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JBJS Classics: Porous-Coated Hip Components

JBJS Classics Logo.pngOrthoBuzz regularly brings 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 highlight the impact that these articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

In their classic 1987 publication, Drs. Charles Engh, Dennis Bobyn, and Andrew Glassman described clinical and radiographic results of a series of 307 hips with 2-year follow-up, and 89 hips with 5-year follow-up after total hip arthroplasty in which the patients had received an extensively porous-coated femoral stem. The authors also described histologic evaluation of 11 hips retrieved at autopsy or revision.

By 1987 the same authors as well as other investigators had already published observations concerning the influence of femoral stem size, shape, stiffness, and porosity on clinical and radiographic evidence of fixation and stress shielding in humans and animal models.1,2 But this study, which so far has been cited more than 1500 times, goes “above and beyond” by carefully correlating previous observations with histologic sections obtained through human femora.

Among other achievements, Engh et al. described radiographic criteria for categorizing a femoral implant as either stable by bone ingrowth, stable by fibrous tissue ingrowth, or unstable. Implants thought to be stable by fibrous ingrowth had a prominent radio-opaque line around the stem, separated from the implant by a radiolucent space up to 1 mm in thickness. This line was thought to represent a shell of bone with load-carrying capability. However, histology demonstrated that the space between the shell and the implant was composed of dense fibrous tissue. When the shell was present, there tended to be little hypertrophy or atrophy of the adjacent femoral cortex.

Engh et al. noted that radiographs and histology of hips with extensive ingrowth from the endosteum often showed parallel increased porosity of the adjacent cortex – an early manifestation of stress shielding. Overall, 259 (84%) of the femoral stems had radiographic findings suggestive of bone ingrowth, 42 (13%) had findings interpreted as stable fibrous ingrowth, and 2% were thought to be unstable (but not yet revised at the time of the study). Stress shielding was much more common in larger-diameter stems and those with good bone ingrowth compared to smaller implants or those with stable fibrous fixation.

Why do we consider this manuscript a classic? First, the authors include a careful correlation of histology with radiographic and clinical findings, helping illustrate the importance of tight press fit at the isthmus to achieve proximal fixation. The authors also document intracortical porosity as the morphologic manifestation of stress shielding and emphasize the impact of a small increase in stem diameter on axial rigidity.

Designs of femoral stems have evolved considerably since the 1980s,3 and the findings described in this paper helped validate fundamental principles related to load transmission and bone remodeling4-6 and thus helped advance that evolutionary process.

Thomas W. Bauer, MD, PhD
JBJS Deputy Editor

References

  1. Bobyn JD, Pilliar RM, Binnington AG, Szivek JA. The effect of proximally and fully porous-coated canine hip stem design on bone modeling. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 1987;5:393-408.
  2. Bobyn JD, Pilliar RM, Cameron HU, Weatherly GC. The optimum pore size for the fixation of porous-surfaced metal implants by the ingrowth of bone. Clinical orthopaedics and related research 1980:263-70.
  3. McAuley JP, Culpepper WJ, Engh CA. Total hip arthroplasty. Concerns with extensively porous coated femoral components. Clinical orthopaedics and related research 1998:182-8.
  4. Huiskes R. Validation of adaptive bone-remodeling simulation models. Stud Health Technol Inform 1997;40:33-48.
  5. Huiskes R, Weinans H, Dalstra M. Adaptive bone remodeling and biomechanical design considerations for noncemented total hip arthroplasty. Orthopedics 1989;12:1255-67.
  6. Weinans H, Huiskes R, Grootenboer HJ. Effects of fit and bonding characteristics of femoral stems on adaptive bone remodeling. J Biomech Eng 1994;116:393-400.

