European Surgical Orthopaedics and Traumatology - The EFORT Textbook, 2014 Edition, 4983 Pages (PDF) (DR - Carson) VRG

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,
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
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
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
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, HeinrichHeineUniversity,
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
Hospital, Stanmore, Middlesex, UK
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
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,
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.
Musculo-Skeletal Imaging 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
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
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).
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
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
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
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
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.
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
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,
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
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
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 polytrauma 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).
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
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.
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
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
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
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)
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.
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
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
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.
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.
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.
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
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.
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)
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.
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)
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.
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)
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.
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
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.
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).
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.
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).
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)
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
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.
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
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].
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.
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
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.
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
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.
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
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
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.
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
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.
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
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
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
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.
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Padhani, Dr. R. Dhawan and Ms. C. Burnett for their 1993;187:1938.
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medicine. 3rd ed. Chapmans & Hall Medical: London;
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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

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;
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,
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
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
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
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)
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;
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.
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
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.
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 matrises 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 aeroportee.
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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of the people who work in an operating room is a global population. N Engl J Med. 2009;360:4919.
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that now a complete programme of risk manage- operating theatre. In EFORT surgical techniques in
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good sense practices. Lyon: Comimprim; 1980.
5. Gallinaro P. Human factors and infection in THA. Hip postoperative wound infection? Ann R Coll Surg Engl.
Int. 2002;12:815. 2007;89:6058. doi:10.1308/003588407X205440.
6. Smyth ET, Emmerson AM. Surgical site infection 15. Al-Maiyah M, Bajwa A, Mackenney P, Port A, Gregg
surveillance. J Hosp Infect. 2000;45(3):17384. PJ, Hill D, Finn P. Glove perforation and contamina-
7. Geubbels EL, Bakker HG, Houtman P, van Noort- tion in primary total hip arthroplasty. J Bone Joint
Klaassen MA, Pelk MS, Sassen TM, Wille JC. Pro- Surg Br. 2005;87(4):5569.
moting quality through surveillance of surgical site 16. Sexton JB, Thomas EJ, Helmreich RL. Error, stress
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the OR? Todays OR Nurse. 1990;12(10):159. the operating room: cohesion or confusion? J Eval
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Candinas D. Impact of intraoperative behaviour on sur- 18. Paige J, Kozmenko V, Morgan B, Shannonhowell D,
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Huma H, Newman JH. Deterioration of theatre disci- of the feasibility and potential impact of true interdis-
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1999;81(4):2625. 19. Reason J. Human error: models and management.
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GC, Blom AW. Adherence to recommendations 20. Grote G, Helmreich RL, Strater O, et al. Setting the
designed to decrease intra-operative wound contami- stage: characteristics of organizations, teams and tasks
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12. Advisory Committee and the HICPAC/SHEA/APIC/ TM, editors. Group interaction in high risk environ-
IDSA Hand Hygiene Task Force. Morbidity and Mor- ments. Adelshort: Ashgate; 2004. p. 11139.
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October 25, 2002, 51 - No. RR-16. Centers for Disease clinics. American Society of Heating, Refrigerating,
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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

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
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
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].
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
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.
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.
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 [6668]. 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
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.
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.
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bone allografts. Clin Orthop. 2005;432:2106. J Bone Joint Surg Br. 2005;87-B:16847.
80. Witso E, Loseth K, Bergh K. Adsorption and release of 83. Delloye C, Cornu O, Dubuc JE, Vincent A, Barbier O.
antibiotics from morselized cancellous bone. In vitro Reconstruction du coude par allogreffe massive osteo-
studies of 8 antibiotics. Acta Orthop Scand. articulaire totale: echec precoce par instabilite. Rev
1999;70:298304. Chir Orthop. 2004;90:3604.
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

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

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
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).
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
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.
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 [7880]. 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.
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
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 SP, Long W. A modification of the

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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

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 fracture classification sys-
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].
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 fracture classification sys-
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.
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
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,
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
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
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
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
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
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
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
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 classification system
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
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),
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 classification system
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.
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
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
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, classification systems
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.
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-
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Schwappach JR, Kreder HJ. Interobserver variation
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

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.
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
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.
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
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].
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
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 plaster with three point fixationa
Spiral +/ fibula fracture plaster with three point fixationa
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
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
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.
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].
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
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.
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
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
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
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,
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
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35. Ekholm R, Ponzer S, Tornkvist H, Adami J, 51. Tare RR, Garfunkel AI, Sarmiento A. The effect
Tidermark J. The Holstein-Lewis humeral shaft of angular and rotational deformities of both
fracture: aspects of radial nerve injury, primary bones of the forearm. J Bone Joint Surg.
treatment and outcome. J Orthop Trauma. 1984;66(1):6570.
2008;22(10):6937. 52. Ring D, et al. Monteggia fractures in children and
36. Larsen LB, Bargfred T. Radial nerve palsy after sim- adults. J Am Acad Orthop Surg. 1998;6:21524.
ple fracture of the humerus. Acta Orthopscand. 53. Rettig ME, Raskin KB. Galeazzi fracture dislocation:
1991;62(2):14853. a new treatment oriented classification. J Hand Surg
37. Schatzker J, Tile M. Fractures of the humerus. Ratio- Am. 2001;26(2):22835.
nale of operative fracture care. 3rd ed. Berlin/Heidel- 54. De Boeck H, Haentjens P, Handelberg F,
berg/New York: Springer; 2005. Casteleyn PP, Opdecam P. Treatment of isolated
38. Shah JJ, Bhatti NA. Radial nerve paralysis associated ulnar fractures with below elbow plaster cast.
with fractures of the humerus. A review of 62 cases. A prospective study. Arch Orthop Trauma Surg.
Clin Orthop. 1983;172:1716. 1996;115:31620.
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

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 4P
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.
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.
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).
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.
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.
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.
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
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

