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