JAOOS

Isolated and Combined Posterior Cruciate Ligament Injuries Daniel M. Veltri, MD, and Russell F. Warren, MD Abstract Posterior cruciate ligament (PCL) injuries represent 3% to 20% of all knee liga- ally involve multiple ligaments. mentous injuries, but the diagnosis often is missed at initial evaluation. Diagnos- Forced hyperextension can injure tic acumen is increased by knowledge of knee biomechanics and selective the PCL, but this usually results in ligament-cutting studies. The examiner must differentiate the isolated PCL injury combined ligamentous injury from combined ligamentous injury to determine appropriate treatment. Isolated involving the anterior cruciate liga- acute PCL tears with less than 10 mm of posterior laxity at 90 degrees of flexion ment (ACL).1,6 Posteriorly directed should be treated with an aggressive rehabilitative program. This amount of laxity force to the anteromedial tibia with is found in the majority of isolated acute PCL tears. Isolated acute PCL tears with the knee in hyperextension may also more than 10 to 15 mm of posterior laxity and PCL tears with combined ligamen- cause a posterolateral corner injury,1 tous injuries should be reconstructed. Large PCL bony avulsions should be fixed which results in varus and external- internally. Small PCL bony avulsions with more than 10 mm of posterior laxity rotation knee instability. Significant should be reconstructed. Chronic PCL injuries initially should be treated with an varus or valgus stress will injure the aggressive rehabilitation program. If such a program is not successful in a patient PCL only after rupture of the appro- with more than 10 to 15 mm of posterior laxity and no significant radiographic evi- priate collateral ligament. dence of degenerative changes, the PCL should be reconstructed. J Am Acad Orthop Surg 1993;1:67-75 Biomechanics Posterior cruciate ligament injuries Injury to the posterior cruciate liga- priate management.5-8 In this article are commonly overlooked during ment (PCL) is thought to account for we will present the current approach the initial evaluation of the acutely 3% to 20% of all knee ligament to the diagnosis and management of injured knee. The physical examina- injuries.1,2 The true incidence of PCL isolated and combined PCL injuries. tion findings in isolated PCL injury injuries remains unknown because are subtle. Knowledge of the biome- many isolated PCL injuries may be chanics obtained from selective liga- undetected. Parolie and Bergfeld3 Mechanism of Injury ment-cutting experiments allows noted a 2% PCL injury rate among correlation of a simulated physical asymptomatic college football play- Most PCL injuries occur as a result of examination with known ligament ers invited to the National Football athletic, motor vehicle, or industrial injury. Such selective cutting studies League predraft examination. accidents. The mechanism of most measure the change in knee motion Accurate diagnosis of the PCL athletic PCL injuries is a fall on the after transection of a specific liga- injury is the first step in determining flexed knee with the foot in plantar ment. The experimentally produced appropriate management. The abil- flexion.3,7 This imparts the force to the change in laxity over a range of knee- ity to differentiate an isolated from a tibial tubercle, which drives the tibia combined ligamentous injury is posteriorly and ruptures the ligament, Dr. Veltri is Chief, Department of Orthopaedic aided by a knowledge of knee bio- usually resulting in an isolated PCL Surgery, Luke Air Force Base, Litchfield Park, mechanics obtained with the use of injury. Similarly, in motor vehicle acci- Ariz. Dr. Warren is Professor of Orthopaedic selective ligament-cutting tech- dents, the knee is flexed, and the tibia Surgery, Cornell Medical College, New York niques.4 It is also important to under- is forced posteriorly on impact with City; and Chief, Sports Medicine and Shoulder Service, The Hospital for Special Surgery. stand the natural history of the the dashboard.6 Hyperflexion of the PCL-injured knee, the results of non- knee without a direct blow to the tibia Reprint requests: Dr. Warren, Sports Medicine operative treatment with aggressive can also cause isolated PCL injury. and Shoulder Service, The Hospital for Special rehabilitation, and the results of sur- The PCL can be involved in other Surgery, 535 E. 70th St, New York, NY 10021. gical treatment to determine appro- mechanisms of injury, but these usu- Vol 1, No 2, Nov/Dec 1993 67 Posterior Cruciate Ligament Injuries flexion angles provides an important varus moment at any angle of angulation are the most useful basis for clinical knee testing. flexion. In contrast, sectioning of the findings for detecting injury to the Gollehon et al4 used selective liga- LCL and the deep ligament complex PCL and the posterolateral corner.1 ment-cutting techniques to evaluate resulted in increased varus angula- Isolated PCL injury will allow maxi- the role of the PCL and the postero- tion at all angles of knee flexion and mum posterior translation with pos- lateral corner in stability of the knee. was maximal at 30 degrees. Addi- teriorly directed force at 70 to 90 They found that isolated sectioning tional sectioning of the PCL further degrees of flexion. Since posterior of the PCL increased posterior trans- increased varus angulation at all translation is greatest at 90 degrees lation with posteriorly directed force angles of knee flexion. of flexion, the posterior drawer test at all angles of flexion, but the maxi- Isolated sectioning of the PCL did should be performed in this posi- mal excursion occurred at 90 degrees not increase external rotation with tion. Achieving 90 degrees of knee of flexion. With an intact PCL, sec- an external rotation moment at any flexion in an acute injury may be tioning of the lateral collateral liga- angle of knee flexion. With an intact difficult, however. Increased poste- ment (LCL) and the deep ligament PCL, sectioning of the LCL and the rior translation, external rotation, complex (arcuate ligament, popli- deep ligament complex increased and varus angulation at 30 degrees teus tendon, fabellofibular ligament, external rotation at all angles of of knee flexion that decreases at 90 and posterolateral capsule) pro- flexion and was maximal at 30 degrees indicates isolated injury to duced small but significant increases degrees. Additional sectioning of the the posterolateral corner. Thus, com- in posterior translation at all angles PCL markedly increased external paring posterior translation, exter- of flexion and was maximal at 30 rotation at 60 and 90 degrees of nal rotation, and varus angulation at degrees. The amount of posterior flexion. 30 and 90 degrees can help differen- translation produced by combined tiate PCL injury from posterolateral sectioning of the LCL and the deep corner injury.4 Increased posterior ligament complex with an intact PCL Clinical Examination translation, varus angulation, and was similar to that produced by iso- external rotation at 90 degrees of lated sectioning of the PCL at 0 and Biomechanical data can be applied flexion indicate combined injury to 30 degrees of knee flexion. to clinical examination of the knee both the PCL and the posterolateral Isolated sectioning of the PCL did (Table 1). Changes in posterior trans- corner.4 not increase varus angulation with lation, external rotation, and varus The posterior drawer test at 90 degrees of flexion is most useful for documenting PCL insufficiency. Table 1 This test is performed with the Usefulness of Clinical Tests in Detection of Knee Injury patient supine, with both feet on the table and the knee flexed to 90 Type of Injury* degrees. At this angle of flexion, the anterior tibial condyles should be PCL and well anterior to the corresponding Posterolateral Posterolateral femoral condyles (approximately 10 Clinical Test PCL Corner Corner mm). The injured knee is compared with the normal knee. If the tibia can Posterior drawer, 30 degrees + + ++ Posterior drawer, 90 degrees ++++ – +++ be moved posteriorly 0 to 5 mm on Posterior sag, 90 degrees +++ – +++ the injured side, this is considered a Quadriceps active ++++ – +++ grade I posterior drawer sign. This Prone external rotation, usually corresponds to posterior 30 degrees – ++++ +++ displacement of the tibial condyles Prone external rotation, to a position that is still anterior to 90 degrees ++ + +++ the femoral condyles. If the tibia can Varus stress, 30 degrees – +++ +++ be displaced 5 to 10 mm posteriorly, Varus stress, 90 degrees ++ + +++ this is a grade II posterior drawer Reverse pivot shift –/+ ++ ++ sign. This corresponds to posterior displacement of the tibial condyles * Symbols represent grading scale for usefulness in detecting type of injury, ranging from – (not useful) to ++++ (most useful). until they are flush with the femoral condyles. If the tibia can be dis- 68 Journal of the American Academy of Orthopaedic Surgeons Many deficient knee. A quadriceps contraction causes anterior tibial sublux- ation. the posterior drawer test. PCL-deficient knee. a tion can also be used. No 2. the examiner should usually rotation. the tibia is posteriorly subluxated (left). The examina- knee. Veltri. also be performed with the foot in tive to the femur. but the supine posi- with the findings in an ACL-deficient the table (Fig.6 The test is posterior drawer test endpoint less formed with the foot in external performed at 90 degrees of hip and sensitive than the endpoint in a Lach. test) has been used to assess postero. rotation (the posterolateral drawer knee flexion and uses gravity to man test done for an ACL injury. A positive finding can Posterior displacement of the tibia luxated posteriorly. jured knee. the tibia is sub. 3. and Russell F. The posterior sag of the should always include a Lachman with this maneuver must be com.9 This test involves placing the should also be examined. which is visible when the examiner is observing the tibial movement from the affected side (right). anterior ment. apply a posteriorly directed force to Examination of the injured knee lateral corner injury. tibia on the injured side is compared test at 30 degrees of flexion. which the most useful tests for diagnosing point may return to normal with provides the secondary restraint to PCL injury. and the Lach. The posterior drawer test should posterior translation of the tibia rela- orly. Thus. In the PCL- deficient knee. The findings the tibia. Warren. 1 The quadriceps active test is performed with the affected hip and knee at 90 degrees of flexion and the foot resting on the table.1 Passive external rotation of the anteroposterior (AP) translation The quadriceps active test is also tibia relative to the femur with the with a firm anterior endpoint. Nov/Dec 1993 69 . In the pared with those in the intact unin. MD. However. man test may demonstrate increased terolateral corner but is not specific. We PCL-deficient knees have an altered ligament. indicates PCL injury. indicate injury to the PCL or pos. MD placed more than 10 mm posteri. time in the chronically PCL-deficient posterior displacement. flexion indicates PCL injury.1 The posterior sag test is similar to knee.7 This finding has been translation with quadriceps contrac- assess an endpoint when performing attributed to PCL injury with an tion with the knee at 90 degrees of a posterior drawer test.7 Such a finding also may consider the quadriceps active test endpoint with a posterior drawer indicate maintenance of the integrity and the posterior drawer test to be test. and condyles posterior to the femoral drawer sign in neutral rotation have a quadriceps contraction produces condyles. The useful in the diagnosis of PCL knee at 30 and 90 degrees of flexion increased AP translation is due to the injury. In the PCL- terior drawer sign. In the intact knee. or Wrisberg’s. the posterior end. drawer test is performed in internal tive to the femur. In this situation we find the The posterior drawer test per. the tibia rests in a to displacement of the tibial patients with a positive posterior posteriorly subluxated position. this represents a grade III pos. with that on the noninjured side. of the posterolateral corner. Most acutely intact Humphry’s. decreased excursion when the anterior translation of the tibia rela- In addition to posterior displace.1 This is posterior subluxation from the PCL patient supine and flexing the knee best evaluated with the patient in the injury and should not be confused 90 degrees with the foot resting on prone position. quadriceps contraction results in tion is done by comparing the axis of Fig. This corresponds internal and external rotation. Daniel M. 1). One of the examiner’s hands restrains the foot of the affected leg while the patient attempts to slide the foot down the table with a quadri- ceps contraction. Vol 1. which has a soft endpoint. In test and the reversed pivot shift test described by Daniel et al. 2 The prone external ligament reconstruction. when excessive varus and Radiographs are useful in docu- 30 and 90 degrees indicates injury to hyperextension are present. associated injuries. This test is also per. We routinely Varus and valgus stress tests are has been used to diagnose postero. At an average follow- 70 Journal of the American Academy of Orthopaedic Surgeons . to detect acute partial PCL tears. the knee falls in varus. degrees of flexion indicates medial used to confirm the diagnosis of PCL pared with that on the noninjured collateral ligament (MCL) injury. quadriceps active test performed can be achieved in the noninjured The external rotation recurvatum with a knee-ligament arthrometer as knee is considered significant. injury. hyperexten. The reverse pivot shift test with PCL injury. External rotation of the which is commonly seen with PCL of instrumented knee testing is the injured knee 10 degrees or more than injury.9 Magnetic addition. tion at 30 degrees that decreases sion. Parolie and knees flexed 90 degrees. Increased external rota. not anteromedial. External rotation of the Natural History and affected foot relative to the Clinical Results thigh is compared with that on the normal side. Slightly increased knee. the foot is forcefully to the PCL and possibly the ACL. Knowledge of the natural history tion on the affected side is 10 and the results of nonoperative and degrees or more greater than surgical treatment is important when that achieved on the normal side. found to a greater degree in the flexion to assess the presence of com- cates LCL and possibly posterolat.1 rotation test with the patient’s knees flexed 30 degrees. 2). Bergfeld3 reported long-term results of nonoperative treatment of isolated PCL injuries. This test which generally present as painful at 90 degrees indicates isolated was originally thought to indicate knees without significant posterior injury to the posterolateral corner. the tibial condyles are pal. The feet are exter- nally rotated by the exam- iner. instability on physical examination. ligament laxity. injury to menting PCL avulsion fractures and both the PCL and the posterolateral the ACL and possibly the PCL is also degenerative changes associated corner.Posterior Cruciate Ligament Injuries the medial border of the foot relative Significant varus opening at full Diagnostic Studies to the femur. This component rotation recurvatum test involves sis of acute PCL injury11 and can be of the examination ensures that the grasping the great toe with the knee used to identify meniscal and chon- increased external rotation is from in extension while the patient is dral pathologic changes. and the degree of Significant valgus opening at 30 netic resonance (MR) imaging can be external rotation of the foot is com. supine. deciding on proper treatment of the formed with the patient’s PCL-injured knee. Merchant views are eral corner injury.1 Instrumented knee testing and mag- externally rotated. The test result is considered significant if external rota. present. Increased external rotation at both ever.4 isolated posterolateral injury. How. obtain standing AP radiographs in performed at full extension and 30 lateral instability.1 Normal intact knees may have used to evaluate the patellofemoral varus opening at full extension is a positive reverse pivot shift. are also used to identify PCL and resonance imaging has proved to be pated to determine their position rel.1 A positive sign occurs when resonance imaging can also be used instability. The most useful application side (Fig. 1 With the patient extension indicates additional injury placed prone. and external rotation.9. 10 This test is full extension and posteroanterior degrees of flexion. Increased varus significant only if a positive result is (PA) radiographs in 45 degrees of opening at 30 degrees of flexion indi. sion from the hip to the ankle are obtained in cases of combined PCL and posterolateral instability to rule out varus alignment that would require proximal tibial valgus osteotomy prior to consideration of Fig. injured knee than in the noninjured partment wear.10 The external sensitive and specific in the diagno- ative to the femur. Standing weight- consistent with combined injury to correlates directly with generalized bearing radiographs in full exten- the LCL and posterolateral corner. Magnetic posterolateral. this compartment. Daniel M. If the avulsed fragment is pendent of acute chondral injury. Acute PCL avulsions ation could result from acute chon- dral injury associated with PCL injury or from increased joint-con. Nov/Dec 1993 71 . MD up of 6. In their series.8 In theory.13 Open reduc. and Russell F. Warren. Fowler PCL-deficient knees.. The degree were satisfied with their results.13 90 degrees of flexion is less than 10 time because there are no pertinent mm. All years after their original injury had tional secondary restraints have been patients returned to their previous moderate to severe articular injury compromised.2 years. and functional results.7. 3). tion and internal fixation of bony reconstructed. with isolated PCL injuries. The patients with avulsions and reconstruction with acutely PCL-deficient knee may straight posterior instability had bet. a nonopera- the strength on the noninjured side although they reported medial com. the PCL should be recon- injury occurs subsequent to or inde. Large fragment Small fragment tact forces created by the absence of the PCL. not required for the treatment of iso. 80% of the patients degenerative changes in these lated acute PCL injuries. Veltri. posterior translation of the tibia at erative changes is not clear at this vide objective stability. it appears that progressive degenerative changes may occur in some PCL-deficient knees. No 2. as in the major- ceps on the injured side to 100% of age in 15 acute PCL injuries. compartment degener. and patients involved both the medial of posterior translation is important 84% had returned to their previous and the lateral compartments. If sport. Clancy et al7 noted no articular dam. ity of isolated injuries. patients with multidirectional insta. The Vol 1. Torg et al8 The long-term results of surgical tion. If the avulsed fragment is small prospective studies.e. or at surgery should be repaired or and 29 with combined multidirec. it is less than 10 mm. with a 4.13 Primary Radiographs are used to docu- bility. in assessing an isolated PCL injury. although this may not activity and experienced no limita. tive aggressive rehabilitative correlated with a successful result of partment changes in chronically program should be utilized.0-mm cancellous screw). be apparent on physical examina- tions in their injured knee. Skyhar et al 12 used a cadaver model to show that isolated Posterior tibial Posterior tibial sectioning of the PCL leads to Open reduction translation translation and internal fixation <10 mm >10–15 mm increased medial and patellofemoral compartment pressures. the iliotibial (Fig. If the the rehabilitative treatment. increase the risk of development of ter functional results than the don have provided good objective degenerative joint disease. since it is likely that addi- PCL tears and five partial tears. Torg et al8 reported that degenerative changes Quadriceps PCL reconstruction noted on radiographs were more rehabilitation common in patients with combined instability patterns than in those Fig. can be internally fixed Despite the lack of prospective stud. the central third of the patellar ten. Routine reconstruction is usually large (i. 3 Treatment algorithm for PCL avulsion fractures. reconstruction is treatment of seven complete isolated PCL reconstruction more than 4 advised.7. to the medial compartment. Patients with better functional repair of interstitial tears and PCL ment the presence of PCL avulsion results were more likely to have reconstructions with the semitendi. band. Nonoperative Treatment structed. posterior translation is greater than and Messieh5 reviewed the results of nine of ten patients who underwent 10 to 15 mm. fractures and osteochondral injury greater quadriceps strength in the nosus and gracilis. and posterior translation at 90 all patients would be followed up to Acute PCL Instability degrees of flexion is greater than 10 determine whether chronic articular to 15 mm. Greater laxity in the tional instability. and the medial gastrocnemius structed when small tibial PCL avul- Whether the PCL-deficient knee is inconsistently produce good func. In such a study. The PCL is not recon- affected extremity. sion fractures are present and at risk for the development of degen. tional results and often fail to pro. ies. Rehabilitation of the quadri. Associated ligament injuries reviewed the data on 14 patients reconstructions for PCL instability identified by physical examination with straight posterior instability also remain unclear. MD. e. Clinical and arthrometric examination lage. PCL reconstruction Isolated sizes quadriceps strengthening.15 Open-kinetic-chain or meniscal injury exercises are performed with the foot PCL and grade III MCL. can take significantly longer.12 Once the MR imaging regain knee motion osteochondral and meniscal injuries have been treated. Rehabilitation to sures in a cadaver model. tional success. ACL. 4 Treatment algorithm for acute PCL injuries other than avulsion fractures. on the normal side. For large tibial return to athletic activity.and closed-kinetic.Posterior Cruciate Ligament Injuries fixation is warranted. knee motion is independent of ACL. free. PCL and chondral chain exercises. When the patient’s return to sports) injured knee has regained 90% of the quadriceps and hamstring strength Fig.. the patient can 72 Journal of the American Academy of Orthopaedic Surgeons . athletes with iso. 4). Meniscal injury is relatively infrequent in acute isolated PCL rup- tures. In closed. we rec. since isolated sec. or posterolateral injury acute tears that are amenable to non. we proceed with a rehabilitation program that empha. one should perform arthroscopy to eval- uate the status of the articular carti. seated knee extensions with No associated weights) are avoided in PCL rehabil. is present in association with a PCL operative treatment. This nonop- erative rehabilitative treatment requires constant maintenance of Rehabilitate quadriceps quadriceps strength to achieve func. If a vertical longitudinal tear in Isolated PCL tear Isolated PCL tear the vascularized portion of the with >10 –15 mm with <10 mm medial meniscus is present. of posterior displacement of posterior ommend repair. PCL tear Rehabilitation follows the princi- ples of open. reconstruction or used to document the location of the to 4 weeks. since they can stress the Acute reconstruction/ patellofemoral joint. If an acute PCL injury is present posterior approach as described by lated acute PCL injuries without and the posterior displacement is Burks and Schaffer. ligament injury itation. In the Operative Treatment avulsions this is performed by a authors’ experience. (if adequate strength. displacement tioning of the PCL has been shown to increase medial compartment pres. The finding of increased signal intensity on the T2 images suggests osseous and possi- bly chondral injury. on occasion. If a grade III ated meniscal or chondral injury in progress. If significant Acute PCL tear chondral injury is suspected. such as chondral pathology squats and leg presses. injuries Treat meniscal and tional closed-chain exercises. The quadriceps repair of all ligament muscles are rehabilitated with func. return to sport MCL. Examination under injury kinetic-chain exercises. but that return must be augmentation of the PCL should be PCL tear and the presence of associ. or posterolateral hip and ankle motion.14 associated chondral or meniscal greater than 10 to 15 mm at 90 Magnetic resonance imaging is injuries can return to their sport in 3 degrees of flexion. based on the individual patient’s performed (Fig. the foot is anesthesia and fixed so that knee motion occurs in arthroscopy concert with hip and ankle motion. Open-kinetic-chain extension exer- cises (i. Daniel M. Veltri, MD, and Russell F. Warren, MD injury, reconstruction of all ligamen- ferred method, provided there is If posterolateral or MCL recon- tous injuries should be undertaken. sufficient length of the patellar ten- struction is performed with PCL If the knee is grossly unstable, plac- don (40 mm or more). reconstruction, additional incisions ing the neurovascular structures at Reconstructions of the PCL can be are used. The posterolateral corner risk, early reconstruction with a performed with open or arthroscop- can be reconstructed with a biceps patellar tendon autograft is per- ically assisted techniques. If the tenodesis or patellar tendon allograft. formed. In such a case, one must be arthroscopically assisted technique The MCL is repaired primarily. If an concerned that a knee dislocation is chosen, we recommend fluoro- ACL reconstruction is needed, this might have occurred and sponta- scopic control and a posteromedial can also be performed arthroscopi- neously reduced. Prior to surgery, portal to assist in tibial tunnel prepa- cally. The ACL and PCL femoral and an angiogram or MR study with vas- ration. 16 This procedure is techni- tibial tunnels are prepared first. The cular imaging capability should be cally demanding, particularly PCL graft is inserted next, followed performed to rule out associated because the patellar tendon graft is by ACL graft insertion. The PCL graft arterial injury. passed at a sharp angle from the is fixed with interference screws With associated posterolateral, tibia to the femur. This may create while the tibia is centered on the ACL, or grade III MCL injury, it fraying of the patellar tendon graft femur in full extension. The ACL is appears best to operate early (within and subsequent laxity. If the tibia is then fixed with interference screws 1 week) to maximize healing poten- of poor bone quality, the patellar with the knee in 20 degrees of flexion. tial, since late surgery for posterolat- tendon graft may erode through the If multiple ligament reconstructions eral injury has relatively poor proximal tibia, creating graft laxity. are required, patellar tendon and results. Delaying ACL reconstruc- Most important, the arthroscopically semitendinosus/gracilis autografts tion after acute ACL injury to regain assisted technique requires a patel- can be used. Finally, multiple allo- full knee motion and to allow for lar tendon length of 40 mm or more grafts can be used to avoid the exten- capsular healing has been found to to maintain the bone blocks within sive dissection necessary for multiple be of benefit in decreasing the inci- their tunnels. graft harvest. dence of postoperative arthrofibro- Although this procedure can be sis. It may be prudent for operative done in most cases, in some patients Postoperative Rehabilitation candidates with acute isolated PCL the autograft patellar tendon will be Postoperative rehabilitation fol- tears to undergo a rehabilitative too short to allow the bone blocks to lowing PCL reconstruction is course to regain knee motion prior to remain in their tunnels, and ade- designed to restore range of motion surgery. quate graft fixation will not be without stressing the graft. Exercises Acute surgical treatment of com- achieved. A posterior approach can that produce posterior tibial transla- plete PCL tears can include primary be used to ensure adequate tendon tion are avoided. Limited weight repair, augmentation, or reconstruc- length and to avoid an acute angle bearing using crutches is allowed tion, depending on the location of for graft passage.14 The femoral PCL with a knee brace locked in full exten- the injury. If the tear is on the bone- tunnel is prepared with arthro- sion to stabilize the joint. Quadriceps ligament interface, we use the prin- scopic assistance. 