Está en la página 1de 7

This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you

requested follows this cover page.

Significance of the straight-leg-raising test in the diagnosis and clinical evaluation of lower lumbar intervertebral-disc protrusion
SQ Xin, QZ Zhang and DH Fan J Bone Joint Surg Am. 1987;69:517-522.

This information is current as of May 14, 2010 Reprints and Permissions Click here to order reprints or request permission to use material from this article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org

Publisher Information

522 65 degrees, movement A small compress 40 degrees and caught at more

XIN

SHIQING,

ZHANG

QUANZHI,

AND

FAN

DEHAO

and

less that was

being painless. be enough to However, moved momentary reached because was the Fu at forward 65

protrusion the nerve

of straight-leg against the

degrees in most elderly people. Protrusion of a disc is usuthan those points and straight-leg raising is seldom limited, alwas not thought ally to minor many patients have pain in the back as well as at found at operation. though the root. A fifty-nine-year-old man in this series had raising the nerve nerve of pain in the perineal and lower sacral region, prominence, causing symptoms

ofthe bladder, and analgesia, together with numbpain. When continued straight-leg raisingweakness area. However, the result of the straightdegrees, the nerve slipped over the protrusion ness in the saddle leg-raising test was negative. At operation, a small central it was small. The disc was removed and the pain protrusion was found at the lumbosacral level; it compressed relieved. is a remarkable and that the nerve protrusion if the relationship during lies between straight-leg anterior to the raising. the site chiefly of the fourth sacral nerve. As the limb, it was not stretched Tao lower nerve, ing. Tay and Chacha reported the this nerve does not during straight-leg cases of four patients reach raiswho

There protrusion found

straight-leg raising obviously will be limited. the thirty-seven patients in our series who protrusion had an angle raising have severe never be this reason. fourth of straight-leg is not sciatica necessarily due

had a prolapse at the midline of the disc between the fifth Thirty-four of and first sacral vertebrae; most did not have any had this type lumbar of of straight-leg raising. We also saw a patient who raising of 40 degreeslimitation limited to a lesion even had acute pain in the limited to 20 degrees, in Myelography back but showed and the straight-leg patient had herniated raising that was no neurological disc between

or less.
Straight-leg patients who and it must present for third, and derive from straight-leg

signs. of a disc,

a large

assumed that a protrusion cannot the fourth be and The dorsal divisions of the second,sage therapy, nerves from Since femoral the flexion nerve, femoral

fifth lumbar vertebrae. the pain ceased and

After a week of masstraight-leg raising rewe found a physiological evident the

lumbar

the lumbar plexus. raising slackens the plexus, if the the third or

turned to a normal nerve nerve of the hip fifth lumbar on diminishing transection of the

range. On examination, to be so compressed that nerve had occurred.

It is quite

tension on the lumbar relieved. Consequently, alad to the level of raising dard and will not Reid. be

pain from this source may that ischemic be atrophy of the nerve, due protrusion lies in a disc cephfrom a huge protrusion, had occurred. lumbar vertebra, straight-leg patient had become subjectively better limited, of a disc as confirmed develops by Godcoming anatomically and was to varyingof surgery References worse. excluded

to extreme pressure In other words, the but in fact was beour offer

painful

Degeneration

The patient refused from the study.

I. 2. 3. 4. 5. 6. 7. 8. 9. 10.

AN-XIA,

LIN;
ALF.

HAN-SHEN.

S1I1N;

SHU-TIAN.

LI:

BING-XIN.

LONG:

and

YU-CHEN. Nerve Roots.

TheLU0:Diagnosis
Acta Radiol.

and

Operative

Treatment

of

Protrusion

of

the
BREIG,

Lumbar I.

Intervertebral
and MARI0N5.

Disc.
OLLE:

Chinese H.: The

J. Signs

Orthop. . 3:
of

162-165.
the

1983. Brudzinski. Arch. Neurol.. 21: Protrusion. With Special Reference 1: Diag., 1 141-1 160. 1963. 215-218. 1969. to the Straight-Leg-Raising

Biomechanics

Lumbosacral

BRODY,
CHARNLEY.

