding

tissue is more amenable to surgery this can be up
to 2 weeks. A pre-operative plan should be care-
fully made taking into consideration displacement,
degree of comminution and the location of the
main fracture line [13]. Three dimensional recon-
struction of computed tomography images has
greatly facilitated this for complex cases.
The plate is most commonly implanted on the
superior surface of the clavicle with the patient in
the beach-chair position. Biomechamical studies
support the use of a superiorly positioned plate in
providing more secure fixation, especially in the
presence of inferior cortical comminution [82].
This approach is associated with an increased
risk of injury to the underlying neurovascular Fig. 6 Beach-chair
position for open reduction and
structures during drilling and fracture manipula- plate fixation of the
clavicle. A roll behind the affected
tion. Prominence of superiorly-placed plates may shoulder elevates the
clavicle into the operative field. The
C-arm of the image
intensifier should be placed to allow
necessitate removal, particularly in thin individ- multi-planar images to be
taken while not compromising
uals. An anterior-inferior approach to allow the surgeons access to
the operative field
inferior implantation of the plate was developed
in an attempt to address these problems. Inferior
implantation was associated with a low complica- clavicle. The arm can be
secured to the patients
tion rate in a series of 58 patients [56]. However, it side and does not require
to be mobile. The shoul-
is technically more demanding and biomechani- der girdle is prepared and
draped exposing the
cally less secure than superior implantation. entire length of the
clavicle, acromion and upper
The most frequently used implants are half of the scapula. The
surgical draping should
dynamic compression and locking plates. Recon- not interfere with the
image intensifier that should
struction plates are susceptible to deformation at be positioned such that
the clavicle can be imaged
the fracture site, leading to mal-union, and are in multiple planes (Fig.
6).
now less popular. Clavicle-specific locking plates An oblique incision,
centred over the fracture
have been introduced that are less prominent after site is made along the
superior border of the clavi-
healing and are less likely to require removal cle. The subcutaneous
tissue and platysma are dis-
once the fracture has united [34, 57]. Locking sected as one layer with
care taken to identify and
screws have improved fixation of fractures that protect any larger
branches of the supraclavicular
occur in elderly patients with osteoporotic bone. nerve. The myofascial
layer that covers the clavicle
These implants are yet to be fully evaluated in is incised and deflected.
It is imperative that every
comparative clinical studies. attempt is made to
preserve soft tissue attachments
to the clavicle while the
fracture site is identified
Surgical Technique: Superior Fixation of and exposed for haematoma
and fracture debris.
Pre-Contoured Plate for Displaced The fracture configuration
may warrant fixation of
Mid-Shaft Clavicle Fractures a free fragment to either
the distal or proximal
The patient is positioned in the beach-chair posi- portion with a lag screw.
This simplifies the fracture
tion with the head held on a dedicated support. pattern and aids
reduction.
The anaesthetic endotracheal tube is deflected and Reduction of the main
fracture line can be
secured to the contralateral side. A rolled towel assisted using pointed
reduction forceps and
can be usefully placed underneath the operative K-wires (Fig. 7). An
interfragmentary lag screw
shoulder to improve manoeuvreability around the secures the reduction but
is not always
1003
Fig. 7 Superior fixation of a

pre-contoured plate for
displaced mid-shaft
clavicle fractures (a)
Reduction of the main
fracture line can be assisted
using pointed reduction
forceps. (b) An
interfragmentary lag screw
secures the reduction and is
desirable but not always
achievable. (c)
b
A pre-contoured plate is
then placed on the superior
aspect of the reduced
clavicle and secured with
bicortical screws
achievable. The size of the pre-contoured plate is documented. A standard sling

is used for comfort
then confirmed and placed on the superior aspect with only simple pendulum
exercises permitted
of the reduced clavicle being secured with in the early post-operative
period. The patient
bi-cortical screws. Ideally three bi-cortical screws should be reviewed in clinic
at 1014 days
on either side of the fracture are inserted. Locking where the wound is
inspected, further radio-
screws are only required if the bone is very oste- graphs obtained and the
sling discarded. At this
oporotic Great care must be taken to protect the stage unrestricted range of
motion is permitted
structures in the subclavicular space, particularly with resisted exercises
reserved until 6 weeks
while drilling and tapping. Compression holes following the procedure.
Patients should be
can be used in stable transverse and short oblique counselled that contact
sports should be avoided
fracture patterns to apply interfragmentary com- until at least 12 weeks
although compliance in
pression. The quality of the reduction, plate place- this young active group of
patients is variable.
ment and screw lengths should be assessed This procedure is
increasingly being done on
intra-operatively with fluoroscopy. Following a day-case basis.
irrigation, the soft tissue layers are closed with
interrupted sutures with subcuticular sutures used
for final skin closure. Intramedullary Fixation
Formal post-operative radiographs should be
taken in the recovery area. The neurovascular Intramedullary (IM) pinning
of clavicular shaft
status of the limb post-operatively must be fractures confers a number
of benefits, although
1004
I.R. Murray et al.
this technique has not been as successful in the An appropriately-sized

drill for the pin is used
clavicle as in the femur or tibia [15, 43, 45, to penetrate the posterior
wall of the clavicle and
83, 84]. The clavicles sigmoid shape poses spe- enter the medullary canal
(Fig. 8). The pin or
cific problems in the use of intramedullary k-wire can then used to
manoeuvre (joystick)
devices. The implant must be narrow and flexible the fracture into a reduced
position together with
enough to pass through the medullary canal and a percutaneous reduction
clamp secured to the
curvature of the clavicle, yet strong enough to medial fragment [13]. A
small incision over the
withstand the forces acting over the fracture fracture site can be made
to assist reduction,
until it unites [25, 33, 85]. Static locking is cur- particularly in comminuted
fractures. This also
rently not possible with the implants that are allows accurate correction
of rotation and length
available. Biomechanical studies suggest that through direct vision of
the intramedullary device
plate fixation provides a stronger construct than as it is inserted across
the fracture site. The med-
intramedullary fixation [86]. ullary canal can then be
prepared to accept the
Implants can be inserted antegrade, through an intramedullary device. The
surgeon should be
anteromedial entry point in the medial fragment, or aware of the potential for
the fracture to be dis-
retrograde, through a posterolateral entry portal in tracted when the pin
engages the medullary wall
the lateral fragment. The medullary canal of the of the proximally-situated
fragment. Available
clavicle is very narrow and therefore, the fracture intramedullary devices
include partially-threaded
site is usually opened through a separate incision to pins or screws, headed pins
and cannulated
expose the proximal and distal parts of the canal to screws. The pin ends can be
left flush to bone
assist implant insertion. The use of a number of minimising disruption to
soft tissues, or left in
different devices, including Knowles pins [70, 78], a more prominent position
for ease of removal.
Hagie pins, Rockwood pins, and minimally- Bone graft or bone graft
substitute can be added
invasive titanium nails, has been described [45]. at the fracture site in an
attempt to shorten
Results of intramedullary fixation have the time to union.
Following thorough irrigation
been more varied than those after plate fixation the soft tissue layers are
closed with interrupted
[43, 70, 78]. Shortening, particularly with commi- absorbable sutures. The
post-operative protocol
nuted fractures, can occur due to an inability is similar to that for
plate fixation.
to statically lock implants [18]. Significant rates
of implant failure, brachial plexus palsy, and
skin breakdown over the insertion site have Other Techniques
also been reported [48, 87]. Intramedullary
fixation has therefore been used less commonly External fixation is
generally suggested only for
than open reduction and plate fixation techniques. open fractures or infected
non-unions [88].
However, It has been argued that the less invasive Kirschner wires and smooth
pins have also been
approach is advantageous in patients with multiple used to hold reduction. A
number of complica-
injuries or other shoulder girdle injuries [45]. tions arising from wire
breakage and migration of
implants have been reported
with catastrophic
Surgical Technique: Retrograde consequences [80, 89]. The
use of these implants
Intramedullary Fixation in the management of acute
closed clavicular
The patient is positioned in the beach-chair fractures is therefore
strongly discouraged.
position in a similar manner to that for plate
fixation. The image intensifier should be posi-
tioned such that multi-planar views of the The Floating Shoulder
clavicle can be obtained, while minimising dis-
ruption to the operating field. An incision is made The term Floating
shoulder has been used to
around two centimetres medial to the AC joint, define an ipsilateral mid-
shaft fracture of the
at the posterolateral corner of the clavicle. clavicle and a fracture of
the scapular neck.
1005
Fig. 8 Retrograde a
intramedullary fixation
with a headed, distally-
threaded, pin. A drill is used
to penetrate the
posterolateral corner of the
clavicle to prepare the
medullary canal (a). Whilst
using pointed reduction
forceps to control the
proximal fragment, the pin
or a wire can be used as
a joy stick to aid reduction
(b). The device can then be
secured across the fracture b
site and bone graft or bone
graft substitute added in an
attempt to shorten the time
to union
Goss [27] described a floating shoulder as a double approximately 0.1 % of all

fractures [91]. This
disruption of the superior suspensory shoulder combination of injuries is
almost always associ-
complex. However, this has been contested by ated with high energy trauma,
usually in associ-
other authors who argue that as the clavicular ation with other injuries
such as head injury, rib
mid-shaft is not part of the SSSC, this injury does fractures, haemo-
pneumothorax, pulmonary con-
not represent a double disruption. Furthermore, tusions, long-bone fractures
and cervical spine
biomechanical studies have demonstrated that ipsi- fractures [92].
lateral fractures of the scapular neck and the cla- No specific classification
system exists for this
vicular shaft do not produce a floating shoulder combination of injury, with
both fractures classi-
without additional disruption of the coracoacromial fied individually. Scapular
neck fractures can be
and acromioclavicular ligaments [90]. divided into two types [27]:
in type A the fracture
Ipsilateral fractures of the scapular neck and line runs to the superior
border of the scapula
shaft of the clavicle are rare and occur in lateral to the coracoid
process (anatomical neck),
1006
I.R. Murray et al.
and in type B fractures the fracture line runs to the scapular fixation [95].
Hashiguchi and Ito [96]
superior border of the scapula medial to the reported satisfactory
outcome after fixation of
corcacoid process (surgical neck). Over 90 % of the clavicle alone in five
patients, although
scapular fractures are type B (surgical neck). recommended this method for
minimally-
Although the diagnosis of floating shoulder is displaced fractures of the
scapula neck, type B
often made on plain radiographs alone, three- (surgical neck) fractures
and those without
dimensional CT reconstruction views offer more involvement of the
coracoclavicular ligaments,
accurate assessment of the fracture configuration, recommending that these
more problematic inju-
displacement and angulation. ries be treated with
fixation of both the clavicle
Despite widespread acceptance that this pattern and scapula. Leung and Lam
reported good or
of injury is unstable, considerable controversy excellent results in 14
patients treated with
remains over the most appropriate treatment for fixation of both the
clavicle and scapula,
these injuries [13]. There is a lack of prospective recommending this approach
to prevent poor
randomised trials evaluating treatment methods, shoulder function resulting
from fracture displace-
with current literature including only a number of ment in non-operatively
treated fractures [92].
small retrospective studies. Possible strategies
include non-operative management, clavicular
fracture fixation in isolation, or fixation of both Complications of Mid-Shaft
Clavicular
the clavicle and scapular fractures. However, due Fractures
to a lack of prospective studies with adequate
numbers, it is not possible to recommend uniform Non-Union
methods of treatment for ipsilateral clavicle shaft
and fractures of the scapular neck. Although non-union was
traditionally considered
Good functional results with non-operative to be rare (reported
prevalence of <1 % following
management have been reported by a number of non-operative treatment)
[25], recent studies
authors. Egol et al. [28] demonstrated compara- report a higher rate of
non-union (up to 15 %;
ble functional outcome scores for patients treated eight of 52) in adults with
displaced fractures
non-operatively and operatively. Furthermore, [3, 25, 32, 38, 39, 67, 69
71, 97]. In a meta-
operatively treated shoulders were found to be analysis of all series of
displaced mid-shaft frac-
weaker in certain movements. Edwards et al. tures from 1975 to 2005,
Zlodowski et al. [62]
[93] reported excellent or good results in 20 found that, for completely
displaced mid-shaft
patients managed non-operatively, including fractures of the clavicle,
the non-union rate with
five with severe displacement (>5 mm) of the non-operative treatment was
15.1 %, while the
glenoid neck. In a retrospective multi-centre non-union rate following
operative treatment was
study, Van Noort et al. [94], showed that in 2.2 %. Increasing age,
female sex, shortening of
the abscence of caudal glenoid displacement, greater than 2 cm, complete
fracture displacement,
non-operative management resulted in good and comminution are thought
to increase the risk
functional outcomes in 28 patients. of non-union [3, 32]. As
most clavicular fractures
A number of authors have recommended occur in a young,
predominantly male population
fixation of the clavicle only. Herscovici et al. [13, 32], the majority of
non-unions occur
[91] reported results on nine patients: seven in patients of this
demographic. Accurately
patients who were treated operatively achieved predicting which patients
will develop non-union
excellent functional scores. Of those treated occur is difficult,
although an assessment of risk
non-operatively, one achieved good functional can be made on the basis of
known independently
scores with the other scoring poorly. A number predictive risk factors for
non-union (Table 2)
of authors argue that fixation of the clavicle neu- [3, 32, 98].
tralizes forces applied to the shoulder, stabilizing Non-unions of the
clavicular shaft are usually
the scapular neck and precluding the need for symptomatic in active
individuals. There are
1007
Table 2 The calculated probability of a non-union at 24 weeks after a clavicle

shaft fracture, based upon age, gender,
comminution and displacement in a study of 581 fractures (Reproduced with
permission from Khan LA et al. [159])
Not displaced, not Displaced, not Comminuted,
not Displaced and
comminuted comminuted displaced
comminuted
Age (years) Males Females Males Females Males
Females Males Females
20 <1 % 2% 8% 16 % 2% 7%
18 % 30 %
30 <1 % 3% 10 % 20 % 4% 9%
20 % 35 %
40 1% 5% 13 % 26 % 5% 12 %
25 % 38 %
50 2% 6% 18 % 28 % 6% 13 %
29 % 40 %
60 2% 7% 19 % 30 % 8% 15 %
31 % 44 %
70 4% 10 % 21 % 37 % 9% 18 %
35 % 49 %
reports in the literature of pain [39, 67, 80, 99, bone fragments with
potentially beneficial
100], a clicking sensation on movement [39, 67], effects on healing over
traditional plates [60, 81].
restriction of shoulder movement [67, 80, 100], Reconstruction and
semi-tubular plates are prone
weakness [39, 67, 100], cosmetic deformity [39, to deformation or
failure when used to treat non-
67, 99], neurological symptoms [80, 99, 101], unions. The use of
wave-plates has been advocated
thoracic outlet syndrome [67, 80, 99, 102], and for clavicular non-
unions to reduce hypertrophic
subclavian vein compression. Patients may com- callus formation, which
may result in thoracic
plain of an inability to perform manual work, outlet obstruction
[105]. Pre-contoured locking
driving difficulty, withdrawal from normal sport- plates specifically
manufactured for the clavicle
ing activities, sleep disturbance, and reduced may also be employed
for non-unions, although
libido secondary to pain [99]. Non-union is results are yet to be
published to our knowledge.
suspected clinically with mobility or pain on Autologous bone-
grafting is widely used and
stressing of the fracture. Radiographic examina- may shorten the time to
union following operative
tions demonstrate an absence of bridging callus treatment of a
clavicular non-union [81, 105, 116].
[32, 103]. If the diagnosis is in doubt, the pres- Iliac crest bone is the
most widely used graft
ence or absence of bridging callus across the to restore length, when
non-union is associated
fracture site can be assessed accurately with with clinically
important shortening and bone
three-dimensional reconstructions of computed loss through
comminution [80]. Vascularized fib-
tomography scans. ular [121, 122] and
medial femoral condylar
[123, 124] grafts have
also been advocated in
Treatment revision cases.
A number of operative techniques have been
described to treat shaft non-unions (Table 3). Surgical Technique:
ORIF Mid-Shaft
Plate fixation is the most widely-used tech- Non-Union of the
Clavicle
nique to treat shaft non-unions (Fig. 3) [30, 55, Patient positioning,
draping and positioning of
60, 67, 7981, 83, 97, 99, 104119], providing the image intensifier
are similar to that of plate
secure fixation and enabling early mobilization of fixation for acute
clavicle fractures with the addi-
the shoulder, with a high rate of union and low tion of contra-lateral
iliac crest site preparation if
risk of complications [80, 104, 105, 107, 111, autologous grafting is
expected. The clavicle is
116, 118120]. Reconstruction [97, 107, 112], approached in the same
way as for acute fractures
dynamic compression [81, 107, 116, 118], and with dissection of the
soft tissues to expose the
low-contact compression plates [60, 81] have all ends of the non-union.
The sclerotic ends and
been used. The foot-printed under-surface of excess callus are
cleared back to bleeding bone
low-contact dynamic compression plates opti- and the medullary canal
re-established with
mally preserve the blood supply to the underlying a drill. Any removed
callus is saved to be
1008
Table 3 Results of English language reports of the treatment of non-union after

clavicle shaft fractures (Edinburgh Type 2) with reported complications and
functional
outcomesa
Number
Persistent nonunions
Technique Authors Method of fixation treated after
treatment (%) Bone graft Complications Functional results
Plating Mullaji and Limited contact - 6 0 (0)
All cases 2 scar sensitivity 6/6 (100 %) full range of
techniques Jupiter [60] dynamic compression
motion
plate
Pedersen 4 hole semi-tubular 12 Not
given All cases 6 failures 9/12 (75 %) good
result
et al. [104]
Olsen et al. Plate fixation 16 1 (6.3)
All cases 1 screw loosening 11/16 (68.7 %) full range of
[105]
motion
Bradbury Plate fixation 15 1 (6.7)
All cases 2 screw cut outs mean Constant score 87
et al. [79]
requiring plate removal
Bradbury Reconstruction plate 17 2 (11.8)
All cases delayed infection mean Constant score 82
et al. [79]
Davids et al. Reconstruction plate 14 0 (0)
All cases I deep infection all normal range of
[97]
motion
Boyer and Plate fixation 7 Not
given All cases all normal range of
Axelrod
motion
[106]
Ebraheim Plate fixation 16 1 (6.3)
All cases 1 removal of hardware all normal range of
et al. [107]
for cosmesis motion
Wu et al. Dynamic compression 11 2 (18.2)
All cases 1 deep infection Not given
[108] or semitubular plate
Ballmer et al. Plate fixation 32 2 (6.3)
65 % 1 wound infection, 23 86 % full range of motion
[109]
plate removals
Laursen et al. Plate fixation 16 0 (0)
All cases 11/12 (91.7 %) constant
[110]
>70 (good/excellent)
Der Tavitian Plate fixation 9 0 (0)
All cases 1 plate breakage 9/9 (100 %) full use
et al. [99]
(semitubular plate)
Marti et al. Wave plate 9 1 (11.1)
All cases 2 delay in wound 7/7 (100 %) Constant score
[111]
healing, 2 infections >80 good/excellent
Marti et al. Plate fixation 19 0 (0)
All cases 1 infection, 4 10/13 (76.9 %) Constant
[111]
brachialgia score>80 good/excellent.
I.R. Murray et al.

Kabak et al. Plate fixation 16 2
(12.5) Selected implant failure, 8 plate mean DASH score
14.8
[81]
cases removals
Kabak et al. Limited contact - 17 0 (0)
Selected 1 plate removal mean DASH score 6.7
[81] dynamic compression
cases
plate
OConnor Reconstruction/dynamic 22 2
(9.1) All cases 6 plate removals, AAOS DASH Mean 55
et al. [112] compression plate
1 deep infection
Coupe et al. Reconstruction/dynamic 19 1
(5.3) Not stated 1 plate breakage Not given
[55] compression
Rosenberg Reconstruction/dynamic 11 0 (0)
Not stated 5/11 (45.5 %) constant>80
et al. [30] compression
Khan et al. Locking plate 9 0 (0)
4 cases 1 infection, 1 reflex mean DASH score 24
[113]
sympathetic dystrophy
Total 293 15
(5.1)
Intramedullary Boehme Hagie intramedullary 21 1
(4.8) All cases 17 pin remonals for Not given
techniques et al. [83] pin
pain
Capicotto Steinman pin 14 0 (0)
All cases 2 refractures, all 12/14 (85.7 %) painless
et al. [114]
hardware removed range of motion
Wu et al. Steinman or Knowles 18 2
(11.1) All cases Not given
[108] pin
Der Tavitian Knowles pin 2 0 (0)
All cases 2/2 (100 %) full use
et al. [99]
Hoe-Hanson Intramedullary 6 0 (0)
All cases 1 screw removal 5/6 (83.3 %) Constant score
et al. [115] cancellous screw
>80 good/excellent
Total 61 3
(4.9)
a
Only English-language studies, or studies with an English-language translation,
appearing in peer-reviewed journals during the last 20 years are shown
AAOS - American Academy of Orthopaedic Surgeons
DASH - Disabilities of the Arm, Shoulder and Hand
1009
1010
I.R. Murray et al.
morsellized and inserted around the fracture site that mal-union was of
radiographic interest only,
at the end of the procedure. Reduction is achieved with success in the clinical
setting equating to
by drawing the two fracture ends together with fracture union [13].
However, it is now accepted
reduction forceps attempting to restore the ana- that mal-union may be
associated with intrusive
tomical shape and natural superior bow of the symptoms [30, 31, 73]
secondary to both
clavicle. The use of an interfragmentary lag anteroposterior angulation
and overlapping of
screw can help to secure a reduced fracture as bone ends [129]. Shortening
of the muscle tendon
the plate is applied. Alternatively, the reduction units over the site of mal-
union may cause weak-
can also be held temporarily with k-wires. As the ness and increase fatigue,
and pseudo-winging of
fracture configuration and lag screw position the scapula [13]. Angular
deformity and shorten-
often interfere with the placement of ing may also alter the
orientation of the glenoid,
central screws, a plate with at least eight holes changing the shoulder
dynamics [131]. Bony
is advocated. In short oblique or transverse encroachment into the
thoracic outlet often
fracture patterns the first screws on either side results in numbness and
paraesthesia that may
can be used in compression mode. The wound is be exacerbated by overhead
activities and is usu-
irrigated thoroughly and the prepared morsellized ally noted in a C8-T1 nerve
root distribution.
graft inserted into the fracture site. The majority Patients may also complain
of discomfort when
of non-unions are atrophic and therefore wearing bags and with
shoulder straps on clothes.
often require addition of autologous iliac crest The factors that
predispose to symptomatic
graft or bone substitute. Wound closure and mal-union are unclear. Hill
et al. [132] reported
post-operative protocol are the same as for acute an association between
shortening of over 2 cm,
fractures. poor outcome and
dissatisfaction with other stud-
ies also supporting this
finding. A number of
Other Methods authors have doubted the
clinical relevance of
Intramedullary fixation [83, 99, 100, 108, 114, shortening, despite its
frequency following frac-
115, 125] and external fixation [88, 120] produce ture [133, 134]. In a
prospective study evaluating
more cosmetically acceptable incisions and disturb risk factors for long-term
functional problems,
the soft-tissue envelope less [83, 114], but provide initial displacement, and
increasing age were
less rigid fixation [70, 80, 116]. Papineaus tech- independently predictive of
symptomatic mal-
nique [126] of external fixation has been utilized union [103]. In this series,
shortening was not
rarely to treat infected pseudoarthroses [61]. associated with poor
outcomes.
Severe bone loss may occur with infection and
multiple failed operative procedures. In such cir- Treatment
cumstances the most radical option is partial or Patients with symptomatic
mal-union despite
complete excision of the clavicle [15, 127, 128]. strengthening physiotherapy
can either accept
Given the clavicles pivotal role in providing the disability or undergo a
further operative pro-
support for the upper extremity this must only cedure that aims to improve
their symptoms [13].
considered a salvage procedure in the most Young, healthy patients with
good bone quality
extreme circumstances [13]. should be considered for
surgery. The patient
should have sufficiently
intrusive symptoms
specific to their clavicular
mal-union to warrant
Mal-Union surgery without any
guarantee of benefit [13].
Corrective osteotomy and
plate fixation has
Although the majority will be asymptomatic, it is been shown to improve
function in patients
inevitable that all displaced clavicular fractures with neurovascular
compression, discomfort and
treated non-operatively will heal with some weakness, or cosmetic
deformity [30, 59, 130,
degree of mal-union due to angulation or short- 131, 135]. An intramedullary
device for
ening [129, 130]. Traditionally, it was thought stabilisation has also been
described [20].
1011
Although restoration of the normal shoulder con- Operative decompression of

the brachial plexus
tour and function has been reported in the litera- by reduction and fixation of
the clavicular frac-
ture, there is only limited information available ture is indicated in the
presence of direct neuro-
on the treatment of symptomatic post-traumatic logical injury [19, 53, 140
143].
shortening in the absence of neurovascular Chronic mal-union or
non-union associated
compression [60, 131, 135137]. with hypertrophic callus
formation, subclavian
pseudoaneurysm, or scar
constriction (delayed
Surgical Technique: ORIF Mid-Shaft type) may result in a more
insidious onset of
Mal-Union of the Clavicle neurovascular symptoms [19,
20, 101, 141, 142,
Clinical and radiological measurement of the 144149]. This condition has
been described as
deformity are essential pre-operatively to assess thoracic outlet syndrome,
costoclavicular syn-
the success of surgery. Patient positioning and drome, and fractured
clavicle-rib syndrome
surgical approach are similar to those used for [146, 150]. Typically, the
medial cord of the
acute fracture fixation [59]. Having cleared the brachial plexus is impinged
by callus around
non-union site, marks are made proximally and the fracture site superiorly
and by the first rib
distally to enable measurement of any lengthen- inferiorly (costoclavicular
space), producing pre-
ing to be made. The original fracture plane is dominantly ulnar nerve
symptoms. Hypertrophic
usually identifiable because of the typical pattern non-union or mal-union
predispose patients to
of the fracture ends relative to each other, with this condition [19, 80, 101,
142]. The diagnosis
the osteotomy performed through this plane. In is subjective, and the
prevalence of this condition
cases where the original fracture line is not easily is therefore poorly defined.
In 1968, Rowe [25]
recognised, an oblique sliding osteotomy can be reported late neurovascular
sequelae after 0.3 %
performed [138]. The medullary canal is re- (two) of 690 fractures,
although prevalences of
established with a drill to restore blood supply between 20 % and 47 % in
series of between 15
to the osteotomy site. Any lengthening can be and 52 patients have been
reported in more recent
determined by re-measuring the distance between studies [57, 71, 99, 147].
the original marks. The pre-contoured clavicular The diagnosis should be
made only when a
plate is then applied over the osteotomy on the patient has a suggestive
history with supportive
postero-superior surface. Adjuvant autologous evidence on
electrophysiological testing [20],
bone-grafting can be used in some cases. arteriography or venography
[21, 23], and
There is limited literature available on the timing specialized imaging.
Treatment should be
of treatment, although corrective osteotomy directed toward correction
of the underlying
performed within 2 years of the fracture appears cause generally the mal-
union or non-union to
to produce better results than when performed re-establish the dimensions
of the pre-injury
a long time after fracture healing [139]. thoracic outlet [19, 20,
101, 142, 149]. Attempts
to simply remove the bump
deformity at the
mal-union site or the first
rib have a high failure
rate as the condition
results from the change in
Neurovascular Complications dimensions of the thoracic
outlet from the
displaced fracture segment
rather than local
Although acute nerve compression may result impingement [13].
from displacement of fracture fragments, most
neurovascular injuries result from excessive trac-
tion [13]. Classically, the clavicular fragments
are distracted rather than shortened in these inju- Re-Fracture
ries. Angiograms can confirm the presence of
vascular injury and can potentially be therapeutic Re-fracture of the clavicle
has been reported
if interventional techniques are available. following fractures treated
operatively and
1012
I.R. Murray et al.
non-operatively. Recognised risk factors include therapy. Deep infections may

occur early or as a
an early return to contact sports, epilepsy and delayed phenomenon, as with
any implant- related
alcoholism [151]. Further trauma with implants infection. Early sepsis with
a stable implant should
in situ may result in fractures at the end of be treated with a protocol
of repeated debridement
plates, or implant breakage or bending [13, 55, and irrigation with a
prolonged parenteral and
99, 114]. Fractures occurring following plate then oral antibiotic
therapy. More radical debride-
removal may occur through the original fracture ment and metalwork removal
may be required
site. Osteoporosis below the plate and the stress to eradicate persisting
infection. Immediate
riser effect at the empty screw holes may con- reconstruction with plating,
bone grafting, and
tribute to re-fracture risk [51, 53, 152]. Internal local antibiotics may be
considered in healthy
fixation is often required following re-fracture patients. Alternatively,
antibiotic-impregnated
because of the high risk of non-union [18]. beads or bone substitute can
be inserted as a tem-
Fractures occurring at the end of a stable porizing measure with
reconstruction performed
implanted diaphyseal plate generally require fix- at a later date. Skin and
soft tissue loss may occur
ation that should ideally span the area of bone in these patients requiring
plastic surgical input
previously repaired in addition to fixing the with soft-tissue flap
coverage [157, 158].
fresh fracture [13].
Other Complications of Operative Conclusions

Treatment
It is widely accepted that
undisplaced fractures of
A feared potential intra-operative complication is the mid-shaft of the
clavicle are best treated non-
injury to the subclavian artery or vein at the time operatively. Although good
outcomes have been
of fracture immobilization or from drill penetra- reported after operative
treatment of acute diaph-
tion [18]. The risk of this complication is low, yseal fractures, it is
difficult to predict which
but if it occurs is potentially catastrophic neces- patients should be offered
primary operative
sitating vascular or cardiothoracic surgical reconstruction and which
technique should be
intervention. Plate failure [53], hypertrophic or used. Factors associated
with a poor prognosis
dysaesthetic scars [153], implant loosening with non-operative treatment
include displace-
[53, 152], have been reported and may require ment (especially
shortening), comminution and
revision surgery. an increased number of
fracture fragments. Oper-
ative reconstructions of
diaphyseal non-unions
have good outcomes, and the
large number of
Infection case series documenting
consistently good out-
comes after plate fixation
lends support to the use
The use of peri-operative antibiotics, selective of this technique as the
treatment of choice. Ran-
operative timing to optimize soft tissue conditions, domized studies are required
to refine the indica-
improved soft tissue handling, two-layer soft tions for primary operative
repair and to establish
tissue closure, and biomechanically superior the most appropriate method
of treatment.
fixation have all been shown to decrease the high
rate of deep infection reported in early series
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Acromioclavicular Injuries
Jonas Franke and Lars Neumann
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1019
Acromioclavicular joint # Aetiology and clas-
sification # Anatomy # Chronic injuries-weaver

Anatomy and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . 1020
Dunn and Surgilig techniques # Complica-

Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . 1020
tions # Diagnosis # Injuries # Operative
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1023 techniques-acute injuries # Rehabilitation #
Results # Surgical indications

Management and Indications for Surgery . . . . . . 1024
Chronic
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1026
Pre-Operative Preparation and Planning . . . . . . 1026
Introduction
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026
Surgical Treatment for Acute AC-Joint
Injuries to the acromioclavicular joint are
Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1027 common. They are usually caused by a direct
Authors Preferred Method . . . . . . . . . . . . . . . . . . . . . . 1027
fall on to the top of the shoulder and are more
common in younger adults than in children and

Surgical Treatment for Chronic AC-Joint
Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1029 elderly. The contentious issue about conservative
or surgical treatment for these injuries seem to be

Authors Preferred Method . . . . . . . . . . . . . . . . . . . . . . 1030
a never- ending debate within the Orthopaedic

Alternative Method with Use of the Artificial
community. The majority of these injuries can
Ligament, the Nottingham Surgilig . . . . . . . 1031
be treated conservatively and usually with very

Post-Operative Care and Rehabilitation . . . . . . . . 1032
good results. However, for the more severe inju-
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1032 ries with greater displacement, surgery is usually
recommended early. For those with chronically

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1033
painful and unstable joints, surgical treatment

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1035 may be required at a later stage.
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1035 Already Hippocrates realized that there would
be a tumefaction or deformity from such an
injury for the bone cannot be properly restored
to its natural situation but he also stated that no
impediment, whether small or great, will result
from such an injury. This statement, as

J. Franke (*) # L. Neumann
Rockwood has commented, Apparently was,
Nottingham Shoulder and Elbow Unit, Nottingham
University Hospitals, Nottingham, UK
has been and will be received by the Orthopaedic
e-mail: jonas.franke@aol.se; larsneumann@me.com
community as a challenge [1].

1019
DOI 10.1007/978-3-642-34746-7_256, # EFORT 2014
1020
J. Franke and L. Neumann
There are numerous arthroscopic and providing stability

throughout the range of move-
open procedures described in the literature. ment of the joint [4].
Several authors are also
We will focus on one method for the emphasizing the importance of
the deltotrapezius
acute open repair and two slightly different muscle fascia for the overall
stability of the joint.
techniques for coracoclavicular ligament There is a fibrocartilagenous
diskc(meniscus) in
repair of the chronically symptomatic disloca- the joint with great
variation in shape and size.
tions; a modified Weaver-Dunn procedure and Injuries to the stabilizing
structures can result in
a repair using an artificial ligament, the Notting- instability and subsequently
in various degrees of
ham Surgilig. dislocation of the joint.
With the joint dislocated
the clavicle will, to some
extent, lose its function
as a strut and the whole of
the shoulder girdle will
Anatomy and Function subsequently be somewhat
destabilised.
The acromioclavicular joint is the diarthrodial

joint between the lateral end of the clavicle Aetiology and Classification
and the medial facet of the acromion. There is
considerable variation in topography of the It has been suggested that as
many as 40 % of
acromioclavicular joint from subject to shoulder injuries affect the
AC-joint and that
subject. Bosworth has stated that the average AC-joint dislocations
accounts for 8 % of all
size of the acromioclavicular joint surface is joint dislocations in the
body [58]. It is more
9 # 19 mm [2]. The inclination of the joint, common in males and in the
age group under
when viewed from the front, may be almost 35 and it is commonly a
sports injury predomi-
vertical or inclined diagonally from medially nantly associated with horse
riding, alpine
inferiorly to more lateral superiorly and thus skiing, snowboarding, ice
hockey, rugby
with the clavicle over-riding the acromion with etc. [6, 912].
an angle sometimes as large as 50# . The majority Injuries to the AC-joint
are most often caused
of movement taking place in the joint is by a fall on to the point of
the shoulder with the
rotation in the long axis of the clavicle. How- arm adducted [13]. The AC-
joint separation is
ever, the degree of rotational movement in caused as the direct force of
the blow drives the
the joint as such is fairly limited (5# 8# ) since acromion and shoulder girdle
inferiorly, whereas
there is simultaneous rotation of the scapula the clavicle remains in its
anatomical position
synchronous scapular rotation. [13, 14]. Once the
stabilizing structures are dam-
The acromioclavicular joint is stabilized by aged, the joint is left
unstable and the remaining
the acromioclavicular (intra-articular) and displacement is a result of
the force of gravity on
coracoclavicular (extra-articular) ligaments as the affected arm causing
vertical displacement
well as the deltoid and trapezius muscles. The and the tractional force of
the trapezius causing
coracoclavicular ligaments are divided into the posterior displacement.
conoid and trapezoid ligaments. The relationship The severity of an injury
to the AC-joint is
of the clavicular and the acromial component determined by the
preservation, or loss of struc-
of the joint is kept rather stable throughout its tural integrity of the
acromioclavicular and
range of movement. It has been suggested that coracoclavicular ligaments
and by the degree of
the anteroposterior stability is provided by damage to the muscular
attachment of the Deltoid
the acromioclavicular ligaments and that the and Trapezius [1417]. In a
more severe lesion
superoinferior stability is supplied by the with subluxation or
displacement of the joint, the
coracoclavicular ligaments [3]. The conoid and periosteum is torn away from
its attachment to
trapezoid ligaments run obliquely from the cora- the inferior surface of the
clavicle. This explains
coid to the clavicle in opposing directions and are the frequent radiographic
finding of subperiostial
analogous to the cruciate ligaments of the knee, new bone formation, inferior
to the clavicle,
1021
following these injuries (Fig. 1a). With increas- These six classifications of
AC joint dislocations
ing force the deltoid and trapezius muscles and are based on the patho-
anatomy and clinically
the clavipectoral fascia, and its condensations are determined by the degree and
direction of dis-
torn from a lateral to a medial direction. placement of the clavicle
(Fig. 2).
The miniscus usually maintains its attachment The Rockwood type I
injury is a sprain, or
to the acromial side of the joint in the complete incomplete injury to the
acromioclavicular liga-
dislocations [4]. ments, with no involvement of
the coracoclav-
After the early works of Cadenet, describing icular ligaments. The joint
is still completely
this sequential patho-anatomy, and previous clas- stable.
sifications by Allman, Tossy and Bannister, The type II injuries
constitute a complete injury
Rockwood and colleagues came up with the to the acromioclavicular
ligaments and an incom-
classification most widely used today [1820]. plete injury to the
coracoacromial ligaments.
Fig. 1 (continued)
1022
Fig. 1 (a) A shoulder AP view of a grade V dislocation in 4 months after trauma,

showing ossification inferior to the
a 30 year-old woman. (b) Axial view x-ray clearly clavicle due to the
detachment of the inferior periosteum.
displaying posterior displacement in the same patient. (d) The same patient as
in Fig. 1ac after Surgilig
Blue arrows indicate clavicle and red the acromion. (c) procedure and removal
of inferior osteophytes on the
Pre-operative films of the same patient as in (a) and (b) clavicle. Note the
clips on the strap incision
There might be some widening of the joint but Type IV injuries are
defined by an additional
only very slight, if any, step deformity in the joint. posterior displacement
of the clavicle, the lateral
In type III injuries both the acromioclavicular end of the bone may
even penetrate posteriorly
and coracoclavicular ligaments are torn through the trapezius.
completely, always resulting in instability and The type V injury
represents a superior dis-
usually also significant, but not severe displace- placement of the
clavicle, which is significantly
ment of the joint, mainly restricted to the sagittal more than in a type III
injury, due a more exten-
plane with the clavicle positioned higher than the sive to loss of the
muscular attachments of the
acromion. deltoid and trapezius
muscles on the clavicle.
1023
Type I Type II Type

III
Type IV Type V Type

VI
Fig. 2 The six classifications of AC-joint injuries according to Rockwood
A type VI injury constitutes a clavicle palpation over the joint

and loading of the joint
displaced inferiorly to the acromion or even will trigger indirect
pain. Pain is localised to the
under the coracoid process. joint and will be
triggered by the cross-body
adduction test when the
arm is in 45# of eleva-
tion and adducted across
the chest. The cross
Diagnosis body test can trigger
pain also in impingement
cases but it thus tends
to be localised more
The diagnosis of an acromioclavicular joint dis- laterally and
subacromial. Sometimes it is also
location is primarily clinical and radiological, possible in this
manoeuvre that the highly
although other methods have been tried [2126]. unstable clavicle will
slide over the cranial
The patient will typically describe a traumatic surface of the acromion.
onset with a fall on to the top of the shoulder In a case with large
displacement the diagnosis
and complain of pain localised over the AC-joint, is obvious, but with
milder cases applying down-
sometimes extending medially along the clavicle. wards, traction to the
arm may reveal the insta-
In more chronic cases, particularly when there is bility, as if gravity
alone does not manage to
no large displacement present, the pain is usually displace the unstable
joint, adding the extra
fairly localised and the patients often point force may do so.
with their finger to the joint when describing To reduce the joint
one must push the arm
the pain source, The finger sign. With upwards whilst
stabilizing the clavicle with
a careful history taking and a good clinical exam- ones opposite hand. To
obtain reduction it may
ination, x-rays will but confirm the clinical be necessary to direct
the upward push slightly
diagnosis. posteriorly and to add
an anteriorly-directed force
A clinical examination will, as for all joints, to the clavicle if there
is significant posterior
consist of inspection, palpation and movement. dislocation. It is
usually not possible to reduce
There will be weakness on flexion and abduc- the dislocation simply
by pushing the clavicle
tion, particularly above 90# in milder cases, downwards. It is rather
the arm that is displaced
a decrease in range of movement with regards inferiorly as described
earlier not the clavicle that
to flexion and abduction, tenderness on is lifted.
1024
As with any musculoskeletal injury, radio- A patient with a type III

AC-joint injury will
graphs must be obtained in two planes, often keep the arm adducted
and supported to
anteroposterior and lateral. An AP view of the relieve pain. The shoulder
complex will typically
shoulder alone is not sufficient since this does be depressed as mentioned
with the lateral end of
not provide a clear view through the AC-joint the clavicle prominent and
seemingly lifted
and there will be overlying shadows from other above the level of the
acromion. AP-view
structures, typically the scapular spine. The cor- X-rays will, for the type III
injury, usually reveal
rect AC-joint AP view is obtained with a 30# displacement with an
increased coracoclavicular
cranial tilt of the x-ray beam and this should be distance, but it can
sometimes be necessary to
routinely used. With a correct AP view there is conduct stress views as
discussed above.
good visualisation not only of the AC-joint as In type IV injury the
posteriorly-displaced
such but also of the coracoid, and the clavicle can sometimes
protrude through the tra-
coracoclavicular distance can consequently be pezius muscle and be clearly
palpated subcutane-
measured to estimate the degree of vertical dis- ously (Fig. 3). X-rays and
particularly the lateral
placement of the clavicle. The lateral, or axial, view will confirm the
posterior displacement and
views are most important to detect any horizon- hence the diagnosis.
tal and posterior displacement and thus differ- It is sometimes difficult,
however important, to
entiating type III and IV injuries, whereas the clinically differentiate the
type III lesion from the
AP views will uncover any supero-inferior type V, where the superior
displacement is signif-
translocation. Furthermore, because there is a icantly larger. The latter
will leave the patient in
significant variation between individuals in nor- considerably more pain, not
rarely continued
mal AC-joint anatomy, the contra lateral joint medially because of the
damage to the insertion
should consequently always be imaged of the deltoid and trapezius
muscles and the
(Fig. 1ad). periosteum further medial on
the clavicle. Again
Stress views can be used to indicate the integ- x-rays will provide support
for the diagnosis and
rity of the coracoclavicular ligaments and have may show a very marked
increase (up to two to
proven to unmask grade III injuries in patients three times normal or more)
of the
with relatively normal plain x-rays [27]. How- coracoclavicular distance. A
comparison with the
ever, it is generally not suggested as a routine other side will define the
normal coracoclavicular
due to its low yield. About 5 kg of weights are distance for the particular
patient.
suspended by loops of webbing round the wrist. The rare type VI injuries
are usually the result
Holding the weight in the hand prevents total of high energy injuries and
are not rarely associ-
relaxation of the muscles around the shoulder ated with concomitant
injuries such as clavicular
and might hinder coracoclavicular separation. and rib fractures and
vascular and brachial plexus
A patient with a type I injury usually has only injuries. The complexity and
severity of this
mild to moderate pain localised distinctly on the injury will frequently
necessitate other investiga-
AC-joint. Pain is triggered or enhanced with tions such as CT-scans and/or
MRIs.
loading of the joint. There is no displacement
clinically and x-rays are normal also when com-
pared to the other side. Management and Indications
for
The type II injury is characterised by pain and Surgery
moderate swelling over the joint and x-rays can
reveal a widening of the acromioclavicular joint, The correct management for
the acute
but no significant vertical displacement should be acromioclavicular injuries
will depend on the clas-
present. If stress X- rays are made there is no sification type of the injury
and on patient factors.
increase in the coracoclavicular distance, since The conservative management
of Rockwood type
the damage to the coracoclavicular ligaments is I and II lesions is fairly
unchallenged historically
not complete. and in modern literature [28,
29].
1025
Fig. 3 Severe posterior dislocation in a grade V injury. The clavicle is

penetrating trough the trapezius muscle
posteriorly and can clearly be seen to over-ride the acromion
The patient suffering a type 1 injury requires deformities may very well
have good functional
no treatment and symptoms will usually subside results [39, 4143].
However, a considerable
within a couple of weeks, even though number of patients do not
become pain-free, and
prolonged symptoms up to 6 months have been are left with discomfort
around the shoulder,
reported. It is also believed that type 1 injuries weakness, and inability to
pursue demanding
and even undiagnosed type 1 injuries will occa- physical activities,
particularly throwing and
sionally cause later post-traumatic AC-joint overhead sports.
Furthermore surgery and ana-
osteoarthritis. tomical restoration of the
joint does not always
For the patient with a type II injury the arm is relieve symptoms
completely [34, 40, 4448].
kept in a sling until pain is under control and early However, It has also been
suggested that the
mobilization is encouraged, not loading the arm results from early
surgical treatment exceed
or returning to sports or heavy manual labour for those of the delayed
therapy for chronic symp-
usually 68 weeks. An almost full recovery can toms [49]. No study has to
our knowledge suc-
generally be expected [13]. However later AC- cessfully delineated a
group of patients who
joint osteoarthritis or arthropathy could result would definitely, with
statistic significance, ben-
from this injury [30]. efit from an early
operation. By offering all early
There is a widespread agreement that the surgical treatment
however, some would
Rockwood type IV, V and VI injuries should undoubtedly have an
unnecessary operation.
be subjected to surgical repair [29]. Hence the The difficulty thus
lies in selecting the right
controversy concerns the type III lesions where candidates for surgery
after an acute type III
the debate is vivid and good scientific evidence injury. It is generally
argued that surgical repair
still scarce and somewhat contradictory [5, 29, for the acute type III
injury should be considered
3140]. in the younger, more
athletic individuals and
Multiple studies have reported that even heavy manual workers,
especially those
patients with reasonably large residual involved in overhead
activities. Other factors
1026
in favour for early surgery are injuries to the case that additional
calcifications has
dominant side and a highly unstable joint. The formed in the meantime,
often inferior to the
patient must be trusted to comply with the post- clavicle or along the torn
coracoclavicular liga-
operative programme and, as always, surgical ments (Fig. 1c). Other
abnormalities, such as
treatment should be strongly questioned in the osteolysis of the lateral
clavicle, may also have
unreliable patient with alcohol or drug abuse or developed.
with a considerable mental disorder. It is also The neurovascular
status of the affected arm
important not to underdiagnose the more unsta- should be thoroughly
checked and clearly noted
ble type V injuries as type III injuries since the pre-operatively since
concomitant damage to
patients with the more severe injury, particularly these structures may have
occurred at the time
if younger or heavy manual workers will proba- of the trauma or developed
over time and because
bly be best helped by being treated early. of the close proximity of
the neurovascular bun-
dle to the coracoid process
and the surgical field
and the risk of iatrogenic
damage.
Chronic Injuries We use for all our AC-
joint procedures
the deck-chair position
with the patients head
For the chronically symptomatic AC-joint inju- slightly tilted away from
the affected
ries the decision-making, is more straightfor- shoulder (Fig. 4). We
generally do not use image
ward. In the case of persistent pain, i.e. intensifiers but this could
of course be considered
secondary osteoarthritis or post-traumatic at the surgeons discretion
in particular cases. The
arthropathy after a type I or II injury, where the arm and shoulder is
scrubbed and draped.
coracoclavicular ligaments are preserved and
the joint is still stable, a resection of the lateral
clavicle according to Mumford is usually Operative Techniques
quite successful [50]. However for the chronic
type III to VI injuries with unstable AC-joints There is an abundance of
methods described
a clavicular resection as above should always be in the literature for the
treatment of both acute
accompanied by a stabilization of the clavicle and chronic dislocations
[17, 5274]. This
[50, 51]. in itself probably
indicates that none of them
are entirely satisfactory.
Historically a great
variety of operations has
been performed
Pre-Operative Preparation and modern techniques,
whether open or
and Planning arthroscopic, use a
combination of a few
basic principles:
acromioclavicular repair and
It is important to have x-rays of the contra lateral fixation, coracoclavicular
repair and fixation
AC-joint as part of the pre- operative planning. and resection of the
lateral clavicle.
As mentioned there are large variations in anat- Acromioclavicular fixation
can be achieved
omy and in some individuals the normal AC-joint with pins, screws, suture
wires, plates etc and
can have a vertical step with the lateral end of the can be performed with or
without
clavicle at a higher level than the acromion. It is acromioclavicular and/or
coracoclavicular
important to consider this to avoid over- ligament repair.
Coracoclavicular fixation can
correcting the displacement with a too- tight be achieved with a screw,
wire, fascia, conjoined
repair. tendon, synthetic sutures
or implants and can
It is furthermore important when dealing be performed with or
without acromioclavicular
with the chronically symptomatic injuries and coracoclavicular
ligament repair or
to have fairly recent x-rays. Even if the diagno- reconstruction.
sis as such can be based on clinical examination The original Weaver Dunn
procedure which
and on previous x-rays it is not rarely the was described in 1972 uses
a transfer of the
1027
Fig. 4 Set-up of the patient

for a right shoulder
Surgilig procedure in the
deck-chair position with
the head slightly tilted to
the left. The procedure is
performed under local
block anaesthesia
coracoacromial ligament to the clavicle to restore possible of the intra-

articular disk. We do not
coracoclavicular stability (Fig. 5) [51]. Bosworth believe that a direct
repair of the
used a screw to achieve coracoclavicular stability coroacoclavicular ligaments
is necessary since
under local anaesthesia without exploring either it requires further
dissection and since good
the acromioclavicular joint or ligaments nor the enough stability has been
proven to occur by
coracoclavicular ligaments [75]. A more recently- direct healing following
acromioclavicular
described technique suggests the use of repair and fixation alone.
All other ruptured
a semitendinosus allograft instead to reconstruct structures including the
acromioclavicular liga-
the ligament [76]. Other authors use Hook plates to ments as well as the
deltoid and trapezius
achieve acromioclavicular stability [77]. Good muscles insertions should
of course be repaired
results have also been reported simply by closed as well.
reduction and percutaneuos pinning under image By using K-wires for
temporary transfixation
intensifier. Several authors have recently reported of the AC joint it is
possible to correct both the
on successful series of arthroscopic repairs [57, 60, horizontal and vertical
dislocation with great
78, 79]. Boileau et al. used a double-button in accuracy and thus to
achieve a correct reduc-
their arthroscopic technique whereas others have tion of the joint. We
believe that this is not as
used suture anchors to achieve coracoclavicular easily achieved neither
with coracoclavicular
stability [57, 80]. fixation, be it with a
Bosworth screw or wires
or sutures, nor with the
use of the hook plate.
Again, since, in the acute
case, the aim is to
Surgical Treatment for Acute AC-Joint restore the joint without
any resection of the
Displacement clavicle, it is important
that exact reduction is
reached.
In the case of surgery for an acute dislocation,
the aim is to restore a functioning anatomy as
close to normal as possible. We recommend an Authors Preferred Method
open technique for repair of an acute AC-joint
dislocation. We believe that it is important to The patient is set up in a
deck-chair position
restore the anatomical position and integrity of (Fig. 4) with the head
slightly tilted to the contra-
the joint and its capsular ligaments and if lateral side. A 57 cm
strap incision is made
1028 J.
Franke and L. Neumann
Fig. 5 Post-operative
x-rays after a Weaver-Dunn
procedure where the
displacement of the clavicle
has been over-corrected
starting 2 cm posterior to the clavicle and 1 cm

medial to the AC-joint (Fig. 6). The skin is
undermined. The AC-joint together with the
deltotrapezius muscle fascia and lateral clavicle
is exposed (Fig. 7). Usually the deltotrapezius
muscle fascia is at least partially ruptured by
the trauma, but if not it should be incised hori-
zontally over the lateral 5 cm of the clavicle and
the muscles should be mobilized accordingly.
The joint is then reduced and the capsule and
the acromioclavicular ligaments are tagged with
untied sutures.
Two 2.5 mm k-wires are used to transfix the
joint in the correct anatomical position. It is
recommended that these wires are double pointed
and introduced in the acromion articular surface Fig. 6 Strap incision
and pulled out posterolaterally through the skin
before again being backed medially into the Furthermore, the medial end of
the wires will
clavicle. However, it is not always possible to with this technique penetrate
the clavicle more
access the acromion this way and alternatively anterosuperiorly, which is
safer with regard to
the wires can be introduced from lateral through the neurovascular bundle
inferior to the bone. In
the skin over the acromion first. the case of fracture and
migration the wires will
We recommend that the wires are directed also most probably penetrate
through the skin
slightly obliquely towards the posterior aspect anteriorly before they have a
chance to escape
of the acromion since the bone is usually thicker to anywhere else. It is also
important that the
here which makes it easier to stay in the bone far cortex of the clavicle
anterior-superiorly
since the anterior part of the acroimion can is penetrated and that the
wire is then not drilled
sometimes be rather thin (Fig. 9). We also back and forwards which may
unnecessarily
believe that there is a mechanical advantage widen the hole which could
increase the risk
with this diagonal placement of the wires. of wire loosening and
migration.
1029
Fig. 7 Figure of
7 incision of the deltoid,
with the use of the bipolar
diathermy
The sutures in the capsule and acrom- a stable link between

the scapula and the clavicle
ioclavicular ligaments are then tied with eliminating direct
contact between the coracoid
particular attention to restoring the position and the acromion and
avoiding impingement
of the intra-articular disk. However if it is between the coracoid and
the clavicle. We
severely damaged or degenerated it should strongly believe in the
use of multiple absorbable
rather be removed. The deltotrapezius muscle sutures for temporary
coracoclavicular stability as
fascia and the muscle insertions are then care- this will give a good
enough stability initially
fully restored with heavy absorbable sutures. during the healing but
will eliminate the possible
The K-wires are then cut and bent laterally. late problem of non-
absorbable sutures eroding
We tend to leave the wires bent over the skin into the clavicle. The
need for a second procedure
which clearly facilitates the removal of them but to remove screws or
other implants is also elimi-
they could of course be left subcutaneously nated by this technique.
Alternatively when the
under the skin if preferred. Finally, routine sub- coracoclavicular
ligament is absent or of poor
cutaneous and skin closure of the wound is quality or in the rare
event of a re-do stabilization
performed. we use the Nottingham
Surgilig artificial ligament.
Whatever technique is
used it is important to
achieve enough resection
of the clavicle. Great
Surgical Treatment for Chronic care must be taken not
to resect too much bone.
AC-Joint Displacement Too little resection
will result in painful impinge-
ment between the
acromion and lateral end of the
For the case of a stable but symptomatic chronic clavicle. Too much
resection will jeopardise
type I or II injury with possible arthritis we, as other stability.
authors, recommend an arthroscopic AC-joint If calcifications or
osteophytes are present in the
excision. This procedure is described elsewhere. torn coracoclavicular
ligaments or inferiorly along
However, for the unstable chronic type III or the clavicle they should
be removed not to hinder
higher grade injuries we use a modified Weaver reduction or cause
coracoclavicular contact and
Dunn procedure where additional temporary sup- impingement. It is
probably better, for the same
port and stabilization is achieved through multiple reason, to accept a
slight step deformity, and not
absorbable sutures tied around the coracoid and fully correct the
vertical dislocation than to
the clavicle. The aim of this procedure is to restore overcorrect the
displacement. If only the vertical
1030
displacement of the clavicle is corrected and not 1

the posterior, there is a risk of the posterior corner
of the clavicle meeting the acromion even if a good
bone resection has been performed which may
2
result in painful impingement. Adequate reduction
of the posterior displacement can sometimes be
hindered by the shortened clavicular fibres of the
3
trapezius muscle and a thorough release of the
muscle is therefore necessary. It is occasionally
also needed to divide even the acromial fibres of
the muscle since they cause direct pressure on the
clavicle and thus hinder reduction.
Authors Preferred Method
The patient is set up in a deck-chair position

with the head slightly tilted to the contra-lateral Fig. 8 Deltoid muscle
incision
side. A 710 cm strap incision is made starting
2 cm posterior to the clavicle and 1 cm medial to
the AC-joint continued forwards to the level of
the tip of coracoid process. The skin is
undermined. The displaced lateral end of the
clavicle and the deltotrapezius muscle fascia is
identified. The deltoid muscle incision is made as
a figure of seven (Figs. 7 and 8): the muscle is
split along its fibres from just over the tip of the
coracoid and onto its insertion on the clavicle.
The deltoid and trapezius fasciae are then divided
along the clavicle and the periosteum is lifted to
both sides and the trapezius and deltoid insertions
are mobilised. A triangular flap of the deltoid
muscle is thus made and retracted laterally with
a stay suture in the superomedial corner. This
gives a very good access to the coracoid process Fig. 9 Correct placement
of K-wires for Ac-joint
and the coracoacromial ligament. As mentioned transfixation
it is crucial to do a good release of the trapezius
muscle insertion, as otherwise a complete reduc-
tion of the posterior horizontal displacement of AC-joint not getting
squeezed there is usually
the clavicle would not be possible. Once the an adequate gap.
muscles have been mobilized the clavicle can be The medullary canal of
the clavicle is curetted
lifted using a bone clamp to allow any inferior and two 2 mm holes are
drilled through the supe-
osteophytes and calcifications to be cleared. rior cortex, 1 cm medial
to the resected joint
The AC-joint is by now well exposed and surface of the clavicle,
into the medullary canal.
about 0.51 cm of the lateral clavicle is excised, The coracoacromial
ligament is released by
leaving a gap of 11.5 cm in the reduced joint. If mobilising its insertion
with a bone chip from
the patients arm can be elevated above 90# the acromion. Two heavy
non-absorbable
with the surgeons index finger in the reduced sutures, No 2 Ethibond,
are sown into the
1031
Fig. 10 The
coracoacromial ligament
mobilised and tied with
sutures into the medullary
canal of the clavicle
mobilised ligament in a Kessler fashion. Should

the ligament be too short to reach the medullary Alternative Method with
Use of the
canal of the clavicle it can be lengthened some- Artificial Ligament, the
Nottingham
what by detaching the anterior part of its coracoid Surgilig
insertion. No less than 68 strands of No 2 Vicryl
absorbable sutures are then passed with a suture Should the coracoacromial
ligament be absent or
passer around the coracoid from medial to lateral of poor a quality we
instead use the Surgilig
and around the clavicle. The non-absorbable ligament, a polyester
implant specifically
sutures from the acromioclavicular ligament are designed for this purpose
[8183] (Fig. 11). The
passed into the medullary canal of the clavicle incision and approach is
the same as mentioned
and through the superior drill holes (Fig. 10). The above but of course the
coracoacromial ligament
AC-joint is then reduced by lifting the arm rather is not detached from the
acromion. Instead of
than depressing the clavicle. The eight absorb- passing absorbable sutures
around the coracoid
able sutures are tied individually over the clavicle the introducer for the
implant, a measuring gauge
while the clavicle is held reduced in the correct is passed around the bone
from medial to lateral.
position. A coracoclavicular distance of about The brachial plexus is
close and it is important
1 cm should be the aim. A finger or instrument that the introducer is
kept close to bone. The
of suitable size between the coracoid and metal tip of the combined
lead and length-
the clavicle facilitates this manoeuvre and measuring gauge for the
Surgilig is then passed
prevents over-correction. The sutures from the through the introducer on
the lateral side of the
coracoclavicular ligament are then tied pulling coracoid and pulled around
it. The combined lead
the ligament with its bone chip into the clavicle. and gauge is then looped
into itself and tightened
The deltoid split and the deltotrapezius interval around the coracoid before
being passed posteri-
are carefully repaired over the clavicle with orly to the clavicle,
around and over it, to the
heavy interrupted absorbable sutures. As the front. After reduction of
the clavicle the length
reduction usually has caused a considerable of the required implant is
measured using the
change of the position of the clavicle in an ante- markings on the gauge. The
correct final implant
rior direction, it is not rare that the deltotrapezius is then daisy-chained to
the measuring gauge
interval no longer lies on top of the clavicle but and pulled around the
coracoid. It is then looped
more posteriorly. Interrupted subcutaneous and into itself and tightened
around the coracoid
intracutaneous skin sutures for wound closure. before it, in the same
fashion, is passed behind
1032
Fig. 11 The Surgilig

artificial ligament in
position on a skeleton:
pulled around the coracoid,
looped around itself and
then continued posterior to
the clavicle and over it to
anterior where it is secured
with a bicortical screw
and over the clavicle. The Surgilig is finally

secured to the clavicle with a 3.5 mm bicortical Results
screw placed horizontally from anterior to poste-
rior. Muscle repair and closure is the same as It is generally argued that
excellent results can be
above. expected from the
conservative treatment of grade
I and II injuries. However
one study reveals that
only 52 % of patients
remained asymptomatic,
Post-Operative Care and that the majority showed
late radiological pathol-
Rehabilitation ogy and that 27 % required
subsequent surgery
thus indicating that the
long-term effects of these
Acute repairs with K-wires are kept in a 45# injuries, and the risk of
post-traumatic osteoarthri-
abduction splint for 6 weeks at which stage the tis, might be
underestimated [84].
K-wires are removed. During this time the patient Several authors have
reported generally good
is allowed to do pendular motions with the arm results for the
conservative treatment of type III
out of the splint after 2 weeks and after 6 weeks injuries [32, 39, 85]. Some
authors have reported
full range of motion is allowed not loading the better results for
surgically-treated type III inju-
arm. Returning to sport or heavy labour is not ries [32, 86]. However,
many others have failed
allowed for 3 months. to prove any improvement
from surgery or even
Chronic dislocations treated with a Weaver found the outcome worse in
the surgically-treated
Dunn repair are kept in a sling at all times for [13, 36, 38, 85, 87].
4 weeks and then seen in the out-patient clinic Other authors have
reported good results
with a check x-ray prior to allowing gentle mobi- with acromioclavicular
repair and temporary
lization but not lifting the arm above 90# of flexion joint transfixation using
techniques similar to the
and abduction for another 4 weeks. At 8 weeks one described here [33,
88]. The outcome
hence full mobilization is allowed but no heavy of the Weaver Dunn
procedure, and modifications
weight-bearing or return to sports is allowed for thereof, has been widely
documented [51, 77, 89].
3 months. Our unit has recently
presented a comparative
When the Surgilig artificial ligament is used the study with a non-randomised
follow up of
patient is only kept in the sling for 2 weeks where 55 patients operated with
our modified Weaver
after full mobilization is allowed but heavy lifting Dunn procedure (n 31) and
the Surgilig artificial
or demanding physical activities are avoided for ligament (n 24) showing
good results in both
3 months post-operatively. groups with the Surgilig
patients returning to work
1033
significantly earlier. No major complications Coracoclavicular

ossification is commonly
where noted in any of the groups in this series [90]. associated with
these injuries whether treated oper-
atively or
conservatively [93, 94]. Osteoarthritis of
the AC-joint or even
osteolysis of the lateral clav-
Complications icle may follow the
acute type I or II injury or be the
result of repeated
micro-trauma it can also affect
Acromioclavicular injuries may be associated the acutely repaired
joint after a grade III injury.
with other injuries around the shoulder. Reports The surgical
treatment of these injuries
of concomitant fractures to the clavicle itself, can apart from the
general post operative
the coracoid process and ribs are reported in complications such
as infection, nerve damage
the literature. Neurological injuries to the and recurrence,
result in erosion of the clavicle
brachial plexus are rare but can occur early from sutures or
metal, migration and/or fracture
or late [91, 92]. of pins or wires and
unsightly scars (Fig. 12c).
a b
Fig. 12 (a) X-ray showing known possible complication to fixation. (c) X-rays
showing complication of non-
fixation with k-wires: fracture of the wire and migration. absorbable sutures
used for coracoclavicular fixation with
(b) Fracture of a screw (Bosworth) used for coracoclavicular the sutures cutting
through the clavicle
1034
Fig. 13 The strap incision hardly visible (right )and also well-positioned and
easily hidden under the bra. strap (left)
The strap incision used follow the lines repaired with

temporary transfixation and
of Langerhans which reduces the risk of ligament repair.
a wide scar and it can also easily be hidden under It has repeatedly
been proven that too rigid or
a bra strap (Fig. 13). too weak
coracoacromial fixations will often
The temporary transfixation with k-wires we fracture or fail
(Fig. 12ab). This is the reason
use for the acute repair will to some extent for us not using
screws or non-absorbable mate-
damage the joint surface and we therefore rials for this
fixation. With the use of multiple
believe it is important to only pass the wires absorbable sutures it
seems as if good enough
through the joint once to limit the damage stability is achieved
to allow good healing yet
(Fig. 9). To avoid loosening, migration and frac- without the long term
risks of sutures cutting
ture of the wires it is important that they are through the clavicle
or fracture of screws and
removed at 6 weeks and that the patient is not without the need for
a second operation to
allowed elevation above 90# prior to this. If late remove fixation.
osteoarthritis occurs, which it will in some The Surgilig
ligament does not seem to cause
patients no matter what kind of initial surgical erosion of the
clavicle in the way previous liga-
treatment is used, a simple arthroscopic Mum- ment implants did and
we believe this is because
ford procedure is recommended if the joint is it only comes around
from posterior. As the
still stable. This does not seem to de-stabilise clavicle rotates, on
elevation of the arm, it slacks
a joint that has been previously successfully the ligament instead
of tightening it, as an
1035
implant going around from anterior as well which are but modifications
of already
would do. The implant will move with the bone described procedures. This
could hopefully,
instead of sawing and cutting through it. There together with the
references mentioned, act as
has to our knowledge been no case with the a platform from where the
reader could then
Surgilig implant eroding through the clavicle. develop his or hers own
modification of these
In a few cases patients have been troubled by basic principles.
the screw protruding under the skin. It has then
easily been removed and this will not
de-stabilised the clavicle.
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The Fibrous Lock (Skeleton)
of the Rotator Cuff
Olivier Gagey
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1039 MRI and anatomical studies of shoulder mus-
cles provide evidence of a deep strong fibrous

The Subscapularis Muscle . . . . . . . . . . . . . . . . . . . . . . . . 1040
organization. The rotator cuff has a strong

The Supraspinatus Muscle . . . . . . . . . . . . . . . . . . . . . . . 1040
deep fibrous frame that emphasizes the most
The Infraspinatus Muscle . . . . . . . . . . . . . . . . . . . . . . . . 1040
important functional areas. The acromial belly
of the deltoid is also multipennate therefore

The Fibrous Frame of the Rotator Cuff . . . . . . . . 1040
the most powerful.

The Deltoid Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1041
Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1042 Keywords
The Delto-Pectoral Approach . . . . . . . . . . . . . . . . . . . . . . 1042
Clinical applications-torn subscapularis,
Shoulder Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1042
shoulder arthroplasty # Constituent muscles #
Rotator Interval Syndrome . . . . . . . . . . . . . . . . . . . . . . 1042
Rotator cuff-fibrous skeleton (lock)
Traumatic Tear of the Subscapularis . . . . . . . . . . . 1042

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1042 Introduction
MRI studies of the shoulder show evidence of an
anatomical organisation of the muscles especially
regarding the presence inside the muscle bellies
of strong deep fibrous bands.
This structure involves all the muscles of the
rotator cuff and includes the deltoid.
These fibrous structures are of great impor-
tance since they modify the mechanical proper-

ties of the muscles. A pennate or multi-pennate
muscle has a shorter contraction but, on the other
hand, a stronger force. In addition if the fibrous
tissue is abundant the muscle has special visco-
elastic properties.
O. Gagey
Orthopaedic Department, Paris-South University, Paris,
France
e-mail: Olivier.gagey@bct.ap-hop-paris.fr

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DOI 10.1007/978-3-642-34746-7_47, # EFORT 2014
1040
O. Gagey
The Subscapularis Muscle
Anatomical studies have demonstrated that the

two upper thirds of its humeral attachment contain
a thick and strong tendon whereas the distal third
has no tendon and is attached directly to the lesser
tuberosity. Inside the muscle belly, at the level of
the tendon, there are 45 strong fibrous digitations
that prolong the tendon inside the muscle. The
most superior digitation is like a 68 mm. thick
tendon coursing 68 cm. along the superior border Fig. 1 MRI view (coronal
plane) of the subscapularis
of the muscle. These digitations are intercalated showing the fibrous bands
(black lines) inside the muscle
with the digitations originating from the spinal belly
border of the scapula. These structures are obvious
on MRI views (Fig. 1).
Then the subscapularis in a multipennate
muscle.
Regarding the superior tendon it should be
emphasized that during abduction with external
rotation this tendon is in strong contact with the
vertical part of the coracod process through a
bursa. The coracod process acts on the subsca-
pularis like a pulley giving to the muscle an impor-
tant role of fixation of the humeral head and strong
internal rotation during the throwing movement [1].
Fig. 2 Supraspinatus
muscle, all the muscles bundles
The Supraspinatus Muscle have been removed leaving
the fibrous part only
A strong fibrous band exists inside the anterior part

of the supraspinatus [2]. This band is attached at
the level of the anterior part of the tendon that is the area transmitting the
maximum applied forces
thicker than the rest of the tendon (Fig. 2). (Figs. 3, 4 and 5).
Considering the
fibrous structures it appears
that a special area of the
rotator cuff is gathering
The Infraspinatus Muscle an amazing concentration of
fibrous structures
[3]. Located in an
anterosuperior position there
There is also a deep fibrous band within the are:
superior part of the muscle according the same i. The anterior part of
the supraspinatus tendon,
pattern as for the supraspinatus. ii. The superior tendon
of suscapularis,
iii. The longer part of
biceps brachialis,
iv. The coracohumeral
ligament, and
The Fibrous Frame of the Rotator Cuff v. The superior gleno-
humeral ligament.
We proposed to name
this area the
These fibrous structures provide the rotator cuff anterosuperior fibrous
lock of the rotator cuff.
with an amazing deep fibrous frame. This frame Basically the fibrous lock
is located just around
indicates the most solid areas of the cuff which is the Rotator interval.
The Fibrous Lock (Skeleton) of the Rotator Cuff
1041
Fig. 3 Upper view of the fibrous frame of the rotator cuff:

this view presents the deep fibrous structures inside the
rotator muscles bellies. Reconstructions obtained from
high-resolution MRI Fig. 5 Anterior view
of the fibrous lock of the cuff. AC
acromion, SS
supraspinatus, S-Scap subscapularis, CP
coracod process, RI
rotator interval. Coracohumeral lig-
ament and superior
glenohumeral ligament are not visible
on this view
Fig. 4 Shoulder MRI in sagittal plane evidencing the

main components of the fibrous lock: Sub-S upper tendon
of subscapularis, LCA coracoacromial ligament, LPBB
tendon of the long head of Biceps, AC acromion, PC
coracod process, Supra-S supraspinatus
The Deltoid Muscle
Our anatomical work [4] has established that the

deltoid is divided into three totally different parts
not only according their bony attachment
(clavicule, acromion and scapular spine) but
also because of strong differences regarding the
deep structure (Fig. 6). The acromial part of the
deltoid is the sole part of the muscle with tendious
attachment on the acromion. This part contains Fig. 6 Middle deltoid
after removal of all the muscle
five fibrous digitations attached on the acromion bundles leaving only
the fibrous frame of the muscle
1042
O. Gagey
and intercalated with five distal fibrous bands strong. Overuse of the
superior part of the
originating from the distal muscle tendon. There subscapularis during
overhead sports may lead
are no bands inside the clavicular or spinal por- to degenerative and micro-
traumatic lesions of
tions of the muscle. This suggests that the the subscapularis (upper
tendon and attachment
acromial part of the deltoid is the most powerful as well). It may also create
middle glenohumeral
and consequently the main engine providing ligament lengthening. These
both lesions may
humeral elevation in the scapulo-humeral joint. progressively lead to a
anterosuperior shoulder
Interestingly this part is orientated to provide instability.
elevation in the plane of the scapula.
Clinical Applications Traumatic Tear of the

Subscapularis
The Delto-Pectoral Approach The most frequent traumatic

lesion of the cuff is
the tear of the upper third
of the subscapularis
This approach is the most used for shoulder sur- tendon. The trauma is highly
specific: the patient
gery; this doesnt mean that it is a totally safe tries to stop a fall, being
suddenly suspended by
approach. The surgeon has to keep in mind that his upper limb. The
functional importance of the
this approach may weaken the fibrous lock either subscapularis tendon
justifies the necessity for
by cutting the subscapularis (that should be care- a surgical repair.
fully repaired especially in its superior tendon) or
by weakening the supraspinatus at the time of
dislocation or when inserting the prosthesis in
the humerus. References
1. Colas F, Nevoux J, Gagey
O. The subscapular
and subcoracoid bursae:
descriptive and functional
Shoulder Arthroplasty anatomy. J Shoulder Elbow
Surg. 2004;13(4):
4548.
A good illustration of the importance of the 2. Gagey NF, Gagey OJ,
Bastian D, Lassau JP. The fibrous
fibrous lock is given by prosthetic surgery of the frame of the
supraspinatus muscle. Correlations
between anatomy and MRI
findings. Surg Radiol
shoulder. In case of failure of the repair of
Anat. 1990;12(4):2912.
the fibrous lock the main complication would be 3. Gagey OJ, Arkache J,
Welby F. Le squelette fibreux de
the anterosuperior migration of the humeral head. la coiffe des rotateurs.
La notion de verrou fibreux. Rev
Chir Orthop.
1993;79(4):4525.
4. Lorne E, Gagey O,
Quillard J, Hue E, Gagey N. The
fibrous frame of the
deltoid muscle. Its functional
Rotator Interval Syndrome and surgical relevance.
Clin Orthop. 2001;386:
2225.
The rotator interval syndrome is not related to
a virtual weakness of the anatomical area, since
we demonstrated that this area is especially
Rotator Cuff Tears-Open Repair
Tim Bunker
Contents
Subscapularis Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1059
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1044 Tendon
Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1059
Pectoralis Major Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 1059

Aetiology of Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Latissimus Dorsi Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 1060
Pattern of Cuff Tearing-Anatomical Factors . . . . . . 1045
Symptoms and Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1048
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1060
Examination and Investigation . . . . . . . . . . . . . . . . . .
1049 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1060
The Poster-Superior Cuff (Supraspinatus) . . . . . . . . .
1049
The Antero-Superior Cuff (Subscapularis) . . . . . . . .
1050
The
Biceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1050
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1051
Magnetic Resonance Imaging (MRI) and MR
Arthrography (MRA) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1052
Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1052
Open Treatment of Posterosuperior Rotator
Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1053
Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1053
Partial Thickness Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1054
Surgical Treatment of Moderate, Large and
Massive
Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1054
Specific Indications for Surgery . . . . . . . . . . . . . . . . . . .
1054
Re-Attaching the Tendon . . . . . . . . . . . . . . . . . . . . . . . . . .
1055
Release of Contractures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1056
Rotationplasty or Margin Convergence? . . . . . . . . . .
1056
Secure Repair. Eliminating the Weakest Link . . . .
1057
Results of Rotator Cuff Repair . . . . . . . . . . . . . . . . . . . . .
1059
T. Bunker

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DOI 10.1007/978-3-642-34746-7_76, # EFORT 2014
1044
T. Bunker
Keywords
Anatomy # Arthroscopy # Clinical signs #
Investigations-ultrasound # MRI # Open cuff
repair-indications # Rotator cuff tears # Shoul-
der # Subscpularis tears # Tear patterns #
Techniques
Anatomy
Supraspinatus is not as most textbooks show it. In

fact it has a strong tendon that passes from the
centre of the muscle belly to insert at the very
front edge of the greater tuberosity, and some-
times even in front of the biceps pulley (Fig. 1).
This anterior column is very strong and it is this
feature that accounts for where tears start, how
they progress, and how we can repair them.
Nakajima [1] showed that the central tendon is
markedly denser and stronger than the rest of the
Fig. 1 The true anatomy of
the cuff, showing the central
tendon on histological preparations of the
oblique tendon of
supraspinatus
supraspinatus tendon. They demonstrated how
the central thick tendon migrates towards the
anterior margin of the tendon as you move pattern of postero-superior
rotator cuff tearing.
towards its insertion. Nakagaki et al. [40] and From these observations a
hypothesis was devel-
Bigliani et al. confirmed this work and provided oped that there is a definite
and progressive pat-
correct illustrations of the nature of the tendon. tern of cuff tear extension
that is determined by
Gagey et al. introduced the concept of the fibrous the special anatomy of this
tendon. Understand-
frame of the rotator cuff. These workers ing this pattern allows the
surgeon to predict
performed three-dimensional reconstruction of which structures are
contracted and need to be
MRI scans and demonstrated the deep fibrous released, and to develop a
plan to close the defect
re-inforcement of the supraspinatus that is the using fundamental surgical
techniques such as
central oblique tendon. They showed how rotationplasty, rather than
treating each surgery
supraspinatus has one tendon, whereas as a magical mystery tour.
subscapularis is multipennate and they show
how the single tendon of supraspinatus inserts
into the anterior extremity of the greater tuberos- Aetiology of Cuff Tears
ity. This pattern of migration of the central
oblique tendon has been confirmed by Roh et al. For many years we have had a
simplistic idea of
Over a 20-year period the chapter author (TDB) why cuff tears occur. It is
time for this simplistic
has made the observation on ultrasound scanning Intrinsic or extrinsic
theory to be challenged.
and at surgery that this central oblique tendon Codman championed the idea of
intrinsic degen-
(that we will term the anterior column), being eration of the cuff tissue
(Fig. 2) as the main
the strongest part of supraspinatus, remains intact cause of rotator cuff
tearing. Forty years later
when all the tendinous tissues around it fail. In Neer suggested that tears
occurred not through
effect it acts as a firebreak and determines the intrinsic damage, but because
of extrinsic
1045
Fig. 2 The footprint of insertion of supraspinatus
damage due to continuing repetitive abutment of

Fig. 3 An arthroscopic view
of the rim rent lesion
the anterior acromion upon the superior bursal
side of the cuff. Neers views held sway for
30 years, and his protege, Bigliani, said there partners they live with. We
also know that they
were morphological differences in the acromion occur with age, Shers
classic work on MRI scan-
(the hooked acromion) that accounted for this ning of asymptomatic
individuals showing that
impingement and tearing. The hooked shape of cuff tears are rare under
the age of 60. In their
the acromion has now been shown to be reactive, study no-one under 40 had a
cuff tear, between 40
and so. although impingement does occur, it is and 60, 4 % did, but of
those over 60, 26 % had
usually secondary to intrinsic cuff failure and not a full thickness tear.
the primary cause of cuff tearing. So cuff tears are
complex, there is a genetic
There are two instances where extrinsic cuff element, an ageing element
a functional element
compression from the acromion may be the pri- due to tensile or shearing
overload, leading to cuff
mary event. The first is the 50 year-old with a large dysfunction and secondary
extrinsic impingement
cuff tear and a mobile Os Acromiale. The second and compressive overload.
Add micro- or macro-
is the rare patient who is shown to have a bursal- trauma into the mix and a
cuff tear results.
side partial cuff tear with no evidence of a partial
thickness articular surface tear or rim rent lesion.
However intrinsic cuff failure is the initiating Pattern of Cuff Tearing-
Anatomical
event in the majority of people. This is why the Factors
rim rent lesion (Fig. 3), or partial thickness artic-
ular surface tear is so commonly seen in patients Repeated tensile, shear or
compressive overload
with the earliest symptoms and signs of cuff dis- can cause changes within
the ageing rotator cuff.
ease undergoing arthroscopy. This rim rent lesion Macroscopically this leads
to the initiating event,
may be caused by repetitive tensile overload with which is the rim-rent
lesion. The rim-rent lesion
work, daily living or sport, or sudden overload as can be demonstrated by
ultrasound or by arthros-
in a fall. It may also be caused by shear of the copy. This lesion is
constantly situated 7 mm.
articular margin against the glenoid rim that behind the biceps pulley
just posterior to the
occurs in the elevated position, either repetitively insertion of the anterior
column. Gradually the
with work or sport, or suddenly with a fall. rim-rent peels further back
off its footprint of
Carrs work showed that genetics plays a part, insertion into the superior
facet of the greater
for cuff tears are twice as common in close rela- tuberosity. As it does so,
secondary reactive
tives of patients undergoing cuff repair as in those changes occur on the bone,
which becomes
1046
T. Bunker
Fig. 4 The small tear starts just behind the anterior pillar
Fig. 5 The
impingement lesion
sclerotic and nodular. These nodules appear on Meanwhile the

cuff tear extends, either
radiographs as tiny sclerotic rings and are often slowly, or it may
suddenly tear with even mild
misreported as cysts, although tiny true cysts can trauma. Knowledge of
the normal morphology of
also occur. Eventually the deep surface rim-rent the tendon explains
the pattern of tear exposed at
will peel so far back that it emerges on the bursal surgical repair.
Knowledge of the morphology of
side as a pinhole full thickness tear (Fig. 4). This the capsule explains
the contractures that occur,
gradual enlargement of the deep surface partial and which will need
to be released during surgi-
thickness tear may take years to evolve. During cal reconstruction.
We must always remember
this time the supraspinatus is weakened and its that the tendon and
capsule merge and blend
normal centring effect is lost. The head subluxes towards their
combined insertion, and that for
upward and secondary impingement occurs a full thickness
tear to occur, both capsule and
between the bursal surface of the cuff and the tendon must have
dis-inserted. The tendon
acromion. retracts, but the
capsule contracts.
These secondary reactive changes can be seen As the small
tear extends into a moderate tear
by placing an arthroscope into the bursa. The the anterior column,
being so strong, acts as
bursa becomes fibrillated, and then wears through a firebreak and
resists extension, and so instead
and the bursal surface of the cuff becomes dam- of becoming a larger
crescentic tear, the tear
aged and fibrillates, this is the impingement becomes asymmetric
or L-shaped (Fig. 6). At
lesion of Neer. Reactive changes will occur on the same time the
superior capsule, having dis-
the acromion (Fig. 5) and have been classified inserted, contracts
back towards the glenoid,
into four grades by Uhtoff: pulling the cuff,
with which it is merged, along
Firstly, there is a loss of areolar tissue under with it. The coraco-
humeral ligament re-inforces
the acromion. the superior capsule
and, as this powerful thick-
Then, the coraco-acromial ligament and the ening of the capsule
contracts, it pulls the anterior
fibrous pad that represents its footprint of column with it,
towards the coracoid. This deter-
insertion into the acromion thicken. mines the releases
that will be necessary for
Thirdly, there is fibrillation of the insertion of a small to moderate
tear.
the coraco-acromial ligament. Now a singular
event happens, at 35 cms. the
Finally, there is eburnation of the undersurface tear extends over
the North Pole of the humeral
of the acromion and loss of the footprint of head, causing a
button-hole (boutonniere) situa-
insertion of the coraco-acromial ligament. tion. Just as in the
PIP joint of the finger when
1047
Fig. 6 The small tear extends to a moderate U-shaped or Fig. 8 The tear
progresses to a massive fixed tear
L-shaped tear
supraspinatus in large
cuff tears. This junctional
scar is hidden under
the acromion and the
suprascapular nerve
runs underneath the
spinoglenoid ligament
just medial to this contrac-
ture. Long head of
biceps hypertrophies and
may start to fray. The
capsule continues to con-
tract. The muscle
bellies, being de-functioned,
waste away.
Finally the tear
continues to extend and
retracts right back to
the edge of the glenoid rim
(Fig. 8). The anterior
column may still be intact,
although now very
stretched. Finally the anterior
column uproots,
uncovering long head of biceps,
which now becomes
painful, frays further, and
Fig. 7 As the tear progresses a Boutonnie`re effect occurs can sublux or rupture.
As the biceps pulley fails
the superior margin of
subscapularis may tear and
the humeral head now
subluxes forward as well
a boutonniere lesion occurs the joint button-holes as upward. The capsule
contracts further.
up through the tear and the lateral slips sublux Infraspinatus subluxes
further back yet, contrary
around the joint (Fig. 7). In the case of the shoul- to popular opinion,
rarely tears although the ten-
der the lateral slips are the anterior column to the don is stretched out
and the wasted muscle belly
front, and infraspinatus to the rear. Because the has no function. The
junctional scar becomes
infraspinatus has subluxed backwards and cannot even thicker. This is
the classic bald head tear.
be retrieved from under the acromion at surgery Arthritic change
may now occur between the
the surgeon may erroneously think that it too has North Pole of the
humerus and the acromion, as
torn, but this is hardly ever the case. The capsule well as the surfaces
of the humerus and superior
at the junction of the supra- and infra-spinatus pole of the acromion,
which are maintained in
contracts severely and it is the release of this a subluxed position.
This arthritic change is
junctional scar that allows advancement of called cuff tear
arthropathy (Fig. 9) and is the
1048
T. Bunker
have had a rim-rent tear

for some time that will
cause intermittent
shoulder pain on reaching, par-
ticularly if sustained or
repeated.
The injury may be
relatively trivial, often
elevating the arm against
resistance (lifting the
garage door, putting a
case in the overhead
locker). The injury can be
severe, and dislocation
of the shoulder over the
age of 40 is a common
cause of cuff tear.
The injury gives
immediate pain. Yet it is
followed by a lucid
interval. This confuses the
emergency room doctor the
following day for,
lacking in knowledge, they
can not understand
Fig. 9 Cuff tear arthropathy how anything serious could
have happened if the
patient continued working
during the afternoon
following the injury.
end-stage of the spectrum of cuff disease. 2 % of That night severe pain
comes on, which is the
the population over the age of 80 will have cuff reason the patient goes to
the emergency room in
tear arthropathy. the following morning,
where a radiograph is
taken, which is always
normal.
The patient has a loss
of power. This may be
Symptoms and Signs quite subtle in a small
tear, but in the large tears
there is a
pseudoparalysis. As supraspinatus is
Codman described the symptoms and signs of the powered up against
resistance the tear is put
patient with a full thickness tear of the rotator cuff under tension and this
hurts. Stooping, the arm
70 years ago. This portrayal still cannot be can be swung forwards
passively, or the patient
bettered. He gave 18 features that are classically can cheat and swing the
arm forwards using
present in such a patient. A manual labourer, aged deltoid alone.
over 40, with a previously normal shoulder, has There is a faulty
rhythm to elevation as pain
an injury, with immediate pain, followed by through the mid-arc makes
the patient protective
a lucid interval, with severe pain coming on that and slows down the
velocity of ascent. During
night, a loss of power, eased by stooping, with ascent supraspinatus is
contracting concentri-
a faulty rhythm, a tender point, a palpable sulcus, cally, but as the arm
descends supraspinatus con-
and eminence, which causes a jog and a wince, tracts eccentrically,
which is weaker, and thus the
and crepitus on elevation, which re-appears on faulty rhythm is even more
apparent and protec-
descent, with a normal radiograph. tive coming down. The
patient may actually lock
A manual labourer. In fact the first patient the glenohumeral joint
through the painful arc,
Codman wrote up in 1911 was a woman who and the scapula pseudo-
wings.
was beating her carpets clean in her back garden. On palpation there is a
tender point over the
Men do get full thickness tears more commonly. insertion of
supraspinatus. In the thin patient
We have already stated how manual labour is a defect can be felt in
the cuff (the sulcus), and
implicated in the aetiology of cuff tears. Full as the finger slides down
the empty footprint of
thickness tears occur rarely under the age of 40. insertion it then bumps up
against the greater
Most shoulder surgeons can count on the fingers tuberosity (the eminence).
of one hand how many cuff tears they have seen As the arm is elevated
the patient hesitates as
in patients under the age of 40! the tear passes under the
anterior edge of the
The shoulder may be previously normal, but acromion causing a jog,
which is so painful as
this is not always the case. Often the patient will to make the patient screw
their eyes up and wince.
1049
The torn edges of the cuff rub against the If there is a tear of
supraspinatus the arm will be
acromion causing crepitus, and all these features weak. The accuracy of Jobes
sign is 58 %. It is
re-appear, often more exaggerated on descent. another good test.
If either Neers,
Hawkinss or Jobes signs are
positive then ultrasound
examination is essential.
Examination and Investigation The ultrasound will show
whether there is a tear,
give its exact position and
a measure of its dimen-
The Poster-Superior Cuff sion; it is worth a great
number of eponymous
(Supraspinatus) tests. However there are
many other tests of
the posterosuperior cuff and
it is pertinent to test
Neers Sign for them.
This is the classic painful arc. Movement into the
first 70# of flexion is easy and pain-free, but then Lag Signs
as the footprint of the supraspinatus passes under Lag signs depend on weakness
of a segment of
the acromion, from 70# to 120# , there is impinge- the cuff. They are the
modern equivalent of the
ment between the surfaces and pain, and motion drop arm sign. The drop
arm sign was
slows. As the footprint clears the undersurface of a particularly unpleasant
way of examining
the acromion, from 120# to full abduction, pain a patient with a massive
supraspinatus tear. The
eases and motion speeds up once more. examiner elevated the arm to
120# in the full
knowledge that, without a
functioning cuff, the
Neers Test patient will find it
impossible to maintain this
Neers test is to inject some local anaesthetic into position. The examiner then
let go and the arm
the bursa, bathing the bursal side of the footprint dropped to the side!
Patients feel severe pain.
of cuff insertion. This abolishes the impingement
and the normal pattern of movement is restored. The External Rotation Lag
Sign
The external rotation lag
sign demonstrates that
Hawkinss Sign there is a significant tear
in supraspinatus. Like the
The arm is elevated in the scapular plane to 90# . drop arm sign this depends
on placing the arm
Now the elbow is flexed to a right angle and the into a position that needs a
strong supraspinatus
arm is internally, and then externally rotated. and then letting go. The
examiner takes the
Pain is seen to occur on internal rotation as the affected elbow and supports
the weight of the
footprint of supraspinatus impinges against the upper arm with the shoulder
in 90# of scapular
anterior acromion. The sensitivity and specificity elevation. Now, using his
other arm, the examiner
for Hawkins sign is 75 %. It is one of the most externally rotates the
forearm into full external
useful tests of the posterosuperior cuff. Beware rotation. Maintaining this
position against gravity
that passive limitation of internal rotation nul- depends upon an intact
supraspinatus. Now the
lifies this test. examiner lets go of the
forearm. If the cuff is intact
this position can be
maintained by the patient, but if
Jobes Sign the cuff is torn then the
forearm will drop by about
The arm is brought up in the scapular plane with 30# , the external rotation
lag. There are problems
the elbow extended and the arm fully internally with the test. The examiner
must understand
rotated so that the thumb points to the ground. exactly what he is doing, as
must the patient. Pain
(The Australians call this the empty tinny test may interfere with the test.
Stiffness will render it
for it is the position in which you test that your null and void. There is
difficulty between assessing
can of beer is finally empty). The patient is asked how much movement is recoil
and how much is
to hold this position against resistance from the lag. It is poorly
reproducible. It has a specificity of
examiner. If there is damage to the supraspinatus 63 % and a sensitivity of 80
%. It has been super-
insertion then pain will register with the patient. seded by portable
ultrasound.
1050
T. Bunker
Hornblowers Sign null and void. Finally

biceps problems can mimic
This is another lag sign. All military hornblowers subscapularis problems
confounding the belly
must assume an identical position when blowing press sign.
their horns. This position is with the hand at the
lips and the elbow as high as it will go so that the The Lift off Test
arm, and forearm are parallel to the ground. This The lift off test is
similar to the belly press sign,
position can be maintained even with a torn rotator but is performed in more
internal rotation. This
cuff. However if the examiner now takes the hand, means that the wrist must
be placed on the small
and fully externally rotates the forearm so that the of the back, rather than
on the abdomen. Now the
forearm is now perpendicular to the ground we patient is asked to
actively increase the internal
now have a position that can only be maintained rotation by lifting the
wrist away from the skin.
with an intact cuff. Let go of the hand now and the The problem with this
test is pain. Patients with
forearm will drop, or lag, by 30# . This test suffers cuff problems do not like
placing the hand into
from the same problems as the external rotation internal rotation, and
pain nullifies the test. Stiff-
lag sign. It has been superseded by portable ness will also nullify
the test.
ultrasound.
Internal Rotation Lag
Sign
This is a modification of
the lift off test. The arm
The Antero-Superior Cuff is placed with the wrist
on the small of the back.
(Subscapularis) The examiner now takes
the wrist and pulls it
5 cms. away from the
skin. With an intact
Tears of the anterosuperior cuff (subscapularis subscapularis, and no
pain or stiffness, the patient
and biceps) are less common than those of should be able to
maintain this position. However
the posterosuperior cuff. These tears start if subscapularis is torn
then the wrist will drop
around the biceps pulley and the superior (lag) back onto the skin
of the small of the back.
part of the insertion of subscapularis into Once again it is
difficult to discriminate between
the lesser tuberosity. Subscapularis has a recoil and lag, and has
the same problems of pain
multipennate tendon of insertion into the lesser and stiffness.
tuberosity.
The belly Press Sign (Napoleons Sign) The Biceps

This is the single most useful test of subscapularis
function. The patient is asked to place the palm of There is no good test for
biceps! Biceps shape is
the hand upon their abdomen. Now they are asked important. All medical
students know the
to keep the hand where it is and bring the elbow Popeye sign of a
ruptured long head of biceps.
forward as far as it will go. If there is a complete However you can have a
complete intra-articular
tear of the subscapularis they will not be able to rupture of long head of
biceps without a Popeye
bring the elbow forwards. If they can pull the sign when the
hypertrophied tendon jams in the
elbow forwards they are then asked to press the sulcus, like a cork in a
bottleneck. Between these
hand hard into the belly. If there is a partial tear of two extremes the biceps
can adopt subtle changes
subscapularis they elbow will drop back (a lag in shape.
sign). Beware; if the shoulder is stiff a false belly
press sign occurs, for instance in patients with Lafosse Sign
limited internal rotation from arthritis. Beware, This test is designed to
isolate biceps by asking
patients can cheat; in this case they flex the the patient to supinate
the forearm against resis-
wrist pulling the elbow forwards, producing tance. The examiner
cradles the elbow with the
a false- negative belly press sign. They must shoulder held at about
40# of scapular elevation.
keep the wrist in a neutral position or the test is The examiner grips the
patients wrist and
1051
pronates the forearm, asking the patient to resist subscapularis, biceps

sulcus and long head of
(supinate) this force. biceps tendon. Secondly an
oblique coronal (or
longitudinal) view is used
to show the greater
OBriens Test tuberosity and the
supraspinatus. Finally
This is designed to detect a SLAP (Superior a saggittal oblique
(transverse) view is used
Labrum antero-posterior) tear. It is performed sim- demonstrating the greater
tuberosity and
ilarly to the Jobe test, but with the arm held at 20# supraspinatus tendon,
rotator interval and biceps.
inside the neutral position (across the body) and at All findings are recorded
in detail at the time. In
90# elevation, and full internal rotation. The each of the three planes a
record is made of the
patient is then asked to resist the attempts of the articular appearance
(normal, positive cartilage
examiner to push the arm towards the ground. reflection sign,
osteophytes), the bone (normal,
Yergason only described his test in one irregular, calcification,
fracture line), the collagen
patient, yet this test has been copied from text- (normal, heterogeneous,
hypertrophic), presence
book to textbook. Speeds test also has a low of a defect (rim-rent,
cleft, de-lamination, focal
sensitivity and specificity. absence, absent cuff), and
the presence of an effu-
sion (nil, effusion,
flattening of bursa, bursal con-
cavity). A firm diagnosis
of the state of the rotator
Ultrasound cuff and biceps is then
recorded. A full thickness
tear is diagnosed on
sonography if the tendon is
Medical ultrasound uses wavelengths of absent, or if there is a
focal deficit. A combination
2.514 MHz. The higher the wavelength the of one or more indirect
signs such as a bursal
better the definition of the returning echoes, but concavity, an effusion
around the biceps, bony
more sound is attenuated, meaning you cant see irregularity or a positive
cartilage reflection sign
as deeply through the tissues. Fortunately the allow a judgement to be
made by the surgeon on
rotator cuff is reasonably superficial so the presence of a
supraspinatus tear.
810 MHz linear array probes can be used that Ultrasound has been
shown to be an effective
give good definition, indeed the pictures captured tool for determining the
presence of a full thick-
on a good machine are so good as to show histol- ness tear in the hands of
trained radiologists with
ogy rather than morphology. The problems come an accuracy of 8195 %.
Errors in detection and
with extremely fat or well-muscled individuals measurement are small in
the hands of experi-
where the definition falls off dramatically. enced radiologists Teefey
[41]. Errors are often
The linear array probe is made of a series of clinically irrelevant such
as a grading error, mis-
crystals that vibrate as electricity is applied to taking a deep partial
thickness tear for a pinhole
them (the piezo-electric effect) producing sound full thickness tear, or a
small measurement error,
waves. In this case ultrasound waves. The crys- mistaking a large tear for
a massive tear due to
tals are arranged in a row, much like the keys of inability to follow the
retracted tendon under the
a piano. Each crystal in turn produces a tiny blip acromion. Such errors would
not change the clin-
of sound and then waits for the echoes to return as ical management of the
patient. Inter-observer
they are reflected by the interfaces between error between experienced
radiologists is low
tissues. The echoes causes the crystal to vibrate with full agreement on
categorization in 92 % of
and this is turned into an electrical impulse, scans Middleton [39].
However referral to a
amplified and displayed as a two-dimensional radiologist for ultrasound
scanning inevitably
picture of the tissues. leads to a delay for the
patient and a journey
In the clinic, time is important, so an abbrevi- that involves three
attendances, the first to see
ated study is permitted, scanning in only three the surgeon, the second for
the scan and the
planes, as opposed to the 12 planes recommended third to return to the
surgeon for the result to be
in most radiological texts. An axial scan is first discussed and a treatment
strategy to be agreed.
used to demonstrate the lesser tuberosity, The delay from first
contact to agreement of
1052
T. Bunker
Unlike ultrasound MRI can

image through the
bone, and it can image the
bone, and it can image
to depths of tissue that
cannot be reached by high
frequency ultrasound. It is
therefore the imaging
instability, as it will dem-
onstrate labral
abnormalities. Visualisation of
SLAP tears and Bankart tears
are improved by
MRA using gadolinium
enhancement.
MRI is the imaging
large rotator cuff tears
where the degree of retrac-
tion under the acromion, and
the degree of
wasting and fatty
infiltration of the muscle belly
will determine whether the
tear should be
repaired, or whether repair
is a forlorn hope.
MRA is useful in
demonstrating articular side
partial tears.
However MRI is not
without problems. The
equipment is extremely
expensive and far from
portable! Patients do not
like MRI. It is claus-
trophobic, noisy and patient
unfriendly. One
third of patients will not
have a second MRI
scan. It will demonstrate
morphology, but not
Fig. 10 Portable ultrasound histology. It suffers from a
phenomenon called
the magic angle effect
that can produce false
positive results. MRI is
very bad at showing
a plan of treatment may vary from a few days to calcific deposits as these
are dark, as is the ten-
several months depending on the efficiency of the don, so there is no contrast
difference between
department of radiology. The new generations of the calcium and the tendon.
back-pack portable high-resolution and relatively MRA suffers from the
problem that it is inva-
inexpensive ultrasound machines (e.g., Sonosite sive. Intra-articular
injection of gadolinium is usu-
180 plus) allow for an ultrasound scan to be ally done under image
intensifier control and local
performed by the surgeon wherever he first anaesthetic. This increases
the degree of difficulty,
meets the patient (Fig. 10). Al Shawi & Bunker often needing two radiology
suites, careful timing,
[38] showed such a scan performed by a surgeon transfer from room to room
and the time of
was sufficiently accurate (96.3 % sensitivity and a skilled radiologist.
Additionally, patients do not
94.3 % specificity for full thickness tears), com- like invasive diagnostic
procedures.
pared to previously published radiology studies, to
allow a one-stop clinic where the patient is seen by
the surgeon, has the ultrasound performed by the
surgeon and a treatment plan agreed at the first Arthroscopy
encounter.
Shoulder arthroscopy remains
the gold standard
forensic investigation for
the shoulder. Not only
Magnetic Resonance Imaging (MRI) can the inside of the gleno-
humeral joint be
and MR Arthrography (MRA) appreciated (Fig. 11), but
also the outside view
of the rotator cuff from
within the subacromial
MRI has revolutionised the field of imaging in the bursa. An essential pre-
amble to arthroscopy is
shoulder, because it can image the soft tissues. examination under
anaesthetic.
1053
Fig. 12 Arthroscopic
subacromial decompression
Conservative treatment
involves turning the
dysfunctional cuff into a
functional cuff again.
Two facets need to be
addressed, pain and func-
Fig. 11 Arthroscopic view of a moderate cuff tear tion. The pain can be eased
by injection of corti-
sone (in any form) into the
subacromial bursa,
and refraining from those
activities that aggra-
vate the condition
(reaching, sport, and overhead
Open Treatment of Posterosuperior work). Therapists can then
supervise muscle
Rotator Cuff Tears re-training, starting with
scapular control, and
then working on to
glenohumeral control.
We have demonstrated how there is a spectrum Indications for surgery
are failure of proper
of advancing pathology, from cuff dysfunction conservative treatment, in
the patient aged over
leading to impingement, through partial 40 who has true impingement,
which has been
thickness cuff tears, to small full thickness abolished temporarily by
subacromial injection
tears and on through moderate to large, to of local anaesthetic.
massive tears of the rotator cuff. Treatment The surgical procedure
of choice is arthro-
must be tailored to fit the symptoms from scopic subacromial
decompression. Dr. Harvard
which the patient is suffering and the pathology Ellman who published his
results in 1987
causing the symptoms. pioneered this technique and
now this is the
benchmark throughout the
advanced world. In
the properly selected
patient arthroscopic
Impingement subacromial decompression
(Fig. 12) should
give excellent or good
results in 88 % of patients.
The patient is usually aged 4050 and has mild These days there is no place
for open decompres-
rotator cuff symptoms. These will include pain on sion except as a method of
exposure for open cuff
reach and exercise, difficulty getting to sleep, but repair. However this does
not mean that lessons
little awakening, a painful arc on elevation that cannot be transferred from
the era of open sur-
interferes with recreation but the patient con- gery. Open acromioplasty
evolved from Neers
tinues in their normal work routine. The pain is first description where a
wedge of anterior
relieved by subacromial injection of local anaes- acromion was removed using
an osteotome,
thetic (Neers Test). and ended with the two stage
Rockwood
1054
T. Bunker
acromioplasty. In this technique the first stage is to injection of cortisone

should be given to relieve
remove the full thickness of the acromion that pain and therapy started
to regain control of the
extends anterior to the acromioclavicular joint. scapula and then the
glenohumeral joint.
The second stage is to remove a wedge of anterior
acromion extending from the initial cut and exiting
the inferior surface of the acromion 1.5 cms. (three Specific Indications for
Surgery
burrs-breadths) posterior to the anterior cut. This
technique is now copied arthroscopically. The indication for surgery
is a proven rotator cuff
tear, demonstrated by
ultrasound or MRI, in the
patient aged over 40 yet
under 70, who has symp-
Partial Thickness Tears toms which interfere with
daily life, or awaken at
night. Weakness up to the
point of pseudo paral-
There is great debate over how partial thickness ysis may or may not be
present. The patient
tears should be treated. Some authorities advo- should have failed a
proper course of conserva-
cate decompression alone, but more these days tive treatment.
advocate excision and repair. This is the area There are six
principles of surgery:
where arthroscopic repair with anchors or arthro- 1. Assess the cuff tear
scopic tacks is of increasing importance. Small 2. Release the capsular
contractures
tears (<1 cm.) can be dealt with in the same 3. Re-introduce healing
biology
manner, either arthroscopically or through the 4. Re-attach the tendon to
its anatomical
mini-open technique. footprint
5. Protect the repair
6. Regain movement and its
control
Surgical Treatment of Moderate, Assessing the cuff
tear means exposing it such
Large and Massive Tears that the front, the medial
retracted edge and the
rear of the tear can be
seen. This is best done
The surgical repair of larger tears remains arthroscopically. However
this is not always
a difficult undertaking for surgeon, patient and easy. The bursa may be
thickened so much that
therapist. Difficulties for the surgeon include the it mimics cuff tissue; de-
lamination makes
surgical approach, retraction of the tendon, con- assessment tricky; the
bursa is often inflamed
traction of the capsule, degenerate tendon, poor with quite an aggressive
nodular synovitis; and
healing, soft bone and weak muscles. Problems the assessment must be
performed rapidly before
for the patient include pain, protection of the swelling occurs. The size
and pattern of the tear,
repair and frustration due to the long time-course the state of long head of
biceps, and subscapularis
for healing. Problems for the therapist include must be assessed. The
degree of retraction and the
weak muscles that have lost their control, adap- mobility of the tendon
edges can be seen by
tive muscle patterning and posture and the psy- inserting a grasper and
pulling. The quality of
chology of protracted recovery. With all these the cuff should be noted
as to whether it is an
difficulties to overcome it is not surprising that acute or chronic tear,
whether the adjacent cuff
re-tear rates vary from 15 % to 50 % in the tissue is malacic or de-
laminated.
massive tears. Contractures must be
released so that the ten-
Conservative treatment should be tried before don can be brought without
tension to its anatom-
recourse is taken to surgery. The only exception ical position. For
moderate tears this means
to this is the acute massive tear following trauma releasing the capsule in
the paralabral gutter
where surgery is far better immediately and just as one would for a
contracted (frozen) shoul-
before the tendon retracts. However most large der. For large tears the
coracohumeral ligament
cuff tears present as a chronic problem or an and rotator interval also
need to be released. For
acute-on-chronic problem. In these cases an massive tears the
junctional scar must be
1055
released. In all cases the bursa needs to be freed

of scar tissue.
Re-introducing healing biology. Most cuff
tears are chronic and any attempts to heal have
long ago been abandoned by the local cells. They
need to be re-awakened by decorticating the
greater tuberosity so that blood and, with it, fibro-
blasts, can actively engage in repair. In the future
it may be possible to stimulate repair using syn-
thetic growth factors.
The tendon must be re-attached to its anatom-
ical insertion point, its footprint, over as wide an
area as possible. This is where the skill of the
surgeon is paramount and will be described in
greater detail below.
Finally the repair must be protected against
forces of a magnitude that would re-tear it during
the healing phase (6 weeks) and the strengthening
phase (3 months). The patient or the therapist, in Fig. 13 Exposure of the
cuff tear with stay sutures
inserted
error or in ignorance, may apply these forces.
Protocols must be adhered. Unfortunately in this
area ignorance is widespread. All-arthroscopic repair
is beginning to come
Recovery is a team effort. The team consists of age for small, mobile
tears, in the hands of an
of the surgeon, the anaesthetist (who gives the expert. However it is a
difficult procedure with
scalene block and controls post-operative pain) a long learning curve. In 5
years time it will
the patient, the nursing teams in theatre, on the probably become the
standard treatment for
wards and in outpatients, and in particular the small and moderate tears.
Presently it should be
therapist. restricted to expert
shoulder arthroscopists only.
The Matsen deltoid-on
approach is a deltoid
split that meets the front
of the acromion half way
Re-Attaching the Tendon across its anterior
surface. Medial and lateral
flaps are created in line
with the split in deltoid
There are three technical objectives for the lifting the periosteum from
the top surface of the
surgeon: acromion, and then if
necessary splitting the tra-
Adequate exposure pezius in the same line.
Thus two flaps are raised
Sufficient release which consist of deltoid-
periosteum-trapezius;
Secure hold much like the direct
lateral approach to the hip
Exposure must be extensile. There are six this technique lifts intact
fascio-periosteal flaps
stages to the extensile exposure. These are: off the bone. In this
manner the acromion is
All-arthroscopic repair exposed, yet the flaps can
be closed side-to-side
Arthroscopic subacromial decompression and with no weakening of
deltoid. The problem with
mini-open repair this approach is that the
periosteum over this part
Matsen deltoid-on with two stage Rockwood of the acromion is very
thin; particularly in
modification of Neers acromioplasty women, and can easily tear.
For this reason this
Plus acromio-clavicular excision author splits the deltoid
so that the split exposes
Plus trapezius take down (Wiley extension) the acromio-clavicular
joint. The superior
Plus oblique acromial osteotomy (Grammont acromio-clavicular ligament
is divided much as
Osteotomy) the periosteum would be
with the true Matsen
1056
T. Bunker
deltoid-on approach, but it is five times as thick as

the periosteum and much easier to repair.
If the tear is too big to be seen through
a deltoid-on approach with an acromioplasty
then the first extension is made, excising the
acromio-clavicular joint. One third of the bone
is taken from the acromion, and two-thirds
from the clavicle, leaving a 1.52 cms. gap.
This now allows the fat pad to be raised off
the belly of supraspinatus and exposure is
increased.
If the whole tear still cannot be seen, stay
sutures are placed in the edges of the tear, and
the humeral head extended and rotated to see if Fig. 14 An extension is
made behind the central oblique
the whole tear can be seen (Fig. 13). If it cannot tendon and A is rotated to
A
then the next extension is made. This is the tra-
pezius take-down, which allows an excellent Large and massive tears
have additional scar-
view of the suprascapular fossa and the belly of ring at the front of the
tear and at the back. At the
supraspinatus. front the coracohumeral
ligament contracts and
If at this point the whole tear cannot be seen,the tethers the anterior
pillar. At the back the junc-
full time shoulder surgeon now has a choice, to tional scar develops at
the base of the spine of the
perform an oblique scapular osteotomy or to per- scapula. This plane
between the supraspinatus
form tendon transposition or augment. The results and infraspinatus needs to
be released, but care
of tendon transfers (deltoid flap or latissimus trans- must be taken not to
damage the adjacent
fer) are to improve the shoulder from a Constant suprascapular nerve.
score (CS) of 30 to a CS of 60. The alternative is
the Grammont osteotomy of the spine of the scap-
ula. This gives a fantastic view of the rotator cuff, Rotationplasty or Margin
and is re-assembled with a small locking plate but Convergence?
is beyond the limits of this text.
Even with all the
contractures released a large to
massive chronic tear may
have such a loss of
Release of Contractures tendon material that the
tidied-up edge of the
tendon cannot be advanced
on to the prepared
The second technical objective is to release the bony footprint. Now what
can be done? The
capsular contractures. Now an understanding of alternatives are to lash
the front of the tear to
the sequence and pattern of tearing will turn the the back (margin
convergence), perform
course of the operation from a pot pourri to a rotator interval slide
(which is now condemned
a controlled predictable experience. as a poor procedure),
perform a rotationplasty, or
Small tears (less than 1 cm.) will not have any give up the idea of direct
repair and either aug-
contractures, the capsule has not retracted enough ment or perform a tendon
transfer.
and so no releases will be needed. Margin convergence is
the preferred method
Moderate tears may have enough capsular for the arthroscopist.
This is because it is rela-
retraction for stiffness to set in. Here the contrac- tively easy and it will
work for a tear that is not
tion will be similar in extent to contracted (fro- extensive from front to
back. It will not work for
zen) shoulder, and the same release (along the a tear that is extensive
in both directions.
paralabral gutter) will need to be performed. This In the rotator interval
slide the only remaining
can be done arthroscopically or open. strong attachment of the
supraspinatus, the
1057
anterior column is detached, this allows the ante-

rior column to be re-attached further back and
what is acheived is to close the back of the defect
by opening up the front. This actually makes
things far worse, for now the head will escape
through the anterior defect, decreasing cuff
function.
If the tear is extensive in both directions then
basic plastic surgical techniques must be adapted
to close the defect, and this means a rotation flap
(Fig. 14). The remaining anterior column and its
attachment should be protected. If the tear pattern
is an anterior L-shape, then an extension is made
along the back of the central oblique tendon and
the cuff is rotated clockwise to close the defect. If
the shape is a posterior L-shape then the exten-
sion is between supra- and infraspinatus (through
the junctional scar) and the cuff is rotated anti-
clockwise to fill the defect. Sometimes if the tear
is massive then both extensions are required and
the block of posterior cuff is advanced.
Fig. 15 Two row repair
gives a stronger and better foot-
print than one row
Secure Repair. Eliminating

the Weakest Link link in the chain. In
rotator cuff repair there are
five linkage points:
The final technical objective is to gain a secure Tendon to suture
repair to the de-corticated and bleeding surface of The suture itself
the greater tuberosity, over as large a footprint The knot
area as possible, for long enough for biological Suture to anchor
union to occur. Most surgeons will use a two-row Anchor to bone
technique in order to attach the tendon to as great A great deal of effort
has gone in to over-
an area of footprint as possible. Two-row arthro- engineering all these
linkages to prevent failure.
scopic repair was first devised by DeBeer from Some of the weak points are
under the surgeons
Cape Town (2002). However, open two-row control, but the quality of
the tendon and the
repair came first. By 1992 it was our favoured quality of the bone are
not.
method of open repair and we first published
and illustrated this in our textbook ((Fig. 15) The Suture-Tendon Junction
Bunker and Schranz: Challenges in Orthopaedic Decades of effort by
generations of hand sur-
Surgery; the Shoulder) in 1997. Two-row repair geons have seen the
grasping core suture become
involves attaching the cuff to both extremities the method of choice for
flexor tendon repair.
of the de-corticated tuberosity. The two-row Gerber and Schneeberger
showed experimentally
repair has been made more secure by over-sewing how grasping sutures remain
secure under load
the cuff, joining the proximal and distal rows when simple sutures cut
out. They found that the
using such techniques as the suture bridge best grasping suture was
the Mason Allen grasp-
(Fig. 16). ing suture, closely
followed by the modified
Any method of linking tendon to bone has Kessler. Grasping sutures
are extremely difficult
a potential to separate wherever there is a weak to perform
arthroscopically, so it was with
1058
T. Bunker
diameter of the suture.

