Skate, Slide and Glide Through Winter Injury-free

Winter sports, such as ice skating, snow skiing, tobogganing and sledding may serve as a great way to get outdoors and exercise, but also can result in injury if proper safety precautions are not practiced. Common injuries include ankle sprains and muscle strains, dislocations or fractures. As part of the American Academy of Orthopaedic Surgeons’(AAOS) on-going Prevent Injuries America!® campaign, the AAOS urges children and adults to consider these winter sports injury prevention tips before braving the snow.

STATISTICS:

• More than 350,000 people were treated in hospitals, doctors’ offices and emergency rooms for winter sports-related injuries in 2009, according to the U.S. Consumer Product Safety Commission,

AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS SAFETY TIPS:

• Check the weather for snow and ice conditions prior to participating. Pay attention to warnings about upcoming storms and severe drops in temperature to ensure safety while outdoors. Skiers and snowboarders should make adjustments for icy conditions, deep snow powder, wet snow, and adverse weather conditions.

• Dress for the occasion. Wear several layers of light, loose and water- and wind-resistant clothing for warmth and protection. Layering allows you to accommodate your body's constantly changing temperature.

• Wear appropriate protective gear, including goggles, helmets, gloves and padding. Also, check that all equipment, such as ski and snowboard bindings are in good working order.

• Skiers and snowboarders should buy boots and bindings that have been set, adjusted, maintained and tested by a ski shop that follows American Society of Testing and Materials (ASTM) standard job practices.

• Never participate alone in a winter sport. If possible, skiers and snowboarders should go with partners and stay within sight of each other. If one partner loses the other, stop and wait. Also, make sure someone who is not participating is aware of your plans and probable whereabouts before heading outdoors.

• Skiers and snowboarders should stay on marked trails and avoid potential avalanche areas such as steep hillsides with little vegetation.

• Avoid sledding near or on public streets. Sledding should be done only in designated and approved areas where there are no obstacles in the sledding path. Speeding down hills in parks that are not designed for sledding puts you at risk to be hit by cars and trucks or slam into parked vehicles, curbs, and fences.

• Sit in a forward-facing position when sledding and steer using your feet or the rope steering handles for better control of the sled.

• Warm up thoroughly before playing. Cold muscles, tendons and ligaments are vulnerable to injury.

• The warm up should be a good 10 minutes of walking, slow jogging or working on the exercise bike. This is to help increase your heart rate and blood flow to your muscles.

• Skiers and snowboarders should take a couple of slow runs to warm up.

• Drink plenty of water before, during, and after outdoor activities. Don’t drink alcohol as it can increase your chances of hypothermia.

• Keep in shape and condition muscles before partaking in winter activities. If over the age of 50, it may be wise to have a medical check-up prior to participating in a winter sport.

• Know and abide by all rules of the sport in which you are participating.

• Take a lesson (or several) from a qualified instructor, especially in sports like skiing and snowboarding. Learning how to fall correctly and safely can reduce the risk of injury.

• Falling techniques aim to protect your vulnerable body parts. If skiing, learn how to hold the poles with the strap (not through your thumb webs space) to avoid skiers thumb.

• If you do fall, try to break your fall with your arms flexible, landing first on your hands and wrists, but let your elbows bend into the fall. Then, try to roll onto the back part of your shoulder. Bad wrist fractures tend to be from falling on arms held out stiff.

• Seek shelter and medical attention immediately if you, or anyone with you, is experiencing hypothermia or frostbite. Early frostbite symptoms include: numbness and tingling in you digits, lack of feeling and poor motion.

• Avoid participating in sports when you are in pain or exhausted. Many skiers are injured on the final, “one last run” -- if tired, call it a day.

• If injured during any winter excursion and pain or discomfort persists, follow up with an orthopedic surgeon to examine the injury.

Reference


Thanks,


JTM, MD

More Complications with Single-incision Repair of Biceps Ruptures from the Elbow

I do many distal biceps tendon repairs every year.  I have only recently performed these repairs through a single incision with an endobutton (a special kind of anchor device which holds the tendon to the bone) with great success.  I had one case where the endobutton would not hold the tendon in place and I had to resort to the standard technique.  That case turned out well but proved to me that new technology is not always better and you always have to have a plan B if plan A does not work.  After 20 years of experience, I had a plan B and beyond.  For years, however, I only performed these biceps ruptures from the elbow through a 2 incision technique.  I believed that the research and my experience confirmed that the 2 incision technique was the gold standard with the lowest rate of complications.  The below study seems to confirm that premise.  I would still use the single incision technique in selected cases.  

