Exercise and Knee Osteoarthritis

Knee osteoarthritis (OA) is one of the most common musculoskeletal disorders in the world. Resistance training has many beneficial effects on musculoskeletal function, cardiovascular disease, insulin action, bone health, energy metabolism, psychological health and functional status. Since quadriceps weakness, obesity and abnormal mechanical joint forces are related to the development and progression of knee OA, resistance training could play a vital role in easing the discomfort of this disease. A new study reviewing trials on resistance interventions in patients with knee OA found that it improved muscle strength, pain and physical functioning in many patients. The study is published in the October issue of Arthritis Care & Research (http://www3.interscience.wiley.com/journal/77005015/home).

Researchers conducted a systematic database search for randomized controlled trials involving adults with knee OA and some form of resistance training, which included resistance machines, free weights, isometric exercise or other devices such as elastic bands.

The literature review found that the development of knee OA depends on a variety of factors, with quadriceps weakness being one of the main factors that was modified by resistance training. More than half of the studies found an improvement in self-reported pain and 79 percent found an improvement in self-reported disability/mobility following resistance training, with progressive resistance training associated with an overall increase in physical activity levels. The authors state that future clinical trials on the benefit of long term exercise interventions in knee OA should also examine long-term changes in the knee cartilage and surrounding bone, which can be assessed with MRI. They note that up until now, research on knee OA and exercise has rarely centered on objective measures such as medication use, nursing home admissions, health care use, progression to joint replacement, and cost-effectiveness.

Overall, the majority of the studies included in the review found that knee OA symptoms, physical function and strength were improved with resistance training. Because strength changes have been shown by several authors to be related to symptoms and physical function at various training intensities, large trials comparing different intensities of progressive resistance training would be needed to answer this question fully, according to the authors. They conclude that further studies are needed to evaluate how strength training affects health-related quality of life, psychological outcomes, disease progression and overall health care use.

My Comments: I am often asked about the benefits of physical therapy on knee arthritis. I often advise patients that it is worth trying but may not help everyone. It is unlikely to make the pain worse and will not cause the arthritis to progress faster. Physical therapy may be worth a try in certain cases of knee osteoarthritis.

Thanks,

JTM, MD

Is Obesity a Risk Factor for Progressive Radiographic Knee Osteoarthritis?

Obesity is known to be a strong risk factor for the onset of knee osteoarthritis (OA), but studies on the relationship between obesity and progression of the disease have shown mixed results and have lacked large numbers of patients. It's important to clarify the relationship between weight loss and the risk of OA progression, since patients with knee OA might be motivated to lose weight if it could be shown that it would prevent advancement of the disease. A new study examined the relationship between body mass index (BMI) and the risk of new and progressive knee OA and found no overall relationship between obesity and the progression of knee OA. The study was published in the March issue of Arthritis Care & Research (http://www3.interscience.wiley.com/journal/77005015/home).

Led by D.T. Felson of Boston University School of Medicine, the study involved more than 2,600 participants who either had OA or were at high risk for developing it due to the fact that they were overweight or obese, had knee pain, aching or stiffness or had a history of knee injury that made walking difficult or had previous knee surgery. Participants underwent an exam, a hip bone mineral density test and X-rays of both legs at the start of the study and knee X-rays after 30 months.

The results showed that obesity was associated with an increased risk of onset of knee OA, but there was no overall effect of BMI on the risk of progression of the disease. However, there was an effect depending on how the knees were aligned: those with high BMI and neutral alignment had an increased risk of progressive knee OA, while those with valgus (knockknee'ed) alignment had a small risk, and those with varus (bowlegged) alignment showed no increased risk.

The authors suggest that obesity has the greatest effect in neutrally aligned knees because the excess load it generates acts without the influence of stress on the knee due to malalignment. In knees inwardly aligned (bowlegged), the stress generated by the malalignment accelerates progression of the disease. "Our findings suggest that this stress is sufficient by itself to produce progression, and that the excess load conferred by obesity may not be necessary as an additional factor," the authors state.

Dr. Felson pointed out that their study did not speak to the effect of weight loss on knee pain but only on structural effects of obesity. Other studies have suggested that obesity worsens knee pain and that weight loss may alleviate this pain.

Among those that did not have knee OA, obesity increased the risk of developing the disease, regardless of the malalignment status. This may be because malalignment was less severe in subjects who did not have OA, which suggests that it occurs with the development of the disease, or because malalignment in knees with OA may not be the same as in knees without it.

"The failure to demonstrate that obesity increases the overall risk of OA progression in our study and others does not eliminate opportunities for weight loss trials aimed at slowing disease progression, especially among knees in extremities with neutral or valgus alignment," the authors note. They point out that the study may help explain the modest effects of weight loss on OA symptoms shown in previous studies and conclude that weight loss has many positive health effects, even if it may not delay the progression of structural damage in knee OA.

My Comments: In my experience, weight loss does improve the level of pain experienced by patients prior to knee replacement. Those eventually having knee replacements do better post operatively with a lower BMI and studies have shown that intraoperative and post operative complications are higher in obese patients.

Thanks,

JTM, MD

Total Knee Replacement Appears Cost-Effective in Older Adults

Journal Report:

CHICAGO—Total knee replacement (arthroplasty) appears to be a cost-effective procedure for older adults with advanced osteoarthritis, according to a report in the June 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The procedure appears to be cost-effective across all patient risk groups, and appeared more costly and less effective in low-volume centers than in high-volume centers.

Approximately 12 percent of adults older than 60 have symptoms of knee osteoarthritis, and their direct medical costs are estimated to range from $1,000 to $4,100 per person per year, according to background information in the article. "Total knee arthroplasty is a frequently performed and effective procedure that relieves pain and improves functional status in patients with end-stage knee osteoarthritis," the authors write. "Almost 500,000 total knee arthroplasties were performed in the United States in 2005 at a cost exceeding $11 billion. Projections indicate dramatic growth in the use of total knee arthroplasty over the next two decades."

Elena Losina, Ph.D., of Brigham and Women's Hospital and the Boston University School of Public Health, and colleagues developed a computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. They then projected lifetime costs and quality-adjusted life expectancy—or the number of years remaining of good health—for patients at different levels of risk and receiving total knee arthroplasty at high-volume or low-volume facilities.

Overall, having a total knee arthroplasty increased quality-adjusted life expectancy of the Medicare population (average age 74) from 6.822 to 7.957 quality-adjusted life years (years of life in perfect health). Total costs increased from $37,100 among individuals not receiving total knee arthroplasty to $57,900 per person undergoing total knee arthroplasty, resulting in a cost-effectiveness ratio of $18,300 per quality-adjusted life year. Therefore, total knee arthroplasty is a highly cost-effective procedure for the management of end-stage knee osteoarthritis compared with non-surgical treatments and is within the range of accepted cost-effectiveness for other musculoskeletal procedures, the authors note.

"This result is robust across a broad range of assumptions regarding both patient risk and hospital volume," they write. "For patients who choose to undergo total knee arthroplasty, hospital volume plays an important role: regardless of patient risk level, higher-volume centers consistently deliver better outcomes. But the additional survival benefits associated with high-volume centers provide limited cost-effectiveness benefits for high-risk patients deliberating between medium- and high-volume centers." Even procedures performed in low-volume centers were more cost-effective than not having total knee arthroplasty, regardless of the patient's risk of complications.

"Clinicians, patients and policy makers should consider the relative cost-effectiveness of total knee arthroplasty in making decisions about who should undergo total knee arthroplasty, where and when," the authors conclude.
(Arch Intern Med. 2009;169[12]:1113-1121. Available to the media pre-embargo at www.jamamedia.org)

Editor's Note: This research was supported in part by National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases grants, and an Arthritis Foundation Innovative Research Grant. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Results Highlight Dilemmas in Health Care System

"Although total knee arthroplasty is a safe and effective treatment for advanced knee osteoarthritis, lingering questions remain regarding variations in patient outcomes due to differences among patients undergoing the procedure and among the hospitals where it is performed," write Stephen Lyman, Ph.D., of Weill Medical College of Cornell University, and colleagues in an accompanying editorial.

"In this issue of the Archives, Losina et al examine these questions from the perspective of cost-effectiveness, with a focus on Medicare enrollees who were 65 years or older," they write. "The overall findings were favorable to total knee arthroplasty, which had an incremental cost-effectiveness ratio of $18,300 per quality-adjusted life year gained compared with medical treatment alone. This figure falls below the cost-effectiveness thresholds often mentioned as appropriate, such as the £20,000 to £30,000 (approximately $29,000 to $44,000) per quality-adjusted life year threshold used by the British National Health Service's National Institute for Health and Clinical Excellence."

"Analyses such as the one conducted by Losina et al, carefully conducted and wholly transparent, highlight several of the dilemmas policy makers face in evaluating widely used medical technologies," they conclude. "At least in the United States, even well-performed cost-effectiveness analyses do not influence either payers or physicians directly. Payers do not use the results to make coverage determinations nor do physicians use them to make treatment decisions. How we move from this current state to a system in which cost-effectiveness of procedures affects medical practice is unclear."
(Arch Intern Med. 2009;169[12]:1102-1103.

A very interesting comment on health care costs.

Thanks,

JTM, MD

Four out of five patients satisfied after TKR

Patients who are older, who have unrealistic expectations, who have comorbidities, who live alone, or who have a complication requiring hospital readmission are most likely to be dissatisfied following total knee replacement (TKR), according to a study presented at the 2009 AAOS Annual Meeting.

Several studies have shown that only 82 percent to 89 percent of patients are satisfied with their TKR.

To determine if certain factors might predict satisfaction or dissatisfaction, the researchers prospectively assessed 2,513 primary TKR patients in the Ontario Joint Replacement Registry. The mean age of patients was 69, and 60 per­cent of patients were female.

Demographic and clinical data, including a preoperative WOMAC questionnaire, were collected at the decision date for surgery. A year later, patients were mailed questionnaires asking if they would be willing to undergo surgery again (yes/no/uncertain), whether they had had postoperative complications requiring admission to a hospital overnight (yes/no/reason), and if their expectations had been met (met/not met/had none). The packet also contained the WOMAC questionnaire and a satisfaction questionnaire.

A total of 1,703 patients com­pleted the 1-year questionnaires.

Four in five are “satisfied” Only 81 percent of respondents reported being “satisfied;” just 70 percent felt their “expectations were met.” Nearly 9 out of 10 “would willingly undergo surgery again.”

The preoperative variables most often associated with dissatisfied patients included increasing age, living alone, knee flexion less than 90°, and extreme pain while sitting or lying.

Postoperative factors frequently associated with dissatisfied patients included lower 1-year WOMAC scores and change totals, unwillingness to have surgery again, expectations that had not been met, and complications requiring hospital admission.

Alas, nothing in life is ever 100%.

Thanks,

JTM, MD

AAOS Now
April 2009 Issue
http://www.aaos.org/news/aaosnow/apr09/clinical4.asp

Osteoporosis and bone health

Osteoporosis is a disease characterized by low bone mass and deterioration of bone structure that increases the risk of fracture. Osteoporosis is often called the “silent disease,” progressing without symptoms until a low-energy fall or minor activity fractures a bone. Osteoporosis can occur without a known cause or be attributed to another secondary condition, such as hyperthyroidism or celiac disease, or to medication, such as steroids.

The epidemiology of osteoporosis has only been fully described in Caucasian women, making estimates of the total number of persons with osteoporosis difficult to determine. In fact, we now know that osteoporosis affects men and women, and all ethnicities. The National Osteoporosis Foundation estimated there were 29.5 million women and 11.7 million men in the U.S. with osteoporosis or low bone mass in 2002. On average in the 1999 to 2004 National Health and Nutrition Examination Survey, nearly 10.5 million men and women aged 65 and older reported they had been told by their doctor they had osteoporosis, a rate of 26 in 100 women and 4 in 100 men. These rates of osteoporosis are dramatically higher than those found a decade earlier, likely due to increased testing of bone mass and extensive educational and awareness efforts. It is believed that osteoporosis is significantly underdiagnosed. In 2004, only 16 percent of persons admitted to the hospital with a low-energy fracture were diagnosed with osteoporosis.

Falls are the leading cause of injury among persons aged 65 and older in the United States. Fractures are the primary cause of hospitalization or death following a fall. Osteoporosis is a leading underlying cause of low-energy fractures after a fall. One in two women and one in four men older than age 50 will have an osteoporosis-related fracture in her or his remaining lifetime.

The cost of osteoporosis
In 2004, the estimated cost of treating patients hospitalized with a diagnosis of osteoporosis was $19.1 billion, although it is unlikely that osteoporosis was the primary, or first, diagnosis of these patients. The estimated cost of treating patients with a low-energy fracture in 2004 was $24.2 billion.

Among persons aged 45 and older, 6.2 million visits to a doctor or other healthcare center were for osteoporosis, and an additional 5.7 million visits were attributed to a low-energy fracture in 2004. While most were treated in a doctor’s office, 704,300 persons were hospitalized for a low-energy fracture, primarily of the hip/pelvic area or vertebrae, and 1.23 million were treated in emergency departments, primarily for wrist fractures.

Hip fractures significantly impact quality of life and are often associated with chronic pain, reduced mobility, disability, and an increasing degree of dependence. The mortality rate in the first 12 months after hip fracture is 20 percent or higher. Current estimates are that one in four hip fractures occurs in males, and recent research indicates that men will have a different course of recovery than women, with higher rates of disability as well as mortality. Fifty percent of persons experiencing a hip fracture will be unable to walk without assistance, and 25 percent will require long-term or nursing home care.

Impact of aging
Osteoporosis is more common among seniors due to the gradual loss of bone, which leads to reduced bone strength. Lifetime factors affecting the rate of bone loss include heredity, menopause, serious health conditions and their treatment, as well as lifestyle factors such as diet, lack of weight-bearing exercise, smoking, or excessive alcohol consumption.

The future
In 2002, an estimated 44 million persons older than age 50 in the United States were at risk for fracture due to osteoporosis or low bone mass. By 2020, if current trends continue and effective treatments are not found and widely implemented, it is estimated that more than 61 million persons will be at risk. Projected costs for care of osteoporosis and low-energy fractures over the next two decades are $474 billion. In addition to dollar cost, osteoporosis-related fractures bring a burden of pain and disability, resulting in time lost from work or the inability to perform activities of daily living.

For most people, the possibility of future low bone mass is set in the late teens and early twenties, a critical time in the building of bone density and quality. Hip fractures at an older age reflect previous history in maintaining maximum bone density and quality. The initiation of society-wide prevention measures for bone health, greater emphasis on identifying individuals at risk for osteoporosis and identification of new strategies to improve treatment and treatment adherence in high-risk groups are needed to combat the growing burden caused by osteoporosis.

References:

1. National Osteoporosis Foundation (NOF): National Osteoporosis Foundation Fast Facts. Available at: ww.nof.org/osteoporosis/diseasefacts.htm. Accessed September 19, 2007.
2. International Osteoporosis Foundation (IOF): Facts and statistics about osteoporosis and its impact in 2007. Available at: www.iofbonehealth.org/facts-and-statistics.html. Accessed September 19, 2007.
3. Moran CG, Wenn RT, Sikand M, Taylor AM: Early mortality after hip fracture: Is delay before surgery important? J Bone Joint Surg Am 2005;87:483-489.
4. Orwig DL, Chan J, Magaziner J: Hip fracture and its consequences: Differences between men and women. Orthop Clin North Am 2006;37:611-622.
5. Hawkes WG, Wehren L, Orwig D, et al: Gender differences in functioning after hip fracture. J Gerontol A Biol Sci Med Sci 2006;61:495-499.
6. Riggs BL, Melton LJ: The worldwide problem of osteoporosis: Insights afforded by epidemiology. Bone 1995;17:505S-511S.
7. National Osteoporosis Foundation (NOF): America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington DC, National Osteoporosis Foundation, 2002.
8. Burge RT, Dawson-Hughes B, Solomon DH, et al: Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007;22:465-475.

Thanks,

JTM, MD

AAOS Now
May 2009 Issue
http://www.aaos.org/news/aaosnow/may09/clinical8.asp

Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements

Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements

This Information Statement was developed as an educational tool based on the opinion of the authors. Readers are encouraged to consider the information presented and reach their own conclusions.

More than 1,000,000 total joint arthroplasties are performed annually in the United States, of which approximately 7 percent are revision procedures.¹ Deep infections of total joint replacements usually result in failure of the initial operation and the need for extensive revision, treatment and cost. Due to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been markedly reduced in the past 20 years.

Bacteremia from a variety of sources can cause hematogenous seeding of bacteria onto joint implants, both in the early postoperative period and for many years following implantation.² In addition, bacteremia may occur in the course of normal daily life^3-5 and concurrently with dental, urologic and other surgical and medical procedures.⁵ The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.⁶

It is likely that bacteremia associated with acute infection in the oral cavity,^7,8 skin, respiratory, gastrointestinal and urogenital systems and/or other sites can and do cause late implant infection.⁸ Practitioners should maintain a high index of suspicion for any change or unusual signs and symptoms (e.g. pain, swelling, fever, joint warm to touch) in patients with total joint prostheses. Any patient with an acute prosthetic joint infection should be vigorously treated with elimination of the source of the infection and appropriate therapeutic antibiotics.^8,9

Patients with joint replacements who are having invasive procedures or who have other infections are at increased risk of hematogenous seeding of their prosthesis. Antibiotic prophylaxis may be considered, for those patients who have had previous prosthetic joint infections, and for those with other conditions that may predispose the patient to infection (Table 1). ^8,10-16 There is evidence that some immunocompromised patients with total joint replacements may be at higher risk for hematogenous infections.^10-18 However, patients with pins, plates and screws, or other orthopaedic hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms.

Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia. This is particularly important for those patients with one or more of the following risk factors.

Table 1. Patients at Potential Increased Risk of Hematogenous Total Joint Infection^8,10-16,18

• All patients with prosthetic joint replacement.
• Immunocompromised/immunosuppressed patients
• Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic lupus erythematosus)
• Drug-induced immunosuppression
• Radiation-induced immunosuppression
• Patients with co-morbidities (e.g.: diabetes, obesity, HIV, smoking)
• Previous prosthetic joint infections
• Malnourishment
• Hemophilia
• HIV infection
• Insulin-dependent (Type 1) diabetes
• Malignancy
• Megaprostheses

Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the basis of its activity against endogenous flora that would likely to be encountered from any secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia, an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that an effective tissue concentration is present at the time of instrumentation or incision in order to protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current prophylactic antibiotic recommendations for these different procedures are listed in Table 2. ¹⁹

Occasionally, a patient with a joint prosthesis may present to a given clinician with a recommendation from his/her orthopaedic surgeon that is not consistent with these recommendations. This could be due to lack of familiarity with the recommendations or to special considerations about the patient's medical condition which are not known to either the clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the orthopaedic surgeon to determine if there are any special considerations that might affect the clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these recommendations with the physician, if appropriate. After this consultation, the clinician may decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis.

This statement provides recommendations to supplement practitioners in their clinical judgment regarding antibiotic prophylaxis for patients with a joint prosthesis. It is not intended as the standard of care nor as a substitute for clinical judgment as it is impossible to make recommendations for all conceivable clinical situations in which bacteremias may occur. The treating clinician is ultimately responsible for making treatment recommendations for his/her patients based on the clinician’s professional judgment.

Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity, allergy, and development, selection and transmission of microbial resistance. Practitioners must exercise their own clinical judgment in determining whether or not antibiotic prophylaxis is appropriate.

References:

1. Number of Patients, Number of Procedures, Average Patient Age, Average Length of Stay - National Hospital Discharge Survey 1998-2005. Data obtained from: U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.
2. Rubin R, Salvati EA, Lewis R: Infected total hip replacement after dental procedures. Oral Surg. 1976;41:13-23.
3. Bender IB, Naidorf IJ, Garvey GJ: Bacterial endocarditis: A consideration for physicians and dentists. J Amer Dent Assoc 1984;109:415-420.
4. Everett ED, Hirschmann JV: Transient bacteremia and endocarditis prophylaxis: A review. Medicine 1977; 56:61-77.
5. Guntheroth WG: How important are dental procedures as a cause of infective endocarditis? Amer J Cardiol 1984;54:797-801.
6. McGowan DA: Dentistry and endocarditis. Br Dent J 1990;169:69.
7. Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y: Relation between mouth and haematogenous infections in total joint replacement. BMJ 1994;309:506-508.
8. Ching DW, Gould IM, Rennie JA, Gibson PH: Prevention of late haematogenous infection in major prosthetic joints. J Antimicrob Chemother 1989;23:676-680.
9. Pallasch TJ, Slots J: Antibiotic prophylaxis and the medically compromised patient. Periodontology 2000 1996;10:107-138
10. Rubin R, Salvati EA, Lewis R: Infected total hip replacement after dental procedures. Oral Surg. 1976;41:13-23.
11. Brause BD: Infections associated with prosthetic joints. Clin Rheum Dis 1986;12:523-536.
12. Jacobson JJ, Millard HD, Plezia R, Blankenship JR: Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986; 61:413-417.
13. Johnson DP, Bannister GG: The outcome of infected arthroplasty of the knee. J Bone Joint Surg; 688:289-291.
14. Jacobson JJ, Patel B, Asher G, Wooliscroft JO, Schaberg D: Oral Staphyloccus in elderly subjects with rheumatiod arthritis. J Amer Geriatr Soc 1997;45:1-5.
15. Murray RP, Bourne WH, Fitzgerald RH: Metachronus infection in patients who have had more than one total joint arthroplasty. J Bone Joint Surg 1991;73-A:1469-1474.
16. Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ, Sledge CB: Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop 1984;182:117-126.
17. Council on Dental Therapeutics. Management of dental patients with prosthetic joints. J Amer Dent Assoc 1990;121:537-538.
18. Berbari EF, Hanssen AD, Duffy MC, Ilstrup DM, Harmsen WS, Osmon DR: Risk factors for prosthetic joint infection: case-control study. Clin Infectious Dis 1998; 27:1247-1254.
19. Antibiotic Prophylaxis for Surgery. The Medical Letter 2006; 4 (52): 83-88.

© February 2009 American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons^®.

Information Statement 1033

Important stuff from the AAOS.

Thanks

JTM, MD

How do sex and gender affect knee OA?

Many factors may influence incidence of disease, effectiveness of treatment in women

Osteoarthritis (OA) of the knee develops at a greater rate in women than in men as they age. In fact, the incidence of knee OA is 1.7 times greater in women overall. Although multiple factors may contribute to this increased prevalence, it’s logical, to consider the influence of hormones and estrogen in postmenopausal women.

We know articular cartilage has estrogen receptors. As such, it is reasonable to suggest that the decline in estrogen with menopause may contribute to this upsurge in knee OA in older women.

In one study of elderly women taking estrogen replacement, knee OA incidence and progression risk was 60 percent lower than women who had never used estrogen replacement therapy, although this finding was not statistically significant.

Insulin-like growth factor 1 (IGF-1)—a hormone that is important for maintaining muscle, bone density, and regulation of fat metabolism—may also play an important role in the risk for development of knee OA. Lower levels of IGF-1 are found in healthy women compared to healthy men; however, women undergoing total knee arthroplasty (TKA) had markedly lower levels of IGF-1 compared to healthy female controls, whereas IGF-1 levels did not differ between men who underwent TKA and healthy male controls. Women may be more physically disabled at the time of TKA compared to men.

Women self-report that they have more symptoms than men who have the same degree of knee OA. Some studies report that women have worse preoperative pain compared to men.

In one study, arthroplasty candidates performed tests that measured normalized strength and the ability to climb stairs and walk. The researchers’ data suggested that women undergo arthroplasty at a more advanced disease state then men do.

What’s keeping women away from TKA?
Surgery for severe hip or knee OA is underutilized by both sexes, but the degree of underutilization is three times greater in women.

A study performed of 300 patients found that TKA patients’ anxiety levels in the perioperative period were higher among blacks, Hispanics, and women than among Caucasian males.

Let’s say a female patient has a Knee Society Score of 50 prior to surgery and a male patient has a score of 60. If both improve 30 points, her score will be 80 and his score will be 90. The male patient didn’t wait long to have surgery, but the female patient delayed. While she improves the same amount of points, she may never reach the same maximum score of the male patient. Thus, she can ‘never catch up’ to a male patient who had surgery sooner.

Another study performed in 2008 focused on two standardized patients, a male and female, with identical clinical presentations and moderate knee OA.

When the study first began, it also included two standardized patients with severe knee OA. They were removed from the study early on because researchers found no difference in terms of recommendations—both men and women with severe knee OA were equally recommended for surgery.

Over a span of 5 years, the standardized patients with moderate knee OA visited 38 family physicians and 33 orthopaedic surgeons. The family practice physicians were twice as likely to recommend TKA to the male patient than to the female patient; the orthopaedic surgeons were 22 times more likely to recommend TKA to the male patient than to the female patient.

The researchers concluded that unconscious gender bias may have played a role in the difference among the recommendations for surgery.

Women tend to be more narrative and personal, while men are sometimes more businesslike, factual, and reserved—perhaps that may have influenced the physician-patient interaction and the recommendation for surgery. The authors of the study do not have an explanation for the discrepancy in recommendations for TKA.

Effectiveness of TKA
Much conflicting data exist about the effectiveness of TKA in both female and male patients.

Some studies report that 15 percent to 30 percent of patients have little or no improvement after surgery.

A 2008 study found that women who underwent TKA had equal or better implant survival compared with male TKA patients. The study was based on a literature review of studies with at least 400 patients and 2 to 5 year follow-up.

The study focused on implant survival, meaning whether the implants failed and needed revision. The results don’t necessarily mean that the female patients were doing as well clinically or that they’re as satisfied with their outcomes.

Female patients’ satisfaction with the results of TKA, may be linked to preoperative function, which studies have suggested is adversely affected the longer a patient waits to have surgery.

Data support that the best predictors of postoperative outcomes are preoperative function and quadriceps strength.

A study performed by the Mayo Clinic in Rochester, Minn., found that women reported more moderate to severe pain after TKA.

This study concluded that female gender, young age, and worse preoperative pain were predictors for a greater risk of moderate to severe postoperative pain in primary and revision TKA.

When female TKA patients come into the office and say they’re unhappy with their knee, you may be able to identify a problem, such as instability. The data show, however, that there’s a 28.9 percent chance of moderate to severe pain 5 years after revision surgery in a female patient compared to an 18.3 percent chance in a male patient. For female patients the risk for continued pain after revision knee arthroplasty is 1 in 4, and for male patients that it is 1 in 5.

Is a gender-specific implant necessary?

Clearly, anatomic differences between men and women can affect TKA outcomes. Women have a differently shaped distal femur. Because a woman's femur tend to be narrower at the medial-lateral plane, selection of a component that avoids medial-lateral overhang may result in overresection of the posterior femoral condyles and instability of the knee in flexion. Conversely, using a larger component will not compromise resection of the posterior bone, but could result in medial-lateral overhang, which causes soft tissue irritation. Using a knee system with multiple sizes and good medial-lateral to anterior-posterior ratios will minimize this risk.

Thanks,

JTM, MD

http://www.aaos.org/news/aaosnow/jun09/clinical5.asp

Calculate Your Boby Mass Index

Go here to calculate your body mass index.

Thanks,

JTM, MD

Pearls and pitfalls: Orthopaedics and obesity

Obese patients, particularly those who are morbidly obese, present a dilemma for many orthopaedic surgeons. From equipment and instrumentation to the surgical approach, orthopaedic surgeons have to make significant adjustments when treating the obese (body mass index [BMI] of 30 or more).

Obesity—High stress for heart and lungs
Before making an incision, the orthopaedic surgeon needs to know the possible complications that accompany obesity.

The hearts of obese patients are not normal. The fatty tissue infiltrates the myocardial tissue, which can lead to arrhythmias, particularly bradycardia. The muscular tissue has decreased compliance.

Obese patients have increased risk factors for coronary artery disease, including hypertension, diabetes, and abnormal lipid profiles. Their hearts are working double time to support their bodies.

The effects of obesity on the pulmonary system can cause shortness of breath and poor exercise tolerance. When you tell your patients to exercise, they really can’t do it. The hyperlordosis and kyphosis associated with obesity prevents rib expansion so they can’t breathe.

Sleep apnea, OSA serious complications
Sleep apnea is an upper airway obstruction during sleep that results in apneic and hypopneic episodes. Once patients become apneic, they rapidly lose their already limited oxygen stores.

OSA is defined by at least five apnea and hypopnea episodes per hour of sleep and is diagnosed in a sleep laboratory using polysomnography. Those who are obese are 6 times more likely to have OSA.

If the results of the polysomnography are positive, the patient can then be treated with a continuous positive airway pressure (CPAP) machine, which will prevent most of the apneas and hypopneas. CPAP machines function by splinting the upper airway open with air pressure that is delivered through a hose to a nasal mask—sealed over the patient’s nose and mouth. The actual air pressure, also known as titrated pressure, is prescribed by a physician following a sleep study.

Orthopedic surgeons may recommend CPAP machines, as well as supplemental oxygen if it is needed, for all obese patients while they are in the hospital.

Wound complications are a major consideration for morbidly obese patients. If a patient is morbidly obese with a BMI of 40 or greater, the risk of a wound complication developing is 5 times greater than for normal-sized patients.

Higher morbidity, increased mortality rates found
Obesity has been associated with higher morbidity and increased mortality rates.

In a large retrospective review of 1,153 trauma patients admitted to the ICU from 1998 to 2003, obese patients had more complications than those who were not obese (42 percent versus 32 percent; P=0.002).

Those who were obese had longer stays in the ICU, more days of mechanical ventilation, and showed a trend toward multi-system organ failure and acute respiratory distress syndrome. Obesity was also found to be an independent risk factor for mortality (odds ratio of 1.6; 95 percent confidence interval, range 1.0–2.3; P=0.03).

Fast Facts

• From 1960 to 2000, the rate of obesity more than doubled in the United States—from 12.8 percent to 30 percent.
• More than 60 percent of all Americans are now considered to be overweight or obese based on a BMI of 30 or more.

Obesity and Joint Replacement
Obesity substantially increases a patient’s chances of needing a joint replacement. The chances of having a knee replacement are 8 times higher for patients with a BMI greater than 30—and 18 times higher for patients with a BMI of 35 or more.

The morbidly obese have higher complication rates, may have more pain after surgery, and have a higher rate of infection and a higher loosening or failure rate that would result in revision. The increase in obesity seems to have a greater effect on knee replacement patients compared to those requiring hip replacements.

Once obese patients have a joint replacement, do they lose weight? Though many obese patients say they will lose weight following a joint replacement, the statistics do not support that claim.

According to one study, patients gained an average of 1.2 kilograms (kg) one year after joint replacement surgery.

If the BMI was 25 to 30, the patients gained an average of 3.6 kg, which is much more than the weight of the implant. If the BMI was 30, there was no significant change.

Surgical outcomes can markedly improve if the patient loses weight prior to surgery, according to several studies.

Some patients have had bariatric surgery and the change is incredible. It makes the joint replacement surgery more predictable and produces better outcomes.

Some orthopedic surgeons will accept patients for joint replacement with BMIs up to 50. After that point, they are referred for bariatric surgery.

Thanks,

JTM, MD

http://www.aaos.org/news/aaosnow/jun09/clinical1.asp

AAOS Now
June 2009 Issue

The Jim Chronicles

Recently, I was interviewed for the purposes of creating educational videos on topics in which I have considerable interest and expertise. The link here goes to blip TV where all of the clips are available. They are also available on my website www.OrthoOnTheWeb.com.

Very scary.

Thanks,

JTM, MD

AAOS Issues New Treatment Guidelines for Carpal Tunnel Syndrome

The American Academy of Orthopaedic Surgeons (AAOS) has approved and released an evidence-based clinical practice guideline on “The Treatment of Carpal Tunnel Syndrome.”

Carpal Tunnel Syndrome, otherwise known as CTS, is among the most common disorders of the upper extremity. It affects up to ten percent of the population and is related to many factors, but is thought to be caused by increased pressure on the median nerve in the carpal tunnel in the wrist.

• According to the National Center for Health Statistics, in 2005, an estimated 3.1 million people sought help from physicians for the treatment of CTS.

The Academy created this clinical practice guideline to improve patient care for those suffering from Carpal Tunnel Syndrome. The document serves as a point of reference and educational tool for both family practitioners and orthopaedic surgeons, streamlining possible treatment processes for this ever-so common ailment.

In June 2007, the Journal of the Academy of Orthopaedic Surgeons (JAAOS) reported about 500,000 CTS surgical procedures are performed each year. The same study also reported the economic impact due to CTS is estimated to exceed $2 billion annually.

The final CTS Treatment guideline contains nine recommendations which include both operative and non-operative treatment options as well as alternative techniques. Some of the recommendations include:

• Traditional bracing or splinting
• Local steroid injection
• Oral steroids
• Ultrasound
• Carpal tunnel release surgery

After doing a thorough analysis of the current literature, the work group found no evidence that supports the following treatments:

• Heat therapy
• Acupuncture
• Diuretics
• Electric stimulation
• Massage therapy
• Magnet therapy
• Nutritional supplements.

This guideline is not intended to stand alone. It can be used as a starting point for physicians and can open up the lines of patient-physician communication on possible treatment options.

As new research, knowledge and literature on CTS becomes available, this guideline will be reviewed and re-evaluated by the Guidelines and Technology Oversight Committee. It will be considered for updating in three to five years, which is consistent with evidence-based standards.

This guideline, which is aimed towards the treatment of Carpal Tunnel Syndrome in adults, was developed by an AAOS physician volunteer work group and was based upon a systematic review of the current scientific and clinical information on accepted approaches to treatment and/or diagnosis. The entire process from beginning to end lasted about eighteen months and included a review panel consisting of internal and external committees, public commentaries and final approval by the AAOS Board of Directors.

The full guideline along with all supporting documentation is available on the AAOS website: http://www.aaos.org/guidelines

Thanks,

JTM, MD

Stay on Par this Golf Season, Injury Free

Swinging the club on the open green, hitting the perfect shot and playing in the warm sun are just a few things golfers love about hitting the links. Golfing can be a treat for both the mind and body. However, an injury to the bones, muscles or joints can cast a big shadow over the day. That is why the American Academy of Orthopaedic Surgeons (AAOS) recommends following the proper techniques to prevent golf-related injuries.