Theoretically one could
over-engineer the suture just
by increasing its
diameter so that its breaking
strain was far greater
than the original tendon, but
the thicker the thread
the more difficult it becomes
to knot, so
a compromise needs to be made.
Any suture
thicker than number 2 knots
poorly. The break-
through with sutures has been
in materials. New
sutures such as orthocord and
fibrewire are
almost unbreakable.
The Knot
All knots have a breaking
strain of half the suture
itself. Clearly it is a weak
link. All knots rely
upon friction between the two
suture ends. One
of these is designated the
post and the other the
loop. Friction is increased by
reversing the post
for alternate half hitches,
and by increasing the
number of half hitches
performed. The surgeons
knot is the strongest knot and
better than sliding
knots of whatever variety.
Because the knot is a weak
link surgeons have
tried to get rid of them using
knotless techniques.
Most of these involve trapping
the knot within the
anchor using a pop-rivet
technique.
Suture to Anchor
The sutures have been linked
to the anchor with
an eyelet. The eyelet has been
a real problem as
early anchors had sharp metal
edges where the
Fig. 16 Suturebridge technique
eyelet had been drilled or
formed in the anchor.
This sharp edge used to cut
the anchor. Gerber
concernthat experienced shoulder surgeons saw and Schneeberger modelled
arthroscopic repair
the arthroscopic pioneers performing cuff repairs and found that the weakest
point was always the
with simple sutures, a technique that they knew eyelet. Better anchor
manufacture and the new
from observation failed at open surgery. However unbreakable super-sutures have
eliminated the
White & Bunker showed that the strength at this eyelet problem.
interface might be proportional to the number of
passes of the suture through the tendon rather The Anchor
than the pattern of passage. Thus two mattress The original descriptions of
rotator cuff repair by
sutures (four passes) are as strong as one Mason- the pioneers such as
McLaughlin and Neer
Allen suture (three passes). The Mason Allen described attaching the suture
to the bone using
suture is easy and quick to perform open and bone tunnels, because they had
nothing else.
remains the gold standard. These days we have suture
anchors and suture
screws. Whereas a bone tunnel
of 1 cm. in length
The Suture will fail with a low force of
16 N, suture anchors
Properties of the suture depend upon the material, will take 280 N to pull out.
Anchors are not
whether it is monofilament or braided and the only stronger but also easier
and quicker to use.
1059
Bone tunnels are still used by some because dislocations. They are
almost impossible to repair
anchors are expensive. Gerber has tried to over- through a superior approach.
An MRI must be
come the weakness of bone tunnels by using performed before surgery to
assess the wasting
a titanium plate to augment the sutures and Bunker and degree of fatty atrophy
of the muscle belly,
has used a metaphyseal screw or post with a pull- because if this is marked
then repair should not be
out strength of 900 N. For the last decade anchors undertaken.
have been so secure compared to all the other links The surgical approach
should be the standard
in the chain that failure was unheard of. However deltopectoral approach to
the shoulder. Often the
the new generation of super-sutures have removed tendon will have retracted
under the conjoined
the weakest link and recently failure by anchor tendon. This means that the
musculo-cutaneous
pull-out has been described. nerve should be identified
and a pre-drilled cora-
coid osteotomy performed.
Subsequently a 360#
release of the subscapularis
tendon should be
Results of Rotator Cuff Repair performed taking care not to
damage the poste-
rior cord of the brachial
plexus that is scarred on
The Panacryl Study appears to give the most to the anterior surface of
subscapularis and
honest appraisal of the results of surgery for rota- always closer than the
surgeon has estimated.
tor cuff repair. This was a British multi-centre The lesser tuberosity is now
de-corticated and
prospective controlled study of rotator cuff a two-row repair of the
mobilised tendon is
repair. 159 patients were analysed from 15 UK performed using the
techniques that have just
centres. 17 % of the tears were small and closed been given for supraspinatus
repair.
with side-to-side sutures, 83 % were closed with Biceps is always damaged
with a substantial
modified Mason-Allen suture technique. Patients subscapularis tear. Biceps
will need to be
were assessed by Constant scores pre-opera- tenotomised close to its
origin and an extra-
tively, at 6 months and at 1 year. They were articular tenodesis
performed.
also followed by real-time dynamic ultrasound
scanning performed by experienced consultant
ultrasonographers. Tendon Transfers
The Constant pain scores improved following
surgery from 6/15 to 12/15 at 6 months where 15 Pectoralis Major Transfer
is no pain at all. Total Constant scores improved
from 46/100 to 66/100 at 6 months. This transfer is reserved
for inoperable
The re-tear rate was 26 % overall at 6 months, subscapularis tears. The aim
of surgery is to
but varied from 15 % in tears less than 5 cms. in replace the absent
subscapularis with a local mus-
diameter to 51 % in massive tears. Despite the cle tendon unit that can
cover the defect, thus
high re-tear rate there is still a good effect from containing the humerus and
increasing the
the surgery with statistically significant improve- power of internal rotation.
The sternal head of
ments in most parameters of the Constant score, pectoralis major has all
these attributes.
including pain and total scores. Surgery is affected
through a standard
deltopectoral approach. The
combined heads of
pectoralis major, or just
the sternal head are
Subscapularis Repair harvested from their
insertion on to the humeral
shaft. They are then
transferred to cover the ante-
Ruptures of the anterior cuff are far less common rior defect and are attached
to the prepared lesser
than postero-superior tears. They are often con- tuberosity using suture
anchors. There is some
sequent on transient or locked dislocation in the theoretical advantage to
using the sternal head
elderly patient. However they may follow on and taking it under the
conjoined tendon so
from expanding pulley lesions or medial biceps that it replicates the line
of pull of subscapularis
1060
T. Bunker
more accurately. However this is more difficult and these must be protected
as well. The muscle
and great care must be taken to identify and belly is now cautiously
released taking care not to
protect the musculocutaneous nerve. damage the neurovascular
supply. The tendon is
Early results with this transfer show that it is now whip-stitched and a
tunnel developed under
the method of choice for irreparable tears of deltoid and the acromion so
that the tendon
subscapularis. can be passed from the
posterior incision
through to the anterior
incision where it is
attached to infraspinatus
stump, or if possible the
Latissimus Dorsi Transfer
supraspinatus stump on the
anterior facet of the
greater tuberosity of the
humerus.
The primary repair of massive postero-superior
Early clinical results of
latissimus transfer, in
rotator cuff tears is extremely difficult and is
well-selected patients,
operated upon by good
associated with prolonged rehabilitation and
surgeons have shown promise.
Time will tell
a high re-tear rate. This then raises the question,
how acceptable this
technique will become.
is there an alternative surgical solution to the
problem of pain and weakness in this situation?
The latissimus dorsi transfer has long been used
Conclusions
in children with brachial plexus palsy, where
it goes by the name of the LEpiscopo proce-
Surgeons are only just
beginning to understand
dure. The effect of this transfer in children
rotator cuff disease. Our
understanding has been
with C5 plexus palsy (effectively causing a
helped by examining the
precise anatomy of the
suprascapular nerve palsy) is to give them exter-
supraspinatus tendon, and by
recent advances in
nal rotation at the shoulder. The idea behind
comprehending the aetiology
of this disease, as
latissimus dorsi transfer is to affect the same
well as advances in
investigation such as ultra-
result in the elderly patient with a massive cuff
sound, MRI and arthroscopy.
We are beginning
tear. The aim of the operation is two-fold, to
to understand the natural
history of rotator cuff
contain the humeral head against upward sub-
dysfunction and tearing, and
the pattern of cuff
luxation, and to increase the power of external
tears and capsular
contractures. Principles for
rotation. It has been found that two criteria must
surgery and technical
objectives are now under-
be satisfied for this transfer to work. The first is
stood and the techniques for
surgery are begin-
that deltoid must be functional, and the second
ning to be worked out.
Despite all of this, surgery
that subscapularis is intact. The results of
remains difficult for the
surgeon, painful and
latissimus transfer in the face of a tear extending
frustrating for the patient
and demanding of the
into subscapularis are so poor that it should not
therapist. We have a long
way to go before we
be attempted.
have all the answers for
this extremely common,
At surgery the patient is placed in lateral
yet extremely disabling,
degenerative disease of
decubitus so that both the front and the back of
the shoulder.
the shoulder are available to the surgeon. A single
posterior incision or the classic two incision
approach can be used. The first is a standard supe-
rior approach to supraspinatus and the main inci-
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2005;184(6):176873.
Partial Rotator Cuff Ruptures
Antonio Cartucho
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1064 Degenerative partial-thickness tears are an
important part of pathology of the rotator

Anatomy of the Supraspinatus Footprint . . . . . . .
1064
Gross Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1064
cuff, that occur mainly on the supraspinatus

Microscopic Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1064 tendon. More recently a more thorough assess-
Blood Supply to the Rotator Cuff . . . . . . . . . . . . . . . . . .
1064 ment of the subscapularis during arthroscopy
Local Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1065 led to better understanding of the potential role
that this tendon may play as a cause of anterior

Definition and Classification . . . . . . . . . . . . . . . . . . . . . 1065
shoulder pain and biceps instability.

Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1066 The supraspinatus footprint has a very par-
Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1066 ticular microscopic anatomy that contributes to
Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1066
create differential shear stress within the tendon.
Symptoms arise from mechanical impair-

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1067 ment with adaptative response of the shoulder
Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1069 girdle, from inflammatory changes and
Diagnosis at Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1069 involvement of the long head of the biceps.
Progression of the tear is more frequent

Treatment Options and Indications . . . . . . . . . . . . . 1071
Conservative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1071
in symptomatic patients and regression was
Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1072 found in less than 10 % of the cases.
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1080
With tear progression, clinical cure by con-
servative measures may be impossible to

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1080 obtain.
The decision for surgical treatment
depends on the type of rupture, the age and
level of activity of the patient and of the
degree of pain and functional impairment.
Keywords
Shoulder arthroscopy # Rotator cuff # Partial
rupture
A. Cartucho
Orthopaedic Department, Hospital Cuf Descobertas,
Lisbon, Portugal
e-mail: a.cartucho@netcabo.pt

1063
DOI 10.1007/978-3-642-34746-7_45, # EFORT 2014
1064
A. Cartucho
Microscopic Anatomy
Introduction
The tendons of the rotator
cuff are composed
Partial rotator cuff ruptures are not rare and occur primarily of water (55 % of
net weight) and type
mainly on the supraspinatus tendon and may I Collagen (85 % of dry
weight). Additional con-
extend to the infraspinatus. Isolated lesions of stituents include other
collagens (III and XII), PGs.
the infraspinatus and teres minor tendons are abd GAGs., elastin and
fibroblasts. The collagen
rare. Isolated ruptures of the, but rarely to, the bundles of the cuff tendons
are confluent and form
subscapularis tendon had a 30 % incidence in a hood over the humeral head
[40].
cadaveric studies [52]. Partial ruptures usually Near the insertions of
the supraspinatus and
occur before the sixth decade of life and can be infraspinatus tendons into
the greater tuberosity,
a cause of unexplained pain in the shoulder, giv- a five-layer complex has
been described that details
ing considerable disability. the density and organisation
of collagen and its
associated elements. Layer
one is the superficial
coraco-humeral ligament.
Layer two represents
the main portion of the
tendon complex with large
Anatomy of the Supraspinatus closely-packed fascicles.
Layer three is also dense,
Footprint but with smaller fascicles
running in a less uniform
direction. Layer four is
loose connective tissue with
Gross Anatomy thick collagen fibres
running perpendicular to the
primary fascicle
orientation. This layer contains
In order to classify and to grade partial rotator the deep coraco-humeral
ligament. Layer five is
cuff ruptures we must be aware of the character- the true joint capsule. It
has been suggested that
istics of supraspinatus insertion on the humerus. this intra-tendinous
variation of collagen fiber
The mean antero-posterior dimension of the density and orientation may
produce shearing
supraspinatus insertion is 25 mm. The mean forces within the layers
during active movement
superior to inferior thickness at the rotator inter- and produce intra-substance
tears [22, 58].
val is 11.6 mm, 12.1 at mid-tendon and 12 mm at
the posterior edge. The distance from the articular
cartilage margin to the bony tendon insertion Blood Supply to the Rotator
Cuff
ranges between 1.5 to 1.9 mm, with a mean of
1.7 mm. This being said, articular partial- The rotator cuff receives
its blood supply from
thickness tears with more than 7 mm of exposed several different branches
of the axillary artery.
bone lateral to the articular margin should be The rotator cuff tendons are
not encased by a true
considered significant tears, approximating synovial sheath or paratenon
[5]. They are sup-
50 % of the tendon substance [51]. plied by the above-named
branches that send
The superficial tendon fibres run longitudi- smaller branches through the
periosteum, across
nally, while the deep fibres run obliquely. The the musculotendinous
junction, and via the over-
supraspinatus tendon fuses with the infraspinatus lying bursa. A critical
zone has been described
tendon approximately 15 mm proximal to their in the supraspinatus tendon,
within 1 cm. of its
insertion on the greater tuberosity. They are not insertion into the greater
tuberosity [45]. Arm
visualised as two individual tendons and cannot position has been shown to
affect the tenuous
be separated by blunt dissection in this region [9]. blood flow pattern in this
region with abduction
In direct communication with the supraspinatus causing compression of the
supraspinatus against
is the deep projection of the coraco-humeral the humeral head, squeezing
the vessels in this
ligament which runs perpendicular and deep to critical region [50]. The
bursal surface blood flow
the supraspinatus tendon but superficial to the in the supraspinatus tendon
is more robust than its
joint capsule. corresponding articular
surface [38].
1065
Although less robust in some areas, this vascu- warrant more concern to
the surgeon. As the results
lar pattern may be adequate to meet the metabolic from this studies may
imply tear propagation in
needs of a healthy rotator cuff, as corresponding the transverse plane in
the antero-posterior
histological evidence of hypoperfusion has not direction [54].
been demonstrated [7]. Therefore, the existence Rotator cuff tears
disrupt the force balance in the
of a true critical zone, and its significance relative shoulder and the gleno-
humeral joint in particular
to pathological changes occurring within the resulting in compromised
arm elevation torques.
rotator cuff remains in question. This dynamic instability
contributes to further
Histologic, immunohistochemical and intra- structural damage
aggravating the initial lesion.
operative Doppler flowmetry analysis have reported
relative hyperperfusion at the area of the critical
zone [17, 28]. The hypervascularity in such cases Definition and
Classification
is thought to come from proliferation in the
subsynovial layer in response to injury. A partial-thickness tear
is considered to be
a definite disruption of
the fibers of the tendon
and is not simply fraying,
roughening or soften-
Local Biomechanics ing of the surface. The
degree of tearing is better
defined by the depth
involved in the thickness of
Variation in fibre orientation within the cuff/ the tendon than by the
area of the tear. There are
capsule complex from superficial to deep affects three sub-types described
for the supraspinatus:
its biomechanical properties. The bursal side of the 1. A bursal-side tear (BT)
which is confined to
supraspinatus tendon has been demonstrated to the bursal surface of
the tendon
have a lower modulus of elasticity with a higher 2. An intratendinous tear
(IT) which is found
ultimate strain and stress, compared with the artic- within the tendon; and
ular side of the tendon. This finding suggests that 3. A joint-side tear (JT)
which is present on the
the articular portion of the supraspinatus may be side of the tendon
adjacent to the joint.
more susceptible to mechanical failure in tension. Ellman [13] proposed a
classification which
Indeed, articular-sided tears have been more com- included the site and
extention of the partial tear,
monly reported [59]. whether its location was
adjacent to the articular or
The bursal layers are composed primarily bursal surface or whether
it was intra-tendinous.
of tendon bundles which may elongate with The grade was defined in
terms of the depth as
a tensile load and are resistant to rupture, whereas measured arthroscopically
by a probe:
the joint-side layers, a complex of tendons, liga- Grade-I tears had a depth
of less than 3 mm,
ments, and joint capsule, do not stretch and tear Grade II of 36 mm and
easily. This suggests that intratendinous lamina- Grade III, involvement of
more than half of the
tion is caused by differential shear stress within the thickness of the
tendon.
supraspinatus tendon. More recently
Habermeyer [25] described
In addition, with a simulated partial-thickness a 2-dimensional
classification of articular-sided
tear in one portion of the tendon, the remainder of supraspinatus tendon tears
in the coronal plane as
the tendon demonstrated increased strain. This well as the sagittal
plane, with regard to the origin
reflects the supraspinatus tendons interconnected of articular-sided partial
tears at the tendon inser-
five-layer complex and helps to explain why par- tion. The authors
described three types of rup-
tial-thickness tears may propagate into large full- tures regarding the
sagital plane:
thickness tears [4]. Other studies support the view Type A tear: tear of the
coraco-humeral ligament
that partial thickness tears could potentially propa- continuing into medial
border of supraspinatus
gate in the transverse plane, especially in >50 % tendon
thickness partial tears. From biomechanical data, Type B tear: isolated tear
within the crescent
bursal sided tears of over 50 % thickness should zone and
1066
A. Cartucho
Type C tear extending from the lateral border of development pathology on

the rotator cuff. Path-
the pulley system over the medial border of ologic changes in tendons
can lead to reduced
supraspinatus tendon up to the crescent zone. tensile strength and a
predisposition to rupture
This classification completes the classifications [26]. Intrinsic
tendinopathy and/or enthesopathy
of Snyder [56] and Ellman that lack anatomic due to changes in
vascularity of the cuff or other
landmarks with reference to the localisation of the metabolic alterations
associated with aging, may
tear at the insertion of the tendon, especially at the lead to degenerative
tears. Extrinsic factors pro-
border of the tendon insertion, at the rotator cable, duce lesions to the
rotator cuff through compres-
or within the crescent zone. sion of the tendons by
bony impingement or
The subscapularis partial ruptures can be direct pressure.
classified in tree different types according to More recently a
postero-superior impinge-
Lafosse [36]: ment due to repetitive
interaction between the
Type1 partial superior third, undersurface of the
supraspinatus tendon and
Type II Complete superior third, the postero-superior
glenoid was found responsi-
Type III Complete superior two-thirds. ble for JT partial tears
[59].
The injured tendon has
inflammatory changes.
Oxidative stress, tissue
remodelling and apopto-
Incidence sis are all important
parts of this pathological
process [28].
The incidence of partial tears of the supraspinatus The loss of dynamic,
fine-tuned control, due
is difficult to access, because most lesions can to rotator cuff pathology
leads to numerous
only be identified during arthroscopy, and MRI adaptative changes on a
regional and broader
may demonstrate partial tears in asymptomatic scale. Increase of
effective moment arms through
individuals [55]. Cadaver studies have consis- connections to other
tendon sub-regions tend
tently shown that partial-thickness are more com- to overload the last [37].
On a broader scale
mon than full-thickness tears [63]. Among the there are modifications on
the shoulder muscle
three sub-types of partial tear, JTs. are two to firing patterns namely the
upper trapezius and
three times more common than BTs. an increase of scapular
contribution to arm
Intrasubstance tears are less frequent, comprising elevation [43].
7.913.6 % in the series of Fukuda et al. [16, 18]. The loss of normal
shoulder kinematics leads
Most of the earlier reports did not include intra- to further stress not only
on the injured tendon but
tendinous lesions. The apparent lack of the last in in all rotator cuff
tendons and scapular muscles
published series is due to the difficulty of the [48]. This fact may
contribute to further aggrava-
diagnosis [19, 33, 44, 48]. tion of the structural
injury, of the functional
According to some authors [30, 52] the inci- problem and of the
clinical presentation.
dence of partial ruptures of the subscapularis is All these
inflammatory, degenerative and
more than 30 %. This fact led many to a more mechanical factors,
contribute to the onset,
thorough assessment of the subscapularis during stabilisation, propagation
and aggravation of the
arthroscopy and appreciation of the potential role partial rotator cuff
rupture (Fig. 1).
that this tendon may play as a cause of anterior
shoulder pain and biceps instability.
Natural History
Pathogenesis Determining the natural

history of partial rotator
cuff ruptures is essential
to decision-making on
Probably, rotator cuff tendinopathy is secondary treatment strategies.
Studies of anatomical find-
to multiple factors. Combinations of intrinsic ings according to age have
established that
and extrinsic factors are responsible in the degenerative rotator cuff
tears are exceedingly
1067
Fig. 1 Propagation and Intrinsic and extrinsic

factors
aggravation of the partial
rotator cuff rupture
Structural/inflammatory changes of tendons

Dynamic impingement
Aggravation of tendon injury

Bursa and acromion changes
Loss of normal shoulder kinematics

Regional adaptative changes
Further aggravation of the

structural injury
rare before the age of 40 and that both their weight of the arm,
hypovascularity, inflammatory
prevalence and their extention increase with changes, oxidative
stress, augmented apoptosis,
advancing age. Thus, partial-thickness tears usu- shear stress within the
tendon, and subacromial
ally occur in the sixth decade of life, full- impingement. In the
same way any process that
thickness tears in the seventh decade, and impairs tissue healing,
like smoking, will also
involvement of multiple tendons in the elderly contribute to cuff
disease and a less effective
patients [2]. These data support clinical experi- healing response [28].
ence regarding the progression of degenerative
rotator cuff pathology.
Not all partial tears are symptomatic but more Clinical Presentation
than 50 % of patients with partial rotator cuff
tears become symptomatic over the years [63], There have been few
data on the characteristics of
especially on a context of a symptomatic contra- asymptomatic rotator
cuff tears such as their size,
lateral tear. location, involvement
of the biceps tendon and
Although anatomical damage fails to correlate bursal or gleno-humeral
effusion. Asymptomatic
with clinical manifestations, tear progression tears are typically
limited to the supraspinatus
may be more common in patients with symptoms. tendon and are very
uncommon in subjects youn-
Nevertheless, half the patients with symptoms ger than the age of 60
but the prevalence
experienced no progression. Pain was far more increases with age
[44].
closely correlated to subacromial bursitis The physical signs
and symptoms of rotator
and long biceps tendinopathy than to tear size or cuff disease can be
separated in two categories.
site [65]. The ones from
mechanical impairment due to the
From the clinical and histological aspects, structural damage with
the adaptative response of
spontaneous healing of partial tears appears to the shoulder girdle and
others resulting from
be unlikely except on rare occasions. Various inflammatory changes
and involvement of the
untoward factors involved in the healing of long head of the
biceps.
the torn tendon include ageing, separation of the Pain especially at
night is the most disturbing
tear caused by muscular contraction and the symptom. There is
evidence that the pain is
1068
A. Cartucho
Fig. 2 Hawkins sign
proportional to the degree of subacromial bursi- The Neer and Hawkins

(Fig. 2) tests have good
tis, not to the depth or extent of the tear [23]. sensitivity but low
specificity for subacromial
Impingement signs, painful arc and a positive impingement syndrome
to diagnose
procaine test are the result of tendon and bursal supraspinatus or
infraspinatus tears, the Jobe
inflammatory status. The consequences of the sign and the full-can test
shows similar perfor-
tendon rupture are muscle atrophy, muscle weak- mance characteristics to the
Patte test and resisted
ness, lack of dynamic control (drop-arm sign), external rotation with the
elbow at the side flexed
crepitus, changes on muscle activation patterns at 90# [3].
with an early activation of the upper trapezius and Clinical assessment of
the subscapularis
changes in the shoulder rhythm with elevation of should include the lift-off
test [20], belly-press
the scapula in the initial two- thirds of movement test [21], Napoleon and
bear-hug test [1] to opti-
[34, 43]. Differential shoulder muscle firing pat- mise the chance of detecting
and predicting the
terns in patients with rotator cuff pathology may size of a subscapularis
tear.
play a role in the presence or absence of symp- The lift-off test (Fig.
3) is performed by plac-
toms. Asymptomatic patients have increased firing the hand of the affected
arm on the back (at the
ing of the subscapularis whereas symptomatic position of the midlumbar
spine) and asking the
subjects continue to rely on torn rotator cuff patient to internally rotate
the arm to lift the hand
tendons and periscapular muscle substitution off of the back. The test is
considered positive if
resulting in compromised function. Increased the patient is unable to
lift the arm off the back.
scapular contribution to arm elevation may The belly-press test
(Fig. 4) is performed with
allow function at a higher level and can be con- the arm at the side and the
elbow flexed to 90# , by
sidered a positive adaptation [34]. At present it having the patient press the
palm of the hand into
his not possible to confirm the direction of these the abdomen by internally
rotating the shoulder.
effects in order to be able to design rehabilitation The active internal rotation
force against the
programs to optimise scapular mechanics. patients belly is assessed
and quantified.
1069
A positive bear-hug and

belly-press tests sug-
gest a tear of at least 30 %
of the subscapularis,
whereas a positive Napoleon
test indicates that
more than 50 % of the
subscapularis is torn.
A positive lift-off test is
not seen until at least
75 % of the subscapularis is
involved.
Diagnostic Imaging
Although it is possible to
use shoulder
arthrography for the
diagnosis of partial rotator
cuff tears MRI and
ultrasonography are the most
commonly used. Arthrography
of the shoulder
allows evaluation of the
integrity of the under-
surface of the rotator cuff.
However, its value in
diagnosing JTs remains
uncertain with an accu-
racy ranging from 15 % to 83
%.
There has been
substantial improvement of
ultrasound technology in
recent years which
enables higher spatial
resolution and superior
image quality with modern,
high-frequency
Fig. 3 Lift off test probes. Recent studies [61]
found comparable
accuracy for ultrasonography
and MRI in the
detection of partial tears,
with MRI having
slightly superior rates
regarding sensitivity in
The test is considered positive if the patient intrasubstance ruptures (Fig.
6).
showed a weakness in comparison to the opposite MRI arthrography has been
considered supe-
shoulder. rior in detecting rotator
cuff pathology, especially
The Napoleon test, a variation of the belly- partial tears [14, 33].
Ultrasound scan, unlike
press test, is performed by placing the hand on MRI, is a dynamic examination
that enables the
the stomach in the same position in which examiner to repeat and re-
scan the suspected
Napoleon Bonaparte held his hand for portraits. area. In addition;
relationships with other tendons
The Napoleon test is considered negative if and the presence of secondary
signs of impinge-
the patient is able to push the hand against the ment may aid correct
diagnosis.
stomach with the wrist straight, and positive if MRI should be reserved
for doubtful cases and
the wrist was flexed to 90# to push against the in patients with involvement
of multiple anatom-
stomach. ical structures on the gleno-
humeral joint like the
The bear-hug test (Fig. 5) is performed with capsule-labral complex.
the palm of the hand involved side placed on the
opposite shoulder and the elbow positioned ante-
rior to the body. The patient is then asked to hold Diagnosis at Surgery
that position (resisted internal rotation) as the
physician tries to pull the patients hand from The use of arthroscopy
permits a very effective
the shoulder with a force applied perpendicular inspection of the cuff.
Nevertheless it is essential
to the forearm. The test is considered positive if to correlate the arthroscopic
findings with the
the patient can not hold the hand against the clinical presentation in
order to understand if
shoulder. the structural change present
is responsible for
1070
A. Cartucho
Fig. 4 The belly-press test
Fig. 5 The bear-hug test
the patients complaints. For confirmation of and a suture marker passed.

Inspection of
the diagnosis a systematic inspection and palpa- the bursal side should
follow by carefully
tion of the joint and bursal sides of the cuff should performing a boursectomy
while assessing the
be performed. Joint side fraying should be qaulity of the tendon. If
an intratendinouse lesion
debrided, the extention of the lesion measured is suspected the surgeon
must look for thinning or
1071
progression and of new onset

of symptoms based
on the quality of the
mechanical balance achieved
by conservative treatment.
Conservative Treatment
Patients with degenerative

partial-thickness tears
due to impingement are treated
similarly to those
with rotator cuff tendinopathy
and subacromial
bursitis. Time, local rest,
application of cold or
heat, massage, non-steroidal
anti-inflammatory
medication for a short period
of time, modification
of activities, gentle
exercises for anterior and
posterior capsular stretching,
and later, muscle-
strengthening for the rotator
cuff and the peri-
scapular musculature to
restore the mechanical
Fig. 6 Intra-substance ruptures
balance [35]. Subacromial or
intra-articular corti-
costeroid injections can also
be used judiciously,
depending on the location of
the tear for those
bulging of the cuff and then, using a shaver, the patients with persistent
symptoms unresponsive
leasion can be put in sight. Also using a probe to other means of pain
reduction. Classically no
while performing elevation and rotation of the more than two or three
injections should be admin-
arm, can locate the lesion [42]. istered but there is no data
to support the view that
patients that do not respond
to an injection and the
described conservative
methods, would benefit
Treatment Options and Indications from the use of more
injections.
Fukuda [17] found no
evidence of healing
It is important to recognise that the choice of occurring in histological
sections obtained from
treatment depends on the exact cause of the partial-thickness tears.
Yamanaka [64] followed
lesion. Treatment of most symptomatic partial 40 articular-sided tears
treated non-operatively
tears should be directed towards a primary diag- during a 2-year period and
found tear progression
nosis such as an impingement syndrome or insta- in 80 % of patients. A
decrease in tear size
bility, with treatment of the partial tear itself occurred in only 10 %, and
complete disappear-
being considered a part of a broader problem. ance of the tear occurred in
another 10 %. There-
Nevertheless in traumatic lesions the rotator fore, tear progression is the
greater concern
cuff lesion is the cause of the dynamic impair- during non-operative
management.
ment and consequently of the secondary inflam- Pain and loss of active
elevation have been
matory process and the repairment of the identified as poor prognostic
factors for success-
structural problem is the key. ful conservative treatment
[62]. Most BTs
The goal is to achieve a clinical cure. If the respond poorly to conservative
treatment [27].
signs and symptoms of inflammation are allevi- Once the round circle of
subacromial impinge-
ated, and if those due to the mechanical defi- ment has been established
and/or the tear is
ciency of the torn cuff are compensated for, by deep, conservative treatment
is rarely helpful.
the residual cuff muscles and prime movers, the Early surgical intervention
should be
patient becomes asymptomatic. Then the benefits considered when the severe
clinical manifesta-
of an operation should be carefully accessed, tions and positive imaging
suggest a BT
taking in to consideration the possibility of tear diagnosis [11].
1072
A. Cartucho
Fig. 7 Assessment and

debridement of the
supraspinatus
In most cases, 3 months of conservative treat- or entirely arthroscopically.

Although, there is not
ment are sufficient to assess the clinical gains sufficient data to support
one technique over the
achievable without surgery. A rapid therapeutic other in the management of
partial-thickness tears,
response predicts better outcomes. Among the arthroscopy permits the
evaluation of the articular
components of the clinical presentation, strength and bursal side of the cuff
which represents a
failed to improve [6, 31]. In contrast, conserva- major advantage over an open
surgical procedure
tive treatment consistently alleviated the pain and especially in articular
partial tears.
improved the range of motion.
Arthroscopic Assessment
Arthroscopy can be performed
on a beach chair
Operative Treatment or lateral decubitus position
depending on the
training and preferences of
the surgeon. Through
The timing of surgical intervention has to be a posterior portal an
articular side inspection
established according to the age and activity of is performed.
the patient, type of rupture (degenerative/ The quality of the
supraspinatus should be
traumatic), the presence of associated pathology assessed, fraying should be
debrided and the pres-
and the response to conservative measures. ence of associated lesions
should be noted
The surgical management of partial-thickness (Fig. 7).
supraspinatus tears basically involves one of Very often a superior
labrum lesion is present.
three options: Normally a Snyder type one
lesion resulting from
1. Arthroscopic debridement of the tear, vertical dynamic instability
of the humeral head
2. Debridement with acromioplasty, or and only a debridement should
be considered
3. Rotator cuff repair with or without (Fig. 8).
acromioplasty. In other rare cases with
type two or three
Surgery may be performed open, slap lesions, the stability
of the fragments and
arthroscopically-assisted with mini-open approach, of the long head of the
biceps should be assessed
1073
Fig. 8 Snyder type one

lesion
in order to decide whether to repair the lesion or At this point the surgeon
must decide
perform a biceps tenodesis. according to his or her
experience and depending
After debriding the lesion, the extent of the on the type of rupture, if an
all arthroscopic
lesion should be measured. Using a bent, prefer- technique, a mini-open
technique or an open pro-
ably calibrated arthroscopic probe, the amount of cedure is should be
performed.
bone footprint undercovered should be measured Visualisation of the
subscapularis tendon and
and a monofilament suture marker should be its footprint on the lesser
tuberosity is best
passed through the tendon (Fig. 9). Care should performed through a posterior
viewing portal.
be taken to assess the integrity of the biceps Positioning the arm in
abduction and internal
posterior pulley and biceps stability (Fig. 10). rotation, the subscapularis
insertion and footprint
Through the same posterior portal the can be easily visualized.
arthroscope is directed to the subacromial Because of the close
proximity of
space. A careful but complete bursectomy subscapularis and the
superior gleno-humeral
should be performed and the suture marker ligament/coraco-humeral
ligament complex on
identified (Fig. 11). The quality of the tendon the humeral side, when the
subscapularis is
on the bursal side should be assessed and any detached from the lesser
tuberosity, the superior
indirect signs of impingement, such as fraying gleno-humeral
ligament/coraco-humeral liga-
of the coraco-acromial arch, should be noted ment complex is also torn but
a portion of it
(Fig. 12). remains attached to the
superolateral corner of
Palpation of the cuff tissue to assess tissue the subscapularis tendon
producing the comma
integrity and the injection of saline into the area sign [29].
in question can be used to diagnose intra- In addition, tearing of
the superior gleno-
tendinous tears. humeral ligament/coraco-
humeral ligament
1074
A. Cartucho
Fig. 9 Suture marker on

the articular side
Fig. 10 Biceps stability

assessment
complex disrupts the medial sling of the bicipital rotation. The long head of
the biceps should be
sheath predisposing the biceps tendon to sublux- also assessed for
degeneration, and the amount of
ation (Fig. 13). Stability can be dynamically eval- partial tearing is estimated
by pulling of the biceps
uated by rotating the arm into internal and external tendon intra-articularly
[30, 36].
1075
Fig. 11 Identification of
the suture mark on the
bursal side
Fraying of the coraco-acromial arch
Fig. 12 Fraying of the

coraco-acrominal arch
Arthroscopic Debridement Alone 58 months and using the (UCLA)

Shoulder
Budoff [8] evaluated 79 shoulders with partial- Rating Scale, found the results
of debridement
thickness cuff tears treated with arthroscopic alone were good to excellent in
89 % in the
debridement alone with a mean follow-up of group of patients with less than
5 years of
1076
A. Cartucho
impingement syndrome or
partial-thickness
tears of the rotator cuff.
There was no difference
in outcome between those with
partial-thickness
tears less than 50 % of
tendon thickness com-
pared with those without any
tears. However, an
increased failure rate in
patients with grade 2B
(bursal-sided tears) even
affecting less than 50 %
of tendon thickness was
detected.
Arthroscopic debridement
should be performed
in ruptures that involve less
than 50 % of the
tendon in the articular side.
The age and level of
activity of the patient
should be taken in to
account. Bursal side, Ellman
type B2 ruptures,
should be repaired at an
early phase. Subacromial
decompression should be
performed if there is
evidence of an anterior
acromial or acromio-
clavicular spur.
Cuff Repair
The critical decision is to
know which patients will
benefit from a repair and the
ones that should be
Fig. 13 Biceps tendon subluxation managed otherwise. Regarding
he supraspinatus,
once a decision for a repair
is made, another deci-
follow-up and decreased to 81 % in those with sion to be made is whether to
do a transtendon
more than 5 years. repair or to remove the
remaining tissue and treat
the rupture as a complete
rupture. Some authors
Arthroscopic Debridement and believe that the cuff
material that remains in the
Subacromial Decompression immediate area is of poor
quality which increases
Release of the coraco-acromial ligament and the possibility of post-
operative pain and re-
debridement of the undersurface of the acromion rupture [49]. Besides a 5 mm
anchor should pass
with a high-speed burr to remove any acromial or the remnant tissue and the
correct positioning
acromioclavicular spurs (co-planing) have been can be difficult to achieve.
The procedure implies
recommended by some authors for the older an articular vision and
working through the
patient with either articular-side or bursal-side subacromial space to pass the
sutures in the cuff
tears due to external cuff impingement [46, 53]. (Fig. 14). After this step
the previously cleaned
Snyder [57] in a retrospective study of 31 subacromial space is accessed
in order to collect
patients with partial thickness tears treated with and tie the sutures (Fig.
15).
debridement and decompression reported 84 % In a recent work in
cadavers from Lomas [39],
good to excellent results. However, 13 of the 31 in situ trans-tendon repair
was biomechanically
patients did not undergo subacromial decompres- superior to tear completion
in articular-sided
sion and no significant difference was found in the supraspinatus tears. If a
completion of the rupture
outcome, regardless of whether decompression is decided upon the
configuration of the fixation
was performed. This fact gives special importance should be designed according
to the extent of the
to the mechanical imbalance produced by the rupture, the tissue quality
and elasticity. If a single-
injured tendon as a major prognosis factor. row technique is used, the
sutures of a double-
Another study [11] evaluated the clinical out- loaded anchor can be passed
in a mattress or in
come of arthroscopic acromioplasty and debride- a modified Matsen-Allen
stitch. If more stability
ment in 162 patients with normal cuffs and and footprint coverage is
necessary, a double-row
1077
Fig. 14 Passing the

sutures
Fig. 15 Passed sutures on

the bursal side
or a suturebridge configuration should be consid- anchors are placed at the

medial margin of the
ered (Fig. 16). The former can be useful especially rotator cuff footprint just
lateral to the articular
on poor quality tendons that wont support the surface, and the lateral
anchors are placed at the
outer stitch. For a double-row repair, medial lateral margin of the
footprint.
1078
A. Cartucho
functional outcome. A pre-

operative assessment
of the acromio-clavicular
joint as a potential
source of pain was
recommended in patients
with arthritic changes of
this joint. Porat, in
a retrospective study of
51 patients with
a minimum follow-up of 2
years, reported 83 %
of excellent/good results
and recommends com-
pletion of full thickness
tears with an all arthro-
scopic repair technique.
Regarding the
subscapularis, the surgical
approach can also be open
or athroscopic. In the
open technique a delto-
pectoral approach should
be preferred. After
identification of the long head
of the biceps the torn
subscapularis tendon lying
medially to this structure
should be free and
mobilised from the
scarring adhesions. Doing
so, the surgeon must be
aware of neurovascular
structures lying medially
to the conjoint tendon.
Once the tendon is mobile,
the lesser tuberosity
should be prepared as well
as the bicipital groove
Fig. 16 Suture bridge configuration if a tenodesis of the long
head of the biceps is to
be performed. Trans-
osseous sutures or suture
anchors are used to
securely fix the tendon
and the biceps to the
lesser tuberosity and to
On bursal-side ruptures, if maintenance of the the groove.
articular tissue is decided upon, a fairly external Arthroscopic repair
can be performed
position of the suture anchor is a good solution to viewing from a standard
posterior portal in
achieve a good position of the tendon on the type I and II ruptures but
frequently in type III
footprint (Fig. 17). an antero-lateral viewing
portal (Fig. 18) is used
If an intra-tendinous tear is identified, it should in order to permit a
complete intra- articular and
be opened on the bursal surface, while viewing extra-articular assessment
of the rupture. The
from the subacromial space. All non-viable tissue tendon edge is identified
after debridement of
is debrided, with care taken not to disrupt the the middle gleno-humeral
ligament from the
articular surface attachment of the cuff. Through posterior aspect of the
subscapularis and of
an accessory anterior working portal multiple the subdeltoid and
subcoracoid adhesions.
vertical mattress No. 2 non-absorbable sutures In more retracted ruptures
the use of a traction
are passed from anterior to posterior along the suture (Fig. 19) can be
helpful. After, the lesser
entire length of the tear. tuberosity is prepared for
anchor placement.
The results of surgical treatment of partial The author prefers the use
of metallic anchors
thickness supraspinatus ruptures have been that should be placed
along the anterior border
presented by several authors [10, 15, 32, 41, 47, of the bicipital groove in
order to achieve an
49, 58, 60]. Park compared the results of arthro- anatomic footprint repair.
The sutures are passed
scopic repair of patients who had partial- through the subscapularis
tendon with use of
thickness rotator cuff tears with those of patients a bird-beak suture-passer
(Fig. 20). Reconstruc-
who had full-thickness tears. Evaluation showed tion of the footprint
should be performed from
that 93 % of all patients had good or excellent the most inferior aspect
of the torn tendon
results, and 95 % demonstrated satisfactory out- progressing superiorly in
the direction to the
come with regard to pain reduction and rotator interval.
1079
Fig. 17 External position

of the suture anchor
Fig. 19 Traction suture of the

subscapularis
Fig. 18 Antero-lateral viewing portal
According to the works of Edwards [12] and Biceps Tenodesis/Tenotomy

Lafosse [36] open and arthroscopic repair of As said previously in this chapter
symptoms are
subscapularis isolated tears can yield marked most dependent on the inflammatory
changes and
improvements in shoulder function and pain involvement of the long head of the
biceps. For
reduction. this reason a careful assessment of
biceps
1080
A. Cartucho
Functionally they
produce mechanical imbal-
ance responsible for an
impingement syndrome.
Morphologically, they can
be placed between
subacromial
bursitis/tendinitis, and the full-
thickness tear.
Symptoms arise from
mechanical impairment
with adaptative response of
the shoulder girdle
and from inflammatory
changes and involvement
of the long head of the
biceps.
The diagnosis is
difficult even with MRI and
ultrasonography.
With progression of the
tear, clinical cure
by conservative measures
may be impossible
to obtain. Surgical
treatment with the correct
indications has consistent
results. The choice of
the surgical treatment
depends on the type of
rupture, the age and level
of activity of the patient
and of the degree of pain
and functional
impairment.
Fig. 20 Passing the sutures through the subscapularis
In the future, better
understanding of injury
mechanism, natural history
and risk of tear
progression, the fine
tuning of indications for
integrity and stability is mandatory [12]. Our operative intervention,
based on prospective,
indications for biceps tenodesis/tenotomy randomised clinical trials
and finally the use of
include degeneration involving 50 % of the thick- growth factors to stimulate
healing [24], as has
ness of the tendon or biceps tendon instability due been applied to other areas
of sports Medicine,
to disruption of the anterior (subscapularis) or may contribute to optimise
the treatment of this
posterior (supraspinatus) pulley. condition.
We perform an arthroscopic biceps tenodesis
to the bicipital groove using a suture anchor or
a simple tenotomy in low function-demanding
patients. References
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Incomplete tears of the subscapularis tendon associ- 64. Yamanaka K,
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March 1991. medical; 2005.
p. 287e94.
Arthroscopic Management of
Full-Thickness Rotator Cuff
Tears
Jean-Francois Kempf, Aristote

Hans-Moevi, and
Philippe Clavert
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1084 Objective Regain shoulder function and
Surgical Principles and Objective . . . . . . . . . . . . . . . . .
1084 freedom of pain through arthroscopic fixation
Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1085 of the torn rotator cuff using anchors and ten-
Pre-Operative Work-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1085 sion bands.
Surgical Instruments and Implants . . . . . . . . . . . . . . . . .
1086
Anaesthesia and Positioning . . . . . . . . . . . . . . . . . . . . . . .
1086 Indications Indications have increased these
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1087 recent years, with the tremendous technical
Portal Placements for Glenohumeral Joint . . . . . . . .
1087 progress of arthroscopic surgeons. They are:
How to Pass Sutures Through Tendons: Tips
1. Isolated full-tendon rupture of the
and Tricks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1088
The Different Suture Techniques . . . . . . . . . . . . . . . . . .
1089 supraspinatus.
Discussion: What Type of Suture: Single or
2. All full-tendon tears of the supraspinatus,
Double
Row? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1094 the infraspinatus or the teres minor, in cases
Tenotomy/Tenodesis of the Long Head of
of moderate retraction.
the Biceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1096
Arthroscopic Suture of a Subscapularis Tear . . . . . .
1097 3. Incomplete tears affecting the superior part
of the subscapularis, either isolated or asso-

Post-Operative Management . . . . . . . . . . . . . . . . . . . . . 1098
ciated with a rupture of the supraspinatus.

Errors, Hazards, Complications . . . . . . . . . . . . . . . . . 1100
4. For lesions of the long head of the biceps:
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1101 tenodesis for patients <60 years of age or for
manual workers; tenotomy in all other
instances.
Contra-indications Fatty infiltration of
infraspinatus and subscapularis of stages 3
and 4.
Frozen shoulder in the active phase.
Narrowing of the subacromial space
(<7 mm).
Relative contra-indications: Patients #65
years.
Surgical Technique Subacromial bursos-

J.-F. Kempf (*) A. Hans-Moevi P. Clavert
# #
copy and glenohumeral arthroscopy.
Centre de Chirurgie Orthopedique et de la Main, Illkirch-
Repair of the tendons using a posterior por-
Graffenstaden, France
tal and an inside-out anterior portal, associated
e-mail: jean-francois.kempf@chru-strasbourg.fr

1083
DOI 10.1007/978-3-642-34746-7_46, # EFORT 2014
1084
J.-F. Kempf et al.
with one or two additional anterolateral All ruptures undergo a

progressive deterioration
portals. accompanied by a medial
retraction of the
Attachment with a single row or double musculotendinous stump. The
muscle loses its
row anchors. elasticity and becomes the
site of a fatty infiltration.
Tenotomy/tenodesis of long head of biceps, Ruptures not only affect
the active range of motion
if indicated. but also the relationship
between humeral head and
glenoid. In instances of
supraspinatus tears,
Keywords a superior translation of
the humeral head occurs
Arthroscopy # Repair # Rotator cuff # Shoulder in abduction and forward
elevation caused by the
# Surgical technique absence of the depressor
effect of this muscle.
This upward displacement
is compensated by
an increased depressor
action of the subscapularis
Introduction and the infraspinatus.
The abnormal movements
may eventually
Shoulder arthroscopy was developed in the USA lead to glenohumeral
osteoarthritis and to
in the 1980s [1, 17, 27, 39, 40, 67] and introduced a progressive loss of the
centric position of the
subsequently in Europe. The surgical technique humeral head.
has improved over the years due to better material Disruption of the
subscapularis can influence
and equipment [50, 51]. the anteroposterior
stability, particularly when its
Tears of the rotator cuff vary, not only in distal part is involved.
respect to their location but also to their degree
of disruption. It is well known that normal ten-
dons never tear and that pre-existing conditions Surgical Principles and
Objective
decrease the tensile strength of the tendon. Two
mechanisms have been discussed: Arthroscopy of the
shoulder, inspection of the
1. Intrinsic factors [4, 18, 41, 55, 61]: age-related glenohumeral joint and the
subacromial space.
changes that take place in a more or less well- Fixation of the torn tendon
with suture anchors
vascularized tendon lead to a weakening of the using the tension band
principle to achieve resti-
tendons mechanical properties. tution of function and
relief of pain.
2. Extrinsic factors: these factors are mechanical
and responsible of an impingement that either Advantages of the
Arthroscopic
leads to a progressive attrition or to a sudden Procedure
traumatic failure at the level of the enthesis of Less damage to peri-
articular structures, in
the tendon. The most common is the particular to the
acromial insertion of the del-
subacromial impingement, according to Neer, toid, in comparison to
open procedures.
[53] that results in a subacromial abrasion of Decreased risk of
infection.
the bursal layers of the supraspinatus. During Shorter hospital stay, in
general 2448 h, or
forward elevation and abduction of the arm the out-patient surgery.
coraco-acromial arch exerts a friction on the Increased patient
comfort.
tendon. A second location of impingement is Shorter functional
recovery period.
found between the subscapularis and the cora- Absence of displeasing
scars.
coid process, also known as subcoracoid
impingement [32, 36]. A third site has been Indications
described posterosuperiorly between the artic- Complete cuff tears in
active patients <65
ular surface of the supra- and infraspinatus and years of age.
the posterosuperior edge of the labrum [37, 38, In older patients the
indications depend on the
63, 64]. Tears at these sites occur mostly in state of the tendon, the
clinical and radiologic
middle- aged persons and manual workers. findings, and the
patients motivation.
Arthroscopic Management of Full-Thickness Rotator Cuff Tears
1085
Partial tears affecting >50 % of the tendon Explain principles of

arthroscopy and the possi-
thickness [66]. ble need for open surgery.
For subscapularis tears the indication is open Enumerate possible
complications such as
to discussion given the technical difficulties. recurrence of the tear,
reaction to sutures, or
Therefore, we personally limit the indications to injury to articular
cartilage.
incomplete tears affecting the superior part, either Insist on the need for
post-operative physiother-
isolated or associated with rupture of the apy and explain the basic
methods to be used.
supraspinatus. Expected absence from
work: 46 months.
For Associated Lesions of the Long Head of If possible, a relevant
patients educational
the Biceps media explaining the
procedure and post-
Tenodesis in patients <60 years of age or in operative care should be
supplied.
manual workers, tenotomy in all other instances.
Contra-Indications Pre-Operative Work-Up

Poor prognosis of repairs, and technical limi-
tation [5, 21, 65]. For the proper patient
selection for arthroscopic
Fatty infiltration of infraspinatus and repair, a detailed
history, a full physical exam-
subscapularis of stages 3 and 4 [34]. ination and complementary
examinations (CT
Frozen shoulder in the active phase. arthrogram, arthro-MRI)
are necessary. Only
Narrowing of the subacromial space (<7 mm). thereafter, a decision
can be made as to whether
As shown by Walch [62], good clinical result an arthroscopic repair is
indicated. The
after repair may be obtained only when the patients history should
include kind of work,
remaining subacromial space is greater than dominant side, onset and
kind of symptoms,
7 mm. It is always the case for an isolated and work-related accident,
previous treatments,
distal supraspinatus tear. and limitation of
function.
Poor compliance expected during rehabilitation. Advanced age, an accident
at work or an occu-
Complete tear of the posterosuperior cuff pational disease
constitute factors contribut-
reaching the teres minor. ing to a poor prognosis.
Compliance of the
Complete tear of the subscapularis (relative). patient is very
important, as a perfect opera-
Patients #65 years (relative). tion without proper post-
operative rehabilita-
tion will lead to a poor
result.
Physical examination
includes inspection of
Patient Information the shoulder to detect
possible muscle atrophy.
Atrophy in the absence of
a tear may indicate
General surgical risks such as thrombo- involvement of the
suprascapular nerve.
phlebitis, embolism, infection, injury to Check for possible
rupture of long head of
neurovascular structures. biceps. Inspection is
followed by palpation
Explain in simple terms the pathological con- with the purpose to find
the site of maximum
dition of the shoulder, preferably with the help pain. The degree of
active and passive motion
of a plastic shoulder model. should be recorded.
Various shoulder-specific
Inform the patient that spontaneous healing can- tests should be executed
(Neer, Hawkins and
not be expected, that the prognosis without sur- Yocum tests, relocation
test, palm-up test,
gery is not favourable, and that in the absence of Speed test, Yergason
test).
repair the eventual outcome may be osteoarthri- Specific tests of the
subscapularis include the lift-
tis of the glenohumeral joint. off and press belly test
[29], for the supraspinatus
Surgery will result in an almost normal function the Jobe test, and for the
infraspinatus the exter-
and will decrease pain. For this to be achieved, nal rotation against
resistance with the elbow at
the torn tendon will be re-attached to bone [33]. the side [46, 56].
1086
J.-F. Kempf et al.
Fig. 1 Different
arthroscopic surgical
instruments. (a) Suture
retriever. (b) Suture Hook.
(c) Punch. (d) arthroscopic
hook. (e): Knot pusher. (f)
Grasper. (g) Scissor. (h)
Bird Peak
Complimentary examinations include plain Anchors and sutures:

radiographs in the scapular plane with true We choose from a wide
variety of anchors
anteroposterior view in internal, neutral and available, including
metallic anchors with
external rotation and a supraspinatus outlet eyelets [3],
bioabsorbables anchors
view [49]. The subacromial space must be We prefer non-resorbable
sutures such as
measured. Ethibond 30 (Ethicon,
Somerville, NJ,
To define the lesion of the rotator cuff in USA, Johnson and Johnson)
or re-inforced
detail, we recommend a CT arthrogram or sutures as Fiberwire 2
0 (Arthrex) or
arthro-MRI. These examinations allow the Orthocord (Mitek).
determination of the degree of fatty infiltration
of the subscapularis and the infraspinatus
based on the classification of Goutallier et al.
[23, 34, 35], as well as the degree of muscular Anaesthesia and Positioning
atrophy involving supraspinatus.
Interscalene nerve block
supplemented by
light sedation [26] or more
often general
Surgical Instruments and Implants anaesthesia. A catheter can
be used for post-
operative pain relief.
Pressure-monitoring fluid-pumping system. Beach-chair position on a
Maquet table
Electrocautery. avoids very often the need
for traction. The
Motorized shaving system with suction. head is placed in a head
support. Care must be
Arthroscopic instruments (Fig. 1): forceps to taken to have a free access
of the posterior part
grasp suture, hook for suture passage, arthro- of the shoulder.
scopic scissors, arthroscopic hook, knot Free draping of arm for
easy manipulation.
pusher, grasping forceps, Bird Beak Slight flexion of knees.
This position is com-
forceps. fortable for the patient.
The entire positioning
1087
Fig. 2 Anterior views of

arthroscopic portals
allows conversion to an open procedure with- the musculocutaneous nerve.

Using the outside-
out the need for repositioning of the patient. in technique, a spinal
needle is passed through the
rotator interval that is
limited medially by the
anterosuperior portion of
the glenoid, superiorly
Surgical Technique by the long head of the
biceps, and inferiorly by
the subscapularis muscle.
The skin incision is
Portal Placements for Glenohumeral located next to the needle,
and a Wissinger rod
Joint is advanced into the joint.
A cannula is then
passed over the rod.
Primary posterior portal (P): 2 cm distal and 1 cm Anterosuperior portal
(AS): this additional
medial to the posterolateral border of the portal is placed 12 cm in
front of the
acromion passing between infraspinatus and acromioclavicular joint. It
must be lateral and
teres minor. A blunt trocar is inserted in the superior to the coracoid
process to avoid injury
direction of the coracoid process permitting to to the musculocutaneous
nerve. The position of
enter the Superior part of the joint. This position the spinal needle used is
checked with the
is checked with the camera before opening the arthroscope.
irrigation (Figs. 2 and 3). Superior portal (N;
Neviaser): the entry point
Postero-inferior portal (not shown): the entry is located between the
posterior margin of the
point lies 2 cm inferior to the posterior portal. distal end of the clavicle
and the medial border
This portal is used to access the postero-inferior of the acromion. To avoid
damage to the
capsule pouch. suprascapular nerve, the
patients head should
Anterior portal (A): this access is created by be inclined to the opposite
side.
the inside-out technique under arthroscopic con- The spinal needle must
pass behind the inser-
trol through the posterior portal to avoid injury to tion of the long head of the
biceps.
1088
J.-F. Kempf et al.
Fig. 3 Posterior views of

arthroscopic portals
Portal Placements for the Subacromial The Tools

Bursoscopy A Needle
In addition to the already described anterior (A) The cheapest tool is a simple
spinal needle! You
and posterior (P) portals, the posterolateral (PL), can deform it, adjust its
curvature, in order to
the anterolateral (AL), the lateral (L), and the adapt the needle and pass a
rigid suture such as
laterosuperior (LS) portals can be used. a PDS which will be used as
shuttle relay to place
The posterolateral portal is placed 2 cm distal the definitive suture through
the tendon (Fig. 4).
to the posterolateral angle of the acromion. The
entry point to the anterolateral portal is found Others Solutions (More
Expensive)
2 cm distal to the anterolateral angle of the A suture-passer such as the
Banana Lasso (Fig. 5)
acromion. The lateral portal is placed 1 or 2 cm or others suture-passers with
various curved tip
lateral to the acromion and 2 cm behind its ante- configurations can be used
for arthroscopic
rior border. The entry point to the laterosuperior Bankart, SLAP & rotator cuff
repairs.
portal is placed 12 cm above the lateral portal Others Suture-passers such
as bird Peak
under the lateral border of the acromion. allow fast tissue penetration
and suture retrieval
(Fig. 6).
Retrievers are designed
for atraumatic suture
How to Pass Sutures Through Tendons: retrieval and manipulation
Tips and Tricks The Crochet Hook (Spectrum
Suture-Passer -
Linvatec) (Figs. 7 and 8)
will offer surgeons an
Many Tools are available to pass sutures through easy suture passing, with the
possibility to choose
tendons. Whatever our choice, some rules must between crescent hook ([45]
right or left hook, or
be respected. more).
1089
Fig. 4 The cheapest tool:

a needle
We recommend to use at the same time of Arthroscopic Knots

a grasper to maintain the tendon stable and facil- A wide variety of
arthroscopic knots exists [42].
itate the passage of the PDS suture through the Fingers needed to make these
knots are
tendon. represented. The dark thread
is wrapped around
the red thread (the post)
that is held by three
fingers: thumb; index and
middle finger. We
The Suture Pinchers
use the following sliding
knots: SMC [43, 44],
The combination of a grasper and a suture pass-
Roeder, MCK, MSK, Duncan,
and Nicky. They
ing pinch combine the need for precision and
have the advantage of not
being too bulky and
speed of arthroscopic surgery. Their design
also are easy to lock.
Before tying the knot, one
allows for one-handed surgery (and one shot!)
has to verify that the
suture slides easily. If it
(Fig. 9).
does not, a standard knot,
with two half hitches
Many companies offer this kind of device,
thrown in the same
direction, should be followed
allowing the surgeon to pass sutures through
by five half-hitches
alternated in direction
soft tissue in a single step, for instance
(Fig. 12).
EXPRESSEW (Mitek), the Scorpion or the
For the last two half-
hitches, the post should
Viper (Arthrex).
be alternated.
Irrespective of the type
of sliding knot used,
Which Kind of Suture? the knot must be backed up
by three half-hitches
The easiest suture is the simple stitch (Fig. 10) to be secured! [60]. Mastery
of the technique is
The most common is the mattress suture mandatory [14, 15, 17, 54].
The strongest is the Mason-Allen modified by
Gerber [30], but difficult to do arthroscopically
1. The simple stitch: The Different Suture
Techniques
Could be enough in some simple cases
2. The mattress suture (Fig. 11): Two main options: the single
row technique and
Simple the double row [52].
The Lasso Loop described by Lafosse [47]. Double-row rotator cuff
repair techniques
The Haubannage (Mattress-Tension-Band incorporate a medial and
lateral row of suture
(Boileau) [6, 7] easy to do with a crochet anchor in the repair
configuration. Clinical
hook. studies, however, have not
demonstrated
1090
J.-F. Kempf et al.
Arthroscopic Suture
Techniques of the
Supraspinatus: Single Row
Technique
Before proceeding with a
rotator cuff repair, an
exploration of the
glenohumeral joint is imper-
ative. This is achieved
through the posterior
portal, and an assessment of
all intra-articular
structures, including the
long head of the biceps,
is carried out. The tear is
visualized and its size
and morphology are assessed.
The tendon
stumps are retracted. The
scope is then intro-
duced into the subacromial
space through the
posterior portal. The
anterior portal is placed
by an inside-out technique.
Careful debridment
of the subacromial space with
a motorized
shaver introduced through a
lateral portal is
performed. If the acromion is
prominent, an
acromioplasty is performed
with a motorized
burr at the beginning of the
procedure to enlarge
the subacromial space.
With the forceps
introduced through the lat-
eral portal the stump of the
tendon is grasped
and pulled toward the greater
tuberosity. This
allows determining whether a
re-insertion is
possible or not.
a A juxtaglenoid
capsulotomy with a hooked
b electrocautery may allow
added mobilization of
the tendon. Two situations
are possible:
c 1. The tendon can be
sufficiently mobilized and
re-inserted.
2. The tendon is retracted
and thus prevents its
suture to the greater
tuberosity requiring the
margin convergence
technique, as described
by Burkhart [1016] (see
Fig. 13).
If re-insertion is
possible, multiple anchors
inserted at the Lateral
Superior surface of the
greater tuberosity are used.
Their number
depends on the size of the
tear. They are spaced
every 58 mm (Fig. 14).
Although several
techniques have been
described, we describe the
authors preferred
Fig. 5 Example of a suture passer with a lasso: The method. The technique using
one row of anchors,
Banana lasso
also known as tension-band
technique, described
by Boileau [68] (Fig. 15).
A Suture Hook
(Linvatec) is used to facil-
a substantial improvement over single-row itate suture passage through
the tendon. Its use
repair with regard to either the degree of struc- involves the initial passage
of a small-diameter
tural healing or functional outcomes! [24]. monofilament-type PDS
suture or of a suture
1091
Fig. 6 Different others

tools to pass the suture
through the tendon: the
Bird Peak
Relay Shuttle (Linvatec). The Suture Hook suture is then shuttled back
through the tendon
with its hook pointing to the right for the right by withdrawing the PDS (or
the Shuttle
shoulder and to the left for the left shoulder is Relay ). The anterior
suture is withdrawn
introduced through the anterior or anterolateral with the suture forceps
through the lateral por-
portal or less often through the lateral portal tal in order to get the two
sutures through the
for very posterior ruptures. By this way the lateral portal.
relay suture is passed through the tendon 1 cm This technique allows
making U-stitches that
medial from its free end and allows a good have a better purchase in
the stump than simple
purchase in the tendon. The free end of the stitches. Moreover, it
allows a perfect and uni-
PDS suture is grasped with a forceps and the form approximation of the
tendon stump to the
definitive non-absorbable suture (or number 5 freshened bony surface
thanks to the tension-
Orthocord , Mytek, or a number 5 Fiberwire , band effect.
Arthrex) is tied to the PDS or placed in the The knot pusher or the
suture forceps is slid
loop of the shuttle Relay. The non-absorbable down each suture to assure
absence of tissue
1092
J.-F. Kempf et al.
Fig. 7 A suture passer: the Spectrum (Livatec)
Fig. 8 Simultaneus use of a

grasper and the Crochet
tangling. To facilitate suturing, the arm is placed Hook
in abduction. The sliding knot is fashioned over
the post and pushed down with a knot pusher
under direct visualization. Once in contact with were assessed with regard to
function and the
the tendon and locked, three half-hitches com- strength of the shoulder
elevation. Results: The
plete and secure the knot. rotator cuff was completely
healed and watertight
The sutures are cut at 5 mm from the knot with in 46 (71 %) of the 65
patients and was partially
the arthroscopic scissors or a suture cutter. The healed in 3. Although the
supraspinatus tendon
other stitches are placed using the same did not heal to the
tuberosity in 16 shoulders, the
technique. size of the persistent defect
was smaller than the
Boileau report good results with this simple initial tear in 15. Sixty-two
of the sixty-five
technique [6]. He reported 65 consecutive shoul- patients were satisfied with
the result. The
ders with a chronic full-thickness supraspinatus Constant score improved from
an average (and
tear which were repaired arthroscopically with standard deviation) of 51.6 #
10.6 points pre-
the use of a tension-band suture technique. operatively to 83.8 # 10.3
points at the time of
Patients ranged in age from 29 to 79 years. The the last follow-up evaluation
(p < 0.001). The
average duration of follow-up was 29 months. average strength of the
shoulder elevation was
Fifty-one patients had a computed tomographic significantly better (p
0.001) when the tendon
arthrogram, and fourteen had a magnetic reso- had healed (7.3 # 2.9 kg)
than when it had not
nance imaging scan, performed between 6 (4.7 # 1.9 kg). Factors that
were negatively asso-
months and 3 years after surgery. All patients ciated with tendon healing
were increasing age
1093
the age of 65 years (p

0.001) and patients with
associated delamination of
the subscapularis
and/or the infraspinatus (p
0.02) have signifi-
cantly lower rates of
healing.
A French multicentric
study of the SFA found
the same conclusions [22].
The Double-Row Technique

Re-establishment of the
native footprint during
rotator cuff repair has
been suggested to be
important for optimizing
fixation strength and
healing potential. However,
the complexity of
most double-row repairs and
the added surgical
time remains a concern.
In this repair method,
2 rows of anchors are
used to fix the cuff (Fig.
16), one along the artic-
ular cartilage margin and
the other at the lateral
ridge of the greater
tuberosity. This technique
increases the strength of
repair by increasing the
number of sutures passed
through the tendon, as
well as increasing the area
of contact between the
tendon and bone [46].
For many cases (small
or medium tears), it is
possible to do a double row
with only two anchors,
using the two strands (of
various colours) of the
first suture of the medial
anchor to do a bar and
then a Haubannage with the
two strands of the
second suture fixed
laterally with a second
impacted anchor (Fig. 17).
In this situation, we
dont need to tie knots
inside the joint, as described
by Boileau [8]. The
technique, termed mattress-
tension-band (MTB), is
performed with 1 screwed
anchor inserted medially at
the articular margin
and an impacted anchor
inserted laterally on the
greater tuberosity. An
extra-corporeally-tied knot
Fig. 9 2 examples of suture Pinches: the Scorpion or figure-of-8 forms the
mattress suture medially,
The Viper (Arthrex)
whereas a knotless tension-
band is placed later-
ally. The mattress-tension-
band technique restores
the rotator cuff footprint
anatomy in a simple,
and associated delamination of the subscapularis quick, and reproducible
manner, thus reducing
or infraspinatus tendon. Only 10 (43 %) of operative time. The main
advantages are that
23 patients over the age of 65 years had there is no need to tie any
knot inside the joint
completely healed tendons (p < 0.001). The and that the only knot,
tied extra-corporeally, can-
author concludes that arthroscopic repair of an not slip, thereby improving
initial strength and
isolated supraspinatus detachment commonly stiffness of the repair.
leads to complete tendon healing. The absence An other possibility,
the suture bridge tech-
of healing of the repaired rotator cuff is associ- nique (Fig. 18), involves
using a medial row
ated with inferior muscle strength. Patients over anchors with sutures passed
and tied through the
1094
J.-F. Kempf et al.
Fig. 10 Different kind of

sutures
tendon medially, after which the suture tails are post-operative follow-up
examinations that the
draped over the remaining lateral cuff tendon and footprint of the rotator cuff
completely regener-
fixed laterally. This repair configuration has been ates to cover the greater
tuberosity ( Crimson
shown to increase the contact area and has an Duvet ) despite having been
completely
Haubannage effect (tension-band technique debrided of all soft tissues
at the time of the
+ medial mattress suture). repair.
According to Dines [19],
we agree that biome-
chanical studies of double-
row repair showed
Discussion: What Type of Suture: increased load to failure,
improved contact areas
Single or Double Row? and pressures and decreased
gap formation at the
healing enthesis [46]. A
double row of suture
Snyder [57, 58] recently recommend a single row anchors increases the tendon-
bone contact area,
of suture anchors with two or three sutures per reconstituting a more
anatomical configuration of
Anchor associated with multiple perforations the rotator cuff footprint.
placed through the cortical bone of the greater The authors recruited 60
patients. In 30
tuberosity into the bone marrow space, laterally patients, rotator cuff repair
was performed with
to the sutures. He commonly observed on MRI a single-row suture anchor
technique (group 1).
1095
Fig. 11 The Lasso loop as described by Lafosse and the Tension Band (Haubannage)
as described by Boileau
In the other 30 patients, rotator cuff repair was arthrography showed an

intact rotator cuff in 18
performed with a double-row suture anchor tech- patients, partial-thickness
defects in 7 patients,
nique (group 2). and full-thickness defects
in 1 patient. The
Results: Eight patients (4 in the single-row authors concluded that
single- and double-row
anchor repair group and 4 in the double-row techniques provide
comparable clinical outcome
anchor repair group) did not return at the final at 2 years. A double-row
technique produces
follow-up. At the 2-year follow-up, no statisti- a mechanically superior
construct compared
cally significant differences were seen with with the single-row method
in restoring the
respect to the University of California, Los anatomical footprint of the
rotator cuff, but
Angeles score and range of motion values. these mechanical advantages
do not translate
At 2-year follow-up, post-operative magnetic res- into superior clinical
performance.
onance arthrography in group 1 showed intact According to the
potentially increased implant
tendons in 14 patients, partial-thickness defects costs and surgical times
associated with the dou-
in 10 patients, and full-thickness defects in ble-row rotator cuff
repair, we recommend this
2 patients. In group 2, magnetic resonance sophisticated technique for
retracted or extended
1096
J.-F. Kempf et al.
Fig. 12 Differents Knots
tears, and we prefer a single row (Tension-Band) In case of a tear of the

postero-superior cuff
for distal tears of the supraspinatus. A systematic (supraspinatus and
infraspinatus), a tenotomy is
review of the rate of structural healing of rotator done in the presence of
pathological changes of
cuff repair (single versus double-row) done by the long head of biceps.
Duquin [20] concluded recently that double-row The tenodesis is
performed only in young,
repair methods lead to significantly lower re-tear active patients, particularly
if they are manual
rates when compared with single-row methods workers. The tenodesis is
done at the upper portion
for tears greater than 1 cm! of the bicipital groove [28].
The arthroscope is
inserted through the
posterior portal and an out-
side-in antero-superior
portal is created at the level
Tenotomy/Tenodesis of the Long Head of the groove to insert a
cannula for instrumenta-
of the Biceps tion. With the arm in forward
elevation and inter-
nal rotation an anchor with
to sutures is employed
A tenotomy of the long head of biceps is always to fix the tendon at the
upper portion of the groove
done in instances of tears of the subscapularis. (Fig. 19), using a lasso-loop
technique [47] with
1097
Fig. 13 Margin
convergence
the help of a sliding knot. Tenotomy medially to Placement of the arm in 30#
of abduction and in
the knot and resection of the proximal intra- internal rotation helps to
visualize the upper
articular stump are then performed. aspect of the subscapularis
insertion on the lesser
Another technique [2], using interference tubercle. The superior
glenohumeral ligament is
screws [9] (Fig. 20), is a little more difficult but often avulsed together with
the superolateral por-
offers a stronger fixation! tion of the tendon.
The distal aspect of the
ligament acts as
a landmark to identify the
proximal point of
Arthroscopic Suture of a Subscapularis re-insertion.
Tear With the help of a
motorized burr the insertion
zone of the tendon is
freshened. A PDS suture is
We perform an arthroscopic repair when the tear placed in the superolateral
part of the tendon
is limited to the superior intra-articular aspect of stump with a Bird Beak or
a Suture Hook (a).
the tendon (authors preferred option). If the tear The suture permits traction
on the tendon stump.
extends further distally, a conventional open Instrumentation through an
anterolateral portal
repair is indicated. may be required to mobilize
the retracted tendon
The arthroscope is inserted into the from the anterior glenoid
(Fig. 21).
glenohumeral joint through a posterior portal. The rupture of the upper
part of the
The anterosuperior portal is created from the subscapularis is often
accompanied by a medial
inside out as already described. The visualization subluxation of the long head
of the biceps. For
of the torn edge is sometimes difficult and the use this reason we always
proceed with a tenotomy of
of a 70# arthroscope should be considered. the long head of biceps or
with a tenodesis.
1098
J.-F. Kempf et al.
Fig. 15 Tension-band suture

technique (Haubanage)
Fig. 14 Single and double rows
Some authors, as Lafosse [48], repair all the

types of lesions, except the type V (complete and
retracted tear with fatty infiltration stage 3 or 4).
Post-Operative Management
Rehabilitation after rotator cuff repair is done in

two stages [25]:
1. The first stage is started on post-operative day
1 and lasts for 6 weeks. During this time the
arm is placed in a sling. The position of the
arm depends on the quality and the tension put
on the tendon. Fig. 16 Double row
1099
Fig. 17 Double row

technique with a bar :
mattress-tension-band
(MTB)
Fig. 18 The Suture bridge technique
Fig. 19 Tenodesis of the

Long Head of Biceps with
suture Anchor
Most of the time, the arm is immobilized
with the elbow at the side to take advantage
of the tension-band effect of the U-stitches. subscapularis tendon was
not torn, and is usu-
Daily pendulum and passive range of motion ally limited to 2030# .
exercises are done under the control of a 2. The second stage begins
after 6 weeks, and
physiotherapist and consist of flexion and is ideally carried out in
an out-patient rehabil-
abduction above the level of the sling. Passive itation specialized
department. It includes
external rotation is only done if the active mobilization
preferably started in a
1100
J.-F. Kempf et al.
Fig. 20 Tenodesis of the

LHB with an interference
screw
Fig. 21 Suture of the upper part of the subscapularis left shoulder
pool, and is associated with a progressive include a search for

Propionibacterium acnes.
increase in the range of motion. Strengthening Appropriate
treatment for infection may then
or active-resisted exercise of the short rotator be initiated.
muscles should be avoided for at least 12 weeks Nerve injuries:
rare, involve the axillary
post-operatively, until the bone-tendon Healing nerve, the
musculocutaneous nerve, or the
is almost, but not quite, mature [59]. suprascapular nerve.
The axillary nerve
can be injured when the
posterior or lateral
portals are placed too dis-
Errors, Hazards, Complications tally. The
musculocutaneous nerve is at risk
when the anterior
portal is placed too medi-
Infection seldom occurs and is usually caused ally. The
suprascapular nerve can be injured
by Staphylococcus aureus. A swab for culture when the posterior
portal is placed too
and sensitivity should be taken, and should medially.
1101
Neurapraxia: transient, most commonly Factors

influencing the results. Clin Orthop.
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Brassart N, Watkinson DJ, Carles M,
dence has been reduced since we adopted the Hatzidakis AM,
Krishnan SG. Arthroscopic repair of
beach-chair position. It remains, however, full-thickness
tears of the supraspinatus: does the ten-
a complication to be feared when significant don really heal?
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40.
7. Boileau P,
Chuinard C, Brassard N, Trojani C. The
in the lateral decubitus position. tension Band
Suture Technique for arthroscopic rota-
Reflex sympathetic dystrophy: the most fre- tor cuff repair.
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Brassard N, Roussanne Y. The Mattress-
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Technique: a knotless double-row
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Arthroscopic treatment of massive rota-
closure to allow drainage. No compartment tor cuff tears.
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Margin convergence: a method of reduc-
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Paris: Elsevier; 1999. p. 319.
Inverse/Reverse Polarity
Arthroplasty
for Cuff Tears with Arthritis
(Including
Cuff Tear Arthropathy)
Alexander Van Tongel and

Lieven De Wilde
Contents
Keywords
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1105
Biomechanics # Complications # Indications #
Inverse/reverse polarity arthroplasty # Rotator

Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1107
cuff-deficient arthritic shoulder # Surgical

Moment Arm, Stability and Loading . . . . . . . . . . . . . . 1107
Scapular Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107
Technique # Shoulder
Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1109
1110 History
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1114
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1115 The first total shoulder replacement is widely
Scapular Notching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1115 credited to Dr. Jules Emile Pean in 1893.
Aseptic Loosening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1117 However, in his original report Pean refers
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1117 to the work of Themistocles Gluck as being
Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1117
Other
Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1117 the inspiration for his shoulder prosthesis, a fact
understated if not completely overlooked during

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1118
the last 100 years. Themistocles almost certainly

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1118 designed the first shoulder arthroplasty in the
late 1800s although he never published on
the implantation of his shoulder designs in

humans [1, 2]. Arthroplasty played a limited
role in the treatment of shoulder problems
until in 1955 when Neer reported the use of a
proximal humerus arthroplasty for fractures with
good results [3]. In 1974, Neer subsequently
described the use of his proximal humeral
arthroplasty for the treatment of glenohumeral
osteoarthritis [4].
But the arthritic shoulder with irreparable
massive cuff deficiency remained difficult and
a challenging issue in shoulder practice.

A. Van Tongel (*) # L. De Wilde
In the 1970s, the idea of reversing the prosthe-
Department of Orthopaedic Surgery and Traumatology,
sis emerged because of difficulties encountered in

e-mail: alexander.vantongel@uzgent.be;
implanting an anatomical glenoid implant large
Lieven.dewilde@ugent.be
enough to stabilize the prosthesis and prevent

1105
DOI 10.1007/978-3-642-34746-7_52, # EFORT 2014
1106 A.
Van Tongel and L. De Wilde
Fig. 1 Trumpet
prosthesis designed by Paul
Grammont
proximal migration [5]. Early in the 1970s Neer abduction. Range of motion
was improved, but
designed three variations of a constrained reversed instability was a concern.
Grammont therefore
shoulder prosthesis. These prostheses created moved to a reverse design
with a large hemi-
a foundation for reverse shoulder arthroplasty. sphere on the glenoid side
to place the centre of
But dislocation and scapular fixation remained rotation at the bone
implant interface. His first
a concern with these implants [2]. In 1973 Kessel reverse design was the
trumpet prosthesis in
described a reversed prosthesis that was fixed to 1985 (Fig. 1). The humeral
component was all
the glenoid by a large central screw. In the same polyethylene, and the
glenoid component was
year, the Bayley-Walker system made advances in a ball made of metal or
ceramic and two- thirds
both design and fixation compared to the Kessel of a sphere with a 42-mm
diameter. Both compo-
design by coating the large central screw with nents were cemented.
Preliminary results of eight
hydroxyapatite and increasing the screw thread cases were published 1987
[7]. Four of these were
diameter [6]. These design changes were made in revisions of failed
anatomic arthroplasties.
an attempt to achieve secure glenoid fixation with- Results varied, but in
three patients the elevation
out a concomitant increase in loosening. During was more than 100# . The
implant was further re-
the next years several other semi-constrained and designed into the Delta 3
arthroplasty (DePuy
constrained prosthesis were designed. Unfortu- International, Ltd),
available in 1991 [8, 9]. In
nately, all these prostheses so far described the first generation, the
metaglenoid was
resulted in only marginal functional improvement a circular plate with a
central peg for press-fit
or were largely abandoned as failures [5]. impaction. It was fixed
with divergent 3.5 mm
It was not until the work of Grammont that screws superiorly and
inferiorly in order to resist
a reliable solution for the treatment of rotator cuff the shearing forces. The
glenosphere was
arthropathy was achieved. In the early 1980s, he screwed directly onto the
peripheral edge of the
advocated a medialized centre of rotation to plate. This concept of
peripheral screwing of the
improve the biomechanics of the deltoid muscle glenosphere had to be
abandoned because of sec-
by restoring length and increasing the lever arm. ondary loosening of the
screws. In the second
The Ovoid arthroplasty was tried in 1983. It had generation the periphery of
the metaglenoid was
an egg-shaped head on the humeral side. conical and smooth with a
Morse-Taper effect.
The centre of rotation was medialized but, due The metaglenoid was coated
with hydroxyapatite
to the ovoid shape, the deltoid muscle was on its deep surface to
improve bony fixation.
maintained in the lateral position to improve The centre of the
metaglenoid was hollow in
Inverse/Reverse Polarity Arthroplasty for Cuff Tears with Arthritis
1107
order to allow locking of the glenosphere with supported part is

concave, also the concavity
a central securing screw. The humeral component compression mechanism
makes the shoulder
was a monobloc with a cup of standard thickness. more stable.
The third generation became available in 1994 Concerning the
third feature, the centre of
with the new features pertaining to the humeral rotation was
lateralized and outside the glenoid
component. Because the cup was of insufficient bone in the old designs
of RTSA. This created
size, it rapidly deteriorated as a result of medial a high stress on the
fixation of the glenoid com-
impingement. It was therefore replaced by ponent, resulting in
aseptic loosening. By using
a lateralized cup available in two diameters of a small lateral offset
(absence of neck), the centre
36 and 42 mm [5]. of rotation is directly
placed in contact with
Reverse total shoulder arthroplasties (RTSA) the glenoid surface and
this reduces the torque
today vary in certain design details, although at the point of
fixation of the glenoid component
their intrinsic design remains based on [1113].
Grammonts principles. The variables in the cur- Concerning the last
point, bringing the centre
rent prostheses have been developed to address of rotation more medial
and distal creates
concerns that have arisen with reverse a mechanical advantage
for the deltoid muscle,
shoulder arthroplasty [2]. These problems and increasing its lever
arm and allowing for a greater
their possible solutions will be discussed exten- recruitment of deltoid
fibres during active
sively in the section on biomechanics and shoulder motion.
Portions of the deltoid initially
complications. medial to the native
glenohumeral joint centre of
rotation become active
abductors and elevators in
their new lateral
position. Distalization further
Biomechanics increases the
efficiency of the deltoid du-
ring shoulder motion
through elongation and
Moment Arm, Stability and Loading an associated increase
in its resting tension
[10, 14, 15].
Grammonts system focusses on four keys fea-
tures [2]:
1. The prosthesis must be inherently stable; Scapular Impingement
2. The weight-bearing part must be convex, and
the supported part must be concave; The biomechanics of
rotation of the reverse pros-
3. The centre of the sphere must be at or within thetic glenohumeral
joint differ from the ana-
the glenoid neck; tomic prosthetic joint
because of the hinging
4. The centre of rotation must be medialized and (rotation around a
lateral axis/point) instead of
distalized. spinning (rotation
around a central axis/point)
Concerning the first two features, RTSA can movement. As a result
of the prosthesis hinging
restore the joint stability by reversing the enve- in the adducted
position, a contact between the
lope of the joint contact forces and by changing humeral component and
the body of the scapula
the critical articulating surface [10]. The half- can occur and thereby
limit the range of motion
spherical glenoid fixation provides a large surface [16]. This mechanical
contact between the
reacting to the increased shear forces. Also the metaphyseal implant and
scapula is called scap-
use of large ball offers more stability than a small ular impingement and it
is related to the design of
ball. The critical stability region is now the area the prosthesis. This
can cause a mechanical
of the humeral cup where the depth determines block. This repetitive
mechanical abutment
the maximum dislocating shear force. In addition, can also be a reason
for glenoid neck erosion.
the humeral cup follows the direction of the del- This erosion is known
as scapular notching.
toid force and the high shear forces are well Most commonly the
impingement is inferiorly
constrained within the cup rim. Because the during adduction of the
arm. But also anterior
1108 A.
0 mm
31
Fig. 2 Notch angle
and posterior scapular impingement is possible.

This may restrict internal and external rotation.
The clinical relevance of inferior scapular
notching is controversial in the literature, with
some authors reporting no impact on post-
operative function [11, 17, 18] and overall out-
5 mm
come and others describing a negative correlation
between a scapular notch and the results after
RTSA [19, 20].
Inferior scapular impingement can be evalu-
ated with the notch angle (Fig. 2). This is the
12
adduction angle in the scapular plane between
the humerus and a vertical line parallel to the
glenoid plane, which is the plane formed by the Fig. 3 Influence of inferior
prosthetic overhang on the
rim of the inferior quadrants of the glenoid, when notch angle
a contact between the polyethylene cup and the
scapular pillar occurs. A positive value means
that contact occurs before the humerus reaches (a decrease in prosthetic
contact area) [21] results
the vertical position. A negative value means that in a gain in notch angle.
Reducing the humeral
the humerus can be adducted further than the component neck-shaft angle
[21, 25] results also
vertical position [21]. in increased gain. However,
this also results in
Several solutions have been described to over- reduced stability and
therefore is not
come the problem of scapular notching. recommended [26, 27]. Also
increasing the offset
Prosthetic overhang creates the biggest gain in of the glenosphere and/or
baseplate can cause less
notch angle (Fig. 3) [2123]. This can be scapular impingement [21,
28, 29]. But there is
achieved by low positioning of the glenosphere a disadvantage of increasing
torque or shear force
(flush to the inferior glenoid rim). This effect can applied to the glenoid
component and potentially
be enlarged with the use of a glenosphere with increasing the risk of
glenoid loosening [11].
increase radius. Also downward glenoid inclina- Concerning the anterior
and posterior scapular
tion [21, 24] and a change in cup depth impingement, Simovitch et
al. found a significant
1109
correlation of posterior notching with increased Superimposed on the

aforementioned changes
external rotation at 0# of abduction [19]. are severe osteopenia,
erosions of the entire
Stephenson et al. described the optimal version glenoid without
osteophyte formation, and
for the humeral component in Grammont-style medialization of the
glenohumeral joint [33].
prostheses which appears to be between 20# and Apatite-associated
destructive arthropathy,
40# of retroversion, giving a potential for impinge- also known as the
Milwaukee shoulder
ment-free ROM from 28# 44# external rotation to syndrome was originally
described by McCarty
83# 99# internal rotation, with the arm in adduc- in 1981 [34]. It is a
degenerative disorder affect-
tion [30]. Karelse et al. found that an increase in ing predominantly
elderly women, characterized
the divergence angle, which corresponds to by dissolution of the
fibrous rotator cuff and
a decrease in humeral component retroversion, destruction of the
glenohumeral joint [35]. It
correlates with an increase in radiographically- consists of a massive
rotator cuff tear, joint insta-
measured passive internal rotation with the arm bility, bony
destruction, and large blood-stained
adducted [16]. They described that a divergence joint effusion
containing basic calcium phosphate
angle of 30# 35# gives a good equilibrium crystals, detectable
protease activity, and
between external and internal rotation. minimal inflammatory
elements.
Cuff tear
arthropathy (CTA) is the extreme
end result of a massive
rotator cuff tear.
Indication Robert Adams first
described the clinical find-
ings of CTA in 1857
[36], however it was not
RTSA is indicated in patients with rotator until 1977 that Charles
Neer coined the term
cuffdeficient arthritic shoulder (RCDA). cuff tear
arthropathy. Neer et al. went on to
RCDA is not one unique pathologic entity but it provide the first
detailed description of CTA in
is a common end-stage of several disease pro- 1983 [37]. CTA
encompasses a condition
cesses such as rheumatoid arthritis, Milwaukee characterized by a
massive rotator cuff tear, prox-
shoulder syndrome and rotator cuff tear arthrop- imal migration of the
humerus resulting in
athy. All these pathologies have a unique clinical femoralization of the
humeral head and
feature which is a painful arthritic shoulder with acetabularization of
the acromion, glenoid
a massive, irreparable rotator cuff defect. RCDA erosion, loss of
glenohumeral articular cartilage,
is one of the most difficult and challenging issues osteoporosis of the
humeral head and eventually
in shoulder practice, due to the combination humeral head collapse
[37].
of severe articular and peri-articular soft tissue To date, the only
attempts to classify RCDA
damage. have been based on
radiographic classifications.
In RCDA large and massive defects in the In the literature three
different classifications
rotator cuff tendons lead to a loss in the centreing have been described,
each focussing on
of the humeral head. Loss of a fixed centre of a specific part of the
pathology.
rotation for the humeral head results in decreased Seebauer et al.
described a biomechanical
power of the deltoid [31]. At the end-stage the classification of cuff
tear arthropathy. It targets
patient presents with a clinically symptomatic, the superior migration
of the humeral head and its
irreparable rotator cuff tear associated with an containment within the
coraco-acromial (CA)
irrecoverable pseudoparesis of anterior elevation arch [38].
and/or abduction [26]. The Hamada
classification system character-
Rheumatoid arthritis (RA) is a common cause izes the structural
changes associated within the
of RCDA. The incidence of radiographic CA arch [39].
glenohumeral joint affection of the rheumatoid Favard et al.
proposed a classification that
shoulder varies from 48 % to 64 %. About 24 % focusses on the glenoid
erosion [20]. The study
of those having glenohumeral arthritis of Iannotti et al.
demonstrated that there was
have a simultaneous rotator cuff tear [32]. a fair to poor
agreement based on these three
1110 A.
x-ray classification systems [40]. One of the rea-

sons is the fact that discrete grades of
a continuous spectrum of the pathology makes it
difficult for different observers to agree on
a reading of an image. The inter-rater reliability
for surgical recommendations was low and
was not improved with the addition of clinical
information, which indicates disagreement on
how to use this information to make a surgical
recommendation. Middernacht et al. also
described that a conventional antero-posterior
radiograph cannot provide any predictive infor-
mation on the clinical status of the patient [41].
The reverse ball-and-socket arthroplasty relies
on the deltoid muscle for function; therefore, the
function of the axillary nerve and deltoid muscle
must be checked before surgery. The easiest way
to evaluate the function is by asking the patient to
elevate the arm while the examiner places his or
her fingers over the anterior third of the deltoid Fig. 4 90# axis of
glenoid component (1), 30# (diver-
muscle. If contraction is felt, the function of gence angle), (2), axis of
the humeral component (3)
the muscle is satisfactory. If it is difficult to
clinically determine the function of the deltoid
muscle, electromyography or electroneurography plane of the body. This
represented the shoulder
can be used. in neutral rotation
approximating the neutral
Also pre-operative testing of the teres minor shoulder orientation in the
surgical position. The
muscle with the hornblower sign [41, 42] and coronal plane parallel with
the back of the patient
the exorotation lag signs [41, 43] because the is the X-plane. A
measurement of the axis of the
integrity of teres minor, is essential for the recov- glenoid component is
performed. This axis is
ery of external rotation and significantly defined, on the level of
the centre of the glenoid
influenced the post-op Constant score [20]. component, as the line
drawn along the bony
surface of the metaglene
and is measured as an
angle made with the X-plane
[16].
Surgical Technique As described, a
divergence angle (the angle
between the axes of the
glenoid and humeral
Every surgical procedure starts with a good pre- components) of 30# gives a
good equilibrium
operative plan. between the external and
internal rotation.
Pre-operatively a strict AP in neutral position This means the optimal axis
of the humeral
and axillary shoulder X-ray is performed. With component 90# 30#
(divergence
the available templates it is possible to determine angle) axis of the
glenoid component (Fig. 4).
the size and the alignment of the humeral com- Per-operatively the
patient is positioned in the
ponent. A template for the glenoid component is beach chair position and,
before sterile draping,
not used because of the use of polyaxial screws. a check is mage for good
extension and
We also perform a CT-scan in a standardized adduction.
fashion, as described previously [44]. In the An RTSA is performed
via a deltopectoral or
supine position, a thoracobrachial orthosis is a superolateral approach.
In the largest currently
applied to position the arm adducted in the coro- available multcentre study,
that of 527 RTSAs for
nal plane and the forearm flexed in the sagittal massive rotator cuff tear,
both approaches had
1111
Fig. 5 Visualization of
humeral head through
superolateral approach
statistically significant advantages and disadvan- of the bone. In the

superolateral approach
tages [45]. A superolateral approach was found to a partial detachment of
the subscapularis may
be much better than a deltopectoral approach in be performed when the
superior dislocation of
terms of post-operative instability and was better the humerus is
difficult to obtain.
in terms of preventing fractures of the scapular If the biceps is
still in place a soft-tissue
spine and the acromion. A deltopectoral approach tenodesis is performed.
afforded better preservation of active external The humeral
resection guide is inserted into
rotation as well as better orientation of the the entry point in line
with the long axis of the
glenoid component, glenoid loosening, and infe- humerus (Fig. 6) and
with the aid of a jig the
rior scapular notching. humeral head is
resected, preserving the greater
In our department a superolateral approach is and lesser
tuberosities. At that time the retrover-
used if this approach has been used previously for sion of the humeral
component can be adapted as
rotator cuff repair, if there is an os acromiale, calculated pre-
operatively on the CT. It is impor-
when the shoulder is not stiff or in patients with tant to not over-resect
the head. The resection is
posterosuperior CTA (Fig. 5). We do not use this adequate if plane of it
corresponds to inferior
approach in revision surgery or for late sequelae glenoid. Afterwards a
protecting plate can be
post-traumatic surgery. The deltopectoral used while preparing
the glenoid.
approach is used when this approach was used The next step is a
very important step. It is
before, in stiff shoulders, in patients with necessary to have a
perfect visualization of the
anteroposterior CTA or in late sequelae post- glenoid before the
positioning of the base plate
traumatic surgery. Also for revision surgery we (Fig. 7). The biceps
remnant and the labrum can
use the deltopectoral approach and if necessary be excised and the
capsule needs to be detached
a clavicular osteotomy as described by Redfern (but not excised). A
complete 360# capsular
and Wallace is performed to gain an excellent release is needed.
Inferiorly, the tendon of the
access to the shoulder [46]. long head of the
triceps is released under protec-
Afterwards complete anterior and posterior tion of the axillary
nerve.
digital humeral release is performed. Concerning The guide-wire for
the glenoid reamer must be
the subscapularis, in the deltopectoral approach it positioned so that the
glenoid baseplate is as low
is necessary to detach the tendon to obtain good as possible. This means
in the centre glenoid
access. We perform a tenotomy at the attachment circle formed by the
outer edge of the inferior
1112
A. Van Tongel and L. De Wilde
Fig. 6 Insertion of humeral resection guide into the entry

point in line with the long axis of the humerus
glenoid quadrants (Figs. 8 and 9). The inferior

border of the baseplate should not be proximal to Fig. 7 Perfect
visualization of the glenoid before the
the inferior glenoid rim, so that the glenoid com- positioning of the
base plate
ponent eventually overlaps the inferior border of
the glenoid [21].
An inferior tilt may favour notching if reaming The humerus is
then broached, and the
is performed far medially. With a glenoid humeral trial is
inserted.
reaming level-checker the adequate reaming can An appropriate-
size glenoid hemisphere
be checked. Locking screws are used to provide (i.e., glenosphere) is
then mounted on the base-
primary stability. They are usually anchored in plate. Current results
suggest that larger
the lateral pillar of the scapula and in the base of glenospheres are
associated with less pain and
the coracoid. If necessary, locking or non-locking better strength and
less notching [20, 21] but it
screws can be used in the anterior or posterior may not be possible to
use a large implant in
holes for compression. a small individual.
Concerning the humeral component, this can After inserting a
humeral cup a trial reduction
be cemented or non-cemented and modular or is performed. The
implanted prosthesis is
monobloc. A modular component can be helpful relocated by pushing
the concave humeral cup
when there is an anterior cortical contact. In these downward rather than
by pulling on the arm.
cases a component with posterior offset can be Seating of the
prosthesis is easiest in approxi-
necessary. mately neutral
rotation and slight anterior
1113
Fig. 9 Status after

reaming glenoid with the use of
Fig. 8 Position of guide-wire in the centre glenoid circle a concave reamer
formed by the outer edge of the inferior glenoid quadrants
elevation [26] (Fig. 10). While testing prosthetic

mobility, no detectable separation between pros-
thetic components should be seen. At that time
correct soft tissue tension and passive range of
movement should be tested. Be aware of any soft
tissue and osseous contact or instability problem
and correct it if necessary. Stability is tested with
the arm in abduction and internal rotation.
This is the position that patients use to get out
of bed or out of a chair, and it represents the most
frequent position of anterior dislocation. When
anterior dislocation occurs with the arm in abduc-
tion and internal rotation, the antetorsion of the
humerus must be increased, and the surgeon has
to ascertain that the glenoid component was not
implanted with anteversion.
With the arm at the side, anterior opening
during external rotation is checked for posterior
impingment. If there are during evaluation signs
of superior bony impingement, it is necessary to Fig. 10 Trial
reduction
1114
neutral position are

taught. The arm can be used
immediately for daily
activities such as brushing
teeth or eating.
During the first 6 weeks strength-
ening exercises of the
external rotator muscle are
performed in neutral
position. If the patient is
able to gain active
external rotation in 90# of
abduction, he can
start to do exercises of the
external rotator
muscles also in this position.
Results
Reverse total shoulder

arthroplasty has been
shown to be effective
in treating RCDA, with
numerous studies
demonstrating improvements
in shoulder motion and
patient satisfaction
[8, 18, 20, 45, 48
62].
Fig. 11 Status after closure of remnants of remaining cuff Sirveaux et al.
published the first large
outcome study
reporting the results of
Dr. Grammonts reverse
prosthesis in 2004.
remove the superior part of the glenoid. With These authors reported
on 80 patients with
subcoracoidal impingement, the use of an eccen- a mean follow-up of
3.6 years [20]. The proce-
tric glenosphere or removal of the greater tuber- dure was associated
with good pain relief in 96 %
osity and/or subcoracoidal release can improve of the patients, mean
active elevation increased
the ROM. The height of the polyethylene from 73# to 138# , and
Constant scores improved
component should be such as to lengthen the from 22 to 65 points.
arm (i.e., tip of the acromion to the elbow) by In 2007 a French
multi-centre study described
approximately 23 cm with a very snug fit after the results in 484
patients after a minimum of
relocation [26]. 24 months. At the
latest follow-up the Constant
While positioning the definitive glenoid hemi- score had increased
from 24 points pre-
sphere, it is essential to check that no soft-tissue is operatively to 62
points post-operatively, pain
between the baseplate and the hemisphere to pre- increased from 3.7 to
12.6 points (15 points rep-
vent early loosening of the component [47]. resents freedom from
pain), and elevation
The definitive humeral component is inserted increased from 71# to
130# . At 52 months post-
and a final check with a trial humeral cup is done. operatively, 90 % of
the patients were very satis-
After evaluation of the proper positioning and fied or satisfied with
their shoulder [37].
stability, the definitive humeral cup is inserted Concerning the
survival rate, Sirveaux et al.
and the shoulder is reduced. found 91.3 % implant
survival rate at 5 years [20].
At the end of the procedure the subscapularis Also Guery et al.
found 91 % implant survival
is re-attached with non-absorbable sutures at a minimum follow-up
of 5 years but there
(Fig. 11) and in a superolateral approach the was a substantially
better survival rate in those
deltoid is also re-attached. patients with
arthropathy associated with a massive
Post-operatively a sling is used only for com- cuff tear (MCT) than
other indications [57].
fort and is discontinued as soon as possible. The study of Favard
et al. showed that the need
Active and active-assisted ranges of motion exer- for revision of
reverse shoulder arthroplasty was
cises are started immediately. No passive relatively low at 10
years, but Constant-Murley
stretching exercises should be performed. Spe- score and radiographic
changes deteriorated
cific anterior and posterior deltoid exercises in with time. They
conclude that therefore caution
1115
must be exercised when recommending reverse patients had less than

50# of shoulder elevation,
shoulder arthroplasty, especially in younger no active external
rotation, moderate to severe
patient [63]. pain and post-operative
complications [67].
It is also reported that the results are dependent
on the indication for which type of RCDA
a reversed shoulder prosthesis is used, and that Complications
functional outcome and complication rates are
distinctly different in primary versus revision Scapular Notching
cases [26].
The best results have been shown in patients Scapular notching is
described as glenoid erosion
with CTA. Reversed shoulder prosthesis has been caused by repetitive
mechanical abutment of the
shown to reliably restore overhead elevation in humeral component with
the scapular neck
patients [18, 28, 45, 57] (Table 1). (Fig. 12). The most
commonly used classification
In patients with rheumatoid arthritis, the most of Sirveaux describes
the erosion according to the
important pre-requisite is appropriate glenoid size of the defect as
seen on the anteroposterior
bone stock. When this is compromised by medial radiograph [20].
and superior erosion of the glenoid cavity, Notching is present
in almost half of the cases
hemi-arthroplasty may remain the least unsatis- using the Grammont-type
reverse shoulder sys-
factory treatment [26]. For the patient with tem (49.8 %) [68], but
no cases of notching were
sufficient glenoid bone stock, however, RTSA reported using the
lateralized prosthetic shoulder
has shown encouraging short-term results, with system [28]. Whether or
not scapular notching
good pain relief and a significant improvement progresses over time
continues to be debated in
in Constant score [50, 53, 60, 62]. However, the Orthopaedic
literature. In the clinical studies
the scores are slightly inferior to some that reported by Werner et
al. [18] and Simovitch
have been reported in patients with cuff tear et al. [19], the extent
of the scapular notch
arthropathy [50]. appeared to plateau
over time. However, another
To our knowledge, there is no literature study has demonstrated
that the extent of scapular
concerning the use of RTSA in patients with notching after reverse
TSA can increase with the
Milwaukee shoulder syndrome. length of follow-up
[17].
Another important factor is the integrity of There is also still
some discussion as to
teres minor. It is reported that the functional whether scapular
notching affects the patients
results of reversed shoulder prosthesis are final outcome. In the
study of Sirveaux et al. the
inferior when the posterior rotator cuff muscles presence of the notch
significantly affected
are absent or are deficient because of atrophy the Constant score when
the notch was either
and fatty infiltration of the teres minor muscle over the screw or
extensive [20]. This was also
[26, 45, 64]. Post-operatively these patients confirmed by the study
of Simovitch et al. [19].
still have a loss of active external rotation These results are in
contrast with the study of
in abduction. This loss has a dramatic impact on some other authors
where no clinical effect was
activities of daily living. Latissimus dorsi # teres found between notching
and the post-operative
major tendon transfer have been described function [11, 17, 18].
through one [65] or two incisions [66], both In our opinion,
although notching is not yet
with good results. a proven precursor of
loosening, it should not be
It is important to know that in evaluation the considered a harmless
and unavoidable phenom-
result of reversed shoulder prosthesis, positive enon of RTSA.
patient ratings of satisfaction may not necessar- As discussed in the
biomechanical section
ily be evidence of positive outcomes. A study of above, several
solutions have been described
Roy et al. suggests 93 % of the subjects were to try to overcome the
problem of scapular
satisfied even though some of the satisfied notching [2125].
1116
Table 1 Summary of reports of clinical outcomes following reversed shoulder

prosthesis in patients with RCDA
Mean Mean Mean Mean

Mean follow-up
Mean CS Mean CS ASES ASES AAE AAE
Year Indication Number (months)
pre-op postop pre-op postop pre-op postop
Baulot et al. [8] 1995 CTA 16 27
14 69 60# 114#
Boileau et al. [11] 2005 CTA- failed SA - FS 45 40
17 58 55# 121#
Boileau et al. [61] 2011 CTA- failed RCR - 42 28
34 75 86# 146#
FS
Cuff et al. [58] 2008 CTA failed 112 27.5
30 77.6 63.5# 118#
RCR failed SA FS
Ekelund et al. [50] 2010 RA 27 18
13 52 33# 115#
Favard et al. [63] 2011 CTA MRCT 331 <60
62.8 130.1#
2011 CTA MRCT 148 >60
61.53 128.6#
2011 CTA MRCT 69 >84
59.9 124.9#
2011 CTA MRCT 41 >108
56.7 124.1#
Frankle et al. [28] 2005 CTA 60 33
34.3 68.2 55# 105.1#
Holcomb et al. [60] 2010 RA 21 36
28 82 52# 126#
Jacobs et al. [52] 2001 CTA 7 26
17.9 56.7 <90# >90#
Mole et al. [45] 2007 CTA MRCT 484
24 62 71# 130#
Rittmeister 2001 RA 8 54.3
17 63
et al. [53]
Sayana et al. [48] 2009 CTA failed RCR 19 30
14.8 60.9
Seebauer et al. [55] 2005 RCDA 46 18.2
37 67 145#
#
Sirveaux et al. [20] 2004 CTA 80 44
22.6 65.6 73 138#
Vanhove et al. [54] 2004 CTA 14 29.5
60
Werner et al. [18] 2005 CTA failed RCR- 58 38
29 64 42# 100#
failed SA
Woodruff 2003 RA 13 87.5
59
et al. [62]
AAE active anterior elevation, ASES American Shoulder and Elbow score, CS Constant-
Murley score, CTA cuff tear arthropathy, FS fracture sequelae, RA reumatoid
arthritis,
RCR rotator cuff repair, SA shoulder arthroplasty, MRCT massive rotator cuff tear

1117
1. Patients with a
painful stiff shoulder.
2. Patients with good
shoulder function but with
a chronic fistula.
The latter can be unevent-
fully treated with a
one-stage revision [69].
Instability
Instability is a common
post-operative complica-
tion with an incidence
of 4.7 %. Instability is
more frequent after
revision of a previous hemi-
or total shoulder
arthroplasty (9.4 %) than in the
primary arthroplasty
group (4.1 %) The delto-
Fig. 12 Scapular notching
pectoral approach was
used in 97.3 % of the
shoulders with
subsequent instability [68]. Insta-
bility is always
anterior and occurs with the arm
in extension and
internal rotation [26].
Aseptic Loosening It is difficult to
analyze the causes of instability.
However, the complete
release of the
Lucent lines around the glenoid are rare in subscapularis,
including the inferior and middle
the Grammont-type reverse shoulder system glenohumeral ligament
at the glenoid insertion
and are almost twice as frequent in the prosthetic site, may predispose to
weakened anterior
shoulder system with a lateralized centre of restraints. Another
potential cause of instability
rotation. Until now no clinical effect has been is loss of tension of
the deltoid [68]. Preventive
reported but premature mechanical failure due measures are focused on
using a superolateral
to loosening is a concern. This is confirmed by approach, avoiding
retroversion of the humeral
the fact that aseptic glenoid loosening is twice as component, avoiding
anteversion of the glenoid
frequent in the studies using the lateralized component, and
establishing optimal length of
prosthetic shoulder system than in the studies the humerus.
using the Grammont-type reverse shoulder To prevent
dislocation, it is important to
arthroplasty system (5.8 % vs. 2.5 %) [68]. create room around the
glenosphere to enable
the prosthesis to
hinge. We also advise to
use a standard
polyethylene insert instead
Infection of an insert with less
contact area (high-mobility
insert). Combined
with an optimal
There is a incidence of deep infection after RSA prosthetic tensioning,
these steps can prevent
of 3.8 % [68]. This is lower than previously the creation of an
opening wedge between the
described [45] and is comparable with anatomic polyethylene and the
glenosphere over the full
arthroplasties but it is still higher than in other range of movement.
Early dislocations can
shoulder procedures. There is an increased rate easily be treated with
closed reduction under
of infection in the revision group compared with general anaesthesia and
an abduction pillow in
the primary group (5.8 % vs. 2.9 %) [68]. Most the first weeks
postoperatively [70].
infections occur early and can be treated
with lavage and antibiotics; some occur after
3 months and appear to respond poorly to Other Problems
debridement and prosthesis retention [45].
Recently two clinical types of infections have Intra-operative
fractures may occur on
been distinguished: the humeral side at the
time of exposure in
1118 A. Van
Tongel and L. De Wilde
fracture of the acromion
patients with severe pre-operative stiffness and

osteopenia, especially in the revision setting. Conclusions
The proximal humerus may also be fractured
by retractors and at the time of glenoid Reverse total shoulder
arthroplasty has been
exposure; it is recommended not to complete shown to be effective in
treating rotator
the humeral preparation until the glenoid cuff-deficient arthritis with
numerous studies
component is implanted to protect the proximal demonstrating initial
improvements in shoulder
humeral bone stock. motion and patient satisfaction.
Long term
Glenoid fractures may occur during results shows that Constant-
Murley score
preparation of the glenoid, especially reaming, and radiographic changes can
deteriorate with
and may prevent component implantation time and therefore caution must
be exe-
[68, 71]. rcised when recommending reverse
shoulder
Post-operative fractures of the acromion are arthroplasty in the younger
patient. Scapular
rare and should be treated conservatively with notching is not yet a proven
precursor of
immobilization (Fig. 13). loosening, but it should not be
considered
Postoperative fractures of the scapular spine a harmless and unavoidable
phenomenon of
lead to poor functional outcome and may require reverse total shoulder
arthroplasty. Prosthetic
osteosynthesis [72, 73]. overhang is the most effective
way to overcome
Glenosphere disengagement has been de- the problem.
scribed in literature and this can be partial or
complete [47]. The presence of partial
disengagement of the glenosphere was not
associated with a difference in clinical outcome
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spine fractures on the results of reverse
2007;89(5):9407. shoulder
arthroplasty. Orthopedics. 2010;33(5):302.
Glenohumeral Instability an
Overview
Pierre Hoffmeyer
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1123
Glenohumoral Instability # Epidemiology #
Clinical features-special tests # Imaging #

Clinical Examination of the Post-Traumatic
Patho-anatomy # Classification-anterior,
Unstable Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1124
posterior, multi-directional, voluntary, chronic

Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1125 # Treatment-closed, surgical stabilisation,
Standard X-Rays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1125
Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1125 complications
Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . .
1125
Patho-Anatomy of Shoulder Instability . . . . . . . . . 1125
Introduction
Dislocation and Instability Types . . . . . . . . . . . . . . . .
1127
Anterior
Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1127
Posterior Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1129 Glenohumeral dislocation is defined as
Multi-Directional Instability . . . . . . . . . . . . . . . . . . . . . . .
1130 a complete loss of contact between the glenoid
Voluntary Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1130 and the humeral head. The dislocation may be
Recurrent Dislocation in the Elderly Patient . . . . . .
1131 traumatic, non-traumatic or voluntary. It may
Chronic Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1132
Complications of Glenohumeral Dislocations . . . . .
1133 be uni-directional, anterior-posterior or infe-
rior, or multi-directional. Subluxation implies

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1133
a partial loss of contact between the joint sur-
faces. Instability is an impression expressed

by the patient. Objectively it may range from
fleeting episodes of subluxation to outright
dislocation. Laxity is a clinical finding where
more than normal passive motion or transla-
tion may be generated during the physical
examination [1].
Most anterior dislocations are of traumatic ori-
gin. The circumstances of the dislocation will give
useful indications as to the extent of the damage
inflicted upon the joint. Usually the dislocation is
caused by a fall on the outstretched hand. In some
areas a high prevalence of sports injuries of

P. Hoffmeyer
a specific type is found. Mountainous and Nordic
e-mail: Pierre.Hoffmeyer@hcuge.ch;
regions will see winter sports-related dislocations
pierre.hoffmeyer@efort.org
while in other areas the injury-producing activities