Read on from the AAOS...

Patients treated with double-incision repair using transosseous drill holes for acute distal biceps rupture may see fewer complications than those treated with single-incision repair using suture anchors, according to the results of a prospective, randomized clinical trial presented at the 2010 ASSH annual meeting.

An intra operative photo of a single incision repair using endobutton anchor.  This ruptured tendon will be reinserted into the bone.

The researchers randomized 90 male patients to receive either single-incision repair (n = 48) or double-incision repair (n = 42). The two groups had no significant differences in patient age, dominant hand, or number of workers compensation cases. Overall mean American Shoulder and Elbow Society pain scores were similar in both groups at all follow-up points (3, 6, 12, and 24 months).

At 24 months, no significant differences were found between the treatment groups in final extension, pronation, or supination. The research team noted a marginal advantage in mean isometric flexion strength regained among participants in the double-incision group (double: 104 percent; single: 94 percent; p = 0.01).

JTM comment:  Double incision technique seems to result in superior strength at least in this study.

Overall, 19 of 48 patients in the single-incision group had complications, compared to 3 of 42 in the double-incision group (p < 0.01)—primarily due to a high number of early transient neuropraxias in the single-incision group. Three neuropraxias in the single-incision group remained symptomatic after 6 months. 

JTM comment: Wow, that's a lot of complication in the single incision group.  Seems like their surgical exposure made seeing the tendon more difficult and they ended up stretching the sensory nerve to see better.  This resulted in a neuropraxia, or stretched nerve, which took at least 6 months to recover.  While the 2 incision technique does reduce the chances of this happening, I have not seen this complication in the single incision cases that i have performed.  In fact, I have had no complications in the single incision repairs that I have performed.

The researchers noted four tendon ruptures, all of which were due to noncompliance or reinjury in the early postoperative period. None of the ruptures was related to fixation technique.

JTM comment:  Tendons re-ruptured because patients did not listen to the doctor.  Where have I heard this before.

Bottom line

The perfect repair.

No overall differences in functional outcomes were found between distal biceps ruptures treated with either a single or double incision repair technique; however flexion strength was slightly greater with a two-incision technique.

• The single-incision group had a greater incidence of complications.

AAOS Now  December 2010 Issue  http://www.aaos.org/news/aaosnow/dec10/clinical9.asp

You can get some additional information on biceps tendon ruptures at the elbow here and here and here.

Thanks,

JTM, MD

The Latest Study on Glucosamine and Chondroitin: Not good

I search the web for valid info related to orthopedics to answer the questions of my patients.  I am sure they are all too busy doing the exercise program I gave them.  I am asked about glucosamine and chondroitin daily by patients with arthritis.

Here is the latest from Journal Watch. 2010;30(21) © 2010 Massachusetts Medical Society

Summary

Alone or in combination, the supplements do not reduce joint pain or limit joint-space narrowing.

Introduction

Randomized trials on the effectiveness of glucosamine and chondroitin for osteoarthritis (OA) have yielded mixed results; the largest trial showed no benefit for these agents, used alone or in combination for knee OA (JW Gen Med Mar 15 2006, p. 45, and N Engl J Med 2006; 354:795).

Now, researchers have conducted a meta-analysis (this is a study that analyzes the other studies) of 10 randomized controlled trials in which about 3800 patients (68% women; median age, 62) with osteoarthritis of the hip or knee received glucosamine, chondroitin, both supplements, or placebo; all patients were evaluated for joint pain — and some for radiological progression of disease — during follow-ups that ranged from 1 to 36 months.

On a 10-cm visual analog pain scale, the difference in pain intensity (compared with placebo) was –0.4 cm for glucosamine, –0.3 cm for chondroitin, and –0.5 cm for the combination. These results were of borderline statistical significance, but they did not approach the researchers' prespecified minimally important clinical difference of 0.9 cm. Six trials contributed data on radiological joint-space narrowing. 

