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Decompression with fusion versus decompression alone in patients with

lumbar spinal stenosis with degenerative spondylolisthesis: A Systematic
Review and Meta-analysis

Article in European Spine Journal · January 2023

DOI: 10.1007/s00586-022-07507-1

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European Spine Journal
https://doi.org/10.1007/s00586-022-07507-1

REVIEW ARTICLE

Decompression alone versus decompression with fusion in patients

with lumbar spinal stenosis with degenerative spondylolisthesis:
a systematic review and meta‑analysis
Pravesh Shankar Gadjradj1 · Mark Basilious1 · Jacob L. Goldberg1 · Fabian Sommer1 · Rodrigo Navarro‑Ramirez1 ·
Catherine Mykolajtchuk1 · Amanda Z. Ng1 · Branden Medary1 · Ibrahim Hussain1 · Roger Härtl1

Received: 21 June 2022 / Revised: 13 November 2022 / Accepted: 15 December 2022

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Introduction Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with sympto-
matic lumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on
this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature.
Methods Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs)
and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal
stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary
outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated
and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up.
Results Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies
had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All
patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no differ-
ence in functionality at two years of follow-up (MD − 0.31, 95% CI − 3.81 to 3.19). Furthermore, there was high-quality evi-
dence of no difference in leg pain (MD − 1.79, 95% CI − 5.08 to 1.50) or back pain (MD − 2.54, 95% CI − 6.76 to 1.67) between
patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after
decompression only, shorter length of hospital stay, and a similar reoperation rate compared to decompression with fusion.
Conclusion Based on the current literature, there is high-quality evidence of no difference in functionality after decompres-
sion alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2 years of
follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying
those patients that may benefit more from decompression with fusion instead of decompression alone. This review was
registered at Prospero (CRD42021291603).

Keywords Lumbar spinal stenosis · Spondylolisthesis · Review · Meta-analysis

Abbreviations MD Mean difference

RCT​ Randomized controlled trial OR Odds ratio
D + F Decompression and fusion CI Confidence interval
PRO Patient-reported outcome
VAS Visual analogue scale
ODI Oswestry disability index Introduction
MRI Magnetic resonance imaging
Degenerative spondylolisthesis (DS) is defined as slip-
page of a vertebral body over the vertebral body below
* Pravesh Shankar Gadjradj due to degenerative changes of the spine. DS can present
p.gadjradj@erasmusmc.nl with spinal stenosis and consequently neurogenic clau-
1
Department of Neurological Surgery, Brain and Spine dication and low back pain. Risk factors for DS include
Center, Weill Cornell, New York, NY, USA age > 70 years, female gender, and sedentary lifestyle [1].

13
Vol.:(0123456789)

Patients with DS are typically evaluated with a physical
and neurologic exam, and imaging including standing
radiographs and MRI. Initial management of symptomatic
DS consists of conservative treatment, including oral pain
medication, injections, and physical therapy.
In patients with progressive neurologic symptoms, dis-
ability, or diminished quality of life, surgical intervention
for DS and associated spinal stenosis is indicated. Previous
research demonstrated that patients undergoing surgery
had substantially greater improvement of pain and func-
tion compared to patients that were treated without surgery
during two years of follow-up [2].
Over the last few decades, instrumented fusion of ver-
tebral bodies in addition to decompression of the spinal
canal has become increasingly more common as the stand-
ard surgical treatment for lumbar DS. In some countries,
90% of decompression surgeries will include concomitant
fusion [3]. The necessity of fusion procedures in addition
to decompression (D + F) in treating DS was the focus
of two randomized controlled trials (RCTs) published
in 2016 [4, 5]. Due to somewhat conflicting results, the
controversy remained [6–8]. Since then, multiple studies
may have been published on this subject which may help
to find consensus on this dilemma [9–12]. Therefore, by
the means of this systematic review and meta-analysis we
aimed to assess if decompression and fusion has better
clinical outcomes (e.g., functionality) than decompression
alone in patients with DS and associated lumbar spinal
stenosis.
Methods
This review follows the Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses (PRISMA) (supple-
mentary material 4) [13, 14]. This study was registered in
the international prospective register of systematic reviews
(Prospero CRD42021291603).
Inclusion criteria for studies
Studies were considered for this review according to the fol-
lowing inclusion criteria: (1) prospective studies, including
RCTs, quasi-randomized studies and non-randomized stud-
ies; (2) patient population older than 18 years of age; (3)
patients undergoing decompression or decompression with
fusion for lumbar spinal stenosis due to DS; (4) measured
one of the clinical outcomes (i.e., functionality, leg pain,
back pain, walking improvement) or radiological outcomes
at least at 1 year of follow-up; (5) were published in English.
Excluded were non-original studies, conference abstracts,
13
European Spine Journal
studies conducting retrospective analyses and studies con-
cerning non-instrumented fusion techniques.
Interventions
Posterior decompression
Posterior decompression could be performed according
to surgeons’ preference. Recent research showed no dif-
ference in clinical outcomes between various posterior
decompression techniques used for decompression in
patients with lumbar spinal stenosis [15].
Fusion
Any form of posterior decompression would be accepted,
before or after the fusion procedure (as long as it is per-
formed in the same surgical session). Fusion should
include posterior instrumented fusion according to sur-
geons’ preference. Selection of grafts, devices or addi-
tional instrumentation was per surgeon preference.
Search strategy
An experienced librarian conducted a systematic search
using a combination of terms related to DS, fusion and
decompression techniques. All databases were searched
for from inception. The search is available in Supplemen-
tary Table 1. On the 12th of November 2021, MEDLINE,
Embase, EmCare, Web of Science and the Cochrane
library were systematically searched for eligible articles.
In addition, additional eligible articles were searched for
by reference checking the included studies. All available
records were screened by two reviewers independently
based on title and/or abstract (P.G. and M.B.). In case
of disagreements, a third independent reviewer was con-
sulted. Following this step, two authors (P.G. and M.B.)
independently screened the full-text of the manuscripts
based on the inclusion criteria. Disagreements were
resolved through consensus with the involvement of a
third reviewer.
Data collection and analysis
Two authors (P.G. and M.B.) independently extracted
all data in a pre-specified spreadsheet. Discrepancies in
extraction were resolved by consensus. Extracted were (1)
study characteristics (e.g., study design, inclusion crite-
ria); (2) clinical outcomes (e.g., Oswestry disability index
(ODI), visual analogue scale (VAS) for leg and back pain,
European Spine Journal
walking improvement, Short-Form-36 Physical Compo-
nent Summary (SF-36 PCS); (3) surgical outcomes (e.g.,
operative time, blood loss, length of hospital stay, reopera-
tions and complications; and (4) postoperative radiological
outcomes.
Assessment of risk of bias
Risk of bias analysis was performed for all (quasi)RCTs
using the criteria recommended by the Cochrane Col-
laboration [16]. These criteria cover: selection bias, per-
formance bias, attrition bias, detection bias and selective
outcome reporting bias. Two authors (P.G. and M.B.) inde-
pendently scored these criteria as: low risk of bias, high
risk of bias, or unclear. Disagreements were resolved by
consensus and if necessary, by evaluation of a third author.
Risk of bias was not formally assessed for non-randomized
studies as the evidence level of these studies, compared to
the RCTs, were expected to be low.
Bias across studies
Conflict of interest was determined for all included stud-
ies based upon the information provided by the authors
in their publication. Publication bias was assessed using
a funnel plot and based upon symmetry; no formal tests
were conducted because there were too few data to reli-
ably test this.
Data analyses
Measures of treatment effect
Only data from RCTs were considered for the meta-analy-
sis. The primary outcome was the continuous outcome the
ODI measuring functional status. Continuous outcomes
were expressed as mean difference (MD), including 95%
confidence intervals (CI). A negative effect size indicates
that decompression is more beneficial than D + F, meaning
patients have better functional status after decompression
only. Patient-reported outcomes were analyzed at two years
of follow-up. When multiple outcomes were available from
a single study, the value was used which was thought to be
best correlated to that time interval. In this specific case,
we used the latest time point of follow-up. Risk for reopera-
tions was calculated as an odds ratio (OR). A random-effects
model was used for all analyses based upon the DerSimo-
nian and Laird approach [17]. RevMan 5.4.1 (The Nordic
Cochrane Center, The Cochrane Collaboration, Denmark)
was used to perform the meta-analysis. Due to heterogeneity
of the complications that were reported, we only described
the reported complications per study.
Statistical heterogeneity
Statistical heterogeneity was examined by inspecting the
Forest plot and formally tested by the Q-test (chi-square)
and ­I2. We were not able to explore cases of considerable
heterogeneity (defined as an ­I2 statistic > 75%) by subgroup
analysis, because there was insufficient data to do so.
Data synthesis and quality of the evidence
We evaluated the overall quality of the evidence for the pri-
mary outcome, and the secondary outcomes, provided that at
least three studies evaluated these outcomes. The GRADE-
method was applied, which ranges from high to very low
quality and is based upon the following five domains: limi-
tations of design, inconsistency of results, indirectness,
imprecision, and other factors (e.g., publication bias) [18].
We downgraded for these determinants as follows: 1) limita-
tions of design if > 50% of the study population originated
from studies with a high or unclear risk of bias for alloca-
tion concealment. We focused on this specific aspect of the
risk of bias because there is empirical evidence from large
meta-epidemiological studies that selection bias results in
exaggerated effects [19]; 2) inconsistency if the ­I2 statistic
exceeded 75% or if only one study reported on the outcome;
3) indirectness if the included study population was thought
not to be generalizable to patients with DS; 4) imprecision
when there were < 400 patients for continuous outcomes
or < 300 events for dichotomous outcomes and 5) other
considerations when publication bias or conflict of interest
was apparent.
Results
Search results
The initial search in November 2021 retrieved 2403 studies.
After removing duplicates and screening based on the title
and abstract, 25 studies remained (Fig. 1). After assessing
full-text articles, 18 additional studies were removed (see
supplementary material 2). Of the remaining 7 studies avail-
able for the qualitative analysis, 5 were suitable for the quan-
titative analysis [4, 5, 9, 11, 20–22]. The search was rerun
on October the ­17th 2022, which did not lead to new studies
for inclusion.
Of the 7 included studies, 5 were RCTs and 2 were pro-
spective observational studies [4, 5, 9, 11, 20–22]. Table 1
gives an overview of these 7 included studies. Of the RCTs,
one was conducted during the 80s, while the others were
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 European Spine Journal

Fig. 1  Flowchart of the study

Identification of studies via databases
selection process

Identification
Records removed before
Records identified from*: screening:
Databases (n = 2403) Duplicate records removed
(n = 918)

Records screened Records excluded

(n = 1485) (n = 1460)

Reports sought for retrieval Reports not retrieved

(n = 25 ) (n = 0)
Screening

Reports excluded:
Reports assessed for eligibility Register study (n = 3)
(n = 25) Non-instrumented fusion (n = 4)
Retrospective design (n = 2)
Various pathology (n = 1)
Only lumbar spinal stenosis (n=5)
Decompression only (n=1)
Other (n=2)

Studies included in review

Included

(n = 7)
Reports of included studies
(n = 5)

conducted from the 2000s. Two RCTs were conducted in the
USA, two in European countries and one in Japan. Samples
sizes of the RCTs ranged from 33 to 267 patients, while
patients had an average age ranging from 62 to 67 across the
studies. One of the RCTs did not report specifically on the
degree of slip of the patients included [20]. Another RCT
only included grade I DS, while the other 3 RCTs included
patients with 3 mm of slip, or more. In two of the five RCTs,
flexion–extension radiographs were used to judge suitabil-
ity for randomization. Decompression and fusion techniques
used in the studies are reported in Table 1. In general, the
decompression techniques used were highly variable and
ranged from limited midline-structure preserving techniques,
to more aggressive decompressions. Fusion techniques used
usually concerned pedicle fixation with the use of autograft.
Risk of bias analysis
The results of the risk of bias analysis of RCTs are shown in
Fig. 2. Three studies had a low risk of selection bias due to
reporting of random sequence generation [4, 9, 11], while
two had a low risk of selection bias due to reporting on allo-
cation concealment. As blinding of patients and personnel
was not possible due to fundamental differences in operating
techniques between decompression and D + F, all studies had
a high risk of performance bias. As all RCTs had PROs and
the patient was not blinded, all studies had a high risk of
detection bias. Risk of attrition bias was low for four RCTs
and unknown for 1 RCT. Furthermore, two RCTs had a high
risk of reporting bias, while all RCTs were estimated to have
a low risk of other forms of bias. Publication bias was not
formally assessed given too few data.
Primary outcome
Oswestry disability index
Of the 7 included studies, three RCTs and two observational
studies reported on the ODI after decompression and D + F
at two years of follow-up (Table 2) [4, 5, 9, 21, 22]. All
three RCTs did not detect a statistically significant difference
between both treatment arms, while both observational stud-
ies found statistically significant more favorable results on
the ODI after D + F compared to decompression alone. Pool-
ing of the data of the three RCTs showed no difference in
ODI at two years of follow-up between both groups, namely

13
 Table 1  Overview of the included studies
Study design Study Study period Study location Sample size (D/ Average age Slip Decompression Fusion technique Outcomes
DF) technique

RCT​ Bridwell et al. 1985–1990 USA 33 (9/24)a 66 NR Decompression Pedicle fixation Radiological out-
1993 preserving bilat- with bone graft comes, subjective
eral facet joints walking distance
European Spine Journal

without diskec-
tomy or extensive
foraminotomy
Main inclusion criteria Degenerative spondylolisthesis Main exclusion Previous spine surgery
criteria Patients with pathologic motion on flex-
ion–extension films would automati-
cally receive fusion
b b
Försth et al. 2016 2006–2012 Sweden 134 (68/67) 67 ≥ 3 ­mm Determined solely Determined solely ODI, EQ-5D, back
by surgeon by surgeon and leg pain, ZCQ,
6MWT, surgical
outcomes, costs,
overall satisfaction,
global assessment,
radiology
Main inclusion criteria Symptoms > 6 months Main exclusion Spondylolysis
1 or 2 adjacent stenotic segments criteria Degenerative scoliosis
Flexion–extension radiographs were not obtained History of lumbar spinal surgery for
stenosis or instability
Stenosis caused by herniated disk
Ghogawala et al. 2002–2009 USA 66 (35/31) 67 Grade I 3–14 mm Complete laminec- Pedicle screws and SF-36 PCS, ODI,
2016 tomy with partial titanium alloy surgical outcomes,
removal of the rods with bone costs
medial facet joint graft
Main inclusion criteria Grade I DS Main exclusion Lumbar instability on flexion–extension
criteria radiographs
Judged by surgeon with lumbar instabil-
ity due to history of mechanical low
back pain
-ASA > IV
Inose et al. 2­ 018c 2003–2012 Japan 60 (29/31) 62 > 3 mm Decompression Posterolateral Back pain, JOA, leg
fusion with pedi- pain, radiological
cle screws and outcomes, surgical
autograft outcomes, SF-36
Main inclusion criteria Degenerative spondylolisthesis at L4-5 Main exclusion Previous lumbar spine surgery
criteria Multilevel or foraminal stenosis

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 Table 1  (continued)
Study design Study Study period Study location Sample size (D/ Average age Slip Decompression Fusion technique Outcomes
DF) technique

13
Austevoll et al. 2014–2017 Norway 267 (134/133) 66 ≥ 3 mm Decompression Pedicle screws ODI, ZCQ, leg pain,
2021 preserving mid- with rods and back pain, surgical
line structures vs. bone grafting outcomes
decompression with optional
with or without fusion device
preserving mid-
line structures
Main inclusion criteria Symptoms not responsive to ≥ 3 months conservative Main exclusion Foraminal stenosis of grade 3
treatment criteria Previous surgery or fracture thora-
Inclusion regardless of dynamic slippage on flexion– columbar
extension radiographs
Prospective Ghogawala et al. 2000–2002 USA 34 (20/14) 69 Grade I 3–14 mm Aggressive Pedicle screw ODI, SF-36, radio-
2004 facet-sparring fixation with logical outcomes
techniques autograft and/or
allograft
Kim et al. 2018 2009–2012 Korea 139 (74/65) 66 Grade I Partial facetec- Pedicle screws Surgical outcomes,
tomy, < 50% of with a titanium back pain, ODI
inferior articular cage and auto-
process, optional graft
foraminotomy,
sparing facet
joints
Cursive indicates the primary outcome measure
A Bridwell et al. consisted of three groups with one group of patients undergoing decompression and non-instrumented fusion. These patients were excluded from this review
B Försth et al. also included patients without degenerative spondylolisthesis. The original sample size was 247 (124/123). These patients were excluded for this review
C Inose et al. had a three-arm RCT with one arm of patients undergoing decompression plus stabilization. These patients were excluded from this review. Long-term follow-up data was published
separately in 2021
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European Spine Journal
Fig. 2  Risk of bias assessment for all included RCTs. A shows the risk of bias summary per study while (B) shows the risk of bias graph
a MD of − 0.31 with a 95% CI − 3.81 to 3.19 (Fig. 3A).
Study heterogeneity was low ­(I2 = 16%). Overall, there is
high-quality evidence of no difference in ODI between both
techniques at two years of follow-up (Table 3).
Secondary outcomes
Leg pain
Three studies reported VAS scores for leg pain at two years
of follow-up. All of these studies were RCTs and showed
no difference in leg pain between decompression and D + F.
Pooled results of these RCTs (Fig. 3B) also showed no dif-
ference in leg pain between both techniques (MD − 1.79,
95% CI − 5.08 to 1.50). Study heterogeneity was low
­(I2 = 0%). Overall, there is high-quality evidence of no dif-
ference in leg pain reduction between decompression and
D + F at two years of follow-up.
Back pain
Four studies reported VAS scores for back pain, three were
RCTs and one was an observational study [4, 9, 11, 21].
The three RCTs reported no difference in VAS for back pain
between both procedures, while the observational study
reported a statistically significant lower VAS for back pain
at two years of follow-up in after D + F (1.8 vs 4.5, N = 139)
[21]. Pooled results of the three RCTs (Fig. 3C) show a
MD of -2.54 with a 95% CI of − 6.76 to 1.67 with a low
study heterogeneity ­(I2 = 0%). Overall, there is high-quality
evidence of no difference in back pain between decompres-
sion and D + F at two years of follow-up.
SF‑36 Physical component summary
Only two studies reported outcomes of the SF-36 and specif-
ically the physical component summary [5, 22]. One of these
studies was an RCT and one an observational study, both
from the same lead author. Both studies showed statistically
significant more favorable outcomes for the D + F-group
(Table 2). Because only one RCT assessed the physical com-
ponent summary, no additional analyses could be conducted.
Improvement of walking
Two RCTs assessed walking capability after surgery [4,
20]. Bridwell et al. assessed walking improvement by ask-
ing patients whether they felt their ability to walk distances
was worse, the same or significantly better after surgery.
Three out of nine patients (33%) of the decompression group
versus twenty out of 24 patients of the D + F-group reported
significantly better walking [20]. Försth et al. assessed the
walking distance by a 6-min walk test and by a single ques-
tion. Walking distance at 2 years after surgery did not differ
significantly between patients undergoing decompression vs.
D + F (396 ± 144 m vs. 382 ± 152 m). Self-reported improve-
ment in walking distance, also did not differ significantly
between both groups (86% for decompression vs 88% for
D + F).
13
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Table 2  Outcomes of RCTs and of prospective observational studies. For clinical outcomes of RCTs values measured at two years of follow-up are shown with their standard deviations, when
reported. If not reported, one-year results are reported. + indicates the outcome is in favor of D + F,—indicates the outcome is in favor of D and ± indicates there is no difference between D + F
and D. Favors means a statistically significant difference was shown in individual studies. In case if differences were not tested, no symbol is shown. Scores for leg pain, back pain and functional
status are reported from 0 to 100 with 0 indicating no pain or disability. Pooled results are results which are reported by at least 3 RCTs in mean differences with their 95% confidence intervals.
NR not reported

Decompression Study ODI Leg pain Back pain Walking SF-36 Physical Blood loss Length of hos- Reoperations Costs
vs. fusion improved Component pital stay

RCT​ Bridwell et al. 33.3% vs 83.3% ± 0 vs 4.2%

1993 N = 33
Försth et al. ± 21 ± 18 vs ± 29 ± 31 vs ± 26 ± 25 vs ± 86% vs 88% + 311 ± 314 vs ± 4.1 ± 6.1 vs ± 22% vs 21%a + 5.4 k
2016 N = 134 25 ± 19 32 ± 30 25 ± 19 686 ± 434 7.4 ± 8.4 vs
12.2 kb
Ghogawala et al. ± 18.4 ± 13.5 vs − 43.5 ± 13.5 vs + 83.4 ± 64 vs + 2.6 ± 0.9 vs ± 34% vs 14%c NR
2016 N = 66 13.5 ± 12.7 46.2 ± 13.2 513 ± 334 4.2 ± 0.9
Inose et al. ± 21 ± 8.5 vs ± 15.8 ± 16.3 vs + 80 ± 63 vs + 11.6 ± 2.5 vs ± 0 vs 3.2%
2018 N = 60 22 ± 7.7d 20.4 ± 23.6 335 ± 206 14.1 ± 3.6
Austevoll et al. ± 18.6 ± 14.7 vs ± 28 ± 25 vs ± 33 ± 24 vs + 141 ± 134 vs + 3.3 ± 0.2 vs ± 12.5% vs
2021 N = 267 18.3 ± 14.8 31 ± 25 37 ± 24 429 ± 278 5.0 ± 0.2 9.1%
Pooled results Overall − 0.31 (− 3.81 − 1.79 (− 5.08 − 2.54 (− 6.67 − 320 (− 389 − 1.7 (− 1.8 to OR 1.4 (0.8 to
to 3.19) to 1.50) to 1.67) to − 252) − 1.7) 2.4)
Prospective Ghogawala et al. – – ±
2004 N = 34
Kim et al. – – + +
2018 N = 139

A Reoperation rate at 6.5 years of follow-up

B Direct costs in U.S. dollars. Indirect costs were similar in both D and D + F groups. These mean costs were calculated based on all 247 patients of the study of Försth et al
C Reoperation rate at 4 years of follow-up
D Inose et al. reported 1-year and 5-year outcomes. One-year outcomes are shown here
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European Spine Journal
Fig. 3  Pooled results of decompression alone versus decompression with fusion on the primary outcome the (A) Oswestry disability index, and
the secondary outcomes (B) leg pain and (C) back pain
Blood loss
Blood loss after both procedures was assessed in four
RCTs and one observational study [4, 5, 9, 11, 21]. All
studies show less blood loss after decompression alone
(Table 2). Pooled results show a MD of -320.41 with a
95% CI ranging from − 389.10 to − 251.73 (supplemen-
tary material 3A). Studies showed moderate heterogeneity
­(I2 = 59%). Overall, there is high-quality evidence of less
blood loss after decompression only compared to D + F
(Table 3).
Length of hospital stay
Length of hospital stay was assessed in five studies, of
which four were RCTs. All studies measured a shorter
hospitalization after decompression compared to D + F.
Pooled results showed a MD of -1.7 with 95% CI − 1.8
to − 1.7 (Supplementary material 3B). Heterogeneity
between studies was low (­ I 2 = 0%). Overall, there was
high-quality evidence of shorter length of hospital stay
between patients undergoing decompression versus D + F
(Table 3).
Reoperations
Reoperations were assessed in six studies of which five
were RCTs. All studies showed no statistically significant
differences in reoperation rates between both groups. Pooled
results (supplementary material 3C) showed an odds ratio
of 1.41 with a 95%CI from 0.84 to 2.36 for reoperations.
Study heterogeneity was low (­ I2 = 0%). Overall, there was
moderate quality evidence of no difference in reoperations
between both groups.
Costs
Costs were assessed by two RCTs, but only reported by one
study [4, 5]. Försth et al. reported higher direct costs for
patients undergoing D + F with a mean difference of $6,800.
Indirect costs were similar for both groups, making D + F on
average more costly.
Radiological outcomes
Radiological outcomes were assessed by two RCTs and one
observational study, but only reported by two studies [4, 20,
22]. Bridwell et al. performed regularly postoperative X-rays
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Table 3  Complications described in the RCTs and prospective observational studies

Study Sample size (D/DF) Total com- Complica- Description Complica- Description
plications N tions D N tions DF N
(%) (%) (%)

Bridwell et al. (1993) 33 (9/24) 3 (9.1%) 0 – 3 (12.5%) 1 (4.2%) wound infection

1 (4.2%) malposition screw
1 (4.2%) adjacent segment
disease
Ghogawala et al. 34 (20/14) 3 (8.8%) 1 (5%) 1 (5%) worsening radicu- 2 (14.2%) 1 (7.1%) pneumonia
(2004) lopathy 1 (7.1%) wound infection
Försth et al. (2016) 247 (124/123)a 49 (21.0%) 23 (19.2%) 13 (11%) dural tears 26 (23.0%) 12 (11%) dural tears
5 (4%) wound infections 11 (10%) wound infections
5 (4%) cardiovascular 3 (3%) cardiovascular
complications complications
Ghogawala et al. 66 (35/31) 3 (4.5%) 2 (5.7%) 1 (2.9%) new neurologic 1 (3.2%) 1 (3.2%) pneumonia
(2016) deficit
1 (2.9%) wound infection
Kim et al. (2018) 139 (74/65) 5 (3.6%) 2 (2.7%) 2 (2.7%) superficial 3 (4.6%) 1 (1.5%) dural tear
wound infections 2 (3.1%) superficial wound
infections
Inose et al. (2018) 60 (29/31) 9 (15.0%) 2 (6.8%) 1 (3.4%) hematoma 9 (29.0%) 2 (6.5%) dural tears
1 (3.4%) lumbar com- 5 (16.1%) meralgia
pression fracture 1 (3.2%) pulmonary
embolism
1 (3.2%) stroke
Austevoll et al. (2021) 267 (134/133) 100 (37.5%) 38 (28.4%) 7 (5.3%) dural tears 62 (46.6%) 17 (13.3%) dural tears
1 (0.8%) wrong side/level 1 (0.8%) wrong side/level
surgery surgery
1 (0.8%) reoperation due 1 (0.8%) reoperation due
hematoma hematoma
3 (2.3%) superficial 3 (2.4%) superficial wound
wound infections infections
4 (3.0%) cardiovascular 3 (2.4%) deep wound infec-
complications tions
6 (4.5%) urological com- 11 (8.5%) urological com-
plications plications
1 (0.8%) respiratory 2 (1.6%) respiratory com-
complication plication
15 (11.4%) neurologic 24 (18.8%) neurologic
deterioration deterioration
Overall 846 (425/421) 172 (20.3%) 68 (16.0%) 106 (25.2%)

A Försth et al. did not report complications for patients with or without DS separately, therefore the complications of all patients that either
underwent D or D + F with or without DS are reported

and showed statistically significant more slip progression in
patients undergoing decompression alone versus D + F [20].
Ghogawala et al. performed various measurements on CT
or MRI imaging to assess whether these were predictors for
clinical outcomes. Only one (negative) radiological predictor
was identified for the PCS in the decompression alone group,
namely disk space height.
of complications seem to be higher after D + F compared to
decompression alone (25.2% vs. 16.0%). Most frequently
reported complications were dural tears and neurologic
deterioration.
Discussion

Complications The current review aimed to determine whether decom-

pression with fusion would lead to any benefits in patient-
Table 4 gives an overview of the reported complica- reported outcomes compared to decompression alone in
tions between both groups. A total of 172 complications patients with low grade DS. Based on the inclusion of only
occurred over a sample size of 846 patients. Total number RCTs and prospective comparative studies, we were able

13
 European Spine Journal

Table 4  GRADE evidence summary of findings for the effect of Decompression vs. Decompression + Fusion
Quality assessment No. of patients Effect (95% CI) Quality of evi-
1 2 3 4 5 dence
No. of Design Limitations Inconsistency Indirectness Imprecision Other D D+F
stud-
ies

Functionality 3 RCT​ No serious limi- No serious No serious indi- No serious No serious con- 230 231 MD − 0.31 High
tations inconsistency rectness imprecision siderations (− 3.84 to
3.19)
Leg pain 3 RCT​ No serious limi- No serious No serious indi- No serious No serious con- 222 230 MD −1.79 High
tations inconsistency rectness imprecision siderations (− 5.08 to
1.50)
Back pain 3 RCT​ No serious limi- No serious No serious indi- No serious No serious con- 222 230 MD −2.54 High
tations inconsistency rectness imprecision siderations (− 6.76 to
1.67)
Blood loss 4 RCT​ No serious limi- No serious No serious indi- No serious No serious con- 262 258 MD −320 High
tations inconsistency rectness imprecision siderations (− 389 to
− 252)
Length of hospi- 4 RCT​ No serious limi- No serious No serious indi- No serious No serious con- 262 258 MD −1.70 High
tal stay tations inconsistency rectness imprecision siderations (− 1.75 to
− 1.65)
Reoperations 5 RCT​ No serious limi- No serious No serious indi- Serious impreci- No serious con- 261 274 OR 1.41 (0.84 to Moderate
tations inconsistency rectness sion siderations 2.36)

1 Quality of evidence is downgraded if > 50% of the study population origins of studies with a high or unclear risk of bias for allocation concealment
2 Quality of evidence is downgraded if the ­I2 statistic > 75% or if only one study reports on the outcome
3 Quality of evidence is downgraded if study results are not generalizable
4 Quality of evidence is downgraded if there are < 400 patients in the study sample for continuous outcomes or if there are less than 300 events in the study sample for dichotomous outcomes
5 Quality of evidence is downgraded if there are signs of publication bias or conflicts of interest

13

to provide high-quality evidence on outcomes as function-
ality, leg pain and back pain, which was previously not
possible due to conflicting evidence. The current review
shows no advantages of D + F in function, leg pain, back
pain, and reoperations, compared to decompression alone
in patients with low grade DS at two years. Furthermore,
decompression alone was associated with a less periop-
erative blood loss, a shorter length of hospital stay, and
lower costs.
Comparison with other studies
Multiple reviews have been published in previous years,
using different methodology [23, 24]. Some of these
included also retrospective studies or may not use the most
efficient methods to perform data synthesis. Because we
wanted to make more firm conclusions, we only included
prospective studies and also included the recently pub-
lished Norwegian study which had the highest weight for
the pooled results [9]. If we look at other studies, that were
excluded for this review, we can identify studies in favor for
decompression and fusion from the same Norwegian study
group as the recently published trial by Austevoll et al. [25],
but also studies from Europe and North America implying
non-inferiority of decompression alone compared to D + F
[26, 27]. These discrepancies in the literature further empha-
size the necessity of the current review.
Strengths and limitations
Based on the recent literature we were able to provide high-
quality evidence on a few patient-reported outcomes. There
are, however, some limitations that have to be acknowl-
edged. One is the heterogeneity in the surgical strategies and
postoperative treatment protocols. Examples of this is the
variability in decompression techniques or the differences
in duration of postoperative hospital stay in Asia compared
to Europe or the USA. This variability in surgical techniques
may be a confounder as there is some evidence that mini-
mally invasive surgery may be associated with lower reop-
eration and fusion rates, less slip progression and greater
patient satisfaction compared to open surgery [28, 29]. We
expect this to have a limited impact on our conclusion, espe-
cially as recent studies show no difference in clinical out-
comes after various decompression techniques for lumbar
spinal stenosis [15]. On the other hand, fusion techniques
have also improved throughout the years and the use of these
novel techniques may as well have led to improved outcomes
after decompression with fusion for DS. Another limita-
tion is that most studies had no long-term data available.
Therefore, we could only draw conclusion for two years of
follow-up on most outcomes, which is a common endpoint in
degenerative spine research. Finally, current study results
13
European Spine Journal
only are applicable to stable DS. Strengths of our study are
the prospective registration, the low statistical heterogeneity
between studies, and the quality of evidence provided.
Implications
Based on the outcomes of this review, there was high-quality
evidence regarding outcomes functionality, leg pain, back
pain and blood loss, meaning that further research would
be unlikely to change the conclusions. Therefore, based on
this data D + F should not be the only treatment option for
all patients with low grade spondylolisthesis and associated
spinal stenosis. However, as we only made conclusions on
clinical outcome data with two years of follow-up, long-
term clinical data is warranted to verify our conclusions at
five- or ten- year follow-up. Furthermore, studies performing
health economic evaluations from societal perspective are
warranted. Only one of the included studies compared costs.
Such studies should evaluate whether there are differences in
functionally or quality-adjusted life years between decom-
pression vs. decompression with fusion and if these differ-
ences would justify differences in costs between both proce-
dures. Finally, as the two U.S. studies included in our review
show, some patients do seem to benefit more from D + F than
from decompression alone. Identifying those patients, who
are more likely to benefit from concomitant fusion, should
also be the focus of further research. One study focusing on
patient selection, is currently underway [30].
Conclusion
Based on the current literature, there is high-quality evi-
dence of no difference in functionality after decompression
alone compared to decompression with fusion in low grade
DS at 2 years of follow-up. Decompression alone, was also
associated with no difference in leg pain reduction, back
pain reduction, and reoperations, but less perioperative
blood loss and a shorter length of hospital stay, compared
to decompression and fusion. Based on the current data,
decompression alone is non inferior to decompression with
fusion as a treatment option for low grade DS. Further stud-
ies should focus on long-term comparative outcomes, health
economic evaluations, and identifying those patients that
may benefit more from decompression with fusion instead
of decompression alone.
Supplementary Information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00586-0​ 22-0​ 7507-1.
Acknowledgements The authors would like to thank Jan W. Schoones
from the Walrus Library, Leiden University Medical Center for per-
forming the systematic search and Saffia Hosseinkheyl for her admin-
istrative help.
European Spine Journal
Funding Not applicable.
Declarations
Conflict of interest None.
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C OPYRIGHT Ó 2022 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Revisiting Cemented Femoral Fixation
in Hip Arthroplasty
Harpal S. Khanuja, MD, Kevin L. Mekkawy, DO, Aoife MacMahon, MD, Claire M. McDaniel, MD, Donald A. Allen, MD, and
Joseph T. Moskal, MD

Investigation performed at Johns Hopkins Bayview Medical Center, The Johns Hopkins University, Baltimore, Maryland,
and Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, Virginia

ä The primary means of femoral fixation in North America is cementless, and its use is increasing worldwide, despite
registry data and recent studies showing a higher risk of periprosthetic fracture and early revision in elderly
patients managed with such fixation than in those who have cemented femoral fixation.

ä Cemented femoral stems have excellent long-term outcomes and a continued role, particularly in elderly patients.

ä Contrary to historical concerns, recent studies have not shown an increased risk of death with cemented femoral fixation.

ä The choice of femoral fixation method should be determined by the patient’s age, comorbidities, and bone quality.

ä We recommend considering cemented femoral fixation in patients who are >70 years old (particularly women), in
those with Dorr type-C bone or a history of osteoporosis or fragility fractures, or when intraoperative broach stability
cannot be obtained.

Cementless femoral fixation, in both total hip arthroplasty (THA)
and hemiarthroplasty, has increased dramatically in North America
during the past 2 decades and continues to grow worldwide1.
Despite the excellent long-term clinical outcomes of cemented
femoral fixation, >94% of THAs in the 2020 American Joint
Replacement Registry (AJRR) Annual Report were cementless2.
This percentage contrasts dramatically with other international
registries. This shift to cementless femoral fixation is multifactorial
but began in the 1980s to address aseptic loosening inaccurately
attributed to cement3. Initially pursued as biologic fixation that was
more durable for younger, active patients, who had excellent results,
and because of concerns about adverse intraoperative effects of
cement, cementless fixation has become the choice of fixation in
the U.S. The efficiency of cementless femoral fixation, requiring less
operative time and fewer supplies, has added to its popularity4,5.
Less exposure to cemented techniques during training and thus
decreasing staff comfort with the technique have also likely con-
tributed to the further decline of cemented fixation.
Recent studies and data from multiple international regis-
tries have shown higher complication rates with cementless than
with cemented femoral fixation, particularly in elderly patients
and women6-9. Despite this finding, of the >500,000 primary
elective THAs in the AJRR, 86% of patients who were 80 to 89
years old and 67% of patients who were ‡90 years old re-
ceived cementless stems2. Additionally, most hemiarthroplasties
for femoral neck fractures in patients who were ‡90 years old were
cementless.
The purposes of this article are to review cemented
femoral stem designs and their outcomes, review indications
for cemented fixation in hip arthroplasty, and highlight the
scenarios in which cemented fixation is more appropriate than
cementless. Additionally, we have provided pearls for the ce-
mented technique.
Cemented Stem Designs and Principles of Fixation
It is important to understand the shapes and the principles of
fixation for the various cemented femoral stem designs. There
are 4 broad categories (Fig. 1)10. We focus on the 2 most utilized
stem designs in North America: type I (polished tapered) and
type II (composite beam)11. Type-III and type-IV stems

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G974).

J Bone Joint Surg Am. 2022;104:1024-33 d http://dx.doi.org/10.2106/JBJS.21.00853

 1025
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
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R E V I S I T I N G C E M E N T E D F E M O R A L F I X AT I O N IN HIP ARTHROPLASTY
V O L U M E 104-A N U M B E R 11 J U N E 1, 2 022
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demonstrate good long-term survival; however, they are used
less frequently12,13.
Type I: Polished Taper
Type-I stems are known by various names including force-
closed and polished taper. Fixation is obtained by controlled
subsidence into the cement mantle, loading the cement in
compression. They are collarless, highly polished, and made of
stainless steel or cobalt-chromium, with a dual or triple taper.
These characteristics discourage bonding of cement to the
prosthesis and allow subsidence of the stem. A flexible distal
centralizer that collapses as the stem subsides prevents point
loading of the cement by the stem tip. Radiostereometric
analysis has consistently demonstrated distal migration of 1 to
2 mm in the first 2 years14. This subsidence causes plastic
deformation of the cement mantle, loads the proximal part of
the femur, and minimizes shear forces at the bone-cement
interface15. Type-I stems have had excellent survival rates in
Great Britain’s National Joint Registry (NJR), with survival of
97.9% at 8 years based on >200,000 implants16. In studies with
aseptic loosening as the end point, survival rates have consis-
tently been reported near 100%, with long-term (20-year)

Fig. 1
Illustration showing the classification of cemented femoral stem designs. A revision stem for each type can be subclassified into the short (Rs) or long
version (Rl,) (e.g., Type 1Rs). (Reproduced from: Cassar-Gheiti AJ, McColgan R, Kelly M, Cassar-Gheiti TM, Kenny P, Murphy CG. Current concepts and
outcomes in cemented femoral stem design and cementation techniques: the argument for a new classification system. EFORT Open Rev. 2020;5[4]:241-
52. Copyright Ó 2020 The authors. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202038/ This is an open access article under the CC BY-NC 4.0
license [http://creativecommons.org/licenses/by-nc-nd/4.0/].)

TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
V O L U M E 104-A N U M B E R 11 J U N E 1, 2 022
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43
TABLE I Grades of Bone Cement Implant Syndrome
Grade Characteristic
I Moderate hypoxia (SpO2 of <94%) or a decrease
(20%-40%) in systolic blood pressure
II Severe hypoxia (SpO2 of <88%) or a
decrease (>40%) in systolic blood pressure
III Cardiovascular collapse requiring
cardiopulmonary resuscitation
*SpO2 = oxygen saturation.
survival of 98.7%17,18. Similar results for patients who were <40
years old have been reported, with 17-year implant survival
rates of 100% with aseptic loosening as the end point19.
Type II: Composite Beam
Type-II stems, also known as shape-closed or composite beam,
differ fundamentally from type-I stems as they rely on cement
bonding to the prosthesis. These are roughened or precoated
with methylmethacrylate and may have grooves to enhance the
cement bond. They are typically collared to prevent subsidence
and to load the medial proximal aspect of the femur. The
Charnley design, the original type-II stem, had a low average
roughness (Ra) of 0.1 mm, but subsequent designs have higher
Ra values ranging from 0.6 to 0.75 mm20. Multiple studies from
the U.S. and Europe have described 25-year survivorship from
85% to 96%21,22. On the basis of the success of the Charnley
design, type-II stems enjoy widespread use. In a study of >47,000
modern-design, composite-beam stems in the NJR, the 8-year
survival rate was 97.5%16. Long-term data have shown that
Charnley stems have a survival rate of 78% at 35 years23.
Comparative Outcomes
Polished tapered and composite-beam stems have excellent clin-
ical results with low revision rates. Few high-level studies have
directly compared the 2 types, and most comparative data are
from national joint registries. A recent report on 292,987 ce-
mented stems in the NJR found that polished tapered designs
had a significantly lower 8-year revision rate for aseptic loosening
in primary THA (1.3%) than forced-closed designs (1.7%)16,
which is consistent with previous studies24-27. A 2008 randomized
controlled trial of 219 hips found no significant difference in
revision rates between the 2 types at 5 years28. Failure modes seem
to differ, with polished tapered stems failing more often because of
fracture and composite-beam stems failing more often because of
aseptic loosening16,28,29. Overall, both show excellent clinical out-
comes, and implant survival is likely more related to technique
than to any modern implant design difference.
Comparison of Outcomes of Cemented and Cementless
Femoral Fixation
Total Hip Arthroplasty
Cemented and cementless stems in hip arthroplasty both have
excellent long-term outcomes. A recent systematic review of 11
1026
d
R E V I S I T I N G C E M E N T E D F E M O R A L F I X AT I O N IN HIP ARTHROPLASTY
composite-beam stems, 1 polished tapered stem, and 1 type-III
*
cemented stem found a 20-year survivorship of 86% to 98%,
with revision for aseptic loosening as the end point30. Similarly,
Rajaratnam et al.31 reported a survival rate of 97.4%, with
revision for any reason as the end point, in 331 fully coated,
cementless stems with a mean follow-up of 17 years. In a cohort
of 330 primary cemented composite-beam stems with a min-
imum follow-up of 35 years, only 10% were revised for aseptic
loosening, and overall survivorship was 78% with revision for
any reason as an end point23. New Zealand Joint Registry data
from 1999 to 2019 on >46,000 patients with an age of ‡65 years
showed that early revision rates within 3 months were higher
for cementless than for fully cemented THAs32. Using Australian
Orthopaedic Association National Joint Replacement Registry data
to compare the 3 best-performing cemented stems (2 polished
tapered and 1 composite-beam) and 3 best performing cementless
stems (1 double-wedge, 1 tapered round, and 1 tapered rectangle)
in THA among patients who were >75 years old, Tanzer et al.9
showed that cementless stems were 9 times (95% confidence
interval [CI], 5.5 to 15 times) as likely to be revised within the first
month, which was mainly attributable to fracture or loosening. No
difference was found in the cumulative percentage revision between
3 months and 13 years.
Higher early revision rates for cementless compared with
cemented femoral stems are related to a greater risk of peri-
prosthetic femoral fracture (PFF) and early implant loosening
seen in elderly patients, most notably women9,11. The risk of early
PFF within 3 months was much higher with cementless fixation
in an AJRR analysis of >10,000 revisions of THAs and hemiar-
throplasties. Cementless femoral fixation accounted for 95%
(596) of all 628 early PFFs, whereas cemented accounted for only
5.1% (32 early PFFs). Women were 1.9 times (95% CI, 1.1 to 3.1
times) as likely as men to undergo early revision8. An evaluation
of >170,000 THAs, between 1992 and 2007, in the Swedish Hip
Arthroplasty Register found that the rate of postoperative PFF
leading to stem revision surgery within 2 years was 17% for
cementless compared with 6% for fully cemented THA (relative
risk [RR], 8; 95% CI, 5 to 14). However, with an end point of
revision of any component during the entire study period, the
TABLE II Grading System of the Quality of Femoral Stem
62
Cementation According to Barrack et al.
Grade Cementation
A Uniform cement mantle without any stem-
bone contact and excellent interdigitation
of cement, which results in a “white out”
B Radiolucency at the cement-bone inter-
face, covering <50% of the implant
C 50% to 99% radiolucency at the cement-
bone interface
D 100% radiolucency at the cement-bone
interface and absence of cement distal to
the tip of the stem
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TABLE III Summary of Prior Cementing Techniques
Generation Description
21,23,63
First Originated in the 1960s
No osseous preparation, such as
washing
Cement inserted in antegrade fash-
ion using finger packing, which led to
inadequate penetration of cement
into cancellous bone, inclusion of
blood in cement, and poor cement
mantle
Second
62,65
Canal preparation through cleaning
to remove blood and fat
Cement restrictor
Cement inserted using gun in retro-
grade fashion
Improved penetration into bone re-
sulted in decreased risk of femoral
component loosening
66
Third Added the use of vacuum mixing to
reduce porosity of cement
Also focused on maintaining pres-
surization before and during inser-
tion of femoral prosthesis
Fourth Femoral canal preparation using a
brush, followed by pulsatile lavage
Canal packing with gauze soaked in
hemostatic solution
Vacuum cement mixing
Retrograde cement introduction
using long-nozzle cement gun, use of
distal cement restrictor
Maintaining cement pressurization
risk of revision related to aseptic loosening was lower for ce-
mentless stems than for cemented stems (RR, 0.4; 95% CI, 0.3 to
0.5)7. In nearly 67,000 THAs in the Norwegian Arthroplasty
Register, between 2005 and 2017, PFF risk was much higher for
cementless THA than for cemented THA (RR, 5.2; 95% CI, 3.2
to 8.5) and for women than for men (RR, 12; 95% CI, 6 to 25)33.
In a large case series of >36,000 THAs performed during a
40-year period, intraoperative fracture occurred in 3% (529) of
17,466 cementless stems and in only 0.23% (35) of 15,178 ce-
mented stems6. Of 564 intraoperative fractures, 94% (529) occurred
in patients with cementless stems compared with 6.2% (35) in
patients with cemented stems, a 14-fold higher rate6. The odds of
having an intraoperative fracture were significantly greater for
women than for men (odds ratio [OR], 1.4; 95% CI, 1.2 to 1.7), and
patients who were >65 years old had significantly greater odds of
fracture than those who were £65 years old (OR, 2.5; 95% CI, 2.1 to
3.0)6. A prospective cohort study34 of >8,000 THAs in patients older
than 70 years using the Danish National Patient Register and the
Danish Hip Arthroplasty Register from 2010 to 2017 found a higher
prevalence of PFF after cementless THAs (1.5%; 70 of 4,728 stems)
than after fully cemented or hybrid THAs (0.2%; 7 of 3,368
stems)34. These findings are similar to those in other studies6,7,33.
R E V I S I T I N G C E M E N T E D F E M O R A L F I X AT I O N IN HIP ARTHROPLASTY
In summary, cemented and cementless femoral fixation have
shown excellent long-term outcomes. Primarily on the basis of
registry data, cemented femoral fixation may be a better option for
patients >70 years old, especially women, to reduce the risk of PPF
and early revision. Cementless femoral fixation is more appropriate
in younger, highly active patients with adequate bone stock35-37.
Hemiarthroplasty
Similar to the findings after THA, studies of hemiarthroplasty
have shown a lower risk of PFF in hips with cement than in
those managed without cement. A systematic review and meta-
analysis of 7 randomized controlled trials of cemented versus
cementless hemiarthroplasty in patients with a mean age of
>75 years found lower intraoperative fracture (OR, 0.29; 95%
CI, 0.13 of 0.68) and postoperative fracture odds (OR, 0.09;
95% CI, 0.02 of 0.38) with cemented stems34. In a meta-analysis
of 6 randomized controlled trials with patients >65 years old
who underwent hemiarthroplasty for femoral neck fractures,
prosthesis-related complications were less likely for cemented
stems (OR, 0.24; 95% CI, 0.14 to 0.41)4. Moreover, in a recent
retrospective cohort study38 of >12,000 patients with an age of
‡65 years who underwent hemiarthroplasty for hip fracture,
cementless fixation was found to be associated with a greater
incidence of aseptic revision at 1 year compared with cemented
fixation (cumulative incidence, 3.0% [239 of 6,042] versus
1.3% [136 of 6,449]; hazard ratio [HR], 1.8; 95% CI, 1.4 to 2.2).
This was primarily because of a greater rate of PFF in the
cementless group (cumulative incidence at 1 year, 1.6% [95%
CI, 1.3% to 1.9%]) compared with that in the cemented group
(cumulative incidence at 1 year, 0.2% [95% CI, 0.1% to 0.4%]).
Compared with cemented fixation, cementless fixation was also
associated with higher HRs of aseptic revision in all age groups
(HR range, 1.2 to 2.8)38. These results suggest that cemented
hemiarthroplasty better protects against PFF and revision,
particularly among older patients.
The available data suggest that hemiarthroplasty for
displaced femoral neck fractures in the elderly should be
TABLE IV Intraoperative Steps to Avoid Bone Cement
Implantation Syndrome
Notify anesthesia team of the plan to use cement and again
at time of cementation
Use invasive monitoring judiciously in at-risk patients
Communicate with anesthesia team regarding blood loss,
volume status, and blood pressure
Ensure adequate volume maintenance before and during
cementation
Prepare for use of vasopressors
Avoid cementation in patients already on vasopressors
Thoroughly irrigate the femoral canal before
instrumentation
Place cement later in curing phase (minimizes monomer
exposure)
Avoid overpressurizing of the cement in susceptible
patients
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Fig. 2
Figs. 2-A, 2-B, and 2-C Intraoperative photographs of a hip arthroplasty showing how to establish appropriate entry into the femoral canal without
perforation. Fig. 2-A A rongeur is used to remove the lateral femoral neck. The medial femoral neck is denoted by the arrow. Fig. 2-B A rongeur is used to
initially enter the femoral neck. Fig. 2-C A canal seeker is used to enter the femoral canal.

performed with cemented femoral fixation. In 2014, the
American Academy of Orthopaedic Surgeons issued a
moderate-strength recommendation for using cemented fem-
oral stems in patients who were >65 years old and undergoing
hemiarthroplasty for femoral neck fractures39. Despite the
recommendation, only 37.1% of patients who were 70 to 79
years old, 43.3% of those who were 80 to 89 years old, and
49.2% of those ‡90 years old received cemented stems in
hemiarthroplasty for femoral neck fractures2.
Cemented femoral fixation should be used in hemiar-
throplasty for displaced femoral neck fractures in patients who
are ‡65 years old, as cementless femoral fixation in hemiar-
throplasty is associated with increased risk of intraoperative
and postoperative PFF, as well as increased risk of aseptic
loosening.
Bone Cement Implantation Syndrome and Death
Reports of cardiovascular collapse related to cementation were
described in the 1970s and became known as bone cement
implantation syndrome (BCIS)40,41. Parvizi et al.42 demonstrated this
increased risk with cementing in a review of 38,488 hip arthro-
plasties performed between 1969 and 1997. There were 23 intra-
operative deaths associated with cardiorespiratory disruption during
cementation, and none were seen in the 15,411 hips managed with
uncemented hip arthroplasty. Microemboli from bone marrow
were observed in the lungs of 11 of 13 patients who underwent
autopsy, and methylmethacrylate particles were found in the lungs
of 3 patients. Modifications of the technique and minimizing
intramedullary pressure resulted in a >3.5-fold decrease in intra-
operative mortality rate in the later years of the study42.
In a comprehensive review, Donaldson et al.43 proposed
that BCIS is characterized by “hypoxia, hypotension or both
and/or unexpected loss of consciousness occurring around the
time of cementation, prosthesis insertion, reduction of the
joint or, occasionally, tourniquet deflation in a patient under-
going cemented bone surgery.” They described 3 grades of
increasing severity (Table I)43. The most severe, grade III (cardi-
ovascular collapse), is rare, occurring in 0.4% to 1.7% of patients
having hemiarthroplasty for a femoral neck fracture43-45, but it can
lead to intraoperative or early postoperative death46. The patho-
physiology of BCIS is unknown but likely multifactorial, related to
an embolic shower from pressurization and a histamine response
to the cement monomer43. Much of our understanding comes
from retrospective studies of hemiarthroplasty for femoral neck
fractures and oncologic conditions47,48.
Rassir et al.46 retrospectively studied BCIS in 915 patients
with a mean age of 85 years who had cemented hemiarthro-
plasties from 2008 to 2019. They reported that grade-III BCIS
occurred in 0.44% (4) of the 915 patients, none of whom
survived despite immediate resuscitation attempts. Severe
BCIS was associated with a greater likelihood of death within
30 days postoperatively compared with less severe or no BCIS

Fig. 3
Figs. 3-A through 3-D Intraoperative photographs showing femoral canal cement preparation for a hip arthroplasty. Fig. 3-A A canal brush (asterisk) is used
to clean the canal of debris. Fig. 3-B A flexible suction catheter (star) is advanced distally in the canal to remove blood. Fig. 3-C Gauze soaked with half-
strength hydrogen peroxide are packed into the canal distally to proximally. Fig. 3-D Sponges packed within the canal.
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Fig. 4
Figs. 4-A through 4-F Intraoperative photographs of femoral canal cementation. Fig. 4-A The packed sponge is removed. Fig. 4-B The canal suction catheter
remains in place. Fig. 4-C The cement is introduced in a retrograde fashion with a cement gun (asterisk), allowing the pressure of the cement to push it
out the nozzle. Note that the endosteal canal is devoid of blood. Fig. 4-D Pressure is held over the cement column (arrow) while removing the catheter.
Fig. 4-E Cement is pressurized with the gun. Fig. 4-F The cement within the canal after pressurization. Again, note the attempts to avoid any blood mixing
with cement.