1123
DOI 10.1007/978-3-642-34746-7_49, # EFORT 2014
1124
P. Hoffmeyer
will be soccer or rugby. Interestingly shoulder

dislocations at the workplace are relatively Clinical Examination of the
uncommon. Post-Traumatic Unstable
Shoulder
Age is an important factor: Younger patients
tend to have higher recurrence rates for antero- In the non-acute setting
inspection of the seated
inferior dislocations than older patients. Young patients shoulder will
reveal global muscular
patients tend to dislocate a previously healthy atrophy, a tell-tale sign
of upper extremity dis-
shoulder in a high energy trauma causing carti- use, due to the
apprehension associated with
laginous and capsuloligamentous damage while multiple of dislocations.
Deltoid atrophy will
older patients will dislocate after low energy falls indicate an axillary nerve
injury. The position
because of a pre-existing degenerative changes or of the humeral head should
be noted and in case
torn rotator cuff. of a prominent coracoid and
a posterior fullness
The first episode of dislocation is usually a posterior dislocation may
be suspected.
due to a memorable traumatic event but the An anterior fullness and a
subacromial depres-
following tend to occur with decreasing amounts sion are pathognomonic of a
chronic anterior
of trauma, some patients reporting dislocations dislocation. Atrophy of the
supraspinatus
after turning in bed. The patient must be and infraspinatus fossae
are indicative of a rota-
questioned as to the frequency of unstable or tor cuff tear or
supraspinatus nerve injury and
dislocating events. This information is useful, in fullness all around the
joint represents an
assessing the amount of ligamentous insuffi- effusion.
ciency, for example. High energy injuries such Strength in internal
and external rotation,
as rugby tackles or high speed ski falls are more abduction, antepulsion and
retropulsion
likely to produce fractures of the glenoid than should be assessed
isometrically with the arm
a countered overhand pass [2]. Patients with an at the side. At the same
time the examiner
accompanying fracture of the greater tuberosity observes the contractions
of the different
tend not to recur. muscles. Loss of strength
in a particular
It is imperative to know whether the patient has direction may signal a
tendinous or neurological
been able to reduce the dislocation by himself or injury.
whether he had to be reduced in a hospital setting Range of motion is
first tested actively. Lim-
under anaesthesia. It is also important to have the itations may be linked to
an underlying
patient precisely describe the events leading to the glenohumeral or subacromial
disorder. The
dislocation. This will often not be possible for onset of apprehension
signals the limits of pas-
patients that are victims of seizures; the origin of sive range of motion
testing. In cases of insta-
which needs careful appraisal. bility the range of motion
of the shoulder should
Family history is important; other family mem- not be limited except for
the apprehension that
bers may have had episodes of shoulder disloca- occurs in abduction and
external rotation with
tions or recurrent sprains of other joints indicating the arm above the
horizontal. Generally in the
familial laxity, congenital malformations or even normal situation, elevation
does not exceed
Marfans syndrome [2, 3]. 170# and if so laxity is
suspected. External rota-
The examiner must question the patient attention with the arm at the
side exceeding 85# is
tively as to the existence of apprehension. Some certainly indicative of
capsular laxity. Gageys
patients may come to fear that even raising the arm sign is positive when
abduction is unilaterally
above shoulder level will cause dislocation. This is greater than 90# with a
blocked scapula [4, 5].
important information before proceeding with the An anteroposterior drawer
test is then
physical examination, an iatrogenic dislocation in performed to evaluate
laxity [6]. Usually it
the examining room is a particularly embarrassing is not possible to
subluxate the shoulder
situation! anteriorly but posteriorly
the compressive
Glenohumeral Instability an Overview
1125
abduction-adduction test may cause a clunk Standard X-Rays

accompanied by pain or discomfort. Jobes
apprehension re-location test is most informa- The investigation of the
painful and unstable
tive and assesses inflammation or scarring of shoulder includes standard
X-rays, and special-
the anterior capsule-labro-ligamentous complex ized studies. AP and
axillary views are manda-
[7, 8]. The shoulder of the supine patient is tory to evaluate the joint
space, the glenoid and
brought to 90# of abduction and maximal external the humeral head. Bony
Bankart lesions are best
rotation. At some point, the patient will feel a seen on the AP view and
Hill-Sachs lesions are
painful sensation. The examiner then presses his evaluated on the axillary
view. Other standard
palm on the humeral head, chasing it posteriorly; views developed the pre-CT
era such as the
this produces immediate relief and external Y view, the transthoracic
view, the Westpoint
rotation can be maximized painlessly. OBriens view or the Bernageau views
all still retain their
test explores the labrum, the bicipital insertion usefulness to delineate
glenoid rim or humeral
and the AC joint. The physician standing behind head defects [1, 1214].
the patient applies a downward pressure on
the maximally-internally rotated and pronated
upper extremity in 90# of elevation and 10# 15# Computed Tomography
of adduction. The provoked pain should disappear
when the pressure is applied to the arm in the CT scan will allow accurate
description of any
same position with the arm in external rotation bony abnormalities (Hill-
Sachs, reverse
with the extremity maximally supinated [9]. Hill-Sachs or bony Bankart
lesions of the
The rotator cuff and acromioclavicular joint antero-inferior glenoid).
Arthro-CT will outline
are checked clinically for integrity and stability cartilage defects, labral
fissures or tearing and
[1, 2]. capsular stretching by
delineating the intervening
Always keep in mind that an acutely pouches.
dislocated shoulder may be accompanied
by severe collateral injuries. Stretching or tearing
of the brachial plexus or axillary nerve occurs Magnetic Resonance Imaging
especially in the elderly or after high energy
injuries. The axillary artery or vein may be torn MRI and athro-MRI will be
used to image
with the ensuing well-known problems if not capsulolabral lesions as
well as cartilage defects.
diagnosed at an early time. Erecta type disloca- The rotator cuff is also
well delineated. Muscle
tions may entail a passage of the humeral head atrophy or changes are well
highlighted by both
through the ribs into the thorax and even into the CT and MRI [15].
abdomen. Caution must be exercised in this situ- In case of clinical
suspicion vascular studies as
ation. With these possible additional injuries in well as electroneurological
studies might prove
mind, a careful neurological and vascular exam- necessary to fully evaluate
the patients condition.
ination must be undertaken for every patient
presenting with a shoulder dislocation [1, 11].
Patho-Anatomy of Shoulder
Instability
Investigations Unstable shoulders present a

multitude of
capsuloligamentous and bony
lesions identified
Because clinical evaluation and tests are not by plain X-ray, MRI, CT or
by direct observation,
always reliable or diagnostic, imaging either arthroscopic or open.
modalities will be necessary to assess the In many cases of antero-
inferior instability
existing lesions [11]. a bony trough in the
posterior-superior region of
1126
P. Hoffmeyer
Post GH ligt
Humeral
Head
a
Ant GH ligt
Hill-Sachs lesion
Antero-inferior dislocation
C
Capsular stretching
Bankart lesion
Bony Bankart
lesion
Fig. 1 Mechanism of sequellar lesions leading to recur- ligamentous Bankart

lesions due forceful passage of the
rence of anterior dislocations (ac). Pre-dislocation situa- humeral head (b).
Sequellar lesions: Capsular stretching
tion (a). Dislocation: Impaction of the humeral head and loss of
glenohumeral ligamentous and/or bony integ-
against the glenoid or Hill-Sachs lesion, bony and rity responsible for
recurrence (c)
the head may be caused by the impaction of the glenoid due to the
violent passage of the head
humeral head against the glenoid rim which if during an episode of
dislocation. Multiple pas-
violent enough can fracture off the greater tuber- sages may also erode
the glenoid to give it
osity: The Hill-Sachs lesion. With MRI bony a rounded
appearance. A defect of the glenoid
oedema without actual fracture may be seen at may thus appear and
augment giving rise in some
the antero-inferior glenoid and in the postero- cases to an
inverted pear appearance. The
superior head region, corresponding to impacts Perthes lesion is an
antero-inferior labral avul-
and spongiosa oedema without fracture (Fig. 1). sion continued by a
peeling off of the intact peri-
In rare cases a fracture of the coracoid may be osteum from the
anterior glenoid neck. The
seen in association with a dislocation usually anterior labrum
periosteal sleeve avulsion
after a seizure. An isolated coracoid fracture (ALPSA) is an
avulsion of the antero-inferior
should always prompt the question: Was this labrum that is
displaced and rolled over medially.
due to a self- reduced dislocation? Appropriate The humeral avulsion
of the glenohumeral liga-
measures and investigations should be ment (HAGL) is a
peeling off of the inferior
undertaken. glenohumeral
ligament on its insertion on the
The Bankart lesion is defined as an avulsion of humeral neck. The
superior labral tear from ante-
the antero-inferior labrum from the anterior rim rior to posterior
(SLAP) represents various
of the glenoid with a disrupted periosteum. Bony levels of avulsion
of the proximal attachment
lesions are also frequent with the bony Bankart of the long head of
the biceps on the glenoid
lesion involving a fracture of the antero-inferior which may be
associated with glenohumeral
1127
a b
Bankart Bony
Bankart
c d
Perthes ALPSA
Anterior Labro
Periosteal Avulsion
e f
HAGL GLAD
Humeral Avulsion of the Glenohumeral Ligament
GLenolabral
Articular Disruption
Fig. 2 Patho-anatomy of traumatic instability (af). labrum periosteal sleeve

avulsion (Arrow) (d). HAGL
Bankart lesion (Arrow) (a). Bony Bankart lesion Humeral avulsion of the
glenohumeral ligament (Arrow)
(Arrow) (b). Perthes lesion (Arrow) (c). ALPSA Anterior (e). GLAD Glenolabral
articular disruption (Arrow) (f)
dislocations. Shoulders with multi-directional

instability will present large and distended capsu- Dislocation and
Instability Types
lar pouches. The lesion glenolabral articular dis-
ruption (GLAD) was first described by Neviaser as Anterior Dislocation
a superficial tear of the antero-inferior labrum with
an associated injury of the adjacent glenoid artic- This is usually related
to sports activities
ular cartilage. As a rule this lesion is not associated (soccer, skiing etc.) or
falls. Recurrence
per se with instability but is the cause of shoulder rates are high in
patients below 20 years
pain [9, 12, 14, 1621] (Fig. 2). (up to 90 %), between 20
and 40 years 60 %
1128
P. Hoffmeyer
a b
c
Fig. 3 Anterior dislocation (a, b). Anteroposterior (a) and axillary view (b). MRI
(c) depicting a Hill-Sachs lesion (arrow)
and a GLAD lesion (*) (For definition see text). A partial avulsion of the
infraspinatus is also present (#)
recurrence rates, above 40 years 10 %. These

numbers vary depending on the authors but trends
remain [1, 2, 22].
Clinical examination is dominated by appre-
hension in abduction and external rotation. Signs
of generalized laxity are often present: Antero-
posterior drawer, inferior sulcus sign, joint
hyperlaxity (fingers, thumb, and elbow).
In acute cases plexular or axillary nerve injury
occurs in 5 % of patients. Imaging involves AP
and axillary views (Fig. 3). Arthro-CT scans
delineate precisely bony morphology of frac-
tures; Hill-Sachs lesions, glenoid brim fractures
or rounding-off are well visualized. MRI may be
helpful to image the rotator cuff and the
capsulolabral soft tissue lesions but demonstrate
poorly bony lesions.
Closed reduction techniques for acute
antero-inferior dislocations abound and should
only be performed after precise neuro-
vascular testing: Care-axillary nerve! (Fig. 4).
Fig. 4 Axillary
nerve injury. Area of cutaneous sensate
Some of the more popular techniques are briefly deficit or numbness
on the lateral aspect of the shoulder
described below: after an axillary
nerve neurapraxia following an anterior
Hippocrates: With the patient under general glenohumeral
dislocation. This zone may be quite small
anaesthesia, traction is exerted on the arm in and its
identification requires meticulous assessment
slight abduction and elevation with the opera-
tors heel simultaneously pushing in the axilla
or better with an aide pulling on a folded bed Stimson: Patient
lies prone with arm left hanging
sheet placed around the axilla). This manoeu- down; 13 kg
weights are taped to the wrist for
vre is traumatic should only be performed traction [24,
25].
when other non- traumatic techniques have Saha: In this
technique a slow elevation in the
failed [23]. plane of the
scapula is performed [26].
1129
Kocher: This is a classical technique but seen by hyperlaxity, a Hill-Sachs

lesion present on an
many as dangerous. It consists in adducting anteroposterior radiograph
of the shoulder in
the dislocated arm in internal rotation external rotation with loss
of the sclerotic inferior
followed by abduction in external rotation glenoid contour, all tend to
indicate open repair
[23]). with a bone block (Latarjet-
Bristow) according to
Davos (Boss-Holzach-Matter method): The these authors [31, 32].
Closed arthroscopic tech-
patient in sitting position hands locked by niques are advocated in
traumatic Bankart lesions,
intertwining his fingers around his ipsilaterally open techniques are
recommended in cases of
flexed knee with elbows extended is then capsular stretching or of
large Hill-Sachs lesions.
instructed to let himself gradually lean back- Recurrence rates range
between 5 % and 30 %
wards [27]. depending on the type of
technique used, solidity
All of these techniques may be facilitated of reconstruction and
patient compliance.
by an intra-articular injection of lidocane or Patients are immobilized
from 3 to 6 weeks in
equivalent [25]. internal rotation;
rehabilitation emphasizes mus-
Post-reduction treatment includes, after cular strengthening in the
first weeks followed by
neurovascular testing, immobilisation in internal range of motion exercises.
Patients are advised to
rotation or in an external rotation splint. avoid contact sports for a
year following
The rationale for the external rotation stabilisation [3341].
immobilisation is to force the Bankart lesion to
stay fixed to the anterior glenoid rim pressured
in place by the subscapularis [28, 29]. Posterior Dislocation
Immobilisation should be 24 weeks followed
by strengthening exercises [24]. Posterior dislocation is
relatively rare; less than
5 % of all instabilities.
Falls on the outstretched
Caution hand, epileptic seizures or
electrical shocks are
Closed reduction manoeuvres after an inaugural the main causes of posterior
dislocations.
episode should be approached with caution. Aprehension can be elicited
in adduction and
A fracture may be associated and it is prudent to internal rotation in
posterior instability. When
obtain an X-ray before embarking on manoeuvres dealing with locked or
chronic posterior disloca-
that could have disastrous results. Beware of tion one has to be beware of
the diagnosic diffi-
interpositions of the labrum, subscapularis, rota- culties: The cardinal signs
are active and passive
tor cuff, biceps tendon or other structures that limitation of external
rotation, fixed abduction
may result in a widened joint space on the post- and limitation of
supination.
reduction X-ray [30]. AP shoulder X-rays and
especially axillary
views are the mainstay of
the diagnosis. On the
Surgical Stabilisation AP view the diagnosis may be
missed by the
Indications for surgical stabilisation of recurrent unwary even though the joint
space is not visible
antero-inferior dislocations include one episode because of overlapping with
the glenoid rim. The
of dislocation too many, or severe apprehension. axillary view is always
diagnostic. Scapular
Techniques include capsuloplasty, Bankart lesion Y views and transthoracic
views are often mis-
re-fixation and bony augmentation if there is interpreted. In case of
doubt a CT scan will solve
severe rounding-off or fracture of the glenoid the issue (Cadet, [13, 42
44]).
rim. Open or arthroscopic techniques are both If a small (i.e. less
than 10 % of head surface)
suitable. Balg and Boileau have delineated the reverse Hill-Sachs impaction
fracture is present,
conditions where open repair is more suitable gentle traction will
generally reduce the shoulder
than arthroscopic repair. Factors such as patient which should then be
immobilized in an external
age less than 20 years, competitive or contact rotation splint for 36
weeks. Rowe has
sports, forced overhead activity, shoulder suggested keeping the
affected arm at the side in
1130
P. Hoffmeyer
neutral rotation fixed with a wide tape across the creating a subacromial
sulcus. For these signs
back [45]. A rehabilitation programme should indicative of laxity to be
clinically relevant, they
follow with muscle strengthening and range of must provoke patient
discomfort [5153]
motion exercises. (Fig. 6).
Indications for surgical stabilisation of Standard X-rays, arthro-
CT or MRI will
a posterior dislocation are an irreducible disloca- delineate the existing
lesions. Surgery is indicated
tion or recurring dislocations. When no major only after 1 year of
serious muscle strengthening
reverse Hill-Sachs lesion is present an open pos- physiotherapy and exercises
[51, 54].
terior approach with a cruciate capsulorraphy and The most commonly
accepted operation is
fixation of the reverse Bankart lesion may be Neers capsular shift which
may be performed
performed. A bone graft taken from the spine of through an anterior
deltopectoral approach but
the scapula or of the iliac crest may be necessary in certain cases may need
an adjunct posterior
if a bony defect is present [46, 47]. Arthroscopic approach. The axillary
nerve must be protected
stabilisation is also an option in experienced during this demanding and
complex intervention.
hands [48]. Six weeks of immobilisation
in neutral (hand-
If a larger reverse Hill-Sachs lesion is present, shake) position is
necessary which should be
a McLaughlin procedure will be necessary and if followed by a muscle-
strengthening programme.
insufficient an adjunct posterior procedure may In experienced hands
arthroscopic techniques
be required. The McLaughlin operation consists may be used [51, 54, 55].
in suturing the subscapularis tendon into the
reverse Hill-Sachs defect. This creates an ade-
quate barrier for any recurrence. Neer has modi- Voluntary Dislocation
fied the technique where the lesser tuberosity is
osteotomized along with the subscapularis This is usually encountered
in adolescents
attachment and screwed into the defect. The and young adults who have
found a way
shoulder is then immobilized in neutral, or to dislocate their shoulder
joint posteriorly.
slightly external, rotation for 6 weeks followed This is used by the patient
to relieve psychic ten-
by a rehabilitation programme [47, 49, 50] sions (Tic), to show off to
their friends and family
(Fig. 5). or both. Treatment should
consist of re-assurance
and counselling to avoid
dislocating the joint as
this augments capsular
laxity. Physiotherapy may
Multi-Directional Instability be helpful. Sometimes
psychiatric help may be
needed. Surgery should be
avoided at all costs
This is a clinical entity formally identified by because of the near 100 %
recurrence rate.
Neer and Foster [51]. The patient complains Some patients will
evolve to involuntary dis-
of a loose and unstable shoulder in multiple location after a period of
voluntary dislocation.
positions such as external rotation and abduc- This is due to excessive
capsular stretching.
tion, adduction and internal rotation. Frequently, Physiotherapy and re-
harmonization exercises
patients report pain, discomfort, apprehension should be started. If not
effective, an operative
and even paraesthesiae in the hand especially intervention consisting of
a capsular tightening
when carrying loads with the arm at the side. procedure such as a
capsuloplasty (Described
On clinical examination, external rotation is below), may be advocated.
The surgeon must be
more than 90# both in the R1 (Arm at the side) certain however that the
voluntary aspects of the
or in the R2 position (Arm at 90# of abduction). dislocation have
disappeared.
Further clinical tests include the inferior sulcus Positional dislocation
may be falsely diagnosed
test; the patient expresses discomfort as the as voluntary dislocation.
Some patients will dislo-
examiner pulls down the arm held at the side cate their shoulder
posteriorly only in a certain
1131
a
b
Fig. 5 Anterior fracture dislocation associated with neu- Associated

paraesthesiae and loss of strength due a radial
rological injury (ac). Anterior dislocation with an asso- nerve injury
causing a wrist drop (c)
ciated fracture of the greater tuberosity (a). Reduction (b).
position usually in 90# of forward flexion, slight Recurrent

Dislocation in the Elderly
adduction and internal rotation. In this position Patient
with a lax capsule combined with a glenoid defec-
tor hypoplasia, the humeral head will tend to dis- Often these
dislocations are associated with minor
locate. Again after thorough investigation and trauma. A
massive rotator cuff tear is the usual
adequate physiotherapy a stabilizing capsuloplasty cause. If
repairable the supra- and infraspinatus
procedure may be performed [56]. lesions should
be repaired. If not repairable the
1132
P. Hoffmeyer
a b
Fig. 6 (AB) Anterior dislocation (a), with resulting rotator cuff tear (*) and
Hill-Sachs impaction (arrow) in an elderly
patient (b)
a b c
Fig. 7 Posterior dislocation (ac). Anteroposterior (a) and axillary view (b). The
CT (c) depicts dislocation sequellae:
Reverse Hill-Sachs fracture impaction (*) and glenoid impaction (arrow)
reverse prosthesis may be an option and if not In cases of a

chronic antero-inferior
glenohumeral fusion may have to be performed dislocation with pain
and discomfort, open
[57] (Fig. 7). reduction with a
rotator cuff repair and glenoid
augmentation
procedure using a coracoid
transfer or an iliac
bone graft, may be
Chronic Dislocation attempted. A
prosthetic replacement may also be
used. It is prudent
to use a bigger head than usual
This condition is usually seen in debilitated, in a little more
retroversion. Some authors advo-
neglected or epileptic patients. The dislocation cate the reverse
prosthesis but the danger of post-
may be anterior or posterior. Closed reduction is operative dislocation
remains a high risk.
usually not successful and attempts at reduction In cases of
chronic posterior dislocation a
may even be dangerous after some weeks in McLoughlin procedure
is indicated whereby,
a chronically dislocated shoulder. In many cases after open reduction,
the detached subscapularis
the best option may be no treatment, the patient is fixed into the
reverse Hill-Sachs impaction frac-
adapting to the situation. It is often surprising to ture, the Neer
variation involves osteotomizing the
see how much mobility is preserved. lesser tuberosity and
fixing it into the anterior
1133
a b c
d e
Fig. 8 Multi-directional instability (ae). Arthro-CT contour (d), Sulcus

sign produced by pulling down on
demonstrates a large capsular pouch (arrows) seen in the the arm held at the
side (e)
transverse (a), frontal (b) and sagittal (c) cuts. Normal
impaction area with screws. When the head or post- operative

stiffness can occur in patients
impaction is too large, i.e. more than 30 % or not following the
rehabilitation regimen. Late-
50 % of the head surface, a hemi-prosthesis can onset post-
dislocation arthritis of varying inten-
be inserted. A larger head with a little less sity may occur in a
fair number of patients
anteversion is a wise choice. Some authors advo- up to 100 %. In
most instances this radiographic
cate a reverse prosthesis but the risk of dislocation finding is
clinically irrelevant but it may become
is significant. In cases of major instability with symptomatic,
needing specific treatment [6065]
avulsed rotator cuff tendons a shoulder fusion (Fig. 8).
may be contemplated [47, 58, 59].
References
Complications of Glenohumeral
Dislocations 1. Matsen FA,
Lippitt S, Bertlesen A, Rockwood CA,
Wirth MA.
Glenohumeral instability. In: Rockwood
Neurovascular complications are common; most CA, Matsen FA,
Wirth MA, Lippitt SB, editors. The
shoulder. 4th
ed. Philadelphia: Saunders/Elsevier;
pertain to infra-clinical lesions of the axillary
2009. p. 617
770.
nerve. Plexular lesions may occur and are more 2. Hovelius L,
Augustini BG, et al. Primary anterior
frequent in elderly patients. Rarely vascular dislocation of
the shoulder in young patients.
lesions may occur after a dislocation with the A ten-year
prospective study. J Bone Joint Surg Am.
1996;78(11):167784.
axillary artery being either sectioned (rarely)
3. ODriscoll SW,
Evans DC. Long-term results of staple
and more frequently presenting intimal tears capsulorrhaphy
for anterior instability of the shoulder.
leading to arterial occlusion. Post-immobilisation J Bone Joint
Surg Am. 1993;75(2):24958.
1134
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Recurrent Glenohumeral
Instability
Mark Tauber and Peter

Habermeyer
Contents
Keywords
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137
Gleno-humeral instability: anterior # Inferior #
Posterior and multidirectional labral lesions #

Superior labral lesions (SLAP tears) # Glenoid

rim bone lesions
and/or Basic Science, e.g., Biomechanics . . . . 1139
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1141
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1141 General Introduction
Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1142
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1143
Glenohumeral instability represents mainly a

Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 1144
pathology of the young patient. An unstable
Indications for Conservative Treatment . . . . . . . . . . . 1144
Indications for Surgical Treatment . . . . . . . . . . . . . . . . 1144
shoulder creates discomfort, pain and restriction
of daily living or sports activities. Additionally,

glenohumeral instability seems to represent a

Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1145 major risk factor for development of osteoarthri-
Arthroscopic Bankart and Capsular Shift
tis. An accurate evaluation of history and clinical

Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1145
Open Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1145 examination is crucial to make the correct
Bone Block Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1145 diagnosis. Uni-directional instabilities can
Surgical Treatment of SLAP-Lesions . . . . . . . . . . . . .
1148 often be the only symptom of multi-directional
forms. Treatment of only the symptomatic
Arthroscopic Bankart-Repair . . . . . . . . . . . . . . . . . . . . . . 1148
direction is associated with a high risk of failure
SLAP Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1148 and recurrence. Objective assessment of the
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1148 patients activity and risk profile should
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1149 determine the treatment algorithm. The surgical
approach and technique is dependent from the

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1149
underlying pathology. It should address in a suf-
ficient manner soft tissue pathologies, bone loss
or associated injuries of the rotator cuff or long
head of biceps tendon. Incorrect diagnosis and
inadequate surgical treatment results in an
increased failure rate requiring revision surgery.

M. Tauber (*) # P. Habermeyer
Section for Shoulder and Elbow Surgery, ATOS Clinic,
Munich, Germany
e-mail: tauber@atos-muenchen.de

1137
DOI 10.1007/978-3-642-34746-7_233, # EFORT 2014
1138
M. Tauber and P. Habermeyer
Aetiology and Classification
Contemporaneously to the evolving science of

Traumatic
structural
shoulder pathologies, new classification systems
of shoulder instability have been presented.
Prerequisites for a classification system are sim-
plicity, completeness, practicability, and high
Habitual
Structural
intra- and interobserver reliability. In addition to non-structural
atraumatic
muscle patterning
a diagnostic value, a therapeutical consequence
should result for the physician. The different
classification systems are based on various
Fig. 1 Classification of
shoulder instability according to
criteria as time (acute chronic), aetiology Bailey [3]. Three main
groups form the base of the
(traumatic atraumatic habitual) or direction classification (traumatic
structural, atraumatic structural,
(unidirectional multidirectional, anterior habitual, non-structural,
muscle patterning) with a fluid
posterior inferior). From an aetiological aspect transition between them
it is essential to distinguish traumatic from
atraumatic instabilities. In addition, an accurate Classification of the
instability according to
history must point out if the trauma was adequate Bailey [3] (Fig. 1)
or not. Traumatic instabilities are associated with Polar group I:
traumatic structural (ade-
typical intraarticular injuries as labrum lesions, quate trauma, often
Bankart lesion, usually
capsular stretching or avulsion, ligament tears, unidirectional, no
muscular dysfunction)
impression fractures at the humeral head Polar group II:
atraumatic structural
(Hill-Sachs or reversed Hill-Sachs-lesion), (no trauma,
structural articular pathology,
bony glenoid rim lesions, rotator cuff tears or capsular dysfunction,
no muscular dysfunc-
SLAP-lesions. tion, sometimes
bilateral)
The most widely used classification systems of Polar group III:
habitual, non-structural,
shoulder instability are: muscle patterning (no
trauma, no structural
The TUBS (traumatic, unidirectional, Bankart, articular damage,
capsular dysfunction,
and usually requiring surgery) and AMBRI muscle dysfunction,
often bilateral)
(atraumatic, multidirectional, bilateral, reha- Bony defects at the
anterior glenoid rim can
bilitation, and occasionally requiring an infe- emerge from an acute or
chronic setting. Acute
rior capsular shift) classification according to glenoid fractures can be
seen either as depression
Matsen and Harryman [1] fractures with medialization
of the fragment
Classification of the instability according to resulting in step formation
at the articular surface
Gerber [2] or as avulsion fractures in
terms of a bony
Type I: chronic dislocation capsulo-ligamentous
detachment.
Type II: unidirectional instability without The most frequently used
classification is:
hyperlaxity Classification of bony
anterior glenoid rim
Type III: unidirectional instability with lesions according to
Bigliani [4]
multidirectional hyperlaxity Type I: the detached
fragment is adjacent to
Type IV: multidirectional instability with- the capsulo-ligament
complex
out hyperlaxity Type II: the fragment
is malunited medially
Type V: multidirectional instability with at the glenoid neck
(Fig. 2)
hyperlaxity Type III: erosion of
the glenoid rim
Type VI: uni- or multidirectional voluntary Type IIIA: defect
size < 25 %
dislocation Type IIIB: defect
size > 25 %
Recurrent Glenohumeral Instability
1139
Type VI: unstable

labrum-flap
Type VII: extension
into the MGHL with
weakening of its
function
Relevant Applied
Anatomy, Pathology
and/or Basic Science,
e.g.,
Biomechanics
Several factors are

responsible for the potential
instability of the
glenohumeral joint. First, the
bony dimensions of the
articulating partners
have to be mentioned
with the large humeral
head articulating with
the small and shallow
glenoid. Furthermore,
stability is provided
Fig. 2 To evaluate the size of the bony glenoid defect
by the soft tissues
including the capsulo-
a computed tomography scan with a 3D reconstruction ligamentous structures,
rotator cuff, scapular
should be performed. On the en-face view the defect size stabilizers, and the
biceps tendon enabling a
can be measured setting the indication for a bone block large range of motion
at the same time [810].
augmentation procedure with a bone loss of 20 % of the
antero-posterior diameter. Note the medialized, partially
Static stabilizers as
the bony articulating
resorbed bone fragment at the anterior glenoid rim structures, the
glenohumeral joint capsule and
its ligaments have to
be distinguished from
A special entity of labral lesion is represented dynamic stabilizers as
the rotator cuff and the
by the so called SLAP (superior labrum biceps tendon. In
patients with multidirectional
anterior to posterior) lesions, first described by instability (MDI) and
posterior instability defi-
Snyder et al. in 1990 [5]. Four types of lesions ciency of the rotator
interval represents a further
have been described: key factor contributing
to increased inferior and
Type I: fraying of the superior labrum and the posterior translation
[11]. Bony factors may influ-
biceps anchor without detachment from ence glenohumeral
stability as well. Glenoid hypo-
the glenoid plasia or excessive
glenoid retroversion represent
Type II: detachment of the superior labrum- important intrinsic
aspects in posterior instability
biceps-complex from the glenoid with an atraumatic
history in most cases. Glenoid
Type III: bucket-handled tear of the labrum. rim bone loss can be
developmental or acquired.
The biceps anchor remains intact This can be either from
an acute fracture or chronic
Type IV: longitudinal splitting of the labrum erosion or rarely from
hypoplasia.
and the biceps tendon. The inferior part of the In a cadaveric
study, Itoi et al [12]. described a
tear can dislocate into the articular rim defect of 20 % of the
glenoid length at the
SLAP-II-lesions have been divided from 6.00 oclock position
as a relevant bone
arthroscopic observations into three subtypes [6]: loss resulting in
antero-inferior gleno-humeral
II A: anterior instability. For
several years this defect size was
II B: posterior the critical size
representing the indication for
II C: combined anterior-posterior bone reconstruction at
the glenoid. Yamamoto
Maffet et al. [7]. extended this classification et al. found that in
recurrent glenohumeral insta-
for further three types: bility the defect is
not located antero-inferiorly, but
Type V: extension of the SLAP-lesion to at the 3.00 oclock
position [13] and as the critical
antero-inferior in terms of a combined size has to be seen a
defect of 6 mm in the sagittal
Bankart-SLAP II lesion plane, which
corresponds to 20 % of the glenoid
1140
length [14]. With this defect size the stability ratio a

decreases significantly from 32 % to 17 %.
In recent years the focus of research
concentrated on glenoid bone loss. Several authors
reported on bony defects of the anterior glenoid
rim as one of the most relevant factors associated
with recurrent instability after surgical stabiliza-
tion [1518]. Thus, it is crucial to detect signifi-
cant glenoid bone loss preoperatively in patients
with recurrent glenohumeral instability, in terms
to recognize the need for a bone block procedure,
which usually has to be performed as open
procedure. This represents essential information
for the surgeon, but for the patient as well. b
In general, intraarticular capsulo-ligamentous
lesions can occur at three different anatomical
locations [19]:
At the antero-inferior glenoid rim (Fig. 3a and b)
Along the anterior capsule or gleno-humeral
ligaments
At their humeral insertion
Capsulo-ligamentous injuries (Fig. 4) in trau-
matic anterior gleno-humeral instability can
be classified according to their morphologic
differences into:
The classic Bankart-lesion includes avulsion Fig. 3 (a) Arthroscopic
view of a longitudinal capsule-
of the capsule-labral complex from the antero- ligamentous avulsion of
the inferior gleno-humeral liga-
inferior glenoid rim. Hereby, the concavity of ment from the labrum in a
20 year-old wrestlers left
the glenoid, which is determined for 50 % by shoulder. (b) The inferior
gleno-humeral ligament has
been sutured by two
mattress sutures to the glenoid rim
the labrum, is reduced significantly and the and labrum. The gap
between labrum and capsule/liga-
MGHL and IGHL lose their origin resulting ment is closed completely.
Arthroscopic view with the
in anterior instability patient in lateral
decubitus position
The Perthes lesion is defined by the subperiosteal
avulsion of the AIGHL from the scapular
neck. The labrum remains still in contact the glenohumeral
ligaments from their inser-
with the glenoid rim (extralabral lesion of the tion at the humeral
head. Variants are the bony
capsular origin) HAGL with detachment
of the IGHL together
ALPSA (anterior labroligamentous periosteal with a bony fragment,
avulsion of the posterior
sleeve avulsion)-lesion [20]: during the IGHL (P-HAGL) in
posterior dislocation and
spontaneous healing process the labrum and avulsion of the IGHL
from the glenoid and
the capsular origin can be slipped medially humeral head (floating
IGHL) [21]
along the scapular neck by the intact Posterior shoulder
instability is rare (about 5 %
periosteum and scar of cases of glenohumeral
instability) and often
Interligamentous capsular tears are rare, occurs as part of MDI. In
traumatic cases, posterior
because isolated capsular stretching occurs labral lesions can occur
equivalently to anterior
due to repetitive microtrauma labrum tears and may be
responsible for recurrent
The HAGL (humeral avulsion of posterior shoulder
instability. In most patients, pos-
glenohumeral ligaments)-lesion: avulsion of terior glenohumeral
instability appears as a result
1141
a b the IGHL, especially

in internal rotation and
90# of flexion
(corresponding to the jerk test
position).
To understand the
entity of SLAP-lesions an
appropriate knowledge
of the anatomy of the
superior labrum-
biceps-complex is required.
The superior labrum
does not insert adjacently
at the glenoid, but
shows a meniscoid shape.
Frequently, at the 12
oclock position a small
c d recessus between the
superior labrum and the
superior glenoid pole
is present, which can lead
to misdiagnosis in
the MR-arthrography.
This kind of
insertion extends to the 4 oclock
position [23]. The
superior labrum forms always
a complex with the
biceps tendon. The insertion
point of the biceps
at the superior labrum differs
and can be postero-
superior or at the superior
glenoid tubercle [24,
25]. The vascular supply
of the superior
labrum-biceps-complex shows
e f
significantly less
blood vessels than the inferior
labrum-capsule-
complex. Cooper et al [23].
observed periosteal
and capsular vessels
supporting the labrum
in its entire circumference
from the periphery,
but reduced vascularity at the
superior and antero-
superior parts.
To avoid
misdiagnoses two anatomical
variants at the
antero-superior labrum insertion
have to be known:
Sublabral foramen
[26]: physiologic detach-
Fig. 4 Anterior rim morphology in glenohumeral insta-
bility. (a) Normal. (b) Bony Bankart lesion. (c) Bankart ment of the
antero-superior labrum from the
lesion involving the labrum and the capsule. (d) Bankart 1 to 2 oclock
position without pathological
lesion with avulsion of only the labrum. The capsule is not character in
contrast to the Andrews lesion
detached from the labrum. (e) Perthes lesion with
[27] at the same
position.
subperiosteal avulsion of the AIGHL from the scapular
neck. The labrum remains still in contact with the glenoid Buford-Complex
[28]: absence of the
rim. (f) ALPSA lesion with the labrum and the capsular anterosuperior
labrum from the 1 to 2 oclock
origin slipped medially along the scapular neck. The peri- position and
presence of a cord-like strong
osteum remains intact
MGHL inserting at
the bony glenoid rim or at
the biceps anchor.
from repetitive microtrauma or from a traumatic

impact to the anterior shoulder. Associated Diagnosis
pathomorphological changes include capsulolabral
detachment, capsular laxity, and rotator interval History
lesions. A special structural pathology represents
the Kim lesion, which is an incomplete and A careful history is
of utmost importance in
concealed avulsion of the posteroinferior aspect patients presenting
with glenohumeral instability.
of the labrum [22]. An effective contributor to Information regarding
the dominating symptoms
posterior stability represents the posterior band of (looseness,
insecurity, or pain), onset, direction,
1142 M.
Tauber and P. Habermeyer
degree of instability, need for reduction, if a reflectory muscle

contracture is seen to
recurrence, and previous surgical treatment prevent subluxation or
dislocation or the
are provided. The presence of an adequate trauma patient refers subjective
instability. The face
suggests the intraarticular pathomorphological of the patient has to be
observed. Discomfort,
lesions, whereas in the absence of a trauma insecurity, movements of
compensation or
hyperlaxity, voluntary dislocation, scapular insufficient abduction
and external rotation
dyskinesia or connective tissue pathologies as are indicative for a
positive test. Pain
Ehlers-Danlos or Marfan syndromes have to alone is no criterion for
a positive test.
be considered. The activity profile of the The test is done in 60# ,
90# and 120# of
patients with traumatic antero-inferior shoulder abduction. In 60#
abduction the medium
dislocation is directly related to the risk for glenhumeral ligament
(MGHL) is tested,
recurrence. Young patients performing contact in 90# of abduction the
MGHL and inferior
sports show a risk of recurrence gaining 90 % glenohumeral ligament
(IGHL). Usually, a
to 95 % [29]. positive Apprehension
test is associated
with a traumatic Bankart-
lesion [32]. The
apprehension test can be
performed in a lying
Clinical Examination position modified as
fulcrum-, relocation- or
surprise-test.
The clinical evaluation of the shoulder must Fulcrum test: with the
patient in a supine
differentiate two entities: laxity and instability: position, the free hand
of the examiner during
Laxity represents the passive and usually the abduction and
external rotation is set as
physiological translation of the humeral hypomochlion under the
proximal humerus.
head in every direction without symptoms This increases the lever
mechanism and
of instability. Laxity is individual and allows the controlled
provocation of the
physiological. Laxity diminishes with anterior subluxation
resulting into subjective
increasing age. instability or pain.
Instability is defined as inability of the patient Relocation test [33]:
With the patient supine
to center and to keep the humeral head the arm is abducted 90#
and external rotated.
centered into the glenoid cavity [30]. Usually, This position provokes
anterior subluxation
instability is symptomatic: the patient suffers a with increasing muscle
fatigue of the
dislocation or subluxation with subjective anterior stabilizing
muscles and apprehension.
instability or pain. Push by the examiner from
an anteroinferior
direction reduces the
humeral head and
Examination of Shoulder Instability reduces the pain and
apprehension. External
Whereas an anterior instability has to be expected rotation is increased
until a positive apprehen-
in abduction and external rotation, for a posterior sion sign appears again.
The positive
instability flexion and internal rotation move- relocation test is valid
for diagnosis of an
ments are typical. The unpleasant position is the internal impingement, as
well. In 79 % of
best indication for the direction of the instability. the throwing athletes,
the pain during the
relocation test
correlates with the contact
Tests to Evaluate Anterior Instability between posterosuperior
rotator cuff and
Apprehension test: [31] With the patient posteriosuperior labrum,
or partial rotator
sitting or standing, the arm is brought in cuff tear and labral
lesion [34].
abduction and external rotation with Surprise(Release) test:
[35]: During one
pressure of the contralateral hand from hand of the examiner
brings the arm of
a posterosuperior direction onto the the patient in abduction
and external
proximal humerus. The test results positive, rotation, the other
pushes against the humeral
1143
head from anterior and stabilizes the

glenohumeral joint. Releasing suddenly
the anterior support, an intense apprehension
can be provoked.
Tests to Evaluate Posterior Instability

Posterior Apprehension test: in patients with
posterior instability a corresponding posterior
apprehension test with the patient supine is
performed [31]
Jerk-test: with the patient in a sitting position
the shoulder girdle is stabilized with one hand
from posterior. The other hand takes the elbow
of the patient with shoulder flexion of 90# .
Performing increasing internal rotation,
adduction of the humerus and posterior com-
pression a posterior drawer or subluxation can Fig. 5 MR-arthrography of a
right shoulder 4 days after
be provoked. With horizontal abduction the traumatic anterior
dislocation. The paracoronar slices
shoulder can be reduced (clunk). show the J-sign, which is
typical for a humeral avulsion
of the inferior gleno-humeral
ligament (HAGL lesion)
Examination of SLAP-Lesions
The clinical image of patients with a SLAP- The patient is asked to
extend the arm against
lesion is complex. Usually, the patients are the resistance of the
examiner. Pain in the
young and active and refer the initial symptoms shoulder is predictive for
a SLAP-lesion with
during sports activities, mainly overhead sports. a sensitivity of 92 %.
During normal routine and daily living activities Positive can be the
impingement test
these patients dont have complaints. The onset according to Hawkins, the
horizontal-
can be traumatic or slowly increasing over the adduction, OBrien, Palm-
up, Yergason,
time. Normally, the range of motion (ROM) is apprehension tests. All
these tests dont have
free, in throwing athletes an increased external a sufficient sensitivity
for clinical diagnosis of
rotation and reduced internal rotation at the a SLAP-lesion [38].
dominant upper extremity can be observed.
The isometric rotator cuff tests present normal
without loss of strength. Imaging
Tests to Evaluate SLAP-Lesions Standard radiographs: true-

a.p.-view in neu-
Biceps load test II [36]: With the patient tral rotation and in
external rotation, Stryker-
supine and flexion of the shoulder of 120# view, West-Point-view,
Bernageaus view,
the arm is brought in full external rotation. Garths apical-oblique
profile view
The elbow is flexed 90# , the forearm in 3D-computed tomography
(Fig. 2): assessment
supination. The test is positive, when increas- of glenoid defect (en-face
view) [3941] and
ing active elbow flexion provokes pain or pain version of the glenoid
(glenoid dysplasia)
enhancement. For this test a sensitivity of MR-arthrography (evaluation
of soft-tissue
89.7 % and a specificity of 92.1 % has pathology): capsular
volume, lesions of the
been reported. capsuloligamentous complex,
HAGL-lesion
Supine flexion resistance test [37]: The patient (Fig. 5), extension of
Bankart-lesion, rotator
is supine with the shoulder in maximal flexion. cuff tears, rotator
interval, SLAP-lesion
1144 M.
Ide [44] and Kim [45] report

on a return rate to
Indications for Surgery previous sports in athletes
in 6070 % and 22 %,
respectively. Out of these
poor perspectives for
Indications for Conservative Treatment athletes, Boileau et al
[46]. proposed biceps
tenodesis using an
interference screw as an alter-
Atraumatic etiology (Polar type II according native procedure to treat
SLAP-type-II lesions.
to Bailey [3]) The return rate to previous
sports differed
Pathologic muscle patterning (Polar type III significantly in favour to
the biceps tenodesis
according to Bailey [3]) group (87 %), compared to
the SLAP-repair
Scapula dyskinesia group (40 %).
Loose shoulder [42] Following therapeutical
strategies are
Ehlers-Danlos syndrome recommended:
Marfan syndrome Type I: debridement,
electrothermical trimming
Incompliance Type II: reconstruction
using
Psychiatric disease II A: anchor and suture
of MGHL
II B: posterior anchor
II C: anterior and
posterior anchor with suture
Indications for Surgical Treatment of MGHL
In microtraumatic cases:
tenodesis of the long
Glenohumeral Instability head of the biceps tendon:
Chronic anterior instability with traumatic Type III: reconstruction
or resection of the
etiology and structural capsulo-labral- bucket-handle, if
necessary tenodesis of the
ligamentous pathologies long head of the biceps
tendon
Recurrent dislocation or subluxation with rel- Type IV: reduction and
reconstruction, if nec-
evant anterior glenoid bone loss (>25 %) essary resection or
tenodesis of the long head
HAGL-/PHAGL-lesions of the biceps tendon
Chronic posterior instability without laxity
Chronic posterior instability with laxity but
without pathologic muscle pattern and poste-
rior glenoid bone loss Pre-Operative Preparation
Multidirectional instability after failure of and Planning
conservative treatment for at least 6 months
Complete imaging is a
prerequisite to determine
the necessity for bone
grafting at the glenoid.
SLAP-Lesions For this purpose we
recommend performance
The surgical strategies to treat SLAP-lesions of a CT-scan with 3D-
reconstruction. This
depend on the type of lesion, the history (trau- information is decisive if
stabilization surgery
matic or microtraumatic repetitive) and from the can be carried out
arthroscopically or open,
activity and sports specific profile of the patient. which has to be told to the
patient preoperatively.
Surgical repair of the SLAP-lesion has most suc- In the case of free bone
autografting, the patient
cess in patients with an acute traumatic injury and has to be informed about
risks and complications,
in low demand patients. Those patients with as well as donor site
morbidity at the iliac crest.
overuse symptoms, chronic microtraumatic [47, 48] Usually, the bone
autograft is harvested
lesions of throwing or overhead sports who from the ipsilateral side.
want to return to their pre-injury sports are not The procedure is
performed under general
candidates for refixation, but for tenodesis anaesthesia combined with an
interscalene
of the long head of the biceps tendon because nerve block (Winnie block).
The beach chair
of the much less predictable results [43]. position is the authors
preferred patient position
1145
Fig. 6 Lateral decubitus

position with antero-lateral
c
arm traction. Note the
padding of the lower 3 Kg
extremities in order to
avoid nerve damage and
skin bruises (From
Schulterchirurgie, 4.
edition. Editor:
Habermeyer P, Lichtenberg
S, Magosch P. Elsevier,
Munich, 2010)
5 Kg
for arthroscopic and open surgery at the Closure of rotator

interval in patients with
anterior aspect of the glenohumeral joint. passive external
rotation of more than 85#
Procedures for posterior or multidirectional (extensive laxitiy) [51]
instability are carried out in the lateral decubitus Remplissage: posterior
capsulodesis and
position with the arm in antero-lateral traction infraspinatus tenodesis
in patients with iso-
(Fig. 6). lated large Hill-Sachs
defect and without
bony Bankart defect [52]
Open Procedures
Operative Technique
Open Bankart repair
Arthroscopic Bankart and Capsular Capsule T-shift
according to Neer [53]
Shift Procedures
Mobilization of medialized labrum and liga- Bone Block Procedures

ment insertion (Fig. 7a)
Proper decortication of glenoid neck Arthroscopic [54]/Open
Trillat Procedure
Labrum reconstruction (the use of fewer than Indication: glenoid
defect < 20 % + capsular
4 suture anchors is risk for anterior shoulder deficiency/capsular
hyperlaxity
stabilization failure) [49] (Fig. 7b and c) Surgical principle:
extra-articular coraco-
Postero-inferior capsular plication (Fig. 8a biceps
tenodesis/ligamentoplasty. The con-
and b) via a posterior-inferior portal in cases joined tendon is fixed
above the subscapularis
with pathologic hyperabduction test according tendon at the level of
the scapular neck using
to Gagey an interference screw.
After the transfer, the
Antero-inferior capsular shift: southnorth/ conjoined tendon
functions as a sling
east-west [50] reinforcing the antero-
inferior capsule-labral
Closure of HAGL and R-HAGL lesions: side structures by lowering
the subscapularis
to side repair musculotendinous unit
[50].
1146
a b
Fig. 7 (a) Graph showing the intraarticular position of the with a double loaded
suture wire using a curved suture
posterior, antero-superior and antero-inferior portals. needle. To fix the
capsule-labrum complex to the glenoid
Using a rasp the anterior capsule-labrum-complex is mobi- rim knotless implants
are used (From Schulterchirurgie, 4.
lized along the anterior glenoid rim. In cases of edition. Editor:
Habermeyer P, Lichtenberg S, Magosch P.
medialization towards the anterior glenoid neck visualiza- Elsevier, Munich,
2010). (c) Final result showing ana-
tion can be improved using the antero-superior portal for tomic capsule-labrum
repair using three knotless anchors.
the scope. The glenoid neck has to be roughened by a burr To introduce the
inferior anchor a transsubscapularis por-
to improve healing of the capsule-labrum complex to the tal is recommended in
order to gain the correct angle
glenoid rim (From Schulterchirurgie, 4. edition. Editor: between implant and
glenoid (From Schulterchirurgie, 4.
Habermeyer P, Lichtenberg S, Magosch P. Elsevier, edition. Editor:
Habermeyer P, Lichtenberg S, Magosch P.
Munich, 2010). (b) The capsule and labrum are perforated Elsevier, Munich,
2010)
1147
Fig. 9 J-Span.
Bicortical bone graft from the iliac crest to
restore the anterior
glenoid bone stock. The dimensions of
b the bone graft are
20 # 15 # 7 mm (length # width # height)
lowering effect
of the inferior part of the
subscapularis by
the conjoint tendon [50].
Arthroscopic
[55]/Open Iliac Crest
Autograft (Eden-
Hybinette)
Tricortical bone
graft as an extra-articular
platform combined
with an anatomic labral
and capsulo-
ligamentous repair [56]
Surgical technique
[55, 56]:
Tricortical bone
graft harvesting (1 cm by
Fig. 8 (a) View from the antero-superior portal to the
postero-inferior glenoid rim in a right shoulder with the 2 cm) from the
iliac crest
patient in lateral decubitus position. Two plication sutures Glenoid
preparation by the detachment of
are already knot. One additional suture at the 6.30 position the anterior
capsulo-ligamentous complex
has sticked through the capsule and underneath the
from the 2
oclock to the 6 oclock position.
labrum. Note the wide postero-inferior capsular pouch in
this patient with hyperlaxity. (b) Two additional sutures Transfer of the
bone graft: fixation of the
complete the postero-inferior plication. Note the tightened bone graft
using two cannulated screws at
capsule with significantly reduced pouch the anterior
glenoid neck, aligned with the
glenoid rim.
Refixation of
the anterior capsulo-
Arthroscopic [54]/Open Coracoid ligamentous
complex.
Transfer (Bristow-Latarjet Procedure)
Surgical technique: transfer of the tip of the Open J-Span
Technique According
coracoid process through a subscapularis mus- to Resch [57]
cle split onto the level of the anterior glenoid Surgical
technique:
surface. Bicortical bone
graft harvesting (#20 mm
Principle: triple locking of the shoulder by by 10 mm) from
the iliac crest (J-span)
Advantages of the coracoid transfer compared (Fig. 9)
with the iliac crest autograft: no morbidity
intraarticular ostoetomy at the anterior
of iliac crest harvesting; vascularised scapular neck
bone graft; a dynamic sling is created press fit
impaction of the J-span into the
additionally to the bone block due to the osteotomized
anterior scapular neck until
1148 M.
the cancellous internal side of the short 90# and external rotation to 0#
. After free range
limb of the J-span is plane to the articular of motion is achieved, muscle
strengthening is
surface of the glenoid. increased including the rotator
cuff, deltoid and
Closure of the capsule over the impacted periscapular muscles.
J-span. Simple sports activities as
jogging or cycling
on an ergometer are allowed
after 8 weeks,
Advantage cycling after 12 weeks, and all
high impact, con-
no implantation of hardware tact or overhead sports
activities after 6 months.
Full and reliable graft integration In patients with atraumatic
shoulder instability
Anatomic remodelling undergoing stabilization
procedures the postop-
erative protocol doesnt differ
from the previous
anterior stabilization program.
In patients with
Surgical Treatment of SLAP-Lesions hyperlaxity we recommend to
extend the immo-
bilization period for 6 weeks.
SLAP-repair: arthroscopic technique using The postoperative protocol
for posterior insta-
a posterior, anteroinferior and lateral bility restricts the internal
rotation for the first
transtendineous portal. 3 weeks to the neutral
position. For further
Debridement of frayed or ruptured labral 3 weeks the internal rotation
is limited to 30# ,
tissue with slow increase after the
sixth postoperative
Glenoid preparation using a burr week. The time of return to
sports activities is
Using either two suture anchors or knotless identical to anterior
stabilization surgery.
anchors to fix the labrum anterior and pos-
terior from the biceps anchor (even one
possible suture through the biceps anchor SLAP Repair
itself)
Tenodesis of the long head of the biceps The shoulder is immobilised for
2 weeks using a
using a suprabicipital portal. Gilchrist bandage. Then passive
shoulder
Tenotomy at the biceps anchor after fixa- motion is begun under a
physiotherapists
tion with a clamp through the suprabicipital guidance with limitation of the
range of motion
portal in abduction and flexion to 90#
and 0# of exter-
Extracorporal suture fixation nal rotation for 6 weeks. For
this time active
Tenodesis screw fixation in a drill hole at exercising of the biceps has to
be avoided.
the entrance of the bicipital groove or Afterwards regain of full range
of motion, active
knotless fixation using anchors exercises within the pain-free
limits. Return to
throwing or overhead activities
is allowed after
4 months.
Post-Operative Care and Most reports in literature
describe a delayed
Rehabilitation postoperative course and some
cases of postop-
erative shoulder stiffness [58,
59].
Arthroscopic Bankart-Repair
The shoulder is immobilized for 3 weeks in 15# Complications

of abduction in a pillar. During this period only
lymph drainage and isometric muscle exercises General complications of
surgical interventions
are allowed. Afterwards, passive mobilization as haemorrhage, wound
infection, vascular or
within the pain limits is begun. Within the first nerve injuries or venous
thrombosis/embolism
6 weeks, flexion and abduction are limited to are rare. More often
complications result from
1149
inadequate preoperative diagnostics or insuffi- to perform an accurate

clinical evaluation after
cient technical performance of surgery. obtaining a detailed history.
Additional imaging
The most frequent complications are: should complete the
diagnostic process leading to
Untreated pathology the correct diagnosis
allowing for the adequate
Underdiagnosed MDI therapy option which often is
surgical. Surgery
Underdiagnosed collagenosis must address the underlying
pathomorphological
Underdiagnosed HAGL lesion substrate and be performed
technically correct.
Underdiagnosed loose shoulder The presence of relevant
glenoid bone defects
Underdiagnosed pathologic muscle usually requires open
procedures. The postoper-
patterning ative protocol must be
followed accurately and
Significant bony defects full return to sports
activities, including risk
Insufficient treatment of pathology sports, is possible after 6
months. The general
Asymmetric capsular repair and complication rate is low. The
failure rate depends
overtightening (tightening of the capsule on various factors including
age, number of dis-
anteriorly and superiorly, untreating the infe- locations, number of anchors
used, tissue quality,
rior instability by violation of the inferior hyperlaxity, and grade of
activity.
glenohumeral ligament and the inferior cap-
sular pouch, which is resulting in a restriction
of the external rotation but a positive
sulcus sign) [60]
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Open Capsuloplasty for
Antero-Inferior
and Multi-Directional
Instability of the
Shoulder
Pierre Hoffmeyer
Contents
Keywords
Antero-inferior and multi-directional instabil-
ity # Bankart lesion # Bankart repair # Capsule

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1153
to glenoid suture # Capsuloplasty # Complica-

Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1153
Examination Under Anaesthesia . . . . . . . . . . . . . . . . . . .
1154 tions # Cruciate repair # Glenoid neck prepara-
Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1154 tion # Preparing humeral neck # Rehabilitation
Delto-Pectoral Interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1154 # Results # Shoulder # Subscapularis repair #
Interval Subscapularis-Supraspinatus . . . . . . . . . . . . . .
1155
Surgical indications # Surgical Technique

Subscapularis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1156
T-eeing the Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1156
Bankart
Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1156
Glenoid Neck Preparation . . . . . . . . . . . . . . . . . . . . . . . . . .
1157 Indications for Surgery
Bankart Sutures or Anchors . . . . . . . . . . . . . . . . . . . . . . . .
1157
Suturing the Capsule (Reverdin Needle) to the
Glenoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1157 Recurrent antero-inferior glenohumeral post-
Preparing the Humeral Neck . . . . . . . . . . . . . . . . . . . . . . .
1158 traumatic dislocation is the main indication for
Cruciate Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1158 this operation. Some patients will have only
Suturing Subscapularis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1158
a perceived subluxation of the shoulder with no

Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1160
Recovery Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1161 real episode of dislocation. Balg and Boileau
have devised a scoring system whereby it is pos-

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1161
sible to choose with some accuracy between open

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1161 and closed (arthoscopic) surgical techniques.
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1162 A distended capsule, whether of post-traumatic
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1162
or congenital origin with or without a Bankart or
Perthes lesion and, an intact non-fractured
glenoid rim, is the ideal situation indicating an
open capsuloplasty [15, 8, 9, 1115].
Technique
Positioning
P. Hoffmeyer
Under general anaesthesia and in some cases

with an additional scalene block, the patient is
placed on the operating table in a semi-sitting

1153
DOI 10.1007/978-3-642-34746-7_3, # EFORT 2014
1154
P. Hoffmeyer
Examination Under
Anaesthesia
Before proceeding with

the procedure a thorough
examination of the
shoulder under anaesthesia
Scalene bloc must be carried out.
Mobility must be assessed
to ensure that it is
full. A posterior drawer test
must be carried out to
assess the posterior laxity
as well as a sulcus
sign test to ascertain any
evidence of inferior
laxity. Direction of disloca-
tion must be determined
first by pushing anteri-
orly on the humeral
head with the arm at the side
in internal rotation,
where it should dislocate
easily if the diagnosis
is correct. A grating sensa-
tion will indicate the
presence of a cartilaginous
Fig. 1 Under General anaesthesia in beach chair posi- defect or of a bony
Bankart lesion [2]. With the
tion, the head secured, the shoulder well exposed at the
arm in external
rotation the anterior structures,
front and the back, the unimpaired upper limb is ready to
be prepared and draped i.e., the capsule and
subscapularis tendon, are
stretched taut and the
shoulder will not dislocate.
The degree of rotation
needed to stabilize the
beach chair position. It is important that the shoulder will give a
gross estimate as to the
table be slightly up-tilted so that the buttocks rest amount of capsular
laxity.
squarely in the seat of the table avoiding any
tendency to downward slippage. The head is
held securely in a head rest with a firm bandage Incision
providing secure fixation. The cervical spine is
in neutral position without inclination, rotation, It is important to draw
the skin incision with
extension or flexion. Special care should be a surgical pen before
applying any type of plas-
given to protecting the patients eyes. It is tic adhesive draping,
iodine impregnated or oth-
important to verify the position of the contralat- erwise, as this will
deform the skin and its
eral upper extremity so as to avoid any untoward natural creases.
Usually the incision is 67 cm
pressure areas. in length, vertical,
extending from the axillary
The totality of the shoulder region from the skin crease to a point
midway to the tip of the
supero-lateral torso and including the whole coracoid. In muscular
patients the incision
upper extremity should be left free. Some modu- might have to be
somewhat longer. It is impor-
lar tables will allow removal of an upper tant to undermine the
skin in the avascular layer
cornerpiece therefore allowing access to all of the subcutaneous
overlying the muscular
parts of the shoulder. The downside of this pos- fascia (Fig. 2).
sibility is that the scapula tends to sag backwards
somewhat. This may be counteracted by rolling
the table slightly towards the opposite side. If this Delto-Pectoral Interval
possibility does not exist a bolster may be used to
prop up the scapula. The delto-pectoral
groove is then identified.
The upper limb may then be prepared In case of difficulty
proceed superiorly while
and draped leaving the shoulder well exposed palpating the coracoid.
At the divergence
at the front and the back with the upper extremity between deltoid and
pectoralis it will usually
fully accessible and mobility unimpaired be easy to find the
groove and the cephalic
(Fig. 1). vein. The vein should
be separated from
Open Capsuloplasty for Instability of the Shoulder
1155
the pectoralis but left adherent to the deltoid. appears and it is

retracted medially with the
The deltoid fascia which extends around and pectoralis (Fig. 3a,
b).
under the anterior third of the deltoid should be
carefully incised so as to give access to
the subdeltoid and subacromial spaces. At this Interval
Subscapularis-Supraspinatus
point some degree of abduction will be helpful.
A retractor will then be placed underneath the With the arm in
external rotation and some
deltoid which will tend to subluxate the adduction, the
subscapularis tendon comes into
humeral anteriorly stretching the underlying view. The upper two-
thirds of the subscapularis
subscapularis and capsule. The conjoint tendon insertion onto the
lesser tuberosity are tendinous
while the lower third
is muscular. The humeral
head is palpated to
identify the biceps tendon in
its groove and the
interval between subscapularis
Deltoid Coracoid
and supraspinatus. If
this interval is deemed too
wide i.e., more than 1
cm, it may be sutured
incision closed at this point.
Palpating the axillary nerve
may be done at this
time. To do so the index
finger is passed under
the conjoint tendons in
front of the
subscapularis with the arm in neutral
Axilla Pectoralis or in slight internal
rotation. The nerve is felt
easily and it is
surprisingly large and taught.
Internal rotation will
tighten the nerve along its
Fig. 2 The vertical incision (solid black line) follows an course while external
rotation will loosen it.
axillary fold and spans from the inferior border of the Some authors also
recommend palpating the
Pectoralis tendon (outlined red) to the mid-point (arrow)
between the coracoid and the axilla (Deltoid outlined
musculocutaneous nerve
that penetrates the
orange). The bony contours are always marked out with coracobrachialis some
35 cm below the cora-
a surgical pen coid tip [7].
a b
l
k
c
h
b
g
Fig. 3 (a) The subcutaneous skin is undermined so as to glenoid neck and

Bankart lesion area, (g) Glenoid, (h)
expose the Deltopectoral groove (dotted line). (b) Sche- Subscapularis muscle,
(i) Axillary nerve, (j) Pectoralis
matic shoulder: transverse plane: (a) Deltoid muscle, (b) muscle (k) Conjoint
tendon (l) Cephalic vein, (m) Hill-
Humeral head, (c) Biceps tendon and groove, (d) Posterior Sachs lesion
capsule, (e) Anterior distended capsule, (f) Anterior
1156
P. Hoffmeyer
a b
Elevated
subscapularis tendon
Deltoid retractor
Pectoralis retraction
Inferior third
subscapularis
Fig. 4 (a) Deltoid separated from the Pectoralis leaving dissection. Leave
attached the inferior muscular third of
the cephalic vein laterally. (b) Subscapularis tendon ele- the subscapularis
insertion
vated from the underlying capsule (*) with sharp
Subscapularis of humerus leaving 1

cm of capsule along its inser-
tion stopping at the
level of the insertion of the
A subscapularis tendon flap extending medially is muscular part of
subscapularis. The horizontal part
now created. This tendinous flap, about 2 cm wide, of the T extends from
the middle of the capsule
extends from just below the supraspinatus- laterally to the
glenoid insertion. Stay sutures are
subscapularis interval to just above the muscular placed on each of the
two corners of the upper and
distal third of the subscapularis insertion. Near the lower triangular
flaps. A Fukuda type retractor
insertion on the lesser tuberosity the subscapularis pushes the humeral
head away so that it is possible
and the capsule are intimately imbricated and to examine the
articular surface of the glenoid. The
therefore the subscapularis must be sharply dis- capsular insertion of
the inferior flap on the glenoid
sected off the capsule. As a rule of thumb it is is inspected. When the
capsular insertion on the
better to err towards a thicker capsule and a thinner glenoid is intact
(Absence of a Bankart lesion)
subscapularis tendon (Fig. 4a, b). the cruciate repair,
as described below, can
As the tendon is dissected off medially, mus- performed without
further ado [11, 12] (Fig. 6a, b).
cular fibres appear and it becomes easier to sep- In the case of
multi-directional instability it will
arate the actual tendon from the smooth capsule be necessary to detach
the humeral insertion of the
underneath. Stay sutures are then inserted to capsule
circumferentially all the way around the
allow for immediate retraction and future re- head to reach its
equator while progressively deliv-
fixation (Fig. 5a, b). ering the humeral head
into external rotation. This
will produce a much
larger inferior capsular flap
which can then pulled
up and sutured to the base of
T-eeing the Capsule the superior flap [12,
13].
The capsular surface is individualized with a soft

tissue rasp such as a Cobb elevator or a Darrach rasp Bankart Lesion
and a Hohmann retractor is placed on the anterior
neck of the glenoid to provide good visualization. Usually a soft tissue
Bankart or Perthes lesion
A smaller blunt retractor may be inserted inferiorly extending from 2
oclock to 6 oclock on a right
to protect the axillary nerve. Using a small blade the glenoid and
accompanied by some glenoid bony
capsule is incised in T fashion. The vertical bar of eburnation or
cartilage damage, is encountered.
the T starts below the interval and follows the neck The labrum is usually
absent or damaged.
1157
a b 1
1
2
3
3
4
Fig. 5 (a) The Deltoid retractor (1) will cause a forward sutures (3). Conjoint
tendon and pectoralis are retracted
subluxation of the humeral head thereby tightening the medially (4). (b) Using
a Cobb elevator [2] to dissect the
anterior structures which eases the dissection of the subscapularis off the
capsule and put stay sutures in the
subscapularis tendon off of the capsule, first by sharp subscapularis tendon
dissection then with a Cobb elevator (2) and held by stay
If a significant bony defect (involving more than usually sufficient; the

sutures should be long to
25 % of the glenoid surface) is found this would allow for ease of tying
and manipulation. Heavy,
justify a bone block operation. Precise pre- cutting, small diameter
Mayo needles are made to
operative imaging will avoid this situation and pass through the pre-
prepared holes using heavy
identify other unsuspected lesions [2]. towel clip type clamps.
For ease of use and
speedy intervention,
many authors use bone
anchors. Resorbable
anchors tend to create
Glenoid Neck Preparation osteolysis and metal
anchors must be placed at
the glenoid bone-
cartilage angle and buried
In the case of a Bankart or Perthes lesion the deeply so as not to
damage the humeral head
glenoid neck should be decorticated to bleeding cartilage [6, 10].
Metallic anchors will interfere
bone. Any loose or poorly-healed bone or cartilage with any future MRI
imaging (Fig. 8a, b).
fragment should be removed. High speed burrs
should be avoided as this tends to cause heat and
bone necrosis; use preferentially a sharp Suturing the Capsule
(Reverdin
osteotome. Occasionally when the anterior glenoid Needle) to the Glenoid
neck is prepared venous bleeding occurs. Tempo-
rary packing will stop this oozing (Fig. 7a, b). Once the Bankart
sutures are in place they must
be passed through the
lower flap of the capsule.
Both strands are passed
in a U pattern. It is impor-
Bankart Sutures or Anchors tant that the sutures
slide freely guaranteeing
a tight knot. The
sutures are then tied down secur-
The next step consists in passing three to four ing the capsule firmly
to the glenoid at the bone-
transosseous sutures. Vicryl# number two is cartilage junction and
thus re-creating a labrum.
1158
P. Hoffmeyer
a b
Fig. 6 (a) The capsule is incised using a lying down the glenoid neck.
Identify the axillary nerve that lies on the
T incision (dotted lines). (b) The upper and lower flaps subscapularis and
passes underneath the capsule
are unfolded allowing identification of the inferior half of
Because of the position of the sutures passing a high speed burr

but preferably with osteotomes
from the glenoid neck anterior cortex through and rongeurs to
avoid overheating the spongiosa.
the spongiosa and exiting on the cartilage surface
the capsule comes automatically to the right place
on the glenoid edge when it is tightened down. To Cruciate Repair
pass the sutures through the capsule a Reverdin
needle is most useful. The index finger is placed The tip of the lower
flap is then sutured as high as
under the conjoint tendon protecting the surpris- possible laterally
at the level of the neck-capsule
ingly close axillary nerve (Fig. 9a, b). junction. At this
point the arm should be in neu-
tral rotation and
slight abduction. More sutures
are placed along the
lateral border of the flap so as
Preparing the Humeral Neck to secure it to the
humeral neck. The upper flap is
lowered and the tip
is sutured as low as possible
The capsular insertion groove on the humeral over the upper flap
(Fig. 10ac).
neck is abraded to bleeding bone. This is espe-
cially important in cases of multi-directional
instability where the abrasion must go all around Suturing
Subscapularis
the humeral neck so as to obtain a bleeding sur-
face favourable for strong adhesion of the Subscapularis is
then sutured back to its original
re-inserted capsule. This may be done with insertion site and
any overtightening is avoided.
1159
a b
3
1 2
Fig. 7 (a) Major Bankart lesion with a bare glenoid neck with a sharp osteotome
of the glenoid neck (2) while
(*) attesting to the avulsion of the glenohumeral ligament the capsule is
retracted with a sharp-tipped Hohmann
insertion and absent labrum. (b) Fukuda retractor (1) retractor (3)
keeps the humeral head away allowing decortications
a b
*
*
*
Fig. 8 (a) Transosseous glenoid sutures (*) using 2Vicryl# and passed with trocar
point needles (inset). (b) Passage of
transosseous sutures (*)
At this point the shoulder stability is tested with should be free as well
as external rotation up to
an anterior drawer manoeuvre in neutral or slight 30# . If sutures tear
during this manoeuvre the
internal rotation with the arm at the side. There subscapularis needs to
be lengthened and the
should be a solid resistance felt. Elevation to 100# flaps might need to be
re-positioned. Usually
1160
P. Hoffmeyer
Passing the transglenoid sutures through the inferior

flap
a b
1
*
Fig. 9 (a) Transglenoid sutures are then passed through should slide freely
to allow a tight knot. The axillary nerve
the inferior capsular flap using a Reverdin needle (1). (b) must be protected
during this phase
The sutures (*) must pass through the capsular flap and
a b
c
Fig. 10 (a) The capsule is tied down to the decorticated possible and sutured
in place on the remaining lateral
glenoid neck (*). The humeral capsular insertion groove is capsule. (c) The
superior flap is pulled down and sutured
also decorticated (arrow) to enhance osseous capsular to the remaining
lateral capsule and to the inferior flap
attachment. (b) The inferior flap is pulled up as high as
overtightening the structures is the problem, not Closure

undertightening (Fig. 11).
In the case of multi-directional instability it is Abundant rinsing is
done with haemostasis as
sometimes necessary to add a posterior capsular needed and the
cephalic vein is inspected for
shift. injury; the
deltopectoral interval can be closed
1161
Contact sports or
sports with a high probability
of falling such as
skiing are permitted after
1 year post-
operatively.
For the patient
with multi-directional instabil-
ity a specific post-
operative regimen is installed.
The shoulder is
maintained in neutral rotation
with 20# of
antepulsion and 20# of abduction.
A handshake brace
is installed in the recovery
room and the patient
is instructed to keep the
brace for a period
of 8 weeks. During this period
of immobilisation,
isometric exercises are
recommended to keep
the shoulder musculature
toned. After removal
of the brace range-of-
motion exercises are
started. All contact or at-
risk sports
activities are forbidden for the year
following the
operation.
Fig. 11 Repair completed: The capsular flaps are doubled

and the subscapularis is sutured back to its original inser- Complications
tion avoiding any overtightening
The most common
immediate complication is
a haematoma which
may need, in rare cases,
aspiration or even
revision. Adhesive capsulitis
with loose sutures. The wound is then closed in may develop in the
post-operative phase but this
the usual fashion using subcuticular sutures over is very uncommon.
Infection is a rare compli-
a 24-h suction drain if felt necessary. cation also. Most
organisms are involved but
one should be
especially aware of infections
with
propionibacterium acnes that is frequent
Recovery Room around the shoulder.
A prompt reaction, with
a surgical wash-out
of the operative wound
In the recovery room the shoulder is tested for along with the
proper antibiotics chosen after
neurovascular integrity. Isometric contractions of an infectious
diseases consultation, should
the deltoid are routinely tested at that time. effectively deal
with the situation. Neurological
An AP Scout film is routinely performed. Over- problems may arise
ranging from temporary
night surveillance and pain control are routine axillary or
musculocutaneous nerve palsy to
although many Surgeons perform this interven- a full blown
permanent plexus injury. As
tion as an out-patient procedure. a rule these lesions
are due to neurapraxia or
axonotmesis and tend
to recover. A neurology
consultation along
with EMG studies is manda-
Rehabilitation tory. In the case of
neurotmesis or outright sec-
tion of the nerve a
reconstructive procedure may
For the first 3 weeks the patient is instructed to be necessary. Later
the main complication is
keep his arm in internal rotation in a sling. After recurrence of the
dislocation or the persistence
3 weeks the arm is freed and may be used for of apprehension. In
the years that follow
activities of daily living. At 6 weeks strength- glenohumeral
arthrosis may set in. It is not
ening exercise are introduced along with some clear whether the
arthrosis is due to the initial
range-of-motion exercises. At 12 weeks the dislocation with its
concomitant cartilaginous
patient is allowed full use of the shoulder. damage or to the
stabilising procedure.
1162
P. Hoffmeyer
average follow-
up. J Shoulder Elbow Surg.
Results 2009;18(2):251
9.
5. Matsen FA,
Lippitt S, Bertlesen A, Rockwood CA,
Wirth MA.
Glenohumeral instability. In: Rockwood
Recurrence rates vary in the literature between 0 % CA, Matsen FA,
Wirth MA, Lippitt SB, editors. The
and 20 %. This depends on the exact technique, the shoulder. 4th
ed. Philadelphia: Saunders Elsevier;
length of follow-up and the completeness of the 2009. p. 61675.
6. Ferretti A, De
Carli A, Calderaro M, Conteduca F.
review process. Most authors agree that loss of Open
capsulorrhaphy with suture anchors for recurrent
range of motion is slight usually not more than anterior
dislocation of the shoulder. Am J Sports Med.
10# for external rotation. As for residual pain and 1998;26(5):625
9.
stiffness neither is reported as occurring with any 7. Flatow EL,
Bigliani LU. An anatomic study of the
musculocutaneous
nerve and its relationship to the
significant frequency. Many authors report a non- coracoid
process. Clin Orthop Relat Res.
negligible percentage of remaining apprehension 1989;244:16671.
in the patients, up to 20 %. The exact cause is not 8. Hamada K, Fukuda
H, Nakajima T, Yamada N. The
determined, whether it is a mechanical phenome- inferior
capsular shift operation for instability of the
shoulder. Long-
term results in 34 shoulders. J Bone
non with subluxation or a deficit of proprioception. Joint Surg Br.
1999;81(2):21825.
Up to 50 % of operated shoulders will be found to 9. Hovelius LJ,
Thorling J, Fredin H. Recurrent anterior
have some degree of arthritis when the x-rays are dislocation of
the shoulder. Results after the Bankart
reviewed and classified according to Samilson. and Putti-Platt
operations. J Bone Joint Surg Am.
1979;61(4):566
9.
For the great majority of patients this does have 10. Kartus J,
Ejerhed L, Funck E, Kohler K, Sernert N,
any significant clinical repercussions [3, 4, 6, 8, 9, Karlsson J.
Arthroscopic and open shoulder stabiliza-
1115]. tion using
absorbable implants. A clinical and radio-
graphic
comparison of two methods. Knee Surg Sports
Traumatol
Arthrosc. 1998;6(3):1818.
11. Neer CS.
Shoulder reconstruction. Philadelphia: W.B.
References Saunders; 1990.
12. Neer CS, Foster
CR. Inferior capsular shift for invol-
1. Balg F, Boileau P. The instability severity index score. untary inferior
and multidirectional instability of the
J Bone Joint Surg Br. 2007;89(11):14707. shoulder. A
preliminary report. J Bone Joint Surg Am.
2. Bankart A. The pathology and treatment of 1980;62(6):897
908.
recurrent dislocation of the shoulder. Br J Surg. 13. Pollock RG,
Owens JM. Operative results of the
1938;26:239. inferior
capsular shift procedure for multidirectional
3. Bigliani LU, Kurzweil PR, Schwartzbach CC, Wolfe instability of
IN, Flatow EL. Inferior capsular shift procedure for 2000;82-
A(7):91928.
anterior-inferior shoulder instability in athletes. Am 14. Simonet WT,
Cofield RH. Prognosis in anterior shoul-
J Sports Med. 1994;22(5):57884. der dislocation.
Am J Sports Med. 1984;12(1):1924.
4. Bonnevialle N, Mansat P. Selective capsular repair for 15. Walch G. La
luxation recidivante anterieure de
the treatment of anterior-inferior shoulder instability: lepaule. Table
ronde. Rev Chir Orthop Reparatrice
review of seventy-nine shoulders with seven years Appar Mot.
1991;77 Suppl 1:17791.
Shoulder Instability in Children
and Adolescents
diger Krauspe
Jorn Kircher and Ru
Contents
Abstract
Shoulder instability is a common problem in
Orthopaedic practice for children and adoles-

cents. Dislocations under the age of 12 are

Relevant Applied Anatomy, Pathology,
rare. The group of adolescents and young
Basic Science and Biomechanics . . . . . . . . . . . . . 1165
adults, especially male, who are active in
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1166 high risk sports have the highest reported
recurrence rates.
There are no widely-accepted classification

systems for shoulder instability of children

1176 and adolescents and the most commonly used
systems are the same as for adults.
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1181
It needs to be emphasized that hyperlaxity
and hypermobility are a frequent clinical con-

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1181
dition in this age group which needs to be

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1181 taken into consideration with regard to deci-
sion-making for therapy.
Every muscular dysbalance and disturbed
scapulo-thoracic rhythm needs intensive con-
servative treatment whether the decision is
made for surgery or not.
Arthroscopic stabilization is the treatment

of choice for severe structural damages, espe-
cially substantial glenoid bone loss, which
results in lower recurrence rates and better

J. Kircher (*)
clinical function.
Shoulder and Elbow Surgery, Klinik Fleetinsel Hamburg,
Hamburg, Germany
Department of Orthopaedics, Medical Faculty,
Keywords
HeinrichHeineUniversity, Dusseldorf, Germany
Aetiology, Classification # Anatomy # Biome-

e-mail: joern.kircher@med.uni-duesseldorf.de;
j-kircher@web.de
chanics # Complications # Diagnosis # Surgical
Techniques # Pathology # Rehabilitation #

R. Krauspe
Department of Orthopedic Surgery, University Hospital of
Results # Shoulder instability-children, adoles-
D
usseldorf, Dusseldorf, Germany
cents # Surgical indications

1163
DOI 10.1007/978-3-642-34746-7_63, # EFORT 2014
1164
J. Kircher and R. Krauspe
anchoring of the joint

capsule in very young
General Introduction individuals than to
dislocate the shoulder [28].
In adolescents a
significant trauma is associ-
Shoulder instability is a common problem in the ated with dislocation in up
to 86 %. The most
general population but is rare in children and common activities and
mechanisms, in
young adolescents under the age of 12 [1, 2]. descending order, are
football, falls, basketball,
It accounts for 0.01 % of all injuries in this age wrestling, hockey, baseball
or softball, swim-
group [3, 4] and for 2.54.7 % of all shoulder ming, and tennis [1, 29].
dislocations [5, 6]. The extent of
dislocation can be graded into
Compared to adult shoulder dislocations there apprehension, subluxation
or dislocation. The
are many more atraumatic dislocations with an direction of instability
can be uni-directional
increasing number of traumatic cases with (anterior, posterior,
inferior and superior) or
increasing age [5, 79]. multi-directional. Shoulder
instability can be
The majority of reported cases (about 80 %) congenital, acute or
chronic (recurrent or fixed).
are classic Bankart-like lesions with only 50 % of According to the
pathogenesis shoulder instabil-
classic Hill-Sachs lesions [1, 7, 10, 11]. ity can be traumatic, due
to repetitive
Girls are generally younger than boys at the microtrauma or non-
traumatic.
time of their first dislocation and are two times There are three
commonly-used classification
less affected [1]. systems which are similar
to those for adult
shoulder instability.
Matsen et al. described two
major forms of instability
which are based on
Aetiology and Classification clinical findings and
treatment:
TUBS (traumatic, uni-
directional, Bankart
The scapula develops by intramembranous ossi- lesion, surgical
repair) and
fication starting at eight centres or more which is AMBRII (atraumatic,
multi-directional, bilat-
complete at the time of delivery except for the eral, rehabilitation,
inferior capsular shift,
glenoid, acromion, coracoid, medial margin and interval) [30, 31].
inferior angle [12]. Gerber et al.
differentiated shoulder instability
The glenoid cavity shows a superior and infe- into six sub-groups which
can easily be used in
rior centre of ossification. The superior centre clinical practice [32]:
appears around the age of ten and fuses at the I. Chronic dislocation
age of 15. At this time the inferior centre appears II. Uni-directional
instability without
as a horseshoe-shaped epiphysis with a thinner hyperlaxity
central portion and a thicker peripheral rim. III. Uni-directional
instability with multi-
Injury to these ossification centres can lead to directional
hyperlaxity
the development of bony abnormalities such as IV. Multi-directional
instability without
glenoid hypoplasia. The association with other hyperlaxity
disorders such as birth palsy, infection, muscular V. Multi-directional
instability with multi-
dystrophy, vitamin deficiency, arthrogryposis directional
hyperlaxity
and others have been described [1325]. VI. Uni- or multi-
directional voluntary
A positive family history and ethnic origin instability
have been reported [15, 22, 24, 26, 27]. Bayley et al. have
introduced a more sophisti-
There are three ossification centres at the prox- cated model consisting of
three major poles [33]:
imal humerus which fuse at about the age of Polar type 1: traumatic,
structural
seven and fuse with the humeral shaft at the age Polar type 2: atraumatic,
structural
of 1418 [28]. Polar type 3: muscle
patterning, non-structural
Therefore a significant trauma is more likely The form of instability
can be assigned to
to injure the open physes based on the epiphyseal one or more poles to a
certain degree which
1165
in our opinion helps in defining each individual

case but at the same time is less accurate and Relevant Applied Anatomy,
comparable to others. We suggest the use of Pathology, Basic Science and
the latter two classification systems and the Biomechanics
addition of supplementary information based
on the facts listed at the beginning of this The glenohumeral joint is the
most mobile joint
section. of the human body with a
complex synergetic
There is still a somewhat poorly-defined inter-operation of several
factors that provide
use of the terms instability, hyperlaxity and sufficient stability.
hypermobility. We prefer the term laxity There are several factors
that influence the
to describe the amount of physiological stability of the glenohumeral
joint [57]:
glenohumeral translation and hyperlaxity as Static stabilizers
a condition with pathologically increased Bone/cartilage
glenohumeral translation, usually involving the Humerus
opposite shoulder also. Instability describes the Glenoid
inability to actively centre the joint and it is Scapula Thorax
certainly pathological. Hypermobility is an Coracoid
increased range of motion of the joint along Acromion
the physiological axes and alone represents Clavicle
a normal variant. Labrum
General joint hypermobility (GJH) has About 50 % increase
of the contact area
a prevalence of 839 % in children of school About 60 %
contribution to resistance
age [3438]. Several studies show a decrease by against applied
forces
increasing age and an increased frequency in SLAP complex with
the biceps tendon
Caucasians and females [3944]. Juul- origin [58, 59]
Kristensen et al. have shown that the presence Glenohumeral ligaments
of general joint hypermobility does not need to Superior
glenohumeral ligament
be associated with musculoskeletal pain and (SGHL) (stabilizing
the biceps tendon
injuries but that children with GJH performed at the pulley
system)
better in motor competence tests. This may be Medium
glenohumeral ligament
an explanation, that hypermobile children are (MGHL)
often found in sports with a high demand for Inferior
glenohumeral ligament (IGHL),
flexibility such as ballet, dancing, gymnastics anterior and
posterior part
and swimming [4548]. In contrast to the find- Long head of biceps
tendon
ings of Juul-Kristensen in 8-year old school Dynamic stabilizers
children there were increased frequencies of Surrounding muscles
injuries observed for participants in elite sports Compression-concavity
mechanism of the
[49, 50]. General joint hypermobility can be rotator cuff
classified using the Beighton score and demar- The position of the scapula
in relation to the
cated from the benign joint hypermobility humerus
syndrome (BJHS) by the Brighton criteria As described in the former
section Aetiology
[41, 5153]. and Classification children
and adolescents
Although the data about general joint commonly present with a
certain degree of
hypermobility is sometimes conflicting, espe- hyperlaxity of the joints
with a particular focus
cially in drawing a line between normal and path- at the shoulder. This
hyperlaxity usually is
ological conditions, it certainly needs to be taken bilateral and decreases with
increasing age.
into account in decision-making for the treatment This condition is often
combined with a varying
of shoulder instability [44, 5456]. degree of motor incompetence
and a disturbed
1166 J.
Kircher and R. Krauspe
scapulo-thoracic rhythm. A physical rehabilita- the joint by the examiner

does not need to be
tion programme with specific attention to these pathological but can present
as a normal variant
problems can often restore normal shoulder func- [6165]. Also an asymmetric
amount of laxity
tion but needs more time than commonly per se does not need to be
pathological or repre-
expected. sent an unstable joint [61,
66]. The amount of
The reduced strength of the soft tissue normal inferior translation
(sulcus test) remains
static stabilizers of the glenohumeral joint controversial [57].
compared to adults make bony injuries to General hyperlaxity can
checked by the
the glenoid (bony Bankart lesion) and Beighton criteria [51, 67]:
the humerus (Hill-Sachs lesion, Malgaigne or Thumb apposition to the
forearm with
reversed Bankart lesion) less likely and a palmar-flexed hand at
both sides
less marked but on the other hand may be Hyperextension >90# of the
fifth finger at both
an important factor in the much higher sides
recurrence rates [5, 6, 8, 60]. Hyperextension >10# of the
knee joint at both
sides
Hyperextension >10# of the
elbows at both
Diagnosis sides
Spine flexion with extended
knees and palms
The diagnosis is based on the history of present on the floor
complaints, a thorough clinical investigation and Hyperlaxity at the
shoulder can be tested by
diagnostic imaging. the Gagey test (Fig. 1) and
an increased external
It is important to define the mechanism of rotation in adduction (Fig.
2) and the sulcus test
injury, if there was any trauma, the amount of (Fig. 3).
displacement (complete dislocation vs. sublux- The apprehension test
(Fig. 4) should be
ation) and the circumstances of reduction performed very carefully, it
can be positive with
(spontaneous, manipulation by the patient, very small amounts of
abduction and external
manipulation by the doctor with or without rotation. As this test can be
very uncomfortable
anaesthesia) and the history of recurrence for children it should be
performed at the
(how often, how much and under which cir- end of the clinical
examination. This applies
cumstances). In younger children it can be as well for the load and
shift test and the sulcus
difficult to obtain these data and the surgeon sign (Fig. 5).
often has to rely on the parents incomplete The clinical examination
is accompanied by
memorisation. During clinical examination the a series of basic
radiographs, which should
patient is assessed for any general abnormality include a true anterior-
posterior view, an
(e.g. asymmetry, differences of appearance, outlet view and an axillary
view (the Velpeau
circumference and length of the upper extrem- view may be used in painful
shoulders or where
ities and shoulder girdle, muscle atrophy, there is inability to perform
the necessary
hyperlaxity, etc.). abduction).
The cervical spine is assessed for any signs of In any case of a traumatic
dislocation we rec-
abnormality. The range of motion of the shoulder ommend an accompanying MRI to
rule out any
is assessed both actively and passively. The osteochondral lesion [7072].
If the clinical
examiner should notice little differences vey examination cannot be
performed properly
carefully without trying to replicate tests and because of non-compliance of
the child,
manoeuvres and save time and compliance of a second attempt at a
different time during clinic
the child for the important issues. should be made, but sometimes
an MRI is indi-
The normal range of motion can have a high cated based on the history of
trauma and the
variability and the ability to anteriorly dislocate parents information alone.
1167
Fig. 1 Hyperabduction
test according to Gagey
[68, 69]: glenohumeral
abduction is performed at
maximum level with a fixed
scapula. A range of motion
of more than 90100# is
considered to be positive
Fig. 2 External rotation of the arm in adduction of more

than 90# is considered to be positive
Fig. 3 Sulcus sign:
Axial traction of the arm in adduction
is graded in three
grades. Note the acromion becomes
obvious (black arrow)
with inferior subluxation of the
Indications for Surgery humeral head out of the
glenoid fossa giving a positive
sulcus sign
There is no consensus about the management of

primary shoulder dislocations in young lesion an arthroscopic
evaluation is recommended
individuals. by the authors. If
osteochondral lesions are found,
In cases of acute injuries with massive they should be addressed
as necessary and of
haematoma and any suspicion of an osteochondral course any attempt
should be made to maintain
1168
Fig. 4 Apprehension sign: External rotation of the 90# abducted arm and additional
anterior push with the left hand
causes discomfort and apprehension (left). This test can be positive in very early
abduction and external rotation (right)
Fig. 5 Anterior drawer

test: The left humeral head
is pushed anteriorly (and
posteriorly) with the left
hand while the right hand
fixes the scapula with the
glenoid
the hyaline joint cartilage [73], but refixation of of the instruments in

relation to the defect and
osteochondral fragments at the shoulder is tech- often a resection and
debridement is necessary.
nically challenging because of the size of the Bony Bankart
lesions in the early post-
defect in relation to the joint and the angulations traumatic period
usually can be anatomically
1169
repaired, as long as they are in contact with the When stratified by

treatment modality (surgi-
labrum and the capsulo-ligamentous complex and cal vs. physical therapy
alone), surgically- treated
not substantially retracted, using suture anchors. patients were more likely
to report moderate dis-
Figure 6ad Conservative treatment is based on comfort, which occurred in
six (21 %) of the
a period of immobilization. We usually use surgically-treated
shoulders compared with one
a customized Gilchrist sling (Fig. 7) for 2 weeks (2 %) of those treated with
physical therapy
with early physiotherapy and passive mobiliza- alone. Otherwise, there
were no significant dif-
tion in a phased rehabilitation protocol. The use ferences in pain when
patients were stratified by
of external rotation orthotic devices has become traumatic versus atraumatic
onset, voluntary
popular in adults but there are no reports about the instability, and direction
of instability. Age at
use in children and adolescents [7477]. first episode was not
related to stability. To sum-
Lawton et al. [1] reported the treatment and marize the broad
statistical information, the
results in the largest study of 101 children and authors identified four
groups of patient profiles:
adolescents with an age below 16 years (mean The first reflects a
positive relationship
age 13.2 years, range 416) from 1976 to 1999. between older boys with
traumatic onset of
Ten percent of the patients were below the age of their instability,
absence of voluntary instabil-
ten. Girls were significantly younger compared to ity, treatment with
surgery, and good out-
boys and atraumatic, voluntary dislocations and comes both at clinical
and survey follow-up.
multi-directional instabilities were more frequent The second grouping shows
that older girls
in younger individuals. 50 % of the patients did not with traumatic
dislocation and voluntary
have frank dislocations but subluxations. Trauma instability had poorer
outcomes independent
was associated with the first dislocation in 86 %. of treatment.
67 % of the patients began physical therapy The third grouping
represents a positive rela-
and 40 % eventually underwent surgery. Of the tionship between
multiple dislocations,
28 operated shoulders, 18 (65.8 %) had partici- atraumatic onset,
treatment with physical ther-
pated in physical therapy before surgery. Bankart apy and surgery, and
favourable outcome. In
repairs with capsular shift were performed in other words, patients
who had those features
11 (39 %) of the surgical patients, Bristow pro- treated with physical
therapy before surgery
cedures in 5 (18 %), Putti-Platt procedures in were more likely to be
stable and less likely to
3 (11 %), capsular shift in 3 (11 %), and Bankart report limitations than
those with fewer
repair alone (no capsular shift) in 1 (4 %). One characteristics.
patient had an arthroscopic anterior Bankart The fourth group reflects
a relationship between
repair with capsular tightening. early atraumatic
instability, multiple disloca-
Surgery was used less often among patients tions, voluntary
instability, and poor outcome
with voluntary instability compared with those after surgical
treatment: patients with these fea-
without, a trend that approached statistical signif- tures did not do as
well with surgery in terms of
icance. Six initially conservatively-treated patients stability and function
at follow-up [1].
underwent secondary surgery at a different insti- Jones et al. [29]
retrospectively reviewed 32
tution. Surgically-treated patients were signifi- consecutive arthroscopic
Bankart repairs (ABR)
cantly less likely to report symptoms at final in 30 paediatric patients
with anterior shoulder
follow-up. Among patients with >2 years of fol- instability mainly after
trauma or sports activities
low-up, 9 % had recurrent instability; of these, two (17 males and 13 females;
average age 15.4
had dislocations and the remaining four had sub- years, range 1118; average
follow-up 25.2
luxations. Both of the patients with dislocation had months). Sixteen shoulders
failed initial non-
been treated with physical therapy alone at their operative therapy before,
whereas surgical
institution. One (4 %) of the 28 surgically-treated stabilization was the
primary treatment in
patients with >2 years of follow-up had recurrent 16 shoulders for patients
who were aiming to
dislocations. return to athletics. In the
initial non-operative
1170 J. Kircher and R. Krauspe
Fig. 6 (continued)
1171
Fig. 6 Supero-lateral arthroscopic view of a left shoulder fragment is shifted

upward and anteriorly into anatomic
(right anterior, left posterior, top inferior). The bony position (c). After
fixation of the suture at the glenoid edge
Bankart fragment is pierced with a left curved suture with a knotless
resorbable suture anchor (3.5 mm
lasso (Arthrex, Naples, FL) (a). Note the drill hole at Biopushlock ,
Arthrex, Naples, FL) the inferior glenoid
the glenoid edge on the left and an inferior fixation point surface is
anatomically restored (d). Note the absence of
already created. After retrograde passing of a non- knots or sutures at
the glenohumeral articulation to avoid
absorbable suture with a cinch-stitch (b) the bony cartilage damage
Hovelius reported
about a recurrence rate of
47 % for patients
with conservative treatment
after primary
shoulder dislocation in the age
group of patients of
1222 years after 2 years
of follow-up [78]. By
further sub-grouping into
the ages of 1214 and
1519 years there were
five males without
recurrence, one with recur-
rence and three
females without recurrence and
two with a
recurrences in the younger group.
In the older group
there were 22 males
without recurrence,
23 with recurrence and
five females without
recurrence and five with
recurrence. Patients
with a tuberosity fracture,
which were highest at
the age 1213 had
a significantly
better long-term prognosis
regarding stability
[79].
Fig. 7 Custom-made Gilchrist sling for very young At the 10 year
follow-up 63 % (initial conser-
individuals vative treatment with
a sling only) and 70 %
(immobilization with
the arm tied with
group, the average SANE score was 92.2 and a bandage to the
torso for 34 weeks) respectively
there were three shoulder re-dislocations in two of the 1222 year old
patients had at least one
patients (18.75 %). In the 16 shoulders treated recurrence. A history
of trivial trauma was found
with ABR as initial therapy, the average SANE in 71 % and a history
of violent trauma in 65 % of
score was 91.8, and there were two shoulder the patients with
recurrent dislocation in the
redislocations in two patients (12.5 %). group 1222 years at
that time [80].
1172
In the sub-group of patients at the age of In conclusion, there is

good evidence for
1216 years 38 % had had operative treatment a conservative treatment
approach in the first
after 10 years compared with 37 % of the line for acute traumatic
dislocations, except in
patients between 17 and 19 years. At the so- some special circumstances,
such as an
far final follow-up of the initial cohort of osteochondral injury,
additional severe ligamen-
patients in 2003, 26 % of the patients overall tous injury, locked
dislocation or the inability to
showed a moderate to severe dislocation keep a centred glenohumeral
joint. With modern
arthropathy (56 % if mild arthropathy was arthroscopic stabilization
techniques the Ortho-
included; this has a predictive value of 60 % paedic surgeon has an
armamentarium that
for progression into moderate to severe arthrop- should allow an anatomical
repair with minimal
athy during the next 15 years) [81]. Younger iatrogenic damage to the
joints in most cases and
patients (<25 years) had less arthropathy than we anticipate an increasing
number of surgical
older ones. In the age group 1216 30 % had interventions with favourable
short and long-
mild arthropathy and 70 % no arthropathy. In term success rates in the
near future.
the age group 1719 there were about 20 %
with moderate to severe arthropathy, about
30 % with mild arthropathy and about 50 % Pre-Operative Preparation and
without arthropathy which is better than all Planning
other groups consisting of older patients. Over-
all, surgically stabilized shoulders were less The pre-operative planning
begins with the iden-
likely to develop dislocation arthropathy. tification of additional
problems associated with
Shoulders that became stable over time had the apparent shoulder
instability. This is based on
more arthropathy than solitary shoulders (one a thorough clinical
investigation and diagnostic
dislocation only). The authors conclude that the imaging. The clinical
examination should include
trauma of shoulder dislocation has long-time both shoulders with the focus
on the amount and
biological effects on the joint physiology. direction of instability (see
above Aetiology and
There is a lot of information and conclusions Classification section).
to be drawn by this excellent longitudinal study There is a variety of
tests, such as the appre-
but it does not answer all of our questions. We hension test, re-location
test according to Jobe,
should keep in mind, that the study began more posterior and anterior drawer
test according to
than 30 years ago in 1978 and all patients were Gerber-Ganz, load and shift
test according to
initially treated conservatively. Since than, the Silliman and Hawkins and
tests for hyperlaxity
evolution of surgical techniques especially the such as the Gagey-test,
sulcus sign and the
arthroscopic stabilization techniques has been increase external rotation in
adduction [89]
tremendous. Therefore comparison of historical (Figs. 15). A special
interest should be focussed
studies (Table 1) and their recurrence rates must on the scapulo-thoracic
rhythm and signs of
be interpreted with caution. scapular dyskinesia [9093].
Risk factors for recurrent dislocations in A series of standard
radiographs (see Diag-
adults are a substantial bony defect of the glenoid nosis section) together with
MRI scans not older
>25 % [8385], hyperlaxity [83] and the pres- than 3 months are the
standard. The patient and
ence of a significant Hill-Sachs-lesion [83, 86]. the parents are informed
about the planned pro-
This is probably true for children and adolescents cedure, the length of the
hospital stay and the
too but has not been worked out so far. duration and modality of
post-operative rehabili-
Patients with a multi-directional instability tation, e.g. duration of
immobilization, the need
do respond well to a specific course of for braces or orthoses,
absences from school and
shoulder-strengthening exercise [87] although sports participation etc. The
operation should be
a number of patients continue to have long-term carefully timed to fit into
bank or school holidays
symptoms [88]. if possible [94].
Table 1 Clinical results of therapeutic intervention (surgical an non-surgical) for
shoulder instability in children and adolescents
Number of Mean age
Follow-up
Authors Year individuals Indication (range)
Treatment period Recurrence Outcome
Complications
Rowe [5] 1956 n8 <10 years
100 %
n 99 1020 years
92 %
n 107 <20
83 %
n 488 Shoulder 48 years
4.8 years 38 % n 27/500
(500 shoulders) dislocation (95 % (primary);
(5.4 %) nerve
anterior) 23 years
injuries (no
(recurrent)
sub grouping
for children)
Hovelius 1983 n 102 Primary <22 years
Non-surgical 2 years 47 %
[79] dislocation
Wagner [6] 1983 n 9 (10 Traumatic 13.5 year
8/9 patients closed 72 months 8% 6/8 underwent None
shoulders) anterior (1216)
reduction and (26135) secondary
dislocation
immobilization in stabilization
sling (Magnuson-
Stack, one
Bristow proc.)
Marans [8] 1992 n 21 (15 Traumatic n
9 patients no 6.5 years 100 % Most of the
boys) anterior shoulder
immobilization, (113) (average operated patients
dislocation n
12 time to returned to
immobilization redislocation preinjury activity;

4
6 weeks; 62 % 8 months) non-operated
open stabilization shoulders without
(12 Putti-Platt, 1 restriction of

Bristow) ROM, operated
loss of ER 1050#
Postaccini 2000 n 33 Primary anterior 1217 n
7 patients 7.1 years Traumatic Mean constant
[10] dislocation (75 %
surgical repair primary score (CS) 75 %
traumatic); 86 % (5
traumatic) dislocations (6596); operated
(continued)
1173
1174
Table 1 (continued)
Number of Mean age
Follow-up
Authors Year individuals Indication (range) Treatment
period Recurrence Outcome Complications
recurrent
age 1417 group 92 %; CS
dislocations
92 %; 71 % non-surgical
atraumatic
primary
dislocations
age 1416
86 %
Lawton [1] 2002 n 101 (107 21 % 13.2 n 40
patients Short-term 9 % recurrent 59 % no
shoulders) multidirectional, (416); initial
surgery, FU instability; 2 instability
16 % voluntary; 10 % < 10 n 2
secondary 624 months; dislocations symptoms, 31 %
62 % Hill-Sachs years surgery;
variety of long-term FU (initially apprehension,
lesion techniques
221 y non-surgical) 6 % subluxation,
(Bankart
repairs 3 % recurrent
with capsular
shift dislocation; 25 %
in 11 (39 %),
instability
Bristow
symptoms after
procedures in
5 surgical treatment
(18 %), Putti-
Platt vs. 51 % non-
procedures in
3 surgical; surgical:
(11 %),
capsular more likely for
shift in 3 (11
%), self-rated
Bankart repair
improvement
alone (no
capsular
shift) in 1 (4
%),
one patient
with
arthroscopic
anterior
Bankart
repair with
capsular
tightening)
Deitch [60] 2003 n 32 1118 n 16
operated 4 years (114) 0.75 Outcome scores
similar for

Traumatic
patients for
anterior shoulder
surgical and non-
dislocation
surgical patients
Lefort [82] 2004 n 29 Voluntary 515 years n 8 with
8 years (710) No n 11 rehab
dislocation; posterior
without
n 15 posterior
capsulorrhaphy; improvement
dislocations; n 3
anterior after 8 months; all
uncertain laxity
capsulorrhaphy stable, ROM
and
normal, sports
multidirectional
resumed
instability
Jones [29] 2007 n 48 (30 Failed 1118 years
Arthroscopic 24 months Primary
reached for FU) conservative Bankart
repair surgery: 2/16
treatment for
(12.5 %)
athletes; 27
redislocation
traumatic
(1 wrestler);
dislocations
secondary
during sports, 3
surgery: 3/16
falls; 1 girls
(18.75 %)
bilateral
redislocation
multidirectional
(2 hyperlax)
instability
1175
1176
tendon with respect to the

angulation to the
Operative Technique glenoid surface for possible
placement of suture
anchors. A probe is
introduced into the joint and
We describe an arthroscopic technique for pri- every structure and
compartment visualized and
mary surgical stabilization which today is the probed if necessary. Rotation
of the humerus
standard of care at our institution. The patient is brings all aspects of the
joint cartilage into the
put in a lateral decubitus position with the field of view and the amount
of engagment of any
affected arm pointing upwards and fixed in Hill-Sachs-lesion is
quantified. The amount of
a lateral and axial arm extension of 3.5 kg and any anterior glenoid bony
defects can be mea-
1.5 kg respectively. The traction needs to be sured with the probe. The
estimation of bone loss
adjusted to the patients age and constitution and can be facilitated if the
centre of the inferior
the amount of laxity of the shoulder. Prolonged glenoid surface is detected
(so-called bare
shoulder traction can cause brachial plexus dis- spot, Tubercle of Assaki
[95]) and the posterior
turbance which usually spontaneously dissolves radius is taken as a
reference for the entire sphere
but should be avoided. A standard intra-articular of the inferior part of the
pearl-shaped glenoid.
pressure of 50 mmHg usually is sufficient If an injury to the upper
labrum and biceps
throughout the procedure. anchor complex (SLAP lesion)
is noted, we sug-
We suggest a watertight draping to avoid the gest starting with the SLAP-
repair. An additional
patient being drenched which could lead to hypo- antero-lateral portal is
created which usually lies
thermia and problems with electrical devices. close to the antero-lateral
tip of the acromion
This can be accomplished by the use of a well entering the joint in the
interval region between
fixed rubber-like first layer and a second layer of the supraspinatus and
subscapularis tendon just
heavy draping. above the long head of the
biceps tendon (Fig. 8).
Bony landmarks (border of acromion with The superior glenoid rim
is mobilized with
posterior corner, clavicle, ac-joint, coracoid pro- a Bankart chisel and rasp or
shaver and debrided
cess) are marked with a pen. We start with down to bleeding bone to
enhance
a posterior portal which usually is located more fibroligamentous healing of
the repaired labrum
laterally and distally compared to standard (Fig. 9). We prefer the use
of absorbable knotless
posterior portals with respect to the changed suture anchors at this
location. The guiding
position of the glenohumeral joint under arm instrument is placed at the
upper glenoid rim
traction. After a thorough inspection of the joint just at the border to the
cartilage and a bone
in all parts tunnel is created with a
drill with angulation
Superior: SLAP-complex, biceps tendon, into the good bone stock away
from the joint
supraspinatus and infraspinatus tendon surface. The superior labrum
is pierced with
Central: joint cartilage; anterior: anterior a Suture-lasso (Arthrex,
Naples, FL) or other
labrum, Malgaigne or reversed Hill-Sachs devices and a partially-
resorbable suture
lesion, subscapularis tendon, glenohumeral (Orthocord, Johnson & Johnson
Medical,
ligaments, GLAD lesion Norderstedt, Germany) is
passed in a retrograde
Inferior: labrum, joint capsule, inferior fashion as a loop. The free
ends of the loop are
glenohumeral ligaments; posterior: labrum, grasped with a suture
retriever and put through
posterior inferior glenohumeral ligament, the loop resulting in a self-
locking cinch-stitch
Hill-Sachs lesion, teres minor tendon around the labrum (Fig. 6b).
Peripheral: joint capsule, HAGL lesion. The suture end is passed
in the eyelet of the
The decision for the kind of surgical therapy anchor, the tip of the anchor
device is put into the
and the strategy in terms of the chronological bone tunnel via the antero-
lateral portal, and
order is then made. the suture is finally
tensioned again and locked
We establish an antero-inferior portal and in the bone tunnel by the
Biopushlock-anchor
a twist-in cannula just above the subscapularis (Arthrex, Naples, FL).
1177
Fig. 8 Arthroscopic view from a posterior portal of SLAP-repair and an

anterior working and shuttle portal
a right shoulder. Note the antero-superior portal just with transparent twist-in
cannula
above the biceps tendon and the SLAP complex for
The sutures are cut as close as possible. The position with bleeding of
the anterior glenoid
same procedure needs to be repeated anteriorly to neck surface a solid basis
for the following re-
the biceps anchor if the lesion extend further fixation is achieved.
anteriorly with a second anchor. The bone tunnel As described above,
most of the lesions are
then usually can be placed more easily from ante- Bankart lesions and
anterior capsulo-ligamentous
riorly. Care should be taken not to violate the labrum repair is
sufficient to stabilize the joint.
rotator cuff with the used instruments by using We prefer double-loaded
threaded absorbable
the antero-lateral portal. The use of an additional suture anchors for this
procedure. The guiding
cannula, which can be used as a tunnel through the device is placed at the
very edge of the glenoid
subacromial space, can be helpful in special cases. rim (rather to the joint
surface than away from it)
After a final check of the stability of the repair and the bone tunnel is
created through the ante-
the arthroscope is switched to the antero-lateral rior portal. By using the
3.5 mm BioFasttak
portal by using two switching sticks (antero- anchor (Arthrex, Naples,
FL) the cortex is
lateral and posterior). After visualization is punched and a thread is
created. The suture
established another transparent twist-in cannula anchor is threaded in and
checked for stability
is inserted from posteriorly. The entire antero- by a powerful pull. We
start placing the most
inferior labrum can be assessed at this time inferior anchor first at
the five-oclock (or seven
(Fig. 11a, b). It needs to be pointed out, that the oclock position for a
left shoulder). Care should
judgement of labrum lesions cannot be made be taken to find the right
angulation away from
from a solitary posterior portal alone, especially the joint surface and to
avoid penetration out of
not for retracted tissue as described for ALPSA the glenoid bone stock.
This can be simulated by
(anterior labrum periosteal sleeve avulsion) a switching stick before.
If the right angulation
lesions. The entire antero-inferior capsulo- cannot be achieved, the
portals need to be
ligamentous complex is mobilized with the adjusted. A deep 5-oclock
portal has been
Bankart knife, meniscus punch and shaver until described with the
advantage of better angulation
the glenoid neck becomes visible (Fig. 9a, b). The but iatrogenic injury to
the muscular part of the
joint distension by the arthroscopy pump can be subscapularis is possible
and therefore it is not
stopped at this time to check for completion of routinely used by the
authors [96].
mobilization: if the capsulo-ligamentous com- The sutures are parked
at the posterior portal
plex spontaneously moves in an anatomical and an additional suture
anchor is placed at the
1178
Fig. 9 Arthroscopic view from superior of a left shoulder (6 oclock) (b) until
full separation and the ability to
with a bony Bankart lesion. The labrum with the bony shift the capsule
together with the fragment upward into
fragment is mobilized using an arthroscopic Bankart knife an anatomic position
(a) down to the inferior pole of the glenoid surface
4-oclock position in the same manner. The suture ends can be put
as a second mattress stitch
antero-inferior capsulo-ligamentous complex is in line with the first,
as an interlocking stitch or in
pierced with the 45# Suture-lasso (Arthrex, a modified Mason-Allen-
technique (Fig. 10).
Naples, FL) (left angulation for a left shoulder) The individual
stitch configuration depends on
from the antero-inferior portal and one of the the surgeons
preferences and more on the quality
dorsally parked sutures is passed through the of the soft tissues.
The less mechanical strength the
capsulo-ligamentous complex in a retrograde tissue provides the
more the surgeon must think
fashion anteriorly. The associated suture-end is about the right stitch
configuration. In cases of
passed in a similar fashion leaving a sufficient very poor tissue
quality, self-locking loop-stitches
soft tissue bridge to prevent pullout of the suture can be used which takes
more time and attention to
resulting in a mattress stitch. The second pair of place them (Fig. 11a
c). As a general rule there is
1179
Fig. 10 Result after knot-tying of two retrograde shuttled non-absorbable sutures

creating a new bumper by two
mattress sutures
the need for an upward shift of the capsulo- and removal of the
instruments for antero-inferior
ligamentous complex because of the retraction uni-directional
instability without hyperlaxity
which is part of the pathology. The amount of (Gerber type II). All
cases with multi-directional
shift needs to be adjusted to every individual instability and remarkable
hyperlaxity may need
case by the appropriate amount, which is based an additional inferior or
postero-inferior capsular
on the experience of the surgeon, and a well ten- shift to stabilize the
joint.
sioned antero-inferior glenohumeral ligament. By For cases without
injury to the labrum and an
using the 4-oclock anchor first for placing the intact fibrous limbus we
prefer the modified arthro-
sutures the upward shift is facilitated and an addi- scopic technique according
to Snyder (Fig. 11ac).
tional shift and placement of the most inferior The amount of shift
depends on the patients
sutures are made much easier. The disadvantage age, the history of
shoulder dislocation and the
of this technique is the nescessity for a careful pre-operative clinical
examination, especially the
suture management to avoid knotting. amount of hyperlaxity
and/or hypermobility.
The third anchor is placed at the 3-oclock There are no established
landmarks to help the
position in a similar fashion. As shifting of the surgeon except the
posterior inferior glenohumeral
capsulo-ligamentous complex already is accom- ligament and its amount of
tension and the general
plished, the placement of these sutures is easier. additional stability
achieved by placing sutures
Care should be taken not to inadvertently grasp and anchors which more and
more limits the abil-
the medial glenohumeral ligament at this point ity to visualize the
inferior aspects of the joint. The
which can lead to a reduced ROM post-opera- traction can be released
to test for joint stability at
tively. In our opinion it is very rarely necessary to this time but joint play
is altered by the preceding
put suture anchors more cranial to that position. surgery and distension.
Care should be taken not to
The additional closure of the rotator interval is inadvertently injure the
joint surface at this time
reserved for exceptional cases because the con- with the arthroscope in
the more and more
tribution to stability is low and external rotation is narrow joint. The used
suture material should
frequently limited by that procedure [9799]. be resorbable or partially
resorbable to avoid
After inspection of the result and thorough mechanical irritation of
the joint surface over
probing the operation can be finished at this time. Although we do
believe in the longevity of
time with photo and/or video documentation our stabilizing
procedures, a number of those
1180
Fig. 11 Illustration of antero-inferior capsular shift for through the inferior

capsule and the intact labrum using
multi-directional instability with hyperlaxity. Arthro- a 90# curved Suture
lasso (Arthrex, Naples, FL) with
scopic view from superior of a right shoulder. Partially a modified loop stitch
(a). After completion of the inferior
absorbable sutures (Orthocord , Johnson & Johnson Med- capsular shift (b) the
anterior labral suture repair and
ical, Norderstedt, Germany) are retrograded passed capsular shift is
completed (c)
1181
sutures may cut through the tissue or get loose by

time which are sometimes found during revision Summary
surgery.
Shoulder instability is
a common problem in
children and adults.
Surgical therapy very
Post-Operative Care and rarely is necessary
under the age of 12 but
Rehabilitation becomes more frequent
during adolescence.
During that period the
number of violent trau-
The patient is rested in a Gilchrist sling for the first matic events increases
and boys are more
2 days with early passive mobilization (pendulum frequently affected than
girls. Surgical stabili-
self exercises, physiotherapy) starting at day one. zation results in higher
amounts of long-term
We usually use an additional abduction splint for success in preventing
redislocation. Hyperlaxity
the first 3 weeks. During that time passive exer- should always be taken
into account in deci-
cises are performed with limitation of 60# flexion sion-making about
surgical therapy. The indi-
and abduction and neutral external rotation. cation for surgery
treating multidirectional
Lymph drainage can be added as necessary but instabilities should be
made with special care
manual therapy and joint mobilization techniques and a course of specific
physiotherapy must be
by the therapist are avoided. After 3 weeks the an important part of any
treatment plans
patient begins with active-assisted exercises in regardless the decision
for surgical therapy.
the pain-free interval with the same limitation for
ROM. After 5 weeks ROM can be increased to 90#
of flexion and abduction. After 6 weeks the patient References
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Frozen Shoulder
Tim Bunker and Chris Smith
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1185
Clinical features # Frozen # Shoulder #
Incidence # Investigations-arthrography,
Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1186
arthroscopy, surgical features # Natural history

Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1186 # Pathology and cytogenics # Terminology #
Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1186 Treatment-steroids, physiotherapy, manipula-
tion, arthroscopic release

Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1187
Symptoms and Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1187
The Condition Comes on Slowly . . . . . . . . . . . . . . . . . .
1188
Painful and Incomplete External Rotation . . . . . . . . .
1188 Introduction
Limitation of the Spasmodic and Mildly
Adherent
Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1188 Until recently Frozen shoulder has been an Ortho-
Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1189 paedic enigma. It is only in the last decade that the
Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1189 histopathology has been described and this has
Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1189 unlocked the pathway towards successful surgical
Blood Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1190
treatment. However although the Orthopaedic sur-

Surgical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1190 gical profession now understands much more
Pathology of Frozen Shoulder . . . . . . . . . . . . . . . . . . . 1191
about this disease, this evidence has not trickled
down to primary care physicians and allied health

The Basic Science of Healing
and Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1192 professionals, let alone the world-wide-web and,
at the end of the chain, the patients. Although we

The Cytogenetics of Frozen Shoulder . . . . . . . . . . . 1194
now understand a lot about the natural history of

Treatment of Frozen Shoulder . . . . . . . . . . . . . . . . . . .
1194 this condition, its associations, the arthroscopic
Steroid Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1195
Physiotharapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1195
appearance of the shoulder, the histopathology,

Manipulation Under Anaesthetic . . . . . . . . . . . . . . . . . .
1195 molecular biology, genetics and evidence-based
Arthroscopic Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1195 treatments there are still many things that we do
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1197 not understand. For instance what is the trigger
that leads to the cascade of inflammation and

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1197
then fibrosis of the joint? Why should it occur in
late middle life, but not in the young, nor the old?
Why should it be associated with diabetes and
Dupuytrens contractures? Why do some respond

T. Bunker (*) # C. Smith
well to treatment, but not others? There is a great
need for on-going research into this condition.

