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:
The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears
L M Galatz, C M Ball, S A Teefey, W D Middleton, K Yamaguchi: JBJS, 2004 February; 86 (2): 219
In one of the earliest studies to investigate the relationship between the anatomic integrity of arthroscopic rotator cuff repair and clinical outcome, these authors found that the rate of recurrent defects was high but that at 12 months after surgery, patients experienced excellent pain relief and functional improvement. However, at the 2-year follow-up, the clinical results had deteriorated substantially. Investigations into the relationship between cuff-repair integrity and clinical outcomes are ongoing.
The Biological Effect of Continuous Passive Motion on the Healing of Full-thickness Defects in Articular Cartilage: An Experimental Investigation in the Rabbit
R B Salter, D F Simmonds, B W Malcolm, E J Rumble, D Macmichael, N D Clements: JBJS, 1980 January; 62 (8): 1232
In this paper, Salter and colleagues hypothesized that “continuous passive motion [CPM] of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.” They found that CPM stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion, and since then CPM has been commonly used in humans after cartilage repair. However, CPM’s actual efficacy in people—after cartilage repair or total knee arthroplasty—remains controversial.
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.
Based in part on clinical observations of persistent stiffness, pain, and cartilage damage after prolonged immobilization, in a 1960 JBJS paper, Robert B. Salter described degenerative changes in cartilage of rabbit knee joints that had been immobilized. He suggested that this “obliterative degeneration” might be related to adherence of synovium to the articular surface, and he wondered elsewhere in the orthopaedic literature, “If intermittent motion is good for articular cartilage, would continuous motion be even better?”
This background led to the classic December 1980 JBJS publication in which Salter and his colleagues hypothesized that “continuous passive motion of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.”
To test the hypothesis, Salter et al. made full-thickness cartilage defects at four sites in the knees of 147 rabbits. The rabbits were subjected postoperatively to either immobilization, intermittent active motion (normal cage activity), or continuous passive motion (CPM) created by a custom-made apparatus. Outcome measures included clinical observation of the animals, joint stiffness, and histology.
The extent of ultimate postoperative stiffness, adhesions, and cartilage healing all varied with the degree of immobilization, leading the authors to conclude that CPM
- Was well tolerated by the animals without causing harm detectable by gross or histologic evaluation
- Was associated with fewer adhesions than immobilization, and
- Stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion.
Subsequent work by Salter and co-workers evaluated the effect of CPM on other animal models of full-thickness cartilage defects, intra-articular fractures, acute septic arthritis, patellar tendon injury, ligament repair, autogenous and allogenic periosteal and osteoperiosteal grafts, and other conditions. Based in part on the favorable results of these pre-clinical studies as well as preliminary clinical trials, Salter suggested in CORR in1989 that CPM might be indicated after a host of other orthopaedic procedures, including open reduction and internal fixation of intra-articular or selected diaphyseal and metaphyseal fractures, capsulotomy and arthrolysis for post-traumatic arthritis, synovectomy for rheumatoid arthritis or hemophilic arthropathy, arthrotomy and drainage of septic arthritis, release of contractures or adhesions, metaphyseal osteotomy with internal fixation, and reconstruction of a medial collateral ligament.
A Google Scholar search in October 2014 indicated that the 1980 Salter at al. JBJS publication has been cited approximately 1,096 times. Many of the articles that cite the 1980 JBJS study appropriately focus on the effect of CPM on either the histology of cartilage repair, or the effect of CPM on adhesions and joint stiffness.
However, Salter’s observation of decreased stiffness in animals treated with CPM has been extrapolated to clinical applications that were not included in his original work, most notably total knee arthroplasty (TKA).Today the clinical use of CPM after arthroplasty is controversial. A 2010 Cochrane review, for example, identified 20 randomized controlled trials of 1,335 patients in which CPM had been evaluated after TKA. The review concluded that there is evidence that CPM increases knee flexion range of motion, but “the effects are too small to be clinically worthwhile.” A more recent 2014 Cochrane review of 11 randomized clinical trials involving 808 patients concluded that there is not enough evidence to conclude that CPM reduces venous thromboembolism after total knee arthroplasty.