A., and WILKINS,

R.

of

Kernig

and

JOHN: Orthopaedic Signs in the Diagnosis of Disc Test. Lancet, 1: 186-192, 1951. DAY. P. L., and HINCHEY. J. J.: Herniated Intervertebral Lumbar Disks Operated upon. A Follow-up Study of200 Cases. Some Southern Med. J. , 55: 663-666, 1962. EDGAR. M. A. . and NUNDY. S.: Innervation of the Spinal Dura Mater. J. Neurol. . Neurosurg. and Psychiat. . 29: 530-534. 1966. EDGAR. M. A. and PARK. . W. M. : Induced Pain Patterns on Passive Straight-Leg Raising Lower in Lumbar Disc Protrusion. A Prospective Clinical. Myelographic and Operative Study in Fifty Patients. J. Bone and Joint . 56-B(4): Surg. 658-667. 1974. FALCONER, M. A. : MCGEORGE. MURRAY: and BEGG. A. C. : Observations on the Cause and Mechanism of Symptom-Production in Sciatica and Low-Back Pain. J. Neurol.. Neurosurg. and Psychiat.. 11: 13-26. 1948. FU. TAo: Discussion on the Relevant Problems of Lumbar Intervertebral Disc Protrusion. Chinese J.1: Orthop.. 65-70. 1981. GODDARD, M. D. . and REID, J. D.: Movements Induced by Straight Leg Raising in the Lumbo-Sacral Roots. Nerve and Plexus. and in the Intra Pelvic Section of the Sciatic Nerve. J. Neurol., Neurosurg. and Psychiat. 12-18. . 28: 1965.

I 1 . GUANGJIE, LIU. and FAXIONG, LIN: Long-Term Follow-up Study of Lumbar Intervertebral Disc Protrusion Operations and Discussion on Some Relevant Problems. Chinese J. Orthop.. 1: 92-96. 1981. 12. JACKSON, H. C.. II: WINKELMANN. R. K.; and BICKEL. W. H.: Nerve Endings in the Human Lumbar Spinal Column and Related Structures. J. Bone and Joint Surg.. 48-A: 1272-1281. Oct. 1966. 13. OCONNELL.. J. E. A.: Sciatica and the Mechanism of the Production of the Clinical Syndrome in Protrusions of the Lumbar Intervertebral Discs. British J. Surg. . 30: 315-327, 1943. 14. RANG, M. C.: Anthology of Orthopaedics, p. 150. Edinburgh, E. and S. Livingstone. 1966. 15. STEINDLER, ARTHUR: An Analysis and Differentiation of Low-Back Pain in Relation to the DiscJ. Bone Factor. and Joint Surg.. 29: 455-460. April 1947. 16. TAY, E. C. K. , and CHACHA. P. B.: Midline Prolapse of a Lumbar Intervertebral Disc with Compression of the Cauda Equina. J. Bone and Joint Surg. , 61-B(l): 43-46, 1979. 17. WOODHALI.. BARNES, and HAYES. G. J.: The Well-Leg-Raising Test of Fajersztajn in the Diagnosis of Ruptured Lumbar Intervertebral Disc. J. Bone and Joint Surg. . 32-A: 786-792. Oct. 1950. 18. YUPU. LU; KAIJUN. SHI: YAOTIAN, HUANG; PING. MA: LAITANG. Xu: and XINDONG. ZHANG: Surgical Treatment for Protrusion of the Lumbar Disc. Chinese J. Orthop.. I: 77-82. 1981.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

Copyright

I 987

by The

Jourrtu!

of Boric

uttd

Joint Stir,eo,

liteiirpiiruted

Revision
BY BERNARD From F. tile MORREY, Department of

Total
M.D.t, AND Orthopedics,

Elbow
RICHARD Mayo S. Clinic

Arthroplasty*
BRYAN, and Mayo M.D.t, boutidation. ROCHESTER, Rochester MINNESOTA

ABSTRACT:

Over revision institution. years

a total after

ten-year elbow These the

period, arthroplasties were revision, months. result poor assessed with

thirty-three were an perIn the ten at a mmelbow-replacement average stitution. were of the due Mayo to revisions initial Clinic

Materials years from procedures of a failed fourteen for prosthetic and

and

Methods 1972 through I, 98 1 total 235 were performed at our

consecutive formed imum length cent) cent) of

at our three

in-

Thirty-three

these. implant had

in

twenty-eight arthroplasty. had been done elsewhere. done

patients. Nineteen at the The

of follow-up of the elbows had a poor

of sixty-one had a good result The

Eighteen (55 per and fifteen per (45 results were prosthesis pain in surgical fifteen the

arthroplasties been

infection in three elbows, six, inadequate motion and sion that good came prosthetic failure in with another implant initially had a poor in twenty-four infected after and all data from is a viable

loosening of the in two, continued two. was Additional done in the Eventually

information in two, consisted revithat had elbowsto surgical

that was sought in the records of the patients of the initial diagnosis, the number of procedures been performed prior to the arthroplasty, the time revision, and the indication for the revision. The

result.

result was

elbows. surgical were this option rated study for

The three elbows that revision had a resection as having indicated the revision

technical difficulties at revision as well as the immediate and delayed becomplications were recorded. ar- Twenty-two of the elbows were affected by rheumatoid

throplasty The tation

a fair result. arthritis; ten, by post-traumatic arthritis; and one. by primary that reimplan- degenerative arthritis. Two of the patients who had rheuof a failed total matoid arthritis had had three surgical procedures and two

elbow arthroplasty, although may be required. They also tients who have post-traumatic undergo a total joint replacement, cedures should be performed several experience tation selected An surgical with as patients. essential feature of any options and these options. procedure

more than one revision had had one procedure prior to the initial joint replacement, suggested that young and pa- the ten patients who had post-traumatic arthritis had arthritis should undergone not one to seven surgical procedures before the initial and that revision proelbow replacement was performed. Thus, fourteen (42 per in settings that can offer cent) of the elbows that required revision had had at least by surgeons Alternatives should one previous who have had to reimplan- replacement be considered in Revision Rutherford, joint-replacement Indiana), procedure Warsaw, surgical surgery. was New procedure required nine for before ten the Mayo (Zimmer, initial elbow-

a revision

(Howmedica, Warsaw, (GSB) (DePuy, (Codman), two Pritand Instem

Jersey),

Coonrad

six Gschwend Indiana), two

Scheier Bahler capitellocondylar

must be the potential for converting a failed arthroplasty Silastic to (Dow Corning, Arlington. Tennessee), one a functional one. Early attempts to replace the elbow joint chard-Walker-lI (DePuy). one Schlein (Howmedica). with a constrained-hinge prosthesis were frequently charone Dee (Orthopedic Equipment Company. Warsaw, acterized by failure because of loosening, requiring removal diana) prosthesis. and for one custom-made ulnar of the prosthesis3
t.13#{149}

The

options

for include and

salvage arthrodesis, reimplantation

that

are (Codman, resecIndications of a All options knowl-the pain

Randolph, for of the being Revision elbows moderate

Massachusetts). (Table I) at the time of revision, in all but three. In four

available in these tion or interpositional

circumstances arthroplasty,

second prosthetic device. have been mentioned by edge such no report has revision. reviewed yet surgical We have

However, although several authors246, dealt critically with experience

these to our the

were painful or severe

results with

a ten-year

of patients. the humerus had bone that followed loosening prospatients the ulna had fractured prosthetic fractured

fractured due to resorption of of the prosthesis. and in two for the same reason (Fig. 1). elbows. The ulnar component humeral frac-

thetic replacement had failed. It was effectiveness


No benefits

in thirty-three the intent particular


form have

elbows in which an implant The of this study to document stem the option
been received

device failed in three in a Mayo device, the

of

this

for

salvage.
be

in any

or will

a commercial party related directly or indirectly to the subject No funds were received in support of this study. 1 Department of Orthopedics. Mayo Clinic. Rochester. 55905. Please address requests for reprints to Dr. Morrey.

