Lateral and Medial Epicondylitis of the Elbow

Frank W. Jobe, MD, and Michael G. Ciccotti, MD

Abstract

Epicondylitis of the elbow involves pathologic alteration in the musculotendi- lateral collateral and annular liga-
nous origins at the lateral or medial epicondyle. Although commonly referred ments, the investing fascia, and the
to as “tennis elbow” when it occurs laterally and “golfer’s elbow” when it intermuscular septum.
occurs medially, the condition may in fact be caused by a variety of sports and
occupational activities. The accurate diagnosis of these entities requires a thor- Biomechanics
ough understanding of the anatomic, epidemiologic, and pathophysiologic fac- The normal biomechanics of the
tors. Nonoperative treatment should be tried first in all patients, beginning lateral epicondylar structures dur-
with an initial phase of rest, ice, nonsteroidal anti-inflammatory agents, and ing sport have been most thoroughly
possibly corticosteroid injection. A second phase includes coordinated rehabil- described for tennis. Morris and
itation, consisting of range-of-motion and strengthening exercises and coun- associates 1 evaluated the muscle
terforce bracing, as well as technique enhancement and equipment activity about the elbow during ten-
modification if a sport or occupation is causative. Nonoperative treatment has nis strokes in healthy professional
been deemed highly successful, yet the few prospective reports available sug- and collegiate players using an elec-
gest that symptoms frequently persist or recur. Operative treatment is indi- tromyographic (EMG) technique.
cated for debilitating pain that is diagnosed after the exclusion of other The greatest muscle activity during
pathologic causes for pain and that persists in spite of a well-managed nonop- the groundstrokes was noted in
erative regimen spanning a minimum of 6 months. The surgical technique those muscles stabilizing the wrist,
involves excision of the pathologic portion of the tendon, repair of the result- specifically, the extensor carpi radi-
ing defect, and reattachment of the origin to the lateral or medial epicondyle. alis brevis, the extensor carpi radi-
Surgical treatment results in a high degree of subjective relief, although objec- alis longus, and the extensor
tive strength deficits may persist. digitorum communis. The extensor
J Am Acad Orthop Surg 1994;2:1-8 carpi radialis brevis was noted to
have the greatest activity of all mus-
cles tested; this occurred during the
acceleration and early follow-
through phases. The authors sug-
gested that these muscles provide
In an austere letter published in Lateral Epicondylitis optimal stability for these phases of
Lancet in 1882, Henry J. Morris intro-
duced a previously undescribed Anatomy
entity, which he aptly termed “lawn The musculotendinous structures Dr. Jobe is Clinical Professor, Department of
tennis arm.” From that seminal about the lateral epicondyle of the Orthopaedics, University of Southern California
description has evolved a vast array elbow are those of the common School of Medicine, Los Angeles. Dr. Ciccotti is
of detailed diagnostic and therapeu- extensor origin, including the exten- Assistant Clinical Professor, Department of
Orthopaedic Surgery, Rothman Institute,
tic treatises on epicondylitis of the sor carpi radialis longus, the exten-
Thomas Jefferson University Hospital, Philadel-
elbow. Morris focused on medial sor carpi radialis brevis, the extensor phia.
epicondylitis as caused by the lawn- digitorum communis, and the exten-
tennis backstroke, but subsequent sor carpi ulnaris. The extensor bre- Reprint requests: Dr. Ciccotti, Department of
works have greatly expanded both vis, which is most commonly Orthopaedic Surgery, Thomas Jefferson Univer-
sity Hospital, Rothman Institute, 800 Spruce
the location and the etiology of this involved in lateral epicondylitis, lies
Street, Philadelphia, PA 19107.
malady. Today, both medial and lat- beneath the extensor longus. The
eral epicondylitis are associated complex origin of the extensor bre- Copyright 1994 by the American Academy of
with a variety of sports activities and vis includes the common extensor Orthopaedic Surgeons.
occupations. tendon at the lateral epicondyle, the

Vol 2, No 1, Jan/Feb 1994 1

Lateral and Medial Epicondylitis of the Elbow
the groundstroke by maintaining the
position of the wrist in extension and
radial deviation.
Epidemiology and Etiology
Lateral epicondylitis typically
occurs in the fourth and fifth
decades, 2 although it has been
identified in patients ranging in age
from 12 to 80 years. The male and
female prevalence rates appear
equal. 3 Seventy-five percent of
patients experience symptoms in
their dominant arm. Morris’ initial
implication of racket sports as the
primary cause of epicondylitis led to
a plethora of works reviewing the
possible epidemiologic and etiologic
factors in tennis. It is estimated that
10% to 50% of persons who play ten-
nis regularly will experience symp-
toms of tennis elbow at some point
during their careers. In 1979 Gru-
chow and Pelletier3 noted an associ-
ation between playing time and the
incidence of tennis elbow in club
players. The risk of developing
symptoms consistent with tennis
elbow was 2.0 to 3.5 times greater in
players with over 2 hours of racket
time per week than in those who
played tennis less than 2 hours per
week. Compared with younger
players, male and female players
over the age of 40 years had a four-
fold and twofold greater incidence
of tennis elbow, respectively.
Several specific technique, equip-
ment, and playing surface factors
have been implicated in the develop-
ment of lateral epicondylitis. A higher
incidence of poor stroke mechanics,
such as leading with a flexed elbow
and striking the ball off center on the
racket, has been identified in affected
players. Improper grip size, racket
weight, and racket stringing generate
higher loads in the lateral muscle-ten-
don unit. Also, harder court surfaces
impart greater momentum to the ball
and subsequently increase the force
transmitted through the racket to the
extensor mass.
2 Journal of the American Academy of Orthopaedic Surgeons
Numerous other sports and occu-
pational activities that require force-
ful or repetitive forearm use have
also led to lateral epicondylitis 2
(Table 1).
Pathophysiology
A wide spectrum of theories on
the pathophysiology of lateral
epicondylitis have been pro-
posed. In 1922 Osgood suggested
that inflammation of an extra-articu-
lar radial humeral bursa was the pri-
mary cause. An inflamed synovial
fringe was described by Trethowan
in 1929. Fibrositis of the annular lig-
ament resulting from trauma was
championed by Bosworth4 in 1955.
Traumatic periostitis of the extensor
carpi brevis from repeated wrist
extension and forearm supination
was advocated by Garden5 in 1961.
Radial nerve entrapment was sug-
gested by Kaplan 6 in 1959, while
chondromalacia of the radiocapitel-
lar joint was proposed by Newman
and Goodfellow7 in 1975.
The current consensus based on
clinical and surgical evidence sug-
gests that lateral epicondylitis is ini-
tiated as a microtear, most often
within the origin of the extensor
carpi radialis brevis. This process
may originate in the extensor
digitorum communis or extensor
carpi radialis longus tendon as well.
The affected tendon usually contains
Table 1
Common Activities Leading to Epicondylitis
Lateral
Recreational Tennis (groundstrokes)
Racquetball
Squash
Fencing
Occupational Meat cutting
Plumbing
Painting
Raking
Weaving
grayish, homogeneous, edematous,
friable tissue. Tendon fibers may
appear fibrillated, with an apparent
sinus tract extending from the elbow
joint. In the series of 88 surgically
treated elbows reported by Nirschl
and Pettrone, 2 97% demonstrated
varying amounts of this gross patho-
logic tissue at the origin of the exten-
sor carpi radialis brevis tendon. Of
those elbows with macroscopic
pathologic tissue within the extensor
carpi radialis brevis, 35% also
demonstrated gross tendon rupture.
Nirschl has described a characteris-
tic microscopic appearance of
“angiofibroblastic hyperplasia” of
the involved tissue. The normal par-
allel orientation of collagen fibers is
disrupted by an invasion of fibro-
blasts and vascular granulation-like
tissue without an acute or chronic
inflammatory component.
Diagnosis
Lateral epicondylitis is character-
ized by pain at the lateral epi-
condyle, which often radiates into
the forearm and is typically insidi-
ous in its onset. A history of repeti-
tive activity or overuse can often be
elicited.
Examination reveals tenderness
over the conjoined tendon origin,
usually localized to the extensor
carpi radialis brevis portion. The
area of maximal tenderness lies 2 to
Medial
Golf
Rowing
Baseball (pitching)
Javelin throwing
Tennis (serving)
Bricklaying
Hammering
Typing
Textile production

5 mm distal and anterior to the mid-
point of the lateral epicondyle.
Resisted wrist and finger extension
with the elbow in full extension will
intensify the pain. Range of motion
of the elbow and wrist is usually
complete. Sensation is typically nor-
mal in the extremity, but wrist exten-
sor weakness secondary to pain may
be detected.
Radiographs of the affected
elbow are usually normal, but 22%
to 25% of patients may have
calcification within the soft tissues
about the lateral epicondyle.2 The
calcification appears to have no
prognostic implications and may
disappear after treatment.
A thorough evaluation of the
neck and entire upper extremity is
prudent in patients with lateral
elbow pain. The differential diagno-
sis includes cervical disease with
radiculopathy, radial nerve com-
pression at the elbow, and intra-
articular elbow disease, such as
arthritis or osteocartilaginous loose
bodies. If the diagnosis is in doubt,
cervical spine radiographs, electro-
diagnostic studies analyzing in par-
ticular the posterior interosseous
nerve, and detailed imaging of the
intra-articular anatomy of the elbow
may be necessary.
Nonsurgical Treatment
The volumes of orthopaedic litera-
ture addressing lateral elbow epi-
condylitis illustrate the success of
nonoperative treatment for this
entity. The common objectives of all
conservative measures are relief of the
pain and reduction of inflammation
followed by guided rehabilitation.
Relief of pain and inflammation is
the primary goal of the first phase of
nonsurgical treatment. Cessation of
the offending activity is required ini-
tially, but complete inactivity or
immobilization is avoided as this
may lead to disuse atrophy, which
compromises later rehabilitation. Ice
is recommended for its local vaso-
Vol 2, No 1, Jan/Feb 1994
Frank W. Jobe, MD, and Michael G. Ciccotti, MD
constrictive and analgesic effects. An
oral anti-inflammatory medication
should be administered for a 10- to
14-day period if the patient has no
medical contraindication to use of
such a drug. Those patients who
demonstrate some improvement
without complete relief may require
a second course of medication after a
brief period of abstinence.
If the patient does not respond to
these initial therapeutic measures, a
corticosteroid injection should be
considered. The choice and dose of
steroid preparation has remained
arbitrary, however, since carefully
controlled prospective comparisons
of commonly used agents have not
been done.8 Care should be taken to
instill the mixture deep to the exten-
sor carpi radialis brevis, anterior and
distal to the lateral epicondyle, into
the fatty subaponeurotic recess.
Injection of the mixture superficially
may result in subcutaneous atrophy,
while intratendinous injection may
lead to adverse permanent changes
within the tendon ultrastructure.
Several short-term studies have
evaluated the use of steroid injec-
tions. Pain relief was observed in
55% to 89% of patients, but recur-
rence of symptoms was noted in 18%
to 54% of those patients who initially
experienced relief.8
The physical therapy modalities
of ultrasound and high-voltage gal-
vanic stimulation have been used
with variable success. However,
there are no prospective, random-
ized, controlled studies to demon-
strate their efficacy.
Upon relief of initial pain and
inflammation, the second phase of
nonsurgical treatment is begun. This
phase emphasizes continued tissue
healing through avoidance of the
abusive aspects of the causative
activity and guided rehabilitation. If
the patient uses aberrant techniques
in sports or occupational activities,
these should be identified and cor-
rected. For example, in tennis, the
forehand stroke should allow the
player to hit the ball in front of the
body with the wrist and elbow
extended. This allows the torso and
upper arm to provide most of the
stroke power, rather than the wrist
extensors solely. The two-handed
backhand stroke allows a distribu-
tion of force between the upper
extremities, and thus greatly dimin-
ishes force at the leading lateral epi-
condyle.
Proper equipment, especially in
the racket sports, is essential to pre-
venting lateral epicondylitis. Proper
racket grip size is assessed by mea-
suring from the proximal palmar
crease to the tip of the ring finger,
along its radial border. Lighter rack-
ets, though providing less momen-
tum, allow ease of positioning for
impact. Frames of low-vibration
materials, such as graphite and
epoxies, dampen impact forces
imparted to the extensor origin.
Using rackets that are less tightly
strung or that have a higher string
count per unit area and playing on
“slower” surfaces, such as clay
courts, will diminish the loads trans-
mitted to the elbow.
Counterforce bracing was intro-
duced by Ilfeld in 1965. Theoreti-
cally, this type of brace inhibits full
muscular expansion and thus
decreases the force experienced by
sensitive or injured muscular tissue
proximal to the band. Groppel and
Nirschl9 demonstrated with three-
dimensional cinematography and
surface electromyography that
lower extensor muscle activity was
produced by the use of counterforce
bracing during the tennis serve and
one-handed backhand. Snyder-
Mackler and Epler,10 employing the
more sensitive indwelling EMG
technique, noted significantly
reduced muscle activity in the exten-
sor carpi radialis brevis and extensor
digitorum communis of healthy sub-
jects during maximum voluntary
isometric contraction while using an
3
Lateral and Medial Epicondylitis of the Elbow
air-bladder type of counterforce
brace. Counterforce bracing may be
used during the early rehabilitation
period; if pain recurs, the first-phase
treatments may be reinitiated.
The rehabilitative program
begins with wrist extensor stretch-
ing and progressive isometric exer-
cises. Initially, these exercises may
be done with the elbow flexed to
minimize the pain; then, as the
symptoms allow, the exercises are
done with the elbow in full exten-
sion. As strength, endurance, and
flexibility improve, eccentric and
concentric resistive exercises are
performed. When the patient is
capable of sprint repetitions to
fatigue without significant elbow
symptoms, a sport or job simulation
is staged. If it is successfully com-
pleted, the patient is encouraged to
return to normal activity and to
gradually increase the duration and
intensity of exposure.
Although most authors report
that the majority of patients with
lateral epicondylitis respond to
nonoperative care, there are few
studies on the long-term outcome
of nonsurgical treatment. The
available literature suggests that
5% to 15% of patients will suffer a
recurrence of symptoms, but the
majority of these patients with
relapses will not have been fully
rehabilitated or will have prema-
turely discontinued preventive
measures. In a prospective review
of nonoperative treatment, Binder
and Hazleman11 noted that 26% of
patients had a recurrence of symp-
toms and over 40% had prolonged
minor discomfort. The previously
documented rates of 85% to 90% for
successful nonoperative treatment
may be somewhat optimistic, and
persistent or recurrent symptoms
may occur more frequently than
has been reported in the past. How-
ever, most clinical reports agree
that nonoperative management
remains the mainstay of treatment
4 Journal of the American Academy of Orthopaedic Surgeons
for lateral epicondylitis and that
surgical treatment is infrequently
necessary.
Surgical Treatment
The indications for surgical treat-
ment of lateral epicondylitis include
persistent debilitating pain at the lat-
eral epicondyle unresponsive to a
well-managed nonoperative pro-
gram spanning a minimum of 6 to 12
months, after the exclusion of other
pathologic causes for the pain.
The history of surgical treatment
for lateral epicondylitis spans
nearly three quarters of a century
and includes a host of techniques of
varying popularity. In general, four
main approaches have been
employed: (1) extra-articular proce-
dures that involve the common
extensor origin; (2) intra-articular
procedures that excise the synovial
fringe and a portion of the orbicular
ligament; (3) extra-articular proce-
dures that lengthen the extensor
carpi radialis brevis tendon dis-
tally; and (4) extra-articular proce-
dures that excise the pathologic
tendon and then reattach the ori-
gin.
Hohmann initiated the surgical
treatment of tennis elbow in 1926
when he described release of the
extensor aponeurosis at the level of
the lateral epicondyle. Modifications
of this extra-articular, tension-reliev-
ing technique have ranged from
open fasciotomy to percutaneous
release and even epicondylectomy.
Although proponents of these tech-
niques suggest that proximal release
reduces tension at the extensor ten-
don origin with low morbidity and
rapid recovery, there remains con-
cern about persistent postoperative
strength deficits, especially in ath-
letes and laborers.
In 1955 Bosworth 4 reported on
several variations of an intra-articu-
lar technique that included a release
of the orbicular ligament at the
radial head. The author proclaimed
this technique “curative,” most
probably due to the inadvertent
debridement or removal of the
extensor brevis origin that accompa-
nied annular ligament resection. The
current consensus on the extensor
origin as the primary site of patho-
logic changes in lateral epicondylitis
has led to the conclusion that annu-
lar ligament resection is unneces-
sary.
In 1961 Garden 5 presented an
alternate extra-articular method of
reducing tension at the extensor carpi
radialis brevis origin by open Z-
plasty lengthening at its distal mus-
culotendinous junction. Although
Garden’s success rate approached
100%, other authors reporting on this
technique have been unable to dupli-
cate those results. In fact, subsequent
reports have noted persistent pain or
recurrence in up to 80% of patients
treated in this manner.
We advocate an extra-articular
technique wherein the pathologic
portion of the extensor tendon origin
is excised, the defect is repaired, and
the origin is reattached to the epi-
condyle.
Technique
With the patient supine and the
arm supported by an arm board, a
tourniquet is applied to the upper
arm. An 8- to 10-cm incision cen-
tered over the lateral epicondyle is
created (Fig. 1, A). The deep ante-
brachial fascia is incised over the
lateral epicondyle and continued
distally toward the radiocapitellar
articulation. The common extensor
tendon is then sharply detached
subperiosteally from the epi-
condyle and reflected distally to
expose the lateral compartment of
the elbow (Fig. 1, B). The undersur-
face of the extensor mechanism is
inspected for granulation tissue or
tears. The degenerated portion of
the tendon, including any granula-
tion tissue and fibrillated edges, is
sharply excised (Fig. 1, C). Decorti-
 Frank W. Jobe, MD, and Michael G. Ciccotti, MD

A B

C D E

F G

Fig. 1 Technique for surgical treatment of lateral epicondylitis. A, Skin incision over the lateral epicondyle. B, Distal reflection of the exten-
sor mechanism exposing the lateral compartment of the elbow. C, Excision of pathologic tissue from the underside of the extensor mecha-
nism. D, Decortication of the lateral epicondyle. E, Drilling of two V-shaped tunnels within the lateral epicondyle. F, Reattachment of the
extensor mechanism to the lateral epicondyle. G, Side-to-side repair of the extensor tendon mechanism.

cation of the lateral epicondyle is
then performed with a rongeur to
provide a bleeding surface for
extensor reattachment (Fig. 1, D).
A 5⁄64-inch drill is used to create
two parallel V-shaped tunnels
directed anteroposteriorly in the lat-
eral epicondyle (Fig. 1, E). A heavy
suture is passed from posterior to
anterior through the proximal tun-
nel, then through the extensor origin
in a horizontal mattress fashion, and
finally back from anterior to poste-
rior through the distal tunnel (Fig. 1,
F). A side-to-side repair of the exten-
sor mechanism is completed with
simple interrupted absorbable
sutures (Fig. 1, G).
After closure of the subcutaneous
tissues and the skin, a molded poste-
rior plaster splint is applied. The
splint is maintained for 7 to 10 days.
The patient then begins a progressive
mobilization program, including
gentle passive and active elbow,
wrist, and hand motion. Light
resisted isometric exercises are
begun by 4 weeks and progressive
strengthening by 6 weeks. Return to
lifting activities or athletics is usually
permissible by the third or fourth
month.
Results
Eighty-five percent to 90% of
patients who undergo such an
extra-articular extensor debride-
ment and repair technique return
to full activity without pain.
Approximately 10% to 12%, how-
ever, are noted to have improve-
ment but with some pain during
aggressive activity. 2 In approxi-
mately 2% to 3% no appreciable
improvement is obtained.2 In those

Vol 2, No 1, Jan/Feb 1994 5

Lateral and Medial Epicondylitis of the Elbow
patients with persistent symptoms,
the other previously mentioned
causes of lateral elbow pain should
be pursued again.
We have reported our experience
at the Kerlan-Jobe Orthopaedic
Clinic, 12 where 1,140 of 1,200
patients (95%) in whom lateral epi-
condylitis was diagnosed over a 10-
year period have been successfully
treated with nonoperative mea-
sures. Sixty patients (5%) were
unresponsive to nonoperative treat-
ment and subsequently underwent
extensor debridement and repair.
Thirty-nine of these patients (65%)
were seen 2.5 to 10 years after the
procedure. Ninety-four percent of
the patients reported drama-
tic improvement in symptoms.
The objective outcome measures
showed that 36% had limitations
with heavy lifting, 15% had grip-
dynamometer deficits, and 100%
had some degree of isokinetic
deficit. These data suggest that the
excellent subjective results after
surgical treatment do not necessar-
ily correlate with the objective
findings of persistent weakness.
These complications of persistent
pain, residual strength deficits, and
functional limitations remain con-
cerns with surgical management of
lateral epicondylitis.
Medial Epicondylitis
Anatomy
The musculotendinous structures
about the medial epicondyle include
the flexor pronator muscle mass ori-
gin. From proximal to distal, this
includes the pronator teres, the flexor
carpi radialis, the palmaris longus,
the flexor digitorum superficialis,
and the flexor carpi ulnaris. The
pronator teres and flexor carpi radi-
alis, which are most commonly
involved in medial epicondylitis,
both arise from the medial supra-
condylar ridge.
6 Journal of the American Academy of Orthopaedic Surgeons
Biomechanics
The biomechanics of the medial
elbow have been most thoroughly
defined by the pitching mechanism.
Peak angular velocity and valgus
forces exceeding the tensile strength
of the medial musculotendinous and
ligamentous structures may be pro-
duced primarily during the accelera-
tion phase, which extends from the
point at which forward velocity of
the ball is essentially zero to ball
release. These forces are transmitted
initially to the flexor pronator mus-
culature at the medial epicondyle
and subsequently to the deeper
medial collateral ligament.
In an EMG evaluation of the ten-
nis serve, Morris and associates1 cor-
roborated the biomechanical theories
of the baseball pitch. They noted that
the highest muscle activity occurred
during the acceleration phase and
was seen in the pronator teres of the
flexor pronator mass. They sug-
gested that during this phase the
pronator is providing optimal fore-
arm positioning while transferring
momentum and power to the ball.
Epidemiology and Etiology
Medial epicondylitis is much
rarer than its lateral counterpart,
the latter occurring from 7 to 20
times more frequently. 13 It also
occurs within the fourth and fifth
decades, with apparently equal
male and female prevalence rates.
Although termed “golfer’s elbow,”
medial epicondylitis occurs often
in baseball pitchers and in those
who participate in a variety of other
sports and occupational activities
that create valgus force at the
elbow13,14 (Table 1).
Pathophysiology
Valgus forces at the elbow create
stress in the flexor pronator origin as
well as the medial collateral liga-
ment. Improper technique, poor
conditioning, inadequate warm-up,
and fatigue can all lead to inflamma-
tion of the flexor pronator mass. The
pronator teres and flexor carpi radi-
alis have been identified as the most
common sites of pathologic
change. 2,13 Vangsness and Jobe 15
noted macroscopic tearing of the
flexor pronator origin in 100% of
their patients who underwent surgi-
cal treatment for recalcitrant medial
epicondylitis.
In 1992 Glousman and associ-
ates 14 used cinematography and
indwelling electromyography to
examine elbow muscle activity in 30
pitchers with normal elbows and 10
pitchers with medial collateral liga-
ment injuries. They noted less
pronator teres and flexor carpi radi-
alis activity during the late cocking
and acceleration phases in the sub-
jects with collateral ligament
injuries. The authors proposed that
flexor pronator overuse subse-
quently led to progressive medial
ligamentous injury in these subjects.
Diagnosis
Medial epicondylitis is character-
ized by pain along the medial elbow
that is worsened by resisted forearm
pronation or wrist flexion. This
medial pain is often insidious in
onset.
Tenderness is usually distal and
lateral to the medial epicondyle,
most often over the pronator teres
and flexor carpi radialis. Resisted
wrist flexion and forearm pronation
exacerbate the pain. The range of
motion of the elbow and that of the
wrist are usually complete. Normal
strength and sensation are typically
noted in the extremity. If, however,
concomitant ulnar neuropathy
exists, varying degrees of dimin-
ished sensibility in the ring and little
fingers, as well as a Tinel’s sign at the
elbow, may be present.
Plain radiographs of the elbow
are most often normal. Throwing
athletes however, may have medial
ulnar traction spurs and medial col-
lateral ligament calcification.

When evaluating the patient with
suspected medial epicondylitis, it is
essential to consider primary liga-
mentous instability or primary ulnar
neuropathy in the differential diag-
nosis. Valgus stress testing with the
wrist flexed and the forearm
pronated will produce pain and lax-
ity if collateral instability is present.
Maximum elbow flexion and wrist
extension for 3 minutes (elbow
flexion test) will produce pain and
numbness if ulnar neuropathy is
present.
Nonsurgical Treatment
The basic principles of nonsurgi-
cal treatment for lateral epicondyli-
tis apply to medial epicondylitis as
well. Phase 1 consists of rest from
the offending activity for initial
relief of pain and inflammation.
The use of nonsteroidal anti-
inflammatory agents, galvanic
stimulation, and possibly cortico-
steroid injection may provide adju-
vant benefit.
The second phase includes tech-
nique enhancement, equipment
modification, possibly counterforce
bracing, and a rehabilitation pro-
gram. The rehabilitation program
begins with wrist flexor and fore-
arm pronator stretching and pro-
gressive isometric exercises. As
A B
Fig. 2 Technique for surgical treatment of medial epicondylitis. A, Skin incision over the medial epicondyle and intended incision of com-
mon flexor pronator mass. B, Distal reflection of the common flexor pronator origin with debridement of pathologic tissue. C, Reattachment
of the common flexor pronator origin to the medial epicondyle.
Vol 2, No 1, Jan/Feb 1994
Frank W. Jobe, MD, and Michael G. Ciccotti, MD
flexibility, strength, and endurance
improve, eccentric and concentric
resistive exercises are included. A
sport or job simulation is then per-
formed, followed by a gradual
return to normal activity. The
majority of authors2,13,15 suggest that
medial epicondylitis, like lateral
epicondylitis, is most often success-
fully treated with such a nonsurgi-
cal regime.
Surgical Treatment
The indications for surgical treat-
ment of medial epicondylitis include
persistent pain at the medial elbow
unresponsive to a well-managed
nonoperative program for a mini-
mum of 6 to 12 months, after exclu-
sion of any other pathologic causes
for the pain.
Historically, there is a dearth of
information regarding the surgical
treatment of medial epicondylitis.
The various techniques that have
been described range from percuta-
neous release of epicondylar mus-
cles to open epicondylectomy. These
techniques, however, result in
significant flexor-pronator strength
deficits that are particularly debili-
tating for the athlete or laborer.
Vangsness and Jobe15 described the
following technique of reactive-tis-
sue excision and flexor-pronator
reapproximation for medial epi-
condylitis.
Technique
With the patient supine and the
arm resting on an arm board, a
tourniquet is applied. An 8- to 10-
cm incision is centered over the
medial epicondyle (Fig. 2, A). The
common flexor origin is incised
sharply and reflected with care not
to violate the medial collateral lig-
ament. The position of the ulnar
nerve is noted, and the nerve is
protected throughout the proce-
dure. The pathologic tissue is
identified on the undersurface of
the flexor pronator mass and
excised (Fig. 2, B). The underlying
medial epicondyle is debrided of
soft tissue, and multiple small
holes are drilled to create a vascu-
lar bed. The common flexor prona-
tor origin is then reattached to this
bleeding surface with interrupted
absorbable sutures (Fig. 2, C). After
appropriate subcutaneous and
skin closure, a molded posterior
plaster splint is applied.
Sponge-squeezing and wrist and
hand range-of-motion exercises are
initiated immediately. The splint
and skin sutures are removed 7 to
10 days postoperatively. Gentle
passive and active elbow, wrist, and
C
7
Lateral and Medial Epicondylitis of the Elbow
hand range-of-motion exercises are
encouraged. Resisted wrist flexion
and pronation exercises are initi-
ated at 4 to 6 weeks, followed by a
progressive strengthening pro-
gram. Return to activity is generally
attained by the fourth postopera-
tive month.
Results
In a review of 35 patients with
recalcitrant medial epicondylitis
treated surgically, Vangsness and
Jobe 15 noted an improvement in
subjective elbow function from 38%
to 98% of normal. Excellent or good
References
1. Morris M, Jobe FW, Perry J, et al: Elec-
tromyographic analysis of elbow func-
tion in tennis players. Am J Sports Med
1989;17:241-247.
2. Nirschl RP, Pettrone FA: Tennis elbow:
The surgical treatment of lateral epi-
condylitis. J Bone Joint Surg Am 1979;
61:832-839.
3. Gruchow HW, Pelletier D: An epidemi-
ologic study of tennis elbow: Incidence,
recurrence, and effectiveness of preven-
tion strategies. Am J Sports Med
1979;7:234-238.
4. Bosworth DM: The role of the orbicular
ligament in tennis elbow. J Bone Joint
Surg Am 1955;37:527-533.
5. Garden RS: Tennis elbow. J Bone Joint
Surg Br 1961;43:100-106.
6. Kaplan EB: Treatment of tennis elbow
(epicondylitis) by denervation. J Bone
Joint Surg Am 1959;41:147-151.
8 Journal of the American Academy of Orthopaedic Surgeons
results were obtained in 97% of the
patients, and 86% had no limitation
in the use of the elbow. Isokinetic
and grip-strength testing in 16
patients revealed no significant dif-
ference between those elbows that
had been treated surgically and
those that had not. All of the 20 ath-
letically active patients returned to
their sport. The surgical treatment
for recalcitrant medial epicondyli-
tis is efficacious in relieving pain
and allowing return to previous
activities; however, the complica-
tion of residual strength deficit
remains a concern.
7. Newman JH, Goodfellow JW: Fibrilla-
tion of head of radius as one cause of
tennis elbow. BMJ 1975;2:328-330.
8. Price R, Sinclair H, Heinrich I, et al:
Local injection treatment of tennis
elbow: Hydrocortisone, triamcinolone
and lignocaine compared. Br J Rheuma-
tol 1991;30:39-44.
9. Groppel JL, Nirschl RP: A mechanical
and electromyographical analysis of the
effects of various joint counterforce
braces on the tennis player. Am J Sports
Med 1986;14:195-200.
10. Snyder-Mackler L, Epler M: Effect of
standard and Aircast tennis elbow
bands on integrated electromyography
of forearm extensor musculature proxi-
mal to the bands. Am J Sports Med
1989;17:278-281.
11. Binder AI, Hazleman BL: Lateral
humeral epicondylitis: A study of nat-
Summary
Since the first description of epi-
condylitis of the elbow in 1882, there
has been a plethora of descriptive,
diagnostic, and therapeutic reports
detailing every aspect of this entity. It
is now known that epicondylitis can
be caused by occupational activities
as well as by sports participation,
that its diagnosis may be confused
with that of a variety of other patho-
logic entities affecting the elbow, and
that the majority of patients will
respond favorably to a well-guided
nonoperative treatment program.
ural history and the effect of conserva-
tive therapy. Br J Rheumatol 1983;
22:73-76.
12. Ciccotti MG, Lombardo SJ: Medial and
lateral epicondylitis, in Jobe FW (ed):
Upper Extremity Injuries in Sports. St
Louis: CV Mosby (in press).
13. Leach RE, Miller JK: Lateral and medial
epicondylitis of the elbow. Clin Sports
Med 1987;6:259-272.
14. Glousman RE, Barron J, Jobe FW, et al:
An electromyographic analysis of the
elbow in normal and injured pitchers
with medial collateral ligament
insufficiency. Am J Sports Med
1992;20:311-317.
15. Vangsness CT Jr, Jobe FW: Surgical
treatment of medial epicondylitis:
Results in 35 elbows. J Bone Joint Surg Br
1991;73:409-411.
 Degenerative Spondylolisthesis:
Diagnosis and Treatment
John W. Frymoyer, MD

