Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 466 | Issue 1 | Jan, 2008

Arthrodesing Operations on the Feet

Richard A. Brand MD Dr. Edwin Warner Ryerson was born in New York City, graduated from Harvard, then trained at Boston Children’s Hospital [1]. After visiting centers in Berlin and Vienna he moved to Chicago in 1899, where he accepted a post at Rush Medical College. In 1916 he was named professor and head of orthopaedics at the University of Illinois College of Medicine. Owing to WWI he entered military service in 1918–1919. Afterward he became head of orthopaedics at Northwestern University until his retirement from the university in 1935. He continued in private practice until 1947, when he retired to Florida.,Dr. Ryerson maintained a lifelong interest in teaching and service to the orthopaedic community. He became a member of the American Orthopaedic Association in 1905 and was President in 1925. Dr. Ryerson was active in the Clinical Orthopaedic Society, which also had a role in forming American Academy of Orthopaedic Surgeons [4]. In the archives of the AAOS, he was described as “a forensic and parliamentary expert” [6]. He was a founding member of the American Board of Orthopaedic Surgery in 1934, became its vice President in 1935, and served on the Board until 1940 [11].,[object Object],[object Object],[object Object]

Arthroplasty of the Elbow

Richard A. Brand MD Willis Cohoon Campbell was born in Jackson, Mississippi in 1880. He received his undergraduate training in his home state and medical training at the University of Virginia, Charlottesville, where he graduated in 1924 [5]. After serving a two-year internship, he went into private practice in Memphis, Tennessee. As with other prominent orthopaedic surgeons (Ryerson among them), he visited medical centers in Europe, particularly London and Vienna. He evidently then spent some time in postgraduate work in New York City prior to returning to private practice in Memphis. (Most formal residencies were not established until the 1930s coincident with the formation of the American Board of Orthopaedic Surgery in 1934, although many doctors took “postgraduate” work following one or two years of internship in general medicine or surgery.) In 1910, he was asked to organize a Department of Orthopaedic Surgery at the University of Tennessee Medical School as the first Professor of Orthopaedics, a post he held until his death.,In addition to forming a department for the university, Campbell helped establish one of the first hospitals for crippled children in the south, then the Willis Cohoon Campbell Clinic in 1920 [1], and finally in 1923 the Hospital for Crippled Adults. The Campbell clinic provided postgraduate training, meeting the requirements of the American Board for the Certification of Specialists. Dr. Campbell, while not one of the original nine board members of the American Board of Orthopaedic Surgery, was influential in establishing the Board in 1934. According to Wickstrom [4], a “...persistent rumor, repeatedly denied, held that Henderson (Melvin) and Campbell were the primary movers behind the establishment of both the American Academy of Orthopaedic surgeons and the American Board in Orthopaedic Surgery; their actions were said to be a retaliatory response to their rejection by the orthopaedic establishment ‘in the East.’” Be that as it may, Dr. Campbell served as President of a number of professional organizations [1]. He published many papers and three monographs, including the classic “Operative Orthopaedics” [3], which has gone through 10 editions, was the standard textbook for orthopaedic surgeons for decades and remains one of the most widely read references. Dr. Campbell was widely known as a kind, courteous man [5].,The article reproduced here describes arthroplasty of the elbow to restore motion to ankylosed joints [2]. In this article Campbell recognized some of the described resection arthroplasties (usually with interposition of various materials) left the elbow unstable and weak. He advocated creating a “double flap” of the triceps aponeurosis and underlying periosteum and suturing that to the anterior capsule of the elbow after resecting bone. This, he suggested, allowed functional motion within 6 months in the two cases he described. Interestingly, in his “Operative Orthopaedics” published in 1939, he recommends covering the exposed bony surfaces with fascia lata, and does not describe attaching the flap of the triceps to the anterior capsule, but rather suggests attaching “at a lower point than its former attachment to permit free play of the joint in flexion” [3].,[object Object],[object Object]

Follow-Up Study of the Use of Refrigerated Homogenous Bone Transplants in Orthopaedic Operations

Richard A. Brand MD Philip Duncan Wilson was born in Columbus, Ohio. His father was a family physician who held the Chair of Obstetrics in the Sterling Medical School [1]. The young Philip graduated from Harvard College in 1909 and then served as President of his graduating class at Harvard Medical School. He spent two years as a surgical intern at MGH, after which he returned to Columbus to practice. During WWI he was invited back to Boston to join the Harvard Unit under Harvey Cushing, and served with that unit when it was housed in the Lycée Pasteur. (The members of that unit included Marius Smith-Petersen, who also spent many years at the Massachusetts General Hospital and also became AAOS President.) He rejoined MGH on the staff in 1919. In 1925 he published an influential monograph with W.A. Cochrane (formerly of the Edinburgh Royal Infirmary), entitled, “Fractures and Dislocations” [5].,Toward the end of his years in Boston he helped found the American Academy of Orthopaedic Surgeons. In 1934 he was appointed as Surgeon-in-Chief at the Hospital for the Ruptured and Crippled in New York City. Dr. Wilson was active in many organizations, and reorganized and renamed the hospital he served (Hospital for Special Surgery), oversaw the building of a new hospital at its current site on the Cornell University medical campus, and raised money for a large research building. His zest inspired generations, and he was known for his gracious hospitality.,Dr. Wilson was one of three of the first fifteen Presidents (the others being Drs. John C. Wilson, Sr. and Melvin Henderson) whose son (Dr. Philip D. Wilson, Jr.) succeeded him as a President of the American Academy of Orthopaedic Surgeons.,[object Object],[object Object],[object Object]

