Anda di halaman 1dari 88

Review Article

Acute Achilles Tendon Ruptures:


An Update on Treatment

Abstract
Anish R. Kadakia, MD Acute rupture of the Achilles tendon is common and seen most
Robert G. Dekker II, MD frequently in people who participate in recreational athletics into their
thirties and forties. Although goals of treatment have not changed in
Bryant S. Ho, MD
the past 15 years, recent studies of nonsurgical management,
specifically functional bracing with early range of motion, demonstrate
rerupture rates similar to those of tendon repair and result in fewer
wound and soft-tissue complications. Satisfactory outcomes may be
obtained with nonsurgical or surgical treatment. Newer surgical
techniques, including limited open and percutaneous repair, show
rerupture rates similar to those of open repair but lower overall
complication rates. Early research demonstrates no improvement in
functional outcomes or tendon properties with the use of platelet-rich
plasma, but promising results with the use of bone marrow–derived
From the Department of Orthopaedic
Surgery, Feinberg School of stem cells have been seen in animal models. Further investigation is
Medicine, Northwestern University, necessary to warrant routine use of biologic adjuncts in the man-
Chicago, IL (Dr. Kadakia and agement of acute Achilles tendon ruptures.
Dr. Dekker) and Hinsdale
Orthopaedics, Hinsdale, IL (Dr. Ho).

Dr. Kadakia or an immediate family


member has received royalties from
Acumed and Biomedical Enterprises;
is a member of a speakers’ bureau or
A cute rupture of the Achilles
tendon is common, especially in
recreational athletes aged 30 to 49
Recent nonsurgical protocols involve
a short period of immobilization in a
boot with early motion and pro-
has made paid presentations on
behalf of Acumed and DePuy
years.1 A 2014 population-based gressive weight bearing. If surgical
Synthes; serves as a paid consultant study reported an increasing inci- treatment is chosen, options include
to or is an employee of Acumed, dence of acute rupture, particularly open, minimally invasive, and per-
BioMedical Enterprises, and Celling in the 49- to 60-year age group, but a cutaneous repair techniques. Treat-
Biosciences; has received research or
institutional support from Acumed and
decrease in the proportion of patients ment goals emphasize restoration of
DePuy Synthes; and serves as a undergoing surgical treatment.2 With physiologic tendon length and ten-
board member, owner, officer, or the emergence of functional bracing sion, which is believed to ultimately
committee member of the American and early motion protocols, non- maximize strength and function.
Academy of Orthopaedic Surgeons
and the American Orthopaedic Foot
surgical management of ruptures has Although biologic adjuncts, such as
and Ankle Society. Neither of the resulted in rerupture rates and func- platelet-rich plasma (PRP) and bone
following authors nor any immediate tional outcomes similar to those of marrow–derived stem cells, have
family member has received anything surgical management, but with less been used in efforts to optimize
of value from or has stock or stock
options held in a commercial company
risk of complications.3 As evidence in postoperative tendon healing, they
or institution related directly or support of nonsurgical treatment have yet to show substantial differ-
indirectly to the subject of this article: grows, the incidence of surgical ences in outcome.
Dr. Dekker and Dr. Ho. repair has declined by up to 55% in
J Am Acad Orthop Surg 2017;25: some countries in recent years.4
23-31 The risk of rerupture, skin com- Nonsurgical Management
DOI: 10.5435/JAAOS-D-15-00187 plications, and nerve complications,
as well as strength and return to The optimal management of an
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. work, must be considered in the acutely ruptured Achilles tendon has
selection of a treatment strategy. been the subject of debate for decades.

January 2017, Vol 25, No 1 23

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Achilles Tendon Ruptures: An Update on Treatment

Figure 1 after the injury because a delay in The functional rehabilitation pro-
initiation and maintenance of tocol for patients with a ruptured
plantar flexion could result in Achilles tendon varies widely but
development of a hematoma that typically consists of initial immobili-
blocks tendon apposition. How- zation for approximately 1 to 2
ever, time to presentation has pre- weeks. The patient is then transi-
viously not been shown to correlate tioned to a controlled ankle motion
with rerupture rates.9 (CAM) walker with initiation of
gentle stretching and resistance exer-
cises that are progressed over time.
Functional Rehabilitation Weight bearing in the CAM walker is
In some countries or regions, acute generally allowed. Randomized con-
Achilles tendon ruptures are pre- trolled trials have demonstrated that
dominantly managed nonsurgically. weight bearing reduces ankle stiffness
For instance, functional rehabilita- and results in better health-related
tion is preferred by more than half of quality of life; however, no studies
surgeons in Finland.10 The exact have shown an effect on the rerupture
definition of functional (dynamic) rate, functional outcomes, or bio-
rehabilitation varies. The term may mechanical tendon properties.8,15
refer to early controlled motion, In one blinded, randomized con-
Photograph showing a commercial
functional brace that permits varying protected weight bearing, or a com- trolled trial, no difference in heel-rise
degrees of static or dynamic ankle bination of both. Furthermore, the work, a measure of plantar flexion
plantar flexion and limited ankle means by which protected motion is strength, or in the rate of rerupture
dorsiflexion. (Courtesy of OPED, achieved differ. Protocols range from was seen at 1 year after injury in 60
Oberlaindern, Germany.)
the use of a rigid boot that is patients randomized to weight-
removed by the patient to perform bearing or non–weight-bearing
The choice of management strategy range-of-motion (ROM) exercises to functional rehabilitation.15 How-
has been influenced by earlier studies the use of adjustable, nonremovable ever, patients in the weight-bearing
showing a lower risk of rerupture with short-leg orthoses that allow pro- group had higher health-related
surgical treatment, but at the expense gressive, restricted ankle motion11 quality of life scores at 1-year
of a higher risk of wound complica- (Figure 1). follow-up. Similarly, in a random-
tions, including infection and The beneficial effects of early ized controlled trial of 74 patients by
impaired wound healing.5 motion on tendon healing have been Young et al,8 weight bearing had no
Historically, nonsurgical man- well described and have been statistically significant effect on
agement consisted of immobiliza- extensively studied in rat models. rerupture rates. Both of these studies,
tion in a cast for 6 to 8 weeks. A Eliasson et al12 showed improved however, are relatively small and
study of this treatment strategy tendon strength in rats with early may not be sufficiently powered to
demonstrated a higher rate of motion at 8 and 14 days after detect true differences in rerupture
rerupture compared with the results rupture. Hammerman et al13 rates.
of surgical treatment (12.6% versus showed that mechanical loading in The extent to which weight bearing
3.5%).5 Recent studies of non- a healing Achilles tendon induces results in tension on the Achilles
surgical treatment with early func- local microtrauma, which eventu- tendon while the patient uses a brace
tional rehabilitation have shown ally produces a stronger tendon for support is unknown. Importantly,
rerupture rates lower than those of callus. Clinically, Schepull and weight bearing has not been shown to
cast immobilization and compara- Aspenberg14 demonstrated a better affect rerupture rates and is a safe and
ble to those of surgical interven- elastic modulus of the tendon with appealing option for select patients
tion.6,7 Nevertheless, one recent early motion than with immobili- who are able to comply with the
investigation reported rerupture zation in a randomized controlled activity restrictions of their func-
rates as low as 3% to 5% with trial of 35 patients. However, this tional rehabilitation protocol.8 Table
casting.8 The authors of the study finding did not translate to sub- 1 summarizes an example of a
suggested that the decreased rates stantial differences in functional functional rehabilitation protocol
stemmed from exclusion of patients outcome, measured by the heel- for the management of an acute
who sought treatment .72 hours raise index at 1-year follow-up. Achilles tendon rupture.6

24 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Anish R. Kadakia, MD, et al

Outcomes Table 1
Few randomized controlled trials Sample Functional Rehabilitation Protocol for Use After Surgical or
have directly compared functional Nonsurgical Management of Acute Achilles Tendon Ruptures
rehabilitation with standard immobi- Postoperative
lization. Saleh et al16 showed that Week Protocol
functional rehabilitation with early
0–2 Posterior slab/splint
motion and the use of a removable Non–weight bearing with crutches immediately post-
CAM walker resulted in faster return operatively in patients who undergo surgical treatment or
to mobility and return to work immediately after injury in nonsurgically treated patients
compared with casting for 8 weeks.16 2–4 Controlled ankle motion walking boot with 2-cm heel lifta,b
Multiple studies have demonstrated Protected weight bearing with crutches
Active plantar flexion and dorsiflexion to neutral, inversion/
rerupture rates with functional reha- eversion below neutral
bilitation that were lower than pre- Modalities to control swelling
viously reported rates of rerupture Incision mobilization if indicatedc
with standard immobilization or Knee/hip exercises with no ankle involvement (eg, leg lifts
from sitting, prone, or side-lying position)
surgical management. Importantly, Non–weight-bearing fitness/cardiovascular exercises (eg,
some,6,7 but not all,17 recent ran- bicycling with one leg)
domized controlled trials comparing Hydrotherapy (within motion and weight-bearing limitations)
functional rehabilitation and surgical 4–6 Weight bearing as tolerateda,b
repair have demonstrated no differ- Continue protocol of wk 2-4
ence in rerupture rates. Soroceanu 6–8 Remove heel lift
Weight bearing as tolerateda,b
et al3 performed a meta-analysis of 10 Slow dorsiflexion stretching
randomized controlled trials consist- Graduated resistance exercises (open and closed kinetic
ing of 418 patients treated surgically chain exercises and functional activities)
Proprioceptive and gait training
and 408 patients treated non-
Ice, heat, and ultrasound therapy, as indicated
surgically. They reported no statisti- Incision mobilization if indicatedc
cally significant difference in the risk Fitness/cardiovascular exercises (eg, bicycling, elliptical
of rerupture between surgical treat- machine, walking and/or running on treadmill) with weight
bearing as tolerated
ment and nonsurgical treatment Hydrotherapy
consisting of functional bracing and 8–12 Wean out of boot
early motion (absolute risk differ- Return to crutches and/or cane as necessary; gradually wean
ence, 1.7%; P = 0.45). However, off use of crutches and/or cane
compared with nonsurgical treatment Continue to progress range of motion, strength, and
proprioception
consisting of prolonged immobiliza-
.12 Continue to progress range of motion, strength, and
tion, such as casting, surgical treat- proprioception
ment reduced the absolute risk of Retrain strength, power, and endurance
rerupture by 8.8% (P = 0.010). Increase dynamic weight-bearing exercises, including
No clinically important long- plyometric training
Sport-specific retraining
term differences in ankle ROM,
strength, calf circumference, or a
Patients are required to wear the boot while sleeping.
b
functional outcome scores between Patients are allowed to remove the boot for bathing and dressing but should adhere to the
weight-bearing restrictions.
functional rehabilitation and sur- c
If, in the opinion of the physical therapist, scar mobilization is indicated (ie, the scar is tight), the
gical repair have been identified.3,6 physical therapist can attempt to mobilize the scar with the use of friction or ultrasound therapy
instead of stretching.
Schepull et al18 compared the Adapted with permission from Willits K, Amendola A, Bryant D, et al: Operative versus
mechanical properties of ruptured nonsurgical treatment of acute Achilles tendon ruptures: A multicenter randomized trial using
accelerated functional rehabilitation. J Bone Joint Surg Am 2010;92(17):2767-2775.
Achilles tendons after surgical
repair with those after functional
rehabilitation by implanting tan-
talum markers into the ends of elongation, or heel-raise index surgical treatment but little differ-
the ruptured tendons. They found after 18 months. ence at 1 year postoperatively in a
no differences in strain per Nilsson-Helander et al7 showed randomized controlled trial of 97
force, cross-sectional area, tendon improved function at 6 months after patients. The surgical group had

January 2017, Vol 25, No 1 25

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Achilles Tendon Ruptures: An Update on Treatment

Table 2 unclear, this factor is important to


consider in the treatment of athletes.
Clinical Pearls for Successful Nonsurgical Management of Midsubstance
Achilles Tendon Ruptures The risk of complications other than
rerupture is lower after nonsurgical
Nonsurgical treatment is not synonymous with no treatment. A proven functional
treatment than after surgical treat-
rehabilitation protocol must be administered and supervised closely.6
ment.3 This finding is consistent with
Patients who are treated nonsurgically must take added caution because suture
fixation makes surgical repair more robust than nonsurgical treatment. those of earlier meta-analyses com-
It is important to avoid dorsiflexing the Achilles tendon beyond neutral in the first paring surgical management with
6 weeks of treatment, after which the patient may begin controlled, progressive immobilization.5 Soroceanu et al3
stretching.6 reported a 15.8% lower risk of
The clinician must ensure that the patient understands that the healing tendon is complications other than rerupture
vulnerable and that care must be taken to avoid sudden loading of the Achilles with nonsurgical treatment. Willits
tendon during activities of daily living (eg, ascending stairs) because it can
result in rerupture. et al6 reported no soft-tissue compli-
Gradual return to low-impact activities may commence at 6 months after injury. cations in patients treated with a
High-impact activities (eg, soccer, football, rugby) may be considered after 9 removable orthosis, early motion,
months if the patient demonstrates the ability to perform a single-limb heel rise. and early weight bearing; in surgi-
Achilles tendon avulsions (ie, distal tears at the calcaneus with or without bone cally treated patients, the authors
fragment) require surgical management. found a 12.5% rate of complications,
including superficial and deep infec-
tion, hypertrophic scar, tendon teth-
ering to skin, and wound dehiscence.
greater improvement in concentric in which patients are stratified on the In a series of 945 consecutive patients
strength, heel-rise height and work, basis of age and activity demands are (949 tendons) treated with non-
and hopping tests at 6 months needed to better assess differences in surgical functional management,
postoperatively, but at 1-year function and the rate of rerupture Wallace et al9 reported low rates of
follow-up, only the heel-rise work between surgical and nonsurgical complications other than rerupture,
was greater. However, the clinical treatment. including heel pain (2.2%), numbness
relevance of this difference in heel-rise The only differences between sur- (0.7%), ulcers (0.5%), deep vein
work is unclear because no difference gical treatment and functional reha- thrombosis (1.1%), pulmonary em-
was found in patient opinions bilitation that have been reported are bolism (0.2%), and orthosis-related
regarding function or physical activity in terms of time to return to work and discomfort (0.4%).
levels at 1-year follow-up. plantar flexion strength. In the meta- Although complication rates are
Existing randomized controlled tri- analysis by Soroceanu et al,3 surgical lower with nonsurgical treatment
als comparing surgical and non- treatment was associated with return than with surgical treatment, orthosis-
surgical treatment may not be to work up to 19 days earlier. related complications can occur. In
adequately powered to detect differ- However, specific criteria for return one randomized controlled trial of 83
ences in physical function or the rate of to work were not defined and likely patients, the rate of skin-related com-
rerupture. In a randomized study of varied among the studies included in plications after nonsurgical treatment
100 patients, Olsson et al17 reported the meta-analysis. In a study of 144 with a nonremovable dynamic
better performance on all functional patients, Willits et al6 found a small, orthosis was 31.7% compared with
tests after surgical repair with accel- yet statistically significant increase in 4.7% after minimally invasive
erated postoperative functional reha- plantar flexion strength at 1 and 2 repair.19 Orthosis-related complica-
bilitation compared with treatment years after surgical repair. They used tions included fungal infection, pres-
consisting of functional rehabilitation a dynamometer to compare peak sure sores, blisters, and superficial
alone. However, only the differences plantar flexion torque of the affected wound infection.
in hopping and drop countermove- extremity with that of the normal Appropriate counseling and regu-
ment jump testing were statistically contralateral extremity at different lar patient follow-up are fundamen-
significant. No reruptures occurred in velocities and found a mean differ- tal to successful outcomes of
patients treated surgically, whereas ence of 14.15% (95% confidence functional rehabilitation (Table 2).
five patients who were treated non- interval, 1.12% to 27.19%) between Rerupture of the healing Achilles
surgically had reruptures; however, surgical treatment and functional tendon during functional rehabilita-
this difference was not statistically rehabilitation. Although the clinical tion usually occurs in conjunction
significant (P = 0.057). Larger studies relevance of this difference is with poor patient compliance. In a

26 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Anish R. Kadakia, MD, et al

prospective, nonrandomized study and soft tissue. Additionally, this Figure 2


of 57 patients treated nonsurgically approach can be used reliably with
with the use of a dynamic ankle the patient placed in a supine posi-
brace, Neumayer et al11 reported tion and the surgical extremity
seven reruptures at a mean 5-year externally rotated with the assistance
follow-up. Five of the seven patients of a beanbag.22 This approach
who experienced rerupture were re- avoids the risks and challenges of
ported to have demonstrated poor prone positioning.
compliance before the rerupture. All Clinically, the choice of approach
reruptures occurred within the first 5 does not appear to be associated with
months of treatment. In their con- differences in wound complication
secutive series of 945 patients, rates. A systemic review by High-
Wallace et al9 retrospectively lander and Greenhagen23 demon-
investigated the long-term rate of strated wound complication rates of
rerupture after functional non- 7% and 8.3% in the midline incision
surgical treatment. The authors group and the posteromedial incision
found a low rate of rerupture (2.8%, group, respectively. Risk factors that
or 27 reruptures) at a follow up of were associated with wound com-
$2 years. Five patients prematurely plications in a retrospective review of
removed their brace, and two of 167 patients by Bruggeman et al24
those patients subsequently experi- included smoking, steroid use, and Angiogram demonstrating the
enced rerupture within the first 3 female sex. Interestingly, the authors integument of the posterior ankle
months of treatment. They were of the study did not find statistically and calf. The Achilles tendon and
paratenon have been removed.
successfully treated with a repeat significant associations of diabetes The solid line over the
functional protocol and returned to mellitus, age, or body mass index hypovascular zone (P) represents
full activities without complication. with wound complications. the standard posterior midline
incision. The dotted line represents
the posteromedial incision through
the zone of greatest vascularity. L =
Surgical Management Percutaneous Repair lateral, M = medial, PA = peroneal
The desire to decrease wound com- artery, PTA = posterior tibial artery.
Surgical management of acute Achilles plications in Achilles tendon repairs (Reproduced with permission from
Yepes H, Tang M, Geddes C,
tendon ruptures historically was has led to the development of new Glazebrook M, Morris SF, Stanish
performed through a posterior mid- repair techniques that decrease the WD: Digital vascular mapping of the
line approach with the patient in a incision size and minimize devital- integument about the Achilles
prone position. Taylor and Palmer20 ization of surrounding soft tissue. Ma tendon. J Bone Joint Surg Am
2010;92[5]:1215-1220.)
showed that this approach is at the and Griffith25 first reported on a
junction between the posterior tibial percutaneous technique for suture
and peroneal arterial supply and repair of the Achilles tendon in 1977. a series of 124 patients after percu-
suggested that an incision at this They used medial and lateral stab taneous repair, thus demonstrating
location would cause the least incisions to pass and tie a suture that sural nerve entrapment remains
amount of vascular insult. However, between the proximal and distal ends a concern despite advances in surgi-
vascular mapping in cadavers per- of the tendon. Although earlier cal technique.
formed by Yepes et al21 demon- studies of percutaneous repair tech- The results of percutaneous tech-
strated the least amount of niques included reports of sural niques have been shown to be similar
vascularization of the skin and sub- nerve injury, the absence or lower to those of open repairs in terms of
cutaneous tissue directly posteriorly rate of these complications in recent decreased wound complications
and the greatest amount of vascu- studies is likely a reflection of without increased rerupture rates. In
larization between the axis of the improved surgical technique, with a prospective randomized controlled
medial malleolus and the medial care taken to identify and protect the trial of 33 patients, Lim et al26 re-
border of the Achilles tendon (Figure sural nerve through the proximal ported no postoperative wound
2). A posteromedial approach to the lateral stab incisions.26,27 Neverthe- infections in the percutaneous repair
Achilles tendon takes advantage of less, in a study by Maes et al,28 eight group and a 21% infection rate in
this zone of increased vascularity sural nerve injuries were reported in the open repair group (P = 0.01).

January 2017, Vol 25, No 1 27

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Achilles Tendon Ruptures: An Update on Treatment

Rerupture rates were 3% and 6%, percutaneous techniques. This lim- quality of the tendon repair and the
respectively, but the difference was ited open technique involves a length of the tendon.
not statistically significant. Compli- small incision over the site of the
cations in the percutaneous repair Achilles tendon rupture and a per-
group included wound puckering in cutaneous suture repair accom- Postoperative Protocol
9% of patients and adhesions in 6% plished by passing suture within the Historically, postoperative care after
of patients. Karabinas et al27 found paratenon (Figure 3). This tech- surgical repair of the Achilles tendon
no substantial difference in return to nique has been improved with consisted of immobilization in a cast
work, return to activities, American modern instrumentation, such as for 6 weeks without weight bearing.
Orthopaedic Foot and Ankle Society modified ring forceps,32 that sim- Costa et al36 compared this regimen
(AOFAS) score, or satisfaction plifies percutaneous passage of the with early weight bearing in a
between open repair and percutane- suture through the Achilles tendon carbon-fiber above-ankle orthosis in
ous repair in a prospective random- within the paratenon. a randomized prospective study of
ized controlled trial of 34 patients. In Assal33 reported excellent results 48 patients and found improved time
a retrospective review of 32 patients, and no wound complications or to normal walking and stair climbing
Henríquez et al29 reported no dif- sural nerve injuries in a prospective in the early weight-bearing group.
ferences in plantar flexion strength, multicenter study of 187 consecutive Two patients in the early weight-
ROM, calf or ankle diameter, or patients treated with a limited open bearing group who were non-
single heel-raise testing. The authors technique with the Achillon Achilles compliant with activity restrictions
reported only two wound compli- Tendon suture system (Integra Life- sustained reruptures in acute falls,
cations and one rerupture, both in Sciences). Three patients experienced demonstrating the importance of
the open repair group. However, rerupture, one resulting from an careful patient selection for early
42% of patients in the study were acute fall and two resulting from weight-bearing protocols.
lost to follow-up. noncompliance with postoperative Suchak et al37 compared weight
The use of endoscopy has been bracing. In a prospective randomized bearing with non–weight bearing in
proposed as an adjunct to percuta- study of 40 patients comparing open patients placed in an ankle-foot
neous techniques to allow visualiza- repair with mini-open repair in orthosis at 2 weeks postoperatively,
tion of the tendon apposition and which the Achillon suture system with early motion exercises initiated at
avoid damage to the sural nerve. was used, Aktas and Kocaoglu34 that time. They reported no reruptures
Although Chiu et al30 reported a found no statistically significant dif- in 110 patients, with improved quality
10% rate of sural nerve numbness ference in AOFAS scores and of life and decreased activity limita-
that resolved in 1 month in a series of decreased local tenderness, skin tions in the weight-bearing group at 6
19 patients treated with endoscopi- adhesions, and scar or tendon weeks but no statistically significant
cally assisted percutaneous repair, thickness in the mini-open repair differences between the groups at 6
they noted that this complication group. They reported no complica- months postoperatively.
occurred in the first two patients and tions in either group. Despite suc- Similar results have been reported in
did not occur after they moved the cessful limited open Achilles tendon patients who underwent percutane-
location of the percutaneous inci- repairs in 36 professional athletes, ous Achilles tendon repairs and were
sions to directly over the lateral Vadalà et al35 showed a decrease in allowed immediate weight bearing
border of the Achilles tendon. endurance of 6.78% at 28-month with ROM exercises at 2 weeks post-
follow-up. operatively. In a study of 52 patients,
Our preferred method of repair is a Patel et al38 reported no reruptures.
Limited Open Repair limited open technique with the use of Patients demonstrated a mean
Percutaneous Achilles tendon repair a vertical posteromedial incision that AOFAS score of 96 with a 3.8% rate
does not provide access that would can be extended proximally or dis- of wound dehiscence that did not
allow the surgeon to visualize the tally if greater tendon visualization is require secondary surgery. In a study
final tendon apposition or judge the required (Figure 2). Sutures are of limited open Achilles tendon
quality of the repair. To ensure that placed deep to the paratenon to repairs, Groetelaers et al39 reported
the length of the tendon is adequately decrease the risk of sural nerve no difference in strength, quality of
restored with a tendon repair that injury. We think that this method life, or return to work or sports with
maximizes contact of the edges of the reduces the risk of wound compli- immobilization with non–weight
ruptured tendon, Kakiuchi31 devised cations while allowing visualization bearing versus full weight-bearing in
a technique that combined open and of the repair and maximizing the a protective brace at 2 weeks

28 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Anish R. Kadakia, MD, et al

Figure 3

Intraoperative photographs showing a mini-open repair technique. A, The mini-open incision is marked on the patient’s skin.
B, Edges of the tendon are grasped. C, A jig is inserted. D, The suture is passed percutaneously through the proximal end of
the Achilles tendon. E, The sutures are shuttled through the mini-open incision. F, Knotless suture anchors are placed in the
calcaneus through a distal percutaneous incision. G, The proximal sutures are passed through the distal tendon stump and
out the distal incision with the use of a suture passer (arrowhead). H, The knotless suture anchor is inserted into the
calcaneus while the proper length and tension of the tendon are maintained.

postoperatively. No statistically sig- to a removable CAM walking boot sports at 9 months postoperatively if
nificant differences in the rates of and is allowed to perform toe-touch they demonstrate the ability to per-
rerupture or wound infection were weight bearing with crutches. The form a single-limb heel rise (Table 1).
found. patient is transitioned to full weight
We prefer a 2-week period of non– bearing by 3 weeks postoperatively.
weight bearing to allow for skin and Daily unloaded ankle motion exer- Augmentation and Biologic
soft-tissue healing after surgical cises and supervised physical therapy Adjuncts
repair. At the first postoperative are started at 2 weeks post- The role of repair augmentation and
evaluation, the patient is transitioned operatively. Patients may return to biologic adjuncts in the surgical

January 2017, Vol 25, No 1 29

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Achilles Tendon Ruptures: An Update on Treatment

management of ruptured Achilles operatively. In contrast, the mesen- 37, and 40 are level I studies.
tendons has continued to evolve as chymal stem cell group showed References 14-16, 18, 19, 27, 34, 39,
surgeons look for ways to decrease improved strength to failure at 7 and and 42 are level II studies. References
rerupture rates and improve clinical 14 days, but no difference at 28 days. 29 and 41 are level III studies.
outcomes. Pajala et al40 examined Similarly, Adams et al44 demon- References 1, 2, 4, 9-13, 23-25, 28,
augmentation of open Achilles strated no difference in ultimate 30, 31, 33, 35, and 38 are level IV
tendon repair with a down-turned strength to failure at 28 days in a rat studies.
gastrocnemius fascia flap in a pro- model with injected mesenchymal References printed in bold type are
spective randomized study of 60 cells. However, they found increased those published within the past 5
patients. They found no statistically ultimate strength to failure at 28 years.
significant differences between days in tendon repairs using suture
1. Suchak AA, Bostick G, Reid D, Blitz S,
rerupture rates with augmentation loaded with mesenchymal cells. Jomha N: The incidence of Achilles tendon
(10%) and without augmentation Although these rat models show ruptures in Edmonton, Canada. Foot Ankle
(10%). No statistically significant promise, the clinical translation Int 2005;26(11):932-936.
differences were noted in calf of these findings is currently 2. Huttunen TT, Kannus P, Rolf C,
strength, pain, ROM, or return to unknown. Felländer-Tsai L, Mattila VM: Acute
Achilles tendon ruptures: Incidence of
work between the two groups. injury and surgery in Sweden between
The drive to improve the results of 2001 and 2012. Am J Sports Med 2014;
acute Achilles tendon repairs has led Summary 42(10):2419-2423.

to consideration of augmentation 3. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A,


Nonsurgical management of acute Glazebrook M: Surgical versus nonsurgical
with biologics, such as PRP or treatment of acute Achilles tendon
Achilles tendon ruptures should con-
bone marrow–derived stem cells. rupture: A meta-analysis of randomized
sist of functional rehabilitation; the trials. J Bone Joint Surg Am 2012;94(23):
Although PRP has shown limited
reported rerupture rates with func- 2136-2143.
effectiveness in the management of
tional rehabilitation are lower than 4. Mattila VM, Huttunen TT, Haapasalo H,
specific pathologies of the shoulder
those with standard immobiliza- Sillanpää P, Malmivaara A, Pihlajamäki H:
and elbow, little evidence has sug- Declining incidence of surgery for Achilles
tion.5,9 Nonsurgical functional reha- tendon rupture follows publication of
gested its efficacy in the management
bilitation offers rerupture rates and major RCTs: Evidence-influenced change
of acute Achilles tendon ruptures. In evident using the Finnish registry study. Br J
outcomes similar to those of surgical
a study of 12 athletes, Sánchez et al41 Sports Med 2015;49(16):1084-1086.
management while avoiding post-
compared open repair with and 5. Khan RJ, Fick D, Keogh A, Crawford J,
operative complications. Although
without PRP and found faster Brammar T, Parker M: Treatment of
surgical treatment is associated with acute Achilles tendon ruptures: A meta-
recovery of ROM and return to analysis of randomized, controlled trials.
increased risk of complications,
sports in the PRP group. However, J Bone Joint Surg Am 2005;87(10):
including wound infections, newer, 2202-2210.
all athletes in both groups were able
less invasive techniques have
to return to sport with satisfaction at 6. Willits K, Amendola A, Bryant D, et al:
decreased the risk of complications Operative versus nonoperative treatment of
1-year follow-up. In a randomized,
without increasing rerupture rates acute Achilles tendon ruptures: A
single-blind study of 30 patients, multicenter randomized trial using
and should be strongly considered if
Schepull et al42 reported no differ- accelerated functional rehabilitation.
surgical treatment is selected. Surgical J Bone Joint Surg Am 2010;92(17):
ence in functional outcome or 2767-2775.
treatment has been shown to provide
mechanical tendon properties at 1-
earlier return to work and slightly 7. Nilsson-Helander K, Silbernagel KG,
year follow-up between the PRP Thomeé R, et al: Acute Achilles tendon
stronger plantar flexion strength, and
group and the control group. rupture: A randomized, controlled study
should be considered in athletes. comparing surgical and nonsurgical
Bone marrow–derived stem cells
Biologic adjuncts, such as PRP and treatments using validated outcome
have shown promise in animal measures. Am J Sports Med 2010;38(11):
bone marrow–derived stem cells, 2186-2193.
models, but clinical data have yet to
currently have no proven role in the
be reported. Okamoto et al43 used 8. Young SW, Patel A, Zhu M, et al: Weight-
surgical management of Achilles bearing in the nonoperative treatment of
a rat model to compare Achilles
tendon ruptures. acute Achilles tendon ruptures: A
tendon repair with and without the randomized controlled trial. J Bone Joint
addition of bone marrow cells or Surg Am 2014;96(13):1073-1079.
mesenchymal stem cells. They found References 9. Wallace RG, Heyes GJ, Michael AL: The
increased ultimate strength to tendon non-operative functional management of
patients with a rupture of the tendo Achillis
failure in the bone marrow cell group Evidence-based Medicine: In this leads to low rates of re-rupture. J Bone Joint
at 7, 14, and 28 days post- article, references 3, 5-8, 17, 26, 36, Surg Br 2011;93(10):1362-1366.

30 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Anish R. Kadakia, MD, et al

10. Barfod KW, Nielsen F, Helander KN, et al: 20. Taylor GI, Palmer JH: Angiosome theory. come [French]. Rev Med Suisse 2006;2(74):
Treatment of acute Achilles tendon rupture Br J Plast Surg 1992;45(4):327-328. 1792-1797.
in Scandinavia does not adhere to evidence-
based guidelines: A cross-sectional 21. Yepes H, Tang M, Geddes C, Glazebrook M, 34. Aktas S, Kocaoglu B: Open versus minimal
questionnaire-based study of 138 Morris SF, Stanish WD: Digital vascular invasive repair with Achillon device. Foot
departments. J Foot Ankle Surg 2013;52(5): mapping of the integument about the Achilles Ankle Int 2009;30(5):391-397.
629-633. tendon. J Bone Joint Surg Am 2010;92(5):
1215-1220. 35. Vadalà A, Lanzetti RM, Ciompi A, Rossi C,
11. Neumayer F, Mouhsine E, Arlettaz Y, Lupariello D, Ferretti A: Functional
Gremion G, Wettstein M, Crevoisier X: A 22. Tan GJ, Kadakia AR, Jeng CL: Supine evaluation of professional athletes treated
new conservative-dynamic treatment for patient positioning during repair of Achilles with a mini-open technique for Achilles
the acute ruptured Achilles tendon. Arch tendon rupture. Foot Ankle Int 2009;30 tendon rupture. Muscles Ligaments
Orthop Trauma Surg 2010;130(3): (11):1124-1125. Tendons J 2014;4(2):177-181.
363-368.
23. Highlander P, Greenhagen RM: Wound 36. Costa ML, MacMillan K, Halliday D, et al:
12. Eliasson P, Andersson T, Aspenberg P: complications with posterior midline and Randomised controlled trials of immediate
Achilles tendon healing in rats is improved posterior medial leg incisions: A systematic weight-bearing mobilisation for rupture of
by intermittent mechanical loading during review. Foot Ankle Spec 2011;4(6): the tendo Achillis. J Bone Joint Surg Br
the inflammatory phase. J Orthop Res 361-369. 2006;88(1):69-77.
2012;30(2):274-279.
24. Bruggeman NB, Turner NS, Dahm DL, et al: 37. Suchak AA, Bostick GP, Beaupré LA,
13. Hammerman M, Aspenberg P, Eliasson P: Wound complications after open Achilles Durand DC, Jomha NM: The influence of
Microtrauma stimulates rat Achilles tendon tendon repair: An analysis of risk factors. early weight-bearing compared with non-
healing via an early gene expression pattern Clin Orthop Relat Res 2004;427:63-66. weight-bearing after surgical repair of the
similar to mechanical loading. J Appl Achilles tendon. J Bone Joint Surg Am
Physiol (1985) 2014;116(1):54-60. 25. Ma GW, Griffith TG: Percutaneous repair 2008;90(9):1876-1883.
of acute closed ruptured Achilles tendon: A
14. Schepull T, Aspenberg P: Early controlled new technique. Clin Orthop Relat Res 38. Patel VC, Lozano-Calderon S,
tension improves the material properties of 1977;128:247-255. McWilliam J: Immediate weight bearing
healing human Achilles tendons after after modified percutaneous Achilles
ruptures: A randomized trial. Am J Sports 26. Lim J, Dalal R, Waseem M: Percutaneous tendon repair. Foot Ankle Int 2012;33
Med 2013;41(11):2550-2557. vs. open repair of the ruptured Achilles (12):1093-1097.
tendon: A prospective randomized
15. Barfod KW, Bencke J, Lauridsen HB, controlled study. Foot Ankle Int 2001;22 39. Groetelaers RP, Janssen L, van der Velden J,
Dippmann C, Ebskov L, Troelsen A: (7):559-568. et al: Functional treatment or cast
Nonoperative, dynamic treatment of acute immobilization after minimally invasive
Achilles tendon rupture: Influence of early 27. Karabinas PK, Benetos IS, Lampropoulou- repair of an acute Achilles tendon rupture:
weightbearing on biomechanical properties Adamidou K, Romoudis P, Mavrogenis AF, Prospective, randomized trial. Foot Ankle Int
of the plantar flexor muscle-tendon Vlamis J: Percutaneous versus open repair of 2014;35(8):771-778.
complex—a blinded, randomized, acute Achilles tendon ruptures. Eur J Orthop
controlled trial. J Foot Ankle Surg 2015;54 Surg Traumatol 2014;24(4):607-613. 40. Pajala A, Kangas J, Siira P, Ohtonen P,
(2):220-226. Leppilahti J: Augmented compared with
28. Maes R, Copin G, Averous C: Is nonaugmented surgical repair of a fresh
16. Saleh M, Marshall PD, Senior R, percutaneous repair of the Achilles tendon a total Achilles tendon rupture: A prospective
MacFarlane A: The Sheffield splint for safe technique? A study of 124 cases. Acta randomized study. J Bone Joint Surg Am
controlled early mobilisation after rupture Orthop Belg 2006;72(2):179-183. 2009;91(5):1092-1100.
of the calcaneal tendon: A prospective,
randomised comparison with plaster 29. Henríquez H, Muñoz R, Carcuro G, Bastías C: 41. Sánchez M, Anitua E, Azofra J, Andía I,
treatment. J Bone Joint Surg Br 1992;74(2): Is percutaneous repair better than open Padilla S, Mujika I: Comparison of
206-209. repair in acute Achilles tendon rupture? surgically repaired Achilles tendon tears
Clin Orthop Relat Res 2012;470(4): using platelet-rich fibrin matrices. Am J
17. Olsson N, Silbernagel KG, Eriksson BI, 998-1003. Sports Med 2007;35(2):245-251.
et al: Stable surgical repair with accelerated
rehabilitation versus nonsurgical treatment 30. Chiu CH, Yeh WL, Tsai MC, Chang SS, 42. Schepull T, Kvist J, Norrman H, Trinks M,
for acute Achilles tendon ruptures: A Hsu KY, Chan YS: Endoscopy-assisted Berlin G, Aspenberg P: Autologous platelets
randomized controlled study. Am J Sports percutaneous repair of acute Achilles have no effect on the healing of human
Med 2013;41(12):2867-2876. tendon tears. Foot Ankle Int 2013;34(8): Achilles tendon ruptures: A randomized
1168-1176. single-blind study. Am J Sports Med 2011;
18. Schepull T, Kvist J, Aspenberg P: Early 39(1):38-47.
E-modulus of healing Achilles tendons 31. Kakiuchi M: A combined open and
correlates with late function: Similar results percutaneous technique for repair of tendo 43. Okamoto N, Kushida T, Oe K, Umeda M,
with or without surgery. Scand J Med Sci Achillis: Comparison with open repair. Ikehara S, Iida H: Treating Achilles tendon
Sports 2012;22(1):18-23. J Bone Joint Surg Br 1995;77(1):60-63. rupture in rats with bone-marrow-cell
transplantation therapy. J Bone Joint Surg
19. Metz R, Verleisdonk EJ, van der Heijden 32. Elton JP, Bluman EM: Limited open Am 2010;92(17):2776-2784.
GJ, et al: Acute Achilles tendon rupture: Achilles tendon repair with modified ring
Minimally invasive surgery versus forceps: Technique tip. Foot Ankle Int 44. Adams SB Jr, Thorpe MA, Parks BG,
nonoperative treatment with immediate full 2010;31(10):914-915. Aghazarian G, Allen E, Schon LC: Stem
weightbearing—a randomized controlled cell-bearing suture improves Achilles
trial. Am J Sports Med 2008;36(9): 33. Assal M: Mini-invasive suture of Achilles tendon healing in a rat model. Foot Ankle
1688-1694. tendon ruptures: A concept whose time has Int 2014;35(3):293-299.