Abstract

Degenerative spondylolisthesis is most often seen at the L4-5 level. The most com- causative of symptoms until a com-
mon complaint is back pain, but the advent of leg symptoms, such as claudication plete clinical and imaging evalua-
and restless legs syndrome, is often the reason for seeking specialized medical tion has been performed.
attention. Conservative treatment usually suffices; extended bed rest is of little
value. The 15% of patients who are surgical candidates are those with clinical signs
and symptoms of cauda equina abnormality, progressive muscular weakness, or Epidemiology and Etiology
progressive incapacitating radicular pain or claudication. The author advocates
pedicle-to-pedicle decompression with preservation of the articular facets as the All clinical and epidemiologic analy-
essential operation. The indications for fusion have been debated, but recent ses have shown the most common
prospective studies show improved outcomes after fusion. The risk of significant site of structural deformity to be at
morbidity associated with laminectomy and fusion increases as a function of age the L4-5 level. Women are more
and magnitude of operation; therefore, careful patient selection for surgical inter- commonly affected than men, and
vention is vital. the prevalence of the condition
J Am Acad Orthop Surg 1994;2:9-15 increases with age. In contrast,
ischemic spondylolisthesis usually
occurs at L5-S1 and is more common
in men; furthermore, the clinical
symptoms often improve rather
Spinal stenosis is thought to be a lumbar vertebra (usually L-4 on L-5) than worsen with age.
growing, potentially major health (Fig. 1). Radiographic surveys show that
problem for the elderly population. The symptoms of lumbar spinal degenerative spondylolisthesis is
In this age group, degenerative stenosis, particularly a complaint of more common in patients with
spondylolisthesis may be the most neural claudication, serve as the hemisacralization. This finding is
common cause of spinal stenosis. common operative indication. thought to have etiologic significance
Although the structural defect was Because the appearance of a because the immobility of the L5-S1
first recognized over a century ago significant deformity or neural clau- level shifts mechanical stresses to the
in anatomic specimen, the associ- dication often is antedated by adjacent L4-5 level.
ated clinical syndrome was not significant and recurring episodes of Diabetic patients and women
described until Macnab’s classic arti- low back pain, the condition is some- who have undergone oophorectomy
cle, 1 in which he correlated the times considered a prototype for are also at significantly greater risk.
symptoms, signs, radiographic segmental instability. However, the These observations have clinical rel-
findings, and treatment. His pro- radiographic abnormality may
posed nomenclature was “spondy- occur without current or prior symp-
lolisthesis with an intact neural toms.
arch,” but soon thereafter “degener- Valkenburg and Haanen2 found Dr. Frymoyer is Dean and Professor of
Orthopaedics and Rehabilitation, College of Med-
ative spondylolisthesis” became the an age-related increased prevalence icine, University of Vermont, Burlington.
preferred term. of degenerative spondylolisthesis in
Degenerative spondylolisthesis women over the age of 60 years; 10% Reprint requests: Dr. Frymoyer, Office of the
can be found in classifications of had the deformity, but many Dean, College of Medicine, Given Building E109,
spondylolisthesis, spinal stenosis, reported that they had never had University of Vermont, Burlington, VT 05405-
2150.
and segmental instability, indicating back or leg pain. This finding is
that the clinical presentation is var- extremely important, and empha- Copyright 1994 by the American Academy of
ied. The basic structural deformity sizes that the obvious radiographic Orthopaedic Surgeons.
involves forward displacement of a deformity cannot be assumed to be

Vol 2, No 1, Jan/Feb 1994 9

Degenerative Spondylolisthesis
evance because the orthopaedist
faced with a patient with degenera-
tive spondylolisthesis, diabetes, and
leg pain often has to determine
whether diabetic neuropathy or
spinal stenosis is the cause of leg
pain. The relationship to oophorec-
tomy suggests the possibility that
estrogen replacement might prevent
or slow the onset of the deformity
and symptoms.
Pathophysiology
The most important requisite for
degenerative spondylolisthesis is
relative immobility of the lumbar
segment below the lesion. The
immobility is most commonly due to
hemisacralization but can also result
from advanced disk degeneration at
the L5-S1 level (Fig. 1). An iatrogenic
cause for immobility is spinal fusion.
The forward slip occurs many years
after the original fusion; surpris-
A B
Fig. l Radiographs of a 72-year-old woman followed up for 10 years. A, She originally pre-
sented with mild recurrent back pain and a minimal slip at L4-5. B, Six years later the dis-
placement had progressed, the disk space had narrowed, and she experienced claudication
after walking 1 mile. The L5-S1 space is very narrowed as well.
10
ingly, many patients are asymp-
tomatic despite the deformity2 (Fig. 2).
There is substantially more con-
troversy about other possible
pathoanatomic causes. The higher
prevalence in diabetic persons is
thought to be due to weakened col-
lagen cross-linking. Other mechani-
cal theories suggest, but do not
prove, that congenital or acquired
abnormalities in the orientation of
the facets predispose to the forward
displacement. Unfortunately, the
various pathoanatomic theories
have no utility for designing specific
prevention strategies.
Differential Diagnosis
The epidemiologic studies suggest
that degenerative spondylolisthesis
is often an asymptomatic ra-
diographic finding. This fact is of
enormous importance because there
is a natural tendency for clinicians to
Journal of the American Academy of Orthopaedic Surgeons
Fig. 2 Lateral radiograph of a 70-year-old
woman who underwent successful fusion
from L-4 to the sacrum 18 years previously.
Current presenting symptom was neuro-
logic claudication with pain, localized pri-
marily to the anterior thigh. Displacement
of L-3 on L-4 above the solid fusion is
demonstrated (arrow).
ascribe symptoms to an obvious
structural lesion. A variety of other
conditions can cause back or leg
symptoms easily confused with the
symptoms of degenerative spondy-
lolisthesis.
Osteoarthritis of the hip occurs in
11% to 17% of patients with degen-
erative spondylolisthesis, and can
mimic the anterior thigh pain of an
L-4 root entrapment.3 Therefore, the
hip needs to be carefully examined
for an alternative cause for symp-
toms of leg pain.
Degenerative scoliosis is often an
associated spinal deformity, and
some believe that degenerative
spondylolisthesis is a common
antecedent for degenerative scolio-
sis in the elderly. In these patients
the neurologic complaints may be
more diffuse, consistent with multi-
level involvement. Treatment of this

subset of patients may also raise sub-
stantially greater issues, such as the
extent of decompression and fusion.
A less common coexistent condi-
tion is diffuse idiopathic skeletal
hyperostosis. This condition is char-
acterized by multilevel bridging
osteophytes and commonly affects
middle-aged and older men, who fre-
quently are diabetic and hyper-
uricemic. If surgery is required, these
patients can be far more challenging
than those with standard degenera-
tive spondylolisthesis.
The other possible causes for
symptoms confused with degenera-
tive spondylolisthesis include cer-
vical spinal stenosis, intrinsic
neurologic disorders, primary or
metastatic tumors, and peripheral
vascular disease. Peripheral vascular
disease is of particular importance
since it produces vascular claudica-
tion easily confused with neurologic
claudication. A useful differentiation
is that patients with a spinal cause
usually are relieved of symptoms
only by cessation of walking and sit-
ting down or flexing the spine. In
contrast, patients with a vascular
cause have only to stop walking and
symptoms disappear in the normal
upright standing position.
Because of the age group affected
and the substantial differential diag-
nosis, it is important to perform a
current and complete medical evalu-
ation before proceeding with
definitive treatment of the spinal
disorder.
Clinical Signs and
Symptoms
The most common complaint of
patients with degenerative spondy-
lolisthesis is back pain. Often the
pain has been episodic and recurrent
for many years. Few patients can
recall a specific traumatic event. As
is the case with all mechanical back
pain, patients usually report that
Vol 2, No 1, Jan/Feb 1994
their symptoms vary as a function of
mechanical loads imposed, and pain
frequently worsens over the course
of the day. Radiation into the pos-
terolateral thighs is also common
and is independent of neurologic
signs and symptoms.
The advent of leg symptoms is the
most common reason why patients
and referring physicians become
truly concerned and seek specialized
medical attention. Monoradiculopa-
thy is the less common type of leg
pain; when present, it is the result of
entrapment of the L-5 root in the lat-
eral recess. The more common pain
presentation is that of neurologic
claudication. The pain may be dif-
fuse in the lower extremities, involv-
ing the L-5 and/or L-4 roots
unilaterally or bilaterally. These
symptoms of spinal stenosis are
reported by 42% to 82% of patients
who seek help from orthopaedists.4
Typically, the leg pain is accentuated
by walking and relieved by forward
flexion of the spine. Additional com-
plaints include cold feet, altered gait,
and “drop episodes,” wherein the
patient unexpectedly falls while
walking.
With extreme stenosis, interfer-
ence with bladder and bowel control
can occur, as was reported by Kostuik
et al5 in 3% of their patients. Unlike
the acute and often devastating blad-
der and bowel symptoms of cauda
equina syndrome in lumbar disk her-
niation, spinal stenosis often has an
insidious and subtle presentation.
The unwary examiner is at risk of
attributing these complaints to age-
related conditions, such as cystocele
in women and prostatism in men.
Stenotic symptoms are the result
of mechanical and vascular factors.
As the slip progresses, facet hyper-
trophy, buckling of the ligamentum
flavum, and diffuse disk bulging
contribute with the forward dis-
placement to compression of the
cauda equina (Fig. 3). As in all
stenotic conditions, the relief of
John W. Frymoyer, MD
Fig. 3 Computed tomographic scan
demonstrates the relationship of the caudal
sac and nerve roots and the very substantial
facet degeneration. Note the marked nar-
rowing of the lateral recesses.
symptoms that follows forward
spinal flexion is thought to be related
to the increase in the anteroposterior
dimensions of the spinal canal that
occurs in that posture. At the
extreme, patients may report the
need to sleep in the fetal position to
relieve leg symptoms.
The significant vascular compo-
nent in complaints of leg pain may
lead to another manifestation, rest-
less legs syndrome, sometimes
called “vespers curse.”6 In this con-
dition, patients are awakened by
aching pain in the calves, restless-
ness, an irresistible urge to move the
legs, and fasciculations. This syn-
drome is reported to be exacerbated
by congestive heart failure, which, in
turn, may increase pressure in the
arteriovenous anastomoses that
characterize the lumbar nerve-root
microcirculation. Accordingly, if the
patient reports increasing night
cramps, it is worthwhile to obtain a
thorough cardiovascular examina-
tion. Other associated neurologic
symptoms, such as numbness and
weakness, are variably present.
As already noted, some patients
present with degenerative spondy-
lolisthesis above a spinal fusion (Fig.
2). A long symptom-free interval is
11
Degenerative Spondylolisthesis
followed by the onset of nerve-root
symptoms and stenosis emanating
from the level above their previous
fusion.7
Physical Examination
As in most patients with lumbar
spinal stenosis, the clinical examina-
tion findings are often nonspecific.
Inspection usually reveals loss of lum-
bar lordosis if the patient is experienc-
ing significant spine or neurologic
symptoms. When stenotic symptoms
are severe, a fixed forward-flexed
posture, sometimes accompanied by
hip-flexion contractures, can be
observed. Except in very thin
patients, the step deformity usually is
not palpable.
One of the surprising features of
degenerative spondylolisthesis is the
retention of normal spinal mobility or,
in some instances, hypermobility. It
has been suggested that patients with
this condition have generalized liga-
mentous laxity, which might have eti-
ologic significance.
The neurologic examination may
be quite useful when the patient has
an isolated unilateral radiculopathy.
The knee-jerk reflex may be reduced
or absent when the L-4 root is
involved. Unilateral dorsiflexion or
quadriceps weakness and the pat-
tern of sensory loss are important
findings. However, a positive nerve-
root tension sign is uncommon, par-
ticularly in the older population.
More commonly, the neurologic
findings are nonspecific and may
include bilaterally absent reflexes,
spotty sensory losses, and muscle
atrophy without frank weakness.
When bladder symptoms are
reported, sensory loss may be pres-
ent in the perineal area, accompa-
nied by a decrease in rectal sphincter
tone. However, these genitourinary
findings are often subtle; therefore,
patients with these complaints
should undergo urologic evaluation.
12
Imaging Studies
The plain radiographic features (Fig.
1) include the essential finding of for-
ward displacement of L-4 on L-5 or,
more rarely, L-5 on S-1 or L-3 on L-4
in the presence of an intact neural
arch. The only lesion that can mimic
these radiographic findings is the far
less common L4-5 ischemic spondy-
lolisthesis (Fig. 4). Patients with that
condition are quite likely to have neu-
rologic symptoms and to be younger.
Unlike L5-S1 ischemic spondylolis-
thesis, the slip increases over time,
and fusion is often necessary.
The remaining radiologic findings
are consistent with a long-standing
degenerative process and include
disk-space narrowing, vacuum sign,
endplate sclerosis, peridiskal osteo-
phytes, and facet sclerosis and
hypertrophy. The anteroposterior
radiograph often, but not always,
demonstrates the accompanying
hemisacralization of L-5.
Fig. 4 Radiograph of a man with L4-5
ischemic spondylolisthesis with an
advanced slip. Note the defect in the pars.
Journal of the American Academy of Orthopaedic Surgeons
Dynamic flexion-extension ra-
diographs are used by some experts
to evaluate for instability. Today, the
criterion for instability in flexion-
extension is displacement exceeding
5 mm. The alternative approach of
using traction-compression ra-
diographs has been described by
Friberg.8 In this technique, a lateral
lumbar radiograph is taken first
after the application of a standard
axial load and then after traction.
The difference in displacement
between these two views is corre-
lated with back pain and instability,
and is considered by Friberg to have
prognostic significance.
Additional imaging studies may
be warranted depending on the
patient’s presentation and the clini-
cal findings. The choice of how soon
these studies are performed is a mat-
ter of clinical judgment. Factors that
speak to the need for further imag-
ing include significant and progress-
ing neurologic claudication or
radiculopathies and the clinical sus-
picion that another condition, such
as metastatic disease, may be
causative. An absolute indication is
the presence of bladder or bowel
complaints.
The imaging alternatives include
computed tomography (CT), myelog-
raphy, contrast material-enhanced
CT, and magnetic resonance (MR)
imaging. Currently, MR imaging is
favored by many experts because of its
noninvasive nature. Others continue
to believe that the contrast material-
enhanced CT scan gives the most
information about the caudal sac. The
pragmatic approach is to choose that
imaging study with which you and
the radiologist have the most experi-
ence and for which you have the best
equipment.
Regardless of the imaging study
chosen, the typical findings are a
significant constriction of the cauda
equina (Fig. 5) associated with a
diminished cross-sectional area and
diameter, facet degeneration and

hypertrophy with subarticular
entrapment of the L-5 nerve roots,
apparent thickening and buckling of
the ligamentum flavum, and diffuse
disk bulging. All of these factors
contribute to the symptoms of spinal
stenosis.
Additional studies that may be
selected include technetium bone
scanning, particularly when a
metastatic tumor is suspected, and
electrodiagnostic studies if a systemic
neurologic disorder is a possibility.
Local anesthetic injections may be
useful in specific cases. The best
indication is concomitant degenera-
tive spondylolisthesis and hip
osteoarthritis. Relief of symptoms
following an intra-articular hip
injection suggests that the hip is the
most probable origin for the symp-
toms.
Conservative Treatment
There are no prospective, random-
ized clinical trials that establish a
preferred method of nonoperative
treatment. However, there is recent
evidence that the natural history of
degenerative spinal stenosis and
degenerative spondylolisthesis may
Vol 2, No 1, Jan/Feb 1994
Fig. 5 Typical lateral (left)
and anteroposterior (right)
myelographic appearance of
degenerative spondylolis-
thesis. Note the significant
constriction of the caudal sac
at L4-5.
be more favorable than previously
thought. Johnsson et al9 followed up
32 patients with clinical symptoms
and myelographically confirmed
stenosis for an average of 49 months.
No patient had significant deteriora-
tion, and surprisingly many patients
improved.
In the absence of definitive clinical
trials, treatment currently is non-
specific and consistent with the con-
servative care of most degenerative
lumbar spinal disorders. The alterna-
tives include (1) nonsteroidal anti-
inflammatory drugs (in the elderly,
there should be careful monitoring
for gastrointestinal complaints and
melena); (2) encouragement of aero-
bic conditioning, on the premise that
this exercise may improve arterial
circulation to the cauda equina
(because walking often aggravates
symptoms, a stationary bicycle is a
good alternative, particularly if the
handlebars and seat are set up to
allow the forward-flexed posture);
(3) weight reduction, although this
strategy often minimally affects neu-
rologic complaints; and (4) careful
management of osteoporosis.
Additional strategies include the
judicious use of braces, other exer-
John W. Frymoyer, MD
cise regimens, and epidural blocks,
but again there are no well-estab-
lished clinical trials. Extended bed
rest appears to be of little value and
carries a significant risk of morbid-
ity in the elderly. Likewise, there is
no information to support the use
of manipulative therapy; that
treatment may be contraindicated,
particularly in the osteoporotic
patient.
Operative Treatment
Because the natural history of
degenerative spondylolisthesis is
still relatively uncertain, it is difficult
to establish what percentage of
patients respond to conservative
management and who requires sur-
gical intervention. However, it is
estimated that no more than 10% to
15% of patients are surgical candi-
dates. Today the indications in order
of relative importance are (1) clinical
symptoms and signs of cauda
equina dysfunction, accompanied
by evidence of a complete block at
the affected level; (2) progressive
muscular weakness of functional
significance, such as a dropped foot
or quadriceps dysfunction; and
(3) progressive and incapacitating
radicular pain or claudication, par-
ticularly when it causes sleep distur-
bance. Back pain per se is a relatively
uncertain indication.
When a patient fulfills any one of
these criteria, the essential operative
intervention is decompressive
laminectomy. Although the extent of
laminectomy required has been
debated, I and others 10 advocate a
pedicle-to-pedicle decompression
with preservation of the articular
facets (Fig. 6). Many experts believe
that the disk should not be excised
unless it is frankly ruptured. It is
thought that excising the disk
increases the risk of later instability.
Following decompression, the
patency of the dural sac is established
13
Degenerative Spondylolisthesis
Fig. 6 Principles of surgical decompression. A, Anatomic relationships of the nerve roots and the extent of decompression required. PA =
pars interarticularis; P = pedicle. B, Area to be removed by undercutting the facets. C, Final decompression.
by the presence of dural pulsations
and the absence of nerve-root tension.
Fusion
The indications for fusion have been
hotly debated, except when ade-
quate decompression requires
sacrifice of more than 50% of the
facets or when the pars has been
breached. Herkowitz and Kurz11 per-
formed a controlled prospective
study that demonstrated signifi-
cantly improved results in patients
who had an accompanying L4-5
intertransverse (“floating”) fusion
(Fig. 7). Their data are sufficiently
compelling for one to consider
fusion, except in those patients
with significant accompanying
systemic diseases and in the
elderly, in whom the systemic and
local complication rates rise
significantly. I believe it is unnec-
essary to extend the fusion to the
L5-S1 level in most patients,
because that level is usually stabi-
lized by bone abnormalities or
marked disk degeneration.
Which fusion technique should be
chosen ultimately depends on the
method with which the surgeon is
most comfortable. Transverse-
process fusion remains the most
common technique, although poste-
14
rior interbody fusions and even ante-
rior interbody fusions have been
advocated. Whether internal fixation
improves the rate of fusion in degen-
erative spondylolisthesis remains
undetermined. There is now some
evidence that the rate of fusion or
lumbar degenerative disease is
enhanced by the addition of fixation
devices. A variety of choices exist
now, most selected from the growing
menu of pedicle-fixation devices.
However, all of these devices have
significant risks, including pedicle
Fig. 7 Floating intertransverse fusion.
Journal of the American Academy of Orthopaedic Surgeons
perforation and neurologic injury.
This is particularly true in the osteo-
porotic patient, and the risks of
neural injury increase when methyl-
methacrylate is used to enhance
screw fixation.
Results
Most studies report surgical success
rates for treatment of radiculopathy
or claudication in the range of 70% to
85%. The relief of low back pain is
less predictable. A longer-term fol-
low-up study performed by Katz et
al 12 demonstrated that the results
deteriorated over time and were less
favorable than those reported in pre-
vious studies. The predictors of fail-
ure were increased age, associated
comorbidities (e.g., cardiac disease),
and a longer duration of surveil-
lance. Their findings are consistent
with the results reported by Nakai et
al.13 However, the latter investiga-
tors thought instability was the most
common cause of failure.
The significant morbidity associ-
ated with laminectomy and with
laminectomy and fusion has been
detailed by Deyo et al.14 They report
that the risks increase as a function
of increasing age and the magnitude
of operation undertaken. Their data
are a sobering compilation of local

and systemic problems that can
affect as many as 20% of elderly
patients. Perhaps the most impor-
References
1. Macnab I: Spondylolisthesis with an
intact neural arch: The so-called
pseudo-spondylolisthesis. J Bone Joint
Surg Br 1950;32:325-333.
2. Valkenburg HA, Haanen HCM: The
epidemiology of low back pain, in
White AA III, Gordon SL (eds): American
Academy of Orthopaedic Surgeons Sympo-
sium on Idiopathic Low Back Pain. St
Louis: CV Mosby, 1982, pp 9-22.
3. Rosenberg NJ: Degenerative spondy-
lolisthesis: Predisposing factors. J Bone
Joint Surg Am 1975;57:467-474.
4. Frymoyer JW: Degenerative spondy-
lolisthesis, in Andersson GBJ, McNeill
TW (eds): Lumbar Spinal Stenosis. St
Louis: Mosby Year Book, 1992.
5. Kostuik JP, Harrington I, Alexander D,
et al: Cauda equina syndrome and lum-
bar disc herniation. J Bone Joint Surg Am
1986;68:386-391.
6. LaBan MM, Viola SL, Femminineo AF,
et al: Restless legs syndrome associated
Vol 2, No 1, Jan/Feb 1994
tant message to be derived from that
study is the importance of careful
patient selection and adherence to
with diminished cardiopulmonary
compliance and lumbar spinal stenosis:
A motor concomitant of “vespers curse.”
Arch Phys Med Rehabil 1990;71:
384-388.
7. Frymoyer JW, Hanley EN Jr, Howe J, et
al: A comparison of radiographic
findings in fusion and non-fusion
patients ten or more years following
lumbar disc surgery. Spine 1979;4:
435-440.
8. Friberg O: Lumbar instability: A
dynamic approach by traction-com-
pression radiography. Spine 1987;12:
119-129.
9. Johnsson KE, Rosen I, Uden A: The nat-
ural course of lumbar spinal stenosis.
Clin Orthop 1992;279:82-86.
10. Grobler LJ, Robertson PA, Novotny JE,
et al: Decompression for degenerative
spondylolisthesis and spinal stenosis at
L4-5: The effects on facet joint morphol-
ogy. Spine 1993;18:1475-1482.
John W. Frymoyer, MD
strict indications when selecting sur-
gical intervention for degenerative
spondylolisthesis.
11. Herkowitz HN, Kurz LT: Degenerative
lumbar spondylolisthesis with spinal
stenosis: A prospective study compar-
ing decompression with decompres-
sion and intertransverse process
arthrodesis. J Bone Joint Surg Am
1991;73:802-808.
12. Katz JN, Lipson SJ, Larson MG, et al:
The outcome of decompressive laminec-
tomy for degenerative lumbar stenosis.
J Bone Joint Surg Am 1991;73:809-816.
13. Nakai O, Ookawa A, Yamaura I: Long-
term roentgenographic and functional
changes in patients who were treated
with wide fenestration for central lum-
bar stenosis. J Bone Joint Surg Am
1991;73:1184-1191.
14. Deyo RA, Cherkin DC, Loeser JD, et al:
Morbidity and mortality in association
with operations on the lumbar spine:
The influence of age, diagnosis and pro-
cedure. J Bone Joint Surg Am 1992;74:
536-543.
15
 Modularity of Prosthetic Implants
Robert L. Barrack, MD

Abstract

The vast majority of total-joint-replacement components currently utilized are and potential benefits, and the
modular to some degree. Modularity reduces inventory and increases the surgeon’s known and potential complications.
options in both primary and revision total-joint arthroplasty. Use of a modular Optimal design features of modular
interface, however, increases the risk of fretting, wear debris, and dissociation and components will be suggested on the
mismatching of components. The use of modular heads in total hip replacement is basis of the current state of knowl-
firmly established. The occurrence of corrosion and fretting has been recognized, edge.
and most manufacturers have improved the quality of the interface to minimize
these problems. Modular polyethylene liners also offer advantages, particularly in
revision procedures, where the option of additional screw fixation remains impor- Total Hip Replacement
tant. Many uncemented acetabular components are inserted without screws,
which may generate renewed interest in one-piece factory-preassembled compo- Acetabular Components
nents. The conformity, locking mechanism, and nonarticular interface of modular The concept of a modular two-
acetabular components have all been studied and improved. Modular tibial com- piece acetabular component was
ponents offer additional flexibility in the performance of total knee replacement but introduced over 20 years ago.1 The
introduce the risk of dissociation and increased polyethylene wear; in revision pro- original objective was the ability to
cedures, modularity provides a valuable option for dealing with bone loss and an replace the liner without disrupting
additional method of fixation by means of press-fit stems. Modular humeral com- the prosthesis-bone interface should
ponents offer a significant advantage with limited apparent risk; however, longer excessive wear occur over time.
clinical experience is required to assess potential problems. Another anticipated advantage was
J Am Acad Orthop Surg 1994;2:16-25 improved stress distribution in the
subchondral bone of the pelvis as
predicted by finite-element models.
A modular total-joint-replacement inventory has resulted in cost sav- Subsequent clinical reports have
component is generally defined as ings; the increasing use of modular failed to show an advantage of
one that the surgeon assembles at the components has, in fact, coincided cemented metal-backed acetabular
time of implantation. Two-piece com- with significant increases in pros- components compared with all-
ponents were originally designed to thetic costs. polyethylene components as mea-
allow replacement of the polyethyl- The widespread use of unce- sured by the incidence of loosening
ene liner or to provide a metal back- mented total-joint-replacement or the development of radiographic
ing, which theoretically improves components has paralleled the lucent lines. Metal backing is neces-
stress distribution. Later, a metal increasing modularity of the compo- sary, however, to provide a surface
backing became necessary to provide nents, but there has been a concomi- for porous coating. The loosening
a metal surface for porous coating. tant increase in the incidence and
With the advent of uncemented com- extent of bone lysis, the rate of poly-
Dr. Barrack is Associate Professor of Orthopaedic
ponents, a dramatic increase in the ethylene wear, and the generation of Surgery and Director, Adult Reconstructive
number of sizes in various implant particulate debris. It is not yet cer- Surgery, Tulane University School of Medicine,
systems was required, since a press fit tain to what extent the modularity of New Orleans.
must provide initial stability. At the these components contributes to
same time, modularity allowed a these problems. Reprint requests: Dr. Barrack, Department of
Orthopaedic Surgery SL32, 1430 Tulane
major decrease in the inventory In this article I will review the Avenue, New Orleans, LA 70112.
required to offer a wide range of rationale for the application of mod-
options. However, there is no evi- ularity to various total-joint-replace- Copyright 1994 by the American Academy of
dence to suggest that the decrease in ment components, the established Orthopaedic Surgeons.