(HR, 3.5; 95% CI, 2.1 to 5.8)46. In another retrospective cohort
study of 1,095 patients (mean age, ‡82 years) who underwent
hemiarthroplasty for femoral neck fracture from 2008 to 2011,
those treated with cemented hemiarthroplasty had higher rates
of hypotension and/or hypoxia (28%; 272 of 986 patients) than
those treated with cementless hemiarthroplasty (17%; 18 of
109 patients) (p = 0.003)44. They also reported a greater inci-
dence of death within 48 hours after surgery in the cemented
group (2%) than in the cementless group (0%) (p = 0.001).
Moreover, the use of cement was independently associated
with a higher hazard of death at 1 year (HR, 1.9; 95% CI, 1.3 to
2.7) after adjusting for sex, age, and comorbidities44.
More severe BCIS has been associated with increasing patient
age, particularly patients who are >75 years old and those with an

Fig. 5
Figs. 5-A, 5-B, and 5-C Intraoperative photographs of femoral stem insertion. Fig. 5-A The femoral prosthesis is introduced centrally in the cement mantle.
Fig. 5-B A thumb is placed over the calcar to help to prevent varus positioning and to further pressurize the cement as the stem is introduced. Fig. 5-C The
final cemented construct. Note that the version matches that desired, as noted by the asterisk medially.
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TABLE V Steps for Femoral Preparation and Cemented Stem Insertion*

Step Description

Anesthetic considerations Notify the anesthesia team approximately 20 minutes before cementing to allow for FiO2
increase and fluid resuscitation and to make vasopressors available
Femoral preparation Large rongeur used to remove medullary contents from lateral femoral neck
Curved canal finder rasp used to enter femoral canal
Flexible reamer used to sound femoral canal
Broach with increasingly sized femoral broaches to templated and/or appropriate size
Trial reduction to confirm appropriately sized/positioned implants
Irrigate and suction femoral canal
Place cement restrictor
Place whistle-tip suction catheter in base of femoral canal; pack ribbon gauze into canal
Place gauze in acetabulum
Cementing and Cement is ready to be inserted when it can be easily molded in surgeon’s hand without
pressurization adhering to the glove
Remove ribbon gauze; keep suction catheter in place
Fill canal in retrograde fashion with cement gun with long nozzle
Use finger to hold pressure over cement and remove suction catheter
Remove long cement nozzle and place foam nozzle on cement gun and replace over canal
Apply firm pulses of pressure for 30-60 seconds and observe for fat and marrow contents
extruding from cortex
Stem insertion Insert stem by hand with long hand attachment, with thumb holding pressure over
medial calcar
Advance stem to two-thirds of its length into canal and remove excess cement;
check position
Advance stem to final depth and remove excess cement; do not alter final position while
cement cures

*FiO2 = fraction of inspired oxygen.

American Society of Anesthesiologists (ASA) physical status clas-
sification of ‡3, renal impairment, chronic obstructive pulmonary
disease, cancer and lung metastases, and use of diuretics or war-
farin43,46,49. Identifying patients with severe systemic disease prior to
surgery is essential and should involve a thorough medical evalu-
ation to address comorbidities to the extent possible43,48,50,51. Severe
BCIS, although rare, can be fatal. More high-level research is
needed to better understand this topic and associated risks.
Mortality
THA
Recent studies have shown no difference in mortality rates
between cemented and cementless femoral fixation in THA.
Richardson et al.52 compared the mortality rates after hybrid
(cemented femoral stem and cementless acetabular cups) and
after cementless hip arthroplasty in nearly 6,000 patients with
femoral neck fractures. They found a lower mortality rate
during hospital stay in the hybrid group than in the cementless
group (OR, 0.70; 95% CI, 0.56 to 0.87). Additionally, they
observed lower mortality rates in the hybrid fixation group at
1 month (OR, 0.56; 95% CI, 0.47 to 0.66), 3 months (OR, 0.56;
95% CI, 0.48 to 0.64), and 1 year postoperatively (OR, 0.56;
95% CI, 0.50 to 0.63)52. Likewise, in a large, matched cohort
study of nearly 180,000 patients in the Swedish Hip Arthro-
plasty Register who underwent THA for primary osteoarthritis
between 1992 and 2012, a supplementary analysis showed no
significant difference in mortality rates up to 14 days after
hybrid compared with cementless THA53.
Hemiarthroplasty
Several randomized controlled trials found no differences in
mortality rates from 30 days to 5 years after cemented and ce-
mentless hemiarthroplasty54-56. A single-center study of 657 patients
who were ‡65 years old with ASA physical status classification of ‡3
who underwent hemiarthroplasty for femoral neck fracture
between 2010 and 2016 found no differences with respect to all-
cause mortality, infection, or reoperation between the patients
managed with cemented stems and those managed with cementless
stems at 1 year postoperatively57. In a recent study of >30,000
patients from the Norwegian Hip Fracture Register who were ‡70
years old and underwent hemiarthroplasty from 2005 to 2017, no
differences in mortality rates at 1 year were found between the
cemented and cementless hemiarthroplasty groups58. Moreover, a
study38 of >12,000 patients with an age of >65 years who underwent
hemiarthroplasty for femoral neck fracture at a large U.S. integrated
health-care system between 2009 and 2017 found no differences
according to cementation status in in-hospital or overall mortality
rates at 1 year postoperatively.
Cemented femoral fixation is not associated with an
increased risk of death and can be protective against PFF in
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67
TABLE VI Dorr Classification of Femoral Bone
Type Characteristics
A Thick, distinct cortices on anteroposterior and
lateral radiographs, “champagne flute”
appearance, and cortical thickness index* of <0.5
B Indicates bone loss from medial and posterior
cortices, wider diaphyseal canal, thinning of
posterior cortex on lateral radiographs, and
cortical thickness index of 0.5 to 0.75
C Substantial loss of medial and posterior cortices,
“stovepipe” appearance, thinning of cortices on
both anteroposterior and lateral radiographs, and
cortical thickness index of >0.75
*Cortical thickness index is the ratio of the difference between the
diaphyseal diameter and canal diameter, divided by the diaphyseal
diameter, 10 cm distal to the midportion of the lesser trochanter.
elderly patients. Cemented femoral fixation should be used
cautiously in patients with severe systemic disease, including
cardiopulmonary disease and cancer and lung metastases48.
Technical Principles and Pearls
Goal of Cementation
Technique is critical to safely implanting cemented femoral stems
and ensuring longevity of the construct. Although the principles
of fixation differ between type-I and type-II cemented stems, the
goals of cementation and technique are the same: to obtain a
uniform cement mantle of 2 to 4 mm with sufficient interdigi-
tation of the cement with the cancellous bone. These character-
istics have been associated with longer implant survivorship59-61.
The quality of the cement mantle is graded on orthogonal post-
operative radiographs. The grading system of A through D
described by Barrack et al.62 is the most widely used (Table II).
Modern Cementing Techniques, Fourth Generation
Since Charnley first described the use polymethylmethacrylate in hip
replacement63, the technique has continuously evolved to optimize
the cement mantle and the longevity of the construct (Table III).
The key aspects of the current, or fourth generation, tech-
nique include osseous debris removal with a brush, pulsatile
irrigation of the osseous bed, use of a distal cement restrictor,
vacuum-mixed cement, retrograde introduction of cement, and
cement pressurization. These techniques are approach-independent
and can be readily adopted by all surgeons. Although not entirely
avoidable, BCIS can be limited by patient selection, appropriate
technique, close management together with the anesthesia team,
and other measures outlined in Table IV.
The first step to an ideal cement mantle begins with
preparation of the femur (Fig. 2). A canal seeker is used to
identify a starting point for entry into the femoral canal.
Removal of the remaining lateral femoral neck with a rongeur
or box osteotome helps to prevent varus positioning. Broaching
proceeds sequentially until loose cancellous bone has been
removed and the broach is both axially and rotationally stable.
R E V I S I T I N G C E M E N T E D F E M O R A L F I X AT I O N IN HIP ARTHROPLASTY
With proper broaching, 2 to 4 mm of supportive cancellous
bone will be compacted adjacent to the cortical bone. Care
during femoral preparation must be taken to avoid removal of
this supportive cancellous bone with curets or the suction tip
because it is necessary for proper cement interdigitation.
After broaching, a canal brush can be used to remove
loose pieces. The prepared bed of bone is irrigated extensively
with pulsatile lavage to remove remaining bone marrow and
blood. A distal cement restrictor is sized and placed, allowing at
least a 1-cm distal cement mantle. The canal is irrigated again
with pulsatile lavage. At this point, the cancellous bed should be
clean and free of any visible bone marrow contents. A narrow
suction catheter is placed in the canal. The canal is then packed
tightly with damp gauze that has been soaked in a hemostatic
solution of the surgeon’s choice (Fig. 3). Cement is mixed
under vacuum at room temperature according to manufacturer
recommendations. We prefer a high-viscosity cement for better
penetration and pressurization and a longer working time.
The cement is ready for application when it has reached
the working phase (i.e., it no longer adheres to the surgeon’s
glove). The gauze is removed from the canal while the suction
catheter remains in place to remove any blood that may pool on
the cement restrictor. The catheter is removed, and the cement
is introduced in a retrograde fashion with a cement gun. One of
the senior authors prefers to leave the catheter while cementing
to vent the canal and avoid further blood pooling and to re-
move it after cementing while placing pressure over the cement
column with a clean thumb or gauze. The cement is then
pressured. Care is taken to hold prolonged pressure against the
cement to enable interdigitation into the cancellous bone. If
TABLE VII Grades of Recommendation for the Use of Cemented
Femoral Stem Fixation in Hip Arthroplasty
Grade* Recommendation
B Elderly patients who are >70 years old,
especially women
B Patients with poor bone stock, thin
femoral cortices, and wide medullary
canals (Dorr type C)
B History of osteoporosis or fragility fracture
B Displaced femoral neck fracture (except in
young patients with fractures related to
high-energy mechanisms)
I When intraoperative broach stability
cannot be obtained in attempting
cementless fixation
68
*According to Wright , grade A indicates good evidence (level-I
studies with consistent findings) for or against recommending
intervention; grade B indicates fair evidence (level-II or III studies
with consistent findings) for or against recommending intervention;
grade C indicates poor-quality evidence (level-IV or V studies with
consistent findings) for or against recommending intervention; and
grade I indicates insufficient or conflicting evidence precluding a
recommendation for or against intervention.
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properly pressured, bone marrow should be seen extravasating
out of the cortical bone of the proximal part of the femur. Any
remaining blood on the proximal cement is removed (Fig. 4).
After pressurization, the femoral prosthesis is introduced
with care to position it centrally in the coronal and sagittal
planes. A thumb is placed over the calcar to help to prevent
varus positioning and to further pressurize the cement as the
stem is introduced. The final position should match that
determined during the trialing process. Care must be taken to
avoid any motion of the leg or pressure on the trunnion by
retractors so that the stem does not move in the cement as it
cures (Fig. 5). A summary of these steps is outlined in Table V.
Overview
Evidence supports the use of cemented femoral fixation in
patients who are >70 years old, especially women, and patients
with osteoporosis, because of the lower rates of PFF and revi-
sion surgery in these patients compared with those who undergo
cementless fixation8,33,64. Compared with those undergoing ce-
mentless fixation, patients undergoing cemented femoral fixation
for femoral neck fracture have a lower risk of PFF, reoperation,
and aseptic revision4,38,58.
We recommend that cemented femoral fixation be con-
sidered in the following scenarios: patients who are >70 years
old (particularly women), those with a history of osteoporosis
or fragility fracture, those with Dorr type-C bone (Table VI)33,64,
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4. Kumar P, Rajnish RK, Neradi D, Kumar V, Agarwal S, Aggarwal S. Hemiarthro-
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arthroplasty in the Swedish Hip Arthroplasty Register. Acta Orthop. 2010 Feb;81(1):34-41.
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the Best-performing Stems. Clin Orthop Relat Res. 2018 Jul;476(7):1428-37.
10. Cassar-Gheiti AJ, McColgan R, Kelly M, Cassar-Gheiti TM, Kenny P, Murphy CG.
Current concepts and outcomes in cemented femoral stem design and cementation
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11. The New Zealand Joint Registry. Sixteen year report January 1999 to December
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12. Nikolaou VS, Korres D, Lallos S, Mavrogenis A, Lazarettos I, Sourlas I, Ef-
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R E V I S I T I N G C E M E N T E D F E M O R A L F I X AT I O N IN HIP ARTHROPLASTY
displaced femoral neck fragility fractures, or when intraoperative
broach stability cannot be obtained in attempting cementless
fixation (Table VII). With careful fourth-generation cementa-
tion technique and appropriate perioperative management, ce-
mented femoral stems provide excellent outcomes and minimize
complications in these patients.
Source of Funding
No outside funding was received for this study. n
NOTE: The authors thank Jenni Weems, MS, Kerry Kennedy, BA, and Rachel Box, MS, in the Editorial
Services group of The Johns Hopkins Department of Orthopaedic Surgery, for their editorial
assistance.
Harpal S. Khanuja, MD1
Kevin L. Mekkawy, DO1
Aoife MacMahon, MD1
Claire M. McDaniel, MD1
Donald A. Allen, MD2
Joseph T. Moskal, MD2
1Department
of Orthopaedic Surgery, The Johns Hopkins University,
Baltimore, Maryland
2Department of Orthopaedic Surgery, Carilion Clinic, Roanoke, Virginia
Email for corresponding author: khanuja@jhmi.edu
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 ORIGINAL ARTICLE

Minimally Displaced Lateral Humeral Condyle Fractures:

Optimizing Follow-up and Minimizing Cost
Denver B. Kraft, MD, Theresa J. Moore, BS, RT(R), Carlos Pargas, MD,
Kenneth Rogers, PhD, ATC, and Mihir M. Thacker, MD

Key Words: lateral humeral condyle fracture, pediatric, follow-up,

Background: Minimally displaced fractures of the lateral humeral cost, minimally displaced, review
condyle (LHC) may be treated nonoperatively in a long arm cast,
but there is not a standardized evidence-based protocol. The aim (J Pediatr Orthop 2023;43:1–6)
of this study was to evaluate our nonoperatively treated LHC
fractures, determine the risk of subsequent displacement, analyze
our practice variability, and develop an evidence-based protocol
to safely manage children with LHC fractures and to evaluate
potential savings related to this analysis.
L ateral humeral condyle fractures (LHC) are the second
most common elbow fractures and account for 16% to
20% of pediatric distal humerus fractures.1 The prevalence
Methods: We retrospectively reviewed clinical and radiographic
is ~1.6/10,000 of pediatric fractures.2 The management of
parameters of all patients with LHC fractures at our institution
displaced LHC fractures is undisputedly surgical (reduc-
from 2009 to 2015. All patients treated nonoperatively initially
tion and stabilization).3 Minimally displaced fractures
were included. We recorded demographic data and calculated the
constitute ~8% of LHC fractures.4 Nonoperative man-
number of visits, casts applied, and radiographs within the first 4
agement for nondisplaced or minimally displaced
weeks. We also analyzed practice variation among 27 treating
(< 2 mm) LHC fractures has been described by multiple
providers. The number of children with subsequent displacement
authors.1,5,6 Patient selection is critical for optimal results.
needing operative fixation was determined. We also looked at the
For nonoperatively treated LCH fractures, close follow-up
average duration for each follow-up visit and the charges/costs
is recommended as the subsequent displacement rate of
associated with casting and radiographs.
1% to 15% has been reported in various studies.7–9 Also,
Results: There were 271 children with LHC fractures treated
there is no standard evidence-based follow-up protocol for
nonoperatively. Twenty-one were excluded because of the lack of
this close follow-up. Weekly imaging has been recom-
adequate radiographs. There were 157 boys and 93 girls (average
mended for the first 2 to 3 weeks6,10–12 and some authors
age 6.7 y). According to the Jakob classification, fracture types
recommend removing the cast for these radiographs.11–13
were as follows: 1 (230), 2 (20), and 3 (0). Within the first 4
Value-based care involves paying for health care
weeks, the average number of visits was 2.6 (range: 1 to 5),
services in a manner that directly links performance to cost,
average number of casts was 2.4 (range: 1 to 4), and the average
quality, and the patient’s experience of care. The Center for
number of radiographs was 9.4 (range: 2 to 31). Only 3 patients
Medicare/Medicaid services defines waste as the over-
with LHC fracture type Jakob 1 were taken to the operating
utilization of services or other practices that, directly or in-
room post injury (9, 12, and 15 d, respectively) for subsequent
directly, result in unnecessary costs to the health care
displacement.
system.14 This study was conducted in a tertiary medical
Conclusion: Displacement in appropriately selected LHC frac-
center with pediatric orthopaedic surgeons and advanced
tures treated nonoperatively was rare (3/250, 1.2%) in this cohort,
practice providers caring for children with LHC fractures.
and the data question the need for multiple visits and radio-
There was some diversity in the follow-up protocol within
graphs in the first 4 weeks. Optimal follow-up (proposed follow-
our group as well. As part of a standardization effort and to
up at 10 to 15 d after injury and then 4 to 6 wk with radiographs,
improve efficiency and minimize waste, our primary pur-
including an internal oblique view) would be safe, minimize
pose was to determine the risk of displacement and need for
waste, and result in better value-based care.
operative intervention in our nonoperatively treated LHC
Level of Evidence: Level IV.
fractures, and to analyze the treatment variability in our
practice. The secondary purpose was to develop an evi-
From the Department of Orthopaedic Surgery, Nemours/Alfred I. dence-based protocol to safely manage children with LHC
duPont Hospital for Children, Wilmington, DE. and evaluate potential savings related to this analysis.
None of the authors received financial support for this study.
The authors declare no conflicts of interest.
Reprints: Mihir M. Thacker, MD, Department of Orthopaedic Surgery, METHODS
Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland
Road, Wilmington, DE 19803. E-mail: mihir.thacker@nemours.org. This was an Institutional Review Board–approved
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. retrospective cohort study of 407 consecutive patients with
DOI: 10.1097/BPO.0000000000002265 LHC fractures diagnosed at our institution between 2009

J Pediatr Orthop  Volume 43, Number 1, January 2023 www.pedorthopaedics.com |1

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Kraft et al
and 2015. No sources of funding supported this study.
Initial treatment included nonoperative (271 patients) and
operative (136 patients) management by 27 providers
including 15 attending orthopaedic surgeons and 12
physician assistants. Twenty nonoperative patients were
excluded because of the lack of adequate radiographs or
follow-up. One patient was excluded because of a meta-
bolic disease. The patients treated surgically initially were
excluded. Records were analyzed for the total number of
radiographs obtained during the first 4 weeks. If the initial
visit occurred at an outside facility, it was not counted as a
visit in this study. If the initial visit was in our office or
emergency department under the supervision of an or-
thopaedic attending, it was counted as the initial visit. For
the purposes of this study, we calculated each view as a
radiograph, for example, a set of 3-view elbow radio-
graphs was counted as 3 radiographs. The number of casts
applied and the duration of each follow-up visit were
counted. Healing time was confirmed by radiographic
assessment. Complication rate was determined by re-
cording the number of patients who experienced increased
LHC displacement in the cast and required operative in-
tervention as a result. Surgery was indicated after the in-
itial nonoperative management if the fracture displaced
further for a total displacement over 2 mm, or any further
displacement if the initial fracture was displaced over
2 mm at the start of treatment. Descriptive statistics were
utilized. The proposed follow-up protocol was based on
this cohort and review of previously published data.6,7,11
Treatment savings were calculated based on charges for
the radiographs and casts.
RESULTS
Of the 250 patients, 157 were boys and 93 were girls.
The mean age at injury was 6.7 ± 3.4 years (range: 4 mo
to 16.8 y). The left side was fractured in 141 and the right,
in 109 children. According to the Jakob classification,15
230 fractures were type 1 with an average displacement of
0.5 mm (range: 0 to 1.9 mm), 20 type 2 with an average of
2.4 mm (range: 2 to 3.2 mm), and no fractures were type 3.
During the first 4 weeks after injury, the mean
number of visits was 2.6 (range: 1 to 5, median, 3 visits)
(Table 1). Of all visits, 5.6% had 1 visit, 42.4% had 2 visits,
42.0% had 3 visits, 9.6% had 4 visits, and 0.4% had 5
visits. Fifty-two percent had 3 or more visits within the
first 4 weeks. The average follow-up period was 6 weeks
(range: 1.4 to 13.7 wk). The mean number of radiographs
was 9.4 (range: 2 to 31, median, 9 radiographs) (Table 1).
TABLE 1. Practice Pattern Variation and Time to Heal
Number of Visits in the First Number of Radiographs in the First
4 wk 4 wk
Mean 2.6 9.4
Median 3 9
Range 1-5 2-31
*In all, 30.4% had 3 or more casts; 60 had 1 cast, 114 had 2 casts, 62 had 3 casts, and 14 had 4 casts.
†Total 35/250 (14.0%) took > 6 weeks to heal (30 type 1 and 5 type 2). There were no nonunions.
2 | www.pedorthopaedics.com
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J Pediatr Orthop  Volume 43, Number 1, January 2023
The mean time to healing was 4.1 weeks (range: 2 to 12,
median, 4 wk) (Table 1). Of these fractures, 14% (35/250)
took > 6 weeks to heal (mean: 7.9 wk). Of the fractures
with healing time beyond 6 weeks, 5 were classified as
Jakob type 2; 30 fractures were type 1 (Table 1). Three
patients (3/250, 1.2%) with an LHC fracture required late
operative intervention (at 9, 12, and 15 d postinjury,
respectively) because of increased fracture displacement
on follow-up. One case of late displacement at day 9 and
subsequent operative intervention is shown in Figure 1.
This girl’s fracture increased from 2.4 to 4.9 mm
displacement and it was treated with open reduction,
percutaneous pinning (Fig. 2). This patients healed after
an additional 4 weeks. One patient had mild displacement
on follow-up (total displacement <2 mm) that did not
require intervention.
There was variability regarding whether imaging
was obtained in or out of cast, or both, at each follow-up
visit (Table 2). Most images were obtained out of the cast
(Table 2). The number of views obtained at each visit was
also variable, but 4 views was the most common at each
follow-up visit (Table 3).
Twenty-eight of 250 fractures were read initially as
supracondylar or epicondylar fractures by radiologists.
Each follow-up visit averaged ~54 minutes. The charge for
a long arm cast application was $712 and for a set of
3-view elbow radiographs was $460.
DISCUSSION
LHC fractures are the second most common elbow
injuries in children. These fractures usually occur around
6 years of age,4 similar to the average age in our cohort of
6.7 years. There are various classification systems de-
scribed for LHC fractures.16 The Milch classification is
commonly used but does not provide treatment guidelines.
The Jakob classification on the other hand can be used to
guide treatment.15 The Jakob classification divides LHC
fractures into 3 types: type 1 is a nondisplaced fracture of
<2 mm, type 2 is a minimally displaced fracture of
> 2 mm with an intact cartilaginous hinge, and type 3
fractures are displaced and the capitellum is rotated from
the joint. In a study by Weiss et al,17 all type 2 fractures
were displaced <4 mm, and all type 3 fractures were dis-
placed > 4 mm, suggesting that fracture displacement on
radiography may be sufficient for classification and
treatment. The treatment of displaced LHC fractures is
surgical, involving reduction and fixation/stabilization
of the fracture with pins or screws. None or minimally
Number of Casts in the First Time to Healing in the Cast in
4 wk* Weeks†
2.4 4.1
2 4
1-4 2-12
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J Pediatr Orthop  Volume 43, Number 1, January 2023 Non-operative management of LHC fractures

FIGURE 1. Case 1. Internal oblique elbow radiographc view of 5-year and 8-month-old patient with diagnosis of type 2 lateral
humeral condyle fracture. Radiographic view at presentation (displacement: 2.4 mm) (A) and radiographic view 9 days later with
increased displacement (4.9 mm) (B).

displaced fractures (< 2 mm) may be treated non- recommend taking the castoff for each radiograph.11–13
operatively. The degree of displacement can be difficult to There was tremendous variation in the follow-up protocol
measure, and radiographs may underestimate displace- among the providers in this study. Almost all patients
ment, which is best appreciated on internal oblique were seen within the first week and placed in a long arm
radiographs.18 Previous studies have recommended cast. However, follow-up protocols varied, with some
the routine use of internal oblique radiographs to de- providers seeing patients weekly for the first 3 weeks with
termine fracture displacement and guide the management new radiographs at each visit (some in cast and some out
of these injuries.19–22 of cast), and then at ~6 weeks from the injury to assess for
Appropriate patient selection is critical for good re- healing and final cast removal (Table 1). Some providers
sults of nonoperative treatment. Although other advanced on the other hand only saw patients once in the first 3 to 4
imaging modalities22,23 and arthroscopy24 have been ad- weeks and then again at 4 to 6 weeks for the evaluation of
vocated by some to get a more accurate sense of fracture healing and discontinuation of immobilization.
stability,25 these were not used in this study population. LHC fractures have variable healing courses with
An internal oblique radiograph was performed routinely occasional prolonged healing times. Flynn et al26,27 re-
on all patients, similar to Bast et al.5 We tried to adhere to ported nonunions in 7/45 cases (15.6%), whereas Launay
the <2 mm guideline as previously proposed by multiple et al10 reported nonunions in 5/97 (5.2%). Recently, a
authors,1,4–6 although we did have 20 patients with frac- systematic review4 reported a 1.6% rate of nonunion.
tures displaced > 2 mm in our cohort. The decision to We had zero nonunions in this series and 35/250 (14.0%)
treat these patients nonoperatively was up to the discretion patients took > 6 weeks to heal.
of the provider. Knapik et al9 published a systematic review of
Many studies suggest that LHC fractures need to be conservative management of LHC fractures. They in-
followed closely. Abzug et al12 and Tejwani et al11 rec- cluded studies with a total of 355 LHC fractures with
ommend obtaining radiographs of the elbow at 4 to 8 days <2 mm of initial displacement that were treated with im-
after injury and weekly thereafter for the next 2 to 3 weeks mobilization. In this review, the rate of subsequent dis-
to look for subsequent displacement. Some authors placement was 14.9% (53/355). This is far higher than in
our series (1.2%, 3/250). This discrepancy may be ex-
plained at least in part by the routine use of internal ob-
TABLE 2. Cast Status for Imaging at Each Patient Follow-up lique radiographs as suggested by Song et al18 to more
Follow- Follow- Follow- Follow- Follow- accurately assess fracture displacement and optimize pa-
up 1, up 2, up 3, up 4, up 5, tient selection for nonoperative management. The in-
Cast Status n (%) n (%) n (%) n (%) n (%) cluded studies for this review did not routinely use internal
oblique radiographs with the exception of Bast et al,5 who
In 63 (25.4) 72 (29.1) 29 (11.7) 7 (2.8) —
In/out 9 (3.6) 1 (0.4) 5 (2) — — also reported a low rate of subsequent displacement (2.1%,
Out 130 (52.6) 157 (63.6) 120 (48.4) 69 (27.8) 26 (10.5) 2/95 patients).
No radiographs 23 (9.3) 4 (1.6) 7 (2.8) 18 (7.3) 21 (8.5) In most patients treated nonoperatively, late dis-
Unknown 22 (8.9) 7 (2.8) 16 (6.5) 8 (3.2) 4 (1.6) placement was seen within the first 7 to 14 days, with only

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Kraft et al J Pediatr Orthop  Volume 43, Number 1, January 2023

AP indicates anteroposterior; avg., average; F, female; Group A, Jakob type 1; Group B, Jakob type 2; Group C, Jakob type 3; L, left; lat, lateral; NA, not applicable; M, male; NR, not reported; obl, oblique; R, right.
Duration of Immobilization
TABLE 3. Number of Radiographic Views at Each Follow-up

Group 3: NA (displaced)
Mean and/or Range
Follow-up Follow-up Follow-up Follow-up Follow-up

4.5 wk (2-12 wk)

26.5 d (11-56 d)
Minimum 6 wk
Group 2: 8-12 wk
Group 1: 6 wk
Views 1, n (%) 2, n (%) 3, n (%) 4, n (%) 5, n (%)

3-7 wk
4-8 wk
3 wk
NR
0 46 (18.5) 17 (6.9) 94 (37.9) 172 (69.4) 222 (89.5)
2 21 (8.5) 18 (7.3) 16 (6.5) 9 (3.6) 2 (0.8)
3 5 (2) 4 (1.6) 1 (0.4) — —
4 148 (59.7) 198 (79.8) 130 (52.4) 63 (25.4) 24 (9.7)
5 3 (1.2) 4 (1.6) 1 (0.4) 3 (1.2) —
6 11 (4.4) 3 (1.2) 1 (0.4) 1 (0.4) —
7 1 (0.4) 3 (1.2) 1 (0.4) — —
— —

1 patient did not have oblique view,

displacement noted on days 4, 13,
4/31 (12.9) All > 2 mm initial displacement, all
8 9 (3.6) 1 (0.4) 3 (1.2)

3/250 (1.2) Displacement noted on days 9,12,

9 — — 1 (0.4) — —
10 3 (1.2) 1 (0.4) — — —
14 3 (1.2) — — — —

Timing/Comments

4 on day 3 and 1 on day 5

23 — 1 (0.4) — — —

Subsequent Displacement

Days 5-15, avg. 7.9 d

Group C: 5/12 (42%)
Group B: 6/35 (17%)
Group A: 0/65 (0%)
1 patient in the Finnbogason et al28 series displacing be-

2/11 beyond 11 d
within 2 wk
tween days 13 and 27, and 1 patient in Zale et al20 dis-

Days 6 and 9

14, 14, 21
placing at day 21 (Table 4). In our series, 3 patients had

and 15
increased fracture displacement > 2 mm during follow-up.

NA
Displacement was noted in case 1 at 9 days (case 1, Fig. 1)
case 2 at 12 days, and case 3 at 15 days after the injury.

5/51 (9.8)

5/59 (8.5)
These patients were taken to the operating room for an

n/N (%)

5/17 (29)
2/95 (2)

0/7 (0)
open reduction and percutaneous pinning of the LHC

11/112
fracture and healed uneventfully in 4 additional weeks
(case 1, Fig. 2). The decision for open or percutaneous Initial Gap
reduction was surgeon preference. One patient displaced

< 2: 230
2-3: 20
(mm)
after initial immobilization but remained displaced <2 mm <4

<2

<2
<2
<2

<2
0.7
total. Nonoperative management was continued, and
satisfactory healing was noted at 6 weeks. We agree with
Pirker et al13 that late displacement is usually detectable in
Radiographic
TABLE 4. Comparison of Results From the Current Study and Previous Studies

the 7-day to 14-day period and subsequent follow-up visits

AP/lat/obl

AP/lat/obl
within the first 4 weeks are unlikely to reveal additional
AP/lat

AP/lat

AP/lat
AP/lat

AP/lat
Views

NR
useful information. The detection of displacement at a
2-week visit still affords the opportunity to intervene in a
timely manner.
In our cohort, we had a median of 3 visits, 2 cast
Side R:L

bilateral

109:141
changes (mean: 2.4 casts), and 9.4 radiographs within the
19:30,1
35:60

20:39
6:11

9:13
NR

NR

first 4 weeks. On the basis of this data, after the initial visit
with a pediatric orthopaedic provider for diagnosis and
cast placement, we can assume that 1 visit with (2 to 3
Sex M:F

157:93
views including anteroposterior and internal oblique with
21:10

65:30

37:13

43:16
13:9
NR

9:8

optional lateral) radiographs at ~10 to 15 days after the

injury with a cast change/application would be sufficient in
the first 4 weeks. Patients do not always present initially to
Age in Years
Mean or

facilities that obtain appropriate imaging, place adequate

Range

1-12

5.8

4.6
6.7

6.7
7

casts, or initiate the proper treatment protocol. Therefore,

the first visit must be with a pediatric orthopaedic provider
either in the office or in an emergency department that is
No. Patients

under the supervision of such faculty. Then, the protocol

suggested in this study is appropriate and the patient may
112

250
31

95
17
51

22
59

be seen around day 10 to 15. Visits at outside facilities

were not counted in the number of visits for our calcu-
lations. Thus, we could eliminate 2 visits, 1 cast change
and 2 sets of radiographs. We mapped out our visit times
Marchiex et al1
Launay et al10

Current study

and found that these visits averaged ~54 minutes. We

Finnbogason

Pirker et al13
Flynn et al27

Zale et al20
References

Bast et al5

would therefore save 108 minutes of time in the hospital,

et al28

not to mention time to travel, time off work and school,

etc. We would also save ~$712 in cast charges with 1 less

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J Pediatr Orthop  Volume 43, Number 1, January 2023
FIGURE 2. Case 1. Surgery was performed on day 10 and healing occurred over the next 4 weeks with no complications. A,
Intraoperative fluoroscopic elbow view showing open reduction and K-wire fixation. B, Postoperative internal oblique radiographic
view of elbow showing fixation with K-wire. C, Radiographs demonstrated excellent alignment and no other complications.
cast. The charge for elbow radiographs is ~$460 at our
institution, yielding savings of roughly $920 in charges
from less radiographs alone. These charges add up to a
savings of $1632 and 108 minutes for the patient/family.
The Centers for Medicare & Medicaid Services currently
defines value-based care as paying for health care services
in a manner that directly links performance on cost,
quality, and the patient’s experience of care.29 This ap-
proach would also decrease radiation exposure to the child
and reduce the time away from work and school for the
parent and child, without compromising quality of care,
potentially leading to higher patient satisfaction. We
therefore propose that seeing these patients as soon as
possible after the injury, if they were not initially seen in
setting that operates under the supervision of a pediatric
orthopaedic attending such as the emergency room or
clinic at a teaching hospital, at the 10-day to 15-day mark
after the injury, and then reevaluating them for healing at
the 4-week to 6-week mark would optimize their follow-
up. This should allow us to identify the patients who have
late displacement (at the 10-day to 15-day visit) and ad-
dress them surgically in an appropriate time frame. If the
fracture displaces, surgery at week 2 or week 3 after the
injury is not sufficiently different to justify earlier radiog-
raphy, and the incidence of interval displacement, in our
cohort, was very small. Even in the cases of fractures that
displace and require operative intervention, outcomes
should not be compromised. The patients who have slow
healing beyond the 4-week to 6-week visit could be
followed further out until they healed or further inter-
vention was needed.
This study is the largest study to date (250 vs. 159
patients in the study by Finnbogason et al28) examining
the nonoperative management of LHC fractures and it
has 1 of the lowest rates of conversion to surgery. None of
the prior studies have looked at the financial data relating
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Non-operative management of LHC fractures
to nonoperative management of LHC fractures. We ex-
amined our data and the published literature to develop a
literature-backed protocol, which can lead to financial
benefits to the patients, as well as the reduction of waste
and cost in our system without compromising the quality
of care, for following nonoperatively treated patients with
LHC fractures. This may improve patient satisfaction and
provide better value. However, there are some limitations
to the study. Patient selection is critical to the success of
nonoperative treatment. The retrospective nature of the
study means that there certainly could be selection bias in
the patients that were included. However, the large
number of patients and providers (27) responsible for the
initial decision-making on treatment, does make the re-
sults more generalizable. This study examines charges and
not necessarily the actual costs to the system (which
would be variable based on each system). Yet, eliminating
visits, as well as imaging and cast application would
certainly lead to benefits for the patients and to the system
in this era of value-based care. This study did not assess
patient satisfaction; this was a limitation of the retro-
spective nature of this study. This study did not assess
interobserver or intraobserver reliability. Our findings will
help us proceed to our next objective, which is to pro-
spectively evaluate this protocol and to assess its safety
and efficacy, while creating standard work, efficiency, and
savings.
To conclude, in this large cohort of nonoperatively
treated LHC fractures, there was a very low rate of late
displacement (1.2%). The analysis of practice patterns and
variability created an opportunity to develop a protocol
aimed at minimizing waste and providing value-based
care. Optimal follow-up (proposed follow-up at 10 to 15 d
after injury and then 4 to 6 weeks with radiographs, in-
cluding an internal oblique view) would be safe, minimize
waste, and result in better value-based care.
www.pedorthopaedics.com |5
Kraft et al
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Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

A. M. Hutchison,
C. Topliss,
D. Beard,
R. M. Evans,
P. Williams
From Morriston
Hospital, ABMU
University Health
Board, Swansea,
United Kingdom
 A. M. Hutchison, BSc Hons,
MSc, PhD, Advanced
Practitioner Physiotherapist
and Honorary Senior Lecturer
(Swansea University)
 C. Topliss, MB BS,
FRCS(Tr&Orth), MD, Consultant
in Trauma and Orthopaedic
Surgery
 P. Williams, BSc Hons, MB
BCh, FRCS (Tr&Orth),
Consultant Trauma &
Orthopaedic Surgeon
Morriston Hospital, ABMU
Health Board, Orthopaedic
Department, Swansea, SA6
6NL, UK.
 D. Beard, MA, MSc, DPhil,
Professor of Musculoskeletal
Sciences
University of Oxford &
Morriston Hospital, Institute of
Musculoskeletal Sciences,
Swansea, UK.
 R. M. Evans, MB BCh FRCR,
Consultant Radiologist, Assoc.
Professor of Imaging
Morriston Hospital / Swansea
University College of Medicine,
Radiology Dept, Morriston
Swansea, SA6 6NL, UK.
Correspondence should be sent
to Dr A. M. Hutchison; e-mail:
Anne-
Marie.Hutchison@wales.nhs.uk
©2015 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.97B4.
35314 $2.00
Bone Joint J
2015;97-B:510–15.
Received 23 October 2014;
Accepted after revision 12
December 2014
510
 FOOT AND ANKLE
The treatment of a rupture of the Achilles
tendon using a dedicated management
programme
The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in
2008. This paper summarises the outcome of this programme. Patients with a rupture of the
Achilles tendon treated in our unit follow a comprehensive management protocol that
includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses,
early weight-bearing, an accelerated exercise regime and guidelines for return to work and
sport. The choice of conservative or surgical treatment was based on ultrasound findings.
The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS)
and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An
elementary cost analysis was also performed.
Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of
whom were managed conservatively and 62 had surgical repair. There were three
re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to
86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0
(SD 14), 64.9 (SD 15) (n = 135), six months 67.8 (SD 16), 73.8 (SD 15) (n = 103) and nine months
(72.4; SD 14) 72.3 (SD 13) (n = 43). The programme realised estimated cost savings exceeding
£91 000 per annum.
The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a
reduced rate of surgical intervention and a reduction in healthcare costs.
Cite this article: Bone Joint J 2015; 97-B:510–15.
The Achilles tendon is the thickest and strong- immobilisation, and the degree of plantar flex-
est tendon in the body, but ruptures are com- ion chosen. The two main specific complica-
mon. The management of this injury remains tions of this injury are re-rupture and incorrect
controversial. Historically, it has been reported tendon length. Both are dependent on the loca-
that conservatively managed ruptures will tion and completeness of the tear, and the prox-
result in fewer complications; but the risk of imity of the ends of the ruptured tendon.5
re-rupture is reported to be higher at 13% Ultrasound may be used to identify the location
compared with 5% after a surgically managed of the rupture, the amount of tissue torn and,
rupture,1 The complications of surgery include importantly, the ability of the torn tendon tissue
infection and sural nerve damage.1,2 Recently, to oppose in varying positions of equinus.6,7
there have been reports of a lower re-rupture This is therefore an essential investigation. For
rate with conservative management involving patients who are treated conservatively, knowl-
functional orthoses.3,4 Wallace et al3 reported a edge of the optimum position for immobilisa-
rate of re-rupture of 2.9% in 945 patients, who tion is obtained by using ultrasound to place the
were managed in this way. ankle in a position in which the ends of the ten-
Several factors probably influence the out- don ends oppose, rather than overlap or fail to
come. These include consideration of the inter- approximate.
relationship between the characteristics of the Re-rupture occurs as a result of compro-
pathology, the physiology of healing/tendon mised mechanical properties of the healed ten-
mechanics and the demands of the patient. don. The tensile strength of the tendon, and its
The crucial decisions include whether to ability to resist load, is dependent on the orien-
treat surgically or not, how to immobilise the tation and number of collagen filaments.
ankle, and what is the optimal rehabilitation, in Although the healing profile is likely to be
particular when to re-introduce tendon load- dependent on the type and position of immobi-
ing. Many different protocols have been pro- lisation, for both conservative and surgically
posed for the use of orthoses,3,4 the duration of managed patients, the subsequent loading
THE BONE & JOINT JOURNAL
 THE TREATMENT OF A RUPTURE OF THE ACHILLES TENDON USING A DEDICATED MANAGEMENT PROGRAMME 511

A&E
Equinus back slab, NWB, Fracture clinic

Fracture clinic
Management decision –
Doctor, Physiotherapist, US examination

Operative management Conservative

Outside other comorbidity, patients who treatment
fulfill the following three criteria: All other cases
1. Age < 55 years
2. Complete rupture in the body of tendon
3. Non opposition of tendon ends (passive
PF) of greater than 1 cm

Immobilisation
• Two weeks equinus cast in best
position of obliteration of gap
• Walking orthosis with gradual
reduction in equinus

Following immobilisation
Physiotherapy – strict rehabilitation guidelines

Fig. 1

Summary of the SMART protocol. (US, ultrasound, NWB, Non-Weight

Bearing, PF, Plantar Flexion).

regime of the healed tendon will dictate the strength of the
scar tissue and influence the likelihood of re-rupture.8-10 A
structured, fully managed, staged rehabilitation protocol,
both during and after immobilisation, is therefore essential.
The objective of the Swansea Morriston Achilles Rup-
ture Treatment (SMART) protocol was to create rational-
ised decision-making for patients with a ruptured Achilles
tendon and a rationalised and comprehensive rehabilitation
regimen. We report the results of patients with a rupture of
the Achilles tendon who were managed using this protocol.
Patients and Methods
Between January 2008 and January 2014 a total of 273
patients presented with an acute rupture of the Achilles ten-
don, all within two weeks of injury. Some patients who pre-
sented more than two weeks after injury were also treated
using the protocol, but their results were not included in
this study. There were 215 men and 58 women with a mean
age of 46.5 years (20 to 86) (median 44, SD 14) six of whom
were elite sports personnel. A total of 211 patients were
treated conservatively and 62 underwent operative repair.
The protocol. The SMART protocol (Fig. 1) was established
in 2008 with three main tenets of management: ultrasound
examination; referral to a dedicated clinic with specialist
physiotherapists rather than an orthopaedic surgeon and
strict rehabilitation guidelines. Between 2008 and 2010,
minor changes were made, such as updating the documen-
tation forms and training other physiotherapists, but since
then no further alterations have been made.
Fig. 2
Ultrasound scan form completed by the Consultant Radiologist.
The protocol covers the period from presentation in the
emergency department to discharge from care when the
patient has returned to their required level of activity. The
rupture was confirmed clinically at presentation using the
Simmonds test,11 a non-weight-bearing equinus back slab
was applied, and a referral to the fracture clinic was
arranged. A consultant musculoskeletal radiologist con-
ducted an ultrasound examination of the Achilles tendon
on a semi-urgent basis, preferably during the same or the
next working day. The primary aim of this was to confirm
the diagnosis. It also detailed the site and extent of the rup-
ture and the smallest gap that could be achieved between
the tendon ends in varying positions of equinus. The radio-
logist completed an injury-specific form (Fig. 2) to docu-
ment this information.
Since 2011, the decision regarding conservative or surgi-
cal treatment has been more strongly influenced by the
ultrasound findings. Operative management was advised
for patients fulfilling all the following criteria: age < 55
years, rupture in the body of the tendon, and a gap of the
tendon ends > 1 cm on passive plantar flexion. This ration-
ale was based on the fact that function is likely to be
impaired if the tendon heals with a gap of > 1 cm.12 Use of
ultrasound examination for all patients resulted in increased
frequency of conservative management. Comorbidities

VOL. 97-B, No. 4, APRIL 2015

512 A. M. HUTCHISON, C. TOPLISS, D. BEARD, R. M. EVANS, P. WILLIAMS

Table I. Management of patients during immobilisation period for operative and non-operative patients

Week Conservative Surgical

0 to 2 Equinus FWB cast with a wedge in the best position that Back slab NWB
opposes the tendon ends
2 to 5 Vacoped boot locked at 30 degrees FWB Vacoped boot locked at 30° FWB
5 to 7 Vacoped boot 30° to 15° FWB Vacoped boot 30° to 15° degrees
Yellow theraband exercises for soleus and gastrocnemius Yellow theraband exercises for soleus and gastrocnemius
7 to 9 Vacoped boot 0-30 degrees with a flat wedge FWB Vacoped boot 0-30 degrees with a flat wedge FWB
9 to 10 Vacoped boot fully unlocked FWB Vacoped boot fully unlocked FWB
10 to 16 Removal of boot Removal of boot
To wear only in vulnerable environments (6/52) To wear only in vulnerable environments (6/52)
FWB, Full Weight Bearing, NWB, non weight bearing

Table II. Rehabilitation guidelines after immobilisation for operative and non operative patients)

Do Do not
Weeks 10 to 12 post injury
Issue patient with a heel raise for shoe
Warn the patient that most re-ruptures occurs during this phase
Advise the patient to avoid activities which involve extreme dorsi flexion
of the ankle combined with active plantar flexion
Advise the patient that they will not return to sports which involve running
until they are 6 to 8 months post injury
Advise the patient on a PWB gait pattern; particularly re-educating the Do NOT attempt running, jumping or hopping
toe off phase of gait
Work on ROM of the ankle and foot. Particularly length of soleus and
gastrocnemius
Lower limb muscle strength work. Particularly of the plantar flexors Do NOT attempt eccentric lowering exercise off a step used for
tendonopathies. Do not attempt resistance plantar flexion exer-
cises which requires more than half the patients body weight
Proprioception exercises
Gentle plyometric exercises
Hydrotherapy – particularly good during this phase
For surgical patients take care of the scar. Any sign of break down
refer patient back to clinic as soon as possible
3 to 5 months post injury
Dispense of heel raise
Continue to avoid activities of extreme dorsi flexion combined
with active plantar flexion
Aim to single leg heel raise
Plyometric – progress for example start with 2 feet jumps (bunny hops),
jogging on trampet, PWB jogging, i.e., leaning on table
5 to 6 months post injury
Gait – Start jogging on the flat
Strength – start eccentric exercises off step
Progress proprioceptive exercises as appropriate
Sports specific rehab exercises
6 to 8 months post injury
Gait – introduce hill running Return the patient to competitive sports until they can: single leg
heel raise; sprint with the toe off phase of gait; until horizontal
single leg hop × 3 is at least 75% of good leg and vertical hop is at
least 75% of good leg
Introduce hopping and progress to long horizontal and vertical hops
Return to sport as able
ROM, range of movement

were also considered. All patients with comorbidities con-
sidered as contra-indications to surgery were treated con-
servatively. Open injuries were always treated surgically.
Non-operative management was selected for all other
cases, including elite athletes (national representation,
semi-professional and professional sports personnel).
The position of immobilisation was determined from the
ultrasound scan. Patients in whom the gap was obliterated
in full plantar flexion were placed in a below-knee weight-
bearing cast in maximum equinus. This cast was retained
for two weeks, after which a walking orthosis that enabled
a gradual reduction in equinus was used.