Glucosamine, chondroitin, and the combination had no effect on joint-space narrowing. The supplements, either alone or in combination, however, caused no reported adverse effects

The Bottom Line

Glucosamine, chondroitin, and the combination are no better than placebo in attenuating joint pain or limiting joint-space narrowing in patients with hip or knee OA.

Nevertheless, clinicians likely will encounter patients who are interested in, or report benefit from, using these preparations. In these situations, clinicians should inform patients of the results of clinical trials. For patients who remain steadfast in their desire to take glucosamine, chondroitin, or both, clinicians should be open to empirical trials of these preparations — given their apparent safety — as long as the patients are willing to pay for the compounds.

It does not seem to work, save your money, according to this study.

References

• Wandel S et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: Network meta-analysis. BMJ 2010 Sep 16; 341:c4675.

Thanks,

JTM, MD

Treating tendinopathy with PRP

Below is a report from the AAOS  web site.  Unabridged and unaltered.

It is in response to several questions this week about PRP.  Enjoy.

Letha Y. Griffin, MD, leads a focused roundtable

Chronic overuse conditions such as Achilles tendinopathy (tendinosis) are not uncommon, but are extremely difficult sports injuries to treat. The pathophysiology of tendinopathy—the term used to refer to chronic inflammation of the tendon (as distinguished from tendinitis, which refers to the acute inflammatory state)—continues to elude physicians studying the issue.

Injecting PRP during surgery on the Achilles tendon is just one of the many ways that PRP is being used in orthopaedics. Courtesy of Allan K. Mishra, MD

Oral and topical anti-inflammatory medications, copper bracelets, high- or low-intensity pulsed ultrasound, extracorporeal shock wave therapy (ESWT), and injected platelet-rich plasma (PRP) have all been used to speed recovery. 

Dr. Griffin: What about the recent trend of using PRP to treat tendinopathy? Is this just another fad or does PRP actually affect healing in this disease entity?

Dr. Cole: Basic science studies seem to support the application of PRP for the treatment of problems related to tendons. Several limitations exist in these models, and healthy tendon cultures exposed to an agent may respond differently than an intact chronically diseased tendon. Thus, drawing clinical conclusions from these studies is difficult.

Unfortunately, a chronic tendon injury model is difficult to reproduce and is not likely to have identical pathophysiology compared to tendinosis. PRP has been studied clinically mostly in the elbow and Achilles tendon, and some studies seem to show it has some benefit. Based upon clinical study alone, we cannot yet categorically conclude that PRP is beneficial for all conditions related to tendinopathy.

Also, combined therapy (such as using ESWT with PRP) may actually be more effective than a single modality therapy. PRP makes sense intuitively and, other than cost, has very little downside.

In addition, I believe PRP may have some anti-nocioceptive effect that is still poorly defined. Many of our patients have rapid resolution of symptoms that cannot possibly be explained by resolution of the pathologic findings associated with a diseased tendon. 

Dr. Mandelbaum: In our clinic, we follow a specific algorithm for using PRP in chronic Achilles tendinopathy. Based on the gross and histologic properties of Achilles tendinosis, an opportunity theoretically exists for improvement by injecting PRP to stimulate angiogenic infiltration and remodeling by tenocytes.

PRP therapy may also facilitate healing in patellar tendinopathy—but it is critical to distinguish patellar tendinosis from other common causes of anterior knee pain, particularly in the adolescent athlete.

Our indications for PRP treatment for patellar tendinosis in adults are severe symptoms present for more than 3 months that are unresponsive to physical therapy and clinical findings corroborated by changes on magnetic resonance images or ultrasound. The athlete must stop using nonsteroidal anti-inflammatory drugs (NSAIDs) for at least 1 week prior to the injection and avoid NSAID use for 3 to 4 weeks postinjection. The postinjection protocol includes standard rehabilitation for strength and functional progress and gradual return to activities over 6 to 8 weeks. Frequent and liberal use of ice, particularly in the early stages, has been helpful in controlling any discomfort from the injection. Criteria for return to sport include full painless range of motion, ability to tolerate going up and down stairs, and no discomfort as sports progression proceeds.

