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JBJS Classics: Blount Disease by Another Name

JBJS ClassicsOrthoBuzz 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.

When Walter Putnam Blount, MD described “Tibia Vara: Osteochondrosis Deformans Tibiae” in the January 1937 issue of The Journal of Bone & Joint Surgery, he probably did not realize that this mouthful of a term would become known simply as “Blount disease.” With a keen interest in children’s limb and spinal deformities, Blount was a pioneer pediatric deformity surgeon. He spent most of his career at the Children’s Hospital in Milwaukee and was clearly ahead of his time.

In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Additionally, he parsed out 16 other cases of genu varum that previous authors had reported as being secondary to rickets, infection, or other etiologies. In vivid detail, including tracings of these other patients’ radiographs, Blount corroborated that this newly described entity was indeed something different. He supplemented his research with histologic specimens from the affected growth plate and surrounding unossified cartilage of the proximal tibia.

Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Although most of his Caucasian patients in the 1937 study were not overweight, with the changing U.S. demographics and the prevalence of childhood obesity, his suggestion of a genetic and a mechanical basis for this growth-plate disorder remains plausible.

Based on the age of onset of the deformity, Blount recognized that there were two distinct forms of tibia vara, which he classified as infantile and adolescent. While the radiographs in the article only show the frontal images, he clearly documented the associated axial plane deformities with internal tibial torsion and ipsilateral shortening. Though Blount was a big proponent of the Milwaukee brace for managing spinal deformities in children, he seemed disenchanted with using orthoses to treat tibia vara. He instead advocated surgical correction via a valgus realignment proximal tibial osteotomy, a recommendation that remains relevant to this day.

Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” as another way of treating pediatric limb deformities. Interestingly, more than a decade after his description of tibia vara, Blount published another masterpiece in JBJS, “Control of Bone Growth by Epiphyseal Stapling.” Prior to this time, (hemi)epiphyseodesis was largely performed by the Phemister technique, with permanent ablation of the growth plate. By recognizing that physeal growth can be harnessed to correct angular deformities by inserting removable implants such as staples across the growth plate, Walter Blount, through these two classic JBJS articles and various other contributions, outlined essentially all viable options that are currently available to treat this disorder that fittingly bears his name.

In his presidential address to the American Academy of Orthopedic Surgeons in January 1956, Blount noted, “I should rather be remembered as a thoughtful surgeon than as a bold one.” His wish has indeed come true.

Sanjeev Sabharwal, MD, MPH
JBJS Deputy Editor

JBJS Classics: The Self-Locking Metal Hip Prosthesis

JBJS ClassicsOrthoBuzz 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.

Austin Moore’s article “The Self-Locking Metal Hip Prosthesis” was published in The Journal of Bone & Joint Surgery in 1957. Dr. Moore had a lifelong professional interest in hip-fracture surgery and was well aware of the problems associated with reduction and fixation of displaced femoral neck fractures. He had previously designed an internal-fixation device for the management of these injuries and had recognized that perfect reduction, accurate placement of the hip nail, and 100% compliance with non-weight bearing were prerequisites for a satisfactory outcome. For patients in whom those criteria could not be met or those in whom reduction and fixation had failed, an alternate method of managing these fractures was required.

Fourteen years prior to the publication of this landmark article, Dr. Moore had published a case report in The Journal (July 1943) in which he documented the use of a metal prosthesis to replace the proximal end of the femur for a patient with an aggressive giant cell tumour. Some years later the patient succumbed from other causes and the femur was retrieved at autopsy. The specimens demonstrated satisfactory osseointegration of this implant in the proximal femur and encouraged Dr. Moore to experiment with a number of models of proximal femoral implants. This progression of implant design and usage is carefully outlined in this classic paper, which is amply illustrated with radiographs and autopsy specimens of the evolving prosthesis that eventually became known as the Austin Moore hip prosthesis.

This paper is notable for a number of reasons. First, Dr. Moore was able to demonstrate satisfactory fixation using an intramedullary stemmed implant—a significant departure from the early efforts of the Judet brothers and others, who used a small stem in the residual femoral neck in patients being treated for hip arthritis. Secondly, the author developed a specific surgical approach allowing for the insertion of these slightly curved stems into the femur—an approach that is still used today in a number of surgical hip procedures.

