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Commentary to "Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty"
In this month’s issue of The American Journal of Orthopedics, Tannenbaum and colleagues present a “5 Points” article on “Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty.” This is an excellent article that summarizes the authors’ methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost.
The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but!
As health care expenditures in the United States continue to increase and approach 20% of the gross domestic product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care.
Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 2015, edition of The New York Times, I was very interested to read the article “What are a Hospital’s Costs? Utah System Is Trying to Learn.”1 The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health Care, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. Analyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 30% in hospital expenditures and fewer complications.1
We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal’s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients.
Reference
1. Kolata G. What are a hospital’s costs? Utah system is trying to learn. New York Times. September 8, 2015:A1. http://www.nytimes.com/2015/09/08/health/what-are-a-hospitals-costs-utah-system-is-trying-to-learn.html. Accessed September 17, 2015.
In this month’s issue of The American Journal of Orthopedics, Tannenbaum and colleagues present a “5 Points” article on “Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty.” This is an excellent article that summarizes the authors’ methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost.
The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but!
As health care expenditures in the United States continue to increase and approach 20% of the gross domestic product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care.
Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 2015, edition of The New York Times, I was very interested to read the article “What are a Hospital’s Costs? Utah System Is Trying to Learn.”1 The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health Care, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. Analyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 30% in hospital expenditures and fewer complications.1
We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal’s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients.
In this month’s issue of The American Journal of Orthopedics, Tannenbaum and colleagues present a “5 Points” article on “Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty.” This is an excellent article that summarizes the authors’ methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost.
The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but!
As health care expenditures in the United States continue to increase and approach 20% of the gross domestic product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care.
Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 2015, edition of The New York Times, I was very interested to read the article “What are a Hospital’s Costs? Utah System Is Trying to Learn.”1 The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health Care, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. Analyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 30% in hospital expenditures and fewer complications.1
We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal’s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients.
Reference
1. Kolata G. What are a hospital’s costs? Utah system is trying to learn. New York Times. September 8, 2015:A1. http://www.nytimes.com/2015/09/08/health/what-are-a-hospitals-costs-utah-system-is-trying-to-learn.html. Accessed September 17, 2015.
Reference
1. Kolata G. What are a hospital’s costs? Utah system is trying to learn. New York Times. September 8, 2015:A1. http://www.nytimes.com/2015/09/08/health/what-are-a-hospitals-costs-utah-system-is-trying-to-learn.html. Accessed September 17, 2015.
Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty
As total health care costs reach almost $3 trillion per year—capturing more than 17% of the total US gross domestic product—payers are searching for more effective ways to limit health care spending.1,2 One increasingly discussed plan is payment bundling.3 This one-lump-sum payment model arose as a result of rapid year-on-year increases in total reimbursements under the current, fee-for-service model. The Centers for Medicare & Medicaid Services hypothesized that a single all-inclusive payment for a procedure or set of services would incentivize improvements in patient-centered care and disincentivize cost-shifting behaviors.4 Bundled reimbursement is becoming increasingly common in orthopedic practice. With the recent introduction of the Bundled Payment for Care Improvement Initiative, several orthopedic practices around the United States are already actively engaged in creating models for bundled payment for common elective procedures and for associated services provided up to 90 days after surgery.3,5
Bundled payment increases the burden on the provider to understand the cost of care provided during a care cycle. However, not only has the current system blinded physicians to the cost of care, but current antitrust legislation has made discussions of pricing with colleagues (so-called price collusion) illegal and subject to fines of up to $1 million per person and $100 million per organization,6 therefore limiting orthopedic physician involvement.
Given these legal constraints, instead of measuring direct costs of goods, we developed a “grocery list” approach in which direct comparisons are made of resources (goods and services) used and delivered during the entire 90-day cycle of care for patients who undergo anatomical total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). We used one surgeon’s practice experience as a model for measuring other orthopedic surgeons’ resource utilization, based on their electronic medical records (EMR) system data. By capturing the costs of the components of resource utilization rather than just the final cost of care, we can assess, compare, understand, endorse, and address these driving factors.
1. The significance of resource utilization
To maximize the efficiency of their practices, high-volume shoulder surgeons have introduced standardization to health care delivery.7 Identifying specific efficiencies makes uniform acceptance of beneficial practice patterns possible.
To facilitate comparison of goods and services used during an episode of surgical care, Virani and colleagues8,9 studied the costs of TSA and RSA and calculated the top 10 driving cost factors for these procedures (Figure 1). Their systematic analysis provided a framework for a common method of communication, allowing an orthopedic surgeon to gain a more complete understanding of the resources used during a particular operative procedure in his or her practice, and allowing several physicians to compare and contrast the resources collectively used for a single procedure, facilitating an understanding of different practice patterns within a local community. At a societal level, these data can be collected to help guide overall recommendations.
2. How we defined utilization
To define the resources used, we had to decide which procedure components cost the most. Virani and colleagues8,9 found that the top 10 cost drivers accounted for 93.11% and 94.77% of the total cost of the TSA and RSA care cycles, respectively (Figure 1). For each cost driver, information on resources used (goods, services, overhead) was collected on 2 forms, the Hospital Utilization Form (7 hospital-based items) and the Clinical Utilization Form (3 non-hospital-based items). To make hospital data easy to compile, we piloted use of a “smart form” in the EpicCare EMR system to isolate and auto-populate specific data fields.
3. EMR data collection
With EMR becoming mandatory for all public and private health care providers starting in 2014, utilization data are now included in a single unified system. Working with our in-house information technology department, we developed an algorithm to populate this information in a separate, easy-to-follow hospital utilization form. This form can be adopted by other institutions. Although EpicCare EMR is used by 52% of hospitals and at our institution, the data points required to make the same measurements are generalizable and exist in other EMRs.
Smartlinks, a tool in this EMR, allows utilization data to be quickly retrieved from different locations in a medical record and allows a form to be electronically completed in seconds. Data can be retrieved for any patient in the EMR system, regardless of when that patient’s hospital stay occurred. We populated data from surgeries performed 2 years before the start of this project.
4. What we can learn from these data
Data from a pilot study of 25 patients who underwent primary anatomical TSA for osteoarthritis and 25 patients who underwent primary RSA for massive rotator cuff tear allowed us to generate graphical representations of a single surgeon’s practice patterns that most affected the cost of care. Time in holding, time in the operating room, time in the postanesthesia care unit, and percentage of patients receiving different medications were recorded for each procedure (Figures 2–11). The study did not capture the wide variances in practice patterns in shoulder arthroplasty, and therefore other surgeons’ resource utilization may differ from ours. However, replicating this methodology at other institutions will produce a more robust data set from which conclusions about resource utilization and, indirectly, cost of care can be made.
5. Future possibilities
By using existing EMR tools to better understand resource utilization, orthopedic surgeons can play a constructive role in the dialogue on health care costs and new reimbursement models. The data presented here are not meant to be interpreted as hard and fast numbers on global resource utilization, but instead we intend to establish a model for collecting data on resource utilization. Resource utilization begins the dialogue that allows orthopedic surgeons and specialty societies to speak a common language without discussing actual cost numbers, which is discouraged under antitrust regulation. The data presented will allow comparisons to be made between surgeons in all practice settings to highlight areas of inconsistency in order to further improve patient care. Although this work involved only 50 patients undergoing only 2 types of surgeries, the resource-capturing methodology can be expanded to include more procedures and orthopedic practices. As all hospitals are now required to have EMRs, the metrics tracked in this work can be found on any patient medical record and auto-populated using our open-source utilization forms. Starting this data collection at your hospital may require no more than a conversation with the informatics department, as the metrics can for the most part be populated into a database on surgeon request.
As orthopedic surgeons return to the economic health care discussion, this information could prove essential in helping the individual surgeon and the orthopedic community justify the cost of care as well as fully understand the cost drivers for musculoskeletal care.
Click here to read the commentary on this article by Peter D. McCann, MD
1. National health expenditures 2013 highlights. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf. Accessed September 14, 2015.
2. Wilson KB. Health care costs 101: slow growth persists. California HealthCare Foundation website. http://www.chcf.org/publications/2014/07/health-care-costs-101. Published July 2014. Accessed August 24, 2015.
3. Froimson MI, Rana A, White RE Jr, et al. Bundled Payments for Care Improvement Initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013;28(8 suppl):157-165.
4. Morley M, Bogasky S, Gage B, Flood S, Ingber MJ. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 2014;4(1).
5. Teusink MJ, Virani NA, Polikandriotis JA, Frankle MA. Cost analysis in shoulder arthroplasty surgery. Adv Orthop. 2012;2012:692869.
6. Fassbender E, Pandya S. Legislation focuses on AAOS priorities. American Academy of Orthopaedic Surgeons website. http://www.aaos.org/news/aaosnow/may14/advocacy2.asp. AAOS Now. Published May 2014. Accessed August 24, 2015.
7. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston, MA: Harvard Business School Press; 2006.
8. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1612-1622.
9. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1601-1611.
As total health care costs reach almost $3 trillion per year—capturing more than 17% of the total US gross domestic product—payers are searching for more effective ways to limit health care spending.1,2 One increasingly discussed plan is payment bundling.3 This one-lump-sum payment model arose as a result of rapid year-on-year increases in total reimbursements under the current, fee-for-service model. The Centers for Medicare & Medicaid Services hypothesized that a single all-inclusive payment for a procedure or set of services would incentivize improvements in patient-centered care and disincentivize cost-shifting behaviors.4 Bundled reimbursement is becoming increasingly common in orthopedic practice. With the recent introduction of the Bundled Payment for Care Improvement Initiative, several orthopedic practices around the United States are already actively engaged in creating models for bundled payment for common elective procedures and for associated services provided up to 90 days after surgery.3,5
Bundled payment increases the burden on the provider to understand the cost of care provided during a care cycle. However, not only has the current system blinded physicians to the cost of care, but current antitrust legislation has made discussions of pricing with colleagues (so-called price collusion) illegal and subject to fines of up to $1 million per person and $100 million per organization,6 therefore limiting orthopedic physician involvement.
Given these legal constraints, instead of measuring direct costs of goods, we developed a “grocery list” approach in which direct comparisons are made of resources (goods and services) used and delivered during the entire 90-day cycle of care for patients who undergo anatomical total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). We used one surgeon’s practice experience as a model for measuring other orthopedic surgeons’ resource utilization, based on their electronic medical records (EMR) system data. By capturing the costs of the components of resource utilization rather than just the final cost of care, we can assess, compare, understand, endorse, and address these driving factors.
1. The significance of resource utilization
To maximize the efficiency of their practices, high-volume shoulder surgeons have introduced standardization to health care delivery.7 Identifying specific efficiencies makes uniform acceptance of beneficial practice patterns possible.
To facilitate comparison of goods and services used during an episode of surgical care, Virani and colleagues8,9 studied the costs of TSA and RSA and calculated the top 10 driving cost factors for these procedures (Figure 1). Their systematic analysis provided a framework for a common method of communication, allowing an orthopedic surgeon to gain a more complete understanding of the resources used during a particular operative procedure in his or her practice, and allowing several physicians to compare and contrast the resources collectively used for a single procedure, facilitating an understanding of different practice patterns within a local community. At a societal level, these data can be collected to help guide overall recommendations.
2. How we defined utilization
To define the resources used, we had to decide which procedure components cost the most. Virani and colleagues8,9 found that the top 10 cost drivers accounted for 93.11% and 94.77% of the total cost of the TSA and RSA care cycles, respectively (Figure 1). For each cost driver, information on resources used (goods, services, overhead) was collected on 2 forms, the Hospital Utilization Form (7 hospital-based items) and the Clinical Utilization Form (3 non-hospital-based items). To make hospital data easy to compile, we piloted use of a “smart form” in the EpicCare EMR system to isolate and auto-populate specific data fields.
3. EMR data collection
With EMR becoming mandatory for all public and private health care providers starting in 2014, utilization data are now included in a single unified system. Working with our in-house information technology department, we developed an algorithm to populate this information in a separate, easy-to-follow hospital utilization form. This form can be adopted by other institutions. Although EpicCare EMR is used by 52% of hospitals and at our institution, the data points required to make the same measurements are generalizable and exist in other EMRs.
Smartlinks, a tool in this EMR, allows utilization data to be quickly retrieved from different locations in a medical record and allows a form to be electronically completed in seconds. Data can be retrieved for any patient in the EMR system, regardless of when that patient’s hospital stay occurred. We populated data from surgeries performed 2 years before the start of this project.
4. What we can learn from these data
Data from a pilot study of 25 patients who underwent primary anatomical TSA for osteoarthritis and 25 patients who underwent primary RSA for massive rotator cuff tear allowed us to generate graphical representations of a single surgeon’s practice patterns that most affected the cost of care. Time in holding, time in the operating room, time in the postanesthesia care unit, and percentage of patients receiving different medications were recorded for each procedure (Figures 2–11). The study did not capture the wide variances in practice patterns in shoulder arthroplasty, and therefore other surgeons’ resource utilization may differ from ours. However, replicating this methodology at other institutions will produce a more robust data set from which conclusions about resource utilization and, indirectly, cost of care can be made.
5. Future possibilities
By using existing EMR tools to better understand resource utilization, orthopedic surgeons can play a constructive role in the dialogue on health care costs and new reimbursement models. The data presented here are not meant to be interpreted as hard and fast numbers on global resource utilization, but instead we intend to establish a model for collecting data on resource utilization. Resource utilization begins the dialogue that allows orthopedic surgeons and specialty societies to speak a common language without discussing actual cost numbers, which is discouraged under antitrust regulation. The data presented will allow comparisons to be made between surgeons in all practice settings to highlight areas of inconsistency in order to further improve patient care. Although this work involved only 50 patients undergoing only 2 types of surgeries, the resource-capturing methodology can be expanded to include more procedures and orthopedic practices. As all hospitals are now required to have EMRs, the metrics tracked in this work can be found on any patient medical record and auto-populated using our open-source utilization forms. Starting this data collection at your hospital may require no more than a conversation with the informatics department, as the metrics can for the most part be populated into a database on surgeon request.
As orthopedic surgeons return to the economic health care discussion, this information could prove essential in helping the individual surgeon and the orthopedic community justify the cost of care as well as fully understand the cost drivers for musculoskeletal care.
Click here to read the commentary on this article by Peter D. McCann, MD
As total health care costs reach almost $3 trillion per year—capturing more than 17% of the total US gross domestic product—payers are searching for more effective ways to limit health care spending.1,2 One increasingly discussed plan is payment bundling.3 This one-lump-sum payment model arose as a result of rapid year-on-year increases in total reimbursements under the current, fee-for-service model. The Centers for Medicare & Medicaid Services hypothesized that a single all-inclusive payment for a procedure or set of services would incentivize improvements in patient-centered care and disincentivize cost-shifting behaviors.4 Bundled reimbursement is becoming increasingly common in orthopedic practice. With the recent introduction of the Bundled Payment for Care Improvement Initiative, several orthopedic practices around the United States are already actively engaged in creating models for bundled payment for common elective procedures and for associated services provided up to 90 days after surgery.3,5
Bundled payment increases the burden on the provider to understand the cost of care provided during a care cycle. However, not only has the current system blinded physicians to the cost of care, but current antitrust legislation has made discussions of pricing with colleagues (so-called price collusion) illegal and subject to fines of up to $1 million per person and $100 million per organization,6 therefore limiting orthopedic physician involvement.
Given these legal constraints, instead of measuring direct costs of goods, we developed a “grocery list” approach in which direct comparisons are made of resources (goods and services) used and delivered during the entire 90-day cycle of care for patients who undergo anatomical total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). We used one surgeon’s practice experience as a model for measuring other orthopedic surgeons’ resource utilization, based on their electronic medical records (EMR) system data. By capturing the costs of the components of resource utilization rather than just the final cost of care, we can assess, compare, understand, endorse, and address these driving factors.
1. The significance of resource utilization
To maximize the efficiency of their practices, high-volume shoulder surgeons have introduced standardization to health care delivery.7 Identifying specific efficiencies makes uniform acceptance of beneficial practice patterns possible.
To facilitate comparison of goods and services used during an episode of surgical care, Virani and colleagues8,9 studied the costs of TSA and RSA and calculated the top 10 driving cost factors for these procedures (Figure 1). Their systematic analysis provided a framework for a common method of communication, allowing an orthopedic surgeon to gain a more complete understanding of the resources used during a particular operative procedure in his or her practice, and allowing several physicians to compare and contrast the resources collectively used for a single procedure, facilitating an understanding of different practice patterns within a local community. At a societal level, these data can be collected to help guide overall recommendations.
2. How we defined utilization
To define the resources used, we had to decide which procedure components cost the most. Virani and colleagues8,9 found that the top 10 cost drivers accounted for 93.11% and 94.77% of the total cost of the TSA and RSA care cycles, respectively (Figure 1). For each cost driver, information on resources used (goods, services, overhead) was collected on 2 forms, the Hospital Utilization Form (7 hospital-based items) and the Clinical Utilization Form (3 non-hospital-based items). To make hospital data easy to compile, we piloted use of a “smart form” in the EpicCare EMR system to isolate and auto-populate specific data fields.
3. EMR data collection
With EMR becoming mandatory for all public and private health care providers starting in 2014, utilization data are now included in a single unified system. Working with our in-house information technology department, we developed an algorithm to populate this information in a separate, easy-to-follow hospital utilization form. This form can be adopted by other institutions. Although EpicCare EMR is used by 52% of hospitals and at our institution, the data points required to make the same measurements are generalizable and exist in other EMRs.
Smartlinks, a tool in this EMR, allows utilization data to be quickly retrieved from different locations in a medical record and allows a form to be electronically completed in seconds. Data can be retrieved for any patient in the EMR system, regardless of when that patient’s hospital stay occurred. We populated data from surgeries performed 2 years before the start of this project.
4. What we can learn from these data
Data from a pilot study of 25 patients who underwent primary anatomical TSA for osteoarthritis and 25 patients who underwent primary RSA for massive rotator cuff tear allowed us to generate graphical representations of a single surgeon’s practice patterns that most affected the cost of care. Time in holding, time in the operating room, time in the postanesthesia care unit, and percentage of patients receiving different medications were recorded for each procedure (Figures 2–11). The study did not capture the wide variances in practice patterns in shoulder arthroplasty, and therefore other surgeons’ resource utilization may differ from ours. However, replicating this methodology at other institutions will produce a more robust data set from which conclusions about resource utilization and, indirectly, cost of care can be made.
5. Future possibilities
By using existing EMR tools to better understand resource utilization, orthopedic surgeons can play a constructive role in the dialogue on health care costs and new reimbursement models. The data presented here are not meant to be interpreted as hard and fast numbers on global resource utilization, but instead we intend to establish a model for collecting data on resource utilization. Resource utilization begins the dialogue that allows orthopedic surgeons and specialty societies to speak a common language without discussing actual cost numbers, which is discouraged under antitrust regulation. The data presented will allow comparisons to be made between surgeons in all practice settings to highlight areas of inconsistency in order to further improve patient care. Although this work involved only 50 patients undergoing only 2 types of surgeries, the resource-capturing methodology can be expanded to include more procedures and orthopedic practices. As all hospitals are now required to have EMRs, the metrics tracked in this work can be found on any patient medical record and auto-populated using our open-source utilization forms. Starting this data collection at your hospital may require no more than a conversation with the informatics department, as the metrics can for the most part be populated into a database on surgeon request.
As orthopedic surgeons return to the economic health care discussion, this information could prove essential in helping the individual surgeon and the orthopedic community justify the cost of care as well as fully understand the cost drivers for musculoskeletal care.
Click here to read the commentary on this article by Peter D. McCann, MD
1. National health expenditures 2013 highlights. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf. Accessed September 14, 2015.
2. Wilson KB. Health care costs 101: slow growth persists. California HealthCare Foundation website. http://www.chcf.org/publications/2014/07/health-care-costs-101. Published July 2014. Accessed August 24, 2015.
3. Froimson MI, Rana A, White RE Jr, et al. Bundled Payments for Care Improvement Initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013;28(8 suppl):157-165.
4. Morley M, Bogasky S, Gage B, Flood S, Ingber MJ. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 2014;4(1).
5. Teusink MJ, Virani NA, Polikandriotis JA, Frankle MA. Cost analysis in shoulder arthroplasty surgery. Adv Orthop. 2012;2012:692869.
6. Fassbender E, Pandya S. Legislation focuses on AAOS priorities. American Academy of Orthopaedic Surgeons website. http://www.aaos.org/news/aaosnow/may14/advocacy2.asp. AAOS Now. Published May 2014. Accessed August 24, 2015.
7. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston, MA: Harvard Business School Press; 2006.
8. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1612-1622.
9. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1601-1611.
1. National health expenditures 2013 highlights. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf. Accessed September 14, 2015.
2. Wilson KB. Health care costs 101: slow growth persists. California HealthCare Foundation website. http://www.chcf.org/publications/2014/07/health-care-costs-101. Published July 2014. Accessed August 24, 2015.
3. Froimson MI, Rana A, White RE Jr, et al. Bundled Payments for Care Improvement Initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013;28(8 suppl):157-165.
4. Morley M, Bogasky S, Gage B, Flood S, Ingber MJ. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 2014;4(1).
5. Teusink MJ, Virani NA, Polikandriotis JA, Frankle MA. Cost analysis in shoulder arthroplasty surgery. Adv Orthop. 2012;2012:692869.
6. Fassbender E, Pandya S. Legislation focuses on AAOS priorities. American Academy of Orthopaedic Surgeons website. http://www.aaos.org/news/aaosnow/may14/advocacy2.asp. AAOS Now. Published May 2014. Accessed August 24, 2015.
7. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston, MA: Harvard Business School Press; 2006.
8. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1612-1622.
9. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1601-1611.
Technique of Open Reduction and Internal Fixation of Comminuted Proximal Humerus Fractures With Allograft Femoral Head Metaphyseal Reconstruction
Proximal humerus fractures are exceedingly common and account for almost 5% of all fractures. As osteoporosis is a risk factor for these fractures, their incidence rises with patient age.1
In 1970, Neer2 described these type of fractures and classified them as having 2, 3, or 4 parts based on the amount of angulation and displacement of the humeral head and the greater and lesser tuberosities with respect to the shaft.
Three- and 4-part proximal humerus fractures can be treated either nonoperatively, or surgically with closed reduction and percutaneous fixation, intramedullary fixation, open reduction and internal fixation (ORIF), or arthroplasty. There remains controversy over the best treatment, but a key component of any surgical treatment is anatomical reduction, stable fixation, and then healing of the tuberosities. A current common form of treatment is augmentation with an allograft fibula placed in the medullary canal. Although not formally reported, anecdotal evidence demonstrates that revision to arthroplasty is very difficult in the setting of an ingrown graft in the medullary canal of the humerus.
In this article, we present a novel technique of using allograft femoral head to reconstruct the metaphysis in ORIF of comminuted proximal humerus fractures.
Technique
Presented in Figure 1 are preoperative images of a representative displaced 4-part proximal humerus fracture treated surgically using the technique described here. General anesthesia is used. After intubation on the operating table, the patient is placed in the beach-chair position with about 75° of hip flexion. All bony prominences are padded, and the head and trunk are well secured. A pneumatic arm positioner is used to alleviate the need for an assistant to manipulate the arm. An image intensifier is used before preparing to verify that appropriate images of the proximal humerus can be obtained. Once adequate images are confirmed, the floor can be marked at the position of the fluoroscopic unit’s wheels to allow easy reproduction of images once the arm is prepared and draped. The intensifier is then removed from the field, the shoulder is prepared and draped in usual fashion, and prophylactic antibiotics are administered.
A deltopectoral incision is used, and sharp dissection is made through the subcutaneous tissue to raise full-thickness subcutaneous flaps on each side. The deltopectoral interval is sharply dissected while protecting the cephalic vein. Subdeltoid adhesions are then released. Palpation of the axillary nerve in the quadrilateral space to identify its location is helpful to avoid injury during the procedure.
The fracture is then identified, and No. 5 permanent suture is placed through the posterior and superior rotator cuff and through the subscapularis insertion (Figure 2). The tuberosities are freed from the humeral head sharply. A blunt elevator is then used to gently elevate the humeral head upward, with care taken to avoid comminuting the metaphyseal bone while levering. Reduction is achieved by manipulating the sutures and levering the head with the elevator while placing the arm in extension and posterior translation. Fluoroscopic images are used to verify correct anatomical alignment. Generally, the metaphysis demonstrates comminution and impaction, with poor bone quality necessitating use of bone graft.
A frozen allograft femoral head is then obtained and split into 2 equal pieces using a saw (Figures 3–5). One piece is fashioned with a saw and a burr into a trapezoid such that the proximal portion is wider, and the distal, tapered portion is sized to fit the canal. The broad, proximal portion of the graft will serve as a pedestal to reduce the head to the shaft. Measuring the internal diameter of the humeral canal can be useful in estimating the necessary dimensions of the distal portion of the allograft. The graft often needs several small adjustments that necessitate attempting to place it in the intramedullary canal and then trimming as necessary to ensure proper fit distally within the shaft. For this reason, it is beneficial to perform the graft preparation near the surgical field. Once completed, the distal portion is then impacted into the humeral canal (Figure 6). Because of this impaction, there is no possibility for subsidence or pistoning of the graft within the canal, which can occur with a fibular graft. The humeral head is reduced onto the shaft with the already placed sutures; this is achieved by abducting the shoulder. The image intensifier is then used to confirm appropriate alignment and positioning of the fragments, making sure that both neck–shaft angle and medial calcar alignment have been restored (Figures 7, 8).
An appropriately sized proximal humerus plate is then selected based on the location of the fracture line. We have used standard lateral proximal humerus locking plates as well as laterality-specific anterolateral proximal humerus plates and found that both are suitable for incorporation of the screws through the graft and into the head. The plate is positioned on the humerus, and a guide pin is placed by hand through the proximal-most hole so that the appropriate height of the plate can be verified on fluoroscopy. The first screw is then a nonlocking bicortical screw placed through the oval hole in the shaft of the plate to allow further fine manipulation of the plate more proximally or distally as needed. The final height is confirmed, and the screw is firmly tightened (Figure 9). The locking-screw guide is fixed to the proximal portion of the plate, and 2 locking screws are then placed into the head. The arm is then rotated to an anteroposterior view by placing the arm in external rotation and neutral flexion and is then abducted and internally rotated to recreate a lateral view to perform final verification of the position of the plate on orthogonal images. If the surgeon is satisfied with the position of the plate, another nonlocking screw is placed distally, and then the proximal holes are used to place locking screws as needed. If the surgeon is not satisfied, the 2 proximal screws can be removed and the plate repositioned.
After each screw is placed, fluoroscopy is used to ensure there has been no breach of the articular surface. The number of proximal screws placed depends on fracture configuration and surgeon preference.
The sutures through the rotator cuff are then fixed to the plate, securing the tuberosities. Final intraoperative radiographs are used to confirm reduction, alignment, and final position of hardware (Figure 10). After copious irrigation, a surgical drain is placed as needed, and the wound is closed in layered fashion. Three years after surgery, follow-up examination revealed no radiographic change in alignment, no necrosis, and no varus collapse (Figure 11), and the patient was pain-free during activities.
Discussion
Surgical treatment of comminuted proximal humerus fractures usually consists of some type of plate fixation with screw fixation of the shaft, screws or smooth pegs to support the chondral surfaces, and screw fixation or suture cerclage of the tuberosities.
Fixed-angle locking-plate-and-screw constructs increased the biomechanical stability and pullout strength of proximal humerus plates.3,4 Nevertheless, avascular necrosis, malunion, and nonunion are still known complications of proximal humerus fractures, especially those with comminution, with up to 14% of patients still experiencing loss of fixation.5
For this reason, several authors have proposed using allograft bone and/or augmentation with calcium-containing cement to supplement fixation and provide an endosteal form of support for the head and tuberosities to decrease the risk for varus collapse. Osteobiologics (eg, calcium phosphate or sulfate cement) have been shown to decrease the risk for loss of reduction of proximal humerus fractures and decrease the risk for intra-articular screw penetration.6,7 Many calcium phosphate cements are commercially available. Cost and availability are 2 reasons that these supplements are not more widely used. Cancellous chips have also been used to aid in the reduction of proximal humerus fractures.8 No randomized study has been conducted to show a clinical advantage of this technique, though retrospective studies have shown that it is not as advantageous as using calcium phosphate cement with respect to loss of reduction or screw penetration.6 Certainly, cancellous chips are easily available in most hospitals and are less expensive than some alternatives. A recent review of these techniques in osteoporotic proximal humerus fractures found no clear indication for using one of these supplements over another.9
However, some fracture patterns require a structural graft to reduce the tuberosities and head component. Although described more than 30 years ago as a treatment for nonunions with an intramedullary “peg” of iliac crest graft,10 the graft most commonly reported today is allograft fibula.11-15 This technique consists of preparing the humeral shaft and often the fractured head segment with reaming to create a channel to receive the graft. Even with use of a small fibula, it is often time-consuming to use a saw, rasp, or burr to size the fibular segment to fit the medullary canal of the humerus. Once in place, the graft provides a strut on which the head fragment can be reduced and around which the tuberosities can be reduced. Although this technique is successful clinically and is biomechanically superior to plate-only constructs,16,17 concerns remain.
One such concern is keeping this graft in routine supply at most hospitals. Supply and pricing from vendors can differ significantly between hospitals, and a surgeon may need to request grafts in advance, which makes their use nonviable in a trauma case. Certain grafts are often kept in routine supply based on their overall utilization. At our institution, allograft femoral heads meet this criterion and are routinely stocked.
Of more importance are the ramifications of these procedures for future revision surgeries. The need for arthroplasty revision is common after ORIF of a proximal humerus fracture.18
Arthroplasty revision is an already challenging procedure that becomes more complex with the need to remove 6 to 8 cm of ingrown endosteal bone from a shell of outer osteoporotic cortical bone. Our experience with these complex revisions provided the impetus to search for an alternate graft type that still provides a strut for reducing the head and tuberosities but limits the amount of endosteal bone that would need to be removed in arthroplasty revision in order to place a stemmed component into the humeral canal.
Some currently available arthroplasty fracture systems modify the previous anatomy of the stem to provide a more anatomical platform to reduce the tuberosities to a broader metaphyseal construct that incorporates bone grafting to assist with healing.
Because of these concerns and factors, we adapted our technique to create an individual-specific pedestal with allograft femoral head that can be anatomically matched to each patient. This provides a strut to reduce the head and tuberosity fragments but still limits the amount of allograft bone needed to seat into the existing canal. The geometry of the allograft can also be customized to the fracture, with most 3- and 4-part fractures needing a trapezoidal strut that resembles the metaphyseal portion of a fracture-specific shoulder arthroplasty implant.
We have used this technique for comminuted 3- and 4-part fractures of the proximal humerus in 14 cases with at least 2-year follow-up and in several more cases that have not reached 2-year follow-up. All cases have gone on to radiographic union; none have had to be revised either with revision ORIF or to an arthroplasty. Formal measurements of final postoperative range of motion have not been tabulated in all cases, as some cases have been lost to follow-up after radiographic union was achieved. Medium- and long-term results are not yet available, but no short-term complications have been noted.
Disadvantages of this technique are that, while an individualized graft is created, proper shaping still takes time, and a moderate amount of the femoral head is not used. However, we have found that, if a graft is inadvertently undersized, there is still ample femoral head remaining to create another sized graft. Other disadvantages are the added cost and the (rare) risk of disease transmission, which come with use of any allograft, but the technique is used instead of another type of allograft, so these disadvantages are largely equivalent. At our hospital, differences in cost and availability between femoral head or fibular allografts are negligible.
This procedure, which is easily performed in a short amount of time, allows a stable base of bone graft to be used as an aid in the anatomical reduction of proximal humerus fractures, without the need for reaming and preparation of the medullary canal and without further increasing the difficulty associated with a future revision procedure.
1. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-249.
2. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
3. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg. 2000;9(5):423-426.
4. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elbow Surg. 2006;15(2):239-243.
5. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681.
6. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741-748.
7. Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma. 2013;27(7):399-404.
8. Ong CC, Kwon YW, Walsh M, Davidovitch R, Zuckerman JD, Egol KA. Outcomes of open reduction and internal fixation of proximal humerus fractures managed with locking plates. Am J Orthop. 2012;41(9):407-412.
9. Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012;21(12):1787-1795.
10. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res. 1982;(167):255-259.
11. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212-215.
12. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300-3306.
13. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195-200.
14. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942.
15. Little MT, Berkes MB, Schottel PC, et al. The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma. 2014;28(6):338-347.
16. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech. 2010;25(7):642-646.
17. Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg. 2012;21(7):894-901.
18. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542-549.
Proximal humerus fractures are exceedingly common and account for almost 5% of all fractures. As osteoporosis is a risk factor for these fractures, their incidence rises with patient age.1
In 1970, Neer2 described these type of fractures and classified them as having 2, 3, or 4 parts based on the amount of angulation and displacement of the humeral head and the greater and lesser tuberosities with respect to the shaft.
Three- and 4-part proximal humerus fractures can be treated either nonoperatively, or surgically with closed reduction and percutaneous fixation, intramedullary fixation, open reduction and internal fixation (ORIF), or arthroplasty. There remains controversy over the best treatment, but a key component of any surgical treatment is anatomical reduction, stable fixation, and then healing of the tuberosities. A current common form of treatment is augmentation with an allograft fibula placed in the medullary canal. Although not formally reported, anecdotal evidence demonstrates that revision to arthroplasty is very difficult in the setting of an ingrown graft in the medullary canal of the humerus.
In this article, we present a novel technique of using allograft femoral head to reconstruct the metaphysis in ORIF of comminuted proximal humerus fractures.
Technique
Presented in Figure 1 are preoperative images of a representative displaced 4-part proximal humerus fracture treated surgically using the technique described here. General anesthesia is used. After intubation on the operating table, the patient is placed in the beach-chair position with about 75° of hip flexion. All bony prominences are padded, and the head and trunk are well secured. A pneumatic arm positioner is used to alleviate the need for an assistant to manipulate the arm. An image intensifier is used before preparing to verify that appropriate images of the proximal humerus can be obtained. Once adequate images are confirmed, the floor can be marked at the position of the fluoroscopic unit’s wheels to allow easy reproduction of images once the arm is prepared and draped. The intensifier is then removed from the field, the shoulder is prepared and draped in usual fashion, and prophylactic antibiotics are administered.
A deltopectoral incision is used, and sharp dissection is made through the subcutaneous tissue to raise full-thickness subcutaneous flaps on each side. The deltopectoral interval is sharply dissected while protecting the cephalic vein. Subdeltoid adhesions are then released. Palpation of the axillary nerve in the quadrilateral space to identify its location is helpful to avoid injury during the procedure.
The fracture is then identified, and No. 5 permanent suture is placed through the posterior and superior rotator cuff and through the subscapularis insertion (Figure 2). The tuberosities are freed from the humeral head sharply. A blunt elevator is then used to gently elevate the humeral head upward, with care taken to avoid comminuting the metaphyseal bone while levering. Reduction is achieved by manipulating the sutures and levering the head with the elevator while placing the arm in extension and posterior translation. Fluoroscopic images are used to verify correct anatomical alignment. Generally, the metaphysis demonstrates comminution and impaction, with poor bone quality necessitating use of bone graft.
A frozen allograft femoral head is then obtained and split into 2 equal pieces using a saw (Figures 3–5). One piece is fashioned with a saw and a burr into a trapezoid such that the proximal portion is wider, and the distal, tapered portion is sized to fit the canal. The broad, proximal portion of the graft will serve as a pedestal to reduce the head to the shaft. Measuring the internal diameter of the humeral canal can be useful in estimating the necessary dimensions of the distal portion of the allograft. The graft often needs several small adjustments that necessitate attempting to place it in the intramedullary canal and then trimming as necessary to ensure proper fit distally within the shaft. For this reason, it is beneficial to perform the graft preparation near the surgical field. Once completed, the distal portion is then impacted into the humeral canal (Figure 6). Because of this impaction, there is no possibility for subsidence or pistoning of the graft within the canal, which can occur with a fibular graft. The humeral head is reduced onto the shaft with the already placed sutures; this is achieved by abducting the shoulder. The image intensifier is then used to confirm appropriate alignment and positioning of the fragments, making sure that both neck–shaft angle and medial calcar alignment have been restored (Figures 7, 8).