With respect to CPM after cartilage-repair procedures, many other investigators have confirmed the findings Salter reported in 1980 in animal models. Indeed, the basic-science support is strong enough that CPM has been commonly used in humans after cartilage repair, yet its actual efficacy in people remains controversial. For example, in a 2010 systematic review, Fazalare and co-workers reviewed 1,087 human clinical studies in which CPM had been used after cartilage repair procedures. In spite of that large number of studies, Fazalare was unable to find any randomized, controlled studies related to CPM, and heterogeneity among procedures and outcome measures in those articles precluded performing a meta-analysis.
Authors of today may be envious of the more than 6,900 words and 52 photographs, photomicrographs, and graphs (totaling 20 printed pages) that JBJS devoted to Salter et al. in 1980, and one can’t help but wonder what this classic JBJS paper would look like if modified to fit today’s standards. But the main message is this: in spite of high-quality basic science studies using animal models, there remains a need for well-controlled studies in humans to test the efficacy of CPM after cartilage repair and other procedures.
Thomas W. Bauer, MD, PhD
JBJS Deputy Editor for Research
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from randomized studies cited in the January 21, 2015 Specialty Update on adult reconstructive knee surgery:
Minimizing Blood Loss
–A randomized study of 101 patients undergoing total knee arthroplasty (TKA) found that those receiving topical tranexamic acid (TXA) intra-articularly at the end of surgery had less blood loss and better postoperative hemoglobin levels than those who received a placebo.
–A randomized study of 50 TKA patients and 50 people undergoing total hip arthroplasty found that those receiving TXA had a significantly smaller decline in postoperative hemoglobin levels and needed 39% fewer units of transfused blood than a group that received normal saline solution.
–A randomized study of 126 patients who underwent denervation or not after TKA with unresurfaced patellae found that the denervation group had better pain scores at three months and higher satisfaction and better range of motion at two years.
–Two randomized studies evaluated the impact of patellar eversion versus lateral retraction/subluxation for joint exposure. One study (n=117) found no between-group differences in quadriceps strength at one year, and the other (n=66) found no between-group differences in pain scores or flexion at three months and one year.
Most of the implant-design studies summarized in this Specialty Update can be summed up as “no difference.” Specifically,
–Three randomized studies attempting to evaluate high-flexion TKA designs (n=74, n=278, and n=122) caused the authors of the update to suggest that “the intention of providing greater clinical flexion through high-flex arthroplasty designs does not translate to a meaningful difference in patient outcomes.”
–A randomized study of 124 patients found no differences in maximal post-TKA flexion or functional scores between a group that received a bicruciate-substituting implant and one that received a standard posterior-stabilized design.
–A randomized trial of 34 patients who received prostheses with either highly cross-linked polyethylene or conventional polyethylene found no differences in wear-particle number, size, or morphology after one year.
–A 4- to 6.5-year follow-up study of 56 patients who received either mobile or fixed bearings during TKA found that the mobile-bearing group had greater mean range of motion, but there were no between-group differences in satisfaction or functional scores.
Instrumentation and Technique
–A randomized study of 47 patients whose surgeons used either customized cutting blocks or traditional instruments found no differences in clinical outcomes or mean component alignment. Moreover, surgeons abandoned customized blocks in 32% of the cases because of malalignment.
–A randomized study of 129 patients whose surgical approach was either medial parapatellar or subvastus, all of whom were managed with minimally invasive techniques, found no differences in pain, narcotic consumption, functional outcomes, and Knee Society Scores at postoperative times ranging from three days to three months.
Postoperative Care and Pain Management
–A trial among 249 post-TKA patients who received either one-to-one physical therapy (PT), group-based PT, or a monitored home program found no difference in outcomes at 10 weeks and one year.
–A randomized study of 160 post-TKA patients investigating the effect of continuous passive motion (CPM) machines led the study authors to conclude that CPM is neither beneficial nor cost-effective.
–A small randomized study of pain-management protocols found that a “multimodal” approach that included peri-articular injection led to less pain, less narcotic use, and higher satisfaction for up to six weeks after surgery than a patient-controlled analgesia approach.
–A three-way randomized pain-management study of 100 patients led study authors to recommend against posterior capsule injections and to conclude that “a sciatic nerve block [for TKA] has a minimal effect on pain control.”
–A three-way randomized study of 120 TKA patients found that those receiving preoperative dexamethasone and ondansetron had less nausea, shorter hospital stays, and used less narcotic medication than those who received ondansetron alone. “Dexamethasone should be part of a comprehensive total joint arthroplasty protocol,” the study authors concluded.