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Perspectives on Modern Orthopaedics

Thoracoscopic Anterior Instrumentation and Fusion for Idiopathic Scoliosis

Daniel J. Sucato, MD, MS


Thoracoscopically assisted surgery is a new approach to access the anterior spine to perform biopsies, anterior releases, diskectomies, and anterior instrumentation and fusion for idiopathic thoracic scoliosis. This approach compromises the chest wall less than an open thoracotomy does because it uses several small portal incisions. It has been suggested that this approach allows fusion of fewer motion segments and better correction of curvature than does posterior spinal fusion and instrumen- tation. The technique, which is still evolving, is technically demanding, requiring advanced training and special instrumentation and anesthesia techniques.

J Am Acad Orthop Surg 2003;11:221-227

Surgical treatment for idiopathic scolio- sis has changed rapidly in the last 20 years. Posterior segmental spinal in- strumentation was an advance over Harrington instrumentation because it improved correction in the sagittal and coronal planes. 1,2 The single solid rod used with anterior surgery was an improvement over the Dwyer ca- ble, especially for thoracolumbar and lumbar curves, because it allowed sur- geons to use a rotational maneuver to correct both the sagittal and coro- nal deformities. 1,2 Recently, the single solid rod placed through an open tho- racotomy has been used to correct tho- racic curves. 3,4 Anterior correction of thoracic scoliosis offers the theoretic advantage of better coronal correction because it permits the surgeon to per- form diskectomies, provides improve- ment in the thoracic hypokyphosis seen in idiopathic scoliosis, and saves mo- tion segments. In a prospective study, Betz et al 4 demonstrated that anterior surgery improved sagittal plane align- ment while saving an average of 2.5 distal motion segments compared with posterior surgery.

Vol 11, No 4, July/August 2003

In the last decade, indications have increased for endoscopic approach-

es to thoracic spine surgery. Endos-


ectomy as well as for anterior release and fusion, in combination with pos- terior spinal fusion and instrumenta- tion, to treat severe curves or when there was risk for the development of the crankshaft phenomenon. 5-7 The en-

doscopic approach also has been used to perform an anterior instrumen- tation, correction, and fusion. Early results are encouraging, but the tech- nique requires further study and im- provement.

Patient Selection and Preoperative Planning

The indications for anterior instrumen- tation and fusion include single tho- racic curves or thoracic curves with a compensatory lumbar and/or up- per thoracic curve, that is, type IA, IB, or IC curves using the Lenke classi- fication. 8 It is important to determine the curve type for preoperative plan-

ning so that the appropriate thoracic curve correction is achieved, especial- ly in the setting of a so-called selec- tive thoracic fusion in the IC curve type. The ideal patient for thoraco- scopic anterior instrumentation and fusion is one who has a relatively small curve size (50° to 65°) of relative flex- ibility (>50% flexibility index); is thin (40 to 60 kg), which makes placement and utilization of the portals easier; and is tall, because the sizable chest provides a greater working space and larger vertebral bodies for easier in- sertion of screws. For surgeons with experience in the technique, the in- dications can include stiffer curves of up to 75°. The primary contraindica- tion for the procedure is poor pulmo- nary function, which limits the pa- tient’s ability to tolerate single-lung ventilation. All patients should have preoperative pulmonary function tests to assess their ability to tolerate the

Dr. Sucato is Assistant Professor, Department of Orthopaedic Surgery, University of Texas at Southwestern, and Staff Orthopaedist, Texas Scot- tish Rite Hospital, Dallas, TX.

The author or the department or departments with which he is affiliated has received something of val- ue from a commercial or other party related di- rectly or indirectly to the subject of this article.

Reprint requests: Dr. Sucato, 2222 Welborn Street, Dallas, TX 75219.

Copyright 2003 by the American Academy of Orthopaedic Surgeons.


Thoracoscopic Anterior Instrumentation and Fusion for Idiopathic Scoliosis

procedure and to help predict the post- operative course. Pulmonary function test findings below 60% of predicted results are a relative contraindication to anterior thoracic surgery. Preoperative assessment of the pa- tient should include a physical exam- ination to confirm radiographic find- ings that the upper thoracic and lumbar curves are compensatory without any structural characteristics. Imaging should include standing lateral and posteroanterior and supine bending right and left radiographs. The lateral radiograph should be used to ensure that excessive kyphosis (>40°) is not present. This is a contraindication for anterior correction because, when com- pression is used, anterior correction can increase kyphosis. 9 Fusion levels for the thoracic curve are determined on the posteroanterior radiograph, us- ing the superior and inferior end ver- tebrae of the Cobb measurement as the upper and lower end instrumented vertebrae. In a smaller patient or one who has marked tilt of the upper end instrumented vertebrae, a level supe- rior to the end vertebra may be cho- sen to provide greater fixation because of the risk of cutout of the superior screws. Analysis of the lower end ver- tebra may reveal that the disk prox- imal to it is in fact neutral. If so, the more proximal level may be chosen as the lower end instrumented ver- tebra. Supine bending radiographs are important to confirm that the lumbar and upper thoracic curves are truly compensatory (bend to <25°). Bend- ing radiographs are used to determine the flexibility of the thoracic curve so that a coronal bend may be placed in the rod if the curve is stiff.

Anesthesia Considerations

Maintaining a proper airway during anesthesia is critical to the success of thoracoscopic surgery. To perform an- terior instrumentation and fusion, the lung on the convexity of the curve must be deflated, and single-lung ven-


tilation techniques are used. This is typically accomplished with a double- lumen endotracheal tube, which has

a bronchial lumen that sits in the de-

pendent mainstem bronchus and a tra- cheal lumen that lies just proximal to

the carina (Fig. 1). The dependent lung

is ventilated through the bronchial lu-

men, while the lung on the convex- ity of the curve becomes deflated when the tracheal lumen is occluded. It is important to recheck tube placement after the patient is in the lateral de- cubitus position because, in up to 80% of cases, the tube tends to move dis- tally. 10 Patients undergoing single-lung ventilation are subjected to significant stresses from the right-to-left shunt through the dependent lung and from that lung’s decreased functional ca- pacity, the result of increased intra- abdominal pressure and compression from the weight of the mediastinal structures. The high pressures that re- sult can lead to airway leaks or trau- ma, which can cause pneumothorax. The so-called down lung syndrome, seen most frequently with lengthy surgeries, is characterized by absorp- tion atelectasis, accumulation of se- cretions, and formation of transudate in the dependent lung. The anesthe- siologist needs to be skilled in the technique to minimize the chance of anesthetic complications. 11,12

Patient Positioning and Operating Room Setup

The patient is positioned in the lat- eral decubitus position on a radio- lucent operating table with the con- vexity of the curve up (Fig. 2). An absolutely lateral position is critical, especially during screw placement, and should be checked periodically to ensure that it is maintained through- out the procedure. The patient may be secured using an inflatable radio- lucent beanbag or other positioning system. Whatever method is used, the patient’s spine must be palpable pos-

method is used, the patient’s spine must be palpable pos- Figure 1 Correct positioning of the

Figure 1 Correct positioning of the double- lumen endotracheal tube to ventilate the left lung. The bronchial lumen should be just dis- tal to the carina and the tracheal lumen just proximal to the carina. The tracheal lumen is occluded to allow for selective ventilation of the left lung.

teriorly, and the umbilicus visible an- teriorly, to allow orientation and ex- posure in case conversion to an open thoracotomy is necessary. The thora- cotomy tray should be available in the operating suite. The arm on the con- vexity of the curve can usually be po- sitioned out of the sterile field, espe- cially when the upper instrumented level is at T5 or below. However, when the upper instrumented level is above T5, the arm may be incorporated into the sterile field to provide better con- trol of the patient’s arm and scapula, making proximal portal placement easier. One or two surgeons are positioned on the posterior aspect and one on the anterior aspect of the patient. The scrub assistant is usually anterior. The video monitors should be at the head of the table on both sides of the patient to give the surgeons on each side a di- rect view. The fluoroscopy C-arm unit is brought in anteriorly when screws are placed, with the monitor at the foot of the table. Although some surgeons perform the diskectomy on the posterior as- pect, the anterior position allows bet- ter control of posterior penetration be- yond the posterior anulus fibrosus and

Journal of the American Academy of Orthopaedic Surgeons

Daniel J. Sucato, MD, MS

Daniel J. Sucato, MD, MS Figure 2 Operating room setup. posterior longitudinal ligament. Dur- ing screw

Figure 2

Operating room setup.

posterior longitudinal ligament. Dur- ing screw placement and instrumen- tation, the surgeon may be more com- fortable at the posterior aspect of the patient because leaning over the op- erating room table is then unneces- sary, and it is safer to direct the screws slightly anteriorly.

Surgical Procedure

Portal Placement

Accurate placement of the portals is critical because they determine the approach for the diskectomies and, more important, the screw starting points and directions. Before the pa- tient is prepared and draped, the spi- nal levels to be instrumented are lo- cated fluoroscopically in the coronal and sagittal planes, and the skin is marked. In general, the incision for

the portals should be directly over the rib so that two portals (above and be- low the rib) can be used for each in- cision.

A single anterolateral portal is placed at the apex of the curve in the anterior-to-midaxillary line, and the thoracoscope is placed through this portal. The thoracoscope consists of a camera and a scope that is angled at 30° or 45°. Seen from the antero- lateral portal, the spine is horizontal on the monitor; seen from the postero- lateral portal, the spine is vertical, giv- ing a good “pipeline” view (Fig. 3). The scope should be oriented to see the disks straight on when the tho- racoscope is in the anterolateral por- tal. This is best achieved by keeping the orientation light from the lens per- pendicular to the spine, with the scope handle at the 3-o’clock position when looking at the most cephalad disk (Fig. 4, A) and at the 9-o’clock position when looking at the most caudad disk (Fig. 4, B). This position allows visu- alization down the axis of the disk space and provides a true anteropos- terior view of the vertebral bodies. The posterolateral portals are made under direct visualization. The place- ment of the most cephalad portal is very important for proper instrumen- tation. The skin mark initially made under fluoroscopic visualization is used to place a guide pin, which is then assessed using the camera in the anterolateral portal. The ribs should be counted to check the level of the

portal. The ribs should be counted to check the level of the Figure 3 Thoracoscopic video

Figure 3 Thoracoscopic video images. A, With the thoracoscope in the anterolateral portal, the spine is horizontal on the monitor and provides a good assessment of the superior and inferior extent of each vertebral body. B, With the thoracoscope in one of the posterolateral portals, the spine is more vertical on the monitor “pipeline” view, providing a good assess- ment of the anterior and posterior aspects of the spine. The diaphragm is visible at the top of the image.

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Thoracoscopic Anterior Instrumentation and Fusion for Idiopathic Scoliosis

Anterior Instrumentation and Fusion for Idiopathic Scoliosis Figure 4 A, Use of the thoracoscope in the

Figure 4 A, Use of the thoracoscope in the anterolateral portal. To view the proximal (cephalad) portion of the spine, the camera is po- sitioned parallel to the floor and the light source handle is at the 3-o’clock position. The spine appears horizontal on the monitor (inset). B, To view the distal (caudad) aspect of the spine, the camera is positioned parallel to the floor and the light source handle is at the 9-o’clock position. This keeps the spine horizontal on the monitor (inset). C, Portal placement for a typical thoracic idiopathic curve. The anterolateral portal is made in the anterior axillary line at the apex of the curve.

guide pin. If the pin is not sufficient- ly superior or posterior to allow the surgeon to place the proximal screw, the pin is moved and the portal in- serted. The camera may then be placed through that portal to check the po- sition further. The remaining posterolateral por- tals are then placed, with close atten- tion paid to the distances between portals and their positions in the an- teroposterior and superoinferior di- rections. Positioning is assessed with the thoracoscope in the anterior por- tal to ensure that the portals are made directly over the vertebral bodies. A typical portal configuration for a seven- or eight-level instrumentation is a single anterolateral portal and four posterolateral portals (Fig. 4, C). Various portal configurations have been described, including posterolat- eral portals only or a combination of three anterolateral with three pos- terolateral portals.


Disk Excision and Bone Grafting

Disk excision is the most important aspect of the procedure. The surgeon incises the pleura in the midvertebral body, then coagulates the segmental vessels. The pleura should be bluntly teased posteriorly past the rib heads and anteriorly around the front of the spine to allow access to the anterior longitudinal ligament and contralat- eral anulus. Sharp incision of the disk can be made with a scalpel blade or harmonicscalpel.Diskshavers,rongeurs, and curettes are used to excise the disk as completely as possible (Fig. 5). An- imal studies comparing open thora- cotomy with thoracoscopic techniques havedemonstratedcomparableamounts of diskectomy. 13,14 Aquantitative anal- ysis of computed tomography (CT) in 12 adolescent patients (mean age, 13.3 years) demonstrated that a mean of 73% of the disk and end plate was removed, allowing correction from a mean of 55° to a mean of 9°. 15

Autologous rib or iliac crest bone grafts can be used and probably are best placed immediately upon com- pletion of the diskectomy at each lev- el. Bone funnels are used to place the grafts and should start in the depths

are used to place the grafts and should start in the depths Figure 5 Axial CT

Figure 5 Axial CT scan of a thoracic disk space after diskectomy and bone grafting done as part of an anterior thoracoscopic in- strumentation and fusion. Note the bone graft material (arrows) packed all the way to the opposite side of the disk space and posteri- orly. The rod is seen on the right side of the vertebral body.

Journal of the American Academy of Orthopaedic Surgeons

of the disk space to ensure that the grafts are packed completely.

Screw Placement

Before screws are placed, the pa- tient’s position should be rechecked


roscopic image should be at right an- gles to the vertebral bodies in the an- teroposterior projection and is used to confirm that the screw is oriented parallel to the end plate. The thora- coscope is placed in the anterior por- tal initially to direct the guidewire with respect to the superoinferior starting point and orientation. The thoracoscope is then moved to a pos- terolateral portal to check the antero- posterior starting point and its direc- tion. The anteroposterior fluoroscopic images are then used to fine-tune the starting point in the superoinferior di- rection. Screws are placed beginning at the apex of the curve, with the starting point of the screw just anterior to the rib head. The screws are directed slightly anteriorly to avoid the spinal canal and to be in the midaxial plane of the rotated apical vertebral bodies. This screw orientation allows for ro- tational correction during rod inser- tion and compression. As screws are placed proximal and distal to the apex, the starting holes move slightly more anteriorly. The cephalad screws are the most difficult to place accurately with good purchase because the vertebral bodies are smaller, the rib heads ob- scure more of the vertebral bodies, and the proximal portals are often not ide- ally placed. The proximal screws must be placed with great care and atten- tion to anatomic landmarks to ensure that these screws are not too poste- rior, which could lead to spinal canal penetration, but are posterior enough to allow secure purchase in good bone stock (Fig. 6). It is often necessary to remove the rib heads at T5 and T6 to gain good access to the vertebral bod- ies at these levels. Present instrumentation systems are modifications of open anterior in-

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strumentation systems, with all in- struments made to fit through a 10.5- mm–diameter portal. Screws in sizes from 5.5 to 7.5 mm and rods in 4.0-, 4.5-, and 4.75-mm diameters are avail- able. The proximity of the aorta to the vertebral bodies in the upper and midthoracic spine limits the amount of bicortical screw purchase that can be achieved 16 (Fig. 6). In the lower thoracic spine in a patient with idio- pathic scoliosis, the aorta is posi- tioned more anterior to the vertebral body. Newer instruments allow the surgeon to place screws without the use of the guide wire, which can lead to complications with inadvertent ad- vance across the vertebral body.

Rod Insertion and Correction Maneuvers

The stiffness of the curve, the pur- chase of the most proximal screws, and whether maximum correction is desired (Lenke IA curve) will deter- mine whether a small coronal bend should be placed in the rod before in- serting it into the chest. In taller pa- tients with smaller, more flexible curves and larger vertebral bodies, no coronal bend in the rod is necessary. In patients with a very lordotic tho- racic segment, a kyphotic bend can be placed in the rod. The rod is inserted through the dis- tal or proximal posterolateral portal and grasped within the chest with a rod grabber so that it can be seated into the screws in one step. The rod is initially seated distally to help con- trol the length of rod that protrudes distal to the screw and prevent it from pushing against the diaphragm. Two correction maneuvers are per- formed: compression and cantilever. Because the rod is essentially straight in the coronal plane, in contrast with the deformity, the rod can be seated only in the distal three or four screws. Initially, compression is performed across these screws, followed by can- tilevering the rod down into the re- maining proximal screws. After the rod is captured in the proximal screw

Daniel J. Sucato, MD, MS

is captured in the proximal screw Daniel J. Sucato, MD, MS Figure 6 Axial CT scan

Figure 6 Axial CT scan of a thoracic ver- tebral body after anterior thoracoscopic in- strumentation and fusion. The starting posi- tion of the screw is just anterior to the rib head. The outline of the aorta is seen at approxi- mately 1 o’clock, just posterior to the left mainstem bronchus. The screw has one to two threads engaging the opposite cortex; how- ever, the screw tip is close to the aorta.

heads, compression is then complet- ed at these levels with care taken to avoid excessive force on the top screws. The securing plugs are then tightened fully. The surgeon must be sure to place the guide sleeve over the screw or grasp the rod to produce a countertorque to prevent screw mi- gration or “plowing.”Anteroposterior and lateral radiographs or fluoroscop- ic images should be checked to en- sure that all screws are safely posi- tioned and that correction is adequate in the coronal and sagittal planes.

Pleural Closure and Chest Tube Insertion

The pleura can be closed to help decrease chest tube output, limit de- velopment of lung adhesions, and contain the bone graft in the disk space. Diaphragmatic repair is incor- porated into the pleural closure when the instrumentation extends to T12 or L1. The pleura is closed with an En- dostitch device (US Surgical, Nor- walk, CT), running a suture begin- ning distally and another beginning proximally, which then meet in the center so that they can then be tied easily. A chest tube is placed through the incision of the most distal poste- rior portal skin incision. Because of the single, small-diameter rod, all pa-


Thoracoscopic Anterior Instrumentation and Fusion for Idiopathic Scoliosis

tients should wear a brace during the day (when not sleeping) for the first 3 months.

Early Results

In one series of 28 girls (average age, 12.1 years) with a mean preoperative curve of 55° (range, 46° to 78°), the mean postoperative curve at 1 year was 14° (74.5% correction) 15 (Fig. 7). Complications included six proximal screws that partially pulled from the vertebral body at the time of compres- sion in four patients; two screws that cut out at the time of insertion because of small vertebral bodies in two pa- tients; guidewire migration into the spinal canal in one patient, with re- sultant dural leak without neurologic sequelae; and asymptomatic pseudar- throsis in one patient who underwent a posterior spinal fusion. 15 Picetti and Bueff 17 reported follow- ups over 2 years on 50 patients (mean age, 12.7 years) with a mean preop- erative curve of 58°. Improvements in techniques resulted in enhanced cor-

rection and fewer complications over the course of this series. Mean curve

correction was 50.1% in the first 10 pa- tients and 68.6% in the last 10. Sur- gical time improved from a mean of

6 hours 6 minutes in the initial 30 cas-

es to 3 hours 58 minutes in the last 10 cases. Mean blood loss was 266 mL. The chest tube was in place for a mean of 2.25 days (range, 1 day to

5 days), and hospital stay averaged

2.9 days (range, 2 to 7 days). Report- ed complications included one screw pullout, three patients with chest wall numbness, five mucous plugs, one wound revision, and two rod frac- tures. A demineralized bone matrix product was used in the initial pa- tients, resulting in a high incidence of pseudarthrosis; however, only 1 patient of the remaining 35 had a pseudarthrosis when autologous rib graft was used. 17


There are no published series of pa- tients who have had thoracoscopic in-

strumentation and fusion for idio- pathic scoliosis, so the prevalence of complications is not known. How- ever, complications that have been presented and discussed at scientific meetings can be categorized as anesthesia-related and surgical. The anesthesia-related complications in- clude the down lung syndrome, with significant atelectasis present on the initial chest radiograph; inability to tolerate single-lung ventilation and conversion to an open technique or posterior spinal fusion; inability to ob- tain single-lung ventilation because of difficulty in tube placement; and pneumothorax secondary to high air- way pressures. 12 Because this proce- dure is new and technically demand- ing, the incidence of complications can be high, especially early in the surgeon’s experience. Complications that can occur during surgery include blood vessel injury, lymphatic injury with resultant chylothorax, guide-pin migration into the opposite side of the chest with resultant pneumothorax, 18 distal migration or plowing of the screw when the rod is seated prox-

or plowing of the screw when the rod is seated prox- Figure 7 Preoperative anteroposterior (A)

Figure 7 Preoperative anteroposterior (A) and lateral (B) radiographs of a 13-year-old girl with a 56° right thoracic idiopathic curve with a notable trunk shift to the right and hypokyphosis (panel B). Anteroposterior (C) and lateral (D) radiographs 1 year after anterior tho- racoscopic instrumentation from T5 to T12, with near-complete correction of the coronal plane deformity and restoration of the normal sag- ittal profile.

imally or is compressed, and screw cutout at the time of screw insertion.