An appropriately sized proximal humerus plate is then selected based on the location of the fracture line. We have used standard lateral proximal humerus locking plates as well as laterality-specific anterolateral proximal humerus plates and found that both are suitable for incorporation of the screws through the graft and into the head. The plate is positioned on the humerus, and a guide pin is placed by hand through the proximal-most hole so that the appropriate height of the plate can be verified on fluoroscopy. The first screw is then a nonlocking bicortical screw placed through the oval hole in the shaft of the plate to allow further fine manipulation of the plate more proximally or distally as needed. The final height is confirmed, and the screw is firmly tightened (Figure 9). The locking-screw guide is fixed to the proximal portion of the plate, and 2 locking screws are then placed into the head. The arm is then rotated to an anteroposterior view by placing the arm in external rotation and neutral flexion and is then abducted and internally rotated to recreate a lateral view to perform final verification of the position of the plate on orthogonal images. If the surgeon is satisfied with the position of the plate, another nonlocking screw is placed distally, and then the proximal holes are used to place locking screws as needed. If the surgeon is not satisfied, the 2 proximal screws can be removed and the plate repositioned.
After each screw is placed, fluoroscopy is used to ensure there has been no breach of the articular surface. The number of proximal screws placed depends on fracture configuration and surgeon preference.
The sutures through the rotator cuff are then fixed to the plate, securing the tuberosities. Final intraoperative radiographs are used to confirm reduction, alignment, and final position of hardware (Figure 10). After copious irrigation, a surgical drain is placed as needed, and the wound is closed in layered fashion. Three years after surgery, follow-up examination revealed no radiographic change in alignment, no necrosis, and no varus collapse (Figure 11), and the patient was pain-free during activities.
Discussion
Surgical treatment of comminuted proximal humerus fractures usually consists of some type of plate fixation with screw fixation of the shaft, screws or smooth pegs to support the chondral surfaces, and screw fixation or suture cerclage of the tuberosities.
Fixed-angle locking-plate-and-screw constructs increased the biomechanical stability and pullout strength of proximal humerus plates.3,4 Nevertheless, avascular necrosis, malunion, and nonunion are still known complications of proximal humerus fractures, especially those with comminution, with up to 14% of patients still experiencing loss of fixation.5
For this reason, several authors have proposed using allograft bone and/or augmentation with calcium-containing cement to supplement fixation and provide an endosteal form of support for the head and tuberosities to decrease the risk for varus collapse. Osteobiologics (eg, calcium phosphate or sulfate cement) have been shown to decrease the risk for loss of reduction of proximal humerus fractures and decrease the risk for intra-articular screw penetration.6,7 Many calcium phosphate cements are commercially available. Cost and availability are 2 reasons that these supplements are not more widely used. Cancellous chips have also been used to aid in the reduction of proximal humerus fractures.8 No randomized study has been conducted to show a clinical advantage of this technique, though retrospective studies have shown that it is not as advantageous as using calcium phosphate cement with respect to loss of reduction or screw penetration.6 Certainly, cancellous chips are easily available in most hospitals and are less expensive than some alternatives. A recent review of these techniques in osteoporotic proximal humerus fractures found no clear indication for using one of these supplements over another.9
However, some fracture patterns require a structural graft to reduce the tuberosities and head component. Although described more than 30 years ago as a treatment for nonunions with an intramedullary “peg” of iliac crest graft,10 the graft most commonly reported today is allograft fibula.11-15 This technique consists of preparing the humeral shaft and often the fractured head segment with reaming to create a channel to receive the graft. Even with use of a small fibula, it is often time-consuming to use a saw, rasp, or burr to size the fibular segment to fit the medullary canal of the humerus. Once in place, the graft provides a strut on which the head fragment can be reduced and around which the tuberosities can be reduced. Although this technique is successful clinically and is biomechanically superior to plate-only constructs,16,17 concerns remain.
One such concern is keeping this graft in routine supply at most hospitals. Supply and pricing from vendors can differ significantly between hospitals, and a surgeon may need to request grafts in advance, which makes their use nonviable in a trauma case. Certain grafts are often kept in routine supply based on their overall utilization. At our institution, allograft femoral heads meet this criterion and are routinely stocked.
Of more importance are the ramifications of these procedures for future revision surgeries. The need for arthroplasty revision is common after ORIF of a proximal humerus fracture.18
Arthroplasty revision is an already challenging procedure that becomes more complex with the need to remove 6 to 8 cm of ingrown endosteal bone from a shell of outer osteoporotic cortical bone. Our experience with these complex revisions provided the impetus to search for an alternate graft type that still provides a strut for reducing the head and tuberosities but limits the amount of endosteal bone that would need to be removed in arthroplasty revision in order to place a stemmed component into the humeral canal.
Some currently available arthroplasty fracture systems modify the previous anatomy of the stem to provide a more anatomical platform to reduce the tuberosities to a broader metaphyseal construct that incorporates bone grafting to assist with healing.
Because of these concerns and factors, we adapted our technique to create an individual-specific pedestal with allograft femoral head that can be anatomically matched to each patient. This provides a strut to reduce the head and tuberosity fragments but still limits the amount of allograft bone needed to seat into the existing canal. The geometry of the allograft can also be customized to the fracture, with most 3- and 4-part fractures needing a trapezoidal strut that resembles the metaphyseal portion of a fracture-specific shoulder arthroplasty implant.
We have used this technique for comminuted 3- and 4-part fractures of the proximal humerus in 14 cases with at least 2-year follow-up and in several more cases that have not reached 2-year follow-up. All cases have gone on to radiographic union; none have had to be revised either with revision ORIF or to an arthroplasty. Formal measurements of final postoperative range of motion have not been tabulated in all cases, as some cases have been lost to follow-up after radiographic union was achieved. Medium- and long-term results are not yet available, but no short-term complications have been noted.
Disadvantages of this technique are that, while an individualized graft is created, proper shaping still takes time, and a moderate amount of the femoral head is not used. However, we have found that, if a graft is inadvertently undersized, there is still ample femoral head remaining to create another sized graft. Other disadvantages are the added cost and the (rare) risk of disease transmission, which come with use of any allograft, but the technique is used instead of another type of allograft, so these disadvantages are largely equivalent. At our hospital, differences in cost and availability between femoral head or fibular allografts are negligible.
This procedure, which is easily performed in a short amount of time, allows a stable base of bone graft to be used as an aid in the anatomical reduction of proximal humerus fractures, without the need for reaming and preparation of the medullary canal and without further increasing the difficulty associated with a future revision procedure.
Proximal humerus fractures are exceedingly common and account for almost 5% of all fractures. As osteoporosis is a risk factor for these fractures, their incidence rises with patient age.1
In 1970, Neer2 described these type of fractures and classified them as having 2, 3, or 4 parts based on the amount of angulation and displacement of the humeral head and the greater and lesser tuberosities with respect to the shaft.
Three- and 4-part proximal humerus fractures can be treated either nonoperatively, or surgically with closed reduction and percutaneous fixation, intramedullary fixation, open reduction and internal fixation (ORIF), or arthroplasty. There remains controversy over the best treatment, but a key component of any surgical treatment is anatomical reduction, stable fixation, and then healing of the tuberosities. A current common form of treatment is augmentation with an allograft fibula placed in the medullary canal. Although not formally reported, anecdotal evidence demonstrates that revision to arthroplasty is very difficult in the setting of an ingrown graft in the medullary canal of the humerus.
In this article, we present a novel technique of using allograft femoral head to reconstruct the metaphysis in ORIF of comminuted proximal humerus fractures.
Technique
Presented in Figure 1 are preoperative images of a representative displaced 4-part proximal humerus fracture treated surgically using the technique described here. General anesthesia is used. After intubation on the operating table, the patient is placed in the beach-chair position with about 75° of hip flexion. All bony prominences are padded, and the head and trunk are well secured. A pneumatic arm positioner is used to alleviate the need for an assistant to manipulate the arm. An image intensifier is used before preparing to verify that appropriate images of the proximal humerus can be obtained. Once adequate images are confirmed, the floor can be marked at the position of the fluoroscopic unit’s wheels to allow easy reproduction of images once the arm is prepared and draped. The intensifier is then removed from the field, the shoulder is prepared and draped in usual fashion, and prophylactic antibiotics are administered.
A deltopectoral incision is used, and sharp dissection is made through the subcutaneous tissue to raise full-thickness subcutaneous flaps on each side. The deltopectoral interval is sharply dissected while protecting the cephalic vein. Subdeltoid adhesions are then released. Palpation of the axillary nerve in the quadrilateral space to identify its location is helpful to avoid injury during the procedure.
The fracture is then identified, and No. 5 permanent suture is placed through the posterior and superior rotator cuff and through the subscapularis insertion (Figure 2). The tuberosities are freed from the humeral head sharply. A blunt elevator is then used to gently elevate the humeral head upward, with care taken to avoid comminuting the metaphyseal bone while levering. Reduction is achieved by manipulating the sutures and levering the head with the elevator while placing the arm in extension and posterior translation. Fluoroscopic images are used to verify correct anatomical alignment. Generally, the metaphysis demonstrates comminution and impaction, with poor bone quality necessitating use of bone graft.
A frozen allograft femoral head is then obtained and split into 2 equal pieces using a saw (Figures 3–5). One piece is fashioned with a saw and a burr into a trapezoid such that the proximal portion is wider, and the distal, tapered portion is sized to fit the canal. The broad, proximal portion of the graft will serve as a pedestal to reduce the head to the shaft. Measuring the internal diameter of the humeral canal can be useful in estimating the necessary dimensions of the distal portion of the allograft. The graft often needs several small adjustments that necessitate attempting to place it in the intramedullary canal and then trimming as necessary to ensure proper fit distally within the shaft. For this reason, it is beneficial to perform the graft preparation near the surgical field. Once completed, the distal portion is then impacted into the humeral canal (Figure 6). Because of this impaction, there is no possibility for subsidence or pistoning of the graft within the canal, which can occur with a fibular graft. The humeral head is reduced onto the shaft with the already placed sutures; this is achieved by abducting the shoulder. The image intensifier is then used to confirm appropriate alignment and positioning of the fragments, making sure that both neck–shaft angle and medial calcar alignment have been restored (Figures 7, 8).
An appropriately sized proximal humerus plate is then selected based on the location of the fracture line. We have used standard lateral proximal humerus locking plates as well as laterality-specific anterolateral proximal humerus plates and found that both are suitable for incorporation of the screws through the graft and into the head. The plate is positioned on the humerus, and a guide pin is placed by hand through the proximal-most hole so that the appropriate height of the plate can be verified on fluoroscopy. The first screw is then a nonlocking bicortical screw placed through the oval hole in the shaft of the plate to allow further fine manipulation of the plate more proximally or distally as needed. The final height is confirmed, and the screw is firmly tightened (Figure 9). The locking-screw guide is fixed to the proximal portion of the plate, and 2 locking screws are then placed into the head. The arm is then rotated to an anteroposterior view by placing the arm in external rotation and neutral flexion and is then abducted and internally rotated to recreate a lateral view to perform final verification of the position of the plate on orthogonal images. If the surgeon is satisfied with the position of the plate, another nonlocking screw is placed distally, and then the proximal holes are used to place locking screws as needed. If the surgeon is not satisfied, the 2 proximal screws can be removed and the plate repositioned.
After each screw is placed, fluoroscopy is used to ensure there has been no breach of the articular surface. The number of proximal screws placed depends on fracture configuration and surgeon preference.
The sutures through the rotator cuff are then fixed to the plate, securing the tuberosities. Final intraoperative radiographs are used to confirm reduction, alignment, and final position of hardware (Figure 10). After copious irrigation, a surgical drain is placed as needed, and the wound is closed in layered fashion. Three years after surgery, follow-up examination revealed no radiographic change in alignment, no necrosis, and no varus collapse (Figure 11), and the patient was pain-free during activities.
Discussion
Surgical treatment of comminuted proximal humerus fractures usually consists of some type of plate fixation with screw fixation of the shaft, screws or smooth pegs to support the chondral surfaces, and screw fixation or suture cerclage of the tuberosities.
Fixed-angle locking-plate-and-screw constructs increased the biomechanical stability and pullout strength of proximal humerus plates.3,4 Nevertheless, avascular necrosis, malunion, and nonunion are still known complications of proximal humerus fractures, especially those with comminution, with up to 14% of patients still experiencing loss of fixation.5
For this reason, several authors have proposed using allograft bone and/or augmentation with calcium-containing cement to supplement fixation and provide an endosteal form of support for the head and tuberosities to decrease the risk for varus collapse. Osteobiologics (eg, calcium phosphate or sulfate cement) have been shown to decrease the risk for loss of reduction of proximal humerus fractures and decrease the risk for intra-articular screw penetration.6,7 Many calcium phosphate cements are commercially available. Cost and availability are 2 reasons that these supplements are not more widely used. Cancellous chips have also been used to aid in the reduction of proximal humerus fractures.8 No randomized study has been conducted to show a clinical advantage of this technique, though retrospective studies have shown that it is not as advantageous as using calcium phosphate cement with respect to loss of reduction or screw penetration.6 Certainly, cancellous chips are easily available in most hospitals and are less expensive than some alternatives. A recent review of these techniques in osteoporotic proximal humerus fractures found no clear indication for using one of these supplements over another.9
However, some fracture patterns require a structural graft to reduce the tuberosities and head component. Although described more than 30 years ago as a treatment for nonunions with an intramedullary “peg” of iliac crest graft,10 the graft most commonly reported today is allograft fibula.11-15 This technique consists of preparing the humeral shaft and often the fractured head segment with reaming to create a channel to receive the graft. Even with use of a small fibula, it is often time-consuming to use a saw, rasp, or burr to size the fibular segment to fit the medullary canal of the humerus. Once in place, the graft provides a strut on which the head fragment can be reduced and around which the tuberosities can be reduced. Although this technique is successful clinically and is biomechanically superior to plate-only constructs,16,17 concerns remain.
One such concern is keeping this graft in routine supply at most hospitals. Supply and pricing from vendors can differ significantly between hospitals, and a surgeon may need to request grafts in advance, which makes their use nonviable in a trauma case. Certain grafts are often kept in routine supply based on their overall utilization. At our institution, allograft femoral heads meet this criterion and are routinely stocked.
Of more importance are the ramifications of these procedures for future revision surgeries. The need for arthroplasty revision is common after ORIF of a proximal humerus fracture.18
Arthroplasty revision is an already challenging procedure that becomes more complex with the need to remove 6 to 8 cm of ingrown endosteal bone from a shell of outer osteoporotic cortical bone. Our experience with these complex revisions provided the impetus to search for an alternate graft type that still provides a strut for reducing the head and tuberosities but limits the amount of endosteal bone that would need to be removed in arthroplasty revision in order to place a stemmed component into the humeral canal.
Some currently available arthroplasty fracture systems modify the previous anatomy of the stem to provide a more anatomical platform to reduce the tuberosities to a broader metaphyseal construct that incorporates bone grafting to assist with healing.
Because of these concerns and factors, we adapted our technique to create an individual-specific pedestal with allograft femoral head that can be anatomically matched to each patient. This provides a strut to reduce the head and tuberosity fragments but still limits the amount of allograft bone needed to seat into the existing canal. The geometry of the allograft can also be customized to the fracture, with most 3- and 4-part fractures needing a trapezoidal strut that resembles the metaphyseal portion of a fracture-specific shoulder arthroplasty implant.
We have used this technique for comminuted 3- and 4-part fractures of the proximal humerus in 14 cases with at least 2-year follow-up and in several more cases that have not reached 2-year follow-up. All cases have gone on to radiographic union; none have had to be revised either with revision ORIF or to an arthroplasty. Formal measurements of final postoperative range of motion have not been tabulated in all cases, as some cases have been lost to follow-up after radiographic union was achieved. Medium- and long-term results are not yet available, but no short-term complications have been noted.
Disadvantages of this technique are that, while an individualized graft is created, proper shaping still takes time, and a moderate amount of the femoral head is not used. However, we have found that, if a graft is inadvertently undersized, there is still ample femoral head remaining to create another sized graft. Other disadvantages are the added cost and the (rare) risk of disease transmission, which come with use of any allograft, but the technique is used instead of another type of allograft, so these disadvantages are largely equivalent. At our hospital, differences in cost and availability between femoral head or fibular allografts are negligible.
This procedure, which is easily performed in a short amount of time, allows a stable base of bone graft to be used as an aid in the anatomical reduction of proximal humerus fractures, without the need for reaming and preparation of the medullary canal and without further increasing the difficulty associated with a future revision procedure.
1. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-249.
2. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
3. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg. 2000;9(5):423-426.
4. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elbow Surg. 2006;15(2):239-243.
5. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681.
6. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741-748.
7. Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma. 2013;27(7):399-404.
8. Ong CC, Kwon YW, Walsh M, Davidovitch R, Zuckerman JD, Egol KA. Outcomes of open reduction and internal fixation of proximal humerus fractures managed with locking plates. Am J Orthop. 2012;41(9):407-412.
9. Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012;21(12):1787-1795.
10. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res. 1982;(167):255-259.
11. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212-215.
12. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300-3306.
13. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195-200.
14. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942.
15. Little MT, Berkes MB, Schottel PC, et al. The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma. 2014;28(6):338-347.
16. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech. 2010;25(7):642-646.
17. Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg. 2012;21(7):894-901.
18. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542-549.
1. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-249.
2. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
3. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg. 2000;9(5):423-426.
4. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elbow Surg. 2006;15(2):239-243.
5. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681.
6. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741-748.
7. Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma. 2013;27(7):399-404.
8. Ong CC, Kwon YW, Walsh M, Davidovitch R, Zuckerman JD, Egol KA. Outcomes of open reduction and internal fixation of proximal humerus fractures managed with locking plates. Am J Orthop. 2012;41(9):407-412.
9. Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012;21(12):1787-1795.
10. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res. 1982;(167):255-259.
11. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212-215.
12. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300-3306.
13. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195-200.
14. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942.
15. Little MT, Berkes MB, Schottel PC, et al. The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma. 2014;28(6):338-347.
16. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech. 2010;25(7):642-646.
17. Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg. 2012;21(7):894-901.
18. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542-549.
Calisthenics May Reverse Age-Related Bone Loss in Middle-Aged Men
Certain types of weight-lifting and jumping exercises, when completed for at least 6 months, improve bone density in active, healthy, middle-aged men with low bone mass, according to a study published online ahead of print June 16 in Bone.
“Weight-lifting programs exist to increase muscular strength, but less research has examined what happens to bones during these types of exercises,” said Pam Hinton, PhD, Associate Professor and Director of Nutritional Sciences Graduate Studies in the University of Missouri Department of Nutrition and Exercise Physiology in Columbia, Missouri. “Our study is the first to show that exercise-based interventions work to increase bone density in middle-aged men with low bone mass who are otherwise healthy. These exercises could be prescribed to reverse bone loss associated with aging.”
Dr. Hinton and colleagues studied 38 physically active, middle-aged men with osteopenia of the hip or spine who completed either a weight-lifting program or a jumping program for 1 year. Both programs required participants to complete 60 to 120 minutes of targeted exercise each week. The participants took calcium (1200 mg/day) and vitamin D (10 mcg/day) supplements throughout their training programs. The researchers measured the men’s bone mass at the beginning of the study and again at 6 and 12 months using DXA scans of the whole body, total hip, and lumbar spine.
The investigators found the bone mass of the whole body and lumbar spine significantly increased after 6 months of completing the weight-lifting or jumping programs, and this increase was maintained at 12 months. Hip-bone density only increased among those who completed the weight-lifting program.
Dr. Hinton said the study results do not indicate that all kinds of weight-lifting will help improve bone mass; rather, targeted exercises made the training programs effective.
“Only the bone experiencing the mechanical load is going to get stronger, so we specifically chose exercises that would load the hip and the spine, which is why we had participants do squats, deadlifts, lunges, and the overhead press,” Dr. Hinton said. “Also, the intensity of the loading needs to increase over time to build strength. Both of the training programs gradually increased in intensity, and our participants also had rest weeks. Bones need to rest to continue to maximize the response.”
Throughout their training programs, participants rated pain and fatigue after completing their exercises. The participants reported minimal pain and fatigue, and these ratings decreased over the year. Dr. Hinton said individuals who want to use similar training programs to improve bone density should consider their current activity levels and exercise preferences as well as time and equipment constraints.
“The interventions we studied are effective, safe, and take 60 to 120 minutes per week to complete, which is feasible for most people,” Dr. Hinton said. “Also, the exercises can be done at home and require minimal exercise equipment, which adds to the ease of implementing and continuing these interventions.”
Suggested Reading
Hinton PS, Nigh P, Thyfault J. Effectiveness of resistance training or jumping-exercise to increase bone mineral density in men with low bone mass: a 12-month randomized, clinical trial. Bone. 2015 June 16 [Epub ahead of print].
Certain types of weight-lifting and jumping exercises, when completed for at least 6 months, improve bone density in active, healthy, middle-aged men with low bone mass, according to a study published online ahead of print June 16 in Bone.
“Weight-lifting programs exist to increase muscular strength, but less research has examined what happens to bones during these types of exercises,” said Pam Hinton, PhD, Associate Professor and Director of Nutritional Sciences Graduate Studies in the University of Missouri Department of Nutrition and Exercise Physiology in Columbia, Missouri. “Our study is the first to show that exercise-based interventions work to increase bone density in middle-aged men with low bone mass who are otherwise healthy. These exercises could be prescribed to reverse bone loss associated with aging.”
Dr. Hinton and colleagues studied 38 physically active, middle-aged men with osteopenia of the hip or spine who completed either a weight-lifting program or a jumping program for 1 year. Both programs required participants to complete 60 to 120 minutes of targeted exercise each week. The participants took calcium (1200 mg/day) and vitamin D (10 mcg/day) supplements throughout their training programs. The researchers measured the men’s bone mass at the beginning of the study and again at 6 and 12 months using DXA scans of the whole body, total hip, and lumbar spine.
The investigators found the bone mass of the whole body and lumbar spine significantly increased after 6 months of completing the weight-lifting or jumping programs, and this increase was maintained at 12 months. Hip-bone density only increased among those who completed the weight-lifting program.
Dr. Hinton said the study results do not indicate that all kinds of weight-lifting will help improve bone mass; rather, targeted exercises made the training programs effective.
“Only the bone experiencing the mechanical load is going to get stronger, so we specifically chose exercises that would load the hip and the spine, which is why we had participants do squats, deadlifts, lunges, and the overhead press,” Dr. Hinton said. “Also, the intensity of the loading needs to increase over time to build strength. Both of the training programs gradually increased in intensity, and our participants also had rest weeks. Bones need to rest to continue to maximize the response.”
Throughout their training programs, participants rated pain and fatigue after completing their exercises. The participants reported minimal pain and fatigue, and these ratings decreased over the year. Dr. Hinton said individuals who want to use similar training programs to improve bone density should consider their current activity levels and exercise preferences as well as time and equipment constraints.
“The interventions we studied are effective, safe, and take 60 to 120 minutes per week to complete, which is feasible for most people,” Dr. Hinton said. “Also, the exercises can be done at home and require minimal exercise equipment, which adds to the ease of implementing and continuing these interventions.”
Certain types of weight-lifting and jumping exercises, when completed for at least 6 months, improve bone density in active, healthy, middle-aged men with low bone mass, according to a study published online ahead of print June 16 in Bone.
“Weight-lifting programs exist to increase muscular strength, but less research has examined what happens to bones during these types of exercises,” said Pam Hinton, PhD, Associate Professor and Director of Nutritional Sciences Graduate Studies in the University of Missouri Department of Nutrition and Exercise Physiology in Columbia, Missouri. “Our study is the first to show that exercise-based interventions work to increase bone density in middle-aged men with low bone mass who are otherwise healthy. These exercises could be prescribed to reverse bone loss associated with aging.”
Dr. Hinton and colleagues studied 38 physically active, middle-aged men with osteopenia of the hip or spine who completed either a weight-lifting program or a jumping program for 1 year. Both programs required participants to complete 60 to 120 minutes of targeted exercise each week. The participants took calcium (1200 mg/day) and vitamin D (10 mcg/day) supplements throughout their training programs. The researchers measured the men’s bone mass at the beginning of the study and again at 6 and 12 months using DXA scans of the whole body, total hip, and lumbar spine.
The investigators found the bone mass of the whole body and lumbar spine significantly increased after 6 months of completing the weight-lifting or jumping programs, and this increase was maintained at 12 months. Hip-bone density only increased among those who completed the weight-lifting program.
Dr. Hinton said the study results do not indicate that all kinds of weight-lifting will help improve bone mass; rather, targeted exercises made the training programs effective.
“Only the bone experiencing the mechanical load is going to get stronger, so we specifically chose exercises that would load the hip and the spine, which is why we had participants do squats, deadlifts, lunges, and the overhead press,” Dr. Hinton said. “Also, the intensity of the loading needs to increase over time to build strength. Both of the training programs gradually increased in intensity, and our participants also had rest weeks. Bones need to rest to continue to maximize the response.”
Throughout their training programs, participants rated pain and fatigue after completing their exercises. The participants reported minimal pain and fatigue, and these ratings decreased over the year. Dr. Hinton said individuals who want to use similar training programs to improve bone density should consider their current activity levels and exercise preferences as well as time and equipment constraints.
“The interventions we studied are effective, safe, and take 60 to 120 minutes per week to complete, which is feasible for most people,” Dr. Hinton said. “Also, the exercises can be done at home and require minimal exercise equipment, which adds to the ease of implementing and continuing these interventions.”
Suggested Reading
Hinton PS, Nigh P, Thyfault J. Effectiveness of resistance training or jumping-exercise to increase bone mineral density in men with low bone mass: a 12-month randomized, clinical trial. Bone. 2015 June 16 [Epub ahead of print].
Suggested Reading
Hinton PS, Nigh P, Thyfault J. Effectiveness of resistance training or jumping-exercise to increase bone mineral density in men with low bone mass: a 12-month randomized, clinical trial. Bone. 2015 June 16 [Epub ahead of print].
Isolated Radiopalmar Dislocation of Fifth Carpometacarpal Joint: A Rare Presentation
Isolated dislocation of the carpometacarpal (CMC) joint of the hand is a rare injury. While the dislocation can be dorsal or palmar, dorsal dislocation is more common. Palmar dislocations can be either ulnopalmar or radiopalmar. There are very few reports of isolated radiopalmar dislocations of the fifth CMC joint in the English-language literature.1-3 We present a case of delayed presentation and management of radiopalmar dislocation of the fifth CMC joint. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 42-year-old man presented with polytrauma to our emergency department. He was stabilized initially, and open fractures were treated by débridement and external fixator application. During an examination 3 days after admission, swelling was noted in the right hand. On further study, there was splaying of the fifth digit and tenderness over the fourth and fifth CMC joints (Figure 1). No abnormal mobility or crepitus could be elicited. Plain radiographs of the right hand in anteroposterior and lateral views revealed radiopalmar dislocation of the fifth CMC joint (Figure 2). It was decided to reduce the dislocation immediately after the patient was declared fit for surgery.
Under axillary block, closed reduction was unsuccessful. Open reduction of the fifth CMC joint was performed through a dorsal incision. The base of the fifth metacarpal bone was found to be stripped of soft-tissue attachments and lying in a radiopalmar location. Reduction, which was checked under image intensifier, was found to be satisfactory (Figure 3). Reduction was stabilized by passing a smooth Kirschner wire (K-wire) from the fifth metacarpal to the hamate bone. After achieving hemostasis, the wound was closed in layers and a below-elbow splint was applied. The perioperative period was uneventful, and sutures were removed on postoperative day 10. The K-wire was removed after 4 weeks, and radiographs showed satisfactory position of the fifth CMC joint. Gentle active and passive mobilization of fingers and wrist were started. The patient had regained good function of the wrist and fingers 2 months after surgery (Figure 4).
Discussion
Carpometacarpal joint dislocations are uncommon injuries and account for less than 1% of hand injuries.4 They are classified as dorsal and volar (palmar) dislocations. Dorsal dislocations of the CMC joints occur more frequently than do volar dislocations, mainly affecting the fourth and fifth digits.5 Isolated volar or palmar dislocation of the fifth CMC joint is an uncommon injury that was first reported in 1918 by McWhorter.6 In 1968, Nalebuff7 classified the volar dislocations into 2 groups according to the direction of the displacement of the fifth metacarpal base: radiopalmar and ulnopalmar. Berg and Murphy8 found the hook of the hamate to deviate the metacarpal bone to either the ulnar or radial side. Tearing of all ligament and tendon attachments of the base of the fifth metacarpal results in radiopalmar dislocation.7 The attachments of ligaments and tendons remain intact in the ulnopalmar dislocation.7
The clinical features of this injury are pain and swelling about the base of the fifth metacarpal and axial deformity of the little finger with apparent shortening. The deep motor branch of the ulnar nerve lies volar to the fifth CMC joint as it courses around the hook of the hamate. It is vulnerable to injury in both dorsal9,10 and volar11 CMC dislocations. For radiologic evaluation, in addition to standard anteroposterior and lateral radiographs, a lateral view in 30º pronation of the hand can provide an improved view of the fifth CMC joint, as suggested by Bora and Didizian.12
The treatment of ulnopalmar dislocation has evolved. Ulnopalmar dislocations have been successfully treated by closed reduction without fixation,8 and by open reduction and K-wire fixation.3,7,13
Radiopalmar dislocations are inherently unstable because of the tearing of all ligament and tendon attachments of the base of the fifth metacarpal.7 In our case of radiopalmar dislocation, diagnosis was delayed and attempts at closed reduction were unsuccessful. Therefore, it was treated by open reduction and K-wire fixation. In our case, open reduction and K-wire fixation for radiopalmar dislocation of the fifth CMC joint provided promising results.
Conclusion
Radiopalmar dislocation of the fifth CMC joint is a rare injury, and very few cases have been reported in the English-language literature. We report one such case, which was successfully treated with open reduction and K-wire fixation.
1. Buzby BF. Palmar carpometacarpal dislocation of the fifth metacarpal. Ann Surg. 1934;100:555-557.
2. Chen VT. Dislocation of carpometacarpal joint of the little finger. J Hand Surg. 1987;12(2):260-263.
3. Dennyson WG, Stother IG. Carpometacarpal dislocation of the little finger. Hand. 1976;8(2):161-164.
4. Domingo A, Font L, Saz L, Arandes JM. Isolated radial palmar dislocation of the fifth carpometacarpal joint with ulnar neuropathy associated: successful treatment with closed reduction and internal fixation. Eur J Orthop Surg Traumatol. 19(2):101-107.
5. Fisher MR, Rogers LF, Hendrix RW. Systematic approach to identifying fourth and fifth carpometacarpal joint dislocations. AJR Am J Roentgenol. 1983;140(2):319-324.
6. McWhorter GL. Isolated and complete dislocation of the fifth carpometacarpal joint: open operation. Surg Clin Chic. 1918;2:793-796.
7. Nalebuff EA. Isolated anterior carpometacarpal dislocation of the fifth finger: classification and case report. J Trauma. 1968;8(6):1119-1123.
8. Berg EE, Murphy DF. Ulnopalmar dislocation of the fifth carpometacarpal joint – successful closed reduction: review of the literature and anatomic reevaluation. J Hand Surg Am. 1986;11(4):521-525.
9. Peterson P, Sacks S. Fracture-dislocation of the base of the fifth metacarpal associated with injury to the deep motor branch of the ulnar nerve: a case report. J Hand Surg Am. 1986;11(4):525-528.
10. Young TB. Dorsal dislocation of the metacarpal base of the little and ring fingers with ulnar nerve branch compression. Injury. 1987;18(1):65-66.
11. O’Rourke PJ, Quinlan W. Fracture dislocation of the fifth metacarpal resulting in compression of the deep branch of the ulnar nerve. J Hand Surg Br. 1993;18(2):190-191.
12. Bora FW Jr, Didizian NH. The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg Am. 1974;56(7):1459-1463.
13. Tountas AA, Kwok JM. Isolated volar dislocation of the fifth carpometacarpal joint. Case report. Clin Orthop Relat Res. 1984;187:172-175.
Isolated dislocation of the carpometacarpal (CMC) joint of the hand is a rare injury. While the dislocation can be dorsal or palmar, dorsal dislocation is more common. Palmar dislocations can be either ulnopalmar or radiopalmar. There are very few reports of isolated radiopalmar dislocations of the fifth CMC joint in the English-language literature.1-3 We present a case of delayed presentation and management of radiopalmar dislocation of the fifth CMC joint. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 42-year-old man presented with polytrauma to our emergency department. He was stabilized initially, and open fractures were treated by débridement and external fixator application. During an examination 3 days after admission, swelling was noted in the right hand. On further study, there was splaying of the fifth digit and tenderness over the fourth and fifth CMC joints (Figure 1). No abnormal mobility or crepitus could be elicited. Plain radiographs of the right hand in anteroposterior and lateral views revealed radiopalmar dislocation of the fifth CMC joint (Figure 2). It was decided to reduce the dislocation immediately after the patient was declared fit for surgery.
Under axillary block, closed reduction was unsuccessful. Open reduction of the fifth CMC joint was performed through a dorsal incision. The base of the fifth metacarpal bone was found to be stripped of soft-tissue attachments and lying in a radiopalmar location. Reduction, which was checked under image intensifier, was found to be satisfactory (Figure 3). Reduction was stabilized by passing a smooth Kirschner wire (K-wire) from the fifth metacarpal to the hamate bone. After achieving hemostasis, the wound was closed in layers and a below-elbow splint was applied. The perioperative period was uneventful, and sutures were removed on postoperative day 10. The K-wire was removed after 4 weeks, and radiographs showed satisfactory position of the fifth CMC joint. Gentle active and passive mobilization of fingers and wrist were started. The patient had regained good function of the wrist and fingers 2 months after surgery (Figure 4).
Discussion
Carpometacarpal joint dislocations are uncommon injuries and account for less than 1% of hand injuries.4 They are classified as dorsal and volar (palmar) dislocations. Dorsal dislocations of the CMC joints occur more frequently than do volar dislocations, mainly affecting the fourth and fifth digits.5 Isolated volar or palmar dislocation of the fifth CMC joint is an uncommon injury that was first reported in 1918 by McWhorter.6 In 1968, Nalebuff7 classified the volar dislocations into 2 groups according to the direction of the displacement of the fifth metacarpal base: radiopalmar and ulnopalmar. Berg and Murphy8 found the hook of the hamate to deviate the metacarpal bone to either the ulnar or radial side. Tearing of all ligament and tendon attachments of the base of the fifth metacarpal results in radiopalmar dislocation.7 The attachments of ligaments and tendons remain intact in the ulnopalmar dislocation.7
The clinical features of this injury are pain and swelling about the base of the fifth metacarpal and axial deformity of the little finger with apparent shortening. The deep motor branch of the ulnar nerve lies volar to the fifth CMC joint as it courses around the hook of the hamate. It is vulnerable to injury in both dorsal9,10 and volar11 CMC dislocations. For radiologic evaluation, in addition to standard anteroposterior and lateral radiographs, a lateral view in 30º pronation of the hand can provide an improved view of the fifth CMC joint, as suggested by Bora and Didizian.12
The treatment of ulnopalmar dislocation has evolved. Ulnopalmar dislocations have been successfully treated by closed reduction without fixation,8 and by open reduction and K-wire fixation.3,7,13
Radiopalmar dislocations are inherently unstable because of the tearing of all ligament and tendon attachments of the base of the fifth metacarpal.7 In our case of radiopalmar dislocation, diagnosis was delayed and attempts at closed reduction were unsuccessful. Therefore, it was treated by open reduction and K-wire fixation. In our case, open reduction and K-wire fixation for radiopalmar dislocation of the fifth CMC joint provided promising results.