The Use of Sulfathiazole in the Treatment of Subacute and Chronic Osteomyelitis*

Richard A. Brand MD [object Object],Dr. Dickson was one of eight individuals at the business meeting of the Clinical Orthopaedic Society, October 30, 1931, when the first concrete steps toward organizing the AAOS were taken [2]. (The Clinical Orthopaedic Society had originally been established as a regional association in 1912 as the Central States Orthopaedic Club with a name change in 1923 to the Clinical Orthopaedic Society [1].) Dr. Dickson was involved in a number of organizations, and was President not only of the AAOS but also the AOA in 1940 (he later served as the AOA treasurer in 1951) and the Clinical Orthopaedic Society [4], the two organizations which founded the AAOS.,[object Object],[object Object],[object Object]

Fractures of the Femur. End Results*

Richard A. Brand MD Melvin Starkey Henderson was born in St. Paul, Minnesota and received his early schooling there and in Winnipeg, Manitoba [4]. He received his undergraduate and medical degrees from the University of Toronto. He then interned in the City and County Hospital in his home town of St. Paul, and in 1907 went to work as an assistant with the founders of the recently formed Mayo Clinic, William James and Charles Horace Mayo. To further his training and evidently at the suggestion of the Mayo brothers, in 1911 Dr. Henderson went abroad to work under Sir Robert Jones in Liverpool and then Sir Harold Stiles in Edinburgh. He returned to organize and direct the section of orthopaedic surgery at the Mayo Clinic and spent his entire professional career there.,Dr. Henderson was involved in many national and international organizations, and was a founder and first President of the American Board of Orthopaedic Surgeons when it was established at the Kahler Hotel in Rochester, Minnesota, on June 5, 1934, after several previous organizational meetings [5]. Wickstrom [5], describing the organization of the Board, commented, “After all, in the opinion of the East coast establishment, Dr. Henderson (who was born in St. Paul, was educated in Canada, and had his beginning with the Mayo brothers as a clinical assistant riding a bicycle around Rochester, making house calls on the Mayo brothers’ patients) was a mere upstart.” However, at the time Dr. Henderson was 50 years old and had been President of the American Orthopaedic Association and Clinical Orthopaedic Society, as well as prominent in the American Medical Association and other organizations. Dr. Henderson was one of three of the first 15 AAOS Presidents (the other two being Drs. Philip D. Wilson and John C. Wilson, Sr.) who had a son who succeeded him as President. He was greatly respected for his organizational abilities, particularly at the Board, whose objectives were uncertain in the beginning and required sage guidance [5].,[object Object],[object Object],[object Object]

Transplantation of Entire Bones with their Joint Surfaces

Richard A. Brand MD Arthur Bruce Gill was born in Western Pennsylvania and obtained his undergraduate degree at Muskingum College in New Concord, Ohio [1]. He then obtained his medical degree at the University of Pennsylvania in 1905, interned there, and remained on the staff for 47 years. He became the third chairman of that department in 1920. He was active in a large number of organizations well into the 1950s.,One writer noted he “...was not a prolific writer, but whatever he wrote was extremely clear and well prepared. There are sixty-nine publications listed under his name in the Index Medicus and Quarterly Cumulative Index...” [1] A substantial number of those publications related to problems of childhood and at least six related to new procedures. Yet, Dr. Gill was wary of new operations. In his Presidential lecture at the AAOS in 1938, he wisely commented, “Let us beware of adopting new methods too hastily.” He added, “Are too many operations performed in the practice of orthopaedic surgery?...many of our young men believe that they can attain distinction only by the invention of a new operation,” and recognized the need to refrain from “fads and fancies” [3].,We republish an abridged version of experiments he performed in 1914 in which he transplanted whole bones with their joint surfaces within one animal [2]. Portions excluded include his description of the six operations and their results, and a scholarly discussion of the knowledge of transplantation and regeneration at the time. (Interested readers in such material would be well advised to also review an extensive discussion of the knowledge of bone biology in Sir Arthur Keith’s classic monograph, “Menders of the Maimed” [4].) Dr. Gill concluded fresh bone with cartilage surfaces was readily transplantable as long as “periosteum, medulla, and bony tissue” were all included in the graft. Immunology as a field was not well developed at the time, nor the known problems with transplantation between individuals and species. Nonetheless, his experiments formed a basis for the principles of whole bone transplantation.,[object Object],[object Object]

Fractures of the Neck of the Femur in Childhood

Richard A. Brand MD John Cree Wilson, Sr, was born in Santa Ana, California, and received his undergraduate degree from the University of California in 1908 and medical degree from the University of California, San Francisco, in 1912 [2]. He had a one year internship, then entered private practice, but apparently believed he needed more training and in 1916 quit his private practice for postgraduate training at the Massachusetts General Hospital. He completed that training, then served in military hospital at Fort McPherson, Georgia, when the US entered WW I. Following discharge he moved to Los Angeles, working at the Los Angeles General Hospital and then the Children’s Hospital of Los Angeles. He became Chief of the Orthopaedic Division at the Children’s Hospital, a post he retained until 1955.,Wilson was one of the first three AAOS Presidents (the others being Drs. Melvin Henderson and Edwin Ryerson) who was also a founding member of the American Board of Orthopaedic Surgery in 1934 [3]. He was also one of the first three AAOS Presidents (the others being Philip D. Wilson and Melvin Henderson) who had a son, John C. Wilson, Jr, who later served as a President of the AAOS. In his Presidential Address to the AAOS in Memphis, Tennessee in 1939, he noted, “It is indeed gratifying to see that our Program Committee has stepped outside the bounds of our specialty to bring speakers from other fields of medicine. A good orthopaedic surgeon must first of all be a good doctor…Unfortunately, many specialists see problems from only one point of view. Such short vision inevitably produces detrimental results which might often be avoided by more frequent exchange of ideas with out medical colleagues” [1].,The article we highlight, “Fractures of the Neck of the Femur in Childhood” [4], relates to his primary interest, children’s orthopaedics. He commented, “A review of the English literature on the subject of fractures of the neck of the femur in childhood leaves one with the impression that they respond to the regular forms of treatment as do those in adults…A study of the author’s series of cases gives rise to a somewhat different view.” He acknowledges several earlier case reports suggesting higher rates of complications, and added to that small literature his own series of ten patients. In documenting the outcomes he remarked, “A study of this series of patients forces us to conclude that fractures of the neck of the femur in childhood are serious injuries.” Clearly, Wilson was one to challenge dogma. One observer remarked, “There were no ex cathedra pronouncements by the Chief, but rather an opportunity for each resident and attending staff member to state his viewpoint and opinions, which were deferentially sorted, analyzed, and coordinated by the Chief” [2].,[object Object],[object Object]