JBJS Classics: Fractures of the Talar Neck

JBJS Classics LogoOrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

One of the most challenging diagnoses for general orthopedic surgeons as well as fracture specialists is a fracture of the talar neck. The infrequency of displaced talar fractures means that orthopaedic residents receive relatively little training in this area. A pivotal JBJS article in 1978 focused attention on these vexatious injuries. “Fractures of the Neck of the Talus” by Canale and Kelly provides clinically useful information and does two things that are very difficult to do today:

  • Follows patients for a long time (an average of nearly 13 years)
  • Obtains direct evidence of outcomes by physical exam, one-on-one measurement, and long-term imaging.

This remarkable duration of follow-up, so important in determining the impact of treatment in musculoskeletal injury, is very difficult today as a result of overly enthusiastic privacy protections and a costly regulatory infrastructure.

This classic JBJS article capitalizes on other classics, such as those by Blair (1943) on talar body salvage and studies by Halliburton (1958) and Mulfinger (1970) on the anatomy of talar blood supply. While Mulfinger showed the vascular supply of the talus,1 that study did not link that information to clinical care. The study by Canale and Kelly provides insight into how our care for patients with these uncommon fractures affects outcomes. In addition, the relatively primitive state of art at the time for the operative treatment of talar fractures led to fear of infection, and limited understanding of the basics of fracture healing and underdeveloped implants for fixation steered many surgeons away from rigid fixation in favor of closed reduction and cast immobilization.

The authors identified 107 fractures treated over a 33-year period; they examined and obtained radiographs on 71 of those fractures in 70 patients at an average follow-up of almost 13 years. (Fourteen of the patients were followed for more than 20 years, and 5 were followed for more than 30 years.) The preferred treatment protocol was closed reduction and casting. A reduction with less than 5 mm of displacement and 5° of misalignment was considered adequate. Open reduction with internal fixation was performed when these criteria were not met.

To assess outcomes, the authors directly measured ankle and subtalar motion, assessed whether a limp was present, and asked patients to rate their pain. Long before “patient-reported outcome measures” was a recognized term, these authors recorded them. Only 59% of patients in this series achieved good or excellent outcomes. The authors identified the high morbidity of these injuries, including avascular necrosis in more than half and 25 who needed later surgical intervention. The authors also recommended against talectomy as a salvage procedure.

While hampered by relatively low-resolution imaging and outcome measures that don’t meet current standards of reproducibility, Canale and Kelly provided a great deal of information that focused attention on the importance of quality of reduction. In addition, the paper created an enduring fracture classification that paralleled complication rates and potential outcomes.

Bruce Sangeorzan, MD
JBJS Deputy Editor

Reference

  1. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970 Feb;52(1):160-7

JBJS Classics: Pollicization of the Index Finger

JBJS Classics Logo.pngOrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Even before hand surgery became a specialty, the characteristics of the thumb that enabled pad-to-pad opposition (and therefore fine motor function) were well-recognized:  shorter length, fewer bony segments, and pronated position relative to the fingers; a wide first web space; and intrinsic muscle control of abduction, rotation, and pinch.  Although these principles were used to devise surgical procedures to restore thumb function prior to Buck-Gramcko’s landmark JBJS article in 1971, most were used for a small number of patients, with limited information available about outcomes.  Thumb absence is uncommon, and no hand surgeon was able to gain sufficient experience with index pollicization to refine and enhance the technique until the confluence of Buck-Gramcko’s exceptional skill and one of the major medical catastrophes of the 20th century.

Dieter Buck-Gramcko was born in Hamburg, Germany in 1927.  Following World War II, he trained in general and trauma surgery and became one of the first hand surgeons in Germany.1  Between 1957 and 1962, thalidomide was marketed in Germany as a sedative, but it also inhibited angiogenesis, causing limb malformations, including thumb deficiency, when fetuses were exposed to the drug during limb development.2  The resulting large number of German infants with thumb deficiency provided Buck-Gramcko with the opportunity to modify the technique of index pollicization and study the outcomes of his modifications to improve results. He described his findings and results in this landmark article.