THE BONE & JOINT JOURNAL

 THE TREATMENT OF A RUPTURE OF THE ACHILLES TENDON USING A DEDICATED MANAGEMENT PROGRAMME
Table III. Modification of final question on achilles tendon repair score
Score
Excellent (15 points) Single leg heel raise to same height as other leg, no hand support required
Good (10 points) Single leg heel raise not to the same height as other leg, min hand support required
Fair (5 points) Just about Single leg heel raise, maximum hand support required
Poor (0 points Unable to single leg heel raise
Table IV. Outcome scores at four, six and nine months post rupture
Achilles tendon rupture Mean achilles repair
Mean score at: score score
4 months (n = 135) 53.0 (SD14) 64.9 (SD 15)
6 months (n = 103) 67.8 (SD 16) 73.8 (SD 15)
9 months (n = 43) 72.4 (SD 14) 72.3 (SD 13)
Table V. Annual cost implications of The Swansea Morriston Achilles
Rupture Treatment protocol comparing 2008 and 2013
Increase costs
20 extra ultrasound scans per year at £60 per scan = £1200
Boots compared with cast × 3 £6867 (inclusive VAT)
Total = £8067
Decreased costs or savings
37 fewer operations at £2300 per operation + £400 a night hospital stay
Total = £99 900
Total saving = £ 91 813 per annum
If the tendon ends overlapped in full plantar flexion the
ankle was dorsi- flexed to a position where the tendon ends
opposed. It was important to flex and extend the knee dur-
ing the ultrasound examination and to assess the amount of
opposition of the tendon ends in varying positions of equi-
nus, including 20° to 30° plantar flexion. This latter posi-
tion could be provided by functional orthoses (Vacoped,
Oped UK Ltd, Devizes, United Kingdom).
All patients were referred to an Achilles tendon clinic
during the period of immobilisation, and their overall man-
agement was conducted by a specialist physiotherapist
(Table I). Following removal of the orthosis, all patients
were referred for physiotherapy at their local hospital with
strict guidelines for rehabilitation (Table II) and were
reviewed in the Achilles clinic until they had returned to
their required activity demands. This varied between four
and nine months after injury. The Achilles Tendon Rupture
Score (ATRS), a valid and reliable outcome measure for
Achilles tendon ruptures,13 and the Achilles Repair Score
(AS)14 were completed. Both these scores are out of 100,
with 100 being regarded as a perfect outcome. In the
absence of an isokinetic machine, the final question of the
AS was modified as described in Table III to include a sin-
gle-leg heel-raise test to assess muscle strength.
If the physiotherapist at the achilles tendon clinic identi-
fied any problems, the patient was referred to a consultant
VOL. 97-B, No. 4, APRIL 2015
513
foot and ankle surgeon in conjunction with the specialist
therapist.
Venous thromboprophylaxis was undertaken selectively.
Any patient with a history or a family history of a deep vein
thrombosis (DVT) or pulmonary embolism (PE) received
low molecular weight heparin subcutaneously, once daily
for the immobilisation period. All other patients were coun-
selled about the risk of DVT and PE and anticoagulated if
they agreed.
Statistical analysis. A descriptive data analysis was per-
formed of the demographic details, the rate of re-rupture,
outcome (ATRS and AS) and complications. The rate of re-
rupture is presented as frequency data, the outcome scores
as means and standard deviations (SD). The financial
impact of the pathway was also analysed using an elemen-
tary health economics evaluation.
Results
The rate of re-rupture was 1.1% (3/273). Two patients with
a re-rupture had been managed conservatively (2/211) and
the other surgically (1/62). Two patients were non-
compliant. One, who was managed surgically, was on
steroid medication and the other, who was managed con-
servatively, was injured in a fight. The third patient, who
was compliant, fell downstairs two weeks after removal of
the orthosis. The ATRS and AS scores at four, six and nine
months are shown in Table IV. The mean ATRS and AS at
four months was 53.0 (SD 14), 64.9 (SD 15) (n = 135), six
months 67.8 (SD 16), 73.8 (SD 15) (n = 103) and nine
months 72.4 (SD 14) 72.3 (SD 13) (n = 43). Once patients
had reached their required level of activity they were dis-
charged from the clinic. Therefore, identical follow-up data
was not available for all patients.
Operating selectively led to an estimated overall cost sav-
ing to the department of £91 813 per annum (Table V).
This was in comparison with operative figures for patients
with a rupture of the Achilles tendon prior to the instiga-
tion of the protocol. The major cost saving, associated with
the introduction of the protocol was the shift from opera-
tive to non-operative treatment. In 2008/2009 just under
half of patients with a rupture of the Achilles tendon were
managed surgically. Between 2011 and 2013, only 6% of
patients were treated operatively (Fig. 3). The change in the
choice of treatment with the passage of time was not asso-
ciated with any obvious changes in self-reported outcome
(Fig. 3).
514 A. M. HUTCHISON, C. TOPLISS, D. BEARD, R. M. EVANS, P. WILLIAMS

persuasive. There are a number of possible reasons why the

2008 2009 2010 2011 2012 2013
protocol could have resulted in this exceptionally low rate
67 65 67 69 79 87
80 of re-rupture. First, decision-making for management is
56 based on ultrasound, with the choice of operative manage-
Treatment ment and/or the position of immobilisation being influ-
50
Conservative enced by the findings. To our knowledge this is the first
Surgical 42 protocol to include a detailed ultrasound examination for
40 this purpose. Other protocols describe positions for immo-
33 bilisation irrespective of the amount of opposition of the
Count

29 30 ends of the tendon as seen on ultrasound in the plantar-

30
21 21
20 18
13
10
5
4 tion of a haematoma may confound the results for those
0 patients with delayed presentation.
2008 2009 2010 2011 2012
Year
Fig. 3
Histogram demonstrating the change in management of
operative to non-operative management with evolution of
the SMART protocol. The change over time of the mean
Achilles Tendon Rupture Score (ATRS) score nine months
post-immobilisation is shown at the top to demonstrate
consistency in outcome scores regardless of the change in
management.
There were 23 major complications in addition to the
three re-ruptures; 15 patients had a DVT (diagnosed on
Doppler ultrasound scanner) and five had a PE (diagnosed
on CT pulmonary angiography). In the 211 conservatively
managed patients, 11 had a DVT and four a PE. In the 62
surgically managed patients four had a DVT and one had a
PE. The overall rate of venous thrombo-embolism (VTE)
was 7.3%. Three patients had a superficial wound infec-
tion. There were 11 minor complications, including sore-
ness from the boot.
During the immobilisation period (either following sur-
gery or during conservative management) most patients
(264/273, 97%) were managed without further involve-
ment of an orthopaedic surgeon; nine required review by an
orthopaedic surgeon. The reasons for this were re-rupture
(n = 3), suspected DVT (n = 2), wound infection (n = 3) and
excessive pain (n = 1).
Discussion
These results demonstrate that the SMART protocol results
in a low rate of re-rupture (three patients, 1.1%), a satisfac-
tory outcome with a mean ATRS = 72.4 and mean
AS = 72.3 at nine months and significant cost savings.
These nine month scores are limited in terms of follow-up
data available but a similar pattern is seen for both the four
and six month follow-up data.
Although this study was not designed to show that any
improvements in the rate of re-rupture resulted directly
from the introduction of the new protocol, the findings are
flexed position.3 The results only relate to patients who
have been assessed and begin treatment within two weeks
of injury. Although data exist for those with delayed pres-
entation, the analysis remains incomplete. Issues such as
partial or non-closure of the gap resulting from organisa-
1
2013 Secondly, all our patients were followed up during the
immobilisation period in a specialised dedicated clinic. This
standardised approach may maximise patient compliance
and understanding of the injury. The role of the specialist
physiotherapist is considered a key component, providing a
dedicated service that allows the patient to develop an
understanding of the management and treatment. Continu-
ity of care is also important, and the provision of this by the
specialist physiotherapist addresses the potential problem
created by rotation of junior doctors and changes in work-
ing practice. Furthermore, the specialist physiotherapists
had access to immediate support from orthopaedic consult-
ants when required. The protocol requires a level of com-
mitment, manpower and dedication that would be difficult
to provide in a large standard fracture clinic.
Thirdly, following the period of immobilisation all
patients followed a strict physiotherapy protocol. The pro-
gression of rehabilitation needs to be balanced against the
risks of re-rupture and lengthening of the tendon. Strict
guidelines throughout all parts of the rehabilitation process
are therefore essential.
We report a rates of VTE of 7.5% (20/273); the incidence
of symptomatic DVTs being 5.5% (15/273) and that of
symptomatic PE 2% (5/273). This incidence of VTE is sim-
ilar to that reported by Healy et al, 2010 who reported an
incidence of 10 DVT and 3 PE from 208 patients that had
ruptured their Achilles tendon.15 The thromboprophylactic
management of patients with Achilles rupture is controver-
sial. Our patients were treated selectively. Interestingly,
both of the patients with a previous history of DVT sus-
tained another DVT despite prophylaxis. Mechanical
methods (i. e. graded compression stockings or intermittent
pneumatic leg compression devices) in conjunction with the
cast/orthosis, have proven ineffective.16
There are a number of limitations to this study. First, it
was a descriptive case series aimed at monitoring our cur-
rent practice, which has evolved over a period of five years,
rather than an experimental study testing the efficacy of a
treatment. Although it clearly shows potential benefit for

THE BONE & JOINT JOURNAL

 THE TREATMENT OF A RUPTURE OF THE ACHILLES TENDON USING A DEDICATED MANAGEMENT PROGRAMME
these patients, it is not a substitute for the proof afforded by
a randomised controlled trial. Previous attempts to conduct
a randomised study in our department failed because of a
high level of patient preference for either non-surgical or
surgical treatment. Secondly, the secondary outcome meas-
ures, the ATRS and AS scores, were not collected from all
the patients (four months, n = 135; six months, n = 103;
and nine months, n = 43), as patients were discharged from
the clinic once they had returned to their required level of
activity. In addition, we did not have access to isokinetic
strength testing and included a single-leg heel-raise test to
give an indication of muscle strength.
Although it was not our intention to conduct a study
testing the efficacy of treatment, there was a need to review
this newly adopted protocol for patient safety on an annual
basis. We felt that it was important to share our case series
report, albeit with the above limitations, as the rate of re-
rupture appears to be the lowest reported to date.
This work has produced local and regional changes in
how patients with a rupture of the Achilles tendon are man-
aged. There has been a move away from an equal ratio of
conservative to surgical management to one favouring con-
servative treatment. In addition, as the protocol was used
for elite sports personnel, it suggests that the regime is safe
and appropriate for the high-performance athlete. In order
to achieve these goals, the SMART protocol requires a
committed team approach and a good relationship between
the orthopaedic surgeons, radiologists, physiotherapists
and nurses.
This protocol is a pragmatic approach to the manage-
ment of patients with a rupture of the Achilles tendon that
can easily be followed by most healthcare providers. Most
importantly, this change has resulted in improved out-
comes, a reduced rate of re-rupture, a reduction in surgical
intervention and cost savings.
Author contributions
A. M. Hutchison: Protocol development, review and amendment, data collec-
tion and analysis, writing of manuscript, performed clinic reviews and rehabil-
itation.
C. Topliss: Part of team setting up protocol with regular review and amendment.
Review of paper. Review of problem patients and support of clinic when
required
D. Beard: Project design and guidance, some analysis, writing and editing of
manuscript.
R. M. Evans: Writing paper, performing ultrasound scans.
P. Williams Supervising Clinical Consultant, algorithm development, decision
making & management, surgery, data analysis, writing manuscript.
We thank the consultant orthopaedic surgeons, consultant musculoskeletal
radiologists, musculoskeletal physiotherapists and fracture clinic nursing staff
VOL. 97-B, No. 4, APRIL 2015
515
at Morriston Hospital, Swansea, for their support in the development of the
SMART protocol.
A. M Hutchison received modest educational support from OPED UK Ltd (Med-
ical Devices) to attend a conference
The author or one or more of the authors have received or will receive benefits
for personal or professional use from a commercial party related directly or
indirectly to the subject of this article.
This article was primary edited by G. Scott and first proof edited by J. Scott.
References
1. Khan RJ, Fick D, Keogh A, et al. Treatment of acute achilles tendon ruptures. A
meta-analysis of randomized, controlled trials. J Bone Joint Surg [Am] 2005;87-
A:2202–2210.
2. Amendola A. Outcomes of open surgery versus nonoperative management of acute
achilles tendon rupture. Clin J Sport Med 2014;24:90–91.
3. Wallace RG, Heyes GJ, Michael AL. The non-operative functional management of
patients with a rupture of the tendo Achillis leads to low rates of re-rupture. J Bone
Joint Surg [Br] 2011;93-B:1362–1366.
4. Wallace RG, Traynor IE, Kernohan WG, Eames MH. Combined conservative and
orthotic management of acute ruptures of the Achilles tendon. J Bone Joint Surg [Am]
2004;86-A:1198–1202.
5. Silbernagel KG, Steele R, Manal K. Deficits in heel-rise height and achilles tendon
elongation occur in patients recovering from an Achilles tendon rupture. Am J Sports
Med 2012;40:1564–1571.
6. Qureshi AA, Ibrahim T, Rennie WJ, Furlong A. Dynamic ultrasound assessment
of the effects of knee and ankle position on Achilles tendon apposition following
acute rupture. J Bone Joint Surg [Am] 2011;93-A:2265–2270.
7. Trickett RW, Hodgson P, Lyons K, Thomas R. Effect of knee position on gap size
following acute Achilles rupture. Foot Ankle Int 2011;32:1–4.
8. Von Forell GA, Hyoung PS, Bowden AE. Failure modes and fracture toughness in
partially torn ligaments and tendons. J Mech Behav Biomed Mater 2014;35:77–84.
9. Schepull T, Aspenberg P. Early controlled tension improves the material properties
of healing human achilles tendons after ruptures: a randomized trial. Am J Sports
Med 2013;41:2550–2557.
10. Krapf D, Kaipel M, Majewski M. Structural and biomechanical characteristics
after early mobilization in an Achilles tendon rupture model: operative versus nonop-
erative treatment. Orthopedics 2012;35:1383–1388.
11. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practitioner
1957;179:56–58.
12. Costa ML, Logan K, Heylings D, Donell ST, Tucker K. The effect of achilles ten-
don lengthening on ankle dorsiflexion: a cadaver study. Foot Ankle Int 2006;27:414–
417.
13. Ganestam A, Barfod K, Klit J, Troelsen A. Validity and reliability of the Achilles
tendon total rupture score. J Foot Ankle Surg 2013;52:736–739.
14. Leppilahti J, Forsman K, Puranen J, Orava S. Outcome and prognostic factors of
achilles rupture repair using a new scoring method. Clin Orthop Relat Res
1998;346:152–161.
15. Healy B, Beasley R, Weatherall M. Venous thromboembolism following prolonged
cast immobilisation for injury to the tendo Achillis. J Bone Joint Surg [Br] 2010;92-
B:646–650.
16. Domeij-Arverud E, Latifi A, Labruto F, Nilsson G, Ackermann PW. Can foot
compression under a plaster cast prevent deep-vein thrombosis during lower limb
immobilisation? Bone Joint J 97-B1227–1231.
 Journal of Clinical Orthopaedics and Trauma 18 (2021) 51e55

Contents lists available at ScienceDirect

Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

Traumatic rotator cuff tears - Current concepts in diagnosis and

management
Ali Abdelwahab a, Neeraj Ahuja b, Karthikeyan P. Iyengar b, Vijay Kumar Jain c, Nik Bakti d,
Bijayendra Singh e, *
a
Medway NHS Foundation Trust, Kent, ME7 5NY, UK
b
Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
c
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi 110001, India
d
East Kent Hospitals University Foundation Trust, William Harvey Hospital, TN24 0LZ, UK
e
Canterbury Christ Church University, Medway NHS Foundation Trust, Kent, ME7 5NY, UK

a r t i c l e i n f o a b s t r a c t

Article history: Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age
Received 26 February 2021 groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in
Received in revised form younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon
4 April 2021
degeneration. Though there has been a considerable debate in the literature of the terms “acute” and
Accepted 5 April 2021
“traumatic” used in the classification of rotator cuff tears, there appears to be consensus about the need
Available online 17 April 2021
for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant
differences in rotator cuff tears between those occurring in younger and older patients could be due to
Keywords:
Shoulder
mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation.
Rotator cuff Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other
Rotator cuff injuries patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination,
Rupture complementary imaging is a pre-requisite for an early diagnosis and effective management.
Surgery We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic
Rehabilitation mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and
Physiotherapy management of these distinct injuries are discussed with review of current literature.
Crown Copyright © 2021 All rights reserved.

Rotator cuff tears (RCT) are a common causes of shoulder
complaints and one of the leading causes of time lost from work or
athletic activity.1 The reported prevalence of traumatic RCT can be
up to 40% of all RCT.2 In general, they tend to be a common cause of
morbidity in the elderly. RCT occur in patients of all ages and have
the potential for both short and long-term disability if they are not
appropriately managed. Despite the high prevalence of this disor-
der, the proper management of RCT has long been a source of
debate among orthopedic surgeons.1 It has been accepted that
there is a role for both non-operative and operative management to
improve outcomes due to RCT.3 Most studies focus on elderly pa-
tients and fail to delineate between a RCT in older and younger
populations or traumatic and degenerative RCT. Studies that focus
purely on traumatic RCT are limited in number. A study by Sher
et al. found that in patients older than 40 years, asymptomatic tears
were common; in contrast to patients younger than 40 years. As
such, patients under 40 years of age with RCT, appear to be a
different patient population that need to be approached differently
to older patients.4 The principal difference in RCT between young
and old patients may be related to differences in healing potential,
etiology of the tear, levels of activity and physical demands, and
differing long-term expectations.5-7
1. Biomechanical consequence of rotator cuff tears

The muscles of the rotator cuff play an important role in normal

* Corresponding author.
E-mail addresses: ali.abdelwahab@nhs.net (A. Abdelwahab), neeraj.ahuja@nhs.
net (N. Ahuja), kartikp31@hotmail.com (K.P. Iyengar), rvijayortho@gmail.com
(V.K. Jain), bijayendra.singh@nhs.net (B. Singh).
glenohumeral motion and stability. The supraspinatus acts to
initiate abduction, the infraspinatus and teres minor are respon-
sible for external rotation, while the subscapularis is the main in-
ternal rotator of the shoulder.8 As the rotator cuff muscles act as a

https://doi.org/10.1016/j.jcot.2021.04.013
0976-5662/Crown Copyright © 2021 All rights reserved.
A. Abdelwahab, N. Ahuja, K.P. Iyengar et al.
force couple with each other and the deltoid, they work together to
contain the inherently unstable glenohumeral joint. Massive RCT
adversely affect normal shoulder biomechanics. Shoulders with
massive traumatic RCT demonstrated an increase in maximum in-
ternal rotation in posterosuperior tears, maximum external rota-
tion in anterosuperior tears, and total rotation range of motion at all
abduction angles in a cadaveric model compared with the intact
state for both.8 Disruption of the muscle-tendon units that
contribute to active external rotation (infraspinatus and teres mi-
nor) leads to weakness in active external rotation and an increase in
passive internal rotation, whereas massive RCT involving the sub-
scapularis led to weakness in active internal rotation and increased
passive external rotation. These cadaveric findings highlight the
important dynamic unloaded effects that the rotator cuff tendons
have on glenohumeral kinematics.9 To restore normal kinematics in
patients with massive traumatic tears of the posterosuperior ro-
tator cuff tendons, greater forces are required by both the deltoid
and the intact muscle-tendon units of the rotator cuff, particularly
the subscapularis, to achieve stable abduction.10 The progression of
a RCT to disrupt the axial force couple leads to superior subluxation
of the humeral head and dysfunction of the shoulder. Pseudo pa-
ralysis of the shoulder can occur when the force couple of the
glenohumeral joint are disrupted.11 The risk factors for pseudo
paralysis are still being investigated; however, a recent study by
Collin et al. found disruption of the entire subscapularis or of 3
rotator cuff muscles to be the major risk factors.12
2. Mechanism of injury, tear characteristics and tendon
involvement
The reported incidence of acute traumatic cuff tears is 8%.13
Traumatic tears are thought to stem from higher energy mecha-
nisms and cause full-thickness tears, whereas the natural history of
attritional tears is that they originate as partial-thickness tears and
perhaps progress to full-thickness tears.14 Also, traumatic RCT may
be larger and more likely to involve the subscapularis. Traumatic
subscapularis tear can result from a forced external rotation or
hyperextension of the shoulder, or in association with anterior
glenohumeral dislocation.15 Overall, it appears that there are 2
patterns of injury for traumatic tears1: traumatic RCT in young
adults from high energy injuries and2 RCT associated with overuse
in overhead athletes. Patients with acute traumatic RCT commonly
present with symptoms of pain, often localised to the subdeltoid
region with loss of function. An inability to elevate the arm on
overhead activity after a traumatic event and normal radiographs
should raise suspicion, as a high proportion of these injuries can be
missed during initial assessment.16 The supraspinatus is the most
commonly involved tendon, as it bears the majority of shoulder-
stabilizing strain.17 Namdari et al., found that 53% of their pa-
tients also had an infraspinatus tear.18 Whereas Ide et al., reported
35% involvement of the infraspinatus in association with supra-
spinatus tears.19 Bjornsson et al., in their study revealed that 15 of
the 42 (36%) shoulders had a single-tendon tear, of which 14
involved the supraspinatus and 1 the subscapularis. Combined
supraspinatus and subscapularis tears were present in 8 patients
and combined supraspinatus and infraspinatus tears occurred in 8
patients. Three-tendon tears were present in only 12 patients.20 In a
systematic review of traumatic cuff tear outcomes by Mall et al.,
supraspinatus tears were present in 84%, infraspinatus tears in 39%,
and subscapularis tears in 78%.14
3. Shoulder terrible triad
The Shoulder Terrible Triad (STT) is defined as a traumatic
anterior shoulder dislocation, associated with RCT and nerve injury
52
Journal of Clinical Orthopaedics and Trauma 18 (2021) 51e55
to the brachial plexus branches, which compromises all functional
structures of the shoulder.22 They also included displaced greater
tuberosity (GT) fractures as they create a discontinuity of the load
transfer between the RC and the proximal humerus, similar to a
complete traumatic RCT in the setting of a STT. The retrospective
cohort study of 30 patients with STT only included patients with
first time anterior shoulder dislocation, and those requiring acute
surgery for a RCT or a displaced GT fracture.22 In this study, the most
frequent injury pattern was a RCT in 83%, an anterior capsular
lesion in 63%, and an isolated axillary nerve injury in 70%. No
additional anterior glenoid injury repair was undertaken in any of
the patients, including the 6% patients that had a Bony Bankart
lesion but involving less than 20% glenoid bone loss. At a median
follow up of 27 months, repaired RCT correlated with better results
than GT fixation, each with a reoperation rate of 20% for RC retear or
GT loosening. No patient suffered a recurrent dislocation or residual
instability after surgery. All neurological injuries were post-
ganglionic and managed conservatively. All patients in this series
showed evidence of partial or full nerve recovery at their last
electromyography during follow-up and clinical evidence of a
reinnervation process. Irreversible nerve injuries associated with
acute shoulder dislocations are uncommon, and most of the nerve
injuries recover partially or completely after a post-traumatic in-
terval between 3 and 24 months with reported rates in the litera-
ture ranging from 87.5% to 100% of cases.23
4. Diagnosis
The British Elbow and Shoulder Society (BESS)/British Ortho-
pedic Association (BOA) patient care pathways provide a helpful
guide to the clinician. It reiterates the importance of history and
examination in the primary care setting, with a useful management
algorithm.24 The pathway stresses the significance of being aware
of those patients who may have had a trauma to the shoulder with
acute pain and weakness, which could be due to an acute rotator
cuff tear. In these circumstances an urgent referral to a shoulder
specialist should be made and/or consideration of imaging of the
rotator cuff. Many patients with suspected acute traumatic tears of
RC also have an unexpected abnormality in the subscapularis
tendon or an occult fracture of the greater tuberosity.25 Radio-
graphically, occult greater tuberosity fractures and complete sub-
scapularis tears are commonly seen on magnetic resonance images
(MRI) in patients suspected of having traumatic tears of the rotator
cuff. Greater tuberosity fractures are more likely in patients
younger than 40 years, whilst subscapularis tears are more com-
mon in patients older than 40 years.25 McCauley looked at the
prevalence of bone marrow oedema in the greater tuberosity of the
humerus on MRI imaging and the injury mechanism which can lead
to this finding. MRI reports from 863 patients over 74 months were
reviewed to identify patients with marrow oedema in the greater
tuberosity.26 Most patient with this finding had a history of a prior
fall, but without a direct blow to the greater tuberosity. This history
suggests the marrow oedema in the greater tuberosity is likely due
to avulsion force rather than direct impact. The lack of oedema in
the overlying soft tissue further supports this hypothesis. The
presence of rotator cuff injuries in most patients could be explained
by avulsion forces generated by contraction of the supraspinatus
muscle during a fall causing greater tuberosity avulsion injury.
Avulsion forces generated by supraspinatus tendon have been
previously described as a mechanism of rotator cuff injury.25,27,28
Similar findings have been reported in a study by Mason et al.28
In conclusion, marrow oedema in the greater tuberosity is an
infrequent finding on MRI imaging of the shoulder. In most patients
with oedema in the greater tuberosity there is a history of trauma
and most patients have rotator cuff abnormalities including partial
A. Abdelwahab, N. Ahuja, K.P. Iyengar et al. Journal of Clinical Orthopaedics and Trauma 18 (2021) 51e55

Table 1
Clinical outcomes.

Study Constant Score VAS Score UCLA Score DASH Active Forward Active External Rotation
Flexion

Gerber et al. (1996) 59 (preop) to 95 NR NR NR NR NR

Braune et al. (2003) Group 1: 94.1 (acute Group 1: 20 (7e10) NR NR Group I: 166 Group 1: 56
repair) Group 2: 13 (7e10), 7 (5-6), 6 Group II: 156 Group 2: 38
Group 2: 75.3 (delayed (<5)
repair)
Lahteenmaki et al. NR NR Pain: 1.8 (preop) to 8.3 NR Small tear: 130-160 Small tear: 62-61
(2006) Function: 1.8e8.6 Medium tear: 112- Medium tear: 60-54
Strength: 2.7e4.4 153
Satisfied 239/
unsatisfied 7
Overall score: 30.6
Namdari et al. (2008) 93.4 6.2e1.2 NR 41.7 81e97 93e109
e12.2
Ide et al. (2007) NR NR 14.9e31.1 NR 97e162 30-43 (internal rotation: L-2 to
T-10)
Hantes et al. (2011) Group 1: 39-82 NR Group I: 10-31 NR NR NR
Group 2: 40-70 Group 2: 12-27
Petersen and Murphy NR 7e1.4 Group 1: 6-30 Group 1: 54-137 39e49
(2011) Group 2: 9-30 Group 2: 52-142
Group 3: 9-25 Group 3: 66-100

Note: VAS, visual analog scale; UCLA, University of California, Los Angeles; DASH, Disabilities of the Arm, Shoulder, and Hand score.

and full thickness tears. The history of trauma without direct blow
to the shoulder and the location of the oedema indicates that
marrow oedema often results from avulsion injury by the supra-
spinatus tendon.26
5. Treatment options and clinical outcomes
5.1. Nonoperative management
Nonoperative management with physiotherapy remains a
cornerstone in the management of RCT. Shoulder pain and function
after RC repair, or physiotherapy without surgical repair of small-to
medium-sized RC tears have been investigated in a few prospective
randomized studies.29-32 These studies have shown no difference,30
or slightly better outcome following a surgical repair.29,32 These
differences have been below or on the thresholds for clinical
importance. However, the majority of studies have included only
degenerative, nontraumatic tears.29,32 A prospective randomized
study focusing exclusively on traumatic cuff tears by Ranebo et al.,
shows that small full-thickness RCT, treated either with operative
repair or physiotherapy without repair can result in good or satis-
factory outcome in a majority of patients at the 1-year follow-up.33
Though, operative repair resulted in slightly higher Constant Score
(CS) and Western Ontario Rotator Cuff (WORC) score, the differ-
ences were neither clinically nor statistically significant. There were
no significant differences in pain or quality of life between the 2
groups; 29% of unrepaired tears had increased in tear size >5 mm
during the observation period.33
5.2. Rotator cuff repair and surgical timing
The goal of repairing a traumatically injured rotator cuff is to
restore biomechanics of the shoulder. This in turn should result in
outcomes of reduced pain and improved function. Repair should be
undertaken with a fixation device that would allow aggressive
rehabilitation process.34,35 Complete anatomic repair, when
reasonable, should be performed.
Healing continues to be a major focus in rotator cuff surgery,
with surgeons and researchers attempting to determine the best
milieu to allow tendon to bone healing. Healing has been consis-
tently shown to dramatically affect outcomes.15
53
Healing rates for traumatic tears should theoretically be
improved as it often involves younger patients. Early repair should
also result in favorable outcome as retraction and muscle atrophy as
not set in and have a favorable biological environment for tendon
healing with ongoing inflammatory response. Mall et al. showed in
his story the poor outcomes related to delayed diagnosis and sur-
gery as a result of retraction, fatty infiltration and tendon retrac-
tion.36 The proportion of muscle fatty infiltration increases with the
degree of musculotendinous retraction, and early surgery has been
recommended to prevent tendon retraction and preserve tissue
quality.37
Spross et al., have shown that acute pseudo-paralysis following
massive traumatic cuff tear can reliably be reversed with early
arthroscopic repair.38
Gerber et al. reported improved outcomes in the 13 patients
who underwent surgery within 20 months of injury as compared to
the 3 patients whose surgeries were delayed more than 36 months
after injury.15 Petersen and Murphy noted that surgical repairs
performed within 16 weeks from injury were associated with a
significantly improved range of motion and outcome scores,
compared to those performed later than 16 weeks.39 Bassett and
Cofield determined that traumatic cuff tears repaired within 3
weeks had a significantly better forward elevation and a trend to-
wards better strength in both abduction and external rotation than
those repaired after 3 weeks.13 However, Bjornson et al. found no
difference in healing, Constant Score, DASH score, or WORC index
with respect to time to repair.20 Millett et al. recently conducted a
meta-analysis of level I randomized clinical trials comparing
arthroscopic single-row vs. double-row rotator cuff repair.40 They
found that single-row repairs had a significantly higher retear rates
compared with double-row repairs, especially with regard to
partial-thickness retears, although, they were not able to detect a
difference in an improvement in outcome scores between single-
row and double-row repairs.40 They also reported failure rates as
low as 7% in small tears <1 cm and upward of 69% retears in larger
tear.40
5.3. Outcome following early cuff repair
Most studies show a significant improvement from preoperative
to postoperative values for the respective outcome’s measures
A. Abdelwahab, N. Ahuja, K.P. Iyengar et al.
used. In cases with early cuff repair. Namdari et al. reported post-
operative DASH and Constant scores (CS) of 12.2 and 93.4.18 Ide
et al. reported good results using UCLA score 31.1 in the acute repair
group.19 Petersen and Murphy reported good outcome with early
repair on UCLA score.39 Gerber et al. in his study of isolated sub-
scapularis repair reported significant improvement on CS to 95.15
Lahteenmaki et al. noted a significant improvement post-
operatively with 30.6 overall score on UCLA.41 Hantes et al. re-
ported significantly better Constant and UCLA scores when
comparing acute repair versus delayed repair.42 (Table 1).
6. Discussion
Traumatic cuff tears demonstrate a particular need for careful
management, given the potential for both short- and long-term
disability if the tears are not appropriately managed. Especially in
cases of acute trauma, early surgical treatment is generally rec-
ommended as delays are associated with tendon retraction, atro-
phy of muscles, and generally poor surgical outcome12,14,17 RCT in
patients younger than 40 years are of traumatic origin and respond
well to both arthroscopic and open rotator cuff repair in terms of
pain relief and self-reported outcomes postoperatively; patients
report high levels of satisfaction. Patients who experience a trau-
matic rotator cuff tear are categorically different from those who
experience a nontraumatic degenerative type of tear. These pa-
tients are more active, sustained more violent mechanism of injury
and this results in large full thickness tear or even massive rotator
cuff tear involving more than one tendon. The subscapularis tendon
is also more likely to be involved. Tendon healing in traumatic tears
is improved when repaired early. In the current available literature,
there is no indication that acute repair in traumatic injuries pro-
duces better outcomes; however, this may be related to the diffi-
culty in differentiating an acute on chronic tear from a definitively
acute, traumatic tear. Further research is needed to directly
compare the results of acute intervention for patients who present
with traumatic RCT.
Source of funding statement
None.
Declaration of competing interest
None.
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action forces at the glenohumeral joint. J Orthop Res. 2002;20:439e446.
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tween massive chronic rotator cuff tear pattern and loss of active shoulder
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13. Bassett RW, Cofield RH. Acute tears of the rotator cuff. The timing of surgical
repair. Clin Orthop Relat Res. 1983;175:18e24.
14. Mall NA, Kim HM, Keener JD, et al. Symptomatic progression of asymptomatic
rotator cuff tears A prospective study of clinical and sonographic variables.
J Bone Joint Surg Am. 2010;92:2623e2633.
15. Gerber C, Krushell RJ. Isolated tears of the subscapularis muscle: clinical fea-
tures in sixteen cases. J Bone Joint Surg Br. 1991;73:389e394.
16. Sorensen AK, Bak K, Krarup A, et al. Acute rotator cuff tear: do we miss the
early diagnosis? A prospective study showing a high incidence of rotator cuff
tears after shoulder trauma. J Shoulder Elbow Surg. 2007;16(2):174e180.
17. Warner JP, Krushell RJ, Masquelet A, Gerber C. Anatomy and relation- ships of
the suprascapular nerve: anatomical constraints to mobilization of the supra-
spinatus and infraspinatus muscles in the management of massive rotator-cuff
tears. J Bone Joint Surg Am. 1992;74:36e45.
18. Namdari S, Henn RF, Green A. Traumatic ante- superior rotator cuff tears: the
outcome of open surgical repair. J Bone Joint Surg Am. 2008;90:1906e1913.
19. Ide J, Tokiyoshi A, Hirose J, Mizuta H. Arthroscopic repair of traumatic com-
bined rotator cuff tears involving the subscapularis tendon. J Bone Joint Surg
Am. 2007;89:2378e2388.
20. Bjornsson HC, Norlin R, Johansson K, Adolfsson LE. The influence of age, delay
of repair, and tendon involvement in acute rotator cuff tears: structural and
clinical outcomes after repair of 42 shoulders. Acta Orthop. 2011;82:187e192.
22. Marsalli MM, Sepúlveda OM, Mora
n NM, Breyer JMM. Shoulder terrible triad:
classification, functional results, and prognostic factors. J Am Acad Orthop Surg.
2020 March 1;28(5):200e207.
23. Hems TEJ, Mahmood F. Injuries of the terminal branches of the infraclavicular
brachial plexus: patterns of injury, management and outcome. J Bone Joint Surg
Br. 2012;94:799e804.
24. Kulkarni R, Gibson J, Brownson P, et al. Subacromial shoulder pain. Shoulder
Elbow. 2015;7(2):135e143.
25. Zanetti M, Weishaupt D, Jost B, Gerber C, Holder J. MR imaging for traumatic
tears of the rotator cuff: high prevalence of greater tuber- osity fractures and
subscapularis tendon tears. Am J Roentgenol. 1999;172(2):463e467.
26. McCauley TR, David G, Disler, Marvin K. Bone marrow edema in the greater
tuberosity of the humerus at MR imaging: association with rotator cuff tears
and traumatic injury. Magn Reson Imag. 2000;(18):979e984.
27. Anzilotti KF, Schweitzer ME, Oliveri M, Marone PJ. Rotator cuff strain: a post-
traumatic mimicker of tendonitis on MRI. Skeletal Radiol. 1996:555e558.
28. Mason BJ, Kier R, Bindleglass DF. Occult fractures of the greater tuberosity of
the humerus: radiographic and MR imaging findings. Am J Roentgenol.
1999;172(2):469e473.
29. Kukkonen J, Joukainen A, Lethtinen J, et al. Treatment of nontraumatic rotator
cuff tears: a randomized controlled trial with two years of clinical and imaging
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30. Schemitsch C, Chahal J, Vicente M, et al. Surgical repair versus conservative
treatment and subacromial decompression for the treatment of rotator cuff
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1100e1106.
31. Ryo€ sa
€ A, Liami K, Aarimaa V, Lehtimaki K, Kukkonen J, Saltychev M. Surgery or
conservative treatment for rotator cuff tear: a meta-analysis. Disabil Rehabil.
2017;39(14):1357e1363.
32. Lambers Heerspink FO, Van Raay JJ, koorevaar RC van Eerden PJ,
Westerbeek RE, van ’t Riet E, et al. Comparing surgical repair with conservative
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33. Ranebo MC, Bjo €rnsson Hallgren HC, Holmgren T, Adolfsson LE. Surgery and
physiotherapy were both successful in the treatment of small, acute, traumatic
rotator cuff tears: a prospective randomised trial. J Shoulder Elbow Surg.
2020;29:459e470.
34. Denard PJ, Jiwani AZ, LVadermann A, Burkhart SS. Long-term outcome of
arthroscopic massive rotator cuff repair: the importance of double row fixa-
tion. Arthroscopy. 2012;28:909e915.
35. Vaishnav S. Millett PJ Arthroscopic rotator cuff repair: scientific rationale,
surgical technique, and early clinical and functional results of a knotless self-
reinforcing double-row rotator cuff repair system. J Shoulder Elbow Surg.
2010;19:83e90.
36. Mall NA, Tanaka MJ, Choi LS, Paletta GA. Current concepts review: factors
affecting rotator cuff healing. J Bone Joint Surg. 2014;96:778e788.
37. Meyer DC, Farshad M, Amacker NA, Gerber C, Wieser K. Quantitative analysis of
muscle and tendon retraction in chronic rotator cuff tears. Am J Sports Med.
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38. Spross C, Behrens G, Dietrich TJ, et al. Early arthroscopic repair of acute trau-
matic massive rotator cuff tears leads to reliable reversal of pseudoparesis:
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39. Petersen SA, Murphy TP. The timing of rotator cuff repair for the restoration of
A. Abdelwahab, N. Ahuja, K.P. Iyengar et al.
function. J Shoulder Elbow Surg. 2011;20:62e68.
40. Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ. Clinical and structural out-
comes after arthroscopic single-row versus double-row rotator cuff repair: a
systematic review and meta-analysis of level I randomized clinical trial.
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41. Lahteenmaki HE, Virolainen P, Hiltunen A, Heikkila J, Nelimarkka OI. Results of
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42. Hantes ME, Karidakis GK, Vlychou M, Varitimidis S, Dailiana Z, Malizos KN.
A comparison of early versus delayed repair of traumatic rotator cuff tears.
Knee Surg Sports Traumatol Arthrosc. 2011:1766e1770.
 REVIEW ARTICLE
What’s New in Pediatric Septic Arthritis? A Review
of Pertinent Clinical Questions
Ahmad Hachem, MD* and Lawson A.B. Copley, MD, MBA†
Background: The evaluation and treatment of children with
septic arthritis (SA) is challenging and requires an organized
approach to address the spectrum of pathogens which appear to
aggregate in age-specific groups. Although evidence-based
guidelines have recently been published for the evaluation and
treatment of children with acute hematogenous osteomyelitis,
there is a relative dearth of literature devoted exclusively to SA.
Methods: Recently published guidance for the evaluation and
treatment of children with SA was reviewed and evaluated with
respect to pertinent clinical questions to summarize what is new
in this area of practice for pediatric orthopaedic surgeons.
Results: Evidence suggests that there is a profound difference
between children with primary SA and those who have con-
tiguous osteomyelitis. This disruption of the commonly accepted
paradigm of a continuum of osteoarticular infections has im-
portant implications in the evaluation and treatment of children
with primary SA. Clinical prediction algorithms have been es-
tablished to help determine the applicability of magnetic reso-
nance imaging during the evaluation of children suspected to
have SA. Antibiotic duration for SA has been recently studied
with some evidence in favor of short-course parenteral followed
by short-course oral therapy may be successful if the pathogen is
not methicillin-resistant Staphylococcus aureus.
Conclusion: Recent studies of children with SA have provided
better guidance for evaluation and treatment to improve diag-
nostic accuracy, processes of evaluation, and clinical outcomes.
Level of Evidence: Level 4.
Key Words: septic arthritis, pediatric, microbiology, epidemiology
(J Pediatr Orthop 2023;43:578–583)
M usculoskeletal infections occur somewhat frequently
among children who are otherwise healthy and
immunocompetent.1 In the United States, SA has an in-
cidence of 4 in 100,000 children per year and occurs more
From the *Department of Pediatrics, College of Medicine-Jacksonville,
University of Florida, Jacksonville, FL; and †Department of Or-
thopaedic Surgery and Pediatrics, University of Texas Southwestern,
Dallas, TX.
None of the authors received financial support for this study.
The authors declare no conflicts of interest.
Reprints: Lawson A.B. Copley, MD, MBA, Children’s Health System of
Texas, 1935 Medical District Drive, Dallas, TX 75235. E-mail: lawson.
copley@childrens.com.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPO.0000000000002453
578 | www.pedorthopaedics.com
Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved.
frequently in those less than 5 years of age. The incidence
varies based on geographical location and population
density. In Europe, a rate of up to 24 per 100,000 is
reported.2 Whereas New Zealand reports a rate of 1 per
16,000 with indigenous populations, like the Māori, hav-
ing an even higher rate of 1 per 4300.3 In addition to racial
and ethnic disparities, another consideration which exists
in interpreting literature devoted to SA is whether the
studies contain cases of SA associated with osteomyelitis.
Recently, substantial effort has been invested to de-
velop clinical practice guidelines for the evaluation and
treatment of pediatric acute hematogenous osteomyelitis
following a systematic literature review by the bone and
joint infection guideline panel of the Pediatric Infectious
Disease Society and Infectious Disease Society of America.4
In contrast, there has been a relative dearth of literature
devoted exclusively to pediatric septic arthritis (SA). The
purpose of this review is to highlight recent research which
has been devoted to the evaluation and treatment of chil-
dren with SA.
MICROBIOLOGY: A CHANGE IN
EPIDEMIOLOGICAL LANDSCAPE
Recent literature suggests that pathogen distribution
in primary SA is dependent on the child’s age. Neonates
up to 6 months are vulnerable to Streptococcus agalactiae
and Enterobacteriaceae which account for ∼90% of
pathogens isolated in this age group. Before the advent of
molecular techniques for microbiological detection,
Staphylococcus aureus was thought to be the predominant
pathogen causing SA in children over 6 months.5,6 Be-
cause of the low rate of positive cultures, many children
were labeled as “culture-negative,” with rates varying
from 21% to 70% in large case series.7,8 However, with the
widespread use of polymerase chain reaction (PCR) the
microbiologic epidemiology landscape has recently been
clarified. Kingella kingae is now reported in some com-
munities to be the most common pathogen among chil-
dren between the ages of 6 and 48 months, followed by
S. aureus and Streptococcus pneumoniae.9,10 In one study
K. kingae was responsible for 79.1% of confirmed patho-
gens causing SA in children less than 24 months, and 93%
before the age of 36 months.9 In that same study, it is
notable that the children who were culture negative and
labeled as “presumed,” had a lower rate of sample PCR
acquisition, and had features which were comparable to
those of children with confirmed K. kingae infections. This
J Pediatr Orthop  Volume 43, Number 9, October 2023
J Pediatr Orthop  Volume 43, Number 9, October 2023
begs the question of whether K. kingae infections are
underestimated due to being incorrectly labeled as “cul-
ture-negative” cases of SA, particularly in communities
where the empiric treatment regimen is directed against
methicillin-sensitive Staphylococcus aureus (MSSA), as the
antibiotics commonly used to cover MSSA often have
effective coverage of Kingella spp.9 In Europe, where there
is widespread use of molecular diagnostic techniques,
K. kingae has been established as the most common
pathogen causing both osteomyelitis and SA in children
less than 4 years of age.11,12 However, S. aureus remains
the most common pathogen isolated from children over
4 years of age.13,14 There has also been noted a geo-
graphical numerical discrepancy for the distribution of
cases of pediatric SA in the United States with the South
census region encompassing 40% of the reported cases
between 2016 and 2019, almost the cases of Northeast and
West census region combined (19%, respectively)
(Fig. 1).15 There was also a perceived seasonal variation in
the cases of pediatric SA and was often common pediatric
orthopaedic teaching, but a recent study using national
database of pediatric hospital centers showed no clear
seasonal variation in the cases of pediatric SA in the
United States. It did however show a seasonal variation
within the Northeast region which is most likely related to
weather changes.16
THE OSTEOARTICULAR INFECTION
CONTINUUM PARADIGM SHIFT
SA has 3 potential mechanisms of onset: hematogenous
spread, direct inoculation, and contiguous spread from ad-
jacent osteomyelitis.17 A widely held belief considers that os-
teomyelitis and SA are along the same disease continuum.18
Joints including the hip, shoulder, elbow, and ankle, which
have an intra-articular metaphysis permit more proximate
access from bone to the synovial space. In children less than
FIGURE 1. Geographical distribution of cases of pediatric septic
arthritis reported in 2019 using number of discharges per census
area for patients aged 0 to 18 years for the diagnosis of infectious
arthritis KID database on HCUP database (http://datatools.ahrq.
gov//hcupnet?type=subtab&tab=hcnis&count=32).
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved.
What’s New in Pediatric Septic Arthritis
18 months of age, SA is also believed to extend from meta-
physeal osteomyelitis through small transphyseal vessels that
cross the growth plate and connect the metaphysis to the ep-
iphysis. One study found no difference between children with
primary SA and those with contiguous osteomyelitis based on
symptoms, sex, age, joint involvement, leukocytosis, and mi-
crobiological etiologies.5 Recently, this longstanding para-
digm has been challenged with evidence illuminating the
many, marked differences between primary and secondary
forms of SA based on age, culture positivity, bacteremia, in-
flammatory markers, duration of hospitalization, and, most
importantly, the rate of long-term adverse outcomes.19,20 In a
study comparing 134 children with primary SA to 105 chil-
dren who had SA with contiguous osteomyelitis, children with
primary SA were younger (2.4 vs. 7.4 y), had lower initial
C-reactive protein (CRP) values (6.4 vs. 15.7 mg/dL), and
lower bacteremia rate (20% vs. 69.5%).20 Children with con-
tiguous osteomyelitis were more likely to be infected with S.
aureus (77.1% vs. 32.1%) and less likely K. kingae (2.9% vs.
32.1%). Comparatively, Children with primary SA had a
much shorter duration of hospitalization (4 vs. 8 d), required
less intensive care (1.5% vs 21%), had a lower readmission rate
(5.2% vs. 17.2%) and a lower complication rate (0.7% vs.
38.1%).20 Intentionally distinguishing between the 2 clinical
entities, primary versus secondary SA, as having unique
pathophysiological processes serves as a better approach for
evaluation and treatment. This differentiation should establish
better guidance for future research devoted to each disease
entity for unique properties.
EVOLUTION OF THE APPROACH TO
EVALUATION AND THE ROLE OF PREDICTIVE
SCORES AND ALGORITHMS
Two challenges face clinicians when evaluating chil-
dren suspected of having SA. The first is to differentiate SA
from other noninfectious etiologies, such as transient syn-
ovitis, Post-Streptococcal Reactive Arthritis (PSRA), or
inflammatory conditions such as Juvenile Idiopathic Ar-
thritis (JIA). Historically, the Kocher criteria helped dif-
ferentiate between SA and transient synovitis.21 This
framework established risk factors, including fever ( > 38.5°
C), inability to bear weight, white blood cell count
> 12,000 cells/mL, and an erythrocyte sedimentation rate
(ESR) of ≥ 40 mm/h.21 Based on logistic regression anal-
ysis, the Kocher criteria were promoted to differentiate SA
of the hip with a 93% or greater positive predictive value
when 3 or 4 risk factors are present.21 A subsequent vali-
dation study showed a diminished positive predictive value
of 72.8% when a child met at least 3 criteria.22 While
helpful, this tool relies on cutoff values based on historical
data of affected children. More recent literature advocates
for a systematic approach that does not rely solely on pa-
rameter cutoff values but takes into consideration labo-
ratory normalcy and the relative magnitude of elevation of
the laboratory values of affected children to establish a level
of concern and guide judgment under conditions of
uncertainty.14
www.pedorthopaedics.com | 579
Hachem and Copley
The second clinical challenge is to differentiate
children with primary SA from those with a contiguous
focus of osteomyelitis. Historically, osteomyelitis was re-
ported to occur concurrently with SA at a rate between
17% and 33%.23,24 More recent retrospective studies re-
port an incidence rate ranging between 59% and 68%
having adjacent infections, including intramuscular-
/subperiosteal abscesses and osteomyelitis.25–27 A common
approach for children with hip effusion on ultrasound has
been to perform hip aspiration before consideration of
advanced imaging. If the aspiration confirms SA, the child
is treated with surgical irrigation and debridement along
with antibiotic therapy with the use of magnetic resonance
imaging (MRI) if there is failure of clinical and laboratory
improvement. A recent study found that the Kocher cri-
teria alone would have missed contiguous osteomyelitis in
43.2% of children with SA.28 The same study demon-
strated that children with 3 or 4 Kocher criteria regardless
of the presence of a hip effusion had a high incidence of
osteomyelitis.28 Hence, the Kocher criteria may be less
specific for SA with contiguous osteomyelitis.28 It is worth
mentioning that the Kocher criteria were developed before
the widespread use of MRI for musculoskeletal infection
evaluations.
Because concurrent osteomyelitis with SA is best de-
tected with MRI, some institutions have implemented con-
sistent use of this modality during the evaluation of children
suspected to have musculoskeletal infection.29 This practice
has the potential for unnecessary resource utilization along
with the risk of anesthesia for young children.30,31 In addi-
tion, forestalling surgical intervention to obtain MRIs for all
children delays intervention for children with primary SA.
Prediction algorithms have been developed to help identify
children with SA who are at greater risk of having con-
tiguous osteomyelitis.24 In a retrospective study of 200 chil-
dren with SA, concurrent infection was found in 21.5%.24
The risk factors for this occurrence included: age (newborns
and adolescents); affected joint (shoulder up to 72%); and
pathogen (S. aureus).24 Pain for > 4 days before presentation
increases the risk of having contiguous osteomyelitis.25 An-
other study identified the following predictors of adjacent
osteomyelitis: Age above 3.6 years, CRP > 13.8 mg/L, du-
ration of symptoms > 3 days, platelets <314,000 cells/mL,
and absolute neutrophil count > 8600 cells/mL.26 Among
children with ≥ 3 of these criteria, adjacent osteomyelitis was
identified with a sensitivity of 90% and specificity of 67%.26
This model was later validated with similar sensitivity (86%)
and improved specificity (85%).29 The investigators advo-
cated that children with ≥ 3 independent predictors should
undergo perioperative MRI while those with zero or one risk
factor may proceed with surgical irrigation and
debridement.29
Although prediction algorithms are attractive for
clinicians, they still require validation on larger and di-
verse patient populations. When the Rosenfeld criteria
were later evaluated by another group the specificity was
47% with a false-positive rate of 50%.32 Similarly, the
Rosenfeld criteria were evaluated in New Zealand with
sensitivity and specificity of 73% and 44%, respectively.3
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Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop  Volume 43, Number 9, October 2023
There is therefore a need not only to refine these pre-
diction algorithms with better data but also to adapt the
prediction models to specific patient populations that
may differ by genetics and environment.
THE MULTIPLE CLINICAL PHENOTYPES OF
PRIMARY SA
The evaluation of children with primary SA is
challenging because of the heterogeneity of clinical phe-
notypes caused by a wide variety of pathogens which ag-
gregate into age-specific groupings.14 K. kingae, for
example, is the most common pathogen identified in
children 6 to 48 months of age.14 Children with K. kingae
tend to have a milder initial presentation. In one study,
children with SA caused by K. kingae had lower CRP (4.8
vs. 9.3 mg/dL) than children with other confirmed
pathogens.9 In addition, most children with K. kingae
SA have joint fluid nucleated cell counts <50,000
cells/mL.13,33 A study of children in Israel with K. kingae
infections found that 22% had normal CRP, 31.8% had
normal ESR, 25% were afebrile, and 57% had white blood
cell <15,000 cells/mL.10 Similarly, in a European study,
70.4% of children with K. kingae SA were afebrile and had
lower inflammatory markers, less bacteremia (3.6% vs.
61.9%), and a lower complication rate.2 This mild clinical
presentation of K. kingae infections in the 6- to 48-month
age group raises concern about the use of clinical pre-
dictive algorithms to differentiate viral reactive or in-
flammatory arthritis from K. kingae SA.
The heterogeneity of clinical phenotypes calls for
unique treatment considerations based on the age of the
child and the commonly isolated pathogens within various
age groups.14 This approach may be challenging in de-
veloping countries or centers with limited access to mo-
lecular technologies such as PCR which greatly improves
the pathogen detection rate in comparison to that of
culture-based methods.34
ROLE OF ADVANCED IMAGING AND USE OF
CONTRAST
SA is an urgent condition which requires an efficient
evaluation and intervention workflow.35 Increased adoption
of MRI has allowed more precise evaluation and treatment
strategies for children with suspected musculoskeletal
infection.36 Preoperative MRI has reduced unplanned re-
turns to the operating room through earlier detection and
intervention for adjacent infections.37 However, gadolinium-
based contrast agents have increasingly been scrutinized due
to the potential for retention in the brain, albeit the long-term
clinical significance of this is still unknown.38,39 Because the
use of contrast is associated with longer scan duration,
adoption of imaging protocols without contrast may prove
to be advantageous.40 Previous studies found that T1-
weighted, T2-weighted fat saturation, and short tau in-
version recovery (STIR) techniques have similar sensitivity
and specificity as contrast-enhanced imaging.41,42 An in-
novative approach for advanced imaging of children sus-
pected to have musculoskeletal infection involves
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J Pediatr Orthop  Volume 43, Number 9, October 2023 What’s New in Pediatric Septic Arthritis

Results cannot be generalized to neonates, patients

Clinical outcome of patients who converted to oral

Similar time to defervescence and normalization of

antibiotics and combination therapy. It was also

3 wk of oral antibiotics) is efficacious and safe in

therapy was similar to those who converted late.