According to the U.S. Consumer Product Safety Commission:

• There were more than 103,000 golf-related injuries treated in doctors’ offices, clinics and emergency rooms in 2007, which incurred a total cost of approximately $2.4 billion in medical, work-loss, pain and suffering, and legal fees.

• Golfers most often suffer from hand tenderness or numbness; shoulder, back and knee pain; golfer’s elbow; and wrist injuries, such as tendonitis or carpal tunnel syndrome.

It’s important for golfers to regularly participate in a muscle conditioning program to reduce the risk of common golf injuries.

Because orthopaedic surgeons not only treat, but try to prevent injuries of the bones, joints and muscles, the AAOS offers the following tips to help prevent golfing injuries:

• Newer golfers should take lessons and begin participating in the sport gradually.

• Practice on real turf instead of rubber mats, when possible.

• Dress for comfort and protection from the elements. Make sure to wear the appropriate golf shoes: ones with short cleats are best.

• Do not hunch over the ball too much; it may predispose you to neck strain and rotator cuff tendinitis.

• Avoid golfer’s elbow – which is caused by a strain of the muscles in the inside of the forearm – by performing wrist and forearm stretching exercises and not overemphasizing your wrists when swinging.

Thanks,

JTM, MD

Glenohumeral joint now thought to cause subacromial impingement syndrome

Anomalies in the morphology of the acromion may not be the cause of subacromial impingement syndrome as has been theorized by some shoulder surgeons. Japanese researchers said they now believe the glenohumeral joint pathologies may be more to blame, including glenoid spurs and greater tuberosity irregularities.

“There is no relationship between impingement syndrome and factors of acromial morphology, such as the shape or slope of the acromion,” said Hiroshi Hashiguchi, MD, of Nippon Medical School in Tokyo.

Hashiguchi and colleagues based their conclusions on results of a radiographic analysis they performed comparing acromion morphology in patients with and without a positive impingement sign.

He reported these findings at the American Academy of Orthopaedic Surgeons 76th Annual Meeting, here.

Glenohumeral instability

“The major factor in the development of impingement syndrome is instability of the glenohumeral joint due to dysfunction of the rotator cuff. Narrowing of the supraspinatus outlet is not the cause of impingement syndrome. Narrowing of the outlet is an effect of the impingement phenomenon,” Hashiguchi said.

Hashiguchi said that glenoid spurs, represented here, may be the cause of subacromial impingement. Images: Hashiguchi H

The researchers now theorize that anterosuperior glenohumeral instability arising from a weak or imbalanced rotator cuff rotator may be mostly to blame, according to their abstract.

For their study, Hashiguchi and colleagues obtained AP shoulder and lateral scapular radiographs for 192 patients with the impingement sign and 184 patients without it. Both groups’ mean age was about 53 years. Patients were excluded from both groups if they had shoulder pain or stiffness, rotator cuff tears or calcium deposits or if they played overhead sports.

Factors analyzed

Using the two groups’ radiographs, investigators identified and statistically analyzed such factors as shape of the greater tuberosity, bone spur formation on the inferior glenoid and in the subacromial area and the overall acromion morphology.

Investigators used the Bigliani classification for the acromion arch shape, where type 1 is flat, type 2 is curved and type 3 is hooked. They also measured the slope of the acromion arch and calculated the size of any subacromial bone spurs.

Both groups’ radiographs showed a similar frequency of sclerotic change in the greater tuberosity, but the group with the positive impingement sign demonstrated more tuberosity irregularities than the controls.

Results of the study indicated a higher incidence of subacromial spurs in the group with a positive impingement sign. Greater tuberosity irrgularities were also related to impingement syndrome.

“Regarding shape of the acromion, there was no significant difference between the two groups. There was also no significant difference in mean values of the slope of the acromion between the two groups,” he explained.

Spur size, location

The main difference the investigators noted between the two groups’ shoulder radiographs was a statistically higher incidence of inferior glenoid spurs in the group with a positive impingement sign. However, the overall frequency of subacromial spurs was not different between the two group, Hashiguchi noted.

“The size of subacromial spur in the impingement group was significantly higher in the control group,” he said.

Hashiguchi added, “This study revealed that radiographic factors related to impingement syndrome are the inferior glenoid spur, the irregularities of the greater tuberosity and the size of the subacromial spur.”

He said during the discussion period acromioplasty for subacromial decompression is a solution for patients with impingement syndrome, but at the outset it is more typically caused by degeneration of the rotator cuff from overloading.

For more information:

• Hiroshi Hashiguchi, MD, can be reached at Nippon Medical School Hospital, Department of Orthopaedic Surgery, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan; +81-3-3822-2131; e-mail: hashi.h@d6.dion.ne.jp. He has no direct financial interest in any products or companies mentioned in this article.

Reference:

• Hashiguchi H, Ito H, Egawa Y, Murashige R. Analysis of radiographic findings on patients with subacromial impingement syndrome. Paper #556. Presented at the American Academy of Orthopaedic Surgeons 76th Annual Meeting. Feb. 25-28, 2009. Las Vegas.

• ORTHOPAEDICS TODAY EUROPE 2009; 12:10 Susan M. Rapp

My thoughts:

I believe that there are factors in the subacromial space that affect the rotator cuff. Spurs from the acromioclavicular joint contribute to crowding of the rotator cuff. When we do a shoulder scope we often see fraying of the surface of the rotator cuff tendons as they rub against the spur. I do agree, however, that it is an imbalance of the shoudler joint related to specific areas of stiffness and weakness that lead to shoulder pain, impingement and eventually a tear of the tendon.

I often tell patients that the painful shoulder is often "out of balance" with selected areas of capsular stiffness and rotator cuff weakness. Therapy is often helpful to stretch and strengthen the shoulder thereby rebalancing the joint and relieveing the pain.

I am not sure of the true significance of the spur on the glenoid. Time and further studies will be needed.

Thanks.

JTM, MD

Calcium, Vitamin D and Hip Fractures

We all know that vitamin D and calcium are good for bones, but research teams in Europe and USA have shown that both taken daily reduces the rate of hip fracture in older people by 20%.

Speaking at the European Symposium on Calcified Tissue in Vienna today (27 May), Professor Bo Abrahamsen from the Copenhagen University Hospital Gentofte in Denmark, described the results from a major study analysing seven trials examining the effects of low doses of vitamin D with calcium in 68,500 patients.

Participants in the study were aged 47 - 107 years old, average age 69. Their age, gender and fracture history were taken into account, together with medication such as hormone replacement therapy and bisphosphonates (used in the treatment of post-menopausal osteoporosis and osteoporosis in males). Patients in all the trials included were randomized to receive either vitamin D (given alone or with calcium, usually in the form of 1000 mg calcium carbonate daily) or no active treatment. "The real strength of this study was that we were looking at groups and individuals, not just summary statistics. We were able to calculate absolute fracture rates and the time to treatment effects," he said.

After about 16 months, the reduction in hip fracture rates by 20% was seen in people who took vitamin D (10ug; 400 IU) and calcium (1000 mg) together, regardless of age, gender and fracture history. Fracture rate in other bones was reduced by 10%. "Vitamin D on its own is not very effective, even if the dose is doubled," said Professor Abrahamsen, a consultant physician at the hospital. "In people over fifty, the combination of vitamin D with calcium, however, seems to work equally well in people with or without a history of bone fractures - this is important new knowledge," he said.

The impact of calcium plus vitamin D on fracture however is somewhat more modest than that seen for other osteoporosis interventions. People with a high risk of fracture will benefit more from being treated with specific osteoporosis drug therapies such as bisphosphonates, together with oral vitamin D and calcium.

Professor Tahir Masud from Nottingham University Hospital and a UK collaborator said, "Previous data have shown that there is a high degree of vitamin insufficiency in the older population in the UK. Many older people at high risk of fracture do not receive vitamin D and calcium supplements."

The study cannot separate the beneficial effects of daily vitamin D from daily calcium, but the results suggest that vitamin D by injection every three months given to many elderly patients does not make a big impact on fracture rates.

"We cannot yet recommend that all adult, healthy people should take oral vitamin D and calcium supplements to prevent bone fracture in later life, but our findings indicate that vitamin D supplements taken daily with calcium is a simple and cheap way of reducing the risk of bone fractures in people in late middle age and onwards, " said Professor Abrahamsen.

Source
The European Calcified Tissue Society


Thanks,


JTM, MD

Preoperative Prep Showers

In 2008, the Association of periOperative Registered Nurses revised its recommendations regarding preoperative skin preparation for surgical patients. The new recommendation is that patients who are scheduled for open, class I surgical procedures that take place on a body part below the chin have 2 preoperative showers or baths with a chlorhexidine gluconate (CHG) preparation (unless contraindicated).^[1] Showering or bathing with a CHG product essentially reduces the patient's skin flora. This recommendation is based on the significance of surgical site infections, which are a commonly reported healthcare-associated infection in the United States. Adequate preparation of the patient's skin before surgery can minimize this risk.

Class I surgical procedures are considered "clean." These incisions are carefully and deliberately created in the surgical (or procedure) setting. They are nontraumatic; have no inflammation; the respiratory or gastrointestinal tracts are not entered; the wound is closed with a primary closure (sutured, stapled, or taped); and if any drains are placed in surgical site, a closed drainage system is used. Operative incisional wounds that follow nonpenetrating (blunt) trauma are included in this category if they meet the criteria. Clean wounds carry a 1% to 5% risk for infection.

A preoperative shower with a 4% CHG product accomplishes 3 objectives: it removes soil, dirt, oil, and transient microorganisms from the epidermis; reduces the resident microbial count to minimal levels in a short time; and prevents regrowth and multiplication of the dermal microbes. A 4% CHG is an effective broad-spectrum antimicrobial product that is effective against gram-negative and gram-positive bacteria, as well as against viruses.

When you provide preoperative education, first ask whether the patient has ever had a skin reaction with any previous surgical procedures. Although reactions to CHG are infrequent, patients with a known hypersensitivity should not use the product.

The salient points to include in patient preoperative education are:

The night before surgery: shower or bathe with the CHG product. After the CHG shower or bath, rinse thoroughly; use a fresh, clean towel to dry; and don clean clothing; and Morning of surgery: repeat the same procedure as the evening before.

If the patient is having a surgical procedure on the head (and the patient's tympanic membrane is intact), instruct them to:

Shampoo with CHG twice (the evening before and the morning of the surgery); Avoid using any conditioners, shampoo, hair spray, or other alcohol-based hair products; and Avoid getting the CHG preparation in their eyes, ears, nose, or mouth.

For hand or wrist surgery, instruct the patient to:

Keep nails short and natural; and Remove artificial nail surfaces;

Other general information (for all patients):

Do not shave or use a depilatory on the surgical site; Remove cosmetics; and Remove all jewelry, including body jewelry (eg, body piercing ornaments).

Infections that develop in clean surgical wounds are primarily caused by exogenous microbes. Educating patients about preoperative showers or baths with CHG products can lower their risk for infection following class I surgical procedures.

Thanks,

JTM, MD

Treating Knee Osteoarthritis without Surgery

Osteoarthritis (OA) is estimated to affect almost 27 million Americans.  Second only to heart disease as a cause of work disability, OA affects people of all ages, although the majority of those experiencing OA are adults. The prevalence of OA has increased and is likely to continue increasing as the “baby boom” generation ages.  The current market for OA treatments, aside from a slight decline in the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and a slight but surprising upswing in the use of cyclooxygenase-2 (COX-2) inhibitors, has remained relatively stable over the past few years. In the past year, use of intra-articular steroids has dropped slightly, while the use of hyaluronic acid (HA) products has remained the same. 

With a goal of symptom relief and improvement in function, many clinicians believe that the HA product likely to yield the best results may be one that most closely resembles endogenous human HA. With this hypothesis in mind, a group of clinicians in the fields of orthopedics, rheumatology, and physical medicine/rehabilitation met in New York City in November 2008. Their purpose was to review the beneficial properties of endogenous HA, evaluate the available exogenous HA products to determine how they compare in their resemblance to endogenous HA, and agree on an umbrella term that would best encompass the features of the ideal HA product for both clinicians and patients.

A monograph was created and published as a result of this meeting.  

It can be downloaded here.  

It was published by the manufacturers of Euflexxa (keep this in mind when you read it) but it contains a great deal of valuable information that I believe will be helpful for patients.  

I'll search the web for the good information so you don't have to.

Thanks,

JTM, MD

Save Your Knees

Great sites from the AAOS

Save Your Knees

Injury Prevention

Thanks,

JTM, MD

AAOS Issues New Clinical Practice Guideline for Osteoarthritis of the Knee

The American Academy of Orthopaedic Surgeons (AAOS) has approved and released an evidence-based clinical practice guideline on “Treatment of Osteoarthritis of the Knee”. These guidelines were explicitly developed to include only treatments which are less invasive than knee replacement surgery. While a wide range of treatment options are available, they should always be tailored to individual patients after discussions with their physicians.

The Guidelines and Evidence Report recommends:

• Not performing an arthroscopic lavage if a patient only displays symptoms of osteoarthritis and no other problems like loose bodies or meniscus tears.

If those mechanical problems—such as loose bodies and meniscal tears - are present then arthroscopy can be potentially beneficial. The current science shows us that just washing out the joint does not decrease the patient’s osteoarthritis symptoms and can expose the patient to additional risk.

Other important recommendations include:

• Patients who are overweight, with a Body Mass Index (or BMI) greater than 25 should lose a minimum of five per cent of their body weight.
• Patients should be encouraged to begin or increase their participation in low-impact aerobic fitness.

These two recommendations are very important because patients can self manage the progression of their OA, and take more control of what their issues are. As far as losing weight, this has the highest potential to actually slow the progression of the disease.

After a thorough analysis of the current scientific literature, the work group recommends against using the following treatments:

• Glucosamine and/or chondroitin sulfate or hydrochloride
• Needle lavage (aspiration of the joint with injection of saline)
• Custom made foot orthotics

The work group does suggest that patients with symptomatic OA of the knee receive one of the following analgesics for pain unless there are contraindications to this treatment:

• Acetaminophen (not to exceed 4 grams per day)
• Non-steroidal anti inflammatory drugs (NSAIDs)
• Intra-articular corticosteroids (for short term pain relief)

In addition, the available evidence does not allow the work group to recommend for or against the use of:

• Bracing
• Acupuncture
• Intra-articular hyaluronic acid

Osteoarthritis (OA) of the knee is a leading cause of physical disability. Some 33 million Americans are affected by osteoarthritis, but it most commonly occurs in people who are 65years of age or older. OA of the knee can have a major effect on a person’s ability to engage in daily activities like walking or climbing stairs. Symptoms associated with osteoarthritis of the knee include:

• Pain, mild to severe
• Joint stiffness
• Swelling in the knee joint.

Several factors increase a person’s risk of developing OA of the knee including:

• Heredity
• Weight
• Age
• Gender
• Injuries or Trauma to the knee
• Other risk factors including poor posture, bone alignment, lack of aerobic exercise and muscle weakness

The Academy created this clinical practice guideline to improve patient care for those suffering from osteoarthritis of the knee. This serves as a point of reference and educational tool for both primary care physicians and orthopaedic surgeons, streamlining possible treatment processes for this ever-so common ailment.

Thanks,

JTM, MD

A Patient's Guide to Reverse Shoulder Replacements

To learn more about the Reverse Shoulder Replacements that can be used for the treatment of irreparable rotator cuff tears and the arthritis that can be associated with irreparable cuff tears check out the links below.

A Patient's Guide to Reverse Shoulder Replacements

Reverse Shoulder Replacements from the University of Washington

Thanks,

JTM, MD

Interesting Note Regarding Total Knee Replacements in Older Patients

Reuters Health

Thursday, November 20, 2008

NEW YORK (Reuters Health) - Total knee replacement not only improves knee mobility in older adults with severe osteoarthritis of the knee, it actually improves the overall level of physical functioning, new research indicates.

Osteoarthritis is the most common form of arthritis, causing pain, swelling and reduced motion of the joints. Its onset is frequently age-related and often affects the hands, knees, hips or spine.

Investigators from Duke University in Durham, North Carolina, analyzed data for 259 adults with knee arthritis who had total knee replacement and 1,816 with knee arthritis who did not have knee replacement surgery.

According to Dr. Linda K. George and colleagues, physical functioning improvements after total knee replacement were "sizeable," while the no-treatment group showed declining levels of physical functioning.

The people who had knee replacement "improved significantly in 1 basic aspect of self care (bathing), 3 more difficult tasks (light housework, heavy housework, and shopping), and 2 advanced activities of daily living (walking 2 to 3 blocks and lifting weights up to 10 pounds)," the Duke team reports in the journal Arthritis and Rheumatism.

"In contrast, persons who did not have total knee arthroplasty exhibited overall patterns of decline in physical functioning," they note.

"Joint replacement," the investigators conclude, "is one likely way that medical care is contributing to declining rates of disability in the older population."

SOURCE: Arthritis and Rheumatism, October 2008.

So when older patients are considering a total knee replacement, one of the benefits to consider is an overall improvement in physical capacity and reduced disability.