16 A posterior exercises are started on the first post- ciples noted above. Primary repair arthrotomy is then used to prepare operative day with active knee exten- of intrasubstance PCL tears should the proximal tibia for graft place- sion (without weights) from 90 to 0 not be done without augmentation ment.14 The tibial bone block is fixed degrees and straight leg raises. Pas- of the repaired PCL with a semi- to the posterior aspect of the tibia sive knee-flexion exercises are used tendinosus and/or gracilis auto- using standard 4.0-mm cancellous to gain knee flexion slowly over 6 graft. Alternatively, the defect can be screws. This allows greater length weeks. Open-kinetic-chain ham- reconstructed with a patellar tendon for passage of the femoral bone string exercises (seated leg curls) are autograft, a semitendinosus or gra- block into its tunnel and a straighter not used, since posterior tibial trans- cilis autograft, or a patellar or graft orientation. lation occurs with open-chain knee Achilles allograft. The optimal In addition to patellar tendon and flexion exercises.15 Running begins at method for PCL reconstruction is semitendinosus or gracilis auto- 5 months and sport-specific agility not clear at this time, but the use of grafts, allografts can be used for PCL drills at 6 to 7 months following patellar tendon autografts appears reconstruction. Patellar or Achilles surgery. Full return to sports is to result in a higher rate of objective tendon allografts should be longer allowed when adequate quadriceps success. 7,13 Reconstruction with a than 40 mm to ensure adequate and hamstring strength is demon- patellar tendon autograft is our pre- length for fixation. strated (90% of that on the noninjured Vol 1, No 2, Nov/Dec 1993 73 Posterior Cruciate Ligament Injuries side) and sport-specific agility and flexion PA radiographs are useful for increased activity on serial bone proprioreceptive skills have been documenting early degenerative scans to be secondary to altered knee mastered. knee changes. If the patient’s main biomechanics from the absence of complaint is pain and the symptoms the PCL. Chronic PCL Instability suggest patellofemoral or medial We recommend nonoperative compartment disease, a bone scan is treatment with quadriceps rehabili- Treatment of chronic PCL instability performed. Increased bone-scan tation for the majority of patients is based on the degree of instability, activity may represent the sequelae with chronic PCL instability. In the radiographic evidence of degen- of an acute chondral injury or altered these cases, the degree of posterior erative changes, and the presence of weight-bearing forces due to the laxity alone is not a criterion for symptoms that have not responded absence of the PCL, or it may be reconstruction; one must also con- to rehabilitative treatment (Fig. 5). unrelated to the chronic PCL injury. sider the presence of symptoms, the The surgeon must evaluate the Whether the chronically PCL- results of diagnostic studies, and results of previous surgical or con- deficient knee is at risk for progres- the results of nonoperative rehabil- servative treatment. It is important to sive degenerative changes is not itation. If posterior displacement is note the mechanical alignment, the known. However, isolated section- greater than 10 to 15 mm and non- patellofemoral function, and the sta- ing of the PCL has been shown to operative treatment with aggres- tus of the medial and lateral com- increase medial and patellofemoral sive rehabilitation has failed, we partments. Standing AP radiographs compartment pressures in a cadaver consider reconstruction. Recon- in full extension and 45-degree- model.12 We consider progressively struction is not performed if there is radiographic evidence of marked degenerative changes. If associated posterolateral instability is present, Chronic PCL tear/avulsion a standing AP radiograph from the hip to the ankle is used to assess mechanical knee alignment. In Chronic posterolateral Chronic pain and/or instability knees with posterolateral instability instability with >10 –15 mm of and varus knee deformity, a valgus posterior displacement tibial osteotomy is recommended. If the patient remains symptomatic Standing AP hip-to-ankle following osteotomy, PCL recon- Rehabilitate quadriceps radiograph in extension struction is considered. Patients selected for a nonoperative aggres- Still symptomatic Improvement sive rehabilitative program are fol- Varus Normal alignment lowed up closely. In the absence of radiographic evidence of progres- Continue rehabilitation sive degenerative changes, bone Consider valgus Standing full-extension AP and scans are performed every 2 years tibial osteotomy 45-degree-flexion PA views to see whether bone-scan activity is increasing. Still symptomatic Although there are no prospective posterior instability Severe degenerative studies that document that PCL changes reconstruction can prevent the devel- opment of degenerative knee No or mild degenerative changes or return bone-scan activity changes on radiographs Quadriceps Progressively increased to normal, we recommend PCL rehabilitation activity on biennial reconstruction if early radiographic or osteotomy bone scans evidence of mild degenerative change or progressively increased bone-scan activity is noted. We have Consider PCL reconstruction found that reconstruction can Fig. 5 Treatment algorithm for chronic PCL injuries. improve stability and decrease pain in such cases. The technique for 74 Journal of the American Academy of Orthopaedic Surgeons Daniel M. Veltri, MD, and Russell F. Warren, MD chronic reconstruction is the same as PCL-injured knee and the results of reconstructed. Small acute PCL that outlined for arthroscopically nonoperative and surgical treatment avulsion fractures with more than 10 assisted acute reconstruction. 16 If provide some guidelines for man- mm of posterior laxity are treated patellofemoral degenerative changes agement of these injuries.5-8,16 In acute with PCL reconstruction. All large are present, one can use a contralat- isolated PCL tears with less than 10 PCL avulsion fractures are treated eral patellar tendon autograft, a mm of posterior laxity at 90 degrees with internal fixation. All chronic semitendinosus or gracilis autograft, of flexion, current knowledge sug- PCL injuries are initially treated or a patellar or Achilles tendon allo- gests nonoperative treatment that with a nonoperative aggressive graft for reconstruction to avoid any stresses aggressive quadriceps reha- rehabilitation program. Reconstruc- effect of graft harvest on the bilitation. In acute PCL tears with tion should be performed in chronic patellofemoral joint. Rehabilitation is more than 10 to 15 mm of posterior PCL injuries when laxity is more similar to that after acute reconstruc- laxity at 90 degrees of flexion or than 10 to 15 mm at 90 degrees of tion. combined ligamentous injury, the knee flexion, minimal radiographic PCL should be reconstructed with a degenerative changes are present, patellar tendon autograft, a semi- and a nonoperative aggressive reha- Summary tendinosus or gracilis autograft, or, bilitation program has failed. Proper in selected cases, a patellar or diagnosis, the knowledge of the nat- Although PCL tears are estimated to Achilles tendon allograft. We recom- ural history, and the results of surgi- account for 3% to 20% of all knee lig- mend a patellar tendon autograft for cal and nonoperative treatment ament injuries, these injuries are the majority of PCL reconstructions. provide the rationale for current commonly missed at initial evalua- In combined-ligament injuries, all management of the PCL-injured tion. 1,2 The natural history of the ligamentous injuries should be knee. References 1. Cooper DE, Warren RF, Warner JJP: The 7. Clancy WG Jr, Shelbourne KD, Zoellner Posterior cruciate ligament: MR imag- posterior cruciate ligament and postero- GB, et al: Treatment of knee joint instabil- ing. Radiology 1990;174:527-530. lateral structures of the knee: Anatomy, ity secondary to rupture of the posterior 12. Skyhar MJ, Warren RF, Ortiz GJ, et al: function, and patterns of injury. Instr cruciate ligament: Report of a new proce- The effects of sectioning of the posterior Course Lect 1991;40:249-270. dure. J Bone Joint Surg Am 1983;65: cruciate ligament and the posterolateral 2. Clendenin MB, DeLee JC, Heckman JD: 310-322. complex on the articular contact pres- Interstitial tears of the posterior cruciate 8. Torg JS, Barton TM, Pavlov H, et al: Nat- sures within the knee. J Bone Joint Surg ligament of the knee. Orthopedics ural history of the posterior cruciate lig- Am 1993;75:694-699. 1980;3:764-772. ament-deficient knee. Clin Orthop 13. Veltri DM, Warren RF, Silver G: Com- 3. Parolie JM, Bergfeld JA: Long-term 1989;246:208-216. plications in posterior cruciate ligament results of nonoperative treatment of iso- 9. Daniel DM, Stone ML, Barnett P, et al: surgery. Operative Techniques Sports Med lated posterior cruciate ligament Use of the quadriceps active test to diag- 1993;1:154-158. injuries in the athlete. Am J Sports Med nose posterior cruciate-ligament disrup- 14. Burks RT, Schaffer JJ: A simplified 1986;14:35-38. tion and measure posterior laxity of the approach to the tibial attachment of the 4. Gollehon DL,Torzilli PA, Warren RF: knee. J Bone Joint Surg Am 1988;70: posterior cruciate ligament. Clin Orthop The role of the posterolateral and cruci- 386-391. 1990;254:216-219. ate ligaments in the stability of the 10. Jakob RP, Hassler H, Staeubli HU: 15. Lutz GE, Palmitier RA, An KN, et al: human knee: A biomechanical study. J Observations on rotatory instability of Comparison of tibiofemoral joint forces Bone Joint Surg Am 1987;69:233-242. the lateral compartment of the knee: during open-kinetic-chain and closed- 5. Fowler PJ, Messieh SS: Isolated poste- Experimental studies on the functional kinetic-chain exercises. J Bone Joint Surg rior cruciate ligament injuries in ath- anatomy and the pathomechanism of Am 1993;75:732-739. letes. Am J Sports Med 1987;15:553-557. the true and the reversed pivot shift 16. Warren RF, Veltri DM: Arthroscopically 6. Kannus P, Bergfeld J, Jarvinen M, et al: sign. Acta Orthop Scand Suppl 1981; assisted posterior cruciate ligament Injuries to the posterior cruciate ligament 52:1-32. reconstruction. Operative Techniques of the knee. Sports Med 1991;12:110-131. 11. Grover JS, Bassett LW, Gross ML, et al: Sports Med 1993;1:136-142. Vol 1, No 2, Nov/Dec 1993 75 JAAOS Home Page Table of Contents Search Help . progress to cause vertebral collapse body must be destroyed before any When symptoms do develop.1:76-86 patient typically will demonstrate either an anterior compression deformity with secondary kyphosis The spine is the most common site Approximately 70% of patients (Fig. unless there is a blastic the following: (1) an enlarging mass or sclerotic reaction. which minimal lysis of pedicular bone can may break through the cortex and Dr. 2). However. and (5) devel- inated cancer and may result in vertebral collapse. course. Today. spinal subluxation through the involved segment. the pedicle tends to be involved early compression or invasion of adjacent and because the pedicle can be seen nerve roots. The most common cause of this destruction. pathologic fracture secondary to 76 Journal of the American Academy of Orthopaedic Surgeons . ties can also result from osteopenic However. In contrast. Primary well vascularized pedicle. magnetic resonance imaging is the most such a fracture. a combination of both anterior and posterior stabilization is tissue and detritus of bone or disk into required. The more changes in the posterior elements. The majority of vertebral lesions requiring compression occurs in approximately decompression and stabilization emanate from the vertebral body and are best man. and progres. tebral osteomyelitis also may between 30% and 50% of a vertebral ered only on routine bone scans. University be appreciated because the cortex of invade paravertebral soft tissues. within the vertebral body. Department of Orthopaedic Surgery. are a consequence of one or more of graphically. been infiltrated and weakened by a Many devices can provide adequate posterior stabilization. spinal instability. (3) compression of the Reprint requests: Dr. 62% showed improve- ment by at least two Frankel grades. The vertebral metastases apparent on posterior column destruction and vertebral body typically is affected careful postmortem examination. Harrington. This para.Metastatic Tumors of the Spine: Diagnosis and Treatment Kevin D. to use Luque rods with sublaminar wire fixation. due to a variety of causes. or lung or from changes unrelated to malignancy. kidney. MD Abstract Metastatic disease of the spine occurs in as many as 70% of patients with dissem. Of first because of its rich blood supply Three fourths of these lesions origi. Harrington is Clinical Associate Professor. Nineteen of the 77 patients remained alive more than 4 years postoperatively. With posterior element cer. Harrington. rapid the onset of the neurologic deficit. 1) or a more uniform vertebral for skeletal metastases. no Spinal cord and/or nerve-root matter what treatment is instituted. the initial radiographic prostate. either of these bony deformi- and sinusoidal vascular distribution. compared with fewer than 5% who improved Radiographic Findings after laminectomy decompression with or without irradiation. but the author prefers metastatic deposit. particularly when effective means of differentiating benign from malignant causation of vertebral col. anteroposterior radiographs. Plain radiographs of a symptomatic J Am Acad Orthop Surg 1993. nate from carcinoma of the breast. San Francisco. they and a lesion difficult to differentiate changes can be recognized radio. finding often is destruction of a less myeloma or lymphoma. based on the imaging patterns and extent of marrow ablation. In a series of 77 patients with major neurologic compromise treated with this technique. opment of spinal instability from sive neurologic compromise. irrespective who die of cancer have evidence of collapse usually associated with of the primary tumor involved. focal spinal instability (Fig. vertebral metastases often are vertebral neoplasms or indolent ver- dox is explainable by the fact that asymptomatic and may be discov. (2) of California. or involvement of compression is the extrusion of tumor the lumbar spine. CA 94118. vertebral destruction. Suite 516. 3838 Califor- well in cross section on conventional spinal cord. (4) development of a nia Street. associated with lytic destructive lapse. San Francisco. the worse the prognosis for recovery. This construct affords collapse of a vertebral body that has instantaneous stability that is not adversely affected by postoperative irradiation. The author’s preference is to perform anterior vertebral replacement with the spinal canal following the partial methylmethacrylate incorporating a Knodt distraction rod. 5% of patients with widespread can- aged by anterior decompression and stabilization alone. This is reflected of acute trauma has been repeatedly by a decreased-signal-intensity proved invalid. Vol 1. MD Other Diagnostic Studies marrow involvement within an affected vertebra. signal and the consequent intensity of that signal (Fig. 5) An acute benign compression from metastatic disease. 1 The T2-weighted image neurologic compromise. the bone substance itself has been ple sites of radioisotope uptake in lost or weakened. compression fractures occur because raphy often will demonstrate multi. the disk tal metastases. even when a patient’s remains unaffected. edema. 2 Spontaneous fracture of L-1 from (darker) image on T1-weighted that acute trauma never results in known metastatic breast cancer. 6) and increased inten- of all three columns of the spine resulted in gradual or progressive neurologic symmetrical vertebral collapse and focal sity on T2 images. image. bleeding increases the focal water ondary to osteoporosis. in the rest of the vertebral body. with hematopoi- other vertebrae. has been magnetic preservation of the normal marrow resonance (MR) imaging. with or without occurs. No 2. and that of benign pathologic fractures sec. the MR imaging of a ate among the various potential compression fracture secondary to causes of spinal deformity. thus helping to symptoms and plain radiographs differentiate either lesion from suggest isolated involvement of a sin. The tumor spreads ini- mity on the basis of distribution of tially through the hematopoietic tis- abnormalities in the spine as well as sue and only later progressively specific patterns of focal bony destroys bone. but its pattern will be irregular. larly on T1 imaging. although there may be dis- this technique most effectively placement of the marrow along vec- Fig. because signal. ribs. typically causes temporary linear ease of the spine may develop col. Characteristically. however. In both instances. An MR image of a benign com- The most helpful and sensitive pression fracture typically reveals study. The availability today of a variety of the malignant pathologic fracture imaging modalities has enhanced our occurs because virtually the entire ability to differentiate between vertebral body has been infiltrated benign and malignant spinal defor. intact. Osteolysis images (Fig. Kevin D. 1 Radiograph of a 66-year-old woman delineates the extent and pattern of tors created by the compression with known breast cancer and scintigraphi- cally demonstrable metastases to T-11 and deformity. their appearance on plain radiography is indistinguishable from hematopoietic tissue. Although the wedge compression ticularly apparent in the T1-weighted fractures demonstrated presumably are sec. In contrast. metastatic malignancy reveals total quoted maxim that sudden fracture or subtotal replacement of the nor- myelopathy invariably is the result mal bone by tumor. Nov/Dec 1993 77 . 4). Even fracture of the superior endplate patients with known metastatic dis. 3). striation of the marrow distribution lapse or instability at other spinal in the rest of the vertebra. incomplete replacement of marrow. There may be compromise has been proved instability. The oft. In contrast. This phenomenon is par- T-12. benign destruction. where the combination of the ondary to metastases. Harrington. osteomyelitis (Fig. A history shows bone-marrow signal intensity of progressive quadriparesis or even in the fractured bone similar to that of specific radiculopathy is of mini. or etic tissue remaining relatively the skull typical of generalized skele. particu- levels due to nonmalignant causes. by tumor. long bones. Technetium-99m scintig. mal benefit in helping to differenti. just as the concept Fig. wrong. gle spinal level (Fig. This finding All of these processes initially usually occurs in a uniform pattern present as back pain of sudden or and is reversible as fracture healing insidious onset. noma. Bulging of the partially spine of a 66-year-old man receiving (Fig. The T1 signal increased risk for hematogenous may mimic the typical tumor pat. early biopsy of the lesion is warranted. 4 Sagittal MR image of the lumbar osteomyelitis involving the spine tern (Fig. pelvis. In these instances. and proximal femora. particularly because corti- costeroids or chemotherapy given as part of systemic cancer treatment reflecting focal destruction rather may result in marked osteopenia than uniform compression of (Fig. If spinal Fig. 7). the CT-directed biopsy should be repeated at different areas of the affected vertebra before resorting to open biopsy techniques. Clinical Course Fig. it is essential to clar- image of a patient with prostatic carcinoma ify whether it is attributable to reveals multiple foci of increased tracer deposition in the shoulders. nomena such as osteoporosis or arthritis. Debilitated cancer may become blurred when an acute patients who are receiving che- benign fracture is associated with motherapy typically become chroni- marked edema and bleeding into cally pancytopenic and are at the marrow space. Insufficiency fractures of the hematopoietic tissue and fat. 3 Anterior whole-body radionuclide pain develops. Spontaneous hematogenous When spinal metastases truly are fuse marrow signal changes extend. 4). its specificity been completed. that pain is usu- ing into the pedicles may be ally of gradual onset. As already noted. Fig. 1).Metastatic Tumors of the Spine strongly suggestive of tumor infiltration. is relentlessly 78 Journal of the American Academy of Orthopaedic Surgeons . the source of pain. Computed tomography (CT)- directed needle biopsy is accurate and safe and has virtually replaced open or percutaneous trocar biopsy in most centers. ribs. osteomyelitis developed at L4-5. chemotherapy for metastatic prostatic carci- collapsed vertebral body and dif. lumbar tumor destruction or to local phe- spine. it is common for ver- tebral metastases to be asymp- tomatic and to be diagnosed only with the use of routine bone scintig- raphy. Such a finding may prompt the oncologist to alter the patient’s chemotherapy or hormonal manipu- lation. treatment (arrows). spine due to local irradiation may Although MR imaging has a high appear years after treatment has level of sensitivity. 5 Sagittal T1-weighted MR image shows two benign compression fractures Once the presence of spinal metas. or in any situation in which an occult symptomatic vertebral metastasis is suspected. with incomplete bone marrow replacement and peripheral low-signal-intensity band tases has been established. but no specific additional measures are indicated. In the event of an equivocal or nondiagnostic speci- men. options can be considered. Harrington. No 2. the patient will canal. Top. Sphincter func- Multiple foci of abnormal replacement of the marrow signal are particularly apparent tion should be carefully and sequen- in the C-1. com- monly being recorded several seg- progressive over weeks or months. a Vol 1. and may not be recognized as reflective of inter- costal root irritation. bulging of the vertebral cortex into the nosis. These which is richly innervated with noci. (28%) had an acute onset with a tures occurring sequentially within delay of less than 48 hours between weakened bone. sometimes produc. ments below the site of fracture or is worse at night. This may images were interpreted as suggestive of caused by gradual cord compression lead the unsuspecting physician to tumor infiltration of the vertebral body. 7 Images of a 72-year-old woman with bral structures. C-2. The sensory level ies. This type of pain has been weakness has considerable bearing attributed to stretching of the perios. mise. sudden onset of severe thoracolumbar pain slower growth rate of the metastasis ing neurologic symptoms from without trauma. and C-8 vertebral bod. indicating in most instances a Fig. conus medullaris. thoracic cord impingement com- rologic compromise. Loss of sphincter control is thought to be a late phenomenon. cauda equina involve- Fig. and is unassociated tumor extrusion into the spinal with significant elevations of white canal. Sagittal T1-weighted and a sparing of the anterior spinal involvement of the lumbosacral image shows marked homogeneously artery. tially evaluated. blood cell count or sedimentation The rapidity of onset of muscle rate. Another potential the manifestation of initial symp- source of pain is from compression toms and the appearance of maximal of the ventral aspect of the dura. However. 6 Sagittal T1-weighted MR image of ment can occur acutely or subtly in the cervical spine of a 69-year-old woman patients with involvement of the with widely metastatic breast carcinoma. motor deficits usually precede sensory changes because of the typi- cally anterior location of cord com- pression. Patients with a slower logic involvement. had a decidedly better prog- decreased signal intensity with posterior plexus. Pain can also evolution of neurologic compro- result from invasion of paraverte. Kevin D. Such pain often is described as “girdle pain. Axial T1-weighted image strated experimentally that even localize the pain at a level below the shows that abnormal signal changes extend major neurologic compromise into both pedicles. C-4. Tarlov and Herz 4 demon- Not infrequently. but was reversible for a longer period attribute initial symptoms to arthri. The presence plain of radicular pain before they of radicular pain may help to locate develop symptoms of cord involve- the level of vertebral involvement. than was compromise due to an tis or disk disease and to continue acute cord lesion. Both T2-weighted actual metastatic lesion. was rendered. Constans et al3 teum by direct pressure of the reported that 166 of 600 patients expanding tumor or to microfrac. and usually occurs only in patients with profound cord involvement. no matter what treatment before there is evidence of neuro. Conversely. Approximately 50% of patients with ment in the face of progressive neu. biopsy revealed only osteoporosis. Nov/Dec 1993 79 . often is not a reliable indicator of the level of cord compression. MD conservative and ineffective treat. Bottom. neurologic compromise.2 With more central neural involve- ment. on the prognosis. ment. Such pain can occur recovery. patients had the worst prognosis for ceptor fibers.” particularly with lesions at T-9 or below. In any rior to the spinal cord and cannot be be treated effectively with one of case. leading to a progressive mise. strated that radiation therapy alone involvement and can be treated suc. 3. Even those who sustain a wound healing. When metastases are causing 4 weeks after any operative interven. After either in radiosensitivity after metastasis radiation osteitis. including myelopathy. laminectomy (with or without radi- apy. bone to tumor. els of the spine. Colon tumors. When the entire vertebral body (both minimal bone destruction and pain tion to limit interference with wound anterior and middle columns) appears to be the result of periosteal healing and graft incorporation. Consequently. Breast sion following adequate local irradia- siderably in the past two decades. and 80 Journal of the American Academy of Orthopaedic Surgeons . and interference patients regained the ability to walk. root compression is due to retropulsed High sensitivity bone or disk fragments or when spinal Myeloma instability or malalignment causes Nonoperative Treatment Lymphoma neural compromise. tumor originates from experience. Decompression is Radiosensitivity of Common prognosis. was as effective as decompressive cessfully with systemic chemother. progressive Metastatic sarcoma management of advanced spinal vertebral metastases are often metastases were dismal. rically. rather than in spite of. local irradiation. nerve roots are compressed by frag. pathologic compression fracture of with graft incorporation consistently It was only after the evolution of one or more vertebral bodies often appears to be between 3. interference with treatment. Squamous cell and hormonal manipulation. In my in excess of 3.000 cGy. instability frequently developed as a becomes of increasing concern. Gilbert et al6 demon- spinal instability or neurologic of 4 months or less or with vertebral. Because the control of stabilization techniques that the clin- porary bed rest and soft bracing. achieving relief. Instead. and presumed metastases when With improvement in chemotherapy Lung the primary tumor is occult. approximately 80% of recommended that local irradiation the vertebral body or soft tissue ante- patients with spinal metastases can be limited to this dose level. the Most patients with spinal metas. ation therapy also should be the result of. many Two decades ago. Prostate gland tion. radiation therapy usually rologic compromise and intractable kyphotic deformity and ultimately to leads to recovery unless the cord or mechanical spine pain unresponsive extrusion of tumor tissue. expansion or reaction within the the vertebral body begins to collapse. and the promise did not improve.2. probably primarily particularly indicated when cord or Metastases attributable to vascular compromise. The major- apparent in patients with a pro. disk. The premorbid involvement of vital Melanoma results of this procedure for the organs. it is generally of patients. cord compression.2.5 be postponed for a minimum of 3 to posterior laminectomy approach. progressive spinal deformity and ity and neurologic compromise ments of bone or disk detritus. As this worsens. primary treatment modality in decompression.000 and anterior spinal decompression and can be treated effectively with tem. as local tumor recurrence in the spine ical results showed dramatic is done for pathologic compression does not seem to improve with doses improvement. prospect of ultimate spinal instabil. ation) in the treatment of epidural bracing. ing vertebral body increases geomet- causing early neurologic compro. Primary tumor types vary plications. Other specific Moderate sensitivity indications include radioinsensitive The philosophy of treatment for ver. body lesions affecting multiple lev. In a large retro- tases do not develop progressive patients with an anticipated survival spective series.500 cGy. adjunctive irradiation should decompressed adequately from a these nonoperative modalities. The principal indications for opera.Metastatic Tumors of the Spine sudden onset of paralysis is almost or unlikely to be responsive to irradi- Table 1 invariably associated with a poor ation or bracing. radiation therapy and the bending moment of the spine alone often is the ideal means of Operative Management shifts posteriorly. becomes weakened by tumor lysis. Radi. or temporary The threshold for radiation com. recurrence of cord compres- tebral metastases has changed con.7 In the vast majority fractures due to osteoporosis. fewer than 50% of (Table 1). “operative Low sensitivity patients with bony metastases now intervention” usually meant lam- Renal survive for long periods without Thyroid inectomy decompression. If the tumor the compression load on the remain- extends into the epidural space. ity of patients with neurologic com- longed life expectancy. tive intervention are progressive neu. restored entirely through an anterior The rare syndrome of progressive approach. within the canal. Kevin D. more often are and posterior decompression and attributable to the neurotoxic effect stabilization. the greatly increased ten. Such patients may enjoy sufficient The only exception to this general relief from external bracing. it is far more likely for progres- soon as a clear-cut motor deficit is sive motor deficits to be caused by gradual spinal instability or local functionally intact. rule pertains to the lumbar spine. the extent of weight-bearing torque chemotherapy must be discontinued and lateral bending forces to which early enough to allow correction of it is subjected. No 2. 