34 patients with SA with median of 3 d of A shortened course of antibiotics (3 d followed by

The implementation of guidelines was effective in

decreasing the extensive use of broad-spectrum
coordinated inter-disciplinary communication between or-

antimicrobial therapy during the 12 mo after

defined as full recovery without the need for
thopaedic surgery, radiology, and anesthesiology services.31

with immunodeficiency, or cases of MRSA

10 vs. 30 d of antimicrobial therapy 130 (63 patients in the 10-d group and 67 No difference in primary outcome which was When compared with a fragmented workflow, the use of a
coordinated MRI algorithm led to decreased scan duration

ESR, and symptomatic resolution

(35 vs. 73.6 min), with fewer sequences per scan (4.6 scans vs.
Outcome

7.5 sequences), shorter anesthesia time (53. vs. 94.1 min), and
a higher rate of procedures performed under the same an-
the treatment of SA

esthesia session as the MRI (84.6% vs. 70.2%).31

safe and efficacious

APPROACH TO ANTIBIOTIC TREATMENT AND
therapy.

MONITORING FOR RESOLUTION

ESR indicates erythrocyte sedimentation rate; IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; RCT, randomized controlled trial; SA, septic arthritis.
The approach to antimicrobial therapy for pediatric
guidelines and 18 following guidelines)
IV then switched to oral for a median

SA has evolved over the decades. The earliest guidance

antibiotic therapy and 103 patients

In a fully vaccinated patient > 3 mo 39 patients (9 preintervention and 12

postintervention not following the

dates back to 1954 describing successful treatment with

antibiotics after 7.4 ± 7.4 d of IV
186 (83 patients converted to oral

penicillin continued until 5 days after defervescence.43

total of 4.4 wk of therapy

However, recurrence of the infection prompted a change

No. patients

in clinical practice and extended the treatment duration to

after 18.6 ± 13.6 d)

1 month.44 This was later reduced to 3 weeks based on the

in the 30-d group)

research of John Nelson which utilized clinical response

and improved ESR as surrogates for clinical resolution.45
This remained the standard of practice for decades until
TABLE 1. Summary of Trials and Studies Evaluating Treatment Modalities and Duration for Pediatric SA

the recent proposal of short-duration antimicrobial ther-

apy. A large clinical trial was conducted in Finland over a
Both groups received a total of 4 wk

age an IV antibiotic for 5-7 d is

22-year period involving 130 children randomized to re-

Evaluate short vs. longer duration

Early transition from IV to oral

ceive either a short course (10 d) or long course (30 d) of

followed by oral switch for

antibiotics for SA.46 The investigators found that short-

of antimicrobial therapy

for the treatment of SA

Intervention

of antibiotic therapy

duration therapy was as effective as long duration outside

the neonatal age group.46 None of the children studied
2-3 wk for SA

had methicillin-resistant S. aureus (MRSA) infections.46

therapy.

Whereas MRSA is not prevalent in other countries, it

continues to be a relevant concern in the United States.17
Therefore, in the absence of clinical outcome data for a
short-duration treatment of bacterial arthritis due to
MRSA, there is not enough support to generalize this in
observational, quasi-
experimental study

the United States. In addition, the Finnish group showed

Retrospective study

Retrospective study
Multicenter RCT
Type

no difference in outcomes when children were treated with

2023 preguidelines (January 2012 through Retrospective,

a shorter course of parenteral therapy (7.4 d) when com-

pared with a longer therapy (18.6 d) before transition to
oral therapy for 4 weeks of total treatment.47 While there
may not be a general consensus about the total duration of
implementation (January 2016 through

therapy, it is current practice to transition patients from

December 2015) and postguidelines

intravenous to oral therapy as soon as they demonstrate

clinical improvement and have a sustained decrease in
October 31, 2022)

inflammatory markers with most clinicians opting for a

total of 3 weeks of therapy.48 Table 1 summarizes the
Year
2002

2009

2009

major trials and studies related to the treatment of

pediatric SA.
While determining a safe transition to oral therapy,
some groups advocate for the sole use of CRP to guide
decision-making.50 The Finnish Study Group has argued
that CRP is a better index than ESR, which tends to
remain elevated after infection is resolved.51 In their
Osteomyelitis-Septic

prospective, randomized trial, no child had relapse after

the CRP reached <2 mg/dL.50 However, this approach
Arthritis group

Minotti et al49

has not been widely adopted. In a recent retrospective

Ballock et al47
Peltola et al46
References
Vinod et al44

(OM-SA)

study evaluating the efficacy of using CRP < 2 mg/dL for

discharge children with SA, the investigators found CRP
to be a poor predictor of readmission and relapse.52

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Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved.

Hachem and Copley
CONCLUSIONS
The evaluation and treatment of children with SA
has evolved over the past decade through a better under-
standing of the clinical heterogeneity of age-specific mi-
crobiologic epidemiology. K. kingae is now increasingly
recognized for its role as a pathogen affecting children
from 6 to 48 months of age. A milder disease course with
less complications compared with other bacterial patho-
gens such as S. aureus implies that a “one-size fits all”
approach may not be optimal for the evaluation and
management of SA in young children. Furthermore, the
osteoarticular infection continuum has been challenged
with the recognition of primary SA as a distinct clinical
entity with a lower risk of complications than children
with contiguous osteomyelitis. Finally, the role and
workflows of advanced imaging have greatly evolved over
the past decade. Concerns for long-term contrast deposi-
tion in the brain as well as a desire to limit the duration of
anesthesia for young children have led to the refinement of
MRI protocols without loss of diagnostic fidelity. While
the optimal duration of antimicrobial treatment remains
to be clearly defined, the work of the Finnish study has led
to greater consideration of shorter duration therapy for
children with primary SA.
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www.pedorthopaedics.com | 583

Symposium III
POSI
IJPO
Dr Mandar Agashe Dr Premal Naik
Address of Correspondence
Dr Mandar Agashe
Paediatric Orthopaedic Surgeon, Dr Agashe Maternity &
Surgical Nursing Home, Mumbai, Maharashtra, India.
E-mail: mandarortho@gmail.com
1
Department of Orthopaedic, Dr Agashe Maternity &
Surgical Nursing Home, Mumbai, Maharashtra, India.
2
Department of Orthopaedic, Rainbow Super Speciality
& Children Orthopaedic Hospital, Ahmedabad, Gujarat,
India.
DOI- 10.13107/ijpo.2021.v07i02.111 | www.ijpoonline.com
This is an Open Access article distributed under the terms of
the Creative Commons Attribution Non-Commercial-Share
Alike 4.0 License(http://creativecommons.org/licenses/
by-nc-sa/4.0) which allows others to remix, tweak, and build
upon the work non-commercially as long as appropriate
credit is given and the new creation are licensed under the
identical terms.
35
International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): Page 35-41
Neglected Lateral Condyle Humerus
Fractures: Current Concepts and Practices
Mandar Agashe MS Ortho.1, Premal Naik MS Ortho.2
Abstract
Neglected lateral condyle fractures present varied and difficult challenges to the
treating orthopaedic surgeon. They have the potential to cause long term
problems like deformities, stiffness, instability and tardy ulnar nerve palsy. The
treatment of lateral condyle non-unions depend on the presence or absence of
deformity, the duration of non-union, skeletal maturity of the child and the
presence or absence of ulnar nerve palsy. Accordingly the treatment ranges from
conservative management in neglected fractures with no deformity and no ulnar
nerve palsy at one end, Open/mini-open or closed in-situ fixation for established
non-unions with instability and corrective osteotomy with fixation of non-union
and ulnar nerve transposition at the other end.
In this article, the authors have endeavoured to go through the various aspects of
clinical presentations and treatment modalities for this difficult fracture.
Keywords: Neglected lateral condyle fractures, Cubitus valgus, Tardy ulnar nerve
palsy, Instability
Introduction
Lateral condyle humerus (LCH) fractures are common fractures around the
elbow and have the potential to cause long term problems of deformities,
restricted range of motion, instability and tardy ulnar nerve palsy [1, 2]. In
systemic review of LCH fractures by Tan et al [3], it was found that most LCH
fractures had union, with 0.9% delayed union, 1.6% non-union and 1.5%
malunion. Common complications following LCH fracture include valgus
deformities (6.1%), varus deformities (7.8%), flexion loss (9.7%), extension loss
(11.5%), prominent lateral condyle (27.3%), fishtail deformity (14.3%),
avascular necrosis (1.7%), premature epiphyseal closure (5.4%) and neurological
deficits (10.6%) [3].
The first report of nonunion of LCH was described by Moorhead in 1919 [4]; the
patient was seen seventeen years after injury; due to acceptable elbow movements
without pain, the non-union was not treated [5] In order to prevent these
complications, it is prudent to treat these fractures well early with stable fixation
whenever indicated. However, especially in the developing world, orthopedists
do get fractures which are neglected or “mis”-treated [6].
Though the treatment of fresh LCH fractures is fairly standardized, management
of neglected LCH fractures still remains controversial. Recently Song
classification has improved our understanding of the LCH fracture and their
treatment guidelines which have been effective as seen by a few studies in the
recent times [7, 8]. Tan et al in their systematic review recommended that non-
displaced extra-articular fractures on all radiographic views could be managed
conservatively, while displaced or intra-articular fractures (with broken cartilage
Submitted: 12 March 2021; Reviewed: 20 March 2021; Accepted: 14 April 2021; Published: 10 May 2021
© International Journal of Paediatric Orthopaedics | Published by Research One Publishing House
Agashe M & Naik P
hinge) with > 2 mm displacement require surgical intervention
[3].
This described treatment of neglected LCH ranges from
conservative management and allowing the fracture to mal-
unite/ cause a deformity, at one extreme [9, 10], to immediate
surgical exploration, recreation of the fracture, anatomical
reduction and rigid internal fixation at the other extreme [1,
11]. There have been a plethora of articles describing these
various treatment modalities for the treatment of neglected
lateral condyle fractures associated with or without
deformities.
In this article, we will attempt to address the problems
associated with these difficult fractures and discuss merits of
various treatments suggested for neglected LCH fractures. In
the process we will put forth a protocol for the management of
the same.
Definition of “neglected” fractures and associated
problems
Various observers have defined “neglected” fractures in
different manners. Jakob and Fontanetta stated that open
reduction should not be performed more than three weeks after
the injury, as the blood supply of the fragment is easily
disturbed, leading to avascular necrosis of the fragment [10].
While Agarwal in their study considered LCH neglected if
presented after 4 weeks [12, 13]. Dhillon et al, suggested
changing the definition of “neglected” to beyond 6 weeks of
injury and theorized that fractures beyond 6 weeks of trauma
should not be treated by open reduction and internal fixation
[14]. Aggarwal et al [12] and Prakash et al [6] have kept the
working definition of “neglected” to be more than 3 months
after injury. One may safely state that when LCH fracture does
not show expected signs of union following conservative or
improperly stabilized fracture it may be labelled neglected as
early as 2-3 weeks. Regardless of the duration of neglect, all
authors do feel that these neglected fractures need to be treated
with utmost caution and have put forth their own protocols for
the same.
The reason for this delay is multi-factorial. Flynn noted that the
most common causes of LCH nonunion is inadequate
treatment of the fresh fracture, with the patient not seeking
medical advice or orthopedist not being able to appreciate the
fracture [15]. In developing world, the reasons for LCH
nonunion include parental lack of awareness, financial
constraint and non-availability of health care facilities [12, 14,
16]. Fracture management by osteopaths is seen in developing
world as well as affluent societies [12, 14, 17, 18]. Roy noted
that LCH nonunion may result from wide separation of
fracture surfaces, missed fractures, failed closed or open
reduction, and separation of undisplaced fracture in follow up.
Moreover, there is considerable debate about the management
36 | International Journal of Paediatric Orthopaedics | Volume 7 | Issue 2 | May-August 2021 | Page 35-41
www.ijpoonline.com
of this fracture after 3 weeks of injury and that adds to the
problems which the child faces as an aftermath of this fracture.
The problems of neglected lateral condyle fractures are related
to its unique vascular and muscular anatomy. Lagrange and
Rigault in their famous study showed that the blood supply of
the lateral condylar fragment enters posteriorly near the
common extensor attachment, and disruption of this blood
supply due to the injury or the surgical procedure can lead to
ischemia of the fragment [19]. Once the fracture displacement
occurs, the fragment is completely separated from the proximal
fragment and then continues to enlarge. It becomes irregular in
shape and gets covered on all sides with articular cartilage that it
may sometimes be impossible to distinguish the normal
articular surface from the newly formed articular surface [20].
The metaphyseal fragment also undergoes hypertrophy,
becomes enlarged and misshapen and does not conform to the
shape of the reciprocal surface on the proximal side [12]).
Masada found olecranon fossa was markedly smaller than
normal and major part of the trochlear groove had disappeared;
in some patients radial head became convex [5]. In such
circumstances, trying to recreate the anatomy during surgery,
leads to significant dissection, with subsequent damage to the
vascularity, avascular necrosis of the fragment and stiffness.
Satoshi et al noted that in patients with nonunion following
Milch type 1 injury, the lateral condyle fragment was small and
radial head was rounded and capitellum was concave while in
nonunion following Milch type 2 injury lateral condyle
fragment was large with almost normal relation of the
radiocapitellar joint [2, 18].
Jeffery in late fifties noted that radiological union of displaced
lateral condyle must be established unequivocally [3, 10, 21]. If
delayed union is recognized in time, steps can be taken to
achieve union, thereby preventing further displacement and
deformity and described treatment of delayed LCH fracture
with minimal displacement by drilling a channel and filling it by
bone-grafting [21]. Flynn described two prerequisites for
successful treatment of lateral condyle nonunion, 1. fragment
in acceptable position, 2. Physis of fragment open, but finally
concluded that that providing stability even without growth
potential may be helpful. He treated LCH nonunion by
freshening metaphyseal side of the fracture, fixing with Hagie
pin, and did peg bone grafting preserving physis. He also
recommended early treatment of nonunion “without
procrastination” and noted that nonunion treated in time will
allow the condylar fragment to grow with the elbow to maturity,
producing a satisfactory functional and cosmetic result [15].
Wilkins et al. stated: "If we believe that we can obtain fracture
union without loss of elbow motion and avoid avascular
necrosis of the lateral condyle, then we recommend surgery for
selected patients”. Shimada et al reported that in children after
osteosynthesis of LCH nonunion, union is achieved easily,
Agashe M & Naik P
elbow motion is maintained, the ulnar nerve function returns
and the articular surface remodels [22, 23]. Many authors
recommended osteosynthesis of nonunion of LCH in children
not only with pain but even with less symptoms [11, 23]. They
noted that osteosythesis prevents progression of a cubitus
valgus deformity with subsequent ulnar nerve dysfunction and
fairly good remodeling of the elbow joint with improvement in
of motion over a several years [11, 22].
Presentation
Children with nonunion of lateral condyle tend to have pain in
the elbow, apprehension, progressive cubitus valgus deformity,
restriction of elbow motion, and ulnar nerve dysfunction [5,
22]). Restriction of elbow movements is one of the main
functional limitation in children with LCH nonunion but
restriction of extension does makes accurate measurement of
carrying angle difficult [2, 18]. Improvement as well as loss in
elbow movements following LCH nonuion surgery is reported
The onset of pain after sports and work occurs after an average
of 9.7 years after injury, and the onset of ulnar nerve
dysfunction began at an average of 12.7 years but as early as 1.5
years [18]. Gay and Love (1947) found the average age of onset
of ulnar neuropathy after an elbow injury is 38 years, and the
average interval between injury and onset of symptoms is 22
years. Flynn reported that Ulnar neuritis usually occurs 15-55
years after the injury [15]. Contarary to that many authors have
reported ulnar neuritis as early as three years postinjury. Satoshi
noted that average carrying angle in children with ulnar nerve
symptoms was 26.7 degrees (Satoshi Toh) [2, 22]. They noted
good resolution of pain and apprehension following successful
union and reported better results in patients with Milch Type 2
injury than patients with type 1 injury with higher
complication rate in type 1 patients (Satoshi Toh). In another
study, patients with nonunion following Milch type 2 injury
rarely developed disabling symptoms except the ulnar nerve
dysfunction; contrarily, pain, instability, and loss of elbow
motion, and ulnar nerve involvement were common in
nonunion following Milch type 1 injury. The authors
recommended early treatment of nonunion of a Milch Type-I
Figure 1: a) Injury film of the elbow of a 6 year old child with lateral condyle humerus fracture which was conserved elsewhere. b)
Xray of the same child 3 months after injury showing non-union of the fragment. c) X-ray of the child 6 months after percutaneous
screw fixation with CC screw showing excellent healing.
37 | International Journal of Paediatric Orthopaedics | Volume 7 | Issue 2 | May-August 2021 | Page 35-41
www.ijpoonline.com
fracture [18].
Management
A) Conservative management
Traditionally, surgery, or more precisely extensive surgery for
neglected lateral condyle fractures is avoided, due to the
propensity to cause damage to the vasculature and subsequent
stiffness [3, 15]. The reason for this may be the fact that these
non-unions may be almost completely asymptomatic
especially for all routine activities and most do have almost full
range of motion. Jakob and colleagues were one of the first to
put forth this theory of non-operative management of
neglected LCH fractures [10]. Flynn et al emphasized that
major dissection and surgery should be avoided especially in
rotated fragments and when the metaphyseal fragment is in a
poor position [15]. The principle which was followed was to
allow the fracture to mal/non-unite and treat it surgically only if
and when it leads to a deformity. The deformity can be treated
at that time, without actually treating or dissecting the non-
union.
Authors find no role of conservative management in children
with LCH nonunion.
B) In-situ fixation
Percutaneous In-situ fixation-
Knight et al reported good results with of minimal invasive
percutaneous screw fixation without formal open reduction in
children with LCH nonunion presented within 16 weeks of
injury [24] It was claimed to be the first report but earlier
Morris had reported use of percutaneous screw for one year old
LCH nonunion in 4 year old child, who had previous ORIF
[25].
This technique has the advantage of not opening the elbow
joint, thereby avoiding soft
tissue stripping and preserving preexisting callus and thus,
reducing the risk of AVN and infection (Figure 1 a, b, c). Screw
compression was found to reduce the amount of joint fluid
passing across the intra-articular nonunion and promoting
union. They found metaphyseal fragment larger than at the
Agashe M & Naik P
Figure 2: a) Injury film of the elbow of a 6 year old boy with
"minimally displaced" fracture lateral condyle humerus,
which was conserved elsewhere. b) X-ray of the elbow of the
same child after 8 weeks showing gross displacement and
non-union. c) X-ray of the child 6 months after mini-open
reduction and internal fixation with cc screw and k wire
fixation.
time of initial injury, allowing use of larger screws.
The authors have found this technique very effective in early
stages of nonunion with minimal displacement.
Open In-situ fixation
Park et al in their study reported a series of 16 patients with mini
open in-situ fixation for LCH nonunion with good results in
terms of union and functional results [26]. They exposed the
interval between the metaphyseal fragment of the LCH and the
distal humeral metaphysis after making a small anterior skin
incision under fluoroscopic guidance. The metaphyseal surface
of fracture site was freshened with small curate preserving the
physis; no attempt to realign the articular surface or distal
mobilization of the metaphyseal fragment was done.
Compression of metaphyseal side was achieved by 3.5 or 4.5
mm cannulated screw without bone graft (Figure 2 a, b, c).
They could achieve union in all patients without premature
growth arrest, avascular necrosis, and fish-tail deformity. All
their patients had Milch type 2 injuries with interval between
injury and operation 4.8 months (range, 3 to 12months). They
recommended their technique for relatively minimal displaced
and fresh nonunion of LCH.
Prakash and Mehtani in 2017 compared in situ fixation (similar
to the method described by Park) with ORIF for LCH
nonunion in terms of elbow score; they used bone graft in all
cases [6]. Both methods showed comparative results in terms
of elbow scores but the rates of radiological union was slightly
lesser with in-situ fixation than ORIF. They found better
functional outcomes, lesser post-operative complications and
decreased surgical times with in-situ fixation.
We do not see advantage of mini-open screw fixation over
percutaneous screw fixation for late presenting LCH. We
recommend In-situ fixation of minimally displaced nonunion
of LCH presenting within 4-5 months of injury. For children
presenting between 4-12 months mini open technique
described by Park without bone grafting should be used. Using
bone grafting for LCH nonunion presenting within one year
38 | International Journal of Paediatric Orthopaedics | Volume 7 | Issue 2 | May-August 2021 | Page 35-41
www.ijpoonline.com
Figure 3: a) Pre-operative xray of the elbow of a 8 year old
child with grossly displaced and rotated (Song type 5)
fracture lateral condyle humerus which was 3 months post-
trauma. b and c) AP and oblique xray of the child after open
reduction and internal fixation with CC screw and k wire
fixation.
may not be necessary.
C) Open reduction and anatomical fixation:
Over the years, with more and more research being done on the
blood supply of the lateral condyle and the ways and means to
prevent damage to it, there have been some articles describing
open anatomical reduction and internal fixation for these
fractures. Agarwal et al in 2012 showed good to excellent results
in most of the cases treated with open reduction and internal
fixation with bone grafting and put forth a few guidelines
regarding the management of neglected LCH fractures [12].
Surgical steps
Lateral Kocher’s approach and posterolateral approach [27] ,
both have been used for established nonunion of LCH;
Kochers approach is more common. Kocher’s approach uses
interval between the Brachialis and Triceps proximally and the
ECU and the Anconeus distally; care should be taken to be
always anterior to the common extensor origin and not to go
too distally. To avoid postoperative joint adhesions and AVN of
the LCH, no attempt is made to mobilize the lateral condyle by
means of extensive soft tissue dissection for the purpose of
reducing the fracture to its original
anatomic position (Figure 3 a, b, c). The nonunion site is
exposed gently and the fibrous tissue in the gap between the
fracture fragments is removed. The fracture surfaces over the
metaphysis is then freshened but the surfaces of the physis and
epiphysis should not be touched [11] Agarwal noted that
sometimes, the overgrowth of condylar fragment makes it
difficult to identify the articular surface from the metaphyseal
region of the fragment, in such cases search for overhang
cartilage is made, and excess overhanging cartilage is trimmed
to get bleeding metaphyseal bone. They recommended
nibbling of metaphyseal area to create space for easy
realignment or rotation of fragment rather than stripping
posterior soft tissue carrying blood supply to the fragment [12,
13] Shabir et al suggested that in order to achieve good
Agashe M & Naik P
apposition of the fracture fragments, it is sometimes prudent to
cut the anterior parts of the capsule and synovial adhesions
taking care to limit the dissection anteriorly [20]. The criteria
for articular step is 2 mm for acute fractures. However, the exact
criteria for neglected late-presenting fractures is not well
defined.
In very late presenting cases, Roye recommended functional
reduction in which LCH fragment is carefully mobilised with
intact soft tissue pedicle preserving vascular supply and fixed in
the position that allows the greatest range of motion. Optimum
position of the fragment can be decided by temporarily fixing
the fragment and dynamically assessing range of movements;
the bone graft is then placed between the freshened apposing
surfaces and should be stabilised with screw Parajit also
recommended that If an anatomic reduction is not possible, the
fragment is fixed in the position that allowed the best motion
and near normal carrying angle. The LCH fragment is
temporarily fixed with k wire; If elbow range at this position is
more than 120 degrees, final fixation in this position is done
but if flexion is at less than 120 degrees, the fragment is moved
in more flexed position [11].
Masada noted that when the olecranon fossa is not deep
enough to allow full extension of the elbow, resection of the
proximal part of the olecranon improves extension) [5]. Gaur
et al have suggested making multiple “pie-crusting” incisions
on the common extensor origin in order to achieve some
mobility of the fragment especially in displaced and rotated
fragments [6].
Some authors have used more extensile approaches for more
displaced or older fractures. Agarwal et al have used the Bryan
and Morrey’s extensile approach in fractures where the
condylar fragment is high riding [12]. Bohler et al have
described using the trans-olecrenon approach for avoiding
extensive soft tissue dissection [28].
Fixation Methods
There is also a wide variation about the choice of fixation- with
k-wires and screw-wire combination being the common two
methods used. Ranjan et al in 2018 were the first to compare
these two methods of fixation for neglected fractures [29].
Though they found that the functional scores to be statistically
similar in both the methods, the period of immobilization was
significantly higher in k-wires as compared to CC screws. They
found that the patient could initiate physiotherapy much earlier
with the more secure fixation of CCS as against k wires. Also,
they found that they could safely pass the CCS through the
capitellar physis and the ossific nucleus without causing any
major damage. They also found CS to be better in terms of final
carrying angle and time to gain final range of motion. Use of
tension band wiring alone or along with screw fixation is also
described [18, 23].
39 | International Journal of Paediatric Orthopaedics | Volume 7 | Issue 2 | May-August 2021 | Page 35-41
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Figure 4: a) Pre-operative radiograph of a child with long-
standing non-union of the lateral humeral condyle with
cubitus valgus with ulnar nerve palsy. b) Immediate post-
operative xray after corrective (lateral closed wedge)
osteotomy along with screw fixation of the lateral condyle
non-union and anterior transposition of the nerve. c) 6
months post-operative showing excellent healing and
alignment d) clinical photograph of the child showing normal
alignment of the elbow.
Bone grafting
Some authors have described adding bone grafting as a routine
for the fixation of all LCH non-unions. Use of Iliac bone graft is
by far the commonest [2, 29] Agarwal et al have described
taking the graft from the lower humerus or the proximal ulna in
order to decrease the donor site morbidity and allowing
grafting through the same incision. They found good results
with this method of peg- grafting, peg grafting is a well-
established technique and was described by Jeffery in 1958
[21]. Ibrahim described use of bone removed from closing
wedge osteotomy as a graft) [28].
Cubitus valgus correction
Simultaneous correction of cubitus valgus with carrying angle
> 20-40 degrees have been described by many authors [11]
(Figure 4 a, b, c, d). The osteotomy was done simultaneously as
well as at later date). Tien used triceps split approach [30] while
Abed used paratricipital approach to correct cubitus valgus
with dome osteotomy [31]. Some have used lateral approach
with lateral closed wedge [28] or dome osteotomy [11] for
correction of cubitus valgus.
Anterior transposition of Ulnar nerve (UNT)
Many authors have transposed Ulnar nerve anteriorly in
patients with Ulnar nerve dysfunction [11, 18] or routinely
with LCH nonunion surgery [30, 31]. Some surgeons have
refrained from doing UNT even in patients with ulnar nerve
dysfunction [28,32]. Masada treated patients of LCH
nonunion with only UNT, UNT with supracondylar
osteotomy with or without osteosynthesis LCH nonuinion.
Bone graft can be harvested from distal humerus or proximal
ulnar metaphysis or from wedge removed for supracondylar
Agashe M & Naik P www.ijpoonline.com

osteotomy. Stable fixation with screw is preferred except in
very young children.
Conclusion
Neglected lateral condyle humerus fractures present many
difficulties both with or without treatment. The earlier
protocol of supervised neglect is slowly changing to one of
prudent fixation with minimal dissection of the fragment,
optimal reduction and stable fixation. Even when accurate
open reduction is performed, soft tissue stripping should not
be performed due to the risk of avascular necrosis and
stiffness. K-wires and cannulated screws are equally used,
though screw fixation provides better stability and allows
early mobilization. Deformity correction and/or ulnar nerve
transposition can be performed if and when deformity
occurs.

Figure 5: Flowchart for the management of neglected lateral condyle humerus fractures

Declaration of patient consent: The authors certify that they have obtained all appropriate patient consent forms. In
the form, the patient has given his consent for his images and other clinical information to be reported in the Journal.
The patient understands that his name and initials will not be published, and due efforts will be made to conceal his
identity, but anonymity cannot be guaranteed.
Conflict of interest: Nil; Source of support: None

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How to Cite this Article
Agashe M, Naik P | Neglected Lateral Condyle Humerus Fractures: Current Concepts and
Practices | International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): 35-41.
41 | International Journal of Paediatric Orthopaedics | Volume 7 | Issue 2 | May-August 2021 | Page 35-41
www.ijpoonline.com
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 Review Article
Mechanical Complications After Intramedullary
Fixation of Extracapsular Hip Fractures
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ABSTRACT
Extracapsular hip fractures occur frequently in the elderly as a result of
low-energy trauma. Achieving stable fixation in osteoporotic bone to
allow early weight bearing is a key objective in the treatment of these
injuries. Many of the intraoperative decisions facing surgeons are
directed by first determining fracture stability. Unstable fracture
patterns should be fixated with intramedullary nails, aiming to control
motion around the implant and at the fracture site. Torsion control
devices provide additional stability and control, although their exact
indications are not precisely defined. Complications that arise as a
result of the early loading can be avoided with a good surgical
reduction, meticulous technique, and proper implant selection.
Mechanical complications include cutout, inordinate proximal femoral
shortening, delayed union, early implant fracture, nail toggle, and cut
through/medial migration.
E
xtracapsular hip fractures in the pertrochanteric and subtrochanteric
region occur frequently in the elderly as a result of low-energy trauma
sustained in osteoporotic bone. In such fractures, the blood supply to
the femoral head and neck remains intact postinjury. The ensuing high rate of
union makes open reduction and internal fixation a viable treatment option.
Therefore, failures tend to be mechanical in origin. Achieving stable fixation in
osteoporotic bone to allow early weight bearing, while avoiding failure, is a
key objective in the treatment of these injuries with intramedullary (IM) nails.
Mechanical failure, by definition, occurs when the implant breaks in response
to loading or, as more commonly seen in osteoporotic fractures, when the
implant loses fixation in bone.1 Although complications may not prevent
fracture union per se, they still adversely affect the outcome potentially re-
sulting in a need for additional procedures.
As there are few prospective studies on extracapsular hip fractures, infor-
mation guiding physicians in clinical practice is limited. This issue is com-
pounded by the fact that mechanical failures occur infrequently, and the low
number of failures investigated in the literature affects the research power and
validity, as demonstrated by the wide confidence intervals that often accom-
pany the related statistical findings. This article reviews the current practices
for preventing complications after IM fixation of osteoporotic extracapsular
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December 15, 2022, Vol 30, No 24 © American Academy of Orthopaedic Surgeons
 Matthew L. Klima, DO, FACS, FAOAO

Review Article
Figure 1
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The OTA/AO 31A classification of pertrochanteric fractures depicted with standard radiographs and 3D CT.4 A1 fractures are stable
injuries that include two-part fractures and three-part fractures with a lateral wall greater than 20.5 mm; A2 fractures are unstable
injuries with a lateral wall thickness less than 20.5 mm; A3 injuries are reverse obliquity and transverse patterns that are also considered
unstable. Depicted by the red line is the proper location for measuring lateral wall thickness at a point 3 cm below the innominate
tubercle. Accurate measurement requires the extremity be internally rotated at the time of imaging. In many instances, the deformity
induced by fracture geometry is more complicated than appreciated on the standard radiographs.

hip fractures. The importance of good surgical technique
and proper implant selection will be highlighted while
discussing recent developments in the literature.
Stability, Deformity, and Prevention of
Mechanical Failure
Successful treatment of extracapsular hip fractures
requires a comprehensive understanding of fracture sta-
bility, as stability more so than classification primarily
determines the management, and prognosis of such in-
juries. Stability is best thought of as the capacity to resist
further displacement, motion, or collapse after internal
fixation.1 Fracture geometry provides the fundamental
basis for stability, in that the cortical contact of the
major pieces primarily prevents displacement after
reduction and fixation. Posterior medial comminution
becomes destabilizing for these injuries, as the loss of
cortical contact at such location results in loss of the
main buttress to resist varus bending moments. Like-
wise, the lateral cortical wall in the proximal femur is
also an important stabilizer against head/neck fragment
collapse during loading. It has been reported that lateral
wall fracture is associated with a 22% risk for revision
surgery compared with 3% when intact (P , 0.001).2
In 2018, the OTA/AO 31A classification system for
the proximal femur was revised to include lateral wall

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 Mechanical Complications After Hip Fracture Fixation

Figure 2
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A, Mechanical failure of a pilon fracture status after internal fixation. Loss of reduction after failure resulted in the fragments resuming
their original varus deformity. B, Mechanical failure of a reverse obliquity fracture after set screw fracture that resulted in displacement
back to the original preoperative position with lateral trochanteric displacement and medialization of the shaft.41

thickness as a key variable to distinguish stable from

Figure 3
unstable injuries (31A1 from 31A2) (Figure 1).3 Hsu et al4
demonstrated that a lateral wall thickness of less than
20.5 mm was prognostic for iatrogenic lateral wall
fractures, resulting in a significantly higher rate of failure
in A2 fractures (49% versus 8.3%; P , 0.001). Under
such circumstances, selecting an IM nail for treatment
would allow the implant itself to substitute for the
missing lateral wall and buttress collapse, which would
maintain the offset. Despite this recent revision, the
classification system remains imprecise, as severe and
moderate collapse has still been described in 13% and Radiographs and 3D reconstruction of an OTA/AO 31A1.3
fracture that is shortened with varus deformity. Rotational
26% of stable two-part injuries, respectively, suggesting deformity of the femoral head/neck fragment along its axis is
that our current understanding of such injuries’ stability more apparent on the 3D reconstruction in addition to the
is incomplete.5 varus and shortening.
The mechanical environment of any fracture is illus-
One of the biggest limitations in our understanding of
trated by the deformity present on the preoperative
deformity is that our knowledge base for extracapsular
radiographs, which is a basic orthopaedic principle
hip fractures is predominately written in a two-
observed in fractures all over the body. In cases of failure,
dimensional language. The terms varus and shortened
loss of reduction often progresses as the fragments drift
are frequently used to describe both initial deformity and
back into their innate position, thus resuming their mechanical failure for such fractures. However, these
original deformity (Figure 2).6 Currently, initial defor- terms only apply to values quantified in the x and y axes.
mity dictates the reduction maneuvers performed for Recent technological advances have allowed for a more
extracapsular hip fractures; however, little is known detailed approach using 3D reconstruction obtained
about its potential application to other decisions around from CT. CT identifies a third plane of deformity, which
stability and implant selection. Promising yet limited is often present in extracapsular hip fractures or rota-
clinical evidence suggests that the degree of varus tional deformity of the femoral head or neck around its
deformity on preoperative radiographs for pertrochan- own axis (Figure 3). The OTA/AO classification for
teric fractures is predictive of varus collapse and cutout.7 pertrochanteric fractures does not currently consider

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JAAOS® December 15, 2022, Vol 30, No 24 © American Academy of Orthopaedic Surgeons
 Matthew L. Klima, DO, FACS, FAOAO

rotational instability, which may partially account for
its imperfect description of stability. The rotational
component of stability for OTA/AO 31A fractures is
substantiated not only by the presence of rotational
deformity due to fracture geometry but also by the
rotational forces present in the mechanical environment
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Review Article
selection and reduction goals to best meet the demands of
the mechanical environment. Common mechanical
complications include cutout, inordinate proximal fem-
oral shortening, delayed union, early implant fracture,
nail toggle, and cut through/medial migration.

postoperatively. In a radiostereometric analysis of Cutout

intertrochanteric fractures after fixation with single- Cutout and loss of fixation of the implant in the femoral
screw implants, it was noted that shortening and rota- head occurs more commonly in osteoporotic hip frac-
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tion around the anatomic axis of the femoral neck
occurred concomitantly with a mean rotation of 10.6°
(228.1 to 6.1°) and mean shortening of 5.0 mm (20.13
to 12.9) at four months.8
Rotational instability has been historically described
among basicervical femoral neck fractures, which are
also extracapsular, where similar rotational deformities
are encountered. Johnson et al9 noted that under uni-
directional loading, rotational failures occurred fre-
quently (27%) in basicervical fractures treated with IM
implants with one point of fixation in the femoral
head/neck. In addition, the higher cutout rate in basi-
cervical femoral neck fractures treated with IM nails
(45% compared with 2% to 6% reported in per-
trochanteric fractures) observed by Watson et al10 was
attributed to the rotational instability inherent to the
fracture pattern, despite an average tip-to-apex distance
(TAD) of 17.4 mm with anatomic/near anatomic
reduction. Therefore, fractures at risk for rotational
failure would not only be purely basicervical but also
pertrochanteric fractures, with significant basicervical
component where rotational deformity is encountered
on the initial radiographs.
The prevention of mechanical failures begins with
identifying sources of instability and tailoring implant
tures, arising in approximately 5% to 6% of these in-
juries.11,12 This failure rate is variable and influenced by
multiple factors related to host, stability, and implant.
These failures occur early, most likely within the first
12 weeks.12 Cutout occurs less frequently in a more
delayed manner secondary to nonunion, osteonecrosis,
or other pathologic processes. Many of the early failures
are caused by several combined mechanical factors;
most notably, neck-shaft malreduction (varus) in
unstable patterns affects screw trajectory into the
proximal fragment resulting in suboptimal TAD and
failure (Figure 4)12 Tip-to-apex distance (TAD) is the
distance from the tip of the screw to the apex of
the femoral head, or center position, as viewed in both
the AP and lateral radiographic views. Fujii et al13
used a multivariable logistic regression model to
establish that a TAD .20 mm was the single most
important risk factor for cutout after internal fixation
with an IM nail (odds ratio 12.4, P = 0.019).
Cutout can still be observed despite good reduction and
adequate TAD, which has recently led to a more detailed
investigation of the underlying biomechanical forces
governing failure. In a biomechanical study of unstable
fractures using a multidirectional load in a cadaver hem-
ipelvis model, it was found that the predominant motion

Figure 4

A, AP radiograph after hip fracture surgery where the tip of the greater trochanter is above the center of rotation for the femoral head
indicating a varus reduction. The varus reduction forces the helical blade into a more superior position in the femoral head, which is
suboptimal compared with a more central location. B, Lateral radiograph of a starting point too far posterior on the greater trochanter
forcing the screw to end up anteriorly in the femoral head instead of the recommended position in the center. Ideal staring point on the
lateral view is right at the junction of the anterior and middle third of the greater trochanter.

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JAAOS® December 15, 2022, Vol 30, No 24 © American Academy of Orthopaedic Surgeons
 Mechanical Complications After Hip Fracture Fixation
during cutout was rotation around the anatomic axis
of the femoral neck over compression/varus collapse
(Video 1). Although this model lacked the iliotibial ten-
sion band to fully simulate one- and two-legged stance,
multiple points of fixation in the proximal fragment via
dual screws reduced failures, compared with a single
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unicortical screw for fixation by controlling rotation
(single screw average rotation: 35.4 6 29.3°; versus dual
screw average: 5.5 6 6.4°; P = 0.006).14 Literature
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support for torsion control IM nails that use dual screws
proximally to improve the cutout rate is currently limited
to smaller retrospective clinical studies, while randomized
prospective studies are lacking.
Technological advances have also focused on achieving
torsion control and improving implant load distribution
by augmenting bone quality with various injectable bone
graft substitutes such as polymethyl methacrylate
(PMMA) or calcium phosphate (CaPO4).1 In a retro-
spective study, a lower rate of mechanical failure has been
reported among PMMA augmentation compared with
nonaugmented fractures (2.1% to 13.8%, P = 0.047).15
Extravasation of the PMMA into both the hip joint and
the fracture site resulting in nonunion was among the
intraoperative complications observed, in addition to
guidewire perforation of the femoral head which, pre-
cluded augmentation. Another randomized controlled
trial could not verify any significant difference between
augmented and nonaugmented groups in terms of
radiographic outcome (blade migration), functional
outcome, or rate of mechanical failure.16 The precise
indications for newer torsion control devices and their
role in preventing failures currently remain undefined,
and their use does not obviate the need for adequate
reduction or proper technique.
The recommended treatment for cutout involves ar-
throplasty owing to destruction of the femoral head and
erosion of the acetabulum. The incidence of complica-
tions after conversion to total hip arthroplasty (THA)
was significantly higher after IM nailing than after pri-
mary THA in terms of infection (6.2% versus 2.6%),
dislocation (8.1% versus 4.5%), and revision (8.4%
versus 4.3%).17 In cases in which failure is detected
before head violation, revision nailing with cement
augmentation has been proposed as a potential alter-
native to arthroplasty. However, limited clinical data
suggest that this technique results in a higher rate of
revision surgery.18
Proximal Femoral Shortening
Proximal femoral shortening is expected by virtue of
controlled collapse, which has long been established as
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JAAOS® December 15, 2022, Vol 30, No 24
the accepted process used to achieve union in such frac-
tures occurring in osteoporotic bone. However, in
unstable injuries, when collapse is uncontrolled, exces-
sive shortening that develops rapidly is associated with
severe pain that limits mobility. Recently, the limits of
acceptable collapse were quantified by a prospective
study, demonstrating that radiographic shortening over
8 mm affected the length-tension relationship of the hip
abductors and correlated with several gait abnormalities
(P = 0.008).19 The newer evidence regarding the effect of
IM nails on proximal femoral shortening after ex-
tracapsular hip fracture fixation is summarized ac-
cording to its strength in the supplemental table.
The first step in controlling collapse is to maximize
contact of cortical bone at the fracture site with a good
reduction. The need for proximal dynamization, or the
slide, should be determined after evaluating fracture
stability and the quality of the reduction. Any gaps or
distraction of the fracture can be compensated for by
unlocking the proximal set screw a quarter turn to allow
some collapse of the construct. Alternatively, when gaps
are eliminated by intraoperative compression, fully
locking the set screw to minimize collapse has also been
shown to achieve union without making constructs
overly rigid and increasing complications.20,21 Although
fully locking the set screw is recommended in unstable
fracture patterns, failure to dynamize or allow con-
trolled collapse in the presence of a persistent fracture
gap may lead to nonunion. It is essential for the surgeon
to determine the set point of control required for each
injury by balancing reduction quality/gapping with the
need for proximal versus distal construct dynamization
to achieve union and minimize shortening.
After reduction, implant selection is an important
consideration because in several randomized prospective
studies, IM nails have demonstrated less radiographic
shortening compared with sliding hip screws (SHS).22-25
These results have only correlated with enhanced
functional outcome scores and have been validated by
prospective randomized studies that performed a sub-
group analysis of patients with high baseline function. A
randomized prospective study reported that patients
who independently ambulated more than 150 feet
before injury treated with SHS had more proximal
femoral shortening and poorer functional outcome
scores than those treated with torsion control nails.23
Another study confirmed that improvements in mobility
were significantly superior for patients over the age of
80 with a preinjury mobility score $7 (good) treated
with a nail compared with SHS, at all follow-up inter-
vals after 8 weeks.24
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© American Academy of Orthopaedic Surgeons

In several retrospective studies, torsion control IM
nails have also been shown to reduce radiographic
shortening compared with standard IM nails.5,20,26,27 A
study of over 400 subjects showed significantly less
shortening with a torsion control IM nail over a stan-
dard IM nail (5.10 versus 2.36 mm at 12 months;
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P , 0.001) in unstable patterns with good reduction.20
Ricci et al5 reported that even in stable two-part injuries,
there was less collapse with torsion control IM nails
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compared with standard IM nails and SHS (P , 0.001).
Surprisingly, among this cohort with a standard IM nail,
26% still collapsed .1 cm, and 5% .2 cm. What is
considered acceptable in terms of these fractures’
shortening should be reconciled with newer data using
modern implants, particularly in active patients with
higher levels of baseline function.
Nonunion/Delayed Union
Delayed union and nonunion are generally defined as
lack of healing beyond four and six months, respectively,
for extracapsular hip fractures, occurring more fre-
quently in subtrochanteric than pertrochanteric patterns
(7% to 20% compared with 1 to 2%).28,29 In addition to
metabolic causes such as diabetes mellitus, smoking
history, or infection, a frequent source of nonunion
among extracapsular hip fractures is poor initial
reduction. It has been observed that an average varus
malreduction of 9° (4 to 14° range) was a feature in
almost every subtrochanteric nonunion and associated
implant failure.29 Krappinger et al30 state that varus
malreduction .5° and lack of medial calcar support
from either malreduction or comminution were pre-
dictive of nonunion in subtrochanteric fractures after
IM nailing. A difference in neck-shaft angle (NSA)
of .4.4° in varus angulation when compared with the
contralateral hip (sensitivity 60%; specificity 90.91%;
P = 0.0035), and sagittal angulation .5.5° (sensitivity
60%; specificity 93.94%; P = 0.0001) were both pre-
dictive of nonunion and failure in atypical subtro-
chanteric fractures.31 In the current study, 31% were
maligned; and alignment was shown to be a greater risk
factor for nonunion compared with opening the fracture
site and diphosphonate use. It is recommended that the
neck-shaft angle be restored to within 5° of the
contralateral side for optimal results.
Varus malreduction in extracapsular hip fractures is
iatrogenic in several scenarios. In a cadaver study of
subtrochanteric femur fractures, an entry point lateral to
the tip of the trochanter was created significant varus
angulation regardless of proximal bend design
(P , 0.0001) than an entry point just medial to the tip of
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JAAOS® December 15, 2022, Vol 30, No 24
Matthew L. Klima, DO, FACS, FAOAO
Review Article
Figure 5
Wedge deformity of a pertrochanteric fracture resulting in
varus malreduction. Having a starting point in the fracture can
result in further displacement of the fragments during
reaming and failure to ream a proximal hole for the implant.
The implant itself then acts as a wedge during insertion
creating varus and can even prevent controlled collapse
resulting in nonunion.
the greater trochanter.32 Eccentric reaming can cause
the starting point to drift laterally, and good technique
during reaming involves stopping the reamer before and
after passing through the entry point to prevent eccen-
tric reaming. In pertrochanteric fractures, a starting
point in the fracture itself can create a varus wedge
deformity that can obstruct collapse and prevent union
(Figure 5).33
Reverse obliquity fractures represent a unique
mechanical environment in which the geometry of the
pieces creates shear forces that predispose implants to
nonunion and failure. Haidukewych et al34 reported
that fixed-angle constructs (blade plates) outperformed
sliding constructs (SHS) for such fracture patterns, as
prevention of sliding minimized the shear forces. The
use of IM nails for these fractures has improved out-
comes. In a retrospective study looking at 193 patients
with OTA/AO 31A3 fractures treated with long IM
nails, an overall nonunion rate of 6% and higher
incidence of failure among malreduced fractures
(11.1% versus 2.6%; P = 0.021) have been observed.35
There was a higher nonunion rate in this cohort with
the use of long stem recon-type IM nail (4.5% versus
23.5%; P = 0.002), which may reflect the lack of fixed-
angle proximal locking options in those specific im-
plants. Cephalomedullary nails are not truly fixed
angle devices, as demonstrated by the continued sliding
observed after fully locking the set screw reported in
several studies. However, when treating a reverse
obliquity fracture with an IM implant, fully locking the
proximal construct is recommended to minimize
sliding.
One of the most common deformities encountered
after IM nailing of the proximal femur supine on a frac-
ture table is an internal rotation deformity.36 With
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© American Academy of Orthopaedic Surgeons
 Mechanical Complications After Hip Fracture Fixation

Figure 6
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A, Sawbones model with a revere obliquity fracture is anatomically reduced. B, Excessive internal rotation of the distal fragment as
demonstrated by the offset line causes asymmetric cortical engagement of the obliquity resulting in a large calcar gap posterior and
medial. In this circumstance, it is recommended to release traction and adjust rotation before distal locking. Any persistent gaps below
the level of the blade/lag screw are best addressed with distal dynamization.