Thanks,

JTM, MD

A New Take On Stretching

Stretching: The Truth

By GRETCHEN REYNOLDS from The NY Times

Published: October 31, 2008

WHEN DUANE KNUDSON, a professor of kinesiology at California State University, Chico, looks around campus at athletes warming up before practice, he sees one dangerous mistake after another. “They’re stretching, touching their toes. . . . ” He sighs. “It’s discouraging.”

Enlarge This Image

Horacio Salinas

The New York Times
Sports Magazine

Go to Complete Coverage »

Enlarge This Image

Illustration by Emily Cooper

STRAIGHT-LEG MARCH (for the hamstrings and gluteus muscles)Kick one leg straight out in front of you, with your toes flexed toward the sky. Reach your opposite arm to the upturned toes. Drop the leg and repeat with the opposite limbs. Continue the sequence for at least six or seven repetitions.

Enlarge This Image

Illustration by Emily Cooper

SCORPION (for the lower back, hip flexors and gluteus muscles) Lie on your stomach, with your arms outstretched and your feet flexed so that only your toes are touching the ground. Kick your right foot toward your left arm, then kick your left foot toward your right arm. Since this is an advanced exercise, begin slowly, and repeat up to 12 times.

Enlarge This Image

Illustration by Emily Cooper

HANDWALKS (for the shoulders, core muscles and hamstrings) Stand straight, with your legs together. Bend over until both hands are flat on the ground. ‘‘Walk’’ your hands forward until your back is almost extended. Keeping your legs straight, inch your feet toward your hands, then walk your hands forward again. Repeat five or six times.

If you’re like most of us, you were taught the importance of warm-up exercises back in grade school, and you’ve likely continued with pretty much the same routine ever since. Science, however, has moved on. Researchers now believe that some of the more entrenched elements of many athletes’ warm-up regimens are not only a waste of time but actually bad for you. The old presumption that holding a stretch for 20 to 30 seconds — known as static stretching — primes muscles for a workout is dead wrong. It actually weakens them. In a recent study conducted at the University of Nevada, Las Vegas, athletes generated less force from their leg muscles after static stretching than they did after not stretching at all. Other studies have found that this stretching decreases muscle strength by as much as 30 percent. Also, stretching one leg’s muscles can reduce strength in the other leg as well, probably because the central nervous system rebels against the movements.

“There is a neuromuscular inhibitory response to static stretching,” says Malachy McHugh, the director of research at the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City. The straining muscle becomes less responsive and stays weakened for up to 30 minutes after stretching, which is not how an athlete wants to begin a workout.

THE RIGHT WARM-UP should do two things: loosen muscles and tendons to increase the range of motion of various joints, and literally warm up the body. When you’re at rest, there’s less blood flow to muscles and tendons, and they stiffen. “You need to make tissues and tendons compliant before beginning exercise,” Knudson says.

A well-designed warm-up starts by increasing body heat and blood flow. Warm muscles and dilated blood vessels pull oxygen from the bloodstream more efficiently and use stored muscle fuel more effectively. They also withstand loads better. One significant if gruesome study found that the leg-muscle tissue of laboratory rabbits could be stretched farther before ripping if it had been electronically stimulated — that is, warmed up.

To raise the body’s temperature, a warm-up must begin with aerobic activity, usually light jogging. Most coaches and athletes have known this for years. That’s why tennis players run around the court four or five times before a match and marathoners stride in front of the starting line. But many athletes do this portion of their warm-up too intensely or too early. A 2002 study of collegiate volleyball players found that those who’d warmed up and then sat on the bench for 30 minutes had lower backs that were stiffer than they had been before the warm-up. And a number of recent studies have demonstrated that an overly vigorous aerobic warm-up simply makes you tired. Most experts advise starting your warm-up jog at about 40 percent of your maximum heart rate (a very easy pace) and progressing to about 60 percent. The aerobic warm-up should take only 5 to 10 minutes, with a 5-minute recovery. (Sprinters require longer warm-ups, because the loads exerted on their muscles are so extreme.) Then it’s time for the most important and unorthodox part of a proper warm-up regimen, the Spider-Man and its counterparts.

“TOWARDS THE end of my playing career, in about 2000, I started seeing some of the other guys out on the court doing these strange things before a match and thinking, What in the world is that?” says Mark Merklein, 36, once a highly ranked tennis player and now a national coach for the United States Tennis Association. The players were lunging, kicking and occasionally skittering, spider-like, along the sidelines. They were early adopters of a new approach to stretching.

While static stretching is still almost universally practiced among amateur athletes — watch your child’s soccer team next weekend — it doesn’t improve the muscles’ ability to perform with more power, physiologists now agree. “You may feel as if you’re able to stretch farther after holding a stretch for 30 seconds,” McHugh says, “so you think you’ve increased that muscle’s readiness.” But typically you’ve increased only your mental tolerance for the discomfort of the stretch. The muscle is actually weaker.

Stretching muscles while moving, on the other hand, a technique known as dynamic stretching or dynamic warm-ups, increases power, flexibility and range of motion. Muscles in motion don’t experience that insidious inhibitory response. They instead get what McHugh calls “an excitatory message” to perform.

Dynamic stretching is at its most effective when it’s relatively sports specific. “You need range-of-motion exercises that activate all of the joints and connective tissue that will be needed for the task ahead,” says Terrence Mahon, a coach with Team Running USA, home to the Olympic marathoners Ryan Hall and Deena Kastor. For runners, an ideal warm-up might include squats, lunges and “form drills” like kicking your buttocks with your heels. Athletes who need to move rapidly in different directions, like soccer, tennis or basketball players, should do dynamic stretches that involve many parts of the body. “Spider-Man” is a particularly good drill: drop onto all fours and crawl the width of the court, as if you were climbing a wall. (For other dynamic stretches, see the sidebar below.)

Even golfers, notoriously nonchalant about warming up (a recent survey of 304 recreational golfers found that two-thirds seldom or never bother), would benefit from exerting themselves a bit before teeing off. In one 2004 study, golfers who did dynamic warm- up exercises and practice swings increased their clubhead speed and were projected to have dropped their handicaps by seven strokes over seven weeks.

Controversy remains about the extent to which dynamic warm-ups prevent injury. But studies have been increasingly clear that static stretching alone before exercise does little or nothing to help. The largest study has been done on military recruits; results showed that an almost equal number of subjects developed lower-limb injuries (shin splints, stress fractures, etc.), regardless of whether they had performed static stretches before training sessions. A major study published earlier this year by the Centers for Disease Control, on the other hand, found that knee injuries were cut nearly in half among female collegiate soccer players who followed a warm-up program that included both dynamic warm-up exercises and static stretching. (For a sample routine, visit www.aclprevent.com/pepprogram.htm.) And in golf, new research by Andrea Fradkin, an assistant professor of exercise science at Bloomsburg University of Pennsylvania, suggests that those who warm up are nine times less likely to be injured.

“It was eye-opening,” says Fradkin, formerly a feckless golfer herself. “I used to not really warm up. I do now.”

You’re Getting Warmer: The Best Dynamic Stretches

These exercises- as taught by the United States Tennis Association’s player-development program – are good for many athletes, even golfers. Do them immediately after your aerobic warm-up and as soon as possible before your workout.

STRAIGHT-LEG MARCH

(for the hamstrings and gluteus muscles)

Kick one leg straight out in front of you, with your toes flexed toward the sky. Reach your opposite arm to the upturned toes. Drop the leg and repeat with the opposite limbs. Continue the sequence for at least six or seven repetitions.

SCORPION

(for the lower back, hip flexors and gluteus muscles)

Lie on your stomach, with your arms outstretched and your feet flexed so that only your toes are touching the ground. Kick your right foot toward your left arm, then kick your leftfoot toward your right arm. Since this is an advanced exercise, begin slowly, and repeat up to 12 times.

HANDWALKS

(for the shoulders, core muscles, and hamstrings)

Stand straight, with your legs together. Bend over until both hands are flat on the ground. “Walk” with your hands forward until your back is almost extended. Keeping your legs straight, inch your feet toward your hands, then walk your hands forward again. Repeat five or six times. G.R.

Thanks,

JTM, MD

Surgical intervention for end-stage shoulder osteoarthritis: When should it be done?

More and more elderly patients are consulting with orthopedic surgeons for problems related to shoulder pain and function loss that limits their quality of life and desired activities.

Q: Surgical intervention for end-stage osteoarthritis (OA) of the shoulder remains controversial. What are indications for surgical intervention?

A: The most common shoulder conditions treated with total shoulder replacement (TSR) are primary degenerative arthritis, inflammatory arthritis, osteonecrosis, post-traumatic arthritis and arthritis following instability procedures with degenerative OA accounting for approximately 60%. Patients with pain, who have failed nonoperative treatment, have ability to comply with postoperative rehabilitation, and who are at acceptable surgical risk are indicated for surgery.

Surgical candidates typically have a pain severity that is nonresponsive to NSAIDs, affects all their daily and routine activities, and does not allow them to sleep. Anatomical factors also greatly influence surgical indications. Total shoulder replacement with glenoid resurfacing requires a functioning rotator cuff, functioning deltoid, and adequate glenoid bone stock to support the glenoid component. Rotator cuff dysfunction allows superior migration of the humeral head that causes eccentric loading of the glenoid component and early loosening. Similarly, a dysfunctional deltoid can result in instability of the humeral component relative to the glenoid component leading to glenoid loosening. Glenoid loosening may also occur if the glenoid bone stock is not capable of supporting the periphery of the component or the keel or pegs of the implant within the glenoid vault.

Q: Is there an indication for humeral head replacement, when both sides of the joint are extensively involved?

Several situations favor humeral head replacement without glenoid prosthetic resurfacing, even when both the glenoid and the humeral head have extensive arthritic changes. These include rotator cuff deficiency, glenoid bone deficiency, and also young, highly active patients. Patients with rotator cuff deficiency risk glenoid component loosening. The cause of loosening is eccentric loading of the glenoid from proximal migration of the humerus. Patients who have ability to raise their arm despite rotator cuff deficiency are treated with a hemiarthroplasty and glenoid reaming to correct version abnormalities but without resurfacing the glenoid. Older patients, eg 80 years old or older, with advanced degenerative changes of the glenohumeral joint, proximal humerus migration, and inability to raise their arm which are characteristics of rotator cuff arthropathy, are indicated for reverse shoulder arthroplasty.

Patients with severe glenoid erosion may not have enough bone stock to support a glenoid component (Figure 1). This can be observed in the setting of OA with severe posterior glenoid wear patterns. Rheumatoid arthritis can result in severe central erosion and limit ability to resurface the glenoid. Revision arthroplasty that requires glenoid removal for a loose glenoid component or infected component can result in deficient bone stock and prohibit revision glenoid implantation.

Standard radiographs must be used to assess degree of both glenoid arthrosis and glenoid wear pattern. The AP radiograph should assess humeral head position with superior migration indicating rotator cuff dysfunction or medialization indicating decreased glenoid vault volume. An axillary view is necessary to assess glenoid vault volume, extent of posterior glenoid wear, and alterations in glenoid version. We now routinely obtain a CT scan in all patients to adequately assess glenoid bone stock. MRI adds additional information on the integrity of the rotator cuff.

Young patients with extensive degenerative arthritis are at risk for glenoid component loosening, particularly if they cannot modify their postsurgical activities and are involved in heavy use of their upper extremities. These patients may be better treated with hemiarthroplasty with concentric reaming of the glenoid. In addition, non-stemmed components to preserve bone stock on the humerus may be beneficial since future revision is anticipated (Figure 2).

Q: What about the OR time, blood loss, learning curve, complication rates between total replacement and humeral head replacement?

A: Many surgeons criticize TSR when compared to simple hemiarthroplasty because of the associated increase in surgical time, blood loss, technical difficulty, and fear of eventual glenoid component loosening. In 2000 a study was performed a prospective randomized study that included 47 patients with 51 shoulders who were randomized to either TSR or hemiarthroplasty. TSR provided superior pain relief but was associated with increased cost, operative time (35 minutes), and blood loss (150 mL) per patient when compared with hemiarthroplasty. None of the total shoulder arthroplasties required revision in contrast to three of the 25 patients who required revision surgery to resurface the glenoid in the hemiarthroplasty group.

The concern for glenoid component loosening in TSR remains despite improvements in implantation technique and prosthetic design.

Another systematic review in 2007 found that only 80 of 1,238 TSRs (6.5%) required revision surgery for any cause. TSRs that used metal-backed glenoids required revision in 6.8% of cases. However, the revision rate for loosening of all-polyethylene glenoids was only 1.7%. Meanwhile, 8.1% of hemiarthroplasties required conversion to TSR because of persistent pain.

As in other surgical procedures, increased surgeon volume is associated with improved outcomes for TSR. Patients of the surgeons who performed an average of less than two shoulder arthroplasties during a 7-year study period had inferior outcomes compared to higher volume surgeons, according to Hammond and colleagues in 2003. In addition, patients treated by high-volume surgeons had fewer complications and shorter lengths of stay.

Q: What are some critical points in the preoperative establishment of an intact rotator cuff?

A: Evaluation of rotator cuff integrity is a requisite for total shoulder replacement. History, physical examination, X-rays, and advanced imaging provide the necessary information.

Patients with .massive rotator cuff tears may give a history of inability to raise their arm or simple weakness to forward elevation in addition to pain. Physical exam maneuvers that suggest an irreparable rotator cuff tear include poor active forward elevation or external rotation with preserved passive range of motion. External rotation lag sign and the horn blower’s sign also indicate massive rotator cuff tears. The lift-off test, belly press, and internal rotation lag sign indicate compromised subscapularis function. X-rays may reveal proximal humerus migration indicating a rotator cuff tear.

Finally, MRI scan can give details of the rotator cuff including tear size, degree of retraction, muscle atrophy, and fat infiltration. Any patient with history, physical, or X-rays suggestive of a rotator cuff tear undergoes an MRI scan prior to surgery.

MRI showing severe glenoid erosion which can result in the patient not having enough bone stock to support a glenoid component. Non-stemmed humeral components may be beneficial for young patients with extensive degenerative arthritis. These components can leave bone stock for future revisions.

References:

• http://www.orthosupersite.com/view.asp?rID=31041
• Gartsman, GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg (Am). 2000;82(1):26-34.
• Hammond, JW, Queale WS, Kim TK, McFarland EG. Surgeon experience and clinical and economic outcomes for shoulder arthroplasty. J Bone Joint Surg (Am). 2003;85-A(12):2318-2324.
• Radnay CS, Setter KJ, Chambers L, Levine WN, et al. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007;16(4):396-402.

This is an excerpt from a recent online ortho journal as referenced above. It is an excellent summary of my own approach to treating osteoarthritis of the shoulder.

Thanks.

JTM, MD

Knee Scope: Medial Meniscectomy

These are some clips from a recent knee arthroscopy. The first clip shows the probing of the medial meniscus tear. The next clip shows the continuation of the medial meniscectomy.

Thanks.

JTM, MD

Arthroscopic Rotator Cuff Repair Pictures

The nice thing about a blog is that I post whatever I want when I have time and energy to do so. This is one of those times. These are some pictures of an arthroscopic cuff repair. The acromioplasty and distal clavicle excision are omitted.

Below are some intraoperative pictures from a recent arthroscopic rotator cuff repair. This first picture reveals the initial debridement of the footprint (attachment) of the rotator cuff. The MRI did not reflect the true extent of the damage to the cuff. The tear was approximately 2 cm from front to back.




The exposed bone is then burred down to bleeding bone.



Here is the anchor inserted into the bone in the greater tuberosity just at the edge of the joint cartilage. The sutures are attached to the bone anchor below. The sutures are then passed through the tendon.


Here I grab the sutures during the repair. I pass the sutures through the small plastic cannulas that pass through the skin.


Below some knots are tied as the first part of the repair. This completes the first row (medial row) of the repair.


Tying knots with a knot pusher below.






Medial row of sutures completed below.



Note the plastic cannula to the left in the below picture.




Sutures from the medial row are then passed through the lateral cannula and are attached to the Versalock suture anchor outside of the shoulder. The anchor is then slid in through the cannula and placed in the correct position on the bone.


Below the first sutures are placed into the bone in the lateral row. Note the closure of the hole in the cuff tear.



Here you see the tiny gap in the repair that I then repaired with another suture. This was passed in a "horizontal mattress" pattern through the tendon. It was then attached to another anchor that was passed into a second Versalock anchor.


Multiple images of the final repair below.











Look, no gaps and a water tight closure.

Thanks.

JM

The Curveball in the Young Pitcher

A biomechanical comparison of forces generated in the curveball, fastball, and change-up pitches has been undertaken by S. Dun et al (Am J Sports Medicine. 2008;36[4]:686-692) to determine the risks of curveball pitches to youthful elbows. There has been a belief that the curveball pitch is harmful, especially to the immature ulnar collateral ligament, more so than, for example, the fastball.

Dun et al observed 29 baseball pitchers, aged 12.5±1.7 years, who threw 5 of each pitch type (ie, fastball, curveball, and change-ups). A three-dimensional motion analytic system was used to measure varus torque, shoulder internal rotation torque, and proximal force at the elbow and shoulder. The greatest force was generated by the fastball, then the curveball, and least the change-up.