Conclusion
Radiopalmar dislocation of the fifth CMC joint is a rare injury, and very few cases have been reported in the English-language literature. We report one such case, which was successfully treated with open reduction and K-wire fixation.
Isolated dislocation of the carpometacarpal (CMC) joint of the hand is a rare injury. While the dislocation can be dorsal or palmar, dorsal dislocation is more common. Palmar dislocations can be either ulnopalmar or radiopalmar. There are very few reports of isolated radiopalmar dislocations of the fifth CMC joint in the English-language literature.1-3 We present a case of delayed presentation and management of radiopalmar dislocation of the fifth CMC joint. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 42-year-old man presented with polytrauma to our emergency department. He was stabilized initially, and open fractures were treated by débridement and external fixator application. During an examination 3 days after admission, swelling was noted in the right hand. On further study, there was splaying of the fifth digit and tenderness over the fourth and fifth CMC joints (Figure 1). No abnormal mobility or crepitus could be elicited. Plain radiographs of the right hand in anteroposterior and lateral views revealed radiopalmar dislocation of the fifth CMC joint (Figure 2). It was decided to reduce the dislocation immediately after the patient was declared fit for surgery.
Under axillary block, closed reduction was unsuccessful. Open reduction of the fifth CMC joint was performed through a dorsal incision. The base of the fifth metacarpal bone was found to be stripped of soft-tissue attachments and lying in a radiopalmar location. Reduction, which was checked under image intensifier, was found to be satisfactory (Figure 3). Reduction was stabilized by passing a smooth Kirschner wire (K-wire) from the fifth metacarpal to the hamate bone. After achieving hemostasis, the wound was closed in layers and a below-elbow splint was applied. The perioperative period was uneventful, and sutures were removed on postoperative day 10. The K-wire was removed after 4 weeks, and radiographs showed satisfactory position of the fifth CMC joint. Gentle active and passive mobilization of fingers and wrist were started. The patient had regained good function of the wrist and fingers 2 months after surgery (Figure 4).
Discussion
Carpometacarpal joint dislocations are uncommon injuries and account for less than 1% of hand injuries.4 They are classified as dorsal and volar (palmar) dislocations. Dorsal dislocations of the CMC joints occur more frequently than do volar dislocations, mainly affecting the fourth and fifth digits.5 Isolated volar or palmar dislocation of the fifth CMC joint is an uncommon injury that was first reported in 1918 by McWhorter.6 In 1968, Nalebuff7 classified the volar dislocations into 2 groups according to the direction of the displacement of the fifth metacarpal base: radiopalmar and ulnopalmar. Berg and Murphy8 found the hook of the hamate to deviate the metacarpal bone to either the ulnar or radial side. Tearing of all ligament and tendon attachments of the base of the fifth metacarpal results in radiopalmar dislocation.7 The attachments of ligaments and tendons remain intact in the ulnopalmar dislocation.7
The clinical features of this injury are pain and swelling about the base of the fifth metacarpal and axial deformity of the little finger with apparent shortening. The deep motor branch of the ulnar nerve lies volar to the fifth CMC joint as it courses around the hook of the hamate. It is vulnerable to injury in both dorsal9,10 and volar11 CMC dislocations. For radiologic evaluation, in addition to standard anteroposterior and lateral radiographs, a lateral view in 30º pronation of the hand can provide an improved view of the fifth CMC joint, as suggested by Bora and Didizian.12
The treatment of ulnopalmar dislocation has evolved. Ulnopalmar dislocations have been successfully treated by closed reduction without fixation,8 and by open reduction and K-wire fixation.3,7,13
Radiopalmar dislocations are inherently unstable because of the tearing of all ligament and tendon attachments of the base of the fifth metacarpal.7 In our case of radiopalmar dislocation, diagnosis was delayed and attempts at closed reduction were unsuccessful. Therefore, it was treated by open reduction and K-wire fixation. In our case, open reduction and K-wire fixation for radiopalmar dislocation of the fifth CMC joint provided promising results.
Conclusion
Radiopalmar dislocation of the fifth CMC joint is a rare injury, and very few cases have been reported in the English-language literature. We report one such case, which was successfully treated with open reduction and K-wire fixation.
1. Buzby BF. Palmar carpometacarpal dislocation of the fifth metacarpal. Ann Surg. 1934;100:555-557.
2. Chen VT. Dislocation of carpometacarpal joint of the little finger. J Hand Surg. 1987;12(2):260-263.
3. Dennyson WG, Stother IG. Carpometacarpal dislocation of the little finger. Hand. 1976;8(2):161-164.
4. Domingo A, Font L, Saz L, Arandes JM. Isolated radial palmar dislocation of the fifth carpometacarpal joint with ulnar neuropathy associated: successful treatment with closed reduction and internal fixation. Eur J Orthop Surg Traumatol. 19(2):101-107.
5. Fisher MR, Rogers LF, Hendrix RW. Systematic approach to identifying fourth and fifth carpometacarpal joint dislocations. AJR Am J Roentgenol. 1983;140(2):319-324.
6. McWhorter GL. Isolated and complete dislocation of the fifth carpometacarpal joint: open operation. Surg Clin Chic. 1918;2:793-796.
7. Nalebuff EA. Isolated anterior carpometacarpal dislocation of the fifth finger: classification and case report. J Trauma. 1968;8(6):1119-1123.
8. Berg EE, Murphy DF. Ulnopalmar dislocation of the fifth carpometacarpal joint – successful closed reduction: review of the literature and anatomic reevaluation. J Hand Surg Am. 1986;11(4):521-525.
9. Peterson P, Sacks S. Fracture-dislocation of the base of the fifth metacarpal associated with injury to the deep motor branch of the ulnar nerve: a case report. J Hand Surg Am. 1986;11(4):525-528.
10. Young TB. Dorsal dislocation of the metacarpal base of the little and ring fingers with ulnar nerve branch compression. Injury. 1987;18(1):65-66.
11. O’Rourke PJ, Quinlan W. Fracture dislocation of the fifth metacarpal resulting in compression of the deep branch of the ulnar nerve. J Hand Surg Br. 1993;18(2):190-191.
12. Bora FW Jr, Didizian NH. The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg Am. 1974;56(7):1459-1463.
13. Tountas AA, Kwok JM. Isolated volar dislocation of the fifth carpometacarpal joint. Case report. Clin Orthop Relat Res. 1984;187:172-175.
1. Buzby BF. Palmar carpometacarpal dislocation of the fifth metacarpal. Ann Surg. 1934;100:555-557.
2. Chen VT. Dislocation of carpometacarpal joint of the little finger. J Hand Surg. 1987;12(2):260-263.
3. Dennyson WG, Stother IG. Carpometacarpal dislocation of the little finger. Hand. 1976;8(2):161-164.
4. Domingo A, Font L, Saz L, Arandes JM. Isolated radial palmar dislocation of the fifth carpometacarpal joint with ulnar neuropathy associated: successful treatment with closed reduction and internal fixation. Eur J Orthop Surg Traumatol. 19(2):101-107.
5. Fisher MR, Rogers LF, Hendrix RW. Systematic approach to identifying fourth and fifth carpometacarpal joint dislocations. AJR Am J Roentgenol. 1983;140(2):319-324.
6. McWhorter GL. Isolated and complete dislocation of the fifth carpometacarpal joint: open operation. Surg Clin Chic. 1918;2:793-796.
7. Nalebuff EA. Isolated anterior carpometacarpal dislocation of the fifth finger: classification and case report. J Trauma. 1968;8(6):1119-1123.
8. Berg EE, Murphy DF. Ulnopalmar dislocation of the fifth carpometacarpal joint – successful closed reduction: review of the literature and anatomic reevaluation. J Hand Surg Am. 1986;11(4):521-525.
9. Peterson P, Sacks S. Fracture-dislocation of the base of the fifth metacarpal associated with injury to the deep motor branch of the ulnar nerve: a case report. J Hand Surg Am. 1986;11(4):525-528.
10. Young TB. Dorsal dislocation of the metacarpal base of the little and ring fingers with ulnar nerve branch compression. Injury. 1987;18(1):65-66.
11. O’Rourke PJ, Quinlan W. Fracture dislocation of the fifth metacarpal resulting in compression of the deep branch of the ulnar nerve. J Hand Surg Br. 1993;18(2):190-191.
12. Bora FW Jr, Didizian NH. The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg Am. 1974;56(7):1459-1463.
13. Tountas AA, Kwok JM. Isolated volar dislocation of the fifth carpometacarpal joint. Case report. Clin Orthop Relat Res. 1984;187:172-175.
Midterm Follow-Up of Metal-Backed Glenoid Components in Anatomical Total Shoulder Arthroplasties
Total shoulder arthroplasty (TSA) is being performed with increasing frequency. According to recent data, the number of TSAs performed annually increased 2.5-fold from 2000 to 2008.1 As more are performed, the need for improved implant survival will increase as well. In particular, advances in glenoid survivorship will be a primary focus. Previous experience has demonstrated that the glenoid component is the most common source of loosening and failure, and glenoid loosening has been documented in 33% to 44% of arthroplasties, with the rate of radiographically lucent lines even higher.2-5 Thus, a correlation between increasing incidence of procedures and high rates of glenoid loosening represents the potential for a significant increase in the number of future revisions. A recent report from Germany indicated that TSA had a 3-fold higher relative burden of revision than hemiarthroplasty.6
Ingrowth metal-backed glenoid components offer the theoretical advantage of bone growth directly into the prosthesis with a single host–prosthesis interface. Use of a novel tantalum glenoid may avoid the stress-shielding, component-stiffness, dissociation, and backside-wear issues that have produced the high failure rates of conventional metal-backed glenoids. According to the literature, the multiple different-style cementless glenoids being used have had unpredictable outcomes and demonstrated an increased need for revisions.7-11
In this article, we present a case series of midterm radiographic and clinical outcomes for TSAs using porous tantalum glenoid components. Our goals were to further understanding of survivorship and complications associated with ingrowth glenoid components and to demonstrate the differences that may occur with use of tantalum.
Materials and Methods
Data were examined for all TSAs performed at a single institution between 2004 and 2013. Before reviewing the data, we obtained approval from the hospital institutional review board. Our retrospective chart review identified all patients who underwent TSA using a tantalum ingrowth glenoid component. Exclusion criteria included revision arthroplasty, use of a non-tantalum glenoid, reverse shoulder arthroplasty, and conversion from hemiarthroplasty to TSA. Twelve shoulders (11 patients) were identified. We obtained patient consent to examine the data collected, and patients were reexamined if they had not been seen within the past 12 months. Figures 1 and 2 show the preoperative radiographs.
The TSAs were performed by 2 fellowship-trained shoulder surgeons using glenoid components with porous tantalum anchors (Zimmer). Indications for this procedure were age under 60 years, no prior surgery, and glenoid morphology allowing for version correction without bone grafting. Patients with severe posterior erosion that required bone graft or with a dysplastic glenoid were not indicated for this glenoid implant.
In each case, the anesthesia team placed an indwelling interscalene catheter, and then the surgery was performed with the patient under deep sedation. The beach-chair position and a deltopectoral approach were used, and biceps tendon tenodesis was performed. The subscapularis was elevated with a lesser tuberosity osteotomy and was repaired with nonabsorbable braided suture at the end of the case. During glenoid implantation, the periphery of the polyethylene was cemented. This is consistent with the approved method of implantation for this device. Closed suction drainage was used. After surgery, the patient was restricted to no weight-bearing. During the first 6 weeks, passive forward elevation was allowed to 130° and external rotation to 30°. Active and active-assisted range of motion was started at 6 weeks, and muscular strengthening was allowed 12 weeks after surgery.
We analyzed standard radiographs at yearly intervals for trabecular bony architecture and lucency surrounding the tantalum anchor of the glenoid. Before and after surgery, American Shoulder and Elbow Surgeons (ASES) scores and active forward elevation (AFE) and active external rotation (AER) measurements were recorded. These measurements served as endpoints of analysis.
Results
Twelve shoulders (11 patients) were identified and examined. Mean follow-up was 20 months (range, 6-84 months). In all cases, annual standard radiographs showed bony trabeculae adjacent to the tantalum anchor without lucency. There was no sign of glenoid loosening in any patient.
ASES scores and AFE and AER measurements were obtained with physical examinations and compared with t tests. ASES scores, available for 8 patients, increased from 32 before surgery to 85 after surgery (P < .01). Mean AFE increased from 117° to 159° (P < .01), and mean AER increased from 23° to 53° (P < .01). Figures 3 and 4 show the postoperative radiographs, and the Table highlights the ASES and range-of-motion data.
Discussion
Data for the 12 TSAs followed in this series showed promising outcomes for cementless ingrowth glenoid components. Much as with other data in the literature, there were significant improvements in ASES scores, AFE, and AER. What differs from the majority of available data is the survivorship and lack of radiolucent lines on follow-up radiographs.
Boileau and colleagues7 randomized 39 patients (40 shoulders) to either a cemented all-polyethylene glenoid or a cementless metal-backed glenoid component. Although the metal-backed glenoid components had a significantly lower rate of radiolucent lines, the metal-backed glenoids had a significantly higher rate of loosening. The authors subsequently abandoned use of uncemented metal-backed glenoid components. Taunton and colleagues8 reviewed 83 TSAs with a metal-backed bone ingrowth glenoid component. In 74 cases, the preoperative diagnosis was primary osteoarthritis. Mean clinical follow-up was 9.5 years. During follow-up, there were improvements in pain, forward elevation, and external rotation. Radiographic glenoid loosening was noted in 33 shoulders; 9 required revision for glenoid loosening. Both series demonstrated a high rate of revisions for cementless glenoid components.
Similar revision difficulties were noted by Montoya and colleagues.9 In their series of 65 TSAs performed for primary osteoarthritis, a cementless glenoid component was implanted. There were significant improvements in Constant scores, forward flexion, external rotation, and abduction but also an 11.3% revision rate noted at 68 months (mean follow-up). Glenoid revisions were required predominantly in patients with eccentric preoperative glenoid morphology. Lawrence and colleagues10 used a cementless ingrowth glenoid component in 21 shoulder arthroplasties performed for glenoid bone loss (13) or revision (8). They noted a high rate of revisions but good outcomes for the cases not revised. In both studies, there was a high rate of revision for glenoid loosening but also a tendency for revisions to be correlated with more challenging clinical applications.
Wirth and colleagues11 followed 44 TSAs using a minimally cemented ingrowth glenoid component. There were significant improvements in ASES scores, Simple Shoulder Test scores, and visual analog scale pain ratings. No revisions for glenoid loosening were noted. The implants were thought to provide durable outcomes at a mean follow-up of 4 years. These results were similar to those appreciated in the present study. In both series, the revision rate was much lower than described in the literature, and there were predictable improvements in pain and active motion.
Our study had several limitations: small number of patients, no comparison group, and relatively short follow-up. More long-term data are needed to appropriately compare cemented and uncemented glenoid components. In addition, it is difficult to compare our group of patients with those described in the literature, as the implants used differ. Despite these limitations, our data suggest that tantalum ingrowth glenoid components provide predictable and sustainable outcomes in TSA. With longer-term follow-up, tantalum ingrowth glenoids may demonstrate a durable and reliable alternative to cemented glenoid components.
1. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254.
2. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg. 1997;6(6):495-505.
3. Kasten P, Pape G, Raiss P, et al. Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique. J Bone Joint Surg Br. 2010;92(3):387-392.
4. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292.
5. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-337.
6. Hollatz MF, Stang A. Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006. J Shoulder Elbow Surg. 2014;23(11):e267-e274.
7. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Molé D. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. J Shoulder Elbow Surg. 2002;11(4):351-359.
8. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am. 2008;90(10):2180-2188.
9. Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635.
10. Lawrence TM, Ahmadi S, Sperling JW, Cofield RH. Fixation and durability of a bone-ingrowth component for glenoid bone loss. J Shoulder Elbow Surg. 2012;21(12):1764-1769.
11. Wirth MA, Loredo R, Garcia G, Rockwood CA Jr, Southworth C, Iannotti JP. Total shoulder arthroplasty with an all-polyethylene pegged bone-ingrowth glenoid component: a clinical and radiographic outcome study. J Bone Joint Surg Am. 2012;94(3):260-267.
Total shoulder arthroplasty (TSA) is being performed with increasing frequency. According to recent data, the number of TSAs performed annually increased 2.5-fold from 2000 to 2008.1 As more are performed, the need for improved implant survival will increase as well. In particular, advances in glenoid survivorship will be a primary focus. Previous experience has demonstrated that the glenoid component is the most common source of loosening and failure, and glenoid loosening has been documented in 33% to 44% of arthroplasties, with the rate of radiographically lucent lines even higher.2-5 Thus, a correlation between increasing incidence of procedures and high rates of glenoid loosening represents the potential for a significant increase in the number of future revisions. A recent report from Germany indicated that TSA had a 3-fold higher relative burden of revision than hemiarthroplasty.6
Ingrowth metal-backed glenoid components offer the theoretical advantage of bone growth directly into the prosthesis with a single host–prosthesis interface. Use of a novel tantalum glenoid may avoid the stress-shielding, component-stiffness, dissociation, and backside-wear issues that have produced the high failure rates of conventional metal-backed glenoids. According to the literature, the multiple different-style cementless glenoids being used have had unpredictable outcomes and demonstrated an increased need for revisions.7-11
In this article, we present a case series of midterm radiographic and clinical outcomes for TSAs using porous tantalum glenoid components. Our goals were to further understanding of survivorship and complications associated with ingrowth glenoid components and to demonstrate the differences that may occur with use of tantalum.
Materials and Methods
Data were examined for all TSAs performed at a single institution between 2004 and 2013. Before reviewing the data, we obtained approval from the hospital institutional review board. Our retrospective chart review identified all patients who underwent TSA using a tantalum ingrowth glenoid component. Exclusion criteria included revision arthroplasty, use of a non-tantalum glenoid, reverse shoulder arthroplasty, and conversion from hemiarthroplasty to TSA. Twelve shoulders (11 patients) were identified. We obtained patient consent to examine the data collected, and patients were reexamined if they had not been seen within the past 12 months. Figures 1 and 2 show the preoperative radiographs.
The TSAs were performed by 2 fellowship-trained shoulder surgeons using glenoid components with porous tantalum anchors (Zimmer). Indications for this procedure were age under 60 years, no prior surgery, and glenoid morphology allowing for version correction without bone grafting. Patients with severe posterior erosion that required bone graft or with a dysplastic glenoid were not indicated for this glenoid implant.
In each case, the anesthesia team placed an indwelling interscalene catheter, and then the surgery was performed with the patient under deep sedation. The beach-chair position and a deltopectoral approach were used, and biceps tendon tenodesis was performed. The subscapularis was elevated with a lesser tuberosity osteotomy and was repaired with nonabsorbable braided suture at the end of the case. During glenoid implantation, the periphery of the polyethylene was cemented. This is consistent with the approved method of implantation for this device. Closed suction drainage was used. After surgery, the patient was restricted to no weight-bearing. During the first 6 weeks, passive forward elevation was allowed to 130° and external rotation to 30°. Active and active-assisted range of motion was started at 6 weeks, and muscular strengthening was allowed 12 weeks after surgery.
We analyzed standard radiographs at yearly intervals for trabecular bony architecture and lucency surrounding the tantalum anchor of the glenoid. Before and after surgery, American Shoulder and Elbow Surgeons (ASES) scores and active forward elevation (AFE) and active external rotation (AER) measurements were recorded. These measurements served as endpoints of analysis.
Results
Twelve shoulders (11 patients) were identified and examined. Mean follow-up was 20 months (range, 6-84 months). In all cases, annual standard radiographs showed bony trabeculae adjacent to the tantalum anchor without lucency. There was no sign of glenoid loosening in any patient.
ASES scores and AFE and AER measurements were obtained with physical examinations and compared with t tests. ASES scores, available for 8 patients, increased from 32 before surgery to 85 after surgery (P < .01). Mean AFE increased from 117° to 159° (P < .01), and mean AER increased from 23° to 53° (P < .01). Figures 3 and 4 show the postoperative radiographs, and the Table highlights the ASES and range-of-motion data.
Discussion
Data for the 12 TSAs followed in this series showed promising outcomes for cementless ingrowth glenoid components. Much as with other data in the literature, there were significant improvements in ASES scores, AFE, and AER. What differs from the majority of available data is the survivorship and lack of radiolucent lines on follow-up radiographs.
Boileau and colleagues7 randomized 39 patients (40 shoulders) to either a cemented all-polyethylene glenoid or a cementless metal-backed glenoid component. Although the metal-backed glenoid components had a significantly lower rate of radiolucent lines, the metal-backed glenoids had a significantly higher rate of loosening. The authors subsequently abandoned use of uncemented metal-backed glenoid components. Taunton and colleagues8 reviewed 83 TSAs with a metal-backed bone ingrowth glenoid component. In 74 cases, the preoperative diagnosis was primary osteoarthritis. Mean clinical follow-up was 9.5 years. During follow-up, there were improvements in pain, forward elevation, and external rotation. Radiographic glenoid loosening was noted in 33 shoulders; 9 required revision for glenoid loosening. Both series demonstrated a high rate of revisions for cementless glenoid components.
Similar revision difficulties were noted by Montoya and colleagues.9 In their series of 65 TSAs performed for primary osteoarthritis, a cementless glenoid component was implanted. There were significant improvements in Constant scores, forward flexion, external rotation, and abduction but also an 11.3% revision rate noted at 68 months (mean follow-up). Glenoid revisions were required predominantly in patients with eccentric preoperative glenoid morphology. Lawrence and colleagues10 used a cementless ingrowth glenoid component in 21 shoulder arthroplasties performed for glenoid bone loss (13) or revision (8). They noted a high rate of revisions but good outcomes for the cases not revised. In both studies, there was a high rate of revision for glenoid loosening but also a tendency for revisions to be correlated with more challenging clinical applications.
Wirth and colleagues11 followed 44 TSAs using a minimally cemented ingrowth glenoid component. There were significant improvements in ASES scores, Simple Shoulder Test scores, and visual analog scale pain ratings. No revisions for glenoid loosening were noted. The implants were thought to provide durable outcomes at a mean follow-up of 4 years. These results were similar to those appreciated in the present study. In both series, the revision rate was much lower than described in the literature, and there were predictable improvements in pain and active motion.
Our study had several limitations: small number of patients, no comparison group, and relatively short follow-up. More long-term data are needed to appropriately compare cemented and uncemented glenoid components. In addition, it is difficult to compare our group of patients with those described in the literature, as the implants used differ. Despite these limitations, our data suggest that tantalum ingrowth glenoid components provide predictable and sustainable outcomes in TSA. With longer-term follow-up, tantalum ingrowth glenoids may demonstrate a durable and reliable alternative to cemented glenoid components.
Total shoulder arthroplasty (TSA) is being performed with increasing frequency. According to recent data, the number of TSAs performed annually increased 2.5-fold from 2000 to 2008.1 As more are performed, the need for improved implant survival will increase as well. In particular, advances in glenoid survivorship will be a primary focus. Previous experience has demonstrated that the glenoid component is the most common source of loosening and failure, and glenoid loosening has been documented in 33% to 44% of arthroplasties, with the rate of radiographically lucent lines even higher.2-5 Thus, a correlation between increasing incidence of procedures and high rates of glenoid loosening represents the potential for a significant increase in the number of future revisions. A recent report from Germany indicated that TSA had a 3-fold higher relative burden of revision than hemiarthroplasty.6
Ingrowth metal-backed glenoid components offer the theoretical advantage of bone growth directly into the prosthesis with a single host–prosthesis interface. Use of a novel tantalum glenoid may avoid the stress-shielding, component-stiffness, dissociation, and backside-wear issues that have produced the high failure rates of conventional metal-backed glenoids. According to the literature, the multiple different-style cementless glenoids being used have had unpredictable outcomes and demonstrated an increased need for revisions.7-11
In this article, we present a case series of midterm radiographic and clinical outcomes for TSAs using porous tantalum glenoid components. Our goals were to further understanding of survivorship and complications associated with ingrowth glenoid components and to demonstrate the differences that may occur with use of tantalum.
Materials and Methods
Data were examined for all TSAs performed at a single institution between 2004 and 2013. Before reviewing the data, we obtained approval from the hospital institutional review board. Our retrospective chart review identified all patients who underwent TSA using a tantalum ingrowth glenoid component. Exclusion criteria included revision arthroplasty, use of a non-tantalum glenoid, reverse shoulder arthroplasty, and conversion from hemiarthroplasty to TSA. Twelve shoulders (11 patients) were identified. We obtained patient consent to examine the data collected, and patients were reexamined if they had not been seen within the past 12 months. Figures 1 and 2 show the preoperative radiographs.
The TSAs were performed by 2 fellowship-trained shoulder surgeons using glenoid components with porous tantalum anchors (Zimmer). Indications for this procedure were age under 60 years, no prior surgery, and glenoid morphology allowing for version correction without bone grafting. Patients with severe posterior erosion that required bone graft or with a dysplastic glenoid were not indicated for this glenoid implant.
In each case, the anesthesia team placed an indwelling interscalene catheter, and then the surgery was performed with the patient under deep sedation. The beach-chair position and a deltopectoral approach were used, and biceps tendon tenodesis was performed. The subscapularis was elevated with a lesser tuberosity osteotomy and was repaired with nonabsorbable braided suture at the end of the case. During glenoid implantation, the periphery of the polyethylene was cemented. This is consistent with the approved method of implantation for this device. Closed suction drainage was used. After surgery, the patient was restricted to no weight-bearing. During the first 6 weeks, passive forward elevation was allowed to 130° and external rotation to 30°. Active and active-assisted range of motion was started at 6 weeks, and muscular strengthening was allowed 12 weeks after surgery.
We analyzed standard radiographs at yearly intervals for trabecular bony architecture and lucency surrounding the tantalum anchor of the glenoid. Before and after surgery, American Shoulder and Elbow Surgeons (ASES) scores and active forward elevation (AFE) and active external rotation (AER) measurements were recorded. These measurements served as endpoints of analysis.
Results
Twelve shoulders (11 patients) were identified and examined. Mean follow-up was 20 months (range, 6-84 months). In all cases, annual standard radiographs showed bony trabeculae adjacent to the tantalum anchor without lucency. There was no sign of glenoid loosening in any patient.
ASES scores and AFE and AER measurements were obtained with physical examinations and compared with t tests. ASES scores, available for 8 patients, increased from 32 before surgery to 85 after surgery (P < .01). Mean AFE increased from 117° to 159° (P < .01), and mean AER increased from 23° to 53° (P < .01). Figures 3 and 4 show the postoperative radiographs, and the Table highlights the ASES and range-of-motion data.
Discussion
Data for the 12 TSAs followed in this series showed promising outcomes for cementless ingrowth glenoid components. Much as with other data in the literature, there were significant improvements in ASES scores, AFE, and AER. What differs from the majority of available data is the survivorship and lack of radiolucent lines on follow-up radiographs.
Boileau and colleagues7 randomized 39 patients (40 shoulders) to either a cemented all-polyethylene glenoid or a cementless metal-backed glenoid component. Although the metal-backed glenoid components had a significantly lower rate of radiolucent lines, the metal-backed glenoids had a significantly higher rate of loosening. The authors subsequently abandoned use of uncemented metal-backed glenoid components. Taunton and colleagues8 reviewed 83 TSAs with a metal-backed bone ingrowth glenoid component. In 74 cases, the preoperative diagnosis was primary osteoarthritis. Mean clinical follow-up was 9.5 years. During follow-up, there were improvements in pain, forward elevation, and external rotation. Radiographic glenoid loosening was noted in 33 shoulders; 9 required revision for glenoid loosening. Both series demonstrated a high rate of revisions for cementless glenoid components.
Similar revision difficulties were noted by Montoya and colleagues.9 In their series of 65 TSAs performed for primary osteoarthritis, a cementless glenoid component was implanted. There were significant improvements in Constant scores, forward flexion, external rotation, and abduction but also an 11.3% revision rate noted at 68 months (mean follow-up). Glenoid revisions were required predominantly in patients with eccentric preoperative glenoid morphology. Lawrence and colleagues10 used a cementless ingrowth glenoid component in 21 shoulder arthroplasties performed for glenoid bone loss (13) or revision (8). They noted a high rate of revisions but good outcomes for the cases not revised. In both studies, there was a high rate of revision for glenoid loosening but also a tendency for revisions to be correlated with more challenging clinical applications.
Wirth and colleagues11 followed 44 TSAs using a minimally cemented ingrowth glenoid component. There were significant improvements in ASES scores, Simple Shoulder Test scores, and visual analog scale pain ratings. No revisions for glenoid loosening were noted. The implants were thought to provide durable outcomes at a mean follow-up of 4 years. These results were similar to those appreciated in the present study. In both series, the revision rate was much lower than described in the literature, and there were predictable improvements in pain and active motion.
Our study had several limitations: small number of patients, no comparison group, and relatively short follow-up. More long-term data are needed to appropriately compare cemented and uncemented glenoid components. In addition, it is difficult to compare our group of patients with those described in the literature, as the implants used differ. Despite these limitations, our data suggest that tantalum ingrowth glenoid components provide predictable and sustainable outcomes in TSA. With longer-term follow-up, tantalum ingrowth glenoids may demonstrate a durable and reliable alternative to cemented glenoid components.
1. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254.
2. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg. 1997;6(6):495-505.
3. Kasten P, Pape G, Raiss P, et al. Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique. J Bone Joint Surg Br. 2010;92(3):387-392.
4. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292.
5. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-337.
6. Hollatz MF, Stang A. Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006. J Shoulder Elbow Surg. 2014;23(11):e267-e274.
7. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Molé D. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. J Shoulder Elbow Surg. 2002;11(4):351-359.
8. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am. 2008;90(10):2180-2188.
9. Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635.
10. Lawrence TM, Ahmadi S, Sperling JW, Cofield RH. Fixation and durability of a bone-ingrowth component for glenoid bone loss. J Shoulder Elbow Surg. 2012;21(12):1764-1769.
11. Wirth MA, Loredo R, Garcia G, Rockwood CA Jr, Southworth C, Iannotti JP. Total shoulder arthroplasty with an all-polyethylene pegged bone-ingrowth glenoid component: a clinical and radiographic outcome study. J Bone Joint Surg Am. 2012;94(3):260-267.
1. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254.
2. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg. 1997;6(6):495-505.
3. Kasten P, Pape G, Raiss P, et al. Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique. J Bone Joint Surg Br. 2010;92(3):387-392.
4. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292.
5. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-337.
6. Hollatz MF, Stang A. Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006. J Shoulder Elbow Surg. 2014;23(11):e267-e274.
7. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Molé D. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. J Shoulder Elbow Surg. 2002;11(4):351-359.
8. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am. 2008;90(10):2180-2188.
9. Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635.
10. Lawrence TM, Ahmadi S, Sperling JW, Cofield RH. Fixation and durability of a bone-ingrowth component for glenoid bone loss. J Shoulder Elbow Surg. 2012;21(12):1764-1769.
11. Wirth MA, Loredo R, Garcia G, Rockwood CA Jr, Southworth C, Iannotti JP. Total shoulder arthroplasty with an all-polyethylene pegged bone-ingrowth glenoid component: a clinical and radiographic outcome study. J Bone Joint Surg Am. 2012;94(3):260-267.
The Role of Computed Tomography in Evaluating Intra-Articular Distal Humerus Fractures
Elbow fractures constitute 7% of all adult fractures, and 30% of these fractures are distal humerus fractures.1,2 Of these, 96% involve disruption of the articular surface.3 Intra-articular distal humerus fracture patterns can be difficult to characterize on plain radiographs, and therefore computed tomography (CT) is often used. The surgeon’s understanding of the fracture pattern and the deforming forces affects choice of surgical approach. In particular, multiplanar fracture patterns, including coronal shear fractures of the capitellum or trochlea, are often difficult to recognize on plain radiographs. Identification of a multiplanar fracture pattern may require a change in approach or fixation. CT is useful for other intra-articular fractures, such as those of the proximal humerus,3-6 but involves increased radiation and cost.
We conducted a study to determine the effect of adding CT evaluation to plain radiographic evaluation on the classification of, and treatment plans for, intra-articular distal humerus fractures. We hypothesized that adding CT images to plain radiographs would change the classification and treatment of these fractures and would improve interobserver agreement on classification and treatment.
Materials and Methods
After obtaining University of Southern California Institutional Review Board approval, we retrospectively studied 30 consecutive cases of adult intra-articular distal humerus fractures treated by Dr. Itamura at a level I trauma center between 1995 and 2008. In each case, the injured elbow was imaged with plain radiography and CT. Multiple machines were used for CT, but all according to the radiology department’s standard protocol. The images were evaluated by 9 independent observers from the same institution: 3 orthopedic surgeons (1 fellowship-trained shoulder/elbow subspecialist, 1 fellowship-trained upper extremity subspecialist, 1 fellowship-trained orthopedic trauma surgeon), 3 shoulder/elbow fellows, and 3 senior residents pursuing upper extremity fellowships on graduation. No observer was involved in the care of any of the patients. All identifying details were removed from the patient information presented to the observers. For each set of images, the observer was asked to classify the fractures according to the Mehne and Matta classification system,7,8 which is the predominant system used at our institution.
Diagrams of this classification system were provided, but there was no formal observer training or calibration. Seven treatment options were presented: (1) open reduction and internal fixation (ORIF) using a posterior approach with olecranon osteotomy, (2) ORIF using a posterior approach, (3) ORIF using a lateral approach, (4) ORIF using a medial approach, (5) ORIF using an anterior/anterolateral approach, (6) total elbow arthroplasty, and (7) nonoperative management. The only clinical data provided were patient age and sex.
Images were evaluated in blinded fashion. Two rounds of evaluation were compared. In round 1, plain radiographs were evaluated; in round 2, the same radiographs plus corresponding 2-dimensional (2-D) CT images. A minimum of 1 month was required between viewing rounds.
Statistical Analysis
Statistical analysis was performed by the Statistical Consultation and Research Center at our institution. Cohen κ was calculated to estimate the reliability of the fracture classification and treatment plan made by different observers on the same occasion (interobserver reliability). Cramer V9 was calculated to estimate the reliability of the fracture classification and treatment plan made by the same observer on separate occasions (intraobserver reliability). It measures the association between the 2 ratings as a percentage of their total variation. The κ value and Cramer V value were also used to evaluate results based on the observers’ training levels. Both κ and Cramer V values are interpreted as follows: .00 to .20 indicates slight agreement; .21 to .40, fair agreement; .41-.60, moderate agreement; .61 to .80, substantial agreement; and ≥.81, almost perfect agreement. Zero represents no agreement, and 1.00 represents perfect agreement.
Results
Overall intraobserver reliability for classification was fair (.393). It was moderate for the treatment plan (.426) between viewing rounds. Residents had the highest Cramer V value at .60 (moderate) for classification reliability, and attending surgeons had the highest value at .52 (moderate) for treatment plan. All 3 groups (residents, fellows, attending surgeons) showed moderate intraobserver agreement for treatment plan (Table 1).
Interobserver reliability did not improve with the addition of CT in round 2. Reliability was fair at both viewing rounds for classification and for treatment. For classification, the overall κ value was .21 for the first round and .20 for the second round. For treatment plan, the overall κ value was .28 for the first round and .27 for the second round. Attending surgeons decreased in agreement with regard to treatment plan with the addition of CT (.46, moderate, to .32, fair). Fellows had only slight agreement for both rounds with regard to classification as well as treatment (Table 2).
ORIF using a posterior approach with an olecranon osteotomy was the most common choice of treatment method overall at both time points (58.1% and 63.7%) and was still the most common choice when each group of observers (residents, fellows, faculty) was considered separately (Figure 1).
When classifying the fractures, attending surgeons chose the multiplanar fracture pattern 25.6% of the time when viewing radiographs only, and remained consistent in choosing this pattern 23.3% of the time when CT was added to radiographs. Fellows and residents chose this fracture pattern much less often (8.9% and 7.8%, respectively) when viewing radiographs only. Both fellows and residents increased their choice of the multiplanar fracture pattern by 10% (18.9% for fellows, 17.8% for residents) when CT was added (Figure 2).