Wrist 6. Davies R, Holt N, Nayagam S. The care of pin sites

with external fixation. J Bone Joint Surg.
2006;88(4):558.
A wrist bridging fixator passes from the radius 7. Kummer FJ. Biomechanics of Ilizarov external
to the index finger metacarpal (Fig. 18a). fixators. Clin Orthop. 1992;280:114.
Proximal pin placement again involves an 8. Gasser B, Boman B, Wyder D, Schneider E. Stiffness
open approach down to the mid-diaphysis of characteristics of the circular ilizarov device as
opposed to conventional external fixators. J Biomech
the radius to avoid damage to the superficial Eng. 1990;112:1521.
radial nerve. 9. Orbay GL, Frankel VH, Kummer FJ. The effect of
The distal pins are placed distal to the flare wire configuration on the stability of the Ilizarov exter-
of the base of the metacarpal. They are placed nal fixator. Clin Orthop. 1992;279:299302.
10. Padolsky A, Chao EY. Mechanical performance of
on the radial side aligned at 45 to the AP plane. Ilizarov circular external fixators in comparison
Avoid the the carpo-metacarpal joint proxi- with other external fixators. Clin Orthop. 1993;293:
mally and the extensor hood distally (Fig. 18b). 6170.
Once the fixator is secure avoid over- 11. Aronson J, Harp Jr JH. Mechanical considerations in
using tensioned wires in a transosseous external fixa-
distraction of the carpus which is associated tion system. Clin Orthop. 1992;280:239.
with wrist stiffness and potential complex 12. Fleming B, Paley D, Kristiansen T, Pope M.
regional pain syndrome. If the fixator is to be A biomechanical analysis of the Ilizarov external
used definitively, once fracture reduction has fixator. Clin Orthop. 1989;241:95105.
13. Geller J, Tornetta 3rd P, Tiburzi D, Kummer F, Koval K.
been obtained (with potential percutaneous Tension wire position for hybrid external fixation of the
Kirschner wire fixation) the tension of the proximal tibia. J Orthop Trauma. 2000;14:5024.
fixator across the joint is released by loosening 14. Hawkins R, Calder PR, Goodier WD. Anatomical
the connecting bars and re-tightening. With considerations and limitations of wire placement
using the taylor spatial frame. J Bone Joint Surg.
the advent of distal radial locking plates the 2006;88-B:170.
use of external fixators in wrist fracture man- 15. Green SA, Harris NL, Wall DM, Ishkanian J, Marinov H.
agement has diminished and is now reserved The Rancho mounting technique for the Ilizarov
as a temporary spanning device in damage- method. A preliminary report. Clin Orthop.
1992;280:10416.
control orthopaedics. 16. Moroni A, Cadossi M, Romagnoli M, Faldini C,
Giannini S. A biomechanical and histological analysis
Acknowledgments Grateful thanks to David Goodier, of standard versus hydroxyapatite-coated pins for
Chris Andrews, Simon Owen-Johnstone and the Institute external fixation. J Biomed Mater Res Part B Appl
of Orthopaedics in Kurgan for their help in this chapter. Biomater. 2008;86B:41721.
17. Magyar G, Toksvig-Larsen S, Moroni A. Hydroxyap-
atite coating of threaded pins enhances fixation.
J Bone Joint Surg. 1997;79-B:4879.
References 18. Pommer A, Muhr G, David A. Hydroxyapatite coated
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1. Ilizarov GA. The tension-stress effect on the genesis osteogenesis a randomized control trial. J Bone Joint
and growth of tissues. Part I. The influence of stability Surg. 2002;84-A:11626.
of fixation and soft-tissue preservation. Clin Orthop. 19. Kenwright J, Richardson JB, Cunningham JL, White
1989;238:24981. SH, Goodship AE, Adams MA, Magnussen PA,
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growth of tissues. Part II. The influence of the rate and A controlled randomised trial of treatment. J Bone
frequency of distraction. Clin Orthop. 1989;239:26385. Joint Surg. 1991;73-B:6549.
3. Ilizarov GA. Clinical application of the tension-stress 20. Gardner TN, Evans M, Hardy J, Kenwright J.
effect for limb lengthening. Clin Orthop. 1990;250:826. Dynamic interfragmentary motion in fractures during
4. Egkher E, Martinek H, Wielke B. How to increase the routine patient activity. Clin Orthop.
stability of external fixation units. Mechanical tests 1997;336:21625.
and theoretical studies. Arch Orthop Traum Surg. 21. Gordon JE, Schoenecker PL, Oda JE, Ortman MR,
1980;96:3543. Szymznski DA, Dobbs MB, Luhmann SJ.
5. Catagni MA. Atlas for the insertion of transosseous A comparison of monolateral and circular external
wires and half-pins. Ilizarov method. Smith & fixation of unstable diaphysealtibial fractures in chil-
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22. Personal Communication from Prof. David Marsh 26. Rotondo MF, Schwab CW, McGonigal MD, et al.
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Sanderson F, Pallister I. Standards for the manage- 27. Giannoudis PV. Aspects of current management. Sur-
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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

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
Fractures with Arterial Injury 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.
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.
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
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)
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
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)
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
Fig. 3 (continued)
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.
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
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
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
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
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.
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
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
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].
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
Fig. 4 (continued)
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
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
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
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
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
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.
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,
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
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).
Afterwards, the patient is advised to take 325 mg 11. Zehntner MK, Petropoulos P, Burch H. Factors
aspirin per day for about 3 months. determing the outcome in fractures of the extremities
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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

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 sensitivity specificity
bone loss, facture type, grade of soft tissue injury MRI 100 % 60 %
and defect, deficiency of bone vascularity, type of sensitivity specificity
Biologics in Open Fractures 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
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
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.
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
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
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
Summary Table of Biologics in Open 14. Sirkin M, Sanders R, DiPasquale T, Herscovici Jr D.

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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,
School of Medicine, University of Leeds, Leeds, UK
e-mail: pgiannoudi@aol.com
G. Kontakis
School of Medicine, University of Crete, Crete, Greece

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].
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Faster closure times of the fasciotomy wounds 7. Henson JT, Roberts CS, Giannoudis PV. Gluteal com-
significantly improved the self-rated health partment syndrome. Acta Orthop Belg.
2009;75(2):14752.
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Pitha-Billroth, publishers: Handbuch der allgemeinen
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Summary Erlangen, 1869. Die ischamischen Muskellahmungen
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a severe complication and an Orthopaedic Muskellahmungen und Kontrakturen. Samml Klin
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10. Thomas JJ. Nerve involvement in the ischaemic paral-
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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

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)
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
a1 a2 a3 a4
b1 b2 b3 b4
c1 c2 c3 c4
Fig. 2 (continued)
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)
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.
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.
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
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].
a b c d
e f g
h i j
Fig. 6 (continued)
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
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)
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)
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)
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
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.
a b c d
e f
h i
Fig. 8 (continued)
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
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)
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)
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
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.
tional Ilizarov frame (Fig. 10), allowing more or 17. Cho TJ, Gerstenfeld LC, Einhorn TA. Differential
less the same functions as the Taylor spatial temporal expression of members of the TGF-B super-
frame [124]. family during murine fracture healing. J Bone Miner
Res. 2002;17:51320.
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Necrotising Fasciitis
Nikolaos K. Kanakaris and Peter V. Giannoudis
Contents Abstract
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Despite the expanded understanding on the
pathophysiology of sepsis, the contemporary
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . . 268
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-
Pre-Operative Preparation and Planning . . . . . . . . 273 sity of multicentre collaboration on this scien-
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
Academic Department of Trauma and Orthopaedics, 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
School of Medicine, University of Leeds, Leeds, UK IL-1/6 Interleukin 1/6
e-mail: pgiannoudi@aol.com IV Intravenous

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].
Necrotising Fasciitis 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].
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].
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
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.
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
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
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.
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
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

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
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
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
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
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.
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
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
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):
sustained a fracture seem motivated to take 93542.
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.
11. Black D, Steinbuch M, Palermo L, et al. An assess-
patient appears with their first fracture. Aware- ment tool for predicting fracture risk in postmeno-
ness by the patients of the osteoporotic disease pausal women. Osteoporos Int. 2001;12:51928.
improves compliance with the suggested preven- 12. Black DM, Schwartz AV, Ensrud KE, Cauley JA,
tive treatments. By actively building relation- Levis S, Quandt SA, Satterfield S, Wallace RB,
Bauer DC, Palermo L, Wehren LE, Lombardi A,
ships with colleagues in primary health care Santora AC, Cummings SR, The FLEX Research
their motivation and knowledge will increase Group. Effects of continuing or stopping alendronate
in order to adequately-treat those patients who after 5 years of treatment. The fracture intervention
are at high risk of fracture. The total number of trial long-term extension (FLEX): a randomized trial.
JAMA. 2006;296(24):292738.
second fractures will thereby be diminished in the 13. Black DM, Delmas PD, Eastell R, et al. Once-yearly
population [75]. zoledronic acid for treatment of postmenopausal oste-
oporosis. N Engl J Med. 2007;356(18):180922.
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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

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.
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
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
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
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
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.
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.
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].
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
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.
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).
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
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
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].
during primary hip and knee arthroplasty. J Bone

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Orthopaedic Management
of the Haemophilias
Richard Wallensten
Contents Simultaneous Operations . . . . . . . . . . . . . . . . . . . . . . . . . . 326

General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Post-Operative Care and Rehabilitation . . . . . . . . . 326
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Economical Considerations . . . . . . . . . . . . . . . . . . . . . . . . 328
Non-Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 321 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 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

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
9
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
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].
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
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
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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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

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)
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:
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.
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.
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
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 110 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
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
(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].
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)
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
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
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

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.
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)
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
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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
inpatients undergoing surgery. 2007 Available at as thromboprophylaxis. Health Technol Assess

http://www.guidance.nice.org.uk/CG46 2005;9(49):194.
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a regulated environment. AAOS Instr Course Lect. gery. Arch Int Med. 2002;162:183340.
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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

