JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis
R N Hensinger, P D DeVito, C G Ragsdale: JBJS, 1986 January; 68 (2): 189
This study of 121 patients with juvenile rheumatoid arthritis (RA) found that severe neck pain was not common, although neck stiffness and radiographic changes were commonly seen in the subset of patients with polyarticular-onset disease. The authors concluded that patients with juvenile RA who present with evidence of disease in the cervical spine should be examined carefully for involvement of multiple joints.
A Functional Below-the-Knee Cast for Tibial Fractures
A Sarmiento: JBJS, 1967 July; 49 (5): 855
In this report of 100 consecutive tibial shaft fractures, Gus Sarmiento encouraged early weight bearing in a skin-tight plaster cast that was molded proximally to contain the muscles of the leg. All 100 fractures healed, and healing occurred with minimal deformity or shortening. While most tibial shaft fractures are now treated with intramedullary nails, the principles developed by Dr. Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the weight-bearing healing process.
JBJS 100: Cuff Tear Arthropathy and Cervical Spine Disorders
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Cuff Tear Arthropathy
Neer CS 2nd, Craig EV, Fukuda: JBJS, 1983 Dec; 65 (9): 1232
These authors 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.
The Treatment of Certain Cervical-spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion
Smith GW, Robinson RA: JBJS, 1958 June; 40 (3): 607
Dr. Robinson’s technique has the support of biomechanical principles, which makes this particular approach and bone-graft fusion construct inherently stable. The versatile approach is utilized for all sorts of anterior procedures, including removal of intervertebral discs, arthrodesis, and vertebrectomy.
July 2017 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of July 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “An Integrated Model of Chronic Whiplash-Associated Disorder.”
This clinical commentary explains how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic whiplash-associated disorder.
JBJS Editor’s Choice—Aggressive Treatment for Upper C-spine Fractures
The March 16, 2016 JBJS includes a careful incidence, treatment, and outcome analysis by Pearson et al. of CMS data regarding C2 cervical-spine fractures that occurred in the Medicare population from 2000 to 2011. The study’s methodological quality comes as no surprise, as the group hails from Dartmouth, the home of the renowned Dartmouth Atlas of Health Care, which has posed many vexing clinical and cost questions for the orthopaedic community.
Pearson et al. found that while the incidence of C2 fractures in the elderly increased 135% from 2000 to 2011, the rate of surgical treatment for this injury remained essentially unchanged. I find that static rate of surgical treatment troubling, because, after controlling for potential confounders, the authors found that surgical treatment was associated with a nearly 50% decrease in 30-day mortality and a 37% decrease in one-year mortality, relative to nonoperative approaches.
I believe that our apparent reluctance to perform surgery in these cases is due to the underlying belief that upper C-spine fixation/fusion in the elderly presents a prohibitively high risk. I question that general proposition because we think quite the opposite nowadays when managing hip fractures and many other metaphyseal fractures with high complication profiles in older people. Certainly, the major risks with upper C-spine surgery are potentially fatal neurologic and vascular injuries, but this well-done analysis demonstrates that the mortality outcomes are markedly better with surgery. In addition, JBJS recently published a paper by Joestl et al. on the outcomes of C2 fusions in geriatric patients with a dens fracture nonunion, which confirmed good outcomes and a favorable risk profile (see related OrthoBuzz post).
I think it is time for the orthopaedic, neurological-spine, and rehabilitation communities to seriously reconsider our approach to elders with C2 fractures. As Pearson et al. conclude, until an RCT is performed on this question (if ever), “surgeons and patients should use the available data in a shared decision-making model to choose the treatment consistent with an individual patient’s values.”
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS Case Connections: Happy Endings to Unusual Cervical Spine Injuries
The November 25, 2015 “Case Connections” looks at four JBJS Case Connector cases involving injuries to the cervical spine in which the outcomes were about as good as anyone could have wished, considering the potential for disaster. Two of the cases required surgical intervention to achieve the positive outcomes, but the outcomes in the other two cases were remarkably positive without surgery.
While these four cases of cervical spine injury had relatively “happy endings,” orthopaedic surgeons and other health-care professionals treating patients with any suspected spine injury are trained to proceed with the utmost care and caution out of concern for devastating neurological sequelae. Watchful waiting under close medical scrutiny is sometimes warranted, but many cases of cervical fracture, dislocation, or instability call for operative stabilization to reduce the risk of life-changing or life-threatening consequences. The potential seriousness of surgical complications when operating on the spine must also be recognized.
JBJS Classics: Cervical Discectomy and Interbody Fusion
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.
It is rare that an article published more than 50 years ago continues to have an impact on clinical practice today. But that is the case with “The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion.” What make this article so unique are the details that Drs. George Smith and Robert Robinson put into describing the procedure and the careful follow-up of their early experience with this technique.
I have had a copy of this article in my files since I was a resident at Yale, training with Wayne Southwick, who had trained with Dr. Robinson at the time this approach to the cervical spine was developed. The two key contributors to anterior cervical spine surgery back in the 1950s were Dr. Robinson and the neurosurgeon Dr. Ralph Cloward.
Dr. Robinson’s technique has the support of biomechanical principles, which makes this particular approach and bone-graft fusion construct inherently stable; hence, its continued use to this very day. However, back in the ‘50s, and even when I trained in the 1970s, hardware to stabilize the spine following discectomy was not available in the US.
The approach that these authors described is very versatile and is utilized for all sorts of anterior procedures, including removal of intervertebral discs, arthrodesis, and vertebrectomy, and it allows for doing multiple-level procedures. The technique I use today is the same one that Dr. Southwick taught me and that he learned directly from Dr. Robinson.
Dr. Robinson has had a major impact on cervical spine surgery, and it was estimated that at one time 33% to 50% of members of the Cervical Spine Research Society were trained by him, by one of his residents or fellows, or by one of their residents or fellows—Dr. Robinson’s “offspring.”
I believe this technique will continue to stand the test of time, as it has during the past half century, and will have a major influence on spine surgery well into the future.
Charles Clark, MD
JBJS Deputy Editor for Adult Reconstruction and Spine
First 3D-Printed Cervical Disc Implanted
For any number of reasons, regulatory issues among them, orthopaedic innovations in China often have modest relevance for the practice of orthopaedics elsewhere in the world, but that doesn’t make them any less fascinating.
Case in point: According to Becker’s Spine Review, surgeons in China recently implanted the first-ever 3D-printed cervical disc in a 12-year-old boy. The surgeon, Dr. Liu Zhongjun, described the procedure as successful, although the patient will have to remain in a head frame with pins for three months.
The Becker’s story did not specify the material from which the cervical disc was printed, but 3D printing is capable of producing porous metal implants, and companies have reported success with 3D-printed implants made from thermoplastic materials.
One theoretical advantage of 3D-printed orthopaedic implants is that they can be customized based on digital images of a patient’s actual anatomy. That would conceivably result in a better fit, quicker recovery, and fewer complications.
Still, don’t expect to find a 3D prosthetic printer in your hospital anytime soon. Clinical studies required to ensure the safe and effective use of even the most promising new technologies take years. And even after such studies are completed, regulatory approval and coverage from payers is not guaranteed.
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