January 2017, Vol 25, No 1 31

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article

Ambulatory Surgical Centers:


A Review of Complications and
Adverse Events

Abstract
Charles A. Goldfarb, MD An increasing number of orthopaedic surgeries are performed at
Anchal Bansal, BS ambulatory surgical centers (ASCs), as is exemplified by the 272%
population-adjusted increase in outpatient rotator cuff repairs from
Robert H. Brophy, MD
1996 to 2006. Outpatient surgery is convenient for patients and cost
effective for the healthcare system. The rate of complications and
adverse events following orthopaedic surgeries at ASCs ranges from
0.05% to 20%. The most common complications are pain and nausea,
followed by infection, impaired healing, and bleeding; these are
affected by surgical and patient risk factors. The most important
surgeon-controlled factors are surgical time, type of anesthesia, and
site of surgery, whereas the key patient comorbidities are advanced
age, female sex, diabetes mellitus, smoking status, and high body
mass index. As the use of ASCs continues to rise, an understanding of
risk factors and outcomes becomes increasingly important to guide
indications for and management of orthopaedic surgery in the
From the Department of
Orthopaedics, Washington University
outpatient setting.
School of Medicine, St. Louis, MO.
Dr. Goldfarb or an immediate family

O
member serves as a paid consultant ver the past two decades, or- costs for both patients and health-
to Arthrex and serves as a board
thopaedic surgery, like other care providers.5-7 A 2006 study by
member, owner, officer, or committee
member of the American Academy of surgical disciplines, has shifted from the US Government Accountability
Orthopaedic Surgeons and the the hospital to the outpatient setting Office demonstrated that procedures
American Society for Surgery of the in association with a rapid growth in done at ASCs cost 84% less than
Hand. Dr. Brophy or an immediate
the number of ambulatory surgical those done at hospital-based out-
family member has stock or stock
options held in Ostesys and serves as centers (ASCs).1 This shift is exem- patient departments (HOPDs).8 It is
a board member, owner, officer, or plified by the 272% increase in estimated that an annual national
committee member of the American outpatient rotator cuff repairs from savings of $60 million to $80 million
Orthopaedic Association, the
American Orthopaedic Society for
1996 to 2006, whereas inpatient in surgical charges would be achieved
Sports Medicine, and the Orthopaedic repairs decreased by 67% for the if most of the CTRs currently done
Research Society. Neither Ms. Bansal same period.2 During those years, in hospitals were moved to ASCs.9
nor any immediate family member has the percentage of carpal tunnel Other studies have reported simi-
received anything of value from or has
stock or stock options held in a
releases (CTRs) and knee arthros- larly notable savings of 20% to
commercial company or institution copies performed at ASCs increased 70%,1,9,10 as well as more favorable
related directly or indirectly to the from 16% to 49%1 and 15.3% to reimbursement/charge ratios,11 with
subject of this article. 50.7%,3 respectively. Similar data conversion to outpatient surgery.
J Am Acad Orthop Surg 2017;25: have been reported for other ortho- ASCs also offer faster surgical times
12-22 paedic procedures.4 and achieve greater efficiency as a
DOI: 10.5435/JAAOS-D-15-00632 Several factors have contributed to result of having consistent and expe-
this shift. Ambulatory facilities pro- rienced surgical teams who are
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. vide greater convenience for patients familiar with the procedures, as well
and families, as well as lower financial as surgical room setups, protocols,

12 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Charles A. Goldfarb, MD, et al

and equipment that are suited to the unplanned admission, or the fre- procedures. Unanticipated admis-
surgeon’s specific preferences.1,10-13 quency with which outpatient pro- sion rates following all surgeries and
These data have prompted some cedures are converted to inpatient orthopaedic surgeries were 1.42%
insurers to adopt payment structures care, is considered a proxy for the and 2.2%, respectively. Although
that encourage patients to select feasibility of performing certain pro- these rates are relatively low, the
ASC-based surgery over HOPD- cedures in the outpatient setting, as absolute number of affected patients
based surgery, contributing to an well as an indicator of the quality of was notable because 2,960 ortho-
increased utilization of ASC services care. These data also provide infor- paedic surgeries were included in the
by approximately 14.3% over the mation on appropriate patient selec- analysis. Many of these admissions
last several years, which is estimated tion for orthopaedic procedures were preventable, given that 25%
to save insurers 17% to 17.6% in performed in an outpatient setting. and 15% of orthopaedic read-
annual payouts.14 However, the definition of admission missions resulted from pain and
However, neither standardization varies in the literature. Although the intractable nausea/vomiting, respec-
nor a widely accepted algorithm for US Centers for Medicaid and tively. More than 60% of admissions
determining the ideal surgical setting Medicare Services defines outpatient for pain and .33% of admissions
for patients exists across ASCs. Few procedures as those requiring hospi- for nausea/vomiting were patients
studies have evaluated complication tal stays of ,24 hours,15 some who underwent orthopaedic proce-
rates and risk factors for adverse studies include any patients who dures. Prophylactic antiemetics were
events of ASC-based orthopaedic require overnight stays as unplanned not used in this study, suggesting
surgery; variable results have been admissions, even if the total time that aggressive pain and nausea
reported, and no consensus has from arrival to discharge falls short control in the ASC setting has the
been reached regarding strategies of 24 hours.15,16 Other investiga- potential to reduce unanticipated
to mitigate the risk of adverse events. tions include only patients who are admissions.
In addition, definitions of post- transferred to a hospital from an In a recent study of 10,032 patients
operative complications are unclear; ASC.17 Furthermore, some ASCs are who underwent orthopaedic surgery
therefore, diagnosis of a surgery- equipped to handle higher levels of over 20 years, Martín-Ferrero et al18
related adverse event is highly sub- acuity, whereas others lack resources reported an unplanned overnight
jective. Currently, most clinical to accommodate sicker patients and admission rate of 0.14%. Patients
practices that use ASCs are driven by extended stays and consequently were carefully selected for surgery at
surgeon preference, with limited transfer these patients to a hospital. an ambulatory center, and only
evidence-based support. Here, we This lack of standardization com- those with minimal comorbidities
review current evidence regarding plicates comparison of the rates of and good home social support
the prevalence of and risk factors for unplanned admissions and hospital who were undergoing technically
complications following orthopaedic transfers. In addition, independent straightforward procedures associ-
surgery performed in the outpatient researchers likely do not have the ated with low bleeding risk were
setting. We think that this informa- transparency required to identify all included. Average patient age was 42
tion will aid decision making and admissions, making an insurance- years, and average surgical time was
foster the development of guidelines based approach (with the use of 27 minutes. In contrast, Fortier
pertaining to patient selection and Medicare being most feasible) ideal. et al16 studied an older population
surgical protocol to maximize effi- Although the concern for identifica- (average age, 46 years) with a greater
ciency, at the same time minimizing tion of postoperative admissions is number of comorbidities (a greater
the risk of complications for ortho- true for any patient who undergoes proportion of patients had a physical
paedic surgery performed at ASCs. surgery, it is magnified for patients status categorized as American
We excluded spine and arthroplasty who undergo surgery at an ASC Society of Anesthesiologists [ASA]
procedures because they comprise a because hospital affiliation may not Physical Status III). These population
risk profile different from those of be clear. differences contributed to the find-
other outpatient procedures. In a study of 15,179 consecutive ings; both Fortier et al16 and Martín-
patients undergoing outpatient sur- Ferrero et al18 found that ASA
gery at their multispecialty ASC over Physical Status II or III and lengthier
General Complications 32 months, Fortier et al16 assessed surgery were associated with over-
the number of unplanned admissions night admissions, although notably,
Several metrics have been used to (defined as patients requiring over- these variables were not tested for
assess complications. The rate of night stay) following ambulatory significance by Martín-Ferrero

January 2017, Vol 25, No 1 13

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ambulatory Surgical Centers: A Review of Complications and Adverse Events

et al.18 Fortier et al16 determined admission. Martín-Ferrero et al18 Furthermore, the study by Mathis
other significant predictors of over- reported only surgery-related re- et al22 included surgeries in HOPDs,
night admission, including male sex; admissions and complications, which are known to serve a pop-
anesthesia duration .1 hour; sur- whereas De Oliveira et al19 re- ulation with a higher number of
gery ending after 3 PM; and excessive ported on all readmissions and comorbidities than that served by
postoperative pain, bleeding, nausea/ mortality. This discrepancy con- ASCs.2 These differences in co-
vomiting, and drowsiness. Martín- firms previous work demonstrating morbidity distribution could influ-
Ferrero et al18 found advanced age to that most postoperative read- ence the results, especially given
be associated with unanticipated missions were associated with rea- that both studies reported low rates
admission rates, although again, this sons unrelated to surgery.20 of adverse events, thus limiting
was not tested for significance. Martín-Ferrero et al18 also noted their ability to reach statistical sig-
Interestingly, neither study found that 1.2% of patients visited the ED nificance. We were unable to find
chronic obstructive pulmonary dis- within 24 hours of discharge for any studies that examined risk
ease or smoking to be associated pain and bleeding, an observation factors for readmission after gen-
with admission. congruent with other studies that eral orthopaedic procedures per-
Three other key metrics for evalu- concluded that bleeding, wound formed at an ASC as an isolated
ating postoperative complications are problems, and infections were the population.
emergency department (ED) visits, primary drivers of postoperative Surgical site infections (SSIs)
outpatient clinic visits, and patient hospital returns.19-21 Martín-Ferrero following ASC-based orthopaedic
inquiries regarding problems follow- et al18 found that 17.8% of patients surgeries range in reported incidence
ing discharge. Recorded at various called within 48 hours of surgery with from 0.33% to 1.89%.23-25 The
postoperative time intervals, these questions about discomfort, bleeding, variability is likely caused by differ-
metrics provide valuable information and prescriptions; 98% of these ences in reporting, follow-up time,
for understanding adverse events, concerns were successfully handled and subjectivity in diagnosing infec-
determining when patients are most over the phone. This suggests that, tions. Two studies that provided
vulnerable to the development of although bleeding and discomfort are specific time frames and diagnostic
complications, assessing the efficacy commonly encountered, most cases criteria include clinical suspicion as
of hospital stay in avoiding such are not serious, and improved patient sufficient for meeting the criteria.23,25
issues, and discerning which clinical education regarding such complica- Surgical setting is one risk factor for
care issues might require additional tions may limit the number of post- postoperative infection. Infection
patient education before ambulatory operative acute care encounters. rates at an orthopaedic-specific ASC
surgery. Martín-Ferrero et al18 re- Careful patient selection can help were found to be lower than those at
ported 24-hour and postoperative to limit complications and read- a multispecialty ASC (0.384% versus
day 1 to 28 readmission rates of missions. However, opinions are 0.809%, respectively), despite the fact
0.06% and 0.05%, respectively. All mixed as to which specific factors that the same surgeons used the same
24-hour readmissions were for pain increase surgical morbidity. De surgical protocols at both facilities.23
and swelling, whereas most of post- Oliveira et al19 recently concluded Both centers showed similar distri-
operative day 1 to 28 readmissions that patient age was the most butions of causative organisms, with
were for infections. Complications important factor in predicting methicillin-susceptible Staphylococ-
noted at postoperative day 7 were morbidity (defined as wound infec- cus aureus, methicillin-resistant S
deep and superficial infections, tions and a wide variety of post- aureus, and S epidermidis being most
suture dehiscence, and intra-articular operative adverse events), with an common.23 Other significant risk
hematomas. odds ratio of 1.54 for patients aged factors for infection include male sex,
The readmission rate reported by .70 years. The authors posited smoking, diabetes mellitus, longer
Martín-Ferrero et al18 was much lower cognitive function, health lit- surgical time (tourniquet time), and
lower than that reported by De eracy, and home support among the longer anesthesia time (induction to
Oliveira et al,19 who noted a 30-day elderly population as potential arousal).24 Possible explanations
readmission rate of 1.28% and a explanations for their findings. offered for male sex being a risk
30-day morbidity rate of 1.42% Some of their risk factors contrast factor included increased body hair,
following several orthopaedic pro- with conclusions published by sex-based differences in hygiene, and
cedures performed at ASCs. Some Mathis et al22 (Table 1). Neither a greater percentage of open and
of the disparity is attributable to study was specifically conducted traumatic wounds seen in men than in
different definitions of 30-day re- on an orthopaedic population. women. The same study found that

14 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Charles A. Goldfarb, MD, et al

Table 1
Comparison of Risk Factors for Morbidity in Outpatient Surgerya
Risk Factor Odds Ratio (99% CI)19 Odds Ratio (95% CI)22

Sex NSUAb NS
Age (Years)
18 to 50 Reference Reference (18 to 30) and NSUAb
(31 to 40, 41 to 50)
51 to 60 NS NSUAb
61 to 70 NS NSUAb
71 to 80 1.68 (1.32 to 2.11) NSUAb
$81 1.83 (1.33 to 2.51) NSUAb
BMI (kg/m2) NSUAb
Normal (18.5 to 24.9) Reference Reference
Underweight (,18.5) NSUAb NS
Overweight (25.0 to 29.9) NSUAb 1.6 (1.1 to 2.3)
Obese ($30.0) NSUAb 2.0 (1.4 to 3.0)
Diabetes mellitus NS
Type 1 1.64 (1.22 to 2.21) —
Type 2 NS —
Current smoker (has smoked in past 30 days) NSUAb NSUAb
Alcohol use (.2 drinks/d in 2 weeks before surgery) NSUAb NS
COPD 2.20 (1.64 to 2.96) 2.4 (1.4 to 4.0)
Hypertension requiring treatment NS 1.7 (1.2 to 2.3)
Current steroid use 2.07 (1.48 to 2.88) NS
Weight loss .10% in past 6 mo NS NSUAb
Pregnancy NSUAb NSUAb
Previous surgery within 30 days 2.10 (1.23 to 3.59) NSUAb
Prolonged surgical timec 1.31 (1.19 to 1.53) 1.7 (1.3 to 2.2)

BMI = body mass index, CI = confidence interval, COPD = chronic obstructive pulmonary disease, NS = Not significant in multivariate regression,
NSUA = Not significant in univariate analysis, — = Not studied
a
Statistical significance defined as an odds ratio ,0.9 or .1.1 because of large data set. Significant factors are listed in boldface type.
b
Not included in multivariate analysis
c
Surgical time in top quartile for Current Procedural Terminology code.

age, hypertension, gastroesophageal a statistical artifact produced by the occur at a rate of 1.2% to
reflux disease, thyroid disease, and limited number of patients with co- 18%.16,26,27 Evidence exists to
cancer were not significant co- morbidities. Recommendations for support the use of interscalene nerve
morbidities.24 These results are con- ASC practice guidelines would blocks rather than general anesthe-
sistent with those of another small clearly vary based on the results of sia to increase patient comfort,
study, which found no correlation such an investigation. decrease postoperative opioid use,
between their comorbidities of limit unplanned admissions, and
interest (eg, age, sex, surgical time, decrease postoperative recovery
ASA group) and the rate of SSIs.25 Complications by Anatomic time26-29 (Table 2). Interscalene
Further study is required to deter- Region nerve blocks provide analgesia for
mine whether this finding is related to up to 14 hours after surgery and
an improved healing trajectory re- have been shown to cause less
sulting from the benefits of early Shoulder postoperative nausea and sore
discharge, diminished influence of Unplanned overnight admissions fol- throat than does general anesthe-
comorbidities on developing SSIs, or lowing shoulder surgery reportedly sia.28,29 Similar outcomes have been

January 2017, Vol 25, No 1 15

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ambulatory Surgical Centers: A Review of Complications and Adverse Events

Table 2
Key Points and Recommendations for ASC-based Surgery by Anatomic Area
Anatomic Deep Vein
Area Overall Complications Infections Thrombosis Optimal Anesthesia
32
Shoulder Unplanned admissions: Limited data Incidence: 0.31% ISBs and ISCs
Incidence: 1.2% to 18%, higher in Further study preferable to GA for
HOPDs versus ASCs16,26,27 required to better long-term pain control,
Risk factors: age .65, define and also limit
arthroscopic rotator cuff repair, determine risk postoperative
less experienced factors recovery time,
anesthesiologist27 nausea, and opioid
Can be limited by use of ISCs use26-31
and ISBs26-31
Further study needed on incidence
of other morbidities and related
risk factors
Hand Slower healing and higher rates of Incidence: 0% to 4.2% Data unavailable Limited data
wound difficulties in patients with (lower in orthopaedic
diabetes mellitus.33,34 ASCs versus
Further study needed on impact of multispecialty ASCs)23
individual comorbidities so Risk factors: smoking,
patients can be profiled into risk longer surgical time34
groups Debate on the impact of
diabetes mellitus33-37
Additional study needed
Current evidence does not
support prophylactic
antibiotics for general
population, those with
diabetics mellitus, or
smokers34,35 but higher
level studies needed
to establish firm guidelines
Hip Incidence of complications from Limited data Incidence: 1.4% to FNBs and posterior
FNBs and posterior lumbar plexus 3.7%41,42 Selective lumbar plexus blocks
blocks ranges from 0% to 3.8%38-40 rather than routine are superior to GA and
Complications: catheter site anti-coagulation IV morphine38-40
leakage, rash, pain, peripheral may be sufficient for Promote patient
neuropathy (rare and manifests hip arthroscopy42 comfort, speed time to
with analgesia, motor deficits, Insufficient data to discharge, reduce
paresthesias) Monitor patients for construct algorithm narcotic usage
anesthetic spread and motor identifying high risk
weakness to prevent falls patients
Recommend nerve blocks to limit
postoperative pain, nausea, and
unplanned admits39,40
Need further study on additional
complications
(continued )
ACLR = anterior cruciate ligament reconstruction, ADLs = activities of daily living, ASA = American Society of Anesthesiologists, ASCs = ambulatory
surgery centers, FNB = femoral nerve block, GA = general anesthesia, HOPD = hospital outpatient department, ISB = interscalene block,
ISC = interscalene catheter, IV = intravenous

achieved using interscalene cathe- tion” (12.8%) than did ASC surgery Data on risk factors, readmission
ters.30,31 In addition, one study as- (1.2%; P , 0.0001).26 Sultan et al27 rates, and morbidity following
serted that, although none of the found that age .65 years, arthro- shoulder surgeries in ASCs are sparse,
studied patient comorbidities scopic rotator cuff repair, and indicating a pressing need for further
increased the risk of unplanned (indirectly) less experienced anesthe- focused investigation of this patient
admission, HOPD surgery led to a far siologists were all associated with subgroup. Kuremsky et al32 reported
higher rate of “unexpected disposi- greater rates of unplanned admission. a 0.31% rate of thromboembolic

16 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Charles A. Goldfarb, MD, et al

Table 2 (continued )
Key Points and Recommendations for ASC-based Surgery by Anatomic Area
Anatomic Deep Vein
Area Overall Complications Infections Thrombosis Optimal Anesthesia

Knee Unplanned admissions: Incidence: 0% to Incidence poorly Unclear


Incidence: 0.0004% to 0.43%21,45,46 Limited understood; one Debate over regional
20%5,16,17,26,43 data on efficacy of study reported versus GA
Highest rates for ACLRs5,43 prophylactic antibiotics an incidence of
Lower rates in ASCs than following arthroscopic 1/2,20021
HOPDs26 procedures; current data Recommend further
Readmissions: does not support routine study to define
Incidence: 0% to 5.7%5,17,21,43,44 use but further study is incidence and risk
Most commonly the result of required47 factors
nausea, pain, infection, wound
complications, sensory loss18,43
Other reasons are re-tears and
arthrofibrosis45
Foot and Unplanned admissions Incidence: 0.38% to Data unavailable Nerve blocks7,31,48
ankle Incidence: 0.001% to 3.3%16,17 3.1%23,49,50 (lower in
Recommend careful patient orthopaedic ASCs
selection and effective versus multispecialty
postoperative anesthesia with ASCs)23
nerve blocks to minimize risk7,31,48 Efficacy of prophylactic
Limited data on incidence and risk antibiotics is unclear49,50
factors
Overall Unplanned admissions: Incidence: 0.33% to Limited data Regional anesthesia
Incidence: 0.14% to 3.9%16,18 1.89%; (lower rates in and nerve blocks
Common causes: pain, nausea, orthopaedic ASCs versus when feasible
bleeding; early aggressive multispecialty ASCs)23-25
control of these can limit Risk factors: male sex,
unplanned admissions smoking, diabetes
Risk factors: ASA status II or III, mellitus, longer surgical
older age, lengthier surgery, time, longer anesthesia
male sex, anesthesia time .1 time23-25
hr, surgery ending after Standardized, objective
3 PM16,18,19,22,27,34,51 criteria needed for
Minimize early readmission with diagnosis and reporting
preoperative patient education
regarding postoperative
course5,7,18,19
Set expectations for pain, nausea,
bleeding
Emphasize good home social
support Plan workarounds for
impediments to ADLs

ACLR = anterior cruciate ligament reconstruction, ADLs = activities of daily living, ASA = American Society of Anesthesiologists, ASCs = ambulatory
surgery centers, FNB = femoral nerve block, GA = general anesthesia, HOPD = hospital outpatient department, ISB = interscalene block,
ISC = interscalene catheter, IV = intravenous

events (6 of 1,908 patients) that was required readmission for anti- hand surgery is generally considered
confirmed on imaging following coagulation and monitoring. to be particularly safe. However,
arthroscopy performed with patients in their calculations, the authors
in the lateral decubitus position. excluded data on commonly per-
Nonfatal pulmonary embolism and Hand formed CTRs and peripheral nerve
deep vein thrombosis (DVT) of Fortier et al16 reported a 4.3% rate of surgeries, both of which had low
either the ipsilateral upper or lower unplanned overnight admissions admission rates of zero and 1.7%,
extremity were identified in most of following hand surgery at an ACS, a respectively. Consequently, these
these cases, and all six patients higher than expected rate given that results overestimate the true

January 2017, Vol 25, No 1 17

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ambulatory Surgical Centers: A Review of Complications and Adverse Events

unplanned admission rate following given individual comorbidity, these (4.95 versus 3.95; P = 0.018). In
hand surgery. Surgical and anes- results are minimally applicable. In addition, patients who received an
thetic advancements made since contrast, another large retrospective FNB required a notably lower mor-
1998 are also likely to have tempered study reported considerably higher phine equivalent dose in the post-
this rate over time, further inflating infection rates in the diabetic and anesthesia care unit than did those
the current estimate. Additional smoking populations, as well as in who did not receive an FNB (2.04
investigation may determine whether those undergoing lengthier proce- versus 4.00 mg; P = 0.025). No sig-
this is the case. dures, with odds ratios of 2.8, 3.0, nificant changes in nausea/vomiting
Infection is the best-studied compli- and 1.02, respectively.34 Another or time to discharge were observed.
cation in the literature on ASC-based factor associated with reduced However, all 56 patients who
hand surgery, with reported rates infection rates is surgery performed received an FNB achieved same-day
ranging from zero to 4.2%.22,33-37 at a single-specialty ASC versus a discharge, whereas 2 of 40 patients
Martín-Ferrero et al18 reported only multispecialty ASC.23 Notably, who did not receive a nerve block
three hand-related readmissions for patients with diabetes mellitus may required overnight admission for
infection from postoperative days 1 eventually obtain surgical results36,37 pain. No complications related to
to 28 but noted that these three events and a risk of SSI similar to those of block placement were reported. In
comprised 60% of all 28-day read- patients without diabetes mellitus. contrast, Ward et al40 placed post-
missions in their overall patient However, patients with diabetes operative FNBs and found that
population. mellitus were found to have slower patients who received a nerve block
The role of prophylactic antibiotics healing times and higher rates of were significantly less likely than
in clean hand surgery is unclear and wound dehiscence and suture gran- control subjects treated with intra-
varies from zero to 100% across dif- ulomas than were patients without venous narcotics to report nausea/
ferent providers and institutions. this chronic condition.33,34 There- vomiting (10% versus 75%) and
However, the efficacy of antibiotics fore, patients with diabetes mellitus were significantly more likely to be
in preventing infection in such cases is may require more vigilant wound satisfied with the procedure (90%
not supported by the literature. One care and follow-up, more conserva- versus 25%). Furthermore, average
large, retrospective, nonrandomized, tive postoperative treatment, and time to discharge was 39 minutes
ASC-specific trial reported that anti- additional patient education to shorter for patients who received
biotics had no effect on the incidence manage expectations. FNBs than for control subjects.
of SSI in the general population or in In a study of patients treated with
patients who smoked or had diabetes continuous posterior lumbar plexus
mellitus.34 These results corroborate Hip Arthroscopy blocks, Nye et al38 reported com-
those of a large retrospective multi- Most of the recent literature on out- plications in 3.8% of patients dis-
center study that analyzed SSI rates patient hip surgery discusses innova- charged with the blocks. Of these,
among general and diabetic pop- tions in anesthesia techniques. Both 9.4% were cases of persistent
ulations.35 The study was under- femoral nerve blocks (FNBs) and weakness or analgesia after block
powered to detect significance in posterior lumbar plexus blocks have removal. Although most cases
antibiotic and nonantibiotic groups been evaluated.38-40 Adverse events resolved spontaneously, prolonged
at the low SSI incidences of 0.4% following nerve blocks include neu- morbidity was present in 2% of
and 0.7%, respectively.35 ropathy, paresthesia, analgesia, and cases. Other reported complica-
The influence of patient comorbid- motor weakness contributing to tions were leakage, pain, and rash
ities on infection rate following hand falls. Two studies evaluated the at the catheter site, as well as one
surgery is debated in the literature. efficacy of FNBs in controlling early fall secondary to the spread of the
Although four studies reported no postoperative pain.39,40 In the study epidural anesthetic.
association between diabetes mellitus by Dold et al,39 preoperative FNBs Venous thromboembolism (VTE)
and SSI,33,35-37 at least three of the were placed. Patients who received and its sequelae are rare but serious
studies were questionably pow- these blocks reported less pain at all complications of hip surgery. In a
ered.35-37 One of the larger studies time points on a 10-point pain scale study of 81 patients who underwent
found no difference in the infection than did patients who received gen- outpatient hip arthroscopy, Salvo
rates of patients with no comorbid- eral anesthesia alone, a difference et al41 documented a 3.7% rate of
ities compared with patients with $1 that achieves significance at 1 hour clinically significant VTEs con-
comorbidities.33 Because only a following surgery (3.68 versus 2.48; firmed on imaging after surgery.
small number of patients had any P = 0.02) and in the step down unit Two patients had no identifiable

18 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Charles A. Goldfarb, MD, et al

risk factors, and one was on oral Khan et al5 qualify the 20% rate DVTs are a serious but infrequently
contraceptives. All three patients reported in their study by noting that reported complication of knee sur-
were subsequently treated with an- 70% of admissions resulted from gery; a large study found only one
ticoagulation, and none experienced failure to fully follow perioperative incidence of DVT among 2,200 knee
a pulmonary embolism. More protocol; barring these events, a arthroscopies.21 Further research is
recently, Alaia et al42 reported a 10% admission rate was attainable. needed to define the incidence of
1.4% incidence of VTE and pro- This argument is plausible because DVT for other procedures.
posed that routine anticoagulation 92% of cases performed with strict Limited infection data exist for
after hip arthroscopy is unneces- protocol adherence were successfully knee surgeries. One study45 reported
sary. They advised patient educa- discharged on the same day, whereas no infection in 155 ACLRs, whereas
tion and selective anticoagulation only 46% of cases associated with another study21 reported a 0.18%
based on careful risk stratification. protocol lapses achieved this goal. incidence of septic arthritis following
Both studies employed small sample Violations included administering arthroscopies. In a recent study of
sizes. There are insufficient data to femoral blocks, failing to mobilize SSIs following outpatient surgery in
compose an algorithm to identify patients within the allotted post- hospital-owned facilities, Owens
high-risk patients because the ASC operative time frame, and failure to et al46 reported that the rates of acute
population is a predominantly low- confirm postoperative transportation care visits for SSIs were 2.45 per
risk group, with few individuals for patients. Excluding these protocol 1,000 procedures (95% confidence
presenting obvious anticoagulation violations, the etiologies of admis- interval [CI], 1.73 to 3.36) and 4.33
criteria. A large well-powered sions were pain, nausea/vomiting, per 1,000 procedures (95% CI, 3.35
investigation is essential for identi- and laryngospasm.5 The findings of to 5.51) within 14 and 30 days of
fying risk factors in this setting; this small study are consistent with surgery, respectively.
previous studies were unable to those of a larger study that presented Prophylactic antibiotics are the
achieve significance because of nausea/vomiting and pain as the only modifying factor to have been
small sample sizes and the low principal causes of unplanned investigated in ASCs to date. Bert
incidence of VTE. admissions, followed by other causes, et al47 discovered no significant
including urinary retention, hypo- differences in deep infection rates
tension, and falls.43 following 2,780 arthroscopic men-
Knee (Excluding Similar postoperative morbidity iscectomies (0.15% of patients
Arthroplasty) rates following knee surgeries at treated with antibiotics and 0.16%
Unplanned admission rates range ASCs and at HOPDs have been re- treated without antibiotics) in a
from 0.0004% to 20% after knee ported.14 Complication and read- community surgical center. S aureus
surgeries and vary by procedure, with mission rates following successful was found in all of the cultures, and
greater numbers of admissions re- same-day discharge range from all patients responded to a single
corded for anterior cruciate ligament zero to 5.7%.5,17,21,43-45 Khan et al5 joint débridement. The limited data
reconstructions (ACLRs).5,16,17,26,43 reported no readmissions or com- on SSIs following arthroscopic knee
In addition, the reported rate of plications in 50 consecutive patients surgeries suggest that prophylactic
unplanned admission is lower in within 6 weeks of ACLR with antibiotics have minimal to no effi-
ASCs than in HOPDs, possibly re- hamstring autograft. Other studies cacy in the ASC setting. Further
flecting a selection bias in which report that the primary drivers of study should be undertaken to
healthier patients are chosen for postdischarge readmission and acute determine precisely which patients
surgery at ASCs.26 Finally, the role care visits are infection; wound and surgical conditions this finding
of regional anesthesia in outpatient complications, including bleeding, applies to and to determine other
knee surgery is unclear, with con- hematoma, effusion, DVT evalua- comorbidities related to SSIs.
flicting evidence presented in the tion; nausea/vomiting; pain; and
literature.5,43,44,52,53 sensory loss.18,43 In a small study,
Patients who undergo ACLR con- Nagda et al45 found no statistically Foot and Ankle
stitute an important subgroup, given significant differences in complica- Fortier et al16 reported a 3.3% rate
the disproportionally high rate of tion rates between ACLRs with of unplanned overnight admission
unplanned admissions. In two studies allografts and autografts (4% versus following outpatient ankle surgery
of ACLR performed in an outpatient 5.7%, respectively). Prominent at an ASC. In a more recent study,
setting, the rates of unplanned complications included re-tears and Fox et al17 reported an admission
admissions were 12%43 and 20%.5 development of arthrofibrosis.45 rate of 0.001% (95% CI, 0.0013 to

January 2017, Vol 25, No 1 19

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ambulatory Surgical Centers: A Review of Complications and Adverse Events

0.0021) in bunionectomies and toe gens were cultured from all patients orthopaedic surgery, and single-
deformity repairs performed at a who developed infection, despite specialty ASCs may be associated
hospital-based ASC. Murray et al7 receiving preoperative antibiotics. with fewer adverse outcomes than
reported no admissions after 40 Furthermore, the study reported no multispecialty facilities. In addi-
bilateral hallux valgus procedures, association between infections and tion, aggressive, proactive man-
and they credited careful patient age, sex, tourniquet use, surgical agement of pain and nausea with
selection and effective post- time, internal fixation, surgical cat- robust preoperative and post-
operative analgesia, for which egory, and medical history, including operative protocols has the poten-
nerve blocks were key. Several diabetes mellitus. Authors of future tial to improve care. The lack of
small nonrandomized investiga- studies should perform subgroup information that addresses out-
tions have similarly reported the risk factor analysis based on pro- comes and risk factors associated
successful application of nerve cedure type to control for surgical with ASCs remains a challenge for
blocks in facilitating ambulatory invasiveness, complexity, length, and developing effective protocols
foot and ankle surgeries.31,48 recovery profile. to minimize readmission, ED visits,
Although infection rates in foot and and complications. Many studies
ankle surgery are thought to be higher have been conducted using small
than in other clean orthopaedic sur- Patient Selection for ASC patient populations and have re-
geries, studies have reported inci- ported conflicting results, suggest-
Surgeries
dences ranging from 0.38% to ing the need for larger high-level
3.1%23,49,50 for foot and ankle pro- Multiple patient and procedural vari- analyses to help ascertain best
cedures performed at ASCs, which is ables have been associated with an practices and raise the standard of
on par with values previously noted increased risk of morbidity and read- care across centers.
for other surgeries. Several risk fac- mission, including age .65 years,
tors have been studied. Mitchell ASA Physical Status II and III, BMI
et al23 found that the surgical setting References
.25 kg/m2, diabetes mellitus, hyper-
influenced infection rates, with lower tension, smoking, chronic obstructive Evidence-based Medicine: Levels of
rates reported for procedures done at pulmonary disease, and longer surgi- evidence are described in the table of
their orthopaedic ASC than for pro- cal time.16,18,19,22,24,27,34,51 Although contents. In this article, references
cedures done at their multispecialty young (,65 years), healthy patients 28, 44, and 51-53 are level I studies.
ASC. However, the magnitude of this undergoing short, straightforward References 1, 3, 6, 9, 16, 20, 22, 25,
difference was less pronounced for procedures are ideal candidates for 40, and 45 are level II studies. Ref-
foot and ankle surgery than for other surgery at an ASC, patients of any erences 2, 4, 5, 10-15, 17-19, 21, 23,
procedures. This study is particularly age with an ASA Physical Status of I 24, 26, 27, 33-36, 39, 43, and 46-50
convincing because the two facilities or II and a BMI ,45 kg/m2 are are level III studies. References 7,
were nearly identical in all aspects, generally acceptable surgical can- 29-32, 37, 38, 41, and 42 are level IV
including perioperative protocol, didates, especially when regional studies.
operating room design, and patient anesthesia is used. Further consid-
population, aside from the risk References printed in bold type are
erations include patient health
factor being studied. Furthermore, those published within the past 5
literacy, available home social sup-
all procedures were performed with years.
port, and expectations for post-
consistent surgical technique by operative recovery because these 1. Fajardo M, Kim SH, Szabo RM: Incidence
four surgeons rotating through both factors heavily influence a patient’s of carpal tunnel release: Trends and
implications within the United States
facilities. ability to comply with postoperative ambulatory care setting. J Hand Surg Am
Two studies reported no sub- instructions, attend to wound care, 2012;37(8):1599-1605.
stantial association between infection maintain normal activities of daily 2. Colvin AC, Egorova N, Harrison AK,
rates and preoperative antibi- living, and tolerate pain and Moskowitz A, Flatow EL: National trends
otics.49,50 However, the antibiotic in rotator cuff repair. J Bone Joint Surg Am
nausea.5,7,18,19 2012;94(3):227-233.
group in one study also underwent
3. Kim S, Bosque J, Meehan JP, Jamali A,
notably longer surgical times and
Marder R: Increase in outpatient knee
more complicated procedures than Summary arthroscopy in the United States: A
did the control group, obscuring comparison of National Surveys of
Ambulatory Surgery, 1996 and 2006.
meaningful comparison between the Complications and readmissions J Bone Joint Surg Am 2011;93(11):
groups.49 Penicillin-resistant patho- are uncommon after outpatient 994-1000.

20 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Charles A. Goldfarb, MD, et al

4. Best MJ, Buller LT, Miranda A: National 17. Fox JP, Vashi AA, Ross JS, Gross CP: analgesia for ambulatory shoulder surgery
trends in foot and ankle arthrodesis: Hospital-based, acute care after in a private practice setting. Reg Anesth
17-year analysis of the National Survey of ambulatory surgery center discharge. Pain Med 2008;33(2):122-128.
Ambulatory Surgery and National Hospital Surgery 2014;155(5):743-753.
Discharge Survey. J Foot Ankle Surg 2015; 31. Grant SA, Nielsen KC, Greengrass RA,
54(6):1037-1041. 18. Martín-Ferrero MÁ, Faour-Martín O, Steele SM, Klein SM: Continuous
Simon-Perez C, Pérez-Herrero M, de Pedro- peripheral nerve block for ambulatory
5. Khan T, Jackson WF, Beard DJ, et al: The Moro JA: Ambulatory surgery in surgery. Reg Anesth Pain Med 2001;26(3):
use of standard operating procedures in orthopedics: Experience of over 10,000 209-214.
day case anterior cruciate ligament patients. J Orthop Sci 2014;19(2):332-338.
reconstruction. Knee 2012;19(4): 32. Kuremsky MA, Cain EL Jr, Fleischli JE:
464-468. 19. De Oliveira GS Jr, Holl JL, Lindquist LA, Thromboembolic phenomena after
Hackett NJ, Kim JY, McCarthy RJ: Older arthroscopic shoulder surgery. Arthroscopy
6. Dorr LD, Thomas DJ, Zhu J, Dastane M, adults and unanticipated hospital 2011;27(12):1614-1619.
Chao L, Long WT: Outpatient total hip admission within 30 days of ambulatory
arthroplasty. J Arthroplasty 2010;25(4): surgery: An analysis of 53,667 ambulatory 33. Cagle PJ Jr, Reams M, Agel J, Bohn D: An
501-506. surgical procedures. J Am Geriatr Soc outcomes protocol for carpal tunnel release:
2015;63(8):1679-1685. A comparison of outcomes in patients with
7. Murray O, Holt G, McGrory R, Kay M, and without medical comorbidities. J Hand
Crombie A, Kumar CS: Efficacy of outpatient 20. Mezei G, Chung F: Return hospital visits Surg Am 2014;39(11):2175-2180.
bilateral simultaneous hallux valgus surgery. and hospital readmissions after ambulatory
Orthopedics. 2010;33(6):394. surgery. Ann Surg 1999;230(5):721-727. 34. Bykowski MR, Sivak WN, Cray J,
Buterbaugh G, Imbriglia JE, Lee WP:
8. Medicare: Payment for Ambulatory 21. Engbaek J, Bartholdy J, Hjortsø NC: Assessing the impact of antibiotic
Surgical Centers Should Be Based on the Return hospital visits and morbidity within prophylaxis in outpatient elective hand
Hospital Outpatient Payment System 60 days after day surgery: A retrospective surgery: A single-center, retrospective
[Internet]. Washington, DC 20548: United study of 18,736 day surgical procedures. review of 8,850 cases. J Hand Surg Am
States Government Accountability Office; Acta Anaesthesiol Scand 2006;50(8): 2011;36(11):1741-1747.
2006 Nov. Report No.: GAO-07-86. http:// 911-919.
www.gao.gov/products/GAO-07-86# 35. Harness NG, Inacio MC, Pfeil FF, Paxton
Accessed September 20, 2016. 22. Mathis MR, Naughton NN, Shanks AM, LW: Rate of infection after carpal tunnel
et al: Patient selection for day case-eligible release surgery and effect of antibiotic
9. Nguyen C, Milstein A, Hernandez- surgery: Identifying those at high risk for prophylaxis. J Hand Surg Am 2010;35(2):
Boussard T, Curtin CM: The effect of major complications. Anesthesiology 2013; 189-196.
moving carpal tunnel releases out of 119(6):1310-1321.
hospitals on reducing United States health 36. Thomsen NO, Cederlund R, Rosén I, Björk J,
care charges. J Hand Surg Am 2015;40(8): 23. Mitchell P, Gottschalk M, Butts G, Dahlin LB: Clinical outcomes of surgical
1657-1662. Xerogeanes J: Surgical site infection: A release among diabetic patients with carpal
comparison of multispecialty and single tunnel syndrome: Prospective follow-up with
10. Mather RC III, Wysocki RW, Mack specialty outpatient facilities. J Orthop matched controls. J Hand Surg Am 2009;34
Aldridge J III, Pietrobon R, Nunley JA: 2013;10(3):111-114. (7):1177-1187.
Effect of facility on the operative costs of
distal radius fractures. J Hand Surg Am 24. Edmonston DL, Foulkes GD: Infection rate 37. Mondelli M, Padua L, Reale F, Signorini
2011;36(7):1142-1148. and risk factor analysis in an orthopaedic AM, Romano C: Outcome of surgical
ambulatory surgical center. J Surg Orthop release among diabetics with carpal tunnel
11. Peterson KS, Lee MS, Buddecke DE: Adv 2010;19(3):174-176. syndrome. Arch Phys Med Rehabil 2004;85
Arthroscopic versus open ankle arthrodesis:
25. Grøgaard B, Kimsås E, Raeder J: Wound (1):7-13.
A retrospective cost analysis. J Foot Ankle
Surg 2010;49(3):242-247. infection in day-surgery. Ambul Surg 2001;
38. Nye ZB, Horn JL, Crittenden W, Abrahams
9(2):109-112.
12. Kadhim M, Gans I, Baldwin K, Flynn J, MS, Aziz MF: Ambulatory continuous
Ganley T: Do surgical times and efficiency 26. Memtsoudis SG, Ma Y, Swamidoss CP, posterior lumbar plexus blocks following hip
differ between inpatient and ambulatory Edwards AM, Mazumdar M, Liguori GA: arthroscopy: A review of 213 cases. J Clin
surgery centers that are both hospital Factors influencing unexpected disposition Anesth 2013;25(4):268-274.
owned? J Pediatr Orthop 2016;36(4): after orthopedic ambulatory surgery. J Clin
39. Dold AP, Murnaghan L, Xing J, Abdallah
423-428. Anesth 2012;24(2):89-95.
FW, Brull R, Whelan DB: Preoperative
13. Avery DM III, Matullo KS: The efficiency 27. Sultan J, Marflow KZ, Roy B: Unplanned femoral nerve block in hip arthroscopic
of a dedicated staff on operating room overnight admissions in day-case surgery: A retrospective review of 108
turnover time in hand surgery. J Hand Surg arthroscopic shoulder surgery. Surgeon consecutive cases. Am J Sports Med 2014;
Am 2014;39(1):108-110. 2012;10(1):16-19. 42(1):144-149.

14. Robinson JC, Brown TT, Whaley C, Bozic 28. Hadzic A, Williams BA, Karaca PE, et al: 40. Ward JP, Albert DB, Altman R, Goldstein
KJ: Consumer choice between hospital- For outpatient rotator cuff surgery, nerve RY, Cuff G, Youm T: Are femoral nerve
based and freestanding facilities for block anesthesia provides superior same- blocks effective for early postoperative pain
arthroscopy: Impact on prices, spending, day recovery over general anesthesia. management after hip arthroscopy?
and surgical complications. J Bone Joint Anesthesiology 2005;102(5):1001-1007. Arthroscopy 2012;28(8):1064-1069.
Surg Am 2015;97(18):1473-1481.
29. Singh A, Kelly C, O’Brien T, Wilson J, 41. Salvo JP, Troxell CR, Duggan DP:
15. Kurd MF, Schroeder GD, Vaccaro AR: Spine Warner JJ: Ultrasound-guided interscalene Incidence of venous thromboembolic
surgery in an ambulatory setting: What can block anesthesia for shoulder arthroscopy: disease following hip arthroscopy.
be done safely? JBJS Rev 2015;3(5):e3. A prospective study of 1319 patients. Orthopedics 2010;33(9):664.
J Bone Joint Surg Am 2012;94(22):
16. Fortier J, Chung F, Su J: Unanticipated 2040-2046. 42. Alaia MJ, Patel D, Levy A, et al: The
admission after ambulatory surgery: incidence of venous thromboembolism
A prospective study. Can J Anaesth 1998; 30. Fredrickson MJ, Ball CM, Dalgleish AJ: (VTE) after hip arthroscopy. Bull Hosp Jt
45(7):612-619. Successful continuous interscalene Dis (2013) 2014;72(2):154-158.

