Post-Traumatic

Arthritis

Diagnosis, Management
and Outcomes
Savyasachi C. Thakkar
Erik A. Hasenboehler
Editors

123
Post-Traumatic Arthritis
Savyasachi C. Thakkar
Erik A. Hasenboehler
Editors

Post-Traumatic Arthritis
Diagnosis, Management and Outcomes
Editors
Savyasachi C. Thakkar Erik A. Hasenboehler
Hip & Knee Reconstruction Surgery Department of Orthopaedic Surgery
Johns Hopkins Adult Trauma Service
Department of Orthopaedic Surgery The Johns Hopkins Medical Institution
Columbia, MD Baltimore, MD
USA USA

ISBN 978-3-030-50412-0    ISBN 978-3-030-50413-7 (eBook)

[Link]

© Springer Nature Switzerland AG 2021

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I would like to dedicate this book to my
parents Mrs. Heena C. Thakkar and Dr.
C.J. Thakkar for their dedicated upbringing
and commitment towards excellence in life. I
would also like to dedicate the book to my
wife Dr. Rashmi S. Thakkar and my children
Sahuri and Shaarav who have provided me
with untiring support, love and patience.
Without these individuals, I would not be
where I am today!
Savyasachi C. Thakkar, MD

This book is dedicated to my beloved father

Dr. Giorgio Hasenboehler, who passed years
ago of cancer, and to my mother Elfriede
Hasenboehler, whom have always supported
me and have fostered my passion for
medicine and the surgical specialty. I also
would like to acknowledge my love Ana
Torregrosa for her infinite support, and last
my dearest children Nikolas and Lukas to
whom this book shall be an example of
commitment to teaching, learning and
dedication to a fulfilling profession.
Erik A. Hasenboehler, MD
Preface

The incidence and prevalence of post-traumatic arthritis is increasing globally due

to longevity of life, increased activity and injuries. Orthopaedic surgeons are skilled
at treating traumatic injuries to the extremities and joints. Early anatomic stabiliza-
tion is required when it comes to traumatic joint reconstructions. Unfortunately,
post-traumatic osteoarthritis (PTOA) of a joint is an unpredictable consequence that
can occur at any time, in different presentations, severity and complexity after an
injury. Delayed post-traumatic complications require a thorough understanding of
anatomic principles, meticulous planning and symphonic surgical execution. Timing
of treatment and subsequent care of PTOA are the most essential aspects to achieve
excellent outcomes in this challenging group of patients.
The book is broadly divided into two parts – upper extremity and lower extrem-
ity – to encompass the breadth of the subject while delving into the unique chal-
lenges of each joint. Additional parts of the book will also cover the basic science of
cartilage degeneration in response to trauma, dedicated imaging modalities that
optimize visualization and surgical planning of the arthritic joint and the economic
impact of post-traumatic osteoarthritis.
It is our hope that the readers of this book will receive a comprehensive frame-
work to base their clinical decisions and learn about the latest techniques in manag-
ing these challenging injuries. The book is geared towards general orthopaedic
surgeons and sub-specialty trained orthopaedic surgeons with equal measure. The
book has also been written for orthopaedic surgeons in training who require a broad
overview of this subject to complement their education.
This book would not have been possible without the tremendous synergy between
basic science experts, radiologists and orthopaedic surgeons with a passion for
teaching by example. On behalf of the editors and the authors, we hope that you
enjoy reading this book and apply the principles of managing post-traumatic osteo-
arthritis for the benefit of your patients.

Columbia, MD, USA Savyasachi C. Thakkar

Baltimore, MD, USA Erik A. Hasenboehler

vii
Acknowledgments

The creation of this book has been a collective effort of several professionals. First,
we would like to thank the authors who have provided us their invaluable time and
energy to assemble various surgical cases that highlight the sentinel principles of
post-traumatic arthritis. Second, we would like to acknowledge Ms. Meera
V.  Shanbhag who has devoted her talents as a pre-medical student at Vanderbilt
University in reviewing manuscripts and collating the contents of this book.
Third, this book would not have been possible without the oversight and plan-
ning provided by Mr. Kristopher Spring and Ms. Abha Krishnan. Both of them have
provided us with tremendous resources to make this book a reality.
Finally, we would like to thank our families for providing us with incredible sup-
port and motivation to devote time to projects such as this.

ix
Contents

Part I Background and Assessment of Post-­traumatic Arthritis

1 The Role of TGF-β in Post-traumatic Osteoarthritis ��������������������������    3
Gehua Zhen and Xu Cao
2 Imaging Modalities for Post-traumatic Arthritis����������������������������������   15
Filippo Del Grande, Luca Deabate, and Christian Candrian
3 Economic Implications of Post-traumatic Arthritis of the Hip and
Knee����������������������������������������������������������������������������������������������������������   25
Richard Iorio, Kelvin Y. Kim, Afshin A. Anoushiravani, and
William J. Long

Part II Post-traumatic Arthritis of the Upper Extremity

4 Post-traumatic Glenohumeral Arthritis����������������������������������������������    45
Uma Srikumaran and Eric Huish
5 Post-traumatic Arthritis of the Elbow����������������������������������������������������   59
Kevin O’Malley, Ryan Churchill, Curtis M. Henn, and Michael
W. Kessler
6 Post-traumatic Arthritis of the Wrist����������������������������������������������������   73
Sophia A. Strike and Philip E. Blazar
7 Post-traumatic Arthritis of the Hand ����������������������������������������������������   97
Andrew P. Harris, Thomas J. Kim, and Christopher Got

Part III Post-traumatic Arthritis of the Lower Extremity

8 Post-traumatic Arthritis of the Acetabulum������������������������������������������  111
Savyasachi C. Thakkar, Erik A. Hasenboehler, and Chandrashekhar
J. Thakkar

xi
xii Contents

9 Post-traumatic Arthritis of the Proximal Femur����������������������������������  135

Raj M. Amin, Erik A. Hasenboehler, and Babar Shafiq
10 Post-traumatic Arthritis of the Distal Femur����������������������������������������  153
Karthikeyan Ponnusamy and Ajit Deshmukh
11 Post-traumatic Arthritis of the Proximal Tibia������������������������������������  167
Stefanie Hirsiger, Lukas Clerc, and Hermes H. Miozzari
12 Post-traumatic Arthritis of the Ankle����������������������������������������������������  185
Nigel N. Hsu and Lew Schon
13 Post-traumatic Arthritis of the Foot������������������������������������������������������  199
Ram K. Alluri and Eric W. Tan

Index�������������������������������������������������������������������������������������������������������������������� 219
Contributors

Ram K. Alluri, MD  Department of Orthopaedic Surgery, Keck School of Medicine

of USC, Los Angeles, CA, USA
Raj  M.  Amin, MD  Department of Orthopaedic Surgery, The Johns Hopkins
Medical Institutions, Baltimore, MD, USA
Afshin  A.  Anoushiravani, MD  Department of Orthopaedic Surgery, Albany
Medical Center, Albany, NY, USA
Philip E. Blazar, MD  Brigham and Women’s Hospital, Boston, MA, USA
Christian Candrian, MD  Servizio di ortopedia, Ospedale Regionale di Lugano,
Ticino, Switzerland
Xu Cao, PhD  Department of Orthopaedic Surgery, The Johns Hopkins University,
Baltimore, MD, USA
Ryan  Churchill, MD  Medstar Georgetown University Hospital, Department of
Orthopaedics, Washington, DC, USA
Lukas  Clerc, MD  Division of Orthopaedic and Traumatology, Department of
Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva,
Geneva, Switzerland
Luca Deabate, MD  Servizio di ortopedia, Ospedale Regionale di Lugano, Ticino,
Switzerland
Filippo  Del Grande, MD  Clinica di Radiologia EOC, Istituto di Imaging della
Svizzera Italiana, Ente Ospedaliero Cantonale, Ticino, Switzerland
Ajit Deshmukh, MD  Department of Orthopaedic Surgery, New York University,
New York, NY, USA
Christopher  Got, MD  Brown University, Warren Alpert Medical School,
Providence, RI, USA

xiii
xiv Contributors

Andrew  P.  Harris, MD  Warren Alpert Medical School of Brown University,
Providence, RI, USA
Erik  A.  Hasenboehler, MD  Department of Orthopaedic Surgery, Adult Trauma
Service, The Johns Hopkins Medical Institution, Baltimore, MD, USA
Curtis  M.  Henn, MD  Medstar Georgetown University Hospital, Department of
Orthopaedics, Washington, DC, USA
Stefanie Hirsiger, MD  Division of Orthopaedic and Traumatology, Department of
Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva,
Geneva, Switzerland
Nigel N. Hsu, MD  Department of Orthopaedic Surgery, Johns Hopkins University,
Baltimore, MD, USA
Eric  Huish, DO  Stanislaus Orthopaedics & Sports Medicine Clinic,
Modesto, CA, USA
Richard  Iorio, MD  Brigham and Women’s Hospital, Member of the Faculty,
Harvard Medical School, Boston, MA, USA
Michael W. Kessler, MD  Medstar Georgetown University Hospital, Department
of Orthopaedics, Washington, DC, USA
Kelvin  Y.  Kim, MD  Department of Orthopaedic Surgery, UNLV School of
Medicine, Las Vegas, NV, USA
Thomas  J.  Kim, MD  Brown University, Warren Alpert Medical School,
Providence, RI, USA
William J. Long, MD, FRCSC  ISK Institute, Department of Orthopaedic Surgery,
NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, USA
Hermes H. Miozzari, MD  Division of Orthopaedic and Traumatology, Department
of Surgery, Geneva University Hospitals, Faculty of Medicine, University of
Geneva, Geneva, Switzerland
Kevin  O’Malley, MD  Medstar Georgetown University Hospital, Department of
Orthopaedics, Washington, DC, USA
Karthikeyan Ponnusamy, MD  Pinnacle Orthopaedics, Canton, GA, USA
Lew  Schon, MD  Department of Orthopaedic Surgery, Mercy Medical Center,
Baltimore, MD, USA
Babar  Shafiq, MD  Department of Orthopaedic Surgery, The Johns Hopkins
Medical Institutions, Baltimore, MD, USA
Uma  Srikumaran, MD, MBA  The Johns Hopkins University, Division of
Shoulder and Elbow Surgery, Columbia, MD, USA
Contributors xv

Sophia  A.  Strike, MD  Johns Hopkins University School of Medicine,

Baltimore, MD, USA
Eric W. Tan, MD  Department of Orthopaedic Surgery, Keck School of Medicine
of USC, Los Angeles, CA, USA
Chandrashekhar  J.  Thakkar, MS (Ortho)  Joints Masters Institute, Mumbai,
Maharashtra, India
Breach Candy Hospital, Mumbai, Maharashtra, India
Lilavati Hospital, Mumbai, Maharashtra, India
Hinduja Hospital, Mumbai, Maharashtra, India
Savyasachi C. Thakkar, MD  Hip & Knee Reconstruction Surgery, Johns Hopkins
Department of Orthopaedic Surgery, Columbia, MD, USA
Gehua  Zhen, MD  Department of Orthopaedic Surgery, The Johns Hopkins
University, Baltimore, MD, USA
 Part I
Background and Assessment
of Post-­traumatic Arthritis
Chapter 1
The Role of TGF-β in Post-traumatic
Osteoarthritis

Gehua Zhen and Xu Cao

Key Points
• Osteoarthritis is a disease that affects the whole joint. Biochemical and
biomechanical interactions among different components within the joint
actively participate in and contribute to the development and progression
of the disease.
• TGF-β plays an important role in the pathogenesis of osteoarthritis.
Temporal and spatial regulation of TGF-β activity is critical for mainte-
nance of homeostasis of joint tissues.
• The effects of TGF-β differ according to tissue type within the joint and
may vary at different time points. Various tissue-specific treatments target-
ing TGF-β signaling may produce optimal therapeutic effects.

Introduction

Osteoarthritis is the most common degenerative joint disease. Although osteoarthri-

tis develops in joints naturally over time, it progresses rapidly after traumatic injury.
Extreme physical demands or injuries to bones, ligaments, menisci, or articular car-
tilage predispose patients to post-traumatic osteoarthritis (PTOA) [1]. Despite sur-
gical reconstruction of the joint components, osteoarthritis still develops at a high
rate after joint injuries. PTOA accounts for an estimated 12% of all cases of osteo-
arthritis, with approximately 5.6 million people in the United States living with
PTOA [2]. The symptoms of PTOA, including joint pain, swelling, stiffness, and

G. Zhen · X. Cao (*)

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
e-mail: gzhen1@[Link]; xcao11@[Link]

© Springer Nature Switzerland AG 2021 3

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
4 G. Zhen and X. Cao

limited movement, are similar to symptoms of other types of osteoarthritis. The

pathological characteristics of PTOA include articular cartilage degeneration,
abnormal bone formation, and aberrant angiogenesis in subchondral bone.
The risk of developing PTOA can be minimized by preventing injuries to the
joint. According to osteoarthritis management guidelines, treatment of PTOA often
starts with lifestyle modifications, including weight loss, low-impact exercise, and
strengthening of the muscles surrounding the joint [2]. Analgesics and anti-inflam-
matory medications are the primary nonsurgical approach to control symptoms.
However, these medications can cause gastrointestinal complications and their effi-
cacy quickly becomes blunted. To date, there is no approved pharmacologic agent,
biologic therapy, or procedure to prevent progressive destruction of the osteoar-
thritic joint. Many agents have been developed and tested to treat osteoarthritis-­
related abnormalities. Glucosamine sulfate, chondroitin sulfate, sodium hyaluronan,
and matrix metalloproteinase (MMP) inhibitors have been tested in various clinical
trials [3]. Unfortunately, the ability of these medications to stop or reverse osteoar-
thritis progression is still limited. In end-stage PTOA, when medications are no
longer effective to control symptoms, surgical treatment such as arthroscopic
debridement, reconstruction, or joint replacement is usually necessary.
A new treatment paradigm relies heavily on novel findings in pathogenesis stud-
ies. Progress in exploring new biologic and pharmaceutical interventions has been
impeded because the pathomechanical cause of PTOA is still poorly understood.
Currently, most patients in the United States receive appropriate surgery and/or
physical therapy immediately after an acute joint injury. However, PTOA develops
eventually in a considerable proportion of these patients. Surgical reconstruction
may not fully restore normal joint kinematics, causing an altered mechanical envi-
ronment that may lead to secondary cartilage degeneration and joint abnormalities
[4]. Osteoarthritis risk factors such as obesity, aging, and joint malalignment accel-
erate decline of joint function. These factors directly or indirectly change the
mechanical environment of the joint after traumatic injury. This evidence collec-
tively indicates that chronic alteration of mechanical stress could be the one of the
primary triggers of PTOA onset and progression. Because osteoarthritis affects the
whole joint, changes in biochemical and/or biomechanical properties of one tissue
may influence the homeostasis and integrity of other parts of the joint.

 he Functional Unit of Articular Cartilage

T
and Subchondral Bone

Recently, patient-specific finite element stress analysis has been used to measure
cartilage stress from residual surface incongruity after traumatic joint injury.
However, factors that trigger stress alterations in cartilage are not limited to carti-
lage itself. As a functional unit, the joint involves constant interaction between vari-
ous tissues [5]. Because of the physical contact between cartilage and bone, the
1  The Role of TGF-β in Post-traumatic Osteoarthritis 5

mechanical influence of the subchondral bone on articular cartilage is critical to the

maintenance of cartilage homeostasis. Articular cartilage buffers loading force and
prevents mechanical damage to subchondral bone, while subchondral bone provides
structural support for the overlying articular cartilage. Thus, the homeostasis and
integrity of these two tissues rely on the biochemical and biomechanical interplay
between them [5]. A finite element simulation study indicated that slight expansion
of subchondral bone volume or elevation of subchondral bone stiffness dramatically
increases the mechanical stress in the overlying articular cartilage [6]. Subchondral
bone responds rapidly to changes in the mechanical environment, and its structural
changes can be detected during the early stages of osteoarthritis. When the ability of
subchondral bone to provide stable mechanical support is impaired, one would
expect the stress distribution in articular cartilage to alter accordingly. The mechani-
cal impact of subchondral bone on articular cartilage is translated into biochemical
signals that influence cartilage homeostasis [7]. Therefore, exploring how subchon-
dral bone responds to an abnormal environment and how it subsequently affects
cartilage homeostasis is critical to understanding the pathogenesis of PTOA.
To maintain proper levels of calcium and phosphorus in circulation and reshape
the micro-damage that occurs during normal activities, adult bone is constantly
resorbed and formed in a process called bone remodeling. To provide stable support
to the overlying cartilage, normal subchondral bone maintains the turnover rate at a
very low level compared with that of the long bone trabeculae. However, the bone
turnover rate increases dramatically in osteoarthritic subchondral bone [8]. The
sequence of events that occurs in normal bone remodeling is disrupted, and the
discordant behavior of osteoblast and osteoclast lineage cells results in abnormal
bone formation with hypo-mineralization. The de novo bone formation in the osteo-
arthritic subchondral bone suggests that the new bone does not form in the resorp-
tion pit of the bone surface but rather in the bone marrow cavity, without appropriate
connections to the original trabeculae. Understanding the mechanism that underlies
the uncoupled bone resorption and formation is imperative for developing effective
measures to mitigate subchondral bone abnormality and consequent cartilage
degeneration. In the osteoarthritic environment, particularly during adaptation to
the new mechanical environment, subchondral bone is destroyed by highly acti-
vated osteoclasts. Consequently, high levels of active transforming growth factor-β
(TGF-β) are released from the sequestration of bone matrix, triggering sequential
pathological events at the onset and during the progression of osteoarthritis [6].

TGF-β

TGF-β is a cytokine that belongs to the TGF-® superfamily, members of which

have been highly conserved through evolution and are involved in a broad range of
biological processes [9]. TGF-β is one of four major subfamilies of this superfamily.
There are three TGF-β isoforms: TGF-β1, TGF-β2, and TGF-β3. These isoforms
have distinct tissue-specific expression profiles but use the same receptor-signaling
6 G. Zhen and X. Cao

systems [10]. On secretion, the homodimers of mature TGF-β peptide link nonco-
valently to latency-associated peptide (LAP), with LAP masking its receptor-­
binding domains and rendering it inactive [11]. The small latent complex formed by
LAP and TGF-β further interacts with latent TGF-β binding protein in the extracel-
lular matrix and forms the large latent complex. Although TGF-β synthesis is wide-
spread, activation is localized to sites where TGF-β is released from latency.
Temporal-spatial regulation of TGF-® activation is crucial for appropriate function
of this cytokine, and the abundant latent TGF-®s that are deposited in the extracel-
lular matrix ensure that sufficient TGF-β can be activated when necessary. The
TGF-β activation mechanism is tissue-specific and cellular context-dependent [12].
For example, enzyme-mediated proteolytic cleavage has been reported to be the
dominant pathway for TGF-β to be activated in tumors or metastasis, whereas pul-
monary fibrosis is induced by integrin-mediated excessive TGF-β activation.
Multiple mechanisms of TGF-β activation may be used or switched from one to
another depending on the cellular context or environmental stimuli [11].
TGF-βs signal via the heteromeric complexes of two related transmembrane ser-
ine/threonine kinase receptors, TGF-β type I and type II receptors (TβR-I and
TβR-II). TβR-I is also termed activin receptor-like kinase (ALK). The dimeric
ligand of TGF-β binds to the extracellular domains of TβR-I and TβR-II, inducing
close proximity of the receptors. Unlike TβR-II, which is unique to its ligand, dis-
tinctive TβR-Is can be phosphorylated by TβR-II, which determines the specificity
of the downstream signaling pathway [13]. Smad2 and Smad3 are substrates of
ALK5, whereas ALK1 phosphorylates Smad1, Smad5, and Smad8. After phosphor-
ylation by the receptor, the phosphorylated receptor-regulated Smad forms a com-
plex with the common mediator Smad4 and translocates to the nucleus where they
interact with other transcription factors (cofactors) to regulate transcriptional
responses. In addition to the Smad-dependent canonical pathway, TGF-β also sig-
nals through the Smad-independent or noncanonical pathways. The tumor necrosis
factor receptor-associated factor 4 (TRAF4), TRAF6, p38 mitogen-activated pro-
tein kinase (p38 MAPK), TGF-β-activated kinase 1 (TAK1; also known as
MAP3K7), Ras homolog gene family, phosphoinositide 3-kinase (PI3K), protein
kinase B, extracellular signal-regulated kinase (ERK), JUN N-terminal kinase
(JNK), and nuclear factor-κB (NF-κB) have all been reported to mediate the TGF-β
signaling pathway [14].

The Role of TGF-β in Osteoarthritic Subchondral Bone

Temporal-spatial regulation of the TGF-β activation process is the prerequisite for

TGF-β to function appropriately. Additionally, the effect of TGF-β is influenced by
the expression levels and activity of TGF-β receptors, as well as downstream fac-
tors. When TGF-β signaling is up- or downregulated, tissue homeostasis fails in the
affected organs. Abnormal TGF-β signaling has been observed in various immune
diseases, cancer, heart disease, diabetes, Camurati-Engelmann disease, Marfan syn-
drome, Loeys-Dietz syndrome, Parkinson disease, and acquired immune deficiency
1  The Role of TGF-β in Post-traumatic Osteoarthritis 7

syndrome [15]. Premature activation of TGF-βs and the consequent pathological

events in subchondral bone were found to contribute to the development and pro-
gression of osteoarthritis. In physiological conditions, TGF-βs in the matrix are
activated and released into the interstitial space or lumens during tissue injury or
remodeling. Stem cells or progenitor cells harbored in the nearby tissue are then
recruited to the remodeling site with the highest TGF-β concentration [16]. In con-
junction with other signals, TGF-βs further regulate whether the stem cells differen-
tiate or self-renew. In this way, TGF-β acts as the key coupling factor during bone
remodeling that directs the migration of mesenchymal stem cells (MSCs) in normal
conditions [17].
Intra-articular injury alters the mechanical environment of the joint dramatically.
Osteoclastic bone resorption is substantially elevated in adaptation to the new
mechanical environment, which results in the release of a large quantity of active
TGF-βs in the relatively confined space of subchondral bone. The normal pattern of
TGF-β gradients from the bone resorption site to the bone marrow cavity is then
disrupted because of the excessive liberation of TGF-β. As a result, MSCs or osteo-
progenitors cluster in the bone marrow cavity or randomly deposit on bone surfaces.
De novo bone formation at inappropriate times and/or locations ensues [6].
TGF-β also regulates stem cell behavior through its direct or indirect effects in
modulating the bone marrow microenvironment. For example, bone formation
always couples with angiogenesis and vascularization, which creates an environ-
ment rich in MSCs. TGF-β can promote angiogenesis, which provides an environ-
ment favorable to bone formation and therefore contributes to the abnormal bone
formation in osteoarthritic subchondral bone. TGF-β signaling plays an important
role in epithelial-mesenchymal and endothelial-mesenchymal transitions [18]. In
the context of different morphogenetic events, epithelial or endothelial cells trans-­
differentiate into stromal lineage cells, which are involved in many pathological
conditions such as fibrosis [19]. Therefore, aberrant elevated active TGF-β could be
associated with formation of poorly mineralized bone and increased marrow perfu-
sion and fibrosis in osteoarthritic subchondral bone. When active TGF-β1 is released
prematurely by osteoblastic cells in the transgenic mouse, early onset of
osteoarthritic-­like changes in knee joints is common [6]. In these mice, the abnor-
mally elevated TGF-β levels in subchondral bone induce abnormal bone formation
and structure alteration and consequently contribute to articular cartilage degenera-
tion [6]. The linkage of gain of function of Smad3 mutations with the early onset of
hip and knee osteoarthritis in humans also supports this notion [20]. Indeed, osteo-
arthritis progression can be attenuated substantially in the mouse PTOA model
when the TGF-β signaling pathway in MSCs is blocked genetically [6].

The Role of TGF-β in Osteoarthritic Articular Cartilage

Cartilage degeneration is another major concern in osteoarthritis. Articular cartilage

has limited self-repair capability, and cartilage lesions rarely heal if the damage is
larger than 3 mm in diameter [21]. The role of TGF-β in cartilage is different than
8 G. Zhen and X. Cao

its role in subchondral bone. For example, genetically deleting TβR-II or Smad3 in
chondrocytes resulted in early onset of osteoarthritis in animal models, as evidenced
by the hypocellularity and decreased matrix protein synthesis of chondrocytes [22].
The effects of TGF-β in stimulating chondrogenic condensation, proliferating chon-
droprogenitors, and inhibiting terminal differentiation of chondrocytes have been
evidenced in multiple in vitro studies. These findings suggest that TGF-β is critical
to maintaining articular cartilage’s functional and structural integrity [23]. The
abundant latent TGF-β storage (~300 ng/mL) in the extracellular matrix of cartilage
provides sufficient raw material for TGF-β activation [24]. In physiological condi-
tions, minimal amounts of active TGF-βs are needed for the maintenance of carti-
lage physiological function. In osteoarthritic cartilage, many mechanisms involved
in the process of TGF-β activation such as MMPs or integrins are altered [25],
which may lead to excessive or insufficient activation of TGF-β. Intra-articular
injury likely alters the mechanical stress distribution in articular cartilage directly or
indirectly through subchondral bone. Subchondral bone changes its structure con-
stantly in response to the mechanical environment. During the period of structural
fluctuation, the capacity of subchondral bone to dissipate the mechanical load is
altered or impaired. Because physiological mechanical stimulation is indispensable
for maintaining the function and structural integrity of articular cartilage, abnormal
mechanical stress (altered intensity or frequency) can promote catabolic events and
induce cartilage degeneration [26]. Although the soluble factors responsible for
propagating mechanical signals into biochemical signaling are still unclear, evi-
dence suggests an important role of TGF-β in mechanical transduction pathways in
chondrocytes [27]. In addition to TGF-β activation pathways, it has been reported
that shear forces can liberate active TGF-β from the sequestration of LAP in syno-
vial fluid [28]. TβR-I-specific inhibitor eliminated the anabolic effect of shear stress
in stimulating protein synthesis in the superficial zone of articular cartilage [29].
These findings indicate that abnormal biomechanical and biochemical environ-
ments alter the TGF-β activation process, and excessive or insufficient levels of
TGF-β, in turn, effect the chondrocytes’ survival and function.
The responsiveness of chondrocytes to TGF-β also depends on the expression
levels and activity of its receptors. The canonic TGF-β signaling pathway includes
the formation of the heteromeric complexes of type I and type II receptors. A
sequential phosphorylation and nuclear translocation of downstream Smads ulti-
mately triggers the expression of the target genes. Dysregulation of TGF-β signaling
pathways or differential expression of TGF-β receptors in the chondrocytes has
been reported in various in vivo studies, including a surgically induced PTOA ani-
mal model. TβR-II degradation and decreased TβR-I expression blunt the sensitivity
of articular chondrocytes to TGF-β, contributing to cartilage degeneration [30]. The
expression pattern of TβR-I in chondrocytes is markedly different in osteoarthritic
cartilage. The dominant TβR-I receptor shifts from ALK5 to ALK1 [31]. TGF-β
signals from these two pathways influence the metabolism of chondrocytes in an
opposing fashion [32]. TGF-β acts as an anabolic factor on chondrocytes, stimulat-
ing matrix protein production when signaling through ALK5, and as a catabolic
1  The Role of TGF-β in Post-traumatic Osteoarthritis 9

factor when ALK1 is mediating its downstream signaling [33]. In addition, there are
several other factors involved in the signaling transduction pathway of TGF-β by
modulating the sensitivity of receptors to the ligand or the internalization process of
the receptors. For example, endoglin can facilitate the binding of TGF-β to its recep-
tors with the preference to recruit ALK1 [34]. Therefore, elevated expression of
endoglin in chondrocytes may promote the catabolic effect by making ALK1/
pSmad1/5/8 the dominant signaling pathway of TGF-β. Betaglycan is a homolog of
endoglin but it has distinctive functions in regulating the TGF-β pathway. Betaglycan
can direct clathrin-mediated endocytosis of TβR-I and TβR-II [35] and increase the
sensitivity of TβR-II to its ligands [36]. CD109 is another identified TGF-β co-­
receptor. It negatively regulates TGF-β signaling by promoting TGF-β receptor
internalization and degradation [37]. Thus, during osteoarthritis development, the
altered TGF-β signaling in articular cartilage may potentially be corrected by target-
ing these co-receptors or modulators.

The Role of TGF-β in the Osteoarthritic Synovial System

As avascular tissue, articular cartilage is nourished mainly by the synovial fluid that
is secreted by the synovium. Therefore, articular cartilage is vulnerable to patho-
logical changes in the synovial system. Although osteoarthritis is defined as “non-­
inflammatory arthritis,” synovial hyperplasia, macrophage infiltration, and
angiogenesis are common characteristics of osteoarthritic abnormality [38].
Histologically recognizable synovitis occurs in more than one-third of patients with
symptomatic osteoarthritis. Persistent or episodic synovitis has been found to be
related closely to osteoarthritic pain. The cytokines released by synovium have been
recognized as being of pathological and clinical importance in the development of
osteoarthritis. Notably, human and animal studies suggest that the concentration of
TGF-β1 might be used as a prognostic indicator for PTOA. In a rabbit meniscec-
tomy model, early postoperative concentrations of TGF-β1 in synovial lavage fluid
were correlated positively with the severity of PTOA [39]. In patients with acute or
chronic anterior cruciate ligament rupture, the levels of TGF-β in the synovial fluid
were consistent with the persistence of inflammatory reactions, and their synovial
fluid cytokine profiles were associated with the risk of developing PTOA [40].
TGF-β typically serves as an important immune suppressor during the process of
inflammation. Knocking out TGF-β1  in mice is usually lethal because it induces
severe inflammatory events. TGF-β receptors are expressed widely in immune cell
types and have broad activities in immune regulation. In most immune reactions,
TGF-β acts as a suppressor. Conversely, TGF-β sometimes plays a pro-­inflammatory
role by promoting the differentiation of TH17 lineage cells [41]. TGF-β was found
to induce the differentiation from “attacking” type I macrophages toward “inflam-
matory molecule secreting” type II macrophages [42, 43]. This may underlie the
mechanism of TGF-β in augmenting the tumor necrosis factor-α- or interleukin
10 G. Zhen and X. Cao

(IL)-1β-induced expression of MMP3, IL-6, IL-8, and macrophage inflammation

protein 1α in synoviocytes [44]. Therefore, TGF-β and its downstream signaling
could potentially be therapeutic targets for osteoarthritic synovitis.

Modulation of TGF-β Activity as a Potential Therapy

for Osteoarthritis

Currently, no medications have shown the disease-modifying efficacy and clinically

meaningful effects needed to gain regulatory approval. In animal studies and clini-
cal trials, controlling subchondral bone abnormality seems to mitigate the advance-
ment of osteoarthritis. Increased osteoclast activity and bone turnover rate are
known pathological characteristics of subchondral bone in osteoarthritis. For this
reason, the efficacy of the common antiresorptive medicine, bisphosphonate, has
been tested for treating osteoarthritis in clinical trials [45]. Though the results in
humans have not been as encouraging as those in animal osteoarthritis models,
some drugs within the bisphosphonate class have shown beneficial effects in human
studies. It is conceivable that the level of active TGF-β released from bone matrix
will decrease substantially when osteoclast bone resorption is inhibited by bisphos-
phonate. Aberrantly activated TGF-β signaling induces abnormal bone formation in
subchondral bone and contributes to osteoarthritis progression. This at least par-
tially explains the efficacy of bisphosphonates in treating osteoarthritis. TGF-β-­
neutralizing antibodies or TβR inhibitors may achieve a high specificity in
suppressing TGF-β signaling in subchondral bone, and their ability to attenuate
degeneration of articular cartilage was observed in anterior cruciate ligament tran-
section osteoarthritis rodent models [6]. However, as a critical growth factor, TGF-β
has a broad spectrum of functional activities such as growth inhibition, cell migra-
tion, cell invasion, epithelial-mesenchymal transition, and immune regulation. The
role of TGF-β in maintaining the homeostasis of articular cartilage is different than
that of subchondral bone. Thus, systemic administration of a TβR-I inhibitor might
disrupt tissue homeostasis of other organs, resulting in unwanted adverse effects
and chemical toxicity. Novel approaches that inhibit TGF-β signaling, specifically
in subchondral bone, may reduce potential adverse effects while maintaining the
therapeutic efficacy of the TβR-I inhibitor.
The function and behavior of cells are not only cell-context-dependent but are
also regulated by the local microenvironment. Aberrant elevation of TGF-β is one of
the primary factors in the microenvironment that drives the sequence of pathologi-
cal changes in osteoarthritic subchondral bone such as clustering of osteoprogeni-
tors, de novo bone formation, and neovascularization in marrow cavities. Many
other growth factors or cytokines such as Wnts, bone morphogenetic protein (BMP),
and insulin-like growth factor are also reported to be involved in the development of
subchondral bone abnormality [46]. Parathyroid hormone (PTH) plays an important
role in bone metabolism and calcium homeostasis. Recently, PTH was found to
1  The Role of TGF-β in Post-traumatic Osteoarthritis 11

orchestrate the signaling of local factors and thereby improve the microenvironment
in bone marrow [47]. TβR-II can form a complex with PTH type I receptor (PTH1R).
The binding of PTH with PTH1R downregulates TGF-β signaling by inducing
internalization of the TβR-II/PTH1R complex [47]. It is known that BMP and Wnt
signaling can promote the commitment of MSCs to osteoblastic lineage cells [48].
PTH upregulates BMP and Wnt signaling and, therefore, positively regulates osteo-
genesis. Additionally, angiogenesis is always coupled with osteogenesis during
bone formation. PTH has been shown to reduce the distance between newly formed
vessels and sites of bone formation [49]. Therefore, by coordinating the effects of
these osteogenic factors, PTH may alleviate abnormal bone formation while stimu-
lating normal bone turnover at the right location. Moreover, PTH is a well-recog-
nized anabolic factor during cartilage development and maintenance [50]. PTH may
be developed as a therapeutic agent because of its potential ability to rescue patho-
logical changes in both osteoarthritic cartilage and subchondral bone.

Summary

The diarthrodial joint works as a functional unit, and osteoarthritis affects almost all
of its structural components. TGF-β is a crucial factor that regulates the physiologi-
cal turnover of subchondral bone and articular cartilage. Dysregulation of TGF-β1
signaling leads to failure in maintenance of joint homeostasis during the develop-
ment and progression of osteoarthritis. Because the effects of TGF-β may differ
according to tissue type within the joint and may vary at different time points, dif-
ferential and tissue-specific treatments targeting TGF-β signaling may produce opti-
mal therapeutic effects.

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Chapter 2
Imaging Modalities for Post-traumatic
Arthritis

Filippo Del Grande, Luca Deabate, and Christian Candrian

Key Points
• Magnetic field strength increases the signal to noise ratio (SNR) and can
influence cartilage detection and grading.
• T2 mapping, dGEMERIC, T1 rho, and Sodium imaging are advanced MRI
techniques that allow the biochemical evaluation of the cartilage.
• Bone marrow edema (also called bone marrow lesions) is commonly pres-
ent in patients with OA mainly in areas of mechanical loading.

Introduction

Osteoarthritis (OA) is a rapidly increasing condition in US population ranging from

21 million in 1995 to 27 million in 2007 [1]. Aging population, male gender, increas-
ing overweight, and genetic predisposition are the main general risk factors for the
disease [2]. Besides these general risk factors, other local biomechanical conditions
such as post-traumatic joint instability and/or misalignment are responsible for OA
[2]. It is estimated that post-traumatic etiology accounts for approximately 12% of
OA of lower extremities [3].
The well-known imaging findings of primary OA such as subchondral bone scle-
rosis, osteophytes, joint space narrowing, and subchondral cysts are similar to

F. Del Grande (*)

Clinica di Radiologia EOC, Istituto di Imaging della Svizzera Italiana,
Ente Ospedaliero Cantonale, Ticino, Switzerland
e-mail: [Link]@[Link]
L. Deabate · C. Candrian
Servizio di ortopedia, Ospedale Regionale di Lugano, Ticino, Switzerland
e-mail: [Link]@[Link]; [Link]@[Link]

© Springer Nature Switzerland AG 2021 15

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
16 F. Del Grande et al.

post-­traumatic OA [3]. Conventional radiography, CT imaging, and MR imaging

are currently the imaging modality available in the clinical practice to assess
OA. The main difference between post-traumatic OA and idiopathic OA is the joint
location. Ankle joint, shoulder joint, and elbow joint are generally atypical locations
for primary OA but are involved in post-traumatic OA (Figs.  2.1 and 2.2). For
instance, less than 2% of hip OA are post-traumatic, whereas approximately 80% of
ankle OA are post-traumatic [3].
The purpose of our chapter is to familiarize oneself with the most common imag-
ing modalities used in clinical practice to assess post-traumatic OA, i.e., conven-
tional radiography and MR imaging, and to review the diagnostic performance, the
reliability, and the correlation of imaging findings with pain. Owing to the scarcity
of the literature on imaging in post-traumatic OA, our chapter will review the gen-
eral principles of imaging of OA and will focus on post-traumatic OA when possible.

Conventional Radiography

Conventional radiography (CR) is the least expensive and most widely available
imaging modality to assess OA in the clinical practice. CR allows not only to detect
morphological changes of OA but also to follow the disease progression by measur-
ing the joint space narrowing (JSN) (Fig. 2.3) [4, 5]. Slowing of the JSN progression
is the official criterion approved by the Federal and Drug Administration (FDA) to
demonstrate efficacy of drugs in phase III trials of OA [4, 5].
JSN is a complex process that involves several anatomical structures depending
on the joint. For instance, in the knee joint, cartilage loss, meniscal degeneration,
and/or meniscal extrusion are involved in the joint space narrowing process [6].
In the clinical practice, radiologists don’t use scoring systems to report
OA. Kellgren and Lawrence (K-L) is the best-known semiquantitative grading sys-
tem to assess OA and was originally developed for anteroposterior knee radiogra-
phies [7]. The 5-point K-L scoring system stratifies OA according to four
conventional radiology findings: presence of bony osteophytes, joint space narrow-
ing, presence and degree of subchondral sclerosis, and bony deformity (Fig. 2.4) [7,
8]. K-L grade 0 indicates none OA, K-L grade 1 indicates doubtful OA, K-L grade
2 indicates minimal OA, K-L grade 3 indicates moderate OA, and K-L grade 4
indicates severe OA. Although the K-L scoring system could help to increase com-
munication between radiologists and clinicians, it shows some important limita-
tions that prevent its introduction in clinical practice and in research protocols. One
of the major limitations of K-L grading system is the grouping of the majorities of
patients in the grade of moderate OA (grade 3) [4]. Furthermore, K-L method shows
high interpretation variability with poor to moderate inter-observer agreement [9].
Experience and training seems to play an important role for reliability reporting.
Differences arise between readers on site and an expert centralized reader as well,
which highlight the importance to use a centralized reader in the research proj-
ects [10].
2  Imaging Modalities for Post-traumatic Arthritis 17

a b

c d

Fig. 2.1 (a) Anteroposterior and (b) lateral conventional radiographies and (c) coronal and (d)
sagittal CT MPR reconstruction of the elbow of a 60-year-old patient after internal fixation of a
radial head fracture. The patient developed post-traumatic OA of the elbow which is an atypical
location for primary OA. Radiographs and CT show humero-ulnar and humero-radial OA. The
osteophyte arising from the olecranon ulnae causes extension deficit
18 F. Del Grande et al.

a b

Fig. 2.2 (a) Anteroposterior shoulder view and (b) 3D reconstruction of the shoulder of a 25-year-­
old patient. The 3D reconstruction (b) shows a displaced comminuted humerus fracture after
MVA. Two years later the patient developed a post-traumatic OA (a)

The major drawbacks of CR are lack of sensitivity [8, 11] and of reliability [9].
In clinical practice, standard anteroposterior and lateral views are generally suffi-
cient; additional views are rarely requested. The role of additional special projection
on knee MRI is debatable in the literature. In patients with arthroscopy-confirmed
grade II femorotibial chondromalacia, the 45°flexion PA and the standing AP view
are both insensitive to detect OA [11]. However, a more recent systematic review
concluded that the 45°flexion PA view was more sensitive than the standing AP
view for the detection of femorotibial OA, especially in patients suffering from
advanced OA [8]. The two studies showed contradictory results, probably because
of the relatively young population (average 38 years old) and the mild femorotibial
OA in the first study compared to the meta-analysis.
To the best of our knowledge, to date, only two studies focus on the reliability of
imaging of post-traumatic OA [12, 13]. K-L scoring system is reliable and corre-
lates with clinical symptoms in patients with ankle OA several years after open
reduction internal fixation of a malleolar fracture. Furthermore, adding the talar tilt
angle (modified K-L scale) will result in even better differentiation of clinical out-
comes [13].
In order to assess the reliability of grading systems for post-traumatic ankle OA,
Cleassen and colleagues analyzed three different methods: the Van Dick, the
Takakura, and the K-L methods. A total of 118 orthopedic surgeons and residents
graded 128 ankle radiographs after bi- or trimalleolar ankle fractures. The authors
2  Imaging Modalities for Post-traumatic Arthritis 19

Fig. 2.3 Anteroposterior
conventional radiography
of medial OA of the knee
with osteophytes,
subchondral sclerosis, and
joint space narrowing

found only fair inter-reader agreement for the Van Dick and low for the Takakura
and K-L classification systems. According to the results of the study, the authors
warned to use these classifications in the clinical practice [12].