Overall, the recognition of a multiplanar fracture pattern increased when CT was added. On 30 occasions, an answer was changed from another classification pattern to the multiplanar pattern when CT was added. Only 6 times did an observer change a multiplanar pattern selection at round 1 to another choice at round 2.
Adding CT in round 2 changed the treatment plan for multiplanar fractures. At round 1, 73.7% chose ORIF using a lateral approach for treatment of the multiplanar fracture versus 10.5% who chose ORIF using a posterior approach with an olecranon osteotomy. The choice of the posterior approach with olecranon osteotomy increased to 51.9% at round 2, using the technique we have previously described.5,10
Overall intraobserver reliability for classification was fair (.393). It was moderate for the treatment plan (.426) between viewing rounds. Residents had the highest Cramer V value at .60 (moderate) for classification reliability, and faculty had the highest value at .52 (moderate) for treatment plan. All 3 groups (residents, fellows, attending surgeons) showed moderate intraobserver agreement for treatment plan (Table 1).
Interobserver reliability did not improve with the addition of CT in round 2. Reliability for classification was fair for round 1 and slight for round 2. Reliability was fair at both viewing rounds for treatment. For classification, the overall κ value was .21 for round 1 and .20 for round 2. For treatment plan, the overall κ value was .28 for round 1 and .27 for round 2. Attending surgeons decreased in agreement with regard to treatment plan with the addition of CT (.46, moderate, to .32, fair). Fellows had only slight agreement for both rounds with regard to classification as well as treatment (Table 2).
Discussion
In this study, CT changed both classification and treatment when added to plain radiographs. Interestingly, interobserver reliability did not improve for classification or treatment with the addition of CT. This finding suggests substantial disagreement among qualified observers that is not resolved with more sophisticated imaging. We propose this disagreement is caused by differences in training and experience with specific fracture patterns and surgical approaches.
Our fair to moderate interobserver reliability using radiographs only is consistent with a study by Wainwright and colleagues,11 who demonstrated fair to moderate interobserver reliability with radiographs only using 3 different classification systems. CT did not improve interobserver reliability in the present study.
To our knowledge, the effect of adding CT to plain radiographs on classification and treatment plan has not been evaluated. Doornberg and colleagues2 evaluated the effect of adding 3-dimensional (3-D) CT to a combination of radiographs and 2-D CT. Using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification12 and the classification system of Mehne and Matta, they found that 3-D CT improved intraobserver and interobserver reliability for classification but improved only intraobserver agreement for treatment. Interobserver agreement for treatment plan remained fair. In parallel with their study, fracture classification in our study was more often changed with CT than the treatment plan was. Training level appeared not to affect this finding. We found fair interobserver agreement for treatment choice as well, which was not improved by adding CT. Doornberg and colleagues2 concluded that the “relatively small added expense of three-dimensional computed tomography scans seems worthwhile.”
When evaluating specific fracture patterns in the Mehne and Matta classification system, we observed that less experienced surgeons (residents, fellows) were much more likely to identify multiplanar fracture patterns with the aid of CT. Use of CT did not change attending surgeons’ recognition of these multiplanar fractures, suggesting that the faculty were more capable of appreciating these fracture patterns with radiographs only (Figure 3). We also observed that adding CT changed the predominant treatment plan for multiplanar fractures from a lateral approach to a posterior approach with an olecranon osteotomy. Failure to appreciate this component of the fracture before surgery could lead to an increased intraoperative difficulty level. Failure to appreciate it during surgery could lead to unexpected postoperative displacement and ultimately poorer outcome.
There are limitations to our study. There is no gold standard for assessing the accuracy of classification decisions. Intraoperative classification could have served as a gold standard, but the fractures were not routinely assigned a classification during surgery. Brouwer and colleagues13 evaluated the diagnostic accuracy of CT (including 3-D CT) with intraoperative AO classification as a reference point and found improvement in intraobserver agreement but not interobserver agreement when describing fracture characteristics—and no significant effect on classification.
We used a single classification system, the one primarily used at our institution and by Dr. Itamura. There are many systems,7,12,14 all with their strengths and weaknesses, and no one system is used universally. Adding a system would have allowed us to compare results of more than one system. Our aim, however, was to keep our form simple for the sake of participation and completion of the viewings by each volunteer.
Only 2-D CT was used for this study, as 3-D images were not available for all patients. Although this is a potential weakness, it appears that, based on the study by Doornberg and colleagues,2 adding 3-D imaging resulted in only modest improvement in the reliability of classification and no significant improvement in agreement on treatment recommendation.
In addition, our results were likely biased by the fact that 8 of the 9 evaluators were trained by Dr. Itamura, who very often uses a posterior approach with an olecranon osteotomy for internal fixation of distal humerus intra-articular fractures, as previously described.8,10 Therefore, selection of this treatment option may have been overestimated in this study. Nevertheless, after reviewing the literature, Ljungquist and colleagues15 wrote, “There do not seem to be superior functional results associated with any one surgical approach to the distal humerus.”
We did not give the evaluators an indication of patients’ activity demands (only age and sex), which may have been relevant when considering total elbow arthroplasty.
Last, performing another round of evaluations with only plain radiographs, before introducing CT, would have provided intraobserver reliability results on plain radiograph evaluation, which could have been compared with intraobserver reliability when CT was added. Again, this was excluded to encourage participation and create the least cumbersome evaluation experience possible, which was thought appropriate, as this information is already in the literature.
Conclusion
Adding CT changed classifications and treatment plans. Raters were more likely to change their classifications than their treatment plans. The addition of CT did not increase agreement between observers. Despite the added radiation and cost, we recommend performing CT for all intra-articular distal humerus fractures because it improves understanding of the fracture pattern and affects treatment planning, especially for fractures with a coronal shear component, which is often not appreciated on plain radiographs.
1. Anglen J. Distal humerus. J Am Acad Orthop Surg. 2005;13(5):291-297.
2. Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the classification and management of distal humerus fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am. 2006;88(8):1795-1801.
3. Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin North Am. 2008;39(2):187-200.
4. Castagno AA, Shuman WP, Kilcoyne RF, Haynor DR, Morris ME, Matsen FA. Complex fractures of the proximal humerus: role of CT in treatment. Radiology. 1987;165(3):759-762.
5. Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol. 1998;14(2):159-164.
6. Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75(12):1751-1755.
7. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825-833.
8. Zalavras CG, McAllister ET, Singh A, Itamura JM. Operative treatment of intra-articular distal humerus fractures. Am J Orthop. 2007;36(12 suppl):8-12.
9. Cramer H. Mathematical Methods of Statistics. Princeton, NJ: Princeton University Press; 1946.
10. Panossian V, Zalavras C, Mirzayan R, Itamura JM. Intra-articular distal humerus fractures. In: Mirzayan R, Itamura JM, eds. Shoulder and Elbow Trauma. New York, NY: Thieme; 2004:67-78.
11. Wainwright AM, Williams JR, Carr AJ. Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J Bone Joint Surg Br. 2000;82(5):636-642.
12. Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification of Fractures in Long Bones. Berlin, Germany: Springer-Verlag; 1990.
13. Brouwer KM, Lindenhovius AL, Dyer GS, Zurakowski D, Mudgal C, Ring D. Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg. 2012;21(6):772-776.
14. Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in 29 cases. J Bone Joint Surg Am. 1969;51(1):130-141.
15. Ljungquist KL, Beran MC, Awan H. Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review. J Shoulder Elbow Surg. 2012;21(1):126-135.
Elbow fractures constitute 7% of all adult fractures, and 30% of these fractures are distal humerus fractures.1,2 Of these, 96% involve disruption of the articular surface.3 Intra-articular distal humerus fracture patterns can be difficult to characterize on plain radiographs, and therefore computed tomography (CT) is often used. The surgeon’s understanding of the fracture pattern and the deforming forces affects choice of surgical approach. In particular, multiplanar fracture patterns, including coronal shear fractures of the capitellum or trochlea, are often difficult to recognize on plain radiographs. Identification of a multiplanar fracture pattern may require a change in approach or fixation. CT is useful for other intra-articular fractures, such as those of the proximal humerus,3-6 but involves increased radiation and cost.
We conducted a study to determine the effect of adding CT evaluation to plain radiographic evaluation on the classification of, and treatment plans for, intra-articular distal humerus fractures. We hypothesized that adding CT images to plain radiographs would change the classification and treatment of these fractures and would improve interobserver agreement on classification and treatment.
Materials and Methods
After obtaining University of Southern California Institutional Review Board approval, we retrospectively studied 30 consecutive cases of adult intra-articular distal humerus fractures treated by Dr. Itamura at a level I trauma center between 1995 and 2008. In each case, the injured elbow was imaged with plain radiography and CT. Multiple machines were used for CT, but all according to the radiology department’s standard protocol. The images were evaluated by 9 independent observers from the same institution: 3 orthopedic surgeons (1 fellowship-trained shoulder/elbow subspecialist, 1 fellowship-trained upper extremity subspecialist, 1 fellowship-trained orthopedic trauma surgeon), 3 shoulder/elbow fellows, and 3 senior residents pursuing upper extremity fellowships on graduation. No observer was involved in the care of any of the patients. All identifying details were removed from the patient information presented to the observers. For each set of images, the observer was asked to classify the fractures according to the Mehne and Matta classification system,7,8 which is the predominant system used at our institution.
Diagrams of this classification system were provided, but there was no formal observer training or calibration. Seven treatment options were presented: (1) open reduction and internal fixation (ORIF) using a posterior approach with olecranon osteotomy, (2) ORIF using a posterior approach, (3) ORIF using a lateral approach, (4) ORIF using a medial approach, (5) ORIF using an anterior/anterolateral approach, (6) total elbow arthroplasty, and (7) nonoperative management. The only clinical data provided were patient age and sex.
Images were evaluated in blinded fashion. Two rounds of evaluation were compared. In round 1, plain radiographs were evaluated; in round 2, the same radiographs plus corresponding 2-dimensional (2-D) CT images. A minimum of 1 month was required between viewing rounds.
Statistical Analysis
Statistical analysis was performed by the Statistical Consultation and Research Center at our institution. Cohen κ was calculated to estimate the reliability of the fracture classification and treatment plan made by different observers on the same occasion (interobserver reliability). Cramer V9 was calculated to estimate the reliability of the fracture classification and treatment plan made by the same observer on separate occasions (intraobserver reliability). It measures the association between the 2 ratings as a percentage of their total variation. The κ value and Cramer V value were also used to evaluate results based on the observers’ training levels. Both κ and Cramer V values are interpreted as follows: .00 to .20 indicates slight agreement; .21 to .40, fair agreement; .41-.60, moderate agreement; .61 to .80, substantial agreement; and ≥.81, almost perfect agreement. Zero represents no agreement, and 1.00 represents perfect agreement.
Results
Overall intraobserver reliability for classification was fair (.393). It was moderate for the treatment plan (.426) between viewing rounds. Residents had the highest Cramer V value at .60 (moderate) for classification reliability, and attending surgeons had the highest value at .52 (moderate) for treatment plan. All 3 groups (residents, fellows, attending surgeons) showed moderate intraobserver agreement for treatment plan (Table 1).
Interobserver reliability did not improve with the addition of CT in round 2. Reliability was fair at both viewing rounds for classification and for treatment. For classification, the overall κ value was .21 for the first round and .20 for the second round. For treatment plan, the overall κ value was .28 for the first round and .27 for the second round. Attending surgeons decreased in agreement with regard to treatment plan with the addition of CT (.46, moderate, to .32, fair). Fellows had only slight agreement for both rounds with regard to classification as well as treatment (Table 2).
ORIF using a posterior approach with an olecranon osteotomy was the most common choice of treatment method overall at both time points (58.1% and 63.7%) and was still the most common choice when each group of observers (residents, fellows, faculty) was considered separately (Figure 1).
When classifying the fractures, attending surgeons chose the multiplanar fracture pattern 25.6% of the time when viewing radiographs only, and remained consistent in choosing this pattern 23.3% of the time when CT was added to radiographs. Fellows and residents chose this fracture pattern much less often (8.9% and 7.8%, respectively) when viewing radiographs only. Both fellows and residents increased their choice of the multiplanar fracture pattern by 10% (18.9% for fellows, 17.8% for residents) when CT was added (Figure 2).
Overall, the recognition of a multiplanar fracture pattern increased when CT was added. On 30 occasions, an answer was changed from another classification pattern to the multiplanar pattern when CT was added. Only 6 times did an observer change a multiplanar pattern selection at round 1 to another choice at round 2.
Adding CT in round 2 changed the treatment plan for multiplanar fractures. At round 1, 73.7% chose ORIF using a lateral approach for treatment of the multiplanar fracture versus 10.5% who chose ORIF using a posterior approach with an olecranon osteotomy. The choice of the posterior approach with olecranon osteotomy increased to 51.9% at round 2, using the technique we have previously described.5,10
Overall intraobserver reliability for classification was fair (.393). It was moderate for the treatment plan (.426) between viewing rounds. Residents had the highest Cramer V value at .60 (moderate) for classification reliability, and faculty had the highest value at .52 (moderate) for treatment plan. All 3 groups (residents, fellows, attending surgeons) showed moderate intraobserver agreement for treatment plan (Table 1).
Interobserver reliability did not improve with the addition of CT in round 2. Reliability for classification was fair for round 1 and slight for round 2. Reliability was fair at both viewing rounds for treatment. For classification, the overall κ value was .21 for round 1 and .20 for round 2. For treatment plan, the overall κ value was .28 for round 1 and .27 for round 2. Attending surgeons decreased in agreement with regard to treatment plan with the addition of CT (.46, moderate, to .32, fair). Fellows had only slight agreement for both rounds with regard to classification as well as treatment (Table 2).
Discussion
In this study, CT changed both classification and treatment when added to plain radiographs. Interestingly, interobserver reliability did not improve for classification or treatment with the addition of CT. This finding suggests substantial disagreement among qualified observers that is not resolved with more sophisticated imaging. We propose this disagreement is caused by differences in training and experience with specific fracture patterns and surgical approaches.
Our fair to moderate interobserver reliability using radiographs only is consistent with a study by Wainwright and colleagues,11 who demonstrated fair to moderate interobserver reliability with radiographs only using 3 different classification systems. CT did not improve interobserver reliability in the present study.
To our knowledge, the effect of adding CT to plain radiographs on classification and treatment plan has not been evaluated. Doornberg and colleagues2 evaluated the effect of adding 3-dimensional (3-D) CT to a combination of radiographs and 2-D CT. Using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification12 and the classification system of Mehne and Matta, they found that 3-D CT improved intraobserver and interobserver reliability for classification but improved only intraobserver agreement for treatment. Interobserver agreement for treatment plan remained fair. In parallel with their study, fracture classification in our study was more often changed with CT than the treatment plan was. Training level appeared not to affect this finding. We found fair interobserver agreement for treatment choice as well, which was not improved by adding CT. Doornberg and colleagues2 concluded that the “relatively small added expense of three-dimensional computed tomography scans seems worthwhile.”
When evaluating specific fracture patterns in the Mehne and Matta classification system, we observed that less experienced surgeons (residents, fellows) were much more likely to identify multiplanar fracture patterns with the aid of CT. Use of CT did not change attending surgeons’ recognition of these multiplanar fractures, suggesting that the faculty were more capable of appreciating these fracture patterns with radiographs only (Figure 3). We also observed that adding CT changed the predominant treatment plan for multiplanar fractures from a lateral approach to a posterior approach with an olecranon osteotomy. Failure to appreciate this component of the fracture before surgery could lead to an increased intraoperative difficulty level. Failure to appreciate it during surgery could lead to unexpected postoperative displacement and ultimately poorer outcome.
There are limitations to our study. There is no gold standard for assessing the accuracy of classification decisions. Intraoperative classification could have served as a gold standard, but the fractures were not routinely assigned a classification during surgery. Brouwer and colleagues13 evaluated the diagnostic accuracy of CT (including 3-D CT) with intraoperative AO classification as a reference point and found improvement in intraobserver agreement but not interobserver agreement when describing fracture characteristics—and no significant effect on classification.
We used a single classification system, the one primarily used at our institution and by Dr. Itamura. There are many systems,7,12,14 all with their strengths and weaknesses, and no one system is used universally. Adding a system would have allowed us to compare results of more than one system. Our aim, however, was to keep our form simple for the sake of participation and completion of the viewings by each volunteer.
Only 2-D CT was used for this study, as 3-D images were not available for all patients. Although this is a potential weakness, it appears that, based on the study by Doornberg and colleagues,2 adding 3-D imaging resulted in only modest improvement in the reliability of classification and no significant improvement in agreement on treatment recommendation.
In addition, our results were likely biased by the fact that 8 of the 9 evaluators were trained by Dr. Itamura, who very often uses a posterior approach with an olecranon osteotomy for internal fixation of distal humerus intra-articular fractures, as previously described.8,10 Therefore, selection of this treatment option may have been overestimated in this study. Nevertheless, after reviewing the literature, Ljungquist and colleagues15 wrote, “There do not seem to be superior functional results associated with any one surgical approach to the distal humerus.”
We did not give the evaluators an indication of patients’ activity demands (only age and sex), which may have been relevant when considering total elbow arthroplasty.
Last, performing another round of evaluations with only plain radiographs, before introducing CT, would have provided intraobserver reliability results on plain radiograph evaluation, which could have been compared with intraobserver reliability when CT was added. Again, this was excluded to encourage participation and create the least cumbersome evaluation experience possible, which was thought appropriate, as this information is already in the literature.
Conclusion
Adding CT changed classifications and treatment plans. Raters were more likely to change their classifications than their treatment plans. The addition of CT did not increase agreement between observers. Despite the added radiation and cost, we recommend performing CT for all intra-articular distal humerus fractures because it improves understanding of the fracture pattern and affects treatment planning, especially for fractures with a coronal shear component, which is often not appreciated on plain radiographs.
Elbow fractures constitute 7% of all adult fractures, and 30% of these fractures are distal humerus fractures.1,2 Of these, 96% involve disruption of the articular surface.3 Intra-articular distal humerus fracture patterns can be difficult to characterize on plain radiographs, and therefore computed tomography (CT) is often used. The surgeon’s understanding of the fracture pattern and the deforming forces affects choice of surgical approach. In particular, multiplanar fracture patterns, including coronal shear fractures of the capitellum or trochlea, are often difficult to recognize on plain radiographs. Identification of a multiplanar fracture pattern may require a change in approach or fixation. CT is useful for other intra-articular fractures, such as those of the proximal humerus,3-6 but involves increased radiation and cost.
We conducted a study to determine the effect of adding CT evaluation to plain radiographic evaluation on the classification of, and treatment plans for, intra-articular distal humerus fractures. We hypothesized that adding CT images to plain radiographs would change the classification and treatment of these fractures and would improve interobserver agreement on classification and treatment.
Materials and Methods
After obtaining University of Southern California Institutional Review Board approval, we retrospectively studied 30 consecutive cases of adult intra-articular distal humerus fractures treated by Dr. Itamura at a level I trauma center between 1995 and 2008. In each case, the injured elbow was imaged with plain radiography and CT. Multiple machines were used for CT, but all according to the radiology department’s standard protocol. The images were evaluated by 9 independent observers from the same institution: 3 orthopedic surgeons (1 fellowship-trained shoulder/elbow subspecialist, 1 fellowship-trained upper extremity subspecialist, 1 fellowship-trained orthopedic trauma surgeon), 3 shoulder/elbow fellows, and 3 senior residents pursuing upper extremity fellowships on graduation. No observer was involved in the care of any of the patients. All identifying details were removed from the patient information presented to the observers. For each set of images, the observer was asked to classify the fractures according to the Mehne and Matta classification system,7,8 which is the predominant system used at our institution.
Diagrams of this classification system were provided, but there was no formal observer training or calibration. Seven treatment options were presented: (1) open reduction and internal fixation (ORIF) using a posterior approach with olecranon osteotomy, (2) ORIF using a posterior approach, (3) ORIF using a lateral approach, (4) ORIF using a medial approach, (5) ORIF using an anterior/anterolateral approach, (6) total elbow arthroplasty, and (7) nonoperative management. The only clinical data provided were patient age and sex.
Images were evaluated in blinded fashion. Two rounds of evaluation were compared. In round 1, plain radiographs were evaluated; in round 2, the same radiographs plus corresponding 2-dimensional (2-D) CT images. A minimum of 1 month was required between viewing rounds.
Statistical Analysis
Statistical analysis was performed by the Statistical Consultation and Research Center at our institution. Cohen κ was calculated to estimate the reliability of the fracture classification and treatment plan made by different observers on the same occasion (interobserver reliability). Cramer V9 was calculated to estimate the reliability of the fracture classification and treatment plan made by the same observer on separate occasions (intraobserver reliability). It measures the association between the 2 ratings as a percentage of their total variation. The κ value and Cramer V value were also used to evaluate results based on the observers’ training levels. Both κ and Cramer V values are interpreted as follows: .00 to .20 indicates slight agreement; .21 to .40, fair agreement; .41-.60, moderate agreement; .61 to .80, substantial agreement; and ≥.81, almost perfect agreement. Zero represents no agreement, and 1.00 represents perfect agreement.
Results
Overall intraobserver reliability for classification was fair (.393). It was moderate for the treatment plan (.426) between viewing rounds. Residents had the highest Cramer V value at .60 (moderate) for classification reliability, and attending surgeons had the highest value at .52 (moderate) for treatment plan. All 3 groups (residents, fellows, attending surgeons) showed moderate intraobserver agreement for treatment plan (Table 1).
Interobserver reliability did not improve with the addition of CT in round 2. Reliability was fair at both viewing rounds for classification and for treatment. For classification, the overall κ value was .21 for the first round and .20 for the second round. For treatment plan, the overall κ value was .28 for the first round and .27 for the second round. Attending surgeons decreased in agreement with regard to treatment plan with the addition of CT (.46, moderate, to .32, fair). Fellows had only slight agreement for both rounds with regard to classification as well as treatment (Table 2).
ORIF using a posterior approach with an olecranon osteotomy was the most common choice of treatment method overall at both time points (58.1% and 63.7%) and was still the most common choice when each group of observers (residents, fellows, faculty) was considered separately (Figure 1).
When classifying the fractures, attending surgeons chose the multiplanar fracture pattern 25.6% of the time when viewing radiographs only, and remained consistent in choosing this pattern 23.3% of the time when CT was added to radiographs. Fellows and residents chose this fracture pattern much less often (8.9% and 7.8%, respectively) when viewing radiographs only. Both fellows and residents increased their choice of the multiplanar fracture pattern by 10% (18.9% for fellows, 17.8% for residents) when CT was added (Figure 2).
Overall, the recognition of a multiplanar fracture pattern increased when CT was added. On 30 occasions, an answer was changed from another classification pattern to the multiplanar pattern when CT was added. Only 6 times did an observer change a multiplanar pattern selection at round 1 to another choice at round 2.
Adding CT in round 2 changed the treatment plan for multiplanar fractures. At round 1, 73.7% chose ORIF using a lateral approach for treatment of the multiplanar fracture versus 10.5% who chose ORIF using a posterior approach with an olecranon osteotomy. The choice of the posterior approach with olecranon osteotomy increased to 51.9% at round 2, using the technique we have previously described.5,10
Overall intraobserver reliability for classification was fair (.393). It was moderate for the treatment plan (.426) between viewing rounds. Residents had the highest Cramer V value at .60 (moderate) for classification reliability, and faculty had the highest value at .52 (moderate) for treatment plan. All 3 groups (residents, fellows, attending surgeons) showed moderate intraobserver agreement for treatment plan (Table 1).
Interobserver reliability did not improve with the addition of CT in round 2. Reliability for classification was fair for round 1 and slight for round 2. Reliability was fair at both viewing rounds for treatment. For classification, the overall κ value was .21 for round 1 and .20 for round 2. For treatment plan, the overall κ value was .28 for round 1 and .27 for round 2. Attending surgeons decreased in agreement with regard to treatment plan with the addition of CT (.46, moderate, to .32, fair). Fellows had only slight agreement for both rounds with regard to classification as well as treatment (Table 2).
Discussion
In this study, CT changed both classification and treatment when added to plain radiographs. Interestingly, interobserver reliability did not improve for classification or treatment with the addition of CT. This finding suggests substantial disagreement among qualified observers that is not resolved with more sophisticated imaging. We propose this disagreement is caused by differences in training and experience with specific fracture patterns and surgical approaches.
Our fair to moderate interobserver reliability using radiographs only is consistent with a study by Wainwright and colleagues,11 who demonstrated fair to moderate interobserver reliability with radiographs only using 3 different classification systems. CT did not improve interobserver reliability in the present study.
To our knowledge, the effect of adding CT to plain radiographs on classification and treatment plan has not been evaluated. Doornberg and colleagues2 evaluated the effect of adding 3-dimensional (3-D) CT to a combination of radiographs and 2-D CT. Using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification12 and the classification system of Mehne and Matta, they found that 3-D CT improved intraobserver and interobserver reliability for classification but improved only intraobserver agreement for treatment. Interobserver agreement for treatment plan remained fair. In parallel with their study, fracture classification in our study was more often changed with CT than the treatment plan was. Training level appeared not to affect this finding. We found fair interobserver agreement for treatment choice as well, which was not improved by adding CT. Doornberg and colleagues2 concluded that the “relatively small added expense of three-dimensional computed tomography scans seems worthwhile.”
When evaluating specific fracture patterns in the Mehne and Matta classification system, we observed that less experienced surgeons (residents, fellows) were much more likely to identify multiplanar fracture patterns with the aid of CT. Use of CT did not change attending surgeons’ recognition of these multiplanar fractures, suggesting that the faculty were more capable of appreciating these fracture patterns with radiographs only (Figure 3). We also observed that adding CT changed the predominant treatment plan for multiplanar fractures from a lateral approach to a posterior approach with an olecranon osteotomy. Failure to appreciate this component of the fracture before surgery could lead to an increased intraoperative difficulty level. Failure to appreciate it during surgery could lead to unexpected postoperative displacement and ultimately poorer outcome.
There are limitations to our study. There is no gold standard for assessing the accuracy of classification decisions. Intraoperative classification could have served as a gold standard, but the fractures were not routinely assigned a classification during surgery. Brouwer and colleagues13 evaluated the diagnostic accuracy of CT (including 3-D CT) with intraoperative AO classification as a reference point and found improvement in intraobserver agreement but not interobserver agreement when describing fracture characteristics—and no significant effect on classification.
We used a single classification system, the one primarily used at our institution and by Dr. Itamura. There are many systems,7,12,14 all with their strengths and weaknesses, and no one system is used universally. Adding a system would have allowed us to compare results of more than one system. Our aim, however, was to keep our form simple for the sake of participation and completion of the viewings by each volunteer.
Only 2-D CT was used for this study, as 3-D images were not available for all patients. Although this is a potential weakness, it appears that, based on the study by Doornberg and colleagues,2 adding 3-D imaging resulted in only modest improvement in the reliability of classification and no significant improvement in agreement on treatment recommendation.
In addition, our results were likely biased by the fact that 8 of the 9 evaluators were trained by Dr. Itamura, who very often uses a posterior approach with an olecranon osteotomy for internal fixation of distal humerus intra-articular fractures, as previously described.8,10 Therefore, selection of this treatment option may have been overestimated in this study. Nevertheless, after reviewing the literature, Ljungquist and colleagues15 wrote, “There do not seem to be superior functional results associated with any one surgical approach to the distal humerus.”
We did not give the evaluators an indication of patients’ activity demands (only age and sex), which may have been relevant when considering total elbow arthroplasty.
Last, performing another round of evaluations with only plain radiographs, before introducing CT, would have provided intraobserver reliability results on plain radiograph evaluation, which could have been compared with intraobserver reliability when CT was added. Again, this was excluded to encourage participation and create the least cumbersome evaluation experience possible, which was thought appropriate, as this information is already in the literature.
Conclusion
Adding CT changed classifications and treatment plans. Raters were more likely to change their classifications than their treatment plans. The addition of CT did not increase agreement between observers. Despite the added radiation and cost, we recommend performing CT for all intra-articular distal humerus fractures because it improves understanding of the fracture pattern and affects treatment planning, especially for fractures with a coronal shear component, which is often not appreciated on plain radiographs.
1. Anglen J. Distal humerus. J Am Acad Orthop Surg. 2005;13(5):291-297.
2. Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the classification and management of distal humerus fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am. 2006;88(8):1795-1801.
3. Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin North Am. 2008;39(2):187-200.
4. Castagno AA, Shuman WP, Kilcoyne RF, Haynor DR, Morris ME, Matsen FA. Complex fractures of the proximal humerus: role of CT in treatment. Radiology. 1987;165(3):759-762.
5. Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol. 1998;14(2):159-164.
6. Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75(12):1751-1755.
7. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825-833.
8. Zalavras CG, McAllister ET, Singh A, Itamura JM. Operative treatment of intra-articular distal humerus fractures. Am J Orthop. 2007;36(12 suppl):8-12.
9. Cramer H. Mathematical Methods of Statistics. Princeton, NJ: Princeton University Press; 1946.
10. Panossian V, Zalavras C, Mirzayan R, Itamura JM. Intra-articular distal humerus fractures. In: Mirzayan R, Itamura JM, eds. Shoulder and Elbow Trauma. New York, NY: Thieme; 2004:67-78.
11. Wainwright AM, Williams JR, Carr AJ. Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J Bone Joint Surg Br. 2000;82(5):636-642.
12. Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification of Fractures in Long Bones. Berlin, Germany: Springer-Verlag; 1990.
13. Brouwer KM, Lindenhovius AL, Dyer GS, Zurakowski D, Mudgal C, Ring D. Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg. 2012;21(6):772-776.
14. Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in 29 cases. J Bone Joint Surg Am. 1969;51(1):130-141.
15. Ljungquist KL, Beran MC, Awan H. Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review. J Shoulder Elbow Surg. 2012;21(1):126-135.
1. Anglen J. Distal humerus. J Am Acad Orthop Surg. 2005;13(5):291-297.
2. Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the classification and management of distal humerus fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am. 2006;88(8):1795-1801.
3. Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin North Am. 2008;39(2):187-200.
4. Castagno AA, Shuman WP, Kilcoyne RF, Haynor DR, Morris ME, Matsen FA. Complex fractures of the proximal humerus: role of CT in treatment. Radiology. 1987;165(3):759-762.
5. Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol. 1998;14(2):159-164.
6. Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75(12):1751-1755.
7. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825-833.
8. Zalavras CG, McAllister ET, Singh A, Itamura JM. Operative treatment of intra-articular distal humerus fractures. Am J Orthop. 2007;36(12 suppl):8-12.
9. Cramer H. Mathematical Methods of Statistics. Princeton, NJ: Princeton University Press; 1946.
10. Panossian V, Zalavras C, Mirzayan R, Itamura JM. Intra-articular distal humerus fractures. In: Mirzayan R, Itamura JM, eds. Shoulder and Elbow Trauma. New York, NY: Thieme; 2004:67-78.
11. Wainwright AM, Williams JR, Carr AJ. Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J Bone Joint Surg Br. 2000;82(5):636-642.
12. Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification of Fractures in Long Bones. Berlin, Germany: Springer-Verlag; 1990.
13. Brouwer KM, Lindenhovius AL, Dyer GS, Zurakowski D, Mudgal C, Ring D. Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg. 2012;21(6):772-776.
14. Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in 29 cases. J Bone Joint Surg Am. 1969;51(1):130-141.
15. Ljungquist KL, Beran MC, Awan H. Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review. J Shoulder Elbow Surg. 2012;21(1):126-135.
Safety of Tourniquet Use in Total Knee Arthroplasty in Patients With Radiographic Evidence of Vascular Calcifications
Tourniquets are often used in total knee arthroplasty (TKA) to improve visualization of structures, shorten operative time, reduce intraoperative bleeding, and improve cementing technique. Despite these advantages, controversy remains regarding the safety of tourniquet use. Tourniquets have been associated with nerve palsies, vascular injury, and muscle damage.1-5 Some have hypothesized they may cause venous stasis or direct endothelial damage that may develop into deep vein thrombosis (DVT). Abdel-Salam and Eyres6 found an increased incidence of postoperative wound complications and DVTs associated with tourniquet use.
Moreover, investigators have analyzed the role of tourniquets in populations at high risk for wound complications. DeLaurentis and colleagues7 performed a prospective and retrospective analysis of 1182 TKA patients, 24 (2%) of whom had preexisting peripheral vascular disease (PVD), defined as a history of arterial insufficiency, absent dorsalis pedis and/or absent posterior tibial pulsations, and arterial calcifications. A tourniquet was used in each case. Arterial complications occurred in 6 of the 24 patients with PVD. As expected, the authors found that a history of intermittent claudication, pain at rest, and arterial ulcers resulted in a high risk for vascular complications. Further studies have supported this finding and expanded the list of predisposing factors to include previous vascular surgery and absent and asymmetric pedal pulsations.7-11 Of particular concern to total joint arthroplasty surgeons was the finding by DeLaurentis and colleagues7 that patients with radiographic evidence of calcification of the distal superficial femoral artery and/or popliteal artery were at risk for arterial complications. This finding is also supported by other studies.8,11 In TKA, damage to arterial structures proximal to the surgical field could manifest as impaired postoperative wound healing or an ischemic limb. Wound healing depends on adequate blood flow to the healing tissue, and any damage to arterial or venous structures can theoretically compromise this process.
Added to vascular/wound complications as concerning complications in orthopedic surgery is venous thromboembolism (VTE). The role of tourniquets in the formation of VTEs is controversial. A tourniquet has the potential to increase the risk for DVT because of the stasis of venous blood in the lower limb or possible damage to calcified blood vessels. Callam and colleagues12 studied the connection between artery disease and chronic leg ulcers and found that half the patients diagnosed with peripheral artery disease also had stigmata of chronic venous insufficiency. Therefore, the entities can occur in tandem, and surgeons should keep this in mind.
Here we report on a study we conducted to determine whether tourniquet use in TKA in patients with preexisting radiographic evidence of vascular disease increases the risk for wound complications or VTE.
Patients and Methods
We retrospectively reviewed 461 consecutive primary TKAs (373 patients) performed between January 2007 and June 2012 by 2 attending orthopedic surgeons specializing in adult reconstruction. Medical records and operative reports of 583 patients were examined after receiving institutional review board approval. Of these patients, 373 (64%) had a minimum of 12-month follow-up data available. Twelve months was deemed long enough to discover wound complications or DVTs secondary to the index procedure. Most of these outcomes manifest within the first 3 months after surgery and certainly by 12 months. Follow-up longer than 12 months may become a confounder, as wound complications outside the acute to subacute postoperative window could be related to patients’ underlying PVD and not directly to tourniquet use during surgery. Patient demographics and comorbidities were recorded. Comorbidities were obtained from preoperative medical evaluations and surgeons’ preoperative evaluations. All patients had preoperative palpable dorsalis pedis and posterior tibialis arterial pulses. No patient required preoperative vascular studies based on preoperative examination or comorbidities. No patient had prior vascular bypass surgery or stenting.
TKA was performed in a nonlaminar flow, positive-pressure, high-efficiency particulate air-filtered room with sterile toga/surgical helmet systems. For all patients, a pneumatic thigh tourniquet was applied, and the patient was prepared and draped. After limb exsanguination using a rubber bandage, the limb was elevated and the tourniquet inflated to a pressure of 250 to 300 mm Hg. The tourniquet was released either just before closure or immediately after closure in all cases; it was always let down before placement of final bandages.
Prophylactic chemical anticoagulation consisting of warfarin, aspirin, or enoxaparin was used in all patients and continued for 4 to 6 weeks after surgery. All patients received mechanical DVT prophylaxis with sequential compression devices, and all were mobilized out of bed beginning either the day of surgery or the next day. All patients received perioperative intravenous antibiotics, with the preoperative dose given before tourniquet inflation and the last postoperative dose stopped within 24 hours of surgery.