Third, Dr. Moore demonstrated the usefulness of proximal femoral replacement in acute displaced femoral neck fractures, avascular necrosis following femoral neck fracture, and non-unions of the femoral neck. He further expanded the use of this implant in the treatment of hip arthritis and documents a number of such cases in this article.

Throughout the article, Dr. Moore emphasizes the importance of meticulous surgical technique, the use of bone ingrowth fixation, careful sizing of the femoral head to the native acetabulum, and the importance of conscientious post-operative care. Finally, he recognized the importance of routine follow-up of endoprostheses and insisted on a yearly visit to ensure appropriate integration of the prosthesis.

In summary, with this article Dr. Moore started a trend of endoprosthetic treatment for displaced femoral neck fractures that is now the standard of care throughout much of the world. During the development of this technique, he demonstrated the importance of bone ingrowth as a method of stabilizing the prosthesis, the importance of good surgical technique, and the value of long-term follow-up in managing patients with hip prostheses. The fact that the implant he designed and reported on 60 years ago is still in widespread use is a reflection of his vision.

James P. Waddell MD, FRCSC
JBJS Deputy Editor

JBJS Classics: The Küntscher Method of IM Fixation

JBJS ClassicsOrthoBuzz 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.

In 1957 Gerhard Küntscher presented his work on intramedullary (IM) nailing to the American Academy of Orthopaedic Surgeons.  His classic JBJS paper on the subject, published in January 1958, summarized his views on this comparatively new technique and encouraged other surgeons to use it for the treatment of long bone fractures and nonunions.

Küntscher pointed out that callus was very sensitive to mechanical stresses, and therefore any treatment method should aim at complete immobilization of the fracture fragments throughout the healing process. External splints, such as plaster casts, did not achieve that, and “inner splints” fixed to the outside of the bone damaged the periosteum.

In advocating for intramedullary fixation, Küntscher was careful to distinguish nails from pins. He was very complimentary about J. and L. Rush, who developed intramedullary pinning, but he pointed out that, unlike pins, nails allowed both longitudinal elasticity and cross-sectional compressibility if they were designed with a V-profile or clover-leaf cross section. This cross-sectional elasticity allowed the nail to fit the canal and expand during bone resorption.

Not only did Küntscher appreciate the biomechanics of the intramedullary nail, but he also pointed out the physical and psychological advantages of early mobilization, particularly in the elderly. He also emphasized that massage was unnecessary—and potentially harmful—during the recovery phase, claiming that any measures that make patients more conscious of their injuries are psychologically disadvantageous.

Küntscher used intramedullary nailing to treat fractures, nonunions, and osteotomies of the femur, tibia, humerus, and forearm. He accepted that it was “a most daring” approach that would destroy the nutrient artery, but he pointed out that proper nailing almost always prevented pseudarthoses and that antibiotics had checked the threat of infection. He said further that perioperative x-rays entailed short exposures and that the “electronic fluoroscope” had, even back then, practically eliminated the risk of x-ray injury to assistants.

The paper clearly illustrates Küntscher’s widespread knowledge and innovative skills. However, it was the subsequent development of locked nails that resulted in intramedullary nailing becoming the treatment of choice for femoral and tibial fractures. Time will tell if modern orthopaedic surgeons will catch up with Küntscher and use nailing for humeral and forearm diaphyseal fractures.

Charles M Court-Brown, MD, FRCSCEd

JBJS Deputy Editor

JBJS Classics: Sarmiento Pioneered Weight-Bearing Fracture Healing

JBJS ClassicsOrthoBuzz 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.

Prior to the innovative work of Gus Sarmiento in the 1960s, most orthopaedic surgeons treated tibial shaft fractures with a prolonged period of immobilization, in a long-leg non-weight bearing cast. While the fracture usually healed, knee joint stiffness and atrophy of the entire limb usually resulted as well.

In this 1967 JBJS classic, Sarmiento extended the concept of early weight-bearing treatment of these fracture as advocated by Dehne and others by incorporating the limb in a below-the-knee total-contact plaster cast, a technique that had recently been developed for the early rehabilitation of a below-the-knee amputation. The skin-tight plaster cast was applied over a single layer of stockinette one to two weeks after the acute swelling had subsided. It was molded proximally to contain the muscles of the proximal leg, and it had medial and lateral condylar flares, similar to a patellar-tendon-bearing (PTB) prosthesis.