8 Replacement of the vertebral body compression) usually must be tion of bone grafts to restore late by tumor results in collapse of the body. One must also be wary of attribut- Fig. relieved by both anterior and poste. Typically. restoration effects of irradiation. 2). MD bony detritus posteriorly into the apparent. 8). dence that. instability who do not have neuro. Harrington. of certain chemotherapeutic agents. dura and compressing the cord circumfer- entially. However. ing spinal stabilization unnecessary. ther systemic corticosteroids nor bility remains intact. render. are necessary in all instances in Spinal canal compromise from which spinal decompression is posterior extrusion of the vertebral required (Fig. If all three columns are severely logic compromise do not require weakened. Nov/Dec 1993 81 . In such a situ. a forward-shear. 9 Unusual “napkin-ring” constriction cations for operative intervention ing progressive motor compromise of the cord caused by a metastatic tumor are present. combined anterior and emergency operative intervention. There is abundant evi- increasing kyphosis. nei- involved. rior approaches (Fig. rior column structures remain bone grafts will not be incorporated Vol 1. In such cases both anterior and pos- pression and stabilization. geon must be aware of the fact that further compromising the spinal numbness and paresthesias. the surgeon must con. if tumor sensory loss in the absence of motor destruction of the posterior elements deficit may respond to local irradia- (particularly the pedicles) is tion. Because of its lordotic curvature and If elective surgery is required. achieve instantaneous and rigid bined anterior and posterior cord intraoperative stability and should compression (so-called napkin-ring not depend on gradual incorpora- Fig. 10). However. posterior stabilization is essential. If the poste. cauda equina compromise. the sur- ing deformity will develop (Fig. overall spinal stability can be beneficial in such circumstances. Com. body can be decompressed only The surgeon should strive to from an anterior approach. and extrusion of tumor and bone fragments into the epidural space. I believe that both anemia and recovery of white blood anterior and posterior stabilization cell and platelet counts. In my experi- pression should be recommended as ence. but only if that deficit cor- spinal canal (Fig. at least in the cer- tumor recurrence than by the late vical and thoracic spine. In my experience. relates with a demonstrable focus of Ordinarily the posterior elements spinal canal intrusion by tumor or (posterior column) are minimally bony debris. local rigidity. Patients with of stability can be achieved by ante- intractable pain secondary to spinal rior vertebral reconstruction alone. 9). with rare exceptions. with that diagnosis. emergency local irradiation is ation. particularly if a peridural tumor advanced. to irradiation-induced transverse within the spinal canal growing around the sider separately the issues of decom. myelitis unless a gadolinium. and posterior tensile sta. decom. mass is apparent without major sile loads posteriorly cannot be spinal instability or bony debris resisted. particu- canal and necessitating both anterior larly if peripheral. For any enhanced MR imaging study clearly terior decompression and stabilization are given patient with spinal cord or demonstrates changes consistent usually necessary. If the previously mentioned indi. and collapse of the L-3 vertebral body. The patient presented with a rapidly progressive cauda equina syndrome (Frankel grade C) despite 4. which precludes that secures the cement mass into the The distraction hook-rod system is secure fixation by pedicle screw-and- adjacent normal vertebral endplates. The patient enjoyed a complete neurologic recovery. 82 Journal of the American Academy of Orthopaedic Surgeons . progressive tumor infiltration. means of screw fixation to the verte. severity of posterior bony destruction level (Fig. a new compression fracture appeared at L-1.500 cGy of local irradiation. not myeloma. Their reduce the tendency of an individual rior stabilization devices in the lum. Distraction or compres- In my hands. pro. For these functions in a similar manner and Most commonly. 10 Radiographs of a 65-year-old woman with multiple myeloma. B. The Rezinian distraction device demonstrable in any given patient. Six years later. bining the sublaminar wires with loads in the cervical and thoracic If posterior fixation is necessary. thus protecting adjacent umn. This fixation construct are more complicated to insert. variety of devices are available. the most effective but is much bulkier and extends into sion rods with hooks may be used but device is the Knodt distraction rod the perivertebral soft tissues. again associated with a progressive cauda equina syndrome. similar in concept to the Knodt rod rod systems. After anterior L-3 vertebrectomy and replacement by methylmethacrylate incorporating a Knodt rod. no advantages over the Knodt rod one or more pedicles (in addition to rating a distraction-fixation device and is many times more expensive. com- tively resists compression and torque axial compression load on the spine. caus. C. and are subject to a higher above and three below the span of soft tissues from injury (Fig. which jacks ing a risk of soft-tissue erosion. The original Luque rods were replaced with longer rods and sub- laminar wiring spanning seven levels. bral bodies is at right angles to the nar bone at any level is suspect. I advocate the technique of also does not extend beyond the metastatic malignant neoplasm replacing the resected vertebral confines of the vertebral bodies. The L-1 vertebral body was replaced using methylmethacrylate incorporating a Rezinian vertebral distractor. process) wire fixation three levels bral bodies. the vertebral body). the fixation stress at only a few levels open the collapsed vertebral space to Alternative anterior-fixation where progressive tumor lysis may its appropriate height and can be devices that depend on screw cause late instability. The incidence of failure because their laminectomy decompression. it offers stabilization have advanced lysis of polymerizing in situ. Pathologic examination of the resected L-1 vertebral body revealed that it had collapsed because of radiation osteitis. and incorpo. have the disadvantage of focusing with hooks (Zimmer). 12).Metastatic Tumors of the Spine A B C Fig. 11). extensive enough to require posterior body with methylmethacrylate. rods with sublaminar (not spinous does not protrude beyond the verte. tion of the affected area. patients with a reasons. a methylmethacrylate may help to spine but requires adjunctive poste. in my experience. a posterior four-level stabilization was accomplished with Luque rods and sublaminar wire fixation. when the strength of lami- late and the Knodt rod very effec. occasion. selection should be based on the wire to cut through soft bone at that bar spine. On combination of the methylmethacry. However. For this reason. trude well outside the vertebral col. A. buried entirely within the long axis of fixation across the vertebral bodies I have usually chosen to use Luque the spine. in the face of postoperative irradia. and a tially ligated. By transecting but not removing one or two additional ribs below the inci- sion. Bottom. tebral bodies involved (Fig. with exposure of the pericardium. I have Operative Technique embolized preoperatively. overnight intubation will be expedi- ent. Large osteolytic effectively obstructs blood flow. the spinal evoked potential monitoring ure 13. After division of these to anticipate how aggressive the thickened paste made of moistened vessels. Nov/Dec 1993 83 . B. lateral aspect of the affected verte- mary malignant neoplasm is one lung. The thoracotomy incision is made one level higher than the highest affected vertebra. it is possible to expose multiple vertebrae above or below the tumor focus. close to the aorta as possible. Section through the methylmethacrylate recon- struction. the normal dimensions These are ligated and transected as of the spinal canal can be appreciated. myeloma or metastatic hyper. Harrington. double-lumen endotracheal tube All remnants of the affected verte- nephroma. Section through the vertebral body just above the vated. In more than 60 such approaches. which the entire anterior aspect of the ver- likely to be. No 2. facilitating exposure of and how vascular the lesion is sponge (Gelfoam) is injected. CT scans. permitting col. thus minimizing disturbance of the par- avertebral anastomoses. Lat. pression and stabilization of the detail. ued subperiosteally to expose the vascular. eral radiograph demonstrates that the height of the vertebral space has been reconstituted fully and remains so without evidence of displacement of the construct despite the absence The parietal pleura is incised. bra should be resected. a single rib resected. we have been able A B to expose from T-8 to L-4 through Fig. Despite the diffraction artifact from the metal rod (arrow). Careful blunt dissection is contin- response are likely to be extremely racic spine requires a thoracotomy. particularly for the patient who is moderately debilitated. 13. By incising the posterolateral crura of the diaphragm and then approaching the lumbar spine retroperitoneally. A bra on the opposite side. using standard some surgeons. Occasionally. and reflected to expose the cement construct. has chest wall or pleural metastases that inter- fere with ideal ventilation. The vertebral bod- ies are easily visualized through the thin overlying parietal pleura. and technique for this procedure in of up to nine vessels on one side. and the rib at that level is removed. Kevin D. In essence. ele- of posterior stabilization. feel that thoracic spine is illustrated in Fig. A). the surgeon should attempt tumor focus are catheterized. arteriographic techniques. A. Such lesions should be may be employed. lesions with minimal host bony Anterior stabilization of the tho. major feeder vessels supplying the is essential as the vessels are sequen- cedure. 13. A chest tube is required postoperatively for a period of 48 to 72 hours for pleural drainage and lung reexpansion. Note that the tip of the Knodt rod hook protrudes slightly in front of the segmental vessels (Fig. MD lapse of the ipsilateral lung for improved exposure. particularly if the pri. B). Olerud seen no evidence clinically of cord et al8 have described the indications vascular compromise after division The technique of anterior decom. however. the aorta can be retracted tumor appears radiographically and morcellized absorbable gelatin carefully. and the great vessels. or shows evidence of pleural metastases. 11 Images of a patient with metastatic breast carcinoma 51⁄2 years after a midthoracic the same thoracotomy incision with vertebrectomy and anterior stabilization with a Knodt rod and methylmethacrylate. together with Vol 1. Top. anterior longitudinal ligament. Before undertaking the pro. using the angled excess cement is removed from out. and great care After complete decompression. L-5. D). been described extensively else- sufficient depth and width to seat bra. trachea. a cross-sectional diameter of the must be taken to avoid tearing the high-speed bur is used to cut a well acrylic-metal construct is nearly vena cava. thirds of the vertebra can be removed across the back of the defect to pro. because an essentially Stability above and below avascular interval is used for the the laminectomy can be approach between the sternomas- enhanced by packing meth- ylmethacrylate into the toid and carotid sheath laterally and areas of wire-rod fixation the strap muscles. until the ureter. through a flank incision. at least for the L-4. procedure in the cervical spine is inar sulcus. F). middle thyroid vein. This forms a rigid esophagus medially. 13. 13. difficult. 11.Metastatic Tumors of the Spine cement into the spinal canal (Fig. it may curet to undercut the posterior cor. This approach has also into the intact vertebral endplates of identical to that of the normal verte. 13. parallel- (Fig. undergone local irradiation. all In patients who have previously canal completely. the Luque rods are cut to appropriate lengths. Exposure is best accomplished rapidly with a gouge and rongeur tect the dura from the heat of poly. 13. fortunate. A CT scan of the vertebral great vessels overlying the L-4 and below the level of resection. cancellous autogenous bone or allograft may be packed around the vertebral construct to enhance the likelihood of bony Fig. with the front of the spinal canal. ing the inferior costal margin. with no encroachment of where. B). vena cava. construct that allows sub- laminar wire fixation at any the only vascular structure requir- single level to reinforce ing ligation and transection is the every other level. construct should show that the L-5 vertebral bodies.2 As already noted. side the confines of the vertebral be very difficult to mobilize the ners of the intact vertebrae above and bodies. more important. bit of debris forced into the spinal brae. an angled cement mass. Before and iliac vessels are encountered. Methylmethacrylate transversalis fascia and abdominal curet is used to avoid inadvertent then is packed about the rod and contents being displaced medially penetration of the dura or damage to hooks and into the defects in the ver. The technique for vertebrectomy and distraction- stabilization is similar to that described for the thoracic spine and has been discussed extensively else- where. This is all tumor tissue. the lumbar spine is the least common location for metastatic lesions requiring anterior decompression. Only by performing the Knodt rod and hooks (Fig. lization. 13. and (right). tebral endplates (Fig. stabilization is also most problem- kyphotic deformity. E). the hooks will where anterior exposure is most surgeon be sure of removing every become seated firmly into the verte. G). The anterior two A malleable retractor is placed atic for these lower lumbar levels. When only a thin shell of merization and. and secured by much simpler than that in the tho- doubled 16-gauge wires at e a c h l e v e l ( l e f t ) . Anterior canal by the posterior vector of the will be corrected (Fig. and the kyphotic angulation and S-1 vertebral bodies. since it is also the area a complete vertebrectomy can the As the rod is twisted. because 84 Journal of the American Academy of Orthopaedic Surgeons . Great care is taken to decompress the polymerization is complete. The decompression-stabilization interdigitated along the lam. Ordinarily. the cord and nerve roots (Fig. Dis- bone and tumor tissue remains in from compression by the expanding section is retroperitoneal. aorta. racic spine.2. arthrodesis. C).9 In my experience. In patients who have a good prognosis for prolonged survival and who will not require further irradiation. 12 For posterior stabi. the segmental vessels are ligated and transected. The defect is filled with methylmethacry- late that polymerizes in situ. myeloma. further decompression is achieved with an angled gouge. tem the extent of sensory and techniques of anterior decompres- motor dysfunction can be conve. it is nevertheless useful as bowel and bladder function. and their bodies become firmly impacted within the adjacent vertebral bone. The Knodt rod has been positioned within the resected space. and the affected vertebral body is easily approached. No 2. in my bar spinal metastases requiring (Table 2). The aorta is retracted gently. D. The endplates of the adjacent vertebrae are undercut with a high-speed bur to allow the ends of the Knodt rod and the bodies of its hooks to be buried within the vertebral bone.5 Of 14 patients be compared. By comparison. sion described herein.2 The metastatic malignancy. series of 77 patients treated by the surgical treatment. The presence of a prominent paravertebral extrapleural tumor mass will often assist in locating the focus of destruction. To avoid compression of the cord. G. tating neurologic compromise pression. at least classification relates primarily to riplegia (grade A). the ability to walk and have normal ity and neurologic compromise from promise. C. Although the Frankel with complete paraplegia or quad- It is essential to discuss. All material adherent to the adja- cent vertebral body is removed. and lymphoma was Vol 1. acute traumatic. As the level of the posterior cortical margin is approached. 13 Technique for anterior decompression and stabilization of the thoracic spine. Kevin D. ally progressive. Only the tips of the hooks extend anterior to the vertebral cortex. moments encountered there. Decompression is accomplished by means of a tho- racotomy with the patient in the lateral decubitus position. of the lordotic configuration of the the aggressive techniques described Using this system. H. or C lesions recovered normal advocate a combination of anterior Frankel et al 10 established a (grade E) or near-normal (grade D) decompression-stabilization and classification system for quanti. A small angled curet is used to complete decom- pression of the spinal canal and to round off the edges of the posterior cortices of adjacent vertebrae. Only by such a means of comparing the efficacy of mean postoperative survival period an assessment can the reader deter. eight improved briefly. F. I stabilization seem justified. incorporating the rod and hooks. A. E. 62% niently discussed and the results improved to the level of either Results of various treatment regimens can grade D or grade E. mine for himself or herself whether metastatic spine disease. MD A B C D E F G H Fig. Harrington. The vertebral space is recreated with a lamina spreader. B. at least two grades. and six regained ment of patients with spinal instabil. Twisting distracts its hooks. Nov/Dec 1993 85 . function after laminectomy decom- posterior stabilization for all lum. Nather and lumbar spine and because of the here for selected instances of cord and Bose11 reported that fewer than 5% torque and lateral bending root decompression and for spinal of patients with Frankel grade A. the overall results for the treat. Most of the tumor and bone-disk debris can be removed with a small periosteal elevator. spinal cord com. different techniques for treating for patients with breast metastases. a malleable retractor is placed between the expanding mass and the spinal canal. B. rather than gradu. With the use of this sys. that patients with major neurologic rest and a course of local irradiation. 1991. struction after anterior decompression 1986. 21 patients operated on for renal cell with methylmethacrylate: A retrospec- 3. 86 Journal of the American Academy of Orthopaedic Surgeons . enjoy a sufficiently long life were no wound-healing problems my enthusiasm for this procedure expectancy to warrant operative with anterior spine approaches. Jonsson H Jr. 12. et al: A Diagnosis and treatment of twenty. 8. do not previously irradiated tissues. J Bone Joint Surg Am Vertebral compression fractures: Dis. 1988. tures. St Louis: tases reduces peroperative blood loss: al: Failure of stabilization of the spine CV Mosby. Twelve had had major sensory loss neurologic compromise preopera.169:103-108.12-17 after vertebral collapse once they Ten of the 19 survivors required Based on these results. At the Table 2 other extreme. Harrington KD: Anterior cord decom. nancy. associated with severe local pain or posterior wound sloughs through The majority can be treated with the neurologic compromise. Olerud C. Errico TJ. Tarlov IM. Donzelli R. Radiology lumbar spine. three patients.172:215-218. References 1. Oncol 1986. J Clin cord compression from metastatic malig. Hyslop G. Grade D Useful motor function below the level of involvement. Posner JB: pression from metastatic extradural diagnosis and surgical treatment of Epidural spinal cord compression from tumors. compression in kidney cancer. Paraplegia 1969. in Frymoyer metastatic tumor: Diagnosis and treat. et carcinoma.68:1145-1157. and many metastases and two with late local or instability should be considered with spinal involvement. et al: JW (ed): The Adult Spine: Principles and ment. Two patients suffered for decompression and stabilization. Scher H. Grade B Complete motor loss. and all 12 had improved by sensory loss at least two grades postoperatively. Siegal T: Vertebral Neurosurg 1983. Harrington KD: Orthopaedic Manage. Clin Orthop 1982. Grade E Normal motor and sensory function As expected. et al: systematic approach to spinal recon. et al: Surgical treatment of spinal cord ment for vertebral collapse and spinal gia: Part I. Bohlman HH. al: The value of postural reduction in the 1985. Kim JH.Metastatic Tumors of the Spine approximately 28 months. I believe have completed an initial period of additional operations for the se. Sachs BL. including breast carci.61:107-117.67:375-382. J Bone Joint Surg Br 1986. patients with lung Frankel Classification System for Neurologic Compromise cancer metastases had a mean post- operative survival period of only 8 Grade A Complete motor and sensory loss months. Outlook with com. compromise or intractable mechani. manifestations: Review of 600 cases. 17. tinction between benign and malignant for neoplastic disease of the thoracic and 13. Bose K: The results of decom. intervention of this magnitude. pp 861-888. Grade C Some motor function below the level of involvement. pression of cord or cauda equina com. et al: Embolization of spinal metas.68:83-90. Martin R. et ment of Metastatic Bone Disease. Constans JP. metastatic spine tumors. quelae of other bony metastases. 2. incomplete eratively.68:483-494. Sundaresan N. 5.72:43-59. tive analysis of twenty-four cases. and stabilization of the spine as a treat. incomplete tively.3:40-51. Acta Orthop Scand 1993. that of other clinical investigators spinal metastases. Nineteen patients sur. patients with metastatic lesions of the sion by malignant tumors: Results of pression studies: IV.7:179-192.59:111-118. Nather A. However. J Bone Joint Surg Am Neurol Psychiatry 1954. Most patients do noma in ten patients and multiple who used similar decompression not continue to suffer severe pain myeloma in six. Primary neoplasms of the cervical spine: Practice. even when recurrence. 11. Bohlman HH. et procedures. Weinstein JN. Carter JR. My must not be construed as an advo. J Neurosurg 1984. forty-seven consecutive operative plete paralysis in man. There anterior approach alone. Most do not experience significant including four with distant spinal cal spine pain from vertebral collapse neurologic compromise. Lofberg AM. Clin Orthop 1988. Ann Neurol 1978. AMA Arch 10. stabilisation of metastatic spinal frac- 1989. 7. McAfee PC. Cooper PR.4:1851-1856. 14. and stabilization techniques. de Divitiis E. New York: Raven Press.32:1-8.233:177-197. pression and spinal stabilization for body resection for epidural compres- 4. J Bone al: Spinal metastases with neurological 64:9-12. DiGiacinto GV. Ducker T. Kostuik JP: Differential 6. incomplete sensory loss vived for more than 4 years postop. Frankel HL. Gilbert RW. the spine with paraplegia and tetraple. Tiqva P. vol 1. Zachar CK. Joint Surg Am 1986. Barloon TJ. Harrington KD: Anterior decompression initial management of closed injuries of 16. Hancock DO. 15. J 9. Siegal T. Neurosurgery 1993. Fidler MW: Anterior decompression and causes with MR imaging. Yuh WTC. spine. the long-term sur- vivors had primary malignant con- ditions with good prognoses for experience seems comparable with cacy for surgical management of all survival. Herz E: Spinal cord com. JAAOS Home Page Table of Contents Search Help . Nov/Dec 1993 87 . A complete rupture the most posterior lateral compart- treatment. Open repair of a torn Achilles and other individuals who are tendon is more predictable than closed treatment. Achilles. Eugene. and. Spontaneous rup. with patients may choose to use a talus. which is frequently difficult to identify. resulting in irri- Every tendon around the foot and Localized swelling. rest. Jones is Clinical Senior Instructor. thickened proximal end of the ten- therefore. tation and tenosynovitis. bor- tibia. Eugene. cate a diagnosis of anterior tibial originates from the lower part of the quently affected are the anterior tib. medially by the medial tuber- insertion onto the navicular. Jones. minimal mechanical demands. tenosynovitis. laterally by the lat- metatarsal base. The straight but can be reapproximated if rup. University of Oregon. in os peroneum syndrome is a newly described spectrum of posttraumatic conditions whom the sur les pointes position is fre- that may be the cause of lateral foot pain. flexor hallucis longus. Oregon course of the tendon under the supe. and the medial diagnosis and treatment are impor. and rior extensor retinaculum results in In cases diagnosed late. and be performed.2 Vol 1. and posterior tibial ten. Dr. Jones. quently implicated). ballet dancers. the origin arising from the covering dons. Fracture Clinic of Eugene. the distal phalanx of the great toe. However. In this article I will review the tures are rare and usually painless. immobilization. 1200 Hilyard Street.1 Health Sciences University. As Anterior Tibial Tendon Such ruptures usually occur in the the tendon courses behind the sixth and seventh decades. The proximal end of the tendon posteriorly by the flexor retinacu- unit supplies 80% of the dorsiflexion retracts to the superior retinaculum power of the ankle. Good clinical judgment is needed involved in repetitive push-off in determining the best treatment for posterior tibial tendon problems. This musculotendinous tant. soft-tissue reconstruction of the superior peroneal retinaculum most frequently affected in athletes is superior to bony procedures for peroneal dislocation. and cuneiform. and outline the appropriate require repair. Most fre. it passes through The anterior tibial muscle originates of complete rupture with foot drop. An incomplete rupture with mini. Tendon ward. be utilized. a fibro-osseous tunnel located on the from the proximal two thirds of the end-to-end surgical repair should posterior aspect of the talus. No 2.1:87-94 transmit tremendous forces across the tendon and its sheath. although elderly dered anteriorly by the body of the the interosseous membrane.g. Achilles tendon rup- tures. eral tubercle of the talus. The flexor hallucis longus tendon result of overuse or injury. Early cle of the talus. the lateral tibial condyle. tum that it shares with other mus- cal syndromes involving these ten. with a portion of peroneal. Tendon Disorders of the Foot and Ankle Donald C. mal dorsiflexion weakness does not cles. These activities J Am Acad Orthop Surg 1993. power. tenderness. may be overlooked or confused with ment of the flexor retinaculum. ture is diagnosed early.. Treatment of overuse-type injuries (tendinitis) remains straightfor. MD Abstract Attritional and traumatic injuries to the tendons around the foot and ankle are not Flexor Hallucis Longus uncommon. expected in a muscle of this size and or a free extensor tendon graft may Suite 600. Portland. ice. half of the Orthopedic Consultant. At the ankle. Treatment includes posterior surface of the fibula lateral ial. the tendon lies in dons. a foot drop from a lumbosacral whence it travels distally to insert on radiculopathy or peroneal palsy. and posterior tibial tendon insufficiency remains somewhat controversial. an overuse syndrome is don may be used as a free graft and Reprint requests: Dr. to the medial crest. on rare occasions. The flexor hallucis longus tendon is Generally speaking. fascia and the adjacent fascial sep- relevant anatomy. The painful maneuvers (e. Orthopedic and less common than would be routed under the cruciate ligament. Athletic Department. discuss the clini. In cases medial malleolus. surgical treatment of peroneal subluxation. OR 97401. the first dorsiflexion-arrestive brace. ankle can cause symptoms as the and crepitus over this tendon indi. calcaneus sometimes are present. shallow peroneal groove are seldom tunnel may cause the tendon to peroneal tendon stabilization pri. it is particularly pre. If surgery is selected. insertions onto early surgical intervention. cast is applied for a total of 6 weeks. a well-molded passive extension is possible with clinical entities. if an avulsion courses behind the medial malleolus and are restrained by the superior fracture of the lateral ridge of the dis- and forms a separate compartment. some. however. Bony procedures are osseous tunnel is present. 