The authors concluded that the curveball is not potentially more harmful to the young elbow than the fastball and that the number of pitches thrown carries a stronger risk than the nature of the pitch.

(ORTHOPEDICS 2008; 31:537)

Even young athletes can sustain strain and overuse injuries from too much training and sports. The problem that I commonly see in the office is the case of the young athlete being pushed by the parents. These kids just want to play for fun, but too often there is some well intentioned (read annoying and delusional) mother of father who thinks their son or daughter is the next great thing in their sport. These kids usually give up the sport as soon as they have the nerve and sense of independence that enables them to do so. Those athletes who really excel and go on to professional careers in sports do not need their parents to push them, they need their parents for support. Big difference.

Thanks.

JTM, MD

Our Office

From 1991 to August, 2007, I practiced as a member of Manchester Orthopedic Surgery and Sports Medicine in Manchester, CT. On August 20, 2007, I open my new practice, The Connecticut Center for Orthopedic Surgery, LLC.

I am very proud of my association with my former partners and continue to maintain a great relationship with them. Practices that split up often degenerate into a messy legal fight over assets and patients. I credit my former partners with fostering a friendly and professional evolution of our practices. We continue to refer patients to each other even though my new office is right across the street from the old one.

I continue to hold them in high regard and consider them two of the finest individuals and best orthopedic surgeons I have had the opportunity to know.

Anyway...

When I moved to start my own practice at The Connecticut Center for Orthopedic Surgery, I knew that it would be a representation of me and the kind of practice I could create on my own. Although I am on the active staff of both Hartford Hospital and ECHN Hospital (Manchester Memorial Hospital), I do not work for nor am I employed by any hospital system. In the Wethersfield office, I am in the Hartford Hospital Health care building on the Silas Deane Highway.

It took me 16 years to figure out what I wanted in an office. Because I spend so much time there, I wanted the office to be someplace of which I could be proud and a place I would not mind spending lots of time. I wanted the office to have a "wow factor" for patients. It had to be functional, modern, high tech and it should not seem like a doctor's office. It should be warm and soothing for patients and a place my staff would enjoy working. I gave considerable thought to the materials and design. Although I had help with some of the specifics and selections, I would like to think it it a great representation of what I was trying to achieve.

The outside of the building was designed by the builder.


Once inside the office, you can see the attention I put into the experience of the "office visit". No one really wants to go to the doctor. If I can make the experience a bit more pleasant and soothing, patients can focus on themselves and their problems.

Just inside the front door...


Our reception area and the check in desk...


The main hallway...


Notice the glass door on the left. It's frosted so you can't see through it. The ceiling is definitely one of the best features of the office design.

We have 6 exam rooms...


Each exam room is open and spacious.


In one of the rooms, we have a power exam table that raises and lowers for patients who cannot step up onto a regular exam table.


The sink faucets in the exam rooms and hallway have infrared activation switches. Very cool!

When I selected the x-ray system, I recognized that one of the biggest delays in an office visit is the trip to x-ray. Below is the latest digital x-ray machine. No old fashioned films are produced. No x-ray cassettes required. Images can be provided to patients on paper or CD. These digital images a superior to standard film x-rays in every way.

The image is taken by the C-arm below. The image goes directly to our computer system where it can be modified. The image contrast can be adjusted or the image can be magnified. Specific bone and joint angles can be measured digitally. The amount of displacement of a specific fracture fragment can be measured to a tenth of a millimeter.

All of this technology allows me to compare patient x-rays from one week to the next and measure limb alignment and joint damage from arthritis.


The above x-ray C-arm takes the images which are then sent to the high resolution computer monitors outside of my office seen below.


Here is the checkout desk...


Patients scheduling tests or surgery can do so in a more private area.

Below is my office. A work still in progress...


Physical therapy is available in the practice. We gave considerable thought to the PT space design as well. It is open and spacious. There is also a private room for evaluations or treatments if necessary.


The treadmill is the newest addition to the PT facility.



The office is only part of the reason that I believe we have the best orthopedic office in the area. Our staff has considerable experience in caring for complicated orthopedic patients. They are totally dedicated to to serving our patients. I know that each one takes great personal pride in their job and taking care of our patients.

A beautiful office would not make any difference if I and my staff did not also provide the finest orthopedic care to our patients. I will take an opportunity to brag about my team at The Connecticut Center for Orthopedic Surgery in a future posting. They just have to sit still long enough for me to take some pictures. Needless to say, I am very proud of them and the job they do.

(Note to the CCOS staff: No, this does not mean you can all ask for a raise!)

Thanks.

JTM, MD

Shoulder Trauma

Trauma to the shoulder is common. Injuries range from a separated shoulder resulting from a fall onto the shoulder to a high-speed car accident that fractures the shoulder blade (scapula) or collar bone (clavicle). One thing is certain: everyone injures his or her shoulder at some point in life.

Anatomy

Shoulder Anatomy

The shoulder is made up of three bones:

• Scapula (shoulder blade)
• Clavicle (collar bone)
• Humerus (arm bone)

These bones are joined together by soft tissues (ligaments, tendons, muscles, and joint capsule) to form a platform for the arm to work.

The shoulder is made up of three joints:

• Glenohumeral joint
• Acromioclavicular joint
• Sternoclavicular joint

The shoulder also has one articulation, which is the relationship between the scapula (shoulder blade) and the chest wall.

The main joint of the shoulder is the glenohumeral joint. This joint comprises a ball (the humeral head) on a golf-tee-shaped joint (the glenoid of the scapula).

The bones of the shoulder are covered by several layers of soft tissues.

• The top layer is the deltoid muscle, a muscle just beneath the skin, which gives the shoulder a rounded appearance. The deltoid muscle helps to bring the arm overhead.
• Directly beneath the deltoid muscle is sub-deltoid bursa, a fluid-filled sac, analogous to a water balloon.

Types of Shoulder Injuries

There are many types of shoulder injuries:

• Fractures are broken bones. Fractures commonly involve the clavicle (collar bone), proximal humerus (top of the upper arm bone), and scapula (shoulder blade).
• Dislocations occur when the bones on opposite sides of a joint do not line up. Dislocations can involve any of three different joints.
• A dislocation of the acromioclavicular joint (collar bone joint) is called a "separated shoulder."
• A dislocation of the sternoclavicular joint interrupts the connection between the clavicle and the breastbone (sternum).
• The glenohumeral joint (the ball and socket joint of the shoulder) can be dislocated toward the front (anteriorly) or toward the back (posteriorly).
• Soft-tissue injuries are tears of the ligaments, tendons, muscles, and joint capsule of the shoulder, such as rotator cuff tears and labral tears.

The following discussion will focus on fractures and dislocations.

Cause

Fractures

Fractures of the clavicle or the proximal humerus can be caused by a direct blow to the area from a fall, collision, or motor vehicle accident.

Because the scapula is protected by the chest and surrounding muscles, it is not easily fractured. Therefore, fractures of the scapula are usually caused by high-energy trauma, such as a high speed motor vehicle accident. Scapula fractures are often associated with injuries to the chest.

Shoulder Dislocations

• Anterior dislocations of the shoulder are caused by the arm being forcefully twisted outward (external rotation) when the arm is above the level of the shoulder. These injuries can occur from many different causes, including a fall or a direct blow to the shoulder.
• Posterior dislocations of the shoulder are much less common than anterior dislocations of the shoulder. Posterior dislocations often occur from seizures or electric shocks when the muscles of the front of the shoulder contract and forcefully tighten.

Shoulder Separations

Dislocations of the acromioclavicular joint can be caused by a fall onto the shoulder or from lifting heavy objects. The term "shoulder separation" is not really correct, because the joint injured is actually not the true shoulder joint.

Symptoms of Fractures

Symptoms of fractures about the shoulder are related to the specific type of fracture.

General Findings

• Pain
• Swelling and bruising
• Inability to move the shoulder
• A grinding sensation when the shoulder is moved
• Deformity -- "It does not look right"

Specific Findings: Clavicle Fracture

Fractured clavicle (collarbone)

• Swelling about the middle of the collarbone area
• An area that may have a "bump," which is actually the prominent ends of the fracture under the skin
• Shoulder range of motion is limited, although not as much as with fractures of the proximal humerus

Specific Findings: Proximal Humerus Fracture

Fractured head of the humerus.

• A severely swollen shoulder
• Very limited movement of the shoulder
• Severe pain

Specific Findings: Scapular Fracture

Fracture patterns in the scapula

(Reproduced with permission from Zuckerman JD, Koval KJ, Cuomo F: Fractures of the scapula, in Heckman JD (ed): Instructional Course Lectures 42. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1993, pp 271-281.)

• Pain
• Swelling
• Severe bruising about the shoulder blade

Specific Findings: Shoulder Separation (Acromioclavicular Joint Separation)

An acromioclavicular joint dislocation with extreme elevation of the clavicle.

(Reproduced with permission from Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.)

• Pain over the top of the shoulder
• A prominence or bump about the top of the shoulder
• The sensation of something sticking up on the shoulder

Specific Findings: Shoulder Dislocation (Glenohumeral Joint Dislocation)

Shoulder instability

• A prominence about the front of the shoulder
• Inability to move the arm
• An arm rotated outward
• The sensation of a "dead arm"

Diagnosis

Most fractures are diagnosed with X-rays of the area and by physical examination. Sometimes, additional imaging techniques, such as computed tomography, are necessary.

Treatment Options

Clavicle Fractures

Most clavicle fractures can be treated without surgery. Surgery is necessary when there is a compound fracture that has broken through the skin or the bone is severely out of place. Surgery typically involves fixing of the fracture with plates and screws or rods inside the bone.

Proximal Humerus Fractures

Most fractures of the proximal humerus can be treated without surgery if the bone fragments are not shifted out of position (displaced). If the fragments are shifted out of position, surgery is usually required. Surgery usually involves fixation of the fracture fragments with plates, screws, or pins or it involves shoulder replacement.

Scapula Fractures

Most fractures of the scapula can be treated without surgery. Treatment involves immobilization with a sling or shoulder immobilizer, icing, and pain medications. The patient will be examined for additional injuries.

About 10% to 20% of scapula fractures need surgery. Fractures that need surgery usually have fracture fragments involving the shoulder joint or there is an additional fracture of the clavicle. Surgery involves fixation of the fracture fragments with plates and screws.

Shoulder Separations (Acromioclavicular Joint)

Treatment of shoulder separations is based on the severity of the injury as well as the direction of the separation and the physical requirements of the patient.

Less severe shoulder separations) are usually treated without surgery.

Severe separations in an upward direction or dislocations in the backward or downward directions often require surgery. Surgery involves repair of the ligaments.

Professional athletes and manual laborers are often treated with surgery, but the results are often unpredictable.

Shoulder Dislocations (Glenohumeral Joint)

The initial treatment of a shoulder dislocation involves reducing the dislocation ("putting it back in the socket"). This usually involves treatment in the emergency room.

The patient is given some mild sedation and pain medicine, usually through an intravenous line. Often, the physician will pull on the shoulder until the joint is realigned. Reduction is confirmed on an X-ray and the shoulder is then placed in a sling or special brace.

Additional treatment at a later date is based on the patient's age, evidence of persistent problems with the shoulder going out of place, and the underlying associated soft-tissue injury (either to the rotator cuff or the capsulolabral complex).

Patients who are 25 years of age or younger generally require surgery. Persistent instability (repeat dislocations) of the shoulder usually requires surgery. Surgery involves repair of the torn soft tissues.

Life After a Shoulder Injury

Life after a shoulder fracture, separation, or dislocation can be greatly affected for several weeks or even months. Most shoulder injuries whether treated surgically or nonsurgically require a period of immobilization followed by rehabilitation.

If the injury was not severe, there is fairly rapid improvement and return of function after the first 4 to 6 weeks. Shoulder exercises, usually as part of a supervised physical therapy program, are usually necessary. Exercises decrease stiffness, improve range of motion, and help the patient regain muscle strength.

Some of the information you should discuss with your orthopaedic surgeon includes the following:

• The exact type of your injury
• The severity of the injury
• The treatment plan
• The possible complications
• Whether surgery will be necessary
• When it is expected that you will be maximally improved
• What is the expected outcome will be both in the short term and in the long term

Thanks

JTM, MD


(http://orthoinfo.aaos.org/topic.cfm?topic=A00394)

Shoulder Fractures and Reverse Total Shoulders

Fractures of the proximal humerus are common in my practice and are some of the toughest fractures to treat. There are as many different types of fractures as there are patients. This is the case of an active 75 year old female who sustained this very severely comminuted fracture of the proximal humerus (shoulder). As you can see, the head of the humerus is fractured into many pieces the a large portion of the joint surface of the head compressed downward away from the joint.






Below is the CT scan of the patient.





The above fracture is so severely comminuted (multiple fragments) with displacement of the humeral head, that it cannot be repaired without a shoulder replacement. A replacement is clearly indicated here. In a younger patient, with an intact rotator cuff, we can perform a partial shoulder replacement, preserving the bone attached to the rotator cuff and repairing it around the prosthesis.

This is a diagram of how that would be performed.

The final repair would like like th diagram below. The rotator cuff would cover the top of the prosthesis and, once the bones heal, the cuff will stabilize the joint enabling the patient to lift the arm.

The key to success here is an intact and functional rotator cuff and tuberosities that heal around the prosthesis.
Unfortunately, in some patients, the bone (greater and lesser tuberosities) will not heal, the rotator cuff may be weak or may tear resulting in extremely poor function and pain. The patient may be unable to lift the arm.

The reverse shoulder replacement does not depend on an intact rotator cuff to provide good function. If the deltoid is intact, patients can elevate the arm and have excellent pain relief and function. If necessary, the rotator cuff and tuberosities can be excised and as long as the prosthesis remain securely fixed to the bone, results are often superior to those of hemiarthroplasty. This approach can be appropriate in patients over 70 years.

I usually do not completely excise the entire cuff. I try to preserve the subscapularis and lesser tuberosity and posterior cuff and greater tuberosity. The supraspinatus is excised and the biceps is treated with tenodesis.

This patient had a massive irreparable rotator cuff tear anyway, making the reverse shoulder replacement the only acceptable option for her.



Here, you can see the retained tuberosities healing around the upper part of the prosthesis. She is doing remarkably well with minimal pain and 90 degrees of forward elevation at only 4 weeks after surgery. We are proceeding slowly with therapy to encourage the tuberosities to heal, although, if they never healed, she would still do well.


Thanks,

JTM, MD

Clavicle Fractures

Midshaft clavicle fractures are often best treated with internal fixation with a plate and screws. Here are a couple of cases.

These are the x-rays of a physician who fell while skiing. Her deformity was significant and her pain considerable due to motion of the fracture.



Active motion begins almost immediately after surgery. Most patients have most to all of their motion at 6 - 8 weeks. Occasionally stiffness delays the return of function. If all goes well, the fracture should be healed b y 6 weeks.



Below are the x-rays of a professional pilot.


Postoperative films below reveal a perfect fracture position.




Occasionally the hardware will bother patients and need to be removed. This patient was bothered by the plate. After confirming complete healing on a CT scan, I removed the plate.



Below are the films of a Lifestar helicopter pilot.





These are just a few of the clavicle fractures treated surgically over the past few months. The only complications that occurred was a neuropraxia of one of the supraclavicular sensory nerves in one patient. (It figures that it was in the physician. This resulted in some hypersensitivity of the skin below the skin incision that is improving.) The other problem encountered was stiffness of the shoulder that completely resolved in another patient.

It is my opinion, that when clinically indicated, the repair of a clavicle fracture with plate fixation yields superior short and long term results when compared to nonoperative treatment. I also believe plate and screw fixation is superior to intramedullary fixation in that it provides immediate stability and an opportunity to resume early use of the shoulder and return of function.

Below is a excerpt from a peer review article from our well respected Journal of the American Academy of Orthopaedic Surgeons regarding the management of clavicle fractures.

From J Am Acad Orthop Surg, Vol 15, No 4, April 2007, 239-248.


Indications
The primary goal in treatment is to restore shoulder function to the preinjury level. By allowing the clavicle to heal with minimal deformity, loss of motion and pain can be minimized. Indications for nonsurgical treatment include a nondisplaced or minimally displaced midshaft clavicular fracture. Indications for surgical treatment include open fractures and fractures associated with skin compromise or with neurologic or vascular injury.

Relative surgical indications include certain multiple-system traumatized patients, a floating shoulder, and a painful malunion or nonunion. More recently, relative indications for surgical treatment have been expanded to include high-energy closed fractures with >15 to 20 mm of shortening, fractures with complete displacement, and fractures with comminution. Although these recently adopted indications have received attention in the current literature, articles dating as far back as the 1960s have described similar surgical indications which is often cited as support for nonsurgical management. Randomized controlled trials, one of which has recently been completed, and another that is currently under way, are necessary to determine whether these relative indications should be considered routine and, if so, in which patients with which fracture types.

Nonsurgical Treatment
Historically, nonsurgical treatment has been the mainstay for clavicular fractures. Most commonly, a sling or figure-of-8 brace is applied in the acute setting. With either device, immobilization is typically for 2 to 6 weeks, based on the patient’s level of comfort. Often, mild discomfort can linger in adults for 3 months. Return to athletics or heavy labor is permitted 4 to 6 weeks after clinical and radiographic union has occurred. Light work with restricted overhead activity can begin once the patient’s comfort allows, usually in 2 to 4 weeks after fracture healing.