1185
DOI 10.1007/978-3-642-34746-7_75, # EFORT 2014
1186
T. Bunker and C. Smith
and painful shoulder. When

Hazelman performed
Terminology arthrograms of 36 patients
diagnosed as frozen
shoulder 40 years ago,
eleven had complete tears
All agree that this is a condition that presents with of the rotator cuff. So of
that study 30 % were
pain and stiffness in the shoulder. The pain is proven misdiagnosed, and
probably 50 % were
unremitting true shoulder pain, excruciating actually overdiagnosed.
Studies in the UK
when the shoulder is jerked, and severe enough 30 years ago showed that
only 50 % of patients
to awaken the patient at night, and often many referred as having frozen
shoulder actually had
times at night. Stiffness gradually appears, after visual/tactile evidence of
the disease (50 %
the onset of the pain, such that in the early stages overdiagnosed), and
studies from Canada
before the stiffness has become apparent the 20 years ago showed that
only 37 of 150 patients
condition can be confused with impingement, referred with the
diagnosis of frozen shoulder
calcific tendonitis and rotator cuff tears. The stiff- actually had the proper
diagnosis (76 %
ness causes global passive limitation to joint overdiagnosed). It is
doubtful that primary care
movement with a firm end-point to movement. physicians and allied
health professionals do any
Rotation might be stiffer than elevation, the key better today! The authors
repeated studies on
being external rotation less than 50 % of the frozen shoulder (all
verified by arthroscopy) show
unaffected side. The condition can be mimicked that it only accounts for
5 % of shoulder disease,
by calcific tendonitis, the late stages of cuff tear- and since shoulder disease
affects, at most, 15 %
ing and arthritis, but the radiographs are normal of the population then it
would be reasonable
in frozen shoulder and abnormal in all the condi- to suggest that the real
incidence of capsular
tions that mimic it. contracture is about 0.75
% of the population.
2009 was the 75th anniversary of the introduc- Frozen shoulder is said
to be more common in
tion by Codman of the term frozen shoulder. females. A recent meta-
analysis quotes 25 papers
Frozen shoulder is termed adhesive capsulitis on frozen shoulder that
studied 935 patients
in the United States of America, although it turns where 58 % were female.
However most of the
out to have no adhesive nor adhesions. The recent studies with
arthroscopic control showed
French call it capsulite retractile, although, in a ratio of 1;1 male to
female, and it was the more
fact, the capsule turns out to be contracted rather historic papers that
showed a higher preponder-
than retracted. The Germans call it ance of female patients.
Steiffschulter, which is honest, but perhaps
too basic, and the Japanese call it fifty-year old
shoulder. Over the last 20 years a large body of Natural History
research has built up that allows us to understand
and treat this common, enigmatic, protracted, The disease follows a
distinct course, starting
painful and disabling condition. Perhaps it is with pain and night
awakening. Jerk pain is
now time to reflect on the progress that has been never mentioned in the
text-books, but if you
made over the last two decades into understand- enquire many patients will
describe a jerk to the
ing and successfully treating this disease. contracted shoulder
bringing tears to the eyes.
The painful phase merges
into the stiffening
phase. Finally there is a
phase of resolution in
Prevalence all but 10 % of patients.
The course of the disease
is very variable, but
follows a Gaussian distribu-
The condition is less common than the oft-quoted tion, some recovering
quickly, some very slowly
figure of 2 % of the population. This figure and 10 % very, very
slowly, if ever.
was arrived at 40 years ago when shoulder Codman stated even
the most protracted
disease was ill-understood and frozen shoulder cases recover with or
without treatment in about
was used as a dustbin diagnosis for any stiff two years. Once again
this statement has been
Frozen Shoulder
1187
handed down from author to author without any but this proved to be the
same as the control
questioning of the evidence. This has led to the group. Our own study of 100
arthroscopically-
commonly held and false view that this is proven frozen shoulder
patients has demon-
a benign condition that resolves completely. strated a significantly
higher incidence of
Many eminent surgeons who have researched diabetics (24 %) compared to
an age- and sex-
this disease have pleaded that complete resolu- matched control group.
Another recent study
tion is not inevitable, but their pleas have fallen showed that the prevalence of
diabetes in
upon deaf ears. Simmonds stated complete patients with frozen shoulder
was 32.9 %. Care
recovery is not my experience and DePalma must be taken in interpreting
studies of type
stated it is erroneous to believe that in all I diabetics, for some studies
look at young
instances restoration of function is attained. patients with an average age
of 30, when frozen
Shaffer et al. [71] in the most detailed follow-up shoulder rarely presents
until the magic age of
study in the literature found that at 7 years 50 % 50. Even in the 30 year-old
diabetics 10 %
had mild pain, stiffness or both. They found that already had a contracted
shoulder.
60 % has measurable restriction of passive mobil- The link with Dupuytrens
disease is robust.
ity and they concluded this made us question Meulengracht and Schwarz
found evidence of
whether this is a benign self-resolving condi- Dupuytrens disease in 18 %
of their patients
tion. Griggs et al. confirmed these findings and with frozen shoulder. Schaer
found that 25 % of
stated that even amongst the patients who were their patients with frozen
shoulder had
satisfied, a substantial number were not pain Dupuytrens contracture. We
studied a group of
free; 10 % had mild pain at rest, and 27 % had 56 patients with contracted
shoulder and found
mild or moderate pain with activity. 40 % of the evidence of Dupuytrens
disease, often in a minor
satisfied patients had abnormal shoulder function. form such as pits and
nodules, in 52 % of our
Our own studies at 25 years showed that patients. This terrible
triad of contracted shoul-
although 86 % had an improvement in their der, Dupuytrens contracture
and diabetes
level of pain, this did not mean that they had no pervades this whole area of
scientific enquiry.
pain. Only 53 % had no pain, 33 % had an occa- Thyroid disease, high
cholesterol and cardiac
sional pain and 14 % had marked residual pain. disease have been said to be
associated with fro-
These findings have been confirmed by the larg- zen shoulder but we found
that the incidence was
est ever study from Oxford on 273 patients similar to an age- and sex-
matched control group.
followed for up to 20 years. Using the Oxford This probably means that
thyroid disease, high
Shoulder Score they demonstrated that 41 % of cholesterol and cardiac
disease are found in
their patients had mild to moderate persistent 50 year-old people, but are
not associated with
symptoms at 7 years and 6 % had severe on- frozen shoulder.
going symptoms with pain and functional loss.
Symptoms and Signs

Associations
Codman was an extremely
astute clinician, and
Many other diseases have been linked to shoulder a keen observer, so he was
able to define this
contracture, yet only two, diabetes and condition very precisely. He
stated that these
Dupuytrens disease withstand scientific scru- patients have 12 features in
common. The con-
tiny. A recent controlled study showed that dition comes on slowly; pain
is felt near the
29 % of patients with a contracted shoulder had insertion of deltoid;
inability to sleep on the
diabetes and that this was significantly elevated affected side; painful and
incomplete elevation
over the control population. This same study and external rotation;
restriction of both spas-
showed that the prevalence of thyroid disease in modic and adherent type;
atrophy of the spinati;
the patients with contracted shoulders was 13 %, little local tenderness; X-
rays negative except for
1188
Table 1 Codmans 12 criteria for frozen shoulder This association with minor
trauma is well
1. The condition comes on slowly; known to all Orthopaedic
surgeons who, for
2. The pain is felt near the insertion of deltoid; instance, always caution
patients with a Colles
3. There is inability to sleep on the affected side; fracture to keep the
shoulder moving lest they
4. There is painful and incomplete elevation develop a frozen shoulder.
Surgery may be another
5. and external rotation; initiating factor, for
instance breast surgery, and it
6. There is restriction of both spasmodic had been thought that it
was the immobilization,
7. and adherent type; which led to the
development of the frozen shoul-
8. Thereis atrophy of the spinati; der, but you will see, as
our story unravels, it is
9. There is little local tenderness; more likely the molecular
response to the injury or
10. X-rays are negative except for bony atrophy;
surgery that is
responsible.
11. The pain was very trying to every one of them;
12. But they were all able to continue their
daily habits and routines.
Painful and Incomplete
External
Rotation
bony atrophy; the pain was very trying to every We now come to the first
distinguishing feature of
one of them; but they were all able to continue frozen shoulder, which is
limitation of external
their daily habits and routines. (Table 1). rotation. There are only
four shoulder conditions
Unfortunately, he did not go on to analyse that restrict external
rotation;
each of these 12 symptoms and signs in detail, Arthritis, locked
posterior dislocation, the late
as he did when discussing the 18 features of stage of a massive cuff
tear and frozen shoulder.
rotator cuff tear, for, had he done so, he could All of these have specific
radiographic changes.
well have solved the enigma forthwith. Arthritis shows diminution
of joint space, inferior
One of the frustrations of frozen shoulder is osteophytes, sclerosis and
occasional cysts;
that it shares many features with those far more locked posterior
dislocation shows a light bulb
common shoulder disorders, impingement, par- sign on the
anteroposterior film and posterior
tial-thickness and full-thickness rotator cuff dislocation on the axillary
view; massive cuff
tears. In particular, its onset, the site of pain, tear shows upward
subluxation of the head with
awakening at night, restricted elevation and mus- a break in Shentons line
of the shoulder and
cle spasm are all found in rotator cuff disease; irregularity of the greater
tuberosity; whilst fro-
although I would disagree with Codman about zen shoulder shows an
entirely normal radio-
wasting, for this is rarely seen in frozen shoulder, graphic appearance of the
shoulder.
whilst it is commonly seen in cuff disease. This
has led to frozen shoulder being a diagnosis of
exclusion. So, let us look critically at three Limitation of the Spasmodic
and Mildly
aspects of Codmans definition, for they hold Adherent Type
the key to the condition.
Terminology has changed and
we would now
state limitation of active
and passive move-
The Condition Comes on Slowly ment. The key to the
puzzle is the limitation
of passive movement that,
in the shoulder, can
This does not get us far, for there are many only be caused by two
things: firstly, irregularity
disorders of the shoulder such as impingement, of the joint surface, as is
found in arthritis and
which are far more common, and also come on locked dislocation; and
secondly, contracture of
slowly. Codman had noticed that they usually the ligaments that bind the
humerus to the
give a story of slight trauma or overuse. glenoid. Certainly, if you
are going to be
Frozen Shoulder
1189
pedantic there are some rare muscular condi- pathological changes occur
under the coracoid
tions, such as deltoid contracture (a handful of process, and ultrasound can
not see through bone.
cases in the world literature), which also cause
restricted passive movement, but in pragmatic
terms, if the radiograph is normal and the joint Arthroscopy
shows passive restriction, then this can only be
caused by contracture of the ligaments. The lig- There have now been
numerous studies that have
aments contract in the late stages of massive detailed the arthroscopic
findings in frozen shoul-
rotator cuff tears and in frozen shoulder. There- der. In the early stages
the major finding is angio-
fore frozen shoulder is caused by contracture of genesis, or new blood
vessel formation (Fig. 1).
the ligaments of the shoulder capsule. Indeed, as This can be quite
spectacular with fan- shaped
our story unfolds, you will see that this is, in areas of blood vessel
formation, vascular fronts,
fact, the case. So Codman actually had the solu- petechial haemorrhages and
even glomeruli.
tion within his grasp, and if only he had realized Within the infraglenoid
recess the vessels line
this and called the condition Contracted shoul- up in a radial fashion that
we term the lava
der, instead of frozen shoulder, three genera- flow. Granulation tissue
that is red, highly vas-
tions of Orthopaedic surgeons would have been cular, with a villous or
fronded appearance of the
spared from puzzling over this elusive synovium occurs in the
rotator interval area.
condition. Angiogenesis occurs on the
adjacent glenoid
labrum, as well as around
the base of the long
head of the biceps tendon.
The granulation tissue
Investigation may extend on to the top
surface of the
subscapularis tendon, and
on to the anterior
Radiology edge of the supraspinatus
tendon. It is interesting
that angiogenesis is a
feature of diabetes for fro-
Radiographs, as we have said, are normal in zen shoulder is common in
diabetics.
frozen shoulder. However the arthrogram is In the late stages the
angiogenesis diminishes.
pathognomonic. Neviaser performed arthro- The joint is less red, but
thick bands of scar tissue
grams on the shoulders of patients with frozen can be found obliterating
the normal structure of
shoulder and showed that the capsule of the the capsule. The superior
gleno-humeral liga-
shoulder is contracted. The joint has ment becomes thickened,
obliterating the rotator
a diminished volume, there is absent filling of interval. Scar can cover
the top edge of
the infraglenoid recess, and the subscapular subscapularis, and we term
this the involu-
recess and bicipital tunnel are obliterated in fro- crum. Occasionally long
head of biceps can be
zen shoulder. It is rare to do arthrograms these scarred to the cuff. The
middle gleno-humeral
days unless as part of an MRA (MR arthrogram). ligament is thickened, as
indeed is the whole of
Magnetic resonance imaging (MRI) has the capsule.
not shed much further light on the condition. The joint surface is
usually normal. There are
Emig et al. described thickening of the joint capsule no intra-articular
adhesions in this condition,
and synovium in frozen shoulder. Tamai et al. 4 a fact that has been
documented in eight recent
have described a technique of gadolinium- arthroscopic studies on
frozen shoulder.
enhanced dynamic MRI, which has shown an The joint volume is
reduced, making insertion
increased blood flow to the synovium of the shoul- of the arthroscope and
navigation around the
der in frozen shoulder. contracted joint difficult.
As was found arthrogra-
Ultrasound can show thickening of the phically, the infraglenoid
recess is contracted,
coracohumeral ligament and increased blood and the synovium is
moderately inflamed in this
flow on Doppler ultrasound. However the worst area as well.
1190
Fig. 1 Angiogenesis seen

arthroscopically in frozen
shoulder
Blood Tests not in the tendon below it.

He does not state
whether he ever opened the
shoulder joint itself.
The full blood count, white cell count and ESR are Neviaser reported on ten
patients with frozen
all normal in this condition. CRP may be elevated shoulder upon whom he had
operated. He
in the early stages. Calcium, phosphate, serum approached the shoulder
using a deltopectoral
globulins and bone alkaline phosphatase are all approach, incising
subscapularis vertically to
normal. Cholesterol and triglycerides may be ele- give a good view of the
capsule.
vated in frozen shoulder but clearly this is not The capsule he found to
be thickened, adherent
a specific test. However, what is interesting is to the humeral head and,
when it was released, it
that cholesterol and triglycerides may also be ele- was found to be under such
tension that it sprung
vated in that other contractile disease, Dupuytrens apart and could not be re-
approximated. Although
contracture, one of many associations shared by he never mentioned the word
contracture, his
these two contractile diseases. description speaks for
itself. Simmonds described
the rotator cuff as looking
like a vascular, leath-
ery hood with no obvious
demarcation between
Surgical Findings the tendons. We now term
the demarcation
between the tendons the
rotator interval. The
Codman was probably the first to surgically rotator interval is the
triangle formed between
explore the frozen shoulder. He stated, I used supraspinatus and
subscapularis, the base being
to give ether and open the (subacromial) bursa. the coracoid process.
Normally, the capsule here
The appearance of the floor of the bursa was is quite thin, being
strengthened by the superior
always the same - a congestion over the glenohumeral ligament, and
also by the
supraspinatus tendon on the base of the bursa coracohumeral ligament,
which runs from the
like that of a bloodshot eye. Adhesions were base of the coracoid process
to the biceps sulcus,
often found. The congestion was in the synovia, the area between the lesser
and greater tuberosities
Frozen Shoulder
1191
of the humerus. This, remember, is the area that coracohumeral ligament became
taught and
appears so abnormal at arthroscopy, being obliter- stood out as a palpable
thickening (DePalmas
ated with granulation tissue. DePalma stated that checkrein), often as thick as
the surgeons little
The coracohumeral ligament is converted into finger. When the tissue was
incised it bled, often
a tough inelastic band of fibrous tissue spanning forcefully, and was found to
be very adherent
the interval between the coracoid process and the (Neviasers adherence) to the
underlying long
tuberosities of the humerus. It acts as a powerful head of biceps, and the
incision was accompanied
checkrein . . . division of the coracohumeral liga- by release of the passive
restraint to gleno-
ment allows early restoration of scapulohumeral humeral external rotation (as
stated by Neer and
movement. This is truly the most elegant descrip- Ozaki). Surgical release gave
us the ability to
tion of a contracture of the coracohumeral liga- inspect the tissue
histologically.
ment. DePalma was clearly a hairsbreadth away
from resolving the enigma of frozen shoulder
when he got distracted by the long head of biceps, Pathology of Frozen Shoulder
and concluded that tethering of biceps was the
cause of frozen shoulder. In 1995 we examined the
tissue excised from the
Lundberg exposed the shoulder in 20 patients rotator interval area of
twelve consecutive
with frozen shoulder. He noted peri-articular patients with severe frozen
shoulder. Macroscop-
inflammatory changes, especially at the insertion ically, the tissue was an
inextensible nodular
of the cuff on to the greater tuberosity. In six fleshy band. Histological
examination of the tis-
patients, he performed an arthrotomy and found sue showed a background
matrix of dense colla-
thickening of the capsule and no intra-articular gen, arranged in nodules and
laminae (Fig. 2).
adhesions. Neer stated, The senior author has The cell population was
moderate to high.
found that in pathological conditions such as fro- The samples were prepared
for immunocyto-
zen shoulder, old fractures, or arthritis, the chemistry to demonstrate
precisely what type of
coracohumeral ligament may become shortened, cell was present. This
staining showed that the
and may have to be released at surgical reconstruc- cells were fibroblasts (Fig.
3), with some transfor-
tion to restore external rotation. mation to the contractile
fibroblast that has been
Ozaki surgically explored 17 patients with termed the myofibroblast.
The samples showed
recalcitrant chronic frozen shoulder and stated, that the tissue was
particularly vascular. As for
At operation, the major cause of the restricted inflammatory cells, none was
present within the
glenohumeral movement was found to be con- thick collagen of the
contracture itself, but some
tracture of the coracohumeral ligament and rota- were present both in the
synovium and around
tor interval. Release of the contracted structures blood vessels. Such an
appearance, of a dense
relieved pain and restored motion of the shoulder collagen matrix, populated by
fibroblasts and
in all patients. myofibroblasts, can be found
in healing scar tissue
In a consecutive series of 25 patients with and in contracture. This
appearance is very similar
severe frozen shoulder, which had failed to to the palmar contracture of
Dupuytrens disease.
resolve with manipulation, we found Historically Neviaser
examined his tissue
a consistent abnormality of the coracohumeral microscopically and found
considerable or exten-
ligament and rotator interval area. This area of sive fibrosis in 6 of 10
cases. Simmonds reported
the capsule was abnormal, thickened and vascu- dense collagen fibres,
increased vascularity and
lar. There seems to be new vessel formation the presence of fibroblasts.
DePalma found fibro-
(much like Codmans bloodshot eye). The thick- sis, increased vascularity,
thickening of the syno-
ening prevented easy determination of the edges vial membrane and cellular
infiltration. Despite
of the rotator interval (Simmonds, no the evidence of fibrosis, all
three authors con-
obvious demarcation). When the shoulder was cluded that the changes
represented low-grade
forced into external rotation the contracted inflammation.
1192
Fig. 2 Pathology shows

bands and nodules of
type III collagen
appearance of this
contracture with palmar con-
tracture, although he
attributed the idea to his
pathologist Norden. Kay and
Slater also noted
the resemblance between the
histology of shoulder
joint capsule in frozen
shoulder and the palmar
contracture of Dupuytren.
Ozaki noted fibrosis in
their tissue, and Hannifin et
al. found diffuse cap-
sular fibroplasia, thickening
and contracture.
In the modern era,
further to our immunocyto-
chemical studies, Killians
group have confirmed
the presence of fibroblasts
laying down collagen
within the capsule. They
performed electron
microscopic studies showing
that the collagen
structure was grossly
abnormal with thickened
fibrils in the frozen
shoulder group. Carrs group
from Oxford confirmed the
presence of fibroblasts
laying down collagen. Like us
they found some
inflammatory cells, but they
have also shown the
presence of mast cells and
postulate that these cells
may be modulating some
inflammatory process
that triggers the
fibroblastic response.
The Basic Science of Healing

Fig. 3 Vimentin stains for fibroblasts and Contracture
The healing process is

divided into three phases:
Lundberg reported a compact, dense capsule an early inflammatory phase;
a repair phase with
with an increase of cells that were fibroblasts; he the formation of granulation
tissue; and finally
was the first to mention the similarity of the scar formation, maturation
and contracture.
Frozen Shoulder
1193
Contracture may be physiological, when the Hamada, in Japan, has

found increased levels of
healing wound contracts to pull the wound vascular endothelial growth
factor (VEGF) in stiff
edges into apposition, or it may be pathological, shoulders that may account
for the angiogenesis
where there is an imbalance between scar forma- that is seen at arthroscopy.
Ryu et al. demonstrated
tion and remodelling, resulting in abnormal scar- strong expression of VEGF and
angiogenesis in
ring and contracture. It is the late stages of diabetic frozen shoulders.
Killian et al. showed an
healing, the formation of granulation tissue, scar increase in alpha-1(I) mRNA
transcription in both
formation, contracture and remodelling that hold frozen shoulder and
Dupuytrens contracture.
the key to understanding the molecular biology of Since Insulin-like growth
factor is known to stim-
frozen shoulder. ulate fibrosis in connective
tissue they measured
Fibroblasts are controlled by certain cyto- the serum IGF-1 and IGF-1
receptor levels but
kines. Cytokines are peptide molecules that act found them to be similar in
contracted shoulder
as cell messengers. They control many aspects and control capsule.
of cell migration and growth, acting in minute Patients with palmar
contracture also have
concentrations by binding to receptors on the elevated levels of cytokines
and growth factors,
target cell. Cytokines regulate fibroblast which, although not identical
to those changes
chemotaxis, fibroblast proliferation and colla- found in frozen shoulder,
show a higher intensity
gen synthesis. for the fibrogenic growth
factors than the inflam-
Because the fibroblast appears to be the key matory ones.
cell in frozen shoulder, we elected to measure Of course, when we look at
the development
cytokine and growth factor levels in 17 consecu- of contractures, we have to
examine not only the
tive patients with severe frozen shoulder? The factors that may act as a
persistent stimulus to
reverse transcription polymerase chain reaction scar formation, but we must
also look at the
(PCR) method was used to measure the levels of opposite side of the
equation, the failure of
cytokines and growth factors in tissue biopsied remodelling. The remodeling
of the extracellular
from these patients with frozen shoulder. The collagen matrix is undertaken
by a family of
tissue showed an over-expression of a number enzymes that used to be
called collagenases, but
of cell-signalling molecules. The intensity of sig- now go by the glorious name
of the matrix
nal for the fibrogenic growth factors such as metalloproteinases (MMPs).
MMPs share five
transforming growth factor (TGF) beta, platelet- basic attributes: they
degrade the extracellular
derived growth factor (PDGF) alpha, and fibro- matrix, they contain zinc,
they are secreted in
blast growth factor (FGF) was elevated and was a latent pro-form, they are
inhibited by tissue
higher than the pro-inflammatory cytokines such inhibitors (TIMPs), and they
share common
as interleukin 1 and tumour necrosis factor amino-acid sequences.
(TNF), although there was a high level of inter- We decided to examine the
levels of MMPs
leukin 6. This work has been elegantly confirmed and TIMPs in frozen shoulder,
once again using
by Colvilles group who took joint fluid from the reverse transcription PCR
technique. We
patients with capsular contracture and found found a strong expression of
MMPs in frozen-
that this tissue caused a 5000 % increase in in- shoulder tissue, particularly
MMP2. However,
vitro fibroblast proliferation compared with con- we found an even greater
expression of their
trol groups. These elevated cytokine levels in natural inhibitor TIMP
frozen shoulder have also been demonstrated by This leads us to speculate
as to whether there
Rodeo, Hannafin and Warren using monoclonal may not be a failure to
remodel in frozen shoulder
antibody techniques. They found TGF-beta and due to persistent high levels
of T1MP.
PDGF to be elevated, and suggested that these A broad-spectrum TIMP has
been synthesized
cytokines may act as a persistent stimulus causing (Marimastat , British
Biotech Ltd, Oxford,
capsular fibrosis and the development of frozen UK) and a remarkable study
has been carried
shoulder. out with it. Twelve patients
with inoperable
1194
gastric carcinoma were enrolled into a study to So where does all this
science take us? We can
see whether TIMP could slow down the progres- now say that the symptoms and
signs of frozen
sion of their disease by inhibiting MMPs (which shoulder make us postulate
that this is
are found to be elevated in gastric carcinoma), a contractile disease. This
is confirmed by
thereby preventing the dissemination of the arthrography, by MRI, by
arthroscopy, by its
tumour through the extracellular matrix and nat- associations with palmar
contracture, by surgical
urally encasing the tumour in scar tissue. Of the exploration, by histology,
and by immunocyto-
12 patients treated, six developed bilateral frozen chemistry. In frozen
shoulder, fibrogenic growth
shoulder within 4 months of starting treatment factors are dominant,
remodelling is prevented by
and three also developed palmar contractures. high levels of TIMP, and
treating cancer sufferers
This remarkable in-vivo experiment would with TIMP causes both frozen
shoulder and pal-
appear to confirm our thoughts on the role of mar contracture. Finally,
both frozen shoulder
TIMP in the formation of frozen shoulder. and palmar contracture
demonstrate clonal chro-
There have been a number of case reports of mosomal abnormalities with
duplication of the
shoulder contracture occurring during treatment same chromosomes.
of HIV-positive patients on protease inhibitors
such as Indinavir.
Treatment of Frozen Shoulder
The Cytogenetics of Frozen Shoulder Do patients want to be

treated? They certainly
do. The pain of capsular
contracture (frozen
Clonal chromosomal abnormalities have been shoulder) is severe, night
pain is worse, night
discovered in a variety of contractile diseases. awakening is universal, sleep
deprivation is con-
In particular trisomy 7 and 8 have been found stant, and these symptoms
persist for months
in Dupuytrens disease, and multiple clonal and months on end. Many
doctors say that
chromosomal abnormalities in Peyronies there is no point treating
frozen shoulder for it
disease. We therefore elected to see if there gets better in 18 months to 2
years. This is
were any clonal chromosomal abnormalities in patronizing in the extreme.
How would you
frozen shoulder. We took capsular tissue from react to a being told that
your severe pain and
ten consecutive patients with frozen shoulder, night awakening was not worth
treating for it
cultured the cells in tissue culture and then would get better in 2 years?
This is akin to
performed metaphase arrest, and performed a woman in labour being told
that there was no
in-situ G banding to look for abnormal karyo- need for pain relief because
the pain would go
types. To our surprise, we found clonal chro- once the baby was delivered!
mosomal abnormalities in frozen shoulder. What do patients desire of
treatment? They
These abnormalities were trisomy of chromo- want the pain to disappear.
They want the pain
somes 7 and 8. to go NOW. If not now they
want the pain to go
A twin study examining 865 pairs of hetero- AS SOON AS POSSIBLE. They
want to be able
zygous and 963 pairs of homozygous twins esti- to sleep. They want to be
able to sleep tonight,
mated a heritability of 42 % for frozen shoulder and it would be a bonus if
their movement could
and stated that genetic factors are implicated in return, at least to a
functional level.
the aetiology of frozen shoulder. Finally, do we have a
treatment that can
Our own study of 100 arthroscopically-proven deliver immediate and long-
lasting freedom
frozen shoulder patients revealed that 16 % of from pain, return of a normal
sleep pattern, and
patients with a sibling, had at least one sibling a functional range of
movement? The short
who had suffered from frozen shoulder and was answer is yes, not for
everyone, not always imme-
significantly higher than that of a sex- and diately, but for the majority
arthroscopic release
age-matched control group. can deliver this package.
Before discussing
Frozen Shoulder
1195
arthroscopic release we should examine the evi- Orthopaedic Association,

asking for their views
dence behind other forms of treatment. on manipulation of frozen
shoulder. Seventy per
cent said they would never
perform
a manipulation, as all would
eventually get bet-
Steroid Therapy ter, and some could be
harmed. Lesser men
would have been put off by
such a reply,
Steroids have been shown in four randomised but not Charnley. In a
consecutive series of
prospective controlled studies to have no benefit 35 patients he found that he
did no harm, pain
over home exercises. However all four papers can was eased by manipulation,
and, however long
be severely criticised as they studied painful stiff the duration of the disease,
most were free of
shoulders, in other words primary and secondary symptoms by 10 weeks.
frozen shoulder so many of the patients would Andersen, Sjobjerg and
Sneppen have shown
have had other shoulder disease. One of these that 79 % of patients with
frozen shoulder are
papers included arthrograms of the study group relieved of their pain, and
75 % regain a near
and 11 of 36 had cuff tears, yet were kept in the normal range of movement
after manipulation.
study! This is a recurring criticism of so many We have arthroscoped
patients before and after
papers on capsular contracture; the diagnosis is manipulation to discover
exactly what is happen-
wrong. A recent randomised double-blind study ing. Essentially, what we
found was that elevation,
of a 3-week course of oral Prednisolone showed no or abduction, tears the
capsule from the neck of the
significant difference between the active and pla- humerus, releasing the
inferior capsule, and this
cebo arms of the study at 6 weeks and 3 months. occurs with relative ease.
It is much harder to free
rotation, but forced
external rotation tears the
coracohumeral ligament. This
is an extra-articular
Physiotharapy ligament, so what is seen
arthroscopically is
haemorrhage in the rotator
interval. Often, the
The best paper on physiotherapy is that of coracohumeral ligament is so
contracted that it
Diercks et al. that showed that intensive physio- will not tear and the
patient is left with limitation
therapy prolonged the natural history of the dis- of external rotation. Loew
has shown that manip-
ease from 15 months to 24 months and achieved ulation is not without
complications.
a lower Constant Score of 76 compared to 87 in
the control group who did home exercises. Once
again we must stress that what the patients want is Arthroscopic Release
not for their disease to be prolonged from 15 to 24
months, but for it to end TODAY. Arthroscopic release, in the
hands of the expert
shoulder surgeon, has
transformed the manage-
ment of capsular contracture
(Fig. 4). Many of the
Manipulation Under Anaesthetic studies can be criticised
for purporting to show
the results of treating
capsular contracture when
Manipulation under anaesthetic has been used the index group was actually
made up of any stiff
historically by many Orthopaedic surgeons, and shoulder including
fractures, cuff disease and
is still used by some today. However, it has had post-surgical stiff
shoulders and then pooling
a chequered career. Professor Sir John Charnley, the results. For instance
one paper started with
before he became famous for his hip replace- 1720 stiff shoulders of
which only 11 had an
ment, was intrigued by frozen shoulder. He arthroscopic release for
primary adhesive
published a paper on his personal results of capsulitis. Four articles
are worthy of study.
manipulation of frozen shoulders in 1959. Ogilvie-Harris et al. [57]
compared the results
Before performing the study, he sent of manipulation versus
arthroscopic release.
a questionnaire to his colleagues in the British Although both groups gained
the same substantial
1196
Fig. 4 Arthroscopic
release of frozen shoulder
improvement in range of motion the arthroscopic Scores from 20/75 to 62/75.

There were no
group had significantly better pain relief and func- complications in three of
these studies, but one
tion, to the extent that twice as many were graded transient axillary
neurapraxia in the Harryman
excellent. The following year J.P. Warner [80] study. Arthroscopic release
appears to show great
showed a 49# increase in elevation, 42# increase promise for it delivers what
the patient wants;
in external rotation and improvement in Constant relief of pain, undisturbed
nights and improved
Scores from 13 to 77/100. Harryman and Matsen function TODAY, or if not
today THIS WEEK,
published a year later [39] and demonstrated fan- in the majority of people,
with minimally invasive,
tastic results. The range of motion went from 41 % keyhole day-case surgery.
of the opposite side to 78 % on the first post- However it is not a
panacea, for it appears that
operative day and 93 % at the end of the study. 10 % of patients fail to
improve whatever treat-
Before surgery 6 % could sleep and after 73 %. ment is used. This group can
be predicted to
They were the first to show the dramatic speed a certain extent. Those who
fall into this worse
of recovery following treatment, which is the group are men, diabetics,
those with marked
very thing that patients want. Berghs et al. [4] Dupuytrens disease,
bilateral disease, severe con-
confirmed this with a dramatic improvement tractures and those with
failed previous treatment.
on day one postsurgery in 36 % and 88 % Arthroscopic release
gives a good improve-
improvement within 2 weeks. Pain improved ment in forward elevation,
and external rotation,
from 3.6/15 to 12.6/15 and the partial Constant but internal rotation can be
disappointing.
Frozen Shoulder
1197
Several authors have seen whether this can be with frozen shoulder.
Remodelling may be slow
improved by posterior release but Snow and in frozen shoulder due to
high levels of
Funk showed no significant difference in range TIMP. In an unusual
study, frozen shoulder
of motion with the addition of a posterior release. has been shown to be
produced by administering
Against this Pouliart and Gagey have described TIMP to humans. Arthroscopic
release now
variations in the superior capsule-ligamentous gives an effective, rapidly-
working, day-case
complex, and explain that the ramifications of minimally-invasive treatment
for this condition.
this limits internal rotation reach in contracture, Understanding the nature of
frozen shoulder
and that the release needs to be extended postero- allows us to apply effective
treatments to the
superiorly. condition, and opens the
doors to the possibility
We have recently published our results from of manipulating the course
of the disease, so that
arthroscopic capsular release in over 100 patients, patients who develop this
common, disabling,
by far the largest series in the world literature to painful and protracted
condition may, in the
date. 98 % of patients would recommend the future, enjoy effective
early resolution of their
surgery to a friend in a similar situation. The disease.
mean post-operative Oxford shoulder score was
41 with an average improvement of 24 points.
70 % had regained full forward flexion, but only References
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8.
Shoulder Arthrodesis
Jean-Luc Jouve, Gerard Bollini, R.

Legre,
C. Guardia, E. Choufani, J. Demakakos,
and B. Blondel
Contents
Post-Operative Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . 1213
Aesthetic Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . 1213

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1215
Relevant Applied Anatomy, Biomechanics . . . . . 1202
Arthrodesis Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1202
Articular
Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1204
Diagnosis, Surgical Indications . . . . . . . . . . . . . . . . . . 1205
1207
Patient Positioning and Surgical Approach . . . . . . . .
1207
Articular Preparing and Osteosynthesis . . . . . . . . . . .
1209
Post-Operative Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1211
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1212
Pseudoarthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1212
Humeral Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1213
J.-L. Jouve (*) # G. Bollini # C. Guardia # E. Choufani

Orthopedic Pediatric Department, Timone Children
e-mail: jean-luc.jouve@ap-hm.fr;
gerard.bollini@ap-hm.fr
R. Legre
Plastic and Reconstructive Surgery Department,
Conception Hospital, Marseille, France
J. Demakakos
Hospital for Joint Diseases, New York University,
New York, NY, USA
B. Blondel
Orthopedic Pediatric Department, Timone Children
Hospital for Joint Diseases, New York University,
New York, NY, USA

1201
DOI 10.1007/978-3-642-34746-7_234, # EFORT 2014
1202
J.-L. Jouve et al.
Abstract
In recent years, surgical indications for
performing a shoulder arthrodesis have
Shoulder arthrodesis or
gleno-humeral arthrode-
continuously decreased. Nowadays, such a
sis is a demanding surgery
with decreasing indi-
procedure is reserved to specific pathological
cations according to
outcomes achieved with
conditions like severe sequelae from brachial
However, it remains a
plexus palsy by Chammas et al. (J Bone Joint
must-know technique in
various salvage situa-
Surg Br 86(5):692695, 2004), repeated
tions such as tumoral
resection. Functional out-
failures after shoulder arthroplasty by Scalise
comes will depend on the
quality and the
et al. (J Bone Joint Surg Am 91(Suppl
positioning of the gleno-
humeral fusion.
2 Pt 1):307, 2009), high energy trauma with
complex fractures or more frequently, malig-
nant tumor of the humeral upper extremity by
Viehweger et al. (Rev Chir Orthop Reparatrice
Appar Mot 91(6):5239, 2005).
Gleno-humeral arthrodesis
consists in a surgical
The main difficulty in shoulder arthrodesis is
bony fusion between the
upper extremity of
to obtain the best position for fusion in order to
humeral bone and the
scapula.
achieve the best functional outcome. While sur-
faces for fusion between the upper humeral
extremity and the scapula are limited, a rigorous
Relevant Applied Anatomy,
arthrodesis technique is necessary, especially
Biomechanics
when using a free vascularized transplant. In
most of the cases, internal osteosynthesis will
Two conditions must be taken
into account:
be necessary and pre-bent custom-made plates
arthrodesis positioning and
quality of the
can therefore be very useful. Such devices will
fusion [10, 11].
use the supraspinous fossa as the upper fixation
and will give adequate angulation for manage-
ment of fusion position in the coronal and sag-
Arthrodesis Positioning
ittal planes however, control of the rotation
remains the trickiest aspect of the procedure
After fusion, residual
mobility will occur in the
[Ruhmann et al. (Orthopade 33(9):106180,
scapulo-thoracic joint.
Therefore, arthrodesis
2004); Safran et al. (J Am Acad Orthop Surg
positioning must be planned
in three dimensions:
14(3):14553, 2006)].
In the coronal plane,
abduction must be fixed
When following a strict and appropriate
in order to allow the
best range of motion for
technique, shoulder arthrodesis leads to satis-
the patient and
preserving the possibility to
factory functional outcomes in complex
stay in anatomical
position. The most common
reconstruction procedures. This is particularly
accepted position is
abduction around 30# to
useful in situations where the rotator cuff and
the vertical but, such
angle is very difficult
deltoid are inefficient, resulting in unsatisfac-
to evaluate during the
surgical procedure.
tory outcomes of shoulder arthroplasty in
According to our
experience, it is easier to
these cases [Clare et al. (J Bone Joint Surg
take into account the
angle between the lateral
Am A(4):593600, 2001; Cofield et al.
side of the scapula and
the humeral diaphysis
(J Bone Joint Surg Am 61(5):66877, 1979].
in the coronal plane
(Fig. 1). The value of this
angle is around 60# and
attention must be paid
Keywords not to increase this
angle in order to avoid pain
Arthrodesis # Bone tumour # Brachial palsy # during adduction movement
by tensioning
Shoulder of the superior fibers of
the trapezius muscle.
1203
30
110
60
Fig. 1 Positioning of the shoulder arthrodesis in the cor- angle of 60# between
the scapula lateral side and the
onal plane. (a) Humerus axis should draw a 30# angle humerus (b) With this
position there is a 110# angle
towards the vertical. This angle is corresponding to an between supraspinous
fossa and the humeral diaphysis
Of note, an angle of 60# between the lateral well fixed in order

to allow the patient a
side of the scapula and the humeral diaphysis range of motion
from the face to the perineum
is equivalent to a 110# angle between area. In cases of
wrong positioning, these
supraspinous fossa and humeral diaphysis. movements will be
restrained and will have
Considering sagittal plane, humeral diaphysis a strong impact on
the patient disability level.
must draw an angle around 20# 30# towards We are referencing
the horizontal plane pass-
the vertical. In prone position during surgery, ing through the
elbow when the arm has the
we take into account the lateral side of the desired flexion and
abduction for the arthrod-
scapula and to give an orientation around esis. In this
situation and when the elbow is
30# 40# in order to achieve this goal (Fig. 2). flexed, the hand
will take the direction of the
Some authors have reported that the resection opposite shoulder
with an angle around
of the distal part of the clavicle could lead to 20# 25# which will
give the patient the neces-
a 20# increase in abduction but we do not have sary range of
motion (Fig. 3).
experience on this complication. In order to
facilitate the surgical procedure, in
Restoring the appropriate rotation in the our institution we use
a custom-made 110#
fusion is the most critical point. It must be angulated plate that
gives the theoretical ideal
1204
J.-L. Jouve et al.
55 m
110
20 20
40
Fig. 2 Positioning of the shoulder arthrodesis in the sag-

ittal plane. Humerus axis should draw a 20# 30# angle
towards the vertical. It is also possible to use as a reference Fig. 4 Example of
a custom-made osteosynthesis plate
a 40# angle between the scapula lateral side and the designed for
supraspinous fossa fixation. Plate is designed
humeral diaphysis with an 110#
angle corresponding to the theoretical ideal
angle between
supraspinous fossa and humeral diaphysis.
The size of the
horizontal part of the plate is around
55 mm, allowing
insertion of three vertical screws in the
supraspinous
fossa
abduction. The
proximal part of the plate is
locked on the
supraspinous fossa while the distal
part is locked on
the humeral diaphysis after
30 setting of the
rotation in order to give the best
compromise
between flexion and rotation (Fig. 4).
Articular
Fixation
Fusion of the
gleno-humeral arthrodesis can be
difficult
regarding the small bony surfaces
Fig. 3 Positioning of the shoulder arthrodesis in rotation. available, the
forces applied by the arm, and
When taking as a reference the elbow horizontal plane
when the shoulder arthrodesis is positioned in both sagittal
the difficulty of
fixation on the scapula [6].
and coronal planes, forearm must draw a 20# 30# angle in Once proper
alignment of bone elements is
the direction of the opposite shoulder achieved, surface
of contact on the glenoid
1205
Fig. 6 Coronal view of

the scapula. Grey part represents
the site for best screw
fixation. Starting from the supra
epinous fossa, three
screws sized 3550 mm can be
inserted on a 55 mm
long surface towards the distal
scapula
humeral diaphysis) in
order to oppose the forces
applied on the
arthrodesis by the arm [4, 10, 11].
Fig. 5 Sagittal view of the scapula. Grey part represents

the site for bone fixation using 3550 mm screws inserted Diagnosis, Surgical
Indications
from the supraspinous fossa
Shoulder arthrodesis is
currently a rare interven-
tion with specific
indications regarding to various
cavity is 35 mm # 20 mm while the thickness of progress in shoulder
surgery such as, rotator cuff
the scapular neck is evaluated around 15 mm. repair or shoulder
arthroplasty.
Considering practical surgical aspects, when Reasons to perform a
shoulder arthrodesis are
a screw is inserted perpendicular to the glenoid now mainly restricted
to situations where shoul-
cavity, satisfactory bone anchorage is possible der locomotor
structures (deltoid muscle and
on the first 35 mm before getting out of the bone rotator cuff) cannot
assume their functions due
(Fig. 5). The scapular spine is therefore the most to palsy or a tumoral
resection. Less frequently, it
reliable site for bone anchorage and when can be a salvage
procedure in case of recurrent
a screw is inserted from the bottom of the shoulder arthroplasty,
high degenerative lesions
supraspinous fossa in the scapular spine, or post-trauma cases.
a solid anchorage is possible for 4050 mm Shoulder palsy
sequela [1]:
before getting out of the bone (Fig. 6). In these cases,
shoulder arthroplasty is a part
Various authors have emphasized the neces- of the global
management of brachial plexus
sity to ensure a bone fixation as far away from the palsy, in
association with nerves grafts and
gleno-humeral arthrodesis as possible (i.e., on the muscular transfers.
Surgical indication is
medial part of the scapular spine and on the distal associated with best
outcomes when there
1206
J.-L. Jouve et al.
a b c
Fig. 7 (a) Indication for shoulder arthrodesis. In this the shoulder

arthroplasty. (c) A shoulder arthrodesis was
clinical example, multiples septic conditions occurred performed using a
vascularized fibular graft. At 18 years
during evolution of shoulder arthroplasty. (b) A failure follow up the patient
is teaching sea scooter in a beach
a latissimus dorsi flap was responsible for an exposure of hotel resort
is an unstable shoulder with a preserved with a high

extensive ability (Giant Cell
active elbow flexion. tumor) [9, 13].
Shoulder arthrodesis after recurrent surgical Performing a
shoulder arthrodesis in these
failures: cases is tricky
considering the large bone loss
In most of these cases, the patients present and the necessity
to achieve satisfactory
major sequelae due to arthroplasty failure stability.
and/or infectious conditions (Fig. 7). In this chapter, we
will mainly focus on the
Post-trauma cases such as chronic disloca- technique of shoulder
arthrodesis for bone
tion or open lesions with bone loss and soft tumors. In these
cases, reconstruction must be
tissues injuries can also be considered for done after tumoral
resection that will not only
arthrodesis due to the impossibility for include the upper
humeral bone extremity but
arthroplasty. also sometimes the
glenoid cavity and scapula.
Tumoral resection: During this surgery,
the axillary nerve is always
It is in our experience the most common case, removed with the
tumor, leading to an inefficient
as the upper extremity of the humeral bone is deltoid. Meanwhile,
the rotator cuff is removed.
the second most frequent site for primary All these resections
erase active shoulder func-
bone tumors. Pathological lesions can be tion leading to two
remaining options: a reversed
malignant (osteosarcoma, Ewing tumor or prosthesis with a
loose shoulder or an arthrodesis
chondrosarcoma), but can also be benign with active mobility.
According to the fact that
1207
mobility in the scapula-humeral joint is reduced, Bone fixation is

using vertical bicortical
it is therefore crucial to plan a good positioning screws with an
increased stability.
for the arthrodesis (Fig. 8). The use of a custom
made pre-bended 110#
plate allows an
automatic positioning of
abduction in the
coronal plane and also
Pre-Operative Preparation helps in the other
planes (Fig. 4).
and Planning
When indication for arthrodesis is decided, plan-

ning will take care of the reconstruction strategy Operative Technique
and the bone fixation. An arthroscopic technic
has been described but we have no experience According to the recent
evolution for shoulder
with these indications [7]. arthrodesis, we will only
describe the internal
In daily practice, three types of fixation are osteosynthesis using a
supraspinous fossa fixa-
described: tion in this chapter. The
custom made pre-bended
Internal osteosynthesis associated with plate allows its use for
palsy sequelae or recon-
a compressive external fixator (Fig. 9). struction after tumoral
resection.
Various authors have reported results asso-
ciated with a primary external fixation followed
by an internal osteosynthesis using two or three Patient Positioning and
Surgical
screws [4]. The primary concern is the limited Approach
quality of bone fixation in the scapula leading
to a fragile construct and risk for bone fracture Position on the surgical
table is related to the
related to external fixation on a poor quality surgical indication. For
paralytic shoulder,
bone. For malignant tumors, this strategy is a sitting position can be
used as well as lateral
not usable due to the risks for patients under decubitus. Patients
undergoing a tumoral resec-
frequent chemotherapy and aplasia. tion will be installed in
a prone position with
Internal osteosynthesis using an acromio- a cushion between the
scapula and the spine
humeral plate (Fig. 10). (Fig. 12). Approach will
be made using
This technique described by Muller is using a deltopectoral incision.
Length of incision will
a pre-bended plate fixed on the scapular spine, be adapted to the planned
resection and can be
the acromion and the upper humeral extremity enlarged towards the
scapular spine and inter-
[3, 8]. The plate must be soft in order to nally, after passing
anteriorly to the coracoid
bend according to the patient anatomy. Due process. Specific
attention must be paid to drap-
to poor bone fixation quality and to avoid ing in order to include
the supraspinous fossa in
rotator disorders, Muller and Cofield have pro- the operative field for
further resection, recon-
posed to add a second posterior plate. One of struction and arthrodesis
(Fig. 13).
the most common problems is related to the Approach of the gleno-
humeral joint will
fact that this plate is just under the skin leading depend on the etiology:
to frequent soft tissues disorders and potential For paralytic shoulder,
the deltoids incision is
infection in patients with previously altered done longitudinally in
its medium part and the
skin. axillary pedicle is
ligatured. This part is nor-
Internal osteosynthesis using a fixation in the mally easy due to
muscular atrophy. Deltoid
supraspinous fossa (Fig. 11). We consider this is then detached from
the acromion and
the best technique for three reasons [5, 9, 13]: the supraspinous fossa
is exposed through
Osteosynthesis is deep, in the fossa, leading the superior part of
the trapezius. The
to few possibilities for hardware exposure, supraspinatus muscle is
subsequently removed
decreasing infectious risks. using a rugine.
1208 J.-L. Jouve et al.
a b
c d
Fig. 8 (continued)
1209
e f
Fig. 8 (a) Functional recovery after shoulder arthrodesis upper humeral

extremity. (b, c, d, e, f) At 4-years follow-
in a 16 year-old patient diagnosed with an Ewing sarcoma up the patient was able
to return to her previous studies
the upper humeral extremity. Previous resection was and became hair-cutter
including axillary nerve, rotator cuff and 21 cm of the
During tumoral
resection, a delto-pectoral
incision approach is
done and the
supraspinous fossa
is exposed in the same
method.
It is fundamental to
have access to the lateral
scapula border and we
commonly expose the
anterior side of the
scapula in order to get suffi-
cient access and
control of this area. This step is
useful for positioning
the arthrodesis but also to
verify screws
effraction on the anterior side of the
scapula and to avoid
excessive length.
Articular Preparing and

Osteosynthesis
For paralytic shoulder,

articular surface abrasion
Fig. 9 Shoulder arthrodesis using an external fixator is done using an
osteotome or a saw and confron-
eventually in association with internal osteosynthesis tation of the bone part
must be perfect. In order to
1210
J.-L. Jouve et al.
limit the risk of

having the plate just under the
skin, mostly around
the great tubercle, the lateral
part of the humerus
can be drilled.
On the other
hand, when dealing with tumoral
resection, we are
using a free vascularized fibular
transplant. A hole is
therefore drilled on the infe-
rior part of the
glenoid cavity and is used for
transplant fixation.
After dissection of the fibular
periosteum, the
transplant is locked in the hole
while the periosteum
is sutured to the scapular
neck in order to
facilitate bone consolidation. On
the distal part, a
tunnel measuring around 2 cm
is drilled in the
remaining humeral diaphysis in
order to affix the
fibular transplant inside. This part
is also associated
with a periosteum suture for
Fig. 10 Osteosynthesis using an acromio-humeral plate. consolidation
purposes (Fig. 11).
Majors inconvenient of this technique are represented by During the next
step, the custom-made
residual pain and conflict between osteosynthesis plate osteosynthesis plate
is fixed. By its angulation
and sub-cutaneous tissues (with potential exposure in
at 110# , abduction
control is automatic (Fig. 4).
front of the acromion)
Then using an angle
of 40# in the sagittal plane
between scapular
pillar and the plate allows for
control in the
sagittal plane. Three screws are
therefore inserted in
the supraspinous fossa in
direction of the
anterior side of the scapula. The
drill and the screws
are inserted with exposure
of the supraspinous
fossa between the clavicle
and the acromion.
Deep retractors can be
necessary to provide
a correct exposure. In
order to ensure a
maximal fixation, the screws
must be bicortical
(around 3550 mm) and pass
at least 2 mm through
the anterior cortex of
the scapula.
Two more screws
are then inserted horizon-
tally through the
scapular glenoid towards the
neck giving a
triangular fixation with the previous
screws (Fig. 14).
Further steps
correspond to the distal fixation of
the plate to the
humerus. At this time, control of
the rotation must be
done and properly planned.
A rotation of 25#
measured with a 90# elbow
flexion will allow
the patient to move the forearm
from the mouth to the
perineum area. The final
Fig. 11 Osteosynthesis using a plate with supraspinous
step consists of
inserting distal screws in the
fossa fixation. Main interest of the 110# pre-bend plate is
the possibility to insert two screws in the glenoid cavity humerus after final
positioning verification.
and three in the supraspinous fossa. This technique is For paralytic
shoulder, horizontal screws
preferentially used in case of large bone loss with free- will be inserted at
the end, after rotation
vascularized fibular graft reconstruction
positioning and
distal fixation since the
1211
Fig. 12 Patients
undergoing a tumoral
resection are installed in
a prone position with
a cushion between the
scapula and the spine.
A tourniquet is installed on
the lower limb considering
the vascular fibular graft
dissection
screws will go through both the humeral hand, fingers and elbow.
Articular range of
head and glenoid cavity. motion must be preserved but
the scapula-
Wound closure is done using habitual tech- thoracic joint must not be
used.
nique, but attention must be paid to bend down As it is hard to establish
clear consolidation
the coracoids process and the acromial angle after criteria, after immediate
postoperative x-ray,
weakening them in order to avoid skin conflict. we used to ask for a second
control at 8 weeks
postoperatively. When a
fibular transplant
has been used, presence of
periosteum apposi-
Post-Operative Course tion around the scapula-
humeral junction
and absence of osteolysis
around the
Immediate post-operative immobilization is screws are comforting
factors. At this time
prescribed using an abduction cushion. scapula-thoracic
physiotherapy can start in
Then according to the clinical context, further order to develop compensatory
mobility and
immobilization is done using the 45# satisfactory functional
outcomes. After starting
abduction cushion or a thoraco-brachial with passive mobilization and
elevatio-
plaster cast for 8 weeks. This period is system- n/abduction movements, active
work is started
atic for us as it is very difficult to obtain a second time. Muscular
reinforcement is
reliable consolidation proofs on x-rays a key parameter for favorable
outcomes and
examinations. is strongly recommended after
a few
months in order to improve
mobility.
The majority of results
improve with time and
Post-Operative Care and global mobility can be
evaluated around 180#
Rehabilitation in the three planes (70#
abduction, 50#
internal rotation, while
external rotation is
Rehabilitation is fundamental in order to achieve fixed around 0# ).
best outcomes after shoulder arthrodesis. During When the arthrodesis is
consolidated
the first 8 weeks, physiotherapy is started for the with good positioning and the
patient is
1212
J.-L. Jouve et al.
Fig. 13 (a) Draping must

include cervical region, a
upper limb and lower limb.
(b) Approach will be made
using a deltopectoral
incision. Length of incision
will be adapted to the
planned resection and can
be enlarged towards the
scapular spine and
internally, after passing
anteriorly to the coracoid
process. Specific attention
must be paid to draping in
order to include the
supraspinous fossa in the
operative field for further
resection, reconstruction
and arthrodesis
following an appropriate physiotherapy

program, functional rehabilitation can be per- Complications
fect (Fig. 8).
In our experience, 15 shoulder arthrodesis pro- Pseudoarthrodesis
cedures have been done using this technique (13
for tumoral reconstruction) and among these This condition corresponds to
a lack of consoli-
patients one is a surgeon, two are hair-cutter and dation. With improvement of
osteosynthesis
all the patients who healed with their tumoral techniques, this complication
is less frequent
disease have been back to work. nowadays and out of our series
of 15 patients,
1213
Post-Operative Chronic
Pain
They can be related to

two different causes:
In most of the
cases, such pain phenomenon is
related to
neurological disorder, mainly for
plexus palsy and
they are not related to the
arthrodesis
technique.
Sometimes they are
related to the surgery by
an excessive
abduction responsible for
a painful traction
on the supra-scapular nerve
or a painful
traction on thoraco-scapular
muscles.
After acromio-
humeral arthrodesis, pain is
also frequent and
mostly related with soft tissues
conflict with the
osteosynthesis or the acromion.
Aesthetic
Complications
During tumoral
resection and reconstruction pro-
cedures, using a
supraspinous fossa plate
Fig. 14 Example of reconstruction using a free- osteosynthesis is
helpful. However, this tech-
vascularized fibular graft in a 15 year-old patient nique can also be
associated with a shortening
diagnosed with a Ewing sarcoma of the humeral upper
extremity. At 6 months follow up the periosteal flap and an inesthetic
shoulder deformation. It is
improves the consolidation on the mild part of the scapula possible in a second
procedure to fill the soft-
tissues defect with a
custom-made silicone
implant. In our
experience, we recommend this
only one showed an absence of consolidation of surgery a minimum of 2
years after the initial
the upper extremity of the fibular graft. A second one (Fig. 15).
procedure with iliac cortico-spongious bone graft
at the junction between the scapula and the fibular
graft was done with a favorable outcome. Of note, Summary
presence of a thin and well-tolerated pseudoar-
throdesis is possible. If the patient is not During the last 20
years, surgical indications for
complaining or if successive x-ray controls do shoulder
arthrodesis have continuously
not show degradation, a second procedure is decreased. They are
now reserved for the man-
not mandatory. agement of brachial
plexus palsy sequelae and
after tumoral
resection. Less frequently it can be
done after recurrent
failures of shoulder
Humeral Fractures arthroplasty or high
energy complex trauma of
the shoulder.
They are a characteristic of paralytic etiologies. Two main
challenges are associated with this
Most of the time it occurs at the level of a screw surgery. First is to
ensure perfect positioning of
or external fixator pin on a porotic bone. In these the arthrodesis as it
will be correlated with func-
cases, due to the consequent traumatic tional outcomes.
Second is to ensure a good qual-
malpositioning of the arthrodesis, a conservative ity fusion with small
bone contact surfaces. This
treatment is not indicated and a second surgery is technique must
therefore be precise and provide
necessary. a satisfactory
stability.
1214
J.-L. Jouve et al.
a b
Fig. 15 Mid-term cosmetic revision after shoulder recon- and a prominent

coracoid process. (b) Insertion of
struction procedure. (a) Results of shoulder arthrodesis in a custom-made
silicone prosthesis in order to fill the
an 18 year-old patient diagnosed with a malignant tumor shoulder cavity after
resection. (c) Cosmetic results
of the upper extremity of the humerus. The patient pre- 5 years after
insertion of the silicone prosthesis and
sents the characteristic aspect after vascularized bone 10 years after
initial resection-reconstruction procedure
reconstruction. There is a large defect under the acromion
Three different kinds of procedures are In our institution

we use a custom-made
described in the literature, internal osteosynthesis osteosynthesis plate
with a proximal fixation in
with external fixation, acromio-humeral internal the supraspinous
fossa. The pre-bended plate pro-
osteosynthesis or internal osteosynthesis using vides an automatic
positioning of the abduction.
the supraspinous fossa as a fixation point. Fives screws with
triangulation directions can be
Patients that will undergo a shoulder arthrodesis inserted in the
scapula (three in the supraspinous
often have had several previous surgeries or will fossa and two
horizontal in the glenoid cavity) for
have postoperative chemotherapy after tumoral optimized fixation.
resection. These situations can lead to soft-tissue This technique
gives a stable osteosynthesis
disorders as well as poor quality bone anchorage. in order to
compensate a late bone consolidation
1215
and a rehabilitation program during the 6. Miller BS, Harper

WP, Gillies RM, Sonnabend DH,
immediate post-operative course. Physiotherapy Walsh WR.
Biomechanical analysis of five fixation
techniques used in
glenohumeral arthrodesis. ANZ
is fundamental in order to provide muscular J Surg.
2003;73(12):10157.
reinforcement and better functional outcomes 7. Morgan CD,
Casscells CD. Arthroscopic-assisted
than a loose shoulder. glenohumeral
arthrodesis. Arthroscopy. 1992;8
(2):2626.
8. Richards RR,
Sherman RM, Hudson AR, Waddell JP.
Shoulder
arthrodesis using a pelvic-reconstruction
References plate. A report of
eleven cases. J Bone Joint Surg
Am.
1988;70(3):41621.
1. Chammas M, Goubier JN, Coulet B, Reckendorf GM, 9. Rose PS, Shin AY,
Bishop AT, Moran SL, Sim FH.
Picot MC, Allieu Y. Glenohumeral arthrodesis in Vascularized free
fibula transfer for oncologic recon-
upper and total brachial plexus palsy. A comparison struction of the
humerus. Clin Orthop Relat Res.
of functional results. J Bone Joint Surg Br. 2005;438:804.
2004;86(5):6925. 10. Ruhmann O,
Schmolke S, Bohnsack M, Kirsch L,
2. Clare DJ, Wirth MA, Groh GI, Rockwood Jr CA. Wirth CJ. Shoulder
arthrodesis. Indications, tech-
Shoulder arthrodesis. J Bone Joint Surg Am. niques,
results, complications. Orthopade.
2001;83-A(4):593600. 2004;33(9):106180
(quiz 1081-).
3. Cofield RH, Briggs BT. Glenohumeral arthrodesis. 11. Safran O, Iannotti
JP. Arthrodesis of the shoulder.
Operative and long-term functional results. J Am Acad Orthop
Surg. 2006;14(3):14553.
J Bone Joint Surg Am. 1979;61(5):66877. 12. Scalise JJ,
Iannotti JP. Glenohumeral arthrodesis after
4. Johnson CA, Healy WL, Brooker Jr AF, Krackow KA. failed prosthetic
shoulder arthroplasty. Surgical tech-
External fixation shoulder arthrodesis. Clin Orthop nique. J Bone
Joint Surg Am. 2009;91(Suppl 2
Relat Res. 1986;211:21923. Pt 1):307.
5. Klonz A, Habermeyer P. Arthrodesis of the 13. Viehweger E,
Gonzalez JF, Launay F, Legre R, Jouve
shoulder. A new and soft-tissue-sparing JL, Bollini G.
Shoulder arthrodesis with vascularized
technique with a deep locking plate in fibular graft
after tumor resection of the proximal
the supraspinatus fossa. Unfallchirurg. humerus. Rev Chir
Orthop Reparatrice Appar Mot.
2007;110(10):8915. 2005;91(6):5239.
Resurfacing Arthroplasty
of the Shoulder
Stephen A. Copeland and Jai

G. Relwani
Contents
Abstract
History and Scope of the Problem . . . . . . . . . . . . . . . 1217
The design of the surface replacement
arthroplasty has evolved over the past

Indications/Contra-Indications . . . . . . . . . . . . . . . . . . 1218
20 years. From cemented prostheses such as

1219 the SCAN, to cementless prosthesis such as
Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1219 the Copeland, the basic concept and design of
Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1219
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1219 the surface replacement favouring maximal
Humeral Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1219 bone preservation has remained constant.
Glenoid Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1221 The indications and surgical technique have
Humeral Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1221 been refined over this period. The indications
Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1221
are similar to those in degenerative conditions,

Post-Operative Restrictions
but its use is contra-indicated in fresh frac-
and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1222
Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1222
tures. The prosthesis can be used as a hemi-
arthroplasty or a total shoulder replacement.

Results of Surface Replacement . . . . . . . . . . . . . . . . . 1222
The surface replacement prosthesis has dem-

Copeland Mark I and II Prosthesis Results . . . . . . . . 1223
Mark III Prosthesis Results . . . . . . . . . . . . . . . . . . . . . . . . 1224
onstrated clinical results at least equal to those
of conventional stemmed prostheses. The

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1224
indications, surgical technique and results of

The Problem Surface Replacement . . . . . . . . . . . . . 1225
surface replacement shoulder arthroplasty are
Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . 1227
presented.
Future Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227
Keywords
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1227
Complications # Copeland results # Future
designs and techniques # History # Problem
replacements # Re-surfacing arthroplasty #
Rehabilitation # Results # Shoulder # Surgical
indications # Surgical Techniques
S.A. Copeland (*)

The Reading Shoulder Surgery Unit, Capio Reading
History and Scope of the Problem

e-mail: stephen.copeland@btinternet.com
Zippel in Germany implanted two surface
J.G. Relwani
replacements that were fixed by a trans-osseous
East Kent University Hospital, Ashford, Kent, UK
screw [1] but no follow-up is recorded for

1217
DOI 10.1007/978-3-642-34746-7_216, # EFORT 2014
1218 S.A.
Copeland and J.G. Relwani
these cases. Steffee and Moore in the United 5. It can be used in

congenital abnormalities of
States were implanting a small hip-resurfacing the humerus that would
not allow the passage
prosthesis into the shoulder [2] and, in Sweden, of standard intra-
medullary stemmed
in greater numbers, a surface replacement SCAN prostheses.
(Scandinavian) cup was being used as a cemented 6. Revision surgery to a
stemmed prosthesis or
surface replacement [3]. arthrodesis can be
performed easily as there is
Development of the Copeland Cementless no loss of bone stock
and no cement to retrieve
Surface Replacement Arthroplasty (CSRA) from within the humeral
shaft.
began in 1979. The prosthesis was first used clin-
ically in 1986. From 1993 the entire bony surface
of the glenoid and humeral components have Indications/Contra-
Indications
been hydroxyapatite- coated so that the initial
mechanical fix is transformed into a biological Primary and secondary
arthritis of the shoulder is
fixation with bony in-growth to the hydroxyapa- the commonest indication.
The prosthesis has
tite coating. also been used
successfully for rheumatoid and
Simple instruments allow anatomical place- other inflammatory
arthritides [37], avascular
ment of the humeral head by identifying the cen- necrosis, cuff tear
arthropathy, instability
ter of the sphere. Once this point has been arthropathy, post- trauma
arthritis, post-infective
identified, the prosthesis can be positioned to arthritis, and arthritis
secondary to glenoid dys-
replicate the original anatomical bearing surface plasia and dysplasia of
the epiphysis. It is not
including version, offset, and angulation. With intended for use in fresh
fractures.
current advances in technology, it is possible to The results of surface
replacement, as in any
determine this centre with extreme accuracy, other shoulder
replacement, depend on the indi-
using computer-assisted navigation techniques, cations and diagnosis. The
best results are
thereby increasing the precision of prosthesis achieved in osteoarthritis
with an intact cuff, and
placement. the worst results in cuff
tear arthropathy and post-
The potential advantages of a cementless sur- traumatic arthritis [8].
The surface replacement
face replacement include: arthroplasty can even be
used in circumstances
1. Anatomical siting of head, restoring anatomi- of moderate to severe
erosion of the humeral
cal variations of version, offset, and angula- head, in conjunction with
bone graft. If there is
tion in each individual patient. more than 60 % contact
between the under-
2. No intra-medullary canal reaming or cemen- surface of the trial
prosthesis and humeral head,
tation, making it a less traumatic and safer after it has been milled,
then it would be suitable
procedure in an elderly patient, with for surface replacement,
that is, up to 40 % of the
a smaller risk of fat embolus or hypotension. humeral head may be
replaced by bone graft.
3. There is no problem if the intra-medullary The contra-indications
for surface replace-
canal has already been filled with cement, ment arthroplasty are
active infection, bone loss
the stem of an elbow replacement, or frac- of the humeral head
exceeding 40 % of the sur-
ture fixation devices. If there is a mal-union face, and acute fractures.
at the proximal end of the humeral with 92 % of our cases
requiring shoulder
secondary osteoarthritis, the mal-union can arthroplasty receive a
surface replacement. We
be left undisturbed, the tuberosities intact, feel that surface
replacement should be the stan-
and just the humeral articulation is re- dard replacement of choice
for all cases, unless
surfaced. specifically contra-
indicated; the question now is
4. Unlike stemmed prosthesis, there is no stress not when to use a surface
replacement, but what
riser effect that could result in a shaft fracture are the limited residual
indications for a stemmed
at the tip of the prosthesis. implant.
Resurfacing Arthroplasty of the Shoulder
1219
changes of the acromio-

clavicular joint and
Surgical Technique symptoms suggest this is a
site of pain, then
perform an excision
arthroplasty at this stage.
Anaesthesia This further improves the
surgical exposure. We
excise the acromio-clavicular
joint in almost all
This operation can be performed under general patients with osteoarthritis
as they usually do not
and/or regional anaesthesia, according to local have adequate pre-operative
range of motion
preferences. We favour a light total intravenous to demonstrate symptoms
arising from this
anaesthetic together with an inter-scalene block joint. At least 80# of
forward flexion is required
for effective analgesia. to induce pain at this site,
and once range of
movement has been restored,
this joint can
become irritable and impede
function of the
Position shoulder. Identify the
rotator interval at the
base of the coracoid. Release
the coracohumeral
The patient is placed in the beach-chair posi- ligament to gain external
rotation. Incise
tion with a sandbag underneath the medial scap- longitudinally along the line
of the long head
ular border to thrust the shoulder forward. An arm of biceps and the rotator
interval to define the
board is attached to the table at the level of the insertion of the
subscapularis. Detach the
elbow to support the forearm. Drape the arm free subscapularis with an
osteoperiosteal flap from
to allow full movement at the shoulder and con- the medial border of the
biceps groove. Deliver
firm that it can be adequately extended and the head of the humerus
through the wound
adducted. by extending and adducting
the shoulder.
If the long head of biceps is
intact, displace it
posteriorly over the humeral
head.
Approach
Either a standard anterior deltopectoral Humeral Preparation

approach or the antero-superior approach as
described by Neviaser [9] and Mackenzie [10] The key landmark for
determining the ideal
can be used to insert the prosthesis. The advan- position of the humeral
component is the
tages of the Mackenzie incision include a line-of-junction of the head
and the anatomical
smaller and neater scar, easier and more direct neck of the humerus.
Demonstrate this by
access via the rotator interval to the glenoid, removing osteophytes around
the neck. Place
and better access to the posterior and superior the humeral drill guide over
the head with
rotator cuff for reconstruction. It also allows for its free edge parallel to the
junction of the
excision arthroplasty of the acromio-clavicular anatomical neck and the
humeral head (Fig. 1).
joint and acromioplasty if these are indicated. The humeral drill guide
should be central on
The acromio-clavicular joint excision can be the humeral head and parallel
to the anatomical
a useful source of bone graft. neck line; this reproduces
the patients own
The antero-superior approach leads onto the version, inclination, and
offset. Using the
rotator cuff. If the cuff is intact or there is centred drill guide, drive a
guide-wire through
a repairable tear, then perform an anterior the centre of the head and
into the lateral
acromioplasty with partial resection of humeral cortex for firm
purchase. Remove
the coraco-acromial ligament. Leave the the guide jig and visually
check that the guide-
coracoacromial arch undisturbed if the rotator wire is in the centre of the
head (Fig. 2). If the
cuff is extensively torn or non-functional. If pre- guide-wire does not look
centred, then it should
operative radiographs have shown arthritic be re-positioned.
1220
S.A. Copeland and J.G. Relwani
Fig. 3 Reaming of the

humeral surface until bone is seen
exiting the
fenestrations in the reamer
Fig. 1 Sizing and alignment using the centralising jig to
insert the guide-wire
Fig. 2 Central position of the guide-wire in the head

confirmed
Fig. 4 The stem cutter
is then used over the guide-wire to
create a hole for the
stem of the prosthesis
With the guide-wire central in the humeral much subchondral bone

as possible to support
head, choose the size of the humeral guide that the prosthesis. The
reamer has a safety mecha-
closest matches the size of the humeral head. nism to prevent over-
reaming and removing too
If the head falls between guide sizes, it is better much bone. Save all the
reamings scavenged
to undersize as this allows you to correct to from the humeral head
for later bone grafting.
a larger size later. Remove any residual
osteophytes from the cir-
The appropriate cannulated humeral surface cumference of the neck.
reamer is then passed over the guide- wire. Whilst Once the appropriate
humeral size is decided,
the reamer is rotating, light pressure is applied on use the corresponding
sized stem-cutter over the
the humeral head to engage the cutting teeth. This guide-wire and drill
down to, but not beyond, the
should be continued until reamings are seen shoulder of the cutter
to remove the correct
exiting from all the holes in the shaper (Fig. 3). amount of bone for the
central stem hole
Ideally all remnants of articular and fibro- (Fig. 4). The cutter
and guide-wire are then
cartilage should be removed, but preserve as removed.
1221
Insert the trial component. If only a hemi-

arthroplasty is to be done, test the stability of the
humeral component and the range of movement.
Consider appropriate soft-tissue releases and
balancing at this stage. If a hemi-arthroplasty is
to be performed, the glenoid still needs to be
prepared at this stage as described below.
Glenoid Preparation
Leave the trial humeral component in situ to protect

the prepared humeral head. Retract the humeral
head postero-inferiorly with a Murphy skid or
Fig. 5 The Copeland Mark
III prosthesis (hydroxyapatite
Fukuda retractor. The decision concerning glenoid coated) containing
autologous bone graft and blood paste
replacement is made at this stage. Pre-operative prior to insertion
imaging using an axillary view radiograph and
C.T. may be helpful in this regard. If glenoid
replacement is not intended, it is our routine
practice to drill multiple holes in the glenoid with
a 2 mm guide-wire, or create a micro-fracture with a
chondral pick just penetrating the hard
osteochondral surface of the bone to induce bleed-
ing and some fibro-cartilaginous regeneration. If the
glenoid requires replacement, it is carried out using
the appropriate technique which we have described
earlier [11] and is beyond the scope of this chapter.
Humeral Replacement
Now return your attention to the humerus. Fig. 6 Surface replacement

in situ prior to reduction
Remove the trial component and create multiple
drill holes, using a 2 mm drill, through the scle-
rotic subchondral bone to improve bone reactiv-
ity. Place the rest of the bone graft mix inside the lengthening by either a
stepwise cut in the
definitive humeral component (Fig. 5). Apply the tendon or by medialization
of the insertion
prosthesis onto the prepared humeral head of the tendon. Close only
the lateral part of
(Fig. 6). Using the impactor, apply two or three the rotator interval. Now
repair any rotator
sharp blows with the mallet to seat the component cuff tear if possible.
Capsulotomy or sutures
fully. Wash away any excess bone, then reduce may be required at this
stage to balance the
the joint and test again for stability. reduction. Ensure a firm
repair of deltoid to
the acromion using
transosseous sutures if
necessary. Close the
subcutaneous fat with
Closure interrupted absorbable
sutures, and insert a
subcuticular running
stitch.
If the centre of rotation has been lateralized, Apply a sterile dressing
and place the patient
then subscapularis may need relative into a sling with a body
belt.
1222
Surgical Confirm that patient position allows arm reviewed in clinic at 3

weeks, 3 months and
pearls to extend and adduct adequately on table 12 months and yearly
thereafter. Radiographs are
Have a low threshold for an obtained post-operatively,
at 3 months, 12 months,
acromioplasty and AC joint excision and yearly thereafter
(Fig. 7).
Expose the junction of the head and
anatomical neck adequately, this step is
crucial and requires removal of all
osteophytes on the humerus Results of Surface
Replacement
Accurately identify the centre of the
humeral head before proceeding Zippel in Germany
implanted two surface
If in doubt about the size, downsize replacements that were
fixed by a transosseous
Preserve as much of the bone reamings in screw [1] but no follow-up
is recorded for these
the patients blood as possible, to
augment any bone loss in the humeral cases.
head. Up to 40 % bone loss can be Good clinical early
results have been obtained
reconstituted during a surface with cups developed by
Steffee and Moore [2],
replacement and by Jonsson et al. [3].
Rydholm and Sjogen [7]
Remember to perform soft tissue release/
from Sweden reported the
results of the SCAN
balancing as necessary
Drill the glenoid surface to stimulate
cup in 1993 and 2003.
Rydholm [5] performed
bleeding and fibrocartilage regeneration 84 SCAN cups, a hemi-
spherical cemented cup,
Carefully reconstruct the soft tissues, in 70 patients, and 72
cups in 59 patients were
including deltoid repair during closure followed for 4.2 years
(range, 1.59.9 years). The
Surgical Do not be too aggressive with the clinical results obtained
showed 94 % of the
Pitfalls acromioplasty and AC joint excision in patients being pleased
regarding pain relief and
cases with poor or irreparable rotator
cuff. Consider using the deltopectoral 82 % reporting improved
shoulder mobility.
approach in these cases Shoulder function was
significantly improved.
Do not use the prosthesis in cases of Radiographs were analyzed
regarding the posi-
fracture or if bone loss from the head tion of the cup, proximal
migration of the
is > 40 %.
humerus, and glenoid
attrition during the
follow-up period. Change
of the distance
between the superior
margin of the cup and the
greater tuberosity and/or
change of inclination of
Post-Operative Restrictions the prosthesis were
regarded as signs of pros-
and Rehabilitation thetic loosening. With
that definition, 25 % of
the cups were found to be
loose at follow up.
Only passive movement is allowed for the first Prosthetic loosening,
however, had no bearing
48 h, then passive assisted movements for 5 days. on the clinical result.
Progressive proximal
Begin active movements at 1 week if pain allows, migration of the humerus
in 38 % of the shoulders
and discard the sling at 3 weeks. Retrict external and central attrition of
the glenoid in 22 % of the
rotation for 3 weeks to protect the subscapularis shoulders did not show any
relationship to gain of
repair. Encourage the patient to stretch and mobility, pain relief, or
functional ability. Note
strengthen for many months as improvement that no central fixation
peg was used for this cup.
will continue up to 18 months post-operatively. Long term follow-up at 13
years included 54 cups
in 46 patients (13
patients deceased, no revi-
sions). Six cups had been
revised 10 years
Follow-Up (range, 516 years) after
the index operation
(4 persistent pain, 1
stiffness, and 1 prosthetic
Patients are discharged home when comfortable loosening). Pain at rest
on a 100-mm visual ana-
and safe, typically 48 h post-operatively. They are logue scale was 15 mm
(range, 062 mm) and
1223
a b
Fig. 7 Radiographs of the Copeland cementless resurfacing arthroplasty (pre- and

post-operative)
pain on motion was 32 mm (range, 085 mm). cuff (group A), 18 had a
partial tearing
Twenty-six (50 %) could comb their hair (com- or a repaired rotator
cuff (group B), and 12
pared with 56 % at first follow-up), 32 (62 %) shoulders a massive cuff
tear (group C).
could wash their opposite axilla (90 % at first In group A rheumatic
shoulders, the Constant
follow-up), and 31 (60 %) could reach behind Score increased from
21.5 # 9.6 points pre-
(77 % at first follow-up). operatively to 66.1 #
9.8 points at 36 months
Alund et al. [12] reported on 40 shoulder sur- post-operatively; in
shoulders of group B, from
face replacements for rheumatoid disease using 19.6 # 9.7 points pre-
operatively to 64.9 # 9.6
the SCAN prosthesis. They reported 1 revision to points at 36 months
post-operatively; and in
total shoulder replacement, and 39 shoulders shoulders of group C,
from17.5 # 8.7 points to
were followed up for a mean of 4.4 years 56.9 # 9.8 points at the
latest follow-up exami-
(0.96.5 years). The median Constant score was nation. All shoulders
were pain-free at the latest
30 (1579), mean proximal migration of the examination. No
complications, component loos-
humerus 5.5 (SD 5.2) mm and mean glenoid ening or changes of cup
position were observed.
erosion 2.6 (SD 1.7) mm. Proximal migration
and glenoid erosion did not correlate with shoul-
der function or pain. Radiographic signs of loos- Copeland Mark I and II
Prosthesis
ening (changes in cup inclination combined with Results
changes in cup distance above the greater tuber-
osity) occurred in 25 % of the shoulders. At The Copeland surface
replacement prosthesis has
follow-up, 26 (65 %) patients were satisfied developed from the
original Mark I version that
with the procedure, despite poor shoulder func- was first implanted in
1986 to the current Mark III
tion and radiographic deterioration. version first implanted
in 1993. The Mark 1 pros-
Fink et al. [13] prospectively evaluated 45 thesis was fixed with a
central smooth round peg
Durom Cups in 39 patients (30 women, 9 men) and a screw passed from
the lateral side of the
with rheumatoid disease. The average follow-up humeral screw into the
prosthesis to act as an
was 45.1 # 11.6 months with a minimum of anti-rotation bar. This
was used clinically on
36 months. Fifteen shoulders had an intact 19 patients. We realized
that the fixation was
1224 S.A.
Copeland and J.G. Relwani
adequate with the impaction peg alone. The radiological outcome was
assessed at an average
screw was unnecessary and we worried that if duration of follow-up of 4.4
years. No evidence
the prosthesis was to loosen, the toggling of this of radiolucency was seen in
any humeral implant.
anti-rotation bar might dissociate or disrupt the Thomas et al. [6] reported a
6.3 % incidence of
tuberosities, presenting a difficult reconstruction lucencies in their series
using the Mark III
problem. Therefore the use of the screw was implant. Asymptomatic non-
progressive lucency
discarded at an early stage, with a modified peg of less than 2 mm was seen in
seven of the
design to improve the press-fit. twenty-nine glenoid
components inserted, which
Between 1990 and 1993, 103 Mark-II prosthe- did not require further
treatment.
ses were inserted into 94 patients (nine bilateral) Six shoulders (2.8 %)
required revision sur-
[8]. The indications included osteoarthritis, rheu- gery (one mal-position of
glenoid, two instability
matoid arthritis, avascular necrosis, instability and three painful
arthroplasties). Using the
arthropathy, post-traumatic arthropathy and cuff Kaplan- Meier analysis, the
probability that the
arthropathy. The mean follow-up was 6.8 years implant would survive to the
start of the tenth
[510]. The best results were achieved in primary year after surgery was
estimated to be 96.4 %.
osteoarthritis, with Constant scores of 93.7 % for The results of Mark III
Copeland Shoulder
total shoulder replacement and 73.5 % for hemi- Replacement Arthroplasty are
comparable to
arthroplasty. The poorest results were encoun- conventional stemmed
prostheses. There was no
tered in patients with arthropathy of the cuff, difference between hemi-
arthroplasty and total
instability arthropathy and other causes such as shoulder arthroplasty in
terms of functional out-
arthropathy secondary to septic arthritis, with come. No hemi-arthroplasty
has been revised for
adjusted Constant scores of 61.3 %, 62.7 % and component loosening.
58.7 %, respectively. Of the 88 humeral implants The table below summarises
the hitherto
available for radiological review, 61 (69.3 %) published results of surface
replacement prosthe-
showed no evidence of radiolucency, nor did 21 ses (Table 1).
(35.6 %) of the 59 glenoid prostheses. Three were
definitely loose, and eight shoulders required
revision (7.7 %), two (1.9 %) for primary loosen- Complications
ing. The results of this series are comparable with
those for stemmed prostheses with a similar 1. Aseptic loosening 5.1 %
(pre hydroxyapatite
follow-up and case mix [1419]. coating), 0 % post HA
coating (Mark III).
2. Deep Infection 0.7 %.
3. Myositis Ossificans 0.7
%.
Mark III Prosthesis Results The revision rate at 510
years of using the Mark
II design has been 5.9 %. The
indications were:
From 1993, the entire non-articular surface 1. Instability following
total shoulder
(implant bone interface) of the glenoid and resurfacing arthroplasty
for instability
humeral components has been hydroxyapatite- arthropathy in two
patients.
coated. The initial mechanical press-fit is thus 2. One peri-prosthetic
fracture (surgical neck)
followed later by a biological fix with bony after a fall. This was
treated in a collar and
ingrowths due to the hydroxyapatite coating. cuff sling for 6 weeks
and healed uneventfully.
This is the current Mark III design. 3. One disassociation of the
polyethylene
Between September 1993 and August 2002, glenoid from the metal
part of the glenoid
209 shoulders underwent surface replacement component (obviated by
immediate design
arthroplasty at our unit using the Mark III pros- change).
thesis with hydroxyapatite coating. Clinical and 4. One glenoid loosening
following a fall.
1225
Table 1 Table comparing the published results of surface replacement prostheses.

Author Copeland/Levy [8] Thomas [6] Alund [12] Rydholm U [5]
Fink [13]
Implant Copeland Mark II Copeland SCAN SCAN
Durom
(pre-HA coating) Mark III
Indication Mixed Mixed Rheumatoid Rheumatoid
Rheumatoid
No. of 103 48 39 72
45
replacements
Average age 64.3 70 55 51
62.7
at surgery
(years)
Follow-up 60120 (mean 80) 2463 2472 5095 (mean
50) 45.1 +/# 11
(months) (mean (mean 52)
34.2)
Mean preop 15.4 16.4 NA NA
19.5
constant
score
Mean postop 52.4 54 30 Not available
but 92 % of 62.6
constant patients
satisfied with pain
score improvement
Preop VAS NA NA 80 (median)
NA
Postop VAS NA NA 16 (median) 1532 (mean)
NA
Radiologic 5.1 % (Pre-HA 6.3 % 20 % 25 %
0%
lucent/lytic coating)
lines
Overall 93.9 % NA 83 % 92 %
94 %
patients
satisfied
5. Two aseptic loosenings one involved both

humerus and glenoid, and one glenoid only. The Problem Surface
Replacement
Revision surgery was greatly simplified hav-
ing originally implanted a Cementless surface The patient returning
with a painful or non-
replacement. At the time of revision of a surface functioning surface
replacement immediately
replacement arthroplasty, the only bone lost was leads one to suspect
glenoid wear as the cause
the bone that would have been removed of pain and to consider
a revision shoulder
had a stemmed prosthesis been used at the first replacement as the
solution. However, several
operation. There was no need to remove causes of the painful
shoulder arthroplasty should
a cemented stemmed prosthesis, which is associ- first be considered
[20].
ated with loss of bone stock, perforation, and The commonest cause
is residual suba-
fracture of the humeral shaft. The preservation cromial impingement
which presents with a
of bone facilitated revision to a stemmed pros- good range of movement
but a positive
thesis or to glenohumeral arthrodesis. impingement arc
abolished by injection of
The current Mark III design has had no cases local anaesthetic into
the subacromial space.
of radiological lucent lines or loosening with its This is resolved by an
arthroscopic subacromial
hydroxyapatite coating. The revision rate of the decompression. Biceps
disorders give rise to
Mark III design is 2.8 %, with a predicted sur- anterior pain, and may
require a tenodesis or
vival probability of 96.4 % at 10 years using tenotomy. Cuff rupture
can occur which
Kaplan Meier analysis. requires re-exploration
and cuff repair or
1226
a b
Fig. 8 (a, b, c) Signature Guide templating for patient-specific Copeland

Replacement
conversion to reverse geometry prosthesis if the other causes are

eliminated. This can be treated
cuff is irreparable. A previously arthritic by an arthroscopic
capsular release. Last but not
acromioclavicular joint can become symptom- the least, the diagnosis
of infection must always
atic following increased glenohumeral be kept in mind. If all
else fails to relieve the
movement after a surface replacement, and we pain, the glenohumeral
joint is injected with
recommend and routinely excise the AC joint local anaesthetic to try
and determine whether
during the primary procedure to avoid this the glenohumeral
articulation is the source of
problem in the post-operative period. Capsular pain. This then requires
a revision to a total
fibrosis is a diagnosis to be considered once all shoulder arthroplasty.
1227
Summary and Conclusions References
Surface replacement of the shoulder has been 1. Zippel J. Dislocation-

proof shoulder prosthesis
model BME. Z Orthop Ihre
Grenzgeb. 1975;113(4):
proven to be at least as successful as stemmed
4547.
implants in the treatment of shoulder arthritis. 2. Steffee AD, Moore RW.
Hemi-resurfacing
The hydroxyapatite coating has been a major arthroplasty of the
rheumatoid shoulder. Contemp
advance in reducing lucent lines and loosening. Orthop. 1984;9:519.
3. Jonsson E, Egund N, Kelly
I, Rydholm U, Lidgren L.
The bone-preserving nature of the implant
Cup arthroplasty of the
rheumatoid shoulder. Acta
allows it to be used in a most situations, Orthop Scand.
1986;57(6):5426.
including cases of deformity. If complications 4. Levy O, Funk L, Sforza G,
Copeland SA. Copeland
do occur, then they can be more easily treated, surface replacement
arthroplasty of the shoulder in
rheumatoid arthritis. J
Bone Joint Surg Am. 2004;86-
and the results of surface hemi-arthroplasty A(3):5128.
appear to be better than stemmed hemi- 5. Rydholm UMD. Humeral head
resurfacing in the
arthroplasty. The geometry and mechanics of the rheumatoid
shoulder. Tech Orthop.
shoulder joint are now much better understood. It 2003;18(3):26771.
6. Thomas SR, Wilson AJ,
Chambler A, Harding I,
is no longer justifiable to continue with Thomas M. Outcome of
Copeland surface replace-
intramedullary (either cementless or cemented) ment shoulder
arthroplasty. J Shoulder Elbow Surg.
fixation in a straightforward arthritic problem. 2005;14(5):48591.
7. Rydholm U, Sjogren J.
Surface replacement of the
humeral head in the
rheumatoid shoulder. J Shoulder
Elbow Surg. 1993;2:286
95.
Future Considerations 8. Levy O, Copeland SA.
Cementless surface replace-
ment arthroplasty of the
shoulder. 5- to 10-year results
Future prostheses for the shoulder are likely to with the Copeland Mark-2
prosthesis. J Bone Joint
Surg Br. 2001;83(2):213
21.
be of the bone-preserving nature. As materials 9. Neviaser RJ,
Neviaser TJ. Lesions of
improve, wear will hopefully become less of a musculotendinous cuff of
shoulder: diagnosis and
problem. Modern technology allows for more management. Instr Course
Lect. 1981;30:23957.
accurate pre-operative planning. Computer 10. Mackenzie DB. The antero
superior exposure of
a total shoulder
replacement. Arthop Traumatol.
assistance during surgery could translate this 1993;2:717.
planning to a practical solution to optimise 11. Copeland SAF, Levy OM,
Brownlow HCF.
implant position and soft tissue balancing, Resurfacing arthroplasty
of the shoulder. Tech Shoul-
which ultimately with improved materials der Elb Surg.
2003;4(4):199210.
12. Alund M, Hoe-Hansen C,
Tillander B, Heden BA,
should increase longevity of the prosthesis Norlin R. Outcome after
cup hemiarthroplasty in the
and improve function after shoulder arthroplasty rheumatoid shoulder: a
retrospective evaluation of 39
[21]. We have performed the first Signature patients followed for 26
years. Acta Orthop Scand.
computer-assisted Copeland surface arthroplasty 2000;71(2):1804.
13. Fink B, Singer J, Lamla
U, Ruther W. Surface
to optimise the three-dimensional positioning replacement of the
humeral head in rheumatoid
of the implant. The centre of the humeral head arthritis. Arch
Orthop Trauma Surg.
(in three axes) is identified by a logarithm with 2004;124(6):36673.
data obtained using high resolution CT scan 14. Neer CS, Watson KC,
Stanton FJ. Recent experience
in total shoulder
replacement. J Bone Joint Surg Am.
and MR scans, and a patient-specific custom 1982;64(3):31937.
disposable jig is then created to anatomically site 15. Barrett WP, Franklin JL,
Jackins SE, Wyss CR,
the guide-wire, and size the implant (Fig. 8ac). Matsen III FA. Total
shoulder arthroplasty. J Bone
This has allowed accurate recreation of the Joint Surg Am.
1987;69(6):86572.
16. Torchia ME, Cofield RH,
Settergren CR. Total
functional anatomy in the individual. The next shoulder arthroplasty
with the Neer prosthesis:
challenge facing us will probably be that of long-term results. J
regenerating the surface! 1997;6(6):495505.
1228
17. Cofield RH. Total shoulder arthroplasty with the Neer 20. Tytherleigh-Strong
GM, Levy O, Sforza G,
prosthesis. J Bone Joint Surg Am. 1984;66(6):899906. Copeland SA. The
role of arthroscopy for the problem
18. Gartsman GM, Russell JA, Gaenslen E. Modular shoulder
arthroplasty. J Shoulder Elbow Surg.
shoulder arthroplasty. J Shoulder Elbow Surg. 2002;11(3):2304.
1997;6(4):3339. 21. Relwani J,
Sivaprakasam M. Principles of computer
19. Boileau P, Walch G. The three-dimensional geometry assisted shoulder
arthroplasty and the signature shoul-
of the proximal humerus. Implications for surgical der replacement.
ICSES. 2010; Instructional course
technique and prosthetic design. J Bone Joint Surg abstracts IC5.4, p.
16.
Br. 1997;79(5):85765.
Treatment of Proximal Humerus
Fractures by Plate Osteosynthesis
David Limb
Contents
Abstract
Plate fixation for fractures of the proximal
humerus is the most reliable technique for

obtaining secure fixation of multi-fragmentary

injuries. Although the security of fixation has
and Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232
further improved with the introduction of
Blood
Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1232 locking plates, the complication rate remains
Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1233 high. This is in part due to the nature of the
injury itself, with the attendant risk of avascu-

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1233
lar necrosis and peri-articular tissue stiffness,

but also due to the difficulties of applying
correct surgical technique. Despite improved
1236
plate designs, the requirement to obtain fixa-

Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1237 tion in good subchondral bone leaves a high
Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1240 risk of intra-articular penetration by screws
and this is one contributor to the relatively
high rate of re-operation. This chapter

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1243
describes current surgical technique for plate

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1244 fixation of proximal humeral fractures, illus-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1244 trated by perhaps the most common method of
locking plate fixation through a deltopectoral

approach.
Keywords
Anatomy, Pathology and Biomechanics #
Bone plate # Complications # Fixation # Frac-
ture # Locking plate # Operative Technique #
Osteosynthesis # Pre-operative planning and
imaging # Reduction # Rehabilitation # Shoul-
der # Surgical indications
D. Limb

1229
DOI 10.1007/978-3-642-34746-7_59, # EFORT 2014
1230
D. Limb
General Introduction Aetiology and Classification
In treating fractures of the proximal humerus the The surgical anatomy of the
shoulder has been
surgeon is faced with some difficult choices. described elsewhere. Most
proximal humeral
Perhaps the most important of these is the one fractures occur as a result
of a fall from standing
that has to be made in the face of conflicting or height and there are several
contributory factors
inadequate evidence should the patient be to the pattern of injury
observed. The energy of
offered surgery or will non-operative treatment injury refers to the energy
dissipated in creating
be adequate? Historically we know that non- the fracture and, in general,
the higher the energy
operative management has good reported dissipated the more fracture
lines exist and the
outcomes, certainly for minimally-displaced greater is the displacement
of fracture fragments.
fractures, but even apparently innocuous inju- The actual pattern of injury
observed depends on
ries can give rise to prolonged stiffness. Stable the direction of force
application, whether this
fixation may allow earlier and faster rehabilita- pushes the humeral head into
the glenoid, up
tion, and perhaps minimise stiffness, but the into the acromion or
translates it to the glenoid
evidence from randomised trials is lacking. It is rim or even into a position
of dislocation. Fur-
also the case that non-operative treatment for thermore the pull of the
strong rotator cuff ten-
significantly displaced fractures, multi-part dons (or lack of it in the
presence of a cuff tear)
fractures and those associated with dislocation, will nave an influence, as
will the degree of
is associated with poor functional results. How- osteoporosis.
ever the surgical management of these injuries is A number of
classification systems have been
also unproved and we still await trials with suf- proposed for proximal humeral
fractures and
ficient power to establish the role of surgical none stands up to rigorous
testing in terms of
fixation. inter- and intra-observer
agreement [1, 2]. Each
The second problem is what fixation method has its own unique attributes
and problems for
to use? Percutaneous methods may minimise example the AO classification
[3] is quite granu-
soft tissue injury and carry less risk to the vas- lar and may be useful for
research, but is quite
cularity of the humeral head, but by their nature difficult to use on a day-to-
day basis, as it is not
do not always give sufficient stability to allow intuitive. However, these
aggressive early motion. Rehabilitation is facil- are very useful in
communication and in helping
itated if strong fixation of the fragments is the surgeon shape his/her
thoughts when
obtained using plates or nails, but there is inev- assessing a fracture. The
Neer classification sys-
itably a greater insult to the blood supply. In tem in particular has become
part of the common
reality the technique a surgeon selects will also language of trauma surgery
[4]. This system sim-
depend on his/her own experience and training plifies the anatomy of the
proximal humerus into
and will be influenced by a range of functional units between
which fracture lines
patient related factors. This chapter will there- tend to pass a concept
proposed by Codman
fore present plate fixation as one method of [5] and more recently
developed by Hertel with
managing proximal humeral fractures and it is the Lego brick model [6].
probably the most popular current method. How- These classification
systems describe the
ever, most shoulder surgeons would include all proximal humerus as four
separate parts that
alternative methods of fixation described in this can be dis-assembled by
injury. The parts are
text in their repertoire, tailoring the choice to the shaft of the humerus, the
articular part of the
their own skills and experience, their assessment humeral head, the greater
tuberosity and the
of the patient and the patients own choice and lesser tuberosity. This is
useful conceptually, as
their interpretation of the literature, which the two tuberosities carry
the attachments of the
shapes the final decision. rotator cuff, which normally
stabilises the
Treatment of Proximal Humerus Fractures by Plate Osteosynthesis
1231
articular part of the humeral head in the socket

and creates a stable fulcrum for movement of the
humeral shaft. It is therefore clear to see that any
significant disruption of any one of these parts
will have a marked effect on shoulder function.
Furthermore it becomes apparent that the best
chance of restoring normal function will be with
treatment that maintains or restores these four
parts into their correct relationship with each
other.
If a classification system is used that considers
the proximal humerus as four parts this does not,
of course, enable accurate description of all frac-
ture patterns. Neer added two further factors to
his classification system to enable description of
injuries that have a prognosis that is more
compromised the presence or absence of asso-
ciated glenohumeral dislocation (which disrupts
capsular attachments, compromises blood supply
and has a higher risk of non-union and avascular
Fig. 1 A valgus impacted
fracture. The medial hinge is
necrosis) and the occurrence of a head
intact, giving this
fracture pattern more mechanical stabil-
split a displaced fracture of the articular sur- ity and a lower risk of
avascular necrosis
face of the humeral head itself. This not only
carries a risk of arthritis if not anatomically
reduced, but also has a significant effect on the between the humeral head
segment and the
blood supply to one or more of the articular head shaft, and indeed between
the tuberosities and
segments, leading Neer to suggest that the appro- the humeral head. However
the fracture lines
priate treatment was humeral head replacement rarely pass directly
between the lesser and greater
in all cases. However the valgus impacted frac- tuberosity as this is the
location of the bicipital
ture (Fig. 1) has a much more favourable prog- groove, which has a floor
of dense cortical bone
nosis than its classification, according to Neer, and a reinforced roof
across the groove,
would suggest [7, 8]. Note that the subdivision connecting the greater and
lesser tuberosities.
into fracture sub-types requires that the fracture is Thus fracture lines tend to
pass lateral to the
displaced by at least 1 cm or rotated by 45# , bicipital groove, or on
both sides with the seg-
according to Neers system most proximal ment of bone containing the
groove separating as
humeral fracture patterns involve displacements a unique fragment the
shield [9]. Whilst this
that are less than this and only those parts meeting might not affect decision-
making it can affect
these criteria should be counted as separate parts. surgery, as the approach to
the fracture for reduc-
Thus the majority of shoulder fractures are in fact tion is usually through the
fracture lines and
one part fractures, even though fracture lines may stabilisation of the
separate fragments will be
involve the surgical neck or tuberosities, and required when definitive
fixation is undertaken.
have a good prognosis and are suitable for non- An appreciation of the
overall pattern of dis-
operative management. ruption is therefore
communicated by classifica-
The most obvious fallacy with classification tion, but the imaging of
each injury has to be
systems that rely on the description of four parts studied carefully in
preparing the surgical tactic,
is that there is an assumption that fracture lines as the anatomy of the
fracture can vary signifi-
occur at the junction between the four parts. This cantly even between
fractures that are classified
description is usually appropriate for fractures into the same group.
1232
D. Limb
scapulohumeral and
axohumeral muscles that
Relevant Applied Anatomy, Pathology cross the joint. After fracture the shoulder
may
and Biomechanics function well with a degree of mal-union, but
it
cannot function normally
if the head and shaft are
The relevant anatomy of the proximal humerus is not restored to their
normal length, alignment and
described by the above classification systems; the rotation (see chapter on
Biomechanics of the
shaft, humeral head, greater- and lesser tuberos- Shoulder). Fortunately
even moderately large
ities often being considered as the four main deficits in range or
strength can be absorbed by
parts upon which these systems are based. the compensatory
mechanisms within the articu-
This concept has not simply been developed for lations of the
ipsilateral upper limb and by trans-
anatomical convenience however. The pattern of fer to the opposite upper
limb, so function may be
fractures has a large part to play in determining maintained.
the long-term outcome, as each of the parts The functions of the
rotator cuff are described
described above is not only structurally important elsewhere in this text.
If the greater and/or lesser
but is integral to the normal biomechanical envi- tuberosities are
separated from the humeral head
ronment of the shoulder and in the pattern of and shaft they will
displace by the pull of the cuff
blood flow around the shoulder. muscles and a significant
functional deficit will
In addressing shoulder fractures some simple occur. Care should be
taken on radiographs to
anatomical facts must be borne in mind. For identify such fractures
and to treat accordingly.
instance, the humeral head is retroverted such Minimally displaced
fractures can displace with
that it faces the glenoid fossa when the humerus time, so repeated
radiographs are required during
is in neutral rotation. We are used to looking at AP rehabilitation. On the AP
view a greater tuberos-
radiographs of the shoulder showing a plate on the ity fragment attached to
supraspinatus may be
lateral cortex of the proximal humerus. However seen displaced into the
acromiohumeral space,
these films are taken also with the humerus turned where it is obvious.
However a larger fragment
so that the forearm faces forwards, so that humeral with infraspinatus
attached (particularly if there
rotation is neutral. In reconstructing the shoulder was a pre-existing
supraspinatus tear not
therefore the patient must not be positioned with uncommon over the age of
65) will displace pos-
the arm across the chest, as this internally rotates teriorly and can be
missed on the AP view. Axial
the shaft by almost 90# if a plate is fixed laterally views are mandatory and
may be the only plain
with the arm across the chest then a gross internal images on which displaced
lesser- and greater
rotation deformity will result and external rotation tuberosity fragments are
visible. The functional
will not return. The arm should be free so that the effects of a displaced
tuberosity may be much
forearm can be pointed forwards, bringing the more significant that a
cuff tear de-functioning
humerus into neutral rotation. In this position a similarly-sized area of
tuberosity, as the bone
screws should be directed about 30# posterior to fragment itself will
malunite and physically
the coronal plane, in the line of the retroverted block rotation through
the subacromial space or
humeral head articulating with the glenoid. It is against the margin of the
glenoid, depending on
also important to restore the length of the humerus the direction of
displacement.
as shortening will weaken deltoid and inhibit
rehabilitation.
The humeral head articulates with the glenoid Blood Supply
and any violation of this relationship, by disloca-
tion or intra-articular injury, will clearly disrupt The blood supply to the
humeral head is derived
glenohumeral joint function. Likewise anything normally from the
nutrient artery, via the shaft.
that impacts or tilts the humeral head will affect This is clearly
interrupted in fractures of the
the length-tension relationships in the rotator surgical neck. A supply
also enters through the
cuff muscles, the deltoid and in the other rotator cuff insertion,
but also at the capsular
1233
insertion. The anterior two-third of the humeral shoulder, which are fixed-
angle devices that can
head is supplied by the anterior circumflex be shown on testing to
significantly resist fracture
humeral artery, which sends an ascending branch displacement. Unfortunately
the complication rate
to the anterior capsule adjacent to the bicipital was found to be high [11]
and impaction of the
groove [10]. Note however that this is a common blade into the head of an
unstable 3 or 4 part
site of fracture and this significant blood vessel fracture was itself apt to
cause displacement of
may be injured by the fracture itself. Worse still, previously minimally-
displaced tuberosity frag-
perhaps, it is vulnerable to injury at surgery if ments. Locking plates were
developed and these
dissection is carried out in the region of the biceps provide stable fixation
[12] and have similar bio-
tendon or if plates are applied in this area. mechanical properties to
blade-plates but are
Medially there are several branches, which inserted in a manner that
is much easier to control,
enter at the capsule insertion, and this has impli- with a hold that includes
bone from a greater pro-
cations for one particular fracture pattern the portion of the head than a
blade can reach.
valgus impacted fracture. It has long been noted Although blades do engage
in the strongest, cen-
that although 4-part fractures, according to the tral bone in the humeral
head, multiple screws or
Neer classification, have a significant risk of pins can take advantage of
the strong bone that is
avascular necrosis, those with minimal displace- distributed around the
entire humeral head in
ment of the medial hinge [6] the junction a subchondral location
[13]. For now, angular
between head and shaft medially do not share stable locking plates are
the implant of choice
this poor prognosis. Thus, valgus impacted frac- when plate fixation is
selected for the fixation of
tures can be carefully reduced and fixed with the shoulder fractures but, as
will be seen, they are not
expectation of a much lower risk of late compli- without complications
themselves.
cations. However this relies on the surgeon
avoiding dissection or significant displacing
forces on the intact hinge, which would interrupt Diagnosis
the supply. Such fractures are therefore ideal for
percutaneous methods of reduction and fixation Diagnosis in trauma cases
is usually straightfor-
or plate fixation after reducing the fracture by ward, with a history of an
impact to the shoulder
careful elevation of the head using access through or transmitted through the
arm followed by
fracture lines. severe pain and
dysfunction. There is tenderness
proximally and, with
fractures involving the sur-
gical neck in particular,
there may be fracture
Biomechanics crepitus. Radiographs in at
least two planes are
mandatory and will be
discussed further when
The biomechanics of the implants that can be used pre-operative planning is
considered. Radio-
to fix proximal humerus fractures also deserves graphs in two planes will
significantly increase
brief mention. Although plate fixation has been the chances of identifying
dislocations and dis-
practiced for years, it was recognised that if the placement of fractured
tuberosities. However,
fracture itself was unstable then displacement thorough clinical
assessment will be needed to
could, and frequently did, occur after fixation identify other aspects of
the injury that can influ-
with conventional screws and plates, as the screws ence management. Thus a
careful assessment of
could toggle in the plate-holes and offered no the skin condition, and any
open wound, should
resistance to relative movement between fracture be followed by a documented
assessment of the
fragments unless the fragments were compressed neurovascular status.
Fracture-dislocations in
together, which is not usually possible in multi- particular can be
associated with nerve and vessel
fragmentary fractures typical of osteoporotic injuries, including
brachial plexus injuries. In
injuries. The situation was improved by the intro- very high energy injuries,
particularly those
duction of specific blade-plates for use in the involving an associated
clavicle fracture, a chest
1234
D. Limb
radiograph will have been taken and should be Two-part fractures

involving the surgical neck
reviewed to ensure the scapulae are equidistant are more likely to be treated
by internal fixation if
from the spine an increase in the distance there is significant medial
displacement of the
between medial border of the scapula and the shaft, particularly if
contact between shaft and
spine is seen in scapulothoracic dissociation, head is lost completely. No
benefit has been
which carries a very high risk of arterial injury shown for internal fixation
of any of these frac-
and brachial plexus avulsion; fixation of the prox- tures in the very elderly and
infirm, particularly if
imal humerus may be an important part of recon- they are incapable of
following a fairly rigorous
struction. Low energy injuries may reflect rehabilitation regime after
surgery.
underlying osteoporosis, but other causes of path- Two-part fractures
involving the surgical
ological fracture may have to be sought and neck are ideal fractures for
fixation using
excluded. intramedullary devices,
though it has to be
borne in mind that locking
nails and locking
plates may be a very
expensive option for
Indications for Surgery a fracture that may heal well
without surgery, or
with simpler devices such as
percutaneous wires
The indications for surgical fixation of proximal or straightforward non-
locking plates and screws.
humeral fractures have not been clearly defined. The question of
intervention thresholds with
Furthermore the suitability of one method of fix- respect to fracture
displacement has not been
ation over another has not been subjected to suf- clearly answered and in any
event has to be con-
ficiently rigorous scientific inquiry to be able to sidered taking in all
patient-related as well as
define where plate fixation has clear advantages injury-related factors.
However we know that
over percutaneous methods, intramedullary fixa- varus deformity of more than
20# is not tolerated
tion and indeed whether a locking plate will give well [14, 15] and it is
generally accepted that
better results than a (usually cheaper) non- greater tuberosity
displacement of more than
locking option. 5 mm carries a high risk of
functional
That being said, it is a fundamental concept in impairment.
the management of fractures by internal fixation
that earlier mobilisation and function are encour-
aged. In practice, therefore, the internal fixation Pre-Operative Preparation
of proximal humeral fractures is carried out when and Planning
the patient and surgeon agree that the risks of
treatment are outweighed by the potential bene- Imaging is important in
deciding whether or not to
fits in restoring proximal humeral anatomy and fix a fracture, as well as in
deciding which methods
allowing early active use. of fixation may be
appropriate. It is then important
Thus plate fixation is usually considered to be in planning surgery, once the
decision has been
indicated when there is a displaced fracture of the made to treat by internal
fixation using a plate. The
proximal humerus that can be reduced to an ana- same images serve both
purposes.
tomic or near-anatomical state, be held there by Plain radiographs in at
least two planes are
devices that are sufficiently robust to allow early essential. The standard
trauma series for the
physiological loading without incurring a very shoulder includes AP,
scapular lateral and axil-
high risk of avascular necrosis of the whole, or lary views. However all of
the necessary infor-
part, of the humeral head. 3- and 4-part fractures mation is usually available
on the AP and axillary
are therefore commonly treated by fixation. views alone (Fig. 2) and many
units limit radia-
Similar fracture configurations associated with tion exposure in the acute
setting to these two
dislocation, or head-splitting fractures, are more projections. A single AP view
is inadequate and
likely to be considered for humeral head replace- poses a particular risk for
missing a posterior
ment, particularly in the elderly. dislocation, with or without
a fracture.
1235
a b
Fig. 2 AP and axial views contain most of the information needed to plan surgical
treatment for proximal humeral
fractures, though supplementary scans, especially CT with multi-planar
reconstruction, can be invaluable
Many units will also supplement plain radio- Neers classification, but
also permits the surgical
graphs with 3D imaging, most usefully CT with tactic to be planned.
multi-planar or 3D reconstruction. Whilst the The vast majority of
fractures can be
latter has the potential to give the surgeon the approached and fixed
through a deltopectoral
best concept of the size and displacement of approach. However this
approach is disadvanta-
the main fracture fragments, it also has some geous when the greater
tuberosity, under the
drawbacks. At present the rendering software influence of the attached
infraspinatus and
that is used to reconstruct 2-dimensional slices supraspinatus, is
displaced posterior to the
into a representation of a solid form relies on humeral head and in a
medial direction, towards
smoothing software to take off steps and the glenoid margin. If
imaging does suggest that
sharp edges between layers. In doing so it can reduction manoeuvres
behind the humeral head
render undisplaced or minimally-displaced frac- may be necessary then a
lateral deltoid split can
ture lines invisible. 3D reconstructions should be performed, as
originally described for the
always therefore be read in conjunction with 2D management of posterior
fracture dislocations,
slices. However, 3D reconstructions are invalu- though originally felt to
be limited to an operative
able in the visualisation of complex fracture window above the axillary
nerve [16]. However,
patterns and in planning the most appropriate more recently it has been
demonstrated that the
approach and fixation construct for such axillary nerve can be
identified and windows cre-
injuries. ated above and below the
nerve for access [17].
Imaging therefore confirms the number of A plate can therefore be
inserted into the superior
fracture lines and therefore the number of main incision and can be slid
under the nerve and down
fracture fragments. It indicates which fragments the lateral shaft. A
separate window below the
are displaced and to what degree. This not only nerve can be used to
insert distal screws in the
allows fractures to be categorised for communi- plate. This approach
places the plate more later-
cation and research purposes, for example with ally on the shaft than a
deltopectoral approach
1236
D. Limb
Fig. 3 Theatre set-up. The

surgeon should have access
to the operative site with
a clear view of the image
intensifier screen. The
intensifier itself should be
positioned to allow imaging
without interference with
the surgical access
and, if a long plate is used, detachment of the to isolate from specimens

taken in cases of
deltoid insertion becomes necessary. However, suspected infection and may
need longer incuba-
the deltoid tendon is in continuity with the lateral tion than the 48 h commonly
employed in clinical
intermuscular septum and there do not appear to laboratories.
Proprionobacter acnes remains the
be any significant functional consequences of commonest organism causing
infection of shoul-
subperiosteal release of the anterior deltoid inser- der replacements and after
rotator cuff surgery
tion to allow plate fixation. It should be borne in and should be considered if
infection develops
mind that whatever approach is used, it should be after plate fixation [19,
20]. Local antibiotic pro-
suitable for re-use at a future time. A recent sys- phylaxis guidelines should
be adhered to and
tematic review of the treatment of 3- and 4-part these should take into
account the potential
fractures with locking plates revealed a re- infecting organisms.
operation rate of 13.7 % [18].
Surgery will entail reduction manoeuvres that
must be carried out with minimal disturbance of Operative Technique
the soft tissue envelope, and any remaining
attachments of tendon, capsule and fascia to frac- Regardless of whether a
deltopectoral or deltoid-
ture fragments must be preserved in order to splitting approach is used
the patient is best
preserve the blood supply. Consequently an prepared in a beach-chair
position with the
image intensifier becomes essential and arrange- arm draped free to allow
manipulation and rota-
ments must be made for the relevant equipment tion of the humeral shaft
via the forearm (if it is
and staff to be available. Theatre set-up must also not also injured). The arm
can be rested on a side
be planned to accommodate the intensifier and table and, by adjusting the
height of this to
allow a clear line of vision between the surgeon abduct the arm slightly,
tension in the deltoid
and the image screen (Fig. 3). can be relieved to
facilitate retraction and expo-
The incidence of infection is low. However, sure of the proximal humerus
(Fig. 4). This
the axillary sweat glands are a reservoir for chapter will describe
fixation using the
Proprionobacter spp. and this can be very difficult deltopectoral approach,
which has the advantage
1237
Fig. 4 The arm is rested on a table so that it can be

manipulated to facilitate reduction. Raising the table and
abducting the arm both relieve tension in the deltoid,
improving access
Fig. 5 The incision
extends from the lateral margin of the
coracoid towards the
upper medial part of the arm, lateral
of being a general utility incision for the shoul- to the axillary fold
der and can be used for almost any future shoul-
der surgery the patient may need.
The skin incision should be sufficient without whichever method is
chosen. A self-retaining
being unnecessarily long. The incision will usu- retractor is inserted
to separate the deltoid and
ally start at the lateral edge of the coracoid pro- pectoralis major.
cess, but this depends partly on the locking plate The surgeon is then
confronted by swollen,
being used as this dictates how high on the lateral bruised tissue quite
unlike the expected appear-
humerus it will sit. The incision then passes down ance gleaned from
anatomy texts and most man-
to the top of the anterior axillary crease and can ufacturers surgical
technique guides. The
continue in the deltopectoral interval for as long thoracobrachial fascia
extends laterally from the
as is necessary to obtain sufficient length of plate conjoined tendon and
contains blood and oedema
beyond the fracture (Fig. 5). For complex frac- from the fracture
site, obscuring any view of the
tures a bridge-plate technique may be used, in subscapularis tendon
and proximal humerus
which case a smaller proximal incision is made (Fig. 6). The fascia
is opened along the lateral
to allow reduction and fixation of the head and edge of the conjoined
tendon and can be excised
tuberosities, the plate being slid in contact with with the underlying
oedematous areolar tissue to
bone distally where it can be exposed through expose the lesser
tuberosity and attached
a separate incision, beyond the zone of bone subscapularis (Fig.
7).
injury, to secure distal fixation. Hereafter the
procedure depends on the frac-
After making the skin incision the deltopectoral ture configuration but
consists of two
interval is opened. The cephalic vein can be steps reduction of
the fracture fragments and
retracted medially or laterally lateral retraction stabilisation with an
internal fixation device.
puts the vein under more tension with retraction
and it is more likely to be injured when using drills
and screwdrivers. However medial retraction often Reduction
results in avulsion of short tributaries from the
deltoid, which can be difficult to control except The rotator cuff,
biceps tendon and its roofed
by tying off and sacrificing the vein. There is no tunnel, pectoralis
major and deltoid insertions
significant morbidity if the cephalic vein is lost, all bind and restrain
elements of the fracture so
1238
D. Limb
length, alignment and