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
Surgical Amputations 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.
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
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.
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
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.
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).
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
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,
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.
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)
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
Fig. 39 Bone section in 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).
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.
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.
Fig. 49 Bone section in 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).
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 J.C. Angel
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):50917.
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):64122.
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 Bone Joint Surg Am. 1971;53(5):87490.
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.
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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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14. Sherk VD, Bemben MG, Bemben DA. BMD and bone 29. Martin P, Wickham JE. Gritti-Stokes amputation
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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
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Rehabil. 2009;90(3):4406. 1997;79(2):1024.
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
Hospital, Reading, UK cations Fusion History Myelopathy Pros-
e-mail: robmarshall100@hotmail.com thesis Prosthetic Design Root Compression

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).
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

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
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
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.
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.
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
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.
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
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
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
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.
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. Neurosurgery. 1998;43(1):515.
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unproven concept. The patients from the Cervical-disc resection: a follow-up of myelographic
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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-
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 ration and even death. It presents a challenge
Pre-Operative Preparation and Planning . . . . . . . . 431 to the treating physician as the pain, neurolog-
ical symptoms and instability cannot be
Posterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 equated with each other.
RA of the cervical spine follows the same
Post-Operative Care and Rehabilitation . . . . . . . . . 442
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

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].
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
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
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
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
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.
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
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,
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.
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.
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
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.
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
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,
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).
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
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
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
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
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
presenting with severe ulnar neuropathy but
Supra-Clavicular Exploration Technique . . . . . . . . 456 including wasting of abductor pollicis brevis
Post-Operative Care and Rehabilitation . . . . . . . . . 457 (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.

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.
Thoracic Outlet Syndrome 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,
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
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
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
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)
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-
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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.

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
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
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
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
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
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
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
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
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
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
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,
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
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
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-
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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

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
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
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).
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
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
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.
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
dosteosynthe`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):3416.
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
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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):3439.
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expensive, time consuming and, of course, carry options in children. Spine. 2010;35(17):164854.
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Surgical Management of
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

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
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
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
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
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] examined 48 patients
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 %.
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
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] examined 298 patients
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.
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 (Phila Pa 1976). 2006;31(20):
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Cobb angle, lung function, reaching, pain and of scoliosis with pelvic obliquity in cerebral palsy:
the influence of intraoperative traction. Spine (Phila
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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

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.
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
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).
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])
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 510 % 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.
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.
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].
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.
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 the surgical treatment of
adult scoliosis. Spine. 2008;33(20):22437.
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 adults. Spine. 2002;27(16):
employed. 17428.
Spondylolysis With or Without
Spondylolisthesis
Philippe Gillet
Contents Spondylolysis With Associated Disc Disease and

Grade 4 Spondylolisthesis or
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534 Spondyloptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . . 534 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
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
Spondylolysis With Associated Disc Disease and
Grade 0 or 1 Spondylolisthesis . . . . . . . . . . . . . . . . . . 553
Spondylolysis With Associated Disc Disease and
Grade 2 or 3 Spondylolisthesis . . . . . . . . . . . . . . . . . . 553
P. Gillet
Centre Hospitalier Universitaire, Lie`ge, Belgium
e-mail: philippe.gillet@chu.ulg.ac.be

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
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.
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
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.
a b c
d e
f g
h
i
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.
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
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
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
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
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;34:233845.
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- spondylolisthesis: long-term outcome. J Bone Joint
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;
degenerative spondylolisthesis often occur at 193:90102.
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.
1986;203:1833.
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).
Rev Chir Orthop. 1988;74:54957.
References 17. Moller H, Sundin A, Hedlund R. Symptoms, signs and
functional disability in adult spondylolisthesis. Spine.
1. Berchuck M, Garfin S, Bauman T, Abitbol J. Compli- 2000;25:6839.
cations of anterior intervertebral grafting. Clin Orthop. 18. Moller H, Hedlund R. Instrumented and
1992;284:5462. noninstrumented posterolateral fusion in adult
2. Boos D, Marchesi D, Zuber K, Aebi M. Treatment of spondylolisthesis. Spine. 2000;25:171621.
severe spondylolisthesis by reduction and pedicular 19. Moller H, Hedlund R. Surgery versus conservative
fixation. Spine. 1993;18:165561. management in 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
resulting from anterior lumbar interbody fusion. J 24. Schlenzka D, Remes 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
17-year follow-up. Spine. 2006;31:24919. posterior lumbar interbody fusion to pedicle screw
22. Roca J, Ubierna M, Caceres E, Iborra M. One stage fixation and posterolateral fusion after decompression
decompression and posterolateral and interbody fusion in spondylolytic spondylolisthesis. Spine. 1997;22:
for severe spondylolisthesis. Spine. 1999;24:70914. 21020.
23. Ruf M, Koch H, Melcher RP, Harms J. Anatomic reduc- 26. Watkins R. Anterior lumbar interbody fusion, surgical
tion and monosegmental fusion in high-grade develop- complications. Clin Orthop. 1992;284:4753.
mental spondylolisthesis. Spine. 2006;31:26974.
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
Hospital, Reading, UK lateral disc History Lumbar intervertebral
e-mail: robmarshall100@hotmail.com

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
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
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
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
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
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.
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
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.
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
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].
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one series 36 % of patients undergoing lumbar demographic factors determining duration of disease.
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Spine (Phila Pa 1976). 1983;8(2):13140.
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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 (*)

e-mail: robmarshall100@hotmail.com
N. Raz
Bnai Zion Medical Center, Haifa, Israel

DOI 10.1007/978-3-642-34746-7_214, # EFORT 2014
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 [4143].
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].
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
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
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.
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;
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.
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].
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.
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.
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
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
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).
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
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).
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
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).
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
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. 3537).
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).
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
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
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
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.
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
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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

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
Spinal Osteotomy Indications and Techniques 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
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
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.
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
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.
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
have a cervical flexion deformity that impedes 10. McMaster MJ. Osteotomy of the cervical spine in
their ability to look straight ahead while walking ankylosing spondylitis. J Bone Joint Surg Br.
1997;79:197203.
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correct the deformity, especially in patients who sagital imbalance). Spine. 1999;24:171220.
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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
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

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].
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.
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
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.
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
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.
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
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
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
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
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
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).
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
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.
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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.
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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.
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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
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 decompression in lumbar spinal steno-
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
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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
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.
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

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.
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
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
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
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
most striking advantage of this technique and Surg Am. 1991;73A:8028.
7. Hodgson AR, Wong AK. A description of a technique
the clinical results seem to be comparable to and evaluation of results in anterior fusion for
conventional fusion techniques [1]. deranged intervetebral disk and spondylolisthesis.
Minimally-invasive approaches for spinal Clin Orthop. 1968;56:13361.
fusion or reconstruction in degenerative diseases 8. Kambin P. Arthroscopic lumbar interbody fusion. In:
White AH, editor. Spine care. St. Louis: C.V. Mosby;
have replaced the standard anterior approaches in 1996. p. 105566.
the last 10 years. Pre-operative planning, modifi- 9. Mack MJ, Aronoff RJ, Acuff TE, Douthit MB,
cation of surgical strategies and innovative instru- Bowman RT, Ryan WH. Present role of thoracoscopy
ments and implants are the key factors for a safe in the diagnosis and treatment of diseases of the chest.
Ann Thorac Surg. 1992;54:4039.
and successful performance. It is mandatory for 10. Mayer HM. A new microsurgical technique for mini-
the spine surgeon to face the challenges of these mally invasive anterior lumbar interbody fusion.
surgical techniques and, if necessary for medico- Spine. 1997;22:691700.
legal reasons, to involve vascular or general sur- 11. Mayer HM. Microsurgical approaches for
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Sub-Total and Total Vertebrectomy
for Tumours
Stefano Boriani, Joseph Schwab, Stefano Bandiera, Simone