11% are flat. While to the malleolar ridge. Conservative treatment consists sive extension of the great toe Most of the attention concerning of a compression dressing fabricated metatarsal joint with the foot in the peroneal pathology has been from a felt pad cut in the shape of a neutral and plantar-flexed positions. Radiographs are seldom are most frequently found when 88 Journal of the American Academy of Orthopaedic Surgeons . Regardless of the sulcus. tenderness. incomplete tears placed on the peroneal tendons and extend the metatarsophalangeal of the peroneus brevis and the the SPR.13 wherein a sling is fabricated future complete or partial rupture of the anterior talofibular ligament. bony procedures and soft-tis- when severe stenosis of the fibro. numerous placed in firm-sole shoes. peroneal tendons can be an occult proprioception education. Sarmiento and results in tenderness over the retro. the peroneal muscles in association of historical interest only and include nied by pain. palpating the fibular ligament. and tendon with rapid plantar flexion and inver. Most tal fibula is present on an x-ray film. peroneal retinaculum (SPR). and that of informed that there is a possibility of ankle sprains cause tenderness over Jones. nonsteroidal anti-inflamma. the peroneal tendons is frequently Bonnin. Some orthopaedists pain. Either condition can be procedures have been described for measures will frequently alleviate difficult to diagnose but should stabilizing the peroneal tendons. dislocation of the peroneal tendons.10 which plicates the attenu- pression of the flexor hallucis ten. of diagnostic significance. strapping of the foot. but the diagnosis of subluxation or dis- the confined space in the fibro. the patient should be the location of tenderness. After cast removal. convex. However.Tendon Disorders of the Foot and Ankle lum. exist. competitive athletes. and inflammation. eral malleolus.e. and longitudinal arch supports event and is probably often over. inability to flex the great toe calcaneus. This is reinforced with a joint beyond neutral with the foot painful os peroneum syndrome 4 plaster splint. Subluxation or dislocation of the emphasizes both strengthening and tory agents. particu- is reported as well. Wolf 14 describe rerouting the per- malleolar area. sudden and forceful contraction of sue procedures. subluxation of the peroneal tendons Achilles tendon. a variety of methods to increase the contracture. directed toward subluxation and keyhole and strapped over the lat- Contracture or triggering is sug. the ated retinaculum. the ankle plantar-flexed. The peroneal tendons (i.6-9 Soft- of release of the constrictive flexor Although acute subluxation of tissue procedures include that of retinaculum and resultant decom.12. Patients complain of single band originating from the troversial. and 82% are and radiographic views that show a flammation or stenosis of the fibrous concave. Surgery is required following any injury that results in gories. but have been recognized as important toms have resolved. significant anatomic variations do location of the peroneal tendons can osseous tunnel.5 The pain and over time facilitate restora. depth of the peroneal groove. from a small strip of the adjacent the central fibers of the tendon.3 The sulcus width ranges from be made with certainty. triggering. The procedure consists sion of the foot and ankle. accompa. confused with ankle sprain. A useful clinical the Achilles tendon and the lateral larly for active. Gentle pressure is gested when the patient is unable to Recently. Once the acute symp- and ankle in the neutral position. that of Eckert and don. while others recommend sionally. Prolonged in. and a snapping posterior ridge of the fibula and believe that conservative treatment is sensation posteromedially. develop a partial rupture. test is to compare the amount of pas. These looked. The associated tendon sheath muscles) pass posterior to the fibula helpful. inserting onto the lateral wall of the of benefit. Occa. Because the tendon runs through fibulae have a definite sulcus. always be considered a possibility procedures fall into two general cate- tion of function.11 who reattach the retinaculum release. Because of the early oneal tendons beneath the calcaneal Peroneal Tendons traumatic swelling.. However. marily depends on the SPR. 7% of these grooves are arthrograms are seldom beneficial. Most Treatment of acute dislocation of times accompanied by snapping or anatomy texts illustrate the SPR as a the peroneal tendons remains con- triggering. Even after successful surgical examiner can differentiate them by Davis. Ankle disposed to mechanical irritation 5 to 10 mm. those of tendons during dislocation is quite Two types of pathologic lesions the peroneus brevis and longus difficult. an aggressive Conservative treatment consists Subluxation or Dislocation ankle rehabilitation program of ice. the entire width of the peroneus painful stenosis. bility. or (5) the presence of a gigantic peroneal tubercle on the lateral wall of the calcaneus that traps the peroneus longus tendon and its os peroneus during peroneus longus tendon excursion. tral portion of the longitudinal split significant fraying. 2 to 5 cm (Fig. The first Longitudinal Tears of the of the fibula. 1). The tear usually involves the toto. this should be Rarely. as a distinct clinical entity. and over fragments are without degenerative continued partial subluxation of the the sharp posterior ridge of the change. They may have a history of multiple advanced and imbricated onto a thereby obliterating the offending ankle sprains or chronic ankle insta. stabilizing the peroneal tendons. tightened if attenuated. Nov/Dec 1993 89 . However. Symptoms usually include tenderness along the Vol 1. the cen. Donald C. inversion ankle injury. the degenerated type” lesion15 is found (Fig. Elevation of the SPR from the posterior fibula either direct trauma to the lateral creates a pouch. fibula. Patients with the painful os per- oneum syndrome have a history of Fig. advancing the SPR to the posterior oneus brevis tendon. Peroneal tendons subluxate or dislocate into this pouch. a “Bankart. or there may be a accomplished through a curved 7. In all cases. A complete or incomplete buried nonabsorbable suture. If the desired goal. 2).16. including one or more of the following4: (1) an acute os peroneum fracture or diastasis of a multipartite os peroneum. and tenodesis of the proximal fibular attachment. The is centered over the distal tip of the segment of the tendon is excised in SPR is lifted from its posterolateral fibula. The repair Patients generally present with Following surgery on the per- consists of reattaching the SPR to the retromalleolar pain and tenderness. Surgical repair is The painful os peroneum syn- ing encroachment. longus tendon is performed (Fig. where it is sutured condition has now been recognized third of the tendon and the smaller through drill holes. I excise the anterior third. Tears of portion of the tear is frayed in any struction of the attenuated SPR is the the peroneus brevis occur when the way. side of the foot or a supination- ment of the SPR to the fibula obliterates the pouch. while over. con- tion. No 2. this If the split is through the anterior edge of the fibula. creating a pouch middle or anterior portion of the and distal stumps to the peroneus that allows anterior subluxation of tendon. (4) frank rupture of the peroneus longus tendon. The SPR is then SPR. The peroneus muscle belly may servative treatment is generally Painful Os Peroneum Syndrome extend into the fibular groove. an anomalous peroneus In patients with documented repaired as well. Historically. Right. caus. If this is the only abnormality. tears of the peroneus brevis. MD surgery is being performed. brevis muscle will cause subluxa. out of the groove. Left. the SPR is posterolateral aspect of the fibula. I repair the tendon with peroneus brevis tendon. Reattach. Failure to advance the anterior portion of the tendon slips tear is in the middle third and both stretched-out SPR adequately allows forward. The competence of the lesion is simple attenuation of the Peroneus Brevis SPR is assessed. 3) the peroneal tendons. If. (2) a chronic os peroneum fracture or diastasis of a multipartite os per- oneum fracture associated with stenosing peroneus longus tenosyn- ovitis. unsuccessful.17 cm incision along the posterior third matic conditions. little mention has opened in such a way that it can be surgical treatment consists of been made about tears of the per. drome is a spectrum of posttrau- bifid tendon. oneus brevis tendon. fresh bony bed. Jones. If there is associated pouch. brevis tendon is involved and there is On other occasions. (3) attrition or partial rupture of the peroneus longus tendon prox- imal or distal to the os peroneum. how- tightening the SPR can lead to longitudinal tear can measure from ever. ankle instability. 1 Repair of a Bankart-type lesion. Anatomic recon. always cast the extremity at least nal tear of the peroneus bre. however. while the soleus origi- nates from the posterior surface of the tibia and the fibula. repetitive heel running. 3 Irreparable tear of the peroneus brevis necessitates excision of the tear and tenode. Fig. which is the usual location of chronic inflamma- tion and rupture. (2) excision of the os per- oneum and degenerated peroneus longus tendon with tenodesis of the peroneus brevis to the peroneus peroneus longus tendon distal to the Patients also have weakness or pain longus tendon. 2 Complete longitudi. such as a sudden increase in training mileage. and 90 Journal of the American Academy of Orthopaedic Surgeons . the peroneus longus tendon. while the administration is optional. The primary etiologic factor resulting in damage to the Achilles tendon is training errors. diographic or magnetic resonance Achilles Tendon The gastrocnemius originates from the lateral and medial femoral condyles. a single severe competitive session (a 10-km race or a marathon). once for 4 to 6 weeks. 4). I Fig. os peroneum with primary repair of by resisted plantar flexion of the first Diagnosis may be based on ra.Tendon Disorders of the Foot and Ankle (MR) imaging data or the findings on exploration motivated by a high degree of suspicion. a sud- den increase in training intensity. Corticosteroid vis. Pain is usually exacerbated with forced foot eversion. recom- sis to the adjacent peroneus longus. ray and the heel-rise phase of gait. Conservative treatment consists of cast immobilization. The peroneus longus remains reduced. with or with- out corticosteroid injections. if palpa- torn peroneus brevis dislo. The least vascular area is 2 to 6 cm above the tendon insertion into the calcaneus. mencement of training after an extended period of inactivity. or (3) excision of the fibula. ble synovitis is present. with the gastrocne- mius segment measuring 11 to 26 cm and the soleus portion measur- ing 3 to 11 cm. The soleus and gastrocnemius contribute sepa- rately to the formation of the Achilles tendon. Sur- fibula. gical treatment consists of (1) exci- sion of the os peroneum and the giant peroneal tubercle with pri- mary repair of the peroneus longus tendon. The blood supply to the Achilles tendon comes from both proximal and distal sources (Fig. I cates over the tip of the routinely perform an injection. While the use of changes in the tendon then follow. we have found that sub. scattered into the calcaneus. injuries is generally considered quite noninflammatory histologic appear- sent several centimeters proximal to hazardous. can be asymptomatic. Initially. achieved by rapid injection of 15 ml Despite these changes. The Achilles tendon becomes fibrotic the scarred peritenon. Fig. leg alignment. Nov/Dec 1993 91 . Those the involved area of tendon. Patients will peritenon space. as this is a source tion along with the intratendinous of the blood supply of the tendon. while trans- verse vessels vascularize the middle por- tion. ance with collagen fiber disorienta- the insertion of the Achilles tendon peritenon infiltration of lidocaine is tion. contrast baths. tively predictable manner. and non. and stenosed. steroidal anti-inflammatory medi. If hindfoot alignment inflamed. ments may also contribute. ing within limits of comfort. and evolves pathologically in a rela- rain. vascular ingrowth. Degenerative symptoms consist primarily of pain. In more advanced or inflamed or hypovascular secondary within the peritenon without associ. If Fig. One patients who become symptomatic should be very careful to protect the usually have peritenous inflamma- anterior fatty tissue. Jones. the tendon has a relieved by rest. open less mass in the Achilles tendon lysis of adhesions is performed approximately 4 to 6 cm proximal to through a medial incision exposing the insertion of the tendon. Initially. and (4) ure or obvious central tissue necrosis careful assessment of the foot and with subsequent mucoid degenera. the condition of local anesthetic into the sub. the peritenon sheath becomes cations. No 2. (1) a 1. the peritenon of the to restriction of blood flow through ated Achilles tendinosis (Fig. Hindfoot and leg malalign. MD running on uneven or slippery ter. effective in relieving symptoms. treatment includes ice. the medial. which is aggravated by activity and steroidal injections for tendon With tendinosis. Donald C. Tenderness is pre. and Nonsurgical treatment includes posterior peritenon can be excised. If the overuse continues. with orthotic correc- tion. 5 Thickened inflamed Achilles peritenon. 5). mucoid degeneration. Vol 1. hypocellularity. Peritendinitis problems are present. Conservative treat- accumulated repetitive microtrauma ment is provided for 6 months. chronic cases. lateral. massage. 4 Blood supply to the Achilles tendon. This is usually the result of tion if necessary. (2) anti-inflammatory The pathology of Achilles tendi.to 2-week period in a non- weight-bearing cast if the symptoms Tendinosis are severe. an orthosis is the tendon itself may become Peritendinitis is inflammation prescribed. However. Note that longitudinal vessels supply the tendon proximally and distally. (3) heel-cord stretch- nosis is interstitial microscopic fail. frequently note a palpable but pain- If conservative means fail. agents and ice. and occasional Mechanical lysis of adhesions can be areas of necrosis or calcification. preoperative symptoms. treatment. partial ruptures Two theories are suggested to occur in well-trained athletes. ankle plantar flexion). the defect is large and the excision The controversy of closed versus extensive. which frequently. conservative treatment con. If a significant area provided the length of treatment is of degeneration. The area tion. characterized by a sufficient to allow the tendon to glossy homogeneous appearance reestablish adequate intrinsic Fig. ing the calf does not cause passive mended. and peroneal tendons. If there are only minor weight because of the plantar- changes on palpation but significant flexion action of the posterior tibial. the physician and the patient immobilization depends on the size undertaken. rupture occurs tend to occur in middle-aged decon. or both. frequently difficult. and rest is Thompson test is positive (squeez- 92 Journal of the American Academy of Orthopaedic Surgeons . ate weakness in push-off is noted. 6). 4 to 6 weeks of immobiliza. should weigh carefully the risks of the defect. the Achilles tendon is rein. several lon. The middle-aged athlete will use of MR imaging (Fig. however. There may be a history of Partial ruptures of the Achilles prerupture intermittent heel pain tendon were thought to be rare until suggestive of long-standing mild Ljungqvist described 24 cases in chronic Achilles tendinosis. sisting of heel lifts. Note the smooth. without preexisting complaints. the patient is immobilized for 2 weeks. surgery is recom. Nonoperative should be excised. 7 Magnetic resonance image of a par- present. and to stimulate a measures can achieve this objective healing reaction. competitive male involved in intermittent athletic Partial Rupture activities. cal overload. taken. although factors are usually involved. On physical examination. Fig. glossy appearance of strength and to avoid elongation of elliptical excision is then closed. if a small defect is followed by pain and swelling. fails to respond to conservative years.Tendon Disorders of the Foot and Ankle symptoms persist. However. has been The symptoms of rupture are fairly enhanced considerably through the classic. the tendon is then palpated in the area of patient is frequently able to plantar- fusiform thickening or nodular flex the foot when it is not bearing enlargement. If a larger defect is Complete Rupture excised. If the involved tendon. When deciding between down flap. transverse. or a turn. it is excised. the tial longitudinal tear of the Achilles tendon. Complete rupture of the Achilles tion may be necessary. ice. gitudinal incisions are made into the The main objective of treatment is tendon. More 1968. Immedi- immediate repair should be under. If a small defect is excised. and the Surgery consists of first debriding patient is usually unable to perform the overlying inflamed peritenon. 6 Nodular Achilles mucoid degenera- (Fig. However. tendon occurs most frequently in the middle-aged. the usually adequate.19 In fact. The purposes of these longi. both of these Diagnosis of partial tears. toe flexor. ditioned persons. surgical excision of the operative and nonoperative treat- The period of postoperative involved area or repair of the tear is ment. encing minimal discomfort.18 Unlike total ruptures. The a single heel rise. 7). open treatment of Achilles tendon forced using the plantaris tendon. If a small defect ruptures has been ongoing for flexor digitorum communis. to provide the patient with a tendon tudinal incisions are to visualize areas as close to normal in length and of central tendon necrosis. is found. with future activities. often hear or feel a pop while experi- If a large partial tear is identified. Partial explain the cause of acute Achilles tears usually involve the lateral tendon rupture: (1) chronic tendon aspect of the Achilles and may be degeneration and (2) acute mechani- longitudinal. which strength as possible. They have reported are pain. attempts should be made either direct visualization of the disrupted rest and anti-inflammatory agents. 1941. nation of hindfoot valgus with performed to stabilize the hindfoot. The advan. An isolated talona- method is functional postoperative of the calcaneus. Bull Hosp Jt Dis and cuboideum. which is now gaining clinical deformity secondary to poste. ture. If the tendon is intact but stiffness. one can normal in the conservatively functions much like a rope being consider a corticosteroid injection into treated patient group. it bilization is unsuccessful. sutured or debrided. weakness. Attrition the tendon sheath without injecting with near normal in the surgical occurs at the bone-tendon points of steroid into the tendon itself. few weeks’ duration. bring the Achilles tendon with posterior tibial tenosynovitis. rerupture. As a result. and percutaneously partial rupture. the mechanical demands months. The second facet impinges on the superior aspect used in this setting. arthrodesis in combination with a cal- popularity. should be instituted. to reattach the tendon to the navicular tendon ends and allows restoration of When the tendon ruptures com. and eventual be based on the degree of deformity.42: 1992. and undergo degeneration and rup. while the patient who ning gait. Lapidus PW: Indirect subcutaneous 3. the treatment plan should repair the tendon.25 References 1. the tendon of choice is the treatment are available. taken. with the development of a valgus lished. and MR imag- which provides protection as well swelling and inflammation of only a ing evaluation. on the patient’s symptoms. If the patient has examination findings. caneal cuboid arthrodesis may also be have described the use of a postop.23 The risks high. The pain is aggravated by If the patient has minimal or no defor- tage of open repair is that it provides activity and is partially relieved by mity. The tendon is also thoroughly suture granulomas. or ends together. Ma and Griffith. Donald C. or complete rupture ruptured. severely attenuated. compared pulled through a pulley. try skiing: A case report. calcaneus. conservative treatment after a few is 18%. Edwards ME: The relations of the per- anterior tibial tendon while cross-coun. Stuart MJ: Traumatic disruption of the 2. No 2. This type of pain is associated deformity is severe and well estab- is accomplished by using a short. At the time of surgery a of surgery include pulmonary and the tendon may become inflamed thorough tenosynovectomy is under- embolism. The risks of closed Posterior Tibial Tendon conservative treatment program treatment utilizing prolonged non. deformity. Surgical repair is gen- as functional treatment. surgical treatment is indi- undergoes open surgical treatment placed on this structure are quite cated to prevent further damage to has a 2% rerupture rate. physical use of a modified boxer’s boot. Posterior tibial tenosynovitis is inspected.21 The average rerupture rate contact. The diagnosis is based and Thermann22 have described the degree of involvement of the poste. This program weight-bearing cast immobilization Inflammation of the posterior tibial consists of 4 to 6 weeks of cast immo- are decreased strength. navicular. also commonly seen in systemic minimal longitudinal rents in the ten- A compromise between open and inflammatory diseases such as don are found. Vol 1.24 They plantar-flex The primary complaints of patients If the tendon is detached from the the ankle. A subtalar arthrodesis is heel for 1 month. group. and infection. Nov/Dec 1993 93 . The eventual severe vicular arthrodesis or a talonavicular treatment. The anterior process of the moderate degree of pain for a period wearing a shoe with an elevated talar articular surface of the posterior of years. Clin Orthop Report of two cases. If immo- tendon is approximately 30% of curves behind the medial malleolus. the pain may be referred from the ruptured tendon.281:193-194.20 The strength of the tibial tenosynovitis. As the tendon inverted and plantar-flexed. erative functional orthosis rather forefoot abduction and pronation. If augmentation Postoperatively. followed by deformity. through a bony tunnel or to augment the tendon to its normal length. microtrauma occurs. rupture of the anterior tibial tendon: oneal tendons to fibula. rior tibial tendon. Am J Anat 1928. This region. the rents are either closed treatment is the technique of rheumatoid arthritis. It should also be noted that If the patient is unresponsive to in the conservatively treated patient during the pronation phase of run. the patient usually has had a leg cast for 6 to 8 weeks. skin problems. Jones. One is the aspect of the ankle in the sinus tarsi flexor digitorum communis. sural nerve injury. an aggressive erally indicated. pletely. An unusual problem is recurrent than cast immobilization. 213-253. two methods of its usual medial location to the lateral is chosen.22.2:119-127. Mahan and Carter 21 rior tibial tendon rupture is a combi. Saltzman Treatment is determined by the subluxation. the tendon. their results as excellent. If the standard rigid immobilization. MD and benefits. tendon is more common than anterior bilization holding the foot slightly and stiffness. dure for chronic peroneal subluxation. 1982. Am J Sports Med 22. Lea RB. pp 194-218. 92-98. Thermann H: Achilles Surg 1920. Eriksson E: Partial tears new technique. Clin tendons. Achilles tendon rupture: A review of the Joint Surg Am 1979.31:548-559. in Mack RP (ed): American 25. 23. Warren RF. Eckert WR. Wills CA. in Pfeffer GB. dislocation of the peroneal tendons nonsurgical treament. Caiozzo V. ed 115-116. 1992. O’Brien SJ: Per.57: Orthop 1968. 12. pp 951-961. eral ankle instability associated with literature comparing surgical versus 10. Mizel MS: Peroneal tendon 13. J 19. 1976.61:292-294. Ma G. DuVries HL (ed): Surgery of the Foot. J Bone 17. et al: location of the peroneal tendon. 15. Frey CC (eds): Cur. Sobel M. 9. modification of the Ellis Jones proce. J Academy of Orthopaedic Surgeons Sympo. Hansen ST Jr: Traumatic sub. 14. Ljungqvist R. Fleming LL.63:682-684. Jones E: Operative treatment of chronic tendon. vol 1. Am J Sports Med 1990. tendon problems. Acta Orthop Scand 1992.Tendon Disorders of the Foot and Ankle 4. Sheridan L. Saltzman CL.58:670-672.14:574-576. 5. ed 5. 1983. of the patellar tendon and the Achilles 247-255.7:502-504. J Bone Joint 18. Sobel M. Mahan KT. Zoellner G. St Louis: CV Mosby. Davis EA Jr: Acute rupture review. Bohne WH. Allman of the tendo Achillis. Griffith T: Percutaneous repair of 11.11:142-146. Carter SR: Multiple ruptures 2. Kelly RE: An operation for the chronic FR: Traumatic dislocations of the per. Sarmiento A. Baltimore: Williams & oneal tendon subluxation in a case of Surgery. St Louis: CV Mosby. Br J oneal tendons. 1965. 30-56. vol 1. Wolf M: Subluxation of Orthop Rev 1975. Bo nnin JG: In j ur i e s t o t h e Ank l e . 1986. Thomas JL. sis of the ruptured Achilles tendon. sium on the Foot and Leg in Running Ankle 1992. treated by the Chrisman-Snook proce.60:115-118. Smith L: Rupture of the achilles luxation/dislocation of the peroneal rerouting tendons under calcaneofibular tendon: Nonsurgical treatment. 1993. Clin Orthop 1977. in Pfeffer GB. dure: A case report and literature 24. Brourman S: Lat. Brage ME. Watson-Jones R: Fractures and Joint 16. Foot Ankle 1992. ligament. Frey CC 8. Wilkins. 21.13:215-219.13:423-431. pp injury.18:539-543. Sobel M. 1970.128: Surg Am 1976. dislocation of the peroneal tendons. Ouzounian TJ. Graviet S: A Sports. Myerson MS: Disloca- dislocation of the peroneal tendons. Washburn S.207:156-163. Di Stefano VJ: Pathogenesis and diagno- New York: McGraw-Hill.4:17-18. anomalous peroneus brevis muscle. p 302. New York: McGraw-Hill. Clin Orthop Darien. Arrowsmith SR. Conn: Hafner Publishing. J Bone Joint Surg Am 1975. J Foot Surg 7. Clancy W Jr: Recurrent dis. tion of the posterior tibial tendon. rent Practice in Foot and Ankle Surgery. peroneal tendons: Case treated by 20. 94 Journal of the American Academy of Orthopaedic Surgeons . 987-993. (eds): Current Practice in Foot and Ankle Injuries. pp Foot Surg 1992.31:454-458. 6. Foot Bone Joint Surg 1932. 1993. acute closed ruptured achilles tendon: A of the peroneal retinaculum. 5 but the first ral fractures. Seattle. and that tures. Large-diameter vent these complications. Following the proper surgical technique for unlocked femoral nailing. Winquist is Clinical Professor. tions were femoral shaft fractures with trochanter has not been a problem in tion rate.1. Second-generation (reconstruction) nails. Department an interlocking (locked) femoral nail including some minimally displaced of Orthopaedics. Winquist type III comminution this population. Static locking has been ommendation. Unfortunately. locked nails. shown to yield nearly the same high union rates as dynamic locking and is now the was that static locking (locking at accepted standard. WA 98104. vidualized. has extended the indications for locked nailing proximally determining the appropriateness of to subtrochanteric fractures and combined femoral neck-shaft fractures. multiple trauma and additional ipsi- ness. came from Gerhard Küntscher. developed this concept.7 patients a starting point for nail inser- development of an intramedullary As experience was gained with these tion a little farther anterior and lateral nail with holes for screw fixation.8-11 of the locked femoral nail inserted In a large series. such as motion but resulted in a higher rate of Interlocking nails were initially indi. starting point should be considered. treatment is indi- bracing. cated for femoral fractures with insta. locked nailing. Apophyseal arrest of the an extremely low nonunion and infec. rotation.2 The advent of plate fixation Indications lateral injuries. My preference is to J Am Acad Orthop Surg 1993. Halloran. either missed fractures or comminu- tures of the midshaft. One should consider improved both alignment and knee flexible intramedullary nails. in younger to these problems appeared to be the fractures (segmental comminution). In the growing child. most surgeons prefer freehand targeting femoral shaft fractures. To pre- the specific nail used is more important than nail material or design. Seattle. Therefore. Distal targeting of the interlocking screw remains the most both ends of the nail) be used in all difficult aspect of the surgical technique. Originally designed to prevent rotation and shortening in comminuted frac. the standard of care for treatment of of comminution could not always be Vol 1.4 The solution comminuted) and Winquist type IV in teenagers. spi.6 Use fractures extending into the knee. anticipated preoperatively. with a sharp trocar. ening and rotation in an additional Achieving a closed reduction and selecting the proper starting point in the piriformis 10% of patients treated with region are crucial to a successful result. nonunion. University of Washington. No 2. In patients fractures has been traction or cast experience on the part of the surgical below these ages.1:95-105 use locked intramedullary nails in most female patients aged 12 years and older and in most male patients Traditional treatment of femoral shaft femoral shaft fractures but demands aged 13 years and older. epiphysis. their rec- reamed nails provide greater strength than unreamed nails. Originally. and implant fail. Suite 1600. in younger infection. its application has been extended proximally and distally to tion caused by surgery led to short- nearly all femoral fractures from the lesser trochanter to the supracondylar area. but avascular necro- Only two problems remained: (greater than 50 percent of the cortex sis of the femoral head has been noted shortening and rotation. Brumback et al12 Reprint requests: Dr. MD Abstract Locked intramedullary nailing has become the standard of care for most femoral frac. Dr. and Huckstep all extended to segmental fractures. patients. ideal indica. and infraisthmal fractures. the nail ure. Ender nails or Rush rods. and must stop short of the distal femoral allowed both excellent function and angulation. Nov/Dec 1993 95 . Winquist. with greater use of inter- these techniques typically led to a nal fixation in younger patients with high rate of malunion and knee stiff. Closed Küntscher nailing 3 bility of length. Locked Femoral Nailing Robert A. 1229 Madison with a closed technique has become clearly demonstrated that the degree Street. indications were than the standard piriformis fossa Modny. Winquist. the use of team. fractures below the lesser published report detailing the use of trochanter. with screws directed The patient’s age is important in toward the femoral head. with which I concur. Also. and heavy traction will be trochanter than use of the supine necessary to maintain the femur at position does and facilitates Preoperative Planning length. The best frac- ture table has a radiolucent perineal post. The knee is flexed to important in the patient with multi. a trac. since the a final time during driving of the nail. 1 Lateral positioning for intramedullary nailing. The proper frac- ture table is also crucial. a femoral pin can be an increased risk of sciatic and after patient resuscitation. a tibial traction pin is much easier access to the greater placed. which can be monitored on intramedullary nailing (Fig. nailed. The table should also be chosen for its usefulness for all intramedullary nailing techniques. inserted for use during the surgical pudendal nerve palsies. it is neck and shaft. In teaching ple injuries. The use of fracture table should be equipped Operating room planning must take preoperative traction makes the with a radiolucent perineal post to place long before the first case of surgical procedure much easier. can be achieved. traction and the femur can be maintain it during the entire proce- ability of staff and implants. passed. experienced when the bulb-tipped guide has been personnel be available to perform When nailing is immediate. If surgery is position on the fracture table allows with delayed fixation. another surgeon should be Fig. Therefore. protect the sciatic nerve. Bone et al13 have clearly institutions with changing and Patient Positioning demonstrated a decreased incidence inexperienced staff. In addition to the operating sur- geon. It is released before tion. there must be undertaken. 