His careful description of index pollicization includes the principles and techniques that remain the hallmarks of this operation.  His diagram of reduction of bones and joints (Figure 3 of his classic article, shown below) is a simple and elegant depiction of the principles of this complex operation.  His rigorous follow-up, measurement of outcomes, and propensity to criticize his own work to improve results are all apparent in this article, which provides an excellent example of applying the scientific method. Not surprisingly, Buck-Gramcko remained rigorous and objective throughout his long career; 20 years later, he published another article focused on complications and poor outcomes after index-finger pollicization.3James Classic Image.png

Index pollicization is one of the paramount operations of hand surgery, largely because Buck-Gramcko applied theoretical principles of thumb function, methodically and meticulously refined the technique of pollicization, studied the outcomes of his work, and passed this valuable information along in this classic article.  It remains a useful guide to the performance of this operation almost half a century later.  The thalidomide tragedy had a silver lining, thanks to Buck-Gramcko’s surgical skills, methodologic rigor, and scientific objectivity.

Michelle A. James, MD
JBJS Deputy Editor

References

  1. Hoffmann R, Lubahn JD. First Hand: Dieter Buck-Gramcko. Journal of Hand Surgery. 2013;38(5):988-90.
  2. Stephens T, Brynner R. Dark remedy: the impact of thalidomide and its revival as a vital medicine. Basic Books, N.Y.; 2009.
  3. Buck-Gramcko D. Complications and bad results in pollicization of the index finger (in congenital cases). Annales de Chirurgie de la Main et du Membre Supérieur 1991;10 (6):506-512).

JBJS Classics: Wiltse’s Paraspinal Muscle-Splitting Approach

JBJS Classics Logo.pngOrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Almost 50 years ago, in a classic 1968 JBJS paper, Leon Wiltse and co-authors described a novel and innovative access route to the lumbar spine. At that time, the vast majority of approaches to the lumbar spine were performed through midline incisions. Wiltse´s approach, however, utilized a more lateral access route to the spine. In this beautifully illustrated paper, the authors described a curved incision of the fascia and the skin with direct access to the transverse processes, pedicles, and the lateral masses.

The advantages of this novel access were multifold. Although wide midline laminectomies represented the gold-standard decompression technique at that time, the lateral approach served to avoid a more challenging and risky midline revision access, adding an elegant access for salvage procedures. Two goals of Wiltse’s approach were to achieve solid, posterolateral fusions and to decompress the neural structures. Graft harvest from the posterior iliac crest was easily facilitated with this approach.

Additional advantages included reduced blood loss and less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments, which served to maintain the stability of the lumbar spine. The main downside was the necessity of performing two skin incisions as opposed to just one midline incision.

Since its introduction, Wiltse´s approach and the anatomic planes have been studied in great detail.1,2 Considering the vast developments in spine surgery over the last years and decades, the Wiltse approach has stood the test of time, as it still represents one of the main access routes to the lumbar spine that any skilled spine surgeon needs to master.

With the arrival of instrumentation, Wiltse´s approach was later employed in interbody fusion and minimally invasive transforaminal lumbar interbody fusion (TLIF) techniques, as it allowed direct access to the pedicles and the disc space. It has also been used for various techniques of direct pars repair.3

With the addition of some minor modifications, Wiltse´s approach still reflects the main access for minimally invasive, microsurgical treatment of foraminal and extraforaminal disc herniations, including bony decompression of the neuroforamen.4 The far lateral access permits sufficient decompression of the exiting nerve roots while preserving the facet joints, which serves to avoid more invasive fusion techniques for a considerable number of patients.

Overall, Wiltse´s innovative approach advanced spinal care by reducing access–related morbidity. Dr. Wiltse passed away at age 92 in 2005. His major achievements in spine surgery and his great accomplishments will remain in our memories and will continue to impact spine surgery over the coming decades.

