JBJS Editor’s Choice—Anatomy: A Variable Key to Success in Orthopaedics
In the July 6, 2016 issue of The Journal, Weinberg at al. carefully measure the rotational profile of 600 cadaveric human forearm bones. The precision of these measurements is outstanding and sets a new standard for this type of investigation. The authors put real numbers on the rotational relationships between the radius and ulna that Evans first proposed in JBJS in 1945—and that many surgeons have relied on for intraoperative assessments of forearm rotational alignment since then.
What this investigation documents is the wide range of rotational profiles in the human forearm, with broad standard deviations. It confirms what all clinicians experience every day—each patient’s anatomy is different. There is commonality in hard- and soft-tissue structure overall, but the range of size, shape, density, length, and rotation is patient-specific and highly variable.
Whether closed, percutaneous, or open methods are applied, the skill and experience of the surgeon trump radiographic rules/tips/guidelines. As is often said with fracture reduction, the surgeon is responsible for 80% of the outcome. Studies comparing different casting methods or fixation devices provide useful information that address the remaining 20%, but surgical technique and surgeon experience/judgment are the major determinants.
We must always remember that each patient is not only emotionally and socially unique, but also anatomically unique. Our job is to restore their individual anatomy to the best of our clinical ability. I am therefore not sure that repeating high-precision measurements of other osseous structures—only to re-confirm anatomic variability—will have much ultimate value for our community.
Marc Swiontkowski, MD