16 Journal of the American Academy of Orthopaedic Surgeons

 Robert L. Barrack, MD

and revision rates of porous-coated improve stability. It is unwise, how- components. The first is liner dis-
components have at least equaled ever, to rely totally on such a modu- lodgment. A number of cases have
those of cemented primary acetabu- lar insert for stability. It is preferable been reported, and at least one
lar components during surveillance in most instances to reposition the component has been removed from
periods of 5 to 8 years. In the revi- metal shell into a more stable orien- the market because of this compli-
sion situation, the uncemented tation. Having done this, however, a cation. Liner dislodgment has also
acetabular components have gener- modular shell affords the ability to been reported with porous-coated
ally outperformed cemented revi- place screws through the shell for acetabular components assembled
sion components in terms of the additional stability, which is proba- at the factory, although many more
incidence of loosening and re-revi- bly advisable in such a circum- cases have occurred following
sion. stance. intraoperative assembly. This com-
In addition to promising clinical The ability to exchange a liner plication occurs by means of sev-
results, the modularity of porous- years after insertion because of eral mechanisms. Failure of a
coated metal-backed acetabular excessive wear is an occasional locking mechanism accounts for
components has other advantages. advantage. In most cases, however, many cases (Fig. 1). In these
Many of the metal shells have holes simple liner exchange is not possi- instances, the symptoms are often
that provide the option of screw ble. Often, either the shell has loos- insidious and are similar to those of
placement for adjunctive screw ened in conjunction with the subluxation. Patients may hear
fixation. Histologic analysis of early polyethylene wear or there has been audible clicking or popping, which
retrieved porous-coated acetabular sufficient damage to the locking is due to contact between the metal
components has indicated that more mechanism or the shell itself to shell and the femoral head. Because
bone ingrowth was present when necessitate revision of the entire the diagnosis may be delayed, the
adjunctive fixation was utilized. 2 acetabular component.4 metal shell may be extensively
With the recent practice of under- In recent years it has become damaged by the time revision is
reaming the acetabulum by 2 to 4 apparent that there are a number of undertaken (Fig. 2).
mm, similar degrees of stability have potential complications associated Liners may also be levered out by
been achieved without screw with the use of modular acetabular a single event. Liner dissociation
fixation. Component modularity
continues to offer the advantage of
allowing judgment of the fit through
the screw holes prior to insertion of
the polyethylene liner. Although
underreaming may provide the sta-
bility afforded by a tight peripheral
rim fit, it does not ensure direct bone
contact over the dome of the compo-
nent. The importance of this contact
is not certain, but it does seem desir-
able in terms of increasing the likeli-
hood of more uniform bone
ingrowth.
Another potential advantage of a
modular acetabular component is
interchangeability of liners. Once
the metal shell is impacted, a variety
of liners can be selected on the basis
of trial reduction and tests of the sta-
bility and range of motion. At least
one manufacturer offers the option
A B
of a modular constrained liner. 3
Some surgeons attempt to improve Fig. 1 A, Radiograph of hip prior to liner dislodgment. B, Appearance after liner dislodg-
stability by utilizing an offset liner ment with broken locking pin.
rotated into a position thought to

Vol 2, No 1, Jan/Feb 1994 17

Modularity of Prosthetic Implants

A B C

Fig. 2 A, Postoperative radiograph of right hip. B, After liner dislodgment, the patient had symptoms of subluxation and heard popping
and clicking. C, The metal shell was extensively damaged, necessitating revision of the acetabular shell as well as the liner.

has been reported, for instance, fol- thickness of 6 to 8 mm, with some of a congruent liner with a sharp metal
lowing reduction of a dislocation. below 3 mm.6 spike of a locking mechanism, and
The security of locking mechanisms Another concern is whether the abrasion of polyethylene by screw
has been found to be extremely modular components are effectively heads, particularly if component set-
variable, with the force necessary backed with metal. Many polyethyl- tling occurs. When the relative lack of
for dissociation ranging from 14.9 ene liners fail to bottom out at physio- conformity is combined with the
to 1,380 lb.5 Liners can rotate within logic loads, resulting in rim loading empty space for screw holes, the
the metal shell, which can lead to and excessively high localized stresses actual surface area supported by
clinical problems without frank dis- in the polyethylene.7 Even among the metal varies from 25% to 75%.8
location. There have been reports of designs that demonstrate congruency, The concerns about excessive
liners with extended lips rotating there are concerns about cold flow of stress and high wear rates on the
within the shell into a position caus- polyethylene into screw holes, contact polyethylene in modular acetabular
ing impingement on the femoral
neck and subsequent recurrent dis-
location that necessitates revision.4
While these dramatic failures are
uncommon, they often require sur-
gical intervention.
Of greater concern is the possibil-
ity that modular acetabular compo-
nents may be contributing to the
increased polyethylene wear, pro-
duction of particulate debris, and
bone lysis currently being observed
(Fig. 3). In recent years, modular
acetabular components have been
more carefully scrutinized, and a
number of design characteristics
B
that predispose to increased wear
have been identified. The first is
inadequate thickness of the polyeth- Fig. 3 A, Radiographic findings of massive
lysis in a minimally symptomatic patient. B,
ylene. The polyethylene liners of The thin acetabular liner in this patient had
many early modular acetabular worn through and dissociated.
components were well below the A
currently recommended minimum

18 Journal of the American Academy of Orthopaedic Surgeons


components are substantiated to a
degree by analysis of retrieved spec-
imens. Collier et al9 found significant
wear on the back side of acetabular
liners in 20 of 111 specimens exam-
ined. Huk et al10 examined 19 speci-
mens and found damage to the back
side in the form of burnishing, sur-
face deformation, and embedding of
metal particles in most, raising con-
cerns about back-side wear, creep
into screw holes, screw heads dig-
ging into the liner, and screw-shell
fretting. In two cases acetabular
osteolysis was present adjacent to
loose screws, and both metal and
polyethylene debris were identified
in the cystic lesion. This is the basis
for the concern that holes in the
acetabular components allow access
to the cancellous bone of the pelvis,
resulting in the destructive lytic
cysts that are increasingly observed
(Fig. 4).
A B
Fig. 4 A, Postoperative radiograph of uncemented total hip replacement with screw
fixation of modular acetabular component. B, Five years later the patient was minimally
symptomatic but had a large cystic lesion in the vicinity of the screw in the ilium. The head
appears eccentric in the liner.
Vol 2, No 1, Jan/Feb 1994
While modular acetabular com-
ponents are now known to present
certain problems, the promising
results with porous-coated unce-
mented acetabular components in
primary cases and particularly in
revision cases have been an impetus
for continued utilization of these
devices. Also, examination of
retrieved specimens and laboratory
testing suggest that many of these
potential problems can be mini-
mized by redesign. Hemispheric
cups afford the best chance of
obtaining conformity between the
porous coating and the acetabular
bone as well as between the shell
and the liner. Since the shell is now
appreciated to represent a wear
interface with the back side of the
liner, it should be highly conform-
ing as well as smooth and surface
treated, like any other weight-bear-
ing surface. The locking mechanism
Robert L. Barrack, MD
should be strong enough to resist
levering out, yet should not present
a sharp interface that can itself gen-
erate wear debris. Finally, elimina-
tion of screw holes is desirable to
minimize the risk of debris genera-
tion. This should be possible in
most primary cases with current
press-fit techniques. However,
elimination of screw holes places
more pressure on the surgeon to
obtain good alignment on initial
impaction, since there will not be
the ability to reposition and reim-
pact the component and add stabil-
ity with screw fixation. In revision
components, making provision for
adjunctive screw fixation is still
advisable in many, if not most,
cases.
Head-Neck Components
Modular heads have a number of
advantages, including the ability to
combine different materials for the
head and the stem, to reduce inven-
tory, and to allow fine-tuning of leg
length after the final stem has been
implanted. In revision cases in which
only an acetabular component is
being replaced, a modular head can
be removed to assist in exposure, and
a head-neck component of a different
length can be impacted onto the stem
to equalize the leg length.
Occasionally, long heads or exten-
sion sleeves are utilized to gain sta-
bility in patients with soft-tissue
laxity or insufficiency. Sciatic nerve
palsy has been reported to resolve
after changing to a shorter modular
head.
Modularity of the head has led
to a number of complications.
Dissociation of the head has been
reported.4 Often this event follows
reduction of a dislocation; there-
fore, this possibility must be kept in
mind when reducing a dislocated
total hip after modular total hip
replacement. There have also been
reports of fracture at the base of a
modular trunnion. 8 Corrosion at
19
Modularity of Prosthetic Implants
the head-neck interface is consid-
ered to be a contributing factor in
these instances.
Another disadvantage associated
with modular heads is related to
their effect on range of motion.
Head modularity requires a neck
with a circular cross section, which
impinges sooner than devices such
as the trapezoidal T-28 system
(Zimmer, Warsaw, Ind). Other
design elements that further restrict
motion include a smaller head, a
longer neck length achieved with an
external skirt, and a modular head
in combination with an eccentric or
offset liner. 11 Impingement can
result in dislocation, excessive poly-
ethylene wear, and liner dissocia-
tion.
A final complication of head and
liner modularity is the potential for
mismatching components (Fig. 5).
The large number of component
combinations increases the potential
for such a mishap and requires
heightened awareness on the part of
surgeons utilizing these systems.
Although these complications are
uncommon, they frequently necessi-
tate reoperation. As with modular
acetabular components, the greater
A B
Fig. 5 A, Postoperative radiograph of a 22-mm liner mismatched with a 26-mm head. B, After revision to a 26-mm liner, the head is seated
congruently with the acetabular liner.
20
concern is that corrosion products
and wear debris generated at the
head-neck interface are contributing
to the clinical problem of accelerated
polyethylene wear and associated
lysis.
Collier et al12 were among the first
to study the modular head-neck
interface. They identified galvani-
cally induced crevice corrosion in
the majority of mixed-metal systems
(cobalt-chrome head on titanium
trunnion). This was invariably pres-
ent in components in situ longer
than 40 months and was not
observed in single-alloy combina-
tions. Cook et al13 examined over a
hundred retrieved components and
came to somewhat different conclu-
sions. Wear and corrosion were pre-
sent in 35% of mixed-alloy
components but in only 9% of single-
alloy systems. However, the pres-
ence and degree of wear and
corrosion were not time dependent,
as reported by Collier et al.
Significant wear and corrosion were
seen in less than 2 years in some sin-
gle-alloy systems and not at all at
time periods beyond 5 years in some
mixed-alloy components. This
observation strongly suggests a
Journal of the American Academy of Orthopaedic Surgeons
problem related to the individual
implants rather than an inevitable
result of material combination.
Cook et al 14 also undertook in
vitro studies to examine the effect of
material combinations, surface treat-
ments, and neck length on genera-
tion of wear debris by modular
head-neck interfaces in a saline envi-
ronment. The combination of a
cobalt-chrome head with a titanium
trunnion did not, in itself, lead to
increase in wear debris. Every com-
bination of materials caused the gen-
eration of millions of particles in the
1- to 2-µm range. The factor most
important in increasing the particle
count was dimensional mismatch.
Roughened and nitrogen-implanted
surfaces produced fewer particles,
while heads larger than 10 mm pro-
duced more particles.
The consensus of a number of
investigators is that the surface dam-
age seen at the head-neck taper is ini-
tiated by fretting. Fretting has been
demonstrated in 100% of test speci-
mens in vitro and in over 50% in
vivo.15 The fretting disrupts the pas-
sive oxide layer and thereby in-
creases the potential for crevice
development and galvanic corrosion.

The number of metallic particles gen-
erated at the head-neck interface is
orders of magnitude less than the
number of polyethylene particles
generated by the femoral head articu-
lation with the acetabular liner, yet
the clinical significance of these parti-
cles is unclear. While fewer in num-
ber, the metal particles may act as a
third body to accelerate polyethylene
wear and/or act synergistically with
polyethylene particles to cause bone
lysis. Corrosion products from mod-
ular head tapers have been demon-
strated at the articulating surface of
the joint as well as in the capsule and
at distant sites of endosteal erosion.16
While a causal relationship has yet to
be established, it remains a reason for
concern (Fig. 6).
Modular heads offer distinct
advantages, their use is well estab-
lished, and the vast majority func-
tion without any clinically apparent
problem. The risk of wear debris,
corrosion, and dissociation can be
minimized by attention to detail
during implantation and by
improvements in manufacturing. If
the prosthesis is cemented, the head
A B
Fig. 6 A, Trunnion from a retrieved femoral stem demonstrates excessive wear. B,
Corresponding significant damage to the modular head component.
Vol 2, No 1, Jan/Feb 1994
should be impacted with several
firm blows on the back table prior to
implantation. Forceful blows
shortly after cement polymerization
can damage the implant-cement
interface. Assembly prior to inser-
tion is therefore advisable. When
implanting an uncemented stem,
the head should be impacted onto
the trunnion after implantation of
the stem, because the vibration of
striking the implant can disrupt the
lock of the Morse taper. In either
case, extreme care should be taken
to keep the interface clean, dry, and
free of any debris. Even a fraction of
a millimeter of blood can substan-
tially weaken the taper lock and
accelerate corrosion and wear.
Modular heads from different man-
ufacturers cannot be interchanged,
as they all have different dimen-
sions and taper angles.
There are a number of manufac-
turing refinements that can mini-
mize head-neck junction wear and
corrosion. Most important is tight-
ening of tolerances to minimize
dimensional mismatch, which will
minimize fretting and limit the
Robert L. Barrack, MD
ingress of fluid and thus minimize
corrosion. It has been noted that
automotive and machine-tool toler-
ances are up to eightfold higher than
the standards for medical tapers.17
Hardening by nitriding or nitrogen
implantation also can improve the
strength and wear resistance of the
Morse taper.14
Stems
Many current component designs
have incorporated modularity into
various design characteristics of the
stem. There are designs that feature
modularity between the stem and a
collar, a distal sleeve, a metaphyseal
segment, and/or proximal pads.
Modularity with the collar rep-
resents an attempt to reduce inven-
tory. Relatively few stems offer this
option. The extent to which modu-
lar collars effectively transfer load
has not been established. At least
one retrieved prosthesis has shown
significant fretting of a modular
collar.7
The rationale for stem modular-
ity is to achieve better fit and fill,
greater initial stability, and more
uniform stress distribution while
minimizing stress shielding, bone
loss, and incidence of thigh pain.
Proponents of stem modularity
believe that the modular compo-
nents offer optimal proximal me-
taphyseal fill and proximal stress
transfer with distal fit for initial tor-
sional stability. Modularity poten-
tially provides an adequate number
of proximal and distal geometry
combinations to facilitate the
achievement of maximal direct bone
contact with porous coating proxi-
mally and stem contact with
endosteal cortex distally.
The goal of distal modularity is to
obtain distal fit and centering of the
stem while reducing stem stiffness.
There is some evidence that distal
filling and centralization improve
the stability of uncemented compo-
nents. 18 There is also clinical evi-
21
Modularity of Prosthetic Implants

dence that cementless stems with ROM system, the Infinity system Distal modularity has been asso-
high degrees of flexural rigidity rel- (Wright Medical, Arlington, Tenn), ciated with erosion of the shaft and
ative to the surrounding femur are and the Richards Modular Hip migration of the distally modular
associated with a higher incidence of System (Smith & Nephew Richards, component in some cases (Fig. 8).
thigh pain.19 Memphis) and found somewhat This raises the concern of wear
An additional advantage of mod- different results. All the modular debris and lysis originating at this
ular stem design is the ability to interfaces were grossly stable, but interface.
address unusual femoral geome- minor degrees of fretting and sur- Although stem modularity offers
tries. This is particularly beneficial in face damage did occur. Although an advantage in complex primary
cases of excessive femoral antever- fewer particles were demonstrated and certain revision situations as an
sion, as is often seen in the chroni- (approximately 2 x 107), the number alternative to a custom uncemented
cally dislocated hip of a patient with of particles was highly dependent stem, the advantage remains theo-
congenital dysplasia of the hip or in on the method of measurement and retical in most primary cases.
revision situations in which the stem varied significantly from one speci-
has subsided into retroversion. men to another. In another study of
Although modular components the S-ROM system,22 minor degrees Total Knee Replacement
offer distinct advantages in these of surface damage and fretting were
revision and complex primary cases, seen. Improvement in the surface Tibial Inserts
the other potential advantages finish was recommended to mini- Modular tibial components offer
remain largely theoretical. mize fretting. As with head-neck a variety of options for the
Although photoelastic models tapers, tight specifications and sur- orthopaedist. The baseplate can be
have predicted more uniform stress face finish are important factors. implanted separately, and trial
distribution with proximal modular Clinical results with proximally reduction can be performed with
stems, plain radiographs and dual- modular stems have generally been modular trial inserts. The tourniquet
energy x-ray absorptiometry scans good. Dissociation has not been can then be deflated and the insert
have shown a high degree of proxi- reported and lysis has rarely been can be removed to facilitate control
mal bone loss and stress shielding observed, although it remains a of bleeding in the posterior aspect of
with designs such as that of the S- concern (Fig. 7). the knee and removal of excess
ROM system (Joint Medical Products,
Stamford, Conn).20 Although better
proximal fill may be obtained, greater
stiffness of the larger proximal meta-
physeal component may lead to
significant stress shielding. In addi-
tion, a number of investigators have
demonstrated a lack of correlation
between radiographic fit and fill and
clinical results, specifically, a reduc-
tion in the incidence of thigh pain.
As with other modular connec-
tions, the potential for failure of the
modular connection and generation
of wear debris remains a concern.
Cook et al21 tested the S-ROM sys-
tem under axial load in a saline
environment and found that slip-
page can occur under physiologic
loads. They found that this situa-
tion is more likely if the interface is
contaminated. At 8 million cycles, A B
over 8 x 107 particles in the 1- to 2- Fig. 7 A, Radiographic appearance of proximally modular stem immediately after surgery.
µm range were generated. Bobyn et B, Five years later, lysis is seen around the metaphyseal sleeve.
al8 performed similar tests on the S-

22 Journal of the American Academy of Orthopaedic Surgeons


Fig. 8 Erosion of distal bullet of distally
modular stem into cortical bone.
cement prior to final insertion of the
modular insert. Modular inserts pro-
vide a number of choices of thick-
ness as well as degree of constraint
of the articular surface. This gives
one the option of switching from a
posterior cruciate ligament (PCL)-
retaining insert to a PCL-sacrificing
insert utilizing the same tibial base-
plate.
Occasionally a revision procedure
is undertaken for excessive polyeth-
ylene wear or knee instability. Use of
a modular insert makes it possible to
simply change to a thicker and/or
more constrained liner without dis-
rupting the component-bone inter-
face. Modular tibial baseplates also
allow adjunctive fixation by the use
of screws through the baseplate,
which has been found to substan-
tially add to stability and decrease
micromotion in uncemented tibial
components, particularly in patients
whose bone quality is poor.
Unfortunately, modular tibial
components are associated with
significant disadvantages. In a num-
ber of early designs, the thickness of
the polyethylene was less than 5
mm. 23 Modular inserts also intro-
duce the possibility of failure of the
locking mechanism used to hold the
polyethylene component in place. At
Vol 2, No 1, Jan/Feb 1994
least one modular knee design has
been recalled because of a series of
failures of the locking pin.
With modular inserts there is also
the possibility of wear at the inter-
face between the polyethylene and
the metal baseplate. A membrane
invariably forms at this interface,
and concern has been expressed
about the possibility that this
increases the potential for late infec-
tion. To date, there is no evidence to
support this concern.24 Modular tib-
ial components can also increase the
likelihood of generation of particu-
late debris and associated osteolysis.
Peters et al 25 reported a 16% inci-
dence of osteolysis in an unce-
mented modular tibial component.
Contributing factors were thought
to be failure of thin polyethylene
modular inserts, abrasion of the tib-
ial spine with secondary wear,
impingement of the locking pin
against the femoral component, and
corrosion between the titanium
screws and the cobalt-chrome base-
plate. All of these factors are a direct
result of the modularity of the tibial
component.
Augmentation Devices
The use of metal augmentation
devices to replace deficient bone has
been another impetus to increase the
modularity of total-knee-replace-
ment components. Utilization of
these devices is generally faster and
technically easier than replacing the
defects with autograft or allograft
bone. Metal augmentation is more
appropriate for small and medium-
size defects than for large defects.
Metal wedges or blocks can be
cemented to the components, fixed
with screws, or snap-fitted. There is
some evidence that the block
configuration distributes the load
more evenly than does wedge aug-
mentation.26 The major disadvantage
is the potential for fretting or failure
of the interface, although these
events have not been reported.
Robert L. Barrack, MD
Because of this potential disadvan-
tage, current systems are split
between providing modular tibial
components that require assembly
and providing a large inventory of
one-piece integral components with
wedge or block augments incorpo-
rated into the tibial baseplate.
Stems
Modular stems add additional
fixation, which is often necessary
because of bone loss in revision knee
replacement. A press fit can be
obtained in the femoral and tibial
canals by utilizing a wide array of
lengths, diameters, and both straight
and curved options. This allows for
a hybrid type of fixation with
cementing of the surfaces and press-
fitting of the stems. These design fea-
tures have the added advantage of
providing reliable reproduction of
the mechanical axis, which is
difficult in many revision cases. The
press-fit stems are easier to revise
should this become necessary, since
cement does not have to be placed
into the medullary canal of the tibia
or femur. At least one clinical review
has reported improved results with
press-fitting of stems and cementing
of only the surface of the tibia and
femur.
Disadvantages include increased
potential for fracture of the tibial or
femoral shaft in an attempt to
achieve a press fit with large stems.
The large, stiff stems also may cause
stress shielding of the distal femur
and proximal tibia. In addition,
there is the ubiquitous concern of
generation of particulate debris
from the modular connection or fail-
ure of the connection. Press-fitting
of the stem also has the disadvan-
tage of dictating the placement of
the condylar surface of the femoral
or tibial components and the kine-
matics of the prosthesis. This places
additional responsibility on the
manufacturer to ensure that the
stem is in the appropriate location
23
Modularity of Prosthetic Implants
on the component. In some femoral
components, for instance, there is a
concern that the stem is posterior to
the femoral component, which
places the anterior femoral flange
anterior to the shaft of the femur.
This changes knee kinematics,
increases the patellofemoral force
with flexion, and effectively pro-
duces collateral ligament laxity and
potential instability with flexion.
Shoulder Arthroplasty
In recent years there been increasing
interest in humeral component mod-
ularity. Modular heads offer a wide
variety of diameters and sizes. The
humeral body can be implanted and
final tissue tension can be adjusted
with a variety of different head sizes.
Probably the single greatest advan-
tage of modular humeral compo-
References
1. Harris WH: A new total hip implant.
Clin Orthop 1971;81:105-113.
2. Cook SD, Thomas KA, Barrack RL, et al:
Tissue growth into porous-coated
acetabular components in 42 patients:
Effects of adjunct fixation. Clin Orthop
1992;283:163-170.
3. Lombardi AV Jr, Mallory TH, Kraus TJ,
et al: Preliminary report on the S-ROM
constraining acetabular insert: A retro-
spective clinical experience. Orthopedics
1991;14:297-303.
4. Barrack RL, Burke DW, Cook SD, et al:
Complications related to modularity of
total hip components. J Bone Joint Surg
Br 1993;75:688-692.
5. Hurley PT, Fehring TK, Braun ER, et al:
Polyethylene liners in modular porous
acetabular components: A comparative
analysis. Orthop Trans 1992;16:647-648.
6. Parsley BS: Current concerns with mod-
ular metal backed acetabular compo-
nents. Orthop Trans 1992;16:648-649.
7. Fehring TK, Hurley PT, Braun ER, et al:
Modular acetabular components: Are
they really metal backed? Orthop Trans
1992;16:646-647.
8. Bobyn JD, Tanzer M, Krygier JJ, et al:
Concerns with modularity in total hip
arthroplasty. Clin Orthop (in press).
24
nents is the ability to revise or insert
a glenoid component without
removing the humeral component.27
Hemiarthroplasty is often per-
formed in young patients for avas-
cular necrosis or posttraumatic
arthritis. Modular components
allow implantation of a glenoid com-
ponent at a later date without the
necessity of revising the humeral
component.
As with modular hip and knee
components, the potential for genera-
tion of wear debris is a concern. Lysis
has not been reported to date; how-
ever, experience with these modular
components is of very short duration.
The other major concern is com-
ponent dissociation. There have been
a few reported cases of humeral head
dissociation with early designs. 28
Dissociation of a modular glenoid
has also been reported.29 The higher
9. Collier JP, Mayor MB, Jensen RE, et al:
Mechanisms of failure of modular pros-
theses. Clin Orthop 1992;285:129-139.
10. Huk OL, Bansal M, Betts F, et al:
Generation of polyethylene and metal
debris from cementless modular acetab-
ular components in total hip arthro-
plasty, in Transactions of the 39th Annual
Meeting of the Orthopaedic Research
Society 1993. Rosemont, Ill: Orthopaedic
Research Society, 1993, vol 18, sect 2, p
506.
11. Krushell RJ, Burke DW, Harris WH:
Range of motion in contemporary total
hip replacement: The impact of modular
head-neck components. J Arthroplasty
1991;6:97-101.
12. Collier JP, Surprenant VA, Jensen RE, et
al: Corrosion at the interface of cobalt-
alloy heads on titanium-alloy stems.
Clin Orthop 1991;271:305-312.
13. Cook SD, Barrack RL, Clemow AJT:
Corrosion and wear at the head-neck
interface of modular uncemented
femoral stems. J Bone Joint Surg Br (in
press).
14. Cook SD, Barrack RL, Baffes GC, et al:
Wear and corrosion of modular inter-
faces in total hip replacements. Clin
Orthop (in press).
Journal of the American Academy of Orthopaedic Surgeons
shear forces on modular shoulder
implants was cited in both reports.
Review of complications reported to
the Food and Drug Administration
between 1986 and July 1993 reveals
that 27 of 55 cases (49%) involving
shoulder implants were the result of
dissociation of a modular compo-
nent. There were 12 humeral head
dissociations and 15 glenoid liner
dissociations
Currently, two basic types of
taper are available. The main differ-
ence is whether the humeral compo-
nent contains a male or female taper.
There is some basis for believing that
the male-taper femoral component
may provide a stronger locking
mechanism, which would theoreti-
cally be less likely to dissociate.
However, a male-taper component
neutralizes the advantage of being
able to revise or implant a glenoid
15. Dujovne AR, Bobyn JD, Krygier JJ, et al:
Fretting at the head/neck taper of mod-
ular hip prostheses, in Transactions of the
39th Annual Meeting of the Orthopaedic
Research Society 1993. Rosemont, Ill:
Orthopaedic Research Society, 1993, vol
18, sect 1, p 83.
16. Urban RM, Jacobs JJ, Gilbert JL, et al:
Corrosion products of modular hip
prostheses: Microchemical identification
and histopathological significance, in
Transactions of the 39th Annual Meeting of
the Orthopaedic Research Society 1993.
Rosemont, Ill: Orthopaedic Research
Society, 1993, vol 18, sect 1, p 81.
17. Dujovne AR, Bobyn JD, Krygier JJ, et al:
Surface analysis of the taper junctions of
retrieved and in-vitro tested modular
hip prostheses. Trans Soc Biomaterials
1993;16:276.
18. Noble PC, Kamaric E, Alexander JW, et
al: What makes cementless implants
work? [exhibit]. Presented at the 56th
Annual Meeting of the American
Academy of Orthopaedic Surgery, Las
Vegas, Feb 9-14, 1989.
19. Skinner HB, Curlin FJ: Decreased pain
with lower flexural rigidity of unce-
mented femoral prostheses. Orthopedics
1990;13:1223-1228.