MR Imaging

MRI has a high soft tissue contrast that allows to visualize the whole joint, i.e., the
bone, the synovia, the ligaments, the capsule, and mainly the cartilage [5, 14, 15].
Furthermore MRIs allow to assess the morphology and the composition of the
­cartilage [16].
20 F. Del Grande et al.

a b

Fig. 2.4 (a) Coronal MPR CT reconstruction of the knee of a comminuted displaced fracture of
the proximal tibia of a 36-year-old male patient after MVA. (b) Anteroposterior conventional radi-
ography 6 years later shows severe medial knee OA (K-L 4)

Studies on morphological cartilage assessment show a large heterogeneity of

results depending on several technical factors. A wide range of sensitivity from 0%
to 86% is reported for the detection of early cartilage lesions and from 47 to 98%
for the detection of more advanced cartilage lesions [17].
Among the several technical factors, higher magnetic field strength increases the
signal-to-noise ratio (SNR) and can influence cartilage detection and grading. Masi
and colleagues demonstrated higher accuracy in cartilage lesion detection and
higher ability to grade cartilage lesions on porcine model on 3 tesla compared to 1.5
tesla MRI [18]. Kijowski et  al. compared the detection of cartilage lesion of the
knee on 3 tesla MRI compared to 1.5 tesla MRI with arthroscopy in two different
study populations. The authors concluded that 3 tesla MRIs show higher specificity
and higher accuracy but not higher sensitivity compared to 1.5 tesla MRI [19].
Wong et al. found a modest but significant increase in sensitivity and accuracy of
diagnostic lesions on 3 tesla MRI compared to 1.5 tesla MRI.  Additionally the
authors found a higher grading and higher confidence in grading cartilage
lesions [20].
T2 mapping, dGEMRIC, T1 rho, and sodium imaging are advanced MRI tech-
niques that allow the biochemical evaluation of the cartilage [16]. A detailed
description of compositional MRI techniques for cartilage evaluation will go far
2  Imaging Modalities for Post-traumatic Arthritis 21

beyond the scope of this chapter. It is only worthy to mention that these composi-
tional techniques are rarely used in clinical practice mainly because of long acqui-
sition time and the need to use special pulse sequences and/or dedicated
­hardware [16].

Association Between Pain and Imaging Findings of OA

Association between pain and imaging findings in OA is one of the greatest chal-
lenges for researchers, radiologists, and referring physicians. Hyaline cartilage is
avascular and aneural and as such cannot be the source of pain [21]. Pain transmis-
sion is probably the result of more complex and indirect mechanisms involving
other articular structures [21]. It is speculated that pain could be secondary to the
exposure of nociceptors of the subchondral bone, to the increased intraosseous pres-
sure secondary to vascular congestion, and/or to cartilage damage that can lead to
synovitis [21].
Prevalence studies on hip OA show only low correlation between imaging find-
ings and pain. In the Framingham OA study, a community-based prevalence study
in which symptomatic and asymptomatic subjects underwent hip radiographies,
nearly one out of five subjects shows CR features of hip OA, but less than 5% were
symptomatic [22].
Another population-based observational study emphasizes the low sensitivity of
CR for OA and the low correlation of MRI findings of OA with pain [23]. In the
study, a cohort of 710 patients without evidence of knee OA (K-L grade 0) under-
went MRI of the knee. The authors assessed the prevalence of MRI finding sugges-
tive for OA such as osteophytes, cartilage damage, bone marrow lesions, synovitis,
subchondral cysts, meniscal lesions, and bone attrition. Some interesting clinical
considerations came out from the study. First, 89% of subjects showed MRI features
compatible with OA. Second, a high prevalence of symptomatic (97%) and asymp-
tomatic (88%) subjects showed at least one MRI feature of OA. According to the
study, MRI features of OA are so common in asymptomatic subjects that should not
be used as a diagnostic tool for OA. The role of MRI will be rather to rule out other
pathologies that can mimic OA such as subchondral bone fractures, osteonecrosis,
and insufficiency fractures [23].
Although the correlation between pain and imaging finding is low, some imaging
findings such as bone marrow edema, synovitis/effusion, and bone attrition are pre-
dictive of pain in patients with OA.
Bone marrow edema (also called bone marrow lesions) is commonly present in
patients with OA mainly in areas of mechanical loading (Fig. 2.5) [24]. Bone mar-
row edema is considered a strong pain generator in patients with OA [25–27] and
predictive for OA progression [24]. Interestingly, the fluctuation of bone marrow
edema on MRI correlates with pain fluctuation [28]. Histologically, bone marrow
edema in patients with OA is a mixture of fibrosis, hemorrhage, trabecular fractures,
22 F. Del Grande et al.

a b

Fig. 2.5 (a) Coronal T1-weighted sequences and (b) T2-weighted sequences of a 71-year-old
female patient with painful OA. Note the osteophytes arising from the medial compartment of the
knee, the meniscus subluxation, and diffuse cartilage loss. T2-weighted sequences show the bone
marrow edema of medial condyle and the medial tibial plateau

and only a minor component of edema [29, 30]. Bone attrition is a common bony
feature in OA and plays an important role in association with bone marrow edema
to generate pain [27]. Lastly, several studies emphasize the association of synovitis/
joint effusion with knee pain [26, 27, 31, 32].

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3.0 T versus 1.5 T of the knee. Skelet Radiol. 2009;38(8):761–9.
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row edema and its relation to progression of knee osteoarthritis. Ann Intern Med. 2003;139(5
Pt 1):330–6.
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of bone marrow lesions with pain in knee osteoarthritis. Ann Intern Med. 2001;134(7):541–9.
26. Lo GH, McAlindon TE, Niu J, Zhang Y, Beals C, Dabrowski C, et al. Bone marrow lesions
and joint effusion are strongly and independently associated with weight-bearing pain in knee
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27. Torres L, Dunlop DD, Peterfy C, Guermazi A, Prasad P, Hayes KW, et al. The relationship
between specific tissue lesions and pain severity in persons with knee osteoarthritis. Osteoarthr
Cartil. 2006;14(10):1033–40.
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changes in bone marrow lesions, effusions, and synovitis on magnetic resonance imaging.
Arthritis Rheum. 2011;63(3):691–9.
29. Bergman AG, Willen HK, Lindstrand AL, Pettersson HT. Osteoarthritis of the knee: correla-
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Skelet Radiol. 1994;23(6):445–8.
30. Zanetti M, Bruder E, Romero J, Hodler J. Bone marrow edema pattern in osteoarthritic knees:
correlation between MR imaging and histologic findings. Radiology. 2000;215(3):835–40.
31. Baker K, Grainger A, Niu J, Clancy M, Guermazi A, Crema M, et al. Relation of synovitis to
knee pain using contrast-enhanced MRIs. Ann Rheum Dis. 2010;69(10):1779–83.
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Chapter 3
Economic Implications of Post-traumatic
Arthritis of the Hip and Knee

Richard Iorio, Kelvin Y. Kim, Afshin A. Anoushiravani, and William J. Long

Key Points
• To understand how patient demographics, injury patterns, and the manage-
ment of hip and knee PTOA contribute to the disease burden
• To assess the direct and indirect economic burden associated with PTOA
of the hip and knee

Introduction

There are 27 million [1] people in the United States who have been diagnosed with
degenerative joint disease (DJD). Patients with osteoarthritis (OA) frequently pres-
ent with joint stiffness, pain, or instability due to degeneration of the articular sur-
face. In the event OA develops after an acute injury, this subcategory of OA is
referred to as post-traumatic osteoarthritis (PTOA). Posttraumatic osteoarthritis of

R. Iorio (*)
Brigham and Women’s Hospital, Member of the Faculty, Harvard Medical School,
Boston, MA, USA
e-mail: riorio@[Link]
K. Y. Kim
Department of Orthopaedic Surgery, UNLV School of Medicine, Las Vegas, NV, USA
A. A. Anoushiravani
Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
W. J. Long
ISK Institute, Department of Orthopaedic Surgery, NYU Langone Medical Center,
Hospital for Joint Diseases, New York, NY, USA

© Springer Nature Switzerland AG 2021 25

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
26 R. Iorio et al.

the lower extremity comprises about 12% of OA overall, of which PTOA of the hip
and knee account for 0.5% and 6.3%, respectively [2].
Following the initial injury, there are two mechanisms by which OA may ulti-
mately develop. One pathway is through damage to the articular surface of the joint
at the time of injury followed by subsequent, chronic degeneration of the joint sec-
ondary to a continuous inflammatory response [3]. Another pathway is through
chronic inflammation to the articular surface caused by joint instability or incongru-
ity following an inadequately treated joint injury. The pathophysiologic mechanism
in PTOA and primary OA is similar; however, PTOA is initiated by an acute trau-
matic episode [4].
Given the association between PTOA and acute injury, the patient population
that typically develops PTOA is younger and more active than patients diagnosed
with primary OA [5]. Patients with a history of lower-extremity joint trauma will
on average develop OA 10 years sooner than those without a history of trauma
[6]. Despite extensive research aimed at better managing PTOA, over 40% of
patients with significant soft tissue injuries to the knee will develop symptom-
atic OA [3].
An abundant amount of resources have been dedicated to understanding the
management of OA.  The Agency for Healthcare Research and Quality (AHRQ)
ranked OA as one of the top 5 most costly conditions in the United States [7]. Yet,
there is a paucity of literature evaluating the economic effects of secondary causes
of OA including PTOA. This is particularly concerning as recent studies have dem-
onstrated that the direct costs associated with managing PTOA are substantially
greater than those diagnosed with primary OA [8]. Additionally, as a growing num-
ber of individuals participate in high-risk activities, the incidence of PTOA is
expected to increase. Given this growing trend, PTOA poses a substantial financial
burden on the healthcare system. Thus, the aim of this review is to shed light on the
clinical and economic implications of PTOA. Emphasis will be placed on the direct,
indirect, and long-term costs associated with PTOA. Finally, we will present poten-
tial solutions which may improve the delivery of care and reduce the financial bur-
den on all stakeholders.

Post-traumatic Osteoarthritis of the Knee

Post-traumatic osteoarthritis of the knee is responsible for 6.3% of the overall prev-
alence of OA [2]. Patients diagnosed with PTOA are on average 10 years younger,
and more active than those with primary OA [2], and have a five times greater likeli-
hood of developing PTOA with a past history significant for knee injury [9].
Specifically, the incidence of ligamentous and meniscal injury is associated with a
50% incidence of knee PTOA within 10–20 years [10]. Given the rapidly progres-
sive nature of PTOA and the young active population often affected by this disease
process, it is not uncommon to see debilitating manifestations of the disease within
the third and fourth decades of life.
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 27

Types of Injuries Associated with PTOA of the Knee

Anterior Cruciate Ligament Injuries

Anterior cruciate ligament (ACL) pathology is commonly associated with PTOA

and is responsible for a quarter of knee injuries subsequently resulting in degenera-
tive changes of the knee [11]. Investigators have reported that 13% to 39% of
patients with isolated ACL injuries and 21% to 48% of individuals with complex
ligamentous injuries will develop symptomatic PTOA within 10 years of injury [12,
13]. Based on the severity of the injury, cartilage damage after ACL and meniscus
injuries can develop into PTOA regardless of whether the ligaments or meniscus is
repaired. Even in those who have their ACL reconstructed, about 50% of patients go
on to develop OA within 14 years (Fig. 3.1) [14].

Meniscus Injuries

Meniscal injuries are another common cause of degenerative knee changes and are
responsible for 23% of patients with PTOA [11]. Swenson et al. [15] observed that
following meniscal injury, the first signs of OA were identified 10 years after injury

Fig. 3.1  Patient with ACL reconstruction that went on to total knee arthroplasty
28 R. Iorio et al.

at an average age of 50 years. The investigators also reported that the age of the
patient at the time of the injury played a role in the timing of the onset of OA as
patients who had an isolated meniscal injury between the ages of 17 and 30 devel-
oped radiologic OA after 15 years, whereas patients over the age of 30 years devel-
oped degenerative changes within 5  years [15]. A study by Badlani et  al. [16]
compared the characteristics of meniscal injury in those who did and did not develop
PTOA within 2 years of injury. The authors reported that complex tears, extrusion
of the meniscus, tears greater than one-third of the radial width of the meniscus, and
injuries longer than one-third of the longitudinal length of the meniscus occurred
more frequently in those who developed PTOA.

Intra-articular Fractures

Patients with fractures of the articular surface are at increased risk for developing
PTOA (Fig. 3.3). Studies have demonstrated that up to 31% of these patients will
develop PTOA of the knee depending on the location of the fracture [17]. In a study
by Honkone [18], 44% of patients with a previous history of tibial plateau fractures
developed arthritis within 7.6 years of surgery. Although Honkone and colleagues
demonstrated the high prevalence of arthritis within patients with history of tibial
plateau fractures, the mechanism and severity of injury is often the best prognostic
indicator of PTOA. Higher load injuries are more likely to be associated with imme-
diate damage to the surrounding cartilaginous structures, whereas joints may be
more forgiving to less severe injuries [19, 20].

Management of Post-traumatic Osteoarthritis of the Knee

Primary Prevention

Primary prevention strategies are implemented in order to prevent the initial injury
from occurring and are considered to be the most effective management tool for
prevention of PTOA. Specifically for ACL rupture prevention, neuromuscular train-
ing, aerobic conditioning, resistance training, and plyometrics have all been shown
to strengthen soft tissue around the knee, reducing the incidence of ligamentous
injury [21]. Recent literature has reported a 70% risk reduction in ACL ruptures
when proper exercise regimens are practiced [22]. The costs associated with pri-
mary prevention of PTOA are not unreasonable. Exercise programs using these pre-
ventative therapies have been estimated to cost between $50 and 400 USD per
session and may require a 3-hour commitment per week. Given the high costs asso-
ciated with ACL reconstruction ($38,121 to $88,538 USD) [23], primary prevention
is particularly worthwhile among high-risk patients.
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 29

Secondary Prevention

Secondary preventative measures are indicated in individuals who have already sus-
tained a joint injury. The goal of secondary prevention is to prevent worsening of a
joint injury. Although surgical techniques and knowledge surrounding the restora-
tion of joint stability and articular surface congruity have improved over the past
25 years, up to 50% of individuals sustaining a serious joint injury warranting surgi-
cal intervention will go on to develop OA [24]. While in the majority of patients,
arthroscopic repair of soft tissue, ACL reconstruction, and partial meniscectomy are
the current standard of care, the literature has not demonstrated a reduced incidence
of PTOA with these interventions (Fig. 3.1) [25].
Similarly, the benefits are unclear in patients undergoing autologous chondrocyte
implantation (ACI), microfracture, and chondroplasty. Knutsen et  al. assessed 5-
[26] and 15-year [27] outcomes following ACI and microfracture repair in symp-
tomatic patients with cartilage defects and reported a failure rate as high as 43% and
33% for the respective procedures. In addition, the study also demonstrated that OA
develops in 33% of patients undergoing ACI and microfracture repair at 5 years and
greater than 50% of patients at 15 years. Given the similar long-term outlook, it is
important for providers and patients to be aware of the direct and indirect costs
associated with the various treatment modalities as there may be substantial differ-
ences between them.

Tertiary Prevention

When primary and secondary prevention measures have failed and PTOA has devel-
oped, alternative treatment modalities may be implemented to slow the progression
of OA. In younger, more active individuals, the clinician is left with the difficult task
of developing a treatment strategy aimed at minimizing pain, improving function,
and delaying TKA. Such an approach requires a host of patient-centered strategies
focusing on tiered interventions. The least invasive therapies should always be
implemented first regardless of the patient’s age. These interventions include weight
loss, orthotics, knee bracing, and physical therapy. Physical exercise has been shown
to provide pain relief, particularly when combined with strengthening and aerobic
activities. Various pharmacological treatments commonly used in combination with
first-line therapies include oral analgesic agents and intra-articular hyaluronic acid
or corticosteroid injections. Although nonsurgical interventions have been shown to
provide temporary relief, they do not have any impact on the reversal of the underly-
ing joint disease.
If nonsurgical management is unsuccessful, there are multiple surgical alterna-
tives available. Total knee arthroplasty (TKA) has been shown to alleviate knee pain
and improve knee function (Fig. 3.1). Although very effective, TKA in patients with
PTOA may be challenging due to anatomic malalignment, bony deficiency, joint
30 R. Iorio et al.

instability, contractures, compromised soft tissue, and retained hardware [28, 29].
These obstacles contribute to high complication rates, increased length of hospital
stay, readmissions, and worse functional outcomes than patients preoperatively
diagnosed with primary OA [8, 30].
Another method of surgical management particularly among younger patients
with significant deformities are osteotomies. These procedures are typically done in
younger (<50  years) more active patients with obvious bony malalignment.
Although an osteotomy has been shown to be associated with delaying the need for
TKA and improved pain and function scores [31], the benefits of surgery gradually
deteriorate as the disease progresses. Long-term studies have demonstrated 10-year
failure rates of 24.6% [32].
For patients with localized cartilaginous defects, osteochondral grafts may
be indicated. The procedure is almost exclusively conducted in younger patients
and has been associated with variable outcomes. A systematic review after a
mean follow-­up of 58 months demonstrated an overall failure rate of 18%, while
65% of patients had little to no radiographic change in knee arthritis on
­follow-up [33].
In order to deliver the highest quality of care, healthcare providers must empha-
size primary and secondary prevention. Tertiary prevention will frequently require
costly surgical procedures which may resolve the underlying joint pathology but
often with suboptimal outcomes. Thus, healthcare providers should continue to
investigate the pathophysiological association between mechanical injury and the
subsequent degenerative changes observed in the joint. Moreover, structured treat-
ment protocols are needed for the management of PTOA as these patients frequently
require multiple surgical interventions during their lifetime, each associated with an
independent list of complications and expenditures.

Post-traumatic Osteoarthritis of the Hip

Although PTOA of the hip is substantially less common than PTOA of the knee [2],
its clinical and economic implications must also be considered. Unlike in the knee,
time between injury and the development of PTOA of the hip is slightly lengthier,
and the population that is affected is generally older. One population-based study
demonstrated that in patients who developed hip PTOA following a traumatic event
to the hip, the median age at which symptoms occurred was 66 years, approximately
13 years following the injury [34]. Furthermore, the study reported that injuries to
the hip have been associated with a 4.3-fold increase in the risk of hip osteoarthritis.
Although there are numerous mechanisms leading to PTOA of the hip, common
causes include articular incongruity and disruption of the articular surface most
frequently due to fractures or hip dislocations.
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 31

Types of Injuries Associated with PTOA of the Hip

Hip/Acetabular Fractures

Hip fractures may predispose patients to secondary arthritis of the hip, mainly as a
result of failed subcapital hip fixation, and to a lesser extent intertrochanteric and
subtrochanteric fractures. The specific mechanisms that lead to PTOA include high-­
energy fracture patterns, injury to the articular surface, and nonunions following
injury. In addition, avascular necrosis resulting from traumatic devascularization or
hardware placement following fracture fixation may subsequently cause PTOA of
the hip (Fig. 3.2) [35].
Although acetabular fractures of the hip are rare compared to other types of frac-
tures in the hip region, up to a quarter of these patients will go on to develop PTOA
[36]. Acetabular fractures have a bimodal distribution occurring in the elderly and
young males. The mechanism of injury in these two populations varies significantly.
Elderly patients are more likely to sustain acetabular fractures following low-energy
falls, whereas younger individuals typically sustain a high-energy injury [37].
Unfortunately, acetabular fractures predominantly occur in the elderly population,
and their incidence has increased substantially in the past quarter century as the
geriatric population continues to be the fastest growing subgroup in the United
States [38] (Fig. 3.3).

a c

Fig. 3.2  AP (a) and lateral (b) view of previous intertrochanteric hip fracture treated with a sliding
hip screw construct that went on to avascular necrosis. AP pelvis after removal of the sliding hip
screw and left total hip arthroplasty treated with a modular diaphyseal engaging stem (c)
32 R. Iorio et al.

Fig. 3.3  Tibial plateau fracture (a) that went on to total knee arthroplasty (b). Clinical picture of
the complex skin incision associated with reconstruction (c)
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 33

Fig. 3.3 (continued)

Hip Dislocations and Osteonecrosis

Posterior hip dislocations represent about 90% of all traumatic hip dislocations
[39], and almost all injuries are a result of motor vehicle collisions. Given the strong
association between these two events, young males (16–40 years) are most likely to
be affected [40]. Hip dislocations lead to PTOA due to joint incongruity and insta-
bility, resulting in chronic inflammation and damage to the articular surface of the
hip. In addition, hip dislocations may also result in acetabular fractures and osteo-
necrosis of the hip head. The overall occurrence rate of PTOA in the hip following
posterior hip dislocations ranges from 19% to 55%, with a direct correlation between
dislocation severity and the likelihood for future PTOA [41].

Management of PTOA in the Hip

Primary Prevention

Given the nature of the injury mechanism responsible for the majority of hip PTOA,
preventing injury to the hip is somewhat more difficult than the knee. Broad mea-
sures have been shown to prevent acetabular fractures and hip dislocations which
include safe driving practices and stringent adherence to fall precautions in the
elderly. If fall precautions are in place, the cause should be investigated by a health-
care provider, medications should be reviewed, strength and balance exercises
implemented, and regular vision checkups obtained. Finally, various medical
34 R. Iorio et al.

conditions can predispose patients to osteonecrosis and, subsequently, PTOA of the

hip. Thus, these high-risk patients may benefit from physician-directed preventative
measures.

Secondary Prevention

Once a hip injury has occurred, a number of secondary measures can be imple-
mented in an effort to prevent progression to PTOA. After an acetabular fracture,
sufficient anatomic reduction is essential to ensure the joint has the best chance of
survival. It should be emphasized that achieving anatomic reduction does not rule
out the occurrence of PTOA [42, 43]. When managing hip dislocations, prompt
reduction has been correlated with improved outcomes and reduced risk of compli-
cations such as the development of avascular necrosis of the femoral head. The
orthopedic literature supports hip reduction as soon as possible or within 12 hours
following the injury [41].

Tertiary Prevention

Once primary and secondary preventative measures have been exhausted, total hip
arthroplasty (THA) may ultimately be indicated. Initially, many of the same nonsur-
gical management strategies of PTOA of the knee are shared with management of
the hip. Once progression of PTOA of the hip can no longer be adequately managed
nonoperatively, more invasive interventions including THA may be required
(Fig.  3.2). Patients receiving these interventions are usually younger than those
receiving THA secondary to primary OA. Although the risk for revision surgery is
higher in younger patients, implant durability has improved substantially over the
last three decades making THA in younger patients feasible. Despite the improve-
ments, THA in the setting of PTOA has been linked with worse peri- and postopera-
tive outcomes [44]. Thus, the possibility for longer operative times, higher rates of
complications, early failures, and revision THA should be discussed with the
patient. In rare circumstances, when the arthritic disease in the hip joint is so severe
and previous attempts of THA have failed, rarely hip arthrodesis or resection arthro-
plasty may be indicated. Studies have demonstrated that although patients may be
functionally limited, these can be effective procedures for the management of pain.
However, arthrodesis has been associated with new onset ipsilateral knee and lower
back pain due to the straining forces being placed on the proximal and distal joints.
Other concerns associated with arthrodesis include highly variable union rates, like-
lihood of returning to work, and satisfaction rates, all of which should be discussed
at length prior to surgery [45].
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 35

Costs Associated with Post-traumatic Osteoarthritis

There has been a robust effort to investigate the economic implications of primary
OA and methods of better managing it while minimizing costs. However, the lack
of large-scale epidemiologic studies evaluating the prevalence of PTOA has proven
to be a major barrier in the development of accurate economic models assessing the
financial fingerprint of PTOA on the US healthcare system. Although these two
diagnoses share many similarities, PTOA affects a younger more active population,
frequently requiring multiple surgical interventions. Thus, it should not be surpris-
ing that patients with PTOA have higher direct and indirect medical costs. Moreover,
many of these patients are uninsured further complicating management of this
debilitating disease. While it is well recognized that OA is one of the leading causes
of disability among all diseases, the costs associated with the management of OA
are difficult to approximate due to the debilitating nature of the disease and the
many modalities of treatment. A recent report by Kotlarz and colleagues [46] uti-
lized data from the Medical Expenditure Panel Survey (MEPS) and estimated that
OA costs the US healthcare system $185.5 billion USD annually, of which $149.4
billion USD was expensed to insurers [46]. The report also found that women
accounted for nearly two-thirds ($118 billion USD) of the dollars spent on manag-
ing OA, further demonstrating the gender discrepancies existing among those diag-
nosed with OA.
Although the literature surrounding the economic implications of PTOA is lim-
ited, a few recent studies have helped provide some perspective on the magnitude of
the associated direct costs. Brown and colleagues [2] were the first to utilize a state-­
based model to estimate the prevalence and disease burden associated with PTOA at
a national level. The investigators demonstrated that 6.8% of all patients with OA
are due to PTOA of the hip and knee, 0.5% and 6.3%, respectively. Given these
reported prevalence rates, the total direct costs associated with PTOA of the hip and
knee can be measured at roughly $900 million and $11.7 billion annually (Fig. 3.4).
In a separate study by Chin et al. [47], cohorts of patients undergoing primary THA
were compared to conversion THA, a common salvage procedure of failed hip frac-
ture fixation secondary to PTOA. The conversion procedures were associated with
a significant increase of 26% in total hospital costs over primary OA treatment
which, notably, did not account for the commonly occurring postoperative compli-
cations and revision procedures following discharge. Despite the paucity of litera-
ture comparatively examining postoperative outcomes and resource expenditures
associated with PTOA, the available evidence clearly suggests an increased disease
burden in patients diagnosed with PTOA compared with primary OA.
The indirect disease burden associated with PTOA is somewhat more concern-
ing, as indirect costs associated with PTOA may be three times greater than direct
costs [48]. Given that this population is younger and more active and frequently
requires multiple surgical interventions (i.e., ACLR, arthroscopy, fracture fixation,
36 R. Iorio et al.

Annual direct costs of OA:

$185.5 billionADDIN

OA due to knee and hip PTOA:

6.8%ADDIN CSL_CITATION

Annual direct costs of knee and

hip PTOA:

$12.6 billion

Knee to hip PTOA ratio– 12.6:1

Annual direct costs of PTOA ‐ Annual direct costs of PTOA ‐

knee: hip:

$11.7 billion $900 million

Fig. 3.4  Total direct cost of PTOA of the knee and hip

TJA) dispersed over their lifetime, the burden of PTOA economically and in terms
of the individual’s quality of life is substantially greater than primary
OA.  Additionally, many individuals with PTOA are of prime working age with
higher rates of absenteeism, and overall work impairment compared with older age
groups, [49] and are frequently forced to apply for disability benefits at each treat-
ment juncture. Thus, although difficult to calculate the job-related loss of economic
activity due to injuries, indirect costs of PTOA of the hip and knee together may be
responsible for more than $35.3 billion annually, far exceeding the direct cost asso-
ciated with PTOA (Fig. 3.5).

Recommendations

Individuals diagnosed with posttraumatic and primary OA often present with simi-
lar symptoms; however, the mechanism of injury varies significantly. Patients with
PTOA have had an acute injury subsequently resulting in degenerative changes of
the joint, whereas individuals with primary OA have nonspecific wear and inflam-
mation leading to cartilage loss. Given the different mechanisms of injury and goals
of treatment, it is crucial that healthcare providers manage PTOA through a
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 37

Annual direct costs of OA:

$185.5 billionADDIN

Indirect vs. direct costs:

2.8:1 ADDIN CSL CITATION

Annual indirect costs of OA:

$519.4 billion

OA due to knee and hip PTOA:

6.8%ADDIN CSL_CITATION

Annual indirect costs of knee and

hip PTOA:

$35.3 billion

Knee to hip PTOA ratio– 12.6:1

Annual indirect costs of Annual indirect costs of

PTOA ‐ knee: PTOA ‐ hip:

$32.8 billion $2.4 billion

Fig. 3.5  Total indirect cost of PTOA of the knee and hip

designated care pathway (ICP) with the aim of delivering high-quality care while
minimizing resource expenditures.
Our review demonstrates the paucity of literature examining postoperative out-
comes and resource expenditures associated with the management of PTOA. This is
at least in part due to the coding limitations associated with the International
Classification for Disease 9th Edition (ICD-9), which fails to differentiate between
primary and secondary OA. Fortunately, as of October 2015, the ICD-10 has been
successfully implemented enabling clinicians to diagnose indications for surgery
with greater specificity. If the ICD-10 codes are properly implemented, future
38 R. Iorio et al.

investigators may link clinical and billing information to better elucidate resource
utilization trends among individuals with OA. However, the utilization of ICD-10
codes alone is not sufficient as several issues still remain if these diagnostic codes
are to be used to estimate the prevalence and economic burdens associated with
complex disease processes such as PTOA.
First, the ICD-10 coding system utilizes nearly 70,000 unique diagnostic codes.
It is therefore essential that healthcare providers be familiar with the diagnostic
codes within the scope of their practice. Healthcare providers must also avoid “gam-
ing the system” by intentionally using a handful of nonspecific diagnostic codes. To
insure that healthcare providers are meaningfully using diagnostic codes, providers
should have the opportunity to participate in courses designed to better define the
strengths and limitations of the ICD-10 coding system. Additionally, as mandated
by the Affordable Care Act (ACA), healthcare organizations and their providers are
responsible for accurately documenting and reporting clinical metrics. Failure to
properly do so will likely result in penalties and withheld payments. Thus, we sug-
gest that healthcare organizations periodically audit the diagnostic codes being
assigned to episodes of care, improving institution-wide compliance, while also
strengthening the quality of the data collected.
Lastly, it is crucial that ICD-10 codes be aligned with CPT and Medicare Severity
Diagnosis-Related Groups (MS-DRGs) in order to differentiate arthroplasty proce-
dures by preoperative indication. Disease-specific procedure codes similar to those
used in conversion THA and revision arthroplasty may enable investigators to better
understand the clinical outcomes and disease burdens unique to PTOA. Without
proper coding methodology, it is nearly impossible to distinguish indications for
surgery at a macro level, thereby leaving many clinical questions unanswered.
Furthermore, proper coding practices would enable investigators to retrospectively
evaluate the value of care delivered, ensuring that care pathways are in line with
organizational standards. Such an approach will also ensure that healthcare organi-
zations are appropriately compensated for the services rendered.

Summary

Posttraumatic osteoarthritis of the hip and knee is a debilitating disease often affect-
ing younger, more active individuals. Currently an estimated 5.8 million individuals
are living with PTOA of the hip and knee at a direct and indirect cost of almost
$48.9 billion annually. As Americans continue to live active lifestyles, the number
of individuals living with PTOA is projected to steadily grow costing billions more
dollars in direct and indirect expenditures. It is therefore critical that healthcare
providers lobby for improved diagnostic and procedure codes so that PTOA can be
properly monitored and objectively evaluated. Through such an approach, providers
will have the resources needed to better address the complexities present in PTOA
patients. Once granular coding instruments have been developed and used for these
complex patients, the full economic impact of PTOA may be realized.
3  Economic Implications of Post-traumatic Arthritis of the Hip and Knee 39

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 Part II
Post-traumatic Arthritis
of the Upper Extremity
Chapter 4
Post-traumatic Glenohumeral Arthritis

Uma Srikumaran and Eric Huish

Key Points
• Proximal humerus fractures, glenohumeral instability, and direct cartilagi-
nous trauma are all causes of post-traumatic glenohumeral arthritis.
• Various injury patterns and previous interventions may alter the anatomy
of the glenohumeral joint, which must be taken into account when surgical
treatment is planned.
• Total shoulder arthroplasty, reverse shoulder arthroplasty, and hemiarthro-
plasty are all utilized in the treatment of post-traumatic glenohumeral
arthritis, each with various benefits and shortcomings.
• Non-arthroplasty options for the treatment of glenohumeral post-traumatic
arthritis show transient benefit and may be beneficial in the appropriately
selected patient.

Introduction

Post-traumatic arthritis of the shoulder can result from a variety of injuries.

Fractures, dislocations, isolated chondral injuries, or rotator cuff pathology may be
implicated. As with other arthropathies, there is a broad spectrum of disease ranging
from mild discomfort to severe disability with pain, stiffness, and inability to

U. Srikumaran (*)
The Johns Hopkins University, Division of Shoulder and Elbow Surgery,
Columbia, MD, USA
e-mail: us@[Link]
E. Huish
Stanislaus Orthopaedics & Sports Medicine Clinic, Modesto, CA, USA

© Springer Nature Switzerland AG 2021 45

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
46 U. Srikumaran and E. Huish

perform activities of daily living. Appropriate treatment should be based on the

initial injury, previous treatment, severity of disease, and patient factors including
age, activity level, hand dominance, and goals.

Causes

Fractures

Multiple traumatic etiologies may lead to arthritic changes in the glenohumeral

joint. Proximal humerus fractures are among the more commonly implicated inju-
ries with one study showing nearly two-thirds of patients with three- and four-part
proximal humerus fractures developed post-traumatic arthritis [50]. This may be
due to direct articular damage at the time of injury, malunion with intra-articular
step-off, screw cutout, or osteonecrosis (Fig. 4.1). The rate of osteonecrosis reported
in the literature varies. A systematic review revealed an overall rate of 2% after
nonoperative treatment of all types of proximal humerus fractures [25]. However,
nearly half of the included cases in this review were one-part nondisplaced frac-
tures. The three- and four-part subgroups had an osteonecrosis rate of 14%. A sepa-
rate systematic review looking at proximal humerus fractures treated with open
reduction and locked plating showed a 7.9% rate of osteonecrosis [48]. This analy-
sis excluded studies that were limited to two-part fractures but did not give results
based on fracture classification. Other studies have shown higher rates of osteone-
crosis after open reduction and internal fixation, with up to 35% in one study [19].
Gerber examined the significance of post-traumatic osteonecrosis and showed that
all patients with osteonecrosis after proximal humerus fracture had some level of
dysfunction compared to a healthy control group. He noted, though, that associated

Fig. 4.1  AP radiograph of

the shoulder after open
reduction and internal
fixation of a proximal
humerus fracture showing
osteonecrosis and collapse
of the humeral head with
resultant screw protrusion
4  Post-traumatic Glenohumeral Arthritis 47

malunion of the fracture fragments significantly worsened the subjective outcome,

pain, forward elevation, and Constant score [20].
Another known complication associated with open reduction and internal fixa-
tion is screw cutout, with rates reported as high as 23% overall and up to 43% in
patients older than 60 [48, 36]. Articular incongruity has been reported in 67% of
malunited proximal humerus fractures [3]. Patients in this study who did not have
the incongruity corrected with arthroplasty or shoulder fusion all had unsatisfactory
outcomes. Both screw penetration and articular incongruity may alter the contact
stresses on remaining intact cartilage leading to post-traumatic arthritis. Further,
altered shoulder mechanics or malunion of the tuberosities may also lead to rotator
cuff damage and subsequent arthropathy.
While proximal humerus fractures are often implicated in post-traumatic arthritis
of the glenohumeral joint, glenoid fractures are less frequently discussed as they are
much less common, making up only 10% of scapular fractures, with only 10% of
those fractures having significant displacement. Goss recommended 5 mm displace-
ment as a relative indication for treatment with 10 mm as an absolute indication
[21]. Fractures with >4 mm step-off were operatively treated, demonstrating good
outcomes for DASH scores, SF-36, pain, and return to pre-injury level of activity
[1]. Another study with 10-year follow-up after operative treatment had a median
Constant score of 94% [42]. Despite good outcomes with intra-articular glenoid
fractures and a high tolerance to step-off, recognition of these injuries is still impor-
tant, as altered glenoid morphology may affect surgical treatment.

Instability

Shoulder dislocations are another potential cause of post-traumatic arthritis

(Fig. 4.2a, b). Dislocation arthropathy has been reported to occur at varying rates.
One study with 10-year follow-up showed 11% of mild arthropathy with 9% devel-
oping moderate to severe arthropathy [23]. Another study showed the presence of
arthritis in patients with previous shoulder instability to be 9.2% prior to undergoing
surgery [6]. Furthermore, this same study showed development of arthritis in 19.7%
of patients after surgery when no arthritis was present preoperatively. It was unclear
whether this was a progression from the previous injury or a consequence from
surgery. The authors noted that older age at time of first dislocation increased the
number of dislocations, and increased follow-up time from surgery were correlated
with the development of arthritis. Further, decreased external rotation was also cor-
related with the development of arthritis. However, it was unknown if this was a
cause or a result of the arthritis.
Capsulorrhaphy arthropathy is used to describe arthritis that develops as a result
of overtightening the capsule. Matsoukis, who evaluated patients undergoing arthro-
plasty after previous instability, did not find any significant differences between
those with previous surgical treatment of the instability and those without. This
finding suggests that dislocation arthropathy and capsulorrhaphy arthropathy may
result in similar outcomes after arthroplasty [33].
48 U. Srikumaran and E. Huish

a b

Fig. 4.2 (a, b) AP and axillary radiographs of a shoulder with post-traumatic arthritis after dislo-
cation and subsequent repair

Other Causes

Other causes of post-traumatic arthritis include isolated chondral or osteochondral

injury. Isolated chondral lesions from shearing are rare but have been reported [41],
as have osteochondral defects [13]. Arthropathy from rotator cuff tear is more com-
monly seen in degenerative cases, but may develop after a traumatic tear if ignored.
More likely the altered mechanics and anatomy of the joint following trauma may
lead to degeneration of the rotator cuff. As with degenerative cases, this pattern is
difficult because the lack of rotator cuff function limits treatment options.

Treatment

There are many factors involved in determining the appropriate treatment of post-­
traumatic glenohumeral arthritis. The surgeon should assess the severity of disease,
initial injury, previous treatments, patient age, and functional requirements.

Nonoperative Treatment

The initial treatment of post-traumatic glenohumeral arthritis in all patients should

include a trial of nonoperative management. This may include physical therapy,
activity modification, medications, or injections. Both corticosteroid and
4  Post-traumatic Glenohumeral Arthritis 49

viscosupplementation (hyaluronic acid) injections may be considered, though use of

viscosupplementation in the shoulder is off-label. The American Academy of
Orthopaedic Surgeons guidelines on the treatment of glenohumeral arthritis are
inconclusive on the efficacy of physical therapy, pharmacotherapy, and corticosteroid
injections. Further, there was limited evidence found to support viscosupplementa-
tion [26]. Only after these modalities have been attempted, surgery should be consid-
ered only in a carefully selected patient population, as patients with low demands and
multiple medical comorbidities may be best managed with continued observation.

Preoperative Evaluation

Workup prior to possible surgical intervention should be thorough. Standard radio-

graphs should be taken to evaluate joint space, arthritic changes, and other abnor-
malities including malunion or nonunion of previous fracture and the presence of
hardware. Further imaging with CT or MRI may be warranted to evaluate glenoid
morphology, rotator cuff integrity, or other soft tissue abnormalities. Careful atten-
tion should be paid to a thorough neurological exam as nerve injuries may result
from the initial trauma or possibly from previous interventions. In such cases, thor-
ough neurologic exam, an EMG, and NCS may be required.
Any previously operated shoulder should be ruled out for infections and possible
source of pain and dysfunction. High rates of positive cultures have been reported
in patients undergoing revision shoulder surgery [24]. Propionibacterium acnes is
often indicated and may be missed unless cultures are held for an extended period
of time for this more indolent organism. Preoperative lab work including WBC,
ESR, and CRP along with intraoperative frozen sections does not have a high sensi-
tivity for indolent infection [49]. More recently synovial cytokines have been inves-
tigated as predictors of periprosthetic joint infections [17] and may lead to improved
detection. If infection is discovered, it should be addressed appropriately.
Preoperative planning should include assessment of prior incisions/approaches
as well as determination of any hardware that may require removal. The choice of
the appropriate surgical procedure is controversial and should be tailored to the
individual patient.

Arthroplasty

Total Shoulder Arthroplasty

Arthroplasty is often chosen for treatment of post-traumatic glenohumeral arthritis.

In these cases it is important to recognize anatomic changes resulting from previous
injury or surgery. Malunited fractures may alter the relationship between the
humeral head and shaft making the placement of a humeral stem difficult. Possible
solutions include using short stem prostheses (Fig. 4.3a, b) or stemless prostheses.
Tuberosity malunion also causes difficulty as arthroplasty components are not
designed to address the tuberosities and will not correct malunions that may be a
50 U. Srikumaran and E. Huish

a b

Fig. 4.3 (a, b) Preoperative and postoperative radiographs of a humerus with malunion and post-­
traumatic arthritis treated with reverse shoulder arthroplasty utilizing a short humeral stem

source of impingement and dysfunction. If malunion is severe, osteotomy may be

required. The need for tuberosity osteotomy has been shown to result in poorer
outcomes [5]. Glenoid degeneration or fracture may also make arthroplasty diffi-
cult. Ensuring adequate fixation as well as appropriate version is crucial. Glenoid
augments have been developed to treat posterior glenoid wear and recently have
been used as an anterior glenoid augment, which may be useful after anterior insta-
bility with bony Bankart lesion [28]. Soft tissue changes must also be addressed.
Green reported that 65% of patients undergoing arthroplasty after previous instabil-
ity repair required subscapularis lengthening and anterior capsular release. Eighteen
percent required glenoid bone grafting, and one required glenoidplasty [22].