January 2017, Vol 25, No 1 21

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ambulatory Surgical Centers: A Review of Complications and Adverse Events

43. Williams BA, Kentor ML, Vogt MT, et al: site infections following ambulatory center. J Foot Ankle Surg 1997;36(1):
Femoral-sciatic nerve blocks for complex surgery procedures. JAMA 2014;311(7): 55-62.
outpatient knee surgery are associated with 709-716.
less postoperative pain before same-day 51. Cotter JT, Nielsen KC, Guller U, et al:
discharge: A review of 1,200 consecutive 47. Bert JM, Giannini D, Nace L: Antibiotic Increased body mass index and ASA
cases from the period 1996-1999. prophylaxis for arthroscopy of the knee: Is physical status IV are risk factors for block
Anesthesiology 2003;98(5):1206-1213. it necessary? Arthroscopy 2007;23(1):4-6. failure in ambulatory surgery: An analysis
of 9,342 blocks. Can J Anaesth 2004;51(8):
44. Pawlowski J, Orr K, Kim KM, Pappas AL, 48. Hunt KJ, Higgins TF, Carlston CV, 810-816.
Sukhani R, Jellish WS: Anesthetic and Swenson JR, McEachern JE, Beals TC:
recovery profiles of lidocaine versus Continuous peripheral nerve blockade as 52. Hsu LP, Oh S, Nuber GW, et al: Nerve
mepivacaine for spinal anesthesia in postoperative analgesia for open treatment block of the infrapatellar branch of the
patients undergoing outpatient orthopedic of calcaneal fractures. J Orthop Trauma saphenous nerve in knee arthroscopy: A
arthroscopic procedures. J Clin Anesth 2010;24(3):148-155. prospective, double-blinded, randomized,
2012;24(2):109-115. placebo-controlled trial. J Bone Joint Surg
49. Zgonis T, Jolly GP, Garbalosa JC: The Am 2013;95(16):1465-1472.
45. Nagda SH, Altobelli GG, Bowdry KA, efficacy of prophylactic intravenous
Brewster CE, Lombardo SJ: Cost analysis of antibiotics in elective foot and ankle 53. Yao J, Zeng Z, Jiao Z-H, Wang A-Z,
outpatient anterior cruciate ligament surgery. J Foot Ankle Surg 2004;43(2): Wang J, Yu A: Optimal effective
reconstruction: Autograft versus allograft. Clin 97-103. concentration of ropivacaine for
Orthop Relat Res 2010;468(5):1418-1422. postoperative analgesia by single-shot
50. Reyes C, Barnauskas S, Hetherington V: femoral-sciatic nerve block in outpatient
46. Owens PL, Barrett ML, Raetzman S, Retrospective assessment of antibiotic and knee arthroscopy. J Int Med Res 2013;41
Maggard-Gibbons M, Steiner CA: Surgical tourniquet use in an ambulatory surgery (2):395-403.

22 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Letter to the Editor
An Approach to Lumbar Revision Spine
Surgery in Adults
To the Editor: I am writing to com- Rather, patients with back pain,
ment on the article “An Approach to absent localization by objective find-
Lumbar Revision Spine Surgery in ings of neurologic deficit, are rou-
Adults” by Bederman et al.1 tinely labeled as having spinal
These authors have made a valu- stenosis, and/or degenerative disk
able contribution in critiquing disease, and/or instability, with
terms of art, such as “failed back hardly any assurance or demonstra-
surgery,” “flatback syndrome,” and tion that a particular level or levels
“postlaminectomy syndrome,” as are necessarily explanatory of the
imprecise descriptors of patients who patient’s symptoms. Where these
continue to complain about back pain “diagnoses” are associated with
despite surgical treatment. Spine sur- multilevel disease, there is no con-
geries for back pain may be unique sistent rationale why any particular
among all surgical disciplines in re- level or levels are necessarily associ-
sorting to failure of the procedure to ated with the symptoms, or perhaps
be effective as its own diagnosis, more to the point, that any currently
rather than understanding that available treatment has proof of
the original diagnosis was incorrect efficacy as being better than the
and/or that the surgical treatment was natural history of the untreated dis-
ineffective. ease. This may be especially so when
Unfortunately, implied is that other the symptoms are associated with, or
terms of art that may have served as perhaps caused by, ailments such as
“diagnoses” leading to the failed depression or obesity that are not
surgical procedures in the first place routinely corrected before engaging
are any more informative or any more in invasive treatments and are left
conducive to successful outcomes in unmentioned as contributory or
the management of back pain. The explanatory diagnoses before the
opening sentence of their article— initial, failed procedure.
“Spinal surgery has been shown to As such, one additional term of art
be beneficial in reducing pain and that can be confounding by its ubiq-
improving function in patients with uity and imprecision is “failure of
specific degenerative conditions”— conservative treatment.” Failure of
was asserted without any citation to a conservative treatments to address
study that is corroborative that sur- the patient’s complaints ought not to
gical treatment is directly associated be an indication for any invasive
with received benefit. surgical treatment, as opposed to
It is the case that some anatomic identification of a condition for
imperfections clearly localize the which surgical treatment is better
nature of pathology to be addressed, than the natural history of the
such as fracture-dislocations of the disorder.
spine, or neoplastic disorders, or The problem of failed back surger-
infection, but in the absence of such ies may be in reality that the initial
J Am Acad Orthop Surg 2017;25:e20-e22 clear-cut or indisputable conditions, surgical treatment was based on
DOI: 10.5435/JAAOS-D-16-00530 the common diagnostic labels imprecise terms of art that likely had
Copyright 2016 by the American Academy of attached to back pain sufferers are only a tangential relationship to the
Orthopaedic Surgeons. woefully inadequate. reason for the patient’s complaints.

e20 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
That is the language that requires degenerative spinal disease, for coding for reimbursement, it is
corrective action. example, would be to consider the two unlikely that a new diagnostic classi-
hallmark diseases of inflammatory fication system will be widely adopted
Stanley R. Askin, MD bowel disease, namely, ulcerative in the near future.
Elkins Park, PA colitis and Crohn disease.2 In the Third, as in most other areas of adult
former, the disease is localized to the degenerative orthopaedics, the treat-
large intestine within the gastroin- ment of degenerative lumbar spinal
testinal tract and typically begins disorders always begins with a thor-
The Authors’ Reply: We would like distally and progresses proximally. If ough assessment and attempts at
to thank Dr. Askin for his thoughtful surgery becomes necessary, then a nonsurgical treatment. The mainstay
comments on our article.1 Dr. Askin colectomy can be curative for the of treatment remains nonsurgical,
raises several important points that disease within the gastrointestinal namely, physical therapy, anti-
would benefit from further clarifi- tract. On the other hand, Crohn inflammatory medications, and, in
cation. Dr. Askin argues that spine disease may occur sporadically any- some circumstances, injection proce-
surgery is unique among all surgical where from the mouth to the anus dures. Fortunately, most patients
disciplines in that there is a specific with inflammatory lesions either respond to these treatment modalities.
diagnosis for failure of the procedure contiguous to other involved areas or In those few patients whose symptoms
to be effective. Furthermore, he notes remote. The mainstay of treatment persist or worsen and both patient and
that no studies have been provided remains medical, and surgery is physician believe they have adequately
that corroborate the effectiveness of reserved for small resections of local exhausted nonsurgical management,
surgical treatment, that current areas of inflammation, fistulae, or then surgery may be an option, de-
diagnostic labels are “woefully inad- abscesses. Surgical resection does not pending on structural or compressive
equate,” and goes on to state that eliminate the need for further resec- pathology. The Spine Patient Research
“failure of conservative treatments to tions and only addresses current Outcome Trials (SPORT) have pro-
address the patient’s complaints pathology. Thus, we must consider vided us with the highest quality of
ought not to be an indication for treatment of spinal pathology to be evidence to support surgical over
any invasive surgical treatment, as palliative and often temporary rather nonsurgical treatment of disk hernia-
opposed to identification of a condi- than as a definitive cure with high tion, spinal stenosis, and degenerative
tion for which surgical treatment is long-term success. spondylolisthesis after attempts and
better than the natural history of Second, because of the different failure of conservative treatment.4-7
the disorder.” We are grateful to patterns of degeneration, involvement Even with high-quality evidence to
Dr. Askin for allowing us to clarify of neural structures, and varied clinical support surgical treatment, the goals
many of our current challenges in symptoms, our diagnostic nomencla- of surgery can vary. For instance, in
dealing with patients having degen- ture has been inconsistent and insuffi- patients with single-level instability
erative lumbar disease. cient. That said, our ability to confer and multilevel stenosis, should we
First, it is important to recognize meaningful information using many perform decompression alone, multi-
that spinal pathology is unique among of these labels alone to other pro- level fusion, or a hybrid technique?8
musculoskeletal disorders because of viders, patients, and payers has been Each of these options has its own
its segmental anatomy. In comparison “woefully inadequate.” Recent advantages and disadvantages and
with other regions, degenerative dis- attempts to improve our ability to may lead to a reoperation in the
ease at one segment can directly affect accurately describe findings have been future despite successfully addressing
those of adjacent segments or remote underway but have not yet gained current symptoms.
spinal regional levels. Furthermore, sufficient traction. Glassman et al3 Finally, Dr. Askin makes the
surgical treatment is never truly proposed a diagnostic classification argument that “failure of conser-
definitive because appropriate treat- system that accounts for clinical vative treatments to address the
ment at one segment will not neces- symptoms, structural pathology, and patient’s complaints ought not to
sarily address pathology at other compressive pathology. The authors be an indication for any invasive
segments that are present at the index found this system to show high inter- surgical treatment, as opposed to
procedure or that develop in the rater consistency for all diagnostic identification of a condition for
future. Thus, we must consider spinal elements, and it possesses real prom- which surgical treatment is better
disease through a different lens. An ise in accurately describing the than the natural history of the
appropriate analogy for comparing patient’s clinical problem. However, disorder.” We would agree that
hip or knee osteoarthritis with with recent changes in diagnostic surgery is not indicated in patients

January 2017, Vol 25, No 1 e21

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
An Approach to Lumbar Revision Spine Surgery in Adults

who have ongoing symptoms fol- procedures to minimize morbidity 3. Glassman SD, Carreon LY, Anderson PA,
Resnick DK: A diagnostic classification for
lowing conservative treatment in and retain motion versus fusion lumbar spine registry development. Spine J
the absence of structural or com- procedures to cease the progression 2011;11(12):1108-1116.
pressive pathology. However, in of degeneration at that level, 4. Weinstein JN, Lurie JD, Tosteson TD, et al:
those patients who have symptoms combined with the segmental nature Surgical vs nonoperative treatment for
that correlate with their underlying of the spine, give rise to the envi- lumbar disk herniation: The Spine Patient
Outcomes Research Trial (SPORT)
pathology and have failed conser- ronment for ongoing or recurrent observational cohort. JAMA 2006;296(20):
vative treatment, surgery may be symptoms following spinal surgery. 2451-2459.
indicated. In those patients who Our paper outlines a more system- 5. Weinstein JN, Tosteson TD, Lurie JD, et al:
fail to improve following a tech- atic approach to evaluating these Surgical vs nonoperative treatment for
lumbar disk herniation: the Spine Patient
nically well-performed procedure patients with an attempt at identify- Outcomes Research Trial (SPORT): A
without another identifiable source ing opportunities for clinical randomized trial. JAMA 2006;296(20):
of spinal pathology, we may be improvement. 2441-2450.
dealing with an instance of mis- 6. Weinstein JN, Lurie JD, Tosteson TD, et al:
diagnosis or failure to achieve the S. Samuel Bederman, MD, PhD, Surgical versus nonsurgical treatment for
lumbar degenerative spondylolisthesis.
goals of surgery. Of course, this is FRCSC N Engl J Med 2007;356(22):2257-2270.
not unique to spinal surgery, even Orange, CA
7. Weinstein JN, Tosteson TD, Lurie JD, et al;
if we have adopted a diagnostic SPORT Investigators: Surgical versus
label. Ongoing knee pain following Vu H. Le, MD nonsurgical therapy for lumbar spinal
total knee arthroplasty, for exam- Newport Beach, CA stenosis. N Engl J Med 2008;358(8):
794-810.
ple, has been seen in 13% to 20%
of patients.9,10 Failure of surgical Sohrab Pahlavan, MD 8. Smorgick Y, Park DK, Baker KC, et al:
Single- versus multilevel fusion for single-
treatment to reliably address pre- Miami, FL level degenerative spondylolisthesis and
operative symptoms remains a multilevel lumbar stenosis: Four-year
results of the spine patient outcomes
challenge for all surgeons. It may research trial. Spine (Phila Pa 1976) 2013;
be that knee surgeons have been References 38(10):797-805.
wiser in preventing a label such as
1. Bederman SS, Le VH, Pahlavan S: An 9. Brander VA, Stulberg SD, Adams AD, et al:
“postarthroplasty syndrome” from Approach to Lumbar Revision Spine Predicting total knee replacement pain: A
gaining any traction. Surgery in Adults. J Am Acad Orthop Surg prospective, observational study. Clin
2016;24(7):433-442. Orthop Relat Res 2003;416:27-36.
Unfortunately, the combination
of underdeveloped and underused 2. Bederman SS: Commentary: The 10. Djahani O, Rainer S, Pietsch M, Hofmann S:
degenerative lumbar spine: A chronic Systematic analysis of painful total knee
diagnostic nomenclature, the bal- condition in search of a definitive solution. prosthesis, a diagnostic algorithm. Arch
ancing choice of decompressive Spine J 2012;12(2):98-100. Bone Jt Surg 2013;1(2):48-52.

e22 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Case Studies
Appropriate Use Criteria: Postoperative
Rehabilitation of Low Energy Hip Fractures
in the Elderly
Varatharaj Mounasamy, MD The American Academy of Ortho- stenting, hypertension and hyper-
Pierre Guy, MD, MBA, FRCSC paedic Surgeons (AAOS) approved lipidemia, and stroke with residual
the Appropriate Use Criteria (AUC) dysarthria. He also had a fracture of
Stephen L. Kates, MD document Postoperative Rehabili- the left hip that was treated in 2010.
tation of Low Energy Hip Frac- His presurgical functional status
tures in the Elderly in an effort to was ambulatory at home.
assist the clinician in caring for
these injuries. Here, we present a
Patient Assessment and
clinical scenario and a post-
operative rehabilitation treatment
Treatment
From the Department of Orthopaedic
Surgery, Virginia Commonwealth option to demonstrate how these The patient was transferred from
University, Richmond, VA (Dr. AUC can be incorporated into another hospital for care, and on
Mounasamy and Dr. Kates) and the clinical decision making. admission to the emergency
Department of Orthopedic Surgery, department, he was found to have a
University of British Columbia,
Vancouver, Canada (Dr. Guy). displaced femoral neck fracture of
History the right hip (Figure 1). Metabolic
Dr. Mounasamy or an immediate
family member serves as a board
A 62-year-old man presented to the bone workup demonstrated a
member, owner, officer, or committee emergency department after expe- serum calcium level of 8.3 mg/dL, a
member of the American Academy of riencing a fall. He was living at 25-hydroxy vitamin D level of 18.4
Orthopaedic Surgeons. Dr. Guy or an home and tripped and fell, sustain- ng/mL, and an intact parathyroid
immediate family member is a
member of a speakers’ bureau or has
ing an injury to the right hip. He has hormone level of 113.2 pg/mL.
made paid presentations on behalf of a history of coronary artery disease, Vitamin D supplementation was
Stryker; serves as a paid consultant to myocardial infarction with prior started preoperatively.
or is an employee of Stryker; has
stock or stock options held in Traumis
Surgical Systems; has received Figure 1
research or institutional support from
DePuy Synthes; and serves as a
board member, owner, officer, or
committee member of the Canadian
Orthopedic Foundation, Orthopaedic
Trauma Association and the West
Coast Hip Fracture Society. Dr. Kates
or an immediate family member is a
member of a speakers’ bureau or has
made paid presentations on behalf of
the AO Foundation; has received
research or institutional support from
DePuy Synthes; and serves as a
board member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons,
the American Orthopaedic
Association, AOTrauma, and the
Orthopaedic Trauma Association.
J Am Acad Orthop Surg 2017;25:
e15-e17
A, Preoperative AP radiograph of the pelvis demonstrating a displaced right
DOI: 10.5435/JAAOS-D-16-00473 femoral neck fracture and a prior left femoral shaft fracture treated with
intramedullary nailing. B, Preoperative AP radiograph of the right hip
Copyright 2016 by the American demonstrating the displaced femoral neck fracture.
Academy of Orthopaedic Surgeons.

January 2017, Vol 25, No 1 e15

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly

Figure 2

Postoperative AP radiographs of the pelvis (A) and the right hip (B) demonstrating a satisfactory result after right total hip
arthroplasty. C, Postoperative lateral radiograph of the right hip demonstrating satisfactory implant position.

Table 1
Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly: Scenario 31
Scenario Treatment Appropriateness Mediana Agreementb

Anterior/Anterolateral, Not able to Weight-bearing restrictions after hip Rarely 2 1


shop without assistance but able to fracture surgery Appropriate
leave house with or without Range-of-motion restrictions after hip May Be 4
assistance. Moderate Function/ fracture surgery Appropriate
Normal to Moderate Demand Interdisciplinary care to manage deep Appropriate 8 1
Patient, Intact (26–30 MMSE), No vein thrombosis prophylaxis/use of
postoperative delirium anticoagulants
Delirium prevention Appropriate 9 1
Interdisciplinary management at IRF Appropriate 9 1
or SNF if unable to return home
Outpatient occupational and physical Appropriate 9 1
therapy
Home care therapy if able to return Appropriate 8 1
home but unable to transport to a
local rehab facility
Osteoporosis assessment and Appropriate 9 1
management (eg, calcium and
vitamin D supplement, diphosphate
use, physical therapy)
Multimodal pain management Appropriate 9 1

IRF = inpatient rehabilitation facility, MMSE = Mini-Mental State Examination, SNF= skilled nursing facility
a
Numbers indicate the median rating of voting panel.
b
A plus symbol (1) indicates agreement between voting panel members and a minus symbol (2) indicates disagreement between voting panel
members.

e16 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The patient was seen and assessed and was taking calcium and vitamin D instructions to continue outpatient
by the internal medicine team for supplements. Radiography showed physical and occupational therapy
preoperative risk assessment. He satisfactory implant position (Figure was the appropriate rehabilitation
was felt to be a satisfactory surgical 2). He did not experience any peri- choice. Assessment for and man-
candidate. On the day after admis- operative adverse events. agement of osteoporosis were per-
sion, the patient underwent total formed, and initial treatment with
hip arthroplasty using an anterior calcium and vitamin D supple-
approach. Discussion mentation was begun to correct the
This case best reflects Scenario 31 significant vitamin D deficiency
of the American Academy of diagnosed preoperatively.
Rehabilitation Orthopaedic Surgeons AUC for the
After surgery, the patient underwent Postoperative Rehabilitation of
Reference
occupational and physical therapy. Low Energy Hip Fractures in the
On postoperative day 5, the patient Elderly1 (Table 1). In this case, hip 1. American Academy of Orthopaedic Surgeons:
Appropriate Use Criteria for Postoperative
was discharged home and began fracture fixation was achieved with
Rehabilitation of Low Energy Hip Fractures in
outpatient rehabilitation, including a total hip arthroplasty using an the Elderly. Available at http://www.aaos.org/
occupational and physical therapy. anterior approach. This patient uploadedFiles/PreProduction/Quality/AUCs_
and_Performance_Measures/appropriate_
At 3 months postoperatively, he was high functioning before the use/Hip%20Fx%20Rehab%20AUC.pdf.
noted no pain, walked using a cane, injury; discharge to home with Published December 4, 2015.

January 2017, Vol 25, No 1 e17

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article

Assessment of the Pediatric Foot


Mass

Abstract
Maryse Bouchard, MD, FRCSC, Masses in the pediatric foot are relatively uncommon and can present
MSc a diagnostic challenge. The literature lacks a comprehensive
Murray Bartlett, MBBS, overview of these types of lesions. Most are benign soft-tissue lesions
FRANZCR that can be diagnosed on the basis of history and physical
Leo Donnan, MBBS (Melb), examination. However, some rare malignant neoplasms can mimic
FRACS, FAOrthA benign masses. It is imperative to recognize these lesions because
the consequences of a delayed or missed diagnosis can be
substantial. A thorough history and physical examination of all
pediatric patients with foot lesions are crucial to ensure that any lesion
not readily identified as benign is appropriately managed.

T he incidence of masses involving


the foot or ankle in adults is
4%.1 Most masses in the foot are
and the differential diagnosis of the
most common soft-tissue and bony
tumors. Typical clinical features,
benign and of soft-tissue origin.1 imaging characteristics, and man-
Masses in the foot or ankle are agement of each type of tumor are
thought to be less common in chil- discussed, as well.
dren; however, the literature is
sparse and consists mostly of case
series.1,2 Tables 1 and 2 summarize History and Physical
the pediatric foot and ankle lesions Examination
most frequently reported in the
literature.1-16 Primary soft-tissue Clinical diagnosis of a mass in the
From the Department of Orthopedics,
Seattle Children’s Hospital, Seattle, masses account for 52% to 88% of foot requires a thorough history and
WA (Dr. Bouchard), I-MED Radiology these lesions.2,6 Although few studies physical examination. Patients may
Network and the University of specifically address masses in the have pain, swelling, skin changes,
Melbourne, Australia (Dr. Bartlett),
pediatric foot, reported lesions are neurovascular changes, deformity,
and the Department of Orthopaedics,
Royal Children’s Hospital, Melbourne, typically benign (range, 61% to and/or disability from pathologic
Australia (Dr. Donnan). 87%).2,6,17,18 Only one study fractures.1 Because the foot is a
None of the following authors or any showed a predominance of malig- weight-bearing surface and has
immediate family member has nant tumors.1 Although malignant minimal muscle, most masses are
received anything of value from or has lesions are uncommon, they can be easily noticed, and patients typically
stock or stock options held in a
difficult to distinguish from benign seek treatment promptly.1 In con-
commercial company or institution
related directly or indirectly to the masses.19 Misdiagnosis of a malig- trast, some lesions are smaller and
subject of this article: Dr. Bouchard, nant tumor in the foot has been painless, and these lesions must be
Dr. Bartlett, and Dr. Donnan. correlated with higher morbidity vigilantly evaluated to rule out
J Am Acad Orthop Surg 2017;25: and recurrence rates.1,12 Therefore, malignancy.19 The history should
32-41 accurate and timely diagnosis of include the child’s age, duration and
DOI: 10.5435/JAAOS-D-15-00397 masses in the pediatric foot is evolution of symptoms, history of
imperative.6 Here, we present an trauma or infection, medical history,
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. approach to the assessment of the and family history.3 Physical exam-
child with a mass in the foot or ankle ination includes observation of the

32 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Maryse Bouchard, MD, FRCSC, MSc, et al

characteristics of the mass (eg, solid Table 1


or cystic, fixed or mobile, tender or
Benign Lesions of the Pediatric Foot and Ankle
painless); the presence of any dis-
coloration, swelling, neurovascular Lesion Type Reported Prevalence (%)
deficits, or deformity; and the loca- Ganglion cyst1-3 Soft tissue 1.5–33
tion of the mass and its relation to
Fibromatosis and desmoid tumor1-4 Soft tissue 3.6–30.3
surrounding structures.3
Exostosisa,1,5 Bony 5.3–27
Giant cell tumor of tendon sheath and Soft tissue 2.2–12.5
pigmented villonodular synovitis1-3,6-8
Imaging Lipoma1-3,6,9,10 Soft tissue 2.2–12.5
Nonossifying fibroma1,2 Bony 7–12.3
When clinical assessment is insuffi-
Hemangioma and vascular Soft tissue 2.5–12.2
cient to establish a diagnosis, or malformations1-3,6
when either the history or the phys- Aneurysmal bone cyst1,2 Bony 2–12.1
ical examination suggests a suspi- Simple bone cyst1,2 Bony 9.6
cious etiology, imaging is required. Schwannoma1,3,6,11 Soft tissue 8.9
Ultrasonography is a good initial test Fibroma3,6 Soft tissue 5.3
for many pediatric foot lesions, espe-
Enchondroma1,2,6 Bony 4.6
cially cystic and superficial masses. It
Hematoma3 Soft tissue 2.2
is generally easy to obtain and does
Abscess3 Soft tissue 2.2
not expose the patient to radia-
Inclusion cyst1-3 Soft tissue 1.7
tion.3,19 Doppler ultrasonography
is the modality of choice for the a
Includes solitary osteochondroma, subungual exostosis, and multiple exostosis.
assessment of vascular lesions.9
Conventional radiography may be
required when deformity is present or
when a bony mass is suspected.9,17 Table 2
If the diagnosis remains uncertain Malignant Lesions of the Pediatric Foot and Ankle
after conventional radiography or if
Lesion Type Reported Prevalence (%)
the lesion is in an unusual location,
CT and MRI may be needed. These Synovial sarcoma1,2,12,13 Soft tissue 2.5–12.1
modalities can also be helpful in the Liposarcoma6,12,14 Soft tissue 3.6
staging of tumors and in preoperative Fibrosarcoma1,6,12,15 Soft tissue 2–3.6
planning.1,17 CT is ideal for imaging Osteosarcoma1,2,6,12,13 Bony 1.3–2
complex and destructive bony Rhabdomyosarcoma1,3 Soft tissue 1
lesions.20 MRI is best for imaging
deep and large soft-tissue masses and
assessing their relation to adjacent
structures.9 The use of gadolinium insidious onset, misdiagnosis or de- Salipas et al19 compared the out-
contrast with MRI helps the physi- layed diagnosis can occur, poten- comes of foot or ankle sarcomas on the
cian characterize lesions and differ- tially leading to poorer outcomes. basis of initial assessment at a non-
entiate between solid and cystic Latt et al12 reported on lesions in the specialist center versus a cancer center.
masses and vascular malformations.9 foot that were excised “without They noted a higher incidence of de-
Biopsy may be required to confirm a preoperative staging or the consid- layed diagnosis and management and
diagnosis that is suspected on the eration of the need for removal of an incorrect initial treatment, resulting in a
basis of advanced imaging. envelope of normal tissue around trend toward worse overall survival in
the tumour.” Even when combined the patients initially treated at a non-
with radiation therapy or chemo- specialist center versus a cancer center
Consequences of Delayed therapy, this type of excision of (69.6% versus 86.8%). Also, soft-
or Incorrect Diagnosis soft-tissue sarcoma led to higher tissue lesions had a worse prognosis
recurrence rates.12 Repeat excision than did primary bony sarcomas.19
Because malignant lesions in the foot was needed to reduce the risk of Therefore, the authors recommended
and ankle are rare and often have an local recurrence.12 early referral to a tumor specialist

January 2017, Vol 25, No 1 33

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Assessment of the Pediatric Foot Mass

Figure 1 Figure 2 Figure 3

Clinical photograph demonstrating


T2-weighted sagittal magnetic
infantile digital fibromatosis in a
resonance image with fat suppression
T1-weighted sagittal magnetic 2-year-old boy with a solid lump on
demonstrating a ganglion cyst in a
resonance image demonstrating the medial aspect of the third toe.
12-year-old boy with a painless lump
in the medial midfoot. plantar fibroma in a 14-year-old boy
with a painless lump in the plantar foot.
the plantar fascia of the foot (Led-
derhose disease; Figure 2). They
before intervention to minimize mor- Malignant lesions, particularly have also been found in the hand
bidity and improve outcomes.19 synovial sarcoma, are rare but can be (Dupuytren contracture) and penis7
Shah and Callahan3 summarized misdiagnosed as ganglion cysts. If (Peyronie disease). These lesions
the characteristics of tumors that the history or physical examination are ,5 cm in diameter, are slow-
should prompt further investiga- is not clearly indicative of a ganglion growing, rarely require imaging,
tion to rule out malignancy: rapid cyst (eg, if the mass is tender, firm, and are rare in children. 4 Deep
growth, predisposition related to fixed, enlarging, deep, or opaque), fibromatoses are larger, are located
syndromes and family history, size imaging is needed.12 Ultrasonogra- deeper in the tissues, and have
.5 cm, involvement of the deep fas- phy typically demonstrates a well- rapid, infiltrative growth. They
cial layers, heterogeneous appearance defined anechoic or hypoechoic tend to recur locally but are not
on MRI, poorly defined margins, and lesion, depending on fluid content in known to metastasize.4 They occur
increased vascularity. benign lesions. Periarticular cysts more often in boys than in girls and
have a cystic, fluid-filled appearance tend to occur in children younger
on MRI.9 If ultrasonography dem- than 2 years, although they have
Benign Soft-tissue Lesions onstrates a solid lesion, MRI is been reported in children as old as
indicated. If MRI confirms that the 8 years.7
lesion is a solid mass, biopsy or Infantile myofibroma and myofi-
Periarticular Cysts excision should be considered. If bromatosis (solitary and multifocal
Periarticular cysts include ganglion MRI demonstrates that the lesion is manifestations, respectively) are
cysts and synovial cysts arising from a simple fluid collection, the diag- the most common fibrous tumors
a joint capsule or adjacent tendon nosis of a periarticular cyst is most in infants, with 88% occurring
(Figure 1). Occasionally they are probable. in patients younger than 2 years.7
intra-articular or intraosseous.9 Pa- Infantile digital fibromatosis oc-
tients typically have a palpable mass curs most often on the lesser toes
and sometimes report pain.3 These Fibroblastic Lesions and less commonly on the fingers.
lesions are typically nontender, pal- Fibromatosis is a benign aggressive These lesions occur more fre-
pable, superficial fluid-filled masses proliferation of fibroblasts.4 These quently in boys than in girls and
that allow transillumination.3 Peri- lesions can be solitary or, less are present at birth or develop
articular cysts resolve spontaneously commonly, multifocal and are within the first year of life23
in many patients.9 If a cyst does not classified as superficial or deep. 7 (Figure 3). Typically, the lesions
involute and is symptomatic, it can be They are typically small, firm, pea- are firm, solitary nodules ,2 cm in
managed with aspiration, with or sized masses that are painful with diameter that are skin colored or
without injection of steroid, or with weightbearing.22 Superficial fi- pale red and have a smooth sur-
open surgical excision.21 bromatoses are generally found in face. They can mimic the clinical

34 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Maryse Bouchard, MD, FRCSC, MSc, et al

appearance of subungual osteo- Figure 4


chondroma. Nonsurgical manage-
ment is recommended because
recurrence rates are high (up to
74%) and some of these lesions
resolve spontaneously.23 If the lesion
affects function and nonsurgical
management (eg, anti-inflammatory
medication, modified footwear) is
unsuccessful, complete surgical re-
section may be indicated.23
MRI is the modality of choice for
the evaluation of fibromatous
lesions. Signal intensity will vary, Intraoperative photograph (A) and T1-weighted sagittal magnetic resonance
and these lesions are often image with fat suppression (B) demonstrating lipoblastoma in a 14-year-old boy
with a painful lump in the medial midfoot. B, The arrow demonstrates
enhanced with gadolinium con- suppression of the pure fat component of the signal.
trast.7 If clinical or radiographic
assessment reveals a particularly
aggressive lesion, biopsy is recom- liposarcomas on the basis of lesion grows quickly until the
mended to rule out malignancy.24 imaging alone.9 Locally aggressive patient reaches 9 to 10 months of
adipocytic lesions should be biop- age. By age 7 to 10 years, the
sied.14 If the patient is symptomatic, hemangioma will involute.9 Con-
Adipocytic Lesions
wide resection of the lipoblastoma genital hemangiomas are rapidly
Adipocytic tumors account for 6% of is recommended.25 Recurrence involuting lesions present at birth
childhood soft-tissue tumors, with rates between 9% and 25% have that do not increase in size.28 They
two thirds being lipomas.3,9,14 They been reported.9,14,25 occur with similar frequency in
are most often found in the torso, boys and girls. When they appear on
neck, and proximal extremities10 the extremities, they are located near
but have been reported in the Benign Vascular Lesions
a joint. They are characterized by
foot.10,14,25 Lipomas are typically pink to purple skin discoloration.9
Vascular anomalies are the most
superficial but can be intermuscular
common soft-tissue tumors found
or intramuscular.9 On MRI, lipomas
in children and often occur in the Vascular Malformations
have the same signal characteristics
foot as boggy, sometimes discrete,
as subcutaneous fat in all sequences.9 Vascular lesions arising in patients
discolored, and/or painful masses.3,9
These lesions are generally painless; older than 3 months are rarely he-
Mulliken and Glowacki26 classified
however, if they cause functional mangiomas and are typically vascular
these lesions into two distinct groups:
disability, excision can be consid- malformations. Some pathologists
hemangiomas and vascular malfor-
ered. The rate of recurrence is low.9 continue to use the term cavernous
mations.27 Most can be diagnosed on
Lipoblastomas account for the hemangioma to describe these lesions,
the basis of a thorough history and
remaining one third of adipocytic but this term creates diagnostic con-
physical examination.9
lesions in children9,14 (Figure 4, A). fusion. Most lesions that occur in
Approximately 70% of lipo- patients older than 3 months or that
blastomas occur in the extremities Hemangiomas do not involute or regress are vascular
of patients in the first 3 years of life, Common hemangiomas of infancy malformations. The age of pre-
and they are more common in are the most usual vascular tumors sentation varies greatly because some
boys than in girls.25 They are typi- in infants. They are typically pres- vascular malformations are present at
cally slow-growing, asymptomatic ent at birth or appear by age 3 birth, whereas slow-growing lesions
tumors.9,14 Although benign with- months, and they occur more often may not become apparent until the
out malignant potential, they can be in boys than in girls. In 15% of patient reaches adolescence or has a
locally aggressive.25 Lipoblastomas patients with hemangioma, the growth spurt.9,27
have lower fat signal intensity on lesion occurs on the extremities.9 Vascular malformations can be
MRI than do lipomas (Figure 4, B). These lesions have a characteristic high-flow or low-flow lesions.
They cannot be distinguished from strawberry-like appearance. The Arteriovenous malformations are

January 2017, Vol 25, No 1 35

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Assessment of the Pediatric Foot Mass

Figure 5 Figure 6

T1-weighted coronal magnetic


Clinical photograph (A) and Doppler sonogram (B) demonstrating arteriovenous resonance image of the toes
malformation in an 8-year-old girl with a discolored, tender lump in the plantar demonstrating a giant cell tumor of the
midfoot and forefoot. tendon sheath in a 15-year-old boy
with a painless lump in the plantar
aspect of the third toe. Arrow indicates
high-flow lesions consisting of an with the use of fitted pressure stock- hypointense signal of a large mass
surrounding the tendon.
abnormal network of tortuous ings and aspirin or other anticoagu-
and dysplastic vascular channels lants. If nonsurgical management is
between arteries and veins, without unsuccessful, the surgeon should (GCTTS) is more common in patients
the normal capillary bed27 (Figure consult with an interventional radi- in their twenties and thirties than in
5, A). Venous malformations are ologist to assess whether the vascular children, pediatric cases have been
the most common type of vascular malformation could be managed reported.8 Localized extra-articular
malformation. These localized with sclerotherapy or surgery.27 GCTTS is the most common type of
masses are soft and fluctuant and Fibroadipose vascular anomaly GCTTS.9 These lesions are typically
can be solitary or multiple.9 If the (FAVA) occurs in the limbs, including ,2 cm in size and wrap around a
lesion is in the upper body, it can the foot and ankle. This intramuscular tendon.9 Diffuse extra-articular
expand with compression, gravity, lesion consists of dense fibroadipose GCTTS is larger and more aggres-
or a Valsalva maneuver.27 In 40% tissue and slow-flow vascular malfor- sive and is found around large joints.9
of patients with vascular malfor- mations.30 FAVA can cause joint The hand is the most common loca-
mations, the lesion is located in the contractures and severe, progressive tion, followed by the foot.8 Most
extremities.27 chronic pain resistant to manage- patients have painless, slow-growing,
Doppler ultrasonography is the ment. It is important to distinguish solitary soft-tissue masses.8
initial, and often best, imaging FAVA from other vascular malfor- GCTTS and PVNS have similar
modality for the diagnosis of a vas- mations.30 On MRI, T1- and T2- appearances on MRI, which is the
cular malformation (Figure 5, B). weighted sequences of the affected modality of choice for imaging.
Almost all of these lesions have a muscle have heterogeneous high sig- They tend to be hypointense on T1-
heterogeneous appearance. MRI can nals, with the latter sequences being and T2-weighted images because of
further characterize the extent and more intense.30 Ultrasonography their hemosiderin content8,9 (Figure 6).
type of vascular lesion.27 They are demonstrates solid, heterogeneous GCTTS is almost always extra-
hypointense or isointense on T1- echogenic changes replacing the nor- articular, whereas PVNS is diffuse
weighted MRI and bright on T2- mal muscle.30 Optimal management and intra-articular.8,9 Calcification of
weighted or short tau inversion of FAVA lesions is controversial.30 the soft tissue and erosion of adjacent
recovery MRI.29 Magnetic reso- bone can occur.31 Despite this classic
nance angiography can be used to appearance, a conclusive diagnosis is
confirm the diagnosis of a suspected
Pigmented Villonodular difficult to determine preoperatively.
fast-flow lesion (as can ultrasonog- Synovitis and Giant Cell The differential diagnosis includes
raphy) and can be used to help plan Tumors of the Tendon Sheath synovitis, tenosynovitis, ganglion cyst,
interventional radiology.27 Pigmented villonodular synovitis lipoma, fibromatosis, and, most
In patients with vascular malfor- (PVNS) typically occurs in younger importantly, synovial cell sarcoma.8
mation who do not have hemorrhage, adults but has been reported in chil- Symptomatic lesions can be excised;
circulatory problems, or other com- dren as young as 3 years but usually however, local recurrence is common,
plications, such as thrombosis or older than 10 years.8,9 Although giant particularly in patients with PVNS.2,3,6
sepsis, symptoms can be managed cell tumor of the tendon sheath Adjuvant irradiation is recommended

36 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Maryse Bouchard, MD, FRCSC, MSc, et al

in patients at high risk of recurrence Figure 7


and in patients with incomplete exci-
sion of a histologically aggressive
lesion with bony involvement. In
patients with PVNS of the toes, espe-
cially if the lesion is aggressive or
recurrent, amputation can be
considered.2,3,6

Neurogenic Lesions
Neurofibroma is the most common
pediatric neurogenic tumor of the
peripheral nerves, although most
patients with neurofibroma are
between 20 and 30 years of age. This
benign nerve sheath tumor consists
mostly of Schwann cells. Neurofi-
bromas are unencapsulated and con- A, Intraoperative photograph demonstrating a localized painful neurofibroma of
tinuous with the normal nerve, the sural nerve in a 10-year-old girl. The arrow points to a fusiform mass within
the nerve. B, T2-weighted sagittal magnetic resonance image demonstrating a
requiring excision of the nerve with the localized neurofibroma of the tibial nerve in a 9-year-old girl with a painful lump in
lesion in symptomatic patients.2,3,7 the posteromedial heel. The arrow points to the heterogeneous signal of the
Neurofibromas are of three types: the fusiform mass.
localized form, which accounts for
90% of neurofibromas; the diffuse
form, which occurs more frequently
tumors, representing 10% to 15% of performed at skeletal maturity
in children than in adults and is usu-
all bony tumors. They are typically to minimize recurrence. Excision in
ally found on the head and neck; and
solitary lesions, can be pedunculated a growing child is recommended
the plexiform type, which is patho-
or sessile, and are variable in size.32 when the lesion causes pain, defor-
gnomonic for neurofibromatosis type
Patients with multiple hereditary mity, or growth disturbance or
111 (Figure 7, A). Neurofibromas are
exostosis, an autosomal dominant increases in size out of proportion to
fusiform masses that are isointense on
disorder, have multiple exostoses.32 the child’s growth.33
T1-weighted MRI and heterogeneous
Multiple hereditary exostosis typi- Subungual exostosis is an os-
on T2-weighted sequences; these
cally occurs in younger patients teochondroma of the distal phalanx
masses also may demonstrate a so-
(,10 years of age) and commonly of a toe. It is relatively common in
called target sign11 (a central low
results in deformity and shortening children and may cause pain and/or
signal surrounded by a peripheral rim
of the limbs.1 nail changes5 (Figure 8). These
of high signal intensity; Figure 7, B).
Exostoses of the foot account for lesions usually require careful
Schwannomas are benign, encap-
only 1% to 8% of osteochon- excision by means of removal or
sulated nerve sheath tumors consist-
dromas.1,31 Exostoses are com- elevation of the nail and resection
ing of Schwann cells.9 Patients with
posed of cortical and medullary of the entire lesion. The nail bed is
neurofibromatosis type 1 may have
bone with an overlying hyaline closed with sutures, with care
multiple lesions.11 MRI demon-
cartilage cap, and the cortex and taken to ensure minimal disruption
strates a well-defined, fusiform mass
marrow of the parent bone and the to the germinal matrix to help
along a nerve with a surrounding fat
exostosis are continuous.32 Patients prevent complications.5 Radio-
rim.11 Symptomatic schwannomas
usually are between 10 and 15 years graphs are generally sufficient to
can be excised without involvement
of age, but these lesions also occur diagnose osteochondroma. How-
of the adjacent nerve.11
in younger children. The lesions ever, MRI or CT may be required
enlarge throughout childhood but to clarify an equivocal radio-
Benign Bony Lesions typically do not change in size after graphic evaluation or to better
the patient has reached skeletal define the lesion anatomically.
Exostoses, or osteochondromas, are maturity.32 In most patients, resec- Exostoses at the epiphysis of a long
the most common benign bony tion of osteochondromas is best bone may indicate Trevor disease (ie,

January 2017, Vol 25, No 1 37

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Assessment of the Pediatric Foot Mass

