Volume 3 | Number 2 | March 2005

ISSN 1612-8060 | eISSN 1612-8087

2 | 05

Orthopedic Trauma Directions

AO Journal Club / Evidence from the Literature

page 1

Supracondylar humeral fractures in children

Open versus closed redution

page 9

Posterior wall fractures of the acetabulum

Prognostic factors for poor outcome

page 21

Implant-related femoral fractures

Factors associated following hip surgery

page 29

OTD classic article review

Swiontkowski MF, Engelberg R, Martin DP, Agel J (1999)
Short musculoskeletal function assessment questionnaire: validity,
reliability, and responsiveness.

Published bimonthly by AO Publishing, Switzerland

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 Supracondylar humeral fractures in children | 1

Clinical topic

Supracondylar humeral fractures

in children
Open versus closed reduction

Summary

Closed reduction and percutaneous pinning may be favored slightly when compared
with open reduction in the treatment of supracondylar humeral fractures in
children. Elbow range of motion appears to be better in this group and there is
a suggestion that these patients may have shorter hospitalization times and slightly
shorter healing times. However, it has also been shown that open reduction can
be safe and effective, and the two methods give similar results in humeral-ulnar
angle differences and neurological impairment. Additional studies are recommended
to verify and further clarify these results.

Strength of evidence | Average methods score (out of 10).

weak medium strong

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 1–8
2 | Summary | Supracondylar humeral fractures in children
Sampling
A MEDLINE search was performed to identify studies
published from January 1998 to April 2004.
From a list of 102 articles identified from the search
strategy, three cohort studies and one randomized con-
trolled trial that made the desired comparisons were
selected. Case series that did not report a comparison
group were not included.
Studies
Study 1
de Buys Roessingh AS, Reinberg O (2003)
Open or closed pinning for distal humerus fractures
in children?
Swiss Surg; 9:76–81.
Study 2
Kaewpornsawan K (2001)
Comparison between closed reduction with percuta-
neous pinning and open reduction with pinning
in children with closed totally displaced supracondylar
humeral fractures: a randomized controlled trial.
J Pediatr Orthop B; 10:131–137.
Study 3
Oh CW, Park BC, Kim PT, et al (2003).
Completely displaced supracondylar humerus fractures
in children: results of open reduction versus closed
reduction.
J Orthop Sci; 8:137–141.
Study 4
Ozkoc G, Gonc U, Kayaalp A, et al (2004)
Displaced supracondylar humeral fractures in children:
open reduction vs. closed reduction and pinning.
Arch Orthop Trauma Surg; 124(8):547–551.
Orthop. trauma dir. 2005; 02; 1– 8
Objective
To critically summarize recently published studies
comparing open versus closed reduction and pinning
in the treatment of supracondylar humeral fractures
in children.
Common outcome measures
■ Cosmetic and functional results according to
Flynn's criteria.
■ Scoring for both the cosmetic results (based on loss
of Baumann angle) and functional results (based
on loss of motion) are as follows: excellent (0–5),
good (6–10), fair (11–15), and poor (> 15). These
subscales may be combined.
■ Humeral-ulnar angle change.
■ Postoperative neurological impairment.
Intervention
■ Open reduction versus closed reduction with
percutaneous pinning.
■ Open reduction through a posteromedial incision,
exploring the ulnar nerve and pinning with
Kirschner wires in a lateral [Oh, Kaewpornsawan]
or crossed fashion [Oh, Ozkoc] (unspecified in
[de Buys Roessingh]).
■ Closed reduction and percutaneous pin fixation
[de Buys Roessingh, Ozkoc], in a crossed [Ozkoc] or
lateral fashion [Kaewpornsawan].
■ In one study, open reductions were performed
when an adequate reduction could not be obtained
by closed manipulation [Oh].
AO Journal Club / Evidence from the Literature
 Supracondylar humeral fractures in children | Summary | 3

Study design
Demographics of studies comparing open versus closed reduction for supracondylar humeral fractures in children.

Author Study design Population Number of patients Average Methods

(year) by group follow-up score
(% followed) (out of 10)

open = 20
de Buys retrospective mean age: 6.7 years closed = 18 17.2 months 4
Roessingh cohort male: 63% 100%
(2003) open = 14
Kaewpornsawan randomized open closed = 14 80 months(53–108) 7
(2001) controlled trial mean age: 6.8 years (range 56–120 months)
male: 79% 100%
closed
mean age: 7.9 years
male: 57% open = 14
Oh retrospective mean age: 6.4 years closed = 21 22 months (range 12–50) 3
(2003) cohort male: 54% open = 44 100%
Ozkoc retrospective open closed = 55 open 5
(2004) cohort mean age: 10.7 years 35 months
Male: 57% (range 27–46)
closed 100%
mean age: 7.6 years closed
male: 54% 21 months
(range 16–27)
100%

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 1–8
4 | Appraisal | Supracondylar humeral fractures in children

Reviewer’s evaluation

Methodological principle* de Buys Roessingh Kaewpornsawan Oh Ozkoc

(2003) (2001) (2003) (2004)

Statement of concealed allocation ■

Intent to treat principle ■

Independent blind assessment ■

Patient reported outcomes ■ ■ ■ ■

Complete follow-up of > 80% ■ ■ ■

Consistent follow-up times ■ ■

Adequate sample size ■ ■ ■ ■

Appropriate analysis and use of effect measures

Controlling for possible confounding ■ ■ ■

Inclusion and exclusion criteria clearly defined

Methodological score (out of 10) 4 7 3 5

* The first two principles apply to randomized controlled trials only.

Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature

Results
■ Generally, the average cosmetic (carrying angle) and
functional scores (movement loss), according to the
Flynn's criteria, were slightly higher in the closed
reduction groups than in the open reduction groups
(Figure 1) [Kaewpornsawan, Oh, Ozkoc].
■ None of the studies showed a statistically significant
difference in the humeral-ulnar angle change as
measured by Bauman's angle (Figure 2); however,
while there was no statistically significant difference
in the incidence of cubitus varus between the open
(25%) and closed (27%) reduction groups (P=.16),
there was a statistically significant difference in the
incidence of cubitus valgus between the open (20%)
and closed (0%) reduction groups (P<.045) [de Buys
Roessingh].
■ There was no statistically significant difference in
the percentage of cases with persistent post-operative
neurological impairment in the ulnar nerves between
the open and closed reduction groups (Figure 3).
Figure 1 | Cosmetic and functional results according to the Flynn criteria.
Open Closed
80
60
40
20
%
Excellent
Good
Fair
Poor
Kapewpornsawan (7*)
* Methods score (out of 10).
† Flynn's criteria is based on two subscales (cosmetic and functional); the Kaewpornsawan and Oh studies combined these subscales,
whereas Ozkoc reported them separately (a combined score was not available).
Statistical significance noted on graph if specified in article.
ns = not significant.
AO Journal Club / Evidence from the Literature
Supracondylar humeral fractures in children | Results | 5
■ Loss of mobility, as measured by elbow extension,
was greater in the open reduction group than in the
closed reduction group: 6.23° versus 0.6° lost
(P=.005) [Ozkoc], 15% versus 11.1% with absence
of total extension (not statistically significant) [de
Buys Roessingh], and 7.14% versus 0% with motion
loss more than 10° (not statistically significant)
[Kaewpornsawan], respectively.
■ Two additional outcomes were also reported to favor
those who received closed reduction compared to
open reduction in cohort studies.
■ Average length of hospitalization: 2.8 days after
closed reduction compared with 6.1 days after open
reduction (P<.018) [de Buys Roessingh].
■ Fracture healing time was longer in the open
reduction group (5.3 months) compared with the
closed reduction group (4.8 months) [Ozkoc].
ns P = .036
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
Oh (3*) Ozkoc (cosmetic)† (5*) Ozkoc (functional)† (5*)
Orthop. trauma dir. 2005; 02; 1–8
6 | Results | Supracondylar humeral fractures in children

Figure 2 | Degree of humeral-ulnar angle change.

Open Closed

Degree
of change

10
P = .83

6
P >= .05

P = .8
2

Kapewpornsawan (7*) Oh (3*) Ozkoc (5*)

* Methods score (out of 10).

Figure 3 | Percentage of subjects with persistent postoperative neural injuries.

Open Closed

16
P = .47

12

8
ns

n=0 n=0 n=0

0

% de Buys Roessingh (4*) Kapewpornsawan (7*) Oh (3*) Ozkoc (5*)

* Methods score (out of 10).

Statistical significance noted on graph if specified in article.
ns = not significant.

Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature
 Supracondylar humeral fractures in children | Clinical notes | 7
James B Hunter I United Kingdom
How might the findings of this study be applied to patient care?
The treatment of supracondylar fractures remains con-
troversial. In France, the Blount method (closed reduction
and immobilization with sling or cast) remains very com-
mon as iatrogenic nerve injury is considered medico-legal-
ly unacceptable. In the UK, traction methods are more
common than elsewhere, reflecting the national health
service and funding differences. In North America, and
increasingly worldwide, closed reduction and pinning is
the standard procedure; the benefits in terms of cost and
length of patient stay are self evident and highlighted again
in this report. Recent large cohort studies from Los Angeles
and Cincinnati have addressed controversies surrounding
pin configuration and timing of surgery, suggesting that in
the absence of neurovascular compromise treatment can
be delayed until morning and two or three lateral pins,
correctly applied, will provide adequate stability.
The findings of this report must be interpreted cautious-
ly. Firstly, the two treatment modalities are not true alter-
natives. Most surgeons would only perform a primary
open reduction for neurovascular indications, otherwise
open reduction is to salvage failed close reduction, just as
it is for the adult femoral and tibial shaft fractures. Second-
ly, the studies are small; too small to detect real differences
that may exist between the groups, particularly in terms
of cosmesis and movement. Thirdly, one of the studies is
of extremely poor quality; it considers a hotchpotch of
small numbers of different fractures. The cubitus valgus re-
sult reported cannot be analyzed as there is no description
of the technique of open reduction that caused it.
AO Journal Club / Evidence from the Literature
Were all clinically important outcomes for this treatment
intervention considered?
The typical range of outcomes used in studies of supra-
condylar fractures has been considered. No vascular
injuries or compartment syndromes are reported, which is
an important negative. It should be remembered that
cubitus varus is mostly a cosmetic problem with no func-
tional consequences, and also that loss of elbow flexion is
generally more disabling than loss of extension. The
increased inpatient stay for open reduction is interesting
as it approaches the stay for traction methods, which are
the true alternative to closed reduction and pinning.
It would be interesting in studies of children's fractures
to see some outcome measures of relevance to children
and families; time off school and return to sport come im
mediately to mind. It is ironic that short patient stays cause
parents to lose time at work and children time at school
that would be provided if they were still in hospital.
Are the likely treatment benefits worth the potential
harm and costs?
Closed reduction and percutaneous pinning is the stan-
dard method for treating displaced supracondylar humeral
fractures in children. This report does not support the rou-
tine use of open reduction in these fractures, and surgeons
whose personal preference is for open reduction should
reconsider closed reduction and pinning. The reported
adverse effects of open reduction are, however, compati-
ble with this as a treatment modality for failed closed
reduction. Studies of supracondylar fractures need to be
large as the important clinical outcomes are the rare
adverse events.
Orthop. trauma dir. 2005; 02; 1–8
8 | Clinical notes | Supracondylar humeral fractures in children

Peter P Schmittenbecher I Germany

How might the findings of this study be applied to patient care? Are the likely treatment benefits worth the potential harm
The important conclusion is that closed reduction is the and costs?
first choice, other than for cases with a vascular injury. Studies with fewer than 20 patients/group have limita-
Experienced departments use closed reduction successfully tions for showing all benefits and harms. K-wire fixation
in more than 90% of cases – without opening the joint and is less invasive and less expensive but is of limited stability.
fracture region and without scarring. Three papers in the Perfect placement of pins makes secondary displacement
report showed that even total initial displacement does not impossible. Sometimes, more than one attempt to fix the
require open reduction. Open reduction is necessary, how- fracture requires repeated perforations of the growth plate,
ever, if adequate reduction and fixation with percutaneous which may result in growth arrest with valgization or
K-wires cannot be obtained. I learned from the report that varization. Nobody can analyze this aspect, which is a
colleagues still have to treat such difficult fractures with- typical harm of K-wiring.
out image intensifying, which, without doubt, makes open Iatrogenic secondary neurological deficiencies are an
reduction necessary to achieve an acceptable alignment. important harm of K-wire fixation and take place in closed
as well as open approaches. This factor needs evaluation
Were all clinically important outcomes for this treatment in comparison with the above-mentioned alternatives, EF
intervention considered? and ESIN.
K-wire fixation is useful in crossed ascending radial/
ulnar application, in crossed radial ascending/descending
application, and in divergent radial application. Whether
this is important for the outcome is not proven.
Open reduction can be done via a dorsal approach with
the triceps split, a lateral/medial approach, or even with a
routine ventral approach, however, the relevance of this
decision for functional outcome is not discussed.
Accompanying soft-tissue injuries (ligaments, joint cap-
sule) are often severe. With external fixation (EF) or elas-
tic-stable intramedullary nailing (ESIN), two methods are
available that allow immediate postoperative movement.
Whether early mobilization may prevent a reduction in
the range of motion is still not evaluated.

Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature
 Posterior wall fractures of the acetabulum | 9

Clinical topic

Posterior wall fractures of the

acetabulum
Prognostic factors for poor outcome

Summary

Factors associated with poor-to-fair functional or radiographic outcomes

following posterior wall fractures of the acetabulum included older age at injury,
delay between time of injury and reduction, gap characteristics, osteonecrosis,
and complete loss of joint space.

Strength of evidence | Average methods score (out of 6).

weak medium strong

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
10 | Summary | Posterior wall fractures of the acetabulum
Sampling
A MEDLINE search was performed to identify studies
published from January 1999 to June 2004 examining
prognostic factors following posterior wall fractures
of the acetabulum. From a list of 23 articles identified
from the search strategy, four articles with similar
outcomes were identified. Two prospective studies
report on the same overall population, however,
different outcomes measures are assessed.
Studies
Study 1
Moed BR, Carr SEW, Watson JT (2002)
Results of operative treatment of fractures of the
posterior wall of the acetabulum.
J Bone Joint Surg Am; 84(5):752–758.
Study 2
Moed BR, Carr SEW, Gruson KI, et al (2003)
Computed tomographic assessment of fractures of
the posterior wall of the acetabulum after operative
treatment.
J Bone Joint Surg Am; 85(3):512–522.
Study 3
Rommens PM, Gimenez MV, Hessmann M (2001)
Posterior wall fractures of the acetabulum:
characteristics, management, prognosis.
Acta Chir Belg; 101(6):287–293.
Study 4
Saterbak AM, Marsh JL, Nepola JV, et al (2000)
Clinical Failure after posterior wall acetabular
fractures: the influence of initial fracture patterns.
J Orthop Trauma; 14(4):230–237.
Orthop. trauma dir. 2005; 02; 9–20
Objective
To critically summarize recently published studies
that examine prognostic factors for a poor outcome
following posterior wall fractures of the acetabulum.
Prognostic factors evaluated:
■ Demographics (age, sex).
■ Time of injury to hip reduction.
■ Injury characteristics (fracture comminution).
■ Gap characteristics (width, length, dimension,
area, location).
■ Bone characteristics (osteonecrosis, heterotopic
ossification).
■ Loss of joint space.
Outcome measures
■ Merle D'Aubigne-Postel hip score to assess
functional outcome (excellent, good, fair, poor).
■ Matta hip rating scale (modification of Merle
D'Aubigne-Postel hip score) to assess functional
outcome (excellent, very good, good, fair, poor).
■ Matta radiographic results (excellent, good, fair,
poor).
■ Musculoskeletal Function Assessment (MFA)
(scores from 0 = minimal dysfunction to
100 = severe dysfunction)
■ Complete loss of joint space.
AO Journal Club / Evidence from the Literature
 Posterior wall fractures of the acetabulum | Summary | 11

Study design
Characteristics of included studies that examine prognostic factors following posterior wall fractures of the acetabulum,
published 1999–2003.

Author Study design Study population Mean follow-up Methods score

(year) (%) (out of 6)

Moed prospective N = 108* 60 months 5

(2002) cohort male: 74% (range, 24–168)
age (mean): 38 years (93%)
(range, 16–74)
Moed prospective N = 114† 48 months ‡ 4
(2002) cohort male: 79% (range, 24–44)
age (mean): 40 years (59%)
(range, 16–74)
Rommens retrospective N = 60 24.6 months 2
(2001) cohort male: 83% (77%)
age (mean): 42 years
(range, 17–84)
Saterbak retrospective N = 52 49 months 4
(2000) cohort male: 79% (range, 24–104)
age (mean): 35 years (81%)
(range, 20–78)

* 108 patients were treated by open reduction and internal fixation; however only 100 patients who were followed for a minimum of two years were included in the
data analysis.
† 114 patients were treated by open reduction and internal fixation; however only 67 patients who were followed for a minimum of two years or had a clearly poor
clinical result after less than two years of follow-up (n = 6) were included in the data analysis.
‡ Mean follow-up does not include the 6 patients who had a poor clinical result after less than two years of follow-up.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
12 | Summary | Posterior wall fractures of the acetabulum

Potential risk factors evaluated and outcome measures

Potential risk factors evaluated and outcome measures for posterior wall fractures of the acetabulum, as indicated
by included studies.

Author Potential risk factors evaluated Outcome measures

Moed Older age at time of injury. Matta hip rating scale.

(2002) Gender. Matta radiographic results.
Delay of more than 12 hours between time
of injury and the reduction of the hip dislocation.
Radiographic evidence of osteonecrosis
of the femoral head.
Radiographic evidence of Class III or IV
heterotopic ossification (Brooker Classification
of Heterotopic Ossification).
Moed Older age at time of injury . Matta hip rating scale.
(2003) Gender. Matta radiographic results.
Delay of more than 12 hours between time
of injury and the reduction of the hip dislocation.
Radiographic evidence of osteonecrosis
of the femoral head.
Radiographic evidence of Class III or IV
heterotopic ossification (Brooker Classification
of Heterotopic Ossification).
Width of gap ≥ 10 mm.
Gap length ≥ 10 mm.
Greatest gap dimension ≥ 10 mm.
Estimated gap area of ≥ 35mm .
2

Location of gap in the superior or posterior of

the acetabulum.*
Rommens Posttraumatic complex articular damage. Merle D'Aubigne-Postel hip score.
(2001)
Saterbak Posterior wall comminution of three Complete loss of joint space.
(2000) fragments or more. Merle D'Aubigne-Postel hip score.
Depth of the posterior wall fracture just below Musculoskeletal Function Assessment (MFA).
the roof of the acetabulum. Activities of daily living.
Complete loss of joint space.

* Location of gap deficit was determined by dividing the posterior half of the acetabular surface into thirds: superior (proximal to the middle third),
posterior (the middle third), inferior (distal to the middle third).

Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
 Posterior wall fractures of the acetabulum | Appraisal | 13

Reviewers’ evaluation

Methodological principle Moed Moed Rommens Saterbak

(2002) (2003) (2001) (2000)

Prospective cohort design ■ ■

Patients at similar point in the course of their treatment ■ ■ ■ ■

Final outcome important to the patient (eg, death, quality of life) ■

Complete follow-up of > 80% ■ ■

Patients followed long enough for outcomes to occur ■ ■ ■ ■

Controlling for possible confounding ■ ■

Methodological score (out of 6) 5 4 2 4

* The first two principles apply to randomized controlled trials only.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
14 | Results | Posterior wall fractures of the acetabulum

Results
■ Overall hip scale ratings indicate that between
10–30% of patients show a poor-to-fair functional
outcome (Figure 1).
■ The factors most associated with poor-to-fair
functional and radiographic results were older age
at time of injury (P=.0056) [Moed 2002], a delay
of more than 12 hours between time of injury and
the reduction of the hip dislocation (P=.0018)
[Moed 2002], and evidence of osteonecrosis of the
femoral head (P=.038) [Moed 2003].
■ Several gap parameters were also significantly
associated with poor-to-fair functional and
radiographic outcomes (Table). Overall, 35.8%
(87.5% with a fair-to-poor clinical outcome, and
28.8% with a good or excellent clinical outcome,
P=.002) of hips contained at least one gap with
a dimension of ≥ 10 mm.
■ Gap parameters associated with poor-to-fair
functional and radiographic outcomes*.
■ Factors significantly associated with complete loss
of joint space included posterior wall comminution
of three fragments or more (P=.001) and depth
of posterior wall fractures just below the roof of the
acetabulum (P=.045) [Saterbak].
■ Complete loss of joint space as a prognostic factor
was associated with a 7-fold increased risk of a
poor-to-fair functional outcome (P=.002) [Saterbak]
(Figure 2) and consistently lower scores on the MFA
subscales compared to those without complete loss
(mean MFA score was 26.1 and 47.3, respectively)
(P<.01) (Figure 3). However, there was no association
between posttraumatic complex articular damage
and functional outcome [Rommens].
■ Several complications were reported: hematomas
[Moed, Rommens], implant loosening [Rommens],
recurrent dislocation [Rommens], deep-vein
thrombosis [Moed, Rommens], pulmonary embolism
[Rommens], deep infection [Moed, Rommens], and
sciatic nerve injury [Saterbak].

Significance (P values)

Gap parameters Functional† Radiographic†

Width < .001 .001

(≥ 10 mm versus < 10 mm)
Length .002 .009
(≥ 10 mm versus < 10 mm)
Greatest dimension .001 .004
(≥ 10 versus < 10 mm)
Area < .001 .001
(≥ 35 mm2 versus < 35 mm2)
Superior or posterior < .001 .004
acetabulum versus inferior

* Study by Moed (2003).

† Outcomes.

Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
 Posterior wall fractures of the acetabulum | Results | 15

Figure 1 | Functional outcomes assessed using hip rating scales (%) after posterior wall fractures of the acetabulum.
Poor Fair

Moed (2002) (5*) 1

10

Moed (2003) (4*) 0

12

Rommens (2*) 15
15

Saterbak (4*) 0
(no joint space loss)
6
Saterbak 0 P= .002
(joint space loss)
45

% 0 10 20 30 40 50

* Methods score (out of 6).

Statistical significance noted on graph if specified in article.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
16 | Results | Posterior wall fractures of the acetabulum

Figure 2 | Relative risks (RR) and 95% confidence intervals of poor-to-fair functional outcomes after posterior wall
fractures of the acetabulum.

100

10

0.1

RR* Posttraumatic complex articular damage versus no damage Complete loss of joint space versus no complete loss

* Crude RRs were calculated from proportions given in the text. The relative risk (represented by the boxes) gives the reader a relative comparison of outcomes between two
groups that have different exposures. For example, patients who have complete loss of joint space are over 7 times more likely to have a poor-to-fair functional outcome
(RR=7.05) compared with those who have no complete loss of joint space. Statistical significance is reached if the 95% confidence intervals (represented by the vertical lines
through the boxes) do not cross the value of 1.

Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
 Posterior wall fractures of the acetabulum | Results | 17

Figure 3 | Mean Musculoskeletal Function Assessment scores.*

Complete loss of joint space No complete loss of joint space

Mobility

Hand/fine motor work

Housework

Sleep/rest

Leisure/recreation

Relationships

Cognition

Emotion/adjustment

Employment

MFA total score

Subscale score 0 10 20 30 40 50 60 70 80

* All P values (comparing the two groups) <.03.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
18 | Clinical Notes | Posterior wall fractures of the acetabulum
Takeshi Sawaguchi I Japan
How might the findings from this report be applied to
patient care?
Posterior wall fracture is the most common acetabular
fracture and is classified as a “simple” fracture type in the
Letournel-Judet classification and type A1 in the Müller
AO Classification. This classification often misleads the
surgeon to understand that this fracture is easy to treat and
has a favorable outcome. However, the outcomes of pos-
terior wall fractures in these four studies are not so good,
ie, 10–30% with poor-fair functional outcome. This find-
ing is consistent with other series (Letournel/Matta etc.).
Posterior wall fractures include a wide spectrum of injury,
ie, fragment size, degree of comminution, articular carti-
lage damage, articular impaction, incarcerated fragments,
concomitant femoral head damage, and sciatic nerve
injuries; all of which have potential influence on the out-
come.
Four studies evaluated prognostic factors after open
reduction and internal fixation of acute posterior wall
fractures. One study also included other fracture types with
posterior wall involvement [Saterbak]. Older age, delay of
more than twelve hours between time of injury and the
reduction of the hip dislocation, and necrosis of the
femoral head are negative risk factors [Moed]. In addition,
posterior wall comminution, the fracture extending into the
acetabular roof [Saterbak], and a fracture gap adversely
affect the outcome [Moed].
Evaluation of surgical reconstruction of the articular
surface by plain x-ray is inadequate and it should be done
by postoperative computed tomography [Moed]. This
process improves the surgeon's skill at reduction.
Were all clinically important outcomes for this treatment
intervention considered?
Yes, in respect of functional evaluation. However, radi-
ological evaluation of osteoarthritis and avascular necrosis
is inconsistent. Clearly, the outcomes of posterior wall
fractures do not depend on the acetabular side only. Asso-
ciated injuries of the femoral head, ie, fracture, impaction,
and cartilage damage also influence the outcome. Sciatic
nerve palsy existing preoperatively and as an iatrogenic
complication also spoils the functional outcome. The cor-
relation between the quality of acetabular reconstruction
and the outcome is not clear enough in most of the series
since a plain x-ray is insufficient to evaluate residual dis-
Orthop. trauma dir. 2005; 02; 9–20
placement [Moed]. The follow-up period of most of the
series was less than five years. Longer follow-up is needed
as the cases with good outcome in the short or mid term
may deteriorate with the progression of arthritic change
(Letournel).
Are the likely treatment benefits worth the potential
harm and costs?
There are many risk factors for poor outcome after pos-
terior wall fractures. Some are controllable by the surgeon
and some are not. Irreducible fracture dislocation should
be operated on as an emergency to preserve the femoral
head blood flow. Surgery should be as early as possible in
other cases. To restore the joint stability and congruity,
accurate surgical reduction and stable fixation with a lag
screw and a buttress plate is the current standard. With
thin and small posterior wall fragments, a spring plate
enhances fracture fixation. Articular impaction should be
elevated and cancellous bone graft placed on the back.
Large free fragments should be reattached and small frag-
ments removed. Any fracture gap should be minimized.
Surgery should be less invasive and care must be taken to
avoid complications.
In the Kocker-Lagenbeck approach, the knee should be
flexed to protect the sciatic nerve. Capsular attachment to
the posterior wall fragment should be preserved to main-
tain circulation. Intraarticular placement of hardware can
be avoided by careful insertion and C-arm control. Proper
treatment of complications is necessary to improve the
outcome. Avascular necrosis should be diagnosed at an
early stage and surgeons should try to preserve the femoral
head if the acetabulum is well restored; for instance, vas-
cularized bone graft or femoral head rotational osteotomy.
In elderly patients with posterior wall comminution, primary
total hip replacement should be considered.
AO Journal Club / Evidence from the Literature