Hemiarthroplasty

Hemiarthroplasty, sometimes used as an acute treatment in trauma, may also be

used to treat sequelae of the injury, including arthritis. Since osteonecrosis and
malunion are typically limited to the humerus, a hemiarthroplasty may be used to
4  Post-traumatic Glenohumeral Arthritis 51

replace the affected surfaces. However, hemiarthroplasty used to treat fracture

sequelae showed the lowest survival and highest complication rate when compared
to other uses of the implant [18]. Further, studies have shown better pain scores,
satisfaction, and survival with a lower reoperation rate after total shoulder arthro-
plasty than hemiarthroplasty when used specifically for post-traumatic osteonecro-
sis of the humeral head [44]. Specifically looking at patients younger than 55, total
shoulder arthroplasty had outperformed hemiarthroplasty with regard to surviv-
ability, pain, motion, and satisfaction [2]. Another study evaluating patients under
50 showed a similar benefit in survival and satisfaction favoring total shoulder
arthroplasty [15]. That said, some surgeons try to avoid total shoulder arthroplasty
in younger patients despite the known facts of glenoid loosening and increased
implant failure over its lifetime [37]. However, the increased survival of total
shoulder arthroplasty at 15  years suggests this may be becoming less of a
­concern [44].
The possibility of poor outcomes with hemiarthroplasty alone coupled with a
desire to avoid glenoid instrumentation in young patients has led to a search for
variations on the technique that may prove superior. One of these techniques known
as the “ream and run” utilizes glenoid reaming without instrumentation at the time
of hemiarthroplasty. This, however, is a not widely used and technically difficult
procedure with a steep learning curve [32]. Another trialed modification to hemiar-
throplasty is biologic resurfacing of the glenoid. Various materials have been used
for resurfacing, including meniscus and acellular matrices. Some studies have
shown success [31], but high rates of early failure have been reported [39, 47] and
the procedure is not routinely performed. Other areas of interest for modifying
hemiarthroplasty include use of pyrocarbon implants [8]. Although success has
been seen in other joints, studies of its use in the shoulder are lacking.
To this end, the choice between hemiarthroplasty and total shoulder arthroplasty
is still debated, especially for young patients.

Humeral Resurfacing

An alternative to hemiarthroplasty is humeral resurfacing. Without addressing the

glenoid, the aim is to maintain as much bone as possible so to prevent issues that
may arise at the time of revision. Its use has been reported for sequelae of proximal
humerus fractures with good results [30, 38]. However, with the advent of stemless
humeral prostheses, these are no longer the only bone-conserving option.

Reverse Shoulder Arthroplasty

If the rotator cuff is deficient, in presence of a functional deltoid and adequate bone
stock, a reverse shoulder arthroplasty may be considered. Although clinical out-
comes for the treatment of fracture sequelae show improvement, results are worse
than for acute fractures [10, 14]. To this end, patients who had previous fracture
surgery had worse outcomes than those treated initially nonoperatively [10].
52 U. Srikumaran and E. Huish

Reverse shoulder arthroplasty has also been used with good results as a revision
from a failed hemiarthroplasty due to development of glenoid arthritis or rotator
cuff failure [29]. However, these results are inferior to those obtained for primary
indications.
Reverse shoulder arthroplasty was originally reserved for elderly patients; how-
ever, in cases where no other option seems appropriate, reverse shoulder arthro-
plasty may be an option in a younger patient. Few studies evaluate patients under 60
undergoing reverse shoulder arthroplasty. The current literature shows good early
outcomes, but follow-up is limited, and the success rate and patient satisfaction are
less than in previous studies looking at an older population [35, 45]. This procedure
must be done with caution in a young patient, as long-term outcomes are not yet
widely reported with midterm outcomes showing a 15% failure rate, 25% reopera-
tion rate, and 38% complication rate after 5–15 years [16].

Alternative Options

If reverse shoulder arthroplasty is determined to be inappropriate due to patient age,

poor glenoid bone stock, nonfunctional rotator cuff, or other reasons, a cuff tear
hemiarthroplasty is an alternative. In the most severe cases, where both rotator cuff
and deltoid are nonfunctional or where significant brachial plexus injury has
occurred, a glenohumeral fusion may be considered. This results in significant
impairment compared to normal shoulder function, but remaining scapulothoracic
motion may allow for utilization of remaining hand/elbow function in the appropri-
ately selected patient [11].

Non-arthroplasty Surgery

Especially in young patients, non-arthroplasty options may be more attractive to

treat post-traumatic glenohumeral arthritis. Arthroscopic debridement has been
shown to improve pain and function in 88% of patients with grade IV glenohu-
meral joint chondral lesions for an average of 28 months [7]. Lesions over 2 cm2
were associated with failure and recurrence of pain, while microfractures have
been shown to improve pain scores, American Shoulder and Elbow Surgeons’
scores, and the ability to return to work/activity at 47 months [34]. This study,
however, had a 19% failure rate, defined as need for additional surgery. The great-
est improvements were seen in isolated humerus lesions. Failure was associated
with a larger defect size. Osteochondral autologous transplantation was shown in
two cases only by Scheibel to improve Constant scores and have good integration
via MRI and by second-look arthroscopy [43]. All patients in this study had evi-
dence of arthritis at latest follow-up, including those with worsening of preexisting
arthritis.
4  Post-traumatic Glenohumeral Arthritis 53

Osteochondral allografts have been reported as an alternative solution without

the risk of donor site morbidity [27]. Autologous chondrocyte implantation was
shown to be effective at 1 year in a case report but has also been reported to cause
overgrowth and mechanical damage due to the thin humeral head cartilage [9, 40].
Juvenile cartilage allograft and subchondral calcium phosphate injections have not
been described in the literature but may be an area of future research.
Biologic resurfacing of the glenoid is an alternative and not widely used method
with a failure rate of up to 28% [12]. That said, as none of these treatments have
shown consistent long-term relief of arthritis pain, they may be considered as a
temporary solution for patients who are not candidates for arthroplasty due to age,
medical condition, or other reasons.

Complications

Postoperative stiffness is a common complication of surgery for post-traumatic

arthritis of the glenohumeral joint. Accordingly, attention should be turned to ade-
quate soft tissue release at the time of surgery and an emphasis placed on postopera-
tive physical therapy. Progression of arthritis may also develop after non-arthroplasty
surgery or hemiarthroplasty. Component failure is also possible and reported as
5.3% for the glenoid and 1.1% for the humerus in a broad review of shoulder arthro-
plasty performed for any indication [4]. Long-term studies are lacking for many of
our current implants and may change survival data. Other complications in this
review include instability in 4.9%, periprosthetic fracture in 1.8%, and nerve injury
in 0.8% [4]. Most concerning is infection. The infection rate after revision shoulder
arthroplasty has been shown to be 3.15% compared to 0.76% in primary arthroplas-
ties at the same institution [46]. These risks must be considered when selecting the
appropriate patient and determining the appropriate treatment.

Summary

The treatment options for post-traumatic arthritis of the glenohumeral joint are as
diverse as its causes. Patients are surgical candidates only after failure of nonopera-
tive treatments and thorough preoperative workup. While arthroplasty may be a
widely accepted treatment for older or lower-demand patients, there is controversy
surrounding the treatment of younger, active patients. In this group, surgical treat-
ment should be individualized after frank discussion of goals and expected out-
comes. While significant improvements are seen after surgical intervention, they
tend to fall short of expected results for primary procedures with high complication
rates. New and emerging implants and techniques may improve treatment in these
challenging cases.
54 U. Srikumaran and E. Huish

Annotated References

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J Bone Joint Surg Am. 2012;94(7):645–53. This level IV study examined 33 displaced glenoid
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arthroplasty as primary versus revision procedure for proximal humerus fractures. J Shoulder
Elbow Surg. 2016;25(7):1133–7. This level III study looked at 49 RSA performed for acute
fracture, fracture sequelae, failed hemiarthroplasty, and failed ORIF.  At 32 months SPADI,
UCLA score, ASES score and Constant score were better in the primary surgery group than
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4  Post-traumatic Glenohumeral Arthritis 55

15. Eichinger JK, Miller LR, Hartshorn T, Li X, Warner JJ, et al. Evaluation of satisfaction and
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J Shoulder Elbow Surg. 2016;25(5):772–80. This level III study examined implant survival
and patient satisfaction for hemiarthroplasty and total shoulder arthroplasty in patients 50 and
younger. Implant survival was 95% for TSA and 89 for hemi with patient satisfaction 95% VS
71.6% respectively.
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irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen
years. J Shoulder Elbow Surg. 2013;22(9):1199–208. This level IV study evaluated 40 RSA
in patients under 65 with 5–15 year follow up. SSV, forward elevation, pain, and strength all
improved but complication rate was 37.5% and failure was 15%.
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Analysis of cytokine profiles in the diagnosis of periprosthetic joint infections of the shoul-
der. J Shoulder Elbow Surg. 2016;26(2):186–96. This level III study analyzed the levels of
9 cytokines in synovial fluid in patients with shoulder arthroplasty who were divided into
infected and non-infected groups. While many were elevated in the infection cases, a com-
bination of IL-6, TNF-α, and IL-2 showed a sensitivity of 0.80 and specificity of 0.93 for
infection.
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term survival analysis according to etiology. Orthop Traumatol Surg Res. 2012;98(6):659–65.
This level IV study reviewed 272 hemiarthroplasties performed for fracture sequelae, primary
OA, cuff tear arthropathy, AVN, RA and other causes with a mean 10 years follow up. Survival
in the fracture sequelae group was the lowest of any group at 76.8%.
19. Gerber C, Werner CM, Vienne P.  Internal fixation of complex fractures of the proximal
humerus. J Bone Joint Surg Br. 2004;86(6):848–55.
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the humeral head. J Shoulder Elb Surg. 1998;7(6):586–90.
21. Goss TP.  Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop
Surg. 1995;3(1):22–33.
22. Green A, Norris TR. Shoulder arthroplasty for advanced glenohumeral arthritis after anterior
instability repair. J Shoulder Elb Surg. 2001;10(6):539–45.
23. Hovelius L, Olofsson A, Sandström B, Augustini BG, Krantz L, et al. Nonoperative treatment
of primary anterior shoulder dislocation in patients forty years of age and younger a prospec-
tive twenty-five-year follow-up. J Bone Joint Surg Am. 2008;90(5):945–52.
24. Itamura JM, Beckett M.  Infection rates and frozen sections in revision shoulder and elbow
surgery holding cultures 21 days. J Shoulder Elbow Surg. 2013;22:e30–1. This abstract from
the ASES 2012 closed meeting examined 109 revision shoulder and elbow cases. 57 patients
had at least one positive culture, most commonly P. acnes. The average time to positive culture
for P. acnes was 12.5 days.
25. Iyengar JJ, Devcic Z, Sproul RC, Feeley BT.  Nonoperative treatment of proximal humerus
fractures: a systematic review. J Orthop Trauma. 2011;25(10):612–7. This systematic review
looked at 12 studies totaling 650 patients with closed treated proximal humerus fractures at
45.7 months follow up. The overall union rate was 98% and the complication rate was 13%
with only 2% AVN.
26. Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, et al. American academy of
orthopaedic surgeons clinical practice guideline on: the treatment of glenohumeral joint osteo-
arthritis. J Bone Joint Surg Am. 2011;93(2):203–5. These AAOS clinical practice guidelines
were based on a systematic review of the literature and recommendations are made based
on the strength of evidence. These recommendations for treating glenohumeral arthritis were
adopted by the AAOS board of directors in December 2009.
27. Johnson DL, Warner JJ.  Osteochondritis dissecans of the humeral head: treatment with a
matched osteochondral allograft. J Shoulder Elb Surg. 1997;6(2):160–3.
56 U. Srikumaran and E. Huish

28. Lenart BA, Namdari S, Williams GR. Total shoulder arthroplasty with an augmented compo-
nent for anterior glenoid bone deficiency. J Shoulder Elbow Surg. 2016;25(3):398–405. This
level IV study reported on 5 patients undergoing TSA with an anterior glenoid augment for
anterior wear, malunited glenoid fracture, or post-traumatic arthritis. At 33.2 months there
were no dislocations or revision surgeries and good patient reported outcomes.
29. Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the
treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg Am.
2007;89(2):292–300.
30. Levy O, Tsvieli O, Merchant J, Young L, Trimarchi A, et al. Surface replacement arthroplasty
for glenohumeral arthropathy in patients aged younger than fifty years: results after a mini-
mum ten-year follow-up. J Shoulder Elbow Surg. 2015;24(7):1049–60. This level IV study
reported on 54 humeral resurfacings in patients younger than 50 for various indications includ-
ing fracture sequelae and dislocation arthropathy. 81.6% survival was seen at 10 years but
18.5% were revised. Constant scores postoperatively were higher in patients undergoing con-
comitant microfracture of the glenoid.
31. Lo EY, Flanagin BA, Burkhead WZ. Biologic resurfacing arthroplasty with acellular human
dermal allograft and platelet-rich plasma (PRP) in young patients with glenohumeral arthritis-­
average of 60 months of at mid-term follow-up. J Shoulder Elbow Surg. 2016;25(7):e199–207.
This level IV study reviewed 55 patients who underwent hemiarthroplasty with human dermal
matrix allograft glenoid resurfacing. A significant improvement was seen in the SANE score
and 81% of patients were satisfied or highly satisfied with the result. 9.1% were revised to TSA.
32. Matsen FA 3rd. The ream and run: not for every patient, every surgeon or every problem. Int
Orthop. 2015;39(2):255–61. This paper discusses the basics of the “ream and run” technique
and stresses the importance of patient selection and patient compliance with the postoperative
regimen.
33. Matsoukis J, Tabib W, Guiffault P, Mandelbaum A, Walch G, et al. Shoulder arthroplasty in
patients with a prior anterior shoulder dislocation results of a multicenter study. J Bone Joint
Surg Am. 2003;85-A(8):1417–24.
34. Millett PJ, Huffard BH, Horan MP, Hawkins RJ, Steadman JR.  Outcomes of full-­thickness
articular cartilage injuries of the shoulder treated with microfracture. Arthroscopy.
2009;25(8):856–63.
35. Muh SJ, Streit JJ, Wanner JP, Lenarz CJ, Shishani Y, et al. Early follow-up of reverse total
shoulder arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am.
2013;95(20):1877–83. This level IV study evaluated 67 RSA in patients 60 or younger at 36.5
months post op. Forward elevation, external rotation, ASES score and pain scores all improved
from preoperative values with 81% of patients satisfied or very satisfied. Forward elevation
greater than 100 degrees was the only predictor of satisfaction.
36. Owsley KC, Gorczyca JT.  Fracture displacement and screw cutout after open reduction
and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am.
2008;90(2):233–40.
37. Papadonikolakis A, Neradilek MB, Matsen FA 3rd. Failure of the glenoid component in
anatomic total shoulder arthroplasty: a systematic review of the English-language literature
between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205–12. This level IV sys-
tematic review showed rates of radiolucent lines, symptomatic loosening, and revision of the
glenoid component in 3853 TSA to be 7.3%, 1.2%, and 0.8% respectively.
38. Pape G, Zeifang F, Bruckner T, Raiss P, Rickert M, et al. Humeral surface replacement for the
sequelae of fractures of the proximal humerus. J Bone Joint Surg Br. 2010;92(10):1403–9.
39. Puskas GJ, Meyer DC, Lebschi JA, Gerber C. Unacceptable failure of hemiarthroplasty com-
bined with biological glenoid resurfacing in the treatment of glenohumeral arthritis in the
young. J Shoulder Elbow Surg. 2015;24(12):1900–7. This level IV study showed revision
to TSA after hemiarthroplasty and biologic glenoid resurfacing with Graftjacket, meniscal
allograft, and capsular interposition to be occur at rates of 83.3%, 60%, and 66.7% in a small
population of 17 patients with only 16 month follow up.
4  Post-traumatic Glenohumeral Arthritis 57

40. Romeo AA, Cole BJ, Mazzocca AD, Fox JA, Freeman KB, et  al. Autologous chondrocyte
repair of an articular defect in the humeral head. Arthroscopy. 2002;18(8):925–9.
41. Ruckstuhl H, de Bruin ED, Stussi E, Vanwanseele B. Post-traumatic glenohumeral cartilage
lesions: a systematic review. BMC Musculoskelet Disord. 2008;9:107.
42. Schandelmaier P, Blauth M, Schneider C, Krettek C. Fractures of the glenoid treated by opera-
tion A 5- to 23-year follow-up of 22 cases. J Bone Joint Surg Br. 2002;84(2):173–7.
43. Scheibel M, Bartl C, Magosch P, Lichtenberg S, Habermeyer P.  Osteochondral autologous
transplantation for the treatment of full-thickness articular cartilage defects of the shoulder. J
Bone Joint Surg Br. 2004;86(7):991–7.
44. Schoch BS, Barlow JD, Schleck C, Cofield RH, Sperling JW. Shoulder arthroplasty for post-­
traumatic osteonecrosis of the humeral head. J Shoulder Elbow Surg. 2016;25(3):406–12. This
level III study examined 37 hemiarthroplasties and 46 TSA for post-traumatic osteonecrosis
at 8.9 years post op. The TSA group had less pain and higher satisfaction at last follow up. 15
year survival for hemi was 79.5% vs. 83% for TSA.
45. Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, et al. Clinical outcomes of reverse
total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg.
2014;23(3):395–400. This level IV study followed 36 RSA performed in patients younger than
60 for 2.8 years. Improvements were seen in ASES score, SST, SANE, and forward elevation.
25% were considered failures due to ASES score below 50.
46. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin
Orthop Relat Res. 2001;382:206–16.
47. Strauss EJ, Verma NN, Salata MJ, McGill KC, Klifto C, et al. The high failure rate of biologic
resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elbow
Surg. 2014;23(3):409–19. This level IV study examined 41 patients who underwent biologic
glenoid resurfacing with meniscal allograft or human acellular dermal matrix at 2.8 year follow
up. Overall failure rate was 51.2%, 45.2% for meniscus and 70% for dermal matrix. Average
time to failure was 3.4 years and 2.2 years for meniscus and dermal matrix respectively.
48. Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus
fractures with locking plates: a systematic review. J Shoulder Elb Surg. 2009;18(6):837–44.
49. Topolski MS, Chin PY, Sperling JW, Cofield RH. Revision shoulder arthroplasty with posi-
tive intraoperative cultures: the value of preoperative studies and intraoperative histology. J
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Chapter 5
Post-traumatic Arthritis of the Elbow

Kevin O’Malley, Ryan Churchill, Curtis M. Henn, and Michael W. Kessler

Key Points
• The risk of post-traumatic arthritis of the elbow is very high after articular
injuries.
• CT arthrography is an excellent modality to assess intra-articular
abnormalities.
• Intra-articular glucocorticoid injections have no efficacy in this population.
• Several operative options are available in cases of failure of conservative
management.

Introduction

Post-traumatic elbow arthritis is relatively common with a reported risk of 44% fol-
lowing articular fractures [1]. Historically, this risk has been well recognized with
Dr. Bigelow [2] writing in 1868 “There is no class of injuries so frequently produc-
tive of discontent, and perhaps so often the cause of litigation, as traumatic lesions
of the elbow joint.” Elbow fracture management continues to progress from pre-
dominantly nonoperative management to operative treatment in line with principles
as shown by Jupiter in 1985 [3]. Treatment of these fractures is complex requiring
an understanding of the various nonoperative and operative treatment modalities as
well as understanding possible complications such as malunion, nonunion,

K. O’Malley (*) · R. Churchill · C. M. Henn · M. W. Kessler

Medstar Georgetown University Hospital, Department of Orthopaedics,
Washington, DC, USA
e-mail: Ko257@[Link]; [Link]@[Link];
[Link]@[Link]

© Springer Nature Switzerland AG 2021 59

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
60 K. O’Malley et al.

stiffness, avascular necrosis, heterotopic ossification, and post-traumatic arthritis. In

this chapter we will outline the diagnosis and surgical management of post-­traumatic
elbow arthritis as well as case examples to further describe treatment options and
techniques.
Elbow fractures account for 6% of adult fractures with 1 of these fractures
3
involving the distal humerus, 1 to 1 involving the proximal radius, and the
3 2
remainder involving the proximal ulna. Fractures follow a bimodal age distribution
with higher rates seen in young males and elderly females [4].
Post-traumatic osteoarthritis of the elbow is a multifactorial consequence of the
initial trauma, the biologic response to the trauma, and the alterations in load distri-
bution that result from articular incongruity and instability [1].
Relatively few studies have analyzed the development of post-traumatic arthritis
following elbow injuries. From the available literature, it appears intra-articular dis-
tal humerus fractures have the highest rate of post-traumatic arthritis [5–7]. Guitton
et al. analyzed radiographs of 139 patients following surgical treatment of an elbow
fracture with over 10 years of follow-up. They found mechanisms of injury, age,
gender, follow-up duration, occupation, and limb dominance not to be associated
with radiographic arthrosis. However, patients with bicolumnar distal humerus,
capitellum, and elbow dislocations were more likely to develop post-traumatic
radiographic arthrosis [6]. Interestingly, although radiographic arthrosis is present
in a high percentage of patients (80% per Doornberg et al.), functional scores do not
appear to correlate. Instead, pain, flexion arc, and limb dominance appear to be the
most important predictors of functional elbow scores [7, 8]. Notably, none of the 30
patients followed by Doornberg 12 years after intra-articular distal humerus fracture
underwent total elbow arthroplasty (TEA) as a consequence of their fracture. Only
one patient underwent arthrodesis for symptomatic post-traumatic arthritis [7].
Radial head and neck fractures also show little correlation between radiographic
degenerative changes and symptomatic elbow pain [9]. Burkhart showed ulnohu-
meral arthritis in 12 of 17 patients at an average of 8.8 years following a proximal
radius fracture. Again, there was no correlation of radiographic arthrosis to func-
tional scores (Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm,
Shoulder and Hand Questionnaire (DASH)) or pain [10].
Long-term data on proximal ulna fractures is limited. Rochet et al. reported on
18 patients with proximal ulna fractures and found 6 to have grade 1 osteoarthritis
based on the Broberg and Morrey classification. In comparison to other elbow frac-
tures, olecranon fractures specifically show relatively low rates (20% or less) of
post-traumatic arthritis, with articular displacement over 2  mm being the most
important risk factor [11, 12].
Classifying post-traumatic elbow arthritis is typically done with the Broberg and
Morrey (BM) classification, which is divided into three grades: grade 1 with slight
joint space narrowing with minimal osteophyte formation, grade 2 with moderate
joint space narrowing and moderate osteophyte formation, and grade 3 showing
severe degenerative changes with gross joint destruction [13]. Another classification
is the Hasting and Rettig (HR) classification, which like the BM classification is
also divided into three grades and has no significant difference in comparison to the
5  Post-traumatic Arthritis of the Elbow 61

BM classification [14]. Lastly, the Morrey classification can be utilized to describe

bone defects of the distal humerus and maybe useful for the preoperative plan-
ning [15].
Closely related to post-traumatic elbow arthritis is post-traumatic elbow
stiffness. While stiffness specifically is outside the scope of this chapter, it is
important to have a basic understanding of post-traumatic stiffness when
approaching complex post-traumatic elbow conditions. Our understanding of
post-traumatic elbow stiffness continues to grow, and as of today we know that
stiff elbows show an increased inflammatory cytokine and myofibroblast infil-
tration [16]. Stiffness is typically classified into two groups: extrinsic stiffness
due to soft tissue and extra-­articular processes and intrinsic stiffness secondary
to articular pathology [17]. It is important to note the functional arc of the
elbow, defined as flexion-­extension motion of 30° to 130° and pronosupination
of 50° to 50° [18]. Achieving functional range of motion typically occurs in the
first 6  months following surgery with minimal range of motion progression
after 6 months [19].

History and Physical Exam

Operative planning for post-traumatic elbow arthritis begins with a thorough his-
tory and physical. The history should include the initial injury mechanism, initial
injuries sustained (fractures and instability), previous operative and nonoperative
treatment (especially ulnar nerve management), and any history of infection or
soft tissue procedures. Detailed information on symptomatic pain and stiffness
should be obtained. For example, pain throughout the range of motion suggests
diffuse arthritic changes, while terminal pain suggests impingement by an osteo-
phyte or soft tissue [20]. Pain at rest carries a wider differential diagnosis includ-
ing infection, cervical spine radiculopathy, soft tissue disease, and reflex
sympathetic dystrophy [21]. Patient expectations and lifestyle factors must also
be addressed as a manual laborer will have different functional demands and
expectations when compared with a sedentary desk worker.
The physical examination should include a thorough inspection of the entire
extremity to assess prior surgical incisions for both fracture treatment as well as
soft-tissue coverage procedures. Hand thenar musculature should also be assessed
(i.e., intrinsic hand wasting). Neurologic evaluation should assess upper extrem-
ity sensory and motor function as well as ulnar neuritis specifically. The patient’s
elbow range of motion should be tested and any painful points should be noted.
Collateral ligament stability of the elbow should also be evaluated.
Imaging evaluation should be aimed at obtaining a complete understanding of
the degree of arthritis, loose bodies, current hardware, and bone stock. Orthogonal
elbow radiographs are the standard initial imaging study. If the patient also com-
plains of wrist pain, full-length forearm and wrist views should be obtained to assess
for a potential Essex-Lopresti lesion. Computed tomography (CT) is typically
62 K. O’Malley et al.

required for further evaluation and is more effective than conventional radiography
in assessing osseous causes of elbow stiffness [22]. CT arthrography has been
shown to provide improved assessment of intra-articular abnormalities such as
osteocartilaginous bodies, hyperplastic synovium, and osteophytes [23]. While
three-dimensional (3D) CT has not been evaluated for preoperative planning in this
population, we find it extremely helpful for procedures such as arthroscopic or open
debridement in patients with large osteophytes and loose bodies. Other diagnostic
tests may include electromyographic evaluation in patients with a concerning exam
for neuropathy or an entrapment syndrome.

Treatment

Nonsurgical Treatment

Conservative management of post-traumatic elbow arthritis is typically limited to

patients with mild arthrosis or low-demand patients. Activity modification, nonste-
roidal anti-inflammatory medication, and physical therapy should be considered
with an emphasis on maintaining range of motion and reducing painful activities.
Intra-articular glucocorticoids may be considered, but have no evidence of efficacy
in this population. Viscosupplementation with hyaluronic acid has been shown to
result in slight short-term pain relief and activity impairment 3 months following an
injection series. However, at 6 months no benefits were shown suggesting it is not
useful for long-term treatment [24].

Surgical Treatment

Several operative options are available once nonsurgical measures have been
exhausted. Surgical options include arthroscopic or open osteocapsular debride-
ment arthroplasty, interposition arthroplasty, partial joint arthroplasty (e.g., distal
humerus hemiarthroplasty or radiocapitellar arthroplasty), total elbow arthroplasty
(TEA), and elbow arthrodesis. Sears and colleagues [15] described an algorithmic
approach to selecting the appropriate surgical intervention for post-traumatic
elbow osteoarthritis. For patients who have pain at the terminal arc of motion, they
recommended arthroscopic or open debridement arthroplasty with possible ulnar
nerve transposition. For the patient who has pain throughout the entire arc of
motion, they describe the use of partial joint arthroplasty for arthritic changes iso-
lated to the radiocapitellar joint or distal humerus and interposition arthroplasty or
total elbow arthroplasty for the patient with diffuse osteoarthritic changes. For
younger patients who have exhausted most surgical options and do not wish to
have 10 pound weight restriction on their extremity from a total elbow arthro-
plasty, elbow arthrodesis is offered.
5  Post-traumatic Arthritis of the Elbow 63

Osteocapsular Debridement Arthroplasty

Open and arthroscopic osteocapsular debridement arthroplasties are good options

for the patient with mild to moderate arthritis and pain at the terminal aspects of
range of motion [25–34]. Open osteocapsular debridement arthroplasty is usually
reserved for patients who have a preoperative flexion contractures greater than 90
degrees, preoperative ulnar neuropathy or documented ulnar nerve EMG changes,
hardware that needs to be removed, or where arthroscopic debridement is excep-
tionally difficult [25, 34]. Open procedures include the Outerbridge-Kashiwagi pro-
cedure, Morrey ulnohumeral debridement arthroplasty, and the column procedure.
In the Outerbridge-Kashiwagi procedure, the patient is positioned in the lateral
decubitus with the involved extremity draped free. A posterior midline incision is
utilized with a triceps split to visualize the posterior compartment of the elbow.
Osteophytes and loose bodies are removed and the capsular undergoes debridement.
The olecranon fossa is then fenestrated with a drill to allow limited access to the
anterior compartment of the elbow. Loose bodies are removed and any osteophytes
about the coronoid are removed. If the patient has a preoperative flexion contracture
greater than 90 degrees and less than 90 to 100 degrees of flexion, the posterior band
of the medial ulnar collateral ligament (MUCL) should be released, and consider-
ation should be given to transpose the ulnar nerve. If the patient has a preoperative
ulnar neuropathy or documented ulnar nerve EMG changes, then the patient should
undergo ulnar nerve release and transposition [15, 25]. The column procedure
involves utilizing a lateral column approach to the elbow to perform anterior and
posterior compartment debridement arthroplasty with care to preserve the lateral
ulnar collateral ligament during the procedure. If there is a significant preoperative
flexion contracture or ulnar neuropathy, then a separate medial incision is made to
address the ulnar nerve and posterior band of the MUCL [25, 35].
Arthroscopic adaptations for osteocapsular debridement have shown good results
with the benefit of greater soft tissue preservation and quicker return to activities
[26–33, 36]. Relative contraindications to elbow arthroscopy are related to aberrant
anatomy of the ulnar and radial nerve from either prior trauma or surgeries.
Additionally, in cases where there is severe arthritis arthroscopic debridement may
be difficult to complete given the difficulty in gaining access to the joint. In these
cases consideration should be given to open identification and protection of the
nerve if arthroscopy is undertaken. Savoie and O’Brien34 described a comprehen-
sive arthroscopic approach to elbow arthritis. To begin, the patient may be posi-
tioned prone or lateral decubitus (Fig. 5.1a). A non-sterile or sterile tourniquet may
be used. The course of the ulnar nerve is palpated and marked (Fig.  5.1b). The
elbow is insufflated utilizing an 18-gauge needle and 20 to 30 milliliters (mL) of
sterile saline injected in the area of the soft spot portal or posterior central portal.
Next the site of the anteromedial portal is marked 2 centimeters (cm) superior and
2 cm anterior to the medial epicondyle. Only the skin is incised and a 4 millimeter
(mm) cannula with a blunt trocar is used to enter the joint. Occasionally this may be
difficult and a hemostat may be needed to open the joint capsule. The anterolateral
64 K. O’Malley et al.

Fig. 5.1 (a, b) The photo

on the left demonstrates a
lateral decubitus patient
positioning in preparation
for elbow arthroscopy.
The photo on the right
demonstrates landmarks
for medial portal
placement including the
ulnar nerve and the medial
epicondyle

b
5  Post-traumatic Arthritis of the Elbow 65

Fig. 5.2  Lateral landmarks

for portal placement are
drawn out with the
overlying incisions for the
anterolateral, posterior
central, and posterolateral
portals shown

portal is then established under direct visualization utilizing a spinal needle. The
spot for the portal is typically 2–3 cm anterior the lateral epicondyle and at the supe-
rior most aspect of the capitellar cartilage (Fig. 5.2). The procedure proceeds then
in a stepwise manner beginning with a diagnostic arthroscopy followed by removal
of any loose bodies from the anterior compartment along with osteophytes and
synovitis. If the radiocapitellar joint is significantly involved, a radial head resection
may be performed through the soft spot portal. Prior to proceeding to the posterior
compartment, a fenestration hole is created through the olecranon fossa. Other
options include a combined arthroscopic and open procedure with arthroscopic
debridement being carried out anteriorly followed by a mini-open posterior elbow
debridement. This can be effective when the elbow has more severe arthrosis that
may require treatment both laterally and medially in the anterior elbow.
A posterior central portal is created 3 cm proximal to the tip of the olecranon and
this serves as the initial viewing portal. A posterolateral portal is made parallel to
the posterior central portal just outside the triceps tendon. Once these portals are
established, the posterior compartment is debrided, loose bodies removed, and syn-
ovectomy performed. The medial and lateral gutters are inspected for loose bodies
and plica that may be contributing to the pathology. Finally the tip of olecranon is
excised and if necessary the anterior capsule is released. If the patient had preopera-
tive symptoms of ulnar neuropathy, the ulnar nerve may be decompressed in situ.
Patients are allowed full range of motion immediately postoperatively without
weight-bearing restrictions.
66 K. O’Malley et al.

Recent literature has found overall good to excellent results with this procedure
in appropriately selected patients with mild to moderate arthritis [25–33, 36].
DeGreef et al. found good results in a cohort of patients with a mean age of 50 years
old who underwent arthroscopic osteocapsular debridement with an increase in
range of motion (ROM) from 94 to 123 degrees, a significant decrease in pain
scores, and an increase in the Mayo Elbow Performance Index (MEPI) by an aver-
age of 34 points [37]. These results are reflected in much of the recent literature
[25–33, 36]. Galle and colleagues reviewed a consecutive series of 46 patients who
underwent arthroscopic osteocapsular debridement. The mean age of the patients in
their study was 48 years. They found a significant increase in ROM (final ROM arc
12 degrees to 135 degrees), a decrease in pain, and an increase in the Mayo Elbow
Performance Score (MEPS) from 57 preoperatively to 88 postoperatively.
Furthermore they had no complications in their cohort of patients [28]. Finally, Lim
et  al. investigated the preoperative factors associated with outcomes after
arthroscopic osteocapsular debridement. Through multivariate analysis they found
that preoperative range of motion was the main factor that affected postoperative
elbow function and range of motion, and through further analysis preoperative arc
of motion greater than 80 degrees was found to be the cutoff for improved postop-
erative function and arc of motion [30].

Interposition Arthroplasty

Given that the majority of patients with post-traumatic elbow arthritis tend to be
younger and of higher demand, interposition arthroplasty serves as a valuable surgi-
cal tool in treating this condition in patients who do not wish to have the weight-­
bearing and activity restrictions associated with TEA.  Options for interposition
arthroplasty include both autograft (e.g., anconeus, fascia lata) and allograft (e.g.,
Achilles tendon, fascia lata, dermis) [15, 25]. Contraindications to this procedure
include active infection, gross elbow instability or deformity, open physes, no flexor-
pronator power, and patients with deficient bone stock about the elbow [25, 38, 39].
As described by Morrey [40], this procedure is performed with the patient posi-
tioned in supine or lateral decubitus position. A posterior approach to the elbow is
typically utilized. Kocher’s interval is then developed between the extensor carpi
ulnaris and the anconeus. The lateral ulnar collateral ligament (LUCL) and elbow
extensors are released from the lateral epicondyle and tagged. A capsular release is
performed and osteophytes are removed. Next the ulnar and humeral articular sur-
faces are prepared so a congruent articulation is obtained and enough bone is
resected so that there is 2–3 mm of laxity to ensure that the joint is not overstuffed.
Following this, three to four drill holes are created in the humerus, and the graft is
prepared with three to four horizontal mattress sutures that are passed through the
drill holes to secure the graft to the distal humerus surface. The joint is then reduced
and range of motion assessed for areas of impingement. Finally, the stability of the
MUCL is assessed and the LUCL and the extensors are repaired back to the lateral
5  Post-traumatic Arthritis of the Elbow 67

epicondyle. If the LUCL is unable to be repaired, then reconstruction should be

performed. Occasionally a hinged external fixator is placed to protect collateral
ligament reconstruction when performed. Patients are allowed range of motion on
postoperative day 1.
While interposition arthroplasty provides a good option for improved pain and
range of motion for the young, active patient, the results tend to be inferior to elbow
arthroplasty [25]. Baghdadi et  al. reported the results of 39 patients treated with
anconeus interposition arthroplasty with an average of 10 years of follow-up. They
found 72% of their cohort had good to excellent results with significant improve-
ments in their MEPS. However, they did find a 24% reoperation rate and 7% com-
plication rate in their cohort [39]. Cheng and Morrey described the results of
interposition arthroplasty using fascia lata in 13 patients. They found good to excel-
lent results in 62% of the patients with eight complications in six patients and four
patients requiring conversion to TEA at an average of 30 months [41]. Furthermore,
Larsen and Morrey reported the results of 38 interposition arthroplasties performed
with Achilles tendon allograft in a cohort of patients with an average age of 39 years.
They found that at an average of 6 years of follow-up, there were significant
improvements in range of motion (51° to 97°) and MEPS. Although 29% of patients
had a poor result with 18% requiring revision surgery, 88% of all patients reported
they would undergo the procedure again. Hence the authors concluded that interpo-
sition arthroplasty is a valid salvage procedure for the young patient with severe
arthritis, limited motion, and no instability [42].

Radiocapitellar Arthroplasty and Distal

Humerus Hemiarthroplasty

There is a relative paucity of literature on radiocapitellar arthroplasty and distal

humerus hemiarthroplasty. Currently they are an off-label for treatment of osteoar-
thritis in the United States, and the situations in which they would be utilized for
post-traumatic osteoarthritis are very limited [25]. The studies on distal humerus
hemiarthroplasty largely are focused on the use for acute treatment of non-­
reconstructable elbow fractures. While these studies show relatively good outcomes,
they have short-term follow-up and are predominantly in elderly patients [43, 44].
For patients with isolated radiocapitellar arthritis, the use of a radiocapitellar replace-
ment has been described. Heijink and colleagues reported the results of six patients
treated with radiocapitellar arthroplasty with an average of 50 months of follow-up.
The patients in the study had improvements in range of motion, their DASH scores,
MEPS, and pain levels. Overall they had three excellent and three good results with
100% survivorship of implants. An added benefit to radiocapitellar arthroplasty is
that it maintains the valgus and external rotation stability of the joint [45]. These
results are limited, and further literature and expansion of the recommendations for
the use need to occur before this intervention can become standard treatment.
68 K. O’Malley et al.

Total Elbow Arthroplasty

Total elbow arthroplasty remains the final operative choice for the majority of
patients who have failed other operative interventions. It remains the definitive
functional treatment for elderly patients with severe end-stage post-traumatic osteo-
arthritis. It is not ideal for young active patients with post-traumatic arthritis espe-
cially in cases of instability due to increased rates of mechanical wear and the need
for early revision [15, 25].
The majority of TEA performed today utilizes a linked semi-constrained pros-
thesis. In addition to this design, there are unlinked TEA that rely on soft tissue
balancing and implant conformity to provide stability. By the nature of being
unlinked, these designs result in decreased bone-cement interface stresses and allow
load sharing between the implant and the soft tissues. However, an inability to bal-
ance the soft tissues is a contraindication to use of this design and as such is not
applicable to the majority of patients with post-traumatic osteoarthritis [25].

Procedure

When performing TEA the patient is positioned supine or in lateral decubitus. A

sterile tourniquet is routinely used. A variety of deep approaches may be utilized.
Originally Bryan and Morrey described elevating the triceps from medial to lateral
to expose the joint. This approach can lead to higher rates of postoperative triceps
insufficiency, and therefore in recent years, triceps-sparing approaches have seen an
increase in utilization. With a triceps-sparing approach, the triceps is left in continu-
ity with windows established medially and laterally for implant placement. After
adequate exposure and soft tissue release, the distal humerus and ulna are prepared.
This typically includes resection of the tips of the olecranon and coronoid processes.
Additionally, the proximal ulna often requires a combination of a bur and bone rasp
to allow for entry of trial components. Once trial implants are inserted, bony impinge-
ment should be assessed and any sites of impingement resected. Also, in cases where
there is concomitant radiocapitellar arthritis, the radial head can be excised with
careful resection as the posterior interosseous nerve will be just anterior to the radial
head. Once trials are placed and impingement sites addressed, a mini C-arm can be
used to confirm appropriate placement. Lastly, in patients with preoperative ulnar
nerve symptoms, transposition should be considered. On postoperative day 1, unre-
stricted range of motion is allowed, but patients are limited to a 1-pound lifting
restriction for the first 3 months and nothing heavier than 10 pounds for life.
Studies on TEA in the younger patients suffering from post-traumatic osteoar-
thritis have been increasing. Schoch et al. recently performed a retrospective review
of 11 patients under 50  years old undergoing TEA with a mean follow-up of
3.2  years. They found improvements in pain scores, MEPS, DASH scores, and
5  Post-traumatic Arthritis of the Elbow 69

range of motion. While these are positive results, they reported an 82% complica-
tion rate with six mechanical failures (54%) and as such recommended caution
when performing TEA in this young patient population [46]. These results correlate
to similar complications with mechanical failure and loosening as reported in sev-
eral earlier studies [47–52].
While there are high complication rates in the young adult population through-
out the literature, a successful TEA does improve function and decrease pain.
Park et al. reported the results of TEA performed in 23 patients under 40 years
old with post-­traumatic arthritis with average follow-up of 10.8  years. The
authors found significant decreases in pain scores and increased MEPS with
improved range of motion with increasing arc of motion from 37.8° to 120.6°.
Furthermore, they reported 95% and 89% implants survival rates at 8 and 15
years, respectively [53]. Welsink et  al. performed a systematic review of TEA
including all indications. Their review included 70 articles with 9379 TEA per-
formed with three different implants. There was an average follow-up time of
81 months of follow-up across all articles. They found for the newer Coonrad-
Morrey-style prosthesis that there was an 87.2% survival at 7 years for all indica-
tions with a mean range of motion of 30° to 129° with significant improvement
in outcomes. They reported an overall 11–38% complication rate with implant
loosening being the most common complication (7%) [54]. Furthermore aseptic
component loosening is the most common cause for revision TEA (38% of revi-
sions) as demonstrated by Prkic et al. in a systematic review on causes of TEA
failure [55].