In a prospective, randomized study, 26% of patients treated with a figure-of-8 bandage were dissatisfied compared with 7% of those treated with a sling. The patients treated with a sling reported less discomfort. There was no difference in overall healing and alignment of the fractures, indicating that a figure-of-8 bandage does little to obtain or maintain reduction.

Surgical Techniques
Plates
Open reduction and internal fixation using plates and screws can be done with the patient in either the supine or the beach-chair position, with the head and neck tilted away from the surgical site. A bump is placed behind the scapula to aid in the reduction. The arm is prepped in the field to allow for traction and manipulation to assist in the reduction. Traditionally, a skin incision is made over the clavicle following Langer’s lines, as the skin permits. A newly described alternative is to incise the inferior skin after pulling it over the fracture site. As the skin is released, it will fall 1 to 2 cm below the clavicle and prevent the wound from being in contact with the plate on the clavicle. The aim is to improve cosmesis and prevent wound complications. The dissection is taken down to bone with care to identify the cutaneous supraclavicular nerves. When necessary, they can be sacrificed. It is important to inform the patient before surgery of the possibility of a patch of numbness in the skin inferior to the clavicle.

Minimizing subperiosteal stripping with gentle handling of the skin and soft tissue helps avoid complications. The plate usually is placed on the tension side of the bone—for the clavicle, the anterosuperior position. The anteroinferior position demands additional soft-tissue stripping and a more difficult contouring of the plate compared with the anterosuperior position.

View larger version (91K): [in this window] [in a new window] Figure 4 Anteroposterior radiograph demonstrating clavicle plating in the anterosuperior position, using a 3.5-mm limited-contact dynamic compression plate.

Ideally, a 3.5-mm dynamic compression plate or plate of similar strength should be used, with at least six cortices on each side. Semitubular plates are not as rigid and should not be used. Reconstruction plates are more easily contoured and have been used with success; however, they account for several failures to obtain union and would not be the author’s first choice. Precontoured plates of suitable thickness offer the advantage of ease of placement without manipulation of the plate. Locked plates are not necessary for the acute plating of nonosteoporotic clavicular fractures; there is no significant advantage over conventional plating, and the cost is higher.

Once plating is completed, the fascia is repaired over the plate, if possible, and the skin incision is closed. Suture closure is preferable to staples. With a sufficiently stable construct, unrestricted shoulder motion is allowed, with the exception of overhead lifting for 6 weeks. Often, the pain relief associated with stabilizing the fracture is dramatic, and efforts to limit the patient’s activity may be needed. Pain relief is cited as one of the potential benefits of surgical intervention.

	Complications

Complications can occur from nonsurgical treatment as well as surgical treatment. Both can produce a cosmetic deformity. Both can result in malunion, nonunion, pain, local tenderness or irritation, and limitation of motion. Other rare complications following surgical or nonsurgical treatment are residual nerve paresthesia; subclavian vessel compression, thrombosis, and pseudoaneurysm; thoracic outlet syndrome; and brachial plexus neuropathy.

View larger version (68K): [in this window] [in a new window] Figure 6 A, Healed clavicular fracture managed nonsurgically. The bump, shortened shoulder width, and subtle droop are evident. B, A healed clavicular fracture treated with plate and screws, showing prominence of the anterior-superior–positioned plate.

Some complications are unique to surgical intervention, such as infection and hardware problems. Infection rates vary from 0% to 18%, with the lower rates reported in the more recent studies. Painful, irritating hardware requiring plate or pin removal is reported to be as high as 50% to 100%. Following plate removal, the risk for refracture ranges from 0% to 8%. Adhesive capsulitis of the shoulder has been reported with surgical treatment in 0% to 7% of cases.

	Results

Whether treated nonsurgically or surgically, most clavicular fractures heal without incident when length and alignment are maintained. Acceptable cosmetic and functional results should be expected. Satisfactory results occur less consistently when the fracture fails to heal or heals with a significant deformity.

Nonunion
Most cases of nonunion are symptomatic, presenting with pain, loss of function, neurologic changes, and/or unsightly clavicular deformity. Although clavicular nonunion has not been clearly defined in the literature, most authors concur that nonunion is present when healing has not occurred by 16 weeks.

Traditional thinking is that clavicular fractures treated nonsurgically almost always heal and that surgical treatment increases the risk of nonunion. Rowe reported a nonunion rate of 3.7% in patients who underwent surgery compared with 0.8% in those treated without surgery. Neer reported nonunion rates of 0.1% with nonsurgical treatment and 4.6% with surgical treatment. Neer suggested that the most important causal factor for nonunion of a midshaft clavicular fracture is improper open surgery. This may be true to some extent; aggressive soft-tissue stripping, inability to reduce the fracture, and inadequate internal fixation all can lead to poor results.

Several recent studies have reported high union rates with surgical intervention using a variety of internal fixation devices, including plating and IM pin or rod fixation. In addition, there is evidence that the nonunion rate after nonsurgical treatment may be higher than previously reported, particularly in certain fracture types and in certain patients. In their review of 581 nonsurgically treated fractures, Robinson et al reported an overall nonunion rate of 4.5% for diaphyseal fractures. Stratification of Robinson’s data revealed that women with displaced diaphyseal fractures had a nonunion rate ranging from 19% to 33%. When comminution was combined with displacement, the nonunion rate in women increased to a range of 33% to 47%. In addition to fracture fragment displacement, female sex, and comminution, other risk factors identified with nonunion include advancing age, lack of cortical apposition, severity of the initial trauma, the extent of fracture fragment displacement, and, arguably, soft-tissue interposition. Early mobilization has not been associated with the development of a nonunion, whether treated surgically or nonsurgically.

A recently published systematic review of the literature on nonunion after treatment of midshaft clavicular fractures revealed a 5.9% nonunion rate in nonsurgically managed fractures. In the completely displaced fractures, the rate increased to 15.1%. In surgically treated displaced fractures, plating of 460 fractures resulted in a nonunion rate of 2.2%, and IM fixation of 152 fractures resulted in a nonunion rate of 2.0%.

Surgical treatment of nonunion has a high success rate. Techniques include plate fixation with bone graft, IM pin fixation with bone graft, and external fixation. Union rates with each method have been reported to be >92% and as high as 100%. Plate fixation has the largest support in the literature and is currently the most predictable and recommended treatment for symptomatic nonunion. Other methods may be successful in the hands of an experienced surgeon.

Malunion
Most nonsurgically treated clavicular fractures heal with some deformity. The literature does not clearly define when a deformity is considered to be a malunion; however, the evidence strongly suggests that some clavicular deformities result in unsatisfactory outcomes. The deformity is a three-dimensional problem; the most consistent characteristic is shortening with inferior displacement of the medial fragment. Symptomatic patients help define the malunion. Symptoms include weakness and pain in the involved shoulder, loss of shoulder motion, loss of endurance, neurologic symptoms consistent with thoracic outlet syndrome and brachial plexus impingement, and cosmetic deformity.

In 1986, Eskola et al noted in 89 patients that shortening >12 mm was associated with increased pain. Wick et al concluded in a retrospective study that shortening of 2 cm in midshaft clavicular fractures was associated with an increased risk of pain, limitation of motion, or nonunion. McKee et al assessed functional outcome following displaced clavicular fractures and noted significantly inferior scores for both the upper extremity–specific (DASH) outcome scores (P = 0.02) and the Constant scores (P = 0.01) compared with the general population. They concluded that fractures with >2 cm of shortening tended to be associated with decreased abduction strength and greater patient dissatisfaction. Hill et al reported on completely displaced middle third clavicular fractures and concluded that final shortening 2 cm was associated with an unsatisfactory result but not with nonunion. After closed treatment, 31% of patients were dissatisfied with the final result, 54% were unhappy with the appearance, and 15% of fractures failed to unite. Using the same subjective patient questionnaire as that used by Hill et al, Lazarides and Zafiropoulos reported that final clavicular shortening >18 mm in males and >14 mm in females was associated with unsatisfactory results and with increased patient symptoms.

Ledger et al showed the effect of clavicular shortening >15 mm on biomechanical parameters of the shoulder. They found a significant increase in upward angulation (mean, 10.7°; P <> the uninjured side. The muscle torque of the injured arm was significantly weaker than that of the uninjured arm in extension (P <>P <> (P <>

These studies indicate that although clavicular deformities are complex and hard to assess, shortening of 1.5 to 2 cm, which results in an increased incidence of clinical symptoms, is one parameter that can be measured. Further investigation is needed to clearly define the patients as well as the fracture deformity that is likely to be symptomatic with a clavicular malunion. In this way, acute surgical treatment could be offered to the patients who are most likely to benefit. In addition, comparative trials are necessary to establish that patients with clavicular fractures that predictably result in deformity have better outcomes when treated surgically rather than nonsurgically. Several randomized trials currently are under way, and one has been completed, assessing the surgical versus nonsurgical management of acute displaced midshaft clavicular fractures. The Canadian Orthopaedic Trauma Society has shown in a multicenter randomized trial of 132 patients that for displaced fractures of the clavicular shaft, surgical fixation with a plate and screws resulted in an improved functional outcome and a lower rate of malunion and nonunion compared with nonsurgical treatment at 1 year.

Treatment of a malunion consists of surgical correction to restore length, angular deformity, and rotation of the clavicle. Treatment may or may not involve an intercalary bone graft. Often, after removing the callus of the malunion, it is possible to identify the proximal and distal fragments in order to anatomically reconstruct the clavicle. The benefit of this technique is that there is no donor-site morbidity for a bone graft. When difficulty in determining the length of the malunited clavicle is anticipated, a preoperative radiographic image of both clavicles is helpful. Both IM devices and plates have been used successfully to treat malunions. Treatment of symptomatic malunions has resulted in improvement of the function of the upper extremity, decreased pain, and increased patient satisfaction.

Thanks.

JTM, MD

Arthroscopy & First Time Shoulder Dislocations

Young, athletic, first-time shoulder dislocation patients benefit from arthroscopic surgery long term, according to a study released today at the 2008 American Orthopaedic Society for Sports Medicine Specialty Day. The study found that for highly active patients, surgery, rather than conservative methods, yielded excellent results. In young, active patients, there were statistics as high as 92 percent that they would dislocate their shoulder again when conservative approaches like rest and immobilization in a sling were used. If we had an operation with a 90 percent failure rate, we would abandon the procedure.

Why should we embrace a treatment with such a high failure rate?

Beginning in 1993, the researchers began performing arthroscopic surgery on young military cadets who suffered their first shoulder dislocation. The short-term results were excellent. The unknown, however, was how these patients would fare over the years. They examined these patients’ long-term results and found that these patients maintained their health and active lifestyle. Surgery for this group of patients was durable and provided excellent shoulder function and a high activity level even after 10 years. They evaluated 39 patients (40 shoulder operations) whose follow-up averaged 11.7 years. Patients were evaluated with patient-derived outcomes measures and asked to compare their repaired shoulder to its function level pre-injury and whether they would be likely to have the surgery again. Additionally, they were physically assessed with a number of tests, including, how many push-ups they completed in two minutes and performance on the Army Physical Fitness Test. Overall, the study found that the patients maintained excellent use of their shoulder. The mean American Shoulder and Elbow Surgeons score was 90.9. The patients compared their repaired shoulders’ function to the pre-injury function. The average response was 93 percent, the study found. When responding to whether they would have the surgery again with 10 being “very likely,” the average score was 9.1, according to the study. In terms of athletic ability, the results were also notable. The study found the average number of push-ups performed in 2 minutes was 72.8 compared to 77.7 prior to their injuries. The mean score of the Army Physical Fitness Test was 282.2 out of a possible 300, according to the study. The study also noted five patients who had eight further dislocations, all of which occurred during athletic activity, for a failure rate of 10 percent long-term. Certainly the study proves that for this group of patients, young, athletic cadets unable to modify their activity level, arthroscopic surgery for first-time dislocations is successful both short and long-term. This treatment allowed our patients to return to sports, graduate from the military academy and engage in active duty military obligations. It may not be the approach that should be taken for a person who lives a sedentary lifestyle, but this could be applicable to the young, 15-25-year-old athlete, who is at high risk for recurrent instability and compromised function.

Some patients may be appropriate for nonoperative treatment of shoulder dislocations. Newer methods of immobilization seem to offer a lower recurrence rate of dislocations. In 2003, researchers found that immobilizing the dislocated shoulder in a position of external rotation significantly reduces the rate of recurrent dislocations in first time dislocations. Below is one of my patients in the Don Joy ER brace.



Below is an arthroscopic view of a post dislocation Bankart lesion (tear of the anterior labrum).


Here is one of my cases of a Bankart lesion of the anterior labrum being repaired arthroscopically. The anchors are embedded in the bone and the sutures have been passed around the labrum.


Below the sutures have been tied and the anterior glenoid labrum have been repaired arthroscopically.


To help you understand further, below is a diagram of what we do. It's from my website at www.OrthoOnTheWeb.com.


Thanks.

JTM, MD

Knee Arthroscopy and Osteoarthritis

More than 80 percent of patients returned to walking, yardwork and other light activity one week after undergoing knee arthroscopy, according to a study published in the January 2008 issue of Arthroscopy: The Journal of Arthroscopic and Related Surgery. The study is the first to quantify recovery times for patients having the minimally-invasive procedure.

Knee arthroscopy, one of the most commonly performed surgical procedures, uses a small camera to diagnose and treat abnormalities inside the knee joint. It has revolutionized orthopaedic surgery in many ways, including the diagnosis and treatment of a wide variety of musculoskeletal ailments.

The pencil-sized arthroscope is inserted into the knee joint through a small incision to give orthopaedic surgeons a clear view inside the knee. The camera is attached to a video monitor allowing the surgeon to thoroughly examine the interior of the knee and determine the source of the problem. During the procedure, the surgeon also can insert surgical instruments through other small incisions in the knee to remove or repair damaged tissues.

The study was conducted to test the hypothesis that a majority of patients return to unrestricted activity within four weeks after knee arthroscopy. The study found:

• 88 percent of patients described knee-related activity restriction before surgery
• 82 percent of patients returned to walking and other light activity one week after surgery.

This improved to 94 percent after two weeks and 100 percent after four weeks.This is good news for baby boomers and athletes alike. For people where non-surgical treatments did not work for their knee damage, arthroscopy appears to yield promising results for people who want to get back on their feet shortly after surgery.

Researchers had 72 knee-surgery patients – whose median age was 44 years of age – compete diaries before the surgery and at intervals up to 24 weeks after surgery.

While most arthroscopies are performed on patients between 20 and 60 years of age, people younger than 10 and older than 80 have benefited from the procedure. Typical candidates for the surgery are active people in their 30's and 40's who are starting to experience knee pain from decades of running, skiing, basketball and other sports. The knee pain usually includes:

• swelling
• catching,
• giving way, and
• general loss of confidence in knee function

When non-surgical treatments such as medications, knee supports and physical therapy provide no significant improvement, orthopaedic surgeons may suggest arthroscopy for certain conditions.

In my own experience, I have found that patients with a meniscus tear and no arthritis will do very well after surgery. These patients recover quickly and have little if any long term pain.

Those with arthritis and a meniscus tear may continue to have some pain even after the surgery due to the presence of the arthritis. How much pain can vary.

Below is some info from a newsletter that I provide to patients preoperatively in the office.

Knee Arthroscopy and the Arthritic Knee

Osteoarthritis is one of the most common causes of adult knee pain, and symptomatic disease of the knee affects up to 6% of the adult population. Arthroscopic débridement is considered when medical management has failed to satisfactorily alleviate symptoms. This procedure involves placing an arthroscope into the knee to remove any loose pieces of joint or meniscus cartilage that may exist.

Knee arthroscopy is the treatment of choice for meniscus tears of the knee with a very high rate of patient satisfaction. However, when meniscus tears of the knee are combined with arthritis of the knee the results become less predictable. The results of knee arthroscopy under these circumstances will depend on what portion of the knee pain is due to the arthritis and how much is due to the meniscus tear. Predicting the amount of pain relief before surgery can be difficult and a successful operation depends on the degree of arthritis.

The reasons why arthroscopic débridement of osteoarthritic knees is so commonly performed are understandable. It is an outpatient procedure with less serious potential complications than other surgical treatments for osteoarthritis. The postoperative course is predictable, and the risk of complications is acceptably small for most patients. It does not preclude later definitive surgery, and so patient and surgeon may feel it is "worth a try." Some studies have found that as only 44% of the patients had a successful outcome from arthroscopic débridement for arthritis. Nevertheless, the finding that some patients have clear improvement has encouraged surgeons to modify the intervention and improve patient selection so that the proportion of patients with a successful outcome is increased.

Patient Variables

Several studies have detailed the influence of certain variables on outcome following arthroscopy. Negative prognostic factors (indicators of a possible poor outcome) include limb malalignment (bow-legged or knock-kneed alignment due to loss of joint cartilage), severe osteoarthritis of the medial (inner) compartment, and a longer duration of preoperative symptoms. The severity of osteoarthritis, as measured by joint-space narrowing on the preoperative weight-bearing x-ray, indicates a higher likelihood of a poorer outcome after arthroscopy due to the presence of continued pain from arthritis.