All patients who had primary TKA underwent preoperative medical evaluation and optimization. The patient’s hospital course was monitored closely, and complications noted by the orthopedic team were documented. Follow-up documentation was retrospectively reviewed for evidence of wound complications or VTE. Wound complications were defined as cellulitis, delayed wound healing, wound dehiscence, and/or periprosthetic joint infection. In the case of VTE, physical examination findings were not sufficient for inclusion. Venous duplex ultrasonography demonstrating the clot was reviewed before inclusion.
Preoperative radiographs were examined for arterial calcification (Figure). We refer to calcification seen above the knee joint as proximal calcification and to calcification observed below the joint as distal calcification. Patients exhibited calcification proximally only, distally only, or both proximally and distally. The 373 patients were placed into 2 groups based on whether they had preoperative arterial calcification on plain radiography of the knee. One group (285 patients with no radiographic evidence of preoperative knee arterial calcification) underwent 365 TKAs, and the other group (88 patients with radiographic evidence of preoperative knee arterial calcification) underwent 96 TKAs.
A sample size calculation was performed to determine how many patients were needed in each group with 80% power and an α of 0.05. With an estimated difference in VTE/wound complication rate between the calcification and no-calcification groups of 12%, we needed to review 316 TKAs total. This 12% difference was based on study findings of a 25% complication rate in PVD patients who underwent tourniquet-assisted TKA, and the rate of VTE/wound complication after TKA in patients overall, which can be up to 12%.7,13,14 We exceeded minimal enrollment and had 461 TKAs. Descriptive statistics were reported, with means and ranges provided where appropriate. Independent t test was used to evaluate the differences in continuous data (age) between the groups. Univariate analysis (using Pearson χ2 and Fisher exact tests) and multivariate logistic regression analysis were used to evaluate the effects of categorical variables (sex, comorbidity, calcification [presence, absence], and location of calcification [proximal only, distal only, both]) on wound complication and VTE rates. All tests were 2-tailed and performed with a type I error rate of 0.05. Data analysis was performed with SPSS Version 19.0 (SPSS).
Results
Patient characteristics are summarized in Table 1. Of the 373 patients, 285 lacked calcification, and 88 had calcification. Mean age was 67.73 years (range, 24-92 years) for all patients, 65.99 years (range, 24-89 years) for the no-calcification group, and 74.32 years (range, 54-92 years) for the calcification group; the calcification group demonstrated a trend toward older age, but the difference was not significantly different (P = .07). Of the 373 patients, 156 (41.82%) were male: 110 in the no-calcification group (38.60%) and 46 in the calcification group (52.27%); sex was significantly (P = .002) different between groups, with more males in the calcification group.
Data on total preoperative comorbidities are summarized in Table 2. Hypertension, hyperlipidemia, diabetes, and coronary artery disease (CAD) were the most common comorbidities, and they were all significantly (P ≤ .05) increased in the calcification group.
No patients had reported arterial complications, such as arterial bleeding, aneurysm, intimal tears, or loss of distal pulses. Wound complication after TKA was detected in 3.04% of all cases (Table 3). Rate of DVT after TKA was 2.60% of all cases, and rate of pulmonary embolism after TKA was 2.17% of all cases. Of the 96 TKAs with preoperative radiographic evidence of calcification, 47 (48.96%) had proximal calcification only, 11 (11.46%) had distal calcification only, and 38 (39.58%) had both proximal and distal calcification (Table 4). There was no significant difference between the rate of wound complication or VTE based on location of vascular calcification.
Univariate analysis demonstrated that presence of arterial knee calcification did not increase the risk for postoperative wound complication (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.28-3.80; P > .05) (Table 5). Location of arterial knee calcification also did not increase the risk for postoperative wound complication. In addition, univariate analysis demonstrated that presence of arterial knee calcification did not increase the risk for postoperative VTE (OR, 1.20; 95% CI, 0.43-3.36; P > .05 (Table 6).
Of the 14 wound complications, the most common infections were cellulitis (5/14 cases; 35.71%) and infected hardware that required component revision (5/14 cases; 35.71%). Mean time from TKA to infection was 137.93 days (range, 5-783 days). The most common organism grown in culture from the wound was Staphylococcus (5/14 cases; 35.71%).
Additional univariate statistical analysis revealed that presence of diabetes, hypertension, prior VTE, CAD, and male sex was linked to higher incidence of wound complication (P < .05) (Table 5). When multivariate analysis was performed, hypertension, prior VTE, and male sex remained significant (P < .05) (Table 5).
Discussion
TKA is a safe and effective procedure used to treat osteoarthritis of the knee and improve patients’ quality of life.15 About 700,000 TKAs are performed annually in the United States.16 Because of improvements in preventive medicine and medical technology, life expectancy is increasing, and TKAs are now being performed in higher numbers and in an older patient population. Over the next few decades, these developments will lead to more postoperative complications. It is projected that, by 2030, the need for TKAs in the United States will increase by 673% to 3.48 million.17 Postoperative complications are rare but unfortunately often lead to poor outcomes or even mortality.18 To help minimize the number of postoperative complications, we must understand the safety of tourniquet use in TKA. Other investigators have concluded that tourniquet use is unsafe in patients with preoperative vascular calcifications on plain radiographs.7,8,11 The present study, designed to elucidate whether preoperative evidence of knee arterial calcification may predispose TKA patients to postoperative wound complication or VTE, had some important findings.
In our study, wound complication and VTE occurred in a considerable number of patients after TKA. Despite exceeding the number of patients calculated by the power analysis, our population may have been inadequate to fully detect statistical significance. Thus, our conclusion of failing to reject the null hypothesis may have been because of sample size, a type II error. We found that, after primary TKA, 3.04% of patients developed wound complications and 4.77% VTE. According to the literature, the incidence of infection after primary TKA is between 0.5% and 12%, and that of VTE reported within 3 months after TKA is 1.3% to 10%.13,14 Although we had 100% VTE prophylaxis, meeting the standard of care, VTE after TKA remains a postoperative complication.19 This study also found that a considerable percentage of primary TKA patients (23.59%) had preoperative calcification of the knee arteries. To our knowledge, this study was the first to quantify the incidence of knee arterial calcification in patients who underwent TKA.
Preoperative calcification of the knee arteries in patients who underwent TKA did not increase the risk for wound complication, VTE, or arterial damage. These calcifications, however, do pose an increased systemic vascular risk.20 Calcification of the vascular wall predicts increased cardiovascular risk, independent of classical cardiovascular risk factors.3,18,21-24 Clinically, patients who have both diabetes and calcifications are at significant excess risk for total mortality, stroke mortality, and cardiovascular mortality, compared with patients with diabetes but without such calcifications. They also had a significantly higher incidence of coronary heart disease events, stroke events, and lower extremity amputations.25,26
All our patients underwent tourniquet-assisted TKA. Although previous studies have indicated that tourniquet use may increase arterial complications and wound complications or even limb loss in patients with calcified arteries, we did not find this link.7,27 Our population had no reported arterial complications related to tourniquet use. Other, smaller studies have had similar findings. Vandenbussche and colleagues28 prospectively studied 80 TKA cases randomized to tourniquet use or no tourniquet use and found no postoperative nerve palsies, wound infections, wound healing problems, or hematomas. Our study is also in accord with studies that have reported tourniquet use did not increase risk for DVT.29 Therefore, unlike earlier data, our data demonstrated that tourniquet use in patients with knee arterial calcification was safe.7,27,30,31
Patients with calcification were more likely to have the medical comorbidities of hypertension, diabetes, hyperlipidemia, and CAD. All these comorbidities are linked to the development of arterial calcification, or atherosclerotic occlusive disease.32,33 As life expectancy and the need for TKA increase, it is likely that a larger percentage of TKA patients will have preoperative radiographic evidence of knee arterial calcification. Although current dogma is that tourniquet-assisted TKA is contraindicated for patients with preoperative radiographic evidence of femoral-popliteal calcification, our study results showed that this calcification should not affect preoperative TKA planning for these patients.
We divided our patients into 3 categories: those with proximal calcification (above the joint line), those with distal calcification (below the joint line), and those with both proximal and distal calcification. Location of arterial calcification did not have an effect on their rates of postoperative wound complication or VTE. We hypothesized that patients with proximal calcification would be at increased risk for direct arterial injury and subsequent wound complication because the tourniquet is placed proximally. Previous research has indicated that arterial occlusion and subsequent wound complication can occur because of low blood flow stemming from tourniquet use.7 Further, intraoperative manipulation (flexing) of a knee with calcified vessels causes arterial complications after TKA because these vessels are less elastic than nonatheromatous vessels.31 However, we found no such effect. At the same time, having arterial calcification might also be an indication of venous disease in this location,12 which may be especially important for proximal calcifications. Proximal DVT more likely is a precursor to pulmonary embolic events than distal DVT is.31,34 However, we found no difference in VTE rates among the 3 arterial location groups, which is supported by studies that have found that tourniquet use does not increase DVT incidence.29,35-40
Risk for wound complications was higher in male patients and in patients with diabetes, prior VTE, hypertension, or CAD. This finding is important because, with the increasing age of patients who undergo TKA, those with serious medical comorbidities will continue to need and have this surgery.17 Diabetes may increase the rate of wound complication because patients with diabetes have poor microcirculation, poor collagen synthesis, and reduced wound strength.41 Malinzak and colleagues42 demonstrated that, compared with patients without diabetes, those with diabetes had a significantly higher risk for infection after TKA. Prior VTE, specifically DVT, may increase the rate of wound complication because after DVT the deep veins may be damaged and exhibit valvular dysfunction. Labropoulos and colleagues43 showed that DVT history was strongly associated with ulcer nonhealing. Perhaps hypertension has been overlooked as a risk factor for wound complication in TKA. No previous studies have assessed the link between hypertension and wound complications after TKA. However, a study of wound healing after total hip arthroplasty found that, compared with normotensive patients, hypertensive patients had delayed wound healing, putting them at higher risk for infection.44 In addition, we found that patients with CAD were at increased risk for wound complications—an unexpected finding, as CAD traditionally is not a risk factor for infection or poor wound healing. Recently, however, CAD was identified as an independent risk factor for surgical site infections in posterior lumbar–instrumented arthrodesis.45 The etiology of this association is unknown. Also, male patients were at increased risk for wound complication. Male sex has been implicated as an independent risk factor for development of surgical site infections and has been established as an important predisposing factor for periprosthetic joint infections.46
It is possible that patients who present with diabetes, VTE, hypertension, or CAD before TKA should have a consultation with a vascular surgeon or should have TKA performed without a tourniquet, but this conclusion cannot be considered definitive without a large prospective randomized trial or possibly registry data. Our data indicate that patients with these comorbidities have higher rates of wound complications irrespective of preoperative radiographic calcifications. On the basis of our study results, however, we certainly recommend that patients with these risk factors have preoperative medical optimization. Orthopedic surgeons should take a thorough history and perform a meticulous physical examination on these patients to look for evidence of PVD. We recommend that, if vascular claudication is elicited in the history, or if there is evidence of peripheral arterial disease—such as hair loss, skin discoloration, dystrophic nail changes, or absent or unequal peripheral pulses—the ankle-brachial index test should be performed. If the index value is less than 0.9, then a preoperative vascular surgery consultation should be obtained.
This study had some weaknesses. First, it was retrospective, so it is possible that some wound or VTE complications were not reported and thus not found in the paper charts or electronic medical records. Some patients may have had VTE diagnostic scans at other hospitals, and their results may not have been recorded across databases. Moreover, some patients may have seen wound specialists for wound infections or wound healing problems, and these may not have been reported to the orthopedic surgeons. Second, though our patient population was not small, it may not have been of adequate size to fully detect statistical significance. We met our enrollment numbers based on our sample size calculations from an a priori power analysis; however, we still draw conclusions with the possibility of committing a type II error in mind by failing to reject the null hypothesis when in reality a statistically significant difference does exist. Third, none of our consecutive patients carried the preoperative diagnosis of PVD, and none had preoperative vascular surgery. Therefore, though calcifications were noted on radiographs, clinically our patients were asymptomatic with respect to vascular health. Last, the 2 groups were not randomized. All patients underwent tourniquet-assisted TKA.
Conclusion
To our knowledge, this is the largest study to examine the effect of preoperative knee arterial calcification on wound complication and VTE after tourniquet-assisted TKA. Contrary to previously published recommendations, we conclude that TKA can be safely performed with a tourniquet in the presence of preoperative radiographic evidence of such calcification. However, we recommend that patients with diabetes, hypertension, CAD, or prior VTE undergo an appropriate physical examination to elicit any signs or symptoms of vascular disease. If before surgery there is any question of vascular competence, a vascular surgeon should be consulted.
1. Guanche CA. Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction. Arthroscopy. 1995;11(5):620-622.
2. Irvine GB, Chan RN. Arterial calcification and tourniquets. Lancet. 1986;2(8517):1217.
3. Patterson S, Klenerman L. The effect of pneumatic tourniquets on the ultrastructure of skeletal muscle. J Bone Joint Surg Br. 1979;61(2):178-183.
4. Rorabeck CH, Kennedy JC. Tourniquet-induced nerve ischemia complicating knee ligament surgery. Am J Sports Med. 1980;8(2):98-102.
5. Shenton DW, Spitzer SA, Mulrennan BM. Tourniquet-induced rhabdomyolysis. A case report. J Bone Joint Surg Am. 1990;72(9):1405-1406.
6. Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br. 1995;77(2):250-253.
7. DeLaurentis DA, Levitsky KA, Booth RE, et al. Arterial and ischemic aspects of total knee arthroplasty. Am J Surg. 1992;164(3):237-240.
8. Holmberg A, Milbrink J, Bergqvist D. Arterial complications and knee arthroplasty. Acta Orthop Scand. 1996;67(1):75-8.
9. Hozack WJ, Cole PA, Gardner R, Corces A. Popliteal aneurysm after total knee arthroplasty. Case reports and review of the literature. J Arthroplasty. 1990;5(4):301-305.
10. Kumar SN, Chapman JA, Rawlins I. Vascular injuries after total knee arthroplasty: a review of the problem with special reference to the possible effects of the tourniquet. J Arthroplasty. 1998;13(2):211-216.
11. Rush JH, Vidovich JD, Johanson MA. Arterial complications and total knee arthroplasty. The Australian experience. J Bone Joint Surg Br. 1987;69(3):400-402.
12. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial disease in chronic leg ulceration: an underestimated hazard? Lothian and Forth Valley Leg Ulcer Study. Br Med J (Clin Res Ed). 1987;294(6577):929-931.
13. Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br. 2004;86(5):688-691.
14. Geerts WH, Bergqvist D, Pinco G, et al. Prevention of venous thromboembolism. Chest. 2008;133(6 suppl):381S-453S.
15. Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):139-145.
16. Arthritis: data and statistics. Centers for Disease Control and Prevention website. http://www.cdc.gov/arthritis/data_statistics.htm. Updated March 11, 2015. Accessed July 27, 2015.
17. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
18. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-1715.
19. Warwick D. Prevention of venous thromboembolism in total knee and hip replacement. Circulation. 2012;125(17):2151-2155.
20. Rennenberg RJ, Kessels AG, Schurgers LJ, van Engelshoven JM, de Leeuw PW, Kroon AA. Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis. Vasc Health Risk Manag. 2009;5(1):185-197.
21. Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46(1):158-165.
22. Iribarren C, Sidney S, Sternfeld B, Browner WS. Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease. JAMA. 2000;283(21):2810-2815.
23. Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology. 2003;228(3):826-833.
24. Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O’Malley PG. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol. 2005;46(5):807-814.
25. Lehto S, Niskanen L, Suhonen M, Rönnemaa T, Laakso M. Medial artery calcification. A neglected harbinger of cardiovascular complications in non-insulin-dependent diabetes mellitus. Arterioscler Thromb Vasc Biol. 1996;16(8):978-983.
26. Niskanen L, Siitonen O, Suhonen M, Uusitupa MI. Medial artery calcification predicts cardiovascular mortality in patients with NIDDM. Diabetes Care. 1994;17(11):1252-1256.
27. Smith DE, McGraw RW, Taylor DC, et al. Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg. 2001;9(4):253-257.
28. Vandenbussche E, Duranthon L, Couturier M, Pidhorz L, Augereau B. The effect of tourniquet use in total knee arthroplasty. Int Orthop. 2002;26(5):306-309.
29. Fukunda A, Hasegawa M, Kato K, Shi D, Sudo A, Uchida A. Effect of tourniquet application on deep vein thrombosis after total knee thrombosis. Arch Orthop Trauma Surg. 2007;127(8):671-675.
30. Butt U, Samuel R, Sahu A, Butt IS, Johnson DS, Turner PG. Arterial injury in total knee arthroplasty. J Arthroplasty. 2010;25(8):1311-1318.
31. Langkamer VG. Local vascular complications after knee replacement: a review with illustrative case reports. Knee. 2001;8(4):259-264.
32. Hussein A, Uno K, Wolski K, et al. Peripheral arterial disease and progression of coronary atherosclerosis. J Am Coll Cardiol. 2011;57(10):1220-1225.
33. Ouriel K. Peripheral arterial disease. Lancet. 2001;358(9289):1257-1264.
34. Monreal M, Rufz J, Olazabal A, Arias A, Roca J. Deep venous thrombosis and the risk of pulmonary embolism. Chest. 1992;102(3):677-681.
35. Angus PD, Nakielny R, Goodrum DT. The pneumatic tourniquet and deep venous thrombosis. J Bone Joint Surg Br. 1983;65(3):336-339.
36. Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1981;63(3):461-465.
37. Harvey EJ, Leclerc J, Brooks CE, Burke DL. Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. J Arthroplasty. 1997;12(3):291-296.
38. Simon MA, Mass DP, Zarins CK, Bidani N, Gudas CJ, Metz CE. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. J Bone Joint Surg Am. 1982;64(2):188-191.
39. Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep-vein thrombosis following total knee replacement. An analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg Am. 1984;66(2):194-201.
40. Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Br. 1999;81(1):30-33.
41. Vince K, Chivas D, Droll K. Wound complications after total knee arthroplasty. J Arthroplasty. 2007;22(4 Suppl 1):39-44.
42. Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24(6 Suppl):84-88.
43. Labropoulos N, Wang E, Lanier S, Khan SU. Factors associated with poor healing and recurrence of venous ulceration. Plast Reconstr Surg. 2011;129(1):179-186.
44. Ahmed AA, Mooar PA, Kleiner M, Torg JS, Miyamoto CT. Hypertensive patients show delayed wound healing following total hip arthroplasty. PLoS One. 2011;6(8):e23224.
45. Koutsoumbelis S, Hughes AP, Girardi FP, et al. Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Joint Surg Am. 2001;93(17):1627-1633.
46. Poultsides LA, Ma Y, Della Valle AG, Chiu YL, Sculco TP, Memtsoudis SG. In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty. 2013;28(3):385-389.
Tourniquets are often used in total knee arthroplasty (TKA) to improve visualization of structures, shorten operative time, reduce intraoperative bleeding, and improve cementing technique. Despite these advantages, controversy remains regarding the safety of tourniquet use. Tourniquets have been associated with nerve palsies, vascular injury, and muscle damage.1-5 Some have hypothesized they may cause venous stasis or direct endothelial damage that may develop into deep vein thrombosis (DVT). Abdel-Salam and Eyres6 found an increased incidence of postoperative wound complications and DVTs associated with tourniquet use.
Moreover, investigators have analyzed the role of tourniquets in populations at high risk for wound complications. DeLaurentis and colleagues7 performed a prospective and retrospective analysis of 1182 TKA patients, 24 (2%) of whom had preexisting peripheral vascular disease (PVD), defined as a history of arterial insufficiency, absent dorsalis pedis and/or absent posterior tibial pulsations, and arterial calcifications. A tourniquet was used in each case. Arterial complications occurred in 6 of the 24 patients with PVD. As expected, the authors found that a history of intermittent claudication, pain at rest, and arterial ulcers resulted in a high risk for vascular complications. Further studies have supported this finding and expanded the list of predisposing factors to include previous vascular surgery and absent and asymmetric pedal pulsations.7-11 Of particular concern to total joint arthroplasty surgeons was the finding by DeLaurentis and colleagues7 that patients with radiographic evidence of calcification of the distal superficial femoral artery and/or popliteal artery were at risk for arterial complications. This finding is also supported by other studies.8,11 In TKA, damage to arterial structures proximal to the surgical field could manifest as impaired postoperative wound healing or an ischemic limb. Wound healing depends on adequate blood flow to the healing tissue, and any damage to arterial or venous structures can theoretically compromise this process.
Added to vascular/wound complications as concerning complications in orthopedic surgery is venous thromboembolism (VTE). The role of tourniquets in the formation of VTEs is controversial. A tourniquet has the potential to increase the risk for DVT because of the stasis of venous blood in the lower limb or possible damage to calcified blood vessels. Callam and colleagues12 studied the connection between artery disease and chronic leg ulcers and found that half the patients diagnosed with peripheral artery disease also had stigmata of chronic venous insufficiency. Therefore, the entities can occur in tandem, and surgeons should keep this in mind.
Here we report on a study we conducted to determine whether tourniquet use in TKA in patients with preexisting radiographic evidence of vascular disease increases the risk for wound complications or VTE.
Patients and Methods
We retrospectively reviewed 461 consecutive primary TKAs (373 patients) performed between January 2007 and June 2012 by 2 attending orthopedic surgeons specializing in adult reconstruction. Medical records and operative reports of 583 patients were examined after receiving institutional review board approval. Of these patients, 373 (64%) had a minimum of 12-month follow-up data available. Twelve months was deemed long enough to discover wound complications or DVTs secondary to the index procedure. Most of these outcomes manifest within the first 3 months after surgery and certainly by 12 months. Follow-up longer than 12 months may become a confounder, as wound complications outside the acute to subacute postoperative window could be related to patients’ underlying PVD and not directly to tourniquet use during surgery. Patient demographics and comorbidities were recorded. Comorbidities were obtained from preoperative medical evaluations and surgeons’ preoperative evaluations. All patients had preoperative palpable dorsalis pedis and posterior tibialis arterial pulses. No patient required preoperative vascular studies based on preoperative examination or comorbidities. No patient had prior vascular bypass surgery or stenting.
TKA was performed in a nonlaminar flow, positive-pressure, high-efficiency particulate air-filtered room with sterile toga/surgical helmet systems. For all patients, a pneumatic thigh tourniquet was applied, and the patient was prepared and draped. After limb exsanguination using a rubber bandage, the limb was elevated and the tourniquet inflated to a pressure of 250 to 300 mm Hg. The tourniquet was released either just before closure or immediately after closure in all cases; it was always let down before placement of final bandages.
Prophylactic chemical anticoagulation consisting of warfarin, aspirin, or enoxaparin was used in all patients and continued for 4 to 6 weeks after surgery. All patients received mechanical DVT prophylaxis with sequential compression devices, and all were mobilized out of bed beginning either the day of surgery or the next day. All patients received perioperative intravenous antibiotics, with the preoperative dose given before tourniquet inflation and the last postoperative dose stopped within 24 hours of surgery.
All patients who had primary TKA underwent preoperative medical evaluation and optimization. The patient’s hospital course was monitored closely, and complications noted by the orthopedic team were documented. Follow-up documentation was retrospectively reviewed for evidence of wound complications or VTE. Wound complications were defined as cellulitis, delayed wound healing, wound dehiscence, and/or periprosthetic joint infection. In the case of VTE, physical examination findings were not sufficient for inclusion. Venous duplex ultrasonography demonstrating the clot was reviewed before inclusion.
Preoperative radiographs were examined for arterial calcification (Figure). We refer to calcification seen above the knee joint as proximal calcification and to calcification observed below the joint as distal calcification. Patients exhibited calcification proximally only, distally only, or both proximally and distally. The 373 patients were placed into 2 groups based on whether they had preoperative arterial calcification on plain radiography of the knee. One group (285 patients with no radiographic evidence of preoperative knee arterial calcification) underwent 365 TKAs, and the other group (88 patients with radiographic evidence of preoperative knee arterial calcification) underwent 96 TKAs.
A sample size calculation was performed to determine how many patients were needed in each group with 80% power and an α of 0.05. With an estimated difference in VTE/wound complication rate between the calcification and no-calcification groups of 12%, we needed to review 316 TKAs total. This 12% difference was based on study findings of a 25% complication rate in PVD patients who underwent tourniquet-assisted TKA, and the rate of VTE/wound complication after TKA in patients overall, which can be up to 12%.7,13,14 We exceeded minimal enrollment and had 461 TKAs. Descriptive statistics were reported, with means and ranges provided where appropriate. Independent t test was used to evaluate the differences in continuous data (age) between the groups. Univariate analysis (using Pearson χ2 and Fisher exact tests) and multivariate logistic regression analysis were used to evaluate the effects of categorical variables (sex, comorbidity, calcification [presence, absence], and location of calcification [proximal only, distal only, both]) on wound complication and VTE rates. All tests were 2-tailed and performed with a type I error rate of 0.05. Data analysis was performed with SPSS Version 19.0 (SPSS).
Results
Patient characteristics are summarized in Table 1. Of the 373 patients, 285 lacked calcification, and 88 had calcification. Mean age was 67.73 years (range, 24-92 years) for all patients, 65.99 years (range, 24-89 years) for the no-calcification group, and 74.32 years (range, 54-92 years) for the calcification group; the calcification group demonstrated a trend toward older age, but the difference was not significantly different (P = .07). Of the 373 patients, 156 (41.82%) were male: 110 in the no-calcification group (38.60%) and 46 in the calcification group (52.27%); sex was significantly (P = .002) different between groups, with more males in the calcification group.
Data on total preoperative comorbidities are summarized in Table 2. Hypertension, hyperlipidemia, diabetes, and coronary artery disease (CAD) were the most common comorbidities, and they were all significantly (P ≤ .05) increased in the calcification group.
No patients had reported arterial complications, such as arterial bleeding, aneurysm, intimal tears, or loss of distal pulses. Wound complication after TKA was detected in 3.04% of all cases (Table 3). Rate of DVT after TKA was 2.60% of all cases, and rate of pulmonary embolism after TKA was 2.17% of all cases. Of the 96 TKAs with preoperative radiographic evidence of calcification, 47 (48.96%) had proximal calcification only, 11 (11.46%) had distal calcification only, and 38 (39.58%) had both proximal and distal calcification (Table 4). There was no significant difference between the rate of wound complication or VTE based on location of vascular calcification.
Univariate analysis demonstrated that presence of arterial knee calcification did not increase the risk for postoperative wound complication (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.28-3.80; P > .05) (Table 5). Location of arterial knee calcification also did not increase the risk for postoperative wound complication. In addition, univariate analysis demonstrated that presence of arterial knee calcification did not increase the risk for postoperative VTE (OR, 1.20; 95% CI, 0.43-3.36; P > .05 (Table 6).
Of the 14 wound complications, the most common infections were cellulitis (5/14 cases; 35.71%) and infected hardware that required component revision (5/14 cases; 35.71%). Mean time from TKA to infection was 137.93 days (range, 5-783 days). The most common organism grown in culture from the wound was Staphylococcus (5/14 cases; 35.71%).
Additional univariate statistical analysis revealed that presence of diabetes, hypertension, prior VTE, CAD, and male sex was linked to higher incidence of wound complication (P < .05) (Table 5). When multivariate analysis was performed, hypertension, prior VTE, and male sex remained significant (P < .05) (Table 5).
Discussion
TKA is a safe and effective procedure used to treat osteoarthritis of the knee and improve patients’ quality of life.15 About 700,000 TKAs are performed annually in the United States.16 Because of improvements in preventive medicine and medical technology, life expectancy is increasing, and TKAs are now being performed in higher numbers and in an older patient population. Over the next few decades, these developments will lead to more postoperative complications. It is projected that, by 2030, the need for TKAs in the United States will increase by 673% to 3.48 million.17 Postoperative complications are rare but unfortunately often lead to poor outcomes or even mortality.18 To help minimize the number of postoperative complications, we must understand the safety of tourniquet use in TKA. Other investigators have concluded that tourniquet use is unsafe in patients with preoperative vascular calcifications on plain radiographs.7,8,11 The present study, designed to elucidate whether preoperative evidence of knee arterial calcification may predispose TKA patients to postoperative wound complication or VTE, had some important findings.
In our study, wound complication and VTE occurred in a considerable number of patients after TKA. Despite exceeding the number of patients calculated by the power analysis, our population may have been inadequate to fully detect statistical significance. Thus, our conclusion of failing to reject the null hypothesis may have been because of sample size, a type II error. We found that, after primary TKA, 3.04% of patients developed wound complications and 4.77% VTE. According to the literature, the incidence of infection after primary TKA is between 0.5% and 12%, and that of VTE reported within 3 months after TKA is 1.3% to 10%.13,14 Although we had 100% VTE prophylaxis, meeting the standard of care, VTE after TKA remains a postoperative complication.19 This study also found that a considerable percentage of primary TKA patients (23.59%) had preoperative calcification of the knee arteries. To our knowledge, this study was the first to quantify the incidence of knee arterial calcification in patients who underwent TKA.
Preoperative calcification of the knee arteries in patients who underwent TKA did not increase the risk for wound complication, VTE, or arterial damage. These calcifications, however, do pose an increased systemic vascular risk.20 Calcification of the vascular wall predicts increased cardiovascular risk, independent of classical cardiovascular risk factors.3,18,21-24 Clinically, patients who have both diabetes and calcifications are at significant excess risk for total mortality, stroke mortality, and cardiovascular mortality, compared with patients with diabetes but without such calcifications. They also had a significantly higher incidence of coronary heart disease events, stroke events, and lower extremity amputations.25,26
All our patients underwent tourniquet-assisted TKA. Although previous studies have indicated that tourniquet use may increase arterial complications and wound complications or even limb loss in patients with calcified arteries, we did not find this link.7,27 Our population had no reported arterial complications related to tourniquet use. Other, smaller studies have had similar findings. Vandenbussche and colleagues28 prospectively studied 80 TKA cases randomized to tourniquet use or no tourniquet use and found no postoperative nerve palsies, wound infections, wound healing problems, or hematomas. Our study is also in accord with studies that have reported tourniquet use did not increase risk for DVT.29 Therefore, unlike earlier data, our data demonstrated that tourniquet use in patients with knee arterial calcification was safe.7,27,30,31
Patients with calcification were more likely to have the medical comorbidities of hypertension, diabetes, hyperlipidemia, and CAD. All these comorbidities are linked to the development of arterial calcification, or atherosclerotic occlusive disease.32,33 As life expectancy and the need for TKA increase, it is likely that a larger percentage of TKA patients will have preoperative radiographic evidence of knee arterial calcification. Although current dogma is that tourniquet-assisted TKA is contraindicated for patients with preoperative radiographic evidence of femoral-popliteal calcification, our study results showed that this calcification should not affect preoperative TKA planning for these patients.
We divided our patients into 3 categories: those with proximal calcification (above the joint line), those with distal calcification (below the joint line), and those with both proximal and distal calcification. Location of arterial calcification did not have an effect on their rates of postoperative wound complication or VTE. We hypothesized that patients with proximal calcification would be at increased risk for direct arterial injury and subsequent wound complication because the tourniquet is placed proximally. Previous research has indicated that arterial occlusion and subsequent wound complication can occur because of low blood flow stemming from tourniquet use.7 Further, intraoperative manipulation (flexing) of a knee with calcified vessels causes arterial complications after TKA because these vessels are less elastic than nonatheromatous vessels.31 However, we found no such effect. At the same time, having arterial calcification might also be an indication of venous disease in this location,12 which may be especially important for proximal calcifications. Proximal DVT more likely is a precursor to pulmonary embolic events than distal DVT is.31,34 However, we found no difference in VTE rates among the 3 arterial location groups, which is supported by studies that have found that tourniquet use does not increase DVT incidence.29,35-40
Risk for wound complications was higher in male patients and in patients with diabetes, prior VTE, hypertension, or CAD. This finding is important because, with the increasing age of patients who undergo TKA, those with serious medical comorbidities will continue to need and have this surgery.17 Diabetes may increase the rate of wound complication because patients with diabetes have poor microcirculation, poor collagen synthesis, and reduced wound strength.41 Malinzak and colleagues42 demonstrated that, compared with patients without diabetes, those with diabetes had a significantly higher risk for infection after TKA. Prior VTE, specifically DVT, may increase the rate of wound complication because after DVT the deep veins may be damaged and exhibit valvular dysfunction. Labropoulos and colleagues43 showed that DVT history was strongly associated with ulcer nonhealing. Perhaps hypertension has been overlooked as a risk factor for wound complication in TKA. No previous studies have assessed the link between hypertension and wound complications after TKA. However, a study of wound healing after total hip arthroplasty found that, compared with normotensive patients, hypertensive patients had delayed wound healing, putting them at higher risk for infection.44 In addition, we found that patients with CAD were at increased risk for wound complications—an unexpected finding, as CAD traditionally is not a risk factor for infection or poor wound healing. Recently, however, CAD was identified as an independent risk factor for surgical site infections in posterior lumbar–instrumented arthrodesis.45 The etiology of this association is unknown. Also, male patients were at increased risk for wound complication. Male sex has been implicated as an independent risk factor for development of surgical site infections and has been established as an important predisposing factor for periprosthetic joint infections.46
It is possible that patients who present with diabetes, VTE, hypertension, or CAD before TKA should have a consultation with a vascular surgeon or should have TKA performed without a tourniquet, but this conclusion cannot be considered definitive without a large prospective randomized trial or possibly registry data. Our data indicate that patients with these comorbidities have higher rates of wound complications irrespective of preoperative radiographic calcifications. On the basis of our study results, however, we certainly recommend that patients with these risk factors have preoperative medical optimization. Orthopedic surgeons should take a thorough history and perform a meticulous physical examination on these patients to look for evidence of PVD. We recommend that, if vascular claudication is elicited in the history, or if there is evidence of peripheral arterial disease—such as hair loss, skin discoloration, dystrophic nail changes, or absent or unequal peripheral pulses—the ankle-brachial index test should be performed. If the index value is less than 0.9, then a preoperative vascular surgery consultation should be obtained.
This study had some weaknesses. First, it was retrospective, so it is possible that some wound or VTE complications were not reported and thus not found in the paper charts or electronic medical records. Some patients may have had VTE diagnostic scans at other hospitals, and their results may not have been recorded across databases. Moreover, some patients may have seen wound specialists for wound infections or wound healing problems, and these may not have been reported to the orthopedic surgeons. Second, though our patient population was not small, it may not have been of adequate size to fully detect statistical significance. We met our enrollment numbers based on our sample size calculations from an a priori power analysis; however, we still draw conclusions with the possibility of committing a type II error in mind by failing to reject the null hypothesis when in reality a statistically significant difference does exist. Third, none of our consecutive patients carried the preoperative diagnosis of PVD, and none had preoperative vascular surgery. Therefore, though calcifications were noted on radiographs, clinically our patients were asymptomatic with respect to vascular health. Last, the 2 groups were not randomized. All patients underwent tourniquet-assisted TKA.
Conclusion
To our knowledge, this is the largest study to examine the effect of preoperative knee arterial calcification on wound complication and VTE after tourniquet-assisted TKA. Contrary to previously published recommendations, we conclude that TKA can be safely performed with a tourniquet in the presence of preoperative radiographic evidence of such calcification. However, we recommend that patients with diabetes, hypertension, CAD, or prior VTE undergo an appropriate physical examination to elicit any signs or symptoms of vascular disease. If before surgery there is any question of vascular competence, a vascular surgeon should be consulted.
Tourniquets are often used in total knee arthroplasty (TKA) to improve visualization of structures, shorten operative time, reduce intraoperative bleeding, and improve cementing technique. Despite these advantages, controversy remains regarding the safety of tourniquet use. Tourniquets have been associated with nerve palsies, vascular injury, and muscle damage.1-5 Some have hypothesized they may cause venous stasis or direct endothelial damage that may develop into deep vein thrombosis (DVT). Abdel-Salam and Eyres6 found an increased incidence of postoperative wound complications and DVTs associated with tourniquet use.