Elbow Arthrodesis

Elbow arthrodesis remains a treatment option for a very specific patient: the rela-
tively young patient with severe unilateral post-traumatic elbow arthritis who can-
not tolerate weight-bearing limitations required for TEA and who is not a candidate
for interposition arthroplasty. Historically, elbow arthrodesis has not been tolerated
well because the adjacent joints do not compensate well for the motion loss seen
with arthrodesis [25].
Arthrodesis may be achieved with compression across the joint utilizing bent
plates, Ilizarov frames, compression screws, and cross strut grafts [25, 56, 57].
When performed, the elbow is typically fused at 90° of flexion although arthrodesis
at 30° to 45° may be considered for patients who require a specific position for
employment or for patients with lower extremity disorders that require the use of the
elbow and forearm for transfer. Patient input into the final elbow position can be
obtained by placing patients in a hinged elbow brace with varying degrees of flex-
ion. This allows a patient to “try out” the fusion position that will work best for
them [40].
70 K. O’Malley et al.

Conclusion

Our understanding of post-traumatic elbow arthritis continues to evolve. The devel-

opment of elbow arthritis is a complex interplay of factors including the initial
trauma, the biologic response to the trauma, and the alterations in load distribution
over time [1]. Radiographic signs of arthritis are relatively common especially with
intra-articular distal humerus fractures. However, patient symptoms and goals need
to be appropriately identified and addressed as many patients with radiographic
arthritis are relatively asymptomatic and the operative treatment course can result in
significant complications and require lifestyle alterations [7]. Conservative manage-
ment of elbow arthritis includes activity modification, NSAIDs, and physical ther-
apy. Intra-articular injections have little evidence to support long-term efficacy.
Surgical treatment includes arthroscopic and open debridement, interposition
arthroplasty, partial joint arthroplasty, total elbow arthroplasty, and elbow arthrod-
esis with each modality having distinct possible benefits and complications.

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Chapter 6
Post-traumatic Arthritis of the Wrist

Sophia A. Strike and Philip E. Blazar

Key Points
• Radiocarpal and intercarpal arthritis, when caused by scapholunate liga-
ment injury or scaphoid nonunion, allow for treatment options based on
predictable patterns of degenerative change.
• Radiocarpal, ulnocarpal, and distal radioulnar joint arthritis may be caused
by intraarticular fractures of the distal radius or distal radius malunion.
• Isolated intercarpal arthritis can occur from less common injuries to the
carpus and associated ligaments.

Introduction

The wrist joint is a complex structure involving articulation of the eight carpal bones
and the forearm. Surrounding ligamentous structures maintain the normal static and
dynamic relationships of the osseous components. Alteration of the anatomic rela-
tionships through fracture, dislocation, or ligamentous injury can cause abnormal
carpal kinematics and, eventually, lead to articular degeneration. Pain, instability,
loss of motion, and deformity may negatively impact function. Functional wrist
motion has been reported at 5 degrees of flexion, 30 degrees of extension, 10 degrees
of radial deviation, and 15 degrees of ulnar deviation [1]. The motion required to

S. A. Strike (*)
Johns Hopkins University School of Medicine, Baltimore, MD, USA
e-mail: sstrike1@[Link]
P. E. Blazar
Brigham and Women’s Hospital, Boston, MA, USA
e-mail: pblazar@[Link]

© Springer Nature Switzerland AG 2021 73

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
74 S. A. Strike and P. E. Blazar

perform daily activities will be unique to each patient based on functional demands
and compensatory mechanisms [2]. While traumatic injury remains a common
cause of arthritis of the wrist, atraumatic etiologies including inflammatory arthritis,
crystalline deposition, hemophilia, and primary osteoarthritis must be considered in
the evaluation of these patients [2].
Traumatic etiologies of wrist arthritis include injury to intercarpal, radiocarpal,
ulnocarpal, or radioulnar ligaments in isolation or as part of a perilunate injury,
nonunion (or malunion) after scaphoid fracture, as well as malunited distal radius
fractures [3, 4, 9]. All of these injuries can induce abnormal carpal mechanics and
over time cause pain and joint degeneration [3–6].
Posttraumatic arthritis may occur in predictable patterns throughout much of the
wrist as will be discussed in the chapter. This allows treatment to be tailored to the
stage of degeneration. The natural history of wrist injuries has been described in
cases such as scaphoid nonunion and distal radius fracture malunion but is less clear
for intercarpal injury such as scapholunate ligament injuries [13–15]. Surgical man-
agement of arthritis typically centers on removal or fusion of involved articulations,
and the complex structure of the wrist requires a thorough understanding of anat-
omy and kinematics to select an appropriate treatment for each patient.

Main Text

Wrist Anatomy

The intricate articulation of the osseous structures of the wrist with ligamentous
support allows for multiple directions of motion. The combination of intercarpal,
radiocarpal, and distal radioulnar joint motions provides multiple degrees of motion:
flexion/extension, radial/ulnar deviation, and pronation/supination. The surround-
ing ligaments of the wrist provide the stability necessary for this wide range of
motion [7]. Fractures or ligamentous injury can alter the normal mechanics of
motion of these articulations, resulting in abnormal joint loading and subsequent
osteoarthritis. This may occur in predictable patterns allowing treatment to be tai-
lored to each patient’s stage of arthritic change. Understanding the specific anatomy
of the wrist is paramount to understanding these patterns of degeneration.

Carpus and Intercarpal Joints

The carpal bones are customarily described in two carpal rows: proximal and distal.
The proximal row consists of, from radial to ulnar, the scaphoid, lunate, triquetrum,
and pisiform (Fig. 6.1). This group of carpal bones is also termed the intercalary
segment as there are no extrinsic ligamentous connections directly to these struc-
tures. The movement of the proximal carpal row is based entirely on their
6  Post-traumatic Arthritis of the Wrist 75

Trapezium Hamate

Trapezoid Pisiform
Capitate
Triquetrum
Scaphoid

Lunate
Radius
Ulna

Fig. 6.1  Illustration: Carpus. Proximal row: Scaphoid, lunate, triquetrum, pisiform. Distal row:
trapezium, trapezoid, capitate and hamate

articulations with the distal carpal row and the radius and ulna as well as their liga-
mentous supports [6].
Ligaments of the wrist include palmar and dorsal radiocarpal, ulnocarpal, inter-
carpal, palmar midcarpal, proximal and distal interosseous, and distal radioulnar
ligaments [7]. The proximal interosseous ligaments, the scapholunate and lunotri-
quetral, provide interconnection between the bones of the proximal carpal row
allowing coordinated movement. These interosseous ligaments each contain proxi-
mal, volar, and dorsal components with the dorsal aspect of the scapholunate inter-
osseous ligament (SLIL) and the volar component of the lunotriquetral interosseous
ligament (LTIL) providing the strongest support for their respective joints [7, 9].
Injury to these ligaments results in atypical patterns of movement between the bones
within the carpal row, termed carpal instability dissociative (CID) [3, 6, 8, 9]. The
distal carpal row includes, from radial to ulnar, the trapezium, trapezoid, capitate,
and hamate (Fig.  6.1). Gelberman reviewed the ring concept of the carpal rows
highlighting the interconnected kinematics based on the scaphoid as a stabilizing
link between rows and the triquetrum as a pivot point for carpal motion [3]. With
radial deviation of the wrist, the distal row moves radially and forces the scaphoid
76 S. A. Strike and P. E. Blazar

Fig. 6.2  Lateral radiograph of the wrist

showing a normal radiolunate angle
of zero degrees

and the entire proximal row into flexion to avoid direct impact. The scaphoid rests
in a position of slight flexion with a normal radiographic scapholunate angle of less
than 70 degrees [6] (Fig. 6.2). The lunate rests in a neutral position, hence the nor-
mal radiolunate angle of zero (Fig. 6.2).

Distal Radioulnar Joint

The distal aspects of the radius and ulna form the distal radioulnar joint (DRUJ) that
allows the forearm to rotate in pronation and supination in coordination with the
proximal radioulnar joint at the elbow. The sigmoid notch of the radius provides a
concavity in which the ulna articulates. The surrounding soft tissue structures pro-
vide not only stability for the DRUJ but also prevent impingement at the ulnocarpal
6  Post-traumatic Arthritis of the Wrist 77

Fig. 6.3 Illustration: Articular Ulnolunate

Structure of the TFCC disc ligament

Ulnotriquetral
ligament

Volar radioulnar
ligament

Ecu sheath

Dorsal radioulnar
ligament

Radius Ulna

joint. The triangular fibrocartilage complex (TFCC) is composed of fibrocartilage,

ligament, and joint capsule and separates the DRUJ from the radiocarpal joint [7].
The TFCC includes the dorsal and palmar radioulnar ligaments, the ECU subsheath,
the ulnocarpal ligaments and the triangular articular disc that lies between the dorsal
and palmar ligaments [7] (Fig. 6.3).

Wrist Arthritis

Evaluation

Diagnosis of posttraumatic arthritis of the wrist requires a history of trauma; how-

ever this is often remote or vague. Tenderness on physical examination is an impor-
tant clue to the location of injury or arthritis; although, anesthetic and/or cortisone
injections may be helpful in localizing pain generators [4]. The scapholunate inter-
val, radial border of the scaphoid, and scaphotrapeziotrapezoidal (STT) joint are
important landmarks for palpation although the entirety of the wrist, including all
intercarpal joints, should be systematically examined [5, 13]. Dorsal wrist swelling
and/or a joint effusion may be present [13]. Pain may be elicited with wrist exten-
sion and radial deviation, which loads the radial side of the wrist [9]. Dynamic tests
such as the scaphoid shift test should be included in the exam [5, 9]. In this test,
scapholunate dissociation may be diagnosed through dorsal subluxation of the
scaphoid with palmar-dorsal pressure on the tuberosity during radial deviation caus-
ing pain. A clunk will occur as the scaphoid reduces into position with radial devia-
tion and/or removal of pressure [3, 9]. Radiographs are necessary in initial evaluation
and should be scrutinized for signs of altered carpal alignment, joint space loss,
osteophyte formation, loose bodies, and subchondral sclerosis or cystic change [3,
4, 13]. Standard posteroanterior and lateral views should be obtained in addition to
78 S. A. Strike and P. E. Blazar

an ulnar-deviated clenched fist, or “scaphoid,” view and a 45-degree pronation view

[5]. Ulnar variance can only be appropriately assessed with the forearm in neutral
rotation, the elbow flexed 90 degrees, and the shoulder at 90 degrees of abduction
[5]. The pencil grip view may also demonstrate an increase in ulnar variance as
compared to a neutral, non-grip view. Advanced imaging is rarely required for diag-
nosis; although, magnetic resonance imaging (MRI) may be useful in evaluating the
status of articular cartilage [4].
In general, nonsurgical options for management of arthritis of the wrist include
immobilization with braces or splints, nonsteroidal antiinflammatory medications
(NSAIDs) if tolerated, and selective cortisone injections; although, they often pro-
vide only temporary relief. These options should be exhausted prior to surgical
intervention [4]. The goals of surgical treatment are to eliminate pain, improve func-
tion, and prevent further damage, if possible [4].

Intercarpal and Radiocarpal Arthritis

In contrast to normal kinematics, with carpal ring disruption the bones of the wrist
move in a discordant fashion [3]. Injuries causing disruption of the carpal ring may
be isolated intercarpal ligament injuries, SLIL injury associated with a distal radius
fracture, or multiple intercarpal ligament injuries associated with perilunate insta-
bility or dislocation [3, 9]. When associated with an extrinsic cause the resulting
deformity is termed carpal instability adaptive (CIA) [3, 6, 9]. When chronic in
nature, these injuries may lead to intercarpal and radiocarpal joint degeneration.

Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced

Collapse (SNAC)

Chronic SLIL injuries causing carpal instability may lead to subsequent radiocarpal
and intercarpal arthritis although the natural history of SL ligament injuries is not
well documented [7, 13]. In the pathologic state where the SLIL is compromised,
the scaphoid will flex while the lunate will independently fall into extension leading
to dorsal angulation of the lunate relative to the radius on a lateral radiographic
view, termed dorsal intercalated segment instability (DISI) [3, 5, 6, 9, 13, 15]
(Fig. 6.4). As this process progresses the capitate may migrate proximally as well
[5]. There are no studies confirming that SL ligament tears, diagnosed with direct
visualization through arthroscopy, inevitably lead to arthritis [13]. When degenera-
tive changes do occur, radiographically, they will follow a predictable pattern
termed scapholunate advanced collapse, or SLAC, wrist [4, 10, 11]. First described
by Watson and Ballet based on their review of 4000 radiographs, of which 210
showed degenerative wrist arthritis, SLAC wrist was the most common pattern
affecting 57% of those patients [10]. Initially, changes are noted at the tip of the
radial styloid and the distal scaphoid (stage I), followed by involvement of the entire
radioscaphoid joint (stage II) (Fig.  6.5). These specific changes result from the
6  Post-traumatic Arthritis of the Wrist 79

Fig. 6.4  Lateral radiograph

demonstrating dorsal intercalated
segment instability (DISI)
deformity

incongruent geometry of the scaphoid with the radius when the scaphoid falls per-
sistently into flexion [5, 12]. The capitolunate joint is the first midcarpal joint
involved (stage III) (Fig. 6.6), and the final stages may include the rest of the carpus
although the radiolunate joint is characteristically uninvolved [2, 3, 5, 10–12]. This
is thought to be from the highly congruent nature of the lunate in the fossa of the
distal radius [10]. It is important to note that patients with a SLAC wrist pattern may
be asymptomatic. Further, atraumatic causes such as calcium pyrophosphate depo-
sition must be considered [2, 13]. Radiographs of the contralateral wrist in an
asymptomatic patient may also show SLAC changes [13].
Less commonly, nonunion of the scaphoid may lead to a scaphoid nonunion
advanced collapse (SNAC) wrist deformity [12, 13] (Fig. 6.7). The SNAC pattern
is similar to a SLAC wrist with the anatomic difference being the maintained
80 S. A. Strike and P. E. Blazar

Fig. 6.5  PA radiograph:

Stage II SLAC wrist

attachment of the proximal pole of the scaphoid to the lunate via the SLIL and,
thus, an arthritis-free articulation between the proximal pole of the scaphoid and
the radius [3, 5, 11, 12, 15]. Two reports on the natural history of scaphoid non-
unions were published in the 1980s [14, 15]. Mack et al. evaluated 47 scaphoid
fractures with a range of five to 53 years of known nonunion and identified three
patterns of degeneration. At an average of 8.2 years, patients developed isolated
scaphoid sclerosis and cystic changes. By 17.0 years, radioscaphoid arthritis devel-
oped, and at an average of 31.6 years generalized arthritis of the wrist developed.
Overall they concluded that by 10 years all nonunions were displaced, unstable, or
arthritic, and by 20  years, generalized arthritis of the wrist was common. Ruby
et al. reviewed their series of 56 scaphoid nonunions and noted a 97% rate of osteo-
arthritis at 5 years or greater after injury [15]. These population studies suggest that
osteoarthritis is likely to develop in patients with an established scaphoid non-
union, particularly those that are displaced, and thus scaphoid fixation is often
recommended for nonunion even in asymptomatic patients, to prevent future
degenerative change.
6  Post-traumatic Arthritis of the Wrist 81

Fig. 6.6  PA radiograph:

Stage III SLAC wrist

Management

Nonoperative options are the mainstay of initial treatment although there are no
long-term studies evaluating these methods specifically in SLAC/SNAC deformities
[4, 13]. As discussed previously, bracing, directed injections, and anti-inflammatory
medications may be used in appropriate patients for symptomatic management.
Symptoms refractory to conservative management or severe symptoms on presenta-
tion warrant consideration of surgical intervention.
Surgical management of SLAC and SNAC wrist is aimed at the stage of involve-
ment. Prior to the development of arthritic changes, direct repair or reconstruction
of the scapholunate ligament, with or without radial styloid excision, or treatment of
the scaphoid nonunion may be undertaken with the goal of preventing the
82 S. A. Strike and P. E. Blazar

Fig. 6.7  PA radiograph:

SNAC wrist

development of end-stage arthritis. Once arthritic changes have occurred, treatment

options change significantly [5].
Wrist arthroscopy has a limited role in management but may be useful for evalu-
ation of cartilage surfaces to select an appropriate salvage procedure. For example,
arthroscopy allows for direct visualization of the radiocapitate joint to determine if
a scaphoidectomy with four-corner fusion (S4CF) is more appropriate than a proxi-
mal row carpectomy (PRC), which is contraindicated in the presence of capitolu-
nate arthritis [2, 5]. For stage I SLAC changes, a radial styloidectomy is appropriate
to improve pain although this will not inhibit progression of arthritis [5]. Key tech-
nical points include protecting the dorsal branches of the radial sensory nerve and
resecting less than 3–4 mm to maintain the volar radiocarpal ligaments so as not to
induce carpal instability [2, 13]. For more advanced stages of arthritis surgical
options include limited wrist fusion, such as a S4CF, scaphocapitate or
6  Post-traumatic Arthritis of the Wrist 83

scaphotrapeziotrapezoidal (STT) arthrodesis, PRC, wrist denervation, total wrist

arthroplasty and total wrist arthrodesis [2, 5, 13]. In contrast to total wrist arthrod-
esis, limited wrist fusions allow for maintenance of wrist motion through preserva-
tion of joints unaffected by arthritis [3].
Simple excision of the distal scaphoid may play a role in arthritis management
after scaphoid nonunion [3, 5, 13, 16, 17]. Malerich et al. performed a distal scaph-
oid excision on 19 patients with radioscaphoid arthritis secondary to a scaphoid
nonunion, 13 of who sustained pain relief. The procedure is not recommended if
capitolunate arthritis is present but has the benefits of minimal ligamentous disrup-
tion, and no need for internal fixation or prolonged immobilization [16]. Ruch and
Anastasios treated 13 patients with distal scaphoid excision after previous surgery
for symptomatic nonunion [17]. At five-year follow-up, only two patients had pain
with activity and reported this as mild. Mean wrist flexion and extension increased
by 23 and 29 degrees, respectively. In six patients they noted a significant increase
in the radiolunate angle, indicating a DISI deformity, but identified no symptomatic
correlation [17].

S4CF Versus PRC

A S4CF involves complete removal of the scaphoid with fusion of the remaining
capitate, lunate, hamate and the triquetrum [13]. Alternatively, a scaphoidectomy
and triquetrectomy can be performed with a three-corner fusion of the capitolunate,
capitohamate and hamatolunate joints. Both procedures require undamaged radiol-
unate articular cartilage, as this joint will remain intact [3, 12]. Correction of a DISI
deformity must be performed intra-operatively prior to stabilization or radiocapitate
impingement can result dorsally [2, 3, 12]. The radioscaphocapitate and long radio-
lunate ligament should be preserved to prevent ulnar translation of the carpus [2].
Meticulous surgical technique with preparation of fusion surfaces, removal of debris
and proper hardware sizing must be emphasized [13]. Benefits of a S4CF include
maintenance of carpal height, preservation of the radiolunate joint and no risk of
degeneration at the radiocapitate joint [3]. Risk of nonunion and hardware compli-
cations are disadvantages of this procedure [12]. Fusion fixation may be performed
with k wires, staples, headless screws or circular plates. K wire fixation is inexpen-
sive but risks pin tract infection, sensory nerve irritation and requires removal [3,
13]. Staples and headless screws provide compression at the expense of possible
dorsal impingement with staples, and technical difficulty in placing screws [3, 12].
Multiple studies have shown higher rates of nonunion and complications with circu-
lar plate fixation [3, 12, 13]. Saltzmann et al. reviewed seven studies and noted a
grouped nonunion rate of seven percent after S4CF [20]. Bain and Watts evaluated
clinical outcomes in 35 patients undergoing S4CF at 1, 2, and 10 years and reported
pain scores of 0/10 at 1 year, and 22% loss of wrist range of motion. Between 1 and
10 years, there was no significant change in pain, wrist function, patient satisfaction,
or arc of wrist motion, suggesting that results are sustainable [18]. Only two patients
went on to wrist arthrodesis [18]. Some authors have advocated capitolunate fusion
84 S. A. Strike and P. E. Blazar

alone, with or without triquetral excision after scaphoidectomy, as outcomes appear

similar to a four-corner fusion [2, 13, 19, 43]. In a series of 12 patients undergoing
scaphoidectomy and capitolunate arthrodesis with headless compression screws
alone, ten patients resumed their prior work activities and the average postoperative
grip strength was 81% of the contralateral extremity [19]. The shorter operative
time, rapid rate of fusion, preservation of lunotriquetral motion and early rehabilita-
tion are reported benefits of the procedure [19].
Proximal row carpectomy involves resection of the scaphoid, lunate and trique-
trum (Fig. 6.8). A new articulation between the capitate and radius is created which
requires ensuring that the capitate has intact cartilage proximally prior to commit-
ting to this procedure, although there is no data providing guidance on exactly how
much cartilage is necessary for a PRC to be successful [2, 3, 12]. Future degenera-
tion of this joint continues to be a risk of PRC particularly in younger patients
although it is not clear that these radiographic changes are consistently symptomatic
[3, 21]. Pain relief from degeneration of the capitate in the setting of PRC has been
obtained with osteochondral resurfacing or interposition procedures however no
improvement in range of motion or grip strength is achieved [13]. Preservation of
the radioscaphocapitate ligament is necessary to prevent ulnar translation of the
capitate off the radius [3]. The benefits of a PRC include a lack of prolonged

Fig. 6.8  PA radiograph

after proximal row
carpectomy
6  Post-traumatic Arthritis of the Wrist 85

postoperative immobilization, no risk of nonunion or hardware complications, tech-

nical ease, greater maintenance of wrist motion and simple conversion to a total
wrist arthrodesis or arthroplasty as a salvage option [2, 3, 12, 13, 21].
Multiple studies have examined these two interventions, although randomized
controlled trials are limited [5, 44]. In their systematic review, Mulford et al. caution
that the current literature lacks unbiased trials and thus interpretation must be made
in this context [21]. Both motion-preserving options, S4CF and PRC remain similar
in outcomes for SLAC wrist in short-term follow up [13]. Cohen and Kozin per-
formed a cohort study comparing two similar groups, each undergoing either S4CF
or PRC at two separate institutions. Pain relief, function, physical score on the
SF-36 and patient satisfaction were similar between groups. Greater radial deviation
was maintained in the S4CF group [13]. Similar results were noted in a small review
of seven studies examining short and medium term outcomes after PRC or 4CF
[20]. Grip strength and radial deviation were greater after S4CF while wrist exten-
sion and flexion were greater after PRC [20]. In a systematic review of 52 studies
examining patients with SLAC or SNAC wrist undergoing either PRC or S4CF, grip
strength averaged 70% after PRC and 75% after 4CF. A majority of studies showed
a loss of motion after either procedure. Subjective outcomes were “good” 84% of
the time after PRC and 85% of the time after 4CF [21]. Grip strength after both is
typically reported at 75–80% of the contralateral extremity with a 40–60 degree arc
of motion after S4CF and a 60-degree arc of motion after PRC [3]. Kiebhafer rec-
ommended PRC for older and less active patients and S4CF in higher demand
patients or those less than 35 years old [12]. In general, the procedures are consid-
ered equivalent for pain relief, subjective outcomes, grip strength and need for con-
version to arthrodesis, in appropriately staged patients [21, 45]. A recent cost-utility
analysis identified both S4CF with screw fixation specifically, and PRC as cost
effective treatments for management of SLAC/SNAC wrist [46]. The method of
fixation in a 4CF alters the cost effectiveness of the intervention, with plate and
staple fixation reported as more costly than compression screw fixation [47].

Wrist Denervation

A relatively simple procedure for management of wrist arthritis, denervation

remains an option that avoids use of hardware and allows for future salvage options
if necessary [13]. Weinstein and Berger reviewed 19 patients undergoing AIN and
PIN neurectomies with 2.5 year follow up [22]. Eighty percent of patients reported
decreased pain and only two patients went on to arthrodesis with no complications
in the group. Overall, 90% of patients would have selected denervation again for
their chronic wrist pain [22]. An isolated PIN neurectomy has also been described
with 90% of patients satisfied with the procedure [48]. These technically simple
procedures can be used as a temporizing measure to delay salvage procedures.
Often performed in Europe, complete wrist denervation is an alternative and more
extensive option for management of chronic wrist pain. Originally described by
Wilhelm, complete wrist denervation involves severance of branches of the PIN,
86 S. A. Strike and P. E. Blazar

AIN, palmar cutaneous nerve, sensory branch of the radial nerve, dorsal branch of
the ulnar nerve, lateral and medial antebrachial cutaneous nerves and requires five
incisions around the wrist [23]. Simon et al. retrospectively reviewed 27 patients
undergoing complete wrist denervation by one surgeon. Forty-four percent of
patients had complete relief of pain that remained stable in 89%. Grip strength was
maintained at 85% of the contralateral arm. Six complications occurred including
one case of complex regional pain syndrome and five neuromas with two patients
requiring reoperation. Overall 67% of patients were very satisfied [24]. In a longer-­
term review of 30 complete wrist denervations with average 10 year follow up, 28
patients had improved pain with 22 maintaining this effect through final follow up.
Grip strength was reported at 82% of the contralateral extremity [25]. In another
review of 71 complete wrist denervations, 22 wrists had complete pain relief and 40
wrists had considerable improvement. Nine patients required reoperation for insuf-
ficient pain relief [26]. A more recent study of 39 wrists undergoing total wrist
denervation with an average 56 months follow up resulted in pain improvement in
79.5% of cases with four revision procedures and four complications [49]. Complete
wrist denervation may provide and maintain sufficient pain relief without sacrific-
ing grip strength or future salvage procedures.

Total Wrist Arthroplasty and Arthrodesis

Severe arthritis of the radiocarpal joint or pancarpal arthritis requires total wrist
arthroplasty or arthrodesis [3] (Fig. 6.9). Total wrist arthroplasty removes painful
arthritic surfaces and replaces them with a prosthetic option. Early designs included
synovitis-inducing silicone implants and unstable prostheses [3]. Newer designs
have improved component fixation [3]. Arthroplasty preserves motion when com-
pared to arthrodesis but requires a lifelong lifting restriction, usually of ten pounds
or less, and is preferred in low demand patients only [2, 3].
Total wrist arthrodesis is preferred in young laborers and patients who want to
continue manual work [3]. Grip strength can be maintained particularly with the
wrist fused in slight extension [3]. Arthrodesis is typically performed with commer-
cially available pre-contoured dorsal plates and autogenous bone graft, with cited
fusion rates of 93–100% [3, 13]. In a retrospective review of 89 patients undergoing
wrist arthrodesis for posttraumatic arthritis, 98% of the 56 patients with plate fixa-
tion went on to union, while 82% of those receiving a different form of fixation
achieved union [27]. The complication rate after plate fixation was 51%, with 59%
of these requiring an additional procedure, while 79% of patients with a different
form of fixation had a complication but only 21% of these required an additional
procedure [27]. Arthrodesis is thought to be reliable for pain relief and allows
patients to perform most activities of daily living through compensation of other
joints [2]. Although many studies report patient satisfaction after total wrist arthrod-
esis, complete pain relief may be less often achieved than perceived based on these
series [28]. Jupiter and Adey reported persistent pain in 64% of their series of 22
patients who underwent arthrodesis for posttraumatic arthritis, suggesting that this
6  Post-traumatic Arthritis of the Wrist 87

Fig. 6.9  PA and lateral radiographs after total wrist arthrodesis

pain relief procedure may be less predictable than previously thought [28]. De Smet
et al. compared PRC to wrist arthrodesis in a nonrandomized retrospective study of
61 patients with posttraumatic osteoarthritis of the radiocarpal joint. While there
was no difference in grip strength between groups, functional outcome scores,
maintenance of professional activity and complication rates were better in the PRC
88 S. A. Strike and P. E. Blazar

group [29]. Additional sources of pain must be considered when opting for wrist
arthrodesis and should be addressed.

Surgical Technique

A dorsal approach is typically preferred for most salvage procedures. Dissection

through the third dorsal compartment with radial transposition of the extensor pol-
licis longus (EPL) is followed by a longitudinal, step cut or transverse ligament-
sparing incision through the dorsal wrist capsule [3]. Lister’s tubercle is easily
identified in the surgical field and can be removed to obtain distal radius bone graft.
For some implants removal of this tubercle allows greater flexibility of plate posi-
tion and less hardware prominence [3]. Weiss and Rodner recommend a surgical
technique that maintains precise capsular incisions to facilitate closure, avoids liga-
ments of the wrist that are not involved to prevent secondary instability, and uses
transverse incisions when possible to preserve motion. Dissection must be per-
formed carefully to protect the sensory branches of radial and ulnar nerves, and
excision of the PIN may assist with denervation of the wrist and pain control. Use
of autogenous bone graft, preferably from the distal radius or iliac crest, as opposed
to resected carpal bone, is recommended [3].

Isolated Radiocarpal Arthritis

Radiocarpal arthritis in the absence of intercarpal arthritis may result after an intra-­
articular or malunited distal radius fracture [3, 6, 9]. Intra-articular step-off or loss
of normal volar tilt, radial height or inclination with malunion may alter points of
contact and load leading to degenerative changes.

Management

Radioscapholunate (RSL) arthrodesis may be performed for pain relief at the expense
of wrist motion, which is typically 33% of normal. Concomitant excision of the dis-
tal scaphoid may increase range of motion to 50–60% of normal [3]. Proponents of
scaphoidectomy have postulated that inclusion of the entire scaphoid in an RSL
arthrodesis leads to degeneration of the STT joint as the distal row is unable to flex
over the proximal row [30]. Garcia-Elias reviewed 15 cases of RSL arthrodesis with
distal scaphoidectomy for posttraumatic arthritis from distal radius fractures (13
patients) or perilunate fracture-dislocations (two patients). The midcarpal joints
were uninvolved in all patients. Complete pain relief was achieved in ten patients and
overall pain relief was noted to be greater than that reported in their previous series
of 27 patients who did not have a concomitant distal scaphoidectomy [30]. In com-
paring their outcomes to the literature on RSL arthrodesis alone, they note greater
motion in wrist flexion and radial deviation with distal scaphoidectomy [30].
6  Post-traumatic Arthritis of the Wrist 89

Isolated Intercarpal Arthritis

Scaphotrapeziotrapezoidal Arthritis

STT arthritis may cause radial-sided wrist pain. The posttraumatic nature of STT
arthritis is unclear. While it has been suggested that an isolated SL ligament rupture,
without instability or rotatory subluxation of the scaphoid, may cause degeneration
of the STT joint, this may be a reflection of the prevalence of STT arthritis as
opposed to confirmation that trauma is a common etiology of degeneration at this
joint [5].

Management

Management options for STT arthritis include joint debridement, distal scaphoidec-
tomy (open or arthroscopic), trapeziectomy, partial trapezoid resection, STT
arthrodesis or arthroplasty [5, 50, 51]. Excisional arthroplasty can be performed for
STT arthritis when not associated with dorsal midcarpal instability as distal scaph-
oid resection could cause collapse into DISI [31]. This technique is technically
simple with few complications and does not require prolonged immobilization [31].
Arthrodesis of the STT joint has been extensively although reports often include
patients with Kienbock’s disease in addition to traumatic etiologies [32]. Radial
styloidectomy should be performed at the time of fusion, with postoperative motion
expected to be approximately 65% of normal [4]. In a review of multiple studies
reporting on a total 238 patients, the average nonunion rate was 13%. The grouped
complication rate was 43% and included pin track infection, progressive arthrosis,
nerve irritation and osteomyelitis, amongst others [33]. Forty-nine percent of
patients reported persistent wrist pain [33]. Alternatively, Pequinot reported a small
series of patients undergoing pyrocarbon STT replacements citing a pain relief pro-
cedure that preserves carpal stability, has a low complication rate and does not pre-
clude salvage with fusion. Patients had a slight loss of pinch strength and wrist
motion with 10 degrees less radial deviation and 15 degrees less wrist extension
while grip strength was maintained at 4 year follow up [34].

Lunotriquetral Arthritis

Injury to the LTIL is significantly more rare than SLIL injury and typically occurs
from a fall onto an outstretched, supinated and extended wrist [2, 5]. Force transfers
from the pisiform into the triquetrum while the lunate remains tethered by the long
radiolunate ligament. The contradictory forces lead to rupture of the intervening
ligament [2]. These injuries may also occur as part of a perilunate dislocation (stage
III). An intact SLIL in the setting of an LTIL rupture will flex the lunate with the
scaphoid resulting in a volar intercalated segment instability (VISI) deformity [2, 5,
6, 9]. Ligament rupture with subsequent VISI deformity is not, however, clearly
90 S. A. Strike and P. E. Blazar

correlated with development of arthritis. In a biomechnical study of ulnar column

instability from LTIL tears, cadaveric wrists were loaded in 12 different positions
with a pressure sensor film measuring load across the radiocarpal joint in each stage
of perilunate injury. No significant differences in pressure were noted in any stage
suggesting that a VISI deformity does not necessarily correlate with clinical devel-
opment of arthritis [35].

Management

After attempting nonoperative interventions, management of lunotriquetral arthri-

tis after an LTIL injury is often with lunotriquetral (LT) fusion. Isolated LT arthrod-
esis will not improve a static VISI deformity and thus Peterson recommends
including the hamate in the fusion or performing a 4CF to correct VISI [5]. Positive
ulnar variance must also be corrected with shortening or resection at the time of LT
fusion [5]. Kirschenbaum reviewed a series of 14 patients undergoing LT arthrod-
esis for chronic LT instability. Twelve patients went onto fusion and one pseudar-
throsis required a second procedure but healed. Wrist motion ranged from 80% to
88% of the contralateral arm depending on direction of motion tested and grip
strength averaged 93% comparatively [36]. LT fusion remains a pain relief opera-
tion with reasonable maintenance of motion and grip strength, at least in the short-
term [36]. Despite wide use of this procedure, a comparison study of arthrodesis,
direct ligament repair and ligament reconstruction reported that the probability of
remaining free from a complication at 5  years was less than one percent in the
arthrodesis group. This compared to 68.6% and 13.5% for the reconstruction and
repair groups, respectively. Results followed the same trend for probability of not
requiring further surgery. While DASH scores did not differ, objective measure-
ments and subjective satisfaction scores were significantly higher in the repair and
reconstruction groups compared to the arthrodesis group [37]. This study suggests
that LT fusion may not be the ideal intervention for degenerative changes due to
LTIL injury.

Pisotriquetral Arthritis

This uncommon location of arthritis, when it occurs, is often posttraumatic in nature

and may result from acute or chronic injuries [4, 5]. Diagnosis may be suggested by
tenderness with loading of the pisotriquetral joint and can be confirmed with a
directed injection. A supinated oblique radiographic view allows direct examination
of the pisotriquetral joint [5]. Ulnar nerve symptoms or rupture of the small finger
flexor profundus are possible with arthritis of this joint, due to the proximity of
these structures [5].
6  Post-traumatic Arthritis of the Wrist 91

Management

As with other forms of arthritis, management with splinting, nonsteroidal antiin-

flammatory medications or injections, is attempted initially [5]. Simple pisiformec-
tomy with care to preserve the flexor carpi ulnaris insertion is the surgical treatment
of choice for cases that do not respond to nonoperative measures [4, 5].

Distal Radioulnar Joint and Ulnocarpal Arthritis

Arthritis of the DRUJ or ulnocarpal joint can have one of many traumatic causes. A
fracture of the distal radius with malunion may result in shortening that alters the
relative length of the ulna. Normally carrying approximately 20% of the load on the
forearm, the ulna is then overloaded inappropriately and ulnocarpal arthritis may
result [3, 4]. Furthermore, the relationship of the distal ulnar articulation with the
sigmoid notch of the radius may be changed predisposing to DRUJ arthritis [4, 38].
Alternatively, a soft tissue injury such as an injury to the TFCC, which includes the
stabilizing ligaments of the DRUJ, can also contribute to the development of post-
traumatic arthritis of the DRUJ and/or ulnocarpal joints [4].

Management

Treatment of ulnocarpal arthritis requires offloading the distal ulna. This can be
achieved through height restoration with a radial osteotomy, ulnar shortening, wafer
procedure or a distal ulnar resection, known as a Darrach procedure.
Arthritis of the DRUJ may be managed with partial or complete distal ulnar
resection, hemiresection interposition (HIT) arthroplasty, endoprosthetic replace-
ment or arthrodesis of the DRUJ with pseudarthrosis of the distal ulna, known as the
Sauve-Kapandji (SK) procedure [4, 38, 41, 52]. Procedures that maintain the TFCC
and ulnar styloid have the benefit of preventing ulnocarpal impingement [4].
Bowers performed a DRUJ HIT arthroplasty in 38 patients with the goal of pre-
serving the ulnocarpal ligament complex. At 2.5  year follow up, 100% of the
patients with a traumatic etiology of arthritis had painless range of motion with an
average 83 degrees of pronation to 83 degrees of supination and no instability [39].
Nawijn et al. reported higher satisfaction scores in patients undergoing HIT arthro-
plasty for inflammatory compared to posttraumatic DRUJ arthritis [53]. Santos
et  al. reported on three patients undergoing DRUJ arthroplasty, two of who had
posttraumatic DRUJ arthritis. In the short term, both patients achieved pain relief
and had increased motion at the DRUJ [41]. Watson performed a matched ulnar
resection in 44 patients, in which a convex resection of the distal ulna is undertaken
92 S. A. Strike and P. E. Blazar

to match the concave shape of the distal radius with maintenance of the TFCC and
ulnocarpal ligaments [40]. Patients were followed for an average 6.5  years and
maintained 80.5 degrees of painless pronation and 88.5 degrees of supination [40].
Endoprosthetic replacement with a semiconstrained DRUJ arthroplasty has been
utilized in the management of DRUJ arthritis with early reports citing low compli-
cation rates and a more recent review reporting further surgery secondary to com-
plications in 29% of patients [54]. Commonly cited soft tissue complications may
be more frequent in patients with a history of rheumatoid arthritis or immunosup-
pression compared to those without [55].
The SK and Darrach procedures are often applicable in similar clinical situa-
tions, each with their benefits and complications. The Darrach procedure may be
complicated by ulnar translation of the carpus and/or distal ulnar stump instability
[4, 40, 41]. The SK procedure may be complicated by a persistently painful pseud-
arthrosis [40]. Studies on these procedures have been primarily in rheumatoid popu-
lations. George et al. published one of the only reports on the use of these procedures
in a posttraumatic setting [42]. They retrospectively reviewed the use of the SK or
Darrach procedures in patients under age 50 with DRUJ arthrosis after distal radius
fracture malunion. Twelve patients after an SK, and 21 patients after a Darrach were
included. At final clinical follow up there were no significant differences in subjec-
tive pain or functional scores, forearm or wrist rotation, or complication rates
between the two groups. One patient required conversion to a Darrach after initial
treatment with an SK [42]. The procedures are considered equivalent for treatment
of posttraumatic DRUJ arthritis in this group [42]. The SK procedure has been mod-
ified to include tenodesis of the ulnar shaft with a distally based portion of the FCU
tendon. In a review of 18 patients undergoing this modification, grip strength
increased from 36% to 73% of the contralateral upper extremity. Sixteen patients
had stable ulnar stumps and overall pain relief was satisfactory [38]. The procedure
is recommended in younger patients who place high demands on their wrist or as a
salvage procedure in patients with severely limited forearm rotation [38].

Summary

Arthritis of the wrist encompasses degeneration of intercarpal, radiocarpal, ulnocar-

pal, and distal radioulnar articulations. More common injuries include scapholunate
ligament injuries leading to a well-described pattern of arthritis termed a SLAC
wrist, and distal radius fractures which can predispose to radiocarpal, ulnocarpal
and/or DRUJ arthritis. Evaluation of patients with wrist arthritis requires a thorough
history and a physical exam centered on identification of areas of swelling and
localizing tenderness on the many articulations of the wrist. Radiographs are often
sufficient for diagnosis of arthritis with advanced imaging rarely necessary. Initial
treatment with nonoperative interventions such as splinting, injections and NSAIDs
are exhausted before surgical intervention. Operative management typically involves
debridement, resection, fusion, or replacement of joint surfaces. Most of these
6  Post-traumatic Arthritis of the Wrist 93

interventions in the wrist have proven to be successful pain relief operations at the
expense of wrist motion and grip strength although most patients are able to main-
tain adequate function.

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Chapter 7
Post-traumatic Arthritis of the Hand

Andrew P. Harris, Thomas J. Kim, and Christopher Got

Key Points
• The goal standard for interphalangeal joint arthritis is arthrodesis.
• Thumb MCP joint arthroplasty is a good option for low demand patients.
• The CMC arthritis treatment algorithm is similar to IP and MCP arthritis.

Introduction

Arthritis of the hand is a common ailment of the general population with a preva-
lence of approximately 20–30% [1]. Being the second most common location of
pain due to osteoarthritis, it is a common condition that hand surgeons must often
treat [1, 2]. The scale of the patient’s debilitation varies in severity, but the most
common complaints involve stiffness, limitations of daily activities, and aesthetic
deformity. Unlike large joints such as the knee or hip, where artificial joint replace-
ment has been successful for many years, the small joints of the hand have not
enjoyed such long-term success to a similar degree with replacement surgery. This
chapter will discuss current treatments and the available literature regarding out-
comes of posttraumatic osteoarthritis of the interphalangeal joints of the fingers and
thumb as well as of the metacarpophalangeal and carpometacarpal joints.

A. P. Harris
Warren Alpert Medical School of Brown University, Providence, RI, USA
e-mail: andrew_harris@[Link]
T. J. Kim (*) · C. Got
Brown University, Warren Alpert Medical School, Providence, RI, USA

© Springer Nature Switzerland AG 2021 97

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
98 A. P. Harris et al.

