How to Conduct a Virtual Orthopaedic Examination
For obvious reasons, the use of telemedicine has surged during the COVID-19 pandemic. If you are wondering what a “virtual” orthopaedic physical exam looks like, Tanaka et al. explain the process in words and images in a recent fast-tracked JBJS article.
At the time they schedule their virtual visit, patients are asked to confirm their audiovisual capabilities, and they receive specific instructions about camera positioning, body positioning, setting, and attire to improve the efficiency of the visit.
Tanaka et al. give step-by-step instructions for virtually evaluating the knee, hip, shoulder, and elbow. They describe how they measure range of motion using a web-based goniometer (see Figure), and they explain how to conduct virtual strength tests for each joint. To enable post-exam follow-up discussions with patients, the authors recommend using “the screen-sharing function that is presumably available on all interactive telehealth platforms.”
The authors acknowledge the limitations inherent in a virtual orthopaedic exam, such as the inability to directly palpate the joint or perform provocative tests. They also admit that the patient population that would potentially benefit the most from televisits—older patients with limited mobility and who are at higher risk for infection during the pandemic—are also those who may have the most difficulty implementing the technology.
The rapid rise of telemedicine in orthopaedics has occurred due to unexpected necessity, but many expect that its widespread use will continue post-pandemic. Tanaka et al. cite future directions for the technology, including the development of validated, modified examination techniques and advancements that will improve interactivity during the physical examination. For now, though, these experience-based guidelines should help orthopaedists optimize the quality and efficiency of their upcoming virtual visits for common musculoskeletal conditions.
A Four-Legged Step Toward Preventing Elbow Contractures
Up to 50% of patients who sustain an elbow injury subsequently develop some type of contracture, making elbow contracture following trauma a common and vexing clinical scenario. While we do not completely understand the molecular basis or structural mechanisms underlying these contractures, we do know that active range-of-motion (ROM) exercises and gentle stretching are often helpful, whereas prolonged immobilization and forceful passive ROM exercises are often, if not always, detrimental.
In the March 6, 2019 issue of The Journal, Dunham and colleagues document with a rat model a better understanding about which specific tissues around the elbow account for this condition. They performed a surgical procedure on rat elbows to simulate a dislocation and then immobilized the injured extremity for 6 weeks. After the authors obtained ROM measurements at that point, some of the rats were allowed an additional 3 or 6 weeks of free active motion before a postmortem surgical dissection was performed to determine which soft tissues were most responsible for the subsequent contracture.
While the authors hypothesized that all soft tissues (muscles/tendons, anterior capsule, and ligaments/cartilage) would play a significant role in posttraumatic stiffness, they found in fact that the ligaments and cartilage caused 52% of the lost motion after 21 days of free motion and 74% of the contracture after 42 days of free motion. With this information, clinical therapies such as pharmacologic infiltrations or biophysical energy delivered to the ligaments or cartilage could be investigated. In addition, refined surgical techniques focused on these structures could be proposed and analyzed. This study represents a small preclinical step in further understanding the mechanisms of joint contracture, but it provides a foundation on which further investigations can be built.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS 100: Knee Hemarthrosis and Achilles Ruptures
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:
Arthroscopy in Acute Traumatic Hemarthrosis of the Knee
F R Noyes, R W Bassett, E S Grood, D L Butler: JBJS, 1980 July; 62 (5): 687
This paper was among the first to identify the high rate of serious knee injuries among patients with acute traumatic hemarthrosis (ATH). Noyes’ paper showed that 72% of knees with ATH also had some degree of ACL injury. While orthopaedists generally no longer use knee arthroscopy as a diagnostic tool in the setting of ATH, because of this article, they often order MRI when patients present with this acute knee injury.
Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures
K Willits, A Amendola, D Bryant, N Mohtadi, J R Giffin, P Fowler, C O Kean, A Kirkley: JBJS, 2010 December 1; 92 (17): 2767
This multicenter randomized trial was not the first to compare surgical treatment of Achilles tendon ruptures with nonoperative treatment that included early functional range of motion, but it confirmed that in patients treated nonoperatively, early functional treatment is preferable to cast immobilization. Since this paper was published, more than 20 studies investigating Achilles tendon ruptures have been published in JBJS, emphasizing that the search goes on for treatment protocols—surgical and nonoperative—that are effective and relatively free of complications.
JBJS 100: Talar Neck Fractures and Elbow Biomechanics
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:
Fractures of the Neck of the Talus: Long-Term Evaluation of 71 Cases
S T Canale and F B Kelly Jr: JBJS, 1978 Jan; 60 (2): 143
One of the most challenging diagnoses for general orthopedic surgeons and fracture specialists alike is a fracture of the talar neck. In this landmark JBJS article, the authors focused attention on the importance of quality of reduction and created an enduring fracture classification that paralleled complication rates and potential outcomes.