The endoscopic approach to curve cor- rection, instrumentation, and fusion for spinal deformity is a new technique that promises improved patient care because it limits the surgical incision and chest wall compromise, improves postoperative pain and pulmonary function, and enhances cosmesis. Compared with posterior instrumen-

tation, anterior instrumentation by ei- ther open or thoracoscopic approach can save fusion levels while improv- ing three-dimensional correction. However, no studies have directly compared thoracoscopic instrumen- tation and fusion with open anterior and/or posterior procedures, making any conclusive statements impossible.

A multicenter prospective study may

be needed to fully elucidate the ad- vantages this technique may have and

to help define the exact indications for

a thoracoscopic approach to treat


Daniel J. Sucato, MD, MS

Several important issues must be kept in mind. First, the proposed ad- vantages have not been confirmed through scientific study. Second, the technique continues to evolve to de- crease the duration of surgery while maintaining the safety of the proce- dure. Third, screw migration and proximity of screws to important soft- tissue structures need further study. Finally, this is a technically demand- ing procedure with a steep learning curve and may not be appropriate for all surgeons who treat spinal defor- mity.


1. Lenke LG, Bridwell KH, Blanke K, Bal- dus C, Weston J: Radiographic results of arthrodesis with Cotrel-Dubousset instrumentation for the treatment of adolescent idiopathic scoliosis: A five to ten-year follow-up study. J Bone Joint Surg Am 1998;80:807-814.

2. Richards BS, Herring JA, Johnston CE, Birch JG, Roach JW: Treatment of ado- lescent idiopathic scoliosis using Texas Scottish Rite Hospital instrumentation. Spine 1994;19:1598-1605.

3. Lenke LG, Betz RR, Bridwell KH, Harms J, Clements DH, Lowe TG: Spontaneous lumbar curve coronal correction after se- lective anterior or posterior thoracic fu- sion in adolescent idiopathic scoliosis. Spine 1999;24:1663-1672.

4. Betz RR, Harms J, Clements DH III, et al: Comparison of anterior and posteri- or instrumentation for correction of ad- olescent thoracic idiopathic scoliosis. Spine 1999;24:225-239.

5. Wall EJ, Bylski-Austrow DI, Shelton FS, Crawford AH, Kolata RJ, Baum DS: En- doscopic discectomy increases thoracic spine flexibility as effectively as open diskectomy: A mechanical study in a porcine model. Spine 1998;23:9-16.

6. Newton PO, Wenger DR, Mubarak SJ, Meyer RS: Anterior release and fusion in pediatric spinal deformity: A com- parison of early outcome and cost of thoracoscopic and open thoracotomy approaches. Spine 1997;22:1398-1406.

7. Regan JJ, Guyer RD: Endoscopic tech-

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niques in spinal surgery. Clin Orthop


8. Lenke LG, Betz RR, Harms J, et al: Ad- olescent idiopathic scoliosis: A new classification to determine extent of spi- nal arthrodesis. J Bone Joint Surg Am


9. Clements DH, Betz RR, Lowe TG, Lenke LG, Newton PO: Abstract: Ado- lescent idiopathic scoliosis with exces- sive thoracic kyphosis: Comparison of anterior versus posterior instrumenta- tion for maintaining correction. Scolio- sis Research Society 35th Annual Meeting Book. Rosemont, IL: Scoliosis Research Society, 2000, p 97.

10. Desiderio DP, Burt M, Kolker AC, Fis- cher ME, Reinsel R, Wilson RS: The ef- fects of endobronchial cuff inflation on double-lumen endobronchial tube movement after lateral decubitus posi- tioning. J Cardiothorac Vasc Anesth 1997;


11. Dieter RA Jr, Kuzycz GB: Complica- tions and contraindications of thoracos- copy. Int Surg 1997;82:232-239.

12. Sucato DJ, Girgis M: Bilateral pneumotho- races, pneumomediastium, pneumoperi- toneum, pneumoretroperitoneum, and subcutaneous emphysema following in- tubation with a double-lumen endotra- cheal tube for thoracoscopic anterior spi- nal release and fusion in a patient with idiopathic scoliosis. J Spinal Disord Tech


13. Huntington CF, Murrell WD, Betz RR,

Cole BA, Clements DH III, Balsara RK:

Comparison of thoracoscopic and open thoracic discectomy in a live ovine model for anterior spinal fusion. Spine


14. Newton PO, Cardelia JM, Farnsworth CL, Baker KJ, Bronson DG: A biome- chanical comparison of open and thora- coscopic anterior spinal release in a goat model. Spine 1998;23:530-536.

15. Sucato D, Kassab F, Dempsey M: Ab- stract: Thoracoscopic anterior spinal in- strumentation and fusion for idiopathic scoliosis: A CT analysis of screw place- ment and completeness of discectomy. Scoliosis Research Society 36th Annual Meeting Book. Rosemont, IL: Scoliosis Research Society, 2001, p 90.

16. Sucato DJ, Duchene C: MRI analysis of the position of the aorta relative to the spine: Acomparison between normal pa- tients and those with idiopathic right tho- racic curves. J Bone Joint Surg Am, in press.

17. Picetti GD III, Bueff HU: Abstract: En- doscopic instrumentation, correction and fusion of thoracic curves in idio- pathic adolescent scoliosis. Scoliosis Re- search Society 35th Annual Meeting Book. Rosemont, IL: Scoliosis Research Soci- ety, 2000, p 110.

18. Roush TF, Crawford AH, Berlin RE, Wolf RK: Tension pneumothorax as a complication of video-assisted thora- scopic surgery for anterior correction of idiopathic scoliosis in an adolescent fe- male. Spine 2001;26:448-450.


Spinal Manipulative Therapy for Low Back Pain Rand Swenson, DC, MD, PhD, and Scott Haldeman,

Spinal Manipulative Therapy for Low Back Pain

Rand Swenson, DC, MD, PhD, and Scott Haldeman, DC, MD, PhD, FRCPC


Growing interest in complementary and alternative medicine in the United States has been paralleled by increased use of spinal manipulative therapy in an attempt to manage symptoms of low back pain, spinal stenosis, and spondylolisthesis. Chi- ropractors have been the main practitioners of spinal manipulative therapy, with osteopaths and physical therapists providing a smaller fraction of these services. The- ories explaining the mode of action of spinal manipulative therapy are largely pre- liminary and have focused on the mechanical effects of manipulative forces on the spine and neurologic responses to manipulation. The effects of spinal manipulation on patients with both acute and chronic low back pain have been investigated in randomized clinical trials. Most reviews of these trials indicate that spinal manip- ulative therapy provides some short-term benefit to patients, especially with acute low back pain.

J Am Acad Orthop Surg 2003;11:228-237

Spinal manipulative therapy (SMT) is one of the oldest therapeutic proce- dures offered to patients with lumbar spine pain. Although it has been used for more than 2,000 years, until recent- ly there has been little scientific ev- idence comparing its mode of action and effectiveness with those of other techniques. Interest in and use of com- plementary and alternative therapies increased in the United States during the last decade of the 20th century. 1 Patients with low back pain often seek care from clinicians who offer relax- ation therapy, yoga, nutritional sup- plements, herbal therapy, massage, acupuncture, and spinal manipulation.


mon and widely recognized of the com- plementary and alternative therapies used to manage low back pain. In fact, it is so commonplace that there is now debate about whether it should be con- sidered part of mainstream health care. Chiropractors, who provide the great- est percentage of manipulative treat- ments, 2,3 are now licensed in all states and are recognized as primary con-

tact health care clinicians; in addition, theirservicesarecoveredbymosthealth insurance systems, including Work- ers’ Compensation, Medicare, and the Military Health System. However, spi- nal manipulation is not practiced ex- clusively by chiropractors. Some os- teopathicphysicians,physicaltherapists, and medical physicians are provid- ing and specializing in SMT. The ex- act utilization rate of spinal manip- ulation in the United States is not known, but it is estimated that >90% of spinal manipulations in the United States are done by chiropractors. 3 Al- though many chiropractors also in- clude other physical modalities, nu- tritional advice, and rehabilitation in their practices, most chiropractic vis- its include SMT. Approximately 30% of patients with low back pain use the services of chiropractors, with addi- tionalpatientsreceivingSMTfromother health care practitioners. 2 Shekelle and Brook 4 studied insurance industry data and reported that 7.5% of patients in their population group used chiroprac- tic services each year and that there

was an average of 41 visits per 100 person-years. The increased volume of research about the effectiveness and mecha- nisms of action of SMT have led to the inclusion of SMT on a very short list of national guidelines for manag- ing acute low back pain (eg, those de- veloped by the Agency for Healthcare Research and Quality 5 in the United States and similar guidelines devel- oped in Great Britain and Denmark). Many patients under the care of prac- titioners of conventional medical tech- niques (eg, orthopaedic surgeons, neu- rosurgeons, physiatrists) have already undergone manipulation or will con- sider spinal manipulation, especial- ly if more commonly practiced med- ical procedures prove to be ineffective. Therefore, it is important for any phy- sician who treats patients with back pain to be knowledgeable enough to advise patients about SMT and to con- sider whether there is a role for such treatment in selected patients.

Dr. Swenson is Associate Professor, Section of Neurology, Dartmouth Medical School, Lebanon, NH. Dr. Haldeman is Clinical Professor, Depart- ment of Neurology, University of California– Irvine, Santa Ana, CA.

One or more of the authors or the departments with which they are affiliated has received some- thing of value from a commercial or other party related directly or indirectly to the subject of this article.

Reprint requests: Dr. Haldeman, 1125 East 17th Street, Santa Ana, CA 92701.

Copyright 2003 by the American Academy of Orthopaedic Surgeons.


Journal of the American Academy of Orthopaedic Surgeons

Rand Swenson, DC, MD, PhD, and Scott Haldeman, DC, MD, PhD, FRCPC

Spinal Manipulation

Many treatment methods are encom- passed within SMT. These techniques can be divided into three broad cat- egories: therapeutic massage, mobi- lization, and manipulative procedures (or adjustments). Massage includes manual procedures applied to the spi- nal soft tissues without causing joint movement, such as deep tissue mas- sage, acupressure, muscle stimulation, and relaxation methods. Mobilization generally refers to procedures that ex- ert stretching, traction, or pressure on the spine within or at the limit of ac- tive range of motion. 6 Mobilization procedures typically involve slow, oc- casionally rhythmic stressing of the joint, ligaments, and muscles. They usually consist of passive force exert- ed by the clinician on the joint but may require active contraction of specific muscles by the patient to assist in the motion. Massage and mobilization often are used in preparation for spi- nal manipulation as a way of re- ducing the force needed to do the ma- nipulation and to relax the patient. Spinal manipulation usually re- quires application of a quick, high- velocity, short-amplitude force, either directly or indirectly, to the spine. 6 Manipulative forces can be applied with the patient lying either on his or her side or prone. Most of these tech- niques involve so-called short levers directed at the vertebral processes (eg, spinous, transverse, mammillary, ar- ticular) to apply force to a specific spi- nal segment. So-called long lever techniques consist of force applied to an extremity (eg, arm, shoulder, hip, leg) to move the spine indirectly. Spi- nal manipulative procedures also may involve traction or a mobilizing force at the end of the physiologic joint range of motion, followed by a short-amplitude impulse to move the joint into the paraphysiologic range, beyond the passive range of motion but short of the point of anatomic dis- ruption of the joint (Fig. 1). The typ- ical forces and movements produced

Vol 11, No 4, July/August 2003

Zone C Paraphysiologic range of Zone A motion Active Zone B range of Passive motion
Zone C
range of
Zone A
Zone B
range of
range of
Joint disruption
Increasing joint range of motion

Figure 1 Mobilization and manipulation take the spine beyond the active range of mo- tion (Zone A). Ligaments and muscles resist motion beyond that point; articular mobili- zation passively stretches them into Zone B, although it may be actively assisted by the patient. Manipulation involves bringing the joint beyond this passive range of motion into a paraphysiologic range of motion (Zone C). Often there is cavitation of the joint being ma- nipulated. Motion beyond that point may cause injury to the structures supporting the joint.

by such types of manipulation have been characterized in studies of vol- unteers. 7 The movement is often ac- companied by an audible sound that may be attributable to joint cavita- tion, 8 which is the release of tissue gas (probably nitrogen) into the joint space as the result of a vacuum cre- ated by the manipulative thrust. This audible sign indicates that there has been motion in the joint. However, many manipulative practitioners do not consider an audible release essen- tial to obtain a good manipulative re- sponse. A common spinal manipulative procedure is the so-called hold-thrust adjustment, in which the force is maintained briefly before and after the application of the impulse. The re- coil technique involves an impulse from a neutral position followed by an immediate termination of contact. In several techniques, very low force is applied in precise directions to ver- tebral structures, under the theory

that the more specific the thrust, the less force necessary. Acupressure and soft-tissue massage may be done in preparation for manipulation or as the sole method of treatment. In ad- dition, several mechanical devices, such as the handheld, spring-loaded Activator (Fig. 2), have been devel- oped to deliver force directly to the spine with or without manual guid- ance. It remains to be determined whether the mechanical and clinical effects produced by these instruments are similar to those of the manual techniques. 9

Theoretic Basis for Symptom Relief

The theoretic basis for SMT has evolved with increased understand- ing of spinal pathology, spinal biome- chanics, and pain physiology. Initial- ly, the manipulable lesion (osteopathic lesion or subluxation in chiropractic terminology) was considered a bone out of place impacting either the vas- cular structures or spinal nerve roots. 10 Most manipulative practitioners and all chiropractic schools have broad- ened this concept to encompass cur- rent theories of spinal pathology that incorporate concepts of abnormal spi- nal biomechanics and include neuro- physiologic theories about reflex func- tion and pain physiology. 11 The most common theory of the manipulable lesion is that a vertebral

common theory of the manipulable lesion is that a vertebral Figure 2 Manipulation with a handheld

Figure 2 Manipulation with a handheld de- vice (Activator; Activator Methods Interna- tional, Phoenix, AZ) designed to deliver force to the tissue of the back.


Spinal Manipulative Therapy for Low Back Pain

unit can display abnormal motion or become fixated (ie, mobility can be re- stricted within the normal physiolog- ic range of joint motion). Addition- ally, it is thought that biomechanical changes are often associated with pain and abnormal spinal reflex function, including muscle spasms and auto- nomic nervous system responses. The manipulation is thought to have a di- rect effect on muscles and joints as well as an indirect effect on the nervous system. Limited experimental and clin- ical evidence supports this theory. Magnetic resonance imaging studies have indicated a direct effect on spi- nal joints consistent with reports de- scribing increased spinal range of mo- tion after spinal manipulation. 12 Spinal manipulation also is accompanied by a reflex contraction of paraspinal mus- culature. 13 Whether this is of thera- peutic benefit and whether these re- flex responses produce long-term changes in muscle tone or muscle spasm are unknown. Recent neurophysiologic research has focused on possible effects of SMT on the central nervous system. 11 Al- tered pain thresholds have been re- ported after SMT, possibly related to activation of endogenous pain- suppression mechanisms. In addition, decreased pain response after lumbar manipulation has been associated with abnormal somatosensory- evoked potentials from paraspinal musculature of patients with low back pain, suggesting a central effect on sensory processing. 14 Activation of zygapophyseal joint receptors in rats is capable of markedly attenuating the reflex response in paraspinal muscles to noxious stimulation of nerves in the intervertebral disk, 15 which suggests interaction between spinal joint recep- tors and the processing mechanisms for spinal pain reflexes, at least in an- imals. Suter et al 16 investigated the ef- fect of manipulation of the sacroiliac joint on the degree of quadriceps mus- cle inhibition produced by knee joint pathology. They showed that manip- ulation of the sacroiliac joint de-

creased the inhibitory effect, suggest- ing interaction between manipulation and the inhibition of voluntary activ- ity produced by pain. Despite exper- imental observations, however, the underlying mechanisms proposed to explain the therapeutic effects of SMT remain poorly understood and re- quire further investigation.

Clinical Trials

Many patients with uncomplicated low back pain do not have clear and quantifiable underlying pathophysi- ology, which has largely prevented the use of physiologic outcome mea- sures in studies of back pain treat- ment. For this reason, studies of the therapeutic efficacy of most treatment approaches to low back pain have tended to be empiric, relying on clin- ical outcome measures such as pain scores, functional capacity, patient sat- isfaction, time lost from work, and cost (mostly from insurance and Workers’ Compensation data). Many of these researchers have attempted to compare chiropractic with conven- tional medical treatment, while others have compared spinal manipulation with other nonsurgical interventions or placebo treatments. Although most patients treated by chiropractors re- ceive spinal manipulation, chiroprac- tic treatment is rarely limited to this modality, and caution must be exer- cised when extrapolating from trials of chiropractic care. For example, studies of patient satisfaction have been very favorable to chiropractic treatment, but that may have more to do with doctor-patient interaction than with SMT. 17 Although compar- ison studies of Workers’ Compensa- tion 18 and private health insurance 19 data have mostly shown similar or lower costs for patients treated by chi- ropractors, this may reflect a differ- ence in the population that seeks al- ternative providers. The most widely accepted model for overcoming the problem of differ-

ent patient populations is the ran- domized clinical trial. Forty-four ran- domized clinical trials evaluating the efficacy of spinal manipulation in pa- tients with low back pain have been published, and there are more than 50 reviews of these trials, each using different criteria to determine their value. There are even systematic stud- ies that rate the quality of these clin- ical trial reviews. 3,20-28 Many of the published clinical tri- als are of relatively low quality, often involving small numbers of patients, differing outcome measures, short follow-up periods, heterogeneous study populations, a range of meth- ods of manipulation or manual ther- apy, and varying degrees of blinding of patients and assessors. It is ex- tremely difficult to blind patients in randomized controlled trials of phys- ical interventions such as spinal ma- nipulation and, therefore, to develop appropriate placebo controls. Many researchers have avoided placebo and instead have tried to use more prag- matic approaches, such as examining and comparing the outcomes of two or more common clinical procedures, one of which is manipulation or man- ual therapy. However, the clinical val- ue of many of the treatments against which manipulation can be compared is mostly unknown or has minimal research support. In addition, many of the manipulative treatment proto- cols in these studies do not model typ- ical clinical practice, making it diffi- cult to extrapolate the results to the clinical setting. This is particularly problematic in studies that attempt to establish rigorous controls or use pla- cebo treatments such as detuned dia- thermy, sham laser treatments, or sham manipulations.

Acute Low Back Pain

The studies by Glover et al 29 and Hadler et al 30 of the effect of manip- ulation in patients with acute low back pain have received high qual- ity scores in most reviews and are widely quoted to have established


Journal of the American Academy of Orthopaedic Surgeons

Rand Swenson, DC, MD, PhD, and Scott Haldeman, DC, MD, PhD, FRCPC

some legitimacy for manipulation. Glover et al 29 compared two groups of patients, one that received a sin- gle manipulative treatment followed by four sessions of detuned diather- my (placebo) and the other five treat- ments of the placebo only. Significant (P < 0.05) improvement was report- ed in patients immediately after the initial manipulative treatment. How-

ever, there was no difference between groups after 3 or 7 days. Hadler et

al 30 randomized patients to receive ei-

ther a single manipulative treatment

or mobilization procedure. In patients

with pain of 2 to 4 weeks’ duration, there was significant (P = 0.009) dif- ference in favor of SMT at 3 days, but not at 6 days, after treatment. Despite the positive short-term beneficial out- come of manipulation in these two studies, the use of a single manipu-

lative treatment in both has been crit- icized as not modeling usual clinical practice. Mathews et al 31 attempted

to remedy this shortcoming by com-

paring a group of patients with acute lower back pain treated with up to 10 manipulative treatments with a group receiving 6 treatments of infra-

red heat applied to the lumbar spine.