Colangeli, Riccardo Ghermandi, and Alessandro Gasbarrini
Contents Abstract
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662 En bloc resections in the spine involve sub-
total and total vertebral body excision
depending on the location of the tumour. The
Relevant Applied Anatomy, Pathology 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
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664 Enneking and validated later in the treatment
of primary tumours. The spine imposes signif-
icant anatomical constraints which make wide
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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
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.
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.
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 1015 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
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).
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
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
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
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
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].
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.
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.
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Non-union and hardware failure are also prob- sarcomas of the spine. Clin Orthop Relat Res.
lems. Again, large portions of bone are removed 2002;397:12732.
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.
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gery itself. The patient, and the surgeon, must resection of a C4 chordoma: surgical technique. Eur
Spine J. 2007;16(12):223842.
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7. Biagini R, Casadei R, Boriani S, et al. En bloc
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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 report and description of surgical
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.
to help organize the surgical plan. Staged pro-
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
of resection is dictated by the location of the C Thomas; 1986.
11. Campanacci M. Bone and soft tissue tumors. 2nd ed. sarcoma of the limbs: a randomised trial. Lancet.
New York: Springer; 1999. 2002;359(9325):223541.
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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 Orthop Relat Res. 2010;468(11):310311.
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 malignant tumours of the spine with pos-
2006;31(21):E7819. terior instrumentation. In: Sundaresan N, Schmidek
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. Philadelphia: WB Saunders; 1990.
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):27887.
model. Spine. 2008;33(14):153341. 20. Tomita K, 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
Total en bloc spondylectomy for spinal tumors: surgi- surgical technique for primary malignant vertebral
cal techniques and related basic background. Orthope- tumors. Spine. 1997;22(3):32433.
dic Clin N Am. 2009;40(1):4763, vi. 21. Boriani S, Bandiera S, Donthineni R, et al. Morbidity
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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

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.
Computer-Aided Spine Surgery 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.
Fig. 2 (continued)
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)
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)
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
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
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 [4658]. 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
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.
7. Nottmeier EW, Crosby TL. Timing of paired points

Summary and surface matching registration in three-
dimensional (3D) image-guided spinal surgery.
J Spinal Disord Tech. 2007;20:26870.
Computer-aided technology increases the accu- 8. Nolte L-P, Slomczykowski MA, Berlemann U, et al.
racy of pedicle screw insertion. Although the A new approach to computer-aided spine surgery:
reported rates of serious complications related fluoroscopy-based surgical navigation. Eur Spine J.
2000;9(Suppl 1):S7888.
to pedicle screw misplacement with the conven- 9. Nottmeier EW, Crosby TL. Timing of vertebral reg-
tional technique remain low, reliance on the safe istration in three-dimensional, fluoroscopy-based,
zone concept is not based on hard evidence. image-guided spinal surgery. J Spinal Disord Tech.
Consequently, surgeons should welcome every 2009;22:35860.
10. Tian N-F, Huang Q-S, Zhou P, et al. Pedicle screw
technical innovation that makes spine surgery insertion accuracy with different assisted methods:
safer for the patient. Various navigational sys- a systematic review and meta-analysis of
tems are available for image-guided spine sur- comparative studies. Eur Spine J 2010, ePub
gery, with no significant difference between the ahead of print
11. Holly LT, Bloch O, Johnson JP. Evaluation of regis-
different commercial systems. Each navigation tration techniques for spinal image guidance.
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for knowledge of the complex three-dimensional guided spine surgery. A cadaver study comparing
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ment, and meticulous surgical technique. Appro- image-guided techniques for pedicle screw place-
ment in posterolateral fusion and nonfusion models.
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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

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.
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.
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].
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
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 thoracolumbar 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
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].
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].
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
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
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
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].
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.
20. Nirula R, Brasel K. Do trauma centers improve func-

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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
School of Medicine, University of Leeds, Leeds, UK a significant socio-economic problem, due to com-
e-mail: pgiannoudi@aol.com plications and sequelae related to spinal cord

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
Injuries of the Cervical Spine 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
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, full range of motion
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
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
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
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.
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,
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
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
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
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).
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)
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.
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
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 % [3235].
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
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 %
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).
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
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.
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.
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
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].
16. Holmes JF, Akkinepalli R. Computed tomography

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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

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.
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 classification system
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
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 thoraco-lumbar frac-
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
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)
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
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 thoraco-lumbar frac-
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)
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. (eg): 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).
4. Driscoll P, Wardrope J. ATLS: past, present, and

Conclusions future. Emerg Med J. 2005;22(1):23.
5. Anderson S, Biros MH, et al. Delayed diagnosis of
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injury do not usually pose decisional problems 6. Bracken MB, Shepard MJ, et al. Methylprednisolone or
for their management strategy. Priority should be tirilazad mesylate administration after acute spinal cord
injury: 1-year follow up. Results of the third National
given to cardiopulmonary resuscitation with ade- Acute Spinal Cord Injury randomized controlled trial.
quate oxygenation and mechanical protection of J Neurosurg. 1998;89(5):699706.
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2001;26(24 Suppl):S55.
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There is still some controversy as to the optimal injury: a tarnished standard. J Neurosurg Anesthesiol.
timing of surgery, but it is generally accepted that 2008;20(2):1402.
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imaging of posttraumatic spinal ligament injury.
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the treatment of choice for the majority of using MRI. J Trauma. 2009;66(6):16105.
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Kyphoplasty - the Current Treatment
for Osteoporotic Vertebral Fractures
Guillem Salo
Contents Abstract
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761 Vertebral osteoporotic fractures are the most
frequent fractures in older patients with low
Indications for Kyphoplasty . . . . . . . . . . . . . . . . . . . . . . . 762
mineral bone density. Kyphoplasty is
Pre-Operative Preparation and Planning . . . . . . . . 763 a technique that tries to recover the height of
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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
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
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
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.
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 [6062], 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.
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]

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 strongly associated with
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).
Strategies for Low Back Pain 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
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).
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
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.
generally be avoided. Predicting poor outcomes for back pain seen in
On-going research focuses mainly on possible primary care using patients own criteria. Spine.
prevention of chronicity of low back pain and 1996;21(24):29007.
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
cific treatment modalities are helpful. There are a long-term follow-up study. North Carolina Back
numbers of randomized trials and systemic reviews Pain Project. Med Care. 1999;37(2):15764.
(and epidemiologic studies) regarding the value of 14. Fordyce WE, Brockway JA, Bergman JA, Spengler D.
specific therapeutic interventions for low back pain Acute back pain: a control-group comparison of
behavioral vs traditional management methods.
treatment, few of which are conclusive. J Behav Med. 1986;9(2):12740.
15. Andersson GB, Lucente T, Davis AM, Kappler RE,
Lipton JA, Leurgans S. A comparison of osteopathic
spinal manipulation with standard care for patients
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3. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Lundberg E. Clinical trial of intensive muscle training
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sis. BMJ. 2003;327(7410):323. 2(86268627):14736.
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problems in adults. Clinical practice guidelines no.14 Weber WE, van Kleef M. Randomized controlled
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nonsurgical treatment for chronic low back pain: Vancouver.
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

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
Treatment of the Aging Spine 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
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
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
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
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)
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
terms of increasing numbers of these patients and vertebroplasty for painful osteoporotic vertebral frac-
tures. N Engl J Med. 2009;361(6):55768.
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infrastructures are heavily loaded by these Liu SY. Adjacent segment degeneration after single-
pathologies and an interdisciplinary approach to segment PLIF: the risk factor for degeneration and its
these patients is unavoidable. More and more the impact on clinical outcomes. Eur Spine J.
2011;20(11):194650.
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which needs to be treated in the context of the with low back pain?: new insights based on skipped
whole medical care. Therefore, complex spinal level disc pathology (SLDD). Spine. 2012;37(7):
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15. Crawford CH 3rd, Carreon LY, Bridwell KH et al.
Long fusions to the sacrum in elderly patients
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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