Sarmiento encouraged early weight bearing in the cast, as he believed that doing so stimulated fracture healing. His confidence was borne out by this report of 100 consecutive tibial shaft fractures treated with a PTB cast. All 100 fractures healed, and healing occurred with minimal deformity or shortening. This success soon led to Sarmiento’s development of a functional below-the-knee tibial fracture brace made of Orthoplast®, a thermoplastic material which, when heated in a water bath, could be molded easily to the injured limb.

While today most tibial shaft fractures are treated with intramedullary nails, the principles developed by Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the healing process. Fracture healing is enhanced by weight bearing, and joint stiffness and muscle atrophy are avoided by early motion.

Sarmiento’s concept of functional treatment was later extended to the treatment of humeral and ulnar shaft fractures, which commonly continue today to be managed effectively with fracture braces that he developed. This emphasis upon early functional restoration while the fracture is healing has allowed many patients to achieve faster healing and to resume full function much sooner.

James D. Heckman, MD

JBJS Editor Emeritus

JBJS Classics: Antibiotics and Open Fractures

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 about these classics by clicking on the “Leave a Comment” button in the box to the left.

From the time of Hippocrates until after the American Civil War, open fractures and other wounds prone to sepsis were fatal injuries in approximately 50% of patients, and amputation of the affected limb was recognized as lifesaving treatment. With the adoption of antisepsis and formal surgical débridement in the late 19th century, improved stabilization techniques in the 20th century, and the introduction of antibiotics, death as an outcome was virtually eliminated, but nonunion with or without infection remained challenging complications.

In the 1960s, reports concluding that in open fracture care “prophylactic antibiotics were of questionable value” created great debate and controversy among surgeons. The pioneering 1974 JBJS study by Patzakis et al., titled “The Role of Antibiotics in the Management of Open Fractures,” addressed this controversy by asking and answering three key questions:

  • Is antibiotic prophylaxis worthwhile in open fractures?
  • Which organisms cause the infections?
  • Which antibiotics are effective?

The study demonstrated that nearly two-thirds of wounds caused by direct injury and an even higher rate of gunshot wounds were contaminated. That finding, along with the fact that several days must elapse before a culture can be considered truly sterile, makes true “prophylaxis” in open fractures practicable only if antibiotics are applied to all patients. Patzakis et al. also stressed that antibiotic treatment is not a substitute for the critically important practice of extensive surgical debridement of all devitalized tissue. Urgent surgical irrigation and debridement remain the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure.

I agree with the authors of this classic article that the term “prophylaxis” is not appropriate because these wounds should presumptively be considered contaminated and treated with effective antibiotics. Wound sampling has a poor predictive value in determining subsequent infections, so a first-generation cephalosporin should be administered as soon as possible, with or without coverage for gram-negative bacteria. In addition, as Lawing et al. found in a 2015 JBJS study, local aqueous aminoglycoside administration as an adjunct to systemic antibiotics may be effective in lowering infection rates in open fractures.

This classic prospective study by Patzakis et al. in the 1970s has prompted us to ask and pursue answers to many more clinical questions regarding open-fracture infections. For example, the optimal duration of antibiotic administration has not been well defined, but they should be continued for more than 24 hours. The evidence to support either extending the duration or broadening the antibiotic protocol for Gustilo type III wounds remains inconclusive, and more investigation into this question with higher-level research methods is needed.

Konstantinos Malizos, MD, PhD

JBJS Deputy Editor

JBJS Classics: Understanding Proximal Humeral Fractures

JBJS-Classics-logoThe contributions to the field of shoulder surgery from Dr. Charles Neer are too numerous to document in any one commentary. A partial list would include shoulder arthroplasty (both hemi and total), the concept of impingement and acromial pathology, multidirectional instability, and the role of the AC joint in rotator cuff pathology.

Dr. Neer also made numerous contributions to the understanding of fracture care, including the distal femur and clavicle. But no area of fracture management was of greater interest to him and his colleagues at Columbia than the proximal humerus. This classic manuscript has been cited thousands of time and remains the seminal piece in the foundation of understanding fracture patterns in the proximal humerus—and the attendant treatment implications.

Dr. Neer introduced the concept of the four parts of the proximal humerus in this manuscript, and with it the implication of isolating the humeral-head blood supply in a four-part fracture. The impetus to understand the complication of avascular necrosis of the humeral head began with this manuscript, as did the critical debates regarding surgical versus nonsurgical intervention and replace-or-fix. An important area of ongoing debate is Neer’s definition of a “displaced” fracture in the proximal humerus as having > 1 cm of displacement. The orthopaedic community to this day is wrestling with this definition and its relevance to treatment and outcomes.