Emanuel Gautier I Switzerland
How might the findings of this study be applied to patient care?
It is widely accepted that ORIF of posterior wall fractures
results in a high rate of early and late failures with devel-
opment of posttraumatic osteoarthritis of the hip joint
[1, 2]. The four analyzed articles identify several factors
that contribute to the poor results and that can be subdi-
vided into patient-related, trauma-related, and surgery-
related factors.
Age and gender of the patient as well as concomitant
osteoporosis are the patient-related factors, which are
often linked with trauma-related factors such as initial
fracture displacement, fracture localization, fracture pat-
tern with comminution, marginal impaction, denudation
of fragments, direct damage to the cartilage of the femoral
head or the acetabulum due to the impact during the
process of fracturing, direct abrasion injury of the femoral
head during dislocation or reduction, and traumatic loss of
the vascular supply of the femoral head (rare).
Thus, only the surgery-related factors need discussing,
ie, their management prior to, during, and after surgery.
Prior to surgery
A fracture-dislocation of the hip needs a gentle reduction
maneuver under general anesthesia and muscle relaxation
to avoid further damage to the cartilaginous surface of the
femoral head. This formal reduction has to be performed
as quickly as possible, but certainly before six hours after
the accident. In general, an anteroposterior x-ray is suffi-
ciently clear to diagnose a posterior fracture dislocation of
the hip, thus oblique x-rays and computed tomography
only need be performed following closed hip reduction.
Only cases of an irreducible fracture dislocation need im-
mediate additional medical imaging.
Soft-tissue or skeletal traction is beneficial in cases of an
extrafoveolar intraarticular-free fragment to avoid second-
ary wear of the femoral head or in the rare case of resid-
ual posterior subluxation of the femoral head. However,
external rotation of the hip in the supine position fre-
quently unloads the fractured posterior wall.
During surgery
Besides accurate anatomical reduction and high stability
fixation, careful handling of the muscle tissue during the
exposure and debridement of all necrotic muscle tissue at
the end of the operation is mandatory to avoid heterotopic
ossification [3]. When faced with a superior fracture ex-
tension of the posterior wall, an additional trochanteric
AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | Clinical Notes | 19
slide osteotomy may be beneficial to avoid stretch on the
superior gluteal neurovascular bundle or direct damage to
the medius and minimus muscles [4]. In addition, surgi-
cally induced avascular necrosis during tenotomy and su-
ture of the external rotators of the hip is relatively frequent
and must be avoided [5]. The integrity of the vascular sup-
ply of the head can be assessed by bleeding control from a
1.5 mm borehole of the femoral head [6].
After surgery
The most important thing is to avoid secondary fragment
displacement during the rehabilitation phase. Thus, flex-
ing the trunk in the standing position or flexing the hip in
the supine position should be strictly prohibited because it
overloads the posterior wall. Thus, utilization of continu-
ous passive motion (CPM), even when beneficial for car-
tilage healing, seems to be contraindicated in posterior
wall fractures.
Were all clinically important outcomes for this treatment
intervention considered?
In general, the important outcomes were reported.
Are the likely treatment benefits worth the potential harm
and costs?
Open reduction and internal fixation of posterior wall frac-
tures is the treatment of choice for almost all posterior frac-
ture-dislocations of the hip joint. There are only a few
indications left for a primary total hip replacement, such
as excessive comminution of the posterior wall associated
with severe osteoporosis making all surgical attempts of
reconstruction illusory, or severe and extensile traumatic
destruction of the weight-bearing part of the femoral head.
Bearing in mind the high rate of possible complications
(nerve injuries, AVN, functional impairment due to het-
erotopic ossifications, early OA due to malreduction, sec-
ondary displacement or intraarticular hardware), it is clear
that this kind of difficult surgery belongs exclusively in the
hands of experienced surgical teams.
Orthop. trauma dir. 2005; 01; 9–20
20 | Clinical Notes | Posterior wall fractures of the acetabulum

1 Letournel E, Judet R (1993)

Fractures of the acetabulum. Springer-Verlag,
2nd edition, Berlin.

2 Matta JM (1996)
Fracture of the acetabulum: accuracy of reduction and
clinical results in patients managed operatively within
three weeks after the injury.
J Bone Joint Surg Am; 78(11):1632–1645.

3 Matta JM, Siebenrock KA (1997)

Does indomethacin reduce heterotopic bone formation
after operations for acetabular fractures? A prospective
randomised study.
J Bone Joint Surg Br; 79(6):959–963.

4 Siebenrock KA, Gautier E, Ziran BH, et al 1998)

Trochanteric flip osteotomy for cranial extension and
muscle protection in acetabular fracture fixation using
a Kocher-Langenbeck approach.
J Orthop Trauma; 12(6):387–391.

5 Gautier E, Ganz K, Krugel N, et al (2000)

Anatomy of the medial femoral circumflex artery and
its surgical implications.
J Bone Joint Surg Br; 82(5):679–683.