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
Infections of the Spine 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
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
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.
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].
Fig. 5 Lumbar infection and vertebral destruction treated with anterior decompression and fusion associated with long
posterior instrumentation
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
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
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,
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
a confirmed 60 % deep wound infection on 3. Richmond BG, Strait DR. Origin of human bipedal-
subsequent implant removal despite previous ism: the knuckle-walking hypothesis revisited. Am
J Phys Anthropol. 2001;44:70105.
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debridement, so they definitely recommended enous lumbar spondylodiscitis in elderly patients with
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stable patients with this technique. When dealing and interbody fusion with iliac crest bone graft. Eur
Spine J. 2010;19:17207.
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[34] also found that implant removal associated of spondylodiscitis in the cervical spine: a minimum
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far as controlling infection was concerned. How- 6. DAgostino C, Scorzolini L, Massetti AP, et al.
A seven-year prospective study on spondylodiscitis:
ever they also noted the appearance of disc col- epidemiological and microbiological features. Infec-
lapse, loss of lordosis or pseudoarthrosis and this tion. 2010;38:1027.
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removal has to be carefully evaluated since the tuberculous spinal infection; management and out-
come. J Bone Joint Surg Br. 2009;91-B(Supp III):478.
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overcome by its consequences. fluorodeoxyglucose positron emission tomography for
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Spine. 2003;28:13149.
9. Schmitz A, Risse JH, Gr unwald F, et al. Fluorine-18
Conclusions fluorodeoxyglucose positron emission tomography
findings in spondylodiscitis: preliminary results. Eur
Spinal infections can endanger patients either Spine J. 2001;10:5349.
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Surgical Management
of Spondylodiscitis
Maite Ubierna and Enric Caceres 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.
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818 Magnetic resonance imaging is the most sen-
Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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,
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
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.
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.
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
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
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
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
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.
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
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.
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 paralysis. J Bone Joint Surg Am.
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.
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Mc Kenna F. Mr imaging appearances of cervical
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osteomyelitis: assessement using MR. Radiology. tion and treatment: an experimental study. Spine.
1985;157:15766. 1989;14:102532.
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:
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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.
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.
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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
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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
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CYC. Seventeen year prospective study of surgical 6771.
Surgical Management of 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
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
Post-Operative Care and Rehabilitation . . . . . . . . . 840 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
Department of Orthopaedics and Traumatology, 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
Department of Orthopaedics and Traumatology,
Hacettepe University, Ankara, Turkey and instrumented fusion, and depending
e-mail: aalanay@hacettepe.edu.tr on the stability of fixation, post-operative

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,
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
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
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 posterior instrumentation
in the treatment of tuberculous spondylitis. have been used in tuberculous spondylitis with
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)
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
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)
Fig. 2 (continued)
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.
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
immuno-compromise. Starting in the pulmonary 9. Peto HM, et al. Epidemiology of extrapulmonary

system, the disease spreads to the vertebral column tuberculosis in the United States, 19932006. Clin
Infect Dis. 2009;49(9):13507.
via the haematological route and causes significant 10. Petitjean G, et al. Vertebral osteomyelitis caused by
disability and deformity, and may lead to neuro- non-tuberculous mycobacteria. Clin Microbiol Infect.
logical deficit. Several characteristic radiographic 2004;10(11):9513.
changes point to tuberculosis of the spine, the most 11. Pablos-Mendez A, et al. Global surveillance for
Antituberculosis-drug resistance, 19941997. World
notable of which is the early sparing of disk space. health organization-international union against tuber-
MRI is the best imaging modality in the diagnosis culosis and lung disease working group on anti-
of tuberculous spondylitis. Diagnosis often requires tuberculosis drug resistance surveillance. N Engl
tissue biopsy which can be done with minimally- J Med. 1998;338(23):16419.
12. Espinal MA, et al. Global trends in resistance to
invasive techniques, under CT guidance or during Antituberculosis drugs. World health organization-
surgery. Treatment of tuberculosis of the spine is international union against tuberculosis and lung
with anti-tuberculosis drugs, but drug resistance is disease working group on anti-tuberculosis drug resis-
becoming a problem. According to the results of tance surveillance. N Engl J Med. 2001;344(17):
1294303.
a series of studies by the British Medical Research 13. Aziz MA, et al. Epidemiology of Antituberculosis
Council on Tuberculosis of the Spine, multi-drug drug resistance (the global project on anti-tuberculosis
therapy combined with surgical intervention leads drug resistance surveillance): an updated analysis.
to best results. Combined with the advances in Lancet. 2006;368(9553):214254.
14. Holtz TH, Cegielski JP. Origin of the term XDR-TB.
surgical technique, anaesthetic procedures and Eur Respir J. 2007;30(2):396.
implant technology, the preferred treatment today 15. Holtz TH. XDR-TB in South Africa: revised defini-
is debridement, instrumentation and fusion of the tion. PLoS Med. 2007;4(4):e161.
spine. While good results are being obtained in 16. Cherifi S, Guillaume MP, Peretz A. Multidrug-
resistant tuberculosis spondylitis. Acta Clin Belg.
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order to obtain eradication. the spineis it the beginning of the end? A study of
twenty-five culture proven multidrug-resistant tuber-
culosis spine patients. Spine. 2009;34(22):E80610
(Phila Pa 1976).
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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

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
Biomechanics of the Shoulder 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
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
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
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
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
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
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
structures can each, alone or in combination, 5. Dempster WT. Mechanisms of shoulder movement.
result in instability. Successful management of Arch Phys Med Rehabil. 1965;46A:4970.
6. De Palma AF. Degenerative changes in the
instability therefore requires careful history tak- sternoclavicular and acromioclavicular joints in vari-
ing and diagnostic skill to identify the responsible ous decades, vol. III. Springfield: Thomas; 1957.
lesions. The most successful surgical procedures 7. Doddy SG, Waterland JC, Freedman L.
to treat instability are specifically directed Scapulohumeral goniometer. Arch Phys Med Rehabil.
1970;51:7113.
towards restoration of normal anatomy and 8. Fehringer EV, Sun J, VanOeveren LS, Keller BK,
biomechanics. Matsen III FA. Full thickness rotator cuff tear
Replacement of the glenohumeral joint also prevalence and correlation with function and
requires attention to the restoration of normal co-morbidities in patients sixty-five years of age and
older. J Shoulder Elbow Surg. 2008;17(6):8815.
anatomy in order to provide the correct length/ 9. Goldberg BA, Nowinski RJ, Matsen III FA. Outcome
tension relationships for function of the muscles of nonoperative treatment of full thickness rotator cuff
crossing the articulation. Furthermore the com- tears. Clin Orthop. 2001;382:99107.
ponents and fixation techniques must withstand 10. Harryman III BT, Sidles JA, Clark JM, et al. Transla-
tion of the humeral head on the glenoid with passive
forces exceeding body weight across the joint glenohumeral motion. J Bone Joint Surg. 1990;72A
and, perhaps more importantly, forces of this (9):133443.
magnitude which sweep across the face of the 11. Hsu HC, Boardman III ND, Luo ZP, An KN. Tendon-
glenoid. These rock the component and in the defect and muscle-unloaded models for relating rota-
tor cuff tear to glenohumeral instability. J Orthop Res.
long-term may lead to loosening, particularly if 2000;18:9528.
the fixation technique is inadequate or the soft 12. Ianotti JP, Spencer EE, Wnter U, Deffenbaugh D,
tissues have not been dealt with correctly, leaving Williams G. Prosthetic positioning in total shoulder
eccentric forces acting on the glenoid. Reverse arthroplasty. J Shoulder Elbow Surg. 2005;14(1S):
111S21.
geometry articulations provide a relatively novel 13. Inman VT, Saunders JR, Abbott LC. Observations on
solution when a functioning rotator cuff is not the function of the shoulder joint. J Bone Joint Surg.
available for reconstruction. 1944;26:130.
The shoulder is very susceptible to disorders of 14. Inokuchi W, Sanderhoff Olsen B, Sojbjerg JO,
Sneppen O. The relation between the position of the
its articular surface or the muscles, tendons and glenohumeral joint and the intra-articular pressure: an
ligaments that contribute to normal function. It is experimental study. J Shoulder Elbow Surg.
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ries. Br J Sports Med. 2010;44:33340.
rewarded with poor function in operated patients. 16. Johnston TB. The movements of the shoulder joint.
A plea for the use of the plane of the scapula as the
plane of reference for movements occurring at the
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Matsen III FA, editors. The shoulder. Philadelphia: Wirth MA. The shoulder. 4th ed. Philadelphia:
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Clin Anat. 2001;14(5):3203. 32. Shevlin MG, Lehmann JF, Lucci JA. Electromyo-
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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
Hospital, Stanmore, Middlesex, UK a comprehensive overview of the imaging
e-mail: paul.odonnell@rnohnhs.uk modalities for investigating shoulder pathology.

