Classic Papers in Orthopaedics [1 ed.] 9781447154518, 1447154517

Table of contents :
Front Matter....Pages i-xx
Front Matter....Pages 1-1
Main Introduction....Pages 3-6
Front Matter....Pages 7-7
Classic Papers in Hip Surgery: Introduction....Pages 9-12
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....Pages 13-17
Functional Results of Hip Arthroplasty with Acrylic Prosthesis....Pages 19-22
Clinical and Radiographic Evaluation of Total Hip Replacement. A Standard System of Terminology for Reporting Results....Pages 23-26
Prognosis of Total Hip Replacement in Sweden: Follow-Up of 92,675 Operations Performed 1978–1990....Pages 27-30
Improved Cementing Techniques and Femoral Component Loosening in Young Patients with Hip Arthroplasty: A 12-Year Radiographic Review....Pages 31-34
“Modes of Failure” of Cemented Stem-Type Femoral Components: A Radiographic Analysis of Loosening....Pages 35-38
Radiological Demarcation of Cemented Sockets in Total Hip Replacement....Pages 39-41
Femoral Component Loosening Using Contemporary Techniques of Femoral Cement Fixation....Pages 43-46
The Correlation Between the Roentgenographic Appearance and Operative Findings at the Bone-Cement Junction of the Socket in Charnley Low Friction Arthroplasties....Pages 47-49
Porous-Coated Hip Replacement. The Factors Governing Bone Ingrowth, Stress Shielding, and Clinical Results....Pages 51-55
Total Hip Arthroplasty. A Review of Three Hundred and Thirty Three Cases with Long Follow-Up....Pages 57-59
Ten-Year Follow-Up Study of Total Hip Replacement....Pages 61-63
A Ten-Year Follow-Up of One Hundred Consecutive Müller Curved-Stem Total Hip Replacement Arthroplasties....Pages 65-67
Total Hip Replacement in Patients Younger Than Thirty Years Old: A Five-Year Follow-Up Study....Pages 69-72
The Long Term Results of Low Friction Arthroplasty of the Hip Performed as a Primary Intervention....Pages 73-75
Reactions of the Articular Capsule to Wear Products of Artificial Joint Prostheses....Pages 77-79
The Initiation of Failure in Cemented Femoral Components of Hip Arthroplasties....Pages 81-83
Periprosthetic Bone Loss in Total Hip Arthroplasty: Polyethylene Wear Debris and the Concept of the Effective Joint Space....Pages 85-87
Front Matter....Pages 7-7
Production of Cytokines Around Loosened Cemented Acetabular Components: Analysis with Immunohistochemical Techniques and In Situ Hybridization....Pages 89-91
The Effect of Conformity, Thickness, and Material on Stresses in Ultra-High Molecular Weight Components for Total Joint Replacement....Pages 93-96
Metallic Wear in Failed Titanium-Alloy Total Hip Replacements: A Histological and Quantitative Analysis....Pages 97-100
Effect of Femoral Head Size on Wear of the Polyethylene Acetabular Component....Pages 101-104
Ectopic Ossification Following Total Hip Replacement: Incidence and a Method of Classification....Pages 105-107
Dislocations After Total Hip Arthroplasty....Pages 109-111
Dislocations After Total Hip-Replacement Arthroplasties....Pages 113-115
The Synovial-Like Membrane at the Bone-Cement Interface in Loose Total Hip Replacements and Its Proposed Role in Bone Lysis....Pages 117-119
Idiopathic Bone Necrosis of the Femoral Head. Early Diagnosis and Treatment....Pages 121-123
Total Hip Replacement in Congenital Dislocation and Dysplasia of the Hip....Pages 125-128
Changes in Trabecular Pattern of the Upper End of the Femur as an Index of Osteoporosis....Pages 129-132
Front Matter....Pages 133-133
Classic Papers in Knee, Sports Medicine and Arthroscopy: Introduction....Pages 135-136
Stiffness and Laxity of the Knee: The Contributions of the Supporting Structures: A Quantitative In Vitro Study....Pages 137-139
Ligamentous Restraints to Anterior-Posterior Drawer in the Human Knee: A Biomechanical Study....Pages 141-143
Biomechanical Analysis of Human Ligament Grafts Used in Knee-Ligament Repairs and Reconstructions....Pages 145-147
Fate of the ACL-Injured Patient: A Prospective Outcome Study....Pages 149-152
Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer: NCAA Data and Review of Literature....Pages 153-155
The Symptomatic Anterior Cruciate-Deficient Knee. Part I: The Long-Term Functional Disability in Athletically Active Individuals....Pages 157-159
Biochemical Changes in the Cartilage of the Knee in Experimental and Natural Osteoarthritis in the Dog....Pages 161-163
Two- to 9-Year Outcome After Autologous Chondrocyte Transplantation of the Knee....Pages 165-168
Front Matter....Pages 133-133
A Comparison of Four Models of Total Knee-Replacement Prostheses....Pages 169-171
Knee Joint Changes After Meniscectomy....Pages 173-175
Late Results After Meniscectomy....Pages 177-179
Factors Effecting Late Results After Meniscectomy....Pages 181-183
The Etiology of Chondromalacia Patellae....Pages 185-187
Roentgenographic Analysis of Patellofemoral Congruence....Pages 189-191
The Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System....Pages 193-195
Rationale of the Knee Society Clinical Rating System....Pages 197-199
Rating Systems in the Evaluation of Knee Ligament Injuries....Pages 201-203
Injuries to Runners....Pages 205-207
Front Matter....Pages 209-209
Classic Papers in Foot and Ankle Surgery: Introduction....Pages 211-211
Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation....Pages 213-215
Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes....Pages 217-219
A Method of Forefoot Reconstruction....Pages 221-223
Fractures of Neck of Talus....Pages 225-227
Operative Compared with Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures: A Prospective, Randomized, Controlled Multicenter Trial....Pages 229-231
Sprained Ankles. VI. Surgical Treatment of Chronic Ligament Ruptures....Pages 233-235
Front Matter....Pages 237-237
Classic Papers in Spine Surgery: Introduction....Pages 239-239
A Study of the Natural History of Back Pain: Part I: Development of a Reliable and Sensitive Measure of Disability in Low-Back Pain....Pages 241-244
Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation....Pages 245-247
Front Matter....Pages 237-237
Volvo Award in Clinical Sciences: A New Clinical Model for the Treatment of Low-Back Pain....Pages 249-251
Lumbar Disc Herniation: A Controlled, Prospective Study with Ten Years of Observation....Pages 253-256
Physical Measurements as Risk Indicators for Low-Back Trouble Over a One-Year Period....Pages 257-259
Risk Factors in Low-back Pain. An Epidemiological Survey....Pages 261-263
Conservative Treatment of Acute and Chronic Nonspecific Low-back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions....Pages 265-267
Nonorganic Physical Signs in Low-Back Pain....Pages 269-271
Treatment of Scoliosis Correction and Internal Fixation by Spine Instrumentation....Pages 273-275
A Radicular Syndrome from Developmental Narrowing of the Lumbar Vertebral Canal....Pages 277-279
A Prospective, Randomized Study of Lumbar Fusion: Preliminary Results....Pages 281-283
Fractures of the Odontoid Process of the Axis....Pages 285-287
The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries....Pages 289-292
The Treatment of Certain Cervical- Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion....Pages 293-295
Front Matter....Pages 297-297
Classic Papers in Upper Limb Surgery: Introduction....Pages 299-300
Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder: A Preliminary Report....Pages 301-303
Impingement Lesions....Pages 305-307
Stabilizing Mechanisms Preventing Anterior Dislocation of the Glenohumeral Joint....Pages 309-311
The Bankart Procedure: A Long-Term End-Result Study....Pages 313-315
Inferior Capsular Shift for Involuntary Inferior and Multidirectional Instability of the Shoulder. A Preliminary Report....Pages 317-318
A Clinical Method for Functional Assessment of the Shoulder....Pages 319-321
Displaced Proximal Humerus Fractures. Part I: Classification and Evaluation....Pages 323-325
Front Matter....Pages 297-297
Recent Experience in Total Shoulder Replacement....Pages 327-329
Normal and Abnormal Motion of the Shoulder....Pages 331-333
Front Matter....Pages 335-335
Classic Papers in Hand and Wrist Surgery: Introduction....Pages 337-338
The Carpal-Tunnel Syndrome: Seventeen Years’ Experience in Diagnosis and Treatment of Six Hundred Fifty-Four Hands....Pages 339-341
The Prehensile Movements of the Human Hand....Pages 343-345
Evaluation of Healed Colles’ Fractures....Pages 347-348
A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome....Pages 349-351
Traumatic Instability of the Wrist. Diagnosis, Classification, and Pathomechanics....Pages 353-355
Intra-articular Fractures of the Distal End of the Radius in Young Adults....Pages 357-360
The Carpal Tunnel Syndrome. A Study of Carpal Canal Pressures....Pages 361-363
Complications of Colles Fractures....Pages 365-366
Interfascicular Nerve-Grafting of the Median and Ulnar Nerves....Pages 367-369
Triangular Fibrocartilage Complex Lesions—A Classification....Pages 371-372
Front Matter....Pages 373-373
Classic Papers in Basic Science I: Introduction....Pages 375-376
Cell Origin and Differentiation in the Repair of Full-Thickness Defects of Articular Cartilage....Pages 377-379
The Response of Articular Cartilage to Mechanical Injury....Pages 381-383
Biochemical and Metabolic Abnormalities in Articular Cartilage from Osteo-arthritic Human Hips. II: Correlation of Morphology with Biochemical and Metabolic Data....Pages 385-387
Articular Cartilage. Part II: Degeneration and Osteoarthrosis, Repair, Regeneration, and Transplantation....Pages 389-391
Walking Patterns of Normal Men....Pages 393-395
Measurement of Lower Extremity Kinematics During Level Walking....Pages 397-398
Front Matter....Pages 373-373
Repeatability of Kinematic, Kinetic, and Electromyographic Data in Normal Adult Gait....Pages 399-401
The Major Determinants in Normal and Pathological Gait....Pages 403-405
The Normal Vascular Anatomy of the Femoral Head in Adult Man....Pages 407-409
Humeral Hypertrophy in Response to Exercise....Pages 411-413
Interrater Reliability of a Modified Ashworth Scale of Muscle Spasticity....Pages 415-417
Calcium Phosphate Ceramics as Hard Tissue Prosthetics....Pages 419-421
Front Matter....Pages 423-423
Classic Papers in Basic Science II: Introduction....Pages 425-425
Biosynthetic Response of Cartilage Explants to Dynamic Compression....Pages 427-429
A Direct Spectrophotometric Microassay for Sulphated Glycosaminoglycans in Cartilage Cultures....Pages 431-432
Chemical Basis for the Histological Use of Safranin O in the Study of Articular Cartilage....Pages 433-435
The Biological Effect of Continuous Passive Motion on the Healing of Full-Thickness Defects in Articular Cartilage. An Experimental Investigation in the Rabbit....Pages 437-439
Mesenchymal Cell-Based Repair of Large Full Thickness Defects of Articular Cartilage....Pages 441-443
Mesenchymal Stem Cells....Pages 445-448
Bone: Formation by Autoinduction....Pages 449-451
Tendon Healing in a Bone Tunnel: A Biomechanical and Histological Study in the Dog....Pages 453-456
The Compressive Behavior of Bone as a Two-Phase Porous Structure....Pages 457-460
Quantitative Microradiographic Studies of Normal and Osteoporotic Bone....Pages 461-463
Bone Morphogenetic Protein....Pages 465-467
Front Matter....Pages 469-469
Classic Papers in Orthopaedic Oncology: Introduction....Pages 471-472
The Registry of Bone Sarcomas as an Example of the End-Result Idea in Hospital Organization....Pages 473-474
Front Matter....Pages 469-469
Osteogenic Sarcoma. A Study of Six Hundred Cases....Pages 475-476
Osteogenic Sarcoma; a Study Based on 133 Patients....Pages 477-478
Metastatic Disease in Long Bones. A Proposed Scoring System for Diagnosing Impending Pathologic Fractures....Pages 479-480
Chemotherapy, En Bloc Resection, and Prosthetic Bone Replacement in the Treatment of Osteogenic Sarcoma....Pages 481-482
The Treatment of Soft-Tissue Sarcomas of the Extremities. Prospective Randomized Evaluations of (1) Limb-Sparing Surgery Plus Radiation Therapy Compared with Amputation and (2) the Role of Adjuvant Chemotherapy....Pages 483-484
Preoperative Versus Postoperative Radiotherapy in Soft-Tissue Sarcoma of the Limbs: A Randomised Trial....Pages 485-486
A System for the Surgical Staging of Musculoskeletal Sarcoma....Pages 487-488
A System for the Functional Evaluation of Reconstructive Procedures After Surgical Treatment of Tumors of the Musculoskeletal System....Pages 489-490
The Hazards of Biopsy in Patients with Malignant Primary Bone and Soft-Tissue Tumors....Pages 491-493
Front Matter....Pages 495-495
Classic Papers in Trauma and Fracture Healing: Introduction....Pages 497-497
The Influence of Induced Micromovent Upon the Healing of Experimental Tibial Fractures....Pages 499-501
Morbidity at Bone Graft Donor Sites....Pages 503-505
Osseointegrated Titanium Implants: Requirements for Ensuring a Long-Lasting, Direct Bone-to-Implant Anchorage in Man....Pages 507-509
Regulation of Bone Formation by Applied Dynamic Loads....Pages 511-513
Closed Intramedullary Nailing of Femoral Fractures. A Report of Five Hundred and Twenty Cases....Pages 515-517
The Tension-Stress Effect on the Genesis and Growth of Tissues Part I. The Influence of Stability of Fixation and Soft-Tissue Preservation....Pages 519-522
The Tension-Stress Effect on the Genesis and Growth of Tissues: Part II. The Influence of the Rate and Frequency of Distraction....Pages 523-525
Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones. Retrospective and Prospective Analyses....Pages 527-530
The Biology of Fracture Healing in Long Bones....Pages 531-533
The Healing of Segmental Bone Defects, Induced by Recombinant Human Bone Morphogenetic Protein (rhBMP-2): A Radiographic, Histological, and Biomechanical Study in Rats....Pages 535-537
Front Matter....Pages 495-495
Early Versus Delayed Stabilization of Femoral Fractures....Pages 539-540
Front Matter....Pages 541-541
Classic Papers in Orthopaedic Paediatric: Introduction....Pages 543-545
Acute Slipped Capital Femoral Epiphysis: The Importance of Physeal Stability....Pages 547-548
Surgical Dislocation of the Adult Hip: A Technique with Full Access to the Femoral Head and Acetabulum Without the Risk of Avascular Necrosis....Pages 549-550
The Natural History of Legg-Calve-Perthes Disease....Pages 551-553
Legg-Calve-Perthes Disease. Part II: Prospective Multicenter Study of the Effect of Treatment on Outcome....Pages 555-557
Classification of Hip Joint Dysplasia by Means of Sonography....Pages 559-561
First Fifteen Years Personal-Experience with Innominate Osteotomy in Treatment of Congenital Dislocation and Subluxation of Hip....Pages 563-565
A Harness for Treatment of Congenital Hip Dislocation in Infants....Pages 567-568
Congenital Dislocation of the Hip: Development of the Joint After Closed Reduction....Pages 569-570
Congenital Club Foot: The Result of Treatment....Pages 571-573
Development and Reliability of a System to Classify Gross Motor Function in Children with Cerebral Palsy....Pages 575-577
Hip Dislocation and Subluxation in Cerebral Palsy....Pages 579-580
Injuries Involving the Epiphyseal Plate....Pages 581-582
Limb Lengthening by Callus Distraction (Callotasis)....Pages 583-584
Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm....Pages 585-587
Front Matter....Pages 589-589
Levels of Evidence....Pages 591-594
How to Review a Scientific Manuscript....Pages 595-607
How to Get Published and Impact Factors....Pages 609-613
Back Matter....Pages 615-624

Citation preview

Paul A. Banaszkiewicz Deiary F. Kader Editors

Classic Papers in Orthopaedics

123

Classic Papers in Orthopaedics

Paul A. Banaszkiewicz • Deiary F. Kader Editors

Classic Papers in Orthopaedics

Editors Paul A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics Queen Elizabeth Hospital Gateshead Northumbria University Newcastle Upon Tyne UK

Deiary F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics Queen Elizabeth Hospital Gateshead Northumbria University Newcastle Upon Tyne UK

ISBN 978-1-4471-5450-1 ISBN 978-1-4471-5451-8 DOI 10.1007/978-1-4471-5451-8 Springer London Heidelberg New York Dordrecht

(eBook)

Library of Congress Control Number: 2013957882 © Springer-Verlag London 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Foreword

Making the correct therapeutic decision when faced with challenging difficulties in which numerous alternatives exist is always difficult. This is particularly so in orthopaedic surgery, where many choices are available for treating an individual with an injury or condition that affects the musculoskeletal system. Making the wrong decision can result in significant morbidity and an impaired quality of life. In the pre-Internet era, an orthopaedic surgeon would have relied on their past experience and information handed down to them from their teachers during their formative training, with assistance from a few textbooks or orthopaedic journals available in their local hospital library. With the arrival of the Internet era, the capacity for acquiring information about the treatment and management of any injury has increased in a non-linear manner, to the point where now the problem has changed from having too little information to make an informed decision to having too much information available, which paradoxically has made making a management decision even more difficult, not just because of the amount of information available, but due to lack of certainty regarding its veracity and source. Classic Papers in Orthopaedics has been written to assist in making more sense of the surfeit of information now available to the clinician or researcher with an interest in orthopaedics. Using citation counts and other objective methods of evaluating both the influence and acclaim of what are regarded as the best scientific papers produced in different ‘areas’ of orthopaedic practice and basic orthopaedic science, the authors have put together a comprehensive and wonderfully readable selection of papers in Classic Papers in Orthopaedics. Not only do they name and describe these papers, but they also evaluate their scientific strengths and weaknesses, so that the clinician or scientist can make the best informed decision of how to use the data described most effectively in taking forward their field of interest. They also have included general sections on interpreting and evaluating research that are helpful to the reader new to the research process. This book will be of interest to orthopaedic trainees coming to terms with the wealth of information available that they need to make sense of in order to pass their higher specialist examinations. It will be of interest to consultant orthopaedic surgeons who wish to remind themselves of the history of their particular field of interest. It will interest scientists and researchers embarking on a research project in the field of orthopaedics. It will be of interest to physiotherapists wishing to understand more about the orthopaedic management of the patients they treat. It will also interest medical historians who wish to learn more about the history of the development of a particular orthopaedic technique. In short, the book will be of interest to a wide variety of people, and I believe it will become a classic reference in its own right in the time ahead. I would encourage you therefore to buy this book and use it to enhance your knowledge of both orthopaedic practice and the ‘art’ of the research endeavour itself. I am sure you will enjoy reading it and learn from it as much as I did and that it will certainly become a treasured ‘gem’ on your bookshelf that you will continue to use as a decision-making aid and educational tool that is both useful and enjoyable to read. Alan St Clair Gibson, MBChB, PhD, MD Department of Sport, Exercise and Rehabilitation University of Northumbria UK v

Preface

The seeds for this book were first sown as an orthopaedic trainee. About 3 months before the FRCS (Tr & Orth) orthopaedic exam, I found myself frantically searching for a book that summarized the key seminal orthopaedic papers that I needed to know to pass this exam. I had become convinced my future examiners were going to grill me mercilessly on these classic orthopaedic articles and I would fail the exam if I couldn’t quote them verbatim. I never found this book despite repeatedly being assured by various consultants that it was out there but perhaps out of print and probably out of date. After passing the FRCS (Tr & Orth) exam I continued to search intermittently for this “Classic Papers in Orthopaedics” book. I was convinced it still existed and that I would eventually find it if I looked hard enough for it. One evening after another fruitless search for this Holy Grail on the Internet, it suddenly dawned on me that perhaps this book had never really existed in the first place. I then began to wonder if we could perhaps take this project on board. I was busy with a number of orthopaedic teaching and training projects and therefore quickly dismissed the idea. Fast forward to 2010 and the Journal of Bone and Joint Surgery (JBJS-British) and Clinical Orthopaedic and Related Research (CORR) both published a paper citing the top 100 orthopaedic papers published in the orthopaedic literature. Both top 100 listings were roughly the same and both lists essentially reflected the number of times an article was cited in specific orthopaedic journals. In a moment of weakness we decided that perhaps the time was right to go ahead and get this book written. As busy orthopaedic surgeons we do not always have the time to be critical in identifying the key papers that influence our own practice. It is revealing and very satisfying to go back to the core papers that changed the face of orthopaedics. The book was more difficult to edit and manage than anticipated. One main aim was to provide a story around each article. We wanted to set the scene and describe where the subject stood before the classic paper had been published and how afterwards the paper had changed practice and stimulated further developments and research. We stuck reasonably closely to citation frequency as a measure of whether or not to include an article despite accepting its inherent weaknesses. Most authors realized this method would miss out some major articles of importance. However citation frequency at least provided an initial framework to review a selected number of articles and authors were then free to revise this list if necessary. In some of the smaller sections such as foot and ankle and orthopaedic oncology, a greater amount of freedom was given with article choice. A new finding was that several orthopaedic journals had recently published reviews citing the top 100 or 50 articles in various orthopaedic subspecialties such as spinal surgery, shoulder and hands based on citation frequency alone in major data bases. This made us realize we couldn’t review every single article that had attained classic status, and in many ways classic status didn’t always equate with the number of times an article was cited in the orthopaedic literature. In addition, it made us more determined to add more substance to the book lest it deteriorated into a number crunching exercise, as we weren’t convinced with the arguments for objectivity with this method. vii

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Preface

Sometimes it was difficult to unravel why an article had reached classic status, and this required a lot of detective work. We traced articles forward in time to ascertain where they had been cited in the literature. On many occasions the last paper in a long line of references unlocked the door as to an article’s relevance and seminal status. Whilst we acknowledge that regular journal club meetings are educationally very important for all grades of orthopaedic surgeons and not just orthopaedic trainees, we wanted to avoid the book coming across as some sort of high-ended journal club handout. Each article has shaped orthopaedic practice and reflects the historical background and also gives insight into future developments. We hope we have avoided this. On several occasions we had to pull back from writing detailed biographies about the brilliance of many of the authors of these important groundbreaking papers. There are a large number of well-written biography books in orthopaedics already and this was not our aim. We did weaken a little with Charnley, Ilizarov, Mankin, Harris, Noyes and Insall who deserve special credit for their enormous contribution to orthopaedic surgery. We originally decided to include a second section covering levels of evidence, how to review a scientific article and impact factor, but changed our minds as we thought most of our readership would be familiar with these subjects. However, a large number of orthopaedic surgeons thought it was an excellent idea to include them as the relevant literature was sometimes difficult to find. They persuaded us to change our minds and we think the book is better for this section. We make no claim for the originality of the material contained in this book. We are not attempting to re-invent the wheel. A large amount of material contained in an article review was accumulated whilst forward reviewing the article’s relevance in its own citation list. We have attempted to credit sources wherever possible. We ask apologizes if we have omitted any one. The ironies of this book are that the examiners never did grill me on any classic papers in the exam. We did eventually manage to find the Holy Grail. The Classics of Orthopaedics was edited by Edgar Bick and published by Lippincott Williams & Wilkins in 1976. The book proved to be somewhat disappointing as it took the format of reprints of the original articles from various journals such as The Journal of Bone and Joint Surgery (JBJS) and Clinical Orthopaedic and Related Research (CORR). Although there was a small author bibliography at the end of the article, there were no explanations or comments as to why these articles were considered classic papers or how and why they had changed the face of orthopaedics. Gateshead, UK Gateshead, UK

Paul A. Banaszkiewicz Deiary F. Kader

Contents

Part I 1

Main Introduction

Main Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

Part II

3

Classic Papers in Hip Surgery: Introduction

2

Classic Papers in Hip Surgery: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

3

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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13

4

Functional Results of Hip Arthroplasty with Acrylic Prosthesis . . . . . . . . . . . Paul A. Banaszkiewicz

5

Clinical and Radiographic Evaluation of Total Hip Replacement. A Standard System of Terminology for Reporting Results . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

23

Prognosis of Total Hip Replacement in Sweden: Follow-Up of 92,675 Operations Performed 1978–1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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7

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Improved Cementing Techniques and Femoral Component Loosening in Young Patients with Hip Arthroplasty: A 12-Year Radiographic Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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“Modes of Failure” of Cemented Stem-Type Femoral Components: A Radiographic Analysis of Loosening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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Radiological Demarcation of Cemented Sockets in Total Hip Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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Femoral Component Loosening Using Contemporary Techniques of Femoral Cement Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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The Correlation Between the Roentgenographic Appearance and Operative Findings at the Bone-Cement Junction of the Socket in Charnley Low Friction Arthroplasties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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Contents

Porous-Coated Hip Replacement. The Factors Governing Bone Ingrowth, Stress Shielding, and Clinical Results . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

51

Total Hip Arthroplasty. A Review of Three Hundred and Thirty Three Cases with Long Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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Ten-Year Follow-Up Study of Total Hip Replacement . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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A Ten-Year Follow-Up of One Hundred Consecutive Müller Curved-Stem Total Hip Replacement Arthroplasties. . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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Total Hip Replacement in Patients Younger Than Thirty Years Old: A Five-Year Follow-Up Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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The Long Term Results of Low Friction Arthroplasty of the Hip Performed as a Primary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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Reactions of the Articular Capsule to Wear Products of Artificial Joint Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

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The Initiation of Failure in Cemented Femoral Components of Hip Arthroplasties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

81

Periprosthetic Bone Loss in Total Hip Arthroplasty: Polyethylene Wear Debris and the Concept of the Effective Joint Space . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

85

16

17

18

19

20

21

22

23

24

25

Production of Cytokines Around Loosened Cemented Acetabular Components: Analysis with Immunohistochemical Techniques and In Situ Hybridization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz The Effect of Conformity, Thickness, and Material on Stresses in Ultra-High Molecular Weight Components for Total Joint Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

61

89

93

Metallic Wear in Failed Titanium-Alloy Total Hip Replacements: A Histological and Quantitative Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

97

Effect of Femoral Head Size on Wear of the Polyethylene Acetabular Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

101

Ectopic Ossification Following Total Hip Replacement: Incidence and a Method of Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

105

26

Dislocations After Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

109

27

Dislocations After Total Hip-Replacement Arthroplasties . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

113

Contents

xi

28

29

30

31

The Synovial-Like Membrane at the Bone-Cement Interface in Loose Total Hip Replacements and Its Proposed Role in Bone Lysis . . . . . . . . . . . . . Paul A. Banaszkiewicz

117

Idiopathic Bone Necrosis of the Femoral Head. Early Diagnosis and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

121

Total Hip Replacement in Congenital Dislocation and Dysplasia of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

125

Changes in Trabecular Pattern of the Upper End of the Femur as an Index of Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Banaszkiewicz

129

Part III

Classic Papers in Knee, Sports medicine and Arthroscopy: Introduction

32

Classic Papers in Knee, Sports Medicine and Arthroscopy: Introduction. . . . . . Nick Caplan and Deiary F. Kader

33

Stiffness and Laxity of the Knee: The Contributions of the Supporting Structures: A Quantitative In Vitro Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

137

Ligamentous Restraints to Anterior-Posterior Drawer in the Human Knee: A Biomechanical Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

141

Biomechanical Analysis of Human Ligament Grafts Used in Knee-Ligament Repairs and Reconstructions . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

145

34

35

135

36

Fate of the ACL-Injured Patient: A Prospective Outcome Study . . . . . . . . . . . Nick Caplan and Deiary F. Kader

37

Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer: NCAA Data and Review of Literature . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

153

The Symptomatic Anterior Cruciate-Deficient Knee. Part I: The Long-Term Functional Disability in Athletically Active Individuals . . . . Nick Caplan and Deiary F. Kader

157

Biochemical Changes in the Cartilage of the Knee in Experimental and Natural Osteoarthritis in the Dog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

161

Two- to 9-Year Outcome After Autologous Chondrocyte Transplantation of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

165

38

39

40

149

41

A Comparison of Four Models of Total Knee-Replacement Prostheses . . . . . . Nick Caplan and Deiary F. Kader

169

42

Knee Joint Changes After Meniscectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

173

43

Late Results After Meniscectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

177

xii

Contents

44

Factors Effecting Late Results After Meniscectomy . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

181

45

The Etiology of Chondromalacia Patellae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

185

46

Roentgenographic Analysis of Patellofemoral Congruence. . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

189

47

The Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

193

48

Rationale of the Knee Society Clinical Rating System . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

197

49

Rating Systems in the Evaluation of Knee Ligament Injuries. . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

201

50

Injuries to Runners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Caplan and Deiary F. Kader

205

Part IV

Classic Papers in Foot and Ankle Surgery: Introduction

51

Classic Papers in Foot and Ankle Surgery: Introduction . . . . . . . . . . . . . . . . . Rajesh Kakwani and Malik Siddique

52

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rajesh Kakwani and Malik Siddique

53

Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rajesh Kakwani and Malik Siddique

211

213

217

54

A Method of Forefoot Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rajesh Kakwani and Malik Siddique

221

55

Fractures of Neck of Talus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rajesh Kakwani and Malik Siddique

225

56

Operative Compared with Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures: A Prospective, Randomized, Controlled Multicenter Trial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rajesh Kakwani and Malik Siddique

57

Sprained Ankles. VI. Surgical Treatment of Chronic Ligament Ruptures . . . . . Rajesh Kakwani and Malik Siddique

Part V

229 233

Classic Papers in Spine Surgery: Introduction

58

Classic Papers in Spine Surgery: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

59

A Study of the Natural History of Back Pain: Part I: Development of a Reliable and Sensitive Measure of Disability in Low-Back Pain . . . . . . . . Alexander D.L. Baker

241

Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

245

60

239

Contents

xiii

61

62

63

Volvo Award in Clinical Sciences: A New Clinical Model for the Treatment of Low-Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

249

Lumbar Disc Herniation: A Controlled, Prospective Study with Ten Years of Observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

253

Physical Measurements as Risk Indicators for Low-Back Trouble Over a One-Year Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

257

64

Risk Factors in Low-back Pain. An Epidemiological Survey . . . . . . . . . . . . . . Alexander D.L. Baker

65

Conservative Treatment of Acute and Chronic Nonspecific Low-back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

261

265

66

Nonorganic Physical Signs in Low-Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

67

Treatment of Scoliosis Correction and Internal Fixation by Spine Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

273

A Radicular Syndrome from Developmental Narrowing of the Lumbar Vertebral Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

277

A Prospective, Randomized Study of Lumbar Fusion: Preliminary Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

281

68

69

269

70

Fractures of the Odontoid Process of the Axis . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

71

The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander D.L. Baker

289

The Treatment of Certain Cervical- Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion . . . . . . . . . . . . . . . . Alexander D.L. Baker

293

72

Part VI

285

Classic Papers in Upper Limb Surgery: Introduction

73

Classic Papers in Upper Limb Surgery: Introduction . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

74

Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder: A Preliminary Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

75

Impingement Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

76

Stabilizing Mechanisms Preventing Anterior Dislocation of the Glenohumeral Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

299

301 305

309

xiv

Contents

77

The Bankart Procedure: A Long-Term End-Result Study . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

78

Inferior Capsular Shift for Involuntary Inferior and Multidirectional Instability of the Shoulder. A Preliminary Report . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

79

A Clinical Method for Functional Assessment of the Shoulder. . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

80

Displaced Proximal Humerus Fractures. Part I: Classification and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

313

317 319

323

81

Recent Experience in Total Shoulder Replacement . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

327

82

Normal and Abnormal Motion of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous and Sarah Eastwood

331

Part VII

Classic Papers in Hand and Wrist Surgery: Introduction

83

Classic Papers in Hand and Wrist Surgery: Introduction. . . . . . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

84

The Carpal-Tunnel Syndrome: Seventeen Years’ Experience in Diagnosis and Treatment of Six Hundred Fifty-Four Hands . . . . . . . . . . . . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

337

339

85

The Prehensile Movements of the Human Hand . . . . . . . . . . . . . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

343

86

Evaluation of Healed Colles’ Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

347

87

A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

349

Traumatic Instability of the Wrist. Diagnosis, Classification, and Pathomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

353

88

89

Intra-articular Fractures of the Distal End of the Radius in Young Adults . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

357

90

The Carpal Tunnel Syndrome. A Study of Carpal Canal Pressures. . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

361

91

Complications of Colles Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

365

92

Interfascicular Nerve Grafting of the Median and Ulnar Nerves . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

367

93

Triangular Fibrocartilage Complex Lesions—A Classification. . . . . . . . . . . . . Jochen Fischer, Neville W. Thompson, and John W.K. Harrison

371

Part VIII 94

Classic Papers in Basic Science I: Introduction

Classic Papers in Basic Science I: Introduction . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

375

Contents

xv

95

Cell Origin and Differentiation in the Repair of Full-Thickness Defects of Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

96

The Response of Articular Cartilage to Mechanical Injury . . . . . . . . . . . . . . Charalambos P. Charalambous