6 Gill TJ, Sledge JB, Ekkernkamp A, et al (1998)

Intraoperative assessment of femoral head vascularity
after femoral neck fracture.
J Orthop Trauma; 12(7):474–478.

Orthop. trauma dir. 2005; 01; 9–20 AO Journal Club / Evidence from the Literature
 Implant-related femoral fractures | 21

Clinical topic

Implant-related femoral fractures

Factors associated following hip surgery

Summary

Studies have identified intrinsic and extrinsic risk factors for implant-related
fractures. The intrinsic factors reported to be associated with an increased risk of
implant-related fracture include older age, lower canal flare index and poorer
bone quality. Extrinsic factors include fracture as an indication for the index surgery
compared with all other reasons for the index operation, use of a gamma nail
compared with the compression hip screw or cannulated screw for hip fixation,
and revision hip arthroplasty compared with primary hip arthroplasty for index
surgery.

Strength of evidence | Average methods score (out of 6).

weak medium strong

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
22 | Summary | Implant-related femoral fractures

Sampling
A MEDLINE search was performed to identify studies
published from January 1998 to June 2004 examining
risk factors associated with implant-related fractures of
the femur following hip surgery.
Objective
To critically summarize recently published studies
that examine risk factors for implant-related fractures
of the femur following hip surgery.

From a list of articles identified from the search strate-
gy, four studies have been included in this Evidence
Report: two studies (retrospective cohort and case-
control) conducted on the same Finnish population, a
retrospective cohort study from China, and a prospec-
tive cohort study conducted in the UK.
Prognostic factors evaluated
■ Demographics (age, sex, body mass index,
prefracture residence, history of previous fracture).
■ Initial diagnosis.
■ Bone characteristics (canal flare index, bone
quality).
■ Treatment (type of prosthesis, complications).

Studies
Study 1 Outcome measures
Wu CC, Au MK, Wu SS, et al (1999) ■ Implant-related femoral fracture following hip
Risk factors for postoperative femoral fracture in surgery.
cementless hip arthroplasty.
J Formos Med Assoc; 98(3):190–194.

Study 2
Robinson CM, Adams CI, Craig M, et al (2002).
Implant-related fractures of the femur following hip
fracture surgery.
J Bone Joint Surg Am; 84–A(7):1116–1122.

Study 3
Sarvilinna R, Huhtala HSA, Puolakka TJS,
et al (2003).
Periprosthetic fractures in total hip arthroplasty.
Int Orthop; 27(6):359–361.

Study 4
Sarvilinna R, Huhtala HSA, Sovelius RT,
et al (2004).
Factors predisposing to periprosthetic fracture after
hip arthroplasty: a case (n=31)-control study.
Acta Orthop Scand; 75(1):16–20.

Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
 Implant-related femoral fractures | Summary | 23

Study design
Characteristics of included studies that examine prognostic factors for implant-related fracture (IRF) following hip
surgery, published 1999–2004.

Author Study design Study Population Type of index Time to implant- Methods score
(year) (out of 6)
procedure/implant* related fracture or
follow-up

Wu retrospective subjects: N = 16 uncemented THA mean (range): 3

(1999) cohort controls: N = 409 13.8 months
male: 63% (1 week–4 years)
age (mean ± SD):
subjects: 66 ± 11 years
controls: 53 ±1 6 years
Robinson prospective subjects: N = 141 internal fixation with median: 4
(2002) cohort controls: N = 6,089 CHS, cannulated 24 (IQR 4–100) weeks
male: 20% screws, or Gamma nail
age (median): 82 years cemented and
uncemented THA
Sarvilinna †retrospective subjects: N = 40 cemented and range, 3–12 years 3
(2003) cohort controls: N = 33,114 uncemented THA
male: 40%
age [median (interquartile
range)]: 69 (62–74)
Sarvilinna †case-control subjects: N = 31 cemented and median: 2
(2004) controls: N = 31 uncemented THA 70 (1–174) months
male: 32%
age [median (range)]:
subjects: 71 (53–89) years
controls: 65 (37–93) years

* THA = total hip arthroplasty, CHS = compression hip screw.

† Both studies analyzed data from the Finnish Arthroplasty Register, collected from 1990–1999.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
24 | Summary | Implant-related femoral fractures

Potential risk factors evaluated and outcome measures

Potential risk factors evaluated and outcome measures for implant-related femoral fracture following index
hip surgery, as indicated by included studies.

Author Potential risk factors evaluated Outcome measures

Wu Age. Implant-related displaced femoral fracture.

(1999) Sex.
Initial diagnosis.
Canal flare index.
Bone quality (Singh's Index of osteoporosis).
Robinson Age. Implant-related femoral fracture, treated operatively.
(2002) Sex.
Prefracture residence.
Type of implant.
History of previous fracture.
Sarvilinna Sex. Implant-related femoral fracture, treated operatively.
(2003) Type of implant.
Sarvilinna Age. Implant-related femoral fracture, treated operatively.
(2004) Sex.
Body mass index.
Type of implant.
Complications.
History of previous fracture.
Initial diagnosis.

Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
 Implant-related femoral fractures | Appraisal | 25

Reviewers’ evaluation

Methodological principle Wu Robinson Sarvilinna Sarvilinna

(1999) (2002) (2003) (2004)

Prospective cohort design ■

Patients at similar point in the course of their treatment

Final outcome important to the patient (eg, death, quality of life) ■ ■ ■ ■

Complete follow-up of > 80%*

Patients followed long enough for outcomes to occur ■ ■ ■ ■

Controlling for possible confounding ■ ■ ■

Methodological score (out of 6) 3 4 3 2

* None of the included studies indicates quantitative measure of loss-to-follow up.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
26 | Results | Implant-related femoral fractures

Results
■ Although more females tended to have implant-
related fractures, sex was not a significant independ-
ent predictor of fracture [Sarvilinna 2003, Sarvilinna
2004, Wu, Robinson].
■ Older patients tended to have more frequent
implant-related fractures compared with younger
patients. In one study, age was significantly higher
among cases with implant-related fracture (mean
65.6 ± 10.9 versus 52.6 ± 16.2 years; P<.001) [Wu]
(Figure 1). In another study, those who were more
than 70 years were nearly twice as likely to sustain
an implant-related fracture compared with those
who were less than 70 years, though this association
did not reach statistical significance (RR = 1.9, 95%
confidence interval = 0.7–5.3) [Sarvilinna 2004].
■ One study observed a 3-fold increased risk of fracture
with use of a Gamma nail compared with the
compression hip screw or cannulated screw to treat
extracapsular fractures (RR 3.0, 95% CI 1.5–6.1;
P=.003) [Robinson]. There was a 4-fold increased
risk of implant-related fracture with revision to an
arthroplasty with cement (RHA) compared with
primary THA with cement (RR 4.0, 95% CI 2.2–7.2;
P<.001) [Robinson] (Figure 2). The risk of implant-
related fracture was not associated with the use of
cement in primary hip arthroplasty [Sarvilinna 2003,
Sarvilinna 2004].