Dr. Griffin: Dr. Arnoczky and Dr. Andrews, could you summarize your thoughts on the effectiveness of PRP injections in treating tendinopathy? 

Dr. Arnoczky: First of all, it is important to determine what, precisely, you are ‘asking’ PRP preparations to do in the treatment of tendinopathy. That is, what aspect(s) of the wound healing process are you trying to stimulate? In chronic tendinopathy, the tissue repair process has been ‘stalled’ and treatments have been based on inciting an inflammatory response to allow the body’s natural repair process to start over. 

Although the increase in growth factor concentration associated with PRP has been used to justify its application in the treatment of tendinopathy, platelets also have the ability to store and rapidly release a variety of other bioactive molecules, including proteases and anti-proteases, adhesion proteins, and inflammatory cytokines. Thus, the PRP injection may provide the inflammatory cytokines needed to incite an acute inflammatory response and kick-start the healing process in a compromised tissue.

In addition, the proteins (albumin and globulins) and clotting factors (fibrinogen) present in the plasma portion of PRP are critical components in the early stages of wound healing, such as in creating a provisional fibrin scaffold and stimulating the inflammatory response. Although PRP contains all the elements needed to initiate and support wound repair, the precise indication (timing, dosage, and proposed mechanism of action) has yet to be precisely unraveled.

Finally, even though the natural history of tendinopathy has been extensively studied and prescribed treatments have been guided by clinical signs, the level of tissue pathology and the ability of the tissue to respond to PRP (or for that matter any therapeutic intervention) could vary greatly, even in patients with similar clinical signs. A chronic condition such as tendinopathy may display a varying subset of cellular pathologies that subtly change over time, which may explain the varied results that have been reported.

Dr. Andrews: We have had success using PRP injections for tendinosis patients. The discomfort to patients and the cost are issues, but athletes are often frustrated with the chronic discomfort associated with tendinosis.

PRP injections should be used in conjunction with other treatments, such as rest, ice, anti-inflammatory medication, and physical therapy in a multimodal plan to promote symptom relief and tendon healing. 

The effectiveness of PRP in treating tendinosis has not been scientifically proven in human trials. Growth factors associated with certain cells can help promote healing; what sort of cell differentiation PRP promotes is unclear. Our experience is anecdotal. More randomized, double-blind studies are needed with human trials.

Note from JTM: So the use of PRP is not yet available in nonresearch practices and is not the standard of care.  Is remains experimental except in rats and lawyers.

Dr. Griffin: Dr. Rodeo, you have used PRP to augment surgical repair of chronic rotator cuff tears. What about the use of PRP in treating chronic rotator cuff pathology in the absence of a full- or partial-thickness tear?

Dr. Rodeo: We have recently completed a prospective, randomized trial examining the effect of platelet-rich fibrin matrix (PRFM) in 67 patients undergoing arthroscopic rotator cuff tendon repair (36 with PRFM at the tendon-bone interface and 31 without). The PRFM was attached to the suture at the interface between the tendon and the greater tuberosity. The postoperative rehabilitation protocol was the same in both groups. The primary outcome was tendon healing evaluated by ultrasound (intact versus defect at repair site) at 6 and 12 weeks. 

We found that PRFM had no demonstrable effect on tendon healing, tendon vascularity, manual muscle strength, or clinical rating scales. Several reasons can be postulated for the lack of an effect, such as variability in platelet recovery, platelet activation, and kinetics of cytokine release from the PRFM. A weakness of our study was the absence of information about the number of platelets actually delivered in patients who received the PRFM, as well as the relatively small number of patients studied. Further study is clearly required to evaluate the role of PRFM in rotator cuff repair

Note from JTM: So the use of PRP in rotator cuff tears still required surgery and has not been proven to have any beneficial effects on healing.  While arthoscopic cuff repairs are less invasive than open repairs, it is still surgery and still requires 6 weeks for the tendon to heal.  We do not heal tendons faster just because the skin incision is smaller.