Distal Interphalangeal Arthritis

Trauma can occur commonly at the distal interphalangeal (DIP) joint as it is located
at the most vulnerable distal aspect of the fingers. Fractures at the distal phalanx can
occur at the tuft (distal), shaft (middle), or at the articular surface (proximal).
Injuries involving the articular surface of the distal phalanx or at the head of the
middle phalanx can lead to arthritis at a later time. Bony mallet finger injuries and
flexor digitorum profundus avulsion injuries can also involve a significant portion of
the DIP joint and can similarly accelerate arthritis.
Treatment for arthritis at the finger joints is similar in algorithm to that of the
large joints. Conservative treatment is the first choice consisting of antiinflammatory
medications and occupational therapy. In contrast to larger joints, immobilization
may be implemented in finger and thumb osteoarthritis. This is often achieved in the
thumb with 1st CMC braces. Steroid injections are also an option but due to the
small volume of the joint, correctly injecting an intraarticular dose is challenging. A
steroid injection can often provide temporary relief for some patients. When these
conservative measures have failed, surgical treatment options can be considered,
including arthrodesis or arthroplasty. The gold standard for symptomatic end-­stage
arthritis at this joint is an arthrodesis [3]. There are many different techniques but the
principle remains the same: removal of any remaining articular surface and sclerotic
bone on both sides of the joint, and creation of a stable fusion bed using hardware
such as a simple Kirschner wires (K-wire) or a compression screw (Fig. 7.1).
The compression screw is usually a cannulated screw which is usually placed in
retrograde fashion. After exposing the joint and preparing the joint surfaces, a
K-wire is advanced antegrade from the distal phalanx. As the wire tents the skin, a
stab incision is made over the wire, and the wire is advanced until it protrudes just
beneath the surface of the proximal aspect of the distal phalanx. The fusion surfaces
are then reduced, and the wire is advanced retrograde across the fusion surface
under direct visualization into the center of the middle phalanx. Then, while the
fusion surfaces are held in compression, the screw is advanced over the wire. There
are two main designs of compression screw that use the concept of variable thread
pitch to achieve compression when the screw is advanced. The Herbert-type com-
pression screw has a smooth center shaft with different thread pitches at the leading
and trailing ends. The other screw design is fully threaded where the pitch varies
along its entire length. Both types serve the same purpose in creating a compression
force across the fusion bed (Fig. 7.2). Rates of union, reported to be from 80% to
100%, are high regardless of technique (Fig. 7.3) [3, 4].
Complications from DIP arthrodesis can include nonunion, failure of hardware,
fracture of the distal phalanx, and infection. Stern et al. reported a nonunion rate of
11% for DIP joint arthrodesis [5]. In the event of a symptomatic nonunion, tech-
niques have been described to remove the screw, curette out the nonunion site, and
place a cortico-cancellous graft either from the distal radius or from the iliac crest
[6]. There are no large series reporting outcomes for revision arthrodesis; however,
the few cases reported have achieved successful revision arthrodesis with these
7  Post-traumatic Arthritis of the Hand 99

Fig. 7.1  Distal interphalangeal joint fusion with a compression screw and a proximal interphalan-
geal joint fusion with cerclage wire and Kirschner wires (AP and lateral views)

techniques [6]. Fractures of the distal phalanx can also occur as the average antero-
posterior diameter of the distal phalanx is 3.5 mm while the trailing thread diameter
of a Herbert standard screw is 3.9 mm, Acutrak Mini screw is 3.6 mm, and Stryker
TwinFix screw is 4.1 mm [7, 8]. This can lead to disruption of the dorsal cortex of
the distal phalanx and pressure on the germinal matrix, which can cause nail defor-
mities [9]. Thus, it is important to select a proper size screw that will fit both the
middle phalanx and the distal phalanx. Herbert compression screws usually range
from 2.5 mm to 3.0 mm with no smaller diameters available. Smaller screw sizes
have been developed, with Acutrak Micro (Regina, Canada) providing diameters
ranging from 2.0 mm to 2.4 mm.
100 A. P. Harris et al.

Fig. 7.2 Herbert
compression screw versus
fully threaded variable
pitch screw

DIP arthroplasty is indicated in a select patient population. In musicians or other

patients with a similar demand for fine dexterity at the fingertips, preserving motion
at the DIP joint is preferred. In contrast, arthrodesis eliminates all motion at site of
fusion and is more suitable for patients requiring increased demand such as heavy
laborers. Fusion, in general, is the most reliable option for pain relief and avoids
complications related to implant loosening and breakage [10]. Silicone arthroplasty
has been reported to be performed for a small number of patients with varying but
similar complication rates compared to arthrodesis at 1–10% [11, 3].

Proximal Interphalangeal Joint Arthritis

Proximal interphalangeal (PIP) joint injuries are notorious for the subsequent stiff-
ness and arthritis that can occur. It is still a problem that has not yet been solved and
because of this, there are many different treatment options. The anatomy of the PIP
7  Post-traumatic Arthritis of the Hand 101

Fig. 7.3  AP and lateral

view of a thumb
interphalangeal joint fusion
with Kirschner wires

joint can be considered as a box with the volar plate forming the floor of the box, the
collateral ligaments forming the sides, and the extensor mechanism forming the
roof. At least two sides of the box must be disrupted for the box to become unstable.
The joint is in a vulnerable position away from the palm but has enough of a lever
arm so that when forces are applied from the fingertip, it can create significant injury.
Treatment options start with hand therapy, splinting, and antiinflammatories.
Because posttraumatic arthritis and stiffness in the PIP joint involves much more
than just the bony articular surface, therapy is essential. The soft tissue structures
that contract respond well to serial digital casting, ultrasound, heat, and stretching
[12–14]. Patient compliance is of utmost importance as it is a long and tedious pro-
cess. Surgical options include arthroplasty and arthrodesis. The gold standard for
symptomatic end-stage posttraumatic arthritis is arthrodesis. This is especially true
for the index finger where pinch strength is desired and for manual laborers with
increased demands on their hands. Other options for PIP joint arthrodesis are simi-
lar to the DIP joint with a tension band, compression screw, and plating commonly
utilized (Fig. 7.4).
102 A. P. Harris et al.

Fig. 7.4  Proximal interphalangeal joint arthrodesis with Kirschner wires and tension band (AP
and lateral view)

Arthroplasty techniques include volar plate arthroplasty, silicone arthroplasty,

and surface replacement arthroplasty. Volar plate arthroplasty was initially a proce-
dure for acute fracture-dislocations of the PIP joint for which the native articular
surfaces were unable to be reconstructed [15]. It has since then become a procedure
that can be used for posttraumatic arthritis of the PIP joint with decent success [16,
17]. The procedure involves resection of the non-reconstructable/arthritic portions
of the remaining articular surfaces and contouring those to fit one another. The volar
plate is then detached distally off of the middle phalanx and transposed into the
joint. Lin and colleagues performed a modified version of this procedure in seven
patients with posttraumatic PIP joint arthritis. They found a decrease in pain scores
and an increase in the average arc of motion by 64 degrees at a 2 year follow-­up
[16]. Dionysian et al. followed 17 patients for an average of 11.5 years with range
of motion ranging from 30 to 110 degrees [15]. Only four patients demonstrated
mild joint narrowing [15]. Silicone arthroplasty has been used to relieve pain and
maintain joint motion since the 1960s [18]. They serve as spacers that allow the soft
tissues to form a capsule and a pain-free stable joint. Studies have found good to
excellent pain relief with no significant change in range of motion [19, 20].
Complications include implant fracture, lateral instability, silicone synovitis, and
bony erosion with a reported 10–14% revision rate [21]. Because of these potential
issues, there have been a number of different surface replacement arthroplasties
developed.
7  Post-traumatic Arthritis of the Hand 103

The two most widely used joint replacements are currently the titanium-­
polyethylene and pyrocarbon implants. The titanium-polyethylene implants typi-
cally consist of proximal and distal titanium shafts, an alloyed proximal joint
surface, and an ultra-high-molecular-weight polyethylene distal joint surface. The
pyrocarbon implants consist of a radiopaque graphite core with a radiolucent pyro-
litic carbon coating. This implant material has a modulus of elasticity that is similar
to cortical bone. Both the titanium and pyrocarbon implants are unlinked, condylar
constrained, noncemented devices. The joint stability is maintained by the joint
surface geometry and the preserved collateral ligaments. A prospective randomized
trial studied the differences between silicone arthroplasty, titanium arthroplasty, and
pyrocarbon arthroplasty. Pain reduction and grip strength were similar in all groups.
Range of motion was superior only temporarily in the titanium and pyrocarbon
groups compared to the silicone group. The complications were more frequent and
severe in the surface replacement groups. The titanium devices group had 27%
removed and eventually replaced by silicone implants. The pyrocarbon group had
39% removed and replaced. Based on this and more recent studies that have demon-
strated poor outcomes with surface replacement arthroplasty, posttraumatic arthritis
is still an unsolved problem [21]. New techniques to gain stronger bone implant
fixation to avoid this all too common complication of loosening with joint surface
replacement are currently being investigated.
Arthrodesis is the gold standard for posttraumatic arthritis of the PIP joint. There
are multiple techniques to fuse the PIP joint, including screw fixation, K-wires, ten-
sion band, and plate fixation. All three techniques are commonly used and are often
dictated by surgeon preference; however, a study performed by Leibovic and
Strickland demonstrated screw fixation provided the lowest nonunion rate [22]. The
PIP is fused in the position of optimal function. The index and middle fingers are
usually more functional in 15–30 degrees of flexion as they are used in fine pinch.
The ulnar digits are more functional in 30–45 degrees of flexion as they are used in
grip. Obtaining these optimal fusion angles are key to retaining maximal hand
function.

Metacarpophalangeal Joint Arthritis

The hand contains five metacarpophalangeal (MCP) joints consisting of articula-

tions with the metacarpal and first phalanx of each digit. The MCP joints are prone
to trauma, especially in the setting of striking an inanimate object with a closed fist.
The 2nd through 5th are the most distally based articulation when viewing a
clenched hand, making them vulnerable to intraarticular damage. Crush injuries and
blunt force trauma, like the other articulations of the hand, are other common mech-
anisms of injury.
Initial treatment of MCP posttraumatic arthritis is similar to other joints of the
hand. Conservative treatment involves a multimodal approach and is generally initi-
ated with nonsteroidal antiinflammatory medications (NSAIDS), commonly
104 A. P. Harris et al.

consisting of ibuprofen, celebrex, naproxen, or meloxicam. Topical treatments such

as voltaren gel can be implemented. Occupational therapy or hand therapy can pro-
vide significant benefit in terms of strength and range of motion, depending on the
severity of arthritis. Splinting may also be employed at the risk of increasing stiff-
ness but providing comfort by immobilizing the affected joint. The thumb MCP
joint is more amenable to maintaining function while splinted as compared to the
digits 2 through 5. As with other larger articulations, the MCP joint may also
undergo a trial of corticosteroid injection. Timing of injection is important because
if near-future operative intervention is possible, the authors of this chapter recom-
mend the last injection to be a minimum 3 months prior to prevent risk of infection
with a maximum trial of three injections spaced at least 3 months apart [23, 24].
When conservative treatments have been exhausted, failing to provide relief and
restoration of function to the affected hand, surgical options may be considered.
MCP joint arthroplasty is one of the most frequently applied surgical interventions
for low demand patients. Early arthroplasty designs were of the constrained hinged
variety but commonly failed due to loosening or fracture [25]. Today’s MCP
arthroplasty components consist of either silicone or pyrocarbon. Chung et  al.
reported significantly improved patient reported outcomes at 1  year for patients
receiving the Swanson MCP joint arthroplasty for rheumatoid arthritis [26]. In
1999, Cook et  al. studied 53 predominately rheumatoid patients receiving 151
MCP pyrocarbon arthroplasties, reporting a 12% revision rate and 81.4% survival
rate at 10 years [27]. Houdek et al. showed excellent results for patients with open
traumatic non-­reconstructable articular MCP injuries treated initially with pyro-
carbon arthroplasty.
For higher demand patients or patients who have failed MCP arthroplasty, fusion
of the MCP joint can be considered an initial surgical treatment or salvage proce-
dure. Arthrodesis is effective at eliminating pain, but fusion at the correct flexion
angle is necessary to provide maximum function given the limited mobility. Bicknell
et al. retrospectively reviewed 27 patients that underwent thumb MCP joint fusion
patients, reporting high patient satisfaction, a low complication rate, and small
losses in dexterity, strength, and motion [28]. No consensus has been reached for the
exact optimal position of fusion. Steiger et al. determined the optimum fusion angle
of the thumb MCP to be 15 degrees of flexion and 10 degrees of pronation in con-
trast to a study by Saldana et al. recommending fusion for men 25 degrees and for
women at 20 degrees. The angles of fusion were based on each patient’s needs at the
time of surgery [29, 30]. The angles of fusion of the 2nd through 5th MCP joints are
generally 10, 20, 30, and 40 degrees respectively, which is the average resting posi-
tions these joints [30]. As shown by Ledgard et al., reporting improved function of
patients treated with simultaneous fusion of the 2nd through 5th MCP joints for
posttraumatic arthritis, the hand is able to retain excellent function if joints are fused
in the appropriate position [31].
7  Post-traumatic Arthritis of the Hand 105

Carpometacarpal Arthritis

Carpometacarpal (CMC) joints are susceptible to trauma much like the MCP, PIP,
and DIP articulations. The hand contains five CMC articulations, with the thumb
CMC articulation being the most complex and important in consideration of hand
function. Much like the MCP joints, the CMC joints of digits are more prone to
injury and dislocation during a clenched fist strike with direct transfer of force to
these articulations. The thumb CMC has two well-known intraarticular fracture pat-
tern eponyms known as the “Rolando” and “Bennett” with the most common mech-
anism of axially directed force to the thumb [32]. The Rolando fracture pattern is
characterized by intraarticular comminution of the 1st proximal metacarpal [33].
The Bennett fracture is characterized by a volar split of the proximal 1st metacarpal,
where the volar oblique ligament inserts on the fracture fragment [34]. Aside from
posttraumatic arthritis, idiopathic osteoarthritis of the thumb CMC is one of the
most commonly treated conditions for practicing hand surgeons.
Even after periarticular fracture fixation of the CMC joints, posttraumatic arthri-
tis may occur. The treatment algorithm employed is very similar to the MCP, PIP,
and DIP joints. Treatment begins with conservative management, consisting of non-
steroidal antiinflammatory drugs (NSAIDS), splinting, and hand therapy or occupa-
tional therapy. Splints specifically constructed for the thumb CMC have been shown
to provide significant improvement in hand function and pain relief and are often
employed early in treatment. Splinting of the CMC joints 2 through 5, however, is
difficult to accomplish while maintaining hand function. Corticosteroid injection is
often instituted in the setting of thumb CMC arthritis but is considered a temporary
solution as the duration of symptom relief has been shown to be dependent on sever-
ity of arthritis [35]. Meenagh et  al., in a randomized controlled trial, showed no
clinical benefit of corticosteroid injection versus placebo for patients with moderate
to severe arthritis [36]. Injection of CMC joints 2 through 5 may also be attempted;
although, posttraumatic arthritis to these joints is much less common than to the
thumb [37].
After conservative modalities of treatment have been exhausted and pain and
function have not improved to the satisfaction of the patient, surgical intervention
may be warranted. Surgical options for the thumb include trapeziectomy (excisional
arthroplasty) with or without suspensionplasty or ligament reconstruction, CMC
fusion, and joint replacement [38, 39]. Excisional arthroplasty is considered the
gold standard treatment for relatively active patients [38]. Patients who are young,
healthy, or high demand and laborers may benefit from CMC fusion [39]. Low
demand patients may be considered for joint replacement. Silicone thumb CMC
joint replacements initially showed excellent results but were later found to be
fraught with complications including synovitis, silicone wear, subluxation, cold
creep, and bony erosion [38]. Early studies of pyrocarbon interpositional thumb
CMC implants have shown promising results for selected low-demand patients [40].
CMC articulations 2 through 5 have relatively small amounts of motion compared
to the thumb and generally respond well to fusion. However, Yong et al. have shown
106 A. P. Harris et al.

promising early results using the Dupert’s arthroplasty technique for the 5th CMC
joint, which involves resection of the base of the 5th metacarpal and fusion of the
proximal shaft to the 4th metacarpal [41].

Conclusion

Posttraumatic arthritis of the hand is a common condition treated by hand surgeons.

Even with proper fixation of fractures, posttraumatic arthritis may be inevitable due
to the nature of the original injury. Treatment options are relative to each patient’s
activity demands, but, in general, conservative measures consisting of NSAIDs,
immobilization, and steroid injections are trialed early on. When conservative mea-
sures have failed to alleviate discomfort and pain, surgical intervention with joint
replacement, excisional arthroplasty, or arthrodesis may be warranted depending on
the joints involved.

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 Part III
Post-traumatic Arthritis
of the Lower Extremity
Chapter 8
Post-traumatic Arthritis of the Acetabulum

Savyasachi C. Thakkar, Erik A. Hasenboehler,
and Chandrashekhar J. Thakkar

Key Points
• Articular step-off greater than 2mm significantly increases the risk of post-
traumatic arthritis.
• The high failure rate of cemented acetabular components has made unce-
mented implants the mainstay for reconstruction in cases of posttraumatic
arthritis.
• The results of THA after acetabular fracture are humbling at 10 years when
compared to THA for cases unrelated to posttraumatic arthritis.
• The overall revision rates after THA following acetabular fractures are
substantially higher than those following a conventional primary THA and,
hence, a multispecialty treatment approach of these challenging injuries is
essential.

S. C. Thakkar (*)
Hip & Knee Reconstruction Surgery, Johns Hopkins Department of Orthopaedic Surgery,
Columbia, MD, USA
e-mail: savya@[Link]
E. A. Hasenboehler
Department of Orthopaedic Surgery, Adult Trauma Service,
The Johns Hopkins Medical Institution, Baltimore, MD, USA
e-mail: ehasenb1@[Link]
C. J. Thakkar
Joints Masters Institute, Mumbai, Maharashtra, India
Breach Candy Hospital, Mumbai, Maharashtra, India
Lilavati Hospital, Mumbai, Maharashtra, India
Hinduja Hospital, Mumbai, Maharashtra, India

© Springer Nature Switzerland AG 2021 111

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
112 S. C. Thakkar et al.

Introduction

Acetabular fractures are challenging injuries that require careful planning and spe-
cific fixation for each fracture pattern. These injuries typically demonstrate a
bimodal distribution – young patients with high-energy trauma and old patients with
osteoporotic bone from low-energy falls [15]. Despite accurate open reduction and
internal fixation of challenging acetabular fractures, there is an undeniable risk of
developing posttraumatic arthritis that can compromise patient outcomes [19].
Certain select fracture types with significant comminution in poor bone quality
require activity modification and weight-bearing restrictions as open reduction and
anatomic fixation would not be successful. However, the majority of the fractures
require anatomic restoration of the articular surface, especially in young patients.
Elderly patients with poor bone quality may be treated conservatively allowing
imperfect articular surface congruency, followed by total hip arthroplasty
(THA) [20].
The incidence of posttraumatic arthritis is 13% in cases where the articular con-
gruity has been adequately restored (less than 2 mm). There is a marked increase in
posttraumatic arthritis to 44% when the step-off between acetabular articular frag-
ments is greater than 2 mm [6]. However, the reported incidence of posttraumatic
arthritis can be as high as 67% per some reports [17, 23]. Most cases of posttrau-
matic arthritis after acetabular fractures require THA as the mainstay of treatment.
Usually, such patients can fall into one of the following three categories [12]:
• Category I – Patients with hip degeneration due to the initial injury or because of
complications associated with prior treatments. Such patients may present with
osteonecrosis of the femoral head, fracture mal-union, or nonunion and remnant
fracture fragments.
• Category II – Comminuted fractures in elderly patients with osteoporosis that are
not amenable to primary open reduction internal fixation and must rely on heal-
ing by secondary congruence. In these cases, patients can either receive a THA
for an acute fracture or delayed arthroplasty for secondary congruence.
• Category III – The nature of the fracture precludes a good result with initial ana-
tomic fixation. Impacted and multifragmentary fractures through the weight-­
bearing dome of the acetabulum are usually not amenable to good function even
after excellent open reduction and internal fixation leading to posttraumatic
arthritis.
THA remains the main treatment for posttraumatic arthritis after acetabular frac-
tures. However, it remains inferior when compared to THA for nonfracture-related
arthritis [7, 19, 21]. Increased failure in posttraumatic situations can be attributed to
cemented acetabular components, initial method of fracture fixation, preexisting
hardware, increased propensity for infection, younger age of the patient, abnormal
anatomy, sclerotic bone bed, and decreased acetabular bone stock [15]. Conversely,
cementless acetabular reconstruction has improved survivorship and has become
the preferred implant choice for posttraumatic arthritis of the acetabulum [1].
8  Post-traumatic Arthritis of the Acetabulum 113

In this chapter, we will outline our treatment algorithm for posttraumatic arthritis
of the acetabulum including surgical planning, implant selection, and surgical tech-
nique, and we will also present some representative cases highlighting key princi-
ples. In addition, we will review current outcomes associated with THA for
posttraumatic arthritis of the acetabulum.

Surgical Planning

Planning for surgery involves a thorough understanding of the patho-anatomy asso-

ciated with the original fracture and possible fixation constructs used initially. A
complete history and physical examination is imperative, and in acute cases, it is
imperative to check the patient’s soft tissue to exclude degloving injuries such as the
Morel-Lavallée lesion [3]. Prior incisions must be examined to understand which
approach to the hip has been previously used. Previous wounds must be examined
for infections such as erythema, fluctuance, drainage, and sinus tracts. Chronic
wounds with exposed bone or hardware will likely require muscle flap coverage and
plastic surgeon consultation. Skin bridges between old and new incisions should be
maximized in order to preserve skin blood supply.
A detailed neurovascular examination must be documented including the motor,
sensory, and peripheral vascular status. Acetabular fractures may be associated with
neurovascular compromise due to the mechanism of injury or subsequent surgical
procedures. Nerve conduction studies, electromyography (EMG), and vascular
studies may be considered preoperatively if the status is compromised. Our prefer-
ence is to use the posterolateral approach to the hip which is extensile and allows
adequate exposure to the acetabulum and the femur.
From the surgical perspective, we can classify the patients in to three types [20]:
• Type I – Patients requiring a conventional primary THA. In these cases, there is
adequate bony support for the cup, and the hip center of rotation is preserved in
its native anatomic location with no need for structural reconstruction. Such
patients typically display posttraumatic arthritis in well-reduced fractures and
osteonecrosis of the femoral head.
• Type II - Patients require fracture stabilization along with THA. In the majority
of cases a primary THA implant would suffice, but, occasionally, there is inade-
quate bony support for an acetabular cup due to the unstable fracture pattern of
present nonunion. Such patients will require cup support with additional internal
fixation.
• Type III – Patients that require significant reconstruction; these are challenging
situations due to significant alterations in the joint anatomy. With such cases, it
is essential to restore the hip center of rotation with revision THA principles
including bone graft or augments, cage or cup-cage constructs, and, possibly,
even custom tri-flange components. Examples include cases with an absent wall,
defective column, or cases with acetabular protrusio.
114 S. C. Thakkar et al.

Radiographic evaluation begins with radiographs consisting of anteroposterior

views of the pelvis and both hips along with Judet views, and inlet-outlet views of
the pelvis [8]. In addition, we typically perform computed tomography (CT) scans
with three-dimensional (3D) reconstruction [9, 14]. These images help with evaluat-
ing the adequacy of bony support for cup fixation at the appropriate location. We
prefer classifying acetabular defects using the Paprosky classification system [16].
The images also help with evaluating the preexistent internal fixation that may or
may not need to be removed to perform a THA. It is also essential to evaluate the
need for supplementary fixation of walls and columns and the need for structural
enhancement by bone grafts, prosthetic augments, cup-cage constructs, or custom
tri-flange implants [2, 5]. This approach will help with the reconstruction of the hip
center of rotation while determining adequate bony coverage of the uncemented cup
over at least 80% of its outer diameter [12].

Implant Selection

The high failure rate of cemented acetabular components has made uncemented
implants the mainstay for reconstruction in cases of posttraumatic arthritis [1, 5,
13]. Uncemented multihole porous metal cups allow the surgeon to plan screw tra-
jectories in the available host bone, while the porous metal surface can achieve ini-
tial scratch fit for primary stability. Based on the type of bone defect created due to
the initial injury and subsequent surgeries, it is also advisable, especially for com-
plex reconstructions, to have various porous metal augments and cages available.
Custom tri-flange components typically require 3D CT reconstructions and subse-
quent manufacturing from the implant company. In such cases implants should be
ordered several weeks in advance.

Surgical Technique

Hypotensive anesthesia is essential to reduce blood loss in such challenging surger-

ies. We prefer the extensile posterolateral approach to the hip for these surgeries for
excellent visualization of the acetabulum and the femur. It is important to securely
fix the patient in the lateral decubitus position using either a peg board or a hip
positioning device. This is because the surgeon must rely on external landmarks for
appropriate cup placement, as internal structures such as the posterior wall, trans-
verse acetabular ligament, and weight-bearing roof may not be in the native ana-
tomic position. Intraoperative fluoroscopy must be available as well to confirm cup
placement and restoration of hip center of rotation.
In cases with prior internal fixation hardware, the position of the implants may
be used to locate the correct placement of the cup. We usually do not remove the
previously placed implants unless they obstruct cup placement. Adequate, careful
8  Post-traumatic Arthritis of the Acetabulum 115

soft tissue dissection is required to visualize the acetabulum in its entirety. Release
of the insertion of the gluteus maximus tendon from the linea aspera should be per-
formed to allow the femur to be shifted anteriorly. Also, removal of the anterior
capsule and scar tissue allows for a pocket to be created for the femur to be trans-
lated anteriorly. A supra-acetabular Steinmann pin or a 90-degree bent Gelpi retrac-
tor, a right angle Hohmann retractor on the posterior column, a ball-spike pusher to
shift the femoral shaft anteriorly, and a blunt Hohmann retractor at the inferior bor-
der of acetabulum usually suffice for a clear 360-degree view of the socket.
Placing the cup in adequate anteversion and abduction is critical to the patient’s
function and implant longevity. With porous metal implants, it is essential to coat
the exposed surface of the implant to avoid excessive fibrosis. While closing the
incision, it is essential to not leave any dead space, and the use of drains with metic-
ulous soft tissue closure must be ascertained. Postoperative care resembles the pro-
tocol for THA such as posterior-hip precautions and physical therapy. However, the
weight-bearing status may vary depending on the stability of the reconstruction
construct and it may have to be modified on an individual basis. In the next section,
we will present several cases that reinforce the aforementioned principles.

Case Examples

We present case examples based on the three types of patients [20] described in the
surgical planning section of the chapter:
• Type I – Patients requiring a conventional total hip arthroplasty. Figures 8.1, 8.2,
and 8.3 are case examples of patients that had prior acetabular fractures which
had united with sufficient bone stock for primary total hip arthroplasty without
additional acetabular reconstruction.
• Type II – Patients requiring fracture stabilization along with THA. Figures 8.4,
8.5, and 8.6 are case examples of patients requiring acute fracture fixation and
concurrent THA to ensure adequate support for the implants.
• Type III – Patients requiring significant acetabular reconstruction to restore the
center of rotation. Figures 8.7, 8.8, and 8.9 are case examples of patients that rely
upon revision hip replacement principles to ensure optimal outcome.

Outcomes

We review several studies that report on the mid-term and long-term outcomes for
THA in cases of posttraumatic arthritis after acetabular fractures. A recent study
from the Mayo Clinic reported their mid-term results on 30 primary THAs that were
performed with a porous metal acetabular component after open reduction internal
fixation (ORIF) of acetabular fractures from 1999 through 2010 [22]. From these
116 S. C. Thakkar et al.

a b

c d

Fig. 8.1 (a) Pre-operative AP Pelvis radiograph of a 42 year-old male with an old acetabular frac-
ture leading to post-traumatic arthritis secondary to femoral head osteonecrosis. (b) Pre-operative
CT scan showing the incarcerated head fragment. (c) Intra-operative photograph of the incarcer-
ated femoral head. (d) Post-operative AP pelvis radiograph displaying press-fit acetabular and
femoral components

Fig. 8.2 (a) Pre-operative

AP pelvis radiograph of a a
patient with a chronic
mal-united acetabular
fracture and pelvic ring
injury. (b) 3D CT
reconstructions of a patient
with a chronic mal-united
acetabular fracture and
pelvic ring injury.
(c) Post-operative AP
pelvis radiograph
displaying press-­fit
acetabular and femoral
components
8  Post-traumatic Arthritis of the Acetabulum 117

Fig. 8.2 (continued)
b

c
118 S. C. Thakkar et al.

Fig. 8.3 (a) Pre-operative AP pelvis radiograph of a patient with a chronic acetabular fracture and
medial protrusion of the femoral head. (b) 3D CT reconstructions of a patient with a chronic ace-
tabular fracture and medial protrusion of the femoral head. (c) Post-operative AP pelvis radiograph
displaying press-fit acetabular and femoral components with medial bone graft
8  Post-traumatic Arthritis of the Acetabulum 119

Fig. 8.3 (continued)

Fig. 8.4 (a) Pre-operative radiographs of a 67 year old patient with a both columns acetabular
fracture and antecedent hip pain associated with osteoarthritis. (b) 3D CT reconstruction of a 67
year old patient with a both columns acetabular fracture and antecedent hip pain associated with
osteoarthritis. (c) Post-operative AP pelvis radiograph displaying press-fit acetabular and femoral
components with medial bone graft and posterior column and wall fixation
120 S. C. Thakkar et al.

b c

Fig. 8.4 (continued)

a b

Fig. 8.5 (a) Pre-operative AP right hip radiograph of a 60 year-old gynecologist who sustained a
fracture-dislocation of her left hip after a fall. (b) 3D CT reconstructions of a 60 year-old patient
with the fracture dislocation. (c) Post-operative AP pelvis radiograph displaying press-fit acetabu-
lar and femoral components with posterior wall fixation
8  Post-traumatic Arthritis of the Acetabulum 121

Fig. 8.6 (a) Pre-operative

AP right hip radiograph of a
a 65 year-old male treated
non-operatively for a right
acetabular fracture. (b) CT
reconstruction showing
posterior wall erosion and
femoral head subluxation.
(c) Intra-operative pictures
showing the acetabular
defect and reconstruction
with a segment of the
femoral head fixed with
inter-fragmentary screws
and supported by a buttress
plate, restoring the socket.
A cemented hip
replacement was
performed. (d) Post-
operative AP pelvis
radiographs showing a
cemented total hip
replacement with posterior
wall and column fixation

b
122 S. C. Thakkar et al.

Fig. 8.6 (continued)
c

d
8  Post-traumatic Arthritis of the Acetabulum 123

Fig. 8.7 (a) Pre-operative AP pelvis radiograph of a 32 year-old patient with a both-columns

acetabular fracture. (b) 3D CT reconstructions of the fracture pattern. (c) Post-operative AP pelvis
radiograph showing a cage-cup construct with fixation of the posterior column. A trochanteric
osteotomy had to be performed to access the acetabulum during the procedure
124 S. C. Thakkar et al.

Fig. 8.7 (continued)

cases, 28 (93%) THAs had a minimum follow-up of 2 years. The authors reported
that the fracture pattern was of the elementary type in 8 of 30 hips (27%, posterior
wall fracture in 6 hips, transverse fracture in 2 hips) and associated type in 13 of 30
hips (43%, T-type fracture in 5 hips, transverse-posterior wall fracture in 4 hips,
posterior column/posterior wall in 3 hips, and associated both column in 1 hip). The
fracture pattern was unknown in 9 of 30 hips. Nine of 30 hips (30%) had radio-
graphic evidence of osteonecrosis of the femoral head, and 6 of those had confirmed
traumatic dislocations at the time of their initial injury. A majority of patients under-
went the anterolateral approach, and only 9 of 30 hips were performed using the
posterolateral approach. No acetabular components were revised for aseptic loosen-
ing. Five-year survival with revision for any reason as the endpoint was 88% (95%
confidence interval, 0.70–0.96). Failures were related to infection. Three hips (11%)
underwent resection for infection, with all being treated with two-stage arthroplasty.
Harris hip scores improved from a median of 39 preoperatively (range, 3–87) to 82
at the most recent follow-up (range, 21–100; p < 0.01). Fifteen of 28 hips (54%) had
a good or excellent result, 3 (11%) had a fair result, and 10 (35%) had a poor result.
Two patients (7%) experienced at least one dislocation postoperatively. Both were
treated with a closed reduction and hip abduction brace treatment.
8  Post-traumatic Arthritis of the Acetabulum 125

Fig. 8.8 (a) Pre-operative

AP pelvis radiograph of a a
patient with failed
acetabular fracture fixation.
(b) Intra-operative images
showing fixation of a cage
and the femoral head
autograft. (c) Post-­
operative images
displaying the cage-cup
construct and restoration of
the hip center of rotation

c
126 S. C. Thakkar et al.

Fig. 8.9 (a) Pre-operative

AP pelvis radiograph of a a
comminuted both columns
fracture. (b) 3D CT
reconstruction of the
fracture pattern. (c)
Post-operative radiographs
showing posterior column
fixation and cage cup
construct

b
8  Post-traumatic Arthritis of the Acetabulum 127

Fig. 8.9 (continued)
128 S. C. Thakkar et al.

Another promising study from the Hospital for Special Surgery describes their
results with 32 THAs performed for posttraumatic arthritis after acetabular frac-
tures; 24 patients were treated with a prior ORIF, and 8 were managed conserva-
tively [18]. Average time from fracture to THA was 36 months (range, 6–227 months).
The average follow-up was 4.7 years (range, 2.0–9.7 years). With regard to fracture
classification, 16 patients (50%) had simple fracture patterns, and 16 patients (50%)
had associated patterns. One patient had a concomitant pelvic fracture. The most
common fracture patterns were isolated posterior wall fractures in 13 (41%) cases,
both-column fractures in 4 (13%) cases, and posterior column–posterior wall in 5
(16%) cases. Cementless acetabular components were used in all 32 cases. The
authors reported 79% 5-year end point survival for revision, loosening, dislocation,
or infection. Survival for aseptic acetabular loosening was 97%. Six (19%) revision
surgeries were necessary due to infection (two cases), aseptic acetabular loosening
(one case), aseptic femoral component loosening (two cases), and a liner exchange
for dislocation (one case). Revision surgery correlated with nonanatomic restora-
tion of the hip center and a history of infection (P < 0.05). Two other patients also
had at least one dislocation, but they both responded to conservative treatment with
closed reduction and bracing, which resulted in a dislocation rate of 9%. Harris hip
scores increased from 28 (0–56) to 82 points (20–100).
Studies from China have reviewed outcomes at 5 years and 6.3 years after THA
for acetabular fractures. Zhang et al. retrospectively analyzed 53 patients (55 hips)
who underwent THA because of failed treatment for acetabular fractures. The mean
duration of follow-up was 64 months (range, 32–123 months) in 49 patients [23].
Thirty-three hips (60%) had simple fracture patterns, and 22 (40%) had complex
patterns. The most common patterns were posterior wall fractures in 28 (51%) hips,
transverse-posterior wall fractures in 13 (23%) hips, and fractures of the posterior
column and posterior wall in 6 (11%) hips. Patients treated without ORIF under-
went a posterolateral approach to the hip. However, in patients with prior fixation, a
posterolateral approach was used in 28 hips, while a direct lateral approach and a
posterolateral plus anterolateral approach were used for removal of hardware in 2
hips, respectively. The authors used cement-less cups in 48 of 55 hips, and cemented
cups in 7 hips with 5 of them in combination with acetabular reinforcement rings
(ARRs). The authors report that with revision or definite radiographic loosening as
the end-point, the 5-year survival in their study was 100%. Three cement-less ace-
tabular components had a partial radiolucency (zones 2 and 3 [4]); in 2, the radiolu-
cency was less than 1 mm wide, and in 1, it was more than 2 mm wide. All of them
were associated with a good or excellent Harris hip score and were considered sta-
ble. A complete radiolucency, from zones 1 to 3, more than 2 mm wide, was seen in
1 cemented cup. None of the acetabular cups or ARRs showed any evidence of
migration. All bone grafts completely incorporated without any complications.
Complications included 1 dislocation and 3 sciatic nerve injuries. No instances of
deep wound infection were present. The dislocation was successfully treated with
closed reduction with no recurrence. The mean duration of follow-up was 64 months
(range, 32–123 months) in 49 patients (51 hips); 4 patients were lost to follow up.
The average Harris hip score increased from 49.5 (range, 22–78) before surgery to
8  Post-traumatic Arthritis of the Acetabulum 129

90.1 (range, 56–100) at the latest follow-up examination (P < 0.001). Results were
excellent for 36 hips, good for 11, fair for 2, and poor for another 2. In the ORIF
group, the average Harris hip score increased from 9.5 (range, 30–78) to 90.1 (range,
56–100) (P < 0.001), and in the non-ORIF group, it increased from 54.3 (range,
22–76) to 92.4 (range, 56–100) (P < 0.001). Moreover, the average postoperative
Harris score was significantly higher in the ORIF group than in the non-ORIF group
(P < 0.05). Similar significant improvements in average Harris hip scores were also
seen both in patients with cement-less acetabular reconstructions and in those with
cemented cups (P  <  0.001). Another study from China evaluated outcomes of
cement-less acetabular components at 6.3 years (range, 3.1–8.4 years) after surgery
in 31 hips with posttraumatic arthritis after acetabular fractures [10]. Of the
31patients, 19 (65%) had undergone ORIF (open-reduction group), and 12 (35%)
had received conservative treatment for the acetabular fractures (conservative-treat-
ment group). 14 patients (45%) had elementary fracture patterns while 17 patients
(55%) had associated fracture types. The posterolateral approach to the hip was
used in all patients. At the follow-up of 6.1 years, the authors reported no infection
and no revision surgery. The rate of anatomical restoration of center of hip rotation
was 100% (19/19) in the open-reduction group, and 67% (8/12) in the conservative-
treatment group (P = 0.02), compared with 93% (13/14) in the simple group and
82% (14/17) in the complex group (P = 0.61). Anatomical restoration was positively
related to fracture treatment (r = 0.48; P = 0.006), but it had no relation to fracture
pattern (r = 0.16; P = 0.40). By the final follow-up evaluation, six acetabular com-
ponents had partial radiolucent lines at the bone implant interface, all 1 mm or less;
and they occurred in zone 1 in five hips and in zone 3 in one hip. Osteolysis was not
observed in any patient. Of the patients with structural bone graft, only one had
minor graft resorption. Four patients (13%) had complications after THA.  One
patient whose complex fracture was treated conservatively fell 4 years after surgery,
causing posterior hip dislocation. Another patient whose complex fracture was
treated with ORIF had posterior hip dislocation 14 days after surgery because of
failure to adhere to posterior hip precautions. Both patients were successfully
treated with closed reduction; neither patient had a recurrent dislocation until the
latest follow-up evaluation. The sciatic nerve was injured during THA in one patient
in the open-reduction group who had a complex fracture. The patient had dorsal
pedal numbness and drop foot after surgery. The average Harris hip score increased
from 49 ± 15 before surgery to 89 ± 5 after surgery, and 29 patients (94%) had either
excellent or good results. The average Harris hip score for the open-reduction and
conservative-treatment groups increased to 87 ± 6 and 91 ± 3 (P = 0.07), respec-
tively, after surgery; for the complex and simple groups, it increased to 88 ± 6 and
90  ±  4 (P  =  0.25), respectively. There was no significant difference between the
open-reduction and conservative-treatment groups or between the complex and
simple groups regarding the number of hips with excellent and good results.
The results of THA after acetabular fracture are humbling at 10 years when com-
pared to THA for cases unrelated to posttraumatic arthritis. Morrison et  al. per-
formed a retrospective case-control study for patients at their institute between 1987
and 2011 [15]. During this period, the authors performed 95 THAs after acetabular
130 S. C. Thakkar et al.

fracture; of those, 74 (78%) met inclusion criteria and had documented follow-­up
beyond 2 years in their institutional registry. They also selected 74 matched patients
based on an algorithm that matched patients based on preoperative diagnosis, date
of operation, age, gender, and type of prosthesis. All surgeries were performed
through the posterolateral approach. The primary outcomes were revision and inci-
dence of complications. Secondary outcomes were radiographic signs of hetero-
topic ossification or implant loosening. The majority of acetabular fractures were
treated by ORIF (58 of 74 [78%]), whereas 16 of 74 (22%) were treated nonopera-
tively. The most frequent type of fracture involved the posterior wall, accounting for
31% of all injuries. Fractures involving both columns were seen in 16%, whereas
other fracture types were less common and were observed in less than 10% of
patients. 49% of patients had elementary fracture types while 51% of patients had
associated patterns. The 10-year survivorship after THA was lower in patients with
a previous acetabular fracture than in the matched cohort (70%, 95% confidence
interval [CI] 64–78% versus 90%, 95% CI 86–95%; p < 0.001). Younger patients
(<60 years) had worse THA survivorship after acetabular fractures than did older
patients (60%, 95% CI 51–69% versus 83%, 95% CI 72–94%; p < 0.038), and both
had inferior survivorship to the matched cohort (92%, CI 87–97% and 96%CI
92–99%; p < 0.001). The 10-year survival for THA after a simple acetabular frac-
ture was 83% (95% CI 77–89%) as compared with 60% (95% CI, 52–68%;
p = 0.032) for associated fractures. Patients with previous acetabular fracture had a
higher likelihood of developing infection (7% [five of 74] versus 0% [zero of 74];
odds ratio [OR], 11.79; p = 0.028), dislocation (11% [eight of 74] versus 3% [two
of 74]; OR, 4.36; p = 0.048), or heterotopic ossification (43% [32 of 74] versus 16%
[12 of 74]; OR, 3.93; p < 0.001). In patients with previous acetabular fracture, 13
patients (20%) were revised for loose acetabular component, 6 patients for wear and
joint instability (8%), 2 for infection, and 1 each for femur fracture, loose femoral
component, and recurrent dislocation. Revisions for the matched cohort included 11
patients for cup loosening and one patient for recurrent dislocations.
Of the 51 patients in the acetabular fracture group, who did not have a revision,
6 had no radiographs available, 46 had well-fixed components, and none had cup
loosening. Of the 62 control patients without revision, 3 had no radiographs avail-
able, 59 had well-fixed components, and none had cup loosening.
To summarize the outcomes of THA in posttraumatic arthritis after acetabular
fractures, Makridis et al. performed a systematic review in 2014 [11]. In total 654
patients were reviewed (659 hips) with a median follow-up of 5.4  years (range
12 months – 20 years). Median follow-up was 3.9 years (range 12 months–12 years)
in the acute THA group and 6.3 years (range 12 months – 20 years) in the delayed
THA group. A large majority of fractures were posterior wall fractures (140 patients;
21.4%) followed by transverse/posterior wall fractures (63 patients; 9.6%), poste-
rior column-posterior wall fractures (51 patients; 7.8%), and both column fractures
(49 patients; 7.5%). Treatment of acetabular fractures was only described in 625
fractures of which 473 fractures (75.7%) were treated with ORIF and 152 fractures
(24.3%) nonoperatively. The majority of the studies reviewed by the authors
reported no failure of initial treatment of acetabular fractures. 237 patients (36%)
8  Post-traumatic Arthritis of the Acetabulum 131

were treated with acute total hip arthroplasty. Delayed total hip arthroplasty was
performed in the remainder of the reviewed patients following either operative or
nonoperative management of the initial acetabular fracture. In the early-THA cases,
the median interval between time of injury and total hip arthroplasty was 10 days
(1–29). In the delayed cases, the average time from injury to THA was 6.6 years
(2 months–45 years).
With regard to acetabular components, an uncemented acetabular component
was used in 484 patients (80.1%) and a cemented one in 120 patients (19.9%). For
femoral components, the data was available in 569 hips with 340 patients (59.8%)
receiving an uncemented and 229 patients (40.2%) a cemented femoral component.
An antiprotrusion acetabular cage was rarely used, and acetabular bone graft was
used in all cases. Anterolateral and posterolateral surgical approaches were used in
a majority of the cases. In the early THA group, Kaplan–Meier survivorship analy-
sis with any loosening, osteolysis, or revision as the end-point revealed that the
10-year cup survival was 81%. In the late THA group, this percentage was 76%. The
log-rank test showed that this difference was not significant (P = 0.287). In the late
THA group where the proportion of uncemented and cemented implants were avail-
able, Kaplan–Meier survivorship analysis with any loosening, osteolysis, or revi-
sion as the end-point revealed that the 10-year survival was 86.7% for the uncemented
cups and 81% for the cemented. The log-rank test showed that this difference was
not significant (P  =  0.163). In the early THA group, 13 cups (7.5%) out of 173
implants were revised. Four cups were revised for aseptic loosening, one for trau-
matic loosening, six for dislocation, and two for infection. It was unclear how many
of these cups were cemented and how many were uncemented. In the late THA
group, 35 cups (9.6%) out of 365 implants were revised. Sixteen cups (45.7%) were
uncemented (13 were revised for aseptic loosening, 1 for traumatic loosening, and
2 for infection). Nineteen cups (54.3%) were cemented (17 were revised for aseptic
loosening, 1 for dislocation, and 1 for infection). The three most common complica-
tions were heterotopic ossification, infection, and dislocation which occurred in a
total of 292 out of 654 patients (44.6%). The Harris hip score was used to describe
the functional outcome with a median value of 88 points. Regardless of the type of
treatment, and according to the Harris hip score, younger patients achieved better
clinical outcomes than older patients (92.94  ±  4.48 versus 81.68  ±  4.58, respec-
tively) (P < 0.001). Almost all of the studies did not compare Harris hip scores for
acute versus delayed THA. Thirty-three patients died, and the overall mortality rate
was 5%. No patient died in the acute perioperative phase. The minimum time of
postoperative mortality was 4 months after surgery and maximum within 10 years
after surgery.
In conclusion, THA for posttraumatic arthritis associated with acetabular frac-
tures shows promising results and satisfactory functional and radiological outcomes.
However, there are no prospective studies to compare directly the outcomes follow-
ing acute or delayed total hip arthroplasty secondary to acetabular fractures. The
largely retrospective data available in the literature indicate that the clinical out-
comes, revision rates, and implant survivorship do not differ when either an early or
a late THA is performed. The overall revision rates after THA following acetabular
132 S. C. Thakkar et al.

fractures are substantially higher than those following a conventional primary THA,
and, hence, a multispecialty treatment approach of these challenging injuries is
essential.