tured in an early non-metal-backed capitellocondylar prosthesis, and a Swanson Silastic prosthesis fractured. One capitellocondylar prosthesis became unstable and dislocated received from recurrently (Fig. 2). ofthis article. In the elbows that were affected by rheumatoid arMinnesota thritis. nine Mayo, six GSB, three Coonrad, two capitel523

VOL.

69-A,

NO.

4,

APRIL

1987

524 locondylar, the elbows there one one that Schlein, were and affected one by

B.

F.

MORREY

AND

R.

S.

BRYAN

Silastic device post-traumatic

failed. In arthritis,

were five Coonrad, three Pritchard-Walker prosthesis Silastic primary


TABLE
INDICAT IONS FOR REVISIO N IN

custom-made, that were prosthetic degenerative


I
THIRTY-THREE

one Dee, and loose. The device fractured arthritis.

stemmed interpositional in the patient who had

ELBOWS

Rheumatoid Arthritis
Loosening

Post-Traumatic Arthritis

Degenerative Arthritis

Humerus
Ulna

Both
Failure of the

I I (4)* 2 (l)* 5 2 2 22

6 I (l)* 3 I 0 10 1 of one fractures fractured after loosening. ulnar component

implant Instability
Total
*

Numbers

in parentheses fractured
Silastic

are numbers
(Mayo) and

t One (capitellocondylar).

stem

1: Fractured Only chard-Walker) who had prostheses constrained The dependent occurred. of the condylar one

implant.

of

the

newer

hinge-design

implants

(Prit-

became post-traumatic that became design type on Loss and of implant the extent of bone

loose, and this occurred in a patient arthritis. All of the other hinged loose were of the so-called tightly had been implanted before 1978. that was chosen for revision was of loss of humeral bone that had was classified as moderate and as severe
II
REVISION

as mild

if all

or

part

trochlea bone

was present, was present,


TABLE

if only the supraifonly the humeral


A Mayo-design fractured at the tip total elbow prosthesis of the prosthesis. became loose. and the humerus

Loss

OF B ONE

AT

THE

TIM

E OF

TIN HIRTY-THREE
Degenerative

ElBOWS

long-stemmed itellocondylar prostheses that

Mayo device; prosthesis. were used for

and one, Over-all, revision

a long-stemmed seventeen had

of

capthe

Rheumatoid

Post-Traumatic

Arthritis Mild Moderate Severe


Total

Arthritis 0 6 4 10

Arthritis I 0 0 1

Total 4 21 8 33

a long-stemmed

3 15 4 22

humeral component, six to eight inches (15.2 to 20.3 centimeters) in length. The mean time to revision was 34.4 months (range, ten to eighty-four months). In the elbows that were affected by rheumatoid months (range, arthritis, nineteen longer than the mean time to eighty-four the average of to revision months), 14.8 months was which 43.4 was

diaphysis severe three

remained loss of bone elbows (Table

(Figs. was II)

3-A, present (Figs.

3-B,

and

3-C).

Moderate of the

significantly or

(range,

in twenty-nine 4-A and 4-B).

thirtyten to thirty-two traumatic arthritis sistent with the

months) for the patients who had post(p< 0.01 . rank sum test). This is conclinical observation that the demands on a in they the are patient in the who patient has who rheumatoid has post-

Revision
used Six different for twenty-nine commercially available prostheses ofthe revision procedures, and

total elbow prosthesis were arthritis are less than custom- traumatic arthritis.