Christoph J. Siepe, MD
JBJS Deputy Editor

References

  1. Vialle R, Court C, Khouri N, et al. Anatomical study of the paraspinal approach to the lumbar spine. Eur Spine J. 2005;14(4):366-71.
  2. Palmer DK, Allen JL, Williams PA, et al. Multilevel magnetic resonance imaging analysis of multifidus-longissimus cleavage planes in the lumbar spine and potential clinical applications to Wiltse’s paraspinal approach. Spine (Phila Pa 1976). 2011;36(16):1263-7.
  3. Xing R, Dou Q, Li X, et al. Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery. Spine (Phila Pa 1976). 2016;41(8):E494-502.
  4. Mehren C, Siepe CJ. Neuroforaminal decompression and intra-/extraforaminal discectomy via a paraspinal muscle-splitting approach. Eur Spine J. 2016.

JBJS Classics: Cuff-Tear Arthropathy Spurred Shoulder Prosthetic Technology

JBJS Classics Logo.pngOrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Charles Neer II , a true pioneer in shoulder surgery, coined the term “cuff-tear arthropathy” in 1977. In a landmark 1983 JBJS publication, Dr. Neer, with coauthors Craig and Fukuda (both of whom became internationally recognized experts in shoulder surgery), reported on the pathophysiology and treatment of this previously little-recognized condition that was associated with long-standing massive rotator cuff tears.

Neer’s early work with total shoulder arthroplasty, also reported in JBJS, included a small cohort of patients with cuff-tear arthropathy. In the 1983 article on cuff-tear arthropathy, Neer and his coauthors described the pathologic presentation and treatment with total shoulder arthroplasty, along with a proposed pathophysiologic mechanism. They noted that, although it was a difficult procedure, their preferred treatment was “total shoulder replacement with rotator cuff reconstruction and special rehabilitation.”

Between 1975 and 1983, they surgically treated only 26 patients. Others later recognized that total shoulder replacement was associated with early glenoid failure and recommended treatment with humeral hemiarthroplasty.1 With either approach, success was limited by rotator cuff deficiency and dysfunction. The results were variable, with a small proportion having good outcomes and others achieving some pain relief and limited functional improvement.

Although it was not the first attempt at a reverse shoulder arthroplasty (RSA), Grammont developed an innovative design with improved implant technology and biomechanics to treat massive rotator cuff tears.2 This solved the biomechanical problem that resulted from a deficient rotator cuff and forever revolutionized the care of cuff-deficient shoulders. The Delta 3 prosthesis became available in Europe in the early 1990s but was not widely available in the US until 2004, when it was approved by the FDA.

Initially developed, approved, and used exclusively for cuff-tear arthropathy, early clinical success led to utilization for other conditions with deficient or dysfunctional rotator cuffs, including pseudoparalysis, revision shoulder arthroplasty, acute proximal humerus fractures, fracture sequelae, and chronic glenohumeral dislocations. The results have been so good that the indications have expanded beyond the initial recommendations for use only in elderly low-demand patients. Initial concerns were mollified by the apparent longevity and reported survivorship. Subsequently, there has been such a huge increase in utilization that RSA is approaching 50 percent of the US market share and some of the international market. The implications of expanded indications and increased utilization are yet to be seen.

In 1983, Neer and coauthors reported on what was then a relatively uncommon degenerative condition of the shoulder. Today, rotator cuff-deficient shoulders are much more common and can be better treated due to advances in our understanding of the pathophysiology and biomechanics of the condition, as well as advances in shoulder arthroplasty technology.

Andrew Green, MD
JBJS Deputy Editor

References
1. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder
arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3(1):39-46.

2. Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993 Jan;16(1):65-8

JBJS Classics: Arthroscopy’s Revolutionary Role in Diagnosing Knee Injuries

JBJS Classics Logo.pngOrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Prior to the advent and subsequently ubiquitous use of MRI that most young surgeons are now accustomed to, it was difficult to determine the incidence of several common sports-related injuriesFrank Noyes’ 1980 classic JBJS manuscript, “Arthroscopy in Acute Traumatic Hemarthrosis of the Knee,” was one of the first articles to establish the clear relationship between hemarthrosis and significant intra-articular knee pathology. While the importance of the anterior cruciate ligament (ACL) had just come to light, Noyes’ landmark findings demonstrated the high incidence of ACL injury in association with acute traumatic hemarthrosis (ATH). Furthermore, he delineated arthroscopy’s critical role in accurately diagnosing other associated knee injuries.