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
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
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
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.
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
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.
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
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).
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

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
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].
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
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
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
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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
Orthopaedic Hospital, Stanmore, Middlesex, UK still the same group warned against using
e-mail: slambert@nhs.net PROMs as a means to define the level of

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
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)
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 shoulder arthroplasty.
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;214:1604.
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

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
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
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.
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.
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.
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
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]
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
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.
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
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
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].
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.
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
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
injuries. Assoc Brit Neurol Proc. 1995;44(abs).
from the posterior face of the scapula. In older 5. Berman J, Anand P, Chen L, Taggart M, Birch R. Pain
children the teres major is transferred to relief from preganglionic injury to the brachial plexus
infraspinatus because this muscle will have by late intercostal transfer. J Bone Jointt Surg.
become defunctioned by longstanding dislocation. 1996;78B:75960.
6. Berman JS, Birch R, Anand P. Pain following human
The early results of this procedure are promising brachial plexus injury with spinal cord root avulsion
[9, 80] (Figs. 20, 21). The problems caused by the and the effect of surgery. Pain. 1998;75:199207.
deformity of the acromio clavicular arch and the 7. Birch R, Bonney G, Wynn Parry CB. Surgical disor-
shortening of the clavicle remain unsolved. ders of the peripheral nerves. 1st ed. London: Chur-
chill Livingstone; 1998.
8. Birch R, Ahad N, Kono H, Smith S. Repair of obstetric
brachial plexus palsy. Results in 100 children. J Bone
Conclusions Joint Surg. 2005;87B:108995.
9. Birch R. Surgical disorders of the peripheral nerves.
2nd ed. London: Springer; 2011.
It is clear that nerve repair may improve 10. Bisinella G, Birch R. Obstetric brachial plexus lesion:
function in the upper limb in cases of BLBP, a study of 74 children registered with the British Sur-
particularly so when avulsed nerves are re- veillance Unit. J Hand Surg. 2003;28B:405.
innervated. A good shoulder is the foundation 11. Bisinella G, Birch R, Smith SJM. Neurophysiological
predictions of outcome in obstetric lesions of the bra-
for function in the upper limb in a growing child chial plexus. J Hand Surg. 2003;28B:14852.
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21724.
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soon as they are detected. Many of these chil- glossal nerve transfer in obstetrical brachial plexus
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from one specialist to another should be the site of lesion in traction lesions of the brachial
avoided. plexus. Brain. 1954;77:588609.
16. Bonney G. Prognosis in traction lesions of the brachial
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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,

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 1224 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
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
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.
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):5914.
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):6479.
Orthop Relat Res. 1995;321:18995.
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
Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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,

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].
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
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
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
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 Pre-Operative Preparation and Planning . . . . . . . . 957

Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 944
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
Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966
Radiographic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952
Frequently-Associated Injuries . . . . . . . . . . . . . . . . . . . . . . 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

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.
Fractures of the Scapula 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].
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)
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.
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
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
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].
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
clavicleacromioclavicular 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.
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
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
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
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.
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
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
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.
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
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]
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
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).
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
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.
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 heterotopic ossification
(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 %
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-
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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
Orthopaedic Hospital, Stanmore, Middlesex, UK glenohumeral instability, and patterns of
e-mail: slambert@nhs.net scapoluthoracic instability may vary in ascent

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
Scapulothoracic Arthrodesis 971
a b
T
D
Ssp
Ssp
T
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
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.
Scapulothoracic Arthrodesis
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].
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
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 muscular dystrophy (FSHD):
due to reduced chest expansion. One study implications for therapeutic trials. The FSH-DY
demonstrated a reduction of forced vital capacity Group. Neurology. 1997;48(1):3846.
by 21 % [19]. Other studies however have shown 2. Personius KE, Pandya S, King WM, Tawil R,
little or no change in respiratory function [8, 9, McDermott MP. Facioscapulohumeral dystrophy
natural history study: standardization of testing
12, 15, 20]. procedures and reliability of measurements. The FSH
Progressive deltoid weakness is a potential DY Group. Phys Ther. 1994;74(3):25363.
cause for concern in patients with fascioscapu- 3. Lunt PW, Harper PS. Genetic counselling in
lohumeral dystrophy. In 4 out of 20 cases facioscapulohumeral muscular dystrophy. J Med
Genet. 1991;28(10):65564.
reported by Diab et al. deltoid weakness
4. Lefkowitz DL, Lefkowitz SS. Fascioscapulohumeral
developed. However others found no loss in muscular dystrophy: a progressive degenerative
achieved function and deltoid strength; Bunch disease that responds to diltiazem. Med Hypotheses.
and Seigel [15], after 23 years, Copeland et al. 2005;65(4):71621.
5. Tawil R, McDermott MP, Pandya S, King W, Kissel J,
[12] after 20 years and Letournel et al. [8] after 6 Mendell JR, Griggs RC. A pilot trial of prednisone in
years. Twyman et al. [19] found maintenance of facioscapulohumeral muscular dystrophy. FSH-DY
achieved range of motion and increased Group. Neurology. 1997;48(1):469.
deltoid strength. 6. Kissel JT, McDermott MP, Mendell JR, King WM,
Pandya S, Griggs RC, Tawil R. Randomized,
double-blind, placebo-controlled trial of albuterol in
facioscapulohumeral dystrophy. Neurology.
Summary 2001;57(8):143440.
7. Krishnan SG, Hawkins RJ, Michelotti JD, Litchfield
The aim of performing a scapulothoracic R, Willis RB, Kim YK. Scapulothoracic arthrodesis:
indications, technique, and results. Clin Orthop Relat
arthrodesis is to stabilise the scapula in an Res. 2005;435:12633.
appropriate position so that it can provide 8. Letournel E, Fardeau M, Lytle JO, Serrault M,
a stable fulcrum against which the abductors Gosselin RA. Scapulothoracic arthrodesis for
can work. Whilst this can result in an improve- patients who have fascioscapulohumeral muscular
dystrophy. J Bone Joint Surg Am. 1990;72(1):7884.
ment in function and periscapular pain, the loss of 9. Diab M, Darras BT, Shapiro F. Scapulothoracic
scapulothoracic movement by arthrodesis means fusion for facioscapulohumeral muscular dystrophy.
that function is not that of a normal shoulder. J Bone Joint Surg Am. 2005;87(10):226775.
10. Berne D, Laude F, Laporte C, Fardeau M, Saillant G. 18. Mackenzie WG, Riddle EC, Earley JL, Sawatzky BJ.
Scapulothoracic arthrodesis in facioscapulohumeral A neurovascular complication after scapulothoracic
muscular dystrophy. Clin Orthop Relat Res. arthrodesis. Clin Orthop Relat Res. 2003;408:
2003;409:10613. 15761.
11. Ketenjian AY. Scapulocostal stabilization for scapular 19. Twyman RS, Harper GD, Edgar MA. Thoracoscapular
winging in facioscapulohumeral muscular dystrophy. fusion in facioscapulohumeral dystrophy: clinical
J Bone Joint Surg Am. 1978;60(4):47680. review of a new surgical method. J Shoulder Elbow
12. Copeland SA, Howard RC. Thoracoscapular fusion Surg. 1996;5(3):2015.
for facioscapulohumeral dystrophy. J Bone Joint 20. Jakab E, Gledhill RB. Simplified technique for
Surg Br. 1978;60-B(4):54751. scapulocostal fusion in facioscapulohumeral dystro-
13. Jeon IH, Neumann L, Wallace WA. Scapulothoracic phy. J Pediatr Orthop. 1993;13(6):74951.
fusion for painful winging of the scapula in nondystrophic 21. Demirhan M, Uysal M, Onen M. The use of the cable-
patients. J Shoulder Elbow Surg. 2005;14(4):4006. grip system in the treatment of winged scapula caused
14. Kocialkowski A, Frostick SP, Wallace WA. One-stage by post-traumatic combined nerve injury: a case
bilateral thoracoscapular fusion using allografts. report. Acta Orthop Traumatol Turc. 2002;36(2):
A case report. Clin Orthop Relat Res. 1991;273:2647. 1626.
15. Bunch WH, Siegel IM. Scapulothoracic arthrodesis in 22. Szomor ZL, Fermanis G, Murrell GA.
facioscapulohumeral muscular dystrophy. Review of Scapulothoracic fusion for a stroke patient with
seventeen procedures with three to twenty-one-year Achilles tendon allograft. J Shoulder Elbow Surg.
follow-up. J Bone Joint Surg Am. 1993;75(3):3726. 2000;9(4):3423.
16. Ziaee MA, Abolghasemian M, Majd ME. 23. Bizot P, Teboul F, Nizard R, Sedel L. Scapulothoracic
Scapulothoracic arthrodesis for winged scapula due fusion for serratus anterior paralysis. J Shoulder
to facioscapulohumeral dystrophy (a new technique). Elbow Surg. 2003;12(6):5615.
Am J Orthop. 2006;35(7):3115. 24. Giannini S, Ceccarelli F, Faldini C, Pagkrati S, Merlini
17. Wolfe GI, Young PK, Nations SP, Burkhead WZ, L. Scapulopexy of winged scapula secondary to
McVey AL, Barohn RJ. Brachial plexopathy follow- facioscapulohumeral muscular dystrophy. Clin Orthop
ing thoracoscapular fusion in facioscapulohumeral Relat Res. 2006;449:28894.
muscular dystrophy. Neurology. 2005;64(3):5723.
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].

