Skeletal Science

Research using unusual historic bone collection yields modern insights for children and families

Department of Pediatrics - January 2017

 Raymond Liu, MD

When evaluating a child with a suspected bone deformity, the pediatric orthopaedic surgeon is often asked by a parent how the condition will affect the child into adulthood. In many cases, the answer may be less than clear.

“Femoral version and tibial torsion, for example, are some of the most common reasons for a child to see a pediatric orthopedic surgeon that don’t involve an injury,” says Raymond W. Liu, MD, Pediatric Orthopedic Surgeon, University Hospitals Rainbow Babies & Children’s Hospital and Assistant Professor of Pediatrics and Associate Professor of Orthopedics, Case Western Reserve University School of Medicine. “What we typically do is tell the parents is that unless the child has significant symptoms, no treatment is necessary. But the data to support that has been somewhat limited.”

To generate better, data-based answers for his patients and their families, Dr. Liu and his colleagues have conducted extensive anatomical studies using the 3,000 skeletons that make up the Hamann-Todd Human Osteological Collection of the Cleveland Museum of Natural History. The skeletons were collected between 1912 and 1938 by an anatomist at Case Western Reserve University; the Hamann-Todd collection is rivaled only by a similar collection at the Smithsonian Institution in Washington, DC.

Using an osteological collection like this has allowed Dr. Liu and his team to collect data on both healthy and unhealthy individuals – an important distinction in answering questions about orthopaedic conditions.

“Most of what we know about the factors that cause arthritis is by looking at people with arthritis that is so bad that they need surgery,” he explains. “That does teach us a lot about those people, but what it doesn’t tell us what to do with the child or young adult who has a condition we think is problem but is not bothering the patient very much. Unfortunately, we often don’t know what is going to happen to this population in 40 years. By looking at these specimens, which are completely random, we can look at certain anatomical features and determine whether they are associated with future arthritis.”

In addition, Dr. Liu says, osteological research allows for taking detailed measurements at different areas of the skeleton – an opportunity modern images of only the diseased joint or limb doesn’t provide.

Already, Dr. Liu and his team have reached several important conclusions. After examining 1,158 cadaveric femurs and tibias, they found that femoral version and tibial torsion are not associated with hip or knee arthritis in adulthood.

“What this does is provide data and reassurance to parents that the concern they have about their child’s in-toeing or out-toeing typically isn’t going to cause them any problems in the future,” Dr. Liu says.

At the same time, they found that the ratio between the tibia and femur when performing limb-lengthening procedures is especially important in preventing ipsilateral hip and knee arthritis.

“It’s a known parameter that there is a 0.8 ratio between the tibia and femur,” Dr. Liu says. “And it seems to be the optimal point when you look at our data and recent evolution of humans. So when it comes to treating children with different limb lengths, this data gives us a lot of guidance as to which bone we should address.”

To read Dr. Liu and his team's published research on the topic, visit:

A cadaveric investigation into the demographic and bony alignment properties associated with osteoarthritis of the patellofemoral joint.

The Association of Tibia Femur Ratio and Degenerative Disease of the Spine, Hips, and Knees.

Femoral Version and Tibial Torsion are Not Associated With Hip or Knee Arthritis in a Large Osteological Collection.

For more information on this research or to refer a patient to Dr. Liu, email Peds.Innovations@UHhospitals.org.