reverse obliquity fractures, excessive internal rotation of
the shaft causes asymmetric cortical engagement at the
oblique fracture line, resulting in a large posterior and
medial calcar gap (Figure 6). In such circumstances,
traction is released and rotation adjusted before distal
locking. Distal dynamization would further help close
the gaps and allow compression in the fracture plane,
particularly with fracture lines that extend below the
proximal blade/screw. In cases in which the blade/lag
screw prevents axial compression, lateral cortical
notching is required to dynamize distally and improve
compression across the fracture.37
The algorithm for surgical management of ex-
tracapsular nonunion is based on the condition of the
femoral head, location of the broken implant, and
presence of fixed deformity to include shortening. Ar-
throplasty is recommended in cases in which there is
destruction or concern regarding the viability of the
femoral head. Valgus osteotomy with revision internal
fixation is considered in the presence of a fixed
deformity/shortening to restore the proper neck-shaft
angle. Implant selection for the revision procedure is
geared toward achieving secure fixation in the proximal
fragment and should target the area where bone stock
remains after implant removal. After restoration of the
neck-shaft angle, revision internal fixation is typically
successful regardless of the type of implant used.38
Early Implant Fracture
Eventual implant fracture is the expected consequence of
repetitive loading in the absence of healing or nonunion.
Early implant fracture, defined as failure before
four months, is concerning because it occurs before the
effects of delayed union and may be related to the implant,
including its damage. Implant notching is the result of
iatrogenic damage to the titanium implant that occurs
during insertion; it is the largest contributor to early
implant fracture, as observed by Klima39 in a large ret-
rospective study of 342 reported IM nail failures.
Although notching can occur at any point along
the implant with an aperture for drilling, implant frac-
tures occur most commonly through the smallest
cross-sectional area located at the proximal screw
aperture (Figure 7)
A key aspect to consider to extend implant survival is
preventing implant damage during its insertion through
meticulous technique. An eccentrically placed Kirschner
wire in the proximal screw aperture will be closer to the
implant wall, resulting in wall contact with the reamer
and notching. Excessive bending forces applied to the
drill/targeting device during insertion, and the contin-
ued use of bent Kirschner wires also contributes to
insertional notching. Not all notches are attributed to
the stepped reamer, as a lag screw/blade inserted over an
eccentrically placed guidewire can still cause minor
notches and abrasions in titanium that compromise the
fatigue strength. Guidewires used for rotational control
of the proximal implant should be strategically placed to
avoid making contact with the proximal aspect of the
implant.
Fractured implants pose several challenges during
their removal. Some titanium alloys fracture via a

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 Matthew L. Klima, DO, FACS, FAOAO

Review Article
Figure 7
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A, Looking at the proximal lateral aspect of an intramedullary implant with a large notch at the proximal screw aperture. IM implants
fracture most commonly at this location through the smallest cross-sectional area. B, Notching of the distal interlocking oblong hole
directly at the point of failure of a short stem implant. Notching of the implant occurs at any point along the implant that has an aperture
for drilling and can result in implant fracture at that specific location. C, Multiple points of contact and notches at the distal aspect of an
IM nail after attempted interlocking. IM, intramedullary.

stepped propagation pathway, resulting in irregular Nail Toggle

pieces with sharp edges, as observed in fatigue failures of
these implants.40 Secondary fracture lines, also
described among these alloys, can contribute to frag-
mentation during removal if increased force is required
for extraction (Figure 8). Additional preoperative
planning is recommended to ensure that the surgeon is
familiar with the implant, removal procedure, and any
broken components before extraction to ensure safe
removal. In cases of early failure, a thorough workup
to rule out infection is also recommended.
Early implant breakage has also been described
among various implant components.41 Auto dynam-
ization is a process of early distal screw breakage that
occurs around 3 months in subtrochanteric fracture
cases and predates proximal implant breakage by
2 months.28 It is an indicator of mechanical instability.
Early revision to a stable construct is recommended to
avoid the consequences of prolonged immobility.
A randomized prospective study of 220 patients showed
that short IM nails maintained reduction with up to 3 cm
of subtrochanteric extension with distal cross-locking.42
However, this study did not evaluate the effect of canal
fill on loss of reduction, as virtually all fractures were
treated with the same size implant. In the setting of a large
or capacious proximal femoral canal, concerns regarding
the use of short IM implants remain. A study revealed
that varus deformation/toggle under compressive loading
occurred, to some degree, in all short IM specimens
loaded; however, it was greatest (17.9 6 2.6; P , 0.05) in
the unlocked specimens in wide canals.43 In this study,
distal interlocking reduced the amount of toggle in the
femoral canal but did not eliminate toggle entirely.
In another biomechanical study, it was observed that
peri-implant fracture of short IM implants was preceded
by almost immediate toggle of the implant in a large
femoral canal that occurred even before loading.44

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 Mechanical Complications After Hip Fracture Fixation
Figure 8
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Titanium alloy fracture via a stepped propagation pathway resulting in irregular implants pieces with sharp edges as observed in fatigue
failures of these implants. The secondary fracture lines of this alloy indicated by the red arrows can contribute to fragmentation during
removal if increased force is required for extraction
Figure 9
Radiographs of implant toggle or early displacement into
varus. When the tip of a short implant does not make direct
contact with the lateral femoral cortex, the oval shape of the
distal interlocking aperture permits accessary motion in the
coronal plane resulting in loss of reduction.
As there are no formal criteria for deciding when the
width of the femoral canal requires the use of a long nail, it
is at the surgeon’s discretion to evaluate when a longer
implant that contacts the femoral isthmus is required to
prevent displacement (Figure 9). In circumstances where
the tip of a short implant does not make direct contact
with the lateral femoral cortex, the oval shape of the
distal interlocking aperture permits accessory motion in
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JAAOS® December 15, 2022, Vol 30, No 24
the coronal plane or toggle and varus deformation.45
Implant toggle may be a precursor to predicting peri-
implant fractures in short IM implants.
Medial Migration
Medial migration, also referred to as axial migration or cut
through, occurs when blade/lag screw cuts outs from the
femoral head medially instead of superiorly, as seen in
typical cutout. In contrast to other mechanical failures, the
blade/lag screw fails to slide in the proximal screw aperture
and, paradoxically, continues to migrate against gravity
into the pelvis after penetrating the acetabulum, thus
placing intra-abdominal structures at risk. In some cases,
medial migration is preceded by a period of uncontrolled
collapse that progresses to the design limits of the proximal
set screw. Further collapse or sliding would then be pre-
vented by the implant itself, resulting in medially directed
penetration of the femoral head and acetabulum.46
A meta-analysis confirmed that medial migration or
cut through (OR = 5.33; 95% CI, 2.09 to 13.56;
P , 0.01) was more common with helical blades than
with lag screws.47 This suggests that the in vivo behavior
of the helical blade differs compared with the large
sliding lag screw used in cephalomedullary nails. This
may also be attributed to surgical technique as described
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© American Academy of Orthopaedic Surgeons
 Matthew L. Klima, DO, FACS, FAOAO

Review Article
Table 1. Literature Review of Level I, II, and III Studies Within Last Five Years Pertaining to IM Nails and Proximal
Femoral Shortening

Number of
Author Study Type Fractures Implants Outcomes Salient Findings
24
Ong , 2019 Subgroup analysis T: 1000 SHS Functional: mobility Significant
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from Parker, 2017 170 stable Taragon IMN score improvement in the
806 unstable mobility score with
23 IMN over SHS if
basicervical independent before
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fracture, age ,80 yrs,

and cognitively intact
Parker25, Prospective T: 1000 SHS Complications No difference
2017 randomized, level I 170 stable Taragon IMN Functional: mobility between two implants
806 unstable score and pain score (LOS, need for
23 revision surgery,
basicervical blood loss, mortality,
and medical/surgical
complications). Trend
toward more mobility
with IM nails was not
statistically significant
Sanders23 Prospective T: 249 Intertan Radiographic: PFS and IMN had fewer
2017 randomized, level I 43 stable SHS alignment patients with limb
206 unstable Functional: FIM, TUG, shortening greater
LEM, and 2MWT than 1 cm (17%)
compared with SHS
(42%). Significantly
higher TUG/FIM
scores with IMN over
SHS among subgroup
of patients able to
ambulate more than
150 feet prior to injury
Berger- Prospective T: 104 Intertan Radiographic: CCD No differences in
Groch49, randomized, level I 28 stable Gamma3 and PFS outcomes at 5 yrs,
2016 76 unstable Functional: HHS and only 33 patients
SF-36 available at 5‐yr
follow‐up. Average
PFS in Intertan was
2mm versus 4mm for
Gamma 3, although
the difference was not
found to be significant
Reindl22, Prospective T: 167 SHS, TFN, Intertan, Radiographic: PFS Less radiographic
2015 randomized, level I 167 unstable and Gamma3 Functional: LEM, FIM, shortening with IMN,
and TUG no difference in
functional outcome
scores, and mean
difference 8-9 mm
Gausden19, Prospective, T: 72 TFN Radiographic: PFS Mean PFS of 4.7mm,
2018 prognostic, level II 30 stable Functional: HHS and shortening more than
42 unstable SF-36 8mm correlated with
decreaed cadence,
decreased step length
(continued )

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JAAOS® December 15, 2022, Vol 30, No 24 © American Academy of Orthopaedic Surgeons
 Mechanical Complications After Hip Fracture Fixation

Table 1. (continued )
Number of
Author Study Type Fractures Implants Outcomes Salient Findings
27
Ciufo , 2021 Retrospective, level III T: 290 SHS, Gamma3, and Radiographic: NSA and More PFS in SHS
290 stable TFN PFS compared with IMN.
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No difference in
implant failure rates
Parry26, 2020 Retrospective, level III T: 158 Gamma3 Radiographic: PFS and Reduction quality and
49 stable TFN NSA stability of fracture
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 02/16/2024

62 unstable patterns associated

with more shortening;
calcar gap .4 mm on
average 3 mm more of
PFS
Ricci5, 2019 Retrospective, level III T: 144 SHS Radiographic: PFS and 26% treated with SHS
144 stable Intertan NSA and SSF collapsed
Gamma3 greater than 10 mm
and 17% more than
20 mm. More PFS in
SHS compared with
DSF, P = 0.021, more
PFS in SSF compared
with DSF P = 0.001
Serrano20, Retrospective, level III T: 413 Intertan Radiographic: PFS and Standard IMN 2.5
2017 234 stable Gamma3 NSA more varus collapse
179 unstable and 2 times more PFS
compared with
torsion control IMN
regardless of stability
of fracture

2MWT = two-minute walk time; CCD = caput-collum-diaphyseal; DSF = dual screw fixation; FIM = Functional Independence Measure; HHS
= Harris Hip Score; LEM = lower extremity measure; NSA = neck-shaft angle; PFS = proximal femoral shortening; SSF = single-screw fixation;
standard IMN = TFN, Gamma3; Torsion Control IMN: Intertan, Taragon IMN; TUG = Timed Up and Go Test.

by Flores et al,48 who found increased odds for com-
bined axial cutout and medial migration with a
TAD ,20 mm when implanting a helical blade (OR =
1.15, P = 0.01). It is proposed that maintaining a slightly
longer TAD with helical blade use will help prevent
medial cut through.
In case of new-onset postoperative pain, medial
migration detected radiographically is progressive.
Hence, limited weight bearing or revision procedures
before perforation are recommended. Ideally, arthro-
plasty is advised, as revision IM nailing and blade
exchange with and without augmentation results in a
higher failure rate than that with THA alone.18
Summary
It is essential that surgeons understand how surgical
reduction, proper implant selection, and meticulous tech-
nique reduce mechanical complications after IM fixation of
extracapsular hip fractures in osteoporotic bone. Unstable
fracture patterns should be fixated with IM nails with the
goal of controlling motion around the implant and at the
fracture site. When indicated, torsion control devices pro-
vide additional stability and control. Although new tech-
nology can be useful, new medical devices alone cannot
obviate the need for good reduction or surgical technique.
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Review Article
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35:87-91.
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evaluation of torsional malalignment after intertrochanteric fracture fixation.
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© American Academy of Orthopaedic Surgeons
 |

Management of Lisfranc Injuries

A Critical Analysis Review

Thomas H. Carter, Abstract

MD, FRCSEd(Tr&Orth) » There is a spectrum of midtarsal injuries, ranging from mild midfoot
sprains to complex Lisfranc fracture-dislocations.
Nicholas Heinz,
MMedSci, MRCSEd » Use of appropriate imaging can reduce patient morbidity, by
reducing the number of missed diagnoses and, conversely, avoiding
Andrew D. Duckworth, overtreatment. Weight-bearing radiographs are of great value when
MSc, PhD, FRCSEd(Tr&Orth) investigating the so-called subtle Lisfranc injury.
Timothy O. White, » Regardless of the operative strategy, anatomical reduction and stable
MD, FRCSEd (Tr&Orth), fixation is a prerequisite for a satisfactory outcome in the management
FFTEd of displaced injuries.

Anish K. Amin, » Fixation device removal is less frequently reported after primary
PhD, FRCSEd(Tr&Orth) arthrodesis compared with open reduction and internal fixation based
on 6 published meta-analyses. However, the indications for further
surgery are often unclear, and the evidence of the included studies is
Investigation performed at Edinburgh of typically low quality. Further high-quality prospective randomized
Orthopaedics, Edinburgh, United trials with robust cost-effectiveness analyses are required in this area.
Kingdom
» We have proposed an investigation and treatment algorithm based
on the current literature and clinical experience of our trauma center.

T
he Lisfranc injury is named
after a French gynecologist
and field surgeon after he
defined an amputation
through the tarsometatarsal joints
(TMTJs)1, although the injury itself was
described by Napoleon’s surgeon Larrey.
The term implies disruption of this joint
with resulting midfoot instability and
encompasses a spectrum of injuries to
bone and/or ligamentous structures2.
Lisfranc injuries are rare making up only
0.2% of all orthopaedic presentations,
although recent literature suggests a ris-
ing incidence, with unstable injuries now
more common in women3. Some injuries
are frequently missed; these are com-
monly subtle injuries sustained through
low-energy mechanisms or in individuals
with distracting injuries, such as the
polytraumatized patient. If not identified
and treated promptly, these injuries carry
high morbidity, typically by accelera-
ted midfoot degeneration and arch
collapse4-6. This, in turn, may lead to
substantial functional impairment and in
some cases, loss of employment7. Open
reduction and internal fixation (ORIF) of
these injuries after delayed diagnosis of
up to 6 weeks is possible8, but outcomes
are less satisfactory compared with timely
intervention.
This article reviews the surgical anat-
omy, presentation, and diagnosis of Lis-
franc injuries, followed by a comprehensive
overview of treatment, concentrating on
the contemporary literature published over
the past decade. A review of subtle Lisfranc
injuries in athletes has been published
recently9 and is not this article’s focus.
Relevant Surgical Anatomy
The Lisfranc joint and the Lisfranc liga-
ment complex are not to be confused and

COPYRIGHT © 2023 BY THE

JOURNAL OF BONE AND JOINT Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online
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JBJS REVIEWS 2023;11(4) :e22.00239 · http://dx.doi.org/10.2106/JBJS.RVW.22.00239 1

 | Management of Lisfranc Injuries
have traditionally been ill-defined10.
The Lisfranc joint consists of all the
TMTJs reinforced by soft-tissue stabi-
lizers, namely the Lisfranc ligament
complex, intermetatarsal ligaments
(connecting metatarsals II-V, but
importantly not I-II), intertarsal liga-
ments, and TMTJ capsular connections.
In the coronal plane, the Lisfranc joint is
formed of contributions from the met-
atarsal bases and their respective cunei-
forms, which are narrower on the plantar
side, resulting in a Roman arch (Fig. 1).
The second metatarsal is recessed
between the first and third metatarsals,
abutting the middle cuneiform and
forming the arch keystone, which if
compromised, destabilizes the midfoot
complex.
Reduced second metatarsal length,
relative to foot length, may be a predis-
posing factor to a ligamentous Lisfranc
injury11. A number of anatomical vari-
ations of the Lisfranc ligament complex
have been described12-14 but, in sum-
mary, consists of plantar, interosseous,
and dorsal components, which span
between the second metatarsal base and
the lateral aspect of the medial cunei-
form10,12 (Fig. 1). Two key plantar lig-
aments exist: a shorter longitudinal
ligament from the medial cuneiform to
the lateral aspect of the second metatar-
sal base and a long oblique ligament,
which extends to the third metatarsal
base14,15. The interosseous ligament is
the largest and strongest, often referred
Fig. 1
The Roman arch of the midfoot showing the Lisfranc ligament complex.
2 APRIL 2023
to as the “Lisfranc ligament,” which if
sectioned in isolation in a cadaveric set-
ting, results in diastasis16. Variations in
the structure of the interosseous and
plantar ligaments, specifically, may play
a role in susceptibility to injury10.
Clinical Presentation
Up to 70% of Lisfranc injuries occur
after a high-energy mechanism, with
over 40% sustained during road traffic
accidents17, although some studies have
noted a higher proportion of low-energy
injuries and are likely related to the
catchment population3. Lower energy
injuries usually occur by a sudden
downward rotational force and are more
commonly sustained during sports
activities9,18-20. Despite a better under-
standing of the pathoanatomy of these
specific injuries21, they are frequently
missed at the time of initial presentation
or diagnosed late because they are largely
isolated ligamentous in nature without
an associated fracture22. Late presenting
patients with persistent pain should be
investigated for a missed Lisfranc injury.
They may exhibit a bony prominence
over the medial aspect of the midfoot, a
so-called Jut sign23. Compared with
low-energy injuries, high-energy
injuries are more commonly associated
with lateral ray involvement and tarsal
bone fractures, predominantly the
cuboid and navicular. Compartment
syndrome of the foot must be considered
in high-energy injuries24,25. Regardless
of the mechanism, in the presence of
midfoot pain, swelling, and/or plantar
ecchymosis, a high index of suspicion is
required to avoid missed diagnoses26.
Investigations
Non–weight-bearing radiographs are
the primary investigation of choice.
Anteroposterior (AP), 30-degree inter-
nal oblique, and lateral radiographs may
demonstrate a diastasis between the
medial cuneiform and the second met-
atarsal base and/or a radiographic “fleck
sign,” which are typically pathog-
nomic27. However, these may miss
subtle injuries, and if there is ongoing
clinical concern, weight-bearing radio-
graphs of both feet to allow side-to-side
comparison, when pain allows, are rec-
ommended3,28-31 (Fig. 2). This is a
routine practice at the authors’ institu-
tion 10 to 14 days after injury and may
highlight not only instability between
the medial and middle columns, but not
infrequently unmask instability at the
first TMT joint (Fig. 5). Side-to-side
asymmetry or a distance of .2 mm
between the second metatarsal base and
the medial cuneiform is highly specific
(96%) in aiding in the diagnosis of a
ligamentous injury32. Deep learning
algorithms have reduced misdiagnosis of
subtle injuries by a factor of 1033.
Dividing the foot into 3 columns
(medial, middle and lateral) helps visu-
alize the normal alignment of the ana-
tomical zone of interest (Fig. 3). The
· VOLUME 11, ISSUE 4 · e 22.00239

medial and middle columns are inher-
ently rigid, both acting to stabilize the
midfoot during gait. Comparatively, the
lateral column permits more movement
in all planes, allowing an adaptive foot
position when navigating uneven
surfaces. TMTJ alignment on weight-
bearing radiographs should be scruti-
nized; the medial border of the second
metatarsal should align with the medial
border of the middle cuneiform on the
AP radiograph, and similarly, the medial
border of the fourth metatarsal should
align with the medial border of the
cuboid on the oblique radiograph.
Dorsal displacement on the lateral
Fig. 3
Anteroposterior (Fig. 3-A) and oblique (Fig. 3-B) schematics of the tarsometatarsal region of the foot, demonstrating the 3 columns of the foot.
APRIL 2023 · VOLUME 11, ISSUE 4 · e22.00239
weight-bearing radiograph is evaluated
by the assessment of collinearity
between the metatarsal bases and their
respective cuneiforms.
At the Lisfranc joint, a fleck sign,
when present, may indicate an osseous
avulsion from either side of the Lisfranc
ligament and a diastasis of .2 mm raises
suspicion of underlying injury. Loss of
radiographic arch height, visualized on
the lateral radiograph, may occur after
injury31,32. Although not extensively
studied in the literature, it may serve as
an adjunct in the diagnosis of subtle
injuries and/or in confirming accurate
reduction intraoperatively. Injury to the
Management of Lisfranc Injuries |
Fig. 2
Non–weight-bearing anteroposterior radio-
graph of the left foot initially reported as
normal. Subsequent bilateral weight-bearing
foot radiographs clearly demonstrate a liga-
mentous Lisfranc injury on the left side.
first TMTJ, including articular damage,
fracture, and/or joint incongruity, may
occur in up to 86% of cases and has been
overlooked previously34. Fractures of
the second metatarsal base with no evi-
dence of radiographic instability at the
Lisfranc joint are commonly (but
incorrectly) interpreted as Lisfranc
injuries and are treated conservatively.
If weight-bearing radiographs are
not tolerated or if these are normal
despite ongoing suspicion, cross-
sectional imaging including computed
tomography (CT) or magnetic reso-
nance imaging (MRI) may be helpful.
CT is valuable in detecting occult
3
 | Management of Lisfranc Injuries
fractures, joint comminution, and
minor degrees of joint subluxation that
may be missed on radiographs35, and 3-
dimensional reconstructions improve
diagnostic accuracy and reliability com-
pared with 2-dimensional interpreta-
tion36. Recognition of articular injury
may aid in surgical decision making
when considering primary arthrodesis
(PA). CT is further recommended in
high-energy injuries where coexisting
fractures, if detected, may affect surgical
management and/or postoperative
rehabilitation (Fig. 4). If previous
investigations have been normal and
there is continuing concern regarding
the injury, MRI is superior in revealing
the so-called subtle injury28,35,37,38.
Stress testing under anesthesia has been
performed historically, but with
advances in imaging, is now seldom used
for diagnostic purposes, although com-
monly performed at the time of opera-
tive stabilization. In summary, the
diagnosis of a Lisfranc injury can be very
challenging. A high index of suspicion
based on the clinical presentation,
combined with appropriately selected
imaging studies, is essential to reduce the
number of missed injuries.
Fig. 4
Computed tomography imaging with 3-
dimensional reconstruction in a patient pre-
senting with a high-energy Lisfranc injury,
demonstrating associated cuboid and base of
fifth metatarsal fractures.
4 APRIL 2023
Classification of Injury
Numerous classifications of Lisfranc
injury have been proposed30,39,40. The
most commonly used is the Myerson-
modified Hardcastle classification,
described in 1986 based on anatomical
zone, direction of displacement, and
TMTJ congruity40. Injuries are classi-
fied into 3 main groups (A/B/C), with a
fourth group (D) added in 201841. This
supplementary group relates to non-
displaced injuries and is further divided
into D1 and D2, depending on whether
nonoperative intervention is appropri-
ate. Although this classification system
has shown excellent intraobserver and
interobserver reliability (intraclass cor-
relation coefficient of 0.94 and 0.81,
respectively)42, it is considered less use-
ful in guiding management or predicting
prognosis43. A classification system for
Lisfranc injuries in athletes9,20 produced
by Nunley and Vertullo in a study of 15
athletes used a combination of clinical
examination, weight-bearing radio-
graphs, and bone scintigrams30. In
summary, no classification system exists
that definitively helps guide treatment.
Treatment
Nonoperative
Patients presenting with clinical features
suggestive of a midfoot sprain (localized
midfoot pain, swelling and/or bruising)
but with #2 mm gap between the
medial cuneiform and the second met-
atarsal base on weight-bearing radio-
graphs and/or CT/MRI imaging may be
suitable for nonoperative treatment in
appropriately selected patients40,44.
Ponkilainen et al. followed up 55
patients of an initial cohort of 110 who
were treated initially in a non–weight-
bearing cast for 4 to 6 weeks, followed by
full weight-bearing for a further 4
weeks45. At a minimum follow-up of 2
years, patients reported excellent func-
tion according to the visual analog scale
(VAS)-foot and ankle, and only 1 patient
required delayed operative intervention.
This study was limited by the large
proportion of patients who did not
respond to the questionnaire (36%) and
the lack of clinical examination and
radiographic outcomes.
Stødle et al. prospectively reviewed
26 patients’ stable injuries who received
a non–weight-bearing cast for 6 weeks
and were evaluated at a median time of
55 months after injury46. No patient
required surgery, and all returned to
employment, although 2 reported limi-
tations with recreation. Chen et al.
investigated the rate of displacement
after nonoperative treatment of mini-
mally displaced Lisfranc injuries47.
· VOLUME 11, ISSUE 4 · e 22.00239

Fourteen of the 26 patients included
(54%) displaced, and 12 required sur-
gery. Despite delayed intervention,
patient-reported outcome data were
comparable with those patients treated
successfully without displacement. The
authors concluded that nonoperative
treatment is feasible, but close radio-
graphic follow-up is mandatory to detect
early displacement. While discomfort
may persist after a midfoot sprain, there
is currently limited evidence to indicate
that surgery improves outcomes, and
consequently, high-quality data in this
area may help guide the best treatment
for this select patient group.
Operative
Percutaneous Fixation
To reduce operative morbidity and
expedite recovery, percutaneous fixation
has been recommended for subtle, low-
energy injuries, which have no lateral
column instability and can be reduced
anatomically through percutaneous
techniques48-53. Insertion of a standard
anterograde or retrograde Lisfranc screw
Fig. 5
Subtle right Lisfranc injury seen on an anteroposterior non–weight-bearing radiograph (Fig. 5-A), which demonstrated additional instability on stress weight-bearing
radiographic assessment between the medial and middle columns and the first tarsometatarsal joint (Fig. 5-B). One-year radiographic follow-up after percutaneous reduction
and fixation (Fig. 5-C).
APRIL 2023 · VOLUME 11, ISSUE 4 · e22.00239
(from the base of the second metatarsal
to the medial cuneiform) has been
described52,54 (Fig. 5). Chen et al.
described the technique in 16 consecu-
tive patients who were compared with a
control group treated with standard
ORIF matched for age, sex, mechanism
of injury, and classification52. At a mean
follow-up of 43 months, patient-
reported outcomes according to the
American Orthopaedic Foot and Ankle
Society (AOFAS) midfoot score and the
Manchester Oxford Foot Questionnaire
were significantly better in the percuta-
neous group, coupled with a lower
nonsignificant rate of radiographic
degeneration.
Similar mid-term findings were
reported by Vosbikian et al. in 38 con-
secutive patients sustaining a low-energy
injury49. Although no patient experi-
enced a serious complication, 22
patients underwent elective hardware
removal, which was offered by the
institution. Wagner et al. reviewed 22
patients treated with percutaneous fixa-
tion and achieved an anatomic or “near-
anatomical” reduction in all53. Patients
Management of Lisfranc Injuries |
were allowed to weight-bear as tolerated
3 weeks postoperatively and reported
excellent rates of return to function.
Only 1 systematic review on per-
cutaneous fixation has been performed
by Stavrakakis et al., including just 4
studies, which concluded that percuta-
neous fixation was simple, safe, and with
a low operative morbidity55. However,
as with any periarticular injury, a posi-
tive outcome was reliant on anatomical
reduction, and some authors consider an
open reduction mandatory for all subtle
Lisfranc injuries to prevent missing
concomitant joint injury, which if left
untreated may lead to post-traumatic
arthritis21. There are currently no Level
1 prospective data on this topic.
Open Reduction and Internal
Fixation
In injuries without significant insult to
the articular surface, ORIF is considered
the gold-standard treatment, combining
anatomical reduction with rigid internal
fixation (IF) to restore normal gait and
functional outcome56 maintained at
long-term follow-up57. Traditionally,
5
 | Management of Lisfranc Injuries
exposure has been achieved through
multiple dorsal longitudinal incisions,
separated by a small skin bridge58. A
single longitudinal, extensile incision
centered over the second metatarsal has a
comparable soft-tissue complication
profile, yet provides superior exposure of
the whole Lisfranc joint using up to 3
windows59. A transverse incision used
for access during arthrodesis procedures
in the setting of TMTJ arthrosis has
been described60, but it is used less fre-
quently than longitudinal incisions in
the trauma setting.
Debate continues regarding fixa-
tion modalities, chiefly transarticular
screw fixation and dorsal bridge plating.
Most clinical studies are single-center
and retrospectively designed and include
relatively small patient numbers61.
Transarticular screws are cheaper and
may be less irritating to local soft tissues.
Opponents of screw fixation report
direct chondral injury and retained
intra-articular hardware in the event of
screw breakage as primary objections.
Bridge plating adds no additional artic-
ular insult beyond that imparted by the
injury and may provide superior fixation
in comminuted fractures, but typically
requires greater surgical exposure and
the associated risks. Often, removal of
dorsal plates has been recommended,
although recent data have suggested that
retention is safe with comparable out-
comes to removal61. Although hardware
is not routinely removed in our institu-
tion, a recent UK study found that 38%
of surgeons routinely remove hardware
in the anticipation that this optimizes
physiological function and reduces the
risk of implant breakage62, although
without evidence to support this
contention.
In the laboratory, comparable fix-
ation stability has been demonstrated by
transarticular screws and dorsal plates
when tested in 13 paired cadaveric limbs
through cyclic loading63. Lau et al.
studied a group of 62 patients who
underwent transarticular screw fixation,
dorsal bridge plating, or a combina-
tion64. Reduction quality was more
predictive of radiographic outcome than
6 APRIL 2023
fixation choice. However, combination
fixation with both screws and plates re-
sulted in worse radiological outcomes,
but was often performed in more severe
injuries and, therefore, may be a con-
founding factor. Kirzner et al. reported
similar findings in their retrospective
review of 108 patients treated with
transarticular screw fixation (n 5 38),
dorsal bridge plating (n 5 45), and
combination fixation (n 5 25)65. Those
managed with combination fixation
reported a poorer mean AOFAS of 63,
compared with 71 in the transarticular
screw fixation group and 82 in the dorsal
bridge plating group. Similar patterns
were reported in the secondary outcome
measures, including patient satisfaction.
Dorsal bridge plating was associated
with improved anatomical reduction,
but did not reach statistical significance,
and there was no difference in compli-
cation rates. Again, more severe injuries
were managed with combination fixa-
tion, commonly including stabilization
of all 3 columns of the foot, which could
explain the inferior outcomes.
Engelmann et al. conducted a sys-
tematic review comparing functional
outcomes and complication rates of
transarticular screw fixation and dorsal
bridge plating66. One prospective and 3
retrospective studies were included and
found that functional outcome accord-
ing to the AOFAS was statistically sig-
nificantly higher in the bridge plating
group (mean difference 7 points),
although below the minimum clinically
important difference (MCID). There
was no difference between the 2 groups
for rates of infection, hardware removal,
chronic pain, or arthrodesis secondary to
ongoing pain and/or functional limita-
tion. However, there was a higher inci-
dence of post-traumatic osteoarthritis in
the transarticular screw group, poten-
tially linked to the greater degree of
chondral injury. Philpott et al. per-
formed a large systematic review and
meta-analysis including all fixation
strategies, both rigid and flexible67. Part
of the analysis compared transarticular
screw fixation with spanning dorsal plate
fixation across individual TMTJs and
concluded that plating was nonsuperior
in the AOFAS with a mean difference of
5 points, which was neither clinically nor
statistically significant. Although lateral
column stabilization is infrequently
reported, these rays are mobile by
design, and therefore, if instability is
present after fixation of medial and
middle columns, temporary stabiliza-
tion with Kirschner wires for no more
than 6 weeks is typically sufficient to
maintain reduction while minimizing
stiffness59.
More high-quality data comparing
screw and plate fixation are required, but
given the scarcity of Lisfranc injuries and
the broad range of injury patterns, con-
ducting meaningful randomized con-
trolled trials (RCTs) on this topic
is challenging. Nevertheless, it is
clear from the evidence available that
anatomical reduction, regardless of
fixation strategy, is critical to treat-
ment outcome.
Flexible Fixation Devices
Recreation of the Lisfranc ligament with
a flexible fixation device has been
investigated in numerous recent bio-
mechanical and clinical studies. Several
commercial constructs are available
aiming to permit residual movement at
the Lisfranc joint, to reduce the inci-
dence of hardware removal, and to
minimize implant breakage. Given the
flexible nature, any observed advantage
will benefit ligamentous injuries only
and stabilization of the first TMTJ is not
feasible with current devices.
Data from biomechanical studies
whereby flexible devices have been
tested to failure through cyclical loading
have found these devices to be non-
inferior to rigid fixation68-70. Cho et al.
compared 31 patients treated with a
suture button device with 32 patients
treated with a rigid Lisfranc screw71. All
procedures were performed percutane-
ously, and hardware was removed within
6 months postoperatively in the rigid
screw group only. The suture button was
superior according to the AOFAS
midfoot score and VAS before screw
removal, but no difference was found at
· VOLUME 11, ISSUE 4 · e 22.00239
 Management of Lisfranc Injuries |

1 year and beyond after hardware
removal. Two patients in the suture
button group experienced recurrent
diastasis with the button failing at the
medial cuneiform, compared with
1 diastasis in the screw group.
Cottom et al. evaluated radio-
graphic reduction and functional out-
comes after suture button stabilization
of the Lisfranc joint supplemented with
an intercuneiform screw (medial to
middle) in 104 patients with ligamen-
tous injuries72. There were 84 patients
with a minimum follow-up of 3 years.
Mean return to full weight-bearing in a
supportive orthosis was 11 days, and
no suture buttons failed, required re-
moval, or resulted in significant radio-
graphic degeneration. Patient-reported
outcome according to the AOFAS
improved from 31 at the time of injury
to 90 postoperatively. Supportive data
from small retrospective series including
both acute73,74 and chronic injuries75
have been reported. Concerns regarding
fixation purchase in poor-quality bone
limit the indication of these implants to
younger patients with purely ligamen-
tous injuries, and there are currently no
level 1 data to support use. Research
including robust cost-effectiveness
analyses to justify the increased implant
cost balanced against the potential
reduction in hardware removal rates is
needed. A protocol for a meta-analysis
of comparative studies has been
published76.
Internal Fixation vs. Primary
Arthrodesis
Historically, arthrodesis was reserved as
a salvage option for either late presenting
patients or after failed initial treat-
ment77. However, there is some evi-
dence that PA may provide superior
results to IF in select patient groups,
including injuries that are purely liga-
mentous, high-energy, and/or in the
presence of severe articular damage at
the time of injury. There are currently
6 published meta-analyses on this
topic78-83 (Table I). However, the
heterogenous nature of the described
surgical techniques and injuries in-
cluded, make it challenging to draw firm
conclusions.
Stødle et al. randomized 48
patients with unstable Lisfranc injuries
to IF (n 5 24) or PA (n 5 24) and
completed follow-up to 2 years84. In the
PA group, the medial 3 TMTJs were
fused primarily, whereas in the IF group,
a temporary bridge plate was placed over
the first TMTJ, with the second and
third TMTJs fused as per the PA group.
The mean AOFAS and median VAS
pain scores were comparable between
the 2 groups at both the 1 and 2-year
assessment points. In those patients
treated with IF, 46% (n 5 11) devel-
oped post-traumatic degenerative
changes in the first TMTJ, but only
1 patient required secondary arthrode-
sis. So et al. performed a retrospective
study comparing complications and re-
operation rates in 130 patients treated
with IF and 66 patients treated with
PA85. The reoperation rate was signifi-
cantly higher in the fixation group (78%
vs. 20%), but when hardware removal
cases were excluded, the reoperation
rates were comparable, as were the
overall complication rates. van den
Boom et al. performed a recent com-
prehensive systematic review on the
topic79. Twenty studies (12 suitable for
meta-analysis) were included, with 392
patients treated with IF and 249 patients
with PA. The RCT performed by Stødle
et al.84 was part of this review and ac-
cording to the Grading of Recommen-
dations Assessment, Development and
Evaluation criteria, was the only study to
yield high-level evidence in relation
to the primary outcome (AOFAS mid-
foot score). Overall, PA performed

TABLE I Summary of Results from Current Meta-analyses in the Literature*

Meta-analysis Year No. of Studies and Patients Included Key Conclusions

van den Boom et al.79 2021 20 including 33 RCTs PA statistically better according to the AOFAS score, but below MCID
435 patients: 252 ORIF, 183 PA Hardware removal higher after ORIF
Alcelik et al.82 2020 8 including 23 RCTs No difference in any functional outcome
547 patients: 389 ORIF, 158 PA Hardware removal higher after ORIF
Yammine et al.80 2019 6 including 13 RCT Return to duty favored PA
269 patients: 176 ORIF, 93 PA Hardware removal higher after ORIF
Magill et al.78 2019 5 including 23 RCTs No difference in functional outcomes
187 patients: 117 ORIF, 70 PA Hardware removal higher after ORIF
Han et al.83 2019 7 including 23 RCTs PA statistically better according to the AOFAS score, but below MCID
287 patients: 184 ORIF, 103 PA Return to duty and pain VAS favored PA
Hardware removal higher after ORIF
Smith et al.81 2016 3 including 23 RCTs No difference in revision surgery or functional outcomes
95 patients: 50 ORIF, 45 PA Hardware removal higher after ORIF

*AOFAS 5 American Orthopaedic Foot and Ankle Score, MCID 5 minimum clinically important difference, ORIF 5 open reduction and internal fixation,
PA 5 primary arthrodesis, RCT 5 randomized controlled trial, and VAS 5 visual analog scale.

APRIL 2023 · VOLUME 11, ISSUE 4 · e22.00239 7

 | Management of Lisfranc Injuries
Fig. 6
Algorithm for diagnosis and management of Lisfranc injuries based on the current literature and clinical experience of our trauma center. AP 5 anteroposterior, CT 5 computed
tomography, FWB 5 full weight-bearing, MRI 5 magnetic resonance imaging, NWB 5 non–weight-bearing, ORIF 5 open reduction and internal fixation, and WB 5 weight-bearing.
statistically significantly better than IF
(AOFAS mean difference of 6.3 points),
but this value was not felt to be clinically
significant and fell below the MCID of
8.486. Furthermore, in addition to the
overall quality of evidence being low, it
was not possible to differentiate between
injury types, energy at the time of injury,
and specific fixation strategies. The authors
stated explicitly that further large pro-
spective multicenter RCTs, including
cost-effectiveness analyses, are required.
Each of the published 6 meta-
analyses found that hardware removal
rates were lower after PA, but there were
conflicting results regarding return to
function and functional outcomes. It
has since been noted that the studies
contained within the meta-analyses used
different variations of the AOFAS ques-
tionnaire, making direct comparisons
invalid87. It must also be noted that the
published MCID for the AOFAS is based
on patients undergoing hallux valgus sur-
gery, and an updated value, specifically for
Lisfranc injuries, would be of assistance
when drawing future conclusions.
Treatment Outcomes
Early failure may be attributed to
multiple factors, including under-
8 APRIL 2023
appreciation of injury severity, non-
anatomical reduction, incorrect implant
selection, and nonunion. Surgical
arthrodesis in these situations provides the
most reliable salvage option77,88. After
successful initial treatment, there are
limited studies reporting the longer term
outcome of Lisfranc injuries, with the
few available reporting outcomes from
small cohorts57,89,90. Dubois-Ferrière
et al. followed up 61 patients at 11 years
and reported satisfactory patient-
reported outcome (AOFAS mean score
79) but with evidence of radiographic
degeneration in 72% of patients90. Half
of the cohort had symptomatic degen-
eration, which was associated with
poorer outcomes, but only 4 patients
required reintervention. Others have
also found no association between
radiographic osteoarthritis and poor
clinical scores, although this cohort was
treated with Kirschner wire stabiliza-
tion89, which may not provide as pre-
dictable fixation as screws or plates.
However, these studies highlight the fact
that the development of radiographic
osteoarthritis does not in itself necessi-
tate secondary arthrodesis and patients
should be assessed for symptom corre-
lation and not through radiographs
alone. Given the young age of many
patients in this cohort, return to activity,
including sport after treatment, has been
addressed in recent literature9,20,91-95.
Rates of return to sport of 94%, with
nearly three-quarters returning to pre-
injury levels, have been reported in a
recent meta-analysis92. By contrast,
change of employment or indeed
unemployment after injury may occur in
up to 30% of patients7, particularly after
delayed diagnosis or in the presence of a
workers’ compensation claim.
Management Algorithm for
Lisfranc Injuries
Based on the current literature and the
experience of the authors’ institution,
we have proposed an investigation and
treatment algorithm for managing Lis-
franc injuries (Fig. 6).
Conclusions
Lisfranc injuries are varied and often
complex, presenting numerous man-
agement challenges (Table II). Weight-
bearing imaging should improve
diagnostic accuracy and reduce the
number of missed or late diagnoses.
Nonoperative treatment is successful in
undisplaced injuries but requires careful
· VOLUME 11, ISSUE 4 · e 22.00239
 Management of Lisfranc Injuries |

TABLE II Grades of Recommendation for the Investigation and Management of Lisfranc Injuries

Recommendations for Care Grade*

Anatomical variability of the Lisfranc joint and associated ligamentous complex play a role in the susceptibility to injury and C
variation of injury patterns.
Weight-bearing radiographs improve the diagnostic accuracy when investigating the “subtle” low-energy Lisfranc injury. B
Percutaneous reduction and fixation of minimally displaced Lisfranc injuries results in satisfactory clinical and radiographic outcomes. B
Once anatomical reduction has been achieved, transarticular screws and dorsal bridge plating can both be considered to B
stabilize the Lisfranc joint complex.
Primary arthrodesis should be considered in elderly patients and/or injuries with a significant insult to the articular surface. B
Flexible fixation devices are not superior to rigid fixation according to the current evidence. High-quality Level I data are C
awaited to make further recommendations.

*Grade A: Good evidence (Level I studies with consistent findings) for or against recommending intervention. Grade B: Fair evidence (Level II or III
studies with consistent findings) for or against recommending intervention. Grade C: Conflicting or poor-quality evidence (Level IV or V studies) not
allowing a recommendation for or against intervention. Grade I: There is insufficient evidence to make a recommendation.

radiographic surveillance to detect late
displacement. In the presence of an
anatomical closed reduction, percuta-
neous stabilization is safe with low
complication rates. Because reduction
quality is a marker of treatment out-
come, a low threshold for performing an
open reduction should be always used.
Once reduced, the choice of implant for
stabilization may be left to surgeon dis-
cretion. While some studies claim to
support PA over IF, most have been
unable to detect a clinically meaningful
difference in functional outcomes and
concerns persist regarding primary
TMTJ fusion in young active patients.
Flexible fixation devices may reduce
hardware removal rates but are limited in
their application to purely ligamentous
injuries only. Further high-quality
Timothy O. White, MD, FRCSEd
(Tr&Orth), FFTEd1,
Anish K. Amin, PhD, FRCSEd(Tr&Orth)1
1Edinburgh Orthopaedics, Royal Infirmary
of Edinburgh, Edinburgh, United
Kingdom
2Centre for Population Health Sciences,
Usher Institute, University of Edinburgh,
Edinburgh, United Kingdom
Email address for corresponding author:
andrew.duckworth@ed.ac.uk
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42. Mahmoud S, Hamad F, Riaz M, Ahmed G, Al
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43. Kuo RS, Tejwani NC, DiGiovanni CW, Holt SK,
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48. Puna RA, Tomlinson MP. The role of
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49. Vosbikian M, O’Neil JT, Piper C, Huang R,
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50. Park YH, Ahn JH, Choi GW, Kim HJ.
Percutaneous reduction and 2.7-mm cortical
screw fixation for low-energy Lisfranc injuries. J
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51. Sharma S, Dhillon MS, Arora C, Patel S.
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52. Chen P, Ng N, Snowden G, Mackenzie SP,
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reduction and internal fixation: results from a
matched case-control study with minimum
12 months follow up. Injury. 2021;52(4):
1042-7.
53. Wagner E, Ortiz C, Villalón IE, Keller A,
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neous reduction and screw fixation for low-
energy Lisfranc injury. Foot Ankle Int. 2013;
34(7):978-83.
54. Panchbhavi VK. Orientation of the “Lisfranc
screw.” J Orthop Trauma. 2012;26(11):e221-4.
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Z. Percutaneous fixation of Lisfranc joint
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56. Teng AL, Pinzur MS, Lomasney L, Mahoney
L, Havey R. Functional outcome following
anatomic restoration of tarsal-metatarsal frac-
ture dislocation. Foot Ankle Int. 2002;23(10):
922-6.
57. Walley KC, Semaan DJ, Shah R, Robbins C,
Walton DM, Holmes JR, Talusan PG. Long-term
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reduction internal fixation patient-reported
outcomes. Foot Ankle Orthop. 2021;6(3):
247301142110394.
58. Arntz CT, Veith RG, Hansen ST Jr. Fractures
and fracture-dislocations of the tarsometatarsal
joint. J Bone Joint Surg Am. 1988;70(2):173-81.
59. Philpott A, Lawford C, Lau SC, Chambers S,
Bozin M, Oppy A. Modified dorsal approach in
the management of Lisfranc injuries. Foot Ankle
Int. 2018;39(5):573-84.
60. Vertullo CJ, Easley ME, Nunley JA. The
transverse dorsal approach to the Lisfranc joint.
Foot Ankle Int. 2002;23(5):420-6.
61. Onochie E, Bua N, Mmerem K, Heidari N, Vris
A, Malagelada F, Parker L, Jeyaseelan L.
Functional outcomes of dorsal bridge plating
for Lisfranc injuries with routine implant
retention: a major trauma center experience. J
Orthop Trauma. 2023;37(1):e22-7.
62. Rhodes A, Elliot R, Marsland D. Elective
removal of metalwork following Lisfranc injury
fixation: results of a national consensus survey
of practice. Foot (Edinb). 2021;47:101811.
63. Ho NC, Sangiorgio SN, Cassinelli S, Shymon
S, Fleming J, Agrawal V, Ebramzadeh E, Harris
TG. Biomechanical comparison of fixation
stability using a Lisfranc plate versus
transarticular screws. Foot Ankle Surg. 2019;
25(1):71-8.
64. Lau SMB, Howells NMBMFMD, Millar MMD,
De Villiers D, Joseph S, Oppy A. Plates, screws, or
combination? Radiologic outcomes after
Lisfranc fracture dislocation. J Foot Ankle Surg.
2016;55(4):799-802.
65. Kirzner N, Zotov P, Goldbloom D, Curry H,
Bedi H. Dorsal bridge plating or transarticular
screws for Lisfranc fracture dislocations: a
retrospective study comparing functional and
radiological outcomes. Bone Joint J. 2018;100-
B(4):468-74.
66. Engelmann EWM, Roelofs A, Posthuma J,
Schepers T. Evaluation of functional outcome
and complications in bridge plating compared
to transarticular screws for Lisfranc injuries: a
systematic review and meta-analysis. J Foot
Ankle Surg. 2022;61(6):1267-74.
67. Philpott A, Epstein DJ, Lau SC,
Mnatzaganian G, Pang J. Lisfranc fixation
techniques and postoperative functional
outcomes: a systematic review. J Foot Ankle
Surg. 2021;60(1):102-8.
68. Koroneos Z, Vannatta E, Kim M, Cowman T,
Fritsche M, Kunselman AR, Lewis GS, Aynardi M.
Biomechanical comparison of fibertape device
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in a cadaveric model. Injury. 2021;52(4):692-8.
69. Pelt CE, Bachus KN, Vance RE, Beals TC. A
biomechanical analysis of a tensioned suture
device in the fixation of the ligamentous
Lisfranc injury. Foot Ankle Int. 2011;32(4):
422-31.
70. Hopkins J, Nguyen K, Heyrani N, Shelton T,
Kreulen C, Garcia-Nolen T, Christiansen BA, Giza
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E. InternalBrace has biomechanical properties
comparable to suture button but less rigid than
screw in ligamentous Lisfranc model. J Orthop.
2020;17:7-12.
71. Cho J, Kim J, Min TH, Chun DI, Won SH, Park
S, Yi Y. Suture button vs conventional screw
fixation for isolated Lisfranc ligament injuries.
Foot Ankle Int. 2021;42(5):598-608.
72. Cottom JM, Graney CT, Sisovsky C.
Treatment of Lisfranc injuries using
interosseous suture button: a retrospective
review of 84 cases with a minimum 3-year fol-
low-up. J Foot Ankle Surg. 2020;59(6):1139-43.
73. Yongfei F, Chaoyu L, Wenqiang X, Xiulin M,
Jian X, Wei W. Clinical outcomes of Tightrope
system in the treatment of purely ligamentous
Lisfranc injuries. BMC Surg. 2021;21:395.
74. Chun DI, Kim J, Min TH, Cho J, Won SH, Lee M,
Yi Y. Fixation of isolated Lisfranc ligament injury
with the TightRope: a technical report. Orthop
Traumatol Surg Res. 2021;107(6):102940.
75. Charlton T, Boe C, Thordarson DB. Suture
button fixation treatment of chronic Lisfranc
injury in professional dancers and high-level
athletes. J Dance Med Sci. 2015;19(4):135-9.
76. Guo W, Chen W, Yu J, Wu F, Qian W, Zhuang
S, Tian K, Zhuang R, Pan Y. Comparison of
flexible fixation and screw fixation for isolated
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timore). 2022;101(42):e31233.
77. Sangeorzan BJ, Verth RG, Hansen ST Jr.
Salvage of Lisfranc’s tarsometatarsal joint by
arthrodesis. Foot Ankle. 1990;10(4):193-200.
78. Magill HHP, Hajibandeh S, Bennett J,
Campbell N, Mehta J. Open reduction and
internal fixation versus primary arthrodesis for
the treatment of acute Lisfranc injuries: a
systematic review and meta-analysis. J Foot
Ankle Surg. 2019;58(2):328-32.
79. van den Boom NAC, Stollenwerck GANL,
Lodewijks L, Bransen J, Evers SMAA, Poeze M.
Lisfranc injuries: fix or fuse? A systematic review
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and meta-analysis of current literature pre-
senting outcome after surgical treatment for
Lisfranc injuries. Bone Jt Open. 2021;2(10):
842-9.
80. Yammine K, Boulos K, Assi C. Internal
fixation or primary arthrodesis for Lisfranc
complex joint injuries? A meta-analysis of
comparative studies. Eur J Trauma Emerg Surg.
2021;47(4):1221-30.
81. Smith N, Stone C, Furey A. Does open
reduction and internal fixation versus primary
arthrodesis improve patient outcomes for
Lisfranc trauma? A systematic review and meta-
analysis. Clin Orthop Relat Res. 2016;474(6):
1445-52.
82. Alcelik I, Fenton C, Hannant G, Abdelrahim
M, Jowett C, Budgen A, Stanley J. A systematic
review and meta-analysis of the treatment of
acute Lisfranc injuries: open reduction and
internal fixation versus primary arthrodesis.
Foot Ankle Surg. 2020;26(3):299-307.
83. Han PF, Zhang ZL, Chen CL, Han YC, Wei XC,
Li PC. Comparison of primary arthrodesis versus
open reduction with internal fixation for
Lisfranc injuries: systematic review and meta-
analysis. J Postgrad Med. 2019;65(2):93-100.
84. Stødle AH, Hvaal KH, Brøgger HM, Madsen
JE, Husebye EE. Temporary bridge plating vs
primary arthrodesis of the first tarsometatarsal
joint in Lisfranc injuries: randomized controlled
trial. Foot Ankle Int. 2020;41(8):901-10.
85. So E, Lee J, Pershing ML, Chu AK, Wilson M,
Halaharvi C, Mandas V, Hyer CF. A comparison
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open reduction and internal fixation versus
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Foot Ankle Spec. 2021;2021:
19386400211058264.
86. Chan HY, Chen JY, Zainul-Abidin S, Ying H,
Koo K, Rikhraj IS. Minimal clinically important
differences for American Orthopaedic Foot &
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Foot Ankle Int. 2017;38(5):551-7.
Management of Lisfranc Injuries |
87. Peters W, Panchbhavi V. Primary
arthrodesis versus open reduction and internal
fixation outcomes for Lisfranc injuries: an
analysis of conflicting meta-analyses results.
Foot Ankle Spec. 2022;15(2):171-8.
88. Swords M, Manoli A, Manoli A. Salvage of
failed Lisfranc/midfoot injuries. Foot Ankle Clin.
2022;27(2):287-301.
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RL. Fourteen years follow up after Lisfranc
fracture-dislocation: functional and radiologi-
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A, Stern R, Dominguez D, Assal M. Clinical
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713-20.
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G, Wood AM. Return to sport following Lisfranc
injuries: a systematic review and meta-analysis.
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92. ter Laak Bolk CS, Dahmen J, Lambers KTA,
Blankevoort L, Kerkhoffs GMMJ. Dahmen J,
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93. Mora AD, Kao M, Alfred T, Shein G, Ling J,
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11
Review Article
Update to Management of Acute
Scaphoid Fractures
Neill Y. Li, MD
David G. Dennison, MD
Alexander Y. Shin, MD
Nicholas A. Pulos, MD
From the Department of Orthopaedic Surgery,
Division of Hand Surgery, Duke University School
of Medicine, Durham, NC (Li), and the
Department of Orthopaedic Surgery, Division of
Hand Surgery, Mayo Clinic, Rochester, MN
(Dennison, Shin, and Pulos).
Dennison or an immediate family member is a
member of a speakers’ bureau or has made paid
presentations on behalf of AO. Pulos or an
immediate family member is a member of a
speakers’ bureau or has made paid
presentations on behalf of Trimed; Shin has
received royalties from Mayo Medical Ventures
and Trimed; Techniques in Hand and Upper
Extremity Surgery: Editorial or governing board.
None of the following authors or any immediate
family member has received anything of value
from or has stock or stock options held in a
commercial company or institution related
directly or indirectly to the subject of this article:
Li.
J Am Acad Orthop Surg 2023;00:1-11
DOI: 10.5435/JAAOS-D-22-01210
Copyright 2023 by the American Academy of
Orthopaedic Surgeons.
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JAAOS® Month 2023, Vol 00, No 00
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
ABSTRACT
The scaphoid is the most commonly fractured carpal bone. With high
clinical suspicion and negative radiographs, expedient evaluation by
CT or MRI has been recommended. When treating nondisplaced
or minimally displaced scaphoid waist and distal pole fractures,
immobilization below the elbow without inclusion of the thumb is an
option. Comparatively, early surgical intervention for nondisplaced
or minimally displaced scaphoid waist fractures allows for quicker
return of function, but with increased risk of surgical complications and
no long-term outcomes differences compared with cast
immobilization. For most patients with such fractures, consideration for
aggressive conservative treatment involving 6 weeks of immobilization
with CT assessment to guide the need for continued casting, surgical
intervention, or mobilization is advocated. Determination of union is
best done with a CT scan at 6 weeks and at least 50% continuous
trabecular bridging across the fracture site deemed sufficient to begin
mobilization. Nonsurgical and surgical management of scaphoid
fractures requires a thorough understanding of fracture location,
fracture characteristics, and patient-specific factors to provide the best
healing opportunity of this notoriously difficult fracture and return the
patient to full function.
S
caphoid fractures are the most common carpal fracture of the wrist,
encompassing approximately 90% of all carpal fractures.1 They
commonly occur in young men with radial-sided wrist pain after a
high-energy impact on a hyperextended wrist. Clinical suspicion, careful
evaluation, and understanding of fracture characteristics and management
options are crucial in timely and accurate diagnosis and treatment
to minimize the risk of nonunion. Studies over the past decades have
provided a greater understanding of scaphoid morphology and vascularity,
timing and utility of imaging modalities, outcomes of immobilization and
surgery, indications for surgery, expansion of surgical techniques, and
assessment of healing and return to activity. With such additions, this review
aims to provide greater insight into the management of acute scaphoid
fractures to optimize scaphoid union and return of function.
1
© American Academy of Orthopaedic Surgeons
Management of Acute Scaphoid Fractures