1). The surgeon must main- tain up-to-date knowledge of the best available image intensifiers and must participate in the selection of this expensive device. equipment be on hand. Closed reduction of the fracture is 96 Journal of the American Academy of Orthopaedic Surgeons . Such prolonged traction is not The ideal timing for intra. trained in the use of the C-arm image is used initially during closed reduc- tion and intramedullary nailing intensifier is the other critical mem. A technician the case when it is necessary. tion while the unscrubbed surgeon is with a locked nail is a personnel.Locked Femoral Nailing Timing of Surgery the most important and difficult part extremely important that traction be of the procedure and requires the used only during those portions of The timing of surgery is an impor. ber of the surgical team. allows adequate visualization of the fracture with the patient in both the lateral and the supine position. in most cases to use the femoral pin Lateral Positioning drome with primary fixation of with the knee flexed to avoid sciatic Placing the patient in the lateral femoral shaft fractures compared and peroneal injuries. For a successful outcome. it may be safer of adult respiratory distress syn. delayed. Traction tant consideration. Closed reduc. foot can be placed in temporary Many surgeons apply traction and timing may be dictated by the avail. concern about applying excessive necessary and can be associated with medullary nailing is immediately traction. determining whether the reduction and equipment-dependent opera. most experience. allow visualization of the femoral locked intramedullary nailing is To prevent nerve palsy. ate nailing appears to be even more procedure. Immedi. It is then relaxed and applied the operation and that the proper tion pin is unnecessary. In patients in whom there is dure. available to reduce the fracture. and is small and easy for the operat- ing staff to manage. it is the incision is made and is reapplied Traction mandatory that skilled. The the lateral radiograph. Interlocking nails and screws in a range of appropriate sizes must be available. Use of a Distractor intensifier to be maneuvered proxi. Robert A. A with lateral positioning because it is table. No 2. extremely difficult. ture table and C-arm image made that either leave the femur too mal fractures. the fracture can be pressure on the anterolateral the trochanter is much more difficult. for whom the supine this method is accurate only to supine positioning of the patient position is more appropriate. but the proponents of rotated 20 to 30 degrees toward the high subtrochanteric fractures. sure on the pudendal nerve. they have gained sufficient experi. particularly in infraisth. Vol 1. creating internal ing used. It requires adduction of the leg. they use it fragment that locks into place prox- and during insertion of the for most patients undergoing locked imally and distally for use in judg- intramedullary nail. and that once too much traction. judging the adequate ing rotation of the fracture. partic.14. Measuring the patient with multiple injuries. access to has been placed.16 It is difficult to place the prox- padded support on the anterior commonly used for fixation of imal distraction pin anterior to the portion of the post is needed to intertrochanteric and femoral neck medullary canal. 2). ative length is possible. Winquist.15 A common error with Evaluating the fracture on the image supine positioning is rotation of the Regardless of the patient position- intensifier is a poor method of judg. high as 10%. Rota. within 1 cm. deformity at the fracture site. I recommend length of the comminuted femur is potential exists for valgus sag at the that the surgical team select a frac. but at best Another popular method is eral lung. knee too far inward. the fracture table. opposite femur to obtain a compar- Supine Positioning ularly those involving the contralat. distracted. femoral nailing. Nov/Dec 1993 97 . Fig. leading tion is best checked by rotating the to an incidence of temporary puden- leg gently and observing the skin dal nerve palsy that can rise to as Determining Length lines in the supracondylar region.17 Errors can be fracture site. An exception is the ing adequate length. Once the device cushion the iliac crest and prevent fractures. Unfortunately. fractures it is best to try to select a ing insertion of the bulb-tipped guide ence with this positioning. beneficial in patients with multiple The patella should be internally which creates a varus deformity in injuries. Note adduction of left (operative) leg. In comminuted must support the fracture both dur. To prevent a valgus intensifier that are appropriate for short or overlengthen it by applying reduction. MD adequate room for the image (Fig. This locked femoral nailing prefer use of floor to prevent an external rotation adduction also places increased pres. ing room staff are generally more Another method of reduction is mally without bumping the upright familiar with this technique than with a distractor instead of a fracture stand supporting the table. 2 Supine positioning for intramedullary nailing. Surgeons and other operat. The rotation deformities. The distractor may be femoral cutaneous nerve. the unscrubbed surgeon lateral positioning. most impor- entire thigh into the sterile field. (inset) assembled from rior and lateral radiographs. The unscrubbed surgeon. must be seen to be aligned with allowing reduction of the fracture by the longitudinal axis of the medullary the medullary canal. fractures with minimal comminution.Locked Femoral Nailing Closed Reduction Closed reduction should be per- formed as soon as the patient is posi- tioned on the fracture table. its restora- 98 Journal of the American Academy of Orthopaedic Surgeons . trochanter is palpated. This canal. Fracture tables with built- in clamps for reduction are available. For second-generation Increasing the nail diameter dramati- of the trochanter is not necessary. piriformis fossa tends to align with tant. permits the use of interlocking screws starting point for nail insertion. may gain Fig. but these then drilled into the proximal femur. Before the cortex is pene. complications have all been rare. who should be familiar with the maneuvers neces- sary to reduce the fracture. The dissection is carried Nails with an increased curvature ter and allows insertion of a down through the fasciae. and its placement is of infraisthmal and subtrochanteric and locating the entry portal in the checked on both anteroposterior and fractures. 3 Use of a sterile insight into the vectors needed for “reduction wrench” reduction by studying anteroposte. but unfortunately these bulky clamps impede movement of the image intensifier and create prob- lems during distal targeting of the interlocking screw. In obese greater rigidity increases the risk of Reaming of the medullary canal pro- patients it must extend even farther comminution during nail insertion. to check the two planes with the sis. Use of the bars used for over- head traction. An alternative a member of the scrubbed team. 3). femur for nail insertion are the two lateral views with the image Although reaming damages the most important steps in the surgical intensifier. The use of piriformis fossa allows easier place. and stress image intensifier (Fig. An awl is placed on the proposed but is not as effective in the large canal Accomplishing the closed reduction starting point. because their should be about 3 cm long. A piriformis starting trated. cally augments nail strength and also image intensifier is used to locate the which have screws that extend prox. a start. the (reconstruction) interlocking nails. intracapsular infection. imally into the femoral head. vides uniformity in the canal diame- proximally. a reduction rod may be placed in the proximal femur to allow manipulation of the proximal procedure. because of the risk of avascular necro. Visualization starting point. endosteal blood supply. before preparation and draping. and the require a slightly more posterior larger-diameter intramedullary nail. becomes even more important with The incision should start at least 2 cm nails that are more rigid than the slot. as the ized in both views and. a larger-diameter intramedullary nail Starting Point for Nail ment of the screws into the femoral also enhances alignment in midshaft Insertion neck and head. The and a reamer is used over the pin to Incision use of the piriformis starting point enlarge the starting point. leaded gloves as well as a crutch may be helpful. Once surgery has begun. with a larger core diameter. Reaming proximal to the greater trochanter and ted interlocking nails. which ing point 5 mm anterior to the further increases strength. 4) The pin is fracture of the femoral neck.18 Küntscher originally advised method is to place a Steinmann pin in can be facilitated by use of a sterile against this medial starting point the appropriate starting position and “reduction wrench” (Fig. Some surgeons drape the point appears to be the best. the awl must be well visual- fragment. Nov/Dec 1993 99 . ing of the femur has not been found to use a vise grip to back the reamer and attempts have been made to to cause a higher infection rate or a out and free it from the femur. over the portion of the isth.19 It is vitally important that saw a slot into the lateral cortex of the expansion of the indications for nail- the surgeon study the specific tech. ing to higher fractures. if it does not do so. Fat embolism may ble reamers should never be run in the fatigue resistance of the nail. the risk of fat to extract the reamer generally indi. A guide rod must ing points to prevent comminution. it has been difficult to substantiate the clinical advantage of one design over the Fig. reaming.5. femur.21 but this property has no clinical significance and may lead to increased com- tion within 6 to 8 weeks has been and then quickly twisting the wrist to minution at the fracture site. femoral neck. The only important factor related embolism is slight except in the mul. Closed-section nails offer increased torsional rigidity. Clinically. there is little evidence that this sequela is partially dependent uncoil to become hopelessly tangled these differences translate into a on reamer design and the degree of within the medullary canal. reamer can be removed. but it also nique advocated by the manufacturer mus where the nail tip is incarcer. No 2. 4 The piriformis entry site should align with the medullary other. ated. free the reamer. Clinically. tion in nail size is necessary. Inter. causes the screw to be placed in the for each nail with regard to over.20 Stainless steel and titanium canal. should advance with each blow of the dard piriformis starting point in mm increments until cortical contact mallet. This difference is of no failure than do reamed nails. Winquist. it should order to avoid shaft comminution. significance except that nails with an A bulb-tipped guide should If the nail fits too tightly during increased curvature require a always be used when reaming to insertion.22 Wall well documented. be immediately removed before it There are subtle differences mm increments is advisable. to allow bone expansion. MD available designs has burgeoned. Flexi. with some risk of reaming. It may be necessary thickness has been studied in detail. In patients with such injuries. Inability higher clinical success rate. Robert A. cates that an infraisthmal fracture has to nail design is that more rigid nails tiply injured patient with a chest caused a piece of bone to obstruct the require further overreaming and injury. A large mallet among nails in the proximal and dis- locking nails are stiffer than flexible is very helpful in removing incarcer. If this is nail. result from reaming. it may be necessary to the interlocking screw holes allows to 2 mm. as the spiral windings can However. and Nails but placing the screws through the Nail Design wide metaphysis to reach the hole in Jammed reamers can usually be freed With the growth in popularity of the nail creates targeting difficulties. In the face of union rates of 98% to 100% and infection rates of 1% with the use of these nails. intramedullary canal and block the perfectly placed trochanteric start- the use of an unreamed nail may be exit of the reamer. ream. is made. becomes incarcerated. but unreamed nails have then be moved down the canal to The radius of curvature of the smaller diameters and unfortunately push the fragment out of the canal femoral nail varies among manufac- carry a higher risk of later fatigue through the fracture site before the turers. A quite distal placement allows expansion of the Jamming of Reamers Nail Selection indications to more distal fractures. tal placement of holes within the Küntscher nails and frequently ated intramedullary nails. nails appear to give equal results. A more proximal placement of require overreaming in the range of 1 not successful. from the femur by applying power interlocking nails. Nails with a closed section (circular nails) and those with an open section (slotted nails) also provide similar results. further reaming or a reduc. the number of Unreamed femoral nails have Vol 1. but the risk of reverse. after which reaming in 0. trochanteric entry point that is a lit- allow extraction of broken reamers. increase the strength and augment lower union rate. The nail tle farther posterior than the stan- The reaming should progress in 1. indicated. femoral neck fatigue. but these increased failure rate. tors have since demonstrated that with a radiolucent handle is then dence that either material or design this is not the case. thus.30 The devices. but it also led to shortening and weakening it. at only one end) has been found to aligns with the middle of the screw More important than either of these result in an increased rate of short.25 Cold locking (locking the nail at each round. Unfortunately. indicating coaxial alignment. the trocar or pin is driven to study the technique outlined by complication rate. Nail screw strength. 28 C-arm- An important aspect of nail risk. Once this point is features is the need for the surgeon ening and rotation and a higher located. this type of screw is less easily resistance of the larger-diameter inserted than the fully threaded Accurate targeting of the distal inter- reamed femoral nails have played screw and is difficult to extract. with their use necessitates the placement of two aid in distal targeting. its been made to create proximal jigs to diameter unreamed nails. point of a sharp. 5).23 In these two set. Confining the threads to benefits of static locking. the partially threaded the screw holes has been the most attainment of high union rates in screw gains purchase on only one difficult operative feature of inter- nailed fractures. Many attempts have sent indications for the smaller. With few at one end of the nail during the can be gently tapped through the nail exceptions. The with small diameters. threads is the core diameter of the laser beam to a C-arm image tings. larger core diameter reduces this widespread clinical use. it has not gained weigh the risk of nail failure. Distal Targeting increased strength and fatigue Also.24 yet all bending tests Freehand targeting is still the most comparing various products are Static Versus Dynamic popular method employed by sur- conducted on the midshafts of the Locking geons experienced in this field. although the device damage to the blood supply out. there is little evi. fluoroscopically placed at the point makes a significant difference in the dynamic locking (locking the nail on the lateral cortex that coaxially performance of interlocking nails. but many clinical investiga. proved to be of little use. cortex. for those fractures that have failed In most femoral shaft fractures. and locking nailing. In the femur. Mag- to fractures in multiply injured screw appears to have the more logi. The fully threaded devices have had limited value. placement of a single distal screw 100 Journal of the American Academy of Orthopaedic Surgeons . Dynamization into the lateral cortex and is then the manufacturer for each nail and to (removal of the interlocking screws replaced with a drill bit. hole (Fig. trochanter to the supracondylar the weakness of the interlocking area. locking screws in their passage into an extremely important role in the thermore. and a appears attractive.27 In ful and requires only slight surgical is somewhat more important than light of adequate evidence of the experience. the use of reamed nails is healing process) was also popular to the medial cortex before drilling to still the standard.20. It is currently the recom- nail design. screw holes.26 Conversely. comes loose more often. with dynamization reserved Number of Distal Screws screw is at the shaft-thread junction. Materials such as titanium and mounted targeting devices have also design involves the area in which the 22-13-5 stainless steel also improve been of limited benefit. working of the interlocking holes end). This freehand tech- Interlocking Screw Design and rotation at the fracture site and nique has proved to be very success- The design of interlocking screws did not increase the union rate. The from a partially threaded screw. the risks of fat embolism and screw.29 Offset-power screw holes penetrate the nail. and thus little advantage is gained to show healing at 4 to 6 months. complication of locked nails. Goulet et al28 and Gustilo grade IIIB and IIIC A more important feature than the have described the attachment of a open fractures. Increased wall thickness of image intensifier is tilted and rotated the nail in the vicinity of the hole Early in the development of static until the hole appears completely provides increased strength. there were concerns that this The placement of the skin incision is has also helped increase strength technique would hinder impaction then determined fluoroscopically. early in the use of interlocking prevent nicking the nail with the bit nails. Fur.Locked Femoral Nailing relatively few indications. rate.26 I recom. backs out more frequently. The drill bit carry it out carefully. equipment with radiolucent drill failure usually occurs through the chucks has provided a slight benefit. mended method for distal placement the distal tip of the screw has been mend static locking of all femoral of interlocking screws. elongated trocar In summary. pre. and is especially important in nails and lead to an increased nonunion and the fascia is split beneath it. Screw failure is a common intensifier. netic and light sources have also patients with severe chest injuries cal design and is easier to use. are confined screws distally. thought to provide additional fractures from below the lesser strength to the screw. Proximal targeting is much more The use of two screws is generally difficult with reconstruction nails indicated in infraisthmal fractures to Open Fractures than with standard interlocking prevent rotation around the nail and nails. Two screws are also indicated tures with interlocking nails. however. Controversy fossa starting point. MD therapy appears to exacerbate this avoid further damage to the blood condition. Many reports now planes is necessary. treatment of choice. There is no evidence that a continu. into the bone. Each patient’s and in Gustilo grade I. a 130-. angles of placement. However. as well as in unreliable first is whether the nailing should be pin along the anterior surface of the patients who refuse to limit weight performed primarily or secondar. sliding. Nov/Dec 1993 101 . persists. The normal femoral neck-shaft this screw is placed in the proximal Screws with greater head heights angle is 125 to 130 degrees. Patients with stable fractures suggest that in open fractures caused femoral neck and head project from are allowed early weight bearing by low-velocity gunshot wounds35 the anterior two thirds of the femoral with crutch support. Winquist.23 These frac. The most screw. and the use of a radiolucent flexion/extension about a single In the treatment of open femoral frac. medullary canal should be reamed the anteroposterior and lateral sary until callus formation is evi.32 There are no long-term leads to an increased rate of nail fail- studies suggesting that removal of ure because these screws require the nail or interlocking screws is nec. Second-generation interlocking ous-passive-motion machine is nec.20 placement of the screws at the 135- threaded screw is preferred. greatly facilitates proximal target- sequela of these injuries. This starting Quadriceps rehabilitation is gen. appears to be unimportant whether pain and pain over the screw heads.12. the patient supply. proximal femur and combined femoral neck-shaft fractures. II.33 Little difference in the infection anteversion. plastic guide is helpful. Correct In patients with unstable fractures. 23 reamed insertion in the proximal femur is 5 according to healing noted on fol. or a 125- decreases time spent in targeting. tion no longer appears necessary. Screws may be provides adequate fixation and essary. and IIIA shaft. It for removal are symptoms of hip degree angle to the femoral shaft. early or late dynamiza. At present. or left unreamed. ment of Gustilo grade IIIB and IIIC alignment with the femoral neck and Chondromalacia is a common open femoral fractures. As the nail is driven rate has been found between frac. the starting point for nail weight-bearing status is progressed open femoral fractures. the indications placed at a 135-. larger screw holes. as a as do screws in subcutaneous areas. No 2. Use of the The indications for nail removal are larger screws is unnecessary and unclear. and ter- minal knee extensions. degree angle increases the difficulty screw with distal threads tends to Except in cases of delayed union and of screw insertion but facilitates back out and necessitates the use of nonunion. ily. two important technique is the place- in severely comminuted femoral important questions remain. and or the distal screw hole. should begin with gentle quadriceps muscle sets. straight leg lifts. 5 The sharp trocar is brought in obliquely and aligned coaxially with the Nail Removal various sizes and with differing screw hole. A fully tend to produce more symptoms. two screws. nails are used for fractures of the essary to obtain good results. locked intramedullary nailing is the mm anterior to the usual piriformis low-up films and clinical progress. Therefore. a starting point early institution of vigorous physical of unreamed interlocking nails to placed too far anteriorly leads to Vol 1. The ment of a percutaneous Steinmann fractures. second question is whether the placement of the proximal screw in protected weight bearing is neces. and the tures may be an indication for the use ing. Because the dent. Robert A. These nails are available with screws of Fig. about the treat.31. femoral neck to define femoral bearing and in head-injury patients. point places the screws in better erally started 1 day postoperatively. it must be rotated Postoperative Management tures nailed primarily and those properly so that the proximal jig is nailed in a delayed manner.34 The parallel to the anterior pin. Progressive Second-Generation quadriceps muscle work should be Interlocking Nails added only as the patient improves. 6 Femoral neck-shaft fractures.18 and the two interlocking screws are cannulated. nondisplaced femoral neck fractures. The femoral shaft is then managed with a plate femoral neck fracture during inser. tion of the nail. Group 1: Locked nail- must be reamed to a diameter 1. It is very important to recognize the anterior location of the femoral neck Group 1 Group 2 Group 3 Neck nondisplaced Neck missed Neck displaced relative to the femoral shaft. After stabilizing pin. 6). a third screw. Treatment.Locked Femoral Nailing fracture of the femoral shaft and fur. Locked nailing is then 102 Journal of the American Academy of Orthopaedic Surgeons . thus. a femoral neck fracture may be difficult to detect on film. in the case of a diaphyseal fracture. carried out with a reconstruction nail. preoperative radio- graphs of the hip should be taken in all patients with a femoral shaft frac- ture.5 to 2 ing is carried out with a reconstruction nail. As a precaution. which makes it possible to place femoral neck pins and screws anteriorly but not posteriorly. If the proximal fragment is rotated. or. missed femoral neck fractures. is added over the anterior placed into the femoral head. plate on shaft femoral neck so that it will not Fig. Group 3: Open anatomic reduction of nail to prevent displacement of the the femoral neck and multiple-screw fixation. Bottom right. Group 1: Nondisplaced obstruct the medullary canal during femoral neck fracture. Group nail placement. The surgical technique involves ini- tially placing a temporary Steinmann Group 1 Group 2 Group 3 pin in the anterior portion of the Second-generation nail Add screws in neck Screws in neck. with a retrograde intramedullary nail. The majority of these femoral neck fractures are high- angle Pauwels type III fractures sus- tained at the time of injury. Femoral neck-shaft fractures can be divided into three clinical patterns: group 1. Top left. Femoral Neck-Shaft Fractures Femoral neck fractures are found in combination with approximately 1% of all femoral shaft fractures. Top right. Group 2: Placement of two additional screws in the femoral mm larger than the reconstruction neck anterior to the intramedullary nail. group 2. nail insertion. and group 3. Top. Top center. Group 1: Nondisplaced Femoral Neck Fracture This fracture combination includes a femoral shaft fracture with a nondis- placed femoral neck fracture and pro- vides an ideal indication for second-generation locked nailing. dis- placed femoral neck fractures (Fig. not during intramedullary nailing. Bottom. which is ther comminution. The medullary canal 3: Displaced femoral neck fracture. Classification. Bottom left. and the two interlocking screws are placed into the femoral head. Group 2: Missed femoral neck fracture. it is helpful to examine the femoral neck under fluoroscopy during nail insertion. Bottom center. Bottom right. reverse intertrochanteric fractures. Bottom. Type 1: Treatment is with a standard (first-generation) interlocking nail. 7 Subtrochanteric fractures. The femoral shaft is then managed either with a plate or. Type 3: Reverse intertrochanteric fracture (lesser trochanter is fractured. Type 3: Stan- these fractures. with a retrograde intramedullary nail. Type 2: Treatment is with The lesser trochanter is intact in a second-generation interlocking nail. The complications of nonunion and avascular necrosis that arise in femoral neck fractures are extremely difficult to manage. Nov/Dec 1993 103 . No 2. Classification. true subtrochanteric fractures. intact fractured fractured The recommended treatment for this fracture combination is an anterior capsular decompression with an open anatomic reduction of the femoral neck and multiple-screw fixation. First-generation nail Second-generation nail Hip screw trochanteric fractures (Fig. the The only patients with true sub. but the greater trochanter and piriformis fossa are intact). which is statically locked. fractures below the lesser trochanter Vol 1. Top. 7). Bottom center. but the greater Fractures trochanter and piriformis fossa are intact). Group 3: Displaced Femoral Neck Fracture This group of fractures includes a femoral shaft fracture and a dis- placed neck fracture that is identified initially. after the femoral shaft fracture has been nailed. Winquist. Treatment.36. intertrochanteric-sub. Fig. Robert A. Type 2: Reverse intertrochanteric fracture (lesser trochanter is fractured. True subtrochanteric dard treatment is with a compression hip screw. whereas the typical complications of Type 1 Type 3 Type 2 femoral shaft fractures are of a lower Lesser trochanter Lesser trochanter Greater trochanter magnitude and easier to manage.37 ond-generation nails are indicated In this group of fractures. There are three clinical patterns: type 1. Top Type 1: True Subtrochanteric right. type 2. Top center. The best form of treat- ment involves returning the patient to the operating room and placing two additional screws in the femoral neck anterior to the intramedullary nail. MD Group 2: Missed Femoral Neck can be managed with a standard trochanteric fractures for whom sec- Fracture (first-generation) interlocking nail. Subtrochanteric Fractures The availability of second-generation nails extends the benefits of locked nailing to fractures of the extreme proximal regions of the femur. Type 1: True subtrochanteric fracture (lesser trochanter is intact). Top left. Bottom left. in the case of a diaphyseal fracture. Type 1 Type 2 Type 3 and type 3. are those with severe osteoporosis or femoral neck fracture has been missed initially and is discovered intraoperatively or postoperatively. Russell TA.212:192-208. Tencer AF.Locked Femoral Nailing with a metastatic lesion that may nails in these fractures has led to a nearly all femoral shaft fractures. A standard Only in those cases with minimal a much smaller role. Clawson Early versus delayed stabilization of al: Intramedullary nailing of the femoral DK: Closed intramedullary nailing of femoral fractures: A prospective ran.26:177-214. Johnson KD: Intra- Unstable femoral shaft fractures: A com. Matta JM. J Orthop Trauma 1987. but the greater trochanter multiple injuries. Küntscher G: Die Marknagelung von locked nailing for treatment of segmen. intramedullary nailing of femoral shaft 5. statically locked nails is the combined femoral neck-shaft frac- if there is any distal comminution. which is statically locked reamed. treatment of choice for the large tures in which the neck is nondis- majority of femoral fractures from placed. Decision-making errors 19. cerclage for ipsilateral fractures of the femoral Bone Joint Surg Am 1992. Brumback RJ. Kyle RF. et al: Am 1984. particularly those and piriformis fossa are still intact. Brien WW. References 1.70:1441-1452. 