Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The most lasting legacy from William Harris’s classic evaluation of post-traumatic mold arthroplasty published in 1969 is embodied in the paper’s subtitle, which refers to “a new method of result evaluation.” This end-result analysis evaluated 39 mold arthroplasties performed to treat traumatic arthritis at Massachusetts General Hospital between 1945 and 1965. Based on this series, the author at the time concluded that mold arthroplasty was the treatment of choice for most patients who require surgery for traumatic arthritis.
However, the most enduring part of this article can be found in the methods section, where the author proposed a hip score, a “single, reliable figure” designed to be equally applicable to different hip problems and different treatments. Dr. Harris designed the 100-point system to be reproducible and reasonably objective, giving a maximum of 44 points to a pain category, 47 points to functional capacity, 5 to range of motion, and 4 to absence of deformity. By using the scores pre- and postoperatively for this series of mold-arthroplasty patients, the author demonstrated how the new rating appeared to give a more accurate assessment of patients, relative to the Shepherd and Larson methods that were widely used at the time.
Dr. Harris broke down the function part of the score into daily activities (including stairs, socks and shoes, and comfort while sitting) and gait (with or without limping, with or without support). Over the years, this scale, along with the Postel Merle d’Aubigné developed in the 1950s, became the international gold standards to evaluate the pre- or postoperative state of the hip joint during everyday life. Not surprisingly, 46 years after its original publication, Dr. Harris’s paper remains the highest cited paper in the hip and knee arthroplasty literature, with nearly 2,500 citations.
Although the findings in this study focused mainly on post-traumatic arthritis treated by mold arthroplasty, the evaluation system proposed in the paper is used today in routine evaluations at almost every orthopedic center involved in hip arthroplasty. It’s used to clinically evaluate the hip joint before surgery and to evaluate the result after surgery at regular short-term follow-ups. It has also been used over the course of decades to evaluate the long-term performance of replaced joints. In addition, it is the clinical tool we use to compare various surgical techniques, different hip prosthesis designs, and case series from different institutions.
More recently, investigators have highlighted the importance of patient-reported measures of outcomes to better appreciate patient expectations before hip arthroplasty and to better evaluate patient satisfaction after surgery. Regardless of whether the primary goal of the operation is to relieve pain or get a person back on the athletic field, I think the system established by William Harris will remain the baseline for all arthroplasty surgeons, even if future scoring systems routinely incorporate patient-reported outcomes or quality-of-life measures.
Jean-Noel A. Argenson, MD, PhD
JBJS Deputy Editor for Adult Hip and Knee Reconstruction