Tag Archive | JBJS Classics

JBJS Classics: Correlating Lumbar MRIs with Clinical Findings

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.

In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain or sciatica underwent magnetic resonance scans of the lumbar spine. In a landmark 1990 JBJS study, Boden et al. reported that three neuroradiologists who had no clinical knowledge of the patients interpreted the images as being substantially abnormal in 28% of the cohort (19 individuals). More specifically, a herniated nucleus pulposus was identified in 24 % of these asymptomatic subjects. These “magnetic-resonance positive” findings were more prevalent in older subjects; abnormal MRI findings were identified in 57% of those aged 60 to 80 years.

Boden et al. concluded that so many MRI findings of substantial abnormalities in asymptomatic people “emphasized the dangers of predicating a decision to operate on the basis of diagnostic tests—even when a state-of-the-art modality is used—without precise correlation with clinical signs and symptoms.”

However, despite the findings of Boden et al., during the last five years of the 1990s, Medicare claims showed a 40% increase in spine-surgery rates, a 70% increase in fusion-surgery rates, and a two-fold increase in use of spinal implants. Although spine-fusion surgery has a well-established role in treating certain spinal diseases, a 2007 systematic review of several randomized trials indicated that the benefits of fusion surgery were limited when treating degenerative lumbar discs with back pain alone. This review suggested the need for more thorough selection of surgical candidates, which was a caution also implied by Boden et al.

Although the three neuroradiologists in the Boden et al. study largely agreed on the absence or presence of abnormal findings on the MRIs, in 2014 Fu et al. reported on the interrater and intrarater agreements by four reviewers of MRI findings from the lumbar spine of 75 subjects. Even though this study used standardized evaluation criteria, there was significant variability in both interrater and intrarater agreement among the reviewers. As the Boden et al. study did 25 years ago, this study demonstrated the diagnostic limitations of MRI interpretation for lumbar spinal diseases.

In 2001, JBJS published a paper by Borenstein et al. that was a seven-year follow-up study among the same asymptomatic subjects studied by Boden et al. Borenstein et al. found that the original 1989 scans of the lumbar spine were not predictive of the future development or duration of low back pain. This led Borenstein et al. to conclude—as Boden et al. did—that “clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.”

Many important subsequent studies were inspired by the original findings of Boden et al. in JBJS. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRIs is variable; and that all imaging information must be correlated to the specific patient’s clinical condition.

Several studies and national surveys indicate that approximately a quarter of US adults report having had back pain during the past 3 months, making this a common clinical complaint. But the findings of Boden, et al. and subsequent studies remind us that surgery is not always the appropriate treatment.

Daisuke Togawa, MD, PhD

JBJS Deputy Editor

JBJS Classics: Bankart Repairs

EaJBJS-Classics-logoch 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.

While our current understanding of glenohumeral dislocation has its roots in antiquity, it was not until later in the twentieth century that the orthopaedic community settled on surgical repair of the capsulolabral structures as a standard treatment. Although Perthes in 1906 and Bankart in 1923 accurately and correctly identified anterior glenoid, labral, and capsular pathology as the “essential lesion” in recurrent anterior dislocations and promoted anatomic repair, other camps favored operative treatment with non-anatomic repairs including the Putti-Platt, Magnusen-Stack, and Nicola procedures. However, by the end of the twentieth century, the Bankart repair was recognized as the “gold standard.”

“The Bankart Procedure” authored by Rowe et al (J Bone Joint Surg Am 1978; 60:1–16), is a true classic paper in the orthopaedic literature. This was the first large clinical series with good follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent and good, with low recurrence rates, and few complications. Although the study suffers from the usual flaws of a retrospective clinical study, it set a standard and contributed to the demise of non-anatomic repairs.

More recent innovations in arthroscopy led to the development of arthroscopic Bankart labral repairs that are now the standard of care for most surgeons treating anterior glenohumeral instability. Although greater experience with arthroscopy appears to improve outcomes, failed instability repairs are not uncommon, and this has led to expanding efforts with alternative procedures such as the Latarjet coracoid transfer and remplissage. Interestingly, the contemporary focus on severe anterior glenoid bone loss and large Hill-Sachs lesions differs from the historical perspective that “The Bankart Procedure” presented in 1978. Is this the result of changes in patient pathology or expectations, or is it driven by surgeon perceptions of outcomes and the desire to innovate? I think it is a bit of both.

Among the many points that Rowe et al. make in their landmark paper is the importance of meticulous technique. Orthopaedists often gloss over such statements in the literature, but I think most would agree that anterior instability repairs, open and arthroscopic, can be technically challenging, especially for the inexperienced surgeon. Referring to the Bankart procedure, Anthony DePalma clearly stated that “the operation is difficult and should only be performed by surgeons who are familiar with the topographic anatomy” (DePalma AF. Surgery of the Shoulder. JB Lippincott Co., Philadelphia, 1950, p. 236).

Rowe et al. correctly identified the important pathologic causes of recurrent glenohumeral instability. The most recent basic and clinical research into the more complex aspects of anterior glenohumeral instability is likely to help better define the appropriate indications for alternative procedures to address these issues.

Andrew Green, MD

JBJS Deputy Editor for the Upper Extremity

JBJS Classics: ACL Graft Strength and Stiffness

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.

JBJS-Classics-logoIn the classic article, “Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions” (J Bone Joint Surg Am 1984; 66:344–352), now 30 years old, Noyes and colleagues studied the mechanical properties of several anterior cruciate ligament (ACL) grafts that were used at that time. Using young donors, they found that the bone-patellar tendon-bone (BPTB) graft was the only graft studied that had a maximum load in excess of the native ACL. Many of the grafts they studied—including iliotibial tract, fascia lata, and quadriceps retinaculum—had exceedingly poor strengths, which is probably why they are no longer used.

Unfortunately, the authors did not double their hamstring grafts (as is commonly done clinically) for testing, and they also used 14-mm BPTB grafts, which are much wider than commonly used clinically, so some of their comparisons may have limited clinical applicability. The authors did note several limitations to their study, including that graft strength is only one of many factors for successful ACL reconstruction, that gripping was sometimes a problem during testing, and that they only performed uni-axial testing. Nevertheless, this article set the stage for critically analyzing graft choice based upon mechanical properties.

Subsequent studies, including those by Woo, Cooper, Howell, Brown, and others, now suggest that several grafts are available that are stronger and stiffer than the native ACL, including BPTB, quadrupled hamstring (strongest and stiffest of all grafts studied), quadriceps tendon, tibialis anterior tendon, and posterior tibial tendon:

Graft Type Ultimate Strength(N) Stiffness (KN/m)
Native ACL 2160 292
BPTB 2977 620
Quadrupled Hamstring 4590 861
Quadriceps Tendon 2352 463
Tibialis Anterior 3412 344
Posterior Tibialis 3391 302

Of course, many other ACL reconstruction controversies continue to be debated, including technique, fixation, and autograft vs. allograft. But graft strength and stiffness will continue to be one of many important factors for the ACL surgeon to consider, especially if future options such as ACL augmentation and the use of synthetics and biologics become available. We welcome comments from JBJS readers.

Mark D. Miller, MD

JBJS Deputy Editor for Sports Medicine