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 October 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Validity of Clinical Small-Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration.”
This prospective, cross-sectional, diagnostic-accuracy study found that pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration in a carpal tunnel syndrome model of neuropathy.
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
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 Level I and II studies cited in the May 20, 2015 Specialty Update on foot and ankle surgery:
Talar and Calcaneal Fractures
- A prospective randomized study comparing the sinus tarsi approach with the minimally invasive approach to the calcaneus found significantly fewer wound healing complications and shorter operative times with the minimally invasive longitudinal approach, but better outcomes were noted with the sinus tarsi approach for Sanders type-IV fractures.
- An RCT comparing outcomes of operative and nonoperative treatment for displaced intra-articular calcaneal fractures found no between-group differences at one year, but a trend toward better pain scores and function was noted in the operative group at eight to twelve years.
- A prospective randomized study of treatments for severe lateral ankle sprains compared a walking boot with restricted joint mobilization for three weeks with immediate application of a functional brace. No between-group differences in pain scores or development of mechanical instability were found, but the immediate functional-brace group had better function scores and shorter recoveries.
- A randomized trial comparing neuromuscular training, bracing, and a combination of the two for managing lateral ankle sprains concluded that bracing is the dominant secondary preventive intervention.
Total Ankle Arthroplasty
- A Level II study comparing total ankle arthroplasty (TAA) with ankle arthrodesis found that both procedures improved gait postoperatively, but TAA came closer to restoring a normal gait.
- A Level II study comparing fixed and mobile-bearing TAA devices found nearly equivalent improvements in pain and function.
- A Level I study looking at TAA outcomes in relation to preoperative coronal-plane malalignment found that results were similar for ankles with a preoperative coronal-plane varus deformity of ≥10° and those with <10° of varus deformity.
Ankle and Hindfoot Arthrodesis
- A pilot RCT comparing B2A-coated ceramic granules with autograft in foot and ankle arthrodesis found that the B2A approach produced a 100% fusion rate, compared with a 92% rate in the autograft group.
- A Level II study found that weight-bearing cast immobilization provided outcomes that were similar to those of non-weight-bearing cast immobilization in non-operative management of acute Achilles tendon ruptures.
- In an RCT comparing standard-of-care orthoses with experimental pressure-based orthoses to prevent plantar foot ulcers, the experimental orthoses outperformed the standard ones.
- A Level I study investigating surgical-site infections after foot and/or ankle surgery found an increased risk of infection associated with concomitant peripheral neuropathy, even in patients without diabetes.