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Chapter 9
Post-traumatic Arthritis of the Proximal
Femur

Raj M. Amin, Erik A. Hasenboehler, and Babar Shafiq

Key Points
• Optimal treatment for posttraumatic arthritis of the proximal femur is
patient specific.
• Hip arthroscopy is on the forefront of treatment modalities.
• Arthroplasty for proximal femur fractures is increasingly indicated during
the index fracture.
• Varus malunion is a common mode of failure following treatment of femo-
ral neck fractures.

Introduction

Epidemiology

Symptomatic posttraumatic osteoarthritis (PTOA) occurs in approximately 12%

proximal femur fracture patients [1–3]. In addition to causing substantial patient
burden, PTOA is an expensive problem that accounts for $3.1 billion in annual treat-
ment spending in the United States [3]. With an increasingly elderly population and
advances in medical care which have improved overall longevity, the incidence of

R. M. Amin · B. Shafiq (*)

Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions,
Baltimore, MD, USA
e-mail: ramin6@[Link]; bshafiq2@[Link]
E. A. Hasenboehler
Department of Orthopaedic Surgery, Adult Trauma Service,
The Johns Hopkins Medical Institution, Baltimore, MD, USA
e-mail: ehasenb1@[Link]

© Springer Nature Switzerland AG 2021 135

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
136 R. M. Amin et al.

PTOA figures will increase [4]. As such, an understanding of the disease and treat-
ment options currently available is a key component of the treating musculoskeletal
practitioners skill set.

Pathophysiology of Failure

Though traumatic osteoarthritis is thought of as a long-term consequence after

proximal femur fracture, it begins immediately after injury. The amount of chon-
dral damage occurring during this time period is difficult to quantify and is due to
a number of factors including acute inflammation, pressure necrosis, and
direct injury.
Given the significant amount of soft tissue disruption and local hemorrhage, the
postfracture milieu contains a high proportion of chondrotoxic mediators. In the
newly fractured proximal femur, this provides an opportunity for cytokines, matrix
metalloproteinases, interleukins, neutrophils, and reactive oxygen species to cause
articular disruption [5]. Additionally, in fracture patterns where the joint capsule is
not violated, a pressure necrosis phenomenon from fracture hematoma may acceler-
ate chondrocyte apoptosis. This has been likened to a “compartment syndrome of
the hip.” As such, there may be a theoretical benefit to early direct capsular decom-
pression in proximal femur fractures to mitigate not only avascular osteonecrosis
but also articular pressure necrosis. However, the general evidence-based consensus
is equivocal regarding the utility of this surgical option in the prevention of osteone-
crosis [6].
Perhaps the most acute causative factor in PTOA is the direct chondral damage
resulting at the time of injury (Fig.  9.1). This is particularly true in high-energy
proximal femur fractures, which are usually seen in younger patients [6]. These
cells are subject to matrix damage, disruption of the collagen fibrils, and potentially
full thickness articular damage depending on the loading rate and force [7]. Factors
predicting worse instantaneous cartilage injury include fracture mechanisms that
have simultaneous compression and shear forces such as Pipkin IV fracture disloca-
tions (Table 9.1), and prolonged increases in both load borne by the articular surface
and duration of the increased load [7].
With repetitive loading, joint instability and incongruity exacerbate the acute
chondral compromise in the form of increasingly symptomatic PTOA. Within the
proximal femur, the factors particularly involved include vascular insufficiency,
which commonly precedes joint incongruity, while abnormal joint reactive forces
via planar malalignment increase instability and contact pressures. The resultant
lack of bony subchondral support diminishes the stress-sharing capacity of underly-
ing trabeculae. As such, increased stresses are seen by the overlying articular sur-
face making it prone to thinning and early arthrosis [7].
9  Post-traumatic Arthritis of the Proximal Femur 137

a b

Fig. 9.1 (a) Radiograph demonstrating Pipkin IV fracture dislocation in a 48-year-old patient. (b)
3-D reconstruction CT image depicting substantial femoral head collapse. (c) Intraoperative image
of excised femoral head with split-depression fracture. (d) Treatment with index total hip arthro-
plasty (THA)

Table 9.1  Pipkin classification Type Fracture pattern

I Infrafoveal
II Suprafoveal extension
III Type I or II with associated femoral
neck fracture
IV Type I or II with associated acetabular
fracture
138 R. M. Amin et al.

Fracture Specifics

Hip Dislocation

Though the articular surface in isolated femoral head fractures experiences substan-
tial shear forces, prompt reduction generally results in minimal long-term conse-
quences. In isolated dislocations without hip fracture, prompt reduction results in
excellent long-term clinical outcomes [8]. At 11-year follow-up, six of seven
patients with isolated dislocations had good to excellent Thompson and Epstein
objective outcome scores and only one patient had mild pain with cystic changes on
radiograph. Therefore, the poor functional outcome in 53% of posterior dislocations
and 25% of anterior dislocations seen in this study were attributed to other injuries
associated with the dislocation as rates of good to excellent subjective clinical out-
comes are 85–100% in isolated hip dislocations [8].

Femoral Head Fracture

PTOA following femoral head fracture results primarily from direct chondral injury.
In the long term, failure following femoral head fractures results from avascular
necrosis, which is apparent in 10% of patients at 12  months postinjury [9].
Additionally at a mean of 12 months postoperatively, Scolaro et al. demonstrated
12% early fixation failure rate in a population primarily treated with open reduction
internal fixation (53%), fragment excision (25%), and hemiarthroplasty (2%) [9]. At
a mean of 5 years postinjury, PTOA is present in nearly 20% of patients [1]. Factors
predicting worse outcome include nonsurgical management and increasing Pipkin
type (Table 9.1) [1, 9, 10].
Fractures of the femoral head present a relatively difficult treatment challenge as
both exposure and fixation options are limited. Pipkin I fractures may be treated
nonoperatively with open fragment excision or internal fixation [11]. Recently,
internal fixation has been described using an arthroscopic approach though long-­
term outcomes are pending [12]. In large Pipkin I fracture fragments, open reduc-
tion with internal fixation (ORIF) has demonstrated better clinical and radiographic
outcomes as compared to fragment excision [13, 14].
In Pipkin III fractures, Scolaro et al. recommend strong consideration of arthro-
plasty based on 100% failure of ORIF in their study [9]. However, AVN-related
failures have been markedly reduced with the vascular preserving surgical hip dis-
location popularized by Gans [15]. This is particularly true in Pipkin I and II frac-
tures treated with early (<6 hour) surgical hip dislocation – one study with a mean
of 36-month follow-up found 0% rate of osteonecrosis, and 100% union rate [11].
Another study demonstrated 85% excellent clinical outcomes (HHS score >80) uti-
lizing a surgical hip dislocation in all operatively managed Pipkin fractures and 8%
avascular necrosis rate [16].
9  Post-traumatic Arthritis of the Proximal Femur 139

While traditionally reserved for Pipkin I and II fractures, a limited series of

patients with Pipkin IV fractures demonstrated 88% success (no PTOA) with a
modified Gibson approach. This posterior approach allows for increased anterior
acetabular exposure through a modification of the proximal exposure via develop-
ment of the plane between the gluteus maximus and tensor fascia lata rather than the
gluteal splitting seen in the Kocher-Langenbeck approach. However, longer-term
and larger-scale studies are needed to substantiate this approach for all Pipkin IV
fractures [17]. We routinely use a modified Smith-Peterson approach for fixation for
infrafoveal fractures while reserving the surgical hip dislocation of Ganz for supra-
foveal and Pipkin type IV fractures.

Femoral Neck

PTOA in femoral neck fractures is primarily a failure of fixation and vascularity.

The latter complication is particularly elevated in femoral neck fractures given the
intracapsular location and tenuous blood supply to the femoral head. This may be
compromised during the initial fracture or iatrogenically during fixation. As such,
proximal femur fractures with higher displacement are at greatest risk of vascular
injury and resultant long-term avascular necrosis (Fig. 9.2). At 5 years postinjury,
20% of femoral neck fractures repaired with internal fixation will undergo revision
arthroplasty primarily due to avascular necrosis [18].
In elderly patients, fixation failure in the form of nonunion occurs in approxi-
mately 4–5% of stable femoral neck fractures (Garden 1 and 2, Table 9.3) patients
[19, 20]. However, all-cause fixation failure is nearly 12–34.6% in this population
due to avascular necrosis, nonunion, and fixation failure [21–24]. In younger
patients with femoral neck fractures (<60 years old), Slobogean reported a substan-
tially elevated rate of both malunion and nonunion at 7.1 and 9.3%, respectively
[25]. Factors predicting a high likelihood of osteosynthesis failure include subcapi-
tal fracture location, Pauwel type 3 fractures (Table 9.2), Garden III or IV fractures
(Table 9.3), and apex anterior tilt of the femoral head when treated with cancellous
screws [26–28].
Pauwel III fractures provide a particularly difficult treatment challenge. Initial
treatment with cannulated screws demonstrated significantly higher nonunion rates
[29]. Moreover, treatment of this fracture pattern with cancellous screw fixation has
also demonstrated significantly lower cycles to 15  mm shortening compared to
dynamic hip screw or blade plate fixation [30]. This is substantial as recent data
demonstrate femoral neck shortening of ≥10  mm has been implicated in worse
functional outcomes including statistically lower Harris Hip Scores and SF-36
physical component scores [31]. Given the higher shear forces experienced in
Pauwel III fractures, the use of autologous bone grafting at the time of the index
procedure has been tried with good short-term success. In a study of 17 patients
with Pauwel III fractures, 100% healed at a mean of 14.1 weeks, and less than 6%
required arthroplasty at 27-month follow-up [32].
140 R. M. Amin et al.

a b

c d

Fig. 9.2 (a) Nondisplaced femoral neck fracture. (b) Immediate postoperative imaging.
(c) Femoral head collapse 6 months following index procedure. (d) Conversion to hemiarthroplasty

Table 9.2  Pauwel classification Type Fracture angle (degrees)

I <30
II 30–50
III >50

Table 9.3  Garden classification Type Fracture pattern

I Incomplete
II Complete, nondisplaced
III Complete, partially displaced
IV Complete, highly displaced
9  Post-traumatic Arthritis of the Proximal Femur 141

Intertrochanteric

PTOA following intertrochanteric fractures primarily occurs due to fixation failure

(Fig. 9.3). Fortunately, due to substantial vascular supply, soft tissue preservation
with closed reduction techniques, and robust cancellous bone, fixation failure occurs
in only 1–2% of trochanteric fractures treated with intramedullary nailing [33, 34].
Factors predicting increased nonunion rate are the essential components of “unsta-
ble” trochanteric fractures including reverse obliquity, subtrochanteric extension,
lateral wall comminution, and loss of medial calcar support [35–37]. However, the
most important factor predicting PTOA via uneven joint force distribution is mal-
reduction [33, 38]. Alteration of greater than 5 degrees of varus in the coronal plane,

a b

d
c

Fig. 9.3 (a) Minimally displaced intertrochanteric fracture. (b) Immediate postoperative radio-
graphs. (c) Varus failure 6 months after index procedure. (d) Valgus intertrochanteric osteotomy
with revision open reduction internal fixation
142 R. M. Amin et al.

10 degrees in the sagittal plane, and 15 degrees in the axial plane focuses load on the
superior femoral head, leading to arthrosis [33, 38].
Additionally, cut-out is of particular concern in trochanteric fractures (Fig. 9.4).
It is estimated to occur in approximately 2% of patients treated with intramedullary
nailing [39, 40]. Factors predicting cut-out including nonanatomic reduction, sub-
optimal bone quality, and tip-apex distance greater than 25 mm [39–41].

a b

c d

Fig. 9.4 (a, b) AP and lateral radiographs of left hip demonstrating cut out of cephalomedullary
device. (c, d) One year following removal of hardware and conversion to THA
9  Post-traumatic Arthritis of the Proximal Femur 143

Management

The most definitive management for PTOA of the femoral head is hemi-, or total
(THA), hip arthroplasty. These surgeries are supported by strong data demonstrat-
ing excellent outcomes, which have led some to opine that prevention of PTOA in
patients with prefracture arthrosis should be accomplished with arthroplasty in ame-
nable proximal femur fractures (7). However, arthroplasty in the setting of fracture
is still associated with inherent risk over internal fixation including higher rates of
wound infection, transfusion, and in-hospital morbidity. Additionally, due to limita-
tions in prosthetic longevity, physiologically younger patients may be better served
with osteosynthesis of native bone which may delay arthroplasty on average by
74  months [42]. Also, consideration of nonoperative and less invasive operative
options are necessary in femoral head PTOA.

Nonoperative

There is a limited role for nonoperative management at the index injury time. This
is usually reserved for critically ill patients. However, some Pipkin I fractures are
amenable to initial nonoperative management but this option is usually not recom-
mended as the rate of PTOA in nonoperatively managed Pipkin 1 fractures is 10%
higher compared to operatively treated patients [10].
In the long-term, given that posttraumatic arthritis is a subset of osteoarthritis, it
responds to the same conservative treatment that is well defined for the more com-
mon degenerative osteoarthritis. Antiinflammatory medications of varying potency
and physical therapy are first-line, and often permanent, solutions to arthritic pain.
Targeted intracapsular corticosteroid injections may also be of benefit from both a
diagnostic and therapeutic perspective.

Operative

Arthroscopy

Hip arthroscopy for joint preservation is an increasingly common procedure.

However, as with other joint arthroscopies, there is limited evidence to suggest that
arthroscopic surgery of hip arthrosis provides improved clinical outcomes [43].
Chondral pathology at the time of hip arthroscopy for all indications is associated
with 58-times greater risk for conversion to arthroplasty compared to patients with-
out evidence of chondral damage [44]. Moreover several studies found that 16–44%
of patients with arthrosis at the time of hip arthroscopy progress to THA within a
maximum of 7 years [44–47].
144 R. M. Amin et al.

Table 9.4  Tönnis classification Grade Radiographic changes

0 No evidence of OA
I Sclerosis with minimal joint space
narrowing or osteophytes
II Moderate joint space narrowing with
subchondral cyst formation
III Severe joint space narrowing, subchondral
cysts, deformation of femoral head

In the trauma population hip arthroscopy has more sparse literature. A study
of 36 patients undergoing arthroscopy following closed reduction of hip disloca-
tion found a 92% rate of loose bodies, and 78% rate of loose bodies in patients
with imaging identifying concentric reduction and no loose bodies [48]. However,
no outcome measures were reported in this study [48]. In a recent 2015 study of
13 patients undergoing hip arthroscopy following femoral head dislocation or
acetabular fracture, 3.5-year follow-up demonstrated significant improvement in
VAS scores and Modified Harris Hip Scores [49]. However, only Tönnis grade 0
or 1 (Table 9.4) patients were included in the study, and only 7 of 13 patients
were femoral head dislocation patients. It is unknown how many of these patients
had a concomitant acetabular fracture, which limits application to the proximal
femur PTOA population. In another early study of hip arthroscopy in 38 patients,
the diagnosis of arthritis resulted in an average Harris Hip Score increase of 18
and 14 points in patients with chondral injury, and arthritis, respectively, over a
10-month period [50]. However, the Harris Hip Score in those patients with a
diagnosis of avascular necrosis decreased by 11 over the same time [50]. As
previously mentioned, the etiology of PTOA in proximal femur fractures is
strongly related to avascular necrosis. As such current data is inconclusive and
further study is necessary to determine whether arthroscopy has a role in the
treatment of young patients with severe PTOA following proximal femur
fractures.

Hip Preservation

Management of femoral head chondral defects includes open and arthroscopic

approaches. A number of treatments including chondroplasty, microfracture, fibrin
adhesives, autologous chondrocyte transplantation, and osteochondral autologous
transplants have been described [51, 52]. Microfracture has demonstrated positive
clinical outcomes at 2-years postsurgery in Tönnis grade 0 or 1 patients [53].
However, there is a high rate of conversion to arthroplasty in patients with greater
than Tönnis 1 radiographic changes. Additionally, other data suggests that micro-
fracture does not improve patient reported outcomes at 2  years [54]. Other tech-
niques including periacetabular osteotomy may have a role in the treatment of
PTOA though this is yet to be described in the literature.
9  Post-traumatic Arthritis of the Proximal Femur 145

Osteotomy

Varus malunion is a common mode of failure following treatment of femoral neck

fractures. If left uncorrected, PTOA occurs usually within 1  year of onset. In
younger patients, and those where arthroplasty is relatively contraindicated, a
valgus-­producing osteotomy is a popular method of deformity correction to allow
more even joint force distribution. This osteotomy may be inter- or subtrochanteric
with success rates ranging between 85% and 100% [55]. One study of 60 patients
with nonunited Garden III/IV, and Pauwel II/III, femoral neck fractures demon-
strated 93% radiographic union rates and 90% good or excellent clinical outcomes
after valgus subtrochanteric osteotomy and dynamic hip screw fixation [56].
However, postosteotomy AVN ranges from 10% and 40% although less than 10% of
these patients are eventually converted to THA [55].

Core Decompression

In early-stage osteonecrosis, core decompression is a validated method of improv-

ing patient function and symptoms [57, 58]. In Fairbank’s original study, 88% of
Ficat stage I patients (mild osteopenia on radiograph and focal edema on MRI)
required no further surgery at 11-year follow-up [58]. However, core decompres-
sion does carry the risk of postsurgical fracture and as such should be used with
caution in those who are high fall risk. While the literature regarding core decom-
pression is robust, there remains limited external applicability to the trauma patient
at the present time. Most studies are based on level IV evidence and primarily evalu-
ate for nontraumatic etiologies of femoral head osteonecrosis [58, 59].

Arthroplasty

Arthroplasty for proximal femur fractures is increasingly indicated during the index
fracture. Elderly patients with displaced femoral neck fractures treated with arthro-
plasty have significantly lower complications, reoperation rates, less postoperative
pain, and better overall function when compared to internal fixation [60]. Options
for arthroplasty include THA and hemiarthroplasty. Hemiarthroplasty is commonly
performed in those patients with relatively poorer health status, and risk factors for
recurrent dislocation as the risk of dislocation for THA following fractures is four
times higher than for THA performed due to arthritic indications [61–63] However
prosthetic-induced acetabular wear causes substantial pain, and at 14 months post-
operatively the clinical outcomes for THA are significantly better than hemiarthro-
plasty in properly selected patients [61, 62, 64]. Additionally, hemiarthroplasty
confers no mortality or infection benefit at 4 years postoperatively when compared
to THA, and uncemented prosthesis carries 720% higher chance of 5  year
146 R. M. Amin et al.

periprosthetic fracture when compared to cemented implants [61, 63, 65]. Therefore,
the decision to perform hemiarthroplasty as the index procedure should primarily
factor in poor projected patient longevity and household ambulation status as large
database outcomes trend toward no difference in short-term complications or mor-
tality in hemi- versus total hip arthroplasty [61, 63]. In younger patients aged 40–65,
recent data indicate these patients may have greater clinical benefit and overall more
cost-effective care with index THA (Fig. 9.1) [66].
With respect to painful PTOA, arthroplasty is the most definitive treatment
option. Nearly 50% of patients with femoral head injury or acetabular impaction
will require future arthroplasty [67]. The results of THA in patients with PTOA of
the hip following acetabular or proximal femur fractures are inferior compared to
primary degenerative OA. In one study of 1199 patients, 63 had THA for PTOA. They
fared worse with respect to perioperative complications and demonstrated 13%
revision rate due to persistent dislocation or infection at an average of 3.5  years
postoperatively [42]. When compared to primary THA, patients undergoing THA
conversion due to failed fixation of femoral neck fractures also have greater compli-
cations including deep infection, dislocation, and periprosthetic fracture [68].
However, 1 year functional outcomes were not substantially different [68].
As mentioned above, failure of fixation in intertrochanteric fractures increases
superior femoral head arthrosis via coxa vara. Arthroplasty is a salvage option for
the treatment of PTOA in this population as well. Compared to intertrochanteric
fractures undergoing primary arthroplasty due to fracture complexity or poor bone
quality, conversion arthroplasty resulted in significantly higher blood loss, operative
time, and risk of postoperative periprosthetic fracture. However, 1 year mortality
rates were not significantly different [69].

Hip Arthrodesis

Due to the above failure rate, and prospect of multiple revisions in young patients,
alternatives to arthroplasty including arthrodesis have been employed. Patients con-
sidered for this procedure include those with monoarticular disease, high functional
demand, and absence of lumbar or ipsilateral knee pathology [70]. Arthrodesis
allows for preservation of bone stock and gluteal musculature and affords the patient
satisfactory clinical outcomes while awaiting arthroplasty at a more age-appropriate
time [70]. While no studies are available specifically addressing postfracture
arthrodesis conversion to arthroplasty, one recent study evaluated 18 patients under-
going the aforementioned procedure. Eight of the 18 patients initially had arthrod-
esis for fracture. Patients undergoing conversion of previous arthrodesis to THA
have substantial clinical improvement but also have increased incidence of neuro-
logic injury and heterotopic ossification and tend to require use of ambulatory aids
over long distances [71].
9  Post-traumatic Arthritis of the Proximal Femur 147

Conclusion

PTOA is a common sequelae following proximal femur injury. Initial forces result
in chondral injury that is exacerbated by chronic changes in underlying bony sup-
port, which increases chondral contact pressures. Fortunately, advances in vascular-­
preserving approaches and an emphasis on prompt treatment of proximal femur
fractures have improved long-term outcomes following these injuries. Given the
number of treatment options with strong outcomes in the literature, the optimal
treatment of symptomatic proximal femur PTOA is patient specific and ranges from
osteotomy to arthroplasty to arthrodesis. With data demonstrating increasingly
robust outcomes in PTOA hip arthroscopy, this surgical technique remains on the
forefront of new treatment options and will continue to have an expanding role in
the diagnosis and treatment of proximal femur PTOA.

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9  Post-traumatic Arthritis of the Proximal Femur 151

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Chapter 10
Post-traumatic Arthritis of the Distal
Femur

Karthikeyan Ponnusamy and Ajit Deshmukh

Key Points
• Distal femoral fracture nonunions are associated with a high burden of
posttraumatic arthritis.
• Surgical options include osteoarticular autograft and allograft, realignment
osteotomies, and unicompartmental or total knee arthroplasty.
• It is critical to restore the joint line in the treatment of posttraumatic arthri-
tis of the knee.
• Higher levels of constraint may be necessary in TKA for posttraumatic
arthritis.

Epidemiology

Adults sustain distal femur fractures at a rate of 4.5/100,000. Most of these fractures
occur in female patients (67% vs. 33% in males) [1]. The two predominant age
groups presenting with this injury are young adults who are involved in high-energy
mechanisms and elderly who are involved in low-energy falls.
As with any periarticular fracture there are concerns that a combination of initial
trauma to the articular cartilage and residual articular step-off or malalignment can
accelerate the development of arthritic changes in the joint. One systematic review
examined the impact of articular step-off for various joints. When they looked at
studies for the distal femur, they only identified rabbit models that demonstrated

K. Ponnusamy
Pinnacle Orthopaedics, Canton, GA, USA
A. Deshmukh (*)
Department of Orthopaedic Surgery, New York University, New York, NY, USA
e-mail: [Link]@[Link]

© Springer Nature Switzerland AG 2021 153

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
154 K. Ponnusamy and A. Deshmukh

that as long as the step-off was smaller than the thickness of the articular cartilage,
there was sufficient remodeling. However, in cases of step-off greater than the thick-
ness of the articular cartilage and knee instability there could be rapid articular
degeneration [2]. Another consideration is that residual malalignment from femoral
malunion can alter joint loading and lead to degenerative changes. Kettelkamp et al.
examined the significance of knee malalignment following fracture malunion and
reported that degenerative knee changes developed at a range of 10–60 years after
the fracture with an average of 31.7 years [3].
There are only a limited number of trials with sufficient follow-up to ascertain the
clinical impact of posttraumatic arthritis from distal femoral fractures. One study by
Rademakers et al. reported outcomes at a mean of 14 years (range 5–25 years) and
found radiological evidence of moderate to severe osteoarthritis in 36% of patients,
but 72% of these patients had good to excellent functional outcome scores [4].
Comparable results were reported by Thomson et al. at an average of 80 months
follow-up, where 54% of patients had significant degenerative changes in the knee
and 32% had no radiographic arthritic changes. None of these patients had under-
gone a total knee arthroplasty by the last follow-up [5]. To summarize, patients who
have sustained a distal femoral fracture are at risk of developing radiological find-
ings of arthritic changes, but clinical follow-up to 14 years afterward suggests almost
three quarters of patients are not impaired by these findings. However, there remain
a quarter of patients with radiological findings of posttraumatic arthritis that have
more severe symptoms. Further follow-up is needed to determine if and when the
previously asymptomatic patients with arthritic changes will become symptomatic.

Natural History of Distal Femur Fracture Healing

Most cases of distal femur fractures are treated surgically with the following
implants as possible options: blade plates, locking plates, condylar screws, and ret-
rograde intramedullary nails [6]. Current first-line management usually focuses on
locking plates and retrograde intramedullary nails. In patients with significant medi-
cal comorbidities and limited ambulatory status, nonoperative options of functional
bracing or casting can be considered.
Surgical treatment of distal femur fractures is usually successful, but the non-
union rate is reported to be 10%. Nonunions have been most commonly associated
with open fractures, comminution, bone loss, and infection. Monroy et al. compared
the results of revision ORIF for distal femur nonunions vs. ORIF for acute distal
femur fractures and found that there was statistically no difference in time to union
(mean of 7 months for nonunions vs. 5 months for acute fractures) and no statistical
difference in range of motion and clinical outcome scores [7]. Ebraheim et al. in
their systematic review on the subject of nonunions in distal femur fractures also
found that open fractures and bone loss were the most common factors, followed by
hardware failure and infection. After revision fixation of nonunions, 97% healed at
an average of 9.86  months. They found that metaphyseal comminution was the
10  Post-traumatic Arthritis of the Distal Femur 155

fracture pattern most associated with nonunion. When the initial fixation utilized
dynamic condylar screws and blade plates, there was a higher likelihood of non-
union than with locking plates. The most common fixation used for revisions was
fixed angle platting with cancellous bone autograft, and this approach was success-
ful in achieving union for 97.4% of patients at an average time of 7.8 months [6].

Patient Evaluation

Despite the generally successful results of the management of distal femur frac-
tures, there will continue to be a subset of patients who will continue to have knee
pain due to nonunion, posttraumatic arthritis, knee instability, or other etiologies. As
with any patient, evaluation needs to begin with the history. Key aspects of the his-
tory that need to be determined is history regarding the treatment and outcomes
from initial distal femur fracture management and time course of symptoms since
then. Any aspects suggestive of infection must be highlighted, such as requiring
antibiotics in the postoperative period, prolonged wound drainage, and repeat sur-
geries. Prior operative reports should be obtained if possible to identify the implant
and facilitate the removal of the implant if warranted. The physical exam should
focus on locating the prior surgical incisions, knee range of motion and ligamentous
stability, and patellar tracking. Imaging should begin with standing AP radiograph,
PA flexed, lateral, and sunrise views. Advanced cross-sectional imaging can be con-
sidered in cases of nonunion with CTs or localized articular injuries or ligamentous
damage with MRIs. Prior hardware may affect the quality of the cross-sectional
imaging, and specific metal suppression techniques should be considered.

Nonoperative Management of Posttraumatic Arthritis

Nonoperative management for posttraumatic arthritis includes the same treatment

modalities as with osteoarthritis. McAlindon et al. conducted a systematic review of
29 treatment modalities to determine whether they should be utilized in nonopera-
tive treatment of knee osteoarthritis. They reported that there was evidence support-
ing the use of intraarticular steroid injections, physical therapy and exercise, weight
loss, acetaminophen, assistive walking devices, and oral or topical NSAIDs [8].

Operative Management of Posttraumatic Arthritis

Surgical options include osteoarticular autograft and allograft, realignment oste-

otomies, and unicompartmental or total knee arthroplasty (TKA) [9]. In cases of
young and active patients with localized articular cartilage defects, osteochondral
156 K. Ponnusamy and A. Deshmukh

autograft or allografts can be considered. Gross et al. have published on the use of
osteochondral allografts for both the distal femur and proximal tibia [10]. Their
distal femur allograft survival rate was 95% at 5 years and 85% at 10 years. With
an average of 10-year follow-up, they had 9 of 60 undergo subsequent total knee
arthroplasty [10]. As reported by Kettelkamp et al., [3] malalignment after femo-
ral fractures can lead to degenerative arthritic changes in the knee at an average of
30 years after initial injury. Consequently, realignment osteotomies can be a use-
ful tool when managing a young patient with knee pain subsequent to malunited
distal femoral fracture. Lustig et al. reported their experience of treating posttrau-
matic knee arthritis with osteotomy alone (femur, tibia, or both). They found that
with an average of 3.8 years of follow-up, two of six patients with an intraarticu-
lar malunion went on to a total knee arthroplasty. Whereas, the 22 patients who
had an extraarticular malunion did not have an arthroplasty during the time of
follow-up. In addition, they found that, in general, patients had improvements in
pain scores, but those with extraarticular malunion had the greatest improve-
ment [2, 3].
For end stage posttraumatic arthritis, the treatment of choice would be
TKA.  However, for patients who undergo TKA for posttraumatic arthritis, it has
been reported that they have higher complication rates than primary TKA for osteo-
arthritis. They have a higher risk for revision surgery with a hazard ratio of 2.23 (CI
95% 1.69–2.88) and postoperative infection of 2.85 (1.97–3.98) [11]. These cases
are technically more demanding, but patients can have good outcomes if appropri-
ate limb alignment and implant positioning are achieved [12].

 rimary Arthroplasty for Elderly Patients with Acute

P
Comminuted Distal Femur Fractures

In the elderly and frail patient population, the 1-year mortality rate has been reported
to be 22% after sustaining a supracondylar femur fracture. This older study went on
to further report that 9% of patients needed an above-knee amputation at a later time
point due to loss of fracture reduction and/or infection [13]. Due to this suboptimal
outcome, over the last couple decades several case series on the use of primary TKA
or distal femoral replacement for distal femur fractures have been published. The
goal was that an immediate arthroplasty would allow immediate weight bearing and
allow patients to regain mobility faster with the theory that they will have fewer
complications.
One case series did not demonstrate any improvement in mortality rate and
reported a 1-year mortality rate of 30%. They did find a revision rate of 9.5% which
is better than reports of complication rates up to 25% for primary TKA for post-
traumatic osteoarthritis [14].
10  Post-traumatic Arthritis of the Distal Femur 157

Malviya et al. examined the use of acute primary TKA for periarticular distal
femur and proximal tibia fractures. They reported that 10 of the 11 distal femur
fractures were treated with a rotating hinge, and one was treated with a varus/valgus
constrained implant and that they had good clinical outcomes in their case series
[15]. Bettin et al. reported on 18 patients who had sustained comminuted intraar-
ticular, osteoporotic, arthritic fractures and were treated with cemented distal femo-
ral replacements. They had two patients who had complications with their implants
(one periprosthetic fracture and one deep infection). They reported that the patients
in their series were extremely or very satisfied with their outcomes but did not have
a comparison arm [16]. Rosen and Strauss reported their use of distal femur replace-
ments in a case series of 24 patients for distal femur fractures and found 71%
returned to their preoperative ambulation level [17].
As of now only one retrospective comparative study of ORIF with distal femur
replacement has been reported by Hart et al. They found that at 1-year follow-up all
the distal femur replacement patients were ambulating while 25% of the ORIF
patients were wheelchair bound, but this was not statistically significant. They
found comparable reoperation rates of 10% in the distal femur replacement group
and 11% in the ORIF group. The ORIF group had fractures healed at an average of
24 weeks but had a nonunion incidence of 18% [18]. Due to the relative rarity of
converting a distal femur ORIF to TKA, Bohm et al. suggested that ORIF should be
used in most acute fracture cases. However, for specific patient populations with
prior arthritis, not compliant with weight-bearing restrictions, and very comminuted
fractures, a primary arthroplasty could be considered [19].
One of the surgical considerations for treating acute fractures is that higher levels
of constraint such as a rotating hinge prosthesis may be necessary since there is a
higher likelihood that the collateral ligaments are compromised by the fracture. In
order to determine the joint line in a highly comminuted fracture, one method that
can be used in acute fractures is obtaining a temporary reduction with the use of an
external fixator or other methods. Alternatively, the joint line can be determined
relative to anatomic landmarks such as 1 cm proximal to the fibular head or 2.5 cm
distal to the femoral epicondyles (based on their reduced position). Sizing the femur
in an acute fracture may be difficult, and estimates based on the trials may be
needed. In addition, depending on the level of bone loss/comminution, augments,
wedges, sleeves, or cones may be needed [20].
When acute fractures with severe comminution of the condyles are treated with
arthroplasty, then a distal femoral replacement may be needed. Some of the techni-
cal challenges are to determine the length and rotation of the femur. This can be
accomplished by obtaining provisional reduction with traction and from there the
rotation can be determined based on the transepicondylar axis. Another consider-
ation is whether to press-fit or cement the stem. Given the likely poor bone quality,
the stem will likely need to be cemented [19]. Arthroplasty can be more challenging
in these cases but focusing on proper alignment, positioning, and fixation can lead
to good patient outcomes.
158 K. Ponnusamy and A. Deshmukh

 urgical Considerations at Arthroplasty

S
for Posttraumatic Arthritis

When comparing posttraumatic arthritis to osteoarthritis for the etiology for TKA,
it has been reported that TKA takes about 30 minutes longer in the posttraumatic
case [21]. Extensor mechanism issues are a common source of difficulty in per-
forming these procedures. Lateral release was needed in 47% of TKAs reported by
Weiss et  al. [12] and 46% for Papadopoulos et  al. [22]. Other techniques that
needed to be used were quadriceps V-Y turndown, vastus medialis advancement,
LCL transfer, extensor mechanism realignment, and collateral ligament recon-
struction [12, 22].
One of the first considerations for performing a total knee arthroplasty is deter-
mining the level of constraint needed. The next step is determining the joint line and
component rotation. If the fracture has healed in appropriate alignment and rotation,
then standard techniques can be used. However, in cases of deformity or retained
hardware that would prevent or severely complicate intramedullary alignment,
patient-specific instrumentation, imageless hand-held navigation devices, or com-
puter navigation can be very helpful to establish the alignment.
For larger bony defects, structural allograft or metal augments can be used. Prior
hardware and whether it will interfere with the procedure needs to be considered,
and the prior hardware can be appropriately removed or retained [12].
Limb alignment needs to be evaluated and malalignment needs to be corrected
with intraarticular resections for an arthroplasty or staged/simultaneous osteot-
omy. If intraarticular resections would compromise the collateral ligaments in
order to obtain the necessary alignment correction, a distal femoral osteotomy
can be secured with a long-stem femoral component or staged with a plate and
screw construct. Bone graft can be placed at osteotomy and nonunion sites [12].
Papadopoulos et al. reported a case series of 48 TKA after distal femoral frac-
tures and found malunions greater than 10 degrees in the coronal plane or 15
degrees in the sagittal plane in 21 knees (44%). Of these with malunions, they
were able to correct 15 through intraarticular bony resections and 6 needed oste-
otomies [22].

Case Example of Staged Osteotomy

A 53-year-old male with a history of a supracondylar left femur fracture treated

nonoperatively 35 years ago presented to the clinic with symptomatic left knee pain
(Fig. 10.1).
10  Post-traumatic Arthritis of the Distal Femur 159

a b

Fig. 10.1 (a–c) Preoperative lower extremity alignment and AP/lateral distal femur

Options to address the deformity would be to perform an intraarticular correction

with a TKA or an extraarticular correction with TKA. In the case of the extraarticu-
lar correction, the osteotomy could be performed in staged or simultaneous settings.
In this case, templating for an intraarticular resection demonstrates that there would
be a risk of compromising the MCL origin (Fig. 10.2). Consequently, it was decided
to perform an extraarticular correction of the deformity, and it was done in a staged
setting.
For this patient a lateral opening wedge osteotomy of the distal femur was
planned and performed (Figs. 10.3 and 10.4).
Five months after surgery the osteotomy site had healed (Fig. 10.5).
160 K. Ponnusamy and A. Deshmukh

Fig. 10.2  Templating for

intraarticular resection

a b

Fig. 10.3 (a) Intraoperative fluoroscopy picture after the osteotomy was performed; (b) change in
alignment after insertion of the bone graft wedge with provisional fixation
10  Post-traumatic Arthritis of the Distal Femur 161

Fig. 10.4 Postoperative
picture of the patient’s
lower extremity

a b

Fig. 10.5 (a, b) AP and lateral X-rays at 5 months after healing of osteotomy

162 K. Ponnusamy and A. Deshmukh

 ase Example of Intraarticular Correction

C
of Deformity and TKA

A 60-year-old male with history of a nonoperatively managed femur 45 years ago

presents with advanced arthritic changes of his knee and instability of his knee
(Figs. 10.6 and 10.7).
Preoperative templating plans for planned resections demonstrated that the cor-
rection could be obtained through intraarticular osteotomies with the TKA
(Fig. 10.8).
For this patient, given the malunion in his femur, a long intramedullary femoral
alignment rod could not be used and instead a short rod was used. A 3-degree valgus
distal femoral cut was performed as templated. Next the tibial cut was performed
with intramedullary referencing and then extension space balancing was performed.
Preoperatively there was concern that the MCL was incompetent, and the surgeons
were prepared to perform a rotating hinge total knee arthroplasty. Intraoperative
evaluation determined that the MCL was still intact and as a result extension space
balancing was performed. After release of the posterolateral capsule and pie-­
crusting of the IT band and LCL, the gaps were within 3–4  mm of each other.