14. review. 13. Butler MS. Meek RN. J Bone Joint Surg 1989. Fleming CH. J Bone Joint Surg Am 1991. et al: Knochenbrüchen. Distal targeting interlocking nail can be used in sub- displacement of the trochanteric of the interlocking screws continues trochanteric fractures below the fracture and extensive shaft com. The and failure. 21. Koval KJ. et al: Pudendal nerve palsy complicating Comminuted femoral-shaft fractures: al: Interlocking intramedullary nailing intramedullary nailing of the femur. Ill: Charles C Surg Am 1988. These nails are also indicated Type 3: Intertrochanteric. 3. generation nail be considered. Hansen ST Jr. et Mechanical characterization of femoral 104 Journal of the American Academy of Orthopaedic Surgeons . Clin Orthop 1986. Taylor JC. Poka A.6:448-451. Brumback RJ. for pathologic fractures in the Subtrochanteric Fractures condylar area.71:336-340. Johnson KD. Browner BD: Pitfalls. Wiss DA. fractures: Part I. Webb LX. et al: interlocking intramedullary nail. Wiss DA. Springfield. with illustrative case presen- locked intramedullary nailing: A Intramedullary nailing of femoral shaft tations. Orthop Trauma 1992. 11. Küntscher G: Practice of Intramedullary with interlocking fixation. J Bone Joint Surg Am J Orthop Trauma 1992. Brumback RJ. Acta Orthop Scand stability and femoral bursting in closed Orthop Clin North Am 1980.73:1492-1502. LaVelle DG. Winquist RA. Shih CH: Interlocking nailing of 18. Summary involving the chest. et 7. Bone LB. randomized study. Wu CC. Cameron CD. J Bone Joint Current concepts in femoral nailing. dred and twenty cases.22:521-525. the traditional compression hip Routine use of second-generation Static nailing is appropriate for screw is still the treatment of choice. Ellison TS. Closed intramedullary nailing with nails provide an ideal treatment for locking nail. Johnson KD. 4. In subtrochanteric fractures into the greater trochanter and the starting point for nail insertion are they are best used when the lesser piriformis fossa. shaft: A prospective. Closed reduction and intertrochanteric and subtrochanteric In this group the fracture extends proper location of the piriformis regions. Stetson WB: Inter. nique of using a femoral distractor.11:633-648. errors. Brumback RJ. Sherman MC: nuted fractures of the femoral shaft distal femoral fractures: 28 patients fol. Reilly JP.2:10-12. et al: fractures. J Trauma 1988. lesser trochanter. 9. domized study. et al: ture table. Orthop Rev 1993. Winquist RA. The incidence of varus use of unreamed nails is appropriate Type 2: Reverse deformity is increased by supine only in Gustilo grade IIIB and IIIC Intertrochanteric Fractures positioning of the patient and open femoral fractures and in In this pattern the lesser trochanter adduction of the hip. Hansen ST Jr: Commi. Second-generation interlocking cation for a second-generation inter. Browner BD. Johnson KD. fractures of the femur treated with an medullary nailing of acute femoral shaft parison of interlocking nailing versus interlocking nail. For fractures minution should the use of a second.6:271-278.1:1-11. Cole JD: Current status of 12. Lyon T. nails. 1967. 1991. high incidence of varus deformity a single distal screw is adequate.72:724-728. McFerran MA. femoral fractures: A report of five hun. J Orthop 35-47. lowed for 1-2 years. the lesser trochanter to the supra. 1940. Thomas Publishers. J Bone Joint cations in the use of locking Küntscher Nailing. and the freehand technique with a extending into the greater trochanter. to be the most difficult surgical step. surgical technique. Pudendal nerve palsy induced by frac- Joint Surg Am 1984. Surg Am 1990. Biomechanical factors affecting fracture treated by intramedullary nailing. Blachut PA.212: fractures without a fracture table: Tech- traction and casting methods. Kummer F. et al: 20. Clin Orthop 1986.66:529-539.62:342-345.200:443-455. and extend into the intertrochanteric area. and compli- 6. J Bone 15.66:1222-1235. 17. Fowler HL: Comminuted and rotationally unstable 16. Molligan H. These fractures provide an ideal indi. 2. Nail design plays formis fossa is intact. 10. Johnston DWC.74:1450-1455. Wiss DA. Gristina AG. Parker B: 8.1:183-195. Arch Klin Chir tal fractures of the femur. J Orthop Trauma 1987. wires and an intramedullary nail or an shaft and distal part of the femur. J Treatment by roller traction. Standard treatment the most important aspects of the trochanter is fractured but the piri- is with a compression hip screw. Weigelt J. femoral fractures in patients with is fractured. Contemp Orthop 1993. Ellison TS. sharp trocar is commonly used. Alho A. J Bone Joint 29. 37. Inserting the distal screws in a locked trochanteric fractures of the femur.74:106-112. 26.6:460-463. Long-term effects of Orthop Trauma Surg 1992. J Orthop Trauma tems. J Bone Joint 23. Winquist. 22. Arch femoral shaft fractures: A report of fractures: Part III. 1992. J Bone Joint Surg Am static interlocking fixation. Renwick SE. et al: 1985. Hansen ST: Immediate nail- Fatigue fracture of the interlocking nail laser light. Am 1988.73:598-606. Wu CC. Moen O.67:709-720. Intramedullary nailing of open fractures 28. Robert A. improved method of screw placement Orthop 1986. Ellison TS. Lhowe DW. Winquist RA.70:1463. Husby T. femoral nail. et al: 32. Saltzman CL. Becker V Jr: Inter- Surg Am 1987. et al: Broken intramedullary nails.8:797-800. part of the femoral shaft.69:1391-1399. J Bone Joint Surg femoral shaft fracture. Ross SE.70:1453-1462.111:91-95. forty-eight cases. Kempf I. J Bone Joint Surg Am 1988. Ellison PS Jr.31:326-333. Vol 1. in the treatment of fractures of the distal 203.67:1313-1320. Uwagie-Ero S. Nov/Dec 1993 105 . J Bone Joint Surg Am Interlocking intramedullary nails: An ullary fixation in open fractures. et al: 33. et al: Slotted 27. Miller R. ing of open fractures of the femoral shaft. Lakatos RP. SK. 30. Thoresen BO. intramedullary nailing: Its application to locking nailing for the treatment of 25. Poka A. No 2. et al: versus non-slotted locked intramedullary Interlocking intramedullary nailing in Intramedullary nailing of femoral shaft nailing for femoral shaft fractures. Grobler GP.71:1324-1331. Ekeland A. Grosse A. 24. Clin Orthop 1992. Beck G: Closed locked 35. J Bone Joint Surg Am 1991. J Bone Joint Surg Am 1988. Close REW: 36. Brumback RJ. Fracture-healing with static al: Removal of intramedullary rods after locking nailing. J femoral fractures due to gunshot wounds. et al: Intramedullary 1991. Bucholz RW.70:812-820. Alho A. Knudsen CJM. Franklin JL.281:199. Clin 1989. Londy F. Lawrence KL: combining image intensification and 34. Wiss DA.73:660-661. J Bone Joint Surg Br Orthopedics 1985. Goulet JA. Chapman MW: The role of intramed- of the femoral shaft. Matta JM. Brumback RJ. DeCoster TA. Wiss DA.5:332-340. J Trauma 1991. interlocking fixation. Brien WW. Shih CH. Sima W.212:26-34. et trochanteric fractures treated with inter- Part II. Benirschke comminuted fractures of the femur. Lee ZL: Sub- nailing of femoral shaft fractures: 31. J Orthop Trauma 1991. Brumback RJ. et al: Sub- 1471. MD interlocking intramedullary nailing sys. Bone Joint Surg Am 1985. Poka A. Surg Am 1992. JAAOS Home Page Table of Contents Search Help . osteophytes J Am Acad Orthop Surg 1993. classically in extension more within a few months. Minn. with or without associ. osteoarthritis of the elbow lowing various injuries. so than in flexion. Also. Carrying any. O’Driscoll is Associate Professor of Orthope- The pattern of involvement of the thing. O’Driscoll. Nonunions in this region usually who have had bilateral elbow sive to men. Rochester. The severity of the disability weight lifters. They usually request impingement pain at the extremes of surgery on the contralateral side motion. function that for years we have where its treatment was also first Posttraumatic arthritis can occur fol- tended to overlook or minimize described. Elbow Arthritis: Treatment Options Shawn W. the The etiology of this condition is metic deformity. Treatment is dictated by the patho- of time and then have one elbow acteristic history of mechanical- replaced. Stiffness is common. There may be crepitus in the to advances in arthroscopic techniques and surgical treatment for contractures elbow. elbow extended is painful. with the primary involvement in the the midportion of the arc of motion is Reprint requests: Dr. 3rd Floor. flexion contracture of approximately ing. further destruction due to malalign. MD. it is a disorder almost exclu.1 Posttraumatic Arthritis results in painful impairment of Originally recognized in Japan. is profoundly realized by patients In fact. degenerative arthritis and osteochon- determine the treatment options and dritis dissecans are so prevalent in the likelihood of patient satisfaction. MN 55905. instability. tures that involve intra-articular results. and throwing athletes. approaching that of total replacement of the knee.1:106-116 filling in the olecranon and coronoid fossae. and usually loose bodies (which may not actually be loose) Although pain is the most com. hip. ness. soft tissues. There remain On the radiographs there are a number of controversies and unanswered questions that require further experi. but is most because of a general pessimism is most commonly seen in men with common with distal humeral frac- regarding treatment options and a history of heavy use of the arm. PhD. but the characteristic finding and improved prosthetic designs. with osteoarthritis have loose bodies. Mayo Clinic. Dr. with the dics. A Research. causes joint laxity that (Fig. O’Driscoll. Loss of present only in the late stage. Orthopedic ulnohumeral articulation. Medical Science Build- bone stock. The reliability of total elbow replacement is is pain on forced extension or flexion. Eventually. only recently recognized and indicating that loose bodies might be Rheumatoid arthritis affects the described in the English-language causally related to the arthritis. but when it does occur. FRCS(C) Abstract The treatment of elbow arthritis is conceptually similar to that for arthritis of associated with some loss of flexion other major joints. patients with elbow results in mechanical wearing and radioulnar joint and finally the radio- arthritis may also complain of stiff. and shoulder. Department of Orthopedics. such as a briefcase. ated destruction of the periarticular 30 degrees is typical and may be 106 Journal of the American Academy of Orthopaedic Surgeons . They present in their result in a flail dysfunctional elbow. or cos. osteophytes on the olecranon and ence and longer follow-up for resolution. The treatment of elbow arthritis has been evolving rapidly due as well. The combination of elbow can become flail. In the advanced stages the mon complaint. The fact that both complaints and their relative severity sive motion in the coronal plane. humeral joint may become involved. elbow less frequently than other literature. comminution. with exces. it cal and radiographic presentations. is characteristic in its clini- joints. still not known. Mayo Clinic elbow is similar to that of other joints. Pain in and Mayo Medical School. 1). weakness. throwing athletes suggests a link Osteoarthritis between the two. ment or subluxation. involvement for an extended period third to eighth decades with a char. Rochester. many patients Rheumatoid Arthritis Primary osteoarthritis of the elbow. coronoid processes. However. and total elbow tions of corticosteroids are easily per. with thick- ening of the normally thin bone separating these two fossae. medical treatment and physical ther. the stage of tomy. such as avoidance Options Acetylsalicylic acid and nonsteroidal of activities that place excessive anti-inflammatory agents are used stresses on the elbow. Nov/Dec 1993 107 . FRCS(C) A B Fig. Surgical Treatment apy for most other joint disorders. Loose bodies (often adherent to the soft tissues) are common. MD. basis to maintain mobility and the disease. and those who are can- elbow arthritis includes the standard didates for surgical synovectomy. heat or cold. intermittent Surgery is indicated following fail- unless precluded by gastrointestinal periods of rest. Occupa- of the patient. pain. More potent agents. and eventually loss of the articular cartilage and involvement of the radioulnar and radiohumeral joints. are resorted to exercises protect the elbow from resection and interpositional arthro- when necessary. should be performed on a regular sistent results. These would include handle Nonsurgical Treatment young patients with inflammatory extensions to cope with elbow- arthritis. O’Driscoll. including arthroscopy. side effects. Radioactive synovec. The nonsurgical management of tory arthritis. Total elbow formed and should be considered can be helpful. Shawn W. characterized by osteophytes on the coro- noid and olecranon processes (arrows). Physical therapy includes pain. and age articular injection of a radioisotope. PhD. immunosuppressive drugs. and corticosteroids. Lightweight hinged splints options. osteotomy. though not seen on these anteroposterior (A) and lat- eral (B) radiographs. Gentle exercises arthroplasty provides the most con- before surgery. Vol 1. is strength in the muscles. that permit active range-of-motion open synovectomy. also minimally invasive and should tional therapy interventions with probably be recommended as a more aids for activities of daily living are conservative treatment option to useful. No 2. varus-valgus stresses and minimize plasty. complaints. coronal osteophytes encroaching on the margins of the coronoid and olecranon fossae. arthrodesis. salts. the age of the patient. 1 Primary degenerative arthritis of the elbow has a classic pattern of radiographic changes. logic findings. performed by sterile intra. Resting or night splints also arthroplasty (TEA). gold useful. Splinting is sometimes There are a number of surgical including antimalarial agents. and application of ure of nonsurgical management. those with early inflamma. flexion contractures. control measures. Intra-articular injec. A complete Open Synovectomy Treatment of osteoarthritis consists of synovectomy is technically possible decompressing the impinging areas. Philadelphia: WB Saunders. Also of elbow problems. improvement is so much greater. as it is in other we believe that the risks are minimal unclear is the role of radial-head exci- joint disorders. of motion is less likely than pain ments in the anterior part of the relief.) 108 Journal of the American Academy of Orthopaedic Surgeons . Osteophytes are removed with a small osteotome and graspers. It is useful to per. (Reproduced with permission from O’Driscoll SW. in Morrey BF (ed): The Elbow and Its Disorders. reported to persist. and ment of primary degenerative with both TEA and synovectomy ulnohumeral rotatory instability. destruction has occurred. fol. Osteotomy from debridement of the area and localized synovectomy. for the management of inflamma. well as from the olecranon fossa (Fig. experience of some surgeons. Currently this is being performed tory or septic arthritis. The advantages of arthro. 1993. Increased range Arthroscopy limeters of the operating instru. Progressive articular destruc- form a synovial biopsy. 2 Arthroscopic treatment of osteoarthritis. tomy is technically possible. Satisfactory involvement are important determi. neurovascular structures.. One must pain relief is obtained in about 70% to nants of treatment choice.g.4 The good results are the nerves may be within a few mil. In general. be constantly aware of the fact that 90% of patients. There is controversy regarding Arthroscopy is assuming a greater elbow. Late valgus radiographs. arthritis is possible in the early favor TEA in the later stages Patients with spontaneous onset of stages by removal of the osteophytes because the patients are so much contracture are often found to have a from the olecranon and coronoid as more satisfied and the functional form of inflammatory arthritis. Treat. causes minimal ulnohumeral loading. A bur is used to smooth off the olecranon (B) and to recreate the olecranon fossa.2. of motion. although head excision is a well-recognized with use of the Outerbridge-Kashi- technically highly demanding and and accepted form of treatment for wagi (ulnohumeral) arthroplasty.3 Removal of osteophytes from matic arthritis sometimes benefit the coronoid fossa is more difficult. 2). It is done as an outpa. posttraumatic arthritis. removing any osteophytes and thickened bone (C). Patients with localized posttrau. Synovectomy with or without radial. Although the safety of this its success in later stages after joint role in diagnosis and management procedure has not yet been proved. tion following synovectomy and nosed painful snapping of the elbow scopic over open synovectomy are radial-head excision has been noted can be associated with cartilaginous impressive.Elbow Arthritis and the presence of other joint associated with a theoretical risk to rheumatoid arthritis. A. Morrey BF: Arthroscopy of the elbow. surgeons experienced lowing radial-head excision). A B C Fig. observed. if certain safety precautions are sion. p 128. dense soft-tissue adhesions (e. Undiag. morbidity. and a complete synovec. and permits rapid return instability has been a problem in the primary degenerative arthritis. and is thought to be due to increased loose bodies that do not appear on tient procedure. Interpositional lowing interposition arthroplasty Arthroplasty (Fig. FRCS(C) which is really a core osteotomy of motion with reasonable stability) is for “biologic resurfacing” because of the distal humerus and osteotomies more likely if the medial and lateral its potential to regenerate articular of the tips of the olecranon and coro. No 2.1 the elbow joint slightly distracted. PhD. although the tech- Resection arthroplasty is an option niques are demanding and require The evolution of TEA has had simi- for salvaging an elbow. It is prob- operatively. loss does not preclude it. Successful results (pain plasty involves the use of a hinged ably never indicated as a primary and motion improved) have been external fixation device that holds procedure. 3). particularly substantial expertise. It is performed through the olecranon and coronoid remain contraindications as well as results to a triceps-splitting approach using the in place. 6). Distraction arthro. Vol 1. Cloward drill to go through the or grossly unstable.5 If the elbow becomes flail be expected are not yet fully known. The indications and noid1 (Fig. Loose bodies are removed anteriorly and posteriorly. core osteotomy of the humerus to remove the marginal osteophytes from the olecranon and coronoid fossae. The procedure for posttraumatic arthritis if bone due to the fact that range of motion characteristically relieves impinge. the limb remains thus.6. Arthrodesis primary osteoarthritis in patients For younger patients (typically with pain at the extremes of motion. Biomechanically. Arthrodesis of the elbow is incom- but not in the midportion of the arc tion arthroplasty is recommended patible with satisfactory function of motion or at rest. this situation is rare. larities to that of total knee arthro- following failed TEA. A. and aligned while permitting patients who perform heavy labor. there are (relatively pain-free functional arc of periosteum from the proximal tibia three types of prosthetic joint A B C Fig. 5). 1). There is no single optimal some improvement in range of reshaping of the articular surfaces position. O’Driscoll. Resection and full motion in the first few weeks fol. Nov/Dec 1993 109 .7 The pro. especially when the rehabil. 3 Outerbridge-Kashiwagi (ulnohumeral) arthroplasty (same patient as in Fig. nonfunctional. Its success In young patients I have used plasty. humerus (Fig. of the elbow is essential for use of the ment pain and frequently permits cedure involves removal and/or hand. intractable sepsis is present and itation program involves the use of tion tissue such as autogenous fascia when reconstruction by revision patient-adjusted static braces post. columns of the distal humerus and cartilage (Fig. and excision of the coronoid osteophytes through the hole in the humerus. Procedure involves excision of the osteophyte from the olecranon (arrows). and the result is This procedure is indicated for unsatisfactory. although controversy reported in 85% of patients. Fenestration created by the arthroplasty mimics a congenital fenes- tration seen in some patients (C) and does not significantly weaken the humerus. TEA is no longer possible. less than 60 years of age). MD. it remains experimental. The results are satisfactory Total Elbow Arthroplasty in most cases. It is indicated when motion. exists in the case of young male stable. B. lata or dermis. In the elbow shown. Fortunately. Shawn W. and resurfacing with an interposi. 4). there are also osteophytes on the capitellum and radial head. interposi. dure. It is able to state categorically that there lation. Large trephine (large Cloward drill) is used to fenestrate the distal humerus. and osteophytes are removed. The same was found to be with the constrained-hinge type of observed that satisfactory pain relief true of hinged designs in the knee elbow prosthesis. All the theoretical arthritis by replacing the elbow joint shoulder. J Bone Joint Surg Am 1990. semiconstrained design with a per- all of the stresses directly to the pros. A.Elbow Arthritis A B C Fig. it was ening. Coronoid osteophyte is removed under direct vision through the fenestration. (Reproduced with per- mission from Morrey BF: Post-traumatic contracture of the elbow: Operative treatment. 4 Surgical technique of ulnohumeral arthroplasty. semicon. therefore associated with a very high is no indication for a certain proce- strained. arthroplasty can be provided by a of constrained prosthesis transfers ening. A major degree of bone advantages of a constrained with a hinged prosthesis. C. and constrained.) 110 Journal of the American Academy of Orthopaedic Surgeons .72:601-618. 5 The hinged elbow distraction device designed by Morrey permits stable alignment of the elbow. including distrac- tion arthroplasty. Olecranon is exposed through a triceps-splitting approach. This type destruction accompanies such loos. making salvage difficult. failure rate due to mechanical loos. Fig. this is true for arthroplasty Over two decades ago. which has now could be provided to patients with and ball-and-socket designs for the been abandoned. Although it is rare in medicine to be manent coupling-bolt type of articu- thesis-cement-bone interfaces. designs: nonconstrained. and motion in both flexion-extension and pronation-supination arcs. B. vari- able distraction. angling it proximally to exit at the margin of the joint. Lowe. The most common diagnosis for would be better termed “minimally ticularly true when loss of bone or which TEA is performed is rheuma- constrained. Instability (disloca. FRCS(C) Pritchard Mark II. London. ses are not truly nonconstrained and nonconstrained TEAs. cations include the treatment of pool. Although it might be theoretically more likely to loosen than a minimally constrained device. knee. nonconstrained surface replacement. cement-bone interface. A true noncon. This is the most com- monly used class of elbow replace- ments today. 8).e.13 Other indi- those by Sorbie. The tion. or than being transferred to the bone. This is par. Examples include those semiconstrained prosthesis offers a Rheumatism Association class III or designed by Ewald (capitellocondy. that they do not dislocate. The majority surgery is the same as that for absorbed by the soft tissues rather of components now available have replacement of the hip. there. GSB III. Koopman WJ [eds]: Arthritis and Allied Conditions. compromise between the stability IV (i.8-12 Thus. and In most designs the ulnar and supracondylar or intercondylar Kudo. problem with nonconstrained functional impairment. Others reserve minimally constrained devices for patients under the age of 60. with osteoporotic bone that cannot be ulna. because the stresses are humeral components. This is indi- fore relying solely on the periarticular replacements. 7). p 957. PhD.6. since 1972. O’Driscoll. No 2. some after surgery show active motion from 20 to 130 degrees with the hinged elbow distractor in consider a semiconstrained prosthesis place. but these components without mally be applied to the prosthesis. age allows for a degree of laxity that condylar or intercondylar fractures of ply replace the articular surfaces of permits the soft tissues to absorb the distal humerus in elderly patients the distal humerus and proximal some of the stresses that would nor. the two most provided by a hinged prosthesis and some or none of the usual occupa- popular in North America. stability. Liver. had a painful stiff elbow with posttraumatic arthri- out to be so in clinical experience and tis secondary to an open fracture-dislocation 4 months earlier. has been a problem in 5% to 20% of less invasive surgical options. toid arthritis. Kudo include the Pritchard-Walker. The typical patient constraint afforded by the articula. reduced and fixed adequately.) ing TEA. and intramedullary stems had a ten. or maltracking) met by nonsurgical means or other. (Reproduced with permission from O’Driscoll SW: Surgery of elbow arthritis. cated when such a goal cannot be soft tissues for stability (Fig. current surface-replacement prosthe. Wadsworth. prevent the rocking or tilting type quality of life by restoration of pain- strained joint replacement provides of motion that causes loosening. These designs have been in use humeral components are linked so nonunions of the distal humerus. and little or no inherent stability by virtue Loosening is no longer a common strength) in a joint that is causing of its shape and articulation. Photographs obtained 3 weeks reports in the literature. as well as the low incidence of loosening of a tional or daily activities). Such designs flail elbow caused by posttraumatic dency to loosen and displace. 