97

Biochemical and Metabolic Abnormalities in Articular Cartilage from Osteo-arthritic Human Hips. II: Correlation of Morphology with Biochemical and Metabolic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

98

Articular Cartilage. Part II: Degeneration and Osteoarthrosis, Repair, Regeneration, and Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

377 381

385

389

99

Walking Patterns of Normal Men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

393

100

Measurement of Lower Extremity Kinematics During Level Walking . . . . . Charalambos P. Charalambous

397

101

Repeatability of Kinematic, Kinetic, and Electromyographic Data in Normal Adult Gait. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

399

102

The Major Determinants in Normal and Pathological Gait . . . . . . . . . . . . . . Charalambos P. Charalambous

403

103

The Normal Vascular Anatomy of the Femoral Head in Adult Man . . . . . . . Charalambos P. Charalambous

407

104

Humeral Hypertrophy in Response to Exercise . . . . . . . . . . . . . . . . . . . . . . . . Charalambos P. Charalambous

411

105

Interrater Reliability of a Modified Ashworth Scale of Muscle Spasticity. . . . . Charalambos P. Charalambous

415

106

Calcium Phosphate Ceramics as Hard Tissue Prosthetics. . . . . . . . . . . . . . . . Charalambos P. Charalambous

419

Part IX

Classic Papers in Basic Science II: Introduction

107

Classic Papers in Basic Science II: Introduction. . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

425

108

Biosynthetic Response of Cartilage Explants to Dynamic Compression . . . . Alun Wall and Tim Board

427

109

A Direct Spectrophotometric Microassay for Sulphated Glycosaminoglycans in Cartilage Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

431

Chemical Basis for the Histological Use of Safranin O in the Study of Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

433

110

111

The Biological Effect of Continuous Passive Motion on the Healing of Full-Thickness Defects in Articular Cartilage. An Experimental Investigation in the Rabbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

437

xvi

112

Contents

Mesenchymal Cell-Based Repair of Large Full Thickness Defects of Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

441

113

Mesenchymal Stem Cells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

445

114

Bone: Formation by Autoinduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

449

115

Tendon Healing in a Bone Tunnel: A Biomechanical and Histological Study in the Dog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

116

The Compressive Behavior of Bone as a Two-Phase Porous Structure . . . . . Alun Wall and Tim Board

117

Quantitative Microradiographic Studies of Normal and Osteoporotic Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

118

Bone Morphogenetic Protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alun Wall and Tim Board

Part X

453 457

461 465

Classic Papers in Orthopaedic Oncology: Introduction

119

Classic Papers in Orthopaedic Oncology: Introduction. . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

120

The Registry of Bone Sarcomas as an Example of the End-Result Idea in Hospital Organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

471

473

121

Osteogenic Sarcoma. A Study of Six Hundred Cases . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

475

122

Osteogenic Sarcoma; a Study Based on 133 Patients . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

477

123

Metastatic Disease in Long Bones. A Proposed Scoring System for Diagnosing Impending Pathologic Fractures . . . . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

479

Chemotherapy, En Bloc Resection, and Prosthetic Bone Replacement in the Treatment of Osteogenic Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

481

124

125

126

The Treatment of Soft-Tissue Sarcomas of the Extremities. Prospective Randomized Evaluations of (1) Limb-Sparing Surgery Plus Radiation Therapy Compared with Amputation and (2) the Role of Adjuvant Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin Preoperative Versus Postoperative Radiotherapy in Soft-Tissue Sarcoma of the Limbs: A Randomised Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

127

A System for the Surgical Staging of Musculoskeletal Sarcoma . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

128

A System for the Functional Evaluation of Reconstructive Procedures After Surgical Treatment of Tumors of the Musculoskeletal System . . . . . . . Craig H. Gerrand and Kenneth Rankin

483

485 487

489

Contents

xvii

129

The Hazards of Biopsy in Patients with Malignant Primary Bone and Soft-Tissue Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Craig H. Gerrand and Kenneth Rankin

Part XI

491

Fracture Healing: Introduction

130

Classic Papers in Trauma and Fracture Healing: Introduction . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

131

The Influence of Induced Micromovent Upon the Healing of Experimental Tibial Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

132

Morbidity at Bone Graft Donor Sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

133

Osseointegrated Titanium Implants: Requirements for Ensuring a Long-Lasting, Direct Bone-to-Implant Anchorage in Man . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

497

499 503

507

134

Regulation of Bone Formation by Applied Dynamic Loads . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

135

Closed Intramedullary Nailing of Femoral Fractures. A Report of Five Hundred and Twenty Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

515

The Tension-Stress Effect on the Genesis and Growth of Tissues Part I. The Influence of Stability of Fixation and Soft-Tissue Preservation. . . . . . . . Gunasekaran Kumar and Badri Narayan

519

The Tension-Stress Effect on the Genesis and Growth of Tissues: Part II. The Influence of the Rate and Frequency of Distraction . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

523

136

137

138

Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones. Retrospective and Prospective Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

139

The Biology of Fracture Healing in Long Bones. . . . . . . . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

140

The Healing of Segmental Bone Defects, Induced by Recombinant Human Bone Morphogenetic Protein (rhBMP-2): A Radiographic, Histological, and Biomechanical Study in Rats. . . . . . . . . . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

141

Early Versus Delayed Stabilization of Femoral Fractures . . . . . . . . . . . . . . . . Gunasekaran Kumar and Badri Narayan

Part XII

511

527 531

535 539

Classic Papers in Orthopaedic Pediatrics: Introduction

142

Classic Papers in Orthopaedic Paediatric: Introduction . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

143

Acute Slipped Capital Femoral Epiphysis: The Importance of Physeal Stability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

543

547

xviii

144

Contents

Surgical Dislocation of the Adult Hip: A Technique with Full Access to the Femoral Head and Acetabulum Without the Risk of Avascular Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

145

The Natural History of Legg-Calve-Perthes Disease . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

146

Legg-Calve-Perthes Disease. Part II: Prospective Multicenter Study of the Effect of Treatment on Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

147

Classification of Hip Joint Dysplasia by Means of Sonography . . . . . . . . . . . Sattar Alshryda and James Wright

148

First Fifteen Years Personal-Experience with Innominate Osteotomy in Treatment of Congenital Dislocation and Subluxation of Hip . . . . . . . . . . Sattar Alshryda and James Wright

149

A Harness for Treatment of Congenital Hip Dislocation in Infants . . . . . . . . Sattar Alshryda and James Wright

150

Congenital Dislocation of the Hip: Development of the Joint After Closed Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

151

Congenital Club Foot: The Result of Treatment. . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

152

Development and Reliability of a System to Classify Gross Motor Function in Children with Cerebral Palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

549 551

555 559

563 567

569 571

575

153

Hip Dislocation and Subluxation in Cerebral Palsy . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

579

154

Injuries Involving the Epiphyseal Plate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

581

155

Limb Lengthening by Callus Distraction (Callotasis) . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

583

156

Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm . . . Sattar Alshryda and James Wright

Part XIII

585

Miscellaneous Topics

157

Levels of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sattar Alshryda and James Wright

591

158

How to Review a Scientific Manuscript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Raymond Pollock and Arkan S. Sayed-Noor

595

159

How to Get Published and Impact Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arkan S. Sayed-Noor, Göran O. Sjödén, and Raymond Pollock

609

..........................................................

615

Index

Contributors

Sattar Alshryda, MRCS, FRCS (Tr & Orth), MSc, PhD Department of Trauma and Orthopaedic Surgery, Royal Manchester Children’s Hospital, Manchester, UK Alexander D.L. Baker, BSc, MBChB, MRCS, MSc, FRCS (Tr&Orth) Department of Orthopaedic Surgery, Lancashire Teaching Hospitals, Royal Preston Hospital, Preston, UK Paul A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK Tim Board, FRCS, BSc (Hons), MBChB (Hons), MSc (Orth Eng), MRCS, FRCS (Orth) Department of Orthopaedic Surgery, Wrightington Hospital, Wigan, Lancashire, UK Nick Caplan, PhD Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK Charalambos P. Charalambous, BSc, MBChB, MSc, MD, FRCS (Tr & Orth) Department of Trauma and Orthopaedics, Victoria Hospital, Blackpool, UK Sarah Eastwood, BSc, MBChB, MRCS Department of Trauma and Orthopaedics, University Hospital of Wales, Cardiff, UK Craig H. Gerrand, MBChB, FRCS (Ed), MD, MBA North of England Bone and Soft Tissue Tumour Service, Freeman Hospital, Newcastle upon Tyne, UK John W.K. Harrison, MSc, FRCS (Ed), FRCS (Tr & Orth), MFSEM (UK) Department of Orthopaedics, Queen Elizabeth Hospital, Gateshead, UK Deiary F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK Rajesh Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) Department of Orthopaedics, Northumbria NHS Trust, Ashington, UK Gunasekaran Kumar, FRCS (Tr & Orth) Department of Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK Badri Narayan, MS (Orth), FRCS (Tr&Orth) Department of Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK Raymond Pollock, PhD, MPH Spinal Unit, University Hospital of North Tees, Stockton on Tees, England, UK Kenneth Rankin, MBChB, MD MRCS North of England Bone and Soft Tissue Tumour Service, University of Newcastle upon Tyne, Newcastle upon Tyne, UK

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xx

Arkan S. Sayed-Noor, MD, PhD, FRCS Department of Orthopaedics, Sundsvall Teaching Hospital, Umea University, Umea, Sweden Malik Siddique, BSc, MBBS, FRCS, MCh Orth, MD, FRCS (Tr & Orth) Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, UK Göran O. Sjödén, MD, PhD Department of Orthopaeducs, Sundsvall Teaching Hospital, Umea University, Umea, Sweden Alun Wall, MRCS, FRCS (Tr&Orth) Department of Orthopaedic Surgery, Wrightington Hospital, Wigan, Lancashire, UK James Wright, MD, MPH, FRCSC Robert B. Salter Chair of Paediatric Surgical Research, Hospital for Sick Children, Toronto, ON, Canada Jochen Fischer, MD, FRCS (Orth) Department of Orthopaedics and Trauma, Macclesfield District General Hospital, Macclesfield, Cheshire, UK Neville W. Thompson, MD, PhD Department of Orthopaedics and Trauma, Altnagelvin Hospital, Londonderry, Northern Ireland

Contributors

Part I Main Introduction

1

Main Introduction Paul A. Banaszkiewicz

Classic Papers in Orthopedics provides a unique insight into the history and development of orthopedic practice in the last 60 years. This collection of the most cited articles in orthopedics identifies seminal contributions and originators. It offers orthopedic researchers hints about what makes an article a most frequently cited classic.

1.1

Definition of a Citation

A citation is a numeric or alphanumeric expression eg (Smith 1) that acknowledges the relevance given by the author to the work of others on a topic of discussion in which the citation appears.

1.2

What Do We Mean by the Word Classic?

What constitutes a classic paper? If only we all could agree on the set criteria. The dictionary defines “classic” as being an excellent role model of its kind, as in famous, traditional, basic, fundamental, and definitive. Thus, in orthopedics, classic would mean an excellent model article of its kind, having a great impact on the field, and influencing research, education, practice, and opinions [1]. Measuring classic status by the number of times an article is cited is one approach to meeting this definition. The top 10, or 100 can easily be generated at the touch of a keystroke on a citation indexing database such as Web of Knowledge or Scopus.

P.A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_1, © Springer-Verlag London 2014

A different approach would be to use a purely subjective method in which one applies a totally personal application of the dictionary definition of classic. Another interesting variation on this theme is to provide a subjective list of the top 50 articles in a particular field of orthopedics and ask colleagues to rank them. To determine the academic influence of an article the rate at which the work is quoted or referenced by other authors is often used as a marker. This is generally viewed as a direct measure of the recognition an article has received in its field. Citation analysis is a bibliometric process that describes the means of analyzing the citation history of published data.It involves ranking and evaluating an article or journal based on the number of citations that it receives. The number of citations has many consequences for both authors and journals. The greater the citation history of an author, the more renowned they become in their chosen field of practice. The more cited an article from a particular journal, the greater the impact factor of that publication. Citation density is determined by the number of citations over the number of years a work has been published. It allows for the relative impact of an article regardless of year of publication. We considered citation density as a method to rank articles but discountered its use. Although a recently published article may have a high citation density because of its newness it usually takes a few years to acquire classic status. Therefore at the start of this book project we had a number of different choices that we could have used to rank and define our own classic papers list, each choice potentially provoking a different reaction as to its relative merits or otherwise amongst our readers. The debate of preferred method for article selection was brought into sharp focus in 2010 when two similar articles published a list of the 100 most cited articles in orthopedics. The first article published by Kelly et al. [2] in the Journal of Bone and Joint Surgery, British edition (JBJS Br) was entitled “The 100 classic papers of orthopaedic surgery”. 3

4

The second article was published a few months later by Lefaivre et al. [3] in Clinical Orthopaedic and Related Research and named “most cited” papers in orthopedics rather than “classic”. Despite the subtle difference in titles both articles generated a list based on the frequency an article was cited in specific orthopedic journals. Both articles selected with minor variations, the same peer-reviewed journals and therefore the top 100 listings were roughly the same. The article by Lefaivre et al. [3] determined which published articles in orthopedic surgery had exerted the most citation influence on the specialty by ranking the 100 most cited works. Their investigation covered all subspecialties of orthopedics and provided a general understanding of the importance of these articles in generating changes in orthopedic practice, shaping future research, stimulating debate or controversy [4]. Science Citation Index Expanded was searched for citations to articles published in any of the 49 journals in the subject category “Orthopedic” listed in 2009 A less rigorous approach was used by Kelly et al. in JBJS Br in that they searched the database of the Science Citation Index from 1945 to 2008 to identify the 100 most frequently cited papers from 15 of the “most respected” journals dedicated to orthopedic surgery. The Science Citation Index (SCI) is a citation index originally produced by the Institute for Science Information (ISI) by Eugene Garfield.It was originally launched in 1964.The larger version (Science Citation Index Expanded) covers significantly more journals across more disciplines. A final twist in the story occurred when Lefaivre in an e-Letter published in JBJS Br expressed misgivings about the methodology used in Kelly’s article. The choice of orthopaedic journals for the Kelly article had been based on previous similar biblometric studies on journals most relevant to orthopedic surgery [5, 6]. However these earlier biblometric studies had been based on imprecise methodology. Bosker and Verheyen [5] had evaluated the rank order of publications in orthopedic surgery from 2000 to 2004 in selected major clinical journals. The journals chosen were selected and ranked by the senior author from the orthopedic section of the Journal Citation Reports which lists an impact factor for each of the journals that it tracts. The 14 journals with the highest impact factor were chosen along with the American Journal of Sports Medicine. An important point made by Lefaivre was that impact factor changes on a yearly basis. Therefore this variation will influence the choice of journals included on any list depending on what year a search is undertaken. This means that an article could make the top 100 cited articles one year but miss out the next year if the journals impact factor falls. In the second biblometric study Hakkalamani et al. [6] investigated the self-citation and citation density of seven orthopedic journals and their possible effect on impact factor. These seven journals were picked by the authors based on “the most respected journals dedicated to orthopedic surgery

P.A. Banaszkiewicz

without a specific selection method. Kelly et al. had included only four of the possible seven journals on their inclusion list. Both the Kelly and Lefaivre studies used a categorical journal by journal method of analysis and make the assumption that the most cited orthopaedic articles and authors are found only in orthopaedic journals which is not always the case. Although the various differences between these 2 studies were accounted for by the time that anaysis was undertaken and by the number of journals anayzed it brought into sharp focus the inherent difficulties when compiling any “best of” list in orthopedics. The choices of articles for any top 100 list based on citation frequency should not necessarily be referred to as objective. Whilst the significance of citation analysis remains a topic of debate we disagree that this method provides the only objective method to determine the significance of an article or journal [7]. For scientific research the impact factor of a journal has become a controversial area of debate in recent years. Previously it was widely accepted that this was the best method of judging the merits of specific journals. The impact factor is often used to determine the importance of a given journal in its specific field of interest. It is regarded as a marker of the quality and rank of a journal. It is calculated from the ratio of the number of citations in the current year to articles published in the journal in the two preceding years, divided by the number of citable items published in the same 2 years. Critics believe there are a number faults and manipulations that can occur with the impact factor The use of citation frequency as a method to rank an article is not an exact science as it is influenced by a number of differing factors. The publication of randomized trials, metaanalyses and basic science reports can lead to significantly more citations than other study designs [1]. Citations are also influenced by the time of publication (old versus new), the size and field of the study, and the particular journal in which the article is published [1]. An additional factor in the evolution of a classic article is the novelty of a subspecialty [4]. Articles written during the development or inception of a field will provide building blocks for the incremental advancement within the field and will likely be highly cited. Articles that present instruments for outcome evaluation or provide classification systems usually result in the most overall citations because these are commonly used in the methodologies of other research studies [8]. In some circumstances the number of citations that an article receives is not necessarily a measure of the quality of the research or even its influence on the practice of the author or authors’ peers. There is considerable disagreement regarding the value of citation rates when used to assess the quality of research. Some authors believe too much emphasis is placed on the number of citations an article receives and believe this method is open to manipulation by either authors or journals. A classic paper in orthopedics should inspire surgeons to

1 Main Introduction

question or review their standard practice, should recognize key advances in orthopaedics, provide an important message, add a useful prospective on historical developments and act as a lighted beacon to guide ships home safe to harbor. It should definitely not be about playing a numbers game or a citation quotient necessary to attain classic status. There is an argument of whether citation analysis should be considered as a significant influence on what constitutes a classic work in a medical specialty. Lefaivre et al. [3] point out five intrinsic concerns with using this method alone to evaluate the academic importance of an article. First, this type of citation analysis does not account for self-citation, citations in textbooks and lectures, and an author’s or authors’ potential preference to cite articles in the journal in which they seek to publish their work. Second, there is a clear temporal effect in citation analysis, with the most recent articles being at a disadvantage. Thirdly language of publication plays a major role, with an obvious bias for articles published in English language journals. Fourthly, there are biases inherent with the use of computerized databases. Articles published in the nineteenth or early twentieth century would be excluded resulting in the omission of truly classis papers. Fifth, as pointed out by Lefaivre, Kuhnian philosophy theorizes that there is often a ‘snowball effect’ to citations in that in a scientific community there is a tendency for other authors to more likely cite an article because of previous citations, rather than for its content or quality [3, 9]. In addition we would add that, current relevance of a citation may be a long way from the historical context in which it should be viewed. This was true of a significant number of articles included in this book. Also a further bias is the “obliteration by incorporation” effect. Older publications are often subject to this effect [10]. This refers to the phenomenon that exists where older publications are no longer cited with the same frequency because their findings become incorporated into the field’s current body of knowledge. Often, the true intellectual milestones are found in the reference list of the most cited papers. Older publications may also become obsolete or simply forgotten. A strong counter argument put forward is that whilst the number of citations and citation density are an imperfect measure of the quality of an article and there is no direct correlation between citation frequency and scientific study quality [10, 11], it does offer an insight into the degree of peer analysis, the readership of the manuscript, a measure of recognition, importance and impact [12]. A high citation frequency also demonstrates that other authors have formulated opinions on the topic and that it has generated discussion and debate. Therefore despite all the arguments against using the frequency of citations as a measure of the classic status of an article, we ended up contradicting ourselves by initially gen-

5

erating our own article list using citation frequency as the defining measure of an articles worth. However as the book unfolded we became less rigid. We realized that a certain amount of autonomy was needed otherwise we would have ended up leaving out some classic articles. The authors of the smaller subspecialties such as foot and ankle and pediatrics were allowed greater freedom to generate their own list of classic articles as very few had made our top 100 list. We decided we didn’t want to be limited to a 100 articles as this seemed to be very much an arbitrary number. We decided to include as many articles as deemed necessary in order to adequately cover the orthopedic subspecialties. This avoided omitting important and influential articles that wouldn’t have made the list. We utilized the database of the Science Citation Index Expanded from 1945 to 2008. The Institute for Scientific Information (ISI) has been collecting citation and other academic impact information since 1945, and it has been available electronically since 1979. ISI calls their journal citation system “Science Citation Index Expanded” and it is one of the databases available under the banner of Web of Science. There are currently 65 journals categorized under the topic heading of “orthopedics” in the Web of Science, which cover all possible subspecialty areas of orthopedics. These journals range from general clinical journals to subspecialtyspecific journals through to basic science journals with direct and peripheral relations to the practice of orthopedic surgery. Each article included in this book has a section reviewing the articles weaknesses. Currently there is no accepted appraisal method for assessing the quality of historic articles by today’s high standards [13]. Hall summarized the citation classics of the British Journal of Anesthesia, identifying marked changes in the design and conduct of clinical research over time [14]. Ethics committees and informed consent were rarely mentioned in older publications, and randomization and blinding were frequently omitted. Our list recognizes the classic papers of orthopaedics,ones that have made long lasting and game changing contributions.It is important to recognize that this list is composed of articles that address various topics and span across multiple disciplines. We have categorized journal articles by field of research wherever possible. Field of research was by clinical subspecialty for clinical articles (trauma/fracture healing, oncology, hip and knee arthroplasty, sports medicine and arthroscopy, spine, pediatric orthopedics, hand, shoulder foot and ankle) and by one of six categories for basic science articles (stem cell, cartilage tissue, bone tissue, ligament tissue, tendon tissue, implants). One of the difficulties with individual sub-specialties is that they tend to be widely dispersed within the book. For example the chapter on knee, sports medicine and arthroscopy would have doubled in size if we had also included

6

all knee related trauma, sports medicine and basic science articles in one chapter. Articles were placed where they instinctively belonged and we accept that not everyone will agree with all the choices we have made. A few observations regarding the list of classic papers included in this book are warranted. The majority of articles originated from the USA. This is explained by the size of the American orthopaedic community and its scientific output, which dominates the world of orthopedic publishing. It is also recognized that American authors tend to favour American journals. In summary the topic of citation analysis and impact factor can appear complicated at times, more so when you are attempting to apply objective criteria to an imperfect science. We hope this introductory chapter provides a basis for your understanding of how we eventually arrived at our classic papers selection. We ask understanding if we have missed out your own personal favorite article.

References 1. Canale ST. In the top 100 classic articles, where’s mine? AAOS Now. 20 May 2010; p. 1–1. 2. Kelly JC, Glynn RW, O’Briain DE, Felle P, McCabe JP. The 100 classic papers of orthopaedic surgery. A bibliometric analysis. J Bone Joint Surg. 2010;92-B(10):1338–43.

P.A. Banaszkiewicz 3. Lefaivre KA, Shadgan B, O’Brien PJ. 100 most cited articles in orthopaedic surgery. Clin Orthop Relat Res. 2010;469(5): 1487–97. 4. Namdari S, Baldwin K, Kovatch K, Huffman GR, Glaser D. Fifty most cited articles in orthopedic shoulder surgery. J Shoulder Elbow Surg. 2012;21(12):1796–802. Elsevier Ltd. 5. Bosker BH, Verheyen C. The international rank order of publications in major clinical orthopaedic journals from 2000 to 2004. J Bone Joint Surg Br. 2006;88(2):156–8. 6. Hakkalamani S, Rawal A, Hennessy MS, Parkinson RW. The impact factor of seven orthopaedic journals: factors influencing it. J Bone Joint Surg Br. 2006;88(2):159–62. 7. Murray MR, Wang T, Schroeder GD, Hsu WK. The 100 most cited spine articles. Eur Spine J. 2012;21(10):2059–69. 8. Gheiti AJC, Downey RE, Byrne DP, Molony DC, Mulhall KJ. The 25 most cited articles in arthroscopic orthopaedic surgery. Arthroscopy. 2012;28(4):548–64. 9. Kuhn TS. Historical Structure of Scientific Discovery To the historian discovery is seldom a unit event attributable to some particular man, time, and place. Science. 1962;136(3518):760–4. 10. Garfield E. 100 citation classics from the Journal of the American Medical Association. JAMA Am Med Assoc. 1987;257(1): 52–9. 11. Baltussen A, Kindler CH. Citation classics in critical care medicine. Intensive Care Med. 2004;30(5):902–10. 12. Hennessey K, Afshar K, Macneily AE. The top 100 cited articles in urology. Can Urol Assoc J. 2009;3(4):293–302. 13. Ollerton JE, Sugrue M. Citation classics in trauma. J Trauma. 2005;58(2):364–9. 14. Hall GM. BJA citation classics 1945–1992. Br J Anaesth. 1998;80(1):4–6.

Part II Classic Papers in Hip Surgery: Introduction

2

Classic Papers in Hip Surgery: Introduction Paul A. Banaszkiewicz

Through the classic papers in hip surgery chapter, it is possible to trace the history of total hip arthroplasty (THA), one of the most successful operations of the twenty-first century. From the ground breaking work of Charnley to the initially poor disappointing results of first generation cementing techniques to the equally poor results of first generation uncemented implants. It provides useful insights into the institutions and authors who have contributed to the development of orthopedics and have since become international leaders in orthopedic research. THA has been described as the operation of the late twentieth century and has revolutionised the management of patients with painful end stage hip arthrosis [1]. The evolution of THA can be traced through these seminal articles that led to changes in practice and refinements in technique thereby improving clinical outcomes. THA was developed in the early 1960s by Sir John Charnley and by the beginning of the 1970s had become firmly established as the method of choice for advanced hip arthritis. Before that time surgeons had to recommend a variety of procedures such as osteotomies, cup arthroplasty, hemiarthroplasty, fusion, and resection arthroplasty the outcomes of which were far less certain. These procedures did not reliably relieve pain, range of motion was infrequently restored to normal (and naturally obliterated with fusion), and while function often improved it was usually abnormal. Further, many of these hips would continue to deteriorate and require further operations. The hip section begins in 1954 with the “Merle d’AubignéPostel” clinical scoring system for the hip [2]. This leads on to the Harris hip score published in 1969, which despite being over 40 years old is still the most widely used hip scor-

P.A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_2, © Springer-Verlag London 2014

ing system and the number one cited orthopedic paper in the world literature [3]. The final paper in this section is from Johnston et al. [4] who introduced standardized clinical and radiographic hip rating systems. This was in response to worries about the proliferation of different hip scoring scales. The subject of clinical outcome scores is even more pertinent today than in 1954 with issues of GMC re-validation, individual surgeon National Joint Registry (NJR) outcome scores and patient related outcome measures (PROM’S) brought into sharp focus. Malchau et al’s article on joint arthroplasty registries is again probably more relevant today than when first published in 1993. This paper reported the results of all revision THA’s performed in Sweden over a 13-year history (1978–1990) based on 92,675 primary THA’s. The importance of the Register and its effect on quality improvement over time was documented in this landmark article. In 2009 the Council of Presidents issued a statement in support of National Joint Registries, endorsed their establishment and maintenance [5]. They recognised the importance of registries in identifying risk factors for early failure and helping to optimize patient outcomes. A current major development is the establishment of an American Joint Replacement Registry (AJRR). This is still in early development and there are worries that the large fragmented health care system in the USA will make compliance with data entry difficult to achieve. It is hoped is that the registry will grow and develop into a powerful research tool that enables researches to ask important questions and ultimately improve clinical outcomes. In the late 1970s both Dee Lee and Charnley [6] and Gruen et al. [7] published radiographic descriptive zones for analysis of loosening of the acetabular and femoral components of THA respectively. These zones are still the most widely used radiographic classification systems in use. In addition Gruens paper presented a detailed analysis of the modes of failure of cemented femoral stems. The next section begins in 1972 with Charnley’s landmark 4–7 year published results of 379 Charnley low friction arthroplasties (LFA) [8]. This followed a change from using 9

10

Teflon to high-density polyethylene for the acetabular component. Relief of pain and ability to walk was excellent in 90 % of patients and good in 10 %. Sepsis rate was 3.8 % and revision rate 1.3 %. This is a seminal paper in which excellent results were published and was important because of the many failures of various hip replacements in this period. It set the gold standard for THA and the Charnley legacy was created. Beckenbaugh published the results of 333 consecutive Charnley LFA hips from the Mayo clinic in 1978. This was one of the first papers to report the early results of a large consecutive series of THAs from North America with follow up (4–7 years). Rather worryingly they demonstrated radiographic stem loosening of 24 % at an mean follow up of 5 years. During the early 1980s, concerns surrounding the use of cement fixation with THA began to surface. Disappointing long-term results emerged using first-generation cementing techniques associated with the development of extensive bone resorption. Two seminal papers by Sutherland et al. [9] from the Cleveland clinic and Stauffer [10] from the Mayo clinic reported a 30–40 % incidence of aseptic femoral stem loosening at 10 years. These concerns were further reinforced by Chandler et al. [11] reporting even poorer results in young patient. They found radiological evidence of either acetabular or femoral stem loosening at 5 years in 57 % of patients who were under 35 years of age at the time of THA. The introduction of improved second and third generation cementing techniques and early development of cementless systems was a reaction to the disappointing long term results of first-generation cemented THAs linked with extensive bone loss. Harris introduced second generation cementing techniques and publishing excellent early results at an average of 3.3 years follow up [12]. He reported a 1.1 % rate of definite cemented femoral stem loosening and a 4 % rate of possible loosening in an older population group. His paper was also important in that he proposed a radiological classification system for femoral stem loosening. Three categories were defined: definite loosening, probably loosening and possible loosening As such the decade of the 1980s was considered by many hip surgeons to be the decade of cement versus cementless. The more frequent occurrence of osteolysis, which in retrospect was erroneously attributed to ‘cement disease’, promoted the renewed interest in improved cementing techniques, improved cemented stem designs, and in cementless fixation with ingrowth or ongrowth of bone into the stem. The first generation of cementless femoral stems produced mixed survivorships with problems being related to fixation failure, thigh pain, wear, and osteolysis. In 1987

P.A. Banaszkiewicz

Engh et al. [13] established radiographic signs of uncemented femoral stem fixation and stability dividing modes of fixation into three categories (1) fixation by bone ingrowth, (2) stable fibrous ingrowth or (3) an unstable implant. These criteria continue to be recommended for use when reporting results of an uncemented series of THA. Engh also reported a high incidence of moderate to severe stress shielding (12 %) and thigh pain (20 %) associated with the AML implant and established a classification system for reporting stress shielding. Subsequent generations of uncemented femoral stems have been developed to address these complications and have achieved longevity at least comparable to that of their cemented counterparts with 10 or more years of follow-up. Barrack et al. [14] in 1992 reported excellent results in patients aged 50 years or under with second generation femoral cementing. In a group of 50 hips at minimum 10 years follow-up no stem had been revised, no stem had lysis and only 2 % of the stems showed radiographic evidence of loosening. In addition the paper described a femoral cement mantle grading system used to evaluate surgical technique and to compare arthroplasty results. Despite these excellent clinical results and further advances in the design of implants and improvements in the bearing articular surface we would still urge caution with the decision to implant cemented total hip replacements into young highly active patients. The next section of classic hip papers deals with the problem of osteolysis around the hip. The issue of osteolysis had not been resolved by implantation of uncemented components. Lytic defects were reported with both stable and loose uncemented prostheses. In the late 1970s, several researchers made important initial contributions to knowledge about the role of particles generated by joint prostheses in the pathogenesis of osteolysis and aseptic loosening. In 1977 Willert and Semlitsch [15] published a seminal paper that served as the basis for much of the current understanding of the relationship of articular wear debris to periprosthetic bone loss and aseptic loosening. They focused attention on particles and macrophages in the tissue adjacent to the hip components. In 1983, Goldring et al. [16] provided a detailed histological assessment of the fibrous membrane surrounding hip components. Whilst establishing that the macrophage dominated the tissue, their research also recognized that the membrane could have a remarkable organization that was similar to that of synovium and that the tissue elaborated high levels of PGE2 and collagenase. The early observations of osteolysis in cemented implants led to a general belief that osteolysis was related to the acrylic cement and the term ‘cement disease’ was introduced [17]. However, with the demonstration of lytic lesions in cementless implants, osteolysis is now considered to be ‘particle disease’.