This classic manuscript also helped launch a decades-old conversation about the role of fracture or musculoskeletal-disease classification systems. Subsequent publications by Zuckerman and Gerber identified issues with inter- and intra-rater reliability when applying the Neer classification system to a set of radiographs. The reliability debate surrounding this classification system led us to understand the issue of forcing continuous variables (fracture lines are infinite in their trajectory and displacement) into dichotomous variables (a classification system). Because of Dr. Neer’s work and subsequent research, our community understands that when we make these classification designations, we will agree about 60% of the time (kappa statistic of 0.6). That level of agreement is not reflective of a “good” or “bad” classification system; rather, it’s a consequence of moving a continuous variable to a dichotomous variable.

So we remain indebted to Dr. Neer not only for laying the foundation for the treatment of patients with proximal humeral fractures, but also for vastly expanding our knowledge regarding the role, strengths, and weaknesses of disease and fracture-classification systems.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

JBJS Classics: Harrington Ushered in Modern Spine Surgery in 1962

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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 JBJS Classic Treatment of Scoliosis: Correction and Internal Fixation by Spinal Instrumentation by Paul R. Harrington describes 15 years of investigation, beginning in 1947, soon after Dr. Harrington completed his residency in Kansas City and headed an Army orthopaedic unit during World War II. The importance of this paper can’t be overstated. With this description of instrumentation that improved deformity outcomes, Harrington ushered in modern spine surgery.  It was also one of the rare early examples of orthopaedic clinical science funded by a national grant.

The need for this daring, revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Polio patients comprised 75% of the first series described in this paper.

This comprehensive study combines theory, basic science, surgical techniques, and outcomes. With it, Harrington started the still-continuing dialogue about indications for scoliosis surgery with the comment that “clinical indications for therapy are still being worked out.” As a partial answer to the indications quandary, he introduced the Harrington factor—the number of degrees of primary curve divided by the number of vertebrae in the primary curve. This calculation continues to be used (renamed) in some current research into risks of curve correction, while debate continues about other indications such as progression, pain, and pulmonary issues.

The technique of spinal instrumentation is extensively described in this landmark article. Noteworthy is Harrington’s gradual embrace of the need for fusion and well-molded body cast immobilization, both of which he credits with improved results. (Initially Harrington had hoped to avoid fusion in many cases.) Although “instrumentation” today is nearly synonymous with “fusion,” some of our most promising ideas in deformity correction now involve instrumentation without fusion.

Also impressive is the respect with which Harrington treated the spinal cord and dura. He describes careful insertion of the hooks and recommends against downward hooks above L2, where the conus ends. This paper reminds us that we should always pursue the lowest-risk approach to instrumentation that will serve our patients. Dr. Harrington was also cognizant of the importance of blood loss, and meticulously measured it by stage of surgery. He showed that most blood loss occurred during subperiosteal dissection, a fact that we still recognize today.

Harrington’s description of selective thoracic fusion was illustrated radiographically in Figure 7, which shows a dramatic result where a 55° unfused lumbar curve declined to 18° after correction of a larger thoracic curve. This concept was further developed by Moe, King, Lenke and others, but the idea of spontaneous correction of lumbar curves started with the power of Harrington’s instrumentation.

The benefits of our more “modern” instrumentation are evident when reading the recommended aftercare in Harrington’s paper: a 16-day hospital stay, 8 weeks of bed rest, and a Risser localizer cast for 3 to 5 months, only to find out whether the patient might need reoperation for instrumentation problems or pseudarthrosis.

A modern journal editor might have expended some red ink on Dr. Harrington’s paper. The organization was less formal than many scientific papers today, but this may reflect the multiple simultaneous investigations and changes that took place during this decade-plus of revolutionary work. Dr. Harrington emphasizes that the results improved with each iteration of the procedure and device, which underwent more than three dozen design modifications.

Details on the curve sizes were not given, but we now recognize that curve size does not correlate linearly with clinical parameters.  While Harrington does not describe the contributions of others who may have been involved in this work, neither does he use the eponymous term (“Harrington instrumentation”) that others attached to his spinal fixation device. While remarkable in its prescience, this paper did not anticipate the problems of distraction instrumentation in the lumbar spine, later characterized as Flatback Syndrome. It also did not elaborate on the need for differing mechanics in kyphoscoliosis or Scheuermann kyphosis.