Figure 8 Figure 9

Intraoperative photograph (A) and intraoperative fluoroscopic image (B) Sagittal gradient-recalled echo–
demonstrating a subungual osteochondroma in a 9-year-old boy who had weighted magnetic resonance
localized pain and toenail deformation. (Copyright Vincent S. Mosca, MD, image demonstrating Trevor dis-
Seattle, WA.) ease of the navicular bone in a
10-year-old boy with dorsal midfoot
pain. The arrow demonstrates
bony outgrowth from the navicular
bone resulting in displacement of
dysplasia epiphysealis hemimelica; cavities typically occurring in ado- the navicular bone in a plantar
Figure 9). This condition typically lescent patients and resulting in a direction.
occurs in early childhood.34 The palpable mass, swelling, and/or
tarsal bones are the most common pain.36 Although ,2% of these
sites, followed by the distal femoral tumors in all age groups occur in the (in which a piece of cortical bone
and proximal tibial epiphyses, and foot, they are locally aggressive and appears to be floating in the cyst) may
the disease occurs three times more cause expansion of the bony cortex. be present; however, this sign is not
frequently in boys than in girls.34,35 On radiographs, these lesions are commonly seen in patients with foot
These exostoses generally involve lytic, sometimes have septa, and do lesions. Although up to 80% of
only half of the epiphysis, usually the not demonstrate calcification (Figure simple bone cysts are asymptomatic,
medial side.35 When they occur in 10). MRI and CT are helpful for lesions occupying a large portion of
long bones, they typically cause limb- further characterization, such as the calcaneus can cause pain or
length discrepancy, joint incongruity, determination of fluid levels.36 ABCs pathologic fracture.37 In symptom-
and deformity.35 Advanced imaging, are generally treated with intrale- atic patients, curettage and grafting
such as CT, is often necessary for sional curettage with or without are recommended (Figure 11).
preoperative planning. MRI will adjuvants, such as phenol, cryo- GCT of bone is rare in pediatric
demonstrate a clear distinction of the therapy, or cement.36 Recurrence patients, accounting for ,2% of foot
lesion from its host bone, in contrast rates have been reported to be higher and ankle tumors in this population.38
to the appearance of a more aggres- when the lesion is managed with GCTs tend to be locally destructive
sive disease process, such as parosteal curettage alone and lowest when and have an associated soft-tissue
osteosarcoma.34,35 Large lesions that adjuvant phenol is used.36 mass or result in a pathologic frac-
cause deformity or pain can be The differential diagnosis of ABC in ture.38 They can be managed with
excised. Although complete excision children can include simple bone cyst intralesional curettage with adjuvant
is preferable, a bump remaining after and giant cell tumor (GCT) of bone. or wide en bloc resection.38
incomplete excision can resorb.35 Simple bone cysts are benign lesions Chondroblastoma is an uncommon
Smaller lesions can be removed ar- that account for 3% of primary benign tumor, accounting for 1% to
throscopically or through an open bony tumors and typically occur in 3% of primary bony tumors. It occurs
surgical approach, whereas larger the metaphyses of long bones.37 mostly in the epiphyses of long bones,
lesions may necessitate joint fusion. Although rarely found in the foot, with 70% occurring in the femur,
After a child is skeletally mature, when they do arise, they tend to occur humerus, or tibia,39 although calcaneal
progression of lesions or develop- in the calcaneus.37 On radiography, tumors have been reported, as well.
ment of new lesions is rare.34 these cysts are typically unicameral, Most chondroblastomas occur in
An aneurysmal bone cyst (ABC) is a with minimal cortical change.37 In males and in patients between 10 and
benign bony tumor with blood-filled long bones, the classic fallen-leaf sign 20 years of age.39 Radiographically,

38 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Maryse Bouchard, MD, FRCSC, MSc, et al

Figure 10 Figure 11 Figure 12

Intraoperative photograph
demonstrating a simple bone cyst in
the calcaneus in a 10-year-old girl who
reported heel ache. Plain radiography
demonstrated a cyst. MRI indicated
that the cyst was benign.

on T1-weighted images and are Proton density–weighted coronal


Axial radiograph of the calcaneus hyperintense and often heteroge- magnetic resonance image demon-
demonstrating an aneurysmal bone strating synovial sarcoma in a 10-year-
neous on T2-weighted images; nearly old boy with a 1-month history of a foot
cyst in a 9-year-old girl with heel 20% have fluid levels7 (Figure 12).
pain. The lesion resulted in a breach lump. The arrow indicates a well-
of the bony cortex (arrow). Synovial sarcomas are often ini- defined, oval-shaped solid lesion.
tially misdiagnosed clinically and
histologically as benign neoplasms,
chondroblastoma is typically lytic with such as ganglions, nerve sheath in the pediatric foot and ankle.1,6
a sclerotic margin.39 tumors, or fibroblastic tumors.13 If a Fibrosarcoma is best evaluated with
child has a foot mass that is painful, MRI; however, its appearance is
enlarging, deep, or firm, and if the variable. The lesions tend to be
Malignant Soft-tissue lesion is not consistent with the heterogeneous on T1- and T2-
Lesions characteristics of these common weighted images. With gadolinium
benign soft-tissue tumors, then enhancement, they often have strong
Synovial sarcoma is the second synovial sarcoma must be considered rim enhancement and may have an
most common pediatric soft-tissue as a possible diagnosis. Diagnosis appearance similar to that of a
sarcoma7 and the most common generally requires advanced imag- spoked wheel.7 The two types,
soft-tissue sarcoma in the foot and ing, biopsy, and confirmation with infantile (or congenital) and adult,
ankle.1,2,6,17,18 Patients younger genetic testing for t(X;18)(p11.2; are differentiated by the age of pre-
than 20 years account for 30% of q11.2) translocation, S100 protein– sentation.7 The infantile form is
these lesions, and they have positive neuroma-like neural prolif- usually seen in patients aged ,5
occurred in patients as young as 2 erations, or SYT-SSX fusion tran- years, with 30% occurring in
years.7 These lesions are commonly scripts.13 These lesions are managed infancy (not all are seen at birth) and
juxta-articular, with only 6% to with wide resection and radiother- 75% located in the extremities.7
10% being intra-articular, and apy.13 Recurrence is common, espe- They grow rapidly at first, some-
range in size from ,1 cm to well cially in the foot, where resection can times becoming large (.10 cm) in
over 5 cm.7,13 Synovial sarcoma be difficult. Factors that are typically proportion to the child’s size.7,15
occurs as a painless, slow-growing consistent with a good prognosis Treatment consists of wide resection
mass of insidious onset. It is best include smaller size (,5 cm), and, in some patients, irradiation.15
evaluated with ultrasonography and peripheral location, lack of poorly Local recurrence rates ranging
MRI. Ultrasonography demonstrates differentiated histology, and patient from 17% to 43% have been re-
a well-defined solid lesion. On MRI, age younger than 40 years.13 ported. Metastasis occurs in 5% to
the lesions are typically a well- Fibrosarcoma is the second most 10% of patients, most commonly to
defined mass isointense to muscle common malignant soft-tissue tumor the lungs. Despite these factors, the

January 2017, Vol 25, No 1 39

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Assessment of the Pediatric Foot Mass

5-year survival rate is .80%, and ankle.40 Patients with Ewing sarcoma 5. DaCambra MP, Gupta SK, Ferri-de-Barros F:
Subungual exostosis of the toes: A systematic
the prognosis is much better in are also treated with wide resection review. Clin Orthop Relat Res 2014;472(4):
children than in adults.7,15 Adult- and adjuvant chemotherapy.16,40 1251-1259.
type fibrosarcoma can occur in older 6. Azevedo CP, Casanova JM, Guerra MG,
children (aged 10 to 15 years) as a Santos AL, Portela MI, Tavares PF:
painful, slow-growing mass that Summary Tumors of the foot and ankle: A single-
institution experience. J Foot Ankle Surg
occurs most often in the proximal 2013;52(2):147-152.
extremities and trunk.15 Five-year Masses in the pediatric foot typically
7. Laffan EE, Ngan B-Y, Navarro OM:
survival of pediatric patients with are benign soft-tissue lesions that can Pediatric soft-tissue tumors and
this type of fibrosarcoma is ,60%.7 be diagnosed on the basis of clinical pseudotumors: MR imaging features with
evaluation. Ultrasonography can be pathologic correlation. Part 2: Tumors of
Liposarcoma is extremely rare in fibroblastic/myofibroblastic, so-called
children but is the third most com- useful in establishing the diagnosis fibrohistiocytic, muscular, lymphomatous,
mon malignancy in the pediatric and/or determining the need for fur- neurogenic, hair matrix, and uncertain
origin. Radiographics 2009;29(4):e36.
foot.6,7,14 Clinically and radio- ther imaging. Advanced imaging can
graphically, liposarcoma can be be used to narrow the differential 8. Gibbons CL, Khwaja HA, Cole AS,
Cooke PH, Athanasou NA: Giant-cell
difficult to differentiate from lipo- diagnosis. Occasionally, benign tumour of the tendon sheath in the foot
blastoma. Miller et al14 reported lesions require surgical excision for and ankle. J Bone Joint Surg Br 2002;84
symptom management. Although (7):1000-1003.
that children with lipoblastoma tend
to be younger (61% are younger rare, malignant neoplasms that 9. Navarro OM, Laffan EE, Ngan B-Y:
mimic benign masses can occur in the Pediatric soft-tissue tumors and pseudo-
than age 3 years), whereas those tumors: MR imaging features with
with liposarcoma are usually teen- foot. Careful history and physical pathologic correlation. Part 1: Imaging
agers. Biopsy is crucial for diagnosis examination of all pediatric patients approach, pseudotumors, vascular lesions,
and adipocytic tumors. Radiographics
before management. Karyotyping with foot lesions are imperative to 2009;29(3):887-906.
can also be useful.7,14 The long-term ensure that any lesion not readily
10. Vandeweyer E, Van Geertruyden J, de
prognosis of liposarcoma is better in identified as benign is appropriately Fontaine S: Lipoma of the toe. Foot Ankle
children than in adults.7 investigated and managed. Int 1998;19(4):246-247.

11. Murphey MD, Smith WS, Smith SE,


Kransdorf MJ, Temple HT: From the
Acknowledgment archives of the AFIP: Imaging of
Malignant Bony Lesions musculoskeletal neurogenic tumors.
Radiologic-pathologic correlation.
The authors wish to thank Vincent S. Radiographics 1999;19(5):1253-1280.
Osteosarcoma is the most common
Mosca, MD, for the use of the images 12. Latt LD, Turcotte RE, Isler MH, Wong C:
pediatric primary bony malignancy
in Figure 8. Case series: Soft-tissue sarcoma of the foot.
of the foot and ankle and typically Can J Surg 2010;53(6):424-431.
occurs in patients aged 10 to 20
13. Michal M, Fanburg-Smith JC, Lasota J,
years.1,2,6 Anninga et al16 published References Fetsch JF, Lichy J, Miettinen M: Minute
a retrospective review of osteosar- synovial sarcomas of the hands and feet: A
clinicopathologic study of 21 tumors less
comas in the hands and feet. More References printed in bold type are than 1 cm. Am J Surg Pathol 2006;30(6):
than 50% of the tumors occurred in those published within the past 5 721-726.
the tarsal bones, most were low years. 14. Miller GG, Yanchar NL, Magee JF,
grade, and the survival rate was 81% Blair GK: Lipoblastoma and liposarcoma in
1. Ozdemir HM, Yildiz Y, Yilmaz C, Saglik Y: children: An analysis of 9 cases and a
at 5 years.16 Osteosarcoma generally Tumors of the foot and ankle: Analysis of review of the literature. Can J Surg 1998;41
has a blastic appearance with bony 196 cases. J Foot Ankle Surg 1997;36(6): (6):455-458.
destruction and can have a periosteal 403-408.
15. Cecchetto G, Carli M, Alaggio R, et al;
reaction and an associated soft-tissue 2. Chou LB, Ho YY, Malawer MM: Tumors Italian Cooperative Group: Fibrosarcoma
mass.15 Standard radiography, CT, of the foot and ankle: Experience with 153 in pediatric patients: Results of the Italian
cases. Foot Ankle Int 2009;30(9):836-841. Cooperative Group studies (1979-1995). J
and MRI are helpful for diagnosis Surg Oncol 2001;78(4):225-231.
3. Shah SH, Callahan MJ: Ultrasound
and preoperative planning. Treat-
evaluation of superficial lumps and bumps 16. Anninga JK, Picci P, Fiocco M, et al:
ment consists of wide resection with of the extremities in children: A 5-year Osteosarcoma of the hands and feet: A
adjuvant chemotherapy.16 retrospective review. Pediatr Radiol 2013; distinct clinico-pathological subgroup.
43(suppl 1):S23-S40. Virchows Arch 2013;462(1):109-120.
Ewing sarcoma should be included
in the differential diagnosis of a lesion 4. Lee JC, Thomas JM, Phillips S, Fisher C, 17. Chou LB, Malawer MM: Analysis of
Moskovic E: Aggressive fibromatosis: MRI surgical treatment of 33 foot and ankle
with an aggressive appearance that features with pathologic correlation. AJR tumors. Foot Ankle Int 1994;15(4):
involves the bones of the foot or Am J Roentgenol 2006;186(1):247-254. 175-181.

40 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Maryse Bouchard, MD, FRCSC, MSc, et al

18. Kirby EJ, Shereff MJ, Lewis MM: Soft- 26. Mulliken JB, Glowacki J: Hemangiomas Natural history and treatment. J Bone Joint
tissue tumors and tumor-like lesions of and vascular malformations in infants and Surg Am 2000;82(9):1269-1278.
the foot: An analysis of eighty-three cases. children: A classification based on
J Bone Joint Surg Am 1989;71(4): endothelial characteristics. Plast Reconstr 34. Brunner R, Freuler F, Hasler C, Jundt G:
621-626. Surg 1982;69(3):412-422. Pediatric Orthopedics in Practice. Berlin,
Germany, Springer-Verlag, 2007, pp
19. Salipas A, Dowsey MM, May D, Choong 27. Legiehn GM, Heran MK: A step-by-step 677-678.
PF: ‘Beware the lump in the foot!’: practical approach to imaging diagnosis
Predictors of recurrence and survival in and interventional radiologic therapy in 35. Smith EL, Raney EM, Matzkin EG,
bone and soft-tissue sarcomas of the foot vascular malformations. Semin Intervent Fillman RR, Yandow SM: Trevor’s disease:
and ankle. ANZ J Surg 2014;84(7-8): Radiol 2010;27(2):209-231. The clinical manifestations and treatment
533-538. of dysplasia epiphysealis hemimelica. J
28. Gorincour G, Kokta V, Rypens F, Garel L, Pediatr Orthop B 2007;16(4):297-302.
20. Jing Z, Wen-Yi L, Jian-Li L, Jun-Lin Z, Powell J, Dubois J: Imaging characteristics
Chi D: The imaging features of meningeal of two subtypes of congenital 36. Casadei R, Ruggieri P, Moscato M,
Ewing sarcoma/peripheral primitive hemangiomas: Rapidly involuting Ferraro A, Picci P: Aneurysmal bone cyst
neuroectodermal tumours (pPNETs). Br J congenital hemangiomas and non- and giant cell tumor of the foot. Foot Ankle
Radiol 2014;87(1041):20130631. involuting congenital hemangiomas. Int 1996;17(8):487-495.
Pediatr Radiol 2005;35(12):1178-1185. 37. Yildirim C, Akmaz I, Sahin O, Keklikci K:
21. Saboeiro GR, Sofka CM: Ultrasound-
guided ganglion cyst aspiration. HSS J 29. Behr GG, Johnson C: Vascular anomalies: Simple calcaneal bone cysts: A pilot study
2008;4(2):161-163. Hemangiomas and beyond. Part 1: Fast- comparing open versus endoscopic
flow lesions. AJR Am J Roentgenol 2013; curettage and grafting. J Bone Joint Surg Br
22. Sammarco GJ, Mangone PG: Classification 200(2):414-422. 2011;93(12):1626-1631.
and treatment of plantar fibromatosis. Foot
Ankle Int 2000;21(7):563-569. 30. Alomari AI, Spencer SA, Arnold RW, et al: 38. Bibbo C: Metatarsal giant cell tumor in
Fibro-adipose vascular anomaly: Clinical- adolescents. Foot Ankle Int 2010;31(8):
23. Braun SA, Helbig D: Infantile digital radiologic-pathologic features of a newly 717-724.
fibromatosis: A rare myofibrocytic tumor delineated disorder of the extremity. J
with characteristic histopathology. J Dtsch 39. Kricun ME, Kricun R, Haskin ME:
Pediatr Orthop 2014;34(1):109-117. Chondroblastoma of the calcaneus:
Dermatol Ges 2014;12(12):1141-1142.
31. Campanacci M: Osteoid osteoma, in Bone Radiographic features with emphasis on
24. Eastley N, Aujla R, Silk R, et al: Extra- and Soft Tissue Tumors. Vienna, Austria, location. AJR Am J Roentgenol 1977;128
abdominal desmoid fibromatosis: A Springer-Verlag, 1990, pp 355-373. (4):613-616.
sarcoma unit review of practice, long term
recurrence rates and survival. Eur J Surg 32. Mavrogenis AF, Papagelopoulos PJ, 40. Berger M, Fagioli F, Abate M, et al:
Oncol 2014;40(9):1125-1130. Soucacos PN: Skeletal osteochondromas Unusual sites of Ewing sarcoma (ES): A
revisited. Orthopedics 2008;31(10):pii. retrospective multicenter 30-year
25. Pirela-Cruz MA, Herman D, Worrell R, experience of the Italian Association of
Miller RA: Lipoblastoma circumscripta of 33. Chin KR, Kharrazi FD, Miller BS, Mankin Pediatric Hematology and Oncology
the toe: A case report and review of the HJ, Gebhardt MC: Osteochondromas of (AIEOP) and Italian Sarcoma Group (ISG).
literature. Foot Ankle 1992;13(8):478-481. the distal aspect of the tibia or fibula: Eur J Cancer 2013;49(17):3658-3665.

January 2017, Vol 25, No 1 41

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Research Article

Effect of Time of Operation on Hip


Fracture Outcomes: A
Retrospective Analysis

Abstract
Gonzalo Barinaga, MD Introduction: Hip fractures are a common source of morbidity,
Erik Wright, BSc mortality, and cost burden for elderly patients. We conducted a
retrospective analysis of patients with hip fracture treated during the
Paul J. Cagle, Jr, MD
day or night at a rural level I academic trauma center and compared the
Afshin A. Anoushiravani, MD postoperative outcomes and resource utilization for both groups.
Zain Sayeed, MSc, MHA Methods: Patients aged $55 years with hip fractures treated with
Monique C. Chambers, MD, definitive surgical fixation from April 2011 to April 2013 were included
MSL in this study. Patients who underwent surgery between 7 AM and 5 PM
Mouhanad M. El-Othmani, MD were included in the day cohort, while those who underwent surgery
between 5 PM and 7 AM were included in the night cohort. A total of
Khaled J. Saleh, BSc, MD, MSc,
441 patients met the study inclusion criteria.
FRCS(C), MHCM, CPE
Results: Comparison of the baseline characteristics of the two
cohorts did not demonstrate significant variance. Although
postoperative outcomes and resource utilization trends varied
between the day and night cohort, only in-hospital cost was
significantly higher in the day cohort (P = 0.04). Postoperative
variables, including blood loss, Δhematocrit level, length of surgery,
length of stay, time to surgery, in-hospital mortality, and 30-day
readmission, did not vary significantly.
Conclusion: Our study demonstrates a significantly higher cost
associated with hip fracture procedures performed between 7 AM and
5 PM. In addition, perioperative blood loss and length of surgery were
used as markers of physician fatigue; however, no statistically
significant difference among these variables was found between hip
From the Division of Orthopaedics and
Rehabilitation (Dr. Barinaga, fracture intervention performed during the day versus at night.
Mr. Wright, Dr. Cagle, and Level of Evidence: III, retrospective observational study
Dr. Anoushiravani) and the
Department of Surgery (Mr. Sayeed
and Dr. Chambers), Southern Illinois

H
University School of Medicine, ip fractures in the United States nursing homes.1 Furthermore, stud-
Springfield, IL, and the Department of
Orthopaedics and Sports Medicine,
are a considerable source of ies suggest that 25% of patients with
Detroit Medical Center, Detroit, MI morbidity and mortality among hip fractures will die within 1 year of
(Dr. El-Othmani and Dr. Saleh). elderly patients.1 In 2004, the US sustaining the fracture.1 Although
Correspondence to Dr. Saleh: Surgeon General’s report on osteo- hip fracture management has been
kjsaleh@gmail.com porosis noted that 325,000 patients investigated extensively, consider-
J Am Acad Orthop Surg 2017;25: sustained hip fractures annually.1 able debate remains regarding the
55-60 Nearly all patients with hip fractures optimal timing of surgical manage-
DOI: 10.5435/JAAOS-D-15-00494 experience considerable disability, ment.2-8 Despite the controversy, the
with reports indicating that 50% current literature suggests that
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. never fully regain functional capacity improved postoperative outcomes
and 24% eventually relocate to and reduced mortality rates can be

January 2017, Vol 25, No 1 55

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Effect of Time of Operation on Hip Fracture Outcomes: A Retrospective Analysis

achieved when early (ie, ,72 hours) report) result in inferior postoperative direct supervision of a board certi-
definitive fixation protocols are outcomes, but we believe hematocrit fied orthopaedic surgeon. Only
implemented.6 values provide a more accurate patients with a hip fracture resulting
Hip fractures, which can result association between blood loss from a low-energy mechanism of
from low-energy trauma, have placed and postoperative outcomes.9,10 We injury, which was defined as a fall
a significant strain on our healthcare hypothesize that surgical manage- from a standing height or lower,
system. The temporal variability in ment of hip fractures at night were included in this study. Patients
the presentation of hip fractures fur- results in a larger decrease in with hip fractures caused by high-
ther complicates medical manage- hematocrit level, indicating in- energy mechanisms, such as motor
ment. Few studies have assessed creased intraoperative blood loss vehicle collision or penetrating
outcomes with respect to the surgical and ultimately resulting in longer trauma, were excluded. In addition,
intervention performed during the length of stay (LOS) and higher patients with a history of myocardial
day (work hours) and night (after- cost than surgical management infarction or acute myocardial
hours). In a retrospective study, performed during the day. infarction on presentation were
Chacko et al7 separated 767 hip excluded from the study because of
fractures into two cohorts treated the need for cardiac clearance and
either during the day or at night and Methods the possible effect on time and cost of
found no marked difference in surgical intervention. Baseline char-
postoperative complications and We retrospectively reviewed 637 acteristics of patients and surgical
mortality. However, the authors consecutive hip fractures treated at fracture instrumentation are re-
reported that physician fatigue may our rural level I academic trauma ported in Table 1.
have led to the increased surgical center between April 2011 and Patients who met the inclusion cri-
time and blood loss observed in the April 2013. Prior to the start of the teria were divided into two groups
night cohort.7 In contrast, Rashid study, Institutional Review Board based on the time of surgical inter-
et al8 found no difference with re- approval was obtained. Our study vention. Patients treated surgically
gard to postoperative complications, combined administrative data from between 7 AM to 5 PM were included
hemoglobin levels, and 30-day the Crimson Database (Advisory in the day group, and those treated
mortality rates in day and night Board Company) with quantitative between 5 PM to 7 AM were included
surgical hip fracture cohorts. data gathered through retrospective in the night group. Baseline charac-
The aim of this study was to retro- chart review. Once data from the teristics, including age, sex, body
spectively compare patient demo- Crimson Database and electronic mass index, Charlson Comorbidity
graphics, in-hospital postoperative medical record had been extracted, Index (CCI), American Society of
outcomes, and resource utilization the data from the two sources were Anesthesiologists (ASA) score, frac-
trends among hip fracture patients merged and all patient identifiers ture type, instrumentation, co-
who received surgical fixation during were removed. morbidities, and preoperative
the day versus at night to determine Inclusion criteria for our study hematocrit levels, were collected
whether postoperative outcomes were included patient age $55 years and from the Crimson Database and
affected by the time surgery was per- radiographic evidence of hip fracture chart review. A similar approach
formed. This study particularly focuses (eg, femoral neck, intertrochanteric, was used to collect in-hospital out-
on blood loss and preoperative and subtrochanteric). Definitive surgical comes including time to surgery,
postoperative hematocrit levels in day fixation was performed at our insti- length of surgery, estimated blood
and night cohorts. Several studies have tution by a board certified ortho- loss (as reported in the intraoperative
noted that increased levels of blood paedic surgeon or a resident, who notes), and in-hospital mortality.
loss (as estimated in the intraoperative performed the procedure under the Economic variables including LOS,

Dr. Saleh or an immediate family member has received royalties from Aesculap/B.Braun; is a member of a speakers’ bureau or has made
paid presentations on behalf of Aesculap/B.Braun; is an employee of Southern Illinois University School of Medicine; serves as a paid
consultant to Aesculap/B.Braun, Memorial Medical Center, and Watermark; has received research or institutional support from Smith &
Nephew, the Orthopaedic Research and Education Foundation, and the National Institutes of Health National Institute of Arthritis and
Musculoskeletal and Skin Diseases (R0-1); and serves as a board member, owner, officer, or committee member of the American Academy
of Orthopaedic Surgeons, the American Board of Orthopaedic Surgeons, the American Orthopaedic Association, the Orthopaedic Research
and Education Foundation, the Board of Specialty Societies, and Notify, LLC. None of the following authors or any immediate family member
has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this article: Dr. Barinaga, Mr. Wright, Dr. Cagle, Dr. Anoushiravani, Mr. Sayeed, Dr. Chambers, and Dr. El-Othmani.

56 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Gonzalo Barinaga, MD, et al

hospital cost, and 30-day read- Table 1


mission rates were available from the
Baseline Characteristics
Crimson Database.
Statistical analysis was performed Baseline Characteristics Day Cohorta Night Cohortb P value
for the interpretation of baseline Female (%) 226 (78.2) 116 (76.3) 0.65
characteristics and clinical variables
Mean age in years (range) 81.67 (55–101) 81.93 (56–101) 0.80
using Wilcoxon signed-ranked test
BMI kg/m2 24.14 23.64 0.14
scores, chi-square test, Student t-tests,
Preoperative ASA Score (%)
and analysis of variance (ANOVA).
1 0 0 0.65
The data was expressed as a mean
2 34 (11.76) 22 (14.47) 0.65
with a 95% confidence interval. A P
3 187 (64.71) 98 (64.47) 0.65
value , 0.05 was considered statis-
tically significant. 4 68 (23.53) 32 (21.05) 0.65
Average 3.12 3.06 0.65
Fracture type (%)
Results Femoral Neck 140 (48.44) 73 (48.03) 0.70
Intertrochanteric 137 (47.40) 75 (49.34) 0.70
Subtrochanteric 12 (4.15) 4 (2.63) 0.70
Baseline Characteristics Instrumentation (%)
A total of 441 patients treated for hip Cephalomedullary nails 133 (46.02) 60 (39.47) 0.42
fracture were eligible for inclusion in Sliding hip screws 34 (11.76) 25 (16.45) 0.42
this study. The patient population Hemiarthroplasty 80 (27.68) 42 (27.63) 0.42
included 342 women (77.6%) with an Percutaneous hip screws 42 (14.53) 25 (16.45) 0.42
average age of 81.8 years and a body
mass index of 23.9 kg/m2. In the 289 ASA = American Society of Anesthesiologists, BMI = body mass index
a
Surgery performed from 7 AM to 5 PM; n = 289
patients who received surgical fixa- b
Surgery performed from 5 PM to 7 AM; n = 152
tion during the day, the average age
was 81.67 years, and the gender
distribution was 226 women (78.2%) and 4 subtrochanteric fractures. Sur- #1 and POD #2 in both cohorts was
and 63 men (21.8%). Preoperative gical fixation was achieved with 60 not significant (P = 0.48 and P =
risk assessment revealed an ASA cephalomedullary nails, 25 sliding hip 0.78, respectively). The average time
score of two in 34 patients, a score of screws, 42 hemiarthroplasties, and 25 to surgery, length of surgery, and
three in 187 patients, and a score of percutaneous hip screws (Table 1). LOS were greater in the day cohort
four in 68 patients (Table 1). In the Comparison of baseline character- than in the night cohort, although
day cohort, there were 140 femoral istics of the day and night cohorts not significantly greater (P = 0.13,
neck fractures, 137 intertrochanteric demonstrated no statistically signifi- P = 0.26, and P = 0.14, respectively;
fractures, and 12 subtrochanteric cant difference (Table 1). Moreover, Table 3). In-hospital costs associated
fractures. Surgical fixation was per- a direct comparison of patient co- with providing hip fracture care were
formed using 133 cephalomedullary morbidities in the cohorts demon- 8.7% greater in the day cohort than
nails, 34 sliding hip screws, 80 hem- strated no statistically significant in the night cohort (P = 0.04). Lastly,
iarthroplasties, and 42 percutaneous variance with regard to individual no statistically significant difference
hip screws (Table 1). comorbidities (Table 2). was found between the two cohorts
The remaining 152 patients were with respect to the rates of 30-day
in the night group. The mean patient readmission and in-hospital mortal-
age was 81.93 years, and 116 Postoperative Outcomes and
ity (P = 0.56 and P = 0.25, respec-
patients were women (76.3%) and Resource Utilization tively; Table 3).
36 were men (23.7%). Preoperative Postoperative outcomes, including
risk assessment revealed an ASA the average hematocrit level on
score of two in 22 patients, a score of postoperative day 1 and 2 (POD #1 Discussion
three in 98 patients, and a score of and POD #2) did not vary signifi-
four in 32 patients. The night cohort cantly (P = 0.27 and P = 0.59, The optimal time for surgical inter-
consisted of 73 femoral neck frac- respectively). Additionally, Δhemat- vention in the setting of hip fracture
tures, 75 intertrochanteric fractures, ocrit level on admission and on POD has gained increasing attention over

January 2017, Vol 25, No 1 57

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Effect of Time of Operation on Hip Fracture Outcomes: A Retrospective Analysis

Table 2 outcomes.11-13 Bhattacharyya et al13


found that closed femoral nailing
Baseline Cohort Comorbidities
done at night required significantly
Day Night more operating room (OR) time than
Comorbidities Group (%) Group (%) P value
did the same procedure done during
Atrial fibrillation 79 (27.34) 31 (20.39) 0.10 the day (261 minutes versus
Hypertension 165 (57.09) 79 (51.97) 0.30 219 minutes, P , 0.04). Hip fracture
Congestive heart failure 67 (23.18) 29 (19.08) 0.32 surgeries and femoral nailing done at
Diabetes mellitus, uncomplicated 35 (12.11) 21 (13.82) 0.60 night were also noted to have a
Diabetes mellitus, complicated 4 (1.38) 3 (1.97) 0.63 higher incidence of surgical compli-
Hypothyroidism 65 (22.49) 29 (19.08) 0.40 cations than did the same procedures
done during the day (P , 0.04 and
Chronic airway obstruction 41 (14.19) 24 (15.79) 0.65
P , 0.036, respectively). Surgeon
Renal disease 43 (14.88) 23 (15.13) 0.94
fatigue may increase surgical errors
Dementia 4 (1.38) 0 (0.00) 0.14
and the duration of surgery.12 Foss
Peripheral vascular disease 17 (5.88) 9 (5.92) 0.98
and Kehlet11 reported that 5- and
Mean Charlson Comorbidity Index 1.37 (1.42) 1.29 (1.53) 0.61
score (standard deviation) 30-day postoperative mortality rates
were significantly higher in patients
admitted during holidays compared
with those in patients admitted over
Table 3 the work week and weekend. The
Postoperative Outcomes and Resource Utilization investigators suggested that reduced
hospital staff may be partially to
Factors Day Cohorta Night Cohortb P value
blame for the increased rates.11 The
CBC hematocrit on admission 35.57 (5.24) 35.63 (5.11) 0.89 aforementioned studies suggest that
(mean, SD) surgeon fatigue and reduced OR
POD #1 CBC hematocrit 28.98 (4.80) 29.53 (5.05) 0.27 staff during off-peak hours may be
(mean, SD) associated with poor postoperative
POD #2 CBC hematocrit 28.55 (4.46) 28.29 (4.72) 0.59 outcomes, potentially leading to
(mean, SD)
increased resource utilization.
Δhematocrit from admission 26.52 (5.02) 26.15 (4.70) 0.48
to POD #1c Halm et al9 reported that higher
Δhematocrit from admission 27.00 (5.59) 27.16 (5.29) 0.78
postoperative hemoglobin is asso-
to POD #2c ciated with shorter LOS and lower
Estimated blood loss (mean, SD) 202.43 (216.06) 177.04 (146.65) 0.19 readmission rates, but it has no
Length of surgery (mean min, SD) 66.83 (33.61) 63.25 (28.18) 0.26 effect on mortality rate or Func-
Length of stay (mean d, SD) 5.64 (3.34) 5.12 (4.09) 0.14 tional Independence Motor mobility
In-hospital cost (%) Reference 28.7 0.04 scores. Foss and Kehlet10 reported
Time to surgery (mean hr) 24.14 (16.94) 21.56 (16.94) 0.13
that increased perioperative blood
loss led to increased LOS and
In-hospital mortality (n, %) 9 (3.11) 2 (1.32) 0.25
medical complications. In a retro-
30-day readmission (n, %) 48 (16.61) 22 (14.47) 0.56
spective review, Chacko et al7
CBC = complete blood count, POD = postoperative day, SD = standard deviation demonstrated no difference in
a
b
Surgery performed from 7 AM to 5 PM mortality in patients who under-
Surgery performed from 5 PM to 7 AM
c
Δhematocrit was calculated as the change from admission to POD #1 and POD #2 for each went surgical intervention during
patient, then averaging the change within each cohort. the day versus at night, but the
authors did report a marked
increase in procedural duration and
the last decade. Consensus on early Within this time frame, intervention blood loss with fixation performed
surgical fixation of hip fractures performed during the day or at with sliding hip screws or intra-
(within ,48 hours of injury) has night may affect patient outcomes. medullary nails at night. Con-
grown and has provided a target Several studies have affirmed the versely, Bosma et al14 compared
window for surgical management in perception that nighttime interven- the rates of complications and
an attempt to optimize outcomes. tions can negatively affect patient mortality associated with surgical

58 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Gonzalo Barinaga, MD, et al

management of femoral fractures with 5.64 and 5.12 days (P = 0.14) with chart review to minimize data
treated during the day or at night reported in the day and night collection error, an inherent degree
and found no significant difference cohorts, respectively. Cost was of error remains in retrospective data
in estimated blood loss or surgical 8.70% higher in the day cohort collection. Furthermore, other than
time. (P = 0.04). The similar LOS in the a quantitative comparison of LOS
Our study compared the difference two cohorts is likely the result of the between the cohorts, we had no
in preoperative and postoperative time of operation. Most patients in effective method of measuring func-
hematocrit levels in the day and night the night group underwent surgical tional outcomes following surgery.
cohorts because this was deemed to fixation before midnight on the day This study may be limited by a
be a more accurate method of mea- of admission, which satisfied hospi- surgeon-preference bias because of
suring perioperative blood loss. No tal day 1 requirements with regard to the study’s retrospective observa-
significant difference was associated the Short Stay Transfer Policy es- tional nature and the fact that it was
with the 6.52% and 6.15% decrease tablished by Congress in 1998.16 conducted at an institutional level,
in hematocrit levels between admis- Patients who were admitted before where care is provided by multiple
sion and POD #1 in the day and night midnight and operated on after- surgeons with different fellowship
cohorts, respectively (P = 0.48). The hours benefited from a night training and preferences. Different
results also demonstrated no signif- admission and could start recovery surgeons may have different pref-
icant difference in surgical time, with from surgery on their first hospital erences with regard to when to
an average of 66.83 minutes in the day, similar to the day cohort. perform surgery, especially given
day cohort and 63.25 minutes in the Therefore, despite after-hours surgi- that the exact optimal timing for
night cohort (P = 0.26). Although cal management, the admission sta- fixation in hip fracture patients is
the length of surgery and differences tus satisfied the federally mandated still lacking in the literature. Sur-
in preoperative and postoperative Short Stay Transfer Policy’s 3-day geons might elect to postpone a case
hematocrit levels were measured in limit. The significant decrease in cost presenting at night to the next
four distinct procedures, the various seen in the night cohort was likely morning, when more staff support
procedures were equally distributed influenced by decreased LOS and would be available, and to avoid
among the day and night cohorts. time to surgery, although there was performing a procedure after-hours.
This allowed us to conclude that no statistically significant difference However, because there was no
perioperative blood loss is equivocal in these variables between the significant difference between the
in patients with hip fracture who cohorts. The lower cost observed two cohorts in terms of fracture
undergo surgical treatment during in our night group might also be type, instrumentation used, CCI
the day or at night. explained by the shorter surgery score, comorbidities profile, and
The Affordable Care Act has duration (average of 4 minutes) other patient characteristics,
recently placed a premium on pro- compared with the surgery duration surgeon-preference bias did not shift
viding quality care at a decreased in the day cohort, although this dif- the more complex cases to the day
cost. This study examined the effects ference was not statistically signifi- cohort, and therefore, did not sub-
of surgical timing on LOS and case cant. Because each minute in the OR stantially affect our results. It
cost to assess the financial burdens costs on average 60 US dollars, this should also be noted that time to
being placed on the hospital and would result in an average savings of surgery may directly affect LOS
payer systems. In a retrospective 240 US dollars, potentially contrib- because earlier fixation likely leads
review of 660 patients with hip frac- uting to the lower total cost in the to a decrease in overall LOS. The
tures, Garcia et al15 found that ASA night cohort. Although this study did night cohort did have a shorter time
score and smoking status reliably not stratify cost by ASA score in the to surgery compared with the day
predicted LOS, and the authors respective cohorts, the similar age, cohort (21.56 hours versus 24.14
found no association between other ASA and CCI scores, fracture type, hours; P = 0.13). In addition, using
multiple medical comorbidities and and instrumentation type mitigates hematocrit level as a marker for
LOS. The ASA score was also found the effects of preoperative variables perioperative blood loss has its
to be predictive of cost, with each on postoperative outcomes and confounders because dehydration
single digit increase in ASA score resource utilization. can cause substantial preoperative
correlating with an increased LOS of The limitations in this study are hemoconcentration and post-
2.05 days (P = 0.001) and a cost largely the result of its retrospective operative fluid retention.10 How-
increase of $9,300.15 In our study, design. Although data from the ever, we believe that change in
difference in LOS was insignificant, Crimson Database were combined hematocrit is a better overall

January 2017, Vol 25, No 1 59

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Effect of Time of Operation on Hip Fracture Outcomes: A Retrospective Analysis

indicator of blood loss than more the night cohort, and this was the only delay before surgery important? J Bone
Joint Surg Am 2005;87(3):483-489.
subjective methods, such as esti- variable measured that proved to be
mated intraoperative blood loss. significantly different between the two 5. Orosz GM, Magaziner J, Hannan EL, et al:
Association of timing of surgery for hip
Another limitation of this study is the cohorts (P = 0.04). To our knowl- fracture and patient outcomes. JAMA
grouping of distinct surgical proce- edge, this is the first study reporting a 2004;291(14):1738-1743.
dures and fracture patterns into large reduction in cost with hip fractures 6. Zuckerman JD, Skovron ML, Koval KJ,
day and night cohorts. The effects of a repaired at night; however, additional Aharonoff G, Frankel VH: Postoperative
complications and mortality associated
particular surgical procedure or frac- studies are needed to better under- with operative delay in older patients who
ture type may go unnoticed because of stand the surgical variables responsi- have a fracture of the hip. J Bone Joint Surg
the mixed cohorts. However, surgical ble for the reduction in cost. In Am 1995;77(10):1551-1556.
procedures were equally mixed in both contrast to earlier literature, this 7. Chacko AT, Ramirez MA, Ramappa AJ,
cohorts, and this study does allow study examined perioperative blood Richardson LC, Appleton PT, Rodriguez
EK: Does late night hip surgery affect
general conclusions to be made loss and length of surgery as a marker outcome? J Trauma 2011;71(2):447-453.
regarding after-hours surgical cases of physician fatigue and found no
8. Rashid RH, Zubairi AJ, Slote MU,
and hip fracture outcomes. Although significant difference between day Noordin S: Hip fracture surgery: Does time
our study is not without limitations, to and night cohorts. of the day matter? A case-controlled study.
Int J Surg 2013;11(9):923-925.
our knowledge it is the only one
available that uses qualitative and 9. Halm EA, Wang JJ, Boockvar K, et al: The
Acknowledgments effect of perioperative anemia on clinical
quantitative variables to thoroughly and functional outcomes in patients with
evaluate postoperative outcome and hip fracture. J Orthop Trauma 2004;18(6):
resource utilization trends in patients The authors would like to thank 369-374.

with hip fractures who undergo sur- Albert Botchway, PhD, for his assis- 10. Foss NB, Kehlet H: Hidden blood loss after
gery during the day or night. tance with the statistical analysis. surgery for hip fracture. J Bone Joint Surg
Br 2006;88(8):1053-1059.
Despite growing evidence that after-
11. Foss NB, Kehlet H: Short-term mortality in
hour surgical outcomes for hip frac-
tures are comparable to those of day
References hip fracture patients admitted during
weekends and holidays. Br J Anaesth 2006;
cases, recent literature has reported a 96(4):450-454.
Evidence-based Medicine: Levels of
demand for dedicated orthopaedic 12. Taffinder NJ, McManus IC, Gul Y, Russell
evidence are described in the table of RC, Darzi A: Effect of sleep deprivation on
trauma rooms to improve patient
contents. In this article, references 5, surgeons’ dexterity on laparoscopy
outcomes. Improved patient out- simulator. Lancet 1998;352(9135):1191.
6, and 12 are level I studies. Refer-
comes and OR efficiency with dedi-
ences 4, 9-11, and 15 are level II 13. Bhattacharyya T, Vrahas MS, Morrison
cated orthopaedic trauma rooms have SM, Kim E, Wiklund RA, Smith RM,
studies. References 2, 3, 7, 8, 13, 14,
been reported.13 In their evaluation of Rubash HE: The value of the dedicated
16, and 17 are level III studies. orthopaedic trauma operating room.
dedicated trauma rooms, Wixted
Reference 1 is level V expert opinion. J Trauma. 2006;60(6):1336-41.
et al17 demonstrated that after-hour
cases decreased 44% and surgeon-to- References printed in bold type are 14. Bosma E, de Jongh MA, Verhofstad MH:
Operative treatment of patients with
surgeon handoffs increased 4.5 times those published within the past 5 pertrochanteric femoral fractures outside
more frequently. Further research will years. working hours is not associated with a
higher incidence of complications or higher
be needed to determine the effects of 1. Office of the Surgeon General: Bone health mortality. J Bone Joint Surg Br 2010;92(1):
postponing hip fracture care until a and osteoporosis: A report of the Surgeon 110-115.
General. Rockville, MD, Office of the US
dedicated traumatologist is available Surgeon General, 2004. 15. Garcia AE, Bonnaig JV, Yoneda ZT, et al:
compared with earlier fixation. Patient variables which may predict length
2. Bergeron E, Lavoie A, Moore L, et al: Is the of stay and hospital costs in elderly patients
delay to surgery for isolated hip fracture with hip fracture. J Orthop Trauma 2012;
predictive of outcome in efficient systems? 26(11):620-623.
Conclusion J Trauma 2006;60(4):753-757.
16. FitzGerald JD, Boscardin WJ, Hahn BH,
3. Majumdar SR, Beaupre LA, Johnston DW, Ettner SL: Impact of the Medicare Short
In our study, time of surgical inter-
Dick DA, Cinats JG, Jiang HX: Lack of Stay Transfer Policy on patients undergoing
vention had no statistically significant association between mortality and timing of major orthopedic surgery. Health Serv Res
difference with regard to blood loss, surgical fixation in elderly patients with hip 2007;42(1 Pt 1):25-44.
fracture: Results of a retrospective
LOS, length of surgery, in-hospital population-based cohort study. Med Care 17. Wixted JJ, Reed M, Eskander MS, et al: The
mortality, or 30-day readmission 2006;44(6):552-559. effect of an orthopedic trauma room on
after-hours surgery at a level one trauma
between day and night cohorts. 4. Moran CG, Wenn RT, Sikand M, Taylor center. J Orthop Trauma 2008;22(4):
In-hospital cost was 8.70% lower in AM: Early mortality after hip fracture: Is 234-236.