rotation before fixation.
With two-part fractures
this is relatively simple
in theory (though often
surprisingly tricky in
practice, especially if
the bone is osteoporotic
and fragmented). The
shaft can be controlled by
gripping the arm and
manually positioning it
under the head to bring
the fracture surfaces
together. Difficulty
can arise if there has been
significant
displacement at the time of injury,
which can leave soft
tissue, including the long
head of biceps tendon,
caught in the fracture over
bone spikes and
blocking reduction.
For multi-
fragmentary fractures it is usually
necessary to obtain
some sort of hold on each
fragment so that all
fragments can be indepen-
dently rotated, pulled
and pushed to secure reduc-
tion. If the humeral
head still has an attached
Fig. 6 The deltopectoral interval is opened and the tuberosity this can be
controlled either by
thoracobrachial fascia is encountered. This is usually a stout wire through
the tuberosity, which can
oedematous and bruised, obscuring vision of the underly-
ing subscapularis and tuberosities
be used as a joystick,
or by taking a bite of the
rotator cuff at its
insertion into the tuberosity with
strong suture material
(No. 5 braided polyester,
for example). For
separated tuberosity fragments
the latter technique is
best, as wires tend to split
the shell of bone
attached to a separated
tuberosity.
The most critical
suture is that which is most
difficult to place
that controlling the greater
tuberosity from
posterior displacement under
the influence of
infraspinatus. If the greater tuber-
osity is displaced
behind the humeral head this
can be difficult to
reach through a deltopectoral
approach and
consideration may have been given
to using a lateral
deltoid split. However the suture
can be positioned by
using a piggy-back tech-
nique. A stout suture
is placed in the
supraspinatus and is
used to pull the greater tuber-
osity forwards. This
exposes a more posterior
Fig. 7 After excising thoracobrachial fascia the tuberos-
ities and fracture lines that are not obscured by cuff
segment of the cuff, in
which a second stout
attachments come into view suture is placed. The
first is removed, then the
second is used to pull
the cuff forwards again.
Stepwise the cuff, and
its attached bony frag-
visualisation requires image intensification. Any ments, is brought into
view until eventually
soft tissue attachments should be preserved, even a suture can be placed
behind the greater tuber-
if release would facilitate direct visualisation of osity, and can be used
to apply traction to reduce
the reduction. The various fragments should and fix the tuberosity.
therefore be mechanically controlled so that For 3- and 4-part
fractures stout sutures, for
they can be brought together with the correct example No. 5 braided
polyester as described
1239
Fig. 8 Reducing the fracture the lesser tuberosity has

been reduced and fixed to the head with a temporary wire
whilst a braided suture through the posterior cuff insertion
is being used to control the greater tuberosity. An elevator Fig. 9 Image
intensifier view of the humeral head being
passes through the neck fracture site and is being used to elevated into the
coracoacromial arch to obtain fracture
elevate the humeral head reduction
above, should be passed through the cuff where it connecting the

greater to lesser tuberosities around
inserts into each bony fragment. Once the tuber- the head (indeed,
one form of minimally-invasive
osity fragments are controlled in this way the surgery does just
this, then secures the greater
head should be reduced. This is achieved by tuberosity to the
shaft with another suture giving
passing an elevator of some sort (the author uses a reduction that can
be maintained without further
the periosteal elevator from a small fragment set) implants, though it
is not capable of withstanding
through the fracture site and into contact with the physiological loads
until union begins). If a suture
fracture surface of the humeral head (Fig. 8). is tied as a lateral
tension band in this way, it will
The head can then be pushed up into the come to lie under
the plate and care will have to be
coracoacromial arch whilst the arm is pulled taken to avoid
damaging the suture when drilling
down, using image intensification (Fig. 9) to holes for screws. If
the plate is applied first, then
check that the force is being applied in the correct the sutures pre-
placed in the rotator cuff insertions
place to reduce the head (for example, pushing up can be passed
through purpose-made holes
on the lateral part of the fracture surface of designed into most
modern locking implants to
a valgus head). Once the head is reduced in rela- stabilise the
tuberosities.
tion to the glenoid fossa the tuberosities can be If there is a
void beneath the humeral head,
pulled out to restore their positions around consideration should
be given at this stage to
the head if the head is correctly reduced the filling this to
improve initial stability. It is not
tuberosities can lock around it and a surprisingly known whether this
makes any difference to the
stable fracture reduction may be obtained. At this risk of loss of
reduction in the longer term. The
point further consideration can be given to tem- void can be filled
with bone graft or bone graft
porary stabilisation with K wires through the substitutes (which
avoid the problem of donor
tuberosities into the reduced head. Sometimes it site morbidity,
particularly in fragility fractures
is possible to take the suture that is passing where donor bone may
also be of poor structural
through the posterior part of the cuff around the quality). Other
authors have used structural sup-
front and take a bite of the subscapularis inser- port beneath the
humeral head, either in the form
tion. This can then be tied as a tension band of fibular strut
graft [21], bone cement or
1240
D. Limb
a b
Fig. 10 After provisional reduction a plate is applied with an initial wire or

screw through the plate (a) to allow
screening in two planes to check correct plate positioning (b)
substitutes [22] or metallic implants specifically straightforward, one may

not be keen to manip-
designed to support the humeral head and resist ulate the shaft
forcefully to lateralise the shaft.
the tendency to tip into varus or valgus. In these circumstances
consider placing the
Once the tuberosities and head are stabilised in plate in its correct
height in relation to the head
this way the 3- or 4-part fracture has been then drilling and
measuring for a non-locking
converted to a 2-part fracture and all that remains screw passing through
the plate into the
is to reduce the shaft beneath the head/tuberosity medially-displaced
shaft. If the displacement is
construct and stabilise this with a plate. not too great,
tightening the screw will pull the
shaft to the plate,
bringing it back under the
head. The screw will
then be too long, but can
Fixation be changed or removed
once the remaining
screws have been placed
in the proximal
Whilst locking plates have the advantages that humerus and the shaft.
come with a fixed-angle design, this also means The placement of
locking screws or pegs into
that the first screw in the construct fixes the posi- the head fragment should
fix the relationship
tion of the plate in relation to the humerus. If this between the head and
shaft (Fig. 11a, b). If the
is incorrect, the locking screws will not evenly screws pass through the
tuberosity fragments then
distribute through the head but will group these too will be
stabilised. However, a laterally-
towards the front or back of the head, making placed plate will not,
in many cases, allow screws
some screw holes unusable. It is good practice, passing through the
plate to stabilise the lesser
therefore, to select the plate position and insert tuberosity or a
separated posterior greater tuber-
a single, central screw (or wire (Fig. 10a, b), if the osity fragment. For this
reason many locking
plate is designed to allow wires to be passed on plate systems allow
heavy sutures or wires to be
a fixed trajectory through the plate) and to screen passed through holes in
the plate this allows the
the device in both AP and axillary planes before No 5 braided sutures
that have been used to
completing the fixation. reduce the fracture to
maintain the reduction by
The shaft may be medially displaced and, if incorporation into the
fixation device. Securing
reduction of the head fragments has not been the tuberosities is a
critical step and migration of
1241
a b
Fig. 11 After confirming plate position the remaining screws and/or pegs are
inserted (a) and checked (b)
the tuberosities results in significant impairment For the same reasons

careful measurement is
of the outcome. Tenuous fixation relying on one required. Blunt pegs,
rather than screws, can be
or two of the screws catching the edge of the used in the humeral
head. These allow the head to
tuberosity fragments is simply not acceptable. sit on an array of pegs
but they do not have sharp
If locking screws are not used great care has to tips, theoretically
reducing the risk of screw cut-
be taken to minimise forces on the screws that out and head penetration
(Fig. 12).
might allow the head fragment to rotate, as this Once the locking
screws have been placed into
will allow the screws to toggle in the plate and the the head, which itself
has already been secured to
head will tilt into varus or valgus (usually the shaft with one
screw, all that remains is for the
returning towards the displacement that was remaining screws to be
placed in the plate as it
reduced before fixation). The most effective way lies on the shaft. If
there is metaphyseal commi-
of neutralising these forces is to obtain anatomi- nution a larger plate
may have been selected to
cal reduction of the head and tuberosities when bridge the area,
otherwise a plate with three bi-
good bone stock is present if there has been cortical screws below
the head is generally suffi-
impaction or comminution, stability may require cient. With modern
systems these screws may be
reconstitution of the defect as described above. locked, improving the
performance of the fixa-
With locking plate systems, however, these tion in osteoporotic
bone. Images are checked in
defects will often fill in without the need for graft. two planes, as the most
common complication of
The placement of screws should take advan- most locking plate
systems is penetration of the
tage of the best bone for fixation and this is humeral head by screws
[23].
inevitably in the subchonral region of the head. Thereafter the wound
is washed out, taking care
Holes for screws should be drilled up to the not to disturb any bone
graft. If graft has not been
subchondral plate but drilling into the joint used by this stage,
there is one more opportunity to
should be avoided, not least because it facilitates consider inserting it
before the wound is closed.
screw penetration into the joint if there is any Otherwise the
deltopectoral groove is allowed to
error in measurement or if the head settles down fall back together, a
drain is inserted if desired and
onto the fixation device during rehabilitation. the fat and skin layers
are closed.
1242
D. Limb
on the guiding
principles. The first of these is
that few health care
systems can afford for reli-
ance to be placed on
a third party for delivering
the rehabilitation
programme. Whilst physio-
therapists may
assess, advise, progress and
facilitate the
programme, the onus is on the
patient to get the
shoulder working again using
the rehabilitation
programme outlined to them,
as this is a job that
can occupy several hours
a day. Indeed this
should be impressed on
patients before
surgery, as a beautifully-fixed
fracture, that is
rested in a sling and all painful
activity avoided
permanently, will become
a useless shoulder.
Rehabilitation
programmes attend to pain,
range of movement,
strength and finally func-
tional restoration of
correct neuromuscular con-
trol. Most studies
show that early rehabilitation
gives the best
results [24]. As the elderly popula-
Fig. 12 After fixation check films are taken in this case tion are primarily
affected attention should be
a system has been used that supports the humeral head on
a series of blunt pegs. Alternatively screws may be used in
paid to secondary
prevention, not only in the
the humeral head segment detection and
treatment of osteoporosis, but also
in falls prevention
with rehabilitation of balance
and neuromuscular
control mechanisms. A sling
may be used for pain
relief a collar-and-cuff
Post-Operative Care and may allow gravity
assistance with the mainte-
Rehabilitation nance of alignment in
non-operatively treated
fractures, though
this is only true when the patient
Open reduction and internal fixation is carried is upright. Many one-
part fractures are suffi-
out to restore the mechanics of the shoulder so ciently stable that
movement can begin
that ultimately a normal, or near-normal, out- immediately often
gentle, unloaded swinging
come is possible. When plate fixation is movements such as
pendular exercises. The same
selected, rather than minimally-invasive or min- is true for
operatively-fixed fractures and the aim
imal fixation methods, the second aim is to of plate fixation is
to allow immediate motion to
allow early physiological loading to accelerate reduce the duration
and extent of stiffness: few
rehabilitation. Thus, early range of movement shoulder fractures,
even after anatomical reduc-
exercises and the promotion of early function tion and fixation,
will regain absolutely normal
are desirable. Patients may be fitted with a sling range of movement.
for comfort, and movements may be delayed No hard and fast
guidelines can be made about
long enough to ensure that wound healing has the speed of progress
through rehabilitation as
commenced (therefore could be delayed if there this depends in part
on the security of fixation
is any wound discharge), but in general the achieved at surgery.
Even in osteoporotic bone
rehabilitation programme can commence as one is usually
confident that the head-shaft fixa-
soon as the patient has recovered from tion is good enough
to allow gentle active motion
anaesthesia. immediately.
Tuberosity fixation that is depen-
There is a wide range of opinion on exactly dant on sutures may
bring an element of caution
how rehabilitation care should be delivered after to the resumption of
loaded use of the muscles
shoulder surgery, and this article will only touch attached to the
relevant tuberosity or passive
1243
stretch of the same to increase range of move- protected, working through

windows above and
ment. However, progressive increase in the appli- below the nerve. The beach-
chair position does
cation of physiological loading to fixed fractures result in a small risk of
air embolus if division of
is needed to stimulate union and in the vast the cephalic vein is not
recognised.
majority of cases one should be able to resume The tissues around the
shoulder are very vas-
active assisted treatment aimed at the resumption cular and this mitigates
against a high infection
of full range by 3 weeks after surgery and the risk. However the reported
infection rate after
commencement of loaded activities by 6 weeks. fracture fixation is still
of the order of 1 % and,
as noted above,
Proprionobacterium acnes is not
uncommon as a causative
organism and can be
Complications difficult to detect [19,
20].
The most common
complications in recent
The overall complication rate of shoulder frac- literature relate to the
biology of the injury and
ture fixation with locking plates is high [18, 25], the mechanics of the
fixation. Even with modern
and although fixation systems are becoming more locking plates and careful
dissection, avoiding
reliable they are also encouraging surgeons to soft tissue stripping, the
rate of avascular necrosis
attempt fixation of fractures that would previ- is significant, the
incidence depending on the
ously have been treated by hemiarthroplasty or fracture pattern. If 2- part
fractures are
by nonoperative means. There is therefore no discounted, rates of 9 % for
avascular necrosis
indication that, as our experience of treating are typical [14]. Decision-
making at the time of
these complex injuries increases, the complica- surgery based on the
presence or absence of
tion rate is decreasing. apparent ischaemia is not
reliable, as this has
Complications can be related to anaesthesia not been shown to be related
to the likelihood of
and, although this is a matter for the anaesthetist future necrosis [27].
to discuss with the surgeon, one should be aware However, the rate of
screw perforation into the
that pneumothorax can acutely compromise respi- glenohumeral joint is higher
still, either occurring
ration but diaphragmatic paralysis can threaten at the time of initial
surgery or later, if displace-
those with pre-existing chest disease. The C4/5 ment or avascular necrosis
of the head occur.
roots are targeted with interscalene blocks for In two large multi-centre
trials the rate of primary
shoulder surgery and many will remember the screw perforation was
reported to be 14 %
aide memoire C345 keeps the diaphragm alive. [28, 29], and secondary
perforation in 8 %.
An interscalene block can therefore easily impair Secondary displacement of
fractures after
diaphragmatic function, which for most patients is locked-plate fixation is
much more common
easily accommodated by their respiratory reserve. when the initial fracture is
displaced into varus
Fortunately this reverses when the block wears off, compared to when the initial
displacement is
but this could mean 24 h of respiratory difficulty valgus 79 % versus 19 % in
one study [15].
for those with poor pre-operative lung function. The true risk-benefit
ratio for internal fixation
Pneumothorax is a much rarer complication, and is (of any kind) of the
proximal humerus is not
becoming rarer with more widespread use of ultra- known. Although many
published studies have
sound to direct needle insertion and anaesthetic failed to show dramatic
benefits the quality of
infiltration. Overall, however, interscalene blocks available studies is not
high. This creates signif-
have proved to be very safe [26]. icant problems in
interpretation as most surgeons
The risks of neurovascular injury in the agree that a well-
motivated, active patient is an
injured limb are particularly high if there is ideal candidate for surgery
but the inclusion
a dislocation. The axillary nerve is also at risk criteria for many studies
are based on radiologi-
with deltoid splitting approaches, though recent cal criteria and the absence
of mental insuffi-
literature indicates the risk can be significantly ciency. Furthermore,
publication bias confounds
minimised if the nerve is properly identified and matters further a moderate
benefit from surgery
1244
D. Limb
in a poorly constructed trial is unlikely to be fracture of the

proximal humerus. J Shoulder Elbow
published but very poor results, even in Surg.
2004;13(4):42733.
7. Jakob RP, Miniachi
A, Anson PS, et al. Four-part
a poorly-constructed study, may be published. valgus-impacted
fractures of the proximal humerus.
Randomised trials are on-going and the most J Bone Joint Surg
Br. 1991;73B:2958.
recent suggest moderate benefit even in elderly 8. Resch H, Povacz P,
Frohlich R, et al. Percutaneous
patients, but at the cost of a reoperation rate of fixation of three-
and four-part fractures of the proxi-
mal humerus. J
Bone Joint Surg Br. 1997;79B(2):
almost one in three [25]. 295300.
9. Edelson G, Kelly
I, Vigder F, Reis ND. A three-
dimensional
classification for fractures of the proxi-
Summary mal humerus. J
Bone Joint Surg Br. 2004;86B(3):
41325.
10. Gerber C,
Schneeberger AG, Vinh TS. The
Plate fixation remains the most versatile method arterial
vascularisation of the humeral head. An ana-
of fixing fractures of the proximal humerus, as it tomical study. J
can be employed from cases of simple surgical 148694.
11. Meier RA, Messmer
P, Regazzoni P, Rothfischer W,
neck fracture with displacement through to Gross T.
Unexpected high complication rate following
complex 3- and 4- part fractures and fracture- internal fixation
of unstable proximal humerus frac-
dislocations. However the evidence about which tures with an
angled blade plate. J Orthop Trauma.
fractures should be treated by internal fixation is 2006;20(4):25360.
12. Chudik SC,
Weinhold P, Dahners LE. Fixed-angle
poor. In the very elderly with poor quality bone plate fixation in
simulated fractures of the proximal
and a mental state that does not allow them to co- humerus: a
biomechanical study of a new device.
operate with a rehabilitation regime there is little J Shoulder Elbow
Surg. 2003;12(6):57888.
doubt that the results of surgical treatment are no 13. Liew AS, Johnson
JA, Patterson SD, King GJ,
Chess DG. Effect
of screw placement on fixation in
better than non-operative management. Likewise the humeral head.
there is little doubt that the open proximal 4236.
humeral fracture with axillary artery division 14. Solberg BD, Moon
CN, Franco DP, Paiement GD.
needs emergency stabilisation. It is making deci- Surgical treatment
of three and four-part proximal
humeral fractures.
J Bone Joint Surg Am. 2009;
sions between these extremes that poses ques- 91A(7):168997.
tions to the surgeon that may be impossible to 15. Solberg BD, Moon
CN, Franco DP, Paiement GD.
answer with our current knowledge base. Locked plating of
3- and 4-part proximal humerus
fractures in older
patients: the effect of initial fracture
pattern on
outcome. J Orthop Trauma. 2009;23(2):
1139.
References 16. Stableforth PG,
Sarangi PP. Posterior fracture-
dislocation of the
shoulder. A superior subacromial
1. Siebennrock KA, Gerber C. The reproducibility of approach for open
reduction. J Bone Joint Surg Br.
classification of fractures of the proximal end of the 1992;74B(4):579
84.
humerus. J Bone Joint Surg Am. 1993;75(A):17515. 17. Gardner MJ,
Griffith MH, Dines JS, Briggs SM,
2. Sidor ML, Zuckerman JD, Lyon T. The Neer classifi- Weiland AJ, Lorich
DG. The extended anterolateral
cation system for proximal humeral fractures. An acromion approach
allows minimally invasive access
assessment of the interobserver reliability and to the proximal
humerus. Clin Orthop. 2005;434:
intraobserver reproducibility. J Bone Joint Surg Am. 1239.
1993;75(A):174550. 18. Thanasas C,
Kontakis G, Angoules A, Limb D,
3. Jakob RP, Ganz R. Proximale humerusfrakturen. Helv Giannoudis P.
Treatment of proximal humerus frac-
Chir Acta. 1981;48:595610. tures with locking
plates: a systematic review.
4. Neer CS. Four-segment classification of proximal J Shoulder Elbow
Surg. 2009;18(6):83744.
humerus fractures. Instr Course Lect. 1975;24:1608. 19. Levy PY, Fenollar
F, Syein A, et al. Propriono-
5. Codman EA. The shoulder: rupture of the bacterium acnes
postoperative shoulder arthritis: an
supraspinatus tendon and other lesions in or emerging clinical
entity. Clin Infect Dis.
about the subacromial bursa. Boston: Thomas Todd; 2008;46:1884.
1934. 20. Sperling JW, Kozak
TKW, Hanssen AD, Cofield RH.
6. Hertel R, Hempfing M, Stiehler M, Leunig M. Pre- Infection after
shoulder arthroplasty. Clin Orthop
dictors of humeral head ischaemia after intracapsular Relat Res.
2001;382:20616.
1245
21. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indi- a randomized
controlled trial. J Shoulder Elbow
rect medial reduction and strut support of proximal Surg. 2011;20:747
55.
humerus fractures using an endosteal implant. 26. Borgeat A,
Ekatodramis G, Kalberer F, Benz C. Acute
J Orthop Trauma. 2008;22(3):195200. and nonacute
complications associated with
22. Kwon BK, Goertzen DJ, OBrien PJ, Broekhuyse HM, interscalene block
and shoulder surgery: a prospective
Oxland TR. Biomechanical evaluation of proximal study.
Anesthesiology. 2001;95(4):87580.
humeral fracture fixation supplemented with calcium 27. Bastian JD, Hertel
R. Initial post-fracture humeral
phosphate cement. J Bone Joint Surgery Am. head ischemia does
not predict development of necro-
2002;84A(6):95161. sis. J Shoulder
Elbow Surg. 2008;17(1):28.
23. Konrad G, Bayer J, Hepp B, et al. Open reduction 28. Brunner F, Sommer
C, Bahrs C, et al. Open reduction
and internal fixation of proximal humeral fractures and internal
fixation of proximal humerus fractures
with the use of the locking proximal humerus plate. using a proximal
humeral locked plate: a prospective
Sugical technique. J Bone Joint Surg Am. 2010; multicenter
analysis. J Orthop Trauma. 2009;23(3):
92A(Supp 1, pt 1):8595. 16372.
24. Hodgson S, Iannotti JP, Evans PJ. Proximal humerus 29. Sudkamp N, Bayer
J, Hepp P, et al. Open
fracture rehabilitation. Clin Orthop Relat Res. 2006; reduction and
internal fixation of proximal humeral
442:1318. fractures with use
of the locking proximal
25. Olerud P, Ahrengart L, Ponzer S, et al. Internal fixa- humerus plate.
Results of a prospective, multicenter,
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study. J Bone Joint Surg Am.
proximal humeral fractures in elderly patients: 2009;91A(6):1320
8.
Intramedullary Nail Fixation
of the Proximal Humerus
Carlos Torrens
Contents
Abstract
Introduction - Epidemiology . . . . . . . . . . . . . . . . . . . . . 1248
Despite multiple published treatment options
proximal humeral fractures remain difficult to

Applied Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1249
manage. When considering treatment options

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1249 the most important factor to be considered is
the osteoporosis nature of the vast majority of
these fractures. Most of poor outcomes and

complications of surgically-treated proximal

1251 humeral fractures are related to osteoporosis.
Simple techniques avoiding rigid construc-
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1254 tions with hard material are preferred to deal
with these elderly-population fractures.

Locked Plates and Hemi-Arthroplasty . . . . . . . . . . 1254
Understanding the forces of cuff tendons

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1256 attached to the fragments is crucial to reduce
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1257 the fractures properly and also to plan the best
osteosynthesis option. Tuberosities must be
anatomically reduced and fixed to re-establish
shoulder function. In such an elderly popula-
tion sutures passed through the cuff attach-
ments seem to be the best option to manage
tuberosity fixation. When significant displace-
ment between the head complex and the
humeral shaft is associated, endomedullary

support has to be provided to ensure stability
of the tuberosity reconstruction, especially in
two- and three-part fractures. Modified
Enders nail have proved to give enough
dynamic stability to obtain consolidation
whilst avoiding rigid constructions.
A supplementary hole to pass sutures has to
be made at the top of the Ender nail to be able

C. Torrens
to deeply introduce the nail into the humeral

Orthopedic Department, Hospital Universitario del Mar
de Barcelona, Barcelona, Spain
head to avoid nail protrusion in the
e-mail: Ctorrens@parcdesalutmar.cat
subacromial space. Few complications are to

1247
DOI 10.1007/978-3-642-34746-7_60, # EFORT 2014
1248
C. Torrens
be expected using this simple technique and the common osteoporotic

proximal humeral frac-
most of the elderly proximal humeral fractures ture [2]. An increase in the
rate of falls, indepen-
can be successfully managed by osteosutures dent of the average rate, may
be associated with
alone or associated with Enders nails when a higher risk of humeral
fractures [4]. Fall-related
there is significant displacement of the risk factors include previous
falls, diabetes
humeral head and the diaphysis. mellitus, difficulty walking
in dim light, seizure
medication use, depression,
almost always
Keywords using a hearing aid and left-
handedness [5].
Anatomy # Complications # Diagnosis # Conversely, patients who
present with a
Epidemiology # Humerus-proximal fractures # proximal humeral fracture are
much fitter than
Intramedullary nailing # Locked plates and those who present with
proximal femoral
hemi-arthroplasty # Operative Techniques # fractures, and pre-fracture
functional status stud-
Rehabilitation # Surgical indications ies reveal that nine-tenths
live at home [2]. When
planning treatment options,
this situation has to
be taken into account to
preserve pre-operative
Introduction - Epidemiology functional status.
Although the majority of
the proximal
Most of the proximal humeral fractures have to humeral fractures are
considered to be
be considered osteoporotic fractures with a - non-displaced that does not
avoid the fact that
uni-modal distribution in older men and mortality after shoulder
fracture is considered to
women [1]. Women are likely to present with be higher than that of the
general population
a proximal humeral fracture three times more immediately after the fracture
and that this
frequently than men and the average age of tendency is maintained until 5
years after fracture
women sustaining a proximal humeral fracture when mortality is not
significantly different from
is significantly older than that in men (70 years- the mortality of the general
population [6]. Even
old in women versus 56 years-old in men) [2]. more, at the age of 60 years-
old, a previous
Proximal humeral fractures are the third most shoulder fracture is
associated with an immediate
frequent fracture in elderly people after hip and risk of hip, forearm or spine
fracture that is
Colles fractures and are exponentially increas- significantly higher than that
of the age and sex-
ing. Palvanen et al. have published that the total matched population [7]. Any
time surgical
number of Finnish adults 60 years and older hos- treatment is to be considered
the osteoporotic
pitalized with a proximal humeral fracture rose condition has to be taken into
account to avoid
during their study period from 208 in 1970 to pitfalls and complications
related to the use of
1120 in 2002. The overall incidence of these materials and strategies
designed to deal with
fractures also increased 63 %, and the mean age hard non-osteoporotic bone.
of patients with proximal humeral fractures also Most proximal humeral
fractures can be
increased from 72 years old (1970) to 77 years properly managed
conservatively, obtaining
old (2002), concluding that if these trends con- reasonable good functional
results, as has
tinue, the current number of fractures in the already been published, even
in severely-
elderly will triple during the next three decades displaced fractures [25].
Patients presenting
[3]. The vast majority of fractures are produced complex humeral fractures and
willing to
by falls from a standing height (87 %), while obtain better functional
outcome than reported
sports injuries and road accidents constitute with conservative management
are candidates
a small number of proximal humeral fractures for surgical treatment.
Fractures with
(8 %) and represent the younger population significant displacement
between the ce-
(33 years-old for sport injuries and 46 years-old phalic complex and diaphysis
are at risk of
for road accidents) whose fracture patterns and non-union and also constitute
an indication for
treatment considerations are not representative of surgical treatment.
Intramedullary Nail Fixation of the Proximal Humerus
1249
view as described by Neer

[9]. In acute fractures
Applied Anatomy good axillary views are not
always easy to obtain
because of the pain induced
by arm mobilization
The displacement of the fragments of proximal and because most of these x-
rays are done in the
humeral fractures follows the attachments of the emergency room. Recently,
the axillary view has
rotator cuff tendons. Understanding of the forces been progressively
substituted by CT studies. It
present in the fracture pattern is mandatory to has been proved that CT
scans provide clinically
obtain reduction of the fracture. useful information for the
treatment of complex
When the humeral head is disconnected from proximal humeral fractures
when radiographs
the diaphysis, the pectoral muscles internally provide inadequate
information [10]. The ratio-
translate the proximal humeral shaft while the nale may be to obtain from
each projection what
humeral head remains in place. Some release of can be obtained instead of
trying to allocate an
the pectoralis major tendon can be done to more image to a rigid
classification system. The antero-
easily obtain good reduction of the fragments. posterior view clearly
defines the relationship
In the valgus impacted three-part fracture of between humeral head and
humeral shaft and
the greater tuberosity, the humeral head is some articular and greater
tuberosity fractures,
displaced into a valgus position pushing out the but fails to inform about
the posterior displace-
greater tuberosity. Because the valgus position of ment of the greater
tuberosity fragment and gives
the humeral head, the greater tuberosity looks little information about the
lesser tuberosity.
upwardly migrated. A closer analysis of the frac- Multiple radiographic views
are needed to eval-
ture pattern shows that the greater tuberosity uate displacement of the
greater tuberosity appro-
remains in place but has no room to be reduced. priately [11]. Lateral
projection provides good
Just elevating the humeral head and restoring the information about anterior
or posterior disloca-
cephalo-diaphysis angle creates enough room to tion and the relationship
between humeral head
properly reduce the greater tuberosity. and humeral shaft but gives
unclear information
When there is disconnection of the cephalic of the position of the
tuberosities. CT scan is
complex of the diaphysis and there is also helpful in the analysis of
greater and lesser tuber-
a greater tuberosity fracture, the greater tuberos- osity fracture pattern as
well as displacement and
ity typically migrates posteriorly because of gives information on the
quality of subchondral
the infraspinatus attachment while the rest bone of the humeral head.
of the humeral head is internally rotated follow- Recently, different
sequential image analysis
ing the subscapularis attachment. Gentle traction systems have been proposed
to rationally analyze
of the greater tuberosity together with external the fracture patterns and
obtain a better under-
rotation of the humeral head is needed to obtain standing of the fracture
itself by answering sim-
good reduction. ple questions [1214].
Before attempting to reduce any proximal
humeral fracture is extremely useful to determine
precisely the fragments taking part in the fracture Indications for Surgery
and the direction of the forces that support these
fragments because of the muscle attachments. Recent studies demonstrate
that even displaced
proximal humeral fractures
can be successfully
treated conservatively in a
selected elderly
Diagnosis population [8]. Any time the
patient has limited
functional expectations or
is not willing to
Traditionally, proximal humeral fractures have undergo a strong
rehabilitation program after
been studied by the so called trauma series surgery, conservative
treatment must be consid-
including a true antero-posterior view, lateral ered. If non-operative
treatment is decided
projection in the scapular plane and axillary upon in impacted proximal
humeral fractures,
1250
C. Torrens
early mobilization seems to be safe and 33 % and 100 % translation of

the surgical
more effective for quickly restoring the physi- neck [20]. It seems
reasonable to consider surgi-
cal capability of the injured arm, although cal treatment in fit patients
with significant dis-
differences tend to disappear at 6 months placement between the humeral
head and the
follow-up [15]. diaphysis where consolidation
of the fracture
The risk of development of avascular necrosis can be compromised.
of the humeral head has routinely been advocated Elderly patients
sustaining a proximal
when considering surgery. Avascular necrosis humeral fracture can be
initially allocated into
rate depends on the fracture pattern, the treatment two groups:
applied and the follow-up accomplished, and has 1. The first one including
elderly fit patients in
been reported from 20 % to 90 %. Despite the fact good mental condition and
willing to restore
that anatomical studies suggest that some fracture their previous functional
level.
patterns strongly correlate with blood supply dis- 2. The second includes
elderly unfit patients in
ruption of the humeral head [16, 17], Hertel et al. fair mental condition and
non-motivated to
in a series of 100 intracapsular fractures of the follow rehabilitations
programmes.
proximal humerus treated by open surgery, In the second group,
almost all proximal
defined that the most relevant predictors of humeral fractures can be
properly managed in
ischaemia were: a conservative way since non-
operative treat-
1. The length of the dorso-medial metaphyseal ment has been proven to
obtain good pain relief
extension (shorter than 8 mm in all ischaemic and a functional level good
enough for this
heads), selected population [8]. In
the first group, pros.
2. The integrity of the medial hinge (also previ- and cons. of surgical
treatment have to be
ously described by Resch et al. [18]), the discussed with the patient
taking into account
basic fracture type determined with the that surgery may almost only
be indicated in
binary description system with an anatomic patients willing to gain good
function. The Sur-
neck component, also stating that besides the geon also has to be aware
that elderly people
disruption of the medial hinge, all other may mostly use their arms in
a below-shoulder
directions of fracture displacement did not level but that active
external rotation is present
strongly correlate to the vascular status [12]. in almost every single daily
activity and must be
Later on, the same group published the preserved. Patients also have
to be aware that
longer follow-up of those patients considered acute treatment of proximal
humeral fractures
to be at risk of developing necrosis of conservatively is relatively
easy and gives good
the humeral head, and surprisingly 8 of the results whereas surgical
treatment is complex
10 initially ischaemic humeral heads did and with limited results.
not collapse over time indicating that In summary, surgical
treatment has to be
re-vascularization may occur and 4 of the 30 considered when, after
sharing with the patient
initially perfused heads developed avascular the pros. and cons. of
conservative treatment,
necrosis with an unclear explanation for that the patient demands better
functional outcome
phenomena [19]. For all these reasons there is than that offered by
conservative treatment.
no strong recommendation for any surgery to Surgical treatment also has
to be planned
prevent avascular necrosis of the humeral when there is reasonable risk
of non-union of
head. the fracture.
Pseudoarthrosis development in proximal Intramedullary nailing of
the proximal
humeral fractures is rare. Court-Brown found humerus is specially
indicated in fractures with
a prevalence of proximal humeral non-union of significant displacement
between the humeral
1.1 %, although a higher percentage is to be head and the diaphysis where
axial stabilization
expected (8 %) if metaphyseal comminution is is required to support
osteosutures passed
present and even more (10 %) if there is between through tuberosity fragments.
1251
and Planning
Despite the increased age of patients suffering

proximal humeral fractures they are usually fit
and present few associated medical disorders. Any-
way any medical disorder present at the time of the
fracture must be corrected previously to surgery.
The patient must be informed of the functional
limits expected and associated with the fracture
pattern as well as of the treatment considered.
The patient also has to be aware of the post-
operative care to plan any home help required
until shoulder is functionally recovered.
X-ray and CT exam are required for every
fracture planned for surgery. The number and
displacement of the fragments must be recorded
and strategy of reduction and fixation has to be
planned. Comminution of the fragments and oste-
oporosis also has to be considered when deciding
treatment options. Fig. 1 AP X-ray view of a
two-part surgical neck fracture
of the humerus
Despite outcomes published of different tech-
niques, surgeons must consider their own skill
with different techniques and choose the one
they are more familiar with.
Operative Technique
The patient is placed in the beach-chair position

with the arm free. The preferred approach is the
deltopectoral to be able to correct any tuberosity
displacement and also because it causes no deltoid
damages. The axillary nerve is routinely identified
under the conjoined tendon. Retractors are placed
beneath the humeral shaft and the humeral head to
retract the deltoid muscle. Special care is given to
the tuberosity fragments as they may be extremely
fragile and porotic. In simple two-part surgical
neck fractures (Fig. 1), a traction suture is placed
through the supraspinatus junction to manage the
cephalic part of the fracture and another non-
absorbable suture is placed through two drilled
holes in the diaphysis (Fig. 2). Sometimes
pectoralis partial release is done to facilitate Fig. 2 Traction sutures
passed through the supraspinatus
humeral shaft reduction. Once proper reduction tendon junction and through
the subscapularis tendon to
has been tested, the first Ender nail is introduced allow management and
reduction of the fragments
1252
C. Torrens
Fig. 3 Insertion of the first Enders nail at the junction of

the greater tuberosity and the humeral head cartilage
Fig. 4 Reduction of
the fracture and stabilization with the
aid of a second
Enders nail
through the junction of the greater tuberosity and
the humeral head cartilage limit (Fig. 3). As the
Ender nail is being pushed down the diaphysis subscapularis
tendon to externally rotate the
the fracture is gently reduced. Direct view of the humeral head that
has been moved to internal
Ender nail progression into the diaphysis is used rotation because
the subscapularis un-balanced
so there is no need of fluoroscopic control of traction (Fig. 9).
Once the humeral head has
nailing. To obtain better rotatory stability been externally
rotated the greater tuberosity is
a second Ender nail is introduced 0.5 cm apart gently pulled to be
reduced properly. The two
from the first (Fig. 4). The suture used for sutures previously
passed through the greater
diaphysis traction is passed through the pre- tuberosity are used
to secure it to the lesser tuber-
manufactured small holes at the top of the Ender osity through pre-
drilled holes taking care not to
nails before they are deeply introduced in the produce a biceps
tenodesis (Fig. 10). After that,
humeral head in an eight-band figure (Figs. 5 the fracture can be
considered as a two-part sur-
and 6). The suture placed in the supraspinatus is gical neck fracture
and can be managed as previ-
then removed and the wound is closed leaving one ously described
(Fig. 11).
deep suction drain (Fig. 7).
In the case of a three-part greater tuberosity
fracture with significant displacement of the Post-Operative Care
and
humeral head and the diaphysis the same Rehabilitation
approach is developed but the first step of surgery
consists of reducing and securing the greater After surgery the
arm is fixed in an internal posi-
tuberosity to the humeral head (Fig. 8). For this tion with a sling-
type immobilization and the
purpose two non-absorbable sutures are placed at drain is removed at
24 h. The patients discharge
the junction of the cuff attachment to the greater from the Hospital
is commonly on the second day
tuberosity. Another suture is placed through the after surgery and
simple instructions are given to
1253
Fig. 7 AP X-ray at
follow-up showing fracture
consolidation
Fig. 8 AP X-ray view

of a three-part greater tuberosity
Fig. 5 Upper part of the Enders nail with the pre-drilled fracture with
displacement of the humeral shaft and the
small hole to pass the sutures and allow deep impaction of cephalic complex
the nail into the humeral head
start rehabilitation
of the hand and the elbow.
After 3 weeks the
sling is removed and the patient
starts with assisted
forward elevation with the
aid of a pulley and is
allowed to use the arm for
self-care tasks such
as dressing or eating. Once
120# of passive
forward elevation are reached
internal rotation
exercises are added. This com-
monly occurs in the
second or third week after
immobilization is
removed. One or two weeks
later, when internal
rotation reaches the L3
Fig. 6 Diaphysis suture passed through the holes at the vertebra, external
rotation exercises are added.
top of the Enders nails in an eight-band fashion Abduction exercises
are avoided during the
1254
C. Torrens
AP X-ray view showing correct
reduction of the
fracture with the aid of osteosutures
The vast majority of

patients can do this sim-
Fig. 9 Traction sutures passed through the greater tuber- ple rehabilitation
program on their own at home
osity at the supraspinatus tendon junction, through the
subscapularis tendon and through the humeral shaft to and just a few cases
require specially- trained
allow proper reduction people to assist them
in specific centres.
Complications
Many different surgical

treatments have been
proposed for the
management of severely-
displaced proximal
humeral fractures, including
osteosutures [20],
Enders-nails together
with osteosutures [21],
plate fixation [22],
extramedullary pinning
[23] and intramedullary
nailing [24]. All of
them achieve reasonable func-
tional results and also
in most of the cases a pain-
free shoulder. The
commonest complications
include loss of
reduction, need for a second
operation to remove
metal implants, avascular
necrosis of the humeral
head, stiffness and
infection at different
rates depending on the
populations selected,
the fracture pattern and the
treatment choice.
Fig. 10 Reduction of the fracture and suture of the
greater tuberosity to the lesser tuberosity transforming
the fracture into a two-part surgical neck fracture Locked Plates and Hemi-
Arthroplasty
entire rehabilitation program. Most of the time Recently-developed

locked plates have changed
strengthening is not necessary as this selected the treatment map of
elderly population may have pain with such and their use has
spread widely over the recent
programmes. years. Specially
developed to obtain strong
1255
fixation in osteoporotic bone, locked plates follow-up (minimum of 5

years) treated with
were expected to improve on older designs. a shoulder hemiarthroplasty
for acute fractures of
Early published results are not so encouraging the proximal humerus with a
mean age of 66 years.
and numerous complications have also been There were 27 patients
satisfied and 30 unsatisfied.
reported. Fankhauser et al. reported in a series 16 % referred moderate or
severe pain and range of
of 29 fractures at a follow-up of 1 year a final motion averaged 100# for
anterior elevation
mean Constant Score result of 74.6, and despite (20# 180# ) and 30# for
external rotation (0# 90# ).
early mobilization, there was a slow functional They concluded that hemi-
arthroplasty gives good
recovery of the patients evaluated at 1.5, 3, 6 and pain relief but
unpredictable functional result [32].
12 months. Age and complexity of the fracture Looking closer to the
results presented, the average
also influenced the end-result [25]. Koukakis movement may not be
representative of the general
et al. in a small series of 20 patients also obtained status due to the wide
range observed, with patients
a mean final Constant Score of 76.1 % in a rela- moving from 20# to 180# of
anterior elevation.
tively young population with a mean age of 61.7 Gronhagen et al. also
found, in a series of
years [26]. Moonot et al. have reported in a series 46 patients a mean Constant
score of 42 but rang-
of 32 patients with a mean age of 59.9 years-old ing from 11 to 83 in
primary hemi-arthroplasty for
a mean final Constant Score of 66.5 in a short comminuted proximal humerus
fractures. Con-
follow-up of 11 months [27]. Handschin et al. in stant score decreased
significantly in 24 prostheses
a series of 31 patients presented a mean final that had migrated
superiorly [33].
adjusted Constant Score of 80 % and compared Boileau et al. in a
series of 66 patients tried to
the results with an historic control group of find out the reasons for
poor outcomes after hemi-
60 patients operated for the same fracture types arthroplasty. There were 27
% of initially badly-
using two one-third tubular plates and found no positioned tuberosities and
23 % of tuberosity
differences in complication rate, return to work detachments and migration.
Final tuberosity mal-
and functional outcome. Differences were noted position was observed in 50
% of the patients and
in the total cost, being of 684 Euros for angular- correlated with
unsatisfactory result, superior
stable plates and of 158 for the one-third tubular migration of the
prosthesis, stiffness or weakness
plate [28]. On the other hand, several complica- and persistent pain. The
factors associated with
tions have been published associated to the use of failure of tuberosity
osteosynthesis were poor ini-
locked plates. Egol et al. reported in a serie of tial position of the
prosthesis, poor position of the
51 patients the development of 16 complications greater tuberosity and
women over age of 75 years
in 12 patients, including screw penetration, necro- [34]. Poor initial
positioning of the prosthesis is
sis, non union, infection and early failure of the related to the lack of
landmarks in acute fractures
implant [29]. Owsley et al in a series of 53 patients with distorted anatomy.
Different attempts have
reported, in 36 % of the patients, the presence of been done to find
anatomical references to prop-
radiographic complications, including 23 % of erly position prosthesis in
acute fractures. The
screw cut-outs, 25 % of varus displacement and bicipital groove has been
considered helpful repro-
4 % of aseptic necrosis. They also reported 13 % of duce accurate retroversion
[35, 36] while others
revision surgery, and showed that complications believe that a significant
internal rotation occurs
tended to affect elderly people. being significant in along the course of the
bicipital groove (15.9# ) that
patients older than 60 years [30]. has clinical implications
if it is used as a landmark
Neer reported in 1970 early results of prosthetic for humeral head
replacement in acute fractures
replacement in severely-displaced proximal [37]. Recently the upper
insertion of the pectoralis
humeral fractures, and although his excellent major has been proposed as
a landmark for proper
results have never been reached again, hemi- restoration of the humeral
height [3840] as
arthroplasty still remains as the treatment of choice well as to determine
retroversion of the humeral
in those more complex fractures [31]. Antuna et al. head. It has been stated
that placing the humeral
have reported the results of 57 patients with a long head at 5.6 cm from the
upper pectoralis major
1256
C. Torrens
insertion and locating the posterior prosthesis fin reduction after surgery and
in eight cases
1.06 cm posterior to the upper pectoralis insertion a secondary displacement was
noted at the final
will result in anatomical height and version radiological exam. Two cases
of avascular necro-
restoration. sis of the humeral head
developed in two four-
Due to the unpredictable functional outcome part fractures but no further
surgery was required
of hemi-arthroplasty in complex humeral because the patients
experienced functional
fractures, reversed designs have increasingly reduction with no pain and
were old enough
become part of the therapeutic choice. Avoiding not to wish to for improved
function through
the need for cuff function by improving the a surgical procedure. Just in
two cases
deltoid, the reverse prosthesis was thought to be the Enders nails needed to
be removed because
the solution for such these osteoporotic commi- of subacromial impingement in
2 three-part
nuted fractures. Once again recent results are not fractures that suffered
secondary displacement.
so encouraging as expected and in a series of Removal of the Enders nails
was done at 3 and
43 patients with a short mean follow-up of 4 months after surgery
because of pain and
22 months, the mean active elevation was of 97# limited rehabilitation
outcome. After removal,
(35# 160# ) and mean external rotation was 30# the patients remained pain-
free and had improved
(0# 80# ). The mean Constant Score was 44 function without
significant differences
(1669). Peri-prosthetic calcification was with the rest of the series
at final follow-up
observed in 90 % of the patients, displacement (unpublished data).
of the tuberosities in 53 % and a scapular notch in
25 % [41]. However, complex fractures will be in
the future more often treated with the reverse Summary
system because it provides more predictable res-
toration of function specially if tuberosities are The total number and
complexity of humeral
preserved and reattached. fractures is increasing, as
is the age of presenta-
Specific complications related to the use tion. When planning treatment
strategies the oste-
of Ender nails is upper migration of the Ender oporotic nature of these
fractures has always to be
nail to the subacromial space causing impinge- considered. In selected
elderly populations with
ment and subsequent pain and loose of function. limited expectations
conservative treatment may
This complication can be avoided by including be an effective option for
almost all the fracture
a tension band suture from the diaphysis to the patterns. Surgical treatment
is indicated when
pre-drilled proximal hole on the Ender nail. In painful pseudoarthrosis is
expected to develop
cases where there is loose reduction of the frac- and also when, after sharing
with the patient
ture and collapse of the fracture, the nails may pros. and cons. of surgical
versus conservative
also protrude to the subacromial space causing management of the fracture
the patient asks for
pain. In such this circumstance, the nails may a better functional outcome.
When there is severe
have to be removed to allow a pain-free rehabil- displacement between the
cephalic part and the
itation program. diaphysis endomedullary
nailing may be consid-
Our personal series includes 38 patients ered in two-part surgical
neck and three-part
(30 female and 8 male), with a mean age of greater tuberosity fractures.
Modified Enders
72 years with a mean follow-up of 7,5 years and nail provide stability enough
to facilitate consol-
comprising 8 two-part surgical neck fractures, 25 idation of these fractures.
An eight-figure osteo-
three-part greater tuberosity fractures and 5 four- suture passed through the
added holes at the top
part fractures. Final Constant score reached 70,1 of the Enders nails avoids
proximal migration of
with most of the patients free of pain and able to the nails to the subacromial
space. In three-part
do activities of daily living and with a mean for- fractures reduction and
fixation of the tuberosity
ward elevation of 117# . After radiological analy- through osteo-sutures is
required prior to nailing
sis four cases were considered to have incomplete the fracture. After a 3-week
immobilization
1257
period most of the patients can follow a simple at- Immediate

mobilization compared with conventional
home rehabilitation programme and end-up with immobilization
for the impacted nonoperatively
treated proximal
humeral fracture. J Bone Joint Surg
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2007;89:258290.
16. Gerber C,
Schneeberger AG, Vinh JS. The arterial
vascularization
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study. J Bone
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Fractures of the Proximal
Humerus
Treated by Plate Fixation
Pierre Hoffmeyer
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1260 Treatment of displaced fractures of the proxi-
mal humerus in the fit and active patient

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1260
remains a challenge. Accurate imaging is

1262 essential first with plain x-rays and with
Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1262 three-dimensional imaging. Knowledge of
Surgical Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1262 the vascular anatomy of the humeral head is
Trans-Deltoid Approach . . . . . . . . . . . . . . . . . . . . . . . . . . .
1262 mandatory to understand the consequences
Delto-Pectoral Approach . . . . . . . . . . . . . . . . . . . . . . . . . . .
1263
Standard Plates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1266
of the fracture pattern. When surgery is con-

Anatomical Plates with Divergent
templated, positioning of the patient must
Locked
Screws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1266 allow a quasi-circumferential approach to the
Blade-
Plates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1266 shoulder. The deltopectoral approach is the
Fractures of the Anatomical Neck
most popular but lesser invasive transdeltoid
(Two Fragments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1266
approaches are coming into vogue. Plates with
Isolated Fractures of the Greater Tuberosity
locking screws afford great stability and ease
(Two Fragments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1267 of use. However the basics of biomechanics
Fractures of the Surgical Neck
must not be forgotten, namely the presence of
(Two Fragments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1267
a medial buttress. Ignoring the principles will
Valgus Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1267 need to failure. Rehabilitation must be tailored
Varus Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1267
to each patient but gentle early motion is

Three and Four Fragment Fractures . . . . . . . . . . . 1268
encouraged in all cases. Complications of the
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1272 technique are reviewed.
Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1273
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1273 Keywords
Deltopectoral approach # locking plates #
proximal humerus fractures # rehabilitation #
surgical technique # transdeltoid approach #
delto-pectoral approach # three and four part
fractures # two-part fractures
P. Hoffmeyer

1259
DOI 10.1007/978-3-642-34746-7_6, # EFORT 2014
1260
P. Hoffmeyer
Introduction Indications
Fractures of the proximal humerus present a The indications for plating

are determined by
major clinical problem and the techniques of the fracture pattern,
essentially displaced two-
fixation including nailing, percutaneous pinning, and three-part fractures,
as determined by
osteosuture and plating have evolved over Codman and Neer and refined
by other authors
time [122]. Plate fixation for proximal using advanced imaging
techniques such as 3D
humerus fractures has gained in popularity CT [2, 3944]. Displaced
head-split fractures
with the advent of new locking plates that not amenable to reduction
should be treated
afford greater stability and are easier to apply with other means such as
hemi- or total
than standard plates because of the immediate arthroplasty whether
anatomic or inverted.
stability they provide [19, 2335]. Clearly Clearly to determine the
indication an accurate
the ultimate prognosis of a fracture of the diagnosis is necessary and
this is only possible
proximal humerus depends largely on the vas- with well executed x-rays,
if possible of digital
cular status of the proximal humerus and the quality, that need to be
perpendicular to the
more specifically on the location of the main glenohumeral joint in the
frontal anteroposterior
fracture line [8, 3638] (Fig. 1). With a high plane and in the transverse
axial plane (Fig. 3).
fracture line an interruption of the vascular CT and 3D CT images may
also be of assis-
supply is likely. If the fracture line is lower tance in the understanding
of complex fractures
the chances of necrosis become lower (Fig. 2). [39, 4547].
1
Axillary A.
2
Arcuate A.
8
3
Acromial A.
1
5 4
Circumflex A.
5
Posterior Circumflex A.
6
Anterior Circumflex A.
6 7
Metaphyseal A.
4 8
Ascending bicipital A.
Fig. 1 Vascularisation of
the humeral head
Fractures of the Proximal Humerus Treated by Plate Fixation
1261
Fig. 2 Fracture line

a b
determines the risk of
necrosis. (a) High fracture
line (arrow) with high risk
of necrosis. (b) Low
fracture line (arrow) with
a lesser risk of necrosis
a b
Fig. 3 Accurate radiological assessment is necessary. (a) AP perpendicular to the

coronal plane is unsatisfactory.
(b) Strict AP view perpendicular to the scapular plane is necessary for diagnosis
1262
P. Hoffmeyer
Surgical Technique Surgical Approaches
Patient Positioning Trans-Deltoid Approach
Under general anaesthesia and in some cases This approach is

appropriate for a displaced
with an additional scalene block, the patient is tuberosity fracture. Some
authors use this
placed on the operating table in a semi-sitting approach as their standard
for fractures of
beach-chair position. It is important that the proximal humerus [27,
29, 34]. The vertical
the table be slightly up-tilted so that the incision of 57 cm starts
from the acromion at
buttocks rest squarely in the seat of the table the junction between the
anterior and the
avoiding any tendency to downward slippage. middle third of the
deltoid. After undermining
The head is held securely in a head rest with a the subcutaneous tissue
the acromion, the
firm bandage providing secure fixation. The acromioclavicular joint,
clavicle and deltoid
cervical spine is in neutral position without muscle are recognized. The
anterior and
inclination, rotation, extension or flexion. mid-deltoid portions are
then split through an
Special care should be given to protecting the often identifiable
tendinous streak using a cold
patients eyes. It is important to verify the posi- knife or electrocautery.
This separation should
tion of the contralateral upper extremity so as to not exceed 5 cm distal to
the acromion
avoid pressure areas [24, 28] (Fig. 4). and the axillary nerve
should be identified
The totality of the shoulder region from the either by palpation or
visualization. Neer [49]
superolateral torso and including the whole upper recommended placing a
suture at the end
extremity should be left free. Some modular of the muscle slit to
avoid unnecessary
tables will allow removal of an upper corner propagation. If absolutely
necessary the deltoid
piece therefore allowing access to all parts of may be economically
released from the
the shoulder. The downside of this possibility is acromion in T fashion. The
subacromial bursa is
that the scapula tends to sag backwards some- then opened and the
surprisingly wide separation
what. This may be counteracted by slightly of the fracture lines will
come into view.
rolling the table contralaterally. If this possibility Traction sutures inserted
through the supra- and
does not exist a bolster may be used to prop-up the infra-spinatus tendons
will aid in reduction. Once
scapula. Care is taken to ensure that the shoulder the fracture is reduced,
the plate is slipped along
may be thoroughly explored with a C-arm fluoro- the bone and screws are
inserted. The distal
scope. Modern smaller C-arms are extremely screws may be inserted
through separate cutane-
manoeuvrable. Test the images obtained before ous incisions underneath
the passage of
definitive draping and adjust so as to obtain the axillary nerve [27,
29]. The imager
AP and axial views of the glenohumeral joint intensifier is used to
control the fracture
[24, 28] (Fig. 5). reduction. Remember that
the vision is limited
Pain management modalities must be discussed using this approach and
that the utmost
with the anaesthetist. In some cases a scalene care in placing the
implant must be exerted.
block may be indicated. In acute cases where The most frequent
complications of this approach
nerve damage is possible this is best avoided. are malreduction of the
fracture, malposition
Routine single dose intravenous prophylaxis with of the plate and injury to
the axillary nerve
an appropriate antibiotic administered before the with denervation of the
anterior deltoid as
incision, usually 20 min, is recommended [48]. a result (Fig. 6).
1263
Fig. 4 Patient positioning.

The patient is in semi-
sitting position and the head
is in the neutral position
fixed in a headrest. The
shoulder and upper
extremity is free so as to
allow image intensifier use.
A scalene block may be
used to provide post-
anesthesia pain control
Delto-Pectoral Approach and distally that respects

the anatomy of the
shoulder [28, 49]. For
The delto-pectoral approach is the favoured a straight or oblique 10
15 cm incision is the best
approach for proximal humerus fractures. It is a choice starting at the
junction of the mid- and lateral
utilitarian and extensile approach both proximally third of the clavicle,
passing over the coracoid and
1264
P. Hoffmeyer
Fig. 5 In a semi-sitting position, the arm is placed on a Mayo stand in abduction

to relax the deltoid. Intra-operatively
the image-intensifier allows control of the reduction manoeuvres
5 cm maximum
distance from the Axillary nerve
acromion
Axillary nerve
Fig. 6 Trans-deltoid approach. The cutaneous incision is the deltoid fibres

should not exceed a point 5 cm. distal to
straight going down from the acromion at the junction of the acromion to
protect the axillary nerve
the anterior and middle third of the deltoid. Separation of
ending distally near the insertion of the deltoid. underside of the

anterior deltoid by running
Subcutaneous tissues are undermined and the a finger around the
proximal humeral metaphysis
delto-pectoral interval must be clearly identified. [3, 9]. The
pectoralis muscle is retracted medially
Haematoma and swelling may render this difficult while the deltoid is
retracted laterally (Fig. 7).
so that it may be necessary to find the interval high Abduction will
facilitate deltoid retraction and
up between the pectoralis and the deltoid proxi- exposure. The
conjoint tendon is then retracted
mally at their clavicular insertion. The cephalic medially to identify
the subscapularis muscle and
vein is preserved and left either laterally along the its tendon. At this
time it is wise to find the axillary
deltoid or medially. The deltoid fascia is incised to nerve coursing on the
anterior surface of the
allow palpation of the axillary nerve on the subscapularis muscle
so as to protect it [50].
1265
a b
Delto-pectoral groove
Deltoid M.
Pectoral M.
Cephalic V.
Fig. 7 Delto-pectoral approach: (a) The skin incision is undermined in

order to visualize the delto-pectoral
begins at the junction of the proximal and lateral thirds groove. Proximally
the vein can be found where it plunges
of the clavicle, passes over the coracoid and stops over the into the brachial
vein in the triangle between deltoid and
direction of pectoralis major. (b) The subcutaneous tissue pectoralis insertion
origins
Fig. 8 Exposing the

fracture. A blunt curved 2
Hohmann retractor (1) is
placed in the subacromial *
space and a wide
Richardson retractor pulls
away the deltoid (2) with
the arm in abduction,
allowing exposure of the
fracture site (*)
Beware of the musculocutaneous nerve that pene- biceps tendon make

up the lesser tuberosity and
trates the coracobrachialis at a mean distance of subscapularis
complex while the structures lateral
5 cm from the tip of the coracoid [28, 49]. The to the long biceps
are the greater tuberosity and
tendon of the long biceps is a precious landmark supra- and
infraspinatus [3, 9, 28]. To augment the
and if damaged should not be sectioned for exposure, the
coraco-acromial ligament may be
tenodesis until the fracture is properly reduced and incised and the
distal insertion of the deltoid may
the implants are in place [3]. The trajectory of be released on the
humerus. Rarely the anterior
the tendon must be straight and lie squarely in the deltoid may be
released from the clavicle. In this
groove. This will guide the reduction as the groove case the incision of
the muscle insertion must be on
can generally be identified in the majority of frac- top of the clavicle
to leave a tendinous band for
tures. Furthermore, the structures medial to the long reinsertion [3]
(Fig. 8).
1266
P. Hoffmeyer
a b c
d
Fig. 9 Two part fracture (a, b) with a long spiral (arrows). (c, d) Fixation with a
long T-plate
Standard Plates This angular stability

with diverging screws is
an advantage for the
stabilization of osteoporotic
There are many different types of plates including fractures [19, 2335].
standard plates. They all have in common the
possibility of inserting multiple screws into
the humeral head. Some are T-shaped, others are Blade-Plates
cloverleaf or racket-shaped [6, 7, 20, 51]. These
implants can be used through delto-pectoral or For indications where
a high degree of stability is
trans-deltoid approaches (Fig. 9). Biomechani- required, 90# angled
blade-plates for the proximal
cally all plates are placed on the lateral cortex humerus provide rigid
fixation and allow
to produce a tension band effect. For best function interfragmentary
compression. These implants
and results a medial buttress and a valgus are useful in certain
situations such as non-unions
reduction must be obtained. If no medial or for fixing
osteotomies after a malunion [52].
buttress is present the implants will fatigue and
ultimately fracture [28, 30, 31, 34, 35]. It should
also be noted that in the osteoporotic bone Fractures of the
Anatomical Neck
multiple screws of a small diameter (3.5 mm) are (Two Fragments)
more efficient than a large diameter screw
(6.5 mm) [8, 27, 28, 31]. This is a rare lesion
often associated with a
dislocation or a
subluxation of the cephalic frag-
ment. This pattern is
most often encountered in
high energy trauma in
the young. Reduction is
Anatomical Plates with Divergent performed through a
delto-pectoral approach and
Locked Screws an arthrotomy through
the rotator interval will
permit visualization
of the displaced fragment.
The trend is towards anatomically designed Once anatomical
reduction is obtained a plate
plates with engineered screw holes able to lock may be used for
fixation, preferably a plate with
angularly stable and diverging screws These locked screws to
obtain a rigid fixation of this
locking screw holes impose a direction to intra-articular
fragment. Prognosis is dismal
the screws although the latest models allow however with a high
rate of post-traumatic necro-
a greater latitude in the choice of angles. sis of the cephalic
fragment [53].
1267
a b c
d
Fig. 10 Plate fixation with a third tubular plate. greater tuberosity (b, c)
Reduction and fixation of the
Glenohumeral dislocation and tuberosity fracture (a) greater tuberosity with a
third tubular plate (d)
After closed reduction a posterior displacement of the
Valgus Displacement
Isolated Fractures of the Greater
Tuberosity (Two Fragments) If a plate is used, a
standard 1/3 or 1/2 tubular
plate may be inserted
using either a delto-pectoral
Fractures of the greater tuberosity with posterior or a trans-deltoid
approach. The plate is placed
and superior displacement are typically associated without any attempt at
contouring. A screw
with antero-inferior dislocations of the shoulder. inserted distally to the
fracture line is gradually
These fractures are in fact completed Hill-Sachs tightened thus bringing
the plate in close contact
fracture impactions. Surgical intervention is with the cortex. In case
of a valgus displacement
considered with a displacement of the tuberosities reduction is obtained
automatically. Care must be
greater than 3 mm in young active patients. taken that the proximal
fragment is well aligned
Up to 1 cm of displacement may be tolerated in in the sagittal plane and
that no excessive flexion
less active elderly patients [49]. A trans-deltoid or extension remain [8]
(Fig. 11).
approach may be used. Once the fracture is
reduced, a plate with locking screws may be
used to stabilize the fragment. To ensure adequate
fixation sutures however are passed through Varus Displacement
the supraspinatus, infraspinatus and subscapularis
tendons and secured to the plate [54] (Fig. 10). In case of varus
displacement it is imperative to
reduce the proximal
fragment so as to obtain
a satisfactory alignment
both in the frontal and
Fractures of the Surgical Neck in the sagittal planes. A
Steinmann pin fixed into
(Two Fragments) the humeral head may be
useful as a joystick to
obtain the reduction.
Sutures are also passed
Fractures of the surgical neck tend to be unstable through the supraspinatus,
subscapularis and
because of the actions of the rotator cuff muscles, infraspinatus tendons.
These may also be useful
the teres minor and major muscles, the deltoid in reducing the varus
displaced proximal
and the pectoralis [23, 25, 32]. With an angularly humerus. Once the proximal
fragment is well
displaced fracture (>30# ) surgical stabilization is seated on the metaphysis
and after ascertaining
necessary. These fractures may be displaced that the reduction is
clinically acceptable, using
into valgus or varus and the fixation technique an image intensifier if
necessary, a plate with
will vary. locking screws is used to
secure the fixation.
1268
P. Hoffmeyer
a b c
d e f g
h
Fig. 11 Three-part fracture in valgus. (a, b, c) In this to the fracture line

will bring about the reduction. It is
situation the spring properties of a semi- or third tubular important not to pre-
bend the plate. (d, e, f) In this exam-
plate may be used to reduce a displaced fracture. After ple two extra screws
are used to fix a non-displaced lesser
a delto-pectoral approach, the plate is applied on the tuberosity fragment.
(g, h) Healed fracture and functional
diaphysis and gradual tightening of a screw placed distally result at 1 year
The cuff tendon sutures are tied to the plate using lines and adequate
control of the fracture frag-
empty screw holes or specific holes in the plate ments for the purpose
of obtaining a satisfactory
(Fig. 12) [18, 28]. reduction. Priority
is given to tuberosity place-
ment. If too high it
will impinge against the
acromion and damage
the cuff, whilst if too low
Three and Four Fragment Fractures there will be undue
tension on the rotator
cuff tendons. Ideally
the greater tuberosity
For a displaced three or four fragment fracture in a should lie 10 mm
under the humeral head [1, 3,
young active individual osteosynthesis with a rigid 8, 28, 32, 34, 35].
fixation and accurate reduction is always the first After the standard
delto-pectoral approach the
choice. For elderly less active patients a less rigid fracture fragments
must be identified. Stay sutures
fixation using heavy suture material may be are placed in the
tendons at the tendino-osseous
sufficient. No matter the fixation technique it is junction of the
fractured tuberosities. These
important to restore the anatomical relationships sutures placed in the
tendons along with
as only this will guarantee the best chances for a 2.5 mm Steinmann
fixed in the cephalic fragment
recovering a functional articulation [4, 28]. as a joystick will
allow manipulation of the
These fractures when displaced should be fragments. The medial
fracture line at the head-
reduced and fixed and the surgical approach metaphysis junction
identified with the image
may be delto-pectoral or trans-deltoid. The intensifier is a
landmark that will aid in
authors preference is the delto-pectoral approach adequately reducing
the cephalic fragment on the
which allows a good visualization of the fracture metaphysis. A solid
medial buttress is essential in
1269
a b c
d
e f g
h
Fig. 12 Two-part fracture in varus. (a, b, c, d) After two-part fracture

fixed with a locking plate. Once reduced
a delto-pectoral approach a Steinmann pin is inserted a locking plate is
applied. (g, h) Result after fracture
into the cephalic fragment and used as a joystick, a plate healing and hardware
removal
is applied for fixation. (e, f) Clinical case: Displaced
ensuring a stable construct. Inspection of the usually has a pointed

triangular point which will
articular surface may necessitate an arthrotomy fit into the
metaphyseal mirror triangular fracture
through the rotator interval if the view afforded line. The position and
alignment of the biceps
by lifting the tuberosity fragment is not sufficient. tendon is a good
witness as to the quality of the
A pin fixing temporarily the cephalic fragment on reduction. After the
biceps tendon has been
the metaphysis is sometimes necessary. Rarely a ascertained to be in
good position, if its integrity
bone graft is needed which may be inserted is in doubt, a
tenodesis may be needed [28, 33].
between the metaphysis and the cephalic fragment The transtendinous
traction sutures may be
to maintain the head in good position. The then passed through
holes in the locking
tuberosities are then coaxed and manipulated screw-plate. The plate
needs to be positioned on
into a reduced position around the cephalic the metaphysis avoid
the bicipital groove. Care
fragment and fixed using the previously-inserted must be taken that the
plate is not too high
transtendinous sutures. The tuberosity fragment or impingement on the
acromion will occur.
1270
P. Hoffmeyer
a b
c d
e f g
Fig. 13 Three-part fracture. (a, b, c, d) Transtendinous Once the reduction

achieved the locking plate is applied
sutures are placed followed by reduction of the humeral and sutures are tied
onto the plate. (e, f, g) Clinical case:
head using a joystick manoeuvre with a Steinmann pin. Three-part fracture
fixed with a locking plate
1271
Fig. 14 Lack of a mechanically sound medial buttress (Circle) such as in this two-
part fracture will lead to fracture
collapse into varus and plate breakage
Fig. 15 Complications of plating. A fracture-dislocation with a head split in a 25

years-old woman. Attempt at plating
leads to failure with collapse and severe necrosis
The image intensifier will control the reduction For Titanium implants
always use the torque-
and position of the plate. The 3.5 mm screws are limiting device on the
screwdriver when
then inserted beginning with a screw in the mid- indicated by the
manufacturer so as to avoid a
dle of the plate and proceeding to insert the prox- so-called cold
welding effect, rendering future
imal cephalic screws. Length must be carefully hardware removal almost
impossible without
gauged to avoid protrusion, more than 35 mm of destroying the screw
head. The lesser tuberosity
length is unusual. Once the screw is inserted the may be fixed with
screws outside the plate but as
transtendinous sutures should be tied on the plate. a rule transtendinous
sutures tied down to the
An image intensifier check will ascertain that the plate will afford an
adequate fixation [28, 33].
fracture is well reduced, that a good medial but- Before closure, a
last image intensifier check,
tress has been achieved and that the screws are of taking the shoulder
through a range of motion
the right length. The last screws are inserted into will verify that no
screws are intra-articular and
the cephalic fragment and locked into the plate. that the reduction is
adequate (Fig. 13).
1272
P. Hoffmeyer
Fig. 16 Common a b
c
complications (a) Plate too
high. (b) Screws too long.
(c) Insufficient medial
buttress and plate breakage.
(d) Impingement of biceps.
(e) Plate not aligned on the
diaphysis. (f) Malreduction
with posterior tilt
d e
f
Humeral Head
Vascularised
Devascularised
Strong bone Weak bone

Strong bone Weak bone
Fig. 17 Algorithm for
managing displaced Anatomic reduction Fixation
Reduction Function
proximal humeral fractures (Screw, plate) (Osteosuture, nail)
(Screw, plate, nail, osteosuture) (Arthroplasty)
in Fig. 15. A plate

too high will lead to impinge-
Complications ment. Screws that
are too long will damage
the articular
surfaces and lead to pain, as a
Complications are many and the literature is rich general rule avoid
screws longer than 35 mm in
in articles and reports detailing the types of com- the humeral head.
Lack of a strong
plications most frequently encountered [26, 27, medial buttress will
lead to fracture collapse in
34, 35]. A strong medial buttress must be present varus. The plate
should not impinge on the
if varus displacement and plate breakage are to be biceps if it is left
in place. The plate should be
avoided (Fig. 14). The indication must be placed on the
diaphysis and not obliquely as this
well determined. Certain head-split fracture- is potentially an
unstable situation. Frequently
dislocations are not amenable to reduction and a malreduction,
where the proximal fragment
fixation and even if that were the case necrotic remains tilted
posteriorly, is encountered. This
collapse is inevitable (Fig. 15). The main will lead to reduced
motion and possibly residual
complications related to technique are described pain (Fig. 16).
1273
As a general rule plates should be used 4. Court-Brown CM, Garg

A, McQueen MM. The
according to the algorithm below. The best indi- translated two-part
fracture of the proximal humerus.
Epidemiology and
outcome in the older patient.
cation is a displaced fracture occurring in strong J Bone Joint Surg
Br. 2001;83:799804.
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Fracture-dislocations of the
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6. Ehlinger M, Gicquel
P, Clavert P, Bonnomet F, Kempf J-
F. A new implant for
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Rehabilitation imental study of the
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of three- and four-part fractures
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Trauma. 1994;8:1522.
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fractures of the
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Stedtfeld H-W, Ewert A, Beck M,
Frosch B, Gradl G.
Stabilization of proximal humeral
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Joint Surg Am. 1996;78:13715.
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Gessel E, Hoffmeyer P, Gamulin Z.
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Injury. 2008;39(3):28498.
Hemi-Arthroplasty for Fractures
of the Proximal Humerus
Tony Corner and Panagiotis D.

Gikas
Contents
Abstract
Complex fractures of the proximal humerus are
some of the most common and difficult

fractures to treat. Treatment options include

Relevant Applied Anatomy and Physiology . . . . 1279
benign neglect, internal fixation or arthroplasty.
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1281 A hemiarthroplasty for a complex proximal
humeral fracture is a challenging procedure

even in the experienced shoulder surgeons

hands.
1282 This chapter aims to explain the operative
technique and tips to aid the surgeon
perform the procedure safely and successfully,

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1289
avoiding complications. A review of published

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1289 outcomes of hemiarthroplasty for proximal
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1290 humeral fractures is presented as well as possi-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1290
ble complications and available rehabilitation
protocols for the patient post-operatively.
Keywords
Fracture # Hemiarthroplasty # Humerus #
Proximal
Complex fractures of the proximal humerus are

T. Corner (*)
some of the most difficult fractures to treat.
West Hertfordshire Hospitals NHS Trust, Watford and
Codman was the first surgeon to help us under-

stand the patho-anatomy of these fractures and

P.D. Gikas
appreciate the mechanics and constituent parts of

The London Sarcoma Service, Royal National
the fracture with respect to the head, tuberosities
and shaft [1]. Charles Neer originally reported

West Hertfordshire Hospitals NHS Trust, Watford and
high failure rates for open reduction and internal
e-mail: panosgikas@me.com
fixation of three-part and four-part fractures of

1277
DOI 10.1007/978-3-642-34746-7_225, # EFORT 2014
1278
T. Corner and P.D. Gikas
the proximal humerus in the 1950s. He therefore Two part fracture of

anatomical neck, articu-
proposed treating these fractures with lar segment displaced
a hemiarthroplasty. The first arthroplasty High risk of AVN
designed by Neer was a monoblock prosthesis Two part fracture of the
surgical neck with
and in 1953 he reported the first shaft displacement
use of such a prosthesis in the treatment of a Two part greater
tuberosity displacement
proximal humerus fracture as part of a fracture Two part lesser tuberosity
displacement
dislocation [2, 3]. Three part displacements:
one tuberosity
Since this first generation monoblock design remains attached to the
head
there have been numerous advances in shoulder Greater tuberosity
displacement
hemiarthroplasty design with new modular Lesser tuberosity
displacement
implants allowing adjustable head neck angles, Four part fractures,
fracture dislocation
variable offset and methods of tuberosity fixation. and head splitting
fractures: articular
Although developments have been made in segment displaced, out
of contact with
arthroplasty technology and instrumentation, glenoid, no soft tissue
attachment, no
excellent equipment cannot compensate for poor tuberosity contact.
surgical technique. Arthroplasty for proximal In Hertels Binary or
Lego description system
humerus fracture is one of the most technically (Fig. 1) for proximal
humerus fractures five basic
demanding operations to perform correctly and fracture planes are
identified:
achieve a satisfactory outcome for the patient. 1. Between the greater
tuberosity and the head
This chapter aims to guide the surgeon perform 2. Between the greater
tuberosity and the shaft
a shoulder hemiarthroplasty safely and effectively 3. Between the lesser
tuberosity and the head
for complex fractures of the proximal humerus. 4. Between the lesser
tuberosity and the shaft
5. Between the lesser
tuberosity and the greater
tuberosity Figure
Aetiology and Classification This leads to 12 basic
fracture patterns:
Six possible fractures
dividing the humerus into
In 1934, Codman [1] described fractures of the two fragments,
proximal humerus and classified them as occur- Five possible fractures
ring in the head, shaft, or greater or lesser tuber- three fragments,
osity. He indicated that surgical treatment is Single fracture pattern
needed if these fractures are displaced. In 1970, four fragments
Neer [2] described a classification system of The AO classification
(Fig. 2), which is less
displaced proximal humeral fractures that clari- frequently used than the
Neer and Codman clas-
fied and expanded on the earlier work of Codman. sification systems,
emphasizes determination of
In the Neer classification, one fragment or part whether vascularity to the
articular fragment is
is the humeral shaft, so the simplest displaced significantly compromised.
Type A is an extra-
fracture is called a two-part fracture. The clas- articular unifocal fracture
that involves one of the
sification includes two-part fractures; three-part tuberosities with or without
a concomitant
fractures; four- part fractures; and fracture-dislo- metaphyseal fracture. Type B
is an extra-articular
cations, including head-splitting fractures. bifocal fracture or
fracture-dislocation with
According to Neer [24], displacement of tuberosity and metaphyseal
involvement. Type
a fracture fragment by more than a centimeter C is a fracture or fracture-
dislocation of the artic-
or angulation of more than 45# is considered ular surface; this type is
considered the most
significant. The Neer Classification is summa- severe because the vascular
supply is thought to
rized as follows: be at the greatest risk of
injury, thereby making
Minimally displaced one part fracture the humeral head susceptible
to the development
No segment displaced >1 cm or angulated >45# of osteonecrosis.
Hemi-Arthroplasty for Fractures of the Proximal Humerus
1279
Fig. 1 Hertels Binary or

Lego description system H+GT+LT H GT
LT
S S+GT+LT H+LT+S
H+GT+S
H+GT H+LT H+LT

H+GT
S+LT S+GT GT
LT
S
S
H H H
H
GT LT GT+LT
GT
LT+S GT+S S
LT
H= HEAD HUMERUS, GT= GREATER TUBEROSITY,

LT= LESSER TUBEROSITY, S=SHAFT HUMERUS
In the preoperative evaluation of patients with the humeral head, head-

splitting fractures, or loose
proximal humeral fractures, we routinely obtain bodies in the shoulder
joint. In those instances CT
an anteropostenor and an axillary (if patient can can be helpful in showing
the abnormality.
tolerate postioning of their arm for the radio-
graph) or scapular lateral radiograph [2]. Some-
times it is difficult to see the exact position of the Relevant Applied Anatomy
fracture fragments, or the patient may be difficult and Physiology
to position. Kristiansen et al. [5] found wide
interobserver variation in the classification of The shoulder has the
greatest range of motion of
proximal humeral fractures when only plain any articulation in the
body; this is due to the
radiographs were used. Accuracy of assessment shallow glenoid fossa
that is only 25 % of the size
improved with more experience in the use of the of the humeral head and
the fact that the major
Neer classification. CT scan can be useful in these contributor to stability
is not bone, but a soft
difficult cases where the amount of displacement tissue envelope composed
of muscle, capsule
or rotation of fragments is difficult to determine and ligaments.
on plain radiographs. Although additional imag- The proximal humerus
can be divided into
ing is routinely used to further characterize these four osseous segments
that have different
fractures, Sjoden et al. [12] demonstrated that the deforming muscular
forces:
addition of CT and three-dimensional imaging The humeral head
did not improve interobserver reproducibility of The lesser tuberosity;
displaced medially by
either the Neer or AO classification system (see the subscapularis
below). Majed and colleagues found only slight The greater tuberosity;
displaced superiorly
to moderate interobserver agreement between and posteriorly by
the supraspinatus and exter-
four senior shoulder surgeons classifying com- nal rotators
plex humeral fractures on CT scans with the The humeral shaft;
displaced medially by the
Neer, AO, Codman-Hertel and prototype classi- pectoralis magor
fication by Resch (see [33]). The highest The major blood
supply to the proximal
interobserver reliability was for the Codman- humerus is by the
anterior and posterior humeral
Hertel classification system. circumflex arteries. The
arcuate artery is
Specific cases in which the plain films may a continuation of the
ascending branch of the
underestimate displacement include greater or anterior humeral
circumflex. It enters the bicipital
lesser tuberosity fractures, impression fractures of groove and supplies most
of the humeral head.
1280
Unifocal 11-A1 Tuberosity 11-A2 Impacted

11-A3 Nonimpacted
extraarticular metaphyseal
metaphyseal
Bifocal 11-B1 With metaphyseal 11-B2 Without

11-B3 With glenohumeral
extraarticular impaction metaphyseal impaction
dislocation
Articular 11-C1 With slight 11-B2 Impacted with

11-B3 Dislocated
displacement marked displacement
Fig. 2 AO classification of proximal humeral fractures
Small contributions to the supply of the humeral reduction and

percutaneous pinning or plate
head arise from the posterior circumflex humeral. osteosynthesis in
patients with these fractures
Fractures of the anatomic neck are uncommon [8]. In the markedly
displaced four-part proximal
but they have a poor prognosis due to the precar- humerus fracture with
significant varus
ious blood supply to the humeral head. malalignment,
disruption of the medial soft-
Preservation of proximal humerus vascularity tissue envelope can
potentially compromise per-
is important when distinguishing between valgus fusion to the humeral
head.
impacted and varus angulated three- and four- The axillary nerve
courses just anteroinferior
part proximal humerus fractures. The valgus to the glenohumeral
joint, traversing the
impacted fracture is characterized by intact quandrangular space. It
is at particular risk for
medial soft tissues, which can potentially pre- traction injury owing
to its relative rigid fixation
serve the blood supply to the humeral head. at the posterior cord
and deltoid as well as its
Acceptable results have been achieved with proximity to the
inferior capsule where it is
1281
susceptible to injury during anterior fracture dis- locally over the shoulder
girdle itself, is
location. The incidence of neurologic injuries often present. Plain
radiographs are sufficient
associated with proximal humerus fractures is to make the diagnosis of
proximal humeral
high (59 % for nondisplaced fractures, but as fracture. To further
delineate the fracture
high as 82 % if the fracture was displaced, lines and position of
fracture fragments
according to Visser et al.). Fortunately, nerve then a CT scan may be
obtained as discussed
recovery is usually expected and only a small earlier.
percentage of fractures result in permanent
nerve damage.
Hertel has identified certain anatomical fea- Indications for Surgery
tures that can help identify those fractures at risk
of avascular necrosis: Hemiarthroplasty of the
proximal humerus is
Good predictors of ischemia: indicated for most
patients with four part frac-
Length of metaphyseal head extension (accuracy tures, displaced three
part fractures, fracture dis-
0.84 for calcar segments <8 mm) locations and also
fractures involving a severe
Integrity of the medial hinge (accuracy 0.79 for head split.
disrupted hinge) Charles Neer reported
[15] 96 % failure of
Basic fracture pattern (accuracy 0.7 for fractures fixation with open
reduction and internal fixation
comprising the anatomic neck) of four part fractures
however those treated with
Poor predictors of ischemia a hemiarthroplasty had
satisfactory or excellent
Angular displacement of the head (accuracy 0.62 results. In Neers paper
as many as 90 % of cases
for angulations over 45 deg) developed avascular
necrosis however more
Extent of displacement of the tuberosities (dis- recent studies [1618]
report much more encour-
placement over 10 mm: accuracy 0.61) aging results for
fixation of four part proximal
Gleno-humeral dislocation (accuracy 0.49) humeral fractures rather
than hemiarthroplasty.
Head-split components (accuracy 0.49) Not all patients with
avascular necrosis of the
By combination of the above criteria: ana- head following internal
fixation do poorly and in
tomic neck, short calcar, disrupted medial fact Gerber et al. [19]
showed that patients who
hinge, are associated with a positive predictive developed avascular
necrosis but had anatomic
value for AVN of up to 97 % according to healing of their
tuberosities post-fixation had out-
Hertels study. However, Hertel later published comes comparable to those
of patients treated
a study evaluating the occurrence of avascular with hemiarthroplasty for
complex proximal
necrosis in intracpsular fractures of the humerus humerus fractures.
treated with internal fixation. Hertel found that Following Neers
original report showing
eight of ten heads that were initially ischaemic 100 % satisfaction with
hemiarthroplasty follow-
did not go on to develop avascular necrosis indi- ing four part proximal
humerus fractures, no
cating that revascularization may occur if ade- other surgeon in recent
times has been able to
quate reduction and stable conditions are replicate these excellent
results. Overall most
obtained (see [34]). patients experience
satisfactory pain relief but
their functional outcome
can be unpredictable
and unsatisfactory to the
patient. In younger
Diagnosis active patients with good
bone quality it is advis-
able to attempt open
reduction and internal fixa-
The diagnosis of a proximal humeral fracture tion for complex proximal
humerus fractures
may be suspected based on the history of however hemiarthroplasty
in older, lower
a traumatic injury and the clinical examination. demand patients with
complex proximal humeral
Significant bruising and swelling, especially fractures remains an
acceptable treatment
notable further down the arm rather than modality.
1282
Osteoporosis is not a contraindication to paramount importance for a

successful outcome.
hemiarthroplasty for proximal humerus fractures. The overriding principal of
treating these frac-
Some surgeons may argue that primary open tures with a
hemiarthroplasty is to restore the
reduction and internal fixation should be advised patients anatomy. To
achieve a satisfactory
first as one can always resort to an arthroplasty as result it is crucial to
restore accurate humeral
a secondary salvage procedure. However, length, humeral version and
achieve stable fixa-
performing an arthroplasty for failed internal fix- tion of the tuberosities to
each other and to the
ation is very difficult and is also associated with shaft/prosthesis.
worse outcomes [20, 21]. Surgery is usually
performed under a general
Contraindications to hemiarthroplasty are sig- anaesthetic with an
interscalene block, which is
nificant medical co-morbidities, which preclude used to ensure satisfactory
post-operative pain
the patient undergoing surgery. In younger relief. Pre-operative
intravenous antibiotics are
patients with good bone stock every effort should given to the patient after
induction of anaesthesia.
be made to perform bone-preserving surgery with The patient is positioned
safely in a beach chair
internal fixation. position (Fig. 3). The skin
is prepared and draped
appropriately allowing
adequate exposure to the
shoulder girdle. An adhesive
impervious sheet is
Pre-Operative Preparation also applied over the skin
and drape to further
and Planning shut off the patients
axilla. This is to minimise
any potential contamination
to the surgeons
Complex fractures of the proximal humerus can gloves by the axillary skin
during surgery.
be associated with significant soft tissue injury The deltopectoral
approach is used with an
and oedema. It may be advisable to allow the incision commencing superior
to the coracoid
surrounding soft tissues to settle for 610 days and extending diagonally
down to an inch lateral
prior to traumatising the tissues further by to the anterior axillary
skin fold. The fascia over
performing a hemiarthroplasty for a fracture. the deltopectoral groove is
incised and the
However, some surgeons prefer to perform sur- cephalic vein retracted
laterally with the deltoid
gery as soon as possible so that the patients can muscle and the pectoralis
major medially.
commence their recovery. A Kolbel shoulder retractor
with adjustable
It is essential that the surgeon is familiar with blades is introduced
underneath the anterior del-
the hemiarthroplasty implant technique being toid and deep to the
conjoint tendon following
used in the operation. digital identification of
the musculocutaneous
As discussed earlier a CT scan may be nerve deep to the conjoint
tendon. A Homan
obtained to identify the fracture fragments and retractor is placed
superiorly over the
plan surgery accurately [6, 7]. coracoacromial ligament and
retracted superi-
orly. The fracture fragments
are identified and
the surgeon must take care
to avoid any injury
Operative Technique to the axillary nerve which
passes the under sur-
face of the subscapularis
tendon. The long head
Rather than considering a hemiarthroplasty for a of biceps is identified and
a tenotomy performed.
complex proximal humeral fracture as a humeral A stay suture is inserted
into the biceps tendon
head replacement arthroplasty it would be better which will later be
incorporated into a soft tissue
for the surgeon to consider the operation as an tenodesis.
osteosynthesis of the displaced tuberosities with Alternatively a deltoid
split approach ,may be
replacement of the humeral head. The position used but it is imperative
that the axillary nerve is
and healing of the tuberosities around a clearly identified and
protected.
correctly positioned arthroplasty with accurate In a four part fracture
the fracture line between
restoration of height and retroversion is of the lesser and greater
tuberosities is invariably
1283
Fig. 3 The patient is

positioned in the beach
chair position and the left
arm is draped free with the
shoulder girdle exposed
and covered in an
impervious sheet
56 mms lateral to the bicipital groove. Stay of biceps completely

resected. The glenoid artic-
sutures are inserted into the tendo-osseous ular surface should be
inspected to exclude any
junction of the subscapularis tendon and lesser concomitant pathology.
Any associated glenoid
tuberosity and also posteriorly at the tendo- fracture should be
treated at this point. If the
osseous junction of the supraspinatus and patient has concomitant
glenoid arthrosis then
infraspinatus tendons inserting onto the greater a glenoid replacement
arthroplasty should also
tuberosity fragment. Care must be taken not to be performed.
inadvertently crush the tuberosities with instru- The excised humeral
head is then sized with
ments such as Kochers, particularly in elderly the trial implants of the
arthroplasty (Fig. 4). If
patients with osteoporotic bone. After stay the patients humeral
head is in between trial
sutures are placed through the tendo-osseous sizes then the smaller
arthroplasty head should
junctions of the lesser and greater tuberosities be used and over
stuffing the shoulder joint
the split through the anterior section of the with a large head should
be avoided.
supraspinatus which runs in line with the fracture The excised native
humeral head will be used
between the tuberosities is identified and later for the acquisition
of cancellous bone graft
extended medially in the line of the rotator cuff when repairing the
tuberosities to the fracture
fibres to allow greater exposure and access to the arthroplasty stem.
humeral head fragment. Often there is a
segment of the medial calcar
Once the tuberosity fragments are mobilised which remains attached to
the excised humeral
the humeral head can be extracted. Any soft tis- head and this length
should be measured as it will
sue attachments to the tuberosities should be pre- be used later to help
guide the position and height
served. If the humeral head is dislocated, for of the arthroplasty stem
and head offset (Fig. 5).
example in an anterior fracture dislocation, then The metaphysis of the
shaft should be exposed
great care should be taken when extracting the by extending, adducting
and externally rotating
head as it will be lying in intimate proximity to the humerus and then
pushing the humerus supe-
the axillary vessels and brachial plexus. After the riorly to deliver it
through the surgical wound.
head is resected the tuberosities can be gently The humeral shaft is
prepared and rasped. The
retracted apart and the remnant of the long head following surgical
principals are of crucial
1284
Fig. 4 The size of the

excised humeral head is
measured against a trial
head from the arthroplasty
implant system
degeneration, as the
anatomical landmarks are
distorted. There is a
variety of techniques avail-
able to the operating
surgeon to achieve the cor-
rect implant height and
retroversion (Fig. 6). By
measuring the length of
medial calcar which was
fractured with the humeral
head the operating
surgeon can use this as a
reference distance that
the hemiarthroplasty head
should be from the tip
of the remaining medial
calcar on the shaft of the
humerus. This is a
reliable technique to help the
surgeon recreate the
anatomical arc of the medial
calcar. If this technique
is used the distance usu-
ally measures
approximately 57 mms unless
there is significant
metaphyseal comminution
associated with a
fracture.
A further option is to
reduce the greater tuber-
osity fracture fragment
back to an anatomical
position in relation to
the humeral shaft and
using the superior margin
of the greater tuberos-
ity as a landmark to judge
the correct height of the
superior margin of the
arthroplasty humeral head
(Fig. 7). The anatomical
study by Iannotti et al
Fig. 5 A ruler is used to measure the length of calcar concluded that the top of
the greater tuberosity
which is still attached to the excised humeral head
sits 8 # 3.5 mm below the
top of the humeral
articular surface [24].
Therefore if the fractured
greater tuberosity is held
in an anatomically cor-
importance when selecting the appropriate size rect position in relation
to the humeral shaft then
and position of implants. The correct humeral the height of the implant
can be judged correctly.
length must be restored and therefore the Some surgeons prefer
to take full-length AP
arthroplasty must be inserted and held at the humeral radiographs of
both the injured arm and
appropriate height. The surgeon must also judge the contralateral humerus
to measure the appro-
the correct humeral version in which to implant priate humeral lengths and
use an intraoperative
the prosthesis. This is obviously difficult in the ruler to judge the
appropriate height for the
case of fracture, contrary to surgery for articular hemiarthroplasty.
1285
achieved by placing
the tangent of the humeral
head 5.6 cm above
the upper insertion of the
pectoralis major
tendon [23]. In the same study
the authors
reported that correct retro version
could be achieved
by placing the posterior fin of
the prosthesis 1.06
cm from the pectoralis major
insertion.
Intraoperative
fluoroscopy can occasionally
be useful in
gauging the correct height of the
humeral implant.
It is of
crucial importance to the long-term
outcome of the
surgery that the correct humeral
height is achieved
for the implant. If the prosthe-
sis is inserted in
a position, which is too low this
will cause a lack
of tension in the deltoid muscle
Fig. 6 A trial stem has been inserted to the humerus. If
and inadequate
space for fixation of the tuberos-
the stem is at the correct height and the head in the correct ities under the
implant head. If the implant is too
position then the distance from the tip of the remaining high then it will
not be possible to reduce the
calcar and medial edge of the implant should be the same tuberosities over
the implant to the correct ana-
distance as the measurement of the section of calcar
attached to the excised head. Also, if the implant is in
tomical position.
the correct position then an imaginary line continuing the To achieve the
correct humeral head retrover-
contour of the humeral medial calcar should meet the sion either the
bicipital groove can be used as
medial tip of the head implant a reference point
or the transepicondylar axis. It
is important not to
excessively retrovert the
implant as this can
lead to poor function and
even posterior
dislocation. If the posterior fin of
the humeral stem is
implanted 8 mm lateral to the
bicipital groove,
with the distance measured
along the lateral
cortex of the shaft, then this
will place the
humeral implant in the correct
version [25].
However, the cadaveric study by
Balg and Boileau
demonstrates that there is
variability in the
orientation of the biceps groove
at the anatomical
neck and surgical neck. As there
is great variation
in groove orientation and the
position for
lateral fin placement at the surgical
neck has not been
documented the authors
caution the surgeon
regarding the use of the
groove as a
reliable landmark for calculating
retroversion in
shoulder replacement surgery for
Fig. 7 The greater tuberosity is reduced to an anatomical fractures (see
[35]).
position and the height of the implant can be correctly Usually the
surgeon would aim to put the
estimated
implant in
approximately 25# of retroversion,
which is the
average retroversion of the humeral
A further reference point to judge the correct head [26] (Fig. 8).
However, we know from pre-
head height is to reference from the pectoralis vious anatomical
studies that the patients native
major tendon insertion. Torrens et al reported retroversion could
vary from 10# to 45# [27, 28].
that anatomical height restoration could be By aiming for 25#
of retroversion this will also
1286
Fig. 8 A retrotorsion bar is

attached to either the
humeral rasp or trial stem
and the goniometer
attached to the bar is
referenced against the axis
of the forearm to determine
the degree of retroverion of
the rasp of implant
avoid undue tension on the greater tuberosity tuberosity fragment. These

wires or sutures
repair with the arm internally rotated. The inter- should ideally be placed
prior to insertion of the
epicondylar axis at the distal humerus can also be humeral implant as access to
this area of the
used as a guide to judge accurate retroversion. greater tuberosity tendo-
osseous junction is
A trial stem is inserted to the humeral shaft and much easier prior to implant
insertion. To prepare
a goniometer attached to the prosthetic stem via for later fixation of the
tuberosities, two 2 mm
a retrotorsion bar is used to measure the correct drill holes should be placed
in the proximal
retroversion in relation to the inter-epicondylar humerus both medial and
lateral to the
axis and forearm axis. bicipital groove 5 mm distal
to the fracture line
Following preparation of the humeral canal at the surgical neck. This
should be done prior to
a cement restrictor is inserted into the humeral implantation of the
prosthesis and high
shaft at the appropriate distance to prevent extru- tensile sutures are now
passed in a horizontal
sion of any cement distally in the humeral shaft. mattress fashion through the
holes for later ten-
The trial stem is again reinserted to ensure that sion band suture fixation to
the rotator cuff and
the cement restrictor is distal enough in the shaft tuberosities.
to allow satisfactory placement of the humeral The humeral stem is
cemented using standard
stem. Modern modular implants allow the offset third generation technique
and the surgeon
of the humeral head to be adjusted and this allows should take care that the
prosthesis is inserted in
the surgeon to ensure that the inferior tip of the the correct retroversion and
height. Excess
head is in line with the medial calcar and the cement around the collar of
the implant should
superior tip of the head is at the correct height be removed. Cementing of the
prosthesis affords
above the superior tip of the greater tuberosity, as the surgeon greater control
in establishing accu-
mentioned earlier. rate height of the implant.
The modular prosthesis is constructed and Cancellous bone graft is
harvested from the
prepared for implantation. native humeral head, which
can then be
The suture or wires that are to be used to implanted around the
proximal stem of the
reattach the tuberosities are inserted via the implant to help encourage
fixation of the
supraspinatus tendo-osseous junction or greater tuberosity fragments to the
implant.
1287
Through
anterior
fin
Sutures between
the
Lateral sutures tuberosities
to the greater
tuberosity
Anterior sutures Medial sutures

to both to the lesser
tuberosities tuberosity
Fig. 9 Suture fixation of tuberosities to the implant
The method of suture fixation of the tuberosi- in the shaft can then
be used to perform a tension
ties to the implant varies with the prosthesis being band suture technique
with one being tied as
used (Fig. 9). Some implants have two holes in a loop anteriorly
through the subscapularis
the proximal stem, which allow either a high tendo-osseous junction
and two sutures through
tensile suture or a 1 mm steel wire to be used to the posterosuperior
rotator cuff tendo-osseous
reattach the tuberosities. With the humeral head junction. The sutures
from the tuberosities to the
implanted but still in an anteriorly dislocated shaft are tied first
followed by the tuberosity-to-
position the cables or sutures are passed through tuberosity sutures.
the corresponding holes of the stem or medial to When fixing the
tuberosities over-reduction
the stem neck and then through the lesser tuber- should be avoided.
Over-reduction of the
osity anteriorly. The head can now be reduced to lesser tuberosity will
restrict external rotation
the glenoid and the tuberosities can be repaired in whereas over-reduction
of the greater tuberosity
place around the humeral stem. Any void under will limit internal
rotation. If the prosthesis is in
the tuberosities should be filled with cancellous the correct position
with respect to height and
bone harvested from the native humeral head. retroversion then it
should not be difficult
The sutures passed earlier through the drill holes to reduce the
tuberosities into a satisfactory
1288
Fig. 10 Final view of the

tuberosities sutured in
place. At the base of the
wound some of the drill
holes for the sutures can be
seen. The tuberosities have
been reduced to an
anatomical position and not
under- or over-reduced.
Knots can be seen from the
sutures linking the
tuberosities and humeral
stem and further sutures,
tied in a figure of 8 fashion,
from the humeral
metaphysis drill holes to the
rotator cuff tendons
position (Fig. 10). If the surgeon is finding it

difficult to reduce the tuberosities adequately Post-Operative Care
then this should be a warning to the surgeon that and Rehabilitation
the prosthesis may not be in the correct anatom-
ical position. Sutures should be removed at
2 weeks following
Successful healing of the tuberosities in surgery and patients will
often require their sling
the correct position is of great importance for the first 6 weeks post-
surgery.
for the success of the hemiarthroplasty and Patients should be warned
preoperatively
this depends on accurate prosthetic implan- that it can take up to a year
to achieve their
tation and also on a fixation technique adequate maximum functional potential
following the
to withstand early passive motion of the hemiarthroplasty and this
recovery may be longer
shoulder. Once the tuberosities are repaired if there is a concomitant
nerve injury secondary
then the shoulder is mobilised through to the initial fracture.
a full range of motion to ensure adequate The post-operative
rehabilitation is divided
stable fixation of the tuberosities without micro into three phases. The
patients arm is initially
motion. immobilised in a sling with
the arm in internal
The split through the leading edge of rotation. Immediate passive
motion is com-
supraspinatus in line with the fracture is repaired menced the day after surgery
and under the super-
with the arm externally rotated 20# . vision of the
physiotherapists passive active
At the end of the procedure the biceps tendon assisted exercises are
allowed during the first
is sutured to the pectoralis major fascia with non- 6 weeks. If at 6 weeks
postoperatively a check
absorbable sutures to perform a soft tissue x-ray shows that the
tuberosities are uniting in
tenodesis. a satisfactory position then
the patient can start
Following sufficient irrigation and active range of movement
exercises. As some
haemostasis, a redivac drain is placed deep to patients may have very
osteoporotic tuberosities
the deltoid and the wound closed in layers. The then each patient should
ideally have an
arm is protected in a sling. The drain is removed individualised rehabilitation
protocol, which the
24 h post surgery. surgeon can decide based on
the patients bone
1289
quality, the intraoperative range of motion, ade- Tanner and Cofield

identified greater tuberos-
quacy of the tuberosity fixation and expected ity displacement as the
most common complica-
patient compliance. In the third phase of rehabil- tion following this type
of surgery.
itation resistance exercises, for example using Complications were more
frequent with fracture
therabands, can be commenced at 12 weeks fol- dislocations and chronic
fractures [31].
lowing surgery. The three-phase system of reha-
bilitation was devised by Hughes and Neer [29].
Outcomes
Complications Functional results

following hemiarthroplasty
surgery for proximal
humerus fractures have
Complications following hemiarthroplasty for been unpredictable
although an arthroplasty usu-
complex proximal humeral fractures include the ally gives adequate pain
relief. As a consequence
standard complications following any surgery. open reduction and
internal fixation is the pre-
Haematoma formation and deep infection are ferred treatment of
choice for younger patients
a significant risk. Kontakis et al. [9] showed with three and four part
proximal humerus frac-
a deep infection rate of 0.64 % and a superficial tures so that the young
patients natural bone
infection rate of 1.55 %. A further complication stock is preserved.
specific to this procedure is proximal migration of Hemiarthroplasty
serves as a viable option for
the head, which was seen in 6.8 % of patients. pain relief in persons
with displaced four-part
Arguably the leading complication following proximal humerus
fracture; however, the affected
a hemiarthroplasty for proximal humeral frac- shoulder rarely returns
to its baseline level of
tures relates to the tuberosities. The tuberosities function, specifically
baseline range of motion.
may fail to unite, displace or even suffer Kontakis et al. [9]
reported the outcomes of early
osteolysis, the vanishing tuberosities. Boileau management of proximal
humerus fractures with
et al. in 2002 reported factors associated with hemiarthroplasty in a
total of 808 patients (810
failure of tuberosity osteosynthesis [30]. hemiarthroplasties). At a
mean follow-up of 3.7
Women over 75 years of age have poorer results years, mean active
forward elevation was 105.7# ,
and a worse outcome was also noted with exces- mean abduction was
92.4# , and external rotation
sive humeral retroversion of over 40# , was 30.4# . These results
are similar to those of
a prosthesis over 10 mm above the tuberosities other reports [10, 11].
Kontakis et al. [9] identi-
or a greater tuberosity over 5 mm above the fied the Constant score
for a total of 560 patients
humeral head. Overall the worst association was in eight studies; the
mean Constant score in
found with a high, retroverted head with a low patients who underwent
replacement of
greater tuberosity forming an unhappy triad a proximal humerus
prosthesis was 56.6 out of
leading to posterior migration of the greater 100 (range, 1198).
tuberosity and a subsequent poor result. In recent years there
has been a trend in
In Boileaus series lengthening the humerus Europe to treat these
complicated injuries in
more than 10 mm correlated with a tuberosity older patients with a
reverse geometry
detachment and subsequent proximal migration arthroplasty on the
theoretical basis that the
of the prosthesis under the coracoacromial arch. patients will achieve a
greater functional out-
This may indeed be from a non-union of the come compared to a
standard hemiarthroplasty,
greater tuberosity at the humeral diaphysis or as a reverse arthroplasty
is not reliant on the
from a subsequent rotator cuff tear secondary to tuberosities and rotator
cuff for function. Bufquin
the tension. Shortening of the humerus was much et al [13] prospectively
studied a cohort of 43
better tolerated clinically. Humeral shortening of patients with three- or
four-part proximal
2 cm or more is required before deltoid power and humerus fractures treated
with RTSA. At an aver-
function is adversely affected [30, 32]. age 22-month follow-up,
mean active forward
1290
elevation and external rotation with the arm in anatomical position,

restoration of humeral
abduction were 97# and 30# , respectively. The height and correct
retroversion are some of the
mean Constant score was 44. The authors con- challenges that must be
conquered to achieve
cluded that adequate clinical results could be successful outcomes
following hemiarthroplasty.
achieved with RTSA in patients with three- or Prosthetic humeral head
replacement has
four part fractures, despite loss of reduction of been shown to be effective
in providing good
the tuberosities. Gallinet et al [14] retrospectively pain relief, however, the
affected extremity
studied a series of 40 patients with complex three- will not reach pre-injury
levels of function.
or four-part proximal humerus fractures who Hemiarthroplasty for
complex proximal humeral
underwent either hemiarthroplasty or RTSA. fractures is a useful
treatment option, however, in
Twenty-one patients underwent hemiarthroplasty younger patients with good
bone stock
with a standard cemented stem, and 19 underwent osteosynthesis should be
the preferred treatment
RTSA using a reverse prosthesis with a cemented of choice.
stem. Constant scores, active abduction, and for-
ward elevation were higher in the RTSA group
compared with the hemiarthroplasty group. How-
ever, external rotation was greater in the
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Humeral Shaft Fractures -
Principles
of Management
Deborah Higgs
Contents
Abstract
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1293 Humeral shaft fractures account for approxi-
mately 3 % of all fractures. Vascular injury

Mechanism of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295
in association with humeral shaft fractures

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1297 occurs in only a small percentage of cases.
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1298 Most humeral shaft fractures can be managed
non-operatively with expected good or

Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1298
excellent results. Both patient and fracture

Initial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1298 characteristics need to be considered when
Methods of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1298
deciding the most appropriate treatment
Non-Operative Management . . . . . . . . . . . . . . . . . . . . . 1298
option.
Operative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 1299
Keywords
Vascular Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1300 Anatomy # Classification # Complications-
Nerve
Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1300 radial nerve and vascular # Diagnosis #
Open Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1301
Humeral shaft fractures # Mechanisms # Non-
operative bracing # Surgical indications

Pathological Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1302
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1302
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1302 Anatomy
The humeral shaft extends from the surgical neck
proximally to the condyles distally. Proximally it

has a cylindrical shape in cross-section and the
cortex is thin. It is conical in its middle section
where the cortex is very thick and the medulla
narrow. In the distal third the humerus becomes
more flattened in the coronal plane giving it
a trapezoidal shape. The medulla ends just
above the olecranon fossa.
The humeral head is just proximal to, and in

D. Higgs
line with the distal end of the canal. The

Royal National Orthopaedic Hospital, Stanmore,
Middlesex, UK
upper arm is completely covered with muscle
e-mail: dhiggs@doctors.org.uk
apart from the medial and lateral epicondyles.