Fig. 10.6  Clinical picture

of the deformity
10  Post-traumatic Arthritis of the Distal Femur 163

Fig. 10.7 (a, b) AP and lateral of his knee demonstrating the extraarticular deformity with
advanced osteoarthritis and significant coronal plane malunion
164 K. Ponnusamy and A. Deshmukh

Fig. 10.8 Preoperative
templating for
intraarticular correction of
deformity

Femoral rotation was determined by flexing the knee to 90 degrees and aligning the
femoral cutting block with the tibial cut. Preoperative templating determined that a
100 mm sleeve-stem length could be used on the femoral side without reaching the
site of malunion. A varus-valgus constrained implant was used, and a stable knee
was achieved with good patellar tracking (Figs. 10.9 and 10.10).
10  Post-traumatic Arthritis of the Distal Femur 165

Fig. 10.9  Clinical picture

of leg after surgery

a b

Fig. 10.10  Postoperative AP and lateral X-rays

166 K. Ponnusamy and A. Deshmukh

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for posttraumatic knee defects. Clin Orthop Relat Res. 2005;435:79–87.
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tis. J Arthroplast. 2016;31:118–23.
12. Weiss NG, Parvizi J, Hanssen AD, Trousdale RT, Lewallen DG.  Total knee arthroplasty in
post-traumatic arthrosis of the knee. J Arthroplast. 2003;18:23–6.
13. Karpman RR, Del Mar NB. Supracondylar femoral fractures in the frail elderly. Fractures in
need of treatment. Clin Orthop Relat Res. 1995;316:21–4.
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arthroplasty for acute knee joint fracture maintain autonomy in the elderly? A retrospective
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Chapter 11
Post-traumatic Arthritis of the Proximal
Tibia

Stefanie Hirsiger, Lukas Clerc, and Hermes H. Miozzari

Key Points
• Although tibial plateau fractures are not rare, symptomatic posttraumatic
osteoarthritis is rather infrequent.
• Stepwise treatment algorithms should be followed, starting with activity
modification, weight loss and physiotherapy, followed by analgesic
medication.
• Existing literature concerning operative treatment options for posttrau-
matic osteoarthritis is mainly limited to small case series with little
evidence.
• Corrective osteotomies should be evaluated; if degenerative lesions are too
advanced, unicondylar or total knee replacement can ameliorate function.

Introduction

Posttraumatic osteoarthritis (OA) occurring after tibial plateau fractures is more

rarely encountered than primary OA. The overall disease burden of posttraumatic
OA is estimated to be 12% of all symptomatic OA of the hip, knee, and ankle [1]
with 1.2% incidence in the proximal tibia [2]. The last is mostly seen during the fifth
decade and secondary to fall from heights or motor vehicle accidents [3]. The com-
plexity of the fracture correlates to the bone quality and the mechanism of injury.

S. Hirsiger · L. Clerc · H. H. Miozzari (*)

Division of Orthopaedic and Traumatology, Department of Surgery, Geneva University
Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
e-mail: [Link]@[Link]; [Link]@[Link]

© Springer Nature Switzerland AG 2021 167

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
168 S. Hirsiger et al.

Despite several classification systems being available, such as Schatzker [4] or

the AO [5], which are based on bony and intraarticular landmarks, none of them are
complete or have a direct implication on the surgical treatment. Most tibial plateau
fractures are treated operatively. There is only sparse literature defining clear crite-
ria for the indication of surgical treatment. According to older literature, every
medial unicondylar fracture (with any displacement) and every medially tilted
bicondylar fracture should be operated as well as lateral plateau fractures with a
lateral tilt or valgus malalignment exceeding 5°, a displacement with condylar wid-
ening of more than 5  mm, and step-offs greater than 3  mm [6]. A recent review
found no consensus about the acceptance for any residual articular step-offs after
reduction, but in comparison to other joints they seem relatively well tolerated [7].
Posterior fractures, present in about 29% of all Schatzker fracture types [8], are
often missed with conventional radiographs; thus CT imaging is recommended for
surgical planning [9]. More recently, a three-column concept for classification and
fixation has been proposed [10]. The medial, lateral, and posterior columns are eval-
uated for intra- and extraarticular cortical disruption on 2D and 3D reconstructed
CT images. In this updated concept the mechanism of injury is considered and eval-
uated by analyzing the position of the knee and the direction of the deforming forces
at the time of injury: by defining the key articular surface, both the articular approach
and hardware to be used can be planned before surgery [11]. The incidence of con-
comitant soft-tissue injuries has been found to be almost 100% when interpreting
acute knee MRI [12]. Meniscal injuries are seen most frequently, followed closely
by cruciate- or collateral ligament ruptures but also predating injuries such as
asymptomatic meniscal changes with diffuse edema [12]. Unrecognized, chronic
ligamentous instability without associate fracture is a major issue that can lead to
symptomatic knee OA (Fig. 11.1) [13]. Further, untreated anterior ligament rupture
shows associated secondary meniscal ruptures of up to 100% at 10  years [14].
Although there is no hard evidence that the surgical treatment of ligamentous insta-
bility can prevent developing symptomatic OA [15], meniscal and ligamentous inju-
ries can lead to instability and persisting pain [16]. They should, therefore, be
diagnosed and addressed during osteosynthesis, and an arthroscopically assisted
approach might be helpful in these cases [17].
Injured soft tissues along with open wounds can lead to discontinuity of the cuta-
neous barrier, resulting in soft tissue infections and/or compartment syndrome.
Thus, not only the bony and intraarticular damage but also the surrounding soft tis-
sue status should be considered for surgical planning [18]. The optimal treatment of
such complex injuries must be individualized, taking into account patients’ factors,
such as comorbidities, activity level, bone quality, and the presence of predating
OA.  Surgical options range from conservative treatment to closed/open fracture
reduction with either internal or external fixation, or even primary prosthetic
replacement in selected cases [19, 20].
Long-term outcomes after tibial plateau fractures are associated with the devel-
opment of secondary OA. The initial injury and the extent of bony, cartilaginous and
soft tissue destruction are crucial to determine the risk of future OA [21]. Indeed,
the incidence of OA rises with the complexity of the fracture [22] and is further
11  Post-traumatic Arthritis of the Proximal Tibia 169

increased by secondary posttraumatic changes such as an altered limb axis, axis

load distribution, or ligamentous instability [23, 24]. Smoking is an independent
risk factor for a secondary conversion to a joint replacement procedure [25]. As of
today, there is still no consensus in the literature of what is considered an acceptable
residual postoperative deformity. However, a persistent postoperative valgus
malalignment >5° and articular step-off of more than 2 mm have been shown to be
risk factors for early OA and poor outcomes in older patients [23, 26] with degen-
erative changes appearing between 2 and 11 years after trauma (mean 7 years) and
an incidence of posttraumatic OA, based on radiographies, reported between 25%
and 45% [27]. Nevertheless, in retrospective analyses, the rate of symptomatic OA
ranges only from 2% to 7.5% [24, 25, 28] with major reconstructive surgery needed
in 4–7% at 10 years follow-up [27].
Recent developments in imaging allow the quantitative and qualitative evalua-
tion of posttraumatic cartilage defects [29]. Genetic and environmental factors also
play an important role in the development of posttraumatic OA [13].

Fig. 11.1  60-year-old patient who sustained a stairway fall with concomitant ACL/PCL/MCL
rupture and a nondisplaced fracture of the medial compartment (tibia and femur condyle). The
patient presented after 5  months at our office; standard X-rays show a secondary OA mostly
involving the medial compartment with joint space narrowing and bone loss, along with ACL and
PCL laxity. (a) Initial MRI sagittal image: anterior and posterior cruciate rupture visible. (b) Long
axes (b1) and knee anterior-posterior (b2) after 5  months showing subluxation and OA of the
medial compartment with beginning tibial bone loss. (c) Stress X-rays: (c1) anterior and posterior
drawer and (c2) varus and valgus stress. (d) Postop X-rays after a primary PS TKA anteroposterior
(d1) and lateral (d2). The MCL and LCL were intact
170 S. Hirsiger et al.

b1 b2

c1

Fig. 11.1 (continued)
11  Post-traumatic Arthritis of the Proximal Tibia 171

c2

d1 d2

Fig. 11.1 (continued)
172 S. Hirsiger et al.

Conservative Treatment for Posttraumatic OA

A stepwise medical treatment is paramount in symptomatic knee OA, regardless of

its origin. Recently, a consensus statement on the algorithm of the European Society
for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) has
been published [30]. Paracetamol (Acetaminophen), despite its minimal efficacy for
OA symptoms, is still largely used due to its low cost and presumed safety, but, with
higher dosage (>3 g/day), there is evidence of increased risk of upper gastrointesti-
nal events, severe liver damage, loss of renal function, and increase in hypertension
[30]. NSAIDs appear to be more effective, but comorbidities and risk of adverse
effects have to be taken into account [31]. Topical NSAIDs seem to have an equiva-
lent effect to oral NSAIDs for knee pain with fewer adverse events and 40% less
need for concomitant oral administration. Therefore, they may be preferred for geri-
atric patients, patients at increased risk for gastrointestinal bleed, and those with
cardiovascular or renal problems [30]. If NSAIDs are contraindicated, tramadol can
be used to provide pain relief [32]. Despite weak evidence, chondroitin sulfate can
lead to clinical improvement [33], and short-time beneficial effects of several weeks
to months can be obtained with intraarticular infiltrations with corticosteroids [34].
Though widely used, intraarticular viscosupplementation does not provide suffi-
cient evidence for benefit, and it is not recommended by the international osteoar-
thritis research society (IOARS) [35]. The interest in biologic treatment such as
intraarticular platelet-rich plasma and mesenchymal stem cells (bone marrow-, adi-
pose-, and amnion-derived) is growing, but a recent review of the published litera-
ture highlights the necessity for larger studies with a higher level of evidence and
more standardized protocols [36]. The role of physiotherapy is still debated [37, 38]
but seems to be moderately effective for improved function and, with some reserva-
tion, for pain [39]. Aquatic exercises may as well have small, short-term and clini-
cally relevant effects on pain, disability and quality of life, though with moderate
quality evidence [40]. Adapting activities is important, and there are a number of
recreational activities of moderate intensity recommended for OA patients such as
swimming, cycling, yoga, tai-chi, and walking. The latter, one of the simplest forms
of exercise, has a positive effect on symptomatic knee OA [41], especially when
associated with an intensive diet [42]. The role of running in developing knee OA is
not clear [43], and some authors advocate a potential protective effect [44]. A pro-
spective control study over two decades in middle- to older-aged long-distance run-
ners could not show any evidence of accelerated OA [45]. In patients with painful
OA, on the other hand, high intensity activities such as running, football, Nordic
skiing, water skiing, handball, and basketball should be avoided [44]. Weight reduc-
tion can have a positive effect on pain and reduce disability in obese patients [46].
A recent study showed that high levels of synovial joint leptine may affect joint pain
and might explain the association of pain with female gender and obesity, but the
mechanism is not obvious and the causal relationship has yet to be proven [47].
11  Post-traumatic Arthritis of the Proximal Tibia 173

Surgical Treatment for Posttraumatic OA

If conservative treatment proves insufficient to obtain an acceptable function and

quality of life for the patient, the evaluation of a surgical treatment deems necessary.
No evidence for a beneficial effect was found for arthroscopic procedures and
are, thus, not recommended [48]. Osteotomies can be used in order to diminish load
on the degenerative compartment. Other options include osteochondral allografts
and, as a last resort, partial or total knee arthroplasty (TKA) [25]. Surgery should be
individually adapted; the options will be discussed subsequently.

Osteotomies

Correction osteotomies are a widely used treatment method to address early OA

related to deformities of the leg axis and/or ligamentous instability [49]. This con-
servative technique allows good middle-term outcomes in a majority of patients
delaying the time to total knee arthroplasty but is correlated to a relatively high rate
of complications of up to 31% [50]. Preliminary results and operative technique of
correction of intra- and extraarticular malunion after tibial plateau fractures have
been described in case series [51–53]. The proposed intraarticular osteotomies aim
at restoring joint anatomy and therefore stability, thus potentially slowing OA devel-
opment. Knee OA combined with complex extraarticular deformities can be
addressed by osteotomy and gradual computer-guided correction with a multiplanar
external fixator such as the hexapod [54] (Fig. 11.2).

Osteochondral Allografts

Osteochondral allografts (OCA) could be a valuable alternative to prolong the

prosthesis-­free lifetime by preserving the joint. The survival of TKA is limited,
indeed, especially in young and active patients, with a significantly higher fail-
ure within the first 2 years after implantation in the posttraumatic setting [55].
Still, reports about OCA to treat posttraumatic tibial OA remain sparse, showing
good outcomes in active patients [56] and a clear improvement of postoperative
function, which is also superior to microfracturing [57]. Kaplan-Meier survivor-
ship analysis showed that the survival rate was 95% at 5 years, 80% at 10 years,
65% at 15 years, and 46% at 20 years [58]. Although almost half of the patient
needed a conversion to TKA eventually, the mean time to conversion was
12 years [58].
174 S. Hirsiger et al.

Unicompartmental Knee Arthroplasty

Posttraumatic OA after tibial plateau fractures can be limited to one compartment.

If symptomatic and in the absence of metaphyseal deformity, a correction osteot-
omy should not be considered, unless for a young patient, as it would add to the
existing intraarticular pathology an extra axis deformity between the knee and the
ankle joint line [59]. In this situation, a unicompartmental knee arthroplasty
(UKA) might be considered. Although long-term-survival is lower and, thus, revi-
sion rates are potentially higher in UKA compared with total knee prosthesis
(TKA) [60], faster rehabilitation, better knee kinematics, and lower complication
rate [61] can be advantageous for both relatively young, active patients [62] and
the elderly [63]. Since patients with posttraumatic OA needing surgery tend to be
younger than for primary OA, this point is relevant [64]. The literature addressing
the outcome in posttraumatic OA is sparse. In primary OA, 10 years survival of
95% has been reported for medial UKA [65, 66] and 92% for lateral, diminishing
to 84% at 16 years [67]. Sah and Scott compared the results in a small series for
lateral UKA used in posttraumatic (10 patients) versus primary OA (38 patients)
[64, 68]. The Knee Society knee and function scores (KSS) were significantly
lower in the posttraumatic group, with 74 and 65, respectively, versus 95 and 86 in
the group for primary OA. More recently, Lustig et al. showed better results for a
retrospective series of 13 lateral UKA in the posttraumatic setting, with implant
survivorship of 100% at 5 and 10 years and 80% at 15 years along with function
and pain relief comparable to primary OA with a KSS score of 89 and 87 for func-
tion [64]. We are not aware of studies comparing outcomes of UKA versus TKA
for posttraumatic OA. Intraoperative conversion from a scheduled lateral UKA to
TKA after evaluation of the neighbor compartments was reported in 52% of the
patients [68]. For this reason, the authors advise the use of a medial parapatellar
approach, and patients should be informed of a potential conversion to TKA for
consent. Alternatively, a lateral parapatellar approach can be used and would eas-
ily allow a conversion to TKA.

Total Knee Arthroplasty

In advanced tricompartmental OA, when impairment of knee function and quality

of life are important and conservative measures have failed, TKA can be indicated.
Compared to a normal population, 10 years after tibial plateau fracture, patients are
5.3 times more likely to need a TKA [24]. The need increases with increasing age
(per year over 48), bicondylar fracture pattern, and greater comorbidities [24].
Patients with instability or nonunion of the proximal tibia need TKA earlier than
those with malunions (13.3 and 14 vs. 50 months), with a higher incidence of com-
plications [69], such as wound problems, deep infection, patellar tendon avulsion,
and reduced range of motion [1, 27]. Outcomes are further diminished in the
11  Post-traumatic Arthritis of the Proximal Tibia 175

a1 a2 b

Fig. 11.2  46-year-old patient with a status post three motor vehicle accidents. At age 17 he sus-
tained an open fracture (unknown open grade) of the right femoral diaphysis, treated with trans-
tibial traction. At 18 he had an open fracture of the right tibia and fibula (unknown open grade) also
treated nonoperatively. At the age of 43 he sustained a new open fracture Gustilo II of the right tibia
and fibula, treated with intramedullary nail fixation despite the preexisting malunion. The fracture
healed uneventfully, and the nail was removed after 2 years. The patient presented with worsening
right knee pain 1 year later, corresponding to a symptomatic lateral OA with gait disturbance due
to a complex valgus deformity of the lower right leg (shortening 5 cm, recurvatum 17°, valgus 11°,
tibial slope 15°, external rotation 38°). Decision was made to perform a dual femoral and tibio-­
fibula distraction osteotomy with computer-guided correction using multiplanar external fixator
for the tibia and distraction nail for the femur. (a) Long leg axis showing the different deformities
of the right side ap (a1) and sagittal plane (a2). (b) Long leg axis after corrective femoral osteot-
omy for a preexisting recurvatum malunion of 17°. A tibial osteotomy was made thereafter without
complete correction of the deformity. (c) Status post removal of hardware, femur ap (c1) and lat-
eral views (c2), tibia ap (c3), and lateral (c4) (d) Long leg axis (EOS) at 4 weeks after femoral
osteotomy (deflexion, slight varisation, and lengthening) with retrograde expandable nail, and
tibia/fibula osteotomy (varisation and translation and slight lengthening) and fixation with hexa-
pod. (e) Long leg axis (EOS) after removal of the hexapod at 3.5 months, ap (e1) and lateral (e2)
views. The whole axis has a slight residual valgus, the tibia has healed, and the callotaxis after
femoral osteotomy is partially consolidated. (f) Long leg axis after healing of the femoral callo-
taxis before nail removal. The patient is still suffering from lateral OA but correction of the axis
did improve the situation and arthroplasty has been delayed
176 S. Hirsiger et al.

c1 c2

c3 c4 d

Fig. 11.2 (continued)
11  Post-traumatic Arthritis of the Proximal Tibia 177

e1 e2 f

Fig. 11.2 (continued)

presence of combined secondary tibial and femoral deformities or soft tissue com-
promise [70], resulting in technically more demanding surgeries with extended
operative time [71], increased length of stay, and 30-day readmission [72]. Abdel
et  al. reported a high rate of complications in TKA for posttraumatic OA (34%)
compared to primary OA, 90% occurring within the first 2 years [73]. Houdek et al.,
in a larger retrospective cohort from the same institution, reported an overall
revision-­free survival of 78% at 15 and 20 years of follow-up with a significant risk
for revision in patient aged 60 or less as well as patients with an infection, hema-
toma, deep vein thrombosis, or pulmonary embolism following arthroplasty [74].
Objective and subjective outcomes rely on sparse literature on (obviously) relatively
small series, showing comparable KSS [73], Patient-Reported Outcome
Measurements (PROMs), and satisfaction [69, 75]. In the existing studies, implants
with different degrees of constraint have been used, from cruciate-retaining to hinge
models with or without tibial augments and a long stem [20, 75–77]. Indeed, the
type of prosthesis should be adapted to ligamentous stability, bone stock, and bone
quality [78].
178 S. Hirsiger et al.

Primary TKA in the acute setting has been proposed in selected cases of complex
fractures in osteoporotic bones of elderly patients; experiences are limited to small
case series, but the results are promising [77, 79–82]. Of importance, autonomy in
the elderly population is reduced after tibial plateau fractures even when TKA is
done in first intention [83]. Additionally, age is an independent risk factor for mor-
tality within 30 days after TKA [84].

Summary

In everyday practice, symptomatic knee OA secondary to tibial plateau fractures is

relatively rare. Radiologic incidences varies between 25% and 45% with major
reconstructive surgery reported to be needed in only 4–7% at 10 years follow-up
[24, 27, 28]. Risk factors for the development of symptomatic OA are complexity of
the fracture [22], concomitant intra- and extraarticular soft tissue injury [18], the
age of the patient at the time of injury [23], persistent postoperative valgus malalign-
ment >5°, and a persistent articular depression >2 mm [23] or ligamentous instabil-
ity [24] as well as smoking [25]. When OA becomes symptomatic, a stepwise
medical treatment is paramount [30] and activity modification should be addressed
at first: moderate activities such as walking have a positive effect on symptomatic
knee OA [41], whereas high-level activities should be avoided [44]. Weight reduc-
tion can reduce pain and thus improve disability in obese patients [46]. The role of
physiotherapy and aquatic exercise is still debated, but given the few side effects, it
is recommended [37–40]. Paracetamol (acetaminophen) is still widely used, even
though symptom relief is minimal and side effects not infrequent [30], and NSAIDs
appear to be more effective [31]. Given the equivalent effect of oral and topical
NSAIDs applications, the latter should be preferred to reduce adverse events [30].
Intraarticular infiltrations with corticosteroids can temporarily reduce symptoms
[34]. Chondroitin and tramadol can provide some pain relief [30, 32, 33]. When
conservative treatment becomes insufficient, surgical treatment must be considered.
Especially in young patients, a conservative, joint-preserving surgery should be pri-
oritized whenever possible. Osteotomies have been described for the correction of
intra- and extraarticular posttraumatic deformities [51–53]. If OA is too advanced
and without extraarticular deformities, unilateral knee arthroplasty (UKA) can be
an option. The revision rate is higher in UKA than in TKA [60], but faster rehabili-
tation, a better knee kinematics, and lower complication rates [61] can be advanta-
geous especially for young, active patients [62]. Good results with implant
survivorship of 100% at 5 and 10 years and 80% at 15 years, and good knee function
are described [64, 68]. Fifty-two percent of conversions during surgery, from UKA
to TKA, after evaluation of the neighbor compartments have been reported [68]. For
severe, generalized OA, TKA is preferred. The type of implant constraint can range
from cruciate-retaining to posterior-stabilized and up to hinge models with or with-
out augments and a long stem, depending on ligamentous stability, bone stock, and
bone quality [20, 75–78]. Compared to TKA for primary OA, the risk for
11  Post-traumatic Arthritis of the Proximal Tibia 179

complications is higher in the posttraumatic setting, and surgery is likely to be more

complex [1, 27, 70, 71, 73]. Still, even if revision rates are higher [74], PROMs and
patient satisfaction are comparable [69, 75]. Primary TKA in the acute fracture set-
ting has been proposed in selected cases of complex fractures in osteoporotic bone
of elderly patients, but experiences are limited to small case series [77, 79].
Despite injury prevention, future research should aim at reducing the develop-
ment of postoperative OA.  Sclerostin has been found to play a role in cartilage
degeneration in mice [85, 86]. When applied intraarticularly or if upregulated trans-
genically, it plays a protective role, maintaining cartilage integrity, while its loss
promotes osteoarthritis [85, 86]. If such approaches would prove to be safe and
effective in humans, pain and functional impairment and, consequently, the need for
arthroplasties could eventually be prevented by modification of the degenerative
cascade.

Conflict of Interest  All authors declare that they have no conflict of interest to disclose and have
not received external funding.

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Chapter 12
Post-traumatic Arthritis of the Ankle

Nigel N. Hsu and Lew Schon

Key Points
• The ankle joint is more susceptible to posttraumatic arthritis than the hip or
the knee joint.
• Ankle biomechanics play a major role in posttraumatic arthritis.
• Weight-bearing CT scans are new imaging modalities to help with the
diagnosis and management of posttraumatic ankle arthritis.
• The mainstay of surgical treatment is total ankle arthroplasty and ankle
arthrodesis.

Introduction

Posttraumatic osteoarthritis accounts for 12% of arthritis across all joints, which
represents 5.6 million people, and cost the US health care 3.06 billion dollars annu-
ally [1]. For the ankle joint, posttraumatic arthritis is the primary cause of arthritis
accounting for 70–79.5% of ankle arthritis [1, 2] compared to 1.6% in the hip and
9.8% in the knee. This variation is due to the mechanical, biochemical, and anatomi-
cal factors of the ankle. Although the prevalence of ankle osteoarthritis is about 9
times lower than that of the knee and hip [3], in 2010, approximately 4400 total ankle
replacements and 25,000 ankle fusions were performed in the United States [4].
Fifty percent of elderly patients have some form of arthrosis of the foot or ankle [5].

N. N. Hsu (*)
Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
e-mail: Nhsu4@[Link]
L. Schon
Department of Orthopaedic Surgery, Mercy Medical Center, Baltimore, MD, USA

© Springer Nature Switzerland AG 2021 185

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
186 N. N. Hsu and L. Schon

In this chapter, we will examine the pathophysiology and biomechanics of posttrau-

matic ankle arthritis and review indications and nonoperative and operative treat-
ment options.

Anatomy

Primary osteoarthritis of the ankle is less common compared to the knee and hip due
to its anatomy and biochemical factors. The bony anatomy of the ankle joint confers
a high degree of stability and congruence when the joint is loaded [6]. The bony
anatomy, ligaments, and joint capsule guide and restrain movement between the
talus and the mortise. There is minimal translation of the talus relative to the mortise
during normal motion due to the soft tissue around the ankle.
Although the ankle has a smaller area of contact between articular surfaces com-
pared to the hip and knee (350 mm2 at 500 N of load compared to 1100 mm2 for the
hip and 1120 mm2 for the knee) [7–9], the tensile fracture stress and tensile stiffness
of ankle articular cartilage deteriorate less rapidly with age than those of the hip
[10]. The articular cartilage of the ankle is 1–2 mm compared to the articular carti-
lage in the hip and knee, which is 3–6 mm [11, 12]. The metabolism of cartilage
degradation is also different between the ankle and that of the knee. The catabolic
cytokine interleukin-1 (IL-1) inhibits proteoglycan synthesis of chondrocytes more
in the knee than the ankle, and this is in part due to fewer IL-1 receptors in the ankle
articular chondrocyte [3].
The high peak contact stress from smaller contact area, the congruency of the
joint, and thinness of ankle articular cartilage make the ankle joint more susceptible
to posttraumatic osteoarthritis than the hip and knee. Injuries that damage the joint
congruency and articular cartilage lead to joint degeneration within 2 years of injury
[6]. Newer studies have found that posttraumatic osteoarthritis can occur after ankle
fracture despite anatomic reduction [13], and early inflammatory response could
lead to irreversible damage to the cartilage [14]. The synovial fluid analysis showed
that after intraarticular ankle fracture, there is a proinflammatory and extracellular
matrix degrading environment similar to that described in idiopathic osteoarthritis.
Specifically IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-10 were sig-
nificantly elevated compared to normal synovial fluid [15].

Epidemiology

Trauma and abnormal ankle biomechanics are the most common causes of degen-
erative changes [16]. Traumatic injuries of the ankle include malleolar fractures,
pilon fracture, talus fracture, fracture dislocations, osteochondritis dessicans, ankle
sprains, and instability. The most common causes of posttraumatic ankle arthritis
are rotational ankle fractures (37%), recurrent ankle instability (14.6%), and single
12  Post-traumatic Arthritis of the Ankle 187

sprain with continued pain (13.7%) [2]. The severity of ankle fractures is correlated
to the development of posttraumatic ankle arthritis. Lindsjo reported that the preva-
lence of ankle arthritis is 14% after ankle fractures and ranges from 4% in Weber A
to 33% in Weber C fractures [17]. Pilon fracture of the tibial plafond is a high-­
energy injury that causes significant morbidity. Posttraumatic osteoarthritis after
pilon fracture is 26.6% [18]. Talus fracture is associated with both subtalar and tib-
iotalar posttraumatic osteoarthritis. The rate of arthritis after talar fracture is
47–97% [19].

Patient Evaluation

History and physical examination are essential in diagnosing posttraumatic osteoar-

thritis. Determining a history of trauma such as a fracture, ankle sprain, or instabil-
ity episode can help with diagnosing posttraumatic osteoarthritis of the ankle.
Careful examination of the ankle in sitting, standing, and walking is helpful.
Examine the range of motion, stability of the soft tissue, and alignment, and defor-
mity of the foot and ankle should be evaluated as well as gait to see the effects of
proximal or distal pathology. Plain weight-bearing radiographs of the ankle should
be obtained. The hindfoot alignment view is important to evaluate the hindfoot
deformity. Computed tomography (CT) can be useful to assess bony issues such as
malalignments, cysts, malunions, and nonunions. Magnetic resonance imaging
(MRI) is useful for evaluating cartilage, adjacent joint arthritis, ligamentous inju-
ries, and tendon pathology, which may also affect an ankle that is arthritic. Weight-­
bearing CT is a newer modality that allows us to evaluate the true bone positions in
their loaded state to see the effects of cysts, malunions, and nonunions, or to maxi-
mize preoperative planning for osteotomies, fusions, or joint replacements.

Conservative Treatment

Nonoperative treatments for posttraumatic ankle arthritis or end-stage arthritis

include nonsteroidal antiinflammatory drugs (NSAIDs), injections, use of cane, and
orthotics. Injection options include corticosteroids, hyaluronic acid (HA), and
platelet-­rich plasma (PRP). Steroid injections can provide short-term relief, but
repeat injections should be avoided due to catabolic risks to the soft tissue. Low
quality studies have shown some improvement in pain and functional scores with
hyaluronic acid injections for ankle osteoarthritis [20] although the Cochran review
in 2015 states that it is unclear if there is benefit or harm for HA as a treatment for
ankle osteoarthritis based on the current evidence [21]. There are a few studies that
examined PRP injections for ankle osteoarthritis. Angthong et al. had a series of 5
patients with improvement in functional scores at mean follow-up of 16 months for
ankle osteoarthritis [22]. Mei-Dan et  al. compared PRP injection to HA in a
188 N. N. Hsu and L. Schon

randomized controlled trial of 30 patients with talar osteochondral lesions and

reported improved pain and function in the PRP group [23]. Bone marrow aspirate
concentrate (BMAC) injection is also being investigated as an option for ankle
arthritis as an isolated treatment or in conjunction with surgical treatment [24]. A
cane can unload the joint mechanically. A custom molded ankle-foot orthosis (AFO)
that is molded to the calf muscle can unload the ankle. A rigid leather ankle lacer
with a solid ankle cushion heel (SACH) and a rocker sole can limit ankle motion
and help with pain relief.

Operative Treatment

The goal of surgical management of posttraumatic ankle arthritis is to improve pain,

function, and restore alignment. The main surgical options include total ankle
arthroplasty (TAA) and ankle arthrodesis (AA). In the last 20 years, we have seen
other alternatives that include arthroscopic debridement, allograft transplantation,
bipolar fresh total osteochondral allograft, periankle osteotomy, and distraction
arthroplasty.
Posttraumatic ankle arthritis is the most common indication for ankle arthrodesis
[25]. It is also an option as primary salvage following pilon fracture. It provides
reliable pain relief with relatively low reoperation rates. The optimal position for
fusion is neutral dorsiflexion, 5 degrees of hindfoot valgus, external rotation compa-
rable to the contralateral side, and the anterior dome of the talus brought to anterior
tibia [26]. Fusion can be achieved with open arthrodesis or arthroscopic arthrodesis,
and internal fixation with screw or plate vs. external fixation can be used. Figure 12.1
shows preoperative and postoperative radiographs of a patient who underwent ankle
arthrodesis for posttraumatic ankle arthritis with valgus deformity. The disadvan-
tages of ankle arthrodesis include loss of ankle motion, decreased gait efficiency,
and adjacent joint arthrosis [27]. Coester et  al. reported 22-year follow-up in 23
patients who underwent ankle fusion for posttraumatic arthritis and found increased
adjacent joint arthritis compared to the contralateral side [28]. Arthroscopic ankle
arthrodesis is a good option for patients with limited angular deformities. O’Brien
et  al. compared arthroscopic to open ankle arthrodesis and found similar fusion
rates with significantly less morbidity, shorter operative and tourniquet time, less
blood loss, and shorter hospital stay [29]. Winson reported 71% excellent and good
outcome in 116 patients who underwent arthroscopic ankle arthrodesis [30].
Total ankle arthroplasty was introduced in the 1970s, and early results were dis-
appointing with a high rate of failure [31]. This was attributed to poor implant
design, loosening, and instability [32]. Since then, the development of newer gen-
eration of total ankle implants with semiconstrained, cementless design with mobile
and fixed bearing has become more popular [33]. The potential benefits of TAA is
restoration of ankle kinematics and preventing adjacent joint arthritis. Figure 12.2
shows preoperative and postoperative radiographs of a patient who underwent a
total ankle arthroplasty for posttraumatic ankle arthritis. Haddad et al. performed a
12  Post-traumatic Arthritis of the Ankle 189

a1 a2 a3

b1 b2 b3

Fig. 12.1 (a) Shows the preoperative AP, oblique, and lateral radiographs of a patient with bimal-
leolar ankle fracture who developed posttraumatic ankle arthritis with collapse of the talus and
valgus deformity. (b) Shows the postoperative AP, oblique, and lateral radiographs after treatment
with removal of hardware and ankle arthrodesis

metaanalysis of the available outcome studies in 2007 that included 852 patients
who underwent total ankle arthroplasty with second-generation implants and found
68% of excellent and good results [34]. The 5-year and 10-year implant survival
rates were 78% and 77% with 7% revision rate [34]. A multicenter prospective non-
randomized trial comparing Scandinavian Total Ankle Replacement (STAR) to
ankle fusion in 593 patients showed that by 24 months, TAA had better function and
equivalent pain relief as the fusion group [35]. Another multicenter prospective trail
in Canada comparing 281 TAA and 107 AA in 5.5 year follow-up reported similar
improvement in pain and function, but there was a higher major complication rate
(19% vs. 7%) and higher revision rate (17% vs. 7%) in ankles treated with TAA vs.
190 N. N. Hsu and L. Schon

a1 a2 a3

b1 b2 b3

Fig. 12.2 (a) Shows the preoperative AP, oblique, and lateral radiographs of a patient with a lat-
eral malleolar ankle fracture with syndesmosis injury status post ORIF and tightrope fixation who
developed posttraumatic ankle arthritis. (b) Shows the postoperative AP, oblique, and lateral radio-
graphs after treatment with transfibular total ankle arthroplasty

AA [36]. A new total ankle coinvented by the senior author was introduced in the
USA 4.5 years ago. The design allows for conservation of bone stock, coronal plane
orientation of the rails, porous tantalum surfaces, and highly crosslinked polyethyl-
ene. A fibular osteotomy is performed for full joint exposure with preservation of
the deep deltoid. This osteotomy allows for correction of sagittal and coronal plane
deformities. Of the 105 performed by the senior author, 80% had deformity correc-
tion of the tibia, talus, and fibula. Early results are promising with no fibular non-
union, malunion, or implant failure after 12 -months follow-up [37].
In patients with posttraumatic impingement syndrome, ankle arthroscopic
debridement can be considered [38]. Arnold reported 81% good or excellent
12  Post-traumatic Arthritis of the Ankle 191

outcome with ankle arthroscopy with resection of hypertrophic synovium, fibrous

bands, or tibial spurs after an ankle sprain. The poor outcomes were associated with
severe chondral lesions found during arthroscopy. Rasmussen reported 62% pain
free 2  years after arthroscopic debridement for impingement, and 27% had pain
improvement [39].
In cases of patients with localized articular cartilage defects, allograft transplan-
tation can be considered. It is performed with anatomically matched fresh allograft
harvested within 24 hours of death and removal of bacteria, blood, and lipids. Hahn
et al. reported significant improvement in pain and functional scores in 18 patients
who underwent allograft transplantation for osteochondral lesions of the talar
dome [40].
Severe posttraumatic ankle arthritis in young and active patients poses a recon-
structive challenge and bipolar fresh total osteochondral allograft (BFTOA) may be
an alternative to arthrodesis and total ankle replacement [41]. Figure 12.3 shows
intraoperative pictures and postoperative radiographs of a patient who underwent
bipolar fresh total osteochondral allograft. Giannini et al. reported improvement in
functional scores at 40.9-months follow-up in 26 patients who underwent BFTOA
for posttraumatic arthritis. Six out of the 26 patients had failure associated with
malalignment of the tibial slope. Bugbee et  al. reported 83% improved pain and
function in 88 patients who underwent BFTOA at 5.3-year follow-up although 29%
required another operation [42].
Supramalleolar osteotomy is an option for patients with varus or valgus ankle
arthritis. The goal is to correct the ankle alignment for improved joint loading while
preserving the ankle joint [43]. Medial opening wedge osteotomy is used to correct
incongruent varus arthritis, and medial closing wedge osteotomy is used for valgus
ankle arthritis [43]. Figure 12.4 shows preoperative and postoperative radiographs
of a patient who underwent medial opening wedge osteotomy for ankle arthritis with
varus deformity. Takakura et al. reported improved pain and function in 9 patients
who underwent tibial osteotomy for varus ankle arthritis at 7-year follow-­up [44].
Pagenstert et al. reported improved pain and function in 22 patients who underwent
osteotomy for valgus ankle arthritis with 4.5-year follow-up [45]. Knupp et  al.
reported statistical significant improvement in functional scores in 92 patients who
underwent osteotomy for varus or valgus ankle arthritis at 43-months follow-­up [46].
In young and active patients with posttraumatic ankle osteoarthritis, ankle dis-
traction is another option to preserve the joint. This technique involves external
fixator with or without a hinge, and progressive distraction for 3  months while
weight bearing. The theory is that by removing the mechanical stress, the cartilage
can repair itself [47]. Figure 12.5 shows preoperative and postoperative radiographs
of a patient who underwent ankle distraction arthroplasty. Tellisi et  al. reported
significant pain and functional improvement in 91% of patients who underwent
ankle distraction in 25 patients with ankle arthritis at follow-up of 30 months [48].
Nguyen et al. reported intermediate-term follow-up of 36 patients who underwent
ankle distraction for end-stage ankle arthritis, and 45% underwent subsequent ankle
arthrodesis or total ankle arthroplasty due to pain [49].
192 N. N. Hsu and L. Schon

b1 b2

Fig. 12.3 (a) Shows an intraoperative photograph of the fresh allograft of the talar dome and tibial
plafond prior to implantation. (b) Show AP and lateral postoperative radiographs of a patient with
posttraumatic ankle osteoarthritis treated with bipolar fresh total osteochondral allograft. Note the
small screw fixation in the tibia and talus
12  Post-traumatic Arthritis of the Ankle 193

a1 a2 a3

c1 c2 c3

Fig. 12.4 (a) Show the preoperative AP, oblique, and lateral radiographs of a patient with varus
deformity ankle arthritis treated with medial opening wedge osteotomy. (b) Shows the intraopera-
tive image of the medial ankle with an allograft wedge. (c) Show the postoperative AP, oblique, and
lateral radiographs demonstrating restored alignment
194 N. N. Hsu and L. Schon

a1 a2

b1 b2 b3

Fig. 12.5 (a) Shows the preoperative oblique and lateral radiographs of a young patient with post-
traumatic ankle arthritis. (b) Shows the postoperative AP, oblique, and lateral radiographs after
distraction arthroplasty with an external fixator that allows for ankle range of motion

Summary

Post-traumatic arthritis is the primary cause of arthritis in the ankle. It dispropor-

tionately affects younger individuals and athletes. Inflammatory events at the time
of injury with release of cytokines can lead to irreversible damage to the cartilage.
Nonoperative treatments for posttraumatic ankle arthritis include NSAIDs, cortico-
steroid injections, orthotics and bracing. Surgical treatment is based on the ankle
alignment and severity of the arthritis. Primary surgical treatments for end stage
ankle arthritis include total ankle arthroplasty and ankle arthrodesis. The literature
supports both ankle arthrodesis and total ankle arthroplasty. Other treatment options
include arthroscopic debridement, allograft transplantation, bipolar fresh total
osteochondral allograft, supramalleolar osteotomy, and distraction arthroplasty.
Patient specific factors such as medical comorbidities, malalignment, adjacent joint
pathology, age and activity levels are important considerations when selecting the
surgical treatment.
12  Post-traumatic Arthritis of the Ankle 195

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12  Post-traumatic Arthritis of the Ankle 197

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years, older age at surgery and fixed distraction.
Chapter 13
Post-traumatic Arthritis of the Foot

Ram K. Alluri and Eric W. Tan

Key Points
• The most common traumatic orthopaedic injuries of the hindfoot and mid-
foot are calcaneus fractures and tarsometatarsal (TMT) fracture-­
dislocations (Lisfranc injury), respectively.
• The hindfoot is structurally composed of the talus and calcaneus, and its
functionality is primarily dependent on motion through the talonavicular
and subtalar (talocalcaneal) joints.
• The Lisfranc complex is a major stabilizer of the midfoot and is composed
of the five metatarsal base articulations with the cuboid and cuneiforms.
• The mainstay for surgical treatment involves selective arthrodesis with the
goal of a creating a stable, functional, and painless plantigrade foot.

Introduction

Traumatic injuries of the foot are common after high-energy trauma, and second
only to hip, thigh, and knee injuries [1]. Although these injuries of the foot are typi-
cally not life threatening, they can result in significant long-term functional disabil-
ity, and in patients with multiple injuries, those with foot injuries have significantly
worse outcomes than matched patients without foot injuries [2]. Much of the dis-
ability sustained after traumatic injuries to the foot is due to acute and chronic post-
traumatic degenerative changes of the articular surfaces.