A significant (P < 0.05) difference was

reported in recovery at 2 weeks for patients with lower back pain who

also had leg pain, but not for patients with lower back pain only. There was no difference in relapse rate after 1 year. MacDonald and Bell 32 compared the effect of five spinal manipulative treatments done in combination with

a low back education program with

the effects of five low back educa- tion sessions alone. The results were not statistically significant in favor of

manipulation but favored manipula- tion. Shekelle et al 3 pooled the results of seven trials, using pain and func- tional outcome as clinical measures, and concluded that spinal manipula- tion had significant (P < 0.05) over- all benefit, averaging approximately

a 34% improvement in recovery com-

pared with several alternative treat-

Vol 11, No 4, July/August 2003

ment methods. They calculated a pooled odds ratio of 0.17 probability of faster recovery at 3 weeks com- pared with other therapies. In a sim- ilar meta-analysis, Brønfort 23 con- cluded that there was moderate evidence of short-term efficacy when SMT was used to manage acute low back pain. van Tulder and Waddell 27 concluded that there is moderate ev- idence that manipulation is more ef- fective than placebo for short-term re- lief of acute low back pain; however, they also stated that it was not yet possible to judge whether manipula- tion is more effective than nonsteroi- dal anti-inflammatory drugs or phys- ical therapy. This type of review led the Agency for Health Care Policy and Research in 1994 to add manip- ulation to its short list of recommend- ed treatments for acute low back pain. 5

Chronic Low Back Pain

The study by Koes et al 33 of SMT in patients with chronic low back pain has received high quality scores. The authors compared a course of 14 SMT treatments with three other treatment approaches. One included massage, heat, and modalities such as electro- therapy, ultrasound, and diathermy; another consisted of medical manage- ment with anti-inflammatory medi- cations and advice; the third invloved detuned modalities (placebo). At 1-year follow-up, they found signif- icant (P = 0.05) benefit in terms of pain, but not physical functioning, for patients treated with spinal manipu- lation compared with the group that received massage, heat, and modal- ities. There was significant benefit for spinal manipulation over medical management (P = 0.05) and over pla- cebo modalities (P = 0.02) at 6 weeks but not at 12 weeks. Pope et al 34 conducted a four-arm clinical trial in patients with chronic low back pain. They compared a group of patients treated with nine spinal manipulative treatments with three other treatment protocols (mas-

sage, transcutaneous electrical mus- cle stimulation, or corsets). At 3-week follow-up, SMT showed a significant (P < 0.05) benefit in terms of disabil- ity score. However, this improvement was not found to extend to pain scores, where the only significant (P = 0.05) benefit was found in the com- parison with transcutaneous muscle stimulation. Triano et al 35 compared conven- tional spinal manipulation provided daily for 2 weeks with a similar num- ber of placebo manipulations using measured forces below a previously identified manipulative threshold. A third group of patients received the same number of structured education sessions. The differences in Oswestry disability scores between those treat- ed with manipulation and placebo reached statistical significance (P = 0.004) at 2 weeks but not at 4 weeks. No comparison was made with the back education program. At 4 weeks, the difference in pain scores between manipulation and placebo manipula- tion were not statistically significant. However, the authors placed con- straints on the manipulative treat- ments to adequately mimic the pla- cebo treatments. The most comprehensive study of the long-term effects of manipulation was done by Meade et al. 36 They com- pared nine spinal manipulative treat- ments done in private chiropractic of- fices with six hospital-based physical therapy clinic sessions that included conventional physical therapy as well as spinal manipulation in a cohort of 741 patients. They reported signifi- cant (P < 0.05) benefits for the group treated by the chiropractors in terms of pain at 6-week, 6-month, and 1-, 2-, and 3-year follow-ups and in terms of disability at 6-month and 2- and 3-year follow-ups. However, this study has been criticized for having excessive numbers of patients lost to follow-up as well as for differences in treatment settings. Cherkin et al 37 conducted a ran- domized clinical trial in a group of 321


Spinal Manipulative Therapy for Low Back Pain

patients with acute or chronic low back pain of at least 7 days’ duration. Patients were assigned to SMT or physical therapy according to the McKenzie method or were provided an educational booklet about back pain. The group treated by chiroprac- tors did significantly better than the group receiving the booklet at 4 weeks (P = 0.02) but not at 12 weeks, 1 year, or 2 years. However, there was no difference between patients who received SMT and those treated with physical therapy. Although disabili- ty scores appeared to be better for the groups treated with manipulation and physical therapy than for the group given the booklet, this was not statistically significant. In the groups that received active treatment, ap- proximately 75% of patients report- ed that their care was good or excel- lent, while only 30% of those in the group given the booklet reported re- ceiving good or excellent care (P < 0.001). One limitation of this study was the rather low level of initial symptoms that, combined with the usual trend to spontaneous improve- ment of low back pain, resulted in a statistical floor effect restricting the ability to detect differences between treatment groups. Until recently, systematic reviews and meta-analyses of trials in patients with chronic low back pain have not been as positive as those of patients with acute pain. The issue has been complicated by inconsistency between studies, with some showing a bene- ficial effect on pain but not disability, and others reaching the opposite con- clusion. However, in none of the stud- ies has it been shown that manipu- lation is less effective than any treatment approach with which it has been compared. In their systematic re- view, van Tulder et al 24 concluded that there was strong evidence that ma- nipulation was more effective than pla- cebo and moderate evidence that ma- nipulation was more effective than several other treatments with which it had been compared. Brønfort 23 con-

cluded that there was moderate ev- idence of a short-term effect of ma- nipulation in chronic low back pain but inconclusive evidence of a long- term effect. In the review by the Swed- ish Council on TechnologyAssessment in Health Care in 2000, using the Cochrane Collaboration methodology, van Tulder and colleagues concluded that “there is strong evidence that man- ual therapy is more effective than a placebo treatment for short-term re- lief” 27 of acute low back pain, although they found insufficient evidence to de- termine whether it is better than other physical therapeutic interventions or drug therapy. In an examination of the literature on chronic low back pain, the authors found that “there is strong evidence that manual therapy provides more effective short-term pain relief than a placebo treatment” and mod- erate evidence that “manual therapy is more effective than usual care by the general practitioner, bed rest, an- algesics and massage for short-term pain relief.” 28 However, they also con- cluded that “there is limited and con- flicting evidence of any long-term ef- fects.” 28 Two recent studies have compared the treatment of back pain patients by chiropractors with that by various other providers. Skargren et al 38 ran- domized 323 patients with back and neck pain to chiropractic treatment or treatment by physical therapists. The authors found no significant overall difference in the cost or outcome of treatment. However, chiropractic treatment was favored in the group with a short duration and high level of symptoms, whereas physical ther- apy was favored in those with more chronic symptoms. Some questions have been raised about their conclu- sions because of restrictions that the experimental protocol placed on the chiropractic treatment. Nonetheless, the findings of Skargren et al 38 sug- gest overall similarity in benefit be- tween treatments incorporating SMT and those using intensive physical therapy.

Hurwitz et al 39 randomized 681 pa- tients with low back pain in a man- aged care setting to conventional med- ical treatment with or without physical therapy or to chiropractic care with or without physical modalities. They found that all groups improved over 6 months of follow-up without any significant differences in disability or pain between the patients treated by chiropractors and those treated by medical providers with or without physical therapy.Although these stud- ies 38,39 do not specifically address the question of benefit of SMT as an iso- lated intervention, their results argue that care incorporating spinal manip- ulation does at least as well as the best medical management.

Radiculopathy and Disk Herniation

While most studies on the effects of spinal manipulation on patients with radiculopathy and/or disk her- niation have been individual case reports or uncontrolled small case se- ries, there have been three random- ized clinical trials 40-42 and one nonran- domized clinical trial. 43 Most of the small studies had no control or com- parison group. The authors of the ran- domized clinical trials compared ma- nipulation with other nonsurgical measures (eg, traction, exercise, heat treatments), and all reported an ad- vantage for spinal manipulation at 2 to 6 weeks. 40-42 In one of the studies, patients were followed for 1 year, and no difference in relapse rates was re- ported. 42 The authors of the nonran- domized trial compared manipula- tion with surgical intervention and reported greater benefit with sur- gery. 43 A trial of single-session lum- bar rotary manipulation was report- ed to significantly (P = 0.0045) improve the abnormal H-reflex am- plitude in patients with unilateral lumbar disk herniation and radicu- lopathy; the abnormal H-reflex laten- cy showed insignificant improvement (P = 0.3877). 44 No complications or se- rious side effects that would preclude


Journal of the American Academy of Orthopaedic Surgeons

Rand Swenson, DC, MD, PhD, and Scott Haldeman, DC, MD, PhD, FRCPC

the use of manipulation in patients with radiculopathy were reported in any of the case series or trials. Manip- ulation is of uncertain benefit in pa- tients with radiculopathy, and well- designed studies in this area are needed. 45

Spinal Stenosis and Spondylolisthesis

No randomized clinical trials of patients with spinal stenosis, spondy- lolisthesis, or spondylolysis have been done. In their case series of pa- tients with spinal stenosis, Kirkaldy- Willis and Cassidy 46 reported favor- able results in the group treated with SMT. They also reported the respons- es of 283 consecutive patients with low back pain to spinal manipulation, 25 of whom had spondylolisthesis. 46 The response was similar to that not- ed in the other patients, and no ad- verse outcomes were reported.

Management of Common Disorders

Premanipulation Examination

The premanipulation evaluation of patients is similar to the routine or- thopaedic assessment of patients with low back pain, but with certain char- acteristics unique to practitioners of manipulation. The three-step process of evaluation consists of establishing a diagnosis, determining whether the patient is a candidate for spinal ma- nipulation, and deciding on the type of manipulation that should be used. Elements of the clinical history, in- cluding the mechanism and timing of onset of the symptoms, as well as ag- gravating and relieving activities and the effects of posture on symptoms, are useful for establishing the treat- ment plan and predicting the likeli- hood of effectiveness of a course of treatment. Many practitioners of spinal ma- nipulation, especially chiropractors, use radiographs to evaluate patients. Radiographs may help the practi-

Vol 11, No 4, July/August 2003

tioner determine the integrity of the underlying osseous structure to with- stand the forces used in the treatment. They also may help in the analysis of spinal distortions and postural rela- tionships that have been perceived as important in planning the type of manipulation. Although the former use of radiographs is clearly impor- tant, the latter is controversial. Radio- graphs, with certain exceptions, have not been shown to be predictive of spinal symptoms. Although there appears to be reasonable reliability in chiropractic interpretation of radio- graphic findings, it has yet to be established that the postural mark- ings of relative vertebral position con- tribute to treatment effect and out- comes. Radiographs often are necessary to aid in the appropriate premanipula- tion evaluation of patients with back pain. Before January 2000, Medicare required radiographic demonstration of a subluxation for all patients treat- ed by chiropractors, forcing most of- fices to maintain their own facilities. With the change in Medicare regula- tions and the revision of medical eth- ics allowing referral to chiropractors, medical radiographic facilities have become more accessible to chiroprac- tors. Also, radiologists have become more aware of the studies required by chiropractors, and there is a trend in the chiropractic community to re- fer patients to medical facilities for the necessary studies. The primary diagnostic proce- dures used to determine the type of manipulation that may be most ben- eficial are postural analysis and man- ual palpation of the spine and paraspinal tissues. Of these two pro- cedures, palpation is the most fre- quently applied for the identification of the manipulable lesion (eg, sublux- ation, fixation, osteopathic lesion). Static palpation, done with the patient in a relaxed (usually prone) position, is used to detect areas of muscle ten- sion, tenderness, spasm, and segmen- tal differences in tissue consistency.

This is often followed by motion pal- pation, in which the clinician palpates individual spinal motion segments through various ranges of motion, evaluating each direction of motion for restriction and asymmetry of movement. Interexaminer reliability and reproducibility of these proce- dures is not high. 47 Intraexaminer reliability is higher for some pro- cedures, but this is of uncertain value. 47

Spinal Manipulation Techniques

SMT for low back pain can be di- vided into three procedures: those preparatory to manipulation, manip- ulation itself, and those subsequent to manipulation. Preparatory treat- ments, such as cryotherapy, various types of stretching, and soft-tissue massage or reflex techniques, are usu- ally done to relax the patient, reduce tension, and ease acute pain. When the pain is acute and severe or when significant muscle spasm is evident, such treatments often are followed by mobilization procedures rather than a specific manipulation. If the preparatory therapies relax the patient sufficiently, spinal manip- ulation with impulse is applied to one or more of the abnormal spinal seg- ments identified during examination. In the lumbar spine, the manipulative force may be directed in a posteroan- terior direction on one of several spi- nal contacts, with the patient prone on a segmented table or plinth (Fig. 3). However, the most common lum- bar manipulation is done with the pa- tient in a side-lying position (Fig. 4), with the lower leg straight and the upper leg bent at the hip and knee. The upper body is braced by putting one hand on the patient’s shoulder, traction is placed on the uppermost leg to produce rotational locking of the facet joints, and a thrusting im- pulse is administered at one of sev- eral spinal contact points. Depending on the findings in the postural and palpatory examination, the manipu- lative thrust can be applied to the


Spinal Manipulative Therapy for Low Back Pain

Spinal Manipulative Therapy for Low Back Pain Figure 3 Prone, short-lever technique with a primary vector

Figure 3 Prone, short-lever technique with a primary vector of thrust from posterior to anterior. Contact is directly on one of several spinal contact points, and the thrust can be delivered with torque, depending on the type of movement desired.

spinous or transverse process, the sacrum, the ilium, or, in the case of long-lever techniques, the leg (Fig. 5). It is not uncommon for spinal manip- ulation to be applied to the thoracic and cervical spine even when the pri- mary symptoms are in the lumbar re- gion. The rationale for this approach is that there is interdependence be- tween regions of the spine to allow proper movement and that each area contributes to correct posture and motion. Although attractive, this rea- soning is largely hypothetical. Flexion-distraction treatment has been recommended for patients with disk herniation and has found favor with many manipulative practi- tioners. The patient is placed on a spe-

practi- tioners. The patient is placed on a spe- Figure 4 nipulative technique. Side-lying, short-lever

Figure 4

nipulative technique.

Side-lying, short-lever spinal ma-

cial table that introduces continuous mobilization of the lumbar spine while manual contact and force are applied to introduce an element of di- rected intersegmental lumbar trac- tion. Although there is some evidence that this approach can increase the mobility of the lumbar spine and also cause some expansion of the interver- tebral disk in the same manner as oth- er traction procedures, its efficacy has yet to be demonstrated in random- ized clinical trials. Spinal manipulative treatment is usually followed by postural and er- gonomic advice, recommendations for home exercise, and nutritional and lifestyle recommendations. Many practitioners also offer supports or orthotics in the hope of reducing pos- tural factors that may cause recur- rence of pain. Increasing numbers of chiropractors and practitioners in in- terdisciplinary treatment centers are incorporating spinal manipulation as part of a comprehensive rehabilita- tion process. A major topic of contention and confusion is the number of manipu- lative treatments that are reasonable and necessary to achieve optimal re- sults. The consensus is that some de- gree of improvement may be expect- ed within 2 weeks of treatment at a frequency of three to five treatments per week. 48 Lack of improvement af- ter 4 weeks, or 12 treatments, is rea- son to discontinue treatment until fur- ther examination of the patient has been done. 48 If the patient shows pro- gressive improvement of symptoms at 4 weeks, treatments may be tapered to two per week, then to one. How- ever, most patients with acute or ep- isodic uncomplicated low back pain respond to just a few treatments and tend to return only when there is re- currence of pain. Standard treatment protocols suggest that patients should be reevaluated every 2 weeks to de- termine whether the treatment is suc- cessful. 48 Such protocols are not very different from those for physical ther- apy, exercise, medication, and other

for physical ther- apy, exercise, medication, and other Figure 5 nipulative technique. Side-lying, long-lever spinal

Figure 5

nipulative technique.

Side-lying, long-lever spinal ma-

nonsurgical treatments for low back pain. The primary difference between the treatment protocols for chronic low back pain and those for acute pain is that, with chronic back pain, a lesser intensity of initial treatment and a longer duration of overall ther- apy is common. Ergonomics, lifestyle, and exercise recommendations also play a greater role in the treatment of patients with chronic back pain. The treatment of asymptomatic or minimally symptomatic individuals on a prophylactic or maintenance ba- sis has been controversial among practitioners of SMT in general and chiropractors in particular. Current- ly, there is no evidence that prophy- lactic treatment either prevents or modifies the occurrence of subse- quent back problems or the appear- ance or course of other disorders.


Serious complications caused by spi- nal manipulation are rare and very poorly documented. 2 There have been a few case reports of herniated intervertebral disks and even of cau- da equina syndrome 3 after manipu-


Journal of the American Academy of Orthopaedic Surgeons

Rand Swenson, DC, MD, PhD, and Scott Haldeman, DC, MD, PhD, FRCPC

lation. The precise incidence of these complications is unknown and is probably underreported, although even the degree of underreporting is not known. Shekelle et al 3 estimated the serious complication rate for lum- bar manipulation at 1 in 100 million manipulations, but that conclusion was based solely on reported cases. Senstad et al 49 reported that minor, self-limited side effects of manipula- tion are quite common. The most typ- ical reactions, usually lasting less than 24 hours but occasionally as long as 48, were local discomfort in the area of treatment, pain in areas other than that of treatment, fatigue, and head- ache. None of the clinical trials of lumbar manipulation reported any complications, which indicates that spinal manipulation is a relatively safe form of lumbar spine treatment and is considerably safer than many of the medications that can be used either alone or in combination with SMT to manage back pain.


Physical force should not be placed on a spine that cannot structurally withstand it. Therefore, destructive lesions of the spine, acute fracture, or osteomyelitis are absolute contrain- dications to lumbar manipulation. Osteoporosis and bleeding disorders are conditions that mandate caution, especially when considering impulse manipulation. Rheumatoid disease with acute inflammation or ligamen-

tous instability is also a contraindi- cation to forceful manipulation, but mobilization and massage may be considered in specific situations. Pa- tients who take medications that could affect the appropriateness of SMT, such as long-term glucocorti- coids or anticoagulants, also may be unsuitable. The presence of disk herniation or severe spondylosis often requires

modification of the treatment ap- proach, but they are not absolute con- traindications to spinal manipulation

in the absence of neurologic deficit.

Progressive neurologic deficits or cauda equina syndrome are absolute contraindications to spinal manipu- lation. However, patients with stable, long-standing, thoroughly evaluated neural defects may be considered as candidates.


Spinal manipulation is a common and generally safe method of lower back pain therapy. Research indicates that SMT for acute and chronic back pain

provides at least short-term benefits.

A growing number of patients with

back pain are treated with manipu- lation, and most express a high de- gree of acceptance of and satisfaction with such procedures. Because of this patient satisfaction, as well as a grow- ing awareness of the clinical trials sup- porting the effectiveness of manipu- lative procedures to treat specific categories of patients with back pain,

SMT and its practitioners have been incorporated into conventional med- ical settings. This assimilation is ex- pected to continue, and models of treat- ment participation and cooperation are being developed and refined. Ma- nipulation therapies in general and chi- ropractic treatments in particular are now covered by Medicare and most health insurance and HMO plans. The primary motivation for inclusion has been demand by patients and insur- ance plan subscribers for such services. The intense scrutiny of spinal ma- nipulative procedures that has been the hallmark of the past decade can be expected to continue. With a more established research infrastructure, it should be easier to conduct studies in multidisciplinary settings. Many questions remain unanswered, such as whether particular subgroups of pa- tients with back pain are more likely tobenefitfrommanipulativetreatments and whether certain manipulative tech- niques are markedly more efficacious or hazardous than others. Identifica- tion of the mechanism through which manipulation affects symptoms is un- der increasing investigation. Compar- ative studies with other forms of treat- ment, as well as studies to determine whether there are added benefits of combining treatment modalities, are ongoing. Further research should de- fine the exact role of spinal manipu- lation in the treatment of patients with low back pain, the optimal duration and intensity of treatment, and the cost- effectiveness of SMT relative to other treatment options.