Elbow and Shoulder Lesions of Baseball Players*

Richard A. Brand MD George Eli Bennett was born in Claryville, NY, in the Catskill Mountains, in 1885 [3]. His parents both died by the time he was 11, leaving him the need to work while going to school, but he excelled in school and sports. He played semipro baseball at the age of 16. After high school he work in various jobs in the Midwest before he could afford to attend the University of Maryland Medical School, from which he graduated in 1908. At the age of 25 in 1910, he joined the staff at the Johns Hopkins Hospital, where he remained until his resignation in 1947.,Dr. Bennett was one of a few men who served as President of both the American Orthopaedic Association and the American Academy of Orthopaedic Surgeons. While Dr. Bennett made many contributions to orthopaedic surgery, including children’s and nonoperative orthopaedics, he was best known for his work in sports medicine (undoubtedly related to his being a gifted athlete). His fame extended well beyond the orthopaedic community, for he treated many famous athletes. Sports Illustrated recognized him upon his death in an article entitled, “Mender of Immortals” [4]. His intimate knowledge of sports undoubtedly contributed to his sage judgments. At an emotional dinner in 1958 many famous athletes sometimes tearfully paid tribute to Dr. Bennett. Joe Garagiola commented on the occasion, “After listening to that all-star team of players Dr. Bennett has mended, I’m sorry I didn’t break my leg” [4].,[object Object],[object Object],[object Object]

Congenital Elevation of the Scapula

Richard A. Brand MD Dr. Robert D. Schrock was born in 1884 in Delaware, Ohio [3]. His father, William A., was a physician, as was his son, Robert D., Jr. The family subsequently moved to Decatur, Indiana. Dr. Robert Schrock obtained his undergraduate work at Wabash College, Crawfordsville, Indiana, in 1908 [2] and his medical degree at Cornell University Medical School in 1912 [2]. He completed postgraduate work at the New York Hospital in New York City. He briefly practiced in Omaha with Dr. John Lord, then served as a surgeon in WW I, working under Lt. Col. Joel Goldthwait in France. After the war he returned to Omaha to again practice with Lord. In 1921 he was appointed to the faculty of the University of Nebraska School of Medicine and became Professor and Chair in 1932, a post he held until 1949, when he became Professor Emeritus.,Dr. Schrock became active in many medical organizations and in 1928 was elected President of the Clinical Orthopaedic Society, one of the two major groups that founded the AAOS, and was also active in the other, the American Orthopaedic Association. He was, as a result, involved in the early foundations of the AAOS, and became its President in 1940. He served as a civilian consultant to the Secretary of War from 1943 to 1945. With great prescience he commented in his Presidential Address to the AAOS in 1941 about Board certification, “This is not a hallmark of excellence in perpetuity. Products are frequently certified for a definite period of time if maintained under certain optimum conditions. Some people, like products, improve with advancing years, others deteriorate and some in cold storage remain frigidly good but no better. Orthopaedic surgeons, like human beings, are influenced by environment, necessity, ambition, health and avocational interest in other pursuits of happiness…If the measure of continued merit is to be maintained through our oncoming years, there need be an awareness of change, open mindedness to new concepts, elasticity in viewpoint, with a ready reception and stimulating encouragement to the newer generation whose future is in the making” [3].,[object Object],[object Object],[object Object]

Two Hundred Cases of Paralytic Foot Stabilization after the Method of Hoke

Richard A. Brand MD Dr. Oscar Lee Miller was born on a farm in Franklin County, in northeast Georgia [6]. He obtained a teachers’ certificate and taught school several years after high school before he attended the University of Georgia and then graduated from the Atlanta College of Physicians and Surgeons (now Emory University School of Medicine) in 1912. He took postgraduate training in Atlanta, working with Dr. Michael Hoke (whose name is associated with hindfoot arthrodesis). He entered military service in 1917, then returned to private practice after the armistice. As with other first Presidents of the AAOS, foreign experience was important, and in 1921 he visited Sir Robert Jones and other British surgeons. Upon returning he moved to Gastonia, North Carolina and helped develop the North Carolina Orthopaedic Hospital, an institution focusing on crippled children. In 1923, he opened an office which eventually became the Miller Clinic in nearby Charlotte. (The Miller Clinic and Charlotte Orthopedic Specialists merged in 2005 to create OrthoCarolina.),Dr. Miller was active in the AOA as well as the AAOS, and was a member of the Argentine Surgical Association. He became President of the AAOS in January, 1942, only days after the bombing of Pearl Harbor. In his Presidential address he emphasized the importance of the care of crippled children and urged a strong relationship with the Latin American orthopaedic community [1]. He served as Chair of a committee that created the Inter-American Orthopaedic Fellowship Program, for Latin American surgeons to visit training centers in the US. He also urged the AAOS to develop a library “as a repository for all pertinent records.” The Executive Committee outlined a program in June, 1941, to present a “motion picture exhibit,” a feature of the meeting which subsequently became the Instructional Course Lecture [2]. Under his leadership at that meeting, the AAOS passed a resolution regarding support of the country during the war years: “It is the desire of the American Academy of Orthopaedic Surgeons to offer its wholehearted support to our Country in this serious emergency.” A telegram with the resolution was sent to the President of the United States.,[object Object],[object Object],[object Object]