20. Mortimer E, Brooks CE: Evaluation of
femoral bone remodelling after nonce-
mented total hip arthroplasty using
dual energy x-ray absorptiometry.
Orthop Trans 1993;17:87.
21. Cook SD, Manley MT, Kester MA, et al:
Torsional resistance and wear of a mod-
ular sleeve-stem hip system. Clin
Materials 1993;12:153-158.
22. Krygier JJ, Bobyn JD, Dujovne AR, et al:
Strength, stability and wear analysis of a
modular titanium femoral hip prosthesis
tested in fatigue. Orthop Trans 1992;16:102.
23. Chillag KJ, Barth E: An analysis of poly-
ethylene thickness in modular total
component since it interferes to
some degree with exposure of the
glenoid.
Vol 2, No 1, Jan/Feb 1994
knee components. Clin Orthop 1991;273:
261-263.
24. Ranawat CS, Flynn WF Jr, Maynard MJ:
Modular total knee systems, in Rand JA
(ed): Total Knee Arthroplasty. New York:
Raven Press, 1993, pp 435-441.
25. Peters PC Jr, Engh GA, Dwyer KA, et al:
Osteolysis after total knee arthroplasty
without cement. J Bone Joint Surg Am
1992;74:864-876.
26. Humble RS, Fehring TK, Peindl RD:
Augmentation wedges versus blocks for
deficient bone stock in total knee arthro-
plasty. Presented at the 60th Annual
Meeting of the American Academy of
Robert L. Barrack, MD
Orthopaedic Surgeons, San Francisco,
Feb 18-23, 1993.
27. Shaffer BS, Giordano CP, Zuckerman
JD: Revision of a loose glenoid com-
ponent facilitated by a modular
humeral component: A technical
note. J Arthroplasty 1990;5(suppl):S79-
S81.
28. Cooper RA, Brems JJ: Recurrent disas-
sembly of a modular humeral prosthe-
sis: A case report. J Arthroplasty
1991;6:375-377.
29. Driessnack RP, Ferlic DC, Wiedel JD:
Dissociation of the glenoid component
in the Macnab/English total shoulder
25
 Anterior Cruciate Ligament Insufficiency:
Principles of Treatment
Robert L. Larson, MD, and Mario Taillon, MD, FRCS(C)

Abstract

Anterior cruciate ligament (ACL) injuries often result in functional disability, eral band. The bands are actually a
particularly in jumping, cutting, and deceleration activities. Some patients can continuum of fascicles, different
accommodate to this functional loss, while others require surgical reconstruc- portions of which are taut through-
tion of the ligament to provide stability and to protect the meniscus from fur- out the range of motion, allowing
ther injury. Nonoperative management involves an intensive rehabilitation the ligament to be functional in all
program, patient counseling about high-risk activities, and measures to prevent degrees of flexion and extension.
recurrent injuries. Surgical reconstruction of the ACL involves the technical The anteromedial portion is tighter
factors of graft selection, positioning, fixation, and tensioning and the avoid- in flexion, and the posterolateral
ance of stress risers. A supervised and intensive rehabilitation program is nec- portion is tighter in extension.
essary to achieve optimal results.
J Am Acad Orthop Surg 1994;2:26-35
Biomechanics and
Function

The ACL functions as the primary

The anterior cruciate ligament
(ACL) has been one of the most
extensively studied ligaments in the
body. Its importance in knee func-
tion has been emphasized, particu-
larly for athletes who require knee
stability in activities such as run-
ning, cutting, and kicking. Although
an improvement in function can be
achieved by present surgical tech-
niques, the biologic and physiologic
characteristics of the normal ACL
are not fully restored. The normal
ACL has proprioceptive senses that
help protect the knee joint during
use; it has a degree of viscoelasticity
that allows it to stretch and return to
its resting length without structural
damage; it has a physical configura-
tion with multiple bands and a mul-
tiaxial function that guides the knee
through its complex helicoid
motion, including both rotational
and translational forces; and it has
broad insertion sites, which allow
the normal kinematics of knee
motion to occur with stability in
activities such as walking, running,
jumping, and kicking.
Anatomy
The ACL is intracapsular but
extrasynovial. Its predominant
source of blood supply is the middle
genicular artery, which arises from
the popliteal artery and pierces the
posterior capsule. The inferior
medial and lateral genicular arteries
also vascularize the ACL via the fat
pad. The ACL has been shown to
contain nerve fibers of the size most
consistent with transmitting pain as
well as mechanoreceptors that are
postulated to function in proprio-
ception.
The femoral origin of the ACL is
on the lateral wall of the intercondy-
lar notch at its posterior aspect and is
oriented in the longitudinal axis of
the femur. The tibial attachment is
parallel to the anteroposterior axis of
the tibia and is on the anterior aspect
of the tibial plateau near the tibial
spines. This produces a twist of the
ACL fibers as the knee moves from
extension to flexion. Traditionally,
the ACL has been divided into an
anteromedial band and a posterolat-
restraint to limit anterior tibial dis-
placement, as a secondary restraint
to tibial rotation, and as a minor sec-
ondary restraint to varus-valgus
angulation at full extension. It pro-
vides nearly 90% of anterior transla-
tional stability of the tibia. Greater
anterior displacement occurs at 30
degrees of flexion. The contribution
of the ACL in restraining rotation is
greater in full extension than it is in
early flexion. If a primary restraint
has been torn but a secondary
restraint remains intact, clinical test-
ing may reveal only slight laxity.
Dr. Larson is Clinical Professor of Surgery,
School of Medicine, Oregon Health Sciences Uni-
versity, Portland; and is in private practice in
Eugene, Oregon. Dr. Taillon is in private prac-
tice in Calgary, Alberta, Canada.
Reprint requests: Dr. Larson, Orthopedic and
Fracture Clinic of Eugene, 1200 Hilyard, Suite
600, Eugene, OR 97401.
Copyright 1994 by the American Academy of
Orthopaedic Surgeons.

26 Journal of the American Academy of Orthopaedic Surgeons

 Robert L. Larson, MD, and Mario Taillon, MD, FRCS(C)

When both primary and secondary

restraints are torn, marked laxity to
clinical testing is evident.1
Six degrees of freedom are
described to show the relationship of
the tibia and the femur to each other
(Fig. 1). These are broadly divided
into rotational and translational. The
three rotational degrees of freedom
are flexion-extension, internal-exter-
nal axial tibial rotation, and varus-
valgus (adduction-abduction). The
three translational degrees of free-
dom are anterior-posterior tibial dis-
placement, medial-lateral tibial
displacement, and proximal-distal
(joint distraction-compression). Con-
straints to excessive degrees of
motion in these freedoms are pro-
vided by ligamentous structures
around the knee. Rupture or chronic
deficiency of the ACL allows a com-
bination of abnormal anterior trans-
lation and rotation of the tibia.
Noyes et al2 performed a study on
the tensile properties of the human
ACL and reported that the ultimate
load for the young ACL was 1,725 ±
269 N. Since that study, the criteria for
the strength of autograft, allograft,
and synthetic substitutes have been
set at 1,730 N. However, factors other
than ultimate strength will influence
performance, such as biologic
changes in graft materials over time
and the effects of repetitive loading.

Clinical Signs and

Symptoms

The history of ACL injury is often a

noncontact injury that occurred
while changing direction or landing
from a jump. The patient may state
that a “pop” was felt or heard. Fig. 1 Translation and rotation around each of the three axes provide the six degrees of free-
dom that allow knee motion.
Swelling (hemarthrosis) is noted
within a few hours. The patient may
say that his or her knee felt too
unstable to continue playing and
had difficulty bearing weight. tions if certain principles are fol- results of the physical examination
A careful physical examination lowed. It is essential that the patient of the injured knee must be com-
will reveal most ligament disrup- be relaxed and comfortable. The pared with those of the normal knee.

Vol 2, No 1, Jan/Feb 1994 27

Anterior Cruciate Ligament Insufficiency
A moderate to severe effusion is
usually present, and this may limit
range of motion. Range of motion
may also be limited by pain, ham-
string spasm, ACL stump impinge-
ment, and meniscal pathology.
If a tense effusion is accompanied
by severe pain, aspiration under
sterile conditions provides relief and
allows the aspirate to be examined
for the presence of blood. Injection of
a mixture of saline and a local anes-
thetic may be used to provide addi-
tional relaxation and to aid in the
clinical examination.
Lachman Test
This is an excellent test for ACL
laxity. The knee is placed in a posi-
tion of 20 to 30 degrees of flexion,
the femur is stabilized, and an ante-
riorly directed force is applied to
the proximal calf. The examiner
should estimate the displacement
(in millimeters) and assess the
firmness of the endpoint (graded as
firm [normal)], marginal, or soft).
Any perceived side-to-side differ-
ence is usually significant.
Pivot Shift Test
There are many variations to the
pivot shift test, including the classic
test, the Losee test, the side-lying
test, and the flexion-rotation
drawer test. They are all based on
the fact that in very early flexion
there is anterior subluxation of the
tibia and that with further flexion
(20 to 40 degrees) the posterior pull
of the iliotibial tract reduces the
tibia. It is the relocation event that
the clinician usually grades subjec-
tively as 0 (absent), 1+ (pivot glide),
2+ (pivot shift), or 3+ (momentary
locking).
Anterior Drawer Test
This test is performed at 90
degrees of flexion. This position
may be difficult to achieve in the
acutely injured knee since ham-
string spasm influences test results.
28
Many normal knees have significant
excursion in this position. For these
reasons, it is the least reliable test.
Imaging the ACL-Injured
Knee
Plain Radiography
Plain radiography should be the
first imaging study ordered. This is
important to rule out other abnor-
malities and associated injuries. An
avulsion of the insertion of the ACL
may be seen on the lateral or the tun-
nel view. A vertically oriented
Segond fracture is often associated
with an ACL injury. This results
from excessive tension on the lateral
capsular ligament of the knee. The
fracture is located posterior to
Gerdy’s tubercle and superior and
anterior to the fibular head. The
anteroposterior standing radio-
graph can be used to evaluate any
joint-space narrowing, as well as the
presence of a varus deformity.
Usually, clinical examination and
plain radiographs are sufficient.
Occasionally, special tests may be
necessary to evaluate the integrity of
the ACL or the meniscus. These
additional tests include arthrogra-
phy, magnetic resonance (MR)
A B
Fig. 2 Magnetic resonance images of a normal (A) and an abnormal (B) ACL (arrow).
Journal of the American Academy of Orthopaedic Surgeons
imaging, instrumented measure-
ment of knee motion, examination
under anesthesia, and arthroscopy.
Arthrography
The role of arthrography is
mainly to evaluate the status of the
menisci. Interpretation of the arthro-
graphic appearance of the ACL is
operator-dependent and may be
misleading in the case of an intact
synovial sheath surrounding the
ACL. The cost of arthrography is
significantly less than that of MR
imaging, but the procedure may be
uncomfortable for the patient. It
does have a role for the patient who
is claustrophobic or who has other
contraindications to MR imaging.
MR Imaging
Although the overall accuracy of
MR imaging in assessing the ACL is
approximately 95%, MR imaging of
the knee with a suspected ACL
deficiency should not be used rou-
tinely. The normal ACL appears as a
smooth, well-defined structure of low
signal intensity on a sagittal image
through the intercondylar notch. The
abnormal ACL shows discontinuity
of the ligament in the sagittal plane
(Fig. 2). If there is an acute injury, the
T2-weighted sequences will demon-

strate high signal intensity within the
ligamentous substance secondary to
edema and local hemorrhage.
Another finding may be a wavy irreg-
ular contour of the anterior margin of
the ACL, indicating loss of tautness.
Acute kinking or anterior bowing of
the posterior cruciate ligament may
also indicate an ACL tear. Magnetic
resonance imaging also allows detec-
tion of bone abnormalities not seen on
conventional radiographs. Approxi-
mately 60% of ACL injuries have
accompanying bone abnormalities
often referred to as “bone bruises”3
(Fig. 3). The significance and the long-
term sequelae of these lesions have
yet to be determined.
Instrumented Ligament Testing
Instrumented ligament testing
devices such as the KT-1000
arthrometer have been used to
measure anteroposterior displace-
ment. These devices may be used
preoperatively, intraoperatively,
and postoperatively. In a unilater-
ally injured patient, a right-left dif-
ference of less than 3 mm is
classified as normal motion and a
right-left difference on any test of 3
mm or greater is classified as
pathologic. 4 The reliability of the
Fig. 3 Magnetic resonance image showing
a bone bruise (arrow).
Vol 2, No 1, Jan/Feb 1994
Robert L. Larson, MD, and Mario Taillon, MD, FRCS(C)
test may be influenced by the
tester’s experience and proficiency.
Examination Under Anesthesia
and Arthroscopy
When the status of the ACL and
menisci remains in doubt, examina-
tion under anesthesia with the
patient completely relaxed gives a
more reliable index of ligamentous
laxity. This is followed by arthro-
scopic inspection of the ACL,
menisci, and other joint structures.
Such an evaluation is usually not
necessary in the chronic case when
the functional status of the knee has
been tested. It is more often used in
the acute or subacute situation when
a definitive diagnosis is imperative.
Treatment Selection
Physicians who treat acute torn
ACLs must understand that there is
still no ideal method that ensures
restoration of normal function. The
final decision between operative and
nonoperative treatment must be
based on many variables that are
unique to each individual. Among
factors to be considered are the pres-
ence or absence of other lesions
involving the knee, the age and level
of activity of the patient, the degree
of instability, the type of injury to the
ACL, and the ability of the patient to
comply with the rehabilitation pro-
gram. The type of sporting activity
in which the patient wishes to par-
ticipate is also important. Jumping,
cutting, and pivoting sports place
the ACL-disrupted patient at risk of
injury, and many patients treated
nonoperatively are unable to return
to these types of activities.
Patients with a chronic ACL
deficiency must be evaluated to
determine whether their instability
is producing a functional disability
and whether their activity level com-
bined with their instability may
cause meniscal damage. The inci-
dence of meniscus tear in an acute
ACL disruption is greater than 50%
in most studies. There are a greater
number of lateral meniscal tears
than medial tears.4 If judged to be
stable, lateral meniscal tears poste-
rior to the popliteal tendon may be
left alone; they will either heal or be
asymptomatic. The decision as to
whether to evaluate the status of the
menisci must be individualized to
each patient and to his or her
progress in the rehabilitation pro-
gram. The menisci should be evalu-
ated by repeat clinical examination.
Arthrography, arthroscopy, or MR
imaging may also be utilized.
Arthroscopy still appears to be the
most accurate method of diagnosing
a meniscal tear in a patient with per-
sisting symptoms.
Because absence of the meniscus
enhances joint deterioration, the
goal should be to preserve as much
meniscal tissue as possible with
every attempt to restore meniscal
function to as near normal as pos-
sible.
Patient Selection
The primary candidates for ACL
surgery are those patients with an
active lifestyle who have an acute
ACL deficiency and those with a
chronic ACL deficiency that results
in functional instability that endan-
gers the menisci.
Daniel et al5 did outcome studies
on 292 patients who had acute ACL
injuries over a 12-year period. Nine-
teen percent underwent surgery
within the first 3 months. Another
19% requested surgery over the
next 5 years. Sixty-two percent were
able to function satisfactorily with-
out an ACL.
Two factors were found to be
most predictive of who would need
later surgery. The first was the num-
ber of hours per year of level I or II
sports (jumping, pivoting, lateral-
29
Anterior Cruciate Ligament Insufficiency
motion sports) in which the patient
participated prior to injury. The sec-
ond factor was the maximum man-
ual displacement difference between
the affected and unaffected knees as
measured by ligament testing. Those
patients who had less than 5 mm of
side-to-side difference and who par-
ticipated for 50 hours or less in level
I or II sports had a low risk of need-
ing further surgery. Those patients
with a 7-mm or greater side-to-side
difference with more than 50 hours
of level I or II sports activity were in
the high-risk group.
Nonoperative Management
The initial nonoperative treatment
of the acutely injured ACL is splint-
ing and use of crutches for comfort
and early active range of motion.
The goal is to obtain full range of
motion as compared with the nor-
mal knee. Strengthening is achieved
by using closed-chain weight-bear-
ing exercises. The goal is to return
the function of the hamstring and
quadriceps muscles to within 90% of
that of the contralateral limb as
determined by isokinetic testing or
functional testing, such as the hop
test. Patients should also receive
counseling concerning high-risk
activities and measures to prevent
recurrent injuries.
The role of functional knee brac-
ing remains controversial. The pro-
posed mechanisms of protection are
mechanical constraint of joint motion
and improvement of joint-position
sense. It has been shown that func-
tional knee braces decrease anterior
joint subluxation at low loads, but
not at physiologic loads. The concept
that braces function to enhance joint
proprioception has been investi-
gated, without definitive results.
Others have evaluated brace use by
performing functional tests in brace
users in and out of their braces. The
fact remains that some patients
30
believe they have better function in a
brace, allowing them to participate in
an increased level of sporting activ-
ity. The use of braces cannot be sub-
stituted for exercise to achieve and
maintain quadriceps or hamstring
strength. The use of a brace is an indi-
vidual and optional decision.
Patients with grade III instability
who participate in vigorous activi-
ties, especially those producing rota-
tional stress to the knee, cannot be
assured that bracing will provide
adequate protection from further
injury. A modification of activity
level will be required if a nonopera-
tive course is to be pursued.
Operative Management
Surgical techniques for intra-articu-
lar and extra-articular reconstruc-
tion of the ACL have included the
use of the iliotibial band, the semi-
tendinosus and gracilis tendons, the
patellar tendon, the meniscus, allo-
graft tissue, and various synthetic
materials.
Graft Selection
Factors considered in the selec-
tion of autogenous graft to replace
the deficient ACL include the bio-
mechanical properties of the graft,
including initial strength; the ease of
graft harvest; the security of graft
fixation; potential donor-site mor-
bidity; and individual patient con-
siderations.4 Noyes et al2 examined
the biomechanical properties of nine
different autograft tissues. Their
results showed that a bone–patellar
tendon–bone complex (14-mm-
wide graft) was approximately 1.6
times as strong as normal human
ACL. The semitendinosus dis-
played only 70% of the strength of
the normal human ACL; the gracilis,
50%; the distal iliotibial tract, 50%;
and the quadriceps–patellar retinac-
ulum–patellar tendon complex,
only 14% to 21%. Other studies have
Journal of the American Academy of Orthopaedic Surgeons
shown that multiple strands of
semitendinosus or semitendinosus-
gracilis composites are stronger
than a normal ACL.
Autogenous tissue used as a graft
merely provides a collagen lattice,
not a structural support, in the early
stages of graft resorption, revascu-
larization, and restructuring with
new collagen. Histologic and elec-
tron microscopy studies have shown
that the collagen tissue produced
after ACL reconstruction does not
match the size or density of normal
ACL collagen fibers.6
Surgeons vary in preference of
autogenous tissue. The patellar ten-
don that has the greater initial tensile
strength, provides greater bulk, and
allows more secure bone-to-bone
fixation is preferred by some. The
tensile strength of a patellar-tendon
graft has been shown to increase by
30% when the tendon is twisted 90
degrees. Others prefer the semi-
tendinosus tendon, which is often
double-looped, used with the gra-
cilis tendon, or quadruple-looped
when endoscopic fixation is used.
The semitendinosus also provides
greater elasticity, requires smaller
drill holes for insertion, is easier to
harvest, and carries less risk of later
patellofemoral pain.
A review of the literature pub-
lished between 1981 and 1986
showed that the percentage of
patients with a 0-1 Lachman test and
a 0-1 pivot shift test was the same 2
years after surgery no matter what
autogenous tissue was used ini-
tially.7
Graft Fixation
The weak link in the reconstructed
knee in the early postoperative
period is the point of ligament
or graft fixation. Kurosaka et al 8
performed fixation studies on
bone–patellar tendon–bone fixation,
and Robertson et al9 studied soft-tis-
sue fixation to bone; their results are
shown in Tables 1 and 2, respectively.
 Robert L. Larson, MD, and Mario Taillon, MD, FRCS(C)

Variables that occur in individual graft does not necessarily ensure

Table 1
Strength After Bone–Patellar
patients may influence which autog- that impingement will not occur.
Tendon–Bone Fixation8 enous graft source is appropriate. A Graft tensioning is important in
history of patellar tendinitis or achieving a successful ACL recon-
Maximum Tensile patellofemoral pain or the finding of struction. A graft that is too tight
Device Strength, N a short, narrow patellar tendon may may lead to poor range of motion,
necessitate the use of another autog- and a graft that is too loose may lead
Kurosaka 9.0 enous graft source. A previous pes to instability. It appears that a 5- to
screw 475.8 anserinus transplant or inadequate 8-lb pull is adequate to provide
AO 6.5 screw 214.8 size of the hamstring tendons may proper tensioning. Graft tension
Sutures over negate this source of graft material. should be checked in different posi-
buttons 248.2
tions of knee flexion and extension
Staples 128.5
intraoperatively.
Surgical Technique

Graft-Site Morbidity Appropriate surgical technique is Extra-articular

Bone–patellar tendon–bone har-
vest has resulted in rare cases of
patellar fracture and patellar-ten-
don rupture. Some animal studies
have shown significantly decreased
patellar-tendon strength at 6
months after harvesting of the mid-
dle third of the patellar tendon. The
clinical significance in humans
remains to be shown.
Several studies have compared
the incidence of anterior knee pain
following ACL reconstruction using
hamstring tendons and autograft or
allograft patellar tendon.10 Even with
modern rehabilitation protocols,
there is an increased incidence of
anterior knee pain in patients receiv-
ing bone–patellar tendon–bone
autografts. Whether this anterior
knee pain is functionally significant
has not been shown.
Table 2
Strength After Soft-Tissue Fixation
to Bone9
Maximum Tensile
Device Strength, lb
Screw with
washer 14
Barbed staple 11
Stone staple 8 femoral impingement of the graft
Screw with plate 5 throughout a full range of motion.
very important in ensuring the
proper function of the reconstructed
ACL, as well as in decreasing wear
and increasing its longevity. These
factors are much more important
than the type of graft tissue or
whether an open or endoscopic tech-
nique is used for reconstruction.
It is clear that the normal anatomy
of the ACL cannot be completely
reproduced. It is of utmost impor-
tance that the graft be positioned in
as near an anatomic position as pos-
sible that will permit a full range of
motion, provide stability, and allow
no impingement. This goal can be
achieved through various means,
either endoscopically or through an
open technique (Fig. 4).
Femoral position can be achieved
by routing the graft “over the top” or
through a bony tunnel. If the over-
the-top method is used, it is neces-
sary to provide a 4- to 5-mm
deepened groove to approximate
the posterior attachment site of the
ACL. Tunnel orientation and con-
tour are important to avoid stress
risers that may lead to increased
wear and graft failure. Avoidance of
impingement can be achieved by
appropriate positioning of the graft
on the tibial side and performing
adequate notchplasty to avoid
So-called isometric placement of the
Reconstruction
Wide variability exists in the
reported results of extra-articular
procedures to control ACL instabil-
ity due to the multiplicity of indica-
tions and techniques. The consensus
is that in the active individual, an
extra-articular reconstruction will
stretch out, especially if its purpose
is to hold the tibia in external rota-
tion.
Extra-articular reconstructions
are used by some surgeons in the
less active or older individual whose
instability produces functional limi-
tations in his or her normal activities.
To be effective, the reconstruction
must be anchored near the isometric
point on the femoral condyle in rela-
tion to Gerdy’s tubercle. This point is
just posterior to the superior attach-
ment of the lateral collateral liga-
ment. Proper attachment may allow
the normal coupling of the anterior
force on the tibia and the rotational
forces to reduce abnormal subluxa-
tion of the lateral tibial plateau.
Most reports suggest that extra-
articular procedures provide no
benefit to augment intra-articular
reconstructions.
Autografts and Allografts
Both experimental and clinical
observations have shown that auto-
grafts undergo biologic and bioma-

Vol 2, No 1, Jan/Feb 1994 31

Anterior Cruciate Ligament Insufficiency

process does not appear to alter the

biomaterial properties of the graft.
Secondary methods of steriliza-
tion, such as the use of ethylene oxide
and gamma radiation, have been
used to treat the graft for bacterial
and viral contamination. These pro-
cedures have been associated with
alterations in graft properties and a
marked inflammatory response
when ethylene oxide was used.
The advantage of an early decrease
in morbidity when using an allograft
may be attractive to some, but there is
little evidence that the long-term
results are better than those associ-
ated with the use of autogenous tis-
sues. Therefore, this advantage must
A B
be weighed against the possible risks
of using an allograft.