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44. Floman Y, Liram N, Gilai AN: Spinal manipulation results in immediate H-reflex changes in patients with uni- lateral disc herniation. Eur Spine J 1997;


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46. Kirkaldy-Willis WH, Cassidy JD: Spinal

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manipulation in the treatment of low- back pain. Can Fam Physician 1985;31:


47. Hestbœk L, Leboeuf-Yde C: Are chiro- practic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. J Manipulative Physiol Ther 2000;23:258-275.

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Extensor Mechanism Failure Associated With Total Knee Arthroplasty: Prevention and Management David A. Parker, MBBS,

Extensor Mechanism Failure Associated With Total Knee Arthroplasty: Prevention and Management

David A. Parker, MBBS, Michael J. Dunbar, MD, and Cecil H. Rorabeck, MD


Extensor mechanism complications are the most commonly reported reasons for re- vision surgery after total knee arthroplasty and are a frequent source of postoper- ative morbidity. Patellofemoral instability is the most commonly reported extensor mechanism complication and has multiple etiologies, including prosthetic malalign- ment and soft-tissue imbabalce. Patellar fracture or rupture of either the quadriceps or patellar tendon can cause catastrophic disruption of the extensor mechanism. Al- though some stable fractures can be successfully managed nonsurgically, displaced fractures or tendon rupture often lead to poor results. Other complications include patellar clunk and soft-tissue adhesions, prosthetic wear or loosening, and osteone- crosis. Increased understanding of implant alignment, rotation, and soft-tissue bal- ance, as well as improved design of the trochlear groove of femoral implants and patellar components, has resulted in a decline in extensor mechanism complications. Appropriate prosthetic selection and meticulous surgical technique remain the keys to avoiding unsatisfactory results and revision surgery.

J Am Acad Orthop Surg 2003;11:238-247

As many as 50% of revision total knee arthroplasty (TKA) procedures have been attributed to patellofemoral com- plications. 1 The incidence of these com- plications has decreased markedly as surgical techniques and component design have been refined. Earlier studies 2-4 reported incidences of 10% to 35%; more recent studies 5,6 cite rates of 1% to 12%. However, patellofemo- ral complications continue to be a sig- nificant source of postoperative mor- bidity and revision surgery. Possible complications include patellofemoral instability, extensor mechanism dis- ruption, soft-tissue impingement, prosthetic wear or loosening, and os- teonecrosis.

Prosthetic Design

Early prosthetic designs did not al- low the option of patellar resurfacing.

Initial experiences with unresurfaced patellae revealed a high rate of per- sistent patellofemoral discomfort among patients with rheumatoid ar- thritis or osteoarthritis, which stim- ulated the development of a patellar implant. Based on an anatomic study of 80 arthritic patellas, Aglietti et al 7 initially described a dome-shaped pa- tellar prosthesis for use with TKA. Subsequently, both symmetric dome- shaped and asymmetric, conforming, anatomic-shaped designs have be- come widely used. Hsu and Walker 8 reported that increased conformity of the patellar component decreased the predicted amount of deformation and wear, whereas Matsuda et al 9 found that conforming patellas had higher contact stresses than did dome- shaped implants, which reduced the load sharing between the patellar component and the quadriceps ten- don. Both types of component dem-

onstrated contact stresses higher than the yield strength of polyethylene. Nevertheless, satisfactory long-term results have been reported with both conforming and dome-shaped com- ponents. Whichever style is used, it is important that the patellar compo- nent be an appropriate match to the femoral component throughout the full range of motion. 5,6 The high failure rate of metal- backed prostheses during the 1980s led to the development of all- polyethylene patellar components (Fig. 1). Failure of the metal-backed implants was predominantly caused by wear of the thin polyethylene with resultant metallosis and, less com- monly, by loosening of the uncement- ed implants. Also, patellar implants should have multiple small pegs be- cause a single large peg produces a

Dr. Parker is Orthopaedic Fellow, University Hos- pital, University of Western Ontario, London, ON, Canada. Dr. Dunbar is Assistant Professor, Department of Orthopaedics, QE II Health Sci- ences Centre, Dalhousie University, Halifax, NS, Canada. Dr. Rorabeck is Professor, Department of Orthopaedic Surgery, University Hospital, Uni- versity of Western Ontario.

One or more of the authors or the departments with which they are affiliated has received some- thing of value from a commercial or other party related directly or indirectly to the subject of this article.

Reprint requests: Dr. Rorabeck, 339 Windermere Road, London, ON N6A 5A5, Canada.

Copyright 2003 by the American Academy of Orthopaedic Surgeons.


Journal of the American Academy of Orthopaedic Surgeons

David A. Parker, MBBS, et al

David A. Parker, MBBS, et al Figure 1 Three types of patellar implant components. Left, All-polyethylene

Figure 1 Three types of patellar implant components. Left, All-polyethylene component with single central peg. Center, All-polyethylene component with three pegs. Right, Metal- backed component.

greater increase in patellar strain and may cause fracture. 2 Femoral component design is also an important factor in patellofemo- ral function. Kirk et al 10 compared two different prosthetic designs and con- cluded that the higher incidence of pa- tellofemoral complications with a spe- cific implant was caused by the less anatomic design of the femoral com- ponent. Mont et al 6 attributed the elim- ination of patellofemoral complications primarily to improvements in femo- ral component design, especially in relation to patellofemoral contact. Early improvements in the femoral compo- nent included the addition of a troch- lear flange and a more anatomic troch- lear groove that improves patellar tracking. A broad, deep trochlear groove is important to accommodate the patellar component congruently throughout the full range of motion. Eckhoff et al 11 showed that the trochlear groove lies lateral to the midplane be- tween the femoral condyles along a line between the anatomic and me- chanical axes of the femur. Therefore, the component groove should extend far enough distally to contain the pa- tella in deep flexion. Such prosthetic design improvements have positively affected patellofemoral function after TKA. Improved surgical technique also has helped decrease the incidence of complications, as has greater appreci- ation of the importance of femoral and tibial component rotation, joint line alteration, and soft-tissue balancing. Although both anatomic and clin- ical studies support the use of an

asymmetric femoral component, Har- win 5 reported only a 0.6% rate of sub- luxation using a symmetric femoral component design. No advantage has been shown to using an asymmetric trochlear groove and/or asymmetric component; in fact, surgical technique may be the most critical factor. 12 In a patient whose patella is not resur- faced, the femoral component should be compatible with the native patel- la, including a long, deep trochlear groove. However, no designs have been able to exactly reproduce nor- mal kinematics, and no femoral com- ponent has been designed specifical- ly for the native patella. Thus, the longevity of the articulation between the native patella and the prosthetic trochlea requires further study.

Patellofemoral Instability

Patellofemoral instability has been one of the most common reasons for re- vision surgery after TKA(Fig. 2), with

a reported incidence of subluxation

and/or dislocation as high as 27% in earlier series. 3,4 Recent studies 5,6 have shown the benefit of improved sur- gical technique and prosthetic design, with reported incidences of sublux- ation and/or dislocation 1%. Insta- bility may be related to several fac- tors, including femoral and patellar component design, as well as mal- alignment of any of the three compo- nents, malrotation of the femoral or tibial component, or soft-tissue imbal- ance. Instability also may be related to overstuffing of the patellofemoral joint or to asymmetric resection of the patella. Preoperative patellar sublux- ation or dislocation should be assessed because it may indicate an anatomic imbalance that would predispose to postoperative instability, which should be addressed intraoperatively. Patellar component positioning has an important effect on patellar tracking. In a cadaveric model, cen- tral placement achieved optimal pa- tellofemoral mechanics, and medial

placement produced increased patel- lar tilt. 13 However, most authors 5,6 still advocate some medialization to avoid

a laterally placed component, which

would increase the risk of sublux- ation. Reproducing the normal patel- lar thickness is important because ex- cessive resection can predispose to fracture, and inadequate resection will result in limited flexion and pa- tellar maltracking. An oversized or anteriorly positioned femoral compo- nent also can lead to increased patel-

femoral compo- nent also can lead to increased patel- Figure 2 Patellar instability 3 years after

Figure 2 Patellar instability 3 years after initial TKA. A, Sunrise radiograph of a lateral sub- luxation of an unresurfaced patella. B, Sunrise view of a lateral dislocation of a resurfaced patella.

Vol 11, No 4, July/August 2003


Extensor Mechanism Failure Associated With TKA

lofemoral pressure. Asymmetric pa- tellar resection frequently leads to patellar tilt and instability. Femoral and tibial component alignment also is critical. Correct ax- ial alignment is important for all as- pects of TKA function; in an ideal alignment, the weight-bearing line is placed at the center of the knee joint. Knees with fixed preoperative valgus or varus alignment can develop post- operative patellofemoral instability if the deformity remains uncorrected. Lynch et al 2 found an increased inci- dence of subluxation in patients with preoperative valgus alignment that was not corrected intraoperatively. Kirk et al 14 reported on a series of 15 knees with patellar dislocation after TKA, of which 13 had preoperative varus alignment. Preservation of the level of the joint line also has been shown to be important in decreasing patellofemoral complications by avoiding elevation of the joint line and patella baja. 15 Femoral and tibial component ro- tation is critical to patellar stability. Internal rotation of the femoral com- ponent will medialize the trochlear groove relative to the patella, result- ing in lateral subluxation. Similarly, excessive internal rotation of the tib- ial component will cause lateraliza- tion of the tibial tubercle, also result- ing in lateral patellar subluxation. Berger et al 16 found a direct correla- tion between combined internal ro- tation of the two components and the severity of patellofemoral complica- tions. Akagi et al 17 found improved patellar tracking and less frequent lat- eral retinacular releases done in knees with femoral components externally rotated to the posterior condylar axis compared with those parallel to the axis. Femoral component rotation can be assessed in several ways. Techniques for cutting the femur parallel to the transepicondylar axis, perpendicular to the anteroposterior axis, or exter- nally rotated 3° to the posterior condy- lar axis have been described, 18 and


each of these axes should be assessed (Fig. 3). The posterior condyles also can be cut parallel to the tibial cut with the flexion gap tensioned and the knee at 90° of flexion. When using the pos- terior condylar axis, it is important to assess for lateral condylar wear and hypoplasia, particularly in the valgus knee, because these can lead to inter- nal rotation of the femoral component. Poilvache et al 18 found the transepi- condylar axis to be the most reliable guide; this axis also has been shown to most closely approximate the flex- ion axis of the knee. In practice, it is prudent to observe all of the available anatomic landmarks; the transepi- condylar axis is probably the best guide if significant disparity exists. Tibial component rotation also is important, particularly in more con- forming designs. The center of the component should be in line with the medial third of the tibial tubercle or internally rotated 18° compared with the plane of the tubercle. 16 Sufficient surgical exposure of the entire tibial plateau is necessary to visualize land- marks for accurate assessment of com- ponent alignment. Excessive internal rotation must be avoided because it will lateralize the tubercle. Placement of femoral and tibial components in the coronal plane also is important. Medial placement of the femoral com- ponent medializes the trochlear groove, and medial placement of the tibial component lateralizes the tuber- cle; both can cause lateral subluxation of the patella. Although these com- ponents generally should be centered over the condyles, lateralization of both components is indicated if the patient’s anatomy cannot be perfect- ly matched. Assessment of patellar tracking should be done intraoperatively with trial implants and after implantation of definitive implants. Use of a thigh tourniquet can alter patellofemoral tracking; if maltracking exists, the tourniquet should be deflated and tracking reassessed before lateral ret- inacular release. The patella should

before lateral ret- inacular release. The patella should Figure 3 Axes of femoral component rota- tion.APA=

Figure 3 Axes of femoral component rota- tion.APA= anteroposterior axis, TEA= trans- epicondylar axis, TFG = tensioned flexion gap, PCA = posterior condylar axis. (Reprinted with permission from Lonner JH, Lotke PA:

Aseptic complications after total knee arthro- plasty. J Am Acad Orthop Surg 1999;7:311-


independently track centrally within the trochlear groove without any tilt- ing or subluxation. This overesti- mates the need for lateral release be- fore closure of the knee joint because of the detachment of the vastus me- dialis muscle and medial retinaculum during exposure. Therefore, it is ap- propriate to place a single suture or towel clip in the extensor mechanism when testing tracking intraoperative- ly to better mimic the postoperative setting. If tilting or subluxation re- mains, all facets of component align- ment should be checked and, if nec- essary, corrected (Table 1). If there is no identifiable compo- nent malalignment or malrotation, then the etiology most likely relates to soft-tissue imbalance. A tight lat- eral retinaculum can lead to sublux- ation and should be addressed with a lateral release. Lynch et al 2 advised doing retinacular release well lateral to the patella to avoid the circum- patellar anastomosis. To avoid in- creasing the risk of quadriceps ten- don rupture, the release should not extend medially at its proximal ex-

Journal of the American Academy of Orthopaedic Surgeons

David A. Parker, MBBS, et al

Table 1 Potential Problems in the Presence of Patellar Subluxation Before Considering Lateral Retinacular Release


Potential Problems


Femoral component

Internally rotated

Revise position Revise position Downsize component Revise position Revise position Measure thickness before resection and reproduce with implant Release and recheck tracking

Medially translated


Tibial component

Internally rotated



Patellar component

Original thickness not reproduced (over- stuffed) Quadriceps restricted


tent, and division of the vastus lat- eralis insertion to the superolateral patella should be avoided. If this does not correct the problem, the proximal realignment can be completed by ad- vancing the vastus medialis muscle as part of the closure. Lateral release and proximal realignment usually correct most degrees of patellar sub- luxation. If frank dislocation or per- sistent subluxation is not corrected by proximal realignment, tibial tubercle malposition may be the cause, and a tubercle transfer may be required. Earlier studies indicated a high com- plication rate with distal realignment and recommended proximal realign- ment only, cautioning against the use of tubercle transfer. 19 However, in lat- er studies, satisfactory correction of patellar maltracking was achieved with this technique with minimal complications. 14,20 Kirk et al 14 report- ed 15 cases of patellar dislocation af- ter TKA that were all successfully treated using a modification of the Trillat procedure. The osteotomy should consist of a long fragment and should be tapered distally to avoid a stress riser. Fixation can be done with either screws or wires (Fig. 4). Trans- fer of the tibial tubercle is rarely nec- essary, and correct component align- ment and soft-tissue balance should ensure good patellar tracking in most cases.

Extensor Mechanism Disruption

Patellar Fracture

Patellar fracture is an uncommon complication of TKA (Fig. 5). Al- though the reported incidence rang- es from 0% 4 to 6%, 21 most series 2,5,6,22 report an incidence of 1% to 2%, with occurrence more common in men than in women. Such fractures usu- ally are described on the basis of lo- cation, integrity of the extensor mech- anism, and stability of the implant.

Goldberg et al 23 described a classifi- cation for patellar fractures compli- cating TKA based on the integrity of the extensor mechanism and fixation of the patellar implant. They found that fractures not associated with


anism disruption, or major malalign- ment generally had good results with nonsurgical management. Other frac- tures required surgery, with a high proportion of unsatisfactory results. Most fractures usually are vertical (similar to stress fractures), without disruption of the extensor mecha- nism, and often are incidental find- ings that require no specific manage- ment. In most series 3,5,6,24 of postoperative patellar fractures, more than half were managed nonsurgical- ly with good or excellent results. Intraoperative fractures are more common in revision surgery but can occur in primary cases, especially if the patella is particularly thin. It is im- portant to avoid overreaming or ec- centric reaming, overcompression of the patellar clamps during reaming, and slippage of the reamer. Resurfac- ing patellas that are <10 mm thick re- quires extra care to avoid fracture; im- plants with increased thickness can

to avoid fracture; im- plants with increased thickness can Figure 4 Tibial tubercle osteotomy used for

Figure 4 Tibial tubercle osteotomy used for exposure during revision of failed TKA caused by metal-backed patellar implant wear with extensive metallosis. A, Long tapered fragment with intact lateral soft tissues. B, Wires through the medial tibial cortex, with proximal wire through the tubercle and the distal two wires around the tubercle. C, Wires tightened and tubercle secured.

Vol 11, No 4, July/August 2003


Extensor Mechanism Failure Associated With TKA

Extensor Mechanism Failure Associated With TKA Figure 5 Patellar fractures. A, Sunrise radiograph of a vertical

Figure 5 Patellar fractures. A, Sunrise radiograph of a vertical fracture with stable implant. B, Sunrise view of a vertical fracture with unstable implant. C, Lateral view of a transverse fracture with unstable implant.

help minimize resection and restore patellar height in such cases. 25 Postoperative fractures may be nontraumatic or traumatic. Nontrau- matic fractures may be associated with any of several possible risk fac-

tors. Resurfacing of the patella has been shown to be associated with a higher rate of fracture. 3,26 Other risk factors include those related to the pa- tient (eg, osteoporosis 1 ) and implant (eg, central peg design, 25 cementless

implants 23 ). Technical factors include excessive or inadequate resection, devascularization of the patella, and patellar subluxation. 26 Malalignment of the limb and implant malrotation also have been associated with in- creased risk of patellar fracture. 16,27 Nontraumatic fractures are usually associated with one or several of these risk factors, especially osteonecrosis. The role of lateral retinacular release in nontraumatic fractures is unclear. Healy et al 22 found increased inci- dence of fracture after lateral release, whereas Ritter and Campbell, 24 in a large series, did not. The technical procedures that add to the risk of os- teonecrosis also increase the risk of fracture (eg, quadriceps turndown). Traumatic postoperative fractures may result from a direct trauma or an indirect cause, such as eccentric quad- riceps muscle contraction resulting in a proximal avulsion. Management depends on the frac- ture pattern, stability of the implant, and integrity of the extensor mech- anism (Fig. 6). Many fractures are asymptomatic and occur with stable implants and an intact extensor mechanism. Such fractures can be

Patellar fracture Transverse Vertical Stable implant Unstable implant Stable implant Unstable implant Extensor
Patellar fracture
Stable implant
Unstable implant
Stable implant
Unstable implant

Figure 6

London Health Sciences Centre algorithm for the management of patellar fractures.