Moreover, investigators have analyzed the role of tourniquets in populations at high risk for wound complications. DeLaurentis and colleagues7 performed a prospective and retrospective analysis of 1182 TKA patients, 24 (2%) of whom had preexisting peripheral vascular disease (PVD), defined as a history of arterial insufficiency, absent dorsalis pedis and/or absent posterior tibial pulsations, and arterial calcifications. A tourniquet was used in each case. Arterial complications occurred in 6 of the 24 patients with PVD. As expected, the authors found that a history of intermittent claudication, pain at rest, and arterial ulcers resulted in a high risk for vascular complications. Further studies have supported this finding and expanded the list of predisposing factors to include previous vascular surgery and absent and asymmetric pedal pulsations.7-11 Of particular concern to total joint arthroplasty surgeons was the finding by DeLaurentis and colleagues7 that patients with radiographic evidence of calcification of the distal superficial femoral artery and/or popliteal artery were at risk for arterial complications. This finding is also supported by other studies.8,11 In TKA, damage to arterial structures proximal to the surgical field could manifest as impaired postoperative wound healing or an ischemic limb. Wound healing depends on adequate blood flow to the healing tissue, and any damage to arterial or venous structures can theoretically compromise this process.
Added to vascular/wound complications as concerning complications in orthopedic surgery is venous thromboembolism (VTE). The role of tourniquets in the formation of VTEs is controversial. A tourniquet has the potential to increase the risk for DVT because of the stasis of venous blood in the lower limb or possible damage to calcified blood vessels. Callam and colleagues12 studied the connection between artery disease and chronic leg ulcers and found that half the patients diagnosed with peripheral artery disease also had stigmata of chronic venous insufficiency. Therefore, the entities can occur in tandem, and surgeons should keep this in mind.
Here we report on a study we conducted to determine whether tourniquet use in TKA in patients with preexisting radiographic evidence of vascular disease increases the risk for wound complications or VTE.
Patients and Methods
We retrospectively reviewed 461 consecutive primary TKAs (373 patients) performed between January 2007 and June 2012 by 2 attending orthopedic surgeons specializing in adult reconstruction. Medical records and operative reports of 583 patients were examined after receiving institutional review board approval. Of these patients, 373 (64%) had a minimum of 12-month follow-up data available. Twelve months was deemed long enough to discover wound complications or DVTs secondary to the index procedure. Most of these outcomes manifest within the first 3 months after surgery and certainly by 12 months. Follow-up longer than 12 months may become a confounder, as wound complications outside the acute to subacute postoperative window could be related to patients’ underlying PVD and not directly to tourniquet use during surgery. Patient demographics and comorbidities were recorded. Comorbidities were obtained from preoperative medical evaluations and surgeons’ preoperative evaluations. All patients had preoperative palpable dorsalis pedis and posterior tibialis arterial pulses. No patient required preoperative vascular studies based on preoperative examination or comorbidities. No patient had prior vascular bypass surgery or stenting.
TKA was performed in a nonlaminar flow, positive-pressure, high-efficiency particulate air-filtered room with sterile toga/surgical helmet systems. For all patients, a pneumatic thigh tourniquet was applied, and the patient was prepared and draped. After limb exsanguination using a rubber bandage, the limb was elevated and the tourniquet inflated to a pressure of 250 to 300 mm Hg. The tourniquet was released either just before closure or immediately after closure in all cases; it was always let down before placement of final bandages.
Prophylactic chemical anticoagulation consisting of warfarin, aspirin, or enoxaparin was used in all patients and continued for 4 to 6 weeks after surgery. All patients received mechanical DVT prophylaxis with sequential compression devices, and all were mobilized out of bed beginning either the day of surgery or the next day. All patients received perioperative intravenous antibiotics, with the preoperative dose given before tourniquet inflation and the last postoperative dose stopped within 24 hours of surgery.
All patients who had primary TKA underwent preoperative medical evaluation and optimization. The patient’s hospital course was monitored closely, and complications noted by the orthopedic team were documented. Follow-up documentation was retrospectively reviewed for evidence of wound complications or VTE. Wound complications were defined as cellulitis, delayed wound healing, wound dehiscence, and/or periprosthetic joint infection. In the case of VTE, physical examination findings were not sufficient for inclusion. Venous duplex ultrasonography demonstrating the clot was reviewed before inclusion.
Preoperative radiographs were examined for arterial calcification (Figure). We refer to calcification seen above the knee joint as proximal calcification and to calcification observed below the joint as distal calcification. Patients exhibited calcification proximally only, distally only, or both proximally and distally. The 373 patients were placed into 2 groups based on whether they had preoperative arterial calcification on plain radiography of the knee. One group (285 patients with no radiographic evidence of preoperative knee arterial calcification) underwent 365 TKAs, and the other group (88 patients with radiographic evidence of preoperative knee arterial calcification) underwent 96 TKAs.
A sample size calculation was performed to determine how many patients were needed in each group with 80% power and an α of 0.05. With an estimated difference in VTE/wound complication rate between the calcification and no-calcification groups of 12%, we needed to review 316 TKAs total. This 12% difference was based on study findings of a 25% complication rate in PVD patients who underwent tourniquet-assisted TKA, and the rate of VTE/wound complication after TKA in patients overall, which can be up to 12%.7,13,14 We exceeded minimal enrollment and had 461 TKAs. Descriptive statistics were reported, with means and ranges provided where appropriate. Independent t test was used to evaluate the differences in continuous data (age) between the groups. Univariate analysis (using Pearson χ2 and Fisher exact tests) and multivariate logistic regression analysis were used to evaluate the effects of categorical variables (sex, comorbidity, calcification [presence, absence], and location of calcification [proximal only, distal only, both]) on wound complication and VTE rates. All tests were 2-tailed and performed with a type I error rate of 0.05. Data analysis was performed with SPSS Version 19.0 (SPSS).
Results
Patient characteristics are summarized in Table 1. Of the 373 patients, 285 lacked calcification, and 88 had calcification. Mean age was 67.73 years (range, 24-92 years) for all patients, 65.99 years (range, 24-89 years) for the no-calcification group, and 74.32 years (range, 54-92 years) for the calcification group; the calcification group demonstrated a trend toward older age, but the difference was not significantly different (P = .07). Of the 373 patients, 156 (41.82%) were male: 110 in the no-calcification group (38.60%) and 46 in the calcification group (52.27%); sex was significantly (P = .002) different between groups, with more males in the calcification group.
Data on total preoperative comorbidities are summarized in Table 2. Hypertension, hyperlipidemia, diabetes, and coronary artery disease (CAD) were the most common comorbidities, and they were all significantly (P ≤ .05) increased in the calcification group.
No patients had reported arterial complications, such as arterial bleeding, aneurysm, intimal tears, or loss of distal pulses. Wound complication after TKA was detected in 3.04% of all cases (Table 3). Rate of DVT after TKA was 2.60% of all cases, and rate of pulmonary embolism after TKA was 2.17% of all cases. Of the 96 TKAs with preoperative radiographic evidence of calcification, 47 (48.96%) had proximal calcification only, 11 (11.46%) had distal calcification only, and 38 (39.58%) had both proximal and distal calcification (Table 4). There was no significant difference between the rate of wound complication or VTE based on location of vascular calcification.
Univariate analysis demonstrated that presence of arterial knee calcification did not increase the risk for postoperative wound complication (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.28-3.80; P > .05) (Table 5). Location of arterial knee calcification also did not increase the risk for postoperative wound complication. In addition, univariate analysis demonstrated that presence of arterial knee calcification did not increase the risk for postoperative VTE (OR, 1.20; 95% CI, 0.43-3.36; P > .05 (Table 6).
Of the 14 wound complications, the most common infections were cellulitis (5/14 cases; 35.71%) and infected hardware that required component revision (5/14 cases; 35.71%). Mean time from TKA to infection was 137.93 days (range, 5-783 days). The most common organism grown in culture from the wound was Staphylococcus (5/14 cases; 35.71%).
Additional univariate statistical analysis revealed that presence of diabetes, hypertension, prior VTE, CAD, and male sex was linked to higher incidence of wound complication (P < .05) (Table 5). When multivariate analysis was performed, hypertension, prior VTE, and male sex remained significant (P < .05) (Table 5).
Discussion
TKA is a safe and effective procedure used to treat osteoarthritis of the knee and improve patients’ quality of life.15 About 700,000 TKAs are performed annually in the United States.16 Because of improvements in preventive medicine and medical technology, life expectancy is increasing, and TKAs are now being performed in higher numbers and in an older patient population. Over the next few decades, these developments will lead to more postoperative complications. It is projected that, by 2030, the need for TKAs in the United States will increase by 673% to 3.48 million.17 Postoperative complications are rare but unfortunately often lead to poor outcomes or even mortality.18 To help minimize the number of postoperative complications, we must understand the safety of tourniquet use in TKA. Other investigators have concluded that tourniquet use is unsafe in patients with preoperative vascular calcifications on plain radiographs.7,8,11 The present study, designed to elucidate whether preoperative evidence of knee arterial calcification may predispose TKA patients to postoperative wound complication or VTE, had some important findings.
In our study, wound complication and VTE occurred in a considerable number of patients after TKA. Despite exceeding the number of patients calculated by the power analysis, our population may have been inadequate to fully detect statistical significance. Thus, our conclusion of failing to reject the null hypothesis may have been because of sample size, a type II error. We found that, after primary TKA, 3.04% of patients developed wound complications and 4.77% VTE. According to the literature, the incidence of infection after primary TKA is between 0.5% and 12%, and that of VTE reported within 3 months after TKA is 1.3% to 10%.13,14 Although we had 100% VTE prophylaxis, meeting the standard of care, VTE after TKA remains a postoperative complication.19 This study also found that a considerable percentage of primary TKA patients (23.59%) had preoperative calcification of the knee arteries. To our knowledge, this study was the first to quantify the incidence of knee arterial calcification in patients who underwent TKA.
Preoperative calcification of the knee arteries in patients who underwent TKA did not increase the risk for wound complication, VTE, or arterial damage. These calcifications, however, do pose an increased systemic vascular risk.20 Calcification of the vascular wall predicts increased cardiovascular risk, independent of classical cardiovascular risk factors.3,18,21-24 Clinically, patients who have both diabetes and calcifications are at significant excess risk for total mortality, stroke mortality, and cardiovascular mortality, compared with patients with diabetes but without such calcifications. They also had a significantly higher incidence of coronary heart disease events, stroke events, and lower extremity amputations.25,26
All our patients underwent tourniquet-assisted TKA. Although previous studies have indicated that tourniquet use may increase arterial complications and wound complications or even limb loss in patients with calcified arteries, we did not find this link.7,27 Our population had no reported arterial complications related to tourniquet use. Other, smaller studies have had similar findings. Vandenbussche and colleagues28 prospectively studied 80 TKA cases randomized to tourniquet use or no tourniquet use and found no postoperative nerve palsies, wound infections, wound healing problems, or hematomas. Our study is also in accord with studies that have reported tourniquet use did not increase risk for DVT.29 Therefore, unlike earlier data, our data demonstrated that tourniquet use in patients with knee arterial calcification was safe.7,27,30,31
Patients with calcification were more likely to have the medical comorbidities of hypertension, diabetes, hyperlipidemia, and CAD. All these comorbidities are linked to the development of arterial calcification, or atherosclerotic occlusive disease.32,33 As life expectancy and the need for TKA increase, it is likely that a larger percentage of TKA patients will have preoperative radiographic evidence of knee arterial calcification. Although current dogma is that tourniquet-assisted TKA is contraindicated for patients with preoperative radiographic evidence of femoral-popliteal calcification, our study results showed that this calcification should not affect preoperative TKA planning for these patients.
We divided our patients into 3 categories: those with proximal calcification (above the joint line), those with distal calcification (below the joint line), and those with both proximal and distal calcification. Location of arterial calcification did not have an effect on their rates of postoperative wound complication or VTE. We hypothesized that patients with proximal calcification would be at increased risk for direct arterial injury and subsequent wound complication because the tourniquet is placed proximally. Previous research has indicated that arterial occlusion and subsequent wound complication can occur because of low blood flow stemming from tourniquet use.7 Further, intraoperative manipulation (flexing) of a knee with calcified vessels causes arterial complications after TKA because these vessels are less elastic than nonatheromatous vessels.31 However, we found no such effect. At the same time, having arterial calcification might also be an indication of venous disease in this location,12 which may be especially important for proximal calcifications. Proximal DVT more likely is a precursor to pulmonary embolic events than distal DVT is.31,34 However, we found no difference in VTE rates among the 3 arterial location groups, which is supported by studies that have found that tourniquet use does not increase DVT incidence.29,35-40
Risk for wound complications was higher in male patients and in patients with diabetes, prior VTE, hypertension, or CAD. This finding is important because, with the increasing age of patients who undergo TKA, those with serious medical comorbidities will continue to need and have this surgery.17 Diabetes may increase the rate of wound complication because patients with diabetes have poor microcirculation, poor collagen synthesis, and reduced wound strength.41 Malinzak and colleagues42 demonstrated that, compared with patients without diabetes, those with diabetes had a significantly higher risk for infection after TKA. Prior VTE, specifically DVT, may increase the rate of wound complication because after DVT the deep veins may be damaged and exhibit valvular dysfunction. Labropoulos and colleagues43 showed that DVT history was strongly associated with ulcer nonhealing. Perhaps hypertension has been overlooked as a risk factor for wound complication in TKA. No previous studies have assessed the link between hypertension and wound complications after TKA. However, a study of wound healing after total hip arthroplasty found that, compared with normotensive patients, hypertensive patients had delayed wound healing, putting them at higher risk for infection.44 In addition, we found that patients with CAD were at increased risk for wound complications—an unexpected finding, as CAD traditionally is not a risk factor for infection or poor wound healing. Recently, however, CAD was identified as an independent risk factor for surgical site infections in posterior lumbar–instrumented arthrodesis.45 The etiology of this association is unknown. Also, male patients were at increased risk for wound complication. Male sex has been implicated as an independent risk factor for development of surgical site infections and has been established as an important predisposing factor for periprosthetic joint infections.46
It is possible that patients who present with diabetes, VTE, hypertension, or CAD before TKA should have a consultation with a vascular surgeon or should have TKA performed without a tourniquet, but this conclusion cannot be considered definitive without a large prospective randomized trial or possibly registry data. Our data indicate that patients with these comorbidities have higher rates of wound complications irrespective of preoperative radiographic calcifications. On the basis of our study results, however, we certainly recommend that patients with these risk factors have preoperative medical optimization. Orthopedic surgeons should take a thorough history and perform a meticulous physical examination on these patients to look for evidence of PVD. We recommend that, if vascular claudication is elicited in the history, or if there is evidence of peripheral arterial disease—such as hair loss, skin discoloration, dystrophic nail changes, or absent or unequal peripheral pulses—the ankle-brachial index test should be performed. If the index value is less than 0.9, then a preoperative vascular surgery consultation should be obtained.
This study had some weaknesses. First, it was retrospective, so it is possible that some wound or VTE complications were not reported and thus not found in the paper charts or electronic medical records. Some patients may have had VTE diagnostic scans at other hospitals, and their results may not have been recorded across databases. Moreover, some patients may have seen wound specialists for wound infections or wound healing problems, and these may not have been reported to the orthopedic surgeons. Second, though our patient population was not small, it may not have been of adequate size to fully detect statistical significance. We met our enrollment numbers based on our sample size calculations from an a priori power analysis; however, we still draw conclusions with the possibility of committing a type II error in mind by failing to reject the null hypothesis when in reality a statistically significant difference does exist. Third, none of our consecutive patients carried the preoperative diagnosis of PVD, and none had preoperative vascular surgery. Therefore, though calcifications were noted on radiographs, clinically our patients were asymptomatic with respect to vascular health. Last, the 2 groups were not randomized. All patients underwent tourniquet-assisted TKA.
Conclusion
To our knowledge, this is the largest study to examine the effect of preoperative knee arterial calcification on wound complication and VTE after tourniquet-assisted TKA. Contrary to previously published recommendations, we conclude that TKA can be safely performed with a tourniquet in the presence of preoperative radiographic evidence of such calcification. However, we recommend that patients with diabetes, hypertension, CAD, or prior VTE undergo an appropriate physical examination to elicit any signs or symptoms of vascular disease. If before surgery there is any question of vascular competence, a vascular surgeon should be consulted.
1. Guanche CA. Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction. Arthroscopy. 1995;11(5):620-622.
2. Irvine GB, Chan RN. Arterial calcification and tourniquets. Lancet. 1986;2(8517):1217.
3. Patterson S, Klenerman L. The effect of pneumatic tourniquets on the ultrastructure of skeletal muscle. J Bone Joint Surg Br. 1979;61(2):178-183.
4. Rorabeck CH, Kennedy JC. Tourniquet-induced nerve ischemia complicating knee ligament surgery. Am J Sports Med. 1980;8(2):98-102.
5. Shenton DW, Spitzer SA, Mulrennan BM. Tourniquet-induced rhabdomyolysis. A case report. J Bone Joint Surg Am. 1990;72(9):1405-1406.
6. Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br. 1995;77(2):250-253.
7. DeLaurentis DA, Levitsky KA, Booth RE, et al. Arterial and ischemic aspects of total knee arthroplasty. Am J Surg. 1992;164(3):237-240.
8. Holmberg A, Milbrink J, Bergqvist D. Arterial complications and knee arthroplasty. Acta Orthop Scand. 1996;67(1):75-8.
9. Hozack WJ, Cole PA, Gardner R, Corces A. Popliteal aneurysm after total knee arthroplasty. Case reports and review of the literature. J Arthroplasty. 1990;5(4):301-305.
10. Kumar SN, Chapman JA, Rawlins I. Vascular injuries after total knee arthroplasty: a review of the problem with special reference to the possible effects of the tourniquet. J Arthroplasty. 1998;13(2):211-216.
11. Rush JH, Vidovich JD, Johanson MA. Arterial complications and total knee arthroplasty. The Australian experience. J Bone Joint Surg Br. 1987;69(3):400-402.
12. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial disease in chronic leg ulceration: an underestimated hazard? Lothian and Forth Valley Leg Ulcer Study. Br Med J (Clin Res Ed). 1987;294(6577):929-931.
13. Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br. 2004;86(5):688-691.
14. Geerts WH, Bergqvist D, Pinco G, et al. Prevention of venous thromboembolism. Chest. 2008;133(6 suppl):381S-453S.
15. Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):139-145.
16. Arthritis: data and statistics. Centers for Disease Control and Prevention website. http://www.cdc.gov/arthritis/data_statistics.htm. Updated March 11, 2015. Accessed July 27, 2015.
17. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
18. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-1715.
19. Warwick D. Prevention of venous thromboembolism in total knee and hip replacement. Circulation. 2012;125(17):2151-2155.
20. Rennenberg RJ, Kessels AG, Schurgers LJ, van Engelshoven JM, de Leeuw PW, Kroon AA. Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis. Vasc Health Risk Manag. 2009;5(1):185-197.
21. Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46(1):158-165.
22. Iribarren C, Sidney S, Sternfeld B, Browner WS. Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease. JAMA. 2000;283(21):2810-2815.
23. Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology. 2003;228(3):826-833.
24. Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O’Malley PG. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol. 2005;46(5):807-814.
25. Lehto S, Niskanen L, Suhonen M, Rönnemaa T, Laakso M. Medial artery calcification. A neglected harbinger of cardiovascular complications in non-insulin-dependent diabetes mellitus. Arterioscler Thromb Vasc Biol. 1996;16(8):978-983.
26. Niskanen L, Siitonen O, Suhonen M, Uusitupa MI. Medial artery calcification predicts cardiovascular mortality in patients with NIDDM. Diabetes Care. 1994;17(11):1252-1256.
27. Smith DE, McGraw RW, Taylor DC, et al. Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg. 2001;9(4):253-257.
28. Vandenbussche E, Duranthon L, Couturier M, Pidhorz L, Augereau B. The effect of tourniquet use in total knee arthroplasty. Int Orthop. 2002;26(5):306-309.
29. Fukunda A, Hasegawa M, Kato K, Shi D, Sudo A, Uchida A. Effect of tourniquet application on deep vein thrombosis after total knee thrombosis. Arch Orthop Trauma Surg. 2007;127(8):671-675.
30. Butt U, Samuel R, Sahu A, Butt IS, Johnson DS, Turner PG. Arterial injury in total knee arthroplasty. J Arthroplasty. 2010;25(8):1311-1318.
31. Langkamer VG. Local vascular complications after knee replacement: a review with illustrative case reports. Knee. 2001;8(4):259-264.
32. Hussein A, Uno K, Wolski K, et al. Peripheral arterial disease and progression of coronary atherosclerosis. J Am Coll Cardiol. 2011;57(10):1220-1225.
33. Ouriel K. Peripheral arterial disease. Lancet. 2001;358(9289):1257-1264.
34. Monreal M, Rufz J, Olazabal A, Arias A, Roca J. Deep venous thrombosis and the risk of pulmonary embolism. Chest. 1992;102(3):677-681.
35. Angus PD, Nakielny R, Goodrum DT. The pneumatic tourniquet and deep venous thrombosis. J Bone Joint Surg Br. 1983;65(3):336-339.
36. Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1981;63(3):461-465.
37. Harvey EJ, Leclerc J, Brooks CE, Burke DL. Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. J Arthroplasty. 1997;12(3):291-296.
38. Simon MA, Mass DP, Zarins CK, Bidani N, Gudas CJ, Metz CE. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. J Bone Joint Surg Am. 1982;64(2):188-191.
39. Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep-vein thrombosis following total knee replacement. An analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg Am. 1984;66(2):194-201.
40. Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Br. 1999;81(1):30-33.
41. Vince K, Chivas D, Droll K. Wound complications after total knee arthroplasty. J Arthroplasty. 2007;22(4 Suppl 1):39-44.
42. Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24(6 Suppl):84-88.
43. Labropoulos N, Wang E, Lanier S, Khan SU. Factors associated with poor healing and recurrence of venous ulceration. Plast Reconstr Surg. 2011;129(1):179-186.
44. Ahmed AA, Mooar PA, Kleiner M, Torg JS, Miyamoto CT. Hypertensive patients show delayed wound healing following total hip arthroplasty. PLoS One. 2011;6(8):e23224.
45. Koutsoumbelis S, Hughes AP, Girardi FP, et al. Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Joint Surg Am. 2001;93(17):1627-1633.
46. Poultsides LA, Ma Y, Della Valle AG, Chiu YL, Sculco TP, Memtsoudis SG. In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty. 2013;28(3):385-389.
1. Guanche CA. Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction. Arthroscopy. 1995;11(5):620-622.
2. Irvine GB, Chan RN. Arterial calcification and tourniquets. Lancet. 1986;2(8517):1217.
3. Patterson S, Klenerman L. The effect of pneumatic tourniquets on the ultrastructure of skeletal muscle. J Bone Joint Surg Br. 1979;61(2):178-183.
4. Rorabeck CH, Kennedy JC. Tourniquet-induced nerve ischemia complicating knee ligament surgery. Am J Sports Med. 1980;8(2):98-102.
5. Shenton DW, Spitzer SA, Mulrennan BM. Tourniquet-induced rhabdomyolysis. A case report. J Bone Joint Surg Am. 1990;72(9):1405-1406.
6. Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br. 1995;77(2):250-253.
7. DeLaurentis DA, Levitsky KA, Booth RE, et al. Arterial and ischemic aspects of total knee arthroplasty. Am J Surg. 1992;164(3):237-240.
8. Holmberg A, Milbrink J, Bergqvist D. Arterial complications and knee arthroplasty. Acta Orthop Scand. 1996;67(1):75-8.
9. Hozack WJ, Cole PA, Gardner R, Corces A. Popliteal aneurysm after total knee arthroplasty. Case reports and review of the literature. J Arthroplasty. 1990;5(4):301-305.
10. Kumar SN, Chapman JA, Rawlins I. Vascular injuries after total knee arthroplasty: a review of the problem with special reference to the possible effects of the tourniquet. J Arthroplasty. 1998;13(2):211-216.
11. Rush JH, Vidovich JD, Johanson MA. Arterial complications and total knee arthroplasty. The Australian experience. J Bone Joint Surg Br. 1987;69(3):400-402.
12. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial disease in chronic leg ulceration: an underestimated hazard? Lothian and Forth Valley Leg Ulcer Study. Br Med J (Clin Res Ed). 1987;294(6577):929-931.
13. Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br. 2004;86(5):688-691.
14. Geerts WH, Bergqvist D, Pinco G, et al. Prevention of venous thromboembolism. Chest. 2008;133(6 suppl):381S-453S.
15. Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):139-145.
16. Arthritis: data and statistics. Centers for Disease Control and Prevention website. http://www.cdc.gov/arthritis/data_statistics.htm. Updated March 11, 2015. Accessed July 27, 2015.
17. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
18. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-1715.
19. Warwick D. Prevention of venous thromboembolism in total knee and hip replacement. Circulation. 2012;125(17):2151-2155.
20. Rennenberg RJ, Kessels AG, Schurgers LJ, van Engelshoven JM, de Leeuw PW, Kroon AA. Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis. Vasc Health Risk Manag. 2009;5(1):185-197.
21. Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46(1):158-165.
22. Iribarren C, Sidney S, Sternfeld B, Browner WS. Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease. JAMA. 2000;283(21):2810-2815.
23. Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology. 2003;228(3):826-833.
24. Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O’Malley PG. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol. 2005;46(5):807-814.
25. Lehto S, Niskanen L, Suhonen M, Rönnemaa T, Laakso M. Medial artery calcification. A neglected harbinger of cardiovascular complications in non-insulin-dependent diabetes mellitus. Arterioscler Thromb Vasc Biol. 1996;16(8):978-983.
26. Niskanen L, Siitonen O, Suhonen M, Uusitupa MI. Medial artery calcification predicts cardiovascular mortality in patients with NIDDM. Diabetes Care. 1994;17(11):1252-1256.
27. Smith DE, McGraw RW, Taylor DC, et al. Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg. 2001;9(4):253-257.
28. Vandenbussche E, Duranthon L, Couturier M, Pidhorz L, Augereau B. The effect of tourniquet use in total knee arthroplasty. Int Orthop. 2002;26(5):306-309.
29. Fukunda A, Hasegawa M, Kato K, Shi D, Sudo A, Uchida A. Effect of tourniquet application on deep vein thrombosis after total knee thrombosis. Arch Orthop Trauma Surg. 2007;127(8):671-675.
30. Butt U, Samuel R, Sahu A, Butt IS, Johnson DS, Turner PG. Arterial injury in total knee arthroplasty. J Arthroplasty. 2010;25(8):1311-1318.
31. Langkamer VG. Local vascular complications after knee replacement: a review with illustrative case reports. Knee. 2001;8(4):259-264.
32. Hussein A, Uno K, Wolski K, et al. Peripheral arterial disease and progression of coronary atherosclerosis. J Am Coll Cardiol. 2011;57(10):1220-1225.
33. Ouriel K. Peripheral arterial disease. Lancet. 2001;358(9289):1257-1264.
34. Monreal M, Rufz J, Olazabal A, Arias A, Roca J. Deep venous thrombosis and the risk of pulmonary embolism. Chest. 1992;102(3):677-681.
35. Angus PD, Nakielny R, Goodrum DT. The pneumatic tourniquet and deep venous thrombosis. J Bone Joint Surg Br. 1983;65(3):336-339.
36. Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1981;63(3):461-465.
37. Harvey EJ, Leclerc J, Brooks CE, Burke DL. Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. J Arthroplasty. 1997;12(3):291-296.
38. Simon MA, Mass DP, Zarins CK, Bidani N, Gudas CJ, Metz CE. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. J Bone Joint Surg Am. 1982;64(2):188-191.
39. Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep-vein thrombosis following total knee replacement. An analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg Am. 1984;66(2):194-201.
40. Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Br. 1999;81(1):30-33.
41. Vince K, Chivas D, Droll K. Wound complications after total knee arthroplasty. J Arthroplasty. 2007;22(4 Suppl 1):39-44.
42. Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24(6 Suppl):84-88.
43. Labropoulos N, Wang E, Lanier S, Khan SU. Factors associated with poor healing and recurrence of venous ulceration. Plast Reconstr Surg. 2011;129(1):179-186.
44. Ahmed AA, Mooar PA, Kleiner M, Torg JS, Miyamoto CT. Hypertensive patients show delayed wound healing following total hip arthroplasty. PLoS One. 2011;6(8):e23224.
45. Koutsoumbelis S, Hughes AP, Girardi FP, et al. Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Joint Surg Am. 2001;93(17):1627-1633.
46. Poultsides LA, Ma Y, Della Valle AG, Chiu YL, Sculco TP, Memtsoudis SG. In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty. 2013;28(3):385-389.
Sustentaculum Lunatum: Appreciation of the Palmar Lunate Facet in Management of Complex Intra-Articular Fractures of the Distal Radius
Fracture of the distal radius is the wrist injury most often encountered by orthopedic and hand surgeons.1 The number of fractures of the distal radius in the United States was estimated to be 640,000 in 2001, and the incidence is increasing.2,3 Recent evidence has shown a substantial increase in treating these fractures with internal rather than closed fixation, even in the elderly.4
Treatment of complex intra-articular fractures of the distal radius requires an accurate diagnosis of the fracture pattern and a thoughtful approach to fixation. Although a majority of the fractures that meet the operative criteria are now treated with various anterior locked-plating techniques with good results, a subset requires more technically demanding fixation approaches, including fragment-specific approaches, dorsal and palmar plating, and combined internal and external fixation.
The sustentaculum lunatum, as we have named the palmar lunate facet, deserves specific attention because of its importance in load transmission across the radiocarpal joint and its key role in restoring the anatomy of the palmar distal radial metaphysis during internal fixation. This fragment in comminuted fractures was first ascribed special importance by Melone5 in his description of common fracture patterns. In the present article, we describe the anatomical characteristics of the sustentaculum lunatum and the clinical relevance of this fragment to management of fractures of the distal radius.
Classification
A variety of classification systems have been proposed to characterize and guide treatment of fractures of the distal radius. The earliest descriptions of fracture patterns were presented by Castaing6 and Frykman7 in the 1960s. The Frykman classification historically has been popular but is limited in accuracy in its characterization of fragments and their displacement and is limited in its ability to guide treatment. The classification system proposed by Melone and colleagues5,8-10 was the first to truly describe fracture of the distal radius fragments in a relevant manner, including their characteristic “4 parts” (Figure 1). The authors emphasized the importance of the “medial complex” as the cornerstone of the radiocarpal and radioulnar joints.
The classification system developed by Müller and colleagues,11 which was adopted by the AO (Arbeitsgemeinschaft für Osteosynthesefragen), might be the most descriptive and informative system, and it is widely used to conduct research and direct treatment. This system classifies fractures into A (extra-articular), B (partial articular), and C (complete articular) types and subclassifies them according to fracture location and comminution. These classifications, along with a conceptualization of the distal forearm as a 3-column structure involving the radial, ulnar, and intermediate columns (including the lunate facet), as proposed by Peine and colleagues,12 gave us a framework for approaching fixation of fractures of the distal radius.
Etymology and Definition
Sustentaculum, from the Latin sustinere, “to support, check, or put off,” and taculum, “receptacle or holding space,” is a fitting description of the most distal portion of the palmar lunate facet, as it supports and holds the carpus, and specifically the lunate, on the radial articular surface. This portion is analogous to the sustentaculum tali, the named portion of the calcaneus that supports and articulates with the middle calcaneal articular surface of the talus13 and provides a reliable fragment for internal fixation of the calcaneus.
Anatomical and Biomechanical Considerations
The distal radial articular surface is composed of distinct scaphoid and lunate facets that articulate with their respective carpal bones. Several studies have characterized the anatomy of the distal radius.14-17 Linscheid14 found that the lunate and scaphoid facets account for 46% and 43% of the contact area across the radiocarpal joint, respectively; this has been corroborated by others.15 A biomechanical study by Genda and Horii18 showed that the majority of stress across the wrist joint was concentrated at the palmar side of the distal radius in the neutral position. Although it is recognized that the scaphoid facet bears most of the load across the wrist in the neutral wrist position, most activities of daily living place the wrist in a slightly extended and ulnarly deviated position. This position results in a shift of the majority of load to the radiolunar articulation, constituting 53% of total force transmission.18 Subchondral bone density analyses have supported this lunate-predominant loading pattern across the radiocarpal articulation in most people.19 This loading pattern is also supported by the observation that failure of fixation and carpal subluxation generally occurs at the radiolunate articulation.
The palmar lip of the distal radius traditionally has been depicted and conceptualized as a flat extension of the metaphysis, leading to the development of implants that are not ideally designed for capturing this area in the fracture setting. A 3-dimensional (3-D) computed tomography (CT) study of the distal radii of healthy volunteers, conducted by Andermahr and colleagues,20 showed that the contour of the palmar lunate facet projects from the palmar cortex of the radius by 3 mm on average and is about 19 mm in width (radial to ulnar dimension) (Figures 2A-2C). In the axial plane, the anterior cortex of the distal radius slopes in a palmar direction, from radial to ulnar. This presents a challenge in attempts to support the entire surface (scaphoid and lunate facets) with a single palmar implant.20-25
A study conducted by Harness and colleagues24 showed that the majority of palmar shear fractures are composed of multiple fragments of the lunar articular facet. Anatomical studies of the distal radiocarpal articulation have also described the ligamentous attachments to the sustentaculum lunatum.26 The short radiolunate ligament, which originates from this fragment and inserts onto the lunate, provides stability to the carpus and, if not adequately fixed, leads to an incompetent restraint to palmar carpal translation. Isolated injuries of the short radiolunate ligament or fractures of the palmar lunate facet have been shown to result in palmar carpal translation.27,28 In addition, attachments of the palmar radioulnar ligament and other more ulnar radiocarpal ligaments act as deforming forces on the palmar lunate facet.24,26
Fracture Pattern Recognition
Although the AO type B palmar shear fracture pattern, also known as the Barton fracture, has classically been recognized as the fracture involving the palmar lunate facet and requiring special attention, many complete articular fractures feature involvement and fragmentation of this portion of the distal radius (Figures 3A-3F).29 In highly comminuted complete articular and palmar shear fracture patterns, the morphology of the sustentaculum lunatum should be appreciated, and its adequate fixation to the radial metaphysis ensured, to prevent loss of reduction.
Visualization of the palmar lunate facet as a distinct fragment might be difficult in cases of highly comminuted fracture patterns. Standard CT or more recently described 3-D CT techniques with subtraction of the carpus might facilitate appreciation of this fragment for preoperative planning of approach and fixation.29,30 Our institutional protocol involves obtaining preoperative traction radiographs of every fracture of the distal radius. These radiographs have reduced the need for CT in understanding the fracture pattern and aid in decision making.31
Besides appreciating the existence of the sustentaculum lunatum fragment, we should recognize that some injury patterns that split the lunate facet into unstable dorsal and palmar fragments might necessitate a separate dorsal approach to reduce and fix the dorsal lunate fragment. Traction radiographs can be especially useful in recognizing these patterns (a V sign is present) (Figures 4A, 4B).
Open Fractures
Highly comminuted fractures of the distal radius presenting with displaced lunate facet fragments can have high-energy mechanisms of injury. Although open fractures of the distal radius are associated with lower risk for infection (compared with open fractures of other long bones), they deserve special attention because of associated tendon and neurovascular injuries. Few studies have specifically assessed open fractures of the distal radius.32-35 Only the study by Rozental and Blazar34 listed associated injuries at the wrist level. The authors identified 4 patients (out of 18) with concomitant flexor tendon or neurovascular injuries that included radial or ulnar artery injury. In our experience, many open fractures of the distal radius are caused by an inside-out mechanism and present with an open wound either over the ulnar styloid or in the area of the ulnar side of the palmar radial metaphysis corresponding to the metaphyseal spike that mates with the sustentaculum lunatum (Figures 5A, 5B). Given these findings, we approach this intermediate column with particular care in cases of open fracture, paying attention to important structures (flexors, neurovascular) and looking for contamination from the environment into the fracture.