2

Classic Papers in Hip Surgery: Introduction

Jasty et al. [18] subsequently reported on an unusual process in which small focal areas of nonprogressive or slowly progressive osteolysis occurred in the face of well-fixed cemented femoral components, which was termed “lysis without looseness”. In 1992 Schmalzried et al. [19] introduced the concept of effective joint space in total hip arthroplasty (THA). This refers to a path in the periprosthetic region for the passage of the particulate debris away from the articulating surfaces. It includes all periprosthetic regions that are accessible to joint fluid and wear debris. The authors suggested that late socket loosening occurred secondary to biological loosening rather than mechanical loosening. The primary event was the ingress of polyethylene particles into the interface between the cement and bone with progressive resorption of bone. Disruption of that interface began from the periphery of the cup progressing toward the dome. Previous studies had reported the initial mechanism of loosening for cemented femoral components was mechanical with debonding and cement fragmentation. Schmalzried et al. found that the histological appearance of the proximal part of the femoral cement bone interface was identical to the acetabulum with debris laden macrophages in association with regions of active bone loss. They suggested a similar biological process of periprosthetic bone resorption rather than mechanical loosening. In 1993 Jiranek et al. [20] used in situ hybridization techniques to identify the cellular components of the periprosthetic membrane. The authors demonstrated that the membrane consists predominantly of macrophages, fibroblasts, and, less commonly, T- lymphocytes (less than 10 %). IL-1β messenger RNA (mRNA) was expressed predominantly in macrophages, whereas IL-1β protein was identified on both macrophages and fibroblasts. This suggested that macrophages actively secrete this cytokine, which is subsequently bound to both macrophages and fibroblasts. Agins et al. [21] reported a marked histocytic, lymphoplasmacytic and foreign-body giant cell reaction to abundant metal, polyethylene, and bone-cement debris in the tissue around nine titanium-alloy stems that had been revised because of aseptic loosening or infection. Focal necrosis was seen in all of the hips. Atomic absorption spectrophotometry, performed on samples of the tissue removed from paraffintissue blocks, revealed that the ratios of titanium, aluminium, and vanadium were similar to those in the alloy, suggesting that the metal debris represented wear particles from the head or stem rather than precipitated dissolution products. Polyethylene wear generated at an articulating surface remains a primary concern in joint arthroplasty surgery. Bartel et al. [22] in a classic paper reported on contact stresses and polyethylene wear in total knee and hip arthroplasty components. They demonstrated the importance of

11

conformity in prosthetic TKA design to increase contact area and decrease contact stress. The greater the conformity, the greater the articular contact area with resulting reduced subsurface polyethylene contact stress per unit of area and therefore less polyethylene wear. In 1990 Livermore et al. [23] described a technique for quantitative measurement of linear cup wear. They noted that there was a greater amount of volumetric wear with the 32 mm femoral head compared to 22 and 28 mm sizes. The 22 mm head was associated with the greatest amount of linear wear. Heterotopic ossification (HO) is a common finding in radiographs of patients after THA and is an important complication that can compromise a patient’s hip function. Brookers et al. [24] seminal paper introduced a classification system for the severity of HO. Although several classification systems exist for developmental dysplasia of the hip the most commonly used system is the Crowe grade. Crowe et al. [25] introduced this grading system based on the amount of femoral head displacement from the acetabulum. Despite the classification of Hartofilakidis and Karachalios [26] offering a better guide to management Crowes grade is preferred as it is simple to use, reliable and reproducible. Both the Woo and Morray [27] and Lewinnek et al. [28] articles deal with THA dislocation. Lewinnek et al. described a safe range (5–25° anteversion and 30–50° abduction) to position the acetabular cup whilst Woo and Morray in a retrospective review of 10,500 hip arthroplasties examined risk factors associated with dislocation after THA. Despite methodological flaws in both articles they are still widely quoted in the hip arthroplasty literature. For completeness sake, the article by Singh’s et al. [29] on assessing osteoporosis from the radiological appearance of trabecular bone structure of the proximal femur has been included. This paper is widely cited because for many years it was the only method used for estimating osteoporosis. However the use of DEXA scans has discredited this technique demonstrating that it shows little correlation with grade of osteoporosis found. This is an example of an article becoming outdated with a citation number remaining fairly static and its relative citation value falling. The current debates in hip arthroplasty continue to revolve around known themes from the past. The optimal method of fixation for primary THA is still being hotly contested and shows no signs of being easily resolved. Cementless acetabular components have gained popularity over the years and have become the primary components of choice in North America [30]. This is despite a large number of studies supporting the use of cemented acetabular components and suggesting a less than optimal survivorship for cementless components [31–34].

12

Despite excellent long-term results and recent data from the NJR demonstrating lower revision rates, the use of cemented femoral components in Europe and Canada is decreasing in favor of uncemented stems [35]. Osteolysis continues to be a dominant feature in compromising longevity of THA. We hope you enjoy the articles that have shaped the practice of hip arthroplasty surgery. Much can be learned from a careful reassessment of the history of THA over the past 40 years.

P.A. Banaszkiewicz

17. 18.

19.

20.

References 21. 1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007;370(9597):1508–19. 2. d’Aubigné RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36-A(3): 451–75. 3. Harris WH. 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. J Bone Joint Surg Am. 1969;51(4):737–55. 4. Johnston RC, Fitzgerald Jr RH, Harris WH, Poss R, Müller ME, Sledge CB. Clinical and radiographic evaluation of total hip replacement. A standard system of terminology for reporting results. J Bone Joint Surg Am. 1990;72(2):161–8. 5. PellegriniJr VD. Position statement in support of national joint registries. J Bone Joint Surg Am. 2009;91(12):2983. 6. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976;121:20. 7. Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;141:17–27. 8. Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br. 1972;54(1):61–76. 9. Sutherland CJ, Wilde AH, Borden LS, Marks KE. A ten-year follow-up of one hundred consecutive Muller curved-stem total hip-replacement arthroplasties. J Bone Joint Surg Am. 1982; 64(7):970. 10. Stauffer RN. Ten-year follow-up study of total hip replacement. J Bone Joint Surg Am. 1982;64(7):983–90. 11. Chandler HP, Reineck FT, Wixson RL, McCarthy JC. Total hip replacement in patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am. 1981;63(9):1426–34. 12. Harris WH, McCarthy Jr JC, O’Neill DA. Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am. 1982;64(7):1063–7. 13. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding, and clinical results. J Bone Joint Surg Br. 1987;69(1):45–55. 14. Barrack RL, Mulroy Jr RD, Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg Br. 1992;74(3):385–9. 15. Willert HG, Semlitsch M. Reactions of the articular capsule to wear products of artificial joint prostheses. J Biomed Mater Res. 1977;11(2):157–64. 16. Goldring SR, Schiller AL, Roelke M, Rourke CM, O’Neil DA, Harris WH. The synovial-like membrane at the bone-cement

22.

23.

24.

25.

26. 27. 28.

29.

30.

31.

32.

33.

34.

35.

interface in loose total hip replacements and its proposed role in bone lysis. J Bone Joint Surg Am. 1983;65(5):575. Jones LC, Hungerford DS. Cement disease. Clin Orthop Relat Res. 1987;225:192–206. Jasty M, Maloney WJ, Bragdon CR, O’Connor DO, Haire T, Harris WH. The initiation of failure in cemented femoral components of hip arthroplasties. J Bone Joint Surg Br. 1991;73(4):551–8. Schmalzried TP, Jasty M, Harris WH. Periprosthetic bone loss in total hip arthroplasty. Polyethylene wear debris and the concept of the effective joint space. J Bone Joint Surg Am. 1992;74(6): 849–63. Jiranek WA, Machado M, Jasty M, Jevsevar D, Wolfe HJ, Goldring SR, et al. Production of cytokines around loosened cemented acetabular components. Analysis with immunohistochemical techniques and in situ hybridization. J Bone Joint Surg Am. 1993; 75(6):863. Agins HJ, Alcock NW, Bansal M, Salvati EA, Wilson PD, Pellicci PM, et al. Metallic wear in failed titanium-alloy total hip replacements. A histological and quantitative analysis. J Bone Joint Surg Am. 1988;170(3):347–56. Bartel DL, Bicknell VL, Ithaca MS, Wright TM. The effect of conformity, thickness, and material on stresses in ultra-high molecular weight components for total joint replacement. J Bone Joint Surg Am. 1986;68(7):1041–51. Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg Am. 1990;72(4):518. Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973;55(8): 1629–32. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am. 2006;61(1):15–23. Hartofilakidis G, Karachalios T. Total hip arthroplasty for congenital hip disease. J Bone Joint Surg Am. 2004;86(2):242–50. Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am. 1982;64(9):1295–306. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60(2):217–20. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am. 1970;52(3):457–67. Toossi N. Acetabular components in total hip arthroplasty: is there evidence that cementless fixation is better? J Bone Joint Surg Am. 2013;95(2):168. Emms NW, Stockley I, Hamer AJ, Wilkinson JM. Long-term outcome of a cementless, hemispherical, press-fit acetabular component. J Bone Joint Surg Br. 2010;92(6):856–61. Veitch SW, Whitehouse SL, Howell JR, Hubble MJ, Gie GA, Timperley AJ. The concentric all-polyethylene Exeter acetabular component in primary total hip replacement. J Bone Joint Surg Br. 2010;92(10):1351–5. Clarius M, Jung AW, Streit MR, Merle C, Raiss P, Aldinger PR. Long-term results of the threaded Mecron cup in primary total hip arthroplasty. Int Orthop. 2009;34(8):1093–8. Mäkelä KT, Eskelinen A, Pulkkinen P, Paavolainen P, Remes V. Results of 3,668 primary total hip replacements for primary osteoarthritis in patients under the age of 55 years. Acta Orthop. 2011;82(5):521–9. Lewthwaite SC, Squires B, Gie GA, Timperley AJ, Ling RSM. The Exeter™ universal hip in patients 50 years or younger at 10–17 years’ followup. Clin Orthop Relat Res. 2008;466(2):324–31.

3

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 Paul A. Banaszkiewicz

3.1

Author

Harris WH

A system for rating hip function is described, and this is compared with the Larson and Shephard methods of grading hip function.

3.2

3.5

Reference

J Bone Joint Surg Am. 1969;51:737–755.

3.3

Institution

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston

3.4

Abstract

The end results of 39 mold arthroplasties performed at the Massachusetts General Hospital were analysed. The study period was between 1945 and 1965. It was found that in the second half of the series results were significantly better statistically than in the first half of the series. In the second half 16 out of 19 unilateral cases obtained good or excellent hip ratings. Out of 39 hips, 3 needed revision and 1 developed postoperative sepsis. The author discusses reasons for differences in the results between the first and the second half of the series and the rationale for choosing between hip fusion or arthroplasty.

P.A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_3, © Springer-Verlag London 2014

Summary

The Harris Hip Score (HHS) is a disease-specific, sitespecific health- related quality of life (HRQoL) instrument originally intended as an outcome score after mold cup arthroplasty. It is an outcome measurement score administered by a qualified health care professional. It was devised to provide an evaluation system for various hip disabilities and methods of treatment. The domains covered are pain, function, absence of deformity and range of movement. • The pain domain measures pain severity and its effect on activities and need for pain medication • The function domain consists of daily activities (stair use, using public transport, sitting, and managing shoes and socks) and gait (presence of a limp, support needed and walking distance). • Deformity takes into account hip flexion, adduction, internal rotation and leg length discrepancy. • Range of movement measures hip flexion, abduction, external and internal rotation and adduction The scores are added together and the maximum score is 100 (best possible outcome) covering pain (1 item, 0–44 points), function (7 items, 0–47points), absence of deformity (1 item, 4 points) and range of motion (2 items, 5 points). Function is subdivided into activities of daily living (14 points) and gait (33 points). Pain and function were the two basic considerations and receive the heaviest weighting (44 and 47 points, respectively). Range of motion and deformity are seldom of primary importance, and therefore received 5 and 4 points, respectively.

13

14

P.A. Banaszkiewicz

A total score 0.5 cm of cement. The loosening rate for such hips was 12 %. In Grade 2, all cancellous bone had been removed and there was 0.5 cm of cement and the loosening rate was 24 %. In grade 4, all cancellous bone also had not been removed and there was 1 mm wide at the bone-cement interface or any migration or tilting of the component. Loosening of the femoral component was diagnosed if the component had shifted or if there was a radiolucent line >1 mm at the bone-cement or cement-prosthesis interface. It was previously reported that the 5-year incidence of loosening was 6.5 for the acetabular component and 24 % for the femoral component. At 10 years the incidence of loosening had increased to 11.3 % for the acetabulum and 29.9 %

P.A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_14, © Springer-Verlag London 2014

14.6

Citation Count

586

14.7

Related References

1. Kavanagh BF, et al. Charnley total hip arthroplasty with cement. J Bone Joint Surg Am. 1989;71:1496–503. 2. Kavanagh BF, et al. Charnley low-friction arthroplasty of the hip: twenty-year results with cement. J Arthroplasty. 1994:9(3):229–34.

14.8

Key Message

This is a 10-year follow up series of the first year’s experience (1969–1970) of 333 consecutive Charnley THA’s performed at the Mayo clinic in 300 patients. The study follows on from the 5-year results evaluated by Beckenbaugh and Ilstrup [1]. Subsequent results from 15 and 20 years have been reported with no patients lost to follow up [2, 3]. 61

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A trochanteric approach was used along with first generation cementing techniques in which cement was hand packed into the canal. Pulsatile intramedullary lavage, an intramedullary canal plug or measures to reduce the porosity of cement were not used. The incidence of loose components at 5 years was 6.5 % for the acetabular component and 24 % for the femoral component. At 10 years the incidence of loosening had increased to 11.3 % for the acetabular component and 29.9 % for the femoral component. The poor results of using first generation cementing technique led to the development and widespread use of uncemented fixation and improvements in cementing technique and component design.

14.9

Why It’s Important

This paper was one of the first North American studies reporting the 10-year results of cemented Charnley THA outside the centre of implant origin (Wrightington). Although THA performed in the early 1970s using first generation cementing techniques produced a revision rate of approximately 10 % at 10 years, radiological review of these patients suggested a higher rate of impending failure with time. It was generally assumed that the weak link in THA was fixation by bone cement. These results gave momentum to the development of cementless THA as an alternative.

14.10 Strengths This is a seminal paper that is frequently referenced in the introduction section of hip arthroplasty articles that either refer to the initial poor results of first generation cementing techniques in THA or quote actual femoral stem loosening rates. The earlier 5-year results of Beckenbaugh and Ilstrup from the same series failed to achieve the same recognition [1]. This is generally assumed to be due to the shorter follow up period of only 4–7 years.

14.11 Weaknesses Follow up consisted of a self-administered questionnaire and review of anteroposterior (AP) and lateral radiographs. The study mainly focused on radiographic features of loosening so that despite the 5-year results containing Harris hip scores no hip scores were performed in this extension study at 10 years. Thirty-eight patients described some pain in the hip but no attempt was made to analyse this with respect to location or cause.

There is an uncertain association between radiographic implant loosening and clinical scores. The study’s radiographic findings were significantly weakened as no hip scores were obtained for the patients in series.

14.12 Relevance Over a 1-year period (1969–1970) 300 patients (333 hips) underwent a Charnley LHA. The technique included a trochanteric osteotomy and the standard Charnley prosthetic components (a high density polyethylene acetabular component, a stainless steel femoral stem with a 22.25 mm diameter head and radiopaque polymethylmethacrylate). At 10 years 207 patients (231 hips) were available for follow up. The rate of loosening of the cemented femoral component was less in the second 5 years than in the first 5 years. Loosening of the cemented acetabular component increased with time, especially after the first 10 years leading to a high number of relatively late acetabular failures. The series was equally matched for males and females with a mean age of 63.6 years. The pre-operative diagnosis was varied and included osteoarthritis (56 %), rheumatoid arthritis (7.5 %), failed femoral endoprosthesis (15.6 %), failed cup arthroplasty (6 %), avascular necrosis (3 %) development dysplasia (3 %) etc. Follow-up consisted of a questionnaire and radiographs sent from the patient’s local hospital for review. Clinical examination was performed in 43 patients. Of the original 300 patients 65 had died and in 28 patients follow up was incomplete due to advanced age, non compliance etc. The study focused on radiographic finding of loosening. There were some difficulties with radiographic comparisons due to differences in standardisation of radiographs. On the acetabular side the following radiographic features were considered as evidence of loosening: a radiolucent zone >1 mm in thickness around the whole circumference of the acetabular component involving zones 1, 2 and 3 or tilting/ migration of the acetabular component. Of the 231 hips evaluated at 10 years, 26 had evidence of a loose acetabular component and 7 had been revised because of a loose cup. In 17 of these hips there had been progression in loosening between the fifth and tenth years whilst in the other 9 hips although the cup was loose no progression was visible. The incidence of cup loosening was much higher in rheumatoid patients and those with failed cup arthroplasty. A crude attempt was made to calculate polyethylene wear from AP radiographs. This was calculated by measuring the distances from the centre of the femoral head to the superior and inferior outside margins of the acetabular component. The difference between these two measurements divided by two represented the wear of the acetabular component.

14

Ten-Year Follow-Up Study of Total Hip Replacement

Stauffer reported that polyethylene cup wear was not a significant long-term problem. The criteria for determining loosening of the femoral component were the appearance of any radiolucent line between the prosthesis and cement, a complete lucent zone between cement and bone or any change in position (angulation or sinking) of the femoral component. The reporting of long-term hip arthroplasty series in major orthopaedic journals has significantly evolved since this publication. Radiographic and clinical follow up nomenclature has become more established with the protocol described by Johnston et al. [4] being strongly recommended for use by most journals. This series has been reported at various time intervals with the numbers of patients at each follow up interval differing with each study. Kavanagh et al. [2] reviewed the 15 year results of this series in 1989. A modified Harris hip score and Mayo clinical score was recorded for each hip. Possible loosening was included as an additional category previously absent from earlier papers. Probable loosening was defined as migration of the acetabular or femoral component, fracture of the cement, a radiolucent line between the prosthesis and the cement, or a complete radiolucent line >1 mm in at least one zone between the bone and cement.

63

The acetabular component was probably loose in 19(14 %) of 136 hips at 15 years, 24 (12 %) of 206 at 10 years and 21 (10 %) of 221 hips at 5 years. The femoral component was probably loose in 51 (38 %) of 136 hips at 15 years, 48(23 %) of 206 at 10 years and 33(15 %) of 221 hips at 5 years. The last follow up data was 1994 at 20 years. It reported an overall probability of surviving without component revision of 84 % [3]. The authors also stressed the influence of age at the time of the initial THA: the risk of revision was 12 % for those over 70 years of age, versus 27 % for those less than 59 years of age.

References 1. Beckenbaugh RD, Ilstrup DM. Total hip arthroplasty. J Bone Joint Surg Am. 1978;60:306–13. 2. Kavanagh BF, Dewitz MA, Ilstrup DM, Stauffer RN, Coventry MB. Charnley total hip arthroplasty with cement. Fifteen-year results. J Bone Joint Surg Am. 1989;71:1496–503. 3. Kavanagh BF, Wallrichs S, Dewitz M, Berry D, Currier B, Ilstrup D. Charnley low-friction arthroplasty of the hip: twenty-year results with cement. J Arthroplasty. 1994;9:229–34. 4. Johnston RC, Fitzgerald Jr RH, Harris WH, Poss R, Muller ME, Sledge CB. Clinical and radiographic evaluation of total hip replacement. A standard system of terminology for reporting results. J Bone Joint Surg Am. 1990;72:161–8.

A Ten-Year Follow-Up of One Hundred Consecutive Müller Curved-Stem Total Hip Replacement Arthroplasties

15

Paul A. Banaszkiewicz

15.1

Author

Sutherland CJ, Wilde AH, Borden LS, Marks KE.

15.2

Reference

J Bone Joint Surg Am. 1982;64:970–982.

15.3

Institution

Cleveland Clinic

15.4

Combining both the clinically loose (revised) implants with the radiographically loose replacements (migration) this study found that aseptic loosening occurred in 29 % of acetabular components and 40 % of femoral components. Acetabular component loosening was more likely to occur in the elderly while femoral component loosening was more likely to occur in males, younger age, heavy weight and unilateral disease. Loosening of the femoral component occurred earlier after surgery whilst acetabular component loosening increased with time after surgery.

Abstract

This study involved review of 100 Müller curved stem total hip arthroplasties (THA’s) at 10 years following surgery. Twenty patients with 22 THA’s had died and 25 THA’s had been revised for various reasons. This left 53 THA’s for analysis and of these 35 were good or excellent with Harris hip scores ≥80 while 18 were classified as poor or fair with Harris hip score 82 kg.

P.A. Banaszkiewicz, FRCS (Tr & Orth), MClin Ed, FAcad MEd, FHEA Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_16, © Springer-Verlag London 2014

16.5

Summary

The article reports the short-term results of a small group of patients younger than 30 years who underwent total hip arthroplasty (THA). This was an unselected series of THA’s performed by a single surgeon in a single institution. Whilst patients were initially doing well at 1 year, 5-year follow up results demonstrated 57 % had impending or actual failure of one or both components, with 21 % requiring revision. Chandler et al. reported revised or radiographically loose components in 57 % of 29 patients aged 30 years or less. The incidence of radiolucent lines was 94 % on the acetabular side and 33 % on the femoral side. The number of revisions for acetabular and femoral loosening, however, were equal (five of each in seven patients). Component migration or ‘ominous’ radiolucency (progressive and >2.5 mm thick) was seen in nine acetabula, one femur, and in one case involved both components.

16.6

Citation Count

507

16.7

Related References

1. Boeree N, Bannister G. Cemented total hip arthroplasty in patients younger than 50 years of age. Ten- to 18-year results. Clin Orthop Relat Res. 1993;(287):153. 2. Joshi A, Porter ML, et al. Long-term results of Charnley low-friction arthroplasty in young patients. J Bone Joint Surg Br. 1993;75:616. 3. Collis D. Long-term (12 to 18 year) follow-up of cemented total hip replacements in patients who were less than fifty

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years old. A follow-up note. J Bone Joint Surg Am. 1991;73:593. 4. Polkowski GG, Callaghan JJ, Mont MA, Clohisy JC. Total hip arthroplasty in the very young patient. Am Acad Ortho Surg. 2012;20(8):487–97.

16.8

Key Message

The results of first generation cemented THA in young patients were extremely poor. This paper acted as a stimulus for improving cementing techniques and directed research towards developing an uncemented implant option. The success of THA in older patients, in tandem with advances in cementing technique and bearing surfaces, had stimulated the demand for the procedure in younger, more active patients. The outcome of THA in young patients varies, largely because of the wide spectrum of diagnoses associated with hip disease in this group, the complexity of the deformities requiring THA, and the need for prolonged durability. Young active patients are at the forefront of a high complication rate with aseptic loosening, short term component durability and excessive conventional polyethylene wear [1] Young patients require careful long-term clinical review following THA. The outcomes of THA have been less predictable in young patients with greater physical demands than in older, less active subjects.

16.9

Why It’s Important

One of the greatest challenge facing orthopaedic surgeons is providing a long term functioning THA in young active patients. The definition of young in patient outcome studies of THA in the literature varies, but young generally refers to patients less than 50 years of age. There are few reports of hip THA implanted in patients 82 kg, high patient activity level and unilateral hip disease. This had never previously been attempted and would allow for identification of patients pre-operatively who had the highest risk factors for early loosening. Patients with a rheumatoid type picture did better presumably because of a generalized reduction in function. Avascular necrosis was associated with a poorer outcome and was present in 11 out of 18 problem hips. Patients with a previous mold cup arthroplasty did poorly and patients with bilateral involvement did better than unilateral disease. The single most important factor for loosening was excessive activity of the patient

16.11 Weaknesses There were only small patient numbers in the series and the heterogeneity of the group meant that statistical analysis was not deemed appropriate. No survival analysis was performed. The operations were performed by ten surgeons, multiple implants were used and follow up was short at 5 years When compared to current guidelines recommended by the JBJS Am for reporting results of THA’s Chandler’s et al. paper is fairly basic and would not meet minimum set criteria for publication. Another concern is that hip arthroplasty surgery has significantly advanced in the ensuring years and Chandler’s survival figures for THA in young patients should now be considered in a historical content.

16 Total Hip Replacement in Patients Younger Than Thirty Years Old: A Five-Year Follow-Up Study

16.12 Relevance In 1981 at the time of article publication there only were limited surgical procedures available for managing established painful end stage osteoarthrosis of the hip in young patients namely arthrodesis, osteotomy or THA. Chandler’s article examined risk factors for hip failure such as high body mass index, diagnosis and level of activity. Although a small number of previous reports on THA in patients less than 30 years old had been published, these had involved patients suffering from inflammatory arthritis only (rheumatoid/ankylosing spondylitis/SLE [3, 4]. These studies mainly discussed the technical difficulties of THA associated with hypoplasia of the pelvis and femur, gross anteversion of the femoral neck and generalised osteoporosis. Bisla et al. [4] had reported 93 % satisfactory results in their series of 66 patients with inflammatory arthritis at average follow up 32.5 month. Halley and Charnley [5] reported that 91 % of 68 young patients had no pain at 5 year followup. These papers essentially reported low revision rates for patients followed up for less than 5 years but it soon became evident that after 5 years many more implants failed. Chandler et al. series of 33 patients 4 cm [2] was the only factor predictive of better outcomes when ACT was compared with a non-autologous chondrocyte implantation surgical technique. The authors concluded that all of the cartilage repair/restoration techniques provide short-term success. Vasiliadis et al. [6] performed a systematic review of nine different trials (n = 626) and found that ACT was an effective treatment for full thickness chondral defects of the knee,

168

providing an improvement of clinical outcomes. The authors were unable to say whether ACT was superior to other treatment strategies in full thickness articular cartilage defects of the knee. Preferred candidates for ACT included: • Adults 2 cm • No significant bone loss • Full range-of-motion, intact ligaments and physiologically correct lower limb axis • No active rheumatoid arthritis autoimmune or connective tissue disease • Motivated patient willing to comply with rigorous rehabilitation program

N. Caplan and D.F. Kader

References 1. Bedi A, Feeley BT, Williams RJ. Management of articular cartilage defects of the knee. J Bone Joint Surg Am. 2010;92(4):994–1009. 2. Brismar BH, Wredmark T, Movin T, Leandersson J, Svensson O. Observer reliability in the arthroscopic classification of osteoarthritis of the knee. J Bone Joint Surg Br. 2002;84:42–7. 3. Spahn G, Klinger HM, Hofmann GO. How valid is the arthroscopic diagnosis of cartilage lesions? Results of an opinion survey among highly experienced arthroscopic surgeons. Arch Orthop Trauma Surg. 2009;129(8):1117–21. 4. Peterson L, Brittberg M, Kiviranta I, Åkerlund EL, Lindahl A. Autologous chondrocyte transplantation biomechanics and longterm durability. Am J Sports Med. 2002;30(1):2–12. 5. Harris JD, Siston RA, Pan X, Flanigan DC. Autologous chondrocyte implantation a systematic review. J Bone Joint Surg Am. 2010; 92:2220–33. 6. Vasiliadis HS, Wasiak J, Salanti G. Autologous chondrocyte implantation for the treatment of cartilage lesions of the knee: a systematic review of randomized studies. Knee Surg Sports Traumatol Arthrosc. 2010;18(12): 1645-55.

A Comparison of Four Models of Total Knee-Replacement Prostheses

41

Nick Caplan and Deiary F. Kader

41.1

Author

Insall JN, Ranawat CS, Aglietti P, Shine J.

41.2

Reference

J Bone Joint Surg Am. 1976;58:754–765.

41.3

Guepar prosthesis showed the best results in those patients with the most severe deformity or disease. However, infection rates were greater in the Guepar than the other prostheses. Loosening of the tibial and femoral components of the Guepar was suggested by radiolucent lines in 60 and 45 % of knees, respectively. In patients with moderate to severe deformity, the geometric prosthesis was found to give the best results. It was not suitable for knees with rheumatoid arthritis, however.

Institution 41.5

The Hospital for Special Surgery, Affiliated with the New York Hospital-Cornell University Medical Centre, New York City

41.4

Abstract

This study presents an evaluation of four types of total knee replacement prosthesis. The prostheses included unicondylar (29 knees), duocondylar (64 knees), Guepar (50 knees) and geometric (50 knees). The prostheses were assessed at follow up durations of 2–3.5 years. The nature of patients receiving each type of prosthesis differed. In the least severe cases, the unicondylar was used. This prosthesis gave the least complications. The best prosthesis to use in knees with rheumatoid arthritis and a mild deformity was the duocondylar. The

N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_41, © Springer-Verlag London 2014

Summary

In this study, 193 patients undergoing knee replacement surgery were investigated. Patients were receiving surgery for either rheumatoid arthritis or osteoarthritis. Patients received one of four implant types, selected based on clinical need, including: unicondylar, duocondylar, geometric (single radius of curvature), or Guepar (hinge). Patients were followed up at between 2 and 3.5 years post surgery. The Hospital for Special Surgery knee rating scale was used both pre and post surgery to evaluate knee structure and function. This was used to assess the relative improvement seen as a result of knee surgery. Patients with complications following surgery were investigated clinically. Following surgery, implant failures were evaluated, as well as pain. Loosening of either the femoral or tibial components was assessed by subjective observation of radiolucencies seen during radiographic investigation. The lowest pre-operative rating score was seen in patients receiving the Guepar implant. The highest scores were in the unicondylar group. The greatest improvement in rating score was in the Guepar group and the smallest improvement was in the unicondylar group. Except for the unicondylar group, where only patients with osteoarthritis were included, patients with rheumatoid arthritis receiving all other types of implant showed greater improvements in knee rating score than those with osteoarthritis. However, this was not analysed statistically. There were 28 implant failures reported. The highest rate of failure was 169

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seen in the geometric group and the lowest rate of failure was in the Guepar group. Despite it’s known limitations in terms of wear and lack of provision for the patella and lack of correspondence to femoral and tibial anatomy, the hinge-type implant showed the greatest improvements in function following surgery.

41.6

Citation Count

613

41.7

complication, and loosening. A range of individual cases are also presented which provide examples of patients that had deep wound infection and dislocation, as well as documenting a number of cases that showed component loosening and axle loosening. In order to investigate changes in the structure and function of the knee joint following joint replacement surgery, the Hospital for Special Surgery knee rating scale was administered prospectively before and after surgical intervention. This rating scale has been shown to a valid measure for assessing pre to post surgery differences in knee function.

Related References 41.11 Weaknesses

1. Diduch DR, et al. Total knee replacement in young, active patients. Long-term follow-up and functional outcome. J Bone Joint Surg Am. 1997;79(4):575–82. 2. Scuderi GR, Scott WN, Tchejeyan GH. The Insall legacy in total knee arthroplasty. Clin Orthop Relat Res. 2001;392:3–14.

41.8

Key Message

None of the four prostheses used in replacing the knee joint offered results approaching the excellence of total hip replacement. The authors attributed that to the inherent difficulties in replacing a joint as complex as the knee and prosthetic design. In the majority of the patients there was a significant improvement from the preoperative state but it was far from ideal.

41.9

Why It’s Important

This paper published follow up data on 193 patients, which would be regarded as a large number of knee joint arthroplasties at that time. The authors used a knee rating scale assessing pain, function, motion and stability and provided detailed information regarding the associated complications. The paper recognised that the patellofemoral joint is a problematic area and this could not be solved by patellectomy (38/193). They also identified that implant design may be a contributing factor in the less than ideal outcome.

41.10 Strengths This descriptive study presented a detailed evaluation of the advantages and disadvantages of four types of knee replacement implants. A range of relevant factors are discussed such as knee structure and function, pain, implant failure,

This study was mostly descriptive in its treatment of the data. Although knee ratings data were obtained before and after surgery for each of the groups, no statistical analysis of the data was performed. Between group differences could have been confounded by the relatively small sample size of each group, as well as the differences in group sizes. Differences in the appropriateness of each implant design for either rheumatoid or osteo-arthritis are discussed, yet no statistical analysis of these differences was performed. Indeed, much of the paper describes and discusses individual cases. This, combined with the small sample size, makes it very difficult to generalise the findings to the wider population of knee joint replacement patients. The paper portrays itself as relating to total knee replacement surgery. However, as the authors state themselves, none of the implants used made any provision for patellofemoral articulation or patellar tracking. Thus, the implants used are not total knee replacement implants in the strict sense of the term. Although a knee rating scale was administered before and after surgery to allow for the improvement in knee function to be evaluated, the validity of any between group comparisons to be made is questionable. Patients in the hinge-type implant group showed the largest improvement in knee function. However, these patients were also those with the most severe involvement. It is hardly surprising then that they showed the largest improvement following knee joint replacement surgery. Although it is thought to be a valid measure of knee joint function, the Hospital for Special Surgery knee ratings scale looks only at knee structure and function. The rating score used in this study does not include any information about physical activity levels or patient expectations. A measure such as the University of California, Los Angeles (UCLA) Activity Scale [1], although not available at the time of this study, might be a useful additional measure. The UCLA Activity Scale has been suggested as being

41

A Comparison of Four Models of Total Knee-Replacement Prostheses

the most reliable and sensitive measure of physical activity for joint replacement patients [2]. Five of the seven items in the Hospital for Special Surgery knee rating scale are scored by the physician. This could lead to bias in the data. These items, including range of motion, muscle strength, flexion deformity, instability and subtraction, will be assessed subjectively. Objective measures using equipment such as goniometers, arthrometers, etc., could be used to reduce this potential bias. However, the additional time and cost requirements of these methods might prevent them from becoming used clinically. Radiolucencies were identified and used to suggest implant component loosening. However, these were only subjectively evaluated. A more recently published way of objectively evaluating component alignment and loosening using radiolucencies involved the measuring of the total length of the radiolucent lines [3]. This method has been found to correlate with measures of clinical outcome [4] and has been shown to be sensitive to differentiate between patients with and without pain [5]. However, there has been some conflict in the literature regarding the reliability and reproducibility of measures taken from radiolucent lines [6, 7].