■ Cases with implant-related fracture had lower canal

flare index scores (3.6 ± 0.4 versus 4.1 ± 0.6; P<.01)
and poorer bone quality (Singh's Index: 3.3 ± 0.6
versus 3.8 ± 0.7; P<.01) than patients without an
implant-related fracture [Wu] (Figure 1).

■ The majority of implant-related femoral fractures

following hip surgery were reported to occur as a
result of subsequent trauma and simple falls
[Sarvilinna 2004, Wu, Robinson]. Fracture as an
indication for index operation was a significant
predictor of implant-related fracture compared with
all other reasons for the index operation (OR 4.4,
95% CI 1.4–14.0) (Sarvilinna 2004] (Figure 2).

Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
 Implant-related femoral fractures | Results | 27

Figure 1 | Prognostic factors for implant-related fracture following uncemented hip arthroplasty (mean ± SD) [Wu]
Subjects Controls

Age
P <.100

Canal flare index

P <.01

Bone quality
P <.01

Mean 0 10 20 30 40 50 60 70 80 90

Figure 2 | Relative risk and 95% confidence intervals of implant-related fractures for three risk factors.

100

10

0.1

RR* Fracture versus other reason for surgery Gamma nail versus CHS RHA (cement) versus primary THA

* Relative risk (RR) or the odds ratio that estimates the relative risk (represented by the boxes) give the reader a relative comparison or risk of a certain outcome between two
groups that have different exposures. For example, patients who receive an implant due to a fracture are over 4 times more likely to have an implant-related fracture
(RR = 4.4) compared with those who receive an implant for other reasons (eg, arthrosis). Statistical significance is reached if the 95% confidence intervals (represented by
the vertical lines through the boxes) do not cross the value of 1.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
28 | Clinical notes | Implant-related femoral fractures
Steven A Olson I USA
How might the findings from this report be applied to
patient care?
Two reports [Sarvillinna and Sarvillinna] only reviewed
patients who required a hip prosthesis revision after frac-
ture. A third [Wu], only reported on cementless hip
arthroplasty. The useful finding here is that poor bone
stock (ie, stovepipe femurs, etc.) predisposes the patient to
fracture. Robinson reviewed fracture fixation implants,
hemiarthroplasty, and total hip replacement and found
that a loose fitting implant that ends in the diaphysis is at
increased risk for fracture (ie, short IM nail, cementless
Austin Moore stems).
Were all clinically important outcomes for this treatment
intervention considered?
Two reports did not report all periprosthetic fractures
that occurred [Sarvillinna and Sarvillinna]. None of the
studies clearly reported the timing of the fracture relative
to the index fixation. The studies did report fracture out-
comes, however, patient survival or other systemic com-
plications were not reported. Robinson performed an
excellent analysis of the relative risk of fracture by type of
implant, which is important information.
Are the likely treatment benefits worth the potential harm
and costs?
Very little in these reports mentions cost/benefit rela-
tionship of fracture treatment. While Robinson and Wu did
report factors that increased the relative risk of fracture, no
study compared the costs of alternative care with the
methods under investigation.
Orthop. trauma dir. 2005; 02; 21–28
Ulrich Stöckle I Germany
How might the findings from this report be applied to
patient care?
The knowledge of predisposing factors for implant-
related fractures is of clinical importance. To aid our under-
standing, it is important that postoperative fractures were
evaluated in all cited studies and that in all cases a real
trauma was the reason for the fracture.
The intrinsic factors of older age, poor bone quality and
low flare index, are well-known risk factors in cementless
total hip replacement (THR). Therefore, cemented THR is
recommended for older patients and those with poor bone
quality.
That the fracture is an extrinsic factor for a subsequent
fracture cannot be altered. It is well-known that patients
over 65 years with a proximal femur fracture have a 20-
30% risk of another fracture within one year. Therefore,
an overall rate of 2.9% of subsequent femoral fractures at
five years is not surprising. Secondary prophylaxis is nec-
essary in these patients to prevent further falls.
The increased risk of a later ipsilateral femoral fracture
from the use of a Gamma nail compared to DCS or cannu-
lated screws needs further evaluation to determine
whether using an intramedullary implant increases the
risk or just the Gamma nail does.
Patients with revision hip arthroplasty usually have
poorer bone quality than patients with primary hip arthro-
plasty. That muscle strength is weakened by repetitive sur-
gery and that coordination abilities might be altered, could
explain the higher incidence of implant-related fractures
in revision THR. As, however, a loose implant is itself a
risk for a periprosthetic fracture, revision THR cannot be
banned.
AO Journal Club / Evidence from the Literature
 Classical article review | 29

Classic article review

Short musculoskeletal function assessment questionnaire:

validity, reliability, and responsiveness
Swiontkowski MF, Engelberg R, Martin DP, Agel J
J Bone Joint Surg Am, 81(9):1245 –1260, 1999

Author summary

The Short Musculoskeletal Function Assessment (SMFA) questionnaire consists

of a thirty-four item “dysfunction index”, assessing patient function, and a twelve
item “bother index” assessing how much a patient is bothered by functional
problems. The SMFA questionnaire demonstrated excellent internal consistency.
Content validity for both indexes was supported with very little skew, few ceiling
effects and no floor effects. The SMFA was significantly correlated to physicians'
ratings of patient function and to standard clinical measures.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 29–34
30 | Classical article review

Background Outcome measures

The purpose of a functional assessment tool is to
provide a standardized measure of the actual physical
limitations of the patient. In a well-planned clinical
study, functional assessment tools can be used to
evaluate the effectiveness of treatments as well as
health-care policies. This tool, which can be completed
in about 10 minutes, can be used to compare the
patient with him/herself over time, patients who have
similar musculoskeletal disorders, and function in the
general population.
Objectives/aims
To describe the development, reliability, validity and
responsiveness of the SMFA questionnaire in a sample
of patients who had musculoskeletal injuries and
disorders.
■ Reliability
Test-retest reliability as measured by intraclass
correlation coefficients.
Internal consistency evaluated with Cronbach's
alpha.
■ Validity
Content validity evaluated for score ranges, ceiling
or floor effects, score distribution and missing
responses.
Construct validity validated against physicians'
rating for activities of daily living, recreational and
leisure activities, emotional function, walking
speed, grip strength and SF-36 scores.
■ Responsiveness
Change from baseline to follow-up and standardized
response means.