A Biomechanical Study of Normal Functional Elbow Motion
B F Morrey, L J Askew, E Y Chao: JBJS, 1981 Jan; 63 (6): 872
This JBJS article convincingly answered the question about the minimal range of elbow motion needed to accomplish activities of daily living. Using modern 3-dimensional optical tracking technology 30 years after Dr. Morrey’s study appeared, Sardelli et al. found only minimal ROM differences compared to findings in the Morrey study.
For Rotator Cuff Deficiency, RSA Delivers Good Long-term Results
In a recent OrthoBuzz post about minimal-incision total hip arthroplasty, we observed that “it is the long-term results [of orthopaedic procedures] that really matter.” Along those lines, in the November 15, 2017 issue of The Journal of Bone & Joint Surgery, Cuff et al. provide 10-year follow-up results of reverse shoulder arthroplasty (RSA) in patients with end-stage rotator cuff deficiency. The 5-year follow-up results were published in a 2012 JBJS article.
Forty-two of the original 96 shoulders were available for clinical follow-up at a minimum of 10 years. Here’s what the authors found:
- Patients retained their gains in total average preop-vs-postop ASES and SST scores.
- Survivorship (percentage of shoulders not requiring revision) was 90.7%.
- There was decreased range of shoulder motion in all planes between 5 and 10 years of follow-up, but there was no consistent trend of an increase in shoulder pain.
Cuff et al. attribute these positive and durable outcomes in part to the use of 5.0-mm peripheral locking screws for baseplate fixation, which they say “provided improved early fixation and allowed for osseous ingrowth into the baseplate.”
Anatomic and Reverse Shoulder Replacement: Comparing Improvements Over Time
Although the indications for anatomic and reverse total shoulder arthroplasty (TSA) are different, better understanding of the rate of improvement with each type of surgery could help establish more realistic patient expectations for recovery—and help surgeons and physical therapists design different strategies for postoperative care. With those goals in mind, Simovitch et al. use prospectively collected data to compare, at a minimum 2-year follow-up, clinical and range-of-motion (ROM) outcomes among 505 anatomic TSA patients and 678 reverse TSA patients. The findings appear in in the November 1, 2017 issue of JBJS.
The authors tracked five clinical outcome scores (SST, UCLA Shoulder, ASES, Constant, and SPADI), along with 4 relevant ROM measures. In both groups, >95% of patients reported clinical improvement in all 5 clinical metrics by 6 months, and full improvement was noted by 24 months. Not surprisingly, the mean age of patients who underwent reverse TSA was >5 years older and their shoulder-function scores and ROM were generally worse than those of the anatomic TSA patients.
At the time of the latest follow-up, patients who underwent anatomic TSA fared significantly better than patients who underwent reverse TSA in 3 of the 5 clinical outcome metrics and in all 4 ROM measurements. On the other hand, those who had reverse TSAs had significantly larger improvements in the Constant score (which emphasizes strength more than the other 4 clinical metrics) and active forward flexion.
ROM-wise, at approximately 6 years after surgery, the authors noted a progressive decrease in the magnitude of improvement for abduction and forward flexion in both groups. According to Simovitch et al., the observed discrepancies between clinical and ROM outcomes at longer-term follow-up suggest that “subjective (e.g., patient-reported) assessments of outcome and function likely continue to be stable or improve despite range-of-motion worsening and, as such, may imply that patient expectations change with follow-up time.”
Both Subjective and Objective Measures Tell the Shoulder Story
When surgeons and patients discuss what treatment will work best for a particular musculoskeletal ailment, they often rely on both “subjective” and “objective” outcome data from previously published assessments. Reviewing both types of data is a good idea, because a study among more than 100 patients with shoulder osteoarthritis by Matsen et al. in the March 1, 2017 issue of The Journal of Bone & Joint Surgery found poor correlation between objective measures of active abduction and subjective patient self-assessments using the Simple Shoulder Test (SST).
The authors used a statistical method called “coefficient of determination”
to confirm “a highly variable relationship” between the patient-reported SST (subjective) and motor-sensor range-of-motion (objective) measurements. In less statistical language, many of the shoulders had good motion and poor self-assessed function, while others had poor motion and good self-assessed function.
The findings led the authors to conclude that “studies of treatment outcomes should include separate assessments of these 2 complementary aspects of shoulder function.” That conclusion was seconded and expanded upon in a commentary by Jeffrey S. Abrams, MD, who wrote that “either [subjective or objective] assessment used independently may lead to the wrong impression.”
JBJS Editor’s Choice—Knee Sepsis: Arthroscopic or Open Treatment?
In the March 15, 2017 issue of The Journal, Johns et al. report results from a Level III cohort study comparing arthroscopic vs open irrigation for control of acute native-knee sepsis. The authors collected information on more than 160 patients with knee sepsis over a 15-year period, which is a large cohort of patients with this relatively unusual clinical problem.