60 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Editorial
JAAOS: A Global Presence
William N. Levine, MD As I noted in an editorial last research section quickly
September marking the twenty- expanded into a monthly fea-
third anniversary of the Journal of ture. Response has been
the American Academy of Ortho- overwhelmingly positive. The
paedic Surgeons, the Yellow Jour- amount of submissions we
nal has become the gold standard receive continues to climb, and
for clinical review journals. More the number of papers we will
orthopaedic surgeons read JAAOS be publishing will continue to
than any other orthopaedic publi- grow.
cation.1 Our leadership position • Online Exclusive. The increase
results from the dedication of our you have seen in online content
editorial board and staff to pro- not only dovetails with the new
viding Academy members and emphasis on electronic pub-
Journal readers with the best clin- lishing, but it also allows us to
ical and academic content. present topical material more
The rapid growth of JAAOS quickly than our print schedule
during the past few years is a tes- typically permits. Thus, for
timony to this dedication. The example, we have been able to
availability of JAAOS on iPad, our publish review articles within 60
fully accredited CME offerings, the days of acceptance. And by
JAAOS Plus webinars, and the taking advantage of the “limit-
publish-ahead-of-print accessibility less” space available online
of upcoming content with the (compared with the space limi-
Advance Access feature on our tations of print publication), we
Website, among other new and can provide lengthy appendices
updated developments, have all and large tables to accompany
been welcome additions. online articles, as well as com-
Recently we have begun doing plementary instructive videos.
even more, expanding the Journal Please note that this option is
to provide original research and NOT associated with any
case reports and to offer our charges (for example the “Article
authors the advantages of both Processing Charge,” or APC).
Online Exclusive publication and • Open Access option. JAAOS is
Open Access publication. Now we now a hybrid journal. Authors
expand our international presence whose work is funded by
to provide authors and readers organizations that require
with the new Open Access title, Open Access (such as the
JAAOS Global Research and National Institutes of Health,
Reviews. We are staying in step Wellcome Trust, or Howard
with all of the dramatic changes Hughes Medical Institute) or
that the publishing industry—that who simply wish unrestricted,
every industry—is undergoing as a global online access of their
result of new technologies. research or review paper (while
Dr. Levine is Editor-in-Chief, Journal • Original Research. You have retaining copyright), may opt to
of the American Academy of
Orthopaedic Surgeons, Rosemont, IL. come to refer to the research publish in JAAOS as Open
section in each issue of JAAOS Access. “The Effect of Cervical
DOI: 10.5435/JAAOS-D-16-00880
as the “Green Journal.” Intro- Interbody Cage Morphology,
Copyright 2016 by the American duced in December 2015, the Material Composition, and Bone
Academy of Orthopaedic Surgeons.

January 2017, Vol 25, No 1 1

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
JAAOS: A Global Presence

Density on Subsidence Risk” by and Reviews places an emphasis this regard. Our pledge is to continue
Suh et al—available online now at on content originating outside the to work to earn your trust by using all
www.jaaos.org (see the Advanced United States and Canada and on of the tools available to us to maintain
Access tab)—is Open Access. This articles of particular interest to the excellence. This is particularly true in
option is associated with the international orthopaedic com- the growing arena of electronic pub-
Article Processing Charge (APC). munity. This option is also asso- lishing. JAAOS’s online presence will
• JAAOS Global Research & ciated with the Article Processing continue to grow and evolve, just as
Reviews—the Blue Journal—is Charge (APC). the Journal itself has evolved over the
the official Open Access, peer- The Academy’s mission—and the course of nearly a quarter century.
reviewed international journal Journal’s reason for being—is to The benefits are yours.
of the American Academy of provide the orthopaedic community
Orthopaedic Surgeons. Featuring with the highest level of educational
an editorial advisory board of service that we can. Your reaction to Reference
international physicians and edu- JAAOS and to all of our educational 1. Levine WN: Celebrating the yellow journal. J
cators, JAAOS Global Research offerings assures us of our success in Am Acad Orthop Surg 2016;24(9):589-590.

2 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article

Management of Acute Proximal


Humeral Fractures

Abstract
Vamsi Krishna Kancherla, MD Proximal humeral fractures, which typically occur in elderly persons,
Anshuman Singh, MD are among the most common fractures. A myriad of nonsurgical and
surgical treatment options exist for these injuries, including short-term
Oke A. Anakwenze, MD
immobilization and early physical therapy, percutaneous fixation,
plate osteosynthesis, intramedullary nailing, hemiarthroplasty, and
reverse shoulder arthroplasty. The choice of treatment depends on
the fracture type and severity, surgeon expertise, patient age, and
patient health status.

P roximal humeral fractures are


the third most common frac-
tures, following hip and distal
insert onto the greater tuberosity,
and the large subscapularis tendon
attaches to the lesser tuberosity.
radius fractures. They account for Innervation to the supraspinatus
approximately 5% of all fractures, and infraspinatus muscles occurs
and they are increasing in fre- through the suprascapular nerve,
quency.1 The elderly population whereas innervation to the sub-
has a higher incidence of proximal scapularis and teres minor muscles
humeral fractures and typically occurs through the subscapular and
sustains more complex fracture axillary nerves, respectively. These
patterns than those sustained by a muscles are not only responsible for
younger patient population.1 Given coronal and axial motion but also
the likelihood of poor bone quality serve as dynamic stabilizers of the
in this population, the surgeon glenohumeral joint. The deltoid
should maintain a high level of muscle is a large muscle innervated
From the Department of Orthopaedic
Surgery, St. Luke’s University Health
suspicion for fragility fracture by the axillary nerve that originates
Network, Bethlehem, PA associated with relatively minimal from the lateral clavicle, acromion,
(Dr. Kancherla) and the Department of trauma. and scapular spine and inserts on the
Orthopaedics, Kaiser Permanente,
San Diego, CA (Dr. Singh and deltoid tuberosity of the humerus. It
Dr. Anakwenze). Anatomy is composed of three heads separated
None of the following authors or any
by intramuscular raphae: the ante-
immediate family member has The proximal humerus is divided rior deltoid (responsible for forward
received anything of value from or has into four parts: the greater and lesser flexion and internal rotation), the
stock or stock options held in a
tuberosities, the head, and the middle deltoid (responsible for
commercial company or institution
related directly or indirectly to the diaphyseal region. Its articulation abduction), and the posterior deltoid
subject of this article: Dr. Kancherla, with the scapula produces a very (responsible for extension and
Dr. Singh, and Dr. Anakwenze. mobile glenohumeral joint, which is external rotation).
J Am Acad Orthop Surg 2017;25: supported by muscle groups about On average, the humeral head-neck
42-52 the shoulder girdle. The rotator cuff angle is 135°, and the humeral head
DOI: 10.5435/JAAOS-D-15-00240 muscle complex is made of four angle is 19° to 22° and is retroverted
muscles that attach to the tuberosi- in relation to the humeral shaft,
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. ties. The supraspinatus, infra- although some evidence would sug-
spinatus, and teres minor tendons gest a variability ranging from 26°

42 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Vamsi Krishna Kancherla, MD, et al

to 47°.2-5 The bicipital groove is Figure 1


between the greater and lesser
tuberosities. Immediately lateral to
this groove is the insertion of the
pectoralis major, which is innervated
by the lateral and medial pectoral
nerves and provides an internal
rotation and adduction force to the
proximal humerus. When these
muscles work together, they provide
wide degrees of motion in multiple
planes simultaneously. However, in
the setting of a proximal humeral
fracture, the muscles become de-
forming forces, translating the bony
attachments in the direction of the
respective muscle force vectors.
Historically, the ascending branch
of the anterior humeral circumflex
artery has been described as the
primary source of the vascular supply
to the humeral head.6 The high rate
of injury to this vessel and lower
rates of osteonecrosis associated
with proximal humeral fractures
emphasize the importance of the
vascular anastomoses about the
humeral head. A cadaver study
found that the posterior humeral
circumflex artery supplied blood to
64% of the humeral head, which
may explain the low rate of osteo-
necrosis after proximal humeral
fractures.7

Fracture Classification
Diagram showing the Neer classification of proximal humeral fractures.
The Neer classification is the most (Reproduced from Jones CB: Proximal humeral fractures, in Boyer MI, ed: AAOS
widely used system for classification Comprehensive Orthopaedic Review 2. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2014, pp 293-302).
of proximal humeral fractures.
Building on the 1934 Codman classi-
fication, which divided the proximal
humerus into the lesser tuberosity, the 0.52),9 this system commonly is used this classification, type A fractures are
greater tuberosity, the head, and the to classify proximal humeral frac- unifocal and extra-articular, involving
shaft, Neer expanded the classifica- tures. The addition of advanced one of the tuberosities without meta-
tion to include the concept of fracture imaging, such as CT, helps to physeal comminution. Type B frac-
displacement and angulation.8 A improve intraobserver and interob- tures are bifocal and extra-articular,
fracture was considered displaced in server reliability, although not sub- with metaphyseal and tuberosity
the setting of “an angulation of .45° stantially.9 These fractures also may involvement. Type C fractures are
or a separation of .1 cm”8 (Figure be classified according to the AO/ intra-articular and include fracture-
1). Despite poor interobserver reli- Orthopaedic Trauma Association dislocations or head-split fractures. As
ability (a mean kappa coefficient of classification system (Figure 2). In in the Neer classification, proximal

January 2017, Vol 25, No 1 43

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Acute Proximal Humeral Fractures

Figure 2 suggesting that osteosynthesis with


preservation of the humeral head is
worth considering in the setting of
adequate reduction and stable con-
ditions for revascularization.

Nonsurgical Management
Most proximal humeral fractures are
amenable to nonsurgical manage-
ment; however, patients must under-
stand the expectations and comply
with the treatment program. In gen-
eral, excellent results have been
achieved with short-term immobi-
lization (,2 weeks) in a sling and
early physical therapy.12-15 Most of
the literature supports early mobili-
zation, but it is important to ensure
that further fracture displacement
does not occur.
Nonsurgical treatment of two-part
fractures with early rehabilitation has
been found to be at least as efficacious
as surgical treatment in injuries
with minimal displacement.16,17 In
the setting of considerable displace-
ment, a block to range of motion, and
involvement of the anatomic neck,
better outcomes may be achieved
with surgical fixation, although
well-designed comparative studies of
surgical versus nonsurgical manage-
ment of two-part fractures are lack-
ing (Figure 3). Some authors have
found that greater tuberosity fractures
with .5 mm of displacement may
Illustrations depicting the AO/Orthopaedic Trauma Association classification of benefit from surgical fixation to reduce
proximal humeral fractures. (Reproduced from Cadet ER, Ahmad CS: the risk of subacromial impinge-
Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad ment.14,18 Lesser tuberosity fracture
Orthop Surg 2012;20[1]:17–27.) with internal rotation impingement
also has been reported and may benefit
humeral fractures carry the risk of ischemia after proximal humeral from surgery if nonsurgical manage-
osteonecrosis; type C fractures, in fracture. The study found that met- ment fails.19 In contrast to other parts
particular, present a substantial risk aphyseal head extension of ,8 mm of the proximal humerus, the anatomic
of osteonecrosis. and medial hinge disruption .2 mm neck is devoid of soft-tissue attach-
Hertel et al10 noted the importance correlated strongly with humeral ments and has a tenuous blood supply,
of the metaphyseal head extension— head ischemia. Despite these find- which may result in an increased risk
a radiographic measurement of the ings, Bastian and Hertel11 later of osteonecrosis.
articular fragment from the head- found that initial postfracture Although three-part and four-part
neck junction to the inferior extent of humeral head ischemia does not fractures often require surgical fixa-
the medial cortex—as a predictor of predict the development of necrosis, tion, nonsurgical management can be

44 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Vamsi Krishna Kancherla, MD, et al

considered for patients with poor Figure 3


baseline function and/or an inability
to tolerate a surgical intervention. In
select three-part and four-part frac-
tures, particularly valgus-impacted
fractures with ,1 cm of displace-
ment of the tuberosities in relation to
the head fragment, nonsurgical
treatment may yield good to excel-
lent results.20 Although surgical
management of complex fracture
patterns generally is advocated, the
efficacy of surgical versus non-
surgical management remains to be
elucidated fully. In a study of 60
elderly patients with a displaced
three-part fracture of the proximal
humerus, Olerud et al21 found that
surgical management with a locking
plate resulted in better functional
outcomes and health-related quality Treatment algorithm demonstrating the surgical options for management of
of life than did nonsurgical treat- proximal humeral fractures. CRPP = closed reduction and percutaneous pinning,
IMN = intramedullary nailing, ORIF = open reduction and internal fixation,
ment, but at a cost of additional PHFx = proximal humeral fracture, RSA = reverse shoulder arthroplasty.
surgery in 30% of patients. In con-
trast, a meta-analysis of randomized
controlled trials did not find improved and frequently need to be ad- 4). For CRPP to be successful, stable
functional outcomes with open dressed surgically. Internal fixa- and satisfactory closed reduction
reduction and internal fixation (ORIF) tion and arthroplasty are the most must be achieved, adequate bone
compared with nonsurgical treatment commonly employed strategies stock with minimal comminution
in elderly patients with displaced three- to manage complex fractures of and an intact medial calcar should be
part or four-part proximal humeral the proximal humerus. In select present, and the patient must comply
fractures.22 The study concluded that patients, percutaneous fixation with postoperative immobilization
these results must be considered in the remains a feasible option in the and management.24
context of variable patient demo- surgeon’s armamentarium. Biomechanical studies have found
graphics. A systematic review sup- CRPP to be inferior to ORIF,
ported the use of nonsurgical although stability can be enhanced
treatment of proximal humeral frac- Percutaneous Fixation with the use of larger diameter pins,
tures and noted a 2% rate of osteo- Closed reduction and percutaneous multiple pins, and cortically engag-
necrosis mainly associated with three- pinning (CRPP) of proximal humeral ing pins placed in a multiplanar
part and four-part fractures, high rates fractures was initially described by configuration.24 Historically, clini-
of radiographic union, and modest Bohler in 1962 and, in some reports, cal studies have found the outcomes
complication rates.23 Ultimately, the has been purported to be superior to of CRPP to be satisfactory;24,25
patient’s baseline physiology and open techniques, with higher union however, in a comparative study of
function may help to quantify the rates, lower rates of osteonecrosis, the outcomes of CRPP, ORIF,
potential advantages of nonsurgical decreased scar formation, and hemiarthroplasty (HA), and reverse
management, even in the setting of improved cosmesis.24 Classic surgi- shoulder arthroplasty (RSA) for
complex fracture patterns. cal indications have included two- management of three- and four-part
part fractures of the surgical neck, proximal humeral fractures, Gupta
greater tuberosity, and lesser tuber- et al1 found that the complication rate
Surgical Management osity; three-part surgical neck frac- associated with CRPP was consider-
tures with involvement of the greater ably higher than those associated
Complex proximal humeral frac- or lesser tuberosity; and valgus- with ORIF, hemiarthroplasty (HA),
tures are challenging to manage impacted four-part fractures (Figure and reverse shoulder arthroplasty

January 2017, Vol 25, No 1 45

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Acute Proximal Humeral Fractures

Figure 4 neurologic injury affecting the axil-


lary and radial nerves laterally and
the musculocutaneous nerve anteri-
orly, soft-tissue injury to the cephalic
vein and biceps tendon anteriorly,
and osteonecrosis (28%), although
the risk of osteonecrosis can depend
largely on the initial fracture
pattern.1,24,25

Plate Osteosynthesis
The advent of fixed-angle locking
plates has revolutionized the man-
agement of proximal humeral frac-
tures because the locking screw
technology allows more secure fix-
ation in comminuted and/or osteo-
porotic bone. Plate fixation is an
excellent choice for management of
substantially displaced two-part
fractures that require surgery and
for three-part fractures without
considerable comminution (Figure
6). Four-part fracture fixation may
AP radiograph (A) and axial (B) and sagittal (C) three-dimensional CT be attempted with a locking plate
reconstructions of the proximal humerus demonstrate a two-part surgical neck construct but may be more chal-
fracture.
lenging, with less predictable
results. We believe that, in active
(RSA). The overall complication rate humeral head to the most inferior patients aged ,65 years with
was highest for CRPP (28.4%), fol- margin of the articular cartilage. acceptable bone stock and minimal
lowed by RSA (18.9%), ORIF Tuberosity fixation can be achieved comminution, internal fixation
(15%), and HA (11.3%). The revi- with pins or with 3.5-mm, 4.0-mm, should be attempted or should be
sion rate for CRPP, excluding neces- or 4.5-mm cannulated screws in- considered strongly. Although low
sary surgery performed for implant serted anterograde from the tuber- bone mineral density may not be
removal, was 1% and involved revi- osity bicortically into the calcar for predictive of mechanical failure,26
sion to RSA. Revision rates for ORIF, the greater tuberosity or unicorti- fracture collapse into varus is a risk
RSA, and HA were 12.7%, 5%, and cally into the head for the lesser after plate fixation; this can
4.9%, respectively. tuberosity.25 Medial calcar fixation be minimized in the setting of a
CRPP techniques vary but have should be performed at least 2 cm noncomminuted medial calcar and
some similar principles. Typically, distal to the articular surface good calcar screw fixation. Care
the humeral head and shaft are fixed to minimize injury to the neuro- should be taken when plate osteo-
first using terminally threaded 2.5- vascular bundle, including the axil- synthesis is performed; proud plate
mm Schanz pins placed in a retro- lary nerve and the posterior humeral fixation may lead to impingement
grade, lateral-to-medial direction, circumflex artery. Pins and screws against the acromion with abduction,
accounting for humeral head retro- are buried underneath the skin, the and a plate that is placed too low
version in a safe zone proximal to the arm is immobilized for 3 to 4 weeks, risks poor humeral head fixation.
deltoid insertion to avoid the radial and the pins are removed in 4 to 6 Compared with HA, locked plate
nerve and distal to the course of the weeks.24,25 fixation has been shown to provide
axillary nerve, approximately 5 cm Complications associated with better functional outcomes and a
distal to the acromion (Figure 5). The CRPP include malunion (28%), pin higher rate of patient satisfaction.
ideal starting point is typically twice migration or loosening in up to one Solberg et al27 compared the results
the distance from the top of the third of patients, pin-track infection, of HA and locked plate fixation for

46 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Vamsi Krishna Kancherla, MD, et al

Figure 5

AP (A) and axillary (B) fluoroscopic images of a shoulder demonstrating intraoperative closed reduction and percutaneous
pin fixation for a proximal humeral fracture. AP (C) and lateral (D) radiographs of the same shoulder at 1 year
postoperatively.

Figure 6

A, AP radiograph of the shoulder demonstrating a three-part proximal humeral fracture-dislocation. B, Coronal CT showing
the three-part proximal humeral fracture post-reduction. C, Intraoperative AP fluoroscopic image of the shoulder. D,
Postoperative AP radiograph demonstrating the shoulder at 11.5 weeks postoperatively.

management of three-part and four- fixation than with HA, and the most rate was 14.5%. The revision rate
part fractures in a consecutive group common complications are osteo- was 13.7%. Therefore, the surgeon
of 48 patients treated with HA and necrosis and screw cutout. Solberg must be aware of the potential
38 patients treated with locked plate et al27 also found that initial varus complications associated with man-
fixation. At a mean follow-up of 36 fracture displacement in a group of agement of these unstable fracture
months, the authors noted higher patients treated with plate fixation patterns; the use of longer screws as
Constant scores in the patients who was associated with lower Constant well as strut grafting should be
underwent ORIF. Poorer results scores, loss of fixation, head perfo- considered in patients with osteo-
were noted in patients with four-part ration, varus malreduction, and porotic bone who lack a sufficient
fractures than in those with three- tuberosity displacement .5 mm. medial calcar.29 Hinds et al30 found
part fractures. A loss of fixation was Osteonecrosis of the humeral head that the clinical outcomes of locked
more common in fractures with ini- associated with a head metaphyseal plating with endosteal fibular strut
tial varus and extension deformities; segment of ,2 mm was noted, as allograft augmentation in patients
patients with these fractures had well.27 In a systematic review of aged .65 years were comparable to
worse outcomes than did those with locking plate fixation, Thanasas those in younger patients (mean age,
valgus impaction fractures. et al28 reported a 7.9% rate of os- 53 years). The authors noted that the
Despite better outcomes, the com- teonecrosis overall; however, in enhanced stability provided by this
plication rate can be higher with patients with four-part fractures, the fixation construct allowed early

January 2017, Vol 25, No 1 47

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Acute Proximal Humeral Fractures

Figure 7 ure in a study of various fixation


options for two-part proximal
humeral fractures and found that IM
nailing with a fixed angle blade was
superior to IM nailing with locking
screws, a 3.5-mm fixed angle plate,
and a 4.5-mm fixed angle plate.
Modern IM nail fixation of proxi-
mal humeral fractures has yielded
favorable results, including high un-
ion rates, low complication rates, and
favorable subjective outcomes.25 In a
retrospective review of 48 patients
with two-part surgical neck fractures
treated with an angular, stable,
locked IM nail, Hatzidakis et al32
A, Preoperative AP radiograph showing a proximal humeral fracture. reported reliable fracture healing, a
Postoperative AP (B) and lateral (C) radiographs of the shoulder following mean Constant score of 71, mean
anterograde intramedullary nail fixation. forward flexion of 132°, and little
residual shoulder pain after
12-month follow-up. In studies of
intensive postoperative therapy and two-part surgical neck fractures, two-part, three-part, and four-part
resulted in excellent outcomes young age, concomitant humeral fractures, other authors found no
regardless of patient age. In this shaft fracture, and impending path- marked objective or subjective dif-
series of 71 adults, osteonecrosis ologic fractures (Figure 7). Improve- ferences between locking plate and
occurred .3 years postoperatively in ments in nail design and surgical IM nail fixation.31,33-35 However,
one elderly patient (1%). technique have led to a resurgence in Zhu et al35 studied two-part frac-
the use of anterograde rigid IM nail tures with a 3-year minimum follow-
fixation for select three-part and up period and reported an overall
Intramedullary Nail Fixation four-part fractures.31 complication rate of 4% and 31%
Although challenging and controver- Modern humeral nails are straight for IM nailing and locking plate
sial because of historical reports of instead of curvilinear, allow the use fixation, respectively. The IM nailing
complications, intramedullary (IM) of multiplanar locking screws, and group had a significantly lower
nail fixation for proximal humeral can be inserted from a more medial complication rate than did the
fractures has become more popular in starting point near the articular locking plate group (P = 0.024).
recent years, with some reports of margin such that injury to the rotator Despite these findings, we do not use
success. Postoperative problems, such cuff tendon attachment site IM nail fixation for acute non-
as nonunion, malunion, rod migra- is minimized.25,36 Most nail inser- pathologic proximal humeral frac-
tion in older patients, shoulder pain tion is performed anterograde with a tures at this time.
caused by rotator cuff violation, and rigid locked construct; however,
nerve injury caused by interlocking some reports support the use of
screw insertion, must be balanced retrograde flexible unlocked im- Hemiarthroplasty
against a small incision, closed plants despite their reduced axial Historically, HA was the treatment of
reduction, and excellent nail-bone and rotational stability.25 choice for complex proximal humeral
purchase in osteoporotic bone.25 A biomechanical study of two-part fractures and has been studied exten-
More research is needed, but some fractures treated with IM nailing sively. It is a technically challenging
recent clinical studies have found versus locking plates demonstrated procedure with mixed results. The
locked rigid IM nail fixation to be higher failure rates in torsion with IM presence of a functioning rotator cuff
equivalent to locked plate fixation for nailing than with locking plates, and healed, anatomically reduced
two-part, three-part, and even four- which suggests that early motion and tuberosities are essential for satisfac-
part proximal humeral fractures.31-35 osteoporotic bone could predispose tory outcomes. A thorough pre-
The indications for IM nailing of to poor results.37 Yoon et al38 operative history and intraoperative
proximal humeral fractures include examined stiffness and load to fail- assessment can alert the surgeon to

48 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Vamsi Krishna Kancherla, MD, et al

Figure 8

Preoperative AP (A) and axillary (B) radiographs of the shoulder demonstrating a four-part fracture in a 63-year-old man.
Postoperative AP (C) and external rotation (D) radiographs showing the same shoulder after hemiarthroplasty with
tuberosity repair.

rotator cuff pathology. Tuberosity may be added to enhance healing and arthropathy and pseudoparalysis.43
malalignment has been noted to be a fill in any defects (Figure 8). The function of the reverse shoulder
major source of failure following HA for fracture management may prosthesis is based on traditional
humeral replacement for proximal have a high complication rate, with Grammont principles of medializing
humeral fractures.39 Other important functional gains that can be less than the glenohumeral center of rotation
parameters include humeral head satisfactory. In a retrospective review and lowering the humerus. This
height and version. The humeral head of 66 patients who underwent shoul- gives the deltoid muscle a mechanical
level should re-create that of the der HA for fracture, Boileau et al39 advantage by increasing its lever
anatomic head. In a cadaver study, noted that 42% of the patients were arm, obviating the need for the
the authors estimated an average unsatisfied with their final outcome. rotator cuff, and providing low shear
distance of 5.6 cm between the top of At final follow-up, the incidence of forces about the glenoid. The
the humeral head and the upper tuberosity malposition was 50%. The increased use and popularity of RSA
border of the pectoralis major muscle average forward flexion and external brought a corresponding rise in the
insertion.40 This distance also may be rotation was 101° and 18°, respec- number of complications, including
assessed by visually ensuring that tively. In a systematic review of 810 scapular notching (44% to 96%),
the head sits on the well-reduced HAs performed for treatment of acute glenoid loosening (5% to 38%),
tuberosities. Humeral lengthening fractures, Kontakis et al41 noted instability (2% to 31%), and infec-
.10 mm causes excessive tension of similarly poor forward flexion tion (1% to 15%).44 The longevity
the supraspinatus muscle and places (105.7°). The average postoperative of RSA implants in patients with
the tuberosities at risk of detach- Constant score in 560 patients was arthropathy or fracture has not yet
ment.39 The natural humeral head 56.6. A recent randomized study been elucidated fully. A recent study
retroversion ranges from 19° to 22°, comparing HA with nonsurgical noted that 91% of the implants were
with some variability.2,3,5 The sur- treatment of four-part fractures found viable 10 years after implantation,
geon should be cognizant of this no substantial difference in out- but a decline in function was noted at
range and should aim to reproduce comes.42 Such results underscore the the 6-year mark.45
similar version when performing HA. importance of performing HA after The indications for RSA have been
Failure to do so may put the tuber- careful preoperative planning and expanded to include acute fractures,
osity repair under undue tension and with meticulous surgical technique. the sequelae of fractures (eg, mal-
may put the prosthesis at risk for union, nonunion), and revision of
instability. Adequate fixation of the failed fixation or humeral replacement.
tuberosities requires secure fixation Reverse Shoulder RSA is an attractive option for patients
of the tuberosities to each other, to Arthroplasty older than 65 years with three-part or
the prosthesis, and to the humeral The initial indications for RSA (as a four-part fractures and comminuted
shaft through drill tunnels. Bone graft salvage option) were rotator cuff tuberosities, and the procedure may

January 2017, Vol 25, No 1 49

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Acute Proximal Humeral Fractures

Figure 9

A, AP radiograph of the shoulder demonstrating a four-part complex fracture in a 68-year-old man with poor bone quality. B,
Axial CT showing a fracture line through the lesser tuberosity. Postoperative AP (C) and external rotation (D) radiographs of
the shoulder after reverse shoulder arthroplasty.

provide more predictable results than abduction, forward flexion, and Several patient factors and techni-
those provided by standard anatomic Constant scores. However, the cal factors are necessary for
HA in select patients. patients who underwent HA had successful management of complex
The effectiveness of HA versus better external rotation than did proximal humeral fractures with
RSA has yet to be determined fully. those who underwent RSA (13.5° RSA. Proper function of the deltoid
Young et al46 retrospectively com- versus 9°).47 The authors claim that muscle is required for RSA. Guide-
pared the outcomes of 10 patients RSA provides more predictable lines for surgical management of
who underwent RSA with those of function; however, the Constant these fractures in the setting of axil-
10 patients who underwent HA for scores of the RSA group were lary nerve palsy are lacking, but RSA
similar proximal humeral fracture comparable to those of the HA can be performed in the setting of
patterns (two three-part fractures group.48 A blinded, randomized neurapraxia provided that some del-
and eight four-part fractures in each prospective study substantiated toid tone is noted on examination. A
group). The greater tuberosity was some of these findings, reporting complete palsy may allow the use of
fixed to the implant in 9 of 10 RSAs. better pain and function and a lower only ORIF, HA, and/or arthrodesis,
At an average follow-up of 22 to 44 revision rate for RSA than for HA.49 however. We recommend the use of
months, the authors noted similar Multiple recent systematic reviews CT imaging in addition to radiogra-
forward flexion, external rotation, have reported equivalent clinical phy when assessing these fractures.
American Shoulder and Elbow scores and a lower revision rate Adequate glenoid bone stock is
Surgeons Shoulder scores, and associated with RSA, as well as required to allow implantation of the
Oxford scores in both groups. improved external rotation with base plate. Bone loss about the
Despite similar results, the authors tuberosity repair.50,51 In a systematic humerus should be noted, and plans
noted at the last follow-up visit that, review of 92 studies with a total of should be made to restore humeral
on radiography, the humeral heads 4,500 patients, Gupta et al1 observed length with an implant or graft
were not centered in five patients that ORIF led to better clinical out- material to ensure that the deltoid
treated with HA. Gallinet et al47 comes than those of RSA but was muscle is tensioned properly. If
retrospectively compared the results associated with considerably higher proximal bone loss is severe, imaging
of 17 patients who underwent HA revision rates. HA and RSA were of the contralateral humerus may be
with those of 16 patients who equivalent with regard to clinical performed to replicate the length of
underwent RSA for three- or four- scores, although tuberosity healing the humerus on the surgical shoulder.
part proximal humeral fracture. At after HA was noted to be 15.4%. As with HA, tuberosity repair is
a mean short-term follow-up (16.5 Uzer et al52 found that tuberosity recommended to improve rotation,
months and 12.4 months in the HA union rates following RSA with tension, and stability (Figure 9).
and RSA groups, respectively), the autologous grafting improved from Substantial bone loss and detach-
outcomes were substantially better 40% (not grafted) to 77.8% (graf- ment of the tuberosity and soft-tissue
in the RSA group than in the HA ted), with associated improvements attachments may predispose the
group. These patients had better in functional outcomes. implant to dislocation.44,46,50

50 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Vamsi Krishna Kancherla, MD, et al

We typically perform HA in 2. Boileau P, Bicknell RT, Mazzoleni N, 14. Platzer P, Kutscha-Lissberg F, Lehr S,
Walch G, Urien JP: CT scan method Vecsei V, Gaebler C: The influence of
active patients aged 40 to 65 years accurately assesses humeral head displacement on shoulder function in
with complex four-part fractures retroversion. Clin Orthop Relat Res 2008; patients with minimally displaced fractures
or head split patterns that are 466(3):661-669. of the greater tuberosity. Injury 2005;36
(10):1185-1189.
likely to have complications with 3. Johnson JW, Thostenson JD, Suva LJ,
Hasan SA: Relationship of bicipital groove 15. Tejwani NC, Liporace F, Walsh M,
plate osteosynthesis. A stem that is
rotation with humeral head retroversion: A France MA, Zuckerman JD, Egol KA:
convertible to an RSA without three-dimensional computed tomographic Functional outcome following one-part
extraction can be advantageous analysis. J Bone Joint Surg Am 2013;95(8): proximal humeral fractures: A
719-724. prospective study. J Shoulder Elbow
and should be considered if the Surg 2008;17(2):216-219.
surgeon is familiar and comfortable 4. Matsumura N, Ogawa K, Kobayashi S,
et al: Morphologic features of humeral head 16. Court-Brown CM, McQueen MM: Two-
with the design. and glenoid version in the normal part fractures and fracture dislocations.
glenohumeral joint. J Shoulder Elbow Surg Hand Clin 2007;23(4):397-414, v.
2014;23(11):1724-1730.
17. Hodgson SA, Mawson SJ, Saxton JM,
Summary Stanley D: Rehabilitation of two-part
5. Robertson DD, Yuan J, Bigliani LU, Flatow
EL, Yamaguchi K: Three-dimensional fractures of the neck of the humerus (two-
Management of proximal humeral analysis of the proximal part of the year follow-up). J Shoulder Elbow Surg
humerus: Relevance to arthroplasty. J Bone 2007;16(2):143-145.
fractures can be challenging, and the
Joint Surg Am 2000;82-A(11):1594-1602.
treatment choice is not always obvi- 18. Park TS, Choi IY, Kim YH, Park MR, Shon
6. Gerber C, Schneeberger AG, Vinh TS: The JH, Kim SI: A new suggestion for the
ous. Most of these fractures can be treatment of minimally displaced fractures
arterial vascularization of the humeral
treated nonsurgically with short-term head: An anatomical study. J Bone Joint of the greater tuberosity of the proximal
immobilization and early physical Surg Am 1990;72(10):1486-1494. humerus. Bull Hosp Jt Dis 1997;56(3):
171-176.
therapy. Most complex fractures or 7. Hettrich CM, Boraiah S, Dyke JP, Neviaser A,
fractures that fail nonsurgical treat- Helfet DL, Lorich DG: Quantitative 19. Neer CS II, Craig EV, Fukuda H: Cuff-tear
assessment of the vascularity of the proximal arthropathy. J Bone Joint Surg Am 1983;65
ment can be managed with a variety part of the humerus. J Bone Joint Surg Am (9):1232-1244.
of surgical options. Surgical experi- 2010;92(4):943-948. 20. Court-Brown CM, Cattermole H,
ence and evidence-based literature 8. Maier D, Jaeger M, Izadpanah K, Strohm McQueen MM: Impacted valgus fractures
can help to guide the surgeon in the PC, Suedkamp NP: Proximal humeral (B1.1) of the proximal humerus: The results
fracture treatment in adults. J Bone Joint of non-operative treatment. J Bone Joint
selection of a surgical option. Com- Surg Br 2002;84(4):504-508.
Surg Am 2014;96(3):251-261.
plex three-part and four-part frac-
21. Olerud P, Ahrengart L, Ponzer S, Saving J,
tures may be managed best by 9. Bernstein J, Adler LM, Blank JE, Dalsey
Tidermark J: Internal fixation versus
RM, Williams GR, Iannotti JP: Evaluation
surgeons who have training in of the Neer system of classification of
nonoperative treatment of displaced
3-part proximal humeral fractures in
shoulder arthroplasty to allow intra- proximal humeral fractures with
elderly patients: A randomized
computerized tomographic scans and plain
operative flexibility as needed. RSA is controlled trial. J Shoulder Elbow Surg
radiographs. J Bone Joint Surg Am 1996;78
a relatively new addition to the 2011;20(5):747-755.
(9):1371-1375.
treatment algorithm and may provide 22. Li Y, Zhao L, Zhu L, Li J, Chen A: Internal
10. Hertel R, Hempfing A, Stiehler M, Leunig M:
more predictable results than those fixation versus nonoperative treatment for
Predictors of humeral head ischemia after
displaced 3-part or 4-part proximal
derived from HA and osteosynthesis intracapsular fracture of the proximal
humeral fractures in elderly patients: A
humerus. J Shoulder Elbow Surg 2004;13(4):
in elderly patients with complex 427-433.
meta-analysis of randomized controlled
trials. PLoS One 2013;8(9):e75464.
fracture patterns. However, all
11. Bastian JD, Hertel R: Initial post-fracture
patients must be counseled pre- humeral head ischemia does not predict
23. Iyengar JJ, Devcic Z, Sproul RC, Feeley BT:
Nonoperative treatment of proximal
operatively about permanent func- development of necrosis. J Shoulder Elbow
humerus fractures: A systematic review. J
tional limitations, even in the absence Surg 2008;17(1):2-8.
Orthop Trauma 2011;25(10):612-617.
of pain. 12. Calvo E, Morcillo D, Foruria AM, 24. Magovern B, Ramsey ML: Percutaneous
Redondo-Santamaría E, Osorio-Picorne F, fixation of proximal humerus fractures.
Caeiro JR; GEIOS-SECOT Outpatient Orthop Clin North Am 2008;39(4):
Osteoporotic Fracture Study Group:
References Nondisplaced proximal humeral fractures:
405-416, v.
High incidence among outpatient-treated 25. Aaron D, Shatsky J, Paredes JC, Jiang C,
References printed in bold type are osteoporotic fractures and severe impact on Parsons BO, Flatow EL: Proximal humeral
upper extremity function and patient fractures: Internal fixation. Instr Course
those published within the past 5 subjective health perception. J Shoulder Lect 2013;62:143-154.
years. Elbow Surg 2011;20(5):795-801.
26. Kralinger F, Blauth M, Goldhahn J, et al:
1. Gupta AK, Harris JD, Erickson BJ, et al: 13. Hanson B, Neidenbach P, de Boer P, Stengel The influence of local bone density on the
Surgical management of complex proximal D: Functional outcomes after nonoperative outcome of one hundred and fifty proximal
humerus fractures: A systematic review of management of fractures of the proximal humeral fractures treated with a locking
92 studies including 4500 patients. J humerus. J Shoulder Elbow Surg 2009;18 plate. J Bone Joint Surg Am 2014;96(12):
Orthop Trauma 2015;29(1):54-59. (4):612-621. 1026-1032.