1993. Souter. Vol 1. subluxation. Mor- rey-Coonrad (Mayo-modified Coon- rad)(Fig. The indications for use of a semi- constrained prosthesis include all cases in which bone-stock or soft-tis- sue integrity is not adequate for use of a minimally constrained device. Philadelphia: Lea & to be indicated in any patient requir- Febiger. Coonrad II. 12th ed. triaxial. Less-constrained prostheses and Iwano 8 reported a 70% inci. capable of performing only lar) and by Pritchard. MD. Indications should be less prone to mechanical dence of loosening for nonstemmed The general indication for loosening. free function (motion. severely comminuted acute supra- There was an initial trend to sim. loss of bone or structural integrity. in McCarty DJ. A loose-hinge or sloppy-hinge undergoing TEA is in American tion itself. 6 The patient. Nov/Dec 1993 111 ..” as there is a degree of soft-tissue integrity is significant. and AHSC (Volz). this is not turning Fig. but the link. intramedullary stems that help to shoulder—improvement in the prosthesis interface. Shawn W. a 22-year-old woman. patients are able to bear weight traindication.13 My limited experience with nonunion because the operation can rarely required. the Technique all other treatment options. Most would recom. usually being simultaneous bilateral elbow replace- be done with less soft-tissue dissec. The results for shoul. Although the controversy sequent lower-extremity surgery. strength. over which joint should be replaced resulting in requirement of walking traindication is active infection of the first continues. including more disabling joint should be oper. tion and without detaching the tri. not an absolute contraindication. A history of postseptic arthritis disabling should probably be oper. This is the old- est elbow prosthesis still in use and is reported by the originator to have excellent long-term results.13 The need for sub- to those for replacement of the other der as well. some or osteomyelitis is a relative con. Patients who Contraindications requiring TEA may have advanced undergo TEA generally have had pre- The contraindications are similar involvement of the ipsilateral shoul.” Although there are many 112 Journal of the American Academy of Orthopaedic Surgeons . Sullivan JA. elbow arthroplasties in patients with and stability and no pain. losis or supracondylar nonunions.) The best results are often seen in Loss or destruction of bone or soft can be done as soon as the patient is patients who preoperatively have tissue is not a contraindication to TEA. the rehabilitation is faster in a With appropriate implant selection. It does not include a radial head component. 7 Patients with adequate bone stock and soft tissues for stability can be treated with a nonconstrained arthroplasty such as the capitellocondylar (Ewald) prosthesis. able to look after himself or herself little or no use of the limb. “The front door to the elbow is at distraction interposition arthroplasty. postoper. juvenile rheumatoid arthritis. As a result. making the operation more complicated. elbow replacement. The only absolute con. custom components are ments. vious operations. The second operation the back. the patient bearing joint in many patients with can use the arm without restrictions Consideration of Other Joint rheumatoid arthritis (as does the immediately following surgery. ated on first.6 Of Similarly. Though a radial head might increase stability. its insertion would require precise alignment and sizing. Surpris. they frequently have normal surgically. reserved for revisions or patients with ments has been very encouraging.75:498-507. der and elbow replacement are similar through the upper extremities far bet- mend reserving TEA for patients over to those seen following replacement of ter after joint replacement of the the age of 60. ated on initially. Involvement shoulder) because of arthritis in the Patients with rheumatoid arthritis lower extremities. major joints. is not a contraindication for joint. have been used for treatment of anky.9 rheumatoid arthritis are as good as ingly. although lesser age is each as an isolated joint. Simmons ED Jr. the joint that is more aids.6 The elbow becomes a true weight- ceps tendon. In fact. the contralateral elbow course. The results of bilateral or near-normal motion.Elbow Arthritis Fig. Custom arthroplasties gone surgery. it is preferable to first exhaust may require replacement. for these problems can be dealt with with the limb that has recently under- atively. those after single-joint replace- patient with a supracondylar however. J Bone Joint Surg Am 1993. (Reproduced with permission from Ewald FC. et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. Again.13 elbow or shoulder than before. the procedure). strength was greater in patients with this method has been disappointing pared for the appropriate compo. Others have suggested laxity. altered and more susceptible to vious incisions. it is also important for sta- eral arthrotomies as well as access to is for internal fixation of distal bility. Morrey et al have shown that the Vol 1. The origin of one ligament is axis of rotation of the prosthesis. Some prefer 2 to 4 weeks of immobilization postoperatively. Ewald et al11 strongly favor a with that of the elbow is important rior. each with its own specific advantages posterior triceps-splitting or triceps. mentioned unless there is significant explained on the basis of surgical ceps with use of the Bryan-Morrey laxity due to bone loss or soft-tissue approach (detachment and reattach- approach. Shawn W. tion of the prosthesis in alignment the posterior approach makes it supe. No 2. which must be properly the humeral component. sure. and the skin incision with pain relief. Exten- anterior approach to the knee. The canal is prepared using current standard cementing tech- niques. FRCS(C) along with release of any contrac- tures. early motion avoiding resisted extension is probably safe. still advocate a Kocher approach or a elbow against resistance for 6 weeks. This design has proved highly versatile and critical for stability of nonconstrained clinically successful. I start motion 36 hours after surgery and limit the patient only from actively extending the surgical approaches to the elbow. and cement is injected and pressurized. olecranon is never osteotomized as it devices. as modified by If a nonconstrained prosthesis is Morrey.13.14 Repair of the triceps is or more. due to a high nonunion rate. elbow via the deep portion of the The fine details of surgical tech. rheumatoid arthritis. Careful han. With nonconstrained mits posteromedial and posterolat. increased 90% in flexion and 60% to analogous to the “universal” straight ally transposed anteriorly as part of 70% in pronation-supination. With semiconstrained prostheses. A posteriorly placed (slightly modified Kocher approach for the for proper balancing of the muscle medial or lateral) skin incision per. ment of the triceps) and offset of the reflecting the triceps with a flake of served. dictable as that found after total hip The skin incision should not cross the tant considerations. and the bones are pre. devices. the ulnar nerve and the anterior humeral fractures. has a porous-mate. The moment arms. which might be accomplished by reflecting the tri. Positioning of the center of rota- and disadvantages. sion strength remained relatively Access to the elbow joint can be nism is reflected in one of the ways unchanged. It is therefore the nique will not be discussed here. the versatility of tongue approach with careful clo. Pain relief is dramatic and as pre- most useful approach for the elbow. This includes the and resist the posterior forces ulnar part of the lateral collateral lig- and torsional moments on ament. there are several impor. Fig. It is explored and retracted gently (usu. Nov/Dec 1993 113 . The ulnar nerve is Morrey et al15 showed that strength wound breakdown and infection. or knee replacement.16 bone from the tip of the olecranon. used. In such situations.15 At least tip of the olecranon in patients with dling of the skin and soft tissues is 90% of patients are highly satisfied olecranon bursitis or rheumatoid important.13. Results Kocher approach. in which case it can be pre. PhD. 8 Coonrad II elbow prosthesis. MD.10. 10. O’Driscoll.15 In a prospective study. Functional improve- arthritis. However. capitellocondylar prosthesis. ment is predictable following over the olecranon are pathologically mised region of skin created by pre. Some nents. Incorporation of the bone repaired to prevent posterolateral graft and cortical remodeling rotatory subluxation of the ulno- are expected in 80% of cases humeral joint. The triceps mecha. 6.15. TEA. in whom the soft tissues must not devascularize a compro.10. released. and proper soft-tissue balancing are under which a bone graft is placed to enhance fixation critical for stability. alignment of the components rial-coated anterior flange. the joint is subluxated or The percentage of improvement in but my personal experience with dislocated. A synovectomy is performed. These data are can exceed three times body weight. sue constraints might not maintain use since 1976. infection. close to the functional range.6 mal articular architecture to function replacement surgery in the past Gains in motion. dislocation. moments applied across the elbow of motion averaging 70 degrees of bility improves.6. time. loosen. Excellent TEA and must be reconstructed. impressive and indicates that the just semantically different from that bearing joint. 16 A Mayo- Two problems that thwarted early Ewald et al11 recently reported the modified Coonrad design with a progress in TEA were mechanical results with 202 capitellocondylar loose hinge (10 degrees of varus/val- loosening of constrained (hinged) prostheses after 2 to 15 years (mean. just as it was with this design lier years had diminished. and humeral prosthetic articular constrained designs. the soft-tissue constraints use for over a decade and has pre- is also possible in patients with com. and moments about the elbow directly to cases for loosening. component are posterior and rota. The early hinged improvement were excellent. The usefulness of the semicon- extension predispose to dislocation term success since 1974. however. the mini. the forces that cross it results do not deteriorate much with of a constrained hinge. mechanical (nonseptic) loosening postoperatively. permits some of the forces and tional arcs. achieved by most patients. with forces and rotational moments was design was a fully constrained pros. especially exten. thought to at least partially explain The principal moments (rotational Both potential problems. Until recently. the low rates of loosening observed forces and torques) about the humeral ing of the constrained-hinge type of clinically in the past decade. Also. tern and limited varus or valgus high. come by use of the semiconstrained at 7 years in 68 patients with rheuma- 114 Journal of the American Academy of Orthopaedic Surgeons . It was the authors’ impres.10. but still is in the range cate or subluxate. in laboratory studies. tion of a nearly normal kinematic pat- The failure rate was unacceptably sion that complications seen in ear. prosthesis and dislocation of the Morrey and Adams12 reported a tional. and triceps muscles permitted reproduc- the prosthesis-cement-bone interface. and results after fol- Use of the former permits complete joint stability. properly. resulted in transfer of all forces and tion was required in only 5% of the Loading of the biceps. the lax- pronation. This on a 100-point rating score.9.. low-up periods averaging up to 9 release of contracted soft tissues and Despite these problems. depend on the integrity of the nor. This problem will ity built into the sloppy hinge usually have less than these func. These forces can be considered nonconstrained type. gus and rotational laxity) and an designs and dislocation of noncon. They have been in minimally constrained prostheses. constrained design. patients of 5% to 20%.” so that they cannot dislo- degrees of supination to 50 degrees of recent reports. design. the soft-tis. dominated the field of elbow plete ankylosis of the elbow. 6 years). with immediate unrestricted motion mally constrained TEA prosthesis. years have been reported. and all appear constrained prostheses than with surfaces is not anatomic. Reopera. tested in cadaver elbows during sim- thesis that linked the ulnar and operatively and 91 postoperatively ulated active motion and with maxi- humeral components directly.12 tissue releases and unrestricted has been used with satisfactory long.13 These aver. This deflections. 95% Kaplan-Meier estimated survival in the design of a prosthesis. brachialis. those required to perform the rent dislocation or subluxation) of a is that the ulnar and humeral com- activities of daily living) are 30 to 130 nonconstrained elbow prosthesis ponents are linked by a “loose degrees of flexion and from 50 appears to have decreased in more hinge. The static (ligamentous) pronation-supination.14 The important on the role that they play in a non- degrees of pronation-supination. likely diminish as our understand. with preoperative ranges ing of the mechanism of elbow insta. to be successful. whereas such soft. we to be absorbed by the soft tissues flexion-extension and 90 degrees of were not aware of the fundamental around it. Before surgery. at least for the one concept in knee replacements. the concept is feasible and not monly referred to as a non-weight. rates of less than 5%. constraints thus theoretically take degrees of flexion-extension and 130 ates or dislocates. might be over. decreasing the “functional arcs of motion” are ament complex is violated during likelihood of loosening. posterolateral rotatory instability and dynamic (muscle) soft-tissue ages increase postoperatively to 100 pattern by which an elbow sublux. If the design of the ulnar decade. follow-up periods of 6 to 7 years. Pain relief and functional anterior flange to resist posterior strained designs. longest-used total elbow is extremely tested. This concept has been in clinical motion. are usually greater with semi. mum varus and valgus moments. The ulnar part of the lateral collateral lig. Thus. such as the capitellocondylar device. There are a number of semi- sion.e.Elbow Arthritis functional arcs of motion of the elbow The problem of instability (recur. 17 report from the originator of the type of semiconstrained prosthesis Although the elbow has been com. patients scoring an average of 26 pre. with average strained concept has been confirmed of surface-replacement prostheses.6 The concept of this design (i. Anderson TE: Elbow Results of reconstruction for failed total arthritis of the elbow: Treatment by arthroscopy in a mostly athletic popula. Elbow and Its Disorders. such as hydroxy. the more sympto. In general. The accuracy during insertion to avoid with this technique. loss of bone or liga. the literature osteoarthritis of the elbow needs might be no more common than on synovectomy antedates that on clarification. certain semiconstrained designs. O’Driscoll SW. The theo. toid arthritis. Ward WG. J Bone Joint Surg Br 1991. pp 120-130. Longer-term fol. There is contro. tion (preserving the epicondyles and matic joint is replaced first. Shawn W. MD. 4. Mow CS. in Morrey BF (ed): The Long-term results. et al: 7. cations. with some overlap. Generally. Adams RA. The role of biologic fixation using more popular in Europe than in ing the timing of shoulder and elbow a porous coating. North America. Morrey BF: Primary degenerative 3. However. where arthroplasties have not been Coonrad prosthesis. exposure than in any intrinsic similar to those for hip and knee The future of TEA is likely to beneficial effect. because of its low morbid- The most rapidly evolving aspects of ing design must be considered in ity. This will occur as our with nonconstrained ones. It Challenges low-up will resolve this matter. Nov/Dec 1993 115 . I currently favor reserving prosthesis. and there is no clear resolu- are indications for a semiconstrained versy regarding its success in the tion. Tulp NJA. 1990. They require more resection procedures with whom I have dis- low incidence of loosening will paral.74:409-413. usually be converted to a functional present time. 73:607-612. arthroplasty and is from centers skills and experience grow. J Bone Joint Surg Br of the elbow.18A:220-224. PhD. by arthro- elbow surgery relate to the use of light of the necessity for anatomic scopic synovectomy by those skilled arthroscopy and arthroplasty. FRCS(C) toid arthritis treated with a Mayo. The elbow does true for TEA. turally strong cancellous bone to fix olecranon) is a more conservative The indications for minimally to such a device. Bryan RS: Total 2. retical advantage of better preserva. ankylosis. advanced arthritis. to TEA. Surg Br 1992. the former is Controversy still remains regard. elbow arthroplasty. Morrey BF: Arthroscopy of the elbow in rheumatoid arthritis: replacement for post-traumatic arthritis of the elbow. References 1. Synovectomy continues to be resection arthroplasty after failure. The seems wise to offer a trial of isotope theoretical advantages of a resurfac. No 2. nor to support it operation that is readily converted constrained surface-replacement once it is firmly fixed. open techniques is still debated. of bone from the ulna and. mentous integrity. TEA can be recom. and used mainly for early stages of Both sides of this argument are the necessity of soft-tissue releases rheumatoid arthritis. hip. from the humerus than do of arthroplasty to be superior in after intermediate follow-up. Morrey BF. It is argued that resec- both. 2nd ed.71:664-666. J Hand Surg 1993. sound. as it has designs. Longer design is not necessarily true for Those surgeons skilled with both follow-up will determine whether the elbows. 1989. Winia WPCA: Synovectomy 6. Clin Orthop ulnohumeral arthroplasty. ratory and clinical research will be ter pain relief and function and can strained ones are not clear. while the opposite is replacement in a patient who requires apatite. Philadel. Whether it The role of radial-head replacement should be done by radioactive iso- in resurfacing designs has never tope injection or by arthroscopic or Controversies and Future been determined. The excellent clinical later stages of arthritis and the indi. if necessary. Further labo. resection as a salvage option. TEA in young patients with rheuma- the knee. arthroplasty. There were no tion of bone stock with a resurfacing commonly performed on the elbow. 5. At the necessary to determine this. moments that can lead to instability reside more in the degree of surgical term results (5 to 10 years) that are and/or loosening. include modifications to the current There is also controversy regard- mended with confidence to patients designs of both nonconstrained and ing the indications for resection or with the appropriate indications semiconstrained prostheses. followed. Finally. With medium. the role of arthroscopy in designs suggest that loosening ovectomy. Certainly. cases of mechanical loosening.253:123-132. is uncertain. not have a large surface of struc. 1993. results with semiconstrained cation for arthroplasty versus syn. The advantage indications are expanding for both unbalanced eccentric forces and of radial-head excision appears to of these procedures. O’Driscoll. Inglis AE. Morrey BF: Post-traumatic contracture Vol 1. in some cussed this tend to regard the results lel that in the hip and knee. Figgie MP. J Bone Joint tion. and shoulder). TEA provides bet- arthroplasties versus semicon. Each interposition arthroplasty versus (similar to those for arthroplasties of will likely continue to have its indi. injection. phia: WB Saunders. 72:601-618. Clin follow-up study. Figgie HE III. Ewald FC. of the ipsilateral shoulder and elbow in elbow arthroplasty. Morrey BF: Pos- 8. J Bone Joint Surg Br fracture of the humerus by total elbow Bone Joint Surg Am 1992. Friedman RJ.73:440-446. Ewald FC: Arthroplasty 17. Kudo H.71:1058-1065. 14. 1987. patients who have rheumatoid arth. An KN: Strength have rheumatoid arthritis: A long-term Long-term results. Askew LJ. Morrey BF. et al: 9. Morrey BF.74:479-490.Elbow Arthritis of the elbow: Operative treatment. Iwano K: Total elbow arthro. J Bone Joint Surg Am 10. 1990. Simmons ED Jr. An KN. et al: Current concepts review: Total ritis. J Bone Joint Surg Am function after elbow arthroplasty. J Bone Joint Surg Am 13. O’Driscoll SW.75:498-507.234:43-50. Korinek S. Goldberg VM.74:297-299. Figgie MP. Mow CS.69:523-532. J Bone Joint Surg Am 661-666. 12. et al: Sal. 1988. Morrey BF. 11. terolateral rotatory instability of the elbow. Inglis AE. strained arthroplasty for the treatment Kinematics of semi-constrained total vage of non-union of supracondylar of rheumatoid arthritis of the elbow. J elbow arthroplasty. arthroplasty. Bone Joint Surg Am 1990. J Bone Joint Surg Am 1993. Sullivan JA.69: including distraction arthroplasty. Bryan RS: Revision total 1989. Inglis AE. Bell DF.72:355-362. 1992. et al: Capitellocondylar total elbow J Bone Joint Surg Am 1991. Orthop 1988. O’Driscoll SW. J Bone Joint Surg Am 1987. Adams RA: Semicon. 16. 116 Journal of the American Academy of Orthopaedic Surgeons . J elbow arthroplasty. replacement prosthesis in patients who replacement in rheumatoid arthritis: 15.70:778-783. plasty with a non-constrained surface. JAAOS Home Page Table of Contents Search Help . JAAOS Home Page Table of Contents Search Help . and utilization patterns in medical simply defined as refined and lus for this major rethinking of the care. The problem is that we have no ticularly as it relates to orthopaedic information to prove the point. Maine Medical Assessment Foundation. they make it Dr. Germany. by using a clinical example. and deficiencies in the research product spent on health care in the literature. Clinical Research Methods In 1973 Wennberg and Gittel- What is outcomes research and sohn2 published their first article on why do we need to be concerned At the outset. marked varia. Keller. Patient. and guideline development. par. underlying the outcomes agenda. MD Abstract A new agenda in outcomes research has developed in the past decade. Additionally. Augusta. Me. They include need to rethink our current knowl. Factors in Rethinking Practice-Pattern Variations lying this concept will be clarified. patient-based outcomes as opposed to Several important factors have measures of process of care. small-area analysis. 1960 to 14. Completed large-database analyses.5% for tion studies. satisfaction. factors like pain. the United States spent 12.3% for Japan. care. and Associate Professor of Ortho- and quality of life. remains the basis of the concept. and a meta-analysis indicate the need for clinical studies. Box 4682. lus to more rigorous evaluation of research there is an important focus on stand and have relied on for so long. and 8% for of the form and content of such a study is presented. It seems clear that the dramatic Assessment Foundation. Keller. 18 Spruce Additional new methodologies. clinical practice. surgery. which provided a major stimu- enhanced clinical research. The stimu.2% of orthopaedics. indicate that our extra expenditures During the past 5 to 10 years a new small-area analysis. In 1990 (the most recent year ods.2% in bases. past 30 years is the major factor 122 Journal of the American Academy of Orthopaedic Surgeons . The Rising Costs of Health Care Reprint requests: Dr. To illustrate these applications in able). Dartmouth Medical School. In this clinical research methods we under. we need to understand the subject of variations in practice about it? Outcomes research can be the factors that have been the stimu. the methods under.1:122-129 of health status. 6. Outcomes research includes methods such as analysis of large data. such as life expectancy and infant mortality.” an important part of outcomes tures in the United States do not pro- The purpose of this article is to define assessment. function.1 Various broad measures J Am Acad Orthop Surg 1993. ily Medicine. Process measures information. but clinical research duce higher quality or more effective and describe this new concept. The percentage of gross domestic tions in utilization of health care services. developed in the past 15 or so years. Keller is Executive Director. United States has risen from 5. edge base and how we develop new Hanover. range of motion. The focus of this research is on patient-oriented outcomes of care rather than for which comparable data are avail- on assessments of the process of care. based outcomes are assessments that Singly and together. ME 04330. increase in health care costs over the Street. Outcomes Research in Orthopaedics Robert B. That is term has appeared in the medical and decision analysis. lus has come as the result of rapidly increasing health care costs. lumbar spine fusion with internal fixation for “spinal instability” its gross domestic product on health is presented as an example. produce no obvious benefit. Adjunct measure the results of care as they are clear that we who practice medicine Professor of Surgery and Community and Fam- perceived by patients. Worcester. prospec. such as large-database analysis. An outline Canada. small-area varia. appearance. pedic Surgery. and lab. Augusta. have become not to say that the increased expendi- vocabulary—“outcomes research. meta-analysis. compared with 8. structured literature reviews (meta-analysis). care. decision analysis.4% in 1992—the highest tive clinical trials. Clinical research percentage among the industrialized should be prospective and should employ modern statistical and assessment meth. nations. Maine Medical oratory results. NH. University of Massachusetts include such factors as radiographic Medical School. small-area important to note that all health care They have found significant prob.3 this method. information based in the scientific cal decision making. we would practice folk residents receive care. Ideally. states. and interpretation of articles is thus Literature low-up. comes of treatment were noted. For instance.7. arthroplasty. analysis. lateral rable data from a number of differ- receiving excessive care. If the high rate of With care. both analyzed the literature of hip of clinical guidelines.000 per analysis is not Vol 1. An important step in all research ments for factors such as age and ify for meta-analysis. and little or no evaluation of avoided. used independently. Meta.000 to $50.10 essentially few conditions that do not show erroneous statistical analysis. Keller. systems. Directly or indirectly. In recent years that fundamental Outcomes Research that there are marked differences in basis of knowledge and learning has Methodologies hospital admission and surgical rates come into question. one would carry out a utilization represents the “right ria to include other reports. tals at which the majority of local literature. data from many articles independent effort. The questions between small areas within states. board examinations are based prising that practice-pattern varia- sumption of health care services. Essentially every The second source comes from a meta-analysis is one method within other condition or procedure in the new technique of scientific literature outcomes research. about a subject up to the current not appropriate. In each analysis. lack of standardized definitions and data from different sources must be measures. but few of is the need to review what is known sex. inadequate and unclear fol. The prob. teach from them. Because meta-analysis is The major source of information patent-oriented outcomes of care. Literature Review that after careful statistical adjust. Gartland 4 and Gross 5 have decision analysis. If the low rate is several orthopaedic conditions. context involves a number of differ- significant differences between tain areas of the clinical literature ent methods—literature review. for analysis. lack of focus on patient-oriented out. In the large. but it does The consistent finding in these cally significant pool of information seem clear that all the rates cannot be reports has been the lack of random. First. variations. It is also regarding its quality and accuracy. these techniques may be ple trauma are examples of low-vari. Nov/Dec 1993 123 . then those above it are including hip fracture. students read deficiencies. ation conditions. almost all analysis have not been possible expressed the incidence of disease in knowledge in orthopaedics is based because the available literature is so terms of the rate of occurrence of a on information that has appeared in weak. Faulty research design. Without the core of which the clinician can rely in clini- graphic regions surrounding hospi. orthopaedics. and a all of these methods are utilized. Researchers and If the literature on which we so per 100. meta-analysis of the literature for rate. ($30. demon. the wide variations that exist are these have occurred in orthopaedics. It turned out. lems. them. There is simply not a firm They further refined the method by on them in their daily practice of knowledge and research base on developing “small areas. time consuming and expensive for clinicians is the published litera. poor descriptions of developed. regions. Outcomes research hopes to ized trials. large-database analysis. Hip fracture and multi. but this kind of specialty shows striking variations review known as meta-analysis. Research Teams studies.” then those below that level are analyses have been published for each and every project. strict correct. In analysis is often undertaken as an in hospital and surgical use rates. Ideally. No 2. some attempts at meta. and nations. regardless