David A. Parker, MBBS, et al

managed nonsurgically, usually with good or excellent results. Fractures with extensor mechanism disruption

movement. Unfortunately, surgical repair has had largely unsatisfactory results in the small series reported,

the knee. If this is difficult, ancillary methods should be used. Careful pos- teromedial dissection from the tibia

or dislocation and/or unstable im-

with persistent extensor lag and lim-


important to allow external rotation

plants require surgical treatment and

ited range of motion. 2


the tibia, which markedly decreas-

have poor results in more than half


tension at the tendon insertion. If

of cases. 23,25 Alignment of the implant

Patellar Tendon Rupture

excessive tension remains, a quadri-

infrapatellar scar tissue also is useful.

also is important because knees with major malalignment have more se- vere fractures and the poorest out- comes. 23,27

Patellar tendon rupture is also un- common, but it is more frequently re- ported than quadriceps tendon rup- ture. Although earlier published incidences ranged from 0.2% to 5%, 2,28,29

ceps snip can be done; in revision sur- gery, a lateral release in association with division of the lateral gutter and

Occasionally, a tubercle osteotomy or

Quadriceps Tendon Rupture

reported incidences in later series were


quadriceps turndown may be nec-

Quadriceps tendon rupture is an extremely rare complication. 5,6,22 Lynch et al 2 reported an incidence of 1.1% in a series of 281 TKAs; other authors 26 have presented single case reports. With such small numbers, the etiology can only be speculated on and could include factors such as overresection of the patella with dam- age to the quadriceps tendon as well as vascular injury and incomplete healing after extended approaches such as V-Y turndown, manipulation, or trauma, particularly if there is pre- existing tendon degeneration. In the study by Lynch et al, 2 all three pa- tients with quadriceps tendon rup- ture had a lateral release, possibly in-

<1%, 5,6 suggesting a decreasing fre- quency of rupture as surgical technique improves. As with quadriceps tendon rupture, the low frequency makes study of etiology difficult. However, rupture should be preventable. In gen- eral, the patients most at risk are those with multiply operated knees. Possi- ble specific etiologies include a stiff knee that causes difficulty everting the patella during exposure; trauma with hyperflexion, including postoperative manipulation; multiple procedures with subsequent devascularized tis- sue; and patient factors (eg, chronic steroid use, systemic disease). 2,30 Dis- tal realignment procedures have been implicated, 29 as has excessive patel-

essary. Treatment of tendon rupture can be difficult and has generally had un- satisfactory results, with few patients regaining full active extension or a satisfactory degree of flexion. 29,30,32 Repair can be primary, with or with- out autograft augmentation, or with allograft reconstruction. If there is partial avulsion or avulsion with an intact periosteal sleeve, the tendon can be reattached primarily to bone either through drill holes or with su- ture anchors 33 or staples. 29 This repair can be augmented using a semiten- dinosus or gracilis tendon autograft left attached distally, particularly if the quality of the primary repair is

dicating reduced vascularity as an etiologic factor. Anterior extension of lateral release also may contribute to

lar resection with damage to the ex- tensor mechanism. 31 Component mal- alignment 27 and hinged implants 4 also

poor or if there is soft-tissue defect. 30 Primary repair of late ruptures gen- erally has had poor results. 29 Abril et

rupture and should be avoided.

are thought to place increased stress


34 reported two cases of tendon rup-

Treatment of the rupture requires

on the extensor mechanism.

ture 1 month after TKA, with success-

direct repair of the tendon. Rupture usually occurs near the distal inser- tion; thus, the tendon can be repaired

Rupture can occur intraoperative- ly, in the immediate postoperative period, or as a delayed complication.

ful primary repair through drill holes and support by a figure-of-8 wire for 3 months. These results are difficult

directly to bone via drill holes or su-

Intraoperative avulsion can occur

to reproduce with a direct repair, and

ture anchors using nonabsorbable su-

during exposure of a stiff knee if ex-

a more extensive reconstruction is

tures. Suture anchors are preferable if patellar bone stock is limited be- cause drill holes may compromise the implant. Supplementation with an al- lograft may be required if there is any deficiency in the extensor mechanism that would prevent satisfactory re-

cessive force is applied to the tendon attachment while the patella is evert- ed and the knee flexed. Rupture can occur in the early postoperative pe- riod, such as during manipulation, at any stage as a result of trauma, or as a delayed complication because of

usually indicated. Cadambi and Engh 30 described a technique in which a semitendinosus tendon autograft is left attached dis- tally and used to augment the patel- lar tendon by passing it along the me- dial border of the tendon through a

pair. The knee is held in full exten-

chronic attrition, such as may occur

drill hole in the patella and suturing

sion for 6 weeks postoperatively be-

with impingement against the tibial


to itself distally. Although the mean

fore beginning gradual restoration of motion, with the priority being du- rable healing of the repair rather than rapid restoration of full preoperative

insert. 31 Preventing this complication re- quires vigilance during exposure when everting the patella and flexing

extensor lag was 10° and flexion only 79°, the authors concluded that this technique was superior to primary re- pair or allograft reconstruction.

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Extensor Mechanism Failure Associated With TKA

Allograft reconstruction was first described by Emerson et al, 31 who used an allograft of quadriceps ten- don, a patella with a cemented pros- thesis, the patellar tendon, and the

tibial tubercle. The tibial tubercle was attached to the tibia with two screws and a tension band wire. The quad- riceps tendon allograft was then placed on slight tension and attached

to host tendon, with the patella main-

tained in the appropriate position on

the femoral component. One third of patients had extensor lag ranging

from 20° to 40°, and there was a high complication rate. However, the au- thors still considered this technique

a satisfactory option for extensor

mechanism deficiency. They suggest-

ed that resurfacing of the allograft pa-

tella was unnecessary. In a larger series, Nazarian and Booth 35 described a modification of this technique using fresh-frozen al- lograft with unresurfaced patellas and the allograft tensioned with the knee in full extension. The mean ex- tensor lag was 13° in 15 of 36 patients and the mean flexion, 98° in all pa- tients. Although the authors quoted a success rate of 34 of 36 patients, 8 required repeat allograft and 12, a

walking aid. Leopold et al 32 also re- ported a high rate of failure using the technique described by Emerson et

al, 31 with progressive extensor lag and

dependence on walking aids. They suggested that improvements were required to tension the graft intraop- eratively and that alternative tech- niques should be considered. Other techniques have been described, including the use of a medial gastroc- nemius flap, 36 use of synthetic liga-

ment augmentation, 37 and patello- tibial fusion, 38 all with small numbers, short follow-up, notable complica- tions, and persistent extensor lag. Delayed rupture of the patellar tendon also can be repaired using an Achilles tendon allograft. The al- lograft, attached to a fragment of cal- caneus, is inset into the tibia and fixed

in that position. The Achilles tendon


is split and wound in a figure-of-8 fashion, through either the extensor mechanism or the patella. The former approach minimizes the risk of fur- ther devitalizing the blood supply to the patella. The allograft is then su- tured back onto itself with the knee in full extension. Our experience with this technique in seven patients has been positive in terms of restoring ex- tensor function to the point that a brace is not required. Most patients are left with an extensor lag, but this has not proved to be problematic.

Patellar Clunk and Soft-Tissue Impingement

Patellar clunk is a well-recognized complication of posterior stabilized TKA, with a reported incidence of up to 3.5%. 39 It is caused by a prolifer- ation of synovial and fibrous tissue at the superior pole of the patella at the quadriceps tendon insertion. This proliferation of tissue is itself caused by articulation of the region with the sharp anterior flange of the inter- condylar notch in flexion. Presum- ably that, in turn, causes an inflam- matory reaction that subsequently leads to development of a fibrous nodule in the notch when the knee is flexed. When the nodule is of suf- ficient size, painful dislodgement oc- curs as the knee is actively extended from a flexed position. The dislodge- ment usually occurs at approximate- ly 30° of flexion and causes the pain- ful clunk for which the syndrome is named. Symptoms usually present a mean of 1 year after the procedure. 39 Prosthetic design seems to be the main risk factor for patellar clunk. Most newer prostheses have a small- er box with a deeper patellar groove and a more posterior position of the femoral cam, thereby decreasing the chance of soft tissue articulating with this region. The incidence of patellar clunk with these newer prostheses seems to be greatly reduced, although longer follow-up is necessary. Preven-

tion may be helped by excision of the synovium on the posterior aspect of the quadriceps tendon in this region. Although a trial of nonsurgical management may be undertaken, most patients with an established clunk require surgery to resolve the symptoms. Excellent results with ar- throscopic resection through a supero- lateral portal have been described, 39 although care must be taken to avoid scratching the femoral component or damaging the patellar polyethylene. An arthrotomy to remove this tissue

is a simple procedure with a relative-

ly rapid recovery time, especially if significant adhesions are expected to make arthroscopic visualization dif- ficult or if other problems with the prosthesis must be addressed. Recur- rence after successful removal is rare. Other complications related to ab- normal soft-tissue formation have been published. Thorpe et al 40 report- ed 11 patients (in a series of 635 ar- throplasties) who had painful patel- lofemoral dysfunction caused by intra-articular peripatellar fibrous bands. Nine of 11 implants were sta- bilized posteriorly and, although the etiology of the pathology is unknown, all patients had resolution of symp- toms after arthroscopic removal of the bands.

Patellar Component Wear and Loosening

Patellar component wear is usually

secondary to either maltracking or im- plant design. 4 Markedly higher fail- ure rates exist with polyethylene im- plants with metal-backed components than with cemented all-polyethylene components. 22 However, it is unusu-

al for wear of an all-polyethylene com-

ponent to be sufficient to require revision surgery. Although metal

backing of the patella improves load distribution, such implants have had

a high rate of failure, 41 primarily be-

cause the thin polyethylene rapidly wears and delaminates (Fig. 7), leav-

Journal of the American Academy of Orthopaedic Surgeons

David A. Parker, MBBS, et al

David A. Parker, MBBS, et al Figure 7 component from articulation with femoral component. Center, Worn

Figure 7

component from articulation with femoral component. Center, Worn delaminated polyeth- ylene. Right, Marked burnishing (arrow) of femoral component.

Failed metal-backed patellar implant. Left, Burnished metal backing of patellar

ing a metal-on-metal articulation. Of- ten, revision of the entire TKA is re- quired. Although some surgeons have had good results with metal-backed implants, most now advocate use of a cemented all-polyethylene compo- nent. Patellarcomponentlooseningisrare. Incidence of up to 2% has been not- ed, 42 but no cases of loosening have been reported in most recent large se- ries using cemented all-polyethylene implants. 5,6 However, loosening has been a reported problem with cement- less, metal-backed implants. Healy et al 22 found an increased rate of loos- ening in cementless implants and also reported loosening secondary to os- teonecrosis. Patients with high activ- ity levels and good range of motion are thought to be at increased risk, as are patients with malpositioned com- ponents or those with small central fixation lugs. Loosening also can oc- cur secondary to fracture, maltrack- ing, and osteolysis; in such cases, the underlying problem requires manage- ment. Improvements in femoral com- ponent rotation and femoral trochlear design should help decrease the prob- lem of patellar loosening.


The vascular supply to the patella has been well described in anatomic stud-

ies that have demonstrated extensive extraosseous and intraosseous sys- tems with contributions from all ge- nicular vessels. The extraosseous ves- sels form an anastomotic ring, which is damaged to some extent during ar- throplasty. The standard medial para- patellar approach divides the three medial contributors; lateral meniscec- tomy and lateral release can divide the two lateral contributors; and ex- cision of the infrapatellar fat pad can damage the inferior part of the ring. Patellar resurfacing can cause dam-

age to the intraosseous supply, put- ting the patella at risk for osteonecro- sis. Scuderi et al 43 reported decreased patellar vascularity on bone scan af- ter lateral release, but follow-up stud- ies showed possible revascularization within 60 days. In a large series of TKAs, Ritter and Campbell 24 report- ed no increase in osteonecrosis in pa- tients who had a lateral release. Healy et al, 22 in one of the few series about osteonecrosis in TKA, reported an in- cidence of 1.4% in 211 TKAs. Failure to recognize this complication is prob- ably the cause of the low reported in- cidence. The highest incidence is in patients who required a quadriceps turndown procedure for exposure in revision surgery. In our experience, radiographic evidence of osteonecro- sis with sclerosis and flattening or fragmentation developed in 8 of 29 TKAs in which quadriceps turndown procedures were done as part of the revision procedure (Fig. 8). The natural history of osteonecro- sis is poorly defined, except in symp- tomatic cases in which the sclerotic appearance and secondary fracture or fragmentation can be associated with prosthetic loosening. Prevention

Figure 8 Patellar osteonecrosis after quadriceps turndown. A, Lateral radio- graph demonstrating sclerosis and flatten-
Figure 8 Patellar osteonecrosis after
quadriceps turndown. A, Lateral radio-
graph demonstrating sclerosis and flatten-
ing of the patella. B, Sunrise radiograph
showing patellar flattening, fragmenta-
tion, and lateral subluxation.

Vol 11, No 4, July/August 2003


Extensor Mechanism Failure Associated With TKA

should include avoiding the turn- down approach and, theoretically, minimizing lateral releases and fat pad resection. Use of the subvastus approach also preserves most of the medial supply, although these mea- sures remain to be proved as effec- tive osteonecrosis prevention tech- niques. Management of established osteonecrosis involves treatment of secondary complications. If asymp- tomatic, nonsurgical management is indicated, whereas patellar fragmen- tation and prosthetic loosening neces- sitate removal of the implant and loose bony fragments. The remaining patella should be preserved as much as possible, although the prognosis is guarded.

Management of the Failed Patellar Component

Appropriate management of a failed patellar component depends primar- ily on the cause of failure. If a com- ponent requires revision because of wear or loosening, considerations should include techniques for pros-

thesis removal, evaluation of the pre- dicted remaining bone stock, the con- dition of the remainder of the extensor mechanism, and the state of the femoral component. If technically possible, revision of the patellar component is preferred because it restores the extensor mech- anism and provides better pain relief than does patellectomy or patello- plasty. However, when there is insuf- ficient bone stock to seat a compo- nent, the chance of failure is high and such revision should not be undertak- en. As mentioned, at least 10 mm of residual bone is required for resurfac- ing; the patella should be left unre- surfaced when <10 mm of bone re- mains. In such a situation, to avoid further loss of tension of the exten- sor mechanism, resection arthroplas- ty and patelloplasty with reshaping of the residual patella to match the femoral component is preferable to a patellectomy. Complete revision and synovectomy is necessary if a failed metal-backed component has caused damage to the femoral component with subsequent metallosis. 41 How- ever, Barrack et al 44 found that retain-

ing well-fixed, undamaged, well- aligned patellar components at the time of revision surgery for other components resulted in equivalent outcome to that achieved with suc- cessful reimplantation.


Extensor mechanism failure is the pri- mary reason for revision TKA. Ad- vances in prosthetic design and sur- gical technique have led to a marked decrease in the incidence of such com- plications, but they continue to be a notable source of morbidity and un- satisfactory results. Because many complications are difficult to manage and often have relatively poor results, prevention is the cornerstone of man- agement. Most of these complications can be avoided with appropriate prosthetic selection and attention to detail in surgical technique. When management is contemplated, a sys- tematic assessment of the specific causative factors of the complication should be done to determine and ap- ply the appropriate treatment.


1. Brick GW, Scott RD: The patellofemo- ral component of total knee arthroplas- ty. Clin Orthop 1988;231:163-178.

2. Lynch AF, Rorabeck CH, Bourne RB:

Extensor mechanism complications fol- lowing total knee arthroplasty. J Arthro- plasty 1987;2:135-140.

3. Cameron HU, Fedorkow DM: The pa- tella in total knee arthroplasty. Clin Orthop 1982;165:197-199.

4. Mochizuki RM, Schurman DJ: Patellar complications following total knee ar- throplasty. J Bone Joint Surg Am 1979;61:


5. Harwin SF: Patellofemoral complica- tions in symmetrical total knee arthro- plasty. J Arthroplasty 1998;13:753-762.

6. Mont MA, Yoon TR, Krackow KA, et al:

Eliminating patellofemoral complica- tions in total knee arthroplasty: Clinical and radiographic results of 121 consec- utive cases using the Duracon system. J Arthroplasty 1999;14:446-455.


7. Aglietti P, Insall JN, Walker PS, et al: A new patella prosthesis: Design and ap- plication. Clin Orthop 1975;107:175-187.

8. Hsu HP, Walker PS: Wear and deforma- tion of patellar components in total knee arthroplasty. Clin Orthop 1989;246:


9. Matsuda S, Ishinishi T, White SE, et al:

Patellofemoral joint after total knee ar- throplasty: Effect on contact area and con- tact stress. J Arthroplasty 1997;12:790-797.

10. Kirk PG, Rorabeck CH, Bourne RB:

Clinical comparison of the Miller Galante I and AMK total knee systems. J Arthroplasty 1994;9:131-136.

11. Eckhoff DG, Burke BJ, Dwyer TF, et al:

Sulcus morphology of the distal femur. Clin Orthop 1996;331:23-28.

12. Bindelglass DF, Dorr LD: Symmetry versus asymmetry in the design of to- tal knee femoral components: An unre- solved controversy. J Arthroplasty 1998;


13. Lee TQ, Budoff JE, Glaser FE: Patellar component positioning in total knee ar- throplasty. Clin Orthop 1999;366:274-281.

14. Kirk P, Rorabeck CH, Bourne RB, et al:

Management of recurrent dislocation of the patella following total knee arthro- plasty. J Arthroplasty 1992;7:229-233.

15. Figgie HE III, Goldberg VM, Heiple KG, et al: The influence of tibial- patellofemoral location on function of the knee in patients with the posterior stabilized condylar knee prosthesis. J Bone Joint Surg Am 1986;68:1035-1040.

16. Berger RA, Crossett LS, Jacobs JJ, et al:

Malrotation causing patellofemoral complications after total knee arthro- plasty. Clin Orthop 1998;356:144-153.

17. Akagi M, Matsusue Y, Mata T, et al: Ef- fect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop 1999;366:155-163.

18. Poilvache PL, Insall JN, Scuderi GR, et al: Rotational landmarks and sizing of

Journal of the American Academy of Orthopaedic Surgeons

the distal femur in total knee arthro- plasty. Clin Orthop 1996;331:35-46.

19. Grace JN, Rand JA: Patellar instability after total knee arthroplasty. Clin Orthop 1988;237:184-189.

20. Whiteside LA: Distal realignment of the patellar tendon to correct abnormal pa- tellar tracking. Clin Orthop 1997;344:


21. Clayton ML, Thirupathi R: Patellar com- plications after total condylar arthroplasty. Clin Orthop 1982;170:152-155.

22. Healy WL, Wasilewski SA, Takei R, et al: Patellofemoral complications follow- ing total knee arthroplasty: Correlation with implant design and patient risk fac- tors. J Arthroplasty 1995;10:197-201.

23. Goldberg VM, Figgie HE III, Inglis AE, et al: Patellar fracture type and progno- sis in condylar total knee arthroplasty. Clin Orthop 1988;236:115-122.

24. Ritter MA, Campbell ED: Postoperative patellar complications with or without lateral release during total knee arthro- plasty. Clin Orthop 1987;219:163-168.

25. Bourne RB: Fractures of the patella af- ter total knee replacement. Orthop Clin North Am 1999;30:287-291.

26. Grace JN, Sim FH: Fracture of the pa- tella after total knee arthroplasty. Clin Orthop 1988;230:168-175.

27. Figgie HE III, Goldberg VM, Figgie MP, et al: The effect of alignment of the im- plant on fractures of the patella after condylar total knee arthroplasty. J Bone Joint Surg Am 1989;71:1031-1039.

28. Lettin AW, Kavanagh TG, Scales JT:

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The long-term results of Stanmore total knee replacements. J Bone Joint Surg Br


29. Rand JA, Morrey BF, Bryan RS: Patellar tendon rupture after total knee arthro- plasty. Clin Orthop 1989;244:233-238.

30. Cadambi A, Engh GA: Use of a semi- tendinosus tendon autogenous graft for rupture of the patellar ligament af- ter total knee arthroplasty: A report of seven cases. J Bone Joint Surg Am 1992;


31. Emerson RH Jr, Head WC, Malinin TI:

Extensor mechanism reconstruction with an allograft after total knee arthro- plasty. Clin Orthop 1994;303:79-85.

32. Leopold SS, Greidanus N, Paprosky WG, et al: High rate of failure of allograft re- construction of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am 1999;81:1574-1579.

33. Sinha RK, Crossett LS, Rubash HE: Ex- tensor mechanism disruption after total knee arthroplasty, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. New York, NY: Churchill Livingstone, 2001, vol 2, pp 1863-1873.

34. Abril JC, Alvarez L, Vallejo JC: Patellar tendon avulsion after total knee arthro- plasty: A new technique. J Arthroplasty


35. Nazarian DG, Booth RE Jr: Extensor mechanism allografts in total knee arthro- plasty. Clin Orthop 1999;367:123-129.

36. Jaureguito JW, Dubois CM, Smith SR, et al: Medial gastrocnemius transposition flap for the treatment of disruption of

David A. Parker, MBBS, et al

the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am 1997;


37. Aracil J, Salom M, Aroca JE, et al: Ex- tensor apparatus reconstruction with Leeds-Keio ligament in total knee arthro- plasty. J Arthroplasty 1999;14:204-208.

38. Kempenaar JW, Cameron JC: Patel- lotibial fusion for patellar tendon rup- ture after total knee arthroplasty. J Ar- throplasty 1999;14:115-117.

39. Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

40. Thorpe CD, Bocell JR, Tullos HS: Intra- articular fibrous bands: Patellar com- plications after total knee replacement. J Bone Joint Surg Am 1990;72:811-814.