Etiology of Congenital Dislocation of the Hip

Richard A. Brand MD Dr. Carl E. Badgley was born in 1893, the son of a Presbyterian minister [2]. He received his medical degree at the University of Michigan in 1919, and became interested in orthopaedic surgery owing to Drs. Hugh Cabot and LeRoy Abbott. He was appointed as an instructor of surgery in 1920 and was appointed professor and head of the Section of Orthopaedic Surgery in 1932, an appointment he retained until 1963 when he retired.,[object Object],[object Object],[object Object],[object Object]

Local Chemotherapy with Primary Closure of Septic Wounds by Means of Drainage and Irrigation Cannulae

Richard A. Brand MD Marius Nygaard Smith-Petersen was born in Grimstad, Norway, of a prominent merchant marine family in 1886 [2]. He came to the States with his mother in 1903 and, initially unable to speak English, completed high school in Milwaukee, Wisconsin, in 1906. He then attended the University of Chicago (1906–07) and graduated from the University of Wisconsin (1910) and the Harvard Medical School (1914) [4]. He completed his surgical internship under Harvey Cushing at the Peter Bent Brigham Hospital, then his postgraduate orthopaedic training under Dr. Elliott Gray Brackett, at the Massachusetts General Hospital and became his assistant in practice 1917. In 1922 Dr. Smith-Petersen entered private practice in Boston, working at the Massachusetts General Hospital. He continued working there with a heavy clinic and operating schedule until shortly before his death from a brief illness in 1953 at the age of 67.,Dr. Smith-Petersen traveled widely, was active in many national and international societies, and received many international awards and honorary memberships. As with other Presidents during the war years, he faced challenges organizing the annual meeting for 1944, although the number of members and guests attending had increased (to 1,018) compared to 1943 [3]. During his tenure the first volume of the Instructional Course Lectures was published. He had an extraordinary capacity for work and ability to focus [2], reflected in his creativity scholarly productivity.,The article we reproduce here reflects not only Smith-Petersen’s innovative thinking, but his willingness to accept challenge with a new approach [7]. In 1934 he began using suction-irrigation cannulae made of glass to allow intermittent irrigation in patients with osteomyelitis in whom the wounds had been tightly closed about the cannulae. For the time, when open packing of chronic osteomyelitis as advocated by Orr was a standard [1], Smith-Petersen’s approach was radical. He commented, “Several members of the Osteomyelitis Service did not look with favor upon this method of treatment, and the orthopaedic surgeon responsible for the treatment did not feel any too confident; consequently, the cases treated in this manner were few and far between, and progress was proportionally slow” [7]. He modified the cannulae design from round to oval to help prevent leakage and began constructing them from vitallium in 1938 to avoid breakage. Initially he used Dakin’s solution, but then tried a silver-pectinate solution, and in the year before publication (1945) began using penicillin. His willingness to continuously modify his approaches (exemplified with other innovations, including the tri-flanged nail [5] and mold arthroplasty [6]) attests to his sense of responsibility and humility. “A great responsibility,” he commented, “rests on the surgeon who introduces a new method of treatment. The desire to have a new idea published is so great that the originator is often led astray, and the method is broadcast before it has proved worthwhile, and before the technique has been perfected” [4].,[object Object],[object Object]

Early Active Motion in Joint Pain and Stiffness

Richard A. Brand MD E. Bishop (“Bish”) Mumford was born in 1879 in Indiana [2] (most likely in or near New Harmony, the birthplace of both of his parents, who were committed to Robert Owen’s concept of that socialistic community established by Owen in 1826 [4]). He graduated from the University of Wisconsin in 1901 and Johns Hopkins in 1905. He obtained postgraduate training at Boston Children’s Hospital and Gouverneur’s Hospital (a hospital originally established to provide care for low income patients of color) in New York. He returned to Indiana to establish a practice in children’s orthopaedics. His practice was interrupted by WW I, where he served as a captain in a base hospital in France. He returned after the war and in 1920 opened the Indianapolis Industrial Clinic with Dr. Jay Reed. He later was appointed to the faculty at the Medical College of Indiana and was one of the first surgeons appointed to the James Whitcomb Riley Hospital for Crippled Children and the first surgeon appointed to the Veteran’s Administration Hospital of Indiana. He continued his appointments at these and other hospitals until his death.,Dr. Mumford was one of the founding members of the AAOS, and was one of eight members listed as attending the business meeting of the Clinical Orthopaedic Society, October 30, 1931, where the concept of a new national organization was discussed [1]. While the record is not entirely clear, Mumford apparently served on the Executive Committee of the AAOS from 1931 (when according to Heck the AAOS was chartered [3]) until 1944, then as President-Elect, President from 1945–1946, and continued on the Executive Committee until 1950 [2]; that being the case, he would have served on the Executive longer than any of the original founders (and perhaps longer than anyone since). He is the only AAOS President to have served two terms: at the written request of the Office of Defense Transportation in 1944, the January, 1945 meeting was canceled, and he remained President during the subsequent year, presiding over the 1946 meeting. He was active in the AOA and the Clinical Orthopaedic Society (he served as Secretary-Treasurer, Vice-President, and President in 1933, the year of the first meeting of the AAOS), as well as the Indianapolis Board of Health, the American College of Surgeons and other organizations. Among all of his many clinical responsibilities and activities in the 1930s, he found time to assume from his father the management of his family’s 5800 acre farm in Indiana.,[object Object],[object Object],[object Object]