Fixation Techniques
The approach to fixation of partial articular palmar shear fractures is fairly straightforward. Buttress plate fixation has been well described and has had reliably good results.36 However, in very distal fracture patterns and in cases in which the palmar lunate facet is fragmented as part of a complete articular fracture, a fragment-specific approach to fixation with or without spanning external fixation often is necessary.37 The unrecognized sustentaculum lunatum fragment in comminuted complete articular fractures can lead to inadequate fixation constructs, resulting in loss of reduction and carpal subluxation in a palmar direction.24,34,38
Our surgical approach uses the standard anterior interval between the radial artery and the flexor carpi radialis, as described by Henry.39 The flexor pollicis longus is retracted ulnarly, revealing the pronator quadratus. We then reflect the pronator quadratus from the distal radial metaphysis until the most proximal and ulnar extent of the fracture is easily visualized. The palmar ulnar metaphyseal cortex that mates with the displaced sustentaculum lunatum is, in our experience, often the least comminuted portion of the metaphysis, thus providing a cortical key for restoration of height and alignment (Figures 5A, 5B). At our institution, fixation typically is achieved by contouring miniplates (1.3 or 1.5 mm) to capture and buttress the sustentaculum lunatum (Figures 6A, 6B). In our experience, the screw lengths in the most distal fixed-angle constructs at the palmar lip are limited to 6 mm or less to avoid penetration of the articular surface, though this has not been previously reported in the literature. After restoring the length and tilt of this intermediate column of the distal radius, we proceed with “rebuilding” the remainder of the fragments to our stabilized initial construct.
Various authors40-43 have described alternative fixation methods for the palmar lunate facet fragment. Jupiter and Marent-Huber42 described 2.4-mm locked-plate fixation with either a standard palmar plate or T- or L-plates for cases in which the palmar lip fragment is very distal and small. In fact, some newer anatomical distal radius implants include features designed to target these fragments (Figures 7A, 7B). An alternative fixation method involves use of a 26-gauge stainless steel wire passed through drill holes in the metaphysis 1 cm proximal to the fracture and then passed through the palmar capsule just distal to the fragment and secured in figure-8 fashion while the fragment is manually held reduced.41 Still others have recommended limited internal fixation of the sustentaculum lunatum through an ulna-sided palmar approach to the distal radius (between the ulnar neurovascular bundle and the flexor tendons) combined with external fixation to restore length and palmar tilt in highly comminuted fractures.40,43
A method involving arthroscopically assisted reduction and fixation of the lunate facet has also been described, though this procedure is technically demanding and has limited indications.44 It uses a Freer elevator passed through the standard 3-4 portal after initial visualization and evacuation of hematoma. The Freer elevator is used to disimpact the sustentaculum lunatum and to elevate it from its depressed position. With the dorsal lunate facet left displaced to facilitate access to the palmar fragment, a nerve hook retractor is used to reduce the palmar facet to the radial styloid, and Kirschner wires are used to achieve interfragmentary fixation. The dorsal lunate fragment is then pieced back to the articular segment, and the entire construct is fixed to the radial metaphysis with additional Kirschner wires.
Discussion
Given the increasing incidence of fractures of the distal radius, internal fixation of these injuries will continue to be relevant. American Academy of Orthopaedic Surgeons guidelines recommend operative fixation for fractures with postreduction radial shortening of more than 3 mm, dorsal tilt of more than 10°, or intra-articular displacement or step-off of more than 2 mm.45 Dr. Eglseder and Dr. Pensy indicate operative treatment of any incongruity of more than 2 mm in a young, active adult with a fracture of the distal radius. For the multifragmentary distal radius being treated operatively, attempts are made to achieve reduction more accurate than this, but formal dorsal exposure or direct visualization of the joint surface via dorsal capsulotomy is carefully chosen based on age, activity level, and bone quality. Recent high-level evidence46 showed that closed treatment of unstable fractures of the distal radius results in good outcomes in the elderly. However, it is important to note that fractures displaced in a palmar direction and palmar shear patterns were excluded from that work. It is widely accepted that palmar carpal translation should be addressed with internal fixation, and specific attention must therefore be paid to the lunate facet as the cornerstone of the distal radius. Furthermore, high-energy comminuted fractures in young patients still necessitate internal fixation of fragments to restore alignment and articular congruity.
Conclusion
The importance of the palmar lunate facet in providing support and restraint to palmar carpal translation and the key role of this facet in restoring the anatomy of the distal radius have been known. This fragment deserves special attention because failure to adequately stabilize it results in loss of fixation and carpal subluxation. Various approaches and fixation techniques have been recommended, including the method we prefer and have described here. Our newly proposed term, sustentaculum lunatum, our review of its structure and function, and our descriptions of fixation techniques are intended to promote awareness of this fragment in the treatment of fractures of the distal radius.
1. Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg Am. 1991;73(3):461-469.
2. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908-915.
3. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113-125.
4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868-1873.
5. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15(2):217-236.
6. Castaing J. Recent fractures of the lower extremity of the radius in adults [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1964;50:581-696.
7. Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967;(suppl 108):3+.
8. Isani A, Melone CP Jr. Classification and management of intra-articular fractures of the distal radius. Hand Clin. 1988;4(3):349-360.
9. Melone CP Jr. Distal radius fractures: patterns of articular fragmentation. Orthop Clin North Am. 1993;24(2):239-253.
10. Rettig ME, Dassa GL, Raskin KB, Melone CP Jr. Wrist fractures in the athlete: distal radius and carpal fractures. Clin Sports Med. 1998;17(3):469-489.
11. Müller ME, Koch P, Nazarian S, Schatzker J. The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag; 1990.
12. Peine R, Rikli DA, Hoffmann R, Duda G, Regazzoni P. Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study. J Hand Surg Am. 2000;25(1):29-33.
13. Williams PL, Warwick R, Dyson M, Bannister LH, eds. Gray’s Anatomy. 37th ed. New York, NY: Churchill Livingstone; 1989.
14. Linscheid RL. Kinematic considerations of the wrist. Clin Orthop Relat Res. 1986;(202):27-39.
15. Mekhail AO, Ebraheim NA, McCreath WA, Jackson WT, Yeasting RA. Anatomic and x-ray film studies of the distal articular surface of the radius. J Hand Surg Am. 1996;21(4):567-573.
16. Schuind FA, Linscheid RL, An KN, Chao EY. A normal data base of posteroanterior roentgenographic measurements of the wrist. J Bone Joint Surg Am. 1992;74(9):1418-1429.
17. Schuind F, Alemzadeh S, Stallenberg B, Burny F. Does the normal contralateral wrist provide the best reference for x-ray film measurements of the pathologic wrist? J Hand Surg Am. 1996;21(1):24-30.
18. Genda E, Horii E. Theoretical stress analysis in wrist joint: neutral position and functional position. J Hand Surg Br. 2000;25(3):292-295.
19. Giunta R, Löwer N, Wilhelm K, Keirse R, Rock C, Müller-Gerbl M. Altered patterns of subchondral bone mineralization in Kienböck’s disease. J Hand Surg Br. 1997;22(1):16-20.
20. Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg Am. 2006;31(6):892-895.
21. Bo WJ, Meschan I, Krueger WA. Basic Atlas of Cross-Sectional Anatomy. Philadelphia, PA: Saunders; 1980.
22. Cahill DR, Orland MJ, Miller GM. Atlas of Human Cross-Sectional Anatomy: With CT and MR Images. 3rd ed. New York, NY: Wiley; 1995.
23. El-Khoury GY, Bergman RA, Montgomery WJ. Sectional Anatomy by MRI. 2nd ed. New York, NY: Churchill Livingstone; 1995.
24. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86(9):1900-1908.
25. Lewis OJ, Hamshere RJ, Bucknill TM. The anatomy of the wrist joint. J Anat. 1970;106(Pt 3):539-552.
26. Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am. 1990;15(6):847-854.
27. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the ulno-palmar distal radial fragment. J Hand Surg Br. 2002;27(2):139-145.
28. Chang EY, Chen KC, Meunier MJ, Chung CB. Acute short radiolunate ligament rupture in a rock climber. Skeletal Radiol. 2014;43(2):235-238.
29. Souer JS, Wiggers J, Ring D. Quantitative 3-dimensional computed tomography measurement of volar shearing fractures of the distal radius. J Hand Surg Am. 2011;36(4):599-603.
30. Pruitt DL, Gilula LA, Manske PR, Vannier MW. Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg Am. 1994(5);19:720-727.
31. Goldwyn E, Pensy R, O’Toole RV, et al. Do traction radiographs of distal radial fractures influence fracture characterization and treatment? J Bone Joint Surg Am. 2012;94(22):2055-2062.
32. Glueck DA, Charoglu CP, Lawton JN. Factors associated with infection following open distal radius fractures. Hand. 2009;4(3):330-334.
33. Kurylo JC, Axelrad TW, Tornetta P 3rd, Jawa A. Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures. J Hand Surg Am. 2011;36(7):1131-1134.
34. Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am. 2006;31(3):359-365.
35. Rozental TD, Beredjiklian PK, Steinberg DR, Bozentka DJ. Open fractures of the distal radius. J Hand Surg Am. 2002;27(1):77-85.
36. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005;13(3):159-171.
37. Bae DS, Koris MJ. Fragment-specific internal fixation of distal radius fractures. Hand Clin. 2005;21(3):355-362.
38. Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures. J Am Acad Orthop Surg. 2009;17(6):369-377.
39. Henry AK. Extensile Exposure. 2nd ed. New York, NY: Churchill Livingstone; 1973.
40. Axelrod T, Paley D, Green J, McMurtry RY. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. J Hand Surg Am. 1988;13(3):372-377.
41. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg Am. 1999;24(3):525-533.
42. Jupiter JB, Marent-Huber M; LCP Study Group. Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series. Surgical technique. J Bone Joint Surg Am. 2010;92(suppl 1, pt 1):96-106.
43. Ruch DS, Yang C, Smith BP. Results of palmar plating of the lunate facet combined with external fixation for the treatment of high-energy compression fractures of the distal radius. J Orthop Trauma. 2004;18(1):28-33.
44. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10(3):139-144.
45. American Academy of Orthopaedic Surgeons. The Treatment of Distal Radius Fractures: Guideline and Evidence Report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009. http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed August 4, 2015.
46. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146-2153.
Fracture of the distal radius is the wrist injury most often encountered by orthopedic and hand surgeons.1 The number of fractures of the distal radius in the United States was estimated to be 640,000 in 2001, and the incidence is increasing.2,3 Recent evidence has shown a substantial increase in treating these fractures with internal rather than closed fixation, even in the elderly.4
Treatment of complex intra-articular fractures of the distal radius requires an accurate diagnosis of the fracture pattern and a thoughtful approach to fixation. Although a majority of the fractures that meet the operative criteria are now treated with various anterior locked-plating techniques with good results, a subset requires more technically demanding fixation approaches, including fragment-specific approaches, dorsal and palmar plating, and combined internal and external fixation.
The sustentaculum lunatum, as we have named the palmar lunate facet, deserves specific attention because of its importance in load transmission across the radiocarpal joint and its key role in restoring the anatomy of the palmar distal radial metaphysis during internal fixation. This fragment in comminuted fractures was first ascribed special importance by Melone5 in his description of common fracture patterns. In the present article, we describe the anatomical characteristics of the sustentaculum lunatum and the clinical relevance of this fragment to management of fractures of the distal radius.
Classification
A variety of classification systems have been proposed to characterize and guide treatment of fractures of the distal radius. The earliest descriptions of fracture patterns were presented by Castaing6 and Frykman7 in the 1960s. The Frykman classification historically has been popular but is limited in accuracy in its characterization of fragments and their displacement and is limited in its ability to guide treatment. The classification system proposed by Melone and colleagues5,8-10 was the first to truly describe fracture of the distal radius fragments in a relevant manner, including their characteristic “4 parts” (Figure 1). The authors emphasized the importance of the “medial complex” as the cornerstone of the radiocarpal and radioulnar joints.
The classification system developed by Müller and colleagues,11 which was adopted by the AO (Arbeitsgemeinschaft für Osteosynthesefragen), might be the most descriptive and informative system, and it is widely used to conduct research and direct treatment. This system classifies fractures into A (extra-articular), B (partial articular), and C (complete articular) types and subclassifies them according to fracture location and comminution. These classifications, along with a conceptualization of the distal forearm as a 3-column structure involving the radial, ulnar, and intermediate columns (including the lunate facet), as proposed by Peine and colleagues,12 gave us a framework for approaching fixation of fractures of the distal radius.
Etymology and Definition
Sustentaculum, from the Latin sustinere, “to support, check, or put off,” and taculum, “receptacle or holding space,” is a fitting description of the most distal portion of the palmar lunate facet, as it supports and holds the carpus, and specifically the lunate, on the radial articular surface. This portion is analogous to the sustentaculum tali, the named portion of the calcaneus that supports and articulates with the middle calcaneal articular surface of the talus13 and provides a reliable fragment for internal fixation of the calcaneus.
Anatomical and Biomechanical Considerations
The distal radial articular surface is composed of distinct scaphoid and lunate facets that articulate with their respective carpal bones. Several studies have characterized the anatomy of the distal radius.14-17 Linscheid14 found that the lunate and scaphoid facets account for 46% and 43% of the contact area across the radiocarpal joint, respectively; this has been corroborated by others.15 A biomechanical study by Genda and Horii18 showed that the majority of stress across the wrist joint was concentrated at the palmar side of the distal radius in the neutral position. Although it is recognized that the scaphoid facet bears most of the load across the wrist in the neutral wrist position, most activities of daily living place the wrist in a slightly extended and ulnarly deviated position. This position results in a shift of the majority of load to the radiolunar articulation, constituting 53% of total force transmission.18 Subchondral bone density analyses have supported this lunate-predominant loading pattern across the radiocarpal articulation in most people.19 This loading pattern is also supported by the observation that failure of fixation and carpal subluxation generally occurs at the radiolunate articulation.
The palmar lip of the distal radius traditionally has been depicted and conceptualized as a flat extension of the metaphysis, leading to the development of implants that are not ideally designed for capturing this area in the fracture setting. A 3-dimensional (3-D) computed tomography (CT) study of the distal radii of healthy volunteers, conducted by Andermahr and colleagues,20 showed that the contour of the palmar lunate facet projects from the palmar cortex of the radius by 3 mm on average and is about 19 mm in width (radial to ulnar dimension) (Figures 2A-2C). In the axial plane, the anterior cortex of the distal radius slopes in a palmar direction, from radial to ulnar. This presents a challenge in attempts to support the entire surface (scaphoid and lunate facets) with a single palmar implant.20-25
A study conducted by Harness and colleagues24 showed that the majority of palmar shear fractures are composed of multiple fragments of the lunar articular facet. Anatomical studies of the distal radiocarpal articulation have also described the ligamentous attachments to the sustentaculum lunatum.26 The short radiolunate ligament, which originates from this fragment and inserts onto the lunate, provides stability to the carpus and, if not adequately fixed, leads to an incompetent restraint to palmar carpal translation. Isolated injuries of the short radiolunate ligament or fractures of the palmar lunate facet have been shown to result in palmar carpal translation.27,28 In addition, attachments of the palmar radioulnar ligament and other more ulnar radiocarpal ligaments act as deforming forces on the palmar lunate facet.24,26
Fracture Pattern Recognition
Although the AO type B palmar shear fracture pattern, also known as the Barton fracture, has classically been recognized as the fracture involving the palmar lunate facet and requiring special attention, many complete articular fractures feature involvement and fragmentation of this portion of the distal radius (Figures 3A-3F).29 In highly comminuted complete articular and palmar shear fracture patterns, the morphology of the sustentaculum lunatum should be appreciated, and its adequate fixation to the radial metaphysis ensured, to prevent loss of reduction.
Visualization of the palmar lunate facet as a distinct fragment might be difficult in cases of highly comminuted fracture patterns. Standard CT or more recently described 3-D CT techniques with subtraction of the carpus might facilitate appreciation of this fragment for preoperative planning of approach and fixation.29,30 Our institutional protocol involves obtaining preoperative traction radiographs of every fracture of the distal radius. These radiographs have reduced the need for CT in understanding the fracture pattern and aid in decision making.31
Besides appreciating the existence of the sustentaculum lunatum fragment, we should recognize that some injury patterns that split the lunate facet into unstable dorsal and palmar fragments might necessitate a separate dorsal approach to reduce and fix the dorsal lunate fragment. Traction radiographs can be especially useful in recognizing these patterns (a V sign is present) (Figures 4A, 4B).
Open Fractures
Highly comminuted fractures of the distal radius presenting with displaced lunate facet fragments can have high-energy mechanisms of injury. Although open fractures of the distal radius are associated with lower risk for infection (compared with open fractures of other long bones), they deserve special attention because of associated tendon and neurovascular injuries. Few studies have specifically assessed open fractures of the distal radius.32-35 Only the study by Rozental and Blazar34 listed associated injuries at the wrist level. The authors identified 4 patients (out of 18) with concomitant flexor tendon or neurovascular injuries that included radial or ulnar artery injury. In our experience, many open fractures of the distal radius are caused by an inside-out mechanism and present with an open wound either over the ulnar styloid or in the area of the ulnar side of the palmar radial metaphysis corresponding to the metaphyseal spike that mates with the sustentaculum lunatum (Figures 5A, 5B). Given these findings, we approach this intermediate column with particular care in cases of open fracture, paying attention to important structures (flexors, neurovascular) and looking for contamination from the environment into the fracture.
Fixation Techniques
The approach to fixation of partial articular palmar shear fractures is fairly straightforward. Buttress plate fixation has been well described and has had reliably good results.36 However, in very distal fracture patterns and in cases in which the palmar lunate facet is fragmented as part of a complete articular fracture, a fragment-specific approach to fixation with or without spanning external fixation often is necessary.37 The unrecognized sustentaculum lunatum fragment in comminuted complete articular fractures can lead to inadequate fixation constructs, resulting in loss of reduction and carpal subluxation in a palmar direction.24,34,38
Our surgical approach uses the standard anterior interval between the radial artery and the flexor carpi radialis, as described by Henry.39 The flexor pollicis longus is retracted ulnarly, revealing the pronator quadratus. We then reflect the pronator quadratus from the distal radial metaphysis until the most proximal and ulnar extent of the fracture is easily visualized. The palmar ulnar metaphyseal cortex that mates with the displaced sustentaculum lunatum is, in our experience, often the least comminuted portion of the metaphysis, thus providing a cortical key for restoration of height and alignment (Figures 5A, 5B). At our institution, fixation typically is achieved by contouring miniplates (1.3 or 1.5 mm) to capture and buttress the sustentaculum lunatum (Figures 6A, 6B). In our experience, the screw lengths in the most distal fixed-angle constructs at the palmar lip are limited to 6 mm or less to avoid penetration of the articular surface, though this has not been previously reported in the literature. After restoring the length and tilt of this intermediate column of the distal radius, we proceed with “rebuilding” the remainder of the fragments to our stabilized initial construct.
Various authors40-43 have described alternative fixation methods for the palmar lunate facet fragment. Jupiter and Marent-Huber42 described 2.4-mm locked-plate fixation with either a standard palmar plate or T- or L-plates for cases in which the palmar lip fragment is very distal and small. In fact, some newer anatomical distal radius implants include features designed to target these fragments (Figures 7A, 7B). An alternative fixation method involves use of a 26-gauge stainless steel wire passed through drill holes in the metaphysis 1 cm proximal to the fracture and then passed through the palmar capsule just distal to the fragment and secured in figure-8 fashion while the fragment is manually held reduced.41 Still others have recommended limited internal fixation of the sustentaculum lunatum through an ulna-sided palmar approach to the distal radius (between the ulnar neurovascular bundle and the flexor tendons) combined with external fixation to restore length and palmar tilt in highly comminuted fractures.40,43
A method involving arthroscopically assisted reduction and fixation of the lunate facet has also been described, though this procedure is technically demanding and has limited indications.44 It uses a Freer elevator passed through the standard 3-4 portal after initial visualization and evacuation of hematoma. The Freer elevator is used to disimpact the sustentaculum lunatum and to elevate it from its depressed position. With the dorsal lunate facet left displaced to facilitate access to the palmar fragment, a nerve hook retractor is used to reduce the palmar facet to the radial styloid, and Kirschner wires are used to achieve interfragmentary fixation. The dorsal lunate fragment is then pieced back to the articular segment, and the entire construct is fixed to the radial metaphysis with additional Kirschner wires.
Discussion
Given the increasing incidence of fractures of the distal radius, internal fixation of these injuries will continue to be relevant. American Academy of Orthopaedic Surgeons guidelines recommend operative fixation for fractures with postreduction radial shortening of more than 3 mm, dorsal tilt of more than 10°, or intra-articular displacement or step-off of more than 2 mm.45 Dr. Eglseder and Dr. Pensy indicate operative treatment of any incongruity of more than 2 mm in a young, active adult with a fracture of the distal radius. For the multifragmentary distal radius being treated operatively, attempts are made to achieve reduction more accurate than this, but formal dorsal exposure or direct visualization of the joint surface via dorsal capsulotomy is carefully chosen based on age, activity level, and bone quality. Recent high-level evidence46 showed that closed treatment of unstable fractures of the distal radius results in good outcomes in the elderly. However, it is important to note that fractures displaced in a palmar direction and palmar shear patterns were excluded from that work. It is widely accepted that palmar carpal translation should be addressed with internal fixation, and specific attention must therefore be paid to the lunate facet as the cornerstone of the distal radius. Furthermore, high-energy comminuted fractures in young patients still necessitate internal fixation of fragments to restore alignment and articular congruity.
Conclusion
The importance of the palmar lunate facet in providing support and restraint to palmar carpal translation and the key role of this facet in restoring the anatomy of the distal radius have been known. This fragment deserves special attention because failure to adequately stabilize it results in loss of fixation and carpal subluxation. Various approaches and fixation techniques have been recommended, including the method we prefer and have described here. Our newly proposed term, sustentaculum lunatum, our review of its structure and function, and our descriptions of fixation techniques are intended to promote awareness of this fragment in the treatment of fractures of the distal radius.
Fracture of the distal radius is the wrist injury most often encountered by orthopedic and hand surgeons.1 The number of fractures of the distal radius in the United States was estimated to be 640,000 in 2001, and the incidence is increasing.2,3 Recent evidence has shown a substantial increase in treating these fractures with internal rather than closed fixation, even in the elderly.4
Treatment of complex intra-articular fractures of the distal radius requires an accurate diagnosis of the fracture pattern and a thoughtful approach to fixation. Although a majority of the fractures that meet the operative criteria are now treated with various anterior locked-plating techniques with good results, a subset requires more technically demanding fixation approaches, including fragment-specific approaches, dorsal and palmar plating, and combined internal and external fixation.
The sustentaculum lunatum, as we have named the palmar lunate facet, deserves specific attention because of its importance in load transmission across the radiocarpal joint and its key role in restoring the anatomy of the palmar distal radial metaphysis during internal fixation. This fragment in comminuted fractures was first ascribed special importance by Melone5 in his description of common fracture patterns. In the present article, we describe the anatomical characteristics of the sustentaculum lunatum and the clinical relevance of this fragment to management of fractures of the distal radius.
Classification
A variety of classification systems have been proposed to characterize and guide treatment of fractures of the distal radius. The earliest descriptions of fracture patterns were presented by Castaing6 and Frykman7 in the 1960s. The Frykman classification historically has been popular but is limited in accuracy in its characterization of fragments and their displacement and is limited in its ability to guide treatment. The classification system proposed by Melone and colleagues5,8-10 was the first to truly describe fracture of the distal radius fragments in a relevant manner, including their characteristic “4 parts” (Figure 1). The authors emphasized the importance of the “medial complex” as the cornerstone of the radiocarpal and radioulnar joints.
The classification system developed by Müller and colleagues,11 which was adopted by the AO (Arbeitsgemeinschaft für Osteosynthesefragen), might be the most descriptive and informative system, and it is widely used to conduct research and direct treatment. This system classifies fractures into A (extra-articular), B (partial articular), and C (complete articular) types and subclassifies them according to fracture location and comminution. These classifications, along with a conceptualization of the distal forearm as a 3-column structure involving the radial, ulnar, and intermediate columns (including the lunate facet), as proposed by Peine and colleagues,12 gave us a framework for approaching fixation of fractures of the distal radius.
Etymology and Definition
Sustentaculum, from the Latin sustinere, “to support, check, or put off,” and taculum, “receptacle or holding space,” is a fitting description of the most distal portion of the palmar lunate facet, as it supports and holds the carpus, and specifically the lunate, on the radial articular surface. This portion is analogous to the sustentaculum tali, the named portion of the calcaneus that supports and articulates with the middle calcaneal articular surface of the talus13 and provides a reliable fragment for internal fixation of the calcaneus.
Anatomical and Biomechanical Considerations
The distal radial articular surface is composed of distinct scaphoid and lunate facets that articulate with their respective carpal bones. Several studies have characterized the anatomy of the distal radius.14-17 Linscheid14 found that the lunate and scaphoid facets account for 46% and 43% of the contact area across the radiocarpal joint, respectively; this has been corroborated by others.15 A biomechanical study by Genda and Horii18 showed that the majority of stress across the wrist joint was concentrated at the palmar side of the distal radius in the neutral position. Although it is recognized that the scaphoid facet bears most of the load across the wrist in the neutral wrist position, most activities of daily living place the wrist in a slightly extended and ulnarly deviated position. This position results in a shift of the majority of load to the radiolunar articulation, constituting 53% of total force transmission.18 Subchondral bone density analyses have supported this lunate-predominant loading pattern across the radiocarpal articulation in most people.19 This loading pattern is also supported by the observation that failure of fixation and carpal subluxation generally occurs at the radiolunate articulation.
The palmar lip of the distal radius traditionally has been depicted and conceptualized as a flat extension of the metaphysis, leading to the development of implants that are not ideally designed for capturing this area in the fracture setting. A 3-dimensional (3-D) computed tomography (CT) study of the distal radii of healthy volunteers, conducted by Andermahr and colleagues,20 showed that the contour of the palmar lunate facet projects from the palmar cortex of the radius by 3 mm on average and is about 19 mm in width (radial to ulnar dimension) (Figures 2A-2C). In the axial plane, the anterior cortex of the distal radius slopes in a palmar direction, from radial to ulnar. This presents a challenge in attempts to support the entire surface (scaphoid and lunate facets) with a single palmar implant.20-25
A study conducted by Harness and colleagues24 showed that the majority of palmar shear fractures are composed of multiple fragments of the lunar articular facet. Anatomical studies of the distal radiocarpal articulation have also described the ligamentous attachments to the sustentaculum lunatum.26 The short radiolunate ligament, which originates from this fragment and inserts onto the lunate, provides stability to the carpus and, if not adequately fixed, leads to an incompetent restraint to palmar carpal translation. Isolated injuries of the short radiolunate ligament or fractures of the palmar lunate facet have been shown to result in palmar carpal translation.27,28 In addition, attachments of the palmar radioulnar ligament and other more ulnar radiocarpal ligaments act as deforming forces on the palmar lunate facet.24,26
Fracture Pattern Recognition
Although the AO type B palmar shear fracture pattern, also known as the Barton fracture, has classically been recognized as the fracture involving the palmar lunate facet and requiring special attention, many complete articular fractures feature involvement and fragmentation of this portion of the distal radius (Figures 3A-3F).29 In highly comminuted complete articular and palmar shear fracture patterns, the morphology of the sustentaculum lunatum should be appreciated, and its adequate fixation to the radial metaphysis ensured, to prevent loss of reduction.
Visualization of the palmar lunate facet as a distinct fragment might be difficult in cases of highly comminuted fracture patterns. Standard CT or more recently described 3-D CT techniques with subtraction of the carpus might facilitate appreciation of this fragment for preoperative planning of approach and fixation.29,30 Our institutional protocol involves obtaining preoperative traction radiographs of every fracture of the distal radius. These radiographs have reduced the need for CT in understanding the fracture pattern and aid in decision making.31
Besides appreciating the existence of the sustentaculum lunatum fragment, we should recognize that some injury patterns that split the lunate facet into unstable dorsal and palmar fragments might necessitate a separate dorsal approach to reduce and fix the dorsal lunate fragment. Traction radiographs can be especially useful in recognizing these patterns (a V sign is present) (Figures 4A, 4B).
Open Fractures
Highly comminuted fractures of the distal radius presenting with displaced lunate facet fragments can have high-energy mechanisms of injury. Although open fractures of the distal radius are associated with lower risk for infection (compared with open fractures of other long bones), they deserve special attention because of associated tendon and neurovascular injuries. Few studies have specifically assessed open fractures of the distal radius.32-35 Only the study by Rozental and Blazar34 listed associated injuries at the wrist level. The authors identified 4 patients (out of 18) with concomitant flexor tendon or neurovascular injuries that included radial or ulnar artery injury. In our experience, many open fractures of the distal radius are caused by an inside-out mechanism and present with an open wound either over the ulnar styloid or in the area of the ulnar side of the palmar radial metaphysis corresponding to the metaphyseal spike that mates with the sustentaculum lunatum (Figures 5A, 5B). Given these findings, we approach this intermediate column with particular care in cases of open fracture, paying attention to important structures (flexors, neurovascular) and looking for contamination from the environment into the fracture.
Fixation Techniques
The approach to fixation of partial articular palmar shear fractures is fairly straightforward. Buttress plate fixation has been well described and has had reliably good results.36 However, in very distal fracture patterns and in cases in which the palmar lunate facet is fragmented as part of a complete articular fracture, a fragment-specific approach to fixation with or without spanning external fixation often is necessary.37 The unrecognized sustentaculum lunatum fragment in comminuted complete articular fractures can lead to inadequate fixation constructs, resulting in loss of reduction and carpal subluxation in a palmar direction.24,34,38
Our surgical approach uses the standard anterior interval between the radial artery and the flexor carpi radialis, as described by Henry.39 The flexor pollicis longus is retracted ulnarly, revealing the pronator quadratus. We then reflect the pronator quadratus from the distal radial metaphysis until the most proximal and ulnar extent of the fracture is easily visualized. The palmar ulnar metaphyseal cortex that mates with the displaced sustentaculum lunatum is, in our experience, often the least comminuted portion of the metaphysis, thus providing a cortical key for restoration of height and alignment (Figures 5A, 5B). At our institution, fixation typically is achieved by contouring miniplates (1.3 or 1.5 mm) to capture and buttress the sustentaculum lunatum (Figures 6A, 6B). In our experience, the screw lengths in the most distal fixed-angle constructs at the palmar lip are limited to 6 mm or less to avoid penetration of the articular surface, though this has not been previously reported in the literature. After restoring the length and tilt of this intermediate column of the distal radius, we proceed with “rebuilding” the remainder of the fragments to our stabilized initial construct.
Various authors40-43 have described alternative fixation methods for the palmar lunate facet fragment. Jupiter and Marent-Huber42 described 2.4-mm locked-plate fixation with either a standard palmar plate or T- or L-plates for cases in which the palmar lip fragment is very distal and small. In fact, some newer anatomical distal radius implants include features designed to target these fragments (Figures 7A, 7B). An alternative fixation method involves use of a 26-gauge stainless steel wire passed through drill holes in the metaphysis 1 cm proximal to the fracture and then passed through the palmar capsule just distal to the fragment and secured in figure-8 fashion while the fragment is manually held reduced.41 Still others have recommended limited internal fixation of the sustentaculum lunatum through an ulna-sided palmar approach to the distal radius (between the ulnar neurovascular bundle and the flexor tendons) combined with external fixation to restore length and palmar tilt in highly comminuted fractures.40,43
A method involving arthroscopically assisted reduction and fixation of the lunate facet has also been described, though this procedure is technically demanding and has limited indications.44 It uses a Freer elevator passed through the standard 3-4 portal after initial visualization and evacuation of hematoma. The Freer elevator is used to disimpact the sustentaculum lunatum and to elevate it from its depressed position. With the dorsal lunate facet left displaced to facilitate access to the palmar fragment, a nerve hook retractor is used to reduce the palmar facet to the radial styloid, and Kirschner wires are used to achieve interfragmentary fixation. The dorsal lunate fragment is then pieced back to the articular segment, and the entire construct is fixed to the radial metaphysis with additional Kirschner wires.
Discussion
Given the increasing incidence of fractures of the distal radius, internal fixation of these injuries will continue to be relevant. American Academy of Orthopaedic Surgeons guidelines recommend operative fixation for fractures with postreduction radial shortening of more than 3 mm, dorsal tilt of more than 10°, or intra-articular displacement or step-off of more than 2 mm.45 Dr. Eglseder and Dr. Pensy indicate operative treatment of any incongruity of more than 2 mm in a young, active adult with a fracture of the distal radius. For the multifragmentary distal radius being treated operatively, attempts are made to achieve reduction more accurate than this, but formal dorsal exposure or direct visualization of the joint surface via dorsal capsulotomy is carefully chosen based on age, activity level, and bone quality. Recent high-level evidence46 showed that closed treatment of unstable fractures of the distal radius results in good outcomes in the elderly. However, it is important to note that fractures displaced in a palmar direction and palmar shear patterns were excluded from that work. It is widely accepted that palmar carpal translation should be addressed with internal fixation, and specific attention must therefore be paid to the lunate facet as the cornerstone of the distal radius. Furthermore, high-energy comminuted fractures in young patients still necessitate internal fixation of fragments to restore alignment and articular congruity.
Conclusion
The importance of the palmar lunate facet in providing support and restraint to palmar carpal translation and the key role of this facet in restoring the anatomy of the distal radius have been known. This fragment deserves special attention because failure to adequately stabilize it results in loss of fixation and carpal subluxation. Various approaches and fixation techniques have been recommended, including the method we prefer and have described here. Our newly proposed term, sustentaculum lunatum, our review of its structure and function, and our descriptions of fixation techniques are intended to promote awareness of this fragment in the treatment of fractures of the distal radius.
1. Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg Am. 1991;73(3):461-469.
2. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908-915.
3. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113-125.
4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868-1873.
5. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15(2):217-236.
6. Castaing J. Recent fractures of the lower extremity of the radius in adults [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1964;50:581-696.
7. Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967;(suppl 108):3+.
8. Isani A, Melone CP Jr. Classification and management of intra-articular fractures of the distal radius. Hand Clin. 1988;4(3):349-360.
9. Melone CP Jr. Distal radius fractures: patterns of articular fragmentation. Orthop Clin North Am. 1993;24(2):239-253.
10. Rettig ME, Dassa GL, Raskin KB, Melone CP Jr. Wrist fractures in the athlete: distal radius and carpal fractures. Clin Sports Med. 1998;17(3):469-489.
11. Müller ME, Koch P, Nazarian S, Schatzker J. The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag; 1990.
12. Peine R, Rikli DA, Hoffmann R, Duda G, Regazzoni P. Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study. J Hand Surg Am. 2000;25(1):29-33.
13. Williams PL, Warwick R, Dyson M, Bannister LH, eds. Gray’s Anatomy. 37th ed. New York, NY: Churchill Livingstone; 1989.
14. Linscheid RL. Kinematic considerations of the wrist. Clin Orthop Relat Res. 1986;(202):27-39.
15. Mekhail AO, Ebraheim NA, McCreath WA, Jackson WT, Yeasting RA. Anatomic and x-ray film studies of the distal articular surface of the radius. J Hand Surg Am. 1996;21(4):567-573.
16. Schuind FA, Linscheid RL, An KN, Chao EY. A normal data base of posteroanterior roentgenographic measurements of the wrist. J Bone Joint Surg Am. 1992;74(9):1418-1429.
17. Schuind F, Alemzadeh S, Stallenberg B, Burny F. Does the normal contralateral wrist provide the best reference for x-ray film measurements of the pathologic wrist? J Hand Surg Am. 1996;21(1):24-30.
18. Genda E, Horii E. Theoretical stress analysis in wrist joint: neutral position and functional position. J Hand Surg Br. 2000;25(3):292-295.
19. Giunta R, Löwer N, Wilhelm K, Keirse R, Rock C, Müller-Gerbl M. Altered patterns of subchondral bone mineralization in Kienböck’s disease. J Hand Surg Br. 1997;22(1):16-20.
20. Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg Am. 2006;31(6):892-895.
21. Bo WJ, Meschan I, Krueger WA. Basic Atlas of Cross-Sectional Anatomy. Philadelphia, PA: Saunders; 1980.
22. Cahill DR, Orland MJ, Miller GM. Atlas of Human Cross-Sectional Anatomy: With CT and MR Images. 3rd ed. New York, NY: Wiley; 1995.