41. Bayley JC, Scott RD, Ewald FC, et al: Fail- ure of the metal-backed patellar compo- nent after total knee replacement. J Bone Joint Surg Am 1988;70:668-674.

42. Colizza WA, Insall JN, Scuderi GR: The posterior stabilized total knee prosthe- sis: Assessment of polyethylene dam- age and osteolysis after a ten-year min- imum follow-up. J Bone Joint Surg Am


43. Scuderi G, Scharf SC, Meltzer LP, et al:

The relationship of lateral releases to patella viability in total knee arthro- plasty. J Arthroplasty 1987;2:209-214.

44. Barrack RL, Rorabeck C, Partington P, et al: The results of retaining a well- fixed patellar component in revision to- tal knee arthroplasty. J Arthroplasty



Magnetic Resonance Imaging of the Pediatric Spine A. Jay Khanna, MD, Bruce A. Wasserman, MD,

Magnetic Resonance Imaging of the Pediatric Spine

A. Jay Khanna, MD, Bruce A. Wasserman, MD, and Paul D. Sponseller, MD


Magnetic resonance is an excellent modality for imaging the pediatric spine. Its suc- cessful use requires understanding both the basic physics and the sedation protocols necessary for acquiring high-resolution images. Interpreting the images accurately depends on appreciating the differences between the normal anatomy of the pedi- atric and the adult spine. Evaluating the images requires familiarity with the dif- ferential diagnosis of pediatric spine disease, including the most common processes (infections, neoplasms, and trauma) as well as spinal dysraphism. Despite the ac- knowledged usefulness of magnetic resonance imaging of the pediatric spine, con- troversies remain related to its safety in this age group and its limitations in di- agnosing and evaluating scoliosis and tethered cord syndrome.

J Am Acad Orthop Surg 2003;11:248-259

Magnetic resonance is an excellent modality for imaging pathologic processes in the pediatric spine. It allows high-resolution views of not only osseous structures (including the vertebral body, spinal canal, and posterior elements) but also soft-tis- sue structures (including the spinal cord, intervertebral disk, and nerve roots). Magnetic resonance imaging (MRI) can show these structures in various planes using different pulse sequences that allow optimal char- acterization of the tissues in and around the pediatric spine. Indica- tions for MRI in children (<18 years) are gradually expanding as technol- ogy improves. Properly interpreting MRI scans in these age groups de- pends on understanding the MRI appearance of the normal pediatric spine anatomy at various stages of development. For entities such as spinal dysraphism, left thoracic curves, and juvenile scoliosis, spe- cific recommendations can help cli- nicians use MRI effectively.

MRI Techniques

The major factors that influence the MRI appearance of various tissues are the density of protons in the tissue, the chemical environment of the pro- tons, and the magnetic field strength of the scanner. Unlike computed to- mography (CT), which produces im- ages based on the density of various tissues, MRI produces images based on free water content and on other magnetic properties of water, yield- ing superior soft-tissue contrast. Various sequences are produced by manipulating the strength of the ra- diofrequency (RF) pulses, the inter- val between the pulses, the repetition time (TR), and the echo time (TE), that is, the time between applying the RF pulse and measuring the signal emit- ted by the patient. By manipulating these variables, the images can be weighted to emphasize the T1, T2, gradient-recalled echo, or proton den- sity characteristics of a tissue. T1- weighted images allow evaluation of

anatomic detail, including that of os- seous structures, disk, and soft tissues. T2-weighted images are used primar- ily to evaluate the spinal cord and to enhance lesion conspicuity.Agradient- recalled echo sequence typically is used when thin axial images are needed, such as for evaluating foraminal nar- rowing in the cervical spine, because its three-dimensional acquisition al- lows for very thin sections. Standard pulse sequences for spi- nal imaging include spin echo T1- weighted images and fast spin echo (FSE) T2-weighted images. The FSE technique allows acquisition of scans without prolonged imaging times. Be- cause cerebrospinal fluid (CSF) is bright on T2-weighted images and the spi- nal cord retains its intermediate sig- nal, the images maximize the contrast between CSF and neural tissue, allow- ing optimal delineation of the spinal cord and nerve roots. T2-weighted im- ages are very sensitive to pathologic changes in tissue, including any pro-

Dr. Khanna is Chief Resident, Department of Or- thopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD. Dr. Wasserman is Assistant Pro- fessor, Department of Radiology, The Johns Hop- kins Hospital. Dr. Sponseller is Professor and Vice Chairman, Department of Orthopaedic Surgery, The Johns Hopkins Hospital.

Reprint requests: Dr. Sponseller, c/o Elaine P. Henze, Room A672, 4940 Eastern Avenue, Bal- timore, MD 21224-2780.

Copyright 2003 by the American Academy of Orthopaedic Surgeons.


Journal of the American Academy of Orthopaedic Surgeons

cesses in which cells and the extra- cellular matrix have an increase in wa- ter content. This pathologic change is usually shown as an increase in sig- nal intensity on T2-weighted images. The signal from fat may be sup- pressed by a variety of techniques, in- cluding chemical saturation of its sig- nal or application of an inversion pulse, and imaging at a short time of inversion (TI) when there is no fat sig- nal present (short TI recovery [STIR]). Chemical suppression typically is used in sequences that result in high fat signal, such as FSE T2-weighted images or postcontrast T1-weighted images. Fat suppression is of little val- ue for noncontrast T1-weighted im- ages because the signal from most pathologic lesions, whether inflam- matory, neoplastic, or infectious, is of- ten low and better visualized because of contrast against the adjacent bright fat signal. Fat suppression on post- contrast T1-weighted images of the vertebral body is useful in adults who have fatty transformation of marrow. Fat-suppressed images may be par- ticularly useful for evaluating liga- mentous injuries or lesions involving the paraspinal tissues. The usefulness of STIR imaging is more limited be- cause the imaging parameters are re- stricted and cannot be optimized to maximize contrast between adjacent tissues of interest. Gradient-recalled echo images ap- pear to be T2-weighted because CSF is relatively bright; however, paren- chymal lesions typically are more con- spicuous on FSE T2-weighted images. The gradient-recalled echo sequence is sensitive to local inhomogeneities of the magnetic field, and signal loss is exaggerated in the presence of such inhomogeneities. Field inhomogene- ities may be caused by metallic im- plants (eg, pedicle screws or paraspi- nal rods), differences in the magnetic susceptibilities of adjacent tissues (eg, air-tissue interfaces), and paramagnetic substances (eg, gadolinium). Blood- breakdown products cause local field distortions resulting in signal loss, mak-

Vol 11, No 4, July/August 2003

ing this technique very sensitive for the detection of blood. Open MRI systems are being used more frequently, especially for chil- dren. These systems have notably lower field strengths than do closed systems and therefore usually pro- duce studies of inferior overall qual- ity, especially of the spine. However, open MRI systems allow easier access to the sedated or otherwise compro- mised patient. Young patients and pa- tients with claustrophobia have ac- cess to parents and the environment, making the procedure less intimidat- ing. However, whenever possible, spinal MRI should be done using closed, 1.5-T systems.

Pediatric Sedation Protocols

Sedation is often required for success- ful MRI in young children. Many studies have evaluated specific seda- tion protocols. 1,2 The American Acad- emy of Pediatrics (AAP) has pub- lished guidelines for the elective sedation of pediatric patients, 3,4 but compliance with these guidelines is not mandatory. The AAP has stated that careful medical screening and pa- tient selection by knowledgeable medical personnel are needed to ex- clude patients at high risk of life- threatening hypoxia. 4 Also, monitor- ing usingAAP guidelines is necessary for the early detection and manage- ment of life-threatening hypoxia. 3 The AAP recommends that before an ex- amination in which sedation is to be used, children from newborn to age 3 years take nothing by mouth for 4 hours and those aged 3 to 6 years take nothing by mouth for 6 hours. 4 Pediatric sedation practices vary, but a few agents are common to most protocols. Oral chloral hydrate is of- ten recommended for children young- er than 18 months. However, its use is controversial because of its variable absorption, paradoxical effects, and nonstandardized dosing. Older chil-

A. Jay Khanna, MD, et al

dren usually receive intravenous pen- tobarbital with or without fentanyl. Although studies have reported successful administration of sedatives by trained nurses, 1,2 an anesthesiol- ogist’s expertise can be beneficial for patients with substantial comorbidi- ties, including cardiopulmonary dis- ease, skeletal dysplasias, neuromus- cular disease, and abnormal airway anatomy. Because of the potential risks of anesthesia and sedation in children, there is a trend toward referring those who require sedation to hospitals with pediatric anesthesiologists. An important consideration after sedation for pediatric MRI is the need for strict adherence to established dis- charge criteria, including return to baseline vital signs, level of con- sciousness close to baseline, and abil- ity to maintain a patent airway. 5 Be- cause of the inherent risks of sedation, alternative techniques have been de- vised, including sleep deprivation and rapid, segmental scanning. The latter permits acquisition of high- quality images without the use of se- dation.

Normal MRI Anatomy

Appreciating normal MRI anatomy (Fig. 1) is essential for understanding and predicting the MRI appearance of pathologic processes. 6

Adolescents and Adults

The lumbar spine is more fre- quently imaged than the cervical and thoracic area in both children and adults. In adolescents and adults, the lumbar spinal canal appears round proximally and triangular distally. The lumbar facet joints, best visual- ized in the axial plane, are covered with 2 to 4 mm of hyaline cartilage. This cartilage can be well visualized with FSE and gradient-recalled echo pulse sequences. The epidural space and ligaments also should be evalu- ated carefully. Epidural fat is seen as high signal intensity on T1-weighted


Magnetic Resonance Imaging of the Pediatric Spine

Figure 1 A, Sagittal T1-weighted MRI scan of a normal lum- bar spine in a
Figure 1 A, Sagittal T1-weighted MRI scan of a normal lum-
bar spine in a 2-year-old boy shows the rectangular shape of
the vertebral bodies. The conus medullaris is seen at the L1-L2
level (arrow). B, T2-weighted image shows the long, thin ap-
pearance of the intervertebral disk. C, Sagittal T1-weighted scan
of a normal lumbar spine in a 10-year-old girl. D, T2-weighted
scan. Lordosis is normal. The posterior elements are well
formed, with a resultant decrease in the canal diameter. E, Sag-
ittal T1-weighted scan of a normal lumbar spine in a 16-year-
old girl shows dark CSF (thin arrow), the conus medullaris at
the L1-L2 level (open arrow), and the basivertebral channel
(arrowhead). Note the normal rectangular appearance of the
vertebral bodies and the lumbar lordosis compared with the
10-year-old girl. F, Sagittal T2-weighted scan shows bright CSF
(thin arrow) and a bright nucleus pulposus (arrowhead).

images; the ligamentum flavum shows minimally higher T1-weighted signal compared with the other lig- aments. The conus medullaris is usu- ally located at the L1-L2 level. The tra- versing nerve roots pass distally from


the conus medullaris and extend an- teriorly and laterally, exiting lateral- ly underneath the pedicle and extend- ing into the neural foramen. The intervertebral disk, consisting of the cartilaginous end plates, anulus fibro-

sus, and nucleus pulposus, normally shows increased T2-weighted signal in its central portion. CSF, well im- aged as low T1-weighted and high T2-weighted signal, often can be used to determine the type of pulse se-

Journal of the American Academy of Orthopaedic Surgeons

quence that is being used. CSF pul- sations often create artifacts that de- grade the image in the lumbar spine; these artifacts must not be mistaken for a pathologic process. The cervical spine shows a mild lordosis on sagittal images. On axial images, the spinal canal is triangular, with the base located anteriorly. A dark band at the base of the dens is a normal variant that is a remnant of the subdental synchondrosis and should not be mistaken for a fracture. In adults, the facet joints are small and triangular, whereas in children they are large and flat. The spinal cord is elliptical in cross section in the cer- vical spine. There is a difference in sig- nal between the normal gray and white matter of the spinal cord. This signal heterogeneity should not be mistaken for intramedullary pathol- ogy. The intervertebral disks are sim- ilar in appearance to, but smaller than, those seen at the thoracic and lumbar levels. An important anatom- ic feature of the cervical spine is the prominent epidural venous plexus, which is not present in the thoracic or lumbar spine. The thoracic vertebral bodies are relatively constant in size, and the spi- nal canal is almost round. Abundant epidural fat is present posteriorly, but there is less anteriorly than in the lum- bosacral region. The cord is more round than in the cervical or lumbar regions, and the cord segment lies two to three levels above the corre- sponding vertebral body. The inter- vertebral disks are thinner than the disks in the lumbar spine. The ap- pearance of the CSF is more variable in the thoracic spine than in the lum- bar region because of more prominent CSF pulsations, but on T1-weighted images, it is commonly seen as a re- gion of low signal dorsal to the spi- nal cord. This artifact is often most se- vere at the apex of curves, including the thoracic kyphosis. Certain tech- niques can minimize this artifact, in- cluding gating to the pulse or cardi- ac cycle.

Vol 11, No 4, July/August 2003


Differences Between the Pediatric and the Adult Spine

The MRI appearance of the grow- ing spine is complex. Substantial changes occur in the vertebral ossi- fication centers and the intervertebral disks, changing the overall appear- ance of the spine markedly, especial- ly between infancy and age 2 years. 7 In general, the vertebral ossification centers are incompletely ossified ear- ly in childhood, and the disks are thicker and have a higher water con- tent than those in adults. The spinal canal and neural foramina are larger, and there is less curvature. In addi- tion, the overall signal intensity of the vertebral bodies is lower than that of the adult spine on T1-weighted im- ages because of the abundance of red (hematopoietic) marrow relative to yellow (fat) marrow in the pediatric, adolescent, and young adult spine.

Full-Term Infant

In the newborn, the overall size of the vertebral body is small relative to the spinal canal, and the spinal cord ends at approximately the L2 level. The lumbar spine does not exhibit the usual lordosis and is straight. The ver- tebral bodies show a markedly low signal intensity on T1-weighted im- ages, with a thin, central, hyperin- tense band that likely represents the basivertebral plexus. The spongy bone of the ossification center is el- lipsoid rather than rectangular and often mistaken for disk. The interver- tebral disk is relatively narrow and often contains a thin, bright central band on T2-weighted images that represents the notochordal rem- nants. 6,7

Age 3 Months

At age 3 months, the osseous com- ponent of the vertebral body has in- creased and the amount of hyaline cartilage has decreased, giving the vertebral bodies a rectangular appear- ance. The ossification centers begin to

A. Jay Khanna, MD, et al

gain in signal intensity, starting at the end plates and progressing centrally. The neural foramina have not sub- stantially changed at this age, remain- ing relatively large and ovoid. 6,7

Age 2 Years

At age 2 years, the spine has be- gun to show its normal sagittal align- ment, most likely because of weight bearing (Fig. 1, A and B). The ossified portion of the vertebral body increas- es substantially and begins to assume its adult appearance, with near- complete ossification of the pedicles and the articular processes. The disk space and nucleus pulposus become longer and thinner. The cartilaginous end plate has decreased in size and is often difficult to identify. The neu- ral foramen also begins to take its adult appearance as its inferior por- tion narrows. 7

Age 10 Years

At age 10 years, sagittal alignment resembles that of an adult (Fig. 1, C and D). Ossification of the vertebral bodies and posterior elements is near- ly complete, with a resultant decrease in the spinal canal diameter. The ver- tebral bodies also develop concave superior and inferior contours. The nucleus pulposus becomes smaller at this age and spans approximately half the disk space in the sagittal plane. The neural foramina continue to nar- row inferiorly. 6

The Conus Medullaris

In early fetal life, the spinal cord extends to the inferior aspect of the bony spinal column. 6 Because the ver- tebral bodies grow more rapidly lon- gitudinally than the spinal cord does, by birth the conus medullaris is re- positioned in the upper lumbar spine. It is important to note the location of the conus medullaris on every pedi- atric spine MRI study (Fig. 1, A and E).Aconus medullaris level below the L2-3 interspace in children older than 5 years is abnormal and indicates pos- sible tethering. 8,9 Saifuddin et al 10 re-


Magnetic Resonance Imaging of the Pediatric Spine

viewed the MRI findings in 504 nor- mal adult spines and found that the average position of the conus med- ullaris was the lower third of L1 (range, middle third of T12 to upper third of L3).

Pathologic Processes in the Pediatric Spine


Infectious processes involving the pediatric spine include osteomyelitis,

diskitis, and epidural and paraspinal abscess. 11-13 In general, the MRI sig- nal characteristics of infection include

a region of low T1 and high T2 sig-

nal intensity in bone and soft tissue. In identifying vertebral osteomy- elitis, MRI is more sensitive than con-

ventional radiographs or CT and more specific than nuclear scintigra- phy. 14,15 Marrow edema can be detect- ed on precontrast, fat-suppressed, FSE T2-weighted images. Postgado- linium enhancement of the disk and adjacent vertebral bodies on postcon- trast, fat-suppressed, T1-weighted images helps confirm the diagnosis. The specificity of MRI for infection is higher in children than adults because one of the primary confounders, de-

generative arthritis, is not part of the differential diagnosis. Differentiating osteomyelitis from neoplastic disease

is a common dilemma; generally, in-

fectious processes are more likely to cross and destroy intervertebral disks than are neoplastic conditions. Diskitis is seen as a disruption of the normally well-defined disk- vertebral borders on T1-weighted im- ages and as an increase in signal of the disk on T2-weighted images. 12 On T2-weighted images, diskitis may obliterate the normally seen horizon- tal cleft within the intervertebral disk. The abnormal signal seen in infec- tious diskitis is associated classically with surrounding soft-tissue inflam- mation and reactive end-plate chang- es. Primary diskitis is more likely to develop in children than adults be-

cause of the greater blood supply to the disk. Secondary diskitis after dis- kography or surgery is more likely to develop in adults. Epiduralabscessesarerare,butwhen they do develop, it is usually after sur- gery or vertebral osteomyelitis. Epi- dural abscesses are diagnosed based on the MRI findings of a collection in the epidural space and the appropri- ate clinical setting. 11 Gadolinium- enhanced T1-weighted images often show a peripheral rim of enhancement that represents the abscess wall. Paraspinal abscesses occur adja- cent to the spinal column, most com- monly in the paraspinal musculature. They may be secondary to a primary infection in the spine or may arise spontaneously in the paraspinal mus- culature. These abscesses may be seen as retropharyngeal abscesses in the cervical spine, paraspinous or retro- mediastinal abscesses in the thoracic spine, or psoas abscesses in the lum- bar spine. The MRI characteristics of paraspinal abscesses include a well- defined wall and peripheral enhance- ment on postgadolinium, T1- weighted images.


MRI can be used to evaluate the pediatric spinal trauma victim who has an abnormal neurologic exami- nation or is unresponsive. The patient is first evaluated with conventional radiographs, which may be normal, even in a child with a neural deficit. Although CT allows for better eval- uation of osseous detail and displaced fractures, MRI provides improved evaluation of nondisplaced fractures because of its ability to detect marrow-signal abnormalities. Spinal cord injury without radio- graphic abnormality (SCIWORA) is a well-defined entity seen in the pe- diatric age group. 16,17 The character- istic hypermobility and ligamentous laxity of the pediatric bony cervical and thoracic spine predispose children to this type of injury. 16 The elasticity of the bony pediatric spine and the

relatively large size of the head allow the musculoskeletal structures to de- form beyond physiologic limits, which results in cord trauma followed by spontaneous reduction of the spine. 16 As with other types of spinal cord injuries, the most important predic- tor of outcome is the severity of neu- rologic injury. A patient with a com- plete neurologic deficit after SCIWORA has a poor prognosis for recovery of neurologic function. The role of MRI in SCIWORA syndrome is to define the location and the degree of neural injury, rule out occult fractures and subluxation that may require surgi- cal intervention, and evaluate for the presence of ligamentous injury. T2- weighted images typically show in- creased signal in the cord, vertebral body, or ligaments. The increased T2 signal in the cord is compatible with edema and can range from a partial, reversible contusion to complete transection of the cord. Two other traumatic entities can oc- cur in children, usually as the result of participation in sports. The first is acute disk herniation. This is often a fracture with a hingelike displacement of fibrocartilage and slipping of the entire disk with vertebral end-plate fracture rather than extrusion of a disk fragment from the nucleus, as is seen in adults. 18 Such avulsion fractures are often occult on conventional radio- graphs and are better detected with CT and MRI. 18 Axial MRI scans dem- onstrate the fracture fragment as an area of low signal intensity protrud- ing into the spinal canal, and sagittal images demonstrate a low signal in- tensity region in the shape of a Y or 7 on all pulse sequences. 18 The second entity is a spondylo- lysis as a cause of back pain in young athletes. MRI, however, is not the op- timal method for evaluating spondy- lolysis. CT offers increased spatial res- olution and the ability to accurately define the osseous defect, whereas ra- dionuclide imaging can demonstrate increased radiotracer activity in the region of the defect.