This classic manuscript advocated for the use of arthroscopy as a diagnostic tool for the evaluation of ATH at a time when the consequences of a “knee sprain” with acute swelling were unclear.  In patients who did not have obvious laxity, an existing acute rupture of the ACL was often left undiagnosed during initial clinical evaluations. Noyes’ innovation pushed the field to couple clinical examination with arthroscopy in cases of acute knee injuries, to allow for more accurate diagnosis. Following this paper’s publication, and well into the 1980s, research continued to confirm Noyes’ findings that one of the best uses of arthroscopy was for diagnosis of acute knee injuries.

This paper and another Noyes study[1] were among the first to identify the high rate of serious knee injuries among patients with ATH. Noyes’ JBJS paper showed that 72% of knees with ATH were characterized by some degree of ACL injury. Moreover, in knees with complete ACL disruption, both the anterior drawer and flexion-rotation drawer tests proved to be more accurate diagnostically when performed with the patient under anesthesia than when the tests were performed in the clinic. Further, he also established that ACL tear, meniscus tear, and/or cartilage injury must be included in the differential diagnosis of an ATH.

Noyes’ group revolutionized the course of treatment and care for patients with ATH. While we generally no longer use knee arthroscopy as a diagnostic tool, because of this article, we routinely order MRI in the setting of ATH. Noyes’ piece remains timeless and well-deserving of the title of a “JBJS Classic.”

Robert G. Marx, MD, MSc, FRCSC
JBJS Deputy Editor

Naaman Mehta, BS

Stephen Thompson, MD, MEd, FRCSC
JBJS Deputy Editor

Reference

[1] Noyes FR, Paulos L, Mooar LA, Signer B. Knee Sprains and Acute Knee Hemarthrosis: Misdiagnosis of Anterior Cruciate Ligament Tears. Phys Ther. 60(12): 1596-1601, 1980.

JBJS Classics: Congenital Dislocation of the Hip

jbjsclassics-2016OrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Having passed the half-century mark with continued relevance, this classic JBJS article by T.G. Barlow, published in the British volume in 1962, rewards the reader with pearls and insights that can still help us make good decisions about treatment of infants with hip dysplasia. Exploring new approaches always pays rich dividends, and this report details Barlow’s observations from a five-year study (1957­­-1962) in which he examined all newborns at his hospital and followed them up at one year of age. This effort was undertaken at a time before the emerging field of pediatric orthopaedics had many full-time adherents.

Barlow studied nearly 10,000 newborns at the Hope Hospital in Manchester, England. He conducted the first examinations during the first week of life, in an era when newborns in the UK stayed in the hospital for at least one week. He carefully recorded his findings and made observations on incidence of hip dislocation, natural history, and treatment.

His first contribution, for which he is still remembered, was to show that in newborns, with their low resting muscle and tissue tension, the Ortolani test is often subtle, and a dislocated hip may escape notice. The Ortolani test was often impressive in older babies, but less so in newborns. Therefore, Barlow devised his eponymous test, which increases the proprioceptive feedback by applying axial pressure and provoking subluxation or dislocation. Simply put, it is often easier to feel the hip displacing with pressure than to feel it slip back in.  The number of babies who have benefited from this method of early detection is too numerous to count!

Barlow’s other observations are equally relevant and useful. He observed that many babies with dislocatable but non-dislocated hips will stabilize naturally. He showed that only one-eighth of unstable hips will have a persistent dislocation, which is why we now only treat dislocated hips immediately upon detection.  Recent articles1 have added further insights in this regard.