Figure 1

Illustration showing palmar and dorsal views of the vascular supply to the scaphoid noting a predominant portion of blood supply enters
the scaphoid distally at the dorsal ridge and flows retrograde to the proximal tubercle. Adapted with permission from: M. Diya Sabbagh,
Mohamed Morsy, Steven L. Moran: Diagnosis and Management of Acute Scaphoid Fractures. Hand Clinic 35 (2019) 259-269), “Used
with permission of Mayo Foundation for Medical Education and Research. All rights reserved.”

scaphoid, in which the capitate fossa length and waist

Anatomy and Vascularity
The scaphoid is an obliquely oriented carpal bone on the
radial side of the wrist. Some have described the scaphoid
shape as a boat (hence its Greek derivation from “sca-
phon”) or like a cashew. It is the only carpal bone to
bridge the proximal and distal carpal rows, playing a
vital role in wrist stability and biomechanics. The
scaphoid stabilizes the proximal row and permits the
translation of motion across the radiocarpal to mid-
carpal joints. With its multiple articular contacts, its
surface is nearly 80% articular cartilage.
Understanding the unique vascular supply of the
scaphoid has remained a topic of research for years.
Gelberman and Menon2 described the extraosseous and
intraosseous vascularity of the scaphoid in 1980
noting a retrograde blood supply that lent credence to
the philosophy that a greater nonunion rate occurred in
proximal pole fractures (Figure 1). Morsy et al3 further
evaluated scaphoid vascularity through 3-dimensional
renderings of 13 cadaver scaphoids noting two different
vascular networks. The first is a vascular supply entering
distally at the scaphoid tubercle and the other entering at
the dorsal ridge with an associated supply of vessels at
the volar waist. Evaluation of scaphoid morphology
also identified two shapes involving a full or type 1
length are almost equal, and a slender or type II
scaphoid, in which the capitate fossa length is greater
than the waist length (Figure 2). Type I scaphoids were
found to have a better vascular network with an average
number of vessels associated with full scaphoids at 3.18
and for slender scaphoids at 1.5 (Figure 3, A and C). The
slender scaphoids typically possessed 1 vessel entering at
the dorsal ridge with no volar waist vessels (Figure 3, B
and D).
Diagnosis: Examination and Imaging
Diagnosis of scaphoid fractures may be difficult and
unrecognized, resulting in nonunion, osteonecrosis, and
carpal collapse. Over time, degenerative changes arise
and become associated with a pattern of scaphoid non-
union advanced collapse, potentially warranting a sal-
vage procedure of the wrist. A thorough history noting
the mechanism of injury such as an impaction with wrist
hyperextension and radial deviation as well as the timing
from injury are important features.4 Physical examina-
tion is directed to identifying a possible fracture, which
involves evaluation for anatomic snuff box and scaph-
oid tubercle tenderness, pain with resisted pronation,

2
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Neill Y. Li, MD, et al

Review Article
Figure 2

Illustration showing comparison between A type I and B type II scaphoids in the simulated posteroanterior view. The CFI is calculated
by dividing the length of the capitate fossa (blue lines) by the longest length of the scaphoid (yellow lines). C Type I and D type II
scaphoids are shown again, but in the simulated lateral view; the WI is calculated by dividing the narrowest width at the waist (red lines)
by the longest length of the scaphoids (yellow lines). Adapted with permission from: Morsy M, Sabbagh MD, van Alphen NA, Laungani
AT, Kadar A, Moran SL. The Vascular Anatomy of the Scaphoid: New Discoveries Using Micro–Computed Tomography Imaging.
Journal of Hand Surgery. 2019;44(11). doi:10.1016/j.jhsa.2019.08.001 “Used with permission © 2019 by the American Society for
Surgery of the Hand. All rights reserved.”

and pain with axial compression of the thumb (the
compression test) (Figure 4).5 Given a suspicion of
scaphoid injury from history and examination, directed
radiographic imaging may identify the fracture, although
radiographs have been noted to be initially normal in up
to 15 to 20% of patients.6 Radiographic views include
posteroanterior, lateral, semipronated oblique with the
wrist in 45 degrees of pronation, semisupinated oblique
with the wrist in 45 degrees of supination, and scaphoid
views. The scaphoid view is taken with the wrist in 30
degrees of extension and 20 degrees of ulnar deviation.
When radiographs are negative with a high index of
suspicion, patients should be treated as though they have a
scaphoid fracture with immobilization and repeat radio-
graphic imaging in two to three weeks. This may result in
overtreatment with prolonged immobilization and loss of
productivity for some patients who do not have a scaphoid
fracture, but may be ideal in patients who do not have
fiscal obligations or time-sensitive dealings or who benefit
from a period of soft-tissue rest. To mitigate overtreat-
ment, immobilization, and loss of productivity, advanced
imaging, such as CT, MRI, bone scans (BSs), or ultraso-
nography (US), is obtained to make a diagnosis sooner.
Comparisons between MRI and CT scans have
demonstrated similar diagnostic performances.3 For either
modality, studies must be evaluated in the long axis of the
scaphoid to provide the optimal image of the fracture.7 As
noted by Backer et al, the risk of false-positive scans is
present in both studies such as bone edema on MRI scan
or vascular channels on CT.8 A Cochrane review involving
11 studies compared CT, MRI, and BSs in patients with
clinically suspected scaphoid fractures, noting the highest
diagnostic accuracy with BSs, but comparable accuracy
between CT and MRI. They further noted a greater
number of false positives with BSs leading to overtreat-
ment, which was lower in CT and MRI. The ultimate
conclusion was that improvement was needed in the
modalities used to detect true fractures.6

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Management of Acute Scaphoid Fractures

Figure 3

Illustration showing comparison between the internal vascularity of A, C type I and B, D type II scaphoids. Adapted with permission
from: Morsy M, Sabbagh MD, van Alphen NA, Laungani AT, Kadar A, Moran SL. The Vascular Anatomy of the Scaphoid: New
Discoveries Using Micro–Computed Tomography Imaging. Journal of Hand Surgery. 2019;44(11). doi:10.1016/j.jhsa.2019.08.001
“Used with permission © 2019 by the American Society for Surgery of the Hand. All rights reserved.”

Rua et al studied the cost-effectiveness of immediate MRI

in patients with suspected scaphoid fractures who presented
to the ED in a randomized trial (SMaRT trial) in England.
They found that the mean cost difference between the cohort
who received immediate MRI to those who did not was
markedly reduced despite the higher initial acute costs.
Overall cost-effectiveness was much greater with acute MRI
compared with initial immobilization and follow-up with
subsequent advanced imaging.9 Consideration of immediate
use of MRI versus CT in occult scaphoid fractures may be
best determined in a patient-specific manner.
In recent years, US has been studied to supplement
radiographically occult scaphoid fractures. Kwee et al
conducted a systematic review of US use in diagnosing
occult scaphoid fractures and included seven studies
comprising 314 patients demonstrating 77.8% to 100%
sensitivity and 71.4% to 100% specificity. The authors
concluded that US may be a useful and cost-effective tool
in diagnosing radiographically occult scaphoid fractures
as opposed to empiric casting when CT or MRI are not
immediately available.10
Determining Management
On diagnosis of a scaphoid fracture, physicians must
determine whether cast immobilization or surgical
intervention is recommended. Determinants of manage-
ment are based on several factors including assessment of
fracture location, fracture displacement and stability,
timing of presentation, and patient-specific factors.
Approximately 60 to 80% of scaphoid fractures involve
the waist, followed by 25% in the distal third and 5 to
10% in the proximal third.11 Prior studies have noted
that the time to union of scaphoid fractures varies with
location. Herbert described a classification system that
accounts for fracture location and stability (Figure 5).12
Distal pole fractures healed at an average of 6 weeks,
scaphoid waist fractures at 12 weeks, and proximal pole
fractures at 12 weeks to 6 months.13
Cooney, Dobyns, and Linscheid introduced a classi-
fication system in the evaluation of acute scaphoid frac-
tures (Figure 6).14 Additional criteria were introduced to
help differentiate between stable and unstable fractures.14

4
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 Neill Y. Li, MD, et al

Review Article
Figure 4

Images of clinical examination of a suspected scaphoid fracture. A, Palpation of the scaphoid in the snuff box with the wrist ulnar-
deviated, (B) compression of the scaphoid tubercle, and (C) longitudinal compression of the scaphoid along the thumb. Adapted with
permission from: Reigstad O, Thorkildsen R, Grimsgaard C, Melhuus K, Rokkum M. Examination and treatment of scaphoid fractures
and pseudarthrosis. TdNJS. 2015;13512-13. (With permission from author: I hereby give you permission to reuse the figure of mine and
my good colleagues (and second authors) hands. 2022 Ole Reigstad).

Stable fractures were noted to have a displacement
of less than 1 mm, normal intercarpal alignment, and
distal pole fractures. Unstable fractures were defined as
greater than 1 mm displacement, with associated carpal
instability morphologies including an intrascaphoid
angle of more than 35°, radiolunate angle greater than
15°, and scapholunate angle greater than 60°. Other
criteria of instability include bone loss or comminution,
dorsal intercalated segmental instability (DISI), and
proximal pole fractures.14
Given the tenuous blood supply (Figure 1) of the
proximal pole, proximal pole fractures (Figures 5 and 6)
commonly require prolonged immobilization with var-
iable rates of union. The incidence of proximal pole
fracture nonunion has been reported to be as high as
15 to 50%.15 Given the wide range of nonunion inci-
dence, early surgical intervention has been recom-
mended. Retig and Raskin published on 17 proximal
pole fixations that all healed within 13 weeks.16 A Mayo
Clinic study reported that fixation of proximal pole
fractures in 23 patients resulted in 43% union at
14 weeks and 87% eventual union with an average time
of 14.4 weeks, further noting displaced proximal pole
fractures were markedly less likely to heal within
14 weeks.17 Comparatively, Grewal et al15 conducted
a CT assessment of 53 patients with proximal pole
scaphoid fractures noting a 90% union rate with cast-
ing. Of the cases that went to nonunion, treatment delay
was found to be a notable factor. Comminution and
cysts were associated with increased union time. They
overall noted that time to union, defined as 50%
osseous bridging, was 14 6 12 weeks for casting alone
and 14 6 8 weeks with surgery. Taken together, when
considering whether all proximal poles are to be fixed
versus casted, variables such as treatment delay, amount
of fracture displacement, and the opportunity for close
monitoring of union progression with CT evaluation
within the first 4 to 6 weeks may help inform such
decisions.
Owing to scaphoid morphology, determination of
fracture location, displacement, and angulation may be
difficult depending on the imaging modality. Given the
importance of clearly defining these measures, utilization
of radiographs alongside CT scan provides a useful
assessment of the fracture and its management (Figure 7,
A–D).1 In considering DISI, Haase et al evaluated the
relationship between type I lunates and type II lunates in
patients with scaphoid nonunions and the presence of
DISI (Figure 8). They found a notable relationship
between type I lunates and the development of DISI
deformity with scaphoid nonunions. This intrinsic sta-
bility afforded by type II lunates in patients with
scaphoid fractures may help in qualifying a greater
potential of union in patients treated nonsurgically
compared with patients with type I lunates.18
Timing of treatment after injury has also been
important for union. Langhoff and Andersen19 noted
that in patients with a scaphoid fracture presenting

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Management of Acute Scaphoid Fractures

Figure 5. Diagramshowingthe

Diagram showing the stable and unstable Herbert classification of acute scaphoid fractures. Adapted with permission from: Herbert TJ.
The fractured scaphoid. St Louis: Quality Medical Publishing; 1990 (Permission granted from Thieme in in accordance with the STM
Permission Guidelines 2014).

4 weeks after injury, the risk of nonunion was as high as
40% compared with 3% risk for nonunion when
treated within four weeks. In determining a manage-
ment plan best for the patient, Rizzo and Shin noted the
need for consideration of patient-specific determinants
such as occupation, athletics, and psychiatric variables
such as cast tolerance, compliance, and patient follow-
up. Comprehensive understanding of fracture location,
fracture stability, timing of treatment, and patient fac-
tors is crucial in determining the ultimate management
plan.
Immobilization for Nondisplaced or
Minimally Displaced Scaphoid Fractures
For stable scaphoid fractures, nonsurgical treatment with
cast immobilization is the preferred option. However, the
extent of immobilization has been a point of study
between above and below-the-elbow casting as well as
inclusion or exclusion of the thumb. Doornberg et al20
published a meta-analysis on randomized control trials
assessing nonsurgical treatment of acute scaphoid
fractures with above versus below-the-elbow casting.
The authors found no notable differences in union rate,
pain, grip strength, time to union, or presence of os-
teonecrosis. Similar findings have been reported in
children as presented by Shaterian et al21 in a meta-
analysis on pediatric acute scaphoid fractures. They
found no differences in long or short arm thumb spica
outcomes for union, wrist range of motion, and pain.
Cast immobilization with and without the thumb has
also been evaluated. Buijze et al conducted a multicenter
randomized controlled trial evaluating casting with and
without the thumb for nondisplaced and minimally dis-
placed scaphoid waist fractures, finding greater extent of
union at 10 weeks on CT with casting that excluded the
thumb. Overall, no differences in union, wrist motion,

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Figure 6
Diagram showing the division of scaphoid fractures into
fractures of the distal tubercle (1), distal intra-articular
surfaced (2), distal third (3), waist (4), and proximal pole (5)
made by Cooney (Mayo). Fracture location influenced both
tendency and time frame for healing. Adapted with
permission from: Cooney WP, Linscheid RL, Dobyns JH, eds.
The Wrist Diagnosis and Operative Treatment. 1st ed. St.
Louis, MO: Mosby; 1998 (Reprinted, permission covered by
STM guidelines).
grip strength, Mayo wrist score, DASH score, or pain
were identified. Thus, in such fracture patterns, thumb
immobilization does not seem to be necessary.22
Overall, authors’ consideration of casting is patient
and fracture-specific. For those with distal 1/3, minimally
displaced, or nondisplaced scaphoid fractures, short arm
casting without the thumb may be ideal for 6 to 8 weeks.
In cases of proximal pole fractures or at-risk waist
fractures such as those that are oblique, comminuted, or
in some separation or those in noncompliant patients,
long arm casting with the thumb may prove safest for the
first 6 weeks with transition to a short arm cast.23
Surgery versus Immobilization for
Nondisplaced or Minimally Displaced
Scaphoid Waist Fractures
A trend toward early fixation of minimally to non-
displaced scaphoids has taken effect in an effort to
improve return to function, work, and athletics. In pur-
suing early surgical fixation for such fractures, patients
are exposed to the risks of surgical complications, which
have been identified to be as high as 23% as opposed to
9% with casting in a meta-analysis of randomized con-
trolled trials with minimal differences in early surgical
benefit.24,25 To determine differences between early
fixation or casting for bicortical scaphoid waist frac-
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Neill Y. Li, MD, et al
Review Article
tures with less than 2 mm of displacement, Dias et al
conducted a randomized controlled trial in 439 adults
termed surgery versus cast immobilization for adults
with a bicortical fracture of the scaphoid waist (SWIFFT
trial). In this study, wrist pain, function, and patient-
reported outcomes were measured at 6, 12, 26, and
52 weeks.1,26 Patients who were treated with casting
underwent early fixation at 6 weeks if the fracture
demonstrated poor progression of union. The primary
outcome from the study demonstrated no difference in
the Patient-Rated Wrist Evaluation (PRWE) score at
52 weeks between early fixation and below-the-elbow
casting. In addition, the nonunion rate was low with no
differences between groups. The surgical group did
demonstrate a 10-fold increased rate of complications
including infection, nerve damage, and CRPS-related
concerns compared with cast immobilization. Revision
surgeries were also greater in the early fixation group
compared with casting. The authors concluded that
casting was as effective as early surgical fixation for
scaphoid waist fractures with ,2 mm displacement.
However, they specified that casted patients need to be
followed closely such that fractures are evaluated at six
to eight weeks and addressed surgically should there be
any concern for displacement or delayed healing.26
In considering secondary complications and the need
for close monitoring of scaphoid fractures, Loisel et al
reported on nondissociative carpal instability in the setting
of nondisplaced scaphoid fractures. In a series of eight
patients treated surgically and nonsurgically, they noted
the development of carpal instability nondissociated
(CIND) with volar or dorsal tilt of the proximal carpal row
secondary to rupture of critical ligament stabilizers. The
authors recommended serial attention to not only fracture
healing but also maintenance of carpal alignment on serial
radiographs with evaluation by MRI or arthroscopy when
CIND is suspected, followed by ligamentous repair as
indicated.27 Ultimately, patients with minimal to non-
displaced scaphoid waist fractures are to be counseled
in a patient-specific manner regarding risks and benefits
of early fixation versus aggressive conservative treatment
with close follow-up weighing tolerance of potential
fracture and surgical complications to optimize return to
work or sport without differences in union rate or long-
term outcomes.
Surgical Management
Several approaches and methods of surgical fixation are
available. Patients may be treated by percutaneous, mini-
open, or open reduction and internal fixation techniques
7
Management of Acute Scaphoid Fractures

Figure 7

Radiographs showing left distal third scaphoid waist fracture. A, PA wrist radiograph noting incongruity and overlap at the distal third
scaphoid waist. B, Lateral wrist radiograph showing no significant deformity of intrascaphoid, scapholunate, or radiolunate angles or
DISI deformity. C, Sagittal CT view noting flexion, translation, and gapping of the distal third scaphoid waist fracture. D, Additional
sagittal CT view noting distal third fracture with flexion and translation. E, PA fluoroscopic view of volar percutaneous placement of a
headless compression screw. F, Lateral fluoroscopic view of the headless compression screw. G, 12-week follow-up PA wrist
radiograph demonstrating anatomic alignment and healing. H, Lateral wrist radiograph noting anatomic alignment and appropriate
screw length and positioning. “Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved.”

from volar or dorsal approaches using one or two
headless compression screws, plates, or Kirschner wires.
The dorsal approach provides good visualization of the
proximal pole, scapholunate ligament, and scaphoid
waist, although it has difficulty in visualizing the entire
scaphoid. The volar approach has less risk to the blood
supply and visualization of distal 1/3 and waist fractures
and, if needed, extensive visualization of the volar
scaphoid surface with the additional ability to correct
humpback deformity.
Screw position is of great importance because studies
have demonstrated the biomechanical advantage of cen-
tral screw placement at an appropriate joint-sparing
length to offer greater stiffness, greater load to displace-
ment and failure, and decreased fracture fragment
motion.28 While this is certainly important in displaced
fractures, its importance in nondisplaced or mini-
mally displaced fractures remains a point of debate.
Morsy et al3 also evaluated the vascular effect after screw
placement finding that central positioning had the least
effect and a dorsal (antegrade) insertion was less dis-
ruptive than volar (retrograde) screw placement. Addi-
tional considerations of fixation include the importance
of screw length to avoid screw prominence and irre-
versible damage to nearby articular cartilage. A meta-
analysis of seven studies by Kang et al29 comparing
dorsal and volar percutaneous approaches did not find
differences in union, postoperative complications, or
functional outcomes. Ultimately, fracture location, ana-
tomic reduction, and placement of the screw in a central
position as perpendicular to the fracture as possible will
facilitate the best setting for union (Figure 7, E–H).

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Figure 8
Diagram showing that type I lunates (L) have a single distal facet that articulates with the capitate (C). Type II lunates have an additional
facet for articulation with the hamate (H). (T = triquetrum, S = scaphoid). “Used with permission of Mayo Foundation for Medical
Education and Research. All rights reserved.”
The clinical utility of two-screw fixation or plating
remains to be ascertained. Biomechanical comparisons
have evaluated fracture stability afforded by a single
compression screw, two compression screws, or a plate.
Mandaleson et al noted in a model of scaphoid nonunion
with bone loss that double-screw or plate fixation pro-
vided markedly greater stability, stiffness, and load
absorption compared with single-screw fixation. Rota-
tional stability was also found to be greater with a plate
or two screws for scaphoid waist fractures than a single
screw.30 Clinical translation in the biomechanical
superiority of two-screw fixation has led to using the
theoretical benefit of earlier range of motion and
strengthening for acute fractures as well as use in set-
tings of scaphoid nonunion. However, no clinical
studies have been conducted to determine the clinical
benefit of one versus two compression screws.
Plate fixation has been used for scaphoid fractures
with comminution, nonunion, and segmental defects or
in patients with osteopenic or osteoporotic bone.31
Goodwin et al found that in a 3-mm segmental defect
model of a scaphoid, locking plate fixation provided
greater load to failure than screw fixation in osteopenic
bone by delivering greater rotational stability and points
of fixation for osteoporotic bone. No differences were
found in normally dense bone.32 Arthroscopic-assisted
scaphoid fracture fixation has also been popularized in
an effort to minimize vascular compromise to the
scaphoid.33
When considering source of bone graft for acute
complex scaphoid fractures with associated comminu-
tion or bone loss, comparison between iliac crest and
distal radius corticocancellous graft has demonstrated no
notable differences in biomechanical strength and no
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Neill Y. Li, MD, et al
Review Article
differences in union rate when further used for cases of
scaphoid nonunion.34 From the authors’ perspective, the
specific approach and fixation technique is based on
surgical experience aligned with fracture location and
displacement to accomplish the goals of fracture
reduction, preservation of blood supply, stable fixation,
and joint preservation to achieve maximal rates of
scaphoid union and return of function alongside
counseling patients that not all fractures will unite
properly.
Assessing Union
After casting or surgical fixation, determination of risk
factors and risk of nonunion versus adequate healing of
the scaphoid to permit progression to wrist motion and
rehabilitation is required. CT has been identified as a
reliable means of evaluating scaphoid union. Grewal et al
reviewed CT scans of 219 nonsurgically treated scaphoid
fractures to determine factors that affect union and time
to union. They found that humpback deformity and
translation and not comminution, sclerosis, or cysts
affected the union rate. However, the presence of trans-
lation, comminution, sclerosis, and cysts each increased
the time to union.15 Clementson et al35 noted that CT
evaluation at 6 weeks of minimal to nondisplaced
scaphoid waist fractures demonstrated 90% union for
fractures treated with casting and 82% for those treated
with surgery.
In assessing factors to determine whether to continue
cast immobilization, Bulstra et al reported on a pro-
spective cohort study of 46 patients with nondisplaced
scaphoid waist fractures evaluated at an average of
9
Management of Acute Scaphoid Fractures
6 weeks of casting. They reported that perception of
inadequate radiographic healing and symptoms of
depression were independently associated with contin-
ued immobilization.36 A survey-based study of 218
surgeons and 16 patient scenarios found that unclear
radiographic evidence of fracture healing, tenderness at
the fracture site, and 8 as opposed to 12 weeks of
immobilization were the most important factors to
influence the continuation of cast immobilization.37
Thus, in assessing union of scaphoid fractures treated
nonsurgically or surgically, we advocate for CT scan at
around 6 weeks of immobilization to determine healing
progression and assessment of fracture characteristics at
that time to help determine continued immobilization
versus progression of rehabilitation.
Studies have been conducted to determine the amount of
healing necessary on CT evaluation to permit discontinu-
ation of immobilization after surgical and nonsurgical in-
terventions. Singh et al38 evaluated 52 scaphoid fractures
from waist to the proximal pole treated nonsurgically with
CT scan at 12 to 18 weeks after 8 to 12 weeks of
immobilization. The authors noted partial union in 42%
of patients. Patients with partial union encompassing less
than 75% of bridging were mobilized, but were asked to
avoid contact sports. Subsequent imaging demonstrated
union at the fracture site at 23 to 40 weeks. The authors
determined that partial unions may commonly be present
after 12 weeks of immobilization, but that patients may be
mobilized with precautions and follow-up to ensure
complete union within 6 months. Brekke et al39
conducted a biomechanical evaluation of scaphoid partial
unions using cadaver scaphoids with 25%, 50%, and
75% scaphoid osteotomies alongside one control group.
Measuring load to failure, stiffness, and work to failure
demonstrated no differences between the 25, 50, and 75%
osteotomy groups. The study concluded that 25% union
of scaphoid waist fractures is supportive of mobilization.
We found that at 6 weeks, should CT scan demonstrate at
least 50% trabecular bridging in the coronal and sagittal
views of the fractures, patients may begin mobilization.
However, if trabecular bridging is less than 50% and there
are no concerning factors that may affect union such as
sclerosis of the fracture, cystic changes, or increased
translation or comminution, we will continue casting and
re-evaluate in 4 to 6 weeks with an additional CT scan or
open conversation for surgical intervention.
Return to Sport
In assessing return to sport of athletes with scaphoid
fractures, understanding position, demands, skill level,
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
and sports guidelines in the context of fracture mor-
phology and treatment is necessary. Positions or sports
that allow protective play with casting such as soccer may
be able to return sooner as opposed to basketball or ball-
handling positions in football. As such, return-to-sport
time lines remain varied between sports and team
physicians. After surgical management of nondisplaced
scaphoid fractures, return to play varied between pro-
fessional team physicians from an immediate return or
after 4 to 6 weeks for protected activity and 4 to 6 to
12 weeks for full activity.40 Determination of healing
and safety to return to unprotected play seems best
determined through CT scans at 6-week intervals with
at least 50% bridging. Ultimately, return to play is
specific to each athlete dependent further on their
fracture location and characteristics, progression of
union, and ability to perform with casting and without
risk of weight bearing or repeat injury.
Conclusion
Recent literature has improved our understanding of
scaphoid anatomy and vascularity and highlighted dif-
ferences in diagnostic techniques, indications for fixa-
tion, methods of fixation, and assessment of union. With
such additional insights, a surgeon must obtain a prompt
diagnosis with interpretation of the specific fracture
pattern to best counsel his or her patient on concepts of
fracture stability and associated management options. A
patient and fracture-specific approach is needed to weigh
the risks and benefits of nonsurgical and surgical man-
agement as well as associated immobilization and sur-
gical techniques to provide the best outcome for the
scaphoid and the patient.
References
1. Dias J, Brealey S, Cook L, et al.: Surgical fixation compared with cast
immobilisation for adults with a bicortical fracture of the scaphoid waist:
The swifft rct. Health Technol Assess (Rockv) 2020;24:1-234
2. Gelberman RH, Menon J: The vascularity of the scaphoid bone. J Hand
Surg 1980;5:508-513
3. Morsy M, Sabbagh MD, van Alphen NA, Laungani AT, Kadar A, Moran
SL: The vascular anatomy of the scaphoid: New Discoveries using
micro–computed tomography imaging. J Hand Surg 2019;44:928-938
4. Weber ER, Chao EY: An experimental approach to the mechanism of
scaphoid waist fractures. J Hand Surg 1978;3:142-148
5. Reigstad O, Thorkildsen R, Grimsgaard C, Melhuus K, Rokkum M:
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suspected scaphoid fractures in patients with negative plain radiographs.
Cochrane database Syst Rev 2015;2015:CD010023
7. Sanders WE: Evaluation of the humpback scaphoid by computed
tomography in the longitudinal axial plane of the scaphoid. J Hand Surg
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8. Bäcker HC, Wu CH, Strauch RJ: Systematic review of diagnosis of
clinically suspected scaphoid fractures. J Wrist Surg 2020;09:081-089
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magnetic resonance imaging in the management of patients with
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10. Kwee RM, Kwee TC: Ultrasound for diagnosing radiographically occult
scaphoid fracture. Skeletal Radiol 2018;47:1205-1212
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12. Herbert TJ, Fisher WE: Management of the fractured scaphoid using a
new bone screw. The J Bone Joint Surg Br volume 1984;66-B:114-123
13. Grewal R, Suh N, MacDermid JC: Use of computed tomography to
predict union and time to union in acute scaphoid fractures treated
nonoperatively. J Hand Surg 2013;38:872-877
14. Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A
rational approach to management. Clin Orthop Relat Res 1980;149;90-97
15. Grewal R, Lutz K, Macdermid JC, Suh N: Proximal pole scaphoid
fractures: A computed tomographic assessment of outcomes. J Hand
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16. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute
proximal pole scaphoid fractures. J Hand Surg 1999;24:1206-1210
17. Brogan DM, Moran SL, Shin AY: Outcomes of open reduction and internal
fixation of acute proximal pole scaphoid fractures. Hand 2015;10:227-232
18. Haase SC, Berger RA, Shin AY: Association between lunate
morphology and carpal collapse patterns in scaphoid nonunions. J Hand
Surg 2007;32:1009-1012
19. Langhoff O, Andersen JL: Consequences of late immobilization of
scaphoid fracture. J Hand Surg J Br Soc Surg Hand 1988;13:77-79
20. Doornberg JN, Buijze GA, Ham SJ, Ring D, Bhandari M, Poolman RW:
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Care 2011;71:1073-1081
21. Shaterian A, Santos PJF, Lee CJ, Evans GRD, Leis A: Management
modalities and outcomes following acute scaphoid fractures in children: A
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23. Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M: Comparison of
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Neill Y. Li, MD, et al
Review Article
or minimally displaced scaphoid fractures. The J Bone Joint Surgery-
American Volume 2010;92:1533-1544,
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11
SICOT-J 2021, 7, 62
Ó The Authors, published by EDP Sciences, 2021
https://doi.org/10.1051/sicotj/2021058

Special Issue: SICOT Education Academy Collection Available online at:

Guest Editor: Hatem Said www.sicot-j.org

REVIEW ARTICLE OPEN ACCESS

Current concepts in the assessment and management of

multiligament injuries of the knee

Waldo Scheepers1,* , Vikas Khanduja2 , and Michael Held1

1
Department of Orthopedic Surgery, Groote Schuur Hospital, Orthopedic Research Unit, University of Cape Town,
7925 Cape Town, South Africa
2
Consultant Orthopedic Surgeon, Addenbrooke’s – Cambridge University Hospital, Cambridge CB2 0QQ, United Kingdom

Received 9 August 2021, Accepted 29 October 2021, Published online 6 December 2021

Abstract – Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon.
They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-
articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required
when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a
thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has
been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence
of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with
conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage
reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found
no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over
delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the
injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards
to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated.
There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of
the most important positive prognostic factors in surgical management and requires a dedicated team-based approach.
Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should
be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and
pragmatism in tailoring a management strategy capable of achieving comparable outcomes.

Key words: Multiligament knee injuries, Knee dislocations, Assessment, Management, Review.

Introduction In 1824, Sir Astley Cooper made the observation about

knee dislocations: “Of this, I have only seen one instance,
A knee dislocation (KD) is defined as tibiofemoral disartic- and I conclude it, therefore, to be a rare occurrence; and there
ulation, but spontaneous reduction and KDs with intact cruciate are scarcely any accidents to which the body is more liable
ligaments have added complexity to this definition [1]. The which more imperiously demand immediate amputation than
term multiligament knee injury (MLKI) is therefore used with these.” [5] Consequently, KDs were historically associated with
less ambiguity when two or more of the four main knee liga- detrimental sequelae such as loss of life and limb, and initial
ments are injured: these are the anterior cruciate ligament management focused on conservative strategies [6–9]. This
(ACL), posterior cruciate ligament (PCL), posterolateral corner has changed as surgical techniques and intricate anatomic and
(PLC) and posteromedial corner (PMC) [2]. KDs are rare, with biomechanical knowledge evolved [10]. Yet, some of these his-
an estimated 0.02–0.2% of orthopaedic injuries, but the true torical findings are still applicable in certain settings.
incidence is likely to be underestimated due to spontaneous The scarcity and heterogeneity of this injury make ade-
reduction or missed injuries in the polytrauma patient [3, 4]. quately powered prospective clinical trials in a similar setting
challenging, resulting in a paucity of high-level evidence
[11]. Consequently, there is much controversy in the literature
*Corresponding author: waldoscheepers@gmail.com about surgical versus non-surgical management, repair versus
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 W. Scheepers et al.: SICOT-J 2021, 7, 62
reconstruction, surgical techniques and the ideal timing of
MLKI surgery. This creates the need for interpretation and con-
temporary insight into the specific considerations that need to
be taken into account when tailoring an individualised,
evidence-based approach to managing a multiple-ligament
injured knee. Therefore, the aim of this article is to review,
debate, and critically interrogate the current literature to provide
an overview of the background, assessment, management, and
outcomes of MLKIs.
Etiology
KDs can result from high-, low- and ultra-low-velocity inju-
ries. High-velocity injuries are usually caused by motor-vehicle
accidents, falls from a significant height or severe crush injuries
and are more likely to have associated injuries [12, 13]. Most
low-velocity knee dislocations occur during sporting activities
or falls from less than approximately 1.5 m and typically have
better overall outcomes [12, 13]. Ultra-low velocity KDs mostly
occur in obese patients and are often sustained during activities
of daily living [12]. With the current obesity pandemic, these
injuries have become more frequent, leading to a demographic
peak of the obese elderly population, besides young patients
with high-energy injuries [14]. The obese patients are especially
challenging to examine [11], which can be detrimental as they
present a higher rate of associated injuries and post-operative
complications than non-obese patients [15].
Classification
The Schenck classification system is most commonly used
to categorise knee dislocations [11]. It describes the anatomical
pattern of ligamentous disruption and has been modified to
include specifiers for neurovascular injuries. More detail can
be added for each of these grades (i.e. via Müeller charts),
which could potentially aid surgical planning [11] and add
prognostic value for clinical outcome [16]. The positional Ken-
nedy classification and other energy-based classification sys-
tems have been found inadequate for communication or
guiding management as they are limited in describing the sever-
ity and pattern of ligamentous injury – especially in cases of
spontaneous reduction [17].
Associated injuries
There is a high incidence of intra-and extra-articular injuries
in MLKIs. The presence of meniscal or chondral injuries has
been reported in up to 76% of cases (55% and 48%, respec-
tively) [18]. Associated vascular injuries are common and
potentially devastating, with amputation rates of 12% [3, 19],
which rises to 80% if limb ischaemia exceeds 8 h [20]. In a sys-
tematic review of 23 studies and 907 patients, an 18% incidence
of vascular injuries in KDs was found, with a rate of 32% in
Schenck KDIIIL patterns [19]. The popliteal artery is most fre-
quently affected in 83.6% of cases, followed by the tibial artery
in 7.54% of cases [20]. The incidence of associated neurologi-
cal injury varies greatly in literature (5–59%), with a 2014 sys-
tematic review by Medina et al. including 862 patients
Figure 1. Imaging in a patient with a suspected MLKI. Left: AP
varus stress radiograph shows a large lateral joint gap indicative of a
complete disruption of the LCL, associated disruption of cruciate
ligaments should be suspected. Right: The injury can also be seen on
coronal T2 MRI with disruption of the posterolateral complex.
estimating it at 25% [19]. A retrospective review of the Amer-
ican College of Surgeons National Trauma Data Bank, includ-
ing 6454 patients, reported an incidence of 6.2% [20]. The
common peroneal nerve (CPN) is most often affected
(53.3%) and is associated with posterolateral corner injuries
in 21.6% of cases [21]. The resultant loss of antigravity strength
is potentially disabling [22]. Furthermore, the presence of an
open injury significantly complicates management as they often
occur in the setting of high-velocity polytrauma with substantial
damage to surrounding soft-tissues [23]. Open injuries occur in
13.6% of KDs [20] and carry a greater infection risk of up to
43% [23]. They also constitute a risk factor for vascular injury
[21] and raise the amputation rate to 15.6% [20].
Evaluation
A detailed history and clinical examination should precede
available imaging techniques. Magnetic resonance imaging
(MRI) has become the gold standard in the evaluation of
injured structures [24], but stress radiography remains useful
in both acute and chronic injuries, especially if MRI is not
available (Figure 1) [25].
Acute injuries
The initial assessment must abide by advanced trauma life
support (ATLS) principles as MLKIs are frequently compli-
cated by comorbid polytrauma [26]. A thorough neurovascular
exam is always warranted, and an Ankle Brachial Index (ABI)
should be performed [27] and serially monitored as the devel-
opment of occlusive thromboses formed by intimal flap tears
may only be revealed with time [28]. An ABI < 0.9 or an
expanding haematoma indicates angiography [29], and CT or
MRI angiography should be considered a first-line modality
for diagnosing arterial injury [27]. In many Level 1 centres in
high-resource settings, polytrauma patients routinely undergo
whole-body CT scans on arrival with CT angiography for
 W. Scheepers et al.: SICOT-J 2021, 7, 62
Table 1. Evaluation of posterior, varus and valgus knee instability using stress radiographs [25].
Poster instability
Kneeling stress Injury Grade of PCL Varus stress
radiographs (PTT) injury test
 7 mm Normal or partial tear I  2.6 mm
8–11 mm Complete PCL tear II 2.7–3.9 mm Isolated LCL tear
 12 mm Combined ligament III  4 mm
injury
LCL, lateral collateral ligament; PCL, posterior collateral ligament; PLC, posterolateral corner; PTT, posterior tibial translation; sMCL,
superficial medial collateral ligament.
suspected KDs. Traditionally, arteriography has been the gold
standard for detecting vascular injuries but is expensive,
requires arterial puncture and has a complication rate of up to
9% [30]. If an arterial injury is found, acute revascularisation
is required, and the limb should be immobilised, ideally in a
transarticular external fixator for 2–6 weeks to preserve the
integrity of the vascular graft and joint reduction keeping in
mind the risk of pin tract infection and joint stiffness [25, 27].
Chronic injuries
As a result of spontaneous reduction of KDs in up to 50%
of cases and concomitant polytrauma, MLKIs are often missed
in the acute setting [4]. Here as well, MRI plays a pivotal role in
assessing damaged intra-articular structures and should be rou-
tinely used when available [25]. Comparative stress radiographs
can objectively and dynamically assess the laxity of healed but
elongated ligaments which are often overlooked, especially in
chronic PCL or MCL tears on MRI scans [27].
Moatshe et al. have devised a grading system of instability
of the PCL, LCL, and MCL based on stress radiographs by
comparing the injured and uninjured knees (Table 1) [25].
The mechanical axis should also be determined radiographi-
cally to detect malalignment prior to ligament reconstruction
[25]. If varus malalignment is present in chronic PLC injuries,
a corrective osteotomy should be considered prior to recon-
struction to prevent excessive graft tension and failure [25].
Surgical versus non-surgical management
Surgical treatment of MLKIs is widely regarded as superior
to non-surgical management. Dedmond and Almekinders
performed a meta-analysis that assessed surgically and non-
surgically treated knees and demonstrated a better range of
motion, flexion contractures and Lysholm scores in the surgi-
cally treated group [10]. An evidence-based review by Peskun
and Whelan found that surgical versus non-surgical manage-
ment improved Lysholm scores, IKDC scores, and Tegner activ-
ity scores. The differences in IKDC and Tegner activity scores
were not statistically significant. No significant differences were
found in ROM between groups, but improvements in instability
as assessed by KT-1000TM measurements were found in the
operative cohort. Return to employment and return to a compa-
rable level of athletic competition were considerably higher
with surgery [31]. A systematic review by Levy et al. found im-
3
Varus instability Valgus instability
Injury Valgus stress test Injury
Normal or  3.1 mm Normal or partial tear
partial tear
3.2–9.7 mm Complete sMCL tear
Complete PLC injury  9.8 mm Complete tear of
all medial structures
proved IKDC scores, return to work rates and return to full
sport rates in the surgical cohorts [2]. Plancher et al. retrospec-
tively evaluated 50 knees, of which 31 were treated surgically
and 19 conservatively and found that the surgical cohort was
significantly less likely to develop severe radiographic degener-
ative changes (47.4% and 88%, respectively) [32, 33]. Most
smaller retrospective studies have found similar improvements
in surgically treated patients when assessing range of motion
and functional outcome scores (Table 2) [34–38].
Although surgical treatment has been demonstrated to be
superior to non-surgical treatment, a pragmatic approach should
be taken, and surgery might not always be feasible in low-
resource settings (LRS). Closed reduction, immobilisation with
an external fixator or cast for 4–6 weeks and a period of non-
weight-bearing has been reported to attain acceptable outcomes
in cases where surgery is not feasible, but regular radiographic
evaluation to ensure that reduction is maintained is essential
[39–41]. Range of motion can subsequently be improved with
manipulation under anaesthesia or arthroscopic adhesiolysis
after immobilisation [40]. However, data supporting conserva-
tive management is old, and advances in surgical methods have
affirmed the superiority of operative treatment. Non-operative
treatment should only be considered when surgical intervention
is unavailable and in special populations such as the morbidly
obese, patients with vascular or open injuries, patients unable
to attend rehabilitation, the elderly and comorbid-burdened
patients [25, 40].
Repair versus reconstruction
Multiligament injured knees can either be repaired with
sutures or reconstructed with the use of various grafts. Repair
is ideally performed in the acute period (within 3 weeks of
the injury), whereas reconstruction can be done early, later or
in stages [42]. Staged surgery consists of acute primary repair
of collateral ligaments with cruciate reconstruction once
improved range of motion has been obtained, and good out-
comes have been reported for range of motion and stability
[43, 44]. Systematic reviews by Jiang et al. and Mook et al.
found improved subjective outcomes and range of motion with
staged procedures [45, 46]. However, a meta-analysis by
Frosch et al. compared suture repair versus reconstruction of
cruciate ligaments and found that a two-staged procedure
wherein collateral ligaments are repaired without addressing
the cruciate ligaments cannot be recommended [47]. A staged
4 W. Scheepers et al.: SICOT-J 2021, 7, 62

Table 2. Outcome comparison of surgical versus nonsurgical treatment [2, 10, 31, 34–38].
Study Design Number Lysholm IKDC Score Tegner Range of Loss of Return to Return to
of Score (% Good/ activity motion flexion work (%) sport (%)
patients excellent) score (°) (°)
S NS S NS S NS S NS S NS S NS S NS S NS
Dedmond and Meta-analysis 132 74 85.2 66.5 123 108 0.54 3.5 58 50 31 14
Almekinders [10]
Levy et al. [2] Systematic 227 107 58 20 126 123 4 3 72 52 29 10
Review
Peskun and Whelan Systematic 855 61 84.3 67.2 61.3 25.0 4.8 2.7 80.9 50 57.8 22.2
[31] Review
Almekinders and Retrospective 6 10 129 108
Logan [35] Study
Richter et al. [34] Retrospective 59 18 78 65 24 6 4 3 85 53 56 17
cohort
Wong et al. [38] Retrospective 15 11 75.84 63.71 129 137 6 2 0 0
cohort
Ríos et al. [37] Retrospective 21 5 77 40 76 0
cohort
Demirağ et al. [36] Retrospective 6 6 84.6 74 116 72
cohort

Abbreviations: S, Surgical; NS, Non-surgical.

reconstruction can cause altered joint kinematics and increase
the risk of graft failure, thus single-stage reconstruction is advo-
cated by some authors to avoid this complication while facilitat-
ing early mobilisation and mitigating joint stiffness [25].
Though acceptable results have been reported with both repair
and reconstruction, repair of the MCL generally does not offer
benefit over nonoperative treatment [47]. In many studies that
include bicruciate injuries, the repair cohort underwent PCL
suturing, and the ACL was left untreated, making the accurate
comparison of repair versus reconstruction challenging [47].
The heterogeneity of knee injuries and lack of high-level evi-
dence on the matter necessitates individualised consideration
when choosing an approach [48].
Mariani et al. demonstrated that reconstruction yielded bet-
ter stability, range of motion, functional outcome scores and
return to pre-injury activities [49]. However, this data is more
than 2 decades old. A meta-analysis by Frosch et al. reported
good or excellent IKDC or Lysholm scores with both methods
and found no significant difference between the two [47]. A
systematic review by Levy et al. showed similar functional out-
come scores with repair and reconstruction, but stability, ROM
and return to pre-injury activity levels was higher in the recon-
struction cohort [2]. A combined repair-reconstruction approach
has been advocated if collateral ligaments and extra-articular
structures are affected [50]. Historically, posterolateral corner
injuries treated with reconstruction have lower reoperation rates
than when repaired [2, 25, 42]. Stannard et al. found failure
rates of 37% with PLC repair compared to 9% failure with
reconstruction. It should be noted that about half of the patients
in both the repair and reconstruction groups (48.5% and 54.5%,
respectively) had a hinged external fixator post-operatively
[51]. Similarly, Levy et al. compared LCL/PLC repair and
reconstruction and found failure rates of 40% and 6%, respec-
tively [52]. Therefore reconstruction is widely accepted as gold-
standard, although some recent prospective and retrospective
studies have found no significant differences in outcomes
between methods [48]. There also seems to be no clear differ-
ence comparing repair to reconstruction regarding medial col-
lateral ligaments and posteromedial corner injuries [42].
Repair is generally favoured for avulsion fractures [40, 42,
48] and has been advocated when ligaments are torn at their
insertions [53]. A recent resurgence of interest in repair has
been brought about with the introduction of internal bracing,
in which primary repairs are synthetically augmented [40, 54,
55]. LRS may benefit from this method as surgical time is
reduced by avoiding graft harvesting, and the stability of a pri-
mary repair is enhanced [40]. Equivalent outcome results have
been reported with this method [54, 56]. A recent descriptive
cross-sectional scenario-based survey compared approaches to
MLKI management between surgeons in emerging markets
and developing nations (EMDNs) and developed economic
nations (DENs). It found that surgeons from EMDNs preferred
conservative management and delayed staged reconstruction
with autograft and often did not have access to a physiothera-
pist. DENs surgeons favour early, single-stage arthroscopic
ligament reconstruction [57].
Timing
Conflicting data exist about the ideal timing of surgery for
MLKIs. Additionally, there is ambiguity about the time frame
defining “early” and “delayed” surgery [42, 48, 58]. Early sur-
gery has typically been described as an intervention within 3
weeks of the injury, when soft-tissue integrity is intact, and tis-
sue planes are still definable [48], whereas late surgery refers to
intervention after 4–6 weeks [58]. Advantages of early surgery
include earlier restoration of normal joint kinematics and earlier
mobilisation, which may improve functional outcomes, though
there is an increase in arthrofibrosis and knee stiffness [40, 42].
Delayed reconstruction allows extra-articular structures to
heal, improving ROM and potentially avoiding additional
 W. Scheepers et al.: SICOT-J 2021, 7, 62 5

unnecessary surgery, but is associated with a higher risk of fur-

ther chondral or meniscal damage [40, 42]. Early post-operative
rehabilitation is the most important positive prognostic factor,
regardless of the timing of surgery [40]. Thus delayed recon-
struction is an attractive option in LRS as structures may heal
independently and negate unnecessary interventions, and where
proper rehabilitation is not readily available. Though controver-
sial, overall recent trends in literature seem to favour early sur-
gery with improved or similar outcomes compared to delayed
surgery [2, 42, 44, 48, 58–60].