1293
DOI 10.1007/978-3-642-34746-7_250, # EFORT 2014
1294
D. Higgs
a b c
Fig. 1 (a) Fracture proximal to the pectoralis major muscle insertion (b) fracture
between deltoid and pectoralis major
insertions (c) fracture distal to deltoid
The muscles are divided into flexor and extensor the artery lies
anteromedially on the brachialis
compartments, separated by medial and lateral muscle. The median
nerve crosses in front of
intermuscular septa. The flexor(anterior) the artery from
lateral to medial in the cubital
compartment contains biceps, brachialis and fossa (Fig. 2).
coracobrachialis. The extensor(posterior) com- The ulnar nerve
lies medial to the brachial
partment contains triceps. If the fracture is situ- artery as it exits the
axilla, and at the junctions
ated between the rotator cuff and the pectoralis of the middle and
distal thirds of the upper arm
major muscle, the humeral head will be abducted perforates the medial
intermuscular septum to run
and internally rotated. If the fracture is between on the posterior
aspect of the medial epicondyle
the pectoralis muscle and the insertion of deltoid, (Fig. 3).
the proximal fragment will be adducted and the The radial nerve
lies posterior to the origin of
distal fragment laterally displaced. In fractures the brachial artery
crossing the subscapularis
distal to the deltoid insertion, the proximal muscle and teres major
tendon. It passes
fragment will be abducted. In fractures proximal obliquely distally
(from medial to lateral) in the
to the brachioradialis and extensor muscles, the spiral groove directly
on the posterior aspect of
distal fragment will be rotated laterally (Fig. 1). the shaft of the
humerus with the profunda brachii
The brachial artery (and vein) lie well medial artery. It perforates
the lateral intermuscular sep-
to the shaft proximally and is superficial through- tum at the junction of
the middle and distal thirds
out its course in the upper arm. In the lower arm of the humerus from
posterior to anterior
1295
Sternocleidomastoid
Trapezius
Clavicle
Deltoid
Long head
of biceps
Pectoralis
major
Short head
of biceps
Coracobrachialis
Triceps
Radial nerve
Ulnar nerve
Median nerve
Brachial artery
Brachialis
Medial intermuscular
septum
Musculocutaneous
nerve
Ulnar artery Pronator

teres
Biceps tendon Flexor
Radial artery carpi
radialis
Brachioradialis Palmaris
longus
Extensor carpi
radialis longus Bicipital
aponeurosis
Flexor
carpi
ulnaris
Fig. 2 Anterior view of the upper arm
compartments. Here the nerve is less mobile and The musculocutaneous

nerve passes through
is vulnerable when fragments displace. It con- the muscle belly of the
coracobrachialis and runs
tinues distally between the brachialis medially between biceps and
brachialis.
and the brachioradialis and extensor carpi radialis
muscles laterally.
The axillary nerve, which is initially posterior Mechanism of Injury
to the axillary artery, crosses the subscapularis
then continues posteriorly traversing the quadri- Typically humeral shaft
fractures occur as
lateral space. It winds around the surgical neck a result of a simple fall,
often in the older patient,
with the posterior circumflex artery about 56 cm or as a result of motor
vehicle accidents. Sporting
below the acromion. injuries and fractures
following a direct blow are
1296
D. Higgs
Fig. 3 Posterior view of

the upper arm
Supraspinatus
Teres minor
Deltoid
Surgical neck
Infraspinatus
of humerus
Anterior division
of axillary nerve
Posterior division
of axillary nerve
Upper lateral
cutaneous nerve
of arm
Lateral head
of triceps
Teres major
Radial nerve
Profunda artery
Long head
of triceps
Lower lateral
cutaneous
nerve of arm
Posterior
cutaneous
nerve of forearm
Brachialis
Lateral
Medial head
intermuscular
of triceps
septum
Brachioradialis
Ulnar nerve
Anconeus
Medial epicondyle
Olecranon process
Extensor carpi
of ulna
radialis longus
Flexor carpi
ulnaris
Extensor carpi
radialis brevis
Extensor carpi
ulnaris
comparatively rare. Pure compressive forces arm wrestling. Higher

energy injuries result in
result in proximal or distal humerus fractures; a greater degree of
comminution and soft tissue
torsional forces in spiral fractures; bending forces injury.
in transverse fractures. Combined bending Pathological fractures
from metastatic bone
and torsion results in an oblique fracture, often disease and myeloma are
an important sub-
with a butterfly fragment. The typical oblique group. A review of 249
humeral shaft fractures
distal shaft fracture described by Holstein by McQueen [21] showed a
bi-modal distribu-
and Lewis (1963) [8] is associated with tion: with peaks in the
third and seventh decades
1297
with the division at 50 years of age. In the A A1

A2 A3
under-50-year group, 70 % of fractures occurred
in men with over two-thirds the result of moder-
ate to severe trauma. In the over- 50-year group
73 % were in women with nearly 80 % of frac-
tures resulting from a simple fall. This epidemi-
ological information differs from other data
published. Mast et al. [9], in a retrospective
study of 240 fractures of the humeral shaft in
a level-1 trauma centre, found that 60 % occurred
in the under-30-year age group, with a fairly even
distribution of injury within the shaft 17 % of
the fractures were the result of gunshot wounds.
Rose et al. [14] reviewed 586 humeral fractures B B1
B2 B3
of which 116 (20 %) were of the shaft. They noted
a bi-modal distribution for the latter injuries with
a peak in the under-30-year and over-30-year age
groups. Nearly 70 % of the fractures occurred in
the former group, and were a result of severe
trauma with just over half being sustained in men.
Classification
Traditionally diaphyseal fractures of the humerus

have been classified depending on:
1. Fracture location proximal, middle, or distal C C1
C2 C3
third of the humeral shaft;
2. The fracture pattern transverse, oblique,
spiral, segmental, or comminuted;
3. Bone quality normal or pathological;
4. Associated soft tissue injury open or closed;
5. Associated neurovascular injury.
Currently as with all diaphyseal fractures, the
major classification for humeral shaft fractures is
the AO classification. This classification com-
bines the position of the fracture in the diaphysis
with the fracture morphology. It divides humeral
diaphyseal fractures into three basic types:
A, B and C:
Fig. 4 AO classification of
humeral shaft fractures
Type A fractures are simple fractures without any
degree of comminution.
Type B fractures are wedge fractures associated sub-groups depending on
fracture pattern.
with intact or fragmented butterfly fragments. In their series McQueen
[21] reported over
Type C fractures are complex fractures with 60 % of humeral shaft
fractures occurred
significant comminution or a segmental comin the middle segment of
the shaft of
ponent. Each AO fracture type is divided the humerus and over 60 %
were AO type
into three groups and each group into three A (Fig. 4).
1298
D. Higgs
The principal disadvantage with the AO clas-

sification is that the state of the soft tissues is not Initial Management
taken into account.
For open fractures of the humerus, as with Initial splinting of
humeral shaft fractures can be
open fractures elsewhere in the skeleton, the difficult. A collar and
cuff allowing the arm to
commonly used Gustilo [5, 6] and Tscherne hang dependent provides
provisional splinting.
[11] classifications can be used. The best pain-relieving
splint is provided by
In the series from Edinburgh [21] less a U-slab of plaster of
paris applied to the outer
than 10 % of the fractures were reported as aspect of the arm from
the acromion around the
open; with a bi-modal age distribution with elbow, held in 90# of
flexion and continued along
a peak in the third decade as a result of moderate the inner aspect of the
arm to the axilla. The
to severe injury in men and a larger peak in the plaster is applied to the
arm over vellband and
seventh decade after a simple fall in women. held in place by crepe
bandage. The radial nerve
should be assessed before
and after application of
the cast. If radial nerve
function is normal
Diagnosis before and abnormal after
application of the cast
then open exploration of
the radial nerve
The mechanism of injury is important. With high with internal fixation of
the fracture should be
energy injuries it is particularly important to assess performed.
for associated injuries. Compliance with conser-
vative treatment needs to be assessed. In cases of
pathological fractures the primary diagnosis and Methods of Treatment
the presence of other metastatic lesions should be
considered when planning treatment. The goal of treatment is
to obtain union with
acceptable alignment to
allow the patient to
return to their previous
level of function.
Examination The decision whether
to treat a humeral shaft
fracture operatively or
non-operatively requires
The upper arm should be examined for swelling, an understanding of the
relevant anatomy and the
bruising, and deformity. The entire upper fracture pattern.
limb should be examined for vascular and neuro- The majority of
humeral shaft fractures can be
logical changes, especially the radial nerve. managed conservatively.
Moderate angulation
Soft tissue abrasions need to be differentiated (less than 20# anterior
and 30# varus angulation),
from open fractures. Examination of the shoulder rotation, and shortening
(less than 3 cm) are well
and elbow can be difficult in the presence of tolerated. Mast et al.
[9], in their retrospective
a humeral shaft fracture but they should be assessed study of 240 humeral
shaft fractures showed
for injury and stiffness secondary to arthrosis. that in 100 patients
treated non-operatively there
X-rays are obtained in two planes, were five non-unions and
15 delayed unions with
anteroposterior and lateral. The elbow and shoul- 96 % incidence of
excellent or satisfactory
der joint should be included on each view. This is results.
to assess for intra-articular fracture extension,
dislocations and pre-existing arthrosis. It is
important not to rotate the arm through the frac- Non-Operative Management
ture site. CT scans and MRI scans are rarely
indicated. In pathological fractures additional There are many options
for non-operative treat-
studies such as MRI, CT or technetium bone ment including U-slabs
and hanging casts. Many
scans are likely to be necessary prior to planning surgeons now use humeral
functional bracing.
treatment. This was described by
Sarmiento in 1977 [17]
1299
and effects fracture reduction through soft tissue

compression. The original casts have given way
to functional braces. These braces have Velcro
straps which can be tightened as swelling
decreases. Proximally the brace approaches the
acromion laterally and the axilla medially
encircling the upper arm. Distally the brace
does not cover the medial and lateral
epicondyles to allow free elbow movement.
Sarmiento and others have reported excellent
results with their use. In a review of 85 extra-
articular comminuted distal-third humeral shaft
fractures Sarmiento reported only one
pseudarthrosis and one asymptomatic mal-
union. The average time to union was 10
weeks. All cases of radial nerve palsy resolved
during treatment. Zargorski et al. [22] reported
a series of 233 humeral shaft fractures treated
with a pre-fabricated humeral brace. Of 170
patients available for follow-up 98 % (167) had
united with an average time to union of 9.5
weeks for closed fractures and 13.6 weeks for
open fractures. 95 % (158) had an excellent Fig. 5 Pre-fabricated
functional humeral brace
functional result (Fig. 5).
A functional brace can be applied acutely
or 12 weeks after application of a U-slab.
Many surgeons choose the latter option. Operative Management
A radiograph after brace application is advisable
to check the fracture position. Radial nerve func- There are absolute and
relative indications for
tion should be assessed before and after applica- surgical stabilization.
tion of the brace. The patient is followed at Absolute indications:
weekly intervals with radiographs for the first Polytrauma
34 weeks. The brace is worn for a minimum of Open fractures
8 weeks. Bilateral humeral shaft
fractures
There can however be problems associated Pathological fracture
with bracing. The straps have to be tightened as Floating elbow
swelling decreases to ensure a firm fit. There is an Vascular injury
incidence of skin problems and shoulder stiff- Radial nerve injury after
closed reduction
ness. Obese patients and certain fracture patterns, Non-union
such as transverse fractures at the level of the Relative indications:
deltoid insertion or segmental fractures, are Long spiral fractures
more difficult to treat in a brace. Zagorski et al. Transverse fractures
[22] identified three patients with significant Brachial plexus injuries
varus angulation all of whom were obese Inability to maintain
reduction
women whose ipsilateral breast had acted as a Obese patients
fulcrum around which the fracture had angulated. The patients age,
fracture pattern, associated
Use of a sling may also result in varus angulation injuries, co-morbidity, and
ability to comply with
(Fig. 6). treatment must be
considered.
1300
D. Higgs
Fig. 6 Mid-shaft humeral fracture in a 31-year-old female sustained in a motor

vehicle accident. Radiograph taken with
arm in a functional brace
repair depends on the

ischaemia time and is
Vascular Injury a decision made by the
vascular and Orthopaedic
surgeon.
Fractures of the humeral shaft are rarely associ-
ated with vascular injury. Mechanisms of bra-
chial artery injury include penetrating trauma, Nerve Injury
entrapment between fracture fragments and sec-
ondary occlusion due to swelling. Fractures com- Radial nerve injuries
have been associated with
plicated by vascular injury are an Orthopaedic up to 11 % of humeral
shaft fractures [19]. The
emergency. Stabilisation of the fracture is site of the fracture is
important. Despite the
required to protect the vascular repair and mini- Holstein- Lewis
fracture (distal-third, oblique
mise further soft tissue injury. Whether the fracture) being
associated with a radial nerve
humerus is stabilised prior to or after the vascular palsy, middle-third
humeral shaft fractures are
1301
Fig. 7 Radiographs taken

8 months post-injury
showing a united fracture
the most common for radial nerve involvement. 1. Level of the fracture,
In this area up to 30 % of fractures may show 2. Degree of fracture
displacement,
radial nerve involvement. Most lesions take the 3. Nature of the soft tissue
injury,
form of a neuropraxia, or rarely axonotmesis, 4. Degree of neurologic
deficit.
with a reported 90 % resolving within 34 months. Other authors recommend
surgical explora-
Indications for early operative exploration of tion 3 or 4 months after
injury if there is no sign
the radial nerve include radial nerve palsies asso- of neurological recovery,
and no later than
ciated with an open fracture, penetrating trauma, 6 months [19].
and secondary nerve palsies post-fracture
reduction.
However management of a primary radial Open Fracture
nerve palsy associated with a closed humeral
shaft fracture remains controversial. Those who The same management
principles should be
advocate non-operative treatment state that applied to open fractures of
the humeral shaft as
8090 % of lesions will resolve spontaneously for any open long-bone
fracture. The wound
and that surgical exploration does not always should be covered with a
sterile dressing, the arm
lead to satisfactory results. Postacchini and splinted, appropriate
antibiotics and tetanus pro-
Morace [12] reported on 42 cases treated non- phylaxis administered. The
fracture and soft tissue
operatively or with early or late exploration of injury should be treated
surgically. The open
the radial nerve. They concluded that the decision wound should be extended
beyond the zone of
to perform an early or late exploration of the nerve injury and all necrotic and
devitalised tissue
should be based on four criteria: excised and the wound
irrigated. The fracture
1302
D. Higgs
should be stabilized to prevent further soft tissue 7. Heim D, Herkert

F, Hess P, Regazzoni P. Surgical
injury. Those with extensive soft tissue injury treatment of
humeral shaft fractures: the Basel expe-
rience. J
Trauma. 1993;35:22632.
require a second-look debridement at 48 h. 8. Holstein A,
Lewis GB. Fractures of the humerus with
radial-nerve
1963;45:13828.
Pathological Fracture 9. Mast JW, Spiegel
PG, Harvey Jr JP, Harrison C.
Fractures of the
humeral shaft: a retrospective study of
240 adult
fractures. Clin Orthop. 1975;112:25462.
The humeral shaft is a relatively common site for 10. M uller ME,
Nazarian S, Koch P, Schatzker J. The
metastatic disease. Operative stabilisation is comprehensive
classification of fractures of long
recommended for these fractures for pain relief bones. Berlin:
Springer; 1990.
11. Oesterne H-J,
Tscherne H. Pathophysiology and clas-
and ease of nursing. Several authors [18] have sification of
soft tissue injuries associated with frac-
recommended the use of polymethylmethacrylate tures. In:
Tscherne H, Gotzen L, editors. Fractures
to aid fixation in cases of large bony defects with soft tissue
injuries. Berlin: Springer; 1984. p. 19.
caused by tumour. 12. Pollock FH,
Drake D, Bovill EG, Day L, Trafton PG.
Treatment of
radial neuropathy associated with
fractures of the
humerus. J Bone Joint Surg Am.
1981;63-A:239
43.
Summary 12. Postacchini F,
Morace G. Fractures of the humerus
associated with
paralysis of the radial nerve. Ital
J Orthop
Traumatol. 1988;14:45564.
The primary aim of treatment should be to restore 13. Rose SH, Melton
LJ, Morrey BF, Ilstrup DM, Riggs
function. The surgeon should be aware of the BL.
Epidemiologic features of humeral fractures. Clin
advantages and disadvantages of all treatment Orthop.
1982;168:2430.
options available. The fracture configuration, 14. Samardzic M,
Grujicic D, Milinkovic ZB. Radial
nerve lesions
associated with fractures of the humeral
the associated soft tissue injury and the patient shaft. Injury.
1990;21:2202.
as a whole, all need to be taken into consideration 15. Sarmiento A,
Horowitch A, Aboulafia A,
when choosing the most appropriate treatment Vangsness Jr C.
Functional bracing for comminuted
option. extra-articular
fractures of the distal third of the
humerus. J Bone
Joint Surg Br. 1990;72:2837.
16. Sarmiento A,
Kinman PB, Galvin EG, Schmitt RH,
Phillips JG.
Functional bracing of fractures of the shaft
References of the humerus.
J Bone Joint Surg Am. 1977;59:596601.
17. Schatzker J,
HaEri EB. Methylmethacrylate as an
1. Amillo S, Barrios RH, Martinez-Peric R, Losada JI. adjunct in the
internal fixation of pathologic fractures.
Surgical treatment of the radial nerve lesions associ- Can J Surg.
1979;22:179.
ated with fractures of the humerus. J Orthop Tr. 18. Shao YC, Harwood
P, Grotz MRW, Limb D,
1993;7:2115. Giannoudis PV.
Radial nerve palsy associated with
2. Balfour GW, Mooney V, Ashby ME. Diaphyseal frac- fractures of the
shaft of the humerus. A systematic
tures of the humerus treated with a ready made fracture review. J Bone
Joint Surg Br. 2005;87:164752.
brace. J Bone Joint Surg Am. 1982;64:113. 19. Sonneveld GJ,
Patka P, Van Mourik JC, Broere G.
3. Dabezies EJ, Banta CJ, Murphy CP, dAmbrosia RD. Treatment of
fractures of the shaft of the humerus
Plate fixation of the humeral shaft for acute fractures, accompanied by
paralysis of the radial nerve. Injury.
with and without radial nerve injuries. J Orthop 1987;18:4046.
Trauma. 1992;6:103. 20. Tytherleigh-
Strong G, Walls N, McQueen MM. The
4. Foster RJ, Swiontkowski MF, Bach AW, Sack JT. epidemiology of
humeral shaft fractures. J Bone Joint
Radial nerve palsy caused by open humeral shaft frac- Surg Br.
1998;80-B:24953.
tures. J Hand Surg. 1993;18:1214. 21. Zagorski JB,
Latta LL, Zych GA, Finnieston AR.
5. Gustilo RB, Anderson JT. Prevention of infection in the Diaphyseal
fractures of the humerus: treatment with
treatment of one thousand and twenty-five open fractures prefabricated
braces. J Bone Joint Surg Am.
of long bones: retrospective and prospective analysis. 1988;70:60710.
J Bone Joint Surg Am. 1976;58-A:4538. 22. Zagorski JB,
Zych GA, Latta LL, McCollough NC.
6. Gustilo RB, Mendoza RM, Williams DN. Problems in Modern concepts
in functional fracture bracing: the
the management of type III (severe) open fractures: upper limb. In:
Instructional course lectures, vol. 36.
a new classification of type III open fractures. Park ridge, IL:
American academy of Orthopaedic
J Trauma. 1984;24:7426. surgeons; 1987.
p. 377401.
Part IV
Arm, Elbow and Forearm
Biomechanics of the Elbow
David Limb
Contents
Abstract
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1305 The elbow acts as a hinge between the arm and
forearm, whilst simultaneously permitting

Movements of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . 1309
forearm rotation. Without the elbow the enor-

Stability of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1310 mous range of movement possible at the
Static
Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1310 shoulder would only give the hand access to
Dynamic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 1313
a shell of fixed distance from the shoulder

Forces Across the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . 1313
articulation, with limited capacity to rotate
Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1314 the hand. The hinge of the elbow opens up
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1316 another dimension, dramatically increasing
the space into which the hand can be placed

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1316
and allowing this with almost any hand posi-
tion, facilitating prehensile function. The col-
lateral ligaments typical of a hinge joint are
modified to accommodate forearm rotation
and, coupled with the close congruity of the
joint, make this a very stable joint but suscep-
tible to specific patterns of instability. Subtle-
ties of the kinematics of the joint, and the fact
that the elbow transmits forces that can be
multiples of body weight, create significant
challenges when reconstructing fractures or
replacing the joint.

Keywords
Anatomy # Biomechanics # Elbow # Forces #
Kinematics # Stability
Anatomy
The elbow joint consists of articulations between

D. Limb
the humerus, ulna and radius. The humerus is
a tubular long bone but distally it flares out to

1305
DOI 10.1007/978-3-642-34746-7_61, # EFORT 2014
1306
D. Limb
Fig. 2 The flexion axis

of the elbow (FF) runs between
the lateral epicondyle
and the anteroinferior aspect of the
medial epicondyle. The
trochlear groove (TT) crosses
this axis obliquely
exception to the above

is that the lateral third of
brachialis is
innervated by the radial nerve. The
ulnohumeral joint
allows hinge-like movement
through the flexion arc
(ginglymoid joint).
The radiocapitellar
articulation allows axial
rotation of the forearm
(trochoid joint) whilst
sharing the movement of
flexion, the radius
also articulating
medially with the proximal
Fig. 1 An anterior view of the distal humerus. A medial ulna at the proximal
radio-ulnar joint. All share
epicondyle, B lateral epicondyle, C trochlea, a common synovial
cavity to form what we know
D capitellum as the elbow joint,
which is therefore categorised
as a trochogynglymoid
joint.
form medial and lateral columns whilst flattening The ulnohumeral
joint is the functionally
in the anteroposterior plane. The flare reaches its essential component of
the elbow joint, as the
maximum width at the medial and lateral movement of forearm
rotation can still occur in
epicondyles, and between these the articular sur- the absence of a
radiocapitellar joint through the
face forms the distinct capitellum (laterally) and distal radio-ulnar
joint and the interosseous mem-
trochlea (medially) for articulation with the brane. At the
ulnohumeral joint the greater sig-
radius and ulna respectively (Fig. 1). The moid notch of the ulna
engages and rotates
epicondyles give rise to the collateral ligaments around the reel-like
trochlea of the distal
of the elbow. humerus. The latter is
covered by articular carti-
The lateral epicondyle and the lateral column lage through an arc of
300# , this extent being
immediately above it also give origin to the wrist possible because of the
coincident olecranon
and finger extensors which, with supinator, are and coronoid fossae.
Thus the greater sigmoid
supplied by the radial nerve. The medial notch of the ulna is
able to enclose an arc of
epicondyle and medial column immediately trochlea of
approximately 190# yet permit
above it give origin to the flexor/pronator muscle a range of flexion of
at least 140# . The trochlear
groups, served by the median and ulnar nerves. groove runs obliquely,
rather than perpendicular,
Anteriorly the elbow flexors, supplied by the to the flexion axis of
the elbow (Fig. 2). The
musculocutaneous nerve, cross the joint whilst radius also articulates
with the ulna at the lesser
posteriorly triceps, the elbow extensor supplied sigmoid notch and the
latter encloses an arc of
by the radial nerve, passes to gain attachment to approximately 70# and
is found just distal to the
the olecranon process of the ulna. The slight coronoid process, on
the lateral aspect of the ulna.
1307
Supination is more likely with

ulna fractures passing through
this point [12]. The
radiocapitellar joint and prox-
imal radio-ulnar
joint allow forearm rotation,
whilst compressive
forces call upon the
Available
radiocapitellar
joints secondary function as
Radius
Ulna
a valgus stabiliser
of the elbow.
The long axis of
the ulna is not co-linear with
the long axis of the
humerus in extension but
instead forms a
valgus angle the carrying
Pronation angle. This measures
1114# in men and 1316#
in women [1], being
very slightly larger on the
dominant side. The
tilted axis of the trochlea
swings the ulna into
alignment with the axis of
Fig. 3 The proximal radius articulates with the lesser the humerus in
flexion, with loss of the carrying
sigmoid notch of the ulna. An arc of approximately 120#
of the margin of the radial head does not come into contact angle in both sexes.
with the lesser sigmoid notch in either full supination The greater
sigmoid notch of the proximal
or pronation. Implants placed here will therefore not ulna is not a segment
of a circle when viewed in
cause a mechanical block to movement at the proximal the lateral plane,
but rather it is elliptical. There-
radio-ulnar joint
fore the sigmoid
notch does not conform pre-
cisely to the
trochlea but articulates through
Forearm rotation does not depend on the pres- separate facets on
the coronoid process and olec-
ence of the radiocapitellar joint but disorders of ranon process [22],
with a non-articular zone
the radial head and radiocapitellar joint can cer- between which is
bare, to a variable extent, of
tainly have an adverse effect on rotation. articular cartilage
(Fig. 4). Since fractures of the
Normally the joint allows 7590# of pronation olecranon commonly
occur through this zone, we
and around 8590# of supination. Thus, not all therefore have the
beginnings of an explanation
of the 360# circumference of the radial head is as to why elbow
arthritis is so rare after olecranon
necessary for articulation with the ulna at the fractures. The mouth
of the greater sigmoid notch
proximal radio-ulnar joint and implants can be is not perpendicular
to the shaft of the ulna, but
fixed to the radial head without blocking rotation. faces posteriorly by
approximately 30# (Fig. 5),
However the implants have to be positioned matching the forward
inclination of the
carefully with the forearm in a neutral position capitellum and
trochlea with respect to the distal
and a lateral approach to the radial head an arc of humerus (Fig. 6).
Without this arrangement full
approximately 120# can be covered by a plate or extension would not
be possible and indeed, fail-
screw heads without mechanically impinging in ure to reconstruct
the distal humerus or proximal
the joint (Fig. 3). The implants will still glide ulna without the
relevant inclination results in
against the elbow capsule, however, and a sensa- loss of elbow
extension. It is also aligned in
tion of crepitus is common even with perfectly approximately 4# of
valgus to the ulnar axis,
positioned plates. partly accounting for
the carrying angle.
The axis of forearm rotation passes through The hinge of the
ulnohumeral joint, like other
the proximal and distal radio-ulnar joints. It is hinge joints in the
body, has collateral ligaments.
therefore not parallel to the axis of either the These are the medial
and lateral ulnar collateral
ulna or radius and forearm rotation is independent ligaments. The radius
is stabilised proximally as
of flexion at the ulnohumeral joint [8]. The axis it rotates in the
proximal radio-ulnar joint by the
coincides with the attachment of the interosseous annular ligament. The
lateral ulnar collateral lig-
membrane to the ulna at the junction between the ament [15] passes
behind the radial head to attach
proximal three quarters and distal quarter of this to the ulna at the
supinator crest and, as will be
bone and this might explain why loss of rotation seen, helps stabilise
against posterior dislocation
1308
D. Limb
Fig. 6 The capitellum

and trochlea are projected anterior
to the axis of the
humerus by approximately 30# , into the
mouth of the greater
sigmoid notch
Fig. 4 The greater sigmoid notch of the distal ulna has
two articular facets (A), one each on the coronoid process of the radial head. It
becomes contiguous with the
and olecranon process, separated by a bare area
annular ligament and
both are structurally con-
densations of the
capsule of the elbow. The cap-
sular condensation
between the lateral
epicondyle and the
annular ligament is termed
the radial collateral
ligament but note that it
is the lateral ulnar
collateral ligament, rather
than the radial
collateral ligament, which is the
true collateral
ligament of the elbow hinge
(Fig. 7). The capsule
itself attaches just above
the olecranon
posteriorly and along the margins
of the greater sigmoid
notch anteriorly. It is thin
and the anterior
capsule is taut in extension and
Fig. 5 The greater sigmoid notch of the proximal ulna has
lax in extension, the
opposite being true for the
a mouth that opens facing approximately 30# posterior to posterior capsule. The
capsule is most redundant
the axis of the ulna in approximately 80#
of flexion and in this
1309
B
A
C
Fig. 8 The medial

collateral ligaments. A Anterior band
Fig. 7 The lateral collateral ligament complex of the of the medial ulnar
collateral ligament, B Posterior band,
elbow. A Lateral ulnar collateral ligament, B Annular C Transverse bundle
ligament, C Radial collateral ligament
position 2530 ml of fluid can be injected into the and has no known
function. Detailed dissections
joint to displace the neurovascular structures have gone on to
describe subcomponents of the
away from the articular surfaces before inserting medial and lateral
ligaments, but the variability
an arthroscope [20]. between individuals is
substantial and detailed
The medial ulnar collateral ligament is usually knowledge of the
possible arrangements of fibre
described as having three parts the anterior, bundles does not help
in making treatment
posterior and transverse bundles (Fig. 8), though decisions.
it is the anterior bundle that proves functionally
and clinically most important [19]. The posterior
bundle is often indistinct except as a thickening Movements of the Elbow
of the joint capsule behind the more discreet
anterior bundle, becoming prominent as the As a trochogynglymoid
joint the elbow has two
elbow is flexed past 90# . It passes to attach to degrees of freedom,
allowing movements in the
the mid-portion of the sigmoid notch on the flexion-extension range
and, as forearm rotation,
medial side of the elbow. The anterior bundle in pronation-
supination.
takes origin with its posterior counterpart from The ulnohumeral
joint has been described as
the anteroinferior surface of the medial a hinge joint but its
arc of movement is not strictly
epicondyle of the humerus. The ulnar nerve in one plane and the
axis about which flexion
passes behind the epicondyle and therefore does occurs is not fixed so
this statement is not strictly
not come into contact with the collateral liga- correct [9, 18].
Electromagnetic tracking devices
ment. The ligament then passes forwards to identify three or four
degrees of varus/valgus and
attach to the medial margin of the coronoid pro- axial rotation during
the flexion arc [23], and this
cess. The transverse bundle, one of the bodys obligate movement is
not permitted by older
ligaments of Cooper, passes between the distal generation, fixed-hinge
elbow replacements.
insertions of the anterior and posterior bundles The axis of flexion can
be taken to be a line
1310
D. Limb
joining the centre of the lateral epicondyle with However, tension in triceps
and contact between
the antero-inferior surface of the medial the muscles of the arm and
forearm usually
epicondyle (Fig. 2). However, detailed analysis prevents this range in life,
full elbow flexion
reveals that the instant centre of rotation actually being usually 140145# .
follows an irregular course when measured at
progressively increasing flexion angles, though
for the purposes of reconstruction after trauma Stability of the Elbow
the variation is slight [11] and the siting of the
axis on the surface of the epicondyles is Stability can be considered
to have contributions
contained within an area of a few mm2. This is from both static and dynamic
factors. The static
within, for example, the area of a drill hole used factors relate to bony
constraints and the
to pass material used to substitute for an injured capsuloligamentous anatomy
of the joint.
collateral ligament. However, work using Dynamic factors are those
that harness forces
radiostereometric analysis suggests that the acting across the joint to
compress the
mean axis of flexion can vary between individ- interlocking surfaces and
enhance the stability
uals by up to 12.7# in the frontal plane and 4.6# in achieved through static
constraints. The elbow
the horizontal plane, a greater variation than is is one of the most congruous
joints in the body,
currently accommodated by most designs of and it is also one of the
most stable.
elbow replacement [4].
The range of elbow flexion varies between
individuals, and up to 10# of hyperextension is Static Factors
not uncommon. A range of almost 150# is nor-
mal, with up to 90# of pronation and supination. It Bony Stability
is accepted that most activities can be carried out Throughout its range of
movement the elbow is
with less than this, and generally a range of flex- observed to remain highly
congruent and it
ion from 30# to 130# , with 50# of pronation and clearly achieves a high
degree of stability from
supination, is felt to be sufficient to live without the close adaptation of the
greater sigmoid notch
disability [17]. This is, however, subject to vari- to the trochlea and the
concavity of the radial
ation with contemporary technology and pres- head to the convex
capitellum. Whilst this is
ently it has been noted that the use of a mobile a relatively straightforward
observation it proves
telephone requires more flexion and supination very difficult to
investigate and quantify.
than this, whilst a keyboard can only be comfort- The contact area has been
studied using
ably operated with at least 80# of pronation [21]. a range of techniques [22]
and it is generally
Extension is normally limited by contact agreed that the central
depression of the radial
between the olecranon and the olecranon fossa head is always in contact
with the capitellum,
and tension in the anterior bundle of the medial whilst the ulna articulates
with the humerus
ulnar collateral ligament [5, 10]. After trauma, through anterior and
posterior facets. In exten-
anterior capsular scarring and contracture may sion the contact points tend
to be further apart,
limit extension before the natural limit is reached. towards the tips of the
olecranon and coronoid
With primary elbow osteoarthritis the olecranon processes within the greater
sigmoid notch. As
fossa begins to fill in with osteophytes and the the elbow flexes the contact
points pinch in closer
margins of the sigmoid notch and trochlea like- together, tending closer
towards the bare area at
wise develop marginal osteophytes, resulting in the floor of the greater
sigmoid notch. The same
the commonly observed flexion contracture. In effect is seen if the load
is increased in any
the cadaveric elbow flexion is possible to particular degree of elbow
flexion, which also
150155# and this is limited by contact between brings about an increase in
contact area [3].
the radial head and coronoid process and their The pattern of contact is
influenced by
respective fossae on the distal humerus. the application of varus and
valgus loads to
1311
the elbow can continue

in a stable fashion even
after significantly
displaced fractures of the
olecranon. It follows
therefore that restoration
of anteroposterior
stability after fracture disloca-
tions of the elbow
relies critically on stable
reconstruction of the
coronoid.
The risk of
instability after coronoid process
fractures is related
to the proportion of the
coronoid, the anterior
buttress of the greater
sigmoid notch, that is
involved in the injury.
Note, however, that at
arthroscopy the tip of the
coronoid is an intra-
articular structure with no
capsule, ligament or
tendon attaching to it. The
capsule attaches
approximately 6 mm distal to the
tip and therefore
fracture fragments have to be
Fig. 9 The net force acting on the distal humerus F is met greater in extent than
this before surgical repair of
by the Joint-Reaction Force F. This can be resolved into the bony injury will
contribute to elbow stability.
a compressive force into the greater sigmoid notch and an The commonly seen tip
fracture is actually
anteriorly directed force from the distal humerus,
buttressed by the coronoid process to prevent posterior a shear injury caused
when the elbow subluxes
dislocation of the ulna and the intra-
articular tip fragment is pushed off
by contact with the
distal humerus. The impor-
tance of the bony
buttress of the coronoid is
the elbow. This becomes clinically important, for increased if there is
ligament injury. In the
example, when the anterior bundle of the medial presence of an
incompetent anterior bundle of
ulnar collateral ligament becomes incompetent in the medial collateral
ligament a deficiency of
throwing athletes. By studying the intact elbow only 25 % of the
coronoid process can allow
with applied varus and valgus forces there is an posterior dislocation
of the ulna [13].
apparent pivot point on the lateral trochlea such
that, for example, a valgus force produces com- Soft Tissue Stability
pression lateral to this point and distraction The collateral
ligaments, or rather elements of
medial to it, and vice versa for a varus force. them, are essential to
stability of the hinge of
Throwing athletes can stretch the anterior bundle the humero-ulnar
joint. However, as discussed,
of the medial collateral ligament, allowing the structure of the
collateral ligaments is com-
the ulna to pivot under the influence of the plex, with multiple
bundles being described. The
valgus stresses induced by throwing. This results anterior bundle of the
medial ulnar collateral
in impingement of the medial border of the ligament is attached
to the isometric point at the
olecranon on the olecranon fossa, with resulting anteroinferior aspect
of the medial epicondyle
pain typical of valgus-extension overload and is the strongest
component of the medial
syndrome. collateral complex.
The posterior bundle is not
As will be discussed, the net force across the isometric and becomes
taut in flexion. Clinically,
elbow joint is directed posteriorly towards the deficiency of the
medial ulnar collateral ligament
distal humerus. Clinically the large majority of is corrected by
reconstruction of the anterior
elbow dislocations that do occur are variants of bundle.
posterior dislocation. The coronoid process is On the lateral side
the collateral complex is
critical in resisting posterior subluxation and adapted to contain the
radial head and stabilise
dislocation (Fig. 9) and fractures involving the this to the proximal
ulna, allowing rotation at
coronoid are not uncommonly associated with the proximal radio-
ulnar joint within the annular
elbow instability. Indeed the hinge function of ligament. The lateral
ulnar collateral ligament
1312
D. Limb
passes behind the radial head and stabilises Table 1 The relative
contributions of bony elements,
the ulnohumeral joint to varus forces. Note that collateral ligaments and
capsule to varus/valgus stability
of the elbow in the flexed
and extended elbow [13]
in this position it also buttresses the radial head
from behind and is a major factor in preventing Elbow
Varus Valgus
position Structure
displacement displacement
posterior subluxation or dislocation of the radial
Extension MCL
30 %
head. LCL
15 %
Thus the collateral ligaments of the Capsule
30 % 40 %
ulnohumeral joint can be thought of as the ante- Articular
55 % 30 %
rior bundle of the medial collateral complex and surfaces
the lateral ulnar collateral component of the lat- Flexion MCL
55 %
eral complex. The annular ligament has already LCL
10 %
been described as a stabiliser of the proximal Articular
75 % 35 %
radio-ulnar joint note that the radius and ulna surfaces
are bound together throughout their length by the
proximal and distal radio-ulnar joint capsules and
the interosseous membrane, so division of the
annular ligament alone does not lead to instability can be tested for
resistance to valgus force before
of the radial head. In cases of instability of the and after division of the
anterior capsule, removal
radial head after trauma the soft tissue lesion is of the radial head and
division of the anterior
always much more extensive than simply rupture band of the medial
collateral ligament. The
of the annular ligament and instability is unlikely sequence of performing
lesions can also
to respond to simple repair or reconstruction of be altered to investigate,
for example, whether
this ligament. the effect of radial head
excision is similar
Ligamentous stability cannot be attributed sim- with and without an
incompetent medial ulnar
ply to the isometric components of the collateral collateral ligament. The
output of this work
complexes however. It is apparent from reading seems clinically useful and
relevant, though the
studies on the anatomy of the collateral ligaments more one analyses it, the
more complex one
that there is variation between individuals. The realises the in vivo
situation is.
ligaments themselves are condensations within Morrey and An
demonstrated that at 90# of
the capsule of the joint and the capsule itself elbow flexion the medial
collateral ligament was
contributes to the integrity of the joint. Thus the the primary stabiliser to
valgus stress, whilst in
resistance of the joint to abnormal movements extension there were
similar contributions from
into varus and valgus is provided by combinations the medial ligament, radial
head and articular
of bony co-aptation, collateral ligament and congruity. Morrey further
published a simplified
capsular integrity, and the relative contribution summary of such
observations overleaf (Table 1),
of each varies with the position of the joint. which indicates the
relative contributions of the
capsule, collateral
ligaments and articular congru-
ity to the resistance to
varus/valgus displacement.
Osseo-Ligamentous Interaction However the tension in the
capsule and ligaments
The relative contribution of osseous and ligamen- and the contacting areas of
the articular surfaces
tous structures to stability of the elbow has been vary with every increment
of elbow flexion and
extensively studied by destructive experiments in these observations do not
take into account the
which the stability of the joint is tested before and dynamic effects of muscle
contractions that occur
after sequential removal or division of the struc- with movement.
Electromagnetic tracking
tures under investigation. Usually a cadaveric devices have helped refine
this data, but the find-
joint is mounted in a materials testing machine ings have to be correlated
with clinical observa-
and the displacements produced by applied exter- tions of lesions in order
to make reliable
nal forces are measured. For example, the elbow extrapolations about how
specific injuries can
1313
safely be managed, as will be discussed in rele- being transmitted, which

has obvious implica-
vant sections on the management of elbow tions for the
requirements of any prosthetic
injuries. replacement [2].
Using these simple
methods and analysing iso-
metric contractions at
various positions of elbow
Dynamic Factors flexion the forces acting
in the sagittal plane have
been calculated and
demonstrate that for most
The interlocking articular surfaces of the humerus positions of the elbow
the resultant force on the
and ulna can be further stabilised by the applica- distal humerus is
posteriorly directed. Anteriorly-
tion of a compressive force across the joint. It directed forces are only
observed with isometric
seems common sense that if the triceps and flexion or extension when
the elbow is acting in
brachialis contract they will pull the olecranon a position of full
extension.
and coronoid processes to compress the sigmoid These calculations,
however, consider only
notch onto the trochlea. Although this is very easy the clockwise and anti-
clockwise moments in
to visualise, it is very difficult to quantify. This is a simple system
consisting of a straightforward
compounded by the fact that the tendons of these hinge with one or two
muscles generating a force
motor units are physically close to the distal to oppose that created by
gravity acting on the
humerus and become passive factors resisting forearm and the mass held
in the hand. In fact
displacement whilst acting as dynamic factors there are three principle
flexors: biceps,
compressing the sigmoid notch onto the trochlea. brachialis and
brachioradialis, with biceps being
This is particularly true of brachialis which, more important in
supinating the forearm than in
although it has the greatest cross-sectional area of flexing the elbow. The
principle contribution to
all elbow flexors, also has the poorest mechanical flexion power is derived
in reality from brachialis
advantage as its tendon is closely applied to the and the long and short
radial extensors laterally
elbow capsule anterior to the joint. In this position, and the ulnar-sided wrist
flexor and pronator teres
however, it is ideally placed to resist posterior medially. The
brachioradialis and other muscles
elbow subluxation. The interplay of dynamic attaching to the medial
and lateral columns have
forces on elbow stability requires a consideration lines of action that in
most positions of the elbow
of the forces across the elbow joint, however. pass further away from
the flexion axis than
biceps, giving a better
mechanical advantage.
Each of these has a
unique line of force and will
Forces Across the Elbow create not only a flexion
force but a varus/valgus
moment and an element of
rotation, whilst co-
Simple free-body diagrams can be used to esti- contraction of other
muscle groups adds to the
mate joint reaction forces in the elbow but, as will complexity of analysis,
summarised by Morrey
become apparent, require an enormous degree of [14]. Add to this the
effect of flexion angle on line
simplification of the dynamic environment of the of action of each muscle,
the varus/valgus move-
joint. Assuming the elbow is a simple hinge with ment of the ulna, the
position of axial rotation of
its centre of rotation on a line connecting the two the radius and ulna, the
variation in direction of
epicondyles of the humerus, estimates of the the externally applied
force and one can see that
dimensions of a typical elbow can be used to any calculation becomes
no more than a best-
analyse forces in the sagittal plane. A worked guess that is useful in
estimating the magnitude
example in Fig. 10 indicates that even with mod- and direction of forces
across this joint.
est weight held in the hand, large forces are Single muscle analysis
has been used to build
transmitted across the articular surface. Using a model of elbow
function. In this, the calculations
this simple methodology it can be shown that of force are made based
upon consideration of
activities such as pushing up from a chair result a single muscle with a
known line of action. This
in forces equivalent to 2 or 3 times body weight can be repeated for
various permutations of joint
1314
D. Limb
Fig. 10 A free-body consideration of elbow forces. At The forearm weighs

0.2 kg (20 N, W2) and the centre of
equilibrium the clockwise and counterclockwise moments gravity is 12 cm
from the elbow (D2). The net effect of the
are equal. The downward force of the known weight (W1) elbow flexors (W3)
acts 0.04 m from the flexion axis.
acts at a measurable distance from the flexion axis of the Then (0 # 0.3) +
(20 # 0.12) (W3 # 0.04) 0 +
elbow (D1). The weight of the forearm can be calculated 2.4 0.04 W3
2.4/0.04 W3 W3 60 N. In this state
(W2) and acts through the centre of gravity of the forearm, the net force is
zero, so the upward (muscle force) and
which acts at a distance from the flexion axis that can be downward (forearm,
weight held and joint reaction force)
closely estimated (D2). The moments are equal to that all balance.
Therefore 60 20 + 0 + JRF. JRF 40 N.
generated by the elbow flexors, acting at an estimated Now assume that W1
is 1 kg (10 N force). (10 # 0.3) +
combined distance (D3) from the flexion axis. The (20 # 0.12) (W3 #
0.04). 3 + 2.4 W3 # 0.04. 5.4/
unknown force generated by the flexors (W3) can there- 0.04 W3. W3 135
N. 135 20 + 10 + JRF.
fore be calculated as (W1 # D1) + (W2 # D2) W3 # JRF 105 N.
Therefore simply holding a 1 kg weight in
D3. In this example, if we assume the following that the hand increases
the joint reaction force at the elbow by
a 1 kg weigh produces a force in the direction of gravity of almost 100 N
10 N W1 0 kg (i.e. there is no weight held), D1 0.3 m.
angle and applied force, and for each muscle he showed that
forces through the radial head
crossing the joint. Eventually a large dataset is were always greatest
from zero to thirty degrees
obtained that can be manipulated to estimate the of extension and
were higher in pronation than
net effect of all contributory elements for any in supination.
given set of conditions, this essentially becoming
a method of multiple muscle analysis. Even this
becomes an uncertain exercise, however, as Clinical
Applications
the load is not normally equally distributed
between all active muscles and methods of An understanding of
the biomechanics of
estimation the relative contribution of each, such the normal elbow
arms the surgeon and the
as EMG analysis coupled to cross-sectional area, implant designer so
that they can plan reconstruc-
are inexact. tion that will
succeed and will be durable.
Morrey has studied force transmission However, it has to
be admitted that we are rela-
through the radial head using a transducer tive novices in the
field and sometimes study data
attached to the radial neck whilst a flexion is extrapolated
further than is reasonable. This
force was applied through the brachialis and leads to poorer-
than-expected outcomes of the
biceps tendons [16]. Using this methodology intervention.
1315
Consider the work that has demonstrated the if the radial head is
incompetent. Specific
biomechanics and function of the radial head. implants have become
available that trap the
This was shown to be an important stabiliser of coronoid process beneath
a specially-shaped
the elbow to valgus forces and it was assumed plate applied from the
medial side.
that its absence would overload the medial liga- Symptoms of pain and
clicking of the elbow
ment and cause pivot wear at the lateral trochlea. after dislocation have
been recognised as being
Radial head replacement was the obvious solu- due to posterolateral
rotatory instability secondary
tion, particularly for young and active people, to lateral ulnar
collateral ligament injury. This can
and a range of different prostheses quickly now be diagnosed with the
pivot shift test and
became available. However, uni-planar testing treated by reconstruction
of the lateral ulnar
of a cadaveric joint in extension almost certainly collateral, whereas in
times past the only option
over-estimated the role of the radial head considered for radial
head instability, if it was
It is only after several years of implantation that ever recognised, was
annular ligament reconstruc-
outcome data becomes available, and not all radial tion. The placement of a
tendon strip (for example
head replacements behave favourably, even palmaris longus) between
the isometric point on
though the overall results can be satisfactory [6]. the lateral epicondyle
and the supinator crest of
It has been shown that it is critically important to the ulna replaces the
collateral ligament, which
size the implant correctly to restore normal elbow prevents lateral joint
distraction when a varus
biomechanics [24]. However the range of avail- force is applied. However
it also cradles the radial
able prostheses does not match the range of possi- head and stops it
escaping posterolaterally under
ble dimensions of the radial head and the stems do the influence of a valgus
force.
not always restore the natural length and alignment Initial attempts to
replace the elbow with a
of the head. It became apparent that a significant fixed hinge failed due to
early loosening. Unlinked
number of implantations failed or were painful. It prostheses allowed the
coupled varus/valgus
was observed that some articulated in a wind- motion of the ulna that
early pioneers of elbow
screen wiper fashion across the capitellum. The replacement were not even
aware of. If the liga-
results were perhaps not as good as might have ments of the elbow were
competent after surgery,
been predicted. Furthermore the long-term elbow very good results were
initially achieved with
function, decades after radial head excision early resurfacing
implants. In the case of poor
(without replacement), for severe fractures bone stock or ligament
deficiency, however,
and fracture dislocations do not look bad by unlinked prostheses were
not stable. However,
comparison [7]. We still do not know which the development of
sloppy hinge prostheses
patients will benefit from radial head replacement, gave us a stable
arthroplasty that did not transmit
except perhaps in the case of Essex Lopresti marked tilting and
twisting forces to its bone/
lesions with an unreconstructable radial head cement interface and a
new solution for difficult
lesion where the results of excision are known to cases was born. We still
do not have an ideal
be extremely poor. We have a long way to go in solution, however.
Experience in the knee
studying our interventions and often the pace of revealed that
polyethylene of at least 6 mm was
commercial development and advertising outstrips required to prevent early
catastrophic failure in
the pace of clinical testing. that joint and similar
requirements were identified
However there are many useful lessons that in the hip. We have seen
that forces across the
we can take from our understanding of the elbow can be multiples of
body weight, yet the
biomechanics of the elbow. The critical role of dimensions of the joint
constrain us to polyethyl-
the coronoid process in preventing posterior sub- ene that is only 23 mm
thick and frequently
luxation and dislocation, particularly in the pres- exposed to edge loading
from the tilting and twist-
ence of medial ligament injury, should alert the ing forces that accompany
normal movement.
surgeon to reconstruct fractures involving as little Whilst thin polyethylene
can keep a low-demand
as 25 % of the height of the coronoid, particularly patient going for a
decade or more, further work in
1316
D. Limb
design and materials is required for us to realise 6. Harrington IJ,

Sekyi-Out A, Barrington TW, Evans DC,
the need for a durable elbow replacement that can Tuli V. The
functional outcome of metallic radial head
implants in the
treatment of unstable elbow
be used in young and active patients. fractures a
long term review. J Trauma Inj Crit Care.
2001;50:4652.
7. Herbertsson P,
Hasserius R, Josefsson PO, Besjakov J,
Summary Nyquist F,
Nordqvist A, Karlsson MK. Mason type IV
fractures of
the elbow. A 14 to 46 year follow up study.
J Bone Joint
Surg Br. 2009;91:14991504.
The elbow gives the hand access to the full volume of 8. Hollister AM,
Gellman H, Waters R. The relationship
the almost spherical shell of possible positions of the
interosseous membrane to the axis of rotation of
enabled by the shoulder. Furthermore the rotation the forearm.
Clin Orthop. 1994;298:272.
9. Ishizuki M.
Functional anatomy of the elbow joint and
that occurs at the forearm, including at the three
dimensional quantitative motion analysis of the
radiocapitellar joint of the elbow, enables the hand elbow joint. J
Jpn Orthop Assoc. 1979;53:989.
to be put into virtually any position within this shell 10. Kapandji IA.
The physiology of the joints: the elbow,
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extension, vol. 1. 2nd ed. London: Living-
stone; 1970.
even if some movement at the elbow is lost, the 11. London JT.
Kinematics of the elbow. J Bone Joint
majority of activities of daily living being possible Surg Am.
1981;63:529.
with a range of flexion from 30# to 130# , though 12. Mori K.
Experimental study on rotation of the
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functional anatomy of the interosseous
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Orthop Assoc. 1985;59:611.
more. The joint remains stable through this range 13. Morrey BF,
editor. The elbow and its disorders.
principally due to its congruence and the collateral Philadelphia: W
B Saunders; 2009.
ligaments, specifically the lateral ulnar collateral 14. Morrey BF, An
KN. Articular and ligamentous contri-
ligament and the anterior band of the medial collat- butions to
stability of the elbow joint. Am J Sports Med.
1983;11:3159.
eral ligament. Considering the joint to be a simple 15. Morrey BF, An
KN. Functional anatomy of the elbow
hinge is an oversimplification, however, a fact that ligaments. Clin
Orthop. 1985;201:8490.
that was underlined by early failure of early elbow 16. Morrey BF, An
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1988;70:2506.
elbow couples hinge movement with a few degrees 17. Morrey BF,
Askew LJ, An KN, et al. A biomechanical
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that can be equivalent to multiples of body weight. 18. Morrey BF, Chao
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19. Ochi N, Ogura
T, Hashizume H, Shigeyama AY, Senda
M, Inoue H.
Anatomic relation between the medial
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Surgical Anatomy, Approaches
and Biomechanics of the
Elbow
Raul Barco, Jose

Ballesteros, Manuel Llusa, and
Samuel A. Antuna
Contents
Abstract
The elbow is a complex anatomical area in
which many neurovascular, tendinous, liga-

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1318
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1320
mentous and osseous structures are in close

Posterior Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1324 vicinity. In order to avoid complications, it is
desirable to have a deep knowledge of

Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1333
Motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1333 the anatomy and to be confident with the
Stability (Constraints) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1334 most commonly-used surgical approaches.
Force
Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1334 Basic understanding of elbow biomechanics
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1336 can aid the surgeon in understanding the
aetiology, pathomechanics and treatment

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1336
rationale of elbow injuries. The current
chapter reviews basic surgical approaches
and biomechanics of the elbow.
Keywords
Anatomy # Approaches-lateral, medial, poste-
rior, anterior # Biomechanics # Elbow # Oper-
ative techniques
As elbow arthroscopy is gaining popularity, lim-
ited exposures of the elbow are less commonly

R. Barco # S.A. Antuna (*)
required. When they are indicated, the surgeon
Shoulder and Elbow Unit, La Paz University Hospital,
should be cautious, and avoid injury to the super-
ficial nerves which may lead to painful neuroma.

e-mail: santuna@asturias.com
When dealing with more complex pathology, it is

J. Ballesteros
desirable to have the possibility of extending the

Orthopedic Department, Hospital Clnico Barcelona,
Barcelona, Spain
approach. An extensile posterior cutaneous inci-
sion, the so-called universal approach, allows

M. Llusa
Orthopedic Department, Valle Hebron Hospital,
the surgeon to access to the posterior, medial and
lateral compartments of the joint.

1317
DOI 10.1007/978-3-642-34746-7_62, # EFORT 2014
1318
R. Barco et al.
The elbow is not only an intermediate joint

that positions the arm in space, but it is also
a load-bearing joint which acts as a fulcrum for
the forearm and hand, requiring complex interac-
tion between mobility and stability to adequately
perform daily activities. Understanding elbow
kinematics is crucial to treat injuries affecting
the ligamentous and bony structures which have
great implications for stability and harmonious
motion of the elbow joint.
Anatomy
The elbow contains three separate articulations.

The ulnohumeral joint is a modified hinge joint
that allows flexion and extension. The
radiohumeral joint is a combined hinge and
pivot joint that permits flexion and extension as
well as rotation of the head of the radius on the
capitellum of the humerus. The proximal radio-
ulnar joint facilitates rotation during supination
and pronation (Fig. 1).
Osseous stability is re-inforced by the medial
and lateral collateral ligament (LCL) complexes.
The MCL complex comprises anterior, posterior,
and transverse bundles and, especially the ante-
rior bundle, provides valgus stability. The poste-
rior band of the MCL is commonly contracted in
post-traumatic elbows, and when dealing with Fig. 1 Anterior aspect of the
elbow. Distal humerus (1),
a stiff elbow it may need to be released (Fig. 2). proximal radius (2) and
proximal ulna (3) (Reproduced by
permission of Llusa et al.
[1])
The LCL complex, especially the lateral ulnar
collateral ligament, confers rotational and varus
stability (Fig. 3). a potential site of entrapment
(Fig. 4). The ulnar
Four muscle groups act on the elbow. The nerve passes along the medial
arm and posterior
major flexors are the biceps brachii (which also to the medial epicondyle
through the cubital tun-
supinates the forearm when the elbow is flexed), nel, a likely site of
compression (Fig. 5). It is
brachioradialis, and brachialis muscles while the important to recognize that
the floor of the cubital
extensors are the triceps and anconeus muscles. tunnel is actually the
superficial aspect of the
The supinators consist of the supinator and biceps anterior band of the MCL; this
anatomic refer-
brachii muscles. Pronation is accomplished by ence should be taken into
consideration when
the pronator quadratus, pronator teres, and flexor dealing with pathology in the
medial compart-
carpi radialis muscles. ment of the elbow. The radial
nerve descends
The elbow also has a complex innervation, and the arm laterally, dividing
into superficial (sen-
all the nerves that cross the elbow may be at risk sory) and deep (motor, or
posterior interosseous)
during certain surgical procedures. The median branches (Fig. 6). The deep
branch must then pass
nerve crosses the elbow medially and passes through the arcade of Frohse,
a fibrous arch
through the two heads of the pronator teres, formed by the proximal margin
of the superficial
Surgical Anatomy, Approaches and Biomechanics of the Elbow
1319
Fig. 2 Medial aspect of the elbow. Distal humerus (1),

anterior bundle of the medial collateral ligament (2), and
proximal ulna (3). Sublimis tubercle (*) (Reproduced by
permission of Llusa et al. [1])
Fig. 4 Anterior aspect

of the elbow. Biceps brachii mus-
cle (1), median nerve
and its branches for the pronator
teres muscle (2),
humeral artery (3) and flexo-pronator
mass (4)
Fig. 3 Lateral aspect of the elbow. Distal humerus (1),
proximal radius (2) and proximal ulna (3). Annular liga-
ment (4) and the lateral collateral cubital ligament (5)
head of the supinator muscle, where it is most

susceptible to injury, especially when developing
lateral approaches to the elbow joint. Proximally,
the radial nerve crosses from the posterior to the
anterior compartment of the arm at a distance
from the lateral epicondyle equivalent to 1.5
times the inter-epicondylar distance. This ana-
tomical reference is also very useful to avoid
complications related to this nerve when devel-
oping triceps-reflecting approaches.
The functional range of motion of the elbow
for activities of daily living is 30130# of flexion
Fig. 5 Medial aspect
of the elbow. Flexor carpi ulnaris
and 50# of supination and pronation. This arc of
muscle (1). Flexor-
pronator mass (2). Triceps brachii muscle
motion allows independent function but may be (3). The intimate
relationship between the ulnar nerve (4) and
very limiting for more specific pursuits. the anterior bundle of
the medial collateral ligament (5)
1320
R. Barco et al.
Approaches
Superficial osseous
landmarks, such as the olecra-
non, the radial head
and both epicondyles, should
be identified before
any surgical approach is
developed. Previous
surgical incisions should be
considered;
particularly those retracted or adher-
ent to the
subcutaneous tissue. Utilizing previous
scars, when possible,
may reduce the risk of skin
necrosis. Any approach
through anatomical planes
of dissection should
be prioritized (Fig. 7).
Elbow surgery should
be routinely done, unless
contra-indicated, with
the aid of an arm tourniquet.
The following
approaches are just the
most commonly-used in
our practice. We tend
to favour surgical
approaches which are versatile
for the whole spectrum
of elbow pathology.
Lateral Approaches
Approaches through the
lateral aspect of the
elbow are probably the
most commonly used in
elbow surgery and are
indicated for fixation of
intra-articular
fractures, removal of osteophytes,
removal of loose
bodies, radial head excision,
capsulectomy and
repair or reconstruction of the
Fig. 6 Anterior aspect of the elbow. Brachioradialis lateral ligaments.
muscle (1), radial nerve (2), brachialis muscle (3) and If we anticipate
that an extensile approach will
biceps brachii muscle (4). Humeral artery (5) and the
be required, our
preference is to use a straight
radial recurrent artery (6) ascending between the branches
of the radial nerve (2) posterior skin
incision. Alternatively, limited
Henry
Hotchkiss
Kaplan
Kocher
Fig. 7 Coronal section of
Boyd
the elbow showing some of Bryan-Morrey
the most commonly-used
Olecranon osteotomy
approaches Campbell, van gorder
1321
Fig. 8 Lateral view of the

superficial muscles of the
forearm. ECRB extensor
carpi radialis brevis, ED
extensor digitorum, EDM
extensor digiti minimi,
ECU extensor carpi ulnaris
incisions proximal or distal to the lateral Technique

epicondyle can be utilized depending on the Our preference is to use a
straight posterior skin
pathology we are dealing with. incision with dissection of
a full-thickness lateral
Several intermuscular intervals have been fasciocutaneous flap.
However, limited distal lat-
described, but Kochers and Kaplans approaches eral skin incisions may be
used. The interval
remain the most frequently-used. Kochers between the anconeus and
extensor carpi ulnaris
approach develops the interval between the muscles can be identified
by palpation. A thin
anconeus and the extensor carpi ulnaris and can strip of fat is frequently
seen in the interval
be extended proximally and distally (Fig. 8) [2]. between these muscles. It
is easier to develop
Kaplan described an approach in the interval the interval in its distal
part and then progress
between the extensor digitorum communis proximally as the muscle
fibres of the anconeus
(EDC) and the extensor carpi radialis brevis and the extensor carpi
ulnaris muscles tend to
(ECRB) and longus (ECRL) [3]. blend together towards the
insertion. The deep
The main concern when using lateral approaches fascia is then opened and
the interval is devel-
is the risk of causing an injury to the radial nerve, oped by dissecting the
anconeus posteriorly. The
particularly with Kaplans approach, so care must lateral elbow capsule with
the annular ligament is
be taken to identify and protect the nerve if neces- identified and incised
anteriorly to the lateral
sary. When dealing with a traumatic elbow, the ulnar collateral ligament.
lateral ulnar collateral ligament must be identified
and preserved or repair to avoid elbow instability. Modifications
When required, this
approach can be extended
proximally above the
lateral epicondyle by devel-
Kocher Approach oping the interval between
the triceps and the
Kochers approach utilizes the intermuscular brachioradialis. The
extensor mass can then be
interval between the anconeus and the extensor sharply incised from the
epicondyle preserving
carpi ulnaris (Fig. 9). This interval permits access the attachment of the
lateral ulnar collateral liga-
to the lateral elbow joint. The radial nerve is ment. Distally, in order to
achieve adequate expo-
relatively safe as it is protected by the extensor sure of the crista
supinatoris, the anconeus, along
carpi ulnaris muscle. with the lateral aspect of
the triceps tendon, may
be reflected posteriorly
[4].
Indications Mansat and Morrey have
described the
Fixation of condylar fractures, radial head pro- column procedure [5],
which is a limited
cedures and repair or reconstruction of the lateral proximal lateral approach
for capsular release
ligaments. in stiff elbows (Fig. 10).
This exposure may
1322
R. Barco et al.
Fig. 10 The column

procedure. The triceps brachii
muscle (1) has been
partially dettached from the posterior
aspect of the lateral
column. The extensor carpi radialis
longus and the
brachioradialis muscle (3) have been
Fig. 9 Kocher approach. Extensor carpi ulnaris muscle retracted anteriorly to
expose the capsule and distal
(1). Anconeous muscle (2). Lateral epicondyle (3). Annu- humerus (2). Extensor-
supinator group (4)
lar ligament (4)
be a proximal extension of the Kocher Kocher Posterolateral

Extensile
approach or a focused isolated proximal Triceps-Sparing Approach
approach. The exposure is based on dissection Indications
made anteriorly and posteriorly to the lateral Open reduction and
internal fixation of fractures,
border of the distal humerus (the column). re-surfacing elbow
replacement, and interposi-
Anteriorly, the distal aspect of the tion arthroplasty.
brachioradialis and the extensor carpi radialis
longus are elevated from the humerus and Technique
the interval between the brachialis and the This exposure is an
extension of the limited expo-
capsule is developed. Posteriorly, in order sures described above
(Fig. 12). A straight mid-
to gain access to the capsule, the triceps line posterior skin
incision avoiding the tip of the
must be dissected from the posterior part of olecranon is used. The
triceps is elevated from the
the humerus. posterior aspect of the
humerus, and the brachior-
radialis and the ECRL
are then dissected anteri-
Kaplan Approach orly. The Kocher
interval is identified and
Indications developed to expose the
joint capsule, as has
Radial head fractures, particularly those involv- been discussed
previously. The anconeus is ele-
ing its anterior half (Fig. 11). vated from the ulna and
the triceps attachment to
the lateral epicondyle
is also reflected posteriorly,
Technique leaving its insertion to
the olecranon intact. At
The skin incision starts on the lateral epicondyle this time, the lateral
collateral ligament is
and extends 4 cm distally, through a line running released from the
humeral origin allowing dislo-
from the lateral epicondyle towards the ulnar cation of the elbow
joint by applying a varus
styloid process in the wrist. The interval between stress.
the EDC and the ECRB and ECRL is developed
exposing the underlying capsule, which is incised Modification
longitudinally to gain access to the radial head. This approach was
modified in the Mayo Clinic to
The radial nerve is at special risk during this include complete release
of the triceps from the
approach. Pronation of the forearm and careful olecranon, reflecting
the triceps mechanism and
use of retractors may diminish the risk of injury to anconeus from lateral to
medial by releasing
the radial nerve [6]. Sharpeys fibers [7].
1323
a b
Fig. 11 Kaplan approach. (a) The incision is in line with supinator muscle
(3). The posterior interosseous nerve
the interval between the extensor carpi radialis brevis (2) lies within the
supinator muscle. With the pronation
muscle (1) and the extensor digitorum muscle (4). (b) of the forearm, the
posterior interosseous nerve moves
After detaching part of the superior origin of both muscles, medially from the
operative field
it is necessary to separate them in order to show the
that do not require

detachment of the flexor pro-
nator mass have
been described for its use in
MCL reconstruction
[8].
Extensile Medial
Approach
Indications
Hotchkiss initially
described this approach for
releasing elbow
contractures as it provides superb
exposure of the
medial aspect of the joint with
access to the
posterior and anterior capsules [9]. It
allows treatment of
concomitant ulnar nerve
pathology and
permits access to the coronoid
and humeral
condyle. The main disadvantage of
Fig. 12 Kocher posterolateral extensile triceps-sparing this approach is
the limited access to the lateral
approach. Subperiosteal dissection of the triceps brachii aspect of the
joint.
muscle (1), the brachioradialis muscle and the extensor
carpi radialis longus muscle (2) of the lateral aspect (3) of
the distal humerus. It is necessary to detach the anconeus Technique
muscle (5) off the proximal aspect of the ulna, to expose A medial skin
incision could be used, but it is our
the interval between this muscle and the extensor carpi preference, as
previously mentioned, to use
ulnaris muscle. For complete exposure of the lateral half
a straight
posterior skin incision for any extensile
of the elbow it is necessary to detach the lateral collateral
ligament (6) off the lateral epicondyle (4) approach used
around the elbow (Fig. 13).
Great care must
be taken at the proximal side
of the incision to
avoid injury to the medial
Medial Approaches antebrachial
cutaneous nerve (Fig. 14). It is usu-
Medial approaches to the elbow are less fre- ally found lying on
top of the superficial fascia
quently-used and have the downside of potential and can cause
disturbing neuroma if damaged.
injury to the ulnar nerve. They may be utilized to The ulnar nerve
should be identified proximally
address pathology of the ulnar nerve, injuries of and dissected from
proximal to distal and mobi-
the MCL, fractures of the coronoid process and lized as necessary.
The medial intermuscular sep-
contracture release. Less-invasive approaches tum should be
released for a distance of about
1324
R. Barco et al.
elevated from the

capsule. It is advisable to com-
plete the muscle
dissection from the capsule
before resecting it.
Another option is to
start the dissection distal to
the coronoid process
and proceed proximally. The
flexor tendon can be
incised with the knife blade
placed almost parallel
to the plane of dissection
and just distal to the
level of the sublime tubercle.
This manoeuvre will
lead us to the plane between
the MCL and the flexor
muscle mass, protecting
the ligament with the
back of the blade. The dis-
section can be then
extended proximally.
The exposure of the
posterior capsular can
be done safely by
mobilizing the ulnar nerve anteri-
orly. The triceps is
then elevated from the capsule
with the use of a
periosteal elevator. This manoeuvre
will allow access to
the posterior band of the MCL,
should we need its
release in stiff elbow surgery.
Posterior Approaches
Posterior skin
exposures can be employed for the
majority of surgical
interventions in the elbow,
because the dissection
may be easily extended
medially or laterally.
It is important to dissect
full-thickness
fasciocutaneous flaps to avoid
wound problems.
Indications include reconstruc-
tion for degenerative
diseases or tumours, distal
humerus fractures, and
elbow stiffness.
Fig. 13 Universal approach. Full thickness fascio-
cutaneous flaps are elevated laterally and medially, Skin Incision
preserving the subcutaneous arterial plexus and the cuta- A straight skin
incision avoiding the tip of the
neous nerves. The ulnar nerve (*) is located and isolated
medially to the medial head (deep) of the triceps brachii olecranon is advisable,
although an S incision
muscle. Olecranon (1) and anconeus muscle (2) has also been
described. Some surgeons advocate
going slightly more
laterally to avoid any tender-
5 cm proximally to avoid entrapment. An incision ness of the scar when
resting the elbow on the side,
is made on the supracondylar ridge 5 cm and to avoid the risk
of damaging the ulnar nerve.
proximally to the medial epicondyle and contin- Other surgeons have
attributed better healing to
ued distally towards the pronator and a portion of a medial incision
compared to a lateral one [7].
the common flexor tendon. Leaving a portion of To preserve the
subcutaneous arterial plexus
flexor carpi ulnaris tendon attached to the and the cutaneous
nerves it is critical to dissect
epicondyle posteriorly makes closure at the end full thickness
fasciocutaneous flaps, which can be
of the procedure easier. A Cobb elevator can be elevated laterally and
medially as necessary
helpful in elevating the anterior structures from (Fig. 13). Post-
operative seromas have been
the distal humerus until an appropriate retractor described as a
complication of this approach
can be introduced. As the dissection proceeds and applying a
compressive dressing at the end
laterally and distally, the brachialis muscle is of the procedure should
aid in preventing them.
1325
a b
Fig. 14 Extensile medial approach by Hotchkiss. (a) (2) and the flexor
carpi ulnaris muscle (3). (c) Anterolateral
Superficial surgical dissection: medial epicondyle (1), retraction of the
flexor digitorum superficialis muscle and
flexor-pronator group (2) and flexor carpi ulnaris muscle the rest of the
flexor-pronator muscles (2) and posteromedial
(3). It is necessary to locate and to preserve the medial retraction of the
flexor carpi ulnaris muscle (3) to expose the
antebrachial cutaneous nerve (4). (b) Location of the inter- anterior bundle of
the medial collateral ligament (5),
val between the flexor digitorum superficialis muscle coronoid process
(6), the anterior joint capsule (*)
Ulnar Nerve is placed on a

subcutaneous pouch. In both pro-
It is controversial which is the best approach to cedures impingement
of the nerve should be
the ulnar nerve, whether to decompress and pro- checked both in
flexion and extension before
tect the nerve throughout the procedure or to final closure.
transpose it. The final decision regarding the
ulnar nerve should be based on pre-operative Triceps
clinical symptoms, the pathology to be addressed Management of the
triceps tendon is a source
and the surgical approach used. of disagreement, and
multiple approaches may be
When performing distal humeral fracture fix- selected based on
the pathology to be addressed.
ation or elbow replacement procedures, our pref- It remains common
sense that any disruption of
erence is to protect the nerve and to transpose it at the triceps can
increase the incidence of extensor
the end of the procedure. In cases of releasing mechanism
complications. Several options are
a severely contracted elbow, it is systematically available, including
approaches in which the triceps
transposed, particularly when the elbow has sig- attachment is
preserved (Alonso-Llames, Patterson,
nificant flexion deficit. Morrey and Adams)
[1012], where it is reflected
Once released and mobilized, the ulnar nerve from medial to
lateral (Bryan and Morrey) [13],
must be protected throughout the procedure reflected from
lateral to medial (Kocher posterolat-
avoiding traction manoeuvres. In cases of eral extensile
approach), split in the midline
anterior transposition, the medial intermuscular (Campbell, Gschwend,
Van Gorder) [1416]
septum should be excised proximally and the or divided using a
triceps tongue (Campbell,
ulnar tunnel retinaculum opened longitudinally Van Gorder,
Wadsworth) [14, 17, 18] (Table 1).
between the flexor carpi ulnaris fascia to avoid The benefit of
obtaining an adequate
late entrapment. Meticulous protection and main- exposure must be
weighed against the risk of
tenance of the vascular supply to the ulnar nerve post-operative
triceps insufficiency. In any case,
should be maximized. any violation of the
extensor mechanism
When a submuscular transposition is may increase the
risk of triceps insufficiency,
performed, the nerve is placed under the flexor so a meticulous
reconstruction of the tendon
pronator mass, closing the muscular layer over it. at the end of the
procedure is a pre-requisite
In cases of subcutaneous transposition, the nerve for any of the
following procedures.
1326
R. Barco et al.
a b
Fig. 15 Triceps-preserving (Alonso-Llames) approach. the ulnar nerve, the

triceps brachii muscle is retracted
(a) Lateral view. To expose the lateral column and the laterally, exposing
the medial column and the posterior
posterior aspect of the distal humerus, retract the triceps aspect of the distal
humerus
brachii muscle medially. (b) Medial view. After isolating
Post-operatively, if the triceps insertion has Modifications

been violated, the surgeon must protect the Morrey described a
variation of this technique
elbow and delay active extension against gravity indicated mainly for
distal humeral non-unions
for a few weeks to enhance healing of the treated with elbow
replacement. The extensor
extensor mechanism. origin and the
lateral collateral ligament complex
are released from the
lateral epicondyle. Medi-
Triceps-Preserving Approach: ally, the common
flexor muscle and tendon
Alonso-Llames mass are elevated
along with the medial collateral
Indications ligament. After
resection of the distal humerus
Although initially described for managing pedi- non-union, the
forearm can be rotated to facilitate
atric supracondylar fractures, it may also be used exposure of the
proximal ulna [7].
for simple distal humeral fractures in adults, non- A modification of
the technique to increase
unions, tumours, and total elbow arthroplasty or distal exposure was
described by Patterson [12].
hemi-arthroplasty in comminuted distal humerus Laterally, the
interval between the extensor carpi
fractures [10]. ulnaris and the
anconeus is developed and, on the
The major advantage of this approach is that it medial side, the
flexor carpi ulnaris is elevated
preserves the extensor mechanism continuity. The subperiosteally.
main disadvantage is the limited exposure obtained,
which may increase the difficulty of the procedure.
Posterior Triceps-
Splitting: Campbell
Technique Indications
A posterior skin incision is made medial or lateral Total elbow
arthroplasty, distal humeral frac-
to the olecranon and full thickness fasciocutaneous tures, sepsis,
synovectomy, ulnohumeral
flaps are elevated. The medial and lateral borders arthroplasty,
ankylosis and unreduced elbow dis-
of the triceps are incised and elevated from the location [14].
posterior aspect of the distal humerus with It is a simple
exposure which can be easily
a periosteal elevator. The ulnar nerve must be extended proximally
up to the level of the radial
identified and protected on the medial side of the nerve and distally
along the ulna. Appropriate
triceps. The distal humerus can be button-holed closure technique is
important to avoid button-
medially or laterally, as required, to gain access to holing of the
olecranon through a defect in the
the proximal forearm (Fig. 15). triceps tendon.
1327
a b
Fig. 16 Posterior triceps-splitting approach. (a) The humerus (2),

detach the triceps tendon from the olecranon
tricipital aponeurosis (1) is incised in line with the skin (4). Distal
enlargement of the approach can be accomplished
incision. It is necessary to identify the ulnar nerve (3). (b) by subperiosteal
dissection of the flexor carpi ulnaris mus-
To gain a better view of the posterior aspect of the distal cle medially, and
the anconeous muscle laterally
Technique Triceps-Splitting-
Tendon Reflection: V-Y
The triceps tendon and muscle are longitudi- Approach
nally incised, exposing the distal humerus This approach was
described by Campbell, and
proximally and proceeding distally by later modified by
van Gorder and Wadsworth
reflecting the anconeus laterally and the [17, 18], for
treating elbow contractures with
flexor carpi ulnaris medially (Fig. 16). a scarred and
shortened triceps.
Subperiosteal dissection should be done at
the level of the olecranon attachment. The Indications
ulnar nerve may be visualized medially and It has the same
indications as the previous expo-
protected. Closure of the aponeurosis is done sure, but it has
been mostly used for chronic
with side-to-side sutures. Transosseous elbow
dislocations.
sutures at the triceps insertion may be added The main
advantage of this approach is that
to augment the repair. it gives good
exposure, allowing at the same time
lengthening of the
extensor mechanism by using
a V-Y advancement
technique. Its main disadvan-
Modifications tages are that it
weakens the triceps and has
A modification of this approach was reported a reported
infection rate higher than other
by Gschwend [15] in which the proximal approaches, due to
vascular compromise of
ulna is exposed with the use of a fine osteotome the distal flap.
For this reason, we prefer a slight
to create osteoperiosteal flaps, in an effort to modification of
this approach in which complete
promote healing of the extensor mechanism. sectioning of the
triceps muscle is avoided.
1328
R. Barco et al.
a b
Fig. 17 Triceps-splitting-tendon reflection: V-Y incision. (b) The flap

is distally-based and should extend
approach. (a) After Isolation of the ulnar nerve (2) The to the outer part of
the humeral condyles to gain a good
tricipital aponeurosis (1) and the medial head of the tri- access to the fat pad
(*), and the posterior aspect of the
ceps brachii muscle (3) are divided by using a V-Y distal humerus (3)
Technique Modifications
In the original approach, the deep head of the Van Gorder [17]
described a modification of this
triceps is divided in its mid-line for a length of technique in which the
incision on the medial
about 8 cm. The flap is distally-based and should head of the triceps
runs obliquely in order to
extend to the outer part of the humeral condyles avoid cutting off the
triceps proximally. The inci-
to gain a good approach (Fig. 17). Enough tendon sion runs from
anterior distal to posterior proxi-
tissue at both sides of the flap must be preserved mal, leaving the
entire thickness of the muscle
to obtain a good repair. To advance the flap, the attached to the base
of the flap.
triceps is approximated in the mid-line using Wadsworth [18]
described a modification to
sutures for the required length. The rest of the enhance the exposure.
After creating the flap, the
flap is then repaired at its new length to the outer incision is extended
distally along Kochers inter-
edges of the aponeurosis with interrupted sutures. val, reflecting the
anconeus medially, allowing
The previous approach has an unacceptable access to the lateral
aspect of the joint.
rate of infection and triceps disruption. Our pref-
erence is to avoid complete triceps disruption Posteromedial
Extensile: Bryan-Morrey
by elevating a flap with the superficial triceps Approach
aponeurosis and then entering the true triceps Indications
tendon longitudinally, through an avascular area Include elbow
arthroplasty, distal humerus frac-
(Fig. 18). This approach better preserves the tures and elbow
stiffness [13].
vascularisation of the distal flap and provides a The advantage of
this approach is that it pro-
superior repair. vides great exposure,
allowing access to the ulnar
Surgical Anatomy, Approaches and Biomechanics of the Elbow 1329
a
b
Fig. 18 (continued)
1330
R. Barco et al.
e f
g
h
Fig. 18 Campbell approach modification. (a) After dis- the tricipital

tendon is performed (4). (e) It may be useful to
section of the ulnar nerve (1), the tricipital aponeurosis has detach the
Anconeus distally. (f) Posterior aspect of the
been carefully incised (3). (b) Expose the true, intramuscular distal humerus
(6). (g) When closing the approach, suturing
and sagittal tendon (4) of the triceps brachii muscle (5). (c) the tricipital
tendon provides resistance. (h) Finally,
Make a longitudinal incision in the tricipital tendon. (d) the tricipital
aponeurosis will be sutured in its anatomical
After the longitudinal incision is completed, a Z incision of situation,
decreasing the possibilities of adherences
1331
nerve or medial collateral ligament. Anterior

transposition of the ulnar nerve is a key step
during the approach and should not be avoided.
The main disadvantage is the possibility of devel-
oping post-operative triceps insufficiency if the
tendon repair fails or the tissue quality is poor.
Meticulous surgical technique during closure is
advisable to prevent complications.
Technique
A mid-line skin incision is used from 8 cm prox-
imal to 8 cm distal to the tip of the olecranon. The
ulnar nerve is dissected proximally, where it is
easily found medial to the triceps, and followed
distally until it gives its first motor branch. The
nerve must be protected throughout the proce-
dure, and it is either transposed anteriorly (more
commonly) or left in place at the end of the
procedure.
The triceps is released from the entire posterior
aspect of the distal humerus. The forearm fascia
and ulnar periosteum are elevated from the
medial margin of the ulna. The triceps tendon is
carefully detached from the tip of the olecranon by
sharp dissection of Sharpeys fibers (Fig. 19).
The lateral margin of the proximal ulna is then Fig. 19 Posteromedial
extensile: Bryan-Morrey
identified and the anconeus is elevated from its approach. (1) olecranon;
(2) anconeus muscle; (3) ulnar
ulnar bed. Finally, the extensor mechanism is nerve; (4) triceps brachii
muscle; (5) Flexor carpi ulnaris
reflected laterally from the margin of the lateral
epicondyle.
Olecranon Osteotomy
Modifications The transosseous exposure
is a very popular way
Wolfe and Ranawat [19] described a modification of approaching the elbow
joint, and it is probably
of this approach in which the ulnar nerve is the most frequently used
for the treatment of
exposed but not transposed and the triceps is distal humerus fractures.
Healing rates are con-
released by osteotomizing its attachment on the sistent, and the major
concern is related to the
olecranon through a thin wafer of bone, in an fixation method (K-wires,
cerclage and plates)
effort to achieve a reliable healing. which often produces
irritation and may require
Shahane and Stanley [20] reported on a mod- secondary procedures.
ification of this approach in an attempt to reduce The chevron osteotomy
is the preferred
the incidence of ulnar neuropathy. After decom- method of osteotomizing the
olecranon in prefer-
pression of the ulnar nerve the triceps is split ence to oblique or
transverse osteotomies due to
leaving a quarter of triceps medially and the rest its increased intrinsic
stability and increased area
is reflected medially as a single unit. for bony healing [21].
In every instance, reconstruction of the
extensor mechanism should include a repair Indications
with transosseous sutures through drill-holes This approach was initially
described for treating
placed in a cruciate fashion in the olecranon. ankylosed joints. Its main
indication today is
1332
R. Barco et al.
open reduction and internal fixation of distal

humerus fractures.
The chevron osteotomy has the advantage
over the one originally described by MacAusland
of an increased surface area for bony healing and
increased stability as described below.
Technique
A posterior mid-line skin incision is used. The
ulnar nerve must be located and protected
throughout the procedure. A 3.2 mm drill-hole
or two parallel Kirschner wires that cross the
osteotomy site can be made to achieve perfect
reduction at the completion of the procedure.
The joint is exposed at the greater sigmoid
notch and a sponge may be introduced in the
joint to protect the articular surface. The
osteotomy is made with a distal chevron and
it is started with a saw and finished with an
osteotome. This allows the formation of cracks
that may facilitate repositioning of the bony
fragment. The fragment and the tendon are
retracted proximally (Fig. 20). Capsular attach-
ments and the posterior component of the col- Fig. 20 Olecranon osteotomy
approach. After the ulnar
lateral ligaments may need to be divided to gain nerve (1) is identified, the
olecranon (2) is osteotomized,
more access to the joint. At the completion of just in the bare area of the
greater sigmoid notch. Note that
the procedure the osteotomized fragment is the anconeus (3 & 4) must be
disrupted in order to achieve
an adequate exposure
reduced and fixed with a cancellous lag screw,
a cerclage with K wires or a plate.
Extensile Anterior Exposure
of the Elbow
Modifications Indications
Concerns about splitting the anconeus after com- These include neurovascular
exploration in cases
pleting the osteotomy, has prompted the develop- of local nerve entrapment,
the reconstruction of
ment at the Mayo Clinic of an approach in which the distal biceps, the
reduction and osteosynthesis
the anconeus is sharply dissected distally and of anteriorly displaced
fracture fragments and
reflected proximally respecting its fascial attach- excision of tumours.
ment to the triceps. It preserves the anconeus in Important neurovascular
structures, which
continuity with the triceps and can be used for should be identified and
protected if necessary,
later reconstructive procedures, should those be are in close vicinity with
any anterior approach to
needed. the elbow. The lateral
antebrachial cutaneous
nerve in the superficial
plane and the median
Anterior Approach nerve and the brachial artery
in the deep plane
Anterior approaches to the elbow have fallen of dissection are structures
at risk during these
out of favour due to the proximity of important approaches. The brachialis
muscle is between the
neurovascular structures, except for biceps ten- joint and the median nerve,
and the radial nerve is
don reconstruction. The anterior approach is in the interval between the
brachialis and the
based on the one described by Henry [22]. brachiorradialis muscle.
These anatomical
1333
between the biceps

tendon and the brachialis
muscle. The aponeurosis
is incised with care not
to injure the radial
artery which runs immediately
under it. There are
multiple vessels that should be
ligated or cauterized.
The vein and the median
nerve are medial to the
artery. If the radial nerve
has to be identified, it
emerges between the
brachialis and the
brachioradialis, in front of the
joint. The radial nerve
can be safely separated
laterally along with the
brachioradialis, and the
pronator teres is
retracted medially showing the
radial artery, the
muscle branch and the recurrent
radial artery.
Modifications
Henrys approach can be
extended proximally
and distally as needed.
Likewise, a more limited
approach than the one
exposed in the technique is
currently used for
reconstruction of distal biceps
ruptures.
Biomechanics
Kinematics of the elbow

joint are complex, and
may be better understood
by clarifying key con-
Fig. 21 Bicipital tendon (1); the lacertus fibrosus (2); cepts in motion,
stability and force transmission.
The radial nerve (3); The recurrent radial artery (4);
cutaneus antebrachii lateralis nerve (5); the brachial
artery and the median nerve (6) (Reproduced by permis-
sion of Llusa et al. [1]) Motion
The elbow is described

as a trochoginglymoid
features must be kept in mind at all times to avoid joint, which provides
motion in two planes:
inadvertent injury (Fig. 21). flexion-extension and
pronation-supination.
Basically, it acts as a
hinge due to the congruity
Technique of the ulnohumeral joint
and to the constraints
The incision is S-shaped with the transverse arm of the surrounding soft
tissues. However,
parallel to the elbow flexion crease. Proximally it we know that it should
be better described
follows the medial border of the biceps, and dis- as a loose hinge,
because it allows a varus-
tally it follows the medial border of the valgus laxity of about
4# throughout the range
brachioradialis. The plane of dissection lies of motion.
between the brachiorradialis and the brachialis In extension, the
long axis of the humerus
muscle proximally and the brachiorradialis and forms a valgus angle
with the forearm of about
the pronator teres distally. 5# in men and 10 in
women (defined as
During the superficial dissection, the lateral the carrying angle).
This valgus alignment
antebrachial cutaneous nerve must be localized diminishes with elbow
flexion due to the obliq-
and protected. This nerve is found in the interval uity of the elbow joint
line. The flexo-extension
1334
R. Barco et al.
axis of rotation of the elbow goes from a point ligament increases (Fig. 22).
The proximal half
immediately distal to the lateral epicondyle of the sigmoid notch is the
osseous articular
to a point distal and anterior to the medial structure resisting valgus
stress, while varus
epicondyle, a line which can be identified in a stress is mainly resisted by
the coronoid and the
lateral view of the elbow as passing through the distal half of the sigmoid
notch.
centre of the arcs formed by the capitellum In a classical article,
Morrey et al. [23]
and trochlear sulcus. studied the contribution of
anatomical struc-
The normal arc of motion in flexion and tures against valgus stress,
concluding that the
extension ranges approximately from 0# to radial head is a secondary
stabilizer for resisting
150# . Flexion is limited by the anterior valgus stress, with the MCL
being the primary
muscles, contraction of the triceps and osseous stabilizer. This implies that
in the presence of
impingement of both the head of the radius a MCL injury all efforts
should be made to
and the coronoid process against the preserve the radial head. In
cases of radial head
radial fossa and coronoid fossa, respectively. resection with an intact MCL
the stability is
Extension is limited by the impingement of slightly impaired although
this situation is
the olecranon process against the olecranon well tolerated over the long
term [24]. Forearm
fossa and tautness of anterior muscles, capsule rotation may affect valgus and
varus laxity.
and ligaments. Pronation may increase valgus
laxity of the
Forearm rotation is independent of elbow elbow and this may be
especially relevant in
flexion and extension and occurs as the throwing athletes and should
therefore be
radius rotates around the ulna through an considered when performing the
clinical exam
axis which is oblique with respect to the in these patients.
longitudinal axis of the forearm, running Similarly, when using a
radial head implant in
from the distal end of the ulna to the centre the setting of an unstable
elbow, it is critical to
of the radial head. Pronation/supination choose the right size. Over-
lengthening or under-
motion involves the radiocapitellar and the lengthening by as little as 2.
5 mm may alter
proximal and distal radio-ulnar joints. The arc elbow kinematics and increase
the rate of com-
of motion in pronation supination is approxi- plications [25].
mately 160# , with slightly more supination
than pronation.
Force Transmission
Stability (Constraints) The elbow can be considered a

load-bearing joint.
The forces that cross the
elbow are the resultant
The role of the ligamentous and osteo-articular of a combination of the loads
applied on the hand
elements of the elbow on joint stability has been or forearm balanced by the
forces exerted by the
extensively studied using biomechanical and musculotendinous units,
ligaments and the joint
electromagnetic testing. anatomy. When considering the
elbow joint as
Varus stability is provided mainly by the joint a hinge, the forces exerted by
the muscles vary
congruity, and ulnohumeral contact, and this with the range of motion.
contribution increases with increasing degrees The force vector crossing
the elbow joint is
of elbow flexion. However, the capsule and the perpendicular to the flexor-
extensor axis of
LCL provide almost half of the stability against rotation and passes through
the centre of the
varus in extension. joint line.
Valgus stress is resisted equally by the joint Single-muscle analysis is
probably a simplis-
articulation, the capsule and the MCL. With tic but quite helpful way to
understand how forces
increasing elbow flexion the role of the MCL, act across the elbow. In this
type of analysis,
more specifically, the anterior band of this changes in the moment arm of
the muscle with
1335
Fig. 22 (a, b) When applying a valgus stress, the primary Proximal ulna (2).
Anterior bundle of the medial collateral
stabilizer is the anterior band of the medial collateral ligament (3)
ligament, especially in flexion. Distal humerus (1).
respect to the position of the joint are balanced by Six muscle groups
participate in flexion-
the magnitude of the muscle force. There is extension: brachialis,
biceps, brachioradialis,
a close relationship between the joint forces and extensor carpi radialis
longus, triceps and
the muscle forces acting through the joint for anconeus [26]. The
contribution of forearm mus-
a particular external load being applied to the cles to flexion and
extension is probably limited.
hand. Increasing the moment arm of a muscle Analysis with surface
electrodes has helped
decreases the joint reaction forces and the muscle to elucidate the
function of arm muscles.
forces required to balance them. The position and The brachialis muscle
shows activity with
orientation of the external load on the forearm or elbow flexion,
especially with the forearm in
hand and the flexion angle of the joint alter the neutral rotation or
pronation, while the biceps
moment arm of the forces and the muscle line of shows activity with
flexion of the elbow if there
action. is supination of the
forearm, diminishing with
Maximum elbow strength occurs at 90# of forearm pronation.
flexion when the cross-sectional area of the mus- The medial head of
the triceps is most active at
cle is largest. With the elbow extended, one-third both 90# and 120# of
extension and is presumed
to one-half of the maximum force can be gener- to be the main extensor
of the elbow. The lateral
ated. Forces around the joint are three times and the long head of
the triceps act as auxiliary
the body weight with maximum force at 30# of muscles. The anconeus
shows activity throughout
flexion. the arc of motion and
is considered a dynamic
1336
R. Barco et al.
stabilizer of the elbow. Although forearm mus- anatomy and kinematics in

order to improve his/
cles were considered stabilizers for lateral liga- her surgical technique and
outcomes.
ments of the elbow, EMG analyses has showed
no electrical activity when testing the elbow for
stability [27].
References
Joint compressive forces with the elbow in
extension occur 40 % across the ulnohumeral 1. Llusa M, Ballesteros
JR, Forcada P, Carrera A. Atlas
joint and 60 % across the radiohumeral articula- de diseccion
anatomoquirurgica del codo. Barcelona:
tion, but varus and valgus alignment can signifi- Elsevier-Masson; 2009.
2. Kocher T. Text-book of
operative surgery. 3rd ed.
cantly shift these forces to the proximal ulna or to
London: Adam and Charles
Black; 1911. p. 3138.
the radiocapitellar joint, respectively [28]. 3. Kaplan EB. Surgical
approaches to the proximal end
Articular stress forces are equally distributed of the radius and its
use in fractures of the head and
across the joint, considering the elbow as a rigid- neck of the radius. J
Bone Joint Surg. 1941;23:86.
4. Nestor BJ, ODriscoll
SW, Morrey BF. Ligamentous
spring model with the line of action of all forces
reconstruction for
posterolateral rotator instability of
centred at the middle of the articular surface. If the elbow. J Bone Joint
Surg Am. 1992;74A:123541.
the line of action is somewhat translated anteri- 5. Mansat P, Morrey BF. The
column procedure:
orly or posteriorly, the bearing surface dimin- a limited lateral
approach for extrinsic contracture of
the elbow. J Bone Joint
Surg Am. 1998;80:160315.
ishes and compressive stresses increase, making
6. Strachan JH, Ellis BW.
Vulnerability of the posterior
joint stress distribution uneven. interosseous nerve
during radial head resection.
J Bone Joint Surg Br.
1971;53B:3203.
7. Morrey BF. Surgical
exposures. In: The Shoulder and
its disorders. 3rd ed.
Saunders.
Summary 8. Dines JS, ElAttrache NS,
Conway JE, Smith W,
Ahmad CS. Clinical
outcomes of the DANE TJ tech-
The elbow is a complex joint both from the ana- nique to treat ulnar
collateral ligament insufficiency of
tomic and biomechanical points of view. the elbow. Am J Sports
Med. 2007;35(12):203944.
9. Kasparyan NG, Hotchkiss
RN. Dynamic skeletal fixa-
A thorough understanding of elbow kinematics
tion in the upper
extremity. Hand Clin. 1997;13:64363.
will greatly aid the surgeon in dealing with com- 10. Alonso-Llames M.
Bilaterotricipital approach to the
plex elbow pathology. The close vicinity of elbow. Acta Orthop
Scand. 1972;43:47990.
neurovascular structures should always be kept 11. Morrey BF, Adams RA. J
Bone Joint Surg. 1999; 88A.
12. Patterson SD, Bain GI,
Mehta JA. Surgical approaches
in mind when selecting a surgical approach.
to the elbow. Clin
Any approach to the elbow joint needs to 13. Bryan RS, Morrey BF.
Extensive posterior exposure
be safe and versatile. Oftentimes we need to of the elbow: a triceps
sparing approach. Clin Orthop
extend our surgical field to address unexpected Relat Res. 1982;166:188
92.
14. Campbell WC. Incision
for exposure of the elbow
associated pathology. In this regard, a universal
joint. Am J Surg.
1932;15:657.
posterior approach is recommended, especially 15. Gschwend N. Our
operative approach to the elbow
for trauma cases. Additionally, it is wise to select joint. Arch Orthop
Trauma Surg. 1981;98:1436.
an approach which runs through intermuscular 16. Van Gorder GW. Surgical
approach in supracondylar
T fractures of the
humerus requiring open reduction.
and internervous planes. One of the key issues
1940;22:27892.
in elbow surgery is the management of the triceps 17. Van Gorder GW. Surgical
approach in old posterior
tendon attachment which should be preserved dislocation of the
elbow. J Bone Joint Surg Am.
whenever possible. The ulnar nerve may also be 1932;14:12743.
18. Wadsworth TG. A modified
posterolateral approach to
a source of complications, and it should be gently
the elbow and proximal
radioulnar joints. Clin Orthop.
handled during surgery. Adequate management 1979;144:1513.
of elbow ligaments during trauma and recon- 19. Wolfe SW, Ranawat CS.
The osteo-anconeus flap. An
structive procedures will reduce the risk of inad- approach for total elbow
arthroplasty. J Bone Joint
Surg Am. 1990;72:6848.
vertent post-operative instability.
20. Shahane SA, Stanley D. A
posterior approach to
In conclusion, any surgeon dealing with elbow the elbow joint. J Bone
Joint Surg Br.
pathology should have basic knowledge of elbow 2000;81:10202.
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21. MacAusland WR. Ankylosis of the elbow, with report deficient elbow.
of four cases treated by arthroplasty. JAMA. (12):262935.
1915;64:3128. 26. An KN, Hui FC,
Morrey BF, Linscheid RL, Chao EY.
22. Henry AK. Extensile exposure. 2nd ed. Edinburgh and Muscles across
the elbow joint: a biomechanical anal-
London: E & S Livingstone; 1966. p. 1135. ysis. J Biomech.
1981;14:659.
23. Morrey BF, Tanaka S, An KN. Valgus stability of the 27. Funk DA, An KN,
Morrey BF, Daube JR. Electromyo-
elbow. A definition of primary and secondary con- graphic analysis
of muscles across the elbow joint.
straints. Clin Orthop Relat Res. 1991;265:18795. J Orthop Res.
1987;5:529.
24. Antuna SA, Sanchez-Marquez JM, Barco R. 28. Amis AA, Dowson
D, Wright V. Elbow joint force
Long-term results of radial head resection following predictions for
some strenuous isometric actions.
isolated radial head fractures in patients younger than J Biomech.
1980;13:765.
forty years old. J Bone Joint Surg Am. 29. Harty M, Joyce
III JJ. Surgical approaches to the
2010;92(3):55866. elbow. J Bone
Joint Surg Am. 1964;46:1598606.
25. Van Glabbeek F, Van Riet RP, Baumfeld JA, Neale 30. Sales JM, Llusa
M, Forcada P, et al. Orozco. Atlas
PG, ODriscoll SW, Morrey BF, An KN. Detrimental de osteos
ntesis. Fracturas de los huesos largos.
effects of overstuffing or understuffing with a radial Vas de acceso
quirurgico. 2rd ed. Barcelona:
head replacement in the medial collateral-ligament Elsevier-Masson;
2009.
Arthroscopic Techniques in the
Elbow
Izaak F. Kodde, Frank T. G.

Rahusen, and Denise Eygendaal
Contents
Abstract
In the last 15 years arthroscopic techniques
of the elbow joint have been developed for the

Anatomy and Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
treatment of osteochondritis dissecans,

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1341 impingement, limitation of motion, lateral
Indications for Arthroscopic Surgery . . . . . . . . . . .
1342 epicondylitis, instability, trauma and
Osteochondritis Dissecans . . . . . . . . . . . . . . . . . . . . . . . . .
1342 post-traumatic deformities. Diagnosis and
Posterior Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1343 management of all these indications for elbow
Stiff Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1344
Lateral Epicondylitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1344
arthroscopy are described in detail. One of the

Instability of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1345 major benefits of arthroscopic management
Trauma and Post-Traumatic Deformities . . . . . . . . . .
1347 over open surgical procedures is that post-
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1348
operative rehabilitation will start earlier and
Arthroscopic Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1348
can be more aggressive. To avoid complica-
tions the surgeon should have thorough knowl-
edge of elbow anatomy and indications versus

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1352
contra-indications for specific elbow disorders.

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1353
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1353 Keywords
Anatomy # Complications # Elbow arthros-
copy # Fracture treatment # Indications and
treatable pathologies # Rehabilitation #

Techniques and portals
The elbow is less generally accepted as a joint
manageable by arthroscopic techniques com-

I.F. Kodde # D. Eygendaal (*)
pared with the knee, shoulder, hip and ankle.
Department of Orthopaedics, Upper Limb Unit, Amphia
Arthroscopy of the elbow was first described by

e-mail: denise@eygendaal.nl
Burman in 1932. However, for a long time, the
indications for elbow arthroscopy were limited to

F.T.G. Rahusen
Department of Orthopaedics, St. Jans Gasthuis, Weert,
diagnostic assistance and removal of loose bod-
The Netherlands
ies. As technology and techniques improved

1339
DOI 10.1007/978-3-642-34746-7_67, # EFORT 2014
1340
I.F. Kodde et al.
during the last decades, Orthopaedic surgeons side in the cubital fossa.
The radial nerve crosses
have considered arthroscopy more frequently in the front of the elbow joint
in the interval between
the treatment of various elbow disorders. In the the brachialis and
brachioradialis muscles. The
last 15 years arthroscopic techniques have been ulnar nerve crosses the joint
in the groove on the
developed for the treatment of osteochondritis back of the medial epicondyle
(Fig. 1).
dissecans, impingement, limitation of motion, Three arteries cross the
elbow joint. The bra-
lateral epicondylitis, instability, trauma and chial artery joins the medial
nerve on its lateral
post-traumatic deformities. Because of the prox- side, lying on the brachialis
muscle. At the level
imity of neurovascular structures in the elbow of the elbow, the brachial
artery separates into the
and the complex anatomy of the joint the arthro- radial and ulnar arteries.
The radial artery passes
scopic management of these disorders depends medial to the biceps tendon.
The ulnar artery
largely on the expertise of the surgeon. passes deep by the deep head
of the pronator
teres. Deep veins run along
with the artery. The
superficial veins are the
cephalic vein and the
Anatomy and Pathology basilic vein [1].
In the normal elbow
joint, stability is
The elbow plays a major role in the flexion and maintained by the combination
of joint congruity,
extension of the arm and supination/pronation of capsuloligamentous integrity
and well-balanced
the forearm. There is also a slight medial and intact muscles. The olecranon
and olecranon
lateral mobility (abduction and adduction in fron- fossa joint provide primary
stability at less than
tal plane) and medial and lateral rotation (about 20# or more than 120# of
elbow flexion.
the ulna in the transverse plane). The elbow is Inbetween stability is
provided primarily by the
formed by three bones: the humerus, the ulna and two distinct ligamentous
complexes. The capsule
the radius. Three joints are involved in the elbow; along with muscle groups may
act as secondary
the humero-radial joint; the humero-ulnar joint; static and dynamic
stabilizers of the elbow. The
and the proximal radio-ulnar joint. volume of the capsule
averages 23 cm3 (Fig. 2).
The elbow is supported by strong medial and Normal range of motion is
from full extension
lateral collateral ligaments. The anterior and pos- of 0145# of flexion. Some
hyperextension can be
terior ligaments are mainly thickened sections in considered physiological in
patients with more
the capsule. The medial or ulnar complex consists generalized laxity of the
joints. Pronation and
of an anterior medial collateral ligament, poste- supination are 85# and 80# ,
respectively. However,
rior medial collateral ligament and a transverse the full range of elbow
motion is not necessary to
band. The lateral or radial ulno-humeral ligament function well in most
activities of daily living.
complex has three components: the radial collat- A flexion-extension (30
130# ) and pronation-
eral ligament, lateral ulnar collateral ligament supination (5050# each) arc
of 100# is sufficient.
and the annular ligament. Flexion is restricted by soft
tissues. Extension is
Four groups of muscles cover the elbow joint: blocked by osseous
structures. Following trauma,
1. Anterior, the elbow flexors supplied by the intra-articular fluid can
also restrict motion. With
musculocutaneous nerve; the elbow in extension, axial
load is transferred
2. Posterior, the elbow extensors supplied by the from forearm to humerus via
two elbow joints.
radial nerve; The radiocapitellar joint
processes takes 57 % of
3. Medial, the flexor-pronator group of muscles the load, the ulno-humeral
joint is responsible for
supplied by the median and ulnar nerves; 43 % of the forces. These
percentages are chang-
4. Lateral, the extensor-supinators supplied by ing during movement as the
axis of the elbow
the radial and posterior interosseous nerves. changes from valgus to varus
during flexion and
The median, radial and ulnar nerves are rele- extension [2].
vant in applied surgical anatomy. The median In most sports with
overhead movement the
nerve crosses the front of the joint on its medial elbow is subjected to high
loads, and this occurs
Arthroscopic Techniques in the Elbow
1341
Medial nerve
Radial nerve
Ulnar nerve
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Pronator teres
Flexor carpi ulnaris
Fig. 1 Anatomy of the radial, medial and ulnar nerve at the elbow
in repetitive movements at very high speeds and ulnar nerve symptoms.

Next, a thorough
with very high forces. Common injuries clinical examination is
performed. Inspection
encountered include Medial Collateral Ligament for varus or valgus
deformity and swelling is
(MCL) tears, flexor-pronator muscle tendinitis important. Synovitis and
swelling of the joint is
or tears, ulnar neuritis, posterior impingement, best established at the
posterolateral part of the
osteochondritis dissecans of the capitellum joint. The ulnar nerve
can be palpated behind
and extensor tendinopathy [3]. the medial epicondyle.
Flexion, extension, pro-
nation and supination are
determined and com-
pared to the un-injured
side. Stability is
Diagnosis assessed with the moving
valgus tests (shoulder
in external rotation,
gentle valgus stress at the
Diagnosing elbow pathology starts as always wrist while stabilizing
the elbow at the lateral
with taking a careful history. Ask for pain, stiff- epicondyle), milking
manoeuvre (elbow is
ness, swelling, locking symptoms, traumatic extended from the fully
flexed position while
moments, repetitive micro-trauma, instability the examinator exerts a
valgus moment by
1342
I.F. Kodde et al.
Fig. 2 Attachments of the

elbow capsule
a b
grasping the thump and resisting extension),

pivot-shift test (on the supine patient, the Indications for
Arthroscopic Surgery
forearm is fully supinated and the examiner
grasps the wrist and slowly extends the elbow Osteochondritis Dissecans
while applying valgus and supination move-
ments and an axial compressive force) and OsteoChondritis Dissecans
(OCD) is a localised
table-top test. After examination of the condition in which a
segment of articular carti-
elbow it is important to review the neck, shoul- lage and bone separates
from the subchondral
der and hand as well. bone. The most common site
of OCD in the
Standard x-rays of the elbow should be elbow is the capitellum. It
is an uncommon dis-
evaluated for loose bodies, degeneration, order in the general
population and usually seen
post-traumatic deformities and joint effusion. in patients that overuse
their elbow in specific
Evaluation of soft tissues can be done using sporting activities. In
children, OCD has been
ultrasound. The ultrasound however is observer- reported between the ages
of 11 and 23 years,
dependent. When better delineation of soft tissue mostly provoked by
throwing sporting activi-
is necessary, Magnetic Resonance Imaging ties. The aetiology of the
condition is unknown.
(MRI) is the next step to take. Computed Topog- The most hypothesised cause
is the combination
raphy (CT) scanning will be of help in detecting of repeated valgus stress
at the elbow and
the extent of a fracture and intra-articular calcifi- a inadequate blood supply
to the capitellum.
cations or deformities [2]. OCD seems to evolve through
three stages. In
Experience over the last has shown that elbow the first stage the bone is
hyperaemic and there
arthroscopy has evolved to be a very useful tool is oedematous peri-
articular soft tissue. The
in diagnosis and evaluation of elbow pathology, second stage consist of
deformation of the epiph-
especially in assessment of instability and the ysis and sometimes with
fragmentation. In stage
treatment of acute trauma. Diagnostic arthros- three necrotic bone is
replaced by granulation
copy of these disorders are described below. tissue. The articular
surface may be unchanged
1343
as the bone heals, flattens and partially separates,

breaks away and forms a loose body. Symptoms
correlate with the degree of loss of articular
surface [2].
OCD lesions can be graded according to the
arthroscopic classification [4]:
Grade 1, smooth but soft, ballotable articular
cartilage;
Grade 2, fibrillation or fissuring of the cartilage;
Grade 3, exposed bone with a fixed osteochondral
fragment;
Grade 4, a loose but undisplaced fragment;
Grade 5, a displaced fragment with resultant
loose body.
Management depends on the integrity of the
cartilage and whether the involved segment is
stable, unstable but attached or detached and
loose. Stable lesions are primarily managed con-
servatively. If conservative management (rest,
physical therapy, NSAIDs) is unsuccessful, sur-
gical treatment is an option. Other indications for
surgery are loose bodies or evidence of Fig. 3 The exact fit of the
olecranon in the olecranon
instability. fossa of the humerus is
critical for maximal extension
Arthroscopic treatment consists of re-fixation and, therefore, for the
function of the elbow. Lower
in the case of large fragments. If re-fixation is not arrow, valgus movement of
the lower arm. Upper arrow,
abutment of olecranon on
the posteromedial border of the
possible, debridement is an option, as it is in the olecranon fossa, resulting
in impingement
case of smaller fragments. Arthroscopy is
performed through 2 anterior and 2 posterior por-
tals. Re-fixation of the fragments remain contro- rodeo-riders, weight-
lifters and fast-pitch softball
versial. Several techniques has been described, pitchers. During the
throwing motion there is
including screw fixation, dynamic stapling, a combination of valgus
forces and rapid exten-
Kirschner wires and bio-absorbable implants. sion. This results in
tensile forces along the
Yet none study has obviously demonstrated medial side, compression on
the lateral side of
marked improvement over excision and debride- the elbow and shear forces
in the posterior com-
ment alone. Debridement is usually performed partment. This combination
is called the valgus-
using a 3.5 mm shaver. All loose fragments and extension-overload
syndrome and forms the
loose cartilage are removed until subchondral basic pathological model of
posterior impinge-
bone is seen. Loose bodies can also be removed ment in the elbow. Thus,
posterior impingement
using a grasper [5, 6]. is the formation of bony or
soft tissue in the
posterior compartment,
which results in mechan-
ical abutment, leading to
pain in the posterior
Posterior Impingement compartment during
extension (Fig. 3) The
exact fit of the olecranon
in the olecranon fossa
Posterior impingement of the elbow is an uncom- of the humerus is critical
for maximal extension.
mon disorder in the general young population. Consequently, the maximal
extension, needed in
It is usually seen in patients who overuse most overhead sports is
reduced in posterior
their elbow in sporting activities such as the impingement. A provocative
examination upon
football linesman, cricket fast bowlers, gymnasts, forced hyperextension with
the absence of laxity
1344
I.F. Kodde et al.
is the most suggestive physical finding. If restricted working space

afforded by the congru-
posteromedial or posterolateral osteophytes are ity of the joint and non-
compliant capsule. The
found at CT-scan, it should alert the surgeon to learning curve shows a
significant decrease in
the possibility of co-existing valgus or varus operative time after an
initial 15 patients [8].
laxity, respectively. When conservative manage- Currently, the results after
open and arthroscopic
ment (physical therapy, rest, ice, NSAIDs, surgery are more or less the
same.
steroid infiltration) is unsuccessful, arthroscopy Arthroscopy for a stiff
elbow is performed
of the elbow can be used effectively in these through three posterior
portals and two anterior
patients. portals. The surgical
procedure depends on intra-
Arthroscopy for posterior impingement is articular findings. In the
anterior compartment
performed through two anterior and two or three extensive scarring and
hypertrophic synovium
posterior portals. After standard arthroscopy of can be debrided. Bony
impingement by
the elbow, debridement of the posterior fossa is osteophytes, the coronoid
process or distal
performed using a 3.5 mm shaver. The shaver is humerus can be removed using
an oval burr.
used until there is no sign of impingement by any Loose bodies can be removed
using a grasper.
soft tissue and/or bony osteophytes visible. In A contracted anterior
capsule can be released at
some cases a high-speed burr is necessary to the proximal one-third level
of the capsule from
remove large osteophytes. Loose bodies can be medial to lateral until the
posterior fibres of the
removed with a grasper [7]. brachialis muscle are
visible proximally, using
a punch. A complete
capsulectomy will require
careful separation of the
capsule from the poste-
Stiff Elbow rior interosseous nerve.
However, often a small
part of the capsule is left
in order to protect this
Limitation of motion of the elbow is most fre- posterior interosseous
nerve. Nevertheless the
quently seen caused by primary capsular contrac- capsule must be divided to
the level of the collat-
ture or stiffness associated with osteoarthritis, eral ligaments on both sides
for a complete
OCD, synovitis and old trauma or fracture. release. In the posterior
compartment, extensive
Elbow contractures can be the result of intrinsic scarring around the
olecranon fossa and posterior
(intra-articular) or extrinsic (extra-articular) capsule is removed. Bony
impingement by
causes. In most post-traumatic contractures both osteophytes on the olecranon
or the posterior
intrinsic and extrinsic causes play a role. The olecranon fossa are relieved
using an oscillating
exact aetiology of post-traumatic contractures is shaver and an oval burr.
Release the capsule
poorly understood. Immobilization resulting in carefully in the medial and
lateral gutter [9, 10].
adhesions seem to play a role.
Therapy starts with physical therapy
and static-progressive splinting for a minimum Lateral Epicondylitis
of 612 months. If conservative management is
unsuccessful, patients who are motivated to com- The tennis elbow, or
lateral elbow pain affects
ply with a strict post-operative rehabilitation pro- 13 % of the population. In
contrast to what is
gram are candidates for surgical release. widely thought, tennis
contributes in only
Recently, there has been progress in elbow 510 % of all cases of
tennis elbow. The
arthroscopy for limitation of motion and advan- aetiology seems to be
overuse or repetitive stress
tages over open release include: smaller scars, on the common extensor
tendon, especially the
improved joint visualisation, reduced pain, accel- Extensor Carpi Radialis
Brevis (ECRB) portion.
erated rehabilitation and shorter hospital stay. Alternatively, the annular
ligament, lateral cap-
However, arthroscopic release is technically sule, radial nerve and
several bands of the exten-
demanding because of the close proximity of sor digitorum communis have
been associated
neurovascular structures to portals and the with lateral elbow pain as
well. However, the
1345
highest level of evidence is for failure of repar- because of excessive

synovitis for instance, an
ative response in the ECRB tendon. The diagno- intra-articular retractor is
easy to establish with
sis can be made clinically, based on the patient or without the addition of
an extra portal. At last
history and physical examination. Palpation the anterior part of the
lateral epicondyle can be
may reveal point tenderness directly on the lat- abraded. At last,
arthroscopy facilitates the eval-
eral epicondyle or slightly anterior and distal to uation of associated intra-
articular pathology
it. Resisted wrist extension or passive stretching which has been described in
up to 30 % of all
with the elbow extended by flexing the wrist can lateral epicondylitis cases
[11, 12].
reproduce the pain. Grip strength is commonly
diminished. Imaging studies are rarely required
for diagnosis, but should be obtained to rule out Instability of the Elbow
other co-existing pathologies. Generally, MRI
findings correlate well with surgical and Instability is often
described as a non-
histological findings, and therefore can be used physiological motion
and is usually
as a decision-making tool in the surgical treat- symptomatic. Elbow
instability can be classified
ment of lateral epicondylitis. Still, treatment in the direction of forces
displacing the elbow.
starts with conservative measures such as Simple patterns of
instability include varus and
NSAIDs, physical therapy, bracing and infiltra- valgus motion at which the
lateral and
tion with corticosteroids, platelet-rich plasma or medial ligamentous complexes
are assessed,
autologous blood. Ninety per cent of patients respectively.
respond to conservative treatment and recover The Lateral Collateral
Ligament (LCL) is the
within 1 year. Patients in which non-operative primary ligamentous
stabilizer of the elbow for
treatment for lateral epicondylitis fails are can- varus and external rotation.
The lateral collat-
didates for arthroscopic release. The reported eral ligament is the most
important soft tissue
success rate of operative intervention is approx- constraint to posterolateral
and posterior
imately 80 %, regardless of surgical method [2]. dislocation of the elbow
joint. Posterolateral
Arthroscopy for lateral epicondylitis is dislocation is the most
common pattern of
performed through an proximal anteromedial elbow dislocations. More
than 95 % of disloca-
portal and a direct lateral portal. After an initial tions occur in a
posterolateral direction. Pos-
intra-articular inspection, a partial capsulectomy terolateral instability
usually results from
is performed with a shaver. After the capsule is a fall on the outstretched
hand with abduction
debrided, the ECRB tendon insertion should of the shoulder. The elbow
undergoes an axial
become visible. The ECRB is distinguished compression force as it is
flexed and the body
from the extensor carpi radialis longus as the approaches the ground. A
combination of supi-
latter appears more red or pink and has fewer nation and valgus forces
leads to posterolateral
fascial fibres. The ECRB insertion is carefully instability. Especially the
ulnar part of the LCL
debrided, from medial to lateral. Care is taken is damaged in posterolateral
instability and dis-
to avoid damage to the lateral collateral liga- location. Simple elbow
dislocations are man-
ments. Subsequently, the shaver is used to aged by functional treatment
or short-term
debride the damaged part of the ECRB until plaster immobilisation.
Posterolateral instabil-
only healthy tendon remains. Pathological ten- ity is diagnosed by the
lateral pivot-shift test
dons fibres can st be easily distinguished from of the elbow. During this
test, the symptomatic
healthy fibres since tendinitis is easily debrided elbow produces pain and/or
apprehension on
giving the appearance of snowflakes, while axial compression, valgus
stress and supination.
healthy tendon is much harder to debride with The diagnosis of chronic
elbow joint instability
the shaver. Just the degenerative ECRB tendons can be difficult since the
symptoms and the
should be debrided and not routinely the whole clinical presentation can be
subtle. Comparison
tendon insertion. If visualization is difficult with the un-involved elbow
should always be
1346
I.F. Kodde et al.
performed to differentiate between physiologi- uninvolved elbow should

always be performed
cal and pathological laxity. The degree of laxity to differentiate between
physiological and path-
is often under-estimated in the conscious ological laxity. In patients
with MCL insuffi-
patient. In chronic symptomatic LCL complex ciency a typically painful
arc can be produced
deficiency there is no role for conservative using the milking
manoeuvre and/or the mod-
treatment. Operative re-insertion or reconstruc- ified moving valgus test.
The elbow is extended
tion is mandatory. This reconstruction may be from the fully flexed
position while the examiner
open or arthroscopic [2]. exerts a valgus moment by
grasping the thump
During arthroscopy the radial head can be seen and resisting extension. The
above mentioned
to subluxate posteriorly while varus stress is instability test can be hard
to perform without
applied. The arthroscope is placed in the proxi- anaesthesia, however most
patients with MCL
mal anteromedial portal from where failure of the insufficiency will report an
apprehension. The
stabilizing aspects of the lateral ligaments can be assessment of elbow
instability is often difficult,
noted. Shifting of the radial head can also be even for experienced
clinicians, since even in the
visualized from this view. Chronic instability presence of a complete tear
of the anterior
may lead to secondary changes such as plica oblique ligament of the MCL,
valgus opening
formation, loose body formation and only occurs to a small
extent.
chondromalacia, all of which can be treated Arthroscopy of the elbow
with examination
arthroscopically. The more advanced under anaesthesia can be
very useful in selected
arthroscopist can perform an arthroscopic plica- cases to diagnose the type
and degree of instabil-
tion technique for this instability. Multiple ity. The MCL cannot be
consistently visualised
sutures are passed using a spinal needle retriever by arthroscopy. However,
arthroscopy can pro-
technique medial to the LCL complex. These vide effective indirect
evidence of MCL insuffi-
sutures are retrieved posterior to the humerus ciency. This can be
accomplished by the
and used to plicate the LCL complex. Next, arthroscopic valgus
instability test. In this test
these sutures may be tied over or under the one visualise the most
medial aspect of the
anconeus muscle and then sutured back to the ulnohumeral articulation,
opening of the
humerus using an anchor [13]. ulnohumeral joint space of
as little of 2 mm at
The medial collateral ligament (MCL) is the valgus stress, represents a
complete tear of the
most important soft tissue constraint to valgus anterior oblique bundle of
the MCL. Next, no
instability of the elbow. The anterior medial col- opening is seen until
complete disruption of the
lateral ligament is the strongest and most stiff of ligament [14].
the collateral ligaments. The three most common Conservative management
of acute isolated
causes of MCL injury are elbow dislocation, MCL injuries consist of a
short period of
chronic attenuation in athletes and acute valgus immobilisation. Subsequently
an intensive exer-
injury. Complete dislocation and MCL injury, cise program is started.
Persistent symptomatic
usually occur in association with a small coronoid instability after a period
of 36 months of non-
fracture. Treatment of these MCL injuries after operative management is an
indication for oper-
dislocation depends on the size of the coronoid ative reconstruction. Since
the contemporary
fragment and is in general surgical. The diagnosis reconstructions options are
extra-articular, there
of medial ulnar instability is based on a history of is no place for primary
ligament reconstruction
medial pain associated with the acceleration by arthroscopic techniques.
However, when an
phase of throwing. At physical examination one open reconstruction is
performed, many surgeons
should assess the degree of extension loss. The complete an arthroscopy for
the evaluation and
joint must be tested for valgus instability in 30# management of intra-
articular damage caused by
and 90# of flexion. Comparison with the the medial instability [2].
1347
Trauma and Post-Traumatic instruments, such as

cannulated screws or reduc-
Deformities tion guides. In patients
with continued pain after
a conservative fracture of
the radial head, arthro-
The elbow is prone to injury. Fractures results scopic evaluation and
management of articular
from a fall on the outstretched hand or occur cartilage irregularities and
loose bodies can be
due to a direct impact to the elbow. Fractures effectively performed [14].
can range from simple fissures to severe open A fracture of the
olecranon process is another
elbow dislocations. Ligamentous injuries and common injury of the elbow.
The force of the
associated fractures can result in instability triceps tendon essentially
avulses the olecranon
and long-term post-traumatic arthritis. Arthros- from the proximal ulna. The
olecranon can also
copy has proven itself to be useful not only in fracture because of an
direct impact. Olecranon
the diagnosis and management of acute elbow fractures usually require
surgical treatment with
trauma, but also in treating the sequelae of these Kirschner wires and tension-
band wiring. This
traumata. Arthroscopy can help in reduction technique is not amenable
for arthroscopy. How-
and internal fixation of fractures. Since cannu- ever, in patients with on-
going pain and loss of
lated screws and Kirschner wires are effective motion after a healed
olecranon fracture, arthros-
in several elbow fractures, there is much poten- copy is perfect to evaluate
secondary
tial for arthroscopic (assisted) fracture post-traumatic changes in
the elbow joint.
treatment. Debridement and
adhesiolysis can improve
Radial head fractures are the most common of elbow function and pain.
all elbow fractures. They occur in 30 % of elbow Coronoid fractures are
amenable for arthro-
fractures and up to 5 % of all fractures. Radial scopic fixation, depending
on size and comminu-
head fractures are classified according to the tion. Coronoid fractures are
classified into three
Mason classification. types according to the Regan
and Morrey
Type 1 fractures are non-displaced; classification:
Type 2 fractures have a displacement of >2 mm; Type 1, involves just the
tip of the coronoid;
Type 3 fractures are comminuted with multiple Type 2, fragment involving
<50 % of the
displaced fragments. process;
Type 1 fractures are managed conservatively. Type 3, fragment involving
>50 % of the
Type 3 fractures require radial head excision with process.
or without placement of a prosthesis. Type two Small type one coronoid
fractures can be
fractures should be treated operatively in most debrided arthroscopically in
order to prevent
cases. This fracture type of the radial head can a loose body in the joint
and possible subsequent
be fixed arthroscopically. However there is no cartilage damage. As long as
type 2 fractures are
scientific evidence in favour of arthroscopic treat- non-comminuted, they are
amenable for
ment over open surgery of radial head fractures. arthroscopic reduction and
fixation with one or
With arthroscopy the radial head is best visual- two cannulated screws placed
from a posterior
ized from the proximal anteromedial portal. Frag- direction in the fracture
fragment [2].
ment size, articular congruity, and chondral Fractures of the distal
humerus can result
damage should be assessed. Next the joint and from high energy trauma, but
also from simple
fracture should be cleared of debris and falls in the osteoporotic
patient. It is important
haematoma. Using the straight lateral or to recognize the difference
between intra-
anterolateral portal, a Kirschner wire can be articular and extra-
articular fractures. Conser-
used as a joystick while an assistant rotates the vative treatment is
justifiable in non-displaced,
forearm to aid in reduction. The posterolateral stable fractures. Other
fractures usually
portal is used typically for fracture fixation require operative
management. In particular
1348
I.F. Kodde et al.
non-comminuted unicondylar distal humerus Arthroscopic Technique

fractures are sometimes amenable to arthro-
scopic evaluation and arthoscopically assisted Arthroscopy begins with
adequate positioning of
fracture fixation. These fractures are classified the patient. For elbow
arthroscopy the supine,
by Milch into two types: prone and lateral decubitus
positions are avail-
Type 1: the lateral wall of the trochlea remains able (Fig. 4). The supine
position allows for easy
attached to the humerus. access to the anterior
compartment and airway
Type 2: the lateral wall of the trochlea is attached management is simplified for
the anaesthetist. If
to the fracture fragment. the arthroscopy needs to be
converted to an open
Type 1 fractures are smaller and affect elbow procedure, the supine
position is preferred. The
stability much less than type 2 fractures. Con- prone and lateral decubitus
positions provide bet-
sequently, type 1 distal humerus fractures are ter access to the posterior
compartment. So posi-
potential candidates for Arthroscopic Reduc- tioning depends mainly on
the surgeons
tion and Internal Fixation (ARIF). preference.
Haematoma and debris at the fracture site There are more than
seven portals obtainable
can be removed. Next, a probe or K-wire for elbow arthroscopy.
Before placement of the
joystick is used to reduce the fracture frag- portals, the surgeon should
outline the important
ment. A cannulated guide-wire can be landmarks of the elbow (Fig.
5) and distend the
advanced after reduction of the fracture frag- joint. On the medial side
lie the medial
ment and thereafter a cannulated screw can be epicondyle and ulnar nerve.
On the lateral side
percutaneously placed over the guide-wire. the radial head and the
lateral epicondyle. On the
In conclusion ARIF can provide anatomic posterior side the
olecranon. Be aware of altered
reduction, stable fixation and debridement landmarks after trauma or
previous ulnar nerve
while minimizing surgical trauma in type 1 transposition.
distal humerus fractures [15]. The joint is distended
with 1030 ml of nor-
The elbow can become inflamed following mal saline to displace the
neurovascular struc-
penetrating trauma. In case of septic arthritis, tures, thereby making portal
placement safer
which is very rare, the arthroscope is an excellent (Fig. 6). Distension is done
in the posterior com-
tool to apply a proper lavage of the septic elbow partment of the elbow, via a
needle placed in the
joint. After lavage it allows for detailed joint centre of the triangle
between lateral
assessment. epicondyle, olecranon tip
and radial head
Dislocations of the elbow are described in the (Fig. 7). The elbow is in
extension and in supi-
section of this chapter: Instability of the Elbow. nation with maximal
distension. For the anterior
compartment are five common
portals used. The
proximal medial and proximal
lateral portals are
Operative Techniques the safest. The anteromedial
and anterolateral
portals allow for more
direct exposure to the
The elbow differs from other joints since it is joint but are at higher risk
for causing
tightly constrained, making manipulation diffi- neurovascular injury during
placement. The
cult. On average the elbow has a capacity of direct lateral portal allows
for joint distension
1030 ml. Several portals are therefore required. and visualisation of the
inferior radial head area.
The proximity of neurovascular structures makes The posterior compartment is
exposed by two
arthroscopy of the elbow riskier than arthroscopy common portals. The direct
posterior and the
of other joints. Indications for elbow arthroscopy posterolateral portals. The
posterior compart-
are determined by the experience of the ment is normally relatively
safe from the
arthroscopist. neurovascular structures.
Arthroscopic Techniques in the Elbow 1349
Fig. 4 The lateral

decubitus position
Fig. 5 Placement of
instruments through portals
according to pre-operative
outlined landmarks. In the
left hand, the arthroscope
and in the right hand,
a shaver
1350
I.F. Kodde et al.
Placement of the above mentioned portals is as arthroscopy. Probes

and graspers are used to
follows: manipulate structures.
Burrs and shavers are used
for debridement and/or
removal of tissues. Cau-
Proximal 2 cm proximal to the medial tery devices are used
for debridement and to con-
medial: epicondyle and 1 cm anterior to the trol bleeding.
Kirschner wires, guide-wires and
medial epicondyle. This is just
anterior to the medial intermuscular cannulated screws can
be used for fracture manip-
septum. It is approximately 6 mm ulation and fixation.
For effective use of the instru-
from the medial antebrachial mentation excellent
visualisation is a necessity.
cutaneous nerve and 1 cm from the Thus, most important,
is to use the correct portals
median nerve.
for every single
activity during arthroscopy. Each
Proximal 2 cm proximal to the lateral epicondyle
lateral: and 1 cm anterior to the lateral of the seven portals
has it own ideal properties:
epicondyle. This is approximately
1 cm from the radial nerve. Proximal A
good starting portal because of safe
Anteromedial: 2 cm distal to the medial epicondyle medial:
access, minimal fluid extravasation
and 2 cm anterior to the medial and
good visualisation of the entire
epicondyle. This is 714 mm from the
anterior compartment, including
median nerve and 05 mm from the
anterior capsule, trochea, capitellum,
medial antebrachial cutaneous nerve.
coronoid process, radial head, medial
Anterolateral: 3 cm distal to the lateral epicondyle and
lateral gutters. Viewing the
and 2 cm anterior to the lateral
radiocapitellar joint. Anterior
epidcondyle. This is approximately
instrumentation.
7 mm from the radial nerve. Proximal Also
a good initial portal because safe
Direct lateral: In the centre of the triangle between lateral:
access, minimal fluid extravasation
lateral epicondyle, olecranon tip and and
good visualisation of the anterior
radial head. Same position as the
compartment, including anterior and
needle used for distension. It is 7 mm
lateral radial head, capitellum and
from the posterior branch of the lateral
lateral gutter. Anterior
antebrachial cutaneous nerve.
instrumentation.
Direct 3 cm proximal to the olecranon tip and Anteromedial:
Inflow portal. Visualization of the
posterior: in mid-line through the triceps tendon.
anterolateral structures. Anterior
This is approximately 2.5 cm from the
instrumentation.
posterior antebrachial cutaneous Anterolateral:
Visualization of the coronoid process,
nerve and the ulnar nerve.
trochlea, coronoid fossa and medial
Posterolateral: 3 cm proximal to the olecranon tip and
radial head. Anterior instrumentation
on the lateral edge of the triceps for
the medial joint.
tendon. Usually 2 cm lateral to the
position of the direct posterior portal. Reversal of the
anterior portals between
This is approximately 2.5 cm from the
medial and lateral,
reverses visualization and
medial antebrachial cutaneous nerve,
posterior antebrachial cutaneous instrument placement.
nerve and the ulnar nerve.
Direct lateral:
Initial joint distension. Visualization
of
the (inferior) radial head,
The posterior portals should be placed with the
capitellum and radio-ulnar joint.