Clinical and Experimental Observations with Regard to the Injection of Certain Agents (Pregl’s Solution) into Chronic Arthritic Joints

Richard A. Brand MD J.E.M. (Tommy) Thomson was born in Los Angeles, California in 1989, of “pious and scholarly” parents with “evangelistic...interests” [3]. His grandfather had been a missionary bishop in the Methodist Church. He attended Evanston Academy and then Northwestern University. While he began his medical studies at Texas Christian College, he completed his medical education at Rush Medical College in 1915. He took an internship in Chicago, where his mentors reportedly included Drs. Edwin Ryerson (first President of the AAOS), John Ridlon, and Dallas Phemister [3]. In 1916 he began medical practice with H. Winnett Orr in Lincoln, Nebraska. During WW I he served in the University of Nebraska Overseas Base Hospital No. 49. He returned to practice after the war in 1919 and remained in Lincoln during his professional life. In addition to his professional interests, he and his wife shared an interest in cattle breeding and for a while had extensive ranching interests in Nebraska. The last few years of his life were spent in semiretirement in Rancho Santa Fe, California.,Dr. Thomson traveled widely and made many friends worldwide. In 1955 he took a trip around the world but he had many other travels and was an honorary member of a number of foreign orthopaedic societies including the Czechoslovakian Orthopaedic Society, The Polish Orthopaedic and Trauma Society, the Finnish Orthopaedic Association, and the Latin American Society of Orthopaedics and Traumatology. Dr. Thomson traveled to all continents except Australia. He was a founding member of the Orthopaedic Research society. As with a number of the early offices of the AAOS, Dr. Thomson was active in the American Orthopaedic Association and the Clinical Orthopaedic Society and served as President of the latter in 1936. The Instructional Course Lectures were evidently his “brainchild” [3]. The record is unclear of the beginnings, although they evidently arose out of motion picture exhibits. What is clear is the first Instructional Course Lectures were presented in 1942 and published in 1943 with Dr. Thomson as editor. At the 1946 annual meeting, Dr. Thomson was selected to “establish and monitor the Instructional Course Lectures” [2]. He continued to serve as editor of the published Instructional Course Lectures until 1948. One account suggests the idea of a central office was his, and that he personally furnished a temporary central office in Lincoln until permanent headquarters could be established [1]. He was a man of great energy and bearing. In his Presidential Lecture he commented, “There is an old saying – you can’t make a silk purse out of a pig’s ear. I sometimes feel that in our post-war fervor, in behalf of the veterans separated from military service, we tend to encourage some conscientious young men to enter a field of training for which they are totally unsuited.” Despite infirmities in his last years (he had bilateral hip prostheses), he continued to be active, and died while giving lectures at the University of Kansas (“as he would have wished ‘with his boots on.’” [3]).,[object Object],[object Object],[object Object]

A New Apparatus for the Lengthening of Legs

Richard A. Brand MD Rexford L. Diveley was born in Bazine, Kansas, in 1892, to the owner of a variety store. The family moved to the Oklahoma Territory (which had been opened for settlement in 1890). He returned to his home state, graduated from Hutchinson High School, and obtained his undergraduate and medical degrees (1917) from the University of Kansas. During WW I he served as head of a radiology unit in Limoges, France. After the armistice, he spent a year at Johns Hopkins in medicine, and then briefly went into private practice in St. Joseph’s, Missouri, north of Kansas City. He then established a radiology unit at Mercy Hospital in Kansas City. Shortly thereafter, he began working with Dr. Frank Dickson at the Christian Church Hospital, and changed his practice to orthopaedic surgery. In 1927 they established the Dickson-Diveley Clinic and by 1928 moved their practice to the St. Luke’s Hospital.,Dr. Diveley’s travels resulted in his becoming a member of the British and Italian Orthopaedic Societies and the Sir Robert Jones Dinner Club. He served as treasurer of the AOA, President of the Clinical Orthopaedic Society, and the Mid-Central States Orthopaedic Society. He was also a member of the Board of Governors of the American College of Surgeons.,[object Object],[object Object],[object Object]

Documentation of Associated Injuries Occurring With Radial Head Fracture

Roger P. Riet MD, PhD, Bernard F. Morrey MD We believe a better way is needed to accurately describe the spectrum of associated injuries that commonly occur in conjunction with a radial head fracture. A review of our institution’s experience with 333 radial head fractures from 1997 to 2002 documented 88 (26%) associated injuries. Based on this clinical experience, our goal was to develop an accurate and comprehensive description of associated injuries. A shorthand suffix method first recognizes the type of radial head fracture with the traditional Mason classification, followed by abbreviations designating the articular injuries, coronoid (c) and olecranon (o), and the ligamentous injuries, lateral collateral ligament (l), medial collateral ligament (m), and distal radioulnar joint (d). The proposed system offers a logical and reproducible (98%) extension of the current Mason fracture classification to document the presence of additional articular and ligamentous injuries. This provides an opportunity to standardize the communication of fracture type with further details of other injuries that ultimately can help with better understanding of treatment outcome based on the precise injury complex.