Nevertheless, in this single article, Dr. Harrington laid the groundwork for three major themes that orthopaedists have further developed:

  • The safety and benefits of metal fixation in spine surgery
  • The use of growth guidance in patients < 10 years old
  • The idea of selective thoracic fusion for double curves

Each of these ideas has generated hundreds of additional studies and papers to get us to modern practice. Just as current hip arthroplasty techniques represent incremental improvements on the monumental contribution of Charnley, current techniques in scoliosis surgery, especially of the thoracic spine, are but stepwise improvements on Harrington’s classic work.

Paul Sponseller, MD, JBJS Deputy Editor for Pediatrics

Marc Asher, MD, Professor Emeritus, Department of Orthopaedic Surgery, University of Kansas Medical Center

JBJS Classics: George Phalen, Master Craftsman

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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.

George Phalen’s article, “The Carpal-Tunnel Syndrome,” was published in The Journal of Bone and Joint Surgery in 1966. I feel some kinship with Phalen because he and I both grew up in Illinois, and we both obtained medical degrees from Northwestern University. (Phalen graduated from Northwestern in 1937, 48 years before me, which makes me feel young.) Dr. Phalen finished his residency at the Mayo Clinic and was a founding member (and later a president) of the American Society for Surgery of the Hand.

Several characteristics make “The Carpal-Tunnel Syndrome” a classic. First, Phalen’s article stands out as the definitive description of a common condition that, while previously noted by others, had never been studied so thoroughly or documented so completely. Phalen’s paper, which reviewed a 17-year experience of diagnosing and treating 654 hands at the Cleveland Clinic, was the pivotal scientific text that identified carpal tunnel syndrome as the most common peripheral compression neuropathy and a highly treatable orthopaedic condition. Moreover, no other article written about carpal tunnel syndrome in the past 50 years has matched Phalen’s paper with respect to both breadth and depth of knowledge.

Phalen’s article is also a classic when considered as medical literature.  It is written in a way that makes critical points of anatomy, diagnostic evaluation, treatment options, and surgical management easy to remember. Although the article is 17 pages long, the content and organization are so well presented that the information flows naturally and is not burdensome to absorb. Packed with clinical and anatomical pearls, this paper is like an antique chair built by an old-school craftsman. It retains its comfort and rock-solid function even after decades of use because of the master-carpenter’s skill. This 1966 article makes me think, “They don’t often build ‘em like this anymore.”

But perhaps the most compelling “classic” feature of Phalen’s article is its lasting insights. Everything Phalen presented about carpal tunnel syndrome holds true 50 years later. This includes his descriptions of the anatomical, epidemiologic, histologic, and clinical features of carpal tunnel syndrome  and his emphasis that careful history-taking and physical examination are by the far the most efficient ways to evaluate patients. He also notes the limitations of electrical testing (see related OrthoBuzz item) and presents a variety of surgical-technique tips that are still relevant today.

What is also amazing is Phalen’s observation that carpal tunnel syndrome is not truly caused by any occupation, but may be only temporarily worsened by repetitive movements. Despite subsequent decades of controversy on this subject, it is becoming clearer that, even on this point, Phalen had it right all along.

“The Carpal-Tunnel Syndrome” is a brilliant contribution to orthopaedic and hand surgery. Its detailed comprehensiveness and bulls-eye accuracy are complemented by the artful way the article is constructed and worded.  Anyone treating carpal tunnel syndrome today should read this article, because a half-century later, it is still the best source of information on the subject.

Leon S. Benson, MD

JBJS Associate Editor

 

JBJS Classics: Anterior Acromioplasty for Chronic Shoulder Impingement

JBJS-Classics-logoEach 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.

For a good long while, the 1972 JBJS article titled “Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder” by Charles S. Neer II completely changed the treatment approach for patients with shoulder disability. Impingement of the rotator cuff beneath the coracoacromial arch was recognized at that time as the cause of chronic shoulder disability, and complete acromionectomy and lateral acromionectomy at various levels had been advocated for the condition. However, disappointment with the results, such as postoperative deltoid weakness, stimulated Neer to publish this study, based on his experiences with patients from 1965 to1970.  The paper describes relevant anatomical findings and then discusses the indications, technique, and preliminary results of anterior acromioplasty.