41.12 Relevance In the early 1970s, total knee arthroplasty was in its infancy and surgeons were seeking alternatives for arthrodesis and fascial arthroplasties in the management of the arthritic knee. Pioneering engineers were developing new implants such as the Polycentric and the ICLH. At that stage Insall became involved the design of modern total knee replacement. Although Insall was involved with the design of the Duocondylar prosthesis, the principle engineer was Peter Walker. Insall became involved with designing an implant as a nonlinked surface replacement with conforming surfaces. Dissatisfied with the Duocondylar prostheses Insall was the major clinical investigator in designing the Total Condylar prosthesis. This was a posterior cruciate sacrificing design with a conforming articular surface, an anterior femoral flange, and a dome-shaped patella component became the first implant of modern design. He accepted the limitations of posterior cruciate retension and the need for soft tissue release for balanced flexion and extension spaces. Adopting the tensor instrumentation of Freeman in 1974, Insall recognized the principles of balanced gaps. In 1976, Insall first coined the terms flexion and extension gaps. To achieve balance, Insall described the classic method of bone resection and soft tissue releases. He described the use of an alignment rod and spacer block to achieve the properly balanced gaps between the femur and tibia. This method of bone resection introduced the concept of rotational alignment of the femoral

171

component. To create a symmetric flexion gap, the femoral component needed to be rotated externally. Many of the principles that were adopted at the time of this early study are still valid today. The authors used unicondyler knees in less severe cases and hinged knees for the knees with severe deformity. It is now established that the level of constraint in the implant used should be appropriate to the severity of joint damage and the degree of deformity. The authors stated in the discussion “perhaps without patellectomy the results would have been better”. This suggests understanding of the complexity of the patellofemoral joint. This has subsequently prompted the design of patella friendly implants. Loosening and low-grade deep infection were the other two causes for persistent pain after knee replacement. The authors stated the importance of knee aspiration when suspecting infection. It is interesting to read that they had only two sizes of the geometric knee and only one size of the hinged knee. At the present time, there are multiple sizes and all systems are highly modular. The Guepar prosthesis is a hinged implant easy to insert at the time of surgery as all ligaments were resected and the stems dictated alignment. Unfortunately the long term results revealed significant rates of loosening, considerable patella pain and instability and high infection rates. In addition severe bone loss made the situation difficult to salvage with arthrodesis Finally, it was fascinating to learn about their postoperative rehabilitation program, which included 1 week immobilisation in cast in extension, non-weight bearing. Flexion was not pursued vigorously until the end of the second week! But if flexion did not approach 90° by the end of the third week they manipulated the knee under anaesthesia. This is in contrast to current practice where patients are mobilised on the day of surgery and leave the hospital within 3 days.

References 1. Zahiri CA, et al. Assessing activity in joint replacement patients. J Arthroplasty. 1998;13(8):890–5. 2. Naal FD, Impellizzeri FM, Leunig M. Which is the best activity rating scale for patients undergoing total joint arthroplasty? Clin Orthop Relat Res. 2009;467(4):958–65. 3. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989;248:9–12. 4. Bach CM, et al. Correlation between radiographic assessment and quality of life after total knee arthroplasty. Knee. 2009;16(3): 207–10. 5. Sadoghi P, et al. Radiolucent lines in low-contact-stress mobilebearing total knee arthroplasty: a blinded and matched case control study. BMC Musculoskelet Disord. 2011;12:142. 6. Bach CM, et al. Reproducible assessment of radiolucent lines in total knee arthroplasty. Clin Orthop Relat Res. 2005;434:183–8. 7. Al-Hadithy N, et al. How to read a postoperative knee replacement radiograph. Skeletal Radiol. 2012;41(5):493–501.

Knee Joint Changes After Meniscectomy

42

Nick Caplan and Deiary F. Kader

42.1

Author

Fairbank TJ.

42.2

Reference

J Bone Joint Surg Br. 1948;30:664–670.

42.3

Institution

London, England

42.4

Abstract

This study investigated changes in the knee following meniscectomy using roentgenographic evaluations. It examines 107 cases, 3 months to 4 years after operation and finds joint space narrowing, ridge formation on the femoral condyle and flattening of the femoral condyle. Factors contributing to these changes were investigated including the influence of weightbearing on the menisci. Weightbearing causes compression of the menisci, the greatest response to compression occurs immediately upon loading, with only minimal further compression over time.

42.5

Summary

Knee joint changes were assessed following meniscectomy. In an initial roentgenographic investigation, comparing radiographs before and after meniscectomy, a number of common changes were observed, including ridge formation on the femoral condyle on the operated side, flattening of the femoral condyle on the operated side, and joint space narrowing on the operated side. Further investigations were undertaken to identify the potential cause of these changes as a result of removing the menisci. The similarity between articular cartilage and sponge rubber immersed in glycerine, in terms of the elasticity of the materials, was noted. A subsequent radiographic investigation then examined changes in the joint space as a function of weightbearing. This showed that the articular cartilage compresses by 1 mm immediately upon weightbearing and then slows its rate of compression to only a further 1 mm after a whole day of weightbearing. The contours of the femoral and tibial parts of two cadaveric knees were then recorded which demonstrated that the femur only starts to come into contact with the meniscus as the joint is compressed. It was also noted that as the joint compresses beyond this point, the meniscus is squeezed outwards, and that tension at the edges of the meniscus allow it to contribute to load absorption during weightbearing.

42.6

Citation Count

804 N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_42, © Springer-Verlag London 2014

42.7

Related References

1. Macnicol MF, Thomas NP. The knee after meniscectomy. J Bone Joint Surg Br. 2000;82:157–9. 2. Roos H, et al. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one 173

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years, compared with matched controls. Arthritis Rheum. 1998;41(4):687–93. 3. Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum. 2003;48(8): 2178–87.

42.8

Key Message

The menisci make a contribution to load absorption in the knee during weightbearing. Meniscectomy therefore alters the mechanics of the knee joint which could cause structural changes to the articular chondral surfaces. Fairbanks suggested that radiographic changes might be a precursor to osteoarthritis. They occurred in 37 % of patients. His conclusion was “that meniscectomy is not wholly innocuous, it interferes at least temporarily with the mechanics of the joint”

42.9

Why It’s Important

This was the first detailed article to characterize the radiographic changes in the knee post meniscectomy. Fairbank also offered an explanation for the changes to the articular surface. He deduced that the changes in the articular surface are caused by overload due to loss of the meniscal tissue. He was the first to suggest that the meniscus may have a load bearing function.

42.10 Strengths For its time, this study presents a logical investigation into the role of the menisci in load absorption during weightbearing in the knee. The authors take a holistic approach, looking at in vivo radiographs, before and after meniscectomy to note structural changes in the knee, as well as controlled in vivo and in vitro investigations into the structure and function of the menisci. The authors acknowledge the difficulties in ensuring pre- and post-surgery radiographs are taken using exactly the same patient positioning and appropriately only noted changes that were seen on a number of occasions for each patient.

42.11 Weaknesses Whilst being an early attempt to document the role of the menisci in the knee during weightbearing, the study is entirely descriptive, using only subjective measures. No

statistical treatment the data is provided. Although a reasonable sample appears to have been used in the initial roentgenographic evaluation of the effects of meniscectomy on structural changes to the bone, no details are provided about the sample, such as age or gender. Similarly, in the second roentgenographic investigation, it is not known how many patients were recruited, and details such as their age and gender are not provided. Although noted by the authors, patient positioning during the roentgenographic investigations was problematic. Achieving the same position post-surgery, compared to presurgery was difficult, although the authors accounted for this. In the second roentgenographic investigation, standing x-rays were used, as well as supine. As the knee is loaded, external rotation of the femur occurs, in comparison to the unloaded knee, which would also make it difficult to obtain exactly the same views of the knee. The cadaveric evaluation of the contours of the tibial and femoral articulating surfaces used two cadavers. These cadavers were both from female donors that were aged 30 and 33 years. The data presented cannot therefore be generalised to male knees, and cannot account for degenerative changes to the knee that take place as a result of the natural ageing process.

42.12 Relevance In the first half of the twentieth century, open total meniscectomy became widespread throughout the world as the recommended management of meniscal tears. Menisci were thought as unnecessary extensions of the tibia with the assumption that the absence of a meniscus had little effect on joint function. No data were available reporting the longterm occurrence of degenerative arthritis following meniscectomy existed. This is a key paper in changing our understanding of the role of the meniscus in the knee. The radiologic changes after meniscectomy are still called Fairbank changes. These included an anteroposterior osteophytic ridge projecting downward from the femoral condyle over the old meniscus site, general flattening of the marginal half of the femoral condylar surface, and narrowing of the cartilage space [1]. Fairbank attributed these changes to loss of weight bearing function of the meniscus, a function unproven for many years after his landmark article. Many different radiographic knee grading systems have been used to grade osteoarthritis including the Ahlbach method, IKDC form classification and Kellgren Lawrence system. This creates significant heterogeneous difficulties when comparing different studies. The Fairbank classification system still remains in popular usage, as the classification is simple and straightforward.

42

Knee Joint Changes After Meniscectomy

Johnson et al. [1] reported on 99 out of 440 patients after meniscectomy with a mean follow up of 17.5 years at the University of Iowa between 1936 and 1956. They found a high incidence of poor results, degenerative arthritis, ligamentous laxity and decreased stance phase flexion. They found 76 % of knees that had a meniscectomy showed at least one of Fairbank’s changes, while only in 6 % of the contra-lateral knee. The frequency of unsatisfactory results increased as the number of Fairbank’s changes found in the knees increased. In 1968, Jackson observed [2] a greater frequency of degenerative changes in the post meniscectomy knee when compared with the uninvolved contralateral knee. The incidence of radiographic signs of degenerative change increased with time. Tapper and Hoover [3] in 1969 reported 10–30 years results of uncomplicated meniscectomy in a series of 213 patients. The literature at the time regarding the ultimate effect of meniscectomy on the knee joint was confusing. At one extreme is the dire prediction that degenerative arthritis and disability were inevitable if a torn meniscus was not completely removed and that degenerative arthritis eventually follows meniscectomy. Other reports indicate that meniscectomy was a relatively benign procedure that allows the patient to return to heavy physical labour and athletic competition without any apparent ill effects. They reported only 38 % had a normal symptom free knee, 68 % of patients had an excellent or good result after 10 years or longer, and 13 % had a poor result. Roos et al. [4] performed a 21-year follow-up study of 107 patients who suffered an isolated meniscal lesion and

175

underwent open total meniscectomy. They reported a relative risk of 14.0 for the development of radiographic changes consistent with osteoarthritis and postulated that patients undergoing total meniscectomy may develop osteoarthritis 10–20 years earlier than patients with primary osteoarthritis. Today, the very idea of total meniscectomy seems primitive and the vast majority of surgery is performed using minimally invasive arthroscopic interventions preserving knee joint function while minimizing the progress of arthritis. It must therefore be noted that these large studies of patients undergoing open total meniscectomy are historical. Furthermore, the degree and nature of concomitant knee pathology (such as ACL injury) was not always documented. The major factors that affect outcome following meniscectomy include the degree of concomitant articular cartilage degeneration, the amount of meniscus removed, medial versus lateral meniscectomy, the status of the ACL and the type of meniscus tear (inferior with degenerative tears).

References 1. Johnson CD, Kettelkskamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56:719–29. 2. Jackson JP. Degenerative changes in the knee after meniscectomy. Br Med J. 1968;2(5604):525. 3. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51:517–26. 4. Roos H, Laurén M, Adalberth T, Roos EM, Jonsson K, Lohmander LS. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum. 1998;41(4):687–93.

Late Results After Meniscectomy

43

Nick Caplan and Deiary F. Kader

43.1

Author

pre-surgery duration of symptoms. Good to excellent outcomes were seen more often in men than in women.

Tapper EM, Hoover NW.

43.5 43.2

J Bone Joint Surg Am. 1969; 51:517–526.

43.3

Institution

Section of Orthopaedic Surgery, Mayo Clinic and Mayo Foundation and the Mayo Graduate School of Medicine, University of Minnesota, Rochester.

43.4

Summary

Reference

Abstract

One thousand and five patients received meniscectomy between 1936 and 1956 at a single centre. Of these patients, 494 were available for follow up at the time of this study, with follow up durations ranging from 10 to 30 years. Questionnaires were sent to each patient, of which 255 were returned. These questionnaires allow patients to report on their current symptoms. One hundred and thirteen of these patients returned for clinical examination. Symptoms reported at follow up did not correlate with age at time of surgery, follow up duration or

N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_43, © Springer-Verlag London 2014

Historically, there has been an association between meniscectomy and the development of osteoarthritis. Tapper and Hoover sought to quantify subjective results after meniscectomy based on patients’ subjective symptoms and disability. Approximately 1,000 patients who underwent meniscal surgery over a 20-year period at a single centre were invited to take part in a follow up evaluation between 10 and 30 years after their date of surgery. Of this initial sample, approximately half were excluded due to reasons including having died, and having had other injuries or disease at the time of original surgery (e.g. ligament injury, cartilage damage, arthritis, etc.). Questionnaires, aimed at determining patients’ current symptoms, were sent to all remaining patients of whom 255 responded. Those patients who had more than one meniscectomy or other injuries were subsequently excluded. A final sample included 213 patients, approximately half of which were able to attend a follow up evaluation in addition to completing the questionnaire. Questionnaires were scored in relation to a rating system proposed by the authors going from (1) excellent to (4) Poor. The follow up clinical examination included tests for McMurray’s, crepitus, knee joint instability, joint line tenderness, atrophy of the quadriceps and range of motion. Duration of symptoms prior to surgery, length of follow up period and age at time of surgery were not found to be related to symptoms at follow up, with the exception of those patients who had symptoms for over 2 years prior to surgery and those patients who were under 20 years of age at the time of surgery. Both of these groups of patients had significantly fewer patients falling within the “excellent” or “excellent + good” categories, respectively. Male patients were more likely to have excellent or good long term outcomes than female patients. 177

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They concluded that only 40 % of patients had normal knees with 40–90 % having good to excellent results and 10 % having bad results. The methodology of this study consisted of a retrospective questionnaire to which 36 % of the patients replied and a clinical exam performed on 35 % of the patients in the study

43.6

Citation Count

407

43.7

Related References

1. Bekkers JE, Inklaar M, Saris DB. Treatment selection in articular cartilage lesions of the knee: a systematic review. Am J Sports Med. 2009;37(Suppl);1148S–55. 2. Johnson CD, Kettelkskamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(4):719–29. 3. Pengas IP, Assiotis A, Nash W, Hatcher J, Banks J, McNicholas MJ. Total meniscectomy in adolescents: a 40-year follow-up. J Bone Joint Surg Br. 2012;94(12): 1649–54. 4. Papalia R, Del Buono A, Osti L, Denaro V, Maffulli N. Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull. 2011;99(1):89–106.

43.8

Key Message

Only approximately 40 % of patients undergoing uncomplicated meniscectomy were symptom free at a follow up of between 10 and 30 years. Male patients were more likely to have excellent or good long term outcomes compared to female patients. They noted a correlation between patient gender and functional results, with excellent or good results reported in 74 % of male patients and 44 % of female patients.

43.9

Why It’s Important

This is a landmark paper, which was one of the first to report the deleterious effect of meniscal excision. At the time it was a common belief among surgeons that the meniscus could be totally excised without long term harm to the patient. In fact some surgeons predicted that degenerative arthritis and disability were inevitable if a torn meniscus was not completely removed [1]. This article stimulated many subsequent basic

science and clinical studies that determined the many important functions of the menisci and the natural history of the post meniscectomy knee.

43.10 Strengths Tapper and Hoover reported long term 10–30 year follow up on 113 patients out of 1,005 that had undergone total meniscectomy at the Mayo clinic from 1936 to 1956. The authors attempted to contact all available patients that received a meniscectomy at the clinic over a period of 20 years. Strict exclusion criteria were used to ensure that those patients included in the study had uncomplicated meniscal injuries, to ensure that the analysis of long term outcomes was not influenced by confounding factors such as other injuries or disease.

43.11 Weaknesses Although the study has some merits, only a relatively small sample was ultimately included in this retrospective study. For some analyses, this sample was split into four or five categories (e.g. age). Thus, in any one category, there could be as few as 40 patients, which over a 20-year period equates to only two cases per year. The relevance of this to a typical case load is clearly debatable. To add to this, the meniscectomies were performed by a large number of surgeons, which could increase the variability in outcomes. The authors did not demonstrate a difference between open total and partial meniscectomy [2]. Patients were sent a questionnaire asking them to indicate their current symptoms. No details of this questionnaire are provided in the method. It appears as though these symptoms were then used to give patients a score ranging from (1) excellent to (4) poor. However no details are given as to how these ratings were applied. For any confidence to be given to the results of questionnaires and rating systems, they should be shown to be valid and reliable. Unfortunately no details are provided in terms of the validity of either the questionnaire or rating system. No data are provided to demonstrate the reliability of the rating system, although a comment is provided in the discussion that similar gradings were applied by both authors independently, thus suggesting interobserver reproducibility. Although some statistically significant differences were reported, no details of statistical treatment of the data were provided in the method section. The questionnaire included an item relating to patients having to give up some sport following meniscectomy. However, no details are available as to the pre-injury level

43

Late Results After Meniscectomy

of sporting activity. It could be that those patients who had high pre-injury sporting levels were unable to return fully to this level, whereas those with lower pre-injury sporting levels could have been able to return to that pre-injury level due to the lower demands being placed on the meniscus. Unfortunately, no assessment of how meniscectomy influenced patient quality of life was included in the study. Apart from listing the results of the physical examination, no details are provided as to the precise methods used for many of the items of the examination. For example, how were anteroposterior and mediolateral instability identified, what was full knee motion classified as, how was quadriceps atrophy identified, and what thresholds were used for identifying unstable knees or atrophied quadriceps?

43.12 Relevance Once dismissed as functionless vestigial structures, knee menisci were routinely removed after injury in the early 1900s [3]. The practice of subtotal or total open meniscectomy continued relatively unabated until 1936 when King [4] found that post-meniscectomy arthrosis was directly proportional to the amount of meniscus removed. Although observations of post-meniscectomy joint space narrowing and broadening of the femoral and tibial condyles were noted by Vandendorp et al [5], Bastien and Vandecasteele in 1939 they did little more than indicate that changes occurred. It was Fairbank’s landmark article in 1948 that provided significant radiographic proof of the adverse effects following meniscectomy, so called Fairbank changes [6]. Although he found no correlation between these radiographic findings and clinical symptoms, Fairbank suggested that the meniscus plays an important role in load transmission across the knee and should therefore be preserved. Saugmann-Jensen reported on 548 patients from the clinics of Copenhagen and found Fairbank’s changes in 23 % after 4 and 38 % after 10–15 years [7]. He thought these changes probably represented early osteoarthritis. At the time of Tapper and Hoover’s landmark paper in 1969 the literature regarding the ultimate effect of meniscectomy on knee joint function was confusing. At one extreme is the dire prediction that degenerative arthritis and disability were inevitable if a torn meniscus was not completely removed and that degenerative arthritis eventually follows meniscectomy. Other reports indicate that meniscectomy was a relatively benign procedure that allows the patient to return to heavy physical labour and athletic competition without any apparent ill effects.

179

After a minimum of 10 years follow up, they reported only 38 % had a normal symptom free knee, 68 % of patients had an excellent or good result and 13 % had a poor result. Johnson et al. [8] reviewed the long term results (mean follow up 17.5 years) after open meniscectomy for 99 patients. They found the clinical outcome was worse with an increased period of preoperative symptoms, lateral meniscectomy, female gender and concomitant ligamentous laxity. In 1984, Allen et al. [9] examined the results for 210 patients who had undergone open total meniscectomy. Radiographic signs of osteoarthritis were seen in 18 %, whereas only 7 % of the patients had significant symptoms and signs of degenerative joint disease. There was an increased incidence of post-meniscectomy radiographic changes noted after lateral meniscectomy in older patients and in patients with lower extremity malalignment. At the present time, clinicians are very conservative in excising meniscal tissue and aim to repair the majority of the tears. In contrast to total meniscectomy which was a standard treatment 50 years ago. This paper contributed to changing practice and prompted surgeons to question the acceptable standard of care. It highlights not only that meniscal excision was not a benign procedure but also recommended leaving a peripheral rim intact after excision to ensure a better outcome. A recent systematic review by Papalia et al. [10] concluded that the amount of meniscal tissue removed remains the strongest predictor of the long term onset of osteoarthritis.

References 1. MacAusland WR. Derangements of the semilunar cartilages: based on a study of 388 operative cases. Ann Surg. 1931;93(3):649. 2. Petty CA, Lubowitz JH. Does arthroscopic partial meniscectomy always cause arthritis? Sports Med Arthrosc. 2012;20(2):58–61. 3. Lee JM, Allen CR, Fu FH. Natural history of the post-meniscectomy knee. Sports Med Arthroscopy Rev. 2002;10(4):236–43. 4. King, D. The function of semilunar cartilages. J Bone Joint Surg. 1936;18(4): 1069-1076. 5. Vandendorp, Bastien, Vandecasteele. Resultats des meniscectomies. Rev Orthop. 1939;26: 629-644. 6. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30B(4):664–70. 7. Jackson JP. Degenerative changes in the knee after meniscectomy. Br Med J. 1968;2(5604):525. 8. Johnson JR, Kettelkskamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56:719–29. 9. Allen PR, Denham RA, Swan AV. Late degenerative changes after meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg Br. 1984;66(5):666–71. 10. Papalia R, Del Buono A, Osti L, Denaro V, Maffulli N. Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull. 2011;99:89–106.

Factors Effecting Late Results After Meniscectomy

44

Nick Caplan and Deiary F. Kader

44.1

Author

Johnson RJ, Kettelkamp DB, Clark W, Leaverton P.

motion during the stance phase of walking gait. These findings suggested that removal of the meniscus should only be performed when absolutely necessary.

44.2

44.5

Reference

J Bone Joint Surg Am. 1974;56:719–729.

44.3

Institution

University of Iowa Hospitals, Iowa City

44.4

Abstract

This study evaluated the effect of meniscectomy on roentgenographic and electrogoniometric outcomes. Ninety-nine patients were assessed at a mean of 17.5 years following meniscectomy. A large number of poor outcomes were found. Evidence of ligamentous laxity and osteoarthritis were observed, as well as a reduced sagittal knee range of

N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_44, © Springer-Verlag London 2014

Summary

Patients who underwent meniscectomy from a single centre over a period of 37 years were initially evaluated in relation to the exclusion criteria of this study. Patients were excluded if they had a range of pre-existing conditions, such as rheumatoid arthritis and moderate to severe ligament tears. Four hundred and forty patients were included in the study, of which 99 that had had a unilateral meniscectomy. The mean follow-up duration was 17.5 years. Patients were examined using a range of measures including clinical history, physical examination, roentgenographic evaluation of the knee, and an assessment of knee function during activity using an electrogoniometer. All data for the knee that had received the meniscectomy were compared to that of the contralateral knee, which was used as each patient’s control. An overall rating was determined for the long term success of the procedure, ranging from (1) excellent to (4) poor. This rating was determined through the use of ten criteria relating to activity and pain. According to the rating scale used, nearly two thirds of patients had unsatisfactory (fair or poor) long term outcomes. Female patients showed poorer outcomes to male patients. Patients had a mean age at time of surgery of 27 years. The best outcomes were observed in slightly older patients. Poorer ratings were related to increased knee joint laxity and an increase in the number of changes seen to the joint during the roentgenographic evaluation. Electrogoniometric evaluation during level walking revealed reduced stance phase flexion on the operated limb.

181

182

44.6

N. Caplan and D.F. Kader

Citation Count

388

44.7

Related References

1. Macnicol MF, Thomas NP. The knee after meniscectomy. J Bone Joint Surg Br. 2000;82:157–9. 2. Roos H, et al. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum. 1998;41(4):687–93. 3. Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year follow-up of meniscectomy with matched controls. Arthritis Rheum. 2003;48(8): 2178–87.

44.8

Key Message

Total meniscectomy is associated with instability and rapid severe articular degeneration. The long-term outcomes after meniscectomy are unsatisfactory for the majority of patients according to a range of measures including activity and pain ratings, knee joint instability, knee joint structure and knee biomechanics during level walking. At the same time Johnston emphasized the necessity of defining the physiological and biomechanical functions of the knee.

44.9

Why It’s Important

The findings of this study concur with Tapper and Hoover [1] and reports on the consequences of meniscectomy. The authors used stringent criteria in their clinical assessment and compared the two legs using the unaffected side as a control. This work reinforced the importance of the meniscus in keeping the knee healthy and strongly recommended that the meniscus should be removed only when it is definitely abnormal.

as anterior-posterior drawer. Structural changes are documented from roentgenographic assessment and functional changes are presented using electrogoniometric assessment during level walking. The authors provide a detailed description of the rating system and the use of ten criteria to formulate each patient’s final rating. Patient selection following stringent exclusion criteria which allowed for other minor pathologies, as most patients are unlikely to present with simply a meniscal injury. The authors fully account for the different types of data that were assessed and their selection of statistical methods reflected this.

44.11 Weaknesses A relatively small sample of patients from a single centre were recruited for follow-up examination in this retrospective study. Considering the wide range of dates of surgery (37 years), the included sample of 99 patients equated to, on average, just less than three patients per year of surgery. For analyses where the differences were examined between different overall rating categories (excellent, good, fair or poor), the subsequent samples become even smaller. Clearly this is unlikely to reflect a typical case load, and differences between data from this study and those of others could be attributed to the different population, as commented on by the authors. Due to the 37 year inclusion period, a large number of different surgeons, half of which were consultants and the other half registrars/residents, some relationships could be due to between-surgeon differences. As with any subjective rating scale, it is necessary to identify its validity and reliability/reproducibility. Many rating scales for meniscal injuries have been the subject of validity and reliability studies, such as the Lysholm and Tegner Activity Scale [2] and the International Knee Documentation Committee (IKDC) scoring system. Unfortunately the current rating system has not since been validated, although Tapper and Hoover [1] alluded to the same scale having acceptable inter-observer reproducibility. The overall rating score evaluated patients according to ten criteria that related to symptoms, pain and activity. It would have been useful to know the pre-injury level of sporting, or other, activity and to evaluate whether patients were able to return to these levels following surgery. Patient quality of life was also not assessed.

44.10 Strengths 44.12 Relevance A range of both subjective and objective measures are used to evaluate long term outcomes following meniscectomy. An overall rating of the long term success of the procedure is determined relating to pain experienced during activity. Joint laxity is documented using typical clinical measures such

The menisci of the knee have an important role in load-bearing, shock absorption and function as secondary stabilisers particularly in the absence of a functioning ACL [3]. Further roles postulated include a proprioceptive role

44

Factors Effecting Late Results After Meniscectomy

and aiding the lubrication and nutrition of the articular cartilage [4]. Meniscectomy used to be viewed as a benign procedure and McMurray concluded in 1942 it was felt that “A far too common error is shown in the incomplete removal of the injured meniscus” [5]. This attitude was biased on observations suggesting that remnants of meniscus in the joint were a potent cause of arthritis. Following on from the studies of Fairbank [6], Jackson [7] and Tapper and Hoover [1] Johnson published this long term review of the results after open total meniscectomy for 99 patients. This article is still relevant and its recommendations are still valid today. An important consideration, however, especially in light of the current practice of overusing imaging studies, is that the meniscus should only be removed when it is abnormal and symptomatic, as its potential to heal has been recognized. This is driven by research that has shown earlier development of osteoarthritis in patients after meniscectomy when compared with their nonoperative conterparts [8]. This paper also hypothesised on the ability of the meniscus to transmit load within the tibiofemoral joint and concluded that meniscectomy may lead to physiologic overload of the articular surface and subsequent degenerative arthritis. Later research by Johnson and Pope demonstrated that load transmission and shock absorption by the menisci occur by way of the orientation of the collagen fibers within the meniscus. Arranged in a circumferential pattern held together by radially oriented struts, axial load is transmitted to the circumferentially arranged collagen fibers. These hoop stresses absorb energy and prevent its transmission to the articular cartilage and subchondral bone. Numerous studies have reported the prevalence of osteoarthritic changes after meniscectomy. Several recent

183

systematic reviews concluded that direct comparison between these studies is difficult owing to the diversity of patients studied, the procedures performed, the duration of follow-up, the radiological criteria used, and the varying qualities of the studies themselves [8, 9]. In 1980, Goodfellow [10] published an editorial in the British edition of the Journal of Bone and Joint Surgery entitled “He who hesitates is saved”. He stated “Meniscectomy is only justifiable if a meniscus is causing more trouble than it is worth, and that is a value judgment which, like much else in clinical surgery, must be taken on inadequate evidence”.

References 1. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51:517–26. 2. Briggs KK, Kocher MS, Rodkey WG, Steadman JR. Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the knee. J Bone Joint Surg Am. 2006;88:698–705. 3. McDermott ID, Amis AA. The consequences of meniscectomy. J Bone Joint Surg Br. 2006;88:1549–56. 4. Englund M, Roemer FW, Hayashi D, Crema MD, Guermazi A. Meniscus pathology, osteoarthritis and the treatment controversy. Nat Rev Rheumatol. 2012;8(7):412–9. Nature Publishing Group. 5. McMurray TP. The semilunar cartilages. Br J Surg. 1942;29(116): 407–14. 6. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;3(4):664–70. 7. Jackson JP. Degenerative changes in the knee after meniscectomy. Br Med J. 1968;2(5604):525. BMJ Group. 8. Salata MJ, Gibbs AE, Sekiya JK. A systematic review of clinical outcomes in patients undergoing meniscectomy. Am J Sports Med. 2010;38(9):1907–16. 9. Petty CA, Lubowitz JH. Does arthroscopic partial meniscectomy result in knee osteoarthritis? A systematic review with a minimum of 8 years’ follow-up. Arthroscopy. 2011;27(3):419–24. 10. Goodfellow J. He who hesitates is saved. J Bone Joint Surg Br. 1980;6(1):1–2.

The Etiology of Chondromalacia Patellae

45

Nick Caplan and Deiary F. Kader

45.1

Author

Outerbridge RE.

45.2

Reference

J Bone Joint Surg Br. 1961;43:752–757.

45.3

Institution

Royal Columbian Hospital, New Westminster, British Columbia, USA.

45.4

Abstract

One hundred and ninety six patients undergoing meniscectomy at a single centre were evaluated. Chondral defects were graded from I-IV, where grade I is near normal and grade IV is a full thickness lesion. Seventy-eight patients had a bucket handle tear. Of these 196 patients that had medial meniscectomy, about 50 % had a normal patella. One hundred and one patients had chondromalacia patellae. The majority of these patients had low grade (I or II) cartilage defects.

45.5

Summary

This study discusses the prevalence of chondromalacia of the patella, as well as factors potentially leading to its progression. Data are presented from a single centre, reporting the proportion of normal and abnormal patella articular cartilage observed during medial menisectomy procedures. In 196 menisectomy patients, ranging in age from 12 to 69 years, a similar proportion of patellae were normal as abnormal. A classification system is subsequently presented to allow for grading of the severity of chondromalacia. A grade I injury is defined as the presence of softening and swelling of the cartilage. A grade II injury is reported where fracturing or fissuring is seen over a relatively small area (diameter less than half an inch). Grade III is characterised by fracturing or fissuring over an area larger than half an inch in diameter, and Grade IV is reported when a lesion extends through the depth of the cartilage to the underlying bone. Of 101 patients with chondromalacia patellae, the majority of lesions were either grade I or grade II. Of the 78 patients who had a bucket handle tear of the medial meniscus, approximately half had a normal patella.

45.6

Citation Count

1,016 N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_45, © Springer-Verlag London 2014

45.7

Related References

1. Kelly MA, Insall JN. Historical perspectives of chondromalacia patellae. Orthop Clin North Am. 1992;23(4): 517–21. 2. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. J Bone Joint Surg Am. 1976;58:1–8.

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N. Caplan and D.F. Kader

Key Message

The incidence of chondromalacia patellae is lower than previously reported. The macroscopic observation of the patella articular cartilage in 196 cases of medial meniscectomy showed healthy cartilage in nearly half of the cases. The Outerbridge grading system for cartilage injury was created for the description of cartilage lesions within the patella. It grades cartilage lesions into 4 stages describing the visual correlates of the damage.

45.9

Why It’s Important

This paper reports on a large number of cases that have had a thorough assessment of their patella during open surgery of the meniscus. The cartilage damage was graded and the affected area was described in detail. This has become the base for cartilage lesion classification. Accurate arthroscopic documentation of chondromalacia is important for multicenter studies. If there is poor agreement between surgeons, arthroscopic evaluations should not be compared or a more reliable classification system should be sought [1].