Prosthetic Ligaments
Augmentation of autogenous tis-
sue has been proposed as a method of
increasing the initial tensile strength
of the graft, as an enhancement to
fixation, and as a means of providing
increased length when necessary.11
The hypothesis is that with a compos-
ite graft of autogenous and synthetic
material, the stiffer material will carry
most of the load. During the early
phases of postoperative healing, the
tensile strength of the autogenous tis-
sue is markedly compromised as it
revascularizes and new collagen is
C
being formed. The synthetic material
Fig. 4 Methods of reconstruction of the ACL. A, The patellar tendon is harvested and taken assumes a load-sharing function with
through a tibial drill hole and “over the top.” B, Dual drill holes through the tibia and femur
with interference-screw fixation of the bone plugs. C, A double loop of semitendinosus ten- the autogenous tissue during this
don is used as the graft and taken over the top of the femoral condyle laterally. Note the time period. Fixation of the synthetic
deepening of the groove to provide a near-“isometric” placement. material at one end only prevents the
autogenous tissue from being stress
shielded, which would diminish its
terial remodeling. 6 The biologic shown to undergo a similar, albeit later capacity to develop tensile
remodeling involves a process of tis- slower, remodeling process. Both strength. The cost of the synthetic
sue ischemia and cell death, revas- autografts and allografts are weak- devices used for augmentation and
cularization, cellular proliferation, est at 6 to 12 weeks. the reported results suggest that their
and eventual tissue remodeling. Deep-freezing and freeze-drying use should be limited to specific indi-
This is a gradual process, which may have been shown to be effective cations, such as the presence of weak
take 6 months or more. The biomate- methods for rendering allografts less tissue or the need for enhancement of
rial-remodeling process never yields antigenic, probably by killing cells length or fixation.
a tissue that is as strong as it was and denaturing the histocompatibil- The use of a synthetic material as a
originally. Allografts have been ity antigens on their surface. This true prosthetic device for ACL

32 Journal of the American Academy of Orthopaedic Surgeons


replacement has certain limitations
that must be recognized. First and
foremost is that the device is ulti-
mately going to fail. Fatigue, fraying,
and wear have resulted in an unac-
ceptably high rate of failure. Thus, it
is our opinion that prosthetic replace-
ment of the ACL has limited applica-
tions (e.g., as a salvage procedure in a
patient who has undergone multiple
attempts at ACL reconstruction).
Rehabilitation
Postoperative rehabilitation has
emerged as an extremely important
aspect of the care of the ACL-
deficient patient. Previously, reha-
bilitation of the ACL-reconstructed
knee focused on protection of the
new ligament, with blocking of full
extension and avoidance of active
quadriceps function in the terminal
degrees of extension. These precau-
tions led to stiffness, weakness, and
patellofemoral problems.
Recently, Shelbourne and Nitz12
advocated an accelerated rehabilita-
tion protocol. The objective of their
protocol remains early and long-
term maintenance of full knee exten-
sion as measured by the ability of the
ACL-reconstructed knee to extend
as much as the opposite normal
knee. This protocol was based on the
use of a central-third bone–patellar
tendon–bone graft. The exact
method of attaining the different
goals of rehabilitation may vary
depending on the graft used and the
type of fixation, but the principles
are similar. Shelbourne and Nitz
divided their accelerated rehabilita-
tion program into four phases:
Phase I: Preoperative Period
The goal is to obtain full range of
motion compared with the normal
knee. At this time, the patient may be
educated about the details of the
operative procedure and the postop-
erative rehabilitation program.
Vol 2, No 1, Jan/Feb 1994
Robert L. Larson, MD, and Mario Taillon, MD, FRCS(C)
Phase II: 0 to 2 Weeks After
Surgery
The goals are to achieve full
extension, allow wound healing,
maintain adequate quadriceps
control, minimize swelling, and
achieve flexion of 90 degrees. Full
extension must be achieved early,
or the notch may fill in with scar
tissue and cause a permanent
block to extension.
Phase III: 3 to 5 Weeks After
Surgery
The goals in this phase are to
maintain full extension and increase
flexion up to full range of motion.
Exercises such as knee bends, Stair-
Master use, and bicycling may be
performed.
Phase IV: 6 Weeks After Surgery
The goal is to maintain motion
and gradually increase strength and
agility depending on the patient’s
progress and desire to return to
sports activities. Increased strength
and agility are best achieved by
using closed-chain weight-bearing
exercises.
ACL Injury in the
Immature Athlete
Traditionally, ACL injuries in the
immature athlete have been thought
to be predominantly tibial-eminence
avulsion fractures. Treatment of
these injuries has been well under-
stood. Nondisplaced and minimally
displaced fractures are treated with
closed reduction, and displaced frac-
tures are treated with open reduc-
tion and internal fixation that does
not violate the growth plate.
Recently, there appear to be an
increasing number of midsubstance
ACL tears in immature athletes. This
may be due to improved diagnostic
testing or increasing participation in
competitive athletics by skeletally
immature athletes.
McCarroll et al13 studied adoles-
cent athletes with open or closing
epiphyses who sustained an ACL
injury. Forty-two percent were able to
return to their original sport, but all
complained of “giving way” in spite
of bracing and a rehabilitation pro-
gram. At follow-up, 50% were found
to have meniscal tears. Reconstruc-
tion of the ACL was done at the age of
13 to 16 years, and 92% of patients
were able to return to their original
sport. No abnormal growth as a result
of damage to the growth plate from
the intra-articular reconstruction was
reported.
Preservation of the menisci is the
primary goal in treatment of these
patients. For the prepubescent child
with wide-open physes, an initial
course of rehabilitation with avoid-
ance of activities that would cause
meniscal damage is the initial goal.
This would allow passage through
the growth spurt and closing of the
physis, at which time ACL recon-
struction could be done safely.
Complications of ACL
Surgery
General complications such as anes-
thetic mortality must always be kept
in mind, but are rare in this usually
young, healthy population. The sur-
geon should be ever mindful of the
possibility of fluid extravasation and
compartment syndrome when per-
forming endoscopic techniques. As
with other surgery on the knee, deep
venous thrombosis and infection are
also possible.
Reflex sympathetic dystrophy
has been reported to be associated
with knee trauma and ACL surgery.
The incidence has generally been
less than 1%.
Nerve and vascular injury can
occur with ligamentous surgery,
although the incidence is less than
1%. A careful neurovascular exami-
nation performed at the initial eval-
33
Anterior Cruciate Ligament Insufficiency
uation would obviate suspicion of its
having been surgically incurred.
Flexion contracture, quadriceps
weakness, and patellar irritability
are the most frequent problems after
ACL reconstruction.
Joint Stiffness
Proper surgical techniques and
rehabilitation help reduce the inci-
dence of joint stiffness. A knee with a
significant flexion contracture repre-
sents a greater impairment than an
ACL-deficient knee. The term
“arthrofibrosis” has been used to
describe the knee stiffness that devel-
ops following ACL reconstruction.
The pathophysiology has been
shown to be inflammation of the fat
pad and synovium followed by
thickening of the capsule, which
obliterates the suprapatellar pouches
and medial and lateral gutters. The
patellar tendon becomes shortened
and may produce patella baja and
articular damage.
The patient presents with the
inability to regain motion, quadriceps
weakness, marked decreased patellar
mobility, and some skin and soft-tis-
sue changes. Paulos et al 14 have
defined three stages: stage 1 (early
stage [2 to 6 weeks]), with findings of
decreased extension, quadriceps lag,
swelling, failure to progress in phys-
iotherapy, and decreased patellar
mobility; stage 2 (active stage [6 to 30
weeks]), with findings of marked
decrease in range of motion, quadri-
ceps atrophy, decreased patellar
References
1. Grood ES, Noyes FR: Diagnosis of knee
ligament injuries: Biomechanical pre-
cepts, in Feagin JA Jr (ed): The Crucial
Ligaments: Diagnosis and Treatment of Lig-
amentous Injuries About the Knee. New
York: Churchill Livingstone, 1988, pp
245-260.
2. Noyes FR, Butler DL, Grood ES, et al:
Biomechanical analysis of human liga-
ment grafts used in knee-ligament
34
motion, osteopenia, skin changes, and
significant limp; and stage 3 (residual
stage [more than 8 months]), with
findings of rigid patella, markedly
decreased range of motion, osteope-
nia, quadriceps atrophy, patella baja,
and possible arthrosis.
The initial treatment for all stages
includes aggressive physiotherapy,
anti-inflammatory agents, and patel-
lar mobilization. In stage 2, arthro-
scopic debridement and dynamic
splinting may be beneficial. Stage 3
usually requires open debridement.
This consists of medial and lateral
capsular incisions with freeing of the
suprapatellar adhesions as well as
those in the medial and lateral gut-
ters. The patellar tendon is identified,
and all scar tissue posterior to it is
excised. If the ACL graft is placed too
far anteriorly and is preventing full
extension, this too must be excised. It
is extremely unlikely that the
arthrofibrotic knee will ever again be
unstable. Adequate pain control and
aggressive rehabilitation must be
employed postoperatively.
Graft impingement has been
shown to block full extension and is
related to inadequate notchplasty
and incorrect placement of the tibial
tunnel too far anteriorly.15 The posi-
tion of the graft in full extension
should always be checked intraoper-
atively to avoid impingement.
Graft Donor-Site Complications
Late patellar fracture has been
reported, and it is postulated that
repairs and reconstruction. J Bone Joint
Surg Am 1984;66:344-352.
3. Graf BK, Cook DA, De Smet AA, et al:
“Bone bruises” on magnetic resonance
imaging evaluation of anterior cruciate
ligament injuries. Am J Sports Med
1993;21:220-223.
4. Daniel DM: Principles of knee ligament
surgery, in Daniel DM, Akeson WH,
O’Connor J (eds): Knee Ligaments: Struc-
Journal of the American Academy of Orthopaedic Surgeons
this is a stress fracture due to
decreased vascularity to the patella.
Intraoperative patellar fracture may
also occur during harvesting of the
patellar graft. Avulsion of the infe-
rior pole of the patella has also
occurred rarely.
Patellofemoral morbidity occurs
more frequently with bone–patellar
tendon–bone grafts than with ham-
string autografts.
Summary
It is clear that the management of
ACL injuries is complex and contin-
ues to evolve. Surgical techniques of
ACL reconstruction require proper
placement and tensioning, avoid-
ance of impingement and stress ris-
ers on the implanted tissue, and
adequate fixation. Biochemical and
enzymatic changes occur in a knee
joint after injury and with the alter-
ation of normal mechanics. These
changes alter articular cartilage func-
tion and may affect the success of
knee ligament surgery. Degenerative
changes in an injured knee are not
necessarily prevented by restoration
of ligament stability. The presence or
absence of the menisci seems to have
the greatest effect in protecting the
knee from wear changes. The
answers to many questions remain to
be shown in carefully designed
prospective, randomized, long-term
outcome studies comparing tech-
niques of treatment.
ture, Function, Injury, and Repair. New
York: Raven Press, 1990, pp 11-29.
5. Daniel DM, Stone ML, Dobson BC, et al:
Fate of the ACL injured patient: A
prospective outcome study. Presented
at the Annual Meeting of the American
Orthopaedic Society of Sports Medicine,
Sun Valley, Idaho, July 12, 1993.
6. Amiel D, Kuiper S: Experimental stud-
ies on anterior cruciate ligament grafts:

Histology and biochemistry, in Daniel
DM, Akeson WH, O’Connor J (eds):
Knee Ligaments: Structure, Function,
Injury, and Repair. New York: Raven
Press, 1990, pp 379-388.
7. Burger RS, Larson RL: Acute ligamen-
tous injury, in Larson RL, Grana WA
(eds): The Knee: Form, Function, Pathol-
ogy, and Treatment. Philadelphia: WB
Saunders, 1993, pp 514-598.
8. Kurosaka M, Yoshiya S, Andrish JT: A
biomechanical comparison of differ-
ent surgical techniques of graft
fixation in anterior cruciate ligament
reconstruction. Am J Sports Med
1987;15:225-229.
Vol 2, No 1, Jan/Feb 1994
Robert L. Larson, MD, and Mario Taillon, MD, FRCS(C)
9. Robertson DB, Daniel DM, Biden E: Soft
tissue fixation to bone. Am J Sports Med
1986;14:398-403.
10. Sachs RA, Daniel DM, Stone ML, et al:
Patellofemoral problems after anterior
cruciate ligament reconstruction. Am J
Sports Med 1989;17:760-765.
11. Larson RL: Prosthetic replacement of
knee ligaments: Overview, in Feagin
JA Jr (ed): The Crucial Ligaments: Diag-
nosis and Treatment of Ligamentous
Injuries About the Knee. New York:
Churchill Livingstone, 1988, pp
495-506.
12. Shelbourne KD, Nitz P: Accelerated
rehabilitation after anterior cruciate lig-
ament reconstruction. Am J Sports Med
1990;18:292-299.
13. McCarroll JR, Rettig AC, Shelbourne
KD: Anterior cruciate ligament injuries
in the young athlete with open physes.
Am J Sports Med 1988;16:44-47.
14. Paulos LE, Rosenberg TD, Drawbert J, et
al: Infrapatellar contracture syndrome:
An unrecognized cause of knee stiffness
with patella entrapment and patella
infera. Am J Sports Med 1987;15:331-341.
15. Howell SM, Taylor MA: Failure of
reconstruction of the anterior cruciate
ligament due to impingement by the
intercondylar roof. J Bone Joint Surg Am
1993;75:1044-1055.
35
 Acute Calcaneal Fractures:
Treatment Options and Results
Lance R. Macey, MD, Stephen K. Benirschke, MD, Bruce J. Sangeorzan, MD,
and Sigvard T. Hansen, Jr, MD

Abstract

The treatment of choice for acute displaced intra-articular calcaneal fractures is based on the premise that all dis-
remains controversial. The authors present a brief historical review of treatment placed calcaneal fractures have one
options and results, coupled with the biomechanical rationale for open reduction fracture line in common, the separa-
and internal fixation. Their current management protocol and surgical technique tion fracture (the primary fracture
are outlined, along with preliminary functional results at an average follow-up of line). This fracture line runs
2.5 years. obliquely anterior to posterior,
J Am Acad Orthop Surg 1994;2:36-43 breaking the calcaneus into two
pieces through the sinus tarsi or the
posterior facet, and always lies
The calcaneus is the most commonly ulative reduction by means of percu- behind the interosseous ligament.
fractured tarsal bone. Despite the taneous pins placed in the tibia and An essential feature of this fracture
orthopaedic community’s length of calcaneus, followed by casting.3 Gal- line is that it creates a fragment (the
experience with this injury, treat- lie4 and Hall and Pennal5 reported sustentaculum tali) that remains
ment remains a source of contro- their results with primary arthrode- attached to the talus by the
versy. Historically, the treatment of sis as the treatment of choice for interosseous ligament. The simplest
acute calcaneal fractures has been severely comminuted os calcis frac- displaced fractures end with this line
largely dissatisfying due to the mar- tures. Recently, open reduction with and are considered two-part frac-
ginal functional results. In 1916 Cot- rigid internal fixation has gained tures (Fig. 1). These are extremely
ton and Henderson, writing on the increasing support. rare injuries, as the associated
basis of their experience with con- The lack of consensus regarding trauma usually creates secondary
servative treatment, stated that “the the most appropriate treatment of fracture lines that extend through-
man who breaks his heel bone is calcaneal fractures has resulted in out the remainder of the calcaneus.
done.” This view was reiterated by part because the association between
Conn, who in 1926 reported that classification and treatment has not
“calcaneus fractures are serious and been consistent. Clearly, a meaning- Dr. Macey is Attending Orthopaedic Surgeon,
disabling injuries in which the end ful classification scheme must St. Joseph Hospital and Nashua Memorial Hos-
results continue to be incredibly include information relative to pat- pital, Nashua, NH; and Attending Orthopaedic
Surgeon, Parkland Medical Center, London-
bad.” In 1942 Bankart’s experience tern of injury, prognosis, and treat- derry, NH. Dr. Benirschke is Associate Professor,
was summarized when he wrote, ment. Several authors have proposed Department of Orthopaedic Surgery, University
“the results of crush fractures of the schemes based on fracture configura- of Washington, Harborview Medical Center,
os calcis are rotten.”1 tion and the degree of involvement Seattle. Dr. Sangeorzan is Associate Professor,
The search for improved results of the posterior facet,1,6-8 but the prog- Department of Orthopaedic Surgery, University
of Washington, Harborview Medical Center. Dr.
has provided a strong impetus for nostic value of these schemes has Hansen is Professor, Department of Orthopaedic
the development of alternative treat- been variable. Consequently, there is Surgery, University of Washington, Harborview
ment methods. Historically, a wide no single method of classification Medical Center.
spectrum of treatment options have that has gained universal acceptance
been advocated. Elevation, compres- or that reliably addresses these Reprint requests: Dr. Macey, 29 Riverside Drive,
Nashua, NH 03062.
sion, and early range-of-motion issues.
exercises without reduction were For the purpose of data collection, Copyright 1994 by the American Academy of
supported by Rowe et al.2 Gissane we use the classification system Orthopaedic Surgeons.
and Bohler advocated closed manip- described by Letournel.6 This system

36 Journal of the American Academy of Orthopaedic Surgeons


A B
Fig. 1 Constant separation fracture line. A, Fracture runs through the sinus tarsi behind the
interosseous ligament. B, Fracture intersects the thalamus (posterior facet). C, Two-fragment
fracture without displacement (exceptional).
In a simple three-part fracture,
there is an additional fracture line
through the posterior facet. If this
fracture line involves only the poste-
rior facet without extension into the
tuberosity, it is considered an
impaction fracture or a joint-depres-
sion fracture (Fig. 2). In a tongue-type
fracture, the fracture line continues
posteriorly to include the posterior
facet and exits through the posterior
aspect of the tuberosity (Fig. 3). In the
simplest fractures, the inferior cortex
of the calcaneus remains intact,
thereby preserving the general mor-
phologic features of the bone.
Complex fractures result in four
or more fragments. These include
the two basic fragments from the pri-
mary fracture line and the posterior
facet fragment in combination with
other fragments created by sec-
ondary fracture lines that extend
through the inferior cortex and the
anterior process of the calcaneus.
These fractures disrupt the whole
morphologic structure of the bone
and are associated with severe dis-
Vol 2, No 1, Jan/Feb 1994
Lance R. Macey, MD, et al
restoration comes from an under-
standing of the relationship between
normal calcaneal morphology and
hindfoot function during normal
gait.
Subtalar Joint Function
One important function of the
subtalar joint is its action as a torque
converter producing a cushioning
effect on the foot. During normal
gait, between the phases of “heel
strike” and “foot flat,” the subtalar
joint converts the normal internal
C
A
ruption of the lateral cortex caused
by violent impaction of the posterior
facet (Fig. 4).
Although we use Letournel’s
classification system for descriptive
purposes, we do not consider this
system comprehensive enough to
B
serve as the only basis for a decision
to proceed with operative interven-
tion. We believe an important crite-
rion is restoration of biomechanical
function.
C
Biomechanical Rationale
for Open Reduction
An evaluation of normal hindfoot
function provides the most com-
pelling evidence in support of
anatomic reduction of calcaneal frac-
tures. Because the majority of cal- D
caneal fractures involve the Fig. 2 Three-fragment fractures. A, Impaction
talocalcaneal articulation, a good of the thalamus; the various fracture lines are
understanding of subtalar joint func- seen from above. B, Horizontal impaction of
the thalamus. C, Possible fracture lines of a ver-
tion is important in comprehending tical impaction. D, Vertical impaction of the
the rationale for anatomic reduction. thalamus.
Further support for anatomic
37
Acute Calcaneal Fractures
A Fig. 5 The osseous and ligamentous struc-
B ally high stresses out of its normal
Fig. 3 Tongue-type fracture vertical
impaction of the thalamus. A, Lateral view.
B, Axial view of the tongue.
A B
Fig. 4 Complex calcaneal fractures comprising four fragments or more. A, Fracture lines on
the upper aspect of the bone. B, Axial view of fracture. C, Lateral view of a complex fracture.
38
rotation of the tibia into pronation of
the foot by increasing the talocal-
caneal angle (producing hindfoot
valgus) and unlocking the trans-
verse tarsal joints. This torque con-
version results in a softening of the
arch, allowing shock absorption
because the arch functions as a leaf
spring (Fig. 5). Between the phases
of “foot flat” and “toe off,” normal
external rotation of the tibia causes
convergence of the talocalcaneal
angle (producing hindfoot varus),
which locks the transverse tarsal
joints and creates a more rigid plat-
form for push-off.9,10
The second important function of
the subtalar joint is to allow the foot
to adapt to uneven surfaces through
inversion and eversion. These
actions protect the tibiotalar joint,
where motion is normally limited to
the sagittal plane. Without free sub-
talar inversion and eversion, the
tibiotalar joint is exposed to unusu-
plane of motion. Long-term studies
of subtalar and triple arthrodeses
have shown that significant degen-
C
Journal of the American Academy of Orthopaedic Surgeons
tures of the foot soften the arch when the
tibia is internally rotated and locked onto
the dome of the talus. Pronation occurs at
the beginning of the weight-bearing portion
of the gait cycle as the foot strikes the
ground and accepts body weight. The foot
rotates laterally under and in front of the
talus, and as a result the arch of the foot
functions as a leaf spring.
erative changes occur in the ankle
when the subtalar joint is unable to
cushion and protect the ankle from
medial and lateral tilt stresses.11
Calcaneal Function
Normal calcaneal morphology
contributes to three principal func-
tions of normal gait, which are vari-
ably disrupted dependent on the
fracture pattern:
1. The normal calcaneus provides
a lever arm to increase the power of
the gastrosoleus mechanism. This
lever arm is extended through the
midfoot and forefoot by normal sub-
talar supination with simultaneous
locking of the transverse tarsal artic-
ulations. To maximize the efficiency
of its lever-arm function, the calca-
neus must provide a fulcrum in the
midbody of the talus, and it must
interact normally with its motor, the
gastrosoleus muscle. High-energy
calcaneal fractures markedly disrupt
these anatomic relationships and
have a profound effect on hindfoot
function. The gastrosoleus muscle is
functionally weakened when the
subtalar joint is disrupted and the
tuberosity of the calcaneus is dis-
placed proximally.
2. Normal calcaneal structure
provides a foundation for body

weight transmitted through the tibia,
ankle, and subtalar joints. The nor-
mal vertical-support function of the
calcaneus is dependent on its normal
alignment beneath the weight-bear-
ing line of the tibia to prevent eccen-
tric weight distribution in the foot.
Lateral displacement of the calca-
neus may result in fibular or per-
oneal impingement. In addition,
eccentric weight-bearing may cause
a valgus tilt of the hindfoot, resulting
in increased stresses on medial soft-
tissue structures (deltoid ligament
and posterior tibialis muscle). Medial
displacement of the body of the os
calcis results in varus alignment,
causing increased compressive
forces on the medial aspect of the
ankle and increased tension on the
lateral soft-tissue structures (lateral
ligaments and peroneal muscles).
This deformity may predispose to
lateral ankle sprain and eventually
lead to varus tilting of the talus and
secondary ankle arthrosis. Direct
vertical collapse of the calcaneus
results in impaction of the talus into
the body of the calcaneus. The talus
then assumes a more dorsiflexed
position in the ankle mortise, which
can result in anterior ankle impinge-
ment, decreased ankle dorsiflexion,
and accelerated arthrosis.
3. Normal calcaneal anatomy
provides structural support for the
maintenance of normal lateral col-
umn length, which affects abduction
and adduction of the midfoot and
forefoot. In addition, lateral support
indirectly assists in supination of the
foot to provide strong push-off dur-
ing gait. When the anterior process
of the calcaneus is fractured, often
there is shortening and loss of lateral
column length. As a result, the mid-
foot and forefoot are forced into
abduction through Chopart’s joint,
the naviculocuneiform joint, or Lis-
franc’s joint. Abduction leads to
increased tension on the posterior
tibial tendon and may lead to lateral
peritalar subluxation or frank dislo-
Vol 2, No 1, Jan/Feb 1994
cation with posterior tibial tendon
rupture. As the calcaneus continues
to migrate laterally, there may be
talocalcaneal impingement in the
sinus tarsi. This degree of malalign-
ment causes severe compromise in
the vertical-support function of the
calcaneus.
Criteria and Goals for Surgery
The important relationships
between the calcaneus and normal
hindfoot function underlie the bio-
mechanical rationale for the surgical
restoration of normal calcaneal
anatomy. Absolute indications for
operative fixation have not been
determined and will vary among
orthopaedists. The important crite-
ria we consider in our decision to
pursue operative intervention
include: (1) the degree of distortion
in the relationship between the pos-
terior facet and the middle and ante-
rior facets, which may contribute to
the development of restricted subta-
lar motion; (2) the amount of dis-
placement within the posterior facet;
(3) the amount of lateralization of
the tuberosity; and (4) the degree of
widening of the foot and other fac-
tors such as displacement of the
tuberosity and/or calcaneocuboid
joints.
The goal of surgery should be to
restore normal calcaneal morphol-
ogy and regain the normal height,
width, length, and longitudinal axis
of the calcaneus, with stable
anatomic reconstruction of all joint
surfaces to allow early motion. Cal-
caneal body fractures that do not
change the weight-bearing surface
of the foot or alter normal hindfoot
mechanics usually receive closed
treatment. In a simple fracture pat-
tern with only a primary fracture
line extending through the posterior
facet, 2 mm of displacement may be
tolerated and closed reduction can
be used. We believe that fractures
with displacement of 3 mm or more
should be treated with open reduc-
Lance R. Macey, MD, et al
tion and internal fixation. We believe
there is no fracture too comminuted
for reduction, because the salvage
for a severely comminuted, mal-
united fracture is usually more
difficult than the initial fracture
surgery.
We try to reconstruct all fractures
within 10 days from the time of
injury if soft-tissue conditions are
favorable. Reduction becomes very
difficult after 3 weeks.
Preoperative Evaluation
and Treatment
Displaced intra-articular fractures
of the calcaneus are the result of
high-energy axial-loading injuries.
Consequently, the damage to the
surrounding soft-tissue envelope
may be extensive, resulting in
significant swelling. Fracture-blister
formation is common. To minimize
soft-tissue compromise during the
preoperative period, the foot should
be elevated to the level of the heart
and immediately splinted with the
ankle in neutral position. Surgical
timing is dependent on the condi-
tion of the soft tissues. Swelling
should be decreased such that tissue
turgor allows skin wrinkling in
response to gentle pressure. Frac-
ture blisters should be debrided and
allowed to epithelialize prior to sur-
gical reconstruction.
Understanding the fracture pat-
tern is dependent on the appropriate
radiographic evaluation. Preopera-
tive lateral and axial plain films are
essential for the preliminary investi-
gation of the fracture type. In addi-
tion, transverse (parallel to the
plantar surface) and coronal (per-
pendicular to the posterior facet)
computed tomographic (CT) scans
should be obtained to evaluate the
fracture pattern and degree of com-
minution. The CT scans should be
evaluated to determine the degree of
widening of the heel and the amount
39
Acute Calcaneal Fractures
of hindfoot varus, calcaneocuboid
disruption, anterior process injury,
and posterior facet involvement. We
have found no real advantage to
three-dimensional CT scans in pre-
operative planning.
Operative Technique
The goal of surgery is anatomic
reduction of the calcaneus and rigid
internal fixation so that early motion
can proceed. Restoration of the artic-
ular surfaces, overall shape, and
alignment of the calcaneus is critical
to achieve successful functional
results.
Historically, the specific surgical
approach for reduction has been the
source of controversy in the treat-
ment of these injuries. The medial
approach has been advocated by
McReynolds.12 The benefits of this
approach include good visualization
of the sustentaculum tali and the
ability to control varus and valgus
alignment. The disadvantages
include poor visualization of the
posterior facet and lateral wall and
the lack of exposure of the calca-
neocuboid articulation.
The lateral approach to the calca-
neus has been favored by Palmer13
and Letournel 6 and has been
modified by Benirschke. 14 This
approach is our method of choice for
treating displaced intra-articular cal-
caneal fractures. The advantages
include excellent exposure of the
tuberosity, posterior facet, lateral
wall, and calcaneocuboid articula-
tion. Reduction of the sustentaculum
to the tuberosity through the lateral
approach is performed indirectly.
Stephenson 15 advocates a com-
bined lateral and medial approach to
difficult fractures. This method
offers the advantages of both
approaches; however it requires
substantial soft-tissue stripping and
disruption of the calcaneal blood
supply.
40
To perform a lateral approach, the
patient is placed on the operating
table in the true lateral position. The
extremity is exsanguinated, and a
pneumatic tourniquet is used for
hemostasis. After identification of
the important superficial landmarks,
including the fibula, the Achilles ten-
don, and the base of the fifth
metatarsal, a J-shaped (left side) or
L-shaped (right side) incision is
made laterally (Fig. 6) with care to
avoid injury to the sural nerve. The
incision should extend directly to
bone plantar to the peroneal tendons
to allow the development of a full-
thickness periosteal-cutaneous flap.
The calcaneofibular ligament and
peroneal tendon sheaths are sharply
dissected off the lateral wall of the
calcaneus and maintained within the
flap. Progressive dorsally directed
dissection results in a full view of the
tuberosity, subtalar joint, and ante-
rior process. Two small K wires can
be placed into the lateral aspect of
the talus to serve as soft-tissue
retractors of the flap. Distal exten-
sion of the incision with dissection
over the peroneal tendons may be
necessary to fully visualize the calca-
neocuboid joint.
Once adequate exposure has been
obtained, the blown-out portion of
the lateral wall is removed and
marked to preserve its orientation.
The posterior facet is then disim-
pacted from the body of the calca-
neus and inspected to document the
extent of comminution and articular
cartilage disruption. If the posterior
facet is comminuted, it should be
anatomically reconstructed on the
back table using 0.045-inch K wires.
We have found that many intra-
articular fractures have associated
extension into the anterior process.
In this situation, the first step is to
reduce the sustentacular fragment to
the anterior process at the critical
angle of Gissane. This reduction is
provisionally held with 0.045-inch K
wires.
Journal of the American Academy of Orthopaedic Surgeons
Fig. 6 Surgical approach (dashed line).
Sural nerve (solid lines) is shown just above
it within the elevated periosteal-cutaneous
flap.
Next, attention is turned to reduc-
ing the posterior facet to the anterior
process–sustentaculum complex.
Again, K wires are used for provi-
sional fixation. The tuberosity is then
indirectly reduced to the sustentacu-
lar complex and the medial wall
with the use of a 4.0- or 5.0-mm
Schanz pin introduced laterally into
the tuberosity. The Schanz pin is
used to manipulate the tuberosity
and secure anatomic alignment in
the varus-valgus planes (Fig. 7). This
reduction is provisionally held with
0.062-inch K wires directed axially.
Alignment and reduction are
then confirmed with intraoperative
lateral and axial radiographs. Bone
defects are filled with cancellous
graft. The lateral wall is replaced,
and a 3.5- or 2.7-mm reconstruction
plate is contoured to span from the
tuberosity to the anterior process lat-
erally. The plate is fixed with 3.5- or
2.7-mm screws. Two additional 3.5-
mm thalamic lag screws are placed
beneath the articular surface of the
posterior facet to maintain the
reduction of the posterior facet to the
sustentacular fragment (Fig. 8).
Additional fixation of the posterior
tuberosity is often necessary if a
tongue component exists. This is
best accomplished with a small or
medium cervical H plate placed
under the reconstruction plate and
extending over the dorsal aspect of