23. El-Khoury GY, Bergman RA, Montgomery WJ. Sectional Anatomy by MRI. 2nd ed. New York, NY: Churchill Livingstone; 1995.
24. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86(9):1900-1908.
25. Lewis OJ, Hamshere RJ, Bucknill TM. The anatomy of the wrist joint. J Anat. 1970;106(Pt 3):539-552.
26. Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am. 1990;15(6):847-854.
27. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the ulno-palmar distal radial fragment. J Hand Surg Br. 2002;27(2):139-145.
28. Chang EY, Chen KC, Meunier MJ, Chung CB. Acute short radiolunate ligament rupture in a rock climber. Skeletal Radiol. 2014;43(2):235-238.
29. Souer JS, Wiggers J, Ring D. Quantitative 3-dimensional computed tomography measurement of volar shearing fractures of the distal radius. J Hand Surg Am. 2011;36(4):599-603.
30. Pruitt DL, Gilula LA, Manske PR, Vannier MW. Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg Am. 1994(5);19:720-727.
31. Goldwyn E, Pensy R, O’Toole RV, et al. Do traction radiographs of distal radial fractures influence fracture characterization and treatment? J Bone Joint Surg Am. 2012;94(22):2055-2062.
32. Glueck DA, Charoglu CP, Lawton JN. Factors associated with infection following open distal radius fractures. Hand. 2009;4(3):330-334.
33. Kurylo JC, Axelrad TW, Tornetta P 3rd, Jawa A. Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures. J Hand Surg Am. 2011;36(7):1131-1134.
34. Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am. 2006;31(3):359-365.
35. Rozental TD, Beredjiklian PK, Steinberg DR, Bozentka DJ. Open fractures of the distal radius. J Hand Surg Am. 2002;27(1):77-85.
36. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005;13(3):159-171.
37. Bae DS, Koris MJ. Fragment-specific internal fixation of distal radius fractures. Hand Clin. 2005;21(3):355-362.
38. Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures. J Am Acad Orthop Surg. 2009;17(6):369-377.
39. Henry AK. Extensile Exposure. 2nd ed. New York, NY: Churchill Livingstone; 1973.
40. Axelrod T, Paley D, Green J, McMurtry RY. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. J Hand Surg Am. 1988;13(3):372-377.
41. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg Am. 1999;24(3):525-533.
42. Jupiter JB, Marent-Huber M; LCP Study Group. Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series. Surgical technique. J Bone Joint Surg Am. 2010;92(suppl 1, pt 1):96-106.
43. Ruch DS, Yang C, Smith BP. Results of palmar plating of the lunate facet combined with external fixation for the treatment of high-energy compression fractures of the distal radius. J Orthop Trauma. 2004;18(1):28-33.
44. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10(3):139-144.
45. American Academy of Orthopaedic Surgeons. The Treatment of Distal Radius Fractures: Guideline and Evidence Report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009. http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed August 4, 2015.
46. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146-2153.
1. Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg Am. 1991;73(3):461-469.
2. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908-915.
3. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113-125.
4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868-1873.
5. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15(2):217-236.
6. Castaing J. Recent fractures of the lower extremity of the radius in adults [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1964;50:581-696.
7. Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967;(suppl 108):3+.
8. Isani A, Melone CP Jr. Classification and management of intra-articular fractures of the distal radius. Hand Clin. 1988;4(3):349-360.
9. Melone CP Jr. Distal radius fractures: patterns of articular fragmentation. Orthop Clin North Am. 1993;24(2):239-253.
10. Rettig ME, Dassa GL, Raskin KB, Melone CP Jr. Wrist fractures in the athlete: distal radius and carpal fractures. Clin Sports Med. 1998;17(3):469-489.
11. Müller ME, Koch P, Nazarian S, Schatzker J. The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag; 1990.
12. Peine R, Rikli DA, Hoffmann R, Duda G, Regazzoni P. Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study. J Hand Surg Am. 2000;25(1):29-33.
13. Williams PL, Warwick R, Dyson M, Bannister LH, eds. Gray’s Anatomy. 37th ed. New York, NY: Churchill Livingstone; 1989.
14. Linscheid RL. Kinematic considerations of the wrist. Clin Orthop Relat Res. 1986;(202):27-39.
15. Mekhail AO, Ebraheim NA, McCreath WA, Jackson WT, Yeasting RA. Anatomic and x-ray film studies of the distal articular surface of the radius. J Hand Surg Am. 1996;21(4):567-573.
16. Schuind FA, Linscheid RL, An KN, Chao EY. A normal data base of posteroanterior roentgenographic measurements of the wrist. J Bone Joint Surg Am. 1992;74(9):1418-1429.
17. Schuind F, Alemzadeh S, Stallenberg B, Burny F. Does the normal contralateral wrist provide the best reference for x-ray film measurements of the pathologic wrist? J Hand Surg Am. 1996;21(1):24-30.
18. Genda E, Horii E. Theoretical stress analysis in wrist joint: neutral position and functional position. J Hand Surg Br. 2000;25(3):292-295.
19. Giunta R, Löwer N, Wilhelm K, Keirse R, Rock C, Müller-Gerbl M. Altered patterns of subchondral bone mineralization in Kienböck’s disease. J Hand Surg Br. 1997;22(1):16-20.
20. Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg Am. 2006;31(6):892-895.
21. Bo WJ, Meschan I, Krueger WA. Basic Atlas of Cross-Sectional Anatomy. Philadelphia, PA: Saunders; 1980.
22. Cahill DR, Orland MJ, Miller GM. Atlas of Human Cross-Sectional Anatomy: With CT and MR Images. 3rd ed. New York, NY: Wiley; 1995.
23. El-Khoury GY, Bergman RA, Montgomery WJ. Sectional Anatomy by MRI. 2nd ed. New York, NY: Churchill Livingstone; 1995.
24. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86(9):1900-1908.
25. Lewis OJ, Hamshere RJ, Bucknill TM. The anatomy of the wrist joint. J Anat. 1970;106(Pt 3):539-552.
26. Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am. 1990;15(6):847-854.
27. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the ulno-palmar distal radial fragment. J Hand Surg Br. 2002;27(2):139-145.
28. Chang EY, Chen KC, Meunier MJ, Chung CB. Acute short radiolunate ligament rupture in a rock climber. Skeletal Radiol. 2014;43(2):235-238.
29. Souer JS, Wiggers J, Ring D. Quantitative 3-dimensional computed tomography measurement of volar shearing fractures of the distal radius. J Hand Surg Am. 2011;36(4):599-603.
30. Pruitt DL, Gilula LA, Manske PR, Vannier MW. Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg Am. 1994(5);19:720-727.
31. Goldwyn E, Pensy R, O’Toole RV, et al. Do traction radiographs of distal radial fractures influence fracture characterization and treatment? J Bone Joint Surg Am. 2012;94(22):2055-2062.
32. Glueck DA, Charoglu CP, Lawton JN. Factors associated with infection following open distal radius fractures. Hand. 2009;4(3):330-334.
33. Kurylo JC, Axelrad TW, Tornetta P 3rd, Jawa A. Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures. J Hand Surg Am. 2011;36(7):1131-1134.
34. Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am. 2006;31(3):359-365.
35. Rozental TD, Beredjiklian PK, Steinberg DR, Bozentka DJ. Open fractures of the distal radius. J Hand Surg Am. 2002;27(1):77-85.
36. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005;13(3):159-171.
37. Bae DS, Koris MJ. Fragment-specific internal fixation of distal radius fractures. Hand Clin. 2005;21(3):355-362.
38. Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures. J Am Acad Orthop Surg. 2009;17(6):369-377.
39. Henry AK. Extensile Exposure. 2nd ed. New York, NY: Churchill Livingstone; 1973.
40. Axelrod T, Paley D, Green J, McMurtry RY. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. J Hand Surg Am. 1988;13(3):372-377.
41. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg Am. 1999;24(3):525-533.
42. Jupiter JB, Marent-Huber M; LCP Study Group. Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series. Surgical technique. J Bone Joint Surg Am. 2010;92(suppl 1, pt 1):96-106.
43. Ruch DS, Yang C, Smith BP. Results of palmar plating of the lunate facet combined with external fixation for the treatment of high-energy compression fractures of the distal radius. J Orthop Trauma. 2004;18(1):28-33.
44. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10(3):139-144.
45. American Academy of Orthopaedic Surgeons. The Treatment of Distal Radius Fractures: Guideline and Evidence Report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009. http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed August 4, 2015.
46. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146-2153.
Perilunate Injuries
Perilunate injuries typically stem from a high-energy insult to the carpus. Because of their relative infrequency and often subtle radiographic and physical examination findings, these injuries are often undetected in the emergency department setting.1 Early anatomic reduction of any carpal malalignment is essential. Even with optimal treatment, complications such as generalized wrist stiffness, diminished grip strength, and posttraumatic arthritis, commonly develop; however, recent studies suggest these issues are often well tolerated.1-5 In this article, the diagnosis, treatment, and outcomes after perilunate injuries are examined.
History and Physical Examination
Perilunate injuries result from high-energy trauma to the carpus. Patients with these injuries often present with vague wrist pain and loss of wrist motion. Their fingers are frequently held in slight flexion. The patient may complain of numbness and tingling in the median nerve distribution. An acute carpal tunnel syndrome can rapidly develop. The general belief is that acute carpal tunnel syndrome occurs more commonly in pure volar lunate dislocations than in dorsal perilunate dislocations. However, no studies compare the incidence of acute carpal tunnel syndrome in lunate versus perilunate dislocations.
Radiographic Evaluation
Standard radiographic evaluation of a potential perilunate injury includes posteroanterior (PA), lateral, and oblique views of the wrist (Figure 1). A scaphoid view (ie, PA view with the wrist in ulnar deviation) may also be helpful. The PA view is particularly helpful because it enables assessment of Gilula lines, which are imaginary lines drawn across the proximal and distal aspects of the proximal carpal row and the proximal aspect of the distal carpal row. These lines should appear as 3 smooth arcs running nearly parallel to each other.6 Any disruption in these lines suggests carpal incongruity. It may be possible to note a triangular-shaped lunate on the PA view, which is a sign of lunate dislocation.7
While the PA view is certainly useful, the lateral view is the most important in diagnosing a perilunate injury. The lateral view allows assessment of the collinearity of radius, lunate, and capitate. Any disruption in this collinearity strongly suggests a perilunate dislocation.7,8
Classification
Mayfield and colleagues9,10 described 4 stages of perilunate instability proceeding from a radial to an ulnar direction around the lunate. Stage I involves disruption of the scapholunate joint, while stage II involves both the scapholunate and capitolunate joints. In stage III, the scapholunate, capitolunate, and lunotriquetral ligaments are disrupted, and the result is a perilunate dislocation, usually dorsal. Finally, in stage IV, all the ligaments surrounding the lunate are disrupted and the lunate dislocates, most often volarly.
Lastly, perilunate injuries can be classified as greater-arc injuries if concomitant fracture of the carpus occurs, lesser-arc injuries if the injury is purely ligamentous, or inferior-arc injuries if there is an associated fracture of the volar rim of the distal radius.8
Treatment
Closed Reduction
All acute perilunate dislocations should be managed initially with an attempted closed reduction.11 If the injury is older than 72 hours, such an attempt may be futile. For any closed reduction performed in the emergency department setting, intravenous sedation is generally advised for muscle relaxation. Gentle traction with finger traps can also be used prior to the reduction attempt. For a dorsal perilunate dislocation, longitudinal traction followed by volar flexion of the wrist with volar pressure on the lunate and dorsal pressure on the capitate (ie, Tavernier’s maneuver) is required. Once reduction is complete, PA and lateral views of the wrist should be obtained to assess carpal alignment. If closed reduction is unsuccessful, an open reduction is required, although the timing of said procedure is an area of debate, which we will discuss later.1,3 Restoration of anatomic carpal alignment is essential to optimizing outcome, although it does not guarantee a good overall result.
Open Reduction
If successful closed reduction is achieved, the patient can be immobilized temporarily in a short-arm plaster splint. However, open reduction and either pinning or internal fixation will be required to maintain this alignment. The exact timing of open reduction and fixation is debatable and often dictated by the absence or presence of median nerve symptoms.1,3 If a patient with no median nerve symptoms undergoes a successful closed reduction, he or she may be stabilized surgically within 3 to 5 days (or longer) with either pins or headless screws. If closed reduction is unsuccessful, an open reduction should be done within 2 to 3 days. However, if the patient has progressive numbness in the median nerve distribution upon presentation that fails to improve or worsens despite a successful closed reduction, an urgent open reduction (within 24 hours) and carpal tunnel release should be performed to prevent permanent damage to the median nerve.
Once open reduction is undertaken, a dorsal, volar, and combined approach can be used.2-4 In most cases the dorsal approach is selected first. A longitudinal incision is made over the dorsum of the wrist, centered on the Lister tubercle. Dissection occurs between the third and fourth dorsal compartments. After the capsule is exposed, reduction of the lunate to the capitate is confirmed. If any fractures are present in the carpus (eg, scaphoid), they are internally fixed. The scapholunate articulation is then addressed. In general, the scapholunate ligament is not disrupted with a transscaphoid perilunate dislocation. However, if the scapholunate ligament is disrupted, the joint should be reduced and pinned. Repair or reconstruction of the scapholunate ligament is performed. Finally, the lunotriquetral articulation is reduced and stabilized with pins. There are no studies that specifically suggest direct repair of the lunotriquetral ligament versus pinning of the lunotriquetral articulation, but the lunotriquetral ligament could be repaired in similar fashion to the scapholunate ligament at the surgeon’s discretion.
As an alternative to percutaneous pinning, intercarpal screw fixation can be used to stabilize the carpus. A 2007 study by Souer and colleagues12 showed no substantial difference in outcome between the 2 methods of fixation. However, a second procedure is required to remove the screws.
The volar approach, if selected, is typically done second and performed via an extended carpal tunnel incision. It allows decompression of the carpal tunnel and enables repair of volar capsular ligaments (ie, long and short radiolunate ligaments, volar scapholunate ligament, and volar lunotriquetral ligament), which increases overall carpal stability. Currently, many surgeons favor a combined dorsal-volar approach for its efficacy.2,3 Some use a dorsal approach in all patients and perform a volar procedure only if the patient has median nerve symptoms.4 However, Başar and colleagues13 report use of only the volar approach for treatment of perilunate injuries. The authors repaired the long and short radiolunate ligaments, volar scapholunate ligament, and volar lunotriquetral ligament. They reported reasonably good outcomes, which are equivalent to those reported in similar studies using dorsal or combined dorsal-volar approaches. However, no studies in the literature directly compare any of the different approaches with each other.
Postoperatively, patients are placed in a long-arm thumb-spica cast for 4 weeks, and then in a short-arm cast for 4 to 8 weeks (Figure 2). If present, pins are removed in 3 to 12 weeks, with most authors recommending removal at 8 weeks.2,14
Lastly, carpal tunnel symptoms can develop late and even after a successful reduction and surgical stabilization. One theory is that a significant perilunate injury can create slightly higher baseline carpal tunnel pressures, which can compromise the blood flow to the median nerve and cause carpal tunnel symptoms. Additionally, it is possible that direct median nerve contusion and/or traction injury via a displaced lunate can also cause these symptoms. Whatever the inciting cause of median-nerve irritation, a delayed carpal tunnel release is sometimes required.
Conclusion
Outcomes after either perilunate or lunate dislocation are fair to good at best but can be optimized with prompt, appropriate treatment. Closed reduction and casting as definitive treatment has been abandoned because of frequent loss of reduction.12 Early open reduction (ie, less than 3 days after injury) has been shown to be beneficial.1,2 However, even those treated early and with anatomic restoration of carpal alignment can expect a loss of grip strength and a range of motion of approximately 70% compared with the contralateral side.2-5 A recent study has suggested that lesser-arc injures generally have a poorer overall outcome than their greater-arc counterparts.15
More than half of all patients with perilunate injuries will develop radiographic signs of osteoarthritis, and some will require additional salvage procedures.3-5 Kremer and colleagues4 showed that overall results after perilunate injuries deteriorate with time. However, according to a paper by Forli and colleagues5 in which patients were followed a minimum of 10 years after their injuries, the authors found that, despite radiographic progression of arthritis, most patients maintained reasonable hand function.
1. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):768-779.
2. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22(1):49-56.
3. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg Am. 2000;25(6):1069-1079.
4. Kremer T, Wendt M, Riedel K, Sauerbier M, Germann G, Bickert B. Open reduction for perilunate injuries--clinical outcome and patient satisfaction. J Hand Surg Am. 2010;35(10):1599-1606.
5. Forli A, Courvoisier A, Wimsey S, Corcella D, Moutet F. Perilunate dislocations and transscaphoid perilunate fracture-dislocations: a retrospective study with minimum ten-year follow-up. J Hand Surg Am. 2010;35(1):62-68.
6. Gilula LA. Carpal injuries: analytic approach and case exercises. AJR Am J Roentgenol. 1979;133(3):503-517.
7. Kozin SH. Perilunate injuries: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6(2):114-120.
8. Graham TJ. The inferior arc injury: an addition to the family of complex carpal fracture-dislocation patterns. Am J Orthop. 2003;32(9 suppl):10-19.
9. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3):226-241.
10. Mayfield JK. Mechanism of carpal injuries. Clin Orthop Relat Res. 1980;149:45-54.
11. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res. 1982;164:199-207.
12. Souer JS, Rutgers M, Andermahr J, Jupiter JB, Ring D. Perilunate fracture-dislocations of the wrist: comparison of temporary screw versus K-wire fixation. J Hand Surg Am. 2007;32(3):318-325.
13. Başar H, Başar B, Erol B, Tetik C. Isolated volar surgical approach for the treatment of perilunate and lunate dislocations. Indian J Orthop. 2014;48(3):301-315.
14. Komurcu M, Kürklü M, Ozturan KE, Mahirogullari M, Basbozkurt M. Early and delayed treatment of dorsal transscaphoid perilunate fracture-dislocations. J Orthop Trauma. 2008;22:535-540.
15. Massoud AH, Naam NH. Functional outcome of open reduction of chronic perilunate injuries. J Hand Surg Am. 2012;37(9):1852-1860.
Perilunate injuries typically stem from a high-energy insult to the carpus. Because of their relative infrequency and often subtle radiographic and physical examination findings, these injuries are often undetected in the emergency department setting.1 Early anatomic reduction of any carpal malalignment is essential. Even with optimal treatment, complications such as generalized wrist stiffness, diminished grip strength, and posttraumatic arthritis, commonly develop; however, recent studies suggest these issues are often well tolerated.1-5 In this article, the diagnosis, treatment, and outcomes after perilunate injuries are examined.
History and Physical Examination
Perilunate injuries result from high-energy trauma to the carpus. Patients with these injuries often present with vague wrist pain and loss of wrist motion. Their fingers are frequently held in slight flexion. The patient may complain of numbness and tingling in the median nerve distribution. An acute carpal tunnel syndrome can rapidly develop. The general belief is that acute carpal tunnel syndrome occurs more commonly in pure volar lunate dislocations than in dorsal perilunate dislocations. However, no studies compare the incidence of acute carpal tunnel syndrome in lunate versus perilunate dislocations.
Radiographic Evaluation
Standard radiographic evaluation of a potential perilunate injury includes posteroanterior (PA), lateral, and oblique views of the wrist (Figure 1). A scaphoid view (ie, PA view with the wrist in ulnar deviation) may also be helpful. The PA view is particularly helpful because it enables assessment of Gilula lines, which are imaginary lines drawn across the proximal and distal aspects of the proximal carpal row and the proximal aspect of the distal carpal row. These lines should appear as 3 smooth arcs running nearly parallel to each other.6 Any disruption in these lines suggests carpal incongruity. It may be possible to note a triangular-shaped lunate on the PA view, which is a sign of lunate dislocation.7
While the PA view is certainly useful, the lateral view is the most important in diagnosing a perilunate injury. The lateral view allows assessment of the collinearity of radius, lunate, and capitate. Any disruption in this collinearity strongly suggests a perilunate dislocation.7,8
Classification
Mayfield and colleagues9,10 described 4 stages of perilunate instability proceeding from a radial to an ulnar direction around the lunate. Stage I involves disruption of the scapholunate joint, while stage II involves both the scapholunate and capitolunate joints. In stage III, the scapholunate, capitolunate, and lunotriquetral ligaments are disrupted, and the result is a perilunate dislocation, usually dorsal. Finally, in stage IV, all the ligaments surrounding the lunate are disrupted and the lunate dislocates, most often volarly.
Lastly, perilunate injuries can be classified as greater-arc injuries if concomitant fracture of the carpus occurs, lesser-arc injuries if the injury is purely ligamentous, or inferior-arc injuries if there is an associated fracture of the volar rim of the distal radius.8
Treatment
Closed Reduction
All acute perilunate dislocations should be managed initially with an attempted closed reduction.11 If the injury is older than 72 hours, such an attempt may be futile. For any closed reduction performed in the emergency department setting, intravenous sedation is generally advised for muscle relaxation. Gentle traction with finger traps can also be used prior to the reduction attempt. For a dorsal perilunate dislocation, longitudinal traction followed by volar flexion of the wrist with volar pressure on the lunate and dorsal pressure on the capitate (ie, Tavernier’s maneuver) is required. Once reduction is complete, PA and lateral views of the wrist should be obtained to assess carpal alignment. If closed reduction is unsuccessful, an open reduction is required, although the timing of said procedure is an area of debate, which we will discuss later.1,3 Restoration of anatomic carpal alignment is essential to optimizing outcome, although it does not guarantee a good overall result.
Open Reduction
If successful closed reduction is achieved, the patient can be immobilized temporarily in a short-arm plaster splint. However, open reduction and either pinning or internal fixation will be required to maintain this alignment. The exact timing of open reduction and fixation is debatable and often dictated by the absence or presence of median nerve symptoms.1,3 If a patient with no median nerve symptoms undergoes a successful closed reduction, he or she may be stabilized surgically within 3 to 5 days (or longer) with either pins or headless screws. If closed reduction is unsuccessful, an open reduction should be done within 2 to 3 days. However, if the patient has progressive numbness in the median nerve distribution upon presentation that fails to improve or worsens despite a successful closed reduction, an urgent open reduction (within 24 hours) and carpal tunnel release should be performed to prevent permanent damage to the median nerve.
Once open reduction is undertaken, a dorsal, volar, and combined approach can be used.2-4 In most cases the dorsal approach is selected first. A longitudinal incision is made over the dorsum of the wrist, centered on the Lister tubercle. Dissection occurs between the third and fourth dorsal compartments. After the capsule is exposed, reduction of the lunate to the capitate is confirmed. If any fractures are present in the carpus (eg, scaphoid), they are internally fixed. The scapholunate articulation is then addressed. In general, the scapholunate ligament is not disrupted with a transscaphoid perilunate dislocation. However, if the scapholunate ligament is disrupted, the joint should be reduced and pinned. Repair or reconstruction of the scapholunate ligament is performed. Finally, the lunotriquetral articulation is reduced and stabilized with pins. There are no studies that specifically suggest direct repair of the lunotriquetral ligament versus pinning of the lunotriquetral articulation, but the lunotriquetral ligament could be repaired in similar fashion to the scapholunate ligament at the surgeon’s discretion.
As an alternative to percutaneous pinning, intercarpal screw fixation can be used to stabilize the carpus. A 2007 study by Souer and colleagues12 showed no substantial difference in outcome between the 2 methods of fixation. However, a second procedure is required to remove the screws.
The volar approach, if selected, is typically done second and performed via an extended carpal tunnel incision. It allows decompression of the carpal tunnel and enables repair of volar capsular ligaments (ie, long and short radiolunate ligaments, volar scapholunate ligament, and volar lunotriquetral ligament), which increases overall carpal stability. Currently, many surgeons favor a combined dorsal-volar approach for its efficacy.2,3 Some use a dorsal approach in all patients and perform a volar procedure only if the patient has median nerve symptoms.4 However, Başar and colleagues13 report use of only the volar approach for treatment of perilunate injuries. The authors repaired the long and short radiolunate ligaments, volar scapholunate ligament, and volar lunotriquetral ligament. They reported reasonably good outcomes, which are equivalent to those reported in similar studies using dorsal or combined dorsal-volar approaches. However, no studies in the literature directly compare any of the different approaches with each other.
Postoperatively, patients are placed in a long-arm thumb-spica cast for 4 weeks, and then in a short-arm cast for 4 to 8 weeks (Figure 2). If present, pins are removed in 3 to 12 weeks, with most authors recommending removal at 8 weeks.2,14
Lastly, carpal tunnel symptoms can develop late and even after a successful reduction and surgical stabilization. One theory is that a significant perilunate injury can create slightly higher baseline carpal tunnel pressures, which can compromise the blood flow to the median nerve and cause carpal tunnel symptoms. Additionally, it is possible that direct median nerve contusion and/or traction injury via a displaced lunate can also cause these symptoms. Whatever the inciting cause of median-nerve irritation, a delayed carpal tunnel release is sometimes required.
Conclusion
Outcomes after either perilunate or lunate dislocation are fair to good at best but can be optimized with prompt, appropriate treatment. Closed reduction and casting as definitive treatment has been abandoned because of frequent loss of reduction.12 Early open reduction (ie, less than 3 days after injury) has been shown to be beneficial.1,2 However, even those treated early and with anatomic restoration of carpal alignment can expect a loss of grip strength and a range of motion of approximately 70% compared with the contralateral side.2-5 A recent study has suggested that lesser-arc injures generally have a poorer overall outcome than their greater-arc counterparts.15
More than half of all patients with perilunate injuries will develop radiographic signs of osteoarthritis, and some will require additional salvage procedures.3-5 Kremer and colleagues4 showed that overall results after perilunate injuries deteriorate with time. However, according to a paper by Forli and colleagues5 in which patients were followed a minimum of 10 years after their injuries, the authors found that, despite radiographic progression of arthritis, most patients maintained reasonable hand function.
Perilunate injuries typically stem from a high-energy insult to the carpus. Because of their relative infrequency and often subtle radiographic and physical examination findings, these injuries are often undetected in the emergency department setting.1 Early anatomic reduction of any carpal malalignment is essential. Even with optimal treatment, complications such as generalized wrist stiffness, diminished grip strength, and posttraumatic arthritis, commonly develop; however, recent studies suggest these issues are often well tolerated.1-5 In this article, the diagnosis, treatment, and outcomes after perilunate injuries are examined.
History and Physical Examination
Perilunate injuries result from high-energy trauma to the carpus. Patients with these injuries often present with vague wrist pain and loss of wrist motion. Their fingers are frequently held in slight flexion. The patient may complain of numbness and tingling in the median nerve distribution. An acute carpal tunnel syndrome can rapidly develop. The general belief is that acute carpal tunnel syndrome occurs more commonly in pure volar lunate dislocations than in dorsal perilunate dislocations. However, no studies compare the incidence of acute carpal tunnel syndrome in lunate versus perilunate dislocations.
Radiographic Evaluation
Standard radiographic evaluation of a potential perilunate injury includes posteroanterior (PA), lateral, and oblique views of the wrist (Figure 1). A scaphoid view (ie, PA view with the wrist in ulnar deviation) may also be helpful. The PA view is particularly helpful because it enables assessment of Gilula lines, which are imaginary lines drawn across the proximal and distal aspects of the proximal carpal row and the proximal aspect of the distal carpal row. These lines should appear as 3 smooth arcs running nearly parallel to each other.6 Any disruption in these lines suggests carpal incongruity. It may be possible to note a triangular-shaped lunate on the PA view, which is a sign of lunate dislocation.7
While the PA view is certainly useful, the lateral view is the most important in diagnosing a perilunate injury. The lateral view allows assessment of the collinearity of radius, lunate, and capitate. Any disruption in this collinearity strongly suggests a perilunate dislocation.7,8
Classification
Mayfield and colleagues9,10 described 4 stages of perilunate instability proceeding from a radial to an ulnar direction around the lunate. Stage I involves disruption of the scapholunate joint, while stage II involves both the scapholunate and capitolunate joints. In stage III, the scapholunate, capitolunate, and lunotriquetral ligaments are disrupted, and the result is a perilunate dislocation, usually dorsal. Finally, in stage IV, all the ligaments surrounding the lunate are disrupted and the lunate dislocates, most often volarly.
Lastly, perilunate injuries can be classified as greater-arc injuries if concomitant fracture of the carpus occurs, lesser-arc injuries if the injury is purely ligamentous, or inferior-arc injuries if there is an associated fracture of the volar rim of the distal radius.8
Treatment
Closed Reduction
All acute perilunate dislocations should be managed initially with an attempted closed reduction.11 If the injury is older than 72 hours, such an attempt may be futile. For any closed reduction performed in the emergency department setting, intravenous sedation is generally advised for muscle relaxation. Gentle traction with finger traps can also be used prior to the reduction attempt. For a dorsal perilunate dislocation, longitudinal traction followed by volar flexion of the wrist with volar pressure on the lunate and dorsal pressure on the capitate (ie, Tavernier’s maneuver) is required. Once reduction is complete, PA and lateral views of the wrist should be obtained to assess carpal alignment. If closed reduction is unsuccessful, an open reduction is required, although the timing of said procedure is an area of debate, which we will discuss later.1,3 Restoration of anatomic carpal alignment is essential to optimizing outcome, although it does not guarantee a good overall result.
Open Reduction
If successful closed reduction is achieved, the patient can be immobilized temporarily in a short-arm plaster splint. However, open reduction and either pinning or internal fixation will be required to maintain this alignment. The exact timing of open reduction and fixation is debatable and often dictated by the absence or presence of median nerve symptoms.1,3 If a patient with no median nerve symptoms undergoes a successful closed reduction, he or she may be stabilized surgically within 3 to 5 days (or longer) with either pins or headless screws. If closed reduction is unsuccessful, an open reduction should be done within 2 to 3 days. However, if the patient has progressive numbness in the median nerve distribution upon presentation that fails to improve or worsens despite a successful closed reduction, an urgent open reduction (within 24 hours) and carpal tunnel release should be performed to prevent permanent damage to the median nerve.
Once open reduction is undertaken, a dorsal, volar, and combined approach can be used.2-4 In most cases the dorsal approach is selected first. A longitudinal incision is made over the dorsum of the wrist, centered on the Lister tubercle. Dissection occurs between the third and fourth dorsal compartments. After the capsule is exposed, reduction of the lunate to the capitate is confirmed. If any fractures are present in the carpus (eg, scaphoid), they are internally fixed. The scapholunate articulation is then addressed. In general, the scapholunate ligament is not disrupted with a transscaphoid perilunate dislocation. However, if the scapholunate ligament is disrupted, the joint should be reduced and pinned. Repair or reconstruction of the scapholunate ligament is performed. Finally, the lunotriquetral articulation is reduced and stabilized with pins. There are no studies that specifically suggest direct repair of the lunotriquetral ligament versus pinning of the lunotriquetral articulation, but the lunotriquetral ligament could be repaired in similar fashion to the scapholunate ligament at the surgeon’s discretion.
As an alternative to percutaneous pinning, intercarpal screw fixation can be used to stabilize the carpus. A 2007 study by Souer and colleagues12 showed no substantial difference in outcome between the 2 methods of fixation. However, a second procedure is required to remove the screws.
The volar approach, if selected, is typically done second and performed via an extended carpal tunnel incision. It allows decompression of the carpal tunnel and enables repair of volar capsular ligaments (ie, long and short radiolunate ligaments, volar scapholunate ligament, and volar lunotriquetral ligament), which increases overall carpal stability. Currently, many surgeons favor a combined dorsal-volar approach for its efficacy.2,3 Some use a dorsal approach in all patients and perform a volar procedure only if the patient has median nerve symptoms.4 However, Başar and colleagues13 report use of only the volar approach for treatment of perilunate injuries. The authors repaired the long and short radiolunate ligaments, volar scapholunate ligament, and volar lunotriquetral ligament. They reported reasonably good outcomes, which are equivalent to those reported in similar studies using dorsal or combined dorsal-volar approaches. However, no studies in the literature directly compare any of the different approaches with each other.
Postoperatively, patients are placed in a long-arm thumb-spica cast for 4 weeks, and then in a short-arm cast for 4 to 8 weeks (Figure 2). If present, pins are removed in 3 to 12 weeks, with most authors recommending removal at 8 weeks.2,14
Lastly, carpal tunnel symptoms can develop late and even after a successful reduction and surgical stabilization. One theory is that a significant perilunate injury can create slightly higher baseline carpal tunnel pressures, which can compromise the blood flow to the median nerve and cause carpal tunnel symptoms. Additionally, it is possible that direct median nerve contusion and/or traction injury via a displaced lunate can also cause these symptoms. Whatever the inciting cause of median-nerve irritation, a delayed carpal tunnel release is sometimes required.
Conclusion
Outcomes after either perilunate or lunate dislocation are fair to good at best but can be optimized with prompt, appropriate treatment. Closed reduction and casting as definitive treatment has been abandoned because of frequent loss of reduction.12 Early open reduction (ie, less than 3 days after injury) has been shown to be beneficial.1,2 However, even those treated early and with anatomic restoration of carpal alignment can expect a loss of grip strength and a range of motion of approximately 70% compared with the contralateral side.2-5 A recent study has suggested that lesser-arc injures generally have a poorer overall outcome than their greater-arc counterparts.15
More than half of all patients with perilunate injuries will develop radiographic signs of osteoarthritis, and some will require additional salvage procedures.3-5 Kremer and colleagues4 showed that overall results after perilunate injuries deteriorate with time. However, according to a paper by Forli and colleagues5 in which patients were followed a minimum of 10 years after their injuries, the authors found that, despite radiographic progression of arthritis, most patients maintained reasonable hand function.
1. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):768-779.
2. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22(1):49-56.
3. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg Am. 2000;25(6):1069-1079.
4. Kremer T, Wendt M, Riedel K, Sauerbier M, Germann G, Bickert B. Open reduction for perilunate injuries--clinical outcome and patient satisfaction. J Hand Surg Am. 2010;35(10):1599-1606.
5. Forli A, Courvoisier A, Wimsey S, Corcella D, Moutet F. Perilunate dislocations and transscaphoid perilunate fracture-dislocations: a retrospective study with minimum ten-year follow-up. J Hand Surg Am. 2010;35(1):62-68.
6. Gilula LA. Carpal injuries: analytic approach and case exercises. AJR Am J Roentgenol. 1979;133(3):503-517.
7. Kozin SH. Perilunate injuries: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6(2):114-120.
8. Graham TJ. The inferior arc injury: an addition to the family of complex carpal fracture-dislocation patterns. Am J Orthop. 2003;32(9 suppl):10-19.
9. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3):226-241.
10. Mayfield JK. Mechanism of carpal injuries. Clin Orthop Relat Res. 1980;149:45-54.
11. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res. 1982;164:199-207.
12. Souer JS, Rutgers M, Andermahr J, Jupiter JB, Ring D. Perilunate fracture-dislocations of the wrist: comparison of temporary screw versus K-wire fixation. J Hand Surg Am. 2007;32(3):318-325.
13. Başar H, Başar B, Erol B, Tetik C. Isolated volar surgical approach for the treatment of perilunate and lunate dislocations. Indian J Orthop. 2014;48(3):301-315.
14. Komurcu M, Kürklü M, Ozturan KE, Mahirogullari M, Basbozkurt M. Early and delayed treatment of dorsal transscaphoid perilunate fracture-dislocations. J Orthop Trauma. 2008;22:535-540.
15. Massoud AH, Naam NH. Functional outcome of open reduction of chronic perilunate injuries. J Hand Surg Am. 2012;37(9):1852-1860.
1. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):768-779.
2. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22(1):49-56.
3. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg Am. 2000;25(6):1069-1079.
4. Kremer T, Wendt M, Riedel K, Sauerbier M, Germann G, Bickert B. Open reduction for perilunate injuries--clinical outcome and patient satisfaction. J Hand Surg Am. 2010;35(10):1599-1606.
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