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].
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].
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].
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].
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).
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
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 conservative treatment
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].
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
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.
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
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].
posterior displacement in sports participants. J Bone

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sternoclavicular dislocations: a review of management 2008;90(4):87580.
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

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.
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].
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
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) Displaced Fractures (Type 2B)
Undisplaced (Type 2A1) Simple or wedge comminuted (Type 2B1)
Angulated (Type 2A2) Isolated or comminuted segmental (Type 2B2)
Cortical Alignment Fractures (Type 3A) Displaced Fractures (Type 3B)
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.
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, 6870]. 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
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 hardware Mean Constant
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 hardware Mean Constant
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)
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
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
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
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.
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),
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, 6971, 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
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
Fractures of the Shaft of the Clavicle
[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
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].
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, 140143].
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
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
[15, 39, 51, 57, 58, 76, 78, 154156]. Superficial References
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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].

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,
Acromioclavicular Injuries 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)
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.
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.
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].
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
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
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
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.
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
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
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
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
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
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
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

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
Princess Elizabeth Orthopaedic Centre, Exeter, UK
e-mail: Tim.bunker@exetershoulderclinic.co.uk

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
Rotator Cuff Tears-Open Repair 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
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.
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
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
modality of choice for 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 modality of choice for
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.
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
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
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.
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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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

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].
Partial Rotator Cuff Ruptures 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
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.
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
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
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].
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
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.
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
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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

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].
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 20 (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
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.
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).
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
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
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
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
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
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).
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
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
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.
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
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
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.
Neurapraxia: transient, most commonly Factors influencing the results. Clin Orthop.
affects the musculocutaneous nerve. Its inci- 1988;236:14853.
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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
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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 boneimplant 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
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
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
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
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
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
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
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, 4862].
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
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
A. Van Tongel and L. De Wilde
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
Fig. 13 Post-operative
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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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

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
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].
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, 4244]).
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
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
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].
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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
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . 1138
Superior labral lesions (SLAP tears) Glenoid
Relevant Applied Anatomy, Pathology 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
Post-Operative Care and Rehabilitation . . . . . . . . 1148 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

DOI 10.1007/978-3-642-34746-7_233, # EFORT 2014
1138 M. Tauber and P. Habermeyer
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
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
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,
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
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
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
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].
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)
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
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
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
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 1153
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
e-mail: Pierre.Hoffmeyer@hcuge.ch; with an additional scalene block, the patient is
pierre.hoffmeyer@efort.org placed on the operating table in a semi-sitting

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
j
k
c
i
e
f
h
b g
m
d
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.
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.
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
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):2519.
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):6259.
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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
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1979;61(4):5669.
For the great majority of patients this does have 10. Kartus J, Ejerhed L, Funck E, Kohler K, Sernert N,
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1. Balg F, Boileau P. The instability severity index score. untary inferior and multidirectional instability of the
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1938;26:239. inferior capsular shift procedure for multidirectional
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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
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1164 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
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167 recurrence rates.
There are no widely-accepted classification
systems for shoulder instability of children
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176 and adolescents and the most commonly used
Post-Operative Care and Rehabilitation . . . . . . . . 1181 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

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
Shoulder Instability in Children and Adolescents 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
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.
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
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
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
Fig. 6 (continued)
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].
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 %
Shoulder Instability in Children and Adolescents
[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;
46 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
J. Kircher and R. Krauspe
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);
Shoulder Instability in Children and Adolescents
dislocations secondary
during sports, 3 surgery: 3/16
falls; 1 girls (18.75 %)
bilateral redislocation
multidirectional (2 hyperlax)
instability
1175
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).
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
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. 11ac). As a general rule there is
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
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)
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
Princess Elizabeth Orthopaedic Centre, Exeter, UK well to treatment, but not others? There is a great
e-mail: Tim.bunker@exetershoulderclinic.co.uk need for on-going research into this condition.

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
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
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.
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
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.
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.
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
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
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
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 post- surgery 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.
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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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
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1202
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1215
Relevant Applied Anatomy, Biomechanics . . . . . 1202
Arthrodesis Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1202
Articular Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1204
Diagnosis, Surgical Indications . . . . . . . . . . . . . . . . . . 1205
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1207
Patient Positioning and Surgical Approach . . . . . . . . 1207
Articular Preparing and Osteosynthesis . . . . . . . . . . . 1209
Post-Operative Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1211
Post-Operative Care and Rehabilitation . . . . . . . . 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

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
shoulder arthroplasty. 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.
Shoulder Arthrodesis 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
m
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
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
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
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.
a b
c d
Fig. 8 (continued)
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
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
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
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,
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.
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
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
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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
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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.
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.
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.
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
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
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.
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
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.
Summary and Conclusions References
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Treatment of Proximal Humerus
Fractures by Plate Osteosynthesis
David Limb
Contents Abstract
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230 Plate fixation for fractures of the proximal
humerus is the most reliable technique for
obtaining secure fixation of multi-fragmentary
Relevant Applied Anatomy, Pathology 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,
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 1234 but also due to the difficulties of applying
Pre-Operative Preparation and Planning . . . . . . 1234 correct surgical technique. Despite improved
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
Post-Operative Care and Rehabilitation . . . . . . . . 1242 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
Chapel Allerton Hospital, Leeds, UK
e-mail: d.limb@leeds.ac.uk

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 classification systems
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
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.
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
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
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
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
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 Bone Joint Surg Am. 1990;72(10):
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. J Shoulder Elbow Surg. 2000;9(5):
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):57984.
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.
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;20:74755.
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,
tion versus nonoperative treatment of displaced 3-part observational study. J Bone Joint Surg Am.
proximal humeral fractures in elderly patients: 2009;91A(6):13208.
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
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249 the osteoporosis nature of the vast majority of
these fractures. Most of poor outcomes and
complications of surgically-treated proximal
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1251 humeral fractures are related to osteoporosis.
Post-Operative Care and Rehabilitation . . . . . . . . 1252 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

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.
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
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
Fig. 11 Post-operative 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 proximal humeral fractures
elderly population may have pain with such and their use has spread widely over the recent
programmes. years. Specially developed to obtain strong
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
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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16. Gerber C, Schneeberger AG, Vinh JS. The arterial
vascularization of the humeral head. An anatomical
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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
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
e-mail: Pierre.Hoffmeyer@hcuge.ch;
pierre.hoffmeyer@efort.org