made implants were used for four. Six of the prostheses Three of the elbows that had a revised arthroplasty were of the early Coonrad design, with a constrained-hinge became infected, leaving thirty revised arthroplasties in articulation. Twelve of the prostheses were of the Coonrad- twenty-six patients for long-term analysis. For nineteen paII design, with a less constrained hinge. and two were tients, of a physical examination was performed at the Mayo the Coonrad-Ill design, with an anterior flange. Five elbowsClinic by one of us at least two years postoperatively. and was examined by a local physician. Six patients had a loose-hinged Pritchard-Walker-Il prosthesis; three, a one patient
THE JOURNAL OF BONE AND JOINT SURGERY

REVISION

TOTAL

ELBOW

ARTHROPLASTY

525

A capitellocondylar

prosthesis

dislocated

recurrently.

and

this

persisted

for

a year

after

the

initial

procedure.

FIG.

3-A The classification of loss of bone

FIG.

3-B in the distal theparthumerus of depends on

Flu. the

3-C natureof the


lesion and the design

Figs. of the Fig. Fig. Fig.

3-A, initial 3-A: 3-B: 3-C:

3-B. and prosthesis. Mild loss Moderate Extensive.

3-C:

stock

of bone. loss of bone. severe loss

of

bone.

VOL.

69-A,

NO.

4.

APRIL

1987

526

B.

F.

MORREY

AND

R.

S.

BRYAN

FIG.

4-A removal a gunshot of a humeral injury and

FIG. component from an infected of a total elbow failure arthroplasty

4-B limb. that had been performed at another institution.

Fig. Fig.

4-A: 4-B:

Moderate Extensive

loss loss

of of

bone bone

after after

had

had

their only All

most one and

recent year current

physical postoperatively, radiographs

examination but were they

in our available

the de-

partment evaluation. of three posterior

completed arthritis patients for

twenty-two and who

four had

elbows good

that and six

were fair

affected or poor arthritis

by results (Table

rheumatoid in the ten IV). The

a questionnaire

post-traumatic

followed for a minimum major cause of the poor and fair results in the patients who A standardized antero-had rheumatoid arthritis was less than 50 degrees of flexion in extension and a lateral two, in uncoupling of the implant in one, painful loosening in infection in two, and pain in one. In the patients radiograph with the elbow flexed to 90 degrees to include two, who had post-traumatic arthritis, loosening was the cause the tip of each prosthetic stem were made for the patients who were evaluated at the Mayo Clinic. The radiographs of a poor or fair result in four, residual pain in one, and were reviewed, with specific attention paid to the effecinfection in one. In the patient who had degenerative arthritis, the early-design high-density-polyethylene ulnar tiveness of the cementing techniques that had been used and of the capitellocondylar resurfacing device that to the progression of radiolucent lines#{176}. he clinical T resultcomponent was rated as good, fair, or poor according to a previously was used in the first revision fractured, and the arthroplasty described7 scale for rating pain, motion, and stability of was revised the a second time with a new ulnar component. elbow quired, (Table III). lf the device the result was classified Results Based were on the fourteen criteria good for and pain, eight motion. fair or and poor failed or as poor. revision was reTechnical Aspects of the Revision Procedure were evaluated. operations were both mean
OF BONE

of the patients were years (average, five years). radiograph with the elbow

rations

Several technical of the initial

and

variables revision

The ducompared had initial

there

stability, for the nineteen elbows in which results been done in at our institution. The
THE JOURNAL

of the procedures duration ofthe


AND JOINT

SURGERY

REVISION TABLE
CLASStFICATION Criterion Pain

TOTAL

ELBOW

ARTHROPLASTY

527 than one millimeter time or noted wide interface. ofrevision, in the around and involved

III
OF RESULTS Points

line

that

was

more

at least one-half of the bone-cement the variable quality ofbone atthe not accurately that was The were not results loose. of the that V. follow-up required In 50 judge due resorption small to bone that loosening was

Because of we could resorption any study, device inof No

differences

None Mild Moderate Severe

occasional,
-

no

medications

occasional incapacitating

medications,

limits

activity

60 40 20 0

stress-shielding.