of their organiza. on them. Reader bias in selection Deficiencies in the Clinical patients. there are also authors have critically reviewed cer. and development tion or financing design. Outcomes research in its broadest one looks more widely. contrary to what one might think. of meta-analysis is to gather compa- correct.9 condition (the number of episodes journals and texts. epicondylitis. and those in practice rely tions exist. Wennberg investigators write them. only randomized trials qual. MD Epidemiologists have typically ture.6-9 to create a larger and more statisti- so-called right rate is. medicine. rules for inclusion and exclusion of answer this conundrum.11 The object being underserved.” geo. The conclusion reached by those are pooled to form a larger mass of who have carried out these studies is information for statistical analysis. and lumbar spine ent sources and combine those data lem is that we do not know what the fusion. it is perhaps not sur- ods to study the utilization or con. teachers heavily depend has such significant and Gittelsohn applied similar meth. strate this kind of variation. Robert B.000 population). prospective clinical trials. As come from two sources. Indeed. time. inadequate study design. one can broaden the crite. there are flaws in it. Each found significant federally funded Patient Outcomes Within orthopaedics. However. The more typi. As the results of improved information in them. Outcomes can be analysis may suffice. this step may not be randomize patients for many kinds of mate the likelihood of various treat- necessary or useful. Other claims databases data-collection instruments. It should be noted plan the study so that the hypothe. feedback. involve alternative forms of treat. complica. and the literature may be randomized clinical trials. Case-series reports (the A Clinical Case Example: Small-area analysis is of specific most common in the literature) pro. that can reasonably effectively con. clinical outcomes research become ditions they treat. shows wide variation in adapted from the business world. careful follow-up protocols for all Clinical Guidelines From these sources one can carry out patients. Recogniz. research. decisions are most critical in which may be subject to significant be tested. a comparison of surgery analysis. ologic subset of large-database ment (e. from perfect health to author picks and chooses which arti. It serves the another treatment. is sub. ment outcomes based on patients’ literature review” in which one there are several other study designs13 health states.12 assessment includes categories useful guidelines is the fact that None of these databases is per. lines. and valid instruments for the con. specific outcomes. I have cho- engaging practitioners in the process sen instrumented lumbar spine of analysis. such as satisfaction. ability of a given outcome. This is a relatively new concept technology. calcu. there is a health factors. analysts tion instruments are available to not been available. such as the It is most important to carefully where critical information is missing Medicare files. Decision error and may require great skill to investigators will design proper analysis provides a numerical prob- interpret. and applies many of the rules of meta. complications. and conduct proper statisti. The analysis may also point out large databases. Evalua.. into an algorithm or decision tree. or perhaps no research. and state-level hospital discharge late adequate sample size. (and research is needed) or which that these are primarily claims data. and Decision Analysis fusion because it represents a new change in practice patterns.” in which an studies should be avoided. This method utilizes analyses of can occur. One of the major mortality. inform the guideline process have and drawing conclusions. and quality of life. This implies that the influencing clinical results. condition). from records that were not set up for outcomes can help to determine the the purpose of a specific study. accurately measure many general deficiencies of clinical research also cise caution. in fact. Retrospective weighted according to their desir- cal “narrative review. extremely difficult to recover valid death). optional strategies that are most Large-Database Analysis Numerous methodologic problems likely to maximize good results.g. it would be helpful to use a important and useful purpose of treatment at all. Patient outcomes problems in developing valid and tions. However. they can be used to Small-Area Analysis Ideally. research can be translated into a With the development of several ducted prospectively. length of stay. available.Outcomes Research in Orthopaedics unusual). collect information rele. and reoperations. 14 It remains for the restrain the development of guide- tremendous amount of valuable specialties to develop standardized lines. and accurate outcomes information and the values assigned to various ject to significant bias. specific clinical example. and in carrying out analyses utility. function. trol for various biases. accurate information and data to fect. Lumbar Spine Fusion interest because it demonstrates to vide very biased information physicians (and others) that there because one never knows how To demonstrate the components and are significant inconsistencies in patients might have fared with methods involved in outcomes their practice patterns.g. plan data abstracts can also be useful. It is ability (e. ses one wishes to test will. Thus. and is a controversial Prospective Clinical Trials The statistical results of clinical procedure. outcomes research. pain. in that one needs to access and medical treatment for a given a large database to carry it out.. utilization. cal analyses. the must be experienced and must exer. Combining the probabilities cles to quote and emphasize. Guidelines are an important epidemiologic studies and limited vant to patient-oriented outcomes product that can be developed from outcomes analyses on factors such as of care. Clinical research should be con. outcomes studies should develop high-quality practice guide- This form of analysis is a method. A “structured medical and surgical treatments. ideally through series of probabilities and placed spinal fixation devices in the past 124 Journal of the American Academy of Orthopaedic Surgeons . so deficient as to defy a high-quality ing that it is not always possible to enabling one to numerically esti- meta-analysis. increased to 12. No 2. Each of these justify the increase in utilization? Fig. although additional clinical of the United States in the period 1988 to ing within it.15 It would appear that the Northeast. work condi. Rates of orthopaedists (and. 10 increase in utilization of the proce- dure has been driven in part by the Small-Area Analysis 5 availability of a new technology. Robert B. 2 Percentage of patients in the five this factor is often not the case for sion procedures was 5. areas contains at least one hospital mance of lumbar fusion per 100. 1 Average annual rates of perfor.6 (Fig. significantly higher (P<. Subspecialty orthopaedists are greater likelihood of spine fusion for located only in the areas with the Midwesterners than for residents of 20 highest fusion rates. There are fellowship-trained written communication. There is a strong growth or any known risk factors implication that there may be that might produce increased 15 14 15 overuse of the procedure in the Mid- Rate. The A study group of orthopaedic have been performed. the rate of lumbar the research process have already fusion across the region varies by a been undertaken. Deyo R: 17 tions. factor of 3.000 adults This clinical situation appears (age. 15 They indicate a 56% high. east. with two excep- the Northeast (Taylor V. it Washington reveals a variation of 5 is possible for spine surgeons to be 240% (Fig. While lumbar disk 1990.17 went fusion (unpublished data provided by geons have the greatest expertise in The only way that these variable Victoria M. These ous variable is the presence of spine- 1990 through analyses of the data do not indicate that any one of fellowship-trained surgeons in those National Center for Health Statistics these regional or state rates is prefer. injury. An analysis of 1990 ical centers located in Vermont and Percentage 11 fusion rates among residents of the 10 8 New Hampshire. Keller. west or underutilization in the cedure. However. Nov/Dec 1993 125 . New Hamp- patient outcomes in a way that can shire. sig. The 25 24 25 the so-called right rate. hospital complications for disk exci. there has been rapid growth able.1% when fusion was of Washington who underwent lumbar Fellowship-trained spine sur- spine procedures in 1990 who also under- combined with diskectomy.01) utiliza- Analyses of spine fusion rates tions. Taylor. this procedure. 3). service areas where the rates are database. The only obvi- determined for the years 1988 to tiveness of this procedure. The We have studied the utilization of question remains: Has the availabil. or other regions of the nation have been beliefs about the efficacy and effec. As with all more likely explanation relates to surgeons from the three states has elective surgical procedures. % patient need or demand for the pro. disease. none of them may be in the rates of lumbar fusion. Deyo et 0 high per capita rates of surgery for Spokane Snohomish Yakima King Pierce al16 determined that the rate of in. and has one or more orthopaedic ideally suited for outcomes research. lumbar fusion across the 72 hospital- 0 ity of this new technology improved Northeast West South Midwest service areas of Maine.4%. demographic factors. be difficult to defend all of them as dure has outpaced the population 20 being appropriate. In another analysis of busy in their subspecialty without the Washington database. explain the variations on the basis of spine fusion across the four major neurosurgeons) as they reflect their population. service areas in the three states have Large-Database Analysis ing spine pathology. and Vermont. several steps in three states. MD. Two clusters of were major differences in underly. 1). or perhaps both. but these tion rates than the rest of the region. But it would increased utilization of this proce. August 15 14 surgeons in the two academic med- 1993) (Fig. excision and cervical procedures more precisely the role of this proce. MD decade. and one would prop- rates would be reasonable is if there erly expect them to perform most of Vol 1.and sex-adjusted to the 1990 US popu. Indeed. Seattle). Fig. the differing practice styles of evaluated these data and cannot nificant variations are seen. which most highly populated counties in the state community-based surgeons. Because of the five largest counties in the state of 7 wide referral areas of these centers. lation) for the four large geographic regions surgeons or neurosurgeons practic- In fact. across large national regional areas differences were not identified. Fusion was performed 180% more fre- research is required to establish quently in the Midwest than in the North. the populations they treat. or injury rates. 2). vary only minimally among the dure in patient care. more recently. 0. ...... ..60 1.. to others. and Vermont (dotted bars)(* = P<.... .. one Patients who reside in service areas ness of treatment are even more must first develop a hypothesis. .....80 ... ever. .. 9%. . undergoing a fusion than those who likelihood of undergoing a lumbar However.... Only ations exist and how their practice gical treatment for “spinal instabil- when population-based rates are patterns compare with those of their ity” is an example...00. New Hampshire (hatched bars). meta-analytic techniques in their 1..S..10 1....60 1.. broadly applied at the community If the provision of this service were demic centers).. . ........ however. Their conclusions and rec- ... because the population served is questions can be asked about most gical rates across the region might be small (as in the northern New Eng. Cherkin DC.20 .. If the surgical practice patterns in the three states were similar...02 1... fusion as those in a community 20 evaluate alternative methods of It should be apparent that one can.90 0. evaluate different fixation devices of the procedure be calculated.50 pertaining to lumbar fusion revealed . miles away? Until these analyses are treatment. To frame a prospective study.08* 1.. undertaken and presented to physi.. ..40 sis of this literature has been pub- 1.40 1.30 1.. fairly level.. .. 1. .94 0.. .70 other published meta-analyses.. . the same them..20 0.10 found an average of 68% satisfactory .. 0. A surgeon doing a small or the technique being utilized for the outside the practice locations of the moderate number of procedures proper patients?) of lumbar fusion. it is always desirable to reside in adjacent service areas... ... they have no idea that the vari.. mented fusions. .. 16% to 95%). spine specialists were referred to might have a high per capita rate As should now be clear...40 0. .. 0. What our data demonstrate ses: which of these rates is the right Clinical Study is that fusion rates vary according to rate? With small-area analyses... One might wish to study a not draw conclusions from evaluat. Spine [in press]...09 .. . 126 Journal of the American Academy of Orthopaedic Surgeons .. Their . .. Why do residents of one would be difficult in one study to have a much greater likelihood of service area have over three times the evaluate all aspects of lumbar fusion.....01).00 Lumbar Disk Lumbar Fusion Cervical Disk results (range... orthopaedic procedures.. (Adapted with permission from Taylor VM.. ommendations are similar to those in 0.. consid...20 cal trials of the procedure..94 0. A applied to similar cohorts of patients given surgeon could perform a large Literature Review to learn whether some are preferable number of operations but provide a As with all investigations. one would anticipate that sur........20 1...14 1...70 . . and patients from areas true. 0... 0. The study also indicated similar cating no variation among the states.10 0. . 0.. Fusion or nonsur- by an individual practitioner...... treatment option. et al: Low back pain hospitalization: Recent U. how- where the experts are in practice... condition for which fusion may be a ing the volume of surgery performed cians. ulation being served (as in the aca.. Deyo RA.. That is because the uti.) The conclusion of this review is that better research is urgently needed on both the effectiveness (does the technology work when the fusion surgery in their hospitals.. . 3 Ratios of observed to expected rates for three commonly performed spine procedures rate of painful donor graft sites of for Maine (solid bars)..10 1....50 about the procedure. eration of outcomes research to hypotheses that can be generated.. It where spine surgeons are in practice compelling... A meta-analy- . . . .. 0. 1.. a pseudarthrosis rate of 14%. . They . One could also determined can the rate of utilization colleagues in the region.. .... ..... The converse is also level?) and the appropriateness (is consistent......40 0... ..30 lished. .... . lization of a service is counted back We are left with the same question to the area of residence of the raised by the large-database analy.....30 that there were no randomized clini- . . 0.. analysis of the available literature .. .60 . ... .... 0. There are numerous low rate of those services to the pop...50 1.8 The authors used standard Observed-Expected Ratio 1. there is a 360% greater utilization of mented as opposed to noninstru- fusion procedures in New Hampshire compared with Maine.. Designing a Prospective patient. 1.. .....00 review...00 0. land service areas noted).....30 ..... There are only minor differences in the utilization of clinical success rates for instru- lumbar diskectomy and cervical disk surgery.... 1.43* . 0. . . . 0. the ratios would be 1..89 0. the questions of appropriate.....90 .50 ... 0... ... indi..Outcomes Research in Orthopaedics study lumbar fusion should be based on what the literature can tell us ..80 0.56* 1...60 0.... . .. trends and regional variations.00 .. and a Fig. One will difficult in most clinical situations methodologists play an important need the support of a research because physicians and patients role in developing and testing patient methodologist. While alternating is not a patients. Survey benefit of a team approach. but they plines is clear. patients who elect to undergo is ample evidence that good clinical Assume that we wish to study the spine fusion are enrolled in the sur. culate the number of patients ent procedures. Process mea- instability. patients and function. statistical deficiencies in 54% of to randomize the physician rather There should be an emphasis on studies and questionable conclu. both process treated nonoperatively. In some situations. At that point.19-22 group. and quality of life. In addition. but this pattern of broad of patients with spinal instability deficiencies in current publications is dissemination and utilization of new secondary to degenerative spondy. even if an article contains required to measure meaningful dif. and may have distinct preferences for a questionnaires. if any. colleagues such as health study. than the patient. one must decide how to impossible. Clinicians are criti. Clinicians generally know answered. outcomes can occur despite failed outcomes of spine fusion for spinal gical cohort and those being treated fusion. sions based on misleading sig. it may be possible to stratify there are few. and outcome need to be evaluated. degree of satisfaction and quality of may be required. order to get the information they seek. studies. life is more relevant to patients than cal to the research. True randomization is about the results of their care. As mining the kinds of information to conducted prior to the wide dissem. analysts will be are various radiographic criteria. The economists. the deficiency of the current litera. the study. known as power analysis.13 In that situation patient-oriented outcomes of care. sions in the usual way. One of the great technology. and we wish to compare nonoperatively are entered in the sures such as strength and range of patients who undergo fusion for this other cohort. it is difficult to ferences in outcome—an exercise different in their presenting condi. Often. Others advocate intraoperative which treatment is better. If physicians and patients able to make this important determi. measurements 23 or physical mea- Vol 1. evidence of fusion. and others physicians arrive at treatment deci. that the correct information is not technologies is very common. all investigators have agreed to use. which are felt to be of variable valid- were completely uncertain about nation and indicate which set of ity. the two groups may be sufficiently valid information. and vice versa. Certainly. undergone spine surgery in order to methods in the spine literature noted An alternative method would be learn what their concerns are. sociologists. No 2. They may need to perhaps a survey methodologist and specific treatment and might there. apply the treatments they prefer. Thus. interview focus groups of patients an epidemiologist. there alone. Herkowitz and Kurz18 collect. In the case of spinal insta. have a solid spine fusion. Data are collected motion may not be related to out- diagnosis with a group who are prospectively from both groups. The first By carefully collecting patient. Some of this may be obvious. mented fusion group or a nonfusion what they would like to learn from It is important to emphasize at group. There select the patients for each treatment carefully collected. One of the reasons for study does demonstrate the impor. clinicians may not know ture is that many research efforts uating patients undergoing different what is really important to patients have been carried out without the treatments. who have the condition or who have of methodologies and statistical ization. step is to find out how many patients specific information in a cohort An additional problem is that are required in each treatment arm. patients are not partic- nificance testing in 46%.17 The need assigned to surgeons. comes measures. ination of spinal instrumentation have carried out a prospective study but much is not. If appropriate data are definition of spinal instability. For more complex Another design is the cohort are interested in factors such as pain. Nov/Dec 1993 127 . tions that comparisons become there is no broadly accepted Next. contrast the outcomes of the differ. and lolisthesis. For example. MD One can make the case that these be possible to randomize patients Of greatest importance is deter- kinds of studies should have been into different treatment groups. a biostatistician. but they frequently do not this point that outcomes research is a pure form of randomization. who would ularly interested in whether they for expert support in these disci. patients would be randomly For example. this have the skill to frame questions in team effort. standardized That will require the assistance of a reasonable comparison groups to definitions and measurements that research methodologist who can cal. A recent review fore be uncomfortable with random. Alternating patients were solicited from patients at the time of the questions still need to be assigned prospectively to an instru. tant principle of prospectively eval. Keller. compare with others. study. it would analyses is possible. In this concept. an example. Robert B. but they cannot patients are enrolled in a prospective is range of motion or radiographic design and carry out these studies protocol. bility. patients are lost to follow-up. patients. but clinically meaningless information. The differ- accepted. Careful statistical analysis is put policy makers. cedure and justify to payers and collect very specific information patient-group selection process. very difficult to draw proper conclu. investigator be sure that all essential Conclusions one must then proceed to assess information is collected. analyses utilized in the study must tures. there is North American Spine Society has comes projects. in considering research isons of various treatments and con. two difficult to undertake. implant failures.Outcomes Research in Orthopaedics sures.” naire. and uncertain surgical and medical complications. that patients whether lumbar fusion produces a are appropriately categorized. In formulating a research ied. one must attempt to on fusion for spinal instability. The performing data analyses in out. Given modern statisti. independently conduct the various “spinal instability. It is been able to describe many of the approaches. the research effort becomes most sions. and complicated surgery for evaluate the outcomes of lumbar obtain statistically significant but spinal instability is cost effective and surgery in a consistent manner. 24 The point is that none of very important to attempt to follow methodologies of this discipline as these measures has been broadly up all patients. At present. graphic or imaging evidence of tance in designing and implement. Thus. and there are no be required by specific outcomes high-quality statistical analysis accurate data about patient out- projects. care. really makes patients better. no agreement on how to define and supported the development of a icians have the expertise to measure the condition referred to as patient-oriented outcomes question. replication of the results. might be more revealing. follow-up. research as we know it. This single step would the outcomes of spine surgery is that research methodologies and a focus improve the quality of all reports and long follow-up is necessary. we will no longer pay for it. cannot. broadly in favor of those who do poorly. Only in this manner can the ity. determine whether the entity that instruments whenever they are ing methods will permit comparison appears to demonstrate radio- available and to obtain expert assis. cal techniques. and patients the significant expendi- (e. Those comparing the out. One of the problems in analyzing ences relate primarily to improved ments. a critical step.. ologies and aggregation of data instability is in fact correlated with a ing new measures when necessary. it may be possible to erful argument: “Demonstrate to us tors will shortly have available at least carry out manipulations such as that this highly variable.18 Relatively few clin. we One of the urgent needs in out. Having accomplished that task. the results will be biased markedly different from clinical quality. we have might result from other treatment time intervals for every patient. complications. Its broad adoption and use analyses and statistical significance The issues discussed in this article across many clinical investigations testing. it is orthopaedic condition and surgical not define the condition being stud. of different techniques and method. this issue is being carry out long-term studies. fusion rates. First. While on patient-oriented outcomes of make possible meaningful compar. investiga. ous intervals. How can we presume to comes of fusion and nonoperative Finally. Conversely. The important thing is to uti. standardized. other symptoms. procedure. measurable clinical presentation of Prospective collection of data is pain. spinal instability is. validated survey instru. and disabil- essential. across reports. payers in a position to make a pow- comes information. If one can. clinically important dif. if a large number approach to this clinical entity. 128 Journal of the American Academy of Orthopaedic Surgeons . Second. At the outset. of patients with excellent results aspects have become clear. and In considering outcomes research as better outcome for patients than that data are collected at consistent applied to spinal instability. we ditions. from spine fusion fail to return for can see that outcomes research is not comes research is the creation of high. very expen- some of the instruments they need to multiple regression analysis and sive. For instance. we cannot agree on what ized measures.g. Common form careful studies and analyses to lize tested and broadly accepted definitions and standardized report. and drug reactions) clearly understand and extract the of major surgery? that might not be part of another material. information can be reported at vari. when information is know who should undergo this pro- treatment for instability will need to reported.” Even with adoption of standard. If you much work remains to be done. and will provide a common set of out. In part. be clearly stated so that readers can outcomes associated with this kind reoperations. find that there are major hurdles to addressed in the field of low back Expert assistance is required in overcome before one can even begin pain and lumbar spine surgery. and perhaps even attempt It thus seems imperative to per- study. ferences might be overlooked if sta. comes. the research methods. such an effort. If a number of they might apply to a specific accepted and validated. additional data will tistical significance is lacking. Education. ture. Spine 1992. Lu-Yao GL. the use of hospitals: The experience of Research. et 14. Rudicel S. et al: ment effectiveness research. et al: Use J Bone Joint Surg Am 1991. 67:1284-1293. Harada T. Surgery for lumbar spinal stenosis: 17.70: health care outcomes: Mortality and al: Radiologic diagnosis of degenerative 1357-1364.74: Means. gies used in clinical studies of hip-joint 13. Herkowitz HN. dence of appropriate statistical testing ence 1973. 10. Ersek M. No 2.107:224-233. research: Deficiencies in experimental 12. Frymoyer JW: Segmental 6. Liang MH. Office. Acknowledgments: The author gratefully No. script and in providing spine surgery data. Wennberg JE.73:802-808. Keller R. diagnosis. et 2. Surg Br 1992. Guibert R. publication WMCP:103-4. Taylor VM. J Bone Joint Surg Am 1988. 21. et al: Lack Low back pain hospitalization: Recent the lumbar spine. Turner JA. et al: flexion-extension roentgenograms of 7. Kurz LT: Degenerative the Maine Medical Assessment Founda. Hosono N. is for orthopaedic surgeons to Taylor. Spine 1987. Ersek M. it should be clear that car. 15.72:1286-1293. Larson MG: motion and instability. Herron L. AHCPR Program Note: Medical treat. et published reports. Cassidy JD.28:632-642.17:1-8. Keller. of scientific evidence for the treatment U. 18. Spine 5. Soule DN. Spine 1992. et al: spinal instability. trends and regional variations. 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US Government Printing 9. J Bone Joint Surg Am 1992. Loeser JD.16:943-950. Wennberg JE. MPH. Stokes AF. neck fractures: A meta-analysis of 106 instruments for orthopedic evaluation. References 1. Lorenz MA. Gartland JJ: Orthopaedic clinical Intern Med 1987. Labelle H. MPH. Rockville. HS 06813 (Outcomes Dissemination: The natives to conducting this kind of acknowledges the advice and assistance of Maine Study Group Model) from the Agency investigation. March 1990. Intraoperative measurement of lumbar attempted meta-analysis. MD. and pro- DC: House Committee on Ways and fusions. Deyo RA. Ann ing decompression with decompression 4. Washington. et al: with operations on the lumbar spine: Spine 1985. Yong-Hing K.74:646-651. Vol 1.268:907-911. Sci. Supported by grant No. Spine 1991. clinical trial in orthopaedics: Obligation dynamic approach by traction-compres- language orthopaedic literature. JAMA 1987. and intertransverse process arthrodesis. 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