45.10 Strengths This study reported data of intraoperative clinical data on the prevalence of chondromalacia patella in patients undergoing surgery for medial menisectomy. These data were recorded in a prospective manner. The definition of a classification system for the recording of patellar cartilage injury allows for the objective assessment of the severity of lesions. Following the presentation of clinical data, a review of the literature surrounding the etiology of chondromalacia patellae is presented. Outerbridge maintains a critical approach throughout, highlighting the fact that the exact mechanisms leading to chondral damage on the patellar articular surface are likely multifaceted. The Outerbridge classification provides a distinction between a partial (Grades 1 and 2) versus nearly full or fullthickness cartilage defect (Grades 3 and 4); between a small (Grade 2) and larger (Grade 3) lesion; and describes a complete loss of cartilage (Grade 4).

45.11 Weaknesses Although the data presented were collected prospectively as part of routine clinical practice, the analysis of these data was retrospective in nature. The study lacked any specific aims or hypotheses, and the number of cases reported was

relatively low. As the data were subdivided into six age ranges, the numbers of patients within some categories were extremely low. Thus, the ability to generalise the data presented to the wider population is poor. Only clinical data recorded intra-operatively are provided. No details of levels of activity, history of injuries, or clinically reported pain are given, which prevent the reader from making a judgement about the potential cause of chondromalacia patellae in the patients included in the study. It was entirely descriptive in nature with no statistical treatment of the data. The data were from the clinical observations of a single surgeon at a single centre. Again, this limits the generalizability of the data to the wider population. There was generally a lack of detail regarding the patients included in the study. Data were only reported for patients who had undergone medial menisectomy. Data from other surgical interventions should also be used in order to obtain a more accurate picture of the number of patients with chondromalacia patellae in a typical knee arthroscopy patient population [2]. Although Outerbridge presents a grading system for the classification of chondral damage to the patellar articular surface, its validity and reliability were not investigated or reported. Spahn et al. [3] surveyed 301 surgeons that regularly performed arthroscopy of the knee. Despite the majority of surgeons using the Outerbridge grading system, most felt that its ability to differentiate between middle grades was poor. Brismar et al. [4] observed relatively good intraobserver reliability when rating chondral lesions in the knee as either normal or grade IV, but not w hen classifying middle grade lesions. Similarly, they found poor interobserver reliability, as low as 61 % which was similar to the other grading systems they investigated [4]. Using a modified Outerbridge scale, Marx et al. [1] investigated interobserver reliability between six surgeons at a range of centres. In their study, grade 2 and 3 lesions were combined into a single group. Interobserver agreement was 93 % for chondral lesions of the patellar, contrary to the low levels of agreement reported in other studies [4]. In a subsequent analysis of only grade 2 and 3 lesions, interobserver agreement was reduced to 67 [1].

45.12 Relevance Although there are a large number of arthroscopic classification systems for assessing chondral damage of the knee, grading is difficult because of a lack of objective measurements. Classification systems include the Install score [5], Casscells system [6], Noyes and Stabler score [7], Beguin [3] and Bentley and Dowd classification [8]. The Outerbridge classification system was originally designed to classify chondromalacia patellae. Over the years, it has been extrapolated for use to classify chondral lesions

45

The Etiology of Chondromalacia Patellae

throughout the body [9]. This was the first classification system used by orthopedic surgeons in describing the extent of cartilage lesion. It continues to be widely used due to its ease of use and acceptable rates of reproducibility and accuracy. This is an arthroscopic classification based on visual inspection and probing of cartilage. Therefore when discussing chondral defects at arthroscopy, it is important to realise most orthopedic surgeons refer to this grading system and therefore it should not be confused with radiologic classifications that often appear on MRI reports. It is still the most widely used grading system to describe the size of the cartilage lesion in the knee [3]. For many years considered the gold standard, most researchers have now replaced this classification system with the ICRS classification from the International Cartilage Repair Society. The advantage of the ICRS system is the use of precise descriptions of cartilage lesions, allowing cartilage evaluations to become much more comparable. The experience of the arthroscopist is possibly an important factor in the validity of any cartilage grading systems [3] However Cameron et al. [9] in a cadaveric study of videotaped arthroscopies found that the Outerbridge classification, when used to grade chondral lesions arthroscopically, was moderately accurate. It had excellent intraobserver reliability, good interobserver reproducibility, and was used accurately by orthopedic surgeons regardless of the level of their experience. One final point is the original classification referred only to radiographic changes of chondromalacia patellae. The modified classifications represent similar grading scales but rely on arthroscopic findings. They describe the spectrum of change from chondral softening on probing to grade 4 changes of bare bone (Table 45.1).

187 Table 45.1 ICRS grading score Grade 1 2 3 4

Properties Superficial lesions, fissures, cracks and indentations Fraying, lesions extending down to 50 % of cartilage depth as well as down to calcified layer Complete loss of cartilage thickness, bone only

References 1. Marx RG. Multirater agreement of arthroscopic grading of knee articular cartilage. Am J Sports Med. 2005;33(11):1654–7. 2. Elson DW, Jones S, Caplan N, Gibson ASC, Stewart S, Kader DF. Clinically insignificant association between anterior knee pain and patellofemoral lesions which are found incidentally. Knee. 2013:1–5, http://dx.doi.org/10.1016/j.knee.2013.02.002) 3. Spahn G, Klinger HM, Hofmann GO. How valid is the arthroscopic diagnosis of cartilage lesions? Results of an opinion survey among highly experienced arthroscopic surgeons. Arch Orthop Trauma Surg. 2009;129(8):1117–21. 4. Brismar BH, Wredmark T, Movin T, Leandersson J, Svensson O. Observer reliability in the arthroscopic classification of osteoarthritis of the knee. J Bone Joint Surg Br. 2002;84:42–7. 5. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the knee society clinical rating system. Clin Orthop Relat Res. 1989;248(248): 13–4. 6. Casscells SW. Gross pathological changes in the knee joint of the aged individual: a study of 300 cases. Clin Orthop Relat Res. 1978;132:225–32. 7. Noyes FR, Stabler CL. A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med. 1989;17(4):505–13. 8. Bentley G, Dowd G. Current concepts of etiology and treatment of chondromalacia patellae. Clin Orthop Relat Res. 1984;189:209–28. 9. Cameron ML, Briggs KK, Steadman JR. Reproducibility and reliability of the Outerbridge classification for grading chondral lesions of the knee arthroscopically. Am J Sports Med. 2003;31(1):83–6.

Roentgenographic Analysis of Patellofemoral Congruence

46

Nick Caplan and Deiary F. Kader

46.1

Author

Merchant AC, Mercer RL, Jacobsen RH, Cool CR.

46.2

Reference

J Bone Joint Surg Am. 1974;56:1391–1396.

46.3

Institution

Mountain View, California

46.4

Abstract

The aim of paper was to present a new method for the roentgenographic evaluation of the knee that is reproducible and accurate. Whilst the patient is supine, the knees are flexed to 45° so that the lower legs and feet extend beyond the table and the feet move below the table. The x-ray beam is angled 30° below horizontal such that it strikes the cassette film at 90°. The cassette is placed distal to the patellae. The angular relationship between the intercondylar sulcus and the patellar ridge was measured to give the congruence angle of the patellofemoral joint. In a sample of 100 healthy control participants, a congruence angle of greater than 16° was found to be abnormal.

46.5

The Merchant view protocol for axial radiographic evaluations of the patellofemoral joint is proposed. The protocol addresses issues with previous techniques, such as acutely flexed knees, practical positioning of the x-ray tube and film, as well as issues of reproducibility of patient positioning and subsequently the images obtained. The Merchant view requires the patient to lie supine on the x-ray table with their knees flexed at 45°, whilst the femur is held parallel to the x-ray table. The legs are strapped together and the feet supported. The x-ray beam is positioned so that it makes an angle of 30° with the femur. The x-ray film is positioned perpendicular to the x-ray beam, distal to the knees. Patients are instructed to keep their quadriceps relaxed to avoid patellae movement. The congruence angle is proposed as the first measure of the relationship between the patella and the intercondylar sulcus. The congruence angle is the angle between a line that bisects the sulcus and a line drawn between the apex of the sulcus and the patellar ridge. The angle is positive if the patellar ridge is lateral to the line bisecting the sulcus and negative if it is medial to this line.

46.6

D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected]; [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_46, © Springer-Verlag London 2014

Citation Count

492

46.7 N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected]

Summary

Related References

1. Vince AS, Singhania AK, Glasgow MM. What knee X-rays do we need? A survey of orthopaedic surgeons in the United Kingdom. Knee. 2000;7:101–4. 2. Davies AP, Bayer J, Owen-Johnson S, Shepstone L, Darrah C, Glasgow MM, Donell ST. The optimum knee flexion angle for skyline radiography is thirty degrees. Clin Orthop Rel Res. 2004;423:166–71. 189

N. Caplan and D.F. Kader

190

Prior to this paper there was no standardised way of radiographing the patellofemoral joint. This publication described previous different roentgenographic techniques for the axial view of the patellofemoral joint and suggested a new way of viewing the patellofemoral joint. This has since been adopted by many imaging departments around the world. It also described how to measure the congruence angle, which was the first measurement that addressed the relationship of the patella and the intercondylar sulcus.

Haim et al. [4] found the congruence angle to be similar in infantry soldiers with and without PF pain syndrome, suggesting it is not sensitive to between-group differences. The congruence angle has been shown to have low inter- and intra-observer reproducibility in comparison with other typical measurements of the patellofemoral joint in total knee replacement patients [5]. In diagnosing patellofemoral osteoarthritis through the assessment of the joint space, Bhattacharya et al. [6] found that the Merchant view provided joint space measurements that were less sensitive than lateral view x-rays, although more specific. As with most radiographic evaluations, only 2D representations of the patellofemoral joint can be obtained. Dupont et al. [7] suggested that 3D imaging techniques need to be developed to address this issue. Images alone cannot provide adequate diagnosis of pathology. Images must be considered in parallel with patient history and clinical examination (Merchant [8]). A congruence angle of +16° was initially proposed as abnormal, based solely on the 95th percentile within their data and not linked directly to symptoms. Later, in their own paper, a group of 25 abnormal knees with recurrent patellar dislocation had a congruence angle of +23°, well above the earlier suggested angle of +16° for abnormality. It is still unclear exactly how the congruence angle relates to patellofemoral symptoms, and more specifically whether +16° is an appropriate threshold to use for the determination of a symptomatic knee.

46.10 Strengths

46.12 Relevance

The Merchant view has been widely accepted as a standardised view for axial x-rays. Vince et al. [1] reported that 75 % of orthopedic surgeons in the United Kingdom obtain Merchant view x-rays, suggesting that it could provide standard images for cross centre comparisons of the patellofemoral joint. The Merchant view was originally proposed using an x-ray beam angle, with respect to the femur, of 30°. This angle has been since shown to be the most appropriate angle to use [2].

Merchant views are still used all around the world to assess the patellofemoral joint. The congruence angle was initially used by clinicians and although it is highly specific it is not sensitive to detect minor degrees of mal-alignment [9]. Inoue et al. [10] found that only 30 % of patients with clinical patellar subluxation had an abnormal congruence angle. Merchant defined the borderline value between a normal and an abnormal congruence angle as 16° on the basis of a group of patients who had a proved recurrent dislocation and a group of normal control subjects. Inoue found that the congruence angle using the criterion of Merchant was much less sensitive than using computer tomography with the knees in full extension.

3. Beaconsfield T, Pintore E, Maffulli N, Petri GJ. Radiological measurements in patellofemoral disorders. A review. Clin Orthop Relat Res. 1994;(308):18–28.

46.8

Key Message

The Merchant view for axial radiographs is a widely used technique for imaging of the patellofemoral joint. The technique is well accepted, reproducible and provides an excellent overview of patellofemoral joint. However, the proposed congruence angle has been questioned as a reliable, valid and reproducible measure of the congruence between the patella and the intercondylar sulcus. Reports of the congruence angle should thus be viewed with caution.

46.9

Why It’s Important

46.11 Weaknesses In their original paper, Merchant et al. [3] claimed that the Merchant view is “reproducible, reliable and quite accurate in clinical practice and has not led to false negative or false positive interpretations”. Unfortunately, no data are provided to support these claims. Although the technique has become well accepted in the orthopedic fraternity for the evaluation of the patellofemoral joint, the validity and reliability of the congruence angle has been the subject of much debate.

References 1. Vince AS, Singhania AK, Glasgow MM. What knee x-rays do we need? A survey of orthopaedic surgeons in the United Kingdom. Knee. 2000;7(2):101–4. 2. Davies AP, et al. The optimum knee flexion angle for skyline radiography is thirty degrees. Clin Orthop Relat Res. 2004;423:166–71.

46

Roentgenographic Analysis of Patellofemoral Congruence

3. Merchant AC, et al. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg. 1974;56(7):1391–6. American volume. 4. Haim A, et al. Patellofemoral pain syndrome: validity of clinical and radiological features. Clin Orthop Relat Res. 2006;451:223–8. 5. Heesterbeek PJ, et al. A comparison of reproducibility of measurement techniques for patella position on axial radiographs after total knee arthroplasty. Knee. 2007;14(5):411–6. 6. Bhattacharya R, et al. The knee skyline radiograph: its usefulness in the diagnosis of patello-femoral osteoarthritis. Int Orthop. 2007; 31(2):247–52.

191 7. Dupont JY, Guier CA. Comparison of three standard radiologic techniques for screening of patellar subluxations. Clin Sports Med. 2002;21(3):389–401. 8. Merchant AC. Patellofemoral imaging. Clin Orthop Relat Res. 2001;389: 15–21. 9. Smith TO, et al. The intra- and inter-rater reliability of x-ray radiological measurements for patellar instability. Knee. 2013;20(2): 133–8. 10. Inoue M, et al. Subluxation of the patella. Computed tomography analysis of patellofemoral congruence. J Bone Joint Surg. 1988; 70(9):1331. American volume.

The Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System

47

Nick Caplan and Deiary F. Kader

47.1

Author

Ewald FC.

47.2

Reference

Clin Orthop. 1989;248:9–12.

47.3

Institution

Knee Society, Brigham and Women’s Hospital, Boston, MA 02115

47.4

Abstract

In an attempt to improve the uniformity of reporting total knee arthroplasty results, The Knee Society endorsed roentgenographic knee evaluation system is presented. The use of a standardized knee evaluation system will improve the ability to directly compare results between centres and surgeons. It is acknowledged that the use of this new system will require the sacrifice of data collected using old rating systems.

47.5

Summary

A relatively simple one page evaluation form for recording the success of total knee replacement surgery is presented. The scoring system, endorsed by the Knee Society, was proposed as a uniform system for the reporting of roentgenographic findings. X-ray films obtained in the anteroposterior, lateral and Merchant views are used to assess the three components of the knee implant. Representations of the tibial, femoral and patellar components are included graphically in the form, each being subdivided into zones. The lengths of radiolucent lines within each zone are measured on the relevant x-ray film to give a score in millimetres. The widths of all zones on each component, respectively, are added together to give a total score for each component. A greater score, achieved through an increase in radiolucent lines, indicates poorer implant alignment. Guidelines are provided to allow surgeons to identify those patients more at risk of future implant failure.

47.6

Citation Count

688

47.7

Related Reference

1. Allen AM, Ward WG, Pope Jr TL. Imaging of the total knee arthroplasty. Radiol Clin North Am. 1995;33(2): 289–303. N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_47, © Springer-Verlag London 2014

47.8

Key Message

The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system provides an objective measure of component alignment and loosening in total knee replacement. Whilst, in principle, such an objective measure 193

N. Caplan and D.F. Kader

194

would be useful to allow better comparison both within and between patients and centres, its reliability and reproducibility has been questioned. Issues with imaging techniques can easily result in radiolucencies becoming obscured, giving incorrect results.

47.9

Why It’s Important

The new system was described to standardize the radiographic rating of total knee arthroplasty. The system encouraged a uniform outcome reporting of changes that can occur after knee implantation in order to help in comparing different implants and their outcome at different institutions.

47.10 Strengths The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system uses x-ray films to measure the lengths of radiolucent lines that appear in a range of zones in either the femoral, tibial or patellar component. This provides a direct, objective, measure of the success of a total joint replacement, as opposed to many physician- or patientcompleted outcome measures that indirectly evaluate the success of surgery, such as knee function, physical activity or quality of life scores. Bach et al. [1] correlated the Knee Society total knee arthroplasty roentgenographic evaluation and scoring system with a range of clinical outcome measures, including the Hungerford Score, Hospital for Special Surgery Score, Knee Society Clinical Rating System (both knee score and function score), the Bristol Score, and the Nottingham Health Profile. Significant correlations, in terms of the extent of radiolucent lines, were found with all clinical outcome scores for the tibial component. For the femoral component, significant correlations were observed in all but the Knee Society Clinical Rating System scores. In both components, the highest correlation was seen with the Nottingham Health Profile. The scoring system has been shown to be sufficiently sensitive to show changes between different patient populations. Sadoghi et al. [2] found that the appearance of radiolucent lines was significantly correlated with reports of knee pain. With more moderate level of pain, radiolucent lines became more apparent in the most medial and lateral zones of the tibial component (zones 1 and 4). Zone 4 radiolucent lines have also been reported to be more apparent in cementless femoral fixation compared to cemented [3], although Rand et al. [4] found similar extents of radiolucent lines in the tibial component for cemented and cementless techniques.

47.11 Weaknesses The use of radiolucent lines in the determination of component loosening and alignment is controversial. Despite some studies showing correlation with clinical outcome measures, others have questioned its value. Ahlberg and Linden [5] observed more radiolucent lines around the plastic tibial component than in the metal femoral component, suggesting this was due to increased heat in this component. They also failed to report a correlation between radiolucent lines and clinical symptoms. The sensitivity of radiolucent lines to angular offsets of the x-ray tube have been reported as a significant issue in the measurement of radiolucent lines on standard x-ray films. Lundberg-Jensen et al. [6] tilted the x-ray tube in 1° increments. They found that up to 4 mm of radiolucencies can be obscured on standard films, bringing into question the validity of the 2 mm threshold often used to indicate component loosening. Similarly, Ecker et al. [7] highlighted the importance of positioning when obtaining radiographs for the measurement of radiolucent lines, with only small x-ray beam offsets being needed to obscure radiolucencies. The reliability and reproducibility of the Knee Society score has been questioned due to its complexity [8]. However, Bach et al. [9] showed an increased inter- and intra-observer reliability and reproducibility of a simplified version of the score, where each component’s total radiolucent line length was categorised as being either 0 mm (none), 4 mm (wide). The use of radiolucencies in the determination of component alignment has been shown to correlate poorly with navigation measurements [10]. A range of issues were highlighted as potentially leading to the poor ability of radiolucencies in determining component alignment, including patient position, limb alignment, and identification of landmarks.

47.12 Relevance The radiographic rating system of total knee arthroplasty was endorsed by The Knee Society and has been a standard way of reporting since this publication. It has made it possible to compare the outcome of different surgeons, implants and centres.

References 1. Bach CM, et al. Correlation between radiographic assessment and quality of life after total knee arthroplasty. Knee. 2009;16(3): 207–10. 2. Sadoghi P, et al. Radiolucent lines in low-contact-stress mobilebearing total knee arthroplasty: a blinded and matched case control study. BMC Musculoskelet Disord. 2011;12:142.

47

The Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System

3. Huddleston JI, Wiley JW, Scott RD. Zone 4 femoral radiolucent lines in hybrid versus cemented total knee arthroplasties: are they clinically significant? Clin Orthop Relat Res. 2005;441:334–9. 4. Rand JA. Cement or cementless fixation in total knee arthroplasty? Clin Orthop Relat Res. 1991;273:52–62. 5. Ahlberg A, Linden B. The radiolucent zone in arthroplasty of the knee. Acta Orthop Scand. 1977;48(6):687–90. 6. Lundberg-Jensen A, et al. Radiolucency adjacent to the tibial component in total knee arthroplasty. Orthopedics. 2002;25(1): 49–51.

195

7. Ecker ML, et al. Long-term results after total condylar knee arthroplasty. Significance of radiolucent lines. Clin Orthop Relat Res. 1987;216:151–8. 8. Al-Hadithy N, et al. How to read a postoperative knee replacement radiograph. Skeletal Radiol. 2012;41(5):493–501. 9. Bach CM, et al. Reproducible assessment of radiolucent lines in total knee arthroplasty. Clin Orthop Relat Res. 2005;434:183–8. 10. Yaffe MA, Koo SS, Stulberg SD. Radiographic and navigation measurements of TKA limb alignment do not correlate. Clin Orthop Relat Res. 2008;466(11):2736–44.

Rationale of the Knee Society Clinical Rating System

48

Nick Caplan and Deiary F. Kader

48.1

Author

Hospital for Special Surgery, New York, NY 10021.

evaluation of the knee (pain, stability, range of motion), and patient function whilst removing the confounder of age related degenerative changes. Pain, stability and range of motion are assessed separately to function. A pain free knee receives 50 points. Pain is assessed according to both severity and frequency, as well as whether pain is present in walking or stair negotiation. A stable knee receives 25 points and is evaluated in terms of anteroposterior and mediolateral stability, with deductions for flexion contracture and extension lag. A range of motion of 125° receives 25 points. Patients that are able to walk for an unlimited distance and negotiate stairs without using the handrails are awarded 100 points, with deductions for use of walking aids.

48.4

48.6

Insall JN, Dorr LD, Scott RD, Scott WN.

48.2

Reference

Clin Orthop. 1989;248:13–14.

48.3

Institution

Abstract

This paper presents a newly proposed rating system for the knee, developed by The Knee Society. The rating system allows for the documentation of the knee in isolation (including pain, stability and range of motion) as well as patient functioning (including walking and stair climbing).

48.5

Summary

The Knee Society Clinical Rating System was proposed as a disease specific assessment tool for use in total knee replacement patients. Its aim was to allow for a comprehensive

N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_48, © Springer-Verlag London 2014

Citation Count

1,600

48.7

Related References

1. Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB, The Kinemax Outcomes Group. Validity and responsiveness of the Knee Society Clinical Ratings System in comparison with the SF-36 and WOMAC. J Bone Joint Surg Am. 2001;83:1856–64. 2. König A, Scheidler M, Rader C, Eulert J. The need for a dual rating system in total knee arthroplasty. Clin Orthop Relat Res. 1997;(345):161–7.

48.8

Key Message

The Knee Society Clinical Rating System has become a simple, widely used and accepted tool for objectively evaluating patients undergoing total knee arthroplasty (TKA) surgery. It contains both a knee score and a patient’s function score for activities such as walking and stair climbing before and after TKA. 197

198

48.9

N. Caplan and D.F. Kader

Why It’s Important

The rating system assesses three parameters, including pain, stability and range of motion. This eliminates the problem of declining knee scores associated with patient infirmity. The Hospital for Special Surgery Rating System is perhaps the most widely used, but was compiled many years ago at a time when knee arthroplasty was in its infancy and expectations of the result were lower. In the past many scoring systems had been used to assess the outcomes of TKA. The Knee Society attempted to standardize outcome measures to allow for valid comparison of patient and prostheses outcome from across different centres. It has become the most popular method of tracking and reporting outcomes after total and partial knee arthroplasty worldwide. In these times of re-validation and audit there is a clear need for orthopedic surgeons to be familiar with the available scoring systems and their relative strength and weaknesses.

48.10 Strengths The Knee Society Clinical Rating System is a relatively simple tool to allow the objective assessment of knee pain, knee joint stability and range of motion. It also assesses walking and stair negotiation ability. Unlike many patient selfreported outcome measures (e.g. WOMAC, SF-36), the Knee Society Clinical Rating System is physician administered. The rating system has been shown to have good responsiveness to changes after total knee replacement surgery [1]. Lingard et al. [2] used a large prospective sample of patients from the United Kingdom, United States of America and Australia to compare the validity and responsiveness of the physician administered Knee Society Clinical Rating System with two patient self-administered questionnaires: WOMAC and SF-36. In order to make valid comparisons, relevant elements of the Knee Society score were compared to the corresponding elements of either the WOMAC or SF-36 (e.g. pain). The Knee Society Rating System pain score was found to show good agreement with both the WOMAC pain score and the SF-36 bodily pain score, both pre- and post-total knee replacement surgery. For physical function, the Knee Society score showed good agreement with SF-36 physical function score and WOMAC function score, both pre- and post-surgery. These findings suggested that the Knee Society Clinical Rating System had adequate construct validity for use as an objective outcome measure for total knee replacement patient populations. The Knee Society Clinical Rating System had separate scales for knee rating and functional assessment in order to

remove the declining scores associated with patient infirmity associated with combined functional and joint related parameters. Konig et al. [3] observed that the knee score element of the Knee Society system was not affected by confounds including walking distance, age, body mass index and patient category.

48.11 Weaknesses The Knee Society Clinical Rating System was originally proposed in 1989 and subsequently became widely used in TKA patients to provide an objective measure of knee pain, stability, range of motion and function. However, the validity of the rating system was not determined until 2001. Lingard et al. [2], despite demonstrating the construct validity of the Knee Society score, suggested that it is not as useful as questionnaires, such as WOMAC and SF-36, due to the additional time taken to complete and required clinical staff to administer. Liow et al. [4] determined the inter- and intra-rater reliability of the Knee Society Clinical Rating System using a group of raters including two arthroplasty nurse practitioners, one junior doctor, two registrars and one consultant. Relatively large inter-rater variability was found for both the knee and function scores, which was influenced by the experience of the rater. Variability in measurements such as mediolateral stability were notably different for the nurse practitioners compared to the consultant. However, due to the small number of raters, any inter-rater variability as a function of clinical post/experience should be viewed with caution. Intra-rater reliability was also relatively poor, suggesting the need to take multiple repeat measurements to improve data reliability. Due to the design of the physician-administered Knee Society Rating System, data are open to researcher bias. Typically the form would be completed by a member of the surgical team, potentially leading to bias in that they will want to demonstrate the success of their surgical intervention. There are also known differences in how patients and physicians rate pain making it difficult to directly compare findings from the Knee Society Clinical Rating System with patient self-administered questionnaires such as WOMAC and SF-36. Guidelines are not provided in the original text to indicate what a good or poor score would be using the Knee Society Clinical Rating System. Other systems provide such information to allow physicians to identify potentially problematic knees. Without such information, the Knee Society system can be used for comparing pre- and post-surgery, but cannot be used to easily identify potential osteoarthritic knees. Despite the knee score element of the Knee Society system not being influenced by confounders such as walking distance, age, body mass index and patient category, Konig

48 Rationale of the Knee Society Clinical Rating System

et al. [3] found that the function score was influenced, suggesting the importance of keeping the knee and function scores separate in any analysis. No explanation is given for the weightings between each section of the Knee Society Clinical Ratings System. Although it provides a score up to 100 each for the knee and function elements, this scale should not be considered continuous. The data are ordinal and any statistical analysis should appropriately reflect this. In the original version of the Knee Society Clinical Rating System, pain was assessed using categories that left the data open to bias and confusion. For example, pain could be reported that was during “stairs only” or during “walking and stairs”. These categories were found under the “mild or occasional” level of pain, and patients experiencing pain that was moderate or severe during stair negotiation alone, for example, would not be able to have this adequately reflected in their score. A subsequent amendment to the form in 1993 split the pain score into two sections, walking and stairs, each giving scores for mild, moderate or severe pain, or no pain. The walking element of the function score is scored out of 50 points, yet unlimited walking only receives a maximum of 40 points. In the original system for range of motion, one point is given for every 5° of knee flexion (maximum 125° and 25 points). In the amended form of 1993, one point is given for 8°. Thus, for the maximum score of 25 points to be achieved a patient would need to demonstrate an unachievable knee flexion range of motion of 200°. Despite providing valid knee and functional measures, the Knee Society Clinical Rating System does not give any indication of patient quality of life or satisfaction with the surgical intervention. It is important that these measures be obtained in many circumstances. This would necessitate the use of additional patient-reported questionnaires.

199

48.12 Relevance Scuderi et al. [5] recently expressed concerns that ambiguities and deficiencies with the original Knee Society Clinical Rating System challenged its utility and validity in contemporary patients, who often have expectations, demands, and functional requirements that were different from those of prior generations of patients who underwent TKA. As such a new Knee Society Knee Scoring System was developed and validated in 2012, in part, to better characterize the expectations, satisfaction, and physical activities of the younger and more diverse population of current patients undergoing TKA. It is both physician and patient derived. The objective knee score, completed by the surgeon, includes a VAS score of pain when walking on level ground and on stairs or inclines, as well as an assessment of alignment, ligament stability, and ROM, along with deductions for flexion contracture or extensor lag. Patients then record their satisfaction, functional activities, and expectations.

References 1. Kreibich DN, Vaz M, Bourne RB, Rorabeck CH, Kim P, Hardie R, et al. What is the best way of assessing outcome after total knee replacement? Clin Orthop Relat Res. 1996;331:221–5. 2. Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB. Validity and responsiveness of the Knee Society Clinical Rating System in comparison with the SF-36 and WOMAC. J Bone Joint Surg Am. 2001;83(12):1856–64. 3. König A, Scheidler M, Rader C, Eulert J. The need for a dual rating system in total knee arthroplasty. Clin Orthop Relat Res. 1997;345: 161–7. 4. Liow RY, Walker K, Wajid MA, Bedi G, Lennox CM. The reliability of the American Knee Society Score. Acta Orthop Scand. 2000;71(6):603–8. 5. Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society Knee Scoring System. Clin Orthop Relat Res. 2012;470(1):3–19.

Rating Systems in the Evaluation of Knee Ligament Injuries

49

Nick Caplan and Deiary F. Kader

49.1

Author

Tegner Y, Lysholm J.

49.2

Reference

nature were variable, and were influenced by what threshold is used for a clinically meaningful difference. The proposed activity rating scale allowed patient activity to be documented based on the type of sport or work activity undertaken. This provided a numerical score between 0 and 10. This activity rating scale was found to be a valuable complimentary rating for use with a separate functional rating scale.

Clin Orthop. 1985;198:43–9.

49.5 49.3

University Hospital, Linköping, Sweden.

49.4

Summary

Institution

Abstract

There are a range of outcome measures available for the assessment of disability following ligament injury in the knee. They differ in what specific aspects of disability are assessed, such as symptoms, function scores during activities such as walking and stair climbing, clinical observations, isolated knee function, or a combination of these. They are typically scored with either yes/no answers or a numerical score based on the level of disability for each assessed element. The aim of this study was to compare a symptom only based score to that using a range of factors. A new patient activity rating scale was also presented. It was found that ratings of a binary

N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_49, © Springer-Verlag London 2014

The Tegner activity scale provides a grading system for the evaluation of work and sporting activities routinely undertaken by patients. It was originally proposed for use in patients with knee ligament injuries, and to be used as a physician-administered tool. It was developed to support the Lysholm Knee Scoring Scale, which provides an evaluation of knee pain and function, specifically in terms of instability and post-operative outcomes. Patients are rated between 0 and 10. A score of zero is given to those who are unable to work due to injury or disability related to the knee joint. Scores of between 1 and 3 are given to those who undertake light work or activities including walking. Scores of between 4 and 5 are given to patients involved in moderately heavy or heavy labour, some recreational and competitive sports including cycling, cross-country skiing and jogging at least twice a week. Scores of between 6 and 7 are given to patients taking part recreationally or competitively in sports such as basketball, tennis, athletics, soccer and jogging at least five times a week. Scores of between 8 and 9 are given for participation in competitive sports such as squash, downhill skiing, wrestling, gymnastics and soccer at lower levels. Finally, a score of 10 is given to those taking part in sport, such as soccer, at a national/international or elite level.

49.6

Citation Count

1,934 201

202

49.7

N. Caplan and D.F. Kader

Related References

1. Lysholm J, Tegner Y. Knee injury rating scales. Acta Orthop. 2007;78:445–53. 2. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function. Arthritis Care Res. 2011;63:S208–28.

either not active or highly active. They also demonstrated both criterion and construct validity and found that the scale was sensitive enough to change in patients receiving surgical intervention for meniscal lesions. Similar observations were made in anterior cruciate ligament reconstruction patients [5].

49.11 Weaknesses 49.8

Key Message

The Tegner Activity Scale has become widely used as a measure of activity levels in support of the Lysholm Knee Scoring System, being most useful for evaluating withinpatient changes following surgical intervention for knee injury.

49.9

Why It’s Important

The Tegner activity scale differentiates between a functional rating that is based on patients’ symptoms during different activities and a rating that includes clinical findings. It is believed that a clinical examination cannot accurately quantify the effect of each test on patient outcome scales. Each ligament injury would have a different degree of effect on the patients’ functional level. Hence, it would be inappropriate to score them in similar manner.