erally through the skin overlying the
sinus tarsi. The drain is routinely
removed 48 hours after the opera-
tion. The periosteal-cutaneous flap is
closed as a single layer using 2-0
Vicryl in an inverted, interrupted
fashion. The skin is closed using a 3-
0 nylon horizontal stitch to minimize
tension on the edge of the flap.
Postoperative Care
Initially, the leg is splinted with the
ankle in neutral position for 72 hours
and then placed in a removable alu-
3 minum splint with a sheepskin lin-
2
ing. When the incision is dry (3 to 5
days), an active ankle and subtalar
1
range-of-motion exercise program is
Fig. 7 A 4.0- or 5.0-mm Schanz pin is begun. The exercise program also
placed laterally in the tuberosity fragment. includes passive stretching of all
Vectors of manipulation, all with reference toes to avoid the development of
to the sustentacular fragment, are as fol-
lows: 1, restoration of height; 2, valgus flexion contractures. Sutures are
alignment; 3, medial translation. Medial removed at 3 weeks, and patients
wall reduction is indirect. avoid weight-bearing for 12 weeks
postoperatively. Patients are fitted
with support stockings to control
the tuberosity. All provisional edema and are encouraged to con-
fixation is then removed. In areas not tinue their use for 6 months. Hard-
suited for screw fixation, such as the ware is usually removed at 1 year,
anterior process at the critical angle depending on symptoms and
of Gissane, K wires are left in, patient preference.
impacted next to the plate.
The wound is closed over a 1⁄8-inch
suction drain brought out dorsolat- Results of Treatment
Literature Review
It is difficult to interpret the com-
parative results of various treatment
modalities advocated in the past.
Studies have been done on patient
populations with different countries
of origin, using numerous fracture
classification systems to describe
injuries treated with various surgical
approaches. To date, there have been
no prospective studies.
Fig. 8 Lateral view of reconstruction per- Letournel6 used a lateral approach
formed with use of a 3.5-mm reconstruction
plate extending from the tuberosity to the
to gain stable anatomic reduction
anterior process, with two separate lag and fixation in 99 patients with
screws to stabilize the posterior facet. intra-articular calcaneal fractures.
His results at 2-year follow-up
Vol 2, No 1, Jan/Feb 1994
Lance R. Macey, MD, et al
were good or very good in 56% of
cases, fair in 33%, and bad in 11%.
The patients with good and very
good results had no functional dis-
ability or only occasional pain
while walking on uneven surfaces.
Forty-seven percent had useful
subtalar motion following open
reduction and internal fixation.
There were three infections (3%)
and six technical failures (6%).
Sanders et al8 used a combination
of the lateral and modified lateral
approach and correlated their opera-
tive results in 120 patients with a
new classification system based on
the CT evaluation of associated com-
minution at the posterior facet of the
calcaneus. They found that the clini-
cal results deteriorated with increas-
ing comminution of the posterior
facet. Seventy-three percent of
patients with mild to moderate com-
minution had excellent or good clin-
ical results, while only 9% of patients
with severe comminution of the pos-
terior facet had good to excellent
results. Reported complications
included two cases of infection lead-
ing to osteomyelitis. Eighteen per-
cent of patients developed peroneal
tendinitis, which responded to plate
removal, and 12 patients had vari-
able symptoms related to sural neu-
romata.
Tscherne and Zwipp 16 used a
combination of medial, lateral, and
bilateral approaches in their treat-
ment of 157 displaced calcaneal
fractures. They developed a fracture-
classification scoring system based
on the number of fracture fragments,
the degree of joint involvement and
soft-tissue injury, and the presence of
associated foot fractures, which they
considered predictive of clinical out-
come following open reduction and
internal fixation. Using their scoring
system, they reported an inverse rela-
tionship between fracture severity
and clinical outcome following
surgery. Complications included
wound margin necrosis in 8.5% of
41
Acute Calcaneal Fractures
cases, hematomas requiring decom-
pression in 2.6%, and a deep infection
in 2.0%. These complications devel-
oped independent of which opera-
tive approach was used.
Authors’ Results
We have yet to fully analyze the
long-term functional results of our
treatment protocol, but we have con-
ducted a preliminary review of over
100 displaced intra-articular cal-
caneal fractures treated with open
reduction and internal fixation
through a lateral approach. To date,
our results have been encouraging,
but our preliminary experience has
not been subjected to rigorous analy-
sis. The ongoing functional assess-
ment is currently at an average
follow-up of more than 2 years.
Patients are evaluated to determine
their level of physical activity and
limitations in activities of daily liv-
ing. In addition, data on pain-med-
ication requirements and work
status are being collected.
Our most recent surveillance
indicates that the majority of
patients (65%) are limited only in
their ability to participate in vigor-
ous activities and sports. Over 50%
of patients are able to walk comfort-
ably on any surface. Sixty percent
report no need for medications to
control discomfort. Forty percent of
References
1. Essex-Lopresti P: The mechanism,
reduction technique, and results in frac-
tures of the os calcis. Clin Orthop
1993;290:3-16.
2. Rowe CR, Sakellarides HT, Freeman
PA, et al: Fractures of the os calcis: A
long-term follow-up study of 146
patients. JAMA 1963;184:920-923.
3. Bohler L: Diagnosis, pathology and
treatment of fractures of the os calcis. J
Bone Joint Surg 1931;13:75-89.
4. Gallie WE: Subastragalar arthrodesis in
fractures of the os calcis. J Bone Joint Surg
1943;25:731-736.
42
patients have been unable to return
to their previous employment due to
functional limitations caused by the
calcaneal fracture. Approximately
70% of patients have been com-
pletely satisfied with their surgical
outcome to date.
Our preliminary evaluation of
morbidity reveals that skin loss at
the wound margin is the most com-
mon complication and occurs in
approximately 10% of patients. This
problem responds well to daily
dressing changes on an outpatient
basis. The incidence of superficial
wound infection has been less than
2%, and deep infection requiring
hardware removal has yet to be
encountered. Approximately 20% of
patients have peroneal tendinitis
necessitating hardware removal. To
determine the longer-term func-
tional results and incidence of mor-
bidity, we will be conducting a
rigorous analysis of our data.
Summary
We have found that there is a steep
learning curve associated with the
demanding surgical technique nec-
essary for the successful reconstruc-
tion of acute calcaneal fractures.
Familiarity with the surgical tech-
nique and the demand for meticu-
lous handling of soft tissues during
5. Hall MC, Pennal GF: Primary subtalar
arthrodesis in the treatment of severe
fractures of the calcaneum. J Bone Joint
Surg Br 1960;42:336-343.
6. Letournel E: Open reduction and inter-
nal fixation of calcaneus fractures, in
Spiegel P (ed): Topics in Orthopaedic
Trauma. Baltimore: University Park
Press, 1984, pp 173-192.
7. Crosby LA, Fitzgibbons T: Computer-
ized tomography scanning of acute
intra-articular fractures of the calca-
neus: A new classification system. J Bone
Joint Surg Am 1990;72:852-858.
Journal of the American Academy of Orthopaedic Surgeons
this approach are critical factors in
achieving a successful result and
avoiding postoperative complica-
tions. There are a number of pitfalls
during the approach to these frac-
tures that can frustrate the inexperi-
enced surgeon and lead to poor
results, such as inability to achieve
adequate reduction to secure
fixation.
Although a number of patients
are left with functional limitations
following open reduction and
fixation of calcaneal fractures, the
majority of limitations are modest
when compared with the previously
reported results of conservative
treatment. These improved results
come from our ability to surgically
restore the articular surfaces of the
subtalar joint and overall calcaneal
morphology, upon which normal
biomechanics and hindfoot function
depend. Unfortunately, the disrup-
tion of articular cartilage is a variable
over which we have no control but
which clearly has an impact on the
functional outcome. Although the
final determination of the treatment
of choice for these difficult fractures
will depend on well-controlled ran-
domized clinical trials, we believe
that reconstruction of normal cal-
caneal anatomy should be the goal
when treating these potentially dev-
astating injuries.
8. Sanders R, Fortin P, DiPasquale T, et al:
Operative treatment in 120 displaced
intraarticular calcaneal fractures:
Results using a prognostic computed
tomography scan classification. Clin
Orthop 1993;290:87-95.
9. Wright DG, Desai ME, Henderson BS:
Action of the subtalar and ankle joint
complex during the stance phase of
walking. J Bone Joint Surg Am 1964;
46:361-367.
10. Mann RA, Coughlin MJ: Surgery of the
Foot and Ankle, 6th ed. St Louis: Mosby-
Year Book, 1993, pp 15-23.

11. Angus PD, Cowell HR: Triple arthrode-
sis: A critical long-term review. J Bone
Joint Surg Br 1986;68:260-265.
12. McReynolds IS: Trauma to the os calcis
and heel cord, in Jahss MH: Disorders of
the Foot. Philadelphia: WB Saunders,
1982, vol 2, pp 1497-1542.
13. Palmer I: The mechanism and treat-
ment of fractures of the calcaneus:
Vol 2, No 1, Jan/Feb 1994
Open reduction with the use of cancel-
lous grafts. J Bone Joint Surg Am 1948;
30:2-8.
14. Benirschke SK, Sangeorzan B: Extensive
intraarticular fractures of the foot: Sur-
gical management of calcaneus frac-
tures. Clin Orthop 1993;292:128-134.
15. Stephenson JR: Treatment of displaced
intra-articular fractures of the calcaneus
Lance R. Macey, MD, et al
using medial and lateral approaches,
internal fixation, and early motion. J
Bone Joint Surg Am 1987;69:115-130.
16. Tscherne H, Zwipp H: Calcaneal frac-
ture, in Tscherne H, Schatzker J (eds):
Major Fractures of the Pilon, the Talus and
the Calcaneus: Current Concepts of Treat-
ment. Berlin: Springer-Verlag, 1993, pp
153-174.
43
 Infected Total Knee Replacements
Russell E. Windsor, MD, and James V. Bono, MD

Abstract

Deep infection is a devastating complication following total knee arthroplasty. universally recommended, 11 it is
Prompt diagnosis and definitive treatment of this complication are essential for a still debated, and prospective stud-
successful outcome. The treatment options for an infected total knee replacement ies have shown a low risk for bacte-
include (1) antibiotic suppression alone; (2) aggressive wound debridement, rial seeding around prosthetic
drainage, and antibiotic suppression therapy; (3) resection arthroplasty; (4) joints.12
arthrodesis; (5) two-stage reimplantation; and (6) amputation. Successful salvage Patients with chronic renal
of this complication can be accomplished only by extensive investment of surgical insufficiency and neoplasm requir-
and infectious disease efforts in eradicating the infection. Two-stage reimplantation ing chemotherapy are at risk for
has been the most successful functional option and should be used whenever possi- infection due to chronic neutrope-
ble to definitively eradicate the infection and ensure good function of the knee joint. nia and, in some cases, compromise
J Am Acad Orthop Surg 1994;2:44-53 of the immune system. Diabetes
mellitus may pose an increased risk
of infection due to the increased
risk of wound-healing problems.
Next to a life- or limb-threatening lete). 1 Patients with rheumatoid Superficial wound necrosis may at
complication, nothing can be more arthritis, who often are immuno- times communicate with the
devastating than infection after total logically deficient,7,8 are at greater deeper tissues of the knee and lead
knee arthroplasty. Only through risk for infection. Wilson et al5 stud- to deep infection.13
identification of risk factors and ied 4,171 total knee arthroplasties The surgeon can influence the ulti-
development of prophylactic regi- that were performed at the mate infection rate not only by tech-
mens has the incidence of infection Brigham and Women’s Hospital in nique but also by selection of the
decreased. The management of this Boston and found that 67 replace- prosthesis. For example, surface
problem requires a considerable ments became infected. The risk of replacements have an overall infec-
expenditure of the patient’s and the infection was significantly increased tion rate of less than 1%. In contrast,
surgeon’s energy for definitive diag- in patients, particularly men, who metal-on-metal constrained hinge
nosis and treatment. Successful had rheumatoid arthritis; in prostheses, such as the GUEPAR
treatment depends on a team patients with skin ulceration; and prosthesis, have an infection rate that
approach, with cooperation of the in patients who had undergone approaches 14%. Many of these infec-
orthopaedic surgeon, the plastic sur- previous knee operations. Skin
geon, and the infectious disease spe- infections were the most common
cialist. source of infection; it is, therefore, Dr. Windsor is Associate Professor of Surgery
necessary to heal skin ulcers, espe- (Orthopaedics), Cornell University Medical Col-
cially those peripheral to a joint lege, New York, and Associate Attending
Incidence of Infection with a prosthesis.5,9 Antibiotic pro- Orthopaedic Surgeon, The Hospital for Special
Surgery, New York. Dr. Bono is Senior Clinical
phylaxis is recommended until the Associate in Surgery, Cornell University Med-
The incidence of infection after wound is healed. In addition, infec- ical College, and Junior Attending Orthopaedic
total knee arthroplasty ranges from tion was associated with obesity, Surgeon, The Hospital for Special Surgery.
1.1% to 12.4%.1-5 At the Mayo Clinic, recurrent urinary tract infections,
1.2% of 3,000 primary total knee and oral corticosteroid use, Reprint requests: Russell E. Windsor, MD, The
Hospital for Special Surgery, 535 E. 70th Street,
replacements developed infec- although the correlation did not New York, NY 10021.
tion.3,6 The higher rates of infection achieve statistical significance.
occurred after implantation of Tooth extraction always causes Copyright 1994 by the American Academy of
cemented linked hinges, such as bacteremia. 10 Although antibiotic Orthopaedic Surgeons.
the GUEPAR prosthesis (now obso- prophylaxis in dental procedures is

44 Journal of the American Academy of Orthopaedic Surgeons


tions occur late, sometimes several
years after implantation. The reason
for this very high incidence of infec-
tion is not altogether clear, but is
probably related to the presence of
metallic debris, which in turn causes
the formation of a membranous sac
containing fluid and debris around
the prosthesis.14,15 Impregnation of the
bone and soft tissues with metallic
fragments and the large bone-cement
interface may become factors, espe-
cially when the prosthesis becomes
loose. Disturbingly, constrained
prostheses with metal-on-plastic
bearing surfaces also seem to have a
higher infection rate. For example,
the stabilocondylar prosthesis had a
8.3% infection rate in a small series of
36 cases. Consequently, constrained
hinged prostheses with cemented
intramedullary stems have become
largely obsolete in this country. For
the great majority of clinical situa-
tions, a non- or semiconstrained sur-
face total knee replacement will
perform well and reduce the poten-
tial for infection.
Skin necrosis with secondary
deep extension may lead to a deep
prosthetic infection. Incisions placed
at the side of the knee, for synovec-
tomy or open fracture reduction and
internal fixation, may predispose to
skin necrosis. They are generally
unsuitable for knee arthroplasty,
which requires a midline, longitudi-
nal incision. Although previous inci-
sions should be utilized as much as
possible during any knee replace-
ment, sometimes it is necessary to
use a separate longitudinal incision
to gain exposure despite the risk of
creating an island of devascularized
skin between the new incision and
the healed old one. A skin bridge of
at least 7 cm may minimize the risk
of skin necrosis. If this complication
occurs, the knee should be immobi-
lized until spontaneous separation
of the eschar occurs. Early and
aggressive attempts at debridement
may lead to deep contamination that
Vol 2, No 1, Jan/Feb 1994
Russell E. Windsor, MD, and James V. Bono, MD
might otherwise have been avoid-
able. Very large areas of necrosis,
however, should be handled aggres-
sively, utilizing appropriate skin
grafts in consultation with a plastic
surgeon.
Slight wound drainage often
requires no modification of the
postoperative regimen. When pro-
fuse wound drainage occurs, the
knee should be immobilized until it
stops. Antibiotics should not be
given, as their administration may
mask a latent deep infection. Some
degree of wound drainage occurs
in about 25% of the cases and may
be further classified as culture-neg-
ative or culture-positive. There
appears to be no relationship
between culture-positive wound
drainage and subsequent deep
infection. In the early postoperative
period, a few patients have persis-
tent drainage, a tense knee effu-
sion, and persisting significant
pain. In these patients, aggressive
open debridement, evacuation of
the retained hematoma, copious
lavage, and reclosure should be
considered.
The organism most frequently
found in infected total knee replace-
ments is Staphylococcus aureus.
Schoifet and Morrey 4 found that
58% of 31 infected total knee
replacements cultured S aureus. Wil-
son et al5 observed S aureus in 42 of
67 infected replacements. Staphylo-
coccal organisms were responsible
for infection in the majority of
patients who had concurrent skin
ulcerations. Gram-negative organ-
isms, such as Escherichia coli and
Pseudomonas aeruginosa, have been
found less frequently. A mixed
polymicrobial infection is usually
encountered in cases in which there
is an actively draining wound
through which the surface bacteria
can gain entrance to the knee. In
addition, patients treated with
chronic antibiotic suppression may
develop resistant bacterial strains.
Diagnosis of Deep
Infection
Deep or periprosthetic infection may
be either early (within 3 months of
surgery) or late (more than 3 months
after surgery). An early infection,
provided that its course is not
modified by injudicious use of antibi-
otics, is usually not difficult to recog-
nize. The clinical course is abnormal,
with prolonged pain, swelling,
inflammation, and fever. The leuko-
cyte count, C-reactive protein level,
and erythrocyte sedimentation rate
remain elevated. Late infection is
much more common than early infec-
tion, and the diagnosis is usually
straightforward unless antibiotics
have previously been given. The
usual presentation is one of acute
pain and swelling in the knee of a
patient with a previously satisfactory
arthroplasty. Late infection usually
develops from hematogenous spread
of microorganisms from a distant
site.
Pain about a prosthesis for
which a cause is not readily appar-
ent should be assumed to be due to
infection until proved otherwise. In
a study of 52 patients with infected
knee replacements treated at our
institution, the preoperative work-
up was evaluated for accuracy in
determining infection.16 Consider-
able pain was present in 96% of the
patients, 77% had swelling of the
knee, 27% were febrile, and 27%
had active drainage. The average
erythrocyte sedimentation rate was
63 mm/h (range, 4 to 125 mm/h).
The average leukocyte count
was 8,300/mm 3 (range, 5,800 to
14,000/mm3). Aspirated knee fluid
was positive in all cases except one;
in that case, no organism was cul-
tured until aspiration was done at
the time of the revision arthro-
plasty for what was thought to be
aseptic loosening.
The diagnosis of an infection after
total knee arthroplasty must depend
45
Infected Total Knee Replacements
on the results of examination of knee
fluid aspirated under strict aseptic
conditions. Knee radiographs are
unclear in showing infection, which
may be present without radiographic
signs of loosening. Large complete
radiolucencies usually indicate an
advanced stage of infection (Fig. 1).
Technetium and gallium bone scans
also may not conclusively show pres-
ence of infection. Cultures of wound
drainage and sinus tracts, if present,
often do not truly reflect the microor-
ganisms found deep in the knee, since
there is the likelihood of contam-
ination of the fluid by other skin
flora. Thus, knee aspiration is the
standard of care for conclusively
determining whether there is deep
joint infection. The fluid aspirated
from the knee is sent to the bacterio-
logic laboratory for direct smear,
Gram stain, and cultures with antibi-
otic sensitivities for aerobic and
anaerobic bacteria, acid-fast bacilli,
and fungi.16-18 If fluid cannot be easily
obtained in the office, a fluoroscopi-
Fig. 1 Infected prosthesis 11 months post-
operatively. Note radiolucency beneath tib-
ial component.
46
cally assisted aspiration should be
considered.
If enough fluid is aspirated from
the knee, a complete blood cell count
and a differential white blood cell
count may also give valuable infor-
mation. If the former shows more
than 25,000 polymorphonuclear
leukocytes per cubic millimeter and
the latter reveals a value greater than
75%, infection should be suspected.
Fluid should also be sent for
determination of glucose and protein
levels. In normal synovial fluid, pro-
tein levels are about a third of serum
levels. Glucose values in synovial
fluid are similar to those in plasma.
In the presence of infection, synovial
glucose values are decreased due to
the presence of organisms that utilize
sugar in their metabolism. Thus, low
glucose and high protein values are
compatible with infection. If the
diagnosis is still unclear, an open
biopsy by arthrotomy or arthroscopy
is recommended.
Frequently, patients referred from
other institutions are already receiv-
ing antibiotic therapy, which may
suppress the infection enough to ren-
der the knee aspiration fluid falsely
negative. The importance of obtain-
ing positive bacterial cultures preop-
eratively cannot be overestimated.
The cultures not only provide
identification of the microorganisms
but also enable the infectious disease
consultant to obtain minimum
serum bactericidal concentrations
regularly during the course of intra-
venous antibiotic therapy. If the
patient has been receiving antibi-
otics, they should be immediately
discontinued, and serial aspirations
of the knee should be done at weekly
intervals until a positive culture is
obtained. This method not only will
provide a positive culture for the
infectious disease specialist but also
will increase the possibility that deep
knee cultures obtained at the time of
surgery will yield adequate microor-
ganism growth. After antibiotics
Journal of the American Academy of Orthopaedic Surgeons
have been discontinued, it may take
up to 1 month before a positive cul-
ture is obtained. Patients taking
antibiotics may, in fact, have positive
cultures that will inaccurately reflect
the bacteriologic status of the
wound. In this case, other organisms
may be suppressed, leading the sur-
geon to erroneously think there is
only a single organism present.
Infections complicating primary
total knee replacement should not be
treated with antibiotic therapy
alone.9,15 This treatment might sup-
press the symptoms of infection
transiently and may be indicated
only as a temporary measure if
surgery is contraindicated due to
medical reasons or if the patient
does not accept other surgical
options. Antibiotic therapy alone is
unlikely to cure the infectious
process.2,19-22 Furthermore, its use can
complicate the problem by selecting
resistant bacterial strains. An
unusual exception to this rule is the
patient with a previously successful
arthroplasty who presents acutely
with pain, swelling of no more than
24 to 48 hours’ duration, a positive
culture, and an obvious source of
hematogenous bacterial contamina-
tion. If aspiration demonstrates an
organism that is exquisitely sensitive
to antibiotic treatment, such as a
Pneumococcus or Streptococcus organ-
ism, antibiotics may be considered
for definitive treatment.
Procrastination and the prolonged
use of oral antibiotics should be con-
demned, particularly when infection
is suspected but not confirmed by
bacteriologic evidence. The end
result of this course is likely to be an
indolent subclinical infection and a
painful prosthesis. In addition, it may
make subsequent culture of the
organism very difficult even after the
components have been removed, so
that appropriate antibiotic therapy is
impossible and ultimate salvage of
the arthroplasty by reimplantation
becomes much less likely.

Treatment Options
The treatment options for an infected
total knee replacement include (1)
antibiotic suppression alone2,20-22; (2)
aggressive wound debridement,
drainage, and antibiotic suppression
therapy4,20,23,24; (3) resection arthro-
plasty25,26; (4) arthrodesis22,27,28; (5) two-
stage reimplantation 3,16-18,29; and (6)
amputation.2,30
Because the knee joint is relatively
superficial, care of the wound is pre-
eminently important. Success of any
treatment option will be severely
compromised by inadequate wound
care or inappropriate choice of inci-
sions.
The original midline incision
should be utilized whenever possi-
ble. Provided the skin margins
remain viable, the original midline
incision should heal well. This inci-
sion may be extended proximally
and distally to improve surgical
exposure of the knee joint. New inci-
sions should be avoided at all costs.
Well-healed medial or lateral inci-
sions from operations that predate
the total knee replacement should
not be reopened, even if wound
drainage develops in those areas.
Frequently, drainage stops and the
wound heals nicely after implant
removal and thorough debridement.
Large areas of skin necrosis or
wound breakdown should be
treated by rotation of a gastrocne-
mius muscle pedicle graft or free
vascularized muscle transfers.
Antibiotic Suppression
The rheumatology literature has
shown that treatment of knee sepsis
may be accomplished adequately by
serial aspirations and antibiotic
treatment.2,20-22 However, treatment
was successful in knees in which a
total joint replacement was not
implanted. The implant and acrylic
cement act as foreign bodies that
Vol 2, No 1, Jan/Feb 1994
Russell E. Windsor, MD, and James V. Bono, MD
limit the ability of the immune sys-
tem to adequately combat the infec-
tion. However, infection is not
confined to cemented total knee
replacements. Wilson et al 5 found
that infection developed in 2.8% of
35 uncemented total knee prosthe-
ses, 1.5% of 138 hybrid total knee
replacements (with an uncemented
femoral component), and 1.6% of
3,998 total knee replacements with
totally cemented components. These
incidences were not statistically
significantly different but show that
infection is possible regardless of the
method of implant fixation.
The success of this treatment
option is quite limited.2,20-22 However,
although not generally recom-
mended, antibiotic suppression
alone may be the only option for a
patient who is a poor surgical candi-
date and does not have other total
joint replacements that would be at
risk of becoming infected by
hematogenous spread of the original
infection. Only organisms with
extreme sensitivity to antibiotics,
such as Streptococcus species and
Staphylococcus epidermidis, can be
treated in this way. The disadvan-
tages of this treatment include the
development of resistant bacterial
strains, eventual painful loosening
of the prosthesis, and the risk of
antibiotic toxicity due to long-term
use of the medication. This method
does not definitively treat the infec-
tion, but rather suppresses it, and is
useful only in the few patients who
are so medically compromised that
surgical methods would threaten
their survival.
Debridement With
Antibiotic Suppression
Therapy
Vigorous wound debridement and
antibiotic therapy with retention of
the components has demonstrated
limited success, even with the addi-
tion of an ipsilateral gastrocnemius
muscle flap to provide adequate
soft-tissue coverage and enhance
vascularity.20,23,24 It has been found
that the success is greater if infec-
tion is diagnosed within 3 weeks of
implantation of the original device.
Schoifet and Morrey 4 specifically
studied the treatment of infection
after total knee arthroplasty by
debridement with retention of the
components. The most successful
results were in seven knees in
which the average time from the
onset of infection to debridement
was 21 days. However, the overall
success rate was 23%, which reflects
the fact that most of their patients
had been infected for longer than 2
to 3 weeks. Borden and Gearen 17
also found that this method was
somewhat more successful than
more radical treatment options
when the infection was diagnosed
within 2 weeks of total joint implan-
tation.
Organisms such as Streptococcus
viridans and S epidermidis may be
successfully treated by this method
if they demonstrate exquisite sensi-
tivity to parenteral or oral antibi-
otics. If this option is chosen, the
patient must take antibiotics for the
rest of his or her life. However, life-
long antibiotic suppression poses
the risk that resistant bacterial
strains may develop and create
breakthrough infections that are
chemically difficult to treat.
Patients with replacements of
other joints are not usually candi-
dates for debridement and suppres-
sion due to the risk of hematogenous
seeding of the resistant microorgan-
ism strains from the site of infection
to the noninfected total joint replace-
ments.
More radical options may become
necessary if infection persists. If one
thorough attempt at debridement
proves unsuccessful, subsequent
attempts are usually futile, and the
prosthesis should be removed.
47
Infected Total Knee Replacements
Repeated attempts at debridement
without removing the implants may
compromise skin viability and may
complicate definitive treatment by
other surgical means.
Debridement may be performed
by arthroscopy or formal arthrot-
omy. Formal arthrotomy allows
removal of most of the scar and devi-
talized tissue but may cause
significant quadriceps weakness in
the postoperative period due to the
incision through the extensor mech-
anism. The surgeon should remove
all synovium and scar tissue and
clear the medial and lateral gutters
of debris. It may be necessary to fully
expose the knee replacement in
order to properly debride the poste-
rior joint capsule.
Arthroscopic intervention may
accomplish the same goals; how-
ever, multiple (up to six) portals may
be required. The procedure is gener-
ally longer than arthrotomy because
of the slower extraction of tissue by
rotary suction blades. Infections that
create significant scarring may ren-
der arthroscopy impossible as a
treatment option.
Regardless of the surgical method
used, a thorough debridement is
done. Frozen tissue sections, Gram
stains, cultures of the tissue, and the
macroscopic appearance of the
wound should provide diagnostic
information. After debridement, the
wound is closed over suction drains,
which should remain in place for 36
to 48 hours. Using ingress and egress
tubes with continuous irrigation is
no longer recommended, as there is
a significant risk of fluid extravasa-
tion as well as a risk of exogenous
superinfection due to communica-
tion of the deep anatomic structures
with the skin. Under no circum-
stances should the wound be left
open to close by secondary forma-
tion of granulation tissue.
The wound is inspected after 2
weeks and is reaspirated under strict
aseptic conditions. If the wound is
48
benign and the cultures are negative,
antibiotic therapy is continued for a
further 4 weeks. When this is not the
case, reoperation with removal of
the prosthetic components and all
cement is performed. This decision
should be made quickly before fur-
ther compromise of the underlying
tissues develops.
Resection Arthroplasty
The two previous treatment options
preserve the total joint replacement.
Due to their limited success, more
radical surgical options are usually
required to eradicate the deep infec-
tion. Resection arthroplasty involves
the complete removal of all compo-
nents of the knee replacement,
acrylic cement, scar tissue, and syn-
ovium25,26 (Fig. 2).
This option as a definitive proce-
dure is generally reserved for med-
ically fragile patients who cannot
tolerate another major operation. It
Fig. 2 Resection arthroplasty in a med-
ically fragile patient following sepsis.
Journal of the American Academy of Orthopaedic Surgeons
may also serve as an intermediate
step for the patient who has reserva-
tions concerning arthrodesis. Falahee
et al25 reported on 28 knees that under-
went resection arthroplasty because
of infection after total knee arthro-
plasty. Eleven patients had multiartic-
ular rheumatoid arthritis, 14 had
osteoarthritis, and one patient had
multiarticular neuropathic arthropa-
thy. Six patients with monarticular
osteoarthritis considered resection
arthroplasty unacceptable and subse-
quently underwent successful sec-
ondary arthrodesis. In three patients,
spontaneous bone fusion developed
after the resection with the knee in
good position. The patients who had
had the most severe disability before
total knee arthroplasty were the most
likely to be satisfied with the func-
tional results of resection arthro-
plasty. Conversely, the patients who
had had the least severe disability
were more likely to find the results of
resection arthroplasty unacceptable.
Fifteen patients were able to walk
independently without assistance.
Five of those patients were able to
stand and walk without external limb
support. The other 10 patients used
either a knee-ankle-foot orthosis or a
universal knee splint. All 15 patients,
however, required either a cane or a
walker and remained either moder-
ately or severely restricted in their
overall walking capacity.
Resection arthroplasty is very
useful for the severely disabled per-
son with a sedentary lifestyle. The
procedure is least suitable for
patients who had a relatively minor
disability before their original total
joint replacement. Those patients
will obtain more tolerable function
from arthrodesis or reimplantation
of a total knee replacement, depend-
ing on the sensitivity of the infective
organism and the adequacy of the
antibiotic treatment.
The advantage of resection
arthroplasty is that some motion is
preserved to allow sitting and to