January 2017, Vol 25, No 1 51

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Acute Proximal Humeral Fractures

27. Solberg BD, Moon CN, Franco DP, a minimum of three years of follow-up. J 44. Cheung E, Willis M, Walker M, Clark R,
Paiement GD: Locked plating of 3- and 4- Bone Joint Surg Am 2011;93(2):159-168. Frankle MA: Complications in reverse total
part proximal humerus fractures in older shoulder arthroplasty. J Am Acad Orthop
patients: The effect of initial fracture 36. Lopiz Y, Garcia-Coiradas J, Garcia- Surg 2011;19(7):439-449.
pattern on outcome. J Orthop Trauma Fernandez C, Marco F: Proximal
2009;23(2):113-119. humerus nailing: A randomized clinical 45. Guery J, Favard L, Sirveaux F, Oudet D,
trial between curvilinear and straight Mole D, Walch G: Reverse total shoulder
28. Thanasas C, Kontakis G, Angoules A, Limb D, nails. J Shoulder Elbow Surg 2014;23 arthroplasty: Survivorship analysis of
Giannoudis P: Treatment of proximal (3):369-376. eighty replacements followed for five to ten
humerus fractures with locking plates: A years. J Bone Joint Surg Am 2006;88(8):
systematic review. J Shoulder Elbow Surg 37. Edwards SL, Wilson NA, Zhang LQ, Flores 1742-1747.
2009;18(6):837-844. S, Merk BR: Two-part surgical neck
fractures of the proximal part of the 46. Young SW, Segal BS, Turner PC, Poon PC:
29. Matassi F, Angeloni R, Carulli C, et al: humerus: A biomechanical evaluation of Comparison of functional outcomes of
Locking plate and fibular allograft two fixation techniques. J Bone Joint Surg reverse shoulder arthroplasty versus
augmentation in unstable fractures of Am 2006;88(10):2258-2264. hemiarthroplasty in the primary treatment
proximal humerus. Injury 2012;43(11): of acute proximal humerus fracture. ANZ J
1939-1942. 38. Yoon RS, Dziadosz D, Porter DA, Frank MA, Surg 2010;80(11):789-793.
Smith WR, Liporace FA: A comprehensive
30. Hinds RM, Garner MR, Tran WH, update on current fixation options for 47. Gallinet D, Clappaz P, Garbuio P, Tropet Y,
Lazaro LE, Dines JS, Lorich DG: Geriatric two-part proximal humerus fractures: A Obert L: Three or four parts complex
proximal humeral fracture patients show biomechanical investigation. Injury 2014;45 proximal humerus fractures:
similar clinical outcomes to non-geriatric (3):510-514. Hemiarthroplasty versus reverse prosthesis.
patients after osteosynthesis with endosteal A comparative study of 40 cases. Orthop
fibular strut allograft augmentation. J 39. Boileau P, Krishnan SG, Tinsi L, Walch G, Traumatol Surg Res 2009;95(1):48-55.
Shoulder Elbow Surg 2015;24(6):889-896. Coste JS, Molé D: Tuberosity malposition
and migration: Reasons for poor outcomes 48. Namdari S, Horneff JG, Baldwin K:
31. Gradl G, Dietze A, Kääb M, Hopfenmüller W, after hemiarthroplasty for displaced Comparison of hemiarthroplasty and
Mittlmeier T: Is locking nailing of humeral fractures of the proximal humerus. J reverse arthroplasty for treatment of
head fractures superior to locking plate Shoulder Elbow Surg 2002;11(5):401-412. proximal humeral fractures: A systematic
fixation? Clin Orthop Relat Res 2009;467 review. J Bone Joint Surg Am 2013;95(18):
(11):2986-2993. 40. Murachovsky J, Ikemoto RY, Nascimento LG, 1701-1708.
Fujiki EN, Milani C, Warner JJ: Pectoralis
32. Hatzidakis AM, Shevlin MJ, Fenton DL, major tendon reference (PMT): A new 49. Sebastiá-Forcada E, Cebrián-Gómez R,
Curran-Everett D, Nowinski RJ, Fehringer method for accurate restoration of Lizaur-Utrilla A, Gil-Guillén V: Reverse
EV: Angular-stable locked intramedullary humeral length with hemiarthroplasty for shoulder arthroplasty versus
nailing of two-part surgical neck fractures fracture. J Shoulder Elbow Surg 2006;15 hemiarthroplasty for acute proximal
of the proximal part of the humerus: A (6):675-678. humeral fractures: A blinded, randomized,
multicenter retrospective observational controlled, prospective study. J Shoulder
study. J Bone Joint Surg Am 2011;93(23): 41. Kontakis G, Koutras C, Tosounidis T, Elbow Surg 2014;23(10):1419-1426.
2172-2179. Giannoudis P: Early management of
proximal humeral fractures with 50. Anakwenze OA, Zoller S, Ahmad CS,
33. Konrad G, Audigé L, Lambert S, Hertel R, hemiarthroplasty: A systematic review. J Levine WN: Reverse shoulder arthroplasty
Südkamp NP: Similar outcomes for nail Bone Joint Surg Br 2008;90(11): for acute proximal humerus fractures: A
versus plate fixation of three-part proximal 1407-1413. systematic review. J Shoulder Elbow Surg
humeral fractures. Clin Orthop Relat Res 2014;23(4):e73-e80.
2012;470(2):602-609. 42. Boons HW, Goosen JH, van Grinsven S,
van Susante JL, van Loon CJ: 51. Ferrel JR, Trinh TQ, Fischer RA: Reverse
34. Lekic N, Montero NM, Takemoto RC, Hemiarthroplasty for humeral four-part total shoulder arthroplasty versus
Davidovitch RI, Egol KA: Treatment of fractures for patients 65 years and older: hemiarthroplasty for proximal humeral
two-part proximal humerus fractures: A randomized controlled trial. Clin fractures: A systematic review. J Orthop
Intramedullary nail compared to locked Orthop Relat Res 2012;470(12): Trauma 2015;29(1):60-68.
plating. HSS J 2012;8(2):86-91. 3483-3491.
52. Uzer G, Yildiz F, Batar S, et al: Does
35. Zhu Y, Lu Y, Shen J, Zhang J, Jiang C: 43. Lawrence TM, Ahmadi S, Sanchez-Sotelo J, grafting of the tuberosities improve the
Locking intramedullary nails and locking Sperling JW, Cofield RH: Patient reported functional outcomes of proximal humeral
plates in the treatment of two-part proximal activities after reverse shoulder fractures treated with reverse shoulder
humeral surgical neck fractures: A arthroplasty: Part II. J Shoulder Elbow Surg arthroplasty? J Shoulder Elbow Surg 2016;
prospective randomized trial with 2012;21(11):1464-1469. pii: S1058-2746(16)30146-X.

52 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
AAOS Appropriate Use Criteria Summary

Postoperative Rehabilitation of Low


Energy Hip Fractures in the Elderly

Abstract
Robert H. Quinn, MD Evidence-based information, in conjunction with the clinical
Pekka A. Mooar, MD expertise of physicians, was used to develop the Appropriate Use
Criteria (AUC) document Postoperative Rehabilitation of Low
Jayson N. Murray, MA
Energy Hip Fractures in the Elderly to improve patient care and
Ryan Pezold, MA obtain the best outcomes while considering the subtleties and
Kaitlyn S. Sevarino, MBA distinctions necessary in making clinical decisions. The AUC
clinical patient scenarios were derived from patient indications
that typically accompany hip fractures, as well as from current
evidence-based clinical practice guidelines and supporting
From the University of Texas Health literature. The 72 patient scenarios and 10 treatments were
Science Center, San Antonio, TX
(Dr. Quinn), the Temple University developed by the Writing Panel, a group of clinicians who are
Health System, Philadelphia, PA specialists in this AUC topic. A separate, multidisciplinary Voting
(Dr. Mooar), and the American Panel made up of specialists and nonspecialists rated the
Academy of Orthopaedic Surgeons,
Rosemont, IL (Mr. Murray, Mr. Pezold, appropriateness of treatment of each patient scenario using a
and Ms. Sevarino). 9-point scale to designate a treatment as Appropriate (median
Dr. Quinn or an immediate family rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or
member has received research or Rarely Appropriate (median rating, 1 to 3).
institutional support from the
Musculoskeletal Transplant
Foundation and serves as a board
member, owner, officer, or committee Musculoskeletal care is provided
member of the American Academy of Overview and Rationale in many settings by different pro-
Orthopaedic Surgeons, the American
Orthopaedic Association, the
This Appropriate Use Criteria (AUC) viders. The AAOS created this AUC
Musculoskeletal Tumor Society, and as an educational tool to guide
the Wilderness Medical Society. for Postoperative Rehabilitation of
Dr. Mooar or an immediate family Low Energy Hip Fractures in the qualified physicians through a
member is a member of a speakers’ Elderly was approved by the series of preventive decisions in an
bureau or has made paid
American Academy of Orthopae- effort to improve the quality and
presentations on behalf of Aesculap/
dic Surgeons (AAOS) Board of efficiency of care. These criteria
B.Braun and serves as a board
member, owner, officer, or committee Directors on December 4, 2015. should not be construed as includ-
member of the American Academy of The purpose of the AUC is to help ing all indications or excluding
Orthopaedic Surgeons. None of the indications reasonably directed to
following authors or any immediate
determine the appropriateness of
family member has received anything treatments of the heterogeneous obtaining the same results. The
of value from or has stock or stock patient population routinely seen criteria are intended to address the
options held in a commercial company in practice. The best available sci- most common clinical scenarios
or institution related directly or
entific evidence is synthesized with facing all appropriately trained
indirectly to the subject of this article:
Mr. Murray, Mr. Pezold, and collective expert opinion on topics surgeons and all qualified physi-
Ms. Sevarino. for which randomized clinical tri- cians managing patients under
J Am Acad Orthop Surg 2017;25: als are not available or are inade- consideration for postoperative
e11-e14 quately detailed for identifying rehabilitation of hip fractures. The
DOI: 10.5435/JAAOS-D-16-00472 distinct patient types. AAOS staff ultimate judgment regarding any
convened two independent volun- specific criteria should address all
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. teer physician panels that devel- circumstances presented by the
oped this AUC. patient and the needs and resources

January 2017, Vol 25, No 1 e11

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly

particular to the locality or institu- discussion of available treatments for each patient scenario. An
tion. Appropriateness treatment and procedures applicable to the in-person voting panel meeting was
ratings for 72 patient scenarios individual patient relies on mutual held in Rosemont, Illinois, on
were developed for the AUC for communication between the patient September 27, 2015. During this
Postoperative Rehabilitation of and/or the decision surrogate and meeting, voting panel members ad-
Low Energy Hip Fractures in the the physician, weighing the poten- dressed the scenarios that resulted in
Elderly. tial risks and benefits for that disagreement. The voting panel
patient. Once the patient and/or members were asked to re-rate their
the decision surrogate has been first-round ratings during the voting
Potential Harms and informed of available therapies and panel meeting only if they were per-
Contraindications has discussed these options with the suaded to do so by the discussion and
patient’s physician, an informed available evidence. The voting panel
Most treatments, especially invasive decision can be made. determined appropriateness by rating
and surgical management, are asso- treatments of the various patient
ciated with some known risks. Con- scenarios as Appropriate, May Be
traindications vary widely based on Methods Appropriate, and Rarely Appropri-
the treatment administered. The ate. There was no attempt to obtain
potential for the overall fracture The AAOS uses the RAND/UCLA consensus about appropriateness.
treatment to result in increased Appropriateness Method to develop This AUC was approved by the
patient mortality or a decreased level the AUC.1 Two panels participated Committee on Evidence-based Qual-
of mobility and independence (com- in the development of the AAOS ity and Value, the Council on Research
pared with the status before the hip AUC for Postoperative Rehabilita- and Quality, and the AAOS Board of
fracture) is of particular concern in tion of Low Energy Hip Fractures in Directors. All tables, figures, and
the management of hip fractures in the Elderly. Members of the writing appendices, as well as the details of the
the elderly. Additional factors that panel developed a list of 72 patient methods used to prepare this AUC, are
may affect the physician’s choice of scenarios, for which 10 treatments described in the full AUC, which
treatment include, but are not lim- were evaluated for appropriateness. is available at http://www.aaos.org/
ited to, associated injuries, as well as The voting panel participated in two uploadedFiles/PreProduction/Quality/
the patient’s comorbidities, and/or rounds of voting. During the first AUCs_and_Performance_Measures/
specific patient characteristics, such round of voting, the voting panel was appropriate_use/Hip%20Fx%20
as low bone mass and osteoarthritis. given approximately 2 months to Rehab%20AUC.pdf
Clinician input based on experience independently rate the appropriate-
increases the probability of identi- ness of each of the provided treat-
fying patients who will benefit from ments for each of the relevant patient Indications and
specific treatment options. The scenarios via an electronic ballot. Classifications
individual patient and/or his or her After the first round of appropriate-
decision surrogate will also influ- ness ratings were submitted, AAOS Table 1 provides the list of pa-
ence treatment decisions; therefore, staff calculated the median ratings tient indications and classifications

These appropriate use criteria were approved by the American Academy of Orthopaedic Surgeons on December 4, 2015.
The complete Appropriate Use Criteria for Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly includes all tables,
figures, and appendices, and is available at http://www.aaos.org/uploadedFiles/PreProduction/Quality/
AUCs_and_Performance_Measures/appropriate_use/Hip%20Fx%20Rehab%20AUC.pdf
Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly Appropriate Use Criteria Writing Panel: W. Timothy Brox, MD; Karl C.
Roberts, MD; Daniel Ari Mendelson, MD; Kathleen Kline Mangione, PT, PhD, FAPTA; Thomas DiPasquale, DO; Pierre Guy, MD, MBA;
Michael C. Munin, MD; William B. Macaulay, MD; Kamal Bohsali, MD; Brett Russell Levine, MD; William Sherman, MD; Victor H. Frankel,
MD; Jan Paul Szatkowski, MD; Farbod Malek, MD; Brian Edkin, MD; Madhusudhan Yakkanti, MD; Julie Switzer, MD; Mark Charles Olson,
MD; Steven Olson, MD; Laura Bruse Gehrig, MD; and Jaimo Ahn, MD, PhD, FACS. Voting Panel: Karen Duane, MD; Stephen L. Kates, MD;
Chick Yates, Jr., MD; Eric G. Meinberg, MD; Lynn McNicoll, MD, FRCPC, AGSF; Steve Morton, DO, FAOAO; Alan M. Adelman, MD; Susan
M. Friedman, MD, MPH, AGSF; Douglas White, PT, DPT; Hilary C. Siebens, MD; Thiru Annaswamy, MD, MA; Daniel Hurley, MD.
Moderators: Robert H. Quinn, MD, and Pekk Mooar, MD. Staff of the American Academy of Orthopaedic Surgeons: William O. Shaffer, MD;
Deborah S. Cummins, PhD; Jayson Murray, MA; Ryan Pezold, MA; Peter Shores, MPH; Ann Woznica, MLS; Kaitlyn Sevarino, MBA; and
Erica Linskey.

e12 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Robert H. Quinn, MD, et al

Table 1 Figure 1
Indications and Classifications
Indication Classification

Surgical approach for arthroplasty Posterior


Anterior/anterolateral
Nonarthroplasty procedure
Preoperative mobility/functional High functioning/high demand patient
status Not able to shop without assistance but able
to leave house with or without assistance
Not able to leave the house—low function/
low demand patient
Nonambulatory/bed-dependent/palliative—
very low function/very low demand patient
Cognitive impairment Intact (26–30 MMSE)
Mild cognitive dysfunction (20–25 MMSE)
Moderate or severe cognitive dysfunction
(,20 MMSE) Summary of appropriateness ratings
of the Postoperative Rehabilitation of
Postoperative delirium No postoperative delirium Low Energy Hip Fractures in the
Postoperative delirium Elderly Appropriate Use Criteria.
MMSE = Mini-Mental State Examination

rated as Rarely Appropriate (Fig-


developed by the Postoperative osteoporosis assessment and man- ure 1). Additionally, the voting
Rehabilitation of Low Energy Hip agement (eg, calcium and vitamin panel members were in agreement
Fractures in the Elderly AUC Panels. D supplements, diphosphate use, on 468 voting items (76%) and
physical therapy); and (10) multi- were in disagreement on 3 voting
modal pain management. items (0.5%). The final appropri-
The following treatment options ateness ratings assigned by the 12-
Treatment
were removed from specific patient member voting panel of the AAOS
The following treatment is addressed scenarios due to clinical irrelevance: AUC Postoperative Rehabilitation
within the AUC for Postoperative delirium prevention in patient scenarios of Low Energy Hip Fractures in the
Rehabilitation of Low Energy Hip with postoperative delirium; delirium Elderly can be accessed via a web-
Fractures in the Elderly: (1) management in patient scenarios based mobile application www.
weight-bearing restrictions after with no postoperative delirium; orthoguidelines.org.
hip fracture surgery; (2) range of and outpatient rehabilitation in
motion restrictions after hip frac- patient scenarios classified as not
ture surgery; (3) interdisciplinary able to leave the house—low func-
AUC Mobile Application
care to manage deep vein throm- tion/low physical demand patient,
bosis prophylaxis/use of anticoag- or nonambulatory/bed dependent/ As part of the dissemination efforts
ulants; (4) delirium prevention; (5) palliative—very low function/very for the Postoperative Rehabilitation
delirium management; (6) inter- low physical demand patient. of Low Energy Hip Fractures in the
disciplinary rehabilitation pro- Elderly AUC, a web-based mobile
gram at inpatient rehabilitation platform was developed to provide
facility or skilled nursing facility if Results of Appropriateness physicians with immediate access
unable to return home; (7) out- Ratings to information to assist them with
patient occupational and physical providing evidence-based patient
therapy (including fall risk assess- Of 612 total voting items (ie, 72 care. The mobile platform includes
ment and prevention) if able to patient scenarios · 10 treatments 2 the list of patient indications and
return home and transport to a 108 deleted treatments), 465 vot- treatment recommendations. Once
local rehabilitation facility; (8) ing items (76%) were rated as the clinician enters a patient indi-
home care therapy if able to return Appropriate, 53 voting items (9%) cation profile specifying the surgi-
home but unable to transport to a were rated as May Be Appropriate, cal approach for arthroplasty,
local rehabilitation facility; (9) and 94 voting items (15%) were preoperative mobility/functional

January 2017, Vol 25, No 1 e13

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly

status, cognitive impairment, and reflect appropriate treatments, yel-


postoperative delirium status, a list
Reference
low caution symbols reflect treat-
of treatment recommendations is ments that may be appropriate, and 1. Fitch K, Bernstein SJ, Aguilar MD, et al: The
RAND/UCLA Appropriateness Method
provided. For the selected patient red circled X’s reflect treatments User’s Manual. Santa Monica, CA, RAND
profile, green circled checkmarks that are rarely appropriate. Corporation, 2001.

e14 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Research Article

The Effect of Two Factors on


Interobserver Reliability for
Proximal Humeral Fractures

Abstract
Jos J. Mellema, MD Introduction: The purpose of this study was to assess whether
Michael T. Kuntz, MD training observers and simplifying proximal humeral fracture
classifications improve interobserver reliability among a large number
Thierry G. Guitton, MD, PhD
of orthopaedic surgeons.
David Ring, MD, PhD Methods: One hundred eighty-five observers were randomized to
receive training or no training in a simple classification for proximal
humeral fractures before evaluating preoperative radiographs of a
consecutive series of 30 patients who were treated with open
reduction and internal fixation.
Results: The overall interobserver reliability of the simple proximal
humeral fracture classification system was low and not significantly
different between the training and the no training group (k = 0.20 and k =
0.18, respectively; P = 0.10). Subgroup analyses showed that training
improved the agreement among surgeons who have been in
independent practice #5 years (k = 0.23 versus k = 0.14; P , 0.001),
surgeons from the United States (k = 0.23 versus k = 0.16; P = 0.002),
and general orthopaedic surgeons (k = 0.42 versus k = 0.15; P = 0.021).
From the Hand and Upper Extremity Discussion: Simplifying classifications and training observers did not
Service, Department of Orthopaedic
Surgery, Massachusetts General improve the interobserver reliability for the diagnosis of proximal
Hospital, Harvard Medical School, humeral fractures. However, training observers improved
Boston, MA (Dr. Mellema and Dr. interobserver reliability of a simple proximal humeral fracture
Kuntz), the Department of Orthopedic
Surgery, Academic Medical Center, classification system among surgeons from the United States and, in
University of Amsterdam, the particular, younger and less specialized surgeons. This finding may
Netherlands (Dr. Guitton), and the suggest that our interpretations of radiographic information might
Department of Surgery and
Perioperative Care, Dell Medical become more fixed and immutable with experience.
School, University of Texas, Austin,
TX (Dr. Ring).

The work was performed at the Hand


and Upper Extremity Service,
Department of Orthopaedic Surgery,
F racture classification systems for
the proximal humerus aim to
categorize fracture patterns into
settings.2,3 Classification according
to these systems remains difficult
because intraobserver and interob-
Massachusetts General Hospital,
Harvard Medical School, Boston, clinically useful groups that predict server reliability is low on radio-
Massachusetts, and the Department outcomes, guide treatment, and graphs4-7 and does not improve with
of Orthopaedic Surgery, Academic
Medical Center, University of facilitate comparison of functional the use of two-dimensional8,9 or
Amsterdam, the Netherlands. and radiographic outcomes between three-dimensional CT.10-14
J Am Acad Orthop Surg 2017;25: groups in the literature.1 The Neer Training observers may help to
69-76 and AO (Arbeitsgemeinschaft für increase interobserver reliability.
DOI: 10.5435/JAAOS-D-16-00223 Osteosynthesefragen) classification Brorson et al15 and Shrader et al16
systems are most commonly used to demonstrated that interobserver reli-
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. characterize proximal humeral frac- ability of the classification according
tures in both clinical and research to Neer improved after training

January 2017, Vol 25, No 1 69

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

sessions. Although training observers versus anatomic neck fractures) humeral fractures in an online survey
before evaluating proximal humeral improve interobserver reliability in October and November 2014.
fractures is promising, its effect has among a large number of ortho- Before evaluation of the radiographs,
been demonstrated only for the Neer paedic surgeons. More specifically, all observers invited to participate
classification and among a small we tested the primary null hypoth- were randomly allocated to receive
number of observers from the same eses that there is no difference in training or no training in a simple
institution. Therefore, results may be interobserver reliability between classification for proximal humeral
less generalizable to other surgeons observers that had training and fractures. Our Institutional Review
and classification systems. Results observers that had no training in a Board approved this study.
may also be biased because observers simple classification system for
were aware of the intervention and proximal humeral fractures. We
were not blinded to the hypotheses of also tested the secondary null Subjects
the study. To our knowledge, the hypothesis that there is no difference In a retrospective search of our billing
effect of training in proximal humeral in proportion of agreement with the data using the Current Procedural
fracture classifications on interob- reference standard (ie, the rating of Terminology, 4th Edition code
server reliability among a sample of the trainer/principal investigator) 23615 for open treatment of proxi-
orthopaedic surgeons from multiple between observers in the group that mal humeral fractures, we selected
countries with different educational received training and those in the preoperative radiographs of a con-
backgrounds and for classification group that did not receive training. secutive series of 30 patients, aged
systems other than the Neer classifi- $18 years, diagnosed with a proxi-
cation has not been reported. mal humeral fracture, and treated
The most crucial distinction Methods with open reduction and internal
among proximal humeral fractures fixation between August 2012 and
is between surgical neck and anat- July 2013. Cases with fracture-
omic neck fractures; therefore, Study Design dislocation, open physes, and poor
simplifying fracture classification Orthopaedic surgeons affiliated with quality radiographs as determined
systems may lead to better agree- the Science of Variation Group by the principal investigator were
ment.12,17 The aim of this study was (SOVG), a web-based collaborative excluded.
to assess whether training observers that aims to study the variation in The number of subjects was deter-
and simplifying proximal humeral interpretation and classification of mined to have an adequate balance
fracture classifications (ie, the musculoskeletal injuries, were invited between the number of subjects and
distinction between surgical neck to evaluate radiographs of proximal the number of observers evaluating

Dr. Ring or an immediate family member has received royalties from Zimmer Biomet, Medartis, Skeletal Dynamics, and Wright Medical
Technology; serves as a paid consultant to Acumed and Zimmer Biomet; has stock or stock options held in IlluminOss; serves as a board
member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons and the American Society for Surgery of the
Hand. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held
in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Mellema, Dr. Kuntz, and Dr. Guitton.
Science of Variation Group: Chauhan, A; Vochteloo, A; Amini, MH; Platz, A; Barquet, A; Kristan, A; Berner, A; Schefer, A; Van den
Bekerom, MP; Walter, FL; Wills, BPD; Cassidy, C; Moreta-Suarez, J; Jones, C; Jones, CM; Crist, BD; Klostermann, C; Van Deurzen, DFP;
Verbeek, DOF; Barreto, CJR; Merchant, M; Grosso, E; Pemovska, ES; Schumer, ED; Suarez, F; Garnavos, C; DeSilva, G; Abis, GC;
McGovern, R; Kawaguchi, A; Gadbled, G; Campinhos, LAB; Nancollas, M; Goost, H; Biert, J; Goslings, JC; Bishop, J; Gillespie, JA; Ko, JH;
Conflitti, JM; Rubio, J; Jeray, K; Malone, KJ; Rumball, KM; Mica, L; Schulte, LM; Leenen, L; Beaumont-Courteau, M; Costanzo, RM; Palmer,
MJ; Prayson, M; Grafe, MW; Rossiter, N; Capo, JT; Brink, O; Kloen, P; Palmer, BA; Lygdas, P; Ramli, RM; Gray, RRL; Papandrea, R;
Gilbert, RS; Rizzo, M; Smith, RM; Pesantez, R; Slater Jr., RR; Ruch, D; Van Helden, SH; Kennedy, SA; Mehta, S; Mitchell, S; Dodds, S;
Kaplan, S; Kronlage, S; Morgan, SJ; Schepers, T; DeCoster, T; Taitsman, L; Dienstknecht, T; Kaplan, FTD; Siff, T; Higgins, T; Mittlmeier, T;
Apard, T; Fischer, TJ; Jokhi, V; Philippe, V; Satora, W; Balogh, Z; Peters; Spoor, AB; Ilyas, A; Basak, A; Wasterlain, A; Miller, AN; Jubel, A;
Broekhuyse, H; Fernandes, CH; Moreno-Serrano, CL; Morrey, CN; Osei, DA; Beingessner, D; Edelstein, DM; Kalainov, DM; Polatsch, D;
Brilej, D; Mannambeth, RV; Harvey, E; Twiss, ELL; Frihagen, F; Sulkers, GSI; Panagopoulos, G; Grunwald, HW; Kreder, HJ; Havenhill, TG;
Awan, H; Kimball, HL; Hofmeister, E; McGraw, I; Harris, I; Erol, K; Huntley, JS; Fanuele, JC; Choueka, J; Ribeiro Filho, JEG; Huang, JI; Izzi
Jr., JA; Roiz, JMR; Kakar, S; Egol, K; Kraan, GA; Kabir, K; Weiss, L; Borris, LC; Elmans, L; Felipe, NEL; Van de Sande, MAJ; Mormino, M;
Oidtmann, M; Di Micoli, M; Bonczar, M; Rau, M; Cimerman, M; Menon, M; Abdel-Ghany, MI; Quell, M; Kessler, MW; Krijnen, MR; Mulders,
MAM; Schep, N; Akabudike, NM; Shortt, NL; Wilson, N; Saran, N; Semenkin, OM; Ortiz Jr, JA; Brink, PRG; Van Eerten, PV; Dantuluri, P;
Althausen, P; Martineau, PA; Choudhari, P; Krause, P; Schandelmaier, P; Jebson, P; Guenter, L; Peters, RW; De Bedout, R; Reid, JG;
Jenkinson, R; Hutchison, RL; Zura, RD; Schmidt, A; Meylaerts, SA; Omara, T; Swiontkowski, M; Baxamusa, T; Begue, T; Chesser, T;
Havlicek, T; Tosounidis, T; Giordano, V; Neuhaus, V; Varecka, TF; Walsh, CJ.

70 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jos J. Mellema, MD, et al

each subject.18 Because the SOVG Table 1


study platform aims to facilitate the
Observer Characteristics
participation of a large number of
observers to improve statistical No. of Training No. of No Training Total
Characteristic Observersa (%) Observersb (%) (n = 185)
power and to allow more complex
study design, the number of subjects Sex
was limited to reduce the burden on Male 84 (94) 89 (93) 173
observers and increase the comple- Female 5 (6) 7 (7) 12
tion rate of the online evaluation. Area
United States 48 (54) 39 (41) 87
Observers Europe 30 (34) 35 (37) 65
Based on computer-generated ran- Other 11 (12) 22 (23) 33
dom numbers (Microsoft Excel), Years in independent practice
observers were randomized (1:1) to 0–5 33 (37) 35 (37) 68
either receive training or not receive 6–10 18 (20) 19 (20) 37
training in a simple classification for 11–20 31 (35) 28 (29) 59
proximal humeral fractures. 21–30 7 (8) 14 (15) 21
A total of 351 observers were asked Specialization
to participate via email. One hundred General orthopaedics 3 (3) 8 (8) 11
seventy-three invitation emails (49%) Orthopaedic traumatology 39 (44) 45 (47) 84
were sent to observers allocated to the Hand and wrist 32 (36) 35 (37) 67
training group and 178 emails (51%) Other 15 (17) 8 (8) 23
were sent to observers allocated to the Supervision of trainees
no training group. In the group that
Yes 72 (81) 83 (87) 155
received training, 90 observers (52%)
No 17 (19) 13 (14) 30
responded, of which 89 (99%) com-
pleted the online survey. In the group a
Total number of training observers = 89
b
that did not receive training, 97 Total number of no training observers = 96
observers (54%) responded, of which
96 (99%) completed the same online
survey. Incomplete responses were surgical neck proximal humeral Observers were asked to evaluate
excluded from analyses, resulting in fractures and to calibrate observers’ all radiographs of the selected
89 observers (48%) in the training definitions of these respective frac- proximal humeral fractures and to
group and 96 (52%) in the no training ture types. The first part of the classify the fractures as an anatomic
group (Table 1). These numbers do module consisted of 10 different neck fracture or a surgical neck
not represent a true response or par- schematic examples of anatomic fracture.
ticipation rate because we do not neck fractures versus surgical neck
know how many of the email fractures. In the second part of the Statistical Analysis
addresses were inaccurate and some module, observers were provided 10
radiographic examples of anatomic A post-hoc power calculation, as
surgeons with working emails are not
neck fractures versus surgical neck described by Guitton and Ring,19
active participants in the SOVG.
fractures (Figure 1). showed that 185 observers provided
However, the size of the group and
37% power to detect a 0.02 differ-
the randomization increase the inter-
ence (effect size = 0.23) in kappa
nal and external validity of the data. Online Evaluation value between the training group
The SOVG provided a link for a sur- and the no training group (a =
Training Module vey (SurveyMonkey). Using DICOM 0.05). In addition, 185 observers
The training group received an online viewer software, radiographs were yielded 100% power to detect a
training module before evaluating the deidentified and converted into JPEG clinical meaningful difference (D =
radiographs of the selected consecu- files. The JPEG files were uploaded 0.20) in kappa value defined as
tive series of patients. The module into SurveyMonkey and displayed the difference between categorical
was designed to illustrate the differ- using a syntax that allowed proper rating scales as defined by Landis
ences between anatomic neck and relative position of the radiographs. and Koch.20

January 2017, Vol 25, No 1 71

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

Figure 1

A, Schematic example of an anatomic neck fracture versus a surgical neck fracture as provided in the first part of the training
module. B, Radiographic example of an anatomic neck fracture versus a surgical neck fracture as provided in the second
part of the training module.

For analysis of our primary significantly higher in the training


hypothesis, interobserver reliability
Results group compared with the no train-
was calculated with the use of the ing group (67% and 62%, respec-
multirater kappa as described by tively; P , 0.001). In subgroup
Interobserver Reliability for a
Siegel and Castellan,21 which is a analyses, the proportion of agree-
frequently used measure of chance-
Simple Proximal Humeral ment with the “trainer” was sig-
corrected agreement between multiple Fracture Classification nificantly higher in the training
observers. According to the guidelines The overall interobserver agreement group compared with the no train-
of Landis and Koch,20 the kappa was not significantly different between ing group for US surgeons (69%
values were interpreted as follows: a the training and the no training group and 62%, respectively; P , 0.001),
value of 0.01 to 0.20 indicates slight (ktraining = 0.20 and knotraining = 0.18; surgeons in independent practice
agreement; 0.21 to 0.40, fair agree- P = 0.10) and the categorical rating for #5 years (67% and 62%,
ment; 0.41 to 0.60, moderate agree- of agreement was slight in both groups. respectively; P = 0.015), surgeons in
ment; 0.61 to 0.80, substantial In subgroup analyses, the chance- practice .5 years (67% and 62%,
agreement; and 0.81 to 0.99, almost corrected interobserver agreement respectively; P = 0.004), hand and
perfect agreement. Kappa values were was significantly higher in the training wrist surgeons (68% and 62%,
compared using the two-sample group for US surgeons (ktraining = 0.23 respectively; P = 0.003), surgeons
z-test. P values of ,0.05 were con- and knotraining = 0.16; P = 0.002), sur- that supervise trainees (67% and
sidered statistically significant. geons in independent practice for #5 63%, respectively; P = 0.001), and
For analysis of our secondary years (ktraining = 0.23 and knotraining = surgeons who do not supervise
hypothesis, proportion of agreement 0.14; P , 0.001), and general ortho- trainees (65% and 57%, respec-
with the reference standard was paedic surgeons (ktraining = 0.42 and tively; P = 0.014). There were no
compared between the training knotraining = 0.15; P = 0.021). There significant differences between
group and the no training group were no significant differences between observers that had training and
using the two-sample test of pro- observers that had training and observers that had no training in the
portions. The reference standard observers that had no training in the other subgroups (Table 3) (See
was based on the ratings of the other subgroups (Table 2). Appendix, Supplemental Digital
principal investigator (D.R.), who Content 1, http://links.lww.com/
Proportion of Agreement
was also considered the “trainer” JAAOS/A25, Overall Proportion
because he shaped the training
With the Reference Standard of Agreement in the Training and
module. Accordingly, a higher pro- of a Simple Proximal Humeral No Training Group For Proximal
portion of agreement with the ref- Fracture Classification Humeral Fracture Classification:
erence standard reflects a higher The overall proportion of agreement Consensus Agreement and Refer-
agreement with the “trainer.” with the reference standard was ence Standard).

72 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jos J. Mellema, MD, et al

Table 2
Interobserver Agreement in the Training and No Training Group for a Simple Proximal Humeral Fracture
Classification
Training (n = 89) No Training (n = 96)
Factor Kappa Agreement 95% CI Kappa Agreement 95% CI P Value

Overall 0.20 Slight 0.19–0.21 0.18 Slight 0.16–0.20 0.10


Area
United States 0.23 Fair 0.21–0.25 0.16 Slight 0.12–0.20 0.002
Europe 0.15 Slight 0.13–0.17 0.19 Slight 0.15–0.23 0.085
Other 0.26 Fair 0.21–0.31 0.20 Slight 0.15–0.25 0.086
Years in independent practice
0–5 0.23 Fair 0.21–0.25 0.14 Slight 0.09–0.19 ,0.001
.5 0.18 Slight 0.17–0.20 0.20 Slight 0.18–0.23 0.17
Specialization
General orthopaedics 0.42 Moderate 0.21–0.63 0.15 Slight 0.06–0.24 0.021
Orthopaedic traumatology 0.18 Slight 0.16–0.20 0.18 Slight 0.15–0.21 0.83
Hand and wrist 0.20 Slight 0.18–0.22 0.19 Slight 0.15–0.23 0.70
Other 0.21 Fair 0.18–0.25 0.17 Slight 0.03–0.31 0.58
Supervision of trainees
Yes 0.20 Slight 0.19–0.21 0.19 Slight 0.17–0.22 0.36
No 0.20 Slight 0.16–0.24 0.14 Slight 0.06–0.22 0.21

CI = confidence interval

pendent practice for #5 years, US reduction and internal fixation. This


Discussion surgeons, and general orthopaedic selection may have increased the
surgeons. In addition, the overall complexity of the fractures and neg-
Fracture patterns of the proximal
proportion of agreement with the atively influenced the agreement
humerus are difficult to define
reference standard was significantly between observers. Third, there may
because of their extreme variability
higher in the training group than in be important differences between the
and potential complexity.16 Catego-
the no training group. These findings web-based evaluation as provided by
rizing these fractures according to
indicate that simplifying proximal the SOVG and the usual method in
current classification systems is dif-
humeral classification systems does which surgeons evaluate radio-
ficult and results in low reliability
not improve interobserver reliability graphs. Finally, training and evalua-
between and among observers on and that training provides only a tion was limited to the choice of a
different imaging modalities.4-14 The small but substantially improved simplified classification system. This
purpose of this study was to assess effect in a subset of observers. could have reduced the effect of
the influence of training observers The results of our study should be training because the distinction
and simplifying proximal humeral interpreted in the light of its limita- between anatomic and surgical neck
classification systems on interob- tions. First, the training module was fractures is clear for most experienced
server reliability among a large short, consisted of schematics and and inexperienced observers. The
number of musculoskeletal surgeons. radiographic examples only, and did strength of this study is that a large
We found that the overall chance- not facilitate discussion between number of observers participated,
corrected interobserver agreement observers. A more extensive training thus maximizing power and general-
was low with no substantially dif- program where observers can inter- izability and allowing randomization
ferent agreement between the train- act with each other and the trainer and subgroup analyses.
ing group and the no training group. may provide a larger effect on the Our findings were partially consis-
However, the interobserver reliabil- interobserver reliability. Second, tent with the studies conducted by
ity was significantly higher in the fractures were selected based on sur- Brorson et al15 and Shrader et al.16
training group for surgeons in inde- gical treatment consisting of open Brorson et al15 randomized 14

January 2017, Vol 25, No 1 73

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

Table 3
Proportion of Agreement with the Reference Standard of a Simple Proximal Humeral Fracture Classification in the
Training and No Training Group
Training (n = 89) No Training (n = 96)
Proportion of Proportion of P
Factor Agreementa SE 95% CI Agreement SE 95% CI Value

Overall 0.67 0.009 0.65–0.69 0.62 0.009 0.60–0.64 ,0.001


Area
United States 0.69 0.012 0.67–0.72 0.62 0.014 0.60–0.65 ,0.001
Europe 0.62 0.016 0.59–0.65 0.60 0.015 0.57–0.63 0.37
Other 0.69 0.025 0.64–0.74 0.65 0.019 0.61–0.68 0.17
Years in independent
practice
0–5 0.67 0.015 0.64–0.70 0.62 0.015 0.59–0.65 0.015
.5 0.67 0.012 0.64–0.69 0.62 0.011 0.60–0.64 0.004
Specialization
General orthopaedics 0.70 0.048 0.61–0.79 0.62 0.031 0.56–0.68 0.18
Orthopaedic 0.66 0.014 0.63–0.69 0.63 0.013 0.61–0.66 0.14
traumatology
Hand and wrist 0.68 0.015 0.65–0.71 0.62 0.015 0.59–0.65 0.003
Other 0.66 0.022 0.61–0.70 0.56 0.032 0.50–0.62 0.010
Supervision of trainees
Yes 0.67 0.010 0.65–0.69 0.63 0.009 0.61–0.65 0.001
No 0.65 0.021 0.61–0.70 0.57 0.025 0.53–0.62 0.014

CI = confidence interval, SE = standard error


a
Proportion of agreement with the reference standard

observers to receive training or no We found that training slightly system (ie, the Neer classification
training in the Neer classification improved the interobserver agree- system) was used in the other studies.
system before evaluating 42 pairs of ment in particular subgroups (ie, US Studies conducted on other
proximal humerus radiographs. For surgeons, surgeons with #5 years of anatomic sites have demonstrated
observers who received two 45- experience, and general orthopaedic improved interobserver reliability
minute training sessions, the inter- surgeons). Surgeons from the United after training in fracture classifica-
observer reliability improved (k = States were less experienced than tion systems. Buijze et al22 selected 64
0.27 to k = 0.62) and the reliability surgeons from other countries, pos- observers to evaluate 20 CT scans of
without training was significantly sibly explaining an increased level of scaphoid fractures. Surgeons were
lower than that with training (k = receptiveness to training from US randomized to receive training or no
0.33 versus k = 0.62). Shrader et al16 surgeons compared with surgeons training before evaluating the CT
selected radiographs of 113 proxi- from other counties. In other words, scans. Surgeons in the training group
mal humeral fractures that were less experienced and more generally had a substantially higher interob-
evaluated by three observers in three oriented surgeons appeared to be server reliability for the classification
sessions: the initial session, the dis- more receptive to training than the of scaphoid fractures than did sur-
cussion session, and the final session. group as a whole. The type of geons in the no training group (k =
After the discussion session, in which training intervention and the classi- 0.60 and k = 0.52, respectively).
observers discussed the reasons for fication system used could explain— Furthermore, Zehnder et al23 pre-
their disagreement in the initial ses- in part—this small effect. In this sented 50 CT scans of patients with
sion, the interobserver agreement study, less extensive training in a cervical spine injuries to six
for the Neer classification improved simple classification system was observers who evaluated the scans
slightly but significantly from k = evaluated, whereas a more extensive before and after a teaching session.
0.42 to k = 0.47 in the final session. training in a complex classification After the teaching session, the

74 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jos J. Mellema, MD, et al

interobserver reliability improved observers appear to have led to between specialists. Int Orthop 2002;26(5):
271-273.
substantially, as indicated with the some but minimal improvement in
intraclass correlation coefficient, reliability and more experienced 8. Bernstein J, Adler LM, Blank JE, Dalsey
RM, Williams GR, Iannotti JP: Evaluation
from 0.928 to 0.947. observers may be less responsive to of the Neer system of classification of
Furthermore, we found that the new classification systems and proximal humeral fractures with
computerized tomographic scans and plain
overall interobserver reliability was training; therefore, future consid-
radiographs. J Bone Joint Surg Am 1996;78
poor in both groups for the simple eration should be given to pursuing (9):1371-1375.
classification system used in our methods for increasing surgeon 9. Sjödén GO, Movin T, Güntner P, et al: Poor
study. This is inconsistent with the receptiveness to training or new reproducibility of classification of proximal
study conducted by Bruinsma classifications. humeral fractures: Additional CT of minor
value. Acta Orthop Scand 1997;68(3):
et al,12 in which 107 observers 239-242.
evaluated CT scans of 15 proximal
humeral fractures and reported References 10. Sallay PI, Pedowitz RA, Mallon WJ,
Vandemark RM, Dalton JD, Speer KP:
higher interobserver agreement for Reliability and reproducibility of
Evidence-based Medicine: Levels of radiographic interpretation of proximal
the identification of simple fracture humeral fracture pathoanatomy. J Shoulder
evidence are described in the table
characteristics compared with a Elbow Surg 1997;6(1):60-69.
of contents. In this article, refer-
more complex classification sys- 11. Sjödén GO, Movin T, Aspelin P, Güntner P,
ences 2 and 3 are level II studies.
tem, suggesting that simple classi- Shalabi A: 3D-radiographic analysis does
References 4-16, 19, 22, and 23 are not improve the Neer and AO
fications systems may lead to better
level III studies. References 1, 17, classifications of proximal humeral
agreement between surgeons. fractures. Acta Orthop Scand 1999;70(4):
18, 20, and 21 are level V expert
The overall proportion of agree- 325-328.
opinion.
ment with the reference standard or 12. Bruinsma WE, Guitton TG, Warner JJ,
trainer (ie, the principal investigator References printed in bold type are Ring D; Science of Variation Group:
those published within the past 5 Interobserver reliability of classification
in our study who designed the train- and characterization of proximal humeral
ing module) indicated the agreement years. fractures: A comparison of two and three-
between the surgeons and the trainer. dimensional CT. J Bone Joint Surg Am
1. Carofino BC, Leopold SS: Classifications in 2013;95(17):1600-1604.
We found that observers who brief: The Neer classification for proximal
humerus fractures. Clin Orthop Relat Res 13. Foroohar A, Tosti R, Richmond JM,
received the training had a sub- 2013;471(1):39-43. Gaughan JP, Ilyas AM: Classification and
stantially higher agreement with the treatment of proximal humerus fractures:
2. Neer CS II: Displaced proximal humeral Inter-observer reliability and agreement
trainer compared with those fractures: I. Classification and evaluation. J across imaging modalities and experience. J
observers that did not receive train- Bone Joint Surg Am 1970;52(6): Orthop Surg Res 2011;6:38.
ing. Although interobserver agree- 1077-1089.
14. Berkes MB, Dines JS, Little MT, et al: The
ment is of greater interest for 3. Marsh JL, Slongo TF, Agel J, et al: Fracture impact of three-dimensional CT imaging on
and dislocation classification compendium -
surgeons because it affects treatment intraobserver and interobserver reliability
2007: Orthopaedic Trauma Association of proximal humeral fracture classifications
protocols, scientific experiments, and classification, database and outcomes and treatment recommendations. J Bone
preoperative planning, the pro- committee. J Orthop Trauma 2007;21(10 Joint Surg Am 2014;96(15):1281-1286.
suppl):S1-S133.
portion of agreement with the trainer 15. Brorson S, Bagger J, Sylvest A,
also measures the effectiveness of the 4. Sidor ML, Zuckerman JD, Lyon T, Hrøbjartsson A: Improved interobserver
Koval K, Cuomo F, Schoenberg N: The variation after training of doctors in the
training. Neer classification system for proximal Neer system: A randomised trial. J Bone
In conclusion, training observers humeral fractures: An assessment of Joint Surg Br 2002;84(7):950-954.
interobserver reliability and intraobserver
and simplifying classification sys- reproducibility. J Bone Joint Surg Am 1993; 16. Shrader MW, Sanchez-Sotelo J,
tems for proximal humeral frac- 75(12):1745-1750. Sperling JW, Rowland CM, Cofield RH:
tures did not improve interobserver Understanding proximal humerus
5. Siebenrock KA, Gerber C: The fractures: Image analysis, classification, and
reliability. The finding that training reproducibility of classification of treatment. J Shoulder Elbow Surg 2005;14
observers can improve interob- fractures of the proximal end of the (5):497-505.
humerus. J Bone Joint Surg Am 1993;75
server reliability of a simple proxi- (12):1751-1755. 17. Müller ME, Nazarian S, Koch P, et al: The
mal humeral fracture classification Comprehensive Classification of Fractures
6. Brien H, Noftall F, MacMaster S, of Long Bones. Berlin, Germany, Springer,
system among younger and less Cummings T, Landells C, Rockwood P: 1990.
specialized surgeons suggests that Neer’s classification system: A critical
appraisal. J Trauma 1995;38(2):257-260. 18. Walter SD, Eliasziw M, Donner A: Sample
interpretations of radiographic size and optimal designs for reliability
information might become more 7. Brorson S, Bagger J, Sylvest A, studies. Stat Med 1998;17(1):101-110.
Hróbjartsson A: Low agreement among 24
fixed and immutable with ex- doctors using the Neer-classification: Only 19. Guitton TG, Ring D; Science of Variation
perience. Interventions to train moderate agreement on displacement, even Group: Interobserver reliability of radial

January 2017, Vol 25, No 1 75

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

head fracture classification: Two- 21. Siegel S, Castellan JN: Nonparametric displacement. Clin Orthop Relat Res 2012;
dimensional compared with three- Statistics for the Behavioral Sciences. New 470(7):2029-2034.
dimensional CT. J Bone Joint Surg Am York, NY, McGraw-Hill, 1988.
2011;93(21):2015-2021. 23. Zehnder SW, Lenarz CJ, Place HM:
22. Buijze GA, Guitton TG, van Dijk CN, Teachability and reliability of a new
20. Landis JR, Koch GG: The measurement of Ring D; Science of Variation Group: classification system for lower
observer agreement for categorical data. Training improves interobserver reliability cervical spinal injuries. Spine
Biometrics 1977;33(1):159-174. for the diagnosis of scaphoid fracture (Phila Pa 1976) 2009;34(19):2039-2043.

