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Letter to the Editor |
Department of Orthopaedic Surgery, University of California, San Francisco
Dear Editor:
As of September 6, 2005, it has been 1 year since the passing of Dr Jack Hughston, the first editor emeritus of this journal. Over these past 12 months, I have often found myself thinking about his life and what his legacy may be for us as orthopaedic surgeons with an interest in sports medicine. Although I am sure that there are many aspects of his work and character that have been and likely will be detailed by others, I would like to offer a perspective on an important aspect of his legacy I believe pertinent to all disciplines within orthopaedic surgery. Dr Hughston is certain to be remembered as one of the founders of sports medicine worldwide and for his love of the knee, in particular. In recent years, however, his work has often been perceived by younger surgeons as rather antiquated and perhaps even passé. However, his absolute dedication to the fundamentals of medicine and clinical diagnosis is still vitally important and likely to indefinitely remain so.
Dr Hughston stressed a thorough knowledge of knee anatomy—especially the extra-articular anatomy—that, despite the availability of modern computer programs and newer representational techniques, remains generally poorly taught and poorly understood. Perhaps of most importance, he emphasized the necessity of a thorough history and a complete, documented knee examination before proceeding with ancillary diagnostic procedures including musculoskeletal imaging.2 He realized that the orthopaedic surgeon must be the one person responsible for properly assessing and integrating all of the data available to arrive at an accurate clinical diagnosis before choosing which treatment recommendations (especially operative) to suggest to the patient. This basic principle is just as important, if not more so, in today’s era of the wide availability of advanced musculoskeletal imaging technology. He would be disappointed but hardly surprised at the current trend for many orthopaedic surgeons to essentially dispense with an adequate history and physical examination in favor of arriving at a clinical diagnosis solely by means of reading the radiologist’s impressions of the MR images. It is ironic and disconcerting in the extreme that the easy access to advanced musculoskeletal imaging technology, especially the MRI, has led to a situation that Dr Hughston greatly feared—the atrophying of basic diagnostic skills of orthopaedic surgeons by the increasing overreliance on the radiologist’s interpretation of the joint of a patient with whom he or she has never spoken, much less examined. I describe this unfortunate and all-too-common situation (allowing the radiologist to make the diagnosis) to our residents as "pushing in the mental clutch." Dr Hughston knew that there are no easy paths to the acquisition of the basic science knowledge and clinical experience required to become a competent, much less excellent, orthopaedic surgeon.
I believe that it would be appropriate in remembering Dr Hughston’s life and work for us as orthopaedic surgeons to take a close look at our own actions and resolve not to put an inadequate diagnostic cart before an inappropriate (and potentially harmful) treatment horse. Perhaps a recent experience from my own clinic might serve as a representation of the importance of Dr Hughston’s principles: a 30-year-old male recreational runner, having moved from a flatter region of the country, developed unilateral knee pain a few weeks after starting to run the hills here in San Francisco. He went to see an orthopaedic surgeon who never directly examined his knee. The patient merely had an in-office MRI and was told that he needed a certain operation to "fix" his problem—a torn meniscus. In addition, he was informed that he could be worked into the surgeon’s busy operative schedule that very week. Sometime later, the patient came to my office, having decided to obtain a second opinion. He handed me his MRIs and asked me whether, based on the images, I thought he should proceed with surgery. I said, "Let’s put the MRIs aside for the moment," and I proceeded with the fundamentals of diagnosis as espoused by Dr Hughston—take a full history and physical examination first! As it turned out, the patient was complaining of the insidious onset of intermittent anterior pain in the right knee that was symptomatic only with running hills and with excessive stair climbing. He had no symptoms representative of a torn meniscal cartilage. On physical examination, the knee exhibited slight warmth, a mild effusion, and peripatellar tenderness. There was no tibial-femoral joint line tenderness or symptoms on loading the medial or lateral compartments. All the clinical evidence pointed directly toward simple patellofemoral overload (loading the joint out of its envelope of function1) resulting in symptomatic loss of patellofemoral tissue homeostasis. A careful examination of the MR images revealed the presence of a mild effusion and patellofemoral synovial hyperplasia (not commented on by the radiologist). The posterior horn of the medial meniscus revealed a type II+ signal. I told the patient that I believed his problem was probably related to simple overload and recurrent inflammation of the patellofemoral joint and that I did not think the medial meniscus findings on the MRI had anything to do with his current symptoms. I advised a commonsense nonoperative treatment program.
After pursuing simple load restriction activities such as bicycling and swimming (along with daily cooling and some oral anti-inflammatory medications), the patient’s symptoms resolved, and he returned to running on flat surfaces without having undergone an inappropriate and unnecessary surgical procedure. In addition, because the patient requested further objective proof of this opinion, a standard technetium 99m-MDP bone scan was performed. This study showed a classic diffuse uptake pattern of the symptomatic patella. In particular, the symptomatic knee showed no increase in activity of the medial compartment on either the femoral or tibial side of the prime MRI diagnosis of structural damage of the medial meniscus. The bone scan was not necessary to make a diagnosis in this case, for there was adequate information on history and physical examination to suggest the appropriate treatment plan, but it did objectively and geographically locate the region of bone overload within the knee and thus confirmed the clinical impression.
In remembering Dr Hughston and his legacy, we would do well to honor his memory by rededicating ourselves to the fundamentals of orthopaedic sports medicine—lifelong study of anatomy; performing a thorough history and physical examination before considering imaging data, no matter how sophisticated; and integrating all data before arriving at a diagnosis and therapeutic recommendation. If we do, I know that he would have been pleased and that vast numbers of patients will benefit by receiving the appropriate care they all deserve.
REFERENCES
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