Journal of the American Academy of Orthopaedic Surgeons


MRI is the modality of choice for evaluating neoplasms in and around the pediatric spine. 19 An effective and commonly used approach is to clas- sify the lesion as extradural, intra- dural-extramedullary (Fig. 2), or in- tradural-intramedullary (Fig. 3). With this anatomic classification system, the primary role of the MRI exami- nation is to define the location of the suspected neoplasm, which is best achieved with axial and sagittal T1- and T2-weighted images. Once the lesion has been classified, the T2- weighted images can be used to char- acterize the lesion further. Specifical- ly, the degree of surrounding edema and tissue infiltration and the pres- ence or absence of a cystic component can be determined. Next, postgado- linium enhancement images should be compared with unenhanced T1- weighted images. The final step in ob- taining a diagnosis is to correlate the imaging findings with the patient’s age and other criteria to narrow the differential diagnosis.

Spinal Dysraphism

Spinal dysraphism is a general term used to describe a wide range of anomalies resulting from incomplete fusion of the midline mesenchyma, bone, and neural elements. The os- seous abnormalities consist of defects

A. Jay Khanna, MD, et al

abnormalities consist of defects A. Jay Khanna, MD, et al Figure 2 A schwannoma in an

Figure 2 A schwannoma in an 8-year-old boy. A, Sagittal T1-weighted MRI scan shows an intradural-extramedullary mass impressing on the anterior cervical cord at the C5 level (ar- row). B, Axial T2-weighted image shows the lesion herniating through the right C5-C6 neu- ral foramen (arrows).

within the neural arch with partial or complete absence of the spinous pro- cesses, laminae, or other components of the posterior elements. MRI has been shown to be the best modality for evaluating spinal dysraphism. 20,21 A classification system has been proposed for evaluating a patient with a suspected spinal dysraphism (Table 1). 21 The differential diagnosis can be narrowed to one of three types:

spinal dysraphism with a back mass either covered or not covered with skin, or with no back mass. The final

diagnosis then can be made based on the lesion’s MRI characteristics. Myelomeningocele is the most common form of spinal dysraphism (Fig. 4). It usually presents in the lum- bosacral region (although it can be seen at higher levels) as a back mass not covered with skin. The mass may or may not be covered by lepto- meninges containing a variable amount of neural tissue. The sac her- niates through a defect in the poste- rior elements of the spine. The spinal cord usually contains a dorsal cleft,

the spine. The spinal cord usually contains a dorsal cleft, Figure 3 An astrocytoma in a

Figure 3 An astrocytoma in a 6-year-old boy. A, Sagittal T1-weighted MRI scan shows an intradural-intramedullary lesion within the spi- nal cord at the T3-T5 levels (arrow). B, Sagittal T2-weighted image shows the partially cystic nature of the lesion. C, Axial T2-weighted image confirms that the lesion (arrow) is within the center of the spinal cord.

Magnetic Resonance Imaging of the Pediatric Spine

is splayed open, and is often tethered

within the sac. 21 Progressive scolio- sis is seen in 66% of patients with my-

elomeningocele, Arnold-Chiari type

II malformation in 90% to 99%, di-

astematomyelia in 30% to 40%, and syringohydromyelia in 40% to 80%. 22 Scarring can occur at the sur- gical site after sac closure, so it is im- portant to monitor these patients for signs and symptoms of tethered cord syndrome. Of the entities presenting with a skin-covered back mass in the pres- ence of spinal dysraphism, lipomen- ingocele is the most common. 6,21 The lipomeningocele consists of lipoma- tous tissue that is continuous with the subcutaneous tissue of the back and also insinuates through the dysraph-

ic defect and dura and into the spi-

nal canal. The spinal cord often con- tains a dorsal defect at the level of the lipomatous tissue and may be teth- ered at this level. The essential MRI feature of this lesion is that the li- pomatous tissue follows the signal characteristics of subcutaneous fat on all pulse sequences, including fat- suppressed pulse sequences. Occult spinal dysraphism pre- sents without a back mass. Diastema- tomyelia is characterized by a sagit- tal splitting into two segments of the spinal cord, conus medullaris, or

Table 1 Classification of Spinal Dysraphism



Back mass not covered with skin

Back mass covered with skin

No back mass (occult)

Myelomeningocele Myelocele Lipomyelomeningocele Myelocystocele Simple posterior meningocele Diastematomyelia Dorsal dermal sinus Intradural lipoma Tight filum terminale Anterior sacral meningocele Lateral thoracic meningocele Hydromyelia Split notochord syndrome Caudal regression syndrome

(Adapted with permission from Byrd SE, Darling CF, McLone DG, Tomita T: MR im- aging of the pediatric spine. Magn Reson Imaging Clin North Am 1996;4:797-833.)

filum terminale, often in the thoracic or lumbar spine. The dural tube and arachnoid are undivided in approx- imately half these patients; clinical findings are rare, and surgery is not indicated. In the remaining patients, the dural tube and arachnoid are completely or partially split at the level of the spinal cord cleft, which results in tethering of the cord and subsequent clinical symptoms. Coro- nal T1- and T2-weighted images best define the sagittal split in the

cord; the findings should be con- firmed on axial images. Another entity often seen in pa- tients with spinal dysraphism is sy- ringohydromyelia, or a syrinx (Fig. 5). Asyrinx is a longitudinal cavity with- in the spinal cord that may or may not communicate with the central ca- nal. Attempts to explain the etiology include developmental, traumatic, in- flammatory, ischemic, and pressure- related causes. Sagittal MRI scans show a linear, low T1 and high T2 sig-

Sagittal MRI scans show a linear, low T1 and high T2 sig- Figure 4 A myelomeningocele

Figure 4 A myelomeningocele in a 6-year-old girl. A, Sagittal T1-weighted MRI scan shows a low-back mass contiguous with the contents of the spinal canal (arrows). B, T2-weighted image shows that the mass is filled with high-signal-intensity fluid, compatible with CSF (ar- rows). C, Axial T1-weighted image confirms that the mass communicates with the spinal canal through a defect in the posterior elements (arrows).

A. Jay Khanna, MD, et al

A. Jay Khanna, MD, et al Figure 5 A large syrinx involving the entire spine in

Figure 5 A large syrinx involving the entire spine in a 2-year-old boy. A, Sagittal T1-weighted MRI scan shows the syrinx to be largest at the level of the lower thoracic spine (arrows). Axial T1-weighted (B) and T2-weighted (C) images confirm that the syrinx is located within the center of the spinal cord.

nal intensity within the parenchyma of the spinal cord. Gibbs artifact, or truncation arti- fact, can mimic a syrinx on sagittal images (Fig. 6). Gibbs artifact is seen on sagittal T1- and T2-weighted im- ages as a linear region of altered sig- nal intensity in the center of the spi- nal cord. Thus, it is important to

evaluate serial axial T1- and T2- weighted images to confirm findings. Gibbs artifact results from not using a sufficiently high spatial frequency for sampling data. It can be corrected by using a higher-resolution matrix.

Chiari Malformations

Chiari malformations are seen fre-

quently in patients with spinal dys-

raphism. Chiari type I malformations consist of cerebellar tonsillar ectopia, in which the cerebellar tonsils extend below the level of the foramen mag-

num. The common measurement for

the degree of herniation of the ton- sils below the foramen magnum is 5

mm. Mikulis et al 23 reported a vari-

Figure 6 A 5-year-old girl had a history of neck and arm pain. A, Sagittal
Figure 6 A 5-year-old girl had a history of
neck and arm pain. A, Sagittal T2-weighted
MRI scan shows a long linear region of high
signal intensity within the center of the cer-
vical spinal cord (arrow). This finding can
easily be mistaken for a syrinx. B, Sagittal
T1-weighted image also suggests low signal
intensity in the same region but fails to
show a syrinx, demonstrating normal cord
anatomy. C, Axial T2-weighted image also
demonstrates normal anatomy. These find-
ings are compatible with a Gibbs artifact.

Magnetic Resonance Imaging of the Pediatric Spine

ation by age in the upper limit of nor- mal: 6 mm in the first decade of life, 5 mm in the second and third de- cades, and 3 mm by the ninth decade.

In Chiari I malformations, the brain-

stem is spared and the fourth ventri- cle remains in its normal location. Chiari I malformations are associat- ed with syringohydromyelia, cranio- vertebral junction anomalies, and basilar invagination. Chiari II malfor- mations are more advanced and con- sist of downward displacement of the brainstem and inferior cerebellum into the cervical spinal canal, with a de- crease in size of the posterior fossa.

Tethered Cord Syndrome

Tethered cord syndrome is seen in

a substantial number of patients with spinal dysraphism, especially those who have undergone surgical closure

of the defect. 24,25 During fetal life, the

spinal cord extends to the sacrococ-


of the vertebral column after birth, the

cord ascends to the L1-L2 level in the newborn. During the formation of a spinal dysraphic defect such as my- elomeningocele, the open neural el- ements often attach to the peripheral ectoderm, resulting in spinal cord teth-

ering. After surgical closure of the sac, there is a tendency for the spinal cord

to become adherent at the repair site.

As the child grows, this adherence may tether the cord and prevent cephalad

cord migration, with eventual symp- toms. Thus, in patients with spinal dys- raphic and related conditions, includ- ing myelomeningoceles, myeloceles, lipomeningoceles, and diastematomy- elia, tethered cord should be ruled out as the potential cause of any deteri- oration in neurologic function. MRI has been proposed as the ini- tial, and possibly only, imaging study for a patient with a suspected teth- ered spinal cord. 9 Sagittal images should be evaluated to determine the level of the conus medullaris (Fig. 7).

A conus level below the L2-L3 inter-

space in children older than 5 years

is abnormal and an indication of pos-

older than 5 years is abnormal and an indication of pos- Figure 7 A 14-year-old boy

Figure 7 A 14-year-old boy had a history of lipomeningocele. After surgical resection, bowel and bladder dysfunction and new lower-extremity paresthesias developed. A, Sagittal T2- weighted image shows the conus medullaris extending to approximately the L4 level and the filum terminale extending to the S1 level (arrow), compatible with tethered cord syn- drome. B, Axial T2-weighted image at the L4 level shows the cord located posteriorly within the thecal sac (arrow). C, Axial T2-weighted image at the L5 level shows the placode (thin arrow) with a right-side nerve root (thick arrow) coursing anteriorly and laterally.

sible tethering. 8,9 In addition, the teth- ered cord is often displaced posteri- orly in the spinal canal. Other findings include lipoma or scar tissue within the epidural space and increased thick- ness of the filum terminale. 9 Although MRI can determine whether a spinal cord is anatomically tethered, these findings should be correlated with the patient’s symptoms and serial phys- ical examinations before surgical re- lease is considered.

Controversies in MRI of the Pediatric Spine

MRI of the pediatric spine remains controversial in several conditions, in- cluding scoliosis and tethered cord

syndrome, as well as with spinal in- strumentation. Safety is also a concern.


The use of MRI imaging in scoli- osis is primarily to detect intraspinal abnormalities, which are more fre- quently associated with uncommon curve patterns such as left thoracic curves, an abnormal neurologic ex- amination, or young age at pre- sentation. 26-30 Recently, Do et al 26 con- cluded that MRI is not indicated before spine arthrodesis in a patient with an adolescent idiopathic scoli- osis curve pattern and a normal phys- ical and neurologic examination. One area of particular controversy is back pain in the presence of scolio- sis. In a retrospective study of 2,442


Journal of the American Academy of Orthopaedic Surgeons

patients, Ramirez et al 31 found that a left thoracic curve or abnormal result on neurologic examination best pre- dicted an underlying pathologic con- dition. They found a significant asso- ciationbetweenbackpainandageolder than 15 years (P < 0.001), skeletal ma- turity (P < 0.001), postmenarcheal sta- tus (P < 0.001), and history of injury (P < 0.018). The authors concluded that it is unnecessary to perform extensive diagnostic studies on every patient with scoliosis and back pain. MRI should be reserved for patients with infan- tile or juvenile scoliosis, left thoracic curves, or abnormal neurologic find- ings. Because coronal views are espe- cially useful in evaluating patients with scoliosis, they should be a part of the routine imaging protocol.

Tethered Cord Syndrome

The rate of MRI in tethered cord syndrome remains controversial. When MRI demonstrates a tethered

cord, a choice between surgical and nonsurgical treatment must be made. Although anatomic tethering of the cord is detected easily on MRI, indi- cations for surgery depend on the clinical history and results of serial physical examinations.

Imaging in the Presence of Implants

MRI of the spine in the presence of instrumentation is generally safe but is limited by the image artifacts the implants produce. The pulse se- quence used for imaging titanium produces less degradation from arti- fact because it is less ferromagnetic than stainless steel (Fig. 8). 32,33 Thus, titanium may be the better choice of implant in a patient who may require follow-up with MRI. However, with appropriate imaging techniques, clin- ically useful information can be ob- tained safely in the presence of both types of implants. 34 Specialized pulse

A. Jay Khanna, MD, et al

sequences such as the metal artifact reduction sequence (MARS) can help reduce the degree of tissue-obscuring artifact produced by spinal hardware and improve image quality compared with conventional T1-weighted spin- echo pulse sequences. 35

MRI Safety

MRI may be contraindicated in pa- tients with ferromagnetic implants, materials, or devices because of the risk of implant dislodgement, heat- ing, and induction of current. 36 Shel- lock et al 36 reviewed and compiled the results of more than 80 studies and described the ferromagnetic qualities of 338 objects, including 30 ortho- paedic implants, materials, and devic- es. They found that most orthopaedic implants are made from nonferro- magnetic materials and therefore are safe for MRI procedures. Another concern is that of safety within the MRI suite. Areas surrounding and

Figure 8 A 6-year-old boy had a history of high-grade astrocytoma. A, Anteroposteriorradiograph6weeks
Figure 8 A 6-year-old boy had a
history of high-grade astrocytoma.
A, Anteroposteriorradiograph6weeks
and posterior spinal arthrodesis from
T4 to L3 with titanium pedicle screws,
hooks, and rods. B, Midline sagittal
allows visualization of the canal con-
tents with minimal artifact from the
pedicle screws (arrows). C, Parasag-
ittal postgadolinium T1-weighted im-
age shows a rod (thick arrow) and
pedicle screw (thin arrow). Neither
obscures the MRI scan. D, Axial post-
gadolinium T1-weighted image also
shows the pedicle screws (arrows) and
a patent spinal canal.

Magnetic Resonance Imaging of the Pediatric Spine

within the suite should be carefully monitored for the presence of ferro- magnetic equipment that may act as a projectile and injure the patient or hospital personnel. A recent report described a series of projectile cylin- der accidents when ferromagnetic ni- trous oxide or oxygen tanks were in the MRI suite. 37 Other equipment (eg,

intravenous pumps, hospital beds, handheld instruments) also should be compatible with MRI.


MRI is an excellent modality for ad- vanced imaging of the pediatric

spine. A basic understanding of the normal MRI appearance of the spine at various ages, the signal character- istics of various pathologic changes, and the differential diagnosis of spi- nal pathology can help the clinician correlate the history and physical examination with MRI findings to establish the most likely diagnosis.


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Mosby-Year Book, 1994, pp 352-387.

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9. Moufarrij NA, Palmer JM, Hahn JF, Weinstein MA: Correlation between magnetic resonance imaging and surgi- cal findings in the tethered spinal cord.


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10. Saifuddin A, Burnett SJ, White J: The variation of position of the conus med- ullaris in an adult population: A mag- netic resonance imaging study. Spine


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Magnetic resonance imaging of the spine. Mayo Clin Proc 1989;64:986-1004.

16. Kriss VM, Kriss TC: SCIWORA (spinal cord injury without radiographic ab- normality) in infants and children. Clin Pediatr (Phila) 1996;35:119-124.

17. Pang D, Pollack IF: Spinal cord injury without radiographic abnormality in children: The SCIWORA syndrome. J Trauma 1989;29:654-664.

18. Banerian KG, Wang AM, Samberg LC, Kerr HH, Wesolowski DP: Association of vertebral end plate fracture with pe- diatric lumbar intervertebral disk her- niation: Value of CT and MR imaging. Radiology 1990;177:763-765.

19. Walker HS, Dietrich RB, Flannigan BD, Lufkin RB, Peacock WJ, Kangarloo H:

Magnetic resonance imaging of the pe- diatric spine. Radiographics 1987;7:1129-


20. Altman NR, Altman DH: MR imaging of spinal dysraphism. AJNR Am J Neuroradiol 1987;8:533-538.

21. Byrd SE, Darling CF, McLone DG, To- mita T: MR imaging of the pediatric

spine. Magn Reson Imaging Clin N Am


22. Modic MT, Yu S: Normal anatomy, in Modic MT, Masaryk TJ, Ross JS (eds):

Magnetic Resonance Imaging of the Spine, ed 2. St. Louis, MO: Mosby-Year Book, 1994, pp 37-79.

23. Mikulis DJ, Diaz O, Egglin TK, Sanchez R: Variance of the position of the cere- bellar tonsils with age: Preliminary re- port. Radiology 1992;183:725-728.

24. Hall WA, Albright AL, Brunberg JA: Di- agnosis of tethered cords by magnetic resonance imaging. Surg Neurol 1988;


25. Heinz ER, Rosenbaum AE, Scarff TB, Reigel DH, Drayer BP: Tethered spinal cord following meningomyelocele re- pair. Radiology 1979;131:153-160.

26. Do T, Fras C, Burke S, Widmann RF, Rawlins B, Boachie-Adjei O: Clinical value of routine preoperative magnetic resonance imaging in adolescent idio- pathic scoliosis: A prospective study of three hundred and twenty-seven pa-

tients. J Bone Joint Surg Am 2001;83:577-


27. Evans SC, Edgar MA, Hall-Craggs MA, Powell MP, Taylor BA, Noordeen HH:

MRI of ‘idiopathic’ juvenile scoliosis: A prospective study. J Bone Joint Surg Br


28. Gupta P, Lenke LG, Bridwell KH: Inci- dence of neural axis abnormalities in infantile and juvenile patients with spi- nal deformity: Is a magnetic resonance image screening necessary? Spine 1998;


29. Mejia EA, Hennrikus WL, Schwend RM, Emans JB: A prospective evalua- tion of idiopathic left thoracic scoliosis with magnetic resonance imaging. J Pediatr Orthop 1996;16:354-358.

30. Schwend RM, Hennrikus W, Hall JE, Emans JB: Childhood scoliosis: Clinical indications for magnetic resonance im- aging. J Bone Joint Surg Am 1995;77:


Journal of the American Academy of Orthopaedic Surgeons

31. Ramirez N, Johnston CE, Browne RH:

The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am 1997;79:364-368.

32. Rudisch A, Kremser C, Peer S, Kathrein A, Judmaier W, Daniaux H: Metallic ar- tifacts in magnetic resonance imaging of patients with spinal fusion: A com- parison of implant materials and imag- ing sequences. Spine 1998;23:692-699.

33. Rupp R, Ebraheim NA, Savolaine ER, Jack-


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uation of the spine with metal implants:

General safety and superior imaging with titanium. Spine 1993;18:379-385.

34. Lyons CJ, Betz RR, Mesgarzadeh M, Revesz G, Bonakdarpour A, Clancy M:

The effect of magnetic resonance imag- ing on metal spine implants. Spine 1989;


35. Chang SD, Lee MJ, Munk PL, Janzen DL, MacKay A, Xiang QS: MRI of spi- nal hardware: Comparison of conven- tional T1-weighted sequence with a

A. Jay Khanna, MD, et al

new metal artifact reduction sequence. Skeletal Radiol 2001;30:213-218.