76 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
On the Horizon From the ORS
The Meniscus
Suzanne A. Maher, PhD The C-shaped, wedge-like, fibro- replacements intended to replace
Scott A. Rodeo, MD cartilaginous menisci of the knee an entire meniscus.4 But before
joint were once thought to contrib- adopting these technologies into
Russell F. Warren, MD ute little to joint function but are widespread clinical care, there is a
now credited with playing a critical need to identify patients most at
role in maintaining joint health. The risk for degenerative changes and
menisci facilitate joint stability, therefore most likely to benefit
congruency, force distribution, from new technologies.
lubrication, and proprioception. Several studies aimed at under-
Thus, meniscal injury leads to standing patient-specific factors
altered mechanics and biochemical indicative of outcome are emerging.
changes that combine to result in a Brophy et al5 found that gene
cascade toward the development of expression in the menisci of patients
posttraumatic osteoarthritis.1 with tears varied by age, sex, and
Surgical treatment of knee joint injury pattern. Most notably,
meniscal injuries has remained patients less than 40 years of age
unchanged for over two decades: had an increased catabolic response
when meniscal damage causes to injury and elevated levels of
pain and/or a locking sensation several osteoarthritis-related genes.
and cannot be repaired, the torn Realizing that younger patients
meniscal tissue is removed in a tend to sustain acute traumatic
partial meniscectomy. Partial tears whereas older patients are
meniscectomy is aimed at relieving prone to chronic degenerative
pain and restoring function. tears, the study nonetheless sug-
However, more than half of all gests that younger patients are
patients who undergo partial more prone to inflammatory
meniscectomy will exhibit changes changes than their older counter-
in articular cartilage as early as 6 parts. In an elegant analysis of
months after surgery2 and develop patients about to undergo surgery
osteoarthritis within 10 to 20 for meniscal tears, Carter et al6
years.3 Because of such variability demonstrated increased total
in outcome, counseling patients as matrix metalloproteinase activity
From the Hospital for Special Surgery, to expectations after surgery is in synovial fluid, the magnitude of
New York, NY. difficult. which was positively correlated
Dr. Maher or an immediate family With the development of scaf- with increased cartilage strain,
member has stock or stock options folds for the repair and/or while Gilbert et al7 used a cadav-
held in Agelity Biomechanics Corp. replacement of the meniscus, eric study to illustrate the com-
Dr. Rodeo or an immediate family
changes in the clinical manage- plexity of load distribution
member serves as a paid consultant
to Ortho Regenerative Technologies ment of meniscal injuries are on patterns under the menisci and
and has stock or stock options held in the horizon. Meniscal reparative across the tibial plateau during
Rotation Medical. Dr. Warren or an technologies range from fully gait and stair climbing. It is pos-
immediate family member has stock
degradable scaffolds intended to sible that as we gain a better
or stock options held in Ivy Sports
Medicine and OrthoNet. facilitate cell ingress and matrix understanding of the interaction
generation as the scaffold de- between the location and volume
J Am Acad Orthop Surg 2017;25:
e18-e19 grades, to nondegradable scaffolds of meniscal tissue removed and the
that remain present in the joint local changes in tissue mechanics,8
DOI: 10.5435/JAAOS-D-16-00689
despite matrix ingrowth, to we might be in a better position
Copyright 2016 by the American completely synthetic nonporous to understand the mechanical
Academy of Orthopaedic Surgeons.

e18 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Suzanne A. Maher, PhD, et al

factors that contribute to var- 5. Brophy RH, Rai MF, Zhang Z, Torgomyan
iability in outcome following me-
References A, Sandell LJ: Molecular analysis of age and
sex-related gene expression in meniscal tears
niscal resection. with and without a concomitant anterior
References printed in bold type are cruciate ligament tear. J Bone Joint Surg Am
In summary, innovative studies are
those published within the past 5 years. 2012;94(5):385-393.
allowing the relationship between
joint-level mechanics and biologic 1. Fairbank TJ: Knee joint changes after 6. Carter TE, Taylor KA, Spritzer CE, et al: In
meniscectomy. J Bone Joint Surg Br 1948; vivo cartilage strain increases following
response of the joint to be evaluated 30B(4):664-670. medial meniscal tear and correlates with
in a patient-specific way. If we synovial fluid matrix metalloproteinase
2. Souza RB, Wu SJ, Morse LJ, Subburaj K, activity. J Biomech 2015;48(8):1461-1468.
can successfully consolidate such Allen CR, Feeley BT: Cartilage MRI
approaches into a unified clinical relaxation times after arthroscopic partial 7. Gilbert S, Chen T, Hutchinson ID, et al:
medial meniscectomy reveal localized Dynamic contact mechanics on the tibial
paradigm and combine it with sensi- plateau of the human knee during activities of
degeneration. Knee Surg Sports Traumatol
tive measures of outcome, vis-à-vis Arthrosc 2015;23(1):188-197. daily living. J Biomech 2014;47(9):2006-2012.
articular cartilage health9 and joint 8. Sutter EG, Widmyer MR, Utturkar GM,
3. Lohmander LS, Englund PM, Dahl LL, Roos
function, then the possibility of EM: The long-term consequence of anterior Spritzer CE, Garrett WE Jr, DeFrate LE: In
predicting outcome in a clinical cruciate ligament and meniscus injuries: vivo measurement of localized tibiofemoral
Osteoarthritis. Am J Sports Med 2007;35 cartilage strains in response to dynamic activity.
environment is within our reach. (10):1756-1769. Am J Sports Med 2015;43(2):370-376.
Until that time, it will remain unclear
4. Moran CJ, Withers DP, Kurzweil PR, 9. Novakofski KD, Pownder SL, Koff MF,
which patients are most likely to Verdonk PC: Clinical application of Williams RM, Potter HG, Fortier LA: High-
benefit from modified meniscal sur- scaffolds for partial meniscus replacement. resolution methods for diagnosing cartilage
Sports Med Arthrosc 2015;23(3):156-161. damage in vivo. Cartilage 2016;7(1):39-51.
gical techniques.

January 2017, Vol 25, No 1 e19

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article

Total Wrist Arthrodesis: Indications


and Clinical Outcomes

Abstract
David H. Wei, MD, MS Total wrist arthrodesis remains an important technique in the surgical
Paul Feldon, MD armamentarium of upper extremity surgeons. The procedure has
evolved over time but continues to provide reliable pain relief at the
expense of wrist motion. It is indicated for management of a wide
variety of upper extremity conditions, including rheumatoid arthritis,
posttraumatic osteoarthritis, cerebral palsy, and brachial plexus
injuries, and as a salvage technique after failed implant arthroplasty.
Recent studies demonstrate high levels of patient satisfaction and
good functional outcomes after bilateral wrist fusion. Compared with
total wrist arthroplasty, total wrist arthrodesis provides more reliable
pain relief with lower rates of complications, but further studies are
needed to compare functional outcomes and cost-effectiveness.

T otal wrist arthrodesis involves


fusion of the carpus to the radius.
The procedure eliminates wrist flex-
compression and rotational control
with the use of one or more staples. In
their study, the primary indication for
ion and extension and radial and surgery was rheumatoid arthritis (43
ulnar deviation but preserves forearm patients), but the authors also used
rotation. It is a well-established stan- the technique in 5 patients with
dard strategy for the management of posttraumatic arthritis and neuro-
painful, advanced pancarpal degen- logic disorders and in 1 patient with
erative arthritis and may be indicated congenital deformity. Their study
in patients with end-stage rheumatoid demonstrated two major advance-
arthritis, posttraumatic osteoarthritis, ments. First, wrist arthrodesis could
spasticity disorders, brachial plexus be performed without external fixa-
injuries, postinfection degeneration, tion or plaster. Second, successful
From the Department of Orthopaedic
Surgery, Greenwich Hospital, or failed implant arthroplasty (Figures fusion could be achieved without the
Greenwich, CT (Dr. Wei), and Hand 1 and 2). use of autograft from remote donor
Surgical Associates, Boston, MA sites, such as the iliac crest. The
(Dr. Feldon). authors reported successful fusion
Neither of the following authors nor Development of the with retention of implants in all but
any immediate family member has one patient, in whom the fusion
received anything of value from or has
Technique
stock or stock options held in a
failed secondary to infection and the
commercial company or institution Wrist arthrodesis was popularized in Rush pin was removed. Two patients
related directly or indirectly to the 1971 by Mannerfelt and Malmsten,1 had postoperative carpal tunnel
subject of this article: Dr. Wei and who introduced a technique that did syndrome that required subsequent
Dr. Feldon.
not require external fixation and decompression. In 1973, Millender
J Am Acad Orthop Surg 2017;25:3-11 retrospectively reviewed the results of and Nalebuff2 modified the
DOI: 10.5435/JAAOS-D-15-00424 49 patients. The authors stabilized technique introduced by Mannerfelt
the wrist joint by placing a retrograde and Malmsten1 by using smooth
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. Rush pin from the third metacarpal Steinmann pins instead of a Rush pin.
to the distal radius and provided This modification expanded the use

January 2017, Vol 25, No 1 3

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Wrist Arthrodesis: Indications and Clinical Outcomes

Figure 1

Preoperative AP (A) and lateral (B) radiographs of the left hand and wrist demonstrating severe end-stage degeneration of
the wrist with complete radiocarpal dislocation in a patient with rheumatoid arthritis. C, Postoperative AP radiograph
demonstrating successful wrist arthrodesis. A dual-pin intermetacarpal technique was used, with two smooth Steinmann
pins inserted in the second and third intermetacarpal spaces to the distal radius. D, Postoperative clinical photograph of the
hand and wrist demonstrating excellent sagittal alignment. E, Clinical photograph of the hand demonstrating removal of the
symptomatic intermetacarpal pins after radiographic healing was confirmed.

of intramedullary fixation to patients surgery included rheumatoid arthri- treated with AO/Association for the
with a variety of rheumatoid wrist tis, degenerative arthritis, and neu- Study of Internal Fixation compres-
deformities (Figures 3 and 4). rologic disorders. Three arthrodesis sion plating and iliac crest autograft
In subsequent years, some authors techniques were included, two of (56 patients) or alternative tech-
reported higher rates of major com- which used corticocancellous iliac niques (33 patients). This study
plications after total wrist fusion. In autograft and one of which used local marked a shift in fixation technique
1981, Clendenin and Green3 pub- distal ulna autograft. The authors to the use of compression plating
lished a retrospective series of 31 cautioned readers regarding the high spanning the metacarpal to the distal
patients who underwent total wrist occurrence of pseudarthrosis and the radius. The authors excluded any
arthrodesis. Nine patients suffered a need for revision surgery. patients with inflammatory arthritis,
major complication, most commonly In 1996, Hastings et al4 published neuromuscular disorders, or soft-
pseudarthrosis requiring a second a retrospective comparison of 89 tissue or tendon problems. In the
fusion attempt. Their indications for patients with posttraumatic arthritis patients treated with plating, fusion

4 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
David H. Wei, MD, MS, and Paul Feldon, MD

Figure 2

PA (A) and lateral (B) radiographs of the right hand and wrist demonstrating symptomatic pancarpal posttraumatic
osteoarthritis in a patient who previously underwent partial wrist fusion. Postoperative PA (C) and lateral (D) radiographs
demonstrating wrist fusion with a tapered, locking wrist fusion plate. The triquetrum was not excised because it was
previously fused to the lunate bone.

rates were significantly higher (98% Figure 3


versus 82%) and complication rates
were significantly lower (51% versus
79%) than in patients treated with
alternative techniques. The method
has continued to evolve. Current
techniques involve the use of a pre-
contoured plate that has a tapered
end tailored to the metacarpal shaft
and the use of locking or nonlocking
screws that allow rigid fixation and
compression across the midcarpal
and radiocarpal joints (Figure 5).

Recent Developments

Outcomes
Clinical evidence regarding the out-
comes of wrist arthrodesis is available
for a variety of surgical indications
(see Table 1, Supplemental Digital A, Preoperative PA radiograph demonstrating the left hand and wrist of a patient
Content 1, http://links.lww.com/ with juvenile rheumatoid arthritis with severe involvement of the wrist. Because
JAAOS/A17, Outcomes of Selected of the thin intramedullary canal of the distal radius and the advanced ulnar
translation of the carpus, a single rod inserted through the second metacarpal
Studies of Total Wrist Arthrodesis). into the distal radius was used for fixation during arthrodesis. B, Postoperative
PA radiograph of the left hand and wrist of a different patient demonstrating the
Rheumatoid Arthritis use of a single rod inserted through the second metacarpal into the distal radius.
The number of total wrist arthrodeses The procedure was performed concurrently with an index metacarpophalangeal
arthroplasty and a matched ulnar head resection.
performed in patients with rheumatoid

January 2017, Vol 25, No 1 5

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Wrist Arthrodesis: Indications and Clinical Outcomes

Figure 4 Figure 5

Photographs showing three available


plate options, including a straight
plate (A), a plate with a standard bend
(B), and a plate with a short bend (C).

A and B, PA radiographs of the left hand and wrist demonstrating the


intramedullary pin technique in two different patients. This technique can be bones as morcellized bone graft, for
combined with third or second metacarpal arthroplasty. After resection of the the management of degenerative or
metacarpal head, a pin that matches the size of the intramedullary canal is posttraumatic arthritis. In their series
inserted by hand and tapped across the carpus into the radius. To avoid cortical
penetration, a drill is not used. The pin is recessed into the metacarpal shaft with of 110 patients, most patients (46%)
a tamp to allow insertion of the metacarpal implant. The resected metacarpal had scapholunate advanced collapse
head can be shaped and impacted distal to the pin to help prevent distal or scaphoid nonunion advanced col-
migration of the pin. lapse preoperatively. Other indica-
tions for fusion in the study included
arthritis has decreased substantially hardware. Elherik et al12 reported end-stage Kienböck disease, spastic
over the past three decades because long-term results of 15 wrists in 14 wrist contracture, nonunion or mal-
medical management with targeted patients who underwent arthrodesis union of distal radius fractures,
medications, such as disease- using the Mannerfelt technique. At pseudarthrosis of previous arthrode-
modifying antirheumatic drugs, has a minimum 6-year follow-up, the sis, failed PRC, failed scapholunate
radically decreased the manifestations patients had improved pain and reconstruction, Preiser osteonecrosis,
of rheumatoid disease in the upper function and reported excellent satis- silicone synovitis, and prior infection.
extremity.37,38 However, for patients faction, with all patients stating that Nonunion occurred in only two
with painful, end-stage rheumatoid they would undergo the procedure patients in the series. The authors of
arthritis affecting the wrist, standard again. the study stated that their technique
wrist arthrodesis techniques can pro- had the advantages of not requiring
vide excellent clinical outcomes. Kluge Posttraumatic Arthritis and the harvesting of distant bone graft,
et al19 retrospectively reviewed a series Osteoarthritis and enabling the use of rigid internal
of 104 wrists in 87 patients with In patients with posttraumatic arthri- fixation that allows immediate reha-
rheumatoid arthritis at a mean follow- tis and osteoarthritis, total wrist bilitation. Although complications
up of 87 months. Using a modified arthrodesis has historically resulted in initially included painful implants, the
Clayton-Mannerfelt technique, the high satisfaction rates, although some authors reported that the introduction
authors attained a 98% rate of fusion patients’ perception of the disability of the tapered AO plate eliminated
at a mean 10 weeks postoperatively, resulting from the reduced wrist this problem.
with two nonunions that required motion may be greater than their
conversion to an AO wrist fusion actual functional loss.6,39 Green and Other Indications
plate. Patients had reliable reduction Henderson16 combined proximal row Other indications for total wrist
in pain and a low rate of complica- carpectomy (PRC) and total wrist arthrodesis include complete brachial
tions, and none required removal of arthrodesis, using the excised carpal plexus paralysis, cerebral palsy, and

6 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
David H. Wei, MD, MS, and Paul Feldon, MD

failed arthroplasty. Addosooki et al5 the wrist to allow optimal function complication rate of 29%, consisting
used a modified technique of wrist of the extrinsic muscles that span the of 19% major and 10% minor com-
arthrodesis to augment the efficiency joint. Beer and Turner41 reported a plications. The overall reported radio-
of muscular forces in patients under- high complication rate in their series of carpal nonunion rate was 4.4%, or 78
going double free-muscle transfers 12 patients who underwent wrist wrists.1-36,39 Common major compli-
after complete brachial plexus paral- arthrodesis for the management of cations include nonunion, ulnocarpal
ysis. The authors used a dynamic failed total wrist arthroplasty. They impaction, carpal tunnel syndrome,
compression wrist fusion plate ex- used a tricortical iliac crest bone graft extensor tenosynovitis, deep infection,
tending from the second metacarpal to bridge the distal radius and second and other implant-related problems
to the radius to prevent friction of the and third metacarpal bases. Although (eg, persistent pain, prominent
plate with the extensor digitorum 11 of 12 patients achieved excellent implants, fracture around implants).
communis, to which the muscle or good results at a mean Minor complications include superfi-
transfer was attached. All 18 patients 28-month follow-up, 5 patients cial wound infections, carpal tunnel
in the series demonstrated fusion at a had pseudarthroses, most often at symptoms, intraoperative fractures,
mean of 12 weeks postoperatively, the graft-metacarpal junction. Other postoperative fractures, and asymp-
with improved Disabilities of the Arm, complications included fractures tomatic radiographic loosening.
Shoulder and Hand (DASH) scores through the graft, migration or ero-
and improved total active digital sion of the pins, and superficial
Current Controversies
motion and hand function. The most wound infection of the graft site. The
common complication was hema- authors of the study recommended Total Wrist Arthrodesis Versus
toma formation leading to delayed more rigid plate fixation and contin- Total Wrist Arthroplasty
wound healing; therefore, the authors ued use of a corticocancellous graft in The recent literature on total wrist
recommended placement of a drain. these patients. Rizzo et al31 examined arthrodesis has focused primarily
Thabet et al40 analyzed outcomes clinical outcomes of wrist arthrodesis on two issues. First, total wrist
of total wrist arthrodesis using for the management of failed total arthrodesis continues to be compared
Steinmann pins or plate fixation in 19 wrist arthroplasty in a retrospec- with total wrist arthroplasty for the
wrists in 14 patients with cerebral tive review of 21 wrists in 17 treatment of patients with rheuma-
palsy who had severe wrist deformities patients. Although radiographic toid arthritis and posttraumatic
interfering with hygienic care. PRC union occurred in only 11 wrists, arthritis. In patients with rheumatoid
was performed to aid in correction of most patients in the study reported arthritis, total wrist arthrodesis typi-
the deformity, with resected bones no pain, and mean DASH scores were cally is well tolerated; however,
used for local bone grafting in all similar between patients with union comparison of the two techniques
patients and some wrists requiring and those with nonunion. The authors with regard to daily activities (eg,
resection of all carpal bones. At a mean concluded that wrist arthrodesis is a hygiene, manipulation of buttons)
follow-up of approximately 6 years, reasonable option for salvage after remains controversial.24 In a sys-
the authors found that most (88%) of failed wrist arthroplasty despite the tematic review comparing total wrist
the patients’ caregivers were satisfied high rate of nonunion. arthroplasty and total wrist
and reported improved hygienic care. arthrodesis in patients with rheu-
The mean correction from wrist flex- matoid arthritis, Cavaliere and
ion to neutral was 37°. One patient did Complications Chung42 reviewed 18 arthroplasty
not achieve bony union, and another Major and minor complications studies (.500 procedures) and 20
patient had a painful partial union. associated with wrist arthrodesis arthrodesis studies (.800 proce-
Both of these patients were treated have been reported in the literature dures). They concluded that all
nonsurgically with a wrist splint. (see Table 2, Supplemental Digital patients were highly satisfied, but
Wrist arthrodesis can be performed Content 2, http://links.lww.com/ total wrist fusion provided more
as a salvage procedure to provide a JAAOS/A18, Complications and reliable pain relief, a lower rate of
definitive long-term solution in patients Nonunion of Total Wrist Arthrodesis complications, and less frequent need
with failed wrist arthroplasty. How- in Recent Studies). Major complica- for revision than total wrist arthro-
ever, wrist arthrodesis can be particu- tions are defined as those requiring plasty provided. Moreover, in the 14
larly challenging in these patients surgical management, whereas minor arthroplasty studies in which range of
because of the loss of bone volume, the complications are managed non- motion was reported, only 3 studies
poor quality of remaining bone, and surgically. A total of 1,782 wrists were demonstrated a return to a functional
the need to maintain adequate length of reported in 45 studies, with an overall arc of motion. The authors cautioned

January 2017, Vol 25, No 1 7

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Wrist Arthrodesis: Indications and Clinical Outcomes

that expensive interventions should questionnaire and that total wrist


not be recommended unless they arthroplasty may offer a functional
Contraindications
demonstrate superior outcomes. advantage over total wrist fusion.
The few contraindications to total
In 2010, Cavaliere and Chung43 They concluded that, although total
wrist arthrodesis include an active
compared the cost utility of total wrist arthroplasty is a viable alter-
wrist infection or lack of an adequate
wrist fusion with that of total wrist native for some patients with post-
soft-tissue envelope. Although inad-
arthroplasty. A survey of 49 patients traumatic arthritis, total wrist fusion
equate bone stock for fusion in
with rheumatoid arthritis and 109 is indicated in patients who are
patients with rheumatoid arthritis
hand surgeons and rheumatologists younger than 50 years, are manual
was historically considered a relative
and an analysis of cost data based on laborers, have a history of infection,
contraindication to plate fixation, the
Medicare fee schedules demon- use a walking aid, or lack active
advent of locking plate technology
strated that both procedures are wrist motion. Despite the data from
has largely overcome this issue.
extremely cost-effective. The cost per these studies, meaningful conclu-
quality-adjusted life year (QALY) sions remain elusive, and whether
for both procedures was well total wrist arthroplasty or total wrist Surgical Techniques
below the historical threshold for arthrodesis provides superior clinical
cost-effectiveness of $50,000 per outcomes has yet to be determined. We routinely use precontoured
QALY.43 Total wrist arthroplasty As total wrist arthroplasty implant stainless-steel locking wrist fusion plates
was found to have an incremental designs and surgical techniques con- in wrist arthrodesis procedures for all
cost of $2,328 per QALY compared tinue to improve, future comparative indications because they provide rigid
with total wrist arthrodesis, which studies should help determine the fixation, even in patients with rheuma-
was greater than the incremental cost appropriate roles of arthroplasty and toid arthritis and poor bone stock. In
of total wrist arthroplasty compared arthrodesis in patients with rheuma- these patients, we have successfully used
with nonsurgical management. The toid and posttraumatic arthritis. locking screws in the metacarpal and
authors concluded that, contrary to carpus. We currently use Steinmann
the findings reported in their pre- Bilateral Total Wrist Arthrodesis rods only in patients who require con-
vious publication, their cost-utility The functional outcomes of bilateral current metacarpophalangeal arthro-
analysis indicated that total wrist wrist arthrodesis have been addressed plasty and in those in whom forearm
arthroplasty was a cost-effective recently in the literature. Historically, dissection cannot be performed. When
procedure, despite its higher com- surgeons have recommended preser- we use Steinmann rods, two rods are
plication and revision rates com- vation of motion in one wrist when the used to control rotation, as described
pared with total wrist arthrodesis.43 other wrist is fused, and several authors previously by the senior author (P.F.).46
In a recent study of patients with continue to advocate this strat- Two technical questions—the ideal
posttraumatic arthritis, Nydick egy.41,44,45 However, in a recent ret- position of wrist fusion and the joints
et al25 compared the clinical rospective review of 13 patients with that must be fused for successful wrist
results of 15 patients treated with bilateral wrist arthrodesis, Wagner arthrodesis—have been debated in the
arthrodesis and 7 patients treated et al36 demonstrated that the patients literature. Some authors advocate a
with arthroplasty. The patient were highly satisfied (93% would neutral fusion position because it
groups were followed for 68 months repeat the surgery) and highly func- provides better pronation and supi-
and 56 months, respectively. The tional (9 patients returned to full-time nation and balances flexor and
two groups had similar satisfactory work) at long-term follow-up (mean, extensor forces,10,21 whereas others
scores on the DASH questionnaire 14 years). Of the 13 patients in the advocate slight extension and ulnar
and comparable complication rates. study, 10 patients had rheumatoid deviation because this position may be
However, the total wrist arthro- arthritis, and 1 patient each had pso- more useful for daily activities.7,34,47
plasty group had a significantly riatic arthritis, osteoarthritis, and Solem et al33 examined wrist position
better mean Patient-Rated Wrist posttraumatic arthritis. The DASH after total wrist fusion in 40 wrists at a
Evaluation (PRWE) score compared scores of the patients with bilateral mean 10.5-year follow-up. Wrists that
with that of the total wrist ar- wrist fusion were comparable to those were fused in extension with the use of
throdesis group (31 for arthroplasty of patients treated for unilateral disease plate fixation had significantly better
versus 73 for arthrodesis, P = 0.01). in other studies, and the PRWE, Mayo grip strength (32 kg versus 17 kg, P ,
Nydick et al25 speculated that the Wrist, and Michigan Hand Question- 0.01). For patients undergoing bilat-
PRWE may provide a better assess- naire scores demonstrated good pain eral wrist fusion, some authors have
ment of wrist motion than the DASH relief, function, and satisfaction. recommended specific positions based

8 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
David H. Wei, MD, MS, and Paul Feldon, MD

on hand dominance, with the domi- Figure 6


nant side in limited extension and the
nondominant side in neutral or slight
flexion to maximize function.48 Our
preferred position is 10° to 15° of
wrist extension with slight ulnar
deviation because we think that this
position allows optimal power during
grip. Because the wrist fusion plates
that we typically use are precontoured
with built-in wrist extension, we typ-
ically allow the amount of wrist
extension to be dictated by the plate. If
a straight plate is used, the plate is
bent in advance to 10° to 15° of
extension, and if the positioning
allows for radial or ulnar deviation,
we err on the side of slight ulnar
deviation.
The specific joints that we routinely Illustrations of total wrist arthrodesis without (A) and with (B) simultaneous
fuse in total wrist arthrodesis with and proximal row carpectomy depicting the mandatory (red line), suggested (dashed
without PRC are shown in Figure 6. red line), and optional (blue line) joint fusions. The senior author (P. F.) prefers to
Nagy and Büchler49 studied the need perform arthrodesis of the dorsal three-fourths of the third carpometacarpal joint
and a portion of the capitohamate joint in both scenarios. The proximal two thirds
to incorporate the third carpometa- of the capitohamate joint is fused when the procedure is performed with a
carpal joint in total wrist arthrodesis proximal row carpectomy, whereas the proximal one third is fused when the
and concluded that it should not procedure is performed without a proximal row carpectomy.
be fused. However, they routinely
removed the plate in their study and
stated that most of their patients were performed. The distal radius should provisionally aligned in the desired
asymptomatic when plates remained be prepared to accommodate the position. The plate is placed on the
in situ. We do not routinely remove plate. To do so, an osteotome is used wrist with the distal end centered over
the plate after surgery, and we fuse to remove part of the dorsal cortical the third metacarpal. The proximal-
the dorsal three-fourths of the third rim so that the plate can be recessed distal location of the most distal
carpometacarpal joint, leaving the into the bone when axial compression metacarpal drill hole through the
volar one-fourth of the joint and its is applied across the fusion sites. We plate is marked. The plate is removed
supporting ligamentous structures commonly excise the triquetrum dur- for the actual drilling to allow direct
intact. ing total wrist arthrodesis because this visualization of the entire width of the
Major complications reported in the method helps to avoid ulnocarpal metacarpal to ensure central place-
literature include nonunion, ulno- impaction and provides a source of ment of the hole. The plate is affixed
carpal impaction, and implant-related autograft bone. The radial styloid is to the metacarpal with the most distal
problems, such as plate prominence also an excellent source of local bone screw, centered along the proximal
and fractures around the plate. Several graft and is easily accessible during the shaft. The more proximal metacarpal
intraoperative technical pearls may be procedure. If the radial styloid is holes are drilled. Both manual com-
helpful to avoid these complications. inadequate, we use the olecranon as pression and compression by design
Adequate preparation of the joints, an alternative source of bone graft through the plate (in healthy bone)
with removal of all cartilage and because this method avoids the mor- are used to adequately appose the
exposure of subchondral bone, is bidity of harvesting iliac crest graft. arthrodesis sites.
crucial. Selection of a plate that most To avoid metacarpal fractures at Preoperative evaluation for distal
closely matches the contour of the the distal end of the plate, we ensure radioulnar joint arthritis can help pre-
fusion site and allows maximal bony that the screw holes are centered in vent symptoms related to unrecognized
contact is important. In our experi- the metacarpal shaft by using the distal radioulnar joint pathology. If a
ence, a short-bend plate may provide a following method. First, all joints are concurrent procedure is indicated, we
better fit when a simultaneous PRC is prepared for fusion, and the wrist is prefer to perform a matched distal

January 2017, Vol 25, No 1 9

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Total Wrist Arthrodesis: Indications and Clinical Outcomes

ulnar resection. However, in patients is a level II study. References 4, 25, patient-reported outcomes in a rheumatoid
population. Surgeon 2014;12(2):78-81.
with soft-tissue laxity, we preserve the 34, 37, 43, and 49 are level III
ulna to prevent postoperative instabil- studies. References 1-3, 5-12, 14-17, 13. El-Kazzi W, Robert C, Mouraux D,
Feipel V, Burny F, Schuind F: Arthrodesis of
ity. Finally, if the finger extensors are 19-21, 23, 24, 26-32, 35, 36, 38-41, the wrist with bone autograft and
found to be directly overlying the plate 44, and 47 are level IV studies. Hoffmann external fixation. J Hand Surg
during closure, we recommend de- References 33 and 45 are level V Eur Vol 2012;37(2):149-154.

taching the wrist extensor (extensor expert opinion. 14. Field J, Herbert TJ, Prosser R: Total wrist
fusion: A functional assessment. J Hand
carpi radialis longus and brevis) ten- References printed in bold type are Surg Br 1996;21(4):429-433.
dons and repositioning them over the those published within the past 5 15. Fontaine C, Mouliade S, Wavreille G,
plate to provide soft-tissue coverage years. Chantelot C: Wrist arthrodesis with
and help prevent postoperative teno- intercalated iliac crest graft in mutilans
synovitis or extensor tendon irritation. 1. Mannerfelt L, Malmsten M: Arthrodesis of rheumatoid arthritis. Chir Main 2014;33
the wrist in rheumatoid arthritis: A (5):336-343.
technique without external fixation. Scand
J Plast Reconstr Surg 1971;5(2):124-130. 16. Green DP, Henderson CJ: Modified AO
Summary arthrodesis of the wrist (with proximal row
2. Millender LH, Nalebuff EA: Arthrodesis of carpectomy). J Hand Surg Am 2013;38(2):
the rheumatoid wrist: An evaluation of 388-391.
Total wrist arthrodesis has been sixty patients and a description of a
demonstrated to be a reliable method different surgical technique. J Bone Joint 17. Houshian S, Schrøder HA: Wrist
Surg Am 1973;55(5):1026-1034. arthrodesis with the AO titanium wrist
for the management of many condi- fusion plate: A consecutive series of 42
tions in both the historical and cur- 3. Clendenin MB, Green DP: Arthrodesis of cases. J Hand Surg Br 2001;26(4):355-359.
the wrist: Complications and their
rent literature. However, further management. J Hand Surg Am 1981;6(3): 18. Howard AC, Stanley D, Getty CJ: Wrist
studies are required to confirm the 253-257. arthrodesis in rheumatoid arthritis: A
comparison of two methods of fusion.
clinical outcomes of bilateral total 4. Hastings H II, Weiss AP, Quenzer D, J Hand Surg Br 1993;18(3):377-380.
wrist fusion. Although Wagner Wiedeman GP, Hanington KR,
Strickland JW: Arthrodesis of the wrist for 19. Kluge S, Schindele S, Henkel T, Herren D:
et al36 demonstrated that patients post-traumatic disorders. J Bone Joint Surg The modified Clayton-Mannerfelt
treated with bilateral wrist fusion in Am 1996;78(6):897-902. arthrodesis of the wrist in rheumatoid
a small series had acceptable func- arthritis: Operative technique and report on
5. Addosooki A, Doi K, Hattori Y, 93 cases. J Hand Surg Am 2013;38(5):
tional outcomes, the results should Wahegaonkar A: Role of wrist arthrodesis 999-1005.
be replicated on a larger scale. The in patients receiving double free muscle
transfers for reconstruction following 20. Kobus RJ, Turner RH: Wrist arthrodesis
procedure should also be studied for complete brachial plexus paralysis. J Hand for treatment of rheumatoid arthritis.
indications other than rheumatoid Surg Am 2012;37(2):277-281. J Hand Surg Am 1990;15(4):541-546.
arthritis. The controversy surround- 6. Adey L, Ring D, Jupiter JB: Health status 21. Lautenbach M, Millrose M, Langner I,
ing total wrist arthroplasty and total after total wrist arthrodesis for Eisenschenk A: Results of Mannerfelt wrist
posttraumatic arthritis. J Hand Surg Am arthrodesis for rheumatoid arthritis in
wrist arthrodesis requires further 2005;30(5):932-936. relation to the position of the fused wrist.
research to better inform both Int Orthop 2013;37(12):2409-2413.
7. Barbier O, Saels P, Rombouts JJ,
patients and surgeons during the Thonnard JL: Long-term functional results 22. Lee DH, Carroll RE: Wrist arthrodesis: A
decision-making process. Although of wrist arthrodesis in rheumatoid arthritis. combined intramedullary pin and
J Hand Surg Br 1999;24(1):27-31. autogenous iliac crest bone graft technique.
the cost-effectiveness of these tech-
J Hand Surg Am 1994;19(5):733-740.
niques has been studied, the evolu- 8. Carlson JR, Simmons BP: Wrist arthrodesis
after failed wrist implant arthroplasty. 23. Masada K, Yasuda M, Takeuchi E,
tion of implants used for total wrist Hashimoto H: Technique of intramedullary
J Hand Surg Am 1998;23(5):893-898.
arthroplasty mandates repeat exam- fixation for arthrodesis of the wrist in
ination with longer-term clinical 9. Christodoulou L, Patwardhan MS, Burke rheumatoid arthritis. Scand J Plast Reconstr
FD: Open and closed arthrodesis of the Surg Hand Surg 2003;37(3):155-158.
outcomes. Rigorous evidence and rheumatoid wrist using a modified (Stanley)
multicenter randomized studies Steinmann pin. J Hand Surg Br 1999;24(6): 24. Murphy DM, Khoury JG, Imbriglia JE,
662-666. Adams BD: Comparison of arthroplasty
comparing the long-term outcomes and arthrodesis for the rheumatoid wrist.
of total wrist arthrodesis and total 10. Clayton ML: Surgical treatment at the wrist J Hand Surg Am 2003;28(4):570-576.
in rheumatoid arthritis: A review of thirty-
wrist arthroplasty are needed. seven patients. J Bone Joint Surg Am 1965; 25. Nydick JA, Watt JF, Garcia MJ,
47(4):741-750. Williams BD, Hess AV: Clinical outcomes
of arthrodesis and arthroplasty for the
11. De Smet L, Truyen J: Arthrodesis of the treatment of posttraumatic wrist arthritis.
References wrist for osteoarthritis: Outcome with J Hand Surg Am 2013;38(5):899-903.
a minimum follow-up of 4 years. J Hand
Evidence-based Medicine: Levels of Surg Br 2003;28(6):575-577. 26. Pech J, Sosna A, Rybka V, Pokorný D:
Wrist arthrodesis in rheumatoid arthritis:
evidence are described in the table of 12. Elherik FK, Beattie N, Breusch SJ: The A new technique using internal fixation.
contents. In this article, reference 42 Mannerfelt wrist arthrodesis: A study of J Bone Joint Surg Br 1996;78(5):783-786.

10 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
David H. Wei, MD, MS, and Paul Feldon, MD

27. Rauhaniemi J, Tiusanen H, Sipola E: Total functional evaluation of two surgical with total wrist arthrodesis for rheumatoid
wrist fusion: A study of 115 patients. techniques. J Bone Joint Surg Br 2007;89 arthritis. Plast Reconstr Surg 2008;122(3):
J Hand Surg Br 2005;30(2):217-219. (12):1620-1626. 813-825.