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).
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 proximal humeral fractures
The delto-pectoral approach is the favoured a straight or oblique 1015 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].
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].
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
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
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).
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.
bone with a pattern that preserves the vascularity 5. Duparc J, Largier A. Fracture-dislocations of the
of the articular cephalic fragment (Fig. 17). upper end of the humerus (French). Rev Chir Orthop
Reparatrice Appar Mot. 1976;62:91110.
6. Ehlinger M, Gicquel P, Clavert P, Bonnomet F, Kempf J-
F. A new implant for proximal humeral fracture: exper-
Rehabilitation imental study of the basket plate (French). Rev Chir
Orthop Reparatrice Appar Mot. 2004;90:1625.
As a rule the shoulder should be mobilized as 7. Esser RD. Treatment of three- and four-part fractures
of the proximal humerus with a modified cloverleaf
early as possible (Rehabilitation will pass through plate. J Orthop Trauma. 1994;8:1522.
three phases -I-II-III). During phase I the accent is 8. Hertel R. Fractures of the proximal humerus in osteo-
placed on passive assisted mobilization in some porotic bone. Osteoporos Int. 2005;16(Suppl 2):S6572.
cases under scalene bloc. The shoulder should be 9. Hoffmeyer P. The operative management of displaced
fractures of the proximal humerus. J Bone Joint Surg
mobilized in elevation in the plane of the scapula Br. 2002;84:46980.
by the physiotherapist and the patient is encour- 10. Ko JY, Yamamoto R. Surgical treatment of complex
aged to mobilize himself the injured shoulder fracture of the proximal humerus. Clin Orthop.
using his uninjured arm. The exercises should be 1996;327:22537.
11. Koval KJ, Gallagher MA, Marsicano JG, Cuomo F,
performed supine and then later in the sitting McShinawy A, Zuckerman JD. Functional outcome
position. Exercising in the water in an adapted after minimally displaced fractures of the proximal part
pool under supervision should be started as soon of the humerus. J Bone Joint Surg Am. 1997;79:2037.
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Frosch B, Gradl G. Stabilization of proximal humeral
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ening exercise. At this time slings and shoulder the proximal humerus treated with suture fixation.
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Hemi-Arthroplasty for Fractures
of the Proximal Humerus
Tony Corner and Panagiotis D. Gikas
Contents Abstract
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277 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
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 1281
even in the experienced shoulder surgeons
Pre-Operative Preparation and Planning . . . . . . 1282 hands.
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1282 This chapter aims to explain the operative
Post-Operative Care and Rehabilitation . . . . . . . . 1288 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-
St. Albans Hospitals, Watford, UK
stand the patho-anatomy of these fractures and
P.D. Gikas
appreciate the mechanics and constituent parts of
The London Sarcoma Service, Royal National
Orthopaedic Hospital, Stanmore, Middlesex, UK the fracture with respect to the head, tuberosities
and shaft [1]. Charles Neer originally reported
West Hertfordshire Hospitals NHS Trust, Watford and
St. Albans Hospitals, Watford, UK high failure rates for open reduction and internal
e-mail: panosgikas@me.com fixation of three-part and four-part fractures of

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 dividing the humerus into
ring in the head, shaft, or greater or lesser tuber- three fragments,
osity. He indicated that surgical treatment is Single fracture pattern dividing the humerus into
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
S
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.
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
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.
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
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
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.
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
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.
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
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
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
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.

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
Humeral Shaft Fractures - Principles of Management 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
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]
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
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 paralysis. J Bone Joint Surg Am.
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:23943.
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
Chapel Allerton Hospital, Leeds, UK the humerus, ulna and radius. The humerus is
e-mail: d.limb@leeds.ac.uk a tubular long bone but distally it flares out to

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.
Biomechanics of the Elbow 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
A
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
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
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.
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,
of possible movement. Good function is possible flexion and 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
computer keyboards and mobile phones demand forearm functional anatomy of the interosseous
membrane. J Jpn 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 KN, Stormont TJ. Force transmission
replacements that were designedassuch.The natural through the radial head. J Bone Joint Surg Am.
1988;70:2506.
elbow couples hinge movement with a few degrees 17. Morrey BF, Askew LJ, An KN, et al. A biomechanical
of varus/valgus movement of the ulna and axial study of normal functional elbow motion. J Bone Joint
rotation along its length whilst transmitting forces Surg Am. 1981;63:8727.
that can be equivalent to multiples of body weight. 18. Morrey BF, Chao EY. Passive motion of the elbow
joint. J Bone Joint Surg Am. 1976;58:5018.
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
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1317 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
University of Barcelona, Barcelona, Spain lateral compartments of the joint.

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)
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
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
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].
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
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.
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.
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.
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.
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
a
b
Fig. 18 (continued)
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
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
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
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
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
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
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:
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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 Orthop Relat Res. 2000;370:1933.
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;166:18892.
14. Campbell WC. Incision for exposure of the elbow
associated pathology. In this regard, a universal
joint. Am J Surg. 1932;15:657.
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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
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.
21. MacAusland WR. Ankylosis of the elbow, with report deficient elbow. J Bone Joint Surg Am. 2004;86-A
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.
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2010;92(3):55866. elbow. J Bone Joint Surg Am. 1964;46:1598606.
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PG, ODriscoll SW, Morrey BF, An KN. Detrimental de osteosntesis. Fracturas de los huesos largos.
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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
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1339 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-
Post-Operative Care and Rehabilitation . . . . . . . . 1351 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

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 (30130 ) 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
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
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
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
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
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].
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
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.
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
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.
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
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
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
Arthroscopy of the elbow was first described by dissecans of the elbow. Br J Sports Med.
Burman in 1932. However, for a long time, the 2006;40(12):9669.
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
arthroscopist. The list of indications for arthros-

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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 . . . . . . . . . . 1

Necrotising Fasciitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Part II Spine ....................................... 405

Applications of Lumbar Spinal Fusion and Disc

Spinal Osteotomy Indications and Techniques ............ 609

Posterior Decompression for Lumbar Spinal Stenosis . . . . . . . . 625

Minimally-Invasive Anterior Lumbar Spinal Fusion . . . . . . . . . 643

Sub-Total and Total Vertebrectomy for Tumours . . . . . . . . . . . 661

Computer-Aided Spine Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 677

General Management of Spinal Injuries . . . . . . . . . . . . . . . . . . . 697

Injuries of the Cervical Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717

Treatment of Thoraco-Lumbar Spinal Injuries . . . . . . . . . . . . . 743

Kyphoplasty - the Current Treatment for Osteoporotic

Strategies for Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777

Treatment of the Aging Spine ........................... 785

Infections of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801

Surgical Management of Spondylodiscitis . . . . . . . . . . . . . . . . . . 813

Surgical Management of Tuberculosis of the Spine . . . . . . . . . . 829

Part III Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845

Recurrent Glenohumeral Instability . . . . . . . . . . . . . . . . . . . . . . 1137

Part IV Arm, Elbow and Forearm . . . . . . . . . . . . . . . . . . . . . . 1303

Surgical Anatomy, Approaches and Biomechanics of

Arthroscopic Techniques in the Elbow . . . . . . . . . . . . . . . . . . . . 1339

Distal Biceps and Triceps Avulsions . . . . . . . . . . . . . . . . . . . . . . 1355

Part V Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1595

Arthroscopy of the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1621

Management of Cerebral Palsy in the Upper Limb . . . . . . . . . . 2033

Surgical Management of the Rheumatoid Hand ............ 2051

Re-Implantation and Amputation of the Digits

Part VI Pelvis and Hip ............................... 2105

Osteonecrosis of the Femoral Head . . . . . . . . . . . . . . . . . . . . . . . 2133

Hip Arthroscopy and Treatment of Acetabular Retroversion

Hip Dislocation and Femoral Head Fractures . . . . . . . . . . . . . . 2179

Fractures of the Femoral Neck and Proximal Femur ........ 2203

Acetabular Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2269

Fractures and Dislocations of the Pelvic Ring . . . . . . . . . . . . . . 2319

Chiari Osteotomy of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2335

Bernese Peri-Acetabular Osteotomy . . . . . . . . . . . . . . . . . . . . . . 2343

Tribology of Hip Joint Replacement . . . . . . . . . . . . . . . . . . . . . . 2365

Cementless Total Hip Joint Replacement . . . . . . . . . . . . . . . . . . 2379