R. K. Alluri · E. W. Tan (*)

Department of Orthopaedic Surgery, Keck School of Medicine of USC,
Los Angeles, CA, USA
e-mail: [Link]@[Link]; erictan@[Link]

© Springer Nature Switzerland AG 2021 199

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
200 R. K. Alluri and E. W. Tan

The most common traumatic orthopaedic injuries of the hindfoot and midfoot
are calcaneus fractures and tarsometatarsal (TMT) fracture-dislocations (Lisfranc
injury), respectively. Calcaneus fractures account for approximately 2% of all frac-
tures, and it is the most frequently fractured bone of the foot [3]. Fracture-dislocations
of the TMT joint are relatively uncommon, only accounting for 0.2% of all frac-
tures; [4] however, up to 20% of these TMT injuries are initially missed or misdiag-
nosed [5]. In both injuries, patients can develop symptomatic posttraumatic
osteoarthritis due to intraarticular fracture fragments, altered biomechanics result-
ing in pathologic force distribution, and direct articular surface damage. Previous
studies have demonstrated that chondrocyte injury and death can immediately occur
due to forceful impaction during the traumatic event [6].
In this chapter, we will discuss the relevant anatomy, evaluation, and manage-
ment of patients who sustain a calcaneus fracture or TMT fracture-dislocation and,
subsequently, develop posttraumatic osteoarthritis of the hindfoot or midfoot.

Anatomy and Biomechanics

Anatomy

The hindfoot is structurally composed of the talus and calcaneus, and its functional-
ity is primarily dependent on motion through the talonavicular and subtalar (talocal-
caneal) joints. The majority of hindfoot motion occurs through the talonavicular
joint with fusion of this joint resulting in 90% loss of subtalar motion. Conversely,
subtalar fusion only results in 26% loss of talonavicular motion [7]. The subtalar
joint is composed of two articulations. Anteriorly, the lip and sustentaculum of the
calcaneus rotate about the talar head; posteriorly, the posterior facet of the calcaneus
provides a surface for which the talus can glide upon. The spring ligament and the
proximal articular surface of the navicular bone augment the calcaneus to form a
complete socket stabilizing the talar head. Overall, the axis of the subtalar joint is
oblique due to the more medial anterior talocalcaneal articulation relative to the
posterior articulation.
The midfoot is composed of navicular, cuboid, and three cuneiform bones and
articulates proximally with the hindfoot and distally with the forefoot. Functionally,
the midfoot is often described in terms of medial, middle, and lateral columns. The
rigid medial and middle columns are composed of articulations between the first
metatarsal base and medial cuneiform, second metatarsal base and intermediate
cuneiform, and third metatarsal base and lateral cuneiform. The mobile lateral col-
umn consists of the cuboid and fourth and fifth metatarsal bases. There are 5–10
degrees of motion at the first TMT joint and minimal motion occurs at the second
and third TMT joints. The fourth and fifth TMT joints are most mobile, with 10–20
degrees of movement. The osseous stability of the midfoot is partly because of the
wedge shape of the metatarsal bases and cuneiforms resulting in a transverse arch,
13  Post-traumatic Arthritis of the Foot 201

or “Roman arch,” of the foot in the coronal plane. A second osseous stabilizer is
provided by recession of the second metatarsal base relative to the first and third
tarsometatarsal joints.
The Lisfranc complex is a major stabilizer of the midfoot and is composed of the
five metatarsal base articulations with the cuboid and cuneiforms. This complex is
stabilized by a combination of ligamentous attachments and a unique bony configu-
ration at the second metatarsal base. The dorsal ligaments are the weakest while the
interosseous and plantar ligaments are the strongest [8]. The specific Lisfranc liga-
ment stabilizes 1–2 intermetatarsal bases, attaching the second metatarsal base to
the medial cuneiform. While intermetatarsal ligaments are present between the sec-
ond, third, fourth, and fifth metatarsal bases, there is no intermetatarsal ligament
stabilizing the 1–2 metatarsal bases directly. Therefore, the integrity of the Lisfranc
ligament is critical for stability.

Altered Biomechanics

Fractures of the calcaneus can result in significant articular damage and progressive
hindfoot deformity resulting in a heel that is wide, flattened, and in varus (Figs. 13.1
and 13.2). Widening of the hindfoot may cause significant difficulty with shoe wear.
The varus deformity can cause lateral deviation of the peroneal tendons and sural
nerve compression [9]; severe varus deformity can cause symptomatic subfibular
impingement between the lateral wall of the calcaneus and distal fibula [9]. When

Fig. 13.1  Axial heel view and lateral radiographs of a simple, intraarticular calcaneal fracture
202 R. K. Alluri and E. W. Tan

Fig. 13.2  Axial heel view and lateral radiographs of a complex, intraarticular calceanal fracture
with significant intraarticular comminution and joint depression

the hindfoot assumes a pathological varus alignment, the transverse tarsal joint
remains locked, resulting in subsequent degeneration of the adjacent midfoot joints
due to persistently increased loads during gait [9]. Hindfoot varus deformity can
also cause lateral column overloading of the midfoot. In addition to varus deformity,
loss of hindfoot height from depression of the posterior calcaneal facet can also
occur after calcaneal fractures [9]. This causes the talus to adopt a more dorsiflexed
position, which may result in anterior impingement of the talus on the anterior tibial
plafond [9]. Additionally, the lever arm of the Achilles tendon is reduced, which can
significantly alter normal gait patterns [9].
Traumatic injuries to the Lisfranc complex occur during torsion of the forefoot
and axial load transmission to the midfoot (Figs.  13.3 and 13.4). These injuries
result in direct articular damage and altered midfoot biomechanics due to instability
and resultant collapse of the longitudinal arch. The normal intact midfoot arch func-
tions as a lever, efficiently transmitting force from the forefoot to hindfoot, and loss
of this arch results in decreased mechanical efficiency [10]. This leads to abnormal
loading of the midfoot and adjacent joints, resulting in arthritic degeneration.
Commonly, patients develop a valgus deformity of the hindfoot, midfoot flattening
from the loss of the longitudinal arch, and forefoot abduction and dorsiflexion
because of pathologic changes in the peroneus brevis and posterior tibialis tendons,
respectively.
13  Post-traumatic Arthritis of the Foot 203

Fig. 13.3  Anteroposterior (AP), oblique, and lateral radiographs of a subtle Lisfranc injury with
mild diastasis between the medial cuneiform and the base of the second metatarsal that could be
missed during initial presentation

Fig. 13.4  Anteroposterior (AP), oblique, and lateral radiographs of a severe Lisfranc injury with
homolateral shift of the first through fifth tarsometatarsal joints
204 R. K. Alluri and E. W. Tan

 atural History of Initial Hindfoot and Midfoot

N
Fracture Healing

During the acute injury, a calcaneus fracture can be treated operatively or nonopera-
tively; however, no definite consensus exists with regard to ideal treatment. Current
relative indications for operative management include large extraarticular fractures,
fractures with greater than 2  mm of intraarticular displacement, flattening of
Bohler’s angle and the angle of Gissane, varus malalignment of the tuberosity,
impending skin necrosis from displaced tongue-type fractures, and open fractures.
Relative nonoperative indications include anterior process fractures involving <25%
of the calcaneocuboid joint, fractures with preserved calcaneal height, nondisplaced
fractures, fractures with less than 2 mm of intraarticular displacement, or patients
with comorbidities (smoking, diabetes, vascular disease) placing them at increased
risk for postoperative complications [11].
Prior studies have stressed the importance of achieving an anatomic reduction to
prevent accelerated wear of the subtalar joint. Minimal displacement of 1–2 mm has
been shown to alter contact pressures of the subtalar joint and posterior facet, result-
ing in significant gait disturbance [12, 13]. Whether achieved through open or closed
reduction, anatomic reduction of calcaneal fractures attempts to recreate a congru-
ent subtalar joint, reduce the lateral wall, and take the hindfoot out of varus while
restoring calcaneal height. Therefore, most surgeons advocate initial operative man-
agement to achieve an anatomic reduction of the joint surface to potentially decrease
the incidence of subtalar osteoarthritis requiring secondary arthrodesis [14, 15].
Several prior studies have attempted to delineate the ideal management of dis-
placed intraarticular calcaneal fractures. In a study by Agren et al., surgical treat-
ment was associated with higher complications and similar functional outcomes at
1 year compared to nonoperative management [16]. Buckley et al. also found little
difference in SF-36 or VAS outcome scores between operatively and nonoperatively
treated calcaneus fractures [15]. However, the authors did note higher rates of even-
tual arthrodesis in patients who received initial nonoperative management [15].
Csizy et al. noted similar findings with a six times higher subtalar arthrodesis rate in
patients receiving initial nonoperative management [14].
Regardless of initial operative or nonoperative management, a high number of
patients who sustain calcaneal fractures with significant intraarticular involvement
will develop posttraumatic osteoarthritis [17]. The initial injury results in the dis-
placement of intraarticular fracture fragments and irreversible cartilage damage. In
a study by Radnay et al., 69 patients who sustained a calcaneal fracture requiring
eventual arthrodesis were reviewed [18]. Thirty-four (49%) underwent initial opera-
tive management, and 35 (51%) were treated initially nonoperatively [18]. Worse
functional outcomes after subtalar arthrodesis were noted in patients who were ini-
tially treated with nonoperative management [18]. Patients with initial nonoperative
management also had greater postoperative wound complications, potentially due to
greater restoration of calcaneal height resulting in postoperative tension along the
surgical wound [18].
13  Post-traumatic Arthritis of the Foot 205

The initial management of Lisfranc injuries also remains without consensus,

partly because the term “Lisfranc injury” reflects a wide and poorly defined injury
spectrum. Initial management includes nonoperative interventions versus open
reduction and internal fixation (ORIF) or primary partial arthrodesis of the midfoot.
Nonoperative management is generally reserved for patients who are minimally
ambulatory, have an insensate foot, or inflammatory osteoarthritis [19]. In patients
without these preexisting comorbidities, nonoperative management is generally
only recommended in patients with a stable injury (no diastasis of the Lisfranc
complex).
Any measurable incongruity greater than 2 mm at the Lisfranc joint is generally
an indication for surgical treatment, ideally within the first two weeks after injury to
optimize outcomes [19]. The most accurate predictor of postoperative outcome is
achieving a stable anatomic reduction after which good to excellent postoperative
outcomes can be expected in 85% of patients whereas nonanatomic alignment
results in similar outcomes in only 17% of patients [20]. Even after adequate reduc-
tion, the incidence of posttraumatic osteoarthritis can be as high as 25–72% [21,
22]. However, up to 100% of patients with an inadequate initial reduction will
develop posttraumatic osteoarthritis [21], and initial radiographic findings are gen-
erally not predictive of which patients will develop this complication [23]. Some
authors have stated that developing osteoarthritis after a Lisfranc injury is almost
inevitable given the damage to the articular surface at the time of initial injury [24].
Given these findings, some surgeons recommend primary partial fusion in Lisfranc
injuries at high risk for developing posttraumatic osteoarthritis such as injuries with
ligamentous disruption and multidirectional instability, significant comminution, or
crush injuries [25]. Although partial midfoot arthrodesis may limit or eliminate the
eventual development of posttraumatic midfoot osteoarthritis, the stiffness and lim-
ited function of the foot following the arthrodesis may not be well tolerated in
young, active patients.

Patient Evaluation

History

The preoperative examination of all patients with posttraumatic osteoarthritis

secondary to a hindfoot or midfoot injury should begin with a thorough history.
The history should focus on the initial mechanism of injury and soft tissue dam-
age, previous nonoperative or operative treatment received, degree of current dis-
ability and pain, and a discussion of current expectations in terms of functional
outcome. An assessment of current medical comorbidities, work status, and
tobacco use can allow for perioperative risk stratification and assessment of non-
union risk.
206 R. K. Alluri and E. W. Tan

Physical Exam

The physical exam should consist of a gait assessment, range of motion measure-
ment, and careful inspection of ankle and foot alignment. Alignment should be
assessed with the patient standing as this best allows for examination of hindfoot
varus or valgus, medial arch height, and forefoot abduction. Patients should also be
asked to walk to assess for dynamic flatfoot deformity or subfibular impingement.
Abnormal alignment should be assessed for passive correctability, and in a patient
with unilateral injury, the contralateral, uninjured side can serve as a reliable con-
trol. In cases of severe deformity, the quality of the soft tissue and presence of ulcers
or impending skin breakdown should be assessed. Previous surgical scars should be
examined as they can dictate choice of surgical exposure. The dorsalis pedis and
posterior tibial pulses should be assessed; nonpalpable pulses may require a preop-
erative vascular consult. Lastly, the strength and sensation of the foot should also be
formally assessed and documented.
In patients with posttraumatic hindfoot deformity and osteoarthritis, the hindfoot
is often in varus and collapsed, and therefore evaluation for contractures of the
gastrocnemius-soleus complex and anterior ankle impingement is important.
Additionally, patients with posttraumatic hindfoot osteoarthritis may have a wid-
ened calcaneus that can cause skin breakdown over the lateral malleolus from con-
tact friction.
In patients with posttraumatic midfoot deformity and osteoarthritis, excessive
pronation and midfoot collapse may be noted secondary to loss of the longitudinal
arch and acquired forefoot abduction. These patients may have pain with palpa-
tion over the midfoot; however, the degree of arthrosis visualized on radiographs
may not correlate with symptoms found on physical examination. In most cases,
patients endorse greatest pain at the second TMT joint as this is the least mobile
joint of the midfoot and undergoes the greatest posttraumatic arthritic change. To
a lesser extent, they may endorse pain at the first and third TMT joints. Patients
with arthrosis of the lateral column may not endorse significant pain because of
the inherent mobility of this column. Stress testing of individual metatarsocunei-
form joints (the “piano key” test) may also help elicit pain across the affected
midfoot TMT joints as it places compression along the medial and lateral midfoot
[26]. A positive test will produce localized pain at the involved tarsometatarsal
joint. Additionally, the examiner may be able to aggravate posttraumatic midfoot
osteoarthritis symptoms by having the patient perform a single heel rise or stair
ascent as these activities require significant load transmission across the midfoot.
Lastly, dorsal osteophytes may cause difficulty with shoe wear, neuritis, or
tendonitis.
13  Post-traumatic Arthritis of the Foot 207

Imaging

Weight-bearing anteroposterior, lateral, and oblique plain radiographs of the foot

are necessary to diagnose and characterize the degree of arthrosis in the hindfoot or
midfoot based on the presence of joint space narrowing, subchondral sclerosis, and
osteophyte formation. The lateral view is particularly useful to assess talar declina-
tion, hindfoot collapse, and the presence of anterior impingement of the talar neck
on the tibial plafond. Measurement of Bohler’s angle or the angle of Gissane can
help quantify the loss of calcaneal height due to posterior facet collapse (Fig. 13.5).
Additionally on the lateral view, Meary’s angle can be calculated in patients with
loss of the medial longitudinal arch and subsequent pes planus deformity (Fig. 13.5).
An axial heel view, or Harris view, can be useful to assess hindfoot alignment and
heel widening. Some surgeons may elect to obtain plain radiographs of the unin-
jured foot for comparative purposes.
The role of computed tomography (CT) in evaluating posttraumatic arthrosis of
the hindfoot and midfoot is unclear. Many surgeons recommend routinely obtaining
CT imaging as it can assist in preoperative planning, particularly in cases of com-
plex deformity. CT imaging allows for more accurate characterization of the degree

a b

c d

Fig. 13.5 (a) Normal lateral radiograph of the foot. (b) Bohler’s angle. (c) Angle of Gissane. (d)
Meary’s angle. Normal values for the respective angles are listed within the image. The curved red
line demonstrates where the angle should be measured
208 R. K. Alluri and E. W. Tan

and location of hindfoot and midfoot arthrosis. Specifically, in hindfoot posttrau-

matic arthrosis, CT may allow for the determination of whether there is subfibular
impingement of the calcaneus and distal tip of the fibula. With regards to midfoot
posttraumatic arthrosis, CT images in three planes can allow for determining which
specific midfoot joint is undergoing posttraumatic degeneration, potentially allow-
ing for limited fusion, thus preserving greater function.
Magnetic resonance imaging (MRI) is not routinely utilized. In rare cases, a
technetium Tc- 99 m bone scan can be ordered in patients with normal plain radio-
graphs to identify early-onset arthritic changes in patients with persistent posttrau-
matic hindfoot or midfoot pain.

Nonoperative Management

The central treatment modalities of nonoperative management for posttraumatic

osteoarthritis of the hindfoot and midfoot center on physical therapy, nonsteroidal
antiinflammatory medications (NSAIDs), injections, and bracing. Activity modifi-
cation, physical therapy, and NSAIDs are generally firstline treatments in this
patient population. Selective injection of corticosteroids or hyaluronic acid in the
hindfoot or midfoot is also an option, but scientific evidence proving their efficacy
is lacking.
Braces and orthotics provide pain relief and increased function for patients with
hindfoot and midfoot osteoarthritis by decreasing force transmission and motion
across the arthritic joint. The selection of the appropriate brace or orthotic depends
on the degree of osteoarthritis present as well as the flexible or rigid nature of the
deformity. In addition, the provider should be cognizant about the materials used
and pressure applied by the brace or orthotic, as this may result in skin breakdown
or ulceration. In early stages of hindfoot or midfoot osteoarthritis with flexible or
minimal deformity, a semirigid ankle brace or custom orthotic may provide enough
stability to support and realign the foot and ankle. As the severity of the osteoarthri-
tis and deformity increases, a more rigid brace, such as a double-upright brace or
custom Arizona brace, or rigid orthotic may be necessary to reduce motion at the
affected hindfoot or midfoot joints, respectively. However, many patients find these
braces cumbersome and difficult to use. Shoe wear modification, particularly
rocker-bottom shoes or customized shoes, may also be effective nonoperative treat-
ment options.

Operative Management

Patients that have failed nonoperative management of posttraumatic hindfoot and

midfoot osteoarthritis with continued debilitating symptoms may be candidates for
surgical intervention. Patient factors such as age, medical comorbidities, smoking
13  Post-traumatic Arthritis of the Foot 209

history, profession, and workers’ compensation status should be considered as these

can significantly affect postoperative outcomes. The mainstay for surgical treatment
involves selective arthrodesis with the goal of a creating a stable, functional, and
painless plantigrade foot.

Hindfoot

Fractures of the calcaneus that develop posttraumatic osteoarthritis can be surgi-

cally treated with in situ subtalar arthrodesis or distraction bone-block arthrodesis
with or without additional corrective osteotomies, lateral wall decompression, or
soft tissue procedures.
In situ arthrodesis can provide significant pain relief with satisfactory functional
outcomes (Fig. 13.6). It is indicated for patients with minimal deformity, significant
subtalar osteoarthritis, and gross preservation of calcaneal height such that there is
no evidence of anterior talar impingement on the tibial plafond. Patient selection is
key for this in situ procedure as patients with deformity that is not addressed will
inevitably have poorer long-term outcomes [27]. The choice of surgical approach
for in situ arthrodesis must be given careful consideration. If previous hardware is
present, but asymptomatic, it can be left in place [9, 28]. If the hardware is symp-
tomatic, some surgeons elect to use the previous surgical incision, which is com-
monly an extensile lateral approach or, more recently, a sinus tarsi approach [9, 28].
After adequate exposure of the subtalar joint has been achieved, cartilage and nonvi-
able bone are completely removed from the subtalar joint with care taken to

Fig. 13.6 Lateral
radiograph of an
intraarticular calcaneus
fracture that was initially
treated with open reduction
and internal fixation (upper
image). The patient
eventually developed
significant subtalar
posttraumatic
osteoarthritis.
Postoperative lateral
radiograph after removal of
hardware and in situ
subtalar arthrodesis (lower
image). (Images courtesy
of Dr. David E. Oji, MD)
210 R. K. Alluri and E. W. Tan

preserve the normal bone contour and subchondral bone. The exposed subchondral
bone is then meticulously prepared and perforated to improve blood flow. The sub-
talar joint is then aligned in approximately 0–5 degrees of valgus and fixed using
partially threaded 6.5 mm screws. It is important to obtain correct hindfoot position-
ing prior to arthrodesis to maximize functional outcomes. Residual bony deficits
can be filled with autologous bone graft, bone allograft, synthetic bone, or cancel-
lous chips.
Previous studies have demonstrated union rates ranging from 84% to 98% after
in situ arthrodesis on average 12 weeks after surgery [29, 30] and improvement in
functional outcomes after arthrodesis: [18, 31] the AOFAS hindfoot score can be as
high as 89 at final follow-up [32], and 93% of patients have good to fair outcomes
using the Angus and Cowell rating system [31]. Overall patient satisfaction can
range from 70% to 90% [33, 34]. The most common complication after this proce-
dure is wound infection, which has recently been shown to be as high as 18%,
especially in patients with an original open fracture or infection after the index
operation [30]. Other complications include neuromas and chronic regional pain
syndrome. Patients at higher risk for poorer functional outcomes include those ini-
tially treated nonoperatively, smokers, diabetics, and patients of advanced age [18,
35, 36].
In patients with loss of hindfoot height and symptomatic anterior tibial impinge-
ment, distraction bone-block subtalar arthrodesis is indicated (Fig. 13.7). An in situ
arthrodesis in these patients, even with lateral wall decompression, will not opti-
mize posttraumatic hindfoot function. The added distraction with a structural bone
graft and arthrodesis will reestablish the calcaneal height as well as the inclination
of the talus and normalize the gastrocnemius-soleus lever arm. Most commonly, the
subtalar joint is approached with a posterior or posterolateral incision for this pro-
cedure. Alternatively, a sinus tarsi incision may also be utilized. However, an exten-
sile lateral approach, commonly used for initial operative fixation of calcaneal
fractures, should be avoided due to concerns about wound healing after distraction,
particularly along the horizontal limb. After initial dissection through the soft tis-
sues, a lateral wall exostectomy may be performed; the bone can be used as bone
graft. The subtalar joint is then distracted using a large distractor or laminar spreader
to correct the calcaneal height and varus malalignment. The joint surfaces are then
prepared in a similar fashion to in situ subtalar arthrodesis. Next, the structural bone
graft is inserted into the distraction gap and the hindfoot is placed into 0–5 degrees
of valgus. Once aligned, the fusion may be secured using partially threaded 6.5 mm
screws placed from the posteroinferior aspect of the calcaneus into the talar dome.
Tricortical iliac crest bone autograft is the main choice for structural grafting.
However, structural allografts such as the femoral neck allograft and tricortical iliac
crest allograft are alternative options. Initial reports comparing structural allograft
to autograft demonstrated significantly lower union rates with allograft [37]; how-
ever, more recent studies report 92% union rates with allograft and favorable out-
comes [38]. Augmentation of structural graft with synthetic bone graft substitutes or
cancellous chips can be utilized at the surgeon’s discretion.
13  Post-traumatic Arthritis of the Foot 211

a b

c d

Fig. 13.7 (a, b) Axial heel view and lateral radiographs of an intraarticular calcaneus fracture
initially treated nonoperatively. The patient developed significant subtalar posttraumatic osteoar-
thritis with varus hindfoot alignment and anterior talar impingement due to loss of calcaneal
height. (c). Intraoperative fluoroscopic image demonstrating distraction of the subtalar joint using
a laminar spreader (d). Intraoperative fluoroscopic image after distraction bone-block arthrodesis
of the subtalar joint

Outcomes after distraction bone-block subtalar arthrodesis are generally favor-

able. Although the procedure is technically more challenging, as two osseous sur-
faces need to be united, union rates are similar to that for in situ subtalar arthrodesis,
ranging from 87% to 95% [35, 37]. In a prospective study by Rammelt et al., AOFAS
hindfoot scores increased from 23.5 to 73.2 at 33 months after distraction arthrod-
esis [39]. Other studies have demonstrated similar results, all with AOFAS hindfoot
scores ranging from 70 to 76 at final follow-up [40–42], and over 90% of patients
report satisfaction with the procedure [37, 39]. Although distraction bone-block
subtalar arthrodesis is generally a successful procedure, complications can occur in
up to 13% of patients [39]. The most common complications include infection,
plantar exostosis, and nerve injury. Patients at risk for complications and poorer
212 R. K. Alluri and E. W. Tan

postoperative outcomes include diabetics, smokers, and workers’ compensation

patients [35, 41].
Occasionally with both subtalar arthrodesis techniques, additional soft tissue
procedures may be needed. In the setting of peroneal subluxation or tendonitis, the
peroneal tendons may need to be debrided, repaired, or reconstructed. Furthermore,
percutaneous lengthening of the Achilles tendon or a Strayer gastrocnemius reces-
sion may be indicated in the setting of equinus deformity.
Importantly, fusion of the hindfoot for symptomatic posttraumatic osteoarthritis
can result in increased stress across adjacent joints. Subtalar joint arthrodesis can
result in greater force transmission across the adjacent transverse tarsal joint and
tibiotalar joint. However, the clinical significance of adjacent joint degenerative
changes remains unclear. Previous studies have demonstrated adjacent joint degen-
erative changes in the tibiotalar and transverse tarsal joints in 10–40% of patients
[32, 33, 36, 37]. Whether these adjacent degenerative changes were present prior to
subtalar fusion or were advanced due to fusion is unclear [32].

Midfoot

Fracture-dislocations of the TMT joint that develop posttraumatic osteoarthritis are

commonly treated with arthrodesis of the medial three TMT joints (Fig. 13.8) [10,
28]. Similar to posttraumatic hindfoot osteoarthritis, the main indication for mid-
foot arthrodesis is patients who continue to have symptomatic pain refractory to
nonoperative management.
The midfoot can be accessed through multiple incisions. In most cases, the inci-
sion used for arthrodesis is similar to that used for primary open reduction of acute
Lisfranc injuries. A longitudinal incision made along the dorsal first intermetatarsal
space allows access to the first and second tarsometatarsal joints. A second incision
can be made over the dorsal fourth metatarsal with care to maintain an adequate skin
bridge to access the third, fourth, and fifth TMT joints, if necessary. Alternatively,
fusion of the first, second, and third TMT joints can be performed through a medial
incision in conjunction with a central dorsal incision just lateral to the second meta-
tarsal. Regardless of the approach, care should be taken to avoid and protect the
dorsal pedis artery, first dorsal metatarsal artery, and the superficial and deep pero-
neal nerves.
The decision of which midfoot joints to fuse is critical and selective fusion is
advocated to avoid making the midfoot overly rigid. Most commonly, the first, sec-
ond, and third TMT joints are included in the arthrodesis. Additional fusion or inter-
positional tendon arthroplasty of the fourth and fifth TMT joints is rarely indicated
but may be needed in cases of significant midfoot osteoarthritis. The selected joints
of the midfoot arthrodesis construct should be denuded of residual cartilage and
fibrous tissue. The subchondral bone is then debrided and perforated to improve
blood flow to the fusion site. After adequate preparation of the bony surfaces, the
mechanical alignment of the midfoot must be restored. A Hintermann distractor or
13  Post-traumatic Arthritis of the Foot 213

a c

b d

Fig. 13.8 (a, b) Anteroposterior (AP) and lateral radiographs of a patient with a prior Lisfranc
injury who developed significant midfoot posttraumatic osteoarthritis. (c, d) Postoperative radio-
graphs after arthrodesis of the first, second, and third tarsometatarsal joints of the midfoot. (Images
courtesy of Dr. David E. Oji, MD)

lamina spreader can aid in restoring alignment and, occasionally, in more severe
deformities, a wedge resection across the midfoot may be necessary [28].
In addition, soft tissue procedures may be needed to fully correct the deformity.
In the presence of severe abduction deformity, lengthening or complete release of
the peroneus brevis tendon may be needed. The tendon can also be transferred to the
peroneus longus to help stabilize the medial column of the midfoot. Furthermore, in
the presence of equinus deformity, percutaneous lengthening of the Achilles tendon
or a Strayer gastrocnemius recession may be necessary.
After reestablishing alignment of the midfoot, residual bony deficits should be
filled with autologous bone graft, bone allograft, synthetic bone graft substitutes, or
cancellous chips. To stabilize the arthrodesis, multiple techniques are available
including use of Kirschner wires, staples, compression screws as well as dorsal,
medial, and plantar plates. There is no clear evidence indicating which construct
leads to the best clinical outcomes [10]. However, Marks et al. demonstrated that
midfoot fusions fixed with a plantarly applied plate result in superior biomechanical
stability compared to midfoot fusion constructs with screw fixation [43]. In most
cases, adequate stability can be achieved with partially threaded cancellous screws
214 R. K. Alluri and E. W. Tan

or cortical lag screws placed across each joint of the arthrodesis construct. In cases
of severe deformity, the addition of compression plates or plantar plate fixation will
add additional stability and should be considered.
The results of midfoot fusion for posttraumatic osteoarthritis after a TMT joint
fracture-dislocation are generally favorable. Union is achieved in greater than 90%
of patients with some studies demonstrating 98% union rates [44, 45]. Sangeorzan
et al. reported good to excellent results in 11 of 16 patients (69%), and 15 of 16
(94%) were satisfied with the procedure [46]. Mann et  al. reported 93% patient
satisfaction following selective arthrodesis [44], and Johnson and Johnson reported
84% patient satisfaction [47]. AOFAS-midfoot scores can improve by up to 34
points with final scores ranging from 71 to 78 [48, 49]. Several studies have shown
that the quality of the initial reduction during the acute TMT fracture-dislocation
correlates with better outcomes after secondary midfoot arthrodesis [20, 46] while
workplace injuries and delay to treatment can negatively affect outcomes [46]. The
most common complications after midfoot fusion include superficial infections,
neuritis, and neuromas [44, 47, 48]. Nerve injuries are common in midfoot fusion
due to the anatomic location of the cutaneous nerves, particularly the deep peroneal
nerve, and the soft tissue retraction needed for adequate exposure and preparation
of the joint surfaces.
Similar to subtalar fusion of the hindfoot, concerns exist for adjacent joint degen-
erative changes after select midfoot fusion; however, no clinical studies exist that
have objectively evaluated this potential complication.

Conclusions

Calcaneus fractures and TMT fracture-dislocations of the hindfoot and midfoot,

respectively, can result in significant long-term morbidity primarily due to the
development of posttraumatic osteoarthritis secondary to acute articular damage at
the time of initial injury and chronic malalignment and abnormal force distribution
across the foot resulting in progressive degeneration. Restoration of the articular
surface and a stable reduction during initial treatment can decrease the risk of devel-
oping posttraumatic osteoarthritis, but, regardless of initial treatment, a certain sub-
set will inevitably develop posttraumatic osteoarthritis. In symptomatic patients
with posttraumatic osteoarthritis refractory to nonoperative management, select
fusion of the subtalar joint with or without bone block distraction or medial and
middle columns of the midfoot can result in good to excellent postoperative func-
tional outcomes and high rates of patient satisfaction.
13  Post-traumatic Arthritis of the Foot 215

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Index

A patient evaluation, 187

Acetabular fractures, 31 prevalence, 185
antero-lateral approach, 124, 131 Scadanavian Total Ankle Replacement, 189
bimodal distribution, 112 supramalleolar osteotomy, 191
cement-less acetabular components, total ankle arthroplasty, 188
128, 129 Anterior cruciate ligament (ACL), 27
complications, 131 Arthroplasty
Harris hip score, 124, 128, 129 hemiarthroplasty, 50, 51
heterotopic ossification, 130 humeral resurfacing, 51
hypotensive anesthesia, 114 reverse shoulder arthroplasty, 51, 52
implant loosening, 130 total shoulder arthroplasty, 49, 50
implant selection, 114 Articular cartilage
incidence, 112 functional unit, 5
internal fixation, 112, 114 homeostasis, 10
intra-operative fluoroscopy, 114 osteoarthritic, 7–9
Kaplan–Meier survivorship, 131
open reduction, 112
open reduction internal fixation, 115, 130 B
postero-lateral approach, 114, 124, Bipolar fresh total osteochondral allograft
130, 131 (BFTOA), 191
post-operative care, 115 Bone marrow aspirate concentrate (BMAC)
revision surgery, 128 injection, 188
surgical planning, 113, 114 Bone marrow edema, 21, 22
total hip arthroplasty, 112, 115, 128–132 Bone remodeling, 5
Affordable Care Act (ACA), 38
Ankle osteoarthritis
allograft transplantation, 191 C
anatomy, 186 Calcaneus fracture, 200, 201
ankle arthrodesis, 188 Capsulorrhaphy arthropathy, 47
bipolar fresh total osteochondral Carpal instability adaptive (CIA), 78
allograft, 191 Carpal instability dissociative (CID), 75
conservative treatment, 187, 188 Carpometacarpal (CMC) arthritis, 105, 106
epidemiology, 186, 187 Carpus and intercarpal joints, 74, 76
fibular osteotomy, 190 Cartilage degeneration, 7
operative treatment, 188–191 Cartilage homeostasis, 5

© Springer Nature Switzerland AG 2021 219

S. C. Thakkar, E. A. Hasenboehler (eds.), Post-Traumatic Arthritis,
[Link]
220 Index

Conventional radiography (CR) distal humerus hemiarthroplasty, 67

arthroscopy confirmed grade II femoro-­ elbow arthrodesis, 69
tibial chondromalacia, 18 interpositional arthroplasty, 66, 67
disadvantages, 18 intra-articular distal humerus fractures, 60
5-point K-L scoring system, 16 nonsurgical treatment, 62
joint space narrowing, 16, 19 osteocapsular debridement
K-L method, 18 arthroplasty, 63–66
malleolar fracture, 18 post-traumatic elbow stiffness, 61
Takakura method, 18 radiocapitellar arthroplasty, 67
talar tilt angle, 18 surgical planning, 61, 62
Van Dick method, 18 surgical treatment, 62
total elbow arthroplasty, 68, 69
Extensor pollicis longus (EPL), 88
D
Darrach procedure, 91
Distal femur fractures F
epidemiology, 153, 154 Finite element simulation study, 5
intra-articular correction of deformity, Foot injuries
162, 164 anatomy, 200, 201
natural history, 154, 155 arthritic degeneration, 202
nonoperative management of post-­ calcaneus fracture, 200, 201
traumatic arthritis, 155 hondrocyte injury, 200
operative management of post-traumatic hindfoot and midfoot fracture healing,
arthritis, 155, 156 204, 205
patient evaluation, 155 hindfoot varus deformity, 202
primary arthroplasty, 156, 157 imaging, 207, 208
staged osteotomy, 158, 159 long-term functional disability, 199
total knee arthroplasty, 158 nonoperative management, 208
Distal humerus hemiarthroplasty, 67 operative management
Distal interphalangeal (DIP) arthritis hindfoot, 209, 210, 212
arthroplasty, 100 midfoot, 212–214
bony mallet finger injuries, 98 physical examination, 206
carpometacarpal arthritis, 105, 106 preoperative examination, 205
complications, 98 symptomatic subfibular impingement, 201
compression screw, 98 TMT injuries, 200
conservative treatment, 98 5-point K-L scoring system, 16
flexor digitorum profundus avulsion
injuries, 98
Herbert compression screws, 99 G
K-wire, 98 Garden III or IV fractures, 139
metacarpophalangeal joint arthritis,
103, 104
proximal interphalangeal joint H
injuries, 100–103 Hand arthritis
steroid injections, 98 artificial joint replacement, 97
Distal radioulnar joint (DRUJ), 76 distal interphalangeal arthritis, 98–100
prevalence, 97
Hemiarthroplasty, 50, 51
E Hip
Elbow arthrodesis, 69 management
Elbow fracture primary prevention, 33
bimodal age distribution, 60 secondary prevention, 34
classification, 60 tertiary prevention, 34
Index 221

post-traumatic osteoarthritis M
acetabular fractures, 31 Malleolar fracture, 18
hip dislocations, 33 Mayo Elbow Performance Index
osteonecrosis, 33 (MEPI), 66
total direct cost, 35, 36 Medial opening wedge
total indirect cost, 36, 37 osteotomy, 191
Humeral resurfacing, 51 Medicare Severity Diagnosis-Related Groups
Hyaline cartilage, 21 (MS-DRGs), 38
Meniscal injuries, 27, 28
Mesenchymal stem cells (MSCs), 7
I Metacarpophalangeal (MCP) joint arthritis,
ICD-10 coding system, 37, 38 103, 104
Intercarpal and radiocarpal arthritis
management, 81–83
S4CF vs. PRC, 83, 85 N
scaphoid nonunion advanced collapse, 79 Non-inflammatory arthritis, 9
scapholunate advanced collapse, 78, 79
surgical technique, 88
total wrist arthrodesis, 86, 87 O
total wrist arthroplasty, 86 Osteoarthritic synovial system, 9
wrist denervation, 85, 86 Osteoarthritis (OA)
International osteoarthritis research society atypical locations, 16, 17
(IOARS), 172 pain and imaging findings, 21, 22
Interpositional arthroplasty, 66, 67 posttraumatic vs. idiopathic, 16
Intra-articular distal humerus fractures, 60 Osteocapsular debridement
Intra-articular fractures, 28, 32 arthroplasty, 63–66
Isolated intercarpal arthritis Osteochondral allografts (OCA), 173
lunotriquetral arthritis, 89, 90 Osteonecrosis, 33
pisotriquetral arthritis, 90, 91
scaphotrapeziotrapezoidal arthritis, 89
P
Parathyroid hormone (PTH), 10
J Patient-specific finite element stress
Joint space narrowing (JSN), 16, 19 analysis, 4
Pauwel III fractures, 139
Pipkin I fractures, 138
K Pipkin III fractures, 138
Knee Pipkin IV fractures, 136, 139
management Pisotriquetral arthritis, 90, 91
primary prevention, 28 Posttraumatic arthritis (PTOA)
secondary prevention, 29 arthroplasty, 143, 145, 146
tertiary prevention, 29, 30 core decompression, 145
post-traumatic osteoarthritis epidemiology, 135, 136
anterior cruciate ligament injury, 27 femoral head fracture, 138, 139
intra-articular fractures, 28, 32 femoral neck fracture, 139
meniscal injuries, 27, 28 hip arthrodesis, 146
total direct cost, 35, 36 hip arthroscopy, 143, 144
total indirect cost, 36, 37 hip dislocation, 138
hip preservation, 144
intertrochanteric fractures, 141, 142
L non-operative management, 143
Latency-associated peptide (LAP), 6 pathophysiology, 136, 137
Lunotriquetral arthritis, 89, 90 trochanteric fractures, 142
Lunotriquetral interosseous ligament (LTIL), 75 varus malunion, 145
222 Index

Post-traumatic glenohumeral arthritis long-term outcomes, 168

arthroplasty osteochondral allografts, 173
hemiarthroplasty, 50, 51 osteotomies, 173, 175
humeral resurfacing, 51 risk factors, 169
reverse shoulder arthroplasty, 51, 52 total knee arthroplasty, 174, 177, 178
total shoulder arthroplasty, 49, 50 unicompartmental knee
causes arthroplasty, 174
fractures, 46, 47 reconstructive surgery, 169
instability, 47 soft-tissue injuries, 168
isolated chondral lesions/ Total elbow arthroplasty (TEA), 68, 69
osteochaondral injury, 48 Total knee arthroplasty (TKA), 29
complications, 53 Total shoulder arthroplasty, 49, 50
non-arthroplasty surgery, 52, 53 Total wrist arthrodesis, 86, 87
nonoperative management, 48, 49 Total wrist arthroplasty, 86
preoperative evaluation, 49 Transforming growth factor-beta (TGF-β)
Proximal humerus fractures, 46 activation mechanism, 6
Proximal interphalangeal (PIP) joint articular cartilage
injuries, 100–103 functional unit, 5
PTH type-I receptor (PTH1R), 11 homeostasis, 10
osteoarthritic, 7–9
bisphosphonates, 10
R clinical effects, 10
Radial head and neck fractures, 60 disease-modifying efficacy, 10
Radiocapitellar arthroplasty, 67 function and behavior, 10
Reverse shoulder arthroplasty, 51, 52 isoforms, 5
latency-associated peptide, 6
osteoarthritic synovial system, 9
S parathyroid hormone, 10
Scaphoid nonunion advanced collapse patient-specific finite element stress
(SNAC), 79, 81 analysis, 4
Scapholunate advanced collapse potential therapy, 10
(SLAC), 78, 79 PTH upregulates BMP and Wnt
Scaphotrapeziotrapezoidal arthritis, 89 signaling, 11
Subchondral bone Smad-dependent canonical pathway, 6
functional unit, 5 subchondral bone
osteoarthritic, 6, 7, 10 functional unit, 5
Supramalleolar osteotomy, 191 osteoarthritic, 6, 7, 10
temporal-spatial regulation, 6
type-I and type-II receptors, 6
T Triangular fibrocartilage complex (TFCC), 77
Tibial plateau fractures, 32 Tricortical iliac crest bone autograft, 210
bicondylar fracture, 168
classifications systems, 168
CT imaging, 168 U
genetic and environmental factors, 169 Ulnohumeral arthritis, 60
incidence, 167
ligamentous injuries, 168
medial unicondylar fracture, 168 W
meniscal injuries, 168 Wrist
posttraumatic osteoarthritis (OA) anatomy
conservative treatment, 172 carpus and intercarpal joints, 74, 76
ligamentous instability treatment, 168 distal radioulnar joint, 76
Index 223

arthritis isolated radiocarpal arthritis, 88

distal radioulnar joint and ulnocarpal lunotriquetral arthritis, 89, 90
arthritis, 91, 92 pisotriquetral arthritis, 90, 91
evaluation, 77, 78 scaphotrapeziotrapezoidal
intercarpal and radiocarpal arthritis (see arthritis, 89
Intercarpal and radiocarpal arthritis) denervation, 85, 86