28. Rayan GM, Young BT: Arthrodesis of the 35. Van Heest AE, Strothman D: Wrist 43. Cavaliere CM, Chung KC: A cost-utility
spastic wrist. J Hand Surg Am 1999;24(5): arthrodesis in cerebral palsy. J Hand Surg analysis of nonoperative management, total
944-952. Am 2009;34(7):1216-1224. wrist arthroplasty, and total wrist
arthrodesis in rheumatoid arthritis. J Hand
29. Rehak DC, Kasper P, Baratz ME, Hagberg 36. Wagner ER, Elhassan BT, Kakar S: Long- Surg Am 2010;35(3):379-391.e2.
WC, McClain E, Imbriglia JE: A term functional outcomes after bilateral
comparison of plate and pin fixation for total wrist arthrodesis. J Hand Surg Am 44. Chim HW, Reese SK, Toomey SN,
arthrodesis of the rheumatoid wrist. 2015;40(2):224-228.e1. Moran SL: Update on the surgical
Orthopedics 2000;23(1):43-48. treatment for rheumatoid arthritis of the
37. Dafydd M, Whitaker IS, Murison MS, wrist and hand. J Hand Ther 2014;27(2):
30. Riches PL, Elherik FK, Breusch SJ: Boyce DE: Change in operative workload 134-141, quiz 142.
Functional and patient-reported outcome for rheumatoid disease of the hand: 1,109
of partial wrist denervation versus the procedures over 13 years. J Plast Reconstr 45. Trieb K: Arthrodesis of the wrist in
Mannerfelt wrist arthrodesis in the Aesthet Surg 2012;65(6):800-803. rheumatoid arthritis. World J Orthop 2014;
rheumatoid wrist. Arch Orthop Trauma 5(4):512-515.
Surg 2014;134(7):1037-1044. 38. Louie GH, Ward MM: Changes in the rates
of joint surgery among patients with 46. Feldon P, Terrono AL, Nalebuff EA,
31. Rizzo M, Ackerman DB, Rodrigues RL, rheumatoid arthritis in California, 1983- Millender LH: Rheumatoid arthritis and
Beckenbaugh RD: Wrist arthrodesis as a 2007. Ann Rheum Dis 2010;69(5): other connective tissue diseases, in
salvage procedure for failed implant 868-871. Wolfe SW, Hotchkiss RN, Pederson WC,
arthroplasty. J Hand Surg Eur Vol 2011;36 Kozin SH, eds: Green’s Operative Hand
(1):29-33. 39. Adams BD, Grosland NM, Murphy DM, Surgery, ed 6. Philadelphia, PA, Elsevier
McCullough M: Impact of impaired wrist Churchill Livingstone, 2011, vol 2, pp
32. Sauerbier M, Kluge S, Bickert B, Germann G: motion on hand and upper-extremity 1993-2066.
Subjective and objective outcomes after total performance. J Hand Surg Am 2003;28(6):
wrist arthrodesis in patients with radiocarpal 898-903. 47. Pryce JC: The wrist position between
arthrosis or Kienböck’s disease. Chir Main neutral and ulnar deviation that facilitates
2000;19(4):223-231. 40. Thabet AM, Kowtharapu DN, Miller F, the maximum power grip strength.
et al: Wrist fusion in patients with severe J Biomech 1980;13(6):505-511.
33. Solem H, Berg NJ, Finsen V: Long term quadriplegic cerebral palsy. Musculoskelet
results of arthrodesis of the wrist: A 6-15 Surg 2012;96(3):199-204. 48. Rizzo M, Cooney WP III: Current concepts
year follow up of 35 patients. Scand J Plast and treatment for the rheumatoid wrist.
Reconstr Surg Hand Surg 2006;40(3): 41. Beer TA, Turner RH: Wrist arthrodesis for Hand Clin 2011;27(1):57-72.
175-178. failed wrist implant arthroplasty. J Hand
Surg Am 1997;22(4):685-693. 49. Nagy L, Büchler U: AO-wrist arthrodesis:
34. Toma CD, Machacek P, Bitzan P, Assadian O, With and without arthrodesis of the third
Trieb K, Wanivenhaus A: Fusion of the wrist 42. Cavaliere CM, Chung KC: A systematic carpometacarpal joint. J Hand Surg Am
in rheumatoid arthritis: A clinical and review of total wrist arthroplasty compared 2002;27(6):940-947.

January 2017, Vol 25, No 1 11

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Instructional Course Lecture

Ulnar Tunnel Syndrome, Radial


Tunnel Syndrome, Anterior
Interosseous Nerve Syndrome,
and Pronator Syndrome

Abstract
Adam B. Strohl, MD In addition to the more common carpal tunnel and cubital tunnel
David S. Zelouf, MD syndromes, orthopaedic surgeons must recognize and manage other
potential sites of peripheral nerve compression. The distal ulnar nerve
may become compressed as it travels through the wrist, which is
known as ulnar tunnel or Guyon canal syndrome. The posterior
interosseous nerve may become entrapped in the proximal forearm as
it travels through the radial tunnel, which results in a pain syndrome
without motor weakness. The median nerve may become entrapped
in the proximal forearm, which can result in a variety of symptoms.
Spontaneous neuropathy of the anterior interosseous nerve of the
median nerve can be observed without external compression.
Electrodiagnostic and imaging studies may aid surgeons in the
diagnosis of these syndromes; however, a thorough physical
examination is paramount to localize compressed segments of these
nerves. An understanding of the anatomy of each of these nerve areas
allows practitioners to appreciate a patient’s clinical findings and
From the Philadelphia Hand Center helps guide surgical decompression.
(Dr. Strohl), and the Thomas Jefferson
University Hospital, Philadelphia, PA
(Dr. Zelouf).
This article, as well as other lectures
presented at the Academy’s Annual
Meeting, will be available in March
P eripheral nerves may become
compressed at multiple anatomic
locations in the upper extremity,
clinical findings of, and treatment
options for compression and intra-
neural pathology of the ulnar, radial,
2017 in Instructional Course Lectures, which can lead to dysfunction, such and median nerves. An understand-
Volume 66. ing of anatomy and nerve topogra-
as motor weakness, sensory distur-
Dr. Zelouf or an immediate family bance, and/or pain. Median nerve phy not only aids in the accurate
member serves as a board member, compression at the wrist, which is diagnosis of peripheral nerve com-
owner, officer, or committee member
of the Eastern Orthopaedic known as carpal tunnel syndrome, pression but also guides appropriate
Association. Neither Dr. Strohl nor any followed by ulnar nerve compression and effective management.
immediate family member has at the elbow, which is known as cu-
received anything of value from or has
bital tunnel syndrome, are the most
stock or stock options held in a
commercial company or institution common compression neuropathies. Ulnar Tunnel Syndrome
related directly or indirectly to the In addition to carpal tunnel and cu-
subject of this article. bital tunnel syndromes, orthopaedic Although the ulnar nerve is most
J Am Acad Orthop Surg 2017;25: surgeons must be familiar with less commonly compressed in the cubital
e1-e10 common compression neuropathies tunnel region at the elbow, compres-
DOI: 10.5435/JAAOS-D-16-00010 that may be encountered in the eval- sion of the ulnar nerve also can occur
uation of patients with peripheral distally at the wrist, which is known
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. nerve entrapment. Surgeons should as ulnar tunnel syndrome. Similar to
understand the patient complaints of, compression of the ulnar nerve in the

January 2017, Vol 25, No 1 e1

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 1 inent claw deformity. Ulnar nerve


compression at the wrist can occur
in isolation or in conjunction with
compression of the ulnar nerve at
more proximal locations. Further-
more, the physical examination
findings of proximal ulnar nerve
compression may mask concurrent
pathology at the wrist.

Anatomy
In 1861, Jean Casimir Félix Guyon
first described the course and divi-
sion of the ulnar nerve through the
hypothenar region. This space,
which is the location at which
Guyon first suggested potential
pathologic constriction of the ulnar
nerve, is currently referred to as the
Guyon canal or the ulnar tunnel.
Gross and Gelberman1 further
described the unique space of the
distal ulnar tunnel, which they
divided into three zones based on
the internal topography of the
ulnar nerve as it courses through
the ulnar tunnel. Characterization
of the zones of the ulnar tunnel
based on the presence of motor and
Illustration showing the anatomy of the ulnar tunnel at the wrist. H = hamate, P = sensory components within the
pisiform (Reproduced from Earp BE, Floyd WE, Louie D, Koris M, Protomastro P: ulnar nerve allows surgeons to
Ulnar nerve entrapment at the wrist. J Am Acad Orthop Surg 2014;22[11]:699-706.) localize the site of compression
within the ulnar tunnel based on a
patient’s symptomatology and
cubital tunnel, distal compression of muscle atrophy and weakness can clinical findings. The distal ulnar
the ulnar nerve may lead to sensory occur, which may lead to hand tunnel is 4 to 4.5 cm long and
and motor deficits in the hand and weakness, clumsiness, and/or dys- begins at the proximal edge of the
digits. Likewise, sensory paresthesias function. However, in patients with volar carpal ligament (Figure 1).
may affect the little finger and the only distal compression of the ulnar The distal ulnar tunnel extends to
ulnar half of the ring finger. Based on nerve, strength is preserved in the the fibrous arch of the hypothenar
anatomic considerations, important flexor carpi ulnaris and the flexor muscles. The borders of the distal
clinical features of ulnar tunnel syn- digitorum profundus (FDP) muscles ulnar tunnel are not constant
drome distinguish it from cubital of the ring and little fingers. Late because the ulnar nerve courses
tunnel syndrome. Because the palmar clinical findings of ulnar claw between ulnar-sided wrist struc-
cutaneous and dorsal cutaneous deformity, which is referred to as tures, most notably the pisiform
branches of the ulnar nerve branch ulnar paradox, are often more pro- and the hamate. In addition, the
off the ulnar nerve before it enters the nounced in patients with distal ulnar artery accompanies the ulnar
ulnar tunnel at the wrist, the ulnar compression of the ulnar nerve. The nerve through the ulnar tunnel.
palm and dorsum of the hand are preservation of proximally inner- Zone 1 of the ulnar tunnel is slightly
spared. vated FDP muscles allows for more more than 3 cm in length and
In patients with advanced cubital flexion of the interphalangeal encompasses the portion of the ulnar
tunnel syndrome at the elbow, intrinsic joints, which creates a more prom- tunnel that is proximal to the

e2 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

bifurcation of the ulnar nerve into its Surgeons should understand that Tenderness over the hamate or
motor and sensory branches. There- the palmar cutaneous branch of the pisiform may suggest a fracture. A
fore, compression of the ulnar nerve ulnar nerve, which is referred to as positive ulnar Allen test and/or
in zone 1 results in both paresthesia the nerve of Henle, is present in only ulceration of the ulnar fingertips
and intrinsic muscle deficit. The ulnar 58% of persons.3 Therefore, the supports a vascular etiology. As
nerve is first compressed between the contribution of the palmar cutane- already mentioned, practitioners
volar carpal ligament palmarly and ous branch of the ulnar nerve to must recognize that ulnar nerve
the transverse carpal ligament dor- palmar innervation is variable, entrapment can occur at multiple
sally. More distally in zone 1 of the unlike the dorsal cutaneous branch locations as part of a double crush
ulnar tunnel, the floor of the ulnar of the ulnar nerve, which consis- phenomenon. In patients without a
tunnel is composed of the pisohamate tently arises approximately 5.5 cm history of trauma to the affected
and pisometacarpal ligaments. Gan- proximal to the ulnar head. As a hand, surgeons should have a high
glion cysts followed by hook of result, sensory examination for suspicion for ganglia, which account
hamate fractures, traumatic adhe- ulnar nerve function is more reliable for 90% of pathology that is present
sions, and anomalous muscles are the in the little and ulnar ring fingers as within zone 1 and zone 2 of the ulnar
most common causes of compression well as the dorsal ulnar hand. tunnel.4 Moreover, patients who
of the ulnar nerve in zone 1 of the have professional duties that require
ulnar tunnel.1,2 Zone 1 of the ulnar the use of repetitive blunt force, such
tunnel is the most commonly Clinical and Diagnostic as jackhammering, and patients who
affected zone of the ulnar tunnel. Findings participate in hobbies such as rac-
After the ulnar nerve bifurcates, the A physical examination, which quet sports should be examined for
deep motor branch of the ulnar nerve should include the Tinel test and possible related factors.
pursues a dorsal and radial course sensory threshold testing, that sug- Electrodiagnostic studies can be
around the hamate as it dives deep to gests distal ulnar nerve compression performed to help support a diag-
the fibrous arch of the hypothenar at the wrist can be further supported nosis of ulnar tunnel syndrome and
muscles. This area composes zone 2 with the use of electrodiagnostic to differentiate the clinical findings
of the ulnar tunnel. Pathology that is studies. Multiple clinical findings, of ulnar tunnel syndrome from
present within zone 2 of the ulnar including the presence of interossei other diagnoses, such as cubital
tunnel leads to deficits in motor wasting, particularly over the first tunnel, thoracic outlet, and cervical
function only, without sensory dis- dorsal interosseous muscle; the radiculopathy syndromes. Surgeons
turbances. Similar to zone 1, ganglion inability to cross fingers; or abducted should expect prolonged motor and/
cysts are the most common patho- positioning of the little finger, which or sensory latencies across the wrist
logic cause of compression of the is known as the Wartenberg sign, but normal values from more proxi-
ulnar nerve in zone 2 of the ulnar suggest motor branch involvement. mal structures. Therefore, palmar
tunnel. Other causes of compression Ulnar claw deformity, which also is and dorsal cutaneous nerves should
of the ulnar nerve in this area include known as the Duchenne sign, may be have normal latencies, and electro-
fractures and a thickened pisohamate observed secondary to lumbrical diagnostic studies should not detect
ligament.1,2 paralysis of the little and ring fingers. abnormality in proximally inner-
Zone 3 of the ulnar tunnel Intact extensor tendons may place vated muscles, such as the flexor
encompasses the superficial sensory the unopposed metacarpophalangeal carpi ulnaris and/or the FDP of the
branch of the ulnar nerve as it joint in hyperextension and the long little finger, which would suggest
courses palmar to the fascia of the flexors may place the proximal cubital tunnel syndrome. Similar to
hypothenar muscles. Pathology that interphalangeal joint and distal all peripheral compression neuropa-
is present within zone 3 of the ulnar interphalangeal joint in a flexed thies, paraspinal muscle findings
tunnel leads to sensory disturbances position. Attempted pinch between suggest cervical radiculopathy.
only. Interestingly, connections the thumb and the index finger may Standard radiographs, including a
between the ulnar and median lead to compensatory thumb inter- carpal tunnel view, may help identify
nerves are identified in zone 3 of the phalangeal flexion (Froment sign) fractures. Advanced imaging, such as
ulnar tunnel. Ulnar artery throm- and, occasionally, hyperextension of MRI or CT, can be obtained to fur-
bosis and ulnar artery aneurysm are the thumb metacarpophalangeal ther evaluate fractures or to assess
the most common causes of com- joint (Jeanne sign), which occur sec- space-occupying lesions within the
pression of the ulnar nerve in zone 3 ondary to paralysis of the adductor ulnar tunnel as well as vascular
of the ulnar tunnel.1,2 pollicis muscle. lesions of the ulnar artery.

January 2017, Vol 25, No 1 e3

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 2 joint. These nerves are subject to


compression at the proximal fore-
arm by various structures; however,
clinical presentation may vary.
Unlike patients with PIN syndrome,
patients with radial tunnel syndrome
(RTS) lack clinical findings of motor
weakness of the PIN-innervated
digital extensors.5 Patients with
RTS have no paresthesias in the
dorsoradial hand but, instead, have
characteristic pain at the area of
entrapment, which, typically, is
located at the lateral forearm distal to
the lateral epicondyle. Occasionally,
vague wrist pain also may be associ-
ated with RTS.6
The diagnosis of RTS, and even the
existence of the phenomenon, has
been a subject of controversy for
many years. The differential diagno-
sis for RTS includes lateral epi-
condylosis, an extensor carpi radialis
brevis (ECRB) tear, osteoarthritis
and/or synovitis of the radiocapitellar
Illustration showing the course of the posterior interosseous nerve through the joint, and posterior plica impinge-
radial tunnel. ECRB = extensor carpi radialis brevis, ECRL = extensor carpi ment. In contrast to carpal tunnel and
radialis longus, EDC = extensor digitorum communis, FCR = flexor carpi radialis cubital tunnel syndromes, the patho-
physiology of RTS is less straight-
forward. Many surgeons believe that
Treatment tunnel. All three zones of the ulnar radial nerve compression in patients
Patients with mild ulnar tunnel syn- tunnel should be addressed, focusing with RTS is not severe enough to
drome may be treated nonsurgically on compressive structures, such as cause radial sensory or motor dys-
with protective splinting and anti- the antebrachial fascia, the volar function, but that, instead, radial
inflammatory medications. In addi- carpal ligament, and the hypothenar nerve irritation is perceived as pain.6
tion, activity modification may help fibrous arch (overlying the deep
alleviate symptoms and prevent the motor branch). The ulnar artery
progression of neuropathy. Aspira- should be inspected, and any vascular Anatomy
tion of ganglion cysts, which has been lesions should be resected, with or Anatomically, the radial tunnel is
used to successfully manage ulnar without vessel reconstruction. approximately 5 cm long and begins
tunnel syndrome, should be per- as the radial nerve courses past the
formed with caution given the prox- Radial Tunnel Syndrome radiocapitellar joint. The roof of the
imity of the neurovascular structures. radial tunnel is formed by the bra-
Surgical treatment should be Located distal to the elbow, the radial chioradialis muscle. Medially, the
reserved for patients with more nerve is composed of the superficial radial tunnel is bounded by the biceps
severe ulnar tunnel syndrome, par- sensory branch, which provides tendon and the brachialis (Figure 2).
ticularly those who have space- innervation to the dorsoradial Laterally, the radial tunnel is
occupying lesions and those in hand, and the posterior interosseous bounded by the ECRB and the
whom nonsurgical treatment fails. nerve (PIN), which provides motor extensor carpi radialis longus muscles
The goals of the surgical management input to the supinator and extensors as well as the brachioradialis muscle.
of ulnar tunnel syndrome include the of the wrist and digits. The terminal Distally, the radial tunnel is classically
removal of compressive masses and PIN also provides sensory innerva- believed to end at the fibrous arch
complete decompression of the ulnar tion and proprioception to the wrist of the proximal edge of the supinator

e4 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

muscle, which is referred to as the Electrodiagnostic studies lack spe- (3) between the brachioradialis and
arcade of Frohse. Although constric- cific findings for RTS and often are the extensor carpi radialis longus.
tive, fibrous bands may exist at the normal in patients with RTS. Patients Regardless of the selected approach,
distal end of the supinator muscle, the with conductive slowing of the radial the goal is complete decompression of
supinator fascia is the most common nerve likely have associated motor the PIN within the radial tunnel. Areas
cause of compression of the radial findings, thereby precluding a diag- of focus for decompression include the
nerve. Other causes of compression nosis of RTS. However, abnormal arcade of Froshe, the leading edge of
of the radial nerve include prominent findings on electrodiagnostic studies the proximal ECRB, and the com-
recurrent radial vessels, a thickened may elucidate other causes of pain, pressive fascia of the distal supinator.
edge of the ECRB, and schwannoma- such as cervical radiculopathy. Occasionally, flattening or congestion
like swelling of the radial nerve.7 Sequential, selective lidocaine injec- that is located proximal to the site of
tions can help localize the source of compression may appear as swelling
pain and rule out other diagnoses, such or a pseudoneuroma.10
Clinical and Diagnostic as lateral epicondylosis. In addition, Reported outcomes of patients with
Findings the scratch collapse test, which local- RTS vary in the literature. Studies
On clinical examination, a patient izes the point of maximum compres- have suggested that patients with
sion in cubital tunnel syndrome, has isolated RTS and no concurrent
with RTS will report proximal, lat-
been reported to be a useful adjunct for compressive neuropathy or tendi-
eral forearm or elbow pain that often
worsens with rotational movements the diagnosis of RTS.9 nopathy have more favorable out-
comes compared with patients with
of the forearm. Pressure that is
isolated RTS who have associated
applied over a patient’s lateral fore- Treatment
arm approximately 3 to 5 cm distal conditions. Lee et al12 reported good
Nonsurgical treatment should be the outcomes in 86% of patients with
to the elbow, more specifically over
first-line treatment for patients with isolated RTS compared with 43% of
the supinator muscle, with the wrist
RTS. Nonsurgical treatment may patients with concomitant lateral
in full supination should reproduce
include the use of NSAIDs, wrist epicondylosis and 57% of patients
substantial pain. Pronation of the
splinting, activity modification, and with other compressive neuropa-
wrist during this maneuver, which
supervised physical therapy. Physical thies. Other studies have reported
moves the radial nerve away from
therapy may include nerve-gliding that workers’ compensation patients
the thumb-directed pressure, should
exercises, ultrasonographic therapy, with RTS have poorer outcomes
relieve the pain.6 Loh et al8 pro-
and heat/cold modalities, which also compared with non-workers’ com-
posed the Rule-of-Nine test, in
may be used to manage associated pensation patients with RTS.10,13
which the volar, proximal forearm
symptoms of lateral epicondylosis.
is divided into nine squares, to aid in
the diagnosis of RTS. The authors The use of counterforce or tennis
elbow braces should be avoided
Anterior Interosseous
reported that RTS pain is confined Nerve Syndrome and
because they apply external pressure
to squares one and two, which Pronator Syndrome
overlay the course of the radial on the radial nerve. Steroid injections
also may play a role in the non-
nerve at the most radial, proximal Anterior interosseous nerve (AIN)
surgical management of RTS.10,11
portions of the forearm.8 Other syndrome and pronator syndrome
provocative maneuvers that can be Surgical treatment may be consid-
are clinical entities of proximal
ered to decompress the radial nerve
used to aid in the diagnosis of RTS median neuropathy in the forearm
within the radial tunnel in patients in
include pain with resisted, active that have similar but uniquely dif-
whom nonsurgical treatment mea-
extension of the wrist or the long ferent presentations and etiologies.
sures fail to alleviate symptoms. The
finger. Slight weakness of the Practitioners must have a thorough
PIN can be accessed via multiple
extensors is believed to occur sec- understanding of the anatomy of the
approaches, including the posterior
ondary to pain rather than motor median nerve to distinguish AIN
and anterior approaches. Dorsal
nerve dysfunction. Often, these syndrome from pronator syndrome.
approaches include the following
provocative maneuvers that can be
intervals: (1) between the ECRB and
used to aid in the diagnosis of RTS Anatomy
the extensor digitorum communis,
are positive in patients with lateral
which also is known as the dorsal Typically, no branches of the median
epicondylosis, which is a closely
(Henry) approach; (2) transmuscular nerve occur proximal to the elbow;
associated differential diagnosis.
via splitting of the brachioradialis; and however, a variable branch to the

January 2017, Vol 25, No 1 e5

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 3

Illustrations showing the course of the median nerve with potential compression points. A, Illustration showing the median-
innervated muscles and potential sites of compression (yellow dots), which include the ligament of Struthers (if present) and the
pronator teres. B, Illustration showing the median nerve passing beneath the lacertus fibrosus of the bicipital aponeurosis, which
is another potential site of compression. C, Illustration showing the lacertus fibrosus and pronator teres divided and the median
nerve passing deep to the fibrous arch of the flexor digitorum superficialis, which is another potential site of compression.

pronator teres may be observed in brosus, which is an ulnarly directed (FPL), the FDP of the index and the
some patients (Figure 3). Distal to the extension of the bicipital aponeuro- long fingers, and the pronator
elbow, the median nerve remains sis, to the antebrachial fascia, which quadratus. The AIN has no cutane-
medial to the brachial artery and the also may have a deep component to ous sensory component, which is an
biceps brachii tendon as well as the pronator teres fascia. The median important characteristic to keep
anterior to the brachialis insertion. nerve continues between the heads of in mind in the localization of median
The median nerve provides motor the pronator teres before it dives nerve dysfunction. The palmar
innervation to the muscles of the deep to the fibrous arch of the FDS cutaneous branch of the median
superficial forearm compartment, muscle origin. At this point, the AIN nerve arises 6 to 7 cm proximal to
which include the pronator teres, the branches off, whereas the rest of the the wrist crease on the ulnar side of
palmaris longus, the flexor dig- median nerve continues deep to the the flexor carpi radialis and does not
itorum superficialis (FDS), and the FDS muscle toward the carpal tun- traverse through the carpal tunnel.
flexor carpi radialis. The median nel. The AIN provides motor inner- The distal AIN is believed to provide
nerve passes below the lacertus fi- vation to the flexor pollicis longus capsular sensory innervation to the

e6 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

radiocarpal, intercarpal, carpometa- attributed to spontaneous AIN palsy ulnar nerve–innervated function of
carpal, and radioulnar joints.14 include viral illness (25% to 55%), thumb adduction against the index
immunizations (15%), preoperative finger. Variations in nerve innerva-
or peripartum periods (.14%), and tion, in which an anastomosis
Pronator Syndrome Versus strenuous exercise (8%).16 A pro- between the ulnar and median nerves
AIN Syndrome dromal phase of flu-like symptoms in the forearm may account for re-
First described by Seyffarth15 in may precede AIN syndrome, and tained motor function despite AIN
1951, pronator syndrome originally patients with AIN syndrome may involvement, are very rare. Although
referred to compression of the report vague forearm pain before similarly rare, intrinsic motor dys-
median nerve between the two heads weakness. Interestingly, Ochi et al17 function may be observed in patients
of the pronator teres through which reported multiple patterns of fas- with AIN palsy if innervation is
the median nerve passes in the cicular constrictions (eg, recessed, median nerve dominant. The FDP of
proximal forearm. Other potential recessed-bulging, rotation, rotation- the long finger also has been reported
sites of median nerve entrapment bulging) of the median nerve in to be innervated by the ulnar nerve.20
include the lacertus fibrosus; the FDS patients with spontaneous AIN Other variations in nerve innervation
aponeurotic arch; the aberrant radial palsy. Other studies also have rec- include AIN innervation to the FDP
artery; the variant muscles; and the ognized intraneural constrictions as muscles of all four fingers and AIN
ligament of Struthers, which is an a potential cause of median nerve innervation to the FDS.21
anomalous extension from the su- dysfunction.18 As mentioned earlier, the presence
pracondylar process of the humerus of sensory deficits rules out an iso-
to the medial epicondyle. In addition lated AIN lesion but supports a
to motor weakness, patients with Clinical and Diagnostic diagnosis of pronator syndrome or
pronator syndrome report paresthe- Findings similar entrapment of the median
sia, most notably of the palm, sec- On physical examination, patients nerve proximal to the point at which
ondary to involvement of the palmar with proximal median neuropathy the AIN branches off the median
cutaneous branch of the median may have motor weakness in the nerve. Palmar paresthesia may help
nerve. muscles that correspond with the surgeons distinguish carpal tunnel
Because the AIN lacks cutaneous branches of the AIN and/or compression from compression at
sensory fibers, patients with a true the median nerve distal to the area(s) more proximal locations. In addition,
AIN palsy, similar to patients with of pathology. Manual motor testing patients with proximal median neu-
pronator syndrome, will lack clini- should focus on the FPL (interpha- ropathy commonly report vague pain
cally relevant sensory deficits. Isolated langeal flexion of thumb), the FDP of in the proximal forearm. Provocative
palsy of the AIN often is spontaneous the index and long fingers (distal maneuvers that reproduce pain and/
in nature and usually is self-limiting. interphalangeal flexion of the respec- or paresthesia may help surgeons to
Iatrogenic injury of the AIN can occur tive digits), and the pronator quad- localize common sites of median
during surgical procedures in the ratus (wrist pronation with the elbow nerve compression. The lacertus fi-
proximal forearm, and direct injury of flexed). The latter may be difficult to brosus can be assessed via resisted
the AIN can occur secondary to pen- assess clinically in patients with a elbow flexion with the forearm in a
etrating trauma. Rarely, entrapment functioning pronator teres muscle. supinated position.22 The pronator
of the AIN is attributed to an acces- Patients with proximal median neu- teres can be assessed via resisted
sory FPL (ie, the Gantzer muscle). If ropathy will be unable to make the forearm pronation. The FDS arch
not related to external forces, such as OK sign, which is known as the Kiloh- can be assessed via resisted finger
trauma or compression, the etiology Nevin sign, whereby the tips of the flexion, particularly the proximal
and pathophysiology of a spontane- thumb and the index finger are interphalangeal joint of the long
ous AIN palsy or AIN syndrome are brought together to form a circle finger. A positive Tinel sign and a
not entirely known; however, spon- shape.16,19 The inability of a patient positive scratch collapse test may be
taneous AIN palsy or AIN syndrome to grip a piece of paper with the tips observed in patients with proximal
is believed to be the result of an of the index finger and the thumb is median neuropathy.23
inflammatory neuritis. AIN syndrome another indication of proximal Practitioners must consider the dif-
often is associated with Parsonage- median neuropathy. To compensate ferential diagnoses of proximal median
Turner syndrome, which is a brachial for this inability, patients with neuropathy, such as Parsonage-Turner
plexus neuritis that also is known proximal median neuropathy will use neuritis of the brachial plexus. Patients
as neuralgic amyotrophy. Triggers a key pinch maneuver, relying on with partial lesions of the lateral cord

January 2017, Vol 25, No 1 e7

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 4

Images showing targeted surgical epineurotomy of a lesion of the median nerve at the level of the upper arm. Illustration (A)
and high-resolution T2-weighted magnetic resonance image (B) demonstrating localization of the lesion 9.2 cm proximal to
the humeroradial joint space (red circle in panel A). C, Intraoperative photograph taken before epineurotomy showing a
subtle increase in nerve caliber. D, Intraoperative photograph taken after epineurotomy showing neurolysis and subsequent
detorsion of the anterior interosseous nerve (asterisk), which was observed within the median nerve. (Adapted with
permission from Pham M, Bäumer P, Meinck HM, et al: Anterior interosseous nerve syndrome: Fascicular motor lesions of
medial nerve trunk. Neurology 2014;82[7]:598-606.)

may have clinical findings similar to may be observed on MRI.18,24 Elec- rest, activity modification, rotational
those of patients with proximal trodiagnostic studies may reveal immobilization, forearm flexor mus-
median neuropathy. Mannerfelt syn- sharp waves, fibrillations, and cle stretching, nerve-gliding exer-
drome, which refers to attritional abnormal latencies in the affected cises, and the use of NSAIDs. Surgical
rupture of the FPL secondary to a car- muscles of patients with AIN syn- treatment may be considered in
pal osteophyte and is observed in drome. Similar findings as well as patients in whom a 3- to 6-month
patients with rheumatoid arthritis, slowing of conduction across the trial of nonsurgical treatment fails to
may account for spontaneous loss of elbow may be observed in patients alleviate symptoms. The goal of sur-
thumb interphalangeal flexion. Unlike with pronator syndrome; however, gical decompression is to relieve all
Mannerfelt syndrome, however, the the electrodiagnostic study findings potential sites of entrapment along
tenodesis effect of the thumb inter- of patients with pronator syndrome the median nerve. In general, surgical
phalangeal joint is retained in patients may be normal or mimic those of decompression has been reported to
with AIN palsy. Although uncommon, patients with carpal tunnel syn- be beneficial in patients with pro-
patients may have congenital absence drome.22,25 Moreover, positive find- nator syndrome.16,22,26,27
of the FDP or the FPL, accounting for ings on electrodiagnostic studies/
motor dysfunction, without any nerve conduction studies may suggest
median neuropathy. other sites of compression or disease, Management of AIN
In general, traditional imaging particularly in patients with brachial Syndrome
studies do not aid in the diagnosis of plexus involvement. A more prolonged period of obser-
proximal median neuropathy, except vation is warranted for patients in
in patients with space-occupying whom spontaneous AIN palsy of the
lesions or in patients in whom the Management of Pronator neuritic variety is suspected.
rare supracondylar process suggests Syndrome Patients in whom AIN syndrome is
the presence of the ligament of Nonsurgical treatment is recom- diagnosed early may be initially
Struthers. If present, edema of AIN- mended as the initial treatment for treated with high doses of cortico-
innervated muscles or intraneural patients with pronator syndrome. steroids and antiviral medications,
abnormalities of the AIN occasionally Nonsurgical treatment may include such as acyclovir.28 Spontaneous

e8 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

recovery of AIN function can occur; via a physical examination and/or differ from that of patients with AIN
however, patients may require up to electrodiagnostic studies. The unique syndrome.
1 year of observation. Despite anatomy of the ulnar tunnel allows
lengthy expectant treatment, some surgeons to further localize pathol-
patients may not recover AIN func- ogy to one or more of the three zones References
tion. Earlier surgical treatment is of the ulnar tunnel based on the
acceptable in patients in whom a clinical findings and symptoms of a References in bold type are those
space-occupying lesion or local patient. Unlike entrapment of the published within the last 5 years.
injury to the AIN is confirmed. Nerve ulnar nerve in the cubital tunnel at 1. Gross MS, Gelberman RH: The anatomy of
exploration and neurolysis may be the elbow, the ulnar nerve often is the distal ulnar tunnel. Clin Orthop Relat
Res 1985;196:238-247.
indicated for patients with AIN syn- compressed within the ulnar tunnel
drome in whom no electrodiagnostic at the wrist by external forces, such 2. Murata K, Shih JT, Tsai TM: Causes of
ulnar tunnel syndrome: A retrospective
evidence of recovery is noted after 7 as masses, adhesions, or fractures. study of 31 subjects. J Hand Surg Am 2003;
to 10 months of observation.14 RTS may be difficult to diagnose, 28(4):647-651. DOI
Some recent studies have reported especially in patients with other 3. Balogh B, Valencak J, Vesely M, Flammer
improved outcomes in patients with symptoms. The management of M, Gruber H, Piza-Katzer H: The nerve of
Henle: An anatomic and
AIN syndrome who undergo earlier RTS remains controversial. A care- immunohistochemical study. J Hand Surg
surgical treatment that consists of ful, clinical examination is para- Am 1999;24(5):1103-1108. DOI
epineurotomy and internal neurolysis mount, and proper patient selection 4. Bachoura A, Jacoby SM: Ulnar tunnel
based on the fascicular constriction for the surgical management of RTS syndrome. Orthop Clin North Am 2012;43
theory, especially if more current MRI is important to achieve successful (4):467-474. DOI

or ultrasonographic techniques sug- outcomes. 5. Moradi A, Ebrahimzadeh MH, Jupiter JB:


gest local swelling or constric- The median nerve is susceptible to Radial tunnel syndrome, diagnostic and
treatment dilemma. Arch Bone Jt Surg
tion17,18,24-26,29 (Figure 4). Wong and entrapment in the proximal forearm 2015;3(3):156-162.
Dellon30 reported that discrepancies as a result of various neuropathic
6. Stanley J: Radial tunnel syndrome: A
in the treatment recommendations etiologies. Lesions of the median surgeon’s perspective. J Hand Ther 2006;
for patients with AIN syndrome exist nerve must be localized proximal or 19(2):180-184. DOI
in the literature. The authors reported distal to the point at which the AIN 7. Ferdinand BD, Rosenberg ZS, Schweitzer
that, prior to 1997, studies from the and the palmar cutaneous branches ME, et al: MR imaging features of
radial tunnel syndrome: Initial
surgical specialty literature reported of the median nerve branch off the experience. Radiology 2006;240(1):
exploration in 46 of 100 patients median nerve. Median nerve entrap- 161-168. DOI
with AIN syndrome (46%), whereas ment before these divisions usually 8. Loh YC, Lam WL, Stanley JK, Soames RW:
studies from the medial specialty lit- will result in distal sensory deficits A new clinical test for radial tunnel
erature reported exploration in only 4 and motor weakness in specific syndrome: The Rule-of-Nine test. A
cadaveric study. J Orthop Surg (Hong
of 32 patients with AIN syndrome muscles. Pronator syndrome origi- Kong) 2004;12(1):83-86. DOI
(12.5%).30 Confusion and discrep- nally referred to compression of the
9. Hagert E, Hagert C-G: Upper extremity
ancy with regard to the treatment of median nerve between the two heads nerve entrapments: The axillary and radial
patients with AIN syndrome still of the pronator teres; however, other nerves: Clinical diagnosis and surgical
treatment. Plast Reconstr Surg 2014;134
exist; however, advances in imaging potential sites of median nerve com- (1):71-80. DOI
and additional studies that evaluate pression include the lacertus fibrosus
10. Naam NH, Nemani S: Radial tunnel
the outcomes of patients with AIN and the FDS aponeurotic arch. Iso- syndrome. Orthop Clin North Am 2012;43
syndrome who undergo surgical lated anterior interosseous neuropa- (4):529-536. DOI
treatment may provide surgeons with thy, if not related to external forces 11. van den Ende KI, Steinmann SP: Radial
additional information with regard to or a direct injury, may be spontane- tunnel syndrome. J Hand Surg Am 2010;35
which patients with AIN syndrome ous and neuritic in nature. Patients (6):1004-1006. DOI

may benefit from surgical treatment with spontaneous AIN palsy may 12. Lee J-T, Azari K, Jones NF: Long term
results of radial tunnel release: The effect of
rather than observation. have profound motor weakness,
co-existing tennis elbow, multiple
with cutaneous sensory function compression syndromes and workers’
spared. Surgeons must be able to compensation. J Plast Reconstr Aesthet
Surg 2008;61(9):1095-1099. DOI
Summary differentiate between pronator syn-
drome and AIN syndrome because 13. Jebson PJ, Engber WD: Radial tunnel
syndrome: Long-term results of surgical
Ulnar neuropathy can be localized to the type and time course of treatment decompression. J Hand Surg Am 1997;22
the ulnar tunnel in a patient’s wrist for patients with pronator syndrome (5):889-896. DOI

January 2017, Vol 25, No 1 e9

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

14. Mackinnon SE, Novak CB: Compression 20. Rodriguez-Niedenführ M, Vazquez T, 26. Ulrich D, Piatkowski A, Pallua N: Anterior
neuropathies, in Wolfe SW, Hotchkiss RN, Ferreira B, Parkin I, Nearn L, Sañudo JR: interosseous nerve syndrome: Retrospective
Pederson WC, Kozin SH, eds: Green’s Intramuscular Martin-Gruber analysis of 14 patients. Arch Orthop
Operative Hand Surgery, ed 6. Philadelphia, anastomosis. Clin Anat 2002;15(2): Trauma Surg 2011;131(11):1561-1565.
PA, Elsevier, 2011, pp 977-1014. DOI 135-138. DOI DOI

15. Seyffarth H: Primary myoses in the M. 21. Spinner M: The anterior interosseous-nerve 27. Tulwa N, Limb D, Brown RF: Median
pronator teres as cause of lesion of the N. syndrome, with special attention to its nerve compression within the humeral
medianus (the pronator syndrome). Acta variations. J Bone Joint Surg Am 1970;52 head of pronator teres. J Hand Surg Br
Psychiatr Neurol Scand, Suppl 1951;74: (1):84-94. 1994;19(6):709-710. DOI
251-254.
22. Hagert E: Clinical diagnosis and wide- 28. MacKinnon SE, Novak CB: Compression
16. Rodner CM, Tinsley BA, O’Malley MP: awake surgical treatment of proximal neuropathies, in Wolfe SW, Hotchkiss
Pronator syndrome and anterior median nerve entrapment at the elbow: A RN, Pederson WC, Kozin SH, eds:
interosseous nerve syndrome. J Am Acad prospective study. Hand (N Y) 2013;8(1): Green’s Operative Hand Surgery: Expert
Orthop Surg 2013;21(5):268-275. 41-46. DOI Consult. Online and Print, ed 6.
Philadelphia, PA, Elsevier, 2010, pp
17. Ochi K, Horiuchi Y, Tazaki K, Takayama S, 23. Davidge KM, Sammer DM: Median nerve 977-1014.
Matsumura T: Fascicular constrictions in entrapment and injury, in Mackinnon SE,
patients with spontaneous palsy of the Yee A, eds: Nerve Surgery. New York, NY, 29. Aljawder A, Faqi MK, Mohamed A,
anterior interosseous nerve and the posterior Thieme, 2015, 207-250. Alkhalifa F: Anterior interosseous
interosseous nerve. J Plast Surg Hand Surg nerve syndrome diagnosis
2012;46(1):19-24. DOI 24. Dunn AJ, Salonen DC, Anastakis DJ: MR and intraoperative findings: A case
imaging findings of anterior interosseous report. Int J Surg Case Rep 2016;21:
18. Pham M, Bäumer P, Meinck HM, et al: nerve lesions. Skeletal Radiol 2007;36(12): 44-47. DOI
Anterior interosseous nerve syndrome: 1155-1162. DOI
Fascicular motor lesions of median nerve 30. Wong L, Dellon AL: Brachial neuritis
trunk. Neurology 2014;82(7):598-606. DOI 25. Bridgeman C, Naidu S, Kothari MJ: presenting as anterior interosseous
Clinical and electrophysiological nerve compression: Implications
19. Kiloh LG, Nevin S: Isolated neuritis of the presentation of pronator syndrome. for diagnosis and treatment: A case
anterior interosseous nerve. Br Med J 1952; Electromyogr Clin Neurophysiol 2007;47 report. J Hand Surg Am 1997;22(3):
1(4763):850-851. DOI (2):89-92. 536-539. DOI

e10 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.