facilitate transferring into and out of
automobiles and aircraft. The disad-
vantage is the possibility of persis-
tent pain and instability on walking.
Arthrodesis
Arthrodesis may be the only option
for treating the infected total knee
replacement when other forms of
treatment are contraindicated.28 Suc-
cessful arthrodesis depends mainly
on technique and the availability of
adequate bone to accomplish fusion.
The success of arthrodesis can be as
low as 50% when it is used to salvage
an infected hinge prosthesis1 (Fig. 3).
Significant bone loss is often associ-
ated with removal of these implants,
making the remaining bone stock
inadequate to attain successful
fusion. Successful arthrodesis has
been accomplished in as many as
90% of the cases in which surface
replacements were utilized and
bone stock was well preserved.22,28
The indications for arthrodesis
are (1) complete destruction of the
Fig. 3 Hinged prosthesis with severe
periprosthetic bone loss.
Vol 2, No 1, Jan/Feb 1994
Russell E. Windsor, MD, and James V. Bono, MD
extensor mechanism by infection,
rendering the patient incapable of
actively extending the knee; (2) a
resistant bacterial infection that
requires high toxic doses of antibi-
otic therapy to reach adequate bacte-
ricidal levels; (3) a knee with
inadequate bone stock for placement
of a new total knee prosthesis; (4) a
knee with inadequate soft-tissue
coverage and multiple incisions that
may compromise future wound
healing; and (5) a young patient in
whom the likelihood of subsequent
infection or revision is great.
Arthrodesis may be accom-
plished by different techniques.
Adequate bacteriologic control of
the wound should be obtained
beforehand. We do not recommend
performing arthrodesis at the time of
the original debridement, as the risk
of persistent infection is high in the
setting of active wound sepsis when
metallic implants are needed to
accomplish fusion. Therefore, we
perform arthrodesis in a staged
manner. However, some advocate
immediate arthrodesis.28
Our protocol is as follows: The
first stage involves complete
removal of the prosthesis and
cement, along with complete wound
debridement. The second stage
involves a 4- to 6-week course of
intravenous antibiotic therapy,
maintaining a minimum bactericidal
concentration of 1:8. Arthrodesis is
then performed as the final stage.
External fixation and intra-
medullary rod fixation are two meth-
ods of arthrodesis particularly
applicable to this clinical situation.
External fixation is particularly
appropriate in patients who have an
ipsilateral total hip replacement
above the affected knee joint and in
patients with an especially virulent
microorganism.
In the second method, a curved
intramedullary rod is placed
through the knee joint from the
greater trochanter of the femur down
to the distal aspect of the tibia just
above the malleoli. The widest-diam-
eter rod that can fit in the tibial
intramedullary canal should be used.
Although Puranen et al28 believe that
no secondary bone grafting is
needed with this technique, ade-
quate bone may be obtained from the
anterior tibial flare or the patella to
aid fusion. Care should be taken to
provide adequate bone contact
between the femur and the tibia.
Postoperatively, the patient may
begin ambulating immediately with-
out the need for external supports.
Puranen et al reported the success of
intramedullary arthrodesis in 33
patients. Fifteen patients had failed
total knee replacements, eight of
which were infected. In the 33 cases,
four nails broke, three at the line of
fusion and one in the area of an
infected supracondylar pseudarthro-
sis. Therefore, protected weight-
bearing should be maintained until
fusion is proved radiographically.
The advantages of arthrodesis as
treatment for an infected total knee
replacement are that it is a definitive
treatment for the infection with little
chance of recurrence and that it
promises reasonably good long-
term function without the risk of
future mechanical failure. The dis-
advantages of arthrodesis are inabil-
ity to bend the knee; difficulty in
transferring from a car or sitting in a
small space, such as an airplane; and
the large increase in the energy
required to walk with a stiff knee,
which may be a particular problem
for patients with cardiovascular and
pulmonary problems.
Two-Stage Reimplantation
The most successful functional
results for the treatment of late infec-
tion of a total knee replacement are
obtained by a technique of two-stage
reimplantation of a new total knee
replacement, 3,16-18,29,31 with success
49
Infected Total Knee Replacements
rates averaging 90%. This method
represents the procedure of choice to
definitively eradicate the infection
and preserve knee function.
Adequate preoperative planning
is necessary and the availability of
special instruments is recom-
mended. Removal of the prosthetic
components and acrylic cement can
prove difficult, particularly if the
septic process is of recent onset. In
this case, the prosthetic components
will most likely be well fixed, and
removal of the tight interdigitation
between bone and cement demands
meticulous technique in order to pre-
vent unnecessary loss of bone stock.
The removal of hinged total knee
replacements with intramedullary
stems in the femur and tibia can also
prove difficult. For these cases, spe-
cial cement osteotomes and a high-
speed cement drill are helpful.
Surgical Protocol
The protocol involves three
stages. 16,19 The patient must be in
good general medical health to with-
stand the rigors of all the stages.
The first stage of the protocol
involves complete debridement of
all infected tissues, along with
removal of the implants and all
cement. All scarred, inflamed, and
devitalized tissues should be thor-
oughly excised, leaving viable,
healthy, well-vascularized tissues.
Primary wound closure can usually
be performed over closed suction
tubes, which are removed after 24 to
48 hours. The knee is immobilized in
a bulky Robert Jones dressing with
plaster splints. During this initial
debridement, a central intravenous
access catheter (e.g., a Broviac or
Hickman catheter) is introduced into
the internal or external jugular vein
to facilitate intravenous administra-
tion of antibiotics.
The dressing is changed after a
few weeks to a hinged brace, with
the knee in full extension or 5
degrees of flexion. Skeletal traction
50
is not advised, and the bone ends are
left in contact to reduce dead space.
Some surgeons recommend the use
of antibiotic-impregnated spacers to
preserve the joint space and to facil-
itate wound exposure during the
reimplantation stage of the proto-
col.31,32 The spacer block does repre-
sent a foreign body in the knee joint,
however, and would remain in place
in the event of a medical complica-
tion.
The second stage involves a 6-
week course of intravenous antibi-
otic therapy, based on the results of
culture and sensitivity studies.
Antibiotics are chosen to yield high
bactericidal effect with low toxicity.
The infectious disease consultant
follows the minimum bactericidal
concentrations and weekly exam-
ines the efficacy of the antibiotic
blood concentration against the bac-
teria available on the culture media.
A minimum bactericidal concentra-
tion of 1:8 must be maintained for
the 6-week period. The time between
the first and last stages of the proto-
col may be prolonged if this mini-
mum bactericidal concentration is
not achieved.
After 6 weeks, if the wound is
completely benign and the patient
has had an uneventful postoperative
period, another total knee prosthesis
may be inserted.16,33 However, if the
wound still shows signs of inflamma-
tion, reimplantation is postponed; a
long cylinder cast is applied, and the
patient starts ambulation and is dis-
charged home as soon as he is inde-
pendent.
Further inspection of the wound
is made a month later. If it is benign,
reimplantation is considered. Alter-
natively, the knee joint fluid may be
serially aspirated after discharge to
determine whether there is persis-
tence of infection.
The last stage of the protocol
involves implantation of a new total
knee replacement. Frequently, a
modular prosthesis is used, which
Journal of the American Academy of Orthopaedic Surgeons
enables the surgeon to reconstruct
any bone loss by adding metal
wedges to the tibial component and
distal and/or posterior augmenta-
tion to the femoral component.
Frozen tissue sections and Gram
stains are obtained at the time of
surgery to assess tissue inflamma-
tion. The macroscopic appearance of
the wound should be completely
benign; all scarred and devitalized
tissue is excised, leaving only viable,
well-vascularized, healthy tissues.
Exposure can sometimes be difficult
after prolonged immobilization;
there is a danger of avulsing the tib-
ial tubercle while attempting to
mobilize the patella and flex the
knee. If this event seems likely,
either a quadriceps snip or a turn-
down is used.
Preoperative planning is essential
in order to have adequate prosthetic
components available. A special cus-
tom-designed prosthesis is occasion-
ally necessary. In most cases, proper
alignment can be reestablished with
adequate tissue tension and the use
of press-fitted fluted intramedullary
rods. The proximal end of the tibial
component and the distal end of the
femoral prosthesis are cemented.
Some surgeons cement the prosthe-
sis completely.
Excision of the patella has
proved helpful in cases in which the
skin closure was too tight. If the
patella has insufficient bone stock
to accept a prosthesis, it may be left
unresurfaced. Normally, recon-
struction can be achieved using
standard designs that provide a
substitution for the posterior cruci-
ate ligament; in some cases, designs
that preserve the posterior cruciate
ligament are used.
In our experience, revision
arthroplasty in a wound without an
acrylic spacer block may be accom-
plished with only slightly greater
difficulty than in one with a spacer.
Other surgeons believe the use of
acrylic spacers makes later surgery

significantly less difficult. They also
feel that the extension of the spacer
into the suprapatellar pouch reduces
scarring.
The use of constrained compo-
nents is often unavoidable. When this
is the case, a constrained condylar
knee prosthesis (e.g., the Total
Condylar III) is selected; such a device
has intramedullary stems on both
components and restricts varus/val-
gus, anteroposterior, and rotary
motions by means of a centrally posi-
tioned peg. Intramedullary stems are
fitted in a modular fashion to the
femoral or tibial prosthesis and are
press-fitted into the intramedullary
canal. While a stemmed component
in the tibia, femur, or both is required
because of bone deficiency, constraint
at the prosthetic surfaces is not auto-
matically required unless there is
uncontrollable ligamentous insta-
bility.
The use of antibiotic-impregnated
cement has been recommended for
reimplantation after infection. 31,34
However, the effectiveness of this
technique in preventing reinfection
has not been statistically proved.
Postoperative Management
Postoperative management after
reimplantation is the same as that
used after a primary arthroplasty
unless a quadriceps turndown was
done to facilitate exposure. In this
event the knee is immobilized with
plaster splints for 3 weeks before
motion is begun. On the assumption
that the knee is sterile at the time of
reimplantation, there is no need for
prolonged antibiotic therapy. Peri-
operative antibiotics are adminis-
tered for 4 days until the final
operative culture readings are
obtained, after which time no addi-
tional antibiotics are given. In most
cases the antibiotic that is used for
the 6-week course is continued
through the postoperative period,
and additional antibiotics may be
given to provide broader antimicro-
Vol 2, No 1, Jan/Feb 1994
Russell E. Windsor, MD, and James V. Bono, MD
bial coverage during the reimplanta-
tion procedure.
Results
Since 1977, it has been the policy
of the knee service at our institution
to implant a new prosthesis when-
ever possible. Between January 1977
and December 1985, 48 patients in
whom 52 total knee arthroplasties
were complicated by infection were
admitted for treatment. 16 Four
patients had bilateral infections.
Thirteen patients (14 knees) were
excluded from study for a variety of
reasons. The reasons for exclusion
can be reduced to a few: (1) patient
preference, (2) antibiotic toxicity
risk, (3) medical infirmity, and (4)
inadequate skin viability and exten-
sor mechanism function.
With an average follow-up time of
4 years (range, 2.5 to 10 years), 37 of
38 knees were successfully treated
without recurrence of the original
infection (97% success rate). In the 37
patients who underwent the proce-
dure, there were 11 excellent, 13
good, 6 fair, and 7 poor results, based
on the Hospital for Special Surgery
Score. The reasons for the poor
results were reinfection by a different
organism and compromise of exten-
sor mechanism function with persis-
tent pain. Overall function was well
maintained in the group, with a
range of motion averaging 95
degrees (range, 80 to 120 degrees).
Twenty-three patients complained of
some pain when walking, 15 patients
had mild pain, 6 patients had moder-
ate pain, and 2 patients had severe
pain. All patients underwent reim-
plantation of a cemented prosthesis,
which frequently had press-fitted
intramedullary stems.
Although Insall et al18 cautioned
against using this protocol for reim-
plantation in the presence of Gram-
negative infection, it has been more
recently shown by Windsor et al 16
that it is feasible to perform this pro-
tocol when certain sensitive Gram-
negative infections are present.
Escherichia coli and P aeruginosa
infections have been successfully
treated with this protocol, and the
presence of newer nontoxic bacteri-
cidal agents has made it possible to
eradicate these Gram-negative infec-
tions.
Other authors have tried to
accomplish successful reimplanta-
tion by utilizing shorter periods of
intravenous antibiotic therapy.
However, Rand and Bryan3 found a
2-week course of therapy totally
unacceptable in definitively eradi-
cating the infection. Borden and
Gearen17 studied a small number of
infections that had been treated with
a 4-week course of intravenous
antibiotics. The overall results fell
between the poor results reported by
Rand and Bryan 3 with a 2-week
course and the excellent results
obtained by Windsor et al 16 and
Insall et al.18 Therefore, use of a 6-
week course of intravenous antibi-
otic administration can ensure
success in the majority of patients
with an infected knee prosthesis,
with a 97% overall success rate in
eradicating the original infec-
tion.16,18,29,31
It is our opinion that the most suc-
cessful method of treating infection
of a total knee replacement with
definitive eradication of the bacteri-
ologic organism is by the two-stage
reimplantation procedure. This pro-
tocol requires meticulous attention
to detail by the surgical and infec-
tious disease staff, but a predictable
outcome can be ensured in most
cases.
Amputation
Amputation may be the final salvage
procedure for severe infections that
are associated with large-bone loss
and compromised antibiotic treat-
ment.30 This procedure was required
most frequently in infected knee
51
Infected Total Knee Replacements
replacements with cemented,
stemmed hinges, which for the most
part have become obsolete. The
remaining shell of bone was fre-
quently inadequate for subsequent
arthrodesis or reimplantation, mak-
ing the limb essentially flail. Ampu-
tation may be the only option in
patients with mixed infection for
whom antibiotic treatment has
proved inadequate or in whom there
is such massive tissue destruction
that knee function is unsalvageable.
This frequently occurs with mixed
infections in which multiple ab-
scesses and sinus tracts are present
and significant destruction of the
surrounding soft-tissue sleeve and
muscle occurs. If successful treat-
References
1. Deburge A, GUEPAR Group: Guepar
hinge prosthesis: Complications and
results with two years’ follow-up. Clin
Orthop 1976;120:47-53.
2. Grogan TJ, Dorey F, Rollins J, et al: Deep
sepsis following total knee arthroplasty:
Ten-year experience at the University of
California at Los Angeles Medical Cen-
ter. J Bone Joint Surg Am 1986;68:226-234.
3. Rand JA, Bryan RS: Reimplantation for
the salvage of an infected total knee
arthroplasty. J Bone Joint Surg Am
1983;65:1081-1086.
4. Schoifet SD, Morrey BF: Treatment of
infection after total knee arthroplasty by
débridement with retention of the com-
ponents. J Bone Joint Surg Am 1990;72:
1383-1390.
5. Wilson MG, Kelley K, Thornhill TS:
Infection as a complication of total knee-
replacement arthroplasty: Risk factors
and treatment in sixty-seven cases. J
Bone Joint Surg Am 1990;72:878-883.
6. Rand JA, Bryan RS, Morrey BF, et al:
Management of infected total knee
arthroplasty. Clin Orthop 1986;205:75-85.
7. Garner RW, Mowat AG, Hazleman BL:
Wound healing after operations on
patients with rheumatoid arthritis. J
Bone Joint Surg Br 1973;55:134-144.
8. Infection in rheumatoid disease [ed-
itorial]. BMJ 1972;2:549-550.
9. Thomas BJ, Moreland JR, Amstutz HC:
Infection after total joint arthroplasty
from distal extremity sepsis. Clin Orthop
1983;181:121-125.
52
ment cannot be accomplished in any
other way, a successful above-knee
amputation may provide the best
function for patients who otherwise
would have a functionless knee joint
and distal extremity.
Summary
Successful treatment of the infected
total knee replacement represents
the most difficult form of revision
surgery. A two-stage reimplanta-
tion procedure for treating this con-
dition has been the most successful
functional option and should be uti-
lized whenever possible to defi-
nitively eradicate the infection and
ensure good function of the knee
10. Lindqvist C, Slätis P: Dental bacteremia:
A neglected cause of arthroplasty infec-
tions? Three hip cases. Acta Orthop Scand
1985;56:506-508.
11. Nelson JP, Fitzgerald RH Jr, Jaspers MT,
et al: Prophylactic antimicrobial cover-
age in arthroplasty patients [editorial]. J
Bone Joint Surg Am 1990;72:1.
12. Ainscow DAP, Denham RA: The risk of
haematogenous infection in total joint
replacements. J Bone Joint Surg Br
1984;66:580-582.
13. England SP, Stern SH, Insall JN, et al:
Total knee arthroplasty in diabetes mel-
litus. Clin Orthop 1990;260:130-134.
14. Rae T: A study on the effects of particu-
late metals of orthopaedic interest on
murine macrophages in vitro. J Bone Joint
Surg Br 1975;57:444-450.
15. Schurman DJ, Johnson BL Jr, Amstutz
HC: Knee joint infections with Staphylo-
coccus aureus and Micrococcus species:
Influence of antibiotics, metal debris,
bacteremia, blood, and steroids in a rab-
bit model. J Bone Joint Surg Am
1975;57:40-49.
16. Windsor RE, Insall JN, Urs WK, et al:
Two-stage reimplantation for the sal-
vage of total knee arthroplasty compli-
cated by infection: Further follow-up
and refinement of indications. J Bone
Joint Surg Am 1990;72:272-278.
17. Borden LS, Gearen PF: Infected total
knee arthroplasty: A protocol for man-
agement. J Arthroplasty 1987;2:27-36.
18. Insall JN, Thompson FM, Brause BD:
Journal of the American Academy of Orthopaedic Surgeons
joint. It is the procedure of choice for
younger healthy patients who can
medically tolerate the protocol.
Other options may be necessary,
depending on the medical condition
of the patient. Initial debridement
with antibiotic suppression should
be considered only in infected total
knee replacements during the first 2
to 3 weeks after the operation.
Antibiotic suppression is limited to
the small minority of patients
medically unable to tolerate fur-
ther surgery and to those few
patients with acute hematogenous
infection of 24 to 48 hours’ dura-
tion in whom the infecting organ-
isms are exquisitely sensitive to
antibiotics.
Two-stage reimplantation for the sal-
vage of infected total knee arthroplasty.
J Bone Joint Surg Am 1983;65:1087-1098.
19. Insall JN: Infection in total knee arthro-
plasty. Instr Course Lect 1982;31:42-48.
20. Johnson DP, Bannister GC: The outcome
of infected arthroplasty of the knee. J
Bone Joint Surg Br 1986;68:289-291.
21. Marsh PK, Cotler JM: Management of
an anaerobic infection in a prosthetic
knee with long-term antibiotics alone: A
case report. Clin Orthop 1981;155:
133-135.
22. Woods GW, Lionberger DR, Tullos HS:
Failed total knee arthroplasty: Revision
and arthrodesis for infection and nonin-
fectious complications. Clin Orthop
1983;173:184-190.
23. Peled IJ, Frankl U, Wexler MR: Salvage
of exposed knee prosthesis by gastroc-
nemius myocutaneous flap coverage.
Orthopedics 1983;6:1320-1322.
24. Sanders R, O’Neill T: The gastrocne-
mius myocutaneous flap used as a cover
for the exposed knee prosthesis. J Bone
Joint Surg Br 1981;63:383-386.
25. Falahee MH, Matthews LS, Kaufer H:
Resection arthroplasty as a salvage pro-
cedure for a knee with infection after a
total arthroplasty. J Bone Joint Surg Am
1987;69:1013-1021.
26. Lettin AWF, Neil MJ, Citron ND, et al:
Excision arthroplasty for infected con-
strained total knee replacements. J Bone
Joint Surg Br 1990;72:220-224.
27. Hagemann WF, Woods GW, Tullos HS:

Arthrodesis in failed total knee replace-
ment. J Bone Joint Surg Am 1978;60:
790-794.
28. Puranen J, Kortelainen P, Jalovaara P:
Arthrodesis of the knee with intra-
medullary nail fixation. J Bone Joint Surg
Am 1990;72:433-442.
29. Rosenberg AG, Haas B, Barden R, et al:
Salvage of infected total knee arthro-
plasty. Clin Orthop 1988;226:29-33.
Vol 2, No 1, Jan/Feb 1994
Russell E. Windsor, MD, and James V. Bono, MD
30. Pring DJ, Marks L, Angel JC: Mobility
after amputation for failed knee replace-
ment. J Bone Joint Surg Br 1988;70:
770-771.
31. Wilde AH, Ruth JT: Two-stage reim-
plantation in infected total knee arthro-
plasty. Clin Orthop 1988;236:23-35.
32. Carlsson AS, Josefsson G, Lindberg L:
Revision with gentamicin-impregnated
cement for deep infections in total hip
arthroplasties. J Bone Joint Surg Am
1978;60:1059-1064.
33. Freeman MAR, Sudlow RA, Casewell
MW, et al: The management of infected
total knee replacements. J Bone Joint
Surg Br 1985;67:764-768.
34. Marks KE, Nelson CL, Lautenschlager
EP: Antibiotic-impregnated acrylic bone
cement. J Bone Joint Surg Am 1976;58:
358-364.
53
 Displaced Proximal Humeral Fractures:
Evaluation and Treatment
Theodore F. Schlegel, MD, and Richard J. Hawkins, MD, FRCS(C)

Abstract
Successful treatment of proximal humeral fractures relies on the surgeon’s abil- tuberosities, are most deformed by
ity to make an accurate diagnosis. Treatment must be predicated on a thorough the rotator cuff musculature. Under-
understanding of the complex shoulder anatomy, a precise radiographic evalua- standing these deforming forces
tion, and use of a well-designed classification system. Appropriate and realistic facilitates treatment (Fig. 1).
goals must be established for each patient. The patient’s general medical health,
physiologic age, and ability to cooperate with intense and prolonged rehabilitation Blood Vessels
are all considerations when selecting the optimal treatment. Disruption of the arterial blood
J Am Acad Orthop Surg 1994;2:54-66 supply to the proximal humerus due
to trauma or surgical intervention
can result in avascular necrosis of
The majority of patients who sustain head, the lesser and greater tuberosi- the humeral head. There are three
proximal humeral fractures are in the ties, and the proximal humeral shaft. main arterial contributions to the
middle and older age groups.1-3 In There is a well-defined relationship proximal humerus (Fig. 2). 7,8 The
younger patients these fractures are between these four parts and the major arterial contribution to the
often the result of high-energy neck-shaft inclination angle, which humeral head segment is the ante-
injuries. Osteoporosis plays a measures an average of 145 degrees rior humeral circumflex artery. The
significant role in the older sedentary in relation to the shaft and is retro- terminal portion of this vessel, the
patient. 4,5 The proximal humerus verted an average of 30 degrees. The arcuate artery, is interosseous and
becomes more susceptible to fracture proximal humerus arises from three perfuses the entire epiphysis.7,8 If this
with age because of the structural distinct ossification centers, includ- vessel is injured, only an anastomo-
changes that occur with senescence.6 ing one for the humeral head and one sis distal to the lesion can compen-
Eighty-five percent of proximal each for the lesser and greater sate for the resulting loss of blood
humeral fractures are minimally dis- tuberosities. The fusion of the supply.
placed or nondisplaced and can be ossification centers creates a weak- Less significant blood supply to
effectively treated with early func- ened area, the epiphyseal scar, which the proximal humeral head is derived
tional exercises. In the remaining makes these regions of the proximal from a branch of the posterior
15%—displaced proximal humeral humerus particularly susceptible to humeral circumflex artery and from
fractures—the knowledge and skill fracture. the small vessels entering through
of the surgeon will in part determine the rotator cuff insertions. The poste-
the functional outcome. Knowledge Rotator Cuff and Girdle Muscles rior humeral circumflex artery,
of the bony architecture, the effect of The rotator cuff and shoulder- which penetrates the posteromedial
muscle action, and the blood supply girdle muscles create forces on the
underlie successful classification proximal humerus, which are in
and treatment of these injuries. equilibrium when the proximal Dr. Schlegel is an Associate, Steadman Hawkins
Clinic, Vail, Colo. Dr. Hawkins is Clinical Pro-
Neer’s classification and treatment humerus is intact. This balance is
fessor, Department of Orthopedics, University of
scheme for displaced proximal disrupted when one or several parts Colorado, Denver; and Consultant, Steadman
humeral fractures1 has greatly facili- of the proximal humerus are frac- Hawkins Clinic.
tated rational management. tured.
The pectoralis major and deltoid Reprint requests: Dr. Hawkins, Steadman
Hawkins Clinic, 181 W. Meadow Drive, Suite
Anatomy muscles exert the most deforming
400, Vail, CO 81657.
forces on the distal shaft fracture seg-
Bones ment, while the proximal fragments, Copyright 1994 by the American Academy of
The proximal humerus consists of consisting of the articular head seg- Orthopaedic Surgeons.
four well-defined parts: the humeral ment and the lesser and greater

54 Journal of the American Academy of Orthopaedic Surgeons

 Theodore F. Schlegel, MD, and Richard J. Hawkins, MD, FRCS(C)

specific enough to lead to accurate

diagnosis and treatment. 9 A num-
ber of classification systems have
been proposed to accomplish these
goals, based on the anatomic level
of the fracture, mechanism of
injury, amount of contact by frac-
ture fragments, degree of displace-
ment, and/or vascular status of the
articular segment. 10,11 However,
these systems have not proved use-
ful in diagnosis and treatment of
the more complex fracture pat-
terns.
In 1970, Neer 1 devised a class-
ification scheme based on the dis-
placement of the four proximal
humeral segments. He later elimi-
nated his numeric groupings and
detailed the application of the sim-
plified version referring only to the
segments involved. In this system, a
segment is considered to be dis-
placed if it is separated from its
neighboring segment by more than 1
cm or is angled more than 45 degrees
from its anatomic position. The frac-
ture pattern refers to the number of
displaced segments (i.e., two-part,
three-part, or four-part). The num-
ber of fracture fragments or lines is
considered irrelevant unless it fits
into the previously described
classification. Although Neer’s sys-
tem does not consider all the various

Fig. 1 Displacement of a fracture fragment is due to the pull of muscles attached to the
various bony components: the head (1), the lesser tuberosity (2), the greater tuberosity
(3), and the shaft (4). The subscapularis inserts on the lesser tuberosity; its unopposed
pull causes medial displacement. The supraspinatus and infraspinatus insert on the
greater tuberosity; unopposed pull can cause superior and posterior displacement. The
pectoralis major inserts on the humeral shaft; its unopposed pull can cause medial dis-
placement.

cortex of the humeral head, supplies Classification

only a small portion of the posteroin-
ferior part of the articular surface of
the humerus compared with the
arcuate artery. The vessels that enter
the epiphysis via the rotator cuff
insertions are also inconsequential, as
well as inconsistent in their vascular
supply to the humeral head.
A functional classification system
provides the means for an accurate
and reproducible diagnosis, facili-
tates communication, and directs
treatment. The system must be Fig. 2 Blood supply of the proximal
sufficiently comprehensive to humerus.
encompass all these factors, yet