Neer first dissected 100 cadaveric scapulae from donors who had been in their sixth decade or older at the time of death,  and he noted spurs and excrescences on the undersurface along the anterior-inferior rim of the acromion in many shoulders  that also had rotator cuff derangement. Without exception, the anterior lip and undersurface of the anterior third of the acromion were involved. He concluded that this part of the acromion rubbed against the supraspinatus when the arm was abducted and caused the rotator cuff to tear over time.

Neer later resected this part of the acromion in fifty shoulders in forty-six patients. When he reexamined twenty-nine of the shoulders between nine months and five years after surgery, he found symptomatic relief in a large percentage of patients. A recent PubMed search identified 471 publications about acromioplasty, the majority of which reference this paper and 50 of which specifically mention Neer by name. Neer’s basic surgical principles are still followed, although this surgery today is performed arthroscopically.

Neer reserved this surgical procedure for patients with long-term disability from chronic bursitis and partial tears of the supraspinatus tendon, or those with complete tears of the supraspinatus associated with tears of varying degree of the adjacent rotator cuff. He emphasized that patients with incomplete tears should not have surgery until the stiffness of the shoulder resolved, and the disability had to persist for at least nine months before surgery was performed. Many patients not included in his series were suspected of having impingement but responded well to conservative treatment.

Neer’s anatomical approach to the challenge of chronic shoulder pain provides readers with photographs of cadaveric shoulders combined with drawings illustrating the pathogenesis and the surgical procedure.  Neer described the results well and in a subsequent discussion concluded that “it is a rare cuff tear that cannot be repaired through this simple approach.” The paper lacked a control group and a detailed description of the rehabilitation protocol, but these shortcomings have been remedied by more recent published research.

Neer’s hypothesis that impingement caused most rotator cuff tears does not appear to have withstood the test of time, however. Arthroscopy and magnetic resonance imaging arthrography have elucidated many other conditions that cause shoulder pain that were previously misdiagnosed as impingement. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete tear of the rotator cuff, and performing aggressive rehabilitation prior to corrective surgery.

Lars Engebretsen, MD, PhD

JBJS Deputy Editor

JBJS Classics: The “Game Changer” for Managing Femoral Shaft Fractures

JBJS-Classics-logoEach 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 classic 1984 JBJS review of 520 cases of intramedullary (IM) nailing by Winquist, Hansen, and Clawson changed everything for patients with fractures of the femoral shaft.

In North America during the 1960s and 70s, the debate was all about details of traction management for femoral-shaft fractures: Balanced skeletal traction versus Perkins traction, where to place the traction pin, how many weeks until the spica cast and what type of spica cast, and whether a fracture brace was a viable option. At the same time in Europe, the Swiss orthopaedic community, which was the focal point for the AO, was advocating plate fixation to avoid “fracture disease,” pneumonia, and pulmonary emboli by mobilizing patients.

Meanwhile, Kay Clawson had traveled extensively in Europe and became aware of the outstanding results being achieved with closed, reamed, femoral nailing, as published (originally in German) by Gerhard Kuntscher.  Dr. Clawson ordered the equipment—including the reamers, intramedullary nails, and fracture table—and had them shipped to the University of Washington in Seattle.

There they sat on a pallet for more than a year until Dr. Clawson sent Bob Smith, one of the chief residents, to Europe to work with Kuntscher directly. Dr. Smith brought back the knowledge to do reamed IM nailing of the femur, and as experience increased, a Spokane farm boy turned orthopaedic resident named Ted Hansen became especially skilled at the procedure. When Dr. Hansen became an attending, he taught the procedure to another highly skilled resident, Bob Winquist.

Experience grew to the point where they were able to publish this classic manuscript with all its tips, tricks, and outcomes, including which fracture patterns could be treated without keeping patients in traction for weeks to maintain length, and which fractures required open cerclage to create length stability. During this time, there were no commercially available interlocking nails, so we developed ways to drill holes through Kuntscher rods and inserted cortical screws through them with free-hand technique. We also began retrograde nailing these fractures by increasing the bend of the rods to allow them to be inserted off the articular surface in the medial condyle.

This paper, which also carefully explains how procedures were refined as the authors’ experience grew from 1968 to 1979, ushered in the standard of care that exists today and spelled the end of traction treatment and plate fixation. It remains one of the most-cited articles in the history of musculoskeletal trauma literature.

Marc Swiontkowski, MD

JBJS Editor-in-Chief