49.10 Strengths The Tegner Activity Scale has been widely used in both clinical and research fields, resulting in it being suggested as being a gold standard to which other scales should be compared [1]. It is a simple scale to use and despite its initial purpose for use in knee ligament injured populations, has been successfully used in other groups, such as articular cartilage repair patients [2]. Many activity rating scales, such as the function element of the Knee Society Clinical Rating Scale, evaluate a patient’s ability to perform typical activities of daily living (e.g. walking or stair negotiation), without any indication of a patient’s prior involvement in more demanding recreational and competitive sports [3]. As such, the Tegner Activity Scale allows clinicians to evaluate the success of clinical interventions in terms of whether a patient is able to return to their pre-injury activity levels. The Tegner Activity Scale has been shown to be a valid and reliable measure of patient activity levels in a number of patient populations. Briggs et al. [4] found the scale to have acceptable test-retest reliability, and did not show floor or ceiling effects due to large proportions of patients being

The Tegner Activity Scale was originally designed as a physician-administered tool, so is open to rater bias. Despite its original intentions, many investigations have used the scale as a patient-completed questionnaire. Due to the subjective nature of the ratings of activity level, results between participants should be treated with caution. The scale is appropriate for identifying within-patient differences in groups, but it has been suggested that it might not be appropriate for use with individual patients [2]. For each grading on the scale, only a small number of activities are provided. Although these are provided as a guide to selecting the appropriate level, many patients could incorrectly categorise themselves due to a potentially poor understanding of how sports compare in terms of loading and stress placed on the knee joint. The activities and sports included under each grading on the scale were initially included following a survey of orthopedic surgeons. Thus the content validity could be questioned. In their original study, Tegner and Lysholm compared Tegner scores with Lysholm scores for a relatively small number of patients. Tegner scores were grouped into four categories: 0, 1–2, 3–4 and 5–10. Differences in Lysholm scores between patients in each of these categories were evaluated. Lysholm scores were significantly increased between Tegner scores of 0 and 1–2, and between 3–4 and 5–10. For patients with scores between 1 and 4, no significant differences in Lysholm scores were observed, suggesting the Tegner Activity Scale might not be sensitive enough to changes in knee function at lower levels of activity. The relatively large range of grades grouped for higher levels of activity (5–10) resulted in the sensitivity of the Tegner score to changes in knee function being not adequately assessed for those involved in more stressful activities. This should be the subject of future research. The Tegner Activity Scale provides a score of 0–10. Data obtained from this scale should therefore be treated as ordinal, with appropriate statistical analysis used and median values calculated rather than means. The value assigned to each activity makes no attempt to be related to the magnitudes of forces generated within the knee, which ultimately will contribute to injury. an activity rating of 2 will not necessarily result in half the knee loading as an activity given a score of 4. Tegner originally stated that non-parametric statistics

49

Rating Systems in the Evaluation of Knee Ligament Injuries

should be used, but many reported studies have not done this [2]. In a systematic review of studies using the activity scale in articular cartilage repair patients, reporting of the Tegner activity score was found to be inconsistent, with the majority of studies reporting means rather than median values [2]. Despite being shown to be valid and reliable, Naal et al. [6] observed reduced correlation with the International Physical Activity Questionnaire (IPAQ), reduced reliability and lower completion rates than the University of California, Los Angeles Activity Scale (UCLA), in total joint replacement patients. This was attributed to the typically lower activity levels of total joint replacement patients than those for which the more sport oriented Tegner Activity Scale was originally intended. The Tegner Activity Scale has been shown to be sensitive to factors such as age and gender. Frobell et al. [7] reported reduced Tegner scores as a function of increasing age, as well as in female participants.

49.12 Relevance The Tegner activity rating scale was designed to complement other functional scores (e.g. the Lysholm knee score) for patients with ligamentous injuries. The Tegner activity rating scale is able to prognosticate to what physical level an individual may return, with and without reconstructive surgery.

203

After 25 years of changes in treatment of anterior cruciate ligament injuries the combination of the Lysholm score and Tegner scale continues to show acceptable temporal responsiveness in the evaluation of early return to function after ACL reconstruction [5].

References 1. Johnson DS, Smith RB. Outcome measurement in the ACL deficient knee – what’s the score? Knee. 2001;8(1):51–7. 2. Hambly K. The use of the Tegner activity scale for articular cartilage repair of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2011;19(4):604–14. 3. Insall JN, et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–4. 4. Briggs KK, et al. Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the knee. J Bone Joint Surg Am. 2006;88(4): 698–705. 5. Briggs KK, et al. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37(5):890–7. 6. Naal FD, Impellizzeri FM, Leunig M. Which is the best activity rating scale for patients undergoing total joint arthroplasty? Clin Orthop Relat Res. 2009;467(4):958–65. 7. Frobell RB, et al. Self-reported activity level and knee function in amateur football players: the influence of age, gender, history of knee injury and level of competition. Knee Surg Sports Traumatol Arthrosc. 2008;16(7):713–9.

50

Injuries to Runners Nick Caplan and Deiary F. Kader

50.1

Authors

James SL, Bates BT, Osternig LR.

the lower limb joints seen during running. This paper presents an approach for the treatment of these issues seen in runners.

50.2

50.5

Reference

Am J Sports Med. 1978;6:40–50.

50.3

Institution

Orthopaedic and Trauma Clinic of Eugene, P.C. Eugene, Oregon and Sports Medicine and Biomechanics Laboratory, Department of Physical Education, University of Oregon, Eugene, Oregon.

50.4

Abstract

Runners are a very unique population to investigate. They are typically fit and healthy and due to the nature of running could perform well in a wide range of other sporting activities. Due to high training volumes, however, runners are more predisposed to injury due to anatomic adaptations that occur. Many runners carry injuries which appear to be better tolerated by the same person taking part in other sports. These injuries are potentially caused by repeated loading of

N. Caplan, PhD (*) Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK e-mail: [email protected] D.F. Kader, FRCS (Tr & Orth), MFSEM (UK) Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, Northumbria University, Newcastle Upon Tyne, UK e-mail: [email protected], [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_50, © Springer-Verlag London 2014

Summary

This paper starts by describing an approach to the assessment of anatomical alignments of the legs. It proposes that the assessment should consider the entire leg, from the hip to the foot. The authors suggest that many physicians will not be familiar with all the proposed assessments, specifically the alignment between the tibia and rear foot, and the rear foot and fore foot, and a protocol is described to allow these measurements to be taken. The biomechanics is also briefly described. One hundred and eighty patients were subsequently reviewed who presented with 232 injuries. The majority (65 %) of these patients were distance runners. The injuries were the result of either training issues, anatomic issues or issues related to the running surface or footwear. Injuries caused by training were typically due to overuse, as a result of high mileage. Those that were of an anatomic nature were found to be largely caused due to the foot being pronated, which was suggested to be a compensatory mechanism to anatomical malalignments elsewhere in the leg or foot. The most common injury location was to the knee (29 %). Less commonly seen injuries included posterior tibial syndrome (13 %), Achilles tendinitis (11 %), plantar fasciitis (7 %), stress fractures (6 %), and iliotibial tract tendinitis (5 %). The three most common knee problems included chondromalacia (25 %), iliotibial tract tendinitis (20 %), and peripatellar pain (15 %). Initial steps in the treatment of running injuries is proposed as a reduction in training load, stretching and modification to running shoes or the use of orthoses. The use of steroid injections or surgery are less often required. In the sample of patients presented in this paper, 47 % underwent a 205

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period of rest, 46 % were prescribed orthoses, running mileage was reduced in 26 %, the running shoe was changed or modified in 19, 17 % received a steroid injection, 14 % were prescribed anti-inflammatory medication and 5 % underwent surgery.

50.6

Citations

455

50.7

Related References

1. Bates BT, Osternig LR, Mason B, James LS. Foot orthotic devices to modify selected aspects of lower extremity mechanics. Am J Sports Med. 1979;7(6): 338–42. 2. Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med. 1986;14(2): 151–5. 3. Van Mechelen W. Running injuries: a review of the epidemiological literature. Sports Med. 1992;14(5): 320–35.

assessment of rearfoot motion (or motion about the subtalar joint), a line is drawn along the vertical axis of the calcaneus and a second line along the long axis of the tibia. Whilst the angle between these lines was described by James et al. for assessing subtalar orientation during clinical evaluation, the method has become widely used for the assessment of subtalar alignment during walking and running gait. It has been shown to be a reliable measure of rear-foot motion during walking gait [1]. The paper includes a number of images and photographs that are useful in understanding the measurements being described. James et al. provide detailed descriptions of factors relating to injuries. In their description of knee problems related to running, the authors comment on the frequent incorrect diagnosis, based on a symptom of anterior knee pain, of chondromalacia, without sufficient evidence. Indeed recently, Elson et al. [2, 3] proposed a new photographic knee pain map to characterise anterior knee pain and found that pain location does not always correlate with the area of pathology seen during arthroscopy.

50.11 Weaknesses 50.8

Key Message

James et al. identified some common problems experienced by a series of 180 runners. They found 164 (71 %) had lower extremity injuries, the largest proportion of which were to the knee. The vast majority of individuals were treated non-operatively. A method for quantifying subtalar motion was proposed which is now a commonly used method in biomechanical laboratories and podiatric clinics.

50.9

Why Is It Important

In the mid 1970’s the authors began gathering data on injuries to runners. This ground breaking article was one of the first to document the biomechanics of running and running injury patterns. It is perhaps even more relevant due to the dramatic increase in the number of runners in the last 30 years and running related injuries. The article serves as a timely reminder of the principles of assessment and treatment.

50.10 Strengths A strength of this paper is its description of the measurement of rear-foot and fore-foot motion. It presents a method for the objective assessment of these alignments. For the

The study is retrospective in nature, evaluating a relatively small sample considering how many runners are injured each year. It is mostly descriptive and speculative – very little reference to appropriate literature is provided. In fact, the paper attempts to give some coaching points which are entirely unsupported. Despite obtaining a wealth of quantitative data from each patient, no attempt is made to use inferential statistics to evaluate trends in the data in sufficient detail. Although there is a lack of statistical treatment of the data, reference is made to terms such as “correlated”. The running shoe and surface were stated as important factors leading to injury, however, no discussion is presented on the types of injuries caused or precisely how these factors could lead to injury. The authors suggest that many of the presented injuries can be treated by reducing mileage or stretching. The authors provide no support for these suggestions based on appropriate literature, and the suggestions are, thus, entirely speculative. In recent years, research has demonstrated that stretching as part of a warm up before exercise does not reduce injury risk [4] and can, in fact inhibit muscular performance [5]. It is more widely accepted that stretching regularly outside of normal training can have a long term benefit on injury [6] and performance [7] due to increasing range of motion about the lower limb joints. The authors warn against ballistic training, however, it is currently more in favour and has been shown to facilitate performance [8, 9].

50

Injuries to Runners

50.12 Relevance About a third of recreational and competitive runners sustain injury [10, 11]. The commonest site of injury is the knee, accounting for almost 50 % [10, 12] in the form of “patellofemoral syndrome” [13]. The shin, foot and ankle are the next commonest sites to be involved. Most injuries sustained by runners are chronic overuse injuries rather than acute traumatic injuries. Repeated stresses within the tensile limit leads to a positive effect on remodelling, as long as there is time for tissues to recover between periods of stress. If there is not enough time for tissues to recover, injury can occur [14]. The exact etiology for any injury is difficult to pinpoint and varies from athlete to athlete. Often there is more than one factor involved. Several studies have been unsuccessful in correlating anatomic or biomechanical factors with a particular injury [15]. Technical issues, such as too high a running distance, excessive intensity or too steep an increase in intensity, can all lead to overuse injuries [16]. Even though biomechanical assessments can quantify the forces, it is not possible to detect the exact forces going through a musculoskeletal structure due to the complexity of the musculotendinous complex and the number of structures that go across a joint. However, in general, athletes who were prone to injury had greater impact forces and loading rates. Other training issues that were suggested could lead to injuries included training surface, footwear, inappropriate or no stretching, landing techniques and overpronation. Although our understanding of some of these factors has improved since the publication of this paper, many of the factors are still believed to be relevant. Anatomic variations like pes cavus, ankle flexibility, excessive Q angle, and femoral anteversion have also been implicated as being associated with these injuries. There is no easy or simple screening process to identify which runners would be prone to injuries. Early intervention obviously helps but a proactive approach of educating the runners and coaches with regards to training techniques, footwear and understanding the individual limits would be even more effective. As described in this article footwear design is one of the most effective prophylaxes against these injuries. There are several papers now that document assessment and management of these highly motivated runners [17–20]. The data indicated that 72 (58 %) of the subjects exhibited pronated feet in the static weightbearing position. The types of injuries associated with pronated feet were similar to those found in the overall injury analysis. This is in keeping

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with a complex interaction between running injuries and anatomical factors and that excessive pronation is one major cause of foot and leg problems in runners.

References 1. Mueller MJ, Norton BJ. Reliability of kinematic measurements of rear-foot motion. Phys Ther. 1992;72(10):731–7. 2. Elson DW, et al. Clinically insignificant association between anterior knee pain and patellofemoral lesions which are found incidentally. Knee. 2013;20(6):471–5. 3. Elson DW, et al. The photographic knee pain map: locating knee pain with an instrument developed for diagnostic, communication and research purposes. Knee. 2011;18(6):417–23. 4. Small K, Mc Naughton L, Matthews M. A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury. Res Sports Med. 2008;16(3): 213–31. 5. Simic L, Sarabon N, Markovic G. Does pre-exercise static stretching inhibit maximal muscular performance? a meta-analytical review. Scand J Med Sci Sports. 2013;23(2):131–48. 6. Behm DG, Chaouachi A. A review of the acute effects of static and dynamic stretching on performance. Eur J Appl Physiol. 2011;111(11):2633–51. 7. Caplan N, et al. The effect of proprioceptive neuromuscular facilitation and static stretch training on running mechanics. J Strength Cond Res. 2009;23(4):1175–80. 8. Sekir U, et al. Acute effects of static and dynamic stretching on leg flexor and extensor isokinetic strength in elite women athletes. Scand J Med Sci Sports. 2010;20(2):268–81. 9. Gelen E. Acute effects of different warm-up methods on sprint, slalom dribbling, and penalty kick performance in soccer players. J Strength Cond Res. 2010;24(4):950–6. 10. Marti B, et al. On the epidemiology of running injuries. The 1984 Bern Grand-Prix study. Am J Sports Med. 1988;16(3):285–94. 11. Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med. 1986;14(2):151–5. 12. Taunton JE, et al. A retrospective case–control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101. 13. Ballas MT, Tytko J, Cookson D. Common overuse running injuries: diagnosis and management. Am Fam Physician. 1997;55(7): 2473–84. 14. Rolf C. Overuse injuries of the lower extremity in runners. Scand J Med Sci Sports. 1995;5(4):181–90. 15. James SL. Running injuries to the knee. J Am Acad Orthop Surg. 1995;3(6):309–18. 16. Paty Jr JG. Running injuries. Curr Opin Rheumatol. 1994;6(2): 203–9. 17. Meininger AK, Koh JL. Evaluation of the injured runner. Clin Sports Med. 2012;31(2):203–15. 18. Hreljac A. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Phys Med Rehabil Clin N Am. 2005;16(3):651–67. vi. 19. Plastaras CT, et al. Comprehensive functional evaluation of the injured runner. Phys Med Rehabil Clin N Am. 2005;16(3):623–49. 20. Jaworski CA. Medical concerns of marathons. Curr Sports Med Rep. 2005;4(3):137–43.

Part IV Classic Papers in Foot and Ankle Surgery: Introduction

Classic Papers in Foot and Ankle Surgery: Introduction

51

Rajesh Kakwani and Malik Siddique

Foot and Ankle is such an upcoming and ever evolving speciality. The selection criterion used for this chapter involved choosing articles that have made a significant impact on the way we manage foot and ankle disease, not just selecting articles based on the highest citation counts. We do not make any claims that these are the only classic papers in this speciality. The book in general is designed for general orthopaedic review; hence only the articles which have made a landmark change in the management of common cases were included. The management of Achilles tendon ruptures, one of the most common conditions encountered in day-to-day practice is still very controversial. There have been numerous randomised controlled trials and meta-analyses regarding the management options – conservative or operative with exactly opposing results. One can find enough evidence to justify one’s own method of dealing with this condition. Most of the studies included prolonged immobilisation of the ankle, but there have been several publications regarding the benefit of functional stimulus to healing tendons. Hence our rationale to include the Canadian study which is the largest study to date using functional rehabilitation for Achilles tendon ruptures. Patient related outcome measures have been gaining increasing importance in orthopaedics. Outcome measures used for hip and knee arthroplasty are well established. The American Orthopaedic Foot and Ankle society have developed a standard scoring system for foot and ankle conditions – the AOFAS score. Although the AOFAS score has not been yet validated, it is still the most widely used system in foot and ankle publications. It provides a basis on which various modalities of management have been compared. R. Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) (*) Department of Orthopaedics, Northumbria NHS Trust, Ashington, UK e-mail: [email protected] M. Siddique, BSc, MBBS, FRCS, MCh Orth, MD, FRCS (Tr & Orth) Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_51, © Springer-Verlag London 2014

The evolution of the surgical management of severe claw toe deformities of the rheumatoid forefoot started with Hoffmann’s description in 1912. The importance of re-positioning of the plantar fat pad under the residual metatarsal heads and the maintenance of the metatarsal parabola was highlighted by Fowler. Various modifications of the two procedures have followed with variable results. Although the management of the great toe has since shifted towards fusion surgery, to give a stable medial ray, the management of claw toes still follows the same principles highlighted by Fowler. The landmark article by Hawkins regarding talar neck fractures has pioneered the understanding of management of this complex injury. The article outlined the extent of vascular insult to the talus as the group increases, and hence the higher risk of avascular necrosis of the talus. The prognostic value of his classification has stood the test of time. The sensitivity of the Hawkins sign is around 100 %. The other extremely controversial topic in this subspeciality is the management of calcaneal fractures. The Buckley study has been one of the largest randomised controlled trials on this topic. It highlights various prognostic factors that help decision making for this injury. Although further studies are needed to compare minimally invasive techniques to non-operative management, this remains the most widely quoted guidance for this severe injury. Finally, last but not the least. The true classic demonstration of the gold standard surgical solution for chronic lateral ligament instability of the ankle. In contrast to the previous concept, that chronic ligament ruptures are not amenable to repair, Brostrom proved that the direct repair of the lateral ankle ligaments yield excellent result. The most commonly used modification is the Gould modification of the Brostrom repair. The tendinous reconstruction of the lateral ligaments is nowadays used only as a revision procedure. The nonanatomical reconstruction techniques have been associated with a high incidence of sural nerve injury. We hope that you will relish this nostalgic journey through the memory lane of evidence based foot and ankle surgery. 211

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation

52

Rajesh Kakwani and Malik Siddique

52.1

Author

Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A.

52.2

Reference

J Bone Joint Surg Am. 2010;92:2767–2775.

52.3

Institute

Fowler Kennedy Sport Medicine Clinic, London, Canada.

52.4

Abstract

Background The age old controversy regarding the management of Achilles tendon rupture has led to various randomised controlled trials comparing operative versus non-operative techniques. The primary outcome measure utilised in most studies has been the re-rupture rate. The pooled relative risk of re-rupture favoured surgical repair. In all but one study, the limb was immobilized for 6–8 weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons.

Aim To compare the outcomes of patients with acute Achilles tendon rupture treated with either operative repair or non-operatively, utilizing accelerated functional rehabilitation in both the groups. Methods One hundred and forty-four patients were randomized to two groups in this multi-center study. Both groups underwent a prescribed accelerated rehabilitation protocol. One group also had operative repair. Primary outcome measure was re-rupture rate. The other outcome measures used were isokinetic strength, Leppilahti score, range of motion, and calf circumference with 2-year follow-up. Results There were 2 re-ruptures in the operative group and 3 in the non-operative group. Comparing isokinetic strength, Leppilahti score, range of motion and calf circumference, there was no statistically significant difference. There were 13 complications reported in the operative group compared to 6 in the non-operative group. The excess complications in the operative group were mostly attributed to soft-tissue related problems. Conclusions Operative treatment of acute Achilles tendon rupture does not offer any clinically significant benefit over accelerated functional rehabilitation alone and is associated with a higher complication rate.

52.5 R. Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) (*) Department of Orthopaedics, Northumbria NHS Trust, Ashington, UK e-mail: [email protected] M. Siddique, BSc, MBBS, FRCS, MCh Orth, MD, FRCS (Tr & Orth) Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_52, © Springer-Verlag London 2014

Summary

Bhandari et al. [1] in a 2002 systematic review and metaanalysis reported the results of 448 patients randomized to either operative or nonoperative treatment following Achilles tendon rupture. They found a relative risk of re-rupture of 0.32 (95 % confidence interval [CI], 0.14–0.71) in favour of surgical repair. In most of the studies, the conservative management involved immobilising the ankle in a plaster for a prolonged period. 213

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The re-rupture rate in such cases has been reported at around 10–12 %. However, more recently, functional bracing and modified postoperative regimens allow patients to perform daily active plantar flexion exercises as soon as 10 days following injury. This is thought to stimulate tendon healing, and it may lower the re-rupture rate that is typically associated with nonsurgical treatment. The present study promotes the use of functional rehabilitation following Achilles tendon rupture. There was no difference in the re-rupture rate, the Leppilahti score, range of motion, and calf circumference between the two groups. There was a small but significant difference in the plantar flexion strength ratio (affected to unaffected limb) in favour of the operative group. Willits et al. stressed the key component of the protocol was the early functional rehabilitation, accelerated to the point that a patient is actually moving their foot and ankle at 2 weeks. The authors think this is the biggest difference between nonsurgical approaches in the past and their study.

52.6

Citation Count

28

52.7

Related References

1. Wallace RG, Heyes GJ, Michael AL. The non‐operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re‐rupture. J Bone Joint Surg Br. 2011;93:1362–6. 2. Keating JF, Will EM. Operative versus non‐operative treatment of acute rupture of tendo Achillis: a prospective randomised evaluation of functional outcome. J Bone Joint Surg Br. 2011;93:1071–8.

52.8

Key Message

Accelerated functional rehabilitation with non-operative management of Achilles tendon ruptures avoids the complications of surgical repair with comparable re-rupture rates. By 24 months, outcomes were essentially identical between the two groups, though there were more than twice as many complications in the surgical group as in the nonsurgical one (13 vs. 6, respectively). These results applied equally to high-level, recreational, and non-athletes.

52.9

Why It’s Important

It is one of the largest multi-centered randomized controlled trials using the functional rehabilitation protocol. It refutes the previous notions of very high re-rupture

rates after conventional non-operative treatment of plaster immobilisation of the lower limb for 6–8 weeks

52.10 Strengths 1. Well conducted large multi-centered randomised controlled trial 2. Clearly defined aims and inclusion/exclusion criteria 3. Well written paper, easy to read 4. Conclusions are valid and are placed in the context of the studies limitations

52.11 Weaknesses A retrospective review with a small sample size (which the authors accept) that presents a convincing argument for the non–operative treatment of acute Achilles tendon rupture Although the current study is the largest study to date comparing the outcomes of patients with an Achilles tendon rupture treated either non-operatively or operatively and whose rehabilitation included early weight-bearing and mobilization, it is still underpowered to provide definitive conclusions about re-rupture rates. It appears, however, that the addition of early weight bearing and mobilization may have resulted in a substantially reduced rate of re-rupture (4.6 %). Proving that such a reduction is indeed real would require a sample size of 1,275 per group. This is based on the absolute risk difference of 1.7 % (relative risk difference, 40 %) estimated from the pooled results of the current study and previous studies. The power calculations were based on a previous metaanalysis with rates of re-rupture of 2.5 and 13 % for patients treated operatively and non-operatively respectively [2]. However, actual re‐rupture rates in this study were markedly lower for those treated non‐operatively (4 %). Therefore the sample size is small (which the authors accept).

52.12 Relevance The Achilles tendon is the most commonly ruptured tendon in the body. There are numerous publications with extremely contrasting results regarding the management of acute ruptures of the Achilles tendon. The operative options have been associated with a lower re-rupture rate but a 10 % risk of major complications including infection, skin and tendon necrosis. The risk of complications other than re-rupture for surgically treated patients was 3.9 times that of non-surgically treated patients, which resulted in an absolute risk increase of 15.8 %; one additional complication other than re-rupture could be expected for every seven patients treated surgically [3].

52

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized

A recent meta-analysis by Soroceanu et al3 found that if the functional rehabilitation was not employed, surgical repair of the Achilles tendon reduced the re-rupture rate by 8.8 %, with the number of patients needed to treat to prevent one re-rupture being 12. The risk of other complications for surgically treated patients was 3.9 times that of non-surgically treated patients, which resulted in an absolute risk increase of 15.8 %. There was no significant difference between non-surgical treatment and surgical treatment with regard to calf circumference, strength, or functional outcomes [3–7] The results of a stratified analysis showed that if a functional rehabilitation protocol with early range of motion was used, surgical and non-surgical treatments were equivalent with regard to the re-rupture rate (absolute risk difference = 1.7 %, p = 0.45). This suggests that no absolute risk reduction was achieved by performing surgery. Similar results were seen in a meta-analysis by Jiang et al. [8]. They reviewed all published RCTs on Achilles tendon ruptures without differentiating ones that utilised a functional rehabilitation programme. They reported that surgical treatment was superior to non surgical treatment regarding lower risk of re-rupture (P = 0.002) and shorter time for sick leave (P = 0.009) but inferior to non-operative treatment regarding complication risks (P = 0.004). No significant difference was identified between the two methods regarding the number of patients who successfully returned to preinjury sports (P = 0.30).

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References 1. Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, et al. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 2002;400: 190–200. 2. Haughton B. Theme: foot and ankle – tendo Achilles Rupture Leeds Orthopaedic Journal Club. J Bone Joint Surg Br. http://www.boneandjoint.org.uk/sites/default/files/journal-club/JC_Leeds_Feb12. pdf. Accessed on 10 Aug 2013. 3. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture. A meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94:2136–43. 4. Möller M, Movin T, Granhed H, et al. Acute rupture of tendon Achillis: a prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br. 2001;83:843–8. 5. Keating J, Will E. Operative versus non-operative treatment of acute rupture of tendo Achillis: a prospective randomised evaluation of functional outcome. J Bone Joint Surg Br. 2011;93:1071–8. 6. Garrick JG. Does accelerated functional rehabilitation after surgery improve outcomes in patients with acute Achilles tendon ruptures? Clin J Sport Med. 2012;22(4):379–80. 7. Kangas J, et al. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma. 2003; 54(6):1171–80. 8. Jiang N, Wang B, Chen A, Dong F, Yu B. Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop. 2012;36(4):765–73.

Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes

53

Rajesh Kakwani and Malik Siddique

53.1

Author

Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M.

53.5

Summary

Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA.

The AOFAS Scale is an anatomic clinical outcome scale that was designed for use among all patients with foot or ankle dysfunction. It comprises four 100-point anatomic region-specific scales, including ankle-hindfoot, midfoot, hallux metatarsophalangeal, and lesser metatarsophalangealinterphalangeal scales. Each scale is clinician-administered and includes subjective and objective criteria. The numerical weighting of data within each category is different for each anatomic scale. Patients may be asked a total of 3–5 questions, and the clinician completes the remaining data. The items include joint motion, gait abnormalities, stability, alignment and callus assessment, with higher scores corresponding with better outcomes.

53.4

53.6

53.2

Reference

Foot Ankle Int. 1994;15:349–353.

53.3

Institute

Abstract

Four rating systems were designed by the American Orthopedic Foot and Ankle Society (AOFAS) to provide a standard method of reporting the clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment and pain.

R. Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) (*) Department of Orthopaedics, Northumbria NHS Trust, Ashington, UK e-mail: [email protected] M. Siddique, BSc, MBBS, FRCS, MCh Orth, MD, FRCS (Tr & Orth) Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, UK e-mail: [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_53, © Springer-Verlag London 2014

Citation Count

1,303

53.7

Related References

1. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg. 2007;46:65–74. 2. SooHoo NF, Vyas R, Samimi D. Responsiveness of the Foot Function Index, AOFAS clinical rating systems, and SF-36 after foot and ankle surgery. Foot Ankle Int. 2006;27:930–4. 3. Baumhauer J, Nawoczenski D, DiGiovanni B, Wilding G. Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 2006;27(12): 1014–9.

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Key Message

The article is an admirable attempt by the AOFAS to provide a standardised scoring system for foot and ankle conditions.

53.9

Why It’s Important

Undoubtedly, AOFAS is the most commonly used scoring system for foot and ankle conditions. It helps provide the best comparison tool between different studies.

53.10 Strengths It includes clinical criteria only. Simple. It does not require sophisticated equipment such as gait analysis or foot pressure measurements. It has a separate scoring system for the hindfoot, midfoot and the forefoot – hallux and lesser toes. The score relies heavily on pain and function components. The AOFAS questionnaire has enough discriminatory power to assess patient improvement [1]. Ibrahim et al. found a moderate level of correlation, satisfactory degree of reliability and responsiveness suggesting that the subjective component of the AOFAS clinical rating scales provides quality of life information that conveys acceptable validity regarding conditions affecting the foot and ankle [2].

53.11 Weaknesses It requires a professional clinical examination in addition to the patient related information. Clinician based scores do not adequately take into account the patient’s point of view. Clinical examination in a score always introduces a confounding factor, as different examiners may measure things differently. Secondly the intra-observer and inter-observer reliability had not been determined for any of the clinician determined scoring systems for the ankle. The use of the American term “blocks” (i.e. city blocks as in street) to quantify the walking distance does not immediately translate into any recognised British or European measure. The inclusion of the objectively measured range of movement presents a problem. A patient being evaluated for ankle arthroplasty would loose out eight points on the AOFAS hind foot score if he/she has had a sub-talar arthrodesis in addition to the ankle arthroplasty [3]. SooHoo et al. [4] reported poor construct validity when comparing AOFAS with the SF-36 in patients with foot and ankle disability; lower than when the SF-36 was compared with scores evaluating shoulder, knee, and upper extremity disability Each of the AOFAS scales relies heavily on a single question regarding pain. This accounts for 40 % of the overall

score. This undermines its validity for conditions where the symptoms such as stiffness or deformity are more important. The AOFAS systems did have the potential advantage of a lower incidence of ceiling and floor effects than the SF-36. Ceiling and floor effects occur when patients record the maximum or minimum health status score on a rating scale. These effects are more likely with generic instruments as some domains measured are not relevant to the disease process being studied. In addition, these effects are more likely when fewer items are used to measure functional domains. The theoretical advantage of minimising ceiling and floor scores is an instrument that better differentiates patients at the extremes of health status. Guyton used Monte Carlo modelling to highlight several conceptual limitations of the AOFAS scores [5]. The small number of answer categories in several subscales of the AOFAS scores can be a major confounding factor leading to skewed data. This offsets any potential advantage the AOFAS systems have from their low incidence of ceiling and floor effects. Guyton also concluded that the score values obtained using parametric statistics must be interpreted with care [5].

53.12 Relevance According to a survey by Baumhauer [6], the top five factors that patients considered important included limitations in walking, constant pain, activity-related pain, difficulty with prolonged standing, and inability to do a job or housework. They found that up to half of physician-derived AOFAS rating scales are composed of elements that are not of primary importance to patients. Although it is very widely used, there is little to no evidence to support its use in terms of relevance, validity, reliability, responsiveness and interpretability. In a separate article Baumhauer [7] concluded that although the AOFAS hallux and lesser toe scales were found to be reliable in a rheumatoid patient population, their validity remains in question. Toolan et al. [8] demonstrated that the preoperative clinical rating scores obtained after elective surgery are a poor predictor of the patient’s pre-operative condition and that studies which employ retrospectively acquired pre-operative AOFAS clinical rating scores may overestimate the benefit of surgery. There have been comparisons of AOFAS with other scoring systems for foot and ankle: 1. Low correlations have been found between the AOFAS and the generic questionnaires: QUALY and MFA [1, 9]. The authors also highlighted the importance of collecting parallel data (along with the AOFAS score) with other available outcome tools to better understand patient function and quality of life. 2. SooHoo et al. [4] showed an increased responsiveness of foot and ankle specific outcomes tools compared to the

53 Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes

SF-36. However, the bodily pain and physical component summary dimensions of the SF-36 had levels of responsiveness approaching those of the FFI and AOFAS Systems after foot and ankle surgery. This suggests that the SF-36 may be used alone to monitor the outcomes in these patients without sacrificing adequate sensitivity to clinical change. 3. The AOFAS hallux subscale for pain correlates strongly with the previously validated Foot Function Index: FFI subscale for pain, suggesting high content validity. Ceiling effects were seen with the AOFAS lesser toe subscale for activity, limiting its usefulness in a general patient population. The AOFAS lesser toe subscale for pain and the AOFAS hallux subscale for activity correlated weakly with the FFI values [7].

References 1. Pena F, Agel J, Coetzee JC. Comparison of the MFA to the AOFAS outcome tool in a population undergoing total ankle replacement. Foot Ankle Int. 2007;28(7):788–93.