Surgical techniques
Various surgical techniques have been described and need
to be tailored to the patient and thorough pre-operative assess-
ment. Historically, open repair of all ligaments was advocated,
an approach that is now outdated [61]. Acute arthroscopic sin-
gle-stage reconstruction is the current gold-standard treatment
for ligamentous injuries but is not always available [40, 62].
Furthermore, if arthroscopy is performed too soon in MLKI,
it may result in fluid extravasation and compartment syndrome
due to capsular disruption [63]. Therefore, some recommend
delaying surgery by 10–14 days to allow swelling to subside
and capsular healing [63]. Open surgery is performed where
arthroscopy is not feasible (Figure 2).
If reconstruction is chosen, graft selection includes auto-
grafts, allografts and synthetic grafts – each with a set of distinct
advantages and disadvantages (Table 3) [42, 64]. Fixation is
dependent on graft choice, and graft size is another important
consideration (Table 4) [64, 65]. Graft selection is dependent
on the preference of the surgeon and patient, availability, and
the number of injured ligaments to be reconstructed [65].
Both the ACL and PCL can be reconstructed with single- or
double-bundles techniques. For the ACL, single-bundle recon-
struction is currently favoured [40]. Double-bundle reconstruc-
tion of the PCL has been shown to better replicate normal knee
kinematics and reduce residual posterior translation, although
clinical outcomes remain similar [42]. Good results have been
reported with single-staged and two-staged procedures, and
the ultimate decision is dependent on resources as well as the
surgeon’s preference and ability [58]. The distinct advantage
of single-stage surgery lies in facilitating early mobilisation
and preventing joint stiffness [25]. In vascular repairs, open
injuries, gross obesity, or in selected cases with severe instabil-
ity, an external fixation device can be indicated to achieve initial
stability [24].
Rehabilitation
Post-operative treatment needs to be individualised, and the
outcome is dependent on the cooperation of the patient, surgeon
and multi-disciplinary team involved. Most experts recommend
an initial period of non-weight-bearing for 4–6 weeks, followed
by active mobilization and progressive weight-bearing [48].
Early surgery combined with early motion (defined as achiev-
ing greater than 30 degrees motion within 3 weeks of surgery)
has been found to reduce posterior instability, varus and valgus
laxity, flexion loss of more than 10°, extension loss of more
Figure 2. Open surgery in a patient with a traumatic knee
arthrotomy and MLKI. Open cruciate surgery done in a patient
with an open knee dislocation, patella tendon rupture and large
traumatic arthrotomy. The PCL tunnel is drilled under direct vision
with a PCL tunnel aimer.
than 5° and results in improved outcome scores when compared
to early surgery with delayed rehabilitation [66]. However,
strength often remains poor at 2 years after surgery for MLKIs
with notable deficits in both quadriceps and hamstrings [66].
The importance of rehabilitation and early mobilisation has his-
torically been a cardinal factor in achieving desirable outcomes
and remains relevant today [61].
Outcomes
Although most studies of MLKIs treated surgically consist
of small cohorts with short follow-up periods, surgical manage-
ment of these injuries results in good functional outcomes as
assessed by validated scoring systems [10]. However, the out-
come can vary with IKDC scores as low as 67 [3] and as high
as 82 [67] on medium-term follow-up. The incidence of radio-
graphic osteoarthritis (OA) varies in the literature, with reports
of 23%, by Fanelli et al. [68] 42% by Moatshe et al. [33] and
87% by Engebretsen et al. [69] over follow-up periods of 2–12
years. Only 6.8% of the patients in the study by Fanelli et al.
eventually underwent total knee arthroplasty [68], with
Moatshe et al. demonstrating a similar rate of 7.7% [33].
Regarding revision MLKI reconstruction, Woodmass et al.
assessed the outcomes in 23 patients at a mean of 7.5 years fol-
low-up and found average Lysholm and IKDC scores of 79.4
and 74.5, respectively [70]. The Multiligament Quality of Life
(ML-QOL) scoring system designed by Chahal et al. has Q5
6 W. Scheepers et al.: SICOT-J 2021, 7, 62

Table 3. A comparison of autografts versus allografts [63].

Autograft Allograft
Cost No additional cost Additional cost
Availability Readily available May not be readily available
Risk No risk of disease transmission Risk of disease transmission
Additional surgical risks No additional surgical risks
Quality Good quality Quality may be reduced if irradiated (relevant in low-resource
settings with a high burden of transmissible disease)
Morbidity Donor site morbidity No donor site morbidity
Operating time Less operating time More operating time
Tissue reaction Minimal Variable

Table 4. Advantages and disadvantages of different grafts [64, 65].

Graft
Bone – Patella Tendon – Bone
Quadriceps tendon
Peroneus longus tendon
Achilles tendon or tibialis
anterior allografts
Hamstring (gracilis and
semitendinosus)
Advantages Disadvantages
Large grafts Risk of patella fracture
Bone-to-bone healing Anterior knee pain
Less graft stretching Quadriceps weakening
Lower incidence of tunnel widening and rupture
Large cross-sectional area Technically challenging to harvest
Low donor-site morbidity
Bone-to-bone healing on one end
Long graft Risk of ankle pain and instability
Large cross-sectional area
Simple harvest technique
No donor site morbidity Low quality when irradiated
Shorter operation time Risk of disease transmission when not irradiated
No size limitation Local bone resorption
Delayed incorporation
Additional costs
No anterior knee pain Prolonged ligamentization and soft-tissue healing
Haematoma formation
Low donor site morbidity Poor predictability of graft size
Fast graft acquisition Weakening of ACL agonists
Easy graft preparation and passage Reduced speed in athletes
High load to failure

recently gained attention to evaluate MLKIs as it is a disease-
specific questionnaire consisting of four relevant subsections
– physical, emotional, activity and social subscales [71, 72].
Increased risk of OA is associated with high-energy trauma,
age over 30 years and associated cartilage injuries [40]. A sys-
tematic review and meta-analysis by Poulsen et al. analysed
approximately one million patients with various knee injuries
and found a four times greater risk of developing OA with
ACL injuries when compared to non-injured knees and a six
fold increase with combined ACL and meniscal injuries [73].
In a retrospective cohort study, Richter et al. found that the
degree of radiological OA as measured by the Jäger and Wirth
Score correlated with the incidence of MCL and LCL ruptures
and with knee stability at follow-up, not with the incidence of
meniscal damage [34, 40]. However, not all patients with radi-
ological OA have symptoms [74]. Though controversial, sev-
eral authors have advocated that early surgery reduces the
risk of severe OA [74]. In cases of intractable pain and func-
tional limitations caused by severe OA, total knee arthroplasty
may offer relief. Poor functional outcomes are also associated
with high-energy trauma and patient age over 30 years, and
additionally with the repair of medial sided injuries and com-
bined medial and lateral meniscal tears [25].
Everhart et al. performed a systematic review of 21 studies,
including 524 patients, to determine overall rates of return to
work or sport after MLKI. They found a return to any level
of sport was 53.6%, with a return to high-level sport signifi-
cantly lower at 22–33% [75]. Return to any work was possible
for 88.4% of patients, although only 62.1% could do so with
minimal modifications [75]. Return to work was lower in
patients with Schenck Grade IV and V injuries, as well as in
patients with vascular injuries. Obese patients had worse Tegner
activity scores when compared to the non-obese (mean scores
of 1.7 vs. 4.5) [75].
Complications
Complications of MLKI are extensive, they can be acute or
chronic and may be injury or intervention related. Vascular
 W. Scheepers et al.: SICOT-J 2021, 7, 62 7

Figure 3. Pyramid of priorities when choosing an approach for knee ligament reconstruction. A summary of arguments for various approaches
outlines the considerations when choosing an approach specific to knee ligament reconstruction. The pyramid of priorities in order of
importance includes life-threatening injuries, vascular compromise, soft-tissue damage, fractures, and ligamentous injury. Available skills, the
setting and patient factors will influence decision making at each step.

injuries are easily missed at presentation or caused iatrogeni-
cally, with the popliteal artery being placed at risk during
PCL reconstruction [76]. Nerve injuries are also common and
often result from the injury itself, though the peroneal nerve
is at risk of injury during PLC repair and reconstruction [76].
Patients are predisposed to venous thromboembolic events
and pulmonary emboli after MLKI surgery, but the risk can
be mitigated with routine thromboprophylaxis [76]. Arthrofi-
brosis after surgery poses another challenge that can be seen
in up to 29% of patients after surgery, especially if performed
in the acute phase [76]. Twenty one percent of these require
manipulation under anaesthesia and potentially arthroscopic
or open surgical adhesiolysis [76, 77].
Preventative measures constitute meticulous handling of
soft-tissue, arthroscopy, minimising ipsilateral autografts,
reduction of post-operative inflammation, and swelling and
8 W. Scheepers et al.: SICOT-J 2021, 7, 62
appropriate rehabilitation [76]. If significant capsular disruption
or fascial damage is present, early arthroscopy within 1–2
weeks of the injury may result in fluid extravasation and com-
partment syndrome [63, 76]. Heterotropic ossification, avascu-
lar necrosis and fractures secondary to loss of bone stock with
surgical tunnelling and hardware implantation can occur [76].
Recurrent instability is another potential complication [40].
Fanelli et al. evaluated knee stability in a cohort of 44 patients
and reported KT1000™ arthrometer side-to-side differences of
>5 mm in 16% of cases (7 patients), a similar rate of instability
to other studies [68]. Post-operative infection rates are as high
as 17% but can be reduced with the routine use of perioperative
antibiotics [40]. Diabetics, the obese and patients undergoing
prolonged surgery are predisposed to developing an infection
[40]. Other intraoperative precautions include avoiding new
incisions which cross scars or wounds, preserving skin bridges
of at least 10 cm between incisions, careful soft-tissue handling,
achieving proper haemostasis before wound closure, minimis-
ing tension with wound closure and using drains when needed
to prevent haematoma formation [76]. Open injuries carry a
much higher rate of post-operative infection, and immediate
debridement, irrigation, intravenous antibiotics and external fix-
ation is often warranted to reduce this risk [76].
Authors’ commentary
As aforementioned, the heterogeneity of MLKIs and varia-
tion in patient and environmental factors necessitate an individ-
ualised approach when choosing a management plan. Above is
a summary of arguments for various approaches that outline the
considerations when choosing an approach specific to knee
ligament reconstruction. The pyramid of priorities in order of
importance includes life-threatening injuries, vascular compro-
mise, soft-tissue damage, fractures and ligamentous injury.
Available skills, the setting and patient factors will influence
decision making at each step (Figure 3).
Conclusion
Multiligament knee injuries are challenging entities and are
often missed in the presence of polytrauma. A high index of
suspicion is required to detect associated injuries with poten-
tially devastating complications. Vascular injuries are common,
and a thorough clinical examination and monitoring of the limb
are crucial. Angiography is indicated if the ABI is <0.9 or in the
presence of an expanding haematoma. Stress radiography plays
a pivotal role in evaluating both acute and chronic injuries, pre-
and postoperatively. MRI should be used routinely where avail-
able. Knee dislocations are fraught with complications, both
injury-related and iatrogenic, which can be mitigated with a
thorough pre-operative assessment and complication-specific
precautions. An open discussion with the patient about their
expectations and likely outcomes is essential. Surgical treatment
is superior to non-surgical treatment and results in good func-
tional outcome scores, though in special populations and
resource-restricted environments, conservative management is
an acceptable treatment option. Despite favourable outcomes,
the incidence of OA in the multiligament injured knee remains
high. The importance of proper post-operative rehabilitation is
emphasised repeatedly as a strong positive prognostic factor,
and patient motivation remains a cornerstone to success. The
heavy burden of MLKIs in LRS requires further consideration
to address the unique challenges faced in their context. As evi-
denced by the literature, intense debate surrounds many aspects
of MLKI surgery, such as timing, repair versus reconstruction
and optimal tensioning sequences. This stresses the need for
future research to produce high-level evidence on the topic,
and the rapid evolution of technology and techniques will
demand continuous and astute critical assessment.
Conflicts of interest
The authors declare they have no relevant financial or non-
financial conflicts of interest to declare.
Funding
This research did not receive any specific funding.
Ethical Approval
Ethical approval was not required.
Informed Consent
This article does not contain any studies involving human
subjects.
Author Contributions
W. Scheepers – writing original draft, editing; V. Khanduja
– writing, reviewing, editing; M. Held – writing, reviewing,
editing.
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https://doi.org/10.1186/s13018-018-0753-x

REVIEW Open Access

Single-bundle versus double-bundle

autologous anterior cruciate ligament
reconstruction: a meta-analysis of
randomized controlled trials at 5-year
minimum follow-up
Haitao Chen†, Biao Chen†, Kai Tie, Zhengdao Fu and Liaobin Chen*

Abstract
Background: Both single-bundle (SB) and double-bundle (DB) techniques were widely used in anterior cruciate
ligament (ACL) reconstruction recently. Nevertheless, up to now, no consensus has been reached on whether the
DB technique was superior to the SB technique. Moreover, follow-up of the included studies in the published
meta-analyses is mostly short term. Our study aims to compare the mid- to long-term outcome of SB and DB
ACL reconstruction concerning knee stability, clinical function, graft failure rate, and osteoarthritis (OA) changes.
Methods: This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines. The PubMed, Embase, and the Cochrane Library were searched from inception to October 2017. The
study included only a randomized controlled trial (RCT) that compared SB and DB ACL reconstruction and that
had a minimum of 5-year follow-up. The Cochrane Collaboration’s risk of bias tool was used to assess the risk of
bias for all included studies. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcome.
Results: Five RCTs were included, with a total of 294 patients: 150 patients and 144 patients in the DB group and
the SB group, respectively. Assessing knee stability, there was no statistical difference in side-to-side difference and
negative rate of the pivot-shift test. Considering functional outcome, no significant difference was found in proportion
with International Knee Documentation Committee (IKDC) grade A, IKDC score, Lysholm scores, and Tegner scores. As
for graft failure rate and OA changes, no significant difference was found between the DB group and the SB group.
Conclusion: The DB technique was not superior to the SB technique in autologous ACL reconstruction regarding knee
stability, clinical function, graft failure rate, and OA changes with a mid- to long-term follow-up.
Keywords: Mid- to long-term outcome, Anterior cruciate ligament, Reconstruction, Single-bundle, Double-bundle,
Meta-analysis

* Correspondence: lbchen@whu.edu.cn
†
Equal contributors
Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University,
Wuhan 430071, China

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Background
Anterior cruciate ligament (ACL) injuries destroy the
normal kinematics of the knee and may be more likely
to cause secondary injuries including meniscal injuries
and knee osteoarthritis (OA) [1, 2]. ACL reconstruction
is widely used to restore knee laxity, reestablish bio-
mechanical homeostasis, and prevent the long-term joint
degeneration [3–5]. In recent years, both single-bundle
(SB) and double-bundle (DB) techniques were com-
monly used in ACL reconstruction [6, 7]. However, up
to now, no consensus has been reached on whether the
DB technique was superior to the SB technique.
It is well known that the ACL may be divided into two
functional bundles, the anteromedial bundle (AMB) and
the posterolateral bundle (PLB) [5, 8]. These two grafts
cross each other inside the joint, acting separately at
different knee angles. Theoretically, the AMB may
prevent an anterior tibial translation at higher flexion
angles, while the PLB may additionally restrain anterior
tibial loads as well as a combined rotatory load at lower
flexion angles [9]. Several biomechanical studies [10–14]
reported that the DB technique could rebuild both the
AMB and the PLB and thus might reproduce knee
stability and kinematics closer to the native knee than
the SB technique in ACL reconstruction. However, other
biomechanical studies of Kondo et al. [15] as well as
Lorbach et al. [16] showed that the DB reconstruction
might not offer significant further advantages than the
SB reconstruction. Previous clinical studies with short-
term follow-ups also got an inconsistent result when
comparing DB with SB ACL reconstruction. On the one
hand, several studies [8, 17, 18] reported that the DB
technique could achieve a superior result in both knee
stability and clinical functions. Meanwhile, some lite-
rature [19–23] indicated that the DB technique could
acquire better knee stability, but get comparable postop-
erative functions to the SB technique. On the other
hand, several researchers [6, 22, 24–28] found that
both knee stability and clinical functions had no sig-
nificant difference between the two techniques in ACL
reconstruction. Given the diverse results of previous
studies, it is imperative to pool the data to compare
the DB and SB techniques and thus provide a reference
for ACL reconstruction.
A recent meta-analysis [29] of 26 randomized con-
trolled trials (RCTs) showed that the DB technique
could yield a better outcome in both functional outcome
and stability of the knee than the SB technique in ACL
reconstruction. In another meta-analysis, Li et al. [30]
found that the DB ACL reconstruction had a better out-
come in rotational stability, while there was no great
difference in functional outcome between the DB and
SB techniques. However, the above two studies [29, 30]
failed to assess some outcome parameters, such as graft
Page 2 of 12
failure and OA changes, between the two techniques.
Furthermore, the follow-up of most of the included
studies in both meta-analyses is short term. It is well
known that OA is a chronic progressive degenerative
disease, which can be found through X-ray as early as 4
to 5 years postoperatively [31]. It is more persuasive and
reliable to compare the DB and SB techniques in ACL
reconstruction with a longer-term follow-up.
The purpose of this meta-analysis was to determine
whether there is a significant difference in postoperative
knee stability, clinical function, graft failure rate, and OA
changes for DB versus SB technique in ACL reconstruc-
tion with a minimum of 5-year follow-up.
Methods
Literature search
This study was designed and conducted according to the
PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines [32]. The
PubMed, Embase, and the Cochrane Library were
reviewed for all English language studies from inception
to October 2017. Two independent reviewers (HTC and
BC) searched each database using the following strategy:
(“anterior cruciate ligament” OR ACL) AND (single-
bundle OR “single bundle”) AND (double-bundle OR
“double bundle”). A manual search for references of
included articles was also conducted to ensure no
eligible studies were missed.
Inclusion criteria and exclusion criteria
Inclusion criteria were as follows: (1) subject—all patients
who underwent arthroscopy-assisted ACL reconstruction,
with no limitation to sex or race; (2) intervention
method—comparison of clinical outcome between the
SB and DB technique in autologous ACL reconstruction;
(3) outcome parameters—side-to-side difference (SSD),
pivot-shift tests, International Knee Documentation
Committee (IKDC) grade A, IKDC scores, Lysholm
scores, Tegner scores, graft failure, and OA changes;
(4) study type—RCT.
The exclusion criteria were as follows: (1) non-prospective
trials (e.g., retrospective studies, observational studies,
case series, and reviews); (2) animal or cadaver studies;
(3) comparisons that were not between SB and DB
method in ACL reconstruction; (4) follow-up less than
5 years; and (5) allograft ACL reconstruction.
Data extraction
Data from eligible studies were extracted independently
by the two same reviewers according to predefined
selected criteria, including article information (author
and publication date), participant demographics, follow-
up period, sample size, implant, femoral drilling technique,
fixation type, and outcome parameter. The KT-1000 and
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
KT-2000 arthrometers in the included studies were
reported in the form of SSD. Disagreements on data
extraction were resolved by discussion.
Assessment of risk of bias
Two reviewers independently assessed the risk of bias
for all included studies using the Cochrane Collaboration’s
risk of bias tool, which contains six items as follows:
random sequence generation (selection bias), allocation
concealment (selection bias), blinding of participants
and personnel (performance bias), incomplete outcome
data (attrition bias), selective reporting (reporting bias),
and other bias. Each of included studies was rated as
having a low, unclear, or a high bias regarding the
above items. Publication bias was not detected because
of the limited number of included studies. Disagreements
were resolved by discussion.
Statistical analysis
The meta-analysis was conducted using Stata/SE version
12.0. When the outcome indicator was dichotomous
outcomes, relative risk (RR) was calculated for effect
size. For continuous outcomes, a weighted mean dif-
ference (WMD) was calculated when the same meas-
urement criterion was used; otherwise, a standardized
mean difference (SMD) was calculated both used 95%
confidence intervals (CI). The intervening effect of an
indicator was considered as zero difference if 95% CI
for WMD or SMD contained 0 and 95% CI for RR
contained 1. The statistical heterogeneity was tested
with the chi-square test and I2. If heterogeneity was
low (P > 0.1 or I2 ≤ 50%), a fixed effects model was
used. If heterogeneity was significant (P < 0.1, I2 > 50%),
Fig. 1 Flowchart of article selection process
Page 3 of 12
sensitivity analysis, subgroup analyses, and meta-regression
were conducted to find the source of the heterogen-
eity. If the heterogeneity could not be eliminated, a
random effects model would be used when the result
of meta-analysis had clinical homogeneity, or descriptive
analysis would be used.
Results
Article selection results
Seven hundred eighty-two relevant articles were initially
selected according to the search strategy. Three hundred
fifty-three were excluded after checking for duplicates
with the literature management software Endnote X7.
Three hundred ninety-eight were excluded after review-
ing the titles and the abstracts, 26 published articles
were excluded by reviewing their full content as 25 stud-
ies had less than 5 years’ follow-up and data in one study
were the same as those in another study with a longer
follow-up. Finally, five articles [33–37] were included in
the meta-analysis. A summary of the review process is
presented in Fig. 1.
Description of included studies
All five selected articles were written in English, which
compared the clinical outcomes of the DB and SB
techniques in ACL reconstruction. All follow-up periods
in the included articles were ≥5 years. There was a total
of 294 patients: 150 patients and 144 patients in the
DB group and the SB group, respectively. All basic
article information is reported in Table 1, and the
mid- to long-term outcome measures of the two techniques
are reported in Table 2.
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50 Page 4 of 12

Table 1 Characteristics of included studies

Study Age, year Follow-up, n (the last Femoral drilling Implant Fixation Outcome
Mean (SD) year follow-up)
FS TS
Jarvela DB: 34 ± 10 10 DB: 24 AM HT (AU) BIS BIS Lysholm score; IKDC score; IKDC grade A;
(2017) [33] SB: 30 ± 8 SB: 23 pivot-shift test; KT-1000 (SSD); OA changes;
revision surgery (graft failure)
Beyaz DB: 33.53 ± 5.47 8 DB: 15 AM HT (AU) EB BIS Tegner activity scale; IKDC score;
(2017) [34] SB: 31.06 ± 5.48 SB: 16 Lysholm score; OA changes; tunnel widening;
Isokinetic muscle strength
Adravanti DB: 26.4 ± 8.5 6 DB: 25 DB: TT (AMB), HT (AU) EB BIS Lysholm score; IKDC grade A; KT-2000 (SSD);
(2017) [35] SB: 28.3 ± 6.2 SB: 25 outside-in (PLB); OA changes; graft rerupture (graft failure)
SB:TT
Karikis DB: 33.53 ± 5.47 5 DB: 46 AM HT (AU) MIS BIS Tegner level; Lysholm score;
(2016) [36] SB: 31.06 ± 5.48 SB: 41 Single-legged hop test; KOOS Outcomes;
KT-1000 (SSD); Lachman test; pivot-shift test;
OA changes
Zaffagnini DB: 27 ± 9 8 DB: 40 DB: medial portal; DB: HT (AU) IS IS IKDC grade A; pivot-shift test; Tegner level;
(2011) [37] SB: 26 ± 9.5 SB: 39 SB: AM SB: BPTB(AU) KT-2000 (SSD)
SD standard deviation, DB double-bundle, SB single-bundle, AM anteromedial portal technique, TT transtibial technique, HT hamstring tendon, BPTB bone-patellar
tendon-bone, AU autologous, FS femoral side, TS tibial side, BIS bioabsorbable screw, MIS metal interference screws, IS interference screws, IKDC International Knee
Documentation Committee, SSD side-to-side difference, KOOS Knee injury and Osteoarthritis Outcome Score, OA osteoarthritis, ROM range of motion

Assessment of risk of bias Pivot-shift test

The results of the assessment of the risk of bias on
included studies are summarized in Fig. 2. The study by
Adravanti et al. [35] used a block randomization scheme
to group the two treatments randomly, and thus this
study was rated as having a high risk of selection bias,
whereas the remaining studies were rated as having a
low risk of selection bias. All included studies [33–37]
failed to conduct the blinding therapists regarding DB or
SB technique, and thus these were rated as having a high
risk of performance bias. The studies by Beyaz et al. [34]
and Zaffagnini et al. [37] did not describe the blinding of
outcome assessment, and thus these were rated as an
unknown risk for detection bias. One study [34] lost
more than 20% of enrolled patients during follow-up
and was regarded as having a high risk of attribution
bias. All included studies [33–37] offered insufficient
information to judge selective outcome reporting, and
thus these were rated as having an unknown risk of
reporting bias. One study [34] included only male
patients and one study [37] used hamstring for DB tech-
nique ACL reconstruction and used bone-patellar
tendon-bone for SB technique ACL reconstruction, and
thus these were rated as having a high risk of potential
other bias.
Postoperative pivot-shift tests were conducted in four
studies. The analysis of negative pivot shift results
showed some heterogeneity among the studies (P = 0.008,
I2 = 79.2%). By using a random effects model, 100 patients
in the DB group and 107 patients in the SB group were
analyzed with no significant difference in postoperative
negative pivot-shift (RR =1.09, 95% CI (0.88, 1.35),
P = 0.441) (Fig. 4). Subsequently, to explore the potential
source of heterogeneity, the pivot shift test was subjected
to a sensitivity analysis by omitting one article at a time
and calculating the pooled RRs for the remaining studies.
It was found that there were no great changes in effect
when any one study was excluded.
IKDC grades
Three studies included IKDC grades, and no heterogen-
eity was found among the studies (P = 0.359, I2 = 2.4%).
Eighty-nine patients in the DB group and 87 patients in
the SB group were analyzed using the fixed effects
model, with no significant difference being found in
proportion with IKDC grade A (RR = 1.15, 95% CI (0.95,
1.38), P = 0.156) (Fig. 5).

SSD
Four studies reported postoperative SSD, and no het-
erogeneity was found among the studies (P = 0.139,
I2 = 45.5%). Using the fixed effects model, 135 patients in
the DB and 128 patients in the SB group were analyzed
with no significant difference in SSD (WMD = 0.17, 95%
CI (− 0.13, 0.48), P = 0.27) (Fig. 3).
IKDC scores
Two studies demonstrated postoperative IKDC scores,
with no heterogeneity being found between the studies
(P = 1, I2 = 0%). Thirty-nine patients in the DB group
and 39 patients in the SB group were analyzed using the
fixed effects model, and no significant difference was
found in the postoperative IKDC scores (WMD = 0, 95%
CI (− 0.57, 0.57), P = 1) (Fig. 6).
Table 2 Mid- to long-term outcome measures of two techniques
Study N SSDa PS test IKDC A IKDC scoresa Lysholm scoresa Tegner scoresa Graft OA
(mm) (N/P) (Y/N) failure changes
(Y/N) (Y/N)
DB SB DB SB DB SB DB SB DB SB DB SB DB SB DB SB
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50

Jarvela (2017) [33] 47 −0.1 ± 2 0.6 ± 1.9 23/1 23/0 19/5 18/5 9±2 9±2 94 ± 7 95 ± 7 – – 1/23 7/16 12/12 8/15
Beyaz (2017) [34] 31 – – – – – – 7.1 ± 0.91 7.1 ± 0.94 81.43 ± 6.45 81.94 ± 7.15 3.43 ± 1.34 3.47 ± 1.12 – – 7/8 5/11
Adravanti (2017) [35] 50 1.4 ± 0.6 1.3 ± 0.8 – – 13/12 13/12 – – 96.4 ± 17.3 94.2 ± 15.3 – – 1/24 0/25 3/22 2/23
Karikis (2016) [36] 87 2.2 ± 2.7 2.3 ± 2.7 32/4 38/7 – – – – 90.1 ± 9.1 84.3 ± 21.2 5.7 ± 1.3 5.7 ± 1.5 – – 8/30 11/34
Zaffagnini (2011) [37] 79 1.1 ± 1.9 0.4 ± 0.6 36/4 26/13 35/5 26/13 – – – – 6±2 4±2 – – – –
SSD side-to-side difference, DB double-bundle, SB single-bundle, PS pivot-shift, N/P negative/positive, IKDC International Knee Documentation Committee, Y/N yes/no, OA osteoarthritis
a
The value is given as mean ± standard deviation
Page 5 of 12
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Fig. 2 Assessment of risk of bias. +, low risk; −, high risk; ?, unknown risk
Fig. 3 Forest plot of SSD. WMD, weighted mean difference
Page 6 of 12
Lysholm scores
Four studies reported postoperative Lysholm scores,
with no heterogeneity being found among the studies
(P = 0.385, I2 = 1.5%). One hundred ten patients in the
DB and 105 patients in the SB group were analyzed
using the fixed effects model, and no significant differ-
ence was found in the postoperative Lysholm scores
(WMD = 0.44, 95% CI (− 2.25, 3.12), P = 0.75) (Fig. 7).
Tegner scores
Three studies reported postoperative Tegner scores, and
obvious heterogeneity was found among these studies
(P = 0, I2 = 86.9%). The random effects model was used
to analyze 101 patients in the DB group and 96 patients
in the SB group, showing no significant difference in
postoperative Tegner scores (WMD = 0.63, 95% CI (− 0.61,
1.87), P = 0.317) (Fig. 8). Subsequently, to explore the
potential source of heterogeneity, the Tegner scores
were subjected to a sensitivity analysis by omitting
one article at a time and calculating the pooled
WMDs for the remaining studies. It was found that
there were no great changes in effect when any one
study was excluded.
Graft failure
Graft failure was conducted in two studies, with obvious
heterogeneity between the studies (P = 0.106, I2 = 61.7%).
The random effects model was used to analyze 49 patients
in the DB group and 48 patients in the SB group, showing
no significant difference in postoperative graft failure rate
(RR =0.5, 95% CI (0.05, 9.91), P = 0.649) (Fig. 9).
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Fig. 4 Forest plot of pivot-shift test
OA
Four studies included OA, and no heterogeneity was
found between the studies (P = 0.756, I2 = 0%). The 102
patients in the DB group and 109 patients in the SB
group were analyzed using the fixed effects model, with
no significant difference being found in OA changes
(RR = 1.22, 95% CI (0.79, 1.89), P = 0.37) (Fig. 10).
Discussion
This meta-analysis was performed to compare the mid-
to long-term outcome of the DB and SB techniques in
autologous ACL reconstruction. The analysis included
Fig. 5 Forest plot of IKDC grades
Page 7 of 12
five RCTs involving 294 patients with at least 5 years of
follow-up. The results revealed that there was no signifi-
cant difference in knee stability, clinical function, graft
rupture, and OA changes between the DB and SB tech-
niques in autologous ACL reconstruction.
It is important to restore both the anterior and rota-
tional stability in ACL reconstruction, which may be
correlated with risk of meniscus and cartilage injury, as
well as graft rupture and OA changes [2]. In our current
study, all four included studies [33, 35–37] found that
no statistical difference was found in anterior stability
regarding KT-1000 or KT-2000 measurements. It was in
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Fig. 6 Forest plot of IKDC scores
line with the previous studies [6, 24, 31]. The authors of
these studies reported that both the DB and SB tech-
niques could closely imitate the AMB in ACL recon-
struction and thus acquire comparable anterior stability.
As for the rotational stability, two included studies [33, 36]
found no great difference between the DB and SB
techniques in ACL reconstruction, whereas one in-
cluded study [37] showed that the DB technique could
yield superior result than the SB technique. Theoretically,
the DB technique also reconstructed the PLB, which func-
tioned at extension and contributed more to rotational
stability. However, our meta-analysis indicated that there
was no significant difference between the DB and SB
Fig. 7 Forest plot of Lysholm scores
Page 8 of 12
techniques in rotational stability. Hemmerich et al. [38]
thought that the ACL could restrict the rotation of the
knee, but its contribution to joint stability was limited
under isolated torsional load. Furthermore, other authors
[39, 40] suggested that peripheral knee structures, such as
collateral ligaments and the musculature that crosses the
knee joint, along with ACL played an important role in
rotational stability.
In our study, clinical function showed no statistical
difference between the DB and SB techniques in autolo-
gous ACL reconstruction. Four included articles [33–36]
found that the DB technique in ACL reconstruction was
not superior to the SB technique regarding the function
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Fig. 8 Forest plot of Tegner scores
parameters, including the Lysholm scores, the proportion
with IKDC grade A, IKDC scores, and the Tegner scores.
One included study [37] show that the DB technique
could yield better functions than the SB technique in
ACL reconstruction. In this study, the DB ACL recon-
struction used an anatomical technique, while the SB
ACL reconstruction used a non-anatomical technique.
Furthermore, the grafts were also different in ACL
reconstruction. That is, autologous hamstring graft
was used in the DB technique, whereas autologous
bone-patellar tendon-bone graft was used in the SB
technique. This subtle difference of femoral drilling
techniques and types of graft might influence the
assessment of functional outcome and thus affect the
accuracy of the result. Meanwhile, it might account for
Fig. 9 Forest plot of graft failures
Page 9 of 12
the difference between the one and the other four
included studies.
Graft failure increases the future economic burden
and individual suffering. Unfortunately, 0.7–20% of
patients experience recurrent instability due to graft
failure [41, 42]. In our meta-analysis, graft failure was
referred to in two included studies. One study [33]
reported that the DB ACL reconstruction resulted in
significantly fewer graft failures than the SB ACL recon-
struction. In this study, Jarvela et al. thought that the DB
graft was stronger and might mimic the normal ACL
anatomy more closely than the SB graft, and thus the
DB technique was less likely to cause graft failure.
However, the other study [35] found no great difference
between the two techniques. In general, it is noteworthy
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Fig. 10 Forest plot of OA
that the cause of graft failure after ACL reconstruction is
not solely influenced by the DB and SB techniques but
also largely influenced by other risk factors, such as new
knee trauma, infection of implanted graft, returning too
soon to pivoting sports, and radical rehabilitation program
[33]. In our current study, the DB technique had no
obvious advantage in graft failure than the SB technique.
OA changes were also discussed in our meta-analysis.
Three included studies found no great difference between
the DB and SB techniques, whereas one included study
showed more OA changes in the SB ACL reconstruction.
The DB technique, in theory, could better delay the
degeneration of knee than the SB technique in ACL
reconstruction. Tajima et al. [43] and Morimoto et al. [14],
for example, thought that SB ACL reconstruction might
result in a significantly smaller patellofemoral and tibiofe-
moral contact area and higher pressures and thus had
more OA changes. However, Jarvela et al. [33] found that
the delay from the primary injury to ACL reconstruction
affected OA changes. Also, some studies [31, 35, 44]
reported the concomitant injury, such as meniscal or
another ligament tear, as well influenced OA changes. In
our study, the DB technique had no great difference with
the SB technique in OA changes. Tunnel widening may
lead to the inability of the implanted graft, long-term joint
laxity, and difficulty in revision surgery [34, 45]. However,
only one included RCT touched upon tunnel widening,
and thus it was not suitable for conducting a meta-
analysis. More prospective long-term RCTs are needed for
future meta-analysis as for tunnel widening.
The advantage of this meta-analysis is that all the included
studies were prospective RCTs with a minimal 5-year
follow-up. Graft failure and OA changes usually needed to
Page 10 of 12
be assessed with a longer-term follow-up. Furthermore, a
mid- and long-term result could offer a more persuasive
and believable assessment of the stability and functional
outcome and thus provide a reference for the choice of
techniques in ACL reconstruction.
The limitations of this study were as follows: (1) The
whole sample size was not large, and the outcome
indicator was not unified, which may have influenced the
outcome. (2) The femoral drilling technique and fixation
technique in the studies were not all the same, which may
not have been sufficiently homogeneous to evaluate the
differences between the DB and SB techniques. (3) Several
indicators, including KOOS outcomes, Lachman test, and
tunnel enlargement were referred to in only one of the
included study and could not be used as outcome para-
meters in the present study.
Conclusion
The DB technique is not superior to the SB technique in
autologous ACL reconstruction regarding knee stability,
clinical function, graft failure rate, and OA changes with
a mid- to long-term follow-up.
Abbreviations
ACL: Anterior cruciate ligament; AMB: Anteromedial bundle;
CI: Confidence intervals; DB: Double-bundle; IKDC: International Knee
Documentation Committee; OA: Osteoarthritis; PLB: Posterolateral bundle;
PRISMA: Preferred Reporting Items for Systematic Reviews and
Meta-Analyses; RCTs: Randomized controlled trials; RR: Relative risk;
SB: Single-bundle; SMD: Standardized mean difference; SSD: Side-to-side
difference; WMD: Weighted mean difference
Acknowledgements
Not applicable.
Chen et al. Journal of Orthopaedic Surgery and Research (2018) 13:50
Funding
There was no external funding for this work.
Availability of data and materials
All the data of the manuscript are presented in the paper.
Authors’ contributions
HTC and BC carried out the entire procedure including the literature
search and data extraction. He performed the statistical analysis, drafted
the manuscript, and revised the submitted the manuscript. LBC conceived
of the study, coordinated and participated in the entire process of drafting,
and revised the manuscript. KT and ZDF contributed to the statistical
analysis and revision of the manuscript. All authors have contributed
significantly. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 27 December 2017 Accepted: 27 February 2018
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Andrzejowski and Giannoudis 
J Orthop Traumatol (2019) 20:21 Journal of Orthopaedics
https://doi.org/10.1186/s10195-019-0528-0
and Traumatology

REVIEW ARTICLE Open Access

The ‘diamond concept’ for long bone

non‑union management
Paul Andrzejowski and Peter V. Giannoudis*

Abstract
Long bone non-union continues to be a significant worldwide problem. Since its inception over a decade ago, the
‘diamond concept’, a conceptual framework of what is essential for a successful bone healing response, has gained
great acceptance for assessing and planning the management of fracture non-unions. Herein, we discuss the epide-
miology of non-unions, the basic science of bone healing in the context of the diamond concept, the currently avail-
able results and areas for future research.
Keywords: Diamond concept, Bone healing, Long bone, Non-union, Mesenchymal stem cells

Introduction non-union [17]. These definitions are based on the radio-

Since its inception, the diamond concept has proven
itself to be an important framework for understanding
the minimal requirements for fracture healing. Moreover,
it has shown itself to be particularly useful when plan-
ning surgical management of fracture non-union of both
upper and lower extremities [1–13].
Non-union has been defined in various ways, with a
55% disagreement amongst clinicians on timing [14].
The US Federal Drug Administration council defines it
as ‘failure to achieve union by 9 months since the injury,
and for which there has been no signs of healing for
3 months’. Others, however, have recommended that for
long bones this should be revised to a period of 6 months
if no evidence of radiological fracture healing is present
[15]. Instability at the fracture site in true non-union is
often associated with ongoing pain, and as such, clinical
signs are as important in diagnosis as the radiological
examination [14, 16].
Well-vascularised fracture sites with abundant fracture
haematoma but an unstable mechanical environment
will usually develop ‘hypertrophic’ non-union, whereas
impaired blood supply in combination with local strain
concentration has been suggested to lead to ‘atrophic’
*Correspondence: pgiannoudi@aol.com
Academic Department of Trauma & Orthopaedics, School of Medicine,
University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds
General Infirmary, Leeds LS1 3EX, UK
graphic appearance of non-union [17]. The presence or
absence of infection is also important in terms of classi-
fication, which can further complicate the clinical picture
and treatment modality [18].
Incidence of non-union has been variably reported in
the literature, depending on study size, patient demo-
graphics, injury location and severity and method of
treatment, from anywhere between 2 and 30% [19] with
an estimated 100,000 episodes of fracture non-union
per year in the USA [16]. A recent study from Australia
on 853 patients showed overall 8% of patients who had
fractures, being admitted to hospital per year for frac-
ture healing complications [20]. However, a recent much
larger population-based study done in Scotland showed
lower overall incidence than previously reported, at 1.9%
in the adult population, with incidence of non-union for
pelvis and femur fractures of 13 per 1000, humerus of 30
per 1000 and tibia of 55 per 1000; incidence was seen to
peak in the 25–44-year age group [21]. This comes with
significant financial implications, with reported overall
costs between £21,183 and £33,752 per patient [22, 23].
Risk of non‑union
Risks of non-union can be defined as patient dependent
and independent, as well as local and systemic, some of
which can be modified to enhance fracture healing.
A recent systematic review into risk stratification
showed that quality of evidence quantifying relative

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Andrzejowski and Giannoudis J Orthop Traumatol (2019) 20:21
Table 1 Risk factors for non-union
Patient dependent
Modifiable Non-modifiable
Smoking Age
Alcohol Male gender
Nutritional deficiency (including vitamin D) Genetic ­predispositionb
High BMI Diabetes (metabolic disease)
Peripheral vascular disease
Osteoporosis
Chronic inflammatory disease
Renal insufficiency
a
Insulin
a
Opiates
a
NSAIDs
Steroidsa
Antibioticsa
Anticoagulantsa
Chemotherapeuticsa
a
Potentially modifiable, bInconclusive—under research
risks is variable, ranging from level 1 to level 5 evidence.
Table 1 illustrates a summary of existing risk factors [16,
24–26].
Attempts have been made to develop scoring systems
to predict the risk of early non-union, including the Non-
Union Scoring System (NUSS) [27] and the Moghaddam
risk score [28]. Some authors have suggested that the
appropriate treatment modality of non-union should be
based on the severity of the non-union scoring system
used.
Fracture healing and the diamond concept
A successful fracture healing response is dependent on
the biological environment at the fracture site (availabil-
ity of molecular mediators, progenitor cells and matrix,
immunoregulatory cells amongst others) and an opti-
mum mechanical environment that provides the fracture
site with adequate stability, facilitating the evolution of a
physiological process leading to a successful bone repair
response. In general terms, there are two mechanisms
by which bone can heal, which are influenced by the
local mechanical fracture environment. Direct, or pri-
mary cortical bone healing occurs where there is ‘abso-
lute stability’ of bony surfaces with close contact of less
than 0.15 mm, and minimal inter-fragmentary strains
of less than 2%; this can only be achieved by compres-
sion lag screw or compression plating [16, 29–31]. The
second mechanism is by indirect, or secondary bone
healing which is facilitated by relative stability. Over-
all, the phases of fracture repair are broadly divided into
fracture haematoma formation, inflammation, cellular
Page 2 of 13
Patient independent
Open reduction (poor quality of primary ORIF)a
Open fracture (more bone loss and soft tissue injury)
Wedge and multi-fragmentary fracture pattern
Initial displacement
Compartment ­syndromea
Affected bone: highest in tibia
Fracture site in relation to vascularisation zone
Presence of fracture gap post-surgerya
Poor mechanical stability by initial ­implanta
Infectiona
proliferation and differentiation, and remodelling [32,
33].
The ‘diamond concept’, being a conceptual framework
for a successful bone repair response, gives equal impor-
tance to mechanical stability and the biological envi-
ronment. Moreover, adequate bone vascularity and the
physiological state of the host are thought to be essential
within this framework of fracture repair. A deficit in the
biological environment or the mechanical environment,
or failure to appreciate the comorbidities of the host and
the lack of vascularity can all lead to an impaired fracture
healing response (non-union). Overall, the diamond con-
cept refers to the availability of osteoinductive mediators,
osteogenic cells, an osteoconductive matrix (scaffold),
optimum mechanical environment, adequate vascular-
ity, and addressing any existing comorbidities of the host
(Fig. 1) [1, 2]. The important constituents of the diamond
concept are discussed in more detail below.
Osteoinductive mediators
Initial bleeding following fracture initiates the coagula-
tion cascade; this leads to development of a fracture hae-
matoma [34]. This contains platelets and macrophages,
which release a series of cytokines (cell signalling mol-
ecules) of different types, stimulating a cascade of events
to initiate healing. These include proinflammatory
interleukins 1, 6, 8, 10 and 12, tumour necrosis factor-a
(TNFa), activated protein C (APC), monocyte chemoat-
tractive protein (MCP), macrophage colony-stimulat-
ing factor (M-CSF), receptor activator of nuclear factor
kappa B ligand (RANKL) and osteoprogenin (OPG) [1,
Andrzejowski and Giannoudis J Orthop Traumatol (2019) 20:21
Fig. 1 Illustration of the ‘diamond concept’ of bone healing
34, 35]. Metalloproteinases and angiogenic factors such
as vascular endothelial growth factor (VEGF) also play
an important role in the overall bone repair process [1,
34, 35]. However, the most important mediators released
having a direct effect on progenitor cells to undergo the
process of mitogenesis and osteoblastic differentiation
include platelet-derived growth factor (PDGF), fibroblast
growth factor (FGF), insulin-like growth factor (IGF) and
transforming growth factor beta (TGFβ) proteins, which
include bone morphogenic protein (BMP)-2, 4, 6 and 7
(Fig. 2) [1, 34, 35].
Osteogenic cells
Osteogenic cells, which comprise both committed osteo-
progenitor cells from the periosteum as well as undif-
ferentiated multipotent stem cells (MSCs) from bone
marrow and endothelial progenitor cells, are also acti-
vated according to the local fracture environment in the
haematoma [1]. The cytokine release leads to an ensu-
ing inflammatory phase, characterised by increased
blood flow and vascular permeability, and chemotaxis
with activation of the complement cascade. Osteoclasts
and fibroblasts initiate conversion of haematoma into
granulation tissue, laying down a fibrin meshwork which
is then invaded by a new capillary network allowing fur-
ther MSC migration. Following activation, cytokines are
also released by endothelial cells, MSCs, chondrocytes,
osteocytes and osteoblasts themselves [1, 15, 34, 36].
This is followed by the proliferation and differentiation
of MSCs, leading to simultaneous hard and soft callus
Page 3 of 13
Fig. 2 Diagrammatic representation of fracture haematoma
composition. Key: IL interleukin, MCP monocyte chemoattractive
protein, M-CSF monocyte colony-stimulating factor, BMP bone
morphogenic protein, PDGF platelet-derived growth factor, VEGF
vascular endothelial growth factor, RANKL receptor activator of
nuclear factor kappa-B ligand, OPG osteoprotegerin, SOST sclerostin
(Adapted from Walters et al. [34] used with permission)
formation, which is highly influenced by the mechani-
cal micro-environment and fracture biology [29, 32, 37].
Higher oxygen tension at periosteal surfaces distal to the
fracture site, as well as other factors, encourages prefer-
ential MSC differentiation into osteoblasts [16]. In the
peripheral (cortical) zone, osteocalcin initiates periosteal
osteoblasts to produce type 1 collagen, leading to intram-
embranous ossification (hard callus). In central (medul-
lary) zones, MSCs develop into chondrocytes, initially
laying down type 2 collagen (soft callus) known as endo-
chondral ossification; by week 3, increasing osteocalcin
induces calcification and hard callus formation here too
(Fig. 3). Mineralisation of fracture callus into an osteoid-
type matrix and type 1 collagen fibrils leads to bridging of
the fracture site and disordered ‘woven bone’ formation
[31, 38–41]. Critical in guiding this process are the BMPs,
which are responsible for inducing osteogenic activity in
mesenchymal stem cells and maturation of lamellar bone,
as well as helping coordinate osteoclastic activity [32, 42–
44]. Inhibitory and fibrinolytic molecules also play a key
role in regulating the process, without which bone heal-
ing has shown to be delayed [32, 35, 45]. This is followed
by a period of remodelling by bone multicellular units
(BMUs) in a process of activation, resorption, reversal
Andrzejowski and Giannoudis J Orthop Traumatol (2019) 20:21 Page 4 of 13