Questionnaire development
The forty-six items selected for the SMFA were
identified from analyses of baseline and follow-up
data on patients who had responded to the original
Musculoskeletal Function Assessment (MFA).

Items retained met three criteria: (1) they were

determined to be clinically and conceptually important,
(2) they were stable with percent agreement statistics
from test-retest data that were greater than 0.80
and kappa values that were greater than 0.70, (3) they
were moderately endorsed at baseline and follow-up
evaluations.

The SMFA contains two parts. The 34-item dysfunction

index assesses the patients' perception of their functional
performance and the 12-item bother index assesses
how much they are bothered by problems in broad
functional areas, Figure 1.

Both indexes utilize a 5-point Likert scale. Item

responses are summed, and then scores are normalized
to a range of 0–100 points with the following formula:
([actual raw score – lowest possible raw score]/possible
range of raw score) × 10. Higher scores indicate poorer
function.

Orthop. trauma dir. 2005; 02; 29–34 AO Journal Club / Evidence from the Literature
 Classical article review | 31

Study design and patient population

Study design Population Inclusion criteria Exclusion criteria Follow-up

(% followed)

prospective mean age: 48.9 ± 16.0 At least 18 years old. Head injury. 3 or 6 months
diagnostic Male: 43% Acute fracture or Fracture of the spine/ (77.6%)
caucasion: 91% soft-tissue injury of an neurological deficit.
N = 420 extremity or the spine. Neuromuscular
A repetitive- diseases.
motion disorder. Amputation secondary
Osteoarthritis or to systemic disease.
rheumatoid arthritis. History of a stroke or
cardiovascular disease.
End-stage renal disease.
Cancer or AIDS.
Serious psychiatric
or cognitive limitation.
Inability to speak
or understand English.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 29–34
32 | Classical article review
Results
■ Both indexes demonstrated excellent reliability with
intraclass correlation coefficients of 0.93 and 0.88
for the dysfunction index and the bother index,
respectively.
Cronbach's alpha values for baseline and follow-up
data, measuring internal consistency, were 0.95
and 0.96 for the dysfunction index and 0.92 and
0.95 for the bother index.
■ Both indexes displayed good score ranges, distribu-
tions with little skew, no floor effects and few ceiling
effects.
■ The SMFA indexes were highly correlated with
physicians' ratings for activities of daily living,
recreational and leisure activities, and emotional
function (rho ≥ 0.40).
Orthop. trauma dir. 2005; 02; 29–34
■ The dysfunction and bother indexes were not
significantly related to the physicians' ratings of
mobility of the lower extremities or mobility of the
upper extremities (rho = 0.10–0.36).
The SMFA indexes were found to be significantly
related to walking speed and grip strength and
the dysfunction index alone correlated with range of
motion of the ankle and wrist (r = 0.40).
The SMFA indexes were found to be significantly
related to all comparable SF-36 subscales (P=.000).
Changes in both indexes from baseline to follow-up
was significantly different (P=.01) for patients who
reported that their health was “worse” or “much
worse” and for those who reported that their health
was “better” or “much better” (Figure 2).
Standardized response means for patients who
reported health changes ranged from 0.76 (patients
who reported “better” or “much better” on the
bother index) to 1.14 (patients who reported “worse”
or “much worse” on the dysfunction index).
AO Journal Club / Evidence from the Literature
 Classical article review | 33

Figure 1 | Summary of the content for the SMFA questionnaire.

SMFA Scale Components

Brother Index (12 items) Dysfunktion Index (34 Items)

Allow patients to assess how much they are ■ Amount of difficulty one has performing certain functions (25 items)

bothered by problems in the following broad ■ How often one has difficulty when performing certain functions (9 items)

functional areas:

■ Recreation and leisure Functions are divided into the following 4 categories

■ Sleep and rest ■ Daily activities

■ Work ■ Emotional status

■ Family ■ Function of the arm and hand

■ Mobility

Each item scored on a 1 to 5-point Likert scale.

Figure 2 | Responsiveness of the SMFA.

Baseline Follow-up

Responsiveness of the SMFA According to the Patient’s Reports of Changes in Health Status

60

40

20

SMFA Score Whorse health Health the same Better health Whorse health Health the same Better health

Dysfunction Index Bother Index

* The higher the score, the greater the disability.

AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 29–34
34 | Classical article review

Beate P Hanson I Switzerland

What are the key findings or principles set forth in this classic In what way does this classic article encourage further research?
article? In what ways is this area difficult to study?
This article describes the development and testing of the This article shows validity, reliability, and responsive-
short version of the Musculoskeletal Function Assessment ness of the instrument on a limited number of patients and
instrument. This instrument is a 101-question tool that has conditions. These findings have to be confirmed in future
shown superior properties to many generic and specific studies involving other conditions. In addition, it would be
health-status instruments. important to evaluate whether this instrument can be used
However, due to its length and complexity, its use is in parallel clinical studies to distinguish efficacy of differ-
limited to research settings. The short version described in ent treatment approaches.
this article promises self-administration and applicability
in community and clinical settings. Why is this article still considered a classic? Has anyone
ever done it better?
By what criteria was this classic article chosen? What made Since the development of the Short Musculoskeletal
this article so good for its time? Function Assessment, there has not been a newer and
This is a recent article describing the development and better version of the musculoskeletal disorder outcome
testing of important new instruments in the area of mus- instrument.
culoskeletal disorder outcome measurement. In spite of
the availability of many outcome measurements, the im-
portance of the Short Musculoskeletal Function Assess-
ment is its universal community and clinical applicability
across wide range of musculoskeletal disorders. This in-
strument positions itself between non-specific generic
instruments, such as SF-36, and disease-specific instru-
ments. Due to its applicability, it has also gained quick
acceptance in non-English speaking countries (German
and Swedish versions are available).

What specific impact do the findings from this article have on

the way we treat patients today?
It is too early to speak about specific changes in the
treatment of patients following application of this instru-
ment, but studies are available on various patient groups
(eg, patients with conservative treatment for hip oteoarthri-
tis, patients with rotator cuff tear undergoing open repair,
patients with coxarthrosis undergoing hip replacement,
patients with primary osteoarthritis undergoing total knee
arthroplasty).

Orthop. trauma dir. 2005; 02; 29–34 AO Journal Club / Evidence from the Literature