elbow in 2030# of flexion.
Instrumentation for the posterior
Normally a 4 mm arthroscope is used for visu-
capitellum and radio-ulnar joint.
alisation of the elbow joint; however in small or Direct
Visualization of the entire posterior
stiff joints a 2.7 mm arthroscope can be preferred. posterior:
compartment. Instrumentation in the
posterior compartment.
Elbow arthroscopy is facilitated by the circulation
Posterolateral:
Visualization of the posterior
of normal saline through the joint via tubes and
compartment including the tip of the
a pump. There is a wide range of instruments
olecranon, olecranon fossa
developed to support the surgeon during
posteriorly, medial and lateral gutters.
1351
At the end of the arthroscopic procedure, only When the patient is conscious
the neurological
the skin is stitched. No drain is left when the status is assessed [16, 17].
tourniquet is deflated. A pressure bandage and
sling provide some comfort for the first post-
operative hours. Immediately thereafter, the Post-Operative Care and
pulse in the radial and ulnar artery are monitored. Rehabilitation
Post-operative care after

elbow arthroscopy con-
sists of standard procedures
as after all surgical
interventions. Assess the
neurovascular status
and range of motion of the
joint and extremity.
Check for adequate wound
healing, signs of
infection, oedema or
thrombosis. A major differ-
ence between elbow
arthroscopy and open surgi-
cal procedures is that
rehabilitation will start
either on the day of surgery
or the day after, and
will be more aggressive.
Active range of motion
exercises are started within
24 h following sur-
gery. After 24 h the pressure
bandage can be
removed and range of motion
is progressed as
tolerated. Oedema and pain
can be reduced with
cold packs [16].
The anatomical structure
and orientation of
the elbow makes it highly
prone to post-operative
stiffness. Prolonged
immobilization contributes
to the development of joint
contracture. There-
fore early mobilization is
most important in
a successful rehabilitation
program. Since
arthroscopy causes minimal
injury to the soft
tissue structures of the
elbow, stability is
maintained and early
exercises are safe. Both
Fig. 6 Distension of the elbow joint active and passive range of
motion exercises
Fig. 7 Distension of the

elbow capsule via a needle
placed in the centre of the
triangle between lateral
epicondyle, olecranon tip
and radial head
1352
I.F. Kodde et al.
may be commenced under supervision of

a physiotherapist. The use of Continuous Passive Complications
Motion (CPM) post-operatively is advocated by
many authors. However, the benefits of CPM In the literature,
complication rates for arthros-
have never been proved in randomized controlled copy of the elbow are as high
as 10 %. Most
trails. CPM can be used for as long as it is neces- complications are minor and
transient. However,
sary to achieve range of motion goals [18]. permanent major injury to all
of the nerves in the
Restoration of range of motion is especially elbow has been described.
Minor complications
important after arthroscopic release of the stiff are transient and considered
as common in
elbow. Rehabilitation in the post-operative arthroscopy. Examples are
haematoma forma-
period after capsular release can be subdivided tion, swelling and persistent
drainage from por-
into four phases: [9] tals. Major complications
involve permanent
1. Acute phase. Goals: Limit pain and swelling, neurovascular injuries or
complications requiring
increase in ROM, isometric strengthening re-intervention or loss of
function of the elbow.
without pain. Nerve injuries are more
common in patients with
Rehabilitation program: Kinetic link exer- rheumatoid arthritis for
several reasons. Because
cises, scapula co-ordination and stabilization of bony erosive changes, the
normal landmarks
exercises, no sporting activities, passive range can be difficult to identify,
and severe synovitis
of motion, pain-free mobilization, cryother- makes visualization at the
commencement of the
apy, non steroid anti-inflammatory drugs procedure often poor [18].
(NSAIDS). The incidence of
complications can be
2. Intermediate phase. Goals: No pain at rest, no reduced by standard
procedures for every arthros-
swelling, limited activity, increasing ROM. copy of the elbow. For
instance, landmarks
Rehabilitation program: See phase 1, and should be defined before
distension. Before portal
stretching of elbow musculature without free, placement the joint should be
distended. Portal
cardiovascular conditioning programme. placement can be located
using a needle or the
3. Advanced strengthening. Goals: Full ROM, inside-out technique after
the first portal is
no pain and no limitation in daily activities, created. Only the skin is
incised with a blade,
sport-specific exercises possible. thereafter blunt dissection
is performed with
Rehabilitation program: See phase 1 and 2, a haemostat in a longitudinal
direction. A blunt
maximal passive and active pain-free mobili- trocar is used to create the
portal. Placement of
zation, maximal muscular strengthening, start portals in the anterior
compartment should be
throwers 10 programme if applicable. done with the elbow in 90# of
flexion. During
4. Return to sports activity. Goals: gradual return the procedure knowledge of
local anatomy most
to sports activity, throwing motion. in compet- important to avoid injuries.
itive way. Last but not least,
complications can be
Rehabilitation program: complete throwers avoided by knowledge of the
correct indications
program, increase strength, start both concen- and contra-indications for
elbow arthroscopy.
tric and eccentric exercises at different speed. Significant disruption of
normal anatomy as
During the rehabilitation progress, splinting a result of trauma or
rheumatoid arthritis is
may protects the healing joint from outside a relative contra-indication
for arthroscopy.
forces. It is, however, crucial that an Another contra-indication is
an elbow with over-
immobilisation splint is only worn for lying local infection or
cellulitis. A history of
a maximum of 2 weeks post-operatively. Its ulnar nerve transposition is
a relative contra-
main use after arthroscopy should be for fracture indication depending on the
position of the
management. nerve and the simplicity of
localising it. Perhaps
1353
the most important indication or contra- 4. Baumgarten TE,

Andrews JR, Satterwhite YE. The
indication for elbow arthroscopy is the experi- arthroscopic
classification and treatment of
osteochondritis
dissecans of the capitellum. Am
ence of the surgeon [19]. J Sports Med.
1998;26(4):5203.
5. Levine Field and
Savoie, Arthroscopic management of
osteochondritis
dissecans of the elbow. Oper Tech
Summary Sports Med.
2006;14:6066.
6. Rahusen FT,
Brinkman JM, Eygendaal D. Results of
arthroscopic
debridement for osteochondritis
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Burman in 1932. However, for a long time, the 2006;40(12):966
9.
indications for elbow arthroscopy were limited to 7. Rahusen FT,
Brinkman JM, Eygendaal D. Arthroscopic
treatment of
posterior impingement of the elbow in
diagnostic assistance and removal of loose athletes: a
medium-term follow-up in sixteen cases.
bodies. The elbow differs from other joints J Shoulder Elbow
Surg. 2009;18(2):27982.
since it is tightly constrained, making manipula- 8. Kim SJ, et al.
Arthroscopic treatment for
tion difficult. On average the elbow has a capacity limitation of
motion of the elbow: the learning
curve. Knee
Surg Sports Traumatol
of 1030 cm3. Several portals are therefore Arthrosc.
2011;19(6):10138.
required. The proximity of neurovascular struc- 9. Cefo I,
Eygendaal D. Eygendaal Irma Cefo and Denise
tures makes arthroscopy of the elbow riskier than Eygendaal,
Arthroscopic arthrolysis for posttraumatic
arthroscopy of other joints. Indications for elbow elbow stiffness.
J Shoulder Elbow Surg. 2011;20
(3):4349.
arthroscopy depend on the experience of the 10. Sahajpal D, Choi
T, Wright TW. Arthroscopic
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stiff elbow. J Hand Surg Am.
copy includes osteochondritis dissecans, 2009;34(3):540
4.
impingement, limitation of motion, lateral 11. Merrell G,
DaSilva MF. Arthroscopic treatment of
lateral
epicondylitis. J Hand Surg Am.
epicondylitis, instability and trauma. A major dif- 2009;34(6):1130
4.
ference between elbow arthroscopy and open 12. Savoie FH,
VanSice W, OBrien MJ. Arthroscopic
surgical procedures is that rehabilitation will tennis elbow
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start either on the day of surgery or the day 2010;19(2
Suppl):3136.
13. Savoie FH, Field
LD, Ramsey JR. Posterolateral rota-
after, and will be more aggressive. Complications tory instability
of the elbow: diagnosis and manage-
can be avoided by knowledge of correct indica- ment. Oper Tech
Sports Med. 2006;14:815.
tions and contra-indications. 14. Field LD, Savoie
FH. The arthroscopic evaluation and
management of
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Tech Sports Med.
1998;6(1):228.
15. Holt MS, et al.
Arthroscopic management of elbow
References trauma. Hand
Clin. 2004;20(4):48595.
16. Brach P, Goitz
RJ. Elbow arthroscopy: surgical tech-
1. Hoppenfeld, deBoer, The anatomic approach. Surgical niques and
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Neumann RD. Orthopaedic secrets. 3rd ed.
2. Eygendaal D, editor. The elbow. 1st ed. Nieuwegein: Philadelphia:
Hanly & Belfus; 2004.
Arko Sports Media; 2009. 18. Steinmann SP.
Elbow arthroscopy: where are we now?
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ics of the elbow joint in tennis players and relation to 19. Savoie 3rd FH.
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Arthroscopy. 2007;23(11):123740.
Distal Biceps and Triceps
Avulsions
R. Amirfeyz and David Stanley
Contents
Abstract
Distal Biceps Avulsion . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1355 Rupture of the distal biceps & triceps tendons
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1355 are uncommon. This article summarises the
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1356 current literature and discusses the incidence,
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1356 aetiology, management and outcome of these
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1356
Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1356 injuries.
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1357
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1357 Keywords
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1357 Anatomy # Biceps # Complications; outcomes
1358
# Diagnosis # Distal avulsions; classification #

Post-Operative Care and Rehabilitation . . . . . . . . . . .
1359
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1359 Imaging # Mechanisms # Rehabilitation #
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1360 Surgical indications # Surgical techniques #
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1360 Triceps
Distal Triceps Avulsion . . . . . . . . . . . . . . . . . . . . . . . . . . .
1360
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1360
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1360
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1360
Distal Biceps Avulsion

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1360
Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1361 Introduction
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1361
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1361
1361
Distal biceps avulsion is an uncommon injury

1361 with an incidence of 1.2 per 100,000 of the pop-
Post-Operative Care and Rehabilitation . . . . . . . . . . .
1362 ulation per year [35]. It accounts for 310 % of all
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1362 biceps tendon ruptures [19] and usually occurs in
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1362
middle-aged men [5] with far fewer cases

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1362 reported in females [4]. In the athletes it is seen
in a slightly younger age group with weight-
lifting and body-building as the two commonest
sports affected [11]. The frequency of this injury
is increasing [5].
R. Amirfeyz
Bristol Royal Infirmary, Bristol, UK
D. Stanley (*)
Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
e-mail: Dave.stanley@sth.nhs.uk

1355
DOI 10.1007/978-3-642-34746-7_66, # EFORT 2014
1356
R. Amirfeyz and D. Stanley
Aetiology such as intra-substance

and musculo-tendinous
tears are rarely seen.
The aetiology is mainly unknown. The vascular A more relevant
classification from the treat-
anatomy of the distal biceps tendon has been ment perspective is
partial versus complete, and if
assessed and three distinct zones described. the rupture is complete,
it is important to know
Zone one is the proximal part of the tendon with whether the injury is
acute (less than 4 weeks-old)
an abundant blood supply derived from the or chronic. The integrity
of the bicipital aponeurosis
brachial artery. is important especially
in chronic cases as an intact
Zone three is the most distal part with a sufficient aponeurosis prevents
proximal retraction of the
blood supply through the posterior recurrent tendon and irreversible
muscle unit damage [33].
artery.
Zone two is located between zones one and three
and has a poor blood supply. This part of the Anatomy
distal biceps tendon is located in the narrow
zone between the proximal radius and ulna. The distal biceps tendon
consists of two separate
The space available for the tendon is even tendons. One is in
continuity with the radial sided
narrower in pronation. The poor blood supply muscle belly, which has
the long head as the
in combination with possible impingement proximal tendon. It
inserts on the radial tuberos-
in this narrow space has been suggested as ity away from the axis of
rotation of the forearm,
a possible cause of distal biceps tendon rupture making it an efficient
supinator. The second part
[38]. However the majority of avulsions usu- of the tendon is in
continuity with the medially
ally occur in zone 3 and are the result of hyp- located muscle belly,
which has the short head as
oxic tendinopathy, mucoid degeneration and the proximal tendon. The
attachment of this part
tendolipomatosis [23]. These changes are con- of distal biceps is a
fan-shaped broad area, distal
sistent with the minimal trauma required for the to the radial tuberosity,
further away from the
complete rupture of the distal biceps tendon. elbow axis of rotation
making it an ideal flexor
Radiographic features like spurring of radial of the elbow.
tuberosity also support the existence of degen- The two muscle
bellies are completely sepa-
eration [40]. The association of anabolic rated in more than half
of the cases and in the
steroids and distal biceps tendon rupture is con- remainder have some
interdigitation. However
troversial. Although animal studies have shown even in the cases of
interdigitation, the two bellies
the stiffening effect of these agents on the can be readily separated,
making the biceps mus-
tendons making them more prone to rupture cle a functional unit
comprised of two different
with less than normal strain [28], the evidence muscles with separate
proximal & distal tendons.
to support this in human is weak [11]. In bilat- The biciptal
aponeurosis, otherwise known as
eral cases the association is stronger but still not the lacertus fibrosus,
covers the distal biceps
statistically proven [37]. Smoking has also tendon. The integrity of
this structure is an impor-
been linked with bilateral cases but the tant factor preventing
proximal migration of the
evidence for this is limited [35, 37]. muscle belly in cases of
chronic ruptures of the
tendon [14].
Classification
Mechanism
Traditionally distal biceps avulsions have been
classified according to the anatomical level The distal biceps tendon
usually ruptures follow-
affected. However the vast majority occur at the ing the application of an
eccentric load to the
distal bone-tendon attachment and the other types flexed elbow. This, in
the vast majority of cases
Distal Biceps and Triceps Avulsions
1357
results in a compete avulsion of the tendon from the lateral antecubital

cutaneous nerve of forearm
the tuberosity. Rarely the rupture occurs in the [12]. The biceps squeeze
and hook tests are help-
middle of the tendon or at the musculo-tendinous ful in chronic cases when
other aspects of phys-
junction. The bicipital aponeurosis usually rup- ical examination may not be
conclusive.
tures at the same time allowing proximal migra-
tion of the tendon but may in rare instances,
remain intact [33]. Imaging
Imaging is unnecessary if
on clinical examination
Diagnosis the diagnosis is obvious.
However in equivocal
cases, plain films, an
ultra-sound scan or MRI can
The diagnosis is made based on the history and be of help. On plain
radiographs spurring and
physical examination. In acute cases, the patient irregularity of the radial
tuberosity may be
gives a history of lifting an object or having an observed [40]. With an
ultra-sound scan the ten-
accidentally applied extension moment applied to don can readily be traced
down to the attachment
a flexed elbow. The patient feels an acute sharp site, however the
disadvantage of this technique
pain in the antecubital fossa, sometimes accompa- is that it is operator-
dependent. MRI is excellent
nied by a popping sensation or noise. The acute to assess the anatomy (Fig.
1). The ideal position
pain settles in a few days leaving a dull ache in the of the upper limb at the
time of scanning is the
area. Bruising and mild swelling is observed at the shoulder in abduction,
elbow flexed and forearm
antecubital fossa. The distal biceps tendon cannot supinated (FABS) [18]. MRI
is specifically help-
be traced down to the depth of this space and ful in cases of partial
tear or tendinosis. In these
sometimes there is an obvious proximal migration circumstances evidence of
tendon thickening,
of the biceps muscle mass, especially if the bicip- oedema and extra fluid in
the surrounding tissue
ital aponeurosis is ruptured. Active elbow flexion or at the bony attachment
is seen.
is accompanied by pain.
A biceps squeeze test has been described. If
the patients elbow is flexed to 90# with the fore- Indications for Surgery
arm resting on the patients lap in neutral or slight
pronation, squeezing the biceps muscle belly Distal biceps tendon
rupture results in loss of
should cause supination of the forearm if the supination and flexion
strength [29]. This weak-
distal biceps tendon is intact. This test is 96 % ness plateaus over time,
but the endurance of
sensitive but the specificity is unknown [34]. elbow flexion and
supination remains [31].
Another diagnostic test is the hook test. If This loss of strength has
been the mainstay of
the distal biceps tendon is intact and the patient is the rationale for operative
intervention. How-
asked to actively flex the elbow to 90# with fore- ever the weakness is not
always a functional
arm in extreme supination, the examiner can problem for the patient and
therefore this must
hook his/her index finger right under the tendon be discussed in detail with
the patient before
like a hook from the lateral aspect of the tendon. proceeding to surgery [17].
As the majority of
The sensitivity and specificity of this test have distal biceps avulsions are
observed in athletes
been reported to be 100 % by the group who keen on lifting heavy
weights (weight-lifters and
initially described the test [32]. body-builders), it is not
surprising that most will
In chronic cases, the main complaint is weak- opt for surgery. In this
situation an early ana-
ness of elbow flexion and supination. Sometimes tomical repair is the
treatment of choice due to
a dull ache can be the presenting symptom. Clin- the ease of the technique
and better outcome.
ical examination may show biceps asymmetry The complication rate
increases in delayed
and sometimes paraesthesia in the territory of repairs [10].
1358
Fig. 1 Sagital MRI scan of elbow showing a distal biceps rupture on left and a
repaired tendon using metal anchors on
right
Operative Technique incidence of proximal

radio-ulnar synostosis
[15]. However the more
recent literature has
Three different surgical treatments exist: highlighted the
importance of other factors
Anatomical repair (mostly in acute cases), associated with
synostosis, such as the timing
reconstruction (mainly in chronic cases) and of the surgical repair
(if repaired in the first 2
non-anatomical tenodesis to the brachialis tendon weeks, there is less
chance of synostosis [6])
in order to partially restore flexion strength (in and the relation of the
posterior incision to the
chronic cases). ulnar subcutaneous
border (the nearer the inci-
sion the more the
likelihood of synostosis [3]).
Approach To reduce the risk of
synostosis, an incision
The traditional surgical approach involves away from the
subcutaneous ulnar border with
a small incision anteriorly to locate the tendon minimal anconeus
dissection or elevation is
and a separate posterolateral incision for recommended [3]. The
alternative approach is
attachment of the tendon to the radial a single anterior
incision technique. Although
tuberosity [7]. This is designed to limit the reducing the risk of
synostosis, it does not
dissection in the antecubital fossa hence reduc- completely avoid it
[3]. The disadvantage is
ing the risk of neurovascular injury. The disad- a higher risk of
neurological compromise [5].
vantage of this technique is an increased With the newer fixation
devices and a careful
1359
minimal dissection around the radial tuberosity, strength, although supination

strength will not
this risk has dropped to an acceptable level necessarily improve which can
cause patient
[27]. The choice between a one- versus two- dissatisfaction [26].
incision technique is therefore at the discretion
of the surgeon. Partial Ruptures
These can be disabling with
chronic pain on
Fixation Method lifting activities. The
initial approach is conser-
Different fixation methods are available. Tradi- vative with activity
modification, application of
tionally transosseous tunnels were used, but a brace and anti-inflammatory
medication. If
newer devices have made the fixation easier. resistant, surgical
debridement of the degenera-
These include suture anchors, EndoButton and tive tendon (usually the
distal 1 cm of the tendon)
interference screws. Numerous in-vitro studies with an acute anatomical
repair will usually
have compared the ultimate tensile strength of improve the symptoms [42].
these methods both under single load and cyclic
testing. The strongest fixation method (in-vitro)
both after cyclic and single load is the Post-Operative Care and
EndoButton followed by suture anchors. Interfer- Rehabilitation
ence screws are the weakest [8].
Re-rupture after surgery is
rarely reported. The
Chronic Cases trend is for early active
mobilisation in the
This poses the additional problem of tendon immediate post-operative
period. A sling for
retraction. The options available are anatomical 12 days followed by active
mobilisation, and
repair, reconstruction of the tendon using a graft encouragement to use the
elbow for activities of
and tenodesis of the biceps to the brachialis daily living has been tried.
The weight limit
tendon. For an anatomical repair, the bicipital recommended is a maximum of
1-lb for the
aponeurosis should be released and the tendon first 6 weeks with a 2-lb for
the second 6 weeks
freed from scarring to brachialis. Then the progressing to free weights
by 3 months.
musculotendinous unit should be lengthened No formal physiotherapy is
recommended and
through cutting the epimysium and application the range of movement is
reported to be
of tensile force for a period of time. Only then if excellent [9].
the tendon can be pulled down to the radial
tuberosity can a repair be achieved using the
above-mentioned fixation methods. The out- Complications
come is not as good as an acute repair [39].
Another method is to employ a tendon graft, The overall complication rate
following surgical
such as an Achilles tendon allograft or fascia repair is just under 20 %.
Traditionally radio-
lata, semitendinosus or flexor carpi radialis auto- ulnar synostosis has been the
commonest and
grafts to reconstruct the tendon. This approach most disabling adverse
outcome following the
has the advantage of sparing the need for a repair two-incision technique with a
rate of 9 %. As
under tension but has potential disadvantages, previously mentioned, making
the incision away
i.e. theoretical risk of disease transmission from the subcutaneous border
of the ulna and
using an allograft or donor side morbidity in a minimal anconeus dissection
has reduced this
the case of autograft. The outcome again is not rate. Transient or permanent
nerve palsies are the
as good as an acute repair but comparable to most common complication
after single incision
chronic repairs [12]. A simplified solution here techniques (12 %), but newer
fixation methods
is tenodesis of the distal biceps to the brachialis have made the repair easier
with less dissection
tendon. The technique is easier and less compli- necessary reducing this risk
to 7 %. The risk of
cated and should achieve a good flexion heterotopic ossification is
36 %, infection less
1360
than 2 % and elbow contracture 1 %. The only pure avulsions [1]. A review
of the English
difference observed between the two surgical literature has shown less
than 50 reported
techniques is a higher risk of radio-ulnar synos- cases [30]. It is more
common in middle-age
tosis in the two-incision method [8]. Re-rupture men [41] and although very
rare, cases in skel-
rarely occurs. etally-immature patients
have also been
reported [24].
Outcome
Aetiology
Combining the subjective and objective assess-
ments, two-thirds of patients have a satisfactory The failure of the tendon
occurs as a result of
outcome following a two-incision exposure. The an eccentric load applied to
a contracting
remaining third are unsatisfied due to a lack of triceps. A weak tendon is
more prone to failure
forearm rotation or weakness. In the single- even under physiologic load.
The association
incision group 94 % are satisfied and the of triceps rupture with
hyperparathyroidism,
remaining 6 % again complain of loss of forearm renal osteodystrophy,
diabetes, chronic acidosis
rotation and weakness. The odds ratio of an and collagenopathies such as
Marfans syn-
unsatisfactory outcome after the two-incision drome and osteogenesis
imperfecta has been
method is 7.6 [8]. Once subjectively assessed reported [43].
(using the DASH score), the score is as good as
the normal population both with single [27] and
two-incision [20] techniques. Classification
Triceps ruptures are broadly

classified into com-
Summary plete and partial. Partial
ruptures are difficult to
differentiate from a triceps
sprain. An MRI scan
Rupture of the distal biceps tendon is mostly seen is valuable in establishing
the diagnosis. In partial
in male athletes involved in weight-lifting and ruptures, on sagittal images
a partial discontinu-
manual workers doing heavy activities. Non- ity of the tendon is
observed. The gap is usually
operative management is an option for patients filled in with a high
intensity signal indicating the
with a more sedentary life style. Acute anatomi- presence of a haematoma
[25]. In sprains the
cal repair gives the best outcome, specifically in triceps tendon can be
followed throughout its
competitive athletes however it is still possible to length on all slices.
repair or reconstruct the chronically ruptured ten-
don if indicated. Partial ruptures if not responsive
to conservative management can be treated with Anatomy
excision of the degenerate tendon and an acute
anatomical repair. Triceps brachii consists of
three heads. Distally
the aponeurosis covers the
muscle. The raphe
is located in the middle of
the muscle. The
Distal Triceps Avulsion tendon has a broad
attachment to the olecranon
with an average surface area
of 466 (#79) mm2
Introduction [45]. Although
macroscopically the tendon
appears to be a single
structure, different areas
Distal triceps avulsions are rare. Out of 1,014 serve different heads. The
maximum force
cases of tendon injury observed by Anzel produced by each head
differs and depends on
et al. only eight involved the distal triceps, the position of the elbow.
The medial head pro-
half of which were penetrating injuries not duces its maximum strength
at 3040# of elbow
1361
flexion and the long and lateral heads at Imaging

90100# [21]. In half of the cases the medial
triceps has a separate tendinous footprint deeper Plain lateral radiographs
sometimes show a small
to the conjoined tendon of the lateral and the fleck of bone detached from
the olecranon indi-
long heads [2]. The innervation is through cating an avulsion of the
tendon [16]. An MRI
the radial nerve, which is covered by the three scan is perhaps the most
accurate investigation
heads. available and will show the
detailed anatomy of
the triceps attachment. It
is specifically useful in
differentiating partial and
complete ruptures (on
Mechanism sagittal slices, Fig. 2).
In addition tendon retrac-
tion can be readily
measured [25]. An ultrasound
Traumatic avulsions are mainly seen either fol- scan is more accessible and
more cost-effective
lowing a fall on the semi-flexed elbow, when providing an experienced
operator is available
eccentric load causes the avulsion, or as a result to report the scans. A
haematoma and
of a direct blow to the posterior elbow [16]. They a disrupted tendon can be
identified indicating
may also occur in association with other injuries a distal tendon avulsion
[13].
such as a distal radius or radial head fracture [16].
In the background of generalized tendinopathy
(patients with chronic renal insufficiency or Indications for Surgery
those suffering from hyperparathyroidism for
instance), triceps avulsion can happen after Clinical differentiation of
partial ruptures and
a trivial trauma [16]. sprains can be difficult.
Initial management
involves activity
modification and analgaesics.
If improvement is not
observed, a diagnosis of
Diagnosis a non-healing partial
rupture is made which
requires surgical
treatment. If improvement is
The history usually reveals a direct fall onto the observed, then perhaps the
initial injury sustained
outstretched arm or less commonly a direct blow was a sprain [30].
to the elbow. This is followed by pain and swell- Unless the general
health of the patient contra-
ing on the dorsum of the elbow. Clinical exam- indicates, surgical repair
of a complete triceps
ination can sometimes highlight a gap in rupture is advised.
between the olecranon and the proximally
retracted tendon. The gap is filled with
haematoma and if acutely presenting, is tender Operative Technique
to touch. The integrity of the extensor mecha-
nism needs to be checked against gravity, other- The aim is to re-attach the
tendon to the olecranon
wise an inexperienced examiner can be tricked with a strong non-
absorbable suture. Early direct
by the ability of the patient to extend the elbow repair is preferable as
late repair is more difficult
using an intact anconeus assisted by gravity. or often impossible [22]. A
running-locked stitch
Both sides should be tested and compared is placed in the tendon
which is then attached to
if subtle weakness is not to be missed. These bone via crossed olecranon
tunnels [30].
injuries are usually missed and are sub-acutely A recent cadaveric study
has highlighted the
or chronically presenting due to an inadequate superiority of the fixation
strength of an anatom-
full initial physical examination [41]. ical repair. This study
compared three different
A modification of the Achilles tendon Thomp- fixation methods: The
anatomical repair using
son test is described which shows no extension 3 mm press-fit bio-
absorbable anchors, 4.5 mm
of the elbow if disruption of the tendon is metal anchors and the
traditional trans-osseus cru-
complete [44]. ciate repair [45]. In
chronic cases due to muscle
1362
Fig. 2 Sagittal MRI scans of three elbows showing triceps enthesitis (left),
partial rupture with limited retraction of the
tendon (centre) and complete rupture with full retraction (right)
shortening and retraction of the tendon, tendon Summary

reconstruction is a more reliable method of restor-
ing the extensor mechanism. An anconeus rotation Distal triceps
tendon avulsions are rare injuries. If
flap is an option providing the defect is small. completely
disrupted, and medically not contra-
Tendon allograft (Achilles tendon) can be used if indicated, the
treatment of choice is acute ana-
the defect is large or anconeus is devitalised [36]. tomical re-
attachment to restore triceps function.
Other methods using autograft hamstring tendon, The reported outcome
is universally good with
forearm fascial flap and ligament augmentation a high rate of
patient satisfaction.
devices have also been described [43].
Post-Operative Care and References

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Epicondylitis, Lateral and
Medial;
Biceps and Triceps Tendonitis
Taco Gosens
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1365
Biceps and triceps tendonitis # Elbow #
Epidemilogy and Incidence . . . . . . . . . . . . . . . . . . . . . . . . 1365

Epicondylitis-lateral and medial
Background and Aetiology . . . . . . . . . . . . . . . . . . . . . . . 1366
Clinical Presentation, Investigation and
Introduction
Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1367
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1367
Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1367 Epidemilogy and Incidence
Treatment Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1368
Surgical Techniques and Rehabilitation . . . . . . . . 1369
In continental Europe, the name lateral
Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1371 epicondylitis is often used for a painful condition
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1371 affecting the lateral side of the elbow, more
specifically, the origin of the extensors of the

Complications of Treatment . . . . . . . . . . . . . . . . . . . . . 1375
wrist. It was first described by Runge in 1873 as

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1377 Schreibers Krampfes (writers cramps), but the
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1378 name used in the English literature was lawn
tennis elbow, coined by Morris in 1882 [1, 2].
Initially seen as an occupational disease and,
actually mostly, not in tennis players, treatment
was focused on changing habits and methods to
properly determine racket grip diameter.
Overuse, especially repetitive forearm activity
and wrist extension, leads to the development of

tendinosis and the formation of granulation tissue
in an attempt to repair the damaged extensor
tendon origin. More recently more and more lit-
erature is focusing on the condition being a
degenerative tendinopathy of the extensors of
the wrist [35].
Although lateral epicondylitis is a very com-
mon problem, actually the most common prob-
lem of the elbow, knowledge about the annual

T. Gosens
St. Elisabeth Hospital Tilburg, Tilburg, The Netherlands
incidence and prevalence rates is limited and
e-mail: t.gosens@elisabeth.nl
outdated. The incidence of lateral epicondylitis

1365
DOI 10.1007/978-3-642-34746-7_64, # EFORT 2014
1366
T. Gosens
in the general population is reported to be 0.6 % These findings do not

directly connect the pain
[6] and 9 % in tennis players [7]. to the lateral
epicondylitis, but they do explain
Prevalencies are between 1 % and 3 % in the the excellent early
results of corticosteroid injec-
general population [8] and 14 % in tennis players tions into the common
extensor tendon origin
depending on the age [7]. One might suspect that although this tendon does
not contain signs of
the computerisation of society has contributed acute inflammation. The
fact that in quite
to a rise of these rates. a substantial number of
so-called tennis elbow
Auto industry workers have a prevalence of up cases intra-articular
abnormalities were noted
to 16 % [9]. (1169 %) such as
synovial plicae or synovitis
Cost and time away from job or activity are or even lateral cartilage
degeneration, may be
significant [10, 11]. another explanation for
lateral elbow pain and is
In this chapter the lateral epicondylitis is mainly used by the proponents
for arthroscopic therapy
discussed because of the great amount of literature of lateral epicondylitis
[4, 1517].
on that subject. The medial and the posterior tennis The usual age at
onset of lateral epicondylitis
elbow are not often separately discussed in the is between 35 and 50
years, with an equal distri-
literature, but usually as attachments to papers on bution between males and
females. Symptoms
lateral tennis elbow. Although the anatomy and are usually more present
in the dominant arm.
therefore the approach will differ, my focus is Overuse is mentioned as
the most common
on lateral epicondylitis, but where appropriate and cause, but also traumatic
and constitutional
necessary additional remarks on medial and factors can play a role
and mechanical, vascular
posterior elbow complaints will be made. and neural aetiological
models have each been
proposed [18].
Nowadays the emphasis
is more on the
Background and Aetiology degeneration of tendon
tissue as the principle
cause with subsequent
tendinous micro-tearing
The lateral humeral epicondyle is the origin and the failed attempt to
repair or at least an
of the anconeus muscle on its posterior surface, incomplete reparative
response. Traditionally
and of the extensor carpi radialis brevis (ECRB) we are taught that
symptoms will get better with
and the extensor digitorum communis (EDC) time: approximately 80 %
of patients with newly-
on the anterior surface. The extensor carpi diagnosed lateral
epicondylitis report symptom-
radialis longus (ECRL) and the brachioradialis atic improvement at 1
year [1922].
have a more proximal origin on the anterior A small number of
residual symptoms is
aspect of the supracondylar ridge. The common however usual, but only
411 % of patients
extensor origin consists of the ECRB and the seek further medical
treatment and surgical
EDC. The degeneration of the tendon usually intervention [4, 19, 20,
23, 24].
occurs on the more superior and deeper fibres, Poor prognostic
factors in obtaining a success
i.e. the articular side of the common extensor with non-surgical
treatment were identified by
tendon. Haahr and Andersen:
manual labour, dominant
There is much dispute about the origin of pain arm involvement, long
duration of symptoms
in lateral epicondylitis. It is therefore likely to be with high base-line pain
levels and poor coping
multi-factorial. The existence of free nerve end- mechanisms [20].
ings in the aponeurosis and granulation tissue Shiri et al.
described the risk factors for lateral
around the lateral epicondyle was shown by and medial epicondylitis.
Smoking or former
Goldie et al. and biochemical analysis showed smoking behaviour was
the presence of substance P receptors within the both lateral and medial
epicondylitis in their
extensor origin and increased levels of the excit- study in 4.783 patients
in Finland. Also physical
atory neurotransmitter glutamate in patients with load factors, smoking,
and obesity are strong
epicondylitis lateralis [1214]. determinants of
epicondylitis [25].
Epicondylitis, Lateral and Medial; Biceps and Triceps Tendonitis
1367
Medial tendinopathy, but especially triceps elbow extended provokes

the pain. Most of the
tendinopathy, are under-represented in the litera- time no redness,
swelling or oedema is present. In
ture. Medial epicondylitis is much rarer than its patients with lateral
elbow pain differential diag-
lateral counterpart, the latter occurring 720 noses should be
considered such as to radial nerve
times more frequently [26]. entrapment, intra-
articular abnormalities and cer-
Concerning the background and aetiology of vical osteoarthritis and
nerve root compression.
the medial and posterior tendinopathy, many par- In cases of radial nerve
impingement (radial tun-
allels are present: primarily occurring in the nel syndrome) in
Frohses arcade (created by the
fourth and fifth decades of life, equal male and supinator muscle), pain
is usually concentrated
female prevalence rates and the initial aetiology more distally in the
mobile wad and resisted
explained by overuse, hence the name extension may not be
painful, whereas resisted
golferselbow. Also in the flexor-pronator ori- extension of the thumb
and the index finger may
gin at the medial epicondyle macroscopic tearing be. Also resisted
forearm supination may be pain-
was noted in 100 % of the cases that underwent ful, something usually
not the case in patients
surgical treatment for recalcitrant medial with lateral
epicondylitis. In 5 % of patients
epicondylitis [27]. both problems are co-
existing [28].
The triceps insertion on the olecranon and its In 16 patients with a
supposedly radial tunnel
tendonitis are more and more discussed with syndrome the compression
on the posterior
reference to the anatomy (being a separate foot- interosseus nerve was
not visible on EMG in 14
print insertion for the medial and lateral triceps of them. Verhaar et al.
concluded that these data
and its re-insertion in case of a rupture). The did not support the
hypothesis that the signs and
degenerative aspect of this lesion is not described symptoms of the majority
of cases diagnosed as
in the literature. For further discussion of the radial tunnel syndrome
are caused by compres-
ruptures of the triceps tendon the reader is sion of the posterior
interosseous nerve [29].
referred to the chapter on ruptures of triceps and Intra-articular
abnormalities are suggested by
biceps tendons. painful clicking at
terminal extension and fore
arm supination, but also
maximal tenderness sit-
uated more posteriorly
over the posterior radio-
Clinical Presentation, Investigation capitellar joint. These
may actually also be the
and Treatment Options symptoms of
posterolateral rotatory instability.
Lateral tennis elbow
is thus seen in patients
Presentation with repetitive stress
to the extensors of the wrist
and fingers and possibly
the supinator muscles.
Pain in the lateral side of the elbow is exacerbated On the other hand,
medial tennis elbow (or
by activities involving active wrist extension or golfers elbow)
characteristically occurs with
passive wrist flexion with the elbow extended, wrist flexor activity
and active pronation and the
when holding items such as a coffee cup. The posterior tennis elbow
might logically be based
diagnosis is made by clinical symptoms and on the development of
tendinosis of the triceps
signs, which are usually both discrete and attachment in patients
with repetitive elbow
characteristic. There should be point tenderness extension movements,
although theliterature is
over the origin of the extensor carpi radialis not conclusive on this.
brevis muscle from the lateral epicondyle
(ECRB origin). There is also pain with passive
wrist flexion and also with resisted wrist exten- Investigation
sion (Cozen test), both tested with the elbow
extended. Pain is less with the elbow flexed. Lateral and medial
epicondylitis is a clinical
Also Mills manoeuvre is used in the diagnosis: diagnosis, but
additional information may be
flexion of the wrist with the fingers fisted and gained by use of
additional investigations.
1368
T. Gosens
Radiographic examination can reveal small cal- Boyer and Hastings

called in 1999 for
cifications over the lateral epicondyle of the evidence in treating the
tennis elbow: An
humerus as a sign of calcifying tendinopathy, examination of the
literature can only lead us
similar to the shoulder. Nirschl reported to believe that most, if
not all, common
2225 % of these calcifications [4]. Usually how- non-operative therapeutic
modalities used for
ever, the radiographs are normal. In medial the treatment of tennis
elbow are unproven
epicondylitis traction spurs or calcifications of at best or costly and time-
consuming at
the medial collateral ligament, especially in the worst. Most of the
published literature on the
throwing athlete can occur, but these should not non-operative treatment of
patients with lateral
be mistaken for intratendinous calcifications, tennis elbow consists of
poorly designed trials.
such as may occur laterally and posteriorly. The selection criteria are
nebulous, the control
Tendinopathy of the extensors of the wrist can group is questionably
designed, and the number
be visualised by sonography or MRI, the latter of patients is often too
low to avoid a serious loss
being more expensive, the former being more of study power. These
studies therefore have
operator-dependent. Ultrasound investigation visu- a high beta error, implying
an inability to detect
alises focal hypo-echoic areas and intra-substance a difference between
groups, even if one truly
tears, as well as peri-tendinous fluid and thickening existed. If clinical signs
and symptoms persist
of the common extensor tendon [30]. beyond the limit of
acceptability of both patient
Sensitivity is reported to be 6488 % for eval- and surgeon, then an array
of surgical options
uation of the common extensor origin architec- are available. These range
from a 10-minute
ture, but specificity is quite variable (36100 %), office procedure (the
percutaneous release of
depending on the study [31, 32]. the extensor origin with
the patient under local
MRI can be used for the investigation of anesthetic) to an extensive
joint denervation, in
suspected intra-articular abnormalities, the integ- which all radial nerve
branches ramifying to the
rity of the radial ligament complex, apart from lateral epicondyle are
directly or indirectly
the extent of tear or disease in the common exten- divided. How is the surgeon
to choose, given the
sor tendon. In 90 % of the patients oedema is fact that most of the
published surgical studies
present in the tendon, but on the other hand this are case series of one type
of operation or
oedema is reported to be present in 1454 % of another, consisting of
patients operated on and
asymptomatic patients. Also the increased T2 evaluated by the same?
[37].
signal may persist for weeks after the symptoms In 2007 Cowan et al.
repeated this cry for good
have resolved [3336]. clinical research in the
treatment of lateral
The relationship between the ultrasound or epicondylitis [38]. Very
few progress has thus
MRI appearance and the clinical signs such as be obtained in almost 10
years!
pain and/or function is therefore not present in Therefore a spectrum of
treatments is
lateral epicondylitis. In medial and posterior presented here knowing that
actually no strong
elbow tendinopathy no literature is available on evidence exists for most.
Most of the palliative
this subject. treatments aim at
diminishing the symptoms
of inflammation: the use of
non-steroidal anti-
inflammatory drugs
(NSAIDs), the application
Treatment Methods of heat or ice, the
injection of corticosteroids
and/or an anaesthetic.
Treatment of lateral epicondylitis can be divided In 2006 Bisset et al.
concluded that physiother-
into conservative or operative, but also a division apy combining elbow
manipulation and exercise
into treatments concentrating on diminishing the has a superior benefit to
wait and see in the
inflammation signs, treatments based on biome- first 6 weeks and to
corticosteroid injections
chanical theories and treatments aiming for after 6 weeks, providing a
reasonable alternative
regeneration of tendinopathy can be used. to injections in the mid-
to long- term [39].
1369
The significant short term benefits of corticosteroid that is failing because

of lack of blood flow and
injection are paradoxically reversed after 6 weeks, growth factors. The
rationale for this treatment
with high recurrence rates, implying that this treat- resides in the fact that
numerous growth factors
ment should be used with caution in the manage- exist in the platelets
and that by creating
ment of tennis elbow. a concentrate of these
platelets at the site of the
repetitively-failing
tendon repair mechanism, the
Natural History repair is stimulated.
All other methods of treat-
Comparing all different treatment options one ment mentioned in this
chapter are not biological,
must consider the natural course of lateral are not aiming for
repair but are actually salvage
epicondylitis. Hay [40] described the effects of procedures.
corticosteroid injections, NSAIDs and a placebo Edwards and
Calandruccio [44] reported that
at 4 weeks (resp. 92 %, 57 % and 50 % success after autologous blood
injection therapy
rate) and after 12 months (resp. 84 %, 85 % and 22 patients (79 %) in
whom non-surgical modal-
82 % success rate) in the early treatment, ities had failed were
relieved completely of pain
suggesting a benign natural course. even during strenuous
activity. Mishra and
Supposedly biomechanically active counter- Pavelko [45] described
at final follow-up of
force braces or tennis elbow straps aim to more than 2 years after
injection of buffered
reduce strain at the elbow epicondyle, to limit platelet-rich plasma a
93 % a reduction in pain
pain provocation and to protect against further compared with before
treatment. In both these
damage. Struijs et al. [41] were not able to dem- studies however the
number of patients was too
onstrate a difference in success between patients few to obtain sufficient
power.
treated with physiotherapy, with a brace or with In the Netherlands
we performed a prospec-
a combination of both. tive randomised double-
blind and multi-centered
Other treatments with limited scientific sup- study comparing one
injection of corticosteroids
port include: pulsed ultrasound to break up scar with one injection of
buffered platelet-rich
tissue, promote healing, and increase blood flow plasma in patient with
complaints of lateral
in the area, extra-corporeal shock wave therapy epicondylitis for more
than 6 months (total of
(ESWT), the injection of botulinum toxin, sclero- 110 patients, power
0.9). Successful treatment
therapy, acupuncture and trigger- point therapy. was defined as more than
a 25 % reduction in
Placzek [42] reported on the use and effects of VAS or DASH score
without a re-intervention
botulinum toxin in lateral epicondylitis, and after 1 year. The
results showed that 21 of the
although the results were good at 18 weeks after 55 patients (40 %) in
the corticosteroid group and
injection, no longer term report exists. Also the 38 of the 51 patients
(75 %) in the PRP group
expected side-effect (complication) of decreased were defined as
successful with the VAS score,
wrist and third finger extension remains a concern. which was
significantlydifferent (P < 0001). 23
On the other hand, Keizer et al. [43] compared of the 55 patients (42
%) in the corticosteroid
the operation with an injection with botulinum group and 36 of the 51
patients (71 %) patients
toxin 2 years after treatment: 15 patients in in the PRP group were
defined as successful with
the botulinum toxin group (75 %) had good to the DASH, which was also
significantly different
excellent results, 17 patients in the operative (P < 0003) [46].
group scored good to excellent (85 %). When
analyzed with an overall scoring system, no
differences were found between the two forms Surgical Techniques and
of treatment. Rehabilitation
Platelet-rich plasma injections and the injec-
tion of full blood are treatment options aiming for The surgical techniques
for treating lateral
reversal of tendinopathy, or at least aiming to epicondylitis can be
grouped into three main cat-
assist the natural repair mechanism of the tendon egories: open,
percutaneous, and arthroscopic.
1370
T. Gosens
Frequently-used open procedures are denerva- radio-capitellar joint, while

others focus on the
tion of the lateral epicondyle as described by debridement of the common
extensor origin.
Wilhelm and Gieseler [47, 48] or incision of the Also the inclusion of
decortication of the lateral
extensor tendon (especially ECRB) as described epicondyle is an issue of
debate. Baker et al. [52]
by Hohmann [49]. classified the arthroscopic
appearance of the
A 3 cm incision is made, centred over the capsule in lateral
epicondylitis, reflecting the
origin of the ECRB on the lateral epicondyle local intensity of the
tendinopathic process. In
(just distal from the lateral epicondyle). Sharply type 1 a smooth capsule
without irregularity is
dissecting the subcutaneous tissues one reaches seen. In type 2 a linear or
longitudinal tear in the
the common extensor origin. In line with its fibres capsule can be visualised,
whereas in type 3
this tendon is incised, making the ECRB visible, a ruptured and retracted
capsule with frayed
deep and posterior to the ECRL. The degenera- ECRB is present.
tive tissue in the ECRB (often looking greyish) is Mullett et al. [53]
described the presence of
debrided and the underlying lateral epicondyle is a synovial fringe/collar-like
band of the
cleared of soft tissue. The remaining tendon radiocapitellar capsular
complex impinging on
should be re-attached by using transosseous the radial head in 30
patients with recalcitrant
sutures or anchors. There is debate concerning symptoms of lateral elbow
pain.
the necessity to perform an arthrotomy, the neces- Resection of this fringe
led to a felief of
sity to repair the tendon or lengthen the tendon or symptoms in 28 of 30
patients. Histological exam-
the need to decompress the radial nerve. ination showed hyaline
degeneration and fibrosis.
The post-operative regimen recommended Cadaveric study showed this
same degenerative
varies from direct functional after-treatment capsular fold in 15 of 34
cadavers. A classification
(move as possible, with a gradual return to activ- system was developed: in type
1 the radial head is
ities), to a splint or sling immobilisation for 12 fully exposed without any
capsular impingement
weeks. The commencing of strengthening exer- or coverage throughout range
of motion, whereas
cises is delayed to 6 weeks post-operatively. in type 2 a partial coverage
develops when the
In cases where the surgeon is aiming for elbow is extended. In type 3
there is subluxation
re-attachment of the ECRB it seems logical to of the capsular edge into the
radio-capitellar joint
postpone range of motion and strengthening exer- and in type 4 the radial head
is completely
cises to a later stage of the recovery, where in obscured in both flexion and
extension.
cases with only debridement the activities may be The technique and set-up
for performing
resumed soon after surgery. elbow arthroscopy is also
presented in other
Also other, but scarcely performed, proce- chapters of this book, but it
can be performed
dures should be mentioned, such as the incision with the patient in the
prone, lateral decubitus or
of the extensor tendon in combination with supine position under
regional or general anes-
a partial resection of the annular ligament as thesia. The joint is first
injected with saline (usu-
described by Bosworth [50] and the elongation ally 30 ml) using the radio-
capitellar portal or the
of the extensor tendons by Garden [51]. soft spot to displace the
neurovascular structures
The mini-open or percutaneous approach to anteriorly and away from the
portal sites. The
the tennis elbow is not aiming for repair or proximo-medial portal is used
to introduce the
re-insertion of the ECRB, but is merely a release arthroscope and the anterior
compartment can
of the ECRB from the lateral epicondyle, with or now be visualised. Using a
needle the supero-
without clearing of the lateral epicondyle. lateral portal can now be
made under direct vision
The correct arthroscopic approach to lateral and the motorised shaver can
be introduced. The
epicondylitis is also disputed Some surgeons degenerative capsule and
undersurface of the
prefer to debride the lateral capsule and the ECRB can thus be released
from the lateral
infolded synovial fringe that may impinge in the epicondyle and the epicondyle
can be
1371
Fig. 1 Lipomatosis (upper

arrow) and vascularisation
(lower arrow) inside
degenerative tendon tissue
decorticated using a motorised burr. The amount

of release of the capsule and ECRB should be Outcomes
limited to the line bisecting the radial head as
described by Smith et al. [54]. Recently published long-
term follow up studies
The anatomical study of Cohen et al. [55] of both the arthroscopic
and open methods have
proved that this amount of release: from the demonstrated remarkably
similar outcomes.
top of the capitellum to the mid-line of the It appears that either
surgical technique is accept-
radio-capitellar joint, is in fact the best way to able, as long as the
pathologic tissue is accurately
perform a safe and complete release of the ECRB. identified and
adequately resected. A 2002
Cochrane Collaboration
Database review found
no conclusions could be
drawn regarding the
Rehabilitation efficacy of operative
treatment given the lack of
controlled trials.
Although there are advantages
The rehabilitation after surgery for lateral (and and disadvantages to
each procedure, no tech-
medial) epicondylitis is seldomly reported but nique appears superior
[57].
after open surgery it is common to advise a splint Dunn et al. [58]
reported the long-term results
or sling immobilisation for 10 days. After that, after the open
procedure: results were rated as
range of motion exercises are started and after excellent in 71 elbows,
good in 6 elbows, fair in
6 weeks strengthening is commenced. The reha- 9 elbows, and poor in 6
elbows by the Nirschl
bilitation after arthroscopic release has an acceler- tennis elbow score. By
the criteria of Verhaar
ated schedule with the incorporation of range of et al., the results were
excellent in 45 elbows,
motion exercises within the first few post- good in 32 elbows, fair
in 8 elbows, and poor in
operative days. Some surgeons might even allow 7 elbows. Eighty-four
percent good to excellent
strengthening exercises within the first week if results were achieved
using both scoring systems.
comfortable, whereas others postpone these exer- Ninety-two percent of
the patients reported
cises to 6 weeks post-operatively [56]. normal elbow range of
motion. The overall
1372
T. Gosens
improvement rate was 97 %. Patient satisfaction management were treated with

arthroscopic
averaged 8.9 of 10. Ninety-three percent of those resection of pathologic
tissue. Thirty of these
available at a minimum of 10-year follow-up patients (30 elbows) were
located for extended
reported returning to their sports. follow-up. At a mean follow-
up of 130 months
Baker and Baker [59] reported the long-term the mean pain score at rest
was 0; with activities
results of arthroscopic tennis elbow release. Forty of daily living, 1.0; and
with work or sports, 1.9.
patients (42 elbows) with lateral epicondylitis The mean functional score was
11.7 out of
who had not responded to non-operative a possible 12 points. No
patient required further
b c
Fig. 2 (continued)
1373
Fig. 2 MRI showing the various tendinopathies of the bicipital tendinopathy

at the insertion on the radial tuber-
elbow (a) Pre- and 6 months post-injection with PRP in osity (d) intra-
tendinous irregularities of the triceps
lateral epicondylitis (b) medial epicondylitis (c) distal tendon
surgery or repeat injections after surgery. One methods are a highly

effective way to treat this
patient continued to wear a counterforce brace common elbow problem.
with heavy activities. Twenty-three patients Another
retrospective comparative study
(77 %) stated they were much better, six between open and
arthroscopic procedures was
patients (20 %) stated they were better, and performed by Peart et
al. [56]. At 6 months no
one patient (3 %) stated he was the same. significant difference
was seen with nearly 70 %
Twenty-six patients (87 %) were satisfied, and good or excellent
outcomes, with patients returning
28 patients (93 %) stated they would have the to work earlier after
arthroscopic lateral release.
surgery again if needed. No prospective
comparison is reported for
Szabo et al. [60] performed a retrospective open versus
arthroscopic lateral release but
evaluation of three methods of operative treat- Dunkow et al. [61]
conducted the only prospec-
ment. He compared the results in open, arthro- tive, randomised,
controlled trial on surgery for
scopic and percutaneous cases and found no lateral epicondylitis
in literature. They compared
difference in pre-operative parameters such as 45 patients (47
elbows), comparing a formal open
age, gender, dominance, conservative measures release or a
percutaneous tenotomy. Those
used, cortisone injections or pre-operative patients undergoing a
percutaneous release
Andrews-Carson scores. Also no differences returned to work on
average 3 weeks earlier and
were found at follow-up (minimum of 2 years) improved significantly
more quickly than those
in recurrences, complications, failures, Visual undergoing an open
procedure. Unfortunately the
Analogue Scales for pain and post-operative groups were not
compared on the outcome, so no
Andrews-Carson scores. It seems that all three conclusion can be
drawn.
1374
T. Gosens
80
CS PRP
70
60
50
40
30
20
10
0
VASincl VAS4wks VAS8wks VAS12wks
VAS6mnth VAS1yr
Fig. 3 VAS scores comparing the time-dependent behaviour of an injection of

corticosteroid versus platelet-rich
plasma
Lo and Safran [62] performed an excellent arm. Direct comparison of

the three methods are
systematic review in 2007 on the surgical treat- thus impossible, according
to Lo and Safran, but
ment of lateral epicondylitis. They compared the most of the results are a
strength of at least 90 %
studies concerning the arthroscopic, percutane- of the opposite side and
all methods seem to do
ous and open release of the extensors form the well.
lateral epicondyle for important items such as The overall result is
good in all methods and
time to return to work, strength and overall func- thus again no answer on
what to do can be dis-
tion after surgical treatment. tilled from this
systematic review. They also
In most publications the time to work issue is remarked that few studies
were actually
not addressed but if it is then they do not distin- performed to the post-
operative treatment and
guish manual labour from desk occupations or that this lack of
knowledge again leads to an
full-time, part-time or modified. They concluded open end in the discussion
what is the best treat-
that comparison of time to work is not possible ment of lateral
epicondylitis.
between the three operative methods with the Thus the operative
ways to treat lateral
available data. The commonly-made claim that epicondylitis result in
just over 80 % successful
arthroscopic or percutaneous surgery leads to results at the long-term
follow-up, the corticoste-
a more rapid recovery is therefore not based on roid injections only have
good results at the short-
evidence, although the trend can be seen towards term follow-up, the long
term results of the
reducing time to work time in arthroscopic biological ways to treat
lateral elbow tendinosis
procedures. are to be awaited but look
promising on the
Concerning the strength after surgery it is also 1-year follow-up (70 %).
When judging the suc-
difficult to decide what method leads to better cess rates from the
various literature citations one
results, since numerous ways to monitor strength must be aware that the
were used and all methods have their disadvan- options such as wait and
see, physiotherapy
tages: comparison with the contra-lateral arm and corticosteroid
injections are used in those
will differ depending on whether the injured patients with acute to
subacute symptoms, and
arm is the dominant arm since the dominant arm that the biological
treatment and the operative
is usually stronger so an equal strength after sur- techniques are used in
patients with chronic com-
gery can mean a loss of strength of the dominant plaints or refractory
lateral epicondylitis.
1375
a b
Fig. 4 Arthroscopic view showing the outside-in tech- needle in position (c)
after shaving away the
nique for resection of the capsule and the origin of the capsule ECRB visible
(d) decortication of the lateral
ECRB from the lateral epicondyle (a) drawing of the anat- epicondyle
omy preceeding arthroscopic tennis elbow release (b)
corticosteroids. Apart
from the virtually
Complications of Treatment non-existing effects on
the longer term of
corticosteroids,
lipodystrophia at the site of
Complications arising from the conservative injection should not
remain unmentioned. This
treatment of lateral and medial epicondylitis in fact can lead to a
bony prominence from
concentrate on the adverse effects of patients perspective,
but it can also be
1376
T. Gosens
explained by the disappearance of the subcuta- Also neuromata of the

posterior interosseous
neous fat surrounding the lateral epicondyle. nerve can be a source of
persistent post-operative
In the treatment with botulinum toxin, a non- pain and paraesthesia and
dysaesthesia distal to
surprising but very invalidating palsy of the the incision. This can be
diagnosed with a local
wrist extensors occurs during 6 weeks to anaesthetic block and can be
treated with the
3 months [42]. excision of the neuroma and
intramuscular trans-
Excessive debridement of the lateral side of position of the proximal nerve
stump.
the elbow may result in compromise of the lat- As an adjunct for chronic or
recurrent cases,
eral ligamentous complex producing iatrogenic the anconeus flap technique has
been used to
posterolateral elbow instability. This is an provide coverage. Indications
for this flap tech-
important item in both open and arthroscopic nique include post-operative
symptom recur-
lateral release. By adhering to the rules pointed rence, draining fistula and
infection. It may also
out by Smith et al. this complication can be be used to close the tissues in
case of wide resec-
prevented [54]. tion of the extensor origin
[63, 64].
Fig. 5 (continued)
1377
almost no evidenced-
based treatment is present
Conclusions for this, many possible
treatments are described,
varying from wait and
see, physiotherapy, all
Despite the commonly-used words lateral and sorts of injectables, to
surgery (Figs. 15).
medial epicondylitis, there is actually no sign of For the acute
complaints of lateral and
inflammation. We as Orthopaedic surgeons are medial epicondylitis the
wait-and-see policy
looking at the attempts of the human body to seems without doubt, but
for the recalcitrant
repair degenerative tendon disease. Although painful elbow the
biological treatment with
Fig. 5 (continued)
1378
T. Gosens
Fig. 5 Sequence of intra-operative photographs showing CEO and the joint

exposed (d) performing a decortication
open tennis elbow release (a) drawing of the incision (b) of the lateral
epicondyle (e) re-insertion of the CEO on the
pointing out the common extensor origin (CEO) (c) the decorticated lateral
epicondyle
either slowing down the repair mechanism microscopy studies.

J Bone Joint Surg. 1999;
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Acute and Chronic
Ligamentous
Injury of the Elbow
David Cloke and David

Stanley
Contents
Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1381
Acute and chronic # Aetiology # Diagnosis #
Elbow # Imaging # Ligament injuries # Patho-

Anatomy and Pathophysiology . . . . . . . . . . . . . . . . . . 1382
physiology # Rehabilitation # Stress tests # Sur-

Aetiology of Elbow Ligament Injury . . . . . . . . . . . .
1383 gical techniques-medial reconstruction, lateral
Traumatic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1383 reconstruction
Iatrogenic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 1384
Chronic Attrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1384
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1384
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 1384
Introduction
Examination Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1385
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1387 Tremendous advances have been made in recent
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1387 years in understanding the aetiology and mechan-
Simple
Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1387 ics of elbow instability, and also in its operative
Acute Ligament Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1387 and non-operative management.
Chronic Ligament Injury . . . . . . . . . . . . . . . . . . . . . . . . . . .
1388 Whilst both the osseous and ligamentous
Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1391
structures are of great importance in elbow sta-

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1391 bility, and some mention of the bony contribution
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1392 to the pathology of instability is both inevitable
and desirable, this chapter will deal primarily

with ligamentous injury and its management.
It should be noted that, whilst injury to both
medial and lateral ligament complexes may occur
in acute trauma, symptomatic deficiency of the
medial ulnar collateral ligament (MUCL) is com-
mon in overhead throwing athletes, in whom it may
occur as an acute or overuse injury, and on whom
much of the available evidence is based. However,

D. Cloke (*)
lateral ligament complex instability is more fre-
Department of Orthopaedics, Freeman Hospital, High
quently a result of a single traumatic event, and
Heaton, Newcastle-upon-Tyne, UK
more often symptomatic in non-sporting individ-
e-mail: clokes@talktalk.net
uals due to the forces imposed upon the elbow in

D. Stanley
daily activities. Whilst medial ligament injury usu-
Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
ally produces pain or instability to valgus load
e-mail: stanley@sth.nhs.uk
(unusual in normal daily activities), lateral

1381
DOI 10.1007/978-3-642-34746-7_229, # EFORT 2014
1382
D. Cloke and D. Stanley
Fig. 1 The medial

collateral ligament
complex (From The Elbow
and Its Disorders by BF
Morrey & J Sanchez-
Sotelo, 4th Edition,
Saunders 2009, Chapter 2
page 21, Fig 2-25, by kind
permission) Anterior bundle
Posterior bundle
Transverse ligament
complex injury produces the posterolateral rota- anconeus providing a

compressive force to the
tory instability (PLRI) phenomenon: such forces joint in active motion, and
the common extensor
are common in daily activities, and hence this and flexor origins provide
secondary dynamic
injury is more commonly symptomatic. stability [1, 2]. These
factors have a role in reha-
bilitation following injury
or after surgery. Both
medial and lateral muscle
groups have been
Anatomy and Pathophysiology suggested as passive
stabilisers, the contribution
of the medial group being
most marked in supi-
The elbow is inherently stable due to its congru- nation, and lateral in
pronation, due to increased
ent osseous anatomy, and must resist loads in all passive tension [3, 4].
planes including rotation. Stabilising factors have The anterior bundle of the
MUCL has been
been divided into primary and secondary, and suggested as the primary
restraint to valgus and
static and dynamic. internal rotation [5]. More
recently the contribu-
Primary static restraints consist of the tion of the posterior bundle
has also been shown
ulnohumeral articulation (including the anterior to be important [6]. Medial
ligament injury is
capsule in extension), the MUCL (Fig. 1) (pre- usually evidenced by pain or
instability to valgus
dominantly the anterior bundle, with the posterior stress. Varus posteromedial
rotatory instability
and transverse bundles), and the lateral ligament (PMRI) has been described [7,
8] but is not an
complex (predominantly the lateral ulnar collat- analogue of PLRI it occurs
in the setting of
eral ligament (LUCL, Fig. 2), with the radial a coronoid fracture with
lateral ligament injury,
collateral ligament and annular ligament). Sec- and will be discussed
elsewhere.
ondary static restraint (to valgus) is provided by Flexor carpi ulnaris and
flexor digitorum
the radiohumeral articulation. Primary dynamic superficialis have been
suggested as the main
stabilisers consist of the triceps, brachialis and dynamic stabilisers to valgus
load [9, 10], which
Acute and Chronic Ligamentous Injury of the Elbow
1383
Fig. 2 The lateral

collateral ligament
complex (From The Elbow
Morrey & J Sanchez-
page 22, Fig 2-28, by kind Annular ligament
permission) Accessory
collateral ligament
Radial
collateral
ligament
Lateral ulnar collateral ligament
provide a potential for focussed rehabilitation, and observational work has

also demonstrated injury
this must be borne in mind in surgical approaches. to the medial ligament
in dislocation, [20].
Whilst the LUCL has generally been Although valgus
instability after dislocation is
suggested as the predominant stabiliser to pos- generally thought to be
rare [21], long term
terolateral rotation [11, 12], cadaveric studies follow up has suggested
a high incidence of
have suggested the importance of both the persistent valgus
instability in association with
LUCL and the radial collateral components of degenerative change
[22].
the lateral complex, as well as the extensor mus- More recently it has
been suggested that dam-
cle mass [1315] and the annular ligament. The age to the lateral
ligament complex plays a role in
function of the radial head as a secondary stabi- the initial stages of
posterior elbow dislocation,
liser is noted particularly if there is laxity of the giving rise to
posterolateral rotatory instability
lateral ligament complex. In this situation it is [23], Fig. 3. In a group
of elbow dislocations
important to perform a lateral ligament repair/ (both simple and
complex), McKee [24] noted
reconstruction together with radial head replace- disruption of the LCL in
all patients. Avulsion
ment if this has been excised [16]. from the distal humerus
was the most common
pattern, followed by
midsubstance rupture. Ulnar
detachment or bony
avulsion was rarely seen.
Aetiology of Elbow Ligament Injury Disruption of the common
extensor origin
(a secondary constraint)
was seen in 66 % of
Traumatic cases. It has been noted
in cadaveric work that
the medial ligament may
provide a final barrier to
Both medial and lateral ligamentous complexes complete dislocation in
an external rotation
may be damaged by trauma. Initial work on mechanism [25].
traumatic elbow instability suggested that Medial ligament
disruption may occur as an
damage to the medial ligaments was a major isolated traumatic event
in throwing activities, in
cause of ongoing symptoms [1719]. Further which a large valgus
stress is seen at the elbow.
1384
approach to avoid
damage to the lateral ligament
through an
osteotomy of the ulnar attachment has
recently been
described [27]. The diagnosis of
lateral
instability should be considered in all
cases of lateral
pain or apprehension following
a lateral approach
to the elbow.
Chronic Attrition
1 Repetitive
throwing activities can overload the
LUCL 3
MUCL medial ligament
complex. The MUCL has
2 a measured
ultimate tensile strength of 35 Nm
[28], but valgus
torque loads of up to 64 Nm have
been calculated
during a throwing motion, ren-
dering it
vulnerable to overuse injury and failure.
This may present
as medial pain and loss of
throwing power,
and may be associated with
posteromedial pain
as the olecranon becomes
overloaded and
undergoes degenerative
change the
Valgus Extension Overload (VEO)
syndrome.
Fig. 3 (From The Elbow and Its Disorders by BF Chronic
attritional injury to the lateral liga-
Morrey & J Sanchez-Sotelo, 4th Edition, Saunders 2009,
Chapter 28 page 438, Fig 28-4, by kind permission). Soft
ment complex is
rarer, and seen in situations of
tissue injury progresses in a circle-like manner, from lat- chronic varus
stress such as crutch walking.
eral to medial, in three stages. In stage 1, the lateral ulnar A well-recognised
mechanism is cubitus varus
collateral ligament (LUCL) is disrupted. In stage 2, the deformity [2931],
in which there is increased
other lateral ligamentous structures and the anterior and
posterior capsule are disrupted. In stage 3, disruption
mechanical load on
the lateral ligaments, in addi-
of the medial ulnar collateral ligament (MUCL) can be tion to
posterolateral rotatory forces with triceps
partial with disruption of the posterior MUCL only contraction.
Lateral instability has also been
(stage 3A), or complete (stage 3B) described in
association with tennis elbow [32].
These patients present with a pop and medial pain

without radiological evidence of dislocation. Diagnosis
Similarly, an isolated lateral ligament injury
may occur with a varus and posterolateral rota- History
tory force, but below the threshold for
dislocation. In the setting of
an acute injury or dislocation, the
diagnosis should
be suspected from the mecha-
nism of injury.
Greater difficulty is however
Iatrogenic encountered with
chronic instability, especially
in attritional
injury.
Lateral ligament injury in particular may result Regarding the
medial ligaments, acute injury
from overenthusiastic lateral release for tennis may be suspected
from a severe valgus force in
elbow, lateral approaches to the elbow [26], and association with a
pop and loss of throwing
surgical dislocation or subluxation. Care should ability in the
athlete. Lateral injury is more com-
be taken to avoid the humeral attachment of the monly associated
with a fall onto the outstretched
lateral ligament in tennis elbow release. A lateral hand, again
possibly in association with a pop.
1385
It should be noted that acute ligamentous injury is alternative diagnoses should

be considered
not always associated with a radiologically (medial or lateral
epicondylitis). In particular,
proven dislocation. posterior tenderness and
pain may indicate valgus
Chronic injury presents more subtly. It should extension overload.
be suspected in all cases of medial or lateral Specific testing for
valgus instability includes
elbow pain, possibly associated with throwing application of a valgus
force in 20# 30# of flexion
(in medial ligament injury) or loading the (to eliminate the
stabilising effect of the olecra-
elbow. Other symptoms suggestive of ligamen- non), while the medial joint
is palpated for ten-
tous injury include subjective instability (pain or derness and opening. More
subtle signs, without
an inability to push up out of a chair or to perform gross valgus laxity, include
the milking
push-ups), mechanical symptoms (popping, manoeuvre and the moving
valgus stress test
catching or clicking), or frank recurrent disloca- [33], in which a valgus
force is applied by
tion. A history of a significant traumatic event grasping the thumb with the
forearm supinated
should be sought, and enquiry made regarding the while the elbow is flexed
and then quickly
patients management. Previous surgery to the extended a positive test
with medial pain is
elbow must also be documented, particularly if produced between 70# and
120# (Fig. 4).
it paradoxically resulted in a new onset of Varus stress in itself
does not reproduce the
symptoms. forces on the lateral aspect
of the elbow that are
In chronic medial ligament insufficiency in symptomatic in lateral
ligament pathology. The
throwing athletes, there may also be an element posterolateral rotatory
drawer test (Fig. 5a) dem-
of posteromedial pain as the varus extension onstrates pathological
posteolateral subluxation
overload syndrome results in degenerative of the radius and ulna on
the distal humerus: the
change in the posterior compartment. Addition- forearm is forcibly
supinated with the elbow
ally, symptoms of ulnar nerve irritation or injury flexed 45# (with valgus and
axial load), and sub-
should be explored, as they commonly co-exist luxation or apprehension may
be seen.
with medial ligament injury. The posterolateral
rotatory pivot shift test
(Fig. 5b-d) demonstrates
subluxation, but this is
rendered more apparent by
also showing reduc-
Examination Findings tion of the joint with
flexion. With the patient
supine, the arm externally
rotated and the forearm
In general examination of the elbow, sequalae of fully supinated, an axial
and valgus load applied
prior injury and surgery such as scars may pro- with the elbow flexed 20#
may reveal posterolat-
vide clues to the cause of instability. Addition- eral rotatory subluxation.
However, as the elbow
ally, care must be taken to document signs of is flexed there is
progressive subluxation before
generalised ligamentous laxity and connective sudden reduction of the
radial head, with a clunk.
tissue disorder, which can in our experience be Apprehension may however be
the only positive
an occasional cause of failed reconstruction. finding in some patients.
The neurological and vascular status of the Reproduction of symptoms
is a valuable part
limb should also be examined, in particular the of the examination. Medial
ligament symptoms
ulnar nerve must be carefully assessed in valgus may be provoked by throwing,
or the moving
instability. Signs of ulnar nerve instability must valgus stress test. For
posterolateral instability,
be recorded as this can be addressed at the time of loading the elbow with
supination and valgus in
any surgical intervention. slight flexion can be
achieved by pushing up out
Cubitus varus and valgus may be predisposing of an armchair with the
hands in supination. Sim-
factors for instability. Loss of movement may ilarly, performing a push-up
in supination repro-
result from trauma or occur secondary to degen- duces these forces. A
positive test in both is
erative change. Tenderness on palpation may be apprehension as the elbow
reaches near full
found in acute or chronic ligament injury but extension, or there is frank
instability. The test
1386
Fig. 4 (From The Elbow

Morrey & J Sanchez-
page 659, Fig 47-3, by kind
permission). Moving
valgus stress test with
arrows indicate the
examiner applying valgus
stress while moving the
elbow from flexion to
extension
a b
Valgus
Axial
compression
Rotatory
sublyxation
Supination
Supination
Extension
Valgus
Axial compression
Subluxation
c d
Fig. 5 (From The Elbow and Its Disorders by BF (c) demonstrates

the visible subluxation of the radial head,
Morrey & J Sanchez-Sotelo, 4th Edition, Saunders 2009, and (d) the
position the test is undertaken in, with appre-
Chapter 48 page 672, Fig 48-3, by kind permission) The hension of the
patient
posterolateral rotatory drawer (a) and pivot shift tests (b).
1387
may also be performed on a table top, in which [39, 40], but the diagnosis
should be evident
the examiners thumb may be used to stabilise after a thorough history and
examination and
the radial head and relieve apprehension, akin the judicious use of the
described investigations.
to the re-location test in anterior shoulder Arthroscopy may however, be
indicated for asso-
instability [34]. ciated pathology such as
loose bodies.
In a small series, most patients with PLRI were
found to demonstrate apprehension with the chair
and push-up tests awake, but the posterolateral Management
rotatory pivot shift test was only positive in less
than half of conscious patients [35]. Simple Dislocation
As apprehension and resistance may be the
only positive finding in patients with unstable A detailed discussion of
simple and complex
elbows, examination under anaesthesia (EUA) is (with fracture) elbow
dislocation is outside the
useful in patients with apprehension but no scope of this chapter, but
clearly should be men-
grossly positive instability signs. It is the senior tioned as a single traumatic
event is often the
authors practice to carry out an EUA with radio- cause of chronic ligamentous
instability.
graphic real time screening in patients with As discussed, elbow
dislocation is thought to
suspected instability. be most frequently the
result of a posterolateral
rotation, and thus more
commonly involves the
lateral rather than medial
complex [41].
Investigations In the majority of acute
simple dislocations,
after reduction early
mobilisation is advocated.
Plain radiology is necessary to assess signs of The muscular dynamic
stabilisers crossing the
degenerative joint disease and previous trauma elbow provide sufficient
stability while ligamen-
that may influence management. Stress views tous healing takes place.
However, in a subgroup
may be taken for additional evidence of instabil- of cases in which concentric
reduction cannot be
ity, and are of particular value under anaesthesia. maintained though a safe arc
of motion, splintage
Ideally comparison should be made with the con- within the stable range,
ligamentous repair
tralateral elbow. In general, greater than 23 mm. (discussed below) or hinged
external fixation
of opening to valgus or varus stress is consistent may be required. Prolonged
incongruous align-
with collateral ligament injury [36]. The postero- ment may result in
instability and/or early degen-
lateral pivot shift test may also be carried out erative change.
under fluoroscopy to demonstrate subluxation.
Computed tomography is occasionally
required to clarify mal- or non-union from previ- Acute Ligament Injury
ous fractures. Magnetic resonance imaging may
be of use in assessing the ligamentous structures Acute, isolated medial
ligament avulsion may
directly, and with the addition of a Gadolinium occur in throwing athletes.
A recent series has
contrast arthrogram can demonstrate leakage highlighted the common
involvement of the
from the joint in conjunction with capsular injury. flexor pronator mass in this
injury, with proximal
However, MRI is not specific a negative result ligament avulsion. Good
results have been dem-
does not exclude instability. onstrated following acute
repair [42].
Dynamic ultrasound scanning has been Occasionally, as part of
a fracture/dislocation
recently described in assessing medial ligament injury pattern, or more
rarely a simple disloca-
continuity, particularly in throwing athletes tion, ligament repair may be
required. This is
[37, 38]. only usually necessary if
following reduction
Examination via arthroscopy has been early motion of the elbow
cannot be undertaken
described to confirm signs of instability without instability. In this
circumstance the
1388
surgical approach must account for all elements of generalised ligamentous

laxity or connective
of the injury with respect being paid to the tissue disorder, artificial
ligament analogues may
dynamic stabilising structures, i.e., the common be considered.
flexor and extensor origins. A further technical
point in collateral recon-
In the setting of a lateral ligament injury with struction is the
commonly practiced
an unreconstructable radial head fracture, liga- extrasynovial graft
placement. In order to avoid
ment repair without radial head replacement has the exposure of the graft
and bone tunnels to the
been found to sufficiently restore varus and inflammatory mediators
within the synovial fluid
posterolateral rotatory instability in cadaveric it is advisable to repair
the capsule or native
studies [16, 25]. It should however be borne in ligament deep to the
reconstruction.
mind that radial head replacement may be
required for other reasons such as the Essex- Associated Pathology
Lopresti injury. Acute collateral ligament injuries In the setting of post-
traumatic instability, asso-
are most commonly avulsions from the ciated injuries such as
intra-articular non-or mal-
epicondyles or midsubstance injuries [24]. Repair union should be addressed,
along with radial head
is undertaken to restore continuity to bone. reconstruction or
replacement if necessary to
Strong, non-absorbable sutures are used to fash- restore stability. Stiffness
may co-exist with
ion a running locking Krakow suture, which is instability, necessitating
arthrolysis.
then placed through bone tunnels centred at the Distal humeral deformity
may need to be
isometric point (on the medial epicondyle, and addressed, for example in
the case of cubitus
geometric centre of the capitellum laterally). varus with lateral
instability, otherwise the attri-
Alternatively, suture anchors may be used. Care tional force will persist
and place the graft at risk
should be taken to avoid over-tensioning the of failure [29, 30].
repair, especially in the setting of multiple liga-
ment injury or fracture dislocations [4345]. Medial Reconstruction
If insufficient ligamentous tissue remains to In the setting of chronic
valgus instability, non-
enable acute repair, consideration should be operative management should
be initially
given to acute ligamentous reconstruction, as pursued the importance of
the dynamic stabilisers
described below. has been discussed, and good
results (42 % return
to throwing activities) have
been reported [51].
Whilst most authors
advocate reconstruction
Chronic Ligament Injury rather than repair in
chronic medial ligament
deficiency [52], good
results have recently been
Grafts described with repair using
anchors in young
In collateral ligament reconstruction, several patients [53].
donor grafts have been described. The Palmaris Surgical reconstruction
is indicated in symp-
longus tendon is commonly used, but not uncom- tomatic valgus instability
interfering with desired
monly absent this must be assessed pre- sporting activity or daily
tasks. The presence of
operatively. degenerative change is not a
contra-indication,
Alternatives include the gracillis, plantaris and but ligament reconstruction
will not improve
Achilles tendon allografts. Semitendinosis graft symptoms from a degenerative
joint, and may
has recently been biomechanically evaluated worsen them.
[46]. The length advantage of the hamstrings The original description
of medial reconstruc-
has been used to fashion an all-in-one circum- tion by Jobe [54] divided
and reflected the flexor
ferential medial and lateral reconstruction [47]. pronator mass. However most
current techniques
Harvesting a strip of ipsilateral triceps fascia split the muscle mass to
reduce morbidity [55].
has also been successful [4850], and is the The ulnar nerve must be
mobilise from its bed, and
authors preferred current practice. In the setting protected throughout the
operation. The tendon
1389
Fig. 6 (From The Elbow

Morrey & J Sanchez-
Saunders 2009, Chapter 47 Ulnohumeral
gapping Humeral tunnel
page 662, Fig. 47-7, by kind
permission) Schematic of
the medial bone tunnel
placements
Medial
epicondyle
Ulnar
Ulnar tunnel
nerve
graft is passed through a bony tunnel at the sub-

lime tubercle of the ulna, then through tunnels
placed anteriorly and posteriorly commencing at
the isometric point of the humerus on the
Blind ended
epicondyle (Fig. 6). In common with lateral recon-
tunnel at
struction, it should be noted that the tunnel at the
humerus
isometric point should be placed such that the
isometric point is at its anterior and distal extent
to maintain graft tension. Isometry is confirmed,
the graft is stress-relaxed with repeated flexion and
extension under load, and then finally tensioned at
60# of flexion with varus stress in supination. This
technique has been shown to be biomechanically
equivalent to the native MCL [56].
The technical difficulties of multiple bone Fig. 7 (From The Elbow and
Its Disorders by BF
tunnel placement has led to modifications of Morrey & J Sanchez-Sotelo,
4th Edition, Saunders 2009,
the technique. In the docking technique [57], the Chapter 47 page 663, Fig
47-9, by kind permission) Sche-
matic of the graft and bone
tunnel placement in the
central portion of the graft is passed though the
docking technique
sublime tubercle tunnel as in Jobes technique,
but the two limbs are then brought into a single
tunnel at the isometric point of the humerus. The technique the DANE TJ
technique [59]. More
sutures from each limb of the graft exit anteriorly recently, various
techniques of fixing the graft
and posteriorly through smaller tunnels, thus through bone tunnels with
the addition of inter-
pulling the graft into the tunnel [58], (Fig. 7). ference screws have been
evaluated [50, 60, 61].
Recent developments include good results With medial
reconstruction, the ulnar nerve
using a hybrid technique with interference must be considered.
Firstly, ulnar nerve symp-
screw fixation to the ulna, and the graft tensioned toms may be present in
conjunction with those of
and fixed to the humerus with a docking valgus instability, due to
compression, traction or
1390
friction, and occasionally instability. The ulnar including arthroscopic thermal

shrinkage [64]
nerve will need to be explored and released as and capsular placation [65]
have been described,
part of the medial exposure, and may require but have yet to gain
popularity.
transposition or stabilisation. In essence, the techniques
described for lateral
reconstruction mirror those
used medially. Simi-
Lateral Reconstruction lar principles regarding
preservation or repair of
Lateral ligament reconstruction has been noted to the dynamic stabilisers,
isometry of the graft,
give better results than ligament repair in the correct tension and an extra-
synovial reconstruc-
chronic setting [62, 63]. Other techniques tion are followed.
b
Posterior
Proximal
Point of
isometry
Fig. 8 (continued)
1391
c d
Fig. 8 (From The Elbow and Its Disorders by BF Morrey humeral

attachment of the tendon graft. (b) Two humeral
& J Sanchez-Sotelo, 4th Edition, Saunders 2009, tunnels connect
the point of isometry with the anterior and
Chapter 48 page 675, Fig 48-6, by kind permission) posterior
aspects of the lateral humeral column. (c) The
Reconstruction of the lateral collateral ligament complex graft is
doubled on itself and passed through the ulnar
using a tendon graft. (a) The ulnar tunnel is started at the tunnel. (d) The
tendon graft ends may be docked into the
tubercle of the supinator crest and directed proximally and isometric
humeral tunnels and the sutures tied over the
posteriorly. A suture placed through the ulnar tunnel may humeral
epicondyle
be used to confirm the isometricity of the point selected for
Exposure through the Kocher interval allows Rehabilitation

repair of the extensor muscle mass, and direct
access to the ligament site. The distal portion of In the initial
post-operative period, the graft recon-
the graft is placed (by bone tunnel or interfer- struction
should be protected from potentially dis-
ence screw) at the supinator crest, and, if bone ruptive forces:
On the lateral side, pronation acts to
tunnels are to be used, a further hole placed protect the
graft by increasing muscular tension, and
posterior and proximal greater than 10 mm. the reverse is
true of the medial side. These protec-
away, and joined to the first. On the humerus, tive forces are
increased with active movement.
the isometric point is identified as the centre of However, in an
unstable post-traumatic situation
rotation of the capitellum, confirmed with the splintage or
external fixation may be required. In
use of a suture through the ulna tunnel, held lateral
reconstruction, abduction of the shoulder
onto the humeral epicondyle, and its tension leads to varus
stress at the elbow, increased by any
noted through flexion and extension. As medi- weight in the
hand, and this should be avoided in the
ally, this point should be used to place the tunnel initial post-
operative period. Flexion and extension
slightly proximally and posteriorly, such that the may be
performed supine with the arm elevated to
inferior and distal part of the graft is at this point. prevent varus
forces.
The graft is secured at each end with a locking
suture, passed thought the ulnar tunnel, and
secured to the humerus either through tunnels, Summary
by a docking technique or screw fixation. Each
technique has similar strength, but more impor- Stability of
the elbow is dependant on both bony
tant is probably correct placement and tension and soft tissue
structures. Damage to any of these
(Fig. 8). will
potentially result in acute or chronic elbow
1392
instability. An understanding of the anatomy of instability:

the basic kinematics. J Shoulder Elbow
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Masters GW, Srivastava S. The effect
types of instability. A high index of suspicion for of arthroscopic
sectioning of the lateral ligament com-
ligamentous injury should be maintained follow- plex of the
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ing acute elbow trauma, or post-traumatic pain J Shoulder
Elbow Surg. 2005;14(3):298301.
and loss of function. Modern surgical techniques 14. Hannouche D,
Begue T. Functional anatomy of the
lateral
collateral ligament complex of the elbow. Surg
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Ogura T, Morito Y, Hashizume H, Inoue H.
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2010;25(1):3742.
Distal Humerus Fractures 90#
Plating
ller
Klaus Burkhart, Jens Dargel, and
Lars P. Mu
Contents
Abstract
Distal humeral fractures are seldom but mostly
severe fractures. As these fractures are mostly

displaced and often involve the articular surface,

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1400 treatment is mainly operative. The complex dis-
tal humeral anatomy and often-comminuted
fracture types make this injury difficult to treat.

In elderly patients osteoporosis may complicate

1402 stable reconstruction. Osteosynthesis is usually
performed with a double plating technique. The
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1404 development of pre-contoured locking plates
represent a real advance in the management of

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1405
distal humeral fractures. This chapter deals with

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1406 the aetiology, diagnosis and treatment of distal
humeral fractures, focussing on the 90# plating
technique as proposed by the AO.
Keywords
Aetiology and classification # Complications #
Diagnosis # Humerus-Distal Fractures # Reha-
bilitation # Surgical indications; technique of
plating
Distal humeral fractures are seldom but severe
injuries that are often difficult to treat [13].
The incidence is about 5.7/100.000 with a
small share of 23 % of all fractures. Coronal

K. Burkhart (*) # J. Dargel # L.P. M
uller
shear fractures represent a special type of distal
Department of Orthopaedic and Trauma Surgery,
humerus fractures. Capitellum and trochlea frac-

University of Cologne, Cologne, Germany
e-mail: klaus.burkhart@uk-koeln.de;
tures are absolutely rare injuries. Capitellum frac-
jens.dargel@uk-koeln.de; lars.mueller@uk-koeln.de
tures are estimated to account for approximately

1395
DOI 10.1007/978-3-642-34746-7_71, # EFORT 2014
1396
K. Burkhart et al.
A1: Apophyseal A2: Metaphyseal

A3: Metaphyseal
avulsion simple
multifragmentary
B1: Sagittal B2: Sagittal

B3: Frontal
lateral condyle medial condyle
C2: Articular simple,

C1: Articular simple, metaphyseal
C3: Articular,
metaphyseal simple multifragmentary
multifragmentary
Fig. 1 AO classification of distal humerus fractures (This German Springer version

is taken from [4]).
1 % of all elbow fractures and 6 % of all distal from standing height

onto the outstretched or
humerus fractures trochlea fractures even less. slightly flexed arm.
These fractures are often
In younger patients there is a predominance in severely comminuted.
Due to the thin soft tissue
men. The mechanism of accident is mostly envelope many distal
humerus fractures are open
a high-energy trauma in this population. Among and additional injuries
are common. The topo-
elderly patients distal humerus fractures affect graphical proximity to
the three main nerves and
mostly women with osteoporotic bone. Fractures brachial artery can
lead to significant lesions of
are caused by a low energy trauma such as a fall these structures.
Distal Humerus Fractures 90# Plating
1397
The aim of the treatment is the reis usually performed with a

double plating
establishment of a stable and functional elbow technique. The development of
pre-contoured
joint. These aims are mostly achieved with open locking plates is a real
advance in the manage-
reduction and internal fixation. Osteosynthesis ment of distal humeral
fractures. Anatomic and
a b
c d
Fig. 2 (continued)
1398
K. Burkhart et al.
Fig. 2 Fixing an AO C2 fracture. An olecranon re-positioned to the shaft

and fixed with clamps. Then an
osteotomy was performed. Then the articular surface ulnar and a dorsolateral
plate were applied. After comple-
was reconstructed using a K-wire, which was the tion of the osteosynthesis
the olecranon osteotomy was
exchanged with a 3.5 mm screw. The articular block was fixed with tension band
wires (copyright by the authors)
stable fixation should allow early active motion Several classification

systems have been
to ensure quick recovery of working ability in described for capitellar
fractures. The most wide-
younger and self-sufficiency in older patients. spread classification
system was described by
Bryan and Morrey in the
early 1980s:
Type I (Hahn-Steinthal
fracture): involves the
Aetiology and Classification entire capitellum
Type II (Kocher-Lorenz
fracture): involves only
Although many different classifications have a thin osteochondral
fragment of the capitellum
been published for distal humerus fractures, Type III: comminuted
fractures of the capitellum
the AO-classification is still the most commonly Dubberly in 2006
introduced a classification
used classification system. Extra-articular system based on three
fracture types, that aims to
fractures are graded as type A, intra-articular give treatment guidelines:
fractures affecting one column as type B and Type I: capitellum
fracture with optional involve-
intra-articular fractures affecting both columns ment of lateral
trochlear ridge
as type C. Each type is divided into three more Type II: capitellum and
trochlea fracture as
sub-types (Fig. 1). one piece
1399
a b
c d
Fig. 3 An extra1acrticluar fracture (AO A2) was fixed Note, that the two plates
do not end up at the same height
with 90# double plating using angle stable 2.7/3.5 mm in order to avoid a stress-
riser (copyright by the authors)
LCP-plates. An olecranon osteotomy was not necessary.
1400
K. Burkhart et al.
Type III: capitellum and trochlea fractures as and vessel injuries are excluded.
A.P. and
separate fragments, optionally comminuted lateral radiographs of the
injured region are
These fractures were further sub-divided mandatory. The radiocapitellar
view may
depending on the absence (A) or presence (B) of be helpful in the case of coronal
shear
dorsal condylar comminution. fractures. For intra-articular
fractures, a CT scan
is recommended to improve
understanding of
fracture morphology and to aid
pre-operative
Diagnosis op-planning (Fig. 4).
Duplex sonography and
angiography are
The patient presents with severe pain at and performed when an arterial injury
is assumed.
perhaps deformaty of the injured elbow. Alternatively a CT angiography
can be
The elbow is checked for open wounds. Nerve accomplished.
a b
Fig. 4 (continued)
1401
d e
Fig. 4 A complex low AO C3 fracture could already be was reconstructed

using headless compression screws.
seen on the plain radiographs, but the real fracture extent The articular block
was the fixed to the shaft using angle
with coronal shear fragments of the capitellum and troch- stable LCP-plates.
The olecranon osteotomy was fixed
lea could only be demonstrated with the help of the CT with tension bad
wires (copyright by the authors)
scan. After an olecranon osteotomy the articular surface
osteosynthesis. Since
the development of anatomic
Indications for Surgery locking plates stable
ORIF is possible in most of the
cases. Total or hemi-
elbow arthroplasty is an alter-
As almost all adult distal humeral fractures are native for severely
comminuted fractures of the
displaced; there is little place for conservative elderly with
osteoporotic bone quality.
treatment. Due to the joint proximity of these
fractures functional bracing is not possible and
joint immobilization of six weeks ends up with Pre-Operative
Preparation
joint stiffness. Therefore, indications for and Planning
conservative treatment are restricted to general
contra-indications for surgery such as severe Routine radiographs
of the injured elbow in
co-morbidities or neurological diseases with an two planes are the
standard diagnostic views
immoveable upper extremity. for distal humerus
fractures. As they often fail
The aim of surgery is the restoration of a painless to indicate the
precise fracture extent, a CT-
and functional stable elbow joint to assure patients scan with sagittal
and frontal as well as three-
independence in activities of daily living. Usually dimensional
reconstructions is necessary for
these goals are achieved by open reduction and pre-operative
planning in cases of intra-
internal fixation (ORIF) with anatomical recon- articular fracture.
Comminution of the articular
struction of the articular surface of the elbow. To surface with
trochlear and/or capitellar shear
achieve these goals and to allow early physiother- fragments, which we
call AO B3/C3 fractures,
apy ORIF should be performed with double plate in the elderly should
alarm the surgeon that this
1402
K. Burkhart et al.
fracture may not be fixed in a stable manner the olecranon to expose

the humeroulnar joint.
and that a hinged external fixator or elbow There is a small area
without cartilage within
arthroplasty may be needed. the centre of the
olecranon fossa that should
be the line of the
osteotomy. The osteotomy is
begun with a thin-bladed
oscillating saw and
Operative Technique finalized with an
osteotome in order not to
harm the articular
surface. A compress may
The patient is placed in a prone or lateral position. be used as an abutment.
The olecranon and
A sterile tourniquet expands the sterile field. triceps tendon are then
elevated and the frac-
A straight longitudinal skin incision is made dor- ture is exposed. To ease
later re-fixation of the
sally down to the triceps tendon. The ulnar nerve olecranon osteotomy it is
recommended to
is identified and released. During preparation of apply the hardware before
the osteotomy. In
the nerve the perineural vesels are spared. It may this way usage of the pre-
drilled drill holes of
be transposed anteriorly to avoid injury during a plate, homerun-screw
(Fig. 5) or tension-
the operative procedure. band wires allow for easy
anatomical re-
Intra-articular fractures are exposed using fixation of the olecranon
tip.
an olecranon osteotomy to allow for The primary goal of
the operation is the
exact anatomical reduction (Figs. 24). anatomic reconstruction of
the articular sur-
A V-shaped cut is performed to allow anatom- face. After cleaning the
fracture of haematoma,
ical and stable re-fixation after osteosynthesis. reduction of the fracture
is begun with recon-
Therefore the anconeus muscle is elevated off struction of the articular
surface before
Fig. 5 Olecranon osteotomy fixed with a homerun screw (copyright by the authors)
1403
re-fixation of the articular block to the humeral (e.g. a 3.5 mm reconstruction

plate). Attention
shaft (Figs. 2 and 4). Mini- and small fragment must be paid that both plates
do not end up at
screws of varying diameters (1.53.5 mm) are the same height proximally as
this would pose
used. Usage of cannulated screws enables the a stress raiser possibly
leading to a fracture at
surgeon to reduce and temporarily fix the frag- the tip of the plates. Two or,
better, three screws
ments with K-wires first before over-drilling should be placed proximal and
distal to the
for the screws. When the articular block is fracture. The distal screws
should be as long
reconstructed, the block is fixed to the humeral as possible and pass as many
fragments as pos-
shaft using K-wires. Afterwards two plates are sible to achieve the highest
stability. Locking
applied: one medially and one dorsolaterally. screws enhance fixation
stability. Usage of pre-
The dorsolateral plate (e.g. a 3.5 mm LCDCP) contoured distal humerus
locking plates facili-
is placed on the dorsal aspect of lateral column. tate the operation
significantly. Placing the
Due to thin soft-tissue coverage the plate must screws into the joint or the
olecranon fossa
be bent to follow the anterior curve of the must be avoided.
capitellum. The dorsolateral plate should not After fracture fixation the
olecranon is provi-
be tightened completely before application sionally re-attached and the
elbow is moved
of the medial plate to allow re-adjustment through the full range of
motion. If the fracture
of the fracture fragments. The medial plate fixation is stable and allows a
must be aligned to the medial epicondyle. the olecranon osteotomy is
finally fixed with
Therefore a more flexible plate should be used a plate, homerun screw or
tension-band wires.
b
Fig. 6 (continued)
1404
K. Burkhart et al.
should be started as early as

possible to pre-
Post-Operative Care vent joint stiffness.
and Rehabilitation
The aim of internal fixation of distal humerus Complications

fractures must be a stable elbow that allows
early active physiotherapy. A dorsal splint Poor results after ORIF of distal
humerus
may be useful until the time of wound healing. fractures can be found in 2047 %
according to
However physiotherapy out of the splint the current literature.
Immobilization longer than
Fig. 6 (continued)
1405
Fig. 6 70 years old female with an AO B3-C3 fracture inside the joint
(ring). The intra-operative photograph
which was stabilized with double plate osteosynthesis shows these bare screws
(two arrows) due to the
according to the AO-technique using 3.5 mm pre-contured dislocated capitellum
and necrotic areas of the trochlea
locking plates. She suffered secondary loss of fixation. (bold arrow).
Conversion to TEA (Total Elbow
The radiograph shows dislocation of the K-wire, the Arthroplasty) was
performed (copyright by the authors)
CT-scan reveals the displaced capitellum with bare screws
10 days, secondary definitive reconstruction, of tension-band wiring

carries a high risk of
delayed initiation of physiotherapy and concom- secondary complications
such as non-union,
itant traumatic brain injuries are factors affecting secondary loss of
reduction and soft tissue
the outcome adversely. irritation (Fig. 7).
Most common complications include
infections especially after open fractures
heterotopic ossifications, osteoarthritis, non- Summary
union, instability as well as secondary loss of
fixation (Fig. 6). Distal humerus
fractures in adults remain
Special care has to be taken re-fixing the a challenging problem
due to anatomical com-
olecranon osteotomy after an exhausting distal plexity of the
articular surface, comminuted frac-
humerus reconstruction. Especially the use ture morphology and the
short distal fragment.
1406
K. Burkhart et al.
a b
Fig. 7 An improperly fixed olecranon osteotomy resulted in a non-union and had to

be revised using a plate
osteosynthesis (copyright by the authors)
The goals of a painless, stable and functional 2. Jupiter JB. The

surgical management of intraarticular
elbow are achieved by ORIF with anatomical fractures of the
distal humerus. In: Morrey BF, editor.
The elbow. 2nd ed.
2002. p. 6582.
reconstruction of the articular surface in younger 3. Barei DP, Hanel DP.
Fractures of the distal humerus. In:
patients. Controversly exist as to the best means Green DP, Hotchkiss
RN, Pederson WC, Wolfe SC,
of maintaining the position of distal humerus editors. Greens
operative hand surgery. 5th ed. 2005.
fractures in the elderly patients with poor bone p. 80944.
4. Lill H, Vogt C.
Injuries of the elbow joint. Chirurg.
quality. Secondary loss of reduction, heterotopic 2004;75:10371051.
ossification and non-union may occur.
References
1. Hessmann MH, Ring DC. Humerus, distal. In: R
udi TP,
Buckley R, Moran CG, editors. AO principles of frac-
ture management. 2007. p. 60926.
Fractures of the Distal
Humerus Total Elbow
Arthroplasty
(Hemi-Arthroplasty)
Lars Adolfsson
Contents
Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 1408 Primary arthroplasty in the treatment of distal
humeral fractures has been described as an

alternative to internal osteosynthesis for

Anatomy and Biomechanics . . . . . . . . . . . . . . . . . . . . . . 1409
elderly patients with comminuted, intra-
The Specific Skeletal Anatomy . . . . . . . . . . . . . . . . . . . 1410
articular fractures. The reported results are
still few, but have in general been good or

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1410
excellent and, in comparison with conven-

tional osteosynthesis, functional outcome has
Pre-Operative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 1412
been superior and complications fewer [8, 22].
1412 More recently hemi-arthroplasty has been pro-
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1412 posed as an alternative but so far only very few
Hemi-Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1414 and short-term results have been published.
Total
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1416 The surgical procedure typically consists of
Post-Operative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1417 a posterior approach, removal of fractured frag-
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1418 ments and replacement of the joint by
a conventional, hinged prosthesis. For a hemi-

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1421
arthroplasty only the cartilage-covered parts of

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1421 the distal humerus are removed and substituted
with a humeral prosthesis around which the
distal humerus is reconstructed as necessary.