Obesity is a risk factor for both the development of osteoarthritis and for radiographic progression. However, it does not negatively affect the outcome after arthroscopic débridement and should not be held as a negative prognostic factor for this procedure.

Female patients reported a greater degree of pain than males at baseline, which, although it was not significant, is worth noting. This observation has been noted in previous studies of patients managed with knee arthroplasty because of osteoarthritis. It is also particularly relevant because female patients reported a significant improvement in function and a trend toward greater improvement in pain, and they may be especially good candidates for this procedure if other indications are appropriate.

The Degree of Arthritis Affects Outcome

Osteoarthritis has a clinical spectrum of severity, with or without coexisting mechanical derangements. Generally speaking, about two-thirds of knees with osteoarthritis have a good clinical response to arthroscopy. The authors of one study reported clinical success rates of 80% at twelve months postoperatively and 59% at sixty months.

In general, 90% of knees with mild osteoarthritis and a joint space width of 3 mm were improved after arthroscopic débridement, and we believe that the procedure should be strongly considered as appropriate treatment in such cases.

Conversely, only 40% of knees with severe osteoarthritis limb malalignment, and a joint space width of <2 mm have clear-cut relief of symptoms. Arthroscopic débridement probably should be approached carefully for such patients; it could be recommended for specific treatment goals (for example, alleviation of mechanical locking).

Valgus knees (knocked kneed) do particularly poorly with arthroscopic débridement but mild varus alignment (bow-legged) is compatible with pronounced pain relief.

Still unresolved is the role of arthroscopy for patients with moderate osteoarthritis. For this group, the severity of the cartilage lesions measured intraoperatively was the only strong indicator of clinical outcome, and the likelihood of substantial pain relief could not be predicted preoperatively. Patients need to be counseled that their clinical outcome may depend on the severity of the cartilage lesions identified at surgery and that their expectations of benefit must take this factor into account.

Limb alignment can only be measure on properly performed weight-bearing x-rays. If your x-rays were performed with you lying flat and were not performed standing they should be repeated in the office before continuing treatment.

In our main office at the Connecticut Center for Orthopedic Surgery, we perform properly positioned weight-bearing x-rays and measure the joint space and limb alignment with great precision on our computerized digital x-ray equipment. We can measure joint space narrowing (the distance between the bone surfaces which reflects the amount of cartilage lost) to within 1/10^th of a millimeter. Limb alignment and joint deformity can be measured accurately to within 1/10^th of a degree.

Surgical Options

Arthroscopic meniscectomy

Arthroscopic partial meniscectomy is a well-tolerated and effective procedure in patients who are at least forty years old and without substantial degenerative changes. The role for resection of degenerative meniscal tears with coexisting joint cartilage wear is more contentious. In one study, a retrospective review of the cases of patients who were more than forty years old when they had a partial meniscectomy, found considerably worse outcomes in those with degenerative tears (an absence of trauma and fissured, horizontal cleavage tears) than in those with traumatic tears (a history of trauma and bucket-handle or parrot-beak tears). Others reported satisfactory short-term results at a mean of 2.5 years after arthroscopic partial meniscectomy in 80% of patients with degenerative joint wear and tear changes (arthritis) compared with 95% of those without degenerative change. The balance of the evidence suggests that partial meniscectomy is an effective treatment in mild-to-moderate forms of osteoarthritis.

In summary, our review of the literature suggested that arthroscopic débridement, consisting of resection of chondral flaps and unstable meniscal tears, can offer a substantial therapeutic advantage

Arthroscopic Débridement

During arthroscopic lavage, the joint is visualized and irrigated with normal saline or lactated Ringer’s solution. Débridement procedures excise damaged portions of articular (joint) cartilage, meniscus, synovial membrane, or ligaments found within the joint. The success of lavage and débridement has been attributed to a decrease in free particles and damaged portions of cartilage and meniscus that stimulate inflammation of the synovial tissue, cause joint effusions, increase the levels of proteolytic enzymes in the synovial fluid, and increase collagenolytic activity that causes friability of the articular cartilage. Lavage alone dilutes the joint fluid, thereby decreasing the concentrations of degradative enzymes in the knee and consequently slowing the breakdown of joint cartilage maintaining the integrity of the joint. The removal of tissue debris during débridement improves symptoms by reducing the source of irritation of the synovial tissue. Patients with mechanical disturbances caused by cartilage and meniscal fragments have demonstrated substantial improvement in function and symptoms when these fragments are removed by arthroscopic techniques. The efficacy of débridement procedure may correlate with the extent of disease.

Although this technique may temporarily improve patient symptoms, they cannot stop the disease process and often provide no benefit to patients with severe disease. In older arthritic patients who had had no success with other methods of nonsurgical treatment and maintained low activity levels, arthroscopic débridement only 52% of patients experienced benefit; 39% had no benefit; and 9% experienced only temporary improvement. Clearly, the severity of the disease has implications for the outcome of treatment.

Some suggest that aggressive removal of tissue may aggravate the patient’s problem. Most commonly, studies report that some patients have maintained improvement, some show no improvement, and some are made worse by these techniques. No consensus favors or opposes arthroscopic lavage and débridement techniques in treating osteoarthritis of the knee. However, patients with extensive loss of articular cartilage, malalignment, instability, restricted range of motion, and marked radiographic evidence of osteoarthritis seem to have a lower probability of experiencing any significant benefits from these techniques. Patients with more advanced arthritis usually require total joint replacement.

Meniscectomy

Patients with meniscus tears usually benefit from arthroscopy to remove or repair the torn meniscus. Many of those patients may also have concurrent arthritis that makes to outcome of arthroscopic meniscectomy less predictable. In an older population (>40 years) with osteoarthritis and a meniscus tear 80% excellent or good results at 2.5-year follow-up are expected. In these patients the degree of arthritis is a predictor of outcome. 80% of patients with severe arthritis who undergo partial medial meniscectomy rated their improvement as significant or moderate at 3.3 years. Those with mild arthritis demonstrate better pain relief than did those with more severe arthritis.

How the tear occurs also affects the outcome of arthroscopic meniscectomy. There are two type of meniscus tears: degenerative (gradual onset, not related to any specific event) and traumatic (related to some event, sudden onset). When comparing the results of traumatic tears to degenerative tears, there is a 95% satisfaction rate at 3-year follow-up with traumatic tears versus 65% with degenerative tears. In patients with degenerative tears, the presence of advanced osteoarthritis was associated with a less favorable outcome.

Patients with normal preoperative radiographs had a greater chance of excellent or good outcomes (90%) than do patients with moderate degenerative changes (21%). Partial meniscectomy in osteoarthritic patients with a documented tear and mechanical symptoms appears to be an effective procedure for the relief of pain at short-term follow-up. However, as the severity of osteoarthritis increases, the results become less favorable.

Microfracture

Microfracture technique is a technique that may be appropriate for certain type of joint cartilage injuries. It is most effective when the defect is isolated, with surrounding normal joint cartilage, in a knee that is properly aligned, in patients with a normal body mass index.

The lesion is débrided and subchondral bone exposed. An arthroscopic awl is used to make "microfractures" in the subchondral bone by picking three or four holes per cm² to a depth of about 4 mm. There is a 75% improvement at 3- to 5-year follow-up using the micro-fracture technique with arthroscopic awls in all patients having the procedure. Continuous passive motion and no weight bearing for 6 to 8 weeks is essential for both the gross healing of the defect and the reduction of pain.

Conclusion

Although the overall benefits of these procedures for osteoarthritic patients remain unclear, certain factors have been associated with a better or worse prognosis. Based on the review of the literature, relevant prognostic factors for the success of arthroscopic management of osteoarthritis of the knee can be established. Four categories are considered—history and symptoms, physical examination, radiographic findings, and surgical findings.

Sudden onset of symptoms related to trauma or symptoms of mechanical damage are associated with better outcomes. Physical findings of malalignment and ligament instability are associated with worse outcomes. The extent and severity of disease play an important role in patient outcome. Patients with radiographic findings of loose bodies and normal alignment have better results than do those with evidence of severe degenerative disease, such as loss of joint space. Knees with isolated lesions at the time of surgery fare better than do knees with diffuse disease. One study found a correlation of outcome with the absolute number of pathologic findings and severity of degenerative changes at the time of surgery. In addition, patients who had a higher pretreatment function fared better than did those with more severe dysfunction. Poor clinical results and higher rates of additional surgery also have been observed when severe chondromalacia is present and only eburnated bone remained.

Thanks.

JTM, MD

Typing and Carpal Tunnel Syndrome

Computer programmers, office workers, college students and Internet addicts everywhere can now breathe a sigh of relief: there is better evidence that genetics rather than hand use is the cause of carpal tunnel syndrome (CTS). A study presented at the 74th Annual Meeting of the American Academy of Orthopaedic Surgeons indicates that the causal link between CTS and repetitive use of the hands is much weaker than has been assumed.

The idea that CTS is related specifically to typing or overuse of the hands in general is pervasive in modern society. The study suggests the link between hand use and carpal tunnel syndrome is overstated and may be inaccurate. In contrast, there is strong evidence for an inherent, genetic risk for CTS.

Patients with CTS experience hand numbness, and eventually develop weakness and atrophy of some of the small hand muscles that control the thumb. Another common misconception is that patients with carpal tunnel syndrome present with complaints of activity-related wrist pain. In fact, the hallmark of CTS is numbness that wakes you at night or is present when you wake in the morning. The numbness can be so intense that it’s painful, but pain without numbness is not characteristic of CTS.

Carpal tunnel syndrome remains poorly understood. Pressure in the carpal tunnel (a tunnel formed by the small wrist [carpal] bones and the transverse carpal ligament) is involved in the pathophysiology, and release of the pressure by dividing the transverse carpal ligament stops the process. The cause of the increased pressure, however, remains unknown in the vast majority of patients.

Researchers evaluated data for the cause of CTS by a quantitative scale, based on the Bradford Hill criteria (widely accepted by the scientific establishment), which determines a causal relationship. Average scores for biological factors (genetics, race, age, etc.) were double those of occupational factors (occupation, repetitive hand use, vibration, etc.). In addition, the average strength of causal association (odds ratio) was about three times as strong for biological factors as it was for occupational factors.

This application of stringent science to theories of causation may affect claims of disability, workers compensation and personal injury. It should also influence the information that physicians are providing their patients about carpal tunnel syndrome. Physicians have the power to increase or decrease illness and disability with their words. In my opinion, we should provide patients with the most optimistic, positive, practical and enabling illness concepts that are consistent with the best available scientific data.

Thanks.

JTM, MD

Navigating Through: "Carpal Tunnel Syndrome"

From the AAOS...

Study assesses prevention, symptoms, treatment options and prognosis of Carpal Tunnel Syndrome

A study appearing in the September 2007 issue of the Journal of the American Academy of Orthopaedic Surgeons reports approximately 500,000 surgical procedures on Carpal Tunnel Syndrome or CTS are performed each year in the United States. The economic impact due to CTS is estimated to exceed $2 billion annually.

The study is from Northwestern University Feinberg School of Medicine in Chicago, looking at CTS evaluation and management.

Most patients with CTS present to their orthopaedic surgeon with numbness, tingling and weakness in their hands and fingers. Occasionally, pain can occur and go up the arm or into the shoulder. Theses symptoms are caused by median nerve compression.

Most cases of CTS do not have an identifiable cause. Women are more commonly afflicted than men and incidence increases with age. Other conditions associated with carpal tunnel syndrome may include:

• Wrist Trauma
• Obesity
• Hypothyroidism

Additionally, rheumatoid arthritis and renal (kidney) failure may lead to an increase in pressure within the carpal tunnel; drug toxicity, diabetes and alcoholism may have direct injurious effects on the median nerve. CTS also occurs in 20-45 percent of all pregnancies, however it typically disappears after childbirth.

Some people believe that work activities that involve overuse of the wrist and hand, repetitive impact on the palm and tools that vibrate can cause CTS. Extremes of wrist flexion and extension have been shown (experimentally) to elevate pressure within the carpal tunnel. However, the relationship between repetitive work activity and CTS has never been objectively demonstrated.

Medical history and physical examination are key in the diagnosis of CTS. An orthopaedic surgeon will evaluate for other conditions that can mimic CTS including neck problems, thoracic outlet syndrome, and other nerve compression syndromes. The examination includes:

• Assessment of cervical spine and upper extremities motion
• Skin and muscle assessment
• Strength testing with grip and pinch measurements
• Sensory testing
• Other provocative tests for CTS.

X-rays, nerve tests, or blood tests may also be ordered.

Conservative, non-surgical treatment for CTS patients includes:

• Splinting
• Corticosteroid injection.

If conservative treatments fail, carpal tunnel release surgery may be necessary. Open carpal tunnel release is the most common method of surgical treatment.

Complications of surgery are infrequent but can occur. Recurrent carpal tunnel syndrome develops in 7 to 20 percent of surgical cases and revision surgery is less successful than primary carpal tunnel release surgery.

Although our understanding of CTS has come a long way, additional basic science and clinical outcome studies are needed to solve the many uncertainties and controversies that still exist.

I (JTM) have personally performed many hundreds of carpal tunnel releases in my career. The success rate is very high with almost immediate relief of the symptoms of tingling, aching and nighttime pain. If there is advanced nerve damage as indicated by permanent damage to the nerve on the preoperative nerve conduction testing, then numbness may persist after the surgery. If the nerve has the potential to recover, it will do so gradually over the months after surgery.

I prefer the mini-open carpal tunnel release since I believe it is the most reliable and associated with very few complications. Recovery is quick. Patients wear a padded dressing dressing for 48 hours after the surgery. The dressing is removed at home and the would is covered with a bandaid. I encourage patients to use the hand as tolerated until the sutures are removed at 10 after surgery. Return to work can be as soon as 1-2 days post op with restrictions. Return to unrestricted work is at 3 weeks post op.

Check out my online presentation on the numb hand at www.OrthoOnTheWeb.com.

Thanks.

JTM, MD

Fractures of the Shoulder

From the AAOS...

Study finds patients at high risk for hip fractures after breaking their proximal humerus

Older women who suffer a proximal humerus fracture (sometimes known as a broken shoulder) have a high risk for also breaking a hip within a year after the shoulder injury. A new study presented today at the 75th Annual Meeting of the American Academy of Orthpaedic Surgeons (AAOS), found that after a shoulder fracture a woman’s risk of fracturing a hip within the following year was five times greater. The risk decreased after the first year but still remained elevated. Understanding the connection between these injuries is important to preventing hip fractures.

Hip fractures account for more than 350,000 hospital admissions in the United States and more than 60,000 nursing home admissions each year. Women have greater risk because of their higher susceptibility to osteoporosis. Statistics show:

• about 70 percent of hip fracture patients are women
• more than 4 percent of hip fracture patients die during their initial hospitalization
• 24 percent die within a year of the injury
• about half of women who sustain hip fractures lose the ability to walk independently

Preventing hip fracture poses s a significant quality-of-life issue. Earlier studies have shown that there is an increased risk of hip fracture after a proximal humerus fracture, but this study found that there is a defined window of time in which the risk is much greater than previously thought. Additionally, other research has shown that interventions within the first three months can reduce the risk of subsequent fractures. If we maximize our hip-fracture prevention efforts up front, we may have a much better chance of helping the patient avoid a life-changing and potentially life-ending injury.

The study from the University of Washington followed a group of older, Caucasian women for nearly 10 years and found that:

• 14 percent of those who suffered a proximal humerus fracture later sustained a hip fracture. (It should be noted that because older women are at very high risk for hip fracture, more than 8 percent of the women who did not break a shoulder also suffered a fractured hip.)

The strongest risk factors for hip fracture were age and hip bone mineral density. Other factors included:

• self-reported health status
• height at 25 years of age
• history of recent falls
• impaired depth perception
• history of prior fractures

Even when controlling these factors, the researchers still found the increased risk for hip fracture in the first year after a proximal humerus fracture.

The reasons for the connection between humerus fracture and hip fracture are still unclear. It may be associated medical problems, limited use of the injured shoulder, or there could be something about the treatment for the first fracture—such as narcotic pain medications—which could have caused the patient to fall and break a hip. Now that we are aware of the relationship between these types of fractures, we can take precautions, intervene early and hopefully help to prevent some hip fractures from occurring. The study authors stress that this message is the key point to be made from their new findings.

http://www6.aaos.org/news/Pemr/press_release.cfm?prnumber=656

Thanks.

JTM, MD

Nonunion of a Humeral Shaft Fracture

This is the case of a 75 year old female with multiple medical problems. She fell in January and sustained this long spiral humeral shaft fracture. Due to her medical conditions, I opted to treat her without surgery. Her films are below.




After 4 months of nonoperative treatment using a humeral fracture brace, her films below demonstrated very little healing and there was still significant motion at the fracture site. She said she could feel the fracture moving a clicking every time she moved the arm despite wearing the brace.