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2. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg. 2007;46:65–74. 3. Naal FD, Impellizzeri FM, Rippstein PF. Which are the most frequently used outcome instruments in studies on total ankle arthroplasty? Clin Orthop. 2010;468(3):815–26. 4. SooHoo NF, Shuler M, Fleming LL. Evaluation of the validity of the AOFAS clinical rating systems by correlation to the SF-36. Foot Ankle Int. 2003;24(1):50–5. 5. Guyton GP. Theoretical limitations of the AOFAS scoring systems: an analysis using Monte Carlo modeling. Foot Ankle Int. 2001; 22(10):779–87. 6. Baumhauer JF, McIntosh S, Rechtine G. Age and sex differences between patient and physician-derived outcome measures in the foot and ankle. J Bone Joint Surg Am. 2013;95:209–14. 7. Baumhauer J, Nawoczenski D, DiGiovanni B, Wilding G. Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 2006;27(12):1014–9. 8. Toolan BC, Wright Quinones VJ, Cunningham BJ, Brage ME. An evaluation of the use of retrospectively acquired preoperative AOFAS clinical rating scores to assess surgical outcome after elective foot and ankle surgery. Foot Ankle Int. 2001;22(10):775–8. 9. Malviya A, Makwana N, Laing P. Correlation of the AOFAS scores with a generic health QUALY score in foot and ankle surgery. Foot Ankle Int. 2007;28(4):494–8.

A Method of Forefoot Reconstruction

54

Rajesh Kakwani and Malik Siddique

54.1

Author

Fowler A.

54.2

Reference

J Bone Joint Surg Br. 1959;41:507–513.

54.3

Institute

Bridgend, Wales, United Kingdom.

54.4

Abstract

1. An operation is described for the relief of irreversible claw toes associated with prominent and painful metatarsal heads. 2. The operation is suggested as an alternative to amputation of the toes. 3. The outcome of the operation performed on 20 patients followed-up for a minimum of 1 year are reported.

54.5

The article describes a salvage operation for the rheumatoid forefoot deformity using excision of the metatarsal heads and re-positioning of the plantar plate. The forefoot reconstruction has two advantages. Firstly, the metatarsal weight-bearing pad is replaced, whereas after amputation of the toes it is drawn farther away on to the dorsum of the foot. Secondly, the cosmetic result is more acceptable. The patients will readily agree to have their toes straightened but they are reluctant to have them removed. It is freely admitted that the toes have little active function after forefoot reconstruction, but they are not entirely useless because, being partly flail, they readily conform to and fill up the empty space at the front of the shoe.

54.6

M. Siddique, BSc, MBBS, FRCS, MCh Orth, MD, FRCS (Tr & Orth) Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_54, © Springer-Verlag London 2014

Citation Count

61

54.7

R. Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) (*) Department of Orthopaedics, Northumbria NHS Trust, Ashington, UK e-mail: [email protected]

Summary

Related References

1. Coughlin MJ. Rheumatoid forefoot reconstruction. A longterm follow-up study. J Bone Joint Surg. 2000;82-A: 322–41. 2. Van der Heide HJL, Louwerens JWK. Reconstructing the rheumatoid forefoot. Foot Ankle Surg. 2010;16(3): 117–21.

54.8

Key Message

The forefoot reconstruction involved pressure relief by removing the prominent bone and disconnecting the proximal phalanx from the metatarsal head. Fowler stated that 221

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222

patients in which the metatarsal head was irregularly trimmed had recurrence of pain and needed further trimming of the metatarsal head. The establishment of the metatarsal parabola after the resection of the metatarsal heads was also important to avoid recurrence of the intractable plantar keratosis.

54.9

Why It’s Important

One of the oldest pioneering attempts to improve the quality of life and pain caused by the extensive disability due to affection of the forefoot by rheumatoid arthritis. The forefoot arthroplasty has two distinct advantages over toe amputations • The weight bearing plantar plate and fat pad are replaced • Cosmetic result is more acceptable

54.10 Strengths The advantage of the proximal plantar incision was that the metatarsal head lies directly under the skin. Resection of a plantar ellipse of the skin helps replace the metatarsal weight bearing pad under the remodelled metatarsal heads.

54.11 Weaknesses Case series so low level of evidence. The toes have very little active function after the forefoot reconstruction other than filling up the empty space at the front of the shoe. The double dorsal and plantar incisions as described by Fowler do not seem to be necessary. The Kates Kessel Kay procedure utilises a single plantar approach effectively to attain the same result.

54.12 Relevance Management of the patient with rheumatoid forefoot deformity requires a multidisciplinary integrated approach for a successful outcome. Despite the latest advances in the pharmacological management of rheumatoid arthritis, the forefoot manifestations of the disease are fairly common and disabling. The typical deformities involve hallux valgus with subluxation or dislocation of the lesser toe metatarsophalangeal joints. Finally the plantar plate fails at its weaker proximal attachment leading to distal migration of the plantar plate. The metatarsal heads are effectively uncovered on

the plantar aspect leading to the formation of plantar callosities due to the increased pressure on weight bearing on the exposed metatarsal heads. Regarding the first ray, the gold standard is the first metatarso-phalangeal joint arthrodesis. Increased first MTP joint weight bearing in the patients treated with first MTP arthrodesis has been reported by Coughlin by pedbarographic studies [1]. The stable medial column protects the lateral rays from recurrent deformity. Resection arthroplasty of the first ray is associated with a high rate of recurrence of intractable plantar keratosis. Maintenance of stable alignment of the first ray by arthrodesis protects not only the hallux but also the lesser toe metatarsophalangeal joint deformity from recurring. Prior to this article, Hoffman in 1912 [2] had described excision of all metatarsal heads through a single plantar incision, without extensor tenotomies. His rationale was that relaxation of the soft tissues by generous metatarsal resection obviated the need for soft tissue correction. The disadvantage of the distal plantar approach was injury to the neurovascular bundles and that the plantar fat pad was not re-positioned [1]. Also, the failure to remove any of the proximal phalanx calls for wider excision of the metatarsal in order to correct the dorsal displacement of the toes. Kates et al. [3] promoted a single curved plantar incision, excising an ellipse for further deformity correction. A panmetatarsal head excision was performed, with the first MTP joint stabilised with a Kirshner wire and a plaster boot applied with the lesser toes plantar flexed. Barouk and Barouk [4] described the joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy was performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. The shortening of the first and second metatarsals was carried out until the ‘Metatarsal shortening’ point as described by Maestro et al. The ‘Metatarsal shortening’ point is the most proximal part of the proximal phalanx of the most deformed ray. The rest of the metatarsals were shortened to follow the metatarsal parabola. The long term results of this technique are awaited. Stainsby’s [5] procedure involves preservation of the metatarsal heads and re-position of the metatarsophalangeal joint plantar plate and forefoot fat pad underneath the metatarsal heads in the correction of severe claw toes. They excised the proximal 2/3 of the proximal phalanx to allow the repositioning of the plantar plate under the metatarsal head. They reported a good or excellent outcome in 93 % of patients with complete relief of pain in 93 % of the patients undergoing forefoot arthroplasty.

54

A Method of Forefoot Reconstruction

References 1. Hoffman MD. An operation for severe grades of contracted or clawed toes. Am J Orthop Surg. 1912;9:441–9. 2. Coughlin MJ. Rheumatoid forefoot reconstruction. A long-term follow-up study. J Bone Joint Surg Am. 2000;82:322–41.

223 3. Kates A, Kessel L, Kay A. Arthroplasty of the forefoot. J Bone Joint Surg Br. 1967;49:552–7. 4. Barouk LS, Barouk P. Joint-preserving surgery in rheumatoid forefoot: preliminary study with more than two-year follow-up. Foot Ankle Clin. 2007;12:435–54. 5. Briggs PJ, Stainsby GD. Metatarsal head preservation in forefoot arthroplasty and the correction of severe claw toe deformity. Foot Ankle. 2001;7:93–101.

Fractures of Neck of Talus

55

Rajesh Kakwani and Malik Siddique

55.1

Author

Conversely, in those fractures associated with AVN, a high percentage of fair or poor results occurred.

Hawkins LG

55.5 55.2

J Bone Joint Surg Am. 1970;52:991–1002.

55.3

Institute

Denver, Colorado.

55.4

Summary

Reference

Abstract

This is a prospective case series of 55 patients with 57 vertical fractures of the neck of the talus that underwent treatment by various methods. Forty-three of the patients were followed-up for more than 1 year after injury. A new fracture classification is proposed based on initial radiographic appearance into three groups depending on the presence and location of dislocation. The overall incidence of avascular necrosis (AVN) was 58 %, with the majority occurring in severely displaced fractures. Generally good to excellent clinical results followed the treatment of vertical fractures of the neck of talus not complicated by AVN.

R. Kakwani, MBBS, MRCS, MS (Orth), FRCS (Tr & Orth) (*) Department of Orthopaedics, Northumbria NHS Trust, Ashington, UK e-mail: [email protected] M. Siddique, BSc, MBBS, FRCS, MCh Orth, MD, FRCS (Tr & Orth) Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_55, © Springer-Verlag London 2014

The aim of the paper was to present a classification scheme for the initial treatment of vertical shear fractures of the neck of the talus, to review the outcomes of 57 such fractures following various treatment methods, and to discuss the recognition, incidence, and treatment of AVN, a common complication associated with this type of fracture. Hawkin’s Classification The Hawkin’s classification of talar neck fractures is based on the amount of displacement and the associated dislocations or subluxations. • Type 1: Undisplaced fracture with no associated joint dislocation was associated with less than 15 % risk of AVN • Type 2: Talar neck fracture with associated dislocation or subluxation of the subtalar joint. Risk of AVN being 42 % • Type 3: Talar neck fracture with dislocation of the talar body from both the ankle and subtalar joints. Risk of AVN was 91 % • Type 4: The classification was later modified by Canale and Kelly [1] (not included in Hawkin’s original paper). Type 4 implies associated dislocation not only of the tibiotalar and subtalar joints but also dislocation of the talar head from the talonavicular joint. The rate of AVN is quoted at 100 %. Hawkin’s Sign A useful objective prognostic sign seen in the form of radiographic evidence of subchondral atrophy in the dome of the talus. Visible 6–8 weeks post fracture neck of talus. This excludes the diagnosis of AVN. Complications By following Hawkins classification it is possible to predict that AVN will not occur following a Type I fracture but 225

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should be expected following a Type III fracture. Type II fractures, however, remain indeterminate. The risk of nonunion following treatment appears to be a concern only for Type III fractures. Overall Clinical Outcome Fractures not complicated with AVN achieved mostly excellent and good clinical results (68 %) compared to those with AVN, which achieved predominantly fair and poor results (88 %). Furthermore, regardless of fracture classification, the risk of a fair or poor clinical outcome continues to be greater when a fracture is complicated by AVN, which continues to be most prevalent in Group III fractures. 1. Pain Fractures not complicated by AVN: • Aching pain with fatigue was reported in two, six, and two patients in Type I, II, and III, respectively. • No pain at any time was reported in three and six patients in Type I and II, respectively. • No patient reported pain with walking. Fractures complicated by AVN: • Aching pain with fatigue was reported in five and seven patients in Type I and III, respectively. • Pain with walking was reported in one and four patients, in Type I and III respectively. • No pain at any time was reported in seven patients in Type III. 2. Range of motion • In fractures not complicated by AVN, mild loss of subtalar motion and dorsiflexion of the ankle was routinely noted. • In fractures complicated by AVN, marked decrease in motion in dorsiflexion and plantar flexion with very little motion in the subtalar joint was routinely seen. 3. Work status • All patients with fractures not complicated by AVN returned to their former work and no late fusion was required. • All but one patient who developed subsequent AVN returned to their prior work, but complained of aching pains with fatigue.

55.6

Citation Count

2. Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD. Functional outcomes following displaced talar neck fractures. J Orthop Trauma. 2004;18(5):265–70. 3. Fetter NL, Chiodo CP. What is the best treatment of displaced talar neck fractures. In: Wright J, editor. Evidencebased orthopaedics the best answers to clinical questions. Philadelphia: Saunders; 2008. p. 502–5.

55.8

Key Message

The higher the fracture Type according to the Hawkin’s classification the higher is the risk of avascular necrosis (AVN) of the talar body. Early anatomic reduction of the talar neck fracture was emphasized to reduce the risk of AVN of the talus. The development of avascular necrosis is associated with poorer prognosis depending on the extent of talar body involvement. The Hawkins sign indicates subchondral talar dome osteopenia and signifies intact vascularity. The presence of this sign after a talar fracture implies that AVN of the talus has not occurred.

55.9

Why It’s Important

The Hawkin’s classification is still one of the most widely used and accepted classification for talar neck fractures. It is based on displacement and dislocation, and therefore, presumed damage to the blood supply of the talus. This classification was further expanded 8 years later by Canale and Kelly [1] who added the type IV category. It provides a foundation for decision making regarding conservative or operative and the risk of AVN of the talar body. Canale and Kelly [1] also described the radiographic view to visualise the talar neck. This is achieved by internally rotating the foot, the foot having been placed plantigrade on the x-ray film and the beam angled 70° cephalad. The rate of AVN of the talus as reported in subsequent studies has been 0–24 % after Hawkins Type I, 0–50 % after Hawkins Type II and 33–100 % after Hawkins Type III and IV fractures [2–4].

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55.10 Strengths 55.7

Related References

1. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004;86:1616–24.

The Hawkin’s classification as well as the Hawkin’s sign has stood the test of time. The use of the classification gives a fair idea of the prognosis of the fracture. There is an AO universal classification that is comprehensive but it is complicated and therefore rarely used.

55 Fractures of Neck of Talus

Hawkins work on vertical fractures of the neck of the talus helped clarify the injury of vascular perfusion to the bone.

55.11 Weaknesses Level 4 evidence In clinical practice, the Hawkins sign is strongly predictive of the absence of AVN. However, the sign has high sensitivity and low specificity, so that its absence does not universally predict AVN.

55.12 Relevance Fractures of the talus are rare. Typically, they are the result of high-energy mechanisms, and are frequently associated with disabling complications. Due to its unique anatomy, the tenuous blood supply, and the multiple complex articulations in the hindfoot, these injuries are associated with arthritis, hindfoot deformity, and AVN. In the twentieth century, before Hawkins work, several clinical studies on talar neck fractures were reported. In 1919, Anderson coined the term “aviator’s astragalus” after observing a series of fractures and dislocations in drowned pilots [5]. In 1952, Coltart reported a large case series examining this injury in British airforce pilots during the Second World War [2]. In this article, a poor outcome was associated with inadequate reduction of the subtalar joint, leading the authors to advocate anatomical reduction with or without internal fixation. In 1970,Hawkins landmark article and classification system of talar neck fractures emphasized the importance of open reduction. However he does not give details of internal fixation in the paper. In another landmark paper Canale and Kelly [1] used closed reduction as well as open reduction with and without internal fixation. Closed reduction was limited to those fractures in which adequate alignment (10 cm) and then 94 patients randomly allocated to preoperative radiotherapy (50 Gy in 25 fractions) and 96 to postoperative radiotherapy (66 Gy in 33 fractions). The primary endpoint was rate of wound complications within 120 days of surgery. Analyses were per protocol for primary outcomes and by intention to treat for secondary outcomes. Results Median follow-up was 3.3 years (range 0.27–5.6). Four patients, all in the preoperative group, did not undergo protocol surgery and were not evaluable for the primary outcome. Of those patients who were eligible wound complications were recorded in 31 (35 %) of 88 in the preoperative group and 16 (17 %) of 94 in the postoperative group (difference 18 % [95 % CI 5–30], p = 0.01). Tumour size and anatomical site were also significant risk factors in a multivariate analysis. Overall survival was slightly better in patients who had preoperative radiotherapy than in those who had postoperative treatment (p = 0.0481). Conclusions Although patient survival was marginally improved for patients undergoing preoperative radiotherapy, tumour size and location had a bearing on the increased frequency of wound complications in this group and therefore these factors should be borne in mind when considering preoperative radiotherapy.

126.5 Summary This multi-centre study demonstrates that preoperative radiotherapy is effective for the treatment of extremity soft tissue sarcoma, but that the risk of wound complications is higher, particularly in the thigh. Preoperative radiotherapy has the advantages of being lower dose (50 vs 66Gy typically) and easier to plan as the tumour can be readily identified.

485

486

126.6 Citation Count

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therapy preoperatively results in improved local control in advanced grades of soft tissue extremity sarcomas [2].

313

126.10 Strengths 126.7 Related References 1. Pervaiz N, Colterjohn N, Farrokhyar F, Tozer R, Figueredo A, Ghert M. A systematic meta-analysis of randomized controlled trials of adjuvant chemotherapy for localized resectable soft-tissue sarcoma. Cancer. 2008;113(3):573–81. 2. Zagars GK, Ballo MT, Pisters PWT, Pollock RE, Patel SR, Benjamin RS. Preoperative vs. postoperative radiation therapy for soft tissue sarcoma. Int J Radiat Oncol Biol Phys. 2003;56(2):482–8.

This is an excellent multi-centre study looking at an important clinical question. The prospective randomised design allows more weight to be attached to the evidence presented.

126.11 Weaknesses The study was powered to look for functional outcomes and wound complications, rather than the tumour outcomes of local and systemic recurrence.

126.8 Key Message

126.12 Relevance

The key message in this paper is that preoperative radiotherapy can be used for extremity soft tissue sarcoma, but that there is a trade-off in terms of complications. Cases should therefore be considered on an individual basis, bearing in mind the grade of the sarcoma.

This study is one which regularly informs practice and multi disciplinary team decision-making. Standard practice in most centres remains postoperative radiotherapy [3], however the high level of evidence presented in this paper allows the teams treating these patients to carefully consider the potential benefit of preoperative radiotherapy in higher grades of tumour considering site and size.

126.9 Why It’s Important The importance of this paper lies in the quantification of the risks of pre and postoperative radiotherapy, in order that informed decision making is possible. It is a prospective randomised multi-centre study and therefore represents an advance in terms of level of evidence provided compared to the retrospective studies often performed in surgical disciplines. There has been a recent study assessing the necrosis rate in soft tissue sarcomas treated with radiotherapy and this demonstrated an unpredictable response with percentage necrosis varying from 5 to 100 % [1]. However further work has demonstrated that combining chemotherapy with radio-

References 1. Canter RJ, Martinez SR, Tamurian RM, Wilton M, Li CS, Ryu J, Mak W, Monsky WL, Borys D. Radiographic and histologic response to neoadjuvant radiotherapy in patients with soft tissue sarcoma. Ann Surg Oncol. 2010;17(10):2578–84. 2. MacDermed DM, Miller LL, Peabody TD, Simon MA, Luu HH, Haydon RC, Montag AG, Undevia SD, Connell PP. Primary tumor necrosis predicts distant control in locally advanced soft-tissue sarcomas after preoperative concurrent chemoradiotherapy. Int J Radiat Oncol Biol Phys. 2010;76(4):1147–53. 3. Grimer R, Judson I, Peake D, Seddon B. Guidelines for the management of soft tissue sarcomas. Sarcoma. 2010;2010:506182.

A System for the Surgical Staging of Musculoskeletal Sarcoma

127

Craig H. Gerrand and Kenneth Rankin

127.1 Authors

127.5 Summary

Enneking WF, Spanier SS, Goodman MA

This paper describes a staging system for bone and soft tissue sarcoma that influences the core surgical management for each patient as well as the adjunctive therapies. Recognizing the need for a specific staging system for sarcoma to enable multidisciplinary teams to manage their patients more effectively and collect data on outcomes was instrumental in shaping orthopedic oncology practice in the 1980s and is still entirely relevant today.

127.2 Reference Clin Orthop Relat Res. 1980;(153):106–120.

127.3 Institution Department of Orthopaedics. University of Florida, Gainesville, Florida, USA.

127.6 Citation Count 705

127.4 Abstract 127.7 Related References This paper proposes a system for the surgical staging of musculoskeletal sarcomas based on the grade of the tumour, its anatomical site and the presence or absence of metastases. There are three stages: I-low grade; II-high grade and III-presence of metastases. These are then divided by (a) whether the tumour is confined within an anatomical compartment, or (b) whether the tumour has extended beyond its compartment of origin or if it is lies within ill-defined fascial planes and spaces. Operative margins are defined as intralesional, marginal, wide, or radical depending upon where the plane of resection passes relative to the tumour, its reactive zone and the boundaries of the anatomical compartment. The system therefore defines stages with prognostic and surgical significance and which can inform treatment.

1. Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res. 1986;(204):9–24. 2. Wolfe RE, Enneking WF. The staging and surgery of musculoskeletal neoplasms. Orthop Clin North Am. 1996;27(3):473–81. 3. Kawaguchi N, Ahmed AR, Matsumoto S, Manabe J, Matsushita Y. The concept of curative margin in surgery for bone and soft tissue sarcoma. Clin Orthop Relat Res. 2004;(419): 165–72. 4. Edge SB, American Joint Committee on Cancer. AJCC cancer staging manual, 7th ed. New York: Springer; 2010.

127.8 Key Message C.H. Gerrand, MBChB, FRCS (Ed), MD, MBA (*) North of England Bone and Soft Tissue Tumour Service, Freeman Hospital, Newcastle upon Tyne, UK K. Rankin, MBChB, MD, MRCS North of England Bone and Soft Tissue Tumour Service, University of Newcastle upon Tyne, Newcastle upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_127, © Springer-Verlag London 2014

The staging system proposed is straightforward to apply (see Table 127.1) and is an important tool for the management of these patients. It was refined and adopted by the Musculoskeletal Tumour Society leading to a follow up paper in 1986 [1]. 487

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C.H. Gerrand and K. Rankin

127.9 Why It’s Important

Table 127.1 Enneking staging system for primary malignant tumours of bone

With the American Joint Committee on Cancer (AJCC) staging group unable to produce an effective system for sarcoma, the criteria proposed by Enneking were appropriate and timely. The concepts introduced in this paper were critical in informing the understanding of the local behaviour of sarcoma, the effect of anatomical barriers to tumour growth and the need to treat the whole of the reactive zone around a tumour. These concepts continue to inform clinical practice.

Stage IA IB IIA IIB III

127.10 Strengths

anatomic compartment (intracompartmental) and is designated T2 if it spreads into an additional compartment or compartments (extracompartmental). The third criterion is that of metastasis: The tumour is designated M0 if there are no metastases and M1 if there are either regional or distant metastases. This staging system is summarized in Table 127.1. As outlined by Enneking [1] the purposes of a staging system for musculoskeletal neoplasms are to “(1) incorporate the significant prognostic factors into a system that describes progressive degrees of risk of local recurrence and distant metastases to which a patient is subject, (2) stratify the stages so they have specific implications for surgical management, and (3) provide guidelines for adjunctive therapies.” According to this system, malignant bone tumors were staged based on histologic grade, the intraosseous or extraosseous extent of the tumor, and the presence of distant metastases. Enneking showed that this system had prognostic significance and that it was able to help guide treatment. The system was evaluated and endorsed by the Musculoskeletal Tumor Society (MSTS) and later by the American Joint Committee on Cancer (AJCC). The surgical staging system (MSTS system) has remained the most widely used system by musculoskeletal oncologists to classify all patients with primary sarcomas. For nearly two decades the AJCC staging system for bone cancers closely reflected the MSTS system and remained relatively unchanged [4].

This is a straightforward system which employs similar principles as the internationally accepted tumour/nodes/metastases (TNM) methodology for common solid cancers. It is easy to remember, which has facilitated its adoption and indeed it became the accepted system of the international Musculoskeletal Tumour Society (MSTS). The system has been validated in clinical studies [2].

127.11 Weaknesses This was primarily a retrospective study. The AJCC systems for staging sarcoma are more discriminating and are regularly updated. Furthermore a more recent study from Japan proposes a system which abandons the concept of compartmentalization and instead uses the reactive zone as the method of planning the surgical margin [3]. However, this system is relatively complicated and the Enneking/MSTS system remains simpler and a favourite of examiners.

127.12 Relevance The Enneking staging system is the gold standard for the MSTS and is used internationally for both the routine management of sarcoma patients as well as providing an important tool for study comparisons. Staging with the Enneking system is based on three criteria. The first criterion is the grade of the tumour, which is a histologic assessment of cellular atypia and relates to the risk of metastasis. The estimated metastatic risk of low-grade (G1) tumours is less than 25 %, whereas that of high-grade (G2) tumours is greater than 25 %. The second criterion is anatomical location in relation to the anatomical osteofascial compartment of origin. The tumour is designated T1 if it remains confined to a single

Grade G1 G1 G2 G2 G1 or G2

Tumour T1 T2 T1 T2 T1 or T2

Metastases M0 M0 M0 M0 M1

Note: G1 low grade, G2 high grade, M0 no regional or distant metastasis, M1 regional or distant metastasis, T1 tumour is intracompartmental, T2 tumour is extracompartmental

References 1. Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res. 1986;204:9–24. 2. Wolfe RE, Enneking WF. The staging and surgery of musculoskeletal neoplasms. Orthop Clin North Am. 1996;27(3):473–81. 3. Kawaguchi N, Ahmed AR, Matsumoto S, Manabe J, Matsushita Y. The concept of curative margin in surgery for bone and soft tissue sarcoma. Clin Orthop Relat Res. 2004;419:165–72. 4. Edge SB, American Joint Committee on Cancer. AJCC cancer staging manual. 7th ed. New York: Springer; 2010.

A System for the Functional Evaluation of Reconstructive Procedures After Surgical Treatment of Tumors of the Musculoskeletal System

128

Craig H. Gerrand and Kenneth Rankin

128.1 Authors Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ.

The system has been field tested in 220 patients with low interobserver variability. Use of the system was recommended by the MSTS to facilitate comparative end result studies of musculoskeletal tumour reconstructions.

128.2 Reference

128.5 Summary

Clin Orthop Relat Res. 1993;(286):241–246.

This paper describes a system for recording functional outcomes, which comprises a physician-completed questionnaire with six domains tailored to the upper or lower limb. The system has been tested in a cohort of 220 patients and demonstrated low interobserver variability.

128.3 Institution University of Florida, Gainesville, Florida

128.6 Citation Count 128.4 Abstract 888 The first International Symposium on Limb Salvage (ISOLS) in 1981 identified the need for a standardized system for reporting the results of the treatment of musculoskeletal tumours in order to compare techniques. The Musculoskeletal Tumour Society (MSTS) and ISOLS subsequently adopted this system of functional evaluation for research and presentation of results. In brief, the system assigns numerical values (0–5) to each of six categories. For the upper limb these are pain, function, emotional acceptance, lifting ability, hand positioning and dexterity. For the lower limb these are pain, function, emotional acceptance, supports, walking and gait. Demographic information and a patient satisfaction component are included. The system derives a numerical score and percentage rating.

C.H. Gerrand, MBChB, FRCS (Ed), MD, MBA (*) North of England Bone and Soft Tissue Tumour Service, Freeman Hospital, Newcastle upon Tyne, UK K. Rankin, MBChB, MD, MRCS North of England Bone and Soft Tissue Tumour Service, University of Newcastle upon Tyne, Newcastle upon Tyne, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_128, © Springer-Verlag London 2014

128.7 Related References 1. Davis AM, Sennik S, Griffin AM, Wunder JS, O’sullivan B, Catton CN, et al. Predictors of functional outcomes following limb salvage surgery for lower‐extremity soft tissue sarcoma. J Surg Oncol. 2000;73(4):206–11. 2. Nagarajan R, Clohisy DR, Neglia JP, Yasui Y, Mitby PA, Sklar C, et al. Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing’s sarcoma: the Childhood Cancer Survivor Study. Br J Cancer. 2004;91(11):1858–65.

128.8 Key Message The key message in this article is that there was a need to develop a system for assessing functional outcomes following reconstructive surgery and that this is a multidimensional concept. 489

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128.9 Why It’s Important The importance of this article lies in the fact that it has provided a foundation on which discussion of the functional impact of treatment for extremity sarcoma can be built. For example, this and other scores have enabled a comparison of limb sparing and amputation [1]. As the system has been widely used by many authors, the article is widely quoted.

C.H. Gerrand and K. Rankin

questionable methodologically. However, more contemporary studies tend to include several assessments such as the more objective patient completed Toronto Extremity Salvage Score (TESS) [2] to measure the concept of disability along with health-related quality of life measures such as the SF-36.

128.12 Relevance 128.10 Strengths This system was developed by the Musculoskeletal Tumour Society (MSTS) and the International Symposium on Limb Salvage (ISOLS) and was adopted by both for use in outcome studies. The system was the first to attempt an evaluation of physical functioning in this population and is easy to use.

This paper is very relevant to modern orthopedic oncology practice where there is an obligation to understand the impact of treatment on physical functioning. It provides a benchmark for functional outcomes. Although some authors prefer newer types of scoring systems such as the TESS, the long established use of the MSTS score makes it an important benchmarking tool for some authors [3].

References 128.11 Weaknesses Although widely adopted, weaknesses in the MSTS system for functional evaluation include the subjectivity of the assessment that is usually performed by the treating medical team. Although the system was intended to measure physical functioning, it includes domains for pain and emotional acceptance. The conversion of these domain scale scores to an overall percentage may be

1. Zahlten-Hinguranage A, Bernd L, Ewerbeck V, Sabo D. Equal quality of life after limb-sparing or ablative surgery for lower extremity sarcomas. Br J Cancer. 2004;91(6):1012–4. 2. Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell RS. Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res. 1996;5(5): 508–16. 3. Hopyan S, Tan JW, Graham HK, Torode IP. Function and upright time following limb salvage, amputation, and rotationplasty for pediatric sarcoma of bone. J Pediatr Orthop. 2006;26(3):405–8.

The Hazards of Biopsy in Patients with Malignant Primary Bone and Soft-Tissue Tumors

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Craig H. Gerrand and Kenneth Rankin

129.1 Authors Mankin HJ, Lange TA, Spanier SS.

129.2 Reference J Bone Joint Surg Am. 1982;64:1121–1127.

129.3 Institution From the Musculoskeletal Tumour Society

129.4 Abstract This study was performed by the Musculoskeletal Tumour Society using questionnaires to assess the following: • The accuracy of biopsy in making a diagnosis • The incidence of complications associated with the biopsy procedure • The effects of errors in diagnosis and of complications on the treatment of patients • Whether these problems occurred with greater frequency when the initial biopsy was performed in a referring institution or in a specialist treating centre Each member of the Society submitted data on 20 sequential, unselected, newly diagnosed patients with malignant

C.H. Gerrand, MBChB, FRCS (Ed), MD, MBA (*) North of England Bone and Soft Tissue Tumour Service, Freeman Hospital, Newcastle upon Tyne, UK K. Rankin, MBChB, MD, MRCS North of England Bone and Soft Tissue Tumour Service, University of Newcastle upon Tyne, Newcastle upon Tyne, UK e-mail: [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_129, © Springer-Verlag London 2014

primary tumours of bone or soft tissue who underwent a biopsy and then a definitive procedure. The study received data from 20 orthopedic surgeons in 16 treating centres. Information on 329 patients included a wide range of diagnoses (but generally conforming to the distribution of these tumours in the general population). The mean age of the patients was 36.5 years (range, 2 weeks to 83 years). Two hundred and twenty two lesions were bone primaries and 107 were derived from soft tissue. One hundred and forty three tumours were biopsied in the referring institution and 171 in the treating centre. The authors demonstrated 60 (18.2 %) major errors in diagnosis and 34 (10.3 %) non-representative or technically poor biopsies. Fifty-seven patients (17.3 %) encountered problems in the skin, soft tissue, or bone following biopsy and the optimum treatment plan had to be altered as a result of problems related to the biopsy in 60 patients (18.2 %). In 15 patients (4.5 %) an unnecessary amputation was performed as a result of problems with the biopsy, and in 28 patients (8.5 %) the prognosis and outcome were considered to have been adversely affected. Patients undergoing a biopsy at the referring institution experienced biopsy-related problems three to five times more frequently than those undergoing biopsy at a treating centre. Given these findings, the authors recommend that the biopsy should be planned as carefully as definitive surgery. In particular, careful attention should be paid to the following: • Asepsis, skin-handling, haemostasis, and wound closure • Precise skin incision placement, which will not compromise subsequent surgery. • The tissue obtained should be sufficient in volume and sufficiently representative of the lesion that the pathologist can provide a definitive diagnosis. If the surgeon or the institution is not prepared to perform accurate diagnostic studies or proceed with definitive treatment for these patients, patients should be referred to a treating centre prior to biopsy.

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129.5 Summary

129.9 Why It’s Important

This survey of 329 consecutive patients in 16 centres demonstrates a high rate of misdiagnosis and an adverse impact on outcome particularly when biopsies are performed before referral to a specialist centre.

Although this classic article is now over 30 years old the message about the hazards of biopsy remains very relevant today, and has informed clinical practice and service provision in the years since publication. Inappropriate biopsy clearly leads to a change in treatment for many patients. Biopsies should be performed by, or in consultation with the expert team, and should be supported by expert pathology review.

129.6 Citation Count 316

129.10 Strengths 129.7 Related References 1. Bickels J, Jelinek JS, Shmookler BM, Neff RS, Malawer MM. Biopsy of musculoskeletal tumors. Current concepts. Clin Orthop Relat Res. 1999;(368):212–9. 2. Springfield DS, Rosenberg A. Biopsy: complicated and risky. J Bone Joint Surg Am. 1996;78:639–43.

This is an important message for health care providers and clinicians who may see patients presenting with a new sarcoma diagnosis. In this series almost half (43.5 %) of patients had biopsies performed before referral, and there is a clear message about the need to improve the care of patients with a suspected sarcoma.