The data show a cumulative success rate of 97% with arthroscopic treatment after 3 irrigations and debridements vs 83% success in the arthrotomy group after the same number of procedures—a clinically important difference. Significantly fewer arthroscopic procedures were required for successful treatment, relative to open procedures, and post-procedure median knee range of motion was significantly greater in the arthroscopic group (90°) than in the open treatment group (70°).
The fact is that arthroscopic instruments allow a greater volume of irrigation fluid to be instilled with better access to the posterior recesses of the knee. With an open arthrotomy, it is more difficult to irrigate with high volumes, and the posterior recesses of the knee are not well accessed. It seems clear that arthroscopic management of acute knee sepsis should be the standard of care for these reasons, as well as because the technique is minimally invasive in terms of soft tissue stripping and incision size.
Treating infections of major-weight bearing joints is following a trend seen in surgical management of many orthopaedic conditions—smaller exposures with use of adjunctive visualization techniques.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS Classics: Biomechanics of the Normal Elbow
OrthoBuzz regularly brings 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 highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
The classic 1981 JBJS article by B.F. Morrey et al. begs to be read carefully, in part because of the name of the lead author. More importantly, this study answers the question that arises with almost every patient with an elbow disorder: Is the achieved range of motion sufficient for activities of daily living? We can answer this question “yes” or “no” after reading this article, and in my own practice, I repeatedly refer to the information provided in it.
Dr. Morrey was an aerospace engineer who worked at NASA for two years before he attended medical school at the University of Texas Medical Branch. After his residency at the Mayo Clinic and after achieving a master’s degree in biomechanics from the University of Minnesota, he joined the staff at Mayo in 1978.
In this article, which integrates Dr. Morrey’s engineering and medical disciplines, he applied a high-tech device of that period (the triaxial electrogoniometer) to answer simple but eternal questions such as what degree of elbow flexion is needed to eat or perform personal hygiene.
It is the nature of human beings to notice particular joint impairments only when they disturb activities of daily living. Patient-reported outcome scores assessing subtle disturbances have recently been published, but we learned from Dr. Morrey’s article that patients with elbow flexion less than 130° will probably be reminded of their elbow problem whenever they try to use a telephone. (With today’s small cellular phones the problem might be even more accentuated.)
There is not much that a contemporary reviewer would criticise if this study were to be submitted today. Yes, the graphics would be nicer, and there would be more than 12 references. Modern computer-aided tools and methods for motion analysis might be more precise (and produce a mass of partially redundant data), but the results would remain essentially the same.
In fact, the question of functional elbow range of motion was revisited in JBJS by Sardelli et al. exactly 30 years after Dr. Morrey’s study appeared. Using modern three-dimensional optical tracking technology, Sardelli et al. found only minimal differences compared to findings in the Morrey et al. study. Only a few contemporary tasks like working on a computer (greater pronation) or using a cellular phone (greater flexion) appeared to require slightly more range of motion than previously reported.
Finally, it is the succinct and pointed results that amaze me whenever I recall the information from Dr. Morrey’s study. All we need to remember are four numbers: 100, 30, 130, and 50. Therein we are reminded that the patient needs to achieve a 100° arc of motion for flexion /extension (from 30° to 130°) and forearm rotation (50° of pronation and 50° of supination).
The authors were able to omit the conclusion sentence we see so often these days: “Further studies are needed…” The question about the minimal range of elbow motion needed to accomplish activities of daily living has been convincingly answered in this article. All residents should read this JBJS classic early, certainly before they examine their first patient with an elbow disorder.
Bernhard Jost, M.D.
JBJS Deputy Editor
Long-Term Repair Success with MCLs Injured During TKA
Intraoperative injury to the medial collateral ligament (MCL) is a rare but important complication of total knee arthroplasty (TKA). Surgeons face two basic choices when it happens: intraoperatively converting to a more constrained TKA prosthesis, or primary repair of the MCL followed by protective bracing.
The retrospective review by Bohl et al. in the January 6, 2016 edition of The Journal of Bone & Joint Surgery does not compare those options head-to-head, but with an average follow-up of more than 8 years, it provides solid evidence that intraoperative repair followed by bracing is a successful long-term strategy.
The authors followed 45 TKAs that sustained either an intraoperative midsubstance MCL tear or an avulsion; 35 injuries occurred during a cruciate-retaining procedure, and 10 during a posterior-stabilized TKA. At a mean final follow-up of 99 months:
- There were no symptoms on physical examination of coronal-plane instability
- All patients were capable of community ambulation without an assistive device, and
- The mean HSS knee score had increased from 47 preoperatively to 85.
Five knees (11%) required intervention for stiffness. Although the authors emphasize that “in all cases the brace was set to allow full range of motion of the knee,” bracing may nevertheless have promoted stiffness by inhibiting range of motion in a cohort that included large proportions of obese and morbidly obese patients. This particular finding suggests that range-of-motion exercises should be emphasized after similar surgeries.
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