Vol 2, No 1, Jan/Feb 1994 55

Displaced Proximal Humeral Fractures
fracture subpatterns that can affect
treatment, it remains the accepted
standardized classification, at least
in North America.
It is important to appreciate that
the terminology used to identify
proximal humeral fractures denotes
first the pattern of displacement and
second the key segment displaced.
For example, in a three-part pattern,
a displaced tuberosity is always con-
sidered the key segment even
though a displaced shaft segment is
also present (e.g., three-part greater-
tuberosity displacement). With frac-
ture-dislocations, the fracture
pattern is identified first, but the
direction of the dislocation replaces
the key segment in the description.
A fractured tuberosity segment is
always displaced in the direction
opposite the dislocation. Therefore,
a three-part anterior fracture-dislo-
cation would refer to anterior dislo-
cation of the head and attached
lesser tuberosity and posterior dis-
placement of the greater tuberosity.
A B
Fig. 3 Standard radiographic examination of the shoulder. A, Anteroposterior view. B, Lateral scapular view. C, Lateral axillary view.
56
The position of the associated dis-
placed shaft segment is variable.
The AO group has proposed an
alternative classification scheme,
which emphasizes the vascular sup-
ply to the articular segment.12 This
system was developed in an attempt
to predict the risk of avascular necro-
sis. Their classification scheme is
divided into three categories accord-
ing to the severity of the injury. Type
A represents the least severe fracture,
with no vascular interruption to the
articular segment and little risk of
avascular necrosis. Type B repre-
sents a more severe injury accompa-
nied by an increased risk of avascular
necrosis. Type C is the most severe
fracture, with total vascular isolation
of the articular segment and a high
risk of avascular necrosis. Each
group is then subdivided according
to a numeric scheme to further delin-
eate severity. Because the AO
classification system is more compli-
cated and has not as yet been shown
to predict long-term outcomes of
Journal of the American Academy of Orthopaedic Surgeons
treatment, most surgeons continue to
use the Neer system.
Radiographic Evaluation
Accurate diagnosis is essential for
optimal treatment of proximal
humeral fractures. Three radi-
ographic views are required in most
cases to ensure consistent iden-
tification of fracture type (Fig. 3). If
only two views can be obtained, true
anteroposterior and axillary would be
ideal for classification. Radiographs
of the injured shoulder are taken both
perpendicular and parallel to the
scapular plane.13 Although fracture
fragments may be shifted with any
movement of the patient’s arm, we
nevertheless advocate an axillary
view, best taken in 20 to 40 degrees of
abduction, as an essential third view
because (1) it contributes valuable
additional information about the frac-
ture configuration, since it is oriented
at right angles to the two previous
C

views; (2) it is the most reliable means
of detecting a locked posterior dislo-
cation with an impression fracture;
and (3) it provides an assessment of
the glenoid margin.
Each of these three views may be
obtained with the patient in a stand-
ing, sitting, or supine position. If a
sling has been applied, it need not be
removed. When the patient is too
uncomfortable to permit the arm to
be abducted, a Velpeau axillary view
can be obtained. 13 The patient is
seated and tilted obliquely back-
ward 45 degrees, and the radiograph
is taken from above.
These three plain radiographs are
sufficient to make an accurate diag-
nosis. On occasion, computed
tomography (CT) is helpful in fur-
ther defining the magnitude of
humeral-head defects in head-split-
ting fractures, impression fractures,
and chronic fracture-dislocations.
Computed tomographic scans can
also be helpful in determining the
amount of displacement of greater-
tuberosity fractures,14 as well as in
assessing glenoid pathology.
Methods of Treatment
Many methods of treatment of prox-
imal humeral fractures have been
proposed. Fortunately, the majority
(85%) of proximal humeral fractures
are minimally displaced or nondis-
placed and therefore can be treated
nonoperatively with a sling for com-
fort and early range-of-motion exer-
cises. The remaining 15% of proximal
humeral fractures are the subject of
the rest of this review.
Two-Part Anatomic-Neck
Fractures
The anatomic neck represents the
old epiphyseal plate, whereas the
surgical neck represents the weak-
ened area below the tuberosity and
head and is approximately 2 cm dis-
tal to the anatomic neck.
Vol 2, No 1, Jan/Feb 1994
Theodore F. Schlegel, MD, and Richard J. Hawkins, MD, FRCS(C)
The two-part anatomic-neck frac-
ture is extremely rare, and insufficient
data have been published to suggest
the ideal method of management.12,15
Some authors have recommended an
attempt at preserving the fragment,
especially if the patient is young.
Closed reduction is difficult because
the articular-head segment is usually
angulated or rotated. Open reduction
and internal fixation with interfrag-
mentary screws is an option; how-
ever, it is difficult to obtain adequate
screw purchase in the small head
fragment without violating the articu-
lar surface.
Most clinical outcome studies
agree that prosthetic hemiarthro-
plasty provides the most predictable
result. A deltopectoral approach
with release of the subscapularis ten-
don from the lesser tuberosity gives
excellent exposure. Following
removal of the head fragment and
reaming of the shaft, the humeral
component is implanted at 30 to 40
degrees of retroversion relative to
the epicondyles of the elbow. Reha-
bilitation begins early following
surgery and progresses rapidly from
assisted to active exercises.
Two-Part Greater-Tuberosity
Fractures
Two-part displaced fractures of
the greater tuberosity are relatively
uncommon. They are often associ-
ated with an anterior glenohumeral
dislocation. After closed reduction,
residual displacement of the greater
tuberosity is common (Fig. 4, A).
Neer reported that displacement of
the fragment by more than 1 cm was
pathognomonic of a longitudinal
tear of the rotator cuff. In most
cases, the greater tuberosity is dis-
placed superiorly and posteriorly
by the unopposed pull of the rotator
cuff. If the fracture heals in this dis-
placed position, it will cause
impingement under the acromion,
limiting forward elevation and
external rotation.
Radiographic findings can be
subtle because of the small size of the
fragment. Plain radiographs fre-
quently underestimate the residual
posterior displacement, which may
be the reason for the low reported
incidence of two-part greater-
tuberosity fractures. Therefore, CT
scans are often warranted to assess
the displacement of the fragment.
McLaughlin 16 found that out-
comes correlated closely with the
amount of residual fragment dis-
placement. Patients with fractures
that healed with more than 1.0 cm of
displacement suffered permanent
disability, while those with less than
0.5 cm of displacement did well. With
0.5 to 1.0 cm of displacement, there
was often a prolonged convalescence,
many patients had persistent pain,
and 20% required revision surgery.
Closed reduction of the fracture
fragment can be attempted with lon-
gitudinal traction, flexion, and
adduction of the arm to the neutral
position. Even if reduction is
obtained, however, the greater
tuberosity is liable to later displace.
Therefore, serial radiographs are
needed to check for subsequent dis-
placement if closed reduction is
selected.
Open reduction and internal
fixation are recommended in cases
with residual displacement greater
than 1 cm. Repair with multiple
heavy nonabsorbable sutures incor-
porated into the rotator cuff tendon
(Fig. 4, B) has produced favorable
results.17 When the fragment is large
enough, the fracture can be stabi-
lized with a screw and washer (Fig.
4, C).18 In all cases, the rotator cuff
tendon should be meticulously
repaired.
Two-Part Surgical-Neck
Fractures
These fractures occur through the
surgical neck and the shaft, which is
displaced more than 1 cm and/or
angulated more than 45 degrees
57
Displaced Proximal Humeral Fractures
A B
Fig. 4 A, Displaced two-part greater-tuberosity fracture. B, Figure-of-eight repair with heavy nonabsorbable sutures. C, Screw-and-washer
fixation.
from its original position. Because
both tuberosities are attached to the
head, it often remains in a neutral
position. A posterior hinge is fre-
quently present, which contributes
to the apical anterior angulation of
the fracture. If the head fragment is
left significantly angulated, limita-
tion of forward elevation may com-
promise eventual function.
Most displaced two-part surgical-
neck fractures are unimpacted, and
the shaft is displaced anteromedially
by the pull of the pectoralis major
(Fig. 5). Although closed reduction
may be attempted, repeated and
forcible attempts at closed reduction
are inadvisable. Reduction may be
prevented by interposition of the
periosteum, biceps tendon, or del-
toid muscle or by buttonholing of
the shaft through the deltoid, pec-
toralis major, or fascia. If the first
attempt is unsuccessful, it is usually
best to attempt the next reduction
with the use of general anesthesia
and an image intensifier. Fluo-
58
roscopy will allow visualization of
the fracture fragments.
The technique of closed reduction
involves distal traction and lateral dis-
placement with simultaneous flexion
Fig. 5 Displaced two-part surgical-neck
fracture.
Journal of the American Academy of Orthopaedic Surgeons
C
of the shaft. Traction is then released
to lock the fragments together. If an
acceptable reduction is achieved,
sling immobilization for 3 to 4 weeks
is adequate. Without fixation, how-
ever, angulation often recurs. With
closed reduction, it is maintaining,
rather than obtaining, the reduction
that presents the challenge.
In many cases, the fracture is
reducible but unstable, and percuta-
neous pin fixation may be used.
Under fluoroscopic control, Stein-
mann pins can be advanced across
the reduced fracture from the ante-
rior and lateral cortex of the shaft
into the proximal segment (Fig. 6). It
is often easier to skewer the head
from above through the greater
tuberosity adjacent to the acromion,
passing the pins into the distal seg-
ment. Fixation may not be rigid;
therefore, sling immobilization for 3
to 4 weeks is required while the frac-
ture segments become secure. The
pins are then removed, and rehabili-
tation is begun.
 Theodore F. Schlegel, MD, and Richard J. Hawkins, MD, FRCS(C)

in osteoporotic patients; impinge- ple rod fixation. Use of a Mouradian

ment of the plate if it is positioned nail or some form of fixation from
too far proximally; and persistent below into the head has also been
varus deformity.18 Screws may also described.
violate the articular surface or limit In complicated fractures, in
motion if left protruding laterally. patients with very osteoporotic bone,
The use of an intramedullary rod and in other circumstances, olecra-
alone is another alternative means of non traction offers an alternative
internal fixation. Ender nails or Rush method of obtaining and maintain-
rods can be inserted through a very ing reduction. Overhead olecranon
limited incision, splitting the deltoid pin traction is continued for 2 to 3
and rotator cuff. The disadvantage weeks or until the fracture is secure
with this technique is that it may not enough to be brought down to the
provide rigid fixation or control for side. A sling is used for comfort and
rotational displacement. Addition- support until there is clinical evi-
ally, a second surgical procedure is dence that the fracture fragments are
often required to remove the hard- moving in unison. Assisted exercise
ware, since it can produce impinge- can then be commenced.
ment on the undersurface of the
acromion. Other intramedullary Three-Part Fractures
Fig. 6 Percutaneous pinning of a two-part devices have been developed to pro- Obtaining and maintaining a
surgical-neck fracture.
vide greater rigidity, as well as rota- reduction with closed treatment is
tional control with the use of a difficult in these injuries (Fig. 8). In
proximal interlocking screw (Fig. 7, the active patient they are usually
In certain cases, a closed reduc- B). These devices have solved many best treated with open reduction and
tion may be too difficult to obtain or of the previous difficulties with sim- internal fixation or, in rare cases,
the reduction of the fracture proves
too unstable to be effectively main-
tained by percutaneous pinning. It
may then be necessary to proceed
with open reduction and internal
fixation. Our preferred method of
fixation involves the use of some
form of intramedullary fixation in
conjunction with the tension-band
technique (Fig. 7, A). The tension-
band technique is inadequate by
itself.19 However, when the tension-
band technique incorporates the
rotator cuff tendon and is used in
conjunction with intramedullary
fixation, adequate stability is
achieved. This more secure con-
struct allows for early passive range-
of-motion exercises.
Many other methods of open
reduction and internal fixation have
been proposed. In young patients
with good bone stock, the use of an A B
AO buttress plate and screws has Fig. 7 Methods of open reduction and internal fixation of a two-part surgical-neck fracture.
been reported to give good results. A, Combination of intramedullary-rod fixation and tension-band technique. B, Use of an
Potential complications include intramedullary rod with a proximal interlocking screw.
loosening of the screws, particularly

Vol 2, No 1, Jan/Feb 1994 59

Displaced Proximal Humeral Fractures
Fig. 8 Three-part displaced greater-
tuberosity fracture.
with prosthetic hemiarthroplasty.
Simply accepting a deformity may
result in malunion and stiffness of
the shoulder.20-22 However, accepting
the deformity of the displaced three-
part proximal humeral fracture may
be an option for selected patients
who are medically unfit or unable to
participate in the intense rehabilita-
tion program required.
Closed reduction and percuta-
neous pinning has been proposed as
an alternative means of achieving
acceptable results with minimal dis-
ruption of the surrounding blood
supply and soft tissues, provided an
acceptable reduction can be
obtained. Although the head-shaft
segment can be reduced, the chal-
lenge is to reduce the tuberosity seg-
ment as well. Jaberg et al3 reported
the results with this method for
unstable two- and three-part frac-
tures.
Open reduction and internal
fixation with a buttress T plate was
once popular, but several studies
have reported inferior results and
high failure rates.18,23,24 This technique
involves extensive soft-tissue dissec-
tion, which may disrupt the remain-
ing blood supply to the humeral
60
head, leading to necrosis. The can- relying on soft tissue rather than
cellous bone of the humeral head is bone. Complications with this treat-
often inadequate to provide ade- ment have been reported to be mini-
quate screw purchase and fracture mal. Avascular necrosis of the
fixation. There is a tendency to place humeral head did develop in two of
the hardware too proximally, which their patients, only one of whom was
may result in secondary impinge- symptomatic enough to require revi-
ment, necessitating a second surgi- sion to hemiarthroplasty. We believe
cal procedure to remove the that tension-band wiring is an excel-
hardware. For these reasons, this lent method of treatment for three-
technique has fallen out of favor for part proximal humeral fractures
the treatment of most displaced because it provides fragment
three-part proximal humeral frac- fixation that is secure enough to
tures unless the patient has excellent allow early passive range-of-motion
bone stock and large fracture frag- exercises.
ments. In this technique, 18-gauge wire
Figure-of-eight tension-band or No. 5 nonabsorbable suture is
wiring was popularized by Hawkins passed through or under the rotator
et al, 2 who reported satisfactory cuff as well as through the tuberos-
results in a series of 14 patients with ity. A colpotomy needle is helpful in
three-part proximal humeral frac- the passage of the wire or suture. A
tures. The advantages of this method drill hole is made in the shaft of the
include adequate visualization of humerus approximately 1 cm below
the fracture fragments, which the fracture site. The wire or suture
should ensure anatomic reduction is then passed through the hole and
with minimal soft-tissue stripping; looped back in a figure-of-eight fash-
preservation of the vascular supply ion (Fig. 9).
to the humeral head; and secure Tanner and Cofield25 have sug-
fixation of the fracture fragments gested that rapid restoration of
A B
Fig. 9 Repair of a three-part displaced greater-tuberosity fracture. A, Reduction of a three-
part fracture with preparation for tension-band technique. A colpotomy needle is helpful in
passage of the wire or suture. B, Figure-of-eight tension-band wiring technique.
Journal of the American Academy of Orthopaedic Surgeons

shoulder function may be more pre-
dictable in some older patients if
immediate hemiarthroplasty is per-
formed. For this goal to be achieved,
adequate fixation of the tuberosity to
the shaft is required. In most cases,
the quality of the rotator cuff tissue
is more than adequate to ensure
blood supply and a means of fixing
the tuberosity.
Four-Part Fractures
Immediate hemiarthroplasty has
become the accepted method of treat-
ment for displaced four-part humeral
fractures (Fig. 10). Such fractures,
with or without associated disloca-
tion, have been reported to be fol-
lowed by avascular necrosis with an
incidence as high as 90%.20 The num-
ber of affected patients who later
become symptomatically disabled is
unknown, but most surgeons agree
that unless the patient is very young
and active, immediate arthroplasty is
the treatment of choice.
Jakob et al 26 have stressed the
need to review the radiographs care-
Fig. 10 Displaced four-part proximal
humeral fracture.
Vol 2, No 1, Jan/Feb 1994
Theodore F. Schlegel, MD, and Richard J. Hawkins, MD, FRCS(C)
fully before proceeding with hemi-
arthroplasty, to ensure that the frac-
ture has not been mistaken for a
four-part valgus impacted pattern.
In the four-part valgus impacted
fracture, the rate of avascular necro-
sis is significantly lower (20%) than
in the classically described four-part
fracture, where it may approach
90%.20 Closed reduction or limited
open reduction and minimal inter-
nal fixation can produce satisfactory
results.26
Immediate prosthetic replace-
ment for proximal four-part
humeral fractures has met with var-
ied success. In Neer’s series,20 overall
good and excellent results were con-
sistently obtained. Other authors
have reported satisfactory but less
optimal results.25 Their poor results
have been attributed to technique
errors, such as failure to appropri-
ately reconstruct the rotator cuff,
failure to obtain bony union of the
tuberosities to the shaft, or failure to
achieve anatomic humeral offset,
which provides a normal lever arm
for the deltoid and supraspinatus.25
Many failures are directly related to
poor selection criteria, such as
accepting alcoholic and demented
patients who are unable to cooperate
in the rehabilitation programs.27
Strict adherence to surgical detail
will avoid the common pitfalls and
ensure more reproducible results.
Most failures of immediate hemi-
arthroplasty for four-part fractures
are the result of inability to restore
normal humeral length and appro-
priate retroversion (Fig. 11, A and B).
If the prosthesis is placed too distally,
there will be a risk of inferior sublux-
ation, and tension will not be
restored to the musculotendinous
aspect of the rotator cuff. If proper
humeral retroversion is not
achieved, instability of the shoulder
may result. Both humeral length and
retroversion can be difficult to assess
intraoperatively since bone is always
missing from the proximal humerus.
Proper humeral height can be
assessed at the time of prosthesis
placement. If the tuberosities can be
easily brought down to the shaft
when the arm is held in a slightly
abducted position and only one finger
can be placed between the head and
acromion, one can be confident that
humeral length has been restored.
With this technique, usually at least
one hole in the flange of the prosthe-
sis can be visualized. Appropriate
head size is assessed by the ability to
close the subscapular tendon and
obtain normal external rotation.
Proper retroversion of the
humeral component is also critical to
the success of the surgical proce-
dure. The goal is to recreate the nor-
mal 35 to 40 degrees of humeral
retroversion. This can be accom-
plished by putting the flange of the
prosthesis with the holes just poste-
rior to the bicipital groove or by
externally rotating the limb 35 to 40
degrees and placing the flange par-
allel to the floor. Once humeral
length has been restored and retro-
version recreated, visual landmarks
will aid the surgeon in cementing
the prosthesis into its proper posi-
tion. This is then followed by bone
grafting and securing the tuberosi-
ties to the shaft (Fig. 11, C).
Success in treating these injuries
is related to an accurate diagnosis,
realistic patient expectations, the
skill of the surgeon, and exclusion of
patients who are unable to cooperate
with the rehabilitation program.
Fracture-Dislocations
Fracture-dislocations require
reduction of the humeral head and
are usually managed according to
the fracture pattern. Left untreated, a
dislocation condemns the patient to
a poor functional result. Manage-
ment can often be complicated by
associated neurologic compromise,
such as axillary or brachial nerve
injury. Unrecognized disruption of
the axillary artery can prove cata-
61
Displaced Proximal Humeral Fractures
A B
strophic. Angiography should be
performed without delay in sus-
pected cases, since early diagnosis
and repair are crucial to outcome.
Articular-Surface Fractures
Impression defects or head-split-
ting fractures may result when the
humeral head has been severely
impacted against the glenoid rim.
Impression fractures most often
occur with posterior dislocation.
McLaughlin 28 was the first to
describe a locked posterior disloca-
tion with an impression fracture in
the area of the lesser tuberosity.
Management is determined by
the size of the impression defect and
the time the locked posterior dislo-
cation has been present. In the case
of an acute injury with less than a
20% impression fracture, the joint
will usually be stable following
closed reduction.29 Immobilization
for 6 weeks in external rotation will
restore long-term stability. When a
20% to 45% defect has been present
for less than 6 months, the McLaugh-
lin procedure or Neer’s modification
of the McLaughlin transfer can be
used. These techniques fix the lesser
tuberosity and its attached sub-
scapularis tendon with a screw into
the head defect. Spica immobiliza-
62
C
tion in external rotation is employed
postoperatively. When there is a
greater than 45% impression defect
or dislocation has been present for
more than 6 months, hemiarthro-
plasty is recommended. If the gle-
noid is involved, total shoulder
arthroplasty may be considered.
The longer the dislocation has been
present, the less retroversion of the
prosthesis should be employed. For
example, in a long-standing locked
posterior dislocation, the humeral
component should be put in approxi-
mately neutral version rather than the
usual 35 to 45 degrees of retroversion.
This positioning will immediately
restore stability and allow early
range-of-motion exercises.
The rare head-splitting fracture
may occasionally be reduced closed
if it consists of two large fragments.
Open reduction and screw fixation
are usually required if there are two
or three large segments. Comminu-
tion with multiple segments usually
requires hemiarthroplasty.
Positioning for Surgery
Most patients are positioned in a
semisitting “beach chair” position,
with the head rotated to the side
Journal of the American Academy of Orthopaedic Surgeons
Fig. 11 Repair of a four-part
displaced proximal humeral
fracture. A and B, Technique of
cementing humeral prosthesis
to restore humeral length and
achieve proper retroversion. C,
Figure-of-eight tension-band
wiring to reapproximate frac-
tured tuberosities.
opposite the affected shoulder.
Either regional or general anesthesia
can be used, depending on the sur-
geon’s preference. To prevent the
patient from sliding down the oper-
ating table, a pillow is placed behind
the knees and a seat belt is placed
across the patient’s thighs. The blad-
der of a blood pressure cuff may be
positioned under the ipsilateral
scapula and inflated to bring the
shoulder into the most advantageous
position for surgical approach. In
complex fracture patterns, especially
in the presence of a posterior disloca-
tion that may entail the need for an
additional posterior approach, the
patient should be placed in the lat-
eral decubitus position. A sterile
stockinette permits free manipula-
tion. Intravenous antibiotics are
administered 30 minutes prior to
surgical incision, and two doses are
given postoperatively.
Surgical Approach
Two utilitarian approaches are used
for the majority of proximal humeral
fractures. The limited deltoid-split-
ting approach is useful for isolated
greater-tuberosity fractures and
two-part surgical-neck fractures
 Theodore F. Schlegel, MD, and Richard J. Hawkins, MD, FRCS(C)

treated with intramedullary nailing free any adhesions. A deltoid retrac-

(Fig. 12). A superolateral incision is
made beginning at the anterolateral
aspect of the acromion and coursing
distally for 4 to 5 cm. The deltoid
fibers are split bluntly, and the frac-
ture is identified. One must remem-
ber during the deltoid split that the
axillary nerve courses laterally,
lying approximately 3 to 5 cm distal
to the lateral margin of the acromion.
The more extended deltopectoral
incision measures 12 to 15 cm in
length and originates at the antero-
lateral corner of the acromion, curv-
ing toward the coracoid and ending
at the deltoid insertion (Fig. 13). The
cephalic vein can be taken medially
or laterally. If the vein is taken later-
ally, excessive tension often results,
leading to venous disruption. The
insertion of the pectoralis major is
partially released for exposure.
Adducting the humerus during the
procedure aids in relaxing the del-
toid. If excessive deltoid tension is
present, a transverse division of the
anterior 1 cm of the deltoid insertion
can be used to reduce muscle
trauma. Blunt dissection is then car-
ried out in the subacromial space to
Fig. 12 Limited deltoid-splitting approach.
tor is placed deep to the deltoid and
acromion and superficial to the rota-
tor cuff and humeral head. The cora-
coacromial ligament may be released
superiorly for improved exposure.
Rehabilitation
The rehabilitation program must be
individualized to optimize the recov-
ery of shoulder function. The sur-
geon and the physical therapist must
convey to the patient a clear under-
standing of what is expected to
achieve short- and long-term goals.
The postoperative management pro-
gram has three well-defined phases:
phase I consists of passive or assisted
range-of-motion exercises; phase II
consists of active range-of-motion
exercises with terminal stretching;
phase III is a resisted program with
ongoing active motion and terminal
stretching.
Phase I begins on day 1, often
with the aid of an interscalene block
for early pain control, and continues
for 6 weeks. It is essential to confirm
that the fracture fragments move in
Fig. 13 Extended deltopectoral approach.
unison and the fracture is stable. In
rare instances, this phase may have
to be delayed for up to 4 weeks if
fixation is not rigid. This phase con-
sists of passive forward elevation
and external rotation of the involved
shoulder assisted by the contralat-
eral extremity. Assisted exercises
begin in the supine position, with
early emphasis on elevation and
external rotation. Internal rotation
exercises are included if the rotator
cuff is intact (i.e., in surgical-neck
fractures) or if secure fixation has
been achieved by internal fixation
(i.e., in tuberosity fractures). This
exercise is frequently avoided in the
early period after hemiarthroplasty
with tuberosity repair for four-part
fractures to avoid tension on the
greater tuberosity segment. Pendu-
lum exercises are used as a warm-up
after a few days. Several days later,
those exercises are performed sitting
or standing. Toward the end of this
initial 6-week phase, isometric
strengthening exercises may be
added. These are performed by
applying gentle resistance to inward

Vol 2, No 1, Jan/Feb 1994 63

Displaced Proximal Humeral Fractures
and outward rotation when the arm
is at the side and the elbow is flexed
to 90 degrees. Similar exercises are
performed for flexion and extension.
These activities need to be moni-
tored carefully by the physician and
the physical therapist. The exercises
are taught to the patient and the
patient’s spouse so that they can be
carried out at home.
Phase II usually begins at 6 weeks
and consists of active range-of-
motion exercises with terminal
stretching. This phase is not begun
until early union has been confirmed
clinically and radiographically. The
ability to resume the supine position
allows the patient to concentrate on
forward elevation and outward rota-
tion. A full active range of motion in
all planes is sought during this
phase.
Phase III focuses on resisted
strengthening and begins 10 weeks
after surgery when union has been
confirmed and adequate range of
motion has been obtained. The chal-
lenge to achieve normal shoulder
function is met with greater resis-
tance during the strengthening
exercises and the ongoing terminal
stretching program. Maximal
recovery is rarely achieved before
the end of the first postoperative
year.
Complications
Many complications, both specific and
nonspecific, are reported to follow
closed and open treatment of dis-
placed proximal humeral fractures.
Infection, neurovascular injury, malu-
nion, nonunion, hardware failure,
joint stiffness, and heterotopic
ossification can result after the treat-
ment of any fracture. Avascular necro-
sis, on the other hand, is a specific
complication of significantly dis-
placed proximal humeral fractures.20
Infection occurs infrequently
after open reduction and internal
64
fixation of displaced proximal
humeral fractures. Fortunately, the
proximal humerus has adequate
soft-tissue coverage with good vas-
cular supply to the tissues, decreas-
ing that risk.
Neurovascular injuries have
been well documented following
displaced proximal humeral frac-
tures. Stableforth30 reported a 5%
incidence of axillary artery com-
promise and a 6.2% incidence of
brachial plexus injuries. Vascular
injuries most often are associated
with penetrating or violent blunt
trauma caused by the initial injury,
but can also occur after open reduc-
tion and internal fixation.31 If a vas-
cular injury occurs, the lesion is
usually found at the junction of the
anterior humeral circumflex and
axillary arteries. The diagnosis may
be difficult to make, since periph-
eral pulses are often normal as a
result of collateral circulation. An
expanding hematoma, pallor, and
paresthesias are all suggestive of a
vascular injury. Paresthesias in the
corresponding neurologic distribu-
tion are often the most reliable clin-
ical sign. Since early diagnosis and
repair are crucial to the outcome,
angiography should be performed
without delay when a vascular
injury is suspected.
The axillary nerve is the most
susceptible to injury following frac-
tures with and without dislocation
of the proximal humerus. The axil-
lary nerve provides motor supply to
the deltoid and teres major, with
sensory distribution over the lateral
aspect of the upper arm. A normal
sensory examination of the skin
overlying the lateral deltoid is not
always indicative of an intact axil-
lary nerve. A more reliable means of
testing the integrity of the axillary
nerve is by palpating all three slips
of the deltoid muscle for active con-
traction. However, this too is some-
times difficult to accurately assess in
an acute fracture when there is asso-
Journal of the American Academy of Orthopaedic Surgeons
ciated pain. Therefore, an elec-
tromyogram should be obtained if a
nerve injury is suspected. This study
should be obtained no earlier than 4
weeks after the injury; the results
are most accurate then and can be
used as a baseline for further com-
parisons of recovery of function.
The majority of these injuries are
secondary to neuropraxia and will
improve with time. If a complete
axillary nerve injury does not
improve within a 3- to 6-month
period, surgical exploration is war-
ranted.
Malunion of the proximal humerus
can cause significant functional limita-
tions. When the greater tuberosity
heals in a superior or medial position,
the space beneath the subacromial
arch is limited, and impingement
occurs when the arm is abducted or
externally rotated. This problem can
be corrected with a salvage surgical
procedure involving an osteotomy of
the greater tuberosity and mobiliza-
tion of the rotator cuff. This procedure
is often difficult because the anatomy
is distorted and there is often exten-
sive searing.
Nonunion at the surgical neck is
not uncommon, particularly in the
case of two-part displaced shaft frac-
tures and three-part fractures. Inter-
position of soft tissue, excessive
soft-tissue dissection, inadequate
immobilization, poor patient compli-
ance, and overaggressive physical
therapy all contribute to nonunion.
Treatment in these cases includes
open reduction and internal fixation,
autogenous bone grafting, and spica-
cast immobilization. The use of Rush
nails with tension-band wiring is the
preferred method of internal fixation
in these difficult cases.
Joint stiffness can occur as a result
of either closed or open treatment.
Prolonged immobilization with
either means of management can
result in bursal or capsular adhe-
sions. Prominent hardware (e.g.,
rods, plates, screws, and wires) can

limit mobility. Persistence with daily
terminal stretching programs is the
best management, but may require
up to 18 months for full benefit.
Forced manipulation carries the risk
of refracture and is rarely required.
Heterotopic ossification appears
to be related to both repetitive force-
ful attempts at closed reduction and
delay in open reduction beyond 1
week of the initial injury. Inadequate
irrigation to wash out bone frag-
ments following open reduction and
internal fixation may also increase
the risk. Exercises to maintain range
of motion should be the mainstay of
treatment. After 1 year, if a bone scan
shows no activity, excision of the
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66 Journal of the American Academy of Orthopaedic Surgeons