Post-operative management is similar,
regardless of the implant used and is the same
as that used for conventional elbow arthroplasty.
Keywords
Complications # Diagnosis # Fractures of distal
shaft-anatomy, Classification and Biomechan-
ics # Humerus # Surgical indications #
Surgical technique-total arthroplasty, hemi-
arthroplasty
L. Adolfsson
Department of Orthopaedics, Linkoping University
Hospital, Linkoping, Sweden
e-mail: Lars.Adolfsson@lio.se

1407
DOI 10.1007/978-3-642-34746-7_72, # EFORT 2014
1408
L. Adolfsson
similar [4]. In cases

where one of the columns
Introduction have been left intact by
the injury, enabling repair
of the condyle and
collateral ligaments, a non-
Fractures of the distal humerus in adults are rela- constrained prosthesis
the IBP has also been
tively rare injuries and almost every publication on found successful in a
small series with
the subject state that their treatment constitutes intermediate-term results
[17].
a considerable challenge. Today it is recognized Hemi-arthroplasty for
fractures of the distal
that surgical treatment is indicated in displaced, humerus has been
infrequently suggested and
unstable fractures due to the frequently disappoint- a few cases with
encouraging short-term results
ing results of conservative treatment. Although it have been reported [1, 12,
25]. We have recently
appears probable that recent developments in tech- reviewed our early and
mid-term results of 31
niques and specially designed implants have hemiarthoplasties and
found that, with a follow-
improved the outcome, surgery is still often diffi- up between 7 months and 6
years, all patients had
cult and some residual dysfunction usually excellent or good results
according to the Mayo
remains even after a successful internal fixation. Elbow Performance Score
(MEPS) without hav-
The key to a functionally acceptable result is early ing encountered any
serious complications
post-operative mobilisation, which requires an (unpublished).
internal fixation of both skeleton and soft tissues To date, the results
of little over one hundred
that is stable enough to allow active training. It is cases with fresh fractures
treated with total- or
considered that range of motion exercises should hemi-arthroplasty have
been reported in the liter-
commence within 3 weeks of the surgery to opti- ature. So far, all studies
report on short or inter-
mize final function [16]. In patients with osteopo- mediate term results and
although the published
rotic bone and severe comminution fracture outcomes have been
encouraging, the true indi-
treatment may be significantly more difficult and cations for these
procedures remain to be
the complication rate after internal fixation under established. The following
presentation aims at
such conditions has been reported to be unaccept- reporting the present
attitude towards indications
ably high [9, 11, 13, 14, 15, 19, 20, 29]. It has been and describing the
surgical techniques of TEA
observed that the incidence of these challenging and hemi-arthroplasty.
fractures appears to be increasing due to the ageing
population [26].
In the event of an intra-articular, comminuted Aetiology and
Classification
fracture in osteoporotic bone, primary
arthroplasty has been advocated and reported The majority of adult
distal humerus fractures
results have compared favourably with those occur in osteopaenic bone
following a low energy
after internal fixation [6, 8, 10, 18, 24]. More trauma and, when young
patients are afflicted
recently a randomised, controlled study found a trauma, with high energy
should be suspected.
that functional outcome was better and The pathomechanics are
most often either
re-operations fewer with total elbow arthroplasty a direct trauma over the
olecranon or an indirect
(TEA) as compared to open reduction and trauma from a fall on to
an outstretched hand in
conventional plate fixation [22]. which case the force is
transmitted through the
The majority of reports on TEA are based on forearm [30]. In the
latter case the fracture may
series where modern semi-constrained implants be caused by a combination
of axial, angular
with a so-called sloppy hinge has been used. and rotational forces,
which sometimes can be
The Coonrad-Morrey prosthesis has been most suspected from the
fracture pattern. Only
commonly-used [6, 8, 10, 18, 27] but the few rarely a direct blow or
crush injury with signifi-
published results of other implants appear cant energy may cause a
distal humeral fracture.
Fractures of the Distal Humerus Total Elbow Arthroplasty (Hemi-Arthroplasty)
1409
In such cases the soft tissues are often severely

affected and may need special attention. Anatomy and Biomechanics
Although the exact mechanism of the
bi-column fractures has not been clearly demon- The elbow is a tight,
highly congruous joint with
strated, the majority of fractures are believed to a large range of motion,
consisting of three artic-
be occur through force transmission via the ulations, the ulno-
humeral, the radio-humeral and
wedge-shaped olecranon which tends to separate the proximal radio-ulnar.
In close proximity are
the capitellum and trochlea, creating the typical major neurovascular
structures and several mus-
T- or Y-pattern of the distal intra-articular cle groups vital for hand
function. The role of the
fracture [5, 7, 30]. A more unusual fracture pat- arm is to provide a firm
foundation for hand
tern is the coronal shear fracture in which the function and enable
practically unrestricted pos-
fracture line runs in the coronal plane separating sibility to manoeuvre the
hand in space. The
varying amounts of the capitellum and trochlea elbow joint plays a
significant role since normal
from the humerus. This is believed to be caused range of motion is around
0145# of flexion and
by a shearing force from the base of the coronoid extension and the radius,
as part of the forearm
process. In the most severely comminuted cases joint allows rotation of
almost 180# . Stability is
combinations of all these patterns may occur, provided by the geometry
of the skeleton and the
creating what has been called a multi-plane medial and lateral
collateral ligament complexes
fracture [23]. together with the flexor
and extensor muscle
The low type A fractures, transcondylar, or groups.
transcolumn fractures are typical in children but Loading of the hand
transmits forces along the
also relatively common in middle-aged and forearm bones and the
interosseous membrane as
elderly individuals. Displacement of the fracture well as creating
compressive forces from the
into flexion is believed to be produced by an muscle groups originating
proximal to the
impact over the olecranon while the elbow is elbow joint. Within the
joint most of the forces
held in more than 115# of flexion. The extension have, under normal
circumstances, been found to
type is most likely caused by an indirect force be distributed over the
ulno-humeral articulation
transmission by a fall on an outstretched hand [3]. This is however
likely to be dependent on the
with the elbow in less than 60# of flexion [28]. degree of flexion and the
position of forearm
Several radiographic classification systems rotation. Any trauma to
the elbow may alter
have been suggested, in general based on the these conditions and in
cases with skeletal defor-
level of fracture extension and the number of mities or increased joint
laxity due to incompe-
fragments. No classification has so far been tence of passive
stabilizers, the load distribution
entirely based on the probable pathomechanics may change dramatically
and predispose to insta-
but using the AO/OTA classification some guid- bility symptoms and joint
degeneration.
ance can be found in the fracture extensions; An In the acute situation
a displaced fracture or
intra-articular C-type fracture is most likely dislocated joint may be
associated with severe
caused by force transmission via the ulna whereas soft tissue injuries. Open
fractures are not uncom-
B-type fractures are primarily the result of an mon, especially with high
energy trauma, and
indirect trauma via the forearm. Type neurovascular lesions
occur. The ulnar nerve is
A fractures are in osteoporotic patients often cre- the major structure that
is most at risk but other
ated from a bending force while in young indi- nerve injuries have also
been observed and care-
viduals the trauma is either a direct blow or ful examination of nerve
function is important in
a twisting force. Depending on these scenarios every case of elbow
trauma. Affection of periph-
the likelihood of a significant soft tissue injury eral circulation is not
uncommon with severe
can be deduced [21]. fracture displacement and
is often associated
1410
L. Adolfsson
with the transcondylar extension type of fracture. condyles. The results

hitherto reported of TEA
In the majority of cases the circulation will are based on studies using
implants that require
recover after closed reduction but, although excision of the radial head.
The resection of the
rare, structural lesions of the brachial artery do radial head reduces the elbow
joint stability in
occur and peripheral circulation should always be valgus-varus stress, which in
turn increases the
carefully monitored. stress on the prosthetic
hinge mechanism. A more
recent design (LatitudeR)
allows replacement
also of the radial head,
which is theoretically
The Specific Skeletal Anatomy advantageous, but so far no
results have been
published. Hemi-arthroplasty
allows the radial
The distal third of the humeral shaft is slightly head to be retained and also
precludes the need
triangular in cross section with a relatively flat for moving mechanical parts,
which has enabled
posterior surface and a rounded ventral aspect. unrestricted load on the
operated joint. The long-
Further distally the shaft continues into the term outcome of these
procedures is however still
medial and lateral columns that terminate in the unproven.
epicondyles. The medial, ulnar, column is
rounded and continues into the prominent medial
epicondyle. The lateral column is flatter and Diagnosis
rather triangular in shape due to the more distinct
lateral ridge that ends in the lateral epicondyle. Pain and swelling around the
elbow following
The columns are separated by the olecranon and a significant trauma should
lead to the suspicion
coronoid fossae. Distally the articular part, of a fracture and standard
radiographs in AP and
consisting of the trochlea and capitellum, is held lateral projections are
usually sufficient to diag-
between the epicondyles with a valgus angle of nose a distal humeral
fracture. In cases with intra-
approximately 67# and in relation to the long articular fracture extensions
a CT-scan is
axis of the humerus, creating the so-called car- recommended and is usually
mandatory in AO/
rying angle when the elbow is in extension. In OTA B-type fractures in order
to allow
the lateral plane the trochlea has a slightly indi- a sufficient planning of a
surgical procedure.
vidually varying anterior offset and is anteriorly It is not uncommon that the
tomography reveals
angulated approximately 40# . cracks and fragments that are
impossible to
The skeletal anatomy of the distal humerus appreciate from standard
radiographs (Fig. 1a, b).
makes the relatively thin columns and the very The choice between an
internal osteosynthesis
thin or absent bone in the fossae in the immedi- and an arthroplasty should
normally not be
ate supracondylar region susceptible to decided without pre-operative
CT-scans.
fracture. The small amount of bone also makes
internal fixation difficult. In order to restore
joint stability the columns and the epicondyles
are essential since they constitute the origins Indications for Surgery
of the collateral ligaments and the forearm
muscles. As a general rule all
patients with a displaced
These specific anatomical and biomechanical distal humerus fracture
should be considered for
factors, and the fact that the elbow joint consists surgery because of the
frequently disappointing
of three articulations, demand particular pre- results from conservative
treatment. Primary
requisites of an elbow prosthesis. The narrow arthroplasty is an option in
cases where the sever-
medullary canal of the distal humeral shaft pre- ity of the fracture and the
quality of the skeleton
cludes large diameter humeral stems and accom- make stable internal fixation
impossible or
modation of the distal part of the humeral implant unreliable. It may also be
the primary choice in
should not require resection of the columns or patients with arthritic
diseases affecting the
1411
a b
Fig. 1 (a) Standard antero-posterior X-ray of a distal affection of the medial

part, which was difficult to appre-
humeral fracture. (b) The CT scan of the same patient ciate on standard
radiographs
reveals the severe comminution of the fracture and the
elbow prior to the fracture. In all reported series a joint prosthesis. Other
relative contra-
the fractures have been intra-articular with sev- indications include poor
compliance, central or
eral separate fragments of the joint surface. In peripheral nervous system
disorder and for
particular distal fractures of trans-condylar type TEA reluctance to accept
a permanent restric-
or coronal shear fractures with two or more sep- tion of heavy load.
Previous arthritic disease
arate fragments have been considered candidates affecting the elbow rules
out the possibility of
for primary arthroplasty. In cases where hemi- a hemi-arthroplasty.
arthroplasty has been used an essential factor in Age of the patient is
another important factor
the decision-making is whether joint stability can that needs consideration.
So far primary
be restored, e.g. if the collateral ligaments can be arthroplasty has been
advocated for the elderly
re-inserted. This requires that the condyles and patient but no clear age
limits have been defined.
epicondyles are intact or can be repaired. Hemi- The recommendation is also
insufficient since the
arthroplasty can be regarded as fracture surgery term elderly is lacking
definition and age is
around a joint replacement spacer rather that mostly referring to a
biological rather than chro-
a conventional arthroplasty. nological age. Judging
from personal experience
Relatively few serious complications have the patient that suffers a
very distal, intra-articu-
been reported in the published series of primary lar, comminuted fracture
that can be considered
arthroplasties for fractures and contra-indications for arthroplasty
invariably has an osteopenic
have not been clearly defined. It however appears skeleton. It appears that
the poor bone quality
obvious that manifest infections and traumatized predispose to the type of
fracture that can be
areas with impaired soft tissue circulation are amenable for primary
prosthesis and without
conditions that should preclude implantation of using any defined age
limit the patients of this
1412
L. Adolfsson
authors personal experience have had an average

age of 76 years (range 6391). As long as data on Operative Technique
the long-term outcome of arthroplasty for frac-
tures is lacking it appears that the procedure Approach
should only be restrictively used in elderly
patients with osteopenia or in patients with Surgery is ideally performed
under general anaes-
previous joint destruction due to arthritic thesia with the patient in
the lateral decubitus
systemic disease. position but the supine
position is also possible
and may be preferable in
patients when anaesthe-
sia is difficult or in
multi-traumatized patients
Pre-Operative Planning when other simultaneous
procedures are indicated.
Regardless of the patients
position the surgical
Before the final decision of surgical treatment approach is usually through
a posterior skin inci-
and surgical method is taken a number of pre- sion, slightly laterally
curved around the olecra-
operative considerations must be made. The skin non, and sharply continued
down to the muscle
and soft tissue envelope must be assessed and fascia (Fig. 2). The
incision must however be
the type of trauma can often predict the amount planned in relation to the
condition of the soft
of soft tissue injuries. In the case of circulatory tissues. In cases of open
fractures the wound and
disturbance or associated life-threatening inju- subcutaneous tissues must be
assessed in order to
ries this will obviously call for emergency sur- minimize the risk of post-
operative necroses.
gery in which case an arthroplasty is not the Small wounds and minor areas
of soft tissue
method of choice. In other instances the surgery devascularisation can be
excised and the skin
can often be planned to an occasion when pre- sutured, or the fracture may
sometimes be
operative conditions are optimal. These involve approached through the same
incision depending
skin with adequate circulation, sufficient radio- on the location. The
procedure is usually
graphic examinations, available necessary performed without the use of
a tourniquet, which
implants and surgical expertise. The general definitely should be avoided
if the quality of the
medical condition of the patient is included in skin circulation is
questionable. For reasons of
the planning as well as the capability of the safety the tourniquet is
however often placed
patient to adhere to the planned post-operative around the upper arm when
possible but not
management. The rest of the injured arm must be inflated unless necessary
for temporary control of
carefully examined in order to rule out concom- bleeding. After elevation of
thick skin flaps, the
itant injuries. ulnar nerve is identified
and followed from the
Pre-operative radiographs should be of suffi- arcade of Struther and
through the cubital tunnel
cient quality to allow the decision of surgical (Fig. 3). The flexor carpi
ulnaris muscle and fascia
method and planning of approach. If a total is split 34 cm to allow the
nerve to move freely
arthroplasty is considered an olecranon during the rest of the
procedure. The decision to
osteotomy should not be used and an anterior mobilise or transpose the
nerve must be taken in
incision - which is often necessary for relation to the injuries and
the implants used. As
osteosynthesis of coronal shear a rule the nerve is kept in
place following decom-
fractures must also be avoided. In any case pression and the adjacent
vessels are left
with intra-articular fracture extensions a pre- undisturbed as much as
possible. Handling of the
operative CT-scan is recommended to ascertain triceps muscle may be
reflection to either side or
the ideal method. If a hemi-arthroplasty is con- mid-line split (Fig. 4). The
decision of approach is
sidered it is imperative that joint stability can be mainly due to the preference
of the surgeon but
restored and this requires stable condyles occasionally the muscle may
have been injured by
allowing for insertion of collateral ligaments sharp, displaced fracture
fragments in which case
and muscles. the muscle may be less
affected by using the
1413
Fig. 2 Posterior incision

with the patient in lateral
decubitus position. The
incision starts in the mid-
line of the humerus, curves
laterally around the
olecranon and is continued
sharply down to the
muscles in order to avoid
compromising circulation
of the skin flaps
Fig. 3 Identification of the

ulnar nerve proximal to the
medial epicondyle. The
nerve is often most easily
located by palpation rather
than sharp dissection
traumatic injury as part of the approach. This osteotomy should not be

performed if a total
decision must however be guided by the muscular arthroplasty is planned
and should normally be
innervation from the radial nerve. In the typical avoided for a hemi-
arthroplasty. We have however
case the triceps split extends up to the flat posterior performed hemi-
arthroplasty in a patient with
portion of the humeral shaft, which means 78 cm a displaced olecranon
fracture at the time of the
proximal to the olecranon tip with the elbow in 90# injury and in another who
had undergone a failed
of flexion (Fig. 5). This author has primarily primary attempt of
internal fixation when an olec-
favoured a mid-line triceps split when the muscle ranon osteotomy had been
performed. In these
fibres are separated by a combination of blunt and cases the joint was
approached via the olecranon
sharp dissection and the central portion of the fracture.
tendon is released from the olecranon with small After the triceps has
been reflected the joint is
bone chips for later repair (Fig. 6). Olecranon opened and final
assessment of feasibility for the
1414
L. Adolfsson
Fig. 4 Incision of the

tendon from the tip of the
olecranon continuing in the
mid-line both proximal and
distal
Fig. 5 Triceps fibres are

separated and the fat pad in
the olecranon fossa is held
to one side, exposing the
fracture
chosen procedure is made. The respective collat- are removed. The removed
pieces are placed on
eral ligaments are identified, marked with a suture an instrument table and put
together to assess size
and released from their humeral insertions if nec- of the trochlea in order to
guide implant selection.
essary. In case the condyles are fractured, with the The joint is dislocated
with preservation of the
collateral ligaments remaining attached, these radial head, which is
believed to be an important
fragments are spared for later re-fixation. contributor to joint
stability.
The medullary canal of
the humerus is then
prepared using the implant-
specific reamers
Hemi-Arthroplasty (Fig. 7). In the case of a
trans-condylar or entirely
intra-articular fracture,
some bone remains to be
In patients found suitable for hemi-arthroplasty resected and an implant
specific resection guide
all cartilage-covered parts of the distal humerus can be of use. After
preparation of the medullary
1415
Fig. 6 The triceps is

reflected with thin wafers of
bone from the proximal
ulna
Fig. 7 The fracture

fragments are removed and
the humeral shaft is
prepared
canal to the desired size, a proximal cement The final decision for
the size of the humeral
restrictor is placed and the trial component implant is determined in
relation to the ulna and
inserted. The joint and the condyles or released the component allowing
optimal congruence is
collateral ligaments are temporarily reduced and chosen. The permanent
implant is then cemented
the facility of reduction and tension of the liga- in place taking care to
ensure correct length and
ments are the factors used to assess correct posi- rotation (Fig. 8). The
collateral ligaments are then
tioning of the prosthesis. The joint is taken sutured back using
osteosutures, placed through
through a full range of flexion and extension to drill holes in the
epicondyles. Condyle fracture
assess correct rotation and varus-valgus angle of fragments with collateral
ligaments remaining
the implant but also to exclude impingement of attached, are reduced and
osteosynthesis is
soft tissues or any mechanical conflict between performed using pins or
cerclage wires
the prosthesis and surrounding bone. (Fig. 9a, b). The triceps
tendon is sutured to the
1416
L. Adolfsson
Fig. 8 The definitive

humeral implant is inserted
olecranon through drill holes, using number 2 a resection guide or a trial

prosthesis can also be
non-resorbable sutures while resorbable sutures used at this stage to
determine if additional
are used for the proximal triceps muscle split osteosynthesis is required
before any bone frag-
(Figs. 10, 11). ments are removed. Even if a
coupled prosthetic
implant provides stability it
appears favourable to
preserve as much bone stock
as possible in order
Total Arthroplasty to reduce load on the
prosthesis but also to allow
the surrounding muscles and
ligaments to heal
After opening of the joint and removal of intra- back to bone. The exact
amount of bone to be
articular loose fragments, the radial head is iden- removed varies somewhat
between the presently
tified and for most available implants an excision available implants.
is mandatory. The radial head resection is Following desired bone
resection the humeral
performed using a saw or an osteotome and medullary canal is prepared
using the appropriate
should be sub-capitular ensuring no contact reamers and a cement
restrictor inserted. There-
between the proximal rim of the radial neck and after the ulna is prepared
using the specific guide
the ulna (Fig. 12). Since the forearm in most instruments for the chosen
implant. Since the
instances is unaffected by the trauma a radial ulna, in most cases will be
normal, the prepara-
head resection appears to be well tolerated if tion is relatively easy but
it is important for final
a semi-constrained prosthesis is used. In the rare function of the prosthesis to
ensure ideal seating
case of concomitant forearm instability, an of the implant. The trial
implants are inserted and
implant that allows the radial head to be retained, the joint is taken through a
or a prosthetic radial head replacement should be allowing for assessment of
rotation, length and
considered. angle and final adjustment of
position of the
After the collateral ligaments have been iden- implants can be made if
necessary. If cerclage
tified and protected and the radial head excised wires are to be used for
osteosynthesis of the
the joint is dislocated and a resection guide is of columns, it is recommended to
drill holes and
use to decide if any additional bone resection is place -but not tighten- the
wires before the defin-
needed. In cases with severe comminution, itive prosthesis is in place
(Fig. 13). After the
extending proximal to the olecranon fossa, prosthesis and cement have
been inserted,
1417
a b
Fig. 9 (a) Pre-operative CT scan of a woman with a trans-condylar fracture. A hemi-

arthroplasty was chosen. (b) Post-
operative radiograph of the same patient after implantation of a Latitude
prosthesis
cerclage wires are tightened, or pins introduced,

to stabilize fractured condyles and the collateral Post-Operative Care
ligaments are re-attached using osteosutures
(Fig. 14a, b). The triceps is replaced and sutured Post-operatively the
elbow is immobilised for
to the olecranon using number 2 non-resorbable 23 days in a splint.
Thereafter active exercises
sutures. The skin is carefully closed with are begun with active
flexion 100# and passive
interrupted subcutaneous sutures and a running extension during the
first 2 weeks until wound
40 skin suture which allows for early post- healing. Gradual
increase of flexion and light
operative training without dehiscence of the active extension is
then allowed. The training is
suture line. conducted 46 times a
day and inbetween
1418
L. Adolfsson
Fig. 10 The triceps

insertion is repaired using
non-absorbable
osteosutures
Fig. 11 The proximal part

of the triceps split is closed
with absorbable sutures
sessions the arm rests in a removable splint dur-

ing the first 4 weeks. Use of the arm in activities Complications
of daily living is allowed at all times. The aim of
training is a functional range of motion, defined Relatively few complications
have been reported
as range of motion (ROM) of, at least, 30120# , after primary elbow
arthroplasty. At the annual
and weight bearing no later than 8 weeks post- meeting of the Swedish
Orthopaedic Society in
operatively. For TEA an upper limit of 5 kg load 2008 this author reviewed 41
patients treated in
has often been advocated while all patients with three Swedish centres, 34
with primary TEA and
hemi-artroplasty have been allowed unrestricted 7 with hemi-arthroplasty due
to a fracture [2].
loading. Average age was 76 years,
range 6992,
1419
Fig. 12 The collateral and

annular ligaments are
identified and, when
necessary, the radial head is
excised by a subcapital
osteotomy
Fig. 13 The triceps split

necessary for
a TEArthroplasty. In this
case a GSB prosthesis has
been implanted
39 women and 2 men, with a follow up of 5 neuropathy, which has been

frequently reported
months to 6 years. In this series one patient had [22, 27], and the fact
that we do not routinely
an early wound complication, two patients never perform a transposition
may have had an impact.
regained a satisfactory range of motion (more Deep infection is a
much-feared complication
than 30120# ) and two other had a new injury but infections requiring
revision surgery have
and suffered peri-prosthetic fractures at a late only rarely been reported
in the publications on
stage. If poor post-operative range of motion is the subject [4]. This
author has had experience of
considered a complication, the overall rate was three patients suffering
from skin necrosis over
12 %, which tallies closely with other series. We the olecranon due to
external pressure. One
have not encountered post-operative ulnar patient had suffered a
stroke and was placed in
1420
L. Adolfsson
a b
Fig. 14 (a) Pre-operative radiograph and CT scan of the after replacement with a
GSB prosthesis and re-fixation of
elbow of a 93-year old male with a grossly comminuted the condyles with pins
elbow fracture. (b) AP and lateral radiographs 2 months
1421
cases are however to

be found in the literature and
so far the longest
reported follow-up is 5 years.
Only one study has a
prospective randomised
design, comparing
TEA and osteosynthesis [22].
So far the method
must therefore be regarded as
a last resort in
cases where there is strong evi-
dence to anticipate
a poor outcome after conven-
tional treatment
methods. The indications and
selection of
patients for these procedures remain
to be established
Hemi-
arthroplasty is even less proven and
although the few
early results indicate that the
results equal those
after TEA the method should
Fig. 15 Result 18 months after a fascio-cutaneous rota-
tional flap for coverage of a defect over the olecranon with
still be regarded as
experimental.
communication of the joint. The wound and the infection
healed with a combination of antibiotics and the well-
vascularised flap and the prosthesis could be retained.
Current ROM 30130# References
1. Adolfsson L,
Hammer R. Elbow hemiarthroplasty for
acute
reconstruction of intraarticular distal humerus
a wheel chair with the elbow on an armrest, fractures: a
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Acta Orthop.
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another 93-year old patient sustained a peri- 2. Adolfsson L,
Etzner M, Ekholm C. Armbagsprotes
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Presented at the annual meeting of the
fitting cast and the third had been injured in an Swedish
Orthjopedic Society, Umea; 2008.
industrial accident with severe soft tissue affec- 3. An KN, Morrey
BF. Biomechanics of the elbow. In:
Morrey BF,
editor. The elbow and its disorders. 3rd ed.
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Phildalphia: WB
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over the tip of the olecranon with a partial rupture 4. Baksi DP, Ananda
KP, Baksi D. Prosthetic replacement
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7. doi:10.1007/s00264-010-1122-5.
revision and lavage and after a few days a local
5. Cassebaum WH.
Open reduction of T and Y fracrures
fasciocutaneous flap from the proximal forearm of the lower end
of the humerus. J Trauma.
was used to cover the defect (Fig. 15). After 1969;9:91525.
3 months of oral antibiotics all healed with the 6. Cobb TK, Morrey
BF. Total elbow arthroplasty as
primary
treatment for distal humeral fractures in
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infection. 1997;79(6):826
32.
Peri-prosthetic fractures have been treated 7. Evans EM.
Supracondylar Y-fractures of the humerus.
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8. Frankle MA,
Herscovici Jr D, DiPasquale TG, Vasey
tion and plate fixation when deemed necessary.
MB, Sanders RW.
A comparison of open reduction
and internal
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arthroplasty in
the treatment of intraarticular distal
Summary humerus
fractures in women older than age 65.
J Orthop Trauma.
2003;17(7):47380.
9. Gambirasio R,
Riand N, Stern R, Hoffmeyer P. Total
Primary arthroplasty in the treatment of distal elbow
replacement for complex fractures of the distal
humeral fractures has only been described for humerus. An
option for the elderly patient. J Bone
elderly patients with comminuted, intra-articular Joint Surg Br.
2001;83(7):9748.
10. Garcia JA,
Mykula R, Stanley D. Complex fractures of
fractures. The published results are in general the distal
humerus in the elderly. The role of total
good or excellent and reported complications elbow
replacement as primary treatment. J Bone
have been few and mostly mild. Relatively few Joint Surg Br.
2002;84(6):8126.
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11. Goodman HJ, Choueka J. Complex coronal shear frac- instability of

the elbow. J Bone Joint Surg Am.
tures of the distal humerus. Bull Hosp Jt Dis.
2003;85A(6):11656 (author reply 6).
2005;62(34):859. 22. McKee MD,
Veillette CJ, Hall JA, Schemitsch EH,
12. Gramstad GD, King GJ, ODriscoll SW, Wild LM,
McCormack R, et al. A multicenter, pro-
Yamaguchi K. Elbow arthroplasty using spective,
randomized, controlled trial of open
a convertible implant. Tech Hand Up Extrem Surg. reduction
internal fixation versus total elbow
2005;9(3):15363. arthroplasty for
displaced intra-articular distal
13. Huang TL, Chiu FY, Chuang TY, Chen TH. The humeral
fractures in elderly patients. J Shoulder
results of open reduction and internal fixation in Elbow Surg.
2009;18(1):312.
elderly patients with severe fractures of the distal 23. McKee MD,
Jupiter JB. A contemporary approach to
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of complex fractures of the distal
2005;58(1):629. humerus and
their sequelae. Hand Clin 1984;10
14. John H, Rosso R, Neff U, Bodoky A, Regazzoni P, (3):47994.
Harder F. Operative treatment of distal humeral frac- 24. Muller LP,
Kamineni S, Rommens PM, Morrey BF.
tures in the elderly. J Bone Joint Surg Br. Primary total
elbow replacement for fractures of the
1994;76(5):7936. distal
humerus. Oper Orthop Traumatol.
15. Jupiter JB, Neff U, Holzach P, Allgower M. 2005;17(2):119
42.
Intercondylar fractures of the humerus. An operative 25. Parsons M,
OBrien RJ, Hughes JS. Elbow
approach. J Bone Joint Surg Am. 1985;67(2):22639. hemiarthroplasty
for acute and salvage reconstruction
16. Jupiter JB, Morrey BF. Fractures of the distal humerus of intra-
articular distal humerus fractures. Tech Shoul-
in the adult. In: Morrey BF, editor. The elbow and its der Elbow Surg.
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disorders. 2nd ed. Phildalphia: WB Saunders; 1993. 26. Palvanen M,
Kannus P, Niemi S. Secular trends in
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fractures of the distal humerus in elderly
17. Kalogrianitis S, Sinopidis C, Meligy EL, Rawal A, women. Eur J
Epidemiol. 1998;14:15964.
Frostick SP. Unlinked elbow arthroplasty as primary 27. Prasad N, Dent
C. Outcome of total elbow replace-
treatment for fractures of the distal humerus. ment for distal
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18. Kamineni S, Morrey BF. Distal humeral fractures failed internal
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J Bone Joint Surg Am. 2004;86-A(5):9407. 28. Robinson CM.
Fractures of the distal humerus. In:
19. Korner J, Lill H, Muller LP, Hessmann M, Kopf K, Bucholz RW,
Heckman JD, Court-Brown CM, edi-
Goldhahn J, et al. Distal humerus fractures in elderly tors. Rockwoods
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20. Kundel K, Braun W, Wieberneit J, Rutter A. 29. Sodergard J,
Sandelin J, Bostman O. Mechanical fail-
Intraarticular distal humerus fractures: factors ures of internal
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1996;332:2008. 30. Wadsworth TG.
Adult trauma. In: Wadsworth TG,
21. McKee MD. Displaced fractures of the lateral editor. The
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epicondyle of the humerus and posterolateral rotatory 1982. p. 21022.
Fracture Dislocations of the
Elbow - the Elbow Fixator
Concept
Konrad Mader, Jens Dargel, and

Thomas Gausepohl
Contents
Operative Technique: Elbow Fixator . . . . . . . . . . . 1440
Axis of the Elbow Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1441
Insertion of Ulnar Screws . . . . . . . . . . . . . . . . . . . . . . . . 1443


Relevant Applied Anatomy on Elbow Stability
and Biomechanical Characteristics of the
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1445
Hinged Fixator Used . . . . . . . . . . . . . . . . . . . . . . . . . .
1428
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1447
Elbow Joint Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . .
1428
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1428 References . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 1448
Kinematics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1430
Elbow Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1431
Biomechanics of Hinged Elbow Fixation . . . . . . . . .
1433
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1433
Conventional Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1435
Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1435
Indications and Timing for Surgery . . . . . . . . . . . . . 1437
Fracture Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 1437
1437
Surgical Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1437
The Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1438
Coronoid
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1438
Radial Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1438
Terrible
Triad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1439
Trans-Olecranon-Dislocation . . . . . . . . . . . . . . . . . . . . . .
1440
K. Mader (*)
Section Trauma Surgery, Hand and Upper Extremity
Reconstructive Surgery, Department of Orthopaedic
Surgery, Frde Sentralsjukehus, Frde, Norway
e-mail: konrad.mader@helse-forde.no
J. Dargel
Department of Orthopaedic and Trauma Surgery,
University of Cologne, Cologne, Germany
T. Gausepohl
Klinik fur Unfallchirurgie, Hand- und
Wiederherstellungschirurgie, Klinikum Vest GmbH,
Marl, Germany

1423
DOI 10.1007/978-3-642-34746-7_74, # EFORT 2014
1424
K. Mader et al.
disrupted, the injury is

termed fracture disloca-
Abstract
tion of the elbow and the
risk of recurrent or
Complex fracture dislocations of the elbow
chronic instability and the
development of
are a challenge even for the experienced
posttraumatic arthrosis of
the elbow are
upper extremity surgeon. Depending on the
increased. Treatment of
these injuries is challeng-
extent of the bony and soft tissue injury they
ing due to difficulties in
applying accurate
display different extents of instability with
definitions of the patterns
of the injury, in evalu-
inability to hold reduction of the elbow
ating the specific roles of
the component struc-
joint or with the delayed development of sub-
tures that contribute to the
instability of the elbow
luxation or dislocation. Avoiding the afore-
and the lack of a
standardized rationale for the
mentioned problems means avoiding elbow
operative treatment. Soft
tissue injury including
stiffness which is a major threat to the inte-
open wounds and vascular or
nerve compromise
grated function of the entire limb, thus mak-
add to the complexity of the
injury. In recent
ing the restoration of motion a basic goal of
years investigative efforts
were put into the def-
most reconstructive efforts following trau-
inition of the components
that contribute to the
matic injury to the elbow. The aim of this
stability of the elbow and
the concept of operative
chapter is to evaluate the aetiology of the
fixation of the osseous and
ligamentous lesions
instability, both osseous and ligamentous by
(i.e. articular fragments of
the distal humerus, the
using adequate diagnostic tools, and to estab-
radial head, the coronoid
process, the olecranon,
lish a protocol of stabilization with
the collateral ligaments and
combinations of
a combination of internal fixation, ligament
these lesions in order to
reconstitute elbow sta-
repair, stabilization of the radial head and
bility. In addition to this
more recently the devel-
neck and, as integrative part of the protocol,
opment and use of the
transarticular external
hinged external fixation as it has become very
fixator with motion capacity
of the elbow has
clear and eminent in the recent years, that it is
extensively broadened the
therapeutic spectrum
an important tool in the treatment of severe
of treating complex elbow
trauma and partially
fracture dislocation of the elbow. In the
changed therapeutic
pathways. The purpose of
recent years the role of hinged external
this chapter is to offer a
strategy in the treatment
fixation has expanded from using it as
fracture dislocations of the
elbow using hinged
last help to a fixed position early in the
elbow fixation as internal
part of the treatment
treatment protocol. Now hinged fixation has
protocol (Fig. 1).
become such an integrated part in the treat-
ment protocol in some centres in Europe, that
it is the advance in the treatment of these
injuries.
Fracture-dislocation of the
elbow mainly occurs
Keywords in the joints between the
humerus and ulna and
Fracture-dislocation elbow # Hinged fixator primarily is caused by
compression, shearing,
and avulsion forces. Radial
head and neck frac-
tures are produced by
compression or shearing
General Introduction force. Olecranon and
coronoid process frac-
tures, accompanied by
dislocation, are also
The elbow joint is one of the most inherently caused by compression or
shearing force. The
stable articulations of the skeleton. When in addi- most common type of fracture
of the olecranon
tion to the dislocation of the joint at least one of is made by traction force or
pulling of the
the osseous or articular component structures that triceps muscle. Concurrent
fractures of both
contribute to the stability of the elbow is condyles are produced mainly
by avulsion or
Fracture Dislocations of the Elbow - the Elbow Fixator Concept
1425
UNSTABLE ELBOW FRACTURE-DISLOCATION
Closed reduction, cast 100
Evaluation of xrays, CT
Coronoid: Olecranon:
Radial head/neck:
Ligaments, soft
Anteromedial facet: Refix coronoid-
Try to refix
tissus,
refixation bearing key-
(on table reconstruction)
instability:
Reduction in fragment(s)
safety corridor
flexion: extension Maintain COD
(plates) threaded wires
Reattach bony ligament
limit Angle stable
(radial head replacement)
avulsion
(ex fix) plating
No direct ligament repair

or refixation
HINGED ELBOW FIXATOR
Fig. 1 Treatment algorithm using hinged external fixation in unstable elbow

fracture dislocation
shearing forces. By definition will all disloca-

tions of the elbow be accompanied by rupture of
collateral ligaments or avulsion fractures of the
medial or lateral epicondyle [1]. ODriscoll
et al. have described the pathoanatomy of an
elbow fracture dislocation can be thought of as
a disruption of the circle of soft tissue or bone,
or both, that begins on the lateral side of the
elbow and progresses to the medial side in cir-
cular fashion (Fig. 2) [2]. This circle of disrup-
tion is referred to as the Horii circle and is
LUCL
analogous to the Mayfield spiral of soft tissue
MUCL
or osseous disruption, or both, in carpal insta-
bility. As disruption progresses from the lateral
to the medial side, the energy is passing through
the soft tissues or bone, or both. Therefore, an
elbow dislocation is most commonly associated
with a torn capsule, but the capsule may be
intact if the coronoid process is fractured.
Because energy is dissipated with a fracture
before the elbow dislocates, the anterior bundle
of the medial collateral ligament is often intact
when the radial head and coronoid process are Fig. 2 Modified
schematic drawing of the circle of Hori
both fractured. in dislocation of the
elbow (Modified after [2])
1426
K. Mader et al.
flexion 145 It is useful

together with David Ring and Jesse
supracondylar 135
Jupiter to distinguish
between four main groups
of complex fracture-
dislocation of the elbow
(Figs. 4 and 5): [4]
1. Posterior
dislocation of the elbow with frac-
intercondylar, ture of radial head
(Fig. 4a)
transcondylar 2. Posterior
dislocation of the elbow with frac-
115
ture of the radial
head and coronoid, so-called
terrible triad (Fig.
4b)
3. Trans-olecranon
fracture-dislocation (Fig. 5a)
4. Posterior oelcranon
fracture-dislocation
olecranon (representing the
most proximal type of pos-
80 terior Monteggia
type fracture (fracture of the
70 proximal ulnar and
dislocation of the radial
head; Fig. 5b).
Although the first
two are well known and
recognized, the latter
two injury patterns are
neck of
radius often mistaken for
simple fractures, which
60 often leads to referral
of complex and challenging
20
head of extension cases (Figs. 6 and 7)
[57]. These two injury
radius supracondylar entities usually
present with disruption, rather
than true dislocation
of the ulnohumeral joint.
40
The radial head is
either anterior or posterior to
0
35 the capitellum, but the
articular surfaces of the
coronoid olecranon and coronoid
processes remain in con-
tact to the trochlear
articular surface of the distal
capitellum
humerus. Even when
there is not a true dislocation
Fig. 3 Modified schematic drawing demonstrating the of the ulnohumeral
joint, the stability of the
flexion-extension arc of injury, which relates fracture ulnohumeral
articulation has been disrupted by
types to elbow position at the moment of impact (Modified
fracture and it is
appropriate to consider these inju-
after [3])
ries as fracture-
dislocations of the elbow. On occa-
sion, a posterior
olecranon fracture-dislocation
presents with true
dislocation of the ulnohumeral
Because the incidence of coronoid, olecranon, joint, but this is the
exception of the rule [4].
and condyle fractures seems to increases to the In order to classify
the different fracture pat-
amount of compression force, the current terns (i.e. of the
proximal radius and ulna) and or
biomechanical studies focussing on fracture- singular fracture
entities several classifications
dislocations resulting from experimental are in use. The AO
classification as the interna-
compression force. Amis and Miller in tional basis and
different location-specific classi-
a cadaveric study demonstrated a flexion- fications as Masonsor
Bados or Regans are
extension arc of injury, which relates fracture depicted in detail in
the chapter Fractures of
types to elbow position at the moment of impact the Olecranon, Radial
Head/Neck, and Coronoid
(Fig. 3) [3]. Radial head and coronoid fractures Process. Tyle has
coined the term character of
followed impact along the forearm up to 80# the fracture in the
pelvis and lower extremity
flexion. Olecranon fractures occurred by direct and this overall
description of the character of
impact around 90# flexion. Distal humeral frac- a fracture dislocation
of the elbow is also useful
tures mostly occurred above 110# flexion. in some extent (Fig.
8).
1427
Fig. 4 Radiographs of posterior dislocation of the elbow with fracture of radial

head (a) and posterior dislocation of the
elbow with fracture of the radial head and coronoid, so-called terrible triad (b)
a b
Fig. 5 Radiographs of trans-olecranon fracture disloca- Monteggia type

fracture (fracture of the proximal ulnar
tion (a) and posterior olecranon fracture-dislocation, and dislocation of
the radial head; b)
representing the most proximal type of posterior
1428
K. Mader et al.
Fig. 6 Radiographs of a complex trans-olecranon frac- female. On the right side

lateral radiograph at referral
ture dislocation with compound olecranon fracture and 2 months after initial
surgery
shear-off fracture of the radial head in a 65-year old
Fig. 7 Radiographs of a complex posterior olecranon a 68-year old male. On the

right side lateral radiograph
fracture dislocation with compound olecranon fracture at referral 5 months after
initial surgery
and dorsal dislocation of the proximal radius in
( Post-Traumatic Elbow
Stiffness - Arthrolysis
Relevant Applied Anatomy on Elbow and Mechanical
Distraction). A detailed under-
Stability and Biomechanical standing of the
biomechanics of elbow function is
Characteristics of the Hinged Fixator essential to effectively
treat pathologic conditions
Used affecting the elbow joint
[8].
Elbow Joint Biomechanics

Anatomy
The elbow is a complex joint that functions as
a fulcrum for the forearm lever system The elbow joint complex
allows two degrees of
responsible for positioning the hand in space freedom in motion:
flexion-extension and
1429
Fig. 8 Radiographs of two different characters of a fracture-dislocation
pronation-supination. The humeroulnar and

a
b
humeroradial articulations allow flexion and
extension and are classified as ginglymoid or
hinged joints. The proximal radioulnar articulation
allows forearm pronation and supination and is
classified as trochoid joint. The elbow joint com-
plex, when considered in its entirety, is
a trochleogynglymoid joint. The trochlea and
capitellum of the distal humerus are internally
rotated 3# 8# and in 2# 6# of valgus with respect
to the longitudinal axis of the humerus (Fig. 9a). 6
The articular surface of the ulna has approximately
a 4# 8# valgus angulation in reference to the long
axis of the shaft when viewed from the top
(Fig. 9b). The distal humerus is divided into medial
and lateral columns that terminate distally with the
5
c
trochlea connecting the two columns. The medial
collumn diverges from the humeral shaft at
a 45# angle and ends approximately 1 cm proximal
Fig. 9 AP view of the
distal humerus reveals a 6# tilt of
to the distal end of the trochlea. The distal one third the articular surface
with respect to its long axis (a). The
is composed of cancellous bone, is ovoid in sec- distal humeral lateral
view (b) shows a 30# anterior rota-
tion, and represents the medial epicondyle. The tion of the condyles
with regard to its long axis. The axial
lateral column of the distal humerus diverges at view of the distal
humerus demonstrates a 5# valgus tilt of
the articulation with
respect to its long axis (c; Modified
a 20# angle from the humerus at the same level as after [8], bone
specimen courtesy of Prof. Koebke,
the medial column and ends with the capitellum. University of Cologne)
The trochlea is shaped like a spool and is com-
prised of the medial and lateral lips with an inter-
vening sulcus. The sulcus articulates with the
semilunar notch of the proximal ulna. The articular an arc of approximately
180# . The articular surface
surface of the trochlea is covered by hyaline carti- of the ulna, which is
rotated posteriorly 30# with
lage of various arcs. The capitellum, comprising respect to its long
axis in the lateral view, matches
almost a perfect hemisphere, is covered with the 30# anterior
rotation of the distal humerus,
1430
K. Mader et al.
4 15
5
A
4
3 C
C
2
X
5
A 1
30
2
4
3
B 5 4
Fig. 10 Evaluation of the angular orientation of the prox-

imal ulna reveals a 4# valgus orientation of the ulnar shaft Fig. 11 Identifying
the centre of rotation of the elbow:
with respect to the greater sigmoid notch (upper left). (a) schematic
drawings of the lateral aspect view of a right
A lateral view of the proximal ulna shows a 30# posterior elbow depicting the
centre of rotation of the elbow (Mod-
slope of the greater sigmoid notch (bottom). The neck of ified after London
1981)
the radius makes an angle of 15# with the long axis of the
proximal radius (upper right; Modified after [8])
The normal range of
pronation-supination averages
from 71# pronation
to 81# supination. Most
providing stability to the elbow in full extension activities are
accomplished within the functional
(Fig. 9c). range of 50#
pronation to 50# supination. Clini-
The arc of articular cartilage of the greater cally, patients can
tolerate flexion contractures up
sigmoid is 180# but is not continuous with the to 30# , which is
consistent with Morreys func-
cartilage in its midportion, which in >90# of tional arc of
motion. There is a considerable and
individuals is comprised of fatty, fibrous tissue. rapid loss of the
ability to position the hand in space
The radial neck is angulated 15# from the long with flexion
contractures >30# , which is described
axis in the AP plane away from the bicipital by the cosine of the
measured flexion contracture.
tuberosity (Fig. 10). Four fifths of the radial The cosine of the
measured flexion contracture
head is covered with hyaline cartilage. The decreases rapidly
after 30# of flexion (Fig. 1,
anterolateral one fifth lacks articular cartilage chapter Post-
Traumatic Elbow Stiffness -
and strong subchondral bone and the shape of Arthrolysis and
Mechanical Distraction).
head and neck vary interindividually [9]. The axis of
rotation for flexion-extension has
been shown by
several investigators to be at the
centre of the
trochlea [8, 10, 11]. London dem-
Kinematics onstrated that the
axis of rotation passes through
the centre of
concentric arcs outlined by the bot-
Elbow flexion and extension takes place at the tom of the trochlear
sulcus and the periphery of
humeroulnar and humeroradial articulation. The the capitellum (Fig.
11) [12]. He also noted that
normal range of flexion-extension is from 0# to the joint surface
changes to a rolling type of
145# , with the functional arc of 30# 130# . motion during the
final 5# 10# of both flexion
1431
Fig. 12 Schematic drawing of the configurations and coordinate centres

(A and O) will be less than the greatest
dimensions of the locus of the instant centres of rotation dimension of the
locus; lower drawing (right) if the point
of the elbow; upper drawing (right): if a point approxi- is incorrectly
placed, this variation in the distance [RO/A]
mating the locus of the instant centres of rotation of the between the two
coordinate centres (A and O) will be
elbow is correctly positioned in the humerus during elbow greater than the
greatest dimension of the locus (Modified
flexion (as a k-wire for marking the centre of rotation), the after [14])
variation of the distance [RO/A] between the two
and extension, and the axis of rotation changes passes through the
centre of the capitulum, and
into a gliding/sliding joint motion. Rolling occurs the distal end of
the ulna. This axis is oblique to
at the end of flexion as the coronoid process the anatomical axis
of the radius and ulna. During
comes into contact with the floor of the humeral pronation-
supination, the radial head rotates within
olcranon fossa and with final extension as the the annular
ligament and the distal radius rotates
olecranon fits into the olecranon fossa [12]. around the distal
ulna outlining the shape of a cone.
In addition, internal axial rotation of the ulna The valgus
position of the elbow in full exten-
has been shown to occur during early flexion sion is commonly
referred to as the carrying
and external axial rotation during terminal flex- angle. The carrying
angle is defined as the angle
ion demonstrating that the elbow cannot be truly between the
anatomical axis of the ulna and the
understood as a simple hinge joint. There is also humerus measured in
the AP plane in extension
evidence to suggest the elbow has a changing or simply the
orientation of the ulnar with respect
individual centre of rotation during flexion- to the humerus. The
angle is less in children and
extension and functions in a more complex man- greater in females
averaging 10# of valgus in
ner than a simple uniaxial hinge [13]. Despite males and 13# in
females with a wide distribution
these variations, Morrey et al. stated the deviation in both.
Controversy exists regarding the change
of the centre of joint rotation with elbow motion in the carrying
angle as the elbow is flexed.
to be minimal, and the ulnohumeral joint could be
assumed to move as uniaxial articulation except
at the extremes of flexion-extension. The axis of Elbow Stability
rotation of flexion-extension occurs about a tight
locus of points measuring 23 mm in its broadest Valgus forces at
the elbow are resisted primarily
dimension and in the centre of the trochlea and by the anterior
band of the medial collateral lig-
capitellum on the lateral view (Fig. 12) [14]. ament (MCL). The
MCL complex includes an
Pronation and supination take place primarily at anterior bundle,
posterior bundle, and
the humeroradial and proximal radiulnar joint. The a transverse
ligament that consists of the thicken-
longitudinal axis of pronation and supination ing of the capsule
(Fig. 13a). The anterior oblique
1432
K. Mader et al.
a b
Fig. 13 (a, b) Photograph of medial collateral ligament complex (MCL, left) and the
lateral collateral ligament complex
(LCL, right) ligament in a bone-ligament cadaver specimen (Courtesy of Univ.-Prof.
J. Koebke)
ligament is tight in extension, and the posterior instability of the

elbow followed by the radial
oblique ligament is tight in flexion. This occurs collateral ligament
and to a lesser extent, the cap-
because the MCL complex does not originate on sule. Structures
limiting passive flexion include
the axis of elbow rotation. The anterior oblique capsule, triceps,
coronoid process, and the radial
ligament of the MCL originates from the inferior head. Passive
resistance to pronation-supination is
surface of the medial epicondyle of the distal provided in large part
by the antagonist muscle
humerus and inserts along the medial edge of group on stretch
rather than ligamentous struc-
the olecranon. With an intact anterior band of tures. The elbow has
both primary and secondary
the MCL, the radial head does not offer signifi- stabilizers. The three
primary stabilizers to elbow
cant additional resistance to valgus stress. How- instability are the
ulnohumeral articulation, the
ever, with a transected or disrupted anterior band medial collateral
ligament (i.e. the anterior bun-
of the MCL, the radial head becomes the primary dle), and the lateral
collateral ligament, especially
resistor to valgus stress, emphasizing its function the ulnar part of the
lateral collateral ligament
as a secondary stabilizer in elbows with intact (also referred to as
the lateral ulnar collateral lig-
MCLs. Limitation of elbow extension is provided ament). The secondary
stabilizers include the
primarily by the anterior capsule and anterior radial head
(radiohumeral joint), the common
bundle of the MCL. Also excision of the olecra- flexor (flexor-
pronator mass (FP-mass) and exten-
non fad pad has been shown to provide 5# of sor origins
(supinator-extensor mass (SP-mass)
additional extension. The lateral collateral and the capsule. The
secondary or dynamic stabi-
ligament complex (LCL) consists of the radial lizers include also to
a great extent the muscles
collateral ligament, which originates from the that cross the elbow
joint and produce compres-
lateral epicondyle and inserts into the annular sive forces at the
articulation [2]. The triceps,
ligament; the lateral ulnar collateral ligament, anconeus and
brachialis are the most important
which originates from the lateral epicondyle and muscles in this
regard. Originating near the lateral
passes superficial to the annular ligament epicondyle and
inserting broadly on the ulna in
attaching on the supinator crest and the accessory a fan shape, the
anconeus is designed to serve its
LCL (Fig. 13b). The origin of the LCL complex major function as a
dynamic stabilizer, preventing
lies on the axis of elbow rotation, explaining its posterolateral
rotational displacement of the
consistent length throughout the flexion- elbow. An elbow with
its three primary stabilizers
extension arc. intact will be stable.
If the coronoid process is
The lateral ulnar collateral ligament is the pri- fractured or lost, the
radial head becomes the
mary constraint to posterolateral rotatory critical stabilizer.
Longitudinal stability of the
1433
foreram is provided by both the interosseous mem- groups were tested with
and without fixator
brane and the triangular fibrocartilage. (Fig. 15). There were
three main messages in this
extensive study:
reconstruction of primary (MCL
anterior band) and
secondary stabilisers (radial
Biomechanics of Hinged Elbow head) gave no sufficient
valgus stability, the hinged
Fixation external fixator used in
the study did stabilize the
elbow against valgus load
in any instability situa-
There are several hinged external fixators on the tion (Fig. 14; it rendered
the elbow more stable than
orthopaedic market with different features and dif- the intact elbow in all
groups) and this worked
ferent biomechanical performances [16]. The first constant over the range of
motion (i.e. 0# , 30# ,
author of this chapter has run a prospective database 60# , 90# and 120# ).
on the use of the Orthofix elbow fixator in a single
centre with more than 900 fixator applications for
different indications. In 2008 a profound biome- Diagnosis
chanical test series of the fixator was conducted
by the second and first author (Dargel et al., sub- Elbow fracture dislocation
is most often the result
mitted). In a cadaver model the stabilization poten- of a high energy trauma to
the affected upper
tial of the Orthofix hinged elbow fixator was tested extremity. If the elbow is
still dislocated, defor-
in a destabilisation/stabilisation model. After test- mity and swelling of the
elbow are visible. After
ing of the valgus stability of the intact elbow with checking and documenting
the neurovascular sta-
(IN) and without the external fixator (with different tus, inspection is aimed
at the soft tissue envelope
valgus deforming forces and in different degrees of and hematoma formation, a
gross medial
flexion/extension using a hinged pulling system hematom pinpoints medial
ligament injury. Con-
(Fig. 14), the elbow was gradually destabilized ventional xrays should be
performed before and
(cutting av anterior band MCL (IBX), removal of after gentle reduction
with appropriate anaes-
the radial had (RKK)) and thereafter restabilised thetic support and a
padded elbow splint is
(Repair of anterior band of the MCL (IBR) and applied in 100# of
flexion, if soft tissues allow
reconstruction of the radial head (RKR). Each this. The postreduction
conventional x-rays are a
step in both destabilization and restabilisation documentary must and
should be scrutinized for
Fig. 14 Schematic
drawing of the
experimental setup used in
testing valgus stability in
the elbow fixator model
1434
K. Mader et al.
Valgus instability after 5 Nm valgus

deformation
*
25
*
*
*
20
Grad []
15
10
5
0
IN
KX
KX
X
KR
X
FI
FI
IB
FI
FI
FI
R
R
+
+
+
+
+
X
KX
KX
KR
IN
R
IB
IB
IB
IB
R
R
+
+
X
R
IB
IB
IB
* = p<0,05
Fig. 15 Results of the biomechanical testing in a valgus destabilized

(cutting av anterior band MCL (IBX),
instability cadaver elbow model: valgus stability of the removal of the
radial had (RKK)) and thereafter
intact elbow with (IN) and without the external fixator restabilised
(repair of anterior band of the MCL (IBR)
(with a valgus deforming force of 5 NM using a hinged and
reconstruction of the radial head (RKR)
pulling system (Fig. 14): the elbow was gradually
Fig. 16 Anterorposterior
and lateral x-ray of
a fracture dislocation of the
left elbow in a 30-year old
male patient: note the
compound fracture of the
proximal ulna, the ventral
(sub)luxation of the distal
humerus, the involvement
of the radial head/neck and
the coronoid process
reduction of the ulnohumeral joint. The found. These

injuries must be suspected to
postreduction neurovascular status again avoid sequelae
impairing function further. In the
should be taken and recorded. As a result of obvious elbow
injury, attention is usually
high energy trauma, associated injuries are often focussed on the
dislocated elbow but there should
1435
be a high index of suspicion for ipsilateral wrist

fractures (radius, scaphoid, and other carpal
bones), acute disruption of the interosseus mem-
brane (ALRUD injury, proximal ulna fractures,
radial neck fractures, or contralateral upper limb
fractures.
Conventional Imaging
Any elbow trauma is assessed initially using stan-

dard anteroposterior (AP) and lateral radio-
graphs, which gives an idea of the type and
personality of injury involved (Figs. 8, 16). The
AP is taken with the elbow extended and Fig. 17 Twenty five year-
old patient with simple radial
head fracture after
missed elbow dislocation. The lateral
the forearm supinated (when possible) with the conventional x-ray reveals
a drop sign
patient seated or supine, the beam is directed
perpendicular to the midpoint of the elbow joint.
The features demonstrated on this view should
include the distal humerus, epicondyles, trochlea,
capitellum, radial head including proximal radius view and then angling the
beam 45# medial to
and olecranon. The lateral view is taken with the lateral and centered 2.5
cm inferior to the
patient seated if possible, the shoulder abducted epicondylar axis. This
view gives an unrestricted
90# , so that the shoulder is level with the film and view of the radial head.
Careful analysis of these
the elbow is flexed at 90# . In this position the three conventional x-rays
will give information
forearm is placed in supination and the beam is about the bony lesions
involved and any existing
directed perpendicular to the humeral dislocation or subluxation
of the elbow joint.
epicondyles centered on the elbow joint. On this Repeat AP and lateral x-
rays after reduction and
view the epicondyles should be superimposed, casting in a well-padded
upper arm cast (in 100# of
the olecranon should be seen in profile, and the flexion) are required and
again cautiously
radial head superimposed on the coronoid pro- analysed for any
persisting subluxation of the
cess. Relationships that should be checked joint. Joint incongruity
or asymmetry (i.e. rotatory
include the radiocapiteller line, which should subluxation) or a drop
sign should be cautiously
bisect the radial head and the capitellum, and evaluated (Fig. 17).
the anterior humeral line, which should run
through the middle third of the capitellum.
A thorough assessment of the initial radiographs Computed Tomography
at this stage should include the soft tissue enve-
lope, anterior and posterior fat pads, cortical con- Computed tomography is the
tool of choice to
tinuity, joint congruendy, and bony alignment. evaluate the type and
extent of bony fragmenta-
Coonrad et al. proposed the drop sign, which tion and presence/absence
and direction of any
is an increase in ulnohumeral distance on the persistent
dislocation/subluxation of the elbow
lateral x-ray-film [17]. This objective and static joint (Fig. 18ae).
Helical scanning with two-
radiographically measurable increase in dimensional reconstruction
can be done quickly
ulnohumeral distance can be viewed as warning with the arm rested in the
cast after reduction.
sign for the presence of ligamentous instability. The Superman position
(with the arms over-
A radial head-capitellum view can be obtained by head) produces the best
image quality, but scans
having the patient positioned for a lateral elbow can be done with the elbow
at the side (giving
1436
K. Mader et al.
a b
c d
Fig. 18 CT scans of the same patient as in Fig. 16; (a) of the proximal ulna;
(c) sagittal reconstruction showing
transverse scan depicting the involvement of the coronoid involvement of the
radial neck; (d) sagittal reconstruction
process; (b) transverse scan showing the ventral disloca- showing the extent of
the ulnar destruction; (e) sagittal
tion of the distal humerus and the compound destruction reconstruction with
subluxation of the humerus
1437
some more volume artefacts). It is useful to start motion in a cast-brace

without subluxation.
with the original transverse sections, followed by The elbow fixator concept
in fracture fixation
the analysis of the frontal and sagittal reconstruc- will in virtually causes
use hinged fixation in
tion images and finally the three-dimensional the treatment protocol and
ligament repair is
reconstruction (Fig. 20). The transverse plane is the exception of the rule
(i.e. if the ligament
used to evaluate the proximal radioulnar joint and are avulsed with bony
attachments).
the distal humerus, olecranon, coronoid and
radial head including the pattern of articular frag-
mentation. The coronal or frontal plane provides Fracture Fixation
an image similar to the standard PA radiograph
and will provide better bone detail and During the last decade, in
America and
intraarticular fragmentation. The sagittal plane Europe standard surgical
protocol to treat com-
will give a clear view ventral or dorsal dislocation plex elbow fracture
dislocations have evolved.
of the humeroulnar joint and the dislodgement These provide guidance in
reconstructing both
of fragments of the coronoid process and ligamentous and bony
components. Recent
the radial head. advances in fracture
fixation of the radial head,
olecranon, the
introduction of angle stable plating
systems in fractures of
the distal humerus,
Indications and Timing for Surgery olecranon and the
strategic use of hinged external
fixation have further
broadened the therapeutic
Virtually all cases of fracture dislocation of the spectrum. The surgical
techniques in dealing
elbow will be managed surgically. These cases with fractures of the
olecranon, radial
are challenging and only a minority of cases head and coronoid process
are outlined in
with neurovascular damage, impossibility to chapter Fractures of
the Olecranon, Radial
achieve reduction due to severy bony and soft Head/Neck, and Coronoid
Process.
tissue destruction and repeated redislocation in
cast require urgent emergency surgery. Other-
wise, as in all complex reconstructive joint sur- Operative Technique
gery, best time, best surgeon and best team are
advocated. A complex fracture dislocation of the Surgical Approaches
elbow is best operated on after some soft tissue
conditioning after 510 days after injury and, if Surgical approaches to the
elbow can be classi-
possible, referral to a specialized centre is fied according to the
aspect of the joint exposed,
recommended. Traditionally and historically, as anterior, lateral,
medial, posterior and global.
open reduction and internal fixation of the The aim of a surgical
approach to the elbow is to
coronoid fracture and/or repair of the anterior provide an adequate
extensile exposure with
capsule, repair or replacement the radial head, preservation of the
neurovascular structures.
and repair of the lateral ligament complex were Modern surgical approaches
to the elbow began
the treatment of choice [2, 1821]. Repair of the with the lateral approach
to the elbow described
medial collateral ligament and/or application of as early as 1911 by
Kocher. Subsequently, many
a hinged external fixation were reserved for authors have described
approaches to the elbow
patients who demonstrate residual instability with the intention of
providing improved visual-
after this standard protocol. Especially repair ization, primarily of the
anterior elbow, without
of an acute ligament injury was indicated in all compromising the surgical
outcome. Henry
fracture-dislocations requiring internal fixation described the generally
followed principle of
of the radial head or the coronoid process, or extensile exposure. The
majority of these expo-
both, and following reduction of a dislocation if sures use internervous or
intermuscular intervals.
gross instability did not allow early protected Therefore, it is a
prerequisite to be familiar with
1438
K. Mader et al.
the surgical anatomy of the major nerves and its injury force resulting in
complex instability
cutaneous branches, the muscles and the medial [27, 40]. They concluded
that anteromedial frac-
and lateral ligament complex [11]. tures of the coronoid are
associated with either
subluxation or complete
dislocation of the elbow
in most patients. In order
to detect this very
The Ligaments unstable subset of coronoid
fractures again a CT
scan seems mandatory. Most
of the times there
In the majority of cases, the ligaments are rup- are two or more fragments,
which make stable
tured in their mid-substance with complex tears refixation a demanding
procedure with possible
in the pronator-flexor or supinator extensor complications such as
masses, or are avulsed degloving some parts of and secondary dislocation
(Fig. 19ad). The
their proximal attachments. Sometimes the liga- operative strategy in
refixation these fragments
ments are avulsed with bony attachment which is outlined in the chapter
Fractures of the
can be readily refixed with fragment specific Olecranon, Radial Head/Neck,
and Coronoid
implants. Using the elbow fixator concept, only Process. Although most
experts recommend
ligaments with avulsed fragments are refixed, open reduction and direct or
indirect fixation of
virtually all other ligament injuries heal by the coronoid fragments there is
a new concept, when
dynamic reorganisation provided by guided and using hinged external
fixation, to limit extension
stable movement with the fixator [2224]. to 30# for a period of 23
weeks and thereby
indirectly to create
stability (Fig. 20).
Coronoid Process
Radial Head
Coronoid fractures of the ulna are relatively
uncommon, yet critical injuries to recognize [25]. If in doubt, resect was
the old dogma regarding
They definitely play an important role in the treatment of fractures
of the radial head.
elbow instability. Historic recommendations are Patients with comminuted
radial head fractures
to fix all large coronoid fracture fragments, as and those with associated
soft-tissue injuries of
well as small fracture fragments associated with the elbow have a poor
outcome if the radial head
instability. The coronoid process acts as a bony is simply resected.
Complications include subse-
buttress to prevent posterior dislocation and has quent distal radioulnar
pain, weakness and insta-
three soft tissue insertions which lend stability as bility of the elbow, cubitus
valgus and ulnar
well: the anterior joint capsule of the elbow, the neuritis [28, 29]. The role
of the radial head as
brachialis muscle and the medial ulnar collateral an important stabiliser of
the forearm and elbow
ligament. If the elbow is unstable, management is now better understood
[30, 31]. It should not be
usually consists of a combination of bony and resected without careful
consideration [29, 32].
soft-tissue repairs often including coronoid pro- The treatment of Mason type-
III fractures and
cess repair. Loss of motion is the most common those with associated
ligamentous damage or dis-
complication of these injuries. The current rec- location (Mason type IV) is
challenging. Several
ommendation was to repair virtually all coronoid methods of reconstruction
have been described
fractures associated with instability [26]. Recent and prosthetic replacement
of the radial head is
biomechanical and clinical investigations have recommended for comminuted
fractures, espe-
emphasized the importance of the coronoid pro- cially if the medial
collateral ligament is
cess in the stability of the ulnohumeral articula- disrupted. There are some
concerns about the
tion. Recently, Doornberg and Ring pointed at the non-anatomical shape of the
prostheses which
importance of the anteromedial facet of the may cause loosening,
subsequent degenerative
coronoid as a distinct type of coronoid fracture changes and instability of
the elbow. We always
resulting from a varus posteromedial rotational try to reconstruct the
radial head, even as
1439
a b
c d
Fig. 19 Fracture-dislocation of the right elbow in a 35 which one is an

anteriomedial facet fragment; (d) X-ray-
year-old man (a) lateral x-ray demonstrating a complex control 3 months
postoperative after open reduction and
coronoid fracture; (b) sagittal ct reconstruction showing internal fixation of
the coronoid with help of an ulnar
basal multifragmented coronoid fracture-pattern; (c) 3-d osteotomy: severe
heterotopic ossification (Ilahi IV) on
ct reconstruction depicting two distinctive fragments, of the ulnar side leading
to complete ankylosis of the joint
on-table reconstruction, as it will be the major Terrible Triad

radial stabilizer after bony healing. If there is
severe comminuation of the radial head and The terrible triad
injury (radial head fracture,
neck, after reconstruction a hinged fixator is man- coronoid fracture and
ulnar ligament disruption)
datory in order to unload the radial head. Next to has a history of
complicated outcomes as the
preformed plates in the so-called save-zone attending surgeon
attempts to maximize func-
headless minifragment screws with fine threads tional range of
motion goals while maintaining
are useful in reconstructing the radial head stability [33]. Several
investigators have
(Fig. 21ag) [29, 33]. displayed standardized
surgical protocols
1440
K. Mader et al.
Fig. 20 Elbow fixator

mounted on plastic elbow
specimen demonstrating
extension limit device
mounted on the ulnar link
of the fixator
relying on stable reconstruction of the bony annular ligament, remain

intact. Most of the fail-
elements and extensive ligament repair [15, 20, ure of the ulnohumeral
joint is a result of the bony
33, 34]. While most of the American colleagues disruption rather than the
ligamentous compo-
rely on the protocol of reconstruction/replace- nent. The osseous injury
can be a simple,
ment of the radial head, the coronoid and liga- noncomminuted, transverse,
or oblique fracture
ment repair, the integrative use of hinged of the olecranon, but is
more commonly
external fixation is challenging this. After repair a complex and comminuted
fracture involving
of the radial column (radial head and neck and the trochlear notch and,
sometimes, the coronoid
the LUCL the elbow fixator is applied, the ulnar process as well (Fig. 22a
x). This lesion, often
ligament complex is not repaired and the caused by high-energy
trauma, can result in
coronoid is only repaired, if there is no congru- a complex skeletal
disruption including an avul-
ent stability with the fixator on. We used this sion or shear fracture. It
became quite clear, that
protocol in 45 consecutive terrible triad this injury represents an
intrinsically unstable
injuries [35]. bony lesion that requires
good preoperative plan-
ning and stable internal
fixation with complete
restoration of articular
congruence and the
Trans-Olecranon-Dislocation coronoid buttress, allowing
early active mobili-
zation, which is critical
to obtain good long-term
Transolecranon fracture-dislocation of the elbow results [36, 37]. If there
is additional soft
occurs when a high-energy direct blow is applied tissue injury or severe
bone loss, maintenance
to the dorsal aspect of the forearm with the elbow of the coronoid-olecranon
tip distance (COD)
in midflexion and causes an olecranon fracture is of utmost importance in
order to avoid
associated with an anterior dislocation of the posttraumatic stiffness.
Again a hinged
forearm with respect to the distal humerus. monolateral fixator is a
suitable tool to control
The trochlea appears to have fractured through the soft tissues and allow
early mobilization.
the olecranon process as the forearm is
displaced anteriorly. The transolecranon frac-
ture-dislocation is different from posterior Operative Technique: Elbow
Fixator
Monteggia Bado 1 lesion, because in the former,
there is a loss of stability in the ulnohumeral joint Application of the fixator
is performed from the
but the radioulnar relationship is preserved. The lateral aspect into the
humerus and distal into
capsuloligamentous restraints, in particular the the ulna. A detailed and
step by step operative
1441
technique as an updated version of the initial individual human being in

both frontal and hori-
technique is available since 2008. zontal plane, which makes
the identification of
the individual centre of
rotation in theory impos-
sible. In surgical
practice, a total arc of motion of
Axis of the Elbow Joint 120# of both the elbow
joint and elbow
fixator without
impingement or mechanical hin-
First, and most important, the axis of the humero- drance is possible. The
aim of the correct place-
ulnar joint is identified and marked with a 2.0 mm ment of the K-wire is to
match the individual
K-wire. Several investigators have shown centre of rotation of the
elbow to
clearly that there is an individual variation of the mechanical centre of
rotation of the external
the inclination of the axis of movement in each fixator. An image
intensifier is positioned in an
a b
Fig. 21 (continued)
1442 K. Mader et al.
e f
Fig. 21 (continued)
1443
exact lateral view of the elbow in such way, that screw and the humeral
ball joint is locked using
both humeral condyles are projected over each appropriate allen
wrenches in order to minimize
other to form a circle (Fig. 23). After this a 2 mm stress and movement of
the pilot-wire (Fig. 26).
K-wire is placed with its tip in the centre of
this circle and drilled from the radial side through
the condyles. Full penetration of the ulnar Insertion of Ulnar
Screws
epicondyle is not performed in order to avoid
damage to the ulnar nerve. At the radial side The distal screws are
implanted from the dorsal
a sufficient length of the wire must protrude to side into the ulna.
Here too the fixator is used as
allow the placement of the central unit of the template. The
dimensions of the ulna make
fixator on it (Fig. 24). a smaller screw
diameter mandatory. Selfcutting
Insertion of humeral screws. Firstly the humeral conical threaded
screws with a diameter of 3.5 mm
screws are placed midshaft from the lateral side at the tip and 4.5 mm
at the base (here drilling with
and during placement the course of the radial nerve 3.2 mm) are used.
These screws are also used at
must be taken into account (Fig. 24). The fixator the humerus in
individuals with extraordinary
mounted on the K-wire is applied as its template small diameter (<20
mm). There again must be
for screw insertion. To protect the soft tissues we sufficient distance
between fixator and skin
always use an appropriate drill guide. The fixator (Fig. 26). A special
problem is the directing of
clamp allows five possible positions of the screws, the ulnar fixator link
towards the joint axis.
position 1 and 4 is recommended (Fig. 25) for Since the humeral link
is positioned always in
gaining additional length by moving the clamp the axis of the bone,
the ulnar screws have to be
(shifting to position 2 and 5). The screws have placed in a way that
the fixator link is at an angle
conical threads with 5 mm diameter at the tip and with the ulna. The
screws must still cross the ulna
6 mm at the basis (drilling with 4.8 mm). centrally. When the
straight clamp does not
The screws should penetrate the humerus cen- achieve positioning of
the ulnar fixator link
trally and both cortices. According to the average according to the
centre of rotation, it must
bone diameter in the midshaft humerus normally be exchanged for an
extended range clamp.
screws with a thread length of 30 mm are suffi- The average time to
apply the fixator takes
cient. The unthreaded portion of the screw should 20 min additional
operative time.
allow positioning of the fixator 1.52 cm away
from the skin to allow eventual postoperative
swelling (screw lengths 100/30 or 110/30). The Post-Operative Care
and
profound anatomical study of Gausepohl et al. Rehabilitation
has provided the safe zone of pin placement in
the area of the insertion of the deltoid muscle (so- The elbow joint is
held in resting position of 90# of
called sweet spot, Fig. 25). With placement of the flexion for at least 6
days and for up to 10 days if
humeral pins in this area both fixator screws are the damage to the soft
tissue envelope is substan-
situated proximal to the radial nerve. After place- tial. Pronation and
supination is free from the
ment of the humeral screws the humeral fixator beginning and
humerulnar elbow motion is started
clamp, the small s called humeral link locking by unlocking of the
screw of the central unit
Fig. 21 Thirty three year-old patient with complex frac- reconstruction of the
bony injury; (e) conventional
ture dislocation of the right elbow with a comminuted anterioposterior x-ray
5 weeks after the injury after ORIF
fracture of the proximal radius; (a) x-rays in cast after of the radial head and
application of an hinged external
reduction; (b) Scout CT scan showing the superman posi- fixator; (f) higher
resolution demonstrating reconstruction
tion. (c) Exemplary CT scans showing the extent of the of the radial head
with fine threaded screws; (g) clinical
radial head destruction and the coronoid fracture; (d) 3-d image 5 weeks after
operation during physiotherapy
1444 K. Mader et al.
a b
Fig. 22 (continued)
1445
a standardized
protocol. Elbow function is deter-
mined by the
questionnaire developed at the Mayo
Clinic for
determining the Mayo Elbow Perfor-
mance Index for
each patient. As outcome mea-
surement for
patient-specific outcome we use in
addition the
Disabilities of the Arm, Shoulder, and
Hand (DASH)
questionnaire. In order to monitor
the patient cohort,
follow-up investigations are
prospectively
performed at 6 and 12 months after
each index
operation and yearly thereafter.
The recorded
physical findings at follow-up
should consist of
the range of elbow movement
using a
conventional goniometer by the same
investigator to
rule out interobserver errors, the
presence of
tenderness during movement, medial,
Fig. 23 Intra-operative lateral fluoroscopic image of the
elbow with a 2 mm K-wire in the individual centre of posterolateral or
rotational instability, motor and
rotation of the elbow sensory examination
with determination of two-
point
discrimination, and grip strength using an
hydraulic hand
dynamometer. Stability is tested
manually and
classified as stable (0 points), mildly
(mobilisation phase). Physiotherapy is of utmost unstable (1 point:
varus-valgus laxity less than 5#
importance and is performed three times per week. in either direction
without symptoms), moderately
In order to avoid formation of heterotopic bone unstable (2 points:
laxity 5# 10# with mild symp-
and to reduce pain, indomethacin (50 mg twice toms) and severely
unstable (3 points: gross varus-
a day with gastric protection) is prescribed for the valgus laxity more
than 10# with serious problems
total treatment period. during patients
daily activities.
X-ray control are performed at 1, 7, 14, 28 days Anteroposterior
and lateral radiographs are
postoperative and before removal of the fixator taken and examined
for the alignment of the
using dental films for unobstructed lateral view. joint, joint space,
presence or advancement in
Pin site care is performed 23 times in the first joint degeneration,
loose bodies or new formation
weeks with and thereafter weekly using mild non- of heterotopic bone
or arthritic changes.
coloured disinfectant (Octenisept, Schulke &
Mayr GmbH, Norderstedt, Germany) and gauze
dressing. The fixator remains in situ for Complications
67 weeks, all fixator pins can be removed in the
outpatient department without local anaesthesia. Posterolateral
rotatory subluxation (identified as
Physiotherapy is continued for at least 1 year a loss of the co-
linearity of the radial head/neck
after fixator removal. Postoperative follow-up and the capitellum
on the lateral view) and/or recur-
should be a minimum of 5 years as in any articular rent posterior
instability were common leading to
lesions and we strongly recommend the use of repeat operative
fixation or external hinged fixator
Fig. 22 Twenty five year-old patient with complex approach. (c)

Intraoperative fluoroscopic image of the
transolecranon fracture of the elbow after a motobycicle reconstruction of
the COD (Coronoid-olecranon-tip
injury (lateral trauma x-ray Fig. 5a): (a) clinical aspect of distance). (d)
Clinical picture of the elbow after application
the left elbow at surgery 6 days after the injury. (b) A pen of the elbow
fixator. (e) Clinical instability testing 6 weeks
reduction of the complex olecranon fracture including indi- after the operation
during outpatient frame removal.
rect reduction of the key koronoid fragment using a dorsal (f) Function of the
affected elbow before fixator removal
1446
K. Mader et al.
Fig. 24 Drawing depicting the safety corridor for humeral pin placement during
elbow fixator application (Modified
after [11])
application before the elbow fixator concept was to loss of motion and
unfavourable results. This
inaugurated [38]. We do have to state here that the concept is maybe
reserved to specialist centres
application of the elbow fixator is not an easy task, with adequate expertise
in the field of advanced
especially in the complex fracture dislocation set- external fixation [39].
Common complications
ting and because of the stability of the fixator used, related the use of
external fixation as pin site infec-
there may be iatrogenic dislocation/subluxation tion, nerve damage
related to pin-placement or
which is created by the fixator and easily iatrogenic fracture
through fixator pin site can be
maintained by the stability of the construct leading reduced to very low
figures in these units [39].
1447
(e.g. the MEPI) and

patient-rated quantitative mea-
sures (e.g. DASH) of
elbow function [41]. Espe-
cially a painful ulnar
nerve will affect the patients
life negatively. Post-
traumatic arthritis in these com-
plex lesions does occur,
but is usually mild or
moderate.
Fig. 25 Intra-operative image of marking of the position Summary

of the humeral clamp and screw position during placement
of the humeral fixator pins Hinged external fixation
has expanded from using
it as last help to a
fixed position in the treatment
protocol of complex
fracture dislocations of the
elbow. The key messages
are:
1. Computed tomography
with three dimen-
sional
reconstructions is helpful (maybe man-
datory) in obtaining
an appropriate diagnosis
of the type and
character of the injury.
2. All equipment needed
for reconstruction must
be available in
place and in the armentarium
(and brain) of the
attending surgeon (screws,
suture anchors,
plates, prosthesis, external
fixator, etc.)
3. Limited approaches
without major scarring
tailored to the
fracture pattern is recommended
Fig. 26 Final sequence of fixing all fixator screws with 4. Repair/replant the
radial head, use a functional
appropriate distance between the fixator and the skin approach to the
ligamenteous injury and
or the coronoid by
using hinged external
fixation.
By pushing the limits on radial head reconstruc- 5. The main goal of the
elbow fixator concept is
tion, radial head nonunion or malunion following to obtain a stable
joint that allows early
open reduction and internal fixation can arise and motion, which is
started a few days
radial head excision after restoration of the ligamen- postoperatively.
tous stability with/without insertion of a metallic 6. A functional elbow
can be expected when
prosthesis can be mandatory. Clinically significant using these current
protocols, with an average
heterotopic ossification is uncommon following this flexion of
approximately 110# .
injury by using prophylaxis with indomethacin and 7. Additional procedures
may be necessary,
creating stability with hinged external fixation. especially for joint
stiffness, removal material
Clear infection is treated with irrigation, debride- or ulnar nerve
symptoms. Degenerative
ment and removal of loose fixation/fragments. changes may develop
but will usually be
Severe stiffness is possible even with optimal treat- tolerated well [15,
39].
ment, and may require release later after healing has
occurred. Special focus on this even greater chal- Acknowledgment The
authors state that they receive no
lenge is outlined in the chapter elbow stiffness royalties from any
company related to the external fixator
recommended in the
study.
including distraction arthroplasty. This chapter is
dedicated to our teachers and mentors Prof.
Doornberg et al. have shown clearly, that pain (emeritus) Juergen
Koebke and Professor Dietmar Pennig,
has a very strong influence on both physician-rated Cologne, Germany.
1448
K. Mader et al.
Surgical
technique. J Bone Joint Surg Am. 2005;87-A
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A:172531.
Fractures of the Olecranon,
Radial
Head/Neck, and Coronoid
Process
Peter Kloen, Thomas Christian

Koslowsky, and Konrad Mader
Contents
Keywords
Olecranon Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1451
Aetiology # Anatomy and Biomechanics #

Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1452 Classification # Complications and outcomes
Anatomy and Biomechanics . . . . . . . . . . . . . . . . . . . . . . .
1452 # Coronoid # Diagnosis # Fractures #
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1452 Introduction # Olecranon # Pre-operative
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1453
1453
preparation # Radial head # Rehabilitation #

Pre-Operative Preparation and Planning . . . . . . . . . . .
1453 Surgical indications # Surgical techniques
Surgical Approach and Technique . . . . . . . . . . . . . . . . .
1454
Post-Operative Management . . . . . . . . . . . . . . . . . . . . . . .
1460
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 1461
Radial Head and Neck Fractures . . . . . . . . . . . . . . . .
1462 Olecranon Fractures
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1462
Anatomy, Classification and Diagnosis . . . . . . . . . . . .
1463
Surgical Technique 1: Internal Fixation . . . . . . . . . . .
1463 Olecranon fractures comprise 10 % of all upper
Surgical Treatment 2: Radial Head Prosthesis . . . .
1468 extremity fractures [1, 2]. Due to its subcutaneous
Coronoid Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1470 position, the olecranon is vulnerable to direct
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1472 trauma. Internal fixation is the treatment of choice
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 1473 for most displaced fractures. Several techniques
Operative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1474 for osteosynthesis are available: tension-band wir-
Outcome and Complications . . . . . . . . . . . . . . . . . . . . . . .
1477
ing, intramedullary screw (with or without

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 1477 tension-band wire), resection and shortening,
intramedullary nail, and plate fixation [3]. Non-
operative treatment and resection with triceps
advancement are reserved for the low demand
patient with small osteoporotic fragments.

P. Kloen
The goals of operative fixation are re-align-
Department of Orthopaedic Surgery, Academic Medical
ment, restoration of articular congruency and sta-
Center, Amsterdam, The Netherlands
bility, normal strength and a painfree functional
T.C. Koslowsky
arc of motion of the elbow [1]. The fracture pattern
Department of Surgery, St. Elisabeth Hospital, Cologne,
determines what type of fixation is best used. Most
Germany
displaced olecranon fractures are relatively sim-

K. Mader (*)
ple, being non-comminuted and transverse. For
Section Trauma Surgery, Hand and Upper Extremity
these, tension-band wiring still is the gold standard

Reconstructive Surgery, Department of Orthopaedic
Surgery, Frde Sentralsjukehus, Frde, Norway
based on current evidence, despite marketing of
e-mail: konrad.mader@helse-forde.no
various pre-contoured plates [3]. For the elderly,

1451
DOI 10.1007/978-3-642-34746-7_228, # EFORT 2014
1452
P. Kloen et al.
outcome data on non-operative treatment and There is a bare area in

the hyaline cartilage of
excision with triceps advancement for small frag- the sigmoid notch between
the distal third and
ments is limited but surprisingly favourable [3]. proximal two-thirds. Its
architecture provides
Complex fractures are those that are commi- intrinsic stability while
allowing flexion-
nuted, involve the coronoid process or are part of extension (0# 150# arc) of
the elbow. Resistance
a fracture-dislocation. These fractures require to valgus and varus force is
provided by the
plate fixation because tension-band wiring cannot medial and lateral
ligamentous complexes.
provide enough stability to allow early post- The triceps tendon inserts
on the olecranon as
operative elbow motion. In addition, plate well as on the fascial
envelope of the forearm.
fixation lowers the risk of fatigue failure caused Anteriorly the brachialis
tendon inserts slightly
by extreme bending stresses. Having been modi- distal from the coronoid
process. The ulnar nerve
fied since Listers first olecranon plating in 1883, is in close proximity to the
olecranon passing
contoured dorsal plating of the olecranon -where through the cubital tunnel
before entering in the
the proximal end of the plate is wrapped around flexor carpi ulnaris
distally.
the tip of the olecranon- is now standard for care Biomechanics: Most
biomechanical studies of
for these complex olecranon fractures [48]. olecranon fixation concern
simple transverse
fracture patterns tested
with various tension-
band techniques [10, 11].
Variations are the
Aetiology material the tension-band is
made of (steel wire,
polyethylene, braided cable,
suture), the position
Olecranon and proximal ulna fractures are often of the K-wires
(intramedullary or penetrating the
the result of direct or indirect forces or volar cortex) and the
position of the drill hole in
a combination of both. Direct force drives the the ulna (anterior or
posterior to the mid-axis).
distal humerus into the sigmoid notch resulting Some studies have focussed
only on plating or
in comminution and/or impaction similar to wiring, while others
compared various tech-
a tibia plateau fracture. The injury pattern is niques. Study designs differ
and make compari-
related to the amount of flexion of the elbow at sons between them difficult.
Overall, evidence
time of impact. If the force is indirect (hyperex- suggests that locking
(pre)contoured plates with
tension with the triceps pulling the proximal frag- an intramedullary screw
provide excellent stabil-
ment away) the result is a transverse or short ity), although locking per
se might not be essen-
oblique fracture. High-energy injuries often tial [12]. Three recent
biomechanical studies of
result in a fracture-dislocation (posterior or ante- an intramedullary (IM)
device compared the IM-
rior fracture-dislocation of the elbow). The pos- nail with tension-band
wiring, or a locking plate,
terior fracture dislocation is considered showed that the IM-nail
performed best [13].
a Monteggia variant and often has an associated
coronoid fracture, radial head damage and liga-
mentous injury. In an anterior trans-olecranon Diagnosis
fracture the ligaments are often spared. In both
anterior and posterior fracture-dislocations the Due to their subcutaneous
position, fractures of
relation of the proximal radio-ulnar joint is the olecranon and proximal
ulna are easy to
undisturbed [9]. detect. There is swelling,
pain, crepitus and
effusion with limited range
of motion. Plain AP
and lateral radiographs
suffice for transverse
Anatomy and Biomechanics non-comminuted fractures.
For more complex
fracture patterns with
comminution, impaction,
Anatomy: The olecranon forms the greater sig- coronoid fractures,
radial head and
moid notch together with the coronoid. This sig- fracture-dislocations a pre-
operative CT-scan
moid notch articulates with the distal humerus. preferably with 3D-
reconstruction is helpful.
Fractures of the Olecranon, Radial Head/Neck, and Coronoid Process
1453
A neurovascular examination with inspection of to tension-band wiring.

Wiring will lead to
soft tissues is paramount. Prior to surgery the collapse of fragments with
shortening and
elbow is placed in a well-padded posterior incongruency of the
olecranon fossa. This in
splint, surgery in complex cases is performed in turn will lead to
impingement, loss of motion
optimum conditions with adequate soft tissue and ultimately arthritis
[1, 6, 8]. These complex
condition. fractures are best treated
with dorsal contoured
plating [8]. The aim of
contoured dorsal plate
fixation in these fractures
is to simulate the
Classification function of a tension band
after re-positioning
of the fragments. Placement
of an
Many classification systems for the olecranon intramedullary screw in an
orthogonal fashion
and proximal ulna exist. Colton classified olec- with bi-cortical screws
dorsally was reported to
ranon fracture as undisplaced (less than 2 mm. provide more support as it
acts as an internal
separation and no increase in displacement with splint, analogous to an
intramedullary nail.
> 90 flexion, with ability to extend elbow Alternatively, the dorsal
plate acts as
against gravity, type I) and type II (displaced). a buttress to prevent
fracture flexion with
Type II is then subdivided into IIA (avulsion), a deficient anterior cortex
[6]. We first reported
IIB oblique and transverse, IIC comminuted and on the use of a locking
compression
IID fracture-dislocations. Schatzker classified plate (LCP) allowing for
uni-cortical
them into six types (transverse, tranverse- fixation and facilitating
placement of the long
impacted, oblique, comminuted, oblique-distal intramedullary screw [8].
Recently, pre-
and fracture dislocation. The AO and OTA contoured locking plates
specifically designed
have their own more comprehensive- classifica- for the olecranon have been
introduced.
tions. The Mayo classification used undisplaced Their holes are designed to
not interfere with
(type I), displaced-stable (type II) and displaced each other.
unstable (type III) fracture types (Fig. 1) [14].
Whatever system you choose, it is helpful to
separate them in transverse, oblique, commi- Pre-Operative Preparation
nuted or elbow fracture-dislocations. It is impor- and Planning
tant to appreciate the mechanical characteristic
of the various fracture patterns to choose the best Abrasions, blisters and
large swelling are gener-
operative strategy. ally a good reason to
postpone surgery. However,
in the young and healthy,
swelling seems in to be
less of a risk for wound
compromise post-
Indications for Surgery operatively in comparison
to pilon or ankle
fractures. Care should be
taken in the complex
The majority of olecranon fractures are trans- proximal olecranon
fractures in the elderly age
verse fractures with no or a limited (up to 3) group, which can lead to
terrible post-operative
number of fragments. They can be treated with soft tissue problems.
General or regional anesthe-
tension-band wiring. sia is used. The patient is
generally supine with
More complex patterns with comminution the arm folded over the
chest on a blanket roll.
(>3 parts), impaction, those that are part of Other options are lateral
decubitus position or
a complex injury pattern (anterior prone with the arm draped
over a bolster attached
transolecranon fracture-dislocation, posterior to the operating table. In
polytrauma patients and
Monteggia fracture-dislocation, oblique olecra- obese patients the supine
position is safest.
non fractures extending distal to the coronoid, A C-arm intensifier is
placed either at the head
or a proximal ulna fracture extending into the or the foot of the bed for
AP and lateral
ulnar shaft fracture) are generally not amenable fluoroscopy.
1454
P. Kloen et al.
Fig. 1 Mayo
Classification of olecranon
fractures. Type I fractures
are non-displaced, non-
comminuted (IA) or
comminuted (IB) fractures.
Type II fractures are stable
displaced fractures, and
may be non- comminuted
(IIA) or comminuted (IIB).
Type III fractures are
unstable, displaced
fractures, and may be non-
comminuted (IIIA) or A - Non-comminuted
comminuted (IIIB) B -
Comminuted
(Modified after [14])
TYPE I Undisplaced
A - Non-comminuted B -
Comminuted
TYPE II Displaced-Stable
A - Non-comminuted B -
Comminuted
TYPE III Unstable
Surgical Approach and Technique nailing and excision the

approach will be smaller.
We will first describe the
general approach and
The approach for all fixation techniques is gener- then specify the reduction
and fixation for each
ally the same but for tension-band wiring, IM technique separately.
1455
General Approach and flexor carpi ulnaris on

either side of the dorsal
A dorsal mid-line incision is made with proximal crest of the ulna.
extension of about 5 cm. above the olecranon tip.
The incision is curvilinear to prevent a painful Specific Techniques
scar over the tip of the olecranon. A subcutaneous Excision or Advancement
flap is elevated over the olecranon from ulnar to For comminution that is
beyond fixation there are
radial. A subcutaneous approach to the interval two options. First, if the
fragment is small and
between the extensor and flexor carpi ulnaris is osteoporotic in a low-
demand patient, the proxi-
used distally (Fig. 2). Proximally the interval is mal fragment(s) can be
excised and the triceps
between anconeus and flexor carpi ulnaris. For tendon can be advanced.
Some authors advocate
most tension-band wiring and plate fixations that the ulnar nerve might
be compromised by
there is no need for formal identification of the resection of the fragment
and advocate ulnar
ulnar nerve. However, one should always be aware nerve transposition during
the same procedure.
of its position at least by palpation. For more Loss of leverage and
instability after excision is
complex patterns such as fracture-dislocations we a concern. If stability
does not seem
use an extensile approach with identification (and compromised by resection,
the triceps is sutured
protection with a vessel loop) of the ulnar nerve. to the adjacent articular
surface with suture
We do not use routine anterior transposition of the anchors or with
transosseous drill holes. Alterna-
ulnar nerve. The fracture is easily identified as it tively, you can resect the
middle comminuted
lies subcutaneously. The fracture hematoma is part and shape the proximal
and distal ends with
carefully rinsed out. Loose fragments are all a rongueur for end-to-end
bony fixation.
saved, as they can be helpful to achieve anatomical
reduction. The periosteum is reflected 12 mm. to Wiring
allow a clear view for reduction. The proximal Most olecranon fractures
are transverse non-
fragment is reflected proximally on the triceps comminuted with articular
displacement.
tendon allowing inspection of the joint. These do well with tension-
band wiring. After
If additional exposure of the radial head is exposure and removal of
intervening
needed for internal fixation, resection or haematoma and debris, the
joint is inspected
prosthetic replacement this can be done through carefully. If there is an
area of impaction this
the same posterior skin incision as skin and sub- is gently elevated with a
small osteotome and
cutaneous tissue can easily be raised laterally and the resulting defect is
filled with cancellous
medially at the level of the deep fascia. One can bone graft. The elevated
area can be protected
thus address each component (radius and ulna) with small K-wires that are
cut short. The dis-
of the injury through a separate muscular interval advantage is that these
wires are difficult to
by using the interval between anconeus and exten- remove once the fracture
heals. Comminution
sor carpi ulnaris (Kocher approach) to reach the can be addressed with small
buried K-wires or
radial head. Alternatively, one can choose to ele- fine threaded implants,
creating essentially a
vate the anconeous and extensor carpi ulnaris 2-part fragment (Fig. 3)
[15]. The fracture is
subperiosteally from posterior to anterior then reduced with a large
pointed reduction
(modified Boyd approach) [6]. With the forearm clamp while the elbow is
kept in extension. It
pronated to protect the posterior interosseous helps to drill a hole on
the posterior crest of the
nerve- the supinator can be stripped of the ulna ulna distally for the
pointed clamp. Alterna-
thus reaching the radial head. Often there is exten- tively you can place two
pointed reduction
sive soft tissue damage that makes a specific clamps on either side of
the ulnar crest. Releas-
approach difficult. Using this window through ing a few fibres of the
anconeus laterally will
the injured soft tissues is often a good option to allow a read of the
fracture and the articular
minimize additional injury. Distally the approach surface verifying excellent
reduction. Two
needed involves minimal stripping of the extensor 1.6 mm. K-wires are drilled
parallel starting
1456
P. Kloen et al.
a at the olecranon
tip aiming towards the anterior
ulnar cortex.
Alternatively (but maybe less
secure) they can
be placed intramedullarly.
The K-wires should
not protrude beyond the
anterior cortex as
they might impinge on the
radius and limit
motion or damage anterior
neurovascular
structures. The transverse hole
for the tension-
band is placed dorsal to
the mid-axis of
the ulna at about twice the
distance from the
olecranon tip to the fracture.
An 18-gauge (1
mm.) wire is then placed under
the triceps
insertion and under the K-wire entry
b point. The K-wires
are withdrawn 5 mm, bent
to 180# (to seat
them better in the bone), cut
short to about 34
mm. and then rotated to
capture the
tension-band. The K-wires are
Anconeus muscle then impacted back
into place. The tension-
Extensor carpi
band is carefully
tensioned in a figure-of-eight
ulnaris muscle fashion with the
elbow in extension with one or
preferably two
loops. The knots are tightened
alternating to
provide a balanced tension. They
are cut short and
then buried in the soft tissues.
Flexor carpi The triceps tendon
is closed over the K-wires to
ulnaris muscle prevent backing
out of the wires. Accuracy of
c reduction and
fixation is checked with fluoros-
copy. With the
forearm in full supination an AP
view will show
whether the K-wires are not
impinging on the
radius.
Anconeus muscle
Extensor carpi Alternative

Technique
ulnaris muscle The use of a
tension-band with an intramedullary
6.5 mm. cancellous
screw instead of 2K-wires
has also been
described. Advocates of this
technique claim
both static and dynamic
Flexor carpi
ulnaris muscle
protect the ulnar
nerve, if needed. Detach the flexor carpi
ulnaris tendon on
the medial side, and the anconeus tendon
on the lateral
side as far as necessary to expose the
Fig. 2 Surgical approach to the proximal ulna: (a) The involved articular
surfaces and for an anatomical reduc-
ulna is a subcutaneous bone. Start the incision a few tion and stable
fixation. Some coronoid fractures can be
centimetres proximal to the tip of the olecranon, as needed addressed through
the lateral extension of this approach,
for access to the injured area. Curve slightly medially particularly with
the elbow dislocated, and/or with dis-
around the tip of the olecranon, and go distally for a few placement of a
proximal radius fracture. (c) For proximal
centimetres, as needed to provide access to the injured ulna fractures
extending into the diaphysis, the posterior
area. (b) Surgical dissection: Elevation of the lateral flap approach can be
extended distally as far as necessary.
provides access to the lateral structures of the elbow. In the Carefully detach
the muscle origins (anconeus, flexor
proximal portion, dissect and elevate the subcutaneous carpi ulnaris and
extensor carpi ulnaris) from the ulna as
tissue. Over the olecranon, remove the olecranon bursa needed to reduce
and fix the fractures (Copyright by AO
and incise the triceps aponeurosis exposing the bone. Foundation,
Switzerland; Source: AO Surgery Reference,
Behind the medial humeral epicondyle, identify and www.aosurgery.org)
1457
Fig. 3 Cerclage osteosynthesis of moderately- The elevated area can

be protected with small K-wires
comminuted proximal olecranon fracture: the area of that are cut short and
left intentially, creating essentially
impaction is gently elevated with a small osteotome and a 2-part fragment
the resulting defect is filled with cancellous bone graft.
compression, decreased hardware prominence Dorsal Contoured

Plating
and stronger biomechanics. The potential weak- Plating of complex
olecranon or proximal ulna
ness of this technique is lack of rotational control fractures requires the
surgeon to be comfortable
and mal-alignment if the screw is engaging the with various deep
approaches to the elbow
distal ulnar canal (there is slight bend in the including the
posterior, medial, lateral, Boyd
dorsal cortex of the ulna) and is not perfectly and Kocher approach.
All of these can be done
placed centrally. If the tension-band technique using a long posterior
skin incision.
is used in an oblique fracture pattern, a lag We usually start
the assembly of the fracture
screw should be placed prior to tensioning. from distal to
proximal and from deep to superficial
1458
P. Kloen et al.
Fig. 4 Intra-operative
reduction of a proximal
complex ulna fracture: Use
of a small intra-operative
distractor can facilitate
reduction
(dorsal) so that we can keep the proximal fragment needs to be released to

get the proximal fragment
hinged open on the triceps tendon to keep a good attached to the triceps
tendon in place. Use of a small
overview. If there is an associated coronoid fracture, intra-operative
distractor can facilitate reduction
this needs to be re-positioned and fixed to the ulna (Fig. 4). Sometimes a
small 2.0 locking plate is
first. Reduction of an associated coronoid fracture placed medially or
laterally to help maintain reduc-
can be obtained through several means based on the tion (Fig. 5). Next, an
incision is made cantered in
specific fracture pattern and associated injuries. the triceps tendon
insertion on the olecranon. A pre-
Most often the proximal ulna fracture pattern is contoured plate or a
plate that is contoured intra-
a posterior olecranon fracture dislocation or operatively is placed
with its proximal tip under the
a trans-olecranon fracture-dislocation. Opening triceps insertion. We use
a titanium 3.5 mm. pelvic
the fracture by hinging the proximal olecranon frag- reconstruction LCP
(Synthes) or a pre-contoured
ment on its triceps attachment will provide a good olecranon plate. For
fractures that extend far distally
overview of the coronoid fragment. Flexion of the or segmental fractures a
long plate is needed that
elbow relaxes tension on the coronoid fragment matches the bend in the
ulna. Place a drill guides on
facilitating reduction. Using a pointed reduction the plate to help with
positioning. Although the
clamp the coronoid fragment can be temporarily locking plate design does
not need tight compres-
reduced. Fixation of a large coronoid fragment can sion of the plate to the
bone, we aim for the closest
be done with threaded K-wires and/or retrograde apposition possible.
Place a uni-cortical screw dis-
(cannulated) lag screw. The lag screw can be placed tally followed by a
second uni-cortical screw prox-
through the plate or outside the plate depending on imally (Fig. 6).
Depending on the fracture
fracture configuration. If part of the coronoid frag- configuration lag screws
(non-locking) can now be
ment is too small for screw or K-wire fixation placed through the plate.
By using an oscillating
a suture can be looped around the tip of the coronoid drill for the long non-
locking intramedullary screw
through its capsular attachments and/or brachialis (home-run screw) the
drill bit is gently guided
tendon and tied dorsally over the ulnar cortex within the canal
decreasing the risk of penetrating
through two tunnels drilled in the ulna (lasso suture). the cortex (Fig. 7).
Depending on the fracture, bone
A large pointed clamp placed in a drill hole distally quality, and chosen plate
length more screws can be
and around the tip of the olecranon proximally added until a stable
mechanical construct is
reduces the olecranon component of the fracture achieved. In comminuted
fractures with large frag-
by extending the elbow. Sometimes the tourniquet ments of the medial
and/or lateral wall these can be
1459
Fig. 5 Plate ostesynthesis in complex fractures of the proximal ulna: Sometimes a

small 2.0 locking plate from the hand
surgery armentarium is placed medially or laterally to help maintain reduction
stabilized with lag screws and/or small buttressing may be injured. If

this is associated with
plates. After fixation is completed the elbow is taken ulnohumeral
instability or sagging (reminiscent of
gently through a range of motion under fluoroscopy, pseudosubluxation of
the shoulder) after stable fix-
and the stability of the elbow is tested. If there is ation of the coronoid,
ulna and radial head, a brace
valgus instability after radial head resection a radial with the forearm in
pronation might be enough to
head prosthesis should be placed. The medial col- ensure stability while
the lateral ligament heals. If
lateral ligament is often intact in this injury pattern. the elbow remains
unstable in pronation, repair of
However, the lateral collateral ligament complex the lateral ligaments
should be considered.
1460
P. Kloen et al.
Fig. 6 For fractures that extend far distally or segmental closest apposition
possible. Place a uni-cortical screw
fractures a long plate is needed that matches the bend in distally followed by a
second uni-cortical screw proxi-
the ulna. Although the locking plate design does not need mally. Use a long
homerun screw after feeling
tight compression of the plate to the bone, we aim for the with the drill in the
proximal ulna for good positioning
Instability of the ulnohumeral joint despite fixation Claimed advantages are

decreased hardware
is a potentially devastating problem. For these prominence. The nail
will allow some com-
patients placement of a hinged external fixator is pression across the
fracture site. Their biome-
a viable option during the post-operative period to chanical behavior
seems adequate [13].
allow for ligamentous healing [16]. Prior to closure At this time we have
no experience with
the tourniquet is deflated and haemostasis is using an IM nail for
olecranon or proximal
obtained. We generally do not leave a drain. The ulna fracture
fixation.
wound is closed in layers and a compressive sterile
dressing is applied followed by a posterior splint.
Post-Operative
Management
Intramedullary Nailing
Various IM nails have been developed for A posterior splint
promotes comfort and help
use in olecranon or proximal ulna fractures. controlling the soft
tissue envelope for the first
1461
Fig. 7 Clinical photograph

of insertion of a home-
run screw
few days, but is not essential. Some authors have treatment of olecranon
fractures). Interestingly,
suggest splinting in full extension for 24 h to 35 % of 20 patients we
examined at long-term
decrease swelling. For high-energy injuries that follow up after fracture-
dislocations of the olec-
required a large approach we generally keep ranon were noted to have
developed an ulnar
a splint in place for 710 days to allow for neuropathy. Only two of
these had been
wound healing. Gentle passive and active assisted identified and treated,
suggesting their symptoms
exercises can start on the first post-operative day. were mild [7].
Slight residual post-operative varus subluxation of Degenerative
radiographic changes were
the elbow can be treated with active exercises and common in the few long-term
follow-up studies
avoidance of varus stress. Weight-bearing (e.g., available. However, few
patients developed oste-
use of crutches for associated injuries) is not oarthritis necessitating
reconstructive surgery in
allowed until healing. If the soft tissues are the Amsterdam material. If
needed, treatment
contused, early motion may be delayed for a few options for severe post-
traumatic arthritis are
days to prevent skin breakdown. If mobility does prosthesis, arthrodesis or
distraction arthroplasty.
not improve despite physical therapy, options are Hardware prominence and
irritation requiring
manipulation under anaesthesia and/or formal sur- removal is common both
after plating and
gical release. Full activities may only be resumed tension-band wiring
according to a recent review.
after full bony consolidation. Hardware removal is Development of even lower
profile plates or
not indicated unless the patient is bothered by its resorbable wiring material
might decrease these
presence but should not be considered until at least percentages.
1.5 years after consolidation. Elbow stiffness without
evidence of arthritis is
common. If this is based on
capsular adhesions
and/or contracture, a
formal release can be
Complications expected to improve range
of motion.
Non-union with or
without hardware failure is
If ulnar neuropathy is present post-operatively rare (08 %) [17]. Most
often this is the result of
and documented with EMG, a release with/with- poor surgical technique. We
reviewed a series of
out anterior transposition can be offered failed fixations of
posterior Monteggia
(ulnar palsy has been described after operative fractures. The most common
error was plate
1462
P. Kloen et al.
Table 1 Comprehensive
classification of radial head
fracture with
description of associated injuries (van Riet
and Morrey)
Radial head
fracture
(Mason) type
Associated injury suffixes
I-III
Articular c coronoid fracture
injuries o olecranon
fracture
Ligamentous m medial
injuries collateral ligament/
f-p mass (Flexor

Fig. 8 Post-operative lateral xray of a complex proximal
pronator mass)
ulna fracture: Massive ventral heterotopic ossification and
l lateral collateral
a radio- ulnar synostis are seen
ligament/s-e mass
(Supinator- extensor
placement on the lateral or medial side, rather than
mass)
on the dorsal (tension) side. Heterotopic ossifica-
tion (HO) is mostly limited to high-energy and
complex injury patterns (Fig. 8). Excision of HO classification of
radial head fractures addressing
at an early stage is generally successful. There is especially
concomitant ligamento-skeletal co-
not enough evidence that prophylactic medication injuries (Table 1)
[20].
such as indomethacin, NSAIDS or radiation help While simple
radial head fractures are treated
prevent heterotopic ossification in any elbow inju- either conservatively
or with internal fixation, the
ries. Formation of a synostosis between proximal treatment of complex
radial head fractures
ulna and radius is rare (Fig. 8). Using a separate remains a challenge
for the Orthopedic surgeon
deep approach for both ulna and radius this risk is [21]. Novel implants
and improved surgical tech-
minimized and after pre- operative planning using niques have made
reconstruction of the radial
CT scans removal of the heterotopic bone in the head with open
reduction and internal fixation
synostosis area followed by sequential casting in possible in most
cases. However, extremely com-
pronation and supination is usually successful and minuted radial head
fractures with associated
treating the synostosis. instability may
require replacement of the radial
head with a radial
head prosthesis to allow reha-
bilitation with early
motion of the elbow, and
Radial Head and Neck Fractures thereby optimize the
functional results of these
potentially
devastating injuries [21].
Introduction In elbow fracture-
dislocations, a radial head
fracture is commonly
associated with other trau-
Radial head fractures represent the most common matic pathologies
including medial collateral lig-
fractures of the elbow in the adult population, ament (MCL) rupture,
olecranon fracture, and/or
accounting for 1.75.4 % of all adult fractures coronoid fracture
(Table 1). Therefore, in the
[18]. Approximately 85 % of these fractures setting of acute
trauma, the elbow must be care-
occur in young, active individuals ranging in fully evaluated to
rule out associated ligamentous
age from 20 to 60 years old. Radial head fractures and bony pathology
(see chapter Fracture Dis-
may occur in isolation but more often as part of locations of the
Elbow - the Elbow Fixator
a more extensive traumatic elbow injury. Recent Concept).
investigations by Kaas et al. in a cohort MRI Radial head
fractures usually result from a fall
study have demonstrated concomitant ligament onto the outstretched
hand with the elbow slightly
or bony lesions in up to 65 %, [19] and van Riet flexed and the
forearm in a pronated position.
and Morrey have proposed a comprehensive Biomechanical studies
have demonstrated that
1463
Fig. 9 The radial head is a fantastic bony architectural structure; on the left
there is a related architectural example of
this architectural beauty in the library of Alexandria by the Norwegian architects
of Snhetta
the greatest amount of force is transmitted from fractures judged

with more than three parts
the wrist to the radial head when the elbow and involving the head #
neck (Fig. 10). Type IV is
forearm are oriented in this position. During a different entity
as it comprises a radial head
a fall, the body rotates internally on the elbow, fracture of (any)
type (I to III) and additional
the weight of the body contributes an axial load to elbow dislocation
(with its concomitant addi-
the radius, and a valgus moment is applied to the tional injury
patterns). Once again it is important
elbow since the hand becomes laterally displaced to state that one
easily can miss a silent sublux-
from the body. The resultant combination of ation of the elbow
with its concomitant injuries
axial, valgus, and external rotatory loading mech- while classifying
the radial head fracture
anisms forces the anterolateral margin of the a simple type I or
II fracture. History taking,
radial head to come into contact with the thorough
investigation, scrutinizing of the stan-
capitellum, resulting in a fracture of the radial dard X-rays for
(subtle) signs of instability in
head and/or capitellum. a standardized
fashion and the use of computed
tomography with 3-D
reconstruction should be
employed to reveal
the true story underlying
Anatomy, Classification and Diagnosis radial head
fractures. MRI is not recommended
as a routine
investigation. Signs of concomitant
The radial head is a fantastic bony architectural injuries after elbow
fracture dislocations are:
system (Fig. 9). The (elliptic) shape, internal, fracture line/true
fracture of the coronoid, bone
biomechanical structure, size and relation of the pieces in the soft
tissues, projection of bone
head to neck produce ideally functioning joints pieces over the
joint line, defect/incongruency
which are unique and can in no way be imitated or in the
trochlea/capitulum, the drop sign and
replaced without compromise by either resection bruises/haematoma
medially (Fig. 11).
or replacement [2225]. We use the Hotchkiss
modification of the Mason classification [26, 27],
where type I fractures represent non- or Surgical Technique
1: Internal Fixation
minimally-displaced fractures amenable to con-
servative treatment, type II are displaced (up to If in doubt,
resect was the old dogma regard-
2 mm.) fractures technically possible to repair by ing the treatment of
fractures of the radial head
ORIF, and type III are the severely comminuted which were first
classified by Mason back in
1464
P. Kloen et al.
Fig. 10 Hotchkiss modification of the Mason classifica- comminuted fractures

judged with more than three parts
tion, where type I fractures represent non- or minimally- involving the head #
neck. Type IV is a different entity as
displaced fractures amenable to conservative treatment, it comprises a radial
head fracture of (any) type (I to III)
type II are displaced (up to 2 mm.) and technically possi- and additional elbow
dislocation (with its concomitant
ble to repair by ORIF, and type III are the severely additional injury
patterns)
1954 [28, 29]. Although good long-term results tested biomechanically

and technically
have been reported after resection of the [2830]. It is our
strong belief that the radial
radial head for Mason type-II fractures, patients should not be resected
without careful consid-
with more comminuted fractures and those with eration. While other
experts in the field do not
associated soft-tissue injuries of the elbow have recommend attempted
reconstruction of radial
a poor outcome if the radial head is simply head fractures with
more than three fragments,
resected. Complications and/or sequelae we even do on table
reconstruction of com-
include subsequent distal radio-ulnar pain, minuted radial head
and neck fractures with
weakness and instability of the elbow, cubitus comminution and
replant it as biological
valgus and ulnar neuritis. The role of the radial spacer using fine-
thread screws and miniatur-
head as an important stabiliser of the forearm ized plates from the
hand surgery field
and elbow is now better understood and mod- (Fig. 12).
ern osteosynthesis techniques with special In cases with large
bone defects and severe
screws and plates have been developed and comminution we
protect the radial head
1465
Fig. 11 Bruises/
haematoma medial as
instability sign of a radial
head fracture with
additional instability
a b LCP
c
1.5, 2.0, 2.4
safe zone
neutral
supination pronation
Fig. 12 (a) to (c) Fig. 12 gives a schematic drawing of the comminuted radial
head and neck fracture with commi-
safety corridor of possible plate placement on the radial nution and
replantation using fine-thread screws and
shaft/neck. LCP plates from the common hand surgery miniaturized plates
from the hand surgery field
armentarium are used for (c) reconstruction of
osteosynthesis after reconstruction with the distal third of

the forearm. A sterile tourniquet
a monolateral hinged fixator in order to unload is used (Fig. 13).
We use and recommend
the radial column of the elbow joint. Kochers approach
without transecting the
The patient is placed in supine position and lateral portion of
the radial ligament complex
draped sterile in a standardized fashion allowing (staying slightly
anterior and superior when
access to the elbow from the proximal humerus to opening the
humeroradial joint in order to avoid
1466
P. Kloen et al.
Fig. 13 Clinical
Photograph intra-peratively
showing the elbow after
placement in supine
position and draped in
a sterile standardized
fashion allowing access to
the elbow from the
proximal humerus to the
distal third of the forearm.
A sterile tourniquet is used
iatrogenic posterolateral de-stabilization of the the forearm, the plate(s) are

applied in the safety
radial ligament complex (Fig. 14af). While zone (60# zone between full
pronation and supi-
AO techniques and implants are most often nation). Although a recently
published
employed, fine- threaded self- drilling and retrospective series by
Neumann et al.
self-cutting implants (Fragment Fixation System, demonstrates less degenerative
changes and
Orthofix International) can act as headless screws less re-operations (for
hardware removal) using
and are inserted directly into the fragment with no fixation of the
reconctruced radial head in
a drill (Fig. 15). No temporary K-wire fixation Mason III type radial head
fractures to the neck
and no pre-drilling are necessary before implan- compared with re-fixation; we
recommend to re-
tation as in AO- techniques. Chisel fractures are fix it [31]. More recently,
specially designed and
fixed with the implants in a transverse direction pre-contoured plates for the
radial head and
and small osteochondral shear fragments can be radial neck have become
available: Burkhardt
addressed in a descending fashion (Fig. 16). If et al. showed that the
currently available radial
the head is separated from the shaft, FFS head implants are heterogenous
and that no
implants are inserted an oblique direction from plate perfectly fits all
radial heads. A new low
the head into the shaft (Fig. 17). In cases with profile plate concept is
promising and under
comminuted and dislocated fragments, the clinical evaluation [30]. At
the end of the
radial head is reconstructed first, even as an procedure, all FFS implants
are cut flush at the
on-table procedure (Fig. 18). Fixation of the cartilage level and any screw
heads should give
head to the radial shaft then follows using the least impingement as implant
removal is not
aforementioned technique or with plates which intended. An above-elbow
plaster cast in 90#
are customized from available hand surgery flexion and neutral forearm
rotation is applied
armentarium (Fig. 12). In neutral position of post-operatively for 6 days.
In all patients,
1467
a b
Extensor
carpi
Extensor carpi ulnaris
muscle
ulnaris muscle
Anconeus muscle Anconeus

muscle
c d
e f
Fig. 14 (a) to (f) Schematic drawing of the radial head and retract it to
achieve better access to the fracture site.
approach (after Kocher): start the incision 2 cm. proximal Reduce and
provisionally fix the fracture with the help of
to the lateral humeral epicondyle. Carry the incision small pointed
reduction forceps and one or two K-wires.
across the elbow joint, over the radial head, and approx. (d) Countersink
the cartilage covering the free fragment in
5 cm. distal to the joint. (b) Incise the subcutaneous tissue order to prevent
protrusion of the screw head. Measure the
and deep fascia in line with the incision. Elevate depth of the hole
and tap the far epiphysis with the appro-
anterolaterally the subcutaneous tissue and find the inter- priate cortical
tap and protection sleeve. (e) Closely
val between the anterior border of the anconeus and the observe the
compression effect on the fracture line while
extensor carpi ulnaris muscle. There may be difficulties in tightening the
lag screw. The K-wire(s) should be
determining the interval between these two muscles removed just
before the final tightening of the screw. (f)
because of bruising and bleeding in trauma. Separate If the fracture
configuration allows the insertion of
anconeus from extensor carpi ulnaris. Elevate them from a second lag
screw, it can be inserted now using the
the joint capsule. Incise the joint capsule to expose the same technique as
described above. Check reduction and
radial head and the annular ligament. The annular liga- screw length with
supination/pronation examination
ment is entered 1 cm. anterior to the ulna to prevent injury (Copyright by AO
Foundation, Switzerland; Source: AO
to the lateral ulnar collateral ligament. (c) Reduction is Surgery
Reference, www.aosurgery.org)
achieved directly. If the annular ligament is still intact, cut
1468
P. Kloen et al.
Fig. 15 Intra-perative images demonstrating the Frag- act as headless screws

and are inserted directly into the
ment Fixation System (FFS, Orthofix International) in fragment with a drilling
machine
use in a complex radial head fracture: The FFS implants
Fig. 16 Intra-perative images illustrating the re-fixation of a small osteochondral

shear fragment addressed with
a 1.6 mm. FFS in a descending fashion and after cutting on cartilage level
physiotherapy starts on day 6 and 50 mg. Indo- used to restore stability

of the elbow and forearm
methacin with gastric protection is given twice if the radial head cannot
be reconstructed. As
a day for 6 weeks. Removal of hardware is not stated before, the radial
head has a complex anat-
intended, when pronation and supination is omy that can be difficult
to restore and is difficult
painfree, without restriction and no crepitation to replicate with a
prosthesis [32]. Only a few
is palpable on examination at intermediate prosthetic radial head
designs attempt to recreate
Follow- up (6 months after the index operation). this anatomy precisely:
most are either spacers
with a loose smooth stem
in the radial neck, or are
more tightly fixed to the
radial neck and have
Surgical Treatment 2: Radial Head a mobile head, or try to
re-create the anatomy
Prosthesis (bi-polar prosthesis).
Three recent studies have
described the results of
a loose, spacer
Replacement of the fractured radial head with arthroplasty type of
radial head prosthetic
a metal prosthesis is, compared to reconstruction, replacement for treatment
of acute traumatic
actually a straightforward procedure and can be elbow instability. The
prosthesis is intentionally
1469
loose and this is

apparent on radiographs, but
these findings do not
correspond with complaints
of pain. There is also an
extensive experience
with a cemented
articulating (or bipolar) prosthe-
sis, primarily in Europe.
The results are compa-

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George Bentley

Committees and Task Forces

EFORT Executive Committee Ethics Committee

With 3294 Figures and 278 Tables

ISBN 978-3-642-34745-0 ISBN 978-3-642-34746-7 (eBook)

Library of Congress Control Number: 2014932431

Springer is part of Springer Science+Business Media (www.springer.com)

In recent years, we have seen Europe going through major changes in

As President of EFORT, I am very proud of this major achievement and

Manuel Cassiano Neves/Lisbon, 2014

This EFORT textbook was developed by the Executive Committee following

George Bentley London, 2014

Professor George Bentley D.Sc., MB, ChB, E.C.F.M.G. (USA), ChM,

Professor Bentley is Emeritus Professor of Orthopaedics at University

RNOH, he established the largest postgraduate training programme in the

General Orthopaedics and Traumatology

Arm, Elbow and Forearm

Hand and Wrist

George Bentley University College London, London, UK

Pelvis and Hip

Thigh, Knee and Shin

Ankle and Foot

Paediatric Orthopaedics and Traumatology

Part I General Orthopaedics and Traumatology . . . . . . . . . .

Part II Spine .......................................

Applications of Lumbar Spinal Fusion and Disc

Spinal Osteotomy Indications and Techniques

Posterior Decompression for Lumbar Spinal Stenosis . . . . . . . .

Minimally-Invasive Anterior Lumbar Spinal Fusion . . . . . . . . .

Sub-Total and Total Vertebrectomy for Tumours . . . . . . . . . . .

Computer-Aided Spine Surgery . . . . . . . . . . . . . . . . . . . . . .

General Management of Spinal

Injuries of the Cervical Spine . . . . . . . . . . . . . . . . . . . . .

Treatment of Thoraco-Lumbar Spinal Injuries . . . . . . . . . . . . .

Kyphoplasty - the Current Treatment for Osteoporotic

Strategies for Low Back Pain . . . . . . . . . . . . . . . . . . . . . .

Treatment of the Aging

Surgical Management of Tuberculosis of the Spine . . . . . . . . . .

Part III Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recurrent Glenohumeral Instability . . . . . . . . . . . . . . . . . . .

Part IV Arm, Elbow and Forearm . . . . . . . . . . . . . . . . . .

Surgical Anatomy, Approaches and Biomechanics of

Arthroscopic Techniques in the Elbow . . . . . . . . . . . . . . . . . .

Distal Biceps and Triceps Avulsions . . . . . . . . . . . . . . . . . . . . . .

Arthroscopy of the Wrist . . . . . . . . . . . . . . . . . . . . . . . .

Management of Cerebral Palsy in the Upper Limb . . . . . . . . . .

Surgical Management of the Rheumatoid

Re-Implantation and Amputation of the Digits

Part VI Pelvis and Hip ...............................

Osteonecrosis of the Femoral Head . . . . . . . . . . . . . . . . . . . . . . .

Hip Arthroscopy and Treatment of Acetabular Retroversion

Hip Dislocation and Femoral Head Fractures . . . . . . . . . . . . . .

Fractures of the Femoral Neck and Proximal

Fractures and Dislocations of the Pelvic Ring . . . . . . . . . . . . . .

Chiari Osteotomy of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bernese Peri-Acetabular Osteotomy . . . . . . . . . . . . . . . . . . . . . .

Cementless Total Hip Joint Replacement . . . . . . . . . . . . . . . . . .

Cemented Total Hip Replacement . . . . . . . . . . . . . . . . . . . . . . . .

Exposure of the Hip - Trochanteric Osteotomy,

Hip Replacement for Old Developmental Dysplasia

Pain Management After Total Hip Replacement . . . . . . . . . . . .

The Role of Navigation in Hip Arthroplasty . . . . . . . . . . . . . . .

Femoral Impaction Grafting . . . . . . . . . . . . . . . . . . . . . . .

Dual Mobility Concept - Bipolar Hip Replacement . . . . . . . . . .