Courses of the Radial Nerve Differ Between Chinese and Caucasians

Po-Hsin Chou MD, Jia-Fwu Shyu MD, PhD, Hsiao-Li Ma, Shih-Tien Wang, Tien-Hua Chen MD We analyzed anatomic distribution of the radial nerve in the upper arms in Chinese-adult embalmed cadavers (120 nerves in 60 cadavers) and compared it with findings reported for Caucasian adults. The acromion, the medial epicondyle, and the lateral epicondyle were used as bony landmarks. We used previously described techniques to quantitatively describe the location of the radial nerve in relation to the surrounding skeleton. Courses of the radial nerve relative to the humeral shaft in Chinese subjects differed from those previously reported for Caucasian subjects. The parameters that differed from Caucasians were: the distances from the acromion to the upper margin (147 ± 21 mm versus 124 ± 12 mm), the acromion to the lower margin (195 ± 36 mm versus 176 ± 17 mm), and the medial epicondyle to the lower margin (111 ± 21 mm versus 131 ± 10 mm). Our study provides information to help identify the radial nerve during surgery and elucidates racial differences in the distribution of the radial nerve between Chinese and Caucasian populations.

Bone Grafting Severe Glenoid Defects in Revision Shoulder Arthroplasty

Jason J. Scalise MD, Joseph P. Iannotti MD, PhD During revision total shoulder arthroplasty, bone grafting severe glenoid defects without concomitant reinsertion of a glenoid prosthesis may be the only viable reconstructive option. However, the fate of these grafts is unknown. We questioned the durability and subsidence of the graft and the associated clinical outcomes in patients who have this procedure. We retrospectively reviewed 11 patients with severe glenoid deficiencies from aseptic loosening of a glenoid component who underwent conversion of a total shoulder arthroplasty to a humeral head replacement and glenoid bone grafting. Large cavitary defects were grafted with either allograft cancellous chips or bulk structural allograft, depending on the presence or absence of glenoid vault wall defects, without prosthetic glenoid resurfacing. Clinical outcomes (Penn Shoulder Score, maximum 100 points) improved from 23 to 57 at a minimum 2-year followup (mean, 38 months; range, 24–73 months). However, we observed substantial graft subsidence in all patients, with eight of 11 patients having subsidence greater than 5 mm; the magnitude of graft resorption did not correlate with clinical outcome scores. Greater subsidence was seen with structural than cancellous chip allografts. Bone grafting large glenoid defects during revision shoulder arthroplasty can improve clinical outcome scores, but the substantial resorption of the graft material remains a concern.,[object Object]

The New Demands by Patients in the Modern Era of Total Joint Arthroplasty

J. Bohannon Mason MD Historians have the opportunity of viewing events, people, and their epoch through an aperture in time. With retrospective clarity, change and the forces effecting change can be appropriately categorized, emphasized, and interpreted. Sociologists see change in a forward-focused manner. When we examine our patients today, it is clear our current patients having total joint arthroplasty are different from those in years past. The sociologic influences effecting this change are many and include the revolutionary explosion of, access to, and dissemination of information; increased wealth, life activity expectation, and life expectancy; and an aging workforce. Concurrent with these forces registering change in our patient population is an erosion in respect for professionalism and vertically oriented authoritarian structure throughout society. Our patients are citizens of our modern age. Our public has come to expect miracles in medicine as the norm, yet these miracles are not without inherent risk. The trap implicit in allowing an incompletely informed populace to drive the decisions we make may be bridged by a more complete understanding of who our patients are and what their needs include. This discussion attempts to offer some insight into the forces at play. It focuses on how the changes in society, population, and technology have affected patients’ knowledge and attitude toward medicine and what our response as physicians should be.

Obesity is a Major Risk Factor for Prosthetic Infection after Primary Hip Arthroplasty

Michelle M. Dowsey RN, BApplSc, Peter F. M. Choong MBBS, MD, FRACS, FAOrthA The incidence of obesity and the number of hip arthroplasties being performed in Australia each year are increasing. Although uncommon, periprosthetic infection after surgery can have a devastating effect on patient outcomes. We therefore asked whether obesity correlated with periprosthetic infection after primary hip arthroplasty. We further asked whether variables such as patient comorbidities, operative time, blood transfusions, use of drains, and cementation practices correlated with periprosthetic infection. We hypothesized obesity was an independent risk factor for the development of acute periprosthetic infection after primary hip arthroplasty. We reviewed 1207 consecutive primary hip arthroplasties separating patients into four weight groups, normal, overweight, obese, and morbidly obese, and compared for incidence of periprosthetic infection between the groups. We observed a considerably higher infection rate in obese patients; the correlation was independent of patient comorbidities such as diabetes and cardiovascular disease. We also observed a correlation between infection rates and using a posterior approach in obese patients. The incidence of periprosthetic infection was not influenced by operative time, transfusion requirements, use of drains, and cementation practices. In this series, obesity was an independent risk factor for acute periprosthetic infection after primary hip arthroplasty.,[object Object]

Survivorship of Monoblock Trabecular Metal Cups in Primary THA

Konstantinos N. Malizos MD, Konstantinos Bargiotas MD, Loukia Papatheodorou MD, Michael Hantes MD, Theofilos Karachalios MD Monoblock trabecular metal cups are made of a novel porous material intended to enhance ingrowth and improve fixation. We prospectively followed 223 consecutive patients with 245 trabecular metal acetabular cups implanted during primary total hip arthroplasties to determine the overall survivorship of the implant, and any association of survivorship to primary diagnosis and age, and to determine the fate of polar gaps and cysts. Minimum followup was 36 months (mean, 60 months; range, 36–112 months). Patients were assessed with the Harris Hip score and the Oxford questionnaire and radiographically with standardized serial radiographs. At last followup, all cups were radiographically stable with no evidence of migration or progressive radiolucencies. The survivorship with reoperation as the end point was estimated at 98.75% with a 95% confidence interval. Three reoperations occurred during the first 36 months. The Harris hip score increased from 48 to 94 and the Oxford score was 16.4 at the last examination. We observed no difference in terms of survivorship among patients with osteoarthritis, osteonecrosis, or hip dysplasia. Seven of 14 (50%) osteoarthritis cysts and 10 of 33 (33.3%) polar gaps detected on postoperative radiographs decreased or filled, whereas none of the remainder deteriorated with time. Our midterm results suggest this implant may enhance fixation, but long-term followup is needed to confirm our findings.,[object Object]

