JBJS 100: Harris Hip Score, Clavicle Fractures
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 full-text 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:
Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures—Treatment by Mold Arthroplasty: An End-Result Study Using a New Method of Result Evaluation
W H Harris: JBJS, 1969 June; 51 (4): 737
The most lasting legacy from this classic 1969 article from William Harris is the author’s proposed hip score. A “single, reliable figure” designed to be equally applicable to different hip problems and different treatments, the Harris Hip Score is still used worldwide today in routine evaluations before and after hip arthroplasty. Not surprisingly, this article remains the most frequently cited paper in the hip arthroplasty literature.
Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures
Canadian Orthopaedic Trauma Society: JBJS, 2007 January; 89 (1): 1
Amid the ongoing debate about whether to operate on which type of clavicle fractures, this multicenter, randomized clinical trial stands out for its rigorous design and focus on patient-oriented outcomes. Local irritation and unsightly prominence from hardware notwithstanding, these findings support primary plate fixation of completely displaced midshaft clavicle fractures in active adult patients.
“Limited Role” for Hip Arthroscopy in Tönnis Grade-2 Arthritis
Many orthopaedists wonder whether—or under what circumstances—arthroscopy confers any clinical benefit in treating hip osteoarthritis. A prospective matched-pair analysis by Chandrasekaran et al. in the June 15, 2016 Journal of Bone & Joint Surgery suggests that arthroscopy does not help prevent the eventual conversion to total hip arthroplasty (THA) in hips with Tönnis grade-2 arthritis (moderate narrowing of the joint space with moderate loss of femoral-head sphericity).
The authors compared two-year outcomes from 37 patients with Tönnis grade-2 hip osteoarthritis who had a hip arthroscopy performed with outcomes from matched cohorts of 37 Tönnis grade-0 and 37 grade-1 hips on which arthroscopy was also performed. In all cases, arthroscopy sought to address symptomatic intra-articular hip disorders refractory to nonoperative management. The cohorts were matched to minimize the confounding effects of age, sex, and BMI on the outcomes.
There were no significant differences among the groups with respect to four patient-reported outcome measures (including the modified Harris hip score), VAS pain scores, and patient satisfaction levels. However, Tönnis grade-2 hips had a significantly higher conversion rate to THA compared to the other two matched cohorts. In absolute terms, a subsequent THA was required for 3 hips in the Tönnis grade-0 group, 5 in the Tönnis grade-1 group, and 15 in the Tönnis grade-2 group.
From this finding, the authors conclude that “hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis…Hip arthroscopy can effectively restore the labral seal and address impingement, but patients may continue to experience symptoms associated with the osteoarthritis.”
JBJS Classics: The Harris Hip Score
Each m
onth 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 most lasting legacy from William Harris’s classic evaluation of post-traumatic mold arthroplasty published in 1969 is embodied in the paper’s subtitle, which refers to “a new method of result evaluation.” This end-result analysis evaluated 39 mold arthroplasties performed to treat traumatic arthritis at Massachusetts General Hospital between 1945 and 1965. Based on this series, the author at the time concluded that mold arthroplasty was the treatment of choice for most patients who require surgery for traumatic arthritis.
However, the most enduring part of this article can be found in the methods section, where the author proposed a hip score, a “single, reliable figure” designed to be equally applicable to different hip problems and different treatments. Dr. Harris designed the 100-point system to be reproducible and reasonably objective, giving a maximum of 44 points to a pain category, 47 points to functional capacity, 5 to range of motion, and 4 to absence of deformity. By using the scores pre- and postoperatively for this series of mold-arthroplasty patients, the author demonstrated how the new rating appeared to give a more accurate assessment of patients, relative to the Shepherd and Larson methods that were widely used at the time.
Dr. Harris broke down the function part of the score into daily activities (including stairs, socks and shoes, and comfort while sitting) and gait (with or without limping, with or without support). Over the years, this scale, along with the Postel Merle d’Aubigné developed in the 1950s, became the international gold standards to evaluate the pre- or postoperative state of the hip joint during everyday life. Not surprisingly, 46 years after its original publication, Dr. Harris’s paper remains the highest cited paper in the hip and knee arthroplasty literature, with nearly 2,500 citations.
Although the findings in this study focused mainly on post-traumatic arthritis treated by mold arthroplasty, the evaluation system proposed in the paper is used today in routine evaluations at almost every orthopedic center involved in hip arthroplasty. It’s used to clinically evaluate the hip joint before surgery and to evaluate the result after surgery at regular short-term follow-ups. It has also been used over the course of decades to evaluate the long-term performance of replaced joints. In addition, it is the clinical tool we use to compare various surgical techniques, different hip prosthesis designs, and case series from different institutions.
More recently, investigators have highlighted the importance of patient-reported measures of outcomes to better appreciate patient expectations before hip arthroplasty and to better evaluate patient satisfaction after surgery. Regardless of whether the primary goal of the operation is to relieve pain or get a person back on the athletic field, I think the system established by William Harris will remain the baseline for all arthroplasty surgeons, even if future scoring systems routinely incorporate patient-reported outcomes or quality-of-life measures.
Jean-Noel A. Argenson, MD, PhD
JBJS Deputy Editor for Adult Hip and Knee Reconstruction
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