progressive

of bone

radiographic

Motion Extension-flexion 90 degrees 60-89 degrees 30-59 degrees <30 degrees


Stability

arc
30 20 10 0
not impairs limit activity certain functions

eluding the elbows are shown in Table had had post-traumatic been used, and

a second or third revision, per cent of the patients who technique a second

arthritis. inadequate cementing four of those elbows required


TABLE IV
E ELBOWS

Mild Moderate Severe Result

does
-

markedly

limits

activity

10 5 0 75 50-74 <50

RESULTS

IN

THIRTY-THRE

Good
(satisfactory)

Fair 2* 1* 0 3 (9) 6t 5 1

Poor

Good
Fair Poor

Rheumatoid Post-traumatic Degenerative


Total

arthritis arthritis arthritis

14 4 0 18 (55k)

12 (36%)

surgical (range, minutes),

procedure two

was

two

hours

and

fifty-six

minutes
*

hours and fifteen minutes and the mean duration of

to four hours and fifty the revision procedure

Infected. with juvenile device. painful elbow. rheu-

was three hours and twenty-one minutes (range. one and thirty minutes to four hours and fifty-five minutes). The increased complexity of the revision procedure was prerevision. dictably reflected in a moderate increase in operating time. menting integrity

One painful elbow. two stiff elbows associated matoid arthritis. two loose devices. and uncoupled OflC hour : Four elbows with a loose device and one
4

These

data

further

document

the

thesis

that

ce-

technique is an important of a cemented replacement that there is a poorer long-term arthritis. post-traumatic

variable implant;

in the long-term they also emin patients

Motion
year ure Motion in the of the

phasize

prognosis

before and after surgery was studied at one who have thirty elbows that did not become infected. FailComplications initial arthroplasty did not adversely affect the At Removal

motion that was obtained after the revision procedure. one year, the average flexion was 128 degrees (range. 100

of

the

cement
TABLE

at the
V

time

of

revision.

partic-

to 140
(range, and

degrees), 5 to 50

the degrees), was

average and

extension the average (range, 90

was 26 degrees arc of pronation to 1 80 degrees).

RADIOGRAPHIC DIAGNOSIS

APPEARANCE IN THIRTY

CORRELATED ElBowS

WITH

supination

1 39 degrees

This amount of motion has been demonstrated to be adequate for most activities of daily living9 and was virtually identical to the amount that had been obtained after the initial arthroplasty.
Rheumatoid arthritis Adequate/progressive

Mean Length of Follow-up (Mos.) 54

Humerus* (No.)

Ulna* (No.)

I 2/0 8/) 1 )

20/( 0/0

I)

Radiographic
The

Analysis

loosening
Inadequate/loose

Post-traumatic or 80 radiographs of the thirty elbows from which the degenerative arthritis implant was not removed because of infection were studied Adequate/loose at a minimum of thirty-six months after surgery. The mean Inadequate/loose length of radiographic follow-up was 53.5 months (range, * Numbers in parentheses indicate thirty-six to eighty-four months) for the patients who had vision was done because of loosening. rheumatoid arthritis and 79.5 months (range, thirty-six to 120 months) for those who had post-traumatic arthritis. ularly from the proximal part The ulnar cortex was The cementing technique that was used for the revision difficult.

51(0) 5/(4) elbows in which

10/2 0/0 subsequent re-

of the ulna, proved penetrated in three arthritis arthritis.

to be elbows that cor-

affected was rated as inadequate if the cement did that were not were affected by extend past the tip of the prosthesis or if a gap of at least one millimeter was visible along at least one-half of tex was similarly the bone-cement interface on either the anteroposterior or two elbows, the both (Fig. 5). A total lateral radiograph. The postoperative radiographs were rated according to the presence or absence of a progressive lucent complication, and procedure
VOL. 69-A, NO.
4. APRIL 1987

by rheumatoid post-traumatic

and in three The humeral

violated in two patients in each the humerus and the ulna were of eight elbows (24 per cent) it was the only complication

group. In penetrated had this in four of