Quality of Life After TKA for Patients With Juvenile Rheumatoid Arthritis

Brigitte M. Jolles MD, MSc, Earl R. Bogoch MD, FRCSC Total knee arthroplasty frequently is required during early adulthood in patients with advanced juvenile rheumatoid arthritis. We queried patients on issues of importance to them, asked whether they were satisfied with surgical outcomes, and ascertained their postoperative status. We retrospectively reviewed 14 adult patients (22 knees) with severe juvenile rheumatoid arthritis who were treated with primary total knee arthroplasty between 1989 and 2001. All patients were evaluated by pain and stiffness visual analog scales, range of motion, the Patient-Specific Index, Hospital for Special Surgery knee score, WOMAC Osteoarthritis Index, EuroQuol in five dimensions, and SF-36 Health Survey. Preoperative scores were assessed by recall. Patients had a minimum followup of 2 years (mean, 8 years; range, 2–13 years). Quality of life improved after TKA as measured by the Patient-Specific Index. Eighteen of 22 patients rated themselves satisfied with the functional outcome of their surgery; all patients were satisfied with pain relief. Final SF-36, EuroQuol in five dimensions, and WOMAC scores were low compared with age-matched population norms. A mean postoperative flexion arc of 77° (range, 30°–130°) was observed. Total knee arthroplasty had a major positive impact on quality of life as reported by patients.,[object Object]

Normative Temporal Values of CRP and ESR in Unilateral and Staged Bilateral TKA

Kwan Kyu Park MD, Tae Kyun Kim MD, PhD, Chong Bum Chang MD, PhD, Su Won Yoon RN, Kyoung Un Park MD, PhD C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) play helpful roles in determining the presence of infection after TKA. To provide baseline values, we documented normative temporal values of CRP and ESR in unilateral and staged bilateral TKAs for osteoarthritis. Levels of CRP and ESR were evaluated before surgery and on the first, second, fifth, seventh, fourteenth, forty-second, and ninetieth postoperative days in 320 uncomplicated primary TKAs. C-reactive protein and ESR levels were compared in three groups: unilateral (108 knees), first knee bilateral (106 knees), and second knee bilateral (106 knees) groups. All three groups exhibited similar temporal patterns. Mean CRP levels increased rapidly, reaching a peak on the second day and decreased to less than the normal reference level on the forty-second day. They returned to preoperative levels on the ninetieth day. Mean ESR levels peaked on the fifth day and returned close to the preoperative levels only on the ninetieth day. Wide variations were observed and many cases (43%) did not follow the typical patterns. C-reactive protein had greater fold changes, less frequent atypical temporal patterns, and lower correlation between preoperative and postoperative levels than ESR. Our findings should help surgeons interpret CRP and ESR to determine the presence of infection after TKA.,[object Object]

Leg Lengthening With a Motorized Nail in Adolescents

Andreas H. Krieg MD, Bernhard M. Speth MD, Bruce K. Foster MBBS, MD Leg lengthening by external fixation is associated with various difficulties. We evaluated eight adolescent patients who underwent leg lengthening with a motorized intramedullary lengthening device. We asked whether this method could reduce the time of hospitalization and rehabilitation and whether the incidence of complications commonly associated with external fixators could be reduced. We compared our preliminary results with those from other reports, with a focus on leg length achieved, time of rehabilitation, and rate of complications. The average leg-length discrepancy was 3.8 cm (range, 3–5 cm). The average lengthening distance was 3.8 cm (range, 2.9–4.7 cm). In six patients, leg lengthening was combined with successful correction of the mechanical axis alignment. The consolidation index averaged 26 days/cm (range, 19–41 days/cm). The average hospital stay was 9.6 days. No bone or soft tissue infections were observed. In comparison to other studies (1.0–2.8 complications/patient), our results suggest that the difficulties commonly associated with external fixators can be reduced with this method. It also allows good angular correction in patients with mechanical axis deviation. These features combined with a short time of hospitalization and rehabilitation make it a promising procedure for limb lengthening.,[object Object]

Anterior Cruciate Ligament Reconstruction

Hyuk Soo Han MD, Sang Cheol Seong MD, PhD, Sahnghoon Lee MD, Myung Chul Lee MD, PhD The bone-patellar tendon-bone has been widely used and considered a good graft source. The quadriceps tendon was introduced as a substitute graft source for bone-patellar tendon-bone. We compared the clinical outcomes of anterior cruciate ligament reconstructions using central quadriceps tendon-patellar bone and bone-patellar tendon-bone autografts. We selected 72 patients who underwent unilateral anterior cruciate ligament reconstruction using bone-patellar tendon-bone between 1994 and 2001 and matched for age and gender with 72 patients who underwent anterior cruciate ligament reconstruction using quadriceps tendon-patellar bone. All patients were followed up for more than 2 years. We assessed anterior laxity, knee function using the Lysholm and International Knee Documentation Committee scores, and quadriceps strength, the means of which were similar in the two groups. More patients (28 or 39%) in the bone-patellar tendon-bone group reported anterior knee pain than in the quadriceps tendon-patellar bone group (six patients or 8.3%). Anterior cruciate ligament reconstruction using the central quadriceps tendon-patellar bone graft showed clinical outcomes comparable to those of anterior cruciate ligament reconstruction using the patellar tendon graft, with anterior knee pain being less frequent in the former. Our data suggest the quadriceps tendon can be a good alternative graft choice.,[object Object]