Fig. 3 Diagrammatic representation of ossification: a Intramembranous ossification. Osteoinductive mediators induce osteogenic MSCs to
differentiate into osteoblasts, which lay down osteoid (collagen-1 rich); this mineralises to form an ossification centre, whence mineralisation
extends. There is terminal differentiation into osteocytes, becoming entombed in the bone matrix. b Endochondral ossification. Osteoinductive
mediators induce osteogenic MSCs to differentiate into chondrocytes; a cartilage matrix is secreted which forms the template for endochondral
bone formation. Chondrocytes then undergo hypertrophic differentiation and mineralise the surrounding matrix. They eventually undergo
apoptosis—resulting in vascular invasion. Invading blood vessels convey osteoblasts which form bone on the cartilage template [46]

and formation, taking at least 6 months to complete. The
disordered woven bone, which is comparatively weak,
develops into stronger, organised lamellar bone follow-
ing in general the principles of Wolff ’s law, who showed
that the trabecular pattern of bone corresponds to the
mechanical stresses placed upon it [46–48].
Extracellular osteoconductive matrix (scaffold)
An osteoconductive extracellular matrix, acting as a
scaffold and promoting migration and adhesion of oste-
oinductive and osteogenic cells to the fracture site, is
essential for fracture healing. Where there is good appo-
sition of bone, necrotic bone at the fracture site serves
this purpose. If there is insufficient ‘natural’ scaffold, then
autograft, or allograft demineralised bone matrix (DBM),
which also has inherent osteoinductive capability thanks
to retained growth factors including BMP, can be used
when treating non-union of bone defects [1, 32, 42, 43,
49, 50].
Mechanical environment
Evidence suggests that cells are able to sense the sur-
rounding mechanical environment, through elec-
trochemical signals generated by fluid shift within
canaliculae (osteocytes), and also other cell types have
cell membrane mechanoreceptors and direct connec-
tions between the cell nucleus and local cytoskeleton,
which are further influenced by the chemical environ-
ment and cellular signalling molecules [37]. Based on
studies of cells in culture, cellular development has been
shown to be greatly influenced by local mechanics, with
the mechanical and physiological environment impact-
ing significantly upon subsequent lineage differentiation
of multi-potent mesenchymal stem cells. In the pres-
ence of appropriate growth factors, tension encourages
fibroblasts, shear encourages chondroblasts, and a com-
bination of compression/distraction encourages osteo-
blasts—reflecting the mechanical environment in which
the cells usually develop [29].
Strain, defined as extension per unit length in relation
to the force applied, reflecting loading and micromotion
at the fracture site, is important to initiate healing, as dis-
cussed by Perren [17, 30]. Axial micromotion seems to
stimulate fracture healing in the early stages; by 8 weeks,
this relationship reverses, being reflected in normal
healing by increasing callus stiffness, which naturally
aims to decrease movement at this stage [29, 30]. Low
strain rates promote intramembranous ossification, but
Andrzejowski and Giannoudis J Orthop Traumatol (2019) 20:21
endochondral ossification is more likely to be initiated
if the strain rate is increased. When strain is increased
too far, however, increased differentiation down the soft
tissue lineage pathway predominates, leading to delayed
or non-union [31]. For ossification to occur, the fracture
gap must have reduced to an appropriate level, impacted
in turn by the relative stiffness of the tissues around it.
Experiments have shown that this should be ideally less
than 2 mm and certainly less than 6 mm, above which lit-
tle callus is seen to form [31, 38].
Vascularity and host factors
If vascular supply or fracture haematoma is compromised
or lost, there is a higher risk of non-union, as insufficient
osteoinductive and osteogenic cells will be available at
the fracture site to initiate osteogenesis, remodelling and
healing [2, 45]. The chance of this significantly increases
in high-energy and open fractures, or in primary surgi-
cal repair where the fracture biology, periosteum and soft
tissue envelope are not respected [24, 51]. Periosteum, as
well as providing critical blood supply, also has unique
regenerative potential [52, 53]. Similarly, if there is altered
systemic host (patient) physiology or comorbidities, this
will also impact healing potential [2, 24, 45, 51, 52].
Biological chamber
The concept of the biological chamber is based on the
need for containment; For instance, where a long bone
non-union case has been managed with the diamond
principle, one has to appreciate that any biological
enhancement that was placed at the site of non-union
must be contained locally so that the maximum effect
will be exerted. It is the development of a chamber which
allows an influx of biological activities to promote a heal-
ing response in a timely fashion. In a sense, what we are
referring to is the development of a ‘bioreactor’. Con-
finement of the treatment selected for non-union can
be achieved with modification of soft tissues, biological
membranes, sealants etc. This is especially important
when one considers the relative mean retention times of
these ingredients [2, 54].
Methods
Search criteria: Ovid SP was used to search Embase
Classic and Embase databases, as well as Ovid Medline.
Search term under ‘all headings’: ‘diamond concept’.
Papers which were not original and not discussing long
bones, not using human subjects, not in the English lan-
guage and review articles and letters were excluded from
the study; one poor-quality case report was excluded
from the study also. However, review articles were down-
loaded and used for reference purposes.
Page 5 of 13
Each paper was systematically searched for: area of
treatment, level of evidence, study size (n), objectives,
study type, patient characteristics, methods, non-union
risk profile, assessment of union, length of follow-up,
time to union, and outcomes: radiological and clini-
cal union, complications, microbiology results, and any
risk factors which correlated with non-union, and docu-
mented in tabulated form, allowing straightforward ref-
erence for discussion.
Results
Overall, we found ten studies which met our inclusion
criteria, including five retrospective cohort or case–
control studies [4, 6, 9, 12, 13], three prospective cohort
studies [10, 11, 55] and two case reports [7, 8]. One
study was excluded (case report by Dilogo et al. 2017),
as it was unclear whether this patient had achieved con-
firmed union at the time of reporting. The total number
of patients included in these studies was 548. Overall
success in treating non-union, when rigorously apply-
ing all aspects of the diamond concept, was 89–100%.
When fewer of the principles and augmented elements
of the ‘diamond’ were applied and depending on fracture
type and location, overall success ranged from 44 to 90%
(Table 2).
Discussion
The search for the best approach to treat long bone non-
union is ongoing. Particularly recalcitrant ones are more
difficult to manage, with long-lasting treatment and high
cost implications. The diamond concept approach offers
a new paradigm for their management. In addition to
correcting the mechanical environment, a potent biologi-
cal stimulus is provided locally by addition of a scaffold,
growth factors and multipotent stem cells whilst respect-
ing the local blood supply and fracture biology. Moreo-
ver, patient-related comorbidities must be addressed to
overcome inherent limitations of the host physiological
processes.
In regard to upper limb studies, Calori et al. [9] per-
formed a study on 54 patients with upper limb non-
union, comparing polytherapy ‘diamond concept’ versus
monotherapy for non-unions. Patients treated with poly-
therapy [BMP-7, MSCs, synthetic or autologous bone
graft (ABG), re-osteosynthesis] had worse cases of non-
union to begin with. Statistical analysis demonstrated
superiority of polytherapy over monotherapy in clinical,
radiological and functional outcomes, and a higher per-
centage (89 versus 63%) went onto union. Despite limita-
tions of fracture diversity, sample size and retrospective
nature of the study, these results are compelling. Miska
et al. [12] looked at 50 patients with humeral non-union,
managed depending on their risk profile with various
Table 2 Summary of literature review
Study, year Area of treatment Level Study size (n) Objectives, study type, patient Follow-up (months) Healing (months) Outcomes
of evidence characteristics, methods,
assessment of union

Calori, 2013 [9] Forearm: 3 52 To assess efficacy of ‘monother-
19 radius apy’ versus ‘polytherapy’ (dia-
26 ulna mond concept) in non-union
6 both Retrospective cohort study:
1 Monteggia Mono: n = 33, poly: n = 19
Non-union risk profiles:
NUSS score: mono: 36 ± 8.88,
poly: 58.84 ± 9.44
Mx:
Both: debridement ± metalwork
revision (stability)
Monotherapy Mx: ABG/MSC/
12 Clinical: Radiological union: mono: 63.6%,
3.65 poly ‘diamond’: 89.5%
Radiological: Time to union: Clinical union
6.18 (months):*
mono: 5.29, poly ‘diamond’: 3.65
Radiological union (months):*
mono 8.43, poly ‘diamond’: 6.18
Andrzejowski and Giannoudis J Orthop Traumatol

BMP7/ABG or synthetic bone

matrix
Polytherapy Mx:
BMP7 + MSCs + ABG (53%) or
synthetic bone matrix
Miska, 2016 [12] Humerus 3 50 To assess if individualising treat- 6 Radiological union: overall: 80.4%,
(2019) 20:21

≥ 12
ment for non-union based on those who received BMP-7: 6/8
diamond concept and risk score (75%)
is effective Patients successful in union much
Retrospective cohort study: n = younger (46.6 ± 17.5 versus
50, Age 51.3 years (14–88) 62.4 ± 16.5 years), p = 0.031*
Non-union risk profiles: Risk scores: did not predict non-
Mean Moghaddam scores: union
treated with BMP-7: 16.5, with- Only 6 patients managed with
out BMP-7: 12.6, p = 0.83 plate/cancellous bone/BMP-7.
Previous interventions: mean 1.5 No MSCs used. No specific data
(1–8) given for these in terms of union
Mx: rates compared with others
According to risk, individual
aspects of diamond addressed:
Low–moderate risk: debridement
and re-osteosynthesis only
Infected cases: two-stage
Masquelet
If large defects > 2 cm or devital-
ised tissue:
Debridement ± BMP-7 ± RIA
(MSCs, scaffold) from femur or
iliac crest ABG ± re-osteosyn-
thesis with stable plate (90%)
Page 6 of 13
Table 2 (continued)
Study, year Area of treatment Level Study size (n) Objectives, study type, patient Follow-up (months) Healing (months) Outcomes
of evidence characteristics, methods,
assessment of union

Giannoudis, 2015 [3] Multiple site: femur 3 64 To assess efficacy of long bone 12 (12–32) 6 (3–12) Radiological union: 63/64 (98%) by
(54.68%) non-union treated with the 12 months
tibia (34.38%) ‘diamond concept’
radius (3.13%) Prospective cohort study:
clavicle (3.13%) n = 64. Age 45 (17–83)
Non-union risk profiles:
All had at least 1 significant
comorbidity, 65.63% suffered
high-energy initial injury
17% initially open fractures.
≥ 1 previous interventions (1–5)
in 43.75%
Andrzejowski and Giannoudis J Orthop Traumatol

Mx:
Debridement + metalwork
revision + Iliac crest BMAC
(MSCs) + BMP-2 (5%) or BMP-7
(95%) + RIA contralateral femur
for ABG (scaffold and osteo-
(2019) 20:21

genic cells)
Giannoudis, 2013 [4] Femur: subtrochanteric 3 14 To assess clinical outcome of dia- 26 (16–48) 6.8 (5–12) Using the ‘complete diamond’ for
mond concept in patients with all patients: Radiological union:
IM nails in non-union surgery 13/14 (92%)
Retrospective cohort study:
n = 14. Age 65 (33–92)
High-energy fracture in 4 patients
Mx: Debridement + blade
plate or revision IM nail + RIA
contralateral femur for ABG
(scaffold and osteogenic
cells) + BMP-7 + BMAC (MSCs)
from iliac crest, watertight
closure in layers
Page 7 of 13
Table 2 (continued)
Study, year Area of treatment Level Study size (n) Objectives, study type, patient Follow-up (months) Healing (months) Outcomes
of evidence characteristics, methods,
assessment of union

Goff, 2014 [8] Proximal femur 4 1 To assess efficacy of diamond 42 6 Radiological union: 6 months
(intertrochanteric) concept in challenging case of Clinical union: 6 months
infected femoral non-union
Case report
n = 1, Age 31, male.
Hx and risk profile: 11 months
following well-sited DHS for
high-energy intertrochanteric
fracture (RTA). Fit and healthy,
non-smoker
Mx: Masquelet technique:
Stage 2 (at 2 months): Debride-
Andrzejowski and Giannoudis J Orthop Traumatol

ment, RIA contralateral femur

for ABG (scaffold and osteo-
genic cells) + BMP-7 composite
graft + removal of ex-fix and
application of blade plate
Haubruck, 2018 [6] Lower limb 3 156 To assess which is superior in No data provided Radiological union:* BMP-2: 42/46
(2019) 20:21

≥12
69 femur non-union surgery: BMP-2 or (91%), BMP-7: 64/110 (58%)
87 tibia BMP-7 Femur union: BMP-2: 11/14 (79%),
Retrospective case–control study: BMP-7: 33/55 (60%)
n = 156, Age 51 (18–64) Tibia union:* BMP-2: 31/32 (97%),
Mx: BMP-7:24/55 (44%)
One stage: limited + no infection One stage: BMP-2: 7/8 (88%), BMP-
Two stage: (Masquelet tech- 7: 35/50 (70%)
nique): significant bone Two stage:* BMP-2: 35/38 (92%),
loss ± signs of infection BMP-7: 29/60 (48%)
Both: debridement + metalwork
revision + ABG (MSCs, scaf-
fold) + BMP-2 or BMP-7
No concentrated BMA used
Page 8 of 13
Table 2 (continued)
Study, year Area of treatment Level Study size (n) Objectives, study type, patient Follow-up (months) Healing (months) Outcomes
of evidence characteristics, methods,
assessment of union

Ollivier, 2015 [13] Tibia 3 20 To assess whether bone grafting
essential as part of diamond
concept for recalcitrant tibia
non-union
Retrospective cohort study: n =
20, Age 46.8 (21–78)
Non-union risk profiles:
open fractures: 8, smokers: 5.
Mx:
Debridement + metalwork revi-
sion + implant composite graft
(BMP and injectable rCPBS)
14 ± 2.7 (3–9) 5 ± 2.3 (3–9) Radiological union: 18/20 (90%): 12
had consolidated by 3 months,
and 18 by 6 months
Micro: nil significant
Did not use all parts of diamond
concept: no osteogenic MSC cells
harvested or implanted
Andrzejowski and Giannoudis J Orthop Traumatol

No MSCs/BMAC used
Moghaddam, 2015 [10] Tibia 3 102 To assess outcomes of single- 12 G1: 6.9 ± 3.1 Radiological union: G1: 84%, G2:
stage (G1) versus two-stage G2:* 8.6 ± 2.9 80%
(Masquelet) repair (G2) meth- Overall: 7.8 ± 3.1
ods in tibial non-union
Prospective cohort study: n:
(2019) 20:21

G1 = 52, G2 = 50. Age 47 ± 13.1

(15–76)
Previous interventions: G1: 3.2,
G2: 6.7
Non-union risk profiles: open
fractures: 44, fracture gap:
2.6 ± 3.4 cm
Moghaddam score:* G1:
13.8 ± 8.5, G2: 19.5 ± 9.5
NUSS score:* G1: 38.3 ± 11.7, G2:
48.2 ± 10.3
Mx:
G1: bone loss < 1 cm (mean
0.9 cm) + no infection
G2: bone loss > 1 cm (mean
4.0 cm) + signs of infection
(Masquelet technique)
Both: debridement ± metalwork
revision (97%), RIA (MSCs, scaf-
fold) from femur (77%) or iliac
crest ABG (23%) + BMP-7 + tri-
calcium phosphate
Page 9 of 13
Table 2 (continued)
Andrzejowski and Giannoudis J Orthop Traumatol

Study, year Area of treatment Level Study size (n) Objectives, study type, patient Follow-up (months) Healing (months) Outcomes
of evidence characteristics, methods,
assessment of union
Douras, 2018 [7] Ankle: medial malleolus 4 1 To assess efficacy of diamond 12 6 Radiological union: by 6 months
concept in medial malleolus Clinical union: by 3–6 months (fully
(2019) 20:21

non-union WB)
Case report, n = 1 Age 20 Complications: none
Hx: 8 months following: Gustilo
IIIb open bimalleolar fracture
dislocation ORIF and free flap
Non-union mx:
Debridement + metalwork revi-
sion with cancellous screws and
locking plate + BMAC (MSCs)
and ABG (scaffold, MSCs) from
iliac crest + BMP-2
ABG autologous bone graft, BMP bone morphogenic protein, RIA reamer/irrigator/aspirator, MSCs mesenchymal stem cells, BMAC bone marrow aspirate concentrate, rCPBS resorbable calcium phosphate bone substitute
Key: n patient number, Mx Management, *p < 0.05
Page 10 of 13
Andrzejowski and Giannoudis J Orthop Traumatol (2019) 20:21
aspects of the diamond concept, with only 6 patients hav-
ing the full spectrum of the diamond addressed. These
were treated using angular stable plating (mechanical
stability), autologous bone graft (MSCs and scaffold) and
BMP-7 application (osteoinductive agent). Overall union
rates of 80% were seen, however it is not clear how out-
comes in the ‘diamond concept’ group faired in compari-
son with the others.
Haubruck et al. [6] treated 156 patients with lower limb
non-unions (69 femurs and 87 tibias), comparing BMP-2
with BMP-7 for single- and two-stage revisions, using
ABG to provide a scaffold and MSCs, and performed re-
osteosynthesis to enhance stability. Overall union rates
were 91% with BMP-2 and 58% for BMP-7 (p < 0.001),
with similar rates of overall healing between femur and
tibia when BMP groups were combined, at 64 and 63%,
respectively, but in the BMP-2 group these were 79% and
97%, respectively, illustrating a good potential of the dia-
mond concept.
Giannoudis et al. [4] published a retrospective cohort
study of 14 patients with subtrochanteric femoral non-
unions, including four open fractures. Excellent outcome
was achieved using all four principles in the diamond
concept: debridement, blade plate or revision IM nail
(mechanical stability), RIA (reamer/irrigator/aspirator)
from the contralateral femur for ABG to use primarily
as a scaffold, BMP-7 and bone marrow aspirate concen-
trate (BMAC) to provide MSCs from the iliac crest, with
watertight closure in layers to ensure containment of bio-
active material in the ‘biological chamber’. Overall union
rate was 90%. This study also highlighted the presence of
varus mal-alignment of fixed acute fractures, emphasis-
ing that failure of mechanical stability was successfully
corrected as part of ‘diamond concept’-focused manage-
ment. Goff [8] also reported an excellent outcome when
applying all aspects of the diamond concept in treating
delayed femoral intertrochanteric non-union, by using
a two-stage modified Masquelet technique augmented
with BMP-7 and RIA used to supply ABG. Giannoudis
et al. [55] performed a further study, looking at fracture
non-union from all sites (upper and lower limb). Apply-
ing the diamond concept to treat 64 patients of whom
65% suffered high-energy injuries, they obtained a union
rate of 98% by 12 months, again showing the potency of
the diamond concept.
Moghaddam et al. [10] in a study of 88 patients with
subtrochanteric femoral non-unions, including 21%
with open fractures, applied all elements of the dia-
mond concept in patients deemed to be in a high-risk
group for healing as part of a single- or two-stage pro-
cedure: RIA samples from the femur or ABG from the
iliac crest used as a source of MSCs as well as a scaffold
material, and some also supplemented with BMP-7 and
Page 11 of 13
tricalcium phosphate. Seventy-two patients received
full ‘diamond concept’ augmentation, 13 cases only had
ABG, and 3 only had revision of metalwork. No com-
plete ‘diamond concept’ group-specific outcome data
are provided. Overall, 69 patients (78%) achieved good
healing when applying this methodology, with union in
single-stage procedures higher (95.1%) compared with
two-stage (63.8%) overall. Rates of union were signifi-
cantly higher in the femoral diaphysis compared with
distal femur (84 versus 70%, respectively), especially
when managed using an intramedullary nail. Larger
defects (5–10 cm) in the diaphysis managed with a
two-stage procedure had poor healing rates (58%),
with smoking having a significant impact. Only in cases
where the defect did not cross the entire diameter and
an osseous bridge was still present did healing occur.
This study demonstrates that poor vascularity and diffi-
culty in achieving mechanical stability lead to impaired
fracture healing, illustrating their importance for inclu-
sion in the diamond.
Moghaddam et al. [11] also investigated the treatment
of tibial non-unions, with successful union of 84% in sin-
gle-stage (group 1) and 80% in two-stage (group 2) pro-
cedures, augmenting elements of the diamond concept
according to risk profile, with 76.8% of patients overall
receiving a combination of RIA, BMP-7 and tricalcium
phosphate, in addition to re-osteosynthesis. Again, no
‘complete diamond’ group-specific data are provided.
Results show that applying ideas of the diamond concept
based on risk profile when treating both fracture types
led to acceptable union rates. Despite having worse ini-
tial starting position, patients in G2 had similar outcome
afterwards. Authors suggest that a higher number of
previous surgeries in G2 patients (mean 3.4 versus 2.4)
contributed to worse healing due to scar tissue imped-
ing blood flow, however provide no absolute values or
multivariate analysis with p values to substantiate the
outcomes of this subgroup. G1 and G2 groups both fell
into the ‘medium’ risk category for non-union on the
Moghaddam prediction score, as well as the NUSS, and
behaved as would have been expected; also patients in G2
who had higher overall scores took longer to heal. Micro-
biology results suggest that, in previously undetected
atrophic non-unions, low-grade infection may be the
cause, and that in these cases, the Masquelet technique
can be used effectively. Results also suggest that antibi-
otic osteitis prophylaxis was beneficial in the G1 group
treated with gentamicin-coated nails.
Douras [7] presented a case study in which the full dia-
mond constituents were applied for a medial malleolus
non-union, and achieved full union by 6 months, with
the patient back to normal function, showing that the
technique is also effective in ankle fracture non-union.
Andrzejowski and Giannoudis J Orthop Traumatol (2019) 20:21
Olivier [13] performed a study on 20 patients with
recalcitrant tibial non-union, which aimed to apply
the diamond concept principles in a different way. As
well as debridement and re-osteosynthesis, a compos-
ite graft using synthetic resorbable calcium phosphate
bone substitute combined with BMP was used instead
of ABG, which may be useful in patients with poor
bone stock. It is worth noting, however, that no aug-
mentation using stem cells was used. Union rates were
90%, suggesting that it could be a safe and effective
alternative where ABG is not possible.
The studies discussed here represent all of the litera-
ture which specifically refers to using the ‘diamond con-
cept’ as a principle in guiding management decisions
in long bone non-union. As one can see, where all of
the diamond concept principles are clearly adhered to
and elements of this augmented during surgery, there
are excellent rates of union after treatment for upper
and lower limbs non-unions. Biological and mechani-
cal environment, systemic factors and local blood sup-
ply as well as fracture pattern, location and frequency
of previous intervention and stability of implants used
all could predict outcome. However, only a few of the
above studies use bone marrow aspirate concentrate
(BMAC) as a direct means of concentrating mesenchy-
mal stem cells to act as osteoprogenitors, with most
relying on the MSCs present in RIA or autologous bone
grafting from the iliac crest. In our experience, we have
found that the RIA process washes most of the MSCs
out of the bone stock, reducing its utility as a source
of potent osteogenic cells. As we have previously pub-
lished, after the age of 55, even the iliac crest becomes
less useful as a source of MSCs with a more ‘yellow’
appearance and fewer stem cells to aid union [56]. We
believe that, in compromised cases, the use of BMAC
to supply a reliable source of MSCs as part of the dia-
mond can help to achieve good results.
The evidence available to show that using ‘polyther-
apy’ with the diamond concept is preferable over ‘mon-
otherapy’ is convincing, but numbers are still small, as
also discussed by Calori et al. [57]. Some of the stud-
ies presented have only augmented all aspects of the
diamond concept for high-risk patients, which may be
obscuring the picture. Further studies in the future,
of prospective randomised nature, would throw more
light on this matter.
Authors’ contributions
PA: performed literature review and wrote main body of manuscript; PG:
provided senior review and editing. Both authors read and approved the final
manuscript.
Page 12 of 13
Competing interests
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this review.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Received: 8 March 2019 Accepted: 20 March 2019
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 Journal of Orthopaedics 24 (2021) 96–101

Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Are we putting ourselves in danger? Occupational hazards and job safety

for orthopaedic surgeons
Robert C. Ryu a, *, Phillip H. Behrens b, Azeem T. Malik a, Jonathan D. Lester c,
Christopher S. Ahmad d
a
Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
b
Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
c
Aurora Orthopaedics, Milwaukee, WI, USA
d
Department of Orthopaedic Surgery, Columbia University, New York, NY, USA

A R T I C L E I N F O A B S T R A C T

Keywords: As physicians, we strive to meet the needs of our patients. In doing so, we are often exposed to hazards that have
Occupational hazards the potential to not only compromise our health, but also our ability to deliver the best possible healthcare.
Occupational medicine Occupational hazards specific to the field of orthopaedics include infectious organisms, radiation, surgical
Industrial medicine
smoke, chemicals, hazardous noise, musculoskeletal injury, and psychosocial stressors. Even though orthopaedic
Orthopaedic surgery
Physician burnout
surgeons acknowledge the risk, most lack in-depth knowledge of the associated long-term harm associated with
Radiation exposure these hazards and ways of reducing risk of exposure. Orthopaedic surgeons should increase awareness, follow
Hazardous noise established guidelines, and integrate preventative measures to create the safest possible work environment. It is
Chemical exposure our hope that by improving our own health, we will be better equipped to address the health concerns of those
Surgical hazards we serve—our patients.
Ergonomics in medicine
Work injury in medicine

1. Introduction
Every day, millions of physicians go to work with the goal of
improving patients’ lives. In doing so, physicians take on considerable
risk of harm to themselves. This is particularly true of orthopaedic sur­
gery—a field that exposes surgeons to an array of harmful agents while
placing them under enormous physical, emotional strain.1 It’s important
for orthopaedists to be aware of not only the potential hazards they face
in the operating room (OR), but also the precautions that should be
taken to avoid them. In this current review, we discuss common occu­
pational hazards encountered by surgeons in daily practice and current
safety recommendations to reduce the risk of experiencing harm.
1.1. Exposure to infection
In the OR, surgeons may be exposed to infectious pathogens through
percutaneous, airborne, and mucocutaneous contact. Orthopaedists face
an elevated risk relative to other specialties due to increased contact
with sharp objects such as saws, drills, and sharp bone fragments that
can cause percutaneous injury. Mucocutaneous exposure to pathogens is
also increased due to splattering from power tools and pulsatile irriga­
tion. In a review of 1828 patients, 74% of exposures were potentially
preventable by using recommended personal protective equipment
(PPE).2 Risk factors for exposure include orthopaedic trauma surgeries,
procedures lasting over 3 h, and those with a blood loss greater than 300
mL.2 Not surprisingly, the majority of percutaneous injuries are caused
by suture needles, largely due to inattentiveness and unsafe practices
such as recapping needles.3 Approximately one third of physicians do
not report needlestick injuries due to a perceived low risk of trans­
mission and lack of time.4
The most frequently encountered and dangerous pathogens include
human immunodeficiency virus (HIV), Hepatitis B (HBV), and Hepatitis
C (HCV) (Table 1). The risk of infection with these pathogens is
dependent on a variety of factors including the type of pathogen, the
infectivity of the pathogen in the patient at the time of exposure, the
type and severity of the injury, and the use of pre- and post-exposure

* Corresponding author. Adjunct Assistant Professor of Orthopaedics, The Ohio State University Wexner Medical Center, 376 W. 10th Ave, 725 Prior, Columbus,
OH, 43210, USA.
E-mail address: Robert.Ryu@osumc.edu (R.C. Ryu).

https://doi.org/10.1016/j.jor.2021.02.023
Received 2 January 2021; Accepted 14 February 2021
Available online 20 February 2021
0972-978X/© 2021 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.

E. A. K. van Delft,
S. G. J. van Bruggen,
K. J. van Stralen,
F. W. Bloemers,
N. L. Sosef,
N. W. L. Schep, Aims
J. Vermeulen There is no level I evidence dealing with the optimal period of immobilization for patients
From VU Medical
Center, Amsterdam,
and Spaarne Gasthuis
Hospital, Haarlem/
Hoofddorp, Netherlands
Correspondence should be
sent to E. A. K. van Delft;
email: evavandelft@gmail.com
© 2023 The British Editorial
Society of Bone & Joint Surgery
doi:10.1302/0301-620X.105B9.
BJJ-2022-0976.R3 $2.00
Bone Joint J
2023;105-B(9):993–999.
THE BONE & JOINT JOURNAL
„„ Wrist & Hand
Four weeks versus six weeks of
immobilization in a cast following closed
reduction for displaced distal radial fractures
in adult patients: a multicentre randomized
controlled trial
with a displaced distal radial fracture following closed reduction. A shorter period might
lead to a better functional outcome due to less stiffness and pain. The aim of this study
was to investigate whether this period could be safely reduced from six to four weeks.
Methods
This multicentre randomized controlled trial (RCT) included adult patients with a dis-
placed distal radial fracture, who were randomized to be treated with immobilization in
a cast for four or six weeks following closed reduction. The primary outcome measure
was the Patient-­Rated Wrist Evaluation (PRWE) score after follow-­up at one year. Sec-
ondary outcomes were the abbreviated version of the Disability of Arm, Shoulder and
Hand (QuickDASH) score after one year, the functional outcome at six weeks, 12 weeks,
and six months, range of motion (ROM), the level of pain after removal of the cast, and
complications.
Results
A total of 100 patients (15 male, 85 female) were randomized, with 49 being treated with
four weeks of immobilization in a cast. A total of 93 completed follow-­up. The mean PRWE
score after one year was 6.9 (SD 8.3) in the four-­week group compared with 11.6 (SD 14.3)
in the six-­week group. However, this difference of -4.7 (95% confidence interval -9.29 to
0.14) was not clinically relevant as the minimal clinically important difference of 11.5 was
not reached. There was no significant difference in the ROM, radiological outcome, level of
pain, or complications.
Conclusion
In adult patients with a displaced and adequately reduced distal radial fracture, immobili-
zation in a cast for four weeks is safe, and the results are similar to those after a period of
immobilization of six weeks.
Cite this article: Bone Joint J 2023;105-B(9):993–999.
Introduction shorter period of immobilization may be associ-
Closed reduction and immobilization in a cast may ated with a better outcome.
lead to excellent results in patients with displaced The treatment of these fractures often involves
distal radial fractures,1,2 although up to 30% have immobilization for five or six weeks after a closed
persistent symptoms such as pain and stiffness.3 reduction.4-­6 However, this length of time is mainly
Stiffness and impaired function may be caused based on expert opinion and few studies have
by prolonged immobilization. Hypothetically, a investigated the optimal period of immobilization.
993
994 E. A. K. VAN DELFT, S. G. J. VAN BRUGGEN, K. J. VAN STRALEN, ET AL

Enrolment Assessed for eligibility (n = 257)

Excluded (n = 157
- Not meeting inclusion
criteria (n = 52)
- Declined to participate (n = 61)
- Indication for surgery (n = 40)
- Other reasons (n = 4)

Randomized (n = 100)

Allocation

Allocated to 4 weeks Allocated to 6 weeks

of cast (n = 49) of cast (n = 51)
- Received allocated - Received allocated
intervention (n = 49) intervention (n = 51)
- Did not receive allocated - Did not receive allocated
intervention (n = 0) intervention (n = 0)

Follow-up

Lost to follow-up (n = 4): Lost to follow-up (n = 3):

- Withdrawal of informed - Withdrawal of informed
consent (n = 1) consent (n = 2)
- Lost to follow-up for - Lost to follow-up for
unknown reasons (n = 2) unknown reasons (n = 1)
- Patient moved to
another city (n = 1)

Analysis

Analyzed (n = 45) Analyzed (n = 48)

- Excluded from analysis - Excluded from analysis
(n = 0) (n = 0)

Fig. 1

Consolidated Standards of Reporting Trials 2010 flow diagram.

A recent systematic review found that a shorter period of immo- Methods

bilization did not lead to a poorer outcome and recommended
further investigation of this aspect.7
The ultimate aim of treatment after closed reduction of a
distal radial fracture would include a short and safe period of
immobilization with an early return to work and normal func-
tion. The shorter the period of immobilization, the earlier a
patient can start range of motion (ROM) exercises and weight-
bearing. This might prevent stiffness and accelerate functional
recovery. The aim of this study was to investigate whether the
period of immobilization in these patients can safely be reduced
from six to four weeks.
This was a single-­blinded multicentre randomized controlled
trial (RCT) performed in two large teaching hospitals,
comparing immobilization in a cast for four or six weeks in
adult patients with a displaced and adequately reduced distal
radial fracture. The study had ethical approval and the protocol
has been published.8 It was registered at the Dutch National
Trial Register: NTR 6600, ABR: NL62861.029.17.
Patients were recruited between July 2019 and October 2020
and were followed up for one year. Patients who were aged
> 18 years and independently active were eligible for inclusion.
Patients were excluded if they had a fracture of the contralateral

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 CAST IMMOBILIZATION FOLLOWING CLOSED REDUCTION FOR DISPLACED DISTAL RADIAL FRACTURES IN ADULT PATIENTS 995

4 weeks 6 weeks 4 weeks 6 weeks

50 40

40
30

Mean QuickDASH
Mean PRWE

30

20

20

10
10

0 0
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Time (weeks) Time (weeks)

a b

Fig. 2

Mean Patient-­Rated Wrist Evaluation (PRWE) and abbreviated version of the Disability of Arm and Shoulder (QuickDASH) scores.

Table I. Baseline characteristics. Orthopedic Surgeons (AAOS): dorsal angulation > 10°, radial
Characteristic 4 wks 6 wks shortening > 3 mm and an intra-­articular ‘step off’ > 2 mm.13
Total, n 49 51 Closed reduction was carried by traction under haematoma
Sex, n (%) block local anaesthesia by the on-­call physician. All patients
Female 40 (82) 45 (88) were treated in a below-­ elbow cast in the neutral position
Male 9 (18) 6 (12) following reduction.14,15 A further radiograph was undertaken
Mean age, yrs 66.0 (20 to 100) 69.1 (29 to 92) to decide whether the reduction was adequate according to the
Current smoker, n (%) 4 (11) 5 (13) guidelines of the AAOS and previously published studies:10–12
Diabetes, n (%) 3 (6) 5 (1) radial shortening < 3 mm, dorsal tilt < 10°, and intra-­articular
Osteoporosis, n (%) 29 (76) 37 (88) ‘step-­off’< 2 mm.
Fracture side, n (%) After providing informed consent, patients were random-
Left 25 (51) 27 (53) ized into the intervention group (immobilization for four
Right 24 (49) 24 (47)
weeks) or the control group (immobilization for six weeks) by
Fracture on dominant side, n (%) 22 (51) 26 (52)
the attending physician. Further radiographs were undertaken
AO classification, n (%)
after one and two weeks and patients with displacement of the
A2 16 (33) 24 (47)
fracture which exceeded the criteria of adequate reduction,
A3 10 (20) 6 (12)
were excluded from the study. No further attempted closed
C1 11 (22) 11 (22)
reduction was undertaken and these patients were referred for
C2 11 (22) 8 (16)
C3 1 (2) 2 (4)
open reduction and fixation (n = 38). The cast was reinforced
USP fracture, n (%) 33 (67) 31 (61)
after one week and changed after two weeks without traction
Mean cast duration, days (IQR) 29 (26 to 36) 42 (38 to 47)
or re-­reduction but with another radiograph. If a change of cast
IQR, interquartile range; USP, ulnar styloid process fracture. was required during follow-­up, another radiograph was under-
taken to check the alignment.
The cast was removed after four or six weeks and patients
wrist, another ipsilateral fracture, pre-­existing abnormalities or were encouraged to start mobilization either with a leaflet
functional limitations of the fractured wrist, or an open fracture. describing exercises, or physiotherapy at the discretion of the
An associated fracture of the ulnar styloid was not a criterion treating physician.16 After removal of the cast, patients were
for exclusion. Only patients with AO type A and C fractures9 given a diary to report their pain score, measured by a visual
were included.10–12 analogue scale (VAS) of 0 to 10. They were reviewed clinically
Patients were treated in the emergency department. The indi- and radiologically at eight weeks, three months, six months,
cations for reduction were those of the American Association of and one year after the fracture. Some of the consultations at

VOL. 105-B, No. 9, SEPTEMBER 2023

996 E. A. K. VAN DELFT, S. G. J. VAN BRUGGEN, K. J. VAN STRALEN, ET AL
Table II. Functional outcome.
Outcome 4 wks
Total, n 45
8 wks
PRWE 36.3 (20.1)
QuickDASH 32.7 (19.5)
3 mths
PRWE 19.3 (15.6)
QuickDASH 17.5 (14.5)
6 mths
PRWE 13.3 (14.3)
QuickDASH 11.5 (13.0)
1 yr
PRWE 6.9 (8.3)
QuickDASH 6.4 (7.5)
*Tweedie analysis.
CI, confidence interval; IQR, interquartile range; PRWE, Patient-­Rated Wrist Evaluation; QuickDASH, abbreviated version of the Disabilities of Arm,
Shoulder and Hand score; SD, standard deviation.
three and six months were undertaken remotely due to the
COVID-­19 pandemic.
A total of 100 patients were included in the study: 49 in
the four-­week immobilization group and 51 in the six-­week
immobilization group. Seven patients were lost to follow-­up
(Figure 1). The baseline characteristics of the patients are
shown in Table I.
The primary outcome measure was function as assessed
using the Patient-­Related Wrist Evaluation (PRWE) after one
year.17 Secondary outcome measures were the abbreviated
version of the Disability of Arm and Shoulder score (Quick-
DASH) after one year;18 and PRWE and QuickDASH scores
after eight weeks, three months, and six months, ROM, the
level of pain after removal of the cast, the radiological outcome,
and complications.
The PRWE is a validated self-­reported 15-­item questionnaire
which assesses function in patients with disorders of the wrist,
and it may be used to monitor changes with the passage of time.
A total of 15 items are scored 0 to 10 and are transformed to a
0 to 100 score. A higher score indicates greater disability. The
minimal clinically important difference (MCID) of the PRWE
is 11.5.19
The DASH score is a validated self-­reported questionnaire of
30 items,18 also assessing function in patients with upper limb
disorders and may also be used to monitor changes with the
passage of time.20 The QuickDASH is a shortened version using
11 items scored from 1 to 5. The scores are transformed to a 0
to 100 scale, a higher score indicating greater disability.18 The
MCID of the QuickDASH is 14.0.20
At each outpatient visit, the ROM of the wrist was measured
using a goniometer and the PRWE and QuickDASH scores
were collected. The radiological outcome was assessed by two
authors (NS, EAKD) by recording the displacement of the frac-
ture, malunion, and nonunion. Malunion was defined according
to the guidelines of the American Association of Orthopedic
Surgeons.10 When there was disagreement, the judgement of a
third author (FWB) was sought. Bone mineral density (BMD)
was assessed during follow-­ up using a dual-­ energy X-­ ray
absorptiometry scan in patients aged > 50 years to diagnose
osteoporosis. BMD was not assessed from digital radiographs.21
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6 wks Difference (95% CI) p-­value*
48
41.8 (22.3) -5.45 (-­15.23 to 4.33) 0.274
37.4 (22.7) -4.65 (-­13.7 to 4.43) 0.315
25.5 (18.6) -6.26 (-­13.32 to 0.80) 0.082
22.9 (15.5) -5.31 (-­12.08 to 1.46) 0.124
16.3 (16.6) -2.97 (-­8.78 to 2.83) 0.316
13.1 (13.5) -1.60 (-­6.60 to 3.40) 0.531
11.6 (14.3) -4.72 (-­9.29 to -0.14) 0.043
10.0 (12.0) -3.61 (-­7.80 to 0.58) 0.091
Statistical analysis. The power of the study was based on the
standard deviation (SD) of the PRWE. The SD of the PRWE is
14.0 and the MCID is 11.5 points.19,20 Based on this difference
of 11.5 points, a sample size of 27 patients per treatment group
was required with a power (1-β) of 80% and a type I error (α)
of 5%, allowing for 10% loss to follow-­up. We decided to in-
clude 45 patients per treatment group and a total of 100 patients
were included to allow for loss to follow-­up. Concealed per-
muted block randomization was performed using a computer-­
generated randomization schedule. Randomization was strati-
fied by age (< 60 or ≥ 60 years) and sex.
The study was not powered to perform subgroup analysis.
Significance was set at p < 0.05 and SPSS v. 25.0 (IBM,
USA) was used for the analysis. Baseline characteristics
were analyzed in a single blinded fashion using descriptive
analysis. Analysis was carried out according to the intention-­
to-­treat principle. All outcome measures were tested for
normality by inspection of histograms, and were tested using
the Kolmogorov-­Smirnov test. Continuous data are presented
as mean scores with SDs and 95% confidence intervals (CIs).
Median scores with interquartile ranges (IQRs) are reported
for nonparametric data.
The patients whose missing data included at least one
PRWE or QuickDASH score at one time during follow-­up
were imputed using multiple imputation (n = 10) based on
age, sex, smoking, diabetes, osteoporosis, dominance and
fracture characteristics, the presence of complications, and
VAS, PRWE, and QuickDASH scores. ROM outcomes were
not imputed.
The results were analyzed according to the outcome vari-
ables. Dichotomous variables were analysed using percent-
ages, and odds ratios (ORs) were calculated using logistic
regression analysis. PRWE and QuickDASH scores are
continuous variables and after one year these scores often
approach zero, but cannot be below zero. They do not follow
a count distribution as they are continuous. Therefore, the
most optimal analyses were Tweedie analyses, with a log link
distribution of 1.5.22,23 The overall difference over time was
analyzed using a GEE model, including time and time2, with
a Tweedie identity link.
THE BONE & JOINT JOURNAL
 CAST IMMOBILIZATION FOLLOWING CLOSED REDUCTION FOR DISPLACED DISTAL RADIAL FRACTURES IN ADULT PATIENTS
Table III. Radiological outcome.
Outcome 4 wks
8 wks, n (%)
Malunion 19 (31)
1 yr, mean (SD)
Radial inclination, ° 18.9 (4.3)
Ulnar variance, mm 1.2 (2.2)
Radial height, mm 9.6 (2.3)
Dorsal angulation, ° 7.4 (6.7)
Step off/gap, % 6 (14)
Malunion, n (%) 16 (38)
Nonunion, n 0 0
CI, confidence interval; N/A, not applicable; OR, odds ratio; SD, standard deviation.
Results
The mean PRWE score after one year was 6.9 (SD 8.3) in the
four-­week group, compared with 11.6 (SD 14.3) in the six-­week
group (Table II). The functional outcome after eight weeks,
three months, and six months were similar in the two groups.
An overview of the distribution of the adjusted means of the
PRWE and QuickDASH scores during follow-­up is shown in
Figure 2. The PRWE scores were a mean of 4.42 (95% CI -9.28
to 0.44; p = 0.075, Tweedie analysis) lower in the four-­week
group. QuickDASH scores were 3.23 points lower (95% CI
-7.39 to 0.9; p = 0.127, Tweedie analysis).
The ROMs are shown in Supplementary table i. Overall,
there was no significant difference in ROM between four and
six weeks of immobilization. At eight weeks, patients who
were immobilized for four weeks had a significantly better
mean dorsal flexion (-­10.6° (95% CI -18.8 to -2.4); p = 0.01,
Kolmogorov-­Smirnov test) and ulnar deviation (-­5.6° (95% CI
-10.0 to -1.2); p = 0.01, Kolmogorov-­Smirnov test). After three
months (-­10.9° (95% CI -20.7 to -1.1); p = 0.03, Kolmogorov-­
Smirnov test) and one year (-­7.8° (95% CI -14.9 to -0.7);
p = 0.03, Kolmogorov-­Smirnov test), palmar flexion was
significantly better in the four-­week immobilization group.
There was no significant difference between the median VAS
scores for pain in the seven days after removal of the cast in the
two groups: 27.5 (IQR 19 to 41) in the four-­week group and
27.3 (IQR 19 to 35) in the six-­week group (p = 0.36).
The radiological outcome in the two groups only showed a
significant difference in ulnar variance after one year, favouring
four weeks of immobilization (-­0.94 mm (95% CI -1.87 to
-0.01); p = 0.047, Kolmogorov-­Smirnov test; Table III). There
was no significant difference in the rate of malunion at eight
weeks or one year. There was also no difference in the mean
PRWE score between patients according to the presence of
malunion (Supplementary Table ii). None of the patients who
had a malunion needed surgical treatment and no patients had
a nonunion.
There was no significant difference in the rate of complica-
tions between the two groups: four (8%) in the four-­week group
compared with six (12%) in the six-­week group (p = 0.551,
Kolmogorov-­Smirnov test). In both groups, one patient had
carpal tunnel syndrome (CTS) that needed surgical treatment.
One other patient in the six-­week group had CTS but did not
require surgical treatment. One patient had complex regional
pain syndrome in the four-­week group compared with two in
VOL. 105-B, No. 9, SEPTEMBER 2023
997
6 wks Difference or OR (95% CI) p-­value
15 (31) 0.92 (0.38 to 2.25) 0.859
20.4 (3.7) -1.51 (-­3.2 to 0.16) 0.077
2.1 (2.3) -0.94 (-­1.87 to -0.01) 0.047
10.1 (1.9) -0.44 (-­1.31 to 0.42) 0.316
8.9 (7.7) -0.18 (-­0.63 to 2.6) 0.419
3 (6) 2.39 (0.56 to 10.23) 0.241
50 (43) 0.80 (0.34 to 1.88) 0.608
N/A
the six-­week group. In the four-­week group, one patient with
tendinitis was treated with a brace, and one patient had a rupture
of the extensor pollicis longus tendon which was treated surgi-
cally. In the six-­week group, one patient had a further distal
radial fracture between three and six months, which was treated
by open reduction and fixation with a volar plate. Another had a
contralateral distal radial fracture during follow-­up, which was
treated by immobilization in a cast.
Discussion
In this multicentre RCT, we found that within six months,
there were no significant or clinically relevant differences in
functional or radiological outcome, or pain, between patients
with a distal radial fracture who were treated with immobi-
lization in a cast for four weeks and those who were treated
with immobilization for six weeks. Although the mean PRWE
score after one year significantly favoured patients who were
treated with immobilization for four weeks, the MCID was
not reached during follow-­up. Other studies, for example
the DRAFFT study, have suggested that a six-­point change
in PRWE score could be clinically relevant at the individual
level.24 If we had used this definition of the MCID, the results
would also have been clinically relevant.
These results are in agreement with previous findings. A
recent systematic review investigated the period of immobi-
lization in a cast in patients with these fractures.7 The period
of immobilization of both non- and minimally displaced,
as well as displaced and reduced distal radial fractures,
was analyzed. Of the 12 studies which were included, one
only involved displaced and reduced distal radial fractures,4
and five included both non- and minimally displaced and
displaced and reduced fractures.6,25–28 Only the studies of
Bentohami et al29 and Christersson et al30 were carried out
within the last five years, with the others all being performed
before 2000. Bentohami et al29 compared three weeks with
five weeks of immobilization in non-­displaced or minimally
displaced distal radial fractures and found that shortening the
period of immobilization was safe and might be beneficial.
The functional outcome after one year based on PRWE and
QuickDASH scores was significantly better in those who
were immobilized for three weeks. This result, however, did
not reach the MCID.29 Christersson et al30 compared removal
of the cast and immediate mobilization after ten days to
immobilization in a cast for four weeks in displaced and
998 E. A. K. VAN DELFT, S. G. J. VAN BRUGGEN, K. J. VAN STRALEN, ET AL
reduced distal radial fractures. The only significant difference
was an improved ROM after one-­month follow-­up in those
immobilized for ten days. There was no overall difference in
the functional outcome between ten days or four weeks of
immobilization at follow-­up of one, four, and 12 months. In
two of the 54 patients, the fracture displaced after ten days of
immobilization, requiring surgical treatment.30
Traditionally, most displaced and reduced distal radial
fractures have been treated by reduction and immobiliza-
tion in a cast. However, the prevalence of volar plating has
increased.31 This increase, however, cannot be justified by the
current literature.32,33 Studies from both a Cochrane Review
and the American Academy of Orthopedic Surgeons were
unable to distinguish between either reduction and immobi-
lization in a cast or surgical treatment by volar plating for
displaced and reduced distal radial fractures.5,10 Therefore, it
is important to provide new evidence of both forms of treat-
ment. This study provides level I evidence for the nonoper-
ative treatment of these fractures and supports the use of a
shorter period of immobilization.
The study has limitations. Due to the COVID-­19 pandemic,
many of the consultations three and six months after the frac-
ture were performed over telephone, and only between 39%
and 59% of the patients attended a clinic for the ROM to be
recorded at these times.
The rate of malunion at eight weeks and one year after
the fracture was about 30% and 40%, respectively, which is
high, but many of these fractures only just met the criteria of
malunion. There was no significant difference in the rate of
malunion in the two groups. Malunion can be an indication for
corrective osteotomy, but no patient in the study underwent this
surgery as the clinical outcome in those with malunion at eight
weeks or one year after the fracture was acceptable, and did not
differ significantly from that of the other patients. A post-­hoc
analysis was carried out which showed no difference in PRWE
score in patients with or without malunion at eight weeks or
one year.
Shortening the period of immobilization is safe and patients
can start exercising the wrist after four weeks instead of six
weeks of immobilization. The ROM was significantly better
at eight weeks after the fracture in the four-­week group.
In conclusion, a shorter period of immobilization in adult
patients with displaced and adequately reduced distal radial
fractures leads to a better short-­term ROM of the wrist, although
this difference will disappear with the passage of time. As
functional outcome is similar in those who were immobilized
in a cast for four or six weeks, without adverse side effects,
we recommend the use of four weeks of immobilization in
these patients.
‍ ‍Take home message
-- In adult patients with displaced and adequately reduced
distal radial fractures, four weeks of cast immobilization is
safe, as results are similar compared to a six-­week period of
immobilization.
Supplementary material
‍ ‍Tables showing range of motion results and radiolog-
ical outcomes.
Follow us @BoneJointJ
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Author information:
E. A. K. van Delft, MD, PhD Candidate, Trauma Surgery Resident
S. G. J. van Bruggen, MD, PhD Candidate, General Surgery Resident
Department of Trauma Surgery, Amsterdam UMC, Amsterdam,
Netherlands; Department of Surgery, Spaarne Gasthuis Hospital, Haarlem,
Netherlands; Amsterdam Movement Sciences, Amsterdam UMC,
Amsterdam, Netherlands.
K. J. van Stralen, PhD, Science Coordinator, Epidemiologist, Spaarne
Gasthuis Academy, Spaarne Gasthuis Hospital, Haarlem, Netherlands.
F. W. Bloemers, MD, PhD, MSc, Professor of Trauma Surgery, Department
of Trauma Surgery, Amsterdam UMC, Amsterdam, Netherlands.
N. L. Sosef, MD, Trauma Surgeon, Department of Surgery, Spaarne
Gasthuis Hospital, Haarlem, Netherlands.
N. W. L. Schep, MD, PhD, MSc, Trauma Surgeon
J. Vermeulen, MD, PhD, MSc, Trauma Surgeon
Department of Trauma & Hand Surgery, Maasstad Hospital, Rotterdam,
Netherlands.
Author contributions:
E. A. K. van Delft: Conceptualization, Methodology, Resources, Project
administration, Investigation, Data curation, Formal analysis, Writing –
original draft, Writing – review & editing.
VOL. 105-B, No. 9, SEPTEMBER 2023
999
S. G. J. van Bruggen: Resources, Software, Investigation, Data curation,
Formal analysis, Writing – original draft.
K. J. van Stralen: Methodology, Investigation, Data curation, Formal
analysis, Software, Writing – original draft.
F. W. Bloemers: Project administration, Supervision, Data curation,
Validation, Writing – review & editing.
N. L. Sosef: Project administration, Data curation, Writing – review &
editing.
N. W. L. Schep: Project administration, Investigation, Formal analysis,
Writing – review & editing.
J. Vermeulen: Conceptualization, Investigation, Resources, Visualization,
Writing – review & editing.
Funding statement:
The authors received no financial or material support for the research,
authorship, and/or publication of this article.
Data sharing:
The datasets generated and analyzed in the current study are not publicly
available due to data protection regulations. Access to data is limited to the
researchers who have obtained permission for data processing. Further
inquiries can be made to the corresponding author.
Ethical review statement:
The study is submitted to the Medical Ethics Committee VU Medical
Center Amsterdam and Regional Ethical Committee and will be carried
out in compliance with the Declaration of Helsinki on Ethical principles for
medical research involving human subjects. The Medical Ethics Committee
VU Medical Center Amsterdam acts as central ethics committee for this
trial (reference number: NL62861.029.17).
The data will be coded by patient number. Research data will be stored in
a database (SPSS Statistics for Windows v. 22.0; IBM, USA), and will be
handled confidentially and anonymously. Research data that can be traced
to individual persons can only be viewed by authorized personnel. These
persons are the members of the research team, members of the health
careinspection, and members of the Medical Ethics Committee of the Am-
sterdam UMC, VU Medical Center Amsterdam. Review of the data may be
necessary to ensure the reliability and quality of the research. The handling
of personal data is in compliance with the Data Protection Act (in Dutch:
Algemene verordening gegevensbescherming, AVG) and the privacy regu-
lation of the Amsterdam UMC, VU Medical Center Amsterdam.
Trial registration number:
Netherlands National Trial Register: NTR 6600, ABR: NL62861.029.17
Medical Ethical Committee VUmc registration number: 2018.004
The study protocol has previously been published: van Delft EAK,
Bloemers FW, Sosef NL, Bonjer HJ, Schep NWL, Vermeulen J. Dislocat-
ed distal radial fractures in adult patients: 4 weeks versus 6 weeks of cast
immobilisation following reduction, a multicentre randomised controlled
trial, study protocol. BMJ Open. 2019 Mar 15;9(3).
This article was primary edited by J. Scott.