Barlow also showed that with a program of screening and treatment, no patient in his experience presented at a year of age with a hip dislocation. We still debate the proper method of early detection, but he properly targeted the neonatal period as the time that instability usually begins. Barlow also demonstrated a simple abduction splint made of aluminum and leather that holds the hips in flexion and abduction. Although the Pavlik harness has become more popular as an initial treatment, experts have recently come to realize that a fixed-angle brace can benefit some children who do not stabilize in a Pavlik.2

This classic article was fun to re-read and remains useful to general and pediatric orthopaedic surgeons. Barlow’s disciplined undertaking has shaped our understanding of this important disorder. The man and his insights are remembered for good reason.

Paul D. Sponseller, MD
JBJS Deputy Editor

References

  1. Upasani VV, Bomar JD, Matheney TH, Sankar WN, Mulpuri K, Price CT, Moseley CF, Kelley SP, Narayanan U, Clarke NM, Wedge JH, Castañeda P, Kasser JR, Foster BK, Herrera-Soto JA, Cundy PJ, Williams N, Mubarak SJ. Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure. J Bone Joint Surg Am. 2016 Jul 20;98(14):1215-21
  1. Sankar WN, Nduaguba A, Flynn JM. Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip. J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7.

JBJS Classics: Biomechanics of the Normal Elbow

jbjsclassics-2016OrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

The classic 1981 JBJS article by B.F. Morrey et al. begs to be read carefully, in part because of the name of the lead author. More importantly, this study answers the question that arises with almost every patient with an elbow disorder: Is the achieved range of motion sufficient for activities of daily living? We can answer this question “yes” or “no” after reading this article, and in my own practice, I repeatedly refer to the information provided in it.

Dr. Morrey was an aerospace engineer who worked at NASA for two years before he attended medical school at the University of Texas Medical Branch. After his residency at the Mayo Clinic and after achieving a master’s degree in biomechanics from the University of Minnesota, he joined the staff at Mayo in 1978.

In this article, which integrates Dr. Morrey’s engineering and medical disciplines, he applied a high-tech device of that period (the triaxial electrogoniometer) to answer simple but eternal questions such as what degree of elbow flexion is needed to eat or perform personal hygiene.

It is the nature of human beings to notice particular joint impairments only when they disturb activities of daily living. Patient-reported outcome scores assessing subtle disturbances have recently been published, but we learned from Dr. Morrey’s article that patients with elbow flexion less than 130° will probably be reminded of their elbow problem whenever they try to use a telephone. (With today’s small cellular phones the problem might be even more accentuated.)

There is not much that a contemporary reviewer would criticise if this study were to be submitted today. Yes, the graphics would be nicer, and there would be more than 12 references. Modern computer-aided tools and methods for motion analysis might be more precise (and produce a mass of partially redundant data), but the results would remain essentially the same.

In fact, the question of functional elbow range of motion was revisited in JBJS by Sardelli et al. exactly 30 years after Dr. Morrey’s study appeared. Using modern three-dimensional optical tracking technology, Sardelli et al. found only minimal differences compared to findings in the Morrey et al. study. Only a few contemporary tasks like working on a computer (greater pronation) or using a cellular phone (greater flexion) appeared to require slightly more range of motion than previously reported.

Finally, it is the succinct and pointed results that amaze me whenever I recall the information from Dr. Morrey’s study. All we need to remember are four numbers: 100, 30, 130, and 50. Therein we are reminded that the patient needs to achieve a 100° arc of motion for flexion /extension (from 30° to 130°) and forearm rotation (50° of pronation and 50° of supination).

The authors were able to omit the conclusion sentence we see so often these days: “Further studies are needed…” The question about the minimal range of elbow motion needed to accomplish activities of daily living has been convincingly answered in this article. All residents should read this JBJS classic early, certainly before they examine their first patient with an elbow disorder.

Bernhard Jost, M.D.
JBJS Deputy Editor

JBJS Classics: The Natural History of Congenital Scoliosis

jbjsclassics-2016OrthoBuzz regularly brings 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 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.