Osteoarticular and Total Elbow Allograft Reconstruction With Severe Bone Loss

F. Daniel Kharrazi MD, Benjamin T. Busfield MS, MD, Daniel S. Khorshad, Francis J. Hornicek MD, PhD, Henry J. Mankin MD Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Our consecutive series consisted of 18 patients with tumors and one patient with trauma. Reconstruction consisted of 16 hemiarticular allografts and three total elbow osteoarticular allografts; patients had a minimum followup of 2 years (mean, 9.9 years; range, 2–12 years). For patients who had hemiarticular allografts, 14 of 16 were able to return to their preoperative level of occupational function, with one patient experiencing failure of the allograft from infection. For the three patients who had total elbow allograft reconstructions, all had degenerative changes develop after surgery and two of the allografts failed. Complications occurred in six of 19 patients. Hemiarticular elbow allograft reconstruction is useful for limb salvage with massive bone loss. Total elbow allograft reconstructions have a high failure rate in the mid-term.,[object Object]

125 I-labeled OP-1 is Locally Retained in a Rabbit Lumbar Fusion Model

Benjamin P. Erickson BA, Allen R. Pierce, Andrew K. Simpson BS, John Nash PhD, Jonathan N. Grauer MD [object Object]

Distal Locking of Tibial Nails

George Anastopoulos MD, Panagiotis G. Ntagiopoulos MD, Dionisios Chissas MD, Athanasios Papaeliou MD, Antonios Asimakopoulos MD The indications for intramedullary nailing have expanded to include most tibial shaft fractures. Nail design has improved since their first introduction, but distal locking remains a difficult part of the procedure, resulting in radiation exposure to the patient and the surgeon and increased operation time. To address these issues, we describe an alternative surgical technique using a newly designed distal targeting device that consists of a proximally mounted aiming arm, and we report the preliminary data from its use in all tibial shaft fractures amenable to surgery for a 2–year period. Sixty-three tibial shaft fractures were treated with this method. The mean duration of the distal locking was 6.5 minutes, and in all successful cases, radiation exposure for distal locking was two shots (one shot before targeting and another for the confirmation of proper screw insertion). Radiation exposure was on average 0.85 seconds (range, 0.4–1.2 seconds) and 1.4 mGy (range, 0.8–1.9 mGy). There were no major intraoperative complications related to the technique. The method has certain advantages and can reduce radiation exposure and operation time. Nonetheless, familiarity with the instrumentation is a prerequisite for accurate distal locking.,[object Object]

Case Report

C. A. J. Pocock MRCS, S. P. Trikha FRCS (Orth), J. S. P. Bell FRCS, FRCS (Orth) Rupture of the quadriceps tendon is an uncommon injury and rapid diagnosis is important because delay in surgical repair generally is believed to adversely affect outcome. One study of 20 patients suggests repair should be done during the first 48 to 72 hours postinjury to achieve a successful outcome and late repair led to unsatisfactory recovery. Cases of delayed tendon repair have been reported, the longest to our knowledge being 11 months before surgical intervention. We present a case of successful outcome of a quadriceps tendon rupture reconstructed at least 8 years after occurrence and a review of the literature of delayed reconstructions. We show that successful restoration of extensor mechanism function can be achieved several years after tendon rupture.

Case Report

Jeffrey F. Sodl MD, Rocco Bassora MD, G. Russell Huffman MD, MPH, Mary Ann E. Keenan MD We present a case of a 20-year-old college student who had myositis ossificans traumatica develop after a fraternity hazing. The patient was struck repeatedly on both of his thighs while standing at attention, and he presented with bilateral thigh pain and stiffness 6 weeks after the incident. Physical examination revealed 130° flexion of his right knee and 50° flexion of his left knee, which had a firm end point. Radiographs showed extensive new bone located adjacent to the anterior and lateral aspects of his left femur with less involvement of his right thigh. Magnetic resonance imaging revealed considerable edema involving much of the rectus femoris and vastus lateralis of both thighs. The patient was treated with physical therapy and indomethacin for pain and inflammation control. At his 1.5-year followup, the patient’s left knee flexion had improved to 130°. Nonoperative treatment with careful followup resulted in a favorable outcome in this patient despite considerable formation of bilateral thigh myositis ossificans traumatica.

Work Satisfaction and Retirement Plans of Orthopaedic Surgeons 50 Years of Age and Older

Frances A. Farley MD, Jeffrey Kramer MS, Sylvia Watkins-Castillo PhD Retirement age and practice patterns before retirement are important for making accurate workforce predictions for orthopaedic surgeons. A survey of orthopaedic surgeons 50 years of age and older therefore was conducted by the American Academy of Orthopaedic Surgeons in cooperation with the Association of American Medical Colleges Center for Workforce Studies. The survey focused on three questions: (1) At what age do orthopaedic surgeons retire? (2) Do they stop working abruptly or do they work part time before retirement? (3) What are the major factors that determine when an orthopaedic surgeon retires? According to the survey, the median retirement age for orthopaedic surgeons was 65 years. Nineteen percent of orthopaedic surgeons worked part time before retirement. Decreasing reimbursement and increasing malpractice costs were consistently cited as factors that strongly influenced retirement plans. Career satisfaction was high and was the strongest factor that kept the respondents in the workforce. The option to work part time would have the most impact on keeping orthopaedic surgeons working past the age of 65 years.,[object Object]

Hip Pain in an 18-year-old Man

Arun Rajaram BA, Robert M. Tamurian MD, John D. Reith MD, Charles H. Bush MD
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