129.11 Weaknesses 129.8 Key Message The key message in this paper is that the biopsy is an important part of the workup of patients with musculoskeletal tumours. Inappropriate biopsy can lead to changes in treatment towards larger procedures, including amputation in some instances. Biopsies should always be discussed with the treating centre. The authors suggest the following important principles for biopsy: 1. Plan the biopsy procedure as carefully as the definitive surgery. It is not a simple procedure. 2. Pay as close attention to asepsis, skin preparation, haemostasis, wound closure, and so on as with any other operation. 3. Place the skin incision in such a manner that it does not compromise the subsequent definitive surgical procedure. (Avoid transverse incisions!) 4. Be certain that an adequate volume of representative tissue is obtained and that the pathologist prepares the slides in a manner that will allow a definitive diagnosis. 5. If the pathologist cannot make a diagnosis because of unfamiliarity with bone and soft-tissue tumours, prompt consultation is essential. 6. If the surgeon or the institution is not equipped to perform accurate diagnostic studies or definitive surgery and adjunctive treatment, the patient should be referred to a treating centre prior to biopsy.

This is an older paper, which is concerned with older techniques in biopsy, in particular open biopsy. Newer techniques, including image guided needle biopsy may be associated with fewer complications.

129.12 Relevance The technique and complications related to the biopsy of musculoskeletal tumours are highly relevant to all orthopedic surgeons. This paper emphasises the need for referral to specialist centres where the definitive surgery is going to take place, and wherever the biopsy is performed, for meticulous technique to avoid complications. Despite the publication in 1982, a follow up paper in 1996 showed no change in the complications associated with the biopsy of musculoskeletal tumours [1]. Therefore further recommendations have been made to reduce the frequency of incorrect biopsy procedures. These include: • The involvement of a pathologist with the relevant training and experience of musculoskeletal tumours [2]. • National peer review systems should be in place to ensure that specialist referral centres meet agreed standards and continue to promote regional awareness of their referral guidelines [3].

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References 1. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. 1996;78:656–63.

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2. Harris M, Hartley AL. Value of peer review of pathology in soft tissue sarcomas. Cancer Treat Res. 1997;91:1–8. 3. Mastrangelo G, Fadda E, Cegolon L, Montesco MC, Ray-Coquard I, Buja A, et al. A European project on incidence, treatment, and outcome of sarcoma. BMC Public Health. 2010;10:188.

Part XI Fracture Healing: Introduction

Classic Papers in Trauma and Fracture Healing: Introduction

130

Gunasekaran Kumar and Badri Narayan

A ‘classic paper’ has no specific definition. The number of citations of a paper often reflects quality, but not always. At best therefore, the number of citations is a surrogate marker of how important a paper is and whether the paper is responsible for significant developments in orthopaedics. It seems intuitive that the chances of citation of a paper increases with time since publication. However, by the same token, an older paper could be less cited as the information in the paper could have become common knowledge. There are other sources of bias, such as the author citing himself, or papers from the author’s institution. If we were to rely purely on the number of citations as the criterion for deciding whether a paper is classic or not, we are at the risk of ignoring several seminal papers on subspecialist topics like paediatric orthopedics, orthopaedic oncology, etc., simply because literature in that subspecialty is more sparse. For example, four of the top five in “The 100 classic papers in Orthopaedic Surgery” [1] are about arthritis or arthroplasty. A paper must be considered “classic” on the basis of it’s mark on the orthopaedic community rather than just by the number of citations. Qualitative criteria to consider could be whether this was one of a kind, with such significant impact that it changed opinion and direction of research. How then do we decide the order of merit based on the impact of the papers? At best this will be subjective, and reflective of the authors’ practice.

The papers selected in Orthopaedic trauma section include papers by Albrektsson (Osseointegration and Titanium), Goodship (micromovement on tibial fracture healing), Gustilo and Anderson (open fracture management), Ilizarov (effects of distraction on tissues), McKibbin (biology of fracture healing), Rubin (regulation of bone formation by dynamic loads), Winquist (closed femoral nailing), Yasko (healing of segmental bone defects by rhBMP 2), Younger (bone graft donor site morbidity), Pape (damage control orthopaedics). All of us will immediately recognise some of the authors listed above and for the “unrecognised” authors, the topic that they wrote about will be immediately recognisable. Each of the papers reviewed here has had an enormous impact on the understanding of these topics and paved the way for further research in the right direction. These papers may not stand up to the rigors of current methods of statistical analysis but will definitely remain the shoulders on which current research stands.

Reference 1. Kelly JC, Glynn RW, O’Briain DE, Felle P, McCabe JP. The 100 classic papers of orthopaedic surgery. A bibliometric analysis. J Bone Joint Surg Br. 2010;92:1338–43.

G. Kumar, FRCS (Tr & Orth) (*) B. Narayan, MS (Orth), FRCS (Tr & Orth) Department of Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_130, © Springer-Verlag London 2014

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The Influence of Induced Micromovent Upon the Healing of Experimental Tibial Fractures

131

Gunasekaran Kumar and Badri Narayan

131.1 Authors

conditions for fracture healing and may assist in the prevention of delayed union.

Goodship AE, Kenwright J.

131.5 Summary 131.2 Reference J Bone Joint Surg Br. 1985;67:650–655.

131.3 Institution Comparative Orthopaedic Research Group, School of Veterinary Science, University of Bristol, UK.

131.4 Abstract Although it has been well established that fracture healing is influenced by the mechanical environment, the optimal parameters have not yet been established. In two groups of sheep an experimental tibial diaphysial fracture was created, and stabilised using external skeletal fixation. In one group rigid fixation was maintained throughout fracture healing; in the other group controlled axial micromovement, with a loading regime known to be osteogenic in intact bones, was applied for a short period daily. A significant improvement in healing was associated with the application of controlled micromovement. Data from these experiments provide the basis for improving the

This paper is an experimental study of the effect of a specific mechanical loading regime in tibial diaphyseal fracture healing. Twelve adult sheep tibia were osteotomised, distracted 3 mm and stabilised with external fixator in a standardised manner. The protocol included a short period (17 min) of intermittent strain (500 cycles at 0,5Hz) applied daily versus no strain across the fracture site with a specific load. Two weekly standardised radiographs, two weekly fracture stiffness assessments and at 12 weeks a post mortem torsional strength testing were performed. On radiographs, fracture callus was greater in the stimulated group. Fracture stiffness was significantly more in the stimulated group at 10 weeks and as was the torsional stiffness. Histological examination showed complete bridging callus formation in all specimens in the stimulated group. In fracture healing, the local mechanical environment determines both the course and success of healing

131.6 Citations 464

131.7 Related References G. Kumar, FRCS (Tr & Orth) (*) B. Narayan, MS (Orth), FRCS (Tr & Orth) Department of Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK e-mail: [email protected]

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_131, © Springer-Verlag London 2014

1. Einhorn TA. Enhancement of fracture-healing. J Bone Joint Surg Am. 2006;77:940–56. 2. Goodship AE, Watkins PE, Rigby HS, Kenwright J. The role of fixator frame stiffness in the control of fracture healing. An experimental study. J Biomech. 1993;26(9):1027–35.

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131.8 Key Message With an animal (sheep) model Goodship and Kenwright showed that application of controlled axial micro-movement resulted in significant improvement of healing as compared to rigid fixation of an osteotomy site. The rates of healing, tissue ossification and stiffness were enhanced by cyclic mechanical loading

131.9 Why Is It Important This study showed in vivo, that micromotion with cyclical loading at a fracture site produced early callus which also had better stiffness than without this stimulation. This study is one of the first to provide objective evidence for cyclic loading in the form of serial radiographs, measured stiffness and histological examination.

G. Kumar and B. Narayan

It is well recognised that mechanical cyclic stimulation can induce fracture healing or alter its biological pathway [8, 9]. Healing requires micromovement, if it is to heal by secondary intention [10, 11]. However, the appropriate degree of strain required for every stage of fracture healing is not clearly identified [12]. The ability of a bone to tolerate fracture gap and axial strain varies with respect to the bone involved and the type of fracture. In general, the larger the fracture gap and larger the micromovement, callus production is reduced. Timing of this micromovement application also is crucial. Early in fracture healing, small micromovements stimulate fracture healing while larger micromovements, in later stages do not stimulate as much callus formation. This is possibly due to deleterious effects on the newly formed blood vessels. Several in vivo and in vitro studies have shown the advantages of cyclical loading of a fracture [13–15]. Controlled mechanical loading of a fracture promotes fracture callus formation.

131.10 Strengths This is one of a number of articles that surfaced in the late 1980s and early 1990s dealing with various characteristics of the mechanical environment that directly influenced the subsequent course of fracture healing [1–4]. Goodship and Kenwright findings have been replicated by other researchers [5–7].

131.11 Weaknesses It is not clear how far extrapolation should be made from the results of animal experimental studies to the treatment of human fractures

131.12 Relevance In 1985 Goodship and Kenwright published their work on the influence of induced cyclic micromotion on the healing of experimental tibial fractures, using an Oxford External Fixator. When 500 cycles were applied per day, they found that the micromotion produced external callus sooner, namely at 1 week, compared with static external fixation where callus was just commencing at 3 weeks. The micromotion resulted in more callus formation, which extended over a wider portion of the diaphysis. Consequently, they found that fracture stiffness increased at a greater rate in the stimulated group than in the rigid group. When the animals were sacrificed at 12 weeks they found that there was increased torsional stiffness in the stimulated group, i.e. 83 % of the intact control stiffness, compared with 54 % in the rigidly-fixed group.

References 1. Blenman PR, Carter DR, Beaupré GS. Role of mechanical loading in the progressive ossification of a fracture callus. J Orthop Res. 1989;7(3):398–407. 2. Claes LE, Heigele CA. Magnitudes of local stress and strain along bony surfaces predict the course and type of fracture healing. J Biomech. 1999;32(3):255–66. 3. Goodship AE, Cunningham JL, Kenwright J. Strain rate and timing of stimulation in mechanical modulation of fracture healing. Clin Orthop Relat Res. 1998;355:S105–15. 4. Hente R, Füchtmeier B, Schlegel U, Ernstberger A, Perren SM. The influence of cyclic compression and distraction on the healing of experimental tibial fractures. J Orthop Res. 2004;22(4):709–15. 5. Isaksson H, Wilson W, van Donkelaar CC, Huiskes R, Ito K. Comparison of biophysical stimuli for mechano-regulation of tissue differentiation during fracture healing. J Biomech. 2006;39(8):1507–16. 6. Jagodzinski M, Krettek C. Effect of mechanical stability on fracture healing – an update. Injury. 2007;38 Suppl 1:S3–10. 7. Kaspar D, Seidl W, Neidlinger-Wilke C, Beck A, Claes L, Ignatius A. Proliferation of human-derived osteoblast-like cells depends on the cycle number and frequency of uniaxial strain. J Biomech. 2002;35(7):873–80. 8. Kenwright J, Goodship AE. Controlled mechanical stimulation in the treatment of tibial fractures. Clin Orthop Relat Res. 1989;241:36–47. 9. Kenwright J, Richardson JB, Cunningham JL, White SH, Goodship AE, Adams MA, Magnussen PA, Newman JH. Axial movement and tibial fractures. A controlled randomised trial of treatment. J Bone Joint Surg Br. 1991;73:654–9. 10. Klein-Nulend J, van der Plas A, Semeins C, Ajubi NE, Frangos JA, Nijweide PJ, Burger EH. Sensitivity of osteocytes to biomechanical stress in vitro. FASEB J. 1995;9(5):441–5. 11. Lacroix D, Prendergast PJ. A mechano-regulation model for tissue differentiation during fracture healing: analysis of gap size and loading. J Biomech. 2002;35(9):1163–71. 12. Palomares KT, Gleason RE, Mason ZD, Cullinane DM, Einhorn TA, Gerstenfeld LC, Morgan EF. Mechanical stimulation alters

131 The Influence of Induced Micromovent Upon the Healing of Experimental Tibial Fractures tissue differentiation and molecular expression during bone healing. J Orthop Res. 2009;27(9):1123–32. 13. Shadmehr A, Esteki A, Oliaie GR, Torkaman G, Sabbaghian A. Augmentation of bone healing by specific frequency and amplitude compressive strains. Orthopedics. 2009;32(3):173.

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14. Wolf S, Augat P, Eckert-Hübner K, Laule A, Krischak GD, Claes LE. Effects of high-frequency, low-magnitude mechanical stimulus on bone healing. Clin Orthop Relat Res. 2001;385:192–8. 15. Yamaji T, Ando K, Wolf S, Augat P, Claes L. The effect of micromovement on callus formation. J Orthop Sci. 2001;6(6):571–5.

Morbidity at Bone Graft Donor Sites

132

Gunasekaran Kumar and Badri Narayan

132.1 Authors

132.5 Summary

Younger EM, Chapman MW.

Younger and Chapman undertook a retrospective review of orthopaedic, maxillofacial and neurosurgical patients undergoing autogenous bone graft during a 2-year period. The donor site that was close to recipient site and ribs were excluded. Several patients were lost to follow up but were included for early in hospital complications. Mean follow up time was 11 months. Complications were classified as early or late and as minor or major. There 239 patients with 243 grafts. The overall major complication rate was 8.6 % and minor 20.6 %. A statistical increase in risk of complications was present for the following: using the same incision for surgery and graft harvest and inner iliac table donor site. In their retrospective study of 54 patients in whom the incision for the primary procedure was also used to procure the graft from the posterior iliac crest, they reported 11 (20 %) major and 15 (28 %) minor complications. Complications were similar to other clean orthopedic surgeries. More complications were detected when a drain was used but this was confounded by the fact that a drain was used in bigger incisions and when a haematoma was anticipated. Some of the complications like hernia, pelvic fractures, injury to lateral cutaneous nerve of thigh could have been avoided with a more careful surgical technique whilst chronic pain cannot be completely avoided as all the risk factors are not known [1].

132.2 Reference J Orthop Trauma. 1989;3(3):192–195.

132.3 Institution Department of Orthoapedic Surgery, University of California, Davis Medical Center, Sacramento, California, USA.

132.4 Abstract A review of the medical records of 239 patients with 243 autogenous bone grafts was undertaken to document the morbidity at the donor sites. The overall major complication rate was 8.6 %. Major complications included infection (2.5 %), prolonged wound drainage (0.8 %), large hematomas (3.3 %), reoperation (3.8 %), pain >6 months (2.5 %), sensory loss (1.2 %), and unsightly scars. Minor complications occurred in 20.6 % and included superficial infection, minor wound problems, temporary sensory loss, and mild or resolving pain. There was a much higher complication rate (17.9 % major) if the incision used for the surgery was also the same incision used to harvest the bone graft.

G. Kumar, FRCS (Tr & Orth) (*) B. Narayan, MS (Orth), FRCS (Tr & Orth) Department of Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_132, © Springer-Verlag London 2014

132.6 Related References 1. Finkemeier CG. Bone-grafting and bone-graft substitutes. J Bone Joint Surg Am. 2002;84:454–64. 2. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res. 1997;(339): 76–81. 503

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3. Lowe JA, Rocca Della GJ, Murtha Y, Liporace FA, Stover MD, Nork SE, et al. Complications associated with negative pressure reaming for harvesting autologous bone graft: a case series. J Orthop Trauma. 2010;24(1):46–52. 4. O’Keeffe RM Jr, Riemer BL, Butterfield SL. Harvesting of autogenous cancellous bone graft from the: proximal tibial metaphysis: a review of 230 cases. J Orthop Trauma.1991;5:469–74.

G. Kumar and B. Narayan

132.10 Strengths This is the first paper to study complications at bone graft donor sites. Overall the number of patients in the study was reasonably large. This study was performed at a single institution with several surgeons and different specialities.

132.11 Weaknesses 132.7 Citations 933

132.8 Key Message Younger and Chapman report a major complication rate of 8.6 % and a minor complication rate of 20.6 % in their series of 243 autogenous grafts, including 215 grafts from the iliac crest. The authors reported that overall, patients with preexisting medical illness were at higher risk of complication than their healthier cohorts. Complication rates at autologous bone graft donor sites were acceptable and comparable to clean orthopedic surgeries. An increased complication rate occurred when the same incision was used for surgery and donor site and inner iliac table donor site. Major complications are less common than minor ones.

132.9 Why Is It Important Bone grafting is a commonly used surgical procedure, particularly in reconstructive orthopedic surgery. Bone graft may be used to fill skeletal defects created by tumors, infections, trauma, or congenital malformations; to bridge joints for arthrodesis; or to promote union at the site of delayed union, nonunion, fracture, or osteotomy. Previous retrospective studies assessing bone grafting complications reported considerable variations in the overall complication rates. The distinction between major and minor complications was often arbitrary, often poorly defined and widely variable between the series [2]. Despite the article being a retrospective study, donor site complications are well documented, the definition between major and minor complications is defined and study numbers are large. The study reported complication rates that were comparable with clean orthopedic surgery.

A retrospective study with the number of patients lost to follow up not mentioned. The statistics used were rudimentary with no in depth analysis into confounding factors. The authors do not provide complete details about the numbers and types of major and minor complications. Little was documented about the impact and duration of complications.

132.12 Relevance Autologous bone grafting is the best choice for enhancing bone repair and reconstructive bone defects. However, the use of autografts is hampered by the limited supply of bone grafts, the necessity of an additional incision site, donor site morbidity, nerve damage, and chronic pain of the donor site. This article puts into perspective the complications at donor site for autogenous bone graft. There were anecdotal mentions of iliac crest fracture, pelvic instabilities, lateral femoral cutaneous nerve or thigh injuries in iliac crest bone graft harvest surgery but none where a overall picture of the risks involved in bone graft harvest until this paper was published. Younger and Chapman divided complications at the donor site into minor and major. Minor complications were defined as self-limited events that did not require an additional surgical procedure and responded to non-operative management. Major complications were those that led prolonged hospitalization and required additional surgery. Early complications were those that occurred in the periopertive period, usually while the patient was still in hospital. This definition has been used in subsequent studies of iliac crest complication rates [1, 3]. Younger and Chapman reported rates of major and minor complications of 5.3 and 25 % at anterior iliac crest donor sites and 11.3 and 18.4 % at posterior sites. However, they stated that “some patients had more than one related complication” but only the most significant one was counted for statistical purposes. Ahlmann et al. [3] reported rates of major and minor complications of 8 and 15 %, respectively, in association with the anterior donor sites and 2 and 0 %, respectively, in association with the posterior donor sites.

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They recommended posterior harvesting of iliac crest bone graft whenever possible. The authors reported only a 2.5 % incidence of complaints of donor site pain greater than 6 months postoperatively. Pain was noted to be present only when documented in patients’ progress notes; continued pain was considered a major complication. This figure is a low compared to more contemporary studies [4]. DePalma et al. [5] reported discomfort lasting for more than 1 year in 36 % of their patients in whom an anterior iliac crest bone graft had been harvested. Goulet et al. [2] in a retrospective analysis after iliac bone graft harvest reported 33 of 87 (37.9 %) patients still had pain 6 months after surgery. The reported frequency of pain declined to 16 of 87 (18.3 %) patients at 2 or more years postoperatively, an incidence considerably higher than reported in Younger and Chapman’s article. Robertson and Wray [6] undertook a prospective study to examine bone graft donor site morbidity in 106 consecutive patients undergoing posterior spinal fusion. They found that whilst the major complication rate was low (1.9 %) for

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posterior iliac crest bone graft donation, donor site morbidity occurred in 35 % of patients.

References 1. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine. 1995;20(9):1055–60. 2. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res. 1997;339:76–81. 3. Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Joint Surg Am. 2002;84:716–20. 4. Heary RF, Schlenk RP, Sacchieri TA, Barone D, Brotea C. Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery. 2002;50(3):510–6; discussion 516–7. 5. DePalma AF, Rothman RH, Lewinnek GE, Canale ST. Anterior interbody fusion for severe cervical disc degeneration. Surg Gynecol Obstet. 1972;134(5):755. 6. Robertson PA, Wray AC. Natural history of posterior iliac crest bone graft donation for spinal surgery: a prospective analysis of morbidity. Spine. 2001;26(13):1473–6.

Osseointegrated Titanium Implants: Requirements for Ensuring a Long-Lasting, Direct Bone-to-Implant Anchorage in Man

133

Gunasekaran Kumar and Badri Narayan

133.1 Authors Albrektsson T, Brånemark PI, Hansson HA, Lindström J.

133.2 Reference Acta Orthop Scand. 1981;52:155–170.

133.3 Institution Laboratory of Experimental Biology, Department of Anatomy, Department of Histology and Department of E. N. T. Surgery, University of Gothenburg and the Institute for Applied Biotechnology, Mölndal, Sweden.

133.4 Abstract A total of 2,895 threaded, cylindrical titanium implants have been inserted into the mandible or the maxilla and 124 similar implants have been installed in the tibial, temporal or iliac bones in man for various bone restorative procedures. The titanium screws were implanted without the use of cement, using a meticulous technique aiming at osseointegration – a direct contact between living bone and implant. Thirty-eight stable and integrated screws were removed for various reasons from 18 patients. The interface zone between bone and implant was investigated using X-rays, SEM, TEM and histology. The SEM study showed a very close spatial relationship between titanium and bone. The pattern of the anchorage of collagen filaments to titanium appeared to be similar to that of Sharpey’s

G. Kumar, FRCS (Tr & Orth) (*) B. Narayan, MS (Orth), FRCS (Tr & Orth) Department of Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK e-mail: [email protected] P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_133, © Springer-Verlag London 2014

fibres to bone. No wear products were seen in the bone or soft tissues in spite of implant loading times up to 90 months. The soft tissues were also closely adhered to the titanium implant, thereby forming a biological seal, preventing microorganism infiltration along the implant. The implants in many cases had been allowed to permanently penetrate the gingival and skin. This caused no adverse tissue effects. An intact bone-implant interface was analyzed by TEM, revealing a direct bone-to implant interface contact also at the electron microscopic level, thereby suggesting the possibility of a direct chemical bonding between bone and titanium. It is concluded that the technique of osseointegration is a reliable type of cement free bone anchorage for permanent prosthetic tissue substitutes. At present, this technique is being tried in clinical joint reconstruction. In order to achieve and to maintain such a direct contact between living bone and implant, threaded, unalloyed titanium screws of defined finish and geometry were inserted using a delicate surgical technique and were allowed to heal in situ, without loading, for a period of at least 3–4 months.

133.5 Summary Albrektsson et al. reported on the microscopic examination of long term well functioning titanium screws retrieved from human subjects. Analysis showed osseointegration of all screws tested. The authors discuss the factors that could potentially affect osseointegration. Thirty-eight titanium screws were removed from the mandible, maxilla, tibia, temporal bone and tibia for non implant related issues. Implants were removed with a core of bone around the screws and analysed with radiographs, light and electron microscopy and histology. All implants examined with radiographs, light microscopy and scanning electron microscopy showed excellent osseointegration. Osteocytes, collagen fibres like Sharpey’s fibres reached the surface of implants. Examination of bone showed no toxic or inflammatory reaction and no titanium 507

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particles in the nearby bone. The authors also discuss the potential factors that could affect this osseointegration between bone and titanium implants. In addition the authors briefly mentioned the possible use of titanium in joint replacement surgery.

133.6 Citation Count 1,016

G. Kumar and B. Narayan

This included the first report of Transmitting Electron Microscopic examination at bone implant junction.

133.11 Weaknesses The authors propose factors that could affect osseointegration of implants. However, they did not study implants removed for implant related issues. Microscopic analysis of implants with problems could have shed light on mechanisms of osseointegration failures.

133.7 Related References 133.12 Relevance 1. Khanuja HS. Cementless femoral fixation in total hip arthroplasty. J Bone Joint Surg Am. 2011;93:500. 2. Le Guehennec L, Lopez-Heredia MA, Enkel B, Weiss P, Amouriq Y, Layrolle P. Osteoblastic cell behaviour on different titanium implant surfaces. Acta Biomater. 2008; 4(3):535–43. 3. Linder L, Carlsson A, Marsal L, Bjursten LM, Brånemark PI. Clinical aspects of osseointegration in joint replacement. A histological study of titanium implants. J Bone Joint Surg Br. 1988;70:550–5.

133.8 Key Message At the time of publication many authors believed that osseointergration was possible only with non-metallic implants. This article provided evidence that permanent anchorage of bone to titanium implants was possible. At a time when the convention was bone implant integration by cement, this article provided proof for the concept of cement free bone integration – osseointegration. On the basis of human retrieval studies, Albrektsson et al. described “osseointegration” as the attachment of lamellar bone to implants without intervening fibrous tissue.

133.9 Why Is It Important Insights into cellular processes occurring at the bone-implant interface are important for the understanding of biocompatibility and osseointegration.

133.10 Strengths This is a comprehensive report on the analysis of microscopic interface and histological evidence for biological compatibility of titanium implants in the human model. Implant surfaces and nearby bone were assessed with the best possible equipment available at the time of publication.

The biological concept of osseointegration was first introduced by Branemark et al. in the 1960s. Since its introduction the term osseointegration has been successively redefined, the common denominator being an inanimate metallic structure anchored long-term in living bone under functional loading. Before 1981, bone cement was the accepted interface for implant stability [1]. Most of the published literature at that time did not believe that osseointegration was possible between metal and bone due to a possible fibrous layer separating bone and metal [2, 3]. If the implant was ceramic then, osseointegration was possible. Several studies were not in favour of a bone metal interface due to the formation of fibrous interface. Though there were publications on uncemented hip replacements, cemented hip replacements provided consistent results. However, cemented total hip replacements also had their problems such as wear and aseptic loosening. The authors had experience of nearly 20 years with implanting almost 3,000 titanium implants inserted into humans – mainly into the mandible or maxilla and also into temporal, tibia and ilium. The potential factors that could affect osseointegration of titanium include, implant material (inert and non corrosive), implant design, implant finish (rough surface better than smooth), healthy bone bed and good surgical technique with minimal soft tissue damage. According to Albrektsson the quality of the implant surface was one major factor that influences wound healing at the implantation site and subsequently affects osseointegration. In recent years, much effort has been made to improve implant anchorage in bone tissue by modifying the surface characteristics of titanium implants [4–6]. The authors were cautious in recommending titanium for possible use in arthroplasty as the bearing surface had poor wear properties. Subsequent finding by Agins of black metallic wear debris deposited in the periarticualr tissues surrounding titanium alloy prostheses suggested this guarded approach was well founded [7].

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Osseointegrated Titanium Implants: Requirements for Ensuring a Long-Lasting, Direct Bone-to-Implant Anchorage in Man

Later human retrieval analyses of femoral stem implants have led to a better understanding of osseointegration [8, 9]. Adequate osseous contact and firm fixation of the implant minimize micromotion. Micromotion of >150 mm leads to fibrous tissue formation, between 40 and 150 mm leads to a combination of bone and fibrous tissue formation, and 40 mm/h), refusal to bear weight, and an elevated serum WCC (>12,000/mm3) (Table 156.1).

156.7 Key Message The above three studies identified predictive criteria to confirm the diagnosis of septic arthritis of the hip. Among 20 criteria investigated, 5 were significantly predictive: nonweight-bearing, ESR >40 mm/h, fever (>38.3), WBC >12,000 mm3 and CRP level (>20 mg/l).

156.5 Citation Count 89

156.6 Related References 156.8 Strengths 1. Kocher MS, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86:1629–35. [1] In this study the same authors tested the above developed criteria prospectively on 213 patients between

This study and its re-validation study are regarded as level I evidence for diagnostic studies. It is a well design study with a clear golden standard definition of outcome. Although, this definition of outcome can be debated, it is widely accepted as the best available.

Table 156.1 Summary of predictors for septic arthritis Predicted probability of septic arthritis (%) No. of predictors 0 1 2 3 4 5

Kocher et al. (1999) [3] 0.2 3 40 93.1 99.6

Kocher et al. (2004) [1] 2 9.5 35 72.8 93

Caird et al. (2006) [2] 16.9 36.7 62.4 82.6 93.1 97.5

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Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children

156.9 Weaknesses As a retrospective study, the accuracy of the data remains in question. This may explain the discrepancy in the result of the three studies but it also may reflect a play of chance. There is significant number of patients excluded from the study (114–40 %). Although it was not unreasonable to exclude these patients, this reduced the generalisability of the findings.

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a relatively low number of patients with true septic arthritis. Predictive values are properties of the test’s interacting with the prevalence of disease in the population and this should be taken in consideration in areas or fields where septic arthritis is more prevalent. Hence, clinical judgment taking the above criteria in consideration is essential in dealing with this common clinical presentation.

References 156.10 Relevance Ruling out the diagnosis of septic arthritis can be challenging, particularly in the early stages. Although the above criteria appear on the surface to be quiet helpful, in reality they are not. A patient with no single predictive criterion still has (0.2–17 %) chance of having septic arthritis. Most patients present with one to two predictive criteria. This means the risk of septic arthritis ranged from 3 to 62 %. The study had

1. Kocher MS, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86:1629–35. 2. Caird MS, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006;88:1251–7. 3. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999;81:1662–70.

Part XIII Miscellaneous Topics

157

Levels of Evidence Sattar Alshryda and James Wright

The concept of evidence based medicine (EBM) probably began with Professor Archie Cochrane, a British medical researcher in the 1970s who wrote in 1979 “It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials” [1]. Subsequently, scientists such as David Eddy of North Carolina and Gordon Guyett and David Sackett of Hamilton advanced Cochranes’ work by promoting randomized trials and coined the term ‘evidence-based medicine”. Evidence-based medicine has been defined as “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients” [2]. However, determining the best evidence is controversial [3]. While a number of systems exist to categorize studies by levels of evidence, they differ in content and have been developed mostly from consensus expert opinions and have not been validated [4]. Examples of these systems are the American College of Chest Physicians (ACCP) [5], Oxford Centre for Evidence-Based Medicine (OCEBM) [6], the Scottish Intercollegiate Guidelines Network (SIGN) [7] and the Journal of Bone and Joints Surgery Levels of Evidence [8]. There are three steps involved in assigning a level of evidence to a study [8]. The first step is to determine the primary research question. Not all studies are clear about the primary research question and some studies may have more than one research question. There are several places where the primary research question can be found; the abstract, the introduction, the

S. Alshryda, MRCS, FRCS (Tr & Orth), MSc, PhD (*) Department of Trauma and Orthopaedic Surgery, Royal Manchester Children’s Hospital, Manchester, UK e-mail: [email protected] J. Wright, MD, MPH, FRCSC Robert B. Salter Chair of Paediatric Surgical Research, Hospital for Sick Children, Toronto, ON, Canada P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, DOI 10.1007/978-1-4471-5451-8_157, © Springer-Verlag London 2014

conclusion or the results. Journal reviewers and editors have a role to ensure that the study purpose and hypothesis are explicit. The second step is to determine the study type: therapeutic, prognostic, diagnostic, and economic or decision analyses. Therapeutic studies evaluate the effect of intervention on the outcome of disease, whereas prognostic studies evaluate the effect of patient characteristics on the outcome of disease. Sometimes, the difference between them can be subtle but important. A simple way to differentiate between therapeutic and prognostic studies is if the factor being studied could be randomly allocated then the study is a therapeutic study. In contrast, patient age, sex, stage of disease or fracture type cannot be randomly allocated to two groups of patients, and therefore any study evaluating the effect of these factors on outcome would be a prognostic study. Diagnostic studies deal with different aspects of evaluating diagnostic tests. Economic or decision analyses evaluate and compare the costs and outcomes of an intervention. The third step is to assign a level to the study, with the number of levels varying by the different systems while each level has different criteria. The general principles of the hierarchy is that controlled studies are generally better than uncontrolled ones, prospective are generally better than retrospective, and randomized are generally better than nonrandomized studies [8]. These are further divided into sub-levels depending on the quality of methodology and or results. Table 157.1 summarizes the levels and sublevels recommended by the Journal of Bone and Joint Surgery [9]. It is important to appreciate that the level of evidence hierarchy is not proposed as an absolute rule. Although RCTs or meta-analyses are rated as the best evidence, well conducted non-randomised trials or cohort studies may provide the same or sometimes even better evidence. Moreover, where “low level” observational studies unequivocally demonstrate clear advantage for an intervention, RCTs are not required and it may be unethical to conduct one. There are several examples in orthopedic practice when a case series (level IV evidence) had changed practice significantly. Charnley hip replacement and Ponseti’s treatment of clubfoot are the classical examples. 591

S. Alshryda and J. Wright

592 Table 157.1 Levels of evidence

Level I

Level II

Prognostic studies— investigating the effect of a Therapeutic studies—investigating the patient characteristic on the results of treatment outcome of disease High-quality randomized controlled High-quality prospective trial with statistically significant studyc (all patients were enrolled at the same point in difference or no statistically their disease with ≥80 % significant difference but narrow follow-up of enrolled confidence intervals patients) Systematic reviewa of Level-I Systematic reviewa of Level-I randomized controlled trials (and studies study results were homogeneousb) Lesser-quality randomized controlled Retrospectivee study trial (e.g.,