Michael McMaster, a widely respected and well-published orthopaedic surgeon from Edinburgh who treated a great number of pediatric spinal deformity patients over a 36-year career, published this classic JBJS article more than 30 years ago. His report continues to serve as the basis for what we as pediatric spinal deformity surgeons recommend for treatment in children with congenital scoliosis. The classification that he proposed allows us to know early in childhood which congenital scoliosis patients require early, aggressive treatment and who can be followed with little need for treatment.

By assessing 251 growing patients with congenital scoliosis in a longitudinal manner, Mr. McMaster determined the rate of progression with growth for 5 different primary curve types. The most progressive deformity is a unilateral vertebral bar (failure of segmentation) with a contralateral hemivertebra (failure of formation). Common congenital single hemivertebrae worsen most in the thoracolumbar and lower thoracic areas, and all hemivertebrae progress at a faster rate after 10 years of age than prior to age 10.

Knowing the natural history of any deformity in pediatric orthopaedics is the major factor in determining the need for treatment.  Mr. McMaster here provided the pediatric spinal deformity surgeon with essential information that still guides our treatment of congenital scoliosis on a daily basis today.

Vernon T. Tolo, MD
JBJS Editor Emeritus

JBJS Classics: The Moseley Straight-Line Graph for Leg-Length Discrepancies

jbjsclassics-2016OrthoBuzz regularly brings 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 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.

One of the hallmarks of a great journal article is whether it changes practice. In 1977, Colin Moseley presented a new method of predicting future leg growth that automatically takes into consideration the child’s growth percentile and the amount of growth inhibition in the short leg. Dr. Moseley’s method has been widely accepted because it is user-friendly and only requires three data points at each visit to the clinic – skeletal age and length of the long and the short legs. The accuracy of the prediction relies on serial measurements at different time points during the child’s growth. The more data points,  the more accurate the prediction. Unlike other methods, no mathematical calculations are necessary.

Then as now, the beauty of the method is that the growth of both the long and short legs can be represented by straight lines on a graph. Dr. Moseley accomplished this by mathematically converting Green and Anderson’s growth-remaining data into a logarithmic form. The straight-line graph improved upon the Green and Anderson data, as it was able to address the influence of the child’s growth in height by providing a nomogram to plot longitudinal skeletal age data to determine the end of growth. Moseley’s graph also provided reference slopes to aid in decision-making about when epiphysiodesis should be performed.

Dr. Moseley compared the accuracy of his method to that of the Green and Anderson growth-remaining method by doing a retrospective study based on data from 30 children treated with epiphysiodesis who had adequate scanograms and skeletal-age radiographs. The patients came from the Shriner’s Hospitals for Crippled Children in Montreal, Canada and the Alfred duPont Institute in Wilmington, Delaware.

Dr. Moseley found that the straight-line graph proved to be as accurate as the growth-remaining method—and more accurate in cases of high growth inhibition. It is interesting to note that Dr. Moseley was the only person doing this study and there was no test for interobserver error, which would certainly be one of the concerns raised by today’s reviewers for JBJS. The study could also have been strengthened if Dr. Moseley had validated his method with a series of prospective cases.

Dr. Moseley made certain assumptions in developing this method for predicting leg-length discrepancy at maturity. He used skeletal age and not chronological age as the norm. He assumed that growth of both the long and short legs was linear and that each individual child would remain in the same growth percentile with respect to skeletal age.

In 1982, Frederic Shapiro from Boston Children’s Hospital reported five developmental patterns in leg-length discrepancies in JBJS. Interestingly, type 1, which comprised a large proportion of the 803 cases reviewed, had a linear growth pattern where the discrepancy increased at the same proportionate rate. This finding supported the assumptions that Dr. Moseley made for the majority of his cases, but it also confirmed that not all discrepancies progress at the same rate, the notable exceptions being in children with Perthes disease and leg-length discrepancies arising from femoral fractures.

Eng Hin Lee, MD, FRCS(C)
JBJS Deputy Editor