36. Shellock FG, Morisoli S, Kanal E: MR procedures and biomedical implants, materials, and devices: 1993 update. Radiology 1993;189:587-599.

37. Chaljub G, Kramer LA, Johnson RF III, Johnson RF Jr, Singh H, Crow WN: Pro- jectile cylinder accidents resulting from the presence of ferromagnetic nitrous oxide or oxygen tanks in the MR suite. AJR Am J Roentgenol 2001;177:27-30.


Injury to the Tarsometatarsal Joint Complex Michael C. Thompson, MD, and Matthew A. Mormino, MD

Injury to the Tarsometatarsal Joint Complex

Michael C. Thompson, MD, and Matthew A. Mormino, MD


Tarsometatarsal joint complex fracture-dislocations may result from direct or in- direct trauma. Direct injuries are usually the result of a crush and may involve as- sociated compartment syndrome, significant soft-tissue injury, and open fracture- dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain-free, functional foot. The preferred treatment is open re- duction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients.

J Am Acad Orthop Surg 2003;11:260-267

Lisfrancdescribedamputationsthrough the tarsometatarsal (TMT) joint for the treatment of severe, gangrenous mid- foot injuries, and his name has been associated with many different inju-

ries to this region. 1 Myerson 2 described


tarsal complex (TMC), which includes the metatarsals and TMT joints, the cuneiforms, the cuboid, and the na- vicular. 2 The spectrum of TMC injury ranges from low-energy trauma, such

as a misstep, to high-energy crush in- juries characterized by extensive os-


promise. Accordingly, the pattern of TMC injury is highly variable and may involve purely ligamentous disrup- tions without fracture, associated meta- tarsal fractures, or fractures of the cu- neiforms, cuboid, or navicular. Accurate diagnosis of these inju- ries is paramount.Although only min- imal displacement may be present on initial radiographs, severe ligamen-

tous disruption might still exist. Left untreated, such disruption may result in marked disability characterized by

painful posttraumatic arthritis and pla- novalgus deformity. 3,4 A high index ofsuspicionshouldbemaintainedwhen examining a patient with an injured foot because delayed or missed diag- nosis occurs in up to 20% of cases. 5-7 The goal of treating TMC injury is to obtain a plantigrade, stable, pain- less foot. Successful outcome largely is related to obtaining and maintain- ing an anatomic reduction. 5,6,8,9 Ear- ly studies documented the failure of closed reduction to maintain an an- atomic reduction. 10-12 In 1982, Hard- castle et al 13 reported that open tech- niques with temporary, nonrigid fixation occasionally resulted in late displacement. Rigid screw fixation, the technique reported by Arntz et al 6 in 1988, has become the preferred meth- od for stabilization of these injuries. 5

Anatomy and


Understanding the anatomy of the TMC is imperative for accurate assess-

ment and treatment of injuries. Sta- bility of the complex is achieved by a combination of bony architecture and ligamentous support. The medial, mid- dle, and lateral cuneiforms articulate distally with the first, second, and third metatarsals, respectively 14 (Fig. 1, A). The cuboid articulates distally with the fourth and fifth metatarsals. The middle cuneiform is recessed proxi- mally relative to the medial and lat- eral cuneiforms. This mortise config- uration accommodates the base of the second metatarsal and lends additional osseous stability at this articulation. In the coronal plane, stability is fur- ther enhanced by the so-called Roman arch configuration of the metatarsal bases, with the second metatarsal base acting as the keystone (Fig. 1, B). Ligaments supporting the TMC are grouped according to anatomic lo- cation (dorsal, plantar, and in- terosseous). The lesser metatarsals are bound together by dorsal and plan- tar intermetatarsal ligaments (Fig. 1, A). Similarly, dorsal and plantar in- tertarsal ligaments hold the cunei- forms and cuboid together. There are

Dr. Thompson is Chief Resident, Department of Orthopaedic Surgery and Rehabilitation, Creighton- Nebraska Health Foundation, University of Ne- braska Medical Center, Omaha, NE. Dr. Mormino is Assistant Professor and Director, Orthopaedic Trauma, Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center.

Reprint requests: Dr. Mormino, 981080 Nebraska Medical Center, Omaha, NE 68198-1080.

Copyright 2003 by the American Academy of Orthopaedic Surgeons.


Journal of the American Academy of Orthopaedic Surgeons

Figure 1 A, Anteroposterior view of the bony and ligamentous anatomy of tarsometa- tarsal joint

Figure 1 A, Anteroposterior view of the bony and ligamentous anatomy of tarsometa- tarsal joint complex. I through V = metatar- sal bones. (Adapted with permission from Myerson MS: Fractures of the midfoot and forefoot, in Myerson MS: Foot and Ankle Dis- orders. Philadelphia, PA: WB Saunders, 2000, vol 2, pp 1265-1296.) B, Coronal section through the metatarsal bases illustrating the Roman arch configuration. (Adapted with permission from Lenczner EM, Waddell JP, Graham JD: Tarsal-metatarsal [Lisfranc] dis- location. J Trauma 1974;14:1012-1020.)

Michael C. Thompson, MD, and Matthew A. Mormino, MD

no ligamentous connections between the first and second metatarsal bases. The largest and strongest interos- seous ligament in the TMC is the so- called Lisfranc ligament, which aris- es from the lateral surface of the medial cuneiform and inserts onto the medial aspect of the second metatar- sal base near the plantar surface. 14 The first metatarsal base is anchored to the dorsal and plantar aspects of the me- dial cuneiform by two longitudinal ligaments. The peroneus longus and tibialis anterior tendon insertions fur- ther stabilize the first TMT joint. A variable network of longitudinal and oblique ligaments secures the remain- der of the metatarsals to the cunei- forms and cuboid on the dorsal and plantar aspects of the complex. In general, the dorsal ligaments are weaker than their plantar counter- parts. To a lesser extent, the plantar fascia and intrinsic musculature of the foot add stability to the TMC. Because of the unique bony and lig- amentous anatomy of the TMC, nor- mal motion of the individual compo- nents varies. Having articular contact with all three cuneiforms, the base of the second metatarsal demonstrates very little motion under normal cir- cumstances, with an average dorsi- flexion-plantarflexion arc of 0.6°. 15 In comparison,dorsiflexion-plantarflexion

at the third TMT joint is approximately 1.6°, and, at the first joint, 3.5°. The fourth and fifth TMT joints are the most mobile, demonstrating an average of 9.6° and 10.2° of dorsiflexion- plantarflexion, respectively. 15

Injury to the Tarsometatarsal Joint Complex

The overall annual incidence of TMC injuries is approximately 1 per 60,000 persons, 13,16 and the injury is two to three times more common in males (Table 1). Motor vehicle accidents are the most frequently cited mechanism, accounting for about 40% to 45% of injuries. Low-energy mechanisms ac- count for approximately 30%. Falls from a height and crush injuries are also commonly reported causes. The mechanism of TMC injury may be either direct or, more commonly, indirect trauma. The direct mechanism involves high-energy blunt trauma, usually applied to the dorsum of the foot. Crush injuries constitute most of these injuries, and many are associ- ated with notable soft-tissue trauma. Associated compartment syndromes and open fracture-dislocations are more often present with direct inju- ry mechanisms. In part as a result of

Table 1 Tarsometatarsal Joint Complex: Mechanisms of Injury

No. of Injuries (%)


No. of Patients/ Injuries (M/F)

Motor Vehicle

Fall From






Kuo et al 5 Arntz et al 6 Vuori et al 16 Myerson et al 9 Hesp et al 36 Hardcastle et al 13 Wilppula et al 12

48/48 (32/16)

20 (42)

7 (14.5)

6 (12.5)

15 (31)

40/41 (28/12)

21 (51)

7 (17)

0 (0)

13 (32)

66/66 (46/20)

22 (33)

9 (14)

14 (21)

21 (32)

52/55 (NA)

34 (62)

8 (14.5)

8 (14.5)



23/23 (16/7)

19 (83)

3 (13)



0 (0)

119/119 (86/33)

48 (40.3)

16 (13.5)

0 (0)

55 (46.2)

26/26 (21/5)

7 (27)

0 (0)

8 (31)

11 (42)

NA = not available.

Vol 11, No 4, July/August 2003


Injury to the Tarsometatarsal Joint Complex

the associated soft-tissue trauma and greater degree of articular injury, di- rect injuries often result in a worse clin- ical outcome compared with indirect injuries. 8,9 The indirect mechanism of injury usually involves axial loading of the plantarflexed foot. An example is a football player falling onto the heel of another player whose foot is planted and plantarflexed. This type of injury also can occur with soccer, basketball, and gymnastics. 17 Falls from a height may result in forefoot plantarflexion at the time of impact. In automobile accidents, injury to the plantarflexed foot occurs with a combination of de- celeration and floorboard intrusion. Less commonly, violent abduction or twisting of the forefoot may result in fracture-dislocation around the TMC. The fracture pattern and direction of dislocation in direct injuries are highly variable and depend on the force vector applied. In contrast, the most frequent pattern seen in indirect injuries involves failure of the weak- er dorsal TMT ligaments in tension, with subsequent dorsal or dorsolat- eral dislocation of the metatarsals. Mi- nor displacement at the TMT joint level results in a marked reduction in articular contact. Dorsolateral dis- placement of the second metatarsal base of 1 or 2 mm results in the re- duction of the TMT articular contact area by 13.1% and 25.3%, respective- ly. 18 Although fractures of the cune- iforms are relatively common, the most frequent fracture in TMC inju- ries involves the second metatarsal base. 16 Less common are associated fractures of the cuboid, navicular, or other metatarsals.


The diagnosis of high-energy or crush injuries to the TMC is relatively straightforward. Examination typical- ly reveals moderate to severe swell- ing of the forefoot and, in open inju- ries, disruption of the skin and

subcutaneous tissue. Inspection of the foot may reveal gross morphologic ab- normalities such as widening or flat- tening. A gap between the first and second toes is suggestive of intercu- neiform disruption as well as TMT

pain after even a minor traumatic event. Patients usually have notable pain on weight bearing or are unable to bear weight on the affected foot. Swelling is present to a variable ex- tent, and ecchymosis occasionally is


injury. 19,20 Palpation of the dor-

found along the plantar aspect of the

salis pedis artery may not be pos- sible, depending on the extent of swelling and deformity. Although dis- ruption of the dorsalis pedis artery has been reported, the incidence of vas-

midfoot. 25 Palpation of the affected TMT joints usually reveals tender- ness. Notable pain on passive abduc- tion and pronation of the forefoot also is suggestive of TMC injury. 17

cular injury appears to be rare. 7,21,22 Significant pain on passive dorsiflex- ion of the toes in a tensely swollen foot is suggestive of a compartment syn- drome; however, evaluation may be hampered by pain associated with the osseous injury. 23,24 When there is un- certainty about the presence of a com- partment syndrome, pressures should be measured.An absolute pressure >40

The initial radiographic examina- tion should include anteroposterior, lateral, and 30° oblique views of the foot. To visualize the Lisfranc joint in the tangential plane, the anteropos- terior radiograph should be taken with the beam approximately 15° off vertical. Standing radiographs are ideal but may be difficult to obtain secondary to pain (Fig. 2, A and B).


Hg is diagnostic and an indica-

If weight-bearing views are not pos-


for emergent compartment re-

sible, a stress view with the forefoot

lease. Particularly in the hypotensive

in abduction often will reveal subtle

patient, a compartment pressure with- in 30 mm Hg of the diastolic pressure

instability, especially at the first TMT joint. 17,26 All radiographs should be


is an indication for release.

evaluated for signs of instability. On

Findings after a low-energy TMC injury may be relatively subtle.Ahigh

the anteroposterior view, the distance between the first and second metatar-

index of suspicion should be main- tained in the patient with forefoot

sal bases varies among uninjured in- dividuals, with up to 3 mm consid-

among uninjured in- dividuals, with up to 3 mm consid- Figure 2 A, Anteroposterior non–weight-bearing radiograph

Figure 2 A, Anteroposterior non–weight-bearing radiograph of a patient with forefoot pain after an axial load injury. Note the subtle widening (arrow) between the bases of the first and second metatarsals. B, Anteroposterior standing view of the same patient as in Panel A dem- onstrating subluxation (arrow) at the base of the second metatarsal. C, Anteroposterior view of a patient with avulsion of the Lisfranc ligament, or fleck sign (arrow), at the base of the second metatarsal.


Journal of the American Academy of Orthopaedic Surgeons

ered normal. 26,27 In subtle cases, radiographs of the contralateral foot should be obtained for comparison. Stein 28 reviewed 100 radiographs of normal feet and noted several con- stant anatomic relationships. On the anteroposterior view, the medial bor- der of the second metatarsal is in line with the medial border of the mid- dle cuneiform, the first metatarsal aligns with the medial and lateral bor- ders of the medial cuneiform, and the first and second intermetatarsal space is continuous with the intertarsal space of the medial and middle cuneiforms (Fig. 1, A). On the 30° oblique view, the medial border of the fourth meta- tarsal is in line with the medial bor- der of the cuboid, the lateral border of the third metatarsal is aligned with the lateral border of the lateral cune- iform, and the third and fourth inter- metatarsal space is continuous with the intertarsal space of the lateral cu- neiform and the cuboid. 28 Other radiographic findings may assist with diagnosis. The fleck sign, or avulsion of Lisfranc’s ligament at the base of the second metatarsal, is diagnostic of TMC injury 9 (Fig. 2, C). Analysis of the medial column line on an anteroposterior abduction stress view may reveal subtle injury 26 (Fig. 3). Flattening of the longitudinal arch may suggest injury to the TMC and can be evaluated by comparing the weight-bearing lateral view to that of the uninjured foot. 29 Computed tomography (CT) has proved to be a valuable tool in the di- agnosis of injuries to the TMC. It is more sensitive than plain radiographs in detecting minor displacement and small fractures. 30-32 Displacement of up to 2 mm may not be detectable on plain radiographs but is visible on CT. 31 Axial and coronal views of both feet should be made for comparison. Subtle widening or dorsal sublux- ation of the metatarsals are CT find- ings suggestive of TMC disruptions, and avulsion fracture of the second metatarsal base is diagnostic of in- jury 33 (Fig. 4). In high-energy fracture-

Vol 11, No 4, July/August 2003

Michael C. Thompson, MD, and Matthew A. Mormino, MD

2003 Michael C. Thompson, MD, and Matthew A. Mormino, MD Figure 3 Medial column line. On

Figure 3 Medial column line. On an anteroposterior radiograph with the forefoot stressed in abduction (dashed outline of first metatarsal), a line is drawn tangential to the medial bor- ders of the navicular and medial cuneiform (heavy dashed line). Failure of this line to in- tersect the base of the first metatarsal is strongly suggestive of TMC injury. A, Normal foot. B, First, second, and third TMT joint disruption (heavy dark line). Arrows indicate direction of forces. (Adapted with permission from Coss HS, Manos RE, Buoncristiani A, Mills WJ:

Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tar- sometatarsal joint. Foot Ankle Int 1998;19:537-541.)

dislocations, a preoperative CT may facilitate surgical planning by delin- eating the extent of osseous injury. The role of magnetic resonance im- aging (MRI) in evaluating TMC inju- ries has yet to be defined. MRI is more sensitive than plain radiographs in detecting small fractures and joint malalignment and in assessing liga- mentous structures around the TMC. 33,34 However, with regard to di- agnosis and decision-making, CT is superior to MRI. 30 Therefore, MRI is not routinely recommended in the as- sessment of these injuries.


The earliest classification system was published in 1909 by Quenu and Kuss 12 and subsequently modified by Hardcastle et al 13 in 1982 and Myer- son et al 9 in 1986. The most recently

published classification system, pub- lished by the Orthopaedic Trauma Association, 35 is similar to the orig- inal Quenu and Kuss classification. These classification systems are all based on the congruency of the TMT joints and the direction of displace- ment of the metatarsal bases. Com- mon to all classification systems is that none appears to be helpful in terms of management or prognosis. 9


Nonsurgical management of TMC in- juries should be limited to those that are without fracture, nondisplaced, and stable under radiographic stress examination. As little as 2 mm of dis- placement or the presence of a frac- ture within the TMC warrants fixa- tion. Nondisplaced, stable ligamentous injuries may be treated in a non–


Injury to the Tarsometatarsal Joint Complex

Injury to the Tarsometatarsal Joint Complex Figure 4 ond metatarsal bases. B, Coronal CT scan showing

Figure 4

ond metatarsal bases. B, Coronal CT scan showing an avulsion fracture (arrow) of the sec-

ond metatarsal base.

A, Coronal CT scan demonstrating subtle widening (arrow) of the first and sec-

stability of the first TMT joint persists after placement of the first screw, a second screw or K-wire may be placed from the medial cuneiform

into the base of the first metatarsal.

The second metatarsal is then re-

duced to the medial border of the middle cuneiform and temporarily

held with a K-wire. Definitive fixation

follows with a 3.5- or 2.7-mm coun- tersunk screw directed from the base

of the second metatarsal into the mid-

dle cuneiform. A 3.5-mm screw is

usually appropriate for most patients;

a 2.7-mm screw may be used for pa-

tients of small stature or when there

is concern about the size of the 3.5-

mm screw relative to the diameter of

the second metatarsal. Medial column

fixation is then completed by placing

weight-bearing short leg cast for a minimum of 6 weeks. Radiographic examination should be done 1 to 2 weeks after injury to ensure that align- ment and stability are maintained. Gradual weight bearing in a protec- tive brace may begin at 6 weeks. Per- mission for unrestricted activity, such as running and jumping, should be withheld for 3 to 4 months. Although displaced or unstable TMC injuries have been treated by closed reduction and casting, loss of reduction was common and outcomes were variable, with a high incidence of poor results. Currently accepted sur- gical techniques involve either closed reduction with percutaneous Kirsch- ner wire (K-wire) or screw fixation 2 or open reduction with screw and/ or K-wire fixation. 4-6 For fixation of the medial three TMT joints, screw fix- ation may be preferable to K-wires be- cause ligamentous healing may re- quire as much as 12 to 16 weeks of immobilization to occur, and K-wires can become loose, necessitating re- moval as early as 6 weeks. Regard- less of the technique used, the goal should be anatomic reduction of the affected joints because numerous stud- ies have documented that clinical out- come correlates with accuracy of

reduction. 1,5-9,12,21,36,37

Ideally, surgical management of


3.5- or 2.7-mm screw from the me-

closed injuries is undertaken when


cuneiform into the base of the

soft-tissue swelling is at a minimum, either immediately or after swelling

second metatarsal. If the third TMT joint is disrupted

has abated. This delay may take up


remains unstable after fixation of

to 2 weeks and can be identified by

the first and second TMT joints, a sec-

the return of wrinkles to the skin. The


dorsal incision is made between

initial incision is made dorsally be- tween the first and second web space.

the third and fourth metatarsals to ex- pose the third TMT joint. This joint

The extensor hallucis longus tendon,


similarly reduced and fixed with a

deep peroneal nerve, and dorsalis pe-

3.5- or 2.7-mm screw directed from

dis artery are identified and retract-

the base of the third metatarsal into

ed as a unit, allowing deep, sharp dis-


lateral cuneiform. Reduction of

section to expose the first and second

the fourth and fifth TMT joints usu-

TMT joints. Small, irreducible bone


occurs with reduction of the me-

fragments are débrided from the


three TMT joints and is secured

joints. The reduction should begin medially and progress laterally. Aligning the medial aspect of the first

with percutaneous K-wire fixation (Fig. 5). Alternative fixation, although typically unnecessary, is done with

metatarsal and the medial cuneiform reduces the first TMT joint. The en- tire medial aspect of this joint is ex-

screw fixation. Occasionally, an associated impact- ed (nutcracker) fracture of the cuboid

posed to ensure that plantar gapping


require treatment. The technique

is not present. The reduction is pro- visionally held with a K-wire, and the joint is stabilized with a countersunk 3.5- or 2.7-mm screw placed from the base of the first metatarsal into the

described by Sangeorzan and Swiont- kowski