Many of these fractures will heal without surgery. As with any fracture, there is no such thing as a 100% union rate with nonoperative treatment. So after recognizing that this fracture would no heal on its own, she was brought to the operating room for a surgical repair. After 4 months of healing the normal anatomy is distorted by scar tissue. Nerves and arteries are not easily definable as they are bound in this scar tissue and displaced by the fracture. Surgical dissections under these circumstances are very tedious and difficult. As I sit there doing the surgery, I often realize how much easier this would be if it were done 4 months earlier. But, as I said, these fractures often heal by themselves.

Getting a nonunion to heal is not easy either. We always use some bone graft. The best bone is usually the patient's own bone taken from the iliac crest (lateral aspect of pelvis). How we harvest the bone varies. A great technique is to use a small acetabular reamer usually used for total hip replacements. This device works like a power grater to grind the outer wall of the pelvis creating bone graft with consistency of grated cheese. Perhaps that's too much information for some of you.

After plating the fracture, as shown below, I created an oval window in the cortex of the bone through which I injected the bone graft. This enable me to fill the canal of the humeral shaft with new bone graft that makes healing of the fracture possible.

Anyway, the final x-rays are below. She is doing very well. The pain is gone and the shoulder function is improving. The fracture is now healed. There is a bit of stiffness of the shoulder that will improve over time.




Despite her medical conditions, she is now doing better 3 months after surgery than she was doing after 4 months of nonoperative treatment. She can now use both arms without any restrictions and can use her walker normally. We don't rush in to do surgery if there is a chance that things will heal without it, but sometimes surgery is the best answer.

Thanks.

JTM, MD

Shoulder Fractures: Another Bad Proximal Humerus Fracture

These are the films of a 77 year old healthy male who fell sustaining this severely displaced proximal humerus fracture. This case demonstrates the importance of proper x-ray positioning. As you can see the first 2 views would suggest that the fracture is really not badly displaced.



This view below demonstrates that the fracture is severely displaced. If left like this, and treated nonoperatively, the fracture would likely not heal. If it did heal (unlikely), function would be severely limited. The physical examination actually revealed that the spike on the humeral shaft was poking directly into the deltoid muscle and the tip of the bone was almost coming through the skin.


After evaluating the patient, we decided to bring him to the operating room for an open surgical repair. Those results are below. The metal anchors seen in the bone are for repair of a tear of the subscapularis tendon encountered at the time of the surgery.






This is a great early result for a severe fracture. He is already starting a home exercise program and his pain is greatly reduced after stabilization of the fracure.

Thanks.

JTM, MD

Golf Injuries

I play golf. To be honest, I am really bad at golf but use it as a outlet to distract from the stresses of real life. Chasing a little white ball around someone else's manicured lawn that I do not have to cut seems like fun to me.

It is also a great way to be able to spend time with my sons ages 15, 17 and 19. They are fortunate to have learned to play golf at a young age and, as a result, have very graceful, athletic golf swings and almost always beat me on the course. The best thing about golf for me however is the time I get to spend with my sons. I hope that as I get older, I can still stay fit and flexible enough to spend that time with them. It won't be long before they don't need me to pay for greens fees and they have their own lives, perhaps far away from home. If life is kind to me, I hope we will be able to still get together to play golf and spend that time together.

I am very aware that as we age, there are certain unavoidable changes that occur to the joints, and other soft tissues like tendons, ligaments and muscle. We heal more slowly as we age as well due to those unavoidable wear and tear changes that we all experience. Some call this "Boomeritis". This is a topic for another day.

From the AAOS website...

Swinging the club on the open green, hitting the perfect shot and playing in the warm sun are just a few things golfers love about hitting the links. Golfing can be a treat for both the mind and body. However, an injury to the bones, muscles or joints can cast a big shadow over the day. That is why the American Academy of Orthopaedic Surgeons (AAOS) recommends following the proper techniques to prevent golf-related injuries.

According to the U.S. Consumer Product Safety Commission:

• There were more than 103,000 golf-related injuries treated in doctors’ offices, clinics and emergency rooms in 2007, which incurred a total cost of approximately $2.4 billion in medical, work-loss, pain and suffering, and legal fees.
• Golfers most often suffer from hand tenderness or numbness; shoulder, back and knee pain; golfer’s elbow; and wrist injuries, such as tendinitis or carpal tunnel syndrome.

Because orthopedic surgeons not only treat, but try to prevent injuries of the bones, joints and muscles, the AAOS offers the following tips to help prevent golfing injuries:

• Newer golfers should take lessons and begin participating in the sport gradually.
• Practice on real turf instead of rubber mats, when possible.
• Dress for comfort and protection from the elements. Make sure to wear the appropriate golf shoes: ones with short cleats are best.
• Do not hunch over the ball too much; it may predispose you to neck strain and rotator cuff tendinitis. Look at Tiger's stance and try to keep the head up, shoulders back and spine straight. Hunching forward with you head down makes a proper back swing more difficult.
  
• Avoid golfer’s elbow – which is caused by a strain of the muscles in the inside of the forearm – by performing wrist and forearm stretching exercises and not overemphasizing your wrists when swinging.
• Shoulder, back and hamstring stretches are also helpful. A fluid back swing requires flexibility.
  
• Yoga is a great exercise to improve your flexibility and strength.

Have fun. Thanks for checking in.

JTM, MD

After your rotator cuff repair...

For years now, I have been placing my postoperative rotator cuff repairs in an immobilizer that has a foam wedge attached to the sling. This serves to keep the arm abducted away from the body thereby placing less tension on the repair. The theory is that less tension on the repair should improve the healing of the rotator cuff tendon to the bone.

Recently there was a study that looked at a very similar type of postoperative immobilization using an external rotation brace. The concept is the same. Less tension on the repair means a better result and quicker recovery.


Derotational Braces after Rotator Cuff Repairs

Using a derotation wedge along with a simple sling after rotator cuff repair can result in significant improvement compared to using just a standard sling, especially for small and medium size tears. These results were presented at the 6th Biennial AAOS/American Shoulder and Elbow (ASES) Meeting.

The research team conducted a prospective, randomized study of 57 patients who underwent arthroscopic rotator cuff repair. Of those, 34 (60 percent) were treated with a sling and wedge, and 23 (40 percent) were treated with a sling only. The patients were randomized regardless of tear size or associated pathology; 34 tears were considered small or medium, and 23 were considered large or massive.

For the first 6 weeks after surgery, only pendulums, passive elevation, and external rotation were allowed. After 6 weeks, patients began active assisted range-of-motion (ROM) exercises and isometrics. At 3 months, active ROM and resistive exercises were allowed.

Superior (top) and frontal (bottom) views of a patient wearing the sling and wedge with a swathe around the torso. Patient had just undergone arthroscopic rotator cuff repair. Note the position of the forearm, and thus the shoulder, in neutral rotation.

Noticing an immediate difference
At 1 week after surgery, the researchers found a significant difference between the two groups of patients. Patients treated with the sling and wedge averaged passive elevation of 94 degrees, while those treated only with the simple sling had an average of 75 degrees of passive elevation (p=0.02). The difference in passive external rotation was even more significant—26 degrees for patients with the sling and wedge vs. 12 degrees for patients with the sling only (p=0.001).

At 3 months, passive external rotation remained significant, at 54 degrees for patients treated with the sling and wedge compared to 43 degrees for patients treated with the simple sling (p=0.05). But no significant differences between the two groups were found at 3 months or 6 months for active ROM, ASES or Simple Shoulder Test scores, or visual analog scale pain scores.

The authors did find that patients with small and medium rotator cuff tears who were treated with the sling and wedge showed significant improvement for longer periods. These patients also showed significant improvement in passive external rotation at the 1-month and 3-month follow-ups, and with active external rotation at the 3-month follow-up. Active forward elevation in these patients was also significantly better at 6 months; patients treated with a sling and wedge had active forward elevation of 175 degrees, compared to just 158 degrees for patients treated with the sling alone.

Because patients treated with a wedge and sling required less therapy effort in the early postoperative period, the authors noted that a potential contributor to repair failure may be minimized.
(http://www.aaos.org/news/aaosnow/jun08/clinical5.asp)

Thanks,

JTM, MD

Boomers: Tips on How to Exercise Safely

Boomers: Tips on How to Exercise Safely

The largest part of my practice is treating the baby boomers for what we often call Boomeritis. I frequently give public presentations of the age related injuries of the knee and shoulder. Here are a few things to know before you venture out on an exercise program.

As the weather gets warmer, people often get motivated to spend more time outdoors. Whether it’s working on projects around the house, playing with the grandkids at the park or out exercising, it’s important that baby boomers remember their bodies are not as young as they used to be and not overdo it.

In 2007, more than 149,000 people between the ages of 45 and 64 were treated in emergency rooms, clinics and doctors’ offices for injuries related to exercise and exercise equipment, according to the U.S. Consumer Products Safety Commission.

When you are 50, you may injure your body more easily than when you were 20. Joints, tissues and muscles may not be as flexible as they used to be. So as you get older, you need to take extra steps to protect yourself from injuries when you exercise.

The AAOS and I would recommend the following tips to help boomers prevent exercise-related injuries:

• Check with your doctor before beginning any exercise program. A physician will make sure your heart is in good condition and can make recommendations based on your current fitness level. This is especially important if you’ve had a previous injury.
• Always warm up and stretch before exercising. Cold muscles are more likely to get injured, so warm up with some light exercise for at least three to five minutes.
• Avoid being a “weekend warrior.” Moderate exercise every day is healthier and less likely to result in injury than heavy activity only on weekends.
• Don’t be afraid to take lessons. An instructor can help ensure you’re using the proper form, which can prevent overuse injuries such as tendonitis and stress fractures.
• Develop a balanced fitness program. Incorporate cardio, strength training and flexibility training to get a total body workout and prevent overuse injuries. Also, make sure to introduce new exercises gradually, so you don’t take on too much at once.
• Take calcium and Vitamin D supplements daily.
• Listen to your body. As you age, you may not be able to do some of the activities that you did years ago. Pay attention to your body’s needs and abilities, and modify your workout accordingly.
• Remember to rest. Schedule regular days off from exercise and rest when tired.

Baby boomers who exercise regularly are less likely to experience depression, weight gain, diabetes, high blood pressure and sleep disturbances, so it’s important to incorporate physical activity into your routine at any age.

Thanks

JTM, MD

Wrist Fracture Repair

Fractures of the wrist are very common. They are more common as we age and as the bone becomes weaker. Younger patients who get wrist fractures may have better bone but just require more force to break the bone.

In weaker bone, a simple fall may result in a wrist fracture often called a Colle's fracture or Smith's fracture depending on the position of the displaced fracture fragments. Below is an animation of how some of these fractures may be repaired. I have performed may of these operations usually with outstanding results. The biggest problem we can encounter is postoperative stiffness that we try to minimize with early physical therapy.

With good bone quality and a relative stable fracture repair, patients wear a splint for approximately 2 weeks after surgery. With soft bone or a severely fragmented fracture, splinting after surgery may be as long as 3-4 weeks. Some patients will require 6 weeks of postoperative splinting. A recent study has demonstrated that outcomes and results are similar regardless of the period of postoperative immobilization. It is really determined by the severity of the fracture.

Sometimes we treat patients with bilateral wrist fractures. Most of these patients will do much better if treated surgically so they can get out of their cast and become functional much earlier than if they were treated in casts alone.

The surgery usually takes between 45 - 60 minutes depending on the severity of the fracture and the degree to which the joint surface is involved in the fracture. Fractures extending into the joint are more difficult to fix. These are also easier to fix within the first 2 -3 weeks but can be done after that if there are extenuating circumstances. It is an out patient procedure.

Without surgery, these fractures are usually treated in a cast above the elbow for 3 weeks followed by a short arm cast for the next 3 weeks before therapy is started. Fractures that healed in an unacceptable / displaced position often result in stiffness, pain, deformity, reduced motion and arthritis.

While patients are rightfully concerned about the risks of surgery, there are certainly risks to nonsurgical treatment of some conditions.

Enjoy the clip...

Thanks,

JTM, MD

Arthroscopic Rotator Cuff Repair

The rotator cuff is the set of four tendons that help us move the shoulder. Technology has progressed over the past several years allowing surgeons to repair torn rotator cuff tendons through very small incision using advanced arthroscopic techniques. This is really on of my favorite procedures. A successful result depends on many factors including the size and age of the tear, preoperative function, the age of the patient, the number of tendons torn, the motivation of the patient and the experience of the therapist. The surgeon's experience is also a crucial factor.

As surgeons, we depend heavily on technological advancements that enable us to repair a cuff arthroscopically. Below are some mpegs from a Smith and Nephew educational DVD.

Patient preparation:

Placement of medial row anchors:

Lateral hole preparation:

Placement of the lateral anchor achieving a double row repair:

Tensioning the sutures:

Completing the repair:

Even though we can repair the rotator cuff through small incisions, it still takes the same amount of time for the tendon to heal as it does when we make a standard incision. The tendon will heal to the bone in 6 - 8 weeks. Usually, we limit shoulder motion for at least 6 weeks permitting only passive home shoulder exercises during that time called pendulum exercises.

Shoulder strengthening is usually not permitted for 8 - 10 weeks. Typical patients are very functional at 12 - 16 weeks. Overhead work is permitted at 6 months and full recovery may take a year.

Thanks.

JTM, MD

Tibial Fracture: Leg vs. Motorcycle

As a member of the active staff of the Department of Orthopedic Surgery at Hartford Hospital, I have many opportunities to be a part of the team of orthopedists that provide care to injured patients admitted to Hartford Hospital. I have been on the active staff for years and, thanks to the my exposure to resident orthopedic surgeons and my colleagues on the staff, weekly educational conferences, and constant exposure to complicated multiply injured patients, I believe that over that time I have become a better surgeon. Patients are often shipped in from all over Connecticut and sometimes from upstate New York and Massachusetts.

As a member of the active staff of Manchester Memorial Hospital (ECHN), I also have the opportunity to bring my experience to the ECHN community.

Below is an example of an injury sustained by a young man who happened to have a little problem with his motorcycle. He sustained this very comminuted tibial shaft fracture. The tissue quality around the knee was poor immediately after the and immediate repair would have put the skin and muscle viability at risk. Therefore, we applied an external fixator for 10 days. Those x-rays are below.




After 10 days, he was returned to the operating room for removal of the fixator and internal fixation with the plate and screws below. A senior orthopedic resident and I spent over 2 hours on this fracture repair with the result below. The fracture through the joint was repaired and the shaft fracture was very well reduced and stabilized. Time will tell if this fracture will go onto complete union. At about 8 weeks out of surgery, the concern is now about whether the fracture will heal before the screws break or pull out of the bone.



Time will tell..........


Well, it has been 3 months since the initial fracture on Mr. Leg vs. Motorcycle. The latest x-rays are below and seem to show very slow healing. The plan at this time is to return to the OR for a bone grafting.

Films fro August, 2008...




Thanks


JM

Malunited Wrist Fracture

These x-rays are those of a young woman who was treated by two other orthopedic surgeons. She came to me after being treated for this wrist fracture that has healed in an unacceptable position. Below you can see the malunited fracture on this AP view.


On this lateral view, you can see that the fracture has healed in what was measured as 45 degrees of angulation. This is not an acceptable position for this fracture.


Below you can see the normal wrist x-rays on the unaffected side, same patient.



This lady came seeking help for her malunited fracture. We took her to surgery where the healed bone was precisely cut (refractured) with a micro saw and realigned. Below is the end result of a restoration of the fracture to a perfect position. The new bone position is held with a special plate and screws which holds the bone while it heals. The gap created by the cut in the bone (osteotomy) is filled with synthetic bone substitute (Norian from Synthes). The plate is from Hand Innovations and is a remarkable way to fix wrist fracture that we once treated in a cast, with pins or with an external fixator. There are no external devices on the wrist. For wrist fractures that we treat primarily, the wrist is usually splinted for 2-4 weeks followed by a removable wrist splint and early therapy. This patient was treated in a splint for 6 weeks before attending therapy due to the complex nature of the reconstruction. This is an outstanding result in a fracture that healed in an unacceptable position initially. So far, the patient and I are extremely pleased.

Her post op films are below.






Thanks,

JM

Shoulder Fractures: Anatomic Neck Fracture

This woman fell and sustained this proximal humerus fracture. This x-ray in her right shoulder shows this significant displacement of the fracture. This fracture would not heal properly if treated without surgery. After discussing this with the patient she agreed to undergo an open fracture repair.



Notice the severe deformity of the fracture in this x-ray.


Surgery was performed to align the fracture in its anatomic position. These screws lock into the plate and the bone holding the fracture in proper position while it heals. Healing will take at least 6 - 8 weeks.

Therapy can begin in the first 1-3 weeks but will depend on the strength of the repair which depends on the strength of the bone.





JTM

Rotator Cuff Tear Arthropathy

This man is a 77 years old male with long standing left shoulder pain and weakness. His initial x-rays confirm the presence of a massive unfixable rotator cuff tear. We know this because the position of the humeral head is immediately beneath the acromion. He has developed pain and weakness as a result of his untreated tendon tear.



The labeled space below indicates how little space exists between the two bone surfaces. There is no room for the rotator cuff tendons in this limited space.

Below the same patient has undergone a reverse shoulder replacement. He now has complete pain relief and is able to lift his arm above his head to 130 degrees at only 2 months after surgery.