As far as PRP treatment of rotator cuff tendinopathy in the absence of a partial- or full-thickness tear, little data are available. Recently published randomized trials on PRP in treating tendinosis have demonstrated variable and conflicting results, making it difficult to extrapolate to rotator cuff tendinosis. I think we need to answer the following important questions:

• What is the best time for injection?
• Are there different effects on acutely injured tendon versus degenerative tendon?
• Is there a risk of increasing inflammation?
• Would serial injections be more effective?
• What is the effect of pH on cytokine release?
• What are the kinetics of cytokine release?

Note from JTM:  OK, so this stuff is cool and may someday be helpful but we cannot prove is does anything for rotator cuff tendinopathy or tendinitis.  People who advertise PRP for rotator cuff tears and tendinopathy are today's snake oil salesman, in my opinion.  You cannot have a tear of the tendon off the bone and expect the injection of PRP to restore that attachment of the tendon to the bone and get it to heal.  That is fantasy at this time.

Dr. Griffin: What do you see as the role of PRP in treating entities such as patellar tendinopathy, Achilles tendinopathy, plantar fasciitis, lateral epicondylitis, and shin splints?

Dr. Maffulli: PRP is increasingly being used, with excellent results being reported. But a systematic review of the literature found that results could not be substantiated when closely scrutinized. A study published in the January issue of the Journal of the American Medical Association showed that PRP in Achilles tendinopathy does not work. We just finished a randomized, controlled trial of PRP in repair of small and moderate rotator cuff tears and found no effect. The studies on tennis elbow are a bit more comforting, and it is possible that the effect changes according to the tendon being treated. 

Dr. Mandelbaum: We have used PRP in treating patellar tendinopathy, Achilles tendinopathy, plantar fasciitis, and medial and lateral epicondylitis. We have had no experience with shin splints. Over the last 4 years, we have developed algorithms for the treatments of these disorders. It is imperative and essential to follow clinical pathways at all times. In my experience, global use of PRP for tendinopathy is not recommended.

Dr. Griffin: Several variations of PRP preparations exist. Can they be used interchangeably? Do some have unique characteristics that make them more advantageous in certain situations? 

Dr. Arnoczky: All PRP preparations are not created equal. Broadly, PRP can be defined as an increase in the concentration of platelets (and their associated contents) in a given volume of plasma that is greater than that found in whole blood. However, the commercial methods by which the final PRP product is made vary markedly. 

Unlike ‘off-the-shelf’ pharmaceuticals, where the exact concentration and character of a product are guaranteed, the precise ‘potency’ of a given PRP concoction cannot always be predicted a priori. For example, the inclusion of white blood cells in some PRP preparations may increase the inflammatory cytokine profile of the final product, while the addition of thrombin has been shown to induce platelet activation and the rapid secretion of the growth factor contents of the a-granules. This is significant, as growth factor half-life is very short, ranging from minutes to a few hours. 

A recent study has shown that the creation of a PRFM can increase the duration of increased concentrations of growth factor availability when compared to a naturally occurring clot. It is important to note that the ability to concentrate platelets (and growth factors) several fold via a given PRP preparation may not always be a positive attribute, because the dose-response curve of most growth factors is not linear (and often cell-type dependent). Indeed, higher concentrations of some growth factors have been shown to be inhibitory to connective tissue cells. Because PRP preparations are not the same, we cannot summarily conclude that the failure or success of one product is invariably applicable to all others.

Dr. Cole: In general, the PRP paradigm is shifting away from “more platelets are better” to “it’s not just about platelets.” Where and when the other cellular components within a PRP preparation will actually matter is probably pathology-specific.

Our recent research in collaboration with Lisa A. Fortier, DVM, PhD, at the Cornell University College of Veterinary Medicine demonstrated that the more white blood cells present, the more matrix metalloproteinases that were produced in tendon culture and the lower the ratio of collagen 1 to collagen 3 becomes, which is consistent with scar formation rather than healthy tissue formation. 

Donor variability is also significant, both between individuals and between same donor PRP preparations. Adding to the complexity is the role of pH and anti-coagulation. Independent of the presence of an anti-coagulant, platelets will degranulate as soon as they come into contact with a cellular basement membrane. 

Finally, we really do not yet understand the proper dose, frequency, and timing of PRP application for any specific condition. 

Dr. Griffin: Dr. Andrews, hearing these responses, how would you summarize our knowledge of the use of PRP to treat tendinosis or tendinopathy? 

Dr. Andrews: Our knowledge of PRP is just beginning. We know it is safe, but the long-term effectiveness is still in question. I believe that the growth factors do play a valuable role on the cells in poorly vascularized tendinous tissue, but whether they make a difference clinically is still up for debate.

Interesting but not yet ready for prime time.

Thanks,

JTM, MD

Battling a Biceps Injury

New study finds early surgical treatment improves level of recovery in both function and strength

People who suffer from injuries to the distal biceps tendon may benefit from earlier surgical intervention and new surgical techniques, according to a review article published in the March 2010 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). 

Located in the front of the elbow, the distal biceps tendon attaches to the lower end of the biceps muscle, and is responsible for two primary motions:

• allowing the elbow to bend (elbow flexion), and

• allowing the arm to turn the palm upward (supination).

The study reported individuals who undergo surgery soon after their injuries experience faster and more complete recoveries than patients who are treated nonsurgically, as well as those whose surgeries are delayed.

Over the last 10 years there has been an increase in techniques to repair the distal biceps tendon.  Newer techniques allow for smaller incisions and often use one incision, instead of two. Moreover, the use of hardware can often return the strength of the tendon to within 90 percent to 95 percent of its original strength.

The study revealed surgical treatment offered a 30 percent greater improvement in elbow flexion and a 40 percent greater improvement in supination when compared to non-surgical treatment. Upper extremity endurance was also improved in patients treated surgically.

The results of the study also indicate surgery is most effective, and much simpler, when completed within two weeks of the initial injury.

Early diagnosis and treatment of these injuries make surgical repair more straightforward.  The ability to locate the end of the tendon in surgery is easier within the first two weeks, and if the tendon is repaired during this two-week period, the patient should regain the majority of his or her elbow flexion and forearm supination strength. After two weeks, the tendon tends to scar, making it more difficult to bring the tendon back to its original attachment.

Injuries to the distal biceps tendon most often occur as the result of a single trauma involving lifting or moving heavy weights, and may occur more frequently in patients over the age of 30 years, as well as those who smoke and individuals who take anabolic steroids.

Because other muscles initially may compensate for some of the loss of function following a trauma, these injuries occasionally can be difficult to detect initially, causing treatment to be delayed in some cases.  A detailed medical history is one of the primary components used to detect these injuries. Patients who injure their arm during exercise or other activity should be aware of the following warning signs which may point to an injury of the distal biceps tendon:

• a “popping” sensation in the arm and bruising around the elbow at the time of injury;

• a change in the contour or shape of the biceps muscle; and

• pain and weakness in flexion and supination of the injured arm

People can help prevent biceps injuries by:

• avoiding smoking and anabolic steroid use, which decrease blood flow to the tendon, increasing the likelihood of injury;

• avoiding lifting heavy weights using a biceps curl; and

• exercising caution when moving heavy objects, especially in individuals who smoke, take steroids, or are older than 30.

When a biceps injury does occur, no matter which surgical technique is used, one of the most important factors in successful treatment is ensuring the surgery is not delayed.

There are multiple ways to repair the tendon surgically, and the specific technique used is based on the experience of the surgeon and the latest biomechanical studies on strength and stability of various repairs.  For a healthy, active individual, it is best to seek medical attention quickly and to be evaluated by an orthopaedic surgeon if a tear is suspected, in order to ensure the best possible outcome.

For more information on the distal biceps tendon click here.

For an interview about distal biceps ruptures, click here.

Since the interview, I have begun to use the single incision endobutton techniques for selected patients.  It is not for every patient but can be very effective in selected cases.

More elbow tendon stuff here.

Thanks,

JTM, MD

Lucky Break: Quit Smoking after Fracture Surgery for Better Healing

Study finds patients who avoid tobacco for six weeks after surgery have fewer postoperative complications

 Smokers who refrain from using tobacco during the six-week period following emergency surgery for an acute fracture heal more quickly and experience fewer complications than patients who continue to smoke during the healing process, according to a study published in the June 2010 issue of The Journal of Bone and Joint Surgery (JBJS).

Study results indicate that a smoking cessation intervention program during the first six weeks after acute fracture surgery decreases the risk of postoperative complications by nearly half.

While earlier research has clearly indicated refraining from smoking prior to surgery results in better healing and fewer postoperative complications, this multi-center, randomized study was the first to examine the effects of smoking cessation following surgery.

Tobacco smoking is a major health and economic concern and also is known to have a significant negative effect on surgical outcomes.  The benefits of a smoking cessation program prior to elective surgery are well known, but there have not been any studies about the benefit of smoking cessation following emergency surgery. Our aim was to assess whether a smoking cessation program, started soon after hospitalization and continuing for six weeks following surgery, could reduce the number of postoperative complications.

In the study, conducted at three hospitals in Stockholm, daily smokers who underwent emergency surgery for an acute fracture were offered a smoking cessation program within two days of surgery, and then followed for six weeks.

Patients included in the program were offered one or two in-person meetings, in addition to regular telephone contact with a nurse trained in the cessation program. During the six-week follow-up, patients were encouraged not to smoke and free nicotine substitution was offered to those who needed it.

Up until this point, the belief was that you needed to stop smoking prior to surgery to gain any benefit.  It is encouraging to see that even stopping smoking following surgery for a period of time can offer significant benefits, including nearly a 50 percent reduction in wound complications.

Smoking inhibits circulation and lowers blood oxygen levels, which can affect short-term and long-term healing in several ways, including:

• failure or delayed healing of bone, skin and other soft tissues; or

• causing wound site infections.

In elective surgery, smoking cessation can become part of a plan preoperatively to reduce risks during and after surgery. But with emergency surgery, such as acute fracture surgery, stopping smoking before surgery is not an option. Therefore, it’s very encouraging to see that stopping smoking following surgery offers some of the same benefits as preoperative smoking cessation.

Stop smoking.  

Thanks,

JTM, MD

Treatment Trends for Biceps Injuries

From AAOS.org.

For patients with tendinopathy both surgical and nonsurgical treatments show promise, need more study

A patient with a long head biceps (LHB) tendinopathy, which is a pain and/or tearing of the tendon, may also have a shoulder problem and/or a rotator cuff tear. LHB tendinopathy can be caused by injury, trauma, overuse, inflammation or degeneration. Because of the variety of the causes and the range of possible severity, a patient needs a thorough examination, including radiographic imaging to determine the diagnosis and treatment. Traditional treatments include both surgical and nonsurgical approaches.

The surgeon’s goal in treating any long head biceps tendinopathy is to address the pain in a way that also respects the patient’s lifestyle. And, as we found, there is a variety of excellent surgical and nonsurgical options. In developing this review, we also discovered the need for more comparative research data on surgical versus nonsurgical treatment outcomes for this condition.

Statistics:

• Recent studies reported no significant difference in function or patient satisfaction between the two primary surgical options, biceps tenotomy or tenodesis.

• Each year, an average of 10 million people seek medical attention in a surgeon or physician’s office or at the ER for a shoulder injury and an average of 4 million people come in with arm injuries.

• Both surgical treatments for LHB tendinopathy are statistically successful, with a complication rate of less than 1 percent.

Trends noted:

• Both surgical options -- biceps tenotomy and tenodesis (between which the article found no preference) now can be performed via arthroscopy.

• The authors agree that nonsurgical treatment is the first – and in many cases may be the only –treatment necessary.

• The authors of this review seem to agree that of the two surgical options, biceps tenodesis should be used in younger, active patients.

• The first line of treatment for LHB tendinopathy is a variety of nonsurgical options, such as:

• Rest;

• anti-inflammatory drugs;

• activity modification; and

• physical therapy.

If those treatments do not offer the patient relief, a course of corticosteroid injections may be attempted. The authors do, however, report a concern about intratendinous (within the tendinous portion of the muscle) corticosteroid injections, which may predispose the patient to tendon rupture. More research is needed to address this concern.

Symptoms:

See your doctor or orthopaedic surgeon if you experience any of these symptoms.

• Sudden, sharp pain in the upper arm

• Audible popping or snapping in the shoulder or elbow

• Cramping of the biceps muscle with strenuous use of the arm

• Bruising from the middle of the upper arm down toward the elbow

• Pain or tenderness at the shoulder and the elbow

• Weakness in the shoulder and the elbow

• Difficulty turning the palm of the hand up or down

• Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow ("Popeye Muscle") may appear, with a dent (signifying absence of muscle) closer to the shoulder.

More on the shoulder biceps tendon here.

Thanks

JTM, MD

Osteolysis of the Distal Clavicle

What is the anatomy of acromioclavicular (AC) joint? 

The shoulder complex is made up of three bones, which are connected by muscles, ligaments, and tendons. The large bone in the upper arm is called the humerus. The shoulder blade is called the scapula and the collarbone is called the clavicle. 

The acromioclavicular joint of the shoulder complex is where the outer (lateral) part of the clavicle is joined to a projection on the top of the scapula known as the acromion process. The joint connecting these two bones is known as the acromioclavicular (AC) joint. The AC joint allows a small amount of movement to occur between clavicle and the acromion process. 

Ligaments are like strong ropes that help connect bones and provide stability to joints. In the AC joint there are three main ligaments. The acromioclavicular ligament connects the acromion process and the clavicle. The coracoclavicular ligaments (the trapezoid ligament and conoid ligament) connect the clavicle with another projection of the scapula called the corocoid process. 

 What is osteolysis of the distal clavicle?

The word "osteolysis" refers to a softening, absorption, and dissolution of bone or the removal or loss of calcium in bone. At the acromioclavicular joint the end of the clavicle can undergo osteolysis. Over time osteolysis of the end of the clavicle can result in the loss of 0.5 to 3 cm of bone. 

What can cause AC joint osteolysis?

No one knows for sure what causes osteolysis of the distal clavicle but some risk factors include:

- A single injury to the AC joint or to the end of the clavicle
- Repetitive minor injuries to the AC joint or to the end of the clavicle
- Repetitive heavy weight lifting such as overhead shoulder press and bench press
- Pre-existing disease states such as rheumatoid arthritis, hyperparathyroidism, infection, multiple myeloma, and scleroderma. 

What does osteolysis of the distal clavicle feel like?

Osteolysis of the distal clavicle usually comes on slowly and results in shoulder pain, stiffness and/or swelling. The pain may is felt in the area of the AC joint or the end of the clavicle. The pain is usually made worse by activities such as bench press, shoulder press, push - ups and throwing. 

This swelling of the AC joint can also result in pressure on the rotator cuff beneath and, as a result, can cause pain fro the shoulder rotator cuff tendons.  This is called impingement or tendinitis.

Can osteolysis of the distal clavicle be detected on X-rays?

X-rays can be an effective tool for identifying osteolysis of the distal clavicle but the bony changes may take weeks or months before they can be seen on an X-ray. A bone scan is an effective tool to help identify early osteolysis. A bone scan will show increased uptake over the distal clavicle and, occasionally, increased uptake in the acromion process. Magnetic resonance imaging exhibits altered signal intensity in the distal clavicle but is not necessary to make a definitive diagnosis.

What is the treatment for osteolysis of the distal clavicle?

The goal of treatment of osteolysis of the distal clavicle is to reduce pain while the clavicle "remineralizes". Rest or activity modification, anti-inflammatory medications and ice are usually prescribed to reduce pain. If these measures are not effective an injection of cortisone into the AC joint may be necessary. In most cases, the clavicle slowly remineralizes (over 4 to 6 months), but may take on a tapered appearance. If you are not better after 4-6 months of treatment or observation, it is less likely that you will improve without surgery.  

In some cases, the bones do not remineralize and surgery may be required. The surgeon may consider resecting (removing) part of the affected clavicle to reduce symptoms.  This can be done arthroscopically and involves burring back the end of the clavicle.

The results of surgery are generally excellent with an eventual resolution of all of the shoulder pain from the AC joint.

Click here for an animated version of the distal clavicle resection.

Can osteolysis of the distal clavicle be prevented?

When symptoms of AC joint pain first develop, avoiding pain provoking activities is recommended. Additional padding for contact sports can also be effective. Finally, weight lifters should avoid locking their elbows during the bench press, use a narrower grip on the bar, and avoid bending their elbows past horizontal. 

Click here for a patient's guide